[Status and recommendations for interventional radiological procedures in COVID-19 patients]. / Status und Empfehlungen zur interventionell-radiologischen Versorgung bei COVID-19-PatientInnen.

BACKGROUND: Particularly at the beginning, the COVID-19 (coronavirus disease 2019) pandemic caused a reduction in the number of interventions in interventional radiology. At the same time, interventional training became more challenging. Infectious patients and disease transmission within interventional radiology departments continue to pose significant challenges. OBJECTIVES: This article describes the status and recommendations for interventional radiological procedures in COVID-19 patients. MATERIALS AND METHODS: Guidelines and recommendations from international and national societies as well as original works and reviews were evaluated. RESULTS: Interventional radiological care of COVID-19 patients with complicated courses of infection has become established during the course of the pandemic. To protect patients and staff, interventions in COVID-19 patients should be prioritized, performed in separate procedure rooms if possible, and patients should be tested before interventions. Logistics, staff planning, and hygiene measures should be continuously optimized. CONCLUSIONS: Structured workflows within interventional radiology in dealing with COVID-19 patients appear necessary to minimize infection risks and to guarantee the staff's work capability and health. In order to develop concepts for the handling of COVID-19 patients and to be prepared for potential upcoming waves of infections, recommendations of the Robert Koch Institute (RKI) and (inter-)national professional societies are helpful.

Remember to Screen the Spleen: A Case Study of Spontaneous Splenic Rupture

Introduction: Splenic rupture is a potentially life-threatening condition often associated with trauma or viral infection. Most cases of splenic rupture are due to trauma, viral infection, lymphoproliferative disease, malaria, tick borne illness, splenic neoplasms, connective tissue disease, or in one case, sneezing. Spontaneous splenic rupture (SSR) is a rare condition with less than five cases reported. In this case, we present a 20-year-old male who was seen with abdominal pain who was found to have an SSR with no clear etiology. Case Description/Methods: A 20-year-old male with no relevant past medical history presented with abdominal pain that radiated to the left shoulder. The patient reported the pain began after an episode of emesis which occurred 12 hours prior to arrival. He reported experiencing shortness of breath and pain on inspiration. He denied any fall or trauma, recent travel or sick contacts, fevers, weight loss, or night sweats. His social history was significant for occasional marijuana use. Upon physical exam, the patient had diffuse abdominal tenderness most pronounced in the left upper quadrant without any palpable masses. Relevant labs included a hemoglobin of 12.2, WBC count within normal limits and unremarkable manual differential, and an INR of 1. Blood parasite, heterophile antibodies, COVID, influenza, CMV, and HIV were negative. Computed tomography angiography (CTA) revealed hematoma at the splenic hilum. Interventional radiology was consulted and did not recommend intervention at time of initial presentation. Patient was admitted;his hemoglobin remained stable and he was monitored with serial abdominal exam then discharged the following day. Imaging was repeated one month later which revealed near complete resolution of hematoma. (Figure) Discussion: SSR should be considered on the differential diagnosis of physicians when encountering patients who present with LUQ pain with unclear etiology. The patient presented with the characteristic Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) but not the Ballance sign (palpable tender mass in the left upper quadrant). The incidence of SSR is estimated to be around 1 to 7% with a mortality rate of 12.2% so a broad differential for young patients presenting with abdominal pain must be entertained and should include splenic rupture as it is a potentially life-threatening condition.

