Fluoroscopic Visualization Research Articles

A PILOT STUDY OF PATIENTS UNDERGOING TRANSCATHETER PARAVALVULAR LEAK CLOSURE WITH FLUOROSCOPY TRUEFUSION INTEGRATED TEE GUIDANCE

Software to fuse transesophageal echocardiography (TEE) images onto live fluoroscopy (FL) allows for fluoroscopic visualization of TEE-derived anatomic landmarks. We compared transcatheter Paravalvular Leak (PVL) Closure using TEE / Truefusion versus TEE / FL guidance only. This prospective pilot

Enhanced Visualization of the Cervical Vertebra during Intraoperative Fluoroscopy Using a Shoulder Traction Device.

Study DesignA retrospective, matched cohort study of a prospective database.PurposeTo evaluate the efficacy and safety of the Cervision system (Spinologics, Montreal, Canada), a new shoulder traction device that improves the fluoroscopic visualization of the lower cervical spine using caudal traction of the shoulders out of the radiographic field.Overview of LiteratureOperating at a wrong level is a common error that may be committed by nearly 50% of surgeons during their career. Intraoperative fluoroscopy of the cervical vertebrae is an extremely important step in cervical spine surgery. Optimal lateral cervical radiography of the C1–T1 vertebrae is not always possible due to overlap of the shoulders.MethodsIn this study, a group of patients (n=33, device group) underwent surgery with the new device used to apply caudal traction to both shoulders, and another group of patients (n=33, matched control group) had surgery with the tape traction. Data about the lowest vertebra visible on lateral fluoroscopic view, installation time, skin irritation under the traction area, and postoperative brachial palsy were recorded, and these parameters were analyzed using the t-test.ResultsThe mean numbers of visible cervical vertebra were 6.3±0.41 in the device group and 5.6±0.32 in the matched control group (p <0.01, unpaired t-test). The mean installation times were 83.9±5.15 minutes in the device group and 73.7±6.32 minutes in the matched control group (p <0.02). Seven patients from the matched control group presented with skin irritation. However, none of the patients from the device group had the condition (p =0.005, Pearson chi-square test). Postoperative brachial palsy was not observed in both groups.ConclusionsThe Cervision system is more effective and superior to tape traction in pulling the shoulders down to improve the visualization of the cervical vertebra on lateral fluoroscopic view during cervical spine surgery.

Lumbar Radiofrequency Ablation: Procedural Technique.

Lumbar radiofrequency ablation is indicated for the treatment of chronic axial low back pain that is mediated by facet arthropathy which has failed more conservative treatment options. This article details proper equipment and medications, patient positioning and setup, step-by-step instructions for multiplanar fluoroscopic visualization, cannula placement, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A90) accompanies this paper.

4-Dimensional Transesophageal Echocardiographic Guidance During TAVR With BASILICA

BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction) is an emerging technique to avoid coronary obstruction during transcatheter aortic valve replacement (TAVR) ([1][1]). Although fluoroscopic visualization during BASILICA is

Capturing infant swallow impairment on videofluoroscopy: timing matters.

Infant videofluoroscopic swallow studies (VFSSs) require clinicians to make determinations about swallowing deficits based on a limited number of fluoroscopically observed swallows. Although airway protection is known to decline throughout a bottle-feed, the paucity of data regarding the timing of this degradation has limited the development of procedural protocols that maximize diagnostic validity. We tested the stability of key components of swallow physiology and airway protection at four standardized timepoints throughout the VFSS. Thirty bottle-fed infants with clinical signs of swallow dysfunction underwent VFSS. Fluoroscopy was turned on to allow visualization of five swallows at 0:00, 0:30, 1:30 and 2:30 (minutes:seconds [min:s]). We evaluated swallows for components of swallow physiology (oral bolus hold, initiation of pharyngeal swallow, timing of swallow initiation) and airway protection (penetration, aspiration). We used model-based linear contrasts to test differences in the percentage of swallows with low function component attributes. All components of swallow physiology exhibited a change throughout the VFSS (P≤0.0005). Changes were characterized by an increase in the number of sucks per swallow (P<0.0001), percentage of swallows with incomplete bolus hold (P=0.0005), delayed initiation of pharyngeal swallow (P<0.0001), delayed timing of swallow initiation (P=0.0004) and bolus airway entry (P<0.0001). These findings demonstrate that infants with dysphagia exhibit a change in swallow physiology throughout the videofluoroscopic swallow exam. Fluoroscopic visualization that is confined to the initial swallows of the bottle feed limit the exam's diagnostic validity. Developing evidence-based procedural guidelines for infant VFSS execution is crucial for maximizing the exam's diagnostic and treatment yield.

Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach.

ObjectiveSafe posterior column screw fixation via an anterior approach under two-dimensional fluoroscopic control.IndicationsAnterior column with posterior hemitransverse fractures (ACPHF); transverse fractures; two-column fractures and T‑type fractures without relevant residual displacement of the posterior column after reduction of the anterior column and the quadrilateral plate.ContraindicationAcetabular fractures requiring direct open reduction via a posterior approach; very narrow osseous corridor in preoperative planning; insufficient intraoperative fluoroscopic visualization of the anatomical landmarks.Surgical techniquePreoperative planning of the starting point and screw trajectory using a standard pelvic CT scan and a multiplanar reconstruction tool. Intraoperative fluoroscopically controlled identification of the starting point using the anterior–posterior (ap) view. Advancing the guidewire under fluoroscopic control using the lateral–oblique view. Lag screw fixation of the posterior column with cannulated screws.Postoperative managementPartial weight bearing as advised by the surgeon. Postoperative CT scan for the assessment of screw position and quality of reduction of the posterior column. Generally no implant removal.ResultsIn a series of 100 pelvic CT scans, the mean posterior angle of the ideal posterior column screw trajectory was 28.0° (range 11.1–46.2°) to the coronal plane and the mean medial angle was 21.6° (range 8.0–35.0°) to the sagittal plane. The maximum screw length was 106.3 mm (range 82.1–135.0 mm). Twelve patients were included in this study: 10 ACPHF and 2 transverse fractures. The residual maximum displacement of the posterior column fracture component in the postoperative CT scan was 1.4 mm (0–4 mm). There was one intraarticular screw penetration and one perforation of the cortical bone in the transition zone between the posterior column and the sciatic tuber without neurological impairment.

Preoperative planning and safe intraoperative placement of iliosacral screws under fluoroscopic control.

ObjectivePreoperative planning of the starting point and safe trajectory for iliosacral screw (SI screw) fixation using CT scans for safe and accurate fluoroscopically controlled percutaneous SI screw placement.IndicationsTransalar and transforaminal sacral fractures. SI joint disruptions and fracture-dislocations. Non- or minimally displaced spinopelvic dissociation injuries.ContraindicationsTransiliac instabilities. Sacral fractures with neurological impairment requiring decompression. Relevant residual displacement after closed reduction attempts. Insufficient fluoroscopic visualization of the anatomical landmarks of the upper sacrum.Surgical techniquePreoperative planning of the starting point and the safe screw trajectory using CT scans and two-dimensional multiplanar reformation tools. Fluoroscopically guided identification of the starting point using the lateral view according to preoperative planning. Advancing the guidewire under fluoroscopic control using inlet and outlet views according to the planned trajectory. Predrilling and placement of 6.5 mm cannulated screws.Postoperative managementWeightbearing as tolerated using crutches. Immediate CT scan in case of postoperative neurological impairment. Generally no screw removal.ResultsFifty-nine screws were placed in 34 patients using the described technique. There were 2 cases of screw malpositioning (anatomical landmarks inadequately identified and fluoroscopically controlled SI screw fixation should thus not have been performed at all; in a case with sacral dysmorphism, preoperative planning suggested a posterior and/or caudal S1 starting point, respectively, but intraoperatively, selection of a different starting point and screw trajectory resulted in screw malpositioning with iatrogenic L5 nerve palsy).

