Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations

Lumbar Transforaminal Injections of Nusinersen in Spinal Muscular Atrophy Patients

Following a review of spinal muscular atrophy pathogenesis and current therapeutics, a comprehensive review of transforaminal lumbar injections is provided. Patient preparation, special considerations, procedural technique, complications, and alternative approaches are discussed.

Dural Puncture Complications

Dural puncture, commonly referred to as lumbar puncture (LP), carries the risk of rare but serious complications including post-dural puncture headache, hemorrhage, herniation, and infection. These complications can lead to suboptimal patient outcomes including significant morbidity and mortality in some instances. This review comprehensively examines potential LP complications, including their incidence, pathophysiology, risk factors, clinical presentations, imaging findings, preventative measures, and treatment strategies. Familiarity with these complications will equip clinicians to effectively manage these complications through prompt recognition, timely diagnosis, and implementation of appropriate preventative measures.

Standard Fluoroscopic and Computed Tomography-Guided Lumbar Punctures

Image-guided lumbar puncture (LP) remains an important part of the modern practice of neuroradiology. This review outlines the relevant anatomy, safety considerations, and techniques in performing fluoroscopic and computed tomography-guided LPs.

CT scan guided drainage in anticoagulated patients to avoid laparotomy: A case report

Direct oral anticoagulant use has increased significantly over the last decade. Their perioperative management is always challenging for the anesthesiologist. Interventional radiology offers an interesting alternative nowadays, especially in emergencies. We report the case of a 52-year-old woman who was admitted to our department to manage a septic shock secondary to an abscessed collection in the right iliac fossa. After a multidisciplinary consultation, given that she was taking anticoagulation medications for venous mesenteric ischemia, it was decided to proceed with computed tomography scan-guided drainage of the collection, which resulted in the evacuation of over 500 cc of pus. This case report emphasizes the importance of interventional radiology and its role in avoiding surgical interventions in risky situations, especially for patients on anticoagulants, or at least to be carried out, in a second step, under better conditions.

FDG PET/CT Performed Prior to CT-Guided Percutaneous Biopsy of Lung Masses is Associated With an Increased Diagnostic Rate and Often Identifies Alternate Safer Sites to Biopsy

Purpose: To determine the benefit of a FDG PET/CT scan prior to CT-guided lung biopsy on the rate of diagnosis, rate of complication, and the identification of potentially safer biopsy sites. Methods: This retrospective observational cross-sectional study evaluated consecutive adult patients who underwent CT-guided lung biopsy in 2020 or 2021 at 2 Canadian tertiary care hospitals. These patients were grouped into those that had PET/CT performed within 8 weeks prior to biopsy, within 8 weeks after biopsy, or no PET/CT scan within this time frame. Biopsy complication rates and pathology diagnostic rates were compared. The PET/CT images of those performed after biopsy were reviewed to determine if alternate safer biopsy sites could be identified. Categorical variables were compared using Pearson chi square test (P < .05 significant). Results: 547 patients who had CT-guided lung biopsy were included. Patients with lung masses (≥3 cm) who had a PET/CT scan prior to biopsy had a higher diagnostic rate (90.8%) compared to those that did not (80.2%). The overall post-biopsy pneumothorax rate was 43.3% with 11.3% overall requiring chest tube insertion and 13.9% requiring hospitalization. There was no difference in complication rate for those who had PET/CT prior to biopsy and those that did not. 28.9% to 42.1% of patients who had PET/CT after biopsy had safer sites amenable to biopsy identified retrospectively outside of the lungs. Conclusion: PET/CT prior to CT-guided lung biopsy improves the diagnostic rate in 10.6% of patients with lung masses (≥3 cm) and identifies alternate safer sites to biopsy in 28.9% to 42.1% of patients (any size lesion).

Percutaneous image-guided mesenteric biopsy: how we do it in a high-volume training center

Lesions in the mesentery are unique from other potential biopsy targets in the abdomen or pelvis for several reasons. Mesenteric lesions are among the deepest in the abdomen and are often surrounded by or adjacent to small bowel or colon. Mesenteric vasculature is often crowded, and traversing the mesentery often involves crossing multiple vascular planes. Mesenteric lesions and the structures surrounding them within the peritoneal cavity are often highly mobile. All these features can be daunting to any radiologist asked to perform a mesenteric biopsy. We provide a comprehensive overview and guide to percutaneous mesenteric biopsy informed by available literature and experience at two high volume teaching centers. Topics covered include the pitfalls of using prior imaging to determine whether mesenteric biopsy is possible, techniques specific to US or CT-guidance and complications including hemorrhage and bowel injury.

Safety and efficacy of different transplant kidney biopsy techniques: comparison of two different coaxial techniques and needle types

PURPOSE

Percutaneous ultrasound-guided renal biopsy is essential for diagnosing medical renal disorders in transplant kidneys. A variety of techniques have been advocated. The purpose of this study is to evaluate the safety and efficacy of two different coaxial techniques and biopsy devices.

METHODS

This single-center dual-arm, observation study cohort included 1831 consecutive transplant kidney biopsies performed over a 68-month period. Two coaxial techniques were used, distinguished by whether the 17 gauge (G) coaxial needle was advanced into the renal cortex (intracapsular technique; IC) or to the edge of the cortex (extracapsular technique; EC). One of two needle types could be used with either technique: an 18G side-cutting (Bard Max-Core or Mission) or an 18G end-cutting (Biopince Ultra) needle. In all cases, the cortical tangential technique was used to reduce the risk of central artery transgression and unnecessary medullary sampling. Patients were monitored for 30 days post-procedurally and complications were evaluated using the SIR adverse event classification.

RESULTS

Of the 1831 patients included in the study cohort, 13 suffered severe bleeding complications requiring operative intervention. Of these patients, 8 underwent biopsy with side-cutting needle and IC, 2 with side-cutting needle and approach not specified, 2 with end-cutting needle and IC, and 1 with end-cutting needle and EC. There was no statistically significant difference in the risk of bleeding complications between different coaxial techniques and needle types. However, there was a significantly increased chance of inadequate sampling when comparing the side-cutting needle (1.0%) to the end-cutting needle (0.1%).

CONCLUSIONS

Transplant kidney biopsy performed with two different coaxial techniques and needle types did not show differences in bleeding complications. There is an increased risk of inadequate sampling when using side-cutting relative to end-cutting biopsy devices.

Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants

BACKGROUND

Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity.

OBJECTIVES

To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents.

METHODS

An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations.

RESULTS

Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended.

CONCLUSION

Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Coagulopathy in acute liver failure

Acute liver failure (ALF) is a rare but rapidly progressing syndrome, marked by severe liver dysfunction and altered mental status. While definitions of ALF vary across different guidelines, with timelines ranging from 4 to 26 weeks between jaundice onset and encephalopathy, the key defining features remain encephalopathy and coagulopathy. Elevated coagulation markers, particularly prothrombin time and international normalized ratio, have traditionally been associated with bleeding risks. However, emerging evidence suggests a rebalanced state of coagulation in ALF, similar to cirrhosis, where bleeding risks-both spontaneous and procedural-are surprisingly low. Viscoelastic hemostatic assays and thrombin generation assays further confirm this rebalanced hemostatic state. Current guidelines for correcting coagulopathy in ALF remain limited, typically reserved for active bleeding or prior to high-risk invasive procedures.

