Ultrasound Guidance Research Articles

Comparative Evaluation of Intra-articular Ozone and Steroid Treatments in Patients with Coxarthrosis under Ultrasound Guidance: A Retrospective Study

Introduction: Osteoarthritis (OA) is the most common degenerative joint disease characterised by the loss of articular cartilage and synovial inflammation. This condition causes stiffness and swelling in the joint, as well as pain, loss of movement and disability. When performed under Ultrasound Guidance (USG), steroid treatments offer several advantages. On the other hand, ozone therapy accelerates anabolic mechanisms, provides vascularisation of cartilage and bone, and slows down the degenerative process. Additionally, it affects inhibitory cytokines, antioxidant enzymes, and neoangiogenesis. Aim: To evaluate and compare the effectiveness of USG intra-articular ozone therapy versus corticosteroid injections in managing hip OA (coxarthrosis) in patients who have not responded to conventional treatments. Materials and Methods: A retrospective comparative study was conducted at Ankara Training and Research Hospital, Ankara, Altındag, Turkey, from August 2021 to August 2022. Patients unresponsive to conventional treatments were divided into two groups: Group A (n=30) received intra-articular steroid (triamcinolone acetonide), and Group B (n=23) received three weekly ozone sessions (200 μg/20 mL), both under USG. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Harris Hip Score (HHS) for functional status, both pre- and post-treatment. Monthly analgesic use was monitored before treatment and at the 1st week, 1st month, 3rd month and 6th month. Statistical analysis were conducted using Unpaired t-tests and Chi-square tests. A p-value <0.05 was considered statistically significant. Results: A total of 53 patients (mean age 63.23±10.50 years) participated in the study. Analgesic needs decreased in both groups, with no significant differences observed in the 1st week, 1st month, 3rd month, and 6th month (p-value=0.139, p-value=0.724, p-value=0.391, p-value=0.546). The most notable improvement occurred one month post-treatment, particularly in low-stage coxarthrosis. Increases in HHS scores and decreases in VAS values for stages 2-3 were statistically significant in both groups (p-value <0.001). Conclusion: The effectiveness of steroid and ozone therapy for coxarthrosis varies by disease stage. Both treatments are more effective in the early stages, while ozone is ineffective and steroids offer limited benefits in advanced stages. Thus, treatment planning should consider the disease stage, and alternative strategies should be explored for advanced cases. Clinicians should prioritise early intervention and seek alternative options for better patient outcomes.

5: Single centre experience of Neonatal multisite VV ECMO - Intensivist led percutaneous cannulation with ultrasound guidance at the bedside.

5: Single centre experience of Neonatal multisite VV ECMO - Intensivist led percutaneous cannulation with ultrasound guidance at the bedside.

Ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks: A cadaveric observational study and a clinical randomized controlled trial.

We developed an innovative method for ultrasound-assisted thoracic epidural catheter placement and assessed its potential to reduce procedural duration for trainees. A cadaveric observational study and a clinical randomized controlled trial. Sapporo Medical University Hospital. A total of 52 adult patients scheduled for thoracic or abdominal surgery and four cadavers. Patients were randomly assigned to either group receiving conventional palpation (conventional group) or combination of the ultrasound examination and conventional palpation (ultrasound group). The primary outcome was total procedure time (sum of skin marking time and needling time) by trainees. The secondary outcomes were (1) skin marking time, (2) needling time, (3) multiple skin punctures, (4) needle redirection, (5) complications, and (6) failed cases. Through dissection of four cadavers, the most dorsal site of the transverse process root was identifiable by ultrasound and the reliable indicator of the interlaminar space. We devised ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks. Trainees in the ultrasound group had significantly longer skin marking time and significantly shorter needling time than those in the conventional group (107 [87-158] vs 46s [34-54] s, p<0.001 and 197 [156-328] vs 341 [303-488] s, p=0.003). Consequently, there was no significant difference between the two groups in total procedure time (326 [263-467] s vs 391 [354-533] s, p=0.167). Moreover, the probability of trainee failure in epidural anesthesia was significantly lower in the ultrasound group (2/26 [17.7%] vs 10/26 [38.5%], p=0.019). Our novel technique for thoracic epidural catheter placement resulted in expedited needling and enhanced success rates among trainees, although there was no significant difference between total procedure time when using ultrasound guidance and that when using conventional palpation.

