Catheters in vascular interventional radiology: an illustrated review

The past five decades have seen significant developments in the knowledge and practice of interventional radiology. Advancements in angiographic equipment have made interventional radiology a safe, minimally invasive preferred option in the treatment of a variety of diseases. Today, a range of catheters are available in the armamentarium of the interventional radiologist to suit different needs when conducting diagnostic angiograms or performing interventions in various vascular territories. The hardware required for interventions includes needles, wires, catheters, balloons, and stents. Catheters, in particular, are an invaluable tool for interventionists. The purpose of this review is to describe the identification characteristics, properties, and uses of the common angiographic catheters used in interventional radiology, with a special focus on peripheral vascular interventions (excluding neurointerventions).

Insights into pelvic venous disorders

Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients-mainly young women's quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.

Door-in-door-out times for patients with large vessel occlusion ischaemic stroke being transferred for endovascular thrombectomy: a Victorian state-wide study

Background

Time to reperfusion is an important predictor of outcome in ischaemic stroke from large vessel occlusion (LVO). For patients requiring endovascular thrombectomy (EVT), the transfer times from peripheral hospitals in metropolitan and regional Victoria, Australia to comprehensive stroke centres (CSCs) have not been studied.

Aims

To determine transfer and journey times for patients with LVO stroke being transferred for consideration of EVT.

Methods

All patients transferred for consideration of EVT to three Victorian CSCs from January 2017 to December 2018 were included. Travel times were obtained from records matched to Ambulance Victoria and the referring centre via Victorian Stroke Telemedicine or hospital medical records. Metrics of interest included door-in-door-out time (DIDO), inbound journey time and outbound journey time.

Results

Data for 455 transferred patients were obtained, of which 395 (86.8%) underwent EVT. The median DIDO was 107 min (IQR 84-145) for metropolitan sites and 132 min (IQR 108-167) for regional sites. At metropolitan referring hospitals, faster DIDO was associated with use of the same ambulance crew to transport between hospitals (75 (63-90) vs 124 (99-156) min, p<0.001) and the administration of thrombolysis prior to transfer (101 (79-133) vs 115 (91-155) min, p<0.001). At regional centres, DIDO was consistently longer when patients were transported by air (160 (127-195) vs 116 (100-144) min, p<0.001). The overall door-to-door time by air was shorter than by road for sites located more than 250 km away from the CSC.

Conclusion

Transfer times differ significantly for regional and metropolitan patients. A state-wide database to prospectively collect data on all interhospital transfers for EVT would be helpful for future study of optimal transport mode at regional sites and benchmarking of DIDO across the state.

The Complexity of Online Patient Education Materials About Interventional Neuroradiology Procedures Published by Major Academic Institutions

Introduction Health literacy is an independent predictor of population health status and is directly related to the readability of available patient education material. The National Institutes of Health (NIH) and the American Medical Association have recommended that patient education materials (PEMs) be written between a fourth- and a sixth-grade education level. The authors assessed the readability of online PEMs about neurointerventional procedures that have been published by several academic institutions across the US. Methods Online PEMs regarding five common neurointerventional procedures, including mechanical thrombectomy for large vessel occlusion, cerebral diagnostic angiography, carotid artery stenting, endovascular aneurysm embolization, and epidural steroid injection collected from the websites of 20 top institutions in Neurology and Neurosurgery. The materials were assessed via five readability scales and then were statistically analyzed and compared to non-institutional education websites (Wikipedia.com and WebMD.com). Results None of the PEMs were written at or below the NIH's recommended 6th-grade reading level. The average educational level required to comprehend the texts across all institutions, as assessed by the readability scales, was 10-11^th grade level. Some materials required a college-level education or higher. Material from non-institutional websites had significantly lower readability scores compared to the 20 institutions. Conclusions Current PEMs related to neurointerventional procedures are not written at or below the NIH's recommended fourth- to sixth-grade education level. Given the complexity of those procedures, significant attention should be pointed toward an improvement in the available online materials.

