Transitioning from interventional radiology: ideas for the inevitable.

BACKGROUND: Interventional Radiology (IR) is a highly rewarding specialty, both for its salutary effects for patients, as will as the satisfaction it provides for the operating radiologists. Nonetheless, arduous work and long hours have led to numerous reports of burnout amongst interventional radiologists (IRs). MATERIALS AND METHODS: Six long-term academic radiologists in leadership positions briefly chronicle their becoming IRs, their type of transitioning from IR, and the pros and cons of those respective transitions. RESULTS: The specific transitions include reduced time in IR, switching to diagnostic radiology, becoming involved in medical school education, ceasing IR leadership, and retirement. Pros and cons of the various transition strategies are highlighted. CONCLUSION: As the taxing work and long hours are so ubiquitous for IRs, and as burnout is so common, transitioning from IR is highly likely eventually for IRs. The varied transition experiences highlighted in this report hopefully will be helpful for current and aspiring IRs.

Pilot Study on the Influence of Incentive Spirometry on Percutaneous Image-Guided Intra-Abdominal Drainage Catheter Pressure: A Potential Method to Enhance Drainage.

Background: To report the evaluation of incentive spirometry (IS)-induced pressure changes in intra-abdominal drainage catheters and consider its use for maintaining catheter patency and enhancing drainage. Methods: Prospective study of patients with indwelling intra-abdominal drainage catheters for abdominal fluid collections who had their intra-abdominal pressures measured while performing incentive spirometry. Patients were instructed in the use of an incentive spirometer. Within a week after initial drainage, pressure changes with IS were evaluated three times at 1500 cc and three times at maximum inspiratory effort. Intra-abdominal pressure (IAP) was measured using a pressure monitor connected to the drainage catheter. Results: Twenty patients (men, 12; women, 8). Fluid collection locations were pelvis, Right-upper quadrant (RUQ), Left-upper quadrant (LUQ), Left-lower quadrant (LLQ), and Right-lower quadrant (RLQ). A total of 16 of 20 patients showed an elevation of IAP with IS. At 1500 cc, the pressure increased by an average of 41.24 mmH2O. At maximal inspiratory effort, the pressure increased by an average of 48.26 mmH2O. Pressure increase was greater in upper abdomen catheters. Four patients with lower abdominal and pelvic collections showed minimal pressure changes with IS. Conclusion: IS increases IAP and fluid flow through abdominal drainage catheters. Future studies are warranted to determine whether the use of IS enhances catheter performance and facilitates drainage via its effect on IAP.

Paired Drainage Catheter Insertion: Feasibility of Placing Two Catheters within the Same Complex Abscess Cavity as a Primary and Salvage Percutaneous Drainage Technique.

RATIONALE AND OBJECTIVES: To assess the feasibility of paired catheter drainage for management of complex abdominal abscesses. MATERIALS AND METHODS: This was a single-center retrospective study of 54 patients (35 males; mean age 48.9 years) that underwent paired catheter insertion for complex abdominal fluid collections in an 18-month period. Complex collections were defined as abscesses ≥6 cm in diameter with septations, high viscosity fluid or necrotic debris, or abscesses with an associated fistula. Abscess etiologies included postoperative (n = 28), pancreatitis (n = 12), perforated bowel (n = 7), liver abscess (n = 4), and perihepatic from gallbladder perforation (n = 3). Paired catheter insertion was defined two catheters co-located within one collection through the same skin incision or two closely spaced insertion sites. Paired catheter insertion was used primarily as initial drainage for complex intraabdominal abscesses and for salvage drainage in collections that could not be evacuated by a single catheter. Primary paired catheter insertion was used in 45 patients and as salvage in nine patients. RESULTS: Abscess resolution occurred in 51 (94.4%) patients. Patients had a median of three drainage procedures. Median duration of paired catheterization was 22 days. Seven abscesses recurred and all resolved with repeated drainage. Complications included one hemorrhage that was taken for surgical exploration. Overall, 48 patients had good clinical outcome, 3 patients died (multiorgan failure, n = 2; sepsis, n = 1), and 3 patients were lost to follow-up. CONCLUSION: Percutaneous paired catheter drainage is a feasible technique for the treatment of both complex intraabdominal abscesses and abscesses unresponsive to single catheter drainage.

