Vasc Interv Radiol Research Articles

Commentary: The Reliability of a 2-mm Minimum Margin as an Adequacy Endpoint for Colorectal Pulmonary Metastasis Ablation Success

The investigators Hasegawa et al ( 1 Hasegawa T. Takaki H. Kodama H. et al. Impact of ablative margin on local tumor progression after radiofrequency ablation for lung metastases from colorectal carcinoma: supplementary analysis of a phase II trial (MLCSG-0802). J Vasc Interv Radiol. 2023; 34: 31-37 Abstract Full Text Full Text PDF Google Scholar ) are to be congratulated for identifying the ablation margin as a key technical element for thermal ablation success in tumor control in their article “Impact of Ablative Margin on Local Tumor Progression after Radiofrequency Ablation for Lung Metastases from Colorectal Carcinoma: Supplementary Analysis of a Phase II Trial.” The study evaluated 95 colorectal cancer (CRC) pulmonary metastases treated with radiofrequency (RF) ablation followed by sequential computed tomography (CT) examinations for at least 12 months after RF ablation and aimed to assess the minimum ablation margin (MM) required for better local tumor control ( 1 Hasegawa T. Takaki H. Kodama H. et al. Impact of ablative margin on local tumor progression after radiofrequency ablation for lung metastases from colorectal carcinoma: supplementary analysis of a phase II trial (MLCSG-0802). J Vasc Interv Radiol. 2023; 34: 31-37 Abstract Full Text Full Text PDF Google Scholar ). The MM was estimated as the shortest distance of the outer tumor boundary to the ground-glass opacity representing the ablation zone (AZ) immediately after RF ablation. Impact of the Ablative Margin on Local Tumor Progression after Radiofrequency Ablation for Lung Metastases from Colorectal Carcinoma: Supplementary Analysis of a Phase II Trial (MLCSG-0802)Journal of Vascular and Interventional RadiologyVol. 34Issue 1PreviewPulmonary oligometastatic disease is considered to be an indication for lung radiofrequency (RF) ablation when patients cannot undergo surgical treatment or external radiation therapy because of poor performance status, comorbid disease, or advanced age (1–3). In particular, the treatment outcomes of lung RF ablation for colorectal cancer (CRC) lung metastases have been well investigated, yielding satisfactory results including a 5-year disease-specific survival rate of 47%–69% and overall survival rate of 33%–68% (2–7). Full-Text PDF

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

Commentary: Coil Packing Density – Not Just for Cerebral Aneurysms

Coil packing density (CPD) has been recognized as a factor related to coil compaction or recanalization in the treatment of visceral and intracranial aneurysms ( 1 Yasumoto T. Osuga K. Yamamoto H. et al. Long-term outcomes of coil packing for visceral aneurysms: correlation between packing density and incidence of coil compaction or recanalization. J Vasc Interv Radiol. 2013; 24: 1798-1807 Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar , 2 Kawanabe Y. Sadato A. Taki W. Hashimoto N. Endovascular occlusion of intracranial aneurysms with Guglielmi detachable coils: correlation between coil packing density and coil compaction. Acta Neurochir (Wien). 2001; 143: 451-455 Crossref PubMed Scopus (186) Google Scholar ). Simple coiling (SC), balloon remodeling (BR), and stent-assisted coiling are 3 commonly used techniques for percutaneously treating aneurysms. In the article by Kesim et al ( 3 Kesim Ç. Özcan Ü.C. Yildirim E. Effects of the cerebral aneurysm treatment method on coil packing density and its relationship with the ostium area. J Vasc Interv Radiol. 2022; 33: 631-638 Abstract Full Text Full Text PDF Scopus (1) Google Scholar ) titled “Effects of the Aneurysm Treatment Method on Coil Packing Density and Its Relationship with the Ostium Area,” the authors demonstrated that it is possible to achieve similar CPDs using these 3 coiling techniques while treating intracranial aneurysms and concluded that “in cerebral aneurysms treated with balloon- or stent-assisted coiling, the CPD value does not differ from that in aneurysms treated with simple coiling.” The authors noted that coiling technique is influenced by aneurysm neck size, with BR and stent-assisted coiling used for aneurysms with unfavorable neck morphology. Another possible conclusion is that for aneurysms with unfavorable neck morphology, BR and stent-assisted coiling make it possible to achieve CPDs similar to those achieved with SC in “simple” aneurysms. Effects of the Cerebral Aneurysm Treatment Method on Coil Packing Density and Its Relationship with the Ostium AreaJournal of Vascular and Interventional RadiologyVol. 33Issue 6PreviewTo test the following hypotheses: (a) balloon or stent assistance increases coil packing density (CPD) in the endovascular treatment of intracranial aneurysms, and (b) CPD correlates to ostium area (OA) and aneurysm volume (AV). Full-Text PDF

Commentary on “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians”

