Safety and Effectiveness of Portal Vein Embolization after Hepatic Arterial Infusion Therapy.

Portal vein embolization (PVE) is a tool potentially useful for inducing future liver remnant (FLR) hypertrophy in patients with advanced hepatic malignancies who are at high risk of hepatic insufficiency if treated with surgical resection. However, the safety and effectiveness of PVE in the context of patients who have undergone hepatic arterial infusion (HAI) are unknown. This retrospective, single-center study identified 9 patients who underwent PVE after HAI between January 2015 and December 2022. There were no major adverse events, including biliary injury or high-grade liver failure. Analysis showed an increase in standardized FLR from 21.1% (SEM ± 2.4) to 34.8% (SEM ± 2.1) over 9.8 weeks (SEM ± 1.2), with a mean kinetic growth rate of 1.9% (interquartile range, 0.9%-2.4%). Patients who have undergone HAI therapy should not be excluded from consideration of PVE as part of their operative clearance strategy.

Irreversible Electroporation of the Hepatobiliary System: Current Utilization and Future Avenues.

Liver cancer remains a leading cause of cancer-related deaths worldwide despite numerous advances in treatment. While surgical resection remains the gold standard for curative treatment, it is only possible for a minority of patients. Thermal ablation is an effective option for the treatment of smaller tumors; however, its use is limited to tumors that are not located in proximity to sensitive structures due to the heat sink effect and the potential of thermal damage. Irreversible electroporation (IRE) is a non-thermal ablative modality that can deliver targeted treatment and the effective destruction of tumors that are in close proximity to or even surrounding vascular or biliary ducts with minimal damage to these structures. IRE produces short pulses of high-frequency energy which opens pores in the lipid bilayer of cells leading to apoptosis and cell death. IRE has been utilized clinically for over a decade in the treatment of liver cancers with multiple studies documenting an acceptable safety profile and high efficacy rates.

The multidisciplinary management of cholangiocarcinoma.

Cholangiocarcinoma is a lethal malignancy of the biliary epithelium that can arise anywhere along the biliary tract. Surgical resection confers the greatest likelihood of long-term survivability. However, its insidious onset, difficult diagnostics, and resultant advanced presentation render the majority of patients unresectable, highlighting the importance of early detection with novel biomarkers. Developing liver-directed therapies and emerging targeted therapeutics may offer improved survivability for patients with unresectable or advanced disease. In this article, the authors review the current multidisciplinary standards of care in resectable and unresectable cholangiocarcinoma, with an emphasis on novel biomarkers for early detection and nonsurgical locoregional therapy options.

Upper Extremity Deep Venous Thrombosis: Etiologies, Diagnosis, and Updates in Therapeutic Strategies.

Upper extremity deep vein thrombosis (UEDVT) is responsible for 4 to 10% of all deep vein thrombosis (DVT). Untreated UEDVT can lead to significant disability secondary to the postthrombotic syndrome. To date, there are no randomized trials specifically comparing different therapeutic strategies. Ultimately, optimal management of UEDVT depends on the underlying etiology, patient symptoms, and degree of thrombosis, with supporting evidence primarily extrapolated from lower extremity DVT data. This article will review the classification, presentation, and diagnosis of both primary and secondary UEDVT. In addition, it will discuss updates in clinical guidelines, anticoagulation, endovascular and surgical treatment strategies.

Therapy Resistant Gastroenteropancreatic Neuroendocrine Tumors.

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a heterogenous group of malignancies originating from neuroendocrine cells of the gastrointestinal tract, the incidence of which has been increasing for several decades. While there has been significant progress in the development of therapeutic options for patients with advanced or metastatic disease, these remain limited both in quantity and durability of benefit. This review examines the latest research elucidating the mechanisms of both up-front resistance and the eventual development of resistance to the primary systemic therapeutic options including somatostatin analogues, peptide receptor radionuclide therapy with lutetium Lu 177 dotatate, everolimus, sunitinib, and temozolomide-based chemotherapy. Further, potential strategies for overcoming these mechanisms of resistance are reviewed in addition to a comprehensive review of ongoing and planned clinical trials addressing this important challenge.

Genicular Artery Embolization for Primary Knee Osteoarthritis.

Genicular artery embolization (GAE) is a novel treatment for knee osteoarthritis (OA) with increasing interest and utilization worldwide. The genicular arteries are selectively embolized using microspheres with subsequent cessation of abnormal synovial hyperemia, a process believed to arrest the inflammatory changes and pain associated with OA. Current data indicate that GAE offers sustained, 6-month improvement in Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) and visual analog scale scores in 80 to 85% of patients with mild to moderate OA. As GAE gains traction, future studies are needed to establish its safety and efficacy relative to placebo and other standard-of-care therapies while also characterizing populations for which it is most effective.

Alternative Access for Peripheral Arterial Disease: A Complete Review with Updates in Clinical and Technical Approaches.

