Society Of Interventional Radiology Research Articles

Abstract No. 40 Embolization of the Superior and Middle Rectal Arteries for the Treatment of Symptomatic Hemorrhoidal Disease using the Combination of Metallic Coils and Microspheres

To investigate the feasibility and initial results of superior and median rectal artery embolization for patients with symptomatic hemorrhoidal bleeding disease. Prospective, single-center cohort that included 10 consecutive patients who underwent superior (SRA) and middle rectal arteries (MRA) embolization with microspheres (1100 μm) and metallic coils, with a follow-up period of 6 months. Embolizations planning and guidance was performed using Embo_ASSIST software with virtual injection (GE Healthcare, IL). Inclusion criteria comprised: Symptomatic hemorrhoidal disease refractory to clinical treatment, and with Goligher classification II or III. Exclusion criteria were previous surgery for hemorrhoidal disease and Goligher classification IV. Technical success was defined as successful catheterization and embolization of the hemorrhoidal arteries using the EmboASSIST software. Hemorrhoid severity (HSS) and the quality of life (QoL) scores were used to evaluate the clinical outcomes. Procedure-related adverse event was defined according to the Society of interventional Radiology in minor or major complications. Ten patients (4 men, 6 women) underwent rectal arteries embolization for hemorrhoidal bleeding disease, with a mean age of 59 (± 13) years old. Goligher classification were level II in 70% and 3 in 30% of patients. Technical success was achieved in all patients. SRA were embolized in 100% and MRA in 80% (90% unilateral and bilateral in 10%). Mean time off work after hospital discharge was 1.4 (±0.7) days. Median procedures time was 102,5 (± 38) minutes. The HSS and QoL scores improved 91% and 85% respectively, without clinical recurrence at the 6 months follow-up (table 1). One patient (10%) had a rectal ischemia that required surgical treatment. Embolization of both superior and middle rectal arteries was feasible and improved symptoms and quality of life in patients with grade II-III hemorrhoidal disease. No clinical recurrence was observed during the first 6-month follow-up.

Abstract No. 595 Endovascular Recanalization and Reconstruction for the Treatment of Symptomatic Venous Ligation

To report techniques, adverse events, and outcomes of endovascular recanalization and stent reconstruction for symptomatic venous ligation. Nine patients, including six (66.7%) men and three (33.3%) women, with mean age 52.9 ± 11.9 years (range, 35-69 years), underwent endovenous recanalization and stent reconstruction for symptomatic venous ligation over eight years. Five (55.6%), one (11.1%), and three (33.3%) patients presented with CEAP 3, 4, and 5 diseases, respectively. External iliac vein ligation occurred in six (66.7%) patients. Ligations were unilateral left, unilateral right, and bilateral in three (33.3%), four (44.4%), and two (22.2%) patients, respectively. Ligation etiologies included surgical injury in four (44.4%), traumatic injury in two (22.2%), chronic lower extremity venous thrombosis in two (22.2%), and malignant resection in one (11.1%) patient. Technical successes, reconstruction parameters, adverse events, hospital stay lengths, clinical outcomes, stent patencies, follow-up evaluations, and mortalities were recorded. Primary single-session recanalization was achieved in nine (100%) patients. Sharp, extravascular, techniques were required in 6 (66.7%) patients. Reconstructions were created with Wallstents, SMART stents, and cTAG devices. Mean number of stents was 2.9 ± 2.5 stents (range, 1-7 stents). Mean stent diameter was 15.5 ± 3.2-mm (range, 12-26-mm). Adverse events (AEs), according to the Society of Interventional Radiology, included one (10.0%) common iliac vein injury (major AE; class D) and one (7.7%) of neck hematoma (minor AE; class A). Mean hospitalization stay length was 1.6 ± 1.6 days (range, 1-6 days). Clinical improvement was achieved in eight (88.9%) patients with six (66.7%) patients downgraded to CEAP 0 disease. Eight (88.9%) reconstructions remained patent with a mean imaging follow-up of 466.4 ± 500.3 days (range, 17-1,400 days). One (9.1%) reconstruction became occluded within sixty days and was unable to be recanalized. Mean total follow-up was 1,086.2 ± 717.5 days (range, 47-2,707 days). Thirty day and study mortality were both zero. Endovenous recanalization and reconstruction is an effective and safe treatment for symptomatic venous ligation.