Effect of needle size on outcomes of vacuum-assisted excision of breast lesions. A randomized controlled trial.

Utilizing a larger needle-size instead of a smaller one in vacuum-assisted excision of breast lesions might enhance the effectiveness of the method. We conducted a clinical trial to investigate the effects of needle size 7G compared to 10G regarding excision completeness and procedural efficiency. In this prospective, single-blinded, randomized clinical trial, the patients were enrolled between November 2019 and August 2022. Follow-up examinations were performed at 6 and 24months after the procedure. In total, 208 patients were screened and enrolled, and following withdrawal of consent, the trial population comprised 194 patients. All patients with ultrasound-visible lesions of <30mm in size and biopsy confirmation corresponding to a B2 or B3 lesion were included in the study. Additionally, patients with BI-RADS 3 and 4a microcalcifications measuring <15mm were also eligible. Eighty-five percent of the patients attended the 6-month follow-up, and 65% attended the 24-month follow-up. There were no significant difference between the two randomization arms in terms of age, and lesion size. The mean procedure time was 7.7min and 8.5min for 7G and 10G needle size, respectively (=0.126). Of the 164 patients who attended the 6-month follow-up, no remaining lesions were found in 90% and 81.5% (p=0.109) patients for 7G and 10G needle size respectively. Thirty percent (6/20) of the patients with microcalcifications excised stereotactically, guided by mammography, had a residual lesion compared to 2.5% (1/42) of the patients with intraductal lesions excised under ultrasound guidance. Using a 10G compared to a 7G needle size resulted in no difference in procedure time or excision completeness. Among the analyzed parameters, only a larger lesion size was consistently associated with a longer procedure time and a higher risk of incomplete excision.

Guidelines for Performing Ultrasound-Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography.

Vascular access is a commonly performed procedure to facilitate patient care. This document provides expert consensus from diverse specialists on best practices and techniques for incorporating ultrasound (US) into vascular access procedures. This update replaces the 2011 American Society of Echocardiography guidelines for US-guided vascular cannulation. It includes recommendations for US-guided access to central and peripheral veins and arteries in adult and pediatric patients based on the strength of the scientific evidence present in the literature. The major roles of US during vascular access include (1) precannulation vessel assessment, (2)dynamic US guidance during cannulation, and (3) identification of local complications. This document discusses the general aspects of anatomic and US imaging of vessels, US-guided vascular cannulation techniques, and the identification of local vascular cannulation complications. Proper training should impart the cognitive knowledge and technical skills necessary to perform US-guided cannulation. There is an increasing body of literature indicating that US-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak. A gap remains between the existing evidence and guidelines for the use of US in clinical practice. The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies.

Fractional flow reserve- and intravascular ultrasound-guided strategies for intermediate coronary stenosis and low lesion complexity in patients with or without diabetes: a post hoc analysis of the randomised FLAVOUR trial.

A recent randomised trial demonstrated fractional flow reserve (FFR) guidance for percutaneous coronary intervention (PCI) was non-inferior to intravascular ultrasound (IVUS) guidance regarding clinical outcomes, with a lower frequency of PCI. We sought to evaluate the prognosis of FFR versus IVUS guidance for PCI of intermediate coronary artery stenosis and low lesion complexity in diabetic and non-diabetic patients. This study is a prespecified post hoc analysis from the FLAVOUR trial. The primary outcome was major adverse cardiac events (MACE) at 24 months, defined as a composite of death, myocardial infarction or any revascularisation. The secondary outcomes were target vessel failure (TVF) and each component of MACE and TVF at 24 months. Among 1,682 randomly assigned patients, 554 (32.9%) had diabetes, and the mean SYNTAX score was 8.64±6.03 at baseline. The FFR group had a lower PCI rate than the IVUS group in both diabetic (48.2% vs 69.1%; p<0.001) and non-diabetic (42.6% vs 63.3%; p<0.001) patients. At 24 months, there was no difference in the cumulative incidence of MACE between the FFR and the IVUS groups in either diabetic (9.3% vs 8.3%; p=0.90) or non-diabetic (7.5% vs 8.6%; p=0.50) patients. The cumulative incidence of TVF was also comparable between the FFR and the IVUS groups regardless of diabetic status. In patients with intermediate coronary stenosis and low lesion complexity, regardless of diabetic status, FFR guidance had no significant differences in MACE or TVF with a lower frequency of PCI compared with IVUS guidance.

