Multicenter Quantification of Radiation Exposure and Associated Risks for Prostatic Artery Embolization in 1476 Patients.

Background Prostatic artery embolization (PAE) is a safe, minimally invasive angiographic procedure that effectively treats benign prostatic hyperplasia; however, PAE-related patient radiation exposure and associated risks are not completely understood. Purpose To quantify radiation dose and assess radiation-related adverse events in patients who underwent PAE at multiple centers. Materials and Methods This retrospective study included patients undergoing PAE for any indication performed by experienced operators at 10 high-volume international centers from January 2014 to May 2021. Patient characteristics, procedural and radiation dose data, and radiation-related adverse events were collected. Procedural radiation effective doses were calculated by multiplying kerma-area product values by an established conversion factor for abdominopelvic fluoroscopy-guided procedures. Relationships between cumulative air kerma (CAK) or effective dose and patient body mass index (BMI), fluoroscopy time, or radiation field area were assessed with linear regression. Differences in radiation dose stemming from radiopaque prostheses or fluoroscopy unit type were assessed using two-sample t tests and Wilcoxon rank sum tests. Results A total of 1476 patients (mean age, 69.9 years ± 9.0 [SD]) were included, of whom 1345 (91.1%) and 131 (8.9%) underwent the procedure with fixed interventional or mobile fluoroscopy units, respectively. Median procedure effective dose was 17.8 mSv for fixed interventional units and 12.3 mSv for mobile units. CAK and effective dose both correlated positively with BMI (R2 = 0.15 and 0.17; P < .001) and fluoroscopy time (R2 = 0.16 and 0.08; P < .001). No radiation-related 90-day adverse events were reported. Patients with radiopaque implants versus those without implants had higher median CAK (1452 mGy [range, 900-2685 mGy] vs 1177 mGy [range, 700-1959 mGy], respectively; P = .01). Median effective dose was lower for mobile than for fixed interventional systems (12.3 mSv [range, 8.5-22.0 mSv] vs 20.4 mSv [range, 13.8-30.6 mSv], respectively; P < .001). Conclusion Patients who underwent PAE performed with fixed interventional or mobile fluoroscopy units were exposed to a median effective radiation dose of 17.8 mSv or 12.3 mSv, respectively. No radiation-related adverse events at 90 days were reported. © RSNA, 2024 See also the editorial by Mahesh in this issue.

Treatment Strategies for Bile Leak Following Pediatric Liver Transplantation.

There are no standard management protocols for the treatment of bile leak (BL) after liver transplantation. The objective of this study is to describe treatment options for BL after pediatric LT. METHODS: Retrospective analysis (January 2010-March 2023). VARIABLES STUDIED: preoperative data, status at diagnosis, and postoperative outcome. Four groups: observation (n = 9), percutaneous transhepatic cholangiography (PTC, n = 38), ERCP (2), and surgery (n = 27). RESULTS: Nine hundred and thirty-one pediatric liver transplantation (859 LDLT and 72 DDT); 78 (8.3%) patients had BL, all in LDLT. The median (IQR) peritoneal bilirubin (PB) level and fluid-to-serum bilirubin ratio (FSBR) at diagnosis was 14.40 mg/dL (8.5-29), and 10.7 (4.1-23.7). Patients who required surgery for treatment underwent the procedure earlier, at a median of 14 days (IQR: 7-19) versus 22 days for PTC (IQR: 15-27, p = 0.002). PB and FSBR were significantly lower in the observation group. In 11 cases, conservative management had resolution of the BL in an average time of 35 days, and 38 patients underwent PTC in a median time of 22 days (15-27). Twenty-seven (34.6%) patients were reoperated as initial treatment for BL in a median time of 17 days (1-108 days); 25 (33%) patients evolved with biliary stricture, 5 (18.5%) after surgery, and 20 (52.6%) after PTC (p = 0.01). CONCLUSION: Patients with BL who were observed presented significantly lower levels of PB and FSBR versus those who underwent PTC or surgery. Patients treated with PTC presented higher rates of biliary stricture during the follow-up.

Recanalization of portal vein thrombosis after pediatric liver transplantation: Efficacy and safety of the transsplenic access.

BACKGROUND: Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. MATERIALS AND METHODS: This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. RESULTS: Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. CONCLUSIONS: Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

Prostatic Artery Embolization Using Polyethylene Glycol Microspheres: A 1-Year Follow-up Prospective Study Including 30 Patients.

