Image-guided Percutaneous Procedures Research Articles

Interventional Magnetic Resonance Imaging Suite (IMRIS): How to build and how to use

Over the last ten years, the number of minimally invasive interventional procedures has been increasing steadily. Magnetic resonance imaging (MRI) is still far less frequently used for image-guided percutaneous procedures or as an intervention method than computed tomography (CT) and ultrasound (US). However, MRI has many advantages, such as lack of ionizing radiation, real-time MR-fluoroscopy placement high resolution, no bone and gas artifacts, the ability to display lesions that are difficult to observe on CT and US visualization of blood vessels without a contrast agent, free selection of imaging planes and in the case of procedures such as thermos or cryoablation it is possible to make an intraprocedural assessment of the process without the application of a contrasting agent (Marini et al. in Diagn Interv Imaging 102: 531-538, 2021; Li et al. in BMC Cancer 21: 366, 2021; Barkhausen et al. in Rofo 189: 611, 2017). Furthermore, in addition to its use in Interventional Radiology, MRI is also becoming a reality in cardiology thanks to the possibility of overcoming all the limits related to the fusion technology used up to now in cardiac ablations (Chubb et al. Arrhythm Electrophysiol Rev 6: 85, 2017). Some suites have been built in Northern Europe and in the United States, but based only on personal experience and industry indication. In our hospital, we have built a new Interventional Magnetic Resonance Imaging Suite (IMRIS), the first in Southern Europe and we have defined what the necessary requirements and equipment were for the safety of the patient and the operator.

Thoracoscopic approach of a complicated pleuro-biliary fistula, after a right hepatectomy

Pleuro-biliary fistula is a rare complication that originates from various causes, including liver resections. There is no consensus on how to manage them. There are 2 types of treatment: surgical and conservative. Both can be combined. The latter involves the combination of minor surgical procedures such as pleural drainage placement, image-guided percutaneous procedures, and endoscopic procedures. Surgical treatment includes more aggressive approaches such as thoracotomy and / or laparotomy, and can be performed at the start of fistula management or in the event of failure of conservative treatment. In these cases open thoracotomy is the most used approach according to the literature. We present the case of a patient undergoing a postoperative right hepatectomy for hepatoarcinoma that complicates with an external biliary fistula and then with a pleuro-biliary fistula with empyema, in which thoracoscopy is used as part of the treatment. the patient resolved the complication and the pleural drainage was removed 7 days later. thoracoscopy is a safe and effective approach in the treatment of this complication.

Safety and Efficacy of a Truncated Deflation Algorithm for Distal Transradial Access

PurposeTo assess safety and efficacy of a modified rapid hemostasis protocol for distal transradial access (TRA). Materials and MethodsA single-center retrospective study of patients undergoing percutaneous image-guided procedures from a distal TRA with rapid deflation hemostasis protocol was performed. Between March 2017 and August 2019, 593 procedures in 434 patients were performed. Mean patient age was 63.5 y (range, 18–94 y). ResultsThe most common procedures were transarterial chemoembolization (218; 36.8%), abdominal and pelvic embolization (116; 19.6%), yttrium-90 mapping (115; 19.4%), yttrium-90 administration (84; 14.2%), and diagnostic angiography (44; 7.4%). Mean (range) values for clotting parameters were international normalized ratio 1.2 (0.9–3.2), partial thromboplastin time 33.5 s (26–44 s), and platelets 23.4 × 109/L (37–552 × 109/L). A hematoma developed in 7 (1.2%) patients. No radial artery occlusions were encountered during follow-up. Nursing intensity was defined as the number of minutes after the procedure required for assessing and managing the access site for bleeding. The mean nursing intensity was 25.1 min (range, 25–40 min). ConclusionsThe rapid deflation hemostasis protocol for distal TRA at the anatomical snuffbox was feasible and safe. No significant difference or association was found between hematoma formation and clotting parameters after the procedure or type of vascular access equipment used.