Comparison of percutaneous liver aspiration biopsy and tru-cut biopsy results

Aims: The aim of this study was to compare the diagnostic rates, complications and histopathologic diagnoses of aspiration biopsy and tru-cut biopsy procedures in liver parenchyma and to reveal the differences between the technical methods. Methods: Patients who underwent liver parenchymal biopsy in our hospital were identified. While tru-cut biopsy needle was used in the radiology department, aspiration biopsy needle was used in the gastroenterology department. Patients who underwent parenchymal biopsy were included in the study, while lesion biopsies were excluded. Indications for biopsy, presence of hepatitis, type of biopsy needle, number of times, size of biopsy material, pathologic diagnosis and complications after biopsy were evaluated. Results: Of the 113 patients who underwent liver biopsy, 74 were male (mean age 40.38.±17.37 years) and 39 were female (mean age 45.49±15.85 years). Among the patients who underwent liver biopsy, tru-cut biopsy needle was used in 46 patients, while aspiration biopsy needle was used in 67 patients. The biopsy size and number of pieces were statistically significantly higher in aspiration biopsy compared to tru-cut biopsy. There was no difference between the two biopsies in terms of diagnosis rate, complication development, fibrosis staging and score. Conclusion: Percutaneous aspiration and tru-cut biopsies are reliable diagnostic methods with high diagnostic rates and low complication rates. The fact that biopsy is performed by experienced hands, under US guidance, and the number of biopsies is limited reduces the development of complications.

Comparison of Procedural Techniques and Variables in Patients Undergoing Arterial Cannulation

Background: This study presents a comprehensive comparative analysis of two methods for arterial cannulation, palpation, and ultrasound guidance (USG), using a sample of 104 subjects for each method. Methods: The primary objective was to evaluate the safety and efficiency of these techniques. Clinical and laboratory parameters were recorded, including hemoglobin levels, platelet count, International Normalized Ratio (INR), albumin, and total protein levels. The number of attempts and total procedure time were documented for each procedure. Additionally, the ultrasound-guided (USG) method and the duration of each recorded procedure were emphasized to provide a detailed comparison between the two techniques. Results: USG required fewer attempts than palpation (1.63 ± 0.83 vs. 2.36 ± 1.18, p

Chronic Exertional Compartment Syndrome in the Forearm: Ultrasound-Guided surgical technique.

Chronic exertional compartment syndrome of the forearm is most commonly associated with exercise. It presents as cramping after a few minutes of activity, requiring cessation of exercise. We describe an ultrasound-guided surgical technique for the treatment of forearm chronic exertional compartment syndrome. The forearm consists of three compartments: the anterior, lateral, and dorsal compartments. These compartments are formed by the muscles of the forearm and are surrounded by a fibroelastic membrane composed of connective tissue. Repetitive activity in the forearm leads to an increase in muscle volume within a non-extensible compartment. This increase in pressure causes pain and cramping, forcing the individual to stop the activity. Diagnosis is based on measurement of intramuscular compartment pressures. Surgical treatment involves performing a fasciotomy. This can be done through an incision along the length of the forearm or through a minimally invasive approach using endoscopic or ultrasound guidance. The ultrasound-guided technique uses two small entry points and a specialized knife. No post-operative immobilization is required, allowing patients to quickly resume their activities. Chronic exertional compartment syndrome of the forearm is a condition that is particularly common among motorcyclists. Diagnosis is based on a combination of a suggestive clinical presentation and pathological intramuscular pressure. Treatment may be conservative or surgical (fasciotomy). Fasciotomy can be performed using an open approach or a minimally invasive ultrasound-guided technique. Published studies on ultrasound-guided treatment report excellent results with a rapid return to sports activities after surgery.