Remote Clinical Quality Management of Endovascular Care

To assess the effectiveness of remote clinical quality management of endovascular Aim care. The system of clinical quality management of medical care in myocardial infarction (MI) including the quality of remote control of endovascular care was developed and introduced into the health care system of the Moscow Region as a part of the comprehensive study in 2008-2020. The number of people under the study was 8375. The ground for assessing the effectiveness of remote clinical management in 2019-2020 was the health care system of megapolis. Based on the analysis of 2966 endovascular procedures protocols, the treatment tactics effectiveness of intraoperative decisions was studied after an emergency coronary angiography (ECA) had been performed by interventional cardiologists. The Methods system of remote clinical quality management of endovascular care included a complex of audiovisual communications, computer system processes, mentoring and the algorithm for making an intraoperative decision. The effectiveness of remote clinical quality management of endovascular care was investigated on the number of percutaneous coronary interventions (PCI) in MI, mortality of patients with MI in the Regional vascular center in 2019-2020. The T-criteria was used to assess the reliability. The material statistical processing was carried out in the Statistica 6.0 package calculating adequate statistical indicators and their reliability at p<=0.005. Ratio PCI/ECA in 2019, January-March 2020 counted up to 48.95%. In April-December 2020 it increased up to 71.6% (p<0.001). The frequency of performing Results PCI increased by 1.46 times (p<0.001). Hospital mortality from MI decreased during the following period 2019, April-December 2020 from 9.7% to 8.2% (p = 0.005). Remote clinical management based on telemedicine and mentoring process Conclusion technologies contributes to improving the quality of endovascular care in MI.Copyright © 2021 Angles. All rights reserved.

Radiologic and Endoscopic Treatment for a Disconnected Pancreatic Duct Syndrome Associated to Percutaneous Pancreatic Fistula: Achieving the "Internalization of the Fistula"

Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Endovascular embolisation of a complex mandibular AVM: a hybrid transarterial and transvenous approach.

Mandibular arteriovenous malformations (AVMs) are rare lesions which can present with life-threatening haemorrhage. Endovascular embolisation can be life saving for these patients. We discuss a patient of mandibular AVM, who initially presented with reports of massive oral bleeding. The lesion was only partially embolised via transarterial route, as the nidus could not be penetrated completely. In view of rebleeding within 72 hours from the same site, a second embolisation procedure was done via combined, transarterial and transvenous approaches. Coils and onyx were used as embolising agents. Complete embolisation was achieved via combined approach. No further bleeding episodes were seen at 1-year follow-up. Endovascular embolisation of mandibular AVMs can be technically challenging and, hence, a sound knowledge of the anatomy as well as the possible modification of technique is essential to achieve complete obliteration of the lesion and to maximise the benefit of embolisation and to avoid major radical surgery.

Lung ultrasound for detection of pneumonic changes in patients with COVID-19 infection

This study aims to determine the suitability of lung ultrasound as an alternative to CT chest to aid in the initial management of these patients. The aim was to determine the value of lung ultrasound in the diagnosis of lung parenchymal affection in patients with COVID-19. Patients and Methods: A prospective including 150 patients was carried out in the Chest, Interventional Radiology and Clinical Pathology Departments in Bab-El-Sha'aria and Al-Hussin Hospitals, Al-Azhar University, during the period from May 2020 to September 2020. Lung ultrasound was performed in 150 patients with COVID-19 pneumonia diagnosed based on the integrated clinical, laboratory, and CT chest radiological data. Result(s): Among 150 patients, there were 86 males and 64 males, ranging in age from 30 to 75 years and a mean age of 55.8+/-12.1 years. Bilateral lung infiltrates in the CT scan were present in 146 patients (97.3%), CXR infiltrates were present in 63 patients (42%), sonographic evidence of pleuropulmonary involvement was present in 139 patients (92.7%), B lines and pleural line thickening were present in all patients with ultrasound findings (100%), subpleural consolidation associated with B lines was present only in 33 patients (23.7%) and pleural effusion was absent in all cases;crackles were only present in 53 (35.3%) patients. Conclusion(s): Because of its simplicity in interpretation, bedside availability, lack of risk of radiation and good sensitivity in the detection of lung parenchymal affection, the chest ultrasound is a useful tool in the management of patients with symptoms suspicious of COVID-19 infection and seems to be a suitable substitute for the CT chest in such circumstances.

Current status of the application of radiodiagnosis and radiotherapy resources in Huai'an City in 2020.

