Radioembolization dosimetry is vital to optimizing therapy. The same effective radiation dose can be delivered on different days by altering the microsphere specific activity. First-week glass administrations have a high specific activity and small number of microspheres. Conversely, second-week administrations have a low specific activity and large number of microspheres. Current literature supports treatment in week 1. We evaluated the treatment response and adverse events of radiation segmentectomy for HCC utilizing first- and second-week glass microspheres. A single-institution retrospective review of patients with HCC treated with radiation segmentectomy using Y90 glass microspheres ( ≥ 200 Gy) between January 2019-2023 was performed. 19 patients were treated with first-week vials (Group 1) and 65 patients with second-week vials (Group 2). All patients had compensated liver function at the time of the procedure (total bilirubin < 2.0 mg/dL) and were without extrahepatic disease. Response was determined by cross-sectional imaging at 3, 6, and 12 mo post treatment using LI-RADS criteria. Incidence of acute liver injury and 30-day admission were recorded. One-tail T-test and chi-square analysis was used. Patient age, target volume, and initial tumor size were similar between the two groups, though dose administered was significantly different (Table 336.1). There was a significant difference in tumor viability at the 3 mo follow-up (p = 0.00154) favoring Group 2, with a trend toward better response in Group 2 at 6 and 12 mo (p = 0.0609 and 0.0889, respectively) (Tables 336.2 and 336.3). Acute liver injury and 30-day admission rates were not significantly different between the groups (Table 336.4). Utilizing second-week glass Y90 vials for radiation segmentectomy is safe and effective with comparable outcomes to first-week vials.

To compare the efficacy of exchange versus removal of implanted/tunneled central venous access devices in patients with bacteremia, evaluating for microorganism recurrence. Retrospective search from 7/2015 to 7/2016 yielded 82 patients with bacteremia referred to IR for management of implanted/tunneled central venous access devices. 44 patients underwent removal and 38 patients underwent exchange. Recurrence rates after bacteremia clearance through 30 days were obtained. Blood cultures from device were considered “matched” if peripheral blood cultures grew same organism. Negative catheter tip culture rates were obtained. See chart. Hospitalized patients with bacteremia undergoing exchange of tunneled/implanted central venous access devices did not experience prolonged leukocytosis compared to those undergoing removal. Device exchange did not lead to significantly increased rates of bacteremia recurrence at 30 days when compared to removal. Negative catheter tip culture rates are high for both cohorts. Work is ongoing to evaluate species of microorganisms cultured and its impact on organism clearance.Tabled 1Patient CohortsPatients (n) with T >38.5°C1Avg WBCmax2(range)Avg WBCprocedure2(range)Number of Days to Normal WBCMatched CulturesNegative Cath Tip Culture RateRecurrence at 30 DaysRemoval (n = 44)16 (36%)13.4 (0.1–44.5)10.1 (0.1–34.9)2.4a25 (57%)18 (41%)4 (9%)Exchange (n = 38)15 (39%)14.9 (0.3–48.5)8.8 (0.2–18.1)1.5b16 (42%)19 (50%)4 (11%)1Within 72 hr of presentation.2Units: K/uL.aTwo patients did not normalize before discharge.bThree patients did not normalize before discharge. Open table in a new tab

