Simultaneous pancreas-kidney (SPK) transplantation is a recognized treatment for patients with insulin-dependent diabetes and advanced chronic kidney disease or end-stage renal disease (ESRD), offering significant survival benefits. However, it is associated with a higher risk of venous thrombosis, which can jeopardize the survival of the pancreaticoduodenal graft. This case report describes a patient with type 2 diabetes, hypertension, and ESRD who developed acute, occlusive deep vein thrombosis (DVT) involving the right common femoral, profunda femoral, and greater saphenous veins on postoperative day 1 (POD1) following a deceased donor SPK transplant, despite systemic prophylactic anticoagulation. Subsequent imaging of the transplanted pancreas revealed a nonocclusive thrombus in the splenic vein with extension into the portal vein and intermittent reversal of diastolic flow in the pancreatic arterial Y-graft. Persistent leg swelling and a nonresolving DVT prompted interventional radiology consultation on POD15, leading to successful mechanical thrombectomy and balloon angioplasty of the external iliac vein. The improved venous outflow following the thrombectomy procedure subsequently contributed to the resolution of the pancreatic graft thrombosis. This case underscores the complexity of managing post-SPK transplantation complications and highlights the role of interventional radiology in addressing persistent thrombotic events to preserve graft function and patient outcomes.

The steerable catheter has become an exceedingly popular device in recent years. A systematic review of steerable catheters in endovascular procedures reported a 95.5% technical success rate with no complications. The device is most commonly used in cardiac procedures, including cardiac mapping, ablation, and valve repair. However, outside of case reports and animal studies, there is little data describing use of the device in periphery. The purpose of this study is to characterize the efficacy of steerable catheters in various types of peripheral endovascular procedures. Candidates for this retrospective study included all patients between the ages of 18-95 who have undergone procedures at the GWU Hospital IR department involving a steerable catheter produced by Medtronic/Aptus TourGuide or Morph from September 2017 to September 2020 (n = 29). Procedure details were gathered from our institution’s EMR. Variables of interest included procedure type, fluoroscopy exposure time (min), radiation dose area product (mGycm2), and complexity of the case. Complexity was rated by a board-certified interventional radiologist based on details of the patient note. Average values were calculated within each procedure type. Total weighted averages were calculated to summarize data across procedure types. In this sample for which the steerable catheter was determined to be the optimal intervention, most cases were rated as high complexity (51.72%) or medium complexity (44.83%). By using the steerable catheter, operators were able to achieve an average fluoro time of 33.33 min and average radiation dose area product of 498,594.24 mGycm2. The steerable catheter has demonstrated great success in cardiac procedures, and additionally, it has significant potential for use in endovascular procedures of the periphery. We found that using this device can be considered as a first-line option for various types of medium- tohigh-complexity cases, potentially resulting in shorter procedure time and less radiation exposure.

CT-guided biopsy and ablation procedures are commonly performed for diagnosis and treatment of abdominal tumors. However, targeting soft tissue lesions using low-resolution CT-fluoroscopy can be technically challenging due to limited visualization. The purpose of this study is to assess the accuracy of IGTFusion, an FDA-cleared device capable of performing real-time, nonrigid, multimodal image registration for targeting assistance, in the registration of pre-procedural abdominal CT with intra-procedural CT-fluoroscopy scans. In this IRB-approved study, we reviewed three years of EMR data to identify CT-fluoroscopy-guided biopsy/ablation cases performed at our institution with available pre-procedural diagnostic CT scans. Of 13 such cases, only 3 cases contained clearly visible lesions in both modalities. IGTFusion registration was applied retrospectively to two of these cases, with technical difficulties preventing use of the third case. Percent overlap was measured in Dice Similarity Coefficient (DSC). As both lesions grew between scans, a modified DSC (coverage) was calculated to measure the percent of the registered pre-procedural lesion covered by the intra-procedural lesion. Case 1 was a biopsy and ablation of an exophytic right renal mass. Case 2 was a biopsy of a left lobe hepatic lesion. On average nonrigid registration took 2 seconds to complete with lesion coverage of 75.50% for case 1 and 77.51% for case 2. Nonrigid image registration showed significantly greater lesion overlap compared to rigid registration (paired t-test; P < 0.05). IGTFusion demonstrates improved deformable registration compared to rigid registration and can accurately register volumetric CTs to intra-procedural CT-fluoroscopy images within seconds. This can be incorporated into existing workflows to provide useful visual assistance during percutaneous CT-guided procedures. The main limitation with this validation approach happens to be one that IGTFusion aims to address: i.e., the scarcity of cases containing visible lesions on CT-fluoroscopy. To this aim, future studies are planned to perform validation by anatomic landmarking.

