Quality assurance for magnetic resonance angiography of the chest in patients suspected of pulmonary embolism during iodinated contrast shortage in the emergency department setting.

Objectives: COVID-19 lockdowns resulted in a global shortage of iodinated contrast media. Therefore, alternative imaging protocols were devised to evaluate patients arriving to the emergency department (ED) with suspicion of pulmonary embolism (PE). This quality assurance (QA) aims to compare diagnostic potential between alternative magnetic resonance angiography (MRA) protocol over the gold standard computed tomography angiography (CTA) by evaluating MRA imaging quality, scanner type/imaging sequence, and any risk of misdiagnosis in patients with symptoms of PE. Material and Methods: This retrospective study compromised of 55 patients who arrived to ED and underwent MRA of the chest for suspicion of PE during the months of May to June 2022. Data regarding their chief complaints, imaging sequence, and MRA results were collected. Two fellowship-trained faculty radiologists reviewed the MRA scans of the patients and scored the quality using a Likert scale. Results: Two patients were positive for PE and 53 patients showed negative results. Regarding the scan quality issues, motion was noted in 80% of the 55 studies that we reviewed. Significant associations (P < 0.009) between Likert scale scores and initial complaint category were found. The characteristic symptoms associated with suspicion of PE, namely, shortness of breath, chest pain, and cough were distributed among the 1 and 2 categories, reflecting the most optimal vessel opacification scores. We found no risk of misdiagnosis after reviewing the electronic medical record for follow-up appointments within 6 months of ED visit. Conclusion: Patients were screened for PE with MRA as an alternative imaging tool during times of contrast shortage. Further, evaluation of MRA with CTA, side by side, in a larger patient population is required to increase the validity of our QA study.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds.

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Republished:Aspiration catheter failure leading to carotid-cavernous fistula during stroke thrombectomy.

Endovascular thrombectomy in acute ischaemic stroke commonly uses aspiration catheters, either alone or in combination with stent retrievers. The Penumbra Aspiration System (Penumbra, Alameda, California, USA) was first approved by the US Food and Drug Administration in 2007, with low reported device-related complications. We present a case of a previously unreported complication related to malfunction of a Penumbra aspiration catheter during stroke thrombectomy resulting in a carotid-cavernous fistula.

Comparative Analysis of Radiology Trainee Burnout Using the Maslach Burnout Inventory and Oldenburg Burnout Inventory.

BACKGROUND: Burnout is an individualized response to imbalances between job demands and resources that has predominantly been evaluated with the Maslach Burnout Inventory (MBI). There are other instruments not validated among healthcare providers that may be comparable to the MBI. Utilizing alternative measurements can allow researchers to assess wellness with a larger array of questions. OBJECTIVE: We explored differences between the MBI- Human Services Survey for Medical Personnel (MBI-HSS [MP]) and Oldenburg Burnout Inventory (OLBI) in evaluating emotional exhaustion (EE)/exhaustion and depersonalization (DP)/disengagement. METHODS: We administered the MBI-HSS (MP) and OLBI to United States (US) radiology trainees during three,1-month intervals in April 2018, October 2018, and April 2019. Student's T-tests or ANOVA was used to evaluate differences between demographic groups and burnout scores in the MBI-HSS (MP) and OBLI. Non-inferiority analysis was completed to evaluate if the OBLI was not inferior to the MBI-HSS (MP) in how its subscales measure exhaustion and disengagement. The MBI-HSS (MP) subtotals for EE and DP were compared with the OLBI scores for exhaustion and disengagement using two-tailed paired T-tests for each trainee. RESULTS: Of 2823 trainees emailed, 770 (27.3%) responded. The mean EE Maslach score was 21/54, and the mean DP Maslach score was 8/30. The average OBLI exhaustion and disengagement score was 2.38 and 2.22, respectively. Comparative analysis of completed MBI-HSS (MP) and OLBI subscales yielded no significant difference between the EE/exhaustion (t(496)=1.038; p=0.30) or DP/disengagement (t(498)=0.084; p=0.933) subscales. CONCLUSIONS: Our national study of radiology trainees demonstrated that the OLBI was not inferior in assessing exhaustion and disengagement to the EE and DP subscales of the MBI-HSS (MP).

Interventional radiology in renal emergencies: a pictorial essay.

Renal emergencies necessitate prompt diagnosis and management to stop active bleeding and retain kidney function. Causes of renal emergencies can be classified into traumatic, atraumatic, iatrogenic, and obstructive etiologies. Interventional radiology (IR) has emerged as an acceptable alternative to surgical treatment in the management of renal emergencies due to its minimally invasive nature. With the rise of interventional procedures, there is a need for further discussion of angiographic and fluoroscopic imaging in the setting of renal emergencies.

Role of imaging in penetrating vascular injuries of the craniocervical region.

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Magnetic Resonance Imaging Evaluation of Ectopic Pregnancy: A Value-Added Review.

