Advanced Interventional Procedures for Knee Osteoarthritis: What Is the Current Evidence?

The prevalence of knee osteoarthritis (OA) is the highest among all joints and likely to increase over the coming decades. Advances in the repertoire of diagnostic capabilities of imaging and an expansion in the availability and range of image-guided interventions has led to development of more advanced interventional procedures targeting pain related to OA pain while improving the function of patients presenting with this debilitating condition. We review the spectrum of established advanced interventional procedures for knee OA, describe the techniques used to perform these procedures safely, and discuss the clinical evidence supporting each of them.

Occupational orthopedic problems and its relation to personal radiation protection in interventional radiology.

PURPOSE: Several studies report occupational orthopedic problems among interventional cardiologists. These health problems are usually multifactorial. However, the personal protective equipment used should play a major role. An online survey was conducted to determine the frequency of such health problems among interventional radiologists and to correlate them with the use of personal radiation protective clothing. MATERIAL AND METHODS: An anonymous online survey that comprised of 17 questions was sent via e-mail to 1427 members of the German Society for Interventional Radiology (DeGIR) in Germany, Austria and Switzerland. The questions were focused on interventional workload, the use of personal radiation protection apparel and orthopedic problems. Given the different scale levels, the associations between the variables were analyzed using different statistical methods. A significance level of p < 0.05 was chosen. RESULTS: There were 221 survey responders (15.5% response rate). About half of responders (47.7%) suffered from more than five episodes of orthopedic problems during their interventional career. Lumbar spine was involved in 81.7% of these cases, cervical spine in 32.8%, shoulder in 28.5% and knee in 24.7%. Because of orthopedic problems, 16.1% of the responders had to reduce and 2.7% had to stop their interventional practice. The number of affected body regions correlates with the fit of the radiation protection means (p < 0.05, r = 0.135) and the reduction of activity as an interventional radiologist (p < 0.05, r = -0.148). CONCLUSION: Overall, the survey reveals widespread orthopedic problems at several body regions among interventional radiologists, associated with the fit of radiation protection systems, among other factors. A connection between the orthopaedic complaints and the radiation protection system used could not be established.

Adverse reactions after intravascular iodinated contrast media administration and their management.

Endovascular interventions and diagnostic examinations using iodinated contrast media (ICM) are standard of care in current vascular medicine. Although ICM use is generally considered safe, it may be associated with adverse reactions, vary from minor disturbances to rare, but severe life-threatening complications. This position paper of European Society of Vascular Medicine integrates current knowledge and summarizes the key information related to the use of intravascular ICM, serving as recommendation on prevention and management of acute, late, and very late adverse reactions. It should help the health professionals in all fields of vascular medicine to make decisions in daily practice for safe use of contrast media.

Adrenal Vein Sampling: Tips and Tricks.

Adrenal vein sampling (AVS) is the standard method for distinguishing unilateral from bilateral sources of autonomous aldosterone production in patients with primary aldosteronism. This procedure has been performed at limited specialized centers due to its technical complexity. With recent advances in imaging technology and knowledge of adrenal vein anatomy in parallel with the development of adjunctive techniques, AVS has become easier to perform, even at nonspecialized centers. Although rare, anatomic variants of the adrenal veins can cause sampling failure or misinterpretation of the sampling results. The inferior accessory hepatic vein and the inferior emissary vein are useful anatomic landmarks for right adrenal vein cannulation, which is the most difficult and crucial step in AVS. Meticulous assessment of adrenal vein anatomy on multidetector CT images and the use of a catheter suitable for the anatomy are crucial for adrenal vein cannulation. Adjunctive techniques such as intraprocedural cortisol assay, cone-beam CT, and coaxial guidewire-catheter techniques are useful tools to confirm right adrenal vein cannulation or to troubleshoot difficult blood sampling. Interventional radiologists should be involved in interpreting the sampling results because technical factors may affect the results. In rare instances, bilateral adrenal suppression, in which aldosterone-to-cortisol ratios of both adrenal glands are lower than that of the inferior vena cava, can be encountered. Repeat sampling may be necessary in this situation. Collaboration with endocrinology and laboratory medicine services is of great importance to optimize the quality of the samples and for smooth and successful operation. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Potential risk assessment: a model for quality evaluation in fluoroscopy-guided interventional procedures.

