General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement.

Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules. Summary: This consensus statement is organized around three key themes: (1) safety of ablation techniques and their implementation, (2) optimal skillset criteria for proceduralists performing ablative procedures, and (3) defining expectations of success for this treatment option given its unique risks and benefits. Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided. Conclusions: Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. Careful patient and nodule selection are critical to the success of these procedures as is extensive pre-procedural patient counseling. Although these emerging technologies hold great promise, they are not without risk and require the development of a unique skillset and environment for optimal, safe performance and consistent outcomes.

Uterine Fibroid Embolization or Myomectomy: How Much Marketing Is Enough? Comparative Analysis of Public Search Trends in Google and Medical Publications in PubMed.

To compare public popularity and volume of scientific publications regarding uterine fibroid embolization (UFE) and myomectomy. Google Trends and PubMed data were queried to assess temporal variations in online public search volumes and number of research publications for UFE and myomectomy. Time series analysis was used to identify meaningful temporal trends and forecast a future trend. Compared with UFE, myomectomy had significantly higher volumes of public online search and research publications, with an increasing trend over time (P < .0001). The forecasting models predicted a continuing increase in both public search volumes and number of research publications for myomectomy and static future trends in these metrics for UFE. This study signals significantly lower public popularity and research efforts for UFE compared with myomectomy for uterine fibroids. More effective marketing strategies and further research support will be needed to fill this gap.

Radiofrequency Ablation for Benign Thyroid Nodules: Radiology In Training.

Two patients, one with benign nonfunctioning nodules and one with functioning thyroid nodules, both of whom underwent radiofrequency ablation, are presented. Preprocedural evaluation, procedural considerations, and follow-up care of thyroid radiofrequency ablation, as well as published evidence on the topic, are discussed.

Rendezvous Technique for Advanced Pancreatic Duct Interventions.

Interventional radiology can be used to perform complex pancreatic duct (PD) interventions in cases in which PD abnormalities limit the feasibility of an endoscopic approach. A multidisciplinary approach with gastroenterology using the rendezvous technique can improve procedural success. The establishment of through-and-through access to the PD via a combined percutaneous and endoscopic approach can be used when endoscopy alone fails. In this study, 3 cases are presented in which the rendezvous technique was successfully employed to access the PD for subsequent interventions.

Image-Guided Percutaneous Ablation for Primary and Metastatic Tumors.

Image-guided percutaneous ablation methods have been further developed during the recent two decades and have transformed the minimally invasive and precision features of treatment options targeting primary and metastatic tumors. They work by percutaneously introducing applicators to precisely destroy a tumor and offer much lower risks than conventional methods. There are usually shorter recovery periods, less bleeding, and more preservation of organ parenchyma, expanding the treatment options of patients with cancer who may not be eligible for resection. Image-guided ablation techniques are currently utilized for the treatment of primary and metastatic tumors in various organs including the liver, pancreas, kidneys, thyroid and parathyroid, prostate, lung, bone, and soft tissue. This article provides a brief review of the various imaging modalities and available ablation techniques and discusses their applications and associated complications in various organs.

Review of the Korean Society of Interventional Radiology and European Thyroid Association Guidelines Regarding the Role of Radiofrequency Ablation for Benign and Malignant Thyroid Tumors.

While radiofrequency ablation (RFA) for the treatment of symptomatic thyroid nodules has been gaining more widespread adoption in the United States, there is limited societal guidance for its role, and safe adoption. As many of the first adopters of thyroid nodule RFA developed their practices, they looked to the Korean Society of Interventional Radiology (KSIR), and European Thyroid Association (ETA) guidelines as a framework. Currently, efforts are underway from the American Thyroid Association to create updated guidelines for US providers. International consensus guidelines are also underway. Until these guidelines are available, a thorough understanding of the current available guidelines is key for interventionalists building a thyroid nodule RFA program.

Radiofrequency Ablation of Solid Benign Thyroid Nodules.

Symptomatic solid benign thyroid nodules may present either as nonfunctioning nodules causing compressive symptoms or as hyperfunctioning nodules causing symptoms of hyperthyroidism. While surgical resection or radioiodine ablation of these nodules can be performed, percutaneous radiofrequency ablation (RFA) of benign solid thyroid nodules has been shown to be a safe and effective alternative in select patients. Preprocedural evaluation should include a history focusing on signs and symptoms of thyroid dysfunction, a physical exam, thyroid ultrasound, thyroid function tests, and discussion of key intraprocedural details with the patient such as the anesthesia plan and risks. Thyroid RFA can be safely performed as an outpatient procedure with less than 2% major and minor complication rates. This report will focus on the basic technique of performing RFA for symptomatic thyroid nodules.

