Efficacy and Safety of Radiation Segmentectomy with 90Y Resin Microspheres for Hepatocellular Carcinoma.

Background Limited data are available on radiation segmentectomy (RS) for treatment of hepatocellular carcinoma (HCC) using yttrium 90 (90Y) resin microsphere doses determined by using a single-compartment medical internal radiation dosimetry (MIRD) model. Purpose To evaluate the efficacy and safety of RS treatment of HCC with 90Y resin microspheres using a single-compartment MIRD model and correlate posttreatment dose with outcomes. Materials and Methods This retrospective single-center study included adult patients with HCC who underwent RS with 90Y resin microspheres between July 2014 and December 2022. Posttreatment PET/CT and dosimetry were performed. Adverse events were assessed using the Common Terminology Criteria for Adverse Events, version 5.0. Per-lesion and overall response rates (ie, complete response [CR], objective response, disease control, and duration of response) were assessed at imaging using the Modified Response Evaluation Criteria in Solid Tumors, and overall survival (OS) was assessed using Kaplan-Meier analysis. Results Among 67 patients (median age, 69 years [IQR, 63-78 years]; 54 male patients) with HCC, median tumor absorbed dose was 232 Gy (IQR, 163-405 Gy). At 3 months, per-lesion and overall (per-patient) CR was achieved in 47 (70%) and 41 (61%) of 67 patients, respectively. At 6 months (n = 46), per-lesion rates of objective response and disease control were both 94%, and per-patient rates were both 78%. A total of 88% (95% CI: 79 99) and 72% (95% CI: 58, 90) of patients had a per-lesion and overall duration of response of 1 year or greater. At 1 month, a grade 3 clinical adverse event (abdominal pain) occurred in one of 67 (1.5%) patients. Median posttreatment OS was 26 months (95% CI: 20, not reached). Disease progression at 2 years was lower in the group that received 300 Gy or more than in the group that received less than 300 Gy (17% vs 61%; P = .047), with no local progression in the former group through the end of follow-up. Conclusion Among patients with HCC who underwent RS with 90Y resin microspheres, 88% and 72% achieved a per-lesion and overall duration of response of 1 year or greater, respectively, with one grade 3 adverse event. In patients whose tumors received 300 Gy or more according to posttreatment dosimetry, a disease progression benefit was noted. © RSNA, 2024 Supplemental material is available for this article.

The Impact of Implementation of a Commercial Inferior Vena Cava Filter Database Program on Filter Retrieval versus Physician Tracking over a 9-Year Period: A Retrospective, Observational Study.

PURPOSE: To compare the impact of a commercial tracking database on inferior vena cava filter retrievals with that of physician tracking and no tracking. MATERIALS AND METHODS: From January 2013 to December 2021, 532 filters were placed at a single institution and followed in 3 phases: (a) Phase 1, pretracking (January 1, 2013, to February 28, 2015); (b) Phase 2, commercial database tracking (March 1, 2015, to June 30, 2019); and (c) Phase 3, commercial database tracking with separate tracking by an interventional radiologist (July 1, 2019, to December 31, 2021). Patients excluded from the commercial database due to human error served as a control group. Outcomes of commercial database entry, 2-year filter retrieval rates, dwell times, and factors contributing to retrieval candidacy were collected. RESULTS: Two-year retrieval rates in Phases 1, 2 and 3 were 20%, 31%, and 46%, respectively (Phase 1 vs 2, P = .04; Phase 2 vs 3, P = .009). Median dwell times across Phases 1, 2, and 3 were 168 days (4-1,313 days), 140 days (3-1,988 days), and 188 days (13-734 days) (P = .33), respectively. There was no difference in retrieval rates (P = .86) and dwell times (P = .50) between patients enrolled in the database group and those enrolled in the control group. Across all phases, 48% of patients enrolled in the database were not successfully contacted, and only 6% were categorized as "likely to consult" filter retrieval. During Phase 3, 100% of patients achieved a retrieval disposition. CONCLUSIONS: A commercial tracking database had low success rates of contacting patients and did not increase filter retrieval rates relative to those in the control group; however, physician tracking increased retrieval rates.

