Patient and Provider Perspectives of Telehealth and In-Person Interventional Radiology Clinic Visits.

PURPOSE: To assess patient and provider satisfaction with interventional radiology (IR) outpatient telehealth and in-person clinic. MATERIALS AND METHODS: This institutional review board-approved study analyzed patient satisfaction with clinic via survey after an IR outpatient telehealth or in-person visit. A physician telehealth experience survey was completed by 8 IR physicians. RESULTS: During the initial survey period, 44 (83%) of 53 patients completed a survey via telephone compared with 37 (23%) of 158 patients who were offered an electronic survey during the second survey period. Of 81 respondents, 18 (22%) were in-person and 63 (78%) were via telehealth. Of the respondents, nearly all patients (97%) in the telehealth group reported satisfaction with their telehealth clinic visit, with similar rates of high patient satisfaction between in-person and telehealth visits (P = .51). Most patients (98%) in the telehealth group strongly agreed that their physician's recommendations were clear in the telehealth visit and that their visit was private, similar to in-person visits (P = .13). A telehealth visit saved time for all patients (100%), with 78% reporting >1 hour of time-saving. All IR physicians (n = 8) reported greater efficiency with telehealth clinic than with in-person clinic and that follow-up patterns would change if telehealth was available. However, all providers (100%) found telephone visits less satisfying than in-person visits, with video visits being either equally satisfying (71%) or less satisfying (29%). CONCLUSIONS: Patient satisfaction with the in-person and telehealth outpatient IR clinic was high, with patients and providers reporting time-saving and greater efficiency with telehealth, suggesting that telehealth should remain an important component of outpatient IR clinic care.

Priming of Sorafenib Prior to Radiofrequency Ablation Does Not Increase Treatment Effect in Hepatocellular Carcinoma.

BACKGROUND: Preclinical studies have shown that modulation of the tumor microvasculature with anti-angiogenic agents decreases tumor perfusion and may increase the efficacy of radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC). Retrospective studies suggest that sorafenib given prior to RFA promotes an increase in the ablation zone, but prospective randomized data are lacking. AIMS: We conducted a randomized, double-blind, placebo-controlled phase II trial to evaluate the efficacy of a short-course of sorafenib prior to RFA for HCC tumors sized 3.5-7 cm (NCT00813293). METHODS: Treatment consisted of sorafenib 400 mg twice daily for 10 days or matching placebo, followed by RFA on day 10. The primary objectives were to assess if priming with sorafenib increased the volume and diameter of the RFA coagulation zone and to evaluate its impact on RFA thermal parameters. Secondary objectives included feasibility, safety and to explore the relationship between tumor blood flow on MRI and RFA effectiveness. RESULTS: Twenty patients were randomized 1:1. Priming with sorafenib did not increase the size of ablation zone achieved with RFA and did not promote significant changes in thermal parameters, although it significantly decreased blood perfusion to the tumor by 27.9% (p = 0.01) as analyzed by DCE-MRI. No subject discontinued treatment owing to adverse events and no grade 4 toxicity was observed. CONCLUSION: Priming of sorafenib did not enhance the effect of RFA in intermediate sized HCC. Future studies should investigate whether longer duration of treatment or a different antiangiogenic strategy in the post-procedure setting would be more effective in impairing tumor perfusion and increasing RFA efficacy.

Neoadjuvant Yttrium-90 Transarterial Radioembolization with Resin Microspheres Prescribed Using the Medical Internal Radiation Dose Model for Intrahepatic Cholangiocarcinoma.

