Image-guided Percutaneous Techniques Research Articles

Cementoplasty to cryoablation: review and current status.

Recent advances in percutaneous image-guided techniques have empowered interventional radiologists with diverse treatment options for the management of musculoskeletal lesions. Of note, there is growing utility for cementoplasty procedures, with indications ranging from stabilization of bone metastases to treatment of painful vertebral compression fractures. Likewise, cryoablation has emerged as a viable adjunct in the treatment of both primary and secondary bone and soft tissue neoplasms. These treatment options have been progressively incorporated into the multidisciplinary approach to holistic care of patients, alongside conventional radiotherapy, systemic therapy, surgery, and analgesia. This review article serves to outline the indications, technical considerations, latest developments, and evidence for the burgeoning role of cementoplasty and cryoablation in the musculoskeletal system, with an emphasis on pain palliation and tumour control.

EUS-guided versus percutaneous liver abscess drainage: A multicenter collaborative study.

Management of hepatic abscesses has traditionally been performed by image-guided percutaneous techniques. More recently, EUS drainage has been shown to be efficacious and safe. The aim of this study is to compare EUS-guided versus percutaneous catheter drainage (PCD) of hepatic abscesses. Patients who underwent EUS-guided drainage or PCD of hepatic abscesses from January 2018 through November 2021 from 4 international academic centers were included in a dedicated registry. Demographics, clinical data preprocedure and postprocedure, abscess characteristics, procedural data, adverse events, and postprocedure care were collected. Seventy-four patients were included (mean age, 63.9 years; 45% male): EUS-guided (n = 30), PCD (n = 44). Preprocedure Charlson Comorbidity Index scores were 4.3 for the EUS group and 4.3 for the PCD group. The median abscess size was 8.45 × 6 cm (length × width) in the EUS group versus 7.3 × 5.5 cm in the PCD group. All of the abscesses in the EUS group were left-sided, whereas the PCD group contained both left- and right-sided abscesses (29 and 15, respectively). Technical success was 100% in both groups. Ten-millimeter-diameter stents were used in most cases in the EUS group, and 10F catheters were used in the PCD group. The duration to resolution of symptoms from the initial procedure was 10.9 days less in the EUS group compared with the PCD group (P < 0.00001). Hospital length of stay was shorter in the EUS group by 5.2 days (P = 0.000126). The EUS group had significantly fewer number of repeat sessions: mean of 2 versus 7.7 (P < 0.00001) and trended toward fewer number of procedure-related readmissions: 10% versus 34%. The PCD group had a significantly higher number of adverse events (n = 27 [61%]) when compared with the EUS group (n = 5 [17%]; P = 0.0001). EUS-guided drainage is an efficacious and safe intervention for the management of hepatic abscesses. EUS-guided drainage allows for quicker resolution of symptoms, shorter length of hospital stay, fewer adverse events, and fewer procedural sessions needed when compared with the PCD technique. However, EUS-guided drainage may not be feasible in right-sided lesions.

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

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

Image-guided tunneled peritoneal dialysis catheter placement.

Patients with end-stage renal disease (ESRD) often will ultimately require dialysis to survive. One type of dialysis is peritoneal dialysis (PD), which utilizes the vessel-rich peritoneum as a semi-permeable membrane to filter blood. In order to perform PD, a tunneled catheter must be placed through the abdominal wall and into the peritoneal space, with ideal positioning of the catheter within the most dependent portion of the pelvis, represented by the rectouterine or rectovesical space in women and men, respectively. There are several approaches to PD catheter insertion, including open surgical, laparoscopic surgical, blind percutaneous, and image-guided with the use of fluoroscopy techniques. Interventional radiology (through the use of image-guided percutaneous techniques) is an infrequently utilized resource to place PD catheters, and offers real-time imaging confirmation of catheter positioning with similar outcomes to more invasive surgical catheter insertion approaches. Although the vast majority of dialysis patients receive hemodialysis instead of peritoneal dialysis in the United States, some countries have moved towards a "Peritoneal Dialysis First" initiative, prioritizing initial PD, as it is less burdensome on healthcare facilities as it can be performed at home. In addition, the outbreak of the COVID-19 pandemic has produced shortages of medical supplies and delays in care delivery worldwide, while simultaneously generating a shift away from in-person medical visits and appointments. This shift may be met with more frequent utilization of imaged-guided PD catheter placement, reserving surgical and laparoscopic placement for complex patients who may require omental periprocedural revisions. This literature review outlines a brief history of PD, the various techniques of PD catheter insertion, patient selection criteria, and new COVID-19 considerations, in anticipation for the increased demand for PD in the United States.

