Publications

PURPOSE: To evaluate the long-term outcomes of primary stent placement for hepatic artery kinks in liver transplant recipients.

METHODS: After institutional review board approval, all patients undergoing liver transplantation between February 2001 and February 2024 at a single institution who underwent primary stent placement were reviewed. Patients who had hepatic artery thrombosis or underwent balloon angioplasty alone were excluded. Patients who underwent stent placement for hepatic artery kink were included. Hepatic artery kinks were defined by an acute arterial bend with coaptation of the arterial wall which is typically due to redundancy of the transplant hepatic artery. Hepatic arterial patency was evaluated at 1, 3, and 5 years. Kaplan-Meier analysis was performed for primary patency.

RESULTS: Fifty-six patients underwent hepatic artery stent placement. Further stratification resulted in 15/56 patients undergoing stent placement for hepatic artery kink. Primary patency rates for hepatic artery kink patients (n = 15) at 1, 3, and 5 years were 92%, 92%, and 92%, respectively. Primary-assisted patency for stent placement for hepatic artery kink was 100% at 1, 3, and 5 years. One patient had mid-stent kinking which was categorized as a technical failure and required re-intervention (n = 1/15). No patients had kink propagation or arterial rupture.

CONCLUSION: In conclusion, primary stent placement for hepatic artery kink has excellent long-term patency.

PURPOSE: To evaluate the pathologic outcomes of 90Y-TARE of HCC with resin microspheres prescribed using the single-compartment model and to correlate posttreatment dose with outcomes.

METHODS: This retrospective single-center study included adult patients with HCC who underwent 90Y-TARE with resin microspheres before liver transplantation or surgery. Histopathologic evaluation of liver tissue was performed. Complete pathologic necrosis (CPN) was defined as 100% tumor necrosis, extensive necrosis as 50-99%, and partial necrosis as < 50%. Posttreatment voxel-based dosimetry was conducted. Additional subgroup analysis was done to compare tumors with complete and incomplete necrosis.

RESULTS: Among 28 patients (median age, 64 years [IQR, 57-69 years]); 86% males,75% BCLC 0-A) with 37 HCC tumors, complete, extensive and partial pathologic necrosis were achieved in 27/37(73%), 8/37(22%) and 2/37(5%) tumors, respectively. Tumors with CPN were significantly smaller than those without CPN (2.2 vs. 3.4 cm, P = 0.03), with longer interval between the 90Y-TARE and liver surgery (274 vs. 143 days, P = 0.048). All tumors with a mean tumor absorbed dose ≥ 433 Gy had CPN. Conversely, all tumors in which 4% or more of the tumor volume received a dose less than 100 Gy had incomplete necrosis. ROC analysis identified D95 ≥ 133 Gy (AUC 0.96 [95%CI: 0.9-1]) and V0-100 (%) < 5% (AUC 0.9 [95%CI: 0.75-0.97]) as predictors of CPN with 100% and 78% specificity, respectively.

CONCLUSION: Among HCC patients who underwent 90Y-TARE with resin microspheres, 73% achieved complete pathologic necrosis. All tumors with a mean tumor absorbed dose ≥ 433 Gy achieved CPN.

CLINICAL TRIAL NUMBER: not applicable.

PURPOSE: To evaluate the safety and effectiveness of percutaneous drainage in the management of infected post-cesarean section (CS) bladder flap hematomas (BFHs).

MATERIALS AND METHODS: This retrospective cohort study examined all post-CS imaging examinations performed between January 1, 1999, and April 1, 2022. Of 90,462 CSs performed, 255 patients underwent postpartum pelvic imaging. Images were assessed for BFH and features of infection. Infected BFH was defined by the presence of the systemic inflammatory response syndrome criteria for sepsis, with or without imaging features of infection. Data on treatment approach, outcomes, hospitalization duration, and readmission were obtained when available. The t-test was used for parametric data and Mann-Whitney U test was used for nonparametric data.

