Initial series of magnetic resonance imaging (MRI)-fusion targeted prostate biopsy using the first transperineal targeted platform available in the USA.

OBJECTIVES: To describe a step-by-step guide for using the first transperineal targeted prostate biopsy platform available in the USA. PATIENTS AND METHODS: A total of 32 men with elevated prostate-specific antigen (PSA) levels were diagnosed with a region of interest on multiparametric magnetic resonance imaging (mpMRI) between February 2017 and January 2018. The transperineal targeted prostate biopsy procedure was accomplished via a transperineal approach and used a stepper, combined with advanced mpMRI/transrectal ultrasound fusion software, to perform targeted prostate biopsy. The detection of overall and clinically significant prostate cancer (PCa) was assessed as well as the rate of complications. RESULTS: The median patient age was 68.0 years and the median PSA was 8.0 ng/mL. Two patients (6%) were active surveillance candidates and 16 (50%) had a prior negative prostate biopsy. The detection rates for overall and clinically significant PCa were 81% and 59%, respectively. The two candidates for active surveillance and eight of the patients with a prior negative prostate biopsy had clinically significant PCa confirmed on targeted biopsy. There were no peri-operative complications. CONCLUSION: These results demonstrate the promising potential of the first transperineal targeted prostate biopsy platform in the USA as an alternative diagnostic method for PCa.

Checklists for Image-Guided Interventions.

OBJECTIVE: Checklists are tools commonly used to help confirm that certain tasks of a process are completed. Within the health care industry, medical checklists are recognized as a means to improve patient safety. CONCLUSION: Recent application of checklists to image-guided interventions has shown positive outcomes; however, there are limited published studies. We review the literature regarding checklist use as a safety measure and focus on implementation of checklists for image-guided interventions.

MRI-Guided Prostate Interventions.

OBJECTIVE: The objective of this study is to discuss the use of MRI-guided and MRI-directed prostate biopsy techniques, describe how interventional MRI focal therapies are used for the treatment of prostate cancer, and predict future directions in prostate interventional MRI. The prospect of establishing a center for prostate imaging, diagnosis, and treatment is also discussed. CONCLUSION: Low- or intermediate-risk prostate cancer can be safely treated with MRI-compatible devices and techniques such as biopsy, cryoablation, high-intensity focused ultrasound, or focal laser ablation performed from a transrectal or transperineal approach. Although the long-term effectiveness of focal therapy for prostate cancer is unknown, the effect on urinary or sexual function is extremely low. These procedures are attracting an increasing number of men who view focal therapies as a better alternative to the uncertainty of no therapy and the more radical whole-gland surgical and radiation therapies with their higher complication rates.

Extrahepatic portal biliopathy: proposed etiology on the basis of anatomic and clinical features.

PURPOSE: To compare the anatomic and clinical features in patients with chronic portal vein thrombosis (PVT) to determine why some patients develop portal biliopathy (PB) while most do not and propose an etiology for PB. MATERIALS AND METHODS: This project satisfied HIPAA regulations and received institutional review board approval for a retrospective review without the need for consent. From 100 patients with PVT, 60 were extracted who had chronic, nonmalignant PVT, after exclusion of those with sclerosing cholangitis, liver transplants, choledocholithiasis, or portosystemic shunts. Clinical and imaging data from 19 patients with biliary dilatation (PB group) were compared with data from 41 patients without biliary dilatation (no-PB group). Statistical analysis was performed with the Fisher exact test for categorical variables or the Wilcoxon rank-sum test for numerical and ordered categorical variables. P values of .05 or less were considered to indicate a significant difference. RESULTS: The etiology of PVT differed between the groups (P < .001); cirrhosis was infrequently seen in the PB group (two of 19, 11%) but was common in the no-PB group (31 of 41, 76%). Only two of 33 (6%) patients with cirrhosis and PVT had PB. Extension of PVT into the mesenteric veins was significantly more common in the PB group (18 of 19, 95%) than in the no-PB group (one of 41, 2%) (P < .001). Compared with the no-PB group, patients in the PB group had more acute angulation of the bile duct (median, 110° vs 128°; P = .008), less frequent gastroesophageal varices (three of 19 [16%] vs 20 of 41 [49%], P = .021), and a smaller mean coronary vein diameter (median, 5 vs 6 mm; P = .014). CONCLUSION: Noncirrhotic patients with hypercoagulable states tend to develop PB when PVT extends to the splenomesenteric veins. A possible etiology is the formation of specific peribiliary venous pathways responsible for bile duct compression and tethering.

