Advances in fetal cardiac magnetic resonance imaging (CMR) have expanded its role as an adjunct to expert fetal echocardiography in the prenatal evaluation of complex cardiopulmonary anomalies. This review outlines an evidence-based framework for integrating fetal CMR when it provides diagnostic or prognostic information that can informs counseling, delivery planning, or postnatal management. Fetal CMR offers high-resolution, multiplanar imaging with superior soft-tissue contrast and wide field of view, enabling improved assessment of cardiopulmonary structures where echocardiography is limited by technical or physiologic factors, or when expert echocardiography raises clinically relevant questions. MRI enables improved delineation of aortic arch and pulmonary venous anatomy, characterization of pulmonary parenchymal changes, and quantify lung and ventricular volumetry without relying on geometric assumptions. Emerging flow-based techniques allow evaluation of fetal hemodynamics and cardiovascular physiology beyond static imaging. These technologies provide diagnostic and prognostic information in select, often critical, congenital heart diseases. Fetal cardiac CMR serves as a complementary modality to expert echocardiography when applied selectively to address clinically meaningful diagnostic or prognostic questions. However, limited availability, technical complexity, and the need for specialized expertise currently constrain widespread adoption. Continued technical refinement and outcome-based validation are required before fetal CMR can be routinely integrated into clinical practice.

Renal cell carcinoma (RCC) is frequently associated with venous tumor thrombus (RCC-TT), which occurs in 5-20% of patients and significantly impacts surgical management. While CT and MRI provide excellent anatomic characterization, they offer limited insight into venous hemodynamics and venous collateralization, which are critical for operative planning in RCC-TT cases. Four-dimensional (4D) flow MRI is a time-resolved technique that enables simultaneous assessment of vascular anatomy and blood flow dynamics. In this pictorial essay, we illustrate the application of 4D flow MRI in RCC-TT across a spectrum of tumor thrombus levels. Through representative cases, we demonstrate how 4D flow imaging provides value over conventional imaging by clarifying vessel patency, flow directionality, and the presence and extent of collateral pathways. These insights are particularly relevant in determining whether the inferior vena cava (IVC) is functionally occluded, assessing redistribution of venous return, and anticipating tolerance to surgical maneuvers such as IVC cross-clamping, ligation, or resection. Our experience highlights that 4D flow MRI can reveal complex and variable patterns of venous drainage that are not readily apparent on standard imaging. By integrating hemodynamic information with anatomic findings, 4D flow imaging may enhance preoperative assessment and support surgical decision-making in patients with RCC-TT.

In cases of inferior vena cava (IVC) obstruction, venous collaterals involving the hemiazygos and azygos veins can provide venous return to the right atrium. This can lead to procedural challenges in right heart catheterization (RHC). A 54-year-old male with end stage renal disease and severe aortic regurgitation underwent RHC for valve replacement planning. Swan Ganz catheter, via left femoral vein, would not advance beyond the distal IVC despite an inflated balloon. It was advanced over a V18 wire, taking a tortuous path to the right ventricle. Imaging revealed infrarenal IVC stenosis due to a dialysis catheter, with venous return through a dilated lumbar vein and hemiazygos and azygos collaterals. When catheter advancement fails, IVC stenosis and collateral pathways should be considered. Wire-guided navigation allows completion of RHC in these settings. Familiarity with venous anatomy enables successful RHC despite IVC obstruction. Early recognition and guidewire use can prevent procedural delays.

Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) offers excellent aesthetic outcomes, but nipple-areolar complex (NAC) necrosis remains a major complication. Although arterial insufficiency has been emphasized, venous injury may also play a critical role. To characterize NAC venous anatomy and determine whether venous injury contributes to clinically significant NAC necrosis after NSM. We performed a cadaveric study of superficial peri-areolar venous anatomy and a prospective clinical cohort study of 123 breasts undergoing NSM with immediate IBBR. Cutaneous NAC veins were visualized using near-infrared (NIR) imaging, and venous injury was quantified as vein branch loss (VBL). We evaluated predictors of clinically significant NAC necrosis and developed a prediction model, compared with intraoperative indocyanine green angiography (ICGA) in 32 breasts. Cadaveric dissection demonstrated a polygonal venous network adjacent to the areolar margin. In the clinical cohort, significant NAC necrosis occurred in 19 of 123 breasts (15.4%). On univariate analysis, higher VBL, greater mastectomy weight, higher body mass index, and diabetes were associated with NAC necrosis (P < .05). Multivariable analysis demonstrated that the effect of VBL increased with mastectomy weight. The final model showed strong discrimination (AUROC 0.902; 95% CI, 0.82-0.98) and identified a low-risk subset among breasts with poor ICGA perfusion in which no significant NAC necrosis occurred. Venous integrity is a key determinant of NAC viability after NSM. NIR-based vein analysis enables quantitative assessment of venous injury and may complement ICGA in perioperative risk stratification and surgical planning.

