American Journal of Interventional Radiology

Journal Information
ISSN / EISSN : 2572-4614 / 2572-4606
Published by: Scientific Scholar (10.25259)
Total articles ≅ 77
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Paul A. Kohanteb, H. Gabriel Lipshutz, Benedette Okonkwo, Kimberly Oka, Eli Kasheri, Jason Cohen, Moshe Barnajian,
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_16_2021

Abstract:
Objectives: Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding. Material and Methods: This is an institutional review board-approved, retrospective study of 20 patients who underwent PMA between 2014 and 2019. All patients had clinical evidence of GI hemorrhage without a definite source. PMA consisted of anticoagulation with 5000 units of heparin and selective transcatheter injection of up to 600 μg of nitroglycerine, followed by slow infusion of up to 24 mg of tissue plasminogen activator into the arterial distribution of the highest suspicion mesenteric artery. Results: Among the 20 patients who underwent PMA, 11/20 (55%) resulted in angiographically visible extravasation. Of these 11 patients, nine patients underwent successful embolization with coil or glue and were discharged upon achieving hemodynamic stability. Two patients spontaneously stopped bleeding. In our series, PMA resulted in the successful treatment of 9/20 (45%) patients with recurrent hemorrhage. No procedure-associated complications were reported with these 20 patients during the procedure and their course of hospitalization. Conclusion: In our experience, PMA is an effective and safe approach in localizing and treating the source of GI bleeding in about half of patients with an otherwise unidentifiable source.
Johnathan Righetti, Shane Morris, Mehran Fotoohi, Danielle La Selva, Troy Zehr,
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_21_2021

Abstract:
Objectives: The objectives of the study were to compare the indications, adverse events, removal rates, and mortality of percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) techniques at our tertiary care institution from 2014 to 2019. Material and Methods: We undertook a 5-year retrospective review of patients who underwent either PEG or PRG at our institution from 2014 to 2019. Common adverse events include tube clogs, leaks, minor bleeds, and wound infections, while more rare major complications include peritonitis, intra-abdominal infection, and major hemorrhage. The procedures were all performed with either conscious sedation or general anesthesia. A total of 789 patients were reviewed, of whom 519 (65.8%) had a PRG and 270 (34.2%) had a PEG. PRGs were more likely to be placed for head-and-neck cancer (P < 0.0001) and amyotrophic lateral sclerosis (P < 0.0001), while PEGs were more likely to be placed for gastric outlet obstruction (GOO) (P <.0001) and malnutrition (P < 0.0001). Results: The rate of major adverse events was similar between the two groups (P = 0.938). GI placed gastrostomy tubes were more likely to have a minor adverse event (P < 0.0001), however, this was secondary to a significant increase in tube clog in the PEG/J group as compared to PEG (P < 0.0001). Conclusion: The decision to place a PEG or PRG should be individualized to the patient’s specific condition and indication. Both procedures have favorable safety profiles, and it is likely that institutional expertise and procedural access will be the primary determinants of the procedural technique chosen for minimally invasive gastrostomy.
Manish J. Patel, Milan N. Patel
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_29_2021

Abstract:
A 27-year-old man with a long history of intermittent, severe abdominal pain for approximately 10 years was evaluated by interventional radiology for a retrocrural cystic lesion found on magnetic resonance imaging (MRI). Prior to evaluation, he was extensively worked up by several gastrointestinal specialties and multiple surgeons without clear etiology of his abdominal pain. This retrocrural cystic lesion found on MRI was thought to be the source of his cyclic abdominal pain occurring every few months. Since the pain was aggravated by the consumption of fatty foods, the patient was advised to intake a large quantity of fatty foods and return for repeat serial computed tomography (CT) scans until this cystic lesion could be identified. Once identified, he was taken back to the procedural CT scanner for drainage and embolization with a mixture of N-butyl cyanoacrylate glue and lipiodol (1:3 ratio). 3 years post-intervention, this patient is now asymptomatic with complete resolution of his pain.
, Derek Mittleider, Kevin Wallace
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_9_2021

Abstract:
A 58-year-old female was admitted to the hospital with bilateral pulmonary embolism (PE) with right heart strain. Her medical history included a previous PE resulting in thrombolysis and inferior vena cava filter placement, heparin-induced thrombocytopenia, morbid obesity, and chronic pain that was treated with an epidural injection 2 weeks prior to admission. This case is unusual due to the need for alternative anticoagulation management during thrombolysis in a patient with a heparin allergy who was at increased risk for bleeding. She was initiated on argatroban to achieve therapeutic aPTTs before receiving both mechanical thrombectomy and alteplase through ultrasound-facilitated catheter-directed thrombolysis. The argatroban was reduced to a flat rate of 0.5 mcg/kg/ min during thrombolysis and was subsequently increased to achieve therapeutic aPTTs upon completion of thrombolysis. The patient was transitioned from argatroban to apixaban for lifelong anticoagulation.
Matthew Wilson, , Grayson L. Baird, Michael S. Furman, David J. Grand
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_10_2021