Multidisciplinary Management of Acute Tetraparesis in an Infant with Achondroplasia, with a Focus on Anesthetic Strategies: A Case Report

Background/Objectives: This report details a rare instance of an infant with achondroplasia developing acute tetraparesis after a cervical whiplash injury, highlighting key multidisciplinary management considerations and specific anesthetic strategies to mitigate potential risks. Case presentation: A 1-year-old boy with achondroplasia presented with acute tetraparesis after a whiplash injury. Initial craniocervical computed tomography demonstrated a reduced volume of the posterior fossa, foramen magnum stenosis, and ventriculomegaly, without any fractures or dislocations. Moreover, magnetic resonance imaging (MRI) revealed pathological signal changes in the medulla oblongata, cervical spinal cord in segments C1 and C2, and the posterior atlantoaxial ligament. After initial conservative therapy and head immobilization using a soft cervical collar, partial remission of the tetraparesis was achieved. Two weeks post-injury, microsurgical posterior fossa decompression extending to the foramen magnum and C1 laminectomy was performed under general anesthesia with intraoperative neuromonitoring. Following an unsuccessful intubation attempt using a fiberoptic bronchoscope, successful airway management was achieved using a combined technique incorporating video laryngoscopy. Venous access was secured under ultrasound guidance. The patient exhibited complete remission of neurological symptoms by the third postoperative month during follow-up. Conclusions: This case report underscores the crucial need for a multidisciplinary approach in managing children with achondroplasia, especially with foramen magnum stenosis and complex cervical spine injuries. Anesthetic management required meticulously planned airway strategies using advanced techniques like video laryngoscopy and fiberoptic bronchoscopy to reduce airway risks. It also highlights the importance of conservative therapy paired with timely neurosurgical intervention, resulting in the patient’s full recovery.

Preoperative Ultrasound Correctly Localized Peripheral Nerve Abnormalities for Operative Guidance: A Retrospective Review.

Correct localization and characterization of nerve abnormality is of critical importance to appropriate intervention. Ultrasound (US) is known to be accurate in the diagnosis of peripheral neuropathy and in preoperative localization of nerve abnormalities and skin marking. We sought to investigate the utility of US-guided preoperative skin marking for the localization of peripheral nerve abnormality and to compare the US findings to electrodiagnostic (EDx) reports. Using the radiology information system at a single institution, we identified US examinations performed for preoperative localization of peripheral nerve abnormality from July 2016 to March 2023. Data collected included US characterization, surgical description, and EDx report of neuropathy. Search parameters identified 67 nerves in 55 patients treated surgically after US-guided localization of the nerve with skin marking. The EDx characterization was performed in 36 (54%) of these cases. The US diagnoses included neuroma, transection, perineural scarring, hardware impingement, and intraneural fascicular constriction. There was 100% accuracy of US findings as confirmed by operative notes. Skin marking by US guidance correlated to the sites of the nerve documented in operative reports of all 67 cases. In this single-institution retrospective review, US-guided preoperative skin marking of nerve abnormality was used to correctly localize peripheral nerve abnormality, and US diagnoses were corroborated by intraoperative findings. Further higher-level study is needed to support these findings suggesting the efficacy of US in mapping the course of peripheral nerves.

Metastatic papillary thyroid carcinoma with internal jugular vein tumor thrombus - A case report and review of the literature

Papillary thyroid carcinoma (PTC) is the most common malignancy of the thyroid gland, typically associated with an indolent course and favourable prognosis. However, although rare, PTC can demonstrate aggressive behaviour, including vascular invasion with extension into major vessels. Intraluminal tumor thrombus involving the great veins, such as the internal jugular vein (IJV), is an uncommon but significant complication. We present the case of a 56-year-old male who was referred to our clinic for evaluation of a right-sided anterior neck mass. Neck ultrasonography revealed a 5.5 x 6.5 cm heterogeneous mass within the right thyroid lobe and a suspected intraluminal thrombus in the right internal jugular vein. Fine-needle aspiration biopsy under ultrasound guidance confirmed the diagnosis of papillary thyroid carcinoma. Subsequent preoperative contrast-enhanced computed tomography (CT) of the neck confirmed the presence of an intraluminal tumours thrombus extending into the right IJV. The patient underwent total thyroidectomy, right modified radical neck dissection, and resection of the involved segment of the IJV. Postoperatively, the patient received radioactive iodine (I-131) ablation therapy. At the one-year follow-up, imaging studies indicated a recurrence of the disease. A review of the literature focusing on vascular involvement in PTC and diagnostic methods for tumours thrombus reveals that, while rare, intraluminal tumor thrombus should be considered in patients with PTC, especially when there is evidence of vascular invasion. Early and accurate preoperative diagnosis using Doppler ultrasonography and/or contrast-enhanced CT is critical for optimal surgical planning and improved prognosis. Given the potential for recurrence, vigilant long-term follow-up is recommended.

