Interventional Suite Research Articles

A Look Back on the History of Cerebral Revascularization for Acute Ischemic Stroke: A Neurosurgeon's Perspective.

This review looks back on our experience with acute middle cerebral artery embolectomies in the 1990s, frowned upon by stroke experts at the time, and no match for the newly introduced and proven treatment of acute ischemic stroke with intravenous recombinant tissue plasminogen activator (alteplase). The past several decades have seen dramatic developments in acute cerebral revascularization, the major paradigm shift being in the form of endovascular thrombectomy. Mechanical thrombectomy has moved from the operating room, where we performed it, to the interventional angiography suite armed with ever-improving clot aspiration and retrieval technologies.

Effectiveness and sustainability of a multidisciplinary care model for patients with hemodialysis access dysfunction.

A multidisciplinary care model involving the interventional radiologist, vascular surgeon, interventional nephrologist, renal advanced nurse practitioner, and renal coordinators was implemented to improve the care for the patient admitted with dysfunctional hemodialysis access. This study aims to evaluate the effectiveness and sustainability of this multidisciplinary care model. A dedicated interventional nephrology suite was established to perform endovascular procedures for patients admitted with hemodialysis access dysfunction via the emergency department of the hospital. We retrospectively collected data from electronic medical records 1-year before and after the implementation (April 2015). Outcome measures include waiting time for intervention, length of stays (LOS), number of dialysis catheter insertions before the intervention, number of inpatient dialysis required, and success rates of the interventions. The waiting time for intervention and LOS was tracked over the next 3 years to determine the sustainability of the care model. Eight hundred eighty-one endovascular interventions (314 angioplasties, 567 thrombolysis) were performed on 554 patients. Post-implementation, a greater proportion of intervention was performed within 24 h (238 (50.2%) vs 70 (17.2%), p < 0.001) with lesser proportion of patients requiring bridging hemodialysis via temporary catheter, 156 (32.9%) versus 215 (52.8%), p < 0.001. A shorter median LOS and days-to-intervention were reported, 3 (IQR 2-6) versus 5 days (IQR 3-8), p < 0.001 and 1 (IQR 1-2) versus 3 days (IQR 2-4), p < 0.001 respectively. Less hemodialysis session/patient required, 2 (IQR 1-3) versus 3 (IQR 2-4), p < 0.001. The procedural success rate was greater, 440 (92.8%) versus 355 (87.2%), p = 0.020. Three years following implementation, the proportion of patients who received intervention within 24 h and were discharged within 48 h was reported to be persistently greater, 43% versus 13%, p < 0.001, and 27% versus 6%, p < 0.001 respectively. This multi-disciplinary collaboration demonstrated a sustainable care model in improving the delivery of healthcare services for patients with dysfunctional hemodialysis access.

RUSH to the Diagnosis: Identifying Occult Pathology in Hypotensive Patients

Case Presentation: A 63-year-old female presented to our emergency department with altered mental status and hypotension. She was transferred from the outpatient interventional radiology suite after becoming unresponsive during the removal of an inferior vena cava filter. The patient arrived somnolent with no other history available. Her physical exam was unremarkable. We used point-of-care-ultrasound to perform a rapid ultrasound for shock and hypotension (RUSH) exam. A large pericardial effusion along with signs of cardiac tamponade were identified. The cardiothoracic surgery team was notified, and the patient was taken to the operating room where pericardial blood and a large hematoma were evacuated. She recovered uneventfully and was discharged one week later. Discussion: The above case describes a very unstable patient whose diagnosis was obtained using the RUSH exam. History and physical did not point to a clear etiology. Options were very limited. She was too unstable to go for computed tomography, and other tests such as electrocardiogram, chest radiograph, and lab work would have been non-diagnostic. It was only after the cardiac view of the RUSH exam was obtained that a pericardial effusion and developing tamponade were identified, facilitating timely management. The RUSH exam, like the extended focused assessment with sonography for trauma, is used to help determine pathologies that need immediate intervention. Incorporation in the evaluation of critically ill patients reduces the time to diagnosis. Our case is a unique example of how point-of-care ultrasound can be used to urgently identify a life-threatening pathology.

The UK resuscitative endovascular balloon occlusion of the aorta in trauma patients with life-threatening torso haemorrhage: the (UK-REBOA) multicentre RCT.

The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis. To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department. Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone. United Kingdom Major Trauma Centres. Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta. Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta. Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon. Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data). Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%). The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates. This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful. The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required. This trial is registered as ISRCTN16184981. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.

Remimazolam As a Sole Sedative Agent for Gastrostomy Tubes Placed in the Interventional Radiology Suite: A Case Series.

Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.

Stroke Evaluation in the Interventional Suite Using Dual-Layer Detector Cone-Beam CT: aFirst-in-human Prospective Cohort Study (the Next GenerationX-ray Imaging System Trial).

Cone-beam CT in the interventional suite could be an alternative to CT to shorten door-to-thrombectomy time. However, image quality in cone-beam CT is limited by artifacts and poor differentiation between gray and white matter. This study compared non-contrast brain dual-layer cone-beam CT in the interventional suite to reference standard CT in stroke patients. Aprospective single-center study enrolled consecutive participants with ischemic or hemorrhagic stroke. The hemorrhage detection accuracy, per-region ASPECTS accuracy and subjective image quality (Likert scales for gray-white matter differentiation, structure perception and artifacts) were assessed by three neuroradiologists blinded to clinical data on dual-layer cone-beam CT 75 keV monoenergetic images compared to CT. Objective image quality was assessed by region-of-interest metrics. Non-inferiority for hemorrhage detection and ASPECTS accuracy was determined by the exact binomial test with aone-sided lower performance boundary prospectively set to 80% (98.75% CI). 27participants were included (74years ± 9; 19female) in the hyperacute or acute stroke phase. One reader missed asmall bleeding, but all hemorrhages were detected in the majority analysis (100% accuracy, CI lower boundary 86%, p = 0.002). ASPECTS majority analysis showed 90% accuracy (CI lower boundary 85%, p < 0.001). Sensitivity was 66% (individual readers 67%, 69%, and 76%), specificity was 97% (97%, 96%, 89%). Subjective and objective image quality were inferior to CT. In asmall single-center cohort, dual-layer cone-beam CT showed non-inferior hemorrhage detection and ASPECTS accuracy to CT. Despite inferior image quality, the technique may be useful for stroke evaluation in the interventional suite. NCT04571099 (clinicaltrials.gov). Prospectively registered 2020-09-04.

Effect of Noise Management in Interventional Radiology Suites on Patients Undergoing Transarterial Chemoembolization: A Retrospective Study.

This study aims to evaluate the effect of noise management in interventional radiology suites on patients undergoing transarterial chemoembolization (TACE). A retrospective cohort study design was employed. The study included a total of 141 patients with hepatocellular carcinoma who underwent TACE surgery in interventional radiology suite of the First People's Hospital of Nantong from January 2022 to December 2022. The patients were divided into an observation group (received noise management, n = 70) and a control group (did not receive noise management, n = 71) on the basis of whether they received noise management. Patient demographics and surgical data were collected, and heart rate, blood pressure, and anxiety levels were assessed before, during and after surgery. Satisfaction and the incidence of adverse reactions were also documented. No significant differences were found in general characteristics. The comparison between the observation and control groups revealed statistically significant differences in noise levels (P < 0.001). Additionally, anxiety levels significantly differed between the two groups (P = 0.040) as well as across different time points (P < 0.001). However, no significant difference was found in the occurrence of adverse events between groups (P = 0.772). Furthermore, patient satisfaction was significantly higher in the observation group than that in the control group (P < 0.001). Although no significant differences were found in heart rate and systolic blood pressure between groups (P > 0.05), and a significant main effect of time was observed for both variables (P < 0.001). Noise management in the interventional radiology suite effectively alleviates intraoperative anxiety among patients with TACE and improves treatment satisfaction but has no significant effect on physiological changes and the incidence of adverse events.

Nonoperating room regional anesthesia in pediatric patients: A review of indications and challenges

Nonoperating room regional anesthesia (NORRA) involves providing regional anesthesia in environments other than the standard operating rooms, such as in intensive care units, emergency departments, or interventional radiology suites. Although regional anesthesia is well-documented for its benefits in perioperative care, its application in nonoperating room environments remains limited. We conducted a narrative literature review using various databases such as PubMed, Embase, Medline, Ovid, PMC, and Google Scholar. Our search strategy involved using different combinations of terms associated with regional anesthesia, nonoperating room anesthesia, intensive care units, and pediatric patients. Regional anesthesia offers significant benefits for pediatric patients, such as reducing the need for opioids and enhancing autonomic, metabolic, and immunological responses. Techniques used in NORRA include central neuraxial blocks, peripheral nerve blocks, and topical anesthesia, with common anesthetic agents being lidocaine, bupivacaine, and eutectic mixture of local anesthetic cream. This review investigates the applications, indications, challenges, and future prospects of NORRA in pediatric patients.

