Diagnostic reference levels and complexity indices in interventional radiology: a national programme.

OBJECTIVES: To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses. METHODS: Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values. RESULTS: The KAP (3rd quartile) in Gy cm2 for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4. CONCLUSIONS: The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology. KEY POINTS: • National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

[Embolotherapy of pulmonary arteriovenous malformations: long-term clinical and radiological follow-up]. / Embolización de malformaciones arteriovenosas pulmonares: seguimiento clinicorradiológico a largo plazo.

Pulmonary arteriovenous malformations (PAVM) are abnormal communications between the pulmonary arteries and pulmonary veins. The large majority are congenital and are commonly associated with Rendu-Osler-Weber disease or hereditary haemorrhagic telangiectasia. The PAVM may remain asymptomatic or manifest with hypoxemia, hemoptysis, hemothorax and/or neurologic symptoms. Despite its low incidence, the PAVM represent a serious entity that must be taken into account since untreated patients are in risk and present a poor prognosis. Transcatheter embolization with coils or detachable balloons is currently accepted as the treatment of choice. We present 6 patients (5 women and one man) who underwent embolotherapy of PAVM showing the long-term clinical and radiological follow-up.

Embolización de malformaciones arteriovenosas pulmonares: seguimiento clinicorradiológico a largo plazo / Embolotherapy of pulmonary arteriovenous malformations: long-term clinical and radiological follow-up

Las malformaciones arteriovenosas pulmonares (MAVP) son comunicaciones directas entre arterias y venas pulmonares sin lecho capilar normal entre ellos. La mayoría son congénitas y se asocian al síndrome de Rendu-Osler-Weber o telangiectasia hemorrágica hereditaria. Clínicamente pueden ser silentes o cursar con hipoxemia, hemoptisis, hemotórax y/o síntomas neurológicos por un mecanismo de embolia paradójica. A pesar de su baja incidencia, presentan un gran interés por el riesgo que suponen para el paciente no tratado. La terapia de elección en la actualidad es el tratamiento endovascular mediante embolización con coils o balones largables. Se presentan 6 pacientes (5 mujeres y un varón) con MAVP tratados en nuestro centro mediante embolización con coils y se muestra el seguimiento clinicorradiológico a largo plazo (AU)

Pulmonary arteriovenous malformations (PAVM) are abnormal communications between the pulmonary arteries and pulmonary veins. The large majority are congenital and are commonly associated with Rendu-Osler-Weber disease or hereditary haemorrhagic telangiectasia. The PAVM may remain asymptomatic or manifest with hypoxemia, hemoptysis, hemothorax and/or neurologic symptoms. Despite its low incidence, the PAVM represent a serious entity that must be taken into account since untreated patients are in risk and present a poor prognosis. Transcatheter embolization with coils or detachable balloons is currently accepted as the treatment of choice. We present 6 patiens (5 women and one man) who underwent embolotherapy of PAVM showing the long-term clinical and radiological follow-up (AU)

[Transient ischemic attack as the presenting symptom of a pulmonary arteriovenous fistula]. / Accidente isquémico transitorio como forma de presentación de una fístula arteriovenosa pulmonar.

INTRODUCTION: Transient ischemic attacks (TIA) occur as the clinical manifestation of a pulmonary arteriovenous malformation in up to 20% of cases. CASE REPORT: We report the case of a 41-year-old female with an episode of TIA lasting half an hour, with right-side hemiparesis caused by a paradoxical embolisation due to the presence of a single pulmonary arteriovenous fistula (PAVF). Complementary analytical and imaging tests (CAT scan of the head without contrast, brain RMI and intra and extracranial MR-angiography) were normal. A transthoracic echocardiogram showed the presence of a patent foramen ovale which obstructed the passage of hemoce, although it was observed in the left auricle after presumably arriving through the pulmonary arteries. Since a pulmonary vascular malformation was suspected, a computerised tomographic angiography scan of the thorax was performed and this confirmed the presence of a single PAVF in the right lung. A pulmonary arteriography was then carried out to confirm the presence of the malformation, which was later embolised. Two months later, the patient was asymptomatic and the fistula did not appear in the computerised tomographic angiography scan of the thorax. CONCLUSIONS: PAVFs can give rise to neurological conditions due to paradoxical embolisms that can produce abscesses and infarcts and/or concomitant lesions in the central nervous system. This is a certain indication of treatment of the malformation and the preferred technique is endovascular embolisation with coils, while surgery is reserved for cases in which endovascular treatment is not possible.

