The status of academic interventional radiologists in Germany with focus on gender disparity: how can we do better?

PURPOSE: The aim was to characterize the framework conditions in academic interventional radiology (IR) in Germany with focus on differences between genders. MATERIALS AND METHODS: After IRB approval, all members of The German Society for Interventional Radiology and Minimally Invasive Therapy (n = 1,632) were invited to an online survey on work and research. Statistical comparisons were undertaken with the Fisher's exact test, Wilcoxon rank sum test or Pearson's Chi-squared test. RESULTS: From 267 available questionnaires (general response rate 16.4%), 200 were fully completed. 40% of these (78/200) were involved in research (71% men vs. 29% women, p < 0.01) and eligible for further analysis. Of these, 6% worked part-time (2% vs. 17%, p < 0.05). 90% of the respondents spent less than 25% of their research during their paid working hours, and 41% performed more than 75% of their research during. leisure time. 28% received exemption for research. 88% were (rather) satisfied with their career. One in two participants successfully applied for funding, with higher success rates among male applicants (90% vs. 75%) and respondents with protected research time (93% vs. 80%). Compared to men, women rated their entrance in research as harder (p < 0.05), their research career as more important (p < 0.05), felt less noticed at congresses (93% vs. 53%, p < 0.01), less confident (98% vs. 71%, p < 0.01), and not well connected (77% vs. 36%, p < 0.01).  CONCLUSION: Women and men did research under the same circumstances; however, women were underrepresented. Future programs should generally focus on protected research time and gather female mentors to advance academic IR in Germany.

Image Quality and Radiation Exposure in Abdominal Angiography: A Head-to-Head Comparison of Conventional Detector-Dose-Driven Versus Contrast-to-Noise Ratio-Driven Exposure Control at Various Source-to-Image Receptor Distances and Collimations in a Pilot Phantom and Animal Study.

OBJECTIVES: This phantom and animal pilot study aimed to compare image quality and radiation exposure between detector-dose-driven exposure control (DEC) and contrast-to-noise ratio (CNR)-driven exposure control (CEC) as functions of source-to-image receptor distance (SID) and collimation. MATERIALS AND METHODS: First, an iron foil simulated a guide wire in a stack of polymethyl methacrylate and aluminum plates representing patient thicknesses of 15, 25, and 35 cm. Fluoroscopic images were acquired using 5 SIDs ranging from 100 to 130 cm and 2 collimations (full field of view, collimated field of view: 6 × 6 cm). The iron foil CNRs were calculated, and radiation doses in terms of air kerma rate were obtained and assessed using a multivariate regression. Second, 5 angiographic scenarios were created in 2 anesthetized pigs. Fluoroscopic images were acquired at 2 SIDs (110 and 130 cm) and both collimations. Two blinded experienced readers compared image quality to the reference image using full field of view at an SID of 110 cm. Air kerma rate was obtained and compared using t tests. RESULTS: Using DEC, both CNR and air kerma rate increased significantly at longer SID and collimation below the air kerma rate limit. When using CEC, CNR was significantly less dependent of SID, collimation, and patient thickness. Air kerma rate decreased at longer SID and tighter collimation. After reaching the air kerma rate limit, CEC behaved similarly to DEC. In the animal study using DEC, image quality and air kerma rate increased with longer SID and collimation (P < 0.005). Using CEC, image quality was not significantly different than using longer SID or tighter collimation. Air kerma rate was not significantly different at longer SID but lower using collimation (P = 0.012). CONCLUSIONS: CEC maintains the image quality with varying SID and collimation stricter than DEC, does not increase the air kerma rate at longer SID and reduces it with tighter collimation. After reaching the air kerma rate limit, CEC and DEC perform similarly.

Interventional Therapy of Pelvic Venous Disorders (PeVD). / Interventionelle Therapie des Beckenvenensyndroms.