Robotics in Interventional Radiology: Past, Present, and Future

Robotic endovascular systems have been successfully used to treat a wide range of pathologies including endovascular aneurysm repairs, uterine artery embolizations, and cardiac electrophysiology ablations. Limited research suggests that the use of robotic systems may help to achieve a more accurate manipulation and increased steerability of the catheter during endovascular procedures. In addition, robotic systems have also been designed to enhance image-guided percutaneous procedures, demonstrating a potential to facilitate needle placements and guidance and diminish radiation exposure risk. There are still many limitations for the widespread of this emerging technology. More studies are needed to validate the use of robotic systems and to show meaningful clinical advantages over traditional methods as well as assessing cost-effectiveness.

4:12 PM Abstract No. 159 Technical feasibility and safety of left distal transradial access for percutaneous image-guided procedures

To assess technical feasibility and safety of left distal transradial access in the anatomical snuffbox for percutaneous image-guided procedures. A retrospective analysis during 2016 – 2017 was performed at our tertiary institution. A total of 43 patients (34 males, 9 females), aged between 38 – 85 years (mean 64.2) were included. The procedures performed were hepatic chemoembolizations (n = 28), visceral embolizations (n = 5), diagnostic angiography (n = 5), internal radiation therapy with Yttrium-90 (n = 3), surgical arteriovenous fistula closure (n = 1) and iliac aneurysm embolization (n = 1). The left radial artery size on ultrasound measured between 1.4 – 3.2 mm at the wrist and 1.4 – 2.7 mm at the anatomical snuffbox (mean 2.4 v 2.2; p = 0.2431). INR range 0.9 – 2.8 (mean 1.6), platelets 37 – 306 × 109/L (mean, 143). Sheath size used was 4 Fr or 5 Fr (Prelude Ease; Merit Medical, South Jordan UT). The technical success rate was 100%, a single grade 1 hematoma occurred in the first patient (1/43; 2.3%), no radial artery occlusions were encountered. The left radial artery size at the anatomical snuffbox is not significantly different than at the wrist and can be accessed without added technical difficulty. The distal approach carries a lower risk for potential radial artery occlusion than conventional radial access, it is suitable for patients with clotting abnormalities and improves patient comfort as it allows movement at the wrist during postprocedural hemostasis. To date, this technique has not been published in the literature. Our data supports that left distal transradial access is feasible, safe and can be utilized as an access site for percutaneous image-guided procedures.

Compact Robotically Steerable Image-Guided Instrument for Multi-Adjacent-Point (MAP) Targeting

Accurately targeting multi-adjacent points (MAPs) during image-guided percutaneous procedures is challenging due to needle deflection and misalignment. The associated errors can result in inadequate treatment of cancer in the case of prostate brachytherapy, or inaccurate diagnosis during biopsy, while repeated insertions increase procedure time, radiation dose, and complications. To address these challenges, we present an image-guided robotic system capable of MAP targeting of irregularly shaped volumes after a single insertion of a percutaneous instrument. The design of the compact CT-compatible drive mechanism is based on a nested screw and screw-spline combination that actuates a straight outer cannula and a curved inner stylet that can be repeatedly straightened when retracted inside the cannula. The stylet translation and cannula rotation/translation enable a 3-D workspace to be reached with the stylet's tip. A closed-form inverse kinematics and image-to-robot registration are implemented in an image-guided system including a point-and-click user interface. The complete system is successfully evaluated with a phantom under a Siemens Definition Flash CT scanner. We demonstrate that the system is capable of MAP targeting for a 2-D shape of the letter “H” and a 3-D helical pattern with an average targeting error of 2.41 mm. These results highlight the benefit and efficacy of the proposed robotic system in seed placement during image-guided brachytherapy.