Accidente isquémico transitorio como forma de presentación de una fístula arteriovenosa pulmonar / Transient ischemic attack as the presenting symptom of a pulmonary arteriovenous fistula

Introducción. Los accidentes isquémicos transitorios (AIT) como manifestación clínica de una malformación arteriovenosa pulmonar aparecen hasta en un 20% de los casos. Caso clínico. Se trata de una mujer de 41 años con un episodio de AIT de media hora de duración con hemiparesia derecha, debido a una embolización paradójica por la presencia de una fístula arteriovenosa pulmonar (FAVP) única. Las pruebas complementarias analíticas y de imagen (TC craneal sin contraste, RM cerebral y angiorresonancia intracraneal y extracraneal) fueron normales. El estudio con ecocardiograma transesofágico mostraba la presencia de un foramen oval sellado por el que no pasaba el hemocé, aunque sí se observaba en la aurícula izquierda, a la que llegaba, presumiblemente, a través de las arterias pulmonares. Ante la sospecha de una malformación vascular pulmonar se realizó una angiotomografía computarizada (ATC) de tórax, que confirmó la presencia de una FAVP única en el pulmón derecho. Posteriormente se le practicó una arteriografía pulmonar, que confirmó la presencia de la malformación, y se embolizó posteriormente. Dos meses después la paciente estaba asintomática y la ATC de tórax no mostraba la fístula. Conclusiones. Las FAVP son una causa de clínica neurológica debido a embolismos paradójicos, que pueden producir abscesos e infartos y/o lesiones concomitantes en el sistema nervioso central, lo cual es una indicación absoluta de tratamiento de la malformación. Para ello, la técnica de elección es la embolización endovascular con espirales. La cirugía se reserva para cuando el tratamiento endovascular no sea posible

Introduction. Transient ischemic attacks (TIA) occur as the clinical manifestation of a pulmonary arteriovenous malformation in up to 20% of cases. Case report. We report the case of a 41-year-old female with an episode of TIA lasting half an hour, with right-side hemiparesis caused by a paradoxical embolisation due to the presence of a single pulmonary arteriovenous fistula (PAVF). Complementary analytical and imaging tests (CAT scan of the head without contrast, brain RMI and intra and extracranial MR-angiography) were normal. A transthoracic echocardiogram showed the presence of a patent foramen ovale which obstructed the passage of hemoce, although it was observed in the left auricle after presumably arriving through the pulmonary arteries. Since a pulmonary vascular malformation was suspected, a computerised tomographic angiography scan of the thorax was performed and this confirmed the presence of a single PAVF in the right lung. A pulmonary arteriography was then carried out to confirm the presence of the malformation, which was later embolised. Two months later, the patient was asymptomatic and the fistula did not appear in the computerised tomographic angiography scan of the thorax. Conclusions. PAVFs can give rise to neurological conditions due to paradoxical embolisms that can produce abscesses and infarcts and/or concomitant lesions in the central nervous system. This is a certain indication of treatment of the malformation and the preferred technique is endovascular embolisation with coils, while surgery is reserved for cases in which endovascular treatment is not possible

[Spontaneous subcapsular hepatic hematoma]. / Hematoma subcapsular hepático espontáneo.

PIP: A case of subcapsular hematoma in a 31-year old woman who had taken oral contraceptives (OCs) for 10 years is described. The woman presented with a painful hepatomegaly immediately after giving birth to twins. The symptons, diagnostic findings, and laboratory test results are given, and X-ray films are reproduced. The interest of the case lies in the fact that 2 factors hypothetically related to this anomaly were present: continuous ingestion of OCs and pregnancy. The echographic image demonstrated a mass of heterogeneous consistency with an alternating liquid-solid content. The diagnosis was confirmed through an arteriograph that revealed the presence of other lesions. The presence of the subcapsular hematoma was confirmed at laparotomy but no macroscopically responsible lesion was found, causing the surgeon not to take a hepatic biopsy.^ieng