Journal of Vascular and Interventional Radiology - Articles in Press

Endovascular Treatment of Descending Thoracic Aortic Disease: Single-Center, 15-Year Experience - Corrected Proof

2012-02-02

Purpose: To report the experience with thoracic endovascular aortic repair (TEVAR) in a single center over a 15-year period. Materials and Methods: All patients undergoing TEVAR during the period 1994–2009 were retrospectively evaluated. Results: The study comprised 133 patients (96 men, age 69.5 years ± 14.7) who underwent 21 emergency and 112 elective TEVAR procedures. Aortic pathologies included 91 aneurysms, 14 pseudoaneurysms, 14 penetrating ulcers with or without pseudoaneurysms or intramural hematomas, 8 type B dissections (3 acute and 5 chronic), and 6 traumatic transections. Technical success was 97.7% with a 30-day mortality of 7.5%. There were 101 patients followed to 1 year, 35 patients followed to 5 years, and 6 patients followed to 10–15 years. The overall estimated survivals at 1 year, 5 years, and 10 years were 81%, 48%, and 36%. The 30-day mortality rates in emergency and elective TEVAR procedures were 23.9% and 4.5% (P = .005). However, among patients who survived > 30 days, there was no significant difference in mortality between groups undergoing emergency and elective TEVAR procedures (P = .9, hazard ratio [HR] 0.94, confidence interval [CI] 0.4–2.2). There was no significant gender survival difference. The 30-day mortality rate in octogenarians (n = 31) was higher than in younger patients (P = .03). Incidences of stroke and paraplegia within 30 days of TEVAR were 6.8% and 2.2%. Endoleaks were found in 39 (29%) patients, and secondary interventions were performed in 6 (4.5%) patients. Conclusions: The data support the safety and efficacy of TEVAR for aortic pathologies with a low mortality rate. Younger patients have fewer complications after TEVAR. After the acute perioperative period, TEVAR procedures performed emergently are as durable as the procedures performed electively.

Technical and Clinical Long-Term Results of Infrapopliteal Percutaneous Transluminal Angioplasty for Critical Limb Ischemia - Corrected Proof

Henk Odink, Aaike van den Berg, Bjorn Winkens — 2012-02-02

Purpose: To evaluate the technical success and clinical long-term effectiveness of percutaneous transluminal angioplasty (PTA) of the infrapopliteal arteries in critical limb ischemia (CLI) and to determine if total vessel dilation (TVD) increases the limb salvage rate (LSR). Materials and Methods: A retrospective study was performed in 90 consecutive patients (35 men and 55 women, median age 79 years, standard deviation [SD] 9 years) over a 5.5-year period to determine the effectiveness of infrapopliteal PTA in treating CLI. Of 90 patients, 61 underwent TVD. Analysis of LSR was performed using the Kaplan-Meier life-table analysis. Results: In 90 limbs, there were 57 infrapopliteal stenoses and 104 occlusions. Including 10 technical failures (TF) (TF = 11%), LSR at 1 year and 3 years for all 90 patients with previously untreated lesions was 78%. For 80 technically successful (TS) procedures (TS = 89%), LSR at 1 year and 3 years was 87%. At 1 year and 3 years, LSR for the 61 patients who had TVD was 89%. In all patients, there were no amputations after the first year. The 30-day mortality rate was 7%. Conclusions: PTA of the infrapopliteal arteries appears to be an effective treatment for patients with CLI. TVD provides an improved LSR and warrants additional evaluation.

The Use of Balloon-Expandable Stent Grafts for Management of Acute Arterial Bleeding - Corrected Proof

2012-01-30

Purpose: To evaluate the efficacy and safety of balloon-expandable stent grafts in the emergency treatment of acute arterial hemorrhage. Materials and Methods: Between July 2008 and December 2009, 15 patients with acute arterial hemorrhage from inflammatory vessel erosion or pseudoaneurysms (n = 9), noninflammatory pseudoaneurysms (n = 3), or iatrogenic vessel injury (n = 3) were treated with emergency stent graft implants. The primary study endpoints to determine treatment efficacy and safety were survival, complication rates, and freedom from recurrent hemorrhaging or reintervention. The secondary study endpoints were technical and clinical success. Results: The survival rate was 73% with a mean follow-up of 119 days ± 220. The complication rate was 20%. The procedure was technically successful in 13 of 15 (87%) patients. One endoleak persisted and led to a reintervention rate of 7%. The bleeding ceased immediately after stent graft implantation in 14 patients. Conclusions: Implantation of balloon-expandable stent grafts is a safe and effective emergency treatment for acute arterial hemorrhage from visceral and peripheral vessels.