Multiple or alternate arterial accesses are often required when tackling more challenging peripheral arterial disease (PAD). Knowledge and familiarity in performing antegrade femoral, popliteal, tibial, and upper extremity access can improve the success rate of complex PAD interventions. This article provides a detailed review of indications, technical how-tos, and outcomes of these alternative accesses.

Multicenter assessment of augmented reality registration methods for image-guided interventions.

PURPOSE: To evaluate manual and automatic registration times and registration accuracies on HoloLens 2 for aligning a 3D CT phantom model onto a CT grid, a crucial step for intuitive 3D navigation during CT-guided interventions; to compare registration times between HoloLens 1 and 2. METHODS: Eighteen participants in various stages of clinical training across two academic centers performed registration of a 3D CT phantom model onto a CT grid using HoloLens 2. Registration times and accuracies were compared among different registration methods, clinical experience levels, and consecutive attempts. Registration times were also compared retrospectively to prior HoloLens 1 results. RESULTS: Mean aggregate manual registration times were 27.7 s, 24.3 s, and 72.8 s for one-handed gesture, two-handed gesture, and Xbox controller, respectively; mean automatic registration time was 5.3 s (ANOVA p < 0.0001). No significant difference in registration times was found among attendings, residents and fellows, and medical students (p > 0.05). Significant improvements in registration times were detected across consecutive attempts using hand gestures (p < 0.01). Compared to prior HoloLens 1 data, hand gesture registration was 81.7% faster with HoloLens 2 (p < 0.05). Registration accuracies were not significantly different across manual registration methods, measuring at 5.9 mm, 9.5 mm, and 8.6 mm with one-handed gesture, two-handed gesture, and Xbox controller, respectively (p > 0.05). CONCLUSIONS: Manual registration times decreased significantly on HoloLens 2, approaching those of automatic registration and outperforming Xbox controller registration. Fast, adaptive, and accurate registration of holographic models of cross-sectional imaging is paramount for the implementation of augmented reality-assisted 3D navigation during CT-guided interventions.

Irreversible electroporation for colorectal cancer liver metastasis: a review.

Irreversible electroporation (IRE) ablation is gaining popularity over the last decade as a nonthermal alternative to thermal ablation technologies such as radiofrequency ablation (RFA) and Microwave ablation (MWA). This review serves as a practical guide for applying IRE to colorectal cancer liver metastases (CRLM) for interventional radiologists, oncologists, surgeons, and anesthesiologists. It covers patient selection, procedural technique, anesthesia, imaging, and outcomes.

Gastrointestinal Computed Tomography Findings in Chronic Granulomatous Disease with Subgroup Clinicopathologic Analysis.

BACKGROUND: Chronic granulomatous disease (CGD) is a rare primary immunodeficiency which can lead to gastrointestinal (GI) complications including inflammatory bowel disease. Radiographic findings in this cohort have not been well described. AIMS: To describe the frequency and spectrum of gastrointestinal abnormalities seen on computed tomography (CT) in patients with CGD and determine whether radiography was predictive of endoscopic or histopathologic inflammatory findings. METHODS: A retrospective review was conducted on 141 consecutive CGD patients seen at the National Institutes of Health between 1988 and 2011. All corresponding CTs were reviewed for gastrointestinal abnormalities including wall thickening. Endoscopic and histopathologic findings were reviewed in subjects with documented endoscopy within 30 days of an imaging study. Findings were compared between patients with and without wall thickening on CT to determine whether bowel wall thickening was predictive of endoscopic or histologic inflammatory findings. RESULTS: Two hundred and ninety-two CTs were reviewed. GI wall thickening was present on CT in 61% of patients (n = 86). Among a subgroup of 20 patients who underwent endoscopy at the time of their imaging, there was a statistically significant correlation between radiographic gastrointestinal wall thickening and endoscopic inflammation in the same intestinal segment (p = 0.035). Additionally, there was a significant correlation between radiographic gastrointestinal wall thickening and inflammatory features on histopathology (p = 0.02). CONCLUSIONS: GI abnormalities are commonly observed on CT in CGD patients. Bowel wall thickening correlates with endoscopic and histopathologic evidence of inflammation. These findings may be used to better facilitate directed endoscopic assessment and histopathologic sampling in patients with CGD.

Percutaneous Therapies for Hepatocellular Carcinoma: Evolution of Liver Directed Therapies.

Percutaneous ablation is a mainstay of treatment for early stage, unresectable hepatocellular carcinoma (HCC). Recent advances in technology have created multiple ablative modalities for treatment of this common malignancy. The purpose of this review is to familiarize readers with the technical and clinical aspects of both existing and emerging percutaneous treatment options for HCC.

"How We Do It" - A Practical Approach to Percutaneous Adrenal Ablation Techniques.

