K. Pallav Kolli

Evaluation of the acute effects of distal coronary microembolization using multidetector computed tomography and magnetic resonance imaging

The purpose of this study was to test the potential of clinical imaging modalities, 64‐slice multidetector computed tomography (MDCT) and 1.5T magnetic resonance imaging (MRI) for qualitative and quantitative evaluation of acute microinfarcts and to determine the effects of <120 μm microemboli on left ventricular function, perfusion, cardiac injury biomarkers, arrhythmia, and cellular and vascular structures. Under X‐ray fluoroscopy, 40–120 μm (16 mm3) microemboli were delivered to embolize the left anterior descending (LAD) coronary artery of nine pigs. MDCT/MRI were performed at 72 h in a single session. Microinfarcts were visible in six of nine animals on delayed contrast‐enhanced MDCT/MR images but measurable in all animals using semiautomated threshold methods. Other MDCT and MRI sequences demonstrated decline in left ventricular ejection fraction, regional strain and perfusion in visible and invisible microinfarcted regions. Microemboli caused significant elevation in cardiac injury enzymes and arrhythmias. Various sizes of microinfarcts appeared microscopically as distinct aggregates of macrophages replacing myocardium. Semiautomated threshold methods are necessary to measure and confirm/deny the presence of myocardial microinfarcts. This study offers support for alternative applications of MDCT/MRI in assessing clinical cases in which microemboli <120 μm escape protective devices during percutaneous coronary interventions. Although microembolization resulted in no mortality, it caused left ventricular dysfunction, perfusion deficit, cellular damage increase in cardiac injury enzymes, and arrhythmias. Magn Reson Med, 2011.

Radioembolization with 90 Y glass microspheres for the treatment of unresectable metastatic liver disease from chemotherapy-refractory gastrointestinal cancers: final report of a prospective pilot study

BACKGROUND This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of radioembolization of liver-dominant metastatic gastrointestinal cancer using 90Y glass microspheres. METHODS Between June 2010 and October 2013, 42 adult patients (26 men, 16 women; median age 60 years) with metastatic chemotherapy-refractory unresectable colorectal (n=21), neuroendocrine (n=11), intrahepatic bile duct (n=7), pancreas (n=2), and esophageal (n=1) carcinomas underwent 60 lobar or segmental administrations of 90Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for up to 5.5 years after radioembolization. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Time to maximum response, response duration, progression-free survival (PFS) (hepatic and extrahepatic), and overall survival (OS) were measured. RESULTS Median target dose and activity were 109.4 Gy and 2.6 GBq per treatment session, respectively. Majority of clinical AE were grade 1 or 2 in severity. Patients with colorectal cancer had hepatic objective response rate (ORR) of 25% and a hepatic disease control rate (DCR) of 80%. Median PFS and OS were 1.0 and 4.4 months, respectively. Patients with neuroendocrine tumors (NET) had hepatic ORR and DCR of 73% and 100%, respectively. Median PFS was 8.9 months for this cohort. DCR and median PFS and OS for patients with cholangiocarcinoma were 86%, 1.1 months, and 6.7 months, respectively. CONCLUSIONS 90Y glass microspheres device has a favorable safety profile, and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.

The inferior emissary vein: a reliable landmark for right adrenal vein sampling:

Background Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization. Purpose To compare the rate of successful RAV sampling in the presence of the IEV. Material and Methods Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling. Results RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling. Conclusion The IEV may serve as a reliable landmark for the RAV during RAV sampling.

Patient Radiation Dose Reduction during Transarterial Chemoembolization Using a Novel X-Ray Imaging Platform

