Same-day discharge after percutaneous renal cryoablation and its effect on 30 day hospital re-admission rates and post-procedural complications.

PURPOSE: The purpose of this study is to identify if the local institutional shift from routine overnight observation to same-day discharge following percutaneous cryoablation (PCA) of renal tumors increases 30 day re-admission rates or serious adverse events (AEs). MATERIALS AND METHODS: This retrospective study included 133 adult patients. PCA patients in calendar years 2018-2019 were routinely observed overnight in the hospital, comprising the control group (Group A). PCA patients in calendar years 2021-2022 were routinely discharged the same day, comprising the test group (Group B). Relevant demographic information, tumor characteristics, technical outcomes, and clinical outcomes were recorded. RESULTS: 15 patients (11.3 %) from the total cohort were re-admitted to the hospital within 30 days of PCA for any reason. Seven patients (10.4 %) and eight patients (12.1 %) were re-admitted for any reason within 30 days in Group A and Group B, respectively, with no difference between the two groups (p = 0.76). Nine patients (6.8 %) from the total cohort were re-admitted to the hospital within 30 days for a diagnosis secondary to the procedure. Four patients (6 %) and five patients (7.6 %) were re-admitted within 30 days for reasons related to PCA in Group A and Group B, respectively, with no significant difference between the groups (p = 0.71). Eight patients (12 %) and four patients (6 %) had major AEs following PCA in Group A and Group B, respectively, with no difference between the two groups (p = 0.43). CONCLUSION: Overall, the change in post-procedural care after PCA did not have a deleterious effect on 30 day re-admission rates or rates of major AEs.

Percutaneous biliary stent removal for benign biliary stricture post hepaticojejunostomy.

This case report presents the percutaneous extraction of a biliary stent in a patient with a history of liver transplant and Whipple procedure, suffering from benign biliary stricture post hepaticojejunostomy. After failed management with conventional benign biliary protocol, a fully covered WallFlex biliary stent was percutaneously placed and later removed using a balloon catheter technique. The procedure demonstrated anastomosis patency without complications, providing a drain-free option for complex anatomy where endoscopic management was not feasible. This case contributes valuable insights to the limited literature on percutaneous stent removal for benign biliary strictures, emphasising the importance of considering alternative approaches in challenging clinical scenarios.

Non-operating room anesthesia workflow (NORA) implementation to improve start times in interventional radiology.

BACKGROUND: Non-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PURPOSE: To investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. MATERIALS AND METHODS: A retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. RESULTS: One hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. CONCLUSION: Implementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.

Challenges, Barriers, and Successes of Standardized Report Templates: Results of a Society of Interventional Radiology Survey.

Registry data are being increasingly used to establish treatment guidelines, set benchmarks, allocate resources, and make payment decisions. Although many registries rely on manual data entry, the Society of Interventional Radiology (SIR) is using automated data extraction for its VIRTEX registry. This process relies on participants using consistent terminology with highly structured data in physician-developed standardized reports (SR). To better understand barriers to adoption, a survey was sent to 3,178 SIR members. Responses were obtained from 451 interventional radiology practitioners (14.2%) from 92 unique academic and 151 unique private practices. Of these, 75% used structured reports and 32% used the SIR SR. The most common barriers to the use of these reports include SR length (35% of respondents), lack of awareness about the SR (31%), and lack of agreement on adoption within practices (27%). The results demonstrated insights regarding barriers in the use and/or adoption of SR and potential solutions.

Transarterial embolization of T1b and T2a renal cell carcinoma prior to percutaneous cryoablation: a retrospective comparative study.

