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Pedersoli F, Fang J, Boas E, Park JJ. Operator radiation exposure during radioembolisation of the liver: transfemoral versus transradial access using real-time dose monitoring. Radiat Prot Dosimetry 2023; 199:2344-2348. [PMID: 37644874 DOI: 10.1093/rpd/ncad236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 07/14/2023] [Accepted: 08/07/2023] [Indexed: 08/31/2023]
Abstract
In this study, operator radiation exposure is compared utilising transradial access (TRA) versus transfemoral access (TFA) during transarterial radioembolisation (TARE) of liver tumors. Patients who underwent Y90 TARE between May 2017 and April 2018 were included. Electronic medical records and interventional data were collected and the following parameters evaluated: technical success, fluoroscopy time, operator radiation exposure and rate of operator radiation exposure per fluoroscopy time. Statistical analysis was performed with the Wilcoxon rank-sum test. A total of 22 patients (12 males, 10 females) underwent 22 procedures. A total of 12 procedures were performed via TFA and 10 via TRA. Technical success was 100% in both groups. Median fluoroscopy time (10 minutes for TRA vs 6.4 minutes for TFA, p = 0.082) was not statistically different. Both operator radiation exposure (49 vs 4.2 μSv, p = 0.00016) and rate of operator exposure (4.9 vs 0.71 μSv per min, p = 0.00021) were significantly higher in the TRA versus TFA groups, respectively.
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Affiliation(s)
- Federico Pedersoli
- Division of Interventional Radiology, Department of Radiology, City of Hope, Comprehensive Cancer Center, Duarte, CA 91010, United States
| | - Jieming Fang
- Division of Interventional Radiology, Department of Radiology, City of Hope, Comprehensive Cancer Center, Duarte, CA 91010, United States
| | - Edward Boas
- Division of Interventional Radiology, Department of Radiology, City of Hope, Comprehensive Cancer Center, Duarte, CA 91010, United States
| | - John J Park
- Division of Interventional Radiology, Department of Radiology, City of Hope, Comprehensive Cancer Center, Duarte, CA 91010, United States
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Pedersoli F, Boas FE, Park JJ. Temporary Vascular Occlusion with Retrievable Microvascular Plugs to Protect Normal Liver during Yttrium-90 Radioembolization. J Vasc Interv Radiol 2023; 34:978-982. [PMID: 36796477 DOI: 10.1016/j.jvir.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/19/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
This case series describes a technique to protect nondiseased liver parenchyma during transarterial radioembolization (TARE) using microvascular plugs to occlude nontarget vessels temporarily and protect normal liver. This technique, defined as temporary vascular occlusion, was performed in 6 patients, with complete vessel occlusion obtained in 5 of the 6 patients and partial occlusion with flow reduction in 1 of the 6 patients. A statistically significant (P = .001) dose decrease of 5.7 ± 3.1 times was measured using postadministration yttrium-90 positron emission tomography/computed tomography in the protected zone compared with that in the treated zone.
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Affiliation(s)
- Federico Pedersoli
- Division of Interventional Radiology, Department of Radiology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Franz Edward Boas
- Division of Interventional Radiology, Department of Radiology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - John J Park
- Division of Interventional Radiology, Department of Radiology, City of Hope Comprehensive Cancer Center, Duarte, California.
