Angiographic Revascularization after Bariatric Embolization in a Swine Model.

This study evaluated fundal arteriole angiographic revascularization after embolization with embolic microspheres of 3 different diameters in a swine model (16 swine, 31 arterioles). In the 50-µm group, 7 of 11 (64%) arterioles recanalized completely, 3 of 11 (27%) arterioles recanalized partially, and 1 of 11 (9%) arterioles had collateralization (no recanalization). In the 100- to 300-µm group, 7 of 10 (70%) arterioles recanalized completely and 3 of 10 (30%) arterioles) recanalized partially. In the 300- to 500-µm group, 7 of 10 (70%) arterioles recanalized completely, 1 of 10 (10%) arterioles recanalized partially, and 2 of 10 (20%) arterioles had collateralization. No difference was found between the groups in the degree of recanalization (P = .64). All embolized arterioles exhibited some degree of angiographic revascularization, irrespective of the microsphere size.

ACR-ABS-ACNM-ASTRO-SIR-SNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies.

PURPOSE: The American College of Radiology (ACR), American Brachytherapy Society (ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology (ASTRO), Society of Interventional Radiology (SIR), and Society of Nuclear Medicine and Molecular Imaging (SNMMI) have jointly developed a practice parameter on selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Radioembolization is the embolization of the hepatic arterial supply of hepatic primary tumors or metastases with a microsphere yttrium-90 brachytherapy device. MATERIALS AND METHODS: The ACR -ABS -ACNM -ASTRO -SIR -SNMMI practice parameter for SIRT or radioembolization for treatment of liver malignancies was revised in accordance with the process described on the ACR website (https://www.acr.org/ClinicalResources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards-Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with ABS, ACNM, ASTRO, SIR, and SNMMI. RESULTS: This practice parameter is developed to serve as a tool in the appropriate application of radioembolization in the care of patients with conditions where indicated. It addresses clinical implementation of radioembolization including personnel qualifications, quality assurance standards, indications, and suggested documentation. CONCLUSIONS: This practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioemboliozation effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient.

Outcomes of Yttrium-90 Radioembolization for Unresectable Combined Biphenotypic Hepatocellular-Cholangiocarcinoma.

PURPOSE: To evaluate outcomes of yttrium-90 radioembolization in patients with combined biphenotypic hepatocellular-cholangiocarcinoma (cHCC-CC). MATERIALS AND METHODS: A retrospective review of patients with biopsy-confirmed cHCC-CC treated with yttrium-90 radioembolization between 2012 and 2018 was performed. Twenty-two patients with cHCC-CC (mean age 65.6 y, 17 men, 5 women) underwent 29 radioembolization treatments (5 resin, 24 glass microspheres). Survival data were available in 21 patients, and hepatic imaging response data were available in 20 patients. Hepatic imaging response to radioembolization was assessed on follow-up CT or MR imaging using modified Response Evaluation Criteria In Solid Tumours criteria. Univariate stepwise Cox regression analysis was used to evaluate the association between demographic and clinical factors and survival. Logistic regression evaluated associations between clinical factors and response to treatment, overall response, and disease control. RESULTS: Hepatic imaging response was as follows: 15% complete response, 40% partial response, 10% stable disease, and 35% progressive disease (55% response rate, 65% disease control rate). Two patients were downstaged or bridged to transplant, and 1 patient was downstaged to resection. Median overall survival was 9.3 mo (range, 2.5-31.0 mo) from time of radioembolization. Nonreponse to treatment, bilobar disease, presence of multiple tumors, and elevated carbohydrate antigen 19-9 before treatment were associated with reduced survival after radioembolization. CONCLUSIONS: Radioembolization is a viable option for locoregional control of cHCC-CC with good response and disease control rates.

Comparison of Response and Outcomes of Drug-eluting Bead Chemoembolization (DEB-TACE) Versus Radioembolization (TARE) for Patients With Colorectal Cancer Liver Metastases.

