The Importance of Optimal Thermal Ablation Margins in Colorectal Liver Metastases: A Systematic Review and Meta-Analysis of 21 Studies.

BACKGROUND: Colorectal cancer (CRC) is the second most common cause of cancer-related deaths in the US. Thermal ablation (TA) can be a comparable alternative to partial hepatectomy for selected cases when eradication of all visible tumor with an ablative margin of greater than 5 mm is achieved. This systematic review and meta-analysis aimed to encapsulate the current clinical evidence concerning the optimal TA margin for local cure in patients with colorectal liver metastases (CLM). METHODS: MEDLINE, EMBASE, and the CENTRAL databases were systematically searched from inception until 1 May 2023, in accordance with the PRISMA Guidelines. Measure of effect included the risk ratio (RR) with 95% confidence interval (CI) using the random-effects model. RESULTS: Overall, 21 studies were included, comprising 2005 participants and 2873 ablated CLMs. TA with margins less than 5 mm were associated with a 3.6 times higher risk for LTP (n = 21 studies, RR: 3.60; 95% CI: 2.58-5.03; p-value < 0.001). When margins less than 5 mm were additionally confirmed by using 3D software, a 5.1 times higher risk for LTP (n = 4 studies, RR: 5.10; 95% CI: 1.45-17.90; p-value < 0.001) was recorded. Moreover, a thermal ablation margin of less than 10 mm but over 5 mm remained significantly associated with 3.64 times higher risk for LTP vs. minimal margin larger than 10 mm (n = 7 studies, RR: 3.64; 95% CI: 1.31-10.10; p-value < 0.001). CONCLUSIONS: This meta-analysis solidifies that a minimal ablation margin over 5 mm is the minimum critical endpoint required, whereas a minimal margin of at least 10 mm yields optimal local tumor control after TA of CLMs.

Nationwide Outcomes following Percutaneous Cholecystostomy for Acute Calculous Cholecystitis and the Impact of Coronavirus Disease 2019: Results of the Multicentre Audit of Cholecystostomy and Further Interventions (MACAFI study).

PURPOSE: To assess the mortality, readmission rates, and practice variation of percutaneous cholecystostomy (PC) in patients with acute calculous cholecystitis in the United Kingdom (UK). MATERIALS AND METHODS: A total of 1,186 consecutive patients (636 men [53.6%]; median age, 75 years; range, 24-102 years) who underwent PC for acute calculous cholecystitis between January 1, 2019, and December 31, 2020, were included from 36 UK hospitals. The exclusion criteria were diagnostic aspirations, absence of acute calculous cholecystitis, and age less than 16 years. The coronavirus disease 2019 (COVID-19) lockdown was declared on March 26, 2020, in the UK, which served to distinguish among groups. RESULTS: Most patients (66.3%) underwent PC as definitive treatment, whereas 31.3% underwent PC as a bridge to surgery. The overall 30-day readmission rate was 42.2% (500/1,186), and the 30-day mortality was 9.1% (108/1,186). Centers performing fewer than 30 PCs per year had higher 90-day mortality than those performing more than 60 (19.3% vs 11.0%, respectively; P = .006). A greater proportion of patients presented with complicated acute calculous cholecystitis during the COVID-19 pandemic compared to prior (49.9% vs 40.9%, respectively; P = .007), resulting in more PCs (61.3 vs 37.9 per month, respectively; P < .001). More PCs were performed in tertiary hospitals than in district general hospitals (9 vs 3 per 100 beds, respectively; P < .001), with a greater proportion performed as a bridge to surgery (50.5% vs 22.8%, respectively; P < .001). CONCLUSIONS: The practice of PC is highly variable throughout the UK. The readmission rates are high, and there is significant correlation between mortality and PC case volume.

The interventional radiology gender gap: perspectives from the international IR training survey.

