Radiofrequency ablation (RFA) is an emerging strategy for treatment of non-surgical candidates lateralized primary aldosteronism (PA). The Aldosteronoma Resolution Score (ARS) is surgically validated metric for prognostication of complete clinical cure after adrenalectomy. The purpose of this study is to validate ARS as a prognosticator for outcomes post RFA of primary aldosteronism patients. A retrospective study included 59 PA patients treated with RFA between 2007-2023. The clinical and biochemical data of the patients were collected, which included pre-operative and post-operative potassium levels, serum aldosterone levels, plasma renin activity levels, blood pressure measurements, and number and doses of antihypertensives and potassium supplements. Primary outcomes include descriptive analysis and AUC- ROC tests to assess the relation between ARS and outcomes post RFA. ARS were defined as "high likelihood of clinical cure" (4-5), "medium likehood of clinical cure" (2-3) and "low likelihood of clinical cure (0-1). Outcomes were defined as Complete clinical response (BP consistently below 140/90 mm Hg, not requiring antihypertensives), Partial clinical response (BP consistently below 140/90 mm Hg, requiring antihypertensives however, less number and doses than before RFA) and Absent clinical response (BP consistently below 140/90 mm Hg, requiring an unchanged number and dose antihypertensives than before RFA). ARS correlation with post RFA biochemical data was performed. 59 patients participated in this study among them were 17 females (29%) and 42 males (71%) with the mean age 54.4 years. The results of the study revealed that 15.3% of patients achieved total clinical success while 9% had high ARS Score (4-5), 45.8% had partial clinical success while 45% had medium ARS score (2-3). Finally, 39%, did not attain clinical success corresponding to 46% who had low ARS score (0-1). The analysis of the curve revealed a substantial confidence interval, suggesting that the accuracy of ARS in predicting biochemical results after surgery was limited. For potassium level the confidence interval was (95% CI: [0.399] to [0.748]), while for aldosterone levels the curve analysis indicated that the confidence interval was (95% CI: [0.280] to [0.849]) indicating that ARS is not a good predicator for the aldosterone level post-surgery (P= 0.647). The study provides preliminary evidence that ARS can be used as a predictive measure for clinical outcome in PA patients treated with RFA. Further larger studies are required to validate our findings.

Supplemental Digital Content is available in the text. Guidelines recommend adrenal venous sampling to determine disease laterality in primary aldosteronism. Adrenocorticotropic hormone (ACTH) stimulation clearly improves the likelihood of successful adrenal vein catheterization but may lead to a decrease in lateralization rates. To examine the impact of ACTH on lateralization, we performed a retrospective analysis of 340 patients with confirmed primary aldosteronism who underwent adrenal venous sampling with a single interventional radiology team using a protocol of sampling both before and after an ACTH bolus. In addition to this original research, we conducted a review of similar studies from the past 5 years to develop a consensus on the impact of ACTH on lateralization for primary aldosteronism. In the original research analysis, following a bolus of ACTH, 58% of patients had a decline in lateralization index which led to discordance between the pre-ACTH and post-ACTH classifications of lateralization in up to 26% of cases. The majority of discordant cases were due to reclassification from unilateral disease pre-ACTH to bilateral disease post-ACTH. In patients who already lateralized with unstimulated sampling, the response to ACTH did not have any impact on surgical outcomes. In a review of contemporary studies, we identified 11 similar studies in the past 5 years, of which 10 reported either no change or a decrease in lateralization index following ACTH, resulting in ≈25% discordance between unstimulated and stimulated lateralization rates. We conclude that ACTH stimulation during adrenal venous sampling can underestimate surgically remediable primary aldosteronism and recommend that the role of ACTH be limited primarily to enhancing selectivity.

The SI is a very good indicator of appropriate catheter position for selective adrenal veins sampling when it is >2. However we aim to demonstrate that when SI is <2 it is not a good indicator of poor catheter positioning. In a significant number of patients the SI may be <2, yet the catheter may still be in appropriate position. Our AVS protocol consists of an initial IVC sample, 3 sets of bilateral simultaneous selective adrenal vein samples, a bolus of Cosyntropin 0.25 mg, minimum of 2 sets of post ACTH stimulation and a final post ACTH IVC sample (for aldosterone and cortisol on all samples). Retrospective evaluation of 100 AVS studies from 6/2016-9/2018 was used to compare pre ACTH baseline Selectivity Index to post ACTH Selectivity Index, to evaluate the sensitivity of pre ACTH Selectivity Index as a marker for evaluating satisfactory catheter position. Retrospective evaluation of 100 recent AVS studies from 6/2016-9/2018 demonstrated a SI index of <2, either unilaterally or bilaterally, in 46% of patients on the baseline adrenal vein samples. There were 4 patients in whom the right adrenal veins were not found and one in whom the left adrenal vein was not found (95% successful AVS). However despite the SI <2, without repositioning the catheter, the baseline samples were shown to be correct in all but 2 patients on the post ACTH stimulation samples, using a SI of >5. There are a number of possible explanations for the SI being <2 but the catheter in satisfactory position in the adrenal vein. The various possibilities will be discussed. The SI is a very good indicator of selective adrenal veins sampling if it is >2. However in a significant number of patients the SI may be <2 yet the catheter may still be in good position. The post ACTH SI of >5 is a much better indicator of a successful AVS.