BACKGROUND: To compare outcomes for patients with colorectal cancer liver metastases (CRCLM) treated by drug-eluting bead chemoembolization (DEB-TACE) or radioembolization (TARE). PATIENTS AND METHODS: A single-center retrospective review was carried out on 202 patients with CRCLM, treated by DEB-TACE (n=47) or TARE (n=155) patients. Propensity-matching yielded 44 pairs. Paired statistical analysis was performed on matched pair demographics, treatment response, and survival. RESULTS: Patients treated with DEB-TACE had worse extra-hepatic metastasis (68.1 vs. 47.7%, p=0.014) and ≥10 liver lesions (42.2 vs. 68.8%, p=0.001). Matched patients treated with DEB-TACE had a trend towards worse toxicity (27% vs. 9.1% (p=0.057). Index DEB-TACE treatment was not a prognostic factor for overall survival (hazard ratio=0.94, 95% confidence intervaI=0.54-1.65; p=0.83). CONCLUSION: In the matched CRCLM cohort, there was a trend towards worse toxicity post-DEB-TACE treatment, but it was not an independent prognostic factor for survival.

Factors influencing selection of an interventional radiology training program.

PURPOSE: To understand factors influencing the choice and ranking of Interventional Radiology (IR) training programs among a cohort of medical students and diagnostic radiology residents pursuing careers in IR. MATERIALS AND METHODS: An IRB approved, 34 question online survey (surveymonkey.com) evaluated the impact of twenty-two different factors and demographics on IR training program selection for medical students and residents. The factors analyzed included programmatic features, location characteristics, academic reputation, program size, benefits/financial incentives, emphasis on clinical care, and future job opportunities. Comparison of Likert scale responses between medical students and residents were performed by using unpaired two-sample t-tests. RESULTS: 181 (145 male, 35 female) individuals responded to the survey, 74 medical students (40.9%) and 107 residents (59.1%). Medical students and residents both selected variety of IR cases as the most important and highest rated factor when choosing an IR program. Medical students ranked availability of a mentor (p = .03), inpatient consultation service (p = .003), outpatient clinic experience (p = .003), and ICU rotation experience (p < .001) significantly higher. Residents rated job placement/accomplishments of prior fellows (p = .03) and opinion of spouse/significant others (p = .002) significantly higher than medical students. CONCLUSIONS: The top rated factors are similar among medical students and residents however medical students value the clinical aspects of the program (ICU experience, inpatient consultation service, outpatient clinic) more than residents. Residents placed more value on job placement opportunities in selecting an IR program.

Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance.

PURPOSE: To compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). MATERIALS AND METHODS: A retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. RESULTS: Radiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. CONCLUSION: iTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.

Cryoablation of low-flow vascular malformations.

PURPOSE: We aimed to evaluate the safety and effectiveness of cryoablation in the treatment of low-flow malformations, specifically venous malformation (VM) and fibroadipose vascular anomaly (FAVA). METHODS: We conducted a retrospective review of 11 consecutive patients with low-flow malformations (14 lesions; 9 VM, 5 FAVA), median lesion volume 10.8 cm3, (range, 1.8-55.6 cm3) with a median age of 19 years (range, 10-50 years) who underwent cryoablation to achieve symptomatic control. Average follow-up was at a median of 207 days postprocedure (range, 120-886 days). Indications for treatment included focal pain and swelling. Technical success was achieved if the cryoablation ice ball covered the region of the malformation that corresponded to the patient's symptoms. Clinical success was considered complete if all symptoms resolved and partial if some symptoms persisted but did not necessitate further treatment. RESULTS: The technical success rate was 100%. At 1-month follow-up, 13 of 14 lesions (93%) had a complete response and one (7%) had a partial response. At 6-month follow-up 12 of 13 (92%) had a complete response and 1 (8%) had a partial response. A total of 6 patients underwent primary cryoablation. Out of 9 VM cases, 7 had prior sclerotherapy and 2 had primary cryoablation. Out of the 5 FAVA cases, 1 had prior sclerotherapy and the remaining 4 cases underwent primary cryoablation. There were 3 minor complications following cryoablation including 2 cases of skin blisters and 1 case of transient numbness. These complications resolved with conservative management. CONCLUSION: Cryoablation is safe and effective in the treatment of low-flow vascular malformations, either after sclerotherapy or as primary treatment.

Using principal component analysis for the prediction of tumor response to transarterial chemoembolization.

