Initial series of magnetic resonance imaging (MRI)-fusion targeted prostate biopsy using the first transperineal targeted platform available in the USA.

OBJECTIVES: To describe a step-by-step guide for using the first transperineal targeted prostate biopsy platform available in the USA. PATIENTS AND METHODS: A total of 32 men with elevated prostate-specific antigen (PSA) levels were diagnosed with a region of interest on multiparametric magnetic resonance imaging (mpMRI) between February 2017 and January 2018. The transperineal targeted prostate biopsy procedure was accomplished via a transperineal approach and used a stepper, combined with advanced mpMRI/transrectal ultrasound fusion software, to perform targeted prostate biopsy. The detection of overall and clinically significant prostate cancer (PCa) was assessed as well as the rate of complications. RESULTS: The median patient age was 68.0 years and the median PSA was 8.0 ng/mL. Two patients (6%) were active surveillance candidates and 16 (50%) had a prior negative prostate biopsy. The detection rates for overall and clinically significant PCa were 81% and 59%, respectively. The two candidates for active surveillance and eight of the patients with a prior negative prostate biopsy had clinically significant PCa confirmed on targeted biopsy. There were no peri-operative complications. CONCLUSION: These results demonstrate the promising potential of the first transperineal targeted prostate biopsy platform in the USA as an alternative diagnostic method for PCa.

Checklists for Image-Guided Interventions.

OBJECTIVE: Checklists are tools commonly used to help confirm that certain tasks of a process are completed. Within the health care industry, medical checklists are recognized as a means to improve patient safety. CONCLUSION: Recent application of checklists to image-guided interventions has shown positive outcomes; however, there are limited published studies. We review the literature regarding checklist use as a safety measure and focus on implementation of checklists for image-guided interventions.

MRI-Guided Prostate Interventions.

OBJECTIVE: The objective of this study is to discuss the use of MRI-guided and MRI-directed prostate biopsy techniques, describe how interventional MRI focal therapies are used for the treatment of prostate cancer, and predict future directions in prostate interventional MRI. The prospect of establishing a center for prostate imaging, diagnosis, and treatment is also discussed. CONCLUSION: Low- or intermediate-risk prostate cancer can be safely treated with MRI-compatible devices and techniques such as biopsy, cryoablation, high-intensity focused ultrasound, or focal laser ablation performed from a transrectal or transperineal approach. Although the long-term effectiveness of focal therapy for prostate cancer is unknown, the effect on urinary or sexual function is extremely low. These procedures are attracting an increasing number of men who view focal therapies as a better alternative to the uncertainty of no therapy and the more radical whole-gland surgical and radiation therapies with their higher complication rates.

Venous access ports: indications, implantation technique, follow-up, and complications.

The subcutaneous venous access device (SVAD or "port") is a critical component in the care of patients with chronic disease. The modern SVAD provides reliable access for blood withdrawal and medication administration with minimal disruption to a patient's lifestyle. Because of improved materials and catheter technology, today's ports are lighter and stronger and capable of high-pressure injections of contrast for cross-sectional imaging. The majority of SVAD placement occurs in interventional radiology departments due to their ability to provide this service at lower costs, lower, complication rates, and greater volumes. Port-insertion techniques vary depending on the operator, but all consist of catheter placement in the central venous circulation followed by subcutaneous pocket creation and port attachment to the catheter with fixation and closure of the pocket. Venous access challenges occasionally occur in patients with central vein occlusions, necessitating catheterization of collateral veins or port placement in alternate locations. Complications of SVADs include those associated with the procedure as well as short- (<30 days) and long-term problems. Procedural and early complications are quite rare due to the near-universal use of real-time ultrasound guidance for vein puncture, but they can include hematoma, catheter malposition, arrhythmias, and pneumothorax. Late problems include both thrombotic complications (native venous or port-catheter thrombosis) and infections (tunnel or pocket infections or catheter-associated bloodstream infections). Most guidelines suggest that 0.3 infections/1000 catheter days is an appropriate upper threshold for the insertion of SVADs.

Extrahepatic portal biliopathy: proposed etiology on the basis of anatomic and clinical features.

