Clinical benefits of MRI-guided freehand biopsy of small focal liver lesions in comparison to CT guidance.

OBJECTIVES: To compare clinical success, procedure time, and complication rates between MRI-guided and CT-guided real-time biopsies of small focal liver lesions (FLL) < 20 mm. METHODS: A comparison of a prospectively collected MRI-guided cohort (n = 30) to a retrospectively collected CT-guided cohort (n = 147) was performed, in which patients underwent real-time biopsies of small FLL < 20 mm in a freehand technique. In both groups, clinical and periprocedural data, including clinical success, procedure time, and complication rates (classified according to CIRSE guidelines), were analyzed. Wilcoxon rank sum test, Pearson's chi-squared test, and Fisher's exact test were used for statistical analysis. Additionally, propensity score matching (PSM) was performed using the following criteria for direct matching: age, gender, presence of liver cirrhosis, liver lobe, lesion diameter, and skin-to-target distance. RESULTS: The median FLL diameter in the MRI-guided cohort was significantly smaller compared to CT guidance (p < 0.001; 11.0 mm vs. 16.3 mm), while the skin-to-target distance was significantly longer (p < 0.001; 90.0 mm vs. 74.0 mm). MRI-guided procedures revealed significantly higher clinical success compared to CT guidance (p = 0.021; 97% vs. 79%) as well as lower complication rates (p = 0.047; 0% vs. 13%). Total procedure time was significantly longer in the MRI-guided cohort (p < 0.001; 38 min vs. 28 min). After PSM (n = 24/n = 38), MRI-guided procedures still revealed significantly higher clinical success compared to CT guidance (p = 0.039; 96% vs. 74%). CONCLUSION: Despite the longer procedure time, freehand biopsy of small FLL < 20 mm under MR guidance can be considered superior to CT guidance because of its high clinical success and low complication rates. CLINICAL RELEVANCE STATEMENT: Biopsy of small liver lesions is challenging due to the size and conspicuity of the lesions on native images. MRI offers higher soft tissue contrast, which translates into a higher success of obtaining enough tissue material with MRI compared to CT-guided biopsies. KEY POINTS: • Image-guided biopsy of small focal liver lesions (FLL) is challenging due to inadequate visualization, leading to sampling errors and false-negative biopsies. • MRI-guided real-time biopsy of FLL < 20 mm revealed significantly higher clinical success (p = 0.021; 97% vs. 79%) and lower complication rates (p = 0.047; 0% vs. 13%) compared to CT guidance. • Although the procedure time is longer, MRI-guided biopsy can be considered superior for small FLL < 20 mm.

Worker's exposure to radiation in fluoroscopy, assessing and instruments: A systematic literature review.

This review aims to identify and analyze the instruments employed for assessing the overall performance of workers exposed to fluoroscopy during surgical procedures and/or interventional procedures, using the PRISMA methodology. The studies were located through searches conducted on PubMed, Web of Science, Lilacs, ScienceDirect, B-ON, EBSCOhost, and EBSCO Discovery Service on March 27, 2023. Additional studies were identified using backward and forward citation techniques. The PEO strategic model was followed. The search spanned studies published between 2012 and 2022. The quality of the studies underwent assessment using the Joanna Briggs Institute checklist for analytical cross-sectional studies. Out of the 23 studies identified, encompassing 3604 individuals, 12 (52%) addressed the reliability and/or validity of the instruments, while 3 (13%) focused on the development and psychometric testing of the instruments. Only 5 instruments (23%), validated and reliable, exclusively evaluated occupational radiological protection. The predominant dimension covered was knowledge (82%, n = 19). The population was assessed in 18 studies, pre- and post-intervention in 2 studies, and 21 studies provided recommendations or tools for improvement. Individuals in the studies utilized passive dosimeters (ranging from 5% to 98%), thyroid shields (15% to 98%), and aprons or lead skirts/coats (28% to 99%). The evidence quality was moderate (6/8). This study underscores the imperative to enhance compliance with protective and monitoring equipment. Furthermore, additional information is warranted concerning the validity and reliability of the instruments used, as well as the development of instruments that are both valid and reliable.

