[Successful therapy of non-cirrhotic non-malignant portal vein thrombosis (NCNMPT) by interventional therapy using transjugular lysis catheter]. / Erfolgreiche Interventionelle Therapie eines Patienten mit nichtzirrhotischer nichtmaligner Pfortaderthrombose mit lokaler Lyse.

NCNMPT is a rare condition with a prevalence of 0.3%. THERAPY: Patient (69 y) with NCNMPT and small bowel ileus received interventional therapy using transjugular local lysis into the superior mesenteric vein. OUTCOME/DISCUSSION: Successful lysis with complete remission. Improved therapeutic efficacy of interventional versus drug therapy alone.

In vitro measurements of radiation exposure with different modalities (computed tomography, cone beam computed tomography) for imaging the petrous bone with a pediatric anthropomorphic phantom.

BACKGROUND: Various imaging modalities, such as multi-detector computed tomography (CT) and cone beam CT are commonly used in infants for the diagnosis of hearing loss and surgical planning of implantation hearing aid devices, with differing results. OBJECTIVE: We compared three different imaging modalities available in our institution, including a high-class CT scanner, a mid-class CT scanner and an angiography system with a cone beam CT option, for image quality and radiation exposure in a phantom study. MATERIALS AND METHODS: While scanning an anthropomorphic phantom imitating a 1-year-old child with vendor-provided routine protocols, organ doses, surface doses and effective doses were determined for these three modalities with thermoluminescent dosimeters. The image quality was evaluated using the signal difference to noise ratio (SDNR) and the spatial resolution of a line-pair insert in the phantom head. The dose efficiency, defined as the ratio of SDNR and effective dose, was also compared. RESULTS: The organ and surface doses were lowest with the high-class CT protocol, but the image quality was the worst. Image quality was best with the cone beam CT protocol, which, however, had the highest radiation exposure in this study, whereas the mid-class CT was in between. CONCLUSION: Based on our results, high-end CT should be used for surgical planning because it has the lowest dose, while the image quality is still sufficient for this purpose. However, if highest image quality is needed and required, e.g., by ENT surgeons, the other modalities should be considered.

Radioembolization With Holmium-166 Polylactic Acid Microspheres: Distribution of Residual Activity in the Delivery Set and Outflow Dynamics During Planning and Treatment Procedures.

PURPOSE: To evaluate the microsphere outflow dynamics and residual Ho-166 activity during and after transarterial radioembolization planning and treatment procedures, and to assess the distribution and predilection sites of residual activity in the proprietary delivery set and the microcatheter. MATERIALS AND METHODS: Fifteen planning and 12 therapeutic radioembolization procedures were performed with poly-l-lactic acid microspheres loaded with Ho-166. The amount and distribution of residual activity was assessed by dose calibrator measurements and SPECT imaging. The activity flow profile from the microcatheter was assessed dynamically. For planning procedures, different injection methods were evaluated in order to attempt to decrease the residual activity. RESULTS: The median residual activities for planning and treatment procedures using standard injection methods were 31.2% (range 17.3%-44.1%) and 4.3% (range 3.5%-6.9%), respectively. Planning residual activities could be decreased significantly with 2 injection methods similar to treatment procedures, to 17.5% and 10.9%, respectively (P = 0.002). Main predilection sites of residual microspheres were the 3-way stopcock and the outflow needle connector. During treatment procedures, more than 80% of the injected activity is transferred during the first 3 injection cycles. CONCLUSION: After treatment procedures with holmium-loaded microspheres, mean residual activity in the delivery set is reproducibly low and between reported values for glass and resin microspheres. The majority of microspheres is transferred to the patient during the second and third injection cycle. An estimated residual waste of 3% to 4% may be included in the treatment activity calculation. For planning procedures, a modified injection technique should be used to avoid high residual activities.

Simultaneous right-sided nephrectomy with orthotopic liver and kidney transplantation-An alternative method for patients with autosomal dominant polycystic liver and kidney disease.

