Society Of Interventional Radiology Classification Research Articles

A comparison of lymphatic embolization and sclerotherapy in the management of iatrogenic abdominopelvic lymphoceles following oncological surgery.

To compare the safety and efficacy of sclerotherapy and lymphatic embolization (LE) in the treatment of symptomatic iatrogenic lymphoceles following the placement of a percutaneous drainage catheter. This is a retrospective study of 46 patients who underwent sclerotherapy (17 patients) or LE (29 patients) for the management of symptomatic iatrogenic lymphoceles following percutaneous drain placement between January 2017 and December 2021. The demographic characteristics, time between surgery and lymphatic intervention, clinical presentation, number of procedures, drain output pre- and post-intervention, time from intervention to drain removal, and adverse events were collected and compared for both groups. The clinical success rate, defined as the successful removal of the drain after one procedure, was calculated. Adverse events were reported according to the Society of Interventional Radiology classification. A statistical analysis was conducted using SPSS, and the P value for statistical significance was set at 0.05. The Mann-Whitney U test was used to compare differences in the scale variables, and Fisher's exact test was used to compare the categorical and ordinal variables between both groups. A total of 46 patients with 49 lymphoceles met the inclusion criteria of the study. Of these patients, 17 patients (19 lymphoceles) underwent sclerotherapy, and 29 patients (30 lymphoceles) underwent LE as their initial procedures. The clinical success after one procedure was significantly higher (83% vs. 47%, P = 0.011), and the median time between the first intervention and drain removal was significantly shorter in the LE group (median duration of 6 vs. 13 days, P = 0.018) compared with the sclerotherapy group. No statistically significant difference in adverse events was noted between both groups (0.26 vs. 0.10, P = 0.11). This study found that LE had a higher clinical success rate after the first procedure and a shorter time to drain removal compared with sclerotherapy. There was no difference in the rate of adverse events between both groups. Although LE is a safe and promising technique, a prospective study is needed to further compare the efficacy of both treatment modalities.

The Safety and Effectiveness of Hepatic Transarterial Embolic Locoregional Therapy in Patients with Contraindications to Hepatectomy after Portal Vein Embolization

The safety and effectiveness of hepatic transarterial embolic locoregional therapy (LRT) was assessed, including transarterial chemoembolization (TACE) and transarterial radioembolization (TARE), in patients who underwent portal vein embolization (PVE) before major hepatectomy in whom surgery was then contraindicated. Adverse events (AEs) were graded according to the Society of Interventional Radiology classification of AEs. Tumor response was assessed based on the Response Evaluation Criteria In Solid Tumors 1.1. Overall survival (OS) and progression-free survival (PFS) were estimated. Fifteen patients underwent 37 transarterial LRTs (25 TACEs, 11 TAREs, and 1 bland embolization), most (73%) with hepatocellular carcinoma. Eleven AEs occurred in 7 patients, including 2 Grade 3/5 (severe) and 2 Grade 4/5 (life-threatening) events. The best response was partial response in 4 (27%) and stable disease in 10 (66%) patients. The median OS and PFS were 42 (95% CI, 35–49 months) and 33 months (95% CI, 24–42 months), respectively. In conclusion, hepatic transarterial LRT can be considered as a therapeutic option in patients with contraindicated liver surgery after PVE.

Synchronous computed tomography-guided percutaneous biopsy and microwave ablation for highly suspicious malignant lung ground-glass opacities adjacent to mediastinum

