Pneumothorax after computed tomography-guided lung biopsy: Utility of immediate post-procedure computed tomography and one-hour delayed chest radiography.

PURPOSE: To evaluate the utility of immediate post-procedure computed tomography (IPP-CT) and routine one-hour chest radiography (1HR-CXR) for detecting and managing pneumothorax in patients undergoing computed tomography (CT)-guided percutaneous lung biopsy. MATERIALS AND METHODS: All CT-guided percutaneous lung biopsies performed between May 2014 and August 2021 at a single institution were included. Data from 275 procedures performed on 267 patients (147 men; mean age: 63.5 ± 14.1 years; range 18-91 years) who underwent routine 1HR-CXR were reviewed. Incidences of pneumothorax and procedure-related complications on IPP-CT and 1HR-CXR were recorded. Associated variables, including tract embolization methods, needle diameter/type, access site, lesion size, needle tract distance, and number of biopsy samples obtained were analyzed and compared between groups with and without pneumothorax. RESULTS: Post-procedure complications included pneumothorax (30.9%, 85/275) and hemoptysis (0.7%, 2/275). Pneumothorax was detected on IPP-CT and 1HR-CXR in 89.4% (76/85) and 100% (85/85), respectively. A chest tube was placed in 4% (11/275) of the cases. In 3.3% (9/275) of the cases, delayed pneumothorax was detected only on 1HR-CXR, but no patient in this group necessitated chest tube placement. The incidence of pneumothorax was not significantly different between tract embolization methods (p = 0.36), needle diameters (p = 0.36) and types (p = 0.33), access sites (p = 0.07), and lesion sizes (p = 0.88). On logistic regression, a lower biopsy sample number (OR = 0.49) was a protective factor, but a longer needle tract distance (OR = 1.16) was a significant risk factor for pneumothorax. CONCLUSION: Following CT-guided percutaneous lung biopsy, pneumothorax detected on IPP-CT strongly indicates persistent pneumothorax on 1HR-CXR and possible chest tube placement. If no pneumothorax is identified on IPP-CT, follow-up 1HR-CXR may be required only for those who develop symptoms of pneumothorax.

An evaluation of the practice of image-guided lumbar puncture.

OBJECTIVE: The purpose of this study was to evaluate the technical success and complication rates of image-guided lumbar puncture (IGLP) and to evaluate for differences in approach employed to help establish the optimum technique. METHODS: A retrospective search of the hospital picture archiving and communications system was performed to identify all IGLPs that had taken place over a 5-year period. Radiology reports and the electronic medical record were examined to identify technical parameters and complications associated with each procedure. RESULTS: The technical success rate was 96% (219/228). 69.4% (n = 161) had a previously failed bedside attempt. The rate of complications was 0.01% (n = 2). No major complications were observed. There was no difference in the rates of failure (2.4% vs 3.6%, p = 0.68) or complications (0.008% vs 0.012%, p = 1) between interlaminar and interspinous approaches. CONCLUSION: IGLP is a safe procedure with a high rate of technical success. Where a difficult bedside attempt is anticipated, it is reasonable to forego this and proceed directly to IGLP. ADVANCES IN KNOWLEDGE:: This paper helps to confirm what is already assumed about a common radiological procedure. This is important as there has been a shift from bedside technique to most lumbar punctures being performed via image guidance.

Central venous access in children: Placement trends over the last decade.