PURPOSE: To evaluate safety and effectiveness of prostatic artery embolization (PAE) using polyethylene glycol (PEG) microspheres in patients with moderate-to-severe benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A single-center, prospective study of 30 patients who underwent PAE from August 2020 to December 2021 using PEG 400-µm microspheres was conducted. Patient evaluation data using International Prostate Symptom Score (IPSS), quality of life (QoL) score, prostate-specific antigen (PSA), peak urinary flow rate (Qmax), postvoid residual volume (PVR), and prostate volume (PV) at baseline and 3 and 12 months after PAE were obtained. RESULTS: Bilateral PAE was performed in all patients. One patient had early clinical failure (3.3%) and another presented with lower urinary tract symptoms (LUTSs) recurrence (3.3%) at the 12-month follow-up. Twenty-eight patients (93.3%) experienced significant and durable LUTS improvement. Mean absolute (and relative) improvement at 3 and 12 months were: IPSS, 14.6 points (-69%) for both; QoL, 3.3 points (-70%) and 3.5 points (-74%); Qmax, 6.3 mL/s (+78%) and 8.6 mL/s (+100%); PSA reduction, 1.2 ng/mL (-22%) and 1.0 ng/mL (-15%); PVR reduction, 48 mL (-56%) and 58.2 mL (-49%); PV reduction, 23.4 cm3 (-29%) and 19.6cm3 (-25%); (P < .05 for all). No major adverse events were observed. Minor adverse events included urinary tract infection (4/30, 13.3%), prostatic tissue elimination (3/30, 10%), penile punctiform ulcer (1/30, 3.3%), and urinary retention (1/30, 3.3%). CONCLUSIONS: PAE using PEG microspheres was observed to be effective with sustained LUTS improvement at the 12-month follow-up. The incidence of urinary infection and prostatic tissue elimination was higher than previously reported for other embolics.

Life-threatening variceal bleeding after liver transplantation and extensive portal vein thrombosis: Desperate times call for desperate measures.

BACKGROUND: The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients. METHODS: Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding. RESULTS: The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. CONCLUSIONS: This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.

Role of Ultrasound Elastography in Patient Selection for Prostatic Artery Embolization.

PURPOSE: To determine the effects of prostatic artery embolization (PAE) on prostate elasticity as assessed using ultrasound elastography (US-E) and to describe baseline US-E's potential role in patient selection. MATERIALS AND METHODS: This was a prospective investigation that included 20 patients undergoing PAE to treat lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH). US-E with measurement of the prostatic elastic modulus (EM) and shear wave velocity (SWV) was performed before PAE and at 1-month follow-up. Baseline, 3-month, and 1-year follow-up evaluations included prostate-specific antigen, uroflowmetry, pelvic magnetic resonance imaging, and clinical assessment using the International Prostate Symptom Score (IPSS) and quality of life (QoL) metrics. RESULTS: Seventeen patients entered statistical analysis. US-E showed a significant reduction in mean prostatic EM (34.4 kPa vs 46.3 kPa, -24.7%, P < .0001) and SWV (3.55 m/s vs 4.46 m/s, -20.0%, P < .0001) after PAE. There were moderate positive correlations between baseline EM and 1-year IPSS (R = 0.62, P = .007) and between baseline SWV and 1-year IPSS (R = 0.68, P = .002). Baseline SWV ≥ 5.59 m/s and baseline EM ≥ 50.14 kPa were associated with suboptimal IPSS and QoL outcomes after PAE with high degrees of sensitivity (100%) and specificity (69-100%). CONCLUSIONS: PAE led to a positive effect on the BPH dynamic component related to prostatic elasticity. There was a moderate positive correlation between baseline prostatic elastographic parameters and 12-month IPSS. Measurement of baseline elastographic characteristics may become useful for the evaluation and selection of patients for PAE.

Intravesical Prostatic Protrusion Does Not Influence the Efficacy of Prostatic Artery Embolization.

