There are many challenges associated with the safe use of fluoroscopy. These challenges include but are not limited to highly variable regulatory requirements, scope of practice concerns, inconsistent education and training, and lack of staff empowerment. Challenges are further compounded by the increasing use of fluoroscopy across a wide range of medical specialties. To facilitate consensus on how to address the issues, the ACR convened the multidisciplinary Blue Ribbon Panel on Fluoroscopy Safety (BRP-FS), with 32 organizations represented. The goal of the BRP-FS is to establish multi- and interspecialty consensus standards for the safe use of fluoroscopy in health care, including minimum and uniform standards for the education and training of fluoroscopy users that apply across geographic and professional boundaries, for the benefit of all patients and health care providers. Recommendations are made for local practices, professional organizations, industry, regulatory agencies, and accreditation bodies. Foundational to the recommendations of the BRP-FS are the personnel training and procedure classification frameworks in National Council on Radiation Protection and Measurement Commentary No. 33.

Management of portal hypertension (PHTN) in pediatric patients presents challenges due to the smaller anatomy and a lack of standardized protocols. While evidence for endovascular management of ectopic varices, maintenance of surgical shunts, portal venous recanalization, and percutaneous portosystemic shunt creation in children grows, adaptation requires specialized techniques and equipment. This review explores the etiologies of pediatric PHTN, including Budd-Chiari syndrome, congenital anomalies, extrahepatic portal vein obstruction, and transplant vascular occlusions, and examines radiologic interventions to address these conditions. Management strategies are divided into relieving the primary cause of PHTN at the level of portal obstruction and managing the secondary effects of PHTN. For each category, the discussion focuses on device selection, postprocedural care, imaging surveillance, and management of pediatric scenarios.

Hepatic venous outflow obstruction (HVOO) is a complication of orthotopic liver transplantation (OLT). This study reported efficacy and safety of bifurcated hepatocaval stent reconstruction for treatment of anastomotic stenoses in OLT. Eight OLT recipients with symptomatic HVOO (6 males; mean age 57.6 ± 7.6 years; range: 48-69 years) underwent combined inferior vena cava (IVC) and hepatic venous (HV) bifurcated T-stent placement between 2004 and 2019. Mean interval from OLT to intervention was 58.6 ± 96.2 months (range: 0.8-265.6 months). Indications included refractory ascites (n = 7; 87.5%), liver function abnormalities (n = 4; 50.0%), and hepatic hydrothorax (n = 1; 12.5%) in the setting of hepatocaval anastomotic stenoses diagnosed on Doppler ultrasound (n = 7; 87.5%) or computed tomography (n = 1; 12.5%). Success, adverse events, and stent patency were assessed. Technical success was defined as intended bifurcated hepatocaval stent placement. Clinical success was defined as improvement of presenting symptoms. All patients underwent technically successful bifurcated hepatocaval stent reconstruction with supra/intrahepatic IVC stent (Wallstent, Wallflex, or Gianturco Z-stent) placement followed by HV stent (Venovo, Smart, or Wallstent) placement through the interstices of the IVC stent. Mean number of stents placed in each patient was 2.3 ± 0.5 (range: 2-3), with mean IVC stent diameter of 22.6 ± 4.7 mm (range: 14-30 mm) and mean HV stent diameter of 12.4 ± 2.2 mm (range 10-16 mm). No IVC stent migrations occurred. One HV stent migration occurred 18 days after placement, requiring retrieval from within the IVC stent and replacement (major adverse event; category D). One patient died 66 days after intervention due to graft rejection. In six (75.0%) patients, clinical success was achieved at a mean time of 41 ± 28.4 days (range: 7-91 days). For the remaining two (25.0%) patients, repeat intervention was performed within two months due to lack of clinical response, including angioplasty (n = 2) and additional IVC stent placement (n = 1) for in-stent stenoses. All stents were patent at the last follow-up (mean: 2126 days; range: 32-4846 days). The bifurcated T-stent reconstruction offers safe and effective therapy for HVOO with anastomotic stenoses in OLT. The interlocking stent construct may offer advantages in treating complex stenosis involving the hepatocaval junction while minimizing the risk of stent migration or jailing of HV outflow by an IVC stent.