Prognostic Value of a Classification System for Iliofemoral Stenting in Patients with Chronic Venous Obstruction.

OBJECTIVE: This retrospective, multicentre study aimed to assess the prognostic value of a proposed classification system for chronic venous obstruction (CVO) patients undergoing successful interventional procedures. METHODS: This study analysed data from 13 vascular centres, including 1 033 patients with CVO treated between 2015 - 2019. The patients were classified into five category types: 1 - non-thrombotic iliac vein lesion; 2 - CVO of iliac segment; 3 - CVO of iliofemoral segment above common femoral vein confluence; 4 - CVO of iliofemoral segment extending into the femoral vein (FV) or deep femoral vein (DFV); and 5 - CVO of iliofemoral segment involving both DFV and FV. Stent deployment, complications, and follow ups were evaluated. Univariate and multivariate analyses were performed to identify predictors of primary patency loss. RESULTS: Mean age of the patients was 44.0 ± 14.7 years, with 59.9% being women. A median of two stents were used for unilateral cases and five stents for bilateral cases. At 12 months of follow up, primary patency rates for types 1 - 5 were 94.9%, 90.3%, 80.8%, 60.6%, and 39.4%, respectively. These rates were strongly correlated with the extension of CVO and showed significant differences between each type. Univariate analysis identified predictors of primary patency loss as the type of CVO, history of deep vein thrombosis, and the total number of stents. In the multivariate analysis, the significant independent predictors of primary patency loss were the type of CVO and the total number of stents. CONCLUSION: The proposed anatomical classification of iliofemoral CVO will help to predict intervention outcomes and facilitate comparison of stent outcomes in future studies. However, further evaluation and validation in prospective studies are needed to confirm the utility of this classification.

Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives.

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach. CONCLUSION: There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures. WHAT IS KNOWN: • Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success. WHAT IS NEW: • A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.

Magnetic Resonance Acoustic Radiation Force Imaging (MR-ARFI) for the monitoring of High Intensity Focused Ultrasound (HIFU) ablation in anisotropic tissue.

OBJECTIVE: We introduce a non-invasive MR-Acoustic Radiation Force Imaging (ARFI)-based elastography method that provides both the local shear modulus and temperature maps for the monitoring of High Intensity Focused Ultrasound (HIFU) therapy. MATERIALS AND METHODS: To take tissue anisotropy into account, the local shear modulus µ is determined in selected radial directions around the focal spot by fitting the phase profiles to a linear viscoelastic model, including tissue-specific mechanical relaxation time τ. MR-ARFI was evaluated on a calibrated phantom, then applied to the monitoring of HIFU in a gel phantom, ex vivo and in vivo porcine muscle tissue, in parallel with MR-thermometry. RESULTS: As expected, the shear modulus polar maps reflected the isotropy of phantoms and the anisotropy of muscle. In the HIFU monitoring experiments, both the shear modulus polar map and the thermometry map were updated with every pair of MR-ARFI phase images acquired with opposite MR-ARFI-encoding. The shear modulus was found to decrease (phantom and ex vivo) or increase (in vivo) during heating, before remaining steady during the cooling phase. The mechanical relaxation time, estimated pre- and post-HIFU, was found to vary in muscle tissue. DISCUSSION: MR-ARFI allowed for monitoring of viscoelasticity changes around the HIFU focal spot even in anisotropic muscle tissue.

A rare complication after an interventional procedure using the common carotid: carotid pseudoaneurysm in an infant.