PURPOSE: To quantitate the tumor blush of hepatocellular carcinoma (HCC) at the time of transarterial chemoembolization (TACE) using principal component analysis (PCA), and to correlate the quantitated tumor blush to response to therapy. MATERIALS AND METHODS: In this proof-of-concept study, 27 primary HCC tumors in 25 patients (18 men, 7 women; mean age 66 years ± 9) were analyzed. We conducted a retrospective analysis of TACE procedures that were performed during March through July of 2017. Digital subtraction angiography (DSA) was combined with PCA to condense spatial and temporal information into a single image. The tumor and liver contrast enhancements were calculated, and the ratio was used to determine the relative vascular enhancement of the tumor. Tumor response to therapy was determined at 1-month post procedure. RESULTS: Using PCA-generated fluoroscopic imaging (PCA-FI), we quantitated the tumor blush and assigned a vascular enhancement value (VEV) to each tumor. Tumors that responded to treatment (N = 12) had statistically higher VEVs compared with the nonresponders (N = 15), with a mean value of 0.96 ± 0.455 vs. 0.57 ± 0.309, (p = 0.013). CONCLUSIONS: We developed a method for quantitating tumor blush using routine angiographic images. The VEVs calculated using these images may allow for the prediction of tumor response to therapy. This pilot study suggests that there is a correlation between tumor blush intensity and tumor response.

Bariatric Embolization of Arteries for the Treatment of Obesity (BEAT Obesity) Trial: Results at 1 Year.

Background Bariatric embolization is a new endovascular procedure to treat patients with obesity. However, the safety and efficacy of bariatric embolization are unknown. Purpose To evaluate the safety and efficacy of bariatric embolization in severely obese adults at up to 12 months after the procedure. Materials and Methods For this prospective study (NCT0216512 on ClinicalTrials.gov ), 20 participants (16 women) aged 27-68 years (mean ± standard deviation, 44 years ± 11) with mean body mass index of 45 ± 4.1 were enrolled at two institutions from June 2014 to February 2018. Transarterial embolization of the gastric fundus was performed using 300- to 500-µm embolic microspheres. Primary end points were 30-day adverse events and weight loss at up to 12 months. Secondary end points at up to 12 months included technical feasibility, health-related quality of life (Short Form-36 Health Survey ([SF-36]), impact of weight on quality of life (IWQOL-Lite), and hunger or appetite using a visual assessment scale. Analysis of outcomes was performed by using one-sample t tests and other exploratory statistics. Results Bariatric embolization was performed successfully for all participants with no major adverse events. Eight participants had a total of 11 minor adverse events. Mean excess weight loss was 8.2% (95% confidence interval [CI]: 6.3%, 10%; P < .001) at 1 month, 11.5% (95% CI: 8.7%, 14%; P < .001) at 3 months, 12.8% (95% CI: 8.3%, 17%; P < .001) at 6 months, and 11.5% (95% CI: 6.8%, 16%; P < .001) at 12 months. From baseline to 12 months, mean SF-36 scores increased (mental component summary, from 46 ± 11 to 50 ± 10, P = .44; physical component summary, from 46 ± 8.0 to 50 ± 9.3, P = .15) and mean IWQOL-Lite scores increased from 57 ± 18 to 77 ± 18 (P < .001). Hunger or appetite decreased for 4 weeks after embolization and increased thereafter, without reaching pre-embolization levels. Conclusion Bariatric embolization is well tolerated in severely obese adults, inducing appetite suppression and weight loss for up to 12 months. Published under a CC BY-NC-ND 4.0 license. Online supplemental material is available for this article.

Embolization of a congenital arteriovenous malformation arising off the internal mammary artery.

Congenital arteriovenous malformations (AVM) of the internal mammary artery (IMA) are exceptionally rare. Patients with AVMs arising off the left IMA may present with continuous precordial murmurs and/or a pulsatile chest mass. AVMs in this location pose a risk of enlargement, rupture, infection, or high-output cardiac failure. The potential risks associated with AVMs warrant early therapeutic intervention. We describe a case of a congenital AVM originating from the left IMA, which was successfully embolized with n­butyl cyanoacrylate (NBCA) using a transcatheter arterial approach.

Radiofrequency Ablation vs. Cryoablation for Localized Hepatocellular Carcinoma: A Propensity-matched Population Study.