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Lindelauf KHK, Thomas A, Baragona M, Jouni A, Nolte T, Pedersoli F, Pfeffer J, Baumann M, Maessen RTH, Ritter A. Plant-based model for the visual evaluation of electroporated area after irreversible electroporation and its comparison to in-vivo animal data. Sci Prog 2023; 106:368504231156294. [PMID: 36803089 PMCID: PMC10450266 DOI: 10.1177/00368504231156294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Electroporation (EP) is widely used in medicine, such as cancer treatment, in form of electrochemotherapy or irreversible electroporation (IRE). For EP device testing, living cells or tissue inside a living organism (including animals) are needed. Plant-based models seem to be a promising alternative to substitute animal models in research. The aim of this study is to find a suitable plant-based model for visual evaluation of IRE, and to compare the geometry of electroporated areas with in-vivo animal data.For this purpose, a variety of fruit and vegetables were selected and visually evaluated after 0/1/2/4/6/8/12/16/24 h post-EP. Apple and potato were found to be suitable models as they enabled a visual evaluation of the electroporated area. For these models, the size of the electroporated area was determined after 0/1/2/4/6/8/12/16/24 h. For apples, a well-defined electroporated area was visual within two hours, while in potatoes it reached a plateau after eight hours only. The electroporated area of apple, which showed the fastest visual results was then compared to a retrospectively evaluated swine liver IRE dataset which had been obtained for similar conditions. The electroporated area of the apple and swine liver both showed a spherical geometry of comparable size. For all experiments, the standard protocol for human liver IRE was followed. To conclude, potato and apple were found to be suitable plant-based models for the visual evaluation of electroporated area after irreversible EP, with apple being the best choice for fast visual results. Given the comparable range, the size of the electroporated area of the apple may be promising as a quantitative predictor in animal tissue. Even if plant-based models cannot completely replace animal experiments, they can be used in the early stages of EP device development and testing, decreasing animal experiments to the necessary minimum.
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Affiliation(s)
- Kim. H. K. Lindelauf
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
- Philips Research, Eindhoven, The Netherlands
| | - Athul Thomas
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
- Philips Research, Eindhoven, The Netherlands
| | | | - Ali Jouni
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
- Philips Research, Eindhoven, The Netherlands
| | - Teresa Nolte
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Joachim Pfeffer
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Baumann
- Institute of Applied Medical Engineering, RWTH Aachen University, Aachen, Germany
| | | | - Andreas Ritter
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
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Van den Bosch V, De Beukelaer F, Isfort P, Keil S, Kuhl CK, Bruners P, Pedersoli F. Long loop technique with bifemoral access as salvage technique for repositioning of dislodged port catheters. CVIR Endovasc 2022; 5:64. [PMID: 36512154 PMCID: PMC9748016 DOI: 10.1186/s42155-022-00341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Repositioning of dislocated port systems' catheters is usually performed with a pigtail catheter and/or a goose snare. In case of an inaccessible port catheter tip due to thrombosis, this classic approach may be not successful. For these cases, we describe a long loop bailout technique with bifemoral access. TECHNIQUE Via a right transfemoral access, a first attempt to reposition the dislodged port catheter using pigtail catheter and goose snare was performed. After an unsuccessful attempt and delineation of thrombosis of the catheter tip, the contralateral femoral vein was subsequently punctured and a sheath was placed. Through both vascular sheaths, pigtail catheter and goose wire were advanced distally to the catheter. The guidewire in the pigtail catheter was snared, thus creating a "Long loop" configuration. Pulling down both catheters simultaneously with improved stability allowed to detach the catheter tip from the vessel wall and replacement into the superior vena cava was possible. Refinement of catheter tip position was done using the goose snare. This technique was applied on 5 patients with dislodged port catheters in the jugular vein (2/5), the innominate vein (1/5), the subclavian vein (1/5) and the azygos vein (1/5) with a technical success of 100%. No complications were observed. CONCLUSION The Long loop technique can be used as salvage approach to reposition a dislodged catheter in case of failure with pigtail catheter and goose snare.
