Guiding the Prostatic Artery Embolization Procedure With Computational Fluid Dynamics.

Benign prostatic hyperplasia (BPH) is a common disease associated with lower urinary tract symptoms and is the most frequent benign tumor in men. To reduce BPH therapy complications, prostatic artery embolization (PAE) was developed to replace the surgical options. PAE is a minimally invasive technique in which emboli are injected into the prostate arteries (PA), obstructing the blood flow in the hypervascular nodules. In this work, a personalized PAE treatment strategy was proposed using patient-specific computational fluid dynamics (CFD). First, the hemodynamics environment in the iliac arterial tree considering a large network of bifurcations was studied. The results showed complex blood flow patterns in the iliac arterial network. Subsequently, the transport of embolic particulates during PAE for the standard horizontal and hypothetical vertical patient positioning was simulated using Lagrangian particle tracking. Emboli of different sizes were released at various locations across the iliac arterial tree. The emboli entering the PA were mapped back to their initial location to create emboli release maps (ERMs). The obtained ERMs during the standard patient positioning for smaller emboli at certain release locations showed distinct regions in which if the emboli were released within these regions, all of them would reach the PA without nontarget embolization. During the hypothetical vertical patient positioning, the larger emboli formed a larger coherent region in the ERMs. Our patient-specific model can be used to find the best spatial location for emboli injection and perform the embolization procedure with minimal off-target delivery.

Interventional Radiology Obesity Therapeutics: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel.

The Society of Interventional Radiology Foundation commissioned a Research Consensus Panel to establish a research agenda on "Obesity Therapeutics" in interventional radiology (IR). The meeting convened a multidisciplinary group of physicians and scientists with expertise in obesity therapeutics. The meeting was intended to review current evidence on obesity therapies, familiarize attendees with the regulatory evaluation process, and identify research deficiencies in IR bariatric interventions, with the goal of prioritizing future high-quality research that would move the field forward. The panelists agreed that a weight loss of >8%-10% from baseline at 6-12 months is a desirable therapeutic endpoint for future IR weight loss therapies. The final consensus on the highest priority research was to design a blinded randomized controlled trial of IR weight loss interventions versus sham control arms, with patients receiving behavioral therapy.

Intraprocedural Superior Hypogastric Nerve Block Allows Same-Day Discharge following Uterine Artery Embolization.

In a single-arm, nonrandomized, retrospective case-control study, 39 patients (mean age, 44 y) who underwent elective outpatient uterine artery embolization with the use of superior hypogastric nerve block (SNHB) for pain control over a period of 3 years were identified. Technical success of SNHB was 87%. Of the 34 patients who received SNHB, 97% did not need a patient-controlled analgesia pump. The median opioid requirement for the 17 patients who needed opioid agents was 7.5 morphine milligram equivalents (interquartile range [IQR], 10). The median length of stay was 2.2 hours (IQR, 1.7 h). SHNB offers a safe and effective intervention that significantly reduces pain and the need for opiate agents and allows same-day discharge after uterine artery embolization.

Three-dimensional printing CT-derived objects with controllable radiopacity.

PURPOSE: The goal of this work was to develop phantoms for the optimization of pre-operative computed tomography (CT) scans of the prostate artery, which are used for embolization planning. METHODS: Acrylonitrile butadiene styrene (ABS) pellets were doped with barium sulfate and extruded into filaments suitable for 3D printing on a fused deposition modeling (FDM) printer. Cylinder phantoms were created to evaluate radiopacity as a function of doping percentage. Small-diameter tree phantoms were created to assess their composition and dimensional accuracy. A half-pelvis phantom was created using clinical CT images, to assess the printer's control over cortical bone thickness and cancellous bone attenuation. CT-derived prostate artery phantoms were created to simulate complex, contrast-filled arteries. RESULTS: A linear relationship (R = 0.998) was observed between barium sulfate added (0%-10% by weight), and radiopacity (-31 to 1454 Hounsfield Units [HU]). Micro-CT scans showed even distribution of the particles, with air pockets comprising 0.36% by volume. The small vessels were found to be oversized by a consistent amount of 0.08 mm. Micro-CT scans revealed that the phantoms' interiors were completely filled in. The maximum HU values of cortical bone in the phantom were lower than that of the filament, a result of CT image reconstruction. Creation of cancellous bone regions with lower HU values, using the printer's infill parameter, was successful. Direct volume renderings of the pelvis and prostate artery were similar to the clinical CT, with the exception that the surfaces of the phantom objects were not as smooth. CONCLUSIONS: It is possible to reliably create FDM 3D printer filaments with predictable radiopacity in a wide range of attenuation values, which can be used to print dimensionally accurate radiopaque objects derived from CT data. Phantoms of this type can be quickly and inexpensively developed to assess and optimize CT protocols for specific clinical applications.

