Jacob J. Bundy

Treatment of Venous Malformations: The Data, Where We Are, and How It Is Done

Venous malformations are the most common type of congenital vascular malformation. The diagnosis and management of venous malformations may be challenging, as venous malformations may be located anywhere in the body and range from small and superficial to large and extensive lesions. There are many treatment options for venous malformations including systemic targeted drugs, open surgery, sclerotherapy, cryoablation, and laser photocoagulation. This article reviews the natural history, clinical evaluation, imaging diagnosis, and treatment modalities of venous malformations.

Percutaneous Cholecystostomy: Long-Term Outcomes in 324 Patients

PurposeTo report technical success and clinical outcome of cholecystostomy tube placement along with timing—and method—of tube removal.Materials and MethodsA retrospective review of cholecystostomy tubes placed from January 2010 to September 2017 was performed at a single academic center. This search yielded 1160 patients. Of these patients, 324 (27.9%) met inclusion criteria for cholecystostomy placement, 199 (61.4%) males and 125 (38.6%) females, with mean age of 67xa0years (range 6–101xa0years). The indication for cholecystostomy tube placement, technical success, surgical candidacy, medical comorbidities, clinical outcome, tube indwelling time, complications, and follow-up were recorded.ResultsIndications for cholecystostomy tube placement included: acute cholecystitis (nxa0=xa0270; 83.3%), perforated cholecystitis (nxa0=xa022; 6.8%), emphysematous cholecystitis (nxa0=xa018; 5.6%), and other (nxa0=xa014; 4.3%). Technical success was 100%. Many patients had multiple medical comorbidities including (most commonly): debilitation (nxa0=xa0211; 65.1%), cardiovascular disease (nxa0=xa0194; 59.9%), multisystem disease (nxa0=xa0181; 55.9%), and malignancy (nxa0=xa0131; 40.4%). After tube placement, 96 (29.6%) patients underwent definitive cholecystectomy, 94 expired (29.0%), 36 (11.1%) had a patent cystic duct on follow-up cholangiogram and subsequent cholecystostomy removal, 14 (4.3%) underwent cholecystoscopy with stone removal, and 3 (0.9%) had liver transplantation. Forty-five (13.9%) patients had indwelling tubes at the end of the study period. Mean tube indwelling time was 89xa0days (range 0–586xa0days).ConclusionTechnical success for cholecystostomy tube placement was 100% with all patients having clinical resolution of acute cholecystitis. Many patients were able to have tubes subsequently removed.

Selective Penile Arterial Embolization Preserves Long-Term Erectile Function in Patients with Nonischemic Priapism: An 18-Year Experience

OBJECTIVEnTo report long term outcomes of selective arterial embolization for nonischemic priapism on erectile function utilizing validated outcome questionnaires after selective arterial embolization.nnnMATERIALS AND METHODSnTwenty men, mean age of 36 years (range: 8-58 years), underwent selective penile embolization for nonischemic priapism between December 1997 and February 2016 (218 months). Each identified case of nonischemic priapism was embolized using gelatin sponge, autologous blood clot, platinum microcoils, polyvinyl alcohol particles, or a combination of these. A variety of procedural details, immediate complications, recurrence of nonischemic priapism, post-procedure performance on Sexual Health Inventory for Men and International Index of Erectile Function Questionnaires, and follow-up duration were recorded.nnnRESULTSnMean time from development of symptoms until treatment was 117 days (range: 1-1,042 days). After selective arterial embolization, nonischemic priapism resolved in 18 (90%) patients. No patients with successful treatment of their nonischemic priapism developed a recurrence of nonischemic priapism during the study period following the initial treatment. Eight (40%) patients experienced ischemic priapism following embolization with 4 (50%) resolving after treatment. Mean post-procedure Sexual Health Inventory for Men score was 22.1 (range: 16-25). Mean post-embolization erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction domains on the International Index of Erectile Function were 25.8 (range: 16-30), 7.8 (range: 6-10), 7.4 (range: 5-10), 10.9 (range: 6-14), and 7.9 (range: 6-10), respectively. Mean follow-up was 4,601 days (range: 970-6,711 days).nnnCONCLUSIONnResolution of nonischemic priapism following selective arterial embolization occurred in 90% of the patients. Two validated questionnaires showed no erectile dysfunction following treatment. Mild orgasmic dysfunction, sexual desire dysfunction, intercourse dissatisfaction, and overall satisfaction dysfunction were noted following treatment.