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Affiliation(s)
- Vincent Van den Bosch
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Frédéric De Beukelaer
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Isfort
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Keil
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane K. Kuhl
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- grid.412301.50000 0000 8653 1507Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
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Khader F, Han T, Müller-Franzes G, Huck L, Schad P, Keil S, Barzakova E, Schulze-Hagen M, Pedersoli F, Schulz V, Zimmermann M, Nebelung L, Kather J, Hamesch K, Haarburger C, Marx G, Stegmaier J, Kuhl C, Bruners P, Nebelung S, Truhn D. Artificial Intelligence for Clinical Interpretation of Bedside Chest Radiographs. Radiology 2022; 307:e220510. [PMID: 36472534 DOI: 10.1148/radiol.220510] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Supine chest radiography for bedridden patients in intensive care units (ICUs) is one of the most frequently ordered imaging studies worldwide. Purpose To evaluate the diagnostic performance of a neural network-based model that is trained on structured semiquantitative radiologic reports of bedside chest radiographs. Materials and Methods For this retrospective single-center study, children and adults in the ICU of a university hospital who had been imaged using bedside chest radiography from January 2009 to December 2020 were reported by using a structured and itemized template. Ninety-eight radiologists rated the radiographs semiquantitatively for the severity of disease patterns. These data were used to train a neural network to identify cardiomegaly, pulmonary congestion, pleural effusion, pulmonary opacities, and atelectasis. A held-out internal test set (100 radiographs from 100 patients) that was assessed independently by an expert panel of six radiologists provided the ground truth. Individual assessments by each of these six radiologists, by two nonradiologist physicians in the ICU, and by the neural network were compared with the ground truth. Separately, the nonradiologist physicians assessed the images without and with preliminary readings provided by the neural network. The weighted Cohen κ coefficient was used to measure agreement between the readers and the ground truth. Results A total of 193 566 radiographs in 45 016 patients (mean age, 66 years ± 16 [SD]; 61% men) were included and divided into training (n = 122 294; 64%), validation (n = 31 243; 16%), and test (n = 40 029; 20%) sets. The neural network exhibited higher agreement with a majority vote of the expert panel (κ = 0.86) than each individual radiologist compared with the majority vote of the expert panel (κ = 0.81 to ≤0.84). When the neural network provided preliminary readings, the reports of the nonradiologist physicians improved considerably (aided vs unaided, κ = 0.87 vs 0.79, respectively; P < .001). Conclusion A neural network trained with structured semiquantitative bedside chest radiography reports allowed nonradiologist physicians improved interpretations compared with the consensus reading of expert radiologists. © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Wielpütz in this issue.
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Affiliation(s)
- Firas Khader
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Tianyu Han
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Gustav Müller-Franzes
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Luisa Huck
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Philipp Schad
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Sebastian Keil
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Emona Barzakova
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Maximilian Schulze-Hagen
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Federico Pedersoli
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Volkmar Schulz
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Markus Zimmermann
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Lina Nebelung
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Jakob Kather
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Karim Hamesch
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Christoph Haarburger
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Gernot Marx
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Johannes Stegmaier
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Christiane Kuhl
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Philipp Bruners
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Sven Nebelung
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
| | - Daniel Truhn
- From the Department of Diagnostic and Interventional Radiology (F.K., G.M.F., L.H., P.S., S.K., E.B., M.S.H., F.P., M.Z., C.K., P.B., S.N., D.T.), Department of Medicine III (J.K., K.H.), and Clinic for Surgical Intensive Medicine and Intermediate Care (G.M.), University Hospital Aachen, Pauwelsstrasse 30, 52064 Aachen, Germany; Physics of Molecular Imaging Systems, Experimental Molecular Imaging (T.H., V.S.), and Institute of Imaging and Computer Vision (J.S.), RWTH Aachen University, Aachen, Germany; Department of Inner Medicine, Luisenhospital Aachen, Aachen, Germany (L.N.); and Ocumeda AG, Erlen, Switzerland (C.H.)
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Pedersoli F, Van den Bosch V, Keil S, Schulze-Hagen M, Isfort P, Kuhl KC, Bruners P. Stentgraftimplantation für die Behandlung von Pseudoaneurysmen der Arteria hepatica: Effektivität und Durchgängigkeit in Follow-up. ROFO-FORTSCHR RONTG 2022. [DOI: 10.1055/s-0042-1749834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- F Pedersoli
- Uniklinik RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - V Van den Bosch
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
| | - S Keil
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
| | - M Schulze-Hagen
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
| | - P Isfort
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
| | - K C Kuhl
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
| | - P Bruners
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Aachen
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Van den Bosch V, Salim HS, Chen NZ, Stroosma O, Bruners P, Kuhl CK, Pedersoli F, Isfort P. Augmented Reality-Assisted CT-Guided Puncture: A Phantom Study. Cardiovasc Intervent Radiol 2022; 45:1173-1177. [PMID: 35750863 PMCID: PMC9307551 DOI: 10.1007/s00270-022-03195-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
Purpose To investigate the feasibility of a novel augmented reality system for CT-guided liver interventions and to compare it with free-hand interventions in a phantom setting. Methods and materials A newly developed augmented reality interface was used, with projection of CT-imaging in multiplanar reconstruction and live rendering of the needle position, a bull`s eye view of the needle trajectory and a visualization of the distance to the target. Punctures were performed on a custom-made abdominal phantom by three interventional radiologists with different levels of expertise. Time and needle placement accuracy were measured. Two-tailed Wilcoxon signed rank test (p < 0.05) was performed to evaluate intraparticipant difference. Results Intraparticipant puncture times were significantly shorter for each operator in the augmented reality condition (< 0.001 for the resident, < 0.001 for the junior staff member and 0.027 for the senior staff member). The junior staff member had an improvement in accuracy of 1 mm using augmented reality (p 0.026); the other two participants showed no significant improvement regarding accuracy. Conclusion In this small series, it appears that the novel augmented reality system may improve the speed of CT-guided punctures in the phantom model compared to the free-hand procedure while maintaining a similar accuracy. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-022-03195-y.
