Over recent decades, optical imaging (OI) has become an integral part of medical imaging, offering significant advantages over other modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI). OI is distinguished by its real-time imaging capability, cost-effectiveness, portability, absence of ionizing radiation, and high patient acceptability. The introduction of advanced optical dyes (including FDA-approved agents like indocyanine green, Cytalux, and Gleolan) has greatly enhanced its clinical utility. OI has shown clear benefits in the management of patients with cancer, originally by open surgery and now extending to minimally invasive, image-guided interventional procedures. This review highlights recent developments in OI for oncology, emphasizing its benefits for clinicians in guiding surgical and interventional procedures.

Endovascular intervention is a safe, effective treatment modality in the management of diverse pulmonary vascular pathologies, including acute or chronic thromboembolic disease, pulmonary arteriovenous malformations (pAVMs), pulmonary artery or bronchial artery hemorrhage, and foreign body retrieval. This article reviews indications, contraindications, techniques, and outcomes in endovascular management of common pulmonary vascular pathologies, with the goal of improving operator familiarity and facility with these procedures.

LEARNING OBJECTIVES:Review the history of debriefing and provide an Interventional Radiologist (IR) specific framework for leading an effective debrief.BACKGROUND:A debrief is often regarded as a meeting with persons who were involved in a stressful, traumatic and/or emotionally challenging situation to review processes, communicate concerns or gather feedback. The goals of these sessions can be for learning/quality improvement (QI) or psychological/emotional support, or a mix of both. Debriefing after tough situations has become a standard tool of many medical specialties, such as surgery, critical care and emergency medicine, with specialty specific literature available. However, there is a paucity of Interventional Radiology specific literature available for debriefing techniques.CLINICAL FINDINGS/PROCEDURE DETAILS:We will review the history and types of debriefing and why a debrief could be considered. We will provide a framework for leading a successful debrief in Interventional Radiology.CONCLUSION:Debriefing can be a useful tool for learning and QI as well as psychological or emotional support after a challenging or tough situation. Debriefing can address multiple variables and can stylistically be tailored to suit specific needs. IRs have an opportunity to take a leadership role in debriefing, providing comfort and quality improvement through communication and support.

PurposeInferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures.Materials and methods252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions.ResultsMean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters.ConclusionLarger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

The roster of the greatest advances in the history of medicine usually includes vaccines, anesthesia, germ theory and antibiotics, X-ray imaging, and, most recently, stem cell therapy and immunotherapy. Perhaps interventional medicine does not make the cut, but its sweeping impact on human health over the last 50 years has been staggering and undeniable ( 1 Mueller R.L. Sanborn T.A. The history of interventional cardiology: cardiac catheterization, angioplasty, and related interventions. Am Heart J. 1995; 129: 146-172 Crossref PubMed Scopus (148) Google Scholar ). All of these procedures have one thing in common—a way to gain access to the body with a needle, a wire, and a catheter. This simple but ingenious technical invention was the brainchild of Sven Ivar Seldinger, a Swedish doctor born 100 years ago this year (Fig). His brilliant discovery transformed the practice of medicine throughout the world.

I am so very honored to be giving the Charles Dotter Lecture this year. First, I want to thank Laura Findeiss for the kind invitation some 18 months ago, although I never could have imagined at the time that I would be giving it from the comfort of my own home. Furthermore, I want to thank the Annual Meeting Committee for moving the talk that never happened to this year’s program. Finally, I want to recognize my faculty colleagues and the hundreds of interventional radiology (IR) fellows and residents whom I have worked with at the University of California, San Diego, and the University of Washington here in Seattle over the last 30 years. You have been my inspiration through this incredibly rewarding career. I believe you will all agree that we work in a fantastic specialty. I have not forgotten what my mentor, Joe Bookstein, once jokingly said to me about being an interventional radiologist: “I can’t believe they pay us to do this!”

Optical imaging (OI) provides real-time clinical imaging capability and simultaneous molecular, morphological, and functional information of disease processes. In this study, we present a new interventional OI technique, which enables in vivo visualization of three distinct pathologic zones of ablated tumor periphery for immediate detection of residual tumors during a radiofrequency ablation (RFA) session. Rabbits with orthotopic hepatic tumors were divided into two groups (n = 8/group): incomplete RFA and complete RFA. Indocyanine green-based interventional OI was used to differentiate three pathological zones: ablated tumor, transition margin, and residual tumor or surrounding normal liver-with quantitative comparison of signal-to-background ratios among the three zones and between incompletely and completely ablated tumors. Subsequent ex vivo OI and pathologic correlation were performed to confirm the findings of interventional OI. Interventional OI could differentiate incompletely or completely ablated tumor peripheries, thus permitting identification of residual tumor. This technique may open new avenues for immediate assessment of tumor eradication during a single interventional ablation session. Significance: Interventional optical imaging can instantly visualize pathologic zones of ablated tumor peripheries to detect residual tumors, which could revolutionize current image-guided interventional oncologic ablation techniques.

