Pelvic congestion syndrome is associated with pelvic varicosities that result in chronic pelvic pain, especially in the setting of prolonged standing, coitus, menstruation, and pregnancy. Although the underlying pathophysiology of pelvic congestion syndrome sunclear, it probably results from acombination of dysfunctional venous valves, retrograde blood flow, venous hypertension, and dilatation. Asymptomatic women may also have pelvic varicosities, making pelvic congestion syndrome difficult to diognose.This article explore stheetiologies of pain, use of imaging techniques, and clinical management of pelvic
congestion syndrome. Possible explanations for the spectrum of pain among women with pelvic varicosities are also discussed.
The Society of Interventional Radiology (SIR) considers the use of catheter directed therapy (CDT) or thrombolysis to be an acceptable treatment option for carefully selected patients with massive (ie, high-risk) pulmonary embolism (PE) involving the proximal pulmonary arterial vasculature, in accordance with multidisciplinary guidelines (1–4). SIR defines acute proximal PE as new main or lobar emboli identified on radiographic imaging within 14 days of PE symptoms. In addition, SIR encourages the investigative use of CDT and new endovascular techniques in prospective outcomes studies and clinical trials, with particular attention to patients with acute submassive (ie, intermediate-risk) PE.
In a single-arm, nonrandomized, retrospective case-control study, 39 patients (mean age, 44 y) who underwent elective outpatient uterine artery embolization (UAE) 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 UAE.
In the high-volume and increasingly complex world of image-guided therapy and medical imaging, awareness of the potential risks secondary to occupational radiation exposure in medical professionals needs greater focus. One of these risks is radiation- induced cataracts, a recently recognized entity, which may impact the physician’s professional proficiency, quality of life, and career span. This review article aims to explain the pathogenesis of radiation-induced cataracts, exploring emerging evidence regarding their development. It also explores the existing monitoring and protection measures available to protect against such radiation-induced pathologic conditions.
There is continuing debate among physicians, nurses, and federal regulatory agencies regarding the correct position for the tip of a central venous catheter. The traditional approach has been to place the catheter tip within the superior vena cava. However, many interventionalists believe that the performance and durability of the catheter will be improved by positioning the catheter tip within the upper right atrium. Recently, this variability in clinical practice has become an increasingly divisive issue among physicians who insert these catheters and nurses who use them. This article is intended to elucidate the controversial issues and provide a brief review of the extensive literature on this important topic.
Eight patients with giant prostatic enlargement > 200 mL and lower urinary tract symptoms who underwent bilateral prostatic artery embolization (PAE) were reviewed. Mean prostate volume decreased from 318.2 mL to 212.2 mL (P < .01). At 5-month mean follow- up, International Prostate Symptom Score decreased by 16.7 points (P < .05), and urinary quality of life improved by 3.0 points (P < .01). Three of 4 catheter-dependent patients no longer needed catheterization after the procedure. No major complications were encountered. Preliminary results suggest PAE is safe and effective in patients with giant prostatic enlargement > 200 mL.
Percutaneous endovascular interventions have been widely used and proven as the standard of care in the management of dysfunctional dialysis access and as an effective alternative compared with similar surgical interventions. This document provides an update on key topics relevant to endovascular management of thrombosed or dysfunctional dialysis access since the first SIR guidelines published in 2003.
To present final, 2-year results of a randomized trial comparing paclitaxel-coated vs uncoated balloon angioplasty following vessel preparation with ultra–high-pressure percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistulae (AVFs).
Materials and Methods
Twenty-three sites enrolled 285 subjects with dysfunctional AVFs located in the arm. Before 1:1 randomization, successful vessel preparation was achieved (full waist effacement, < 30% residual stenosis). Follow-up was clinically driven except for a 6-month office visit.
Ninety-six of 141 subjects in the drug-coated balloon (DCB) arm and 111 of 144 in the control arm completed the study. Target lesion primary patency (TLPP) rates for the DCB and control groups were 58% ± 4 vs 46% ± 4 (P = .02) at 9 months, 44% ± 5 vs 36% ± 4 (P = .04) at 12 months, 34% ± 5 vs 28% ± 4 (P = .06) at 18 months, and 27% ± 4 vs 24% ± 4 (P = .09) at 24 months, respectively. Mean time to TLPP event for subjects with an event was longer for DCBs (322 vs 207 d; P < .0001). Fewer interventions were needed to maintain target lesion patency in the DCB group at 9 months (P = .02) but not at 12 (P = .08), 18 (P = .13), or 24 months (P = .19). The noninferiority safety target was met at all intervals (P < .01). Mortality did not differ between groups (P = .27). Post hoc analyses showed equivalent DCB effect in all subgroups.
