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To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation.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.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).Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.

Short bowel syndrome (SBS) has traditionally been regarded as a rapidly fatal medical catastrophe. The advent of pharmacological options directly targeting disease pathophysiology justified this review.Since the 1970s, home parenteral nutrition has reduced mortality, converting SBS into a chronic and disabling compensated and occasionally curable illness. Off-label antidiarrheal drugs and related products, though having minimal scientific evidence of efficacy, represent the standard-of-care and are here reviewed. Trophic intestinal hormones, including GLP-2 and its analogs, have great promise for alleviating malabsorption, the most important symptom within a nonsurgical, routine outpatient framework. Current indications involve adults with massive intestinal losses (fecal wet weight1500 g/day). Surgical options such as intestinal lengthening or transplantation are also addressed although these options are considerably more aggressive and have stricter indications.GLP-2 analogs are the first candidates from a pioneering pharmacotherapic family within the SBS framework, namely disease-modifying, absorption-restoring agents. This family of drugs, potentially applicable in all contexts of severe intestinal loss, could become the therapeutic benchmark of the near future.

Purpose To evaluate the technical and clinical success rates and safety of bilateral gelfoam uterine artery embolization (UAE) for symptomatic acquired uterine arteriovenous shunting due to prior obstetric or gynecologic event. Materials and Methods This was a retrospective study of consecutive patients of reproductive age who presented with abnormal uterine bleeding after recent gynecologic procedures or obstetric events between January 2013 and February 2018. Bilateral UAE was performed in all patients using gelfoam slurry. Technical success was defined as angiographic resolution of arteriovenous shunting. Clinical success was defined as cessation of symptomatic bleeding, resolution on follow-up imaging, or minimal estimated blood loss (EBL) ( Results Eighteen patients (mean age, 32.8 ± 7.1 years) were included. Technical success and clinical success were experienced by 17/18 (94.4%) and 16/17 (94.1%) patients, respectively. Angiography demonstrated arteriovenous shunting in 18/18 (100%) patients, with early venous drainage. Seven of 18 (38.9%) patients underwent subsequent scheduled D&C due to remaining retained products of conception, with an EBL of 17.9 ± 15.6 ml. There was 1 minor complication of a self-limited vascular access groin hematoma (1/18, 5.6%) and 1 major complication (1/18, 5.6%) of a pulmonary embolism detected 3 days after UAE. The length of clinical follow-up was 19.3 ± 15.5 months, in which 41.2% (7/17) of the patients became pregnant. Conclusions UAE with gelfoam alone for symptomatic uterine arteriovenous shunting is a feasible treatment option that has a high technical and clinical success rate with a low rate of complications.

Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ©RSNA, 2021.

To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung.A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung.SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

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 (

Preclinical studies have shown that modulation of the tumor microvasculature with anti-angiogenic agents decreases tumor perfusion and may increase the efficacy of radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC). Retrospective studies suggest that sorafenib given prior to RFA promotes an increase in the ablation zone, but prospective randomized data are lacking.We conducted a randomized, double-blind, placebo-controlled phase II trial to evaluate the efficacy of a short-course of sorafenib prior to RFA for HCC tumors sized 3.5-7 cm (NCT00813293).Treatment consisted of sorafenib 400 mg twice daily for 10 days or matching placebo, followed by RFA on day 10. The primary objectives were to assess if priming with sorafenib increased the volume and diameter of the RFA coagulation zone and to evaluate its impact on RFA thermal parameters. Secondary objectives included feasibility, safety and to explore the relationship between tumor blood flow on MRI and RFA effectiveness.Twenty patients were randomized 1:1. Priming with sorafenib did not increase the size of ablation zone achieved with RFA and did not promote significant changes in thermal parameters, although it significantly decreased blood perfusion to the tumor by 27.9% (p = 0.01) as analyzed by DCE-MRI. No subject discontinued treatment owing to adverse events and no grade 4 toxicity was observed.Priming of sorafenib did not enhance the effect of RFA in intermediate sized HCC. Future studies should investigate whether longer duration of treatment or a different antiangiogenic strategy in the post-procedure setting would be more effective in impairing tumor perfusion and increasing RFA efficacy.

To review the technical feasibility of resin microsphere (SIR-Spheres®) yttrium-90 radioembolization prescribed using the medical internal radiation dose (MIRD) model.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.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.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.•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.

Telehealth has not previously been widely implemented as a result of regulatory and reimbursement concerns; however, in the current national emergency of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services has relaxed many of its rules, allowing increased adoption of telehealth services, improving the safety and access of outpatient health care. A complete understanding of the regulatory requirements, technologic options, and billing processes of telehealth is required to initiate a successful clinic. A model is presented here based on a single institution's experience with implementing telehealth in the outpatient interventional radiology clinic.

To review the current status of radiofrequency ablation as a primary treatment for hyperfunctioning adrenal nodules, predominantly aldosterone-producing adenomas (APAs).Radiofrequency ablation is an established treatment for focal benign and malignant lesions, including metastatic disease to the adrenal gland. Hyperaldosteronism is the leading cause of secondary hypertension with up to 80% due to APA, statistically the most common functioning adrenal nodule. Although surgery remains the recommended treatment of choice for confirmed unilateral functioning adrenal nodules, radiofrequency ablation offers a less-invasive approach, with results comparable with surgery.Radiofrequency ablation of functioning adrenal nodules is a newer application of a technology in use for almost 2 decades. Although limited, reports to date suggest that results are comparable with those of laparoscopic adrenalectomy, but with advantages including being a less-invasive outpatient procedure with lower morbidity, faster recovery, and lower cost. However, the current data are all retrospective, the number of patients treated is small, and reported long-term results are limited.

