Safety and Effectiveness of Abre Self-Expanding Venous Stent for Treatment of Superior Vena Cava Syndrome.

PURPOSE: Superior vena cava (SVC) syndrome is a constellation of symptoms that results from partial or complete SVC obstruction. Endovascular SVC stenting is an effective treatment for SVC syndrome with rapid clinical efficacy and low risk of complications. In this study, we assess the technical and clinical outcomes of a cohort of patients with SVC syndrome treated with the AbreTM self-expanding venous stent (Medtronic, Inc, Minneapolis, MN, USA). METHODS: An institutional database was used to retrospectively identify patients with SVC syndrome treated with AbreTM venous self-expanding stent placement between 2021-2023. Patient demographic data, technical outcomes, treatment effectiveness, and adverse events were obtained from the electronic medical record. Nineteen patients (mean age 58.6) were included in the study. Thirteen interventions were performed for malignant compression of the SVC, 5 for central venous catheter-related SVC stenosis, and 1 for HD fistula-related SVC stenosis refractory to angioplasty. RESULTS: Primary patency was achieved in 93% of patients (17/19). Two patients (7%) required re-intervention with thrombolysis and angioplasty within 30 days post-stenting. Mean duration of clinical and imaging follow-up were 228.7 ± 52.7 and 258.7 ± 62.1 days, respectively. All patients with clinical follow-up experienced significant improvement in clinical symptoms post-intervention. No stent related complications were identified post-intervention. CONCLUSIONS: Treatment of SVC syndrome with the AbreTM self-expanding venous stent has high rates of technical and clinical success. No complications related to stent placement were identified in this study.

Transcatheter arterial tendinopathy embolization as a treatment for painful and refractory tendinopathy: a systematic review and meta-analysis.

OBJECTIVE: Transcatheter arterial embolization (TAE) is a novel minimally invasive therapy for painful tendinopathy in patients with pain refractory to conservative management. The purpose of this study was to evaluate evidence on the efficacy of TAE for tendinopathy related pain. MATERIALS AND METHODS: Using Embase, PubMed, and Web of Science, a systematic review and meta-analysis was performed to identify studies evaluating TAE for painful tendinopathy. The primary outcome measure was change in pain scale score at 6 months. A Ratio of Means (ROM) was used to compare the effect size post treatment as compared to baseline. The Visual Analog Scale (VAS) was used as the metric for comparison. RESULTS: After screening titles, abstracts, and the full text, 5 studies met inclusion criteria. A total of 97 tendinopathy embolization procedures performed in 74 patients were included. Patients who underwent TAE demonstrated declines in VAS ROM at 1 day 0.53 [95% CI 0.31,0.88], 1 week (0.51 [95% CI 0.32,0.79]), 1 month (0.45 [95% CI 0.29, 0.71]), 3-4 months (0.33 [95% CI 0.22,0.48]), and 6 months following embolization (0.18[95% CI 0.13,0.26]), respectively. DISCUSSION: TAE provides substantial short-term reductions in pain scores for patients suffering with refractory tendinopathy related pain of the rotator cuff, elbow extensor and flexor, Achilles, and patellar tendons.

Awareness of interventional radiology and image guided musculoskeletal interventions among orthopaedic surgeons, rheumatologists, and physiatrists: A multi-site analysis.

PURPOSE: Evaluate physicians who treat musculoskeletal (MSK) disorders in their knowledge of image-guided MSK interventions, and identify areas that could benefit from education. MATERIALS AND METHODS: A 17-question survey was distributed to orthopaedic surgeons, physiatrists, and rheumatologists in the 14-hospital health system. It inquired about demographics, practice environment, awareness of interventional radiology (IR) and MSK radiology (MSKR) training, referral patterns, and knowledge of image-guided MSK interventions. RESULTS: In total, 59 of 303 physicians completed the survey (41% orthopaedists, 35% physiatrists, and 24% rheumatologists). Most (93%) were attendings and 41% were female. A minority of survey respondents (17%) recognized the designation of IR as a distinct specialty of medicine per the American Board of Medical Specialties, in contrast to MSKR, which is not designated as a distinct specialty. When queried about IR procedures not under investigation, 24% selected genicular artery embolization and 31% selected embolization for adhesive capsulitis. Barriers to referral were as follows: 21% of specialists performed the procedure, 17% listed electronic medical record challenges, 14% reported scheduling difficulty, 13% reported no barriers, 11% reported difficulty consulting, 11% referred to another specialty, 10% did not have enough knowledge of image guided procedures, and 3% reported the procedure is not performed by IR or MSKR. CONCLUSIONS: Survey data reveal a knowledge gap among surveyed physicians regarding IR as a specialty as well as areas of IR research in MSK disorders. Findings suggest areas where referring physicians can be educated and identify barriers to referral.