Effects of Postpartum Family Planning Counselling on Contraceptives Knowledge, Attitude and Intention Among Women Attending a General Hospital in The Gambia: A Randomized Controlled Trial

Purpose

This study aimed to evaluate the effectiveness of PPFP counselling on contraceptives knowledge, attitudes and intention among women attending a general hospital in The Gambia.

Materials and Methods

A quasi-experimental design with an intervention and comparison group was used. The intervention was PPFP counselling using the GATHER approach. A sample size of 674 participants was determined by a formula for comparison between the two groups. The questionnaire was developed based on a literature review and was pre-tested on 10% of the total study sample size (68). A reliability of 0.731 was obtained. A systematic random sampling method was employed to select study participants who met the inclusion criteria. Data were collected during face-to-face interviews in local languages with a 100% response rate at baseline and 96% at post-test. Data were analysed using the SPSS version 21.00 and the statistical analysis included both descriptive and inferential methods. An ethical approval was obtained from the Research and Ethics Committee, School of Basic Medical Sciences, College of Medicine, University of Benin (CMS/REC/2017/017) and the Gambia Government/Medical Research Council Laboratories Joint Ethics Committee (R017016Av1.1).

Results

Baseline respondents' socio-demographic characteristics revealed that the two groups had similar characteristics. A statistically significant difference existed on knowledge, attitude, and intention to use contraceptive methods between the intervention and comparison groups at post-intervention (p<0.05) while no significant difference was observed at baseline. Significant gains were achieved in the intervention group in terms of knowledge, attitude, and intention post-intervention.

Conclusion

PPFP counselling during the postpartum period and before the discharge of women from the hospital may improve knowledge, attitude and intention to use contraceptives and, therefore, increase the likelihood of contraceptive uptake and thus prevent unwanted and closely spaced pregnancies.

Microwave ablation without subsequent lumpectomy versus breast-conserving surgery for early breast cancer: a propensity score matching study

PURPOSE

To compare the efficacy of ultrasound-guided percutaneous microwave ablation (MWA) without subsequent lumpectomy and breast-conserving surgery (BCS) in patients with early breast cancer (BC).

MATERIALS AND METHODS

This retrospective cohort study enrolled 106 patients with early BC (T_0/1/2 N_0/1 M₀) treated by MWA (n = 21) or BCS (n = 85) from October 2014 to December 2020. Propensity score matching (PSM) was performed to balance the baseline characteristics between MWA and BCS groups. The tumor progression, overall survival (OS), disease-specific survival (DSS), complications, and cosmetic results were compared.

RESULTS

After PSM, there were 21 patients with balanced baseline characteristics in each group. After a median follow-up of 43 months (range, 15-89 months), there was no significant difference in tumor progression (10% vs 2%, p = 0.18), OS (96% vs 99%, p = 0.36), DSS (100% vs 99%, p > 0.99), and complications (0% vs 19%, p = 0.58). The operation time of MWA was shorter (60 min vs 101 min, p < 0.001) than that of BCS. For the management of metastatic lymph nodes, five (5/21, 24%) patients with six metastatic nodes underwent ablation in the MWA group and three patients (3/21, 14%) with six metastatic nodes underwent axillary lymph node dissection in the BCS group. All the patients in the MWA group reported excellent cosmetic results, but 29% of BCS patients expressed dissatisfaction with breast asymmetry (10%) and scar formation (19%) (p < 0.001).

CONCLUSION

This pilot study indicated that in selected early BC patients, microwave ablation without subsequent lumpectomy had comparable tumor control effect with breast-conserving surgery and better cosmetic results at an intermediate follow-up.HighlightsMWA without subsequent lumpectomy has a comparable interim survival effect and better cosmetic results as BCS in the treatment of selected early breast cancer.MWA has the potential to be a viable and promising therapeutic option for breast cancer patients reluctant or intolerant to surgery with the advantage of minimal invasion.