The article “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians” addresses an important and controversial issue of whether nonneuroscience interventional physicians should be performing stroke thrombectomy ( 1 Sacks D. Dhand S. Hegg R. et al. Outcomes of stroke thrombectomy performed by interventional radiologists versus neurointerventional physicians. J Vasc Interv Radiol. 2022; 33: 619-626 Google Scholar ). There is convincing evidence that stroke thrombectomy improves the clinical outcomes of large vessel occlusion (LVO) anterior circulation strokes and that it is cost effective ( 2 Powers W.J. Rabinstein A.A. Ackerson T. et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1847) Google Scholar , 3 Bulwa Z. Chen M. Stroke center designations, neurointerventionalist demand, and the finances of stroke thrombectomy in the United States. Neurology. 2021; 97: S17-S24 Crossref PubMed Scopus (2) Google Scholar ). This article provides data to support the position that interventional radiology (IR) physicians with additional training can achieve technical and clinical outcomes similar to those obtained by neurointerventional (NI) physicians. We do not take sides in this controversy. The purposes of this commentary are to appraise the current article critically, to examine its potential implications, and to provide an update on the issues of the supply of, demand for, and access to stroke thrombectomy. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional PhysiciansJournal of Vascular and Interventional RadiologyVol. 33Issue 6PreviewTo test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. Full-Text PDF

Pediatric Renovascular Hypertension: Not Just a “String of Beads”

It is with great enthusiasm ( 1 Zhao L Zhao X Hu X Yang H Wu L Midterm outcome of angioplasty for pediatric renovascular hypertension. J Vasc Interv Radiol. 2022; 33: 399-407 Google Scholar ) that I read the recent publication on the midterm outcome of angioplasty for the treatment of pediatric renovascular hypertension in children. This publication expands on the pre-existing pediatric renal angioplasty literature with the addition of diethylenetriaminepentaacetic acid (DTPA) renal function outcome measurements. Midterm Outcomes of Angioplasty for Pediatric Renovascular HypertensionJournal of Vascular and Interventional RadiologyVol. 33Issue 4PreviewTo evaluate the midterm outcomes of percutaneous transluminal renal angioplasty (PTRA) for pediatric renovascular hypertension (RVH). Full-Text PDF

Leveraging Value-Based Payment Models to Reduce Health Inequities in Radiology

Leveraging Value-Based Payment Models to Reduce Health Inequities in Radiology

Genicular Artery Embolization: Beyond the Placebo Effect, and Planning for the Long Road Ahead

Genicular artery embolization (GAE) has emerged in the field of interventional radiology as a treatment for knee pain related to osteoarthritis. This novel treatment is based on the hypothesis by Okuno et al and supported by multiple small single-arm studies ( 1 Okuno Y. Korchi A.M. Shinjo T. et al. Transcatheter arterial embolization as a treatment for medial knee pain in patients with mild to moderate osteoarthritis. Cardiovasc Intervent Radiol. 2015; 38: 336-343 Crossref PubMed Scopus (50) Google Scholar , 2 Okuno Y. Korchi A.M. Shinjo T. et al. Midterm clinical cutcomes and MR imaging changes after transcatheter arterial Embolization as a treatment for mild to moderate radiographic knee osteoarthritis resistant to conservative treatment. J Vasc Interv Radiol. 2017; 28: 995-1002 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar , 3 Lee S.H. Hwang J.H. Kim D.H. et al. Clinical outcomes of transcatheter arterial embolisation for chronic knee pain: mild-to-moderate versus severe knee osteoarthritis. Cardiovasc Intervent Radiol. 2019; 42: 1530-1536 Crossref PubMed Scopus (40) Google Scholar , 4 Landers S. Hely R. Page R. et al. Genicular artery embolization to improve pain and function in early-stage knee osteoarthritis-24-month pilot study results. J Vasc Interv Radiol. 2020; 31: 1453-1458 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 5 Bagla S. Piechowiak R. Hartman T. et al. Genicular artery embolization for the treatment of knee pain secondary to osteoarthritis. J Vasc Interv Radiol. 2020; 31: 1096-1102 Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar , 6 Little M.W. Gibson M. Briggs J. et al. Genicular artEry embolizatioN in patiEnts with oSteoarthrItiS of the knee (GENESIS) using permanent microspheres: interim analysis. Cardiovasc Intervent Radiol. 2021; 44: 931-940 Crossref PubMed Scopus (26) Google Scholar ) that pain is in part due to hypervascularity and inflammation, but several considerations need to be addressed. These include GAE's indications, mode of action, mechanism of clinical success achieved by short-term embolization using imipenem/cilastatin crystals vs other embolics, and the possibility of symptom improvement due to the placebo effect. In particular, concern about the placebo effect is plausible given that embolization using imipenem/cilastatin crystals, which are smaller and more rapidly soluble than typical embolic materials ( 7 Yamada K. Jahangiri Y. Li J. et al. Embolic characteristics of imipenem-cilastatin particles in vitro and in vivo: implications for transarterial embolization in joint arthropathies. J Vasc Interv Radiol. 2021; 32: 1031-1039.e2 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar ), have yielded outcomes similar to those of permanent embolic materials ( 2 Okuno Y. Korchi A.M. Shinjo T. et al. Midterm clinical cutcomes and MR imaging changes after transcatheter arterial Embolization as a treatment for mild to moderate radiographic knee osteoarthritis resistant to conservative treatment. J Vasc Interv Radiol. 2017; 28: 995-1002 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar ). Osteoarthritic pain response is also highly susceptible to the placebo effect ( 8 Doherty M. Dieppe P. The “placebo” response in osteoarthritis and its implications for clinical practice. Osteoarthritis Cartilage. 2009; 17: 1255-1262 Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar ). Therefore, a sham-controlled study is extremely valuable to assess the efficacy of GAE. However, it is difficult to justify a sham-controlled study in the field of interventional radiology because subjects in the control arm would be at risk of adverse events that may not be trivial, such as infection or bleeding after arterial access.

