Transarterial Yttrium-90 Radioembolization for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the overall efficacy and survival profile of yttrium-90 (90Y) radioembolization for unresectable intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS: A systematic literature review and meta-analysis was completed using a random-effects model. Studies describing the use of 90Y for unresectable ICC were included. The disease control rate (DCR), downstaged-to-resectable rate, cancer antigen 19-9 (CA19-9) response rate, pooled median overall survival (OS), pooled median progression-free survival (PFS), and mean reported survival rates ranging from 3 to 36 months were evaluated. RESULTS: Twenty-one studies detailing a total of 921 patients were included. The overall DCR was 82.3% (95% confidence interval [CI], 76.7%-87.8%; I2 = 81%). In 11% of the cases, patients were downstaged to being surgically resectable (95% CI, 6.1%-15.9%; I2 = 78%). The CA19-9 response rate was 67.2% (95% CI, 54.5%-79.8%; I2 = 60%). From the time of radioembolization, PFS was 7.8 months (95% CI, 4.2-11.3 months; I2 = 94%) and median OS was 12.7 months (95% CI, 10.6-14.8 months; I2 = 62%). Lastly, the mean overall reported survival proportions were 84% at 3 months (standard deviation [SD], 10%), 69% at 6 months (SD, 16%), 47% at 12 months (SD, 19%), 31% at 18 months (SD, 21%), 30% at 24 months (SD, 19%), 21% at 30 months (SD, 27%), and 5% at 36 months (SD, 7%). CONCLUSIONS: Radioembolization with 90Y for unresectable ICC results in substantial downstaging, disease control, and survival.

Thrombin Injection to Treat an Iatrogenic Internal Mammary Artery Pseudoaneurysm.

A 71-year-old female presented to the emergency room eight weeks status post open heart surgery for aortic valve replacement with right-sided chest wall pain and swelling. Computed tomographic (CT) angiography demonstrated a hyperattenuating structure arising from the right internal mammary artery surrounded by a heterogeneously-attenuating fluid collection in the anterior right chest wall, compatible with a right internal mammary artery pseudoaneurysm with surrounding chest wall hematoma. Follow up color Doppler ultrasound confirmed the diagnosis. Under direct ultrasound visualization, we injected four hundred units of thrombin into the neck of the pseudoaneurysm using a 25-gauge spinal needle. Post-injection imaging demonstrated a successful cessation of flow within the pseudoaneurysm sac.

Assisted maturation of native fistula in two patients with a continuous flow left ventricular assist device.

Patients who receive a left ventricular assist device (LVAD) are prone to develop end-stage renal disease. Primary arteriovenous fistula (AVF) maturation in these patients may be unsuccessful secondary to the nonpulsatile flow with an LVAD. Two patients with LVADs are described in whom assisted maturation aided long-term AVF patency.

Comparison of technical success and complications of percutaneous transhepatic cholangiography and biliary drainage between patients with and without transplanted liver.

OBJECTIVE: The purpose of this study is to compare technical success and complications of percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD) between patients with and without transplanted liver. MATERIALS AND METHODS: Between 2007 and 2011, 89 PTCs, including 34 PTBDs, in 87 patients with transplanted liver were attempted, and 131 PTCs, including 118 PTBDs, in 126 patients without transplanted liver were attempted. Technical success, diameters of the bile ducts, fluoroscopy time, and complications were statistically compared between the two groups. RESULTS: The technical success rate of PTC for transplanted liver was significantly lower than that for nontransplanted liver (88.8% vs 98.5%; p = 0.004). Consequently, the technical success rate of PTBD for transplanted liver was also significantly lower than that for nontransplanted liver (75.0% vs 95.8%; p < 0.001). The average diameters of the first branches and second branches of the bile ducts of transplanted liver were significantly smaller than those of nontransplanted liver (5.8 ± 3.4 mm vs 8.7 ± 3.9 mm for the first branches [p < 0.001]; and 3.7 ± 1.7 mm vs 5.8 ± 2.4 mm for the second branches [p < 0.001]). No significant difference of fluoroscopy time of unilateral successful PTBD was observed (21.8 ± 11.7 vs 19.3 ± 12.9 min; p = 0.372), and no significant difference of overall complication rates was observed (8.0% vs 8.7%; p = 1.000) between transplanted and nontransplanted liver. CONCLUSION: The technical success rates of PTC and PTBD for transplanted liver are slightly lower than those for nontransplanted liver because the bile ducts are smaller. There is no significant difference in complication rate.

