Interventional Radiology Techniques Research Articles

Renal embolization for trauma: a narrative review

Renal injuries commonly occur in association with blunt trauma, especially in the setting of motorvehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imagingmodality to assess patients for renal injuries in the setting of blunt and penetrating trauma, andto help classify injuries based on the American Association for the Surgery of Trauma injury scoringscale. The management of renal trauma has evolved in the past several decades, with a notable shifttowards a more conservative, nonoperative approach. Advancements in imaging and interventionalradiological techniques have enabled diagnostic angiography with angiographic catheter-directedembolization to become a viable option, making it possible to avoid surgical interventions that posean increased risk of nephrectomy. This review describes the current management of renal trauma,with an emphasis on renal artery embolization techniques.

Interventional Radiology for Bleeding Ectopic Varices: Individualized Approach Based on Vascular Anatomy.

Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.

Comprehensive Review of Surgical and Radiological Management of Hemorrhagic Pancreatitis: Current Strategies and Outcomes.

Hemorrhagic pancreatitis, a severe complication of acute and chronic pancreatitis, involves bleeding due to vascular disruptions. This condition presents significant clinical challenges and is associated with high morbidity and mortality. The bleeding can result from arterial or venous complications, often exacerbated by inflammatory and enzymatic damage to blood vessels within the pancreas. Patients with hemorrhagic pancreatitis may experience symptoms such as abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Diagnostic imaging, including CT and MRI, is crucial in identifying the source of bleeding and guiding treatment decisions. Management strategies have evolved over the past two decades, shifting from purely surgical approaches to including interventional radiology techniques. Surgical intervention is often reserved for hemodynamically unstable patients or those with large pseudoaneurysms, offering definitive treatment but carrying higher risks of complications. Endovascular techniques, such as transcatheter embolization, provide a less invasive alternative with high success rates and shorter recovery times, though rebleeding may occur. Treatment choice depends on various factors, including the patient's stability, the size and location of the bleeding, and the availability of specialized expertise. Overall, the management of hemorrhagic pancreatitis requires a multidisciplinary approach, combining surgical and radiological techniques to optimize patient outcomes and reduce the risk of mortality. Long-term follow-up is essential to monitor for recurrent disease and manage the metabolic consequences of pancreatic insufficiency.

Endovascular embolization of a biliary–digestive loop bleeding

Delayed massive hemorrhage after biliary surgery is a severe complication and carries a high mortality rate. Upper gastrointestinal (GI) tract bleeding is usually managed endoscopically. However, the presence of altered anatomy following hepato-biliary surgery does preclude endoscopic exploration of the anastomoted loop. In our case of hemorrhage from biliodigestive anastomosis, CT angiography provides accurate information about the presence of active bleeding and its source. We present a case of bleeding from a biliary–digestive loop. The patient exhibited several bleeding risk factors, notably cirrhosis and dual antiplatelet therapy. Furthermore, the site of bleeding, the biliarydigestive loop, had experienced a fistula with a hepatic abscess 2 years earlier, following percutaneous thermoablation. Endovascular embolization with microparticles 300–500 µm and one microcoil 2mx4cm proved to be a safe and effective treatment in this high-risk patient with persistent bleeding. Developments in interventional radiology equipment and techniques, such as low-profile catheter systems and advanced embolic agents, validate embolization as a suitable therapeutic option.

The Management of Esophageal Perforation: A Systematic Review.

Esophageal perforation, a rare and serious condition, has seen a reduction in mortality from 30% to 15% over the last three decades due to advancements such as gastrointestinal stents, minimally invasive surgeries, and improved interventional radiology techniques. This review analyzes management strategies for esophageal perforation based on 14 English-language articles published from 2009 to 2024, primarily utilizing surveys and national database analyses. The management of esophageal perforation is complex, with challenges in diagnosis and treatment strategy. Despite surgery being the traditional treatment, the role of less invasive methods is growing. Effective management of esophageal perforation involves advanced imaging for diagnosis, hemodynamic stabilization, and a multidisciplinary approach to treatment, including surgical and non-surgical interventions. The evidence for different treatment outcomes remains limited, highlighting the need for comprehensive care involving thoracic surgery, interventional radiology, gastroenterology, and critical care in an intensive care unit setting.

Methods of interventional radiology in the diagnosis and treatment of liver tumor

Over the past two decades, interventional radiology techniques have become an integral part of the treatment of primary and metastatic liver tumors. Today, interventional radiology has at its disposal a wide range of diagnostic and therapeutic minimally invasive technologies that are used as stand-alone treatment options or in combination with other therapies for cancer patients. The development and increasing adoption of interventional radiology in clinical practice makes it possible to achieve treatment results comparable to classical surgery. The aim of the present work is to provide an overview of the possibilities of interventional radiology methods in the treatment of primary and metastatic liver tumors. The description of techniques, brief historical reviews, classifications and indications for their performance are given.

