Outcome of Children with Transjugular Intrahepatic Portosystemic Shunt: A Meta-Analysis of Individual Patient Data.

PURPOSE: The purpose of the study was to investigate outcome after pediatric transjugular intrahepatic portosystemic shunt (TIPS) with respect to survival MATERIAL AND METHODS: After searching for studies on TIPS in children in Ovid, Medline, Embase, Scopus and Cochrane published between 2000 and 2022, individual patient data were retrieved from five retrospective cohorts. Overall survival (OS) and transplant-free survival (TFS) were calculated using Kaplan-Meier analysis and log-rank test and compared to the indication (ascites vs. variceal bleeding) as well as to the level of obstruction (pre-hepatic vs. hepatic vs. post-hepatic). Additionally, TIPS patency was analyzed. RESULTS: n = 135 pediatric patients were included in the final analysis. Indication for pediatric TIPS creation was heterogeneous among the included studies. TIPS patency decreased from 6 to 24 months, subsequent pediatric liver transplantation was performed in 22/135 (16.3%) of cases. The presence of ascites was related with poorer TFS (HR 2.3, p = 0.023), while variceal bleeding was not associated with impaired survival. Analysis of the level of obstruction (pre-hepatic, hepatic and post-hepatic) failed to prove significantly reduced OS for post-hepatic obstruction (HR 3.2, p = 0.092) and TFS (HR 1.3, p = 0.057). There was no difference in OS and TFS according to age at time of TIPS placement. CONCLUSIONS: The presence of ascites associates with impaired survival after TIPS in children, with no differences in survival according to the age of the child. Interventional shunt procedures can be considered feasible for all ages. LEVEL OF EVIDENCE: Level 2a.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates.

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

How Endoscopic Guidance Augments Nonvascular Image-guided Interventions.

Endoscopy can improve guidance in nonvascular procedures performed by interventional radiologists (IRs). Historically, the major limiting factors preventing the widespread use of endoscopic tools by IRs were the large diameter (>20F) and length of the endoscopes. IRs had to significantly upsize their access into vascular organs such as the kidney and liver to allow endoscope placement. With the advent of newer endoscopes with sizes smaller than 11F (approximately 4 mm in diameter), percutaneous endoscopy has become more feasible than before. IRs routinely place percutaneous drains (eg, abscess drains, biliary drains, percutaneous nephrostomies, and percutaneous cholecystostomies). Once the drain is in position and the acute infection (if present) has resolved, the IR can use the percutaneous access to perform image-guided and endoscopically guided procedures, depending on the clinical situation. Most percutaneous image- and endoscopically guided interventions performed by IRs involve procedures for biliary and gallbladder pathologic conditions. Image-guided procedures with additional endoscopic guidance can also be used to manage urinary, gastrointestinal, and gynecologic pathologic conditions. The authors review the current applications and techniques of percutaneous endoscopy in interventional radiology. In unique situations, IRs can also perform endoscopy through natural orifices (eg, the urethra) or surgically created orifices (eg, urostomies). The authors also discuss the adjunctive techniques that are enhanced or made possible because of endoscopy in interventional radiology, including but not limited to endoscopic forceps biopsies, endobiliary ablation, laser stricturotomy, lithotripsy, and stone extraction. An invited commentary by Srinivasa is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Balloon-occluded middle adrenal artery embolization and percutaneous microwave ablation of a metastatic adrenal tumor from renal cell carcinoma.

Renal cell carcinomas present with locally advanced or metastatic disease in 25% of patients. Thermal ablation may be considered in selected patients with single-site or oligometastatic disease in selected patients. We describe single-session transarterial particle embolization with the assistance of a balloon-occlusion catheter and microwave ablation of a large hypervascular adrenal metastasis using cone beam CT and fluoroscopic XperGuide needle guidance.

Research Priorities in Percutaneous Image- and Endoscopy-Guided Interventions for Biliary and Gallbladder Diseases: Proceedings from the Society of Interventional Radiology Foundation Multidisciplinary Research Consensus Panel.