PURPOSE: To evaluate outcomes of patients with intrahepatic cholangiocarcinoma (iCCA) undergoing neoadjuvant yttrium-90 (90Y) transarterial radioembolization (TARE) with resin microspheres prescribed using the Medical Internal Radiation Dose (MIRD) model. MATERIALS AND METHODS: This retrospective institutional review board-approved study included 37 patients with iCCA treated with 90Y-TARE from October 2015 to September 2020. The primary outcome was overall survival (OS) from 90Y-TARE. The secondary outcomes were progression-free survival (PFS), Response Evaluation Criteria In Solid Tumors 1.1 imaging response, and downstaging to resection. Patients with tumor proximity to the middle hepatic vein (<1 cm) and/or insufficient future liver remnant were treated with neoadjuvant intent (n = 21). Patients were censored at the time of surgery or at the last follow-up for the Kaplan-Meier survival analysis. RESULTS: For 31 patients (69 years; interquartile range, 64-74 years; 20 men [65%]) included in the study, the first-line therapy was 90Y-TARE for 23 (74%) patients. Imaging assessment at 6 months showed a disease control rate of 86%. The median PFS was 5.4 months (95% confidence interval [CI], 3-not reached). The PFS was higher after first-line 90Y-TARE (7.4 months [95% CI, 5.3-not reached]) than that after subsequent 90Y-TARE (2.7 months [95% CI, 2-not reached]) (P = .007). The median OS was 22 months (95% CI, 7.3-not reached). The 1- and 2-year OS rates were 60% (95% CI, 41%-86%) and 40% (95% CI, 19.5%-81%). In patients treated with neoadjuvant intent, 11 of 21 patients (52%) underwent resections. The resection margins were R0 and R1 in 8 (73%) and 3 (27%) of 11 patients, respectively. On histological review in 10 patients, necrosis of ≥90% tumor was achieved in 7 of 10 patients (70%). CONCLUSIONS: First-line 90Y-TARE prescribed using the MIRD model as neoadjuvant therapy for iCCA results in good survival outcome and R0 resection for unresectable patients.

Society of Interventional Radiology Multidisciplinary Position Statement on Percutaneous Ablation of Non-small Cell Lung Cancer and Metastatic Disease to the Lungs: Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology.

PURPOSE: To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung. MATERIALS AND METHODS: A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements. RESULTS: A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung. CONCLUSION: SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

Image-guided Microinvasive Percutaneous Treatment of Breast Lesions: Where Do We Stand?

Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ©RSNA, 2021.

Analysis of Kinematic Differences in Hand Motion between Novice and Experienced Operators in IR: A Pilot Study.

PURPOSE: To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation. METHODS: Sheath task: Six attending interventional radiologists (experts) and 6 radiology trainees (trainees) placed a wire through a sheath and performed a "pin-pull" maneuver, while an electromagnetic motion detection system recorded the hand motion. Radial task: Eight experts and 12 trainees performed palpatory radial artery access task on a radial access simulator. The trainees repeated the task with the nondominant hand. The experts were classified by their most frequent radial artery access technique as having either palpatory, ultrasound, or overall limited experience. The time, path length, and number of movements were calculated. Mann-Whitney U tests were used to compare the groups, and P < .05 was considered significant. RESULTS: Sheath task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (11.7 seconds ± 3.3 vs 19.7 seconds ± 6.5, P < .01; 1.1 m ± 0.3 vs 1.4 m ± 0.4, P < .01; and 19.5 movements ± 8.5 vs 31.0 movements ± 8.0, P < .01, respectively). Radial task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (24.2 seconds ± 10.6 vs 33.1 seconds ± 16.9, P < .01; 2.0 m ± 0.5 vs 3.0 m ± 1.9, P < .001; and 36.5 movements ± 15.0 vs 54.5 movements ± 28.0, P < .001, respectively). The trainees had a shorter path length for their dominant hand than their nondominant hand (3.0 m ± 1.9 vs 3.5 m ± 1.9, P < .05). The expert palpatory group had a shorter path length than the ultrasound and limited experience groups (1.8 m ± 0.4 vs 2.0 m ± 0.4 and 2.3 m ± 1.2, respectively, P < .05). CONCLUSIONS: Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.

Yttrium-90 radioembolization using MIRD dosimetry with resin microspheres.

