[Ablation of liver tumors : From pre-interventional imaging to post-interventional assessment]. / Ablation von Lebertumoren : Von der prä-interventionellen Bildgebung bis zur post-interventionellen Beurteilung.

The aim of this article is to provide an overview on the most frequently applied image-guided, percutaneous, local ablative techniques for treatment of primary and secondary liver tumors. The technical procedures of microwave ablation (MWA) and radiofrequency ablation (RFA) are presented. The pre-interventional diagnostics, indications and feasibility are also discussed, taking the current national guidelines into consideration. Finally, treatment outcomes and recommendations on post-interventional imaging following local tumor ablation are presented.

Image Quality and Radiation Exposure in Abdominal Angiography: A Head-to-Head Comparison of Conventional Detector-Dose-Driven Versus Contrast-to-Noise Ratio-Driven Exposure Control at Various Source-to-Image Receptor Distances and Collimations in a Pilot Phantom and Animal Study.

OBJECTIVES: This phantom and animal pilot study aimed to compare image quality and radiation exposure between detector-dose-driven exposure control (DEC) and contrast-to-noise ratio (CNR)-driven exposure control (CEC) as functions of source-to-image receptor distance (SID) and collimation. MATERIALS AND METHODS: First, an iron foil simulated a guide wire in a stack of polymethyl methacrylate and aluminum plates representing patient thicknesses of 15, 25, and 35 cm. Fluoroscopic images were acquired using 5 SIDs ranging from 100 to 130 cm and 2 collimations (full field of view, collimated field of view: 6 × 6 cm). The iron foil CNRs were calculated, and radiation doses in terms of air kerma rate were obtained and assessed using a multivariate regression. Second, 5 angiographic scenarios were created in 2 anesthetized pigs. Fluoroscopic images were acquired at 2 SIDs (110 and 130 cm) and both collimations. Two blinded experienced readers compared image quality to the reference image using full field of view at an SID of 110 cm. Air kerma rate was obtained and compared using t tests. RESULTS: Using DEC, both CNR and air kerma rate increased significantly at longer SID and collimation below the air kerma rate limit. When using CEC, CNR was significantly less dependent of SID, collimation, and patient thickness. Air kerma rate decreased at longer SID and tighter collimation. After reaching the air kerma rate limit, CEC behaved similarly to DEC. In the animal study using DEC, image quality and air kerma rate increased with longer SID and collimation (P < 0.005). Using CEC, image quality was not significantly different than using longer SID or tighter collimation. Air kerma rate was not significantly different at longer SID but lower using collimation (P = 0.012). CONCLUSIONS: CEC maintains the image quality with varying SID and collimation stricter than DEC, does not increase the air kerma rate at longer SID and reduces it with tighter collimation. After reaching the air kerma rate limit, CEC and DEC perform similarly.

New perspectives in unresectable cholangiocarcinoma? Evaluation of chemosaturation with percutaneous hepatic perfusion as a palliative treatment option.

Cholangiocarcinoma (CCA) are the second most common primary liver tumors and carry a dismal prognosis. Chemosaturation with percutaneous hepatic perfusion (PHP) is a palliative, intra-arterial therapeutic approach that provides a high dose chemotherapy of the liver with reduced systemic exposure. Aim of this retrospective, monocentric study was to analyze PHP as a palliative treatment for unresectable CCA. Toxicity, adverse events and complications were classified using the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Overall response rate (ORR) and disease control rate (DCR) were evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic mPFS (mhPFS) were computed using Kaplan-Meier estimation. In total 17 patients were treated with 42 PHP between 10/2014 and 09/2020. No significant complications occurred during the interventions. mOS was 27.6 (interquartile range (IQR) 16.5-37) months from first diagnosis and 9.9 (IQR 3.8-21) months from first PHP. mPFS was 4 (IQR 2-7) and mhPFS was 4 (IQR 3-10) months. ORR was 25% and DCR 75%. Significant, but transient hematotoxicity was frequent with grade 3/4 thrombopenia after 50%, leukopenia after 26% and anaemia after 21% of the interventions. An increase of transaminases (AST increase after 21% and ALT increase after 14% of the PHP) developed more often than a deterioration of the liver synthesis capacity. Salvage treatment with PHP has the potential to prolong life in selected patients with unresectable, refractory cholangiocarcinoma. The interventional procedure is safe. Post-interventional toxicity is frequent but manageable.