The carotid artery is a valuable vascular access that can be used in patients who have undergone repetitive interventional and surgical procedures and premature babies. In the past, cut-down was used but nowadays, mostly the procedure is performed under ultrasonographic guidance. Complications such as bleeding, haematoma, and pseudoaneurysm may occur when the carotid artery is used as a vascular access for the procedures such as aortic balloon valvuloplasty, coarctation balloon angioplasty, or after interventional or surgical treatments to the carotid artery. Although pseudoaneurysm is very rare, prompt diagnosis and accurate treatment planning are life-saving. In this article, the diagnosis and treatment of pseudoaneurysm in the left common carotid after transcatheter coarctation balloon angioplasty in a 6-month-old infant will be presented.

Recurrent multi-cameral cardiac myxomas in a child with Carney complex.

Cardiac myxoma is a relatively rare tumour, usually solitary, that occurs primarily in the left atrium of adults, but comprises only 30% of cardiac tumours in children. We recently treated a 12-year-old girl with multiple recurrent myxomas in three cardiac chambers(following surgical resection 3 years earlier). Genomic analysis showed the PKAR1A mutation typical for Carney complex.

Evaluation of a New Real-Time Dosimeter Sensor for Interventional Radiology Staff.

In 2011, the International Commission on Radiological Protection (ICRP) recommended a significant reduction in the lens-equivalent radiation dose limit, thus from an average of 150 to 20 mSv/year over 5 years. In recent years, the occupational dose has been rising with the increased sophistication of interventional radiology (IVR); management of IVR staff radiation doses has become more important, making real-time radiation monitoring of such staff desirable. Recently, the i3 real-time occupational exposure monitoring system (based on RaySafeTM) has replaced the conventional i2 system. Here, we compared the i2 and i3 systems in terms of sensitivity (batch uniformity), tube-voltage dependency, dose linearity, dose-rate dependency, and angle dependency. The sensitivity difference (batch uniformity) was approximately 5%, and the tube-voltage dependency was <±20% between 50 and 110 kV. Dose linearity was good (R2 = 1.00); a slight dose-rate dependency (~20%) was evident at very high dose rates (250 mGy/h). The i3 dosimeter showed better performance for the lower radiation detection limit compared with the i2 system. The horizontal and vertical angle dependencies of i3 were superior to those of i2. Thus, i3 sensitivity was higher over a wider angle range compared with i2, aiding the measurement of scattered radiation. Unlike the i2 sensor, the influence of backscattered radiation (i.e., radiation from an angle of 180°) was negligible. Therefore, the i3 system may be more appropriate in areas affected by backscatter. In the future, i3 will facilitate real-time dosimetry and dose management during IVR and other applications.

Recommendations to standardize patients' follow-up after interventional procedures in chronic pain treatment: A Delphi study.

OBJECTIVE: To determine, using the Delphi method, standardized recommendations for the follow-up of patients undergoing an interventional procedure for the treatment of chronic pain in Spain. METHODS: First, a systematic literature review was performed to identify the literature on the management of patients with chronic pain undergoing interventional techniques; subsequently, a two-round Delphi survey with 108 questions was conducted. The questionnaire was validated by a Scientific Committee (5 experts) and sent to 47 experts specialized in chronic pain. "Consensus" or "intermediate consensus" was determined when ≥ 75% or < 75% to ≥ 65% of the experts selected the same answer for each item, respectively. Then, a face-to-face deliberation process was held with the Scientific Committee to analyze and discuss the results. RESULTS: The questionnaire was completed by 24 panelists (51%). Consensus was reached on 88.4% of the questions. The panelists identified pain, drug consumption, and quality of life as essential variables in the follow-up of patients with chronic pain. Consensus was reached on most of the scales/questionnaires to be used in measuring outcomes during follow-up, except for psychological status. Regarding the follow-up frequency, in radicular spinal chronic pain, a consensus was reached on the first visit 1-2 months after the intervention, during the first year, at 1, 3, 6, and 12 months, and then every 6 months thereafter. For non-radicular spinal chronic pain, the first visit 1-2 months after surgery was agreed upon, however, there was no consensus on follow-up during the first year. For non-spinal chronic pain, consensus was reached regarding the first visit at 1-2 months after surgery and during the first year at 1, 3, 6, and 12 months. No consensus was reached on follow-up frequency for oncological chronic pain. After receiving a permanent neurostimulator implant for chronic pain, the first visit was agreed upon at 1-3 weeks, during the first year, at 2 weeks, 1, 3, 6, and 12 months, and after, every 6 months. For intrathecal infusion, it was agreed that the first visit should occur during the first month, and thereafter whenever the pump requires a refill. CONCLUSIONS: These findings provide recommendations in relation to the frequency of follow-up and the scales to be used with chronic pain patients undergoing interventional techniques in Spain.

