Background:Estimation of the lung shunt fraction (LSF) is an integral part of liver radioembolization treatment planning to prevent excessive lung irradiation from arterio-venous shunting in the liver. 99mTc macro-aggregated albumin (99mTc-MAA) nuclear imaging is the standard method. Recent literature suggests that 99mTc-MAA nuclear imaging may be omitted in selected patient populations. Purpose:This study investigates the potential of contrast-enhanced computed tomography (CECT) as a non-invasive method for estimating LSF as an alternative for 99mTc-MAA nuclear imaging. Materials and Methods:This single-center retrospective study included 30 consecutive patients who underwent 90Y radioembolization between January 2015 and December 2024, where both four-phase CECT and 99mTc-MAA planar imaging were performed within one month of each other. Hypervascular tumor enhancement was identified on the CECT by subtracting the portal venous phase from the arterial phase and applying an intensity threshold. Additional perfusion characteristics were captured. Statistical analysis assessed the agreement between the CECT-derived volume ratios and the LSF values derived from 99mTc-MAA imaging. Results:The cohort consisted of 23 male and 7 female patients with a median age of 66 years (interquartile range: 58-71), diagnosed with hepatocellular carcinoma (n = 24), intrahepatic cholangiocarcinoma (n = 2), pancreatic neuroendocrine tumors (n = 2), metastatic colorectal cancer (n = 1), and lymphocyte carcinoma (n = 1). Regression of the hypervascular-tumor-to-perfused volume ratio on CECT against LSF from 99mTc-MAA imaging showed R 2 = 0.95 (P < .001). In contrast, the correlation between tumor volume and LSF was R 2 = 0.38 (P = .001). The root mean square error between the LSF estimated from CECT and that measured using 99mTc-MAA planar imaging was 3%. Conclusion:Hypervascular-tumor-to-perfused volume ratio computed from CECT may offer a suitable alternative to 99mTc-MAA nuclear imaging for LSF estimation in patients undergoing transarterial radioembolization.

BACKGROUND:In the setting of a known thrombotic event, computed tomography (CT) studies provide reasonable sensitivity for the diagnosis of deep venous thrombosis (DVT). However, the incidence and accuracy of a DVT diagnosis on CT studies not targeted for the detection of DVT are not well described. In addition, the clinical impact of DVTs incidentally identified on CT is unknown. METHODS:In this single-institution retrospective study, we queried all contrasted CT studies of the lower extremities performed over a 10-year period. Regular expressions applied to the radiology reports associated with the CT studies identified studies with positive findings associated with DVT. These selected reports were then manually reviewed to confirm the presence of a DVT. Patient demographics and relevant medical and surgical history were obtained through a chart review. Follow-up information was obtained for 1 year after the incident CT and included treatment course, additional imaging, and adverse events. An incidental DVT was one identified in a patient in whom the DVT was not noted in a prior study and for whom the study indication did not include concern for DVT or pulmonary embolism. RESULTS:Of 16,637 lower extremity contrasted CT studies queried, 37 study reports identified a DVT. However, only 13 patients had a finding of an incidental DVT (10-year incidence of 0.08%). Among these 13 patients, 11 underwent additional imaging, including 9 who had a subsequent venous duplex and 2 who had subsequent CT studies. Among those with a subsequent duplex, DVT was not identified in eight cases, whereas in one case, DVT was confirmed. Among those with subsequent CT studies, DVT was not identified in one case and was confirmed in one case. Of the 13 patients with incidental DVTs, 3 were initiated on anticoagulation based on their initial CT findings alone. Among these, two did not experience any complications from their DVT or anticoagulation regimen. One did experience major bleeding complications, requiring additional procedures. CONCLUSIONS:Incidental DVTs are a rare finding in lower extremity CT studies, noted to occur in only 0.08% of studies. Most patients with incidental DVTs receive additional imaging, with negative findings in 80% of cases. This study identified that 23% of patients were initiated on anticoagulation due to the CT findings, with a 33% rate of significant complications. Currently, a CT venogram is not recommended as a first-line modality for the diagnosis of DVT. However, there is no guidance regarding the need for repeat imaging in patients with incidentally diagnosed lower extremity DVTs identified on CT. Additional study is needed to provide evidence for guideline development.