Association between Patient Experience Scores and Low Utilization of Hepatocellular Carcinoma Treatment in the United States: A Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Analysis (SEER-CAHPS).

PURPOSE: To study the experiences of patients with hepatocellular carcinoma (HCC) contributing to treatment discrepancy in the United States. MATERIALS AND METHODS: Using Surveillance, Epidemiology, and End Results data from National Cancer Institute (NCI), Medicare (2002-2015) beneficiaries with HCC who completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were included. Six CAHPS items (3 global scores: global care rating [GCR], primary doctor rating [PDR], and specialist rating [SR]; 3 composite scores: getting needed care [GNC], getting care quickly [GCQ], and doctor communication [DC]) assessed patient experience. Covariates assessed between treated and nontreated groups included patient, disease, hospital, and CAHPS items. RESULTS: Among 548 patients with HCC, 211 (39%) received treatment and 337 (61%) did not receive treatment. Forty-two percent (GCR), 29% (PDR), 30% (SR), 36% (GNC), 78% (GCQ), and 35% (DC) of patients reported less-than-excellent experiences on the respective CAHPS items. Chronic liver disease (CLD) was present in 52% and liver decompensation (LD) in 60%. A minority of the hospitals were NCI-designated cancer centers (47%), transplant centers (27%), and referral centers (9%). On univariable analysis, patients with at least a high school degree (odds ratio [OR], 1.9), admittance to a ≥400-bed hospital (OR, 2.7), CLD (OR, 3.0), or LD (OR, 1.7) were more likely to receive treatment, whereas older patients (≥75 years) (OR, 0.5) were less likely to receive treatment. On multivariable, patients with CLD (OR, 6.8) and an excellent experience in GNC with a specialist (OR, 10.6) were more likely to receive treatment. CONCLUSIONS: HCC treatment discrepancy may be associated with patient-related factors, such as lack of specialist care (GNC), and disease-related factors, such as absence of underlying CLD.

Angiography with cone-beam CT versus contrast-enhanced MRI for living donor transplant imaging: Is MRI enough?

The purpose of this study is to compare the subjective and objective quality and confidence between conventional angiography with cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) for the preoperative evaluation of potential donors for living donor liver transplant. Seventeen patients undergoing preoperative donor evaluation for living donor liver transplantation that underwent angiography with CBCT and contrast-enhanced MRI for evaluation of hepatic vascular anatomy were included in the study. Four attending radiologists interpreted anonymized, randomized angiography with CBCT images and MRIs, rating the diagnostic quality and confidence of their interpretation (on a 3-point scale) for each element, as well as clinically relevant measurements. Overall, the readers rated the quality of angiography with CBCT to be higher than that of MRI (median [interquartile range] = 3 (2, 3) vs. 2 (1-3), p < 0.001) across all patients. Readers of angiography with CBCT had more confidence in their interpretations as an average of all elements evaluated than the MRI readers (3 (3) vs. 3 (2, 3), p < 0.001). When the same reader interpreted both MRI and CBCT, the right hepatic artery diameter (3.8 mm ± 0.72 mm vs. 4.5 mm ± 1.2 mm, p < 0.005) and proper hepatic artery diameter (4.43 mm ± 0.98 mm vs. 5.4 mm ± 1.05 mm, p < 0.003) were significantly different between MRI and CBCT. There was poor interrater reliability for determining segment IV arterial supply for both modalities (κ < 0.2). Angiography with CBCT provides higher subjective diagnostic quality and greater radiologist confidence than MRI. The difference in measurements between CBCT and MRI when the same reader reads both studies suggests CBCT adds additional information over MRI evaluation alone.

Patient and Provider Perspectives of Telehealth and In-Person Interventional Radiology Clinic Visits.