Notifications and alerts in patient dose values for computed tomography and fluoroscopy-guided interventional procedures.

The terms "notifications" and "alerts" for medical exposures are used by several national and international organisations. Recommendations for CT scanners have been published by the American Association of Physicists in Medicine. Some interventional radiology societies as well as national authorities have also published dose notifications for fluoroscopy-guided interventional procedures. Notifications and alerts may also be useful for optimisation and to avoid unintended and accidental exposures. The main interest in using these values for high-dose procedures (CT and interventional) is to optimise imaging procedures, reducing the probability of stochastic effects and avoiding tissue reactions. Alerts in X-ray systems may be considered before procedures (as in CT), during procedures (in some interventional radiology systems), and after procedures, when the patient radiation dose results are known and processed. This review summarises the different uses of notifications and alerts to help in optimisation for CT and for fluoroscopy-guided interventional procedures as well as in the analysis of unintended and accidental medical exposures. The paper also includes cautions in setting the alert values and discusses the benefits of using patient dose management systems for the alerts, their registry and follow-up, and the differences between notifications, alerts, and trigger levels for individual procedures and the terms used for the collective approach, such as diagnostic reference levels. KEY POINTS: • Notifications and alerts on patient dose values for computed tomography (CT) and fluoroscopy-guided interventional procedures (FGIP) allow to improve radiation safety and contribute to the avoidance of radiation injuries and unintended and accidental exposures. • Alerts may be established before the imaging procedures (as in CT) or during and after the procedures as for FGIP. • Dose management systems should include notifications and alerts and their registry for the hospital quality programmes.

Availability of and factors related to interventional procedures for refractory pain in patients with cancer: a nationwide survey.

BACKGROUND: Cancer pain may be refractory to standard pharmacological treatment. Interventional procedures are important for quality of analgesia. The aim of the present study was to clarify the availability of four interventional procedures (celiac plexus neurolysis/splanchnic nerve neurolysis, phenol saddle block, epidural analgesia, and intrathecal analgesia), the number of procedures performed by specialists, and their associated factors. In addition, we aimed to establish how familiar home hospice physicians and oncologists are with the different interventional procedures available to manage cancer pain. METHODS: A cross-sectional survey using a self-administered questionnaire was conducted. Subjects were certified pain specialists, interventional radiologists, home hospice physicians, and clinical oncologists. RESULTS: The numbers of valid responses/mails were 545/1,112 for pain specialists, 554/1,087 for interventional radiology specialists, 144/308 for home hospice physicians, and 412/800 for oncologists. Among pain specialists, depending on intervention, 40.9-75.2% indicated that they perform each procedure by themselves, and 47.5-79.8% had not performed any of the procedures in the past 3 years. Pain specialists had performed the four procedures 4,591 times in the past 3 years. Among interventional radiology specialists, 18.1% indicated that they conduct celiac plexus neurolysis/splanchnic nerve neurolysis by themselves. Interventional radiology specialists had performed celiac plexus neurolysis/splanchnic nerve neurolysis 202 times in the past 3 years. Multivariate analysis revealed that the number of patients seen for cancer pain and the perceived difficulty in gaining experience correlated with the implementation of procedures among pain specialists. Among home hospice physicians and oncologists, depending on intervention, 3.5-27.1% responded that they were unfamiliar with each procedure. CONCLUSIONS: Although pain specialists responded that the implementation of each intervention was possible, the actual number of the interventions used was limited. As interventional procedures are well known, it is important to take measures to ensure that pain specialists and interventional radiology physicians are sufficiently utilized to manage refractory cancer pain.