This study investigated the effectiveness of portal interventions on refractory chylous ascites or chylothorax related to portal hypertension. After institutional review board approval, a single-center retrospective review identified 10 patients from 2011 to 2023 who underwent portal interventions (8 transjugular intrahepatic portosystemic shunt creation and 2 portal vein recanalization) for documented chylous ascites (n = 8) or chylothorax (n = 2). Procedural details, clinical data, and chylous fluid volumes were recorded. Descriptive statistics and paired t-testing were used. Technical success was 100% with a median reduction of portal pressure gradient by 7.5 mm Hg. In 5 patients (50%), the chylous ascites or chylothorax resolved within 30 days of the intervention. All patients (n = 10) had decreased weekly fluid volume production after intervention (64% mean reduction, P < .001). Median time to last paracentesis or thoracentesis was 54 days. No moderate or severe adverse events occurred. In the setting of refractory chylous ascites or chylothorax associated with portal hypertension, decompressive portal interventions are safe and clinically effective.

Pediatric ultrasound (US)-guided percutaneous liver biopsy is a commonly performed procedure in children, and may be performed in a variety of clinical settings. However, there is little research on the relative costs associated with different sedation methods and locations. This study uses time-driven activity-based costing (TDABC) to identify relevant costs associated with different biopsy sedation techniques and locations to help inform providers and patients as well as guide value-conscious care. This study analyzes the direct costs associated with pediatric liver biopsy performed in an OR versus a dedicated pediatric sedation clinic. A single-center retrospective review including data from consecutive procedures all completed by one board-certified interventional radiology physician between June 2021 and April 2024 was performed. Exclusion criteria included procedures with lack of timestamps (N = 3), and multiple procedures being completed causing a deviation from the standard pathway process (N = 19). Direct costs were calculated using cost capacity rates (CCR) and TDABC methodology. Propensity score matching between procedures performed in a sedation clinic versus an operating room (OR) was performed adjusting for age, gender, American Society of Anesthesiologists (ASA) status, and inpatient status, and subsequent matches were analyzed via paired t-test in SPSS. A total of 111 procedures performed in the OR (N = 71) or sedation clinic (N = 40) were found and considered for analysis (N = 55 male, N = 56 female; mean age = 9.13, SD = 6.69 years). A technical success rate of 100

To describe the use of a large-bore mechanical aspiration system (FlowTriever Aspiration Catheter) as an off-label intervention for the evacuation of complex intra-abdominal abscesses that were refractory to standard percutaneous drainage techniques. Two patients with large, complex intra-abdominal abscesses underwent aspiration using the FlowTriever Aspiration Catheter following failure of conventional catheter drainage. One patient had a walled-off necrotic collection from necrotizing pancreatitis; the other developed a postoperative abscess following appendectomy for perforated appendicitis. In each case, tract dilation was performed to accommodate the large-bore aspiration catheter, and follow-up CT imaging was used to assess treatment response. In both cases, the FlowTriever Aspiration Catheter enabled high-flow aspiration of solid and purulent material, with successful placement of large-bore drainage catheters. Follow-up imaging demonstrated marked reduction or near-complete collapse of the abscess cavities. No procedure-related complications were observed. Large-bore mechanical aspiration with the FlowTriever Aspiration Catheter may offer an effective adjunct or alternative to catheter upsizing and fibrinolytic therapy in patients with complex intra-abdominal abscesses, particularly when standard drainage techniques are unsuccessful. This approach may reduce the need for repeat interventions or surgical debridement in appropriately selected patients.

Percutaneous mechanical thrombectomy (PMT) has emerged as a prominent treatment option for venous thromboembolism, offering advantages over catheter-directed thrombolysis and anticoagulation therapy, such as reduced bleeding risk and faster thrombus resolution. PMT devices operate through three main mechanisms: aspiration to directly extract thrombi, mechanical fragmentation to break thrombi into smaller pieces, and rheolytic disruption using high-pressure saline jets to dislodge and remove thrombi. This review summarizes the modern PMT device landscape, technical specifications, and indications while exploring extended and off-label uses and highlighting its expanding clinical applications.