OBJECTIVE: This study sought to examine international interventional radiology (IR) training standards and perceptions. This survey aims to identify gender-based barriers and inequities effecting uptake, retention and experience of trainees in IR. METHODS: An anonymous survey was created using Survey Monkey and distributed as a single-use weblink via eight IR national and international societies around the world. Data analysis was conducted to highlight gender-specific trends and identify any differences. RESULTS: Motivation factors given for following a career in IR revealed gender differences in factors such as mentoring (8.7 F vs 21.6% M) and influence from senior colleagues (15.2 F vs 25.0% M). The overwhelming majority across both genders (82.6 F vs 81.3% M) agreed or strongly agreed that early exposure to IR training at Year 1 had a positive impact on career choice. A good work life balance was positively reported in 48.2% of female respondents compared to 45.2% in males. There were no significant differences in satisfaction with the various aspects of IR training. All differences observed between genders, exceeded the 0.05 significance level. CONCLUSION: This survey offers many insights into the current international landscape of IR training. Ongoing evaluation is vital to inform recruitment practices and initiatives to bridge gender inequities and attract more females into IR. ADVANCES IN KNOWLEDGE: This study has revealed that increasing and optimising mentoring opportunities may be the first step in increasing awareness of IR and maximising potential female recruits.

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.

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence.

PURPOSE: To assess the efficacy and safety of a catheter-directed hemorrhoidal dearterialization technique for the management of hemorrhoidal bleeding. MATERIALS AND METHODS: A systematic review and meta-analysis of pubmed, cochrane, and scopus databases was conducted according to the preferred reporting items for systematic reviews and meta-Analysis (PRISMA) guidelines. Clinical studies reporting on catheter-directed hemorrhoidal dearterialization for rectal bleeding were analyzed. RESULTS: Fourteen studies (n = 362) were identified. The mean maximum follow-up duration was 12.1 months (SD, 7.31; range, 1-28; median, 12), and the mean length of hospital stay was 1.5 days (SD, 1.1; range, 0-2.5). The mean technical success was 97.8% (SD, 3.5), and the mean clinical success was 78.9% (SD, 10.5). A statistically significant reduction in the french bleeding score before and after embolization was noted (P = .004). In subgroup analysis, when the coils-only group was compared with the coils and particles group, the average rebleeding rate was 21.5% (n = 111; SD, 18.2; range, 0%-44%) versus 10.05% (N = 108; SD, 4.8; range, 5%-15.7%), respectively (P < .0001). No bowel ischemia/necrosis or anorectal complications were reported. CONCLUSIONS: The current preliminary clinical evidence suggests that catheter-directed hemorrhoidal dearterialization is an effective and safe procedure for the treatment of hemorrhoidal bleeding. The standardization of the technique and the generation of higher level evidence will be required to compare this minimally invasive procedure with more invasive surgical options for patients with grades I-III hemorrhoids and chronic bleeding.

Future Interventional Radiologists and Where to Find Them-Insights from Five UK Interventional Radiology Symposia for Junior Doctors and Medical Students.

BACKGROUND: The interventional radiology (IR) trainee recruitment in the UK is lagging behind the pace of service expansion and is potentially hindered by underrepresented undergraduate curricula. Understanding the contributing factors that encourage junior doctors and medical students to consider an IR career will help the IR community to better focus the efforts on recruiting and nurturing the next generation. METHODS: Anonymised questionnaires on undergraduate and postgraduate IR exposure were distributed to attendees of five UK IR symposia between 2019 and 2020. RESULTS: 220 responses were received from 103 (47%) junior doctors and 117 (53%) medical students. Prior IR exposure strongly correlates with individuals' positive views towards an IR career (Pearson's R = 0.40, p < 0.001), with involvement in clinical activities as the most important independent contributor (OR 3.6, 95%CI 1.21-10.50, p = 0.021). Longer time spent in IR (especially as elective modules) and IR-related portfolio-building experiences (such as participating in research, attending conferences and obtaining career guidance) demonstrate strong association with willingness to pursue an IR career for the more motivated (p values < 0.05). The symposia had overall positive effects on subjective likelihood to pursue an IR career, particularly among junior doctors who face near-term career choices (p < 0.001). CONCLUSION: Our study, focusing on a self-selected cohort, identified contributing factors to individuals' willingness to pursue an IR career. Symposia have additional recruitment effects in extra-curricular settings. Active engagement with junior doctors and medical students through clinical activities and non-clinical portfolio-related experiences are key to generate informed and motivated candidates for the future of IR.

Vascular and Interventional Radiology Training; International Perspectives and Challenges.