To assess the impact of pre-procedural evaluation of patients with symptomatic uterine fibroids and adenomyosis in interventional radiology (IR) clinic. In this IRB-approved, HIPAA-compliant retrospective study, consecutive patients evaluated in the IR clinic in a tertiary academic hospital between 1/1/2015 and 9/30/2018 by a single board-certified interventional radiologist were included. Medical records were reviewed to obtain medical history, imaging and endometrial biopsies results. Impact of IR clinic assessment of clinical, imaging, and pathological findings on patient’s clinical course was assessed. Descriptive statistics were used. 208 consecutive patients were evaluated in clinic for uterine fibroids 176/208 (85%), adenomyosis 8/208 (4%) or both 24/208 (11%) with age of 44.4 ± 5.8 years and BMI of 30.1 ± 8.6 kg/m2. Leading presenting symptom was menorrhagia in 172/208 (80%) patients, pelvic pain in 91/208 (44%), and urinary symptoms in 88/208 (42%) patients. 159/208 (76%) patients underwent UAE, 12/208 (6%) patients underwent surgery, and 37/208 (18%) patients chose conservative management. 189/208 (91%) patients had pelvic MRI that altered management course in 7/189 (4%) patients due to intracavitary fibroids in two patients, endometrial polyps in two patients, non-enhancing fibroids in two patients, and adnexal mass in one patient. 166/208 (80%) underwent endometrial biopsy that altered management course in one patient (0.6%) due to endometrial intraepithelial neoplasia. Endometrial biopsy and pelvic MRI are helpful to detect cases of non-enhancing fibroids, intracavitary fibroids, and ovarian and endometrial malignancies and thus altered management of five percent of patients with symptomatic fibroids and adenomyosis.

Most clinical services limit weekend care to urgent or emergent situations. However, providing access to nonemergent procedures on weekends may reduce length of hospital stay and unnecessary admissions. No data are available on the impact of providing nonemergent interventional radiology (IR) procedural services on weekends. A retrospective review of nonurgent IR inpatient services on weekends over a 12-month period was performed. Using intent-to-treat analysis, 453 procedures were performed on 447 patients on 100 weekend days. Procedures included venous access (116 of 453, 25.6%), dialysis interventions (83 of 453, 18.3%), enteral access (73 of 453, 16.1%), genitourinary interventions (37 of 453, 8.2%), venous interventions (35 of 453, 7.7%), biliary interventions (33 of 453, 7.3%), percutaneous drainage (32 of 453, 7.1%), biopsy (24 of 453, 5.3%), arterial interventions (14 of 453, 3.1%), and other (3 of 453, 0.7%). Routine weekend procedural services allowed 108 of 447 (24.2%) patients to be discharged earlier than anticipated if such services were not available, resulting in 174 hospital days gained. Procedures were performed earlier than anticipated in 268 of 447 (60.0%) patients resulting in 415 days of progression of care gained over the 12-month period. For dialysis interventions, 35% (29 of 83) of patients received hemodialysis within 24 hours of intervention, and 25 patients were discharged early with 33 hospital days saved. IR procedures were performed on patients from 97% of the hospital inpatient units (22 of 23 inpatient or observation units, and 10 of 10 intensive care units) over the 12-month period. In conclusion, increased availability of nonurgent IR services on weekends can directly reduce hospital length of stay as well as improve progression of inpatients toward an early discharge.

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.

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.

Transjugular intrahepatic portosystemic shunts (TIPS) have been used for almost 40 years as a safe and effective alternative to surgical shunts, mostly in the setting of portal hypertension. Well described procedural complications include hepatic encephalopathy, hemorrhage, liver infarction and failure. The risk of post procedural acute kidney injury (AKI) associated with intraprocedural intravenous contrast administration has not been evaluated. Using a retrospective chart review of all consecutive patients undergoing a TIPS procedure as part of routine clinical care between 2001 and 2011, we examined whether the volume of administered intravenous contrast was associated with AKI. Of 163 patients who had a TIPS procedure, 16 % developed AKI as defined by a 0.3 mg/dl increase in serum creatinine within 48 h of the procedure. In adjusted analysis, a 50 ml increase of intravenous contrast was associated with a 1.27 (95 % CI 1.01–1.60), p = 0.04 increased risk of AKI. Baseline serum creatinine was also associated with post procedural AKI; a 0.1 mg/dl increase in creatinine was associated with a 1.17 (1.04–1.31), p = 0.008 risk. In patients with underlying kidney dysfunction, a 50 ml increase of intravenous contrast was associated with a 1.63 (1.20–2.31), p = 0.003 adjusted risk of AKI. In conclusion, intravenous contrast administered during a TIPS procedure is associated with an increased risk of AKI, particularly in patients with impaired renal function at baseline.