The Value of C-Arm Computed Tomography in Addition to Conventional Digital Subtraction Angiography in the Diagnostic Work-up of Patients with Suspected Chronic Thromboembolic Pulmonary Hypertension: An Update of 300 Patients.

RATIONALE AND OBJECTIVES: To assess the value and possible benefit of combined C-arm computed tomography (CACT) and conventional digital subtraction angiography (DSA) of the pulmonary arteries in the diagnostic work-up of patients with suspected chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS: We evaluated 308 pulmonary artery angiographies of 308 consecutive patients with suspected CTEPH. Seven patients were excluded because of incomplete imaging. Thus, 301 datasets were included in our study. The pulmonary artery segments and their subsegmental branching were independently evaluated by two readers (R1, R2) using both, DSA and CACT for optimal image quality. Subsequently, the diagnostic findings were compared. Inter-modality and inter-observer agreement were calculated. Consensus reading was done and correlated to a standard of reference, representing the overall consensus of both modalities. Fisher's exact test and Cohen's Kappa were applied. RESULTS: A total of 5719 pulmonary segments were evaluated of which only 28 segments (0.4%) were rated to be nondiagnostic on both, CACT and DSA. Overall, 5640 (98.6%) and 5600 (97.9%) pulmonary segments were rated to be diagnostic in DSA and CACT, respectively. The main causes of nondiagnostic image quality were motion artifacts on both, CACT (R1:81, R2:50) and DSA (R1:60, R2:48). Interobserver agreement was excellent for DSA (κ = 0.9) and CACT (κ = 0.91) and intermodality agreement was substantial (R1: κ = 0.69, R2: κ = 0.77). Compared to standard of reference, the intermodality agreement for CACT was excellent (κ = 0.96), whereas it was inferior for DSA (κ = 0.75), due to the higher number of pathologic findings in CACT read as normal on DSA. CONCLUSION: CACT of the pulmonary arteries can provide additional information to DSA during CTEPH work-up. Moreover, the combination of CACT and DSA can minimize the portion of non-diagnostic examinations, therefore being a reasonable combination to optimize the diagnostic work-up.

Phantom study for comparison between computed tomography- and C-Arm computed tomography-guided puncture applied by residents in radiology. / Phantomstudie zum Vergleich zwischen Computertomografie- und C-Arm-Computertomografie-gesteuertem Punktionsverfahren bei Anwendung durch Weiterbildungsassistenten in der Radiologie.

PURPOSE: Comparison of puncture deviation and puncture duration between computed tomography (CT)- and C-arm CT (CACT)-guided puncture performed by residents in training (RiT). METHODS: In a cohort of 25 RiTs enrolled in a research training program either CT- or CACT-guided puncture was performed on a phantom. Prior to the experiments, the RiT's level of training, experience playing a musical instrument, video games, and ball sports, and self-assessed manual skills and spatial skills were recorded. Each RiT performed two punctures. The first puncture was performed with a transaxial or single angulated needle path and the second with a single or double angulated needle path. Puncture deviation and puncture duration were compared between the procedures and were correlated with the self-assessments. RESULTS: RiTs in both the CT guidance and CACT guidance groups did not differ with respect to radiologic experience (p = 1), angiographic experience (p = 0.415), and number of ultrasound-guided puncture procedures (p = 0.483), CT-guided puncture procedures (p = 0.934), and CACT-guided puncture procedures (p = 0.466). The puncture duration was significantly longer with CT guidance (without navigation tool) than with CACT guidance with navigation software (p < 0.001). There was no significant difference in the puncture duration between the first and second puncture using CT guidance (p = 0.719). However, in the case of CACT, the second puncture was significantly faster (p = 0.006). Puncture deviations were not different between CT-guided and CACT-guided puncture (p = 0.337) and between the first and second puncture of CT-guided and CACT-guided puncture (CT: p = 0.130; CACT: p = 0.391). The self-assessment of manual skills did not correlate with puncture deviation (p = 0.059) and puncture duration (p = 0.158). The self-assessed spatial skills correlated positively with puncture deviation (p = 0.011) but not with puncture duration (p = 0.541). CONCLUSION: The RiTs achieved a puncture deviation that was clinically adequate with respect to their level of training and did not differ between CT-guided and CACT-guided puncture. The puncture duration was shorter when using CACT. CACT guidance with navigation software support has a potentially steeper learning curve. Spatial skills might accelerate the learning of image-guided puncture. KEY POINTS: · The CT-guided and CACT-guided puncture experience of the RiTs selected as part of the program "Researchers for the Future" of the German Roentgen Society was adequate with respect to the level of training.. · Despite the lower collective experience of the RiTs with CACT-guided puncture with navigation software assistance, the learning curve regarding CACT-guided puncture may be faster compared to the CT-guided puncture technique.. · If the needle path is complex, CACT guidance with navigation software assistance might have an advantage over CT guidance.. CITATION FORMAT: · Meine TC, Hinrichs JB, Werncke T et al. Phantom study for comparison between computed tomography- and C-Arm computed tomography-guided puncture applied by residents in radiology. Fortschr Röntgenstr 2022; 194: 272 - 280.