Percutaneous Management of Cancer Pain.

To describe several effective imaging-guided, minimally invasive treatments to relieve cancer-associated pain in oncologic patients. Clinical applications, technical considerations, and current controversies are addressed. The great variability in tumor subtype, location, and growth rates dictate the necessity for a tailored treatment approach. While opioids and radiotherapy may provide adequate relief for some patients, alternative minimally invasive procedures may augment theses more traditional treatments or even provide superior palliative relief. Recent image-guided percutaneous techniques applied to reduce cancer-associated pain and minimize opioid dependence include neurolysis, ablation, high intensity focused ultrasound, and bone consolidation. Each technique treats cancer pain in a unique method. Minimally invasive interventional radiology techniques can provide effective and lasting pain palliation for cancer patients through both indirect and direct effects. Selection among treatments techniques should be based upon an individually tailored approach, to include consideration of all treatment modalities.

Prevention of Pathological Fracture of the Proximal Femur: A Systematic Review of Surgical and Percutaneous Image-Guided Techniques Used in Interventional Oncology.

Background and objectives: Patients suffering from bone metastasis are at high risk for pathological fractures and especially hip fractures. Osteolytic metastases can induce a high morbidity rate (i.e., pain, facture risk, mobility impairment), and operation on them can be difficult in this frail population having a reduced life expectancy. Several medical devices have been investigated for the prevention of these pathological hip fractures. Materials and Methods: To investigate these solutions, a literature review and a meta-analysis of primary studies was performed. Data sources included electronic databases (PubMed, CENTRAL and ClinicalTrials.gov) from 1990 until 1 January 2019. Titles, abstracts and full-text articles were reviewed in order to select only studies evaluating the performance of the studied solution to prevent osteoporotic and/or pathological hip fracture. The main outcomes were the occurrence of hip fracture, pain evaluation (VAS score) and adverse events occurrence (including severe adverse events and deaths). All randomised controlled trials (RCTs) and cohort studies were considered. A Bayesian cumulative meta-analysis was undertaken on the primary studies conducted in patients with bone metastasis. Results: A total of 12 primary studies were identified, all were cohort studies without a control group, and one compared two devices, and were thereafter considered separately. In those 12 samples, 255 patients were included, mean age 61.7 years. After implantation, the cumulative risk of fracture was 5.5% (95% confidence interval, 3.0% to 8.6%), and adverse event occurrence was 17.4% (95%CI, 12.6 to 22.8%), with a median follow-up of 10 months. The posterior probability of a fracture rate below 5% was 40.3%. Conclusions: The literature about medical devices evaluation for preventing hip fractures in metastatic patients is poor and mostly based on studies with a limited level of evidence. However, this systematic review shows promising results in terms of efficacy and tolerance of these devices in patients with bone metastases. This treatment strategy requires further investigations.

Percutaneous Treatments of Benign Bone Tumors.

Benign bone tumors consist of a wide variety of neoplasms that do not metastasize but can still cause local complications. Historical management of these tumors has included surgical treatment for lesion resection and possible mechanical stabilization. Initial percutaneous ablation techniques were described for osteoid osteoma management. The successful experience from these resulted in further percutaneous image-guided techniques being attempted, and in other benign bone tumor types. In this article, we present the most common benign bone tumors and describe the available results for the percutaneous treatment of these lesions.

Death Due to a Rare Complication of USG-Guided Needle Aspiration of Liver Abscess: A Case Report

Liver abscesses (LA) are common in tropical countries, having significant morbidity or mortality. The image-guided percutaneous techniques play a very important role in the management of liver abscesses and are considered to reduce mortality rates in liver abscess. Percutaneous Needle Aspiration (PNA) is the least invasive, inexpensive procedure and much safer as compared to the other surgical methods. We present an autopsy case of a patient of amoebic liver abscess who died of hemorrhagic shock because of bleeding from rupture of liver abscess during PNA. The authors intend to increase the awareness of treating clinicians about this rare and unforeseen complication of a seemingly less risky procedure of PNA for the betterment of patient care.