Background This retrospective study aimed to assess the safety and efficacy of synchronous biopsy and microwave ablation (MWA) for highly suspected malignant lung ground-glass opacities (GGOs) adjacent to the mediastinum (distance ≤10 mm). Materials and methods Ninety patients with 98 GGOs (diameter range, 6–30 mm), located within 10 mm of the mediastinum, underwent synchronous biopsy and MWA at a single institution from 1 May 2020, to 31 October 2021 and were enrolled in this study. Synchronous biopsy and MWA involving the completion of the biopsy and MWA in a single procedure was performed. Safety, technical success rate, and local progression-free survival (LPFS) were evaluated. The risk factors for local progression were calculated using the Mann–Whitney U test. Results The technical success rate was 97.96% (96/98 patients). The LPFS rates at 3, 6, and 12 months were 95.0%, 90.0%, and 82.0%, respectively. The diagnostic rate of biopsy-proven malignancy was 72.45% (n = 71/98). Invasion of lesions into the mediastinum was a risk factor for local progression (p = 0.0077). The 30-day mortality rate was 0. The major complications were pneumothorax (13.27%), ventricular arrhythmias (3.06%), pleural effusion (1.02%), hemoptysis (1.02%), and infection (1.02%). Minor complications included pneumothorax (30.61%), pleural effusion (24.49%), hemoptysis (18.37%), ventricular arrhythmias (11.22%), structural changes in adjacent organs (3.06%), and infection (3.06%). Conclusions Synchronous biopsy and MWA was effective for treating GGOs adjacent to the mediastinum without severe complications (Society of Interventional Radiology classification E or F). Invasion of lesions into the mediastinum was identified as a risk factor for local progression.

Abstract No. 268 Modified Radiation Lobectomy as Bridge to Liver Resection: A Single-Center Experience

To investigate outcomes of patients who received modified radiation lobectomy for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Institutional review board approved this retrospective study of patients who underwent modified radiation lobectomy with yttrium-90 (90Y) glass microspheres for HCC or ICC with intent to grow the future liver remanent (FLR) between 2019-2022. Outcome measures included tumor response according to modified Response Evaluation Criteria in Solid Tumors (mRECIST), FLR kinetics, tumor progression, and surgical resection or liver transplantation. Adverse events were assessed according to the Society of Interventional Radiology classification. Descriptive statistics were used to assess data. Fifteen patients (7 women, 8 men; mean age 66 ± 11 years) with HCC (n = 7) and ICC (n = 8) underwent modified radiation lobectomy of left (n = 1) or right (n = 14) sided tumors. Mean index tumor size was 7.8 ± 3.7 cm (range, 2.4-16.2). HCC patients were intermediate stage BCLC B (n = 6), or advanced stage BCLC C (n = 1) due to portal vein tumor invasion. Six patients had cirrhosis. Neoadjuvant chemotherapy was concurrently given to 4/8 (50%) of the ICC patients. The average lobar dose was 198 ± 58 Gy and the average segmental boost dose was 186 ± 81 Gy, with an average of 1.6 segmental doses per patient. No severe adverse event from 90Y treatment occurred. Mean bilirubin was unchanged at 30-days. All patients had objective response at 30 days, including 6/15 (40%) with complete response and 9/15 (60%) with partial response. FLR increased by an average of 16.8% ± 14.6% at 30 days (n = 15), and 42.1% ± 22.8% at 90 days (n = 9). A total of 12/15 (80%) were eligible for surgical resection after treatment. One patient refused surgery and another developed concurrent breast cancer, thus 10/15 (67%) went on to hepatectomy (n = 9) or transplant (n = 1) with negative margins at a mean 122 ± 77 days post-treatment. Surgical resection included right (n = 4), extended right (n = 4), or extended left (n = 1) hepatectomies. The remaining 3 patients were ineligible for resection due to new disease progression in the contralateral liver lobe (n = 2) or to lungs (n = 1) at 1-, 2- and 3-months post-treatment. This study demonstrates that modified radiation lobectomy is safe and effective for treatment of HCC and ICC, with a high number of patients going on to definitive surgical management. This is an effective method to attain liver remnant hypertrophy while maintaining control over tumor progression.

Combined CT-guided high-dose-rate brachytherapy (CT-HDRBT) and transarterial chemoembolization with irinotecan-loaded microspheres improve local tumor control and progression-free survival in patients with unresectable colorectal liver metastases compared with mono-CT-HDRBT.