Quality Improvement Guidelines for Transhepatic Arterial Chemoembolization, Embolization, and Chemotherapeutic Infusion for Hepatic Malignancy - Corrected Proof

2012-01-27

The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production.

High-Powered Microwave Ablation with a Small-Gauge, Gas-Cooled Antenna: Initial Ex Vivo and In Vivo Results - Corrected Proof

2012-01-25

Purpose: To evaluate the performance of a gas-cooled, high-powered microwave system. Materials and Methods: Investigators performed 54 ablations in ex vivo bovine livers using three devices—a single 17-gauge cooled radiofrequency(RF) electrode; a cluster RF electrode; and a single 17-gauge, gas-cooled microwave (MW) antenna—at three time points (n = 6 at 4 minutes, 12 minutes, and 16 minutes). RF power was applied using impedance-based pulsing with maximum 200 W generator output. MW power of 135 W at 2.45 GHz was delivered continuously. An approved in vivo study was performed using 13 domestic pigs. Hepatic ablations were performed using single applicators and the above-mentioned MW and RF generator systems at treatment times of 2 minutes (n = 7 MW, n = 6 RF), 5 minutes (n = 23 MW, n = 8 RF), 7 minutes (n = 11 MW, n = 6 RF), and 10 minutes (n = 7 MW, n = 9 RF). Mean transverse diameter and length of the ablation zones were compared using analysis of variance (ANOVA) with post-hoc t tests and Wilcoxon rank-sum tests. Results: Single ex vivo MW ablations were larger than single RF ablations at all time points (MW mean diameter range 3.5–4.8 cm 4–16 minutes; RF mean diameter range 2.6–3.1 cm 4–16 minutes) (P < .05). There was no difference in mean diameter between cluster RF and MW ablations (RF 3.3–4.4 cm 4–16 minutes; P = .4–.9). In vivo lesion diameters for MW (and RF) were as follows: 2.6 cm ± 0.72 (RF 1.5 cm ± 0.14), 3.6 cm ± 0.89 (RF 2.0 cm ± 0.4), 3.4 cm ± 0.87 (RF 1.8 cm ± 0.23), and 3.8 cm ± 0.74 (RF 2.1 cm ± 0.3) at 2 minutes, 5 minutes, 7 minutes, and 10 minutes (P < .05 all time points). Conclusions: Gas-cooled, high-powered MW ablation allows the generation of large ablation zones in short times.

Yttrium-90 Radioembolization of Renal Cell Carcinoma Metastatic to the Liver - Corrected Proof

2012-01-24

Purpose: To investigate the safety and efficacy of yttrium-90 (90Y) hepatic radioembolization treatment of patients with liver-dominant metastatic renal cell carcinoma (RCC) refractory to immunotherapy and targeted therapies. Materials and Methods: Between March 2006 and December 2010, six patients with metastatic RCC underwent eight radioembolization treatments with 90Y-labeled resin microspheres for unresectable liver-dominant metastases. All six patients had previous hepatic tumor progression despite targeted therapies or immunotherapies. All had bilobar disease and required whole-liver treatment. Clinical and biochemical toxicities were recorded, and tumor response was assessed every 2–3 months after treatment by cross-sectional imaging. Results: The median dose delivered was 1.89 Gbq (range 0.41–2.03 Gbq). Grade 1 and 2 toxicities were noted in all patients, primarily fatigue. Follow-up imaging was available for five patients. In follow-up periods from 2–64 months (mean 25 months), three patients showed complete responses, and 1 patient showed a partial response by standard imaging criteria, and these patients are alive at 64 months, 55 months, 17 months, and 7 months after treatment. Two patients with rapid progression of disease died within 2 months of treatment, although hepatic malignancy or failure was not the cause of death in either patient. Conclusions: 90Y radioembolization is a promising option for liver-dominant metastatic RCC with potential for providing long-term survival in patients refractory to or intolerant of targeted therapies.