Placement of the Abbvie Peg-J Tube for the Treatment of Parkinson's Disease in the Interventional Radiology Suite

The primary treatment for Parkinson's disease is dopaminergic stimulation. Although levodopa has historically been administered orally, maintaining a predictable plasma concentration of the drug is challenging. As a result, enteral administration of carbidopa/levodopa (Duopa) has emerged as a promising tool in the treatment of the disease. This requires placement of an enteric catheter, two of which have been approved by the Food and Drug Administration for delivery of Duopa. The approved tubes are placed using the “peroral” or “pull” technique, a method traditionally requiring endoscopy. This technical note describes placement of the AbbVie PEG-J tube by means of the peroral route while utilizing only sonographic and fluoroscopic guidance. After placing an orogastric tube and achieving percutaneous access to the stomach under fluoroscopic visualization, a snare catheter is advanced through the percutaneous access into the stomach. The orogastric tube is engaged with the snare and retracted, bringing the attached snare with it to the mouth. The AbbVie PEG tube is attached to the snare, pulled back down the esophagus and into the stomach before being retracted through the percutaneous access to the skin. Finally, the AbbVie J tube is advanced through the gastrostomy tube into the proximal jejunum and attached with the provided connectors. As demonstrated, the AbbVie PEG-J tube can be placed safely and effectively using a percutaneous image-guided technique without the use of an endoscope.

Percutaneous Management of Accidentally Retained Foreign Bodies During Image-Guided Non-vascular Procedures: Novel Technique Using a Large-Bore Biopsy System.

To describe a novel percutaneous image-guided technique using a large-bore biopsy system to retrieve foreign bodies (FBs) accidentally retained during non-vascular interventional procedures. Between May 2013 and October 2015, five patients underwent percutaneous retrieval of five iatrogenic FBs, including a biopsy needle tip in the femoral head following osteoblastoma biopsy and radiofrequency ablation (RFA); a co-axial needle shaft within a giant desmoid tumour following cryoablation; and three post-vertebroplasty cement tails within paraspinal muscles. All FBs were retrieved immediately following original procedures under local or general anaesthesia, using combined computed tomography (CT) and fluoroscopic guidance. The basic technique involved positioning a 6G trocar sleeve around the FB long axis and co-axially advancing an 8G biopsy needle to retrieve the FB within the biopsy core. Retrospective chart review facilitated analysis of procedures, FBs, technical success, and complications. Mean FB size was 23mm (range 8-74mm). Four FBs were located within 10mm of non-vascular significant anatomic structures. The basic technique was successful in 3 cases; 2 cases required technical modifications including using a stiff guide-wire to facilitate retrieval in the case of the post-cryoablation FB; and using the central mandrin of the 6G trocar to push a cement tract back into an augmented vertebra when initial retrieval failed. Overall technical success (FB retrieval or removal to non-hazardous location) was 100%, with no complications. Percutaneous image-guided retrieval of iatrogenic FBs using a large-bore biopsy system is a feasible, safe, effective, and versatile technique, with potential advantages over existing methods.

Abstract No. 403 - Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet’s disease

