Pre-procedure MRI Research Articles

Can Tumor Recurrence Be Predicted by Magnetic Resonance Imaging Findings Before Microwave Ablation in Patients with Hepatocellular Carcinoma?

Purpose: Hepatocellular carcinoma (HCC) is a common cancer. The primary treatment is surgery or liver transplantation. Percutaneous ablation techniques constitute the primary treatment in patients who are not suitable for surgery. Although it gives successful results, some studies report a recurrence rate of up to 50%. This study aimed to obtain an idea about the possibility of possible recurrence by evaluating the lesion characteristics in the pre-procedure MRI images of patients with and without recurrence. Methods: Forty-eight patients who underwent microwave ablation for HCC in our center between 2018 and 2021 were included in the study. Lesion size, presence of peripheral enhancement, arterial contrast enhancement, and T2 signal characteristics were evaluated on MRI. Subsequently, the relationship of these features with tumor recurrence was evaluated. Results: When lesions with and without recurrence were compared during follow-up, it was shown that the risk of recurrence was high in patients with lesion sizes larger than 3 cm and in lesions showing peripheral contrast enhancement (p 0.036 and p 0.021, respectively). Conclusion: Since there is a high probability of recurrence after ablation in HCCs larger than 3 cm and showing peripheral contrast, close follow-up will be beneficial.

Diagnostic Yield of Decubitus CT Myelography for Detection of CSF-Venous Fistulas.

Various imaging techniques have been described to detect CSF-venous fistulas in the setting of spontaneous intracranial hypotension, including decubitus CT myelography. The expected diagnostic yield of decubitus CT myelography for CSF-venous fistula detection is not fully established. The purpose of this study was to assess the yield of decubitus CT myelography among consecutive patients presenting for evaluation of possible spontaneous intracranial hypotension and to examine the impact of brain MR imaging findings of spontaneous intracranial hypotension on the diagnostic yield. The study included a single-center, retrospective cohort of consecutive patients presenting during a 1-year period who underwent CT myelography and had no CSF identified in the epidural space. Patients with epidural CSF leaks were included in a secondary cohort. Subjects were grouped according to positioning for the myelogram, either decubitus or prone, and the presence of imaging findings of spontaneous intracranial hypotension on preprocedural brain MR imaging. Diagnostic yields for each subgroup were calculated, and the yield of decubitus CT myelography was compared with that of prone CT myelography. The study cohort comprised 302 subjects, including 247 patients with no epidural fluid. The diagnostic yield of decubitus CT myelography for CSF-venous fistula detection among subjects with positive brain MR imaging findings and no epidural fluid was 73%. No CSF-venous fistulas were identified among subjects with negative findings on brain imaging. Among subjects with an epidural leak, brain MR imaging was negative for signs of spontaneous intracranial hypotension in 22%. Prone CT myelography identified a CSF-venous fistula less commonly than decubitus CT myelography (43% versus 73%, P = .19), though the difference was not statistically significant in this small subgroup. We found the diagnostic yield of decubitus CT myelography to be similar to the yield previously reported for digital subtraction myelography among patients with positive findings on brain imaging. No CSF-venous fistulas were identified in patients with negative findings on brain imaging; epidural CSF leaks accounted for all cases of patients who had spontaneous intracranial hypotension with negative brain imaging findings. This study provides useful data for counseling patients and helps establish a general benchmark for the decubitus CT myelography yield for CSF-venous fistula detection.

The role of urology and radiology in prostate biopsy: current trends and future perspectives.

Prostate biopsy is central to the accurate histological diagnosis of prostate cancer. In current practice, the biopsy procedure can be performed using a transrectal or transperineal route with different technologies available for targeting of lesions within the prostate. Historically, the biopsy procedure was performed solely by urologists, but with the advent of image-guided techniques, the involvement of radiologists in prostate biopsy has become more common. Herein, we discuss the pros, cons and future considerations regarding their ongoing role. A narrative review regarding the current evidence was completed. PubMed and Cochrane central register of controlled trials were search until January 2024. All study types were of consideration if published after 2000 and an English language translation was available. There are no published studies that directly compare outcomes of prostate biopsy when performed by a urologist or radiologist. In all published studies regarding the learning curve for prostate biopsy, the procedure was performed by urologists. These studies suggest that the learning curve for prostate biopsy is between 10 and 50 cases to reach proficiency in terms of prostate cancer detection and complications. It is recognised that many urologists are poorly able to accurately interpret multi parametric (mp)-MRI of theprostate. Collaboration between the specialities is of importance with urology offering the advantage of being involved in prior and future care of the patient while radiology has the advantage of being able to expertly interpret preprocedure MRI. There is no evidence to suggest that prostate biopsy should be solely performed by a specific specialty. The most important factor remains knowledge of the relevant anatomy and sufficient volume of cases to develop and maintain skills.