Transrectal and transvaginal catheter drainages and aspirations for management of pelvic fluid collections: technique, technical success rates, and outcomes in 150 patients.

PURPOSE: To evaluate outcomes of image-guided transrectal/transvaginal (TR/TV) drainage for symptomatic pelvic fluid collections (SPFCs). MATERIALS AND METHODS: Single-center retrospective study of 150 consecutive patients (36 males, 114 females, average age 41 years) who underwent attempted TR/TV drainages of SPFCs during an 11-year, 5-month period. All patients presented with pain and had SPFCs with rectal or vaginal contact on preceding diagnostic CT. Routine technique included Foley catheter insertion, image-guidance with ultrasound and fluoroscopy, 18 g/20 cm Chiba needles, and Seldinger technique for catheter insertion. No anoscope or speculum was used. SPFCs causes were classified by etiology including postoperative-70 (47%); gynecologic-49 (33%); and gastrointestinal-31 (21%). Resolutions of the SPFCs without the need for surgical intervention, collection recurrence, and complications were assessed. Surgical management after attempted TR/TV drainage was considered a failure. RESULTS: Technical success was achieved in 172/180 procedures [TR 128/134 (95%); TV 44/46 (96%)]. TR/TV drainage successfully managed SPFCs in 141/150 patients (94% success rate) and 145/150 patients (97%) did not require surgical intervention; 4 patients with failed TR/TV drainage attempts were managed conservatively. In 5 patients requiring surgery, 4 were after technically successful TR/TV and 1 was after a failed TR attempt. Complications occurred in 4 (3%) patients: 2 bladder punctures (both resolved with medical management), 1 propagation of sepsis, and 1 hemorrhagic return from TR drainage that prompted surgical exploration. CONCLUSION: Transrectal and transvaginal drainage had high technical success rates and were successful in managing the majority (141/150; 94%) of patients with pelvic fluid collections.

3D Printed Antibiotic and Chemotherapeutic Eluting Catheters for Potential Use in Interventional Radiology: In Vitro Proof of Concept Study.

RATIONALE AND OBJECTIVES: Additive manufacturing may be used as a form of personalized medicine in interventional radiology by allowing for the creation of customized bioactive constructs such as catheters that can act as a form of localized drug delivery. The purpose of the present in vitro study was to use three-dimensional (3D) printing to construct bioactive-laden bioabsorbable catheters impregnated with antibiotics and chemotherapeutics. MATERIALS AND METHODS: Polylactic acid bioplastic pellets were coated with the powdered bioactive compounds gentamicin sulfate (GS) or methotrexate (MTX) to incorporate these drugs into the 3D printed constructs. The pellets were then extruded into drug-impregnated filament for fused deposition modeling 3D printing. Computer-aided design files were generated in the shapes of 14-F catheters. Scanning electron microscope imaging was used to visualize the presence of the additive powders on the surface of the printed constructs. Elution profiles were run on the antibiotic-laden catheter and MTX-laden catheters. Antibiotic-laden catheters were tested on bacterial broth and plate cultures. RESULTS: Both GS and MTX catheter constructs had sustained drug release up to the 5-day limit of testing. The 3D printed GS-enhanced catheters inhibited all bacterial growth in broth cultures and had an average zone of inhibition of 858 ± 118 mm2 on bacterial plates, whereas control catheters had no effect. CONCLUSION: The 3D printing manufacturing method to create instruments in percutaneous procedures is feasible. Further in vivo studies will substantiate these findings.

Multimodality Imaging Review of Anorectal and Perirectal Diseases with Clinical, Histologic, Endoscopic, and Operative Correlation, Part II: Infectious, Inflammatory, Congenital, and Vascular Conditions.

