Clinical Performance Status and Technical Factors Affecting Outcomes from Percutaneous Transhepatic Biliary Interventions; A Multicentre, Prospective, Observational Cohort Study.

PURPOSE: The purpose of this study was to evaluate the predictive value of a 'Modified Karnofsky Scoring System' on outcomes and provide real-world data regarding the UK practice of biliary interventions. MATERIALS AND METHODS: A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure. RESULTS: A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky 'high risk' group the 7 day mortality was 9.7% versus 0% for the 'low risk' group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001) CONCLUSION: Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.

Measurement of Aortic Atherosclerotic Disease Severity: A Novel Tool for Simplified, Objective Disease Scoring Using CT Angiography.

Introduction Vascular calcification is a recognized indicator of cardiovascular morbidity and mortality. Calcium scoring is a widely used tool to measure coronary artery calcification, however has limitations for use elsewhere in the body. There is currently no gold standard for quantifying abdominal aortic calcification (AAC). We propose a simple and reproducible method to assess the severity of AAC using multiplanar reconstruction (MPR) in CT angiograms (CTA). Methods A retrospective analysis of CTAs from 75 patients over two years was performed. Using a novel six-point scoring system, three radiologists independently scored the severity of AAC in the distal abdominal aorta. Interclass correlation (ICC) was used to assess the degree of agreement between the three raters. Calcium scoring of the same region was also calculated for each patient. We used Spearman's rank correlation coefficient to compare the CT calcium score with the corresponding average rater's atheroma score. Results There was significant agreement between raters' scores, with an ICC value = 0.972, 95% (CI 0.959-0.981, p < 0.0001). There was also a strong correlation between an average rater's atheroma score with the corresponding CT calcium score, rho = 0.85 (p < 0.0001). Conclusion The results show excellent reproducibility of scores between radiologists, as well as a strong correlation between this novel scoring tool and calcium scores, indicating that it is a reliable method for the grading of AAC.  We propose that this simple semi-quantitative method could form a widely used system for AAC disease stratification.

Patterns of Reperfusion and Clinical Findings in Repeat Prostate Artery Embolisation for Recurrent Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia.

PURPOSE: To present our experience of the patterns of revascularisation of the prostate and efficacy of repeat prostate artery embolisation (rPAE) in patients with recurrence of lower urinary tract symptoms. MATERIALS AND METHODS: We retrospectively analysed 12 patients who underwent rPAE at a single centre between November 2015 and March 2020. The patients had their intraprocedural angiography and cone beam CT images as well as their pre-procedural CT retrospectively reviewed to establish the patterns of revascularisation. Clinical follow-up occurred at a minimum of 3 months. RESULTS: 11/12 patients (91.6%) had significant international prostate symptom score (IPSS) reduction following rPAE with change in mean IPSS from 18.4 to 8.1 at 3 months (p < 0.0001). Mean prostate volume was reduced by 41.6% (p = 0.03). 8/12 (75%) had a complete clinical success. 20/24 hemiprostates demonstrated revascularisation angiographically, of which 16 (80%) had prostatic arterial supply at rPAE by the main prostatic artery. Other mechanisms of revascularisation included supply from capsular prostatic artery branches and supply from other internal iliac pelvic branches. Unilateral embolisation at rPAE, where bilateral embolisation was not feasible (4/12), resulted in no difference in clinical outcomes compared with bilateral rPAE (p = 0.55). CONCLUSION: We have found rPAE to be an effective treatment for recurrent lower urinary tract symptoms in patients who had good clinical response to initial PAE. The mechanisms of revascularisation are variable, but most patients that underwent rPAE had recanalisation of their main prostatic artery.

Predictors of technical outcome for prostatic artery embolisation using pre-procedural CT angiography.