PURPOSE: To assess patient and provider satisfaction with interventional radiology (IR) outpatient telehealth and in-person clinic. MATERIALS AND METHODS: This institutional review board-approved study analyzed patient satisfaction with clinic via survey after an IR outpatient telehealth or in-person visit. A physician telehealth experience survey was completed by 8 IR physicians. RESULTS: During the initial survey period, 44 (83%) of 53 patients completed a survey via telephone compared with 37 (23%) of 158 patients who were offered an electronic survey during the second survey period. Of 81 respondents, 18 (22%) were in-person and 63 (78%) were via telehealth. Of the respondents, nearly all patients (97%) in the telehealth group reported satisfaction with their telehealth clinic visit, with similar rates of high patient satisfaction between in-person and telehealth visits (P = .51). Most patients (98%) in the telehealth group strongly agreed that their physician's recommendations were clear in the telehealth visit and that their visit was private, similar to in-person visits (P = .13). A telehealth visit saved time for all patients (100%), with 78% reporting >1 hour of time-saving. All IR physicians (n = 8) reported greater efficiency with telehealth clinic than with in-person clinic and that follow-up patterns would change if telehealth was available. However, all providers (100%) found telephone visits less satisfying than in-person visits, with video visits being either equally satisfying (71%) or less satisfying (29%). CONCLUSIONS: Patient satisfaction with the in-person and telehealth outpatient IR clinic was high, with patients and providers reporting time-saving and greater efficiency with telehealth, suggesting that telehealth should remain an important component of outpatient IR clinic care.

Transjugular Intrahepatic Portosystemic Shunt and Thrombectomy (TIPS-Thrombectomy) for Symptomatic Acute Noncirrhotic Portal Vein Thrombosis.

PURPOSE: To report the safety and effectiveness of transjugular intrahepatic portosystemic shunt and mechanical thrombectomy (TIPS-thrombectomy) for symptomatic acute noncirrhotic portal vein thrombosis (NC-PVT). MATERIALS AND METHODS: Patients with acute NC-PVT who underwent TIPS-thrombectomy between 2014 and 2021 at a single academic medical center were retrospectively reviewed. Thirty-two patients were included (men, 56%; median age, 51 years [range, 39-62 years]). The causes for PVT included idiopathic (n = 12), prothrombotic disorders (n = 11), postsurgical sequelae (n = 6), pancreatitis (n = 2), and Budd-Chiari syndrome (n = 1). The indications for TIPS-thrombectomy included refractory abdominal pain (n = 14), intestinal venous ischemia (n = 9), ascites (n = 4), high-risk varices (n = 3), and variceal bleeding (n = 2). Variables studied included patient, disease, and procedure characteristics. Patients were monitored over the course of 1-year follow-up. RESULTS: Successful recanalization of occluded portal venous vessels occurred in all 32 patients (100%). Compared with pretreatment patency, recanalization with TIPS-thrombectomy resulted in an increase in patent veins (main portal vein [28% vs 97%, P < .001], superior mesenteric vein [13% vs 94%, P < .001], and splenic vein [66% vs 91%, P < .001]). Three procedure-related adverse events occurred (Society of Interventional Radiology grade 2 moderate). Hepatic encephalopathy developed in 1 (3%) of 32 patients after TIPS placement. At 1-year follow-up, return of symptoms occurred in 3 (9%) of 32 patients: (a) ascites (n = 1), (b) variceal bleeding (n = 1), and (c) intestinal venous ischemia (n = 1). The intention-to-treat 1-year portal vein and TIPS primary and secondary patency rates were 78% (25/32) and 100% (32/32), respectively. Seven patients required additional procedures, and the 1-year mortality rate was 3% (1/32). CONCLUSIONS: TIPS-thrombectomy is a safe and effective method for treating patients with symptomatic acute NC-PVT.

Evaluation of Technical Performance of Ultrasound-Guided Procedures through Hand Motion Analysis: An Exploration of Motion Metrics.

