ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update.

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up.

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Multi-institutional Retrospective Study of Percutaneous Cholangioscopy-Assisted Lithotripsy for Inoperable Calculous Cholecystitis.

PURPOSE: This study aimed to assess the safety and efficacy of percutaneous lithotripsy for gallstone eradication in patients with calculous cholecystitis with stones >1 cm. MATERIALS AND METHODS: Multi-institutional institutional review board approved retrospective review of patients who presented with calculous cholecystitis and were not determined to be surgical candidates. All patients underwent percutaneous cholecystostomy tube placement for acute infection, which was later exchanged for a large sheath for ShockPulse (Olympus, Tokyo, Japan) lithotripsy and stone destruction. Review parameters included procedural technical and clinical data, including clinical presentation, mean length of hospital stay, and postintervention symptom reduction. RESULTS: Twelve patients (mean age, 74.6 years; range, 52-94 years; 6 men and 6 women) underwent large-bore sheath (24-30 F) cholangioscopy-assisted gallstone destruction via rigid lithotripsy. The size of the gallstones ranged from 1.2 to 4.0 cm. All patients had prior cholecystostomy access for a mean of 25 weeks before gallstone extraction to ensure tract maturation via transhepatic or transperitoneal access. The technical success rate in single-session stone removal was 100%, with no major procedure-related adverse events. All patients were symptom- and pain-free after the procedure. The mean procedure time was 111.5 minutes, and the mean fluoroscopy time was 19.2 minutes. The median length of hospital stay was 1 day after the procedure. The mean time from percutaneous lithotripsy to biliary tube removal was 35 days (range, 17-45 days). CONCLUSIONS: Fluoroscopy-guided percutaneous rigid lithotripsy is a safe and effective procedure for gallstone destruction and extraction in patients who are poor surgical candidates with large lumen-occupying cholelithiasis.

Predictors of biliary intervention in patients hospitalized for COVID-19.

BACKGROUND: Gastrointestinal complications of coronavirus disease-2019 (COVID-19) include abnormal liver function and acalculous cholecystitis. Cholecystostomy performed during the COVID-19 pandemic reflected a shift toward non-surgical treatment of cholecystitis and increased number of critically ill patients suffering from acalculous cholecystitis. PURPOSE: (1) To determine demographic, clinical, laboratory, and ultrasound features associated with cholecystostomy placement during hospitalization for COVID-19. (2) To develop multivariable logistic regression modeling for likelihood of biliary intervention. METHODS: This retrospective review received institutional review board approval. Informed consent was waived. Between March 2020 and June 2020, patients with confirmed SARS-CoV2 infection admitted to New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, NYP/Lower Manhattan Hospital, and NYP/Queens were evaluated for inclusion in this study. Inclusion criteria were (1) patient age ≥ 18, (2) confirmed COVID-19 infection by polymerase chain reaction testing of a nasopharyngeal swab, and (3) abdominal ultrasound performed during hospitalization. Exclusion criteria were (1) history of cholecystectomy and (2) biliary intervention performed prior to abdominal ultrasound. Patients were stratified into two groups based on whether they received cholecystostomy during hospitalization. Differences in demographics, medical history, clinical status, medications, laboratory values, and ultrasound findings between the two groups were evaluated using Chi-square test or Fisher's exact test for categorical variables and t test or Wilcoxon-rank sum test for continuous variables. Multivariable logistic regression was used to model likelihood of biliary intervention. RESULTS: Nine patients underwent cholecystostomy placement and formed the "Intervention Group." 203 patients formed the "No Intervention Group." Liver size and diuretics use during hospitalization were the only variables which were significantly different between the two groups, with p-values of 0.02 and 0.046, respectively. After controlling for diuretics use, the odds of receiving cholecystostomy increased by 30% with every centimeter increase in liver size (p = 0.03). ICU admission approached significance (p = 0.16), as did mechanical ventilation (p = 0.09), septic shock (p = 0.08), serum alkaline phosphatase level (p = 0.16), and portal vein patency (0.14). CONCLUSION: Patients requiring biliary intervention during hospital admission for COVID-19 were likely to harbor liver injury in the form of liver enlargement and require diuretics use.

Percutaneous evacuation of anterior abdominal wall hematomas using catheter-based mechanical thrombectomy.

Post-operative hematoma is a common surgical complication, often treated conservatively. However, persistent, recurrent or symptomatic hematomas may require percutaneous or surgical drainage. The authors present two cases of persistent post-surgical hematomas which were successfully evacuated in a single-setting using a percutaneous mechanical thrombectomy system.

Role of interventional radiology in the treatment of COVID-19 patients: Early experience from an epicenter.

