Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study.

RATIONALE AND OBJECTIVE: Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway. METHODS: 142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically. RESULTS: The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 - 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001). CONCLUSION: A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.

Boosted-Dose Yttrium-90 Radiation Segmentectomy or Lobectomy for Hepatocellular Carcinoma Refractory to Prior Transarterial Embolization or Chemoembolization: A Single Institution Retrospective Case Series.

PURPOSE: To assess the tumor response rates and liver toxicity of boosted-dose transarterial radioembolization (TARE) for treatment of hepatocellular carcinoma (HCC) refractory to previous transarterial embolization (TAE) and/or chemoembolization (TACE). MATERIALS AND METHODS: All patients were identified who had HCC treated between 2017 and 2020 that had been refractory to prior TAE or TACE, then treated with boosted-dose segmental or lobar TARE. Tumor response was assessed by multiphasic CT or MRI using localized mRECIST imaging criteria and serological alpha-fetoprotein levels at three and six months after TARE, if available. Liver toxicity was evaluated using serial serological liver function tests, platelet counts, and clinical Child-Pugh and MELD scores. RESULTS: Twenty-four patients met inclusion criteria. Mean age was 68.7 years (54-89); 8 were females. Three (12.5%) patients had Barcelona Clinical Liver Cancer stage A, 4 (16.7%) stage B, and 17 (70.8%) stage C disease. Three months after TARE, 52% of patients had a complete response and 33% had a partial response. Mean AFP decreased from 33.2 ng/mL at baseline to 17 ng/mL at 3 months (p = 0.782). The median MELD-Na score increased from 11 at baseline to 16 at 6 months post-TARE (p = 0.044); the mean Child-Pugh score rose from 5 at baseline to 6 at 3 months post-TARE (p < 0.01). CONCLUSION: Boosted-dose TARE resulted in statistically significant favorable tumor responses by imaging criteria in 85% of patients previously refractory to TAE or TACE. TARE resulted in transient but acceptable deterioration of liver function and clinical scores.

Successful mechanical thrombectomy and stent exclusion of sacral chordoma tumor thrombus.

A 77-year-old man with history of sacral chordoma and pulmonary embolism presented to the emergency room with a 1-day history of diffuse left flank and lower extremity swelling. The patient was found to have thrombus in the left common and external iliac veins. The patient was brought to Interventional Radiology for mechanical thrombectomy using the Inari ClotTriever and a sample of extracted thrombus was sent to pathology. Analysis on the sample was positive for sacral chordoma, consistent with tumor thrombus. The patient returned after 6 weeks with similar symptoms and repeat mechanical thrombectomy was performed with the Inari ClotTriever and stent placement through the left common and external iliac vein with an Ovation iX stent graft. The patient remained asymptomatic following the second procedure at repeat follow-up at 6 weeks.

Pleurovenous Shunt Placement for the Management of Nonmalignant Pleural Effusion.

Therapeutic thoracentesis is a first-line therapy in the management of patients with medically refractory, nonmalignant pleural effusion. However, when required in short intervals, serial thoracenteses can lead to increased procedure-related complications and negatively impact quality of life. Alternative treatment options vary depending on the etiology of fluid accumulation. Hepatic hydrothorax secondary to cirrhosis is a common cause of medically refractory pleural effusion encountered by interventional radiologists. In select patients in whom surgical pleurodesis, transjugular intrahepatic portosystemic shunt placement, and/or tunneled pleural catheter placement cannot be performed or provide inadequate relief, implantation of a pleurovenous (Denver) shunt may assist in palliation. The Denver shunt system allows decompression of pleural fluid into the central venous circulation by utilizing unidirectional valves and a manually operated subcutaneous pump. Though limited reports have described favorable technical and clinical success, more research is required to determine the safety and efficacy of this procedure. This article discusses pleurovenous shunt placement, postprocedure shunt evaluation, and potential associated complications.

Utility of Cone-Beam CT for Bronchial Artery Embolization and Chemoinfusion: A Single-Institution Retrospective Case Series.

PURPOSE: To describe the technique and document utility of adjunctive cone-beam CT (CBCT) in patients undergoing bronchial artery embolization (BAE) or chemoinfusion (BAC). MATERIALS AND METHODS: Between August 2010 and February 2021, 26 patients (62 bronchial arteries) were evaluated with CBCT in addition to the usual digital subtraction angiography (DSA) during BAE or BAC. 19 patients (43 arteries) underwent BAE for hemoptysis; 7 patients (19 arteries) had BAC for palliation of lung malignancy. Retrospective review of procedural reports and the archived DSA and CBCT images was assessed for (1) whether CBCT findings added unique diagnostic information prior to treatment of target arteries compared to DSA alone; and (2) whether these unique CBCT findings led to modification of embolization or chemoinfusion technique. RESULTS: In 61 of 62 (98%) interrogated bronchial arteries, CBCT provided additional unique diagnostic information over planar DSA, primarily cross-sectional assessment of the spinal canal for spinal arteries. In 46/62 (74%) of the bronchial arteries the unique information did not lead to a change in therapeutic technique. In 15 bronchial arteries (24%), the added information from CBCT led to change in embolization and/or chemoinfusion technique. Embolization of one small unrecognized spinal artery branch (1.6%), which was missed intra-procedurally but retrospectively seen on CBCT led to transient spinal cord ischemia. CONCLUSIONS: These results suggest that adjunctive use of CBCT technique may improve diagnostic confidence from information provided by DSA in nearly all cases of BAE and BAC leading to improved therapeutic targeting or change in technique of embolization or chemoinfusion.