PURPOSE: To compare the anatomic and clinical features in patients with chronic portal vein thrombosis (PVT) to determine why some patients develop portal biliopathy (PB) while most do not and propose an etiology for PB. MATERIALS AND METHODS: This project satisfied HIPAA regulations and received institutional review board approval for a retrospective review without the need for consent. From 100 patients with PVT, 60 were extracted who had chronic, nonmalignant PVT, after exclusion of those with sclerosing cholangitis, liver transplants, choledocholithiasis, or portosystemic shunts. Clinical and imaging data from 19 patients with biliary dilatation (PB group) were compared with data from 41 patients without biliary dilatation (no-PB group). Statistical analysis was performed with the Fisher exact test for categorical variables or the Wilcoxon rank-sum test for numerical and ordered categorical variables. P values of .05 or less were considered to indicate a significant difference. RESULTS: The etiology of PVT differed between the groups (P < .001); cirrhosis was infrequently seen in the PB group (two of 19, 11%) but was common in the no-PB group (31 of 41, 76%). Only two of 33 (6%) patients with cirrhosis and PVT had PB. Extension of PVT into the mesenteric veins was significantly more common in the PB group (18 of 19, 95%) than in the no-PB group (one of 41, 2%) (P < .001). Compared with the no-PB group, patients in the PB group had more acute angulation of the bile duct (median, 110° vs 128°; P = .008), less frequent gastroesophageal varices (three of 19 [16%] vs 20 of 41 [49%], P = .021), and a smaller mean coronary vein diameter (median, 5 vs 6 mm; P = .014). CONCLUSION: Noncirrhotic patients with hypercoagulable states tend to develop PB when PVT extends to the splenomesenteric veins. A possible etiology is the formation of specific peribiliary venous pathways responsible for bile duct compression and tethering.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac.

PURPOSE: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. CASE REPORT: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. CONCLUSION: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Pancreas transplant venous thrombosis: role of endovascular interventions for graft salvage.

Venous thrombosis of pancreas transplant allografts often leads to graft loss. We evaluated the efficacy of emergent endovascular techniques to salvage thrombosed pancreatic allografts in a series of six patients. Of the 76 pancreas transplants performed between 2002 and 2006, six patients were diagnosed with venous thrombosis on MRI between 2 and 28 days posttransplant (mean, 9 days). Five patients were systemic-enteric (donor portal vein anastomosis to recipient iliac vein) and one patient was portal-enteric (donor portal vein anastomosis to recipient superior mesenteric vein). Conventional venography confirmed the diagnosis of venous thrombosis in all patients. One patient was treated with catheter-directed venous thrombolysis and balloon thrombectomy. Another patient was treated with rheolytic thrombectomy alone. The remaining four patients were treated with a combination of these mechanical and thrombolytic techniques. Completion venography revealed >50% clot reduction and resumption of venous drainage in all patients. One patient required additional intervention 16 days later for recurrent thrombosis. Two patients required metal stent placement for anastomotic stenoses or kinks. One patient required pancreatectomy 36 h after attempted salvage secondary to a major hemorrhage and graft necrosis. Two patients recovered pancreatic function initially but lost graft function at 8 and 14 months, respectively, from severe chronic rejection. Patient survival was 100%, long-term graft survival was 50%, rethrombosis rate was 16.6%, and graft loss from rejection was 33%. In conclusion, early recognition and treatment of venous thrombosis after pancreas transplantation has acceptable morbidity and no mortality using short-term endovascular pharmacomechanical therapy.

Preoperative portal venous and hepatic arterial embolization of tumor.

Although the goal of embolization is usually to create therapeutic ischemia or hemostasis without surgery, the rationale for preoperative embolotherapy is different in several respects. First, the aim is to prepare patients for definitive surgical resection rather than cure or palliation, and, thus, the goals and expectations are limited and defined by close communication between the interventionalist and the surgeon. Second, when considering segmental resection, the normal liver should be protected from procedural damage. Third, the search for extrahepatic disease is crucial for these patients because resection is typically abandoned in favor of alternative therapies for patients with systemic disease. Finally, intraoperative ultrasound should always be considered to survey the future liver remnant for unsuspected small tumors and allow ablation of these lesions to maximize the success of partial hepatectomy. This article describes preoperative hepatic arterial and portal venous embolization in patients with or without cirrhosis complicated by tumors judged eligible for surgical resection or orthotopic liver transplantation (OLT). Each type of embolization will be reviewed in terms of indications and contraindications, technique, and complications. Finally, the outcomes will be evaluated in terms of morbidity, mortality, and tumor recurrence rates.

Spontaneous hepatic hemorrhage in older women.

Spontaneous liver hemorrhage in older women is not well described. We report an experience with five postmenopausal women who spontaneously bled from the liver. All five patients presented with acute bleeding. Four were treated nonoperatively. No tumor was identified in any patient. Four patients acutely were discharged alive and well, but one died after operation to control bleeding. Spontaneous liver hemorrhage can occur in a variety of clinical settings, but an association with older women taking hormone replacement and anticoagulation has not been reported.