Partially open stent after balloon catheter iatrogenic perforation. How to solve this complication using a novel technique? The Mij-Her technique.

Complications related to pulmonary artery stenting are potentially life-threatening. We reported a novel technique of how to achieve the introduction of a partial dilated stent into a long sheath using a snare in the event of a iatrogenic perforation of a balloon catheter.There are no publications of similar techniques describing successful resolution of this type of complication.

Radiofrequency ablation of subcapsular lesions with internally cooled perfusion electrode: ex vivo study.

PURPOSE: To compare the ex vivo efficiency of an internally cooled perfusion (ICP) electrode and an internally cooled (IC) electrode for radiofrequency ablation (RFA) of subscapular lesions. MATERIAL AND METHODS: Using 200 W generator and ICP electrode (group A, n = 10) or 15 gauge or 17 gauge IC electrode (group B, n = 10 and group C, n = 10), RFA was applied to the bovine liver for 12 min. Each electrode was inserted at a 3 cm depth into the liver block, and the proximal end of the active exposure portion of each electrode was located at a capsule of the liver block. During RFA, normal saline was pumped through the side hole of the ICP electrode into the tissue at an injection rate of 0.5 mL/min. RESULTS: The ICP electrode achieved larger capsular ablative area and ablative volume than the IC electrode: 7.29 ± 1.59 cm2 and 44.56 ± 10.08 cm3 in group A; 4.36 ± 1.29cm2 and 30.15 ± 5.97 cm3 in group B; and 3.57 ± 0.99cm2 and 24.52 ± 4.21 cm3 in group C (p < .05), respectively. Mean impedance of ICP RFA was lower than IC RFA: 41.5 ± 3.75Ω in group A; 52.4 ± 5.64Ω in group B; and 58.1 ± 10.98Ω in group C (p < .05). CONCLUSION: RFA using the ICP electrode more efficiently created a larger capsular ablative area and ablative volume of ablation than IC RFA for subcapsular lesions. The results were obtained in an ex vivo liver model without tumor simulation inside.

Passive needle guide tracking with radial acquisition and phase-only cross-correlation.

PURPOSE: Acceleration of a passive tracking sequence based on phase-only cross-correlation (POCC) using radial undersampling. METHODS: The phase-only cross-correlation (POCC) algorithm allows passive tracking of interventional instruments in real-time. In a POCC sequence, two cross-sectional images of a needle guide with a positive MR contrast are continuously acquired from which the instrument trajectory is calculated. Conventional Cartesian imaging for tracking is very time consuming; here, a higher temporal resolution is achieved using a highly undersampled radial acquisition together with a modified POCC algorithm that incorporates the point-spread-function. Targeting and needle insertion is performed in two phantom experiments with 16 fiducial targets, each using 4 and 16 radial projections for passive tracking. Additionally, targeting of eight deep lying basivertebral veins in the lumbar spines is performed for in vivo proof-of-application with four radial projections for needle guide tracking. RESULTS: The radially undersampled POCC sequence yielded in the phantom experiments a lateral targeting accuracy of 1.1 ± 0.4 mm and 1.0 ± 0.5 mm for 16 and 4 radial projections, respectively, without any statistically significant difference. In the in vivo application, a mean targeting duration of 62 ± 13 s was measured. CONCLUSION: Radial undersampling can drastically reduce the acquisition time for passive tracking in a POCC sequences for MR-guided needle interventions without compromising the targeting accuracy.

Diagnostic accuracy and safety of percutaneous MRI-guided biopsy of solid renal masses: single-center results after 4.5 years.

