Comparing outcomes of right verse left hepatic approach percutaneous biliary drainage catheters.

Purpose: Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures. Materials & methods: This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004-3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant. Results: Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37). Conclusion: Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE?

PURPOSE: To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements. MATERIALS AND METHODS: This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. RESULTS: A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599). CONCLUSIONS: Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis.

BACKGROUND: Peripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF. METHODS: A retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal. RESULTS: During the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively. CONCLUSIONS: Many adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

Utilizing 3D printing to assist pre-procedure planning of transjugular intrahepatic portosystemic shunt (TIPS) procedures: a pilot study.

BACKGROUND: 3D (three-dimensional) printing has been adopted by the medical community in several ways, procedure planning being one example. This application of technology has been adopted by several subspecialties including interventional radiology, however the planning of transjugular intrahepatic portosystemic shunt (TIPS) placement has not yet been described. The impact of a 3D printed model on procedural measures such as procedure time, radiation exposure, intravascular contrast dosage, fluoroscopy time, and provider confidence has also not been reported. METHODS: This pilot study utilized a quasi-experimental design including patients who underwent TIPS. For the control group, retrospective data was collected on patients who received a TIPS prior to Oct 1, 2020. For the experimental group, patient-specific 3D printed models were integrated in the care of patients that received TIPS between Oct 1, 2020 and April 15, 2021. Data was collected on patient demographics and procedural measures. The interventionalists were surveyed on their confidence level and model usage following each procedure in the experimental group. RESULTS: 3D printed models were created for six TIPS. Procedure time (p = 0.93), fluoroscopy time (p = 0.26), and intravascular contrast dosage (p = 0.75) did not have significant difference between groups. Mean radiation exposure was 808.8 mGy in the group with a model compared to 1731.7 mGy without, however this was also not statistically significant (p = 0.09). Out of 11 survey responses from interventionists, 10 reported "increased" or "significantly increased" confidence after reviewing the 3D printed model and all responded that the models were a valuable tool for trainees. CONCLUSIONS: 3D printed models of patient anatomy can consistently be made using consumer-level, desktop 3D printing technology. This study was not adequately powered to measure the impact that including 3D printed models in the planning of TIPS procedures may have on procedural measures. The majority of interventionists reported that patient-specific models were valuable tools for teaching trainees and that confidence levels increased as a result of model inclusion in procedure planning.

Blueprint for Implementing and Improving Eligible Inferior Vena Cava Filter Retrieval Across Institutions.

Introduction: Placement of removable inferior vena cava filters (rIVCFs) has increased, but this has not been accompanied by timely removal, with retrieval rates as low as 8.5% at some institutions. Failure to remove rIVCFs that were not medically necessary resulted in increased complications. This study discussed the development of an inferior vena cava (IVC) filter follow-up protocol. Methods: A method to monitor IVC filter placement and retrieval was developed. A weekly report was generated detailing placement and removal of rIVCFs. A standardized retrieval calculator was utilized to determine efficacy of removal. An IVC filter Retrieval Assessment Form was developed. Managing physicians and patients with medically unnecessary filters were sent letters with a retrieval checklist and order form. If not removed within one year, additional letters were sent. Standardized IVC filter reporting templates were created and utilized after insertion of all filters with retrieval status. Letters eventually were built into the electronic medical record for direct routing. Results: From 2015 to 2020, IVC filters were placed in 719 patients. Of those, 58% were eligible for retrieval. Initial rates of rIVCF removal in eligible patients were as low as 30-33% in 2015. The retrieval rate of eligible filters rose to 44% in September 2018. The rate of retrieval rose to 61% in January 2021. Conclusions: Employing a systemic protocol to aid in follow-up of patients following rIVCF placement may improve rates of retrieval. Regular evaluation and revision of the process demonstrated a significant role in achieving an increase in retrieval rates.

3D printed model to assist endovascular prostate artery embolization for benign prostatic hyperplasia.

With the growth and ease of 3D printing accessibility, the medical community has begun to adopt it in various ways. Modeling of prostatic arteries for embolization is an application that has yet to be fully explored. We present a case where a patient specific 3D-printed model was used as a reference during prostate artery embolization for a 70-year-old male with obstructive benign prostatic hyperplasia refractory to medical treatment. The prostate arteries were segmented from preoperative contrast enhanced computed tomography using 3D Slicer software and printed on a FormLabs Form2 resin printer. The models were then used for operative planning for the embolization of both right and left prostate arteries. The procedure was a success without complications and the patient returned 1 month later with significantly improved symptoms. Additionally, interventionists found the model to be helpful in selecting approach for arterial embolization.