Genicular Artery Embolization as a Treatment for Osteoarthritis Related Knee Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: Genicular artery embolization (GAE) is a minimally invasive therapy for symptomatic osteoarthritis (OA) in patients with knee pain refractory to conservative management. The purpose of this study was to evaluate evidence on the effectiveness of GAE for OA related knee pain as part of a systematic review and meta-analysis. MATERIALS AND METHODS: Using Embase, PubMed, and Web of Science, a systematic review was performed to identify studies evaluating treatment of knee OA with GAE. The primary outcome measure was change in pain scale score at 6 months. A Hedge's g was computed as a measure of effect size, selecting Visual Analog Scale (VAS) first if available and Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index if VAS was not available. RESULTS: After screening titles, abstracts, and the full text, 10 studies met inclusion criteria. A total of 351 treated knees were included. Patients who underwent GAE demonstrated declines in VAS pain scores at 1 month {- 34 points [95% CI (- 43.8, - 24.6)], 3 months {- 30 points [95% CI (- 41.7, - 19.2)], 6 months {- 41 points [95% CI (- 54.0, - 27.2)], and 12 months {- 37 points [95% CI (- 55.0, - 18.1)]. Hedges' g from baseline to 1, 3, 6, and 12 months, was {- 1.3 [95% CI (- 1.6, - 0.97)]}, {- 1.2 [95% CI (- 1.54, - 0.84)]}, {- 1.4 [95% CI (- 2.1, - 0.8)]}, and {- 1.25 [95% CI (- 2.0, - 0.6)]}, respectively. CONCLUSION: GAE provides durable reductions in pain scores for patients suffering with mild, moderate, and severe OA.

Review of genicular artery embolization, radiofrequency ablation, and cryoneurolysis in the management of osteoarthritis-related knee pain.

Osteoarthritis (OA) of the knee represents one of the most common diseases in the world, affecting an estimated 14 million people in the United States alone. Exercise therapy and oral pain medication are first-line treatments but have limited efficacy. Next-line treatments such as intra-articular injections are limited in durability. Moreover, total knee replacements, although effective, require surgical intervention, which has considerable variability in patient satisfaction. Novel minimally invasive image-guided interventions are becoming more widespread for treating OA-related knee pain. Recent studies of these interventions have revealed promising results, minor complications, and reasonable patient satisfaction. In this study, published manuscripts were reviewed in the field of minimally invasive, image-guided interventions for OA-related knee pain, with a focus on genicular artery embolization, radiofrequency ablation, and cryoneurolysis. Recent studies have demonstrated a significant decrease in pain-related symptoms following these interventions. Reported complications were mild in the reviewed studies. Image-guided interventions for OA-related knee pain exist as valuable options for patients who fail other therapies, may not be good surgical candidates, or wish to avoid surgical intervention. Further studies with randomization and an increased length of follow-up are needed to better characterize outcomes following these minimally invasive therapies.

Genicular artery embolization as a treatment for refractory osteoarthritis related knee pain.

Genicular artery embolization (GAE) is a minimally invasive outpatient therapy for osteoarthritis (OA) related knee pain, refractory to conservative management. This intervention targets neovasculature which arises in the setting of angiogenesis in OA. Various clinical trials highlighted in this manuscript suggest that GAE is effective in durably reducing OA-related knee pain, with a limited adverse event profile. This review also explores the clinical evaluation of GAE candidates, genicular artery anatomy, technical components of the procedure, and imaging from various GAE embolizations. It also discusses future directions for research which may illuminate predictors of clinical success as well as avenues for evolution in the GAE treatment.

Percutaneous nephrostomy placement in pregnant patients: a retrospective single center experience.