Partial Anomalous Pulmonary Venous Return Detected Incidentally during Port Placement - Corrected Proof

Cicero Matthew R. Habito, Sanjeeva P. Kalva — 2012-01-24

Partial anomalous pulmonary venous return (PAPVR) was diagnosed incidentally in an asymptomatic 56-year-old female patient as a result of a peculiar catheter tip malposition (which was subsequently redirected) during port placement () before chemotherapy for an ovarian malignancy. PAPVR, also known as partial anomalous pulmonary venous drainage, is a rare congenital vascular condition with an incidence of 0.4%–0.7% (). Usually, a single pulmonary vein is anomalous. PAPVR arising from the right lung is more common than PAPVR from the left lung. The typical configuration is that of a right upper pulmonary vein draining into the superior vena cava (as seen in this case; ; arrows) or into the right atrium. Other configurations include right pulmonary venous drainage into the inferior vena cava and left pulmonary venous drainage into the innominate vein, coronary sinus, right atrium, or left subclavian vein. PAPVR may be isolated or associated with an atrial septal defect, complex congenital heart disease, or Scimitar syndrome ().

Interventional Radiologic Treatment of Hepatocellular Carcinoma—A Cost Analysis from the Payer Perspective - Corrected Proof

2012-01-24

Purpose: To determine whether there is a cost advantage for one of the three commonly performed interventional radiology (IR) procedures (chemoembolization, selective internal radiation therapy [SIRT], radiofrequency ablation [RFA]) in the treatment of hepatocellular carcinoma (HCC). Materials and Methods: A cost analysis from the payer perspective was performed. Primary data were collected from a university hospital, and sensitivity testing was done by comparing coding information obtained at two other tertiary care medical facilities. Medicare allowable reimbursements were used to estimate costs. Decision analytic models using decision tree analysis and Monte Carlo simulations were used to compare alternatives. Simulations were performed comparing all three procedures, followed by a two-way comparison of chemoembolization and SIRT. Results: Simple decision tree analyses showed that RFA was less expensive compared with chemoembolization and SIRT. Monte Carlo simulations showed average reimbursements for each of the three procedures that was largely dependent on the number of repeat procedures required ($9,362 vs $30,107 vs $35,629 for RFA, chemoembolization, and SIRT; P < .001). When comparing only chemoembolization and SIRT, chemoembolization was the lower cost strategy in most scenarios, but SIRT was lower in cost in more than one-third of the simulations. Conclusions: RFA was the least costly of the three IR strategies in nearly all scenarios studied in these models. Although chemoembolization was less expensive than SIRT in most instances, Monte Carlo simulation showed a preference for SIRT in more than one-third of all scenarios. Sensitivity analyses showed that the most important variables assessed were the need for repeat procedures.

Estimates of Effective Dose to Pediatric Patients Undergoing Enteric and Venous Access Procedures - Corrected Proof

Kiara Govia, Bairbre L. Connolly, Karen E. Thomas, Christopher L. Gordon — 2012-01-24