Recent technological advancements, including the introduction of disposable endoscopes, have enhanced the role of interventional radiology (IR) in the management of biliary and gallbladder diseases. There are unanswered questions in this growing field. The Society of Interventional Radiology Foundation convened a virtual research consensus panel consisting of a multidisciplinary group of experts to develop a prioritized research agenda regarding percutaneous image- and endoscopy-guided procedures for biliary and gallbladder diseases. The panelists discussed current data, opportunities for IR, and future efforts to maximize IR's ability and scope. A recurring theme throughout the discussions was to find ways to reduce the total duration of percutaneous drains and improve patients' quality of life. After the presentations and discussions, research priorities were ranked on the basis of their clinical relevance and impact. The research ideas ranked top 3 were as follows: (a) percutaneous multimodality management of benign anastomotic biliary strictures (laser vs endobiliary ablation vs cholangioplasty vs drain upsize protocol alone), (b) ablation of intraductal cholangiocarcinoma with and without stent placement, and (c) cholecystoscopy/choledochoscopy and lithotripsy in nonsurgical patients with calculous cholecystitis. Collaborative, retrospective, and prospective research studies are essential to answer these questions and improve the management protocols for patients with biliary and gallbladder diseases.

Looking beyond the gunsight: A potential bailout technique for arterial and venous recanalization.

The "gunsight approach" was initially described as the use of overlapping snares and through- and-through puncture of the portal vein and inferior vena cava for the creation of a transcaval portosystemic shunt. This technique can be adapted for the creation of an extra-anatomic chan- nel between any 2 locations where snares can be deployed. We explain the technique, discuss finer technical points, and describe 2 cases where refractory vascular occlusions are crossed using this technique. The first case involves an extensively calcified femoral arterial chronic total occlusion where subintimal tracking past the occlusion is achieved, but luminal re-entry is ham- pered by dense calcific plaque refractory to multiple re-entry devices. The second case involves a chronic venous occlusion along the femoral vein with loss of in-line flow due to prior stenting. In both cases, the gunsight technique was successfully used as a bailout option after standard recanalization techniques were unsuccessful.

Concomitant AngioVac thrombectomy and patent foramen ovale closure in a patient with a large right atrial thrombus and recent paradoxical embolic stroke.

A 59-year-old male with a history of gallbladder adenocarcinoma receiving chemotherapy and on therapeutic anticoagulation for portal vein thrombosis presented to the emergency department via ambulance after being found unresponsive and in cardiac arrest. Initial workup upon return of spontaneous circulation revealed a large right atrial mass, patent foramen ovale (PFO), and bilateral acute cortical infarctions. This constellation of findings were concerning for PFO-related paradoxical embolic strokes. Given the risk of recurrent paradoxical embolic events and the absolute contraindication to thrombolysis due to recent cerebral infarction, the decision was made to proceed with percutaneous vacuum-assisted thrombectomy using the AngioVac device. To prevent intraoperative thrombus propagation, PFO-closure was performed immediately prior to thrombectomy. Aspiration thrombectomy and PFO-closure were successful with complete thrombus removal and no intraoperative thrombus propagation. This case presents a minimally invasive and rapid treatment for a complex problem. An efficient and effective interdisciplinary team-based approach allowed the patient to resume cancer treatment relatively unabated.

Retrieval of Bard Simon Nitinol inferior vena cava filters: Approaches, technical successes, complications, and clinical outcomes.