ABSTRACT: Ectopic pregnancy (EP) is a known cause of maternal mortality and may be misdiagnosed in up to 50% of pregnant female individuals (Ann Emerg Med. 1996;28(1):10-17). Magnetic resonance imaging, with its superior soft tissue resolution, is a valuable alternative diagnostic modality to diagnose EP when transvaginal ultrasound results are inconclusive. Although an extrauterine gestational sac is the most specific finding, there are other key MRI findings that can aid in diagnosing EP. As availability of MRI access in the emergency department setting increases across the nation, its utility in women with a positive pregnancy test has also increased. Specific MRI findings that are diagnostic of EP include absence of intrauterine pregnancy, adnexal mass separate from the ovary, and hemoperitoneum. In addition, intrauterine ectopic locations, especially intramural, cornual, and cervical pregnancies, can be diagnosed with increased accuracy with the help of MRI. Magnetic resonance imaging is also useful in excluding potential mimics of EP, including adnexal cysts, ovarian neoplasms, and fibroids. In summary, providing an accurate diagnosis and determining the precise location of an EP, which is supported by the use of MRI, is imperative for guiding a patient's treatment to prevent a potentially fatal outcome.

Predictors Between the Subcomponents of Burnout Among Radiology Trainees.

OBJECTIVE: The aim of this study was to investigate the effect of various predictors on burnout among radiology residents during their training. METHODS: In this cross-sectional analysis, we distributed the Maslach Burnout Index for Medical Personnel (MBI-HSS [MP]) to eligible United States (US) radiology residents. Covariates of interest included age, child status, debt burden, partner status, and self-identified gender. Primary outcomes include MBI-HSS (MP) subcomponent scores - emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Mann-Whitney tests were used to compare averages between groups. RESULTS: Out of the 770 of 2823 residents (27.3%) who responded, 488 of 770 completed the MBI-HSS (MP). During the R1 year, male sex was associated with marginally higher PA scores (36.5 versus 33.5; P = .029). Having children or a partner was associated with lower EE scores (18.7 versus 26.8, P = .012; 22 versus 28.9, P = .022, respectively) and higher PA scores (37 vs 32.7, P = .024; 35 versus 31.3, P = .039, respectively) among the R3 cohort. Reporting debt < $200,000 was associated with lower EE scores among the R3 (21.2 versus 27.3, P = .028) and R4 (16.4 versus 21.9, P = .033) cohort. DISCUSSION: There are several predictors of burnout that transiently impact residents at different years of training and primarily impact EE or PA, but not DP scores. R3 residents' scores are most sensitive to these covariates.

Exploration of the Relationship Between the Subcomponents of Burnout Throughout Radiology Training.

PURPOSE: The aim of this study was to investigate the relationship between the subcomponents of burnout and year of training among radiology residents. METHODS: In this cross-sectional analysis, the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS [MP]) was distributed to eligible United States (US) radiology residents. Primary outcomes included the MBI-HSS (MP) subcomponents: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Multivariate analysis of variance, tests of between-subjects effects, and Tukey post hoc analysis with 95% confidence interval were conducted. RESULTS: A total of 770 of 2,823 residents (27.3%) responded, with 488 of 770 completing the MBI-HSS (MP). There was a statistically significant difference in subcomponent scores between cohorts based on year of training (P < .005) and a statistically significant effect between year of training and EE (P < .05) and DP (P < .005), but not PA. Third-year (R3) residents reported a higher frequency of EE than first-year (R1) residents and a higher frequency of DP than R1 and second-year (R2) residents. Fourth-year (R4) residents reported more DP than R1 residents. CONCLUSIONS: This analysis shows variation in burnout subcomponents during training, with the highest recorded EE and DP means and lowest recorded PA means among R3 residents. Although these findings demonstrate evidence of burnout among radiology residents, mean subcomponent scores for EE (21.3) and DP (8.4) were lower and for PA (35.1) was higher for all trainees than in previous studies assessing radiology residents, which correlates with less burnout. DP was the only subcomponent that remained statistically elevated between matriculating R1 and graduating R4 residents.

Aspiration catheter failure leading to carotid-cavernous fistula during stroke thrombectomy.

Endovascular thrombectomy in acute ischaemic stroke commonly uses aspiration catheters, either alone or in combination with stent retrievers. The Penumbra Aspiration System (Penumbra, Alameda, California, USA) was first approved by the US Food and Drug Administration in 2007, with low reported device-related complications. We present a case of a previously unreported complication related to malfunction of a Penumbra aspiration catheter during stroke thrombectomy resulting in a carotid-cavernous fistula.

Mind the gap: A novel endovascular technique to repair a transected vessel.