PURPOSE: To evaluate central venous access placement trends for radiology and non-radiology services over the last decade. MATERIALS AND METHODS: Children who had central venous access procedures included in a large administrative database of 49 pediatric institutions in the United States between 2010 and 2020 were included. Patient demographics and patient specific factors were compared between groups. The percentage of procedures performed by interventional radiology (IR) and non-radiology services were compared over time and by region. RESULTS: A total of 483,181 vascular access encounters were recorded (45.3% female; median age 2 years (IQR 0-11 years)). Approximately one quarter of vascular access encounters were IR-led, with a slight increase of 3.8% between 2010 and 2020. Children who underwent IR-placed vascular access were older (median age of 4 years compared to 1 year in non-radiology encounters). Interventional radiology-placed access was greatest in the Midwest (33.5%) with a decrease of 5.9% over the study period; in the other three regions, IR-performed encounters increased. Patient comorbidities more prevalent in the IR encounters were technology dependence (42.4% of all radiology encounters), gastrointestinal (34.9%), respiratory (20.8%), and transplant (8.1%), while those which were more prevalent in the non-radiology encounters were nephrology/urology (21.4% of all non-radiology encounters), prematurity/neonatal (17.3%), and malignancy (17.3%). CONCLUSIONS: Interventional radiology-provided vascular access services have slightly increased over the last decade without significant service-line transfer to other specialties. Underlying comorbidities in IR-led vascular access encounters vary across institutions based on referral patterns, possibly reflecting the adoption of ultrasound guidance by other pediatric subspecialties.

CT-guided microcoil localization for scapula-blocked pulmonary nodules using penetrating lung puncture before video-assisted thoracic surgery.

PURPOSE: To retrospectively analyze the effectiveness and safety of computed tomography (CT)-guided microcoil localization for scapula-blocked pulmonary nodules using penetrating lung puncture prior to video-assisted thoracic surgery (VATS). METHODS: One hundred thirty-eight patients with 138 pulmonary nodules were included in this single-center retrospective study. Among them, 110 patients who underwent CT-guided microcoil localization using the routine puncture technique formed the routine group; the other 28 patients who underwent the CT-guided microcoil localization using the penetrating lung puncture technique formed the penetrating lung group. The main outcomes were the success rate and complication rate of the two groups. RESULTS: The localization success rate was 95.5% (105/110) in the routine group and 89.3% (25/28) in the penetrating lung group (P = 0.205). There was no statistical difference in any of the complications (pneumothorax, intrapulmonary hemorrhage, or moderate and severe chest pain) in both groups (P = 0.178, P = 0.204, P = 0.709, respectively). Localization procedure time was significantly increased in the penetrating lung group compared with the routine group (31.0 ± 3.0 min vs. 21.2 ± 2.8 min, P < 0.001). CONCLUSION: CT-guided microcoil localization for scapula-blocked pulmonary nodules using penetrating lung puncture prior to VATS resection is effective and safe. However, the deployment of the microcoil using penetrating lung puncture required more time than the routine puncture method.

Characterization of patient dose distributions and probabilistic risk analysis in cardiovascular catheterization laboratories.

Purpose: Patient radiation doses in cardiovascular and interventional radiology are highly variable for similar procedures. This random nature may be better described by a distribution function, compared to a linear regression. This study develops a distribution function to characterize patient dose distributions and estimate probabilistic risk.Methods: Reference air kerma from 8647 patients over six years were retrospectively collected from an EP lab and two Cath labs. Data was first sorted into low dose (<100mGy) and high dose cases (>100mGy), and histograms of the data created. Dagum and Inverse gamma distributions were chosen to initially fit to both low and high dose cases. Fits between model and the data was optimized, and a linear regression analysis performed to obtain R squared values and standard errors for the correlation between model and data. Risk probabilities were estimated according to the modeled distribution function. BMI and time distributions were analyzed to understand their influence on the inverse gamma distribution error found in the data. 75th percentiles from both descriptive statistics and model were calculated.Results: The inverse gamma distribution can be used to characterize radiation dose distributions. Model predicted cases for radiation dose 3000mGy< x <5000mGy and >5000mGy are approximately 42 and 0 for 3651 cases for lab#1, and 14 and 1 for 3197 cases for lab#2, respectively, while the actual cases are 10 and 0, and 16 and 2. Descriptive and model statistics generated different 75th percentile levels for sorted data compared to unsorted data. Time has a greater influence on inverse gamma distribution function than BMI.Conclusion: This study creates a framework to understand the random error present in radiology practices that cause wide variations in patient radiation doses. It also provides an approach to evaluate different IR areas in terms of effectiveness of dose reduction measures.