Evaluation of the performance of robot assisted CT-guided percutaneous needle insertion: Comparison with freehand insertion in a phantom

PurposeTo evaluate the performance of a novel robot for CT-guided needle positioning procedures and compare it to the freehand technique in an abdominal phantom. MethodsOne interventional radiology fellow and one experienced interventional radiologist (IR) performed twelve robot-assisted and twelve freehand needle positionings in a phantom over predetermined trajectories. The robot automatically aimed a needle-guide according to the planned trajectories, after which the clinician manually inserted the needle. Using repeated CT scans, the needle position was assessed and adjusted if the clinician deemed it necessary. Technical success, accuracy, number of position adjustments, and procedure time were measured. All outcomes were analyzed using descriptive statistics and were compared between the robot-assisted and freehand procedures using the paired t-test and Wilcoxon signed rank test. ResultsCompared with the freehand technique, the robot system improved the number of technically successfully needle targeting (20/24 vs 14/24), with higher accuracy (mean Euclidean deviation from target center: 3.5 ± 1.8 mm vs 4.6 ± 2.1 mm, p = 0.02) and required fewer needle position adjustments (0.0 ± 0.2 steps vs 1.7 ± 0.9 steps, p < 0.001), respectively. The robot improved the needle positioning for both, the fellow and the expert IR, compared to their freehand performances, with more improvement for the fellow than for the expert IR. The procedure time was similar for the robot-assisted and freehand procedures (19.5 ± 9.2 min. vs 21.0 ± 6.9 min., p = 0.777). ConclusionsCT-guided needle positioning with the robot was more successful and accurate than freehand needle positioning and required fewer needle position adjustments without prolonging the procedure.

Standards and quality assurance in interventional oncology: The establishment of the International Accreditation System for Interventional Oncology Services (IASIOS).

Quality assurance is integral to benchmarking and continuous improvement in the clinical care of people affected by cancer. Quality assurance systems are built upon agreed clinical and administrative standards. The Cardiovascular and Interventional Radiology Society of Europe (CIRSE) first developed a set of Standards for Interventional Oncology Services modelled on the Standards of Practice in Radiation Oncology developed in Australia and New Zealand. A subset of these Standards has been used to develop a tiered International Accreditation System in Interventional Oncology (IASIOS). This system covers the entirety of the patient care pathway from referral through to discharge and is clearly aimed at setting the benchmark for safe, quality interventional oncology (IO) services. Such a system has multiple benefits, including increasing the awareness of the availability of IO services and assurance in the quality of the care delivered to patients.

Low-Dose CT Fluoroscopy-Guided Drainage of Deep Pelvic Fluid Collections after Colorectal Cancer Surgery: Technical Success, Clinical Outcome and Safety in 40 Patients

To assess the technical (TS) and clinical success (CS) of CT fluoroscopy-guided drainage (CTD) in patients with symptomatic deep pelvic fluid collections following colorectal surgery. A retrospective analysis (years 2005 to 2020) comprised 43 drain placements in 40 patients undergoing low-dose (10-20 mA tube current) quick-check CTD using a percutaneous transgluteal (n = 39) or transperineal (n = 1) access. TS was defined as sufficient drainage of the fluid collection by ≥50% and the absence of complications according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE). CS comprised the marked reduction of elevated laboratory inflammation parameters by ≥50% under minimally invasive combination therapy (i.v. broad-spectrum antibiotics, drainage) within 30 days after intervention and no surgical revision related to the intervention required. TS was gained in 93.0%. CS was obtained in 83.3% for C-reactive Protein and in 78.6% for Leukocytes. In five patients (12.5%), a reoperation due to an unfavorable clinical outcome was necessary. Total dose length product (DLP) tended to be lower in the second half of the observation period (median: years 2013 to 2020: 544.0 mGy*cm vs. years 2005 to 2012: 735.5 mGy*cm) and was significantly lower for the CT fluoroscopy part (median: years 2013 to 2020: 47.0 mGy*cm vs. years 2005 to 2012: 85.0 mGy*cm). Given a minor proportion of patients requiring surgical revision due to anastomotic leakage, the CTD of deep pelvic fluid collections is safe and provides an excellent technical and clinical outcome. The reduction of radiation exposition over time can be achieved by both the ongoing development of CT technology and the increased level of interventional radiology (IR) expertise.

Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: Comparison of outcomes.

Type 2 endoleak (T2EL) is the most common type of endoleak after endovascular abdominal aortic aneurysm repair (EVAR), and increases the risk of aneurysm sac rupture if it persists beyond 6 months. The purpose of this study is to compare the efficacy and safety of direct sac puncture versus transarterial embolization of T2ELs. Retrospective review of 42 consecutive T2EL embolization procedures, 19 by DSP and 23 by transarterial technique, between January 2015 and December 2020. Primary outcome was aneurysm sac stability and resolution of endoleak at follow-up imaging. Adverse events (AE) were classified based on the Society of Interventional Radiology (SIR) practice guidelines. Technical success was 94.7% (18/19) in the DSP group and 86.9% (20/23) in the transarterial group (p = 0.32 (-0.77-0.25)). Treatment efficacy was evaluated in 16 patients in the DSP group and 18 patients in the transarterial group who had follow-up imaging ≥6months after embolization. Mean imaging follow-up was 17.1 ± 11.2 (range, 6-41) months in the DSP group and 26.5 ± 15.4 (range, 6-48) months in the transarterial group (p = 0.06, -19.24-0.37). Treatment efficacy was 75% (12/16) in the DSP group and 33.3% (6/18) in the transarterial group (p = 0.02, 95% CI, 0.09-0.97). There was no procedure-related mortality. Moderate-severe AE occurred in 15.7% (3/19) in the DSP group and 8.7% (2/23) in the transarterial group (p = 0.44, -0.12-0.26). In this study, DSP embolization of T2EL was equally safe and more effective than transarterial embolization in achieving aneurysm sac stability and resolution of endoleak.

Best practices for interventional pain procedures in the setting of a local anesthetic shortage: A practice advisory from the Spine Intervention Society

Representatives from the Spine Intervention Society (SIS) Standards Division and Evidence Analysis Committee have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of a local anesthetic shortage. The practice advisory has been endorsed by SIS, the American Academy of Pain Medicine, the American College of Radiology, the American Society of Neuroradiology, the American Society of Spine Radiology, the North American Neuromodulation Society, the North American Spine Society, and the Society of Interventional Radiology, who support the following best practice recommendations and statements for the performance of intra-articular, extra-articular, paraspinal, and epidural injections in the setting of a local anesthetic shortage.1.Use of preservative-containing local anesthetics is discouraged in the performance of neuraxial procedures where the injectate may enter the epidural (or intrathecal) spaces.2.When performing procedures with risk of arterial injection, ropivacaine should not be mixed with dexamethasone and injected due to the risk of crystallization and embolization.3.Physicians should not withdraw directly from vials of local anesthetic for multiple patients due to infection risk as per Centers for Disease Control and Prevention (CDC) and Joint Commission guidelines [1].4.Only pharmacists may repackage local anesthetic vials for multiple patients. This must be performed under strict, sterile conditions and only in times of critical need. In such situations, physicians must adhere to the beyond-use-date and storage conditions on the repackaged label [2,3].5.Joint, tendon, bursa, and/or ligament injections may be performed with local anesthetic with or without preservative.6.Interventional pain physicians should weigh the relative chondrotoxicity risks associated with each anesthetic when performing joint injections.7.Topical anesthetics, infiltration with diphenhydramine, and nonpharmacologic therapies (i.e., cognitive behavioral therapy, guided imagery, virtual reality, mechanodesensitization) may be used as alternatives to skin infiltration of local anesthetic for reducing procedural pain.8.Use of small-gauge needles (25 gauge or thinner) mitigates the need for local anesthetic prior to needle insertion.9.For local anesthetic infiltration prior to insertion of large bore needles or incision, 0.5% lidocaine may be as effective as 1%, and for that reason current supplies of lidocaine can be stretched by dilution with normal saline.10.If using an ester local anesthetic due to an amide local anesthetic shortage, interventional pain physicians should be aware (as always) of the potential for an allergic reaction and should be able to respond accordingly.11.Local anesthetic systemic toxicity (LAST) differs between the varying local anesthetics, and interventional pain physicians should be well acquainted with these differences when switching between local anesthetics.Physicians should carefully weigh the risks and benefits of performing procedures without local anesthetic or using an alternative agent in the context of each unique patient's situation and should involve patients in shared decision making before proceeding.Procedures should be performed following Spine Intervention Society Guidelines [4]. The physician should confirm placement of the needle in at least two imaging planes. Please refer to the SIS Practice Guidelines for the full details and standards related to each unique procedure [4].