Clinical Implications and Management of Spontaneous Portosystemic Shunts in Liver Cirrhosis.

Portal hypertension from chronic liver disease leads to the formation of collateral blood vessels called spontaneous portosystemic shunts (SPSS). These shunts may form from existing vessels or through neo-angiogenesis. Their location affects clinical outcomes due to varying risks and complications. This review summarizes current knowledge on SPSS, covering their clinical impact and management strategies. Recent data suggest that SPSS increases the risk of variceal bleeding, regardless of shunt size. The size of the shunt is crucial in the rising incidence of hepatic encephalopathy (HE) linked to SPSS. It also increases the risk of portopulmonary hypertension and portal vein thrombosis. Detecting and assessing SPSS rely on computed tomography (CT) and magnetic resonance imaging. CT enables precise measurements and the prediction of cirrhosis progression. Management focuses on liver disease progression and SPSS-related complications, like HE, variceal bleeding, and portopulmonary hypertension. Interventional radiology techniques such as balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration play a pivotal role. Surgical options are rare but are considered when other methods fail. Liver transplantation (LT) often resolves SPSS. Intraoperative SPSS ligation is still recommended in patients at high risk for developing HE or graft hypoperfusion.

Advancements in Interventional Radiology for Managing Hepatic Encephalopathy: A Comprehensive Review.

Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome resulting from liver dysfunction, leading to cognitive, behavioral, and motor impairments. The management of HE has traditionally relied on pharmacological treatments, dietary modifications, and liver transplantation. However, recent advancements in interventional radiology (IR) have introduced minimally invasive procedures that offer promising alternatives. This comprehensive review explores the latest IR techniques, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), portal vein embolization (PVE), and Yttrium-90 (Y90) radioembolization. The efficacy, clinical outcomes, and potential complications of these techniques are examined through an analysis of current studies and trials. The review highlights the benefits of IR in reducing portal hypertension and improving hepatic blood flow, ultimately alleviating HE symptoms. Additionally, it underscores the importance of multidisciplinary collaboration, ongoing research, and the development of clear patient selection criteria to optimize the use of IR in HE management. By integrating these advancements into clinical practice, healthcare providers can enhance the quality of care and improve outcomes for patients with HE.

Role of Interventional Radiology in the Management of Liver Transplant Complications in Children

AbstractLiver transplantation (LT) is a common solid organ transplant in the pediatric population. The common indications for LT, as well as its complications, differ between adults and children. This difference necessitates unique pediatric interventional radiology (IR) interventions. This article focuses on unique vascular complications occurring post-pediatric LT and highlights the importance of IR in their management. It explores IR's involvement in the workup of patients' pre-LT and management of complications following portosystemic shunts. We discuss advantages and disadvantages of different access routes as well as the prevalence, clinical picture, diagnosis, and management of complications after pediatric LT. These complications encompass portal vein stenosis, portal vein thrombosis, hepatic artery stenosis, hepatic artery thrombosis, hepatic artery pseudoaneurysm, arterioportal fistula, hepatic vein stenosis, and inferior vena cava stenosis. The choice of endovascular technique for a clinical indication depends on vascular anatomy, time since LT, and patient-specific factors. Transsplenic access is a useful alternative to transhepatic or transjugular access. The decision to place a stent in a child is influenced by the expected growth of the child and risk of focal narrowing at stent edge (because of recipient growth). Technical challenges in pediatric patient management, including uncooperative patients and sedation issues, must be considered. Pediatric LT complications can present with significant challenges in the posttransplant care of recipients and may lead to serious morbidity and graft failure if not managed effectively. IR techniques like balloon angioplasty, stent placement, thrombolysis, and embolization have demonstrated success in treating these complications, improving patient outcomes, and reducing long-term morbidity and mortality. By enhancing the understanding of medical practitioners and interventional radiologists about complex vascular complications, this article aims to contribute to better posttransplant care and improved outcomes for LT in pediatric populations. Continued collaboration between specialties and research will advance the field of pediatric LT and IR, to create even more effective treatment strategies.

Local Treatment of Desmoid Tumors: An Update.

Desmoid tumors (DTs) are rare fibroblastic proliferations, characterized by infiltrative growth and a propensity for local recurrence. Traditional strategies such as surgery, radiotherapy, and chemotherapy are the mainstays of treatment, each with its limitations and associated risks. The trend in DT management leans toward a "wait-and-see" strategy, emphasizing active surveillance supported by continuous MRI monitoring. This approach acknowledges the unpredictable nature of the disease, and a multidisciplinary management of DT requires a nuanced approach, integrating traditional therapies with emerging interventional techniques. This review highlights the emerging role of minimally invasive interventional radiological technologies and discusses interventional radiology techniques, including chemical, radiofrequency, microwave, cryoablation, and high-intensity focused ultrasound ablations as well as transarterial embolization.

