Kai Wilhelm

Nonsurgical Fluoroscopically Guided Dacryocystoplasty of Common Canalicular Obstructions

AbstractPurpose: To assess dacryocystoplasty in the treatment of epiphora due to obstructions of the common canaliculus. Methods: Twenty patients with severe epiphora due to partial (n=16) or complete (n=4) obstruction of the common canaliculus underwent fluoroscopically guided dacryocystoplasty. In all cases of incomplete obstruction balloon dilation was performed. Stent implantation was attempted in cases with complete obstruction. Dacryocystography and clinical follow-up was performed at intervals of 1 week, and 3, 6. 12, and IS months after the procedure. The mean follow-up was 6 months (range 3–18 months). Results: Balloon dilation was technically successfully performed in all patients with incomplete obstructions (n=16). In three of four patients with complete obstruction stent implantation was performed successfully. Subsequent to failure of stent implantation in one of these patients balloon dilation was performed instead. The long-term primary patency rate in patients with incomplete obstructions was 88% (n=14/16). In three of four cases with complete obstruction long-term patency was achieved during follow-up. Severe complications, infections, or punctal splitting were not observed. Conclusion: Fluoroscopically guided balloon dacryocystoplasty is a feasible nonsurgical therapy in canalicular obstructions with good clinical results that may be used as an alternative to surgical procedures. In patients with complete obstructions stent placement is possible but further investigations are needed to assess the procedural and long-term results.

90Y Radioembolization After Radiation Exposure from Peptide Receptor Radionuclide Therapy

Previous radiation therapy of the liver is a contraindication for performing 90Y microsphere radioembolization, and its safety after internal radiation exposure through peptide receptor radionuclide therapy (PRRT) has not yet been investigated. Methods: We retrospectively assessed a consecutive cohort of 23 neuroendocrine tumor (NET) patients with liver-dominant metastatic disease undergoing radioembolization with 90Y microspheres as a salvage therapy after failed PRRT. Toxicity was recorded throughout follow-up and reported according to Common Terminology Criteria for Adverse Events (version 3). Radiologic (response evaluation criteria in solid tumors), biochemical, and symptomatic responses were investigated at 3 mo after treatment, and survival analyses were performed with the Kaplan–Meier method (log-rank test, P < 0.05). Results: The median follow-up period after radioembolization was 38 mo (95% confidence interval, 18–58 mo). The mean previous cumulative activity of 177Lu-DOTA-octreotate was 31.8 GBq. The mean cumulative treatment activity of 90Y microspheres was 3.4 ± 2.1 GBq, administered to the whole liver in a single session (n = 8 patients), in a sequential lobar fashion (n = 10 patients), or to only 1 liver lobe (n = 5 patients). Only transient, mostly minor liver toxicity (no grade 4) was recorded. One patient (4.3%) developed a gastroduodenal ulcer (grade 2). The overall response rates for radiologic, biochemical, and symptomatic responses were 30.4%, 53.8%, and 80%, respectively. The median overall survival was 29 mo (95% confidence interval, 4–54 mo) from the first radioembolization session and 54 mo (95% confidence interval, 47–61 mo) from the first PRRT cycle. A tumor proliferation index Ki-67 greater than 5% predicted shorter survival (P = 0.007). Conclusion: Radioembolization is a safe and effective salvage treatment option in advanced NET patients with liver-dominant tumor burden who failed or reprogressed after PRRT. The lack of relevant liver toxicity despite high applied 90Y activities and considerable previous cumulative activities of 177Lu-octreotate is noteworthy and disputes internal radiation exposure by PRRT as a toxicity risk factor in subsequent radioembolization.

Iodine-131-lipiodol therapy in hepatic tumours.

The incidence of hepatocellular carcinoma (HCC) is worldwide sharply on the rise and patients with advanced disease carry a poor prognosis. HCC is the sixth most common cancer and the third leading cause of cancer associated deaths in the world. Intra-arterially administered (131)I-Lipiodol is selectively retained by hepatocellular carcinomas, and has been used as a vehicle for delivery of therapeutic agents to these tumours. In this review we focus on the therapeutic indications, usefulness and methods of treatment with 131-Iodine Lipiodol. The effectiveness of (131)I-Lipiodol treatment is proven both in the treatment of HCC with portal thrombosis and also as an adjuvant to surgery after the resection of HCCs. It is at least as effective as chemoembolization and is tolerated much better. Severe liver dysfunction represents theoretic contraindication for radioembolization as well as for TACE. In such cases (131)I-Lipiodol is an alternative therapy option especially in tumours smaller than 6cm.