Recent guidelines recognize that the pulsatile pattern of adrenal hormone secretion may affect results of adrenal venous sampling (AVS)1. No outcome data comparing sequential and simultaneous AVS is currently published. At our institution, we perform simultaneous bilateral AVS under baseline and stimulated conditions and draw three samples each under both conditions. We compare baseline and stimulated lateralization indices (LI) obtained using simultaneous and simulated sequential AVS in patients. Between 2008 and 2013, 139 patients underwent AVS at our institution. We assessed lateralization using LI (baseline > 2, stimulated > 4)1 using simultaneous (L1R1, L2R2, L3R3) and simulated sequential (L1R2, L1R3, L2R1, L2R3, L3R1, L3R2) samples in three groups: all patients (G1), patients with follow-up (92/139; G2) and patients with lateralized treatment (surgery or radiofrequency ablation) resulting in decreased need for anti-hypertensives (39/145; G3). From 2008-13, 145 patients (Age 52±11 years, 57% male) underwent AVS at our institution. For each patient, there were 3 LI calculated using distinct simultaneous samples (basal and stimulated) and 6 LI calculated using distinct sequential samples (basal and stimulated). There was no significant difference in the proportion of patients with baseline or post-ACTH LI above threshold using simultaneous or sequential samples (Table 1). Sequential and simultaneous AVS show similar results in baseline and stimulated LI in all patients as well as patients with lateralization hyperaldosteronism.

The purpose of this educational exhibit is to explore pertinent history and physical exam findings when an interventional radiologist initially assesses a patient. We will explore key pre-procedural history questions and clinical exam findings universal to all patients being assessed by an interventional radiologist. We will also identify pre-procedure findings that will help guide clinical decision making and post-procedure follow-up exam findings to assess for treatment success through specific common clinical cases seen by interventional radiologists. With the evolution of interventional radiology as a new clinical specialty, history and physical exam findings are important for interventional radiologists to make clinical decisions both prior to and following intervention. These findings will help interventional radiologists tailor treatment options, identify procedure success and decide on the need for re-intervention. 1.Universal risk factor assessment prior to any IR procedure (i.e. renal failure, bleeding diathesis, contraindication to sedation or contrast).2.Important history and physical exam findings for common interventional radiology procedures through specific clinical cases including, but not limited to bleeding interventions, drainage procedures (genitourinary, biliary, abscess), dialysis intervention, TIPS placement and venous access procedures.3.Pertinent questions (history) and physical exam findings post-treatment to identify common IR procedure-related complications (i.e obstructed drains, leakage, pseudoanuerysm, fistula, etc.).4.Key post-procedure history and physical exam findings to assess treatment success and possible need for re-intervention. History and physical exam findings are important tools for an interventional radiologist when deciding on clinical management and treatment options during initial assessment of a patient. In addition, post-treatment follow-up also helps interventional radiologists identify common early complications, assess treatment success and need for subsequent intervention.