Percutaneous Vacuum-Assisted Thrombectomy for Right Atrial Mass

CATHETER-RELATED right atrial thrombi (CRAT) and right heart thrombi (RiHT) can have devastating complications secondary to pulmonary embolism (PE) if left untreated. 1 Barrios D Rosa-Salazar V Jiménez D et al. Right heart thrombi in pulmonary embolism. Eur Respir J. 2016; 48: 1377-1385 Crossref PubMed Scopus (33) Google Scholar ,2 Rose PS Punjabi NM Pearse DB. Treatment of right heart thromboemboli. Chest. 2002; 121: 806-814 Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar Conventional therapy consists of oral and intravenous anticoagulation, catheter-directed thrombolytics, and surgical embolectomy. However, these therapies are not always successful or carry significant risk of periprocedural complications and mortality. 1 Barrios D Rosa-Salazar V Jiménez D et al. Right heart thrombi in pulmonary embolism. Eur Respir J. 2016; 48: 1377-1385 Crossref PubMed Scopus (33) Google Scholar ,3 Tran MH Wilcox T Tran PN. Catheter-related right atrial thrombosis. J Vasc Access. 2020; 21: 300-307 Crossref PubMed Scopus (11) Google Scholar ,4 Stein PD Alnas M Beemath A et al. Outcome of pulmonary embolectomy. Am J Cardiol. 2007; 99: 421-423 Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar The AngioVac (Angiodynamics, Latham, NY) device is a potentially safe and effective alternative to conventional therapy. 5 Hameed I Lau C Khan FM et al. AngioVac for extraction of venous thromboses and endocardial vegetations: A meta-analysis. J Card Surg. 2019; 34: 170-180 Crossref PubMed Scopus (20) Google Scholar ,6 Moriarty JM Rueda V Liao M et al. Endovascular removal of thrombus and right heart masses using the AngioVac system: Results of 234 patients from the prospective, multicenter registry of AngioVac procedures in detail (RAPID). J Vasc Interv Radiol. 2021; 32: 549-557 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The AngioVac is a vacuum-assisted thrombectomy device that uses a venovenous extracorporeal circuit to generate negative pressure through a specialized 22-F expandable funnel-tipped catheter in order to aspirate thrombi, emboli, or other masses in the major veins, right heart chambers, and pulmonary artery. The authors present a case of a 40-year-old woman with metastatic adrenocortical carcinoma and a CRAT who was treated with the AngioVac device.

THE CONUNDRUM OF TREATING SUB-MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary embolism (PE) is an important cause of morbidity and mortality during pregnancy. 20% of maternal deaths during pregnancy are related to PE. Treatment decisions are further complicated by pregnancy, in which the outcome of the fetus is also at stake. While emerging data support the use of thrombolytic therapy during pregnancy for life-threatening PE, there are no conclusive data on the appropriate treatment (1). CASE PRESENTATION: A 7-week pregnant, 31-year-old women with history of protein C deficiency was admitted for acute onset dyspnea and syncopal episode. On physical examination, the heart rate was 136 bpm and blood pressure was 121/87 mm Hg. Oxygen saturation was 97% on room air. There was no heart murmur, lungs were clear to auscultation, and the extremities appeared normal. Troponin I level was 0.908 ng/mL and Bnp was 115pg/ml. Electrocardiogram showed sinus tachycardia. Computed tomography pulmonary angiography showed large pulmonary emboli involving the distal main pulmonary artery, left and right pulmonary arteries extending into the proximal lobar and segmental arteries bilaterally (Image 1 and 2). Echocardiogram showed a dilated right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Multi-disciplinary team meeting was done to discuss the risks and benefits of systemic thrombolysis and catheter-directed thrombolysis. The patient chose catheter-directed thrombolysis and after the procedure, patient's symptoms improved significantly. Due to risk of fetal anomalies from radiation exposure, patient decided to terminate her pregnancy. DISCUSSION: The guidelines on management of life-threatening acute PE in pregnancy is not well established. Teratogenicity due to thrombolytic agent has not been reported, though the risk of maternal hemorrhage is high. Catheter directed thrombolysis reduces the complications encountered in systemic thrombolysis yet require radiation exposure. CTPA and catheter directed thrombolysis usually exposes patient between 50-100mGy of radiation. During the 5th-10th week of gestation, exposures between 50-100Gy have uncertain potential side effects to the fetus. Systemic review of case series and case reports among 172 pregnant females treated with thrombolytic agents, the maternal mortality was 1%, the incidence of fetal loss was 6%, and the incidence of maternal hemorrhagic complications was 8% (2). Limited data is available for catheter directed thrombolytic therapy during 1st trimester of pregnancy, and if deemed necessary, a shared decision making with patient regarding termination of pregnancy should be made (3). CONCLUSIONS: The use of systemic or catheter directed thrombolysis is associated with positive outcomes and relatively low risk of complications. Yet, clinical judgements should be made based on individual patients risks versus benefits. REFERENCE #1: Heavner MS, Zhang M, Bast CE, Parker L, Eyler RF. Thrombolysis for Massive Pulmonary Embolism in Pregnancy. Pharmacotherapy. 2017 Nov;37(11):1449-1457. doi: 10.1002/phar.2025. Epub 2017 Oct 10. REFERENCE #2: Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv. 1995;50(7):534. REFERENCE #3: Bloom AI, Farkas A, Kalish Y. Pharmacomechanical catheter directed thrombolysis for pregnancy related iliofemoral deep vein thrombosis. J Vasc Interv Radiol 2015;26:992-1000. 10.1016/j.jvir.2015.03.001 DISCLOSURES: No relevant relationships by Ki Lee, source=Web Response No relevant relationships by Pratik Patel, source=Web Response No relevant relationships by SHREY SHAH, source=Web Response