To compare the effectivity and toxicity of monotherapy with computed tomography-guided high-dose-rate brachytherapy (CT-HDRBT) vs. combination therapy of transarterial chemoembolization with irinotecan (irinotecan-TACE) and CT-HDRBT in patients with large unresectable colorectal liver metastases (CRLM) with a diameter of > 3 cm. Forty-four retrospectively matched patients with unresectable CRLM were treated either with mono-CT-HDRBT or with a combination of irinotecan-TACE and CT-HDRBT (n = 22 in each group). Matching parameters included treatment, disease, and baseline characteristics. National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0) were used to evaluate treatment toxicity and the Society of Interventional Radiology classification was applied to analyze catheter-related adverse events. Statistical analysis involved Cox regression, Kaplan-Meier estimator, log-rank test, receiver operating characteristic curve analysis, Shapiro-Wilk test, Wilcoxon test, paired sample t-test, and McNemar test. P-values < 0.05 were deemed significant. Combination therapy ensued longer median progression-free survival (PFS: 5/2 months, p = 0.002) and significantly lower local (23%/68%, p < 0.001) and intrahepatic (50%/95%, p < 0.001) progress rates compared with mono-CT-HDRBT after a median follow-up time of 10 months. Additionally, tendencies for longer local tumor control (LTC: 17/9 months, p = 0.052) were found in patients undergoing both interventions. After combination therapy, aspartate and alanine aminotransferase toxicity levels increased significantly, while total bilirubin toxicity levels showed significantly higher increases after monotherapy. No catheter-associated major or minor complications were identified in each cohort. Combining irinotecan-TACE with CT-HDRBT can improve LTC rates and PFS compared with mono-CT-HDRBT in patients with unresectable CRLM. The combination of irinotecan-TACE and CT-HDRBT shows satisfying safety profiles.

Safety of Periprocedural Antithrombotics during Pediatric Transplant Liver Biopsies

The purpose of this study was to compare the adverse event (AE) rates of percutaneous pediatric transplant liver biopsies in patients receiving periprocedural antithrombotic agents with those in patients not receiving them. A 19-year retrospective single-center study of ultrasound-guided transplant liver biopsies was conducted. Patients who received aspirin for <5 days (n = 51) or heparin <4 hours (n = 15) before biopsy were separately grouped. AEs were reported using the Society of Interventional Radiology classification. In 276 biopsy samples from patients with a mean age of 6.75 years ± 5.80, the overall AE (P = .72) and moderate AE (P = .78) rates for control and antithrombotic groups were not significantly different. No severe AEs or deaths occurred. In conclusion, aspirin continuation during percutaneous pediatric transplant liver biopsies may be safe, but more studies are necessary to confirm the safety of periprocedural heparin.

Partial Nephrectomy versus Percutaneous Cryoablation of Small Renal Cell Carcinomas: A Comparison of Adverse Events in a Prospective Multicenter Cohort Study

PurposeTo assess and compare complications and readmissions after partial nephrectomy and percutaneous cryoablation of cT1 renal cell carcinoma (RCC). Materials and MethodsPatients treated for cT1 RCC between 2019 and 2021 were prospectively and consecutively enrolled. Complications recorded within 30 and 90 days were graded according to the Clavien-Dindo classification, and percutaneous cryoablation was graded according to the Society of Interventional Radiology classification of adverse events. Major complications were defined as complications with a grade of ≥3 based on the Clavien-Dindo classification. Readmission within 30 days was recorded. ResultsThe cohort included 86 partial nephrectomies and 104 cryoablations. The complication rate within 90 days was 23% after partial nephrectomy and cryoablation (P = .98), with major complication rates of 3% after partial nephrectomy and 10% after cryoablation (P = .15). The readmission rates were 14% and 11% after partial nephrectomy and cryoablation, respectively (P = .48). Double-J stents were associated with overall complications (odds ratio [OR], 9.88; 95% confidence interval [CI], 2.18–44.68; P = .003) and readmissions (OR, 5.39; 95% CI, 1.37–21.06; P = .015) after cryoablation. A high versus low radius-endophytic-nearness-anterior-location score (OR, 5.86; 95% CI, 1.08–31.81; P = .040) and endophytic location (OR, 7.70; 95% CI, 1.72–34.50; P = .008) were associated with a higher complication rate after cryoablation. The Charlson Comorbidity Index (CCI) was associated with major complications after partial nephrectomy (OR, 2.12; 95% CI, 1.05–4.30; P = .036). ConclusionsPartial nephrectomy and cryoablation are comparable regarding complications within 90 days after treatment. Tumor complexity and double-J stents were associated with complications after cryoablation, and a high CCI was associated with complications after partial nephrectomy.