PurposeTo determine utility of liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HO) after liver transplantation.Materials and MethodsAdult liver transplant patients treated with PTA for HO (2003-2013) at our institution were included, and reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HO on early and late biopsy (EB and LB, < or >60 days after PTA) ), and clinical outcome, defined as good (no clinical issues, non-HO-related death or death greater than 200 d after PTA) or bad (surgical correction, repeat PTA, persistent HO or HO-related death).Results15 patients met inclusion criteria and had 21 PTA, 658d (range30-4566d) after transplant. There were 10/21 pts with EB after PTA (mean 29d, range 2-48d); 6/10 patients had both EB and LB, 3/21 patients had only LB after PTA and 8/21 patient had no biopsy after PTA. 9 patients had LB after PTA (mean 153d, range 62-304d). Clinical follow-up was available in all patients (mean 392d). All patients with HO on LB had bad outcomes and all with no HO on LB had good outcomes. EB (<60d post-PTA) does not predict good or bad outcomes: patients with HO on EB (3/7 good, 4/7 bad) and no HO on EB (2/3 good, 1/3 bad) had mixed outcomes (see table). In patients without biopsy post-PTA (8/21), 6/8 had bad and 2/8 had good outcomes.There was no significant difference (p >0.05) in time between transplant and PTA, improvement in luminal diameter or manometry (pre- vs. post-PTA) in patients with good vs. bad outcomes, and patients with HO vs. no HO on EB or on LB.ConclusionLiver biopsy is an important diagnostic and prognostic tool in transplant patients needing PTA for HO. Biopsy >60d (rather than early biopsy) after PTA accurately separates patients with good long-term clinical outcomes from patients with persistent HO requiring further interventions.Tabled 1Outcomes in patients with early or late biopsy after transplant hepatic venous obstruction.Biopsy resultsHepatic venous obstructionNo Hepatic Venous obstructionOutcomeGoodBadGoodBad(Mean, Range)(Mean, Range)(Mean, Range)(Mean, Range)Early biopsy (<60 d) 10 pts3/74/72/31/3(1181d, 205-3096 d)(27d, 1-47 d)(513d, 62-964 d)(66 d)Late biopsy (>60 d) 9 pts0/22/27/70/7(207d, 66-349 d)(994d, 62-3096 d) Open table in a new tab PurposeTo determine utility of liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HO) after liver transplantation. To determine utility of liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HO) after liver transplantation. Materials and MethodsAdult liver transplant patients treated with PTA for HO (2003-2013) at our institution were included, and reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HO on early and late biopsy (EB and LB, < or >60 days after PTA) ), and clinical outcome, defined as good (no clinical issues, non-HO-related death or death greater than 200 d after PTA) or bad (surgical correction, repeat PTA, persistent HO or HO-related death). Adult liver transplant patients treated with PTA for HO (2003-2013) at our institution were included, and reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HO on early and late biopsy (EB and LB, < or >60 days after PTA) ), and clinical outcome, defined as good (no clinical issues, non-HO-related death or death greater than 200 d after PTA) or bad (surgical correction, repeat PTA, persistent HO or HO-related death). Results15 patients met inclusion criteria and had 21 PTA, 658d (range30-4566d) after transplant. There were 10/21 pts with EB after PTA (mean 29d, range 2-48d); 6/10 patients had both EB and LB, 3/21 patients had only LB after PTA and 8/21 patient had no biopsy after PTA. 9 patients had LB after PTA (mean 153d, range 62-304d). Clinical follow-up was available in all patients (mean 392d). All patients with HO on LB had bad outcomes and all with no HO on LB had good outcomes. EB (<60d post-PTA) does not predict good or bad outcomes: patients with HO on EB (3/7 good, 4/7 bad) and no HO on EB (2/3 good, 1/3 bad) had mixed outcomes (see table). In patients without biopsy post-PTA (8/21), 6/8 had bad and 2/8 had good outcomes.There was no significant difference (p >0.05) in time between transplant and PTA, improvement in luminal diameter or manometry (pre- vs. post-PTA) in patients with good vs. bad outcomes, and patients with HO vs. no HO on EB or on LB. 15 patients met inclusion criteria and had 21 PTA, 658d (range30-4566d) after transplant. There were 10/21 pts with EB after PTA (mean 29d, range 2-48d); 6/10 patients had both EB and LB, 3/21 patients had only LB after PTA and 8/21 patient had no biopsy after PTA. 9 patients had LB after PTA (mean 153d, range 62-304d). Clinical follow-up was available in all patients (mean 392d). All patients with HO on LB had bad outcomes and all with no HO on LB had good outcomes. EB (<60d post-PTA) does not predict good or bad outcomes: patients with HO on EB (3/7 good, 4/7 bad) and no HO on EB (2/3 good, 1/3 bad) had mixed outcomes (see table). In patients without biopsy post-PTA (8/21), 6/8 had bad and 2/8 had good outcomes. There was no significant difference (p >0.05) in time between transplant and PTA, improvement in luminal diameter or manometry (pre- vs. post-PTA) in patients with good vs. bad outcomes, and patients with HO vs. no HO on EB or on LB. ConclusionLiver biopsy is an important diagnostic and prognostic tool in transplant patients needing PTA for HO. Biopsy >60d (rather than early biopsy) after PTA accurately separates patients with good long-term clinical outcomes from patients with persistent HO requiring further interventions.Tabled 1Outcomes in patients with early or late biopsy after transplant hepatic venous obstruction.Biopsy resultsHepatic venous obstructionNo Hepatic Venous obstructionOutcomeGoodBadGoodBad(Mean, Range)(Mean, Range)(Mean, Range)(Mean, Range)Early biopsy (<60 d) 10 pts3/74/72/31/3(1181d, 205-3096 d)(27d, 1-47 d)(513d, 62-964 d)(66 d)Late biopsy (>60 d) 9 pts0/22/27/70/7(207d, 66-349 d)(994d, 62-3096 d) Open table in a new tab Liver biopsy is an important diagnostic and prognostic tool in transplant patients needing PTA for HO. Biopsy >60d (rather than early biopsy) after PTA accurately separates patients with good long-term clinical outcomes from patients with persistent HO requiring further interventions.

Right adrenal vein (RAV) catheterization is a challenging component of adrenal venous sampling (AVS). Currently pre-procedure imaging, stat cortisol or selectivity ratios (SR) (RAV:IVC cortisol) confirm successful RAV catheterization. We confirm RAV location using intra-procedural cone-beam computed tomography (CCT) during contrast venography. We compare different SR in baseline and post-ACTH samples for accurate prediction of RAV selection. 76 patients underwent AVS for clinically/biochemically established hyperaldosteronism. Our AVS protocol involves bilateral venous catheters, sampling the IVC (representative of a peripheral level), selective catheterization of both adrenal veins and confirming the RAV catheterization by a CCT venogram. Simultaneous bilateral adrenal baseline (3 samples) and post-cosyntropin (5, 10 and 15 minutes after injection) samples for both aldosterone and cortisol were obtained. A receiver operator curve analysis was used to evaluate the data. 76 patients (50 yrs, 23-75 y, 58% male) underwent AVS with pre-sampling CCT to confirm catheterization. RAV catheterization was confirmed with cone-beam CT in 71/76 patients. SR (RAV:IVC cortisol) at baseline was a good predictor of RAV catheterization (AUC: 0.90). At baseline, a SR of 2.15 had 100% specificity (spec) and 70% sensitivity (sens) and SR of 1.56 had optimal accuracy (sens 89%, spec 86%). SRs of post-ACTH samples (post-ACTH RAV:IVC cortisol) was available in 72/76 patients. 5 minute post-ACTH SR was the best predictor of RAV catheterization (AUC 5min: 0.92, AUC 10 min: 0.82, AUC 15 min: 0.88). A 5 minute post-ACTH SR of 17.81 had 100% specificity and SR of 8.14 had optimal accuracy (sens 89%, spec 80%). A 10 minute post-ACTH threshold of 64.96 had 100% specificity and SR of 10 had optimal accuracy (sens 87%, spec 83%). A 15 minute post-ACTH threshold of 21.84 had 100% specificity and 14.42 had optimal accuracy (sens 86%, spec 75%). Five minute post-ACTH biochemical SR has the best accuracy in predicting RAV catheterization compared to an anatomical standard. A baseline SR threshold of 2 has 100% specificity but 70% sensitivity.