Abstract:
Objectives: The aim of this retrospective study was to investigate the relationship between lung lesion lobar distribution, lesion size, and lung biopsy diagnostic yield. Material and Methods: This retrospective study was performed between January 1, 2013, and April 30, 2019, on CT-guided percutaneous transthoracic needle biopsies of 1522 lung lesions, median size 3.65 cm (range: 0.5– 15.5 cm). Lung lesions were localized as follows: upper lobes, right middle lobe and lingual, lower lobes superior segments, and lower lobes basal segments. Biopsies were classified as either diagnostic or non-diagnostic based on final cytology and/or pathology reports. Results were considered diagnostic if malignancy or a specific benign diagnosis was established, whereas atypical cells, non-specific benignity, or insufficient specimen were considered non-diagnostic. Results: The positive predictive value (PPV) of a diagnostic yield was 85%, regardless of lobar distribution. Because all PPVs were relatively high across locations (84–87%), we failed to find statistically significant difference in PPV between locations (P = 0.79). Furthermore, for every 1 cm increase in target size, the odds of a diagnostic yield increased by 1.42-fold or 42% above 85%. Although target size increased the diagnostic yield differently by location (between 1.4- and 1.8-fold across locations), these differences failed to be statistically significant, P = 0.55. Conclusion: Percutaneous transthoracic needle biopsy of lung lesions achieved high diagnostic yield (PPV: 84– 87%) across all lobes. A 42% odds increase in yield was achieved for every 1 cm increase in target size. However, this increase in size failed to be statistically significant between lobes.
Austin Snyder, Silvia Salamone, Nicholas J. Reid, Tristan Yeung, John Di Capua, , Dania Daye, Raul Uppot
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_11_2021

Abstract:
Objectives: During the COVID-19 pandemic, there was a perceived increase in the number of cholecystostomy tube placements. We have retrospectively analyzed the incidence and outcomes of cholecystostomy tube placement during the COVID-19 pandemic surge. Material and Methods: Cholecystostomy tube placement and overall interventional radiology (IR) case volume were analyzed at our tertiary care center during the pandemic (March 15, 2020–July 30, 2020) and compared to the same time period in 2019. In addition, an age- and gender-matched control study of outcomes for 40 patients (25 from our home institution and 15 from our affiliated hospitals) grouped by COVID-19 status who received percutaneous cholecystostomy tubes between March 15, 2020, and July 30, 2020, was performed. Results: We observed a significant increase in relative cholecystostomy tube volume during the pandemic, despite a decrease in total IR case volume. There was no significant difference in pre- or post-procedural laboratory data, vital signs, imaging, or mortality between COVID-positive and COVID-negative patients who received cholecystostomy tubes. Conclusion: Percutaneous cholecystostomy tube placement is likely a safe treatment for acalculous cholecystitis in patients with COVID-19 with equivalent outcomes to patients without COVID-19.
, Mohamed Abdelsalam
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_44_2020

Abstract:
We present a case of a serious complication during placement of a tunneled central venous line due to rupture of the right subclavian vein and subsequent right hemothorax and hemomediastinum that warranted surgical intervention. The surgery was successful, however, the patient died of multiple comorbidities and multiorgan failure 4 days later.
, Akash Desai, Jung Hyun Yun, Eric Soltycki, Vinit Khanna, Balasubramani Natarajan
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_19_2021

Abstract:
Yttrium-90 (Y-90) radioembolization, also called transarterial radioembolization (TARE), is a catheter-directed therapy for direct delivery of internal radiation to tumors in the form of microspheres. It is currently available in two forms, either as a constituent of glass microspheres called TheraSphere® (BTG Ltd., London, UK [now Boston Scientific, Marlborough, MA, USA]) or as a biocompatible resin-based microsphere called SIR-Spheres® (Sirtex Medical Ltd., Woburn, MA, USA). Once these microspheres are delivered to the tumor through an arterial pathway, they are embedded within the tumor microcirculation and emit β-radiation at therapeutic levels. TARE is a commonly used treatment for unresectable primary or secondary hepatic malignancies and has led to improved survival rates and increased success rates in downstaging patients before liver resection or transplantation. Immediately following the pre-treatment angiogram, each patient undergoes a nuclear medicine study, otherwise known as technetium (99mTc) macroaggregated albumin scan, to determine the amount of radiotracer that has accumulated in the lungs (lung shunt fraction). Finally, after several calculations, the appropriate radiation dose to be delivered to the tumor is determined. While the technical aspects of radioembolization are quite complex, the collective clinical experience presented in the literature supports the use of Y-90 radioembolization for unresectable hepatic malignancies. Those ordering and administering radioembolization particles must be deemed an authorized user (AU) by the Nuclear Regulatory Commission (NRC). The NRC defines an AU as the individual responsible for ensuring that radioactive materials are handled and used safely and following NRC regulations and the terms and conditions of the NRC license. The NRC has published licensing guidance on Y-90 brachytherapy with the 10th revision released on November 8, 2019. This guidance has outlined specific requirements for obtaining a license for the use of TheraSphere and SIR-Spheres. Following the revised licensure guidelines from the NRC on Y-90 usage, a conditional authorization has been obtained at our institution by the PGY-6 interventional radiology/diagnostic radiology (IR/DR) resident. While the full guidelines and extensive alternative requirements can be found online, we will highlight the specific guidelines applicable to and fulfilled by IR/DR residents. The traditional ABR pathway takes approximately 18 months after graduation, including passing the ABR certification examination to become an AU. With the proposed alternate pathway, trainees will potentially become AU immediately after graduation. The primary aim of this submission is to describe the process for obtaining conditional authorization for Y-90 microspheres for PGY-6 IR/DR residents.
, Erin E. Ball, Rob Satriano, Jenni Stokes
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_13_2021

