Enhancing your practice: debriefing in interventional radiology.

LEARNING OBJECTIVES: Review the history of debriefing and provide an Interventional Radiologist (IR) specific framework for leading an effective debrief. BACKGROUND: A debrief is often regarded as a meeting with persons who were involved in a stressful, traumatic and/or emotionally challenging situation to review processes, communicate concerns or gather feedback. The goals of these sessions can be for learning/quality improvement (QI) or psychological/emotional support, or a mix of both. Debriefing after tough situations has become a standard tool of many medical specialties, such as surgery, critical care and emergency medicine, with specialty specific literature available. However, there is a paucity of Interventional Radiology specific literature available for debriefing techniques. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the history and types of debriefing and why a debrief could be considered. We will provide a framework for leading a successful debrief in Interventional Radiology. CONCLUSION: Debriefing can be a useful tool for learning and QI as well as psychological or emotional support after a challenging or tough situation. Debriefing can address multiple variables and can stylistically be tailored to suit specific needs. IRs have an opportunity to take a leadership role in debriefing, providing comfort and quality improvement through communication and support.

Inferior vena cava filter tilting between placement and retrieval is associated with caval diameter and need for complex retrieval techniques.

PURPOSE: Inferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures. MATERIALS AND METHODS: 252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions. RESULTS: Mean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters. CONCLUSION: Larger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

Interventional Optical Imaging Permits Instant Visualization of Pathological Zones of Ablated Tumor Periphery and Residual Tumor Detection.

Optical imaging (OI) provides real-time clinical imaging capability and simultaneous molecular, morphological, and functional information of disease processes. In this study, we present a new interventional OI technique, which enables in vivo visualization of three distinct pathologic zones of ablated tumor periphery for immediate detection of residual tumors during a radiofrequency ablation (RFA) session. Rabbits with orthotopic hepatic tumors were divided into two groups (n = 8/group): incomplete RFA and complete RFA. Indocyanine green-based interventional OI was used to differentiate three pathological zones: ablated tumor, transition margin, and residual tumor or surrounding normal liver-with quantitative comparison of signal-to-background ratios among the three zones and between incompletely and completely ablated tumors. Subsequent ex vivo OI and pathologic correlation were performed to confirm the findings of interventional OI. Interventional OI could differentiate incompletely or completely ablated tumor peripheries, thus permitting identification of residual tumor. This technique may open new avenues for immediate assessment of tumor eradication during a single interventional ablation session. SIGNIFICANCE: Interventional optical imaging can instantly visualize pathologic zones of ablated tumor peripheries to detect residual tumors, which could revolutionize current image-guided interventional oncologic ablation techniques.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series.

BACKGROUND: Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure. CASE PRESENTATION: This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days. CONCLUSIONS: TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

Fluoroscopically-guided interventions with radiation doses exceeding 5000 mGy reference point air kerma: a dosimetric analysis of 89,549 interventional radiology, neurointerventional radiology, vascular surgery, and neurosurgery encounters.