Percutaneous cholecystostomy (PC) can be used to treat cholecystitis in patients who cannot safely undergo immediate cholecystectomy (CCY). PC tube outcomes can be divided into three categories: surgical removal during CCY (SR), non-surgical removal (NSR), and non-removal due to patient death (NRD). Retrospective studies have established that each outcome is equally likely. The purpose of this study is to identify predictors of PC tube outcome, allowing physicians to better manage patient and family expectations. A retrospective study of 137 patients who underwent PC for cholecystitis between 1/2007 and 9/2015 was undertaken. All patients underwent PC because they were poor surgical candidates. A multinomial logistic regression model was used to determine the odds of experiencing a specific outcome as a function of comorbid conditions, admitting diagnoses, ICU status, bile cultures, and the presence of gallstones. The Table demonstrates that the odds of undergoing NRD vs SR or NSR were significantly increased in patients in the ICU, as well as those with ascites, sepsis, at least one pulmonary comorbidity, or an admitting diagnosis unrelated to cholecystitis. None of these factors significantly altered the odds of undergoing SR vs NSR. Gallstones (p = .36), bile cultures (p = .08), cirrhosis (p = .64), cardiac comorbidity (p = .22), diabetes (p = .63), renal insufficiency (p = .12), and age (p = .87) had no significant impact on outcome. Patients undergoing PC from the ICU and those with ascites, sepsis, at least one lung comorbidity, or an admitting diagnosis unrelated to cholecystitis are more likely to die before PC tube removal.Tabled 1Odds ratios (and 95% CI) of predictors and outcomes. Significance defined as p<.05PredictorNRD vs. NSRNRD vs. SRAdmitted for cholecystitis0.4 (0.1–0.9; P = 0.02)0.2 (0.05–0.13; P = 0.001)Ascites4.4 (1.7–11.2; P = 0.002)3.2 (1.1–9.1; P = 0.03)Sepsis3.5 (1.4–8.7; P = 0.01)3.9 (1.4–11.1; P = 0.01)ICU3.0 (1.1–8.0; P =0.03)6.2 (2.1–18.6; P = 0.001)Pulmonary comorbidity3.2 (1.3–7.9; P = 0.01)3.2 (1.1–9.1; P = 0.02) Open table in a new tab

PurposeCholecystitis is a prominent disease most commonly treated with antibiotics and cholecystectomy (CCY). For high-risk patients, placement of a percutaneous cholecystostomy (PC) can be easily performed. These tubes are classically considered a “bridge to surgery” until CCY can be safely accomplished. The purpose of this study was to define the role and clinical course of PC, i.e., to determine the rate of surgical vs. non-surgical tube removal after PC.MaterialsA retrospective study of 137 men and women (mean age, 65.9; range, 22-98) who underwent PC for cholecystitis between 1/2007 and 9/2015 was undertaken. All patients underwent PC because they were deemed poor surgical candidates. One hundred eleven patients (81.0%) had cardiovascular comorbidities, 49 (35.8%) had pulmonary comorbidities, 20 (14.6%) had cancer, and 16 (11.7%) had cirrhosis. Data on the method of tube removal and subsequent surgical interventions were recorded. Patients who underwent non-surgical tube removal were divided into calculous and acalculous groups based on radiological studies. Fisher’s exact test was used to determine if there was a statistically significant difference in the rate of CCY following PC between the two groups.ResultsIn total, 119/137 had endpoint data available. Fifty-five tubes (46.2%) were removed non-surgically either in a doctor’s office (20, 36.4%), a hospital bed (12, 21.8%), an IR suite following cholangiogram (11, 20%), or accidentally (12, 21.8%). Nine patients (16.4%) eventually underwent CCY. There was no statistically significant difference between the non-surgical removal calculous group (5/26, 19.2%) vs. acalculous group (4/29, 13.8%) undergoing CCY (p = 0.72). Thirty-one PC tubes (26.1%) were removed during CCY. Thirty-three patients (27.7%) expired with a PC tube in place, but none were due to complications of the procedure. The mean day of death was 23.5 days after PC (range: 1-86). In total, 40 of 119 patients (33.6%) underwent CCY.ConclusionsThe majority of patients who undergo PC do not bridge to CCY. Non-surgical tube removal is performed regardless of the presence of calculi, creating a paradigm shift in clinical care, patient expectation and management. PurposeCholecystitis is a prominent disease most commonly treated with antibiotics and cholecystectomy (CCY). For high-risk patients, placement of a percutaneous cholecystostomy (PC) can be easily performed. These tubes are classically considered a “bridge to surgery” until CCY can be safely accomplished. The purpose of this