PURPOSE: To compare outcomes in patients with T1b and T2a renal cell carcinoma (RCC) treated with percutaneous cryoablation (PCA) who underwent transarterial embolization (TAE) of the RCC prior to PCA (TAE + PCA) to patients who were treated with PCA alone. METHODS: Retrospective review of all adult patients with T1b (4.1-7 cm) and T2a (7.1-10 cm) RCC treated with PCA from 2008 to 2021. Data collected included age, sex, tumor diameter, RENAL nephrometry score, technical success, adverse events (AEs), changes in serum creatinine, local control, and recurrence rates. A p value of 0.05 was considered the threshold for statistical significance. RESULTS: 13 patients with 13 RCCs (mean age: 72.7 ± 10.4; 54% male) and 35 patients with 37 RCCs (mean age: 66.7 ± 10.6; 60% male) were included in the TAE + PCA and PCA groups, respectively. The TAE + PCA group had larger mean tumor diameter (5.7 ± 1.1 cm vs. 4.7 ± 0.6 cm; p < 0.0001) and higher mean RENAL nephrometry score (8.9 ± 1.1 vs. 7.8 ± 1.5; p = 0.02). There were no differences between the groups with respect to technical success of PCA (p = 0.46), local tumor control (p = 0.3), or mean number of procedures to achieve local tumor control (p = 0.85). Mean increase in serum creatinine was not significantly different between the two groups (p = .63). Major AEs were similar between the groups (p = 1); however, the TAE + PCA group had no major hemorrhagic AEs while the PCA alone group had three (8.3%). CONCLUSION: TAE + PCA in patients with T1b or T2 RCC is technically feasible without significant added detriment to renal function. This combined approach may help to reduce hemorrhagic AEs but larger patient cohorts are needed.

Antibiotics Tubes and Lines.

Antibiotic prophylaxis in interventional radiology (IR) is widely used; however, such practice is based on data from the surgical literature. Although published guidelines can help determine the need for prophylactic antibiotic use in the patient undergoing percutaneous procedures, local practice patterns often dictate when such medications are given. In this article, the current state of periprocedural antibiotic use in commonly performed IR procedures (i.e., tube and catheter placements) is presented.

Nononcologic Embolization.

The scope of conditions managed by embolization, which was initially used for the treatment of hemorrhage and vascular malformations, is constantly expanding. Apart from oncologic indications, embolization is used to treat a wide range of benign pathology, including uterine fibroids and benign prostatic hyperplasia. While various particulate embolic agents are successfully used for benign embolization, there is growing evidence that unique properties of these may result in different outcomes. This article reviews available evidence comparing various particles used for uterine fibroid embolization and prostate artery embolization. In addition, we provide an overview of periprocedural pharmacology and protocols facilitating same-day discharge for these interventions.

Portal Interventions in the Setting of Venous Thrombosis or Occlusion.

Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.

Radiological correlation of mechanism of intravascular migration of the ventriculoperitoneal shunt and technical considerations for endovascular retrieval.

Migration of ventriculoperitoneal shunt into the pulmonary artery is a rare complication that can lead to shunt malfunction and cardiopulmonary complications. This case illustrates the significance of accidental transvenous placement of the shunt. Identification of the transvenous course of the catheter on cross sectional imaging can predict future catheter migration and also aid at surgical extraction. Formation of knot within the distal portion of the shunt catheter during migration or endovascular retrieval can occur, therefore measures to retrieve with knot and adhesions should be factored in before.

Intrahepatic renal cell carcinoma implantation along a percutaneous biopsy and cryoablation probe tract.

A man in his 60s underwent percutaneous biopsy and cryoablation of a right upper pole clear cell renal cell carcinoma followed by repeat cryoablation 8 months later for possible residual disease. The patient was followed with imaging with documented stability for 19 months after repeat ablation. However, imaging at 32 months demonstrated intrahepatic nodular enhancing lesions along the initial percutaneous biopsy and ablation tract, consistent with metastatic implantation. The patient underwent repeat percutaneous biopsy and two rounds of microwave ablation for treatment of the intrahepatic implants, with no residual disease at 10 months postablation. While needle tract seeding is a known complication of percutaneous manipulation of various abdominopelvic malignancies, there have been no prior reports of intrahepatic metastatic implants related to percutaneous renal cell carcinoma ablation. Awareness of this potential complication is important for treatment planning, informed consent and surveillance. This report shares our experience of the management of intrahepatic metastatic implants.

Effect of a dedicated inferior vena cava filter retrieval program on retrieval rates and number of patients lost to follow-up.