Depiction of mosaic perfusion in chronic thromboembolic pulmonary hypertension (CTEPH) on C-arm computed tomography compared to computed tomography pulmonary angiogram (CTPA).

To evaluate mosaic perfusion patterns and vascular lesions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) using C-Arm computed tomography (CACT) compared to computed tomography pulmonary angiography (CTPA). We included 41 patients (18 female; mean age 59.9 ± 18.3 years) with confirmed CTEPH who underwent CACT and CTPA within 21 days (average 5.3 ± 5.2). Two readers (R1; R2) independently evaluated datasets from both imaging techniques for mosaic perfusion patterns and presence of CTEPH-typical vascular lesions. The number of pulmonary arterial segments with typical findings was evaluated and the percentage of affected segments was calculated and categorized: < 25%; 25-49%; 50-75%; < 75% of all pulmonary arterial segments affected by thromboembolic vascular lesions. Inter-observer agreement was calculated for both modalities using the intraclass-correlation-coefficient (ICC). Based on consensus reading the inter-modality agreement (CACTcons vs. CTPAcons) was calculated using the ICC. Inter-observer agreement was excellent for central vascular lesions (ICC > 0.87) and the percentage of affected segments (ICC > 0.76) and good for the perceptibility of mosaic perfusion (ICC > 0.6) and attribution of the pattern of mosaic perfusion (ICC > 0.6) for both readers on CACT and CTPA. Inter-modality agreement was excellent for the perceptibility of mosaic perfusion (ICC = 1), the present perfusion pattern (ICC = 1) and central vascular lesions (ICC = 1). However, inter-modality agreement for the percentage of affected segments was fair (ICC = 0.50), with a greater proportion of identified affected segments on CACTcons. CACT demonstrates a high agreement with CTPA regarding the detection of mosaic perfusion. CACT detects a higher number of peripheral vascular lesions compared to CTPA.

Comparison of a contrast-to-noise ratio-driven exposure control and a regular detector dose-driven exposure control in abdominal imaging in a clinical angiography system.

PURPOSE: The first purpose of this phantom study was to verify whether a contrast-to-noise ratio (CNR)-driven exposure control (CEC) can maintain target CNR in angiography more precisely compared to a conventional detector dose-driven exposure control (DEC). The second purpose was to estimate the difference between incident air kerma produced by CEC and DEC when both exposure controls reach the same CNR. METHODS: A standardized 3D-printed phantom with an iron foil and a cavity, filled with iodinated contrast material, was developed to measure CNR using different image acquisition settings. This phantom was placed into a stack of polymethylmethacrylate and aluminum plates, simulating a patient equivalent thickness (PET) of 2.5-40 cm. Images were acquired using fluoroscopy and digital radiography modes with CEC using one image quality level and four image quality gradients and DEC having three different detector dose levels. The spatial frequency weighted CNR and incident air kerma were determined. The differences in incident air kerma between DEC and CEC were estimated. RESULTS: When using DEC, CNR decreased continuously with increasing attenuation, while CEC within physical limits maintained a predefined CNR level. Furthermore, CEC could be parameterized to deliver the CNR as a predefined function of PET. To provide a given CNR level, CEC used equal or lower air kerma than DEC. The mean estimated incident air kerma of CEC compared to DEC was between 3% (PET 20 cm) and 40% (PET 27.5 cm) lower in fluoroscopy and between 1% (PET 20 cm) and 55% (PET 2.5 cm) lower in digital radiography while maintaining CNR. CONCLUSION: Within physical and legislative limits, the CEC allows for a flexible adjustment of the CNR as a function of PET. Thus, the CEC enables task-dependent examination protocols with predefined image quality in order to easier achieve the as low as reasonably achievable principle. CEC required equal or lower incident air kerma than DEC to provide similar CNR, which allows for a substantial reduction of skin radiation dose in these situations.