Learning ObjectivesTo briefly describe the principles of cone beam CT (CBCT) in percutaneous biliary interventionsTo provide practical tips on performing high quality CBCT of the biliary systemTo provide examples of the use of CBCT as a problem solving tool in a variety of biliary casesBackgroundCBCT has a well established role in arteriography and also spinal interventions. Its use in biliary interventions is less well established but is proving to be a useful tool. We illustrate the expanding role of CBCT in percutaneous biliary interventions.Clinical Findings/Procedure DetailsCBCT is the latest in 3D imaging technology and gives the ability to acquire real time 3D images in the IR suite. This exhibit describes the practical steps in obtaining high quality 3D images of the biliary tree with accompanying CT reconstructions. Case examples are provided demonstrating the utility of this technique in evaluating the biliary tree including evaluating the extent of hilar biliary obstruction prior to resection or metallic stenting, providing guidance for percutaneous biliary stone extraction, aiding in challenging left lobe access, evaluation of undrained hepatic lobe segments, providing guidance and planning in performing sharp recanalisation of occlusive obstructing biliary stenoses and in the early detection of percutaneous biliary access related complicationsConclusion and/or Teaching PointsCBCT is a relatively new imaging technology available on most modern angiographic systems.It is becoming a standard technique in many IR procedures providing CT quality images wit h high spatial resolution, all acquired within the IR suite. CBCT is a powerful tool in percutaneous biliary intervention with a growing number of clinical applications (1,2,3). Learning ObjectivesTo briefly describe the principles of cone beam CT (CBCT) in percutaneous biliary interventionsTo provide practical tips on performing high quality CBCT of the biliary systemTo provide examples of the use of CBCT as a problem solving tool in a variety of biliary cases To briefly describe the principles of cone beam CT (CBCT) in percutaneous biliary interventions To provide practical tips on performing high quality CBCT of the biliary system To provide examples of the use of CBCT as a problem solving tool in a variety of biliary cases BackgroundCBCT has a well established role in arteriography and also spinal interventions. Its use in biliary interventions is less well established but is proving to be a useful tool. We illustrate the expanding role of CBCT in percutaneous biliary interventions. CBCT has a well established role in arteriography and also spinal interventions. Its use in biliary interventions is less well established but is proving to be a useful tool. We illustrate the expanding role of CBCT in percutaneous biliary interventions. Clinical Findings/Procedure DetailsCBCT is the latest in 3D imaging technology and gives the ability to acquire real time 3D images in the IR suite. This exhibit describes the practical steps in obtaining high quality 3D images of the biliary tree with accompanying CT reconstructions. Case examples are provided demonstrating the utility of this technique in evaluating the biliary tree including evaluating the extent of hilar biliary obstruction prior to resection or metallic stenting, providing guidance for percutaneous biliary stone extraction, aiding in challenging left lobe access, evaluation of undrained hepatic lobe segments, providing guidance and planning in performing sharp recanalisation of occlusive obstructing biliary stenoses and in the early detection of percutaneous biliary access related complications CBCT is the latest in 3D imaging technology and gives the ability to acquire real time 3D images in the IR suite. This exhibit describes the practical steps in obtaining high quality 3D images of the biliary tree with accompanying CT reconstructions. Case examples are provided demonstrating the utility of this technique in evaluating the biliary tree including evaluating the extent of hilar biliary obstruction prior to resection or metallic stenting, providing guidance for percutaneous biliary stone extraction, aiding in challenging left lobe access, evaluation of undrained hepatic lobe segments, providing guidance and planning in performing sharp recanalisation of occlusive obstructing biliary stenoses and in the early detection of percutaneous biliary access related complications Conclusion and/or Teaching PointsCBCT is a relatively new imaging technology available on most modern angiographic systems.It is becoming a standard technique in many IR procedures providing CT quality images wit h high spatial resolution, all acquired within the IR suite. CBCT is a powerful tool in percutaneous biliary intervention with a growing number of clinical applications (1,2,3). CBCT is a relatively new imaging technology available on most modern angiographic systems.