Vascular and lymphatic complications after thoracic duct cannulation

OBJECTIVEnThe objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation.nnnMETHODSnThere were 58 patients who underwent attempted thoracic duct cannulation. Patients presented with chylexa0leak in the chest (nxa0= 40), abdomen (nxa0= 9), neck (nxa0= 8), and pelvis (nxa0= 1). Vertebral body level and geographic access, needle gauge, additional access for treatment, technical success, intervention performed, immediate and delayed complications, and follow-up duration were recorded. Imaging and electronic medical records were reviewed at follow-up for complications and treatment success.nnnRESULTSnAccess into the lymphatic system was obtained at L1 (nxa0= 21), T12 (nxa0= 17), L2 (nxa0= 14), L3 (nxa0= 3), T11 (nxa0= 1), L4 (nxa0= 1), and L5 (nxa0= 1). Lymphatic access was achieved in the center (nxa0= 28), on the right (nxa0= 16), or on the left (nxa0= 14) of the vertebral body; 21-, 22-, and 25-gauge needles were used in 45 patients, 12 patients, and 1 patient, respectively. Arm venous and percutaneous supraclavicular access was successful in 15 patients and eight patients, respectively. Cannulation of the thoracic duct was achieved in 52 (89.7%) patients. Embolization, disruption, and stenting were performed in 41 (70.7%), 12 (20.7%), and 2 (3.4%) patients; 3 (5.2%) patients had normal thoracic ducts after successful cannulation. Immediate complications consisted of shearing of the access wire in two (3.4%) patients. Retrospective analysis of initial follow-up imaging in 49 (84.5%) patients revealed the following late complications: inferior vena cava and right renal vein thrombosis and one perinephric lymphatic collection.nnnCONCLUSIONSnOf 58 patients who had attempted thoracic duct cannulation, successful access was achieved in 90% of patients. Early and delayed complications occurred in 3.4% and 4% of patients, respectively. Thoracic duct cannulation represents a highly successful technique that aids in the treatment of chyle leaks in medically complex patients.

Contemporary Interventional Radiology Dosimetry: Analysis of 4,784 Discrete Procedures at a Single Institution

PURPOSEnTo report dosimetry of commonly performed interventional radiology procedures and compare dose analogues to known reference levels.nnnMATERIALS AND METHODSnDemographic and dosimetry data were collected for gastrostomy, nephrostomy, peripherally inserted central catheter placement, visceral arteriography, hepatic chemoembolization, tunneled catheter placement, inferior vena cava filter placement, vascular embolization, transjugular liver biopsy, adrenal vein sampling, transjugular intrahepatic portosystemic shunt (TIPS) creation, and biliary drainage between June 12, 2014, and April 26, 2018, using integrated dosimetry software. In all, 4,784 procedures were analyzed. The study included 2,691 (56.2%) male subjects and 2,093 (43.8%) female subjects with mean age 55 ± 21 years (range: 0-104 years) and with mean weight of 76.9 ± 29.4 kg (range: 0.9-268.1 kg). Fluoroscopy time, dose area product (DAP), and reference dose were evaluated.nnnRESULTSnTIPS had the highest mean fluoroscopy time (49.1 ± 16.0 min) followed by vascular embolization (25.2 ± 11.4 min), hepatic chemoembolization (18.8 ± 12.5 min), and visceral arteriography (17.7 ± 3.2 min). TIPS had the highest mean DAP (429.2 ± 244.8 grays per square centimeter [Gy·· cm2]) followed by hepatic chemoembolization (354.6 ± 78.6 Gy·· cm2), visceral arteriography (309.5 ± 39.0 Gy·· cm2), and vascular embolization (298.5 ± 29 Gy·· cm2). TIPS was associated with the highest mean reference dose (2.002 ± 1.420 Gy) followed by hepatic chemoembolization (1.746 ± 0.435 Gy), vascular embolization (1.615 ± 0.381 Gy), and visceral arteriography (1.558 ± 1.720 Gy). Of the six procedures available for comparison with the reference levels, the mean fluoroscopy time, DAP, and reference dose for each procedure were below the proposed reference levels.nnnCONCLUSIONnAdvances in image acquisition technology and radiation safety protocols have significantly reduced the radiation exposure for a variety of interventional radiology procedures.