PURPOSE: To quantify and categorize fluoroscopically-guided procedures with radiation doses exceeding 5000 mGy reference point air kerma (Ka,r). Ka,r > 5000 mGy has been defined as a "significant radiation dose" by the Society of Interventional Radiology. Identification and analysis of interventions with high radiation doses has the potential to reduce radiation-induced injuries. MATERIALS AND METHODS: Radiation dose data from a dose monitoring system for 19 interventional suites and 89,549 consecutive patient encounters from January 1, 2013 to August 1, 2019 at a single academic institution were reviewed. All patient encounters with Ka,r > 5000 mGy were included. All other encounters were excluded (n = 89,289). Patient demographics, medical specialty, intervention type, fluoroscopy time (minutes), dose area product (mGy·cm2), and Ka,r (mGy) were evaluated. RESULTS: There were 260 (0.3%) fluoroscopically-guided procedures with Ka,r > 5000 mGy. Of the 260 procedures which exceeded 5000 mGy, neurosurgery performed 81 (30.5%) procedures, followed by interventional radiology (n = 75; 28.2%), neurointerventional radiology (n = 55; 20.7%), and vascular surgery (n = 49; 18.4%). The procedures associated with the highest Ka,r were venous stent reconstruction performed by interventional radiology, arteriovenous malformation embolization performed by neurointerventional radiology, spinal hardware fixation by neurosurgery, and arterial interventions performed by vascular surgery. Neurointerventional radiology had the highest mean Ka,r (7,799 mGy), followed by neurosurgery (7452 mGy), vascular surgery (6849 mGy), and interventional radiology (6109 mGy). The mean Ka,r for interventional radiology performed procedures exceeding 5000 mGy was significantly lower than that for neurointerventional radiology, neurosurgery, and vascular surgery. CONCLUSIONS: Fluoroscopically-guided procedures with radiation dose exceeding 5000 mGy reference point air kerma are uncommon. The results of this study demonstrate that a large proportion of cases exceeding 5000 mGy were performed by non-radiologists, who likely do not receive the same training in radiation physics, radiation biology, and dose reduction techniques as radiologists.

Monitoring and Follow-Up of High Radiation Dose Cases in Interventional Radiology.

RATIONALE AND OBJECTIVES: To assess the implementation of radiation dose monitoring software, create a process for clinical follow-up and documentation of high-dose cases, and quantify the number of patient reported radiation-induced tissue reactions in fluoroscopically guided interventional radiology (IR) and neuro-interventional radiology (NIR) procedures. MATERIALS AND METHODS: Web-based radiation dose monitoring software was installed at our institution and a process to flag all procedures with reference point air kerma (Ka,r) > 5000 mGy was implemented. The entrance skin dose was estimated and formal reports generated, allowing for physician-initiated clinical follow-up. To evaluate our process, we reviewed all IR and NIR procedures performed at our hospital over a 1-year period. For all procedures with Ka,r > 5000 mGy, retrospective medical chart review was performed to evaluate for patient reported tissue reactions. RESULTS: Three thousand five hundred eighty-two procedures were performed over the 1-year period. The software successfully transferred dose data on 3363 (93.9%) procedures. One thousand three hundred ninety-three (368 IR and 1025 NIR) procedures were further analyzed after excluding 2189 IR procedures with Ka,r < 2000 mGy. Ten of 368 (2.7%) IR and 52 of 1025 (5.1%) NIR procedures exceeded estimated skin doses of 5000 mGy. All 10 IR cases were abdominal/pelvic trauma angiograms with/without embolization; there were no reported tissue reactions. Of 52 NIR cases, 49 were interventions and 3 were diagnostic angiograms. Five of 49 (10.2%) NIR patients reported skin/hair injuries, all of which were temporary. CONCLUSION: Software monitoring and documentation of radiation dose in interventional procedures can be successfully implemented. Radiation-induced tissue reactions are relatively uncommon.

An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis.

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ©RSNA, 2018.

Value of Antibiotic Prophylaxis for Percutaneous Gastrostomy: A Double-Blind Randomized Trial.

PURPOSE: To compare peristomal infection rates following percutaneous gastrostomy (PG) after a single dose of prophylactic antibiotics versus placebo and evaluate rates of peristomal infection in patients receiving concurrent antibiotics. MATERIALS AND METHODS: This single-center, randomized trial (2012-2016) enrolled 122 patients referred for image-guided PG; all enrolled patients completed the study. Of enrolled patients, 68 were randomly assigned to receive either antibiotics (n = 34) or placebo (n = 34) before PG placement. The remaining 54 patients were taking pre-existing antibiotics and were assigned to an observation arm. Stoma sites were assessed for signs of infection by a blinded evaluator at early (between 3-5 d and 7-10 d) and late (between 14-17 d and 28-30 d) time points after the procedure. The primary outcome was peristomal infection. RESULTS: Under intention-to-treat analysis, early infection rate was 11.8% (4/34 patients; 95% CI, 0.0%-9.4%) in the placebo arm and 0.0% (0/34 patients; 95% CI, 0.0%-8.4%) in the antibiotic arm (P = .057 for comparison of infections in the 2 arms). Under per-protocol analysis, early infection rate was 13.3% (4/30 patients; 95% CI, 4.4%-29.1%) in the placebo arm and 0.0% (0/32 patients; 95% CI, 0.0%-8.9%) in the antibiotic arm (P = .049). The number needed to treat to prevent 1 early infection was 8.5 and 7.5 from the 2 analyses, respectively. CONCLUSIONS: There is a trend toward reduction in rate of peristomal infection after PG when prophylactic antibiotics are administered.