OBJECTIVES: Predicting patients that will pose procedural technical challenges in prostate artery embolisation (PAE) remains difficult, with prolonged procedural times impacting on both patient dose and resource planning. Understanding the factors that influence these parameters as well as the likelihood of technical success is therefore important in effective patient selection and procedural planning. METHODS: Data were collected retrospectively for 75 consecutive patients who underwent PAE. Multiple patient predictor variables available from planning computed tomography angiography (CTA) were identified and measured objectively. The vessel angles navigated during the procedure, prostate volume, prostate artery (PA) diameter, PA origin, aortic atheroma, iliac tortuosity and baseline demographics were correlated with outcome variables (fluoroscopy time, air kerma (AK), dose area product (DAP), the number of cone beam CTs (CBCTs)) performed and whether bilateral embolisation was possible (technical success). Data were analysed using linear regression, ANOVA, t tests and chi-squared tests. RESULTS: Aortic atheroma severity significantly increased fluoroscopy time (p = 0.004), whilst air kerma (AK) was significantly greater in patients with smaller prostatic arteries (p = 0.009) and smaller pre-procedural prostate volumes (p = 0.038). Increased vascular tortuosity and prostatic artery origin were not shown to significantly affect fluoroscopy time or DAP. Smaller prostate artery size (p = 0.007) also increases the likelihood of either unilateral embolisation or technical failure. CONCLUSIONS: Pre-operative prediction of technical outcome measures in PAE remains challenging. However, vascular calcification, prostatic artery diameter and prostate volume are likely to be important factors when considering the risk/benefits of PAE. KEY POINTS: • Increased severity of atheroma and the presence of small prostate arteries increase fluoroscopy time and AK respectively during prostate artery embolisation. • Lower pre-procedural prostate volume increases the AK during procedures. • Smaller prostate artery size increases the likelihood of either unilateral embolisation or technical failure.

The STREAM Trial (Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia) 24-Month Clinical and Radiological Outcomes.

PURPOSE: To establish factors predictive of success prior to Prostate Artery Embolization (PAE) with MRI imaging. MATERIALS AND METHODS: A prospective cohort study of 50 patients with Benign Prostatic Hyperplasia (BPH) were treated with PAE in a single institution. Patients had moderate to severe symptoms of BPH refractory to medical management for at least 6 months. Patients were imaged with multiparametric MRI imaging pre-PAE and at 3 months, 12 months and 24 months post-PAE. Clinical success was measured with IPSS, IIEF and EQ-5D-5L quality of life questionnaires. RESULTS: The technical success was 48/50 (96%).The mean age of the group was 67 (range 54-83). The mean IPSS score pre-PAE was 21 and at 24 months was 8 (p < 0.001). There was no deterioration in erectile function. The mean volume of the prostate post-PAE was reduced at 3 and 12 months post-PAE but not significantly different at 24 months. This did not correlate with the IPSS score. Patients with median lobe enlargement has similar symptomatic improvement as those without median lobe enlargement. Internally within the prostate patients with adenomatous-dominant BPH initially did better than patients with stromal enlargement; however, at 24 months patients with stromal enlargement of the prostate improved greatest. Initial volume of the prostate was not a good predictor of clinical success. CONCLUSION: PAE is a safe and effective treatment strategy for treating men with BPH. Patients with Adenomatous BPH clinically do better until 12 months but not at 24 months. Initial prostate volume does not affect outcome, and patients with median lobe enlargement do as well as those without.

Prostatic artery embolization (PAE) for prostatic origin bleeding in the context of prostate malignancy.

Prostate artery embolization (PAE) has been shown to be beneficial in treating men with benign prostatic hypertrophy (BPH). Here we describe treating four patients with prostate cancer (two with organ-confined and two with metastatic prostate cancer) with prostatic bleeding with PAE. Patients had other causes of hematuria excluded and were followed up at 3, 12, and 18 months after PAE. All four cases were technically successful and all cases of hematuria had resolved by the three-month follow-up (100%). There was one case of recurrence at 13 months after PAE which was successfully treated. PAE is useful for controlling significant prostatic bleeding in patients with prostate cancer and improves quality of life. Patients may, however, need repeated treatments to control the bleeding.

Tumour Seeding in the Tract of Percutaneous Renal Tumour Biopsy: A Report on Seven Cases from a UK Tertiary Referral Centre.

The role of percutaneous renal tumour biopsy (RTB) in the management of radiological indeterminate renal masses is long established. Patients with small renal masses who have biopsy-proven renal cell carcinoma (RCC) may be offered surgery, ablative therapy, or active surveillance, and RTB can provide diagnostic tissue from patients with metastatic disease who might benefit from systemic therapy. Current guidelines suggest that tumour seeding along the needle tract is anecdotal, but several cases have been reported recently, although some have been associated with lack of a coaxial sheath. We report on seven patients who underwent surgical resection of RCC in our tertiary referral institution following diagnostic RTB between 2014 and 2017 for whom RTB tract seeding by tumour was identified on histological examination of the resection specimen. One of these patients subsequently developed local tumour recurrence at the site of the previous biopsy.

Prostatic Artery Embolization (PAE) for Benign Prostatic Hyperplasia (BPH) with Haematuria in the Absence of an Upper Urinary Tract Pathology.