Waveform characteristics in thoracic paravertebral space: a prospective observational study

Background With increased use of thoracic paravertebral block (TPVB) in thoracic surgery, many faced the challenge of locating the thoracic paravertebral space (TPVS) ultrasonographically. This observational study aimed to investigate the waveform characteristics and pressure value within the TPVS in anaesthetized patients with controlled ventilation. Methods 50 patients scheduled for elective lung surgery were enrolled. After conduction of anesthesia, all patients underwent TPVB at T4/5 and T6/7 using transverse, in-plane ultrasound guidance. A pressure transducer system with a desktop monitor was connected to the needle hub to measure pressure values and waveform characteristics in three locations: the paraspinal muscles, immediately behind the superior costotransverse ligament, and within the TPVS. Next, 15 mL of 0.33% bupivacaine was injected into each desired TPVS. After completion of the surgery, the extent of dermatomal blockade and the pain score was assessed in all patients. Results 98 typical regular respiratory waveforms with a mean pressure of ≤ 25 mmHg were detected in the TPVS of 50 patients. The sensitivity of the combined ultrasound and pressure waveform measurement technique to identify the TPVS was 95.45% (95% confidence interval, 84.527–99.445). Nontypical respiratory waveforms were present in two patients. Factors interfering with the TPVS waveform characteristics were previous thoracic surgery. Conclusion The TPVS had low pressure and showed a smooth, regular waveform pattern corresponding to respiration.

First-Attempt Success in Ultrasound-Guided vs Standard Peripheral Intravenous Catheter Insertion

Pediatric peripheral intravenous catheter (PIVC) insertion can be difficult and time-consuming, frequently requiring multiple insertion attempts and often resulting in increased anxiety, distress, and treatment avoidance among children and their families. Ultrasound-guided PIVC insertion is a superior alternative to standard technique (palpation and visualization) in high-risk patients. To compare first-time insertion success of PIVCs inserted with ultrasound guidance compared with standard technique (palpation and visualization) across all risk categories in the general pediatric hospital population. An open-label, pragmatic, superiority, randomized clinical trial was conducted in an Australian quaternary pediatric hospital. Children (ages 0-18 years) requiring PIVC insertion were included between July 2021 and December 2022. One catheter was studied per patient, and analysis was by intention to treat. Data analysis was performed from April to October 2023. Eligible children were randomly assigned (1:1 using computer-generated randomization and concealed allocation) to receive ultrasound-guided or standard PIVC insertion. Randomization was stratified by insertion difficulty (low, medium, or high risk) defined using a standardized tool. The primary outcome was first-time insertion success. Secondary outcomes included number of insertion attempts, insertion failure, postinsertion complications, dwell time, patient and parent satisfaction, and health care costs. A total of 164 children were randomly assigned to ultrasound-guided insertion (n = 84) or standard care (n = 80), with 81 (96.4%) and 78 (97.5%) receiving their allocated intervention, respectively. The median (IQR) age was 24 (10-120) months, and 93 children (56.7%) were male. First-time insertion success was higher with ultrasound-guided PIVC insertion (72 children [85.7%]) compared with standard technique (26 children [32.5%]) (risk difference [RD], 53.6%; 95% CI, 41.7%-65.4%; P < .001). Ultrasound-guided insertion led to significantly greater first-time insertion success across all risk categories, with the following RDs: low risk, 30.8% (95% CI, 8.1%-53.5%); medium risk, 56.2% (95% CI, 37.1%-75.3%); and high risk, 69.6% (95% CI, 52.3%-87.0%). Ultrasound-guided PIVC insertion had higher immediate health care costs (between group difference in total mean cost per person, A$9.33; 95% credible interval, A$8.83-A$10.86 [US $5.83; 95% credible interval, $5.52-$6.78]). These findings suggest that ultrasound-guided PIVC insertion improves first-time insertion success across all risk categories in pediatrics, supporting the widespread adoption of ultrasound-guided PIVC insertion in children. anzctr.org.au Identifier: ACTRN12621000206820.