Surgical approaches to the fourth ventricle involve the suboccipital surface of the cerebellum, where the inferior vermian vein (IVV) and inferior hemispheric vein (IHV) are often encountered and are at risk of injury. Iatrogenic injury to these veins could thereby lead to venous infarction and other postoperative complications; however, venous anatomy of these veins remains less well characterised. A retrospective bilateral analysis of contrast-enhanced MRI was conducted for 79 patients (n = 158 hemispheres) focusing on presence, termination and diameter of these veins. Additionally, the dominant patterns of this surface were documented. These factors were then compared on the basis of laterality and sex. The IVV had an overall presence of 88.6% with no bilateral absence noted. The prevalent termination of the IVV was the straight sinus (47.9%). A single IHV was the frequent configuration (65.2%), with a maximum of 3 IHVs per hemisphere. IHVs were further investigated based on their configuration as longitudinal and transverse veins. The prevalent drainage point of the IHV was the tentorial sinus (42.8%). The mean diameter for the IVV and IHV was 1.7 ± 0.5mm and 1.5 ± 0.4mm, respectively. The suboccipital surface exhibited a prevalent co-dominant pattern (58.9%), followed by IVV dominant (32.3%) and IHV dominant patterns (8.9%), respectively. These findings provide clinically relevant data that will assist in surgical planning and reduce risk of iatrogenic injury during posterior fossa approaches.

Risk factors for postoperative motor complications in middle-third parasagittal meningioma surgery.

Treacherous Pitfalls in Liver Transplantation for Budd-Chiari Syndrome: When the Devil Hides in the Shadows-A Case Report.

Precise delineation of hepatic and portal venous anatomy is crucial for the diagnosis of liver disease, surgical planning, and prognosis prediction. Current three-dimensional visualization of these complex vascular structures relies on manual or semi-automated CT segmentation, which is time-consuming and operator-dependent. Although artificial intelligence (AI) presents a promising alternative, existing methods remain constrained by the scarcity of publicly available datasets with fine-grained vascular annotations and inadequate validation in real-world diseased liver populations, which represent the majority of patients undergoing hepatic procedures. To address this gap, we present the Hepatic Vessel Map (HVM) Dataset, a dual-center resource comprising contrast-enhanced CT scans from 282 patients with over 4,1400 slices and 4,8300 annotations, each with meticulously annotated hepatic veins, portal veins (to third-order branches), and liver tumors. The dataset comprises a substantial proportion of cases with underlying hepatic pathology and has been validated for use in preoperative planning for major hepatectomy, ensuring both clinical relevance and model generalizability. This dataset supports: 1) development and benchmarking of robust hepatic and portal venous segmentation models; 2) vasoimcs research through quantitative analysis of vascular morphology, topology, and radiomic features; 3) generation of patient-specific 3D "digital vascular roadmaps" to enhance surgical precision and safety. As such, this dataset establishes a foundational resource for advancing AI-driven innovations in hepatobiliary surgery and intervention.

Anatomical Variations of Portal Vein Branches in Subsegment IVb: A 3D Reconstruction-Based Classification to Inform Radical Resection for Gallbladder Cancer.

Tunnel-transposition with veno-venous or veno-arterial re-anastomosis versus skin-flap elevation for second-stage superficialization of brachiobasilic arteriovenous fistula.

Gastrointestinal (GI) bleeding is a frequent and potentially life-threatening emergency for which endoscopy remains the primary diagnostic and therapeutic modality. However, a subset of patients experiences persistent or recurrent bleeding, that requires stabilization before endoscopy or presents with lesions, that are inaccessible or unsuitable for endoscopic treatment. This review outlines the role of radiological intervention in these clinical settings. This article reviews the use of computed tomography angiography as the principal preprocedural imaging modality, focusing on its ability to localize active bleeding, characterize the underlying etiologies, and delineate the vascular anatomy relevant to catheter-based interventions. The indications, techniques, and outcomes of transcatheter arterial embolization for non-variceal GI bleeding are also summarized, including the application of superselective catheterization and commonly used embolic materials. This review describes the hemodynamically targeted interventional approaches for variceal GI bleeding associated with portal hypertension. The technical principles and clinical roles of the transjugular intrahepatic portosystemic shunt (TIPS) for portal decompression and balloon-occluded retrograde transvenous obliteration (BRTO) and its variants for gastric varices are discussed. Percutaneous variceal embolization has also been reviewed as an adjunctive option in selected situations in which endoscopic therapy, TIPS, or BRTO is not feasible or unsuccessful. Overall, this review summarizes the current imaging strategies and interventional techniques for GI bleeding, emphasizing patient selection based on bleeding etiology, vascular and portal venous anatomy, and hemodynamic status.