Purpose: To determine the range of effective doses encountered during common enteric and venous access procedures by using a method to estimate effective dose based on fluoroscopy time. Materials and Methods: A pediatric phantom and metal oxide semiconductor field-effect transistor model was used to calculate effective doses associated with nine enteric and venous access procedures involving fluoroscopy only. Enteric procedures included primary gastrostomy, gastrojejunostomy, cecostomy tube insertions, and their “maintenance procedures” (eg, tube checks and changes, reinsertions, and exchanges). Venous access procedures included insertion of peripherally inserted central catheters, central venous catheters, and port catheters. Effective dose estimates were determined from phantom simulations of each procedure accounting for patient age, collimation, magnification, and tube position. Effective dose calculations from the simulations were normalized to fluoroscopy time, resulting in age- and procedure-specific factors (in mSv·min−1). These factors were retrospectively applied to fluoroscopy times logged in a database for 7,074 patient encounters, yielding a range of effective dose estimates for each procedure type. Results: From 3,699 venous access procedures reviewed, the mean effective dose was 0.1 mSv (range, 0.01–3.28 mSv). Review of 3,405 enteric access procedures showed doses that vary considerably, with mean doses of 0.3–1.7 mSv (range, 0.01–11.35 mSv). Several complex cases were identified with doses exceeding 4 mSv. Maintenance enteric procedures usually required lower doses (approximately 50%) than primary insertions. Conclusions: Effective doses for pediatric enteric and venous access procedures performed in children are generally low. In difficult cases, effective doses can reach levels comparable to those of pediatric computed tomography.

Transarterial Chemoembolization for Hepatitis B Virus–Associated Hepatocellular Carcinoma: Improved Survival after Concomitant Treatment with Nucleoside Analogues - Corrected Proof

Hidenori Toyoda, Takashi Kumada, Toshifumi Tada, Yasuhiro Sone, Masashi Fujimori — 2012-01-23

Purpose: To determine whether nucleoside analogue therapy is associated with improved survival in patients with hepatitis B virus (HBV)–associated hepatocellular carcinoma (HCC) who are treated solely with transarterial chemoembolization. Materials and Methods: A retrospective chart review of patients diagnosed with HBV-associated HCC was performed to identify patients treated solely with chemoembolization. Relevant demographic and clinical data were extracted and recorded. The influence of therapy with nucleoside analogues (lamivudine, adefovir dipivoxil, or entecavir) was determined by estimating the survival function using the Kaplan-Meier product-limit method. Results: The inclusion criteria for chemoembolization were met by 81 patients (67 men and 14 women, mean age 60.6 years ± 9.2); 21 (25.9%) of these patients had been treated with nucleoside analogues. The number of chemoembolization treatments was significantly greater in the patients who were treated with nucleoside analogues (3.43 ± 2.32) than in the patients who did not receive nucleoside analogues (1.82 ± 0.95; P = .0022). The 1-year, 3-year, and 5-year survival rates were 89.5%, 66.8%, and 40.5% in the patients treated with nucleoside analogues and 72.6%, 27.5%, and 14.3% in the patients not treated with nucleoside analogues. The survival rate was significantly higher in the patients who received nucleoside analogues (P = .0051). Nucleoside analogue intake was an independent factor that was associated with increased survival (P = .0063). Conclusions: Administration of nucleoside analogues was associated with longer survival in patients with HBV-associated HCC who were treated with transarterial chemoembolization.

Development and Preliminary Testing of a Translational Model of Hepatocellular Carcinoma for MR Imaging and Interventional Oncologic Investigations - Corrected Proof

2012-01-23

Purpose: To develop a translational rat hepatocellular carcinoma (HCC) disease model for magnetic resonance (MR) imaging and image-guided interventional oncologic investigations. Materials and Methods: Male rats underwent sham control surgery (n = 6), selective bile duct ligation (SBDL; n = 4), or common bile duct ligation (CBDL; n = 6), with procedure optimization in four rats and N1S1 hepatoma cell injection into two or three sites in the livers of 12 rats. All rats subsequently underwent MR imaging to assess tumor establishment and volume. Mesenteric angiography and percutaneous MR-guided laser ablation of the liver were performed in a subgroup of animals (n = 4). Animal weight and liver test results were monitored. After harvesting, the livers were subjected to gross and microscopic analysis. Tumor volume and laboratory parameters were assessed between ligation groups. Results: MR imaging demonstrated hyperintense T2 and hypointense T1 lesions with tumor induction in five of 10 (50.0%), seven of eight (87.5%), and 12 of 12 (100%) sites in the control, SBDL, and CBDL groups, respectively. Tumor volumes differed significantly by group (P < .02). Mesenteric angiography demonstrated an enhancing tumor stain. Clinical and laboratory assessment revealed a significant decrease in weight (P = .01) and albumin level (P < .01) and an increase in total bilirubin level (P = .02) in CBDL rats but not SBDL rats (P = 1.0). Histologic examination showed high-grade HCCs with local and vascular invasion within the context of early fibrosis in CBDL and SBDL rats. MR-guided laser ablation generated a 1–2-cm ablation zone with histologic findings consistent with reversible and irreversible injury. Conclusions: A biologically relevant rat HCC disease model has been developed for MR imaging and preliminary interventional oncologic applications.