Use of percutaneous imaging-guided biopsy for Liver Imaging and Reporting Data System (LI-RADS) observations: A retrospective study from two liver transplant centers

Since the adoption of guidelines for the non-invasive imaging diagnosis of hepatocellular carcinoma (HCC), the need for sampling of a lesion in cirrhosis has decreased. We aimed to retrospectively investigate the use of percutaneous imaging-guided biopsy for LI-RADS observations in cirrhosis in two large liver transplant centers. A review of the pathology database in the two Institutions (Institution A, Institution B) was conducted to identify patients that underwent percutaneous imaging-guided biopsy for a liver lesion in the interval time 01/01/2015-12/312020. Liver observations on pre-procedure contrast-enhanced CT or MRI were classified according to LI-RADS v2018. Among the 728 patients who underwent imaging guided biopsy of a liver lesion in Institution A, and among the 749 patients who underwent imaging guided biopsy of a liver lesion in Institution B, respectively 50 (6.8 %) and 16 (2.1 %) were cirrhotic with available pre-procedural contrast-enhanced CT or MRI. A total of 67 lesions were biopsied. 30/67 (45 %) biopsied observations were classified as LR-M. 55/67 (82 %) biopsies were positive for malignancy at histopathology and among them 33 (60 %) were HCC. In conclusion, a small percentage of percutaneous, imaging-guided biopsies for liver lesions are performed in cirrhosis, and more frequently for LR-M observations.

Neuroendocrine liver metastases treated using transarterial radioembolization: Identification of prognostic parameters at 68Ga-DOTATATE PET/CT

PurposeTo identify prognostic clinical and imaging parameters for patients with neuroendocrine liver metastases (NELMs) undergoing transarterial radioembolization (TARE). Materials and methodsForty-seven patients (27 men; mean age, 64 years) with NELMs who received TARE, along with pre-procedure liver MRI and 68Ga-DOTATATE positron emission tomography/computed tomography were included. Apparent diffusion coefficient and standardized uptake value (SUV) of three liver metastases, normal spleen and liver were measured. SUVmax or SUVmean were used for the calculation of tumor-to-organ ratios (tumor-to-spleen and tumor-to-liver ratios) using all possible combinations (including SUVmax/SUVmax, SUVmax/SUVmean, and SUVmean/SUVmean). Clinical parameters (hepatic tumor-burden, presence of extra-hepatic metastases, chromograninA, Ki-67 and bilirubin levels) were assessed. Overall survival, progression-free survival (PFS) and hepatic progression-free survival (HPFS) were calculated using Kaplan-Meier curves. ResultsMedian overall survival, PFS and HPFS were 49.6, 13.1 and 28.3 months, respectively. In multivariable Cox regression analysis, low Ki-67 (≤ 5%), low hepatic tumor-burden (< 10%), absence of extrahepatic metastases, and increased Tmean/Lmax ratio were significant prognostic factors of longer overall survival and HPFS. High baseline chromograninA (> 1330 ng/mL) was associated with shorter HPFS. Tmean/Lmax > 1.9 yielded a median overall survival of 69 vs. 33 months (P < 0.04), and a median HPFS of 30 vs. 19 months (P = 0.09). For PFS, high baseline SUVmax of NELMs was the single significant parameter in the multivariable model. SUVmax > 28 resulted in a median PFS of 16.9 vs. 6.5 months, respectively (P = 0.001). ConclusionHigh preinterventional Tmean/Lmax ratios, and high SUVmax on 68Ga-DOTATATE positron emission tomography/computed tomography seem to have prognostic value in patients with NELMs undergoing TARE, potentially aiding patient selection and management alongside conventional variables.

