Fluoroscopic-Guided vs. Multislice Computed Tomography (CT) Biopsy Mode-Guided Percutaneous Radiologic Gastrostomy (PRG)-Comparison of Interventional Parameters and Billing.

BACKGROUND: This study investigated and compared the efficacy, safety, radiation exposure, and financial compensation of two modalities for percutaneous radiologic gastrostomy (PRG): multislice computed tomography biopsy mode (MS-CT BM)-guided and fluoroscopy-guided (FPRG). The aim was to provide insights into optimizing radiologically assisted gastrostomy procedures. METHODS: We conducted a retrospective analysis of PRG procedures performed at a single center from January 2018 to January 2024. The procedures were divided into two groups based on the imaging modality used. We compared patient demographics, intervention parameters, complication rates, and procedural times. Financial compensation was evaluated based on the tariff structure for outpatient medical services in Switzerland (TARMED). Statistical differences were determined using Fisher's exact test and the Mann-Whitney U test. RESULTS: The study cohort included 133 patients: 55 with MS-CT BM-PRG and 78 with FPRG. The cohort comprised 35 women and 98 men, with a mean age of 64.59 years (±11.91). Significant differences were observed between the modalities in effective dose (MS-CT BM-PRG: 10.95 mSv ± 11.43 vs. FPRG: 0.169 mSv ± 0.21, p < 0.001) and procedural times (MS-CT BM-PRG: 41.15 min ± 16.14 vs. FPRG: 28.71 min ± 16.03, p < 0.001). Major complications were significantly more frequent with FPRG (10% vs. 0% in MS-CT BM-PRG, p = 0.039, φ = 0.214). A higher single-digit number of MS-CT BM-guided PRG was required initially to reduce procedure duration by 10 min. Financial comparison revealed that only 4% of MS-CT BM-guided PRGs achieved reimbursement equivalent to the most frequent comparable examination, according to TARMED. CONCLUSIONS: Based on our experience from a retrospective, single-center study, the execution of a PRG using MS-CT BM, as opposed to FPRG, is currently justified in challenging cases despite a lower incidence of major complications. However, further well-designed prospective multicenter studies are needed to determine the efficacy, safety, and cost-effectiveness of these two modalities.

Gastric band removal: mind the arterial anastomoses!

Bariatric surgery may sometimes be challenging and may lead to severe complications. Surgical re-intervention in such cases is not the preferred option due to co-morbidities. When severe bleeding occurs, embolization of the lacerated vessels is the preferred minimal invasive management option and needs to be available if possible. We would like to report a case of young patient who underwent severe bleeding after migration of a gastric band. The patient was successfully embolized and the band was removed. However, on the second post-operative day, the patient complained again for acute abdominal pain and turned haemodynamically unstable. Fresh blood was aspirated from the surgical drain. A new emergency CT scan was performed and a new large pseudoaneurysm was revealed taking origin from the left gastric artery. The second bleeding occurred due to an anastomotic communication and was also successfully embolized. The main take home messages are that bariatric surgery may lead to several complications including bleeding, gastric band may cause vessel erosion but also offer a tamponade effect, endovascular embolization of the lacerated vessels is the preferred management and pseudoaneurysms arising in hepato-splenic or gastroduodenal arteries should be treated with the sandwich embolization technique.

Combination of Doxorubicin and Antiangiogenic Agents in Drug-Eluting Beads: In Vitro Loading and Release Dynamics in View of a Novel Therapeutic Approach for Hepatocellular Carcinoma.