Role of prostate artery embolization in the management of refractory haematuria of prostatic origin.

Prostatic haematuria is among the most common genitourinary complaints of emergency room visits, distressing and troublesome to men and a challenging clinical problem to the treating physician. The most common aetiologies of prostatic haematuria include benign prostatic hyperplasia and prostate cancer. Prostatic haematuria usually resolves with conservative and medical methods; failure of these interventions results in refractory haematuria of prostatic origin (RHPO), a potentially life-threatening scenario. Several different treatments have been described, with varying degrees of success. Patients with RHPO are often elderly and unfit for radical surgery. Prostate artery embolization (PAE) has evolved as a safe and effective technique in the management of RHPO. Use of a superselective approach optimizes clinical success while minimizing complications. This minimally invasive approach improves patients with haemodynamic instability, serves as a bridge to elective surgery, and is a highly effective treatment for RHPO. It may obviate the need for more invasive and morbid surgical therapies. The aim of the present review was to describe the current management of RHPO and the technique of PAE and to review its efficacy and associated morbidity.

Endovascular Coil Embolization in the Treatment of a Rare Case of Post-Traumatic Abdominal Aortic Pseudoaneurysms: Brief Report and Review of Literature.

Traumatic aortic injury, a consequence of penetrating injuries or blunt trauma, is a life threatening condition which requires prompt diagnosis and management. Most abdominal aortic injuries have been repaired via an open surgical approach with endovascular stent graft as an alternative. Traumatic pseudoaneurysms (PSA) of the abdominal aorta are uncommon, and they are managed similar to other abdominal aortic injuries. However, the presence of a perianeurysmal hematoma and the potential risk of an associated concomitant bowel communication could make surgery and endovascular stent graft placement risky. In such patients, coil embolization could be a valued option. In this article, we present a case in which traumatic PSAs are repaired using coil embolization with technical and clinical success. Endovascular coil embolization could be an alternative approach for PSAs that cannot be treated by stent grafting or open surgical repair, in the appropriate anatomy and by using the right coil material and technique.

Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy.

Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure-related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.

The RAVI registry: prospective, multicenter study of radial access in embolization procedures - 30 days follow up.

BACKGROUND: There is a lack of registry studies about transradial access (TRA) outcomes. This prospective registry evaluated the TRA and procedure outcomes of visceral embolizations performed via TRA with 30-day follow-up. MATERIAL & METHODS: Prospective, multicenter registry included uterine fibroids (UFE), prostate artery (PAE), liver tumors (LT), and other hypervascular tumors (OHT) embolization performed in six US hospitals. Between February 2020 and January 2022, 99 patients underwent one radial artery visceral intervention (RAVI); 70 had UFE (70.7%), 16 PAE (16.2%), 7 LT (7.1%), and 6 OHT (6.1%). The mean age was 50.1 (±11.1) years, and 74/99 (74.7%) were females. The primary safety endpoints included hand ischemia, stroke, and death. Procedural success was defined as completing the intended procedure via radial artery (RA) access. Technical success was defined as the successful delivery of HydroPearl™ microspheres and complete embolization of the target vessel. RESULTS: Procedural and technical successes were 100% and 97%, respectively. There was no stroke, hand ischemia, radial-to-femoral conversion, access-related serious adverse events, or clinically evident radial artery occlusion at 30 days. There were two deaths: one respiratory failure and one progression of liver disease. Minor RA-related adverse event included arterial spasm, hematoma, and post-procedure discomfort. CONCLUSION: This prospective, multicenter, open-label registry confirmed the high safety profile and effectiveness of radial access in UFE, PAE, LT, and OHT embolization procedures without stroke, hand ischemia, or access-related serious adverse events at 30-day follow-up.

