Central venous obstructions that impedes catheter placement or results in catheter dysfunction is a significant problem for haemodialysis patients. Recanalization can be performed with an intent to restore central venous access, improve outflow from arteriovenous fistula or to relieve symptomatic venous obstructions. Sharp recanalization encompasses various interventional techniques using a sharp instrument to puncture through or bypass around a venous obstruction. In this paper we outline our experience performing CT guided sharp recanalization and review alternative sharp recanalization techniques that are specifically used to restore haemodialysis access in patients with thoracic central venous obstruction.

During a routine post-operative orthopaedic radiograph reading session, repeated unusual radiographic soft tissue and bone appearances became evident. It was discovered that these patients had received biodegradable magnesium implants which have recently been introduced into orthopaedic clinical practice. To the untrained eye, the combination of peri-metallic bone resorption with associated soft tissue gas, could easily be mistaken for post-operative infection. The aim of this study is to properly characterise the radiographic post-operative appearances of biodegradable magnesium orthopaedic hardware. We retrospectively evaluated radiographs of all patients who underwent magnesium screw implantation for fractures over a 6 month period. Four patients, mean age of 9.75 (range: 6-15) years who underwent magnesium screw fixation following fracture were included in the study. Follow up duration was 100 days (range: 75-122) with a mean of 2.5 postoperative radiographs being performed per patient during this period. All cases demonstrated post-operative peri-metallic radiolucency which developed around the magnesium screws on x-ray, which subsequently resorbed over time. Peri-metallic soft tissue gas was observed in all patients. In two cases, magnesium implants fractured. As the use of biodegradable metal implants becomes more common, it is important for radiologists to be aware of their imaging characteristics. Prior to reporting a case, it would be prudent to know if biodegradable screws have been utilised and whether there exists a clinical concern for post-operative infection in patients with these particular implants, in which case it would be critical not to dismiss peri-prosthetic radiolucencies and soft tissue gas as merely a sequela of the natural metal degradation process.

Pulmonary embolism (PE) can be life-threatening and is the third most common cause of cardiovascular mortality. For patients suffering from high and medium risk PE, potential treatments include a thrombolytic drug which is injected into the blood stream to dissolve the embolism. However, this treatment can increase the risk of bleeding occurring, particularly in susceptible patients. To reduce the level of drug required, it can be delivered directly to the site of the embolism through catheter-directed thrombolysis. Benchtop models have the potential to accelerate the development of catheter-based devices. Good benchtop models enable tests that allow issues to be identified and solved at an earlier stage in the development lifecycle, saving both time and money. In the present work, a patient-specific benchtop model of the relevant vascular anatomy has been proposed. Three different commercially available materials, namely Clear, Elastic, and Flexible from Formlabs, were evaluated for their capacity to represent the native anatomy. These materials were all 3D printable via stereolithography. Standard tensile and flexural testing samples were prepared and tested. The elastic material was far superior in resembling blood vessel's mechanical properties. Computer tomography (CT) scans were used to develop a patient-specific benchtop model which includes Vena Cava, Right Heart, and Pulmonary Artery Computer Aided Design (CAD) models. Elastic material was used to 3D print the patient-specific models and assemble them for prototyping. A catheter was used for the demonstration of the developed benchtop model. The proposed methodology and material have shown successful candidacy to be used as a rapid method to create benchtop models that can test and validate catheter-based medical devices for the pulmonary system.

Background and aims This retrospective cohort study evaluated the degree of pelvic inflow and internal pudendal artery (IPA) calcification in male smokers versus non-smokers. As erectile dysfunction (ED) is strongly associated with IPA vascular, we wanted to investigate radiologically if there was a statistically significant difference in the degree of IPA calcification in smokers and potentially be a contributing factor in the cause of ED. Methods CT studies of 100 men aged between 40 and 60 years of age were blindly reviewed and assigned a calcium score of their vascular calcification levels. We compared scores of 50 smokers versus 50 non-smokers. The Mann Whitney U test statistic was used to test for a statistical difference in calcification score between the smoking and non-smoking groups. Results Results show a statistically significant association between smoking and pelvic inflow and IPA calcification. The Mann Whitney U test demonstrated a statistically significant higher calcium score in the smoking group (mean = 4.8, SD 3.7), versus the non-smoking group, (mean = 1.8, SD 1.9) ( U = 701.5, p < 0.05). Conclusions This research is the first of its kind based on an extensive literature review. The association between vascular calcification and smoking is well established, in addition to the direct relationship of IPA calcification and ED. This unique study has demonstrated an increased rate of IPA calcification in smokers with a potential inferred association with ED. Findings represent a novel and useful deterrent for health authorities to include in anti-smoking campaigns.