Percutaneous Therapies for Hepatocellular Carcinoma: Evolution of Liver Directed Therapies.

Percutaneous ablation is a mainstay of treatment for early stage, unresectable hepatocellular carcinoma (HCC). Recent advances in technology have created multiple ablative modalities for treatment of this common malignancy. The purpose of this review is to familiarize readers with the technical and clinical aspects of both existing and emerging percutaneous treatment options for HCC.

Analysis of Costs and Payments for Inferior Vena Cava Filter Retrieval in the Medicare Population.

Over the past decade, inferior vena cava (IVC) filter retrieval has been increasing, in part due to Food and Drug Administration recommendations and legal pressure. The costs and margin of IVC filter removal are poorly understood. Medicare claims data from 2016 for the 103 highest volume centers for IVC filter retrieval were examined. Pooled mean charges, costs, payments, and margin were calculated by institution. Mean ± SD charges, costs, and payments were $14,138.00 ± $8,400.48, $3,693.28 ± $2,294.27, and $1,949.82 ± $702.91, respectively. Average (range) margin was -$1,706.18 (-$7,509.93 to $362.77). The margin was negative in 99 of the 103 (96%) institutions evaluated. The most significant contributors to the total procedure cost were operating room, supplies, and recovery (44.5%, 23.5%, and 10.4%, respectively). While IVC filter retrieval is often medically indicated, it is typically associated with a financial loss under current reimbursement structure.

Relationship of Antenna Work and Ablation Cavity Volume Following Percutaneous Microwave Ablation of Hepatic Tumors.

PURPOSE: To formulate a statistical model relating ablation time, power, and work with posttreatment cavity volume following percutaneous microwave ablation of hepatic tumors in vivo. MATERIALS AND METHODS: A retrospective review (October 2015 to October 2018) yielded 122 hepatic tumors treated with microwave ablation. Ablation cavity dimensions were measured at 1-month follow-up examination and calculated using an ellipsoid volume formula. The antenna manufacturer (Neuwave Medical, Madison, Wisconsin) provided the activation time and energy used to calculate the antenna work. Generalized estimating equations with ordinary least-squares regression models were obtained to relate tumor volume with cumulative antenna work. Coefficient of determination (R2) and mean square error were used as statistical measures of model prediction performance. RESULTS: There is a logarithmic relationship between postablation cavity volume (cm3) and cumulative work (kJ), represented by the formula: log10 cm3 = -0.4583 + 0.9887 × cumulative work (log10 kJ) (R2 = 0.41, mean square error, 0.102). Ablation volumes were predicted as a function of antenna work, calculated using an antilog transformation. When a single antenna was used, ablation cavity volume was predicted using a generalized estimating equation ordinary least-squares regression model of power and time: log10cm3= -0.0546 + 0.0485 × total time (min) + 0.0107 × power (W) (R2 = 0.30; mean square error, 0.106). Using this model, a nomogram was developed to predict the postablation cavity volume based on total activation time and target power. CONCLUSION: There is a logarithmic relationship between the ablation work and posttreatment ablation cavity volume, which can be expressed in a nomogram when using a single probe.

Effect of timing on endovascular therapy and exploratory laparotomy outcome in acute mesenteric ischemia.

BACKGROUND: Abdominal exploration followed by vascular bypass has been the standard of care for acute mesenteric ischemia (AMI), but there is increasing use of endovascular treatment with selective exploratory laparotomy. METHODS: We performed a retrospective review of patients diagnosed with AMI who underwent mesenteric artery angioplasty or stenting at a single institution from 2010-2017. Patients were divided into 3 groups: those who did not undergo exploratory laparotomy; those who received endovascular treatment before laparotomy (post-reperfusion laparotomy group); and those who had endovascular treatment after laparotomy (pre-reperfusion laparotomy group). RESULTS: Patients who did not undergo exploratory laparotomy showed 85.7% (12/14) survival, compared with 63.6% (7/11) in the post-reperfusion group and 25.0% (2/8) in the pre-reperfusion group, P=0.077). Time to reperfusion was significant (P=0.009) in predicting survival for patients who underwent exploratory laparotomy. CONCLUSION: Emergent endovascular treatment prior to laparotomy seems to be associated with a higher survival.

Predictors of All-Cause Mortality after Endovascular Aneurysm Repair: Assessing the Role of Psoas Muscle Cross-Sectional Area.