BACKGROUND: Pelvic venous disorders (PeVD) are an underdiagnosed cause of chronic pelvic pain in women. They are caused by venous insufficiency of the pelvic or ovarian veins, leading to the development of mainly periuterine and periovarian varices. It is a progressive disease if left untreated and can cause swelling, dyspareunia, dysmenorrhea, and other symptoms, some non-specific, that affect the patient's quality of life. Interventional therapies are a central component of the treatment of PeVD, with a variety of techniques available for both diagnosis and treatment. METHOD: This review provides an overview of the pathophysiologic background, diagnosis, and, most importantly, interventional treatment options for PeVD. RESULTS: There is a lack of standardized nomenclature and internationally accepted diagnostic criteria for PeVD as well as randomized controlled trials demonstrating clinical success. However, in clinical trials, endovascular therapy for PeVD has been shown to be safe and effective. This review presents the various interventional techniques for the treatment of PeVD, including embolization, stenting, and sclerotherapy. CONCLUSION: The importance of PeVD is receiving growing recognition. Recent advances, such as the development of the Symptoms-Varices-Pathophysiology (SVP) classification, provide an impetus to standardize nomenclature and are the first step toward systematizing disease management. Interventional therapies provide a safe and tailored minimally invasive treatment option for patients with PeVD. KEY POINTS: · Pelvic venous disorders are an underdiagnosed condition with frequently delayed diagnosis and debilitating symptoms.. · Until now, the PeVD nomenclature has been imprecise, with terms like May-Thurner syndrome/Nutcracker syndrome.. · Interventional approaches are effective and play a central role in PeVD treatment.. CITATION FORMAT: · Dewald CL, Becker LS, Meyer BC. Interventional Therapy of Pelvic Venous Disorders (PeVD). Fortschr Röntgenstr 2024; DOI: 10.1055/a-2229-4100.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]. / Spontane retroperitoneale und Rektusscheidenhämatome und ihre interventionelle Therapie: ein Review.

BACKGROUND: Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy. METHOD: Analysis, summary, and discussion of published review articles and expert recommendations. RESULTS: The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance. CONCLUSION: Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome. KEY POINTS: · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.. CITATION FORMAT: · Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more?

PURPOSE: Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP. MATERIALS AND METHODS: All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0). RESULTS: Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine. CONCLUSION: Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.

Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) with superior mesenteric vein access and balloon-assisted shunt placement.

BACKGROUND: To report the technique and outcome of ultrasound-guided percutaneous access to the superior mesenteric vein (SMV) for balloon-assisted portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in a patient with chronic portal venous and splenic vein occlusion. CASE PRESENTATION: A 51-year-old, non-cirrhotic patient with severe portal hypertension was admitted for PVR-TIPS. Neither splenic nor hepatic access was feasible due to chronic portal and splenic vein occlusion. Percutaneous ultrasound-guided direct puncture of the SMV was performed to obtain access for balloon-assisted PVR-TIPS. The transmesenteric approach in combination with a balloon puncture technique for PVR-TIPS was successful, and no immediate complications were observed post-procedure. The subsequent follow-up exams showed patent TIPS and SMV without signs of intraabdominal hemorrhage. CONCLUSION: Percutaneous ultrasound-guided superior mesenteric vein access for balloon-assisted PVR-TIPS is a feasible option in cases where hepatic or splenic access is not.

Automated Classification of Free-Text Radiology Reports: Using Different Feature Extraction Methods to Identify Fractures of the Distal Fibula.

PURPOSE: Radiology reports mostly contain free-text, which makes it challenging to obtain structured data. Natural language processing (NLP) techniques transform free-text reports into machine-readable document vectors that are important for creating reliable, scalable methods for data analysis. The aim of this study is to classify unstructured radiograph reports according to fractures of the distal fibula and to find the best text mining method. MATERIALS & METHODS: We established a novel German language report dataset: a designated search engine was used to identify radiographs of the ankle and the reports were manually labeled according to fractures of the distal fibula. This data was used to establish a machine learning pipeline, which implemented the text representation methods bag-of-words (BOW), term frequency-inverse document frequency (TF-IDF), principal component analysis (PCA), non-negative matrix factorization (NMF), latent Dirichlet allocation (LDA), and document embedding (doc2vec). The extracted document vectors were used to train neural networks (NN), support vector machines (SVM), and logistic regression (LR) to recognize distal fibula fractures. The results were compared via cross-tabulations of the accuracy (acc) and area under the curve (AUC). RESULTS: In total, 3268 radiograph reports were included, of which 1076 described a fracture of the distal fibula. Comparison of the text representation methods showed that BOW achieved the best results (AUC = 0.98; acc = 0.97), followed by TF-IDF (AUC = 0.97; acc = 0.96), NMF (AUC = 0.93; acc = 0.92), PCA (AUC = 0.92; acc = 0.9), LDA (AUC = 0.91; acc = 0.89) and doc2vec (AUC = 0.9; acc = 0.88). When comparing the different classifiers, NN (AUC = 0,91) proved to be superior to SVM (AUC = 0,87) and LR (AUC = 0,85). CONCLUSION: An automated classification of unstructured reports of radiographs of the ankle can reliably detect findings of fractures of the distal fibula. A particularly suitable feature extraction method is the BOW model. KEY POINTS: · The aim was to classify unstructured radiograph reports according to distal fibula fractures.. · Our automated classification system can reliably detect fractures of the distal fibula.. · A particularly suitable feature extraction method is the BOW model.. CITATION FORMAT: · Dewald CL, Balandis A, Becker LS et al. Automated Classification of Free-Text Radiology Reports: Using Different Feature Extraction Methods to Identify Fractures of the Distal Fibula. Fortschr Röntgenstr 2023; 195: 713 - 719.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience.