PURPOSE: Literature on percutaneous nephrostomy (PCN) placement in pregnant patients is limited. The purpose of this case series of 20 pregnant patients was to report short term maternal and fetal outcomes in this population. MATERIALS AND METHODS: A 12-year retrospective study was performed on pregnant patients undergoing PCN. Clinical indications, technical success, maternal outcome, fetal outcome, and complications were obtained from the electronic medical record. RESULTS: Indications for PCN placement included urolithiasis (40%), congenital ureteral dysfunction in the setting of prior ureteral repair (30%), obstruction associated pain (15%), infection (10%), and ureteral injury in the setting of surgery for ovarian torsion (5%). Catheter insertion was successful in all patients (n = 20), with one major complication (urosepsis). Follow up data was available in 19 patients (95%). Catheters were in situ for a median of 82 days. All patients had clinical and symptomatic improvement. Emergency C-sections were required in two cases. Radiation exposure data were available in 15 of 19 patients and revealed a median fluoroscopy time of 2.8 min, median cumulative dose of 43 mGy, and median dose area product of 635 µGy × m2. No adverse fetal outcomes were recorded at time of delivery. CONCLUSION: PCN placement has good clinical results as a treatment option for ureteral obstruction in a pregnant cohort.

Single center experience with ultrasound guided axillary vein port placement.

PURPOSE: To retrospectively review a single institution experience of ultrasound guided axillary vein port placement. METHODS: In this retrospective study, a patient list was generated after searching our internal database from 1/1/2012 to 10/1/2018. Patients who had undergone axillary vein port placement were included. Chart review was performed to confirm approach, laterality and to gather demographic data, clinical indications, technical outcomes, and complications. Descriptive statistics were used to analyze this cohort. Chi-square statistics were used to compare outcomes by laterality. RESULTS: Three hundred seven patients (51% female) with an average age of 58 years were included. The port was placed via the right axillary vein in 85% (261/307), predominantly for the indication of chemotherapy access (296/307). Technical success was achieved in all 307 cases. Peri procedural complications occurred in 1% (4/307) of cases and included port malpositioning requiring replacement and a case of port pocket hematoma. Post procedural complications including deep vein thrombosis and port malfunction occurred in 17% (52/307) of cases and port removal as a result of complication occurred in 9% (29/307) of cases. CONCLUSIONS: Ultrasound guided placement of an axillary port is a safe procedure to perform and demonstrates good clinical outcomes.

Genicular Artery Embolization for Osteoarthritis Related Knee Pain: A Systematic Review and Qualitative Analysis of Clinical Outcomes.

Objective To systematically review the published literature on genicular artery embolization (GAE) for osteoarthritis (OA) related knee pain. Materials and Methods Using three databases, a systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Outcome measures included the Visual Analog Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results Three single-arm studies were included from an initial search yielding 305 results. One hundred and eighty-six knees in 133 patients with either mild-to-moderate (174/186, 94%) or severe (12/186, 6%) OA underwent embolization with either imipenem/cilastatin sodium (159/186, 85%) or embozene (27/186, 15%). Technical success was 100%. Average VAS improved from baseline at 1 day, 1 week, 1 month, 3 months, 4 months, 6 months, 1 year and 2 years (66.5 at baseline vs 33.5, 32.7, 33.8, 28.9, 29.0, 22.3, 14.8 and 14.0, respectively). Average WOMAC scores improved from baseline at 1, 3, 4, 6, 12 and 24 months (45.7 at baseline vs 24.0, 31.0, 14.8, 14.6, 8.2 and 6.2). Severe OA in 12 cases showed initially improved VAS, but was not sustained. Minor adverse events such as erythema in the region of embolization (21/186, 11%), puncture-site hematoma (18/186, 10%), paresthesia (2/186, 1%) and fever (1/186, 0.5%) were reported. Conclusion Limited single-arm studies report GAE is promising for treating OA-related pain. Most treatments performed for mild-to-moderate OA demonstrated durable clinical responses from 6 months to 4 years. Limited data for severe OA suggest a non-durable response. Future studies should be standardized to facilitate comparison and control for placebo effect.

Treatment of malignant inferior vena cava obstruction with Gianturco-Rosch-Z stents: a single center 13-year experience.

RATIONALE AND OBJECTIVES: Malignant obstruction of the IVC can cause severe morbidity and impairment of quality of life in end-stage oncology patients. However, medical literature regarding minimally-invasive palliation using large diameter percutaneous stents, particularly the Gianturco-Rosch-Z (GRZ) stent is limited. MATERIALS & METHODS: A retrospective review from January 2004 to February 2017, revealed 17 subjects with malignant obstruction of the IVC who were treated with a total of 34 GRZ stents. Pre- and post-stent pressure gradients were measured in 10. Available data regarding clinical presentation and follow-up were recorded. RESULTS: Technical success for stent deployment was 100%. A median of 2 stents (range 1 to 5) were deployed per patient, with median stent diameter 20 mm (range 15 to 30 mm). The median pre-treatment pressure gradient of 17.5 mmHg (range 9-31 mmHg) decreased to a median of 4.5 mmHg (range 0-21 mmHg, p < .0004) after stent placement. One subject developed recurrent stent occlusion due to disease progression requiring additional intervention, for a primary patency rate of 94%. Lower extremity edema improved or resolved in 58% of those for whom follow-up data was recorded. Median survival after treatment was only 28 days (range 5 to 607 days). There were no procedural complications. CONCLUSION: Endovascular treatment of malignant IVC obstruction can be safely performed with GRZ stents. Although overall survival is poor, this technique can effectively palliate lower extremity edema symptoms.