PURPOSE: Assess international interventional radiology (IR) training standards and trainee satisfaction to identify challenges and drive positive change. MATERIALS AND METHODS: An anonymous survey was created using Survey Monkey and distributed as a single-use web link via eight IR national and international societies around the world. It consisted of two parts: the first assessed the general exposure of radiology trainees to IR and whether this influenced their decision to pursue a career in IR; the second focussed on satisfaction and quality of training by those who are in training or have recently completed an IR training program. RESULTS: There were 496 participants of which 274 were eligible to complete part one of the survey and 222 were eligible to complete the whole survey. UK and Europe contributed 52% of the responses. The USA and Middle East contributed 23%, and the rest of the world 9%. Over half of responders expressed that exposure early in their career was the main inspiration to pursue a career in IR. Overall satisfaction with training was high across all regions; however, satisfaction regarding vascular training varied. The negative impact of competition from other specialities ranged from 9% (USA) to 61% (UK). Great variability was reported regarding the amount of time spent dedicated to IR and IR on call. CONCLUSION: Despite significant progress in creating structured and comprehensive IR training, there is still room for improvement. Early promotion of IR is essential for on-going high-quality recruitment. Monitoring and standardization of the training environment at a national and international level are necessary to equip IR trainees and to consolidate IR's speciality status in the medical field.

Editor's Choice - Systematic Review of the Use of Endoanchors in Endovascular Aortic Aneurysm Repair.

OBJECTIVE: Endoanchor fixation might be a potential adjunct for the prevention and treatment of type Ia endoleak (TIaE) and graft migration in thoracic or abdominal endovascular aortic aneurysm repairs (TEVAR or EVAR). This review aimed to explore the safety and effectiveness of endoanchor fixation in TEVAR and EVAR. METHODS: A systematic review and random effects meta-analysis was conducted. Data sources were PubMed/MEDLINE, Embase, and the Cochrane Library. RESULTS: Seven EVAR and three TEVAR studies using the Heli-FX™ EndoAnchor™ system were included in the meta-analysis. A total of 455 EVAR patients underwent primary endoanchor fixation. Technical success was 98.4% (95% CI 95.7-99.8%). The rate of TIaE and graft migration was 3.5% (95% CI 1.7-5.9%) and 2.0% (95% CI 0.12-6.0%), respectively, after 15.4 months (95% CI 1.76-29.0) follow up. A total of 107 EVAR patients underwent secondary fixation with a technical success of 91.8% (95% CI 86.1-96.2%). Rates of TIaE and graft migration were 22.6% (95% CI 9.1-40.0%) and 0% after a mean 10.7 month (95% CI 7.8-13.6) follow up. Adverse events included three endoanchor fractures, three dislocated endoanchors, one entrapped endoanchor, and one common iliac artery dissection. All cause 30 day EVAR mortality was 0.82% (95% CI 0.20-1.85%). Sixty-six TEVAR patients underwent endoanchor fixation with a mean 9.8 month (95% CI 8.1-11.5) follow up. Technical success was 90.3% (95% CI 72.1-99.4%). The rates of TIaE and migration were 8.7% (95% CI 1.0-18.9%) and 0%, respectively. Adverse events included two misdeployed endoanchors with one fatal aortic dissection. All cause 30 day TEVAR mortality was 11.9% (95% CI 5.4-20.6%). CONCLUSION: Endoanchor fixation in EVAR is technically feasible and safe, with at least comparable early outcomes to the latest generation of stent grafts. Endostapling in TEVAR is associated with lower technical success, higher peri-operative mortality, and potential serious adverse events. Current evidence lacks long term follow up and case controlled trials to recommend endoanchor use in routine practice.

Pain Management Protocols During Uterine Fibroid Embolisation: A Systematic Review of the Evidence.