PurposeTo determine incidence and clinical significance of non-targeted embolization (NTE) after superselective (S-TACE) and lobar transarterial chemoembolization (L-TACE).Materials and MethodsConsecutive patients that underwent TACE in 2000-2013 were included. NTE was defined as presence of ethiodized oil in organs other than liver seen on non-contrast CT performed day after TACE. CTs and angiography images were reviewed on PACS by abdominal imaging and interventional radiologist. Medical record were reviewed for clinical outcomes. Chi-square and Fischer exact tests were used for statistical analysis.Results583 TACE procedures for 360 patients were evaluated. HCC was treated in 394 cases (68%), 110 neuroendocrine tumors (19%) and 79 metastases (14%). Overall incidence of NTE was 33% (194), with 20% to lung, 13% gallbladder, 5% stomach, 1% pancreas, 1% spleen, 0.5% duodenum and 0.3% adrenal. S-TACE (164 cases) resulted in lower NTE rate (21% (34/164) vs. 38% (159/419), p<0.001). Organ-specific incidence of NTE was reduced with S-TACE for stomach (1% (2/164) vs. 6% (25/419), p=0.01) and gallbladder (4% (7/164) vs. 16% (67/419), p<0.001), but not for lungs (16% (26/164) vs. 21% (88/419), p=0.17). NTE to pancreas, duodenum and spleen occurred only with L-TACE. Two cases of NTE to adrenal occurred only with S-TACE. Pulmonary symptoms were present in 23/469 (5%) cases without lung oil deposition, but much more frequent in patients with lung oil deposition 24/114 (21%), (p<0.001). 3/8 (38%) patients with pancreas oil deposition had clinical pancreatitis. Eight patients were admitted to intensive care unit, 7 (1.7%) after L-TACE and 1 (0.6%) after S-TACE. In 7 there was evidence of NTE, in 6 cases to lung and in 2 to gallbladder. Three patients (0.5%) expired during the post TACE admission; all of them had L-TACE and lung NTE. Patients with NTE had longer hospital stay 2.6 vs 1.9 days, p=0.01.ConclusionTransarterterial chemoembolization has a high rate of non-targeted embolization, which can be reduced significantly using a superselective approach. Non-targeted embolization was associated with longer hospital stay and complicated post procedure course. PurposeTo determine incidence and clinical significance of non-targeted embolization (NTE) after superselective (S-TACE) and lobar transarterial chemoembolization (L-TACE). To determine incidence and clinical significance of non-targeted embolization (NTE) after superselective (S-TACE) and lobar transarterial chemoembolization (L-TACE). Materials and MethodsConsecutive patients that underwent TACE in 2000-2013 were included. NTE was defined as presence of ethiodized oil in organs other than liver seen on non-contrast CT performed day after TACE. CTs and angiography images were reviewed on PACS by abdominal imaging and interventional radiologist. Medical record were reviewed for clinical outcomes. Chi-square and Fischer exact tests were used for statistical analysis. Consecutive patients that underwent TACE in 2000-2013 were included. NTE was defined as presence of ethiodized oil in organs other than liver seen on non-contrast CT performed day after TACE. CTs and angiography images were reviewed on PACS by abdominal imaging and interventional radiologist. Medical record were reviewed for clinical outcomes. Chi-square and Fischer exact tests were used for statistical analysis. Results583 TACE procedures for 360 patients were evaluated. HCC was treated in 394 cases (68%), 110 neuroendocrine tumors (19%) and 79 metastases (14%). Overall incidence of NTE was 33% (194), with 20% to lung, 13% gallbladder, 5% stomach, 1% pancreas, 1% spleen, 0.5% duodenum and 0.3% adrenal. S-TACE (164 cases) resulted in lower NTE rate (21% (34/164) vs. 38% (159/419), p<0.001). Organ-specific incidence of NTE was reduced with S-TACE for stomach (1% (2/164) vs. 6% (25/419), p=0.01) and gallbladder (4% (7/164) vs. 16% (67/419), p<0.001), but not for lungs (16% (26/164) vs. 21% (88/419), p=0.17). NTE to pancreas, duodenum and spleen occurred only with L-TACE. Two cases of NTE to adrenal occurred only with S-TACE. Pulmonary symptoms were present in 23/469 (5%) cases without lung oil deposition, but much more frequent in patients with lung oil deposition 24/114 (21%), (p<0.001). 3/8 (38%) patients with pancreas oil deposition had clinical pancreatitis. Eight patients were admitted to intensive care unit, 7 (1.7%) after L-TACE and 1 (0.6%) after S-TACE. In 7 there was evidence of NTE, in 6 cases to lung and in 2 to gallbladder. Three patients (0.5%) expired during the post TACE admission; all of them had L-TACE and lung NTE. Patients with NTE had longer hospital stay 2.6 vs 1.9 days, p=0.01. 583 TACE procedures for 360 patients were evaluated. HCC was treated in 394 cases (68%), 110 neuroendocrine tumors (19%) and 79 metastases (14%). Overall incidence of NTE was 33% (194), with 20% to lung, 13% gallbladder, 5% stomach, 1% pancreas, 1% spleen, 0.5% duodenum and 0.3% adrenal. S-TACE (164 cases) resulted in lower NTE rate (21% (34/164) vs. 38% (159/419), p<0.001). Organ-specific incidence of NTE was reduced with S-TACE for stomach (1% (2/164) vs. 6% (25/419), p=0.01) and gallbladder (4% (7/164) vs. 16% (67/419), p<0.001), but not for lungs (16% (26/164) vs. 21% (88/419), p=0.17). NTE to pancreas, duodenum and spleen occurred only with L-TACE. Two cases of NTE to adrenal occurred only with S-TACE. Pulmonary symptoms were present in 23/469 (5%) cases without lung oil deposition, but much more frequent in patients with lung oil deposition 24/114 (21%), (p<0.001). 3/8 (38%) patients with pancreas oil deposition had clinical pancreatitis. Eight patients were admitted to intensive care unit, 7 (1.7%) after L-TACE and 1 (0.6%) after S-TACE. In 7 there was evidence of NTE, in 6 cases to lung and in 2 to gallbladder. Three patients (0.5%) expired during the post TACE admission; all of them had L-TACE and lung NTE. Patients with NTE had longer hospital stay 2.6 vs 1.9 days, p=0.01. ConclusionTransarterterial chemoembolization has a high rate of non-targeted embolization, which can be reduced significantly using a superselective approach. Non-targeted embolization was associated with longer hospital stay and complicated post procedure course. Transarterterial chemoembolization has a high rate of non-targeted embolization, which can be reduced significantly using a superselective approach. Non-targeted embolization was associated with longer hospital stay and complicated post procedure course.