ACR Appropriateness Criteria® Radiologic Management of Iliofemoral Venous Thrombosis.

Iliofemoral venous thrombosis carries a high risk for pulmonary embolism, recurrent deep vein thrombosis, and post-thrombotic syndrome complicating 30% to 71% of those affected. The clinical scenarios in which iliofemoral venous thrombosis is managed may be diverse, presenting a challenge to identify optimum therapy tailored to each situation. Goals for management include preventing morbidity from venous occlusive disease, and morbidity and mortality from pulmonary embolism. Anticoagulation remains the standard of care for iliofemoral venous thrombosis, although a role for more aggressive therapies with catheter-based interventions or surgery exists in select circumstances. Results from recent prospective trials have improved patient selection guidelines for more aggressive therapies, and have also demonstrated a lack of efficacy for certain conservative therapies. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Radiologic Management of Venous Thromboembolism-Inferior Vena Cava Filters.

Venous thromboembolism (VTE)-deep vein thrombosis and pulmonary embolism-is a common cause of morbidity and mortality. The mainstay of VTE prophylaxis and therapy is anticoagulation. In select patients with VTE, inferior vena cava (IVC) filters are used to prevent pulmonary embolism by trapping emboli as they pass from the lower extremity venous system through the IVC. These guidelines review the indications for placement of IVC filters in acute and chronic VTE, as well as the indications for retrieval of implanted IVC filters. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Septic Shock and Death after Microwave Ablation of Hepatocellular Carcinoma in a Liver Transplant Patient with a Bilioenteric Anastomosis.

Percutaneous thermal ablation of hepatic tumors continues to play an integral role in the treatment of early-stage primary or secondary hepatic malignancies. Interventional radiologists must be familiar with potential complications of this procedure, associated risk factors, and methods for prevention. The authors report a devastating case of septic shock and death following percutaneous microwave ablation of a solitary hepatocellular carcinoma in a liver transplant patient with a bilioenteric anastomosis (BEA). We review the literature regarding prophylactic antibiotic regimens and bowel preparation prior to performing thermal ablation in patients with BEAs.

Retrievable inferior vena cava filters in neurosurgical patients: Retrieval rates and clinical outcomes.

OBJECTIVE: To assess inferior vena cava (IVC) filter retrieval rates and clinical outcomes in neurosurgical patients and to determine patient characteristics associated with filter retrieval. PATIENTS AND METHODS: This single-center retrospective study included 204 consecutive neurosurgical patients (120 men, 84 women; mean age 60 ± 13 years) who underwent retrievable IVC filter insertion between 1/2011-9/2013. Institutional IVC filter database review was used to identify demographic and clinical data, indication for IVC filtration, and IVC filter type. Patients were followed clinically by the neurosurgical, hematology, and interventional radiology services until removal or conversion to a permanent device. Measured outcomes included filter retrieval rates and parameters associated with device removal. RESULTS: The majority of filters were placed for venous thromboembolism (200/204, 98%). Of 204 filters, 38(19%) were retrieved at median 186 days post-placement (range 3-665 days), 112(55%) converted to permanent devices, 44(22%) patients were deceased, and 10(5%) patients were lost to follow-up after transfer to an outside healthcare facility. Patients with subarachnoid hemorrhage (18% vs. 35%, p = 0.025) and malignancy (5% vs. 25%, p = 0.009) were less likely to have filters removed. Filter type (p = 0.475), gender (p = 0.221), neurosurgical procedure (p = 0.639), and insurance status (p = 0.207) did not demonstrate a significant association with filter retrieval. CONCLUSION: IVC filter retrieval rates in neurosurgical patients are low despite tracking patients clinically in a multidisciplinary setting. Those neurosurgical patients with intracranial hemorrhage or malignancy requiring IVC filters have a lower likelihood of filter retrieval and may benefit from use of permanent devices.

ACR Appropriateness Criteria® Lower Extremity Arterial Revascularization-Post-Therapy Imaging.

Peripheral arterial disease (PAD) affects millions across the world and in the United States between 9% to 23% of all patients older than 55 years. The refinement of surgical techniques and evolution of endovascular approaches have improved the success rates of revascularization in patients afflicted by lower extremity PAD. However, restenosis or occlusion of previously treated vessels remains a pervasive issue in the postoperative setting. A variety of different imaging options are available to evaluate patients and are reviewed within the context of asymptomatic and symptomatic patients with PAD who have previously undergone endovascular or surgical revascularization. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Liver-directed therapy for hepatocellular carcinoma.