CT- and MR-guided interventions in radiology /

Pre- and Post-interventional Imaging.- CT-guided Interventions - Indications, Technique, Pitfalls.- MR-guided Interventions - Indications, Technique, Pitfalls.- Radiation Protection in CT-Guided Interventions.- Medical Management of the Patient.- Ways to the Target.- Navigated Interventions - Techniques and Indications.- Special Consideration of Image-guided Interventions in Pediatric Patients.- Biopsies.- MR-guided Breast Biopsy.- Drainage.- Localization Techniques.- Interventional Oncology.- Interventional Pain Management.- Muskulo-Skeletal Interventions.- Special Techniques.- Quality Management in Interventional Radiology.- Cost Effectiveness in Interventional Radiology.- Building an Interventional Department.- Medical Education in Interventional Radiology.

Evaluation of polyurethane nasolacrimal duct stents: in vivo studies in New Zealand rabbits.

The purpose of this study was to evaluate the radiographic and biological effects of different polyurethane nasolacrimal duct stents in an animal model. Fifteen polyurethane nasolacrimal duct stents (n = 5 mushroom-type stents, n = 5 newly designed S-shaped TearLeader stents without hydrophilic coating, and n = 5 S-shaped TearLeader stents with hydrophilic coating) were implanted in the nasolacrimal ducts of eight unaffected New Zealand rabbits. One nasolacrimal system served as control. Clinical and radiographic follow-up was performed at 1-, 2-, and 4-week intervals, then after a 3-month interval, after which the animals were euthanized. All stents were implanted without major periprocedural complications. The stents proved to be patent by the end of the procedure. During follow-up, all mushroom-type stents were occluded at 4 weeks. None of these stents opened to forced irrigation. Clinically, all rabbits demonstrated severe dacryocystitis. Three out of five TearLeader stents without hydrophilic coating were blocked at 4 weeks; one out of five was open to irrigation. Best results were observed in the stent group with hydrophilic coating. Follow-up dacryocystography demonstrated patent stents in nasolacrimal ducts of all animals after 4 weeks. In only one of five cases, the coated stent became partially occluded after 2 months. These animals were free of clinical symptoms. After 3 months, at least three out of five stents still opened to forced irrigation and only one stent was completely blocked. Dislocation of the stents was not observed. Refinement of the stent surface and stent design improves the results of nasolacrimal duct stenting in this animal model. Implantation of hydrophilic-coated S-shaped stents is highly superior to conventional mushroom-type stents and noncoated stent types. Hydrophilic coating seems to prevent foreign-body reactions, resulting in maximized stent patency.

Cone-Beam Computed Tomography (CBCT) Dacryocystography for Imaging of the Nasolacrimal Duct System