PURPOSE: To compare the outcomes of prostatic artery embolization (PAE) in patients with different intravesical prostatic protrusion (IPP) grades. MATERIALS AND METHODS: This retrospective single-center study included 128 patients (aged 50-86 years) who underwent PAE from 2013 to 2017. IPP grades were classified as follows: grade I (<10 mm), grade II (10-19 mm), and grade III (≥20 mm). Nineteen patients (14.8%) had grade I [mean IPP 7.8 mm, prostatic volume (PV) 64.1 cm3], 77 (60.2%) had grade II (mean IPP 14.9 mm, PV 87.0 cm3), and 32 (25%) had grade III (mean IPP 26.2 mm, PV 132.6 cm3), P < .01. The outcomes, including PV, international prostate symptom score (IPSS), and quality of life (QoL), were compared between the IPP grades at the 12-month follow-up. Clinical failure was defined as IPSS >7 or QoL >2. RESULTS: IPP decreased (I: -8.2%, II: -27.3%, and III: -38.7%, P = .01), and all other endpoints improved (P < .01). Adjusted covariance analysis, considering baseline PV as a confounding factor, showed no correlation between the 12-month outcomes and baseline IPP. Clinical failure was observed in 17/128 patients (13.3%) and was similar in prevalence among the IPP groups (P = .20). Minor complications occurred in 43 patients (33.6%) and major in 3 (2.3%). There were statistical differences in the complications between IPP grades II and III (P < .01). CONCLUSIONS: PAE was similarly effective in all the IPP grades at the 12-month follow-up, and there was no difference in the clinical failure between the groups. Complications in IPP grade III were more frequent than those in IPP grade II.

Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications.

Benign prostatic hyperplasia (BPH) is a noncancerous growth of the transitional zone of the prostate, which surrounds the prostatic urethra. Consequently, it can cause lower urinary tract symptoms (LUTS) and bladder outlet obstruction symptoms that may substantially reduce a patient's quality of life. Several treatments are available for BPH, including medications such as α-blockers and 5α-reductase inhibitors and surgical options including transurethral resection of the prostate and prostatectomy. Recently, prostatic artery embolization (PAE) has emerged as a minimally invasive treatment option for selected men with BPH and moderate to severe LUTS. Adequate pre- and postprocedural evaluations with clinical examinations and questionnaires, laboratory tests, and urodynamic and imaging examinations (particularly US, MRI, and CT) are of key importance to achieve successful treatment. Considering that the use of PAE has been increasing in tertiary hospital facilities, radiologists and interventional radiologists should be aware of the main technical concepts of PAE and the key features to address in imaging reports in pre- and postprocedural settings. An invited commentary by Lopera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years' Experience.

Background Long-term experience with prostatic artery embolization (PAE) for benign prostatic hyperplasia remains limited. Purpose To evaluate the efficacy, safety, and long-term results of PAE for benign prostatic hyperplasia. Materials and Methods This retrospective single-center study was conducted from June 2008 to June 2018 in patients with moderate to severe benign prostatic hyperplasia-related symptoms. International Prostate Symptom Score (IPSS), quality-of-life score, maximum urinary flow rate, postvoid residual volume, prostate-specific antigen (PSA), and prostate volume were assessed. PAE was performed with 100-500-µm embolic microspheres. Mixed-model analysis of variance and Kaplan-Meyer method was accessed, as appropriate. Results A total of 317 consecutive men (mean age ± standard deviation, 65 years ± 8) were treated. Follow-up ranged from 3 months to 96 months (mean, 27 months). Bilateral and unilateral PAE was performed in 298 (94%) and 19 (6%) men, respectively. Early clinical failure occurred in six (1.9%) and symptom recurrence in 72 (23%) men at a median follow-up of 72 months. Mean maximum improvement was as follows: IPSS, 16 points ± 7; quality-of-life score, 4 points ± 1; prostatic volume reduction, 39 cm3 ± 39 (39% ± 29); maximum urinary flow rate, 6 mL/sec ± 10 (155% ± 293); and postvoid residual volume, 70 mL ± 121 (48% ± 81) (P < .05 for all). Unilateral PAE was associated with higher recurrence (42% vs 21%; P = .04). Baseline PSA was inversely related with recurrence (hazard ratio, 0.9 per nanograms per milliliter of PSA; 95% confidence interval [CI], 0.8, 0.9; P < .001). Embolization with combined particle sizes (100-500 µm) did not relate to symptom recurrence (hazard ratio, 0.4; 95% CI: 0.2, 1.1 for 100-500-µm group vs 300-500-µm group and hazard ratio, 0.4; 95% CI: 0.1, 1.5 for 100-500-µm group vs 100-300-µm group; P = .19).None of the patients presented with urinary incontinence or erectile dysfunction. Conclusion Prostatic artery embolization was a safe and effective procedure for benign prostatic hyperplasia with good long-term results for lower urinary tract symptoms. © RSNA, 2020 Online supplemental material is available for this article.

Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel.

PURPOSE: To summarize the Society of Interventional Radiology Foundation's Research Consensus Panel development of a research agenda on prostate artery embolization (PAE). MATERIALS AND METHODS: PAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data. RESULTS: Final consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data. CONCLUSIONS: Level 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.

Angiographic Findings during Repeat Prostatic Artery Embolization.

PURPOSE: To describe mechanisms of prostate revascularization based on imaging findings during repeat prostatic artery embolization (PAE; rPAE). MATERIALS AND METHODS: This is a retrospective analysis of 10 rPAEs performed between October 2012 and September 2018 in patients with recurrent lower urinary tract symptoms (LUTS) after PAE (mean age, 68.2 y ± 4.5). Two interventional radiologists reviewed PAE and rPAE images and defined 6 patterns of revascularization. Correlation between embolization of the posterolateral (PL) prostatic branch during previous PAE and prostate revascularization on rPAE was assessed by Fisher exact test. One hemiprostate was excluded because no detectable revascularization was observed. RESULTS: All patients showed LUTS improvement after previous PAEs (P < .01 for 5 outcome measures) and had recurrence during follow-up. rPAEs were performed a mean of 40.9 months after previous PAEs (18-96 mo). Of 19 hemiprostates analyzed, 11 presented revascularization by 2 or more branches (57.9%). The PL branch (29.0%) and the recanalized main prostatic artery (25.8%) were the most frequent revascularizing branches observed, followed by distal branches of obturator (12.9%), internal pudendal (12.9%), superior vesical (12.9%), and contralateral arteries (6.5%). Embolization of the PL branch during previous PAE significantly reduced the incidence of revascularization by this branch (P = .002). CONCLUSIONS: Mechanisms of revascularization in rPAE are diverse and complex. Revascularization by the PL branch and recanalization of the previously embolized prostatic artery were the most frequent patterns observed. Embolization of the PL branch may reduce the incidence of prostate revascularization and LUTS recurrence after PAE.

Impact of 5-Alpha-Reductase Inhibitors Use at the Time of Prostatic Artery Embolization for Treatment of Benign Prostatic Obstruction.

PURPOSE: To compare the 12-month post-prostatic artery embolization (PAE) clinical outcomes of patients who were and were not taking 5-alpha-reductase inhibitors (5ARIs) at the time of PAE. MATERIALS AND METHODS: A retrospective review was conducted of patients who underwent PAE from 2010 to 2017 due to lower urinary tract symptoms, secondary to benign prostatic hyperplasia (BPH). One hundred fifty-five patients were included and divided in 2 groups; these groups did not present statistically significant differences in their baseline characteristics-those taking 5ARIs (Y-5ARIs, n = 40) and those not taking 5ARIs (N-5ARIs, n = 115). International Prostate Symptom Score (IPSS), the sub-item Quality of Life (QoL), and the incidence of clinical failure were used as primary endpoints. Secondary endpoints included mean prostate volume reduction and mean peak flow rate (Qmax) improvement. Clinical failure or recurrence was defined as absence of symptomatic improvement (IPSS ≥ 8 or QoL ≥ 3) or the need for invasive BPH treatment (PAE or transurethral resection of the prostate) during the 12-month follow-up period. RESULTS: After 12-month follow-up, IPSS, QoL, and prostatic volume were significantly lower compared to baseline in both groups, and Qmax showed a significant increase. No statistically significant differences were observed in outcomes between N-5ARIs and Y-5ARIs, and the clinical failure rate for both groups was approximately 20%. CONCLUSIONS: The use of 5ARIs did not show a detrimental effect on clinical outcomes of PAE, in either subjective (IPSS, QoL, and clinical failure) or objective (prostatic volume and Qmax) parameters.

Evaluation of Morphological and Clinical Factors Related to Failure of Percutaneous Treatment with Thrombin Injection of Femoral Pseudoaneurysms from Cardiac Catheterization.