BACKGROUND:Inferior vena cava (IVC) filters are widely used in clinical practice to prevent large, clinically significant pulmonary emboli. Modern filters are designed to be retrievable within a specific time window; however, many become lost to follow-up.AIM:To examine the insertion and retrieval patterns of IVC filters in a tertiary referral teaching hospital in Ireland.METHODS:A retrospective review of all IVC filter insertions and retrievals was performed in a tertiary referral university teaching hospital which incorporates the national referral centre for pelvic and acetabular trauma, over a 22-month period.RESULTS:Fifty-seven patients underwent IVC filter insertion with 100% technical success. The most common indication was prophylaxis in patients at high risk of deep venous thrombosis or pulmonary emboli (64.9%), followed by patients with contra-indication to anticoagulation (24.6%) and breakthrough thromboembolic events despite anticoagulation (10.5%). IVC filter retrievals were attempted in 48.9% of patients with a success rate of 86.9%. The mean dwell time for retrieved IVC filters was 159.4 days.CONCLUSION:Inferior vena cava filter insertion and retrieval patterns in our centre were comparable to trends reported internationally with scope for improvement in terms of filter retrieval rates and minimising filter dwell time. Particular vigilance is required in younger patients where the indication for filter insertion was prophylactic.

PURPOSE:Emergency laparotomy has a high reported thirty-day mortality, ranging from 11 to 15%. Current peri-operative risk assessment tools may poorly estimate the risk of perioperative mortality. We sought to determine if CT-determined sarcopenia may be a useful predictor of post-operative outcomes in patients undergoing an emergency laparotomy.METHODS:A retrospective review of a prospectively maintained database of consecutive adult patients who underwent an emergency laparotomy at our institution was performed. Post-operative mortality (90-day mortality), admission to HDU or ICU and APACHE-II scores were recorded for these patients. Sarcopenia was calculated by determining psoas area and density at the level of the third lumbar vertebra. The lowest quartile was determined to be sarcopenic. Univariate statistical analysis investigated associations between sarcopenia and these outcome measures.RESULTS:Eighty patients were included in the study following application of exclusion criteria. Thirty-eight were male. The 90-day mortality rate was 11%. Compared to their non-sarcopenic counterparts, sarcopenic patients were significantly more likely to have died by 90 days post-operatively (χ2 = 9.51, p = 0.002) and to require admission to either the HDU or ICU in the post-operative period (χ2 = 10.62, p = 0.001).CONCLUSIONS:CT determined sarcopenia is significantly associated with 90-day mortality and post-operative admission to HDU or ICU in patients undergoing an emergency laparotomy. The future development of a validated scoring tool incorporating sarcopenia could help to better select out those patients who will require higher levels of post-operative care as well as identifying those for whom surgery may not confer a survival benefit and be deemed futile.

To evaluate the nephro-ureteric stent (NUS) insertion and exchange practice in a tertiary referral cancer centre, and determine the safety and compliance with current guidelines. We also reviewed if increasing exchange time interval from 6 to 12 weeks was safe, and if this could be adopted into our local guidelines. A retrospective review was performed covering 24 months from January 2017 to December 2018. All NUS insertions and exchanges performed in that period were analysed, including the number of exchanges the patient underwent, the time between subsequent exchanges, and the screening time. We also reviewed the indications for stent insertion, possible causes for failed stent exchange, and factors which led to significant delays in stent exchanges for some patients. A scatterplot of screening time versus time in situ was derived and correlation analysis performed using the Pearson coefficient. Thirty-two patients underwent de novo NUS insertion during the period, and 102 NUS exchanges were performed. The interval between stent exchanges ranged from 1 to 40 weeks, with a mean of 12.3 weeks (SD = 8.96 weeks). Screening time ranged from 33 s to 17 min, with a mean of 3 min 50 s (SD = 3 min 35 s). There were 100 successful exchanges, and two failed exchanges, accounting for 1.9% of total exchanges. In both failed cases, the reason for failed exchange was due to a prolonged period between exchanges (6 months in both cases). The reason for delay for stent exchange was due to non-attendance for scheduled appointments. There was a weakly positive correlation coefficient of 0.06 (screening time versus time period between insertions); however, this was not statistically significant (p = 0.81). In this retrospective review, we have demonstrated that the recommended 6-week period between stent exchanges is unnecessary in the vast majority of cases, and that a longer interval between NUS exchanges, e.g. 8–12 weeks, is safe for the patient, and reduces screening time. This reduction in procedures also provides a significant potential saving to the radiology department in both monetary expense and limited angiography suite time.