Interventional Radiology in the Coronavirus Disease 2019 Pandemic: Impact on Practices and Wellbeing.

PURPOSE: To report the impact of the coronavirus disease 2019 (COVID-19) pandemic on interventional radiology (IR). MATERIALS AND METHODS: A 78-question survey was distributed to practicing interventional radiologists and IR trainees. The survey consisted of demographic and practice environment queries. Anxiety symptoms were evaluated using the Generalized Anxiety Disorder-7 (GAD-7) screener, and coping strategies were assessed using the Brief-Coping Orientation to Problems Experienced (Brief-COPE) questionnaire. RESULTS: There were 422 respondents including 333 (78.9%) attending interventional radiologists and 89 (21.1%) interventional radiologists-in-training from 15 counties. Most respondents were from academic medical centers (n = 218; 51.7%). A large majority (n = 391; 92.7%) performed a procedure on a patient with confirmed COVID-19 infection. An N95 mask was the most common (n = 366; 93.6%) safety measure employed. Cancellation or limitation of elective procedures were reported by 276 (65.4%) respondents. Many respondents (n = 177; 41.9%) had self-reported anxiety (GAD-7 score >5) with an overall mean GAD-7 score of 4.64 ± 4.63 (range: 0-21). Factors associated with reporting anxiety included female gender (p = 0.045), increased call coverage (p = 0.048), lack of adequate departmental adjustments (p <0.0001), and lack of adjustments in a timely manner (p <0.0001). The most utilized coping strategy was acceptance (mean of 5.49 ± 1.88), while the most employed dysfunctional coping strategy was self-distraction (mean of 4.16 ± 1.67). The odds of reporting anxiety increased by >125% with adoption of dysfunctional strategies. CONCLUSION: The COVID-19 pandemic induced practice alterations and high rates of self-reported anxiety in IR. Female gender, increased call coverage, and lack of adequate or timely departmental adjustments were associated with increased anxiety levels.

Superior hypogastric nerve block (SHNB) for pain control after uterine fibroid embolization (UFE): technique and troubleshooting.

BACKGROUND: Superior Hypogastric nerve Block (SHNB) has been shown to be an effective pain management technique after Uterine Fibroid Embolization (UFE), reducing the need for opiates and allowing same-day discharge after UFE. In this technical note we discuss relevant anatomy and technical details in performing SHNB. MAIN BODY: The Superior hypogastric plexus (SHP) is the part of the abdominopelvic sympathetic nervous system that provides a targeted intervention to sympathetic-mediated pain pathways of pelvic organs and a target for an anterior approach Superior Hypogastric nerve Block after embolization. Vascular structures are in close relation to the intended site of target of the SHP at the L5 vertebral body include aortic bifurcation and IVC confluence, hence a detailed knowledge of this is essential. A step by step technical approach to SHNB includes patient positioning for the block, image guidance and needle positioning, choice and technique of anesthetic injection. Traversing a large fibroid uterus, inadvertent vascular opacification and Local anesthetic systemic toxicity present challenges to performing the block and are addressed. CONCLUSION: Superior Hypogastric nerve Block (SHNB) can be a useful tool in the Interventional armamentarium to make UFE a better experience for patients with fibroids, allowing for better pain control as well as facilitating same day discharge. Performing SHNB appear to be can be performed with technical ease for an interventional radiologist.

Treatment Strategies for the Claudicant.

Peripheral arterial disease (PAD) is a prevalent, morbid, and mortal disease. Claudication represents an early, yet common manifestation of PAD. A clinical history and physical examination combined with an ankle-brachial index can help make a diagnosis of claudication. Due to the polyvascular nature of the underlying atherosclerosis, PAD is often associated with heart disease and stroke. Although health implications of PAD derive from both its limb and cardiovascular manifestations, claudication is life-threatening, less limb-threatening. Medical modification of cardiovascular risk factors and exercise are the cornerstone in the treatment of claudication. Revascularization in claudication is focused at improvement in claudication symptoms and functional status, rather than aggressive attempts at limb salvage. The aim of this article is to summarize the strategies in the treatment of claudication, to serve as a concise and informative reference for physicians who are managing these patients. A framework of the decision-making process in the management of patients with claudication is shown, which can be applied in clinical practice.