This study presented a model applied for potential risk assessment in an interventional radiology setting. The model of potential risk assessment (MARP) consisted of the creation of a scale of indicators ranging from 0 to 5. The radiation levels were categorized according to gender, kind of procedure, value of kerma air product (Pka), and accumulated radiation dose (mGy). The MARP model was applied in 121 institutions over 8 y. A total of 201 656 patient radiation doses (Dose-area product and accumulated kerma) data were launched into the system over time, with an average of 22 406 doses per year. In the context of the workers (cardiologists, radiographers, and nurses) monitored during the MARP application, 8007 cases (with an average of 890 per year) of occupational radiation doses were recorded. This study showed a strategy for quality evaluation in fluoroscopy using a model with a compulsory information system for monitoring safety.

Intravenous Opioid Medication with Piritramide Reduces the Risk of Pneumothorax During CT-Guided Percutaneous Core Biopsy of the Lung.

PURPOSE: CT-guided percutaneous core biopsy of the lung is usually performed under local anesthesia, but can also be conducted under additional systemic opioid medication. The purpose of this retrospective study was to assess the effect of intravenous piritramide application on the pneumothorax rate and to identify risk factors for post-biopsy pneumothorax. MATERIALS AND METHODS: One hundred and seventy-one core biopsies of the lung were included in this retrospective single center study. The incidence of pneumothorax and chest tube placement was evaluated. Patient-, procedure- and target-related variables were analyzed by univariate and multivariable logistic regression analysis. RESULTS: The overall incidence of pneumothorax was 39.2% (67/171). The pneumothorax rate was 31.5% (29/92) in patients who received intravenous piritramide and 48.1% (38/79) in patients who did not receive piritramide. In multivariable logistic regression analysis periinterventional piritramide application proved to be the only independent factor to reduce the risk of pneumothorax (odds ratio 0.46, 95%-confidence interval 0.24, 0.88; p = 0.018). Two or more pleura passages (odds ratio 3.38, 95%-confidence interval: 1.15, 9.87; p = 0.026) and prone position of the patient (odds ratio 2.27, 95%-confidence interval: 1.04, 4.94; p = 0.039) were independent risk factors for a higher pneumothorax rate. CONCLUSION: Procedural opioid medication with piritramide proved to be a previously undisclosed factor decreasing the risk of pneumothorax associated with CT-guided percutaneous core biopsy of the lung. LEVEL OF EVIDENCE 4: small study cohort.

Percutaneous Microwave Ablation Versus Robot-Assisted Partial Nephrectomy for Stage I Renal Cell Carcinoma: A Propensity-Matched Cohort Study Focusing Upon Long-Term Follow-Up of Oncologic Outcomes.

PURPOSE: To retrospectively compare long-term oncologic outcomes of percutaneous computed tomography-guided microwave ablation (MWA) and robot-assisted partial nephrectomy (RAPN) for the treatment of stage 1 (T1a and T1b) renal cell carcinoma (RCC) patients. MATERIALS AND METHODS: Institutional database research identified all T1 RCC patients who underwent either MWA or RAPN. Models were adjusted with propensity score matching. Kaplan-Meier log-rank test analyses and Cox proportional hazard regression models were used to compare the oncologic outcomes. Patient and tumor characteristics, technical success as well as oncologic outcomes were evaluated and compared between the 2 groups. RESULTS: After propensity score matching, a total of 71 patients underwent percutaneous MWA (mean age 70 ± 10 years) and 71 underwent RAPN (mean age 60 ± 9 years). At 8-year follow-up, the estimated survival rates for MWA cohort were 98% (95% confidence interval [CI] 95-100%) for overall survival, 97% (95% CI 93-100%) for recurrence-free survival, and 97% (95% CI 93-100%) for metastasis-free survival. The matched cohort that underwent RAPN exhibited survival rates of 100% (95% CI 100-100%) for overall survival, 98% (95% CI 94-100%) for recurrence-free survival, and 98% (95% CI 94-100%) for metastasis-free survival. After performing log-rank testing, these rates were not significantly different (p values of 0.44, 0.67, and 0.67, respectively). CONCLUSION: The results of the present study suggest that both MWA and RAPN are equally effective in terms of oncologic outcome for the treatment of T1 RCC.