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Affiliation(s)
- Vincent Van den Bosch
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | | | - Njin-Zu Chen
- Philips Research Europe, Eindhoven, The Netherlands
| | | | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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Van den Bosch V, Pedersoli F, Keil S, Neumann UP, Kuhl CK, Bruners P, Zimmermann M. Safety and efficacy of right portal vein embolization in patients with prior left lateral liver resection. Acta Radiol 2022; 63:727-733. [PMID: 33951926 DOI: 10.1177/02841851211014192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In patients with bilobar metastatic liver disease, surgical clearance of both liver lobes may be achieved through multiple-stage liver resections. For patients with extensive disease, a major two-staged hepatectomy consisting of resection of liver segments II and III before right-sided portal vein embolization (PVE) and resection of segments V-VIII may be performed, leaving only segments IV ± I as the liver remnant. PURPOSE To describe the outcome following right-sided PVE after prior complete resection of liver segments II and III. MATERIAL AND METHODS In this retrospective study, 15 patients (mean age = 60.4 ± 9.3 years) with liver metastases from colorectal cancer (n = 14) and uveal melanoma (n = 1) who were scheduled to undergo a major two-stage hepatectomy, were included. Total liver volume (TLV) and volume of the future liver remnant (FLR) were measured on pre- and postinterventional computed tomography (CT) scans, and standardized FLR volumes (ratio FLR/TLV) were calculated. Patient data were retrospectively analyzed regarding peri- and postinterventional complications, with special emphasis on liver function tests. RESULTS The mean standardized post-PVE FLR volume was 26.9% ± 6.4% and no patient developed hepatic insufficiency after the PVE. Based on FLR hypertrophy and liver function tests, all but one patient were considered eligible for the subsequent right-sided hepatectomy. However, due to local tumor progression, only 9/15 patients eventually proceeded to the second stage of surgery. . CONCLUSION Right-sided PVE was safe and efficacious in this cohort of patients who had previously undergone a complete resection of liver segments II and III as part of a major staged hepatectomy pathway leaving only segments IV(±I) as the FLR. .