Background Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis. Purpose To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis. Material and Methods A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images. Results Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year. Conclusion Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

Artificial intelligence (AI) has been defined as a branch of computer science dealing with the capability and simulation of a machine to imitate intelligent human behaviour. Diagnostic radiology, being a computer-based service, is unsurprisingly at the forefront of the discussion of the use of AI in medicine. There are however differing schools of thought regarding its use; namely, will AI eventually replace the radiologist? Or indeed will it ever be fully capable of replacing radiology as a speciality, but rather be used as an aid to the profession whereby a human's input will always be required? Furthermore, what will the legal implications of AI in radiology mean to the profession? Who will be liable for missed diagnoses? Is it possible that the introduction of AI to radiology will in fact make the profession busier?

The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus, urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT, positron emission tomography CT and MRI.

British Journal of Hospital MedicineVol. 80, No. 10 Case ReportsCatheter-directed therapy in deep vein thrombosis: May–Thurner syndromeFergal Howley, Ronan Motyer, William Torreggiani, Pradeep GovendarFergal HowleyCorrespondence to: Dr F Howley (E-mail Address: [email protected])Medical Senior House Officer, Acute Medical Assessment Unit, Tallaght University Hospital, Dublin, IrelandSearch for more papers by this author, Ronan MotyerSpecialist Registrar, Department of Radiology, Tallaght University Hospital, Dublin, IrelandSearch for more papers by this author, William TorreggianiConsultant Radiologist, Department of Radiology, Tallaght University Hospital, Dublin, IrelandSearch for more papers by this author, Pradeep GovendarConsultant Radiologist, Department of Radiology, Tallaght University Hospital, Dublin, IrelandSearch for more papers by this authorFergal Howley; Ronan Motyer; William Torreggiani; Pradeep GovendarPublished Online:7 Oct 2019https://doi.org/10.12968/hmed.2019.80.10.610AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bozkurt A, Kırbaş İ, Kösehan D, Demirçelik B, Nazlı Y. Pharmacomechanical thrombectomy in the management of deep vein thrombosis using the cleaner device: an initial single-center experience. Ann Vasc Surg. 2015 May;29(4):670–674. https://doi.org/10.1016/j.avsg.2014.12.013 Crossref, Medline, Google ScholarBush RL, Lin PH, Bates JT, Mureebe L, Zhou W, Lumsden AB. Pharmacomechanical a for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. J Vasc Surg. 2004 Nov;40(5):965–970. https://doi.org/10.1016/j.jvs.2004.08.025 Crossref, Medline, Google ScholarEnden T, Haig Y, Kløw NE et al.; CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012 Jan;379(9810):31–38. https://doi.org/10.1016/S0140-6736(11)61753-4 Crossref, Medline, Google ScholarGarcia MJ, Lookstein R, Malhotra R et al.. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: final report of the prospective multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) registry. J Vasc Interv Radiol. 2015 Jun;26(6):777–785, quiz 786. https://doi.org/10.1016/j.jvir.2015.01.036 Crossref, Medline, Google ScholarKim JY, Choi D, Guk Ko Y, Park S, Jang Y, Lee DY. Percutaneous treatment of deep vein thrombosis in May-Thurner syndrome. Cardiovasc Intervent Radiol. 2006 Aug;29(4):571–575. https://doi.org/10.1007/s00270-004-0165-7 Crossref, Medline, Google ScholarMousa AY, AbuRahma AF. May-Thurner syndrome: update and review. Ann Vasc Surg. 2013 Oct;27(7):984–995. https://doi.org/10.1016/j.avsg.2013.05.001 Crossref, Medline, Google ScholarNational Institute for Health and Clinical Excellence. 2015. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE guideline (CG144). (accessed 26 October 2017) https://www.nice.org.uk/Guidance/cg144 Google ScholarVedantham S, Goldhaber SZ, Julian JA et al.; ATTRACT Trial Investigators. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017 Dec 07;377(23):2240–2252. https://doi.org/10.1056/NEJMoa1615066 Crossref, Medline, Google ScholarWatson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 2016 Nov 10;11:CD002783. https://doi.org/10.1002/14651858.CD002783.pub3 Medline, Google Scholar FiguresReferencesRelatedDetails 2 October 2019Volume 80Issue 10ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 7 October 2019 Published in print 2 October 2019 Information© MA Healthcare LimitedPDF download