A case of two shunts in the endovascular treatment of type II Abernethy syndrome.

BACKGROUND: Abernethy malformation is a rare condition defined by a congenital extrahepatic portosystemic shunt, often leading to absence or hypoplasia of the intrahepatic portal venous system. Although there are no consensus treatment guidelines, interventional techniques now offer minimally invasive treatment options for Abernethy malformations. This case report describes a case of Abernethy Syndrome Type II where the patient had two separate extrahepatic portosystemic shunts treated with endovascular occlusion with two Amplatzer plugs and demonstrates the feasibility of this treatment for this rare condition. This case was in a young adult, adding to the scarce literature of treatment for Abernethy syndrome in the adult population. CASE PRESENTATION: We report a case of a 20-year-old female patient with neurocognitive behavioral difficulty, voracious appetite, and chronic encephalopathy secondary to type II Abernethy malformation with not one, but two extrahepatic portosystemic shunts. The patient had failed medical management and was not a liver transplant candidate. Therefore, she presented to us for an endovascular treatment option. The two shunts were treated with endovascular occlusion using Amplatzer vascular plugs. Following embolization, flow into the hypoplastic portal vein improved with near complete occlusion of flow into the portosystemic shunts, thus restoring blood flow into the native portal system. At 3 month follow up, a CT demonstrated complete occlusion of the two portosystemic shunts, and a portal vein diminutive in caliber. The portal vein measured 7 mm in diameter on both pre and post-procedure CT scans. The total volume of the liver was found to be 843 cm3 on pre-procedure CT & 1191 cm3 on post-procedure CT. CONCLUSIONS: This report demonstrates the feasibility of using endovascular embolization to treat Abernethy II malformations. The management strategy of Type II Abernethy Syndrome should be to redirect blood flow into the hypoplastic native portal system, allowing for physiologic hepatic metabolism of splanchnic blood, hypertrophy of the portal system, and growth of the liver from the increased trophic flow.

Do Video Games Predict an Early Advanced Capacity to Learn Interventional Radiology Skills?

PURPOSE: To elucidate the relationship between video game (VG) play and interventional radiology (IR) technical skills in medical students. MATERIALS AND METHODS: Twenty medical students recruited at our institution's IR symposium completed a survey to ascertain demographics and prior VG experience, then participated in a 3-part trial of skills assessing IR and VG skill and visuospatial aptitude (VSA). IR skill was evaluated via an endovascular simulation task, VG skill by performance on three separate VGs, and VSA using the Cube Comparison test. Regression analysis was tested the strength of relationship between IR skill and VG experience, VG skill, and VSA, respectively, and participants were stratified by IR skill to top and bottom halves for survey-response comparison. RESULTS: There was no correlation between either VG skill or visuospatial aptitude and IR skill (r = -0.22, p = 0.35; and r = 0.14, p = 0.57). Greater number of years playing VGs correlated with superior IR skill (Spearman's rho=-0.45, p<0.05). Students who selected IR as their specialty of interest had extensive VG experience, playing for > 15 years (n = 4, 80%), at least 10 hours per week at their peak (n = 3, 60%), and reported being either "skilled" or "highly skilled" at VGs (n = 3, 60%). CONCLUSIONS: In our study, though limited by power, number of years playing VGs correlated positively with IR skills in medical students. Prior VG experience may predict an early advanced capacity to learn IR skills and an interest in the specialty.

Spontaneous Bleeding From Multiple Intercostal Arteries in a Patient With Coarctation of the Aorta.

A 59-year-old man with a history of coarctation repair, mechanical aortic valve, and warfarin therapy presented with right flank pain. Computed tomography showed a large hematoma encircling an intact descending thoracic aorta. Computed tomography angiography demonstrated multiple areas of intercostal artery extravasation. An interventional radiologist performed angiography and embolization. The patient's course was complicated by an effusion and hypoxia, but no further bleeding was noted. We hypothesize that coarctation associated aneurysms and potential vessel wall weakness are the causes of hematoma in our case. We present this case with history of repaired coarctation with multiple spontaneous intercostal artery aneurysmal rupture.

Rare presentation and endovascular treatment of multifocal iliac venous stenoses due to right sided May-Thurner Syndrome.

May-Thurner Syndrome (MTS) is a well-recognized anatomical variant describing compression of the left common iliac vein and may manifest as lower extremity swelling, pain, ulceration, discoloration, and paresthesia. Right-sided MTS is documented in the literature, though exceedingly rare. Specifically, no current reports describe a multifocal stenoses of the right iliac vein due to anatomical variants associated with left sided IVC. We present a case involving a patient with this pathophysiology, radiographic/sonographic correlate imaging, and subsequent endovascular treatment.