Accurate estimation of the Lung Shunt Fraction (LSF) is a standard of care in yttrium-90 (90Y) radioembolization treatment planning to prevent excessive lung irradiation due to arterio-venous shunting in the liver. LSF is assessed using 99mTc macroaggregated albumin (99mTc-MAA) imaging, but this approach adds risk, complexity, and expense to the treatment planning. This study investigates the potential of Contrast-Enhanced Computed Tomography (CECT) as a non-invasive alternative for LSF estimation. Methods We developed a novel metric to estimate the LSF from differences between CECT phases, based on the premise that LSF results from tumor angiogenesis and arterio-venous shunting that create excessive local opacity in the CECT arterial phase. Hypervascular volumes were identified by subtracting the portal phase from the arterial phase and contouring the corresponding regions using an density threshold. The perfused volume corresponded to the lobe and to the volume injected with 99mTc-MAA. We conducted a retrospective analysis involving 30 liver cancer patients who underwent 4-phase liver CECT and 99mTc-MAA imaging prior to 90Y radioembolization to study several markers based on the subtraction images. The patient cohort included several types of liver tumors (primary or metastatic), predominantly hepatocellular carcinoma. Correlations between the hypervascular-to-perfused volume ratio from CECT and LSF values from standard-of-care 99mTc-MAA planar imaging were assessed. Results The strongest correlation was obtained between the hypervascular-to-perfused volume ratio from CECT and LSF values from 99mTc-MAA planar gamma imaging (R^2=0.95). The best correlation was demonstrated when the hypervascular volume was corrected by the hypoxic volume and then normalized by the perfused volume. In contrast, the tumor volume did not show a strong correlation with LSF (R^2=0.38). Moreover, the predictive power of the hypervascular-to-perfused volume ratio on LSF demonstrated a 1-sigma uncertainty of 3%. Conclusion CECT-based LSF estimation shows promise as a non-invasive alternative to 99mTc-MAA imaging in 90Y treatment planning. Further validation with prospective studies on larger cohorts is necessary to confirm the accuracy and safety of this approach. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work has been funded by a UC Davis Comprehensive Cancer Center pilot award (CCSG NCI P30 CA093373) ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of California Davis Institutional Review Board. Ethical approval was given. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Some data produced in the present study are available upon reasonable request to the authors

Objective. Contrast-enhanced computed tomography (CECT) is commonly used in the pre-treatment evaluation of liver Y-90 radioembolization feasibility. CECT provides detailed imaging of the liver and surrounding structures, allowing healthcare providers to assess the size, location, and characteristics of liver tumors prior to the treatment. Here we propose a method for translating CECT images to an expected dose distribution for tumor(s) and normal liver tissue. Approach. A pre-procedure CECT is used to obtain an iodine arterial-phase distribution by subtracting the non-contrast CT from the late arterial phase. The liver segments surrounding the targeted tumor are selected using Couinaud's method. The resolution of the resulting images is then degraded to match the resolution of the positron emission tomography (PET) images, which can image the Y-90 activity distribution post-treatment. The resulting images are then used in the same way as PET images to compute doses using the local deposition method. CECT images from three patients were used to test this method retrospectively and were compared with Y-90 PET-based dose distributions through dose volume histograms. Main results. Results show a concordance between predicted and delivered Y-90 dose distributions with less than 10% difference in terms of mean dose, for doses greater than 10% of the 98th percentile (D2%). Significance. CECT-derived predictions of Y-90 radioembolization dose distributions seem promising as a supplementary tool for physicians when assessing treatment feasibility. This dosimetry prediction method could provide a more comprehensive pre-treatment evaluation-offering greater insights than a basic assessment of tumor opacification on CT images.

INTRODUCTION:Adrenal hemorrhage (AH) can occur due to multiple etiologies with variable radiographic appearance, often indistinguishable from underlying adrenal neoplasms. There is a lack of AH literature and evidence-based guidelines. Our study aimed to understand the prevalence and etiology of AH, follow-up, and incidence of underlying neoplasm. METHODS:An institutional database was queried from January 2006 to October 2021 for patients with AH on imaging, excluding patients with known malignancies, adrenal masses, or prior adrenal surgery. Demographics, medical history, hematoma size, laterality, biochemical evaluation, intervention, and additional imaging were reviewed. RESULTS:Of 490,301 imaging reports queried, 530 (0.11%) with AH met inclusion criteria. Most imaging (n = 485, 91.5%) was performed during trauma evaluation. Two patients underwent dedicated intervention at presentation. Interval imaging was performed in 114 (21.5%) patients at a median of 2.6 (interquartile range 0.99-13.4) mo, with resolution (n = 84, 73.7%) or decreased size of AH (n = 21, 18.4%) in most patients. Only 10 patients (1.9%) saw an outpatient provider in our system to address AH or evaluate for underlying mass, and 9 (1.7%) underwent biochemical screening. Thirteen patients (11% of 118 patients with any follow-up) had evidence of an adrenal mass, confirmed on serial imaging (n = 10) or adrenalectomy (n = 3). Scans performed for nontrauma indications were significantly more likely to have an underlying mass (n = 6/26 [23.1%]) than those performed for trauma evaluation (n = 7/92 [7.6%], P = 0.04). CONCLUSIONS:AH is a rare finding associated with an increased rate of underlying adrenal mass, particularly when unrelated to trauma. Most AH resolves spontaneously without intervention. Follow-up imaging at 6 mo can help distinguish mass-associated AH from simple hemorrhage.