Use of regional anesthesia within a pediatric interventional radiology suite reduced periprocedural opioid use without delaying the overall workflow: a retrospective study

BackgroundNerve block utility has been extensively described in the operating room, however, there is a paucity of evidence regarding blocks in the interventional radiology (IR) suite, with no studies examining...

Cardiovascular Imaging, Climate Change, and Environmental Sustainability.

Environmental exposures including poor air quality and extreme temperatures are exacerbated by climate change and are associated with adverse cardiovascular outcomes. Concomitantly, the delivery of health care generates substantial atmospheric greenhouse gas (GHG) emissions contributing to the climate crisis. Therefore, cardiac imaging teams must be aware not only of the adverse cardiovascular health effects of climate change, but also the downstream environmental ramifications of cardiovascular imaging. The purpose of this review is to highlight the impact of climate change on cardiovascular health, discuss the environmental impact of cardiovascular imaging, and describe opportunities to improve environmental sustainability of cardiac MRI, cardiac CT, echocardiography, cardiac nuclear imaging, and invasive cardiovascular imaging. Overarching strategies to improve environmental sustainability in cardiovascular imaging include prioritizing imaging tests with lower GHG emissions when more than one test is appropriate, reducing low-value imaging, and turning equipment off when not in use. Modality-specific opportunities include focused MRI protocols and low-field-strength applications, iodine contrast media recycling programs in cardiac CT, judicious use of US-enhancing agents in echocardiography, improved radiopharmaceutical procurement and waste management in nuclear cardiology, and use of reusable supplies in interventional suites. Finally, future directions and research are highlighted, including life cycle assessments over the lifespan of cardiac imaging equipment and the impact of artificial intelligence tools. Keywords: Heart, Safety, Sustainability, Cardiovascular Imaging Supplemental material is available for this article. © RSNA, 2024.

MT40 Budget Impact of Implementing an Advanced Interventional Suite Platform for Interventional Procedures

MT40 Budget Impact of Implementing an Advanced Interventional Suite Platform for Interventional Procedures

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case.

Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration. A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well. Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Automating sedation state assessments using natural language processing.

Common goals for procedural sedation are to control pain and ensure the patient is not moving to an extent that is impeding safe progress or completion of the procedure. Clinicians perform regular assessments of the adequacy of procedural sedation in accordance with these goals to inform their decision-making around sedation titration and also for documentation of the care provided. Natural language processing could be applied to real-time transcriptions of audio recordings made during procedures in order to classify sedation states that involve movement and pain, which could then be integrated into clinical documentation systems. The aim of this study was to determine whether natural language processing algorithms will work with sufficient accuracy to detect sedation states during procedural sedation. A prospective observational study was conducted. Audio recordings from consenting participants undergoing elective procedures performed in the interventional radiology suite at a large academic hospital were transcribed using an automated speech recognition model. Sentences of transcribed text were used to train and evaluate several different NLP pipelines for a text classification task. The NLP pipelines we evaluated included a simple Bag-of-Words (BOW) model, an ensemble architecture combining a linear BOW model and a "token-to-vector" (Tok2Vec) component, and a transformer-based architecture using the RoBERTa pre-trained model. A total of 15,936 sentences from transcriptions of 82 procedures was included in the analysis. The RoBERTa model achieved the highest performance among the three models with an area under the ROC curve (AUC-ROC) of 0.97, an F1 score of 0.87, a precision of 0.86, and a recall of 0.89. The Ensemble model showed a similarly high AUC-ROC of 0.96, but lower F1 score of 0.79, precision of 0.83, and recall of 0.77. The BOW approach achieved an AUC-ROC of 0.97 and the F1 score was 0.7, precision was 0.83 and recall was 0.66. The transformer-based architecture using the RoBERTa pre-trained model achieved the best classification performance. Further research is required to confirm the that this natural language processing pipeline can accurately perform text classifications with real-time audio data to allow for automated sedation state assessments. Automating sedation state assessments using natural language processing pipelines would allow for more timely documentation of the care received by sedated patients, and, at the same time, decrease documentation burden for clinicians. Downstream applications can also be generated from the classifications, including for example real-time visualizations of sedation state, which may facilitate improved communication of the adequacy of the sedation between clinicians, who may be performing supervision remotely. Also, accumulation of sedation state assessments from multiple procedures may reveal insights into the efficacy of particular sedative medications or identify procedures where the current approach for sedation and analgesia is not optimal (i.e. a significant amount of time spent in "pain" or "movement" sedation states).

