Endovascular retrieval of a migrated covered stent from the pulmonary artery.

Stent migration is a rare but significant complication following endovascular procedures. Techniques for managing dislodged stents have included surgical, endovascular, and conservative approaches. This case details a patient who had a covered stent placed within the left renal vein which later migrated to the pulmonary artery causing damage to the tricuspid valve. The migrated stent was successfully removed using a percutaneous endovascular approach utilizing fluoroscopy and transesophageal echocardiogram guidance.

Transplant Hepatic Artery Complications.

Hepatic artery complications can be divided into 2 different categories, nonocclusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while nonocclusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.

Persistent Bleeding after Coil Embolization of a Pancreatic Transplant Pseudoaneurysm: Should Covered Stents Be the Primary Management?

Life-threatening arterial complications after pancreatic transplantation can be dire. Pseudoaneurysms can be challenging to treat. There are multiple strategies to treat such complications. We present a case of pancreatic pseudoaneurysm which was initially treated by coiling followed by subsequent covered stent placement for a more durable outcome. We advocate for a "stent first" approach to these lesions if feasible.

Acute decompensation of patient following an outpatient CT-guided needle biopsy: A case report.

A 74-year-old female with history of type 2 diabetes, hypertension, and uterine adenocarcinoma presented for CT-guided lung biopsy that was ultimately complicated by an arterial air embolus requiring intensive care. Systemic air embolism is a very rare event but can be devastating. Prompt recognition can be difficult due to an often-vague presentation but is essential and should be considered upon rapid deterioration of a patient's status following high risk procedures. Hyperbaric oxygen therapy is preferred; however, if this is unavailable, additional treatments are predominately supportive care with 100% supplemental oxygen, rapid volume expansion, and ionotropic medications as needed.

Paracentesis: Faster and easier using the RenovaRP® pump.

PURPOSE Paracentesis is commonly performed in interventional radiology practice, and large volume paracentesis (LVP) using wall suction can take up to an hour to complete, placing significant stress on room and resource time. As the number of LVP procedures performed by Interventional Radiologists continue to increase, this study was undertaken to analyze the impact of the RenovaRP® Paracentesis Management System (GI Supply) on procedure time and patient satisfaction. METHODS Between March 9, 2020 and May 29, 2020, procedural data and patient satisfaction was collected as part of a practice quality improvement project and retrospectively analyzed on 39 sequential paracenteses performed with wall suction prior to acquiring the RenovaRP® system and subsequently on 42 paracenteses performed with use of the device. RESULTS A substantially higher fluid flow rate was found using the RenovaRP® system compared to wall suction, 237.2 mL/min vs. 108.6 mL/min (P < .001). This resulted in a significant decrease in procedure room time from 53 min to 31 min (P < .001). There was associated improvement in the patient experience during paracentesis. CONCLUSION The RenovaRP® decreases procedure time for LVP with improvement in the patient experience during paracentesis.

Single Institution Outcome of Minimally Invasive Enterocutaneous Fistula Management Utilizing the Biodesign® Fistula Plug.

PURPOSE: To report the outcomes of the Biodesign Fistula Plug as an alternative treatment for enterocutaneous fistulae by presenting our institutional experience from 2013 to 2020. MATERIALS AND METHODS: A retrospective review of all attempted fistula closures utilizing the Biodesign Fistula Plug at a single institution from 2012 to 2020 was performed under IRB approval and in compliance with HIPAA. Patient demographics were obtained including age at the time of the procedure, etiology, location of the fistula, history of malignancy, prior chemotherapy or radiation, and history of prior surgery or other interventions. Patient follow-up was performed through 7/2020 to evaluate for fistula closure, complications, or subsequent treatments. RESULTS: There were 25 patients who underwent 35 Biodesign Fistula Plug placements. Of these, 7 procedures were successful, defined as closure of the fistula, and 28 procedures were unsuccessful, defined as persistent fistula output or requiring further intervention on the EC fistula. There were 7 major complications, SIR classification D = 3, E = 2 and F = 2. No statistically significant risk factors were found predicting fistula plug failure although there was a trend towards patients with malignancy having unsuccessful outcome (p = 0.057). The average number of procedures for patients with successful closure was 1.4 versus 4.22 for those with unsuccessful closure. The average time to plug failure was 27.8 days (range 3-163 days), and the average time to fistula closure following plug placement was 21.4 days (range 14-30). CONCLUSION: Enterocutaneous fistulae are complex and morbid with no good treatment options. These findings demonstrate the Biodesign Fistula Plug can be successful in select patients, however, should be used with great caution due to high rate of failure and complications including two patient deaths.

Extracellular Matrix Enterocutaneous Fistula Plugs Show Promise for Low-Flow Colocutaneous and Enterocutaneous Fistulae.

