PurposeTo evaluate the effectiveness and safety of image-guided percutaneous ablation in the management of primary and metastatic adrenal tumors.Materials and MethodsAn IRB approved, retrospective analysis identified 57 patients (42 men, 15 women; mean age 64 years; range 41-81) at two institutions who underwent a total of 74 adrenal tumor ablation procedures between January 2001 and June 2012 using CT-guided radiofrequency ablation (n= 30; 6 with supplemental ETOH injection), and MRI (n=34) or CT (n=10) guided cryoablation. Tumors included primary adrenal cell cancer and metastases from NSCLC, RCC, TCC, colonCa, breastCa, melanoma, endometrial Ca, ovarian teratoCa and medullary thyroidCa and ranged from 1 to 11 cm in size. Medical records and imaging studies were reviewed for procedural details, complications, results and outcome. Clinical and imaging follow-up was available for an average of 13 months (range 1-57 mos).ResultsLocal tumor progression was observed in 8 patients, all of which were retreated. Immediate complications included hypertensive crisis (n= 8), which resulted in demand ischemia in two patients, and correlated with tumor size <4 cm and pre-procedural visibility of normal adrenal tissue. One patient went into atrial fibrillation which was treated medically. Two patients experienced adrenal insufficiency. Performing adrenal ablations under general anesthesia and identifying tumors most likely to cause a hypertensive crisis based on imaging criteria aided in peri-procedural preparation.ConclusionImage-guided ablation of adrenal tumors can be used for both palliation and tumor eradication. Careful pre-procedural evaluation should include assessment of tumor size and visibility of normal adrenal tissue. Our presentation details how to prepare for and manage intra-procedural adrenaline surge and to maximize patient benefit. PurposeTo evaluate the effectiveness and safety of image-guided percutaneous ablation in the management of primary and metastatic adrenal tumors. To evaluate the effectiveness and safety of image-guided percutaneous ablation in the management of primary and metastatic adrenal tumors. Materials and MethodsAn IRB approved, retrospective analysis identified 57 patients (42 men, 15 women; mean age 64 years; range 41-81) at two institutions who underwent a total of 74 adrenal tumor ablation procedures between January 2001 and June 2012 using CT-guided radiofrequency ablation (n= 30; 6 with supplemental ETOH injection), and MRI (n=34) or CT (n=10) guided cryoablation. Tumors included primary adrenal cell cancer and metastases from NSCLC, RCC, TCC, colonCa, breastCa, melanoma, endometrial Ca, ovarian teratoCa and medullary thyroidCa and ranged from 1 to 11 cm in size. Medical records and imaging studies were reviewed for procedural details, complications, results and outcome. Clinical and imaging follow-up was available for an average of 13 months (range 1-57 mos). An IRB approved, retrospective analysis identified 57 patients (42 men, 15 women; mean age 64 years; range 41-81) at two institutions who underwent a total of 74 adrenal tumor ablation procedures between January 2001 and June 2012 using CT-guided radiofrequency ablation (n= 30; 6 with supplemental ETOH injection), and MRI (n=34) or CT (n=10) guided cryoablation. Tumors included primary adrenal cell cancer and metastases from NSCLC, RCC, TCC, colonCa, breastCa, melanoma, endometrial Ca, ovarian teratoCa and medullary thyroidCa and ranged from 1 to 11 cm in size. Medical records and imaging studies were reviewed for procedural details, complications, results and outcome. Clinical and imaging follow-up was available for an average of 13 months (range 1-57 mos). ResultsLocal tumor progression was observed in 8 patients, all of which were retreated. Immediate complications included hypertensive crisis (n= 8), which resulted in demand ischemia in two patients, and correlated with tumor size <4 cm and pre-procedural visibility of normal adrenal tissue. One patient went into atrial fibrillation which was treated medically. Two patients experienced adrenal insufficiency. Performing adrenal ablations under general anesthesia and identifying tumors most likely to cause a hypertensive crisis based on imaging criteria aided in peri-procedural preparation. Local tumor progression was observed in 8 patients, all of which were retreated. Immediate complications included hypertensive crisis (n= 8), which resulted in demand ischemia in two patients, and correlated with tumor size <4 cm and pre-procedural visibility of normal adrenal tissue. One patient went into atrial fibrillation which was treated medically. Two patients experienced adrenal insufficiency. Performing adrenal ablations under general anesthesia and identifying tumors most likely to cause a hypertensive crisis based on imaging criteria aided in peri-procedural preparation. ConclusionImage-guided ablation of adrenal tumors can be used for both palliation and tumor eradication. Careful pre-procedural evaluation should include assessment of tumor size and visibility of normal adrenal tissue. Our presentation details how to prepare for and manage intra-procedural adrenaline surge and to maximize patient benefit. Image-guided ablation of adrenal tumors can be used for both palliation and tumor eradication. Careful pre-procedural evaluation should include assessment of tumor size and visibility of normal adrenal tissue. Our presentation details how to prepare for and manage intra-procedural adrenaline surge and to maximize patient benefit.