Objective: To investigate the current status of the radiodiagnosis and radiotherapy resources and medical exposure frequencies in Huai'an City. Method(s): According to the monitoring data in the " Radiological Health Information Management Platform of Jiangsu Province" in 2020, a descriptive analysis was conducted on the personnel, equipment, and exposure frequencies in the institutes engaged in radiation-based diagnosis and treatment in Huai'an. Result(s): A total of 181 hospitals were investigated in 2020, including 7 tertiary hospitals(3.9%), 24 secondary hospitals(13.3%), 126 primary hospitals(69.6%), and 24 ungraded hospitals(13.3%). There were 1 397 radiation workers, including 948 males and 449 females, and 459 pieces of radiation equipment, including 420 for radio diagnosis, 13 for radiotherapy, 4 for nuclear medicine, and 22 for interventional radiology. The hospitals of different grades greatly differed in the number of radiation workers and equipment. There were 80.1, 20.9, 2.2, and 2.0 radiation workers and 15.7, 5.5, 1.4, and 1.6 pieces of radiation equipment in the tertiary hospitals, secondary hospitals, primary hospitals, and ungraded hospitals, respectively on average. There were 2 903 246, 27 648, 8 087, and 17 874 receiving radiodiagnosis, radiotherapy, nuclear medicine, and interventional radiology, respectively in 2020. The medical exposure frequencies in the whole city were calculated to be 599.50 per 1 000 population, including 334.59 treated with conventional X-rays, 239.82 receiving CT scan, 14.18 for breast and dentistry, 3.62 receiving interventional radiology, 5.61 treated with radiotherapy, and 1.69 receiving nuclear medicine. Conclusion(s): The radiodiagnosis and radiotherapy resources are unbalanced in the hospitals of different grades in Huai'an City. Therefore, it is necessary to pay more attention to the reasonable allocation of medical resources. Meanwhile, radiation workers in secondary hospitals may be more prone to job burnout. Facing the normalization of the prevention and control of COVID-19 epidemic, the supervision and management of radiological health should be strengthened to ensure the legitimacy of radiological diagnosis and radiotherapy and theoptimization of protection. The frequencies of medical exposure are consistent with the local economic level. To analyze the differences in medical exposure frequencies and predict the developmental trends in different regions, it is necessary to establish a more accurate prediction model.Copyright © 2021 by the Chinese Medical Association.

Image-guided tunneled peritoneal dialysis catheter placement.

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

An audit of patient radiation doses in interventional radiology at a South African hospital.

Background: Interventional radiology (IR) is becoming more relevant in patient care and is associated with increased patient radiation exposure and radiation-induced adverse effects. Diagnostic reference levels (DRLs) are crucial for radiation control. There is a paucity of published DRLs for IR in South Africa and sub-Saharan Africa. Objectives: This study aimed to determine local DRLs for fluoroscopically-guided IR procedures and compare the achieved DRLs with published local and international DRLs. Method: Retrospective, descriptive, single-centre study. Kerma air product (KAP), reference point air kerma (Ka,r) and fluoroscopy time (FT) were collected for patients (12 years and older) who underwent IR procedures at a university hospital from 01 January 2019 to 31 December 2019. The 75th percentile of the distribution of each dose parameter (KAP, Ka,r and FT) per procedure was calculated and taken as the local diagnostic reference levels (LDRL). The established LDRLs were compared to published DRLs. Results: A total of 564 cases were evaluated. The 13 most frequent procedures (with 15 or more cases) represented 86.1% (487/564). Percutaneous transhepatic biliary drainage was the most common procedure (n = 146, 25.9%). Diagnostic cerebral angiogram DRLs exceeded the published DRL data ranges for all parameters (DRL 209.3), and interventional cerebral angiogram exceeded published ranges (DRL 275). Uterine artery embolisation (UAE) exceeded these ranges for KAP and Ka,r. (KAP-954.9 Gy/cm2, Ka,r-2640.8 mGy). Conclusion: The LDRLs for diagnostic cerebral angiogram, interventional cerebral angiogram and UAE exceeded published international DRL ranges. These procedures require radiation optimisation as recommended by the International Commission on Radiological Protection (ICRP). Contribution: In addition to informing radiation protection practices at the level of the institution, the established LDRLs contribute towards Regional and National DRLs.

Diagnostic and Therapeutic Radiology of the GI Tract, Liver, and Pancreas in Patients with COVID.

