Colette M. Shaw

Temporary Balloon Occlusion of the Common Hepatic Artery for Administration of Yttrium-90 Resin Microspheres in a Patient with Patent Hepatoenteric Collaterals

The most common serious complication of yttrium-90 ((90)Y) therapy is gastrointestinal ulceration caused by extrahepatic microsphere dispersion. The authors describe the use of a balloon catheter for temporary occlusion of the common hepatic artery to reverse hepatoenteric flow for lobar administration of resin microspheres when coil embolization of a retroportal artery was impossible. At 9 months after treatment, the patient had no gastrointestinal side effects and showed a partial response.

Efficacy and Safety of Portal Vein Embolization for Two-Stage Hepatectomy in Patients with Colorectal Liver Metastasis

PURPOSE To examine the efficacy and safety of portal vein embolization (PVE) when used during two-stage hepatectomy for bilobar colorectal liver metastases (CLM). MATERIALS AND METHODS PVE was performed as an adjunct to two-stage hepatectomy in 56 patients with CLM. Absolute future liver remnant (FLR) volumes, standardized FLR ratios, degree of hypertrophy (DH), and complications were analyzed. Segment II and III volumes and DH were also measured separately. All volumetric measurements were compared with a cohort of 96 patients (n = 37 right portal vein embolization [RPVE], n = 59 right portal vein embolization extended to segment IV portal veins [RPVE+4]) in whom PVE was performed before single-stage hepatectomy. RESULTS For patients who completed RPVE during two-stage hepatectomy (n = 17 of 17), mean absolute FLR volume increased from 272.1 cm(3) to 427.0 cm(3) (P < .0001), mean standardized FLR ratio increased from 0.17 to 0.26 (P < .0001), and mean DH was 0.094. For patients who completed RPVE+4 during two-stage hepatectomy (n = 38 of 39), mean FLR volume increased from 288.7 cm(3) to 424.8 cm(3) (P < .0001), mean standardized FLR increased from 0.18 to 0.26 (P < .0001), and mean DH was 0.083. DH of the FLR was not significantly different between two-stage hepatectomy and single-stage hepatectomy. Complications after PVE occurred in five (8.9%) patients undergoing two-stage hepatectomy. CONCLUSIONS PVE effectively and safely induced a significant DH in the FLR during two-stage hepatectomy in patients with CLM.

Contrast-Enhanced Ultrasound Evaluation of Residual Blood Flow to Hepatocellular Carcinoma After Treatment With Transarterial Chemoembolization Using Drug-Eluting Beads A Prospective Study

To evaluate the accuracy and change over time of contrast‐enhanced ultrasound (US) imaging for assessing residual blood flow after transarterial chemoembolization of hepatocellular carcinoma with drug‐eluting beads at 2 different follow‐up intervals.

Transarterial chemoembolization for palliation of paraneoplastic hypoglycemia in a patient with advanced hepatocellular carcinoma.

The patient underwent an unremarkable open surgical repair of his AAA with the use of polyester graft. At 6-month, follow-up, he remained free from complications. Thrombus from the aneurysm sac was cultured but proved sterile. Infected AAA is uncommon, comprising fewer than 3% of infrarenal AAAs (1), and can be asymptomatic despite the increased risk of rupture and mortality (2). Gas within the sac wall and periaortic inflammatory tissue are features of mycotic aneurysm. In the present case, the immunosuppressive effect of methotrexate could have increased the risk of mycotic aneurysm, as previously reported (3); however, no organisms were cultured in blood or thrombus. Severe rheumatoid disease can cause aortitis, but no periaortic inflammation was seen in the present case (Fig 1). Spontaneous aortoenteric fistula is less common, and reported only in the presence of infection. When there is communication between the aorta and part of the gastrointestinal tract, ectopic gas adjacent to or within the aorta is the predominant CT finding (4). Degenerative disease of the lumbar intervertebral discs may exhibit gas within the degenerate disc. Perhaps the intervertebral gas diffused into the aneurysm sac; however, we are unaware of any reported cases of spontaneous aneurysm sac gas associated with this condition. In conclusion, the present report suggests that aortic sac gas can be a benign finding, independent of aortic infection or aortoenteric fistula.

Acute Thrombosis of Left Portal Vein during Right Portal Vein Embolization Extended to Segment 4

Portal vein thrombosis (PVT) is an uncommon, but potentially devastating complication of portal vein embolization (PVE). Its occurrence relates to both local and systemic risk factors. In the setting of PVE, precipitating factors include injury to the vessel wall and reduced portal flow. Contributory factors include portal hypertension, hypercoagulopathy, inflammatory processes, malignancy, pregnancy, oral contraceptive use, and asplenia. The goal of therapy is to prevent thrombus progression and lyse existing clot. Hepatectomy is impossible if adequate recanalization has not occurred and/or overt portal hypertension develops. The mechanisms for thrombus development, its diagnosis, management, and prognosis are discussed.

ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation

Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. Methods: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. Results: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. Conclusions: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery.