Chest Injury - Horseback Riding

Chest Injury - Horseback Riding Philipp J. Underwood, Bryan M. McCarty, Hillary Moss, North Shore University Hospital, Manhasset, NY HISTORY: A 56 year old female fell off of her horse, causing her to land on her right shoulder. She experience immediate severe pain in her right shoulder and chest. She denied any head, neck or spine injury or pain, and denied numbness, weakness, paresthesia or headache. She reported no shortness of breath, abdominal pain or extremity injury or pain. PHYSICAL EXAMINATION: The patient reported pain of 10/10 on arrival and had an elevated blood pressure. Other vital signs were normal. Primary survey was unremarkable. On secondary survey, head, neck and spine were normal. Ribs and abdomen were also normal. Examination of upper extremity revealed deformity of the right shoulder girdle with tenderness and swelling over the proximal right clavicle. The neuro-vascular exam of the upper extremities were normal and symmetrical. She was not able to move the right shoulder due to severe pain. The lower extremities were normal. Neurological examination was normal as was examination of the skin. DIFFERENTIAL DIAGNOSIS: 1.Clavicle fracture 2.Sterno-clavicular (SC) dislocation 3.Rib fracture 4.Pectoralis muscle tear TESTS AND RESULTS: Chest Xray, Clavicle Xray, Shoulder Xray - fracture medial right clavicle and possible dislocation of SC joint CT of Head and Cervical spine - unremarkable and without acute injury CT of Abdomen and Pelvis - unremarkable and without acute injury CT of Chest - fracture and posterior dislocation of the right SC joint with compression of the brachiocephalic artery and vein FINAL/WORKING DIAGNOSIS: Fracture and posterior dislocation of the right SC joint with compression of the brachiocephalic artery and vein TREATMENT AND OUTCOMES: 1.Evaluation by Trauma Surgery, Cardio-Thoracic Surgery with admission to Orthopedics for operative repair 2.Taken to OR and under general anesthesia and fluoroscopic visualization, reduction of SC dislocation 3.Reduction was unstable and ORIF performed with trans-osseous sutures and reconstruction of capsule 4.Discharged next day on Xarelto for 8 weeks and no weight bearing of right upper extremity 5.Physical therapy for 8 weeks begun 2 weeks post op. 6.Patient has returned to riding and experiences only minimal stiffness at right SC joint

Endoscopic Ultrasound Placement of Preloaded Fiducial Markers Shortens Procedure Time Compared to Back-Loaded Markers

Fiducial markers are inert radiopaque gold or carbon markers implanted in or near pancreatic tumor to demarcate areas for image-guided radiation therapy. Endoscopic ultrasound (EUS) pre-loaded fiducial needles (PLNs) have been developed to circumvent technical issues associated with traditional back-loaded fiducials (BLNs). We performed a randomized controlled trial to compare procedure times in patients with pancreatic adenocarcinoma undergoing EUS-guided placement of BLNs vs PLNs. In a prospective study, 44 patients with pancreatic adenocarcinoma referred for fiducial marker placement at 2 tertiary care centers were assigned to groups that received PLNs (n=22) or BLNs (n= 22); each group had the same proportion of patients with tumors of different locations (head or neck vs body or tail).The procedure was standardized among all endoscopists and placement of a minimum of 3 markers inside the tumor was defined as technical success. The times for procedure and fiducial placement were recorded, total number of fiducial markers used documented, and grade of procedure difficulty ranked by passing the needle or deploying the fiducials. Other recorded variables included tumor characteristics, fluoroscopy use, and the number of fiducials clearly seen by EUS and fluoroscopy. The primary aim was to compare the duration of EUS-guided fiducial insertion of BLNs vs PLNs. The median placement time was significantly shorter in the PLN group (9 min) than the BLN group (16 min) (P < .001). However, the 44% reduction in time did not reach pre-specified levels (≥60%). Similar results were found after stratifying by tumor location. Deployment of BLNs was easier than deployment of PLNs (P= .03). There was no significant difference between groups in technical success, number of fiducials placed, EUS or fluoroscopic visualization, or adverse events. During simulation computed tomography and image-guided radiation therapy, there was no difference between groups in visualization of fiducials, migration rate, or accuracy of placement. In a randomized controlled trial of 44 patients with pancreatic adenocarcinoma, we found EUS-guided placement of PLNs to require less time and produce similar results compared withBLNs. Further refinements in PLN delivery system are needed to increase the ease of deployment. Clinicaltrials.gov no: NCT02332863.