CT-guided Left Stellate Ganglion Cryoneurolysis for Refractory Ventricular Arrhythmias

Background Ventricular arrhythmias (VAs), including ventricular tachycardia and ventricular fibrillation, present substantial therapeutic challenges due to their high morbidity, mortality, and increasing prevalence. Current treatments often prove infeasible or inadequate in patients with refractory VAs. Purpose To evaluate the safety and effectiveness of CT-guided left stellate ganglion cryoneurolysis (SGC) in the treatment of refractory VAs. Materials and Methods This retrospective study reviewed all consecutive patients with refractory VAs who underwent SGC between June 2020 and December 2023 at two tertiary care centers. Patients with refractory VAs who underwent CT-guided left SGC were included. No patients were excluded. Data on preprocedural clinical status, procedural approach, procedural outcomes, and adverse events were analyzed. The pre- and postprocedural number of defibrillations were compared using the Wilcoxon matched-pairs signed rank test. Results A total of 17 patients (mean age, 60.4 years ± 2.7 [standard error of the mean]; 14 male) were included; seven patients (41%) were receiving β-adrenergic blocking agents. The mean number of antiarrhythmic medications per patient was 2.2 ± 0.2. CT-guided left SGC led to a significant reduction in defibrillations, from a median of 3 (IQR, 3-15) to 0 (IRQ, 0-0) in the 24 hours before and after the procedure, respectively (P < .001). Clinical success, defined as freedom from defibrillation within the preceding 24-hour period, was achieved in 14 of 17 patients (82%) 24 hours after and 15 of 17 patients (88%) 72 hours after the procedure. Of 17 patients, 12 (71%) proceeded to additional procedural management after SGC. At a mean follow-up of 469.2 days ± 90.8, 14 of 17 patients (82%) were alive. No moderate or high-grade adverse events were observed; mild adverse events included left upper extremity neurapraxia (n = 1) and transient Horner syndrome (n = 3). Conclusion CT-guided left SGC demonstrated promising effectiveness and safety in treating patients with refractory VAs. Thus, SGC warrants consideration for inclusion in a multidisciplinary treatment algorithm for VAs. © RSNA, 2024 See also the editorial by Cadour and Scemama in this issue.

Image-guided renal parenchymal biopsies- how we do it

This paper is a multi-institutional review of image-guided renal parenchymal biopsies. Among the topics covered are indications, preprocedural considerations, biopsy technique, complications, and postprocedural management. Both native kidney and transplant kidney biopsies are considered in this review.

The Bleeding Edge: Managing Coagulation and Bleeding Risk in Patients with Cirrhosis Undergoing Interventional Procedures

This review addresses the peri-procedural bleeding risks in patients with cirrhosis, emphasizing the need for careful coagulation assessment and targeted correction strategies. Liver disease presents a unique hemostatic challenge, where traditional coagulation tests may not accurately predict bleeding risk, complicating the management of procedures like paracentesis, endoscopic therapy, and various interventional procedures. As such, this paper aims to provide a comprehensive analysis of current data, guidelines, and practices for managing coagulation in cirrhotic patients, with a focus on minimizing bleeding risk while avoiding unnecessary correction with blood products. The objectives of this review are threefold: first, to outline the existing evidence on bleeding risks associated with common invasive procedures in cirrhotic patients; second, to evaluate the efficacy and limitations of standard and advanced coagulation tests in predicting procedural bleeding; and third, to examine the role of blood product transfusions and other hemostatic interventions, considering potential risks and benefits in this delicate population. In doing so, this review highlights patient-specific and procedure-specific factors that influence bleeding risk and informs best practices to optimize patient outcomes. This review progresses through key procedures often performed in cirrhotic patients. The discussion begins with paracentesis, a low-risk procedure, followed by endoscopic therapy for varices, and concludes with high-risk interventions requiring advanced hemostatic considerations. Each chapter addresses procedural techniques, bleeding risk assessment, and evidence-based correction approaches. This comprehensive structure aims to guide clinicians in making informed, evidence-backed decisions in managing coagulation in cirrhosis, ultimately reducing procedural complications and improving care quality for this high-risk population.

Modernizing metabolic dysfunction-associated steatotic liver disease diagnostics: the progressive shift from liver biopsy to noninvasive techniques

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health concern worldwide. Liver biopsy is the gold standard for diagnosing and staging MASLD, but it is invasive and carries associated risks. In recent years, there has been significant progress in developing noninvasive techniques for evaluation. This review article discusses briefly current available noninvasive assessments and the various liver biopsy techniques available for MASLD, including invasive techniques such as transjugular and transcutaneous needle biopsy, intraoperative/laparoscopic biopsy, and the evolving role of endoscopic ultrasound-guided biopsy. In addition to discussing the various biopsy techniques, we review the current state of knowledge on the histopathologic evaluation of MASLD, including the various scoring systems used to grade and stage the disease. We also explore current and alternative modalities for histopathologic evaluation, such as whole slide imaging and the utility of immunohistochemistry. Overall, this review article provides a comprehensive overview of the progress in liver biopsy techniques for MASLD and compares invasive and noninvasive modalities. However, beyond clinical trials, the practical application of liver biopsy may be limited, as ongoing advancements in noninvasive fibrosis assessments are expected to more effectively identify candidates for MASLD treatment in real-world settings.

Safety of abdominal paracentesis in hospitalised patients receiving uninterrupted therapeutic or prophylactic anticoagulants

BACKGROUND

Abdominal paracentesis is a frequently performed procedure in hospitalised patients with ascites. Concurrently, most hospitalised adult patients receive pharmacologic anticoagulation, either for therapeutic purposes or prophylactically to prevent venous thromboembolism. Despite this, minimal evidence exists to guide management of anticoagulant therapy pre- and post-paracentesis.

AIMS

The authors aimed to investigate the safety of abdominal paracentesis in hospitalised patients receiving therapeutic or prophylactic anticoagulation, including in patients for whom these medications were withheld periprocedurally.

METHODS

TriNetX, an electronic health record data set, was queried to identify patients between the ages of 18 and 80 years who received an abdominal paracentesis while hospitalised at the authors' institution between September 2017 and June 2022. Patients receiving prophylactic anticoagulation (137), therapeutic anticoagulation (74) and no anticoagulation because of coagulopathy or thrombocytopenia (15) were compared. Rates of withholding anticoagulation, performing service, pre- and post-paracentesis haemoglobin, bleeding complications, thrombotic complications and need for red blood cell transfusion were analysed.

RESULTS

Procedure-related bleeding complications occurred in two (1.4%) patients in the prophylactic group and 0 (0%) patients in the therapeutic group (P = 0.54). No thrombotic complications occurred. Rates of red blood cell transfusions post-paracentesis were similar between groups. Analysis of secondary end-points identified significant differences in rates of withholding anticoagulation and mean change in haemoglobin between performing services.