Superior gluteal vein entrapment: targeted surgical decompression for aberrant anatomy.

Endovascular electroencephalography (eEEG) using the EP-01 electrode requires reliable venous access and secure fixation to maintain stable positioning. This technical note aims to describe a standardized workflow for EP-01 placement, focusing on preprocedural planning, step-by-step deployment, and fixation strategies. We report 12 consecutive EP-01 placements performed between May 2024 and October 2025. Preprocedural planning utilized venous-phase angiography with three-dimensional reconstructions, as well as contrast-enhanced three-dimensional MRI when available, to assess venous anatomy and select appropriate access routes. Procedures were performed under general anesthesia using jugular venous sheaths and arterial angiographic guidance. EP-01 electrodes were deployed through microcatheters, and signal recordability was confirmed. Microcatheters were withdrawn using an extension wire to maintain electrode position. Electrodes were secured using Tuohy-Borst fixation and additional skin-level fixation with film dressing. All 12 procedures were completed successfully (mean age 40.6±11.0 years; 4 women). The mean procedure time was 165.6±35.5 min and the mean fluoroscopy time was 51.8±9.4 min. Six electrodes were placed in 11 of 12 cases, while three electrodes were placed in one case due to venous anatomical limitations. Alternative venous routes were used when standard approaches were not feasible. No procedure-related complications occurred. The median electrode dwell time was 2 days. A standardized planning and placement workflow enabled feasible EP-01 electrode placement without procedure-related complications in this consecutive series. Careful preprocedural assessment of patient-specific venous anatomy is essential and may necessitate alternative access strategies.

Hybrid arteriovenous grafts (AVGs) incorporating a stented venous outflow were developed to facilitate access creation in patients with unfavorable venous anatomy. Following discontinuation of dedicated hybrid graft devices, off-the-shelf (OTS) stent-graft configurations have been adopted. We report our 10-year institutional experience and evaluate patency outcomes and reintervention burden. A retrospective review of consecutive hybrid AVGs created between 2014 and 2024 was performed. Patients were stratified by configuration: dedicated Gore Hybrid Vascular Graft (GHVG) versus OTS graft plus covered stent. Primary, assisted primary, and secondary patency were calculated using Kaplan-Meier analysis. Reinterventions were analyzed descriptively and expressed per patient-year. Forty hybrid AVGs were created (GHVG, 7 (17.5%); OTS, 33 (82.5%)). Median follow-up was 37.3 months. Primary patency was 50.7% at 6 months and 31.0% at 12 months (median 6.4 months). Assisted primary patency was 68.8% at 6 months and 52.3% at 12 months (median 12.1 months). Secondary patency was 89.3% at 12 months and 83.6% at 24 months (median 71.2 months). A total of 172 reinterventions were performed (1.30 per patient-year). The most frequent lesions were venous stent-edge and cannulation-site stenoses. No statistically significant difference in patency was observed between GHVG and OTS configurations. Hybrid AVG construction provides durable secondary patency despite limited primary patency, with an acceptable reintervention burden. Off-the-shelf configurations demonstrate outcomes comparable to dedicated hybrid devices and represent a practical option for patients with complex venous outflow anatomy.

The portal vein branching pattern in the right anterior section (RAS) shows frequent variations. In such cases, Hjortsjö's classification1-which divides RAS into ventral and dorsal parts2,3-is often more appropriate than Couinaud's classification, which separates RAS into cranial (S8) and caudal (S5) parts.4 However, anatomical resection of the ventral or dorsal part is technically demanding, as the ventral-dorsal boundary is difficult to identify laparoscopically due to the lack of surface landmarks. The ventral-dorsal boundary can be identified by referring to hepatic venous anatomy, as the course of a hepatic vein branch (V8) generally corresponds to this intersegmental plane.2,5,6 Furthermore, venous congestion induced by temporary occlusion of the middle hepatic vein (MHV) corresponds to this boundary and can be visualized using indocyanine green (ICG) fluorescence.7,8 RESULTS: A man in his 60s presented with recurrent hepatocellular carcinoma, including a 20-mm lesion at the S4/S8 border and a 10-mm lesion near the umbilical portion of S4. S4 plus S8-ventralresectionwas performed laparoscopically, while preserving the MHV. After transecting the G4 pedicles, the MHV trunk was exposed from the left side and temporarily clamped. The congestion area was visualized by intravenous ICG injection, and the congestion border served as a guide to the ventral-dorsal boundary. Parenchymal transection was completed along the ventral side of the MHV and V8. Integration of hepatic venous anatomy, congestion mapping, and ICG fluorescence enables identification of the ventral-dorsal boundary and facilitates safe and precise anatomical resection of segment 8-ventral.

