This multisociety, multidisciplinary consensus—formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology—was developed to standardise the assessment of ablation margins in liver tumour thermal ablation. A modified Delphi process, consisting of two online surveys and a hybrid (online and in-person meeting in Innsbruk) consensus meeting of 72 experts from North America, South America, Europe, and Asia. Formal consensus was reached for 150 (75%) of 199 statements. Strong agreement was observed between interventional and surgical oncologists, with only 12 (6%) of 199 statements showing significantly different ratings. Participants agreed that ablation margins should be assessed and documented for every treated tumour. Margins should be assessed quantitatively in three dimensions, with contrast-enhanced CT or MRI, preferably intraprocedurally with ablation confirmation software. Ablation margins should be categorised as A0 (tumour completely covered with sufficient margin), A1 (tumour completely covered but insufficient margin), or A2 (portion of tumour remains unablated). This effort is, to our knowledge, the first international consensus initiative to define best-practice recommendations for margin assessment in liver tumour thermal ablation to standardise practices, aiming to improve and promote uniform outcomes.

Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablation can deliver similar oncological outcomes. However, effectiveness in routine practice varies because structured training, planning, and procedural governance remain scarce. These international multidisciplinary, multi-society guidelines—formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology—define key domains contributing to procedural difficulty and practice variation in liver tumour thermal ablation. A Delphi consensus initiative held in Innsbruck, Austria, engaged 72 experts across three iterative rounds of scoring across 135 statements grouped into five domains: credentialing, indications, approach, procedural factors, and safety measures. Consensus was achieved for 94 (70%) of 135 statements. The least invasive route—typically percutaneous—should be prioritised, and margin adequacy was reaffirmed as the principal technical goal. Procedural difficulty was considered context-dependent, shaped by tumour factors, institutional infrastructure, and operator experience. Organ displacement techniques were endorsed to maintain safety and expand treatable indications. Complex ablations should be done by experienced operators (more than 100 previous cases), with programmes underpinned by structured training, multidisciplinary team participation, and routine audit. Future efforts should develop and validate practical tools such as difficulty scoring systems, standardised procedural reporting templates, and comprehensive training curricula to improve consistency, standardisation, and clinical outcomes globally.

Treatment failure and local tumor progression (LTP) after thermal ablation (TA) have been attributed to insufficient minimal margin (MM) ablation zone coverage of the target tumor. This prospective, open-label, multicenter, international trial will enroll approximately 275 patients with one to three colorectal liver metastases (CLM) (for a total of 330 tumors) each up to 2.5 cm in largest diameter, eligible for local cure using microwave ablation (MWA). Any FDA cleared or CE-marked MWA device can be used. MWA will be performed with the intent to create a MM of at least 5 mm and ideally ≥ 10 mm. MM size will be documented intraprocedurally with contrast-enhanced computed tomography (CECT) immediately post-MWA and again within 4–8 weeks after MWA using any FDA cleared or CE-marked image-processing software to provide a 3D assessment of the ablation zone (AZ) and MM. An independent assessment of the MM by a central physician reviewer with expertise on AZ assessments will be conducted within 7 days of the MWA with 3D image-processing confirmation software and again within 7 days after the 4–8 weeks post-MWA CECT. A MM of 5.0 mm will represent the necessary condition for technical success of MWA. For MMs under 5 mm, repeat MWA will be performed within the same session whenever feasible/safe, and/or within 30 days from detection of the insufficient MM to create a sufficient MM (> 5 mm). MM size will be correlated with time to local tumor progression (TTLP). Local progression-free (LPFS) and hepatic disease-free survival (accounting for all tumors ablated) stratified by MM of 5.0–9.9 mm and ≥ 10.0 mm will be assessed with Kaplan–Meier and competing risk methodologies. This study aims to demonstrate that MWA of CLM ≤ 2.5 cm with 3D image-processing confirmation software of MM over 5 mm achieves definitive local tumor control. This will help establish margin confirmation as a new standard of care for MWA of CLM. ClinicalTrials.gov NCT05265169. Registered on January 13, 2023.

Thank you for the kind introduction. President Patel, President-elect Tam, Executive Director Hume, dear colleagues, and friends, thank you for the honor of allowing me to give the 2023 Dotter Lecture. Congratulations to the award winners this morning, Tom Sos, Curt Bakal, Ziv Haskal, and Jim Caridi. I would also like to thank the Society of Interventional Radiology (SIR) Foundation for supporting the Dotter Lecture.