PURPOSE: Antiangiogenic agents have been used for many years as a first-line systemic treatment for advanced HCC. Embolization with cytostatic drugs on the other hand is the first-line treatment for intermediate HCC. The two types of drugs have not been combined for intraarterial delivery yet. The loading and release dynamics and the in vitro effect of their combination are tested in this experimental study. MATERIALS AND METHODS: Drug-eluting beads were loaded with doxorubicin, sunitinib and sunitinib analogue piperazine (SAP) alone and with their combinations. Diameter change, loading, release, and effect in cellular proliferation were assessed. RESULTS: The average microsphere diameter after loading was 473.7 µm (µm) for Doxorubicin, 388.4 µm for Sunitinib, 515.5 µm for SAP, 414.8 µm for the combination Doxorubicin/Sunitinib and 468.8 µm for the combination Doxorubicin /SAP. Drug release in 0.9% NaCl was 10% for Doxorubicin, 49% for Sunitinib, 25% for SAP, 20%/18% for the combination Doxorubicin/Sunitinib, and 18%/23% for the combination Doxorubicin/SAP whereas in human plasma it was 56%, 27%, 13%, 76%/63% and 62%/15%, respectively. The mean concentration of Doxorubicin that led to inhibition of 50% of cellular proliferation in an HCC Huh7 cell line was 163.1 nM (nM), for Sunitinib 10.3 micromolar (µΜ), for SAP 16.7 µΜ, for Doxorubicin/Sunitinib 222.4 nM and for Doxorubicin/SAP 275 nM. CONCLUSIONS: Doxorubicin may be combined with antiangiogenic drugs with satisfactory in vitro loading and release outcomes and effect on cellular lines.

Histology profiling of lung tumors: tru-cut versus full-core system for CT-guided biopsies.

PURPOSE: We aimed to compare the diagnostic yield and procedure-related complications of two different types of systems for percutaneous CT-guided lung biopsy. MATERIAL AND METHODS: All patients with a lung lesion who underwent a CT-guided lung biopsy at our institution, between January 2019 and 2021, were retrospectively analyzed. The inclusion criteria were: (a) Procedures performed using either a fully automated tru-cut or a semi-automated full-core biopsy needle, (b) CT images demonstrating the position of the needles within the lesion, (c) histopathological result of the biopsy and (d) clinical follow-up for at least 12 months and\or surgical histopathological results. A total of 400 biopsy fulfilling the inclusion criteria were selected and enrolled in the study. RESULTS: Overall technical success was 100% and diagnostic accuracy was 84%. Tru-cut needles showed a significantly higher diagnostic accuracy when compared to full-core needles (91% vs. 77%, p = 0.0004) and a lower rate of pneumothorax (31% vs. 41%, p = 0.047). Due to the statistically significant different of nodules size between the two groups, we reiterated the statistical analysis splitting our population around the 20 mm cut-off for nodule size. We still observed a significant difference in diagnostic accuracy between tru-cut and full-core needles favoring the former for both smaller and larger lesions (81% vs. 71%, p = 0.025; and 92% vs. 81%; p = 0.01, respectively). CONCLUSION: Our results demonstrated that the use of automated tru-cut needles is associated with higher histopathological diagnostic accuracy compared to semi-automated full-core needles for CTLB.

Lung cancer: CT guided BX-EBUS: How and when?

Histological diagnosis is mandatory for the majority of solid lesions in the lungs in order to characterize the lesions but also to assess the response to treatment. Flexible bronchoscopy has a variable and often poor success rate in sampling pulmonary lesions which are not visible endoscopically. Such focal radiological opacities without endobronchial extension are referred to as peripheral pulmonary lesions and sampling is usually performed under guidance with computed tomography that is a safe and effective technique and became a common procedure representing an essential step for diagnosis and treatment planning. It is usually performed with an 18G or 20G coaxial needle system and several novel guidance and navigation tools may be integrated to clinical practice to offer more accurate lesion targeting. There is however still a percentage of negative sampling a recent study revealed that small lesion size, lower 18F-FDG uptake or location at the lung bases may lead to inconclusive histology. The diagnostic yield may be increased if PET/CT fusion imaging is used intraprocedurally. CT guided biopsies may also be applied in the same setup with interventions such as ablation of lung lesions offering a "one-stop" approach for such patients.

Local and Regional Therapies for Hepatocellular Carcinoma and Future Combinations.