Impact of left ventricular scar burden on response to two different modalities of conduction system CRT

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Introduction Cardiac resynchronisation therapy (CRT) in the form of His bundle CRT and left bundle area CRT can be more effective than the gold standard, biventricular pacing (BVP). In BVP scar burden is known to predict response whether this is true for these novel modalities is not known. Purpose The purpose of this study was to determine whether left ventricular scar burden assessed using cardiac MRI can be used to predict the electrical and acute haemodynamic response to two novel CRT modalities. Methods Patients with standard CRT indications were recruited. They underwent a pre-procedure cardiac MRI, with late gadolinium enhancement (LGE) to quantify scar. His bundle CRT (His CRT) and left bundle area CRT (LBA CRT) were attempted. The electrical response was measured using high precision non-invasive mapping ECGi (CardioInsight, Medtronic). The haemodynamic response was measured with a high precision protocol. We investigated the impact of scar and baseline electrical characteristic on ECGi and haemodynamic response. Results 26 patients were recruited (85% male, mean age 69 ± 10, with ischaemic cardiomyopathy in 35%). LGE was observed in 96% of cases and the mean (range 1-39%). We found a significant correlation between scar extent and the electrical response with both modalities. There was a significant correlation between a lower scar burden and better electrical response. For His CRT the reduction in left ventricular activation time was better with lower scar burden (R= 0.77, p &amp;lt; 0.01, Picture 1), for LBA CRT for reduction in left ventricular activation was also better with lower scar burden (R = 0.53, p = 0.05, Picture 2). With His CRT there was also a significant correlation between lower scar extent and better acute haemodynamic response ( R = 0.6, p = 0.002) but this was not observed with LBA CRT (R = 0.07, p = 0.77). Conclusion Left ventricular myocardial scar can be used to predict the electrical response to two different conduction system CRT modalities.

CE-452773-3 ASSESSMENT OF OPTIMAL VOLTAGE THRESHOLDS FOR VENTRICULAR SCAR SUBSTRATE CHARACTERIZATION

Despite the advancement in technology, historic cut-offs of <0.5mV for dense scar and 0.5-1.5mV for scar borderzone continue to be used in contemporary electrophysiology. Modern multipolar mapping catheters employ smaller electrodes and interelectrode spacing that theoretically allows for mapping with increased resolution and reduced far-field electrogram (EGM) component. We aimed to assess the optimal voltage cut-offs for ventricular scar substrate characterization using HD Grid multipolar mapping catheter against cardiac MRI-derived scar. We compared optimal voltage cut-offs using conventional bipolar sampling,Best Duplicate Algorithm and HD wave solution plus best duplicate algorithm on. A multicenter study of 33 patients with ischaemic heart disease undergoing VT ablation. Substrate mapping was performed using the high-density HD-grid multipolar mapping catheter. Bipolar voltage maps were co-registered with cardiac MRI/CT obtained before the procedure to assess the voltage characteristics of the scar defined by the image. Pre-procedure contrast-enhanced MRI data were analysed using ADAS software (Galgo medical). Data points were collected in regions of scar during (1) HD wave mapping with best duplicate algorithm on(Waveon), (2) Mapping with HD wave off and best duplicate on (Waveoff) and (3) with conventional bipolar mapping (Alloff). 29,633 voltage points were analyzed and compared to their location with the fused MRI voltage map. The median bipolar voltage for regions of dense MRI/CT scar using (Waveon) HD wave solution and best duplicate algorithm was 0.24mV (IQR 0.12 – 0.43). The median voltage with (Waveoff) HD wave off was 0.29mV (0.15 – 0.45). The median voltage with (Alloff) HD wave off and best duplicate off was 0.32mV (0.19 – 0.5). ROC analysis using AUC suggested the optimal cut-off for endocardial dense scar using (Waveon) HD wave mapping and best duplicate algorithm was 0.31mV (sensitivity: 69.6%, specificity: 60.74%) (Figure), (Waveoff) cut-off with the best duplicate and without the HD wave mapping was 0.34mV (sensitivity: 88.0%, specificity: 42.96%) and (Alloff) without wave mapping or best duplication was 0.36mV (sensitivity: 84%, specificity: 52%). Ventricular substrate characterization with newer mapping technology using narrow electrode spacing and smaller electrode sizes suggests that traditional voltage cut-offs may need revision. The optimal cut-off for dense scar delineation with the HD Grid and wave technology is 0.31mV.