Abstract B001: Double targeted therapy PSCA-CAR-T cells and PSMA-radioligand in metastatic castration-resistant prostate cancer

Abstract Targeted radioligand therapy (PSMA-RLT) extends survival in advanced castration-resistant prostate cancer (CRPC) (Sartor et al., 2021), yet half of patients experiences limited responses or relapse with additional metastases (Stuparu et al., 2020). Given that metastatic CRPC has a tumor environment lacking immune infiltration and resisting immune checkpoint therapies, combination strategies that actively bring immune cells into the tumor are urgently needed (Choudhury et al., 2024). Prostate stem cell antigen (PSCA) is another promising target, as it is frequently overexpressed in advanced CRPC. PSCA-CAR-T cells, engineered to specifically attack PSCA-expressing tumors, may complement PSMA-RLT by overcoming immune resistance (Dorff et al., 2024; Murad et al., 2021). This study explores the therapeutic potential of combining PSMA-RLT with PSCA-CAR-T cells to strengthen immune response and increase response rates and survival. For this reasons, PC3-PIP human metastatic prostate cancer cells expressing PSMA were transfected to express human PSCA. PSMA and PSCA expression was confirmed by flow cytometry. Double positive PSMA-PSCA cells were inoculated by intracardiac injection in NSG mice under ultrasound guidance. Tumor progression was followed up twice a week by bioluminescence imaging. Mice were randomized before treatment into 5 groups: (1) Control NT (2) 225Ac-PSMA-617 (15 kBq) alone (3) CAR-T (0.2 x 106 cells) alone (4) Combo 225Ac-PSMA-617 (15 kBq) + CAR-T (0.2 x 106 cells) (day 4 post-RLT) (5) Combo 225Ac-PSMA-617 (15 kBq) + CAR-T (0.2 x 106 cells) (day 6 post-RLT). 4 mice per group were used to determine blood toxicity of RLT and 8 mice in each group were followed up until the end point for efficacy study. No blood toxicity related to RLT was observed in treated mice. Compared to control group, the Combo 225Ac-PSMA-617 and PSCA-CAR-T demonstrated a synergistic effect with a significant delay in tumor growth. Comparison between 68Ga-PSMA-11 PET and bioluminescence imaging showed heterogenous localization in 3 mice randomized to Combo groups and CAR-T alone group. In conclusion, our study shows promising results from combining PSMA-RLT with PSCA-CAR-T cell therapy. In a dual prostate cancer expressing in vivo model (PC3-PIP PSMA-PSCA), we observed a delay in tumor growth. However, the increase of survival rates in combo groups compared to CAR-T alone was limited. Additional studies are required to improve overall survival. Thus, we plan to extend our study to test the combination of PSCA-CAR-T with PluvictoTM, a recent FDA approved theranostics agent for metastatic CRPC (Hennrich &amp; Eder, 2022). Moreover, we will modify the expression of PSCA to mimic the heterogeneity expression observed in patients, to validate the performance of the combination. Citation Format: Iveta Fajnorova, Pauline Jeanjean, Ines Camille Azrour, Ava Fakharpour, Venna Jiangyue Liu, Johannes Czernin, Caius Radu, Saul Priceman, Christine Mona. Double targeted therapy PSCA-CAR-T cells and PSMA-radioligand in metastatic castration-resistant prostate cancer. [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Translating Targeted Therapies in Combination with Radiotherapy; 2025 Jan 26-29; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(2_Suppl):Abstract nr B001.