Endovascular stenting is widely accepted as the standard treatment for central venous obstruction syndromes such as superior vena cava (SVC) syndrome due to its demonstrated clinical efficacy and improved patient outcomes. However, its application in axillosubclavian vein thrombosis (ASVT) has been limited due to concerns about stent compression within the thoracic outlet. This report aims to evaluate the feasibility and safety of the off-label use of dedicated venous stents—engineered with enhanced mechanical features—as an alternative endovascular approach for the treatment of ASVT. Thirty-eight patients (43 affected limbs) with symptomatic ASVT and no prior treatment or surgical decompression underwent endovascular placement of dedicated venous stents across the thoracic outlet with Abre Venous Stents (Medtronic, Dublin, Ireland), Venovo Venous Stents (BD, Franklin Lakes, NJ, USA), or Vici Venous Stents (Boston Scientific, Marlborough, MA, USA). Stents were extended peripherally to the subclavian or axillary veins and centrally to the brachiocephalic vein or SVC. Technical success was defined as successful stent deployment across the costoclavicular space, and clinical success as symptomatic improvement. Stent placement was technically successful in all 43 limbs (100

Thoracic central vein obstruction (TCVO) refers to occlusive disease of the thoracic central veins leading to compromised venous return from the head, neck, chest, and upper extremities to the right atrium. TCVO has benign and malignant causes and involves intraluminal, intramural, or extravascular obstruction. TCVO is the preferred term to describe the anatomic and/or pathologic process; however, the clinical manifestations (and historically, the anatomic description) are commonly referred to as superior vena cava syndrome. Diagnostic evaluation of patients with suspected TCVO starts with US or venography (ie, typically MR or CT venography but possibly catheter-directed or conventional venography). Treatment of TCVO has evolved, with endovascular therapy emerging as the preferred treatment option to alleviate symptoms rapidly and safely. Endovascular recanalization techniques include thrombectomy, thrombolysis, and blunt or sharp recanalization. Endovascular reconstruction can be performed by means of placement of stents or stent-grafts. Antiplatelet and anticoagulant agents may be used after recanalization and reconstruction to improve patency rates or to treat deep vein thrombosis. Overall, technical and clinical success rates are high and major adverse events are rare, occurring in 1%-2% of patients. ©RSNA, 2025 Supplemental material is available for this article.

This pictorial review provides a comprehensive visual and textual overview of interventional radiology approaches in treating complicated appendicitis and other abdominal abscesses in children. This review discusses the incidence and complications associated with appendicitis in pediatric patients, highlighting the role of percutaneous drainage in managing appendicitis with abscesses. We present common mimics of intra-abdominal abscesses from other diseases such as tubo-ovarian abscesses, inflammatory bowel disease, and lymphomatous bowel involvement, emphasizing imaging pitfalls that can mimic appendiceal abscesses. The review also covers interventional radiology considerations, including antibiotic indications, local anesthesia considerations for children, the comparison between percutaneous and endocavitary approaches, and the roles of fibrinolytics are discussed here. Detailed discussions on catheter selection and insertion techniques, such as Seldinger and trocar, are provided along with post-procedure management strategies. These include drain maintenance, navigating drain associated complications, and determining when to remove the drain. Through high-quality images and concise descriptions, we illustrate procedural intricacies and clinical scenarios encountered in practice, offering a valuable educational resource for clinicians managing pediatric abscesses.

