Ernesto Santos

Comparison of Patient Dose in Two-Dimensional Carotid Arteriography and Three-Dimensional Rotational Angiography

Background and PurposeIt is known that interventional neuroradiology (IN) involves high radiation dose to both patients and staff even if performed by trained operators using modern fluoroscopic X-ray equipment and dose-reducing technology. Therefore, every new technology or imaging tool introduced, such as three-dimensional rotational angiography (3D RA), should be evaluated in terms of radiation dose. 3D RA requires a series with a large number of images in comparison with 2D angiography and it is sometimes considered a high-dose IN procedure. The literature is scarce on the 3D RA radiation dose and in particular there are no data on carotid arteriography (CA). The aim of this study was to investigate patient dose differences between 2D and 3D CA.MethodsThe study included 35 patients undergoing 2D CA in hospital 1 and 25 patients undergoing 3D CA in hospital 2. Patient technical data collection included information on the kerma area product (KAP), fluoroscopy time (T), total number of series (S), and total number of acquired images (F).ResultsMedian KAP was 112 Gy cm2 and 41 Gy cm2 for hospitals 1 and 2, respectively, median T was 8.2 min and 5.1 min, median S was 13 and 4, and median F was 247 and 242. Entrance surface air-kerma rate, as measured in “medium” fluoroscopy mode measured in 2D acquisition using a 20 cm phantom of polymethylmethacrylate, was 17.3 mGy/min for hospital 1 and 9.2 mGy/min for hospital 2.Conclusion3D CA allows a substantial reduction in patient radiation dose compared with 2D CA, while providing the necessary diagnostic information.

A Case-Based Approach to Common Embolization Agents Used in Vascular Interventional Radiology

OBJECTIVE The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.

Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage

PURPOSE To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

Comparative Analysis of Intranodal Lymphangiography with Percutaneous Intervention for Postsurgical Chylous Effusions

PURPOSE To evaluate clinical success and time to resolution of intranodal lymphangiography (INL) alone or with thoracic duct embolization (TDE) or thoracic duct disruption (TDD) based on initial effusion volume for postsurgical chylothorax. MATERIALS AND METHODS Retrospective review was performed of 57 patients (mean age 63 y; 65% male) undergoing INL alone or in conjunction with other percutaneous techniques for postsurgical chylous effusions. INL alone was performed when chylothorax output was ≤ 500 mL/d and no leak was identified during fluoroscopy. RESULTS INL was technically successful in all patients. There was 1 major and 2 minor complications. Clinical success rate was 71% (40/56). Clinical success rate meeting algorithmic inclusion criteria was 71.4% (5/7) for INL only, 41.7% (5/12) in INL with TDD, and 90.5% (19/21) in INL with TDE. Hazard ratio (HR) of clinical success of INL with TDE versus INL only was not statistically significant (HR 2.3, 95% confidence interval [CI], 0.70-5.87, P = .19). Median time to resolution was 14 days for INL only (95% CI, 0 days to not reached), 7 days for INL with TDD (95% CI, 4 days to not reached), and 3 days for INL with TDE (95% CI, 2 to 5 days) (P = .007). No statistically significant difference in median time to resolution existed between INL with TDE and INL only (P = .04). CONCLUSION In patients with postsurgical chylothorax, INL alone had similar rates of clinical success and time to resolution compared with INL with TDE when initial effusion volume was ≤ 500 mL/d and no leak was visualized during fluoroscopy.

Incidentally Discovered Uterine Sarcoma in a Premenopausal Patient after Hysterectomy for Postembolization Endometritis

Uterine leiomyomas (fibroids) are the most common benign tumor of the female reproductive system. Fibroids can become symptomatic with symptoms such as menorrhagia and menometrorrhagia, pelvic pain, and reproductive dysfunction. Hysterectomy, myomectomy, and the less invasive uterine artery embolization are now commonly performed if conservative management of symptomatic fibroids fails. Moreover, uterine artery embolization (UAE) is the preferred minimally invasive procedure for the treatment of symptomatic fibroids. Major complications of UAE are extremely rare but well known. Additionally, there is a risk of undiagnosed uterine sarcoma found post embolization, which has been reported in literature during the past 12 years. Herein, we describe a case of an incidentally discovered uterine sarcoma in a premenopausal female after hysterectomy for post uterine artery embolization endometritis and sepsis.

Endovascular Management of Massive Hemoptysis in Patients With Pulmonary Pseudosequestration

Idiopathic chronic lung consolidation is a rare cause of massive hemoptysis. We describe 2 patients with chronic pulmonary consolidation of unknown etiology who presented with massive hemoptysis resulting in airway compromise. Selective angiography demonstrated multiple hypertrophied systemic arteries supplying the area of consolidation, consistent with pulmonary pseudosequestration. Initial endovascular management with embolization resulted in immediate control of hemoptysis. Short interval repeat angiography and embolization was necessary in both patients to treat recurrent hemoptysis secondary to hemorrhage from multiple feeding arteries. Selective bronchial and nonbronchial systemic arterial embolization is an effective treatment for massive hemoptysis secondary to pulmonary pseudosequestration.