Recent advances in catheter devices for patent foramen ovale closure

INTRODUCTION

Over the last 5 years, the armamentarium of the interventional cardiologist dealing with percutaneous closure of patent foramen ovale (PFO) has been enriched by some novel devices and further improvements of existing ones that have or promise to increase the safety and effective closure rate of PFO patients.

AREAS COVERED

This review presents and discusses recent advancements in device design and composition from both technical and clinical perspectives.

EXPERT OPINION

Device technology is continuously evolving. The recent modification of delivery system, device hooking, and composition, as well as the advent of new bioabsorbable materials, is promising to make percutaneous PFO closure devices safer. The search for more effectiveness with possibly less metal behind is still ongoing.

Efficacy of Ultrasound-Guided Injection of Botulinum Toxin, Ozone, and Lidocaine in Piriformis Syndrome

Background: Piriformis syndrome (PS) is a painful musculoskeletal condition characterized by a deep gluteal pain that may radiate to the posterior thigh and leg. This study was designed to compare the effectiveness of ozone and BTX to lidocaine injection in treating piriformis syndrome that was resistant to medication and/or physical therapy. Study design: Between November 2018 and August 2019, we involved eighty-four subjects diagnosed with piriformis syndrome in a double-blinded, prospective, randomized comparative study to receive an ultrasound-guided injection of lidocaine (control group), botulinum toxin A, or local ozone (28 patients each group) in the belly of the piriformis muscle. Pain condition evaluated by the visual analog score (VAS) was used as a primary outcome, and the Oswestry Disability Index (ODI) as a secondary outcome, before, at one month, two months, three months, and six months following the injection. Results: The majority (58.3%) of patients were male, while (41.7%) were female. At one month, a highly significant decrease occurred in VAS and ODI in the lidocaine and ozone groups compared to the botulinum toxin group (p < 0.001). At six months, there was a highly significant decrease in VAS and ODI in the botulinum toxin group compared to the lidocaine and ozone groups (p < 0.001). Conclusion: Botulinum toxin may assist in the medium- and long-term management of piriformis syndrome, while lidocaine injection and ozone therapy may help short-term treatment in patients not responding to conservative treatment and physiotherapy.

Tunneled Hemodialysis Catheter Insertion: Technical and Clinical Considerations

Tunneled hemodialysis catheter insertion is a common and important procedure. Clinicians involved in the placement or maintenance of tunneled catheters require an appreciation of their best clinical application. Although comprehensive guidelines are available, many aspects of the published literature on this subject remain uncertain. This primer offers a concise, evidence-based discussion of 10 fundamental, everyday questions with respect to tunneled hemodialysis catheter insertion.

Outcomes of a High-Volume Organ Procurement Organization in the Era of Increasing Donation After Circulatory Death

Introduction: Donation after circulatory death (DCD) is rapidly increasing in the United States. Detailed data outlining the process from referral to organ transplantation is lacking. Project Aims: We sought to quantify differences at each stage along the referral to donation pathway by donor type. Additionally, we examined factors associated with successful DCD organ utilization. Design: This program evaluation analyzed data from a single organ procurement organization in 2018 to assess demographic and clinical predictors of progression through the donation process, including the role of first-person authorization in DCD. Descriptive statistics were examined by donation stage for demographic characteristics using chi-square; univariate and multivariate logistic regression was used to model predictors of utilization and authorization by organ type, respectively. Results: There were 2466 organ donation referrals during 2018, including 575 donations after brainstem death (DBD), 1890 controlled DCD referrals, and 1 uncontrolled DCD referral. Univariate and multivariate logistic regression models highlighted differences in authorization rates by donor type (DCD vs DBD) and by age, race, and ethnicity. Next-of-kin authorization was declined in 23% of first-person authorized potential DCD, highlighting issues related to the role of donor registration in DCD. Pre-mortem heparin administration was predictive of DCD organ utilization; donor age and warm ischemia time of less than 30 min was statistically significantly associated with DCD extra-renal organ utilization. Conclusion: These results provided insight into strategies for increasing authorization and transplantation of organs from DCD donors and identified areas of improvement for process standardization and policy development.