Utility of the RENAL Nephrometry Scoring System in Predicting Adverse Events and Outcomes of Percutaneous Microwave Ablation of Renal Tumors

PurposeTo assess the utility of the radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines (RENAL) nephrometry scoring system at predicting adverse events and outcomes in percutaneous microwave ablation (MWA) of renal tumors. Materials and MethodsA retrospective review of 116 patients who underwent MWA from 2004 to 2018 at 2 large university hospitals was conducted. Patient demographics and tumor characteristics were collected. The RENAL nephrometry scores were calculated, and procedure-related adverse events were stratified into minor and major (the Society of Interventional Radiology classification of class C or higher). Technical and oncologic outcomes were based on follow-up magnetic resonance imaging and computed tomography scans after ablation. ResultsThe mean RENAL score was 6.6 (range, 4–11), and the mean tumor size was 24 mm. Follow-up ranged between 16 and 161 weeks (median, 50 weeks; mean, 65 weeks). Oncologic control was achieved in 96% (n = 111) of patients. The major and minor adverse event rates were 8.6% (n = 10) and 17% (n = 19), respectively. The mean RENAL score for patients with recurrent and/or residual tumor (8.2 ± 2.7) was higher than that for patients without disease recurrence (6.5 ± 3.5, P = .05). However, in a multivariate analysis, the RENAL score was not found to be an independent predictor of oncologic outcomes (odds ratio, 1.548; P = .092). ConclusionsThe RENAL nephrometry score has minimal utility for predicting outcomes and adverse events in MWA of renal tumors. The inconsistent nature of RENAL nephrometry scoring in percutaneous ablation procedures underscores the need for an ablation-specific risk stratification system.

WITHDRAWN: Intralesional interstitial injection of bleomycin for management of extracranial arteriovenous malformations in children

Despite many advances in the treatment for extracranial arteriovenous malformations (AVMs), they still result in tedious dissection and potential unacceptable complications, particularly in children. Therefore, this study aimed to investigate the efficacy and safety of intralesional interstitial injection of bleomycin for the treatment of children with AVMs. A total of 10 children (6 boys and 4 girls) with AVMs were treated with serial interstitial bleomycin injections between May 2014 and January 2017. Maximum single doses of 15 U and 1 U/kg per session were administered for six sessions at a 1-month interval. Therapeutic effectiveness was evaluated and classified into four categories: complete response (CR), partial response (PR), no response, and worsening at 3 months after the last session. Further clinical follow-up outcomes were classified as improved, stable, or aggravated. Adverse events were recorded according to the Society of Interventional Radiology classification. All 10 children completed the sessions and follow-ups. CR occurred in 3 (30%) patients, PR in 6 (60%), and no response in 1 (20%). Minor complications (class A) included maculopapular rash, bulla, vomiting, and hyperpigmentation, whereas no major complications occurred. Intralesional interstitial injection of bleomycin is a feasible approach for the treatment of AVMs in children and provides safe and effective outcomes. This method may be an earlier treatment alternative in children to prevent potential destructive progression, considering the serious complications of currently available therapeutic methods.

Intralesional Interstitial Injection of Bleomycin for Management of Extracranial Arteriovenous Malformations in Children

Despite many advances in the treatment for extracranial arteriovenous malformations (AVMs), they still result in tedious dissection and potential unacceptable complications, particularly in children. Therefore, this study aimed to investigate the efficacy and safety of intralesional interstitial injection of bleomycin for the treatment of children with AVMs. A total of 10 children (6 boys and 4 girls) with AVMs were treated with serial interstitial bleomycin injections between May 2014 and January 2017. Maximum single doses of 15 U and 1 U/kg per session were administered for six sessions at a 1-month interval. Therapeutic effectiveness was evaluated and classified into four categories: complete response (CR), partial response (PR), no response, and worsening at 3 months after the last session. Further clinical follow-up outcomes were classified as improved, stable, or aggravated. Adverse events were recorded according to the Society of Interventional Radiology classification. All 10 children completed the sessions and follow-ups. CR occurred in 3 (30%) patients, PR in 6 (60%), and no response in 1 (20%). Minor complications (class A) included maculopapular rash, bulla, vomiting, and hyperpigmentation, whereas no major complications occurred. Intralesional interstitial injection of bleomycin is a feasible approach for the treatment of AVMs in children and provides safe and effective outcomes. This method may be an earlier treatment alternative in children to prevent potential destructive progression, considering the serious complications of currently available therapeutic methods.