A broad spectrum of pathology affects the rectum, anus, and perineum, and multiple imaging modalities are complementary to physical examination for assessment and treatment planning. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented for a range of rectal, perirectal, and perineal disease processes, including infectious/inflammatory, traumatic, congenital/developmental, vascular, and miscellaneous conditions. Key anatomic and surgical concepts are discussed, including radiological information pertinent for surgical planning, and current operative approaches of these anatomic spaces to assist radiologists in comprehensive reporting for gastroenterologists and surgeons.

Multimodality Imaging Review of Anorectal and Perirectal Diseases With Histological, Endoscopic, and Operative Correlation, Part I: Anatomy and Neoplasms.

A broad spectrum of pathology affects the rectum, anus, and perineum and understanding of its relevant anatomy is important in accurate reporting, particularly in rectal cancer. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented to illustrate normal anorectal anatomy and neoplastic conditions that affect the anus and rectum. A particular case-based focus is given to rectal adenocarcinoma with pelvic MR and surgical histopathology. Additionally, carcinoid tumor, gastrointestinal stromal tumor, condylomata acuminata, squamous cell carcinoma, melanoma, and metastatic disease about the rectum and anus are reviewed.

Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis. MATERIALS AND METHODS: This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control. RESULTS: Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period. CONCLUSIONS: Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.

Percutaneous management of enterocutaneous fistulae and abscess-fistula complexes.

Abscess-fistula complexes and enterocutaneous fistulae are due to postoperative, spontaneous, and inflammatory etiologies. Conservative, percutaneous, endoscopic, and surgical treatment options are available options. Interventional radiologists have an array of different treatment strategies, often starting with percutaneous drainage of associated intra-abdominal abscesses. This review article details different percutaneous management strategies, focusing on percutaneous catheter strategies for abscess-fistula complexes along with tract closures strategies for enterocutaneous fistulae.

Fluid Flow Patterns Through Drainage Catheters: Clinical Observations in 99 Patients.

PURPOSE: To describe patterns of fluid flow through locking pigtail and biliary catheters in patients that underwent biliary and abdominopelvic fluid drainage. METHODS: Contrast movement through catheter sideholes in pigtail and biliary catheters was evaluated retrospectively using sinograms and cholangiograms at 7-10 days post insertion. Dilute contrast injected through the catheter was evaluated by following flow through the catheter shaft and exit from side holes within the body cavity. Exit of contrast through side holes was appreciated and recorded. Included patients underwent biliary and abdominopelvic fluid drainage using 10.2-F catheters. Exclusion criteria included masking of contrast flow through sideholes by catheter angulation, contrast pooling or other imaging artifacts. RESULTS: A total of 99 patients meeting inclusion criteria underwent evaluation of contrast flow through pigtail (n = 81) and biliary (n = 18) catheters. For pigtail and biliary catheters, 91/99 cases (91.9%) showed contrast exiting the catheter from only the sidehole located most proximally to the catheter hub. In 6/99 cases (6.1%) contrast exited no further than the second most proximal sidehole. In 2/99 cases (2.0%) contrast exited no further than the third most proximal sidehole. In no cases was contrast observed exiting from distal sideholes beyond the third most proximal sidehole. CONCLUSION: Retrograde contrast injection through catheters suggests that the majority of the contribution to total output in drainage catheters comes from the most proximal side hole. Contribution of distal side holes to total drainage is negligible or non-existent, therefore the distal segment of the catheter may be considered non-functional.

Intracavitary ethanol ablation for the management of uterine hemorrhage refractory to uterine artery embolization.

A 57-year-old postmenopausal woman with end-stage liver disease secondary to alcoholic cirrhosis, esophageal varices, severe alcoholic cardiomyopathy, and metrorrhagia causing persistent anemia despite multiple transfusions presented with heavy vaginal bleeding. The patient underwent two uterine artery embolizations with proximal coils instead of directed particles due to difficult anatomy but the bleeding continued despite these interventions. Since she was a poor surgical candidate for hysterectomy, the decision was made to attempt achievement of hemostasis via ethanol injection into the uterine cavity. The patient's bleeding ceased, her hemoglobin and hematocrit stabilized post-procedure, and she was discharged home in stable condition.

Observations on failed retrieval of optional inferior vena cava filters.