Background Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure. Case presentation This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days. Conclusions TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

Abstract Purpose To quantify and categorize fluoroscopically-guided procedures with radiation doses exceeding 5000 mGy reference point air kerma (Ka,r). Ka,r > 5000 mGy has been defined as a “significant radiation dose” by the Society of Interventional Radiology. Identification and analysis of interventions with high radiation doses has the potential to reduce radiation-induced injuries. Materials and methods Radiation dose data from a dose monitoring system for 19 interventional suites and 89,549 consecutive patient encounters from January 1, 2013 to August 1, 2019 at a single academic institution were reviewed. All patient encounters with Ka,r > 5000 mGy were included. All other encounters were excluded (n = 89,289). Patient demographics, medical specialty, intervention type, fluoroscopy time (minutes), dose area product (mGy·cm2), and Ka,r (mGy) were evaluated. Results There were 260 (0.3%) fluoroscopically-guided procedures with Ka,r > 5000 mGy. Of the 260 procedures which exceeded 5000 mGy, neurosurgery performed 81 (30.5%) procedures, followed by interventional radiology (n = 75; 28.2%), neurointerventional radiology (n = 55; 20.7%), and vascular surgery (n = 49; 18.4%). The procedures associated with the highest Ka,r were venous stent reconstruction performed by interventional radiology, arteriovenous malformation embolization performed by neurointerventional radiology, spinal hardware fixation by neurosurgery, and arterial interventions performed by vascular surgery. Neurointerventional radiology had the highest mean Ka,r (7,799 mGy), followed by neurosurgery (7452 mGy), vascular surgery (6849 mGy), and interventional radiology (6109 mGy). The mean Ka,r for interventional radiology performed procedures exceeding 5000 mGy was significantly lower than that for neurointerventional radiology, neurosurgery, and vascular surgery. Conclusions Fluoroscopically-guided procedures with radiation dose exceeding 5000 mGy reference point air kerma are uncommon. The results of this study demonstrate that a large proportion of cases exceeding 5000 mGy were performed by non-radiologists, who likely do not receive the same training in radiation physics, radiation biology, and dose reduction techniques as radiologists.

Almost 40 years after the first published reports, percutaneous balloon angioplasty (PTA) remains the fundamental endovascular means for restoring patency of dialysis fistula and grafts.[1] Evolution of technology, such as the development of very high-pressure balloons and cutting balloons, has improved overall technical success of the procedure. Still, long-term patency remains modest. The U.S. National Kidney Foundation Dialysis Outcomes Quality Initiative (K-DOQI) guidelines set a target of 6-month primary patency after balloon angioplasty in the venous outflow of dialysis grafts of only about 40 to 50%.[2] And once angioplasty has been done, the stenotic process is accelerated in many patients, leading to recurrent obstruction and sometimes complete thrombosis in a short period of time. Despite decades of research into the mechanisms underlying restenosis and potential means to combat the problem (whether systemic or directed therapy at the treatment site), significant advances have remained elusive. However, two devices that have emerged in the last decade are worthy of careful consideration by interventional radiologists (IRs).

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ©RSNA, 2018.

This issue of Digestive Disease Interventions addresses a variety of diseases that fall under the broad rubric of mesenteric vascular disorders. The topics range from common conditions such as intestinal ischemia and bleeding to unusual entities like middle aortic syndrome. The papers focus on clinical presentations, diagnostic methods, and appropriate endovascular and open surgical treatment options. Our intended audience is broad, including diagnostic and interventional radiologists as well as gastroenterologists and surgeons who manage these often difficult clinical situations. Apart from the few articles that review frequently encountered diseases, a general theme of the collection is mesenteric vascular diseases that are often diagnostically challenging. These entities may only be seen sporadically in general practice but often require specific (and sometimes urgent) invasive treatment by vascular specialists. In that situation, understanding the current “state-of-the-art” is critical. Even the experienced practitioner can fall into the trap of not recognizing a rare disease based on the mindset of “common things being common.” It can be humbling to miss a rare diagnosis that, in retrospect, seems so obvious to all. We are proud to collaborate with several highly regarded experts in the field and are grateful for the invitation to collect this work in Digestive Disease Interventions.