Assessing the Effectiveness of a Primary Care Provider Office-Based Intervention for Increasing Organ Donor Registration Rates in Two New York State Counties

Introduction: Despite strong public support, organ donor registration rates (RR) continue to lag while need only grows. In the United States, the traditional registration site is the Department of Motor Vehicles (DMV), however Primary care provider (PCP) offices have been considered as alternate locations for increasing RR. Methods: Twelve PCP offices across 2 New York Counties were subjected to a control week where participants received only a registration opportunity and an intervention week with the addition of a motivational poster and informational brochure. Zip code level sociodemographic data were obtained for each site. RR from the DMV over the same period served as historical control. Results: There were 1292 participants in the control phase and 1099 in the experimental phase. New registration rate for the control was 33.8% (289/897); experimental phase 7.88% (61/769); DMV registration 21.02% (1902/9050). The intervention was associated with a significant decrease in registrations (OR 0.181 (95% CI 0.135-0.244, P < 0.001)). Offices were clustered based on sociodemographic factors and regressed in 2 clusters. Lower educational attainment was associated with lower registration in the first but not second cluster (OR = 0.948 (0.923-0.974, P < 0.001)). Conclusions: This study provided evidence that PCP offices were a feasible site for organ donor registration and calls into question the efficacy of written materials-only interventions for increasing organ donor RR. It reiterated the negative effect of lower educational attainment on registration and suggested future studies focus on more active methods of engagement.

Chronic Pain: An Update of Clinical Practices and Advances in Chronic Pain Management

Chronic pain affects a significant amount of the population and represents a heavy personal and socioeconomic burden. Chronic pain mechanisms can be categorized as nociceptive, neuropathic, or nociplastic. Although mechanism-based pain treatment is optimal, different types of pain mechanisms may overlap in patients. Recently, the biopsychosocial model with the multidisciplinary pain management program is widely accepted as one of the most effective methods to assess and manage chronic pain. The treatment of chronic pain consists of a personalized, stepwise, and multimodal approach that includes pharmacotherapy, psychotherapy, integrative treatments, and interventional procedures. Somatic and peripheral nerve blocks for the treatment of chronic pain are often deferred. With the increasing use of ultrasound in pain medicine, newly defined interfascial plane blocks, which may be performed alone or as an adjuvant to multimodal management, have gained popularity. Adequate pain management can improve physical functioning, mental health and quality of life indicators, and reduce pain chronification. The aim of this current article is to perform a comprehensive and updated review of existing treatment options, particularly interfascial plane blocks in chronic pain syndromes.

Complete Surgical Excision Is Necessary following Vacuum-Assisted Biopsy for Breast Cancer

Vacuum-assisted breast biopsy (VABB) has been replacing excisional biopsy in the treatment of benign breast lesions. Complete surgical excision is still needed for the lesions occasionally diagnosed with breast cancer after VABB. We aimed to characterize residual tumors after VABB and define a subset of patients who do not need surgical excision after VABB. From a retrospective database, we identified patients diagnosed with breast cancer after VABB guided with ultrasonography. Patients who underwent stereotactic biopsies were excluded. We reviewed clinicopathologic data and radiologic findings of the sample. We identified 48 patients with 49 lesions. After surgical excision, the residual tumors were identified in 40 (81.6%) lesions, and there was no residual tumor in nine (18.3%) patients. Imaging studies could not accurately locate residual tumors after VABB. A small tumor size on a VABB specimen was associated with no residual tumor on final pathology. However, residual tumors were identified in four (40%) of 10 lesions with a pathologic tumor size less than 0.5 cm. In conclusion, complete surgical excision remains the primary option for most of the patients diagnosed with breast cancer after VABB. Imaging surveillance without surgery should be carefully applied for selected low-risk patients.

Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review

Musculoskeletal soft-tissue infections include a wide range of clinical conditions that are commonly encountered in both emergency departments and non-emergency clinical settings. Since clinical signs, symptoms, and even laboratory tests can be unremarkable or non-specific, imaging plays a key role in many cases. MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections. Ultrasound is a fundamental tool, especially for the evaluation of superficially located diseases and for US-guided interventional procedures, such as biopsy, needle-aspiration, and drainage. Conventional radiographs can be very helpful, especially for the detection of foreign bodies and in cases of infections with delayed diagnosis displaying bone involvement. This review article aims to provide a comprehensive overview of the radiological tools available and the imaging features of the most common musculoskeletal soft-tissue infections, including cellulitis, necrotizing and non-necrotizing fasciitis, foreign bodies, abscess, pyomyositis, infectious tenosynovitis, and bursitis.

Ultrasound-Guided Percutaneous Arteriovenous Fistula Creation Simulation Training in a Lifelike Flow Model

Objectives: To assess the feasibility and training effect of simulation training for ultrasound-guided percutaneous arteriovenous fistula (pAVF) creation in a lifelike flow model. Methods: Twenty vascular trainees and specialists were shown an instructional video on creating a pAVF in a dedicated flow model and then randomized to a study or control group. The procedure was divided into five clearly defined steps. Two observers rated the performance on each step, and the time to perform the exercise was recorded. The study group participants underwent supervised hands-on training on the model before performing a second rated pAVF creation. All participants subsequently completed a feedback questionnaire. Results: After supervised simulation training, the study groups participants increased their mean performance rating from 2.2 ± 0.9 to 3.2 ± 0.7. A mean of 3.8 ± 0.8 procedure steps was accomplished independently (control group 2.1 ± 1.4; p < 0.05). The time taken to perform the procedure was 15.6 ± 3.8 min in the study group (control group 27.2 ± 7.3, p < 0.05). The participants with previous experience in ultrasound-guided vascular procedures (n = 5) achieved higher overall mean scores 3.0 ± 0.8 and accomplished more steps without assistance (2.0 ± 1.0) during the simulation training compared to their inexperienced peers (1.5 ± 0.3 and 0.8 ± 0.4, respectively). The feedback questionnaire revealed that the study group participants strongly agreed (n = 7) or agreed (n = 3) that training on the simulation model improved their skills regarding catheter handling. Conclusions: The study group participants increased their overall performance after training on the simulator. More experienced attendees performed better from the beginning, indicating the model to be lifelike and a potential skill assessment tool. Simulation training for pAVF creation using a lifelike model may be an intermediate step between acquiring ultrasound and theoretical pAVF skills and procedure guidance in theatre. However, this type of training is limited by its reliance on the simulator quality, demonstration devices and costs.

MitraClip™ implantation plus left atrial appendage occlusion in a hereditary hemorrhagic telangiectasia patient

Hereditary hemorrhagic telangiectasia is regarded as a high hemorrhagic risk condition, and the management of anticoagulation and heart surgery in these patients can be challenging. The authors describe a combined percutaneous treatment of mitral regurgitation and left atrial appendage occlusion in a patient affected by hereditary hemorrhagic telangiectasia and atrial fibrillation, supporting the safety and feasibility of the procedure and the optimal short-term outcome.

Development and implementation of interprofessional education activity among health professions students in Jordan: A pilot investigation

Implementing interprofessional education (IPE) in health professions curricula requires considerations of students' attitudes and readiness. Interventional studies that assess students' perceptions about IPE are needed. As IPE is an emerging concept in Jordan, our study aimed at exploring the attitudes of health profession students about IPE and collaborative practice before and after implementing an IPE activity. Students completed the validated Interprofessional Attitudes Scale (IPAS) before and after completing a 3-hour interprofessional activity. Students' attitudes toward IPE were compared using the subscales and total IPAS scores. A total of 41 health profession students attending the professional health programs of Doctor of Pharmacy, Medicine, Nursing, Nutrition, or Pharmacy completed IPAS before and after conducting the interprofessional activity. Students reported positive attitudes toward IPE prior to the activity. Significant increases were observed in IPAS scores from pre- (median [interquartile range: IQR] score = 4.19 [0.61]) to post-activity (median [IQR] = 4.48 [0.65]), and in its subscales (teamwork, roles and responsibilities, diversity and ethics, and community-centeredness). Students' experience with the IPE activity was positive and optimistic. The findings revealed for the first time the perception and readiness of health profession students toward IPE and collaborative practice in Jordan. This readiness can help draw a path for strategic integration of IPE in health profession curricula.