In the United States, 90Y microspheres have been approved for more than 20 y for treatment of hepatic malignancies. Glass microspheres (TheraSphere; Boston Scientific) received a humanitarian device exemption for treatment of hepatocellular carcinoma (HCC) from the Food and Drug Administration (

To characterize the learning curve of implementing intracardiac echo (ICE) to guide portal vein (PV) access during transjugular intrahepatic portosystemic shunt (TIPS) creation. An institutional review board–approved retrospective review of all TIPS creations performed between 7/2016 and 10/2022 was performed. ICE was incorporated into the practice in 11/2018. Cases were divided into two groups: ICE or conventional. Cases were reviewed for time between hepatic (HV) and portal vein (PV) access (calculated by time from hepatic venogram to wire access into the PV) and categorized by operator and use of ICE. Differences in PV access time were compared using a Mann-Whitney U test. A total of 176 cases were reviewed; 89/176 (51%) used ICE. PV access times were significantly shorter when using ICE compared to when ICE was not used (33 vs 51 min, p = 0.002). Comparing the access times for cases without ICE and the first 5 cases with ICE for each provider, there was a significant reduction in time (38.5 vs 64 min, p = 0.009). PV access times using ICE did not significantly decrease over time following ICE adoption (p = 0.056). There appears to be a short learning curve for utilization of ICE for TIPS creation, with significant time savings in PV access seen within the first few instances of ICE use. Recognition of this short learning curve may make ICE-guidance during TIPS creation more attractive to interventional radiologists or institutions considering adoption of this technique.

To evaluate the impact of a change in discharge opioid prescription protocol after conventional transarterial chemoembolization (cTACE). An institutional review board–approved retrospective review of patients undergoing cTACE between 5/2021 and 5/2023 was performed. Patients were divided into pre-protocol and post-protocol groups. The protocol change in 5/2022 was a transition from prescribing 3 days of opioids for all cTACE patients to providing an opioid prescription only if a subcapsular tumor was treated or prior need for opioids after liver-directed therapy was documented. Patients were excluded for non-hepatic cTACE, incompletely documented pain/opioid prescriptions, or follow-up less than 30d. Patient demographics, relevant oncologic history, intra-procedural details, concurrent procedures, pain scores, complications, and opioid prescriptions for 30d post-procedure were recorded. Chi-squared, Fischer's exact, Mann-Whitney U, and linear regression analyses were performed to evaluate factors impacting post-discharge opioid use. 102 patients undergoing first cTACE were reviewed (pre-protocol, n=68 and post-protocol, n=34). The majority of procedures were for hepatocellular carcinoma (HCC) (n=75, 74%). The protocol change resulted in significantly fewer post-procedure opioid prescriptions (17/34 (50%) vs 56/68 (82.4%), p< 0.001) and median morphine milligram equivalents (MME) (90 (range: 0-480) vs 15 (0-195), p =0.003). There was no significant difference between groups in reported post-procedure pain after discharge (35/68 (51.5%) vs 19/34 (55.9%), p=0.67). The change in protocol did not delay opioid prescription for pain after discharge. Opioid prescriptions by interventional radiology were significantly lower in patients with concurrent opioid prescriptions from other providers (B=-39.6, p=0.02). A revised discharge opioid prescribing practice for cTACE patients results in significantly fewer opioid prescriptions and total MME by interventional radiology without increased rates of reported post-procedure pain or delayed opioid prescriptions for pain.