PURPOSE: To retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH). MATERIALS AND METHODS: Retrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed. RESULTS: Pre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms. CONCLUSION: Embolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

New perspectives in unresectable cholangiocarcinoma? Evaluation of chemosaturation with percutaneous hepatic perfusion as a palliative treatment option.

Cholangiocarcinoma (CCA) are the second most common primary liver tumors and carry a dismal prognosis. Chemosaturation with percutaneous hepatic perfusion (PHP) is a palliative, intra-arterial therapeutic approach that provides a high dose chemotherapy of the liver with reduced systemic exposure. Aim of this retrospective, monocentric study was to analyze PHP as a palliative treatment for unresectable CCA. Toxicity, adverse events and complications were classified using the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Overall response rate (ORR) and disease control rate (DCR) were evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic mPFS (mhPFS) were computed using Kaplan-Meier estimation. In total 17 patients were treated with 42 PHP between 10/2014 and 09/2020. No significant complications occurred during the interventions. mOS was 27.6 (interquartile range (IQR) 16.5-37) months from first diagnosis and 9.9 (IQR 3.8-21) months from first PHP. mPFS was 4 (IQR 2-7) and mhPFS was 4 (IQR 3-10) months. ORR was 25% and DCR 75%. Significant, but transient hematotoxicity was frequent with grade 3/4 thrombopenia after 50%, leukopenia after 26% and anaemia after 21% of the interventions. An increase of transaminases (AST increase after 21% and ALT increase after 14% of the PHP) developed more often than a deterioration of the liver synthesis capacity. Salvage treatment with PHP has the potential to prolong life in selected patients with unresectable, refractory cholangiocarcinoma. The interventional procedure is safe. Post-interventional toxicity is frequent but manageable.

Fully Integrated Laser Guidance for CT-Based Punctures: A Study in Phantoms and Patients.

PURPOSE: To test the hypothesis of equal or even superior applicability and accuracy of a fully integrated, laser-based computed tomography (CT) navigation system compared with conventional CT guidance for percutaneous interventions. MATERIALS AND METHODS: CT-guided punctures were first performed in phantoms. Four radiologists with different experience levels (2 residents (L.B., C.D.) and 2 board-certified radiologists (B.M., K.R.) performed 48 punctures using both conventional image-guided and laser-guided approaches. Subsequently, 12 punctures were performed in patients during a clinical pilot trial. Phantom targets required an in-plane or a single-/double-angulated, out-of-plane approach. Planning and intervention time, control scan number, radiation exposure, and accuracy of needle placement (measured by deviation of the needle tip to the designated target) were assessed for each guidance technique and compared (Mann-Whitney U test and t test). Patient interventions were additionally analyzed for applicability in a clinical setting. RESULTS: The application of laser guidance software in the phantom study and in 12 human patients in a clinical setting was both technically and clinically feasible in all cases. The mean planning time (P = .009), intervention time (P = .005), control scan number (P < .001), and radiation exposure (P = .013) significantly decreased for laser-navigated punctures compared with those for conventional CT guidance and especially in punctures with out-of-plane-trajectories. The accuracy significantly increased for laser-guided interventions compared with that for conventional CT (P < .001). CONCLUSIONS: Interventional radiologists with differing levels of experience performed faster and more accurate punctures for out-of-plane trajectories in the phantom models, using a new, fully integrated, laser-guided CT software and demonstrated excellent clinical and technical success in initial clinical experiments.