No. 403 Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet’s disease S. Lee, S. Kim, D. Lee, M. Kim, J. Won, S. Park, Y. Yoon, D. Choi, Y. Ko; Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiothoracic Surgery, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea; Internal Medicine, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea Purpose: To evaluate the effectiveness of endovascular stentgrafting for surgical management of aortic pseudoaneurysm in patients with Behcet’s disease (BD). Materials and Methods: We present a single-institution retrospective cohort of patients with aortic pseudoaneurysm and BD treated with aortic stent-grafting. CT imaging was obtained preoperatively in all patients and once within two weeks postoperatively, and then annually. Clinical followup and erythrocyte sedimentation rate (ESR) were used to follow BD activity. Immunosuppressant therapy was instituted prior to endovascular treatment unless a contraindication existed. Results: From 1998 to 2012, 10 patients (eight male, two female; median age 39) with BD and aortic pseudoaneurysm were treated with endovascular stent-grafting at this institution. 90% of these patients received immunosuppressive therapy before and after surgical treatment. The median follow-up period was 57 months (interquartile range, IQR 43-72).The locations of the 12 pseudoaneurysms treated in this cohort were infrarenal abdominal aorta (seven), descending thoracic aorta (four), and aortic arch (one). Median pseudoaneurysm size was 4.5 cm (IQR 3.4-5.9). At long-term followup, complete resolution of the aortic pseudoaneurysm was noted in all patients. No endoleaks occurred. Newly developed pseudoaneurysm at the distal margin of the stentgraft was noted in one patient 17 months after the stentgraft procedure. One patient required a subsequent stentgraft placement for an expanding pseudoaneurysm of the subclavian artery. No patient deaths occurred during the follow-up period. Conclusion: Endovascular treatment of aortic pseudoaneurysm with stent-grafting in patients with BD is safe and effective with long-term durability. Educational Exhibit Abstract No. 404 CT-guided sacral and transsacral interventions for benign and malignant pathologies: a pictorial review J. Pinter, E. Santos, K. Ching, V. Gavrilovic; Interventional Radiology, UPMC, Pittsburgh, PA Learning Objectives: 1) Review pertinent anatomy of the sacrum and critical neurovasculature structures. 2) Outline relevant techniques for percutaneous ablation and cementoplasty of primary and metastatic sacral tumors. 3) Describe transsacral ablation for recurrent presacral malignancies. Background: Sacral tumors include a wide range of benign and malignant pathology. While these lesions are uncommon, they may lead to debilitating clinical symptoms and can be challenging to diagnose and manage. Numerous treatment options may be employed depending on the characteristics and location of the offending lesion. Patient comorbidities and life-expectancy should must be considered in these patients when determining the best treatment options. Interventional techniques are useful in both the diagnosis and management of sacral and presacral lesions. Appropriate patient selection, a multidisciplinary treatment approach, and careful review of diagnostic imaging are essential to achieve strong clinical outcomes. Clinical Findings/Procedure Details: This exhibit reviews the complicated neurovascular anatomy of the sacrum and pelvic structures. Image guided percutaneous techniques including transsacral biopsy, transsacral ablation, and sacral ablation and cementoplasty are presented. Image-rich cases include transsacral ablation for recurrent colorectal carcinoma, ablation and cementoplasty for painful neoplasms, and cementoplasty for pathologic sacral fractures. Conclusion and/or Teaching Points: While sacral tumors are rare, the complicated anatomy of the sacrum and tightquarters of adjacent neurovascular structures requires a multidisciplinary approach in order to achieve the best patient outcomes. Percutaneous image-guided techniques are often the treatment of choice for managing these complex patients. Educational Exhibit Abstract No. 405 An interactive educational website for interventional radiology S. Hanif, E. Matto, B.A. Bianco, A.E. Trebelev; Hahnemann University Hospital, Philadelphia, PA Learning Objectives: Online educational modules have proven to be an effective method of training medical students and new residents. We developed a website that describes interventional radiology (IR) procedures, demonstrates IR instruments, provides imaging correlates, and presents clinically oriented physics. Rigorous multiple choice assessments accompany each section and allow program directors to track a student’s performance and provide feedback. Background: A dedicated website was established on a secure internet hosting service. The website was developed using PHP, javascript, and MySQL programing languages. Clinical Findings/Procedure Details: Leading IR textbooks and journal articles are reviewed to accurately describe 58 IR JVIR ’ Posters and Exhibits S177

Educational Exhibit Abstract No. 404 - CT-guided sacral and transsacral interventions for benign and malignant pathologies: a pictorial review