A novel technique to remove migrated esophageal stent under fluoroscopy.

PURPOSE: To evaluate the efficacy and safety of a novel technique for removal of migrated esophageal stent (MES) under fluoroscopy. METHODS: From January 2009 to April 2023, 793 patients with a dysphagia score of 3-4 underwent esophageal stenting at our center, and 25 patients (mean age: 70.06 years old; male/female: 15/10) underwent stent removal using "loop method" under fluoroscopy. The primary outcomes were technical success and complications. The secondary outcomes were procedure time, radiation exposure, biochemical indicators [white blood cell (WBC), hemoglobin (Hb), platelet (PLT), albumin (ALB), alanine transaminase (ALT), total bilirubin (TB), urea nitrogen (UN) and C-reactive protein] of pre- and post-treatment at 2 weeks. RESULTS: Technical success was 100% without major complications. The mean procedure time was (39.44 ± 9.28) minutes, which showed no statistical significance between benign (n = 5) and malignant (n = 20) group [(42.40 ± 8.85) vs (38.71 ± 9.46) mins, p > 0.05]. The mean radiation exposure was (332.88 ± 261.47) mGy, which showed no statistical significance between benign and malignant group [(360.74 ± 231.43) vs (325.92 ± 273.54) mGy, p > 0.05]. Pre- and post-procedure Hb [(114.46 ± 11.96) vs. (117.57 ± 13.12) g/L] and ALB [(42.26 ± 3.39) vs. (44.12 ± 3.77) g/L] showed significant difference (p < 0.05), while WBC, PLT, CRP, and ALT showed no significance (p > 0.05). CONCLUSION: Fluoroscopy-guided "Loop method" for MES removal is an effective and safe alternative technique.

Impact of equipment technology on reference levels in fluoroscopy-guided gastrointestinal procedures.

OBJECTIVES: To evaluate the effect of equipment technology on reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time for fluoroscopically-guided gastrointestinal endoscopic procedures and establish benchmark levels. METHODS: This retrospective study included the consecutive patients who underwent fluoroscopically-guided gastrointestinal endoscopic procedures from May 2016 to August 2023 at a tertiary care hospital in the U.S. Fluoroscopic systems included (a) Omega CS-50 e-View, (b) GE Precision 500D, and (c) Siemens Cios Alpha. Radiation dose was analyzed for four procedure types of endoscopic retrograde biliary, pancreas, biliary and pancreas combined, and other guidance. Median and 75th percentile values were computed using software package R (version 4.0.5, R Foundation). RESULTS: This large study analyzed 9,459 gastrointestinal endoscopic procedures. Among four procedure types, median Ka,r was 108.8-433.2 mGy (a), 70-272 mGy (b), and 22-55.1 mGy (c). Median PKA was 20.9-49.5 Gy∙cm2 (a), 13.4-39.7 Gy∙cm2 (b), and 8.91-20.9 Gy∙cm2 (c). Median fluoroscopic time was 2.8-8.1 min (a), 3.6-9.2 min (b), and 2.9-9.4 min (c). Their median value ratio (a:b:c) was 8.5:4.8:1 (Ka,r), 2.7:2.1:1 (PKA), and 1.0:1.1:1 (fluoroscopic time). Median value and 75th percentile are presented for Ka,r, PKA, and fluoroscopic time for each procedure type, which can function as benchmark for comparison for dose optimization studies. CONCLUSION: This study shows manifold variation in doses (Ka,r and PKA) among three fluoroscopic equipment types and provides local reference levels (50th and 75th percentiles) for four gastrointestinal endoscopic procedure types. Besides procedure type, imaging technology should be considered for establishing diagnostic reference level. SUMMARY: With manifold (2 to 12 times) variation in doses observed in this study among 3 machines, we recommend development of technology-based diagnostic reference levels for gastrointestinal endoscopic procedures.

