Purpose: To determine the efficacy and safety of transabdominal direct sac puncture embolization of type II endoleaks after endovascular
abdominal aortic aneurysm repair (EVAR).
Materials and Methods: This retrospective review included 30 patients (4 women, 26 men; mean age ¼ 79.1 years) who underwent
33 transabdominal direct sac puncture embolization procedures for type II endoleaks after EVAR. Embolization agents included
cyanoacrylate glue only (45.5%), glue/coils (36.4%), and Onyx with or without glue/coils (18.1%). Technical success was defined as
complete endoleak embolization on intraprocedural fluoroscopy. The primary outcome was freedom of aneurysm growth, which was
defined as 5% aneurysm sac volume change on follow-up computed tomography (CT) imaging or 5 mm aneurysm sac diameter
change on ultrasound without definite endoflow. Aneurysm sac volumes before and after embolization were manually segmented from
CT images. The procedural complication rate was calculated.
Results: Technical success was achieved in 97% of patients (29/30). Follow-up imaging was available in 27 patients (25 CT; 2 ultrasound),
and mean imaging follow-up duration was 15.5 months. Freedom of aneurysm growth was achieved in 85.2% of patients (23/
27) after 1 or more embolization procedures. Median fluoroscopic and procedure times were 11.3 minutes and 90 minutes, respectively.
The complication rate was 9.1% (3/33) and included 1 case of nontarget embolization with transient neuropraxia and 2 self-limiting
rectus sheath hematomas relating to the percutaneous puncture site. No aneurysm-related mortality occurred during the follow-up period.
Conclusions: Percutaneous transabdominal embolization is a safe and efficacious treatment for type II endoleak, with a short procedure
Purpose: To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS)
placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke
onset in a single comprehensive stroke center.
Materials and Methods: Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed.
Results: Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate
or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs
CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P ¼.08). Complication rates were similar between groups. mRS scores showed a significant improvement
over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A
subanalysis in patients with NIHSS scores 4 showed no differences in complication rate and outcome.
Conclusions: CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced
centers, even after major atherosclerotic stroke.
Purpose: To evaluate long-term effects of yttrium-90 (90Y) transarterial radioembolization (TARE) for unresectable hepatic metastases of neuroendocrine tumors (NETs).
Materials and Methods: Retrospective analysis of 93 patients (47 women, 46 men; mean age 59 y) who underwent resin-based 90Y TARE was performed. Variables associated with overall survival were analyzed using univariate and multivariate models. Changes in serologic values and imaging characteristics were assessed with long-term follow-up.
Results: Unilobar TARE was performed in 48 patients, and staged bilobar TARE was performed in 45 patients. In multivariate analysis, ascites (P 1⁄4 .002) and extrahepatic metastases (P 1⁄4 .038) at baseline were associated with poor survival. Among 52 patients who had> 1 year of follow-up, significant increases in alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were observed; however, only 4 patients experienced grade 3 serologic toxicities. Imaging signs of cirrhosis-like morphology and portal hypertension were observed in 15 of 52 patients, more frequently in patients treated with bilobar TARE compared with unilobar TARE. Patients treated with bilobar TARE exhibited significantly increased hepatobiliary enzymes and decreased platelet count. Sustained increases in liver enzymes were observed in patients with > 4 years of follow-up. No radioembolization-related liver failure or grade 4 toxicity was observed.
Conclusions: 90Y radioembolization using resin microspheres demonstrated a high safety profile for NET liver metastases, with low-grade, although sustained, long-term liver toxicity evident > 4 years after treatment. Bilobar treatment suggested a trend for treatment-related portal hypertension. Ongoing research will help define parameters for optimizing durable safety and efficacy of radioembolization in this setting.
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.
Purpose: To compare safety and efficacy of vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS).
Materials and Methods: A randomized, prospective, single-center study enrolled 100 women with PCS from January 2014 to January 2015. Patients were randomly assigned to 2 groups, and embolization was performed with FPCs (n 1⁄4 50) or VPs (n 1⁄4 50). Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60. Primary outcome (clinical success at 1 y using a VAS), number of devices, procedure and fluo- roscopy times, radiation doses, costs, and complications were compared, and participants were followed at 1, 3, 6, and 12 months.
Results: Clinical success and subjective improvement were not significantly different at 1-year follow-up (89.7% for FPCs vs 90.6% for VPs; P 1⁄4 .760). Mean number of devices per case was 18.2 ± 1.33 for FPCs and 4.1 ± 0.31 for VPs (P < .001). Three FPCs and 1 VP migrated to pulmonary vasculature approximately 3–6 months after the embolization procedure; all were retrieved without com- plications. The FPC group had a significantly longer fluoroscopy time (33.4 min ± 4.68 vs 19.5 min ± 6.14) and larger radiation dose (air kerma 948.0 mGy ± 248.45 vs 320.7 mGy ± 134.33) (all P < .001).
Conclusions: Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.
Purpose: To identify clinical predictors of port infections in adult patients with hematologic malignancies.
Materials and Methods: A retrospective chart review identified 223 adult patients (age ! 18 y) with hematologic malignancies, including lymphoma (n 1⁄4 163), leukemia (n 1⁄4 49), and others (n 1⁄4 11), who had a port placed from 2012 to 2015. Early (< 30 d after port placement) and overall port infections (bloodstream and site infections) were recorded. To elucidate clinical predictors for early and overall port infections, proportional subdistribution hazard regression (PSHREG) analyses were conducted with variables including patients’ demographics, medications used, laboratory data, and port characteristics.
Results: Total duration of follow-up was 83,722 catheter-days (median per patient, 274 catheter-days). Early and overall port infections were identified in 8 (3.6%) and 26 (11.7%) patients, respectively. Early and overall infection rates were 1.2 and 0.3 infections/1,000 catheter-days, respectiv
Purpose: To determine facility and patient demographics associated with survival in early-stage non-small cell lung cancer (NSCLC)treated with radiofrequency (RF) ablation.
Materials and Methods: The National Cancer Database was queried for cases of stage 1a NSCLC treated with RF ablation without chemotherapy or radiotherapy from 2004 to 2014. High-volume centers (HVCs) were defined as the top 95th percentile of facilities by number of procedures performed. Overall survival (OS) was estimated with the Kaplan-Meier method, and comparisons between survival curves were performed with the log-rank test. Propensity score-matched cohort analysis was performed. P values less than .05 were considered statistically significant.
Results: In the final cohort, 967 cases were included. Estimated median survival and follow-up were 33.1 and 62.5 months, respectively. Of 305 facilities, 15 were determined to be HVCs, treating 13 or more patients from 2004 to 2014. A total of 335 cases (34.6%) were treated at HVCs. On multivariate Cox regression analysis, treatment at an HVC was independently associated with improved OS (hazard ratio [HR] 1⁄4 0.766; P 1⁄4 .006). After propensity score adjustment, 1-, 3-, and 5-year OS was 89.8%, 51.2%, and 27.7%, respectively, for patients treated at HVCs, compared to 85.2%, 41.5%, and 19.6%, respectively, for patients treated at non-HVCs (P 1⁄4 .015). Increasing age (HR 1⁄4 1.012; P 1⁄4 .013) and higher T-classification (HR 1⁄4 1.392; P < .001) were independently associated with worse OS.
Conclusion: Patients with early-stage NSCLC treated with RF ablation at HVCs experienced a significant increase in OS, suggesting regionalization of lung cancer management as a means of improving outcomes.
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.
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.