PURPOSE: In patients suffering from autosomal dominant polycystic liver and kidney disease (ADPLKD), combined organ transplantation often poses a technical challenge due to the large volume of both organs. To simplify the transplantation procedure by improving the exposure of anatomical structures, we introduce a novel surgical technique of orthotopic liver and kidney transplantation. METHODS: The modified simultaneous liver and kidney transplantation technique via a right-sided L-incision included three steps: (1) right-sided nephrectomy in the recipient followed by (2) orthotopic liver transplantation in cava replacement technique and (3) the orthotopic kidney transplantation with arterial reconstruction to the right common iliac artery. RESULTS: In total, seven patients with ADPLKD were transplanted by using the modified transplantation technique. The mean operation time was 342.43 min (±68.77). Postoperative patients were treated for 6.28 days (±2.50) in the intensive care unit and were discharged from the surgical ward approximately 28 days (±5.66) after the operation with normal graft function. Complications associated with the use of the modified technique, such as bleeding, anastomotic stenosis, biloma, or urinoma, did not occur. CONCLUSION: Modified simultaneous liver and kidney transplantation is a safe alternative for patients with ADPLKD. By combining right-sided nephrectomy and orthotopic graft transplantation, the approach optimizes the exposure of anatomical structures and simplifies the transplantation procedure. Additionally, the modified transplantation technique does not require a particular organ explantation procedure and can be applied for all liver and kidney grafts.

Virtual inverted classroom to replace in-person radiology lectures at the time of the COVID-19 pandemic - a prospective evaluation and historic comparison.

BACKGROUND: In the time of the coronavirus disease 2019 (COVID-19) pandemic, in-person lectures had to be shifted to online learning. This study aimed to evaluate students' and lecturers' perception and effectiveness of a virtual inverted classroom (VIC) concept on clinical radiology in comparison to a historic control. METHODS: In the winter semester 2020/21, 136 fourth year medical students who completed the clinical radiology VIC during the pandemic, were included in the single centre, prospective study. Results were compared with a historic control that had finished the physical inverted classroom (PIC) in the immediately preceding year. The VIC consisted of an initial phase of self-determined preparation with learning videos and a second interactive phase of clinical case studies alternating between the virtual lecture hall and virtual buzz groups. At the end of the lecture series, students rated the lecture on a scale of 1 (most positive assessment) to 6 (most negative assessment) through an online survey platform. Additionally, they reported their impressions in free-form text. Lecturers were invited to comment on the VIC in a group interview. Main outcomes were final grades and student perception of the VIC. RESULTS: Students' general impression of VIC was lower than that of PIC (median value of 3 [IQR 4, 2] and 1 [IQR 0, 0], p < 0.001), respectively, p < 0.001). The highest rating was achieved concerning use of the audience response system (median 1 [IQR 1, 0]), and the lowest concerning the buzz groups (median 4 [IQR 5, 3]). Students stated that they would have appreciated more details on reading images, greater focus on plenary case studies, and provision of exam related scripts. Lecturers would have liked better preparation by students, more activity of students, and stronger assistance for group support. Exam grades after VIC were better than after PIC (median 1 [IQR 2, 1] and 2 [IQR 2,1], respectively, p < 0.001). CONCLUSIONS: Students' overall perception of VIC was satisfactory, although worse than PIC. Final grades improved compared to PIC. Provided an adapted buzz group size and support, VIC may serve as complement in medical education once the pandemic is over.

Structured work-based learning in undergraduate clinical radiology immersion experience.

BACKGROUND: Practical courses in undergraduate medical training often lack a didactic concept. Active participation and learning success largely depend on chance. This study was initiated to evaluate a novel concept of structured work-based learning (WBL) in the course of students' half-day radiology immersion experience (IE). METHODS: This prospective, single-centre cohort study included 228 third-year students of the 2019 summer semester who underwent the obligatory radiology IE at a university hospital. The course was based on a novel structured WBL concept that applied established didactic concepts including blended learning, the FAIR principles of feedback, activity, individualization, and relevance, and Peyton's four-step approach. Outcomes of equal weight were student and supervisor satisfaction with the clinical radiology IE assessed by paper-based- and online survey, respectively. Secondary outcome was achievement of intended learning outcomes assessed by means of mini clinical evaluation exercises and personal interviews. RESULTS: Satisfaction with structured WBL was high in 99.0% of students. Students' expectations were exceeded, and they felt taken seriously at the professional level. Dissatisfaction was reasoned with quality of learning videos (0.6%), little support by supervisors (0.5%), or inadequate feedback (0.6%). Supervising resident physicians rated achievement of intended learning outcomes regarding cognitive and psychomotor competences as excellent for all students. Personal interviews revealed achievement of affective competence in some students. Twelve of 16 (75.0%) supervising physicians were satisfied with focussing on intended learning outcomes and student preparation for IE. Two of 15 (13.3%) supervisors were unsatisfied with time spent, and 4 of 16 (25%) with the approach of assessment. CONCLUSIONS: This study demonstrated that both students and supervisors were satisfied with the novel concept of structured WBL within the scope of clinical radiology IE. Achievement of intended learning outcomes was promising.

Drug-coated Balloon Angioplasty of Femoropopliteal Lesions Maintained Superior Efficacy over Conventional Balloon: 2-year Results of the Randomized EffPac Trial.