OBJECTIVE: The Simon Nitinol filter is a bi-level filtration device designed for permanent implantation that is no longer commercially available, but may result in similar complications to current commercially available long term indwelling temporary or permanent filters. Complications related to indwelling inferior vena cava filters include inferior vena cava thrombosis, inferior vena cava penetration, filter migration, and filter fracture. There is a paucity of reports describing the technical aspects related to retrieval of Simon Nitinol filters. MATERIALS AND METHODS: This study consisted of five patients with Simon Nitinol filters and describes the indication for retrieval, the retrieval techniques used to remove the filters, technical success, complications, and clinical course. RESULTS: The indications for retrieval included: abdominal pain (n = 2; 40%), iliocaval thrombosis (n = 1; 20%), identification of an intracardiac filter fragment (n = 1; 20%), and recurrent venous thromboembolic events (n = 1; 20%). Retrieval techniques included: biopsy forceps (n = 3; 60%), excimer laser extraction sheaths (n = 3; 60%), hangman modified loop snares (n = 3; 60%), rigid endobronchial forceps (n = 2; 40%), and balloon deflection (n = 2; 40%). All filters were successfully retrieved. One patient developed a post-procedural intramuscular hematoma near the site of right internal jugular sheath placement. CONCLUSIONS: Simon Nitinol filters may be retrieved safely and effectively using advanced inferior vena cava filter retrieval techniques.

Preservation of Posterior Tibial Artery Flow Following Dissection With Associated Aneurysmal Degeneration in Ehlers-Danlos Syndrome Type IV Treated With Flow-Diverting Stent.

Ehlers-Danlos syndrome type IV (EDS-IV), the vascular type, is a rare genetic disorder affects the large and medium size arteries resulting in dissections, often with aneurysmal degeneration, intramural hematomas and pseudoaneurysms. Embolization or ligation is standard management for aneurysm formation. We present a case of an EDS-IV patient with a posterior tibial artery dissection with associated aneurysm successfully treated with Flow Diversion stent (FDS) preserving vessel patency and excluding the aneurysm. FDS technology allows for low profile, micro-catheter deliverable treatment options to exclude aneurysms in EDS-IV patients that are may be prone to spasm and dissection using more conventional stent graft technology.

Yttrium-90 radiation segmentectomy for hepatic metastases: A multi-institutional study of safety and efficacy.

BACKGROUND AND OBJECTIVES: This study assessed the outcomes of Yttrium-90 (90 Y) radiation segmentectomy for hepatic metastases unamenable to resection or ablation. MATERIALS AND METHODS: Over 6 years, 36 patients with 53 tumors underwent segmental radioembolization. Patients were not candidates for surgical resection or thermal ablation. Malignancies included metastases from colorectal cancer (31%), neuroendocrine tumors (28%), sarcoma (19%), and others (22%). Eighty-one percent of patients had undergone prior treatment with systemic chemotherapy. Ongoing systemic chemotherapy was continued. Toxicity, tumor response, tumor progression, and survival were assessed. RESULTS: The median tumor size was 3.6 cm (range 1.2-6.1 cm). Adverse event rates were low, with no hepatic-related Common Terminology Criteria for Adverse Events Grade 3 or 4 toxicity. Target tumor Response Evaluation Criteria in Solid Tumors disease control rate was 92% (28% partial response, 64% stable disease). For patients with enhancing tumors (n = 14), modified Response Evaluation Criteria in Solid Tumors target tumor objective response rate was 100%. During a median follow-up of 12 months, target tumor progression occurred in 28% of treated tumors. Overall survival was 96% and 83% at 6 and 12 months, respectively. CONCLUSIONS: 90 Y radiation segmentectomy for hepatic metastases demonstrates high rates of tumor control and minimal toxicity. Radiation segmentectomy should be considered for patients with metastatic hepatic malignancy who are not candidates for surgical resection.

Aortoesophageal fistula involving the central aortic arch salvaged with emergent percutaneous TEVAR, great vessel coverage and in vivo graft fenestration.

Immediate intervention is needed for aortoesophageal fistulas (AEF), a rare but highly lethal cause of massive gastrointestinal hemorrhage. Emergent thoracic endovascular aortic repair (TEVAR) is considered first-line treatment for massive bleeding from AEFs. We describe an unusual and challenging case of TEVAR coverage of an AEF involving the central aortic arch immediately followed by in vivo endograft fenestration to regain arch vessel perfusion. In vivo fenestration, currently a procedure for emergency or investigational purposes only, was shown to be life saving in our case. The main complications associated with the procedure included stroke and infection, requiring esophagectomy and cervical diversion as well as ongoing antibiotic treatment.

Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients.

PURPOSE: To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. METHODS: Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. RESULTS: In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. CONCLUSION: Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Scholarly Activities and Indices Among Academic Endovascular Specialists: A Comparative Analysis Between Interventional Radiologists and Vascular Surgeons.

PURPOSE: To report scholarly metrics amongst academic endovascular specialists. MATERIAL AND METHODS: Faculty pages identified interventional radiologists and vascular surgeons at academic institutions. Members were classified as assistant, associate, or full professors. Scopus was used to extract publication and citation records. Data extracted included: number of publications, number of citations, h-index, i-10 index, hc-index, m-quotient, e-index, and g-index. RESULTS: Two hundred seventy six interventional radiologists and 266 vascular surgeons were included. Mean publications for interventional radiology assistant, associate, and full professors were 17.81, 48.77, and 131.65 and the citation counts were 311.45, 1051.08, and 3981.71, respectively. Mean publications for vascular surgeon assistant, associate, and full professors were 24.00, 48.7, and 161.37 and the citation counts were 414.33, 1147.89, and 5747.00, respectively. Multivariable proportional odds model for interventional radiologists showed a positive correlation between the academic rank and publication count (c = 0.028), h-index (c = 0.090), i10-index (c = 0.014), hc-index (c = 0.052), e-index (c = 0.016), and g-index (0.037). There was a negative correlation between m-quotient (c = -1.745) and citations (c = -0.001) and academic rank. Multivariable proportional odds model for vascular surgeons showed a positive correlation between the academic rank and publication count (c = 0.037) and g-index (c = 0.083). There was a negative correlation between m-quotient (c = -2.232) and hc-index (c = -0.065) and academic rank. CONCLUSION: Citation count and h-index are positively correlated while m-quotient is negatively correlated with academic performance for endovascular specialists.

Minimally Invasive Repair of Ascending Aortic Pseudoaneurysms: An Alternative to Open Surgical Repair in High-Risk Patients.

Development of a pseudoaneurysm of the ascending aorta is an uncommon complication of aortic surgery. Several nonsurgical techniques are available for treatment of ascending aortic pseudoaneurysms (AAPs). This report outlines a single-center retrospective experience with 14 nonsurgical procedures for treatment of AAPs in 10 patients. Modified stent grafts, septal defect occlusion devices, coil embolics, and liquid embolics were deployed by transthoracic and endovascular approaches. Complete stasis of the AAP was achieved in 7 of 10 patients (70%). Mean postprocedural recoveries occurred within 3.5 days. Nonsurgical techniques for repair of AAPs offer a comparatively safe and effective alternative to open surgical repair.

Interventional Radiology Image-Guided Suprapubic Cystostomy Using Trocar versus Seldinger Technique: A Comparative Analysis of Outcomes and Complications.

OBJECTIVE: To compare two techniques-trocar and Seldinger-for performing percutaneous suprapubic cystostomy. MATERIALS AND METHODS: 125 patients, mean age 71.8 ± 16.5 years (range, 15-102 years), underwent primary suprapubic cystostomy from January 2013 to December 2018. Trocar access (N = 60) was performed as a single step using a puncture cannula without guidewire access. Seldinger access (N = 65) involved needle puncture, guidewire placement, and serial dilation. A retrospective review of patient records was conducted. RESULTS: All procedures were technically successful. Mean catheter size was 13.1 ± 2.0 and 13.9 ± 2.0 French for trocar and Seldinger, respectively (P = .044). Mean procedure time was significantly reduced using trocar technique, 12.4 ± 7.7 versus 25.7 ± 12.1 minutes (P <.001), and was associated with lower anxiolytic dose, 1.2 ± 0.8 versus 1.9 ± 1.1 mg midazolam (P = .003), and less radiation exposure, 20.2 ± 59.5 versus 100.7 ± 98.5 mGy (P <.001). Catheter occlusion was the most common complication (28.8%), followed by UTI (13.6%) and bladder spasm (8.0%). All but 2 complications were classified as Clavien-Dindo grade I or II. Catheter occlusion was more frequent in the trocar group (41.7% vs 16.9%, P = .003), while bladder spasms were more frequent in the Seldinger group (13.8% vs 1.7%, P = .018). CONCLUSION: Suprapubic cystostomy via trocar is associated with faster procedure time, lower anxiolytic dose, and less radiation. While major complications are rare, catheter occlusion is a common occurrence that may be overlooked. Although we detected more occlusions with trocar technique, this may be confounded by a catheter-tract size discrepancy.