Identification of Relevant Attributes for Liver Cancer Therapies (IRALCT): a maximum-difference-scaling analysis.

The Identification of Relevant Attributes for Liver Cancer Therapies (IRALCT) project is intended to provide new insights into the relevant utility attributes regarding therapy choices for malignant primary and secondary liver tumors from the perspective of those who are involved in the decision-making process. It addresses the potential value of taking patients' expectations and preferences into account during the decision-making and, when possible, adapting therapies according to these preferences. Specifically, it is intended to identify the relevant clinical attributes that influence the patients', medical laymen's, and medical professionals' decisions and compare the three groups' preferences. We conducted maximum difference (MaxDiff) scaling among 261 participants (75 physicians, 97 patients with hepatic malignancies, and 89 medical laymen) to rank the importance of 14 attributes previously identified through a literature review. We evaluated the MaxDiff data using count analysis and hierarchical Bayes estimation (HB). Physicians, patients, and medical laymen assessed the same 7 attributes as the most important: probability (certainty) of a complete removal of the tumor, probability of reoccurrence of the disease, pathological evidence of tumor removal, possible complications during the medical intervention, welfare after the medical intervention, duration and intensity of the pain, and degree of difficulty of the medical intervention. The cumulative relative importance of these 7 attributes was 88.3%. Our results show that the physicians', patients', and medical laymen's preferences were very similar and stable.Trial registration DRKS-ID of the study: DRKS00013304, Date of Registration in DRKS: 2017/11/16.

Effectuality study of a 3D motion correction algorithm in C-arm CTs of severely impaired image quality during transarterial chemoembolization.

BACKGROUND: To evaluate effectivity of a 3D-motion correction algorithm in C-Arm CTs (CACT) with limited image quality (IQ) during transarterial chemoembolization (TACE). METHODS: From 1/2015-5/2021, 644 CACTs were performed in patients during TACE. Of these, 27 CACTs in 26 patients (18 m, 8f; 69.7 years ± 10.7 SD) of limited IQ were included. Post-processing of the original raw-data sets (CACTOrg) included application of a 3D-motion correction algorithm and bone segmentation (CACTMC_no_bone). Four radiologists (R1-4) compared the images by choosing their preferred dataset and recommending repeat acquisition in case of severe IQ-impairment. R1,2 performed additional grading of intrahepatic vessel visualization, presence/extent of movement artifacts, and overall IQ. RESULTS: R1,2 demonstrated excellent interobserver agreement for overall IQ (ICC 0.79,p < 0.01) and the five-point vessel visualization scale before and after post-processing of the datasets (ICC 0.78,p < 0.01). Post-processing caused significant improvement, with overall IQ improving from 2.63 (CACTOrg) to 1.39 (CACTMC_no_bone;p < 0.01) and a decrease in the mean distance of identifiable, subcapsular vessels to the liver capsule by 4 mm (p < 0.01). This proved especially true for datasets with low parenchymal and high hepatic artery contrast. A good interobserver agreement (ICC = 0.73) was recorded concerning the presence of motion artifacts, with significantly less discernible motion after post-processing (CACTOrg:1.31 ± 1.67, CACTMC_no_bone:1.00 ± 1.34, p < 0.01). Of the 27 datasets, ≥ 23 CACTMC_no_bone were preferred, with identical datasets chosen by the readers to show benefit from the algorithm. CONCLUSION: Application of a 3D-motion correction algorithm significantly improved IQ in diagnostically limited CACTs during TACE, with the potential to decrease repeat acquisitions.

[Local and locoregional treatment of intrahepatic cholangiocarcinoma]. / Lokale und lokoregionäre Therapie des intrahepatischen Cholangiokarzinoms.