Spontaneous hepatic hemorrhage in older women.

Spontaneous liver hemorrhage in older women is not well described. We report an experience with five postmenopausal women who spontaneously bled from the liver. All five patients presented with acute bleeding. Four were treated nonoperatively. No tumor was identified in any patient. Four patients acutely were discharged alive and well, but one died after operation to control bleeding. Spontaneous liver hemorrhage can occur in a variety of clinical settings, but an association with older women taking hormone replacement and anticoagulation has not been reported.

Stent placement for tracheobronchial disease.

Early treatment for airway stenoses or occlusions involved open repair with the attendant risks of thoracotomy or sternotomy. With the advent of rigid and, more recently, flexible bronchoscopy, the placement of airway stents has come to the forefront in the treatment of benign and malignant tracheobronchial disease. This paper describes the history of surgical and endoluminal treatment of airway disease and discusses the indications and contraindications for airway stent placement. The advantages and limitations of such therapy are reviewed as well as the procedural details and the imaging evaluation and follow-up of patients undergoing endoluminal treatment. Although the placement of tracheobronchial stents is now primarily performed by interventional pulmonologists, imaging anatomically complex airway disease also requires the skills of an accomplished cross-sectional radiologist. Additionally, interventional radiologists using fluoroscopic guidance and alternative access routes to the airways can salvage failed bronchoscopic procedures and primarily treat selected cases. Due to the importance of pre- and post-procedural imaging in these patients, radiologists should be aware of airway anatomy suitable for stent placement and the appearance of various complications of this procedure.

Clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas: a clinicopathologic study of three cases and review of the literature.

Solid pseudopapillary tumors are rare pancreatic neoplasms of uncertain pathogenesis that rarely metastasize and usually occur in young women. We describe the clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas. We reviewed the clinical presentation, imaging, morphologic/immunochemical features, and follow-up of three women (age range 26-44). Cases 1, 2, and 3 presented with abdominal wall abscess, multiple endocrine neoplasia, and solid/cystic mass in the pancreatic head, respectively, and computed tomography of abdomen revealed solid/cystic masses with heterogeneous enhancement in body, tail and head of the pancreas, respectively. Case 2 also exhibited a left adrenal mass. Case 3 underwent endoscopic ultrasound of the pancreas, which showed a complex solid/cystic mass with septations. Sampling consisted of fine-needle aspiration (percutaneous or endosonography-guided), and additionally, core biopsy of the pancreatic mass and adrenal lesion in case 2. Aspirates and core biopsy revealed vascular structures with attached monotonous neoplastic cells in papillary-like arrays. Tumor cells had bland nuclear features with grooves, cytoplasmic periodic acid Schiff-positive hyaline globules, and associated myxoid/stromal fragments. Immunochemistry expressed alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin, and focal neuron-specific enolase. Cases 1 and 3 underwent pancreatectomy with follow-up consisting of yearly imaging and no recurrences. Case 2 proved metastatic disease to adrenal gland and no follow-up was available. In the setting of typical clinical and imaging findings, an accurate preoperative diagnosis of pancreatic solid pseudopapillary tumor can be established by aspiration cytology and immunochemistry with or without concomitant core biopsy, on the basis of which clinicians decide treatment. This tumor can behave in a malignant fashion.

Combined transthoracic and transtracheal closure of large bronchopleural fistulae.

