Angio-CT-Assisted Balloon Dissection: Protection of the Adjacent Intestine during Cryoablation for Patients with Renal Cancer

Is cryoablation a valid option for renal cell carcinomas in direct contact with critical organs?

PURPOSE

This study aimed to assess the outcomes of percutaneous cryoablation (PCA) for renal cell carcinomas (RCCs) contacting critical organs without intervening fat tissue.

MATERIAL AND METHODS

Twenty-three patients with 24 RCCs (mean size, 28.8 mm) contacting critical organs on preprocedural images were included. The organ displacement techniques, technical success, efficacy, and adverse events per Clavien-Dindo classification were retrospectively reviewed.

RESULTS

The organs contacting the RCCs included the colon (n = 16), pancreas (n = 3), duodenum (n = 3), small intestine (n = 1), and stomach (n = 1). In all procedures, hydrodissection was conducted, and probe traction was additionally utilized in one to displace organs. Two procedures were terminated with an insufficient ice-ball margin (<6 mm) due to recurring proximity of the colon or thermal sink effect by renal hilar vessels, yielding a technical success rate of 91.6% (22/24). No severe adverse events were noted. All patients were alive without any metastases during a median follow-up of 34.4 months. The primary and secondary technical efficacy rates were 91.6% (22/24) and 95.8% (23/24) of tumors, respectively.

CONCLUSION

PCA can be a valid option for RCCs contacting critical organs with a good safety profile and sufficient technical efficacy.

Imaging in interventional oncology, the better you see, the better you treat

Imaging and image processing is the fundamental pillar of interventional oncology in which diagnostic, procedure planning, treatment and follow-up are sustained. Knowing all the possibilities that the different image modalities can offer is capital to select the most appropriate and accurate guidance for interventional procedures. Despite there is a wide variability in physicians preferences and availability of the different image modalities to guide interventional procedures, it is important to recognize the advantages and limitations for each of them. In this review, we aim to provide an overview of the most frequently used image guidance modalities for interventional procedures and its typical and future applications including angiography, computed tomography (CT) and spectral CT, magnetic resonance imaging, Ultrasound and the use of hybrid systems. Finally, we resume the possible role of artificial intelligence related to image in patient selection, treatment and follow-up.

Cryoablation for Bone and Soft Tissue Lesions in Pediatric Patients: Complications and Preventive Measures

PURPOSE

To evaluate complications associated with cryoablation in a pediatric population and review preventive measures to mitigate these complications.

MATERIAL AND METHODS

Retrospective study including all the image guided cryoablations performed on pediatric population. Immediate and delayed complications were analyzed, and we identified the different protective measures used and the clinical outcomes from follow-up. Point estimates for the percentage of complications were calculated by maximum likelihood, and 95% confidence intervals for the true percentages were calculated using the Clopper-Pearson exact method.

RESULTS

Eighty-seven ablations were performed on 68 patients (age range of 2-18 years, mean 12.4 years) for non-neoplastic (70%) and neoplastic (30%) lesions. The percentage of ablations resulting in complications was 18% (95% confidence interval (CI) 11% to 28%). Of these, 5% (95% CI 1% to 11%) were grade 3 complications, and 14% (95% CI 7% to 23%) were grade 2 complications. Thermal protection was performed in 27.6% of ablations (n = 24). The mean clinical follow-up duration was 348 days.

CONCLUSION

Cryoablation in pediatric patients is relatively safe, with a major complication rate per ablation of 5%. Thermal protective measures can be considered to mitigate these complications.

Percutaneous Radiologic Gastrostomy in Patients After Partial Gastrectomy: A Retrospective Study to Assess the Technical Feasibility of Postsurgical Remnant Stomach Access

PURPOSE

To evaluate the technical feasibility of percutaneous radiologic gastrostomy in patients after partial gastrectomy.

MATERIALS AND METHODS

This retrospective study included 15 consecutive gastrectomized patients with attempted percutaneous radiologic gastrostomy at our institution between April 2014 and March 2021. When the stomach was sufficiently insufflated to distend below the left anterior subcostal margin, percutaneous radiologic gastrostomy with gastropexy was conventionally performed by the Seldinger technique. When the stomach was still highly positioned and/or overlaid by the other organs, some adjunctive maneuvers, such as hydro-displacement, intragastric balloon support, or cephalad oblique puncture or left intercostal puncture, were employed as modified gastrostomy. Ultrasonography or x-ray or computed tomography fluoroscopy was used for imaging guidance during the gastric puncture. Adequate tube placement was defined as technical success. Technical details, clinical outcomes, and complications were reviewed.

RESULTS

One patient underwent percutaneous radiologic jejunostomy instead of gastrostomy because safe gastric access could not be ensured. Seven patients underwent conventional gastrostomy; the other seven underwent modified gastrostomy with no gastropexy. The technical success rate was 100% (7/7) in the conventional group and 85.7% (6/7) in the modified group. The stomach was punctured under x-ray or computed tomography fluoroscopy for conventional gastrostomy. In contrast, the combination of various modalities was used for modified gastrostomy except for one failed case with unintentional transhepatic access. During a median follow-up of 108 days, no major complications occurred.

CONCLUSION

The adequate combination of multimodal imaging guidance and technical modifications could secure radiological creation of gastrostomy for the postsurgical stomach.

LEVEL OF EVIDENCE

Level 4, Case Series.

Implementation of a hybrid angiography-CT system: increased short-term revenue at an academic radiology department

PURPOSE

To analyze the financial impact following implementation of a hybrid Angio-CT system at a tertiary care academic medical center.

