Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute submassive pulmonary embolism: a propensity-matched analysis.

PURPOSE: To determine if mechanical thrombectomy (MT) for submassive pulmonary embolism (PE) positively impacts length of hospital stay (LOS), intensive care unit stay (ICU LOS), readmission rate, and in-hospital mortality compared with conservative therapy. METHODS: This was a retrospective review of all patients with submassive PE who either underwent MT or conservative therapy (systemic anticoagulation and/or inferior vena cava filter) between November 2019 and October 2021. Pediatric patients (age <18) and those with low-risk and massive PEs were excluded from the study. Patient characteristics, comorbidities, vitals, laboratory values (cardiac biomarkers, hospital course, readmission rates, and in-hospital mortality) were recorded. A 2:1 propensity score match was performed on the conservative and MT cohorts based on age and the PE severity index (PESI) classification. Fischer's exact test, Pearson's χ2 test, and Student's t-tests were used to compare patient demographics, comorbidities, LOS, ICU LOS, readmission rates, and mortality rates, with statistical significance defined as P < 0.05. Additionally, a subgroup analysis based on PESI scores was assessed. RESULTS: After matching, 123 patients were analyzed in the study, 41 in the MT cohort and 82 in the conservative therapy cohort. There was no significant difference in patient demographics, comorbidities, or PESI classification between the cohorts, except for increased incidence of obesity in the MT cohort (P = 0.013). Patients in the MT cohort had a significantly shorter LOS compared with the conservative therapy cohort (5.37 ± 3.93 vs. 7.76 ± 9.53 days, P = 0.028). However, ICU LOS was not significantly different between the cohorts (2.34 ± 2.25 vs. 3.33 ± 4.49, P = 0.059). There was no significant difference for in-hospital mortality (7.31% vs. 12.2%, P = 0.411). Of those that were discharged from the hospital, there was significantly lower incidence of 30-day readmission in the MT cohort (5.26% vs. 26.4%, P < 0.001). A subgroup analysis did not demonstrate that the PESI score had a significant impact on LOS, ICU LOS, readmission, or in-hospital mortality rates. CONCLUSION: MT for submassive PE can reduce the total LOS and 30-day readmission rates compared with conservative therapy. However, in-hospital mortality and ICU LOS were not significantly different between the two groups.

Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism.

BACKGROUND: Evidence supporting interventional pulmonary embolism (PE) treatment is needed. AIMS: We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population. METHODS: FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement. RESULTS: Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p<0.0001) and a 0.3 L/min/m2 mean increase in cardiac index (18.9%; p<0.0001) in patients with depressed baseline values. Most patients (62.6%) had no overnight intensive care unit stay post-procedure. At 48 hours, the echocardiographic right ventricle/left ventricle ratio decreased from 1.23±0.36 to 0.98±0.31 (p<0.0001 for paired values) and patients with severe dyspnoea decreased from 66.5% to 15.6% (p<0.0001).  Conclusions: Mechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE.

Urinoma formation following renal mass cryoablation treated with nephroureteral stent placement.

Renal cryoablation (CA) has become an accepted treatment option for patients with small renal tumors and co-morbidities that make them less favorable for surgical intervention. Complications from renal CA have been previously reported and are generally associated with increasing size and central location of the tumor. Ureteral injury from renal CA, although rare, can be difficult to manage and may require complex surgeries in patients who are poor surgical candidates to begin with. We report a case of a renal mass CA complicated by proximal ureteral necrosis and transection, treated with multiple minimally invasive procedures ultimately resulting in successful bridging of the necrotic segment with nephroureteral stent and thus avoiding major surgery.

Demystifying Sacral Masses: A Pictorial Review.

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

Extraosseous Ewing's Sarcoma: Pictorial Review of Imaging Findings, Differential Diagnosis, and Pathologic Correlation.

Extraosseous Ewing's sarcoma (EES), first described in 1969, is a malignant mesenchymal tumor just like its intraosseous counterpart. Although Ewing's sarcomas are common bone tumors in young children, EESs are rarer and more commonly found in older children/adults, often carrying a poorer prognosis. We discuss the multimodality imaging features of EES and the differential diagnosis of an aggressive appearing mass in proximity to skeletal structures, with pathologic correlates. This review highlights the need to recognize the variability of radiologic findings in EES such as the presence of hemorrhage, rich vascularity, and cystic or necrotic regions and its imaging similarity to other neoplasms that are closely related pathologically.

Image-guided percutaneous cryo-ablation of peri-urethral unresectable recurrent pelvic malignancy: A case report and brief review.