Flat-panel Detector Perfusion Imaging and Conventional Multidetector Perfusion Imaging in Patients with Acute Ischemic Stroke

PurposeFlat-panel detector computed tomography (FDCT) is increasingly used in (neuro)interventional angiography suites. This study aimed to compare FDCT perfusion (FDCTP) with conventional multidetector computed tomography perfusion (MDCTP) in patients with acute ischemic stroke.MethodsIn this study, 19 patients with large vessel occlusion in the anterior circulation who had undergone mechanical thrombectomy, baseline MDCTP and pre-interventional FDCTP were included. Hypoperfused tissue volumes were manually segmented on time to maximum (Tmax) and time to peak (TTP) maps based on the maximum visible extent. Absolute and relative thresholds were applied to the maximum visible extent on Tmax and relative cerebral blood flow (rCBF) maps to delineate penumbra volumes and volumes with a high likelihood of irreversible infarcted tissue (“core”). Standard comparative metrics were used to evaluate the performance of FDCTP.ResultsStrong correlations and robust agreement were found between manually segmented volumes on MDCTP and FDCTP Tmax maps (r = 0.85, 95% CI 0.65–0.94, p < 0.001; ICC = 0.85, 95% CI 0.69–0.94) and TTP maps (r = 0.91, 95% CI 0.78–0.97, p < 0.001; ICC = 0.90, 95% CI 0.78–0.96); however, direct quantitative comparisons using thresholding showed lower correlations and weaker agreement (MDCTP versus FDCTP Tmax 6 s: r = 0.35, 95% CI −0.13–0.69, p = 0.15; ICC = 0.32, 95% CI 0.07–0.75). Normalization techniques improved results for Tmax maps (r = 0.78, 95% CI 0.50–0.91, p < 0.001; ICC = 0.77, 95% CI 0.55–0.91). Bland-Altman analyses indicated a slight systematic underestimation of FDCTP Tmax maximum visible extent volumes and slight overestimation of FDCTP TTP maximum visible extent volumes compared to MDCTP.ConclusionFDCTP and MDCTP provide qualitatively comparable volumetric results on Tmax and TTP maps; however, direct quantitative measurements of infarct core and hypoperfused tissue volumes showed lower correlations and agreement.

Interventional Imaging Systems in Radiology, Cardiology, and Urology: Energy Consumption, Carbon Emissions, and Electricity Costs.

BACKGROUND. The energy demand of interventional imaging systems has historically been estimated using manufacturer-provided specifications rather than directly measured. OBJECTIVE. The purpose of this study was to investigate the energy consumption of interventional imaging systems and estimate potential savings in the carbon emissions and electricity costs of such systems through hypothetical operational adjustments. METHODS. An interventional radiology suite, neurointerventional suite, radiology fluoroscopy unit, two cardiology laboratories, and two urology fluoroscopy units were equipped with power sensors. Power measurement logs were extracted for a single 4-week period for each radiology and cardiology system (all between June 1, 2022, and November 28, 2022) and for the 2-week period from July 31, 2023, to August 13, 2023, for each urology system. Power statuses, procedure time stamps, and fluoroscopy times were extracted from various sources. System activity was divided into off, idle (no patient in room), active (patient in room for procedure), and net-imaging (active fluoroscopic image acquisition) states. Projected annual energy consumption was calculated. Potential annual savings in carbon emissions and electricity costs through hypothetical operational adjustments were estimated using published values for Switzerland. RESULTS. Across the seven systems, the mean power draw was 0.3-1.1, 0.7-7.4, 0.9-7.6, and 1.9-12.5 kW in the off, idle, active, and net-imaging states, respectively. Across systems, the off state, in comparison with the idle state, showed a decrease in the mean power draw of 0.2-6.9 kW (relative decrease, 22.2-93.2%). The systems had a combined projected annual energy consumption of 115,684 kWh (range, 3646-26,576 kWh per system). The systems' combined projected energy consumption occurring outside the net-imaging state accounted for 93.3% (107,978/115,684 kWh) of projected total energy consumption (range, 89.2-99.4% per system). A hypothetical operational adjustment whereby all systems would be switched from the idle state to the off state overnight and on weekends (versus being operated in idle mode 24 hours a day, 7 days a week) would yield the following potential annual savings: for energy consumption, 144,640 kWh; for carbon emissions, 18.6 metric tons of CO2 equivalent; and for electricity costs, US$37,896. CONCLUSION. Interventional imaging systems are energy intensive, having high consumption outside of image acquisition periods. CLINICAL IMPACT. Strategic operational adjustments (e.g., powering down idle systems) can substantially decrease the carbon emissions and electricity costs of interventional imaging systems.