An Interventionist's Guide to Endocrine Consultations.

Endocrinopathies are a heterogeneous group of disorders often resulting from pathologic sources of hormone production. When the clinical scenario, laboratory testing, and noninvasive imaging fail to aid confident identification of the source of hormone excess, endocrine venous sampling may localize obscure lesions to guide subsequent treatment. Knowledge of basic hormone signaling pathways, common pathophysiologic disruptions of these pathways, and serologic evaluation fosters informed conversations with referring physicians and effective patient selection. Success in the angiography suite requires familiarity with normal and variant anatomy of the multiple organs of the endocrine system, patient preparation, stimulation and sampling techniques, specimen handling, and results interpretation. ©RSNA, 2017.

Who We Are and What We Can Become: An Analysis of Professional Identity Formation in IR.

PURPOSE: To characterize the unique experiences, values, and perspectives of interventional radiology (IR) fellows. MATERIALS AND METHODS: Sixteen fellows from 4 US vascular and IR programs were interviewed within 2 months of beginning and 2-3 months following their 2015-2016 fellowships about patient interactions, training experiences, and views of IR and other specialties. Interviews were systematically analyzed for dominant themes by using constructivist grounded theory. Four interviews with 2015-2016 interventional cardiology fellows, 16 interviews with IR attending physicians, and online descriptions of IR were also analyzed for context. Themes were compared qualitatively and quantitatively. RESULTS: Interobserver agreement was good for interview themes (κ = 0.70; P < .0001). IR fellows' professional identity emerged primarily from radiologic and surgical interests, with distinct emphasis on being "innovators," "thinking differently," and "needing to adapt and advertise abilities to survive." Fellows' descriptions of patient care were more clinically focused than past interviews with attending physicians (P = .05), but clinical interests common in medical specialties were limited, and descriptions of "nonprocedural patient care" were primarily periprocedural (81%). Descriptions of the future of the field conveyed competing pressures, loose role definition, and disconnect between academic and private-practice IR. CONCLUSIONS: IR fellows share professional interests, views of their field and others, and descriptions of patient care, but there is uncertainty regarding future roles of the specialty and a need for more specific and unified definitions of nonprocedural patient care in IR.

Orthotopic Esophageal Cancers: Intraesophageal Hyperthermia-enhanced Direct Chemotherapy in Rats.

Purpose To determine the feasibility of using intraesophageal radiofrequency (RF) hyperthermia to enhance local chemotherapy in a rat model with orthotopic esophageal squamous cancers. Materials and Methods The animal protocol was approved by the institutional animal care and use committee and the institutional review board. Human esophageal squamous cancer cells were transduced with luciferase lentiviral particles. Cancer cells, mice with subcutaneous cancer esophageal xenografts, and nude rats with orthotopic esophageal cancers in four study groups of six animals per group were treated with (a) combination therapy of magnetic resonance imaging heating guidewire-mediated RF hyperthermia (42°C) plus local chemotherapy (cisplatin and 5-fluorouracil), (b) chemotherapy alone, (c) RF hyperthermia alone, and (d) phosphate-buffered saline. Bioluminescent optical imaging and transcutaneous ultrasonographic imaging were used to observe bioluminescence signal and changes in tumor size among the groups over 2 weeks, which were correlated with subsequent histologic results. The nonparametric Mann-Whitney U test was used for comparisons of variables. Results Compared with chemotherapy alone, RF hyperthermia alone, and phosphate-buffered saline, combination therapy with RF hyperthermia and chemotherapy induced the lowest cell proliferation (relative absorbance of formazan: 23.4% ± 7, 44.6% ± 7.5, 95.8% ± 2, 100%, respectively; P < .0001), rendered the smallest relative tumor volume (0.65 mm3 ± 0.15, P < .0001) and relative bioluminescence optical imaging photon signal (0.57 × 107 photons per second per square millimeter ± 0.15, P < .001) of mice with esophageal cancer xenografts, as well as the smallest relative tumor volume (0.68 mm3 ± 0.13, P < .05) and relative photon signal (0.56 × 107 photons per second per square millimeter ± 0.11. P < .001) of rat orthotopic esophageal cancers. Conclusion Intraesophageal RF hyperthermia can enhance the effect of chemotherapy on esophageal squamous cell cancers. © RSNA, 2016.