Recurrent or metastatic peri-urethral pelvic malignancies are a difficult-to-treat entity. Re-resection is recommended when possible but is frequently unfavorable due to scar tissue, fibrosis, and obliteration of tissue planes following previous interventions such as surgical resection and/or radiation therapy. Curative options for patients that have unresectable cancer are limited. Cryo-ablation has been extensively studied in the treatment of unresectable renal, liver and lung malignancies and has the potential to provide definitive treatment for recurrent pelvic malignancy. There is a paucity of reports of salvage cryo-ablation in patients with recurrent pelvic malignancies, as most of these tumors are located close to critical structures that could be irreversibly injured by thermal ablation and are hence treated with some form of radiation therapy. But, for patients who fail surgical and radiation treatments, options are limited. Here, we describe two cases of regional tumor recurrence in the pelvis treated with percutaneous cryoablation using protective techniques to avoid thermal injury to adjacent structures. In each case, cryo-ablation was performed successfully despite extensive previous surgical and radiation interventions. Salvage cryo-ablation resulted in a positive clinical and imaging response with an improvement in quality of life and absence of recurrence on follow-up imaging which continues to persist at the writing of this manuscript about 8 and 12-months following treatment.

Balloon assisted stent deployment in the cephalic arch (BASCA).

Cephalic arch stenosis causes repeated dysfunction and failure of arteriovenous access. Outcomes following balloon angioplasty alone in this location are unsatisfactory. Stent grafts have very good patency rates in this location. However, stent graft placement is technically challenging in this location due to the adverse angles and vectors of the cephalic arch. Stent graft deployment in this location is associated with a real risk of jailing the axillary vein, thereby precluding the use of that arm for future accesses and/or predisposes to venous edema. We describe a technique that was used to safely and effectively deploy a stent graft in the cephalic arch of a 65-year-old male patient.

Current Endovascular Treatment Options in Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.

The Pain Crisis: Interventional Radiology's Role in Pain Management.

Pain is a complex syndrome that is difficult to treat. The increasing numbers of patients living with chronic diseases has led to increasing pain management needs and the rise of opioid use disorder (OUD) as a major and potentially lethal public health concern. Treatment of chronic pain with prescription opioids alone is not always successful, and a multidisciplinary approach is paramount to address the needs of patients at risk of developing or suffering from OUD. Interventional radiologists trained to perform minimally invasive procedures with negligible downtime and postprocedure pain can help stem the tide of opioid-related deaths and disability. This article reviews a wide range of minimally invasive procedures, including vertebral augmentation, sacroplasty, thermal ablation of osseous metastasis, nerve blocks, and gonadal vein embolization, that interventional radiologists are now using successfully to treat chronic pain. The evidence to support use of such procedures is highlighted. This article also briefly discusses emerging techniques such as arterial embolization and ablation for knee and shoulder osteoarthritis that have not yet been fully tested but exhibit strong potential in chronic pain management. By reducing opioid use in patients suffering from chronic pain, these minimally invasive procedures can potentially prevent escalation to OUD.

Factors Affecting Radiation Dose in Computed Tomography Angiograms for Pulmonary Embolism: A Retrospective Cohort Study.

OBJECTIVES: Computed tomography pulmonary angiogram (CTPA) is one of the most commonly ordered and frequently overused tests. The purpose of this study was to evaluate the mean radiation dose to patients getting CTPA and to identify factors that are associated with higher dose. MATERIAL AND METHODS: This institutionally approved retrospective study included all patients who had a CTPA to rule out acute pulmonary embolism between 2016 and 2018 in a tertiary care center. Patient data (age, sex, body mass index [BMI], and patient location), CT scanner type, image reconstruction methodology, and radiation dose parameters (dose-length product [DLP]) were recorded. Effective dose estimates were obtained by multiplying DLP by conversion coefficient (0.014 mSv•mGy-1•cm-1). Multivariate logistic regression analysis was performed to determine the factors affecting the radiation dose. RESULTS: There were 2342 patients (1099 men and 1243 women) with a mean age of 58.1 years (range 0.2-104.4 years) and BMI of 31.3 kg/m2 (range 12-91.5 kg/m2). The mean effective radiation dose was 5.512 mSv (median - 4.27 mSv; range 0.1-43.0 mSv). Patient factors, including BMI >25 kg/m2, male sex, age >18 years, and intensive care unit (ICU) location, were associated with significantly higher dose (P < 0.05). CT scanning using third generation dual-source scanner with model-based iterative reconstruction (IR) had significantly lower dose (mean: 4.90 mSv) versus single-source (64-slice) scanner with filtered back projection (mean: 9.29 mSv, P < 0.001). CONCLUSION: Patients with high BMI and ICU referrals are associated with high CT radiation dose. They are most likely to benefit by scanning on newer generation scanner using advance model-based IR techniques.

Technical efficiency, short-term clinical results and safety of a large-bore aspiration catheter in acute pulmonary embolism - A retrospective case study.

BACKGROUND: Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE. MATERIALS AND METHODS: A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019-January 2020). Technical and clinical results, including complications, are reported. RESULTS: Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE. CONCLUSIONS: The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

Risk Factors for Major Hemorrhage Following Percutaneous Image-Guided Renal Biopsy: What is the "core" of the Problem? A Retrospective Case-control Study.

OBJECTIVES: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. MATERIAL AND METHODS: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. RESULTS: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28-32.30) and 15 times higher with >2 AAs (95% CI, 1.41-169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. CONCLUSION: There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.

CT-guided gastrostomy tube placement-a single center case series.

