Strategies in Interventional Radiology: Formation of an Interdisciplinary Center of Vascular Anomalies - Chances and Challenges for Effective and Efficient Patient Management

Background Radiology is an interdisciplinary field dedicated to the diagnosis and treatment of numerous diseases and is involved in the development of multimodal treatment concepts. Method Interdisciplinary case management, a broad spectrum of diagnostic imaging facilities and dedicated endovascular radiological treatment options are valuable tools that allow radiology to set up an interdisciplinary center for vascular anomalies. Results Image-based diagnosis combined with endovascular treatment options is an essential tool for the treatment of patients with highly complex vascular diseases. These vascular anomalies can affect numerous parts of the body so that a multidisciplinary treatment approach is required for optimal patient care. Conclusion This paper discusses the possibilities and challenges regarding effective and efficient patient management in connection with the formation of an interdisciplinary center for vascular anomalies with strengthening of the clinical role of radiologists. Key points  · Vascular anomalies, which include vascular tumors and malformations, are complex to diagnose and treat.. · There are far more patients with vascular anomalies requiring therapy than interdisciplinary centers for vascular anomalies - there is currently a shortage of dedicated interdisciplinary centers for vascular anomalies in Germany that can provide dedicated care for affected patients.. · Radiology includes a broad spectrum of diagnostic and minimally invasive therapeutic tools which allow the formation of an interdisciplinary center for vascular anomalies for effective, efficient and comprehensive patient management.. Citation Format · Sadick M, Dally FJ, Schönberg SO et al. Strategies in Interventional Radiology: Formation of an Interdisciplinary Center of Vascular Anomalies - Chances and Challenges for Effective and Efficient Patient Management. Fortschr Röntgenstr 2017; 189: 957 - 966.

Interdisciplinary Management of Head and Neck Vascular Anomalies: Clinical Presentation, Diagnostic Findings and Minimalinvasive Therapies

OBJECTIVES

Vascular anomalies are included in the 30 000 rare diseases worldwide affecting less than 5/10 000 people. Depending on their morphology and biological properties, they can cause varied disorders with organ involvement. Almost 60% of vascular anomalies have a predilection for the head and neck region in children. Clinical and scientific effort to establish interdisciplinary management concepts for vascular anomalies is increasing worldwide.

METHODS

Especially in the head and neck region, clinical impairment and organ dysfunction is associated with cosmetic issues that may represent a physical and psychological issue for the patient. Correct diagnosis, based on clinical presentation and symptoms, is a prerequisite for appropriate therapy, ranging from conservative management to a spectrum of minimally invasive treatment options. We searched PubMed for German and English language published data until December 2016 with focus on clinical studies, review articles and case reports on vascular anomalies with a focus on the head and neck region.

RESULTS

The last ISSVA update in 2014 has contributed to a better understanding of vascular anomalies, classifying them in vascular tumors and vascular malformations. The predominant representatives of vascular tumors are congenital and infantile hemangiomas. Infantile hemangiomas have the ability of spontaneous regression in more than 80%. Patients with symptomatic growing hemangiomas with ulcerations, bleeding complications and restriction of hearing, swallowing disorder, impairment of vision, or cosmetic dysfigurement require treatment. Therapies include oral propanolol, transcatheter embolization and surgery. Vascular malformations tend to progress with patientś age and are subdivided in slow flow and fast flow lesions. Symptomatic slow flow lesions, e.g. venous and lymphatic malformations, benefit from percutaneous sclerotherapy. Fast flow lesions, as arteriovenous malformations, are rare but undoubtedly therapeutically the most challenging vascular anomaly. Depending on location and size, they may require multiple transcatheter embolization procedures for successful occlusion of the AVM.

CONCLUSIONS

This review provides knowledge on the current ISSVA classification of vascular anomalies, their clinical presentation, diagnostic evaluation and minimally invasive therapy options to encourage the establishment of a comprehensive interdisciplinary management for head and neck vascular anomalies.

The "Intermediate" CD14++CD16+ monocyte subset increases in severe peripheral artery disease in humans

Monocytes are key players in atherosclerotic. Human monocytes display a considerable heterogeneity and at least three subsets can be distinguished. While the role of monocyte subset heterogeneity has already been well investigated in coronary artery disease (CAD), the knowledge about monocytes and their heterogeneity in peripheral artery occlusive disease (PAOD) still is limited. Therefore, we aimed to investigate monocyte subset heterogeneity in patients with PAOD. Peripheral blood was obtained from 143 patients suffering from PAOD (Rutherford stage I to VI) and three monocyte subsets were identified by flow cytometry: CD14⁺⁺CD16⁻ classical monocytes, CD14⁺CD16⁺⁺ non-classical monocytes and CD14⁺⁺CD16⁺ intermediate monocytes. Additionally the expression of distinct surface markers (CD106, CD162 and myeloperoxidase MPO) was analyzed. Proportions of CD14⁺⁺CD16⁺ intermediate monocyte levels were significantly increased in advanced stages of PAOD, while classical and non-classical monocytes displayed no such trend. Moreover, CD162 and MPO expression increased significantly in intermediate monocyte subsets in advanced disease stages. Likewise, increased CD162 and MPO expression was noted in CD14⁺⁺CD16⁻ classical monocytes. These data suggest substantial dynamics in monocyte subset distributions and phenotypes in different stages of PAOD, which can either serve as biomarkers or as potential therapeutic targets to decrease the inflammatory burden in advanced stages of atherosclerosis.