The Role of Percutaneous Ablation in Musculoskeletal Metastases

The Role of Percutaneous Ablation in Musculoskeletal Metastases

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

EMERGENT THROMBECTOMY OF HIGH RISK PE

SESSION TITLE: Fellows Pulmonary Vascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Some physiologic consequences of high risk pulmonary emboli (PE), such as shock and refractory hypoxemia, require urgent reperfusion therapy. Delaying management in those cases may lead to catastrophic consequences including hemodynamic collapse. However, comorbid conditions often limit treatment options complicating management. Here we present two cases of acute onset severe hypoxemia attributable to PE. Neither patient was a candidate for pharmacological thrombolysis due to recent or active GI bleeding. CASE PRESENTATION: Patient A, a 52-year-old male with prior colectomy due to ulcerative colitis, was admitted with duodenal perforation and post-ERCP pancreatitis with one day of significant dyspnea and hypoxemia. He underwent testing with a computed tomography pulmonary angiogram (CTPA) which revealed pulmonary emboli. Despite intubation, FiO2 of 100%, recruitment maneuvers, and inhaled vasodilator therapy with epoprostenol, he had persistent and refractory hypoxemia (Table). After the initiation of heparin, he had recurrent gastrointestinal hemorrhage and required vasopressors. Patient B, a 71-year-old female with multiple myeloma and on chemotherapy with pancytopenia and lower GI bleed two weeks prior, presented with acute onset of dyspnea for less than one day and high oxygen requirements and labile hemodynamics with signs of hypoperfusion (Table). CTA confirmed pulmonary emboli. Point of care ultrasonography demonstrated signs of right heart strain. DISCUSSION: Both patients had bilateral pulmonary emboli and filling defects in distal left main pulmonary artery extending into left upper and lower lobar arteries and lobar and segmental arteries on the right. After rapid discussion with a multidisciplinary PE response team, percutaneous aspiration thrombectomy via the FlowTriever System was utilized in both patients. The FlowTriever System is a large bore catheter device which is FDA approved for mechanical thrombectomy in the pulmonary arteries. Both patients were successfully treated with acute clinical and technical success, with intraprocedural improvements of mean pulmonary artery pressures of > 25%. Patient A had immediate improvement of hypoxemia. Patient B had improvement in her hemodynamic stability and organ perfusion. Both patients did require packed red blood cell transfusions. This is partially attributed to both patients having active GI bleeding, but can be exacerbated aspiration of blood during thrombectomy if multiple passes are required. CONCLUSIONS: Percutaneous thrombectomy is an alternative treatment option in critically ill patients with high risk of hemodynamic collapse or refractory hypoxemia, especially in those with contraindications to thrombolysis. One limitation is the possibility of intraprocedural blood loss which should be anticipated and address with volume expansion with or without transfusion. Reference #1: Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med. 2011;26(5):275-294. doi:10.1177/0885066610392658 Reference #2: Wible BC, Buckley JR, Cho KH, Bunte MC, Saucier NA, Borsa JJ. Safety and Efficacy of Acute Pulmonary Embolism Treated via Large-Bore Aspiration Mechanical Thrombectomy Using the Inari FlowTriever Device. J Vasc Interv Radiol. 2019;30(9):1370-1375. doi:10.1016/j.jvir.2019.05.024 DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response Consultant relationship with Bellerophon Please note: $1001 - $5000 Added 06/01/2020 by Roger Alvarez, source=Web Response, value=Travel Advisory Committee Member relationship with United Therapeutics Please note: $1001 - $5000 Added 06/01/2020 by Roger Alvarez, source=Web Response, value=Consulting fee No relevant relationships by Adhiraj Gosine, source=Web Response No relevant relationships by Susanna Leonard, source=Web Response