May-Thurner syndrome (MTS) is a venous anatomical abnormality where the right iliac artery compresses the left iliac vein. Magnetic resonance venography (MRV) is often used to diagnose stenosis associated with MTS. While previous studies have hypothesized that MRV may inaccurately estimate the extent of compression in MTS, there is need to clarify the role of MRV in the diagnosis of this disease.1,2 The purpose of this study is to evaluate interobserver variability in diagnosis and classification of MTS by MRV. An IRB-approved retrospective analysis of 33 MRVs performed at The George Washington University Hospital between January 2012 and December 2015 for “left leg swelling” was performed. These studies were evaluated by three board certified interventional radiologists for iliac vein compression on a simple grading scale (“none,” “mild” i.e., 25% stenosis, “moderate” i.e., 50% stenosis, or “severe” i.e., 75% stenosis) in a blinded fashion. Physician ratings were compared to assess provider variation in MRV evaluation. An analysis was then performed to determine the interrater reliability for assessing the degree of compression. 33 MRVs were reviewed in total. On average, the providers agreed 85.86% of the time on the presence of any stenosis. However, the interrater consensus dropped to 44.44% when reporting the degree of stenosis. Fleiss’ Kappa scores were calculated to quantify the interrater reliability on assessing the degree of stenosis. Interestingly, the grading of compression severity had a low interrater reliability (Fleiss’ k = 0.24) demonstrating only fair agreement between providers. While MRV appears reliable in assessing the presence of any stenosis, Fleiss’ Kappa analysis indicates substantial variability in clinical judgement of the degree of stenosis of the left common iliac vein when diagnosing or ruling out MTS. Low interrater reliability of reading MRVs therefore suggests that more definitive diagnostic methods such as catheter venography supplemented with Intravascular Ultrasound (IVUS) may be more accurate to diagnose MTS.

With the rise of the COVID-19 pandemic, interventional radiology (IR) clinics nationwide have adopted a virtual healthcare delivery model. The purpose of this study was to gauge the success of virtual visits at an outpatient interventional radiology practice in Washington, DC and compare the demographics and types of conditions seen before and after the transition to telemedicine. In this IRB-approved retrospective study, appointments scheduled with interventional radiology at an academic tertiary care institution between April 1st, 2019 and July 15th, 2019 were compared with appointments scheduled during the same time frame in 2020. All appointments scheduled in 2019 were in-office visits while all appointments scheduled in 2020 were telemedicine visits. Charts were reviewed for sociodemographic characteristics, types of visits, diagnoses, comorbidities, and scheduled procedures. Descriptive statistics and Pearson's chi-squared tests were used to compare appointments scheduled in 2019 and 2020. Of 180 appointments, 66.6% (n = 100) were scheduled in 2019 and 44.4% (n = 80) were scheduled in 2020. There was no difference in age, age ranges, gender, race distribution, or insurance status between both groups. While a greater percentage of patients presented for oncology-related problems in 2020 than in 2019, the overall difference in presenting problems was not significant (P = 0.13). The percentage of follow-up patients rose from 44.0% in 2019 to 56.3% in 2020 (P = 0.10). Of all telemedicine encounters, 91.3% demonstrated success of establishing a two-way secure audio and video connection with patients. This interventional radiology department cared for similar demographics of patients and case types via telemedicine visits when compared to clinic visits of the same time frame in 2019. While limited by the small sample size, these results indicate that outpatient interventional radiology practices are amenable to transitioning to online-only visits with improved ability to perform longer term follow up.