OBJECTIVE: To review the technical feasibility of resin microsphere (SIR-Spheres®) yttrium-90 radioembolization prescribed using the medical internal radiation dose (MIRD) model. METHODS: All radioembolization procedures for hepatic malignancies using resin microspheres with MIRD model between November 2015 and February 2019 were included in this IRB-approved study (n = 60). Student's T test was used to compare prescribed activity based on MIRD and BSA models. Adverse events were assessed immediately, 30 days, and 6 months post-treatment. RESULTS: Sixty radioembolizations were performed in 54 patients (age 68 ± 9 years, 48-87 years, 35% female). Mean prescribed activity calculated by the MIRD model (target absorbed dose 120-200 Gy for primary and 80-200 Gy for metastatic liver cancers) was 1.7 GBq (0.3-6.4) compared with 0.6 GBq (0.12-2.1) if BSA had been used (p < 0.0001). The prescribed activity was successfully delivered in 93% (56/60) treatments. Prophylactic embolization and anti-reflux catheters were used in 20% (12/60) and 5% (3/60) treatments, respectively. No immediate post-procedural complications occurred. Abdominal pain was the most common clinical Grade 3 CTCAE in 30 days (10%) and 6 months (12%). Radiation pneumonitis occurred in 3 (5%) patients but no radiation-induced gastric ulcer or radiation-induced liver disease occurred. CONCLUSION: MIRD dosimetry results in higher prescribed activity compared with BSA dosimetry with resin microspheres. MIRD prescribed activity with target absorbed doses up to 200 Gy can be successfully administered without prophylactic embolization in selected patients. KEY POINTS: •MIRD dosimetry results in higher prescribed activity compared with BSA dosimetry for radioembolization. •MIRD dosimetry can be used for yttrium-90 resin microsphere radioembolization with acceptable safety profile.

Transitioning the IR Clinic to Telehealth: A Single-Center Experience during the COVID-19 Pandemic.

Telehealth has not previously been widely implemented as a result of regulatory and reimbursement concerns; however, in the current national emergency of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services has relaxed many of its rules, allowing increased adoption of telehealth services, improving the safety and access of outpatient health care. A complete understanding of the regulatory requirements, technologic options, and billing processes of telehealth is required to initiate a successful clinic. A model is presented here based on a single institution's experience with implementing telehealth in the outpatient interventional radiology clinic.

Treating short bowel syndrome with pharmacotherapy.

INTRODUCTION: Short bowel syndrome (SBS) has traditionally been regarded as a rapidly fatal medical catastrophe. The advent of pharmacological options directly targeting disease pathophysiology justified this review. AREAS COVERED: Since the 1970s, home parenteral nutrition has reduced mortality, converting SBS into a chronic and disabling compensated and occasionally curable illness. Off-label antidiarrheal drugs and related products, though having minimal scientific evidence of efficacy, represent the standard-of-care and are here reviewed. Trophic intestinal hormones, including GLP-2 and its analogs, have great promise for alleviating malabsorption, the most important symptom within a nonsurgical, routine outpatient framework. Current indications involve adults with massive intestinal losses (fecal wet weight >1500 g/day). Surgical options such as intestinal lengthening or transplantation are also addressed although these options are considerably more aggressive and have stricter indications. EXPERT OPINION: GLP-2 analogs are the first candidates from a pioneering pharmacotherapic family within the SBS framework, namely disease-modifying, absorption-restoring agents. This family of drugs, potentially applicable in all contexts of severe intestinal loss, could become the therapeutic benchmark of the near future.

Impact of evaluation in interventional radiology clinic prior to uterine artery embolization: changes in management.