Percutaneous protective coil occlusion of the proximal inferior mesenteric artery before N-butyl cyanoacrylate embolization of type II endoleaks after endovascular repair of abdominal aortic aneurysms.

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Fatal hemorrhage secondary to ulcerated epiphrenic pseudodiverticulum.

A 47-year-old man was found unconscious after experiencing severe hematemesis. He had a history of alcohol abuse, hepatic cirrhosis, and previous episodes of gastrointestinal bleeding. Imaging studies indicated that the left gastric artery was the probable source of bleeding. A severe coagulopathy was also noted clinically. Angiographic embolization of the left gastric artery failed to staunch bleeding, and the patient died shortly after admission. Autopsy demonstrated a large, ulcerated epiphrenic esophageal pseudodiverticulum, the base of which was in close proximity to an esophageal branch of the left gastric artery. Cystic dilatation of adjacent esophageal submucosal glands was also seen. Gelatin embolic material, without associated thrombus formation, was found within the left gastric artery. Esophageal pseudodiverticulosis is an uncommon disorder that may be associated with dysphagia, stricture, and odynophagia. Bleeding and perforation are very rare complications. This case may be the first fatality proven by autopsy to be secondary to esophageal pseudodiverticulosis.

Transjugular portosystemic shunt in chronic portal vein occlusion: importance of segmental portal hypertension in cavernous transformation of the portal vein.

The authors describe a patient with bleeding varices due to chronic portal vein occlusion. A transjugular intrahepatic portosystemic shunt (TIPS) attempt failed because of cannulation of a low-pressure network of portal veins, which communicated only with the chronically thrombosed native portal vein. A second TIPS attempt was successful after transhepatic catheterization of a high-pressure portal system that was continuous with periportal collateral veins and mesenteric veins. After 8 months and one TIPS revision for hepatic vein stenosis, the patient has improved liver function, collapsed varices, and a patent TIPS on ultrasonogram. This case illustrates that cavernous transformation of the portal vein may result in variable intrahepatic portal perfusion and pressures and that TIPS in such cases requires careful selection of an intrahepatic portal vein to achieve adequate portal decompression.

Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration.

PURPOSE: To compare the clinical outcome of needle aspiration versus percutaneous catheter drainage of sterile fluid collections in patients with acute pancreatitis. METHODS: We reviewed the clinical and imaging data of patients with acute pancreatic fluid collections from 1998 to 2003. Referral for fluid sampling was based on elevated white blood cell count and fevers. Those patients with culture-negative drainages or needle aspirations were included in the study. Fifteen patients had aspiration of 10-20 ml fluid only (group A) and 22 patients had catheter placement for chronic evacuation of fluid (group C). We excluded patients with grossly purulent collections and chronic pseudocysts. We also recorded the number of sinograms and catheter changes and duration of catheter drainage. The CT severity index, Ranson scores, and maximum diameter of abdominal fluid collections were calculated for all patients at presentation. The total length of hospital stay (LOS), length of hospital stay after the drainage or aspiration procedure (LOS-P), and conversions to percutaneous and/or surgical drainage were recorded as well as survival. RESULTS: The CT severity index and acute Ransom scores were not different between the two groups (p = 0.15 and p = 0.6, respectively). When 3 crossover patients from group A to group C were accounted for, the duration of hospitalization did not differ significantly, with a mean LOS and LOS-P of 33.8 days and 27.9 days in group A and 41.5 days and 27.6 days in group C, respectively (p = 0.57 and 0.98, respectively). The 60-day mortality was 2 of 15 (13%) in group A and 2 of 22 (9.1%) in group C. Kaplan-Meier survival curves for the two groups were not significantly different (p = 0.3). Surgical or percutaneous conversions occurred significantly more often in group A (7/15, 47%) than surgical conversions in group C (4/22, 18%) (p = 0.03). Patients undergoing catheter drainage required an average of 2.2 sinograms/tube changes and kept catheters in for an average of 52 days. Aspirates turned culture-positive in 13 of 22 patients (59%) who had chronic catheterization. In group A, 3 of the 7 patients converted to percutaneous or surgical drainage had infected fluid at the time of conversion (total positive culture rate in group A 3/15 or 20%). CONCLUSIONS: There is no apparent clinical benefit for catheter drainage of sterile fluid collections arising in acute pancreatitis as the length of hospital stay and mortality were similar between patients undergoing aspiration versus catheter drainage. However, almost half of patients treated with simple aspiration will require surgical or percutaneous drainage at some point. Disadvantages of chronic catheter drainage include a greater than 50% rate of bacterial colonization and the need for multiple sinograms and tube changes over an average duration of about 2 months.