METHODS

Aggregate case types and volumes were compared 24 months before and 12 months after a hybrid Angio-CT system replaced a traditional interventional C-arm angiography suite at an academic medical center. Procedure revenues from this 36-month study period were derived from five payors mixes (Medicare, Medicaid, commercial insurance, out-of-pocket and managed care program) and Medicare-rate adjusted to each individual payor types.

RESULTS

Average case volume per month increased 12% in the hybrid Angio-CT suite when compared to the previous traditional angiography suite (P < 0.05). The variety of IR procedures in the hybrid Angio-CT suite also expanded to include more complex interventional radiology and interventional oncology procedures; the breadth of cases performed in the hybrid Angio-CT suite were associated with CPT codes of higher rates (average CPT value/case increased from $2,334.61 to $2,567.25). The estimated average annual revenue of the hybrid Angio-CT suite increased 23% as compared to previous traditional angiography suite.

CONCLUSION

A hybrid Angio-CT system is a financially feasible endeavor at a tertiary care academic medical center that facilitated higher complexity procedure codes and increased procedure-related revenue.

Improved Utilization Following Conversion of a Fluoroscopy Suite to Hybrid CT/Angiography System

PURPOSE

To assess changes in operational utilization following conversion of a single IR suite to a hybrid CT/angiography (Angio-CT) system at an academic tertiary care center.

MATERIALS AND METHODS

The total number of interventional procedures and diagnostic CT examinations performed in 29 rooms (20 diagnostic radiology, 7 IR, 2 shared between divisions) was calculated in the 24 months before conversion of an IR suite to Angio-CT and 12 months after conversion. The total number of IR procedures (global IR/month) and diagnostic CT scans per month (global CT/month) in both before and after conversion periods was calculated and defined as baseline institutional growth. This was compared against the change in the number of IR procedures performed in the before and after periods in the converted room (Angio-CT/month) as well as the number of diagnostic CT scans performed in the shared rooms (shared CT/month).

RESULTS

The percent change in global CT and global IR from the before to the after periods was 39.2% and 3.1%, respectively. Shared CT per month and Angio-CT per month increased by 46.7% and 12.0% across the same time periods, respectively. The ratio of the percent increase in Angio-CT per month to percent increase in global IR per month was 3.87. The ratio of the percent increase in shared CT per month to percent increase in global CT per month was 1.19.

CONCLUSIONS

Operational utilization improved in both diagnostic radiology and IR sections following conversion of a conventional fluoroscopic IR suite to an Angio-CT room.

Renal cryoablation - a practical guide for interventional radiologists

Renal cryoablation is a treatment option for early stage renal cell carcinomas with excellent oncological outcomes and low morbidity. This review outlines the technique of renal cryoablation and provides a guide for interventional radiologists on setting up an integrated service within a renal cancer network multidisciplinary setting. Patient selection and preparation, together with the technical aspects which ensure optimal oncological outcomes and avoid collateral damage to adjacent organs are highlighted.

A new management strategy for renal angiomyolipomas: superselective arterial embolization in combination with radiofrequency ablation

Background

The present study analyzed the safety and efficacy of superselective arterial embolization (SAE) combined with radiofrequency ablation (RFA) to treat renal angiomyolipoma (RAML).

Methods

This retrospective study included the clinical data of 6 patients with RAML treated between March 2016 and October 2017. All patients underwent RFA treatment immediately after SAE guided by angio-computed tomography (angio-CT). The tumor size, renal function and complications, and time to recurrence were compared before and after treatment.

Results

The success rate of the SAE + RFA technique was 100%, and no serious complications were found during or after surgery. After treatment, the patients' symptoms, including low back pain and hematuria, were relieved. The pre-treatment creatinine level (55.6±11.0 µmol/L) did not differ significantly from the post-treatment creatinine level (68.2±13.7 µmol/L), which was measured 1 day after surgery (t=1.75, P=0.109). The mean follow-up time was 29.5±6.1 months. By the end of the follow-up period, the maximum diameter of the tumor was 3.1±0.6 cm, which was significantly smaller than the pre-treatment diameter of 5.9±1.01 cm (t=5.83, P<0.001). At 3 months after surgery, the maximum diameter of the tumor was reduced by 22-38% in all 6 patients. At the last follow-up examination, the maximum diameter of the tumor was reduced by 36-61%. Contrast-enhanced CT or magnetic resonance imaging scans showed that the enhanced part of the original lesion had disappeared, the renal parenchyma was full of even fat signals, and only one patient had new enhanced lesions at the site of the original lesions.

Conclusions

SAE combined with RFA is a safe and effective treatment for RAML, and its strengths qualify it to become a new treatment strategy for RAML.

Protection from injury of organs adjacent to a renal tumor during percutaneous cryoablation

Renal cryoablation has become accepted as treatment for small renal tumors as an alternative to surgery. However, parallel with the increase in the use of this therapy, there also has been increases in the number of reports of complications related to renal cryoablation. One potential complication is injury to important non-renal structures adjacent to the ablated renal tumor, such as the colon, duodenum, ureter, psoas muscle and so on. To prevent injury of adjacent organs, separating organs from the tumor is desirable. Over the past 15 years, several techniques have been developed to protect against injury of organs adjacent to renal tumors that are targets of cryoablation. The most commonly used technique for this purpose has been hydrodissection. Others include dissection with gas, balloon dissection and probe traction. To avoid injury of a ureter running near the renal tumor, pyeloperfusion is known to be useful. The rate of cases necessitating avoidance of organ injury by using these techniques is relatively high. In some cases, more than two techniques are combined. In the present review, we provided an overview of techniques currently available to protect against organ injuries, and discussed the advantages and disadvantages of each technique.