Society of Interventional Radiology Research Reporting Standards for Genicular Artery Embolization.

Genicular artery embolization (GAE) is an emerging, minimally invasive therapy to address the global burden of knee osteoarthritis (OA) and the unmet needs for medically refractory disease. Although total knee arthroplasty has been a standard intervention for severe cases, GAE is developing into a promising alternative, particularly for patients ineligible for or unwilling to undergo surgery. GAE targets the inflammatory cascade underlying OA pathophysiology by arresting neoangiogenesis and preventing pathological neoinnervation, offering potential pain relief. Although early studies have established safety and short-term effectiveness, ensuing studies are needed to validate long-term safety, durability, and comparative effectiveness and to optimize patient selection, embolic agent selection, and administration techniques. Standardized reporting guidelines are therefore essential to enhance transparency and reproducibility across clinical trials, facilitating data aggregation and comparison. This Society of Interventional Radiology (SIR)-endorsed reporting standards consensus document provides a framework to harmonize future research efforts and to improve the interpretation of outcomes.

Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report.

BACKGROUND: Infection of a transjugular intrahepatic portosystemic shunt (TIPS) stent is a rare and serious complication that most commonly occurs during TIPS creation and revision. Patients typically present with recurrent bacteremia due to shunt occlusion or vegetation. To date there are approximately 58 cases reported. We present a patient diagnosed with late polymicrobial TIPS infection five years following TIPS creation. CASE SUMMARY: A 63-year-old female status-post liver transplant with recurrent cirrhosis and portal hypertension presented with sepsis and recurrent extended-spectrum beta-lactamase Escherichia coli bacteremia. Computed tomography of the abdomen revealed an occluded TIPS with thrombus extension into the distal right portal vein, and focal thickening of the cecum and ascending colon. Colonoscopy revealed patchy ulcers in these areas with histopathology demonstrating ulcerated colonic mucosa with fibrinopurulent exudate. Shunt thrombectomy and revision revealed infected-appearing thrombus. Patient initially cleared her infection with antibacterial therapy and TIPS revision; however, soon after, she developed Enterobacter cloacae bacteremia and Candida glabrata and C. albicans fungemia with recurrent TIPS thrombosis. She remained on antifungal therapy indefinitely and later developed vancomycin-resistant Enterococcus faecium with recurrent TIPS thrombosis. The option of liver re-transplant for removal of the infected TIPS was not offered given her critical illness and complex shunt anatomy. The patient became intolerant to linezolid and elected hospice care. CONCLUSION: Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.

Improving Cone-Beam CT Angiography for Prostatic Artery Embolization: Is a Low-Dose Protocol Equivalent to the Standard?

PURPOSE: To compare the utility of low-dose versus standard cone-beam computed tomography (CT) angiography protocols in identifying nontarget embolization (NTE) during prostatic artery embolization (PAE). MATERIALS AND METHODS: A prospective, single-center, Phase-1 study (NCT02592473) was conducted for lower urinary tract symptoms in benign prostatic hyperplasia. Prostate volume, international prostate symptom score (IPSS), quality of life score (QoL), International Index of Erectile Function (IIEF), peak flow rate, UCLA Prostate Cancer Index (UCLA-PCI), and postvoid residual were recorded at baseline and 1, 3, 6, 12, and 24-months after PAE. Six-second (standard protocol, n = 29) or 5-second (low-dose protocol n = 45) rotations were made. Images were selected and matched in pairs by areas of NTE and compared by readers using a binomial generalized estimating equation model. Procedural outcomes were analyzed using a linear mixed model. RESULTS: Seventy-four cone-beam CT angiographies were performed in 21 patients. IPSS and QoL scores significantly improved (P <.05). There was no change in UCLA-PCI or IIEF scores. Dose area product of the low- and standard-dose protocol were 37,340.82 mGy·cm2 ± 104.66 and 62,645.66 mGy·cm2 ± 12,711.48, respectively, representing a dose reduction of 40.4%. A total of 120 comparisons showed no preference between the 2 protocols (P =.24). Observers identified 76 and 69 instances of NTE in the standard- and low-dose protocols, respectively (P =.125). CONCLUSIONS: Low-dose cone-beam CT angiography achieved equivalent clinical utility in identifying NTE during PAE, with the advantage of a lower radiation dose.

Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia.

PURPOSE: To perform meta-analysis of available data on prostatic artery embolization (PAE). MATERIALS AND METHODS: Meta-analysis was conducted on articles published between November 2009 and December 2015. Peer-reviewed studies with > 5 patients and standard deviations and/or individual-level data on one or more of the following outcomes were included: prostate volume (PV), peak flow rate (Qmax), postvoid residual (PVR), International Prostate Symptom Score (IPSS), quality of life (QOL) score, International Index of Erectile Function (IIEF) score, and prostate-specific antigen (PSA) level. A random-effects meta-analysis was performed on the outcomes at 1, 3, 6, and 12 months after PAE compared with baseline values, with a P < .05 decision rule as the null hypothesis rejection criterion. RESULTS: Nineteen of 268 studies were included in data collection, with 6 included in the meta-analysis. At 12 months, PV decreased by 31.31 cm3 (P < .001), PSA remained unchanged (P = .248), PVR decreased by 85.54 mL (P < .001), Qmax increased by 5.39 mL/s (P < .001), IPSS improved by 20.39 points (P < .001), QOL score improved by -2.49 points (P < .001), and IIEF was unchanged (P = 1.0). There were a total of 218 adverse events (AEs) among 662 patients (32.93%), with 216 being Society of Interventional Radiology class A/B (99%). The most common complications were rectalgia/dysuria (n = 60; 9.0%) and acute urinary retention (n = 52; 7.8%). No class D/E complications were reported. CONCLUSIONS: PAE provided improvement in Qmax, PVR, IPSS, and QOL endpoints at 12 months, with a low incidence of serious AEs (0.3%), although minor AEs were common (32.93%). There was no adverse effect on erectile function.

Recommendations for multimodal noninvasive and invasive screening for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency: a position statement of the International Society for Neurovascular Disease.

Under the auspices of the International Society for Neurovascular Disease (ISNVD), four expert panel committees were created from the ISNVD membership between 2011 and 2012 to determine and standardize noninvasive and invasive imaging protocols for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency (CCSVI). The committees created working groups on color Doppler ultrasound (US), magnetic resonance (MR) imaging, catheter venography (CV), and intravascular US. Each group organized a workshop focused on its assigned imaging modality. Non-ISNVD members from other societies were invited to contribute to the various workshops. More than 60 neurology, radiology, vascular surgery, and interventional radiology experts participated in these workshops and contributed to the development of standardized noninvasive and invasive imaging protocols for the detection of extracranial venous abnormalities indicative of CCSVI. This ISNVD position statement presents the MR imaging and intravascular US protocols for the first time and describes refined color Doppler US and CV protocols. It also emphasizes the need for the use of for noninvasive and invasive multimodal imaging to diagnose adequately and monitor extracranial venous abnormalities indicative of CCSVI for open-label or double-blinded, randomized, controlled studies.

Percutaneous endovascular creation of an inferior vena cava in a patient with caval agenesis, Budd-Chiari syndrome, and iliofemorocaval thrombosis.

A 29-year-old woman with acute iliofemorocaval thrombosis was discovered to have suprarenal caval agenesis with azygous continuation, hepatic congestion, and fibrosis as a result of chronic Budd-Chiari syndrome. Three staged procedures were performed: pharmacomechanical thrombolysis of acute thromboses, transfemoral liver biopsy and hemodynamic assessment, and percutaneous endovascular creation of a "neocava" lined with endografts. Symptomatic improvement and patency were maintained at 12-week follow-up.