Surgical Versus Nonsurgical Management of Traumatic Major Pancreatic Duct Transection

The objective of this study was to review the literature, report our experience, and compare operative versus nonoperative management of patients with major pancreatic duct transection (MPDT) from blunt trauma. We compare the outcome of 39 patients reported in the literature who had surgical management (S group) with 12 patients who were conservatively managed with combined expectant and image-guided percutaneous procedures (NS group). We also review the surgical and nonsurgical management of 7 patients with MPDT treated in the past 12 years at our center (Louisiana Series [LS] group). Age at time of injury and complication and fistula formation rates were not significantly different between the 2 groups. Total parental nutrition was administered in 10.3% of patients in the S group and 66.7% in the NS group (P = 0.0003). The NS group required longer hospitalization compared with the S group (P = 0.005). The LS group length of stay was significantly shorter than that of the NS group (P = 0.04). Although some centers kept their patient with nonsurgical management as inpatient until the drain was removed, LS patients were discharged home with the drain. Both operative and nonoperative approaches for management of MPDT from blunt trauma can be entertained successfully with similar complication rates. The management of these patients should be individualized based on their clinical condition.

E-044 Percutaneous image guided c-spine procedures

Introduction/purposeAim of this educational exhibit is to offer an overview on neuroradiological armamentarium in the minimally invasive percutaneous image-guided procedures on cervical spine.Materials and MethodsSpinal neuro-interventional radiology offers a wide...

Procedimentos percutâneos pélvicos guiados por imagem: revisão das principais vias de acesso

Os procedimentos percutâneos orientados por imagem têm ganhado espaço crescente na radiologia intervencionista, constituindo ferramenta eficaz para a abordagem diagnóstica e terapêutica de massas e coleções nos diversos segmentos corporais. No entanto, localizações pélvicas profundas ainda representam grande desafio para o radiologista, por causa da interposição de estruturas anatômicas. Para que o procedimento seja bem sucedido é fundamental o planejamento da via de acesso baseado no conhecimento detalhado da anatomia radiológica da pelve. As principais vias de acesso para a abordagem destas lesões são: transabdominais (anterior e lateral), extraperitoneal ântero-lateral, transvaginal, transretal e transglútea. O objetivo deste trabalho é fazer uma revisão da anatomia seccional pélvica normal, demonstrando as diversas vias de acesso para biópsias e drenagens guiadas pela ultra-sonografia e pela tomografia computadorizada, bem como discutir as principais vantagens e complicações potenciais de cada uma delas.

Percutaneous laser ablation of benign and malignant thyroid nodules

Percutaneous image-guided procedures, largely based on thermal ablation, are at present under investigation for achieving a nonsurgical targeted cytoreduction in benign and malignant thyroid lesions. In several uncontrolled clinical trials and in two randomized clinical trials, laser ablation has demonstrated a good efficacy and safety for the shrinkage of benign cold thyroid nodules. In hyperfunctioning nodules, laser ablation induced a nearly 50% volume reduction with a variable frequency of normalization of thyroid-stimulating hormone levels. Laser ablation has been tested for the palliative treatment of poorly differentiated thyroid carcinomas, local recurrences or distant metastases. Laser ablation therapy is indicated for the shrinkage of benign cold nodules in patients with local pressure symptoms who are at high surgical risk. The treatment should be performed only by well trained operators and after a careful cytological evaluation. Laser ablation does not seem to be consistently effective in the long-term control of hyperfunctioning thyroid nodules and is not an alternative treatment to 131I therapy. Laser ablation may be considered for the cytoreduction of tumor tissue prior to external radiation therapy or chemotherapy of local or distant recurrences of thyroid malignancy that are not amenable to surgical or radioiodine treatment.