3D Printed Percutaneous Transhepatic Cholangiography and Drainage (PTCD) Simulator for Interventional Radiology.

Learning how to perform percutaneous transhepatic bile duct drainage (PTCD) is challenging for interventional radiology (IR) trainees. Therefore, simulators are crucial for IR training and are being increasingly demanded in the evolving healthcare environment of value-based care. To facilitate interventional training, we tried to evaluate our newly developed liver phantom for further use in IR training. We developed a liver phantom with a flexible hollow biliary tree, hydrogel-based liver parenchyma, plastic ribs, and silicone skin. The phantom was evaluated by 20 radiology residents from two hospitals. After an introduction, all participants tried to obtain biliary access by fluoroscopic guidance within 25min. Puncture time, fluoroscopy time, and kerma area product were measured. After 7days, the participants repeated the procedure on an altered and more difficult model. Additionally, a survey was handed out to every participant (20 residents, 5 experts, and 5 IR fellows) to evaluate the phantom in terms of accuracy and haptic feedback, as well as general questions regarding simulation. The residents performed significantly faster and were more self-confident on Day 7 than on Day 1, significantly decreasing puncture time, fluoroscopy time, and kerma area product (p ≤ 0.0001). The participants were very satisfied with their simulation experience and would trust themselves more in real-life scenarios. We were able to develop a phantom with high anatomical accuracy for fluoroscopy and ultrasound-guided interventions. The phantom successfully helped residents learn and improve their PTCD performance.

Deep Learning ResNet101 Deep Features of Portable Chest X-Ray Accurately Classify COVID-19 Lung Infection

This study is designed to develop Artificial Intelligence (AI) based analysis tool that could accurately detect COVID-19 lung infections based on portable chest x-rays (CXRs). The frontline physicians and radiologists suffer from grand challenges for COVID-19 pandemic due to the suboptimal image quality and the large volume of CXRs. In this study, AI-based analysis tools were developed that can precisely classify COVID-19 lung infection. Publicly available datasets of COVID-19 (N = 1525), non-COVID-19 normal (N = 1525), viral pneumonia (N = 1342) and bacterial pneumonia (N = 2521) from the Italian Society of Medical and Interventional Radiology (SIRM), Radiopaedia, The Cancer Imaging Archive (TCIA) and Kaggle repositories were taken. A multi-approach utilizing deep learning ResNet101 with and without hyperparameters optimization was employed. Additionally, the features extracted from the average pooling layer of ResNet101 were used as input to machine learning (ML) algorithms, which twice trained the learning algorithms. The ResNet101 with optimized parameters yielded improved performance to default parameters. The extracted features from ResNet101 are fed to the k-nearest neighbor (KNN) and support vector machine (SVM) yielded the highest 3-class classification performance of 99.86% and 99.46%, respectively. The results indicate that the proposed approach can be better utilized for improving the accuracy and diagnostic efficiency of CXRs. The proposed deep learning model has the potential to improve further the efficiency of the healthcare systems for proper diagnosis and prognosis of COVID-19 lung infection.

Transarterial Chemoembolization for Hepatocellular Carcinoma: 2023 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association.

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post-procedural patient care.

Current and Future Needs for Interventional Radiologists in Saudi Arabia: Position Statement by the Saudi Interventional Radiology Society

AbstractSaudi Arabia has gone through a huge expansion in the medical services, which increased the demand for interventional radiologist (IR) services. However, the current number of IRs is considerably less than the needed number, which poses a challenge to provide a 24/7 IR service coverage. The shortage may improve in the future, but it will continue through 2030 despite the successful local fellowship training program.