GSOR7 Presentation Time: 9:30 AM: Shortening the Learning Curve: Pre-Planning with a Digital Library of 3D Printed Custom Templates for Improved Dosimetry on Day One in Combined Tandem and Ovoid + Interstitial Cases

<h3>Background</h3> In cervical brachytherapy the addition of interstitial (IS) needles to intra-cavitary (IC) applicators can significantly enhance dosimetry by improving target coverage without increasing dose to normal tissues when needles are optimally placed. It usually takes more than one implant to learn and adapt to the patient specific challenges to provide the best possible needle distribution, resulting in improved dosimetry metrics over the course of multi-fraction treatments. <h3>Material and Methods</h3> We developed a digital library of customized supplemental templates that attach to the tandem applicator and guide needles to optimized positions for different tumor topologies. The library consists of CT scans of tandem and ovoid (T&O) applicators with needles guided through these 3D printed templates that can be used for treatment planning (Figure 1A). Following a pre-procedure MRI, CTV contours were drawn and a grid overlaid. Then, an appropriate template can be selected based on tumor dimensions and extent from the uterine canal and a treatment plan generated to best prepare for the first implant (Figure 1B). An appropriate strategy could thus be defined for the first implant, including the specific custom applicator, number of needles and depth of needles. We started using this preplanning library approach in March 2021. We compared the dosimetry of hybrid implants with library preplanning to those that we were not pre-planned from the preceding year and compared the CTV V100%. <h3>Results</h3> Thirteen patients were pre-planned (PP) using the digital library and compared to the previous year's hybrid cases without preplan (n=16). The mean CTV V100% for the no pre-plan (NPP) group was 86.2%, 90.8%, 91.5% and 93.0% for fractions 1-2-3-4 respectively whereas the pre-planning group achieved a V100% of 90.8%, 94.7%, 94.3% and 92.9%. The difference in the first fraction's V100% is statistically significant (p=0.015). Similar dosimetry was achieved in the second fraction of the NPP cohort as compared to the first fraction of the PP cohort, showing the benefit of detailed preplanning (Figure 1C). By taking into account all the available pre-procedure anatomic information and potential implant geometry options in preplanning, many of the challenges of the first applicator insertion can be overcome and thereby shortening the learning curve to optimized dosimetry right from the first implant. <h3>Conclusions</h3> By developing a digital library of customized hybrid applicators and then utilizing it for planning on pre-procedure MRI, we were able to execute dosimetrically on the first fraction what was historically achieved on the second fraction. The pre-planning steps outlined above significantly improved the CTV coverage of the first fraction, showing that many of the patient specific learning steps can be surmounted before the first implant.

GPP10 Presentation Time: 10:10 AM: Using 3D Printed Vaginal Individualized Applicator (VIA) to Simplify Needle Insertion, Guide Needle Distribution and Optimize Dosimetry for Gynecologic Interstitial and Cervix Hybrid Brachytherapy

<h3>Purpose</h3> Optimally placing interstitial needles either as part of hybrid procedures for the treatment of cervical cancer or for interstitial only gynecologic brachytherapy requires time and expertise. Individualized templates to guide needles to dosimetrically beneficial positions could simplify interstitial and hybrid procedures, decrease procedure time, improve needle distribution and optimize dosimetry. <h3>Materials and Methods</h3> We developed a novel approach using 3D printed Vaginal Individualized Applicator (VIA) templates that contain internal channels that guide interstitial needles from the vaginal introitus to the desired locations within the tumor. The use of 3D printing allows for curved and angled needle trajectories allowing needle distribution to be individualized based on patient and tumor anatomy, such as having a narrow vaginal applicator with needle paths to cover a much wider tumor diameter. The channel directions and needle depths are based on a pre-planning approach. Following a pre-procedure MRI, CTV contours are drawn and converted to a Computer Aided Design (CAD) format. Within the 3D design software, a simple 25 mm diameter cylinder is used to start. Needle paths are manually designed to cover the target following a set of basic rules, which include needle spacing and bending angles. The cylinder with curved needle paths is intended to be slid over the tandem after insertion, or used on its own with a needle in the central location (Figure 1A). The resulting design is 3D printed with biocompatible materials and sterilized pre-procedure. Depending on the printing options (in-house printer or external vendor), the process takes from one week to 24 hours, thereby enabling fraction-to-fraction modifications. <h3>Results</h3> We have created and used clinically 3D printed VIA templates for both hybrid cervix brachytherapy for patients with narrow vaginal canals and for interstitial only gynecologic brachytherapy. The VIA design allows for dwell times within the needles and also within the cylinder component. By allowing the placement of needles from the vaginal introitus, the VIA increases the ease and simultaneously decreases the complexity of optimally placing interstitial needles within the region of the tumor. This design approach also allows additional needles to be placed through available potential channels, if found to be needed, following 3D imaging with CT or MRI, without removing any of the applicator (Figure 1B). For hybrid procedures (n=7), use of the VIA decreased procedure time by 45% (from 33.1 to 18.3 minutes) and improved or maintained excellent dosimetry with an average CTV V100% of 93.4% vs. 90.9% for other hybrid applicators. Similarly, in using the VIA for interstitial-only cases (n=1), we found that needle placement was reduced by 30 minutes or 33% quicker than standard interstitial procedures with similar dosimetry (CTV V100% 95.4 % for VIA vs. 93.4%). <h3>Conclusions</h3> Our team developed a novel 3D printed VIA template that significantly facilitates gynecologic interstitial and cervix hybrid brachytherapy by simplifying the placement of needles, decreasing procedure time and optimizing dosimetry. The clinical data above demonstrates the benefits of this approach for patients with narrow vaginal canals that do not accommodate commercial hybrid applicators. The VIA can easily be designed to facilitate interstitial gynecologic brachytherapy for multiple clinical situations.