Prediction of Complication Risk in Computed Tomography-guided Thoracic Biopsy: A Prescription for Improving Procedure Safety.

PURPOSE: Computed tomography-guided transthoracic biopsy (CTTB) is a minimally invasive procedure with a high diagnostic yield for a variety of thoracic diseases. We comprehensively assessed a large CTTB cohort to predict procedural and patient factors associated with the risk of complications. MATERIALS AND METHODS: The medical record and computed tomography images of 1430 patients who underwent CTTB were reviewed individually to obtain clinical information and technical procedure factors. Statistical analyses included descriptive and summary statistics, univariate analysis with the Fisher test, and multivariate logistic regression. RESULTS: The most common type of complication was pneumothorax (17.4%), followed by bleeding (5.9%). Only 26 patients (1.8%) developed a major complication. Lung lesions carried a higher risk of complications than nonlung lesions. For lung lesions, the nondependent position of the lesion, vertical needle approach, trespassing aerated lung, and involvement of a trainee increased the risk of complication, whereas the use of the coaxial technique was a protective factor. The time with the needle in the lung, the number of biopsy samples, and the distance crossing the aerated lung were identified as additional risk factors in multivariate analysis. For nonlung lesions, trespassing the pleural space was the single best predictor of complications. A logistic regression-based model achieved an area under the receiver operating characteristic curve of 0.975, 0.699, and 0.722 for the prediction of major, minor, and no complications, respectively. CONCLUSIONS: Technical procedural factors that can be modified by the operator are highly predictive of the risk of complications in CTTB.

Effectiveness of radiation protection systems in the cardiac catheterization laboratory: a comparative study.

BACKGROUND: As numbers and complexity of percutaneous coronary interventions are constantly increasing, optimal radiation protection is required to ensure operator safety. Suspended radiation protection systems (SRPS) and protective scatter-radiation absorbing drapes (PAD) are novel methods to mitigate fluoroscopic scattered radiation exposure. The aim of the study was to investigate the effectiveness regarding radiation protection of a SRPS and a PAD in comparison with conventional protection. METHODS: A total of 229 cardiac catheterization procedures with SRPS (N = 73), PAD (N = 82) and standard radiation protection (N = 74) were prospectively included. Real-time dosimeter data were collected from the first operator and the assistant. Endpoints were the cumulative operator exposure relative to the dose area product [standardized operator exposure (SOE)] for the first operator and the assistant. RESULTS: For the first operator, the SRPS and the PAD significantly decreased the overall SOE compared to conventional shielding by 93.9% and 66.4%, respectively (P < 0.001). The protective effect of the SRPS was significantly higher compared to the PAD (P < 0.001). For the assistant, the SRPS and the PAD provided a not statistically significant reduction compared to conventional shielding in the overall SOE by 38.0% and 30.6%, respectively. CONCLUSIONS: The SRPS and the PAD enhance radiation protection significantly compared to conventional protection. In most clinical scenarios, the protective effect of SRPS is significantly higher than the additional protection provided by the PAD. Comparison of the additional radiation protection provided by protective scatter-radiation absorbing drapes (PAD) and the suspended radiation protection system (SRPS) system over standard protection with lead aprons.

Local reference and achievable dose levels for vascular and enterostomy access procedures in pediatric interventional radiology.