PURPOSE: To assess the impact of pre-procedural evaluation of patients with symptomatic uterine fibroids and adenomyosis in interventional radiology (IR) clinic. METHOD: In this IRB-approved, HIPAA-compliant retrospective study, consecutive patients evaluated in the IR clinic in a tertiary academic hospital between 1/1/2015 and 9/30/2018 by a single board-certified interventional radiologist were included. Medical records were reviewed to obtain medical history, imaging and endometrial biopsies results. Impact of IR clinic assessment of clinical, imaging, and pathological findings on patient's clinical course was assessed. Descriptive statistics were used. RESULTS: 208 consecutive patients were evaluated in clinic for uterine fibroids 176/208 (85%), adenomyosis 8/208 (4%) or both 24/208 (11%) with age of 44.4 ± 5.8 years and BMI of 30.1 ± 8.6 kg/m2. Leading presenting symptom was menorrhagia in 172/208 (80%) patients, pelvic pain in 91/208 (44%), and urinary symptoms in 88/208 (42%) patients. 159/208 (76%) patients underwent UAE, 12/208 (6%) patients underwent surgery, and 37/208 (18%) patients chose conservative management. 189/208 (91%) patients had pelvic MRI that altered management course in 7/189 (4%) patients due to intracavitary fibroids in two patients, endometrial polyps in two patients, non-enhancing fibroids in two patients, and adnexal mass in one patient. 166/208 (80%) underwent endometrial biopsy that altered management course in one patient (0.6%) due to endometrial intraepithelial neoplasia. CONCLUSION: Endometrial biopsy and pelvic MRI are helpful to detect cases of non-enhancing fibroids, intracavitary fibroids, and ovarian and endometrial malignancies and thus altered management of five percent of patients with symptomatic fibroids and adenomyosis.

Transradial and Transfemoral Uterine Fibroid Embolization Comparative Study: Technical and Clinical Outcomes.

PURPOSE: To compare clinical and technical outcomes of transradial (TRA) uterine artery embolization (UAE) with those of the transfemoral (TFA) approach. MATERIALS AND METHODS: Consecutive patients who underwent UAE with TRA and TFA in an academic hospital between May 2014 and June 2018 were included in this study. The ability to perform the procedure as planned, complication rates, and reduction in uterine volume, fibroid enhancement, and symptomatic improvement were compared using descriptive statistics, Student t-test, and chi-square test. RESULTS: There were 91 patients in the TFA group and 91 patients in the TRA group, with 1 crossover to TFA due to vasospasm (1 of 91; 1%). The tallest patient in the TRA UAE group was 178 cm and 4 patients taller than 178 cm in the TFA UAE group. Larger particles (900-1,200 µm) were more often used in the TFA group than in the TRA group (P < .001). There were similar low rates of minor access site complications. In the TFA group (6 of 91, 7%), 5 patients had groin hematomas, and 2 patients had groin pain compared to the TRA group (5 of 91, 5%): in which 4 patients had transient focal occlusion of the radial artery and 1 patient had focal pain, all of which resolved with conservative management. There were similar rates of uterine volume reduction in 40% ± 17% in the TFA versus 36% ± 16% in the TRA group (P = .22) and no residual enhancement in 49 of 58 [84%] in the TFA group versus 66 of 77 [86%] in the TRA group (P = .84). There were similar reductions in modifying symptoms (60 of 64 [94%] in the TRA group; and 37 of 40 [93%] in the TFA group; P = NS) was noted at follow-up. CONCLUSIONS: Transradial UAE in women up to 178 cm tall and transfemoral UAE have similar technical and clinical outcomes, with low rates of access site complications.

Uterine Artery Embolization with Gelfoam for Acquired Symptomatic Uterine Arteriovenous Shunting.

PURPOSE: To evaluate the technical and clinical success rates and safety of bilateral gelfoam uterine artery embolization (UAE) for symptomatic acquired uterine arteriovenous shunting due to prior obstetric or gynecologic event. MATERIALS AND METHODS: This was a retrospective study of consecutive patients of reproductive age who presented with abnormal uterine bleeding after recent gynecologic procedures or obstetric events between January 2013 and February 2018. Bilateral UAE was performed in all patients using gelfoam slurry. Technical success was defined as angiographic resolution of arteriovenous shunting. Clinical success was defined as cessation of symptomatic bleeding, resolution on follow-up imaging, or minimal estimated blood loss (EBL) (<50 ml) on subsequent elective dilation and curettage (D&C) procedure. RESULTS: Eighteen patients (mean age, 32.8 ± 7.1 years) were included. Technical success and clinical success were experienced by 17/18 (94.4%) and 16/17 (94.1%) patients, respectively. Angiography demonstrated arteriovenous shunting in 18/18 (100%) patients, with early venous drainage. Seven of 18 (38.9%) patients underwent subsequent scheduled D&C due to remaining retained products of conception, with an EBL of 17.9 ± 15.6 ml. There was 1 minor complication of a self-limited vascular access groin hematoma (1/18, 5.6%) and 1 major complication (1/18, 5.6%) of a pulmonary embolism detected 3 days after UAE. The length of clinical follow-up was 19.3 ± 15.5 months, in which 41.2% (7/17) of the patients became pregnant. CONCLUSIONS: UAE with gelfoam alone for symptomatic uterine arteriovenous shunting is a feasible treatment option that has a high technical and clinical success rate with a low rate of complications.