Two-year results demonstrate long-term safety and variable efficacy of DCB angioplasty in AVFs.
Image-guided percutaneous drainage or aspiration of abscesses and abnormal fluid collections (PDAFC) has become the diagnostic and therapeutic treatment of choice for a wide variety of fluid collections. The procedures have resulted in reduced morbidity and mortality and have helped to reduce length of hospital stay and hospital costs (1–18). This Society of Interventional Radiology (SIR) Quality Improvement (QI) Guideline outlines the specifications and principles for performing high-quality PDAFC.
Purpose: To determine if magnification spot radiographs acquired before attempting inferior vena cava (IVC) filter removal have value in the assessment for filter fractures.
Materials and Methods: A retrospective review of complex IVC filter removals performed at a tertiary referral center from October 2015 to May 2017 was performed. Magnification spot radiographs (frontal and at least 2 oblique views) were obtained with the fluoroscopic unit in the procedure suite prior to venous access for filter removal. Patients were included in the study if a computed tomography (CT) scan of the abdomen/pelvis before filter removal was available. Ninety-six patients (47 women and 49 men) were included. Most removed filters were the Recovery/G2/G2X/Eclipse/Meridian (n ¼ 28), the Günther Tulip (n ¼ 26), and the Celect/Celect Platinum (n ¼ 22). Blinded review of the pre-procedural CT scans and spot radiographs for the presence of filter fractures was performed by 2 interventional radiologists. Accuracy of each modality was assessed using the status of the explanted filter as the gold standard. Agreement between the 2 readers was assessed with the kappa statistic.
Results: Fractures were present in 27 explanted filters (28%). Accuracy of CT was 88% and 68% for readers 1 and 2, respectively, which increased to 98% and 97% with magnification spot radiographs. The kappa statistic was 0.12 for CT and 0.97 for spot radiographs.
Conclusions: Magnification spot radiographs acquired before attempting IVC filter removal improve detection of filter fractures and agreement among interventional radiologists. Therefore, these should be performed routinely to allow for optimal treatment planning.
Although a snare is the commonly used device for antegrade double J (DJ) stent removal, there are some cases in which DJ stent removal using only a snare is particularly difficult. In the present study, an unfavorable positioning of the proximal DJ stent tip and tip embeddedness were significantly associated with a simple snare technique failure; thus, present the modified snare technique to overcome the simple snare technique failure. By applying these 2 techniques together, we can increase the overall technical success rate up to 97% (196/202). The modified snare technique is safe and effective in cases of simple snare technique failure.
Purpose: To evaluate the rate and risk factors for hemorrhage in patients undergoing real-time, ultrasound-guided paracentesis by radiologists without correction of coagulopathy. Materials and Methods: This was a retrospective study of all patients who underwent real-time, ultrasound-guided paracentesis at a single institution over a 2-year period. In total, 3116 paracentesis procedures were performed: 757 (24%) inpatients and 2,359 (76%) outpatients. Ninety-five percent of patients had a diagnosis of cirrhosis. Mean patient age was 56.6 years. Mean international normalized ratio (INR) was 1.6; INR was > 2 in 437 (14%) of cases. Mean platelet count was 122 x 103 /μL; platelet count was < 50 x 103 /μL in 368 (12%) of patients. Seven hundred seven (23%) patients were dialysis dependent. Patients were followed for 2 weeks after paracentesis to assess for hemorrhage requiring transfusion or rescue angiogram/embolization. Univariate analysis was performed to determine risk factors for hemorrhage. Blood product and cost saving analysis were performed. Results: Significant post-paracentesis hemorrhage occurred in 6 (0.19%) patients, and only 1 patient required an angiogram with embolization. No predictors of post-procedure bleeding were found, including INR and platelet count. Transfusion of 1125 units of fresh frozen plasma and 366 units of platelets were avoided, for a transfusion-associated cost savings of $816,000. Conclusions: Without correction of coagulation abnormalities with prophylactic blood product transfusion, post-procedural hemorrhage is very rare when paracentesis is performed with real-time ultrasound guidance by radiologists.
Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle
allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102
patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the
curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all
unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5–19.2 min). Single-step PGT
placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.