Yttrium-90 Radioembolization as a Salvage Treatment following Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: To determine safety and efficacy of yttrium-90 ((90)Y) transarterial radioembolization (TARE) in patients who have undergone chemoembolization for hepatocellular carcinoma. MATERIALS AND METHODS: A retrospective study identified 40 patients (median age 61 y; range, 44-84 y) who underwent (90)Y mapping angiography and had undergone ≥ one prior chemoembolizations. There were 4 (10%) patients in Barcelona Clinic Liver Cancer stage A, 7 (17.5%) in stage B, and 29 (72.5%) in stage C; 28 (70%) were Child-Pugh class A and 12 (30%) were class B. Median tumor diameter was 4.2 cm (range, 1-11.6 cm). The most common indications for changing to TARE were tumor progression (35/40; 86%) and development of portal vein thrombus (15/40; 37.5%). RESULTS: Of 40 patients, 29 (72.5%) underwent TARE; the most common reasons for not undergoing TARE were attenuated hepatic arteries (5/11), high pulmonary shunt (4/11), and poor arterial flow (2/11). Patients who underwent ≤ 4 chemoembolizations to the TARE target tended to be more likely to undergo TARE after mapping than patients who had > 4 chemoembolizations (P = .056). Most common grade ≥ 3 toxicities were fatigue (9/29; 31%) and biochemical alterations (bilirubin [3/29; 10.3%], albumin [4/29; 13.8%], aspartate aminotransferase [5/29; 17.2%]). Of 27 patients treated with TARE with follow-up, responses were 11 (41%) complete response, 5 (19%) partial response, 2 (7%) stable disease, and 9 (33%) progressive disease. Median progression-free survival and overall survival were 90 days and 257 days. CONCLUSIONS: TARE is safe and effective salvage therapy in patients after chemoembolization. In patients who have undergone > 4 chemoembolizations to the (90)Y target, feasibility of TARE tends to be decreased.

Intra-Arterial Thrombolysis for Hepatic Artery Thrombosis following Liver Transplantation.

PURPOSE: Hepatic artery thrombosis (HAT) is a major cause of morbidity and death following liver transplantation. The purpose of this study was to evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) in liver transplant recipients with HAT. MATERIALS AND METHODS: Adult liver transplant recipients who underwent attempted IAT for HAT were identified. This included patients with early and late HAT (occurring less than or greater than 30 d after transplantation). Records were reviewed to determine the rates of technical success, complications, surgical revascularization, repeat liver transplantation, and ischemic cholangiopathy. RESULTS: Twenty-six patients underwent attempted thrombolysis, 13 of whom had early HAT. IAT was successfully initiated in 23 patients (88%), with a median IAT duration of 28 hours (range, 12-90 h). Recanalization was achieved in 12 patients (46%). Major complications were observed in 11 patients (42%). The early HAT group showed a trend toward increased major bleeding compared with the late HAT group (50% vs 9%; P = .07). Among 12 patients who had technically successful thrombolysis, five (42%) required surgical revascularization or repeat transplantation within 2 months. At 6 months after thrombolysis, 45% with unsuccessful recanalization avoided surgery or development of ischemic cholangiopathy, similar to the proportion in those who had successful recanalization (42%; P = .88). CONCLUSIONS: Posttransplantation hepatic artery thrombolysis yields suboptimal results with a high complication rate, especially in early HAT. Even with successful restoration of flow, clinical outcomes are poor. Although thrombolysis may still be considered in view of the limited treatment options for HAT, awareness of potential complications and suboptimal success rate is essential.