Percutaneous Cryoablation of Lung Tumors: Feasibility and Safety - Corrected Proof

2012-01-23

Purpose: To evaluate the safety and feasibility of cryoablation for lung tumors as well as the incidence of, and risk factors for, complications. Materials and Methods: This study included 193 cryoablation sessions for 396 lung tumors in 117 consecutive patients. Univariate and multivariate analyses were performed to assess risk factors for common complications. Changes in laboratory values were analyzed the day after cryoablation. Results: Pneumothorax, pleural effusion, and hemoptysis occurred after 119 (61.7%), 136 (70.5%), and 71 (36.8%) sessions, respectively. Phrenic nerve palsy, frostbite, and empyema occurred after one session each (0.52%). Proximal tumor implantation was observed in one of 471 punctures (0.20%). Of 119 sessions with pneumothorax, 21 (17.6%) required chest tube insertion and two (1.7%) required pleurodesis. Delayed and recurrent pneumothorax occurred in 15 of 193 sessions each (7.8%). A greater number of cryoprobes was a significant (P = .001) predictor of pneumothorax. Male sex (P = .047) and no history of ipsilateral surgery (P = .012) were predictors for the need for chest tube insertion, and no history of ipsilateral surgery (P = .021) was a predictor for delayed/recurrent pneumothorax. Greater number of cryoprobes (P = .001) and no history of ipsilateral surgery (P = .004) were predictors for pleural effusion. Greater number of cryoprobes (P < .001) and younger age (P = .034) were predictors for hemoptysis. Mean changes in white blood cell count, platelet count, hemoglobin level, and C-reactive protein level were 2,418/μL ± 2,260 (P < .001), −2.0 × 104/μL ± 3.2 (P < .001), −0.77 mg/dL ± 0.89 (P < .001), and 3.0 mg/dL ± 2.9 (P < .001), respectively. Conclusions: Percutaneous cryoablation could be performed minimally invasively with acceptable rates of complications.

Central Venous Stenosis Associated with Pacemaker Leads: Short-Term Results of Endovascular Interventions - Corrected Proof

2012-01-23

Purpose: To determine the safety and outcomes of performing endovascular interventions across pacemaker (PM) lead–related central vein stenosis/occlusion. Materials and Methods: Clinical and imaging records from April 2002 to August 2010 were reviewed for patients presenting with clinically significant central venous stenosis or central venous obstruction with indwelling PM leads and were evaluated to determine if any lead dysfunction or complications occurred following intervention. Thirteen patients were identified who underwent 14 interventions. Outcomes were assessed based on recurrent clinical symptoms and repeat venograms, and patency was determined with Kaplan–Meier analysis. Results: All procedures were technically successful (100%) with no procedural complications. All patients underwent balloon angioplasty; two patients also underwent stent placement for persistent flow-limiting stenosis within the superior vena cava. No incidence of PM or lead dysfunction, infection, or need for PM intervention was identified in any patient at the time of the index procedure and at 30 or 90 days. In the two patients who received stents across PM leads, no manifestations of PM or lead dysfunction or infection, or need for intervention, were identified at 1 year after stent placement in one patient and at 3 years in the other patient. For eight patients, sufficient follow-up studies were available, with 30-, 60-, and 120-day primary patency rates of 87.5%, 75%, and 50%, respectively. Conclusions: Endovascular interventions across PM leads resulted in no adverse clinical cardiac or PM sequelae, but with limited primary patency compared with historical outcomes for central venous interventions in the absence of PM leads.