Digital subtraction angiography (DSA) obtained at conventional intravascular locations assumes a typical appearance, or angiographic signature, unique to the location with similar imaging features across patients with conventional anatomy. Identification of these angiographic signatures is necessary for intraprocedural localization and planning and for appropriate post-procedural reporting and billing. The purpose of the study is to evaluate the use of deep-learning algorithms to identify angiographic signatures. An imaging database was developed based upon queries to an institutional PACS to identify abdominopelvic angiographic studies performed between 2010 and 2020, with correlate cross-sectional imaging performed within the preceding 150 days. Individual DSA series representing the angiographic signature of the abdominal aorta, celiac axis, superior mesenteric artery, inferior mesenteric artery (IMA), and right and left external iliac arteries were selected from the identified studies. In each DSA series, the sequence of images in which the parent vessel was opacified were labeled as diagnostic and used for the analysis. An Inception-ResNet v2 model was fine-tuned on a training subset for multiclass classification of angiographic signatures. Diagnostic performance was characterized by the precision, recall, and weighted F1 score across all angiographic signature classes and individually by class on a test subset. 647 unique angiographic sequences were included, comprising 3949 individual diagnostic images. The 5-fold cross validation multiclass classification performance was 0.917, 0.910, and 0.902 for precision, recall, and weighted F1 score, respectively. The angiographic signature classes were imbalanced with the percentage of the total images per class ranging from 29% for the celiac axis to 6% for the IMA. Performance by individual signature class tracked with the class imbalance. Recall performance, ranging from 0.992 for the celiac axis to 0.459 for the least represented IMA class, was most strongly influenced by class imbalance. Angiographic signature prediction is feasible and may be performed with high fidelity using deep learning algorithms.

Purpose: To model the effect of the injection location on the distribution of yttrium-90 (Y-90) microspheres in the liver during radioembolization using computational simulation and to determine the potential effects of radial movements of the catheter tip. Materials and Methods: Numerical studies were conducted using images from a representative patient with hepatocellular carcinoma. The right hepatic artery (RHA) was segmented from contrast-enhanced cone-beam computed tomography scans. The blood flow was investigated in the trunk of the RHA using numerical simulations for 6 injection position scenarios at 2 sites located at a distance of approximately 5 and 20 mm upstream of the first bifurcation (RHA diameters of approximately 4.6 mm). The Y-90 delivery to downstream vessels was calculated from the simulated hepatic artery hemodynamics. Results: Varying the injection location along the RHA and across the vessel cross-section resulted in different simulated microsphere distributions in the downstream vascular bed. When the catheter tip was 5 mm upstream of the bifurcation, Y-90 distribution in the downstream branches varied by as much as 53% with a 1.5-mm radial movement of the tip. However, the catheter radial movement had a weaker effect on the microsphere distribution when the injection plane was farther from the first bifurcation (20 mm), with a maximum delivery variation of 9% to a downstream branch. Conclusions: An injection location far from bifurcations is recommended to minimize the effect of radial movements of the catheter tip on the microsphere distribution.

A subset of trauma patients with active contrast extravasation on initial portal venous (PV) CT imaging may undergo a second scan with CT arteriography (CTA) to distinguish between arterial and venous etiologies. This study investigates the effect of pre-procedural CTA in trauma patients on intraprocedural angiography metrics.

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

Primary hepatic neoplasia is uncommonly reported in dogs. Hepatocellular carcinoma (HCC) is the most frequent neoplasia identified in dogs and considerable effort has been committed towards identifying definitive and palliative treatment options. HCC is well recognized in humans as a sequelae of liver disease such as hepatitis or cirrhosis, while in dogs a similar link has failed to be fully elucidated. Management of HCC in people may be curative or palliative dependent on staging and transplant eligibility. Despite differences in etiology, there is substantial similarity between treatment options for liver neoplasia in human and veterinary medicine. The below summary provides a comparative discussion regarding hepatic neoplasia in dogs and people with a specific focus on HCC. Diagnosis as well as descriptions of the myriad treatment options will be reviewed.

Investigate the degree to which morbidity and mortality (M&M) conferencing is utilized in interventional radiology (IR), identify impediments to its adoption, and assess the experience of those using this tool.

Limited data currently guide the evaluation and clinical management of patients with submassive pulmonary embolism (PE). Due to the heterogeneity of the submassive PE population, prospective identification of patients who require escalation in treatment is challenging. This investigation evaluates the correlation of serial transthoracic echocardiography (TTE) to clinical outcomes for submassive PE patients.