The purpose of our study is to assess the efficacy and safety of percutaneous radiologic gastrostomy/gastrojejunostomy performed using “push” technique and T-fastener gastropexy in providing enteral nourishment in amyotrophic lateral sclerosis patients with severe motor impairment. In this retrospective study, we included 250 ALS patients (130M: 120F, mean age-59 yrs, age range 20-87yrs) who underwent percutaneous gastrostomy/gastrojejunostomy tube placement using “push” technique and T-fastener gastropexy over a 10-year period. The procedures were performed using a combined fluoroscopy and ultrasound or CT guidance. The electronic medical records and imaging studies in these patients were retrospectively evaluated for type of sedation, duration of patient hospital stay, procedure success rate, complications, no.of re-interventions and impact on patient’s nutritional status The technical success rate for percutaneous radiologic gastrostomy/gastrojejunostomy using the push technique was 98.5% (246/250). In the 250 patients, 240 gastrostomies (96%) and 10 gastrojejunostomies (4%) were performed using fluoroscopic (n=247) or CT guidance (n=3). The presence of severe motor impairment necessitated general anesthesia in 243 patients (97.2%). The average hospital stay for the patients for the percutaneous procedure was 2.5 days. The procedure related complications (major/minor) were 15/250 (6%) including bleeding, infection, aspiration pneumonia, pneumoperitoneum. Revisions of the gastrostomy/gastrojejunostomy tube were required in 60 occasions (24%) for tube dislodgement, leakage and clogging. Percutaneous placement of gastrostomy and gastrojejunostomy catheters using the “Push” technique is a safe and effective procedure for enteral nourishment in ALS patients who form a complex subset of patients due to severe motor function impairment.

Purpose Fiducial markers may be used to localize the prostate during radiotherapy using portal film and/or cone-beam CT. The purpose of this study is to describe the technique, efficacy, and complications of transrectal ultrasound (TRUS)-guided prostate fiducial marker placement by interventional radiology. Materials and Methods With IRB approval, medical records of patients who underwent TRUS-guided prostate fiducial marker placement between 1/2011 and 8/2012 were reviewed. Three gold markers, Visicoil (IBA, Bartlett, TN) or AnchorMarker (Biocompatibles, Oxford, CT), were placed, 1 each in the right and left prostate base as well as right apex (1). Post-procedure frontal and lateral radiographs confirmed placement. An additional marker was placed if malposition was noted. Complications of fiducial placement and need for additional localization modality at radiotherapy were recorded. Results In total 111 men with mean age 69 years (range 52—90), mean PSA 11 (range 1—106), mean Gleason score 7 (range 6—9), and clinical stage T1c—T3b underwent marker placement. Prior TURP was noted in in 6 (5.4%), and cryotherapy in 1 (0.9%). Mean prostate volume was 31.5 mL (range 2—130). In 60 (54%), 1% lidocaine was injected into the neurovascular bundle; 51 (46%) received no lidocaine. Moderate sedation due to anxiety was used in 1 (0.9%) and general anesthesia due to anal canal stenosis was used in 1 (0.9%). Malposition of 1 marker was recognized at US in 4 (3.6%) and on radiograph in 2 (1.8%), necessitating additional fiducial placement. In all cases, the fiducials were still used during radiotherapy. Poor visualization of the fiducial markers required additional prostate localization in 3 patients (2.7%) using B-mode acquisition and targeting US. Post-procedure urinary tract infection requiring oral antibiotics occurred in 1 (0.9%). Urosepsis requiring admission and IV antibiotics occurred in 1 (0.9%). Conclusion TRUS-guided prostate fiducial marker placement is a safe and reliable technique that may be performed by the interventional radiologist for subsequent prostate localization during radiotherapy. Reference 1. Shinohara K, Roach M, 3rd. Technique for implantation of fiducial markers in the prostate. Urology. 2008 Feb;71:196–200.