PURPOSE: To evaluate the ability of hand motion analysis using conventional and new motion metrics to differentiate between operators of varying levels of experience for central venous access (CVA) and liver biopsy (LB). MATERIALS AND METHODS: In the CVA task, 7 interventional radiologists (experts), 10 senior trainees, and 5 junior trainees performed ultrasound-guided CVA on a standardized manikin; 5 trainees were retested after 1 year. In the LB task, 4 radiologists (experts) and 7 trainees biopsied a lesion on a manikin. Conventional motion metrics (path length and task time), a refined metric (translational movements), and new metrics (rotational sum and rotational movements) were calculated. RESULTS: In the CVA task, experts outperformed trainees on all metrics (P < .02). Senior trainees required fewer rotational movements (P = .02), translational movements (P = .045), and time (P = .001) than junior trainees. Similarly, on 1-year follow-up, trainees had fewer translational (P = .02) and rotational (P = .003) movements with less task time (P = .003). The path length and rotational sum were not different between junior and senior trainees or for trainees on follow-up. Rotational and translational movements had greater area under the curve values (0.91 and 0.86, respectively) than the rotational sum (0.73) and path length (0.61). In the LB task, experts performed the task with a shorter path length (P = .04), fewer translational (P = .04) and rotational (P = .02) movements, and less time (P < .001) relative to the trainees. CONCLUSIONS: Hand motion analysis using translational and rotational movements was better at differentiating levels of experience and improvement with training than the conventional metric of path length.

Echocardiographic and Other Preprocedural Predictors of Heart Failure After TIPS Placement in Patients With Cirrhosis: A Single-Center 15-Year Analysis.

BACKGROUND. Heart failure (HF) is an uncommon complication after TIPS placement; its development represents a poor prognostic factor. OBJECTIVE. The purpose of our study was to evaluate the frequency, risk factors, and association with survival of HF developing within 90 days after TIPS placement in patients with cirrhosis. METHODS. This retrospective single-center study included patients with cirrhosis who underwent nonemergent covered-stent TIPS placement from June 2003 to December 2018 and who underwent echocardiography within 2 months before TIPS placement and had at least 90 days of post-TIPS follow-up. Development of HF within 90 days after TIPS was recorded. Frequency of TIPS reduction for post-TIPS HF was determined. Univariable logistic regression analysis and ROC curve analysis were performed to assess potential risk factors for post-TIPS HF. Association of post-TIPS HF and 1-year survival was assessed by the log rank test. RESULTS. The study sample included 107 patients (71 men and 36 women; median age, 58 years). Post-TIPS HF developed in 11 of 107 (10%) patients; median time to development of HF was 16 days (range, 2-62 days). Of these 11 patients, three (27%) required TIPS reduction to achieve resolution of HF symptoms after unsuccessful diuretic therapy. Pre-TIPS right atrium size (odds ratio [OR], 3.26 [95% CI, 1.22-10.16]; p = .03], left ventricle (LV) end-systolic dimension (OR, 5.43 [95% CI, 1.44-24.50], p = .02), LV end-diastolic dimension (OR, 4.12 [95% CI, 1.51-13.47]; p = .009), and estimated peak pulmonary artery systolic pressure (PASP) (OR, 1.27 [95% CI, 1.12-1.50]; p = .001) were associated with post-TIPS HF. AUC of right atrium size, LV end-systolic dimension, LV end-diastolic dimension, and estimated peak PASP for development of post-TIPS HF were 0.71, 0.74, 0.72, and 0.83, respectively. At a cutoff of 31 mm Hg, PASP achieved sensitivity of 70% and specificity of 86% for post-TIPS HF. Patients with post-TIPS HF and those without post-TIPS HF had 1-year survival of 46% versus 73% (p = .06). CONCLUSION. Multiple pre-TIPS echocardiographic variables predict the development of post-TIPS HF in patients with cirrhosis. CLINICAL IMPACT. Preprocedural echocardiography may guide risk stratification in patients with cirrhosis being considered for TIPS placement.

Motion-Tracking Machines and Sensors: Advancing Education Technology.