PURPOSE: Postoperative central bronchopleural fistulae (BPF) are difficult to close using percutaneous or endoscopic techniques. We devised an alternative method to treat BPF using a combined transthoracic and transtracheal approach with the use of a multifilamented polypropylene (Prolene) mesh patch. METHODS: Two patients with large, central BPF after thoracic surgery and lobar resection had minimally invasive BPF closure using a transtracheal approach with catheterization of the fistula and thoracoscopically guided Prolene mesh placement over the bronchial stump defect. This technique was adopted after conservative management and multiple endobronchial interventions had failed in both patients. RESULTS: One patient had closure of his BPF within one week and remains symptom-free one year after chest tube removal. The other patient had a BPF and chest tube for two years prior to our procedure. His BPF initially closed, but recannalized 2 weeks later. He subsequently had two thoracotomies and continues to suffer a BPF which remains externalized to his chest wall. CONCLUSIONS: Post-thoracotomy central BPF that is resistant to nonsurgical treatments can be closed with a combined thoracoscopic and transtracheal placement of a polypropylene patch. The success of this repair seems to depend on early intervention and aggressive sterilization of the pleural space.

Venous access ports: indications, implantation technique, follow-up, and complications.

The subcutaneous venous access device (SVAD or "port") is a critical component in the care of patients with chronic disease. The modern SVAD provides reliable access for blood withdrawal and medication administration with minimal disruption to a patient's lifestyle. Because of improved materials and catheter technology, today's ports are lighter and stronger and capable of high-pressure injections of contrast for cross-sectional imaging. The majority of SVAD placement occurs in interventional radiology departments due to their ability to provide this service at lower costs, lower, complication rates, and greater volumes. Port-insertion techniques vary depending on the operator, but all consist of catheter placement in the central venous circulation followed by subcutaneous pocket creation and port attachment to the catheter with fixation and closure of the pocket. Venous access challenges occasionally occur in patients with central vein occlusions, necessitating catheterization of collateral veins or port placement in alternate locations. Complications of SVADs include those associated with the procedure as well as short- (<30 days) and long-term problems. Procedural and early complications are quite rare due to the near-universal use of real-time ultrasound guidance for vein puncture, but they can include hematoma, catheter malposition, arrhythmias, and pneumothorax. Late problems include both thrombotic complications (native venous or port-catheter thrombosis) and infections (tunnel or pocket infections or catheter-associated bloodstream infections). Most guidelines suggest that 0.3 infections/1000 catheter days is an appropriate upper threshold for the insertion of SVADs.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac.

PURPOSE: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. CASE REPORT: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. CONCLUSION: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Pancreas transplant venous thrombosis: role of endovascular interventions for graft salvage.

Venous thrombosis of pancreas transplant allografts often leads to graft loss. We evaluated the efficacy of emergent endovascular techniques to salvage thrombosed pancreatic allografts in a series of six patients. Of the 76 pancreas transplants performed between 2002 and 2006, six patients were diagnosed with venous thrombosis on MRI between 2 and 28 days posttransplant (mean, 9 days). Five patients were systemic-enteric (donor portal vein anastomosis to recipient iliac vein) and one patient was portal-enteric (donor portal vein anastomosis to recipient superior mesenteric vein). Conventional venography confirmed the diagnosis of venous thrombosis in all patients. One patient was treated with catheter-directed venous thrombolysis and balloon thrombectomy. Another patient was treated with rheolytic thrombectomy alone. The remaining four patients were treated with a combination of these mechanical and thrombolytic techniques. Completion venography revealed >50% clot reduction and resumption of venous drainage in all patients. One patient required additional intervention 16 days later for recurrent thrombosis. Two patients required metal stent placement for anastomotic stenoses or kinks. One patient required pancreatectomy 36 h after attempted salvage secondary to a major hemorrhage and graft necrosis. Two patients recovered pancreatic function initially but lost graft function at 8 and 14 months, respectively, from severe chronic rejection. Patient survival was 100%, long-term graft survival was 50%, rethrombosis rate was 16.6%, and graft loss from rejection was 33%. In conclusion, early recognition and treatment of venous thrombosis after pancreas transplantation has acceptable morbidity and no mortality using short-term endovascular pharmacomechanical therapy.