Imaging findings in epithelioid hemangioendothelioma.

PURPOSE-OBJECTIVE: Epithelioid hemangioendothelioma (EHE) is a rare vascular malignancy with varying biologic behavior. The purpose of this study was to identify imaging findings most characteristic of EHE. METHODS: Retrospective review of clinical and imaging records in patients referred to our Vascular Anomalies Center over a 17 year period with biopsy proven EHE. RESULTS: We evaluated 29 patients (17 F) with median age of 16 years (range 2-76 y). The most common presenting symptoms were pain (n = 13) and palpable mass (n = 7). 22 (70%) had multifocal disease. Most common sites of involvement were lung (n = 25), liver (n = 16), bone (n = 12), soft tissue (n = 3) and lymph nodes (n = 1). Of patients with single site disease, 3 had lung, 3 liver, and 1 had bone lesions. In 18/25 with lung disease, there were multiple nodules of varying sizes and characteristics. In 14/16 with hepatic disease there were multiple nodules with predominantly peripheral distribution. Subcapsular retraction was seen in 10/16 and a "lollipop" sign (hepatic or portal vein tapering at the edge of a well-defined hypoenhancing lesion) identified in 5/16. Of 12 osseous lesions, 11 were lytic, 8 involved vertebrae and 9 involved the axial skeleton. CONCLUSION: EHE has varied imaging findings. The most common sites are lungs, liver, and bone, with multi-organ involvement seen in most. Lung disease is most commonly characterized by multiple nodules. Hepatic lesions demonstrate the most distinctive findings, with peripheral distribution, lack of early enhancement, subcapsular retraction and "lollipop" sign. Osseous lesions are commonly lytic and more prevalent in the axial skeleton.

Crohn Disease: FDG PET/CT Before and After Initial Dose of Anti-Tumor Necrosis Factor Therapy to Predict Long-term Response.

PURPOSE: Clinical assessments of Crohn disease activity are limited in their capacity to assess treatment response to biologic therapy. The purpose of this study was to determine if changes in FDG activity between baseline PET and repeat PET performed prior to the second dose of induction anti-tumor necrosis factor (TNF) therapy correlate with clinical response. METHODS: In this prospective, institutional review board-approved, Health Insurance Portability and Accountability Act-compliant pilot study of 8 adult patients with active Crohn disease, FDG activity before and 2 weeks after initiation of anti-TNF therapy was assessed using low-dose PET/CT. FDG activity was measured in the most inflamed bowel loop using an SUVratio (SUVmax/liver SUVmean). Changes in SUVratio were compared with a blinded gastroenterologist assessment of clinical response and steroid-free remission, as well as C-reactive protein (CRP), during a 12-month follow-up period. RESULTS: Of 8 patients, 7 showed FDG activity decline at 2 weeks, 5 of whom achieved a clinical response and steroid-free remission at 8, 26, and 52 weeks. The remaining 2 patients with FDG activity decline did not achieve a clinical response or steroid-free remission at these time points, but there were reductions in CRP. The 1 patient without FDG activity decline was a clinical nonresponder, had no reduction in CRP, and did not achieve steroid-free remission. CONCLUSIONS: A change in FDG activity at FDG PET/CT performed prior to the second induction dose of anti-TNF therapy has the potential to predict clinical response and steroid-free remission in patients with Crohn disease.

Use of a 3D-Printed Abdominal Compression Device to Facilitate CT Fluoroscopy-Guided Percutaneous Interventions.

OBJECTIVE: The purpose of this article is to describe a handheld external compression device used to facilitate CT fluoroscopy-guided percutaneous interventions in the abdomen. CONCLUSION: The device was designed with computer-aided design software to modify an existing gastrointestinal fluoroscopy compression device and was constructed by 3D printing. This abdominal compression device facilitates access to interventional targets, and its use minimizes radiation exposure of radiologists. Twenty-one procedures, including biopsies, drainage procedures, and an ablation, were performed with the device. Radiation dosimetry data were collected during two procedures.