Contrast-Enhanced Subharmonic and Harmonic Ultrasound of Renal Masses Undergoing Percutaneous Cryoablation

RATIONALE AND OBJECTIVES The objective of this study was to evaluate and compare contrast-enhanced subharmonic and harmonic ultrasound as tools for characterizing solid renal masses and monitoring their response to cryoablation therapy. MATERIALS AND METHODS Sixteen patients undergoing percutaneous ablation of a renal mass provided informed consent to undergo ultrasound examinations the morning before and approximately 4 months after cryoablation. Ultrasound contrast parameters during pretreatment imaging were compared to biopsy results obtained during ablation (n = 13). Posttreatment changes were evaluated by a radiologist and compared to contrast-enhanced magnetic resonance imaging (MRI)/computed tomography (CT) follow-up. RESULTS All masses initially showed heterogeneous enhancement with both subharmonic and harmonic ultrasound. Early contrast washout in the mass relative to the cortex was observed in 6 of 9 malignant and 0 of 4 benign lesions in subharmonic mode and 8 of 9 malignant and 1 of 4 benign lesions in harmonic imaging. In cases where the lesion was adequately visualized at follow-up (n = 12), subharmonic and harmonic ultrasound showed accuracies of 83% and 75%, respectively, in predicting treatment outcome. Although harmonic imaging showed less overall error, no significant differences (P > .29) in ablation cavity volumes were observed between MRI/CT and either contrast-imaging mode. CONCLUSIONS Subharmonic and harmonic contrast-enhanced ultrasound may be a safe and accurate imaging alternative for characterizing renal masses and evaluating their response to cryoablation therapy. Although subharmonic imaging was more accurate in detecting effective cryoablation, harmonic imaging was superior in quantifying ablation cavity volumes.

Metastatic Liver Disease: Indications for Locoregional Therapy and Supporting Data

Metastatic liver disease is a major cause of cancer-related morbidity and mortality. Surgical resection is considered the only curative treatment, yet only a minority is eligible. Patients who present with unresectable disease are treated with systemic agents and/or locoregional therapies. The latter include thermal ablation and catheter-based transarterial interventions. Thermal ablation is reserved for those with limited tumor burden. It is used to downstage the disease to enable curative surgical resection, as an adjunct to surgery, or in select patients it is potentially curative. Transarterial therapies are indicated in those with more diffuse disease. The goals of care are to palliate symptoms and prolong survival. The indications and supporting data for thermal ablation and transarterial interventions are reviewed, technical and tumor factors that need to be considered prior to intervention are outlined, and finally several cases are presented.

Characterization of renal masses with harmonic and subharmonic contrast-enhanced ultrasound

The objective of this study was to compare coded harmonic imaging (HI) to pulse-inversion subharmonic imaging (SHI) in the characterization of renal masses. Twelve patients with 13 renal masses provided informed consent for an off-label CEUS exam prior to renal mass biopsy and cryoablation. All scanning was performed on a modified Logiq 9 ultrasound scanner with a 4C probe (GE Healthcare, Milwaukee, WI). Following baseline imaging, patients received a 2 ml bolus IV injection of the ultrasound contrast agent Optison (GE Healthcare, Princeton, NJ) and 10 ml flush during simultaneous 2D dual imaging in both grayscale (f = 4.0 MHz) and SHI (ftransmit = 2.5 MHz, frecieve= 1.25 MHz). Following a 15 min wait, patients received a 1 ml contrast injection during imaging with the units HI package (ftransmit = 2.0 MHz, frecieve= 4.0 MHz). A blinded radiologist with experience in CEUS evaluated the heterogeneity, intensity, and wash-in/wash-out kinetics of enhancement in the mass relative to the renal cortex. Additionally, contrast signal time intensity curves (TICs) were constructed from both the renal mass and cortex, fit to a contrast wash-in model, and used to calculate the time to peak, perfusion, maximum intensity, and area under the curve. Finally, the radiologist and TIC findings from each CEUS imaging mode were compared to pathology. Biopsy findings showed the 13 renal masses consisted of 9 renal cell carcinomas, 2 areas of benign renal parenchyma, 1 area of renal necrosis, and 1 oncocytoma. All masses showed heterogeneous enhancement with both SHI and HI. Increased enhancement of the mass relative to the renal cortex was observed during the early contrast wash-in phase in 2/9 malignant and 3/4 benign lesions on SHI, and 3/9 malignant and 1/4 benign lesions on HI. Early contrast wash out in the mass relative to the cortex was observed in 6/9 malignant and 0/4 benign lesions in SHI (sensitivity = 67%, specificity = 100%), and 8/9 malignant and 1/4 benign lesions in HI (sensitivity = 89%, specificity = 75%). Comparison of the TIC parameters obtained from the renal mass and cortex of malignant lesions showed no statistically significant differences when compared to benign lesions (p > 0.2). Thus, visualization of early contrast washout on HI or SHI appears to be a reliable indicator of renal carcinoma on CEUS; albeit based on a limited sample size.