#Radiology: A 7-Year Analysis of Radiology-Associated Hashtags

PURPOSEnTo describe the radiology-related Twitter network through the analysis of the most commonly used radiology-associated hashtags.nnnMATERIALS AND METHODSnA total of 959,366 tweets containing the hashtags from the 9 most commonly used radiology-associated hashtags composed by 66,568 Twitter users from October 13, 2010 to February 22, 2018 were analyzed. Twitter activity metrics, engagement, user characteristics, content analysis, and network analysis were obtained using the health care social media analytics platform, Symplur Signals.nnnRESULTSnThe number of tweets containing the most commonly used radiology hashtags increased by 198% during 2011. Regarding tweet content, 246,949 (46.9%) tweets were related to patients, 140,562 (26.7%) tweets were cancer related, 47,704 (9.1%) tweets were related to research, and 26,994 (5.1%) tweets were related to radiation. As for engagement, there were 374,082 retweets (39%), 512,919 mentions (53.5%), and 12,919 replies (1.3%). Health care organizations not directly involved with patient care, physicians, and patients authored 283,698 (29.6%), 217,152 (22.6%), and 27,595 (2.9%) tweets, respectively. Network analysis demonstrated health care organizations not directly involved with patient care, physicians, media organizations, and individuals working in the health care industry in nonclinical roles to be the users most active on the radiology-related hashtags on Twitter.nnnCONCLUSIONnRadiology-related hashtag use has grown substantially over the years, with a majority of the discussions involving physicians and health care organizations not directly involved with patient care.

Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training

PURPOSEnTo create a three-dimensional endoscopic model of the biliary tract from magnetic-resonance cholangiopancreatography imaging and to evaluate its effectiveness as a tool for training in endoscopic biliary interventions.nnnMATERIALS AND METHODSnA magnetic-resonance cholangiopancreatography study was performed on a patient with biliary obstruction secondary to a distal bile duct cholangiocarcinoma. Using Vitrea, a three-dimensional volume-rendered image was created, and exported as a standard tessellated language file. The standard tessellated language model was then edited with MeshMixer. Three cylindrical entry ports were created. The ports were aligned and overlapped with the dominant ducts in three separate areas of the model and fused to the model. A 0.2 cm shell was created around the model and the model was hollowed. The ends of the ports were cut off, allowing access to the hollowed-out model. The model was printed at 125% scale to allow easy access with a 9.5-French (≤3.23 mm) endoscope. The model was printed using a Stratasys Dimension Elite Plus printer. After printing, the model was post-processed to remove support materials. A 10-question survey was administered to all trainees before and after use of the printed phantom to practice endoscopy skills.nnnRESULTSn11 trainees participated in the three-dimensional endoscopy simulation with most of the trainees (73%) having no prior formal endoscopy training. Using a 10-point Likert scale, the mean comfort-level of the trainees to use endoscopy alone for cholecystostomy, percutaneous biliary drainage, percutaneous nephrostomy, and percutaneous gastrostomy increased by 38.9%, 32.8%, 32.8%, and 34.3%, respectively, following the training experience.nnnCONCLUSIONnThe use of a three-dimensionally printed endoscopic model as a simulation tool has the potential to improve trainee comfort using endoscopy during interventional radiology procedures.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study

PURPOSEnSplenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation.nnnMATERIALS AND METHODSn406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18u202fyears old were included. Mean age of the cohort was 58u202f±u202f15u202fyears (range: 18-88u202fyears). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1u202fg ampicillin and 80u202fmg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success.nnnRESULTSnPartial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (nu202f=u202f178; 56.9%) followed by particulates (nu202f=u202f114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (Pu202f=u202f0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (Pu202f=u202f0.03). Mean time to abscess identification was 74u202fdays ±120u202fdays (range: 9-1353u202fdays).nnnCONCLUSIONnSplenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Balloon and Coil Occlusion of a Superior Sagittal Sinus Cortical Vein Facilitates Percutaneous Supraorbital Venous Malformation Sclerotherapy

Venous malformations are the most common of all vascular anomalies. Venous malformations are treated using a multidisciplinary approach with sclerotherapy representing the primary treatment modality. While rare, sclerotherapy in the central nervous system carries the risk of venous thrombosis, non-target embolization, and venous infarction and hemorrhage. Options for controlling venous outflow when treating venous malformations in the head and neck are limited. This report details the use of balloon and coil occlusion of a superior sagittal sinus cortical vein to facilitate percutaneous sclerotherapy of a supraorbital venous malformation.

Percutaneous Embolization of a Saccular Omental Artery Aneurysm

Omental artery aneurysms are a unique subset of splanchnic artery aneurysms that are associated with intraperitoneal hemorrhage and high mortality rates. Detecting omental artery aneurysms prior to rupture is especially challenging; as such there are limited data surrounding unruptured aneurysms. Various methods of treating ruptured omental artery aneurysms have been previously described including omentectomy and transcatheter arterial embolization. Because of the mortality rate associated with ruptures, elective intervention in unruptured splanchnic artery aneurysms is recommended regardless of their size. This report details the successful embolization of an unruptured omental artery aneurysm utilizing a percutaneous approach.