BACKGROUND: Knowledge of radiation quantities delivered in routine practice is an essential responsibility of a pediatric interventional radiology department. OBJECTIVE: To review radiation indices in frequently performed vascular and enterostomy access procedures at a quaternary pediatric hospital to formulate dosimetric reference levels and achievable levels. MATERIALS AND METHODS: A retrospective review of patient demographics, procedure information and quantitative dose metrics over a 2-year period was performed. Dosimetric details for common procedures (central line insertions, gastrostomy/gastrojejunostomy insertions and maintenance) were evaluated, correlated with demographic data and stratified across five weight groups (0-5 kg, 5-15 kg, 15-30 kg, 30-50 kg, 50-80 kg). Achievable (50th percentile) and reference (75th percentile) levels with confidence intervals were established for each procedure. RESULTS: Within the evaluation period, 3,165 studies satisfied the inclusion criteria. Five were classified as device insertions (peripherally inserted central catheter, n=1,145; port-a-catheter, n=321; central venous line, n=285; gastrostomy-tube [G-tube], n=262, and gastrojejunostomy-tube [GJ-tube], n=66), and two were classified as maintenance procedures (G-tube, n=358, and GJ-tube, n=728, checks, exchanges and reinsertions). Representative reference and achievable levels were calculated for each procedure category and weight group. CONCLUSION: This work highlights the creation of local reference and achievable levels for common pediatric interventional procedures. These data establish a dosimetric reference to understand the quantity of radiation routinely applied, allowing for improved relative radiation risk assessment and enriched communication to interventionalists, health care providers, parents and patients.

Cone-beam computed tomography-assisted percutaneous gastrostomy tube insertion in children with challenging anatomy.

BACKGROUND: Percutaneous radiological gastrostomy tube insertion is a common procedure in children. An approach using ultrasound and fluoroscopy may not be feasible in patients with challenging anatomy; therefore, advanced techniques or other imaging modalities may be required. OBJECTIVE: To describe our experience using cone-beam computed tomography (CT)-assisted percutaneous gastrostomy insertion in pediatric patients with challenging anatomy. MATERIALS AND METHODS: A retrospective review was performed in children who underwent cone-beam CT-assisted percutaneous radiologic gastrostomy between January 2015 and July 2019. Indications, technique, outcomes, complications, and radiation dose (reference-point air kerma, air kerma area product) were assessed through chart and imaging review. Descriptive statistics only were used. RESULTS: Twenty-seven procedures were attempted in 26 patients. Reasons for utilizing cone-beam CT guidance were high-positioned stomach (n = 10), interposing bowel loops and liver (n = 19), omphalocele (n = 1), severe scoliosis (n = 1), and ventriculoperitoneal shunt (n = 1). Technical success was 85% (23/27). Mean procedure time was 96 min (range 50-131 min). No safe access route into the stomach was encountered in four patients; three were referred for surgical gastrostomy and one had a successful re-attempt. Radiation dose data was obtained from 19 procedures (17 successful) with a total dose in successful procedures ranging from 8.1 to 63.6 mGy (average 26.2 mGy, median 24.9 mGy). The number of cone-beam CT acquisitions per procedure ranged from 1 to 4. Major complication frequency was 11% (3/27) (bleeding, peritonitis, and aspiration pneumonia); minor complication frequency was 3.7% (1/27). CONCLUSION: This study shows that cone-beam CT guidance can be useful for assisting percutaneous radiologic gastrostomy in children with challenging anatomy.

Cananga odorata Aromatherapy Reduces Anxiety in Unexperienced Patients Hospitalized for Interventional Neuroradiology Procedures: A Randomized Control Trial.

The hospitalization and the unfamiliar experiences of patients in interventional radiology procedures cause a moderate to high levels of anxiety. This study was aimed to evaluate the anxiolytic effect of Cananga odorata essential oil (COE) aromatherapy in unexperienced patients hospitalized for interventional neuroradiology (INR) procedures. Forty-four patients admitted for their first INR procedure were randomly divided into COE and placebo control groups. COE or distilled water was dropped onto 2 pieces of mulberry paper and attached to the participant's gown at the shoulder level overnight. The main outcomes were observed from the morning salivary cortisol levels and salivary alpha-amylase activity after intervention. The Thai version of Spielberger State-Trait Anxiety Inventory (STAI) and the vital signs (blood pressure and heart rate) were also assessed before and after COE intervention as the secondary outcome. The demographic and baseline data of both groups did not show any significant difference. After intervention, COE group had a significantly lower salivary alpha-amylase activity than placebo control group. The post-intervention scores of Trait (STAI-T) and State (STAI-S) anxiety were significantly less than those of baseline in both groups. Interestingly, the COE group had a greater percentage reduction on STAI-T after intervention than placebo control group. No significant difference was observed in other outcomes. In addition, the salivary alpha-amylase activity was weak but showed significant correlation with STAI anxiety scores. This study indicates that COE aromatherapy reduces the saliva alpha amylase activity and STAI-T anxiety in unexperienced patients hospitalized for INR procedures.