PURPOSE:To investigate the degree to which morbidity and mortality (M&M) conferencing is utilized in interventional radiology (IR), identify impediments to its adoption, and assess the experience of those using this tool.MATERIALS AND METHODS:Members of the Society of Interventional Radiology (SIR) were offered a 9-question survey of practices and experiences regarding M&M conferencing within their quality assessment (QA) programs.RESULTS:Among 604 respondents, 37.8% were university-based practitioners and 60% were from outside of university practices. Of all respondents, 43% reported practicing 100% IR, with 28.5% practicing IR 75%-99% and 11% practicing IR <50% of the time. The use of M&M conferencing was significantly greater in university practices (90.7%) than in nonuniversity practices (37.1%) and among practitioners performing at least 75% IR (71.2%) than among those practicing <75% (28.8%). The conferences were held monthly (66.6%) or more often, and the majority (56%) of the events identified were scored using the SIR severity score. Approximately 20% of M&M conferences were multidisciplinary, shared most commonly with vascular surgery. The reasons cited for not using M&M included the lack of time and the logistical challenges of the process. However, among those who participate in M&M conferences, the QA goals of the conference were met at very high rates.CONCLUSIONS:M&M conferencing is well established in university IR programs and among full-time practitioners but much less so elsewhere. For those sites that do not utilize M&M conferencing, there may be a considerable benefit to addressing the obstacles that are limiting their implementation of this tool.

Clinical outcomes of implantable port catheters (IPCs) placed via alternative veins such as the external jugular and cervical collaterals have not been well established. This investigation evaluates the short- and long-term outcomes of IPCs inserted via alternate cervical veins (ACV) compared to traditionally inserted IPCs via the internal jugular vein (IJV). A total of 24 patients who received an IPC between 2010 and 2020 via an ACV—defined as the external jugular vein, superficial cervical vein, or unnamed collateral veins—were identified. Based on power analysis, a matched control group of 72 patients who received IPCs via the IJV was identified. Non-inferiority analysis for port complications was performed between the two groups based on the selected non-inferiority margin of 20 IPC placement via ACVs was non-inferior to IPCs placed via traditional access through the IJV. When abnormal pathology obviates the use of IJV access, other cervical veins may be considered prior to seeking alternate locations such as femoral, translumbar, inferior vena cava, and hepatic veins.

