Interventional Radiology Techniques Research Articles

The Use of Interventional Radiology Techniques in the Treatment of Pancreatic Fistula.

(1) the use of interventional radiology methods in the closure of pancreatic fistula is an effective and safe procedure; and (2) the recurrence of fistula is dependent on the etiology and often occurs after surgery or trauma.

Spontaneous Hepatic Hemorrhage: A Single Institution's 16-Year Experience

Spontaneous hemorrhage from hepatic tumors is an uncommon but serious complication. Recently, interventional radiologic (IR) techniques are being used increasingly in the management of these patients. We report our 16-year experience in managing spontaneous hemorrhage from liver tumors. Twenty-six consecutive patients were diagnosed with spontaneous liver hemorrhage between 1995 and 2011. Initial management was operative in eight, IR in six, and supportive in 12 patients. Of those managed operatively, five were segmentectomies; one hemihepatectomy; one wedge resection; and one packing who later died from coagulopathy. In the IR patients, seven had an angiographic embolization; two required reembolization; one underwent resection of a hepatic adenoma 21 days after angiographic embolization. The malignant lesions included hepatocellular carcinoma (n = 6), angiosarcoma (n = 1), metastatic squamous cell carcinoma (n = 1), metastatic leiomyosarcoma (n = 1), nonsquamous cell carcinoma (n = 1), or metastatic angiosarcoma (n = 1). Benign diseases included hepatic adenoma (n = 5), end-stage liver disease (n = 1), and polycystic liver (n = 1). Spontaneous hemorrhage from the liver occurs evenly from benign or malignant causes, one-third of which are primary liver disease. If the patients presents emergently, angiographic embolization may control the bleeding and allow for elective resection once the sequelae of bleeding have resolved.

A comparison of dose area product from different angiography procedures

Introduction The increased use of Interventional Radiology (IR) techniques the last decade and the extend fluoroscopy time during IR procedures deliver high radiation dose to patients and raised serious concerns about exposure to ionizing radiation. Purpose The purpose of this study is to evaluate the radiation exposure to patients during different IR procedures. The measurement of Dose Area Product (DAP) values and fluoroscopy time, allows a relative estimation of patients’ effective dose in interventional operations. Materials and methods A retrospective analysis of 333 procedures performed during last year at KAT General Hospital of Athens, the biggest trauma hospital of Greece in Athens has been conducted. All the procedures were performed on an image intensifier angiography system (Siemens Axiom Artis). Data concerning dose area product (DAP) and fluoroscopy time have been collected and divided in categories according to the type of procedure – technique. Results DAP, presented as median and range values, for 210 coronary angiographies (CA), 75 coronary angioplasty procedures (PCI), 19 cerebral Digital Subtraction Angiography (DSA) and 29 lower limbs DSA was 3.10 mGy∗m2 (0.26–25.39 mGy∗m2), 6.58 mGy∗m2 (1.33–18.28 mGy∗m2), 5.43 mGy∗m2 (0.65–14.80 mGy∗m2) and 30.03 mGy∗m2 (0.02–137.87 mGy∗m2) respectively. The corresponding values for fluoroscopy duration were 5.99 min (1.4–32 min), 12.98 min (4.3–32.2 min), 17.82 min (6–103 min) and 10.1 min (1–63.7 min). Conclusion Obtained results indicate that PCI procedures deliver statistically higher doses compared to CA procedures. Furthermore, radiation exposure was significantly greater for lower limbs DSA compared to cerebral DSA technique. Disclosure All authors confirm that none relationship may bias this presentation.