PURPOSE: To evaluate extracellular matrix enterocutaneous fistula plugs (ECMFPs) in treatment of enteric fistulae at a single institution. MATERIALS AND METHODS: The study included 18 patients who had an ECMFP placed between 2012 and 2018 with treatment follow-up through July 2020. Median patient age was 52.5 years (interquartile range, 11.5 y). There were 28 ECMFP procedures performed on 19 separate fistulae. Fistulae locations were gastrocutaneous (n = 4), enterocutaneous (n = 9), and colocutaneous (n = 6). Descriptive statistics were used to define closure rates, recurrence rates, and complications. RESULTS: Fistula closure was achieved in 1 of 4 gastrocutaneous (25%), 4 of 9 enterocutaneous (44%), and 3 of 6 colocutaneous (50%) locations. The median time from procedure to fistula tract closure was 29 days interquartile range 25 days. The median time from ECMFP placement to fistula recurrence was 28 days (interquartile range 27 days). Of the fistulae that eventually closed, 6 of 8 closed after the first attempt (75%), and 2 closed after the second attempt (25%). Of the procedures that resulted in complete closure, 7 of 8 were categorized as low flow, and 1 of 8 was categorized as high flow. Complications were seen in 4 patients (23%), with major complications in 3 patients (17%). CONCLUSIONS: Low-flow fistulae originating from the small bowel are most likely to have complete closure. High-flow and/or gastrocutaneous fistulae are less likely to benefit from this intervention. In patients who are not surgical candidates or who have failed surgical management, ECMFPs may provide a solution.

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments.

Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.

Short- to Midterm Safety and Efficacy of Prostatic Artery Embolization: A Systematic Review.

PURPOSE: To review the available safety and efficacy data for prostatic artery embolization (PAE) in the treatment of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: PubMed was searched for publications that included PAE for the treatment of BPH through May 2015. Two independent reviewers determined the appropriateness for inclusion of each article and compiled data by using pooled weighted means and standard deviations. RESULTS: The literature search identified 161 articles, of which 7 studies, with a total of 562 patients, met all inclusion/exclusion criteria. PAEs were performed bilaterally in 85% of patients, unilaterally in 12%, and unsuccessfully in 3%. International Prostate Symptom Score decreased from 24.51 ± 6.12 at baseline to 10.42 ± 5.39 at 6 months. Quality of life score decreased from 4.76 ± 0.98 at baseline to 2.51 ± 1.13 at 6 months. Peak urinary flow rate increased from 8.41 mL/s ± 2.63 at baseline to 15.44 mL/s ± 5.64 at 6 months. Postvoid residual measurement decreased from 105.94 mL ± 76.77 at baseline to 39.57 mL ± 15 at 6 months. Prostate-specific antigen level decreased from 4.79 ng/mL ± 5.42 at baseline to 3.16 ng/mL ± 1.5 at 6 months. None of these parameters showed clinically significant changes from 6 months to 12 months. Total prostate volume decreased from 96.56 cm3 ± 35.47 at baseline to 46.73 cm3 ± 20.51 at 12 months. There were 200 minor complications and 1 major complication. CONCLUSIONS: PAE improves lower urinary tract symptoms caused by BPH, with a favorable short- to midterm safety profile.

A Resident Perspective on Adding Value as Radiologists.

During the annual 46th annual American Alliance of Academic Chief Residents in Radiology (A(3)CR(2)) meeting in New Orleans, chief residents discussed the role of residents within American College of Radiology 3.0 campaign. Our discussion was directed toward the evolving role of fourth-year radiology residents and how we might improve their training to better prepare them to add value as both leaders and radiologists. The ideas resulting from our Problem Solving session were divided into three categories: clinical presence in the wards and subspecialty clinics; visibility to clinicians and patients; and the education of medical students, residents, and advanced practice clinicians to aid in realizing the long-term goals of Imaging 3.0.

Results of the 2015 Survey of the American Alliance of Academic Chief Residents in Radiology.

RATIONALE AND OBJECTIVES: The American Alliance of Academic Chief Residents in Radiology conducts an annual survey of chief residents in Diagnostic Radiology programs in North America. The survey serves as a resource for observing trends and disseminating ideas among radiology training programs. MATERIALS AND METHODS: An online survey was distributed to chief residents at 181 residency programs, with questions on a broad range of topics including resident benefits, program and call structure, American Board of Radiology Core exam preparation, fellowships, and the job market. RESULTS: A total of 193 individual responses were received from 120 programs, for a response rate of 66%. The responses were compared to data from prior years' surveys, principally from 2012 to 2014. CONCLUSIONS: Programs are shifting resident benefits spending toward Core exam preparation resources and away from lead aprons. In addition, 24-hour attending coverage continues to spread among programs, and the fraction of programs providing face-to-face postcall readouts continues to decline. Finally, although resident perception of the job market is now improving, residents feel that the job market continues to discourage medical students from entering radiology, a fact borne out by the 2015 match results. How the upcoming change to a direct interventional radiology residency will affect medical student interest is as yet uncertain.

Prospective analysis of the safety and efficacy of percutaneous cryoablation for pT1NxMx biopsy-proven renal cell carcinoma.