Feasibility study of computational occupational dosimetry: evaluating a proof-of-concept in an endovascular and interventional cardiology setting

Individual monitoring of radiation workers is essential to ensure compliance with legal dose limits and to ensure that doses are As Low As Reasonably Achievable. However, large uncertainties still exist in personal dosimetry and there are issues with compliance and incorrect wearing of dosimeters. The objective of the PODIUM (Personal Online Dosimetry Using Computational Methods) project was to improve personal dosimetry by an innovative approach: the development of an online dosimetry application based on computer simulations without the use of physical dosimeters. Occupational doses were calculated based on the use of camera tracking devices, flexible individualised phantoms and data from the radiation source. When combined with fast Monte Carlo simulation codes, the aim was to perform personal dosimetry in real-time. A key component of the PODIUM project was to assess and validate the methodology in interventional radiology workplaces where improvements in dosimetry are needed. This paper describes the feasibility of implementing the PODIUM approach in a clinical setting. Validation was carried out using dosimeters worn by Vascular Surgeons and Interventional Cardiologists during patient procedures at a hospital in Ireland. Our preliminary results from this feasibility study show acceptable differences of the order of 40% between calculated and measured staff doses, in terms of the personal dose equivalent quantity H_p(10), however there is a greater deviation for more complex cases and improvements are needed. The challenges of using the system in busy interventional rooms have informed the future needs and applicability of PODIUM. The availability of an online personal dosimetry application has the potential to overcome problems that arise from the use of current dosimeters. In addition, it should increase awareness of radiation protection among staff. Some limitations remain and a second phase of development would be required to bring the PODIUM method into operation in a hospital setting. However, an early prototype system has been tested in a clinical setting and the results from this two-year proof-of-concept PODIUM project are very promising for future development.

Technical Outcome, Clinical Success, and Complications of Low-Milliampere Computed Tomography Fluoroscopy-Guided Drainage of Lymphoceles Following Radical Prostatectomy with Pelvic Lymph Node Dissection

To evaluate the technical outcome, clinical success, and safety of low-milliampere CT fluoroscopy (CTF)-guided percutaneous drain (PD) placement in patients with lymphoceles following radical prostatectomy (RP) with pelvic lymph node dissection (LND). This retrospective analysis comprised 65 patients with PD placement in lymphoceles following RP under low-milliampere CTF guidance. Technical and clinical success were evaluated. Complications within a 30-day time interval associated with CTF-guided PD placement were classified according to SIR. Patient radiation exposure was quantified using dose-length products (DLP) of the pre-interventional planning CT scan (DLPpre), of the sum of intra-interventional CT fluoroscopic acquisitions (DLPintra) and of the post-interventional control CT scan (DLPpost). Eighty-nine lymphoceles were detected. Seventy-seven CT-guided interventions were performed, with a total of 92 inserted drains. CTF-guided lymphocele drainage was technically successful in 100% of cases. For all symptomatic patients, improvement in symptoms was reported within 48 h after intervention. Time course of C-reactive protein and Leucocytes within 30 days revealed a statistically significant (p < 0.0001) decrease. Median DLPpre, DLPintra and DLPpost were 431 mGy*cm, 45 mGy*cm and 303 mGy*cm, respectively. Only one minor complication (self-resolving haematoma over the bladder dome; SIR Grade 2) was observed. Low-milliampere CTF-guided drainage is a safe treatment option in patients with lymphoceles following RP with pelvic LND characterized by high technical and good clinical success rates, which provides rapid symptom relief and serves as definite treatment or as a bridging therapy prior to laparoscopic marsupialisation.