TRANSUDATIVE CHYLOTHORAX IN LIVER CIRRHOSIS: A RARE MANIFESTATION OF PORTAL HYPERTENSION

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hepatic hydrothorax is a well-recognized pulmonary complication of decompensated liver cirrhosis that can be found in 5-11% of cases. It typically presents as exertional dyspnea in patients with Child-Pugh Class (CPC) B or C cirrhosis and abdominal ascites. The pleural effusion involves the right lung approximately 80% of the time, and pleural fluid analysis is consistent with a transudative effusion. Underlying infection or malignancy should be ruled out. Transudative chylothorax is an exceedingly rare manifestation of portal hypertension in this patient population. CASE PRESENTATION: A 46-year-old man with CPC B, MELD 19 alcoholic liver cirrhosis who recently underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure with revisions for refractory ascites, presented with progressive cough and dyspnea on exertion for 2 weeks. He reported needing a therapeutic paracentesis approximately every 10 days prior to TIPS; however, since his most recent TIPS revision 4 weeks prior to presentation, he did not have recurrence of his ascites. Exam was notable for diminished breath sounds throughout the right lung fields and trace ascites. Chest radiograph revealed a moderate pleural effusion at the right lower lobe. A thoracentesis yielded 1.5 liters of milky yellow fluid with initial labs suggesting a transudative effusion. A chest tube was placed. Given the milky appearance, further studies were sent, revealing triglycerides at 335 mg/dL and cholesterol at 11 mg/dL, consistent with chylothorax. To evaluate for other etiologies of chylothorax, lymphoscintigraphy was performed, which did not reveal any lymphatic leak or thoracic duct injury. A CT scan of the chest did not demonstrate any lesions concerning for infection or malignancy, and pleural fluid cultures and cytology confirmed the absence of either. The patient underwent TIPS revision with angioplasty, with improvement of the transhepatic pressure gradient. The patient was discharged after increasing his home dose of diuretics and remained asymptomatic at his follow-up appointment 1 week later. DISCUSSION: Liver cirrhosis is an underappreciated cause of chylothorax, with only about 20 cases described in the literature. The pathophysiologic mechanism is thought to be mediated by elevated venous pressures caused by portal hypertension. Diagnostic thoracentesis is required in these patients to rule out malignancy or infection, which are also known etiologies of chylothorax. When the effusion is transudative, interventions aimed at decreasing portal hypertension, such as TIPS, should be considered to prevent recurrence of the chylothorax. CONCLUSIONS: Chylothorax is a rare complication of liver cirrhosis that can be successfully treated by medically managing ascites and/or by TIPS. Reference #1: Chaaban T, Kanj N, Aki IB. Hepatic hydrothorax: an updated review on a challenging disease. Lung. 2019; 197:399-405. Reference #2: Mukherjee A, Sehgal IS, Mittal BR, Dhooria S. Transudative chylothorax: an uncommon illness due to a common cause. BMJ Case Rep. 2018; Feb 7. pii: bcr-2017-223158. Reference #3: Tsauo J, Hoon Shin J, Han K, Yoon HK, Ko GY, Ko HK, Gwon DI. Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systematic review of the literature. J Vasc Interv Radiol. 2016; 27: 112-116. DISCLOSURES: No relevant relationships by Argin Baghramian, source=Web Response No relevant relationships by Stefano Iantorno, source=Web Response No relevant relationships by Sonia Lin, source=Web Response No relevant relationships by Alex Rosenberg, source=Web Response

STITCH TO STENT: A VASCULAR COMPLICATION OF LUNG TRANSPLANTATION

SESSION TITLE: Medical Student/Resident Transplantation Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung transplantation (LTx) is an established treatment for end-stage lung diseases. Pulmonologists will be well-served to be familiar with its complications. We describe a patient with a vascular complication of LTx which is often associated with significant mortality and morbidity. CASE PRESENTATION: A 61-year-old man was admitted with hypoxic respiratory failure 3 months following bilateral LTx for bronchiectasis from Kartagener’s syndrome. Infection, rejection, and heart failure were all ruled out with x-ray, non-contrast CT scan and echocardiography. Bronchoscopy revealed scant clear secretions with negative cultures and no evidence of rejection on transbronchial biopsy. CT pulmonary angiography (CTPA) performed to rule out embolism revealed a severe right pulmonary artery stenosis (PAS) at the anastomotic site. The lesion was dilated with balloon angioplasty resulting in mild improvement on follow up CT scans. Quantitative perfusion scan estimated only 18% perfusion in the right lung due to stenosis of the right pulmonary artery. Angiography was repeated and an Express LD ® 10 mm x 25 mm balloon-expandable stent was placed across the stenosis. Right pulmonary artery blood flow and hypoxia improved, and the patient was soon discharged. At 1 month follow up, right lung perfusion improved to 41%. DISCUSSION: Anastomotic PAS is defined as an anastomotic diameter of 75% or less that of the neighboring vessels. Causes include mismatched lengths of donor and recipient pulmonary artery segments, twisting of the anastomosis, and thrombosis. Clinical presentation is usually within 6 weeks of LTx with unexplained hypoxia and pulmonary hypertension. Delays in diagnosis and correction of PAS can lead to respiratory failure, hemodynamic compromise, and graft failure. Modalities for diagnosis include CTPA, magnetic resonance angiography, echocardiography and quantitative perfusion scanning. CTPA shows detailed anatomy after surgery thus helping to rule out other causes of hypoxia. Invasive pulmonary angiography is the gold standard for confirmation but is usually reserved for cases in which catheter-based intervention (CBI) is required. PAS can be corrected by surgical revision or CBI (angioplasty with or without stenting). The latter is becoming more common due to lower procedural risk, better tolerability and utility in late-presenting cases. Anticoagulants are used if thrombosis is present. CONCLUSIONS: LTx patients with persistent unexplained hypoxia should be evaluated for vascular complications, including anastomotic PAS, given high risk of mortality and morbidity. CTPA is a popular choice for diagnostic imaging. Although historically LTx patients with PAS had extremely poor prognosis, catheter-based stent intervention has the potential to prevent graft failure. Reference #1: Anaya-Ayala JE, Loebe M, Davies MG. Endovascular management of early lung transplant-related anastomotic pulmonary artery stenosis. J Vasc Interv Radiol 2015;26:878–882 Reference #2: Siddique A, Bose AK, Özalp F, Butt TA, Muse H, Morley KE, Dark JH, Parry G, Clark SC. Vascular anastomotic complications in lung transplantation: a single institution's experience. Interact Cardiovasc Thorac Surg. 2013 Oct;17(4):625-31 Reference #3: Batra K, Chamarthy MR, Reddick M, Roda MS, Wait M, Kalva SP. Diagnosis and interventions of vascular complications in lung transplant. Cardiovasc Diagn Ther. 2018 Jun;8(3):378-386. DISCLOSURES: no disclosure on file for Usman Ahmad; No relevant relationships by Christian Cuvillier Padilla, source=Web Response No relevant relationships by ihab Haddadin, source=Web Response No relevant relationships by Lirim Krveshi, source=Web Response No relevant relationships by Carli Lehr, source=Web Response No relevant relationships by Uddalak Majumdar, source=Web Response No relevant relationships by Atul Mehta, source=Web Response No relevant relationships by Wayne Tsuang, source=Web Response No relevant relationships by Maryam Valapour, source=Web Response