Quality care guidelines for uterine artery embolisation in women with symptomatic uterine fibroids in Australia and New Zealand: According to the AGREE-II checklist and endorsed by the Interventional Radiology Society of Australasia.

Quality care guidelines for uterine artery embolisation in women with symptomatic uterine fibroids in Australia and New Zealand: According to the AGREE-II checklist and endorsed by the Interventional Radiology Society of Australasia.

Incidence of amenorrhea and premature ovarian failure in women who underwent uterine fibroid embolization: single centre study

Purpose: To retrospectively determine the incidence of amenorrhea and premature ovarian failure in women who underwent uterine fibroid embolization (UFE) in King Fahad Specialist Hospital in Dammam (KFSH-D).&#x0D; Patients and methods: All women who had undergone UFE in KFSH-D from August 2007 to October 2015 were included for a total of 82 patients. Follow up consisted of a questionnaire inquiring about symptoms, improvement after the procedure and whether menstruation resumed or not. The pre-procedure and post-procedure pelvis MRI as well as UFE images and reports were reviewed for all patients. &#x0D; Results: One patient (1.5 %) was found to have amenorrhea out of the 67 patients we were able to contact. She was 52 years old at the time of UFE and had irregular period. Menstruation did not resume following UFE along with menopausal symptoms including night sweats, mood swings and irritability, likely due to premature ovarian failure (POF). The rest of patients had normal resumption of menses. &#x0D; Conclusion: The incidence of amenorrhea is less than what’s reported in the literature could be due to advances in UFE since its introduction as a treatment for uterine fibroids, likely due to advances in image quality, tans-catheter embolization equipments/techniques and embolic material used in UFE.

Quantitative imaging features predict spinal tap response in normal pressure hydrocephalus.

Gait improvement following high-volume lumbar puncture (HVLP) and continuous lumbar drain (cLD) is widely used to predict shunt response in patients with suspected normal pressure hydrocephalus (NPH). Here, we investigate differences in MRI volumetric and traditional measures between HVLP/cLD responders and non-responders to identify imaging features that may help predict HVLP/cLD response. Eighty-two patients with suspected NPH were studied retrospectively. Gait testing was performed before and immediately/24h/72h after HVLP/cLD. A positive response was defined as improvement in gait post-procedure. Thirty-six responders (26 men; mean age 79.3 ± 6.3) and 46 non-responders (25 men; mean age 77.2 ± 6.1) underwent pre-procedure brain MRI including a 3D T1-weighted sequence. Subcortical regional volumes were segmented using FreeSurfer. After normalizing for total intracranial volume, two-way type III ANCOVA test and chi-square test were used to characterize statistical group differences. Evans' index, callosal angle (CA), and disproportionately enlarged subarachnoid space hydrocephalus were assessed. Multivariable logistic regression models were tested using Akaike information criterion to determine which combination of metrics most accurately predicts HVLP/cLD response. Responders and non-responders demonstrated no differences in total ventricular and white/gray matter volumes. CA (men only) and third and fourth ventricular volumes were smaller; and hippocampal volume was larger in responders (p < 0.05). Temporal horns volume correlated with degree of improvement in gait velocity in responders (p = 0.0006). The regression model was 76.8% accurate for HVLP/cLD response. CA and third and fourth ventricular volumes and hippocampal volume may serve as potentially useful imaging features that may help predict spinal tap response and hence potentially shunt response.

MRI-Derived Sarcopenia Associated with Increased Mortality Following Yttrium-90 Radioembolization of Hepatocellular Carcinoma.