BACKGROUND/AIM: To compare overall survival (OS) and liver cancer-specific survival (LCSS) of Surveillance, Epidemiology and End Results (SEER) hepatocellular carcinoma (HCC) database patients treated with cryoablation (cryo) or radiofrequency ablation (RFA). MATERIALS AND METHODS: This was a retrospective review of Stage I or II HCC patients from the SEER database treated with cryo and RFA from 2004-2013. Kaplan-Meier and Cox regressions were performed on pooled and propensity-matched cohort. RESULTS: Out of 3,239 patients, RFA showed a significant survival advantage over cryo in liver cancer specific survival (LCSS) (HR=1.634 p=0.0004). A total of 91 propensity-matched pairs had similar OS (HR=1.006 p=0.9768), but no difference in LCSS was observed between the groups [HR=1.412 (95%CI=0.933-2.137) p=0.1023]. Survival Cox models did not reveal treatment type as an independent prognostic factor. CONCLUSION: Propensity-matched cohort showed no significant difference in terms of OS and LCSS was found for patients treated with either cryo or RFA for localized HCC.

SEER study of ablation versus partial nephrectomy in cT1A renal cell carcinoma.

AIM: Compare ablation versus partial nephrectomy (PN) in T1A renal cell carcinoma (RCC) treatment, using the SEER database. METHODS: Patients with diagnosed T1A RCC from 2004 to 2013 were identified. Propensity matching paired subjects with similar background variables. Kaplan-Meier and Cox proportional hazards regression were performed before and after matching. RESULTS: Cohort included 4592 patients (809 ablation, 3783 PN). PN compared with ablation group had significantly increased overall survival (OS; 93.6% vs 81.9% 5-year survival; p < 0.0001) and cancer-specific survival (CSS; p < 0.0001). After matching (1222 pairs), PN group had significantly increased OS (91.0% vs 86.3% 5-year survival; p = 0.0457) but similar CSS (p = 0.4023). CONCLUSION: Ablation offers similar CSS but lower OS as PN for T1A RCC in this SEER database.

Analysis of weight changes after left gastric artery embolization in a cancer-naive population.

PURPOSE: We aimed to evaluate weight changes after left gastric artery (LGA) embolization in a retrospective cancer-naive cohort. METHODS: A retrospective study was conducted to identify patients who underwent LGA embolization for gastrointestinal bleeding (GI). Patients with known cancer diagnoses at the time of LGA embolization were excluded. Pre- and postprocedure weights were assessed. Statistical analysis was performed using paired t-test and Wilcoxon signed-rank test. RESULTS: A total of 39 patients were identified. In 21 patients who had documented pre- and postprocedural weights, a median of 16.3 kg weight loss (P = 0.045) was observed over a median time of 12 months (range, 2-72). In patients who had pre- and postprocedure endoscopies (n=6), 2 had worsening ulcers following LGA embolization and 4 had stable or no abnormal findings. CONCLUSION: Our preliminary observation suggests that LGA embolization is well tolerated and results in unintended weight loss. Larger studies are needed to confirm these preliminary findings.

Acute Lower Extremity Deep Venous Thrombosis: The Data, Where We Are, and How It Is Done.

The incidence of venous thromboembolism, including both deep vein thrombosis and pulmonary embolism, is estimated at 300,000-600,000 per year. Although thrombosis may occur anywhere, it is thrombosis of the deep veins of the lower extremities that is of interest as this is where thrombosis occurs most often within the venous system. This article discusses the evaluation and interventions, including endovascular catheter-direct treatments, for patients with acute deep venous thrombosis.

Liver-dominant Breast Cancer Metastasis: A Comparative Outcomes Study of Chemoembolization Versus Radioembolization.

AIM: To compare toxicity, response, and survival outcomes of patients with hepatic metastases from breast cancer who underwent transarterial chemoembolization (TACE) or radioembolization (TARE). MATERIALS AND METHODS: A retrospective review was carried out of all patients who underwent TACE or TARE for liver-dominant breast cancer metastases between January 2006 and March 2016 at an academic medical center in the United States. RESULTS: Seventeen patients in the TACE group and 30 patients in the TARE group received 32 TACE and 49 TARE treatments, respectively. Median follow-up was 9 months. Both groups had similar background variables. More all-grade adverse events were seen in the TACE group (71% vs. 44%; p=0.02). Median overall survival in the TACE group was 4.6 months compared to 12.9 months in the TARE group (p=0.2349). Treatment type was not an independent prognostic factor. CONCLUSION: TARE is better tolerated than TACE for the treatment of liver-dominant breast cancer metastasis. There was a trend towards improved survival with TARE; however, it did not approach statistical significance. Larger studies are needed to validate these findings.