Graduate medical education is predominantly based on a time-based apprenticeship model, with implied acquisition of proficiency after a pre-set amount of clinical exposure. While motion metrics have been used previously to measure skill performance indicators, these assessments have largely been performed on a summative scale to describe the performance of complete tasks or procedures. By segmenting performances of interest and assessing the essential elements individually, a more comprehensive understanding of the aspects in need of improvement for a learner can be obtained. The purpose of this review is to discuss technologies applicable to motion tracking, their benefits and limitations, approaches to data processing, and potential applications based on recent improvements in this technology. Objective analysis of motion metrics may improve educational standards of learning and efficiency by both standardizing the feedback process for trainees and reducing the volume of instructors required to facilitate practice sessions. With rigorous validation and standardization, motion metric assessment may also prove useful to demonstrate competency in technical procedures as part of a comprehensive certification process.

Assessing Skill Acquisition in Anesthesiology Interns Practicing Central Venous Catheter Placement Through Advancements in Motion Analysis.

OBJECTIVES: The study authors hypothesized that a combination of previously used (path length, translational motions, and time) and novel (rotational sum) motion metrics could be used to analyze learning curves of anesthesiology interns (postgraduate year 1) practicing central venous catheter placement in the simulation setting. They also explored the feasibility of using segmented motion recordings to inform deliberate practice. DESIGN: A prospective cohort study. SETTING: A single academic medical center. PARTICIPANTS: Anesthesiology interns (postgraduate year 1). INTERVENTIONS: Anesthesiology interns underwent a 2-day training course in which they performed 9 central venous catheter placements, while attached to motion sensors on the dorsum of their dominant hand and ultrasound probe. MEASUREMENTS AND MAIN RESULTS: Motion metrics were analyzed using generalized estimating equations for both the overall procedure and predefined segments. Five attending anesthesiologists performed 3 trials each for comparison. Overall, there was a negative trend in path length, translational motions, rotational sum, and time (p < 0.001), with the exception of translational motions of the ultrasound probe. Interns reached within 1 standard deviation of the attending anesthesiologists by trials 7-to-8 for most metrics. Segmentation identified specific components of the procedure that were either significantly improved upon or required deliberate practice. The novel metric of rotational sum exhibited a moderate-to-strong positive correlation with other metrics (p < 0.001). CONCLUSIONS: A comprehensive series of motion metrics was able to describe the learning curves of novices training to perform central venous catheter placement in the simulation setting. Furthermore, it was determined that segmentation may provide additional insight into skill acquisition and inform deliberate practice.

Yttrium-90 radioembolization using MIRD dosimetry with resin microspheres.

OBJECTIVE: To review the technical feasibility of resin microsphere (SIR-Spheres®) yttrium-90 radioembolization prescribed using the medical internal radiation dose (MIRD) model. METHODS: All radioembolization procedures for hepatic malignancies using resin microspheres with MIRD model between November 2015 and February 2019 were included in this IRB-approved study (n = 60). Student's T test was used to compare prescribed activity based on MIRD and BSA models. Adverse events were assessed immediately, 30 days, and 6 months post-treatment. RESULTS: Sixty radioembolizations were performed in 54 patients (age 68 ± 9 years, 48-87 years, 35% female). Mean prescribed activity calculated by the MIRD model (target absorbed dose 120-200 Gy for primary and 80-200 Gy for metastatic liver cancers) was 1.7 GBq (0.3-6.4) compared with 0.6 GBq (0.12-2.1) if BSA had been used (p < 0.0001). The prescribed activity was successfully delivered in 93% (56/60) treatments. Prophylactic embolization and anti-reflux catheters were used in 20% (12/60) and 5% (3/60) treatments, respectively. No immediate post-procedural complications occurred. Abdominal pain was the most common clinical Grade 3 CTCAE in 30 days (10%) and 6 months (12%). Radiation pneumonitis occurred in 3 (5%) patients but no radiation-induced gastric ulcer or radiation-induced liver disease occurred. CONCLUSION: MIRD dosimetry results in higher prescribed activity compared with BSA dosimetry with resin microspheres. MIRD prescribed activity with target absorbed doses up to 200 Gy can be successfully administered without prophylactic embolization in selected patients. KEY POINTS: •MIRD dosimetry results in higher prescribed activity compared with BSA dosimetry for radioembolization. •MIRD dosimetry can be used for yttrium-90 resin microsphere radioembolization with acceptable safety profile.