Multidisciplinary management of vertebral metastases in patients not amenable to surgery

Bone metastases occur in up to 70% of cancer patients, and frequently involve the spine. Spine metastases are often associated with pain, disability and progressive deformity, and may also have neurological complications, all of which can dramatically impair quality of life. There are a number of different approaches to managing vertebral metastases, including surgery, vertebroplasty and radiotherapy. The variety of treatment modalities involved, the presence of underlying cancer and frequent severe pain means that patients with vertebral metastases need to be managed by a multidisciplinary team, ideally including a medical oncologist, radiation oncologist, interventional radiologist, pain therapist and spine surgeon. Although a number of different multidisciplinary therapeutic algorithms have been proposed, there is no clear consensus on the best way to manage vertebral metastases. After reviewing current literature, this article proposes a new visual algorithm created by merging some existing guidelines and introducing additional interventional radiology techniques.

Ultrasound guided placement of the distal catheter in paediatric ventriculoatrial shunts-an appraisal of efficacy and complications.

PurposeVentriculoatrial (VA) shunts are commonly used as a second-line treatment of hydrocephalus when the peritoneum is an unsuitable site for the distal catheter. Many centres now utilise ultrasound and interventional radiology techniques to aid placement of the distal catheter. The purpose of this study was to conduct a contemporary audit of VA shunting in children using interventional radiology techniques for placement of the distal catheter.MethodsA retrospective analysis of all patients who had VA shunts inserted between June 2000 and June 2010 was conducted using a prospectively updated surgical database and case notes review.ResultsNinety-four VA shunts were inserted in 38 patients. Thirty-seven patients had been treated initially with ventriculoperitoneal (VP) shunts. Twenty-two patients required at least 1 shunt revision (58 %). The 6-month, 1- and 2-year shunt survival rates were 53, 43 and 27 %, respectively. Blockage was the commonest reason for shunt failure (68 %). The site of failure was proximal (ventricular catheter +/− valve) in 32 % and distal (atrial catheter) in 21 % of cases. The overall infection rate was 6 % per procedure and 11 % per patient. There were 7 deaths, of which 3 were shunt related.ConclusionsVA shunting provides a viable second-line option for shunt placement in complex hydrocephalus. The causes of shunt failure (blockage, infection and equipment failure) are similar to VP shunting though shunt survival rates are inferior to VP shunts. Ultrasound guided VA shunt placement provides a relatively safe, second-line alternative to the placement of a ventriculoperitoneal shunt when this route is unsuitable.

Renovascular Hypertension

Renovascular hypertension is now a curable disease in most cases by interventional radiological techniques. The authors reviewed diagnostic and therapeutic aspects of renovascular hypertension, focusing on practical points, and introduced several cases of renovascular hypertension, treated by surgery or interventional radiological techniques.

Pacemaker implantation in superior vena cava obstruction: Re-canalization, venoplasty, and stenting

Techniques to overcome challenging venous anatomy have become an increasingly important part of modern day cardiac device implantation. Complete superior vena cava (SVC) obstruction, however, is a rare and serious clinical entity, and consequently there is limited clinical experience in addressing this pathology in the context of transvenous pacemaker implantation.We present the case of a 48-year-old renal transplant patient with sick sinus syndrome and recurrent syncope, who had an upper SVC occlusion and a failed epicardial pacing system. The SVC was re-canalized and stented using techniques derived from chronic total occlusion coronary angioplasty, thus allowing successful implantation of a transvenous pacemaker lead. This case highlights the increased risk of developing central venous occlusion that exists in renal dialysis patients, and demonstrates the benefits of utilizing transferable interventional coronary and radiology techniques to overcome this pathology and facilitate pacemaker implantation.<Learning objective: Renal dialysis patients with implantable cardiac devices are at an increased risk of developing complications that include central venous obstruction. Advanced angioplasty techniques can be used to overcome complete venous obstruction and facilitate endovascular lead implantation.>

Interventional oncology for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and is increasing in incidence. The overall prognosis of patients with liver cancer is poor. The Barcelona Clinic Liver Cancer (BCLC) classification in 5stages is endorsed by European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Disease (AASLD). This classification is recommended for treatment allocation. Because a small proportion of patients are suitable for curative surgical treatment, various locoregional therapies are widely used to manage patients with HCC. The image-guided therapies, also called interventional radiology or interventional oncology (IO) techniques consisted in percutaneous or endovascular approach. This article reviews the different IO treatments available in HCC patients and the strength of the data.