CONCLUSION

Performance of abdominal paracentesis in patients receiving therapeutic or prophylactic anticoagulation appears to be safe regardless of whether anticoagulation was interrupted periprocedurally, with low rates of bleeding complications, thrombotic complications or need for red blood cell transfusions post-paracentesis.

Tips and Tricks for Image-Guided Breast Biopsies: Technical Factors for Success

Image-guided biopsy is an integral step in the diagnosis and management of suspicious image-detected breast or axillary lesions, allowing for accurate diagnosis and, if indicated, treatment planning. Tissue sampling can be performed under guidance of a full spectrum of breast imaging modalities, including stereotactic, tomosynthesis, sonographic, and MRI, each with its own set of advantages and limitations. Procedural planning, which includes consideration of technical, patient, and lesion factors, is vital for diagnostic accuracy and limitation of complications. The purpose of this paper is to review and provide guidance for breast imaging radiologists in selecting the best procedural approach for the individual patient to ensure accurate diagnosis and optimal patient outcomes. Common patient and lesion factors that may affect successful sampling and contribute to postbiopsy complications are reviewed and include obesity, limited patient mobility, patient motion, patients prone to vasovagal reactions, history of anticoagulation, and lesion location, such as proximity to vital structures or breast implant.

Is a two-hour monitoring period sufficient and safe for patients undergoing ultrasound-guided percutaneous liver mass biopsy?: A prospective and multicenter experience

PURPOSE

To investigate whether patients undergoing percutaneous liver mass biopsy (PLMB) can be safely discharged following a two-hour monitoring period.

METHODS

A multi-center prospective analysis was conducted for 375 patients (196 males and 179 females), mean age 63 ± 12.45 years (range 37-89) who underwent PLMB between August 2023 and March 2024. Patients were monitored for 24 h, and complications were classified as minor or major. The timing of complications was categorized into three groups: within the first two hours, between the 2nd and 24th hours, and within 1 week after 24 hours.

RESULTS

Minor complications occurred in 18.93% (71/375) and major complications in 2.13% (8/375). Most minor complications (80.2%, 57/71) appeared within the first two hours, 12.7% (9/71) between 2 and 24 h, and 7.1% (5/71) after 24 h. All major complications (62.5%, 5/8) except late-onset cases, occurred within the first two hours. No major complications occurred between 2 and 24 h. Late-onset major complications occurred in 37.5% (3/8) after 24 h.

CONCLUSION

The two-hour monitoring period did not adversely impact patient management regarding minor complications and is safe for identifying all major complications except for late-onset ones. Extending the post-biopsy recovery period does not significantly improve patient care.

Anemia and Transfusion Medicine

Peri-operative anemia is a common condition encountered in adult surgical patients. It is increasingly recognized as a predictor of post-operative morbidity and mortality. Evaluation and treatment of anemia pre-operatively can reduce transfusion needs and potentially improve outcomes in surgical patients. This article discusses anemia optimization strategies in peri-operative setting with special focus on use of intravenous iron therapy. Additionally, the authors describe the role of transfusion medicine and best practices around red blood cell, platelet, and plasma transfusions.

Platelet and INR Thresholds and Bleeding Risk in Ultrasound Guided Percutaneous Liver Biopsy: A Before-After Implementation of the 2019 Society of Interventional Radiology Guidelines Observational Quality Improvement Study

Purpose: To evaluate if implementation of the 2019 Society of Interventional Radiology (SIR) guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy is associated with increased haemorrhagic adverse events, change in pre-procedural blood product utilization, and evaluation of guideline compliance rate at a single academic institution. Methods: Ultrasound guided percutaneous liver biopsies from (January 2019-January 2023) were retrospectively reviewed (n = 504), comparing biopsies performed using the 2012 SIR pre-procedural coagulation guidelines (n = 266) to those after implementation of the 2019 SIR pre-procedural guidelines (n = 238). Demographic, preprocedural transfusion, laboratory, and clinical data were reviewed. Chart review was conducted to evaluate the incidence of major bleeding adverse events defined as those resulting in transfusion, embolization, surgery, or death. Results: Implementation of the 2019 SIR periprocedural guidelines resulted in reduced guideline non-compliance related to the administration of blood products, from 5.3% to 1.7% (P = .01). The rate of pre-procedural transfusion remained the same pre and post guidelines at 0.8%. There was no statistically significant change in the incidence of bleeding adverse events, 0.8% pre guidelines versus 0.4% post (P = 1.0). Conclusion: Implementation of the 2019 SIR guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy did not result in an increase in bleeding adverse events or pre-procedural transfusion rates. The guidelines can be safely implemented in clinical practice with no increase in major adverse events.

Evaluation of factors associated with bleeding following haemodialysis catheter-related procedures and the risk with anti-platelet agents

BACKGROUND

Bleeding is a potential complication following haemodialysis catheter-related procedures. Besides uraemia, bleeding risk is perceived to be even higher in patients receiving antiplatelets. This study aims to evaluate the risk factors for bleeding following dialysis catheter-related procedures.

METHODS

This is a secondary analysis of a single-centre, prospective cohort study between March 2019 and June 2020. Potential risk factors for bleeding were collected, including use of antiplatelets and anticoagulants, serum urea and haematological results. Patients were observed closely for external bleeding following haemodialysis catheter-related procedures.

RESULTS

From 413 patients screened, 250 were recruited. Of these, 177 underwent dialysis catheter insertion (157 tunnelled and 20 non-tunnelled) while 73 had dialysis catheter removed (35 tunnelled and 38 non-tunnelled). One hundred and four patients (41.6%) were on a single anti-platelet agent, of whom 75 (30.0%) were on aspirin and 29 (11.6%) had clopidogrel alone. Twenty-nine patients (11.6%) were on both aspirin and clopidogrel.There were 36 episodes (14.4%) of bleeding. The risk of bleeding was not significantly higher with the use of aspirin alone (odds ratio = 0.85, 95% CI: 0.36-2.02, p = 0.709), clopidogrel alone (odds ratio = 1.04, 95% CI: 0.31-3.49, p = 0.953) and both aspirin and clopidogrel (odds ratio = 0.95, 95% CI: 0.28-3.25, p = 0.938). In a multivariate analysis, none of the known bleeding risk factors had a statistically significant association with bleeding.

CONCLUSIONS

Overall, the use of antiplatelet agents was not associated with an increased risk of bleeding.

Common Ultrasound-Guided Procedures

Ultrasound guidance is fundamental to procedural safety and success. For many emergency department (ED) procedures, the use of ultrasound improves first-pass success rate, time-to-completion, and complication rate when compared with traditional landmark-based techniques. Once learned, the general principles of ultrasound guidance may be adapted across a broad range of bedside procedures.