RESULTS: BFH was diagnosed in 56 (22%) of 255 patients, with a median age of 31 years (interquartile range, 26.8-35.0 years). Forty-five (80%) of 56 patients presented with infection and were treated either with antibiotics alone (26/45, 58%) or drainage procedures (19/45, 42%) combined with antibiotics (surgical [3/19, 16%] and percutaneous drainage [16/19, 84%]). Percutaneous drainage had a success rate of 94% (15/16). Conservative management with antibiotics alone also had a high success rate of 96% (25/26); however, 1 (4%) of 26 developed uterine scar dehiscence. The median lengths of hospital stay were 4 days (range, 1-12 days) for the antibiotic-only group and 6 days (range, 3-39 days) for the drainage group (P < .01). Readmission within 30 days occurred in 7 (27%) of 26 patients in the antibiotic group compared with 3 (19%) of 16 in the drainage group.

CONCLUSIONS: Percutaneous image-guided drainage is safe and highly effective in managing infected BFHs that do not respond to antibiotics with no increased risk of uterine scar dehiscence.

BACKGROUND: Pneumatosis intestinalis on CT presents a diagnostic dilemma, because it could reflect bowel ischemia or benign finding.

PURPOSE: To determine radiological and clinical features that can predict bowel ischemia in patients with pneumatosis intestinalis on CT.

MATERIALS AND METHODS: Patients with "pneumatosis" in abdominal CT reports performed between 1/1/2002 and 12/31/2018 were retrospectively included. Pneumatosis intestinalis was confirmed by review of images. Radiological features of pneumatosis, laboratory data, clinical signs and symptoms were collected. Pathologic pneumatosis intestinalis (PPI) was defined as presence of ischemic (viable or dead) bowel on surgery or death during admission or within 30 days of discharge due to ischemia. Univariate statistical analysis was used to identify features associated with PPI, followed by multivariate logistic regression models.

RESULTS: A total of 313 consecutive patients with pneumatosis intestinalis (162 (52%) men, median age 67 years, IQR 55-78 years) were included. Pathologic pneumatosis intestinalis was present in 114/313 (36%) patients. Presence of arterial or venous thrombosis, porto-mesenteric gas, fat stranding, and location in the small bowel were significantly associated with PPI. A combined clinical and radiological model, which included age, WBC, creatinine, abdominal distention, rebound or guarding, shock, presence of porto-mesenteric gas and fat stranding showed an AUC of 0.85 for prediction of PPI, higher than models using clinical (AUC = 0.80, p = 0.005) or radiological factors (AUC = 0.80, p < 0.0001) alone.

CONCLUSION: Improved prediction of pathological pneumatosis intestinalis can be achieved by a model incorporating both clinical and radiological features (AUC = 0.85)rather than by either clinical (AUC = 0.80) or radiological (AUC = 0.80) features alone.

PURPOSE: To evaluate how the implementation of superior hypogastric nerve block (SHNB) during uterine artery embolization (UAE) for uterine fibroids impacts same-day discharge and healthcare encounters (HCEs) within 30 days.

MATERIALS AND METHODS: A total of 240 patients who underwent successful UAE for fibroids between January 2018 and December 2022 were retrospectively reviewed. HCEs within 30 days, including emergency department and urgent care visits, admissions, and readmissions, were categorized as early (0-7 days of discharge) and late (8-30 days of discharge) and related or unrelated to interventional radiology (IR) care. Factors associated with same-day discharge and HCE were identified using univariate analyses. Rates of HCE based on SHNB status were compared using the chi-square tests.

RESULTS: The mean age of the patients was 46 years (SD ± 5); 125 patients received UAE with SHNB. Patients who underwent SHNB were significantly more likely to undergo same-day discharge (113/125, 90%) than those without SHNB (55/115, 48%) (P < .001). No factors were associated with rates of all-cause 30-day HCE, including SHNB status (SHNB, 17% [21/125], versus no SHNB, 10% [12/115]; P = .20). A majority of HCEs were due to an IR-related cause (26/33, 79%), including abdominal or pelvic pain (22/33, 67%); nausea, vomiting, or poor oral intake (18/33, 55%); and vaginal bleeding (4/33, 12%). Comparison of patients who underwent SHNB with those without SHNB showed no difference in the proportion of IR-related HCE (17/21 [81%] versus 9/12 [75%], P = .69).

