Increasing Medical Student Exposure to Interventional Radiology

Correction To: Where is the Origin of the Last Normal Branch from Feeding Artery of Pulmonary Arteriovenous Malformations? On page 1852, the first sentence of the second paragraph “In all PAVMs, the mean diameter of the feeding artery was 7.24 ± 0.015 mm, and the mean maximum diameter of the sac was 19.10 ± 0.585 mm” should be corrected to read as follows:

Transapical Coil Embolization of a Postsurgical Ascending Thoracic Aortic Pseudoaneurysm Abstract Ascending aortic pseudoaneurysms are a rare but potentially life-threatening complication of aortic root or cardiac surgery. Surgical repair is established as first-line treatment; however, patient comorbidities, technical considerations, and anatomic limitations often preclude patients from repeat surgery, thus necessitating alternative approaches. Here, we present a case of coil embolization of an ascending aortic pseudoaneurysm via a transapical approach in a particularly complex scenario where percutaneous and peripheral access was technically unfeasible.

Endovascular Neck Stabilization Before EVAR for Infrarenal Aortic Aneurysm in Chronic Aortic Dissection Abstract Background Endovascular treatment of infrarenal abdominal aortic aneurysm (AAA) with proximal chronic aortic dissection is challenging as a false and true lumen at the level of the infra-renal neck does not allow a sufficient landing zone. We describe staged endovascular neck stabilization prior to standard endovascular aortic repair (EVAR) for AAA with chronic aortic dissection. Technique To create a stable proximal neck (PN) by closing entry tears, thereby resulting in total false lumen thrombosis (FLT) prior to standard EVAR. Case 1 false lumen fenestrations were present at the descending aorta, the right renal artery orifice and PN. After closing the entry tear by thoracic EVAR, an aortic cuff was placed in the true lumen of the PN and renal stenting for the right renal artery was performed. After 2 months, total FLT was achieved, and EVAR was performed. Case 2 false lumen fenestrations were present at the descending, super celiac aorta and PN. After closing the entry by TEVAR, aortic cuffs were placed at infrarenal aorta to close residual entries. After 1 month of achieving total FLT, EVAR was performed. Both cases had no type 1 endoleak during follow-up. Conclusion The endovascular neck stabilization is a useful treatment option that facilitates standard EVAR for AAA in chronic aortic dissection.

A Simple Approach to Gastrojejunostomy Tube Exchange Complicated by Clogged Jejunal Port

Commentary on Drug-Eluting Technologies

Safety and Feasibility of Helical I-125 Seed Implants Combined with Transcatheter Arterial Chemoembolization in Hepatocellular Carcinomas with Main Portal Vein Tumor Thrombus Abstract Purpose To investigate the feasibility and safety of a helical iodine-125 (I-125) seed implant combined with transcatheter arterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (MPVTT). Methods From December 2016 to February 2018, 26 cases of HCC with MPVTT patients were enrolled in this prospective study. Helical I-125 seed implants were placed into the portal vein through the percutaneous transhepatic route. Subsequently, TACE was performed. Follow-up with enhanced CT was performed every 6–8 weeks and TACE was repeated if the residual or recurrent tumor was found. Treatment response was measured with the modified response evaluation criteria in solid tumors. Complication rates and overall survival were also evaluated. Results Implantation and TACE were successful in all patients. There were no grade ≥ 3 complications observed in the patients. The objective response rates (ORR) and disease control rates (DCR) of MPVTT at 3 months after implantation were 42.3% and 84.6%, respectively, whereas ORR and DCR of the liver lesions were 34.6% and 46.2%, respectively. The median overall survival was 10.7 months (95% CI 6.2–15.2 months). Conclusion Helical I-125 seed implants can be safely placed into the human main portal vein. Helical I-125 seed implants combined with TACE for HCC with MPVTT are safe and feasible.

A Novel Technique for the Treatment of Type 2 Endoleak After Endovascular Aortic Repair: Sac Embolization with Balloon Occlusion of the Aorta (SEBOA) Abstract Purpose We presented a new method of sac embolization using n-butyl-cyanoacrylate (NBCA) with balloon occlusion of the aorta (SEBOA) that can facilitate decreasing flow rate of the involved branches with the goal of type 2 endoleak resolution after endovascular aortic repair (EVAR). Technique This technique is demonstrated in six patients who required type 2 endoleak treatment including previous technical failure. A transarterial approach was performed in four patients and transabdominal direct puncture in two. Technical success was defined as complete embolization of both involved branches and sac on postoperative CT. Sacography under balloon occlusion of the aorta demonstrated decreased flow rate of the all involved branches in all patients. SEBOA was performed using 25 or 33% of NBCA diluted with lipiodol. Technical success was obtained in 3 of 6 patients, and one major complication was observed with adhesion of NBCA to the microcatheter resulting in foreign body retention. Conclusion SEBOA may help solve the difficulty of type 2 endoleak treatment after EVAR as decreased flow rate of the involved branches under balloon occlusion of the aorta was achieved in all patients. However, protocols regarding concentration of NBCA or using other embolic materials are needed to improve the success rate.

Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment Abstract Introduction Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC. Materials and Methods Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA. Results All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand–foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively. Conclusion Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.

CT-Guided Percutaneous Needle Biopsy in Patients with Suspected Retroperitoneal Fibrosis: A Retrospective Cohort Study Abstract Purpose The outcome of CT-guided biopsy in patients with suspected retroperitoneal fibrosis (RF), regarded as technically challenging, remains unclear. This study aimed to evaluate the results of CT-guided biopsy in patients with lesions considered in the differential diagnosis of RF and compare them with results from patients with other retroperitoneal lesions. Materials and Methods Patients who underwent CT-guided biopsy of retroperitoneal lesions between January 2010 and September 2018 were retrospectively reviewed. The study cohort with retroperitoneal lesions surrounding the infra-abdominal aorta, iliac vessels, and/or ureters was divided into two groups: Group F included patients with lesions for which RF was considered in the differential diagnosis, and Group C comprised patients with a retroperitoneal mass or lymphadenopathy. Lesion size and depth, and biopsy details including technical success, position, procedure time, diagnostic yield, and complications between the two groups were compared. Results Group F included 27 patients (mean age 68.5 years ± 11.6, 17 male) and Group C 30 patients (mean age 65.0 years ± 11.8, 16 male). The short axis was significantly smaller in Group F than in Group C (19 mm vs 26 mm, P = 0.041), and procedure time was significantly longer in Group F than in Group C (31.5 min ± 13.2 vs 20.3 min ± 8.4, P = 0.001). Technical success rate (93% vs 100%), accuracy (93% vs 93%), and complications (3.7% vs 10%) between Groups F and C were not significantly different. Conclusions CT-guided biopsy of patients with suspected RF is considered safe and effective.