Lowering Platelet Threshold to 20,000/μL for Fluoroscopy-Guided Lumbar Puncture Does Not Result in Observed Clinical Adverse Outcomes

PURPOSE

Fluoroscopic-guided lumbar puncture (FG-LP) is a common neuroradiologic procedure. Traditionally, a minimum platelet count (MPC) of 50,000/μL for this procedure has been required; however, we recently adopted a lower MPC threshold of 20,000/μL. The purpose of this study was to compare adverse events in patients undergoing FG-LP with MPCs above to those below the conventional 50,000/μL threshold.

MATERIALS

This was an institutional review board-approved, retrospective study on adult patients with hematologic malignancy undergoing FG-LP in the neuroradiology division between May 2021 and December 2022, after lowering the minimal required MPC to 20,000/μL. Recorded data included indication for FG-LP, preprocedure and postprocedure MPC, need for and number of platelet transfusions within 24 hours of FG-LP, presence of traumatic tap, FG-LP-related complications, and any platelet transfusion-related adverse event. Patients were classified into 2 groups based on MPC: (1) those above 50,000/μL and (2) those below 50,000/μL. Descriptive statistics were used comparing these 2 groups.

RESULTS

One hundred twenty-eight patients underwent FG-LP, with 46 having an MPC between 20,000 and 50,000/μL and 82 having an MPC above 50,000/μL. No postprocedural complications were encountered in either group. Traumatic taps occurred in 10/46 (22%)​ with MPC below 50,000/μL versus 10/82 (12%)​ in those with MPC above 50,000/μL. Forty of 46 patients (87%) were transfused with platelets within 24 hours prior to FG-LP. One patient developed a transfusion-related reaction.

CONCLUSION

Lowering the MPC threshold from 50,000/μL to 20,000/μL for FG-LP did not result in a higher incidence of spinal hematoma.

CT-guided Coaxial Lung Biopsy: Number of Cores and Association with Complications

Background Percutaneous CT-guided lung core-needle biopsy is a frequently performed and generally safe procedure. However, with advances in the management of lung cancer, there is a need for a greater amount of tissue for tumor genomic profiling and characterization. Purpose To determine whether the number of core samples obtained with percutaneous CT-guided lung biopsy is associated with postprocedural complications. Materials and Methods This retrospective study included consecutive patients who underwent percutaneous CT-guided coaxial lung core-needle biopsy for suspected primary lung cancer between November 2012 and August 2023 at an academic tertiary referral hospital. Patient data from medical records were collected, including demographics, lesion size and distance from pleura, and number of obtained biopsy samples. Postprocedural complications of pneumothorax, chest tube placement, perilesional hemorrhage, and hemoptysis were recorded. Multivariable logistic regression models were used to assess whether the number of cores was a predictive factor for lung biopsy complications. Results A total of 827 patients (mean age, 70.9 years ± 9.6 [SD]; 474 [57.3%] female patients) were included. The median lesion size was 22 mm (IQR, 15-34 mm), with 517 of 827 (62.5%) patients diagnosed with lung adenocarcinoma. Pneumothorax was noted in 171 of 827 (20.7%) patients, with a chest tube placed in 32 of 827 (3.9%), perilesional hemorrhage in 353 of 827 (42.7%), and hemoptysis in 20 of 827 (2.4%) patients. The median number of samples obtained was four (range, one to 12). Multivariable analysis showed no evidence of an association between the number of core samples obtained and any complications: pneumothorax (coefficient, -0.02; P = .81), chest tube (coefficient, 0.18; P = .26), perilesional hemorrhage (coefficient, -0.03; P = .63), or hemoptysis (coefficient, -0.10; P = .60). Conclusion In patients suspected of having lung cancer who underwent percutaneous CT-guided coaxial lung core biopsy, there was no evidence of an association between the number of core biopsy samples obtained and any postprocedural complications. © RSNA, 2024 See also the editorial by Zuckerman in this issue.

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Genicular Artery Embolization: A Promising Treatment Option for Recurrent Effusion Following Total Knee Arthroplasty

Background

Selective genicular artery embolization (GAE) has shown promise as a minimally invasive treatment option for persistent symptomatic recurrent effusions (REs) following total knee arthroplasty (TKA).

Purpose

We sought to investigate the radiographic and clinical success of GAE for RE after TKA.

Methods

We performed a retrospective review of prospectively collected data on primary and revision TKA patients with RE, both hemorrhagic and non-hemorrhagic, who underwent GAE between 2019 and 2021 with a minimum of 6-month follow-up. All embolization procedures were performed by a single interventional radiologist. Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and visual analog scale (VAS) scores were collected prior to GAE and at 1, 3, and 6 months post-procedure. Recurrence of effusion following GAE was assessed at 6 months using ultrasound.

Results

Seventeen patients, 10 female and 7 male, with 18 TKAs and a mean (SD) age of 63.1 (8.6) years were included. We saw a mean (SD) of 36.1 (24.4) and 3.3 (3.0) point improvement in WOMAC and VAS scores, respectively. In addition, 14 of the 18 TKAs (77.8%) seen at final follow-up had complete resolution of effusion confirmed by ultrasound.

Conclusion

Our retrospective review found that a majority of patients showed significant clinical improvement and resolution of effusion following GAE. These findings suggest that GAE may be an effective minimally invasive treatment option for RE following TKA and should be further investigated.

Image-Guided Liver Biopsy: Perspectives from Interventional Radiology

Liver biopsy is a crucial aspect of interventional radiology and plays a significant role in the management of hepatobiliary diseases. Radiologists commonly perform two major image-guided liver biopsy techniques: percutaneous and transjugular approaches. It is essential for radiologists to understand the role of liver biopsy in diagnosing and treating hepatobiliary conditions, the procedural details involved, and how to manage potential complications. This article reviews the indications, contraindications, techniques, and efficacy of image-guided liver biopsy, with a focus on both percutaneous and transjugular methods.

Percutaneous Cholecystostomy: Procedural Guidance and Future Directions for Clinical Management

Percutaneous cholecystostomy (PC) is a recognized treatment option for the management of acute cholecystitis and is an integral component of the treatment algorithm in the 2018 Tokyo Guidelines. The utilization of PC has significantly increased over the past 30 years, particularly in the setting of critically ill patients and those with extensive comorbidities who are poor surgical candidates. The indications, complications, patient selection considerations, and technical complexities of the procedure will be discussed. Postprocedural drain management and the potential for shortened indwelling time are reviewed.

What is the Safe Observation Period for Image-Guided Percutaneous Liver Biopsies?

PURPOSE

Current observation period post-liver biopsy is typically 4 h. This study investigates the safety of reducing the observation period after percutaneous liver biopsy.

METHODS

Patients who underwent percutaneous liver biopsy between 2017 and 2022 in the Radiology Department of a tertiary centre were included in this retrospective, institutional review board-approved study. Patient demographics, procedure details and complication data were collected from the electronic medical records. Complications were graded according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification. Conditional survival probabilities were calculated for the 4-h observation period.