The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation

BackgroundTunnelled cuffed haemodialysis catheters are at increased risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods of time. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. Whilst there are several strategies published for the removal of these incarcerated lines, there is no consensus on the best approach. Here we present a challenging case of a stuck haemodialysis catheter in the acute post transplantation period.Case PresentationA 66-year-old female on haemodialysis presented for kidney transplantation with a tunnelled-cuffed haemodialysis catheter in situ for five years. Following transplantation, removal of the line was unsuccessful despite dissection of the cuff, with traction causing a choking sensation with tracheal movement. Eventually, the line was removed without complications utilising sequential balloon dilatation by interventional radiology and the patient was discharged without complications.ConclusionsThis case serves as a timely reminder of the risks of long-term tunnelled haemodialysis catheters and as a caution towards proceeding with kidney transplantation in those with long-term haemodialysis catheters in situ. Greater nephrologist awareness of interventional radiology techniques for this challenging situation will help to avoid more invasive strategies. The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient.

Pathophysiology, Diagnosis, and Management of Portal Hypertension in the Pediatric Population

AbstractPortal hypertension is caused by resistance to the portal blood flow, which most commonly occurs in the setting of cirrhosis. Complications of portal hypertension can cause significant morbidity and mortality in the pediatric population. Portal hypertension is diagnosed when the hepatic venous pressure gradient (HVPG) is more than 5 mm Hg, and potential bleeding complications from esophageal and gastric varices are more likely when the HVPG is more than 10 mm Hg. Diagnosis can be made clinically; however, liver biopsy with measurement of the HVPG is ultimately required. The management of portal hypertension in pediatric patients is typically aimed at treatment of the complications. Despite the multiple pharmacologic, endoscopic, surgical, and interventional radiologic management techniques that are available, some pediatric patients will ultimately require liver transplant. Prompt referral is needed in such cases.

Evaluation of Radiation Exposure and Influential Factors in Cone-Beam Computed Tomography (CBCT) of the Head and Abdomen during Interventional Procedures.

Cone-beam computed tomography (CBCT) is a widely used imaging technique in interventional radiology. Although CBCT offers great advantages in terms of improving comprehension of complex angioarchitectures and guiding therapeutic decisions, its additional degree of radiation exposure has also aroused considerable concern. In this study, we aimed to assess radiation exposure and its influential factors in patients undergoing CBCT scans of the head and abdomen during interventional procedures. A total of 752 patients were included in this retrospective study. Dose area product (DAP) and reference air kerma (RAK) were used as measures of patient dose. The results showed that the median values of DAP were 53.8 (50.5-64.4) Gy⋅cm2 for head CBCT and 47.4 (39.6-54.3) Gy⋅cm2 for that of the abdomen. Male gender and body mass index (BMI) were characterized by increased DAP and RAK values in both head and abdominal CBCT scans. Larger FOV size was associated with a higher DAP but a lower RAK value, especially in head CBCT scans. Exposure parameters under automatic exposure control (AEC) also varied according to patient BMI and gender. In conclusion, the patients received slightly higher radiation doses from head CBCT scans than from those applied to the abdomen. BMI, gender, and FOV size were the key factors that influenced the radiation dose administered to the patients during CBCT scans. Our results may help to define and minimize patients' exposure to radiation.

Portal Embolization: Algerian Experience

Portal embolization is an interventional radiology technique aimed at occluding the right portal branches to induce hypertrophy of the remaining liver. In this article, we will discuss the experience of the radiology department at Bab el Oued University Hospital.

Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy.

Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. (i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.

Post-cholecystectomy iatrogenic bile duct injuries: Emerging role for endoscopic management.

Post-cholecystectomy iatrogenic bile duct injuries (IBDIs), are not uncommon and although the frequency of IBDIs vary across the literature, the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy. These injuries caries a great burden on the patients, physicians and the health care systems and sometime are life-threatening. IBDIs are associated with different manifestations that are not limited to abdominal pain, bile leaks from the surgical drains, peritonitis with fever and sometimes jaundice. Such injuries if not witnessed during the surgery, can be diagnosed by combining clinical manifestations, biochemical tests and imaging techniques. Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate. Surgical approach was the ideal approach for such cases, however the introduction of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was a paradigm shift in the management of such injuries due to accepted success rates, lower cost and lower rates of associated morbidity and mortality. However, the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs. ERCP management of IBDIs can be tailored according to the nature of the underlying injury. For the subgroup of patients with complete bile duct ligation and lost ductal continuity, transfer to surgery is indicated without delay. Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP. For low-flow leaks e.g. gallbladder bed leaks, conservative management for 1-2 wk prior to ERCP is advised, in contrary to high-flow leaks e.g. cystic duct leaks and stricture lesions in whom early ERCP is encouraged. Sphincterotomy plus stenting is the ideal management line for cases of IBDIs. Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy. Future studies will solve many unsolved issues in the management of IBDIs.