Abstract No. 531 Novel radiopaque Yttrium-90 glass microspheres in a porcine model: clinical potential for real-time targeting and dosimetry

Conventional Yttrium-90 (Y-90) microspheres for Radioembolization are not directly visible on X-ray fluoroscopy or computed tomography (CT) precluding microsphere visualization at administration. We investigate the use of novel radiopaque microspheres for real-time X-ray and CT confirmation of tissue targeting. Intra-procedural CT region of interest (ROI) quantification of microsphere radiopacity may be translated to absorbed dose, allowing for personalized therapy. 30 μm (mean) diameter, multi-component, non-irradiated Y-89 glass microspheres were injected through a .021” microcatheter into the segmental arteries of the right and left kidneys of a hybrid farm pig. Fluoroscopy at time of injection and static X-ray and Cone-beam CT (CBCT) after embolization were obtained. After sacrifice, kidneys were explanted and imaged using fan beam CT (FBCT) and co-registered to CBCT. Average Hounsfield Units (HU) and voxel enhancement ratio (VER) data were obtained and analyzed (ANOVA, p<0.01) from spherical ROI’s placed on embolized (n=1) and non-embolized tissue (n=3) for CBCT and FBCT respectively. Real-time fluoroscopic and static x-ray visualization of microsphere delivery was confirmed. Three embolized parenchymal (microvasculature) ROIs with CBCT had mean voxel values from 191 to 229 HU. Non-embolized CBCT ROI had a mean value of 68 HU with VER of 2.8-3.4. Three embolized FBCT mean voxel values ranged from 80 to 107 HU, non-embolized FBCT ROI had a mean value of 34 HU with 2.4-3.2 VER. Embolized tissue ROIs had significantly greater voxel values than the non-embolized ROI for both CBCT (p<0.001) and FBCT (p<0.001). 3-dimensional HU threshold map data demonstrate the potential for CT based absorbed dose microsphere quantification. Novel radiopaque Y-90 Glass Microspheres demonstrate real-time fluoroscopic and static X-ray visualization and significant increase in tissue CBCT and FBCT radiopacity relative to non-embolized tissue with potential for tumor targeting, assessment of microsphere distribution and absorbed dose quantification.Tabled 1Parenchymal Tissue ROICBCT Mean (HU)CBCT Standard DeviationFBCT Mean (HU)FBCT Standard DeviationNon-embolized ROI68153411Embolized ROI 1217299624Embolized ROI 22294810742Embolized ROI 3191258019 Open table in a new tab

03:54 PM Abstract No. 389 Iron particle coating of venous endothelium for in vivo fluoroscopic visualization and real-time biomechanical analysis

03:54 PM Abstract No. 389 Iron particle coating of venous endothelium for in vivo fluoroscopic visualization and real-time biomechanical analysis

Surgical Explantation of a Dehiscent Cardioband

The Cardioband (Edwards Lifesciences, Irvine, California) is a new mitral valve transcatheter annuloplasty device implanted transseptally on the beating heart under fluoroscopic and transesophageal echocardiographic visualization [(1–3)][1]. We report on a delayed Cardioband dehiscence. A 56-year

Refill Port Identification of Intrathecal Drug Delivery System Devices With a Raised Fill Port

The aim of this study was to assess the accuracy of the manual identification of the reservoir fill port (RFP) for refill of intrathecal drug delivery systems (IDDSs) with a raised RFP on the pump surface (raised-RFP-IDDSs), and compare this to previously reported data of patients with IDDSs with a recessed RFP (recessed-RFP-IDDSs). Nineteen patients underwent 2 IDDS refills for the treatment of noncancer pain or spasticity. The primary endpoint of this prospective observational study was the deviation between the needle insertion point and the RFP center, quantified by fluoroscopic visualization. A distance surpassing that between the center and the margin of the RFP of 4mm was considered a clinically relevant deviation. The results were compared with previously reported data of a patient cohort with recessed-RFP-IDDSs, and the differences were tested using Student's t-test. The mean deviation from the RFP center was 4.9mm (standard deviation=3.7). The RFP identification accuracy deviated more than the clinically relevant difference in 17 out of 35 instances (48.6%). The number of attempts and median procedural time was significantly correlated to the needle deviation. The mean deviations in the raised-RFP-IDDS cohort were consistently lower compared to the recessed-RFP-IDDS cohort (first refill procedure 4.0 vs. 8.5, P<0.001; second procedure 5.9 vs. 8.1, P=0.074). The results of this study suggest that the manual localization of the RFP for raised-RFP-IDDSs is moderately accurate, and more accurate if compared to previously published accuracy of the template-guided technique for recessed-RFP-IDDSs.