RESULTS

Among 1125 patients, 275 complications were seen; 255 grade 1, 15 grade 2 and five grade 3. Post-procedural pain represented 93% (256) of complications, whereas post-procedural haemorrhage occurred in 17 (6%) patients: 13 were of grade 2 severity requiring prolonged observation, and 4 were of grade 3 severity. Of these grade 3 complications, two required blood transfusion whereas two required embolization. A total of 215 (78%) complications occurred within 1 h, 244 (89%) within 2 h of observation. 16 (94%) of 17 post-procedural haemorrhages occurred within 2 h post-biopsy. If complication-free after 2 h, the probability of experiencing a complication within the next 2 h was 4%.

CONCLUSION

The majority of complications were identified within 2 h of observation. Complications recognised after this period were largely pain-related, with only one grade 3 complication seen (post-procedural haemorrhage).Our findings suggest 2 h of post-procedural observation may be safe.

LEVEL OF EVIDENCE

Level 2B, Retrospective Cohort Study.

Breast Biopsy Procedure Toolkit: Ultrasound, 2D Stereotactic, 3D Tomosynthesis, and MRI-Guided Procedures

This article explores various techniques and tips for performing successful percutaneous biopsies of the breast and axillary lymph nodes using different imaging modalities. The discussion includes detailed image guidance on ultrasound-guided, stereotactic/tomosynthesis-guided, and MRI-guided biopsies. Advice for draining fluid collections in the breast is also reviewed. Key findings include the comparative effectiveness of different imaging techniques and practical advice for improving procedural outcomes. This information is particularly relevant for radiologists involved in diagnostic and interventional breast care. Recommendations for optimizing biopsy procedures and managing complications are also presented.

Nonvascular Renal Interventions: A Review and Procedural Considerations for the Interventional Radiologist

Interventional radiology plays a vital role in performing noninvasive, nonvascular genitourinary interventions. This article discusses practical aspects of the biopsy technique using the cortical tangential approach for native and transplant kidneys. Additionally, the indications, contraindications, and procedure details of the nephrostomy tube and nephroureteral placement will be reviewed.

Australian fresh frozen plasma audit: A National Blood Transfusion Committee and Blood Matters collaboration

BACKGROUND

There is a paucity of high-quality data to guide appropriate fresh frozen plasma transfusion with current recommendations based on consensus opinion. The limitations of the product and testing modalities are poorly understood with the rare but potentially serious side effects underappreciated. Combined this has resulted in the widespread misuse of FFP.

STUDY DESIGN AND METHODS

Retrospective data capturing FFP transfusion within the 12-month period of April 1, 2022 and March 31, 2023 was entered by Australian health care providers. Appropriate transfusion was assessed by the adjudicators and defined as one in keeping with current recommendations. Descriptive and comparative analyses were performed using SAS Studio version 9.4.

RESULTS

During the study period, 935 FFP transfusion episodes were captured. The most frequent indications for FFP were massive hemorrhage 344 (37%), bleeding 141 (15%), and preoperative use 90 (10%). Males received 534 (60%) transfusions. Critical care specialists were the largest users of FFP, prescribing 568 (63%) of transfusions. FFP was used appropriately in 546 (61%) transfusions. However, when massive hemorrhage was excluded only 202 (37%) transfusions were appropriate. Patients with an INR <1.5 received 37% of transfusions. Transfusion associated adverse events were reported in 2% (15) of transfusions including two non-fatal anaphylactic reactions.

DISCUSSION

This audit assesses the appropriate use of FFP across all major clinical indications and provides the largest body of evidence of Australian plasma transfusion practices. It highlights the widespread misuse of FFP, which is predominantly guided by consensus recommendations due to a lack of high-quality data.

Ultrasound-Guided Percutaneous Biopsy With Needle Track Plugging in Patients With Focal Liver Lesions on an Outpatient Basis: A Randomized Controlled Trial

OBJECTIVE

The increasing utilization of various molecular tests for diagnosing and selecting treatments for patients with malignancies has led to a rising trend in both the frequency of biopsies and the required tissue volume. We aimed to compare the safety of outpatient ultrasound (US)-guided percutaneous liver biopsy (PLB) between the coaxial method with needle track plugging (NTP) and the conventional method.

MATERIALS AND METHODS

This single-center, prospective, randomized controlled study was conducted from October 2022 to May 2023. Patients referred for US-guided PLB with target liver lesions measuring ≥1 cm and requiring ≥3 tissue cores were enrolled. Patients with severe coagulopathy or a substantial volume of ascites were excluded. Patients were randomly assigned to undergo PLB using either the coaxial method with NTP or the conventional method, in a 1:1 ratio, and were subsequently discharged after 2 hours. The primary endpoint was the presence of a patent track sign, defined as a linear color flow along the biopsy track on Doppler US, as an indication of bleeding. The secondary endpoints included clinically significant bleeding, delayed bleeding after discharge, and diagnostic yield. The incidences of these endpoints were compared between the two methods.

RESULTS

A total of 107 patients completed the study protocol. Patent track signs were observed significantly less frequently in the coaxial method with NTP group than in the conventional method group: 16.7% (9/54) vs. 35.8% (19/53; P = 0.042). Clinically significant bleeding and delayed bleeding did not occur in either group, and both methods achieved a high diagnostic yield: 94.4% (51/54) vs. 98.1% (52/53; P = 0.624).

CONCLUSION

Compared with the conventional method, the coaxial method with NTP may potentially be safer, with a reduced risk of overall bleeding complications after PLB when retrieving ≥3 tissue cores. The coaxial method with NTP could be considered a viable option for acquiring multiple liver tissues on an outpatient basis.

Thromboelastography-Guided versus Standard-of-Care or On-Demand Platelet Transfusion in Patients with Cirrhosis and Thrombocytopenia Undergoing Procedures: A Randomized Controlled Trial

PURPOSE

To determine the rate of platelet transfusion in patients with cirrhosis and severe thrombocytopenia (platelet counts <50 × 109/L) undergoing high-risk invasive procedures when prescribed by thromboelastography (TEG) compared with empirical and on-demand transfusion strategies.

MATERIALS AND METHODS

This was a single-center, single-blinded, randomized controlled trial. Patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures were randomized into 3 groups: TEG group, transfusions based on TEG parameters; standard of care (SOC) group, 3 units of random donor platelets before procedure; and on-demand group, transfusions based on procedural adverse events/clinician's discretion. The primary outcome was periprocedural platelet transfusion in each arm.

RESULTS

Eighty-seven patients were randomized (29 in each group) with no significant differences in demographics/coagulation profile/procedures. The median platelet count was 33 × 109/L (interquartile range, 26-43 × 109/L). Percutaneous liver biopsy was the most common procedure (46, 52.9%). Significantly lower number of patients in the TEG group received platelets (4 cases, 13.8%; 95% CI, 3.9-31.7) compared with SOC group (100%; 95% CI, 88.1-100; P < .001). Four patients in the on-demand group received platelets (13.8%; 95% CI, 3.9-31.7). Minor (World Health Organization [WHO] Grade 2) procedure-related bleeding occurred in 3 (10%; 95% CI, 2.2-27.4) patients in the TEG-guided transfusion group compared with 1 (3.4%; 95% CI, 0.1-17.8) patient each in the SOC and on-demand groups (P = .43), although the study was not powered for comparison of bleeding rates. No bleeding-related mortality was observed in any of the 3 groups.