Background Paclitaxel drug-coated balloon (DCB) catheter angioplasty is the preferred treatment for revascularization of femoropopliteal lesions in peripheral artery disease, but mortality is a safety concern. Purpose To assess 2-year efficacy and safety of DCB angioplasty compared with conventional balloon angioplasty (also known as plain old balloon angioplasty or POBA). Materials and Methods This prospective, multicenter, randomized controlled trial enrolled consecutive participants with symptomatic superficial femoral and/or popliteal artery disease at 11 German centers between September 2015 and December 2016. Participants underwent DCB angioplasty or conventional balloon angioplasty. Primary outcome of 6-month late lumen loss showed superiority of DCB angioplasty over conventional balloon angioplasty. Evaluation at 2 years included secondary outcomes of primary patency and target lesion revascularization (TLR) estimated with Kaplan-Meier analysis, clinical and hemodynamic improvement, quality of life, target limb amputation, and all-cause mortality. Results A total of 171 participants (mean age, 69 years ± 8; 111 men) were evaluated. At 2 years, primary patency was achieved in 90.2% (95% confidence interval [CI]: 80.4%, 95.2%) of DCB angioplasty and 62.7% (95% CI: 50.0%, 73.0%) of conventional balloon angioplasty participants (P < .001). Freedom from TLR occurred in 97.2% (95% CI: 89.1%, 99.3%) of DCB angioplasty and 78% (95% CI: 66.5%, 86.0%) of conventional balloon angioplasty participants (P = .001). The groups did not differ in sustained improvement from baseline to 2 years in Rutherford-Becker category (row mean scores difference, 1.7; P = .19) and showed no difference in mean improvement in the Walking Impairment Questionnaire score (-0.8%; 95% CI: -11.8%, 10.2%; P = .88), EuroQol Group's five-dimension index of quality of life (-0.06; 95% CI: -0.17, 0.03; P = .20), or ankle-brachial index (0.03; 95% CI: -0.08, 0.14; P = .57). No major amputation was necessary. One DCB angioplasty and two conventional balloon angioplasty participants died (risk ratio, 0.48; 95% CI: 0.04, 5.10). Conclusion At 2 years after paclitaxel drug-coated balloon (DCB) angioplasty, primary patency and freedom from target lesion revascularization remained superior compared with conventional balloon angioplasty. DCB angioplasty resulted in sustained clinical and hemodynamic improvement with no increased risk of mortality. © RSNA, 2020 Online supplemental material in available for this article.

Transarterial Radioembolization with Yttrium-90 Glass Microspheres: Distribution of Residual Activity and Flow Dynamics during Administration.

PURPOSE: To evaluate the microsphere flow dynamics and residual yttrium-90 (90Y) activity during and after transarterial radioembolization with glass microspheres and to assess the distribution and predilection sites of residual activity in the administration devices. MATERIALS AND METHODS: In this laboratory investigation, after 18 consecutive clinical transarterial radioembolization and 4 ex vivo experimental procedures with 90Y glass microspheres, the distribution of residual activity in the administration devices was assessed by activimeter and positron emission tomography (PET)/CT measurements. During ex vivo procedures, microsphere outflow from the administration device was assessed by dynamic scintigraphic measurements. RESULTS: Mean residual activity was 3.4% ± 1.7 (range, 0.9%-8.8%). Calculations showed a negative correlation between relative residual activity and prescribed activity (r = -0.4258, P = .0486) and a positive correlation between absolute residual activity and prescribed activity (r = 0.5345, P = .0104). The main predilection site was the Luer-Lok microcatheter connector. Lower activities were detected in the dose vial. Flow measurements showed that more than 98% of the final injected activity was transferred to the patient with the first 20 mL of saline solution. CONCLUSIONS: Residual activity in the standard administration device for glass microsphere radioembolization is considered to be low compared with similar procedures, but is variable. The microsphere flow profile shows an initial peak, resulting in a rapid activity transfer at the beginning of the injection process. The findings may have implications for safe handling of the administration device and for dose calculation of 90Y glass microspheres.

Prostatic Artery Embolization-Anatomic Predictors of Technical Outcomes.