To evaluate the influence of sarcopenia on survival in patients with hepatocellular carcinoma (HCC) treated with 90Y radioembolization. This single-center retrospective cohort study analyzed 82 consecutive patients (65 men and 17 women, mean age 65years, range 31-83years) with HCC treated with 90Y radioembolization between December 2013 and December 2017. Sarcopenia was assessed on pre-procedure MRI performed within 100days prior to 90Y radioembolization by segmenting the paraspinal musculature at the level of the superior mesenteric artery origin and subtracting fat-intensity pixels to yield fat-free muscle area (FFMA). Sarcopenia was defined as FFMA ≤31.97 cm2 for men and ≤28.95 cm2 for women. Survival at 90days, 180days, 1year, and 3years following initial treatment was assessed using medical and public obituary records. Sarcopenia was identified in 30% (25/82) of patients. Death was reported for 49% (32/65) of males and 71% (8/17) of females (mean follow-up 19.6months, range 21days-58months). Patients with sarcopenia were found to have increased mortality at 180days (31.8% vs. 8.9%) and 1year (68.2% vs. 21.2%). Sarcopenia was an independent predictor of mortality adjusted for BCLC stage and sub-analysis demonstrated that sarcopenia independently predicted increased mortality for patients with BCLC stage B disease. Sarcopenia was associated with increased 180-day and 1-year mortality in HCC patients undergoing 90Y radioembolization. Sarcopenia was an independent predictor of survival adjusted for BCLC stage with significant deviation in the survival curves of BCLC stage B patients with and without sarcopenia.

Diagnostic Yield of Lateral Decubitus Digital Subtraction Myelogram Stratified by Brain MRI Findings.

To assess the diagnostic yield of lateral decubitus digital subtraction myelography (LDDSM) and stratify LDDSM diagnostic yield by the Bern spontaneous intracranial hypotension (SIH) score of preprocedure brain MRI. This retrospective diagnostic study included consecutive adult patients investigated for SIH who underwent LDDSM. Patients without preprocedure brain and spine MRI and patients with extradural fluid collection on spine MRI (type 1 leak) were excluded. LDDSM images and brain MRIs were assessed by 2 independent blinded readers; a third reader adjudicated any discrepancies. Diagnostic yield of LDDSM was assessed, both overall and stratified by Bern SIH scoring. Of the 62 patients included in this study, 33 (53.2%) had a CSF leak identified on LDDSM. Right-sided leaks were more common (70.6%), and the most commonly identified levels of leaks were at T6, T7, and T10. No leak was found in any of the 9 patients with Bern SIH score of 2 or less. Of the 11 patients with Bern SIH score of 3-4, 5 (45.5%) had a CSF leak identified; of the 42 patients with Bern SIH score of 5 or higher, 28 (66.7%) had a CSF leak identified. LDDSM has a high diagnostic yield for finding the exact location of spinal CSF leak, and the diagnostic yield increases with higher Bern SIH score. No leaks were found in patients with Bern SIH score of 2 or less, suggesting that foregoing invasive testing such as LDDSM in these patients may be appropriate unless accompanied by high clinical suspicion. This study provides Class II evidence that for patients with suspected SIH, higher Bern SIH scores are associated with a greater likelihood of LDDSM-identified CSF leaks.

Iliac vein pathology and short-term stenting outcomes in a South-East Asian population: A single-centre experience.

Current literature regarding iliofemoral intervention and stenting is mostly based on Western populations. We present our experience of iliofemoral stenting for chronic venous disease within a South-East Asian population. This is a single-centre retrospective review of a prospectively collected registry. Seventy-one patients with 105 limbs underwent iliac vein IVUS and stenting between 2016 and 2019. All patients underwent pre-procedure ultrasound venous scan and MRI venogram. Pre- and post-operative CEAP classification, Villalta score and Venous Clinical Severity Score (VCSS), technical results, stent patency rates and complication rates are documented. Seventy-six per cent of the cases are non-thrombotic iliac vein lesion, and 68% of patients have C4 to C6 disease. Ten percentage of patients had acute thrombosis on presentation. There was 100% technical success. A 6- and 7-point reduction in the mean VCSS and Villalta score, respectively, were noted post-stenting (baseline of 10 points and P<0.001 in both categories). Post-stenting ulcer healing rate was 91% at 6 and 12months. One-year ulcer recurrence and cellulites recurrence were at 8% and 7%, respectively. One unplanned 30-day readmission (not related to procedure) and no 30-day mortality were noted. Bleeding complication from anticoagulation was 3%. There was 10% in-stent non-flow limiting stenosis on surveillance. One-year primary patency was 91%, and secondary patency was 100%. Within our series, iliofemoral stenting has 100% technical success, with statistically significant reduction in VCSS and Villalta score, good wound healing rates, low ulcer and cellulites recurrence and good primary and secondary patency rates at 1year.