No. 403 Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet’s disease S. Lee, S. Kim, D. Lee, M. Kim, J. Won, S. Park, Y. Yoon, D. Choi, Y. Ko; Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiothoracic Surgery, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea; Internal Medicine, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea Purpose: To evaluate the effectiveness of endovascular stentgrafting for surgical management of aortic pseudoaneurysm in patients with Behcet’s disease (BD). Materials and Methods: We present a single-institution retrospective cohort of patients with aortic pseudoaneurysm and BD treated with aortic stent-grafting. CT imaging was obtained preoperatively in all patients and once within two weeks postoperatively, and then annually. Clinical followup and erythrocyte sedimentation rate (ESR) were used to follow BD activity. Immunosuppressant therapy was instituted prior to endovascular treatment unless a contraindication existed. Results: From 1998 to 2012, 10 patients (eight male, two female; median age 39) with BD and aortic pseudoaneurysm were treated with endovascular stent-grafting at this institution. 90% of these patients received immunosuppressive therapy before and after surgical treatment. The median follow-up period was 57 months (interquartile range, IQR 43-72).The locations of the 12 pseudoaneurysms treated in this cohort were infrarenal abdominal aorta (seven), descending thoracic aorta (four), and aortic arch (one). Median pseudoaneurysm size was 4.5 cm (IQR 3.4-5.9). At long-term followup, complete resolution of the aortic pseudoaneurysm was noted in all patients. No endoleaks occurred. Newly developed pseudoaneurysm at the distal margin of the stentgraft was noted in one patient 17 months after the stentgraft procedure. One patient required a subsequent stentgraft placement for an expanding pseudoaneurysm of the subclavian artery. No patient deaths occurred during the follow-up period. Conclusion: Endovascular treatment of aortic pseudoaneurysm with stent-grafting in patients with BD is safe and effective with long-term durability. Educational Exhibit Abstract No. 404 CT-guided sacral and transsacral interventions for benign and malignant pathologies: a pictorial review J. Pinter, E. Santos, K. Ching, V. Gavrilovic; Interventional Radiology, UPMC, Pittsburgh, PA Learning Objectives: 1) Review pertinent anatomy of the sacrum and critical neurovasculature structures. 2) Outline relevant techniques for percutaneous ablation and cementoplasty of primary and metastatic sacral tumors. 3) Describe transsacral ablation for recurrent presacral malignancies. Background: Sacral tumors include a wide range of benign and malignant pathology. While these lesions are uncommon, they may lead to debilitating clinical symptoms and can be challenging to diagnose and manage. Numerous treatment options may be employed depending on the characteristics and location of the offending lesion. Patient comorbidities and life-expectancy should must be considered in these patients when determining the best treatment options. Interventional techniques are useful in both the diagnosis and management of sacral and presacral lesions. Appropriate patient selection, a multidisciplinary treatment approach, and careful review of diagnostic imaging are essential to achieve strong clinical outcomes. Clinical Findings/Procedure Details: This exhibit reviews the complicated neurovascular anatomy of the sacrum and pelvic structures. Image guided percutaneous techniques including transsacral biopsy, transsacral ablation, and sacral ablation and cementoplasty are presented. Image-rich cases include transsacral ablation for recurrent colorectal carcinoma, ablation and cementoplasty for painful neoplasms, and cementoplasty for pathologic sacral fractures. Conclusion and/or Teaching Points: While sacral tumors are rare, the complicated anatomy of the sacrum and tightquarters of adjacent neurovascular structures requires a multidisciplinary approach in order to achieve the best patient outcomes. Percutaneous image-guided techniques are often the treatment of choice for managing these complex patients. Educational Exhibit Abstract No. 405 An interactive educational website for interventional radiology S. Hanif, E. Matto, B.A. Bianco, A.E. Trebelev; Hahnemann University Hospital, Philadelphia, PA Learning Objectives: Online educational modules have proven to be an effective method of training medical students and new residents. We developed a website that describes interventional radiology (IR) procedures, demonstrates IR instruments, provides imaging correlates, and presents clinically oriented physics. Rigorous multiple choice assessments accompany each section and allow program directors to track a student’s performance and provide feedback. Background: A dedicated website was established on a secure internet hosting service. The website was developed using PHP, javascript, and MySQL programing languages. Clinical Findings/Procedure Details: Leading IR textbooks and journal articles are reviewed to accurately describe 58 IR JVIR ’ Posters and Exhibits S177

The role of interventional radiology in management of benign and malignant gynecologic diseases.

This article focuses on the role of interventional radiology in the therapeutic and diagnostic management of benign and malignant gynecologic conditions. The subspecialty of interventional radiology utilizes minimally invasive advanced image-guided percutaneous techniques in gynecology that include central venous catheter placement, fluid aspiration, drainage catheter placement, tissue biopsy, inferior vena cava filter placement, and pelvic arterial embolization. Central venous catheters, such as ports, peripherally inserted central catheters, and tunneled catheters, are placed for intermediate to long-term intravenous chemotherapy or total parental nutrition or antibiotics. Patients with refractory malignant ascites or pleural effusion from seeding of advanced gynecologic cancers may benefit by percutaneous aspiration of fluid collections or placement of drainage catheters. Postoperative fluid collections including abscess, seroma, or lymphocele are managed by percutaneous drainage catheter insertion. Pelvic, peritoneal, or retroperitoneal masses can be sampled by image-guided percutaneous biopsy or aspiration of fluid to determine a pathologic diagnosis. Certain patients are at risk for deep venous thrombosis with pulmonary embolism and may benefit from an inferior vena cava filter. Patients with uncontrolled postoperative or postpartum bleeding can be effectively managed with emergent transarterial pelvic embolization. Each of the aforementioned interventions with indications, expected benefits, and complications is described including a published literature.