PURPOSE: The role of computed tomography (CT)-guided gastrostomy tube placement is still evolving. It is a valuable alternative to guide gastrostomy tube placement in a few selected patients, who are not candidates for the established endoscopy- or fluoroscopy-guided gastrostomy tube placement. Our objective was to describe our institutional experience placing gastrostomy tubes using CT guidance and to conduct a review of literature for similar studies to provide the best current evidence on success rates and complications. METHODS: We identified gastrostomy tubes placed under CT guidance at our institution using a comprehensive case log. We also identified studies in the literature, through a systematic search of PubMed. In both the local and literature analyses, we recorded success and complication rates. RESULTS: A total of 31 patients underwent 33 attempted CT-guided gastrostomy tube placements at our institution, with 32 successful procedures yielding a success rate of 97%. The overall rate of successful gastrostomy tube placement using CT-guidance was 94.9% (634/668), as reported in the existing literature. CONCLUSION: CT-guidance is an effective method for gastrostomy tube placement and may play an important role in patients for whom endoscopic or fluoroscopic gastrostomy tube placement is not feasible.

Appendiceal diverticulosis in a patient with family history of Birt-Hogg-Dubé syndrome--a case report.

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder that predisposes patients to cutaneous tumors, pulmonary cysts with recurrent spontaneous pneumothoraces, and a variety of renal neoplasms including hybrid oncocytic and chromophobe renal cell carcinomas. There has been much debate regarding the genetic link with the occurrence of colorectal cancer and other colonic anomalies. Associations between BHD and intestinal adenomatous polyposis and sigmoid diverticulosis have been described in the literature, but there have been no prior reports of appendiceal diverticulosis in patients with BHD. Here, we present a 40-year-old female patient with a known family history of BHD, who was found to have diverticulosis of the appendix and pulmonary blebs on computed tomography upon routine screening for renal and pulmonary abnormalities, suggesting additional focus be given to the gastrointestinal tract (including the appendix) at the time of CT assessment.

Chemorefractory liver metastasis from cervical cancer successfully treated with a combination of yttrium-90 and immunotherapy.

Liver metastases in cervical cancer is rare and can be difficult-to-treat. The current guidelines established by the Gynecologic Oncology Group recommend platinum-based systemic chemotherapy in combination with an anti-angiogenic agent such as bevacizumab, however, overall survival remains poor following diagnosis and options for patients who fail chemotherapy are limited. Yttrium-90 (Y90) radioembolization (RE) has shown great promise in the treatment of chemo-refractory colorectal liver metastases. We describe a 30-year-old female with a history of stage IB endocervical adenocarcinoma who later developed metastases to the liver, that were unresponsive to multiple chemotherapeutics and chemoembolization, and was successfully treated with Y90 RE with concurrent systemic Pembrolizumab. The Y90 RE treatment resulted in positive clinical and imaging responses with improvement in her quality of life, all of which continue to persist at the time of writing this manuscript about 8-months into her RE treatment.

Role of Computed Tomography-guided Biopsies in the Era of Electromagnetic Navigational Bronchoscopy: A Retrospective Study of Factors Predicting Diagnostic Yield in Electromagnetic Navigational Bronchoscopy and Computed Tomography Biopsies.

OBJECTIVES: Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN. MATERIALS AND METHODS: One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy. RESULT: Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions <21.5 mm were non-diagnostic in 71% of cases (42/59); 14 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% of them were diagnostic (12/14). ENB biopsies of lesions in the lower lobes were non- diagnostic in 59% of cases (35/59); 12 of these patients with non-diagnostic ENB biopsies had CTBs, and 83% were diagnostic (10/12). ENB biopsies of lesions in the outer 2/3 were non-diagnostic in 57% of cases (50/87); 21 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% were diagnostic (18/21). CONCLUSION: CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies. Although CTBs have a slightly higher pneumothorax rate, these lesions would be more successfully diagnosed with CTB as opposed to ENB biopsy, in the process expediting the diagnosis and saving valuable medical resources.

Metastatic retro-crural lymph nodes from transitional cell carcinoma of bladder successfully treated with single session cryoablation.

Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.

Metalophagia: Splenic artery pseudoaneurysm after foreign body ingestion and retrieval.

Persistent eating of non-nutritive, nonfood substances (Pica) is seen in children and adult patients with psychiatric problems. Ingestion of multiple metallic FBs with resultant bezoar formation is rare. While many FBs are passed without complication, mucosal injury, bleeding, obstruction or perforation can occur in some cases. Endoscopic FB removal is performed in 20% of patients following FB ingestion. Generally, these are safe procedures, and very effective in extracting ingested FBs. We report, a 25-year-old male patient with a metal ingestion predominant Pica, requiring multiple prior extraction procedures (including open gastrostomy). He developed a splenic artery pseudoaneurysm following his latest endoscopic FB removal, that was successfully treated with transarterial coil embolization. The unique circumstances leading to this rare complication and its successful endovascular management make this case worthy of report.

Spontaneous hemorrhage of an adrenal myelolipoma treated with transarterial embolization: A case report.

Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.