Survival comparison of hepatocellular carcinoma patients treated with radioembolization versus nonoperative/interventional treatment.

AIM: To compare the overall survival (OS) and liver cancer-specific survival of advanced-stage hepatocellular carcinoma (HCC) patients who received transarterial radioembolization (TARE) with those who received nonoperative/interventional treatment (NOT). MATERIALS & METHODS: A total of 12,520 HCC patients from the Surveillance, Epidemiology and End Results database were categorized by treatment with either radioembolization or NOT. Kaplan-Meier and multivariate Cox regression were conducted. RESULTS: The TARE group had both a significantly longer median overall survival than the NOT group (TARE = 9 months; NOT = 2 months; p < 0.0001) and a significantly higher probability of liver cancer-specific survival (hazard ratio = 0.474). CONCLUSION: TARE appears to provide a significant survival advantage over the NOT population in advanced HCC patients.

Thermal ablation versus surgical resection for localized hepatocellular carcinoma: a population study using the SEER database.

AIM: To compare overall survival (OS) and liver cancer-specific survival (LCSS) in patients with localized hepatocellular carcinoma treated with surgical resection (SR) or thermal ablation (TA) using the Surveillance, Epidemiology and End Results database. MATERIALS & METHODS: Kaplan-Meier, competing risk and Cox regression analyses were performed after identifying patients. Propensity score matching was then applied. RESULTS: There was significantly better OS in the SR group and significantly lower probability of LCSS in the TA group. After matching, there was significantly longer OS in the SR group and a lower probability of LCSS in the TA group. CONCLUSION: SR offered a significant survival benefit over TA for localized hepatocellular carcinoma.

Endovascular Management of SVC Syndrome due to Fibrosing Mediastinitis-A Feasibility and Safety Analysis.

PURPOSE: To assess the outcomes of endovascular management for superior vena cava (SVC) syndrome secondary to fibrosing mediastinitis (FM). METHODS: Between January 2004 and December 2016, 10 consecutive patients with endovascularly managed SVC syndrome secondary to FM were identified in an institutional database. Venograms were performed to assess the severity and location of the lesion and allow measurement for stent selection. Standard stenting and angioplasty techniques were utilized to establish luminal patency. The safety, feasibility, clinical success, and the primary and secondary patency were evaluated. Kaplan-Meier survival analysis was used to determine median duration of stent patency. A log-rank test was used to test differences in prior stent use. RESULTS: Our cohort was predominantly female (7/10) with an average age of 42.2 years. Of the 10 patients, 3 had undergone endovascular stenting at an outside institution prior to referral to our institution due to new, recurrent, or worsening symptoms. All patients underwent venography demonstrating stenosis (8/10) or occlusion (2/10) at initial presentation. Stenting or angioplasty was technically successful in 9 (90.0%) patients. Eight of 10 patients had primary stenting, while 1 achieved vascular patency and symptom resolution with angioplasty alone. Median duration of primary patency was 31.3 months (95% confidence interval: 5.9-103). Six (54.5%) patients required secondary revision procedures. Median duration of secondary patency was 6.1 months, with 25% of revisions occurring by 4 months and 75% occurring by 20.9 months. All treated patients (9/9) reported symptomatic relief at 1-month follow-up, establishing a clinical success rate of 100%. There were no 30-day adverse effects related to the procedure. CONCLUSION: This study demonstrates that endovascular therapy is a safe and feasible approach for managing FM-related SVC syndrome.

Renal Embolization: Current Recommendations and Rationale for Clinical Practice.

PURPOSE OF REVIEW: Renal embolization (RE) is a minimally invasive endovascular procedure performed primarily by interventional radiology that can be used to treat a variety of urologic conditions including malignant renal tumors, angiomyolipomas, renal trauma, and complications following biopsy. The following review examines renal embolization indications, technique, and potential complications. RECENT FINDINGS: Renal embolization is a versatile therapeutic and adjunctive tool for many acute and chronic urologic conditions. RE has become a first-line therapy for renal trauma in lower grade injuries and increasing in prevalence for higher grade injuries. Additionally, the safety and efficacy of chemoembolization for primary treatment of renal cell carcinoma is under evaluation. A multidisciplinary approach between urology and interventional radiology should be pursued for all patients undergoing renal embolization regardless of indication. Preprocedural planning and careful monitoring of complications should be performed to optimize clinical outcomes.

Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO).

Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of various modified BRTO techniques.