Usefulness of Electroanatomical Mapping with Contact Force Monitoring for Accessory Pathways Ablation in Pediatric Population.

The current approach for catheter ablation (CA) of accessory pathways (AP) includes the use of standard catheters under fluoroscopic visualization. We hypothesize that use of contact force (CF) irrigated tip catheters might increase procedural safety in pediatric patients compared to standard irrigated tip catheters, by decreasing the number of radiofrequency (RF) pulses required to obtain AP elimination. Seventy-one pediatric patients (13.7 ± 2.5years, 45 male) with ventricular pre-excitation were enrolled in the study. CA was performed with a standard irrigated tip catheter up to June 2013 in 41 patients (Group S) and with a CF sensing irrigated tip catheter later on in 30 patients (Group CF). In the Group CF, RF was applied with a minimal CF of 5g; CF > 35g was avoided. Group CF procedures required less fluoroscopy (6.8 ± 4.8min), compared to Group S (12.2 ± 10.8min, p = 0.007). The number of RF pulses was smaller in Group CF compared to Group S (2.5 ± 2.0 vs 5.5 ± 1.9, p < 0.01). The mean CF during the effective RF pulse was 18 ± 7.7g, force-time integral was 1040.7 ± 955.9gs, Ablation Index was 513.0 ± 214.2. The procedure was acutely successful in 70 patients; at 12months follow-up 2 patients had AP recurrence, one for each group. No major complications were reported. The use of CF irrigated tip catheters was associated with a smaller number of RF pulses and less fluoroscopy, as compared to mapping and ablation with standard irrigated tip catheters.

Adhesive capsulitis: review of imaging findings, pathophysiology, clinical presentation, and treatment options.

Adhesive capsulitis, commonly referred to as "frozen shoulder," is a debilitating condition characterized by progressive pain and limited range of motion about the glenohumeral joint. It is a condition that typically affects middle-aged women, with some evidence for an association with endocrinological, rheumatological, and autoimmune disease states. Management tends to be conservative, as most cases resolve spontaneously, although a subset of patients progress to permanent disability. Conventional arthrographic findings include decreased capsular distension and volume of the axillary recess when compared with the normal glenohumeral joint, in spite of the fact that fluoroscopic visualization alone is rarely carried out today in favor of magnetic resonance imaging (MRI). MRI and MR arthrography (MRA) have, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening of the coracohumeral ligament, axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle. Additional findings include T2 signal hyperintensity and post-contrast enhancement of the joint capsule. Similar changes are observable on ultrasound. However, the use of ultrasound is most clearly established for image-guided injection therapy. More aggressive therapies, including arthroscopic release and open capsulotomy, may be indicated for refractory disease, with arthroscopic procedures favored because of their less invasive nature and relatively high success rate.

A NOVEL ENDOBRONCHIAL FLUOROSCOPIC NAVIGATION AND LOCALIZATION SYSTEM: A SUMMARY OF A MULTICENTER LUNGVISION TRIAL

A NOVEL ENDOBRONCHIAL FLUOROSCOPIC NAVIGATION AND LOCALIZATION SYSTEM: A SUMMARY OF A MULTICENTER LUNGVISION TRIAL

Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injection

Fluoroscopically guided lumbar transforaminal epidural steroid injections are indicated for the treatment of lumbar radicular pain that has failed more conservative options. This article details proper equipment and medications, patient positioning and set-up, step-by-step instructions for multiplanar fluoroscopic visualization, needle advancement and medication instillation, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper.

Invivo evaluation of the new PHIL low viscosity in a swine rete mirabile model.