BACKGROUND: Ultrasound-guided thrombin injection (UGTI) has become the method of choice in the treatment of pseudoaneurysm caused by endovascular procedures because it is minimally invasive, costs less, and effective, with short hospitalization time. The objective was identify the morphological aspects of femoral pseudoaneurysms and clinical aspects of patients that may lead to the failure of UGTI in femoral pseudoaneurysms after cardiac catheterization. POPULATION AND METHOD: From December 2012 to December 2016, 60 patients with pseudoaneurysms caused by cardiac catheterization were referred to the interventional radiology unit to be treated with UGTI. Medical charts were retrospectively reviewed for comorbidities, use of antiplatelet agents, anticoagulation, indication of cardiac catheterization, and so forth. Morphological aspects of the pseudoaneurysms such as volume, diameter (anteroposterior, laterolateral, and longitudinal), length, and diameter of the neck were analyzed. RESULTS: Technical success of UGTI was achieved in 100%. No clinical aspects of the patients were statistically significant for UGTI failure in occlusion of the pseudoaneurysms. For morphological aspects of pseudoaneurysm: anteroposterior (P = 0.029), longitudinal (P = 0.020), and neck diameters (P = 0.004) were statistically significant for UGTI failure. Logistic regression analysis for longitudinal diameter showed that for each centimeter, there was a 2.66 chance of failure of pseudoaneurysm thrombosis in a single thrombin injection session (95% confidence interval: 1.33-5.30). For longitudinal and neck diameters greater than 1.8 cm and 0.55 cm, respectively, there is a greater probability of needing more than one UGTI session for complete thrombosis. CONCLUSIONS: Among variables, the longitudinal dimension was more significant, and in a larger diameter, the treatment with thrombin injection presented greater complexity.

Outcomes of endovascular treatment of renal arterial stenosis in transplanted kidneys.

OBJECTIVE: To evaluate the effectiveness and outcomes of endovascular treatment of TRAS with PTA. MATERIALS AND METHODS: We searched our prospectively collected database looking at cases of TRAS between January 2005-December 2011. CCT was the gold-standart for diagnosis of TRAS. Parameters analysed comprised technical aspects, arterial blood pressure variation, and renal function. A minimum follow-up of 24 months was considered. RESULTS: Of the 2221 renal transplants performed in the selected period, 22 (0.9%) patients were identifi ed with TRAS. Fourteen (63.6%) were male and mean age was 377±14.8years (12-69). Kidney graft was from deceased donnors in 20 (80%) cases. On doppler evaluation, mean blood fl ow speed after transplantation, at TRAS diagnosis and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p<0.001). For SBP and DBP, there was a signifi cant difference between between preintervention and all post-treatment time points (p<0.001). After 1 month of the procedure, there was stabilization of the Cr level with a signifi cant difference between mean Cr levels along time (p<0.001). After a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. CONCLUSIONS: Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS, ensuring the functionality of the graft and normalization of blood pressure and renal function.

Role of Urodynamic Studies in Management of Benign Prostatic Obstruction: A Guide for Interventional Radiologists.

Urodynamic testing is the most accurate representation of bladder outlet obstruction physiology. As prostate artery embolization becomes an increasingly common therapy for benign prostatic obstruction, knowledge of urodynamic assessment and reports can assist the interventional radiologist in selecting appropriate patients. This review summarizes the role of urodynamic studies in the management of benign prostatic obstruction, including patient selection, interpretation of urodynamic studies, and their potential to predict patient outcomes.

Pediatric Liver Transplant: Techniques and Complications.

Liver transplant is considered to be the last-resort treatment approach for pediatric patients with end-stage liver disease. Despite the remarkable advance in survival rates, liver transplant remains an intricate surgery with significant morbidity and mortality. Early diagnosis of complications is crucial for patient survival but is challenging given the lack of specificity in clinical presentation. Knowledge of the liver and vascular anatomy of the donor and the recipient or recipients before surgery is also important to avoid complications. In this framework, radiologists play a pivotal role on the multidisciplinary team in both pre- and postoperative scenarios by providing a road map to guide the surgery and by assisting in diagnosis of complications. The most common complications after liver transplant are (a) vascular, including the hepatic artery, portal vein, hepatic veins, and inferior vena cava; (b) biliary; (c) parenchymal; (d) perihepatic; and (e) neoplastic. The authors review surgical techniques, the role of each imaging modality, normal posttransplant imaging features, types of complications after liver transplant, and information required in the radiology report that is critical to patient care. They present an algorithm for an imaging approach for pediatric patients after liver transplant and describe key points that should be included in radiologic reports in the pre- and postoperative settings. Online supplemental material is available for this article. ©RSNA, 2017.