BACKGROUND:The Protrieve Sheath (Inari Medical; Irvine, CA) is a thromboembolic protection device for venous thrombectomy. An extended feasibility study was conducted for device use in deep vein thrombectomy and inferior vena cava (IVC) filter removal. METHODS:Twenty-two patients, including 12 (55.5%) females and 10 (45.5%) males (mean age 55.8 ± 13.9 years, range 28-81 years), underwent deep venous thrombectomy using the Protrieve Sheath for embolic protection between November 2022 and July 2024 (21 months). The Food and Drug Administration-approved modified sheath contains an extendable nitinol mesh for large vessel thrombectomy outside the heart including the extremities, ileocaval, IVC, and superior vena cava. The following demographic information was recorded: presenting symptoms, procedural indications, obstructed venous segments, Protrieve Sheath access and deployment sites, thrombectomy devices utilized (ClotTriever, Inthrill, Lightning Flash 16, RevCore), need for stent reconstruction, technical success, clinical success, procedural complications related to device access and deployment, clinically significant embolic events, procedure-related injury, hematoma, mortality, death, and removed thrombi histological analyses. Technical success was defined as successfully deploying the Protrieve Sheath funnel proximal to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism. All patients were followed with bilateral lower extremity duplex ultrasounds and computed tomography venogram abdomen and pelvis at 1 month, 3 months, 6 months, and 12 months. Patients were seen in clinic at 1 month, 3 months, 6 months, and 12 months. RESULTS:The most common presenting symptom was extremity swelling (n = 19; 86.4%). Nine (40.9%) patients had malignant, and 13 (59.1%) had benign etiologies of venous obstruction. Of the 9 patients with malignancy, 5 were determined to be tumor thrombus on histological analysis (n = 5, 55.5%). Obstructed venous segments included the IVC and lower extremity (n = 13; 59.1%), isolated lower extremity (n = 4; 18.2%), isolated IVC (n = 3; 13.6%), thoracic central veins and superior vena cava (n = 1; 4.5%), and isolated thoracic central vein (n = 1; 4.5%). The Protrieve Sheath access sites included the right internal jugular vein (n = 20; 90.9%) for IVC and lower extremity obstructions and the right common femoral vein (n = 2; 9.1%) for thoracic central vein and superior vena cava obstructions. The Protrieve Sheath funnel deployment locations included intrahepatic IVC in 18 patients (n = 13; 81.8%), suprarenal IVC in 2 (n = 2; 9.1%), and superior cavoatrial junction in 2 (n = 2; 9.1%). Ten (45.5%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 21 (95.5%) patients. No immediate device-related adverse events including mesh maldeployment of the Protrieve Sheath, hemorrhage, or clinically significant embolic events occurred. CONCLUSION:Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events. These results suggest further implementation and investigation of the devices use in complex large vessel thromboembolic disease. Comparative studies to standard technique can better quantify the potential benefits of this device.

PURPOSE:Endovascular recanalization and stent reconstruction constitute an effective and safe treatment option for symptomatic thoracic central venous obstruction (TCVO). Rare life-threatening adverse events are possible during or immediately following the procedure, with the most feared one being hemopericardium with cardiac tamponade. A technique to improve efficiency in detection and treatment of cardiac tamponade is described. MATERIALS AND METHODS:An institutional protocol was established for intraprocedural transthoracic echocardiographic monitoring during the TCVO recanalization procedures. The lower chest and upper abdomen were prepared within the sterile field. A separate stand was set up with unopened supplies needed for pericardial drain placement. Intermittent echocardiographic monitoring was performed throughout the TCVO procedure using a dedicated curvilinear probe prepared on the field. If indicated, an image guided pericardial drain was placed expeditiously. RESULTS:Four cases of cardiac tamponade were encountered during or immediately post-procedure. All cases demonstrated technically successful and prompt pericardial drain placement with immediate reversal of the tamponade physiology. CONCLUSION:Echocardiographic monitoring during TCVO reconstruction by interventional radiologists is a useful technique which may aid in early diagnosis and management of cardiac tamponade.

Following a review of spinal muscular atrophy pathogenesis and current therapeutics, a comprehensive review of transforaminal lumbar injections is provided. Patient preparation, special considerations, procedural technique, complications, and alternative approaches are discussed.