BACKGROUND: Hepatocellular carcinoma (HCC) can be treated by local and regional methods of percutaneous interventional radiological techniques. Indications depend on tumor size, type and stage, as well as patient's condition, liver function and co-morbidities. According to international classification systems such as Barcelona Clinic Liver Cancer (BCLC) classification, very early, early or intermediate staged tumors can be treated either with ablative methods or with transarterial chemoembolization (TACE), depending on tumor characteristics. The combination of both allows for individualized forms of treatment with the ultimate goal of improving response and survival. In recent years, a lot of research has been carried out in combining locoregional approaches with immune therapy. Although recent developments in systemic treatment, especially immunotherapy, seem quite promising and have expanded possible combined treatment options, there is still not enough evidence in their favor. The aim of this review is to provide a comprehensive up-to-date overview of all these techniques, explaining indications, contraindications, technical problems, outcomes, results and complications. Moreover, combinations of percutaneous treatment with each other or with immunotherapy and future options will be discussed. Use of all those methods as down-staging or bridging solutions until surgery or transplantation are taken into consideration will also be reviewed. CONCLUSION: Local and regional therapies remain a mainstay of curative and palliative treatment of patients with HCC. Currently, evidence on potential combination of the local and regional treatment options with each other as well as with other treatment modalities is growing and has the potential to further individualize HCC therapy. To identify the most suitable treatment option out of these new various options, a repeated interdisciplinary discussion of each case by the tumor board is of utmost importance.

ePTFE/FEP stents for malignant biliary obstruction.

BACKGROUND: Biliary obstruction due to malignant disease causes debilitating symptoms and palliation of the disease involves placement of biliary stents. Covered self-expanding metal biliary stents may provide a longer patency and a lower risk of complications and dysfunction compared to uncovered stents, making them better for patients' quality of life and cost effectiveness. This study aims to evaluate the indications and outcomes for a group of cases where expanded polytetrafluoroethylene/fluorinated ethylene propylene (ePTFE/FEP) covered metal stents were used to palliate malignant biliary obstruction. METHODS: All cases of ePTFE/FEP-covered Viabil stent implantation in a 4-year period in a single hospital were identified and details of indications and outcomes for stent placement were recorded. Kaplan-Meier estimator analysis was used to create plots for stent patency and survival time. RESULTS: The median stent patency was 173 days (standard error of the mean, SE = 54) and the median survival time was 247 days (SE = 88). No complications of stent implantation were recorded and in seven cases no dysfunction was noted. In one case, tumour ingrowth was observed, and in one other case the stent was no longer found in situ on subsequent imaging. CONCLUSION: The use of the ePTFE/FEP-covered Viabil stent in the palliation of malignant obstruction where indicated is promising, providing a low rate of stent dysfunction and complications. More data need to be collected to conclusively ascertain whether covered stents have a longer patency and lower complication rate compared to uncovered stents.

Diagnostic yield of CT-guided lung biopsies: how can we limit negative sampling?

OBJECTIVES: To investigate whether lesion imaging features may condition the outcome of CT-guided lung biopsy (CTLB) and to develop a scoring system of biopsy outcome prediction. METHODS: This is a single center retrospective study on 319 CTLBs that were performed in 319 patients (167 males/152 females, mean age 68 ± 12.2). Uni- and multivariate analysis were performed aiming to assess the imaging features that are likely to be correlated to a negative biopsy outcome and patients were stratified in groups accordingly. RESULTS: Technical success was 100%. 78% of the biopsies (250/319) led to a concrete histology report (218 malignant/32 benign). The remaining lesions led to concrete histology at a second attempt that occurred on a later time. Multivariate analysis revealed increased risk of inconclusive result for nodules with low fludeoxyglucose uptake [odds ration (OR) = 2.64, 95% confidence interval (CI) 1.4-4.97; p = 0.003], for nodules with diameter smaller than 18 mm (OR = 2.03, 95% CI 1.14-3.62; p = 0.017) and for nodules that are located in one of the lung bases (OR = 1.96, 95% CI 1.06-3.62; p = 0.033). Three different groups of patients were identified accordingly with low (<30%), medium (30-50%) and high (>50%) probability of obtaining an inconclusive biopsy sample. CONCLUSION: This study confirms that percutaneous CT-guided biopsy in nodules that are either small in diameter or present low positron emission tomography-fludeoxyglucose uptake or are in one of the lung bases may lead to inconclusive histology. This information should be factored when planning percutaneous biopsies of such nodules in terms of patient informed consent and biopsy strategy. ADVANCES IN KNOWLEDGE: Inconclusive histology after lung biopsy may be subject to factors irrelevant to technical success. Lung biopsy histology outcomes may be predicted and avoided after adequate planning.