Image-guided intranodal lymphangiogram for chylous leaks: preliminary experience

Purpose To demonstrate the efficacy of image-guided intranodal lymphangiography (IGIL) in the management of chylous leaks. Materials and Methods IGIL was attempted in 11 patients (six men and five women, mean age 65.4, [range, 42-83 y]) with chylous leaks. These patients were unlikely to be cured with conservative treatment, therefore they underwent IGIL. Under ultrasound guidance a groin lymph node was injected with lipiodol. Contrast progression was followed with fluoroscopy. IGIL was attempted in 8 patients (72%) with thoracic lymphatic leakage from chylothorax (six) or mediastinal chylous leaks (two). Of the eight patients, 6 of the patients had chest surgery and 2 patients had lymphoma. Within this group, 5 (62%) underwent thoracic duct disruption or embolization. Two patients were operated 2 and 3 days after IGIL and IGIL plus thoracic duct disruption, respectively (pleurodesis and thoracic duct ligation). IGIL was performed in 3 patients (28%) who developed abdominal retroperitoneal chylous leaks after nephrectomy associated with lymphadenectomy. One patient in this group had also chylothorax. No additional interventions were performed in this group. Results Technical success of IGIL was 90.9%. IGIL could not be performed in one patient with lymphoma. The amount of ethiodized oil injected ranged between 4 and 14 ml (mean volume 8 ml) and 2 patients (18.1%) underwent 2 IGIL procedures. In 7 of the 10 patients in which IGIL was possible, the site of the chylous leak was identified. No complications were observed in relation with the technique. Thoracic lymphatic leak group: One patient was demonstrated to have a pleural effusion in relation with cryptogenic cirrhosis instead a chylothorax. This patient was excluded from the secondary analysis. Both patients who underwent surgery were considered treatment failures. The chylous leak was sealed in 4 patients (57.1%). Abdominal retroperitoneal chylous leak group: IGIL was therapeutic in all 3 patients (100%). The mean length of time between IGIL and cure in both groups was 22 days (range, 1-55 days). Conclusion IGIL is an effective method in the diagnosis and treatment of lymphatic leaks and it can be used instead of traditional bi-pedal lymphangiography.

Tu1042 Post Pancreatectomy Hemorrage Endovascular Management: Single Instution Experience Using Covered Stents

Background: There is limited data on the utility of the percentage of lens culinaris agglutininreactive α-fetoprotein (AFP-L3%) measured on the new μTASWako i30 Immunoanalyzer for the diagnosis of early stage HCC in the U.S. population. The utility of AFP, AFP-L3% or des-γ-carboxy prothrombin (DCP) for predictingHCC recurrence after liver transplantation is also unknown. Aims: To 1) determine the sensitivity and specificity of AFP, AFP-L3%, and DCP for the diagnosis of early stage HCC; and 2) evaluate the utility of AFP, AFP-L3% and DCP in predicting HCC recurrence after orthotopic liver transplantation (OLT). Methods: Three hundred and thirteen HCC patients and 307 non-HCC controls with end-stage liver disease who were transplanted at Mayo Clinic, Rochester, MN and Jacksonville, FL between 2000 2008 and had serum samples available for biomarker testing were included in the study. Demographic and clinical information were abstracted from the medical record. AFP, AFP-L3% and des-γ-carboxy prothrombin (DCP) assays were performed on the μTASWako i30 Immunoanalyzer. Receiver operating characteristic (ROC) curves were generated to determine the sensitivity and specificity of the biomarkers for diagnosis of HCC. Predictors of HCC development and HCC recurrence were analyzed using the Logistic regression model. Results: AFP had the best area under the ROC curve (0.75, 95%CI 0.72-0.78) for diagnosis of early stage HCC, followed by AFP-L3% (0.63, 95% CI 0.60-0.66) and DCP (0.46, 95%CI 0.43-0.49). The optimum cut-off value of AFP was 9.4 ng/ml with the sensitivity of 62.6% and specificity of 80% and of AFP-L3% was 15.8% with a sensitivity of 30.1% and specificity of 85.1%. AFP and AFP-L3% were independently associated with early stage HCC. Every 10 ng/mL increase in AFP value and every 10% increase in AFP-L3% value were associated with a 36.6% and 43.0% increased risk for HCC diagnosis (OR=1.37, 95%CI 1.20-1.56 for AFP, p,0.0001,and OR 1.43, 95% CI 1.18-1.58 for AFP-L3%, p,0.0001). Of the 313 HCC patients, 301 (96.2%) patients were treated with transarterial chemoembolization (TACE) prior to transplantation. Forty-seven (15%) patients had HCC recurrence after transplant (median time for recurrence was 18.4 months). The post-TACE pre-OLT AFP-L3% was significantly associated with HCC recurrence after OLT. Every 10% increase in post-TACE AFP-L3 was associated with a 48.2% increased risk of HCC recurrence after OLT (OR=1.48, 95% CI 1.11 to 1.97, p=0.007). AFP, AFP-L3% and DCP at the time of HCC diagnosis were not associated with HCC recurrence after OLT. Conclusions: AFP-L3% is potentially useful in predicting HCC recurrence after liver transplantation in US patients. Validation of these results in additional cohorts is needed.