Analysis of Kinematic Differences in Hand Motion between Novice and Experienced Operators in IR: A Pilot Study.

PURPOSE: To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation. METHODS: Sheath task: Six attending interventional radiologists (experts) and 6 radiology trainees (trainees) placed a wire through a sheath and performed a "pin-pull" maneuver, while an electromagnetic motion detection system recorded the hand motion. Radial task: Eight experts and 12 trainees performed palpatory radial artery access task on a radial access simulator. The trainees repeated the task with the nondominant hand. The experts were classified by their most frequent radial artery access technique as having either palpatory, ultrasound, or overall limited experience. The time, path length, and number of movements were calculated. Mann-Whitney U tests were used to compare the groups, and P < .05 was considered significant. RESULTS: Sheath task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (11.7 seconds ± 3.3 vs 19.7 seconds ± 6.5, P < .01; 1.1 m ± 0.3 vs 1.4 m ± 0.4, P < .01; and 19.5 movements ± 8.5 vs 31.0 movements ± 8.0, P < .01, respectively). Radial task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (24.2 seconds ± 10.6 vs 33.1 seconds ± 16.9, P < .01; 2.0 m ± 0.5 vs 3.0 m ± 1.9, P < .001; and 36.5 movements ± 15.0 vs 54.5 movements ± 28.0, P < .001, respectively). The trainees had a shorter path length for their dominant hand than their nondominant hand (3.0 m ± 1.9 vs 3.5 m ± 1.9, P < .05). The expert palpatory group had a shorter path length than the ultrasound and limited experience groups (1.8 m ± 0.4 vs 2.0 m ± 0.4 and 2.3 m ± 1.2, respectively, P < .05). CONCLUSIONS: Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.

Neoadjuvant Yttrium-90 Transarterial Radioembolization with Resin Microspheres Prescribed Using the Medical Internal Radiation Dose Model for Intrahepatic Cholangiocarcinoma.

PURPOSE: To evaluate outcomes of patients with intrahepatic cholangiocarcinoma (iCCA) undergoing neoadjuvant yttrium-90 (90Y) transarterial radioembolization (TARE) with resin microspheres prescribed using the Medical Internal Radiation Dose (MIRD) model. MATERIALS AND METHODS: This retrospective institutional review board-approved study included 37 patients with iCCA treated with 90Y-TARE from October 2015 to September 2020. The primary outcome was overall survival (OS) from 90Y-TARE. The secondary outcomes were progression-free survival (PFS), Response Evaluation Criteria In Solid Tumors 1.1 imaging response, and downstaging to resection. Patients with tumor proximity to the middle hepatic vein (<1 cm) and/or insufficient future liver remnant were treated with neoadjuvant intent (n = 21). Patients were censored at the time of surgery or at the last follow-up for the Kaplan-Meier survival analysis. RESULTS: For 31 patients (69 years; interquartile range, 64-74 years; 20 men [65%]) included in the study, the first-line therapy was 90Y-TARE for 23 (74%) patients. Imaging assessment at 6 months showed a disease control rate of 86%. The median PFS was 5.4 months (95% confidence interval [CI], 3-not reached). The PFS was higher after first-line 90Y-TARE (7.4 months [95% CI, 5.3-not reached]) than that after subsequent 90Y-TARE (2.7 months [95% CI, 2-not reached]) (P = .007). The median OS was 22 months (95% CI, 7.3-not reached). The 1- and 2-year OS rates were 60% (95% CI, 41%-86%) and 40% (95% CI, 19.5%-81%). In patients treated with neoadjuvant intent, 11 of 21 patients (52%) underwent resections. The resection margins were R0 and R1 in 8 (73%) and 3 (27%) of 11 patients, respectively. On histological review in 10 patients, necrosis of ≥90% tumor was achieved in 7 of 10 patients (70%). CONCLUSIONS: First-line 90Y-TARE prescribed using the MIRD model as neoadjuvant therapy for iCCA results in good survival outcome and R0 resection for unresectable patients.