To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists. This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed. More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p

Recently, arterial embolization has been proposed as a safe and effective treatment for benign prostatic hyperplasia (BPH) [1]. Nonetheless, prostatic arterial embolization (PAE) is not a new procedure; it has been used for almost 40 years to control prostatic bleeding [2]. In 2000, De Merritt et al. [3] reported a case of embolization to treat hematuria after prostate biopsy in a patient with BPH. Interestingly, embolization not only stopped the bleeding, but also reduced the size of the gland and led to improvement in lower urinary tract symptoms. This observation sparked interest in a potential new application for embolotherapy. Early proponents of this new application noticed some similarities between prostatic artery embolization (PAE) and the well-established uterine artery embolization (UAE) procedure. UAE for treatment of symptomatic fibroids is now considered an excellent alternative to hysterectomy based on level I scientific evidence [4]. But what is the relationship between embolization for uterine fibroids and BPH? There are indeed some similarities. Both diseases are the most common benign tumors of the female and male pelvis, respectively. Both diseases have a tissue structure characterized by the presence of stromal and smooth muscle components, which are intrinsically hormone-dependent for their development and growth—estrogen and testosterone, respectively. Although considered benign tumors, both illnesses cause symptoms that produce a deep impact on quality of life, and usually are treated with conventional medical and surgical therapies, intrinsically associated with risks and morbidity, including sexual dysfunction. In contrast, embolization is a minimally invasive alternative that delivers embolic agents with the aim of causing targeted and controlled tissue ischemia and necrosis of the offending tumors. However, aside from these similarities, there are also many differences, which should be kept in mind for those who have experience in UFE and intend to explore the PAE field. Uterine fibroids affect premenopausal, therefore young, women up to the fifth decade of life, whereas BPH affects men starting from the fifth decade of life, with most symptomatic patients requiring treatment when they are even older. As a consequence, many BPH patients have significant atherosclerotic changes in their vessels, which make endovascular procedures more difficult and challenging. Uterine arteries in women with fibroids have a fairly constant anatomic location, distribution, and course, and their diameter grows proportionally to the size of the leiomyomatous uterus. In contrast, prostatic arteries are subject to numerous anatomic variations in terms of their origin and distribution, while remaining quite small in diameter, even when the prostate reaches fairly large volumes. It is also not uncommon to find more than one prostatic artery on each side [5]. In an anatomic description published recently, two main arterial pedicles to the prostate have been identified: the superior and inferior prostatic pedicles [5]. The former provides the main arterial supply of the prostate, in addition to both the inferior bladder and N. Kisilevzky (&) Interventional Radiologist at Endovascular Center, Rua Guararapes 682, City Lapa, SP CEP 05077051, Brazil e-mail: dr.nestor@embolution.com.br

Although breast-conserving therapy or mastectomy remains the gold standard for breast cancer treatment, minimally invasive alternatives to surgery are becoming more attractive for select patient populations. Advances in technology, reduced morbidity, improved cosmesis, and the ability to provide treatment in an outpatient setting are some of the advantages of image-guided therapy. Radiofrequency ablation (RFA) has been investigated because of its relatively low cost, low morbidity, and favorable technical success rates (76%-100% in published series). Image guidance during ablation involves the use of real-time ultrasound or magnetic resonance imaging to target the tumor and monitor the adequacy of ablation. Tumor size, location, histologic type, and reliable visualization under ultrasound (or other imaging modalities) are important to determine patient eligibility and procedural planning. In patients with localized breast cancer who decline surgery or are not candidates for surgery, RFA alone, or in combination with hormonal therapy, or followed by conventional radiation therapy with or without chemotherapy may prove to be viable treatment options. In patients with locally advanced or metastatic disease, RFA may be suitable for palliation of larger symptomatic tumors. Additional studies with long-term patient follow-up are necessary to better understand response to RFA and to determine its future role in the treatment algorithm for breast cancer.

To evaluate percutaneous brush cytology, forceps biopsy and a tandem procedure consisting of both, in the diagnosis of malignant biliary obstruction. 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. 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. 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. • 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.

Purpose To compare adrenal radiofrequency (RF) ablation with adrenalectomy in treating unilateral aldosterone-producing adenoma (APA). Materials and Methods Between April 2008 and September 2013, 44 patients with adrenal venous sampling–confirmed (lateralization index ≥ 4) unilateral APA underwent adrenal RF ablation (12/44 [27%]) or adrenalectomy (32/44 [73%]). Outcomes of adrenal RF ablation (patient age, 51 y ± 11; 4/12 men) were compared with adrenalectomy (patient age, 50 y ± 11; 19/32 men). Blood pressure (145/94 mm Hg ± 19/13 vs 144/89 mm Hg ± 10/8, P = .92), number of antihypertensives (3.0 ± 1.3 vs 2.7 ± 0.89, P = .38), and serum potassium (3.2 mEq/L ± 0.6 vs 3.5 mEq/L ± 0.6, P = .65) of patients were similar before treatment. Results RF ablation and adrenalectomy resulted in normokalemia (RF ablation, 4.2 mEq/L ± 0.1, P = .0004; adrenalectomy, 4.3 mEq/L ± 0.6, P P = .02/ P = .001; adrenalectomy, 128/85 mm Hg ± 13/12, P P = .07) in all patients. Proportions of RF ablation and adrenalectomy patients cured of hypertension (2/12 [17%] vs 12/32 [38%], P = .28) or requiring fewer antihypertensives (7/12 [58%] vs 13/32 [40%], P = .29) were similar. RF ablation patients had a shorter length of stay (0.6 d ± 0.8 [range, 0–2 d] vs 1.7 d ± 1.4 [range, 0–7 d]; P = .01) and less intraoperative blood loss (1.2 mL ± 3 vs 40 mL ±85; P = .01). Procedural complications occurred in 5/32 (15%) adrenalectomy patients (2 major, 3 minor) and in 0/12 RF ablation patients. Conclusions RF ablation to treat APA can achieve similar clinical outcomes as adrenalectomy and results in shorter hospital stays. Larger, prospective trials are needed to validate these results.