Abstract No. 487 Expanding the diagnostic toolbox: introduction of core needle liver biopsies in Tanzania

Hepatocellular carcinoma (HCC) is the fourth most common cancer in Africa and tends to present earlier with worse outcomes in Africa than in Europe and North America. Although risk factor management plays a key role in reducing the burden of HCC, early and accurate detection are equally as important. Additionally, for cultural reasons, patients wish to have pathologic confirmation of diagnosis even when there is no treatment available. In Tanzania, no core needle biopsies (CNBs) were routinely performed at the nation’s largest public hospital until the introduction of an interventional radiology (IR) service in 2018. All patients who underwent liver CNB by the IR service at Muhimbili National Hospital (MNH) from October 2018 to September 2020 were included in the study. All procedures were performed by Tanzanian IR trainees as primary operators. Patient and procedural data, including demographic information, complications, and pathology results were collected and analyzed. Data was stored in REDCap, a HIPAA-compliant data management platform. A total of 51 core needle biopsies of the liver were performed on 49 patients. While 22 were done under direct supervision by US visiting faculty (43.1%), 29 were done independently by Tanzanian IR fellows (56.9%). All 51 were technically successful. No minor complications occurred. One major complication (Society of Interventional Radiology Class C) occurred (patient developed abdominal pain and rigors 30 minutes post-procedure). Of the 38 samples returned, 37 were diagnostic (97.4%); 33 confirmed malignancy, the most common types of which were hepatocellular carcinoma (14/33, 42.4%) and metastatic disease (14/33, 42.4%). Previously at MNH, fine-needle aspiration was used to assess hepatic lesions. While cheaper, it is not as reliable as CNB, with a lower sensitivity, specificity, and diagnostic accuracy. The introduction of a superior method of diagnosing hepatic lesions has provided surgeons and oncologists with a tool for earlier diagnosis. Furthermore, with the introduction of new IR procedures like transarterial catheter embolization and radiofrequency ablation to the region, patients can expect better treatment and prolonged survival.

Microwave Ablation of Small Hepatic Metastases Using MR Guidance and Monitoring: Clinical Safety and Efficacy

BackgroundTo evaluate the technical success and clinical safety of magnetic resonance (MR)-guided microwave ablation (MWA) of small hepatic metastases.Materials and MethodsInstitutional review board approval and informed patient consent were obtained. A retrospective analysis of the patient data revealed 50 patients with small hepatic metastases (34 men, 16 women) who underwent MWA under MR guidance and monitoring. After the procedure, the intervention-related complications were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) and Society of Interventional Radiology (SIR) classification system. Furthermore, the overall survival (OS) and local tumor-free survival (LTP) of the patients were analyzed.ResultsThe patients who underwent MR-guided MWA achieved technical success. The mean energy, ablation duration per tumor, and procedure duration were 55.3 ± 9.4 kJ, 11.7 ± 5.6 min and 89.5 ± 30.9 min, respectively. Most adverse events and complications were CTCAE grade 1 or 2 or SIR classification grade A or B. The 1-, 2-, and 3-year local tumor progression (LTP) rates were 65.9%, 31.5% and 18.5%, respectively, with a mean LTP of 19.216 months (95% CI: 16.208, 22.224); and the 1-, 2- and 3-year overall survival (OS) rates were 81.8%, 60.8% and 44.7%, respectively, with a mean OS of 26.378 months (95% CI: 23.485, 29.270). Multivariate Cox’s regression analysis further illustrated that tumor location (challenging locations vs ordinary locations) and the anesthesia (general anesthesia VS local anesthesia) were important factors affecting LTP and OS.ConclusionMR-guided MWA can successfully treat small hepatic metastases with potentially favorable safety and technical efficacy.