Modern diagnostic and therapeutic interventional radiology in lung cancer.

Imaging has an important role in the multidisciplinary management of primary lung cancer. This article reviews the current state-of-the-art imaging modalities used for the evaluation, staging and post-treatment follow-up and surveillance of lung cancers, and image-guided percutaneous techniques for biopsy to confirm the diagnosis and for local therapy in non-surgical candidates.

Quantitative Discomanometry: Correlation of Intradiscal Pressure Values to Pain Reduction in Patients With Intervertebral Disc Herniation Treated With Percutaneous, Minimally Invasive, Image-Guided Techniques

To illustrate quantitative discomanometry's (QD) diagnostic efficacy and predictive value in discogenic-pain evaluation in a prospective study correlating intradiscal pressure values with pain reduction after percutaneous image-guided technique (i.e., percutaneous decompression, PD). During the last 3 years, 36 patients [21 male and 15 female (mean age 36 ± 5.8 years)] with intervertebral disc hernia underwent QD before PD. Under absolute sterilization and fluoroscopy, a mixture of contrast medium and normal saline (3:1 ratio) was injected. A discmonitor performed a constant rate injection and recorded pressure and volume values, thus producing the relative pressure-volume curve. PD was then performed. Pain reduction and improved mobility were recorded at 3, 12, and 24 months after PD using clinical evaluation and a numeric visual scale (NVS; 0 to 10 units). Mean pain values of 7.5 ± 1.9 (range 4 to 8) NVS units were recorded before PD; these decreased to 2.9 ± 2.44 at 3 months, 1.0 ± 1.9 at 12 months, and 1.0 ± 1.9 NVS units at 24 months after PD. Recorded correlations (pressure, volume, significant pain-reduction values) with bilateral statistical significance included a maximum injected volume of 2.4 ml (p = 0.045), P (o) < 14 psi [initial pressure required to inject 0.1 ml of the mixture inside the disc (p = 0.05)], P (max) ≤ 65 psi [greatest pressure value on the curve (p = 0.018)], and P (max) - P (o) ≤ 47 psi (p = 0.038). Patients meeting these pressure or volume cut-off points, either independently or as a total, had significant pain reduction (>4 NVS units) after PD. No complications were noted. QD is an efficient technique that may have predictive value for discogenic pain evaluation. It might serve as a useful tool for patient selection for intervertebral disc therapies.

Fire and Ice: Percutaneous Ablative Therapies and Cement Injection in Management of Metastatic Disease of the Spine

Oncology intervention is actively moving beyond simple bone cement injection. Archimedes taught us that a volume displaces its volume. Where does the tumor we displace with our cement injection go? It is no longer acceptable that we displace tumor into the venous system with our cement injections. We must kill the tumor first. Different image-guided percutaneous techniques can be used for treatment in patients with primary or secondary bone tumors. Curative ablation can be applied for the treatment of specific benign or in selected cases of malignant localized spinal tumors. Pain palliation therapy of primary and secondary bone tumors can be achieved with safe, fast, effective, and tolerable percutaneous methods. Ablation (chemical, thermal, mechanical), cavitation (radiofrequency ionization), and consolidation (cementoplasty) techniques can be used separately or in combination. Each technique has its indications, with both advantages and drawbacks. To prevent pathological fractures, a consolidation is necessary. In spinal or acetabular tumors, a percutaneous cementoplasty should be associated with cryoablation to avoid a compression fracture. The cement is injected after complete thawing of the ice ball or the day after the cryotherapy. A syndrome of multiorgan failure, severe coagulopathy, and disseminated intravascular coagulation following hepatic cryoablation has been described and is referred to as the cryoshock phenomenon.