Increased intermediate CD14++CD16++ monocyte subset levels associate with restenosis after peripheral percutaneous transluminal angioplasty

BACKGROUND AND AIMS

We aimed at studying the association of three major human monocyte subsets after percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal disease.

METHODS

We prospectively studied 67 sequential patients (40 male, 27 female; mean age 71 ± 11 years) treated with femoropopliteal angioplasty. Multi-color flow cytometry characterized monocyte subsets from venous blood for expression of CD14 and CD16 and intracellular myeloperoxidase (MPO) prior to, and 3, 6 and 12 months post PTA. Analyses tested associations between monocyte subsets and risk for restenosis.

RESULTS

16/67 patients (24%) developed restenosis within 12 months after PTA. Patients with hyperlipidemia had increased risk for restenosis (HR = 1.7, 95% CI 0.7-2.9, p = 0.001). Increased baseline monocytes associated with an increased risk of late restenosis (HR = 4.9, 95% CI: 1.3-18.6, p = 0.047). CD14⁺⁺CD16⁺⁺ 'intermediate' monocytes assessed at baseline, and after 3, 6, and 12 months significantly associated with the risk for subsequent restenosis: HR = 3.9 (95% CI: 2.4-6.5, p = 0.029), HR = 5.7 (95% CI = 0.7-44.7, p = 0.013), HR = 6.5 (95% CI: 2.5-16.9, p = 0.001) and HR = 1.5 (95% CI = 1.4-15.5 p = 0.001), respectively. Moreover, the probability for freedom of restenosis decreased with increased levels of intermediate subsets at 12 months after PTA. Additionally, intracellular MPO expression in CD14⁺⁺CD16⁺⁺ measured at 3, 6 and 12 months associated with an increased restenosis risk (HR = 1.5, 95% CI: 0.8-2.1, p = 0.214, HR = 1.9, 95% CI: 1.0-2.3 p = 0.051 and HR = 1.4, 95% CI: 1.0-1.8, p = 0.052).

CONCLUSIONS

Our results imply altered innate immunity after angioplasty. Elevated CD14⁺⁺CD16⁺⁺ intermediate monocyte frequencies and increased MPO expression may identify individuals at heightened risk for restenosis.

Direct Effective Dose Calculations in Pediatric Fluoroscopy-Guided Abdominal Interventions with Rando-Alderson Phantoms - Optimization of Preset Parameter Settings

Objective

The aim of the study was to calculate the effective dose during fluoroscopy-guided pediatric interventional procedures of the liver in a phantom model before and after adjustment of preset parameters.

Methods

Organ doses were measured in three anthropomorphic Rando-Alderson phantoms representing children at various age and body weight (newborn 3.5kg, toddler 10kg, child 19kg). Collimation was performed focusing on the upper abdomen representing mock interventional radiology procedures such as percutaneous transhepatic cholangiography and drainage placement (PTCD). Fluoroscopy and digital subtraction angiography (DSA) acquisitions were performed in a posterior-anterior geometry using a state of the art flat-panel detector. Effective dose was directly measured from multiple incorporated thermoluminescent dosimeters (TLDs) using two different parameter settings.

Results

Effective dose values for each pediatric phantom were below 0.1mSv per minute fluoroscopy, and below 1mSv for a 1 minute DSA acquisition with a frame rate of 2 f/s. Lowering the values for the detector entrance dose enabled a reduction of the applied effective dose from 12 to 27% for fluoroscopy and 22 to 63% for DSA acquisitions. Similarly, organ doses of radiosensitive organs could be reduced by over 50%, especially when close to the primary x-ray beam.

Conclusion

Modification of preset parameter settings enabled to decrease the effective dose for pediatric interventional procedures, as determined by effective dose calculations using dedicated pediatric Rando-Alderson phantoms.