Comparison of the Uptake of Hepatocellular Carcinoma on Pre-Therapeutic MDCT, CACT, and SPECT/CT, and the Correlation with Post-Therapeutic PET/CT in Patients Undergoing Selective Internal Radiation Therapy.

(1) Background: To comparatively analyze the uptake of hepatocellular carcinoma (HCC) on pre-therapeutic imaging modalities, the arterial phase multi-detector computed tomography (MDCT), the parenchymal phase C-arm computed tomography (CACT), the Technetium99m-macroaggregates of human serum albumin single-photon emission computed tomography/computed tomography (SPECT/CT), and the correlation to the post-therapeutic Yttrium90 positron emission tomography/computed tomography (PET/CT) in patients with selective internal radiation therapy (SIRT). (2) Methods: Between September 2013 and December 2016, 104 SIRT procedures were performed at our institution in 74 patients with HCC not suitable for curative surgery or ablation. Twenty-two patients underwent an identical sequence of pre-therapeutic MDCT, CACT, SPECT/CT, and post-therapeutic PET/CT with a standardized diagnostic and therapeutic protocol. In these 22 patients, 25 SIRT procedures were evaluated. The uptake of the HCC was assessed using tumor-background ratio (TBR). Therefore, regions of interest were placed on the tumor and the adjacent liver tissue on MDCT (TBRMDCT), CACT (TBRCACT), SPECT/CT (TBRSPECT/CT), and PET/CT (TBRPET/CT). Comparisons were made with the Friedman test and the Nemenyi post-hoc test. Correlations were analyzed using Spearman's Rho and the Benjamini-Hochberg method. The level of significance was p < 0.05. (3) Results: TBR on MDCT (1.4 ± 0.3) was significantly smaller than on CACT (1.9 ± 0.6) and both were significantly smaller compared to SPECT/CT (4.6 ± 2.0) (pFriedman-Test < 0.001; pTBRMDCT/TBRCACT = 0.012, pTBRMDCT/TBRSPECT/CT < 0.001, pTBRCACT/TBRSPECT/CT < 0.001). There was no significant correlation of TBR on MDCT with PET/CT (rTBRMDCT/TBRPET/CT = 0.116; p = 0.534). In contrast, TBR on CACT correlated to TBR on SPECT/CT (rTBRCACT/TBRSPECT/CT = 0.489; p = 0.004) and tended to correlate to TBR on PET/CT (rTBRCACT/TBRPET/CT =0.365; p = 0.043). TBR on SPECT/CT correlated to TBR on PET/CT (rTBRSPECT/CT/TBRPET/CT = 0.706; p < 0.001) (4) Conclusion: The uptake assessment on CACT was in agreement with SPECT/CT and might be consistent with PET/CT. In contrast, MDCT was not comparable to CACT and SPECT/CT, and had no correlation with PET/CT due to the different application techniques. This emphasizes the value of the CACT, which has the potential to improve the dosimetric assessment of the tumor and liver uptake for SIRT.

Impact of a contrast-to-noise ratio driven and material specific exposure control on image quality and radiation exposure in angiography.