Cost-effective use of breast biopsy techniques in a veterans health care system

Background Breast health has become an increasingly important issue among the veteran population. Options for the evaluation of a breast mass or a suspicious mammographic finding include open surgical biopsy at the Veterans Affairs (VA) hospital or percutaneous image-guided biopsy at an affiliated academic institution. We examined the costs and trends in the use of surgical versus percutaneous image-guided biopsy procedures in this diagnostic algorithm. Methods A retrospective review was performed of 62 patients who presented to the VA General Surgery Clinic with a breast mass or abnormal mammogram from 2003 to 2005. The Massachusetts Utilization Multiprogramming System and the Decision Support System software packages were used to track costs of procedures, by Current Procedure Terminology code and date of service, performed at the affiliated academic institution and at the VA hospital. These data were analyzed and described using the R statistical computing environment. Results Forty-six patients were evaluated using open biopsy techniques in the VA operating room, including 8 incisional biopsies, 21 excisional biopsies, and 17 needle-localization excisional biopsies. Sixteen patients were evaluated using minimally invasive biopsies at the affiliated academic institution, including 3 ultrasound-guided cyst aspirations, 6 ultrasound-guided core biopsies/vacuum-assisted core biopsies, 10 stereotactic breast biopsies, and 1 fine-needle aspiration. The average cost to evaluate a breast mass or abnormal mammographic finding in the operating room was $4,368.00 (SD, $2,586.00), with a median cost of $3,479.00. The average cost to evaluate a breast mass or mammographic abnormality using percutaneous image-guided procedures was $1,267.00 (SD, $536.00), with a median of $1,239.00. From 2003 to 2005, the proportion of percutaneous biopsies increased from 13% to 48%, whereas the proportion of open biopsies decreased from 88% to 52%. Conclusions Over a recent 3-year period, we observed a 3.8-fold increase in the use of percutaneous image-guided techniques for the evaluation of breast lesions in the VA Tennessee Valley Healthcare System. Diagnosis by percutaneous techniques allows planning for a definitive surgery if a lesion is malignant or possible avoidance of a surgical intervention if the lesion is benign. Our data show that the costs associated with open biopsy techniques exceed those associated with percutaneous biopsies. For VA hospitals with available resources, the option of image-guided percutaneous biopsy techniques is a cost-effective alternative to open surgical biopsy.

Virtual Remote Center of Motion control for needle placement robots

Objective: We present an algorithm that enables percutaneous needle-placement procedures to be performed with unencoded, unregistered, minimally calibrated robots while removing the constraint of placing the needle tip on a mechanically enforced Remote Center of Motion (RCM).Materials and Methods: The algorithm requires only online tracking of the surgical tool and a five-degree-of-freedom (5-DOF) robot comprising three prismatic DOF and two rotational DOF. An incremental adaptive motion control cycle guides the needle to the insertion point and also orients it to align with the target-entry-point line. The robot executes RCM motion without having a physically constrained fulcrum point.Results: The proof-of-concept prototype system achieved 0.78 mm translation accuracy and 1.4° rotational accuracy (this is within the tracker accuracy) within 17 iterative steps (0.5–1 s).Conclusion: This research enables robotic assistant systems for image-guided percutaneous procedures to be prototyped/constructed more quickly and less expensively than has been previously possible. Since the clinical utility of such systems is clear and has been demonstrated in the literature, our work may help promote widespread clinical adoption of this technology by lowering system cost and complexity.

A prospective study of the removal rate of imaged breast lesions by an 11-gauge vacuum-assisted biopsy probe system

Background: More than 1,000,000 breast biopsies are performed each year as a result of abnormalities identified by imaging techniques. This prospective study was designed to determine whether complete removal of the imaged evidence of an abnormal mammogram or ultrasonogram could be achieved with percutaneous image-guided procedures using an 11-gauge vacuum-assisted biopsy probe. Methods: Forty-five women over the age of 18 years entered the study; 50 breast lesions were identified by ultrasonography or mammography. Biopsies were obtained using an 11-gauge vacuum-assisted probe. At 6 months after biopsy, ultrasonography or mammography examinations of the biopsy site were performed. Results: Forty-five lesions (90%) were completely removed. At 6 months after biopsy, 82% of the sites were lesion free. The percentage of nonrecurring lesions at 6 months after surgery was inversely related to the size of the original lesion. Conclusion: This device allows biopsies to be successfully combined with complete removal of the imaged lesion in a one-step minimally invasive procedure.