The Influence of Preoperative Aneurysmal Thrombus Quantity and Distribution on the Development of Type II Endoleaks with Aneurysm Sac Enlargement After EVAR of AAA

PURPOSE

To determine the influence of preoperative aneurysmal thrombus quantity and distribution on the development of type II endoleak with aneurysm sac enlargement after endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

We retrospectively analyzed the pre- and postoperatively performed CT scans of 118 patients who had follow-up imaging for at least 1 year after EVAR available. We assessed preoperative thrombus perimeter (T Peri), diameter (T Dia), cross-sectional area (T CSA), and volume (T Vol). The preoperative thrombus distribution was classified into no thrombus, semilunar-shaped (anterior, right side, left side, posterior) thrombus, and circumferential type thrombus. The number of preoperative patent aortic side branches (ASB) was identified. Endpoint was type II endoleak with aneurysm volume (A Vol) increase of ≥5 % during follow-up.

RESULTS

During follow-up (2 years, range 1-9 years), 17 patients with type II endoleak had significant A Vol increase. Less preoperative T Peri, T Dia, T CSA, and T Vol were associated with A Vol increase. A circumferential thrombus distribution significantly protected against aneurysm enlargement (p = 0.028). The variables with the strongest significance for A Vol increase were preoperative T Vol/A Vol ratio (OR 0.95; p = 0.037) and number of patent ASB (OR 3.52; p < 0.001).

CONCLUSION

A low preoperative T Vol/A Vol ratio and a high number of patent ASB were associated with aneurysm sac enlargement after EVAR.

Clinical Management of Acute Portal/Mesenteric Vein Thrombosis

Background

Acute thrombosis of the portal vein (PV) and/or the mesenteric vein (MV) is a rare but potentially life-threatening disease. A multitude of risk factors for acute portal vein thrombosis (PVT)/mesenteric vein thrombosis (MVT) have been identified, including liver cirrhosis, malignancy, coagulation disorders, intra-abdominal infection/inflammation, and postoperative condition.

Methods

This article analyses the treatment options for acute PVT/MVT.

Results

Initially, the clinical management should identify patients with an intra-abdominal focus requiring immediate surgical intervention (e.g. bowel ischaemia). Subsequently, emphasis is placed on the recanalization of the PV/MV or at least the prevention of thrombus extension to avoid long-term complications of portal hypertension. Several therapeutic options are currently available, including anticoagulation therapy, local/systemic thrombolysis, interventional or surgical thrombectomy, and a combination of these procedures. Due to the lack of prospective randomized studies, a comparison between these therapeutic approaches regarding the efficacy of PV/MV recanalization is difficult, if not impossible.

Conclusion

In patients with acute PVT/MVT, an individualized treatment based on the clinical presentation, the underlying disease, the extent of the thrombosis, and the patients' comorbidities is mandatory. Therefore, these patients should be considered for an interdisciplinary therapy in specialized centres with the option to utilise all therapeutic approaches currently available.

CT features of early type II endoleaks after endovascular repair of abdominal aortic aneurysms help predict aneurysm sac enlargement

PURPOSE

To determine computed tomographic (CT) features of early type II endoleaks associated with aneurysm sac enlargement after endovascular aortic aneurysm repair (EVAR) of abdominal aortic aneurysm.

MATERIALS AND METHODS

Institutional review board approval was not required for this retrospective study. The authors reviewed imaging and clinical data from 56 patients (seven women, 49 men; mean age ± standard deviation, 71 years ± 7.9; age range, 52-85 years) with early type II endoleak who had undergone EVAR between December 2002 and December 2011 and who had been followed up with imaging and clinical evaluation for at least 6 months. The number and diameter of all feeding and/or draining arteries were measured, and endoleaks were classified according to their sources into simple inferior mesenteric artery (IMA), simple lumbar artery (LA), complex LA, and complex IMA-LA type II endoleaks. Volume and attenuation of the nidus were measured. Aneurysm enlargement was defined as an increase in the aneurysm volume of more than 5% during follow-up. Simple and multivariate logistic regression analyses were performed to identify independent clinical and imaging variables associated with aneurysm enlargement.

RESULTS

Twenty-three of the 56 patients (41%) showed aneurysm sac enlargement during follow-up (mean follow-up, 3.0 years ± 2.0). With the multivariate model, the variables that showed the strongest indicators for aneurysm sac enlargement were complex IMA-LA type II endoleak (odds ratio [OR] = 10.29, P = .004) and the diameter of the largest feeding and/or draining artery (OR = 4.55, P = .013). Patients without complex IMA-LA type II endoleak in whom the largest feeding and/or draining artery was larger than 3.8 mm and patients with a complex IMA-LA type II endoleak in whom the largest feeding and/or draining artery was larger than 2.2 mm were at high risk for aneurysm sac enlargement.

CONCLUSION

The strongest indicators for aneurysm sac enlargement are complex IMA-LA type II endoleak and the diameter of the largest feeding and/or draining artery.

[Do we need hybrid operating theaters?: a critical appraisal]

CLINICAL ISSUE

Infrastructural improvements with a combination of interventional and open surgical procedures.