study was to define the role and clinical course of PC, i.e., to determine the rate of surgical vs. non-surgical tube removal after PC. Cholecystitis is a prominent disease most commonly treated with antibiotics and cholecystectomy (CCY). For high-risk patients, placement of a percutaneous cholecystostomy (PC) can be easily performed. These tubes are classically considered a “bridge to surgery” until CCY can be safely accomplished. The purpose of this study was to define the role and clinical course of PC, i.e., to determine the rate of surgical vs. non-surgical tube removal after PC. MaterialsA retrospective study of 137 men and women (mean age, 65.9; range, 22-98) who underwent PC for cholecystitis between 1/2007 and 9/2015 was undertaken. All patients underwent PC because they were deemed poor surgical candidates. One hundred eleven patients (81.0%) had cardiovascular comorbidities, 49 (35.8%) had pulmonary comorbidities, 20 (14.6%) had cancer, and 16 (11.7%) had cirrhosis. Data on the method of tube removal and subsequent surgical interventions were recorded. Patients who underwent non-surgical tube removal were divided into calculous and acalculous groups based on radiological studies. Fisher’s exact test was used to determine if there was a statistically significant difference in the rate of CCY following PC between the two groups. A retrospective study of 137 men and women (mean age, 65.9; range, 22-98) who underwent PC for cholecystitis between 1/2007 and 9/2015 was undertaken. All patients underwent PC because they were deemed poor surgical candidates. One hundred eleven patients (81.0%) had cardiovascular comorbidities, 49 (35.8%) had pulmonary comorbidities, 20 (14.6%) had cancer, and 16 (11.7%) had cirrhosis. Data on the method of tube removal and subsequent surgical interventions were recorded. Patients who underwent non-surgical tube removal were divided into calculous and acalculous groups based on radiological studies. Fisher’s exact test was used to determine if there was a statistically significant difference in the rate of CCY following PC between the two groups. ResultsIn total, 119/137 had endpoint data available. Fifty-five tubes (46.2%) were removed non-surgically either in a doctor’s office (20, 36.4%), a hospital bed (12, 21.8%), an IR suite following cholangiogram (11, 20%), or accidentally (12, 21.8%). Nine patients (16.4%) eventually underwent CCY. There was no statistically significant difference between the non-surgical removal calculous group (5/26, 19.2%) vs. acalculous group (4/29, 13.8%) undergoing CCY (p = 0.72). Thirty-one PC tubes (26.1%) were removed during CCY. Thirty-three patients (27.7%) expired with a PC tube in place, but none were due to complications of the procedure. The mean day of death was 23.5 days after PC (range: 1-86). In total, 40 of 119 patients (33.6%) underwent CCY. In total, 119/137 had endpoint data available. Fifty-five tubes (46.2%) were removed non-surgically either in a doctor’s office (20, 36.4%), a hospital bed (12, 21.8%), an IR suite following cholangiogram (11, 20%), or accidentally (12, 21.8%). Nine patients (16.4%) eventually underwent CCY. There was no statistically significant difference between the non-surgical removal calculous group (5/26, 19.2%) vs. acalculous group (4/29, 13.8%) undergoing CCY (p = 0.72). Thirty-one PC tubes (26.1%) were removed during CCY. Thirty-three patients (27.7%) expired with a PC tube in place, but none were due to complications of the procedure. The mean day of death was 23.5 days after PC (range: 1-86). In total, 40 of 119 patients (33.6%) underwent CCY. ConclusionsThe majority of patients who undergo PC do not bridge to CCY. Non-surgical tube removal is performed regardless of the presence of calculi, creating a paradigm shift in clinical care, patient expectation and management. The majority of patients who undergo PC do not bridge to CCY. Non-surgical tube removal is performed regardless of the presence of calculi, creating a paradigm shift in clinical care, patient expectation and management.