Objective To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies. Results Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks ( n = 18) and peripheral arteriovenous malformations ( n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days). Conclusion The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

Prostate artery embolization (PAE) has emerged as a promising treatment modality for lower urinary tract symptoms in men secondary to benign prostatic hypertrophy since 2000, when its therapeutic effects were first documented in a case report. Since then, multiple studies have shown the efficacy and safety of PAE. Although transurethral resection of the prostate remains the gold standard, new data from randomized control trials comparing PAE with surgical techniques continues to emerge.

‘In the published article (Salaskar et al. 2018) the statement under the subheading ‘Consent for publication’ is incorrect.

Recent advances in radiation therapy have positioned it as a potentially effective therapy for patients with advanced hepatocellular carcinoma (HCC) who are ineligible for surgery or transplant. Here we compare patterns of care and cause specific survival between two main modalities of RT used for HCC: external beam (EBRT) and radioembolization (RE). Data on 550 HCC patients treated with radiation from 2004-2013 were obtained from the Surveillance, Epidemiology, and End Results (SEER) program database. We calculated cause specific survival (CSS) of HCC patients treated with EBRT vs. RE, at 6, 12 and 24 months. We also examined the influence of factors such as disease stage, age, and race on survival with univariate and multivariate analysis. Regarding race, we combined several ethnicity categories from regions where HBV, a common HCC precursor, is endemic per the CDC (e.g. East/Southeast Asia/ Pacific Islands) for comparison with other ethnic groups. 386 patients were treated with RE and 164 patients were treated with EBRT. The proportion of patients treated with RE in stage II, IIIA and IIIB patients were 70%, 72%, and 54% (p<.001). Among patients with ethnic backgrounds consistent with HBV endemic regions (n=57, 10% of population), the proportion treated with RE was 67%. Median CSS for all patients was 24.4 months, with 25.7 months for 386 patients treated with RE, and 22.1 months for 164 patients treated with EBRT. CSS at 6, 12 and 24 months were 72%, 49% and 30% for EBRT and 78%, 52% and 33% for RE respectively (p=0.17). Median CSS in stage IIIB patients was greater after RE compared to EBRT (16.4 vs 7.5 months, p<.001). However, CSS was similar for RE vs. EBRT for patients with less advanced disease with 33.6 vs 29.8 for stage II and 19.0 vs 17.6 for stage IIIA (p<.001). No significant CSS differences between treatment modalities were observed in race or patient age subgroups. Radioembolization and EBRT have comparable rates of CSS in the overall population. RE may be more favorable in the treatment of stage IIIB disease.

With an aging population acute gastrointestinal bleeding (GIB) requiring hospitalization and treatment continues to rise with an incidence of approximately 36/100,0001. The diagnostic imaging gold standard has historically been radionuclide labeled red blood cell scintigraphy (RBC scan) that has been able to detect bleeding rates as low as 0.1 ml/min2. However, RBC scans have several shortcomings such as preparation and scan time, technologist and equipment availability, and the requirement for relative hemodynamic stability for an extended time period. Additionally, RBC scans cannot identify other mimickers of GIB or provide anatomic detail. Given these limitations, our institution has begun employing triple phase CT angiography (CTA) as the initial, preferred diagnostic test for GIB, thought to have a minimum detectable bleeding rate of 0.35 ml/min3. Our institutional CTA GIB protocol requires no special patient preparation. Scanning is performed through the abdomen and pelvis starting with a non-contrast phase, followed by an arterial phase and finally a five-minute delay scan. As many of these GIB patients are critically ill and trend towards being hemodynamically unstable, the increased availability offered by CT scan is paramount for rapid treatment stratification. Since January 2017, over an 8-month time period, our institution performed a total of 31 RBC scans and 42 CTA GIB scans. The mean turnaround time from test initiation to release of a completed report was 208 minutes for RBC scans and 48 minutes for CTA GIB scans. RBC scans resulted in 38.7% (12/31) positive cases with six going onto catheter directed angiography. Conversely, 23.8% (10/42) of CTA GIB scans were positive and five proceeded to the interventional suite. RBC scans have been part of the diagnostic armamentarium since the 1970s and will continue to have a role in GIB management. However, given the tenuous clinical status of these patients, the speed, accuracy, and ubiquity of CTA will continue to grow. RBC scans and CTA GIB had the same rate (50%) of patients going onto mesenteric angiography. However, our results show that CTA’s reduced turnaround time to definitive therapy greatly impr

The present report describes a case of an Essure device (Bayer, Whippany, New Jersey) that was inadvertently placed in the venous system and migrated to the pulmonary arterial system. The institutional review board did not require approval for this case report.

