Volume 24 ’ Number 9 ’ September ’ 2013 1421

was removed at laparoscopy, it had adhered to a scarredloop of ilium. The remainder of the Bird’s Nest filterremained within the IVC and was not removed. Aftersurgery, the patient was pain-free (1). Ford et al (2)described symptomatic pancreatitis following IVC wallperforation by a Celect IVC filter (Cook) (2). Thepatient’s symptoms were ameliorated after removal ofthe filter. Arabi et al (3) described two patients whopresented with abdominal pain after caudal migration oftheir retrieval-optional IVC filters with associated cavalpenetration. These patients’ pain improved after removalof the filters.Nutting and Coldwell described the placement and

immediate removal of a TrapEase IVC device placed asa temporary IVC filter (4). The filter was placed beforethrombectomy and thrombolysis of an IVC thrombus.They removed the filter in a fashion similar to thatdescribed in the present report, by using slings to stretchthe filter and release it from the wall and capturing thefilter with a sheath to remove it.Venbrux et al (5) described the removal of a TrapEase

IVC filer 1 year after it was placed. A permanent IVCfilter had been placed in a trauma patient, who, inretrospect, would have been better served by a retrieval-

http://dx.doi.org/10.1016/j.jvir.2013.05.045

Present address of M.A.A.: Department of Radiology, Sohag Faculty ofMedicine, Sohag University, Sohag, Egypt.

None of the authors have identified a conflict of interest.

optional IVC filter. This report differs from the presentreport in that the present patient’s filter removal after 2years was associated with resolution of her chronic IVCfilter–related pain.IVC filters can be associated with chronic abdominal

pain. This can be secondary to caval perforation,although perforation was not the cause in the presentcase. IVC filter removal can ameliorate the pain andshould be considered even in the case of a permanentIVC filter such as the TrapEase.

REFERENCES

1. Al-Basheer MA, Hamilton M, Holdaway C. Chronic pain syndromecaused by a birds nest filter: first case report. Cardiovasc Intervent Radiol2008; 31(suppl):S182–S184.

2. Ford ME, Lippert JA, McGraw JK. Symptomatic filter penetrationpresenting as pancreatitis. J Vasc Interv Radiol 2010; 21:574–576.

3. Arabi M, Willatt JM, Shields JJ, Cho KJ, Cwikiel WB. Retrievability ofoptional inferior vena cava filters with caudal migration and cable penetra-tion: report of 3 cases. J Vasc Interv Radiol 2010; 21:923–926.

4. Nutting C, Coldwell D. Use of a TrapEase device as a temporary cavalfilter. J Vasc Intervent Radiol 2001; 12:991–993.

5. Venbrux AC, Yanagi GJ, Martell BS. A complex case of IVC filter removal.Endovasc Today, February 2010. Available at: http://bmctoday.net/evtoday/2010/02/article.asp?f=a-complex-case-of-ivc-filter-removal. AccessedMay 14, 2013.

Recurrent Retrograde Intussusception

after Roux-en-Y Gastric Bypass:

Intussusception Reduction by the

Transhepatic Approach

From: Mohammad A. Abusedera, MDKyung Cho, MDNarasimham Daika, MDDivision of Interventional RadiologyDepartment of RadiologyUniversity of Michigan Health System1500 E. Medical Center Dr.Ann Arbor, MI 48109

Editor:

Intussusception after a gastric bypass represents acomplication associated with the potential for bowelischemia, perforation, subsequent sepsis, and death (1).We describe a case of a 47-year-old woman whodeveloped retrograde intussusception twice after Roux-en-Y gastric bypass for morbid obesity. The first com-plication occurred 2 years after Roux-en-Y gastricbypass, requiring open surgery with bowel resectionand anastomosis. The second intussusception occurred3 years after the first intussusception and was treated by

using a combination of air, contrast medium, and acatheter from the percutaneous transhepatic approach.The patient had a history of severe epigastric and right

upper quadrant pain associated with fever and elevationof serum amylase and lipase levels for 3 months. Hersurgical history was significant for cholecystectomy 11years earlier, Roux-en-Y gastric bypass surgery withsubsequent 130-pound weight loss, and ventral hernior-rhaphy (1 y after Roux-en-Y gastric bypass). Within 2years after Roux-en-Y gastric bypass, the patient devel-oped retrograde Roux limb intussusception at thejejunojejunostomy site, which was managed surgicallywith resection and anastomosis.Liver ultrasound and magnetic resonance (MR)