Effectiveness of CT-guided epidural infiltration of steroids and local anesthetics for acute and chronic herpes zoster neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness and complication rate of computed tomography (CT)-guided epidural injection of steroids and local anesthetics for pain relief in patients with neuralgia due to acute or chronic herpes zoster (HZ). Materials and methodsA prospective study was conducted from April 2017 to February 2019 including patients with HZ neuralgia (HZN) at any stage (acute or chronic, the latter being defined as pain lasting more than 3 months and also called post herpetic neuralgia [PHN]). The sensory ganglion of the affected dermatome and/or the affected sensory nerve was targeted under CT-guidance and local injection of a mixture of two vials of methylprednisolone 40mg/mL and 2mL of Lidocaine 1% was performed. Using a visual analogue scale (VAS, 0 to 10), pain was assessed prior to the procedure, and at day 7, 1 month, 3 months and 6 months. Adverse effects were graded according to the Society of Interventional Radiology classification. ResultsTwenty patients were included. There were 9 men and 11 women with a mean age of 67±13.9 (SD) years (range: 27–83 years). Of these, 14 patients had acute HZN and 6 had PHN. Mean VAS at baseline was 8.1±1.2 (SD) (range: 6–10) with significant decrease (P<0.0001) at day 7 (3.4±3.2 [SD]; range: 0–10), day 30 (3.4±3.2 [SD]; range: 0–9), day 90 (2.9±3.2 [SD]; range: 0–9), and day 180 (2.5±3.1 [SD]; range: 0–9). Infiltrations were significantly more effective on acute HZN than on PHN (P<0.001) and required significantly fewer infiltrations for pain relef (P=0.002). Only one grade A adverse event was reported. ConclusionEpidural injection of a mixture of steroids and local anesthetics under CT-guidance is effective on HZN with a persisting effect over 6 months.

Efficacy and safety of irreversible electroporation for malignant liver tumors: a systematic review and meta-analysis.

The data regarding overall survival (OS) and progression-free survival (PFS) following irreversible electroporation (IRE) is scarce. We performed a systematic review of the safety and efficacy of IRE for liver malignancies. Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through September 1, 2019. Studies reporting the survival data (OS and PFS) and complications (graded according to the Society of interventional Radiology classification) were included. A generalized linear mixed method with a random-effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs). A total of 25 studies (n = 776, 15 prospective, 10 retrospective) were included. Metastasis, hepatocellular carcinoma, and cholangiocarcinoma were present in 354, 285, and 100 patients, respectively. The pooled OS at 6, 12, 24, and 36 months was 93.28% (95% CI: 63.23-99.12, I2= 67%), 81.29% (95% CI: 69.80-89.22, I2 = 73%), 61.47% (95% CI: 52.81-69.46, I2 = 0%), and 40.88% (95% CI: 28.43-54.61, I2 = 64%), respectively. The pooled PFS at 6, 12, and 24 months was 79.72% (95% CI: 67.88-87.97, I2 = 70%), 64.19% (95% CI: 56.68-71.06, I2 = 57%), 49.05% (95% CI: 11.47-87.73, I2 = 96%), respectively. Overall complication rate was 23.7%. Major complications (grade C-F) occurred in 6.9% patients. IRE is associated with favorable OS and PFS. Although the overall complication rate is high, most complications are graded as minor. • The pooled OS and PFS at 6, 12, and 24 months for all the tumor types was 93.28% and 79.72%, 81.29% and 64.19%, and 61.47% and 49.05%, respectively. • HCC was associated with a better OS at 12 and 36 months. • The overall complication rate was 23.7%, with major complications (SIR grade C-F) comprising 6.9%.

Lymphatic malformations in children: treatment outcomes of sclerotherapy in a large cohort

This retrospective study examines the outcomes of sclerotherapy in children with (veno)lymphatic malformations who received sclerotherapy between 2011 and 2016 (116 children, 234 procedures). Complication severity was classified using the Society of Interventional Radiology classification. Clinical response was rated on a scale of 0 (no change) to 3 (good improvement). The sclerosants used were bleomycin (n = 132; 56%), lauromacrogol (n = 42; 18%), doxycycline (n = 15; 6%), ethanol (n = 12; 5%), or a combination (n = 33; 14%). Four major and 25 minor complications occurred without significant differences between the agents. The median response rate per procedure was 2—some improvement—for all sclerosants. However, in pure LMs (67%), bleomycin and a combination of agents resulted in the best clinical response. On patient level, all had some or good clinical response. Mixed macrocystic and microcystic lesions showed a significantly lower clinical response (median 2 versus 3; p = 0.023 and p = 0.036, respectively) and required significantly more procedures (median 2 versus 1; p = 0.043 and p = 0.044, respectively) compared with lesions with one component.Conclusion: Sclerotherapy for (V)LMs in children is safe and effective. Bleomycin is the most frequently used agent in this clinic and seemed most effective for pure LMs. Mixed macrocystic and microcystic lesions are most difficult to treat effectively.What is Known:• A variety of agents can be used for sclerotherapy of lymphatic malformations in children.• Macrocystic lesions have favorable outcomes compared with microcystic and mixed lesions.What is New:• Bleomycin and a combination of agents seem to be most effective to treat lymphatic malformations in children.• Mixed macrocystic and microcystic lesions are more difficult to treat effectively compared with lesions with either one of these components.