To evaluate the use of radiofrequency (RF) ablation as a primary treatment for symptomatic primary functional adrenal neoplasms and determine the efficacy of treatment with use of clinical and biochemical follow-up.After obtaining institutional review board approval, the authors retrospectively evaluated images and medical records from 13 consecutive patients with symptomatic functional adrenal neoplasms (3.2 cm in diameter) who underwent RF ablation during a 7-year period. There were six men and seven women with a mean age of 54.1 years (range, 42-71 years). Cross-sectional images, findings from clinical examination, and adrenal biochemical markers were available for all patients. Ten of the 13 patients (77%) had an aldosteronoma and one patient each had a cortisol-secreting tumor, testosterone-secreting tumor, and pheochromocytoma. RF ablation was performed by two radiologists using an internally cooled electrode and a pulsed technique according to manufacturer's specifications. Clinical and laboratory follow-up was performed for all patients. Three patients underwent imaging follow-up for other reasons.All patients demonstrated resolution of abnormal biochemical markers after ablation (mean biochemical follow-up, 21.2 months). In addition, all patients experienced resolution of clinical symptoms or syndromes, including hypertension and hypokalemia (in patients with aldosteronoma), Cushing syndrome (in the patient with cortisol-secreting tumor), virilizing symptoms (in the patient with testosterone-secreting tumor), and hypertension (in the patient with pheochromocytoma). For the patients with aldosteronoma, improvements in hypertension management were noted. The mean blood pressure before ablation was 149/90 mm Hg with a mean (±standard deviation) of 3.1 ± 0.6 blood pressure medications, and this decreased to 122/77 mm Hg at a mean of 2.8 months after ablation with 1.3 ± 0.9 medications (P.001) and 124/75 mm Hg at a mean of 41.4 months. There were two minor complications: one small pneumothorax and one limited hemothorax, neither of which required overnight admission. There were two episodes of transient self-remitting procedural hypertension-one in a patient with aldosteronoma and one in the patient with a cortisol-secreting tumor; however, none of these patients required further therapy during overnight observation.RF ablation may be an effective, minimally invasive method for treating small functional primary adrenal tumors.

Radiofrequency (RF) ablation is one of several local treatment strategies that can be used for the destruction of a variety of primary and secondary liver tumors. As experience with RF ablation grows, it becomes increasingly evident that successful ablation requires meticulous technique. In addition, knowledge of potential complications is critical for both the interventionalist and the radiologist, whose postablation interpretation can facilitate identification of complications and treatment failures. Hepatic RF ablation offers significant advantages in that it is less invasive than surgery and carries a low risk of major complications. Successful prevention of complications and treatment failures begins at initial consultation and continues with preablation evaluation of specific patient factors such as coagulation profiles, use of medications, and risk factors for infection. Other predisposing factors include background liver cirrhosis, prior hepatectomy, and portal hypertension. During ablation, careful attention must be given to tumor size, number, and location. For large or multiple ablations, separate ablation sessions can help reduce the prevalence of postablation syndrome, and clustered electrodes and multiple overlapping treatment zones may be used to reduce the risk of treatment failure. It is critical to reevaluate tumors during ablation to determine the best approach and to compensate for changes in size and relative location due to patient positioning. With use of these strategies, hepatic RF ablation can be performed with greater safety, better patient tolerance, and a reduced risk of complications and treatment failures.

Arteriovenous fistula (AVF) is a rare but well-documented complication of pancreatic allotransplantation. Small, tortuous vessels in the head of the transplanted pancreas may complicate transarterial embolization. The authors recently encountered two women who developed clinical pancreatitis after right pelvic transplant placement with documented AVF in the head of the transplanted pancreas. In the first patient, embolization was successfully performed transarterially. In the second patient, transarterial embolization was not feasible due to the small caliber and extreme tortuosity of the pancreaticoduodenal arcade and transvenous embolic occlusion was successfully performed. Both patients recovered with normalization of enzyme levels and pain reduction.