Purpose In expert hands, initial surgery for hyperparathyroidism was successful in more than 95% of cases; consequently pre-operative imaging was not routinely performed. Since the shift to minimally invasive parathyroidectomy imaging is routinely performed, usually Sestamibi scan and ultrasound. If those two tests are negative, in many institutions 4DCT is then considered. In those cases where the hyperparathyroid state persists following surgery, localizing and treating residual parathyroid tissue becomes much more challenging due to the increased incidence of ectopic location and post-operative scarring. When lesions are localized to or suspected to be within the mediastinum (even during the initial imaging in the preoperative patient), angiographic ablation provides an appealing, minimally invasive alternative to sternotomy or mediastinoscopy. The purpose of this study is to describe the pre-procedural work-up, technical approach and results of angiographic ablation of mediastinal parathyroid adenomas. Materials and Methods A retrospective review was performed of angiographic studies for localization and ablation of ectopic parathyroid adenomas. Pre-procedural imaging was reviewed as well as the electronic medical record for pre- and post-procedural laboratory values including calcium and PTH levels. Technical details of the angiographic procedure were recorded including the vessels accessed and the material used for ablation. Results 9 patients who underwent angiographic ablation of mediastinal parathyroid adenomas were identified. All patients had a suspicious lesion identified on angiography which was targeted for ablation. In all cases, there was an excellent angiographic response to ablation which was subsequently confirmed by normalization of the serum calcium levels. The internal mammary artery was the most frequently feeding vessel supplying these mediastinal lesions. Conclusion If a single feeding vessel supplying a parathyroid adenoma is identified it can be effectively treated by gradual injection of hyperosmolar contrast medium. Patients must be followed closely for development of symptoms, calcium and PTH levels. Angiographic ablation of mediastinal parathyroid adenomas is an infrequently performed procedure but can be an extremely effective minimally invasive technique to treat ectopic parathyroid adenomas. Familiarity with the pre-procedural work-up required and the technique is essential for achieving the optimal results.

Adrenal vein sampling (AVS) is the gold standard to differentiate adrenal adenoma from hyperplasia in patients with hyperaldosteronism. Catheterization of the right adrenal vein is often considered technically difficult. The aim is to explore feasibility of C-arm CT (CCT) to confirm selective catheterization of the right adrenal vein during adrenal vein sampling. 14 patients (8 females, 6 males; aged 27 to 74) undergoing adrenal vein sampling at our institution between July and October 2011 were included. Contrast venography was performed in all cases to confirm selective catheterization of the adrenal veins prior to venous sampling and the right adrenal vein was also studied by CCT during contrast injection. Clinical indication in 13 cases was hyperaldosteronism and excess androgen secretion in one. Initial catheter position was assessed on conventional venography as "probable" or "definite" right adrenal vein location and "adrenal" and "not adrenal" on CCT. Eight cases were categorized by conventional angiography as "definitely" adrenal in location and 6 as "probable." All 8 "definite" cases on angiography were confirmed as adrenal by CCT. Out of 5 cases categorized on conventional angiography as "probable", CCT confirmed 4 as adrenal. In one "probable" angiographic visualization of presumed right adrenal vein, initial CCT demonstrated catheter malposition. The catheter was repositioned and confirmed by repeat RSA as adrenal. In 13 cases (86.7%) CCT imaging was concordant with angiographic identification of the right adrenal gland. CCT with retrograde venography during the procedure confirms unequivocally that the right adrenal vein has been catheterized and, accordingly, that the blood samples are valid. The technique is likely to be especially valuable in centers in which AVS is performed infrequently.