CONCLUSIONS

TEG-prescribed transfusion reduced prophylactic transfusions in patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures. The study was not powered for comparison of bleeding rates.

Bone Biopsies: Practical Considerations and Technical Tips

Percutaneous image-guided needle biopsies are a safe and minimally invasive method of obtaining tissue of bone lesions. Radiologists are an integral part of a multidisciplinary team (MDT) approach to patient care in obtaining tissue for both pathologic diagnosis and advanced genetic/molecular testing. By utilizing image guidance, radiologists can target bone lesions with a very low complication rate. This review will discuss our approach to image-guided biopsies of bone lesions. Radiologists should be familiar with patient selection and imaging workup prior to performing biopsies, as well as the importance of coordinating the biopsy approach and sampling with the patient's clinical team. Management of bleeding and thrombotic risk in patients undergoing bone biopsies is also an important preprocedural consideration and will be discussed. The majority of bone biopsies are performed utilizing moderate sedation for patient analgesia and comfort, but close attention should be paid to patient comorbidities and potential interacting medications. Although computed tomography guidance remains the mainstay of image-guided biopsy, there are some circumstances in which ultrasound or fluoroscopic guidance may be beneficial. New advances in powered drill technology have made tissue sampling of bone lesions particularly sclerotic bone lesions both safer and faster with increased tissue yield. Finally, we will discuss image-guided biopsy of difficult anatomic regions that require special techniques to yield tissue safely.

Highest 3-month international normalized ratio (INR): a predictor of bleeding following ultrasound-guided liver biopsy

OBJECTIVES

To determine whether international normalized ratio (INR), bilirubin, and creatinine predict bleeding risk following percutaneous liver biopsy.

METHODS

A total of 870 consecutive patients (age 53 ± 14 years; 53% (459/870) male) undergoing non-targeted, ultrasound-guided, percutaneous liver biopsy at a single tertiary center from 01/2016 to 12/2019 were retrospectively reviewed. Results were analyzed using descriptive statistics and logistic regression models to evaluate the relationship between individual and combined laboratory values, and post-biopsy bleeding risk. Receiver operating characteristic (ROC) curves and area under ROC (AUC) curves were constructed to evaluate predictive ability.

RESULTS

Post-biopsy bleeding occurred in 2.0% (17/870) of patients, with 0.8% (7/870) requiring intervention. The highest INR within 3 months preceding biopsy demonstrated the best predictive ability for post-biopsy bleeding and was superior to the most recent INR (AUC = 0.79 vs 0.61, p = 0.003). Total bilirubin is an independent predictor of bleeding (AUC = 0.73) and better than the most recent INR (0.61). Multivariate regression analysis of the highest INR and total bilirubin together yielded no improvement in predictive performance compared to INR alone (0.80 vs 0.79). The MELD score calculated using the highest INR (AUC = 0.79) and most recent INR (AUC = 0.74) were similar in their predictive performance. Creatinine is a poor predictor of bleeding (AUC = 0.61). Threshold analyses demonstrate an INR of > 1.8 to have the highest predictive accuracy for bleeding.

CONCLUSION

The highest INR in 3 months preceding ultrasound-guided percutaneous liver biopsy is associated with, and a better predictor for, post-procedural bleeding than the most recent INR and should be considered in patient risk stratification.

CLINICAL RELEVANCE STATEMENT

Despite correction of coagulopathic indices, the highest international normalized ratio within the 3 months preceding percutaneous liver biopsy is associated with, and a better predictor for, bleeding and should considered in clinical decision-making and determining biopsy approach.

KEY POINTS

• Bleeding occurred in 2% of patients following ultrasound-guided liver biopsy, and was non-trivial in 41% of those patients who needed additional intervention and had an associated 23% 30-day mortality rate. • The highest INR within 3 months preceding biopsy (AUC = 0.79) is a better predictor of bleeding than the most recent INR (AUC = 0.61). • The MELD score is associated with post-procedural bleeding, but with variable predictive performance largely driven by its individual laboratory components.

Percutaneous Biopsy and Drainage of the Pancreas

Percutaneous biopsy and drainage of pancreatic lesions, though less frequent due to advancements in endoscopic techniques, remain vital skills for interventional radiologists. This review details the indications, options, approaches, and technical considerations for pancreatic biopsy and (peri)pancreatic fluid drainage by examining a comprehensive range of literature. The importance of a multidisciplinary approach is emphasized to ensure optimal patient care and outcomes, highlighting current best practices and recent advancements.

Evaluation of a novel central venous access port for direct catheter insertion without a peel-away sheath

PURPOSE

This study retrospectively evaluated the feasibility and safety of implanting a newly developed central venous access port (CV-port) that allows catheter insertion into a vein without the use of a peel-away sheath, with a focus on its potential to minimize risks associated with conventional implantation methods.

MATERIALS AND METHODS

All procedures were performed using a new device (P-U CelSite Port™ MS; Toray Medical, Tokyo, Japan) under ultrasound guidance. The primary endpoint was the implantation success rate. The secondary endpoints were the safety and risk factors for infection in the early postprocedural period (< 30 days).

RESULTS

We assessed 523 CV-port implantations performed in a cumulative total of 523 patients (240 men and 283 women; mean age, 61.6 ± 13.1 years; range, 18-85 years). All implantations were successfully performed using an inner guide tube and over-the-wire technique through 522 internal jugular veins and one subclavian vein. The mean procedural time was 33.2 ± 10.9 min (range 15-112 min). Air embolism, rupture/perforation of the superior vena cava, or hemothorax did not occur during catheter insertion. Eleven (2.1%) intraprocedural complications occurred, including Grade I arrhythmia (n = 8) and subcutaneous bleeding (n = 1), Grade II arrhythmia (n = 1), and Grade IIIa pneumothorax (n = 1). Furthermore, 496 patients were followed up for ≥ 30 days. Six early postprocedural complications were encountered (1.1%), including Grade IIIa infection (n = 4), catheter occlusion (n = 1), and skin necrosis due to subcutaneous leakage of trabectedin (n = 1). These six CV-ports were withdrawn, and no significant risk factors for infection in the early postprocedural period were identified.

CONCLUSION

The implantation of this CV-port device demonstrated comparable success and complication rates to conventional devices, with the added potential benefit of eliminating complications associated with the use of a peel-away sheath.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma, a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage hepatocellular carcinoma. The lack of organized evidence and expert opinions regarding patient selection, preprocedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-Guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Penetrating cardiac injury after percutaneous breast core-needle biopsy, unusual life-threatening complication: a case report

BACKGROUND

Complications after percutaneous breast biopsy are infrequent but may include hematoma, pseudoaneurysm formation, persistent pain, infection, delayed wound healing, vasovagal reaction, hemothorax, pneumothorax, and neoplastic seeding. The risk factors include tumor factors (size, location, vascularity), procedure-related factors (needle diameter, number of biopsies), and interventionist experience. There has been no previous report of a fatal complication resulting from percutaneous breast biopsy.