The purpose of this study was to evaluate the impact of pre and post-operative neoadjuvant chemoradiation on the clinical outcome of percutaneous drainage of pelvic abscesses developing in patients with rectal cancer after surgical resection. The study included a retrospective review of 45 patients (M: F-25:20, mean age-66 yrs, age range: 29-91yrs) with rectal cancer who underwent CT guided percutaneous drainage of pelvic abscesses developing after low anterior or abdomino-perineal resection. In this cohort, thirty-one patients (M: F-19:12, mean age -65 yrs, age range 29-91yrs) had received neoadjuvant chemoradiation either prior to or after surgical resection (Group A) and fourteen patients did not receive any chemoradiation (Group B). The electronic medical records and imaging studies in these patients were retrospectively evaluated to determine the abscess characteristics, details of catheter drainage and clinical outcome. A total of 72 CT-guided percutaneous abscess drainage procedures were performed on the 45 patients (Group A, n=52 and Group B, n=20). The technical success rate for CT guided catheter drainage of pelvic abscess was 97% (70/72). The mean period of catheter drainage was significantly longer in patients receiving peri-operative chemo-radiation (mean period: 107 days vs 27 days, p=0.02). Enteric fistulas complicating drainage of pelvic abscesses were also more common in chemo-radiation group [A: 42% (21/50), B: 21% (4/19)]. Recurrence of abscesses requiring re-drainage or catheter manipulation was also higher in pelvic abscesses in the chemoradiation group (54% vs 40%). Percutaneous CT guided catheter drainage is useful and effective in the management of pelvic abscesses developing after low anterior or abdomino-perineal resection in patients with rectal cancer. Peri-operative chemoradiation impacts outcome after abscess drainage necessitating prolonged drainage, frequent recurrences and multiple catheter manipulations.

CT-guided interventions are increasingly replacing more invasive techniques for a variety of tumors in the abdomen.Despite benefits, procedure related radiation dose to patients are of concern. Our purpose was to measure existing radiation dose following image-guided percutaneous thermal ablations of hepatic and renal tumors and the effect on image-quality of weight based CT protocol modification for lowering the overall dose in these procedures. Between January 2009 and December 2009, CT-guided renal and hepatic ablations were reviewed to determine radiation doses as CT Dose index and Dose Length Product for the pre-, intra- and post-procedure scanning phases. A weight-based protocol modification (changes in kVp=100-120, mA=80-220) was then prospectively applied to renal and hepatic ablation performed subsequently. Patients were assigned to three weight categories as follows: Group 1= <180 pounds (lbs), Group 2 =180-250 lbs and Group 3 >250 lbs. Image quality, needle localization, lesion detection, ability to detect complications and overall operator satisfaction was noted for each case (score 1-5). The dose reduction following modification was then calculated. Retrospective analysis found the average CTDi and DLP for CT guided ablations to be 16.5 and 268.5.The distribution of doses, pre, intra and post procedure was 29.88%, 35.11% and 35.0% and average CTDI was 14.8, 17.4 and 17.3 respectively. After protocol modifications, the mean CTDI for pre, intra and post procedure were 7.4, 6.2, 6.3, with a mean 59.64% reduction The operator showed high overall satisfaction with the modified images and rated the quality as diagnostic (3-5) and found adequate needle localization (4-5), lesion visibility (3-5) and ability to detect complications in all the cases. CT guided liver and renal ablation contributes substantial dose to the patients with significantly higher dose with liver ablation. Simple weight-based protocol modification of various phases of CT guidance can facilitate optimal procedure success with > 50% dose reduction.There was a significantly higher dose reduction for patients >200lbs as compared to patients with weight <180lbs.