Burnout among Interventional Radiologists.

PURPOSE: To characterize burnout, as defined by high emotional exhaustion (EE) or depersonalization (DP), among interventional radiologists using a validated assessment tool. MATERIALS AND METHODS: An anonymous 34-question survey was distributed to interventional radiologists. The survey consisted of demographic and practice environment questions and the 22-item Maslach Burnout Inventory-Human Services Survey (MBI). Interventional radiologists with high scores on EE (≥ 27) or DP (≥ 10) MBI subscales were considered to have a manifestation of career burnout. RESULTS: Beginning on January 7, 2019, 339 surveys were completed over 31 days. Of respondents, 263 (77.6%) identified as male, 75 (22.1%) identified as female, and 1 (0.3%) identified as trans-male. The respondents were interventional radiology attending physicians (298; 87.9%), fellows (20; 5.9%), and residents (21; 6.2%) practicing at academic (136; 40.1%), private (145; 42.8%), and hybrid (58; 17.1%) centers. Respondents worked < 40 hours (15; 4.4%), 40-60 hours (225; 66.4%), 60-80 hours (81; 23.9%), and > 80 hours (18; 5.3%) per week. Mean MBI scores for EE, DP, and personal achievement were 30.0 ± 13.0, 10.6 ± 6.9, and 39.6 ± 6.6. Burnout was present in 244 (71.9%) participants. Identifying as female (odds ratio 2.4; P = .009) and working > 80 hours per week (odds ratio 7.0; P = .030) were significantly associated with burnout. CONCLUSIONS: Burnout is prevalent among interventional radiologists. Identifying as female and working > 80 hours per week were strongly associated with burnout.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience.

PURPOSE: To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods. MATERIALS AND METHODS: This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers. RESULTS: Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case. CONCLUSIONS: The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

Endoscopy as an Adjunct to Image-Guided Interventions: A New Frontier in Interventional Radiology.

Endoscopy is an underutilized technique in the practice of interventional radiology. The objectives of this article are to discuss potential uses of interventional radiology-operated endoscopy and to outline basic endoscopy setup and equipment uses. Endoscopy represents a new frontier to the fluoroscopically-guided procedures in biliary, gastrointestinal, and genitourinary disease that interventional radiologists commonly perform. It shows promise to improve interventional radiology procedure success rates and reduce procedure-associated risk for patients. Endoscopy has been traditionally performed by gastroenterologists and urologists and is relatively new in the practice of interventional radiology. The hand-eye coordination and manual dexterity required to perform standard image-guided procedures places interventional radiologists in a unique position to introduce endoscopy into standard practice. A focused and collaborative effort is needed by interventional radiologists to learn the techniques required to successfully integrate endoscopy into practice.

Collaboration is Key - Bridging the Gap and Building an IR Endoscopy Practice.

While the tools and techniques employed by interventional radiologists on a day-to-day basis translate well to learning the skills required to perform basic endoscopic interventions, collaboration with other specialties is crucial to the success of an interventional radiology endoscopy program. As in any field in medicine, the paramount goal is to improve patient care. Adding the ability to directly visualize structures through an endoscope to certain interventional radiologic procedures may greatly augment the efficacy, safety, and success of interventional radiology procedures. Colleagues in urology, gastroenterology, and surgery should be involved in decision-making and treatment planning to ensure that a shared vision for optimal patient care is achieved.