The purpose of this study was to review outcomes in treatment of iliocaval/iliofemoral venous disease using stents with and without a specific venous indication and identify factors that may impact patency. An institutional review board–approved retrospective review of patients with iliocaval/iliofemoral venous stent placement for both acute and chronic thrombosis between 2011 and 2022 was performed. Cases of stents placed only in the IVC or in the upper extremity/chest were excluded. Demographics, laboratory values, imaging findings, procedural details, prescription medication, stent patency, clinical symptoms, and re-intervention data were obtained. Baseline descriptive statistics were performed. Primary patency was evaluated using regression analyses. 74 patients (21 M) with median age 45 years (range: 18-82 years) underwent iliocaval/iliofemoral venous reconstruction with stenting. 66/74 (89.1%) patients were treated for chronic post-thrombotic disease. Comorbid etiologies included May-Thurner Syndrome (42/74, 56.8%), hormone use (18/74, 24.3%), and pro-thrombotic conditions (18/74, 24.3%). The median length of follow-up was 502 days (range: 4-4051 days). Stents with a specific venous indication were used in 18/74 (24.3%). Median primary patency for stents with a specific venous indication was 162.5 days (2-617 days). Median primary patency for stents without a specific venous indication was 341 days (range 1-4051 days). Rate of failure was not significantly different between stents with and without specific venous indication (6/18 (33.3%) vs. 13/56 (23.2%), p=0.39). Female patients were at a significantly higher risk of venous stent thrombosis (HR: 6.05, 95% CI: 1.35-27.10, p=0.02). Anticoagulation was associated with significantly less stent thrombosis while controlling for antiplatelet medication use (HR: 0.24, 95% CI 0.07-0.82, p=0.02). Anticoagulation regimen and female gender appear to be significantly associated with stent patency. Stent patency between FDA-approved venous stents and stents without a specific venous indication does not appear significantly different, although long-term follow-up is needed.

Purpose To demonstrate the feasibility of using chemical shift fat-water MRI methods to visualize and measure intrahepatic delivery of ethiodized oil to liver tumors following conventional transarterial chemoembolization (cTACE). Materials and Methods Twenty-eight participants (mean age, 66 years ± 8 [SD]; 22 men) with hepatocellular carcinoma (HCC) treated with cTACE were evaluated with follow-up chemical shift MRI in this Health Insurance Portability and Accountability Act-compliant prospective, institutional review board-approved study. Uptake of ethiodized oil was evaluated at 1-month follow-up chemical shift MRI. Measurements of tumor size (MRI and CT), attenuation and enhancement (CT), fat content percentage, and tumor:normal ratio (MRI) were compared by lesion for responders versus nonresponders, as assessed with modified Response Evaluation Criteria in Solid Tumors and European Association for the Study of the Liver (EASL) criteria. Adverse events and overall survival by the Kaplan-Meier method were secondary end points. Results Focal tumor ethiodized oil retention was 46% (12 of 26 tumors) at 24 hours and 47% (18 of 38 tumors) at 1 month after cTACE. Tumor volume at CT did not differ between EASL-defined responders and nonresponders (P = .06). Tumor ethiodized oil volume measured with chemical shift MRI was statistically significantly higher for EASL-defined nonresponders (P = .02). Doxorubicin dosing (P = .53), presence of focal fat (P = .83), and a combined end point of focal fat and low doxorubicin dosing (P = .97) did not stratify overall survival after cTACE. Conclusion Chemical shift MRI allowed for assessment of tumor delivery of ethiodized oil out to 1 month after cTACE in participants with HCC and demonstrated tumor ethiodized oil volume as a potential tool for stratification of tumor response by EASL criteria. Keywords: MRI, Chemical Shift Imaging, CT, Hepatic Chemoembolization, Ethiodized Oil Clinicaltrials.gov registration no.: NCT02173119 Supplemental material is available for this article. © RSNA, 2023.

Background. Pretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center.Methods. We performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months.Results. Among the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I = 1.8% and Group II = 1.9% (P = .9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P = .1 and .2, respectively).Conclusions. Our study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE.

Singal, Amit G.; Llovet, Josep M.; Yarchoan, Mark; Mehta, Neil; Heimbach, Julie K.; Dawson, Laura A.; Jou, Janice H.; Kulik, Laura M.; Agopian, Vatche G.; Marrero, Jorge A.; Mendiratta-Lala, Mishal; Brown, Daniel B.; Rilling, William S.; Goyal, Lipika; Wei, Alice C.; Taddei, Tamar H. Author Information

Histotripsy is a noninvasive, nonthermal, and nonionizing focused ultrasound method to treat cancer. Histotripsy is based on the creation of controlled acoustic cavitation from focused short-duration ultrasound pulses at high negative pressures to mechanically destroy tissue at the cellular level without damaging intervening tissue. Treatment zones are highly precise, acellular, involute rapidly, and have relative preservation of collagenous structures such as bile ducts and large vessels. The focus of this review is the development and current status of histotripsy for the treatment of liver tumors.