PURPOSE We aimed to assess the efficacy of a dedicated inferior vena cava (IVC) filter retrieval program on filter retrieval rates and number of patients lost to follow-up. METHODS A dedicated IVC filter retrieval program began in July 2016. This consisted of tracking all patients with retrievable filters placed by interventional radiology (IR). At the time of filter placement, patients were scheduled for a retrieval consult in the IR clinic. Any missed appointments were followed up by a physician assistant. The program was overseen by a single IR physician. To assess this program's efficacy, we reviewed the records of all patients who had retrievable IVC filters placed by IR nine months prior to and nine months after program initiation. Demographics and clinical factors were then collected and compared. A P value of < 0.05 was considered statistically significant. RESULTS Prior to the program, 76 patients (31 males, 45 females; mean age, 64.2 years) had retrievable filters placed; 75% were placed due to a contraindication to anticoagulation. From this group, five filters were removed (6.6%), 42 patients were lost to follow-up (55.3%), 22 patients died (29.0%), and seven filters were deemed permanent by a physician after placement (9.2%). All five retrievals were successful and no complications were reported. After program initiation, 106 patients (59 males, 47 females; mean age, 58.8 years) had retrievable filters placed; 75.5% were placed due to a contraindication to anticoagulation. In this group, 30 filters were retrieved (retrieval rate 28.3%), 17 patients were lost to follow-up (16%), 23 patients died (21.7%), 28 filters were deemed permanent by a physician after placement (26.4%), and decisions were still pending in eight patients (7.5%). One patient (3.3%) had a minor complication during filter retrieval. Initiation of a filter retrieval program increased our retrieval rate (6.6% vs. 28.3%; P < 0.001) and reduced the number of patients with filters that were lost to follow-up (55.3% vs. 16%; P < 0.001). CONCLUSION Dedicated filter retrieval program is effective in increasing filter retrieval rates and decreasing the number of patients lost to follow-up.

Percutaneous Cryoablation of Stage T1b Renal Cell Carcinoma: Safety, Technical Results, and Clinical Outcomes.

PURPOSE: The use of percutaneous cryoablation for T1b (4.1-7.0 cm) renal cell carcinoma, has not yet been widely adopted. The purpose of this study was to describe our experience in the cryoablation of stage T1b tumors with an emphasis on safety, technical results, and clinical outcomes. MATERIALS AND METHODS: A retrospective review of hospital records identified 37 patients who underwent cryoablation for T1b lesions from 2008 to 2018. Patient demographics, comorbidities, tumor characteristics, technical parameters, and outcomes were recorded and analyzed. Recurrence-free, overall, and cancer-specific survival rates were estimated using the Kaplan-Meier method. RESULTS: Thirty-seven patients (22 males, 15 females; mean age 66.5 ± 11.3) with 37 T1b tumors (mean diameter 47.3 ± 6.3 mm) were included. A median of 3 probes were used (range: 1-7). Angio-embolization was used in 3/37 (8.1%) and 2/37 patients (5.4%) required hydrodissection. The mean number of total cryoablation procedures for each patient was 1.5 (median 1; range: 1-4). Technical success was achieved in 88.2% of patients. Recurrence-free survival was 96.5%, 86.1%, and 62.6% at 1, 2, and 3 years respectively. Cancer-specific survival was 100% at 1, 2, and 3 years respectively. Overall survival was 96.7%, 91.8%, and 77.6% at 1, 2, and 3 years respectively. Complications classified as CIRSE grade 2 or higher occurred in 6/37 (16.2%) patients. CONCLUSION: T1b cryoablation is associated with high rates of technical success, excellent cancer-specific survival, and an acceptable safety profile. LEVEL OF EVIDENCE: Level 4, Case Series.

May-Thurner Syndrome.

This single-center, retrospective review identified 6 patients (n = 6, 100% female) treated by endovascular therapy for May-Thurner syndrome from June 2013 to September 2015. Patients consisted of 3 African American, 2 Caucasian and 1 Asian; mean age was 53.50 ± 8.31 years, range: 39-63 years. Clinical presentations consisted of left lower extremity deep vein thrombosis in 4, left lower extremity deep vein thrombosis with pulmonary embolism in 1 and pulmonary embolism with left common iliac vein thrombosis in 1 patient. All 6 patients were treated with catheter-directed thrombolysis and venous stenting to correct the underlying anatomical defect. Hypercoagulability work up revealed antiphospholipid antibody syndrome in 1 patient. No major periprocedural complications were observed. Median follow-up period was 22 ± 5.5 months (range: 13-30 months). One patient with pre-exiting antiphospholipid antibody syndrome developed stent thrombosis with secondary loss of patency. Endovascular therapy for May-Thurner syndrome in our adult cohort seemed safe and effective. One patient with pre-existing thrombophilia developed secondary loss of stent patency, suggesting need for further investigation in this subgroup.