PURPOSE: To determine if cone-beam CT and digital subtraction angiography analysis of pelvic arterial anatomy has predictive value for radiation exposure and technical success of prostatic artery embolization (PAE). MATERIALS AND METHODS: This prospective, nonrandomized, single-center study included 104 consecutive patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. Cone-beam CT was performed in 160/208 (76.9%) hemipelves to determine prostatic artery (PA) origin. Classification of pelvic arterial tortuosity was possible in 73/104 (70.2%) patients. Learning curves of 2 interventionalists who performed 86.5% of PAEs were analyzed. RESULTS: Tortuosity of pelvic arteries was classified as mild in 25 (34.2%) patients median age 64 years, moderate in 40 (54.8%) patients median age 69 years, and severe in 8 (11.0%) patients median age 70 years (mild vs moderate, P = .002; mild vs severe, P = .019); median fluoroscopy times were 24, 36, and 46 minutes (P = .008, P = .023); median contrast volumes were 105, 122.5, and 142 mL (P = .029, P = .064); and bilateral PAE rates were 84.0%, 77.5%, and 62.5% (P = .437), respectively. PA origin from superior vesical artery was most frequent (27.5%) and showed higher dose area product (median 402.4 vs 218 Gy ∙ cm2, P = .033) and fluoroscopy time (median 42.5 vs 27 min, P = .01) compared with PA origin from obturator artery, which was least frequent. Interventionalist experience revealed significant impact on procedure times (median 159 vs 130 min, P = .006). CONCLUSIONS: Tortuosity of pelvic arteries was more frequent in older patients and predicted worse technical outcomes of PAE. PA origin from obturator artery was associated with lower dose area product and fluoroscopy time, especially compared with PA origin from superior vesical artery. Interventionalist experience showed significant influence on technical outcome.

Case report of a cystic parathyroidal adenoma with rapid growth induced by cinacalcet.

BACKGROUND: Primary hyperparathyroidism is a rare condition of disease which can seldomly present as giant retrotrhyroideal cysts, complicating the localization of the adenoma to resect. CASE PRESENTATION: A 56-year old female presented with hypercalcaemia of 3.38 mmol/L (2.2-2.65 mmol/L) and a history of breast cancer. A fast growing cystic parathyroidal adenoma was diagnosed by a multimodal approach including comprehensive diagnostic imaging (ultrasonography, scintigraphies, dynamic MRI) and cytopathological investigations after ultrasonography-guided puncture. The patient was cured by surgical extraction of the whole adenoma. In retrospect, the rapid growth was most likely induced by cinacalcet (initially 30 mg/d, later 60 mg/d) therapy which the patient received for few months only. Primary hyperparathyroidism was ascertained because surgical removal of the solitary adenoma cured the patient. Furthermore, there was no relevant renal insufficiency or history of prolonged calcium-level deregulation. CONCLUSIONS: This phenomenon of cystic degeneration of parathyroidal adenoma under therapy with cinacalcet has previously been described in secondary hyperparathyroidism, but not in primary hyperparathyroidism and should be considered in diagnostic approach.

Dyna-CT of the temporal bone for case-specific three-dimensional rendering of the stapedial muscle for planning of electrically evoked stapedius reflex threshold determination during cochlear implantation directly from the stapedius muscle via a retrofacial approach: a pilot study.

PURPOSE: Evaluation of 3D Dyna-CTs to improve cochlear implantation (CI) planning and intraoperative electrically elicited stapedius reflex threshold (ESRT) measurements. METHODS: A prospective observational cohort study was performed. Anonymized data collection of Dyna-CTs and CI surgeries in which a retrofacial approach was implemented to access the stapedius muscle. 3D Dyna-CTs of 30 patients and the intraoperative confirmation of the predication in 5/30 patients during CI surgery were evaluated. Inter-rater reliability was also analyzed along with the predictive value of this evaluation. RESULTS: 36 representative structures of the middle and inner ear and 3D renderings of the Dyna-CTs were evaluated by four otoneurological surgeons. Fleiss' kappa values for the evaluation of the visibility were high (> 0.7) for most of the anatomical structures. The stapedius muscle was visible in 90% of the cases. Using the 3D data, the retrofacial access to the stapedius muscles was estimated as feasible in 86.7%. Fleiss' kappa value of the evaluation of the accessibility was 0.942. The intraoperative exploration of the stapedius muscle confirmed the preoperative prediction in all five selected patients (four patients with predicted accessibility and one patient with predicted inaccessibility). CONCLUSIONS: The use of Dyna-CT and 3D rendering is a helpful tool for preoperative planning of cochlear implantations and ESRT measurements from the stapedius muscle via the retrofacial approach.

[Endovascular Therapy of Splanchnic Artery Aneurysms: For Each and Every Aneurysm?] / Endovaskuläre Therapie von Viszeralarterienaneurysmata ­ geht das immer?