OBJECTIVES: To retrospectively evaluate diagnostic accuracy and complications of magnetic resonance imaging (MRI)-guided biopsy of radiologically indeterminate solid renal masses (RM). METHODS: Electronic records of all consecutive patients undergoing MRI-guided biopsy of solid RM (using free-breathing T2-BLADE and BEAT-IRTTT sequences) between April 2014 and October 2018 were reviewed; 101 patients (69 men, 32 women; median age 68 years; range 32-76) were included. Patient and RM characteristics, procedural details/complications, pathologic diagnosis, and clinical management were recorded. Diagnostic accuracy was calculated on an intention-to-diagnose basis. Diagnostic yield was also evaluated. Multi-variable analysis was performed for variables with p < .20, including patient age/sex; RM size/location/contact with vascular pedicle, RENAL score, number and total length of biopsy samples, and biopsy tract embolization, to determine factors associated with diagnostic samples, diagnostic accuracy, and complications. RESULTS: Median RM size was 2.4 cm (range 1-8.4 cm). There were 86 (85%; 95%CI 77-91%) diagnostic and 15 (15%; 95%CI 9-23%) non-diagnostic samples; 6/15 (40%) non-diagnostic biopsies were repeated with 50% malignancy rate. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 96% (95%CI 89-99%), 100% (95%CI 77-100%), 100% (95%CI 95-100%), 82% (95%CI 57-96%), and 97% (95%CI 90-99%), respectively. Primary and secondary diagnostic yields were 85% (95%CI 77-91%) and 91% (95%CI 84-96%), respectively. Seven (7%; 95%CI 1-10%) complications were observed. No tested variables were associated with diagnostic samples, diagnostic accuracy, or complications. CONCLUSIONS: MRI-guided biopsy of solid RM is associated with high diagnostic accuracy and low complication rate. The technique might be helpful for inaccessible tumors. KEY POINTS: • MRI-guided biopsy of radiologically indeterminate solid renal masses (RM) appears safe, with a low rate of minor self-limiting hemorrhagic complications. • Diagnostic accuracy and primary/secondary diagnostic yield are high and appear similar to reported estimates for US- and CT-guided RM biopsy. • MRI guidance may be particularly useful for RM with poor conspicuity on US and CT, for relatively inaccessible tumors (e.g., tumors requiring double-oblique steep-angled approaches), and for young patients or those with renal failure.

Long-term MRI-guided vacuum-assisted breast biopsy results of 600 single-center procedures.

OBJECTIVES: The objective of this study is to report on the performance of the MRI-guided VABB in our center and to look at the long-term outcome of biopsies with benign histology over a period of 19 years. METHODS: In a single-center retrospective review study, data of 600 VABB procedures performed between September 1999 and March 2017 were evaluated. We collected patient demographics, histopathological diagnosis at MRI-VABB, and basic lesion characteristics (size, location). Data from the Belgian Cancer Registry was cross-referenced with our database to find out which patients with benign MRI-VABB results developed a malignant lesion over time. RESULTS: These 600 VABB procedures were performed in 558 women with a mean patient age of 51.8 years (range 18-82 years). Our technical success rate was 99.3%. We found 27.67% B5 lesions, 9.82% B3 lesions, and 0.17% B4 lesions. Of 362 benign MRI-guided VABBs, follow-up data was available for a mean follow-up period of 7.6 years (0.8-18.3). Only one (0.3%) biopsy was a false negative lesion after MRI-guided VABB during follow-up. Short-term FU-MRI provided no increase in detection rate. CONCLUSION: The accuracy of MRI-guided VABB is high with a very low false negative rate of 0.3% on long-term follow-up. The value of short-term FU-MRI for every case after MRI-guided VABB may be questioned. KEY POINTS: • MRI-guided vacuum-assisted breast biopsies yield a large portion of clinically relevant lesions (9.82% B3, 0.17% B4, and 27.67% B5 lesions). • The false negative biopsy rate of MRI-guided VABB in this study with a mean follow-up time of 7.6 years was only 0.3%. • Performing a short-term follow-up MRI after a benign MRI-guided VABB concordant to the MRI appearance may be questioned.

Vendor-independent skin dose mapping application for interventional radiology and cardiology.