To determine how hypnosis and empathic attention during percutaneous tumor treatments affect pain, anxiety, drug use, and adverse events.For their tumor embolization or radiofrequency ablation, 201 patients were randomized to receive standard care, empathic attention with defined behaviors displayed by an additional provider, or self-hypnotic relaxation including the defined empathic attention behaviors. All had local anesthesia and access to intravenous medication. Main outcome measures were pain and anxiety assessed every 15 minutes by patient self-report, medication use (with 50 mug fentanyl or 1 mg midazolam counted as one unit), and adverse events, defined as occurrences requiring extra medical attention, including systolic blood pressure fluctuations (or =50 mm Hg change to180 mm Hg or105 mm Hg), vasovagal episodes, cardiac events, and respiratory impairment.Patients treated with hypnosis experienced significantly less pain and anxiety than those in the standard care and empathy groups at several time intervals and received significantly fewer median drug units (mean, 2.0; interquartile range [IQR], 1-4) than patients in the standard (mean, 3.0; IQR, 1.5-5.0; P = .0147) and empathy groups (mean, 3.50; IQR, 2.0-5.9; P = .0026). Thirty-one of 65 patients (48%) in the empathy group had adverse events, which was significantly more than in the hypnosis group (eight of 66; 12%; P = .0001) and standard care group (18 of 70; 26%; P = .0118).Procedural hypnosis including empathic attention reduces pain, anxiety, and medication use. Conversely, empathic approaches without hypnosis that provide an external focus of attention and do not enhance patients' self-coping can result in more adverse events. These findings should have major implications in the education of procedural personnel.

To assess the feasibility of bilateral endovenous laser ablation (EVLA) of saphenous veins in a single session with use of diluted lidocaine for tumescent anesthesia.Among 122 consecutive EVLA procedures (112 patients; mean age, 49 years; 75% women) over a 12-month period, there were 75 unilateral procedures (n = 67) and 47 bilateral interventions (n = 45). Tumescent anesthesia consisted of lidocaine diluted to 0.10% for unilateral procedures versus 0.05% for bilateral cases (lidocaine dose4.5 mg/kg body weight). Procedural data, immediate success rates on an intent-to-treat basis, and outcomes at 3-6-month follow-up were compared between groups with nonparametric tests.Bilateral procedures could be performed successfully with low lidocaine dilutions with a similar success rate (96%) as unilateral procedures (100%). No significant variation in systolic and diastolic blood pressure and heart rate was observed between bilateral and unilateral groups. No patient experienced signs of lidocaine toxicity. After adjusting for length of vein treated, there were no significant differences in the total lidocaine dose used, tumescent anesthesia volume, or procedure duration.Bilateral saphenous vein ablation in a single session appears safe and effective when tumescent anesthesia is given with very dilute lidocaine (0.05%). This approach may help meet patients' requests for simultaneous bilateral treatment and reduce duration of postprocedural discomfort.

The objective of this study was to assess the diagnostic value of attenuation measurements of the kidney on unenhanced helical CT in patients with obstructive ureterolithiasis.Consecutive unenhanced helical CT scans of patients referred for acute unilateral renal colic were retrospectively reviewed. Patients with CT evidence of other urinary system diseases were excluded. Included scans (n = 145) were assessed for ureteral stone and secondary signs of obstruction such as unilateral collecting system or ureteral dilatation, perinephric stranding, and periureteral edema. Renal attenuation in Hounsfield units was measured in the upper, middle, and lower portions of the parenchyma, and a mean value was determined for each kidney.Ureteral stones were present in 76 patients. Renal attenuation on the side with lithiasis was lower than on the opposite kidney: 27.2 +/- 3.9 H vs 32.6 +/- 3.4 H (p0.001). Attenuation differences between kidneys were higher for patients with ureterolithiasis: 5.4 +/- 3.2 H (range, -3.3 to 13.0 H) versus 1.2 +/- 1.0 H (range, 0-4.7 H) (p0.001). An attenuation difference between kidneys greater than or equal to 5.0 H had 61% sensitivity, 100% specificity, 100% positive predictive value, 69% negative predictive value, and 79% accuracy for diagnosis of ureteral lithiasis.Attenuation difference between kidneys greater than or equal to 5.0 H was a valuable sign and had diagnostic performance similar to other secondary signs of obstructive ureterolithiasis. Furthermore, attenuation difference had the advantage of being an objective, measurement-based indicator.

Prostatic artery embolization (PAE) is a promising new treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). It has therefore garnered much interest in the interventional community. This article will review the scientific background for this therapy, describe the current devices available for treatment, and state the position of the Society of Interventional Radiology (SIR) with regard to the study and potential adoption of this therapy.

We report a life-threatening subcapsular hepatic hemorrhage after VATS, successfully treated with Gelfoam embolization of the right hepatic artery. The postprocedure course was complicated by infarction of the right hepatic lobe.

Percutaneous tumor ablation is now commonly used to treat a wide range of focal tumors. Patients eligible for ablation often have complex medical problems that preclude them from receiving other treatments. The interventional radiologist needs to perform a careful clinical evaluation of each patient before the procedure to determine which patients are suitable candidates for treatment and to identify patients who may be at a higher risk for complications. The clinical consultation also provides an opportunity to prepare the patient for the ablation and to appropriately plan the procedure. In this article, we discuss key components of the consultation and concepts regarding patient evaluation and preparation for a tumor ablation procedure.