Treatment Outcomes of Embolization for Peripheral Arteriovenous Malformations

PurposeTo evaluate treatment outcomes of embolization for peripheral arteriovenous malformations (AVMs) in a tertiary referral center where ethanol is the primary agent of choice. MethodsA retrospective study was performed of 93 patients (median age, 31 years; range, 2–66 years) with peripheral AVMs treated with embolization (n = 442; median, 2 per patient; range, 1–82) between January 2010 and July 2016. Ethanol was used in most cases (n = 428; 97%). AVMs were classified as type I (n = 3), type II (n = 57), type IIIa (n = 5), type IIIb (n = 15), and type IV (n = 13) according to the Yakes classification system. Effectiveness of embolization was based on AVM devascularization on angiography: 100% (total), 90%–99% (near-total), 70%–90% (substantial), 30%–70% (partial), and 0%–30% (failure). Complications were graded according to the Society of Interventional Radiology classification. ResultsIn 69% of patients, 70%–100% devascularization was achieved. Total and near-total occlusion of the nidus were more often achieved in AVMs of types I and IIIa (both 100%) than in AVMs of types II, IIIb, and IV (56%, 67%, and 39%, respectively; P = .019). A total of 109 complications were identified: 101 minor (22.9%) and 8 major (1.8%). Major complications included wounds (n = 5), false aneurysm (n = 1), finger contracture (n = 1), and severe pain (n = 1) requiring therapy. The patient complication risk was significantly affected by the number of procedures (relative risk = 2.0; P < .001). Age, AVM location, and angioarchitecture type did not significantly affect complication risk. ConclusionsAVM embolization resulted in 70%–100% devascularization in 69% of patients, with few major complications. This study indicates that the type of AVM angioarchitecture affects the number of procedures needed and the achievability of AVM devascularization.

Feasibility and Safety of CT-Guided High-Dose-Rate Brachytherapy Combined with Transarterial Chemoembolization Using Irinotecan-Loaded Microspheres for the Treatment of Large, Unresectable Colorectal Liver Metastases

To evaluate feasibility and safety of combined irinotecan chemoembolization and CT-guided high-dose-rate brachytherapy (HDRBT) in patients with unresectable colorectal liver metastases > 3 cm in diameter. This prospective study included 23 patients (age, 70 y ± 11.3; 16 men) with 47 liver metastases (size, 62 mm ± 18.7). Catheter-related adverse events were reported per Society of Interventional Radiology classification, and treatment toxicities were reported per Common Terminology Criteria for Adverse Events. Liver-related blood values were analyzed by Wilcoxon test, with P < .05 as significant. Time to local tumor progression, progression-free survival (PFS), and overall survival (OS) were estimated by Kaplan-Meier method. No catheter-related major or minor complications were recorded. Significant differences vs baseline levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT; both P < .001), γ-glutamyltransferase (GGT; P = .013), and hemoglobin (P=.014) were recorded. After therapy, 11 of 23 patients (47.8%) presented with new grade I/II toxicities (bilirubin, n = 3 [13%]; AST, n = 16 [70%]; ALT, n = 18 [78%]; ALP, n = 12 [52%] and hemoglobin, n = 15 [65%]). Moreover, grade III/IV toxicities developed in 10 (43.5%; 1 grade IV): AST, n = 6 (26%), grade III, n = 5; grade IV, n = 1; ALT, n = 3 (13%); GGT, n = 7 (30%); and hemoglobin, n = 1 (4%). However, all new toxicities resolved within 3 months after therapy without additional treatment. Median local tumor control, PFS, and OS were 6, 4, and 8 months, respectively. Combined irinotecan chemoembolization and CT-guided HDRBT is safe and shows a low incidence of toxicities, which were self-resolving.