Conventional detector-dose driven exposure controls (DEC) do not consider the contrasting material of interest in angiography. Considering the latter when choosing the acquisition parameters should allow for optimization of x-ray quality and consecutively lead to a substantial reduction of radiation exposure. Therefore, the impact of a material-specific, contrast-to-noise ratio (CNR) driven exposure control (CEC) compared to DEC on radiation exposure was investigated. A 3D-printed phantom containing iron, tantalum, and platinum foils and cavities, filled with iodine, barium, and gas (carbon dioxide), was developed to measure the CNR. This phantom was placed within a stack of polymethylmethacrylate and aluminum plates simulating a patient equivalent thickness (PET) of 2.5-40 cm. Fluoroscopy and digital radiography (DR) were conducted applying either CEC or three, regular DEC protocols with parameter settings used in abdominal interventions. CEC protocols where chosen to achieve material-specific CNR values similar to those of DEC. Incident air kerma at the reference point(Ka,r), using either CEC or DEC, was assessed and possible Ka,r reduction for similar CNR was estimated. We show that CEC provided similar CNR as DEC at the same or lower Ka,r. When imaging barium, iron, and iodine Ka,r was substantially reduced below a PET of 20 cm and between 25 cm and 30 cm for fluoroscopy and Dr When imaging platinum and tantalum using fluoroscopy and DR and gas using DR, the Ka,r reduction was substantially higher. We estimate the Ka,r reduction for these materials between 15% and 84% for fluoroscopy and DR between 15% and 93% depending on the PET. The results of this study demonstrate a high potential for skin dose reduction in abdominal radiology when using a material-specific CEC compared to DEC. This effect is substantial in imaging materials with higher energy K-edges, which is beneficial, for example, in long-lasting embolization procedures with tantalum-based embolization material in young patients with arterio-venous malformations.

Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. / Chemosaturation durch perkutane hepatische Perfusion mit Melphalan bei hepatisch metastasiertem Aderhautmelanom: eine Überlebens- und Sicherheitsanalyse.

PURPOSE: Chemosaturation percutaneous hepatic perfusion (CS-PHP) allows selective intrahepatic delivery of high dose cytotoxic melphalan in patients with curatively untreatable liver tumors while limiting systemic toxicity through hemofiltration of the hepatic venous blood. Aim of this study was to investigate the response to therapy, survival and safety of the CS-PHP procedure in patients with liver-dominant metastatic uveal melanoma (UM). MATERIALS AND METHODS: Overall response rate (ORR) and disease control rate (DCR) were assessed according to Response Evaluation Criteria In Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic progression-free survival (mhPFS) were analyzed using Kaplan-Meier estimation. Adverse events were evaluated with Common Terminology Criteria for Adverse Events (CTCAE) v5. RESULTS: Overall, 30 patients were treated with 70 CS-PHP in a salvage setting from October 2014 to January 2019. In total, ORR and DCR were 42.3 % and 80.8 %, respectively. Overall, mOS was 12 (95 % confidence interval (CI) 7-15) months, and both, mPFS and mhPFS were 6 months, respectively (95 % CI 4-10; 95 % CI 4-13). Adverse events (AE) most frequently included significant but transient hematologic toxicities (87 % of grade 3/4 thrombocytopenia), less frequent AEs were hepatic injury extending to liver failure (3 %), cardiovascular events including one case of ischemic stroke (3 %). CONCLUSION: Salvage treatment with CS-PHP is effective in selected patients with UM. The interventional procedure is safe. Serious hepatic and cardiovascular events, although rare, require careful patient selection and should be closely monitored. KEY POINTS: · CS-PHP is safe for selected patients with liver-dominant metastatic uveal melanoma.. · CS-PHP resulted in hepatic disease control in 80 % of patients.. · Hematologic events following CS-PHP are common but manageable.. CITATION FORMAT: · Dewald CL, Hinrichs JB, Becker LS et al. Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. Fortschr Röntgenstr 2021; 193: 928 - 936.

Evaluation of perfusion changes using a 2D Parametric Parenchymal Blood Flow technique with automated vessel suppression following partial spleen embolization in patients with hypersplenism and portal hypertension.