STANDARD TREATMENT

Separate performance of interventional and open surgical procedures.

TREATMENT INNOVATIONS

Implementation of hybrid operating rooms.

DIAGNOSTIC WORK-UP

Intraoperative high-quality digital subtraction angiography.

PERFORMANCE

Best hygienic conditions Intraoperative improved image quality Improved patient management Increased patient safety Broadening of indications

ACHIEVEMENTS

Major improvement from a medical standpoint Different implications from a management perspective Economic aspects challenging

PRACTICAL RECOMMENDATIONS

Exact planning of all aspects and effects is necessary.

Gelfoam for closure of large percutaneous transhepatic and transsplenic puncture tracts in pediatric patients

PURPOSE

Evaluation of the efficacy and safety of Gelfoam for the closure of transhepatic or transsplenic parenchymal puncture tracts with large-bore sheaths in pediatric patients.

MATERIALS AND METHODS

Between January 2012 and May 2013, 8 percutaneous transhepatic accesses and 3 percutaneous transsplenic accesses were closed using percutaneous Gelfoam in pediatric patients. The primary study endpoints to determine treatment efficacy and safety were patient survival, technical success defined as successful closure of the puncture tract without signs of bleeding, and complication rates. The secondary study endpoints were the occurrence of local and systemic inflammation.

RESULTS

Overall survival was 100 % with a median follow-up of 256 days. The procedure was technically successful in 10 of 11 procedures. One patient suffered from bleeding, which was successfully managed by a single blood transfusion. No re-bleeding was detected during follow-up and no surgical interventions were necessary. No signs of local or systemic infections related to the Gelfoam application occurred.

CONCLUSION

Percutaneous Gelfoam application is an effective and safe technique for the closure of transhepatic or transsplenic accesses in pediatric patients.

KEY POINTS

Interventional closure of large transhepatic and transsplenic parenchymal accesses in children after interventional treatment is recommended to avoid bleeding. Gelfoam application does not cause artifacts in magnetic resonance imaging and does not increase the risk of local or systemic inflammation in comparison to permanent embolic agents. Thus, especially children under immunosuppressive therapy can benefit from the application of Gelfoam.

[Potential and limitations of modern embolization therapy]

Correct clinical and angiographic classification of vascular anomalies, including consideration of their flow pattern (high-flow versus low-flow), is the basis of accurate indications for minimally invasive therapy modalities such as embolization. Technical advancements and miniaturization of catheter materials (including steerable microwires, flow-directed microcatheters and detachable tips) gained access for embolotherapy to lesions anywhere in the body. The aim of embolization, which is mainly indicated for therapy of high-flow arteriovenous malformations, is the complete, permanent occlusion of the lesion nidus. Nowadays, embolotherapy is performed using permanent liquid embolization agents, in multiple staged sessions. This technique reduces complications such as ischemic necrosis and peripheral nerve lesions compared to alcohol embolization. Sole occlusion of the arterial inflow by surgical resection or interventional coil application is considered obsolete. The size of the lesion and the high treatment costs limit the use of embolotherapy.

Degradable starch microspheres versus ethiodol and doxorubicin in transarterial chemoembolization of hepatocellular carcinoma

PURPOSE

To compare outcomes of transarterial chemoembolization with degradable starch microspheres (DSMs) and conventional transarterial chemoembolization with doxorubicin and Ethiodol in patients with unresectable intermediate-stage hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 69 patients underwent 169 chemoembolization procedures with Ethiodol (n = 35) or DSMs (n = 34) as the embolic agent. The same chemotherapeutic agent was used for all patients (50 mg doxorubicin). The primary endpoint was patient survival, and secondary endpoints were local tumor response and incidence of therapy-associated complications with conventional or DSM chemoembolization. Tumor response was evaluated by consensus reading by two radiologists in accordance with modified Response Evaluation Criteria In Solid Tumors. Mean survival was calculated according to Kaplan-Meier analysis, and differences in survival curves were assessed by univariate log-rank test. The statistical significance of quantitative variables was determined by parameter-free Wilcoxon-Mann-Whitney U test.

RESULTS

The study groups were similar with regard to demographic data and disease stage. For the DSM chemoembolization group, the objective response rate (ie, complete or partial response) was 44.1%, and the rate of stable disease was 38.2%. The respective rates for the conventional chemoembolization group were 48.6% and 31.4%. Mean survival (P = .337) and complications did not significantly differ between groups (P = .907; P = 1.000).

CONCLUSIONS

DSM chemoembolization represents an alternative method of HCC treatment with a safety profile similar to that of conventional transarterial chemoembolization. Regarding local tumor response and overall survival, results of DSM chemoembolization were similar to those of conventional chemoembolization.