PURPOSE To evaluate radiation dose reduction in patients undergoing transarterial chemoembolization with the use of a new image acquisition and processing platform. MATERIALS AND METHODS Radiation-dose data were obtained from 176 consecutive chemoembolization procedures in 135 patients performed in a single angiography suite. From January 2013 through October 2013, 85 procedures were performed by using our institutions standard fluoroscopic settings. After upgrading the x-ray fluoroscopy system with an image acquisition and processing platform designed to reduce image noise and reduce skin entrance dose, 91 chemoembolization procedures were performed from November 2013 through December 2014. Cumulative dose-area product (CDAP), cumulative air kerma (CAK), and total fluoroscopy time were recorded for each procedure. Image quality was assessed by three interventional radiologists blinded to the x-ray acquisition platform used. RESULTS Patient radiation dose indicators were significantly lower for chemoembolization procedures performed with the novel imaging platform. Mean CDAP decreased from 3,033.2 dGy·cm(2) (range, 600.3-9,404.1 dGy·cm(2)) to 1,640.1 dGy·cm(2) (range, 278.6-6,779.9 dGy·cm(2); 45.9% reduction; P < .00001). Mean CAK decreased from 1,445.4 mGy (range, 303.6-5,233.7 mGy) to 971.7 mGy (range, 144.2-3,512.0 mGy; 32.8% reduction; P < .0001). A 20.3% increase in mean total fluoroscopy time was noted after upgrading the imaging platform, but blinded analysis of the image quality revealed no significant degradation. CONCLUSIONS Although a small increase in fluoroscopy time was observed, a significant reduction in patient radiation dose was achieved by using the optimized imaging platform, without image quality degradation.

Safety and Efficacy of Doxorubicin Drug-Eluting Embolic Chemoembolization of Hepatocellular Carcinoma Supplied by Extrahepatic Collateral Arteries

PURPOSE To assess safety and efficacy of doxorubicin drug-eluting embolic (DEE) transarterial chemoembolization of hepatocellular carcinoma (HCC) by extrahepatic collateral arteries. MATERIALS AND METHODS Records of 177 patients with HCC who underwent 338 consecutive DEE chemoembolization procedures from 2011 to 2014 were retrospectively reviewed. A subgroup of 16 patients (13 men, 3 women, median age 66 y) underwent 24 procedures for 17 HCCs via extrahepatic arteries and was included in the study. Median tumor size was 3.1 cm (range, 1.0-10.3 cm). Extrahepatic collaterals included right inferior phrenic (19 procedures; 12 patients), adrenal (4 procedures; 3 patients), and cystic arteries (2 procedures; 2 patients). Radiographic response was assessed by Modified Response Evaluation Criteria in Solid Tumors criteria. Complications were defined by National Cancer Institute Common Terminology Criteria for Adverse Events. RESULTS DEE chemoembolization achieved stable disease in 6 (35.3%), partial response in 6 (35.3%), and complete response in 4 (23.5%) HCCs. Disease progression was ultimately observed in 8 tumors (47.1%), with mean time to progression of 8.3 months after chemoembolization (range, 2-13 mo). Three minor and 5 major complications occurred in 8 patients; 2 minor complications were rash in vascular distribution after right inferior phrenic artery DEE chemoembolization. The 5 major complications were transient hepatotoxicity that resolved within 4-80 days; 1 was accompanied by pleural effusion requiring hospitalization. A mean 13.4 months after DEE chemoembolization, 67% of transplant candidates proceeded to liver transplant. CONCLUSIONS DEE transarterial chemoembolization via extrahepatic collaterals was effective and facilitated bridging to transplant. It was generally well tolerated; transient hepatotoxicity was the most common major complication.

Implications of Discordant Findings Between Hepatic Angiography and Cross-Sectional Imaging in Transplant Candidates With Hepatocellular Carcinoma

The goal of this study was to determine whether the detection of discordant numbers of hypervascular foci at hepatic angiography versus contrast‐enhanced (CE) cross‐sectional imaging [computed tomography (CT) or magnetic resonance imaging (MRI)] is associated with adverse clinical outcomes in patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation. We retrospectively reviewed the records of 218 consecutive patients with HCC who were listed for a liver transplant and who underwent transarterial chemoembolization at our institution between January 1, 2006 and December 31, 2010. Patients were grouped into 3 categories: (1) the number of nodules at CT/MRI was concordant with the number of hypervascular foci detected at angiography (n = 136), (2) the number of nodules at CT/MRI was greater than the number of hypervascular foci at angiography (n = 45), and (3) the number of nodules at CT/MRI was fewer than the number of hypervascular foci at angiography (n = 37). The study outcomes were liver transplantation and tumor recurrence after transplantation. The detection of at least 3 more hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly lower rate of transplantation [multivariate subhazard ratio (SHR), 0.39; 95% confidence interval (CI), 0.17‐0.92]. The detection of fewer hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly higher rate of tumor recurrence after transplantation (multivariate SHR, 3.49; 95% CI, 1.27‐9.56). In conclusion, liver transplant candidates with HCC who demonstrate discordant findings between angiography and CE CT or MRI may be at a higher risk for dropout from the transplant list and for tumor recurrence after transplantation. Liver Transpl 21:454‐467, 2015.