cholangiopancreatography performed during the cur-rent admission revealed dilation of the central bileducts. Laboratory tests showed an alkaline phosphataselevel of 239 IU/L (normal range, 30–130 IU/L), aspar-tate aminotransferase level of 200 IU/L (normal, 8–30IU/L), alanine aminotransferase level of 231 IU/L(normal, 7–35 IU/L), and total bilirubin level of 0.4mg/dL (normal, 0.2–1.2 mg/dL). Because of elevation ofalkaline phosphatase level and right upper abdominalpain, percutaneous transhepatic cholangiography andbiliary drainage was performed (Fig, a). It showednarrowing at the confluence of the three main hepaticducts. Three days after biliary drainage, the drainagecatheter was capped. During the subsequent 2 months,the patient visited our hospital more than four timesbecause of intermittent left upper-quadrant colicky painassociated with nausea and vomiting. Biliary brush and

Figure. (a) Percutaneous transhepatic cholangiogram obtained with the injection of contrast medium into the right hepatic duct

through a sheath positioned in the right hepatic duct shows mild strictures at the central bile ducts. (b) Contrast-enhanced T1-weighted

MR image of the abdomen. A section below the level of the kidneys demonstrates an air-filled bowel loop (arrow) invaginating into the

contrast medium–filled bowel loop, suggestive of intussusception. (c) Contrast medium was injected into the Roux limb from the

transhepatic approach, which shows a coil-spring appearance of intussusception. (d) After hydrostatic reduction of the intussusception,

contrast medium flows normally into the distal small bowel.

Abusedera et al ’ JVIR1422 ’ Letters to the Editor

punch biopsies of the narrowed central ducts showedno evidence of malignancy. Her abdominal pain wasrelieved after the biliary catheter was uncapped andrestored to external drainage and a gush of fluid anddebris was noted. Contrast-enhanced T1-weightedMR imaging of the abdomen showed abnormalitysuggestive of intussusception (Fig, b). We decidedto evaluate the Roux limbs by using transhepaticbiliary drainage access. After removal of the biliarycatheter over a guide wire, an 8-F sheath (25 cm long)was advanced into the duodenum. Through the sheath,a 5-F pigtail catheter (Cook, Bloomington, Indiana)was advanced over a 0.035-inch Amplatz Super Stiffguide wire (145 cm long, Boston Scientific, Natick,Massachusetts) into the Roux limb, and contrast

medium was injected. It demonstrated subtotal obstruc-tion of the Roux limb at the suture line with a ball-likefilling defect and the coil-spring appearance of intussuscep-tion (Fig, c). The intussusception was successfully reducedby alternating flushing of the bowel loop with 5–7 mL ofdiluted water-soluble contrast agent by hand, each timefollowed by air to develop hydrostatic pressure, in additionto manipulation of the looped guide wire–supportedcatheter back and forth (Fig, d). Two days later, a small-bowel follow-through examination showed no evidence ofintussusception. The biliary drainage catheter wasremoved, and the patient remained asymptomatic duringa 3-year period of follow-up.Retrograde intussusception is a rare complication af-

ter open or laparoscopic Roux-en-Y gastric bypass (2).

Volume 24 ’ Number 9 ’ September ’ 2013 1423

The largest series reported in the literature (1) involves23 cases in a unit that performed more than 15,000Roux-en-Y gastric bypasses, for an incidence of 0.15%.Recurrent retrograde intussusception after Roux-en-Ygastric bypass, as in the present case, is even more rare.The mechanism of retrograde intussusception

after Roux-en-Y gastric bypass remains unclear.Although retrograde peristalsis occurs naturally inthe small intestine, retrograde intussusception has notbeen reported in patients without previous Roux-en-Ygastric bypass. Previous reports (3) documented somemanometric evidences of abnormal retrograde peri-staltic activity in patients who had Roux-en-Y gastricbypass. The extreme weight loss after Roux-en-Ygastric bypass leads to creation of a floppy, mobilemesentery that may provide a lead point for intussus-ception (4). The significant weight loss during the firstyear after Roux-en-Y gastric bypass in the patient

http://dx.doi.org/10.1016/j.jvir.2013.04.029

None of the authors have identified a conflict of interest.

described here might have contributed to the devel-opment of intussusception. The resected bowelfrom the first intussusception disclosed no pathologicprocesses that might have accounted for the intus-susception.

