Findings of the UK national audit evaluating image-guided or image-assisted liver biopsy. Part II. Minor and major complications and procedure-related mortality.

PURPOSE: To determine the frequency of complications and death following image-guided and/or image-assisted liver biopsy and to identify significant variables associated with an increased risk of complications or death. MATERIALS AND METHODS: Institutional review board approval for this type of study is not required in the United Kingdom. United Kingdom radiology departments with a department leader for audit registered with the Royal College of Radiologists were invited to participate. The first 50 consecutive patients who underwent liver biopsy in 2008 were included. Audit standards were developed for minor pain (<30%), severe pain (<3%), vasovagal hypotension (<3%), significant hemorrhage (<0.5%), hemobilia (<0.1%), puncture of another organ (<0.1%), and death (<0.1%). Organizational, clinical, and coagulation variables were investigated statistically for their association with complications and/or death. RESULTS: Data were obtained from 87 of 210 departments (41%). Audit standards were met for pain, hypotension, hemorrhage, hemobilia, and puncture of another organ. There were four hemorrhage-related deaths, and this target was narrowly missed (rate achieved in practice, 0.11% [four of 3486 patients]). Fifteen additional patients experienced at least one major complication. The international normalized ratio (INR) was absent in 3% of cases (97 of 2951 patients), the platelet count was absent in 1% (32 of 2986 patients), the INR was more than 1 week old in 8% (229 of 2888 patients), and the platelet count was more than 1 week old in 10% (291 of 2955 patients). CONCLUSION: Results of this audit confirm that image-guided and image-assisted biopsy is performed safely in United Kingdom radiology departments, with complication rates within expected parameters. Preprocedural clotting assessment was inadequate in some cases and would merit repeat audit. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120224/-/DC1.

Spontaneous aortic dissection within an infrarenal AAA.

Aortic dissection occurring in the infrarenal abdominal aorta is uncommon. We present the case of a patient presenting with an enlarging abdominal aortic aneurysm and concurrent dissection (with associated radiological imaging) and briefly discuss the literature relating to this phenomenon.

Findings of the UK national audit evaluating image-guided or image-assisted liver biopsy. Part I. Procedural aspects, diagnostic adequacy, and accuracy.

PURPOSE: To assess procedural aspects, diagnostic adequacy, and accuracy of liver biopsy across the United Kingdom. MATERIALS AND METHODS: Institutional review board approval for this type of study is not required in the United Kingdom. All radiology departments with an approved leader for departmental audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients who underwent image-guided or image-assisted liver biopsy in 2008 were included. Audit standards relating to procedural aspects of biopsy, sample adequacy, and accuracy were prepared with reference to published data. Sensitivity, specificity, positive and negative likelihood ratios, and accuracy were calculated. Organizational and clinical variables were investigated for their association with diagnostic specimen quality. RESULTS: Eighty-seven (41%) of 210 departments supplied data for this study, with a total of 3496 cases (1225 focal disease, 2262 nonfocal disease, nine unspecified). Ultrasonographic (US) guidance was the technique most commonly used for focal lesions and for cases of nonfocal disease (2808 [96.38%] of 3490 cases). The audit standard for sample adequacy (98%) was narrowly missed in practice (3401 [97.96%] of 3472 cases); however, the standard for diagnostic accuracy (90%) was met (3187 [98.55%] of 3234 cases). Poor compliance with postbiopsy documentation was observed. CONCLUSION: The majority of liver biopsies in this audit were performed by radiologists using image guidance or assistance, usually in the form of US. Biopsies were performed with a high degree of accuracy. Some postprocedural aspects of biopsy failed to meet required standards and would merit reaudit after practice changes. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12111562/-/DC1.

CT study of the relationship between the common iliac artery and vein and their juxtaposition: implications for conduit construction prior to endovascular stent-graft repair of aortic aneurysms.