Hook, Line, and Sinker: Hook Wire Localization of a Retained Suture Needle in the Perineum

Editor: Despite efforts to minimize the incidence of retained surgical instruments, this complication continues to occur in approximately 1 in 8,000–18,000 of all operations (1). Preoperative localization of breast lesions with a hook wire has become a standard radiologic practice (2). This technique is advantageous because the needle is accurately positioned under imaging guidance, and when deployed, the hook maintains the wire in position until the patient can undergo surgical resection of the suspicious lesion. We describe a case of a retained suture needle in the perineum that was successfully localized using a hook wire (Modified Kopans; Cook, Inc, Bloomington, Indiana) and subsequently retrieved. Institutional review board approval was not required for this single retrospective case report. A 30-year-old woman presented to our institution with pain and purulent discharge from her perineum 6 days following a forceps-assisted vaginal delivery with second-degree perineal laceration. On examination, necrotic tissue was present at the edges of the prior laceration repair site, and purulent material was draining from the wound. She underwent incision, debridement, and packing of the wound, in anticipation of a secondary wound closure. During the secondary wound closure procedure, the tissues were approximated using 3-0 polyglactin 910 (VICRYL RAPIDE; Ethicon, Inc, Somerville, New Jersey) sutures. During performance of the crown stitch portion of wound closure, the tip of the suture needle was visualized in the perineal soft tissues, but it could not to be grasped with pickups or a needle driver. Smooth pickups were used to grasp the suture near the base of the needle. When this area of the suture was grasped, the suture detached from the needle, and the needle remained buried in the perineal soft tissues and was not visible or palpable. Limited intraoperative ultrasound of the wound and the perineal soft tissues did not localize the needle. Extensive wound exploration and dissection were not performed because of the patient’s recent history of perineal abscess. Hook wire localization was performed using a helical computed tomography (CT) scanner (HiSpeed Advantage; General Electric Medical Systems, Milwaukee, Wisconsin). An initial CT scan through the right perineum was obtained so that the entry skin site, depth, and angulation of the hook wire needle could be planned with respect to the retained suture needle (Fig 1). The length of the hook wire was determined by the depth required to reach the retained suture needle from the skin surface plus an additional 1.5 cm to position the stiff portion of the hook wire adjacent to the retained suture needle. Using serial CT scans to confirm location, the hook wire needle was positioned past the retained suture needle, and the hook wire was deployed; additional CT images confirmed final placement (Fig 2). The portion of the hook wire external to the patient was secured to the patient with gauze and tape. In the operating room, a sharp dissection from the edge of the vaginal wall in the direction of the hook wire was performed, and the retained suture needle was located and retrieved along with the hook wire. The perineum

Clinical outcomes of percutaneous drainage of breast fluid collections after mastectomy with expander-based breast reconstruction.

PURPOSE To determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction. MATERIALS AND METHODS A retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander-based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed. RESULTS The mean age of patients was 51.5 years (range, 30.9-69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4-235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6-34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures. CONCLUSIONS Percutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

Crossed legs: an unexpected occurrence during an ALN filter placement

Inferior vena cava (IVC) filter placement is indicated for patients with pulmonary embolism and/or deep venous thrombosis when anticoagulation therapy is contraindicated. IVC filter placement, however, is not without complications. In this case, we noted crossing of the filter struts immediately after deployment of the ALN IVC filter (ALN Implants Chirurgicaux Ghisonaccia, France). The filter was then successfully removed.