PURPOSE: To assess the effectiveness of prostate artery embolization (PAE) in the control of haematuria and in patients with benign prostatic hyperplasia (BPH) and normal upper urinary tracts. SUBJECTS/PATIENTS: Twelve consecutive patients with haematuria were included in the prospective study. All patients had prior imaging and cystoscopy to exclude other causes of haematuria. Patients prostate arteries were embolized with particles (200-500 µm), and they were followed up at 3, 12 and 18 months following the procedure. QOL questionnaires, IPSS, IIEF and clinical review were all employed to assess the success of the treatment. To allow useful comparison, patients were age- and prostate volume-matched and compared to patients treated with PAE for BPH without haematuria. RESULTS: All 12/12 cases were technically successful with bilateral PAE being performed. All cases of haematuria resolved by the 3-month follow-up (100%). There was one case of recurrence during the 12-month follow-up (overall clinical success at 18 months 92%). This was due to over anticoagulation and ceased once corrected. There was a reduction in lower urinary tract symptoms noted by improvements in QOL indices, IPSS and IIEF. There was continued success even if the patient was subsequently anticoagulated. There was no associated sexual dysfunction. There was more prostatic arterial branching and volume of embolic required to achieve stasis in BPH and haematuria than in BPH alone (p < 0.05). CONCLUSION: PAE is a very useful technique for controlling the quite debilitating condition of haematuria in patients with visible haematuria of prostatic origin. Controlling haematuria and BPH allows a significant improvement in QOL.

Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review.

OBJECTIVE: The purpose of this study is to assess the current evidence regarding the safety and effectiveness of the various embolic materials used in varicoceles embolization. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for clinical studies that investigated the clinical outcomes of embolization treatment for the management of testicular varicoceles. Study methodological quality was analyzed. RESULTS: 23 retrospective and 7 prospective clinical studies were identified with a total of 3505 patients. Technical success rates appear to be above 90% for all embolic materials without any significant differences. In terms of recurrence rates, glue (N = 251) appeared to have the lowest and sclerosants alone (N = 728) the highest recurrence rates which were 4.2% (11-3.08%, SD: 5.9) and 11.03% (18.8-5.15%, SD: 6.06) within an average follow up (f/u) of 16.13 and 25.48 months respectively. Coils alone (N = 898) had an average recurrence rate of 9.1% (17.8-1.4%; SD: 5.79) and a mean f/u of 39.3 months. After an average of 12 months of f/u, the addition of sclerosants (N = 1628) as an adjunct to coils did not improve recurrence rates (8.44%, 16.5-5.1%; SD: 3.4). No differences were reported regarding the safety profile of the various embolic materials. CONCLUSION: Despite the heterogeneity of the included studies, preliminary evidence supports the safe and effective use of the various embolic materials currently used for the management of varicoceles. At 1 year, glue appears to be the most effective in preventing recurrence with coils being the second most effective. The addition of sclerosants to the coil embolization did not appear to have an impact on recurrence rates. Further research is required to elucidate the cost-effectiveness of these approaches. Advances in knowledge: Varicocele embolization appears to be a safe and effective technique regardless of the embolic agent. Addition of a sclerosant agent to coil embolization does not appear to improve outcomes.

Effects of Sublingual Glyceryl Trinitrate Administration on the Quality of Preprocedure CT Angiography Performed to Plan Prostate Artery Embolization.

PURPOSE: To determine the effects of sublingual glyceryl trinitrate (GTN) on the quality of planning computed tomography (CT) angiography performed prior to prostate artery embolization (PAE). MATERIALS AND METHODS: A retrospective cohort study was performed on patients who had previously undergone CT angiography before a procedure for PAE at our institution. Early CT angiography studies for PAE at our single center had initially been performed without GTN. These were compared to subsequent CT angiography studies that had been performed with GTN, after a previously implemented change in practice. Prostate arteries were examined by 2 blinded observers for peak enhancement (Hounsfield units [HU]) and lumen diameter. In addition, assessors' interpretation of the prostate artery origin from CT angiography was compared with the true anatomy demonstrated at the time of procedure. RESULTS: A total of 16 patients, corresponding to 32 prostate arteries, were examined on CT angiography. Mean diameter of the prostate artery was found to be significantly greater in those receiving GTN (2.2 mm vs. 1.6 mm, P < .001). Peak prostate artery enhancement was also greater in the GTN group (218 HU vs 173 HU, P = 0.042). Observers correctly identified the prostate artery origin more frequently in the GTN group; however, this difference was not statistically significant (56% vs 25%, odds ratio = 3.9, P = .149). CONCLUSIONS: The administration of sublingual GTN immediately prior to CT angiography is associated with a significant increase in prostate artery diameter and peak opacification. This was not associated with a statistically significant increase in the ability of observers to correctly identify the origin of the prostate artery.

Correction to: British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.

On page 1553, the caption on Table 1 should read: Retrieval of filter by filter make/model and % retrievals within the manufacturer timescale.