CLINICAL/METHODICAL ISSUE: In the new edition of the German S3-guideline published in June 2021, the diagnosis and treatment of cholangiocarcinoma (CCA) and gallbladder carcinoma are addressed for the first time. This article discusses the local and locoregional treatment options for intrahepatic CCA (iCCA). STANDARD RADIOLOGICAL METHODS: Mortality is high in iCCA and the incidence is rising. In unresectable patients, treatment options include local and locoregional approaches. METHODICAL INNOVATIONS: Besides recommendations regarding surgery, biliary drainage, intraductal locoregional therapy and radiation therapy, two recommendations regarding interventional radiologic therapies are included in the updated S3-guideline. Percutaneous thermal ablation via radiofrequency or microwave ablation (RFA/MWA) is suggested for unresectable tumors with up to 3 cm in diameter as primary therapy and for recurrent tumors. In advanced, liver dominant iCCA, intra-arterial therapies such as transarterial radioembolization (TARE), transarterial chemoembolization (TACE) or hepatic arterial infusion (HAI) are recommended as single therapy or in combination with other therapies. ACHIEVEMENTS: Due to a lack of randomized controlled studies, the efficacy of locoregional therapies in iCCA is challenging to assess; however, various cohort studies, meta-analyses and review articles confirm their efficiency. PRACTICAL RECOMMENDATIONS: Interventional radiological therapies alone or in combination with systemic therapies have the potential to improve the prognosis of patients with iCCA. Due to the various therapeutic options, patients with iCCA should be treated in centers which cover the entire therapeutic spectrum.

The Value of C-Arm Computed Tomography in Addition to Conventional Digital Subtraction Angiography in the Diagnostic Work-up of Patients with Suspected Chronic Thromboembolic Pulmonary Hypertension: An Update of 300 Patients.

RATIONALE AND OBJECTIVES: To assess the value and possible benefit of combined C-arm computed tomography (CACT) and conventional digital subtraction angiography (DSA) of the pulmonary arteries in the diagnostic work-up of patients with suspected chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS: We evaluated 308 pulmonary artery angiographies of 308 consecutive patients with suspected CTEPH. Seven patients were excluded because of incomplete imaging. Thus, 301 datasets were included in our study. The pulmonary artery segments and their subsegmental branching were independently evaluated by two readers (R1, R2) using both, DSA and CACT for optimal image quality. Subsequently, the diagnostic findings were compared. Inter-modality and inter-observer agreement were calculated. Consensus reading was done and correlated to a standard of reference, representing the overall consensus of both modalities. Fisher's exact test and Cohen's Kappa were applied. RESULTS: A total of 5719 pulmonary segments were evaluated of which only 28 segments (0.4%) were rated to be nondiagnostic on both, CACT and DSA. Overall, 5640 (98.6%) and 5600 (97.9%) pulmonary segments were rated to be diagnostic in DSA and CACT, respectively. The main causes of nondiagnostic image quality were motion artifacts on both, CACT (R1:81, R2:50) and DSA (R1:60, R2:48). Interobserver agreement was excellent for DSA (κ = 0.9) and CACT (κ = 0.91) and intermodality agreement was substantial (R1: κ = 0.69, R2: κ = 0.77). Compared to standard of reference, the intermodality agreement for CACT was excellent (κ = 0.96), whereas it was inferior for DSA (κ = 0.75), due to the higher number of pathologic findings in CACT read as normal on DSA. CONCLUSION: CACT of the pulmonary arteries can provide additional information to DSA during CTEPH work-up. Moreover, the combination of CACT and DSA can minimize the portion of non-diagnostic examinations, therefore being a reasonable combination to optimize the diagnostic work-up.

Depiction of mosaic perfusion in chronic thromboembolic pulmonary hypertension (CTEPH) on C-arm computed tomography compared to computed tomography pulmonary angiogram (CTPA).

To evaluate mosaic perfusion patterns and vascular lesions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) using C-Arm computed tomography (CACT) compared to computed tomography pulmonary angiography (CTPA). We included 41 patients (18 female; mean age 59.9 ± 18.3 years) with confirmed CTEPH who underwent CACT and CTPA within 21 days (average 5.3 ± 5.2). Two readers (R1; R2) independently evaluated datasets from both imaging techniques for mosaic perfusion patterns and presence of CTEPH-typical vascular lesions. The number of pulmonary arterial segments with typical findings was evaluated and the percentage of affected segments was calculated and categorized: < 25%; 25-49%; 50-75%; < 75% of all pulmonary arterial segments affected by thromboembolic vascular lesions. Inter-observer agreement was calculated for both modalities using the intraclass-correlation-coefficient (ICC). Based on consensus reading the inter-modality agreement (CACTcons vs. CTPAcons) was calculated using the ICC. Inter-observer agreement was excellent for central vascular lesions (ICC > 0.87) and the percentage of affected segments (ICC > 0.76) and good for the perceptibility of mosaic perfusion (ICC > 0.6) and attribution of the pattern of mosaic perfusion (ICC > 0.6) for both readers on CACT and CTPA. Inter-modality agreement was excellent for the perceptibility of mosaic perfusion (ICC = 1), the present perfusion pattern (ICC = 1) and central vascular lesions (ICC = 1). However, inter-modality agreement for the percentage of affected segments was fair (ICC = 0.50), with a greater proportion of identified affected segments on CACTcons. CACT demonstrates a high agreement with CTPA regarding the detection of mosaic perfusion. CACT detects a higher number of peripheral vascular lesions compared to CTPA.