Spinal metastases are a common and morbid condition in America. Of the 1.6 million new cases of cancer estimated to be diagnosed in the USA in 2015, approximately 5–10 % will develop spinal metastases. This number is expected to increase as the life expectancy of cancer patients increases. Patients with osteolytic spinal metastases experience severe and often debilitating pain, which significantly reduces quality of life. Due to the morbidity of open surgery, particularly in oncologic patients, the treatment paradigm has shifted towards minimally invasive therapy. The advent and evolution of percutaneous treatments of spinal metastases has shown progressive success in reducing pain, improving function, and providing mechanical stability. There are various currently available interventions including vertebroplasty, vertebral augmentation, and coblation and radiofrequency ablation systems. For more complex spinal metastases, combined treatments including vertebral augmentation in conjunction with radiofrequency ablation, external beam radiation, and the novel treatment of intraoperative radiotherapy are also available. Ultimately, the goal of treatment in this patient population is palliative with the intention of improving the remaining quality of life. There is no established algorithm or specific technique that has proved best for the many variations of vertebral compression fractures (VCFs), so treatment tends to be dependent on the operator and/or based on institution preference or bias. Each technique provides its own unique value in the various types of metastatic VCFs encountered, and understanding the uses, advantages, and safety profile of each specific treatment is imperative in providing the best patient care. Percutaneous treatment of metastatic spinal disease is an excellent alternative to medical and surgical management in carefully selected patients. We believe that a multidisciplinary approach and combination therapy allows for optimal pain reduction and improvement of function.

PurposeTo compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access.MaterialsData from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared.ResultsAn intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells.ConclusionsMultiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden.References1. Staghorn Calculi—Safety and Efficacy of Multiple Tracts Percutaneous Nephrolithotomy. J Urol 2008; 71(6):1039–1042. 10.1016/j.urology.2007.11.072.2. Hegarty N, Desai M. Percutaneous Nephrolithotomy Requiring Multiple Tracts- Comparison of Morbidity with Single-Tract Procedures. J Endourology 2006; 20(10):753–760.3. Patel S, Nakada S. The Modern History and Evolution of Percutaneous Nephrolithotomy. J Endourol 2015; 29(2):153–157. 10.1089/end.2014.0287. PurposeTo compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access. To compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access. MaterialsData from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared. Data from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared. ResultsAn intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells. An intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells. ConclusionsMultiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden. Multiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden.

Review of current literature on pancreaticoduodenal arcade (PDA) aneurysms including anatomy, clinical presentation, diagnosis, pathophysiology, and treatment options. PDA aneurysms are rare, accounting for only ~2% of visceral aneurysms. Although symptoms are often vague or nonexistent, spontaneous rupture can lead to hemorrhagic shock and death, most commonly due to retroperitoneal hemorrhage. We present two cases of PDA aneurysms at our institution that were emergently treated with an endovascular approach. Pseudoaneurysms are most common and true aneurysms are more rare, often related to celiac artery stenosis. A hemodynamically significant stenosis of the celiac axis causes increased blood flow in the peripancreatic arterial network through the superior mesenteric artery. This provides collateral supply for revascularization of the celiac trunk, thereby dilating the vascular walls, promoting aneurysm formation. While these aneurysms are most often asymptomatic, they have a high propensity to rupture. We report two cases of sudden onset abdominal pain and retroperitoneal hemorrhage. Mesenteric angiograms were performed demonstrating celiac trunk stenosis with a dense network of hypertrophied collaterals from the SMA supplying the ruptured aneurysms, as well as the collateral flow to the celiac trunk. One case was due to median arcuate ligament syndrome, and the otherdue to atherosclerosis. The patients were successfully treated with coil embolization and their post-procedure courses were uneventful. The current management of PDA aneurysms is multifactorial and ranges from no treatment to surgical repair. Interventional Radiology provides a minimally invasive endovascular therapy which is the preferred treatment according to current literature, and in some cases, the only treatment. Treatment of the celiac artery stenosis depends on the etiology of the stenosis and has no formal guidelines. In one of our cases, surgical decompression of the median arcuate ligament could prove beneficial by preventing the risk for further aneurysm formation. Rapid diagnosis and treatment of PDA aneurysms can lead to decreased mortality and morbidity.