4:21 PM Abstract No. 174 Uterine artery embolization for fibroids versus fibroids and adenomyosis

To compare outcomes following uterine artery embolization (UAE) for patients with fibroids versus those with fibroids and adenomyosis A total of 145 patients underwent UAE at a single institution between August 2016 and June 2019. A retrospective review was performed of patient demographics, pre procedure MRI findings, and post procedure clinical and MRI outcomes. Statistical analysis was used to compare patients with fibroids only versus those with a combination of fibroids and adenomyosis. Eight patients were excluded due to lack of complete MRI studies available in PACS. Of the eligible patients, 103 had fibroids only and 34 patients had a combination of fibroids and adenomyosis. 81.4% of patients in the fibroid only group presented with menorrhagia vs. 91.2% in the combination group (P = 0.179). Significantly fewer patients with combination fibroids and adenomyosis presented with bulk symptoms, 67.6% vs. 85.1% in the fibroids only group (P = 0.025). There was no difference in demographics, uterine volume (P = 0.727) or amount of embolic material used during the UAE (P = 0.092) between groups. Clinical follow-up was available for 72 fibroid only patients and 23 combination patients with no difference in outcomes between the two groups. Menorrhagia improved in 91.4% of the fibroid only group vs. 82.6% in the combination group (P = 0.236) and bulk symptoms improved in 81.9% of the fibroid only group vs. 94.4% in the combination group (P = 0.191). Post-procedure MRI was available for 58 fibroid only patients and 15 combination patients and demonstrated no significant difference in the degree of nonenhancement (NE) when graded on a 4 tier scale of 100% NE, >90% NE, >80% NE and <80% NE (P = 0.226). Of the patients with adenomyosis, 86.7% (13/15) had improvement in the appearance of adenomyosis on post procedure MRI. This demonstrates that the presence of adenomyosis does not have an impact on the clinical or imaging success rate of uterine artery embolization when treating patients with a combination of fibroids and adenomyosis.

Effect of Direct Marketing for Uterine Artery Embolization on Rates of Leiomyomas, Incidental Findings, and Management After Pelvic MRI

PurposeThe aim of this study was to determine whether a self-referred population screened by an interventional radiology (IR) clinic and a non-IR, physician-referred population differed with regard to suitability for uterine artery embolization (UAE) for symptomatic leiomyomas on the basis of preprocedure MRI. MethodsThis was an institutional review board–approved, HIPAA-compliant retrospective study of 301 women evaluated in an IR clinic for possible UAE from January 2009 to September 2012. Subjects were retrospectively divided into two groups: self-referred via direct marketing (group A, n = 203; mean age, 41.8 years; range, 22-58 years) and physician referred (group B, n = 98; mean age, 42.9 years; range, 30-65 years). ResultsThere was no significant difference between groups in presenting symptoms (multiple symptoms, bleeding, bulk-related symptoms, pain). After initial screening, 73.4% of group A (149 of 203) and 79.6% of group B (78 of 98) underwent MRI (P = .242). On the basis of MRI findings, 91.3% of group A (136 of 149) and 94.9% of group B (74 of 78) had uterine leiomyomas (P = .328). Adenomyosis without leiomyoma was present in 4.0% of group A (6 of 149) and 3.8% of group B (3 of 78) (P = .947). Incidental findings requiring further clinical or imaging evaluation were found in 20.8% of group A (31 of 149) and 24.4% of group B (19 of 78) (P = .539). After MRI, 41.6% of group A (62 of 149) and 48.7% of group B (38 of 78) proceeded to UAE (P = .306). ConclusionsAfter initial screening, similar proportions of self-referred and physician-referred patients were candidates for UAE. The rates of confirmed leiomyomas and incidental findings on MRI were similar between groups.