PURPOSE: To evaluate causes of failed optional inferior vena cava filter (IVCF) retrievals. METHODS: Single-center retrospective study. RESULTS: IVCF retrievals were attempted in 26/211 (12%) patients at a mean 42.9 days. There were 9 failures (all OptEase) due to: inability to snare the hook (n=5), noncollapsible IVCF (n=3), and unusual procedural pain (n=1). Median duration of retrieved IVCFs was 31 days compared to 53 days for failures (P<.05). IVCFs aligned with the IVC's cephalocaudal axis were retrieved in 13/16 cases, while misaligned IVCFs were retrieved 4/10 cases (P<.05). CONCLUSION: Filter duration and misalignment were significantly associated with retrieval failures.

Ethanol ablation in postbiopsy liver hemorrhage following two failed embolizations.

A 42-year-old male presented with intraperitoneal hemorrhage 5days following percutaneous liver biopsy for suspected hepatocellular carcinoma. Diagnostic angiogram localized the bleeding to segment VI hepatic artery branches. Two consecutive arterial embolizations with microspheres and platinum coils failed to control the bleeding. The patient was a poor surgical candidate, so ultrasound-guided ethanol ablation of the bleeding source and surrounding liver segment was employed as salvage therapy. The patient stabilized clinically and was discharged home to begin palliative therapy.

Abscess-Fistula Complexes: A Systematic Approach for Percutaneous Catheter Management.

PURPOSE: To describe a systematic catheter management approach for treatment of abscesses with enteric fistulae by abscess evacuation and selective fistula tract cannulation in a series of patients with postprocedural abscess-fistula complexes. MATERIALS AND METHODS: This single-center retrospective study included 27 patients (17 male; mean age, 51.3 y) who underwent percutaneous drainage of postprocedural abscess-fistula complexes from January 2005 to September 2013. There were 15 low-output and 12 high-output fistulae. Intra-abdominal abscesses were evacuated by percutaneous drainage. Multiple catheters were used for collections with viscous fluid or size ≥ 6 cm in diameter. High-output fistulae and recurrent low-output fistulae had additional catheter cannulation of the enteric hole to facilitate the creation of a controlled enterocutaneous tract. There was no preexisting cutaneous tract before catheter insertion in 23 fistulae. RESULTS: Abscess-fistula complex resolution occurred in 24 patients (88.9%). Of the 3 cases of failure, 2 patients required surgical repair of the fistula, and 1 patient died. Mean number of drainage procedures was 7.0, and mean catheter duration was 76.1 days. There was no significant difference in catheter duration of low-output and high-output abscess-fistula complexes (P = .34); however, high-output patients underwent significantly more procedures (9.1 vs 6.1, P = .025). There were 15 fistulae that were cannulated (11 high-output and 4 low-output fistulae). Cannulated abscess-fistula complexes had significantly longer catheter duration (102.5 d vs 53.2 d, P = .04) and underwent significantly more procedures (8.4 vs 5.4, P = .04). CONCLUSIONS: The catheter management strategy was successful in resolving most abscess-fistula complexes in this series.

Torsed hepaticoileostomy-an unusual complication of Bile Duct injury repair.

We present a 42-year-old male with strictured bilioenteric anastomosis after bile duct injury repair. The patient improved after percutaneous biliary drainage and balloon dilation of the stricture. Persistent bile reflux around the catheter insertion site prompted a cholangiogram that suggested an error in the enteric limb. Surgical exploration revealed that a torsed ileal loop was used for bilioenteric anastomosis. This error was repaired surgically. The patient had immediate and long-term resolution of symptoms.

In vitro evaluation of the insertion force for different dilator tip configurations.

The purpose of this study was to evaluate the tissue penetration insertion force of different dilator tip geometries in simulated tissue. Four different dilator tip designs-conical (control), triangular, diamond, and biconvex-were appraised. The penetration force for each dilator was measured by using an ad hoc device. Each modified dilator required significantly less force necessary for "tissue" insertion compared with the conical control (P < .05 for all designs). These data suggest that angled dilator tips may facilitate insertion and may contribute to new dilator and catheter tip design.