Comparison of the Uptake of Hepatocellular Carcinoma on Pre-Therapeutic MDCT, CACT, and SPECT/CT, and the Correlation with Post-Therapeutic PET/CT in Patients Undergoing Selective Internal Radiation Therapy.

(1) Background: To comparatively analyze the uptake of hepatocellular carcinoma (HCC) on pre-therapeutic imaging modalities, the arterial phase multi-detector computed tomography (MDCT), the parenchymal phase C-arm computed tomography (CACT), the Technetium99m-macroaggregates of human serum albumin single-photon emission computed tomography/computed tomography (SPECT/CT), and the correlation to the post-therapeutic Yttrium90 positron emission tomography/computed tomography (PET/CT) in patients with selective internal radiation therapy (SIRT). (2) Methods: Between September 2013 and December 2016, 104 SIRT procedures were performed at our institution in 74 patients with HCC not suitable for curative surgery or ablation. Twenty-two patients underwent an identical sequence of pre-therapeutic MDCT, CACT, SPECT/CT, and post-therapeutic PET/CT with a standardized diagnostic and therapeutic protocol. In these 22 patients, 25 SIRT procedures were evaluated. The uptake of the HCC was assessed using tumor-background ratio (TBR). Therefore, regions of interest were placed on the tumor and the adjacent liver tissue on MDCT (TBRMDCT), CACT (TBRCACT), SPECT/CT (TBRSPECT/CT), and PET/CT (TBRPET/CT). Comparisons were made with the Friedman test and the Nemenyi post-hoc test. Correlations were analyzed using Spearman's Rho and the Benjamini-Hochberg method. The level of significance was p < 0.05. (3) Results: TBR on MDCT (1.4 ± 0.3) was significantly smaller than on CACT (1.9 ± 0.6) and both were significantly smaller compared to SPECT/CT (4.6 ± 2.0) (pFriedman-Test < 0.001; pTBRMDCT/TBRCACT = 0.012, pTBRMDCT/TBRSPECT/CT < 0.001, pTBRCACT/TBRSPECT/CT < 0.001). There was no significant correlation of TBR on MDCT with PET/CT (rTBRMDCT/TBRPET/CT = 0.116; p = 0.534). In contrast, TBR on CACT correlated to TBR on SPECT/CT (rTBRCACT/TBRSPECT/CT = 0.489; p = 0.004) and tended to correlate to TBR on PET/CT (rTBRCACT/TBRPET/CT =0.365; p = 0.043). TBR on SPECT/CT correlated to TBR on PET/CT (rTBRSPECT/CT/TBRPET/CT = 0.706; p < 0.001) (4) Conclusion: The uptake assessment on CACT was in agreement with SPECT/CT and might be consistent with PET/CT. In contrast, MDCT was not comparable to CACT and SPECT/CT, and had no correlation with PET/CT due to the different application techniques. This emphasizes the value of the CACT, which has the potential to improve the dosimetric assessment of the tumor and liver uptake for SIRT.

Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. / Chemosaturation durch perkutane hepatische Perfusion mit Melphalan bei hepatisch metastasiertem Aderhautmelanom: eine Überlebens- und Sicherheitsanalyse.