Few liquid embolic materials are available for treatment of arteriovenous malformations. We describe the invivo experience with the new PHIL low viscosity (LV) liquid embolic agent in a swine rete mirabile model. Eight swine were treated. Two animals underwent embolization of a rete with PHIL LV and the contralateral rete with Squid 12 (euthanized the same day). Six animals underwent embolization of the right rete: two with balloon flow arrest (euthanized at 14 d) and four with a microcatheter alone (euthanized at 14 and 90 d). Performance characteristics of the embolic agents were evaluated. Microscopic and histological analysis of the harvested retia was performed. Macroscopic examinations and high contrast digital-based radiographs of the central nervous system were obtained. We did not experience any technical complication during embolization of each rete. Overall occlusion ability, on/off injection and ease to retrieve the microcatheter/balloon with PHIL LV were optimal. Fluoroscopic visualization of the PHIL LV cast was adequate to optimal. Average embolization time with flow arrest was 9.5 min versus 19.5 min with microcatheter plugging. Embolizations with PHIL LV required less volume and were shorter when compared to Squid 12. Subacute (14 d) and chronic (90 d) microscopic and histological analysis demonstrated minimal inflammatory changes in the perivascular tissues and permanent occlusion of the embolized vasculature. In this swine rete model, the new PHIL LV embolic agent had an excellent embolization performance. Vessels embolized remained occluded up to 90 d from the procedure with minimal inflammatory changes.

Improving Fluoroscopic Visualization for Lower Cervical Medial Branch Blocks with a Modified Swimmer’s View: A Technical Report

Neural blockade of the cervical medial branches is a validated procedure in the diagnosis and treatment of cervical zygapophyseal joint pain. Fluoroscopic visualization of the lower cervical medial branch target zones (CMBTZs) in lateral view is sometimes challenging or not possible due to the patient's shoulders obscuring the target. Large shoulders and short necks often exacerbate the problem. Clear visualization is critical to accuracy and safety. We aim to describe a method for optimal fluoroscopic visualization of the lower CMBTZs using a modified swimmer's view. A technical report. A private practice. Discussion with accompanying fluoroscopic images of the cervical spine, focusing on the lateral aspects of the lower cervical articular pillars in both the traditional lateral view and modified swimmer's view. Four authors served as volunteers for undergoing fluoroscopic x-rays in both views. Visualization of each lower CMBTZ was attempted and stored. The most caudal, clearly visualized levels were compared in both views for each participant. Visualization of the lower CMBTZs can be successfully obtained with the modified swimmer's view and in select patients is superior to a lateral view. A limitation to this study is the design as a technical report. A future prospective study is warranted. Modified swimmer's view can serve as a primary method of visualizing the lower CMBTZs or an alternate view when a lateral view is unable to clearly demonstrate target landmarks. This can improve the ease, accuracy, and safety of performing diagnostic cervical medial branch blocks (CMBBs). Swimmer's view, cervical medial branch block, facet joint, fluoroscopy.

Real-Time 3D Virtual Target Fluoroscopic Display for Challenging Hepatocellular Carcinoma Ablations Using Cone Beam CT.

Three-dimensional virtual target fluoroscopic display is a new guidance tool that can facilitate challenging percutaneous ablation. The purpose of this study was to assess the feasibility, local efficacy, and safety of liver ablation assisted by three-dimensional virtual target fluoroscopic display. Sixty-seven hepatocellular carcinomas (mean diameter: 31 mm, range: 9-90 mm, 24 ≥ 30 mm, 16 of an infiltrative form) in 53 consecutive patients were ablated using irreversible electroporation (n = 39), multibipolar radiofrequency (n = 25), or microwave (n = 3) under a combination of ultrasound and three-dimensional virtual target fluoroscopic display guidance because the procedures were considered to be unfeasible under ultrasound alone. This guidance technology consisted of real-time fluoroscopic three-dimensional visualization of the tumor previously segmented from cone beam computed tomography images acquired at the start of the procedure. The results were assessed by cross-sectional imaging performed at 1 month and then every 3 months in the event of complete ablation. Factors associated with overall local tumor progression (initial treatment failure and subsequent local tumor progression) were assessed using a logistic regression model. Sixty-one (91%) tumors were completely ablated after 1 (n = 53) or 2 (n = 8) procedures. After a median follow-up of 12.75 months (1-23.2) of the 61 tumors displaying imaging characteristics consistent with complete ablation at 1 month, local tumor progression was observed in 9, so the overall local tumor progression rate was 22.3% (15 of 67). Under multivariate analysis, dome locations and infiltrative forms were associated with local tumor progression. No major complications occurred. Three-dimensional virtual target fluoroscopic display is a feasible and efficient image guidance tool to facilitate challenging ablations that are generally considered as infeasible using ultrasound alone.