Could a disruptive out patient healthcare delivery model reduce escalating in-hospital healthcare costs in knee osteoarthritis

BackgroundHealthcare costs from in-hospital joint surgery for degenerative joint diseases are predicted to significantly increase to potentially unsustainable levels in the next several decades.AimAs an index model, this paper presents...

Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry.

In recent years, yttrium-90 ((90)Y) microsphere radioembolization has been establishing itself as a safe and efficacious treatment for both primary and metastatic liver cancers. This extends to both first-line therapies as well as in the salvage setting. In addition, radioembolization appears efficacious for patients with portal vein thrombosis, which is currently a contraindication for surgery, transplantation and transarterial chemoembolization. This article reviews the efficacy and expanding use of (90)Y microsphere radioembolization with an added emphasis on recent advances in personalized dosimetry and interventional radiology techniques. Directions for future research into combination therapies with radioembolization and expansion into sites other than the liver are also explored.

Récidive tumorale osseuse locale après cimentoplastie : à propos d’un cas ; discussion de l’intérêt de la radiothérapie après cimentoplastie

Interventional radiology techniques – vertebroplasty, kyphoplasty and vertebroplasty – are part of the therapeutic arsenal in oncology. They are not, however, antitumoural by themselves. A combination of these techniques with an antitumoral treatment is thus required. We present the case of a patient with a spinal metastasis who received antitumor vertebroplasty without additional treatment. The follow-up has found a tumour development around the cement. This case illustrates the need for a complementary antitumor treatment following a consolidative procedure. Many combinations of treatment and techniques have been published; however, no study reached a sufficient proof of efficiency for any combination to be recommended. Prospective trials are needed to guide clinicians.

Angiomes de la bouche

Hemangiomas are benign tumors that occur after a few days of life. The capillary malformations are isolated or constitute part of a complex angiomatosis. Venous malformations are low flow malformations with a blue color. They are of different types. The arteriovenous malformations are high flow lesions. They are difficult to treat. Lymphatic malformations are micro- or macrocystic. MRI is the gold standard for explorations. Some patients undergo maxillofacial surgical procedures and interventional radiology techniques for venous malformations, macrocystic lymphatic malformations, arteriovenous malformations.

Treatment of Basilar Artery Occlusion using Various Techniques of Interventional Radiology

Basilar Artery Occlusion (BAO) is a rare cause of stroke, occurring in about 1% of all the cases. BAO is characterized by bad prognosis and high death rate, which is about 75-91%. Neurological symptoms which accompany BAO are of large variety. BAO may occur suddenly, with or without previous prodromal symptoms or it may proceed progressively. Basilar artery occlusion always demands quick diagnosis and treatment. We are describing 5 cases of patients with basilar artery occlusion who were subjected to endovascular methods. The patients were treated with different intravascular techniques. Two patients had a stent Solitaire FR inserted, two others were applied targeted thrombolysis, one patient had combined therapy using targeted thrombolysis and mechanical thrombectomy- Penumbra device. Neurological symptoms were determined by using National Institutes of Health Stroke Scale (NIHSS). 60% of patients achieved the result, according to NIHSS, equal 0 or 1 point or improvement of ≥ 10 points, which is defined as neurological state changing for the better as well as the reduction of symptoms. Unblocking the basilar artery (TICI ≥ 2b) was successful with 80% of patients. The lack of disability was stated with 40% of the group under treatment (mRS ≤ 2). No patient had any complications connected with intravascular treatment. The treatment of basilar artery occlusion is difficult as nowadays there are no precise guidelines defining the most successful therapy. Our study shows that using intravascular methods is a good alternative for standard therapy of basilar artery occlusion, especially with those patients who cannot be qualified for intravenous thrombolysis due to overrunning the time window or with whom intravenous using of rt-PA was not efficient. The usage of endovascular methods is hoped to have great future prospects.