A comprehensive three‑dimensional understanding of limb venous anatomy, including venous pathways, valve distribution, and superficial-deep connections, is essential for anatomical education and preclinical surgical training. However, preparation of venous anatomical specimens remains technically challenging because of venous valves, fragile vessel walls, leakage, and incomplete perfusion using conventional techniques, which limits their pedagogical value and reproducibility. The present study aimed to develop and validate a standardized venous perfusion protocol for producing high‑fidelity venous specimens of human limbs. Fifteen fresh adult cadaveric limb specimens were prepared using an optimized technique incorporating ammonia solution pre‑perfusion, bidirectional venous cannulation through dorsal venous networks and transected major veins, latex perfusion assisted by directional manual massage and selective micro‑needle valve penetration, localized leakage control, staged supplementary perfusion, and low‑temperature curing followed by formalin fixation. Following anatomical dissection, 14 of 15 specimens demonstrated complete and continuous perfusion of both superficial and deep venous systems. Major venous structures, distal branches, venous valves, and anastomotic patterns were clearly visualized with accurate in situ morphology and preserved spatial relationships. This optimized approach reliably overcomes key limitations of traditional venous perfusion methods and yields durable, anatomically accurate specimens that enhance three‑dimensional learning and provide realistic, non‑biological platforms for procedural skills training, thereby bridging anatomical science and applied surgical education.

Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is largely determined by venous anatomy, but the contribution of systemic cardiovascular factors and their medical therapy remains poorly defined. This study examined associations between cardiovascular risk factors and antithrombotic use and hemorrhagic presentation, angiographic obliteration, and early functional outcomes after treatment. We analyzed 1350 adults with intracranial dAVFs from the international Consortium for Dural Arteriovenous Fistula Outcomes Research registry, which retrospectively accrued cases across 14 centers in 4 countries between 1990 and 2017. Demographics, cardiovascular comorbidities, antithrombotic use, angioarchitectural features, treatment strategies, and follow-up outcomes were collected from prospectively maintained databases. Primary end points were hemorrhagic presentation, angiographic obliteration, and 90-day functional status after treatment. Univariable and multivariable logistic regressions were performed with model-specific adjustments. Hemorrhage occurred in 375 patients (27.8%) and was most strongly associated with high-grade dAVF classification and male sex; antithrombotic therapy was associated with lower odds of hemorrhagic presentation. Other cardiovascular risk factors showed no independent relationship with bleeding. Angiographic obliteration was achieved in 621 of 845 patients (73.5%). Hemorrhagic onset, high dAVF grade, and surgical treatment were independently associated with angiographic obliteration, whereas smoking and embolization demonstrated only nonsignificant trends after adjustment. At 90 days, 934 patients (88.9%) were functionally independent. Baseline modified Rankin Scale score was the strongest factor associated with 90-day functional outcome, while neither cardiovascular comorbidities nor treatment modality independently influenced functional status. In this large multicenter dAVF cohort, hemorrhagic presentation was most strongly associated with venous angioarchitecture. Male sex and antithrombotic therapy were also independently associated with hemorrhagic presentation. Angiographic obliteration was common, particularly among surgically treated lesions, and 90-day functional outcome was most strongly associated with baseline functional status.

Superior petrosal sinus dural arteriovenous fistulas (SPSdAVFs) are uncommon tentorial fistulas with aggressive venous drainage and complex anatomy. We evaluated endovascular treatment outcomes in our cohort and propose an anatomy-driven framework for treatment selection, with particular emphasis on transvenous route selection. We retrospectively reviewed consecutive SPSdAVFs treated endovascularly at two tertiary centers (January 2005-March 2024). Clinical, angiographic, procedural, and follow-up data were analyzed, including arterial supply, venous outflow, superior petrosal sinus (SPS) patency, embolic agent, and access route. Transvenous access to the junction of the SPS and superior petrosal venous confluence was categorized as duro-pial, anteromedial dural, or posterolateral dural. Twenty-two patients (20 men; mean age, 51.7 years) were included; 6 (27.3%) presented with infratentorial hemorrhage. Ten underwent transvenous embolization (TVE) and 12 underwent transarterial embolization (TAE). TVE was achieved via a duro-pial route in four cases, anteromedial dural in four, and posterolateral dural in two. All anteromedial cases required recanalization of a thrombosed SPS segment; one posterolateral case required adjunctive snare-assisted pull-through. Complete angiographic occlusion was achieved in all patients after a single session. Periprocedural complications occurred in three patients (13.6%): one localized subarachnoid hemorrhage after TVE and two transient facial pareses after TAE. There were no procedure-related deaths or radiologic recurrences. Mean modified Rankin Scale score improved from 1.5 to 0.3 at last follow-up (mean, 6.5 years). TVE is a viable curative option for SPSdAVFs. An anatomy-driven strategy centered on venous foot access may facilitate route selection and durable occlusion.