The use of transarterial chemoembolization in the treatment of unresectable hepatocellular carcinoma: a response to the Cochrane Collaboration review of 2011.

This commentary is written in response to a recent Cochrane Collaboration review published in March 2011 (1). The authors of this commentary would like to express their concerns over the conclusions of the Cochrane review, which state, "There is no firm evidence to support or refute transarterial chemoembolization (TACE) or transarterial embolization (TAE) for patients with unresectable hepatocellular carcinoma (HCC)."

Uterine fibroid embolization for patients with acute urinary retention.

Acute urinary retention due to uterine fibroids is rare. In reported cases, hysterectomy and myomectomy have been the recommended therapies. Herein, the authors describe two patients with acute obstructive urinary retention who experienced immediate improvement and the ability to spontaneously void after uterine fibroid embolization. The rapidity of response and the nonsurgical nature of this therapy suggest that it may be used as the first-line therapy for this rare event.

Eye lens exposure to radiation in interventional suites: caution is warranted.

PURPOSE: To report estimated radiation doses to the eye lens of the interventionalist from procedures performed with and without use of radiation protection measures. MATERIALS AND METHODS: Scattered radiation doses for seven interventional radiology fluoroscopic systems were measured by using phantoms simulating patients 16-28 cm in thickness undergoing low-, medium-, and high-mode fluoroscopy, cine cardiac imaging, and digital subtraction angiography (DSA). The radiation doses to the eye lens in low- and high-dose scenarios were estimated. Beam angulation, biplanar equipment, working distance, procedure complexity, imaging collimation, and use of eyeglasses and/or protective suspended screens were taken into account. The doses to the lens in several procedures were assessed. RESULTS: Mean scattered radiation doses to the lens during fluoroscopy were 6.0 and 34.5 microSv/min in the low- and high-dose scenarios, respectively. For DSA, typical doses to the lens ranged from 0.77 to 3.33 microSv per image. Operation modes involving increasing or decreasing radiation doses were quantified. For hepatic chemoembolization, iliac angioplasty, pelvic embolization, and transjugular intrahepatic portosystemic shunt creation, lens doses ranged from 0.25 to 3.72 mSv per procedure when protection was not used. Lens doses in the neuroembolization procedures could exceed 10 mSv per procedure. CONCLUSION: With typical reported workloads, radiation doses to eye lenses may exceed the threshold for deterministic effects (ie, lens opacities or cataracts) after several years of work if radiation protection tools are not used.

Massage-induced delayed venous stent migration.

Catheter-directed therapies in chronic deep vein thromboses can help improve leg function by mechanically addressing residual obstruction in lower extremity or pelvic veins, although the reported use of stents in leg veins is relatively unusual. The author reports a case of this type with long-term patency and clinical success, culminating in asymptomatic delayed venous migration of a stent to the right atrium after 3 years. Open heart surgery was required to remove the embedded stent fragments. The attributed mechanism was deep tissue massage of the thigh.

Use of the Arrow percutaneous thrombectomy device and transjugular liver biopsy cannula for mechanical thrombectomy of the inferior vena cava in a patient with Budd-Chiari syndrome.

A 33-year-old woman with Budd-Chiari syndrome and hypercoagulability was sequentially treated with the placement of hepatic vein stents and transjugular intrahepatic portosystemic shunts (TIPS), all of which repeatedly thrombosed. Four months after TIPS revision with an endoprosthesis, a large inferior vena cava (IVC) thrombus developed caudal to an IVC stenosis. A percutaneous thrombectomy device was introduced coaxially through a transjugular liver biopsy cannula to extend its effective diameter range of attack and was steered within the IVC to successfully clear the thrombus. The condition recurred 9 months later, and the technique was repeated successfully. At subsequent 12-month follow-up, the IVC remains patient and symptoms resolved. This combination of cannula and percutaneous thrombectomy device proved essential in facilitating successful mechanical thrombectomy of the IVC.