Transjugular Intrahepatic Portosystemic Shunt Placement During Pregnancy: A Case Series of Five Patients.

BACKGROUND AND AIMS: Complications of portal hypertension, such as variceal hemorrhage and ascites, are associated with significant increases in both mortality and complications during pregnancy. Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating portal hypertension, but the safety of TIPS during pregnancy is largely unknown. In this series, we review five patients who underwent TIPS placement while pregnant and describe their clinical outcomes. METHODS: Five pregnant patients with cirrhosis and portal hypertension underwent elective TIPS for complications of portal hypertension (four for secondary prevention of variceal bleeding and one for refractory ascites). Outcomes measured were recurrent bleeding episodes or need for further paracenteses during pregnancy, estimated radiation dose to the fetus and gestational age at delivery. All patients were followed after delivery to evaluate technical and clinical success of the procedure. RESULTS: All five patients survived pregnancy and went on to deliver successfully. When TIPS was performed for secondary prevention of variceal bleeding (n = 4), no patients demonstrated variceal bleeding after TIPS placement. When TIPS was performed for refractory ascites (n = 1), no further paracenteses were required. All patients delivered successfully, albeit prematurely. Average radiation dose estimated to the fetus was 16.3 mGy. CONCLUSIONS: This series suggests that TIPS can be performed in selective pregnant patients with portal hypertension, with little added risk to the mother or fetus.

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts.

PURPOSE: Locoregional therapy for hepatocellular carcinoma (HCC) can be challenging in patients with a transjugular intrahepatic portosystemic shunt (TIPS). This study compares safety and imaging response of ablation, chemoembolization, radioembolization, and supportive care in patients with both TIPS and HCC. METHODS: This retrospective study included 48 patients who had both a TIPS and a diagnosis of HCC. Twenty-nine of 48 (60%) underwent treatment for HCC, and 19/48 (40%) received best supportive care (i.e., symptomatic management only). While etiology of cirrhosis and indication for TIPS were similar between the two groups, treated patients had better baseline liver function (34 vs. 67% Child-Pugh class C). Tumor characteristics were similar between the two groups. A total of 39 ablations, 17 chemoembolizations, and 10 yttrium-90 radioembolizations were performed on 29 patients. RESULTS: Ablation procedures resulted in low rates of hepatotoxicity and clinical toxicity. Post-embolization/ablation syndrome occurred more frequently in patients undergoing chemoembolization than ablation (47 vs. 15%). Significant hepatic dysfunction occurred more frequently in the chemoembolization group than the ablation group. Follow-up imaging response showed objective response in 100% of ablation procedures, 67% of radioembolization procedures, and 50% of chemoembolization procedures (p = 0.001). When censored for OLT, patients undergoing treatment survived longer than patients receiving supportive care (2273 v. 439 days, p = 0.001). CONCLUSIONS: Ablation appears to be safe and efficacious for HCC in patients with TIPS. Catheter-based approaches are associated with potential increased toxicity in this patient population. Chemoembolization appears to be associated with increased toxicity compared to radioembolization.

Percutaneous sclerotherapy for treatment of tumoral calcinosis.

Massive tumoral calcinosis developed in a 29-year-old woman with type 1 diabetes and failed pancreas and kidney transplant on peritoneal dialysis. The patient had a symptomatic calcified, fluid-filled posterior thigh mass. After percutaneous drainage of 260 mL of milky fluid, she had rapid recurrence of the collection. She underwent catheter-based sclerotherapy first with 110 mL of povidone-iodine followed 2 days later by 40 mL of 3% sodium tetradecyl sulfate foam. At 5.5 months after the procedure, the patient remained asymptomatic, and computed tomography imaging showed complete resolution of the collection.