PurposeTo compare intra-procedural pain levels in patients with and without administration of intrathecal morphine before UAE.Materials & MethodsA retrospective review of patients who underwent UAE for fibroids between 2004 and 2008 at the Metrowest Medical Center and Beth Israel Deaconess Medical Center was performed to evaluate patients' pain levels during UAE. Patients were categorized in two groups according to administration of preprocedural intrathecal morphine. Standard group (n=69) had no preprocedural medication and morphine group (n=18) received an intrathecal morphine dose of 0.27 mg (±0.08, 0.2-0.4 mg) followed by UAE. Analysis of intraprocedural records included the reported pain levels on a scale (0= no pain, 10=worst pain). Side effects from the use of intrathecal morphine and its effect on the length of procedure were also compared between two groups.ResultsThere were no differences in patients' age, size of the fibroids, subjective symptoms of fibroids between the two groups. Patients in the standard group presented with higher pain scores (2.36±0.24) as compared to the morphine group (0.40± 0.27); p<0.01. Regarding side effects from administration of morphine, 3 patients presented with pruritus (n=2) and/or nausea (n=1) that required treatment (IV Diphenhydramine 25-100 mg or IM Butorphanol 1mg). Procedure length of intrathcal morphine group (mean: 1.54 hours) was decreased compared with the standard group (mean: 2.03 hours), p < 0.01.ConclusionThe use of intrathecal morphine before UAE significantly lowers the reported pain levels as compared to the standard treatment and also shortens the procedure length. Intrathecal morphine is a feasible for pain management during UAE with treatable side effects in this study. PurposeTo compare intra-procedural pain levels in patients with and without administration of intrathecal morphine before UAE. To compare intra-procedural pain levels in patients with and without administration of intrathecal morphine before UAE. Materials & MethodsA retrospective review of patients who underwent UAE for fibroids between 2004 and 2008 at the Metrowest Medical Center and Beth Israel Deaconess Medical Center was performed to evaluate patients' pain levels during UAE. Patients were categorized in two groups according to administration of preprocedural intrathecal morphine. Standard group (n=69) had no preprocedural medication and morphine group (n=18) received an intrathecal morphine dose of 0.27 mg (±0.08, 0.2-0.4 mg) followed by UAE. Analysis of intraprocedural records included the reported pain levels on a scale (0= no pain, 10=worst pain). Side effects from the use of intrathecal morphine and its effect on the length of procedure were also compared between two groups. A retrospective review of patients who underwent UAE for fibroids between 2004 and 2008 at the Metrowest Medical Center and Beth Israel Deaconess Medical Center was performed to evaluate patients' pain levels during UAE. Patients were categorized in two groups according to administration of preprocedural intrathecal morphine. Standard group (n=69) had no preprocedural medication and morphine group (n=18) received an intrathecal morphine dose of 0.27 mg (±0.08, 0.2-0.4 mg) followed by UAE. Analysis of intraprocedural records included the reported pain levels on a scale (0= no pain, 10=worst pain). Side effects from the use of intrathecal morphine and its effect on the length of procedure were also compared between two groups. ResultsThere were no differences in patients' age, size of the fibroids, subjective symptoms of fibroids between the two groups. Patients in the standard group presented with higher pain scores (2.36±0.24) as compared to the morphine group (0.40± 0.27); p<0.01. Regarding side effects from administration of morphine, 3 patients presented with pruritus (n=2) and/or nausea (n=1) that required treatment (IV Diphenhydramine 25-100 mg or IM Butorphanol 1mg). Procedure length of intrathcal morphine group (mean: 1.54 hours) was decreased compared with the standard group (mean: 2.03 hours), p < 0.01. There were no differences in patients' age, size of the fibroids, subjective symptoms of fibroids between the two groups. Patients in the standard group presented with higher pain scores (2.36±0.24) as compared to the morphine group (0.40± 0.27); p<0.01. Regarding side effects from administration of morphine, 3 patients presented with pruritus (n=2) and/or nausea (n=1) that required treatment (IV Diphenhydramine 25-100 mg or IM Butorphanol 1mg). Procedure length of intrathcal morphine group (mean: 1.54 hours) was decreased compared with the standard group (mean: 2.03 hours), p < 0.01. ConclusionThe use of intrathecal morphine before UAE significantly lowers the reported pain levels as compared to the standard treatment and also shortens the procedure length. Intrathecal morphine is a feasible for pain management during UAE with treatable side effects in this study. The use of intrathecal morphine before UAE significantly lowers the reported pain levels as compared to the standard treatment and also shortens the procedure length. Intrathecal morphine is a feasible for pain management during UAE with treatable side effects in this study.

This brief case report describes the successful outcome after surgical excision of multiple adventitial cysts of the popliteal artery in a 75-year-old man with rapidly worsening claudication. It highlights several unsettled points concerning the diagnosis, cause, and management of cystic adventitial disease of the popliteal artery and compares duplex ultrasound, computed tomography, and magnetic resonance angiography in the noninvasive diagnosis and treatment of this condition.

The purpose of this retrospective study was to review our experience with a consecutive group of end-stage renal disease (ESRD) patients using simple strategies to increase the use of autogenous vascular access, and determine whether the current trend of using synthetic bridge-graft fistula (BGF) rather than autogenous arteriovenous fistula (AVF), could be reversed, despite an aging population and broadening criteria for hemodialysis. All patients for vascular access surgery had careful preoperative clinical examination of the arm veins with outflow occlusion to determine the venous anatomy and continuity. Where no veins were apparent or their continuity in doubt, selective preoperative venography was performed. Where veins were unsatisfactory for forearm AVF, new or modified surgical procedures to use both the basilic and cephalic veins in the upper arm were performed. Intraoperative angioscopy was used to monitor vein quality and surgical technique. Ninety-eight primary vascular access procedures were performed in 76 patients, 75 (76.5%) AVF (forearm, n = 41; upper arm, n = 34) and 23 (23.5%) BGF. Forty-one of 76 (54%) had already had at least one previous access procedure prior to this study. More than one access procedure was needed in 16 patients. Preoperative venography was performed in 22 (22.4%) and intraoperative angioscopy in 45 (45.9%) of the 98 procedures. The number of revisions required to maintain patency was significantly higher for BGF (37 revisions in 14/23) than AVF (16 revisions in 13/75) (p<0.0001, Poisson test) with an annualized secondary revision rate of 1.168 for BGF and 0.173 for AVF (p<0.0001, Poisson test). AVF had both longer primary (p=0.0001, log rank test) and secondary patency (p=0.038, log rank test) than BGF. AVF as the primary vascular access can be significantly increased and the current trend of using BGF reversed with the use of simple clinical strategies to evaluate the suitability of the arm veins for vascular access.

WE report a case in which a fracture occurred within the third of three sequential overlapping 39-mm-long Palmaz stents (Johnson & Johnson Interventional Systems, Warren, NJ) placed in the right common iliac to proximal external iliac arteries. The fracture occurred where the third stent overlapped with the distal end of the second. Substantial intimal hmer- . plasia occurred in the bare area between the fracture fragments, resultinn in substantial recurrent stenosis llmonths after initial la cement. Although it is impossible to conclusively prove the cause for this complication, possible mechanisms are discussed.

