Interventional Therapy of Pelvic Venous Disorders (PeVD). / Interventionelle Therapie des Beckenvenensyndroms.

BACKGROUND: Pelvic venous disorders (PeVD) are an underdiagnosed cause of chronic pelvic pain in women. They are caused by venous insufficiency of the pelvic or ovarian veins, leading to the development of mainly periuterine and periovarian varices. It is a progressive disease if left untreated and can cause swelling, dyspareunia, dysmenorrhea, and other symptoms, some non-specific, that affect the patient's quality of life. Interventional therapies are a central component of the treatment of PeVD, with a variety of techniques available for both diagnosis and treatment. METHOD: This review provides an overview of the pathophysiologic background, diagnosis, and, most importantly, interventional treatment options for PeVD. RESULTS: There is a lack of standardized nomenclature and internationally accepted diagnostic criteria for PeVD as well as randomized controlled trials demonstrating clinical success. However, in clinical trials, endovascular therapy for PeVD has been shown to be safe and effective. This review presents the various interventional techniques for the treatment of PeVD, including embolization, stenting, and sclerotherapy. CONCLUSION: The importance of PeVD is receiving growing recognition. Recent advances, such as the development of the Symptoms-Varices-Pathophysiology (SVP) classification, provide an impetus to standardize nomenclature and are the first step toward systematizing disease management. Interventional therapies provide a safe and tailored minimally invasive treatment option for patients with PeVD. KEY POINTS: · Pelvic venous disorders are an underdiagnosed condition with frequently delayed diagnosis and debilitating symptoms.. · Until now, the PeVD nomenclature has been imprecise, with terms like May-Thurner syndrome/Nutcracker syndrome.. · Interventional approaches are effective and play a central role in PeVD treatment.. CITATION FORMAT: · Dewald CL, Becker LS, Meyer BC. Interventional Therapy of Pelvic Venous Disorders (PeVD). Fortschr Röntgenstr 2024; DOI: 10.1055/a-2229-4100.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]. / Spontane retroperitoneale und Rektusscheidenhämatome und ihre interventionelle Therapie: ein Review.

BACKGROUND: Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy. METHOD: Analysis, summary, and discussion of published review articles and expert recommendations. RESULTS: The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance. CONCLUSION: Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome. KEY POINTS: · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.. CITATION FORMAT: · Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Convolutional Neural Network for Fully Automated Cerebellar Volumetry in Children in Comparison to Manual Segmentation and Developmental Trajectory of Cerebellar Volumes.

The purpose of this study was to develop a fully automated and reliable volumetry of the cerebellum of children during infancy and childhood using deep learning algorithms in comparison to manual segmentation. In addition, the clinical usefulness of measuring the cerebellar volume is shown. One hundred patients (0 to 16.3 years old) without infratentorial signal abnormalities on conventional MRI were retrospectively selected from our pool of pediatric MRI examinations. Based on a routinely acquired 3D T1-weighted magnetization prepared rapid gradient echo (MPRAGE) sequence, the cerebella were manually segmented using ITK-SNAP. The data set of all 100 cases was divided into four splits (four-fold cross-validation) to train the network (NN) to delineate the boundaries of the cerebellum. First, the accuracy of the newly created neural network was compared with the manual segmentation. Secondly, age-related volume changes were investigated. Our trained NN achieved an excellent Spearman correlation coefficient of 0.99, a Dice Coefficient of 95.0 ± 2.1%, and an intersection over union (IoU) of 90.6 ± 3.8%. Cerebellar volume increased continuously with age, showing an exponentially rapid growth within the first year of life. Using a convolutional neural network, it was possible to achieve reliable, fully automated cerebellar volume measurements in childhood and infancy, even when based on a relatively small cohort. In this preliminary study, age-dependent cerebellar volume changes could be acquired.

A Hyperdynamic Arteriovenous Fistula Aneurysm After Long Time Renal Transplantation.

CONCLUSION: Closure of arteriovenous fistula should be considered in patients who underwent successful renal transplantation to avoid potential complications that may result from the presence of unused fistula especially, in patients who are predisposed to aneurysm formation in the future.

Tantalum-specific contrast-to-noise ratio or conventional detector dose-driven exposure control in angiography: radiation dose and image quality evaluation in a porcine model.

BACKGROUND: The aim of this animal study was to compare the fluoroscopic image quality (IQ) and radiation dose between a tantalum (Ta)-specific contrast-to-noise ratio-driven exposure control (Ta-CEC) and a detector dose-driven exposure control (DEC) in abdominal angiography. METHODS: Nine angiography scenarios were created in seven anaesthetised pigs using Ta-based embolisation material during percutaneous liver and kidney intervention. Fluoroscopic images were acquired using three DEC protocols with different dose levels and Ta-CEC protocols with different IQ levels, sampled in small steps. Polymethyl-methacrylate and aluminium plates were used to simulate attenuation of three water equivalent thicknesses (WET). Three blinded readers evaluated the IQ of DEC and dose equivalent Ta images and selected the Ta-IQ equivalent image corresponding to the DEC image. RESULTS: Interobserver agreement for the IQ assessment was 0.43 for DEC, 0.56 for Ta-CEC and for the assessment of incident air kerma at the interventional reference point (Ka,r) for the Ta-IQ equivalent image 0.73. The average IQ of the dose equivalent Ta images was superior compared to the DEC images (p < 0.001) and also for every WET (26, 31, or 36 cm) and dose level (p ≤ 0.022). The average Ka,r for the Ta-IQ equivalent images was 59 ± 16% (mean ± standard deviation) lower compared to the DEC images (p < 0.001). CONCLUSIONS: Compared to DEC, Ta-CEC significantly improved the fluoroscopic depiction of Ta, while maintaining the Ka,r. Alternatively, the Ka,r can be significantly reduced by using Ta-CEC instead of DEC, while maintaining equivalent IQ.

Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. / Chemosaturation durch perkutane hepatische Perfusion mit Melphalan bei hepatisch metastasiertem Aderhautmelanom: eine Überlebens- und Sicherheitsanalyse.

PURPOSE: Chemosaturation percutaneous hepatic perfusion (CS-PHP) allows selective intrahepatic delivery of high dose cytotoxic melphalan in patients with curatively untreatable liver tumors while limiting systemic toxicity through hemofiltration of the hepatic venous blood. Aim of this study was to investigate the response to therapy, survival and safety of the CS-PHP procedure in patients with liver-dominant metastatic uveal melanoma (UM). MATERIALS AND METHODS: Overall response rate (ORR) and disease control rate (DCR) were assessed according to Response Evaluation Criteria In Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic progression-free survival (mhPFS) were analyzed using Kaplan-Meier estimation. Adverse events were evaluated with Common Terminology Criteria for Adverse Events (CTCAE) v5. RESULTS: Overall, 30 patients were treated with 70 CS-PHP in a salvage setting from October 2014 to January 2019. In total, ORR and DCR were 42.3 % and 80.8 %, respectively. Overall, mOS was 12 (95 % confidence interval (CI) 7-15) months, and both, mPFS and mhPFS were 6 months, respectively (95 % CI 4-10; 95 % CI 4-13). Adverse events (AE) most frequently included significant but transient hematologic toxicities (87 % of grade 3/4 thrombocytopenia), less frequent AEs were hepatic injury extending to liver failure (3 %), cardiovascular events including one case of ischemic stroke (3 %). CONCLUSION: Salvage treatment with CS-PHP is effective in selected patients with UM. The interventional procedure is safe. Serious hepatic and cardiovascular events, although rare, require careful patient selection and should be closely monitored. KEY POINTS: · CS-PHP is safe for selected patients with liver-dominant metastatic uveal melanoma.. · CS-PHP resulted in hepatic disease control in 80 % of patients.. · Hematologic events following CS-PHP are common but manageable.. CITATION FORMAT: · Dewald CL, Hinrichs JB, Becker LS et al. Chemosaturation with Percutaneous Hepatic Perfusion: Outcome and Safety in Patients with Metastasized Uveal Melanoma. Fortschr Röntgenstr 2021; 193: 928 - 936.

Motion Reduction for C-Arm Computed Tomography of the Pulmonary Arteries: Image Quality of a Motion Correction Algorithm in Patients with Chronic Thromboembolic Hypertension During Balloon Pulmonary Angioplasty.

PURPOSE: To evaluate the feasibility and image quality of a motion correction algorithm for supra-selective C-arm computed tomography (CACT) of the pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing balloon pulmonary angioplasty (BPA). MATERIALS & METHODS: CACT raw data acquired during 30 consecutive BPAs were used for image reconstruction using either standard (CACTorg) or a motion correction algorithm (CACTmc), using 400 iterations. Two readers independently evaluated 188 segmental and 564 sub-segmental contrast-enhanced pulmonary arteries in each reconstruction. The following categories were assessed: Sharpness of the vessel, motion artifacts, delineation of bronchial structures, vessel geometry, and visibility of treatable lesions. The mentioned criteria were rated from grade 1 to grade 3: grade 1: excellent quality; grade 2: good quality; grade 3: poor/seriously impaired quality. Inter-observer agreement was calculated using Cohen's Kappa. Due to an excellent agreement, the ratings of both readers were merged. Differences in the assessed image quality criteria were evaluated using pairwise Wilcoxon signed-rank test. RESULTS: Inter-observer agreement was excellent for all evaluated image quality criteria (κ > 0.81). For all assessed image quality criteria, the ratings on CACTorg were good but improved significantly for CACTmc to excellent for the whole vascular tree (p < 0.01). When considering segmental and sub-segmental levels individually, all image quality criteria improved significantly for CACTmc on both levels (p < 0.01). While ratings of CACTmc were constant for both levels (segmental and sub-segmental) for all criteria, the ratings of CACTorg were slightly impaired for the sub-segmental arteries. CONCLUSION: Motion correction for supra-selective contrast-enhanced CACT of the pulmonary arteries is feasible and improves the overall image quality. KEY POINTS: · Motion artifacts can severely impair the diagnostic accuracy of CACT.. · A motion correction algorithm can significantly improve image quality in CACT of the pulmonary arteries.. · Especially the overall image quality of sub-segmental branches is significantly improved.. CITATION FORMAT: · Maschke S, Werncke T, Becker LS et al. Motion Reduction for C-Arm Computed Tomography of the Pulmonary Arteries: Image Quality of a Motion Correction Algorithm in Patients with Chronic Thromboembolic Hypertension During Balloon Pulmonary Angioplasty. Fortschr Röntgenstr 2021; 193: 1074 - 1080.