Editor's Choice - Risk of Major Amputation Following Application of Paclitaxel Coated Balloons in the Lower Limb Arteries: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

OBJECTIVE: There have been concerns about the long term safety of paclitaxel coated devices in the lower limbs. A formal systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to examine the long term risk of major amputation using paclitaxel coated balloons in peripheral arterial disease (PAD). METHOD: This systematic review was registered with PROSPERO (ID 227761). A broad bibliographic search was performed for RCTs investigating paclitaxel coated balloons in the peripheral arteries (femoropopliteal and infrapopliteal) for treatment of intermittent claudication or critical limb ischaemia (CLI). The literature search was last updated on 20 February 2021 without any restrictions on publication language, date, or status. Major amputations were analysed with time to event methods employing one and two stage models. Sensitivity and subgroup analyses, combinatorial meta-analysis, and a multivariable dose response meta-analysis to examine presence of a biological gradient were also performed. RESULTS: In all, 21 RCTs with 3 760 lower limbs were analysed (52% intermittent claudication and 48% CLI; median follow up two years). There were 87 major amputations of 2 216 limbs in the paclitaxel arms (4.0% crude risk) compared with 41 major amputations in 1 544 limbs in the control arms (2.7% crude risk). The risk of major amputation was significantly higher for paclitaxel coated balloons with a hazard ratio (HR) of 1.66 (95% CI 1.14 - 2.42; p = .008, one stage stratified Cox model). The prediction interval was 95% CI 1.10 - 2.46 (two stage model). The observed amputation risk was consistent for both femoropopliteal (p = .055) and infrapopliteal (p = .055) vessels. Number needed to harm was 35 for CLI. There was good evidence of a significant non-linear dose response relationship with accelerated risk per cumulative paclitaxel dose (chi square model p = .007). There was no evidence of publication bias (p = .80) and no significant statistical heterogeneity between studies (I2 = 0%, p = .77). Results were stable across sensitivity analyses (different models and subgroups based on anatomy and clinical indication and excluding unpublished trials). There were no influential single trials. Level of certainty in evidence was downrated from high to moderate because of sparse events in some studies. CONCLUSION: There appears to be heightened risk of major amputation after use of paclitaxel coated balloons in the peripheral arteries. Further investigations are warranted urgently.

Hepatocellular Carcinoma Drug-Eluting Bead Transarterial Chemoembolization (DEB-TACE): Outcome Analysis Using a Model Based On Pre-Treatment CT Texture Features.