A Comparison of the Efficacy and Safety of US-, CT-, and MR-Guided Radiofrequency and Microwave Ablation for HCC: A Systematic Review and Network Meta-Analysis

Objectives: The aim of this study was to compare the efficacy and safety of thermal ablation, focusing on radiofrequency ablation (RFA) and microwave ablation (MWA), for hepatocellular carcinoma (HCC) using US-, CT-, and MR-guidance. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched for studies comparing US, CT, and MR guidance in thermal ablation for HCC. Observational studies and randomized controlled trials (RCTs) were included. Overall survival (OS), local tumor recurrence (LTR), primary technique effectiveness (PTE), and major complications were assessed with network meta-analysis. Results: One RCT and 13 retrospective cohort studies reporting on 2349 patients were included. For OS at 3 years, compared to CT, US had hazard ratios (HRs) of 0.98 (95%CI: 0.77–1.26), and MR had HRs of 1.60 (95%CI: 0.51–5.00); For OS at 5 years, US had HRs of 0.80 (95%CI: 0.64–1.01), and MR had HRs of 1.23 (95%CI: 0.52–2.95) compared to CT. LTR rates, PTE, and major complications did not show statistical significance among the three guidance modalities (LTR: RR = 0.29 (95%CI: 0.08–1.14), p = 0.97 MR vs. CT; RR = 0.25 (95%CI: 0.06–1.02), p = 0.97 MR vs. US; PTE: RR = 1.06 (95%CI: 0.96–1.17), p = 0.90 MR vs. CT; RR = 1.08 (95%CI: 0.98–1.20), p = 0.90 MR vs. US. Major complications: RR = 0.27 (95%CI: 0.13–0.59), p = 0.94 MR vs. CT; RR = 0.41 (95%CI: 0.10–1.74), p = 0.94 MR vs. US). Conclusions: CT-, US-, and MR-guided RFA and MWA are equally effective and safe for HCC patients.

Calibration correction to improve registration during cone-beam CT guided histotripsy.

Histotripsy is a non-invasive, non-ionizing, non-thermal focused ultrasound technique. High amplitude short acoustic pulses converge to create high negative pressures that cavitate endogenous gas into a bubble cloud leading to mechanical tissue destruction. In the United States, histotripsy is approved to treat liver tumors under diagnostic ultrasound guidance but in initial clinical cases, some areas of the liver have not been treated due to bone or gas obstructing the acoustic window for targeting. To address this limitation in visualization, cone-beam computed tomography (CBCT) guided histotripsy was developed to expand the number of tumors and patients that can be treated with histotripsy. The purpose of this work is to improve the accuracy of CBCT guided histotripsy by calibrating the therapeutic bubble cloud location relative to the histotripsy robot arm. The calibration correction involves creating a bubble cloud sized treatment (a few mm) in an agar-based phantom consisting of 11 layers with alternating high and low x-ray attenuation. The layers were spaced ∼3mm apart to allow visualization of mixing after mechanical disintegration from the histotripsy treatment. Bubble cloud treatments were localized using an automated algorithm that minimized a cost function based on the intensity difference within the treatment region on the pre- and post-treatment CBCT. The actual treatment location can be compared to the theoretical bubble cloud location (focal point based on the CAD model of the transducer assembly) to calculate a 3D offset (X, Y, Z), which is used as the calibration correction between the therapeutic bubble cloud location and the histotripsy robot arm. The phantom and algorithm were analyzed to determine parameters that maximized bubble cloud treatment detection (treatment duration, localization accuracy of the phantom, number of bubble clouds) and were tested on four different histotripsy transducers. Bubble cloud locations were accurately identified with the automated algorithm from post-treatment CBCT images of the multilayer agar phantom. Treating the phantom for 20seconds was associated with the greatest change in CBCT intensity. The phantom and algorithm were able to localize changes in bubble cloud location with mean residual errors (MRE) between the measured and planned translations of 0.3±0.3mm in X, -0.2±0.6mm in Y, and 0.1±1.0mm in Z. A multi-bubble cloud calibration approach with four adjacent bubble clouds provided a statistically significant lower mean absolute deviation (MAD) in measured 3D offset (0.1, 0.0 and 0.2mm in X, Y, and Z, respectively) compared to using a single bubble cloud (MAD of 0.2, 1.1 and 1.2mm in X, Y, and Z, respectively). The calibration correction method measured statistically significantly different 3D transducer offsets between the four histotripsy transducers. Creating and analyzing four adjacent bubble clouds together produced more accurate and reproducible 3D offset measurements than analyzing individual bubble clouds. The presented histotripsy bubble cloud calibration correction method is automated, accurate, and can be easily integrated in the current histotripsy workflow to improve accuracy of CBCT guided histotripsy.