Tracheoinnominate Fistula: Endovascular Treatment with a Stent Graft in a 4-Year-Old Child.

A 4-year-old boy presented with acute and profuse bleeding at the tracheostomy site. An emergency angiography was performed and identified a pseudoaneurysm at the innominate artery. A selective catheterization of the artery was executed and 2 Advanta V12 balloon-expandable covered stents were implanted in an overlapping manner to occlude the pseudoaneurysm. Final angiography demonstrated patency of the innominate artery and no signs of bleeding. The patient had no postoperative complications and no further bleeding during follow-up. A contrasted computed tomography scan was performed after 20 days and demonstrated no signs of pseudoaneurysm or bleeding. After 4 months, the patient was readmitted to tracheal dilatation and change of T-tube and died of respiratory complications.

Retrograde Proximal Anterior Tibial Artery Access for Treating Femoropopliteal Segment Occlusion: A Novel Approach.

Some challenges have been detected when there are long and complex lesions of femoropopliteal arterial occlusive disease, even with descriptions of the retrograde pedal approaches. The aim of this article is to describe the retrograde proximal anterior tibial artery access for treatment of femoropopliteal segment occlusion when antegrade recanalization failed (retrograde recanalization and rearranging the system into an antegrade position). Technical and clinical success was achieved in 100% of 4 cases, with an improvement of at least 2 Rutherford classes. Minor complication, small hematoma in an anterior compartment of the limb, occurred in 1 patient. No sign of compartmental syndrome was observed.

Malignant paraganglioma in children treated with embolization prior to surgical excision.

BACKGROUND: Paragangliomas (PGL) are rare tumors derived from neural crest cells, whose origins may vary along the chain of the sympathetic nervous system. Such tumors are often characterized by secretion of catecholamines, but sometimes they are biochemically inactive, which makes diagnosis often challenging. Malignant paraganglioma is defined by the presence of this tumor at sites where chromaffin cells are usually not found or by local invasion of the primary tumor. Recurrence, either regional or metastatic, usually occurs within 5 years of the initial complete resection but long-term recurrence is also described. Malignancy is often linked to a SDHB mutation. Preoperative embolization has been applied in the surgical management of PGLs with the objective to decrease intra-operative blood loss and surgery length without complications. CASE PRESENTATION: We report two cases of patients with abdominal or pelvic malignant PGLs who have been treated surgically at our center after preoperative embolization. Surgery was a very challenging procedure with multiple surgical teams involved and embolization did not prevent major blood loss and intraoperative complications. Patients required adjuvant treatment with either chemotherapy or radiotherapy. CONCLUSIONS: Many studies in the adult population have established recommendations for the diagnosis and therapeutic management of PGL, but few studies concern the pediatric population. Because malignant PGL is more important in the pediatric population, screening and early diagnosis of PGL is advisable in children with genetic predisposing. Surgical resection is the mainstay of treatment, but a multimodal approach is often required due to the complexity of cases.  The role of preoperative embolization is not established and in our experience it has provided little benefit and major complications.

Prostatic artery embolization for treatment of benign prostatic hyperplasia in patients with prostates > 90 g: a prospective single-center study.

PURPOSE: To describe the safety and efficacy of prostatic artery embolization (PAE) with spherical microparticles to treat lower urinary tract symptoms associated with benign prostatic hyperplasia in patients with prostate volume > 90 g. MATERIALS AND METHODS: This prospective, single-center, single-arm study was conducted in 35 patients with prostate volumes ranging from 90-252 g. Mean patient age was 64.8 years (range, 53-77 y). Magnetic resonance imaging, uroflowmetry, and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes. RESULTS: Mean prostate size decreased significantly from 135.1 g before PAE to 91.9 g at 3 months of follow-up (P < .0001). Mean IPSS and quality-of-life index improved from 18.3 to 2.7 and 4.8 to 0.9 (P < .0001 for both), respectively. A significant negative correlation was observed between prostate-specific antigen at 24 hours after PAE and IPSS 3 months after PAE (P = .0057). CONCLUSIONS: PAE is a safe and effective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia in patients with prostate volume > 90 g. Excessively elevated prostate-specific antigen within 24 hours of PAE is associated with lower symptom burden in short-term follow-up.