OBJECTIVES:Interventional radiology plays a central role in the management of complicated acute pancreatitis, contributing to image-guided drainages, treating haemorrhagic complications and maintaining the patency of the biliary tree. In addition, many of these patients require long-term venous access for antibiotics or parenteral feeding. The aim of this study was to evaluate the role and level of involvement of the interventional radiology in this sub-group of patients.METHODS:This was a single-centre retrospective review of all admissions for acute pancreatitis over a 5-year period. Each case was assessed to determine whether radiological intervention was utilised.RESULTS:Our review included 401 patients. A total of 18.7% (75/401) of patients required vascular access procedures and 18.4% (74/401) required image-guided drainage. A total of 1.2% (2/401) patients had embolisation procedures performed. The embolisation procedures were performed to treat a pseudoaneurysm that had formed. Overall, 20.9% (84/401) of patients were referred to the interventional radiology department for a procedure; a majority of these patients were referred for multiple procedures over the course of their admission. The patients in the 'severe pancreatitis' category had a total of 154 procedures performed, which was 65.5% of the total procedures. On average, the patients who underwent multiple interventional procedures tended to have a longer admission and more complex disease.CONCLUSION:The diagnosis and treatment of complicated acute pancreatitis is heavily dependent on the interventional radiology department. A substantial proportion of patients with pancreatitis required radiological intervention as part of their management, the proportion of which increased significantly in complex disease.

AimsTo assess if there was a significant difference in the number of positive studies for pulmonary embolism between obese and non obese patients.MethodsA retrospective analysis of all CTPAs performed in our institution over one year in patients aged 18-50 was performed. Data regarding the diagnosis of pulmonary embolism, the presence of airways disease, other significant chest findings, D dimer values and demographic data including a BMI surrogate was obtained.ResultsTwo hundred and thirty CTPAs were performed in our institution over 12 months. Two hundred and twenty-one were included for analysis, of which 129 were male and 92 were female. Sixty-nine (31%) patients were classified as obese. Eleven (16%) of these had positive studies. One hundred and fifty-two patients were in the non obese category, of which 24 (15%) had positive studies.ConclusionsWe are not over imaging the obese patient, but are over imaging patients in general with suspected PE, but are exposing a significant number overall, to unnecessary radiation.

Poster: ECR 2018 / C-0629 / Are we over imaging the obese patient with suspected pulmonary embolus? by: M.-L. Gargan1, M. O'sullivan2, W. Torreggiani3; 1Dublin, N/A/IE, 2Dublin/IE, 3Dublin 24/IE

Background: Inferior vena cava filter (IVCF) placement is performed for multiple indications in the prevention of complications associated with deep venous thrombosis. Removal is generally recommended in 4–6 weeks or as soon as no longer required. The aim of this study was to examine the relationship between length of time between insertion and removal of the filter and the technical difficulty in device removal (indicated by procedure screening time and procedure dose area product (DAP).

INTRODUCTION: Intussusception in adults is a rare condition, accounting for just 5% of all cases. Approximately 50% of cases of large intestine intussusception occur due to a malignant neoplasm. We present here a novel case report of colo-rectal intussusception arising secondary to a primary rectal melanoma. PRESENTATION OF CASE: We present the case of an 85 year-old patient, who underwent a colonoscopy for investigation of weight loss and altered bowel habit. At colonoscopy, a pigmented polypoid mass was visualised in the upper third of the rectum. The lesion was causing colo-rectal intussusception. Initial biopsies of the specimen stained positive for S-100. The patient had an MRI (magnetic resonance imaging) pelvis, which demonstrated a mass at the rectosigmoid junction, which was diffusely high signal on the fat sat T1 weighted sequence. The patient proceeded to a laparoscopic anterior resection and had an uncomplicated post-operative course. The resected specimen was sent for pathological analysis. The morphological and immunohistochemical profile was consistent with malignant melanoma. There was no evidence of cutaneous melanoma following a full skin examination. DISCUSSION: Rectal melanoma is a rare condition. We present a novel case report of colo-rectal intussusception arising secondary to rectal melanoma. CONCLUSION: This is a rare entity. This patient's pre-operative MRI and biopsy samples suggested this lesion was a rectal melanoma, which was subsequently confirmed on analysis of the resected specimen. Surgical resection of such neoplasms should be attempted where possible. (C) 2018 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