HomeRadiologyVol. 301, No. 2 PreviousNext Reviews and CommentaryFree AccessEditorialPercutaneous Sclerotherapy with Bleomycin and Ethiodized Oil: A Welcomed Minimally Invasive Treatment for Giant Liver HemangiomasJohn P. McGahan , Roger E. GoldmanJohn P. McGahan , Roger E. GoldmanAuthor AffiliationsFrom the Department of Radiology, UC Davis Health, 4860 Y St, Suite 3100, Sacramento, CA 95817.Address correspondence to J.P.M. (e-mail: [email protected]).John P. McGahan Roger E. GoldmanPublished Online:Aug 17 2021https://doi.org/10.1148/radiol.2021211594MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Ayoobi Yazdi et al in this issue.Dr John McGahan is the professor and vice chair within the Department of Radiology at the University of California, Davis Medical Center located in Sacramento, Calif. Much of his research focuses on the development of new minimally invasive interventional techniques. He has recently received lifetime achievement awards from the Society of Abdominal Radiology and the Society of Radiologists in Ultrasound for his contributions to research.Download as PowerPointOpen in Image Viewer Dr Roger Goldman is an assistant professor in the Division of Vascular and Interventional Radiology at the University of California, Davis Medical Center. His clinical work consists of interventional oncology, venous thromboembolic disease intervention, and diagnostic sampling for endocrine disorders. His research focuses on novel technologic and engineering solutions to complex problems in diagnostic and interventional radiology and surgery.Download as PowerPointOpen in Image Viewer Hemangiomas are the most common benign tumors of the liver, with an estimated incidence of 0.3%–20% in autopsy studies (1). The International Society for the Study of Vascular Anomalies has classified adult hemangiomas as venous malformations (2). Most hemangiomas are detected at imaging performed for other reasons. These lesions are usually small and are not treated, as they have no malignant potential, cause no biochemical or hormonal disturbances, and do not produce mass effect on adjacent organs or vascular structures. As hemangiomas grow, they may be defined as giant hemangiomas. Giant liver hemangiomas (GLHs) are usually considered hemangiomas greater than 5 cm, although some authors define giant hemangiomas as being greater than 10 cm (3). In this issue of Radiology, Ayoobi Yazdi et al (4) defined giant hemangiomas as lesions greater than 5 cm.As these GLHs enlarge, the lesions may cause emergent symptoms requiring intervention. There are no consensus guidelines on the treatment of GLH, with most therapeutic options supported by a combination of retrospective case series and expert consensus. Rarely, emergency surgery is needed for ruptured giant hemangioma or for those patients who develop Kasabach-Merritt syndrome. This syndrome consists of hypofibrinogenemia, anemia, thrombocytopenia, and prolonged prothrombin time that can develop with giant hemangiomas and is life-threatening.Enlargement of GLH may produce symptoms or disease sequelae. Pain is hypothesized to be the result of infarct and necrosis of the tumor or mass effect on the liver capsule or adjacent organs. Mass effect of large hemangiomas may lead to organ or vessel compression, producing gastric or bowel obstruction, Budd-Chiari syndrome, portal hypertension, inferior vena cava thrombosis or occlusion, or obstructive jaundice (5). Surgical treatment of symptomatic GLH was traditionally considered the standard of care, either through resection, enucleation, or transplantation. A growing body of evidence points to the utility, efficacy, and safety of minimally invasive approaches to management. To our knowledge, no studies have prospectively evaluated modern minimally invasive percutaneous image-guided techniques. Ayoobi Yazdi et al (4) concisely review these minimally invasive approaches, which include transarterial embolization, percutaneous transabdominal radiofrequency or microwave ablation, and percutaneous transabdominal sclerotherapy. These approaches have shown promise in reducing both size and symptoms related to GLH. The authors describe and prospectively evaluate a percutaneous transabdominal approach to symptomatic GLH with excellent medium-term efficacy and minimal complications (4). These data provide additional compelling evidence for the minimally invasive management of symptomatic GLH. The article contextualizes the results of percutaneous transabdominal sclerotherapy, highlighting similar clinical efficacy and lower rates of complications.In this study, Ayoobi Yazdi and colleagues investigate the safety and medium-term (12-month) efficacy of percutaneous injection of bleomycin mixed with ethiodized oil for treatment of symptomatic GLH. They describe the participants who were followed up to ensure excellent clinical efficacy and safe injection of the sclerosant mixture. They prospectively excluded patients with hepatic impairment and other possible causes of abdominal pain at rates of 14% (five of 37) and 5% (two of 37), respectively. It should be noted that the study participant population differs from that in prior studies in the relatively low number in whom an alternate cause of pain could not be identified. Multiple prior works identify a number of patients in whom symptoms could be attributable to an alternate diagnosis to liver hemangioma, including peptic ulcer disease or cholelithiasis (6).Several portions of the technique were described to ensure safe injection of the mixture. First, the authors used a small (22-gauge) spinal or Chiba-type needle. They always placed the needle through normal liver parenchyma and near the center, avoiding hypoechoic or anechoic regions. Next, they used fluoroscopic injection of radiopaque contrast agent to check for any communication with their injection site and surrounding veins, hepatic artery, or the biliary system. It is surmised that the total fluoroscopy time, total procedural time, and requirements for intraprocedural analgesia would be equivalent or reduced as compared with transarterial intervention, though the data and comparison analysis have not been presented.The technical success, safety profile, and moderate-term clinical efficacy of their procedure were impressive. The technical success was 100% in the 28 participants enrolled in the postprocedural follow-up. Sixty-eight percent of the participants experienced moderate or severe pain controlled with intravenous medication without the need for hospitalization. There were no major complications. At 1 year, 61% of the participants had complete pain relief, and the rest had partial pain relief as documented by the widely used and validated visual analog scale for pain. The hemangioma volume was reduced by 76% at 1-year follow-up.Injectables have been used to treat GLH. There have been no case series or trials directly comparing the use of different sclerosing agents in the treatment of giant cavernous hemangiomas. However, percutaneous injection of alcohol, bleomycin, and sodium morrhuate have been comparatively studied in treatment of nonvisceral vascular malformations, predominantly of the head and neck. Alcohol is thought to cause dehydration and subsequent sloughing of the dysmorphic endothelial cells lining the venous channels. Detergent sclerosants—such as sodium morrhuate, sodium tetradecyl sulfate, polidocanol, and ethanolamine—are hypothesized, like ethanol, to cause direct damage to endothelial cells. Alternatively, bleomycin is a cytotoxic antitumor antibiotic resulting in vascular endothelial destruction through inhibition of DNA synthesis in addition to sclerosis that leads to vascular endothelial destruction. One potential adverse effect with the use of bleomycin is that it has been shown to cause pulmonary fibrosis when injected intravenously for cancer therapy. Meta-analysis of the use of intralesional bleomycin in multiple case series demonstrated no such pulmonary effect (7). The authors postulated that this was because low dosage of bleomycin was used, with little escaping into the vascular system.A systematic review and meta-analysis of bleomycin injections versus other sclerosants demonstrated statistically equivalent size reduction with a lower rate adverse events and fewer severe complications after bleomycin administration (7). Muir et al (8) showed that intralesional bleomycin injection was effective in complete resolution (42%) or partial resolution (38%) of head and neck hemangiomas, vascular malformations, or venous malformations in 95 patients.More recently, Spence et al (9) matched percutaneous treatment of facial malformations treated with alcohol with those treated with bleomycin. They showed that while alcohol required fewer sessions, it was associated with a much higher incidence of complications, and thus, they preferred bleomycin for treatment of venous malformations. Notably, comparing sclerosants in case series treating nonvisceral vascular malformations, with the overwhelming majority involving the head and neck, may not extrapolate well to the treatment of GLH.The study by Ayoobi Yazdi et al (4) has several notable limitations to broad applicability. No control or randomization was performed in their single-arm prospective study. The investigation was carried out at a single referral center with the ethnic, socioeconomic, and genetic heterogeneity of the participant population undefined. The study specifically excluded patients with hepatic impairment, narrowing the applicability of the results to this population that made up 14% of the initially screened patients. The authors stated that their inclusion criteria for percutaneous use of bleomycin were patients who declined surgery for giant cavernous hemangiomas. This could have been an opportunity to compare the results of patients with giant cavernous hemangiomas treated with surgery versus percutaneous bleomycin therapy.In summary, Ayoobi Yazdi et al provide compelling prospective evidence for single-session percutaneous image-guided sclerotherapy of GLH using a combination of bleomycin and ethiodized oil. The study used a fixed dose of bleomycin and ethiodized oil regardless of participant or lesion size. They cogently note the optimal pharmacotherapy of the intralesional sclerosant is yet to be resolved. The dose dependence of both bleomycin and ethiodized oil, and the injectable form—such as liquid versus foam—need further investigation. The study discussion highlights a substantial minority of participants (21%) with increased visual analog scale pain scores at 12 months after the procedure as compared with 6 months, without demonstration or suggestion of concomitant increase in lesion size. The subcohort raises the question of the long-term efficacy of sclerotherapy and natural history of sclerosed GLHs. These lesions were shown to have significantly decreased in size, though they remained identifiable in all participants at 12 months and may begin to enlarge. The indications, technique, and safety of repeat intervention in the treated patient population need further investigation. However, we believe this technology is a promising treatment for GLH.Disclosures of Conflicts of Interest: J.P.M. disclosed no relevant relationships. R.E.G. disclosed no relevant relationships.References1. Choi BY, Nguyen MH. The diagnosis and management of benign hepatic tumors. J Clin Gastroenterol 2005;39(5):401–412. Crossref, Medline, Google Scholar2. Merrow AC, Gupta A, Patel MN, Adams DM. 2014 revised classification of vascular lesions from the International Society for the Study of Vascular Anomalies: radiologic-pathologic update. RadioGraphics 2016;36(5):1494–1516. Link, Google Scholar3. van Tilborg AA, Nielsen K, Scheffer HJ, et al. Bipolar radiofrequency ablation for symptomatic giant (>10 cm) hepatic cavernous haemangiomas: initial clinical experience. Clin Radiol 2013;68(1):e9–e14. Crossref, Medline, Google Scholar4. Ayoobi Yazdi N, Mehrabinejad MM, Dashti H, Pourghorban R, Nassiri Toosi M, Rokni Yazdi H. Percutaneous sclerotherapy with bleomycin and ethiodized oil: a promising treatment in symptomatic giant liver hemangioma. Radiology 2021.https://doi.org/10.1148/radiol.2021204444. Published online August 17, 2021. Google Scholar5. Liu X, Yang Z, Tan H, et al. Characteristics and operative treatment of extremely giant liver hemangioma >20 cm. Surgery 2017;161(6):1514–1524. Crossref, Medline, Google Scholar6. Herman P, Costa MLV, Machado MAC, et al. Management of hepatic hemangiomas: a 14-year experience. J Gastrointest Surg 2005;9(6):853–859. Crossref, Medline, Google Scholar7. Horbach SER, Rigter IM, Smitt JHS, Reekers JA, Spuls PI, van der Horst CMAM. Intralesional bleomycin injections for vascular malformations: a systematic review and meta-analysis. Plast Reconstr Surg 2016;137(1):244–256. Crossref, Medline, Google Scholar8. Muir T, Kirsten M, Fourie P, Dippenaar N, Ionescu GO. Intralesional bleomycin injection (IBI) treatment for haemangiomas and congenital vascular malformations. Pediatr Surg Int 2004;19(12):766–773. Crossref, Medline, Google Scholar9. Spence J, Krings T, TerBrugge KG, Agid R. Percutaneous treatment of facial venous malformations: a matched comparison of alcohol and bleomycin sclerotherapy. Head Neck 2011;33(1):125–130. Crossref, Medline, Google ScholarArticle HistoryReceived: June 24 2021Revision requested: July 12 2021Revision received: July 13 2021Accepted: July 16 2021Published online: Aug 17 2021Published in print: Nov 2021 FiguresReferencesRelatedDetailsCited ByConsiderations Regarding Image-guided Treatment of Liver HemangiomaPooya Torkian, Shahram Akhlaghpoor, 17 May 2022 | Radiology, Vol. 304, No. 2Accompanying This ArticlePercutaneous Sclerotherapy with Bleomycin and Ethiodized Oil: A Promising Treatment in Symptomatic Giant Liver HemangiomaAug 17 2021RadiologyRecommended Articles Percutaneous Sclerotherapy with Bleomycin and Ethiodized Oil: A Promising Treatment in Symptomatic Giant Liver HemangiomaRadiology2021Volume: 301Issue: 2pp. 464-471Vascular Anomaly Syndromes in the ISSVA Classification System: Imaging Findings and Role of Interventional Radiology in ManagementRadioGraphics2022Volume: 42Issue: 6pp. 1598-1620Considerations Regarding Image-guided Treatment of Liver HemangiomaRadiology2022Volume: 304Issue: 2pp. E45Update on Pediatric Interventional RadiologyRadioGraphics2022Volume: 42Issue: 6pp. 1580-1597One Step Closer to Precision Medicine for Transarterial Therapy of HCCRadiology2020Volume: 297Issue: 1pp. 235-236See More RSNA Education Exhibits Not Just "Hemangiomas"! Diagnostic Approach to Pediatric Vascular AnomaliesDigital Posters2019Classification of Vascular Anomalies: What’s New?Digital Posters2019Imaging of Orbital Vascular AnomaliesDigital Posters2020 RSNA Case Collection CavernomaRSNA Case Collection2020Cerebral Cavernous Venous MalformationRSNA Case Collection2021Scalp Arteriovenous MalformationRSNA Case Collection2022 Vol. 301, No. 2 Metrics Altmetric Score PDF download

