Publications

PURPOSE: To report outcomes in hepatocellular carcinoma (HCC) patients with lobar and segmental vascular invasion treated with resin Yttrium-90 transarterial radioembolization (Y90-TARE) with single-compartment MIRD (Medical Internal Radiation Dose) model.

MATERIALS AND METHODS: This was a retrospective IRB approved study of patients with a diagnosis of HCC with vascular invasion undergoing resin Y90-TARE from 2014 to 2022 (n = 61). Patients with Body Surface Area dosimetry (n = 20), main portal vein invasion (n = 6) and patients with an ECOG of > 2 were excluded (n = 1) with a final cohort of 34 patients.

RESULTS: Study population consisted of 34 patients, median age 62 years [60-71], tumor size 4.2 (2.8-7.4) cm, and 82% male. The median prescribed dose was 170 (126-200) Gy. The objective response rate at 6 months was 67% and disease control rate was 72%. The median survival was 18 months, median progression-free survival was 9.8 months. The 1- and 3-year survival rates were 76% and 57% in patients prescribed > 180 Gy, compared to 29% and 15% in patients with < 180 Gy (p = 0.01). Five of 15 Childs-Pugh A, ECOG < 1 patients (33%) were downstaged to resection, with complete pathologic necrosis in 40%, and 1 and 3-year survival rates of 100%. Grade-3 adverse events were seen in only 5/34 (15%), with no grade-4 or 5 adverse events.

CONCLUSION: Resin Y90-TARE using single compartment MIRD model for HCC with segmental and lobar vascular invasion can result in downstaging to resection in 33% of patients and higher prescribed doses (> 180 Gy) result in improved survival.

RATIONALE AND OBJECTIVES: To evaluate the impact of an Interventional Radiology resident night float system on resident well-being and clinical workflow.

MATERIALS AND METHODS: This study spanned a period of 12 months, 6 months in which residents worked on night using a traditional call system without guaranteed post-call days, and 6 months of a night float system in which a night float dedicated resident was taking a week of night calls, with no daytime duties. "IR short communication notes", and "Full patient consult notes", documented by the on-call- resident between 6 PM and 7 AM were reviewed. The overall number of notes and the number of notes documented per resident were compared between the two periods. Additionally, current and alumni residents, advanced practice providers, and faculty physicians were surveyed about their perception of the night float system as it compares to the old call system.

RESULTS: The volume of notes increased significantly with the implementation of the night float system, from 127 to 375 (p=0.03). Over the 6-month night float period, the median number of short communication notes per resident increased from 4.5 (4-6.5) to 9.5 (9-13), p=0.04, while full patient consult notes rose from 16 (8.75-19.5) to 53 (36.25-61.5), p=0.002. Survey results from residents showed a better perception of their wellness under night float (25% were positively affected, compared to 0% during the traditional call system). A perceived overall improvement in patient care was reported by 100% of IR faculty and APPs with night float.

CONCLUSION: Night float implementation enhanced IR resident productivity and wellness as evidenced by increased documented clinical encounters and positive feedback.

PURPOSE: This study aims to examine if the hand motions of operators associated with certain parts of central venous access are more important than others in distinguishing between experts and non-experts.

MATERIALS AND METHODS: Experts (n = 10) and Trainees (PGY2; n = 18) performed central venous access on a phantom 4 times each as their needle hand and ultrasound probe motions were tracked. Path length-time graphs were used to divide the procedure into three phases: (1) the access phase: visualizing the internal jugular vein on ultrasound and needle placement; (2) the wire phase: passing a wire through the needle; and (3) the confirmation phase: confirming the intravascular wire position and threading a dilator on the wire. Comparisons between trainees and experts were made for the complete trial, and each phase using Mann-Whitney U tests with Benjamini-Hochberg correction. Receiver Operating Characteristic analysis was performed to compare the performance of each phase in differentiating between experts and trainees.

RESULTS: Motion data from 10 experts and 18 trainees was analyzed. Experts and trainees differed significantly for all the motion metrics (p < 0.001). A comparison of the phases showed that the access phase (AUC = 0.96; R2 = 0.79) and the wire phase (AUC = 0.95; R2 = 0.59) were able to distinguish between experts and trainees with an accuracy comparable to the complete trial (AUC = 0.94; R2 = 0.69).