A clinical study was designed that aimed to analyze whether resection of the large bowel in cancer patients might benefit diabetes mellitus. This prospective case–control study included retrospective information. Patients (n = 247) included diabetic and euglycemic groups with colorectal cancer operations (n = 60), cancer gastrectomy (n = 72), exclusive chemoradiotherapy for rectal cancer (n = 46), and noncancer clinical controls (n = 69). Follow-up periods were, respectively, 79.2 ± 27.4, 86.8 ± 25.1, 70.0 ± 26.3, and 85.1 ± 18.2 months (NS). Diabetes groups included patients with prediabetes. Diabetes remission, defined as conversion from diabetes to prediabetes or from this condition to normal, was documented in, respectively, 32.4 % (11 of 34), 41.2 % (14 of 34), 7.1 % (1 of 14), and 7.7 % (3 of 39) in the four cohorts (P = 0.004). Within the same period, progression of euglycemic participants to diabetes occurred in 30.8 % (8 of 26), 63.2 % (24 of 38), 25.0 (8 of 32), and 20.0 % (6 of 30) (P = 0.028). Diabetes amelioration was associated with weight loss in gastrectomy patients but not in the other groups. Dietary intake, estimated in the two surgical populations, did not predict outcome. Diabetes amelioration after colorectal interventions was demonstrated, but progression of euglycemic patients toward prediabetes was not changed in comparison with nonsurgical controls. It is speculated that reshaping of the bowel microbiome or hormone changes after colorectal interventions underlay the improvement in diabetes. Body weight fluctuations could not be incriminated in this investigation.

The purpose of this study was to describe the imaging findings after radiofrequency ablation of adrenal tumors.We retrospectively reviewed the imaging findings of all patients with adrenal tumors treated with radiofrequency ablation in our department from January 2001 through August 2009. The studies were reviewed in consensus by two attending abdominal imaging radiologists and an abdominal imaging fellow. Imaging findings before, immediately after, and at short- and long-term follow-up after ablation were recorded.Fourteen patients (seven men, seven women; mean age, 56 ± 8.4 years) underwent radiofrequency ablation of adrenal tumors. One case of small pneumothorax and one case of small hemothorax were the only minor complications (complication rate, 14%). The expected side effects of radiofrequency ablation were found in 35% of patients: in two patients adjacent liver parenchyma was ablated, in two patients the diaphragmatic crus was injured, and in two patients local hematoma occurred (in one patient, both adjacent liver and diaphragmatic crus were ablated). Immediate soft-tissue findings after radiofrequency ablation included air bubbles in 12 patients (86%) and fat stranding around the adrenal gland in 13 patients (93%). A fat rim sign was found in 60% of patients at long-term follow-up. The attenuation of the tumor immediately after the procedure increased an average of 7 HU (median, 5 HU; range, -2 to 18 HU) and tended to decrease in long-term follow-up. At long-term follow-up, most (75%) of the tumors had decreased in size and attenuation.Air bubbles and fat stranding are frequently seen immediately after radiofrequency ablation of adrenal tumors. A fat rim sign is a common finding at long-term follow-up. Attenuation of the ablated zone increases immediately after the procedure and decreases in long-term follow-up. The volume of the ablated zone has a variable size response, suggesting the need for baseline imaging.

To determine the success rate for reinsertion of interventional radiology-placed catheters that were accidentally removed by using the existing percutaneous track and to investigate factors that influence success rate.The authors performed a retrospective analysis of 225 patients who presented with dislodged catheters (24 tunneled central venous catheters, 170 gastrostomy/jejunostomy tubes, 25 nephrostomy catheters, five biliary catheters, and one transhepatic hemodialysis catheter) and underwent attempts for reinsertion between 1999 and 2007. Data obtained from the radiology information system included the type of catheter and the indwelling and reinsertion times.The overall success rate for reinsertion was 87%. Success of reinsertion was associated with longer catheter indwelling times compared to patients who failed reinsertion (254 vs 100 days, P.01). Success of reinsertion was associated with shorter reinsertion times compared to patients who failed reinsertion (1.1 vs 2.7 days, P.05).Reinsertion of catheters by using the cutaneous track can be performed successfully during the first days after dislodgement. Success rates vary on the basis of catheter type and indwelling and reinsertion times.

To assess the potential of macroembolization, the authors compared the downstream particulate profile generated with use of two thrombectomy devices, a 20-kHz ultrasound-based sonothrombolytic (ST) device and a rotating dispersion wire (RDW).An arterial flow model was pressurized to 100 mm Hg and perfused with 1,000 mL/min normal saline. Tubing containing 7-mm x 30-cm bovine thrombus proximal to a 75% stenosis was inserted distal to a nonstenosed bypass. The effluent was passed successively through 1,000-, 500-, and 200-microm filters and a particle analyzer. The ST device and RDW were activated for 10 and 15 minutes, respectively, in randomized sequences of experimental sets with and without the use of 10-mg tissue-type plasminogen activator (tPA). Results are expressed as means and standard deviations of fraction of lysed clot in each category.The ST device produced significantly fewer particulates larger than 1,000 microm (1.3% +/- 1.4) than did the RDW (16.8% +/- 8.4, P.001) and significantly more particulates smaller than 10 microm (90.7% +/- 7.6) than did the RDW (73.9% +/- 9.5; P.001) at comparable thrombolytic efficacy (P = .982) and without significant effect from tPA (P = .988). There were no significant differences between particles measuring 500-1,000 microm (ST device: 0.3% +/- 0.3, RDW: 0.4% +/- 0.3; P = .653) and those measuring 10-199 microm (ST device: 7.5% +/- 7.5, RDW: 8.6% +/- 3.8; P = .624). The amount of particles on the 200-microm filter after RDW activation (0.4% +/- 0.3) exceeded those trapped after use of the ST device (0.1% +/- 0.1, P = .007) but contributed relatively little overall.In this in vitro model, the use of the ST device resulted in fewer large particulates than did the use of the RDW, with more clots being reduced to less than 10 microm.