PURPOSE: To evaluate psoas muscle area (PMA) as a predictor of all-cause mortality after endovascular aneurysm repair (EVAR) and compare it with other predictor variables. MATERIAL AND METHODS: Retrospective review of 407 patients who underwent EVAR over a 7-year period was performed. Demographics, comorbidity variables, and outcomes were collected. Preprocedure computed tomography scans were used to measure the PMA. Descriptive statistics summarized the demographic information and predictor variables. Kaplan-Meier analysis and univariate and multivariate Cox proportional regression analyses were performed. The main outcome measure was survival time. RESULTS: Median survival time for patients with PMA in the lowest quartile of the distribution (≤1442 mm2) was 65.5 months (95% confidence interval [95% CI] 37.7-78.9) vs 91.2 months (95% CI 77.9-110.0 when PMA >1442 mm2). Multivariate analysis revealed lower PMA was associated with decreased survival (adjusted hazard ratio [AHR] 1.68; 95% CI 1.15-2.40, P = .006). Similarly, the presence of coronary artery disease (AHR 1.54, 95% CI 1.01-2.35, P = .045) and statin use after EVAR were associated with decreased survival (AHR 2.36, 95% CI 1.24-4.49, P = .009). Hyperlipidemia was associated with increased survival after EVAR (AHR 0.51, 95% CI 0.33-0.81, P = .004). Compared with patients with low body mass index (BMI) (<18.5), a normal BMI was associated with increased survival (AHR 0.21, 95% CI 0.08-0.53, P = .001). CONCLUSIONS: Although PMA is a risk factor for decreased survival time, other factors such as patient hyperlipidemia, presence of coronary artery disease, post-EVAR statin use, and BMI are also predictive of postoperative mortality.

Impact of a Commercially Available Clinical Decision Support Program on Provider Ordering Habits.

PURPOSE: Clinical decision support (CDS) software designed around the ACR Appropriateness Criteria assists health care providers in choosing appropriate imaging studies at the time of order entry. The goal of this study was to determine the impact of commercially available CDS on the ordering habits of inpatient and emergency providers. METHODS: In 2014, ACR Select was integrated into our electronic health record, though without displaying appropriateness scores in a "silent" mode for 6 months. Then, feedback regarding examination appropriateness was "turned on" at order entry for adult patients in the emergency and inpatient settings for 24 months. We retrospectively compared the appropriateness scores of imaging tests before and after displaying feedback at order entry and evaluated these data by modality and attending versus trainee status. RESULTS: The commercially available CDS-generated scores for 34% and 20.4% of pre- and postintervention studies, respectively. After feedback, the relative frequency of low utility studies decreased to 5.4% from 11%, and the relative frequency of indicated studies increased to 82% from 64.5%. This was most pronounced in trainees for whom the percentage of low utility studies decreased from 10.8% (95% confidence interval [CI]: 10.0%, 11.7%) to 4.8% (95% CI: 4.4%, 5.2%) and the percentage of indicated studies increased from 65.6% (95% CI: 64.3%, 66.9%) to 83.7% (83.0%, 84.3%). CONCLUSIONS: After implementation of a commercially available decision support tool integrated into the electronic health record, there was a significant improvement in imaging study appropriateness scores, more pronounced in studies ordered by trainees.

Developing an Interactive Data Visualization Tool to Assess the Impact of Decision Support on Clinical Operations.

Due to mandates from recent legislation, clinical decision support (CDS) software is being adopted by radiology practices across the country. This software provides imaging study decision support for referring providers at the point of order entry. CDS systems produce a large volume of data, providing opportunities for research and quality improvement. In order to better visualize and analyze trends in this data, an interactive data visualization dashboard was created using a commercially available data visualization platform. Following the integration of a commercially available clinical decision support product into the electronic health record, a dashboard was created using a commercially available data visualization platform (Tableau, Seattle, WA). Data generated by the CDS were exported from the data warehouse, where they were stored, into the platform. This allowed for real-time visualization of the data generated by the decision support software. The creation of the dashboard allowed the output from the CDS platform to be more easily analyzed and facilitated hypothesis generation. Integrating data visualization tools into clinical decision support tools allows for easier data analysis and can streamline research and quality improvement efforts.

The Role of Interventional Radiologists in the Use of Extracorporeal Membranous Oxygenation in the Catheter-Directed Treatment of Pulmonary Embolism.

Patients with pulmonary embolism who are in hemodynamically unstable condition present a special challenge to the interventionalist. When treating such patients, extracorporeal membranous oxygenation (ECMO) can help to stabilize these patients' condition; however, specific criteria for its use do not exist. Two patients are presented here to familiarize the reader with the use of ECMO and to demonstrate its utility for the interventional radiologist.