REFERENCES

1. Simper S, Erzinger J, Mckinlay R, Smith S. Retrograde (reverse) jejunalintussusception might not be such a rare problem: a single group’sexperience of 23 cases. Surg Obes Relat Dis 2008; 4:77–83.

2. Al-Sabah S, Christou N. Intussusception after Laparoscopic Roux-en-Ygastric bypass. Surg Obes Relat Dis 2008; 4:205–209.

3. Hocking MP, McCoy DM, Vogel SB, et al. Antiperistaltic and isoperistal-tic intussusception associated with abnormal motility after Roux-en-Ygastric bypass: a case report. Surgery 1991; 110:109–112.

4. Ver Steeg K. Retrograde intussusception following Roux-en-Y gastricbypass. Obes Surg 2006; 16:1101–1103.

Inadvertent Esophageal Stent

Deployment into a False Passage with

Subsequent Endoscopic Retrieval

From: Charles Ross Tapping, FRCR, MB, ChB (Hons), BSc(Hons)James H. Briggs, FRCRRaman Uberoi, MRCP, FRCRMark J. Bratby, MRCP, FRCRJane Phillips-Hughes, MRCP, FRCRDepartment of Radiology (C.R.T., J.H.B., R.U., M.J.B., J.P.-H.)Oxford University HospitalsJohn Radcliffe HospitalHeadington, Oxford, OX3 9DU, UKDepartment of Radiology (C.R.T., J.P.-H.)Oxford University Hospitals, Churchill HospitalOxford, United Kingdom

Editor:

A 73-year-old man presented to our department in 2009with dysphagia and weight loss. After performance ofendoscopy and biopsy, a diagnosis of midesophagealsquamous cell carcinoma was made. Positron emissiontomography performed with computed tomography(CT) demonstrated a moderately fluorodeoxyglucose(FDG)-avid tumor with a single round FDG-avid lymphnode of 15 mm � 10 mm between the aorta and trachea.Endoscopic ultrasound demonstrated a mainly exophytictumor with a polypoid component prolapsing into theesophageal lumen. The tumor was staged as T2N1M0.The patient was unfit for curative treatment and receivedpalliative radiotherapy to the distal tumor and the FDG-avid lymph node. However, on a subsequent CT scan

performed 21 months later, the primary tumor hadincreased in size to 28 mm � 12 mm, and the FDG-avid lymph node had increased in size to 25 mm � 16mm. The lymph node was causing compression of thetrachea and eroding the esophageal wall immediatelyinferior to the cricopharyngeus muscle. Subsequentcontrast esophagography revealed almost complete eso-phageal obstruction at this level with minimal obstruc-tion being caused by the esophageal tumor (Fig, a).To allow oral nutrition, a self-expanding esophageal

stent was inserted under fluoroscopic guidance with con-scious sedation (3 mg of midazolam and 50 μg of fentanyladministered intravenously). A 6-F BMC catheter (Cordis,Miami Lakes, Florida) and hydrophilic guide wire (Ter-umo; Terumo Corporation, Tokyo, Japan) were used tonavigate the esophagus. The Terumo guide wire was thenexchanged for an Amplatz Super Stiff guide wire (BostonScientific, Natick, Massachusetts). A Niti-S covered stent(18/26 cm � 12 cm) (Taewong Medical, Seoul, Korea) wasdeployed and dilated to 8 mm (EverCross balloon; ev3,Inc, Plymouth, Minnesota) to allow improved drainagethrough the stent lumen. It is not our usual practice to usea balloon to dilate a stent once inserted, but in this case thepatient’s severe dysphagia and the tight stricture suggestedthat expansion with a balloon was appropriate. However,the following day the patient complained of aphagia andregurgitation.Esophagography subsequently was performed. The

cranial margin of the stent was narrowed and unableto expand fully because of its position just below thecricopharyngeus. Contrast material was seen to passthrough the proximal stent, but there was stasis ofcontrast material through the distal end of the stent(Fig, b). It was assumed that the primary tumor in thedistal esophagus was the cause of obstruction, and asecond overlapping Niti-S stent (18/26 cm � 12 cm) wasinserted fluoroscopically over the distal tumor.