PURPOSE: Our objective was to determine the efficacy and safety of image-guided, percutaneous cryoablation for American Joint Committee on Cancer pT1ANxMx and pT1BNxMx biopsy-proven renal cell carcinoma (RCC). MATERIALS AND METHODS: Computed tomography (CT)-guided, percutaneous cryoablation was used to treat 117 renal lesions in 113 consecutive patients with pT1NxMx RCC. All 117 ablations were included in the safety analysis, and complications were categorized according to Common Terminology Criteria for Adverse Events version 3.0 (CTCAE v3.0). Eighty-one lesions were biopsy-proven RCC and were included in the efficacy analysis. Technical success was defined as the "ice-ball" covering the entire lesion plus a minimum 5-mm margin. Efficacy was defined as complete lack of enhancement and continuous decrease in size on subsequent follow-up imaging studies. RESULTS: Technical success was 100%, with 15% of ablations requiring air or saline injection to prevent nontarget ablation. We recorded a 7% rate of clinically significant complications (CTCAE category≥2) and 0% mortality. Renal function was not adversely affected. Seventy percent of patients were discharged to home on the same day. Efficacy was 98.7% for a median follow-up of 67 weeks (range 7-172). For the subgroup of patients that reached a median follow-up of 2 (n=59) and 3 years (n=13), efficacy was 98.3 and 92.3%, respectively. Cancer specific survival was 100%. CONCLUSIONS: CT-guided, percutaneous cryoablation has an excellent safety and efficacy profile for stage T1A and T1B RCC; however, longer follow-up is needed to compare it with other nephron-sparing surgical treatments. It is a great option for nonsurgical patients, those in whom renal function cannot be further sacrificed, and those at risk for metachronous lesions.

Trichostatin A increases SMN expression and survival in a mouse model of spinal muscular atrophy.

The inherited motor neuron disease spinal muscular atrophy (SMA) is caused by mutation of the telomeric survival motor neuron 1 (SMN1) gene with retention of the centromeric SMN2 gene. We sought to establish whether the potent and specific hydroxamic acid class of histone deacetylase (HDAC) inhibitors activates SMN2 gene expression in vivo and modulates the SMA disease phenotype when delivered after disease onset. Single intraperitoneal doses of 10 mg/kg trichostatin A (TSA) in nontransgenic and SMA model mice resulted in increased levels of acetylated H3 and H4 histones and modest increases in SMN gene expression. Repeated daily doses of TSA caused increases in both SMN2-derived transcript and SMN protein levels in neural tissues and muscle, which were associated with an improvement in small nuclear ribonucleoprotein (snRNP) assembly. When TSA was delivered daily beginning on P5, after the onset of weight loss and motor deficit, there was improved survival, attenuated weight loss, and enhanced motor behavior. Pathological analysis showed increased myofiber size and number and increased anterior horn cell size. These results indicate that the hydroxamic acid class of HDAC inhibitors activates SMN2 gene expression in vivo and has an ameliorating effect on the SMA disease phenotype when administered after disease onset.

Optical computer recognition of facial expressions associated with stress induced by performance demands.

Application of computer vision to track changes in human facial expressions during long-duration spaceflight may be a useful way to unobtrusively detect the presence of stress during critical operations. To develop such an approach, we applied optical computer recognition (OCR) algorithms for detecting facial changes during performance while people experienced both low- and high-stressor performance demands. Workload and social feedback were used to vary performance stress in 60 healthy adults (29 men, 31 women; mean age 30 yr). High-stressor scenarios involved more difficult performance tasks, negative social feedback, and greater time pressure relative to low workload scenarios. Stress reactions were tracked using self-report ratings, salivary cortisol, and heart rate. Subjects also completed personality, mood, and alexithymia questionnaires. To bootstrap development of the OCR algorithm, we had a human observer, blind to stressor condition, identify the expressive elements of the face of people undergoing high- vs. low-stressor performance. Different sets of videos of subjects' faces during performance conditions were used for OCR algorithm training. Subjective ratings of stress, task difficulty, effort required, frustration, and negative mood were significantly increased during high-stressor performance bouts relative to low-stressor bouts (all p < 0.01). The OCR algorithm was refined to provide robust 3-d tracking of facial expressions during head movement. Movements of eyebrows and asymmetries in the mouth were extracted. These parameters are being used in a Hidden Markov model to identify high- and low-stressor conditions. Preliminary results suggest that an OCR algorithm using mouth and eyebrow regions has the potential to discriminate high- from low-stressor performance bouts in 75-88% of subjects. The validity of the workload paradigm to induce differential levels of stress in facial expressions was established. The paradigm also provided the basic stress-related facial expressions required to establish a prototypical OCR algorithm to detect such changes. Efforts are underway to further improve the OCR algorithm by adding facial touching and automating application of the deformable masks and OCR algorithms to video footage of the moving faces as a prelude to blind validation of the automated approach.