PURPOSE: Chemosaturation percutaneous hepatic perfusion (CS-PHP) allows selective intrahepatic delivery of high dose cytotoxic melphalan in patients with curatively untreatable liver tumors while limiting systemic toxicity through hemofiltration of the hepatic venous blood. Aim of this study was to investigate the response to therapy, survival and safety of the CS-PHP procedure in patients with liver-dominant metastatic uveal melanoma (UM). MATERIALS AND METHODS: Overall response rate (ORR) and disease control rate (DCR) were assessed according to Response Evaluation Criteria In Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic progression-free survival (mhPFS) were analyzed using Kaplan-Meier estimation. Adverse events were evaluated with Common Terminology Criteria for Adverse Events (CTCAE) v5. RESULTS: Overall, 30 patients were treated with 70 CS-PHP in a salvage setting from October 2014 to January 2019. In total, ORR and DCR were 42.3 % and 80.8 %, respectively. Overall, mOS was 12 (95 % confidence interval (CI) 7-15) months, and both, mPFS and mhPFS were 6 months, respectively (95 % CI 4-10; 95 % CI 4-13). Adverse events (AE) most frequently included significant but transient hematologic toxicities (87 % of grade 3/4 thrombocytopenia), less frequent AEs were hepatic injury extending to liver failure (3 %), cardiovascular events including one case of ischemic stroke (3 %). CONCLUSION: Salvage treatment with CS-PHP is effective in selected patients with UM. The interventional procedure is safe. Serious hepatic and cardiovascular events, although rare, require careful patient selection and should be closely monitored. KEY POINTS: · CS-PHP is safe for selected patients with liver-dominant metastatic uveal melanoma.. · CS-PHP resulted in hepatic disease control in 80 % of patients.. · Hematologic events following CS-PHP are common but manageable.. CITATION FORMAT: · Dewald CL, Hinrichs JB, Becker LS et al. Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. Fortschr Röntgenstr 2021; 193: 928 - 936.

Evaluation of perfusion changes using a 2D Parametric Parenchymal Blood Flow technique with automated vessel suppression following partial spleen embolization in patients with hypersplenism and portal hypertension.

ABSTRACT: To evaluate the feasibility and potential value of 2D Parametric Parenchymal Blood Flow (2D-PPBF) for the assessment of perfusion changes following partial spleen embolization (PSE) in a retrospective observational study design.Overall, 12 PSE procedures in 12 patients were included in this study. The outcome of the study was the platelet response (PR), calculated as the percentage increase of platelet count (PLT), following PSE. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography series were post-processed. A reference region-of-interest (ROI) was placed in the afferent splenic artery and a target ROI was positioned on the embolization territory of the spleen on digital subtraction angiography series pre- and post-embolization. The ratios of the target ROIs to the reference ROIs were calculated for the Wash-In-Rate (WIR), the Time-To-Peak (TTP) and the Area-Under-the-Curve (AUC). Comparisons between pre- and post-embolization data were made using Wilcoxon signed-rank test and Spearman's rank correlation coefficient (r). Afterwards, the study population was divided by the median of the TTP before PSE to analyze its value for the prediction of PR following PSE.Following PSE, PLT increased significantly from 43,000 ±â€Š21,405 platelets/µL to 128,500 ±â€Š66,083 platelets/µL with a PR of 255 ±â€Š243% (P = .003). In the embolized splenic territory, the pre-/post-embolization 2D-PPBF parameter changed significantly: WIRpre-PSE 1.23 ±â€Š2.42/WIRpost-PSE 0.09 ±â€Š0.07; -64 ±â€Š46% (p = 0.04), TTPpre-PSE 4.41 ±â€Š0.99/TTPpost-PSE 5.67 ±â€Š1.52 (P = .041); +34 ±â€Š47% and AUCpost-PSE 0.81 ±â€Š0.85/AUCpost-PSE 0.14 ±â€Š0.08; -71 ±â€Š18% (P = .002). A significant correlation of a 2D-PPBF parameter with the PLT was found for TTPpre-PSE/PLTpre-PSE r = -0.66 (P = .01). Subgroup analysis showed a significantly increased PR for the group with TTPpre-PSE >4.44 compared to the group with TTPpre-PSE ≤4.44 (404 ±â€Š267% versus 107 ±â€Š76%; P = .04).2D-PPBF is an objective approach to analyze the perfusion reduction of embolized splenic tissue. TTP derived from 2D-PPBF has the potential to predict the extent of PR during PSE.

Motion Reduction for C-Arm Computed Tomography of the Pulmonary Arteries: Image Quality of a Motion Correction Algorithm in Patients with Chronic Thromboembolic Hypertension During Balloon Pulmonary Angioplasty.