PURPOSE: The purpose of this paper is to present and validate an originally developed application SkinCare used for skin dose mapping in interventional procedures, which are associated with relatively high radiation doses to the patient's skin and possible skin reactions. METHODS: SkinCare is an application tool for generating skin dose maps following interventional radiology and cardiology procedures using the realistic 3D patient models. Skin dose is calculated using data from Digital Imaging and Communications in Medicine (DICOM) Radiation Dose Structured Reports (RDSRs). SkinCare validation was performed by using the data from the Siemens Artis Zee Biplane fluoroscopy system and conducting "Acceptance and quality control protocols for skin dose calculating software solutions in interventional cardiology" developed and tested in the frame of the VERIDIC project. XR-RV3 Gafchromic films were used as dosimeters to compare peak skin doses (PSDs) and dose maps obtained through measurements and calculations. DICOM RDSRs from four fluoroscopy systems of different vendors (Canon, GE, Philips, and Siemens) were used for the development of the SkinCare and for the comparison of skin dose maps generated using SkinCare to skin dose maps generated by different commercial software tools (Dose Tracking System (DTS) from Canon, RadimetricsTM from Bayer and RDM from MEDSQUARE). The same RDSRs generated during a cardiology clinical procedure (percutaneous coronary intervention-PCI) were used for comparison. RESULTS: Validation performed using VERIDIC's protocols for skin dose calculation software showed that PSD calculated by SkinCare is within 17% and 16% accuracy compared to measurements using XR-RV3 Gafchromic films for fundamental irradiation setups and simplified clinical procedures, respectively. Good visual agreement between dose maps generated by SkinCare and DTS, RadimetricsTM and RDM was obtained. CONCLUSIONS: SkinCare is proved to be very convenient solution that can be used for monitoring delivered dose following interventional procedures.

Pain During COVID-19: A Comprehensive Review and Guide for the Interventionalist.

BACKGROUND: Chronic pain, the leading cause of disability in the world, imposes limitations on activities of daily living and diminishes quality of life leading to unnecessary patient suffering. The personal and socioeconomic costs of chronic pain cannot be overstated. Physicians are at the crux of the pandemic and must attempt to limit the spread of the virus while maintaining their professional responsibility to their patients and staff members. OBJECTIVE: The aim of this review is to analyze the existing literature to develop consensus recommendations for treating pain during the current COVID-19 pandemic. METHODS: Relevant literature was located via computer-generated citations between the months of March and May of 2020. Online computer searches of multiple databases including Google Scholar, CINAHL, PubMed, and Cochrane Review were conducted in conjunction with a thorough review of local, state, national, and international governmental and organizational websites to locate research on the area of interest. RESULTS: The guidelines in this review are meant to offer a framework to pain practitioners and organizations for providing highly effective, ethical, and safe care to patients while maintaining their commitment to mitigating the spread of the COVID-19 pandemic. Specific areas addressed include general and interventional-specific treatment and mitigation recommendations. CONCLUSIONS: We believe that the recommendations in this review, if used in conjunction with evolving recommendations of Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and federal, state, and local governing bodies, provides a path to not only mitigate the spread of the pandemic but also limit the adverse impact of pain and suffering in chronic pain patients.

The Focused Ultrasound Myoma Outcome Study (FUMOS); a retrospective cohort study on long-term outcomes of MR-HIFU therapy.