Time to Catheter Angiography for Gastrointestinal Bleeding after Prior Positive Investigation Does Not Affect Bleed Identification.

OBJECTIVE: To determine, time to angiography for patients with positive gastrointestinal bleeding (GIB) on prior investigation (endoscopy [ES], nuclear medicine [NM] Tc99m red blood cells (RBC) scan, or computed tomography angiography), affects angiographic bleed identification. MATERIALS AND METHODS: Visceral Angiograms performed from January 2012 to August 2017 were evaluated. Initial angiograms performed for GIB were included in the study. Exclusion criteria included recent abdominal surgery or procedure (30 days), empiric embolization (embolization without visualized active bleeding), and use of vasodilators, or subsequent angiogram. Timing and results of ES, NM Tc99m RBC scan, or computed tomography angiogram and catheter angiogram were recorded. In addition, age, gender, angiogram time, anti- platelet therapy, anti-coagulation therapy, bleed location, international normalized ratio, and units of packed RBCs received in the 24 h before catheter angiography were included in the study. RESULTS: One hundred and seventy angiograms were included in the final analysis. Forty-three angiograms resulted in the identification of an active bleed (68.9 years, and 67.4% male). All of these patients were embolized successfully. One hundred and twenty-seven angiograms failed to identify an active bleed (70.4 years, and 49.6% male). No significance was found across the two groups with respect to time from prior positive investigation. Receiver operating characteristic analysis demonstrated that units of packed RBCs received in the preceding 24 h were correlated with positive bleed identification on catheter angiography. CONCLUSION: Time to angiography from prior positive investigation, including ES, NM Tc99m RBC scan, or computed tomography angiogram does not correlate with positive angiographic outcomes. Increasing units of packed RBCs administered in the 24 h before angiogram do correlate with positive angiographic findings.

Mycotic Aneurysm of the Hepatic Artery: A Case Report and its Management.

Cholecystectomies are one of the most common surgical procedures performed in the United States, with complications being relatively common. We submit a case of a ruptured mycotic aneurysm of the hepatic artery, a complication of a recent cholecystectomy which was successfully treated with the use of transarterial thrombin.

Management of small renal masses: An interventional radiologist's perspective.

Renal cell carcinoma is relatively common malignancy. Its imaging features are often non-specific and can present a diagnostic dilemma for clinicians. Historically, all patients with a renal mass underwent radical nephrectomy. Advances in technology have allowed for an increase in partial nephrectomies and percutaneous ablations. This essay briefly describes some of the imaging findings of renal cell carcinoma and several of its mimics followed by an in-depth review of procedural management with a particular focus on recent advancements.

Pearls and pitfalls of thyroid nodule sonography and fine-needle aspiration.

PURPOSE: To review the ultrasound appearances of thyroid nodules with an emphasis on morphological features and to illustrate pearls and pitfalls related to ultrasound interpretation and fine-needle aspiration. METHODS: The ultrasound features of 156 consecutive thyroid nodules with available cytological diagnoses were retrospectively reviewed. The presence of "honeycomb" morphology, aspect ratio, taller-than-wide shape, presence of colloid, consistency, echogenicity, presence of halo, margin definition, multiplicity of the nodules, largest nodule dimension, and lesion vascularity were compared between benign and malignant nodules. RESULTS: Sonographic features that are significantly more common among malignant lesions include the presence of microcalcifications, coarse internal calcifications, markedly hypoechoic components, mostly solid-to-solid contents, infiltrative or microlobulated margins, taller-than-wide shape, and a high aspect ratio (0.85 vs 0.71). Characteristics that are statistically significantly associated with benignity include peripheral calcification and purely cystic composition. The honeycomb morphology was 100% specific for nodular hyperplasia. Benign and malignant follicular and Hürthle cell neoplasms can have identical sonographic and cytological features. Colloid on both ultrasound and cytology may be found in malignant lesions, whereas microcalcifications can sometimes be found in benign lesions. Cystic components in malignant nodules are not uncommon and should not be dismissed as benign on this basis alone. Fine-needle aspiration may alter the appearance of thyroid nodules. CONCLUSIONS: Certain morphological sonographic features are helpful for differentiating between benign and malignant thyroid nodules and guided subsequent management. However, thyroid nodule ultrasound and fine-needle aspiration must be interpreted with awareness of potential pitfalls.