Novel Gene Therapy Strategy for Hemophilia a By Hydrodynamic Gene Delivery Combined with Non-Viral Piggybac Transposon Vector in Canine Model

Currently, hemophilia A patients are treated with plasma-derived or recombinant factor VIII (FVIII) concentrates. These treatments have substantially improved the management of bleedings in hemophilia and more recently long-acting recombinant FVIII concentrates are available in clinic, but hemophilia A patients still require the repeated intravenous injections frequently 2-3 times per week. Therefore, gene and cell-based therapy is an attractive strategy for the treatment of the disease because continuous expression of FVIII levels as low as 1-5 % of normal have been shown to ameliorate the bleeding phenotype as well as improve the quality of life. Although several attempts have been made for hemophilia A gene therapy, systemic delivery of viral vectors into liver cells in vivo, however, resulted in a transient and low-level expression of FVIII, because the large size of FVIII cDNA prohibited the efficient delivery of conventional viral vectors. Moreover, there remain concerns over the safety of these approaches such as adverse immunological reactions or virus-mediated cytotoxicity. Hydrodynamic gene delivery (HGD) is considered to be an alternative candidate to viral vectors. Previously, we tested the HGD in hemophilia A mouse model with the combination of non-viral piggyBac transposon vectors which can transfer the full-length FVIII transgene. As a result, we confirmed the sustained FVIII expression for over 300 days without any immune responses (Matsui H, et.al. PLos One 9(8) e104597, 2014).While HGD system is effective and safe in small animal such as mouse (20-25g body weight), the major challenge is in applying this functioning procedure in the patients with hemophilia A. For this purpose, the current study focus on an assessment of the safety of liver-target HGD in dogs as the first step toward hydrodynamic gene therapy in clinic. Hemophilia A carrier dog was provided from Dr. Lillicrap group at Queen's University and we have already developed hemophilia A dog colony in our institution. We used both normal and hemophilia A dogs in this study. In brief, under general anesthesia using isoflurane, beagle dog (10-12Kg body weight) was placed on the table of fluoroscopy machine. A 18G peripheral catheter was directly inserted into the saphenous vein followed by insertion of a 0.038 inch guide wire, a long sheath (5Fr) and an injection balloon catheter. The balloon catheter was placed and inflated just below the branch of hepatic vein using the image-guided interventional radiology technique. Liver-targeted HGD was performed into 4 liver lobes, the right lateral, right medial, left medial, and left lateral lobe, separately using piggyBac transposon vector expressing either GFP or FVIII. An injection of saline containing plasmid DNA were performed at the speed of 10mL/second sequentially into 4 liver lobes through the hepatic veins with 20 minutes interval between each injections.Various physiological parameters including heart rate, blood pressure, oxygen saturation were continuously monitored and recorded before, during and after each injection. For the assessment of tissue damage, blood samples were collected at the various time points. For the assessment of GFP expression, the liver samples were collected under echo-guided liver biopsy both 5 and 120 days after HGD. Although, transient 5-10 fold increase in hepatobiliary enzymes, including AST, ALT, were observed, there is no significant impact on physiological parameters, such as systemic circulation, respiration and cardiac function.By histological examination of liver samples, approximately 70-80% of hepatocytes in all 4 lobes were positive with GFP both 5 and 120 days after HGD. These results suggest that HGD system combined with interventional radiology technique is capable for the large animal with safe, efficient and less invasive. Now, we are conducting FVIII gene transfer by HGD in canine hemophilia A model. DisclosuresNo relevant conflicts of interest to declare.

Congenital Portosystemic Shunts: Clinic Heterogeneity Requires an Individual Management of the Patient.