Objective: In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. Methods: This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) >= 3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. Results: AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. Conclusion: Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

To evaluate the safety and performance of the Caterpillar Arterial Embolization Device when used for arterial embolization

474 Background: FLO is a rare variant of liver cancer that disproportionately affects young adults and is frequently progressive and fatal as it is often detected in a clinically advanced stage. It is seldom associated with cirrhosis of liver, viral hepatitis or other risk factors associated with conventional HCC. Treatment options are largely limited to surgical resection, and there is dearth of effective targeted therapies for FLO. Methods: Comprehensive genomic profiling (CGP) was performed using the Foundation Medicine Inc. (FMI) data base on 63 FLO and 1,793 HCC clinically advanced cases between 6/2013-12/2020 using a hybrid capture-based assay of up to 324 genes a to detect genomic alterations (GA), tumor mutational burden (TMB) and microsatellite instability (MSI). PD-L1 expression in tumor cells (Dako 22C3) was measured by IHC and scored using the tumor proportion score (TPS) method. Results: The FLO patients (pts) were significantly younger than HCC pts (median age 20 vs. 64, respectively) and the male preponderance was similar. The HCC group featured significantly more GA/tumor than FLO group (3.74 vs 1.31 p<.0001). In the currently untargetable GA group, CTNNB1, TERT and TP53 GA were significantly more frequent in HCC than FLO. GA in potentially targetable genes were extremely uncommon in both FLO and HCC with HCC featuring slightly more MTOR pathway targets ( PTEN, TSC2, NF1). GA in DNA damage and repair (DDR) pathway including BRCA2 were infrequent in both groups. GA in targetable kinases including EGFR, ERBB2, ALK, RET and PIK3CA were extremely uncommon in both groups. GA associated with intrahepatic cholangiocarcinoma (IDH1, FGFR2) were extremely uncommon in these tumors. Although the mean TMB was significantly higher in HCC than FLO, overall TMB was low with very few cases having TMB > 10 mutations/Mb. PD-L1 expression was relatively low in both groups. GA in genes associated with immune checkpoint inhibitors (ICPI) drug response like PBRM1, CD274, MDM2, STK11 were rarely identified in both groups. Additional details are illustrated in the table. Conclusions: Comparison of CGP of FLO with HCC illustrates the multifarious nature of these cancers. In HCC, there is a high prevalence of GA in TERT, CTNNB1 and TP53. CGP identified certain targetable GA in the MTOR and DDR pathways and TMB was higher in HCC. These findings warrant further evaluation of clinically advanced FLO and HCC pts by CGP to identify possible targetable genomic pathways. [Table: see text]

INTRODUCTION:While adrenal venous sampling (AVS) differentiates between the unilateral and bilateral disease in patients with primary aldosteronism (PA), it is unknown if AVS can determine laterality of pheochromocytoma in patients with bilateral adrenal masses. This study analyzes adrenal vein (AV) epinephrine and norepinephrine levels in nonpheochromocytoma patients to determine the "normal" range. MATERIALS AND METHODS:We reviewed patients who underwent AVS for PA between 2009 and 2019 at a single institution; pheochromocytoma was excluded. Aldosterone, cortisol, epinephrine, and norepinephrine levels were obtained from the inferior vena cava (IVC), left adrenal vein (LAV), and right adrenal vein (RAV). Successful AV cannulation was defined by an AV/IVC cortisol ratio of ≥3:1 or an AV epinephrine level ≥364 pg/mL. Plasma measurements (pg/mL) are median values with interquartile ranges; normal ranges for epinephrine and norepinephrine are 10-200 pg/mL and 80-520 pg/mL, respectively. RESULTS:AVS was performed in 172 patients in 405 AVs (173 LAV and 232 RAV). Median epinephrine levels were IVC = 19 (14 and 34), LAV = 3811 (1870 and 6915), and RAV = 2897 (1500 and 5288). Median norepinephrine levels were IVC = 325 (186 and 479), LAV = 1450 (896 and 2050), and RAV = 786 (436 and 1582). There was a difference between LAV and RAV epinephrine levels (P = 0.024) and between LAV and RAV norepinephrine (P = 0.002) levels. CONCLUSIONS:This extensive experience with AVS demonstrated a wide range of "normal" AV catecholamine levels in patients without pheochromocytoma, which suggests that the utility of AVS to determine disease laterality in patients with pheochromocytoma and bilateral adrenal nodules is likely to be limited.