TOPIC: Cardiothoracic Surgery TYPE: Fellow Case Reports INTRODUCTION: Pulmonary artery catheters (PAC) are used in cardiac surgery to provide critical clinical data. While safe, they are not harmless with multiple associated risks, including surgical entrapment. Causes of include suture snaring and PAC knotting. We present the case of a surgically entrapped PAC that was successfully removed in a percutaneous fashion. CASE PRESENTATION: A 61-year-old man with MV regurgitation presented for surgical repair. A PA catheter was placed through an 8-FR sheath in the RIJ vein. Sternotomy was performed and the patient was placed on central cardiopulmonary bypass with bicaval venous cannulation. The LA was entered through the inter-atrial groove, and MV repair performed. Following both atriotomy closure and venous decannulation, the anesthesia team reported seamless PAC mobility and the chest was closed. On POD1, removal of the PAC was met with resistance. Imaging confirmed normal PAC position without obvious entrapment. The patient was taken to the IR suite where fluoroscopy revealed tethering of the PAC at the inferior third of the SVC. The proximal aspect of the PAC was then cut and the indwelling sheath was replaced with a 9-FR braided sheath over the PAC, which served as 'guide-wire'. A point of obstruction was detected by tactile sensation. The sheath was then upsized to a 10-FR braided vascular sheath. With gentle, simultaneous, back-and-forth maneuvering of the catheter and sheath, the PAC was liberated and removed. Superior venacavogram revealed brisk flow of contrast through the SVC, RA and pulmonary outflow tract with no evidence of injury. Mediastinal tubes were removed on POD2 and the patient was discharged on POD5. DISCUSSION: PACs provide critical data to help guide therapy. In a review of over 15,000 patients, Kaplan et al reported a low risk associated with their use with entrapment constituting only 0.065%-0.1% of cases. The most common reported sites of entrapment are around the atrio-caval and atriotomy closure site. While a re-do sternotomy has been the traditional approach for retrieval, it carries inherent associated risks. Percutaneous options can be considered if the offending suture is sufficiently loose and has not perforated the PAC. This must be performed in a controlled environment with the appropriate resources available for a re-do sternotomy. Clinical surveillance with a repeat TTE in 24-HR are critical. Ultimately prevention is the best therapy with heightened vigilance during surgery to avoid PAC suture entrapment. CONCLUSIONS: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this surgical complication does occur, a percutaneous approach for recovery is a viable and safe option to consider as discussed in our report. REFERENCE #1: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this complication does occur, a percutaneous approach for recovery is a viable and safe option to consider. REFERENCE #2: Pfeiffer K, Widmann M, Deusch H, Guggenberger H, Duda S, Seboldt H. Inadvertant suture fixation of a Swan-Ganz catheter to the pulmonary artery following heart surgery. Anaesthetist. 1995;44:782–4 REFERENCE #3: Kaplan M, Demirtas M, Cimen S, et al. Swan-Ganz Catheter Entrapment in Open Heart Surgery. J Cardiothorac Surg. 2000;15:313-315. DISCLOSURES: No relevant relationships by Roger Goldman, source=Web Response Consultant relationship with Medtronic Please note: 5 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Johnson and Johnson Please note: 3 Years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Boston Scientific Please note: 4 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Edwards Life Sciences Please note: 3 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Abbott Please note: 6 months Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria No relevant relationships by David Li, source=Web Response No relevant relationships by AMIR SARKESHIK, source=Web Response