OBJECTIVES: Since 2004, uterine fibroids have been treated with MR-HIFU, but there are persevering doubts on long-term efficacy to date. In the Focused Ultrasound Myoma Outcome Study (FUMOS), we evaluated long-term outcomes after MR-HIFU therapy, primarily to assess the reintervention rate. METHODS: Data was retrospectively collected from 123 patients treated with MR-HIFU at our hospital from 2010 to 2017. Follow-up duration and baseline (MRI) characteristics were retrieved from medical records. Treatment failures, adverse events, and the nonperfused volume percentage (NPV%) were determined. Patients received a questionnaire about reinterventions, recovery time, satisfaction, and pregnancy outcomes. Restrictive treatment protocols were compared with unrestrictive (aiming for complete ablation) treatments. Subgroups were analyzed based on the achieved NPV < 50 or ≥ 50%. RESULTS: Treatment failures occurred in 12.1% and the number of adverse events was 13.7%. Implementation of an unrestrictive treatment protocol significantly (p = 0.006) increased the mean NPV% from 37.4% [24.3-53.0] to 57.4% [33.5-76.5]. At 63.5 ± 29.0 months follow-up, the overall reintervention rate was 33.3% (n = 87). All reinterventions were performed within 34 months follow-up, but within 21 months in the unrestrictive group. The reintervention rate significantly (p = 0.002) decreased from 48.8% in the restrictive group (n = 43; follow-up 87.5 ± 7.3 months) to 18.2% in the unrestrictive group (n = 44; follow-up 40.0 ± 22.1 months). The median recovery time was 2.0 [1.0-7.0] days. Treatment satisfaction rate was 72.4% and 4/11 women completed family planning after MR-HIFU. CONCLUSIONS: The unrestrictive treatment protocol significantly increased the NPV%. Unrestrictive MR-HIFU treatments led to acceptable reintervention rates comparable to other reimbursed uterine-sparing treatments, and no reinterventions were reported beyond 21 months follow-up. KEY POINTS: • All reinterventions were performed within 34 months follow-up, but in the unrestrictive treatment protocol group, no reinterventions were reported beyond 21 months follow-up. • The NPV% was negatively associated with the risk of reintervention; thus, operators should aim for complete ablation during MR-guided HIFU therapy of uterine fibroids. • Unrestrictive treatments have led to acceptable reintervention rates after MR-guided HIFU therapy compared to other reimbursed uterine-sparing treatments.

Development and clinical evaluation of a 3-step modified manipulation protocol for MRI-guided high-intensity focused ultrasound of uterine fibroids.

OBJECTIVES: The clinical applicability of magnetic resonance image-guided high-intensity focused ultrasound (MR-HIFU) treatment of uterine fibroids is often limited due to inaccessible fibroids or bowel interference. The aim of this study was to implement a newly developed 3-step modified manipulation protocol and to evaluate its influence on the number of eligible women and treatment failure rate. METHODS: From June 2016 to June 2018, 165 women underwent a screening MRI examination, 67 women of whom were consecutively treated with MR-HIFU at our institution. Group 1 (n = 20) was treated with the BRB manipulation protocol which consisted of sequential applications of urinary bladder filling, rectal filling, and urinary bladder emptying. Group 2 (n = 47) was treated using the 3-step modified manipulation protocol which included (1) the BRB maneuver with adjusted rectal filling by adding psyllium fibers to the solution; (2) Trendelenburg position combined with bowel massage; (3) the manual uterine manipulation (MUM) method for uterine repositioning. A comparison was made between the two manipulation protocols to evaluate differences in safety, the eligibility percentage, and treatment failure rate due to unsuccessful manipulation. RESULTS: After implementing the 3-step modified manipulation protocol, our ineligibility rate due to bowel interference or inaccessible fibroids decreased from 18% (16/88) to 0% (0/77). Our treatment failure rate due to unsuccessful manipulation decreased from 20% (4/20) to 2% (1/47). There were no thermal complications to the bowel or uterus. CONCLUSIONS: Implementation of the 3-step modified manipulation protocol during MR-HIFU therapy of uterine fibroids improved the eligibility percentage and reduced the treatment failure rate. TRIAL REGISTRATION: Registry number NL56182.075.16 KEY POINTS: • A newly developed 3-step modified manipulation protocol was successfully implemented without the occurrence of thermal complication to the bowel or uterus. • The 3-step modified manipulation protocol increased our eligibility percentage for MR-HIFU treatment of uterine fibroids. • The 3-step modified manipulation protocol reduced our treatment failure rate for MR-HIFU treatment of uterine fibroids.