Electronic IR Group Peer Review and Learning Performed during Daily Clinical Rounds.

PURPOSE: To describe the implementation and efficacy of electronic capture of interventional radiology (IR) group peer review performed during morning rounds in an academic institution. MATERIALS AND METHODS: Peer-review submissions 24 months before (July 2012 through June 2014) and 24 months after (July 2014 through June 2016) implementation of an electronic group IR peer review were evaluated. Electronic IR peer review assessed clinical decision-making, patient care, and technique appropriateness by using the following responses: agree, acceptable alternative, or inappropriate. Complications, near-misses, and learning opportunities were also noted, and explanations were provided in the comments. An IR attending physician documented the consensus discussion via an online form or mobile app. RESULTS: After implementation of electronic capture of IR group peer reviews, 9.5% of all IR procedures (773 of 8,152) were reviewed, compared with 0.9% (63 of 7,152) before the implementation (P < .0001). On average, 3.4 ± 0.5 IR attending physicians participated in each review, and 17.3 ± 9.7 IR cases were reviewed per month by each attending physician. Peers fully agreed with the chosen technique in 729 of 773 cases (94.3%) and noted an acceptable alternative technique in 40 of 773 (5.2%). In 4 cases (0.5%), the chosen technique was rated as inappropriate. Peers fully agreed with chosen clinical decision-making and patient care in 765 of 773 cases (99%), with 8 cases (1%) deemed as acceptable alternatives. Learning opportunities were documented in 9.6% of cases (74 of 773). CONCLUSIONS: Electronic IR-specific group peer review captures the clinical decision-making process, patient outcomes, technical appropriateness, and short-term complications and may provide practice-improvement solutions.

Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates.

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.

Impact of Performing Nonurgent Interventional Radiology Procedures on Weekends.

Most clinical services limit weekend care to urgent or emergent situations. However, providing access to nonemergent procedures on weekends may reduce length of hospital stay and unnecessary admissions. No data are available on the impact of providing nonemergent interventional radiology (IR) procedural services on weekends. A retrospective review of nonurgent IR inpatient services on weekends over a 12-month period was performed. Using intent-to-treat analysis, 453 procedures were performed on 447 patients on 100 weekend days. Procedures included venous access (116 of 453, 25.6%), dialysis interventions (83 of 453, 18.3%), enteral access (73 of 453, 16.1%), genitourinary interventions (37 of 453, 8.2%), venous interventions (35 of 453, 7.7%), biliary interventions (33 of 453, 7.3%), percutaneous drainage (32 of 453, 7.1%), biopsy (24 of 453, 5.3%), arterial interventions (14 of 453, 3.1%), and other (3 of 453, 0.7%). Routine weekend procedural services allowed 108 of 447 (24.2%) patients to be discharged earlier than anticipated if such services were not available, resulting in 174 hospital days gained. Procedures were performed earlier than anticipated in 268 of 447 (60.0%) patients resulting in 415 days of progression of care gained over the 12-month period. For dialysis interventions, 35% (29 of 83) of patients received hemodialysis within 24 hours of intervention, and 25 patients were discharged early with 33 hospital days saved. IR procedures were performed on patients from 97% of the hospital inpatient units (22 of 23 inpatient or observation units, and 10 of 10 intensive care units) over the 12-month period. In conclusion, increased availability of nonurgent IR services on weekends can directly reduce hospital length of stay as well as improve progression of inpatients toward an early discharge.