Postembolization syndrome (PES) after transcatheter uterine artery embolization (UAE) is classically described as including self-limited pain, nausea, vomiting, and fever. However, the expected components of PES after UAE might also include leukocytosis, the incidence and magnitude of which have not yet been determined. A retrospective review of 78 patients who underwent elective UAE for symptomatic leiomyomas showed an increase in white blood cell (WBC) counts within 24 hours after the procedure in 86% of patients, with clinically defined leukocytosis (WBC count11,000/microL) present in 21% of patients. Interventional radiologists and other clinicians involved in the care of these patients should expect such changes and not be alarmed regarding early infectious complications.

To retrospectively evaluate solid renal tumor sizes before and after treatment with radiofrequency (RF) thermal ablation to assess for immediate changes on cross-sectional imaging.Medical records were retrospectively reviewed in consecutive patients who underwent percutaneous image-guided RF thermal ablation for solid renal tumors between December 12, 2000, and December 13, 2006. All patients underwent noncontrast computed tomography (CT) immediately before and after RF ablation. Maximum renal tumor diameters were measured before and after ablation. Statistical analysis of tumor sizes before and after ablation and change in tumor sizes was performed with the paired Student t test with confidence intervals calculated.Seventy-two renal tumors were treated with RF ablation in 66 patients (42 men, 24 women; mean age, 68.4 years; range, 25-88 y). Mean tumor sizes were 27.5 mm (range, 9.8-64.8 mm; 95% CI, 24.9-30.1 mm) before ablation and 22.1 mm (range, 5.3-67.3 mm; 95% CI, 19.4-24.8 mm) immediately after ablation. An average decrease in renal tumor size of 21% (range, -10% to 50%) was identified, with a mean tumor diameter decrease of 5.4 mm (P.05; 95% CI, 4.4-6.4 mm). No relationship between size or location of tumors and percentage decrease in size after RF ablation was identified. Measurement of tumors on 1-month follow-up CT showed no appreciable change compared with immediate postprocedural measurements.Renal tumors decrease in size immediately after treatment with RF thermal ablation. Immediate tumor involution after RF ablation should be anticipated and follow-up imaging studies should ideally be compared to a baseline tumor size measured as soon as possible after ablation.

Because many retrievable inferior vena cava (IVC) filters are placed without ever being removed, placement of a retrievable device that is not removed incurs greater technical cost for the institution than a cheaper permanent filter (PF), with no clinical benefit for the patient and no additional professional or technical revenue for the interventional radiologist and institution. The purposes of this study are to identify patient characteristics associated with lack of removal of a retrievable filter (RF) and to develop a cost-effective strategy for placement of a retrievable IVC filter.A retrospective evaluation of 160 consecutive patients who underwent IVC filter placement with or without removal in our interventional radiology (IR) unit over a period of 31 months was performed. Patient characteristics were identified that were associated with lack of removal of retrievable IVC filters, and the cost savings were calculated in the event that a PF had been substituted for an RF in these patients.A total of 160 consecutive IVC filters were placed during the study period. Of these, 42 (26%) were PFs and 118 (74%) were RFs. During the study period, only 27 of the 118 RFs (23%) were subsequently removed. Factors associated with lack of removal of an RF included patient age (P = .003), presence of ongoing malignancy (P = .04), and indication for filter placement (P = .01). Retrospectively, the use of retrievable devices only in the presence of two of the three selection criteria (ie, age65 years, no ongoing malignancy, prophylactic indication) would have resulted in a net incremental benefit of $59,562 for the IR service.The preferential use of retrievable versus permanent devices for filter placement is financially advantageous for an IR unit only if at least 41% of them are eventually removed. The use of clinical criteria to select device type allows significant cost savings.

OBJECTIVE. Central venous catheter malfunction often results from fibrin sheath formation and is routinely addressed with thrombolytic therapy or mechanical stripping. Mechanical stripping from a distant access site such as a femoral vein is the only option for a subcutaneous port that has failed thrombolytic therapy. When a fibrin sheath has rendered the catheter tip inaccessible to snaring, catheter salvage cannot be achieved, requiring port exchange. We report two cases in which an inaccessible catheter tip was mobilized via advancing a wire through the port and through the catheter, allowing for successful snaring, mechanical stripping, and return of normal port function.CONCLUSION. Passage of a hydrophilic wire through a subcutaneous port and beyond the catheter tip is technically possible. The wire can be snared from a femoral access to achieve successful catheter stripping when direct catheter snaring is not possible.