Causes and Rates of 30-Day Readmissions After Transjugular Intrahepatic Portosystemic Shunts.

OBJECTIVE. The purpose of this study was to investigate the causes and rates of 30-day readmission after transjugular intrahepatic portosystemic shunt (TIPS) at a single liver transplant center. MATERIALS AND METHODS. We reviewed 165 TIPS procedures performed between 2003 and 2013. After excluding patients who died during the index admission (n = 16), any readmission within 30 days of discharge was identified, and cause of readmission was determined. Causes were categorized as planned or unplanned and interventional radiology (IR)-related or IR-unrelated. Unplanned readmissions were independently categorized as preventable or unpreventable by two interventional radiologists. Discrepant opinions were resolved by consensus. Factors predictive of 30-day readmission were identified by univariate and multivariate analysis. RESULTS. The reviewed TIPS procedures were performed in 165 patients (mean age ± SD, 56 ± 11 years; 69% male, 31% female). TIPS were placed for ascites or hydrothorax in 82 patients (50%) and variceal bleeding in 83 patients (50%). The 30-day readmission rate was 21% (31/149). The most common causes for readmissions were ascites or hydrothorax (23%, 7/31) and hepatic encephalopathy (23%, 7/31). All 30-day readmissions were unplanned; 17 (55%) of them were potentially preventable. Of the 17 potentially preventable readmissions, five (29%) were IR-related and 12 (71%) were IR-unrelated. In IR-related readmissions, all patients presented with a recurrence of symptoms (rebleeding or ascites) and were found to have TIPS stenosis or occlusion. Mortality rates were similar between patients who were and were not readmitted (p = 0.23). On multivariate analysis, spontaneous bacterial peritonitis during the index admission was the only variable associated with 30-day readmission (odds ratio = 4.81, p = 0.02). CONCLUSION. Over half of 30-day readmissions after TIPS could have been prevented by early outpatient follow-up and intraprocedural technique to optimize stent landing zones.

Causes and Rates of 30-day Readmissions after Percutaneous Transhepatic Biliary Drainage Procedure.

Purpose To investigate rates and causes of 30-day readmission for patients who undergo percutaneous transhepatic biliary drainage (PTBD) procedures. Materials and Methods In this retrospective study, PTBD procedures performed at a tertiary care institution (June 2008 to May 2013) were reviewed. For each patient, the first 30-day readmission was used to determine cause of readmission. Two interventional radiologists independently categorized causes for readmission as planned or unplanned, and unplanned causes as related to or unrelated to interventional radiology. Interventional radiology-related readmissions were categorized as potentially preventable or unpreventable. Factors associated with higher odds for 30-day readmission were identified with univariable and multivariable analysis. Results There were 266 procedures in 266 patients (mean age, 67 years; interquartile range, 57-76 years; 53.4% men). The cause of obstruction was malignant in 50.0% of patients (133 of 266). There were 122 of 266 patients (45.9%) readmitted within 30 days. Of these readmissions, 44 of 122 (36.1%) were planned and 78 of 122 (63.9%) were unplanned. A majority of unplanned readmissions (57 of 78; 73%) were related to interventional radiology. Of unplanned interventional radiology-related readmissions, 16% (nine of 57) were related to periprocedural complications and 51% (29 of 57) were considered preventable. At multivariable analysis, Medicaid insurance (odds ratio, 3.68; 95% confidence interval: 1.52, 9.99; P = .009) and bilateral PTBDs (odds ratio, 5.81; 95% confidence interval: 1.79, 18.90; P = .003) were associated with 30-day readmission. Conclusion Thirty-day readmissions after primary biliary drainage are common and a majority of unplanned readmissions are drain-related. Nearly half of unplanned interventional radiology-related readmissions are potentially preventable. © RSNA, 2018 See also the editorial by Nikolic in this issue.

Electronic IR Group Peer Review and Learning Performed during Daily Clinical Rounds.