AbstractPurpose:To evaluate the usefulness and safety of cone-beam computed tomography (CBCT) dacryocystography in detecting lesions, identifying coexisting soft-tissue changes and determining treatment options in patients with epiphora.Patients and Methods:Unilateral digital subtraction dacryocystography and CBCT dacryocystography were carried out on 45 patients. Stenoses and occlusions were identified and coexisting changes such as septal deviation and dacryoliths were noted. The diameter of the bony lacrimal duct of affected and unaffected side was measured and related to the clinically evident epiphora. An attempt was made to base the subsequent therapeutic planning on the CBCT dacryocystographic findings. Additionally, the radiation dose levels for CBCT dacryocystography in comparison to those of multislice computed tomography (MSCT) were evaluated in a standardized head-neck Rando-Alderson phantom.Results:Nasolacrimal duct obstructions were present in 37/45 patients, 18 with a stenosis and 19 with an occlusion in parts of the lacrimal outflow system. The minimal bony diameter of the side with epiphora was significantly decreased compared to the unaffected side. Coexisting soft-tissue changes did not correlate significantly with the clinical sign of epiphora. Eight patients showed no underlying reason for the epiphora and were treated conservatively. A total of eleven patients received interventional therapy for their stenosis and 23 patients had to be treated surgically. A further three patients received medical treatment for infection, before surgery and interventional therapy, respectively, were carried out. Dose levels for CBCT imaging remained far below those of MSCT.Conclusion:CBCT dacryocystography is a safe and time-efficient modality for assessing the nasolacrimal duct system in patients with epiphora. CBCT dacryocystography provides detailed images of the nasolacrimal drainage system, surrounding soft tissue, and bony structures in one diagnostic tour. It allows clear measurement of the bony nasolacrimal duct and displays information beyond that of the drainage lumen, improving the planning of therapeutic interventional and surgical procedures.ZusammenfassungZiel:Evaluation der dreidimensionalen (3-D) Flachdetektor-Rotationsdakryozystographie zur funktionellen und morphologischen Diagnostik der ableitenden Tränenwege bei Patienten mit Epiphora.Patienten und Methodik:Bei 45 Patienten (32 Frauen, 13 Männer, mittleres Alter 57 Jahre) mit einseitiger Epiphora und dem klinischen Verdacht auf einen stenosierenden Prozess der ableitenden Tränenwege wurden insgesamt 45 Tränenwegsdarstellungen durchgeführt. Bei allen Patienten wurden beide knöchernen Tränen-Nasen-Kanäle vermessen. Die 3-D-Rota- tionsdakryozystographien wurden an einer Flachdetektor-Angiographieanlage (Philips Allura Xper FD20, Philips Medical Systems, Best, Niederlande) in einem Messbereich von 240° C-Bogen-Rotation durchgeführt. Die 3-D-Datensätze wurden bezüglich der Beurteilbarkeit der morphologischen und funktionellen Ursachen der Epiphora sowie der Planungsmöglichkeiten weiterer Therapieoptionen ausgewertet. Zur Beurteilung der bei der 3-D-Rotationsdakryozystographie auftretenden Strahlenexposition für die strahlensensiblen Risikoorgane (Augenlinse, Parotis und Schilddrüse) wurden vorab Dosismessungen an einem Kopf-Hals-Phantom durchgeführt und die Ergebnisse mit denen einer Standard-Mehrschicht-Computertomographie (MSCT) des Gesichtsschädels verglichen.Ergebnisse:Die technische Durchführbarkeit und Auswertbarkeit waren bei allen 45 Untersuchungen gegeben. Bei acht (17,8%) der untersuchten Tränenapparate zeigte sich trotz bestehender Symptomatik der Epiphora eine unauffällige Darstellung der ableitenden Tränenwege. Ein pathologischer Befund bestand bei 37 (82,2%) der untersuchten Tränenapparate. In 18 Fällen (48,6%) lag der Abflussbehinderung eine Stenose, in 19 Fällen (51,4%) ein Verschluss der ableitenden Tränenwege zugrunde. Bei 34 der 45 Patienten konnten ein oder mehrere Zusatzbefunde erhoben werden. Die statistische Analyse der Zusatzbefunde ergab jedoch keinen signifikanten Zusammenhang zwischen dem Vorliegen eines oder mehrerer dieser Zusatzbefunde und dem Auftreten von Epiphora. Bei der Ausmessung des minimalen knöchernen Durchmessers des Tränen-Nasen-Kanals konnte jedoch eine signifikante Korrelation zwischen einem kleinen Durchmesser der symptomatischen Seite gegenüber der asymptomatischen Gegenseite nachgewiesen werden (p = 0,003). Die Strahlenexposition für die Augenlinse bei der 3-D-Rotationsdakryozystographie betrug 4,1 mSv und war damit geringer als die einer üblicherweise durchgeführten MSCT. Die weiterführende Therapieplanung war in allen Fällen ohne die Durchführung zusätzlicher radiologischer bildgebender Verfahren möglich.Schlussfolgerung:Die 3-D-Rotationsdakryozystographie bietet erstmals eine Option zur umfassenden Darstellung der ableitenden Tränenwege, bei der außerdem eine suffiziente Beurteilung der angrenzenden Weichteile und knöchernen Strukturen möglich ist. Bei Patienten mit Epiphora sollte die 3-D-Rotationsdakryozystographie aufgrund der im Vergleich zur CT geringeren Strahlenexposition als Standardverfahren zur bildgebenden Diagnostik der ableitenden Tränenwege eingesetzt werden. Hierdurch lässt sich der für die Abklärung der Symptomatik erforderliche apparatetechnische Aufwand bei gleichzeitiger Reduktion von Strahlenexposition des Patienten, Untersuchungszeit und -aufwand verringern.