CASE PRESENTATION

We report a 54-year-old Asian woman with a 3 cm BI-RADS® 4B left breast mass in the lower-inner quadrant who was biopsied by a 16 G needle under ultrasound guidance at a province hospital. She experienced dizziness and near-syncope afterward. The initial evaluation showed evidence of cardiac tamponade with hemodynamic instability. She underwent urgent subxiphoid pericardial window and was transferred to our facility. We brought her directly to the operating room to perform an explorative median sternotomy and found a 0.2 cm hole in the right ventricle. The injured site was successfully repaired without cardiopulmonary bypass. Postoperative echocardiography demonstrated mild right ventricular dysfunction without evidence of septal or valvular injury. She survived with no significant complications.

DISCUSSION

This case might be the first report of a life-threatening complication related to percutaneous breast core-needle biopsy. The rapid pericardial release is key to the survival of cardiac tamponade. The patient subsequently required cardiac repair and monitoring to avoid long-term complications. In this report, we suggested a safe biopsy method, complications recognition, and appropriate management of penetrating cardiac injury.

CONCLUSION

Penetrating cardiac injury resulting from percutaneous breast biopsy is extremely rare but can occur. A biopsy must be done cautiously, and worst-case management should promptly be considered.

Epidural steroid injection technique

An epidural steroid injection (ESI) is a minimally invasive, image guided procedure for the treatment of back pain. Pain originating in the lumbar spine is the most common referral for ESI but the entire spine may be targeted. ESI can provide temporary but meaningful relief for patients who may have failed conservative management with oral analgesics and physical therapy. ESI may provide analgesia and anti-inflammatory effects that allow more conservative measures like physical therapy to become more effective. ESI also serves as a bridge between conservative and surgical management, intervention for postsurgical pain, or an alternative for nonsurgical candidates. This article reviews the technique for performing ESI in the cervical, thoracic, and lumbosacral spine.

Venous Thromboembolism Rates in Trauma Patients Significantly Increase With Missed Prophylactic Enoxaparin Doses

Background: Current literature demonstrates prophylactic enoxaparin to be efficacious in reducing venous thromboembolism (VTE) rates without significantly increasing risk for bleeding complications. Despite this evidence, prophylactic enoxaparin doses are frequently withheld for surgery or procedures. This exploratory study aims to quantify the risk of a VTE event in trauma patients associated with missed doses of prophylactic enoxaparin. Methods: This retrospective cohort study evaluated trauma patients admitted to our Level 1 trauma center from January 1, 2012 to January 31, 2021. A 1:1 propensity match with ten variables was performed to compare patients receiving prophylactic enoxaparin that had a VTE and those that did not. The primary outcome was a VTE event. Results: 493 patients met inclusion criteria; 1:1 propensity score matching was performed resulting in a cohort of 184 patients. The percentage of patients that missed a prophylactic enoxaparin dose in the VTE group was higher than the no VTE group (34.8% vs 21.7%, P = 0.049). This is consistent when examining total missed doses (P = 0.038) and consecutively missed doses (P = 0.035). The odds of having a VTE for patients that missed at least one dose or more of enoxaparin are nearly two times greater (OR 1.92, 95% CI 0.997, 3.7). Conclusion: Missing enoxaparin doses significantly increases the risk of VTE in matched populations. Most prophylactic enoxaparin doses were held for procedures, and not for bleeding events. Trauma teams should carefully weigh the risk of bleeding complications associated with continuing enoxaparin prophylaxis against the significant thromboembolic risk of withholding it.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma (HCC), a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Vertebral augmentation: How we do it

Vertebral augmentation consists of minimally invasive techniques indicated in the treatment of vertebral compression fractures (VCFs). These compression fractures cause vertebral body height loss and consequent significant pain and are most frequently the result of osteoporosis, cancer metastasis, or trauma. The deleterious effects of VCFs often compound, as greater load-bearing stress is transferred to the remaining healthy vertebrae. Kyphoplasty, vertebroplasty, and intravertebral implants are closely related vertebral augmentation techniques that serve to relieve pain and to counter pathophysiological stress and structural degradation of the vertebral column alignment. All 3 approaches are performed percutaneously and are therefore attractive options for patients deemed to be poor candidates for open surgery. Each technique involves transpedicular needle access to the vertebral body matrix, followed by introduction of a cement-like polymer through a catheter to fill the space and provide structural fortification. Vertebroplasty involves injection of the cement material into the matrix space without any adjunctive measures. In kyphoplasty, a balloon is first introduced to expand the collapsed, fractured area with the goal of approximating the prefracture anatomy of the vertebral body and thereby spinal curvature, promptly followed by cement introduction. In intravertebral implantation procedures, a permanent jack is inserted into the vertebral body matrix and expanded craniocaudally, with the same purpose of restoring normal structure, before the matrix space is filled with cement polymer. This article provides an overview of these vertebral augmentation techniques, including pre and postprocedural considerations, with an emphasis on the technical aspects of the interventions.

Correction of Thrombocytopenia before Elective Surgery / Invasive Procedures in Patients with Liver Cirrhosis (Experts’ Agreement)

Introduction. As a result of portal hypertension (sequestration of platelets in an enlarged spleen) and liver failure (decreased production of thrombopoietin in the liver) in liver cirrhosis, thrombocytopenia develops, which is associated with the risk of periprocedural/perioperative bleeding complications. There are still unresolved questions regarding risk stratification of bleeding complications, the prognostic role of thrombocytopenia, as well as the need for treatment of thrombocytopenia and its methods.

Materials and methods. The Russian Scientific Liver Society selected a panel of experts in the field of therapeutic and surgical hepatology, hematology, transfusion medicine to make reasoned statements and recommendations on the issue of treatment of thrombocytopenia before elective surgery / invasive procedures in patients with liver cirrhosis.

Results. Relevant clinical issues were determined based on the PICO principle (patient or population, intervention, comparison, outcome). The Delphi panel made five questions and gave reasoned answers, framed as ‘clinical practice recommendations and statements’ with evidence-based comments. The questions and statements were based on the results of search and critical analysis of medical literature using keywords in English- and Russian-language databases. The formulated questions could be combined into four categories: bleeding risk stratification, the prognostic value of thrombocytopenia, the necessity and methods of thrombocytopenia drug correction, and bleeding risk reduction.

Conclusions. The results of experts' work are directly related to high-quality management of patients with liver cirrhosis and thrombocytopenia, who have scheduled invasive procedures/surgery. Thus, this recommendations and statements can be used in clinical practice.

Camrelizumab, apatinib and hepatic artery infusion chemotherapy combined with microwave ablation for advanced hepatocellular carcinoma

BACKGROUND

Hepatic arterial infusion chemotherapy and camrelizumab plus apatinib (TRIPLET protocol) is promising for advanced hepatocellular carcinoma (Ad-HCC). However, the usefulness of microwave ablation (MWA) after TRIPLET is still controversial.