PURPOSE: To describe the implementation and efficacy of electronic capture of interventional radiology (IR) group peer review performed during morning rounds in an academic institution. MATERIALS AND METHODS: Peer-review submissions 24 months before (July 2012 through June 2014) and 24 months after (July 2014 through June 2016) implementation of an electronic group IR peer review were evaluated. Electronic IR peer review assessed clinical decision-making, patient care, and technique appropriateness by using the following responses: agree, acceptable alternative, or inappropriate. Complications, near-misses, and learning opportunities were also noted, and explanations were provided in the comments. An IR attending physician documented the consensus discussion via an online form or mobile app. RESULTS: After implementation of electronic capture of IR group peer reviews, 9.5% of all IR procedures (773 of 8,152) were reviewed, compared with 0.9% (63 of 7,152) before the implementation (P < .0001). On average, 3.4 ± 0.5 IR attending physicians participated in each review, and 17.3 ± 9.7 IR cases were reviewed per month by each attending physician. Peers fully agreed with the chosen technique in 729 of 773 cases (94.3%) and noted an acceptable alternative technique in 40 of 773 (5.2%). In 4 cases (0.5%), the chosen technique was rated as inappropriate. Peers fully agreed with chosen clinical decision-making and patient care in 765 of 773 cases (99%), with 8 cases (1%) deemed as acceptable alternatives. Learning opportunities were documented in 9.6% of cases (74 of 773). CONCLUSIONS: Electronic IR-specific group peer review captures the clinical decision-making process, patient outcomes, technical appropriateness, and short-term complications and may provide practice-improvement solutions.

Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates.

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.

Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction.

OBJECTIVES: To evaluate percutaneous brush cytology, forceps biopsy and a tandem procedure consisting of both, in the diagnosis of malignant biliary obstruction. METHODS: A retrospective review of consecutive patients who underwent biliary brush cytology and/or forceps biopsy between 01/2010 and 09/2014 was performed. The cytology and pathology results were compared to the composite outcome (including radiological, pathological and clinical data). Cost for tandem procedure compared to brush cytology and forceps biopsy alone was calculated. RESULTS: A total of 232 interventions in 129 patients (70.8 ± 11.0 years) were included. Composite outcome showed malignancy in 94/129 (72.9%) patients. Sensitivity for brush cytology, forceps biopsy and tandem procedure was 40.6% (95% CI 32.6-48.7%), 42.7% (32.4-53.0%) and 55.8% (44.7-66.9%) with 100% specificity, respectively. There were 9/43 (20.9%) additional cancers diagnosed when forceps biopsy was performed in addition to brush cytology, while there were 13/43 (30.2%) more cancers diagnosed when brush cytology was performed in addition to forceps biopsy. Additional costs per additionally diagnosed malignancy if tandem approach is to be utilised in all cases was $704.96. CONCLUSION: Using brush cytology and forceps biopsy in tandem improves sensitivity compared to brush cytology and forceps biopsy alone in the diagnosis of malignant biliary obstruction. KEY POINTS: • Tandem procedure improves sensitivity compared to brush cytology and forceps biopsy. • Brush cytology may help to overcome "crush artefacts" from forceps biopsy. • The cost per diagnosed malignancy may warrant tandem procedure in all patients.

Percutaneous Ablation for Hepatocellular Carcinoma.

OBJECTIVE: The purpose of this article is to discuss the use, comparative efficacy, and general technical considerations of percutaneous ablation, alone or in combination with other therapies, for the treatment of hepatocellular carcinoma (HCC). CONCLUSION: Percutaneous ablation is a mainstay treatment for early-stage HCC, offering survival comparable to that of surgical resection for small lesions. It can act as a primary curative therapy or bridge therapy for patients waiting to undergo liver transplant. New ablation modalities and combining tumor ablation with other therapies, such as transarterial chemoembolization, can improve clinical outcomes and allow treatment of larger lesions. Combining thermal ablation with systemic chemotherapy, including immunotherapy, is an area of future development.