Lymphatic Interventions for Treatment of Chylothorax

PURPOSE To determine effectiveness of lymphatic interventional procedures for treatment of chylothorax. MATERIAL AND METHODS Analysis of interventions performed from 2001 to 2014. RESULTS In 21 patients with therapy resistant chylothorax a lymphatic radiological intervention was attempted, which could be performed in 19 cases: 17 thoracic duct embolizations (15 transabdominal, one transzervical and one retrograde transvenous procedure), 2 percutaneous destructions of lymphatic vessels, one CT-guided injection of ethanol next to a duplicated thoracic duct. Fourteen of seventeen (82.3 %) of the technically successful embolizations lead to clinical cure. This encluded three patients with prior unsuccessful surgical thoracic duct ligation. Also the injection of ethanol was clinically effective. Complications were a bile peritonitis requiring operation, and one clinical deterioration of unknown cause. CONCLUSION Interventional lymphatic procedures allow for effective treatment in many cases of chylothorax, and should be considered early during treatment. KEY POINTS • Thoracic duct embolization is an effective treatment method for chylothorax. • If embolization is impossible, percutaneous lymphatic destruction or injection of sclerosants/tissue adhesive next to the thoracic duct may be tried.

Percutaneous CT-Guided Radiofrequency Ablation of Solitary Small Renal Masses: A Single Center Experience.

PURPOSE To analyze the outcome of patients undergoing percutaneous CT-guided radiofrequency ablation (RFA) of small renal masses (SRM) at a single center during a ten-year time period. MATERIALS AND METHODS Patient records of renal RFAs (07/2003 - 11/2013) were reviewed. Indications were SRM suspicious of malignancy on imaging and one of the following: severe comorbidity; old age; solitary kidney; impaired renal function; patient wish. Biopsy was performed at the time of RFA. Patients were excluded if no follow-up was available. Patient and procedural characteristics were recorded. Survival rates were calculated using the Kaplan-Meiers method and compared with log-rank or cox tests. RESULTS 38 patients (16 females, mean age 70.0 years [range 52 - 87]) presenting with a solitary SRM were included in the study. Biopsy showed malignancy in 29 patients; 9 had benign tumors. 26 patients suffered from cardiovascular, respiratory or hepatic comorbidities. Technical success (complete ablation on first follow-up) was achieved in 95 % of cases. Two major complications (bowel perforation; hematothorax) occurred. The 3- and 7-year overall survival (OS) [any cause] rates were 73.4 ± 0.8 % and 50.3 ± 1.0 %, respectively (mean follow-up 54.6 months, range 1 - 127). 4 recurrences and 2 metastases were observed. The presence of comorbidities was the only independent predictor of OS. There was no difference in survival between patients with benign and malignant tumors. CONCLUSION RFA of SRM is successful in a large percentage of cases with a low complication rate and durable local control. As RFA is typically performed in multimorbid patients, overall survival seems to depend primarily on comorbidities rather than cancer progression. Key Points • RFA of SRM is technically successful in the majority of cases. • RFA leads to a high degree of local tumor control. • Post-RFA most patients ultimately die of comorbidities. • Overall survival post-RFA does not significantly differ between benign and malignant tumors in multimorbid patients.

Endovascular Repair of an Ductus Arteriosus Aneurysm Causing Ortner Syndrome

A ductus arteriosus aneurysm (DAA) is a rare but potentially fatal condition in adults. In the past, open surgery was the only available option for treatment. Nowadays, endovascular repair has emerged as a safe and less invasive treatment option for aortic aneurysms. However, there is little experience with DAA and its anatomic location can complicate endovascular repair. Here, we describe the case of a 69-year-old patient who presented with Ortner syndrome caused by DAA, which was successfully treated using a solely endovascular approach and a standard stent graft.

Interventional Pain Managment

Chronic back pain is a widespread disease (Manchikanti et al. 2004; Neuhauser et al. 2005; Schwarzer et al. 1995). Due to the anatomy of the intervertebral joints and the increasing static load toward the lumbar spine, the lumbar facet syndrome is definitely more frequently observed than the cervical or thoracic one (Masharawi et al. 2004; Yoganandan et al. 2003). In many cases, the origin of pain may not be attributed to a focus, e.g., disc damage, neither by clinical examination nor by imaging methods.