OBJECTIVE:To determine a relationship between increased body mass index (BMI) and fatty involution of the thymus in subjects aged between 20 and 30 years.METHODS:CT images of 94 patients aged between 20 and 30 years were reviewed. Quantitative thymic mean attenuation was recorded and qualitative thymic attenuation was assigned to 1 of 4 possible grades. BMI and subcutaneous fat thickness were documented. Correlations between thymic attenuation, and BMI and subcutaneous fat thickness were assessed using linear regression models. Differences in thymic attenuation in overweight vs normal weight patients were assessed using t-test and Pearson Χ2 analysis.RESULTS:Low mean thymic attenuation values were associated with higher patient BMI (p = 0.024). Normal weight patients had a mean quantitative thymic attenuation of 15.5 Hounsfield unit and overweight patients had a mean quantitative thymic attenuation of -16.4 Hounsfield unit (p = 0.0218). There was a significant association between increasing subcutaneous fat thickness and reduced mean quantitative thymic attenuation (p < 0.0001). There was also a significant difference in subcutaneous fat thickness when comparing qualitatively assessed thymic Grade 0 with grades 2 and 3 (p = 0.027 and 0.001 respectively); and Grade 1 with Grade 3 (p = 0.001).CONCLUSION:In patients between 20 and 30 years old, the degree of thymic fatty infiltration is related to BMI. Advances in knowledge: Multidetector CT can assess fatty involution of the thymus gland. This retrospective study demonstrates a relationship between BMI and thymus gland fatty involution. Subjects with increased subcutaneous fat have decreased mean thymus gland attenuation.

Lower limb injuries account for most of all injuries suffered by athletes and the knee joint accounts for over half of these. The etiology of knee pain is multifactorial; a good history focusing on the mechanism of injury and the chronicity of pain is extremely useful in correlating with radiologic findings and establishing a clinically meaningful diagnosis. This review article will discuss several important and common causes of acute and chronic knee pain in athletes, focusing on their mechanism of injury and site of pain as well as their salient imaging findings.

Spinal metastases are the most commonly encountered tumour of the spine, occurring in up to 40% of patients with cancer. Each year, approximately 5% of cancer patients will develop spinal metastases. This number is expected to increase as the life expectancy of cancer patients increases. Patients with spinal metastases experience severe and frequently debilitating pain, which often decreases their remaining quality of life. With a median survival of less than 1 year, the goals of treatment in spinal metastases are reducing pain, improving or maintaining level of function and providing mechanical stability. Currently, conventional treatment strategies involve a combination of analgesics, bisphosphonates, radiotherapy and/or relatively extensive surgery. Despite these measures, pain management in patients with spinal metastases is often suboptimal. In the last two decades, minimally invasive percutaneous interventional radiology techniques such as vertebral augmentation and radiofrequency ablation (RFA) have shown progressive success in reducing pain and improving function in many patients with symptomatic spinal metastases. Both vertebral augmentation and RFA are increasingly being recognised as excellent alternative to medical and surgical management in carefully selected patients with spinal metastases, namely those with severe refractory pain limiting daily activities and stable pathological vertebral compression fractures. In addition, for more complicated lesions such as spinal metastasis with soft tissue extension, combined treatments such as vertebral augmentation in conjunction with RFA may be helpful. While combined RFA and vertebral augmentation have theoretical benefits, comparative trials have not been performed to establish superiority of combined therapy. We believe that a multidisciplinary approach as well as careful pre-procedure evaluation and imaging will be necessary for effective and safe management of spinal metastases. RFA and vertebral augmentation should be considered during early stages of the disease so as to maintain the remaining quality of life in this patient population group.