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Affiliation(s)
- Vincent Van den Bosch
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
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9
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Pedersoli F, Wilkmann C, Penzkofer T, Disselhorst-Klug C, Schmitz-Rode T, Kuhl C, Bruners P, Isfort P. An accelerometer-based guidance device for CT-guided procedures: an improved wireless prototype. MINIM INVASIV THER 2021; 31:902-908. [PMID: 34865602 DOI: 10.1080/13645706.2021.2002363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The aim of the study was to demonstrate the feasibility of a prototype for accelerometer-based guidance for percutaneous CT-guided punctures and compare it with free-hand punctures. MATERIAL AND METHODS The prototype enabled alignment with the CT coordinate system and a wireless connectivity. Its feasibility was tested in a swine cadaver model: 20 out-of-plane device-assisted punctures performed without intermittent control scans (one-step punctures) were evaluated regarding deviation to target and difference between planned and obtained angle. Thereafter, 22 device-assisted punctures were compared with 20 free-hand punctures regarding distance to target, deviation from the planned angle, number of control scans and procedure time. Differences were compared with the Mann-Whitney U-test (p < .05). RESULTS The one-step punctures revealed a deviation to target of 0.26 ± 0.37 cm (axial plane) and 0.21 ± 0.19 cm (sagittal plane) and differences between planned and performed puncture angles of 0.9 ± 1.09° (axial plane) and 1.15 ± 0.91° (sagittal planes). In the comparative study, device-assisted punctures showed a significantly higher accuracy, 0.20 ± 0.17 cm vs. 0.30 ± 0.21 cm (p < .05) and lower number of required control scans, 1.3 ± 1.1 vs. 3.7 ± 0.9 (p < .05) compared with free-hand punctures. CONCLUSION The accelerometer-based device proved to be feasible and demonstrated significantly higher accuracy and required significantly less control scans compared to free-hand puncture.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Christoph Wilkmann
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany.,Institute of Applied Medical Engineering, Deptartment of Rehabilitation & Prevention Engineering, RWTH Aachen University, Aachen, Germany
| | - Tobias Penzkofer
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Catherine Disselhorst-Klug
- Institute of Applied Medical Engineering, Deptartment of Rehabilitation & Prevention Engineering, RWTH Aachen University, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Deptartment of Rehabilitation & Prevention Engineering, RWTH Aachen University, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
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10
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Pedersoli F, Van den Bosch V, Sieben P, Barzakova E, Schulze-Hagen M, Isfort P, Keil S, Wiltberger G, Kuhl CK, Bruners P. Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up. Cardiovasc Intervent Radiol 2021; 45:21-28. [PMID: 34734334 PMCID: PMC8716354 DOI: 10.1007/s00270-021-02993-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/14/2021] [Indexed: 12/27/2022]
Abstract
Purpose To investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm. Materials and Methods A retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients’ surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined. Results In total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up. Conclusion Stent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.
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Affiliation(s)
- F Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - V Van den Bosch
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Sieben
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - E Barzakova
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - M Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - S Keil
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - G Wiltberger
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - C K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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11
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Gombert A, Ketting S, Rückbeil MV, Hundertmark AK, Barbati M, Keschenau P, Pedersoli F, Schurink GW, Mees B, Kotelis D, Jacobs MJ. Perioperative and long-term outcome after ascending aortic and arch repair with elephant trunk and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2021; 75:824-832. [PMID: 34606958 DOI: 10.1016/j.jvs.2021.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. METHODS This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. RESULTS Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. CONCLUSIONS Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
| | - Shirley Ketting
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcia Viviane Rückbeil
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ann-Kathrin Hundertmark
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mohammad Barbati
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Federico Pedersoli
- Department of Radiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany; Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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12
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Han T, Nebelung S, Pedersoli F, Zimmermann M, Schulze-Hagen M, Ho M, Haarburger C, Kiessling F, Kuhl C, Schulz V, Truhn D. Advancing diagnostic performance and clinical usability of neural networks via adversarial training and dual batch normalization. Nat Commun 2021; 12:4315. [PMID: 34262044 PMCID: PMC8280105 DOI: 10.1038/s41467-021-24464-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 06/17/2021] [Indexed: 11/09/2022] Open
Abstract
Unmasking the decision making process of machine learning models is essential for implementing diagnostic support systems in clinical practice. Here, we demonstrate that adversarially trained models can significantly enhance the usability of pathology detection as compared to their standard counterparts. We let six experienced radiologists rate the interpretability of saliency maps in datasets of X-rays, computed tomography, and magnetic resonance imaging scans. Significant improvements are found for our adversarial models, which are further improved by the application of dual-batch normalization. Contrary to previous research on adversarially trained models, we find that accuracy of such models is equal to standard models, when sufficiently large datasets and dual batch norm training are used. To ensure transferability, we additionally validate our results on an external test set of 22,433 X-rays. These findings elucidate that different paths for adversarial and real images are needed during training to achieve state of the art results with superior clinical interpretability.
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Affiliation(s)
- Tianyu Han
- Physics of Molecular Imaging Systems, Experimental Molecular Imaging, RWTH Aachen University, Aachen, Germany.