Coronavirus disease 2019 (COVID-19) pulmonary involvement has been extensively reported in the literature. Current data highlight how COVID-19 is a systemic disease, affecting many other organs, including the gastrointestinal, hepatobiliary, and pancreatic organs. Recently, these organs have been investigated using imaging modalities of ultrasound and particularly computed tomography. Radiological findings of the gastrointestinal, hepatic, and pancreatic involvement in patients with COVID-19 are generally nonspecific but are nonetheless helpful to evaluate and manage COVID-19 patients with involvement of these organs.

Renal artery thrombosis as a long-term complication of COVID-19

Coronavirus disease 2019 (COVID-19) has been extensively associated with microvascular and macrovascular thrombosis. Several reports have demonstrated a link between COVID-19 and pulmonary embolism, deep vein thrombosis, myocardial infarction, stroke, and aortic thrombosis. Renal artery thrombosis is of special interest because of its life-threatening consequences, such as acute kidney injury and renal infarction. We present a case of left renal artery thrombosis as a long-term complication of COVID-19. Moreover, we demonstrate the effectiveness of interventional radiology to regain vascularization of the affected kidney. © 2022

Leveraging the virtual learning environment to enhance medical student engagement with interventional radiology.

PURPOSE: To evaluate medical student engagement with Interventional Radiology (IR) before and after a virtual elective course. METHODS: The elective was nine, one-hour lectures over ten weeks. An anonymous pre and post-course survey was administered to students. The hypothesis was that this course would increase student engagement with IR. Respondents answered nine questions to score their interest in, exposure to, familiarity with, and understanding of IR using a five-point Likert scale. Demographics were reported for the pre-course group only. A Wilcoxon signed-ranked test was performed to assess for significant mean change in pre and post-course responses. Among the 276 registered students, there were 144 individual, complete responses for the pre-course survey, and 60 paired responses for both surveys. RESULTS: Thirty-seven percent of respondents were first or second year medical students. Thirty percent of participants were enrolled at an institution outside of the United States, 26% are the first in their family to attend college, and 41% identified as female. Thirty-six percent reported this virtual course was one of their earliest experiences with IR. There was a significant increase in student exposure to IR generally, familiarity with IR compared to other specialties, familiarity with the IR training pathway(s), understanding of what an Interventional Radiologist does, understanding of the difference between IR and Diagnostic Radiology, and understanding of when to consult IR for patient care after completion of the course. CONCLUSION: A virtual IR elective is an effective means to increase exposure to, familiarity with, and understanding of IR.

The Role of Interventional Radiology and Management of an Angiography Suite in the Treatment of COVID-19 Patients: Single-Center, 2-Year Experience.

Background and Objectives: Hospital angiography suites with negative-pressure ventilation facilities are challenging to equip. During the COVID-19 pandemic, we aimed to introduce interventional radiology procedures performed on COVID-19 patients and understand management of the angiography suite without a negative-pressure ventilation facility before and after the procedures to prevent the spread of infection. Materials and Methods: Between December 2020 and November 2022, 52 COVID-19 patients underwent interventional radiology procedures in an angiography suite, where no negative-pressure ventilation facility was installed. During the procedure, all staff members wore full personal protection equipment, and after the procedure for the COVID-19-positive patient was completed, the angiography suite was disinfected and entry to the angiography suite was prohibited for 1-3 h. In this angiography suite, procedures for COVID-19 patients and non-COVID-19 patients were performed. Results: A total of 61 interventional radiology procedures were performed in 52 patients with COVID-19. Of 52 patients, 21 underwent procedures under intubation and mechanical ventilation. All procedures were performed according to the guidelines set by the Infection Control Committee of our hospital. No major or minor complications were associated with the procedures. There were no cases of infection among staff members or other non-COVID-19 patients related to procedures on COVID-19 patients. Conclusions: Interventional radiology can play an important role in solving the complications of COVID-19 and the problems caused by patients' underlying diseases. In addition, if accurate guidelines are followed, both COVID-19 and non-COVID-19 patients can undergo procedures in an angiography room without negative-pressure ventilation while preventing infection.

COVID-19-related arterio-ureteral fistula formation in a post-transplant patient.