Focal Hepatic Glycogenosis in a Patient With Uncontrolled Diabetes Mellitus Type 1.

Hepatomegaly and elevated liver enzymes in patients with diabetes are commonly associated with fatty liver disease. However, physicians often forget about another intrinsic substance that can cause a similar clinical picture-glycogen. Liver stores approximately one third of the total body glycogen and is responsible for blood glucose homeostasis. Excessive hepatocellular glycogen accumulation occurs not only in congenital glycogen storage diseases, but also in acquired conditions associated with hyperglycemic-hyperinsulinemic states such as uncontrolled diabetes mellitus, high-dose corticosteroid use, and dumping syndrome. All reported cases of acquired abnormal glycogen deposition described a diffuse form of hepatic glycogenosis with the entire liver involved in the accumulating process. To our knowledge, this is the first reported case of abnormal focal glycogen deposition in a patient with diabetes mellitus type 1 with imaging and pathologic correlation. Awareness of the imaging appearance of focal glycogen deposition can help to distinguish it from other pathologic conditions.

Role of Optimal Quantification of FDG PET Imaging in the Clinical Practice of Radiology.

The combination of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and computed tomography (CT) for dual-modality imaging (PET/CT) plays a key role in the diagnosis and staging of FDG-avid malignancies. FDG uptake by the tumor cells offers an opportunity to detect cancer in organs that appear normal at anatomic imaging and to differentiate viable tumor from posttreatment effects. Quantification of FDG uptake has multiple clinical applications, including cancer diagnosis and staging. Dedicated FDG PET/CT-based visual and quantitative criteria have been developed to evaluate treatment response. Furthermore, the level of tumor FDG uptake reflects the biologic aggressiveness of the tumor, predicting the risk of metastasis and recurrence. FDG uptake can be measured with qualitative, semiquantitative, and quantitative methods. Qualitative or visual assessment of PET/CT images is the most common clinical approach for describing the level of FDG uptake. Standardized uptake value (SUV) is the most commonly used semiquantitative tool for measuring FDG uptake. SUV can be measured as maximum, mean, or peak SUV and may be normalized by using whole or lean body weight. SUV measurements provide the basis for quantitative response criteria; however, SUVs have not been widely adopted as diagnostic thresholds for discriminating malignant and benign lesions. Volumetric FDG uptake measurements such as metabolic tumor volume and total lesion glycolysis have shown substantial promise in providing accurate tumor assessment. SUV measurement and other quantification techniques can be affected by many technical, physical, and biologic factors. Familiarity with FDG uptake quantification approaches and their pitfalls is essential for clinical practice and research.

Two bullets to the head and an early winter: fate permits Kutuzov to defeat Napoleon at Moscow.

General Mikhail Kutuzov (circa 1745-1813) brilliantly repelled Napoleon's invasion of Russia. Honored as a national hero and a savior of Russia, Kutuzov has a unique medical story. He was shot in the head twice while fighting the Turks (1774 and 1788) and survived the serious injuries seemingly against all odds. The first bullet "ran through the head from one temple to the other behind both eyes." The second bullet entered the cheek, destroyed upper teeth, traveled through the head, and exited the occiput. Massot, a French surgeon with the Russian army, wrote after treating Kutuzov's seemingly two mortal wounds: "It must be believed that fate appoints Kutuzov to something great, because he was still alive after two injuries, a death sentence by all the rules of medical science." Aided by Massot's expert surgical technique, Kutuzov lived to become intimately engaged in events that altered world history. His health did, however, suffer significant effects due to the bullet wounds. In 1812, as Napoleon's Grande Armée approached, Kutuzov realized he could not confront Napoleon and he strategically retreated from Moscow, submitting the French to the harsh winter and Russian cavalry. Napoleon's devastated army retreated to Paris, and Kutuzov became the personification of Russian spirit and character. Kutuzov's survival of two nearly mortal head wounds created the legends, additional mystery, and drama surrounding him, not the least astonishing of which was the skilled neurosurgical care that probably saved his life.