Interventional Radiology Workforce Shortages Affecting Small and Rural Practices: A Report of the SIR/ACR Joint Task Force on Recruitment and Retention of Interventional Radiologists to Small and Rural Practices.

Radiology practices characterized as small and rural are challenged to recruit and retain interventional radiologists. Lack of access to interventional radiologic services results in a failure to meet the needs of patients, hospitals, and other community stakeholders. Acknowledging this challenge, the ACR's Commission on General, Small, Emergency and/or Rural Practice and Commission on Interventional and Cardiovascular Imaging and the Society of Interventional Radiology partnered to establish a joint task force to study this issue and identify strategies the ACR and the Society of Interventional Radiology should take to improve small and rural practice recruitment and retention of interventional radiologists. This report describes the deliberations and recommendations of the task force.

The current status of interventional radiology in the undergraduate medical curriculum and the way forward.

Interventional radiology (IR) is underrepresented in undergraduate medical school curricula. Despite the introduction of a suggested undergraduate curriculum for IR by the British Society of Interventional Radiology (BSIR), current evidence suggests there is inadequate knowledge and awareness of IR amongst medical students. As a result of this, there is a lack of visibility of the subspeciality amongst medical students and junior doctors contributing to the shortage of IR trainees resulting in an IR workforce crisis in the UK. The uptake of the proposed undergraduate IR curriculum remains unclear, highlighting the need for a thorough audit and improvement of IR teaching in undergraduate medical education. In this commentary, we discuss the importance of including IR in the undergraduate curriculum, the evidence surrounding undergraduate IR education, the reasons for the potential lack of interest in IR from medical students and future steps to ensure optimal IR exposure in undergraduate medical school curricula.

One hour observation of patients after image-guided percutaneous renal mass biopsy.

Imaging-guided percutaneous biopsy of renal masses is regarded as safe and is widely used for histopathology diagnosis before treatment. Recommended observation time after tumour biopsy varies in international guidelines and the literature is sparse. To assess the effect of a 1-h post-biopsy observation time of percutaneous image-guided renal mass biopsy. This was a single-centre retrospective study. During January 2015 to September 2019, a total of 484 patients underwent renal mass biopsies. 4-h-observation-group: 178 patients and 1-h-observation-group 306 patients. All records were retrospectively reviewed, and data such as complications was obtained and compared between the two groups. A total complication rate of 4.5% (n = 22) without any major complications (Cardiovascular and Interventional Radiological Society of Europe-grade (CIRSE) 5-6). Furthermore, a non-significant difference of 1.3% of the 1-h group and 3.4% in the 4-h group experiencing complications was found (p = .18). A total biopsy-accuracy of 84% was observed. This study shows that renal mass biopsy is safe with no major complications. This suggests that an outpatient approach with 1-h-observation time can be safely implemented for renal mass biopsy.

Splenic embolisation practices within the UK: a national survey

•There is wide variability in the selection and technique of splenic embolisation. •There is a lack of clear evidence and guidelines on the use of splenic embolisation. •Urgent investment in the provision of 24/7 IR services is still required. AIM To review UK splenic embolisation (SE) practices for traumatic injury. MATERIALS AND METHODS An online survey approved by the British Society of Interventional Radiology (BSIR) Audit and Registry Committee was distributed to BSIR members between 15/11/2021–29/11/2021. Data obtained included the interventional radiology (IR) trauma service response, service design, institutional treatment pathways, and key clinical decision-making factors. Descriptive statistics were carried using Microsoft Excel. RESULTS A total of 62 responses, of which 61.29% (n=38) worked at a major trauma centre (MTC); 70.97% (n=44) had an interventional radiologist on-call 24/7; 77.42% (n=48) had no direct involvement with the trauma team until an eligible case was identified with only 19.35% (n=12) being part of the acute receiving trauma team; 88.71% (n=55) did not have a standard imaging pathway for conservatively managed splenic injury in their institution. In terms of the proportion of respondents considering embolisation based on severity of splenic injury, 51% (n=32) would embolise grade 5 injuries, 66% (n=41) for grade 4, 54% (n=34) for grade 3, and 12.9% (n=8) for grade 2. CONCLUSION Wide variability exists in the SE practice and decision-making within the UK IR community. A UK consensus on management of traumatic splenic injuries is required; however, an improved evidence base is essential to support these guidelines. To review UK splenic embolisation (SE) practices for traumatic injury. An online survey approved by the British Society of Interventional Radiology (BSIR) Audit and Registry Committee was distributed to BSIR members between 15/11/2021–29/11/2021. Data obtained included the interventional radiology (IR) trauma service response, service design, institutional treatment pathways, and key clinical decision-making factors. Descriptive statistics were carried using Microsoft Excel. A total of 62 responses, of which 61.29% (n=38) worked at a major trauma centre (MTC); 70.97% (n=44) had an interventional radiologist on-call 24/7; 77.42% (n=48) had no direct involvement with the trauma team until an eligible case was identified with only 19.35% (n=12) being part of the acute receiving trauma team; 88.71% (n=55) did not have a standard imaging pathway for conservatively managed splenic injury in their institution. In terms of the proportion of respondents considering embolisation based on severity of splenic injury, 51% (n=32) would embolise grade 5 injuries, 66% (n=41) for grade 4, 54% (n=34) for grade 3, and 12.9% (n=8) for grade 2. Wide variability exists in the SE practice and decision-making within the UK IR community. A UK consensus on management of traumatic splenic injuries is required; however, an improved evidence base is essential to support these guidelines.