ABSTRACT: To evaluate the feasibility and potential value of 2D Parametric Parenchymal Blood Flow (2D-PPBF) for the assessment of perfusion changes following partial spleen embolization (PSE) in a retrospective observational study design.Overall, 12 PSE procedures in 12 patients were included in this study. The outcome of the study was the platelet response (PR), calculated as the percentage increase of platelet count (PLT), following PSE. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography series were post-processed. A reference region-of-interest (ROI) was placed in the afferent splenic artery and a target ROI was positioned on the embolization territory of the spleen on digital subtraction angiography series pre- and post-embolization. The ratios of the target ROIs to the reference ROIs were calculated for the Wash-In-Rate (WIR), the Time-To-Peak (TTP) and the Area-Under-the-Curve (AUC). Comparisons between pre- and post-embolization data were made using Wilcoxon signed-rank test and Spearman's rank correlation coefficient (r). Afterwards, the study population was divided by the median of the TTP before PSE to analyze its value for the prediction of PR following PSE.Following PSE, PLT increased significantly from 43,000 ±â€Š21,405 platelets/µL to 128,500 ±â€Š66,083 platelets/µL with a PR of 255 ±â€Š243% (P = .003). In the embolized splenic territory, the pre-/post-embolization 2D-PPBF parameter changed significantly: WIRpre-PSE 1.23 ±â€Š2.42/WIRpost-PSE 0.09 ±â€Š0.07; -64 ±â€Š46% (p = 0.04), TTPpre-PSE 4.41 ±â€Š0.99/TTPpost-PSE 5.67 ±â€Š1.52 (P = .041); +34 ±â€Š47% and AUCpost-PSE 0.81 ±â€Š0.85/AUCpost-PSE 0.14 ±â€Š0.08; -71 ±â€Š18% (P = .002). A significant correlation of a 2D-PPBF parameter with the PLT was found for TTPpre-PSE/PLTpre-PSE r = -0.66 (P = .01). Subgroup analysis showed a significantly increased PR for the group with TTPpre-PSE >4.44 compared to the group with TTPpre-PSE ≤4.44 (404 ±â€Š267% versus 107 ±â€Š76%; P = .04).2D-PPBF is an objective approach to analyze the perfusion reduction of embolized splenic tissue. TTP derived from 2D-PPBF has the potential to predict the extent of PR during PSE.

2D-Perfusion Angiography Using Carbon Dioxide (CO2): A Feasible Tool to Monitor Immediate Treatment Response to Endovascular Therapy of Peripheral Arterial Disease?

PURPOSE: Patients with peripheral arterial disease (PAD) or critical limb ischemia (CLI) require revascularization. Traditionally, endovascular therapy (EVT) is performed with iodinated contrast agent (ICM), which can provoke potential deterioration in renal function. CO2 is a safe negative contrast agent to guide vascular procedures, but interpretation of CO2 angiography is challenging. Changes in blood flow following iodine-aided EVT are assessable with 2D-perfusion angiography (2D-PA). The aim of this study was to evaluate 2D-PA as a tool to monitor blood flow changes during CO2-aided EVT. MATERIAL AND METHODS: 2D-PA was performed before and after ten EVTs (nine stents; one endoprosthesis; 10/2012-02/2020) in nine patients (six men; 65 ± 10y) with Fontaine stage IIb (n = 8) and IV (n = 1). A reference ROI (ROIINFLOW) was placed in the artery before the targeted obstruction and a target ROI (ROIOUTFLOW) distally. Corresponding ROIs were used pre- and post-EVT. Time to peak (TTP), peak density (PD) and area under the curve (AUC) were computed. The reference/target ROI ratios (TTPOUTFLOW/TTPINFLOW; PDOUTFLOW/PDINFLOW; AUCOUTFLOW/AUCINFLOW) were calculated. RESULTS: 2D-PA was technically feasible in all cases. A significant increase of 82% in PDOUTFLOW/PDINFLOW (0.44 ± 0.4 to 0.8 ± 0.63; p = 0.002) and of 132% in AUCOUTFLOW/AUCINFLOW (0.34 ± 0.22 to 0.79 ± 0.59; p = 0.002) was seen. A trend for a decrease in TTPOUTFLOW/TTPINFLOW was observed (- 24%; 5.57 ± 3.66 s-4.25 ± 1.64 s; p = 0.6). CONCLUSION: The presented 2D-PA technique facilitates the assessment of arterial flow in CO2-aided EVTs and has the potential to simplify the assessment of immediate treatment response.

Safety and feasibility of transjugular intrahepatic portosystemic shunt in elderly patients with liver cirrhosis and refractory ascites.

BACKGROUND & AIMS: The management of patients with refractory ascites (RA) is challenging, particularly at higher age. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for RA, but safety data in elderly patients are rare. Our aim was to evaluate the safety and feasibility of TIPS in elderly patients with RA. METHODS: Overall, 160 consecutive cirrhotic patients receiving a TIPS for RA at Hannover Medical School between 2012 and 2018 were considered for this retrospective analysis. Periinterventional complications such as acute-on-chronic liver failure (ACLF) as well as survival were compared between patients <65 and ≥65 years. Propensity score matching was conducted to match elderly TIPS patients and patients treated with paracentesis. RESULTS: A number of 53 out of the 160 patients were ≥65 years (33%). Periinterventional course in those ≥65 years appeared to be slightly more complicated than in <65 years as reflected by a significantly longer hospital stay (p = 0.030) and more ACLF-episodes (21% vs. 9%; p = 0.044). 28-day mortality was similar between both groups (p = 0.350), whereas survival of the younger patients was significantly higher at 90 days (p = 0.029) and numerically higher at 1 year (p = 0.171). In the multivariate analysis age ≥65 years remained an independent predictor for 90-day mortality (HR: 2.58; p = 0.028), while it was not associated with 28-day and 1-year survival. Importantly, after matching for potential confounders 1-year survival was similar in elderly patients if treated with TIPS or paracentesis (p = 0.419). CONCLUSIONS: TIPS placement in elderly patients with RA appears to be slightly more complicated compared to younger individuals, but overall feasible and at least not inferior to paracentesis.

Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy.

BACKGROUND: To assess the technical feasibility, success rate, puncture complications and procedural characteristics of transjugular intrahepatic portosystemic shunt (TIPS) placement using a three-dimensional vascular map (3D-VM) overlay based on image registration of pre-procedural contrast-enhanced (CE) multi-detector computed tomography (MDCT) for portal vein puncture guidance. MATERIALS AND METHODS: Overall, 27 consecutive patients (59 ± 9 years, 18male) with portal hypertension undergoing elective TIPS procedure were included. TIPS was guided by CE-MDCT overlay after image registration based on fluoroscopic images. A 3D-VM of the hepatic veins and the portal vein was created based on the pre-procedural CE-MDCT and superimposed on fluoroscopy in real-time. Procedural characteristics as well as hepatic vein catheterization time (HVCT), puncture time (PT), overall procedural time (OPT), fluoroscopy time (FT) and the dose area product (DAP) were evaluated. Thereafter, HVCT, PT, OPT and FT using 3D-VM (61 ± 9 years, 14male) were compared to a previous using classical fluoroscopic guidance (53 ± 9 years, 21male) for two interventional radiologist with less than 3 years of experience in TIPS placement. RESULTS: All TIPS procedure using of 3D/2D image registered 3D-VM were successful with a significant reduction of the PSG (p < 0.0001). No clinical significant complication occurred. HVCT was 14 ± 11 min, PT was 14 ± 6 min, OPT was 64 ± 29 min, FT was 21 ± 12 min and DAP was 107.48 ± 93.84 Gy cm2. HVCT, OPT and FT of the interventionalist with less TIPS experience using 3D/2D image registered 3D-VM were statistically different to an interventionalist with similar experience using fluoroscopic guidance (pHVCT = 0.0022; pOPT = 0.0097; pFT = 0.0009). PT between these interventionalists was not significantly different (pPT = 0.2905). CONCLUSION: TIPS placement applying registration-based CE-MDCT vessel information for puncture guidance is feasible and safe. It has the potential to improve hepatic vein catherization, portal vein puncture and radiation exposure.

Non-occlusive mesenteric ischemia (NOMI): evaluation of 2D-perfusion angiography (2D-PA) for early treatment response assessment.

PURPOSE: To evaluate the feasibility of 2D-perfusion angiography (2D-PA) for the analysis of intra-procedural treatment response after intra-arterial prostaglandin E1 therapy in patients with non-occlusive mesenteric ischemia (NOMI). METHODS: Overall, 20 procedures in 18 NOMI patients were included in this retrospective case-control study. To evaluate intra-procedural splanchnic circulation changes, post-processing of digital subtraction angiography (DSA) series was performed. Regions of interest (ROIs) were placed in the superior mesenteric artery (SMA; reference), the portal vein (PV; ROIPV), as well as the aorta next to the origin of the SMA (ROIAorta). Peak density (PD), time to peak (TTP), and area under the curve (AUC) were assessed, and parametric ratios 'target ROIPD, TTP, AUC/reference ROI' were computed and compared within treatment and control group. Additionally, a NOMI score was assessed pre- and post-treatment compared to 2D-PA. RESULTS: Vasodilator therapy leads to a significant decrease of the 2D-PA-derived values PDAorta (p = 0.04) and AUCAorta (p = 0.03). These findings correlated with changes of the simplified NOMI score, both for overall (4 to 1, p < 0.0001) and for each category. Prostaglandin application caused a significant increase of the AUCPV (p = 0.04) and TTPPV was accelerated without reaching statistical significance (p = 0.13). When compared to a control group, all 2D-PA values in the NOMI group (pre- and post-intervention) differed significantly (p < 0.05) with longer TTPAorta/PV and lower AUCAorta/PV and PD Aorta/PV. CONCLUSION: 2D-PA offers an objective approach to analyze immediate flow and perfusion changes following vasodilatory therapies of NOMI patients and may be a valuable tool for assessing treatment response.