Combined autologous blood patch-immediate patient rollover does not reduce the pneumothorax or chest drain rate following CT-guided lung biopsy compared to immediate patient rollover alone.

PUPROSE: The purpose of this study was to evaluate a combined autologous blood-patch (ABP)-immediate patient rollover (IPR) technique compared with the IPR technique alone on the incidence of pneumothorax and chest drainage following CT-guided lung biopsy. METHODS: In this interventional cohort study of both prospectively and retrospectively acquired data, 652 patients underwent CT-guided lung biopsy. Patient demographics, lesion characteristics and technical biopsy variables including the combined ABP-IPR versus IPR alone were evaluated as predictors of pneumothorax and chest drain rates using regression analysis. RESULTS: The combined ABP-IPR technique was performed in 259 (39.7 %) patients whilst 393 (60.3 %) underwent IPR alone. There was no significant difference in pneumothorax rate or chest drains required between the combined ABP-IPR vs IPR groups (p =.08, p =.60 respectively). Predictors of pneumothorax adjusted for the combined ABP-IPR and IPR alone groups included age (p =.02), lesion size (p =.01), location (p =.005), patient position (p =.008), emphysema along the needle track (p =.005) and lesion distance from the pleura (p =.02). Adjusted predictors of chest drain insertion included lesion location (p =.09), patient position (p =.002), bullae crossed (p =.02) and lesion distance from the pleura (p =.02). CONCLUSION: The combined ABP-IPR technique does not reduce the pneumothorax or chest drain rate compared to the IPR technique alone. Utilising IPR without an ABP following CT-guided lung biopsy results in similar pneumothorax and chest drain rates while minimising the potential risk of systemic air embolism.

DIAGNOSTIC REFERENCE LEVELS AND COMPLEXITY INDICES IN INTERVENTIONAL RADIOLOGY.

The establishment of typical diagnostic reference levels (DRLs) values according to the complexity indices (CIs) for hepatic chemoembolisation (HC), iliac stent placement (ISP) and femoropopliteal revascularisation (FR) is reported in this study. To estimate patients' stochastic effects, effective dose was calculated through dose area product (DAP) values of this study and E/DAP conversion factors derived from the literature. Data for DAP, Reference Air Kerma (Ka,r) and fluoroscopy time (FT) were collected for 218 patients and CIs were assigned to each procedure to extract DRLs. To estimate effective dose, conversion factors and DAP values were used for seven IR procedures. DRL values for DAP were 141, 130 and 28 Gy*cm2 for HC, ISP, and FR, respectively. The corresponding DRL values for Ka,r were 634.6, 300.1 and 112.0 mGy, and for FT were 15.3, 12.4 and 17.9 min, respectively. CIs in interventional radiology are a useful tool for the optimisation of DRLs since they contribute to patient's doses.

Reduction of radiation dose using real-time visual feedback dosimetry during angiographic interventions.