Routine use of concurrent fluoroscopic imaging during superficial endovenous interventions: A position statement of the International Union of Phlebology, the Australasian College of Phlebology, the Australia and New Zealand Society for Vascular Surgery, the American Venous Forum, the American Vein and Lymphatic Society, the European College of Phlebology and the Interventional Radiology Society of Australasia.

International evidence-based guidelines recommend preoperative duplex ultrasound mapping in the assessment of chronic venous disease, and concurrent ultrasound imaging to guide superficial endovenous interventions such as endovenous laser ablation, radiofrequency ablation, cyanoacrylate adhesive closure, and sclerotherapy (ultrasound-guided sclerotherapy). Other imaging modalities such as venography, alone or in combination with computed tomography scan or magnetic resonance imaging, may be included in the preoperative assessment of a small and select group of patients to exclude central venous obstruction, certain deep venous pathologies, pelvic origin extrapelvic varices, and complex vascular malformations. The signatory scientific and medical societies recommend against the routine use of fluoroscopy and other radiation-based imaging in the investigation and treatment of superficial venous disease.

Barriers to research in interventional radiology within the UK

To identify these barriers to research within interventional radiology (IR) and suggest potential solutions to support IR academia within the UK and beyond. An electronic survey was compiled using Google Forms and distributed to the British Society of Interventional Radiology (BSIR) members by email and through social media (Twitter). The survey was open between 15 October 2021 and 15 December 2021. Questions included prior research experience and qualifications, research interests and barriers to research development. The data were analysed in Microsoft Excel 365. One hundred and six responses were received with the majority from junior (42.5%) and senior radiology trainees (25.5%). Eight-three percent had not undertaken formal research qualifications with 56.4% stating they would like to undertake a PhD or MD; 81.1% stated they planned to be involved in research. The most common perceived barriers were lack of time (64.2%), lack of research experience (61.3%), and lack of senior supervision (58.5%). Developing and supporting the academic IR infrastructure is vital to ensure the future of IR. Radiology trainees have shown interest in being involved with IR research and undertaking formal research training. Additional support from local hospitals, national societies, and the Royal College of Radiologists are required.

Predicting Suitable Percutaneous Endovascular Arterial Embolization for Traumatic Abdominopelvic Injuries: A Retrospective Cohort Study.