Radiation protection in CT-guided interventions: does real-time dose visualisation lead to a reduction in radiation dose to participating radiologists? A single-centre evaluation.

AIM: To evaluate if real-time dose visualisation during computed tomography (CT)-guided interventions leads to a reduction in radiation dose to participating radiologists. MATERIALS AND METHODS: The individual radiation dose radiologists are exposed to during CT interventions was measured using dedicated dosimeters (RaySafe i2-system, Unfors RaySafe GmbH, Billdal, Sweden) worn over the usual radiation protective apron. Initially, only the total radiation dose was measured, without visualisation (control group). In the following study period, the radiation dose was shown to participants on a live screen in real-time (experimental group). In both groups, the dose was recorded in 1-second intervals. The results collected were evaluated by comparison using descriptive statistics and mixed-effect models. In particular, the variables experience, gender, role, and position during the intervention were analysed. RESULTS: In total, 517 measurements of 304 interventions (n=249 with and n=268 without live screen) performed by 29 radiologists acting as interventionalists or assistants were analysed. All CT-guided interventions were performed percutaneously, the majority of which (n=280) were microwave ablations (MWA). Radiation doses in the group without visualisation were comparable with usual dose rates for the corresponding intervention type. The mean total radiation dose was reduced by 58.1% (11.6 versus 4.86 µSv) in the experimental group (p=0.034). The highest reduction of 78.5% (15.55 versus 3.35 µSv) was observed in radiologists with the role of assistant (p=0.002). Sub-analysis showed significant dose reduction (p<0.0001) for the use of live screen in general; considering all variables, the role "assistant" alone had a statistically significant influence (p=0.002). CONCLUSION: The real-time visualisation of active radiation dose during CT interventions leads to a relevant reduction in radiation dose to participating radiologists.

Establishment of Diagnostic Reference Levels in Portuguese Interventional Radiology departments.

PURPOSE: To establish Portuguese Diagnostic Reference Levels (DRLs), for six body fluoroscopy guided interventional procedures (FGIP). METHOD: A retrospective study was conducted in five interventional departments most representative of Interventional Radiology (IR) practice. Dose values, in terms of air kerma area product (PKA in Gy.cm2), air kerma at the patient entrance reference point (Ka,r in mGy), and exposure parameters (fluoroscopy time (FT) and number of cine runs) were collected. Examinations were selected per procedure (at least 20), according to the antero-posterior and lateral diameter mean value (±5 cm), measured on previous Computed Tomography (CT) examinations. RESULTS: Data of 489 body FGIP show a large variation on dose values per procedure and per department. National DRLs in terms of PKA were 20.2 Gy.cm2 for Percutaneous transhepatic biliary drainage (PTBD), 98.2 Gy.cm2 for Bronchial artery embolisation (BAE), 247.7 Gy.cm2 for Transarterial chemoembolisation (TACE), 331.6 Gy.cm2 for Inferior epigastric arteries embolisation (IEAE), 312.0 Gy.cm2 for Transjugular intrahepatic portosystemic shunt (TIPS) and 19.3 Gy.cm2 for Endovascular treatment of femoral popliteal arteries (ETFPA). CONCLUSIONS: This is the first study reporting Interventional Radiology DRLs in Portugal and we propose preliminary national estimates for the six more common body FGIP. The results of this study will be presented and discussed with all Portuguese IR departments, to promote procedures optimisation.