AIM

To compare the efficacy and safety of TRIPLET alone (T-A) vs TRIPLET-MWA (T-M) for Ad-HCC.

METHODS

From January 2018 to March 2022, 217 Ad-HCC patients were retrospectively enrolled. Among them, 122 were included in the T-A group, and 95 were included in the T-M group. A propensity score matching (PSM) was applied to balance bias. Overall survival (OS) was compared using the Kaplan-Meier curve with the log-rank test. The overall objective response rate (ORR) and major complications were also assessed.

RESULTS

After PSM, 82 patients were included both the T-A group and the T-M group. The ORR (85.4%) in the T-M group was significantly higher than that (65.9%) in the T-A group (P < 0.001). The cumulative 1-, 2-, and 3-year OS rates were 98.7%, 93.4%, and 82.0% in the T-M group and 85.1%, 63.1%, and 55.0% in the T-A group (hazard ratio = 0.22; 95% confidence interval: 0.10-0.49; P < 0.001). The incidence of major complications was 4.9% (6/122) in the T-A group and 5.3% (5/95) in the T-M group, which were not significantly different (P = 1.000).

CONCLUSION

T-M can provide better survival outcomes and comparable safety for Ad-HCC than T-A.

Risk of bleeding after abdominal paracentesis in patients with chronic liver disease and coagulopathy: A systematic review and meta-analysis

Abdominal paracentesis is a common procedure performed for both diagnostic and therapeutic purposes in patients with chronic liver disease and ascites. This review aims to provide an overview of the current evidence on the risk of bleeding associated with abdominal paracentesis. Electronic search was performed using PubMed, MEDLINE, and Ovid EMBASE from inception to 29 October 2023. Studies were included if they examined the risk of bleeding post-abdominal paracentesis or the efficacy of interventions to reduce bleeding in patients with chronic liver disease. Random-effects model was used to calculate the pooled proportions of bleeding events following abdominal paracentesis. Heterogeneity was determined by I 2, τ2 statistics, and P-value. Eight studies were included for review. Six studies reported incident events of post-abdominal paracentesis bleeding. Pooled proportion of bleeding events following abdominal paracentesis was 0.32% (95% CI: 0.15-0.69%). The mean values for pre-procedural INR and platelet count of patients in these studies ranged between 1.4 and 2.0, and 50 and 153 × 109/L, respectively. The highest recorded INR was 8.7, and the lowest platelet count was 19 × 109/L. Major bleeding after abdominal paracentesis occurred in 0-0.97% of the study cohorts. Two studies demonstrated that the use of thromboelastography (TEG) before paracentesis in patients with chronic liver disease identified those at risk of procedure-related bleeding and reduced transfusion requirements. The overall risk of major bleeding after abdominal paracentesis is low in patients with chronic liver disease and coagulopathy. TEG may be used to predict bleeding risk and guide transfusion requirements.

The historical origins of modern international normalized ratio targets

Prothrombin time (PT) and its derivative international normalized ratio (INR) are frequently ordered to assess the coagulation system. Plasma transfusion to treat incidentally abnormal PT/INR is a common practice with low biological plausibility and without credible evidence, yet INR targets appear in major clinical guidelines and account for the majority of plasma use at many institutions. In this article, we review the historical origins of INR targets. We recount historical milestones in the development of the PT, discovery of vitamin K antagonists (VKAs), motivation for INR standardization, and justification for INR targets in patients receiving VKA therapy. Next, we summarize evidence for INR testing to assess bleeding risk in patients not on VKA therapy and plasma transfusion for treating mildly abnormal INR to prevent bleeding in these patients. We conclude with a discussion of the parallels in misunderstanding of historic PT and present-day INR testing with lessons from the past that might help rationalize plasma transfusion in the future.

Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee

BACKGROUND

Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management.

OBJECTIVES

To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)?

METHODS

Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases.

STUDY SELECTION

Independently performed by 2 reviewers, disagreements resolved by a third reviewer.

DATA EXTRACTION

Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology.

RESULTS

Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions.

CONCLUSIONS

Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care.

LEVEL OF EVIDENCE

III. This study was registered as PROSPERO 2019 CRD42019124077.

Management of coagulopathy among patients with cirrhosis undergoing upper endoscopy and paracentesis: Persistent gaps and areas of consensus in a multispecialty Delphi

Patients with cirrhosis have abnormal coagulation indices such as a high international normalized ratio and low platelet count, but these do not correlate well with periprocedural bleeding risk. We sought to develop a consensus among the multiple stakeholders in cirrhosis care to inform process measures that can help improve the quality of the periprocedural management of coagulopathy in cirrhosis. We identified candidate process measures for periprocedural coagulopathy management in multiple contexts relating to the performance of paracentesis and upper endoscopy. An 11-member panel with content expertise was convened. It included nominees from professional societies for interventional radiology, transfusion medicine, and anesthesia as well as representatives from hematology, emergency medicine, transplant surgery, and community practice. Each measure was evaluated for agreement using a modified Delphi approach (3 rounds of rating) to define the final set of measures. Out of 286 possible measures, 33 measures made the final set. International normalized ratio testing was not required for diagnostic or therapeutic paracentesis as well as diagnostic endoscopy. Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy. No consensus was achieved for these items in therapeutic intent or emergent endoscopy. The risks of prophylactic platelet transfusions exceed their benefits for outpatient diagnostic paracentesis and diagnostic endosopies. For the other procedures examined, the risks outweigh benefits when platelet count is >20,000/mm 3 . It is uncertain whether risks outweigh benefits below 20,000/mm 3 in other contexts. No consensus was achieved on whether it was permissible to continue or stop systemic anticoagulation. Continuous aspirin was permissible for each procedure. Clopidogrel was permissible for diagnostic and therapeutic paracentesis and diagnostic endoscopy. We found many areas of consensus that may serve as a foundation for a common set of practice metrics for the periprocedural management of coagulopathy in cirrhosis.

How to undertake procedures while on antiplatelet agents: a hematologist's view

Cardiovascular diseases (CVDs) are the leading cause of mortality globally while also contributing to excess health system costs. Significant advancements have been made in the understanding and prevention of deaths from CVD. In addition to risk factor modifications, one of the key developments in this area is the appropriate prescribing of antiplatelet medications for secondary prevention of CVD. With the advent of vascular devices, there has been an increased use of potent antiplatelet agents to mitigate thrombosis risk. A well-recognized, albeit rare complication of antiplatelet drugs is the heightened risk of bleeding. This adverse effect is particularly relevant when a patient receiving these medications may require an urgent surgery. In addition, for elective surgeries, although these drugs can be withheld, there may be some situations when interruption of antiplatelet agents, even for short duration, may lead to thrombotic events. There are no robust guidelines on how to manage these clinical scenarios, although there have been some important studies published recently in this area. In this review, we provide our approach to patients on antiplatelet drugs who may require urgent surgeries or surgical interventions.