Abstract:
Some clinicians privately report a lack of confidence of being able to safely perform trigger point dry needling (TrPDN) or trigger point injection (TrPI) on muscles that require intercostal blocking, presumably resulting in procedural underutilization. Participatory action imaging (PAI), combined with procedural training and literature review of adverse event incidence, can be a useful tool in enhancing clinician confidence. A 6’ 2”, 185 lbs, 53-year-old male clinician subject with a latissimus dorsi trigger point (TrP) and privately reported high anxiety of performing TrPDN using the intercostal blocking technique, was examined to determine how clinician subject confidence could be improved through PAI and education regarding the degree of coverage of the intercostal space and rib during intercostal blocking. The clinician subject was placed in a left lateral decubitus position and rib imaged with a Siemens Acuson S2000 Ultrasound system with an 18L6 16 Hz high definition linear probe without intercostal blocking, and subsequently with intercostal blocking during maximal exhalation and inhalation, respectively. During intercostal blocking with maximal exhalation, the pleural space and an additional 13% of each side of the rib’s superior and inferior borders were completely blocked by the examiner’s fingers. During intercostal blocking with maximal inhalation, the pleural space and an additional 3% of each side of the rib’s superior and inferior borders were completely blocked by the fingers of the clinician. On visual inspection and interpretation of the images (e.g., PAI), the clinician subject reported a “significant” decrease in self-reported anxiety in performing the intercostal blocking technique (STAI Y-1 score improvement to “low to no anxiety range”). While more study is needed to investigate how variation in patient anatomy (weight, height, and morphology), clinician anatomy (hand size), needle direction, and specific rib being used for influences patient safety, this case report presents PAI as a previously undescribed means for future research and clinician education regarding risk assessment of TrPDN or TrPI of muscles requiring intercostal blocking.
, Tomas M. Appleton Figueira, Joe Ensor, Alda L. Tam, Rony Avritscher, Ahmed O. Kaseb, Sanjay Gupta
American Journal of Interventional Radiology, Volume 5; https://doi.org/10.25259/ajir_7_2021

Abstract:
Objectives: The objectives of the study were to evaluate the use of C-arm cone-beam computed tomography (CBCT) for tumor targeting for transarterial chemoembolization (TACE) and its impact on overall survival (OS) in hepatocellular carcinoma patients. Material and Methods: Two groups were retrospectively evaluated according to the date of the first TACE session before and after C-arm CBCT installation in late 2005 (group A [n = 34], 2004–2005; group B [n = 104], 2008+). The years 2006 and 2007 were excluded to allow for the incorporation of this new imaging technology into clinical practice. The vessel selection order was recorded for all TACE sessions. Univariate and multivariate analyses were performed to assess the impact on and predictors of survival. Results: The average TACE selection order for each patient was significantly higher in group B than in group A (P < 0.0001). The median OS was significantly longer in group B (29.34 months) than in group A (19.65 months; P = 0.0088), and the difference in duration was most pronounced in patients with tumor burdens < 25% (n = 93; P = 0.0075), in whom the 3-year survival rate was 56.1% in group B and 15.3% in group A. In these 93 patients, the OS was significant longer (P = 0.018) for high (41.07 months) versus low (19.65 months) vessel selection order across both groups. In multivariate analyses, both the period in which TACE was performed (P = 0.022) and the use of C-arm CBCT (P = 0.0075) were significant predictors of improved OS. Conclusion: Use of advanced C-arm CBCT during TACE enhances the operating physician’s ability to deliver targeted, effective therapy for hepatocellular carcinoma, an aggressive approach that favorably impacts survival.
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