Balloon Pulmonary Angioplasty for the Treatment of Nonoperable Chronic Thromboembolic Pulmonary Hypertension: Single-Center Experience with Low Initial Complication Rate

PurposeTo evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) for nonoperable chronic thromboembolic pulmonary hypertension (CTEPH) patients during the initial experience of a single center. MethodsA total of 18 CTEPH patients (5 with residual pulmonary hypertension after pulmonary endarterectomy) were treated with BPA during the period 2014–2018 and were retrospectively reviewed. Mean age was 61 ± 19 years; 55% were female; mean pulmonary artery pressure was 44 ± 12 mmHg; cardiac output was 4.3 ± 1.0 l/min; and pulmonary vascular resistance was 8.4 ± 3.6 WU. Patients were evaluated by New York Heart Association functional class, 6-minute walk distance, N-terminal pro b-type natriuretic peptide, echocardiography, right heart catheterization, and before and after completions of BPA. ResultsA total of 91 procedures were performed, with a median number of 4 BPA sessions per patient (range, 2–8). There were no deaths or major complications requiring extracorporeal support or (non)invasive ventilation. The most common complication was self-limiting hemoptysis (3%). According to Society of Interventional Radiology classification, 4 mild, 4 moderate, and 1 severe adverse events were noted. Invasive hemodynamics significantly improved, with a cardiac index increase of 15% (P = .0333), decrease of mean pulmonary artery pressure of 30% (P = .0013), and decrease of pulmonary vascular resistance of 45% (P = .0048). Stroke volume index (P = .0171) and pulmonary arterial compliance (P = .0004) were also significantly enhanced. ConclusionsBPA significantly improves cardiopulmonary hemodynamics with an acceptable safety profile. Further studies assessing the long-term efficacy of BPA are required.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety

PurposePortal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. Materials and MethodsConsecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose–area product (DAP) were recorded. ResultsTechnical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). ConclusionsPVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

Recanalization of Chronic Portal Vein Occlusion in Pediatric Liver Transplant Patients

PurposeTo evaluate technical and clinical success and report long-term outcomes of portal vein (PV) recanalization in pediatric orthotopic liver transplant (OLT) patients with chronic PV occlusion. Materials and MethodsThis is a retrospective review of 15 OLT patients (5 males) with chronic PV occlusion who underwent PV recanalization (33 procedures) between October 2011 and February 2018. Median age was 4.5 years (range, 1–16 years); median weight was 16.6 kg (range, 11.5–57.3 kg). Median time interval from OLT to first intervention was 3.25 years (range, 0.6–15.7 years). Clinical presentations included hypersplenism (n = 12), gastrointestinal bleeding (n = 9), and ascites (n = 3). One patient had incidental diagnosis of PV occlusion. Primary, primary-assisted, and secondary patency at 3, 6, 12, and 24 months were evaluated. ResultsTechnically successful PV recanalization and reduction of PV pressure gradient to ≤ 5 mm Hg was performed in 13/15 patients (87%). Ten of 15 (67%) patients had successful recanalization with the first attempt. Clinical success, defined as improvement in signs and symptoms of portal hypertension, was achieved in 12/13 (92%) patients. Five of 33 (15%) major complications (Society of Interventional Radiology class C), including perisplenic hematoma (n = 2), hemoperitoneum (n = 2), and hepatic artery pseudo aneurysm (n = 1), were managed with pain medication and blood product replacement. Median follow-up was 22 months (range, 1–77 months). Median primary patency was 5 months. Primary patency at 3, 6, 12, and 24 months was 53.8%, 46.2%, 38.5%, and 30.8%, respectively. Primary-assisted patency was 84.6%, 76.9%, 53.8%, and 46.2%, respectively. Secondary patency was 92.3%, 84.6%, 53.8%, and 46.2%, respectively. ConclusionsPV recanalization is a safe and effective minimally invasive option in the management of chronic PV occlusion after pediatric OLT.