Hiring Through the Lens of Diversity: Strategies to Create Diverse Departments

There is increasing scrutiny of the lack of diversity in the radiology workforce as well as the lack of significant progress in increasing the proportion of women and underrepresented minorities (URM) in radiology training programs ( 1 Chapman CH Hwang WT Both S et al. Current status of diversity by race, Hispanic ethnicity, and sex in diagnostic radiology. Radiology. 2014; 270: 232-240 Crossref PubMed Scopus (99) Google Scholar , 2 Higgins MC Hwang WT Richard C et al. Underrepresentation of women and minorities in the United States IR academic physician workforce. J Vasc Interv Radiol. 2016; 27 (1837-1844.e2) Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar ). For over a decade, our radiology societies and journals have urged us to increase the diversity of radiology teams to better reflect the demographics of our patients and our society in the United States ( 3 Grimm LJ Ngo J Pisano ED et al. Men (and women) in academic radiology: how can we reduce the gender discrepancy?. AJR Am J Roentgenol. 2016; 206: 678-680 Crossref PubMed Scopus (54) Google Scholar , 4 Fielding JR Major NM Mullan BF et al. Choosing a specialty in medicine: female medical students and radiology. AJR Am J Roentgenol. 2007; 188: 897-900 Crossref PubMed Scopus (57) Google Scholar , 5 Lightfoote JB Fielding JR Deville C et al. Improving diversity, inclusion, and representation in radiology and radiation oncology part 1: why these matter. J Am Coll Radiol. 2014; 11: 673-680 Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar , 6 Lightfoote JB Fielding JR Deville C et al. Improving diversity, inclusion, and representation in radiology and radiation oncology part 2: challenges and recommendations. J Am Coll Radiol. 2014; 11: 764-770 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 7 Lightfoote JB Deville C Ma LD et al. Diversity, inclusion, and representation: it is time to act. J Am Coll Radiol. 2016; 13: 1421-1425 Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar ). It is argued that this is the right thing from a moral and social justice perspective, from a public health perspective, and from a business perspective ( 5 Lightfoote JB Fielding JR Deville C et al. Improving diversity, inclusion, and representation in radiology and radiation oncology part 1: why these matter. J Am Coll Radiol. 2014; 11: 673-680 Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar , 8 National Academy of Sciences, National Academy of Engineering, and Institute of Medicine of the National AcademiesBeyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering. The National Academies Press, Washington, DC2007 Google Scholar , 9 Norbash A Kadom N. The business case for diversity and inclusion. J Am Coll Radiol. 2020; Abstract Full Text Full Text PDF Scopus (9) Google Scholar ). These “calls to action” are not being ignored. Many departments (including our own) have made concerted efforts to enhance our diversity. Despite limited success at some institutions, a frequent and recurrent concern that emerges from these efforts is that the pool must be enlarged from the ground up—high school, college. But as we work on enlarging the pool, we also must look at the hiring process.

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

Trifluoroacetic Acid as a Theranostic Ablation Agent.