Purpose: To compare peristomal infection rates following percutaneous gastrostomy (PG) after a single dose of prophylactic antibiotics versus placebo and evaluate rates of peristomal infection in patients receiving concurrent antibiotics. Materials and Methods: This single-center, randomized trial (2012-2016) enrolled 122 patients referred for image-guided PG; all enrolled patients completed the study. Of enrolled patients, 68 were randomly assigned to receive either antibiotics (n = 34) or placebo (n = 34) before PG placement. The remaining 54 patients were taking pre-existing antibiotics and were assigned to an observation arm. Stoma sites were assessed for signs of infection by a blinded evaluator at early (between 3-5 d and 7-10 d) and late (between 14-17 d and 28-30 d) time points after the procedure. The primary outcome was peristomal infection. Results: Under intention-to-treat analysis, early infection rate was 11.8% (4/34 patients; 95% CI, 0.0%-9.4%) in the placebo arm and 0.0% (0/34 patients; 95% CI, 0.0%-8.4%) in the antibiotic arm (P =.057 for comparison of infections in the 2 arms). Under per-protocol analysis, early infection rate was 13.3% (4/30 patients; 95% CI, 4.4%-29.1%) in the placebo arm and 0.0% (0/32 patients; 95% CI, 0.0%-8.9%) in the antibiotic arm (P =.049). The number needed to treat to prevent 1 early infection was 8.5 and 7.5 from the 2 analyses, respectively. Conclusions: There is a trend toward reduction in rate of peristomal infection after PG when prophylactic antibiotics are administered.

Endocrinopathies are a heterogeneous group of disorders often resulting from pathologic sources of hormone production. When the clinical scenario, laboratory testing, and noninvasive imaging fail to aid confident identification of the source of hormone excess, endocrine venous sampling may localize obscure lesions to guide subsequent treatment. Knowledge of basic hormone signaling pathways, common pathophysiologic disruptions of these pathways, and serologic evaluation fosters informed conversations with referring physicians and effective patient selection. Success in the angiography suite requires familiarity with normal and variant anatomy of the multiple organs of the endocrine system, patient preparation, stimulation and sampling techniques, specimen handling, and results interpretation. ©RSNA, 2017.

Purpose: To characterize the unique experiences, values, and perspectives of interventional radiology (IR) fellows.Materials and Methods: Sixteen fellows from 4 US vascular and IR programs were interviewed within 2 months of beginning and 2-3 months following their 2015-2016 fellowships about patient interactions, training experiences, and views of IR and other specialties. Interviews were systematically analyzed for dominant themes by using constructivist grounded theory. Four interviews with 2015-2016 interventional cardiology fellows,. 16 interviews with IR attending physicians, and online descriptions of IR were also analyzed for context. Themes were compared qualitatively and quantitatively.Results: Interobserver agreement was good for interview themes (kappa = 0.70; P < .0001). IR fellows' professional identity emerged primarily from radiologic and surgical interests, with distinct emphasis On-being "innovators," "thinking differently," and "needing to adapt and advertise abilities to survive." Fellows' descriptions of patient care were more clinically focused than past interviews-with attending physicians (P = .05), but clinical interests common in medical specialties were limited, and descriptions of "nonprocedural patient care" were primarily periprocedural (81%). Descriptions of the future of the field conveyed competing pressures, loose role definition, and disconnect between academic and private-practice IR.Conclusions: IR fellows share professional interests, views of their field and others, and descriptions of patient care, but there is uncertainty regarding future roles of the specialty and a need for more specific and unified definitions of nonprocedural patient care in TR.

Purpose To determine the feasibility of using intraesophageal radiofrequency (RF) hyperthermia to enhance local chemotherapy in a rat model with orthotopic esophageal squamous cancers. Materials and Methods The animal protocol was approved by the institutional animal care and use committee and the institutional review board. Human esophageal squamous cancer cells were transduced with luciferase lentiviral particles. Cancer cells, mice with subcutaneous cancer esophageal xenografts, and nude rats with orthotopic esophageal cancers in four study groups of six animals per group were treated with (a) combination therapy of magnetic resonance imaging heating guidewire-mediated RF hyperthermia (42°C) plus local chemotherapy (cisplatin and 5-fluorouracil), (b) chemotherapy alone, (c) RF hyperthermia alone, and (d) phosphate-buffered saline. Bioluminescent optical imaging and transcutaneous ultrasonographic imaging were used to observe bioluminescence signal and changes in tumor size among the groups over 2 weeks, which were correlated with subsequent histologic results. The nonparametric Mann-Whitney U test was used for comparisons of variables. Results Compared with chemotherapy alone, RF hyperthermia alone, and phosphate-buffered saline, combination therapy with RF hyperthermia and chemotherapy induced the lowest cell proliferation (relative absorbance of formazan: 23.4% ± 7, 44.6% ± 7.5, 95.8% ± 2, 100%, respectively; P < .0001), rendered the smallest relative tumor volume (0.65 mm3 ± 0.15, P < .0001) and relative bioluminescence optical imaging photon signal (0.57 × 107 photons per second per square millimeter ± 0.15, P < .001) of mice with esophageal cancer xenografts, as well as the smallest relative tumor volume (0.68 mm3 ± 0.13, P < .05) and relative photon signal (0.56 × 107 photons per second per square millimeter ± 0.11. P < .001) of rat orthotopic esophageal cancers. Conclusion Intraesophageal RF hyperthermia can enhance the effect of chemotherapy on esophageal squamous cell cancers. © RSNA, 2016.