PURPOSE: To evaluate the feasibility and image quality of a motion correction algorithm for supra-selective C-arm computed tomography (CACT) of the pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing balloon pulmonary angioplasty (BPA). MATERIALS & METHODS: CACT raw data acquired during 30 consecutive BPAs were used for image reconstruction using either standard (CACTorg) or a motion correction algorithm (CACTmc), using 400 iterations. Two readers independently evaluated 188 segmental and 564 sub-segmental contrast-enhanced pulmonary arteries in each reconstruction. The following categories were assessed: Sharpness of the vessel, motion artifacts, delineation of bronchial structures, vessel geometry, and visibility of treatable lesions. The mentioned criteria were rated from grade 1 to grade 3: grade 1: excellent quality; grade 2: good quality; grade 3: poor/seriously impaired quality. Inter-observer agreement was calculated using Cohen's Kappa. Due to an excellent agreement, the ratings of both readers were merged. Differences in the assessed image quality criteria were evaluated using pairwise Wilcoxon signed-rank test. RESULTS: Inter-observer agreement was excellent for all evaluated image quality criteria (κ > 0.81). For all assessed image quality criteria, the ratings on CACTorg were good but improved significantly for CACTmc to excellent for the whole vascular tree (p < 0.01). When considering segmental and sub-segmental levels individually, all image quality criteria improved significantly for CACTmc on both levels (p < 0.01). While ratings of CACTmc were constant for both levels (segmental and sub-segmental) for all criteria, the ratings of CACTorg were slightly impaired for the sub-segmental arteries. CONCLUSION: Motion correction for supra-selective contrast-enhanced CACT of the pulmonary arteries is feasible and improves the overall image quality. KEY POINTS: · Motion artifacts can severely impair the diagnostic accuracy of CACT.. · A motion correction algorithm can significantly improve image quality in CACT of the pulmonary arteries.. · Especially the overall image quality of sub-segmental branches is significantly improved.. CITATION FORMAT: · Maschke S, Werncke T, Becker LS et al. Motion Reduction for C-Arm Computed Tomography of the Pulmonary Arteries: Image Quality of a Motion Correction Algorithm in Patients with Chronic Thromboembolic Hypertension During Balloon Pulmonary Angioplasty. Fortschr Röntgenstr 2021; 193: 1074 - 1080.

2D-Perfusion Angiography Using Carbon Dioxide (CO2): A Feasible Tool to Monitor Immediate Treatment Response to Endovascular Therapy of Peripheral Arterial Disease?

PURPOSE: Patients with peripheral arterial disease (PAD) or critical limb ischemia (CLI) require revascularization. Traditionally, endovascular therapy (EVT) is performed with iodinated contrast agent (ICM), which can provoke potential deterioration in renal function. CO2 is a safe negative contrast agent to guide vascular procedures, but interpretation of CO2 angiography is challenging. Changes in blood flow following iodine-aided EVT are assessable with 2D-perfusion angiography (2D-PA). The aim of this study was to evaluate 2D-PA as a tool to monitor blood flow changes during CO2-aided EVT. MATERIAL AND METHODS: 2D-PA was performed before and after ten EVTs (nine stents; one endoprosthesis; 10/2012-02/2020) in nine patients (six men; 65 ± 10y) with Fontaine stage IIb (n = 8) and IV (n = 1). A reference ROI (ROIINFLOW) was placed in the artery before the targeted obstruction and a target ROI (ROIOUTFLOW) distally. Corresponding ROIs were used pre- and post-EVT. Time to peak (TTP), peak density (PD) and area under the curve (AUC) were computed. The reference/target ROI ratios (TTPOUTFLOW/TTPINFLOW; PDOUTFLOW/PDINFLOW; AUCOUTFLOW/AUCINFLOW) were calculated. RESULTS: 2D-PA was technically feasible in all cases. A significant increase of 82% in PDOUTFLOW/PDINFLOW (0.44 ± 0.4 to 0.8 ± 0.63; p = 0.002) and of 132% in AUCOUTFLOW/AUCINFLOW (0.34 ± 0.22 to 0.79 ± 0.59; p = 0.002) was seen. A trend for a decrease in TTPOUTFLOW/TTPINFLOW was observed (- 24%; 5.57 ± 3.66 s-4.25 ± 1.64 s; p = 0.6). CONCLUSION: The presented 2D-PA technique facilitates the assessment of arterial flow in CO2-aided EVTs and has the potential to simplify the assessment of immediate treatment response.