PURPOSE:To evaluate access site adverse events following ClotTriever-mediated large-bore mechanical thrombectomy via small upper extremity deep veins (< 6-mm). MATERIALS AND METHODS:Twenty patients, including 24 upper extremity venous access sites, underwent ClotTriever-mediated large-bore thrombectomy of the upper extremity and thoracic central veins for symptomatic deep vein obstruction unresponsive to anticoagulation. Patients without follow-up venous duplex examinations (n = 3) were excluded. Patients who had > 6-mm diameter veins accessed (n = 3) were excluded. Temporary purse-string sutures and manual pressure were used for access site hemostasis in all patients. Vein access site and diameter, technical success (defined as placement of the 13.5-French ClotTriever sheath followed by thrombectomy), and early (< 30-days) and late (> 30-days) access site-related adverse events (according to the Adverse Event Classification by the Society of Interventional Radiology criteria) were recorded. RESULTS:Fourteen patients (8 males, 6 females; mean age 51.7 ± 13.6 years) comprising 16 upper extremity venous access sites were included in this study. Access sites included: right brachial (n = 7), left brachial (n = 5), and bilateral brachial (n = 2) veins. The mean access site diameter was 4.3-mm ± 0.67-mm. Technical success was achieved via all access sites. Six (42.9%) patients underwent stent reconstruction following thrombectomy through the same accesses. After the procedure, all purse-string sutures were removed within 24 h. Three (21.4%) patients experienced small access site hematomas that did not require transfusion, intervention, or prolonged hospitalization. Initial follow-up venous duplex ultrasounds were performed at 29.3 ± 21.7 days following intervention. The mean follow-up interval to the second and third venous duplex ultrasounds were 124.3 ± 64-days and 225.1 ± 80.1 days, respectively. One (7.1%) patient developed right arm swelling six days after the procedure and was found to have thrombosis of the previously accessed right brachial vein. No other clinically or sonographically significant access site adverse events were observed. CONCLUSION:ClotTriever-mediated large-bore thrombectomy via small upper extremity veins is safe with minimal access site adverse events.

Bifid ribs are rare congenital anomalies, usually asymptomatic and discovered incidentally on imaging. However, they can cause significant pain, posing diagnostic and therapeutic challenges, particularly in pediatric populations. We report a case of a 3-year-old female with chronic anterior chest wall pain attributed to a bifid right fourth rib. Imaging confirmed the anomaly without associated soft tissue masses. After transient symptom relief with lidocaine patches and intercostal nerve blocks, she underwent successful percutaneous image-guided cryoneurolysis of the right third to fifth intercostal nerves. The patient experienced marked pain relief post-procedure without complications, with sustained benefit at 4 months. Bifid ribs may be an under-recognized cause of intercostal neuralgia in children. Image-guided percutaneous cryoneurolysis may represent a safe and effective treatment option for symptomatic relief.

PURPOSE:The aim of this study was to assess diversity within integrated interventional radiology (IR) residency programs. METHODS:The annual Association of American Medical Colleges Report on Residents, an observational cross-sectional study, was accessed from 2018 through 2023 to extract demographic information (gender, race, and type of medical school) on the various residency programs, including integrated IR. Demographic data were compared among different specialties using the χ2 test, with a significance level of P < .05. RESULTS:In 2023, integrated IR ranked 20th, 21st, and 19th out of the 21 specialties assessed for the representation of women, black, and Hispanic residents, respectively. The proportion of women increased from 20% in academic year (AY) 2018-2019 to 22.3% in AY 2022-2023. The percentage of black residents increased from 2.2% in AY 2019-2020 to 3.8% in AY 2022-2023, whereas that of Hispanics decreased from 7.1% to 6.6%. Additionally, the percentage of American Indians and Alaska Natives decreased from 0.8% to 0.7%, whereas that of Native Hawaiians and Pacific Islanders increased from 0% to 0.1%. CONCLUSIONS:Diversity in integrated IR residency is one of the lowest among the medical specialties and has progressed minimally. A concerted effort to increase awareness and inclusion in the specialty would broaden its appeal and may eventually improve its availability.

Rationale and Objectives: To evaluate moral injury (MI) among interventional radiologists using validated assessment tools. Materials and Methods: An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale-Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score >= 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests. Results: Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 +/- 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 +/- 17.0 vs. 76.6 +/- 16.0; P < 0.05). 223 (61.1%) respondents scored >= 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 +/- 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 +/- 9.6 vs. 28.0 +/- 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement. Conclusion: MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.