Liver-directed therapy is a critical component of treatment strategies for hepatocellular carcinoma. These therapies included percutaneous image-guided ablation, transarterial chemoembolization, and transarterial radioembolization, and are administered by interventional radiologists. Depending on the stage of disease, a particular treatment modality, or a combination thereof, is expected to be most efficacious in achieving the goals of treatment for a particular patient. This article seeks to review the various liver-directed treatment modalities for treatment of hepatocellular carcinoma, with attention to their efficacy and patient selection criteria.

ACR Appropriateness Criteria® Radiologic Management of Central Venous Access.

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Iliac Artery Occlusive Disease.

Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chylothorax Treatment Planning.

Chylothorax is an uncommon but serious medical condition, which arises when intestinal lymphatic fluid leaks into the pleural space. Treatment strategies depend on the daily output and underlying etiology, which may be due to direct injury to lymphatic vessels or a nontraumatic disorder. Chest radiographs confirm the presence of pleural fluid and lateralize the process. In the setting of direct injury, lymphangiography can often be both diagnostic and facilitate a minimally invasive attempt at therapy. CT and MRI in this setting may be appropriate for cases when lymphangiography is not diagnostic. When the etiology is nontraumatic or unknown, CT or MRI can narrow the differential diagnosis, and lymphangiography is useful if a minimally invasive approach to treatment is desired. 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 include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia.

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. 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 include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Loss of intratumoral macroscopic fat in renal angiomyolipoma following chemoradiation therapy for pancreatic cancer.

Angiomyolipoma (AML) is the most common benign mesenchymal tumour of the kidney. Classically, AML can readily be diagnosed by identifying the negatively attenuating intratumoral macroscopic fat component on non-enhanced CT scans. However, intratumoral macroscopic fat may not be visible on CT scans, mimicking renal cell carcinoma. We report a case of renal AML with CT scan evidence of macroscopic intratumoral fat that was not readily visible on subsequent CT or MRI, presumably owing to a generalized rapid loss of adipose tissue due to cachexia in a patient with pancreatic adenocarcinoma. Radiologists should be aware that AML may lose its intratumoral fat on follow-up imaging and may simulate renal cell carcinoma.

Hepatopulmonary Shunting: A Prognostic Indicator of Survival in Patients with Metastatic Colorectal Adenocarcinoma Treated with 90Y Radioembolization.

Purpose To determine if high lung shunt fraction (LSF) is an independent prognostic indicator of poor survival in patients who undergo yttrium 90 radioembolization for unresectable liver-dominant metastatic colorectal cancer. Materials and Methods Retrospective data were analyzed from 606 patients (62% men; mean age, 62 years) who underwent radioembolization to treat liver metastases from colorectal adenocarcinoma between July 2002 and December 2011 at 11 U.S. centers. Institutional review board exemptions were granted prior to the collection of data at each site. Overall survival was estimated by using Kaplan-Meier survival and univariate Cox proportional hazards models to examine the effect of LSF on survival and to compare this to other potential prognostic indicators. Multivariate analysis was also performed to determine whether LSF is an independent risk factor for poor survival. Results LSF higher than 10% was predictive of significantly decreased survival (median, 6.9 months vs 10.0 months; hazard ratio, 1.60; P < .001) and demonstrated a mild but significant correlation to serum carcinoembryonic antigen levels and tumor-to-liver volume ratio (Pearson correlation coefficients, 0.105 and 0.113, respectively; P < .05). A progressive decrease in survival was observed as LSF increased from less than 5% to more than 20% (P < .05). LSF did not correlate with the presence of extrahepatic metastases or prior administration of bevacizumab. Conclusion Increased LSF is an independent prognostic indicator of worse survival in patients undergoing radioembolization for liver-dominant metastatic colorectal adenocarcinoma. High LSF correlates poorly to other potential markers of tumor size, such as tumor-to-liver volume ratio or serum carcinoembryonic antigen level, and does not correlate to the presence of extrahepatic metastases. © RSNA, 2016 Online supplemental material is available for this article.

Management of Renovascular Hypertension.

Renal artery stenosis is a potentially reversible cause of hypertension, and transcatheter techniques are essential to its treatment. Angioplasty remains a first-line treatment for stenosis secondary to fibromuscular dysplasia. Renal artery stenting is commonly used in atherosclerotic renal artery stenosis, although recent trials have cast doubts upon its efficacy. Renal denervation is a promising procedure for the treatment of resistant hypertension, and in the future, its indications may expand.

Inferior Vena Cava Filters: Guidelines, Best Practice, and Expanding Indications.

Vena caval interruption, currently accomplished by percutaneous image-guided insertion of an inferior vena cava (IVC) filter, is an important therapeutic option in the management of selected patients with venous thromboembolism. The availability of optional (or retrievable) filters, in particular, has altered the practice patterns for IVC filters, with a shift to these devices and expansion of indications for filter placement. As new devices have become available and clinicians have become more familiar and comfortable with IVC filters, the indications for filter placement have continued to evolve and expand. This article reviews current guidelines and expanding indications for IVC filter placement.