(1) Introduction and Aim: The aim of this study is to investigate the prognostic value, in terms of response and survival, of CT-based radiomics features for patients with HCC undergoing drug-eluting beads transarterial chemoembolization (DEB-TACE). (2) Materials and Methods: Pre-treatment CT examinations of 50 patients with HCC, treated with DEB-TACE were manually segmented to obtain the tumor volumetric region of interest, extracting radiomics features with TexRAD. Response to therapy evaluation was performed basing on post-procedural CT examination compared to pre-procedural CT, using modified RECIST criteria for HCC. The prognostic value of texture analysis was evaluated, investigating the correlation between radiomics features, response to therapy and overall survival. Three models based on texture and clinical variables and a combination of them were finally built; (3) Results: Entropy, skewness, MPP and kurtosis showed a significant correlation with complete response (CR) to TACE (all p < 0.001). A predictive model to identify patients with a high and low probability of CR was evaluated with an ROC curve, with an AUC of 0.733 (p < 0.001). The three models built for survival prediction yielded an HR of 2.19 (95% CI: 2.03-2.35) using texture features, of 1.7 (95% CI: 1.54-1.9) using clinical data and of 4.61 (95% CI: 4.24-5.01) combining both radiomics and clinical data (all p < 0.0001). (4) Conclusion: Texture analysis based on pre-treatment CT examination is associated with response to therapy and survival in patients with HCC undergoing DEB-TACE, especially if combined with clinical data.

The role of imaging in the management of renal masses.

The wide availability of cross-sectional imaging is responsible for the increased detection of small, usually asymptomatic renal masses. More than 50 % of renal cell carcinomas (RCCs) represent incidental findings on noninvasive imaging. Multimodality imaging, including conventional US, contrast-enhanced US (CEUS), CT and multiparametric MRI (mpMRI) is pivotal in diagnosing and characterizing a renal mass, but also provides information regarding its prognosis, therapeutic management, and follow-up. In this review, imaging data for renal masses that urologists need for accurate treatment planning will be discussed. The role of US, CEUS, CT and mpMRI in the detection and characterization of renal masses, RCC staging and follow-up of surgically treated or untreated localized RCC will be presented. The role of percutaneous image-guided ablation in the management of RCC will be also reviewed.

Use of heparin coated vascular stents in femoropopliteal chronic total occlusions: Long term outcomes.

PURPOSE: To evaluate the long-term clinical efficacy of the Tigris © stent (Gore ©) in femoropopliteal chronic total occlusions (CTOs). MATERIAL AND METHODS: This single centre retrospective study included 29 patients treated with 47 Tigris© stents for CTOs. Lesion location, type, length, revascularisation method, smoking status and diabetes were reviewed. Clinical follow-up was performed. Primary safety points were complications and adverse events. Secondary efficacy points were symptom deterioration, freedom from target lesion revascularization (TLR) and amputation rate. Freedom from TLR was evaluated with Kaplan-Meier analysis; Cox multivariable logistic regression analysis of the factors associated with stent re-occlusion was also performed. RESULTS: All procedures were technically successful without any peri- or post-procedural complications and adverse events. Median follow-up was 48 months (range: 7-70). Lesions were located in the superficial femoral (19), popliteal (3) and femoropopliteal (7) arteries with mean lesion length 13.9 ±â€¯7.6 cm. In 12 patients subintimal recanalization was performed. Freedom from TLR rates at 6, 12, 18, 24 and 36 months were 96.6 %, 85.7 %, 81.9 %, 78.2 % and 74.3 % respectively. No stent fracture was observed and no amputation was performed in any of the patients. Smoking status, the presence of diabetes, lesion localization and recanalization type were not associated with stent re-occlusion. CONCLUSION: This study demonstrated that use of a heparin coated vascular stent for femoropopliteal CTOs appears to offer satisfactory long-term results.

Demystifying the Use of Self-Expandable Interwoven Nitinol Stents in Femoropopliteal Peripheral Arterial Disease.

Femoropopliteal atherosclerosis affects a significant percentage of the world population, leading to intermittent claudication and critical limb ischemia. The femoropopliteal segment has a unique set of biomechanical challenges that must be considered and overcome for treatment. The use of stents is a reality and a necessity in peripheral interventions. The success of first-generation femoropopliteal stents was limited by their rigidity and deformability. The standard nitinol stents overcame certain biomechanical challenges because of their superelasticity and thermal shape memory, although stent fracture is still an issue. Therefore, interwoven nitinol stents with helical structure have been developed, borrowing the concept from biliary stents, aiming to provide good flexibility while still maintaining a uniform cell size and significant radial strength. This unique interwoven structure gains it advantage in the femoropopliteal region. The purpose of this review article is to investigate the current published evidence of the use of self-expandable interwoven nitinol stents in femoropopliteal arterial disease and compare them with other endovascular treatment options.