Role of interventional radiology in obstetrics and gynaecology: a clinical review of an experience in a quaternary care centre.

The study aims to equip both Obstetricians and Gynaecologists with the knowledge of clinical conditions that will benefit from interventional radiology, equipment and materials that are commonly used, benefits, complications and the side effects of these techniques. It was a single-centre, retrospective cohort study with examples from hospital practice during the period of 2015 to 2021, acquired through computerised database including all obstetrics and gynecological cases in which interventional radiology techniques were used. No statistical analysis of data was applicable as it was a single-centre retrospective analysis of cases. We had a total of 35 cases, including but not limited to placenta accreta spectrum disorders, fibroid, pelvic congestion syndrome and arteriovenous malformation who underwent various interventional radiological procedures ranging from embolization of uterine artery, peripheral angiography, embolization, and internal iliac artery balloon placement to ovarian vein embolization and coil insertion. Increased collaborative efforts between interventional radiology and gynaecology would allow patients to be fully informed on the complete spectrum of surgical and nonsurgical treatment options available to them.

HPB P30 The role of interventional radiology in managing post-pancreatectomy hemorrhage at a major hepatobiliary centre in the UK

Abstract Background Pancreatoduodenectomy (PD) is a common surgery performed by hepatobiliary surgeons. Mortality is 5% and morbidity is 30-40%. An important cause is post-pancreatectomy hemorrhage (PPH). As per the International Study Group for Pancreatic Surgery (ISGPS), grade C PPH represents most cases of hemorrhage post-PD and always requires intervention. They tend to be arterial in origin and CT angiogram of the celiac axis and superior mesenteric artery is recommended. Historically, the treatment for PPH was a re-look laparotomy. With the development of interventional radiology (IR) techniques, morbidity and mortality has improved. Transcatheter arterial embolization is a well-established treatment for bleeding. Methods Southampton General Hospital is a tertiary centre for hepatobiliary surgery and interventional radiology. All patients who underwent PD between 2019 and 2023 were checked for complications. Patients who developed PPH were selected and their PACs was checked for what investigation they underwent. The findings of the angiogram and intervention done were recorded. Morbidity and mortality data was also collected including whether patients returned to theatre. Results Seven male patients aged 57 to 75 had type C PPH. Symptom onset including melaena and haematemesis was between 24 hours to 38 days. The time to CT from the request was between one to six hours. One patient was bleeding from the gastroduodenal artery stump. The other six patients had no obvious bleeding point identified. Of the seven patients, five had bleeding points identified on angiograms done by IR and underwent embolization. One patient returned-to-theatre for a re-look laparotomy. Two of seven patients died within one year of PPH. One had repeated PPH and had embolization multiple times. Conclusions Harnoss et al., (2014) reported that the rate of PPH post PD was 5.9%. The use of angiography with embolization is being adopted worldwide for arterial bleeding in hemodynamically stable patients due to its minimal invasiveness. Even if embolization fails, angiography can help identify the bleeding point and guide surgical management. The reported immediate mortality rate from PPH is 30% and at our centre it was 0% in our small sample size.

Advanced Image-Guided Percutaneous Technique Versus Advanced Laparoscopic Surgical Technique for Peritoneal Dialysis Catheter Placement

Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia. Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques. Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system. PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques. One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time. Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques. We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P=0.01). Major complications were<1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P=0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Retrospective study with practice preference influenced by timing, local expertise, and resources. Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD. Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.

Challenges in the Management of Complex Soft-Tissue Sarcoma Clinical Scenarios.

With nearly 15,000 new cases of soft-tissue sarcoma (STS) in the United States each year, early diagnosis and therapeutic management is imperative for successful patient outcomes. Primary STS is conventionally treated with a combination of wide-margin resection, neoadjuvant or adjuvant radiation therapy, and, in specific cases, adjuvant chemotherapy. However, in situations of complex disease presentation, guidelines for treatment are less clearly outlined. Limited metastatic disease, local recurrence, fungating STSs, and unplanned or incomplete resections of STSs present unique challenges for the multidisciplinary care team. The management of complex STS clinical scenarios usually involves limb-salvage resection or amputation as well as some combination of radiation therapy and/or ablative interventional radiology techniques. As a result, a multidisciplinary team approach is essential for treating patients in these challenging scenarios, with a recent focus on the integration of plastic and reconstructive surgery into the treatment algorithm.