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.

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.

Retroperitoneoscopic nephrectomy with a modified hand-assisted approach.

OBJECTIVES: To present the first experience with a 3-port technique for retroperitoneoscopic (HARP) radical nephrectomy, radical nephroureterectomy, and total and live donor nephrectomy. We believe that the retroperitoneoscopic (RP) approach to nephrectomy is advantageous, as it avoids mobilization of intraperitoneal organs and provides direct access to the renal artery. Nonetheless, this approach is not as popular as the transperitoneal approach, likely because of the steeper learning curve. We believe that hand-assistance reduces the learning curve because of the tactile feedback and similarity to open surgery. METHODS: Over a 4-year period, 133 HARP nephrectomies were performed, including 92 radical nephrectomies, 19 radical nephroureterectomies, 12 total nephrectomies, and 10 live donor nephrectomies. Mean patient age was 62 years and mean body mass index was 30; 42% of patients had abdominal scars. Our technique uses a 7-cm muscle-sparing Gibson incision for the hand-port with 2 endoscopic ports. RESULTS: Mean operative time, including ureterectomy, was 109 minutes, with a mean operative blood loss of 167 mL. Average hospitalization was 3.8 days. Two cases (1.5%) required open conversion. The complication rate was limited to 3.8% for blood transfusion, 3.8% for cardiac issues, 1.5% for pulmonary embolism, 2.3% for wound infection, and 1.5% for urinary retention. CONCLUSIONS: Based on our results, we conclude that HARP nephrectomy is safe and effective and can be expeditiously performed. It is a versatile approach that is applicable for both neoplastic and non-neoplastic indications. In addition, HARP provides a minimally invasive alternative to open conversion in difficult cases of simple nephrectomy.

Notalgia paresthetica associated with cervical spinal stenosis and cervicothoracic disk disease at C4 through C7.

Notalgia paresthetica (NP) is a common refractory, sensory, neuropathic syndrome with the hallmark symptom of localized pruritus of the unilateral infrascapular back. It generally is a chronic noncurable condition with periodic remissions and exacerbations. While the dermatologic syndrome may be multifactorial in etiology, a possible association with underlying cervical spine disease should be evaluated for proper treatment. Collaborative multispecialty evaluation by dermatology, radiology, orthopedic surgery, and neurology may be indicated for primary management of this condition. First-line therapy for NP with associated cervical disease may include nondermatologic noninvasive treatments such as spinal manipulation, physical therapy, massage, cervical traction, cervical muscle strengthening, and oral nonsteroidal anti-inflammatory drugs and muscle relaxants. Notalgia paresthetica may in fact be a cutaneous sign of an underlying degenerative cervical spine disease. We report a case of a patient with cervical spinal stenosis that corresponded directly with the clinical findings of NP.

Treatment of bilateral hand frostbite using transcatheter arterial thrombolysis after papaverine infusion.

Standard therapy for frostbite has been unaltered for more than 20 years. Recently there have been reports of improved outcomes with the addition of a vasodilator to intra-arterial thrombolytic therapy. We report the case of severe frostbite of the hands successfully treated with transcatheter intra-arterial tPA after papaverine infusion in a 37-year-old man. Upper extremity and hand angiography within 16 h of the insult showed thrombotic occlusive disease and vasospasm. Intra-arterial catheters were placed in the brachial arteries and a papaverine infusion was initiated, followed by intra-arterial tPA thrombolysis. Follow-up examination at 4 months revealed full hand function and complete resolution of symptoms.

Injectables in the prostate.

PURPOSE OF REVIEW: Benign prostatic hyperplasia with associated symptoms and morbidity is increasingly common among aging men. Medical treatment of lower urinary tract symptoms is the mainstay of therapy with progressive disease requiring more invasive intervention. Transurethral resection of the prostate remains a widely applied gold standard therapy. Numerous minimally invasive surgical therapy options have arisen and subsequently faded over recent years. Those remaining in use are largely positioned between pharmacological treatment and transurethral resection of the prostate. Intraprostatic injection therapy, the oldest minimally invasive surgical therapy, has been investigated for over 100 years with renewed interest recently. This review will provide some history of intraprostatic injection for benign prostatic hyperplasia including the most recent reports using transperineal, transrectal and transurethral routes with different injectables. RECENT FINDINGS: For benign prostatic hyperplasia, transperineal and transurethral injection routes have received the most systematic evaluation. Intraprostatic injection of botulinum toxin type A has received much recent attention with regards to mechanism of action and efficacy. Anhydrous ethanol remains the most extensively studied injectable to date. SUMMARY: Injection therapy remains a very promising minimally invasive surgical therapy for benign prostatic hyperplasia with increased attention from the urologic community in recent years. Further experience both with systematic laboratory and clinical trials investigation will be necessary before widespread clinical adoption.

Injection therapy for prostatic disease: A renaissance concept.

PURPOSE: Initially conceived as an intervention for prostatic infection, injection therapy has been used to alleviate urinary retention, and is now primarily investigated for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). For over a century, intraprostatic injection has been used as a minimally invasive surgical therapy (MIST), and is on the verge of a rebirth. This review will familiarize the reader with the origins and history of intraprostatic injection, and its evolution using transperineal, transrectal and transurethral routes with multiple injectants. MATERIALS AND METHODS: A MEDLINE review of the literature on intraprostatic injections published between 1966 and 2007 was performed, augmented with articles and documents dating back to 1832. RESULTS: Transperineal and transurethral injections have the most systematic evaluation in patients. There are advantages and disadvantages associated with each route. Most injectants consistently produce localized coagulative necrosis and gland volume reduction with varying degrees of LUTS relief. Anhydrous ethanol (AE) is the most extensively studied injected agent to date. CONCLUSIONS: Injection therapy is a promising minimally invasive treatment option for various prostatic conditions and has been examined for over 100 years. Further experience in systematic laboratory research and completion of currently ongoing clinical trials is necessary before widespread clinical application.