Ex vivo performance comparison of three percutaneous biopsy needle systems.

PURPOSE: The aim of this study is to identify the micro-mechanical characteristics that define biopsy performance in normal ex vivo animal organs. MATERIALS AND METHODS: Three biopsy systems with differences of needle external diameter, tray height and effective tray length were assessed. Sampling was performed in porcine liver and kidneys with commercially labelled 14G, 16G and 18G, using 2-cm throw needle systems. Five samples were obtained per needle size and per organ, and the experiment was repeated twice for a total of 90 biopsy cores. Samples were analysed and compared in terms of macroscopic aspect, sample length, weight and tissue architecture. RESULTS: The system with the longest effective needle tray (system A) has shown significant superiority (p < 0.001) versus the other systems regarding the mean weight of tissue obtained for all needle sizes. Furthermore, the 14G needle of system A has shown superiority regarding the number of portal spaces and the 16G regarding the length of kidney fragments obtained. CONCLUSION: The outcomes obtained with the different biopsy systems were not equal. The micro-mechanical characteristic that appears to influence the quantity and quality of the obtained tissue is the effective needle tray length and not the needle external diameter or the needle tray height. This information should be taken into account in the future design of biopsy needle systems, particularly when potentially used in the assessment of biomarkers and the characterisation of tumour micro-environment. KEY POINTS: • The amount of obtained tissue mass is not the same among percutaneous biopsy needle systems. • There are different micro-mechanical characteristics that condition the amount of obtained tissue. • The micro-mechanical characteristic that offers more tissue mass for the same calibre is the effective length of the needle tray.

Thyroid skeletal metastasis: pain management with verteblation.

The combination of percutaneous vertebroplasty with radiofrequency ablation (verteblation) has not shown to be an effective measure of pain management in patients with metastatic lesions of the spine. The use of this novel technique has not been previously described in metastatic disease from thyroid cancer. We would like to report our experience after treating a patient affected by a thyroid carcinoma and an osteolytic spine metastasis. The patient suffered from life-limiting pain and was successfully treated with a combination of vertebroplasty and radiofrequency ablation. This case shows that the indications of verteblation may be expanded in the palliative treatment of metastatic disease from thyroid carcinoma.

Trans Arterial Embolization of Non-variceal Upper Gastrointestinal Bleeding: Is the Use of Ethylene-Vinyl Alcohol Copolymer as Safe as Coils?

PURPOSE: The safety of liquid embolics over the conventional coils for the treatment of non-variceal upper gastrointestinal bleeding (UGIB) approach is still unclear. Purpose of this study is to assess the safety of ethylene-vinyl alcohol copolymer (EVOH 6%) over coils in the treatment of UGIB. MATERIALS AND METHODS: All the upper gastrointestinal tract embolization procedures performed in a single center in a 6-year period were reviewed. Patients embolised with coils (Group A) versus those embolised with EVOH 6% (Group B) were compared. Technical/clinical success, bleeding recurrence, complication and mortality rates were analyzed. RESULTS: A total 71 patients were included in the study (41 Group A and 30 Group B). Coagulopathy was present in 21% of Group A and 46% of Group B patients (p < 0.05). Technical and clinical success was 97.6 and 92.7% for Group A, and 100 and 93.3% for Group B respectively, (p > 0.05). Ten patients (17% Group A; 10% Group B) re-bled within the first 36 h and all of them were re-treated successfully with a second embolization. In Group A one major complication (bowel ischemia) occurred. No complication occurred in Group B. The survival rate in the first 30 days was 90.3% for group A and 90% for group B (p > 0.05). CONCLUSION: This study demonstrated EVOH 6% appears to be as safe and effective as coils in the treatment of non-variceal UGIB.