Image-Guided Biopsy of Suspicious Lymph Nodes in Patients with Known Primary Malignancies - Corrected Proof

2012-01-23

Purpose: To determine how often abdominal, pelvic, and inguinal lymphadenopathy in patients with a known malignancy arises from a second primary cancer or from benign causes, rather than from the cancer already known. Materials and Methods: A total of 196 patients with a history of a single biopsy-proven malignancy underwent image-guided abdominal or pelvic lymph node (LN) biopsies between January 2000 and January 2005. Three patients were excluded. The medical records and imaging of the remaining 193 patients were reviewed. Pathologic results were assigned to one of three outcomes: LN involvement by known malignancy, newly diagnosed malignancy, or no malignancy identified. Patients in whom malignancy was not identified required repeat biopsy or stability or reduction in size of LN on follow-up imaging for confirmation while not receiving treatment. Results: Of the 193 included biopsies, there was LN involvement by the known malignancy in 148 (76.7%; 95% CI, 70.1%–82.5%), a newly diagnosed malignancy in 19 (9.8%; 95% CI, 6.0%–14.9%), and no malignancy identified in 26 (13.5%; 95% CI, 9.0%–19.1%). Conclusions: Biopsy of a suspicious abdominal or pelvic LN in patients with known malignancy reveals a newly diagnosed malignancy or no evidence of malignancy in 23% of cases, emphasizing the importance of biopsy.

The Role of the Nurse Practitioner in Interventional Radiology - Corrected Proof

Kathy Taylor, Gail Egan Sansivero, Charles E. Ray — 2012-01-19

Interventional radiology (IR) has been expanded over the past decade to include an outpatient-based clinical practice as well as inpatient practice. This fundamental change in workload and the demands of longer term care and expanded clinical services has necessitated an examination of IR resources and practice strategies. Interventional radiologists have assumed a more pronounced and responsible role in managing the care of patients before, during, and after their procedures. Concurrently, the scope of interventions provided and performed by IR has expanded, with an increasing demand for these minimally invasive procedures. These two factors have challenged IR practices to manage the procedural workload while supporting the increasing demands of an outpatient or hospital-based clinical practice. This robust growth, coupled with difficulty in filling IR fellowship positions, has resulted in a shortage of properly trained IR physicians.

In Vivo Evaluation of Cisplatin-Loaded Superabsorbent Polymer Microspheres for Use in Chemoembolization of VX2 Liver Tumors - Corrected Proof

2011-12-30

Purpose: To investigate the pharmacokinetics and efficacy of chemoembolization with a cisplatin-loaded superabsorbent polymer (SAP) suspension in a rabbit model with transplanted liver VX2 tumors. Materials and Methods: VX2 tumors were implanted into the left lobe of the liver in eight rabbits. Embolization of the proper hepatic artery was performed with cisplatin-loaded or unloaded SAP. In the cisplatin-loaded SAP group (n = 4), 5 mg of SAP (106–150 μm) loading 2.35 mg of cisplatin and 0.5 mL of ionic contrast material (ioxaglic acid 320 mgI/mL) was injected into the proper hepatic artery. In the control group (hepatic arterial infusion [HAI] + SAP; n = 4), 5 mg of SAP loading 0.5 mL of ioxaglic acid alone was injected after a bolus infusion of an equivalent amount of cisplatin. Sequential change of the plasma platinum concentration within the first 24 hours was measured. Blood sampling and histopathologic examination were performed at 1-week follow-up. Magnetic resonance (MR) images were used to calculate the growth rate of the VX2 tumor. Results: All animals underwent successful embolization. Both total and free plasma platinum mean concentrations within the first 24 hours remained lower in the cisplatin-loaded SAP group, although without statistical significance (P > .05). The mean tumor growth rate was significantly lower in the cisplatin-loaded SAP group than the control group (20% vs 116%; P = .049). Histopathologic examination revealed coagulative necrosis to nontumorous liver parenchyma in two rabbits in the cisplatin-loaded SAP group, although no deaths occurred. Conclusions: These results suggested that chemoembolization with cisplatin-loaded SAP was a safe and tolerable treatment and was more effective in suppressing the tumor growth.