OBJECTIVE: To highlight the role of interventional radiology (IR) in the treatment of patients hospitalized with coronavirus disease 2019 (COVID-19). METHODS: Retrospective review of hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and had one or more IR procedures at a tertiary referral hospital in New York City during a 6-week period in April and May of 2020. RESULTS: Of the 724 patients admitted with COVID-19, 92 (12.7%) underwent 124 interventional radiology procedures (79.8% in IR suite, 20.2% at bedside). The median age of IR patients was 63 years (range 24-86 years); 39.1% were female; 35.9% in the intensive care unit. The most commonly performed IR procedures were central venous catheter placement (31.5%), inferior vena cava filter placement (9.7%), angiography/embolization (4.8%), gastrostomy tube placement (9.7%), image-guided biopsy (10.5%), abscess drainage (9.7%), and cholecystostomy tube placement (6.5%). Thoracentesis/chest tube placement and nephrostomy tube placement were also performed as well as catheter-directed thrombolysis of massive pulmonary embolism and thrombectomy of deep vein thrombosis. General anesthesia (10.5%), monitored anesthesia care (18.5%), moderate sedation (29.8%), or local anesthetic (41.1%) was utilized. There were 3 (2.4%) minor complications (SIR adverse event class B), 1 (0.8%) major complication (class C), and no procedure-related death. With a median follow-up of 4.3 months, 1.1% of patients remain hospitalized, 16.3% died, and 82.6% were discharged. CONCLUSION: Interventional radiology participated in the care of hospitalized COVID-19 patients by performing a wide variety of necessary procedures.

Three-Dimensional Printing for Procedure Rehearsal/Simulation/Planning in Interventional Radiology.

With the advances in affordable three-dimensional (3D) printing technology, 3D reconstruction and patient-specific 3D printed models are establishing a crucial role in the field of medicine for both educational purposes and procedural planning. 3D printed models provide physicians with increased 3D perception and tactile feedback, and enable a team-based approach to operational planning. However, performing an effective 3D reconstruction requires an in-depth understanding of the software features to accurately segment and reconstruct the human anatomy of interest from preacquired image data from multiple modalities such as computer tomography, 3D angiography and magnetic resonance imaging, and the different 3D printers/materials available in the market today. Increased understanding of this technology may benefit radiologists by developing techniques and tricks specific to interventional radiology and establishing a criterion to determine when to use these. Thus, the purpose of this manuscript is to provide physicians with an update on currently available 3D reconstruction software as well as printers and materials. Our initial experience using this technology is introduced based on a specific case of developing a 3D printed aorta for a patient with severe stenosis of the abdominal aorta.

Discovery of Tirasemtiv, the First Direct Fast Skeletal Muscle Troponin Activator.

The identification and optimization of the first activators of fast skeletal muscle are reported. Compound 1 was identified from high-throughput screening (HTS) and subsequently found to improve muscle function via interaction with the troponin complex. Optimization of 1 for potency, metabolic stability, and physical properties led to the discovery of tirasemtiv (25), which has been extensively characterized in clinical trials for the treatment of amyotrophic lateral sclerosis.

Gadofosveset trisodium-enhanced MR angiography for detection of lower gastrointestinal bleeding.

The purpose of our study is to determine if Gadofosveset trisodium-enhanced magnetic resonance angiography (MRA) could be used for detection and localization of acute lower gastrointestinal (LGI) bleed. Four patients underwent MRA (4 females, mean age of 65 years) for suspected LGI bleeding. MRA detected an active rectal bleed in one patient. All other patients did not demonstrate active bleeding and these true negatives were confirmed by computed tomography angiography, endoscopy, and tagged-red blood cell scan or digital subtraction angiography. Preliminary results suggest that MRA may serve as an alternative technique for detecting acute LGI bleeding when nuclear scintigraphy is unavailable or in the younger radiosensitive population but further investigation in a larger cohort is required.

Activation of fast skeletal muscle troponin as a potential therapeutic approach for treating neuromuscular diseases.

Limited neural input results in muscle weakness in neuromuscular disease because of a reduction in the density of muscle innervation, the rate of neuromuscular junction activation or the efficiency of synaptic transmission. We developed a small-molecule fast-skeletal-troponin activator, CK-2017357, as a means to increase muscle strength by amplifying the response of muscle when neural input is otherwise diminished secondary to neuromuscular disease. Binding selectively to the fast-skeletal-troponin complex, CK-2017357 slows the rate of calcium release from troponin C and sensitizes muscle to calcium. As a consequence, the force-calcium relationship of muscle fibers shifts leftwards, as does the force-frequency relationship of a nerve-muscle pair, so that CK-2017357 increases the production of muscle force in situ at sub-maximal nerve stimulation rates. Notably, we show that sensitization of the fast-skeletal-troponin complex to calcium improves muscle force and grip strength immediately after administration of single doses of CK-2017357 in a model of the neuromuscular disease myasthenia gravis. Troponin activation may provide a new therapeutic approach to improve physical activity in diseases where neuromuscular function is compromised.