True visceral artery aneurysms (VAA) and visceral artery pseudoaneurysms (VAPA) are located in the celiac trunk, the superior mesenteric artery and inferior mesenteric artery. In addition to surgical treatment, endovascular embolisation therapy of visceral aneurysms and pseudoaneurysms is an alternative interventional method that has developed precipitously over the last two decades and is considered a first-choice method in many centres. The procedure is characterised by a high technical success rate with a low complication rate. This article presents the basic principles of endovascular treatment and discusses the indications and limitations of the procedure.

Prostatic Artery Embolization with 250-µm Spherical Polyzene-Coated Hydrogel Microspheres for Lower Urinary Tract Symptoms with Follow-up MR Imaging.

PURPOSE: To evaluate clinical outcomes and possible MR imaging predictors of clinical success after prostatic artery embolization (PAE) with 250-µm hydrogel particles. MATERIALS AND METHODS: During a span of 1.5 years, 30 patients with moderate to severe lower urinary tract symptoms were included in a prospective, nonrandomized study. Embolization of at least one prostatic artery was considered as technical success. International Prostate Symptom Score (IPSS), quality of life (QOL), peak urinary flow rate (Qmax), residual urine volume, prostate volume, prostate-specific antigen level, and International Index of Erectile Function (IIEF) were recorded at baseline and at 1, 3, and 6 months after PAE. Multiparametric MR imaging was performed before PAE (n = 25) and 1 day (n = 25), 1 month (n = 7), 3 months (n = 7), and 6 months (n = 22) after intervention. A Wilcoxon-Mann-Whitney test was used to assess changes over time, and Spearman rank-correlation coefficient was used for outcome prediction. RESULTS: PAE was technically successful in 90% of patients (n = 27). Clinical success (IPSS < 18 with decrease > 25% and QOL score < 4 with decrease ≥ 1 or Qmax ≥ 15 mL/s and increase of ≥ 3.0 mL/s) rates were 59% (16 of 27), 63% (17 of 27), and 74% (20 of 27) after 1, 3, and 6 mo, respectively. IIEF scores did not differ significantly during follow-up. The following adverse events occurred after PAE: urethral burning (5 of 27), fever (2 of 27), and urethral bleeding, rectal bleeding, cystitis, and penile burning sensation (1 of 27 each). No statistical correlations between initial multiparametric MR imaging changes and clinical parameters after 6 months were found (P values from .14 to .98). CONCLUSIONS: PAE with 250-µm hydrogel microspheres led to good clinical success after 6 months with a low complication rate. Significant MR imaging predictors of clinical success were not identified.

Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer.

GOALS: The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. BACKGROUND: TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. STUDY: This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. RESULTS: The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. CONCLUSIONS: Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.

Pulmonary Artery Calcification in a 57-Year-Old Man.

CASE PRESENTATION: A 57-year-old man was admitted to our hospital via the ED presenting in reduced general condition because of an infection of unknown origin, generalized edema, and dyspnea at rest (peripheral capillary oxygen saturation, 89%) that required 2 L/min intranasal oxygen. Anamnesis was complicated by an infection-triggered delirium, but his wife reported an increasing physical decay that had led to bed confinement. The BP was reduced at 88/55 mm Hg with a normal heart rate of 86 beats/min. Lung auscultation showed mild bipulmonal rales. Previous comorbidities were a BMI of 42 kg/m2, an insulin-dependent type 2 diabetes mellitus with a severe diabetes-related chronic kidney disease stage G4A3, and systemic arterial hypertension.

A Very Rare Cause of Thrombotic Peripheral Occlusion.

A 45-year-old healthy woman presented with claudication of the right leg. The resting ankle-brachial index (ABI) was reduced to 0.6, and a duplex scan revealed an occlusion of the right popliteal artery. Angiography presented a patent superficial femoral artery that ends above the knee joint. Laterally, there was delayed retrograde contrast filling of the popliteal artery. After exploring the internal iliac artery, we crossed a thrombotic occlusion of a persisting sciatic artery (PSA). Local thrombolysis with recombinant tissue plasminogen activator (1 mg/h) was initiated. The Angiography 18 hours later showed a reduction of thrombotic material and relevant stenosis in the proximal part of the vessel. Residual thrombus and the stenosis were covered by two stentgrafts (Gore Viabahn Endoprosthesis) that were stabilized by an interwoven stent (Supera). Final angiography displayed a patent sciatic artery and a three-vessel run off. Postinterventional ABI was normalized to 1.0. The magnetic resonance imaging 6 days after the intervention demonstrated a patent PSA again and a normal blood flow on the left leg. A PSA should be included in the differential diagnosis of lower limb ischemia or suspected aneurysm formation. We demonstrated the feasibility of an interventional approach with an excellent outcome in this case.