To identify the volume of diagnostic vascular imaging studies (CTA/MRA/US) interpreted by interventional radiologists in comparison to other medical specialties. The Medicare Physician and Other Supplier Public Use File claims were used to categorize radiologists whose practice was interventional radiology by identifying radiologists with the majority of their wRVUs from interventional codes according to the NITOS classification system. Vascular imaging was defined by HCPCS billing codes for all diagnostic vascular studies including CTA, MRA, and vascular ultrasound studies of the head, neck, chest, abdomen, pelvis, and extremities. Importantly, physicians not submitting at least 10 claims for any particular code were excluded from the database for that specific HCPCS code per CMS data policy. A total of 2251 radiologists submitted the majority of their wRVUs under interventional codes and were identified as interventional radiologists. Of these, 366 interpreted a sufficient number of vascular imaging studies to be included in the dataset, while 1885 IR physicians interrupted less than 10 studies for all vascular imaging codes during the 2017 calendar year. For the 366 IR physicians included in the study, 58,345 (1.60%) of the total 3,656,480 diagnostic vascular imaging studies performed were interpreted by dedicated IRs. In comparison, radiologists with the majority of their wRVUs in non-interventional codes interpreted 52.3% of vascular studies. Vascular Surgery and Cardiology interpreted 16.1% and 12.3%, respectively. There was a statistically significant difference in rate of vascular imaging interpretation among frequent providers between IR and Vascular Surgery which recorded an average of 159 and 638 studies read per physician in 2017 respectively (P < 0.01). The majority of interventional radiologists do not interrupt or perform a low number of diagnostic vascular imaging studies for Medicare patients. These findings have important implications for the potential management, referral patterns and training of IR physicians.