The additional value of high-resolution vessel wall imaging in screening suitable chronic internal carotid artery occlusion candidates for endovascular recanalization: comparison with digital subtraction angiography

BACKGROUND

High-resolution vessel wall imaging (HR-VWI) can provide information about exact occluded length, etiology, and the presence of intraluminal thrombus or residual cavity.

PURPOSE

To investigate the extra value of HR-VWI in screening patients with chronic internal carotid artery occlusion (CICAO) for recanalization suitability in comparison with digital subtraction angiography (DSA).

MATERIAL AND METHODS

We retrospectively reviewed patients who underwent endovascular recanalization with no internal carotid artery signal on magnetic resonance angiography (MRA) and whose both preoperative DSA and HR-VWI data were available. Patients were classified into type I (focal occlusion distal to ophthalmic artery), type II or III (occlusion proximal or at/distal to clinoid segment), and near-occlusion. Occlusion etiology and suitability for recanalization were analyzed both on preoperative DSA and HR-VWI. Accuracy of occlusion classification and differences in the modified Rankin scale scores between the baseline and follow-up were estimated.

RESULTS

A total of 20 patients were included. With intraoperative DSA as the gold standard, we found HR-VWI could additionally show intraluminal thrombi. Preoperative DSA misclassified one near-occlusion, one type I occlusion, and one type II occlusion as type III occlusions, and one near-occlusion as a type II occlusion. Therefore, compared with the preoperative DSA, three additional cases were successfully recanalized based on HR-VWI. The accuracy of HR-VWI was higher than preoperative DSA (100% vs. 80%). Prognosis improvement of type I was significantly better than type II and near-occlusion (P<0.05).

CONCLUSION

HR-VWI can identify occluded etiology, extent, and classification of CICAO. This information is potentially useful in screening candidates for endovascular recanalization and helpful to indicate prognosis.

Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room

BACKGROUND

Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance.

AIMS

The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access.

METHODS

We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors.

RESULTS

12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p < .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p < .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value <.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p < .001) were associated with successful intravenous catheter placement.

CONCLUSIONS

Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room.

The practice of radiation protection in an interventional neuroradiology service

Introduction

Interventional neuroradiology procedures subject professionals who work in this area to high doses of ionizing radiation, and such exposure leads to a higher chance of occupational diseases related to this physical risk. Radiation protection practices aim to reduce the occurrence of such damage to the health of these workers.

Objectives

To identify how the practice of radiation protection occurs in a multidisciplinary team of an interventional neuroradiology service in the state of Santa Catarina, Brazil.

Methods

A qualitative, exploratory, and descriptive research conducted with nine health professionals from the multidisciplinary team. Non-participant observation and a survey form were used as data collection techniques. For data analysis, descriptive analysis based on absolute and relative frequency and content analysis were used.

Results

Although some practices showed the use of radiation protection measures in practice, such as workers taking turns to perform procedures and continuous use of the lead apron as well as the mobile suspended protection, we found that most of the practices violate the principles of radiation protection. Among these inadequate radiological protection practices, the following aspects were observed: not wearing lead goggles, not using collimation to obtain the image, poor knowledge of the principles of radiation protection and biological effects of ionizing radiation, and non-use of an individual dosimeter.

Conclusions

There was a lack of know-how of the multidisciplinary team working in interventional neuroradiology regarding the practice of radiation protection.

Transcatheter arterial embolization of iatrogenic massive arterioportal fistula in the liver

BACKGROUND

Massive arterioportal fistula (APF) is naturally irreversible and can induce portal hypertension and portal vein thrombosis (PVT), worsening survival outcomes.

PURPOSE

To evaluate the clinical course and details of transarterial embolization (TAE) procedures for massive APF.