CONCLUSIONS: UAE with SHNB was associated with significantly higher rates of same-day discharge but similar rates of 30-day HCEs compared with UAE alone.

OBJECTIVE: To analyze outcomes of non-malignant concordant, discordant, and indeterminate results of CT-guided biopsies determined by standardized radiology-pathology concordance evaluation.

METHODS: In this study, consecutive patients undergoing CT-guided omental and mesenteric biopsy between March 2005 and August 2021 were included. A standardized radiology-pathology concordance workflow was implemented in July 2016, with retrospective concordance assessment applied to earlier cases. Concordance between pathology results and imaging findings was assessed by procedural radiologists.

DEFINITIONS: concordant, for malignant biopsy results or benign pathology where imaging findings agree; discordant, if pathology results are not congruent with imaging; and indeterminate, if imaging could be explained by pathology, but could also represent malignancy.

RESULTS: 222 biopsies were included. Pathology showed non-malignant results in 43/222 (19%), further classified by radiology-pathology concordance evaluation as discordant in 24/43 (56%), indeterminate in 8/43 (19%), and concordant in 11/43 (26%). One patient was lost to follow-up in the indeterminate category. The prevalence of malignancy on follow-up was higher in discordant (13/24, 54%) and indeterminate (2/7, 29%) groups vs. concordant cases (0/11, 0%), p < 0.001. There were 15/42 (36%) patients with final diagnosis of malignancy that would have been missed if radiology-pathology concordance evaluation had not been performed. Median time to diagnosis was shorter with repeat biopsy (18 days, IQR 9-34) and surgery (41 days, IQR 17-60) vs. imaging (185 days, IQR 107-239) and clinical follow-up (330 days, IQR 240-374), p < 0.001.

CONCLUSION: Radiology-pathology concordance evaluation in CT-guided omental and mesenteric biopsies showed high malignancy rates in initially non-malignant discordant (54%) and indeterminate (29%) cases. This practice prevented missed cancer diagnoses in 36% of patients with initial non-malignant results.

Portal vein embolization (PVE) is a minimally invasive intervention that has become the standard of care in preoperative liver augmentation for patients undergoing extended hepatic resections for primary and secondary liver cancers. PVE provides permanent and complete occlusion of the portal venous inflow to diseased hepatic segments, re-directing portal flow to the future liver remnant and inducing hypertrophy sufficient to proceed to major hepatectomy. The aim of this review is to discuss the methods of identifying an insufficient future liver remnant, technical considerations for performing effective PVE, and the alternative/adjunctive measures for PVE.

BACKGROUND: The lateral upper arm (LUA) pathway is a route of superficial lymphatic drainage that bypasses the axilla by draining to the deltopectoral, clavicular, and cervical lymph nodes. Despite the fact that anatomic variations of the LUA pathway have been implicated in breast cancer-related lymphedema (BCRL) risk after axillary lymph node dissection (ALND), the incidence of the LUA pathway variations in the healthy population has never been reported.

METHODS: Healthy female volunteers underwent bilateral lymphatic mapping of the upper extremities with indocyanine green (ICG) lymphography. ICG was injected in six standard sites in the hand/wrist and upper arm. Major anatomic variations of the LUA pathway were recorded including bundle phenotype (long, short, or absent), proximal visualization sites, and forearm pathway continuation to the long bundle phenotype.

RESULTS: 90 arms of 45 volunteers were included. The LUA pathway was present in 99% of arms and a long-versus-short bundle phenotype was observed in 71% versus 28% of arms. When the long bundle was present, it was formed by continuity with the forearm posterior radial channel alone (47%), posterior ulnar channel alone (34%), or both channels (19%). The LUA pathway was traced proximally to the deltopectoral groove in 89% of arms and to the axilla in 11% of arms.

CONCLUSIONS: We observed similar proportions of arms with long and short bundle phenotypes in comparison to our previous report of the LUA pathway in breast cancer patients with nodal disease. Defining the incidence of the LUA pathway with its variations in the general population is important as variations in this pathway may have implications for an individual's risk of developing BCRL.