Purpose: To analyze technique, outcomes, and complications of a large series of pediatric percutaneous nephrostomy (PCN) procedures performed at 4 tertiary pediatric centers. Materials and Methods: Retrospective multicenter study of PCNs performed during an 11-year period. Six hundred seventy-five PCNs were performed on 441 patients (median age: 4 y, range: 1 d–18 y, median weight: 17 kg, range: 0.7–112 kg); 31% were younger than 1 year. The most frequent indications for PCN procedures included hydronephrosis (57%), calculus (14%), and infection (12%). Forty-five percent of patients had severe and 32% had moderate hydronephrosis. Results: Technical success was 99% (n ¼ 668); 7 failures occurred from lost access, during tract dilatation (n ¼ 5) and during staghorn calculi without dilatation (n ¼ 2). General anesthesia was used in 73% of procedures. Combined ultrasound and fluoroscopy was used in 98% of procedures. Of the 668 procedures, 561 (84%) were primary nephrostomy insertions, and 107 (16%) were a variety of exchanges (secondary catheter insertions). Twenty-four of 675 (4%) were transplanted kidneys. Access sites included lower (47%), mid (28%), and upper (12%) poles and pelvis (11%). Catheters were predominantly 7-8 French (n ¼ 352). The mean catheter dwell time was 25 days (0–220 d). Total primary catheter days were 14,482, with an additional 2,241 days after secondary procedures. Follow-up in 653/668 (98%) procedures documented elective removal (79%) and salvage procedures (21%), which included wire exchange (8.7%), nephroureteral stent/catheter conversion (8.8%), and tube upsizing (3.5%). Periprocedural complications occurred in 30/668 (4.5%) procedures: 1 major (0.1%) self-limiting hematuria requiring transfusion and 29 (4.4%) minor complications. Conclusions: PCN is safe and successful in children of all ages, with few major complications. PCN in children is associated with specific technical challenges and requires ongoing management tailored to the very young to achieve good outcomes.
Purpose: To compare: (i) rate of arteriovenous fistula (AVF) interventions in both incident and prevalent end-stage kidney disease patients; (ii) their associated costs; and (iii) intervention-free survival between patients with surgical hemodialysis arteriovenous fistula (SAVF) versus those with an endovascularly created fistula (endoAVF). Materials and Methods: Data from the United States Renal Data System (USRDS) were abstracted to determine the rate of AVF interventions performed in the first year and associated costs (based on Medicare payment rates) for SAVFs created from 2011 to 2013 in the incident and prevalent patient cohorts. Comparative data for endoAVF were obtained from the Novel Endovascular Access Trial (NEAT). Event rates, intervention-free survival, and costs were compared between endoAVF and SAVF cohorts after 1:1 propensity score (PS) matching. Results: In the matched incident patients, the event rate was 0.74 per patient-year (PY) for endoAVF versus 7.22/PY for SAVF (P < .0001), with a difference in expenditures of $16,494. Similarly, in matched prevalent patients the event rate was 0.46/PY for endoAVF vs 4.10/PY for SAVF (P <.0001), resulting in a cost difference of $13,389. Time-to-event analysis showed that at 1 year, 70% of endoAVF patients experienced freedom from intervention versus only 18% of SAVF patients for incident patients; these numbers were 62% and 18% for endoAVF and SAVF prevalent patients, respectively (P < .0001 for both). Conclusions: Both incident and prevalent patients with endoAVF required fewer interventions and had lower costs within the first year compared with matched patients with SAVF.
Purpose: To assess biopsy technique, technical success rate, and diagnostic yield of image-guided percutaneous biopsy of omental and
Materials and Methods: This retrospective study included 186 patients (89 men, 97 women; mean [SD] age, 63 [13.8] y) who
underwent percutaneous image-guided biopsy of omentum and mesentery between March 2007 and August 2015. Biopsies were
performed with computed tomography (CT) (n 1⁄4 172) or ultrasound (US) (n 1⁄4 14) guidance using coaxial technique yielding core and
fine-needle aspiration (FNA) specimens. Biopsy results were classified as diagnostic (neoplastic or nonneoplastic) or nondiagnostic
based on histopathology and cytology. Technical success rate and diagnostic yield of omental and mesenteric lesions were calculated.
Results: There were 186 image-guided percutaneous biopsies of omental (n 1⁄4 95) and mesenteric (n 1⁄4 91) lesions performed. Technical
success rate was 99.5% for all biopsies, 100% for omental biopsies, and 98.9% for mesenteric biopsies. Overall sensitivity was 95.5%,
specificity was 100%, negative predictive value was 78.3%, and positive predictive value was 100%, which was comparable for omental
and mesenteric biopsies. Core biopsies had higher diagnostic yields compared with FNA: 98.4% versus 84% overall, 99% versus 88% for
omental biopsies, and 97.7% versus 80% for mesenteric biopsies. Spearman rank correlation showed no correlation between lesion size
and diagnostic yield (P 1⁄4 .14) and lesion depth and diagnostic yield (P 1⁄4 .29) for both groups. There were 5 complications.