This article will be devoted to a variation in the percutaneous drainage of pancreatic pseudocysts, a technique called percutaneous cystogastrostomy (PCG).(1-7) This approach is modeled on the standard surgical therapy for pseudocysts, creation of a large communication between the pseudocyst and an adjacent loop of bowel to achieve long-term direct drainage. Experience with PCG in the United States is limited, but groups in Europe, India, and Australia(1-5) have used this approach very successfully for many years. The fact that they have had sustained success with this technique, and the emergence of endoscopic techniques that establish the same drainage (endoscopic cystoenterostomies),(8-20) validate these approaches as bona fide treatments for pseudocysts and viable alternatives to standard surgical therapy.Regardless of the method chosen to drain a pseudocyst (percutaneous, endoscopic, or surgical), patients should fulfill established criteria to warrant active intervention. These include a pseudocyst larger than 4 to 6 cm in diameter, no resolution after six weeks of conservative therapy, deterioration, pain or evidence of infection, and pseudocysts associated with chronic pancreatitis. The incidence of spontaneous resolution in these pseudocysts is extremely low (<30%), and subsequent untreated complication rates (>50%) are very high, supporting the need for intervention. Although the criteria are important guidelines, often decisions to treat conservatively or proceed to intervention may be influenced by clinical circumstances or radiographic features in a particular patient.Once the decision for percutaneous drainage of the pseudocyst has been made, a variety of approaches are possible. There is general agreement that simple needle aspiration is unsatisfactory because of the high recurrence rate.(3,22,23) Patients with pseudocysts require long-term decompressive drainage (usually longer than 6 weeks)(4,7,22-27) and in some cases permanent drainage. Percutaneously: long-term external catheter drainage is the most frequently used approach in the United States,(3,21-23) most recently via the transgastric route.(24-27) The technique is similar to percutaneous abdominal abscess drainage, with a percutaneous pigtail catheter draining by gravity into an external bag. This requires patients, their families, or visiting nurses to flush and dress external tubes and drainage bags for a long time. Apart from the inconvenience, additional risks include development of a chronic pancreatico-cutaneous fistula (except when drained transgastrically) and the pseudocyst's becoming secondarily infected. The percutaneous placement of a long-term internal drainage catheter solves many of these problems and permits convenient, comfortable, and effective long-term drainage for six weeks or more, as needed. The major advantages are that the procedure is done using local anesthesia and intravenous conscious sedation (like any other percutaneous biopsy or abscess drainage) with computed tomography (CT) guidance and, more importantly, creates internal drainage similar to surgical cystenterostomy. There is usually faster recovery, earlier discharge, and lower morbidity and mortality than with surgery. The main disadvantages are small catheters (8 to 10 Fr) that run the risk of becoming occluded by debris (potentially resulting in pseudocyst recurrence) and the inability to perform serial sinography or catheter exchanges once the double pigtail has been completely internalized.Percutaneous radiologic intervention is not the only alternative to surgery Creation of pseudocystenterostomy via the endoscopic approach is also gaining popularity, more so in Europe than in the U.S.(8-18) Although the number of patients treated with percutaneous or endoscopic therapy is still small by comparison with the numerous surgical series,(28-35) success rates using either ''non-surgical'' approach have been impressive, and morbidity, mortality, and recurrence rates low (Tables 1 and 2). With more experience and technical modifications (larger catheters and stents), the results should improve even more.

Underdiagnosis of parathyroid adenomas by sonography.R M LernerAudio Available | Share

OBJECTIVE:The purpose of this study was to assess the value of measuring parathormone levels in percutaneous needle aspirates of suspicious cervical lesions in patients with hyperparathyroidism to confirm whether the lesion represents abnormal parathyroid tissue.SUBJECTS AND METHODS:The study group consisted of 66 patients with hyperparathyroidism in whom 80 cervical lesions were aspirated and levels of parathormone in the aspirates were measured. CT guidance was used for two patients and sonographic guidance for the remainder. The lesions selected for aspiration were demonstrated on either sonography or CT and had either an unusual position (separate from the thyroid gland or were intrathyroidal) or configuration (irregular shape or atypical heterogeneous sonographic texture). In 15 patients, an indeterminate, posteriorly located intrathyroidal mass was detected and felt most likely to represent a thyroid nodule by sonographic criteria. These masses were aspirated to rule out atypical parathyroid adenomas. In patients who had been previously explored for hyperparathyroidism and presented with persistent or recurrent hypercalcemia, all indeterminate, cervical, potentially parathyroid masses were aspirated for parathormone determination. The level of parathormone in each aspirate was measured by using an immunoradiometric assay.RESULTS:Levels of parathormone were increased in the aspirates in 37 of the 45 patients in whom sonography showed classic lesions suggestive of parathyroid adenoma. This included the 25 patients who had previously undergone exploratory surgery. At surgery, all 37 had parathyroid adenomas in the indicated locations, for a specificity of 100%. In six patients, the results of the aspiration were false-negative. Parathyroid adenomas were suspected on sonograms and confirmed at surgery, but no parathormone was detected in the aspirate. Results of aspiration of indeterminate lesions were true-negative in two patients who had both characteristic and indeterminate lesions on sonography and in the 15 patients who had indeterminate lesions that were felt to be of thyroid origin. Aspirates contained no parathormone, and surgical findings confirmed the lesions were not of parathyroid origin.CONCLUSION:Our results show that increased levels of parathormone in percutaneous needle aspirates of cervical masses in patients with hyperparathyroidism confirm the mass is a parathyroid adenoma. Although absence or low levels of parathormone in the aspirates usually excludes a parathyroid adenoma, this is not absolute as sometimes the needle may miss the mass, rendering the parathormone value invalid (false-negative).