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | | | | | - Fabian Kiessling
- The Institute for Experimental Molecular Imaging, RWTH Aachen University, Aachen, Germany.,Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany.,Comprehensive Diagnostic Center Aachen (CDCA), University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - Volkmar Schulz
- Physics of Molecular Imaging Systems, Experimental Molecular Imaging, RWTH Aachen University, Aachen, Germany. .,Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany. .,Comprehensive Diagnostic Center Aachen (CDCA), University Hospital RWTH Aachen, Aachen, Germany.
| | - Daniel Truhn
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany.
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13
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Pedersoli F, Hitpass L, Isfort P, Zimmermann M, Schulze-Hagen M, Gombert A, Kuhl CK, Bruners P, Keil S. Recanalization and Stenting of the Celiac and the Superior Mesenteric Artery Supported by Use of a Steerable Introducer Sheath: Report on 2 Years' Experience. Vasc Endovascular Surg 2020; 55:158-163. [PMID: 33213286 DOI: 10.1177/1538574420975264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare technical parameters and success of recanalization of celiac (CA) or superior mesenteric artery (SMA) with usage of steerable vs not steerable introducer sheaths. METHODS A retrospective analysis was performed on all consecutive patients who underwent recanalization with stent implantation of CA or SMA between 2015 and 2019. Data regarding technical success (successful stent placement with restoration of sufficient blood flow by the first attempt without changing kind of introducer sheath or access site), indication for treatment, vascular access, kind of introducer sheath, fluoroscopy time and radiation dose were collected. Preinterventional CT were analyzed to classify the difficulty of catheterization of target vessels. Technical parameters were compared with independent t-test (p ≤ 0.05). RESULTS 66 patients underwent recanalization of CA or SMA. Usage of steerable introducer sheaths was associated with higher technical success compared to not steerable introducer sheaths with transfemoral approach respectively of 8/8 vs 15/19 for the CA and 11/11 vs 17/20 for the SMA. Steerable introducer sheaths were used in recanalization considered more technically difficult compared to not steerable introducer sheaths (58% vs 33%). Usage of steerable introducer sheath showed a statistically significant reduction of radiation dose in the recanalization of the SMA (respectively 32035 ± 15716 cGy cm2 vs 60102 ± 28432 cGy cm2; p = 0.005). CONCLUSION Even if used in more difficult interventions, steerable introducer sheaths showed a higher technical success compared to not steerable introducer sheaths with transfemoral access.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Lea Hitpass
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
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14
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Tamura M, Pedersoli F, Schulze-Hagen M, Zimmerman M, Isfort P, Kuhl CK, Schmitz-Rode T, Bruners P. Predictors of Occlusion of Hepatic Blood Vessels after Irreversible Electroporation of Liver Tumors. J Vasc Interv Radiol 2020; 31:2033-2042.e1. [PMID: 33267950 DOI: 10.1016/j.jvir.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To examine predictors of midterm occlusion in portal and hepatic veins within or adjacent to the ablation zone after irreversible electroporation (IRE) of liver tumors. MATERIALS AND METHODS This retrospective cohort analysis included 39 patients who underwent CT-guided IRE of liver tumors. Vessels within or adjacent to the ablation zone were identified on CT images acquired immediately after the procedure, and the positional relationships with the ablation zone (within/adjacent), locations (proximal/distal), and diameters (< 4 mm or ≥ 4 mm) were evaluated. Using contrast-enhanced follow-up scans, each vessel was classified as patent, stenosed, or occluded. Associations between vessel occlusion and each variable were investigated. RESULTS Overall, 33 portal veins and 64 hepatic veins were analyzed. Follow-up scans showed occlusion in 12/33 (36.7%) portal veins and 17/64 (26.6%) hepatic veins. Vessels within the ablation zone were occluded significantly more frequently than vessels adjacent to the ablation zone (portal: 55.6% [10/18] vs 13.3% [2/15], P = .04; hepatic: 45.4% [15/33] vs 6.4% [2/31], P = .011). Vessels with a diameter < 4 mm were also occluded significantly more frequently than vessels with a diameter ≥ 4 mm (portal: 72.7% [8/11] vs 18.1% [4/22], P = .011; hepatic: 54.8% [17/31] vs 0% [0/33], P < .001). The respective positive and negative predictive values for occlusion of vessels categorized as both within and < 4 mm were 88% (7/8) and 82% (20/25) for portal veins and 79% (15/19) and 