Conclusions: Image-guided percutaneous omental and mesenteric biopsies have high technical success rates and diagnostic yield
regardless of lesion size or depth from the skin for both omental and mesenteric specimens.
Purpose: To characterize the utility of monitoring transcranial electrical motor evoked potentials (TCeMEPs) and somatosensory evoked potentials (SSEPs) for neural thermoprotection during musculoskeletal tumor ablations. Materials and Methods: Retrospective review of 29 patients (16 male; median age, 46 y; range, 7–77 y) who underwent musculoskeletal tumor radiofrequency ablation (n ¼ 8) or cryoablation (n ¼ 22) with intraprocedural TCeMEP and SSEP monitoring was performed. The most common tumor histologies were osteoid osteoma (n ¼ 6), venous malformation (n ¼ 5), sarcoma (n ¼ 5), renal cell carcinoma (n ¼ 4), and non–small-cell lung cancer (n ¼ 3). The most common tumor sites were spine (n ¼ 22) and lower extremities (n ¼ 4). Abnormal TCeMEP change was defined by 100-V increase above baseline threshold activation for a given myotome; abnormal SSEP change was defined by 60% reduction in baseline amplitude and/or 10% increase in latency. Results: Abnormal changes in TCeMEP (n ¼ 9; 30%) and/or SSEP (n ¼ 5; 17%) occurred in 12 procedures (40%) and did not recover in 5 patients. Patients with unchanged TCeMEP/SSEP activities throughout the procedure (n ¼ 18) did not have motor or sensory symptoms after the procedure; 3 (60%) with unrecovered activity changes and 2 (29%) with transient activity changes had new motor (n ¼ 1) or sensory (n ¼ 4) symptoms. Relative risk for neurologic sequelae for patients with unrecovered TCeMEP/SSEP changes vs those with transient or no changes was 7.50 (95% confidence interval, 1.66–33.9; P ¼ .009). Conclusions: Abnormal activity changes of TCeMEP or SSEP during percutaneous ablative procedures correlate with postprocedural neurologic sequelae.
Purpose: To report initial experience with safety and efficacy in the treatment of pulmonary embolism (PE) using the FlowTriever
Materials and Methods: A single-center retrospective study was performed in all patients with acute central PE treated using the
FlowTriever device between March 2018 and March 2019. A total of 46 patients were identified (massive 1⁄4 8; submassive 1⁄4 38), all
with right ventricular (RV) strain and 26% with thrombolytic contraindications. Technical success (according to SIR reporting guide-
lines) and clinical success (defined as mean pulmonary artery pressure intraprocedural improvement) are reported, as are major device
and procedure-related complications within 30 days after discharge.
Results: Technical success was achieved in 100% of cases (n 1⁄4 46). Average mean pulmonary artery pressure improved significantly
from before to after the procedure for the total population (33.9 ± 8.9 mm Hg before, 27.0 ± 9.0 mm Hg after; P < .0001; 95%
confidence interval [CI], 5.0–8.8), submassive cohort (34.7 ± 9.1 mm Hg before, 27.4 ± 9.2 mm Hg after; P <.0001; 95% CI, 5.2–9.5)
and massive cohort (30.4 ± 6.9 mm Hg before, 25.4 ± 8.2 mm Hg after; P < .05; 95% CI:0.4–9.6). Intraprocedural reduction in mean
pulmonary artery pressure was achieved in 88% (n 1⁄4 37 of 42). A total of 100% of patients (n 1⁄4 46 of 46) survived to hospital
discharge. In total, 71% of patients (n 1⁄4 27 of 38) experienced intraprocedural reduction in supplemental oxygen requirements. Two
major adverse events (4.6%) included hemoptysis requiring intubation, and procedure-related blood loss requiring transfusion. No
delayed procedure-related complications or deaths occurred within 30 days of hospital discharge.
Conclusions: Initial clinical experience using the FlowTriever to perform mechanical thrombectomy showed encouraging trends with
respect to safety and efficacy for the treatment of acute central, massive, and submassive pulmonary embolism.
The AVIR is pleased to announce that our Annual VI Board Prep course, offered at our annual meeting each year, is now available as an online webinar.
This second edition of the VI Review Course was created for the 2018 annual meeting and includes 4 hours of lectures from new speakers and reviews all of the sections of the ARRT exam matrix. This package also includes AVIR's proprietary mock registry exam and answer sheet to prepare for your test. Both the lecture and the exam can be watched and practiced as many times as you would like, but you must complete the post lecture quiz to recieve CE credits for you time.
This course is approved for 4 CE credits.