CONCLUSIONS: The access phase of simulated central venous access can best differentiate between experts and trainees. This sample of hand motion performance may be able to simplify motion analysis of technical performance and obviate the need for recording hand motion for the entire procedure.

PURPOSE: To validate the Aldosteronoma Resolution Score (ARS), a validated metric for prognostication of complete clinical response after adrenalectomy, as a prognosticator for outcomes after radiofrequency (RF) ablation for treatment of primary aldosteronism (PA).

MATERIAL AND METHODS: After institutional review board (IRB) approval, patients treated with RF ablation for a unilateral aldosteronoma between 2007 and 2023 were retrospectively reviewed. Clinical and biochemical data were collected, including preprocedural and postprocedural potassium, aldosterone, and plasma renin activity levels; blood pressure (BP); and number and doses of antihypertensives. Analysis included descriptive analysis and area under the curve (AUC)-receiver operator characteristic tests assessing the relation between ARS and outcomes after RF ablation. ARSs were defined as "high likelihood of clinical response" (4-5), "medium likelihood of clinical response" (2-3), and "low likelihood of clinical response" (0-1). Outcome definitions were complete clinical response (BP < 140/90 mm Hg, without antihypertensives), partial clinical response (BP < 140/90 mm Hg, requiring less antihypertensives before RF ablation), and absent clinical response (BP < 140/90 mm Hg, requiring unchanged antihypertensives before RF ablation). ARS correlation with post-RF ablation biochemical data was performed as an exploratory endpoint.

RESULTS: In 59 patients (71% men) with a mean age of 54.4 years (SD ± 10.3), 15% achieved complete clinical response and 8% had high ARS, 46% had partial response and 46% had medium ARS score, and 39% had absent clinical response and 46% had low ARS score. The AUC for predicting complete clinical response was 0.891 (95% CI, 0.795-0.987; P < .001).

CONCLUSIONS: Preliminary evidence demonstrated that ARS can be used for predicting clinical outcomes in PA after RF ablation.

PURPOSE: To evaluate the use of immediate post-yttrium-90 (90Y)-radiation segmentectomy (RS) positron emission tomography (PET)/computed tomography (CT) and dosimetry software in predicting incomplete response in early-stage hepatocellular carcinoma (HCC).

MATERIALS AND METHODS: Patients with early-stage HCC undergoing resin 90Y-RS (July 2014 to December 2022) prescribed using the single-compartment Medical Internal Radiation Dose (MIRD) model with post-90Y transarterial radioembolization (TARE) PET/CT were reviewed. Forty patients (42 HCCs; 69 years [interquartile range {IQR}, 63-77]; male, 75%), with a median tumor size of 3.4 cm (IQR, 2.2-4.6) met criteria. Dose-volume histograms were generated using dosimetry software (MIM SurePlan LiverY90, v7.2.3). Modified Response Evaluation Criteria in Solid Tumours (mRECIST) treatment responses were correlated with quantitative volumetric analyses of tumor absorbed dose (TAD) and underdosed tumor volume, defined as volume of tumor receiving less than 100 Gy (V0-100). Additional subgroup dosimetry analysis was performed between tumors with complete response (CR) and incomplete response.

RESULTS: Tumors treated showed 86% CR and 100% objective response rate at 6-month follow-up. Subgroup analysis between CRs and incomplete responders showed no difference in tumor size, volume, prescribed tissue dose, or prescribed, delivered, or specific activity. Incomplete responders had a lower D50 than CRs (162 vs 273 Gy, P = .040), lower particle density (36,310 vs 66,980 particles/cm3, P = .040), and higher absolute (10 vs 0.7 mL; P = .011) and proportion (33% vs 5%; P = .001) of underdosed tumor volumes (V0-100). An underdosed tumor volume (V0-100) of ≥28% had an increased likelihood of incomplete response (odds ratio, 75; P = .001).

CONCLUSIONS: 90Y-TARE PET/CT can identify tumors incompletely treated with an ablative 90Y-RS dose and guide decision for closer follow-up or early retreatment.

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.

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.

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.