Purpose: To demonstrate that OPTEASE and TRAPEASE filters can be removed after dwell times greater than 60 days.Materials and Methods: A retrospective review was performed of patients who underwent an attempted removal of a TRAPEASE or OPTEASE filter with a greater than 60-day dwell time between 2009 and 2015 at a single institution. Eleven patients within that time span were identified, and 10 were included in the review. One patient was excluded from the study because the date of filter placement was unknown.Results: All filters were successfully retrieved. The average dwell time for removed TRAPEASE filters was 1,273 days (range, 129-3,582 d), with a median of 492 days (n = 5). The average dwell time for OPTEASE filters was 977 days (range, 123-2,584 d), with a median of 661 days (n = 5). The average dwell time of all filters was 1,125 days (range, 123-3,582 d), with a median of 577 days (n = 10). All patients exhibited inferior vena cava (IVC) stenosis after filter retrieval. An IVC pseudoaneurysm was present following retrieval in one case and resolved. In one case, a fractured filter strut was left completely embedded in the caval wall. Two patients reported unilateral leg swelling on clinical follow-up, and the remainder reported no leg swelling or tightness.Conclusions: Initial experience suggests that TRAPEASE and OPTEASE filters can be removed after extended dwell times.

Vascular closure devices (VCDs) are used to obtain hemostasis at the vascular access site while limiting the need for manual compression. They have gained significant popularity since their introduction in the mid-1990s. In the past 20 years, there has been a multitude of different devices introduced with various mechanisms of action. Manual compression remains the gold standard but can be very time consuming and painful for the patient. VCDs are advantageous in that they can reduce time to hemostasis and patient recovery and improve patient comfort. However, a large number of catheter-based procedures are performed without these closure devices owing to lack of operator familiarity, risk of complications, and cost. Most VCDs are approved for arteriotomies between 5 and 8F, with 1 device approved for up to 21F. Major complications include infection and limb ischemia. This article provides an update on currently approved VCDs, a brief overview of the literature, and our institutional experience with these devices.

Endometrial stromal sarcoma metastases usually occur within the pelvis and rarely involve the great vessels or the heart. We present the case of a 55-year-old woman who was referred for endovascular therapy to treat presumed thrombosis of the inferior vena cava. The suspected thrombus was recalcitrant to endovascular removal with use of an AngioVac venous drainage device. Results of an intraprocedural transvenous biopsy revealed the mass to be the intravascular extension of an endometrial stromal sarcoma. The patient underwent surgical excision of the tumor, and, shortly thereafter, a hysterectomy and salpingo-oophorectomy. This complex case highlights both the rarity of malignancy masquerading as caval thrombus and the importance of multispecialty collaboration.

The insulin‐like growth factor‐1 (IGF‐1) signaling pathway plays an important role in the pathology of Ewing sarcoma (ES). Retrospective studies have suggested that levels of IGF‐1 and IGF binding protein 3 (IGFBP‐3) are correlated with the outcome of patients with ES.

The insulin-like growth factor (IGF) family consists of ligands (IGF-I, IGF-II, insulin), several receptors (including IGF-1R), and six binding proteins (IGFBP-1 through IGFBP-6). Members of this family regulate key cellular activities and they also play an important role in the development and progression of both adult and childhood cancers. Binding of a ligand to the receptor leads to its activation, followed by signal transduction along several pathways. In some childhood malignancies, IGF-1R can be activated by endocrine, autocrine, or paracrine mechanisms. Although mutations in IGF-1R have not been identified, this signaling pathway is upregulated in many childhood cancers. These findings have led to the development of a host of IGF-1R signaling modulators that are currently being tested in clinical trials. This review explores the role of IGF-1R in a range of childhood malignancies.