PurposeSymptomatic bladder outlet obstruction and neurogenic bladder are common patient complaints, frequently requiring suprapubic bladder tubes (SPT). The purpose of this paper is to describe our institutional experience with minimally invasive radiological image guided percutaneous SPT placement, subsequent SPT exchanges and up-sizes; clinical and technical success and complications encountered.Materials and MethodsThis study is a Health Insurance Portability and Accountability Act (HIPPA) compliant study and patient informed consent was waived. A total of 585 primary SPT insertions and 439 SPT exchanges were referred to be performed on 549 patients (469 males, 80 females; 66 yrs(15-106y). The details of percutaneous SPT placement (indication, tube type and size at insertion and change, method of insertion) were retrospectively recorded. Technical success was defined as successful placement of the SPT in the bladder and clinical success defined as resolution of symptoms after catheter placement. Complications encountered were recorded and categorized as minor or major.ResultsThe technical success rate for primary SPT insertion was 99.6% (547/549)(on a per patient basis). The technical success rate for SPT exchanges was 92% (405/439). Clinical success rate for primary insertion was 98% (572/583) with symptoms unresolved in 2% (11/583). At SPT insertion, minor complications occurred in 7.2% (42/583) and at SPT exchanges minor complications occurred in 4.7% (21/439). There was one major complication (a patient requiring surgery as the small bowel was traversed by at catheter) and no procedure related mortality.ConclusionRadiological image guided percutaneous SPT placement is a safe and effective procedure. PurposeSymptomatic bladder outlet obstruction and neurogenic bladder are common patient complaints, frequently requiring suprapubic bladder tubes (SPT). The purpose of this paper is to describe our institutional experience with minimally invasive radiological image guided percutaneous SPT placement, subsequent SPT exchanges and up-sizes; clinical and technical success and complications encountered. Symptomatic bladder outlet obstruction and neurogenic bladder are common patient complaints, frequently requiring suprapubic bladder tubes (SPT). The purpose of this paper is to describe our institutional experience with minimally invasive radiological image guided percutaneous SPT placement, subsequent SPT exchanges and up-sizes; clinical and technical success and complications encountered. Materials and MethodsThis study is a Health Insurance Portability and Accountability Act (HIPPA) compliant study and patient informed consent was waived. A total of 585 primary SPT insertions and 439 SPT exchanges were referred to be performed on 549 patients (469 males, 80 females; 66 yrs(15-106y). The details of percutaneous SPT placement (indication, tube type and size at insertion and change, method of insertion) were retrospectively recorded. Technical success was defined as successful placement of the SPT in the bladder and clinical success defined as resolution of symptoms after catheter placement. Complications encountered were recorded and categorized as minor or major. This study is a Health Insurance Portability and Accountability Act (HIPPA) compliant study and patient informed consent was waived. A total of 585 primary SPT insertions and 439 SPT exchanges were referred to be performed on 549 patients (469 males, 80 females; 66 yrs(15-106y). The details of percutaneous SPT placement (indication, tube type and size at insertion and change, method of insertion) were retrospectively recorded. Technical success was defined as successful placement of the SPT in the bladder and clinical success defined as resolution of symptoms after catheter placement. Complications encountered were recorded and categorized as minor or major. ResultsThe technical success rate for primary SPT insertion was 99.6% (547/549)(on a per patient basis). The technical success rate for SPT exchanges was 92% (405/439). Clinical success rate for primary insertion was 98% (572/583) with symptoms unresolved in 2% (11/583). At SPT insertion, minor complications occurred in 7.2% (42/583) and at SPT exchanges minor complications occurred in 4.7% (21/439). There was one major complication (a patient requiring surgery as the small bowel was traversed by at catheter) and no procedure related mortality. The technical success rate for primary SPT insertion was 99.6% (547/549)(on a per patient basis). The technical success rate for SPT exchanges was 92% (405/439). Clinical success rate for primary insertion was 98% (572/583) with symptoms unresolved in 2% (11/583). At SPT insertion, minor complications occurred in 7.2% (42/583) and at SPT exchanges minor complications occurred in 4.7% (21/439). There was one major complication (a patient requiring surgery as the small bowel was traversed by at catheter) and no procedure related mortality. ConclusionRadiological image guided percutaneous SPT placement is a safe and effective procedure. Radiological image guided percutaneous SPT placement is a safe and effective procedure.