HomeRadiology: Imaging CancerVol. 2, No. 1 Previous Research HighlightsFree AccessTrifluoroacetic Acid as a Theranostic Ablation AgentGary D. LukerGary D. LukerGary D. LukerPublished Online:Jan 31 2020https://doi.org/10.1148/rycan.2020204005MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Take-Away Points■ Major Focus: To test efficacy of trifluoroacetic acid (TFA) for chemical ablation of liver tumors and optimize a fluorine 19 (19F) MRI sequence to detect TFA in tissue.■ Key Result: Real-time 19F MRI successfully detected TFA in porcine liver tissue, and histologic findings effectively verified coagulation and disruption of liver architecture.■ Impact: This study established an integrated imaging and therapy protocol to apply TFA as a theranostic agent for chemical ablation of solid tissue.Ablation methods encompass a wide range of minimally invasive techniques to destroy liver tumors, particularly smaller tumors in patients for whom surgery is not safe or feasible. Incomplete ablation remains a clinical challenge with residual tumor leading to local recurrence and potentially more aggressive disease. Although ablations most commonly use radiofrequency, laser, or other thermal methods, high-flow blood vessels can produce a local heat-sink effect that reduces peak temperatures of ablation and elimination of nearby tumors. Chemical ablations do not suffer from limitations of a local heat-sink, but agents used for chemical ablation may flow irregularly in tissue with associated off-target injury and systemic toxicities. To develop a theranostic agent for chemical ablation of liver tumors, the authors combined trifluoroacetic acid (TFA) as an ablation agent with fluorine 19 (19F) MRI. 19F MRI provides quantitative images with very minimal background signal, although low sensitivity typically requires millimolar concentrations of 19F to produce diagnostic quality images. Chemical ablation uses much higher concentrations, potentially overcoming sensitivity limits of 19F MRI. The investigators optimized a 19F MRI sequence to detect TFA in phantoms with signal-to-noise correlating directly with concentration. 19F MRI detected distribution and relative amounts of TFA used to ablate porcine liver tissue ex vivo, and histologic findings showed extensive damage to hepatocytes at concentrations of 0.5 mol/L TFA or higher. By developing a 19F MRI method to detect TFA in liver tissue, this research provides a new approach to optimize chemical ablation strategies and potentially a novel theranostic technique for future clinical translation.Highlighted ArticleEinstein SA, Thompson EA, Guo C, Whitley EM, Bankson JA, Cressman ENK. Application of trifluoroacetic acid as a theranostic agent for chemical ablation of solid tissue. J Vasc Interv Radiol 2020;31(1):169–175. doi: https://doi.org/10.1016/j.jvir.2019.05.002Highlighted ArticleEinstein SA, Thompson EA, Guo C, Whitley EM, Bankson JA, Cressman ENK. Application of trifluoroacetic acid as a theranostic agent for chemical ablation of solid tissue. J Vasc Interv Radiol 2020;31(1):169–175. doi: https://doi.org/10.1016/j.jvir.2019.05.002 Crossref, Medline, Google ScholarArticle HistoryPublished online: Jan 31 2020 FiguresReferencesRelatedDetailsRecommended Articles Colorectal Cancer Liver Metastases: Biopsy of the Ablation Zone and Margins Can Be Used to Predict Oncologic OutcomeRadiology2016Volume: 280Issue: 3pp. 949-959Combined Angio-CT Systems: A Roadmap Tool for Precision Therapy in Interventional OncologyRadiology: Imaging Cancer2021Volume: 3Issue: 5Hepatocellular Carcinoma: Intra-arterial Delivery of Doxorubicin-loaded Hollow Gold Nanospheres for Photothermal Ablation—Chemoembolization Therapy in RatsRadiology2016Volume: 281Issue: 2pp. 427-435Effects of Microwave Ablation on Arterial and Venous Vasculature after Treatment of Hepatocellular CarcinomaRadiology2016Volume: 281Issue: 2pp. 617-624Midterm Safety and Efficacy of Irreversible Electroporation of Malignant Liver Tumors Located Close to Major Portal or Hepatic VeinsRadiology2017Volume: 285Issue: 3pp. 1023-1031See More RSNA Education Exhibits Maximizing Procedural Success! A Trainee's Guide to Imaging Equipment in the IR SuiteDigital Posters2018The Emerging Role of Contrast-Enhanced Ultrasound in Oncological InterventionDigital Posters2018A Practical Guide of Locoregional Treatment for Patients with Hepatocellular CarcinomaDigital Posters2019 RSNA Case Collection Spindle cell lipomaRSNA Case Collection2022Extralobar Pulmonary Sequestration RSNA Case Collection2021Hepatic AdenomatosisRSNA Case Collection2021 Vol. 2, No. 1 Metrics Altmetric Score PDF download

Left Subclavian Artery Revascularization for Thoracic Aortic Stentgrafting: Single Center Experience in 101 Patients