Level one trauma centers experience horrific injuries on a regular basis. Blunt or penetrating trauma causing vascular injuries are treated by surgeons and interventional radiologists. When a blood vessel is completely transected, the ends of the vessel retract and vasospasm occurs as a normal survival response. When this phenomenon occurs, it is sometimes impossible to reattach the two ends of the injured vessel by surgical means and a bypass graft is often required. However, from an endovascular perspective, covered stents can serve as a vascular bypass as well. The limiting factor with an endovascular approach is the ability to successfully gain wire access across the injured vessel. The technique described in this manuscript describes a "rendezvous" method of repairing a transected axillosubclavian artery from a high-speed motorcycle accident using a steerable microcatheter. Initially, multiple failed attempts to cross the injured vessel were encountered despite using a wide variety of conventional guidewires and catheters. A steerable microcatheter was then used to safely and effectively navigate more than 15 cm through soft tissue to the opposite end of the vessel. In this critically ill patient, this technique significantly reduced the procedural time when compared to our previous experiences repairing arterial transections using traditional catheters.

Pipe-Cleaning Plugged Portacaths: How to Unclog an Implanted Port After Development of a Fibrin Sheath.

Industry has long fought the battle to design a vascular catheter that is less thrombogenic. Indwelling catheters provide long-term central venous access, but they develop fibrin sheaths as the vascular system recognizes them as foreign bodies. Peripheral catheters and central catheters can be changed over a guidewire when they form a fibrin sheath or otherwise malfunction. However, totally implantable venous access devices such as a port cannot be easily exchanged over a wire. Therefore, when a port malfunctions, thrombolytics are usually the only option attempted before the port is explanted and a new site is prepared for access. We present a minimally invasive technique demonstrating port salvage that does not require explant.

Pediatric Traumas and Paradigm Shifts: The Necessary Adaption of the Steerable Microcatheter in Pediatric Interventional Radiology.

The use of traditionally available intra-arterial devices have historically been designed with the adult patient population in mind. Currently, there are not manufactured devices specifically tailored for use during pediatric interventional procedures, pressuring interventional operators to adapt commonplace and readily available devices for interventional management. Experienced interventional operators understand that pediatric and adult interventions can entail vastly different management, affecting patient care and outcomes. To address the pitfalls in pediatric interventional management, an accredited fellowship specifically for pediatric interventional radiology is available. However, devices must equally evolve with the training available in order to adequately address interventional management of the pediatric patient population. Interventional device innovation can be considered the initial step towards bridging the technical and procedural gaps necessary for refining pediatric intervention. The introduction of steerable microcatheters in interventional radiology has innovated procedural protocols, but has never been documented in pediatric patients until this time.

A Route Less Traveled: Anomalous Venous Drainage of the Right Heart.

Congenital anomalies of the coronary sinus and veins have been well documented, but only one instance of an anomalous small cardiac vein draining into the superior vena cava (SVC) has been reported. The majority of patients with anomalies of the coronary venous system are asymptomatic, but these variants are important to document as they may have clinically significant implications in the management and possible interventions patients may receive. This report describes an anomalous connection from the coronary venous system to the superior vena cava discovered incidentally in a patient with SVC syndrome and end-stage renal disease (ESRD). This may reflect a congenital variant which accommodated collateral flow to bypass the fully occluded SVC. Alternatively, it may be the result of repeated venoplasty of the stenotic SVC which opened an iatrogenic tract that was maintained and vascularized over time.

Embolization-induced Renal Tumor Shrinkage Followed by Definitive Cryoablation.

Significant incidental findings reported on computed tomography (CT) scans are common. This article describes a 72-year-old man evaluated for possible bowel obstruction in whom was found a 3.1-cm x 2.6-cm centrally located enhancing mass in the left kidney highly suspicious for renal cell carcinoma. Due to substantial medical comorbidities, the patient was deemed a poor surgical candidate for either partial or complete nephrectomy. Interventional radiology was consulted for a minimally invasive ablation procedure. The large size and central location of the tumor involving the renal collecting system initially precluded definitive percutaneous cryoablation. Intra-arterial embolization was used as neoadjuvant therapy to decrease tumor burden. Fluoroscopy-guided bland embolization was performed targeting the arterial supply of the mass until stagnation of flow was achieved. A subsequent two-month post-embolization follow-up CT scan showed a 30% reduction in tumor size. Shrinkage of the mass from a central to a more peripheral location allowed for a cryoablation approach that would avoid damage to the vulnerable collecting system. Cryoablation was performed, and intraoperative CT demonstrated complete coverage of the tumor by the ice ball with no damage to the renal collecting system. A follow-up CT scan four years later showed no residual malignancy at the ablation site.

Hydro-marking Your Territory: Using a Novel Percutaneous Tagging System to Assist Pulmonary Nodule Identification During Video-assisted Thoracoscopic Surgery.

The management of lung cancer is highly dependent on surgical resection. There are different surgical managements that are utilized on a patient to patient basis. Small lung nodules are particularly difficult to resect and have a higher postoperative complication rate. Video-assisted thoracoscopic surgery is the preferred method of surgery over open thoracotomy, but requires the preoperative percutaneous placement of a marker to help the surgeon identify the nodule once conducting surgical resection. There are various methods to place percutaneous markers, but have reported complications. The following case will present the novel placement of a hydrogel tagging system on a small pulmonary nodule, demonstrating superiority to other methods of percutaneous marker placement.