PurposeThis study evaluated the pre-procedural attributes of trauma patients to determine their suitability to undergo Percutaneous Endovascular Arterial Embolization (PEAE), and the current state of endovascular repair as an option for trauma-related injuries in traumatic abdominopelvic arterial injuries was explored.Patients and MethodsWe retrospectively evaluated the charts of 638 adults with traumatic abdominopelvic injuries treated from March 2011 to February 2021, extensively reviewing their pre-operative indices, pre-operative optimization requirements, and multi-modality imaging records.ResultsIn total, 235 patients (30.63%) were “hemodynamically unstable” on admission, mainly due to hypotension (n=437 [68.5%]). Additionally, laboratory-defined acquired coagulopathies and inherited bleeding disorders were found in 268 patients (42.01%). The computerized tomography bleeding protocol was performed on 408 (63.94%) patients. Percutaneous endovascular therapy by arterial embolization was performed on 146 patients. The mean number of requested pre-intervention blood units for trauma patients significantly exceeded the number of units transfused post-intervention (P<0.0005). Apart from hemodynamics (ie heart rate, mean blood pressure); hemoglobin, and lactic acid levels were independently associated indices of PEAE outcomes (p <0.01).ConclusionDespite the recommendations from the Society of Interventional Radiology on endovascular intervention for trauma and bleeding risk, 36.84% of study patients had hemodynamic instability and other unfeasible parameters that would limit the option of minimally invasive procedures. Early recognition and consideration of suitable treatment options is essential for optimizing patient outcomes. It is imperative that standardized algorithms and management protocols based on available resources be developed.

S1701 Bile Leak: A Rare Complication of Percutaneous Liver Biopsy

Introduction: Percutaneous liver biopsy is a cornerstone in diagnosing various hepatobiliary disorders. It is generally a safe procedure. Bile leak is a very rare complication, with rates less than 0.001%. Case Description/Methods: A 79-year-old woman presented to the emergency department with severe right upper quadrant abdominal pain along with nausea and vomiting after undergoing an ultrasound-guided percutaneous liver biopsy for elevated liver enzymes. On examination, right upper quadrant tenderness was appreciated. Computed tomography (CT) and Magnetic resonance imaging (MRI) of the abdomen were suggestive of blood products within the gallbladder. She underwent Endoscopic retrograde cholangiopancreatography (ERCP) for increased bilirubin (Table). On Fluoroscopy, she was found to have a bile leak at the level of the common hepatic duct (Figure). A temporary plastic biliary stent was placed into the common bile duct (CBD). Discussion: There are guidelines by the American Association for the Study of Liver and the Society of Interventional Radiology to prevent complications after percutaneous needle biopsies and liver biopsies. Utilizing ultrasound can help avoid injury to the gall bladder and large bile ducts. A biopsy of at least 2-3 cm length and 16-gauge caliber is considered sufficient. Patients should be closely observed for at least 2-4 hours after the procedure. Keeping a low threshold for prompt evaluation with appropriate imaging modalities and timely intervention can help overcome this challenge and reduce morbidity and mortality.Figure 1.: Fluoroscopy demonstrates extravasation of contrast at the level of the common hepatic duct, suggestive of bile leak Table 1. - Trend of total bilirubin through the hospital course. Notice the 50% decrease after biliary stent placement Total Bilirubin (mg/dL) 0.8 3.6 6.2 6.7 7.4 3.1 2.7 2.2 0.9

Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs

SPINAL CORD ISCHEMIA (SCI) after thoracoabdominal aortic repair is a well-known complication of both open and endovascular surgery, with reported rates as high as 5%-to-21% after open repair. 1 Gravereaux EC Faries PL Burks JA et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysm. Jour of Vasc Surg. 2001; 34: 997-1003 Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Resultant morbidity, including paraparesis and paraplegia, are devastating, and a fair amount of research has gone into developing strategies for mitigating SCI-related complications. Cerebrospinal fluid drainage (CSFD) with the placement of lumbar drains (LDs) is considered the current recommendation for both prevention and treatment of SCI in high-risk patients. 2 Coselli JS LeMaire SA Koksoy C et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar ,3 Hiratzka LF Bakris GL Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121: e266-e369 Crossref PubMed Scopus (1914) Google Scholar While there is some controversy over the utility of CSFD for endovascular repairs, it is still a widely accepted practice that is performed frequently for patients at high risk of developing SCI postrepair. 4 Isaak RS Furman W. Con: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should not receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1381-1383 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Protocols regarding the placement of LDs can vary by institution, whereby some centers may routinely use imaging guidance for the procedure. In this review, the authors examine the specifics of using fluoroscopic guidance for the preoperative placement of LDs in patients who are at a high risk of developing SCI after thoracoabdominal aortic repair. It is the authors’ belief that the universal use of fluoroscopic guidance is unnecessary, potentially harmful, confers additional expense, and is unsupported by the current body of evidence.