Radiofrequency ablation of pulmonary tumors

The development of image-guided percutaneous techniques for local tumor ablation has been one of the major advances in the treatment of solid tumors. Among these methods, radiofrequency (RF) ablation is currently established as the primary ablative modality at most institutions. RF ablation is accepted as the best therapeutic choice for patients with early-stage hepatocellular carcinoma when liver transplantation or surgical resection are not suitable options and is considered as a viable alternate to surgery for inoperable patients with limited hepatic metastatic disease, especially from colorectal cancer. Recently, RF ablation has been demonstrated to be a safe and valuable treatment option for patients with unresectable or medically inoperable lung malignancies. Resection should remain the standard therapy for non-small cell lung cancer (NSCLC) but RF ablation may be better than conventional external-beam radiation for the treatment of the high-risk individual with NSCLC. Initial favourable outcomes encourage combining radiotherapy and RF ablation, especially for treating larger tumors. In the setting of colorectal cancer lung metastases, survival rates provided by RF ablation in selected patients, are substantially higher than those obtained with any chemotherapy regimens and provide indirect evidence that RF ablation therapy improves survival in patients with limited lung metastatic disease.

Cost-effectiveness Analysis of Implantable Venous Access Device Insertion Using Interventional Radiologic versus Conventional Operating Room Methods in Pediatric Patients with Cancer

Percutaneous image-guided techniques are associated with less tissue trauma and morbidity than open surgical techniques. Interventional radiology has received significant health care investment. The purpose was to determine the cost effectiveness of inserting implantable venous access devices (IVADs) by interventional radiologic means versus conventional operating room surgery in pediatric patients with cancer. In a retrospective cohort analysis, patients presenting with a new tumor diagnosis and receiving a first-time IVAD in January to June 2000 (operative group; n = 30) and January to June 2004 (interventional group; n = 30) were included. A societal costing perspective was adopted. Costs included labor, materials, equipment, inpatient wards, parent travel, and parental productivity losses for 30 days after insertion. Severe complications related to IVAD insertion were microcosted. Costs related to cancer therapy were not included. Incremental cost-effectiveness analysis and sensitivity analysis were performed. Interventional patients were older (7.3 years vs 4.1 years; P = .01). There were no significant differences between groups in sex, American Society of Anesthesiologists score, or length of hospital stay. Interventional radiologic procedures were shorter (84.9 minutes vs 112.8 minutes; P = 0.01). Interventional radiologic insertion was slightly less costly than operative insertion (Can$622,860 and Can$627,005 per 30-patient group, respectively) and more effective in reducing the complication rate (two vs eight complications per group, respectively; P = .039). The results were sensitive to the cost of operating the operating room. Interventional radiology was slightly less costly than operative IVAD insertion and resulted in fewer serious complications. It should be considered for IVAD insertions in pediatric patients with cancer.

Quality Improvement Guidelines for Radiofrequency Ablation of Liver Tumours

The development of image-guided percutaneous techniques for local tumour ablation has been one of the major advances in the treatment of liver malignancies. Among these methods, radiofrequency ablation (RFA) is currently established as the primary ablative modality at most institutions. RFA is accepted as the best therapeutic choice for patients with early-stage hepatocellular carcinoma (HCC) when liver transplantation or surgical resection are not suitable options [1, 2]. In addition, RFA is considered a viable alternate to surgery (1) for inoperable patients with limited hepatic metastatic disease, especially from colorectal cancer, and (2) for patients deemed ineligible for surgical resection because of extent and location of the disease or concurrent medical conditions [3]. These guidelines were written to be used in quality-improvement programs to assess RFA of HCC and liver metastases. The most important processes of care are (1) patient selection, (2) performing the procedure, and (3) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rates.

Computed Tomography Fluoroscopic-guided Percutaneous Spinal Interventions in the Management of Spinal Pain

Local back pain and radiculopathy can be debilitating for sufferers of these conditions. There are a multitude of treatment modalities, ranging from conservative approaches such as bed rest, physical therapy and chiropractic manipulation, to more invasive options such as percutaneous spinal intervention (PSI) and surgery. We present here the techniques employed in the use of minimally invasive, image-guided percutaneous techniques under computed tomography fluoroscopy in our institutions. The inherent high spatial and tissue contrast resolution not only allows ease of trajectory planning in avoiding critical structures, but also allows precision needle placement. Cervical, lumbosacral, and sacroiliac pain can therefore be evaluated and treated both safely and effectively.