The Outpatient Endovascular & Interventional Society (OEIS)—The Voice of Advocacy for the OBL: Origins, Principles, and Historical Perspective

The physician office offering imaging guided endovascular and minimally invasive interventional procedures is often referred to as an OBL (office based lab), OIS (office interventional suite), or OES (office endovascular suite). Initially, OBL's depended upon the national societies of interventional radiology (SIR), vascular surgery (SVS) and interventional cardiology (SCAI) to advocate for them. However, the OBL space needed a voice dedicated to advocating for the appropriate reimbursement of procedures in the OBL to allow the OBL to survive as a viable site of service and become integral to healthcare delivery in the US healthcare system. This need led to the formation of the Outpatient Endovascular & Interventional Society (OEIS). The society is multispecialty and ensures safety in outpatient care in all sites of service while maintaining a focus on the OBL. The mission of the OEIS is to advocate for patients to have the ability to choose their provider and be able to receive safe and effective healthcare in a more friendly and far less costly site of service for them.

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BackgroundVideo-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.MethodsRetrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.Results30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).ConclusionsWe demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Tripod Fixation of Periacetabular Metastatic Lesions Using the IlluminOss Device.

Percutaneous tripod fixation of periacetabular lesions is performed at our institution for patients with metastatic bone disease and a need for quick return to systemic therapy. We have begun to use the IlluminOss Photodynamic Bone Stabilization System instead of the metal implants previously described in the literature because of the success of the IlluminOss implant in fixing fragility fractures about the pelvis. At our institution, the procedure is performed in the interventional radiology suite in order to allow for the use of 3D radiographic imaging and vector guidance systems. The patient is positioned prone for the transcolumnar PSIS-to-AIIS implant and posterior column/ischial tuberosity implant or supine for the anterior column/superior pubic ramus implant. Following a small incision, a Jamshidi needle with a trocar is utilized to enter the bone at the chosen start point. A hand drill is utilized to advance the Jamshidi needle according to the planned vector; alternatively, a curved or straight awl can be utilized. The 1.2-mm guidewire is placed and reamed. We place both the transcolumnar and posterior column wires at the same time to ensure that there is no interference. The balloon catheter for the IlluminOss is assembled on the back table and inserted according to the implant technique guide. The balloon is inflated and observed on radiographs in order to ensure that the cavity is filled. Monomer is then cured, and the patient is flipped for the subsequent implant. Following placement of the 3 IlluminOss devices, adjunct treatments such as cement acetabuloplasty or cryoablation can be performed. Alternative treatments include traditional open fixation of impending or nondisplaced acetabular fractures in the operating room, or percutaneous implant placement in the operating room. Implant placement may be performed with the patient in the supine, lateral, or prone position, depending on surgeon preference. Alternative implants include standard metal implants such as plates and screws, or cement augmentation either alone or with percutaneous screws. Finally, ablation alone may be an alternative option, depending on tumor histology. Open treatment of acetabular fractures is a more morbid procedure, given the larger incision, increased blood loss, longer time under anesthesia, and increased length of recovery. Percutaneous fixation may be performed in either the operating room or interventional radiology suite, depending on the specific equipment setup at an individual institution. At our institution, we prefer utilizing the interventional radiology suite as it allows for more precise implant placement through the use of an image-based vector guidance system and 3D fluoroscopy to accurately identify safe corridors. The use of percutaneous fixation allows for faster recovery and earlier return to systemic therapy. Because the IlluminOss implant is radiolucent, it allows for better evaluation of disease progression and can better accommodate nonlinear corridors or fill a lytic lesion to provide stability. Postoperatively, we expect the patient to be weight-bearing as tolerated with use of an assistive device. We expect the small incisions to fully heal within 2 weeks. Patients should be able to return to systemic therapy as indicated earlier than with an open procedure. The use of a hand drill with the Jamshidi needle and trocar can help adjust a drilled pathway and allow for close adherence to a planned vector.Vector guidance systems can be useful to fully capture the area at risk for fracture and to provide maximal stability with the expandable implant, but they are not necessary to perform the procedure.Placing both posterior implants at the same time can be helpful to avoid interference. This is accomplished by drilling and placing the guidewire for both implants prior to reaming and placing the balloon implant. CT = Computed tomographyPSIS = posterior superior iliac spineAIIS = anterior inferior iliac spine.

MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development.

Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Prospective study examining the impact of cerebral angiography on quantitative pupillometer values in the interventional radiology suite

ObjectivesThe purpose of this pilot study was to obtain baseline quantitative pupillometry (QP) measurements before and after catheter-directed cerebral angiography (DCA) to explore the hypothesis that cerebral angiography is an...