BACKGROUND: Uterine fibroid embolisation (UFE) is an effective treatment for fibroids. There are varying analgesia protocols published to control procedure associated pain. We aimed to assess what protocols are most effective in controlling post-procedural pain. MATERIALS AND METHODS: A systematic review of the Embase and Medline databases was conducted according to PRISMA guidelines. Studies regarding analgesia protocols post-uterine fibroid embolisation with Visual Analogue Scale or Numerical Rating Scale pain scores were included. The mean maximal pain scores of patients post-procedure were evaluated. ANOVA and t tests were performed. RESULTS: We identified 26 studies (total 3353 patients), with a mean procedural success rate of > 87%. We stratified protocols into four groups. Mean pain scores were: opioids ± NSAIDs ± acetaminophen (4.84, SD = 1.56); opioids ± NSAIDs ± acetaminophen + nerve block (4.7, SD = 1.37); opioids ± NSAIDs ± acetaminophen + intrauterine artery drug administration (4.09, SD = 0.60); and opioids ± NSAIDs ± acetaminophen + other (5.30, SD = 1.13) without significant difference between groups (p = 0.71). Similarly, there was no difference (p = 0.057) between groups for time to discharge or side effects. CONCLUSIONS: There is no evidence to suggest that there is any superiority of one protocol above another in the published literature. Appropriate use of opioids ± NSAIDs ± acetaminophen alone appears to be sufficient to control pain post-UFE. However, due to large heterogeneity of the literature no firm conclusions can be reached, and further research is warranted. LEVEL OF EVIDENCE: Level 1, Systematic review.

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.

Minimally invasive pancreatic necrosectomy; a technical pictorial review.

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Lower limb arterial calcification (LLAC) scores in patients with symptomatic peripheral arterial disease are associated with increased cardiac mortality and morbidity.

AIMS: The association of coronary arterial calcification with cardiovascular morbidity and mortality is well-recognized. Lower limb arterial calcification (LLAC) is common in PAD but its impact on subsequent health is poorly described. We aimed to determine the association between a LLAC score and subsequent cardiovascular events in patients with symptomatic peripheral arterial disease (PAD). METHODS: LLAC scoring, and the established Bollinger score, were derived from a database of unenhanced CT scans, from patients presenting with symptomatic PAD. We determined the association between these scores outcomes. The primary outcome was combined cardiac mortality and morbidity (CM/M) with a secondary outcome of all-cause mortality. RESULTS: 220 patients (66% male; median age 69 years) were included with follow-up for a median 46 [IQR 31-64] months. Median total LLAC scores were higher in those patients suffering a primary outcome (6831 vs. 1652; p = 0.012). Diabetes mellitus (p = 0.039), ischaemic heart disease (p = 0.028), chronic kidney disease (p = 0.026) and all-cause mortality (p = 0.012) were more common in patients in the highest quartile of LLAC scores. The area under the curve of the receiver operator curve for the LLAC score was greater (0.929: 95% CI [0.884-0.974]) than for the Bollinger score (0.824: 95% CI [0.758-0.890]) for the primary outcome. A LLAC score ≥ 4400 had the best diagnostic accuracy to determine the outcome measure. CONCLUSION: This is the largest study to investigate links between lower limb arterial calcification and cardiovascular events in symptomatic PAD. We describe a straightforward, reproducible, CT-derived measure of calcification-the LLAC score.

The role of intravascular ultrasound in lower limb revascularization in patients with peripheral arterial disease.

INTRODUCTION: The aim of this review is to explore the safety and effectiveness of intravascular ultrasound (IVUS) during lower limb endovascular interventions in patients with peripheral arterial disease (PAD). EVIDENCE ACQUISITION: A systematic review of the PubMed and Scopus databases was performed according to PRISMA guidelines. Clinical studies evaluating IVUS as an adjunct to angiography during revascularization procedures in patients with PAD were included. EVIDENCE SYNTHESIS: Thirteen studies were identified, with a total number of 2258 patients having had IVUS for PAD intervention. Seven investigated the role of IVUS for angioplasty and stenting, with the majority being retrospective cohorts. Technical success and patency rates ranged from 90-100% and 45-100%, respectively, with a follow-up that ranged from 4.3-63 months. Three of these studies compared IVUS and non-IVUS guided angioplasty and demonstrated a significant difference in the events of amputations or re-interventions in favor of the IVUS group. Furthermore, five studies evaluated IVUS use in true-lumen re-entry, with the technical success ranging between 97-100%. In one study, where IVUS was used for atherectomy, the technical success was 100% and the long-term patency was 90% during a 12-month follow-up. Overall, no significant peri/postoperative IVUS related complications were reported, whereas, 2 studies suggested an IVUS-associated increase in procedure costs that ranged from $1080-$1333. CONCLUSIONS: There is limited and heterogeneous evidence regarding the use of IVUS for the management of PAD. Further research is required to elucidate the optimal role of IVUS in PAD as well as the cost effectiveness of this approach for routine use in the management of PAD.