1. To assess the factors influencing the duration of catheter indwelling and re-drainage. 2. To assess the impact of abscess-bowel communication on need for surgery. 3. To assess the safety of drainage techniques used to treat sigmoid diverticular abscess. Patients who underwent image-guided drainage of sigmoid diverticular abscess from Jan 2000 to Dec 2008 (study cohort) were identified from departmental database. Details of patient demographics, diverticular abscess, catheters, drainage technique, complications, drain injections, re-drainages, follow up imaging, duration of catheter stay and final outcome were retrospectively collected and analyzed. A total of 140 patients underwent image-guided drainage of sigmoid diverticular abscess between Jan 2000 and Dec 2008. Catheters used to drain: 8 fr (23), 10 fr(71), 12 fr(43) and 14 fr (3). Drainage technique: Tandem-Trocar (121); Seldinger (17); Transvaginal (2). Only 1 (0.8%) complication was seen with misplacement of catheter in a bowel loop. Re-drainage was performed in 38 (27.1%) patients. Initial drainage catheter size / re-drainage:- 8 fr/ 6 (26%), 10 fr/18 (25%), 12 fr/13(30%) and 14 fr/1(33%). Catheter injection was performed in 60 patients, of which 31 had abscess-bowel communication and 29 did not. Mean duration of catheter indwelling was more (29.8 days) when there was communication and less (18.2 days) when there was none, which is statistically significant, p<0.02. 22 of 31 patients with bowel communication had surgery and 19 of 29 without bowel communication also had surgery (no statistically significant difference, p=0.86). In the total study group, 85 had surgery, 47 had no surgery, 5 had no follow up details in 5, 1 refused surgery and 2 deceased with catheter in place. 1. Catheter indwelling is prolonged when there is abscess-bowel communication and drain injection should be considered once the patient is clinically stable. 2. Need for surgery is not influenced by the presence of bowel communication. 3. Need for re-drainage is not influenced by the size of the catheter used for initial drainage. 4. Both Tandem-Trocar and Seldinger techniques are safe and effective in draining the abscesses.

We aimed to assess management by interventional radiology techniques of patients with urinary diversion procedures (UD) complicated by urinary obstruction (UO). A 12-year electronic database of interventional cases was searched for urinary access in patients with UD. Patients' records were assessed for aetiology of obstruction, indication for procedure, types of interventional radiology, complications and outcome. Management issues included frequency of visits for catheter care, type of catheter placement and technical problems associated with catheter maintenance. Three hundred and seventy eight procedures were carried out in 25 patients (mean age 70 years; Male : Female ratio 13:12). Indications for UD were malignancy (n = 22) and neuropathic bladder (n = 3). UD included ileal conduits (n = 17), cutaneous ureterostomy (n = 3 (2 patients)) and sigmoid colon urinary conduit (n = 6). In most patients, catheters were placed antegradely through nephrostomy tract, but subsequent access was through the UD. Twenty of 25 patients had unilateral stents where as 5 had bilateral stents (8-10- Fr pigtail catheters (20-45 cm in length)). The mean number of procedures including catheter changes was 15 +/- 4 per patient and 331 of 378 procedures (87 %) were carried out as outpatients. Since catheter placement, 11 patients required hospital admission on 22 occasions for catheter-related complications. Ureteric strictures in patients with UD can be successfully managed by interventional radiology.