Differences in the imaging features and distribution of non-indolent and indolent mastocytosis: a single institution experience of 29 patients.

PURPOSE: Compare imaging features of indolent and non-indolent mastocytosis. METHODS: For 29 patients, imaging features, imaging indications, and distribution of indolent and non-indolent mastocytosis subtypes were analyzed. RESULTS: 16/29 (55%) patients had three distinct patterns of osseous abnormality, not significantly differing between cohorts. Non-indolent disease was more likely to present with hepatomegaly (p=0.0004), splenomegaly (p=0.0097), and lymphadenopathy (p=0.0079). CT, was the most common initial imaging modality, ordered to stage disease in 20 of 29 patients (69%). CONCLUSION: Understanding patterns of involvement of indolent and nonindolent mastocytosis across modalities could assist radiologists in evaluating mastocytosis.

Ultrasound diagnosis of fetal hypospadias: Accuracy and outcomes.

OBJECTIVES: The purpose of this study was to assess the positive predictive value of a prenatal ultrasound diagnosis of hypospadias when compared with postnatal diagnosis based on physical exam. METHODS: We retrospectively identified all pregnant women between 2004 and 2014 who were either referred to our fetal care center carrying a fetus with an ultrasound diagnosis of possible hypospadias or who had a new diagnosis of hypospadias after imaging in our center. RESULTS: A total of 32 cases of possible hypospadias were identified, with our fetal center ultrasound suggesting hypospadias in 25 of the 32 cases (78%). Of the 25 cases, 18 infants were confirmed to have hypospadias on postnatal physical exam (Table), reflecting a positive predictive value of 72%. Twenty-one of twenty-five cases with suggested hypospadias on ultrasound were found to have either hypospadias or another penile anomaly on postnatal physical exam, reflecting a positive predictive value for any genital anomaly of 84%. Infants with confirmed hypospadias often had several associated GU anomalies on postnatal clinical exam. CONCLUSIONS: Our single center experience with the fetal ultrasound diagnosis of hypospadias demonstrates a high positive predictive value for a penile anomaly (21/25, 84%), and a moderately high positive predictive value for the specific diagnosis of hypospadias (18/25, 72%) when compared with the postnatal diagnosis.

The interindividual variation in femoral neck width is associated with the acquisition of predictable sets of morphological and tissue-quality traits and differential bone loss patterns.

A better understanding of femoral neck structure and age-related bone loss will benefit research aimed at reducing fracture risk. We used the natural variation in robustness (bone width relative to length) to analyze how adaptive processes covary traits in association with robustness, and whether the variation in robustness affects age-related bone loss patterns. Femoral necks from 49 female cadavers (29-93 years of age) were evaluated for morphological and tissue-level traits using radiography, peripheral quantitative computed tomography, micro-computed tomography, and ash-content analysis. Femoral neck robustness was normally distributed and varied widely with a coefficient of variation of 14.9%. Age-adjusted partial regression analysis revealed significant negative correlations (p < 0.05) between robustness and relative cortical area, cortical tissue-mineral density (Ct.TMD), and trabecular bone mineral density (Ma.BMD). Path analysis confirmed these results showing that a one standard deviation (SD) increase in robustness was associated with a 0.70 SD decrease in RCA, 0.47 SD decrease in Ct.TMD, and 0.43 SD decrease in Ma.BMD. Significantly different bone loss patterns were observed when comparing the most slender and most robust tertiles. Robust femora showed significant negative correlations with age for cortical area (R(2) = 0.29, p < 0.03), Ma.BMD (R(2) = 0.34, p < 0.01), and Ct.TMD (R(2) = 0.4, p < 0.003). However, slender femora did not show these age-related changes (R(2) < 0.09, p > 0.2). The results indicated that slender femora were constructed with a different set of traits compared to robust femora, and that the natural variation in robustness was a determinant of age-related bone loss patterns. Clinical diagnoses and treatments may benefit from a better understanding of these robustness-specific structural and aging patterns.

Emergent embolization of arterial bleeding after vacuum-assisted breast biopsy.

Vacuum-assisted core breast biopsy has become important in evaluating patients with suspicious breast lesions. It has proven to be a relatively safe procedure that in rare cases can result in vascular complications. These are the first reported cases of transcatheter embolization of uncontrolled breast hemorrhage after vacuum-assisted breast biopsy. With increased use of biopsy and larger-gauge devices, breast imaging groups may consider embolotherapy as a safe alternative for treatment of hemorrhage in a select group of patients.