CONTEXT AND OBJECTIVE: Recent studies have shown noncontrast computed tomography (NCT) to be more effective than ultrasound (US) for imaging acute ureterolithiasis. However, to our knowledge, there are few studies directly comparing these techniques in an emergency teaching hospital setting. The objectives of this study were to compare the diagnostic accuracy of US and NCT performed by senior radiology residents for diagnosing acute ureterolithiasis; and to assess interobserver agreement on tomography interpretations by residents and experienced abdominal radiologists. DESIGN AND SETTING: Prospective study of 52 consecutive patients, who underwent both US and NCT within an interval of eight hours, at Hospital São Paulo. METHODS: US scans were performed by senior residents and read by experienced radiologists. NCT scan images were read by senior residents, and subsequently by three abdominal radiologists. The interobserver variability was assessed using the kappa statistic. RESULTS: Ureteral calculi were found in 40 out of 52 patients (77%). US presented sensitivity of 22% and specificity of 100%. When collecting system dilatation was associated, US demonstrated 73% sensitivity, 82% specificity. The interobserver agreement in NCT analysis was very high with regard to identification of calculi, collecting system dilatation and stranding of perinephric fat. CONCLUSIONS: US has limited value for identifying ureteral calculi in comparison with NCT, even when collecting system dilatation is present. Residents and abdominal radiologists demonstrated excellent agreement rates for ureteral calculi, identification of collecting system dilatation and stranding of perinephric fat on NCT.

Medical procedures in outpatient settings have limited options of managing pain and anxiety pharmacologically. We therefore assessed whether this can be achieved by adjunct self-hypnotic relaxation in a common and particularly anxiety provoking procedure. Two hundred and thirty-six women referred for large core needle breast biopsy to an urban tertiary university-affiliated medical center were prospectively randomized to receive standard care (n=76), structured empathic attention (n=82), or self-hypnotic relaxation (n=78) during their procedures. Patients' self-ratings at 1 min-intervals of pain and anxiety on 0-10 verbal analog scales with 0=no pain/anxiety at all, 10=worst pain/anxiety possible, were compared in an ordinal logistic regression model. Women's anxiety increased significantly in the standard group (logit slope=0.18, p

Rationale and Objectives To evaluate the relationship between intramammary arterial calcifications detected by screening mammography and concomitant coronary artery disease, detected by coronary angiography. Materials and Methods We retrospectively evaluated screening mammography and coronary angiography results of 131 consecutive patients, ages 42–81 years. Risk factors for coronary artery disease (hypertension, diabetes mellitus, dyslipidemia, smoking, and obesity) were obtained from medical records to identify possible simultaneous risk factors for coronary artery disease. Results Eighty-five women had coronary artery disease (41 with intramammary arterial calcifications and 44 without such calcifications) and 46 had normal coronary angiography (11 had intramammary arterial calcifications and 35 did not). A strong association between intramammary arterial calcifications and coronary artery disease was seen, with an OR of 2.96 and P = .006 in the raw model and OR of 4.6 in the adjusted one. The evaluated risk factors did not present as confounding variables. Most patients had only two risk factors or less. The most prevalent risk factor for coronary artery disease was hypertension, with significantly higher prevalence in the coronary artery disease group ( P Conclusion A strong association exists between intramammary arterial calcifications and coronary artery disease. Therefore a mammographic finding of intramammary arterial calcification should receive more of the radiologists’ attention and its presence should never be omitted from the final report.

PURPOSE To assess feasibility and success of venous recanalization in patients with short gut syndrome who have lost their traditional central venous access and required intestinal or multivisceral transplantation. MATERIALS AND METHODS Twelve patients between the ages of 7 and 55 years with short gut syndrome and long-standing total parenteral nutrition (TPN) dependency and/or hypercoagulability were treated. All had extensive chronic central venous occlusions and survival was dependent on restoration of access and planned transplantation. Central venous recanalizations were obtained via sharp needle recanalization techniques, venous reconstructions with stents, and/or extraanatomic access to the central venous system for placement of central venous tunneled catheters. RESULTS Central venous access was restored in all patients without operative-related mortality. Three major hemodynamic perioperative technical complications were recorded and successfully treated. There were three selflimited early infectious complications. With a mean follow-up of 22 months, eight of the 12 patients were alive with successful small bowel or multivisceral transplantation; six of those became independent of TPN. The remaining four patients died of complications related to TPN ( n = 3) or transplantation ( n = 1). With a mean follow-up of 20 months, all but two of the recanalized venous accesses were maintained, for a success rate of 83%. CONCLUSIONS Recanalizations of extensive chronic vein occlusions are feasible but associated with high risk. The technique is life-saving for TPN-dependent patients and can restore candidacy for intestinal and multivisceral transplantation. This approach is likely to be increasingly requested because of the current clinical availability of the transplant procedure.

Our objective was to determine if there is a single parameter that can be used as a marker of splenomegaly using CT.Splenic length, width, and thickness were measured in 249 CT scans and multidimensional indexes were obtained from the multiplication of these measurements. Volume was calculated by summing the volumes of multiple contiguous scans. The relationship of the spleen to the left liver lobe and inferior third of the left kidney was also evaluated. Linear equations were obtained to correlate each measurement to the splenic volume.The unidimensional measurements with best correlation to volume were splenic length (r = 0.81, p0.01) and width (r = 0.804, p0.01). Correlation was better for the multidimensional indexes (r = 0.95, p0.01). Using a previously described upper limit of normality for splenic volume of 314.5 cm3 in the linear regression equation obtained, a maximum spleen length of 9.76 cm was the upper limit of normality. The relation of the lowest point of the spleen to the inferior third of the kidney also showed that if the spleen reached or extended below this portion of the kidney, it could be used as evidence of splenomegaly (p0.005), although it had a low sensitivity.Splenic length and multidimensional indexes correlate well with splenic CT volume. A splenic length of 9.76 cm can be used to accurately diagnose splenomegaly and can replace multiple-measurement, time-consuming methods in the clinical routine.