Fluoroscopically Guided Cervical Inter-Laminar Epidural Injections: Correlation Between Degree of Spinal Stenosis and Contrast Dispersal Pattern

Objectives: Cervical inter-laminar injections at C7-T1 have been routinely performed for many years as an effective means of palliating neck pain. The purpose of this study is to measure the extent of contrast spread following C7-T1 cervical inter-laminar epidural steroid injection (CIESI), and to correlate the upper extent of contrast spread with degree of cervical spinal stenosis. Methods: We retrospectively identified 41 consecutive patients over a six months’ time frame fulfilling the following inclusion criteria: (1) Had image guided CIESI at C7-T1, (2) Had PA and oblique epidurogram pre and post procedure, (3) Had procedural notes indicating the amounts injected and (4) Had an antecedent MRI. The epidurograms were reviewed for their extent of injectate spread. MRI studies were evaluated separately and blinded to the epidurograms. For each level the degree of cervical spine narrowing was noted. We correlated the extent of contrast spread with the level of maximal cervical narrowing. Results: Maximal contrast spread was up to the skull base and down to T4-T5; minimal extent was C6-C7 to T2. We found statistically significant correlation (2-tailed Pearson correlation r= 0.867, p<0.001) between the upper-most extent of contrast spread and the lowest level of significant central canal stenosis according to pre-procedure MRI. Conclusion: Following CIESI injectate will spread up as far as the cranio-cervical junction or near the lowest level where there is moderate degenerative central stenosis.

Periprocedural imaging and outcomes after catheter ablation of atrial fibrillation.

Catheter ablation of atrial fibrillation (AF) has become an increasingly safe and effective therapy. This has been partly attributed to the use of adjunctive imaging modalities. We aimed to describe the use and associated outcomes of periprocedural imaging for AF ablation. We studied all Medicare fee-for-service claims for AF ablation from July 2007 to December 2009, and identified associated imaging studies before and during ablation, including transoesophageal echocardiography (TEE), intracardiac echocardiography (ICE), CT and MRI. The primary outcomes were death, stroke or transient ischaemic attack (TIA), repeat ablation, and bleeding (pericardial or vascular) at 6 months. 11 525 patients underwent AF ablation during the study period. There was significant variation in imaging use at the practice level. In addition to electroanatomic mapping, 53% (n=6060/11 525) underwent TEE, 67% (n=7715/11 525) received ICE, and 50% (n=5724/11 525) underwent a preprocedure CT or MRI. Imaging generally increased from 2007 to 2009. After adjustment, the use of preablation CT or MRI was associated with a significantly lower risk of stroke or TIA (0.4% vs 0.9%, adjusted HR 0.46, 95% CI 0.28 to 0.74, p=0.002), and the use of ICE was associated with a lower risk of repeat ablation (5.7% vs 8.5%, adjusted HR 0.59, 95% CI 0.37 to 0.92, p=0.02) but higher risk of bleeding (1.1% vs 0.7%, adjusted HR 1.76, 95% CI 1.15 to 2.70, p=0.009). Periprocedural imaging for AF ablation is increasingly used, although practice patterns vary widely. Our data suggest that periprocedural imaging is associated with better outcomes after catheter ablation; however, prospective studies of periprocedural imaging strategies are warranted.

Evaluation and Reduction of Asymptomatic Cerebral Embolism in Ablation of Atrial Fibrillation, But High Prevalence of Chronic Silent Infarction

Background— This prospective, multicenter study sought to evaluate the incidence of asymptomatic cerebral emboli (ACE) during ablation of atrial fibrillation (AF) using a multielectrode radiofrequency (MER) system when specific procedural changes were applied. Methods and Results— Sixty subjects (age 60±10 years; 87% paroxysmal; CHADS 2 score, 0.6±0.7) undergoing AF ablation with a circular MER catheter were studied. Three procedural changes were specified: (1) ablation was performed under therapeutic vitamin K antagonist and heparin to maintain activated clotting time &gt;350 seconds; (2) submerged loading of the catheter into the introducer before sheath insertion to minimize air ingress; and (3) either the distal or proximal electrode of the circular MER catheter was deactivated to prevent inadvertent bipolar radiofrequency interaction. MRI was performed &lt;7 days preablation and 2 days postablation. Subjects with new cerebral findings after ablation underwent repeat MRI after 1 month. An acute ACE lesion was defined by a new hyperintensity on diffusion-weighted and fluid-attenuated inversion recovery cerebral MRI sequences. Neurological function was evaluated at baseline, postablation, and 1 month. All target pulmonary veins were isolated. In 60% (36/60) of patients, pre-existing cerebral lesions were seen on the preprocedure MRI (8 lesions per subject; interquartile range, 3–22). New postprocedural ACE occurred in only 1/60 patients (incidence, 1.7%; 95% confidence interval, 0.04–8.9), which was no longer visible on MRI after 1 month. Conclusions— Applying procedural changes to MER ablation significantly reduces the ACE incidence to 1.7%, which is on the low end of reported ACE rates of any technology. Clinical Trial Registration Information— ClinicalTrials.gov; Identifier: NCT01520532.