Congenital portosystemic shunt (CPSS) is a rare entity without insufficiency in treatment issues. The aim of this article is to show our experience in the heterogeneity of this condition. A retrospective study of 25 CPSS in the period 1995 to 2014 was conducted. Description of the morphology, clinical impact, and treatment is given. According to the imaging techniques (IT), the shunt was apparently intrahepatic in 14 patients, extrahepatic in 10 patients, and mixed in 1 patient. In 14 children, IT showed hepatic portal circulation. In total shunts in which radiological examination was performed, invasive radiological techniques were able to demonstrate intrahepatic portal vein. In other patients, it was not investigated as they are asymptomatic. A child presented multiorgan failure with fulminant hepatic failure at birth. The shunt was radiologically closed and clinical impairment reversed rapidly. He is now asymptomatic with no longer images of CPSS in ultrasound scan controls. Also, seven children are asymptomatic at this time and are monitored periodically. Seven children had prenatal diagnosis, in five the shunt closed spontaneously. Nine children were symptomatic in their evolution (hyperammonemia, regenerative nodules, cholestasis, gastrointestinal bleeding). Of these, in five we performed balloon test occlusion, tolerated in all patients, followed by radiological closure. In our experience, the advancement of interventional radiology techniques avoided surgery to close the shunt. Morphologically, the CPSS is extremely heterogeneous, with multiple possible connections established. CPSS has multiple clinical presentations, from asymptomatic patients to acute liver failure. The therapeutic approach should be individualized and therefore held in overspecialized centers.

Noncirrhotic portal hypertension: Medical and endoscopic management.

Noncirrhotic portal hypertension: Medical and endoscopic management.

CT-guided high-dose-rate brachytherapy in the interdisciplinary treatment of patients with liver metastases of pancreatic cancer

CT-guided high-dose-rate brachytherapy (CT-HDRBT) is an interventional radiologic technique for local ablation of primary and secondary malignomas applying a radiation source through a brachycatheter percutaneously into the targeted lesion. The aim of this study was to assess local tumor control, safety and efficacy of CT-HDRBT in the treatment of liver metastases of pancreatic cancer. Twenty consecutive patients with 49 unresectable liver metastases of pancreatic cancer were included in this retrospective trial and treated with CT-HDRBT, applied as a single fraction high-dose irradiation (15-20 Gy) using a 192Ir-source. Primary endpoint was local tumor control and secondary endpoints were complications, progression-free survival and overall survival. The mean tumor diameter was 29 mm (range 10-73). The mean irradiation time was 20 minutes (range 7-42). The mean coverage of the clinical target volume was 98% (range 88%-100%). The mean D100 was 18.1 Gy and the median D100 was 19.78 Gy. Three major complications occurred with post-interventional abscesses, three of which were seen in 15 patients with biliodigestive anastomosis (20%) and overall 15%. The mean follow-up time was 13.7 months (range 1.4-55.0). The median progression-free survival was 4.9 months (range 1.4-42.9, mean 9.4). Local recurrence occurred in 5 (10%) of 49 metastases treated. The median overall survival after CT-HDRBT was 8.6 months (range 1.5-55.3). Eleven patients received chemotherapy after ablation with a median progression-free survival of 4.9 months (mean 12.9). Nine patients did not receive chemotherapy after intervention with a median progression-free survival of 3.2 months (mean 5.0). The rate of local tumor control was 91% in both groups after 12 months. CT-HDRBT was safe and effective for the treatment of liver metastases of pancreatic cancer.