This prospective study sought to evaluate potential savings of radiation dose to medical staff using real-time dosimetry coupled with visual radiation dose feedback during angiographic interventions. For this purpose, we analyzed a total of 214 angiographic examinations that consisted of chemoembolizations and several other types of therapeutic interventions. The Unfors RaySafe i2 dosimeter was worn by the interventionalist at chest height over the lead protection. A total of 110 interventions were performed with real-time radiation dosimetry allowing the interventionalist to react upon higher x-ray exposure and 104 examinations served as the comparative group without real-time radiation monitoring. By using the real-time display during interventions, the overall mean operator radiation dose decreased from 3.67 (IQR, 0.95-23.01) to 2.36 µSv (IQR, 0.52-12.66) (-36%; p = 0.032) at simultaneously reduced operator exposure time by 4.5 min (p = 0.071). Dividing interventions into chemoembolizations and other types of therapeutic interventions, radiation dose decreased from 1.31 (IQR, 0.46-3.62) to 0.95 µSv (IQR, 0.53-3.11) and from 24.39 (IQR, 12.14-63.0) to 10.37 µSv (IQR, 0.85-36.84), respectively, using live-screen dosimetry (p ≤ 0.005). Radiation dose reductions were also observed for the participating assistants, indicating that they could also benefit from real-time visual feedback dosimetry during interventions (-30%; p = 0.039). Integration of real-time dosimetry into clinical processes might be useful in reducing occupational radiation exposure time during angiographic interventions. The real-time visual feedback raised the awareness of interventionalists and their assistants to the potential danger of prolonged radiation exposure leading to the adoption of radiation-sparing practices. Therefore, it might create a safer environment for the medical staff by keeping the applied radiation exposure as low as possible.

Effect of an optimized X-ray blanket design on operator radiation dose in cardiac catheterization based on real-world angiography.

BACKGROUND: There is increasing concern and focus in the interventional cardiology community on potential long term health issues related to radiation exposure and heavy wearable protection. Optimized shielding measures may reduce operator dose to levels where lighter radioprotective garments can safely be used, or even omitted. X-ray blankets (XRB) are commercially available but suffer from small size and lack of stability. A larger XRB may reduce operator dose but could hamper vascular access and visualization. The aim of this study is to assess shielding effect of an optimized XRB during cardiac catheterization and estimate the potential reduction in annual operator dose based on DICOM Radiation Dose Structured Report (RDSR) data reflecting everyday clinical practice. METHODS: Data accumulated from 7681 procedures over three years in our RDSR repository was used to identify projection angles and radiation doses during cardiac catheterization. Using an anthropomorphic phantom and a scatter radiation detector, radiation dose to the operator (mSv) and patient (dose area product-DAP) was measured for each angiographic projection for three different shielding setups. Relative operator dose (mSv/DAP) was calculated and multiplied by DAP per projection to estimate effect on operator dose. RESULTS: Adding an optimized XRB to a standard shielding setup comprising a table- and ceiling-mounted shield resulted in a 94.9% reduction in estimated operator dose. The largest shielding effect was observed in left and cranial projections where the ceiling-mounted shield offered less protection. CONCLUSIONS: An optimized XRB is a simple shielding measure that has the potential to reduce operator dose.

Percutaneous Radiology Gastrostomy (PRG)-Associated Complications at a Tertiary Hospital over the Last 25 Years.

OBJECTIVES: We aimed to describe and compare the complications associated with different percutaneous radiologic gastrostomy (PRG) techniques. METHODS: A retrospective and prospective observational study was conducted. Patients who underwent a PRG between 1995-2020 were included. TECHNIQUES: A pigtail catheter was used until 2003, a balloon catheter without pexy was used between 2003-2009 and a balloon catheter with gastropexy was used between 2015-2021. For the comparison of proportions, X2 tests or Fisher's test were used when necessary. Univariate analysis was performed to study the risk factors for PRG-associated complications. RESULTS: n = 330 (pigtail = 114, balloon-type without pexy = 28, balloon-type with pexy = 188). The most frequent indication was head and neck cancer. The number of patients with complications was 44 (38.5%), 11 (39.2%) and 54 (28,7%), respectively. There were seven (25%) cases of peritonitis in the balloon-type without-pexy group and 1 (0.5%) in the balloon-type with-pexy group, the latter being the only patient who died in the total number of patients (0.3%). Two (1%) patients of the balloon-type with-pexy group presented with gastrocolic fistula. The rest of the complications were minor. CONCLUSIONS: The most frequent complications associated with the administration of enteral nutrition through PRG were minor and the implementation of the balloon-type technique with pexy has led to a decrease in them.