MATERIAL AND METHODS

This retrospective single-center observational study evaluated the time until embolization after puncture, imaging, embolization methods, and laboratory data of 10 consecutive patients who were diagnosed with massive APF after puncture and underwent TAE at our hospital from 1 April 2012 to 30 September 2019.

RESULTS

Out of 10 cases, eight demonstrated a simple type and the other two cases a complex network type on the digital subtraction angiography pattern of massive APF. In two simple-type cases for which re-embolization was required, other subsegmental branches were embolized. The two cases showing a complex network type had been embolized via not only the subsegmental branch, but also the extrahepatic and multiple subsegmental branches. Child-Pugh scores were improved in eight of the ten cases. PVT was seen in six cases before embolization, but disappeared after embolization in all cases, despite the fact that three cases had not received anticoagulant therapy. Six cases had digestive varices before embolization, suggesting portal hypertension, and two of the six cases with esophageal varices and one with gastric varices decreased after embolization.

CONCLUSION

TAE for massive APF contributed to the improvement of hepatic reserve, the disappearance of PVT, and the improvement of portal hypertension; however, embolization of multiple branches may still be required in some cases.

Anticoagulation after transjugular intrahepatic portosystemic shunt for portal hypertension: A systematic review and meta analysis

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is widely applied to decrease portal hypertension. Because of the lack of strong evidence, it is controversial whether anticoagulation should be performed after TIPS. This meta-analysis aimed to assess the safety and efficacy of anticoagulation for patients with portal hypertension following TIPS.

METHODS

Studies making comparisons between combination treatment and TIPS alone were searched in China National Knowledge Infrastructure, Cochrane Library, PubMed, the Wan Fang electronic databases, and EMBASE, delivered between the earliest accessible date and September 4, 2021. The RevMan version 5.3 was applied to conduct all statistical analyses. I2 index statistic was used to assess heterogeneity.

RESULTS

Five eligible studies were selected, and total 707 patients were enrolled. According to the meta-analysis, compared to TIPS alone, TIPS + anticoagulation led to much lower incidence of portal vein thrombosis (PVT; odds ratio [OR] = 0.39, 95% confidence interval [CI] 0.18-0.84, P = .02) as well as low heterogeneity (P = 0.36, I2 = 3%). Other index like the stent dysfunction rate (OR = 1.27, 95% CI 0.71-2.77, P = .42), bleeding rate (OR = 1.27, 95% CI 0.71-2.77, P = .42), and incidence of hepatic encephalopathy (OR = 0.87, 95% CI 0.56-1.36, P = .55) showed no statistical significance.

CONCLUSIONS

In certain patients with portal hypertension, anticoagulation following TIPS may not be required. However, for patients who do not have a PVT before TIPS, post-TIPS anticoagulation can decrease the incidence of PVT. Nonetheless, further research is still required.

Percutaneous transluminal forceps biopsy with an adjustable curved sheath for obstructive jaundice

PURPOSE

To evaluate the feasibility and safety of percutaneous transluminal forceps biopsy (PTFB) with an adjustable curved sheath in patients with obstructive jaundice.

MATERIAL AND METHODS

Forty-two patients who underwent PTFB with an adjustable curved sheath were analyzed retrospectively. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were calculated for all populations and in different situations. Technical success and safety were evaluated.

RESULTS

The technical success rate was 100%. Thirty-five of 42 cases were diagnosed malignant diseases, the sensitivity of PTFB with an adjustable curved sheath was 74.29% (26/35), the specificity was 100%, the positive predictive value was 100%, the negative predictive value was 43.75% (7/16), and the accuracy rate was 78.57% (33/42). There was a better sensitivity for bile duct malignancies when compared with non-bile duct malignancies (p = 0.012). No statistical difference was found in the sensitivity of the upper part of the biliary tree and the lower part of the biliary tree, and none in the sensitivity of different approaches (left vs. right). The complication rate was 11.90%, and no serious complications were observed.

CONCLUSIONS

PTFB with an adjustable curved sheath is an effective and safe technique, without being limited by approaches and obstruction sites.