Percutaneous Jejunostomy

AbstractDirect percutaneous jejunostomy placement is an often underutilized procedure that can allow for supplemental enteral nutrition in a certain subset of patients, in which percutaneous gastrostomy is not technically feasible, or in patients who require post-pyloric feeding. Percutaneous jejunostomy catheter placement was first described in the 1980s; since that time there have been minimal case series on the procedural technique and outcomes. At our institution, we perform percutaneous jejunostomy placement as a planned two-stage procedure. During the initial stage, direct jejunostomy is performed under a combination of fluoroscopic and ultrasound guidance, after distending the jejunum through a nasojejunal tube. After confirming intraluminal access, at least one Cope suture anchor is deployed, and guidewire access is maintained. Subsequently, the track is serially dilated, and a 14-Fr pigtail catheter is placed into the jejunum. Approximately 4 to 6 weeks later, the patient returns for conversion of the pigtail drain into a formal jejunostomy catheter with retention balloon, under fluoroscopic guidance. Several of the prior larger studies on the technique have noted major complications to occur in 12% of patients and minor complications to occur in 9.8% of patients. While percutaneous jejunostomy placement is not a frequently performed procedure, technical success and complication rates are comparable to that of surgical jejunostomy.

The Evidence for Office-Based Carpal Tunnel and The Use of UltraSound: A Systematic Review and Meta-Analysis

Introduction Carpal Tunnel Syndrome (CTS) is a common condition characterized by compression of the median nerve at the wrist, leading to neuropathy and associated symptoms that can significantly impair hand function and quality of life. Recent interest has focused on the use of ultrasound-guided carpal tunnel release (CTR-US) as a treatment modality, given its potential to facilitate faster recovery, minimize complications, and enhance patient satisfaction. This systematic review aims to evaluate the efficacy and safety of in-office CTR-US in managing CTS in comparison to interventions performed without ultrasound. Methods A systematic review and meta-analysis were conducted in SPSS v29 using PRISMA 2020 guidelines. Five databases (PubMed, Embase, Scopus, Cochrane, and Web of Science) were searched yielding a total of 713 articles and 5 after the exclusion criteria was applied. The review included clinical trials regarding office based carpal tunnel release (CTR) surgeries with and without ultrasound guidance. Outcome measures included the QuickDASH at 2 weeks and 1 year. Results QuickDASH improved with CTR in both groups at 2 weeks and a year. There was a large effect size difference, 4.42, at 2 weeks and at 1 year, 2.15, between CTR-US and CTR without US, indicating clinical significance. However, the results were not statistically significant, p&gt;0.05. Conclusion The findings show that carpal tunnel release is effective at improving QuickDash scores at 2 weeks and 4 years post treatment. Though more research is required, CTR-US may provide superior clinical outcomes when compared to CTR without US.

MEST: Modified electrosclerotherapy to treat AVM (Extracranial Arterio-venous malformations). Better than BEST.

Arteriovenous Malformations (AVM) can present themselves in an ample clinical spectrum. They worsen over time, creating local complications such as ulceration, destruction, infection, pain, and severe bleeding. Small focal AVMs can effectively be cured by surgery and/or endovascular techniques, whereas larger ones are of difficult management. Accordingly, S3 AVMs (according to SECg staging) are particularly troublesome. Here, endovascular treatment is only episodically curative while surgery leads to significant structural and functional damage. Electrochemotherapy is an established means to manage selected neoplasms. Recently it was successfully used to treat sclerotherapy-resistant or extensive low-flow vascular malformations (electrosclerotherapy, EST). EST was only anectodically tried with AVMs. A conventional EST is unlikely to effectively have an AVM responding. We conceived the Modified EST (MEST) protocol and started a pilot study. Modification of conventional EST was done by administering bleomycin locally, under ultrasound guidance, in the tissues around the nidus. After 8min, electroporation was started and covered the entire involved area. MEST was adopted in 10 patients with S3 AVMs of the cervicofacial region. Most patients received 2 sessions of MEST. The response was significant, and the patients all had a complete or near-complete reduction in the size of the AVM. Excellent aesthetic results were achieved. On follow-up imaging the AVMs were not detectable. Side effects were minor and easily managed. Results were stable. The results of the present study suggest that MEST may be the treatment of choice in selected AVMs. However, a longer follow-up is needed to further evaluate the risk of recurrence.