Peripheral Intrahepatic Biliary Stones Removed Using a Hybrid Percutaneous and Endoscopic Approach

Introduction: Intrahepatic biliary stones pose a challenge to endoscopic removal with low rates of success with treatment and high recurrence rates. Therefore, at this point, surgical resection of the affected lobe has a primary role in the treatment of hepatolithiasis. However, alternative treatment options should be considered in patients in whom surgery is not an option. Case Report: A 57 year-old male with a history of HBV cirrhosis who underwent a liver transplant 11 years ago presented with fever and abnormal liver enzymes. He was found to have E. Coli bacteremia with abnormal ultrasound and MR imaging of the abdomen significant for left intrahepatic biliary dilatation and left intrahepatic calculi with presence of microabscesses. Given his history of liver tranplantation, surgical resection was not an option. Interventional radiology performed a percutaneous transhepatic cholangiogram with placement of an internal-external biliary drainage catheter. Eight weeks later the patient underwent a hybrid percutaneous and endoscopic procedure. To address the biliary stones. A guidewire was inserted into the existing drainage catheter and exchanged for a 12 Fr sheath. Cholangioscopy using the Spyglass (Boston Scientific, Natick, MA) platform was performed through the sheath. Multiple biliary stones were visualized within the left hepatic duct. Electrohydraulic lithotripsy was performed using irrigation with 0.9 normal saline. All visualized stones were fragmented into sand like particles. The fragments were flushed distally into the small bowel. Subsequent cholangiogram confirmed clearance of all stones. The patient is now six months post-procedure and doing well without recurrence. Conclusion: Hepatolithiasis typically poses a clinical challenge often requiring surgery. Our case illustrates a minimally invasive hybrid approach utilizing interventional radiology techniques along with direct cholangioscopy to allow complete fragmentation and clearance of hepatolithiasis.

Paediatric musculoskeletal interventional radiology.

Interventional radiology technique is now well established and widely used in the adult population. Through minimally invasive procedures, it increasingly replaces surgical interventions that involve higher percentages of invasiveness and, consequently, of morbidity and mortality. For these advantageous reasons, interventional radiology in recent years has spread to the paediatric age as well. The aim of this study was to review the literature on the development, use and perspectives of these procedures in the paediatric musculoskeletal field. Several topics are covered: osteomuscle neoplastic malignant and benign pathologies treated with invasive diagnostic and/or therapeutic procedures such as radiofrequency ablation in the osteoid osteoma; invasive and non-invasive procedures in vascular malformations; treatment of aneurysmal bone cysts; and role of interventional radiology in paediatric inflammatory and rheumatic inflammations. The positive results that have been generated with interventional radiology procedures in the paediatric field highly encourage both the development of new ad hoc materials, obviously adapted to young patients, as well as the improvement of such techniques, in consideration of the fact that childrens' pathologies do not always correspond to those of adults. In conclusion, as these interventional procedures have proven to be less invasive, with lower morbidity and mortality rates as well, they are becoming a viable and valid alternative to surgery in the paediatric population.

Simultaneous Rapid Saline Flush to Correct Catheter Malposition: A Clinical Overview

Central venous catheters and peripherally inserted central catheters are fundamental in the delivery of pharmacologic and nutrition therapies to patient populations, including individuals with cancer. Malposition and migration of these catheters outside of the superior or inferior vena cava can contribute to delays in therapy as individuals await repositioning, and in some cases replacement of the catheter. Traditional repositioning using overwire or interventional radiology techniques can be costly and may delay care. The placement and management of these catheters has increasingly become the domain of specially trained vascular access nurses. A team of specially trained vascular access nurses, in collaboration with interventional radiologists at a National Cancer Institute-designated comprehensive cancer center developed a procedure for catheter repositioning using a simultaneous rapid saline flush technique (SRSFT). We present this procedure, along with implications for cost and clinical outcomes. Clinical outcomes suggest that 68% of catheters have been successfully repositioned using this technique with no adverse events associated with the procedure noted to date. In addition, the use of the SRSFT represents a cost savings of up to 90% compared with traditional repositioning procedures. The SRSFT is identified as safe, timely, cost-conscious, and therapeutically effective, although further research is needed to formally evaluate the efficacy of repositioning using this technique compared with overwire and interventional-radiology-guided repositioning, including complications and quality outcomes.