Strategy for effective percutaneous drainage of pancreatic collections: results on 121 patients.

UNLABELLED: There is a lack of technical guidelines for image-guided percutaneous drainage (IGPD) of pancreatic fluid collections (PFCs). To fill that void, we present a strategy and guidelines for systematic IGPD for effective PFCs evacuation. METHODS: Institutional Review Board (IRB)-approved study of 121 pancreatitis patients with symptomatic PFCs that underwent IGPD. IGPD strategy aimed at evacuation of the PFCs compartments using vigorous catheter drainage and manipulations. PFCs resolution and patients' outcome were measured. RESULTS: Pancreatitis pathogenesis and etiology included: necrotizing, 79 patients (alcoholic, 40; biliary, 20; hyperlipidemia, 8; other, 11); traumatic, 32 patients; and chronic ductal, 10 patients (pseudocysts). An ipsilateral retroperitoneal access was used for pararenal spaces PFCs (61, 50% patients), a transabdominal IGPD approach for anterior PFCs (49 patients, 41%), an intercostal/subcostal access for left subphrenic PFCs (22 patients, 18%), and a transgastric drainage route for retrogastric PFCs (9 patients, 7%). Table 1 lists the site of the pancreatic fluid collections and number and size of the catheter(s) used for IGPD of the PFCs in the 121 patients. Fifty-seven (47%) patients had positive cultures PFCs. Of these, 24 (20%) had polymicrobial infections, and 18 (15%) had fungal infections. There were 20 (11%) patients with multi-compartment drainage. PFCs resolution occurred in 102 (84%) patients. PFCs recurrence was treated by surgery (four patients) or IGPD (one patient). Pancreatic fistulas closed, except in one patient. Nine patients (7%) experienced multiorgan failure/death; 5 (4%) were lost to follow-up.

Biliary spills and collections: causes, diagnosis, and multidisciplinary management.

PURPOSE: To evaluate the role of image-guided percutaneous interventions in patients with bile leaks and bile collections managed by a multidisciplinary team. MATERIAL & METHODS: Selection criteria included those patients from February 1999 to August 2007 who had bile leaks and bile collections in whom an image-guided procedure was performed. Ultrasound (US), computed tomography (CT), and nuclear medicine studies were used for diagnostic imaging. Patients were evaluated and managed in a multidisciplinary fashion by gastroenterologists, surgeons, and interventionists. Parameters measured in the study were drainage indications, cause and location of the biliary injury, location and size of bile collections, volume of fluid drained, fluid microbiology results, duration of catheterization, and patient outcome. Patients were followed up by the interventionist on daily rounds while inpatients and at the interventional clinic as outpatients. RESULTS: There were 31 patients who underwent image-guided percutaneous interventions as part of the management of bile leaks and bile collections. Causes of biliary injuries were surgical procedures, 18 patients (laparoscopic cholecystectomy, 11 patients; hepatectomy, 7 patients); abdominal trauma, 8 patients; percutaneous biliary procedures, 3 patients; liver abscess, 1 patient; gallbladder rupture, 1 patient. Bile collections were localized in 23 patients and diffuse in 8 patients. Localized collections were extrahepatic in 17 patients and intrahepatic in 6 patients. The size of the bile collections ranged from 4 to 12 cm (mean, 8 cm) in maximum diameter. The volume of fluid drained ranged from 25 mL to 4300 mL (mean, 915 mL). Microbiology studies showed sterile bile in 24 patients and bacterial infections in 7 patients. Duration of catheterization ranged from 3 days to 202 days (mean, 36 days). Of the 31 patients, 28 (90%) were cured from their condition and 3 (10%) patients died. Image-guided percutaneous interventions were able to resolve bile leaks and bile collections in 24 (86%) patients while 4 (14%) required additional procedures (endoscopic, 3 patients; surgery, 1 patient). CONCLUSION: Under multidisciplinary management, image-guided interventions are effective for resolution of most bile spills and collections. Additional endoscopic and surgical procedures are necessary when the percutaneous approach fails.