The objective of this study was to determine the anatomical relationship and juxtaposition between the common iliac artery and vein in a population of patients with aortic aneurysmal disease and a population clinically and radiologically free of atheroma. It was a retrospective study of 100 consecutive patients undergoing computed tomographic assessment of abdominal aortic aneurysm prior to endovascular or open surgical repair and 100 patients undergoing computed tomographic assessment for other pathologies who did not have clinical or imaging signs of aorto-iliac atheroma. In both groups the anatomical relationship between the right and left iliac artery and vein was studied, and the thickness of the fat plane separating the artery from the vein measured. The right iliac vein was posterolateral to the artery at the level of the common iliac artery bifurcation in 95% of patients in both groups. At the same level the left iliac vein was posterior in 23% (p B 0.001). Eighty-three percent of patients in the aneurysm group had a fat plane between the right artery and vein that measured 0 mm (no visible fat plane = 52%) to 1 mm (= 31%). Ninety-eight percent of patients in the aneurysm group had a measurable fat plane between the left iliac artery and vein of up to 5 mm (p = 0.001). Six percent of the control group demonstrated no visible fat plane between the right iliac artery and vein (p B 0.001), while the fat plane measured more than 1 mm (1-5 mm) on the left in 100%. We conclude that in patients where conduit construction is required for aortic stent-graft access, the anatomical configuration and intimate relationship of the iliac arteries and veins should be assessed and taken into account at CT scan evaluation. The distal right common iliac artery should not be used, as venous damage can be predicted from the anatomical and intimate relationship of the iliac artery and vein at this level in patients with atheroma and the difficulties this relationship presents if venous repair is necessary.

Efficacy of renal artery angioplasty and stenting in a solitary functioning kidney.

OBJECTIVE: The aim of this study was to share our experience of percutaneous renal artery angioplasty and stenting (PTRAS) in our patients with a solitary functioning kidney over a 10-year period. METHODS: The procedures were performed on 75 patients from 1995 to 2004. Data were collected retrospectively from case notes of patients. The definition for solitary functioning kidney was a contralateral kidney size of <8 cm, complete occlusion of contralateral renal artery or previous nephrectomy. Serum creatinine was considered improved or worse if the deviation from the baseline value was >20%. RESULTS: For the purpose of halting renal deterioration (n=47), there were improvement and stabilization in 21% and 55% at 3 months and 28% and 28% at 12 months. Systolic blood pressure (n=27) improvement and stabilization were achieved in 33% and 56% both at 3 and 12 months. Diastolic blood pressure (n=27) improvement and stabilization were 22% and 70% at 3 months and 33% and 48% at 12 months. Five out of seven patients with acute renal failure (serum creatinine>500 micromol/l and requiring haemodialysis) pre-procedure were dialysis-free at 12 months. Complications occurred in 19 (25%) patients and these included bleeding (n=16), pseudoaneurysm (n=3), renal artery dissection (n=2) and cholesterol embolization (n=1). CONCLUSION: PTRAS in a solitary functioning kidney produced clinical benefits in the majority of patients with resistant hypertension and renal function deterioration.

Pelvic congestion syndrome, who should we treat and how?

Pelvic congestion syndrome (PCS) is a condition that is difficult to diagnose but causes distress to a significant number of women. It is not difficult to treat by embolization but the technique is still evolving and results are by no means perfect. Nevertheless, the results of endovascular treatment are at least equivalent to those of surgery and better than conventional medical therapy. This paper will review the techniques and results reported for treatment of pelvic congestion syndrome.

A suggested training programme for carotid artery stenting (CAS).

Carotid artery stenting as an alternative to traditional carotid endartrectomy is becoming increasingly important in the treatment of transient ischemic attack and stroke. Physicians from several different medical disciplines are interested in treating appropriate patients by this method. Patients are entitled to know what training and experience the surgeon or clinician has before giving consent. This should involve endovascular experience in all systems and experience and knowledge of cerebral angiography and intervention. A multidisciplinary approach and reporting of adverse events is vital for patient safety.

Selective embolization of large symptomatic iatrogenic renal transplant arteriovenous fistula.

We report on the successful treatment of hypertension by occlusion of a large iatrogenic renal transplant arteriovenous fistula using detachable embolization coils with concomitant flow reduction by occlusion balloon in two patients.

Managing inadvertent arterial catheterization during central venous access procedures.

PURPOSE: Approximately 200,000 central venous catheterizations are carried out annually in the National Health Service in the United Kingdom. Inadvertent arterial puncture occurs in up to 3.7%. Significant morbidity and death has been reported. We report on our experience in the endovascular treatment of this iatrogenic complication. METHODS: Retrospective analysis was carried out of 9 cases referred for endovascular treatment of inadvertent arterial puncture during central venous catheterization over a 5 year period. RESULTS: It was not possible to obtain accurate figures on the numbers of central venous catheterizations carried out during the time period. Five patients were referred with carotid or subclavian pseudoaneurysms and hemothorax following inadvertent arterial catheter insertion and subsequent removal. These patients all underwent percutaneous balloon tamponade and/or stent-graft insertion. More recently 4 patients were referred with the catheter still in situ and were successfully treated with a percutaneous closure device. CONCLUSION: If inadvertent arterial catheterization during central venous access procedures is recognized and catheters removed, sequelae can be treated percutaneously. However, once the complication is recognized it is better to leave the catheter in situ and seal the artery percutaneously with a closure device.