Introduction: Various transarterial embolotherapies for different hepatic etiologies are performed through the celiac axis (CA). However, this pathway is not always patent due to the extensive stenosis or occlusion of the origin of CA. In such situations, the pancreaticoduodenal arcades (PDAs) catheterization is the main alternative to gain access to the hepatic arteries as demonstrated in clinical studies. Presentation of case: We report two cases of life-threating hepatic hemorrhage indicated for emergency transarterial embolization (TAE). Discussion: The massive hemorrhage was due to spontaneous rupture of hepatocellular carcinoma (HCC) in the first case and due to post liver blunt trauma in the second case. Owing to severe stenosis of the origin of CA, PDAs were used as a salvage alternative route for emergency TAE of hepatic arteries. Conclusion: Endovascular management of massive hepatic hemorrhage in cases of inaccessibility to hepatic arteries through CA is a highly challenging situation in which the technical success depends on the operator experience, choice of the material and anatomical knowledge of hepatic arterial collateral supply. Highlights:

Background: Portomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient’s clinical details, radiological findings, safety, and efficacy are reported. Cases presentation: Two patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery. Conclusion: PMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.

Rectal variceal bleeding is one of the rarer manifestations of portal hypertension caused by chronic liver disease. The management of these varices is very challenging. Our patient had portal vein thrombosis and presented with chronic recurrent rectal bleeding requiring transfusion secondary to rectal varices. The patient was treated from trans-splenic access with liquid embolics (sclerotherapy and glue) without balloon occlusion, leading to the successful cessation of his bleeding. Access hemostasis was achieved using a vascular plug in the access tract. There are no clear guidelines for the management of these patients. If rectal varices cannot be managed by colonoscopy, this approach to embolization with liquid embolic is an excellent minimally invasive alternative.

Colonic varices are an uncommon type of ectopic varices that can occur due to underlying liver cirrhosis and portal hypertension. They form a very rare cause of lower gastrointestinal bleeding that can result in massive hemorrhage. We present a 38-year-old woman with a background of ulcerative colitis complicated by primary sclerosing cholangitis-induced liver cirrhosis presenting with fresh rectal bleeding. The colonoscopy failed to identify the source of bleeding. Then, computed tomography scan showed multiple dilated tortuous venous collaterals around the descending colon that extended into the colonic submucosa and drained via the left ovarian vein representing colonic varices. She underwent balloon-occluded retrograde transvenous obliteration (BRTO), which successfully embolized these varices with no significant complications. Despite there being no established management guidelines for colonic variceal bleeding, BRTO is a minimally invasive procedure that can be considered as good option for the treatment of these varices, especially when other alternatives are not applicable.

Rosai-Dorfman disease (also known as sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman-Destombes disease) is a rare reactive histiocytic disease, classically involving the lymph nodes of the neck, but it can also occur in extranodal sites. Isolated spinal involvement is rare but important to identify as it can mimic malignancy with males being affected more than females. We present a case of a 52-year-old female patient who had breast cancer and was admitted with long-standing anal and sacral pain. The MRI lumbar spine showed a mass concerning for metastasis. CT-guided biopsy results showed sheets of histiocyte-like cells, some of which were positive with S100 and showed emperipolesis along with plasma cells, lymphocytes, and neutrophils. Features were in keeping with Rosai-Dorfman syndrome. The patient responded to steroids. The familiarity with this entity saved the patient from going through the agony of this being considered a metastasis of her primary malignancy.

Introduction This sy stematic review and meta-analysis aimed to evaluate the efficacy and safety of TACE combined with I-125 brachytherapy versus TACE alone in Hepatocellular carcinoma (HCC) patients. Methods Following the PRISMA guidelines, we searched databases, including PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and grey literature, for articles published between January 1, 2010 and November 30, 2023. Eligible studies compared TACE with and without I-125 brachytherapy, from randomized controlled trials (RCTs) and non-randomized comparative studies. Primary outcomes were overall survival (OS) at 1, 2, and 3 years. Secondary outcomes comprised progression-free survival (PFS), overall response rate (ORR), disease control rate (DCR), and adverse events. Data extraction and quality assessment were conducted using Covidence software and validated risk-of-bias tools. Meta-analyses were performed using Stata. Results Eighteen studies (n=1,872 patients) were included. TACE + I-125 brachytherapy significantly improved OS at 1 year (OR: 1.30, 95%; CI: 1.05–1.56), 2 years (OR: 1.02, 95%; CI: 0.65–1.39), and 3 years (OR: 1.28, 95%; CI: 0.85–1.71) compared to TACE alone. Tumor response rates, including overall response rate (ORR: 1.74, 95%; CI: 0.65–2.83) and disease control rate (DCR: 1.04, 95%; CI: 0.07–2.01), were also significantly higher in the combination group. Subgroup analyses showed consistent OS outcomes between higher and lower doses of I-125. Adverse event rates were insignificant and comparable between groups. Conclusion TACE combined with I-125 brachytherapy enhances survival and tumor response without increasing adverse events, offering a promising strategy for managing advanced HCC. Further RCTs are warranted to confirm these findings.