Case report: interventional radiology's potential role for in vitro fertilization post ovarian transposition and pelvic radiation.

INTRODUCTION: Ovarian transposition is a procedure that can help preserve fertility for female patients requiring radiation in the abdominopelvic region. However, the displacement of ovaries from its original anatomic location can make oocyte retrieval challenging. CASE PRESENTATION: A 24-year-old nulligravid patient recently diagnosed with colorectal carcinoma [CRC] underwent ovarian transposition prior to radiation. After radiation and chemotherapy, she began in vitro fertilization [IVF] by reproductive endocrinology and infertility physicians. Right ovary demonstrated nonviability due to failed transposition and radiation. Left ovarian oocytes were not able to be harvested due to risk of left kidney puncture via transvaginal ultrasound [TVUS]. Interventional Radiology [IR] was involved and performed a transabdominal ultrasound guided egg retrieval which led to successful IVF. CONCLUSION: This case highlights the utility of IR-assisted transabdominal ultrasound approach for oocyte retrieval in patients with history of ovarian transposition.

MRI findings of absorbable hydrogel spacer for prostate cancer therapy: a pictorial review.

Prior studies have shown that dose-escalated radiation therapy for prostate cancer improves clinical outcomes. However, this is associated with increased rectal toxicity. Hydrogel spacer for prostate cancer therapy is an effective way of decreasing rectal toxicity in the late post-therapeutic stages. In some occasions, the gel spacer may not be placed symmetrically between the rectum and prostate. There are several forms of a malpositioned spacer, including lateral displacement, rectal wall infiltration, and prostate capsule infiltration. This manuscript is aimed at evaluating appropriately positioned and malpositioned gel spacers, primarily via magnetic resonance imaging. There are limited educational imaging guides that address what radiologists should evaluate on post-spacer placement imaging. This pictorial review will specifically evaluate post-injection pitfalls such as asymmetry, rectal wall infiltration, and subcapsular injection.

Reducing radiation exposure with iterative reconstruction: an inter- and intra-scanner analysis.

Our purpose in this study was to compare delivered radiation exposure via computed tomography dose index volume (CTDIvol) and dose length production (DLP) measurements from computed tomography (CT) examinations performed on scanners with and without image-quality enhancing iterative reconstruction (IR) software. A retrospective analysis was conducted on randomly selected chest, abdomen, and/or pelvis CT examinations from three different scanners from 1 January 2013 to 31 December 2013. CTDIvol and DLP measurements were obtained from two CT scanners with and one CT scanner without IR software. To evaluate inter-scanner variability, we compared measurements from the same model CT scanners, one with and one without IR software. To evaluate intra-scanner variability, we compared measurements between two scanners with IR software from different manufacturers. CT scanners with IR software aided in the overall reduction in radiation exposure, measured as CTDIvol by 30% and DLP by 39% when compared to a scanner without IR. There was no significant difference in CTDlvol or DLP measurements across different manufacturers with IR software. As a result, IR software significantly decreased the radiation exposure to patients, but there were no differences in radiation measurements across CT manufacturers with IR software.

Disseminated cat-scratch disease in an adult with selective IgA deficiency.

A 51-year-old man with history of undiagnosed pulmonary nodules 4 years prior, presented with right-sided chest pain. Acute cardiac workup was negative, and a chest computed tomography examination demonstrated marked improvement in bilateral pulmonary nodules. A concordant abdominal computed tomography examination showed new subcentimeter hypodense lesions throughout the liver and spleen, mild progressive abdominopelvic lymphadenopathy, and new small lytic lesions of T11 and L4 vertebrae. A positron emission tomography examination demonstrated hypermetabolic activity of these abdominopelvic lesions suggesting metastatic disease. Extensive laboratory workup was negative, aside from IgA deficiency. Eventually, biopsy of a hepatic lesion was performed and compatible with Bartonella species. An elevated Bartonella IgG titer was noted, consistent with Bartonella Hensalae infection, or "cat-scratch disease." Radiographic findings showed marked improvement after clinically appropriate antibiotic therapy.

Spectrum of radiological manifestations of paediatric cat-scratch disease.

Cat-scratch disease (CSD) is usually a self-limiting condition that may mimic more serious disorders due to its variable clinical and imaging presentations. Many cases are diagnosed throughout the United States annually, with the majority occurring in children and adolescents who have had contact with a cat, usually in the form of a scratch or bite. This manuscript will discuss the spectrum of radiologic manifestations of CSD emphasising key imaging findings of lymphadenopathy, hepatosplenic lesions, osteomyelitis, discitis, encephalitis, neuroretinitis and cranial neuritis.