Venous access port placement is a widely performed procedure and is the preferred form of long-term central venous access due to low infection rates and greater patient satisfaction when compared to other forms of long-term access. When the preferred internal jugular vein is unavailable, due to stenosis, obstruction, or other considerations, other access sites in the neck—such as the external jugular veins and unnamed collaterals—offer a potential alternative. The clinical outcome of using of these alternative sites has not previously been investigated. The purpose of the present study is to report the experience and evaluate the safety and efficacy of alternative access sites for central venous access port placements at a single tertiary care center. Single-site retrospective review was performed of all patients receiving a port placement procedure at a single tertiary academic care facility over the period of 2010 through 2019. Patients were excluded when central venous access was achieved via internal jugular or subclavian vein. In addition, patients were excluded if they had imaging and documentation without definite site location. Inclusion criteria identified patients who had received access via an external jugular vein or a collateral vein in the neck. The records of these patients were reviewed for age, sex, port placement technique, peri-procedural and delayed complications, patency, dwell time, and overall clinical outcome. During the study period, a total of 26 subjects received a port via an alternative access site. The indication for alterative access was occlusion or severe stenosis (n = 17) of the internal jugular vein (either due to thrombus or other mechanical causes), internal jugular vein not reliably identified (n = 4), and unknown (n = 6). Of the 26 subjects, only one (4%) patient had immediate complication of pain requiring escalation of therapy. Two subjects had delayed complications of port infection (n = 1, 4%) and post-procedural hematoma which did not require intervention (n = 1, 4%). Nine patients had elective port removal with an average indwelling time of 789 days (168–1616). Among the remaining 17 patients, 7 ports are currently still present, 4 were lost to follow-up, and 6 patients died because of unrelated causes. In our single-center experience, alternative access sites for port placement were an acceptable alternative for long-term venous access. Our data demonstrate that port function and periprocedural and long-term complication rates were equivalent to traditional internal jugular access port placement.