Patients with superior vena cava (SVC) obstruction (SVCO) are referred for stenting to alleviate symptoms such as plethora and dyspnea. Accurate visualization and measurement of the central veins are essential for appropriate stent selection and optimal placement. This is critical to avoid extension into the right atrium, which can lead to arrhythmias or stent migration. However, in cases of severe SVCO, the sinoatrial junction (SAJ) often cannot be opacified on angiograms. Altered flow dynamics cause suboptimal perfusion and distention, complicating precise measurements and challenging stent planning-especially when the tumor encroaches near or beyond the SAJ. We integrated intravascular ultrasound (IVUS) into our procedural workflow and evaluated its utility in a series of 27 cases involving malignancy-related SVCO between November 2023 and March 2025. We measured the distance from the midpoint of the stenosis to the SAJ (stenosis-to-SAJ distance) and identified cases requiring IVUS for accurate assessment of the caudal landing zone. Parametric testing revealed a stronger correlation between stenosis-to-SAJ distance measurements on IVUS and computed tomography (CT) than between digital subtraction angiography and CT. Statistical analysis determined that a stenosis-to-SAJ distance of ≤ 40 mm was significantly associated with the need for IVUS (P = 0.008), whereas the association at ≤ 50 mm was not statistically significant (P = 0.069). Stenting becomes particularly challenging when tumors invade the SAJ. Our findings suggest that IVUS provides valuable visualization and measurement, particularly in cases with a stenosis-to-SAJ distance of ≤ 40 mm, making it a useful adjunct for safe and effective SVC stent placement. Visualization of venous anatomy and the exact extent of SVC stenosis is difficult in cases of severe obstruction, especially when the tumor encroaches upon the SAJ, making stent selection and deployment challenging. The use of IVUS facilitates visualization of the precise extent of the stenosis and delineates the location of the SAJ. A stenosis-to-SAJ distance of ≤ 40 mm significantly benefits from the concomitant use of IVUS for accurate stent placement.

Posterior fossa lesions pose significant surgical challenges due to their proximity to critical neurovascular structures and the difficulty of obtaining adequate exposure with reliable dural closure. The traditional Y-shaped durotomy after a median suboccipital craniotomy remains the standard approach for midline infratentorial lesions but is often associated with cerebrospinal fluid leakage and complex dural repair. This study describes a vertical paramedian durotomy, performed parallel to the occipital sinus (OS) and combined with systematic C1 posterior arch removal, as a pragmatic alternative that preserves venous anatomy and facilitates linear primary closure. We conducted a retrospective, single-surgeon case series (January 2020-January 2025) including patients with midline infratentorial lesions whose operative corridor did not extend beyond the foramina of Luschka. All patients underwent median suboccipital craniotomy, routine C1 posterior arch removal, and a vertical paramedian durotomy parallel to the OS. Clinical records, operative notes/videos, and imaging, including preoperative magnetic resonance venography, were reviewed. Nine patients (median age 44 years, range 9-69; 5 female) were treated. Lesion locations included the pons (5/9, 55.6%), cervicomedullary junction (2/9, 22.2%), fourth ventricle (1/9, 11.1%), and medulla (1/9, 11.1%). Diagnoses were cavernous malformation (5/9), ependymoma, hemangioblastoma, choroid plexus papilloma, and 1 unspecified tumor. The OS was identified in 2/9 cases; no marginal sinus was visualized. Gross total resection was achieved in 8/9 patients; 1 pontine lesion underwent biopsy only. No durotomy-related or wound-related complications occurred, and linear primary closure was achieved in all cases. Vertical paramedian durotomy is a safe and effective alternative for selected midline posterior fossa lesions. By preserving the OS and simplifying dural reconstruction, it reduces the risk of cerebrospinal fluid-related complications and provides a straightforward method for achieving watertight closure. Larger prospective studies are warranted to further validate its long-term outcomes and broader applicability.