Introduction - Endovascular treatment of thoracic aortic pathology (TEVAR) requires a landing zone of at least 20mm in length, necessitating coverage of the left subclavian artery (LSA) in approximately 40% of the patients.1 Coverage of the LSA may increase the risk of ischaemic stroke, spinal cord ischaemia (SCI) and/or left arm claudication. Besides some endovascular options to preserve LSA flow, in the majority of cases the LSA is surgically revascularized by either a carotid-to-subclavian bypass graft or subclavian-carotid transposition. A relatively safe option, which has been shown to decrease the risk of stroke compared to LSA coverage without revascularization.2,3 Conflicting data and opinions exist in literature on the (additional) risk of surgical LSA revascularization (requiring temporary occlusion of the left common carotid artery (LCCA) for the anastomosis).4,5,6 In this study, we retrospectively analysed the indications, as well as the operative results of LSA revascularization in 97 patients, in our single centre TEVAR experience. Methods - Between 2000 and 2017, a total of 101 consecutive patients underwent surgical revascularization of the LSA prior to, concomitant, or following TEVAR. Data were retrospective collected. Revascularization was performed through a small supraclavicular incision and consisted of a transposition or bypass graft, using perioperative transcranial Doppler. Data regarding the indication for LSA revascularization, procedural details and early and late postoperative results were analysed. Results - A total of 64 carotid-subclavian bypass grafts and 33 subclavian-carotid transpositions were performed in the context of TEVAR. The majority was performed prior to stentgrafting, indicated to reduce the risk of stroke (n=58, incomplete Willis’ circle, dominant left vertebral artery (LVA) and/or exclusion of an arteria lusoria), to reduce the risk of SCI (n=18, in case of previous aortic repair, and/or stenting the entire descending aorta) or to reduce the risk of left arm malperfusion (n=8, small or absent LVA or LVA originating from the aortic arch). In two patients there was a patent left internal mammary artery to coronary artery bypass graft. In fourteen patients LSA revascularization was performed secondary to the stentgraft procedure, either immediately due to acute left arm malperfusion (n=2) or during follow-up due to invalidating left arm claudication (n=12). There was no in-hospital mortality, two ischaemic strokes (2%) were noted and one patient experienced permanent SCI (1%). Both strokes were considered to be related to the stentgraft procedure rather than the preceding LSA bypass. Additional complications observed were sympathetic chain nerve palsy (Horner’s syndrome) (n=6), phrenic nerve palsy (n=5), recurrent nerve palsy (n=4), chyle leakage requiring diet or re-exploration (n=6). In one patient, the LSA bypass occluded during follow-up requiring a redo surgical bypass. Conclusion - Selective surgical revascularization of the left subclavian artery in case of LSA coverage in TEVAR may be indicated to lower the risk of stroke, spinal cord ischaemia, and left arm malperfusion. The procedure can be performed safely when using perioperative monitoring and result in a low risk of stroke and peripheral nerve injury. References1)Kotelis D, Geisbüsch P, Hinz U, Hyhlik-Dürr A, von Tengg-Kobligk H, Allenberg JR, Böckler D. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg. 2009 Dec;50(6):1285-1292.2)Patterson BO, Holt PJ, Nienaber C, Fairman RM, Heijmen RH, Thompson MM. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg 2014;60:1491-1497.3)Saouti N, Hindori V, Morshuis WJ, et al. Left subclavian artery revascularization as part of thoracic stent grafting. Eur J Cardiothorac Surg. 2015 Jan;47(1):120-125; discussion 125.4)Maldonado TS, Dexter D, Rockman CB, Veith FJ, Garg K, Arko F, Bertoni H, Ellozy S, Jordan W, Woo E. Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization. J Vasc Surg. 2013 Jan;57(1):116-124.5)Cooper DG, Walsh SR, Sadat U, Noorani A, Hayes PD, Boyle JR. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg. 2009 Jun;49(6):1594-1601.6)Contrella BN, Sabri SS, Tracci MC, Stone JR, Kern JA, Upchurch GR, Matsumoto AH, Angle JF. Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta. J Vasc Interv Radiol. 2015 Nov;26(11):1609-1614.

Prostatic Artery Embolization and the Median Lobe: Stuck in the Middle with You?

We read with great interest the study by Yu et al. ( 1 Yu S.C.H. Cho C.C.M. Hung E.H.Y. et al. Thickness-to-Height Ratio of Intravesical Prostatic Protrusion Predicts the Clinical Outcome and Morbidity of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2019; 30: 1807-1816 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar ) that provides in-depth knowledge on the implications of the median lobe for patients with benign prostatic hyperplasia (BPH) treated with prostatic artery embolization (PAE). Frequently, physicians and patients ask if the median lobe is a contraindication for PAE in patients with BPH and if results are worse in these patients. The present study sheds some lights on this specific topic, proving that not all median lobes are the same, but many questions arise. What is the median lobe? What type of imaging classification can we use to assess it? What is the impact of the median lobe on the natural progression of disease in patients with BPH? Does the median lobe also limit the efficacy of other minimally invasive surgical techniques such as prostatic urethral lift (PUL) or water vapor thermal therapy? What do we know already about the effect of PAE for the median lobe? Can we target the median lobe during PAE? Is PAE effective when treating patients with BPH and a median lobe? Thickness-to-Height Ratio of Intravesical Prostatic Protrusion Predicts the Clinical Outcome and Morbidity of Prostatic Artery Embolization for Benign Prostatic HyperplasiaJournal of Vascular and Interventional RadiologyVol. 30Issue 11PreviewTo evaluate the presence of intravesical prostatic protrusion (IPP) and its thickness-to-height (T/H) ratio as a predictor for the clinical outcome and morbidity of prostatic artery embolization (PAE) for benign prostatic hyperplasia. Full-Text PDF