Incidental adrenal masses are common and are found in 4% of the CT scans.1 While clinical history, laboratory results, and imaging characteristics are typically sufficient for diagnosis of an adrenal lesion, a biopsy is sometimes warranted. In some cases, adrenal mass ablation is subsequently indicated. This article serves as a brief but comprehensive review of preprocedural work-up and planning before an adrenal mass ablation, as well as a discussion on ablation techniques, associated challenges and solutions, and management of expected and unexpected outcomes.

Bridging the Gender Gap in the Society of IR: A Benchmark Study.

PURPOSE: To evaluate the evolving representation of women in the Society of Interventional Radiology (SIR). MATERIALS AND METHODS: A retrospective review of the available gender demographic data of various SIR subgroups between 2008 and 2017 was performed. The gender makeup of the following groups was analyzed: SIR membership, SIR Executive Council members and officers, Annual Meeting invited speakers, committee chairs, Journal of Vascular and Interventional Radiology (JVIR) first and senior authors, JVIR editorial board, IR Quarterly (IRQ) authors, and active interventional radiology (IR) residents and fellows. RESULTS: From 2008 to 2017, the percentage of female representation in SIR members doubled (from 6% to 13.1%). In the same period, female representation also significantly increased in Executive Council members (0% to 20%) and officers (0% to 50%), SIR Annual Meeting presenters (5.1% to 15.4%), and JVIR first authors (10% to 14.5%) and senior authors (7.1% to 11.9%). From 2012 to 2017, there were increases in female representation among SIR committee chairs (21% to 28%) and IRQ authors (4.5% to 27%). However, the percentage of female IR residents and fellows did not significantly change between 2008 and 2017 (11% vs 16.2%; P = .51). CONCLUSIONS: Women interventional radiologists are underrepresented within SIR, representing only 9.2% of active IR physicians. There has been a steady increase in female representation within most areas of SIR evaluated in this study. Although these trends are reassuring, efforts toward increasing recruitment and retention of women in IR need to improve in light of the infancy of IR as a residency program.

Accuracy and efficacy of percutaneous biopsy and ablation using robotic assistance under computed tomography guidance: a phantom study.

OBJECTIVE: To compare the accuracy of a robotic interventional radiologist (IR) assistance platform with a standard freehand technique for computed-tomography (CT)-guided biopsy and simulated radiofrequency ablation (RFA). METHODS: The accuracy of freehand single-pass needle insertions into abdominal phantoms was compared with insertions facilitated with the use of a robotic assistance platform (n = 20 each). Post-procedural CTs were analysed for needle placement error. Percutaneous RFA was simulated by sequentially placing five 17-gauge needle introducers into 5-cm diameter masses (n = 5) embedded within an abdominal phantom. Simulated ablations were planned based on pre-procedural CT, before multi-probe placement was executed freehand. Multi-probe placement was then performed on the same 5-cm mass using the ablation planning software and robotic assistance. Post-procedural CTs were analysed to determine the percentage of untreated residual target. RESULTS: Mean needle tip-to-target errors were reduced with use of the IR assistance platform (both P < 0.0001). Reduced percentage residual tumour was observed with treatment planning (P = 0.02). CONCLUSION: Improved needle accuracy and optimised probe geometry are observed during simulated CT-guided biopsy and percutaneous ablation with use of a robotic IR assistance platform. This technology may be useful for clinical CT-guided biopsy and RFA, when accuracy may have an impact on outcome. KEY POINTS: • A recently developed robotic intervention radiology assistance platform facilitates CT-guided interventions. • Improved accuracy of complex needle insertions is achievable. • IR assistance platform use can improve target ablation coverage.

Image-guided nerve cryoablation for post-thoracotomy pain syndrome.

Chronic post-thoracotomy pain syndrome (PTPS) can cause significant patient distress and is frequently difficult to manage. Percutaneous intercostal nerve (ICN) cryoablation by palpation of surface landmarks can be risky, as inaccurate probe placement can lead to hemo- or pneumothorax. Experience with image-guided ICN cryoablation with treatment planning and device navigation is limited. A patient with intractable PTPS was treated with ICN cryoablation under cone-beam computed tomography guidance with software-assisted needle trajectory planning and ablation zone simulation. This procedure provided the patient ~8 weeks of relief. This case demonstrated that ICN cryoablation is feasible under image guidance with device navigation and ablation simulation and may result in a few months of pain relief in cases of intractable PTPS.

PET-guided biopsy with needle navigation facilitates diagnosis of angiosarcoma in neurofibromatosis type 1.

Malignant degeneration frequently arises from preexisting plexiform neurofibroma in patients with neurofibromatosis type 1 (NF1). Image guided biopsy for diagnostic purposes, such as with CT guidance, can be technically challenging in these patients, as CT cannot distinguish malignant from benign areas within the same tumor. Navigation with multi-modality (PET, CT, and ultrasound) image fusion facilitated the successful biopsy and diagnosis of angiosarcoma arising from a pelvic neurofibroma in a patient with NF1. Successful targeting assisted treatment selection in this case. This novel navigation technique may facilitate the otherwise difficult diagnosis of malignancy in patients with NF1.