Arterio-ureteral fistulas (AUF) are extremely rare and are not commonly suspected in the setting of patients with post-renal allograft transplantation. The diagnosis, while uncommon, can be potentially lethal which is only exacerbated by the clinical conundrum associated with their under-recognition and various treatment algorithms. This case identifies a unique patient with a history of 2 failed renal transplants who presents with new onset intermittent hematuria after contracting coronavirus disease 2019 (COVID-19). Despite the patient having his second renal transplant graft embolized, the patient continued to present with refractory hematuria, leading to the realization and identification of an AUF to his right renal graft. This sequence of events brings forth a case of unique significance, underscoring the potential ramifications that COVID-19 poses to the renal transplant population.

Bleeding complication after percutaneous-dilatational tracheostomy with several days of latency - interventional haemostasis

Percutaneous dilatational tracheostomy (PDT) is a standard procedure, which is performed in critically ill patients requiring prolonged mechanical ventilation. In general, PDT is a relatively safe procedure and has several advantages when compared to open (surgical) tracheostomy. Haemorrhage is the most common and mortality-associated complication. Here, we report a COVID-19-positive patient with a cerebral insult requiring dual anti-platelet medication and mechanical ventilation, who developed a severe bleeding complication from a dissection of the inferior thyroid artery with a delay of several days after PDT, which was angiographically diagnosed and successfully managed by interventional radiology. Interventional radiology is a treatment option which enables to control bleeding less invasively in comparison to surgical management, being highly preferable in critically ill patients. Copyright © Anasth Intensivmed 2022;63:475-480 Aktiv Druck & Verlag GmbH.

Renal artery thrombosis as a long-term complication of COVID-19

Coronavirus disease 2019 (COVID-19) has been extensively associated with microvascular and macrovascular thrombosis. Several reports have demonstrated a link between COVID-19 and pulmonary embolism, deep vein thrombosis, myocardial infarction, stroke, and aortic thrombosis. Renal artery thrombosis is of special interest because of its life-threatening consequences, such as acute kidney injury and renal infarction. We present a case of left renal artery thrombosis as a long-term complication of COVID-19. Moreover, we demonstrate the effectiveness of interventional radiology to regain vascularization of the affected kidney.

Wunderlich syndrome, an unexpected urological complication in a patient with coronavirus disease 2019 (COVID-19): A case report.

We describe the first case of Wunderlich syndrome as a hemorrhagic complication in a patient with severe acute respiratory syndrome coronavirus 2 infection and acute respiratory distress syndrome. The possible underlying pathophysiological mechanisms have been extensively discussed. Emergency management included selective angioembolization of the upper polar arterial branches of the left kidney and discontinuation of thromboprophylaxis. The patient was discharged after 18 days. No other localizations or local recurrence of bleeding occurred during the hospitalization. Our report suggests a broad spectrum of clinical manifestations in patients with coronavirus disease 2019. As observed in our clinical case, in addition to thrombotic complications, bleeding is a significant cause of morbidity in coronavirus disease 2019 patients. Further studies should determine whether these urological bleeding sequelae are a direct manifestation of the infection or an indirect effect of thromboprophylaxis.

Management of Spontaneous Major Rectus Sheath Hematoma in a COVID-19 Patient: A Case Report and Literature Review.

A rectus sheath hematoma, which is mostly encountered due to abdominal traumas or anticoagulant use, can be challenging, and a delayed diagnosis may lead to hypovolemic shock and even death. In this study, we aimed to present the management of a case of rectus sheath hematoma that developed in a patient who was hospitalized and under coronavirus disease 2019 (COVID-19) treatment. A 70-year-old female patient was admitted to the intensive care unit (ICU) due to respiratory failure and developed a sudden onset of tachycardia and hypotension. The patient was then diagnosed with a rectus sheath hematoma and after ensuring hemodynamic stability she was treated with angiographic embolization. Following the treatment, the patient remained hemodynamically stable and a control computed tomography (CT) revealed regression in the hematoma. Rectus sheath hematomas especially accompanied by additional comorbidities or aggressive surgical interventions may result in high mortality rates in the early period. It should also be kept in mind that during the COVID-19 pandemic, which has affected the world in the last two years, rectus sheath hematomas may be the underlying cause of sudden hypotension and abdominal distension, and it should not be forgotten that angiographic embolization performed by experienced interventional radiologists is the mainstay of treatment in cases where hemodynamic stability can't be achieved.