Transarterial chemoembolization for hepatocellular carcinoma: quality of life, tumour response, safety and survival comparing two types of drug-eluting beads.

PURPOSE: To compare two different types of drug-eluting microspheres with regard to impact on HRQoL after first TACE, tumour response, peri-procedural complications, adverse events and 1-year survival in patients suffering from unresectable hepatocellular carcinoma (HCC). METHODS: HRQoL was prospectively assessed with validated questionnaires (EORTC QLQ-C30 and -HCC18) before and 2 weeks after treatment with their first drug-eluting beads (DEB-)TACE with either acrylamido-polyvinylalcohol-AMPS hydrogel microspheres (groupDCB; 20 patients) or polyvinyl alcohol-co-acrylic acid microspheres (groupHS; 16 patients). Baseline characteristics, peri-procedural complications, treatment-related adverse events and 1-year survival were compared between both types of microspheres. Treatment response and objective response rates (ORR) were analysed using established tumour response criteria. Subgroup analysis for pooled groups with small (groupSMALL; 21 patients) versus large particles (groupLARGE; 15 patients) was performed. RESULTS: At baseline, there were no significant differences between the treated microsphere groups. No significant differences were found in absolute HRQoL changes after first DEB-TACE between the different types of microspheres. Response rates and survival were comparable between the investigated microsphere groups. For groupSMALL, we found a significant difference in post-interventional deterioration of physical function (- 19.4%) compared to groupLARGE (- 8%; p = 0.025). Tumour response and ORR according to mRECIST were significantly higher in groupSMALL (p = 0.008; p = 0.009). CONCLUSION: DEB-TACE is generally well tolerated and effective, with comparable changes in HRQoL for both types of drug-eluting microspheres. Tumour response is better with small microspheres. A relevant deterioration of physical function underlines that an aggressive TACE using small beads should be well deliberated.

Chemosaturation Percutaneous Hepatic Perfusion (CS-PHP) with Melphalan: Evaluation of 2D-Perfusion Angiography (2D-PA) for Leakage Detection of the Venous Double-Balloon Catheter.

PURPOSE: To evaluate the feasibility of 2D-perfusion angiography (2D-PA) for detecting leakage of the double-balloon catheter used for chemosaturation percutaneous hepatic perfusion (CS-PHP). MATERIALS AND METHODS: Overall, 112 CS-PHP (09/2015-09/2018) in 52 patients were retrospectively screened for leakage alongside the double-balloon catheter on standard venograms. Finally, 18 procedures with visually detected leakage were included. Fifteen consecutive procedures without leakage served as control. To evaluate 2D-PA for leakage detection, the acquired digital subtraction venograms were post-processed. For each balloon, two different target ROIs were evaluated to assess a possible impact of localization and shape of the ROIs. Time to peak (TTP), peak density (PD), area under the curve (AUC), and ratios of target ROI/reference ROIs (PDtROI/PDREF; AUCtROI/AUCREF; and TTPtROI/TTPREF) were calculated. RESULTS: Leakages were located as follows: 15/18 cranial and 3/18 caudal. At the cranial balloon both ROIs showed a significant decrease in PDtROI/PDREF and AUCtROI/AUCREF (ROI1: p < 0.0001; p < 0.0001; ROI2: p < 0.0001; p < 0.0001) and a significant increase in TTPtROI/TTPREF (ROI1: p = 0.0009; ROI2: p = 0.0003) after double-balloon correction. Following balloon adjustment, the 2D-PA ratios (PD and AUC) of the tested ROIs differed significantly (p < 0.05). The inter-individual comparison of the 2D-PA parameters of the group with leakage before balloon correction and the non-leakage group showed significantly different 2D-PA values for the cranial balloon in both ROIs (p < 0.05). No significant differences were found for the caudal balloon. CONCLUSION: 2D-PA provides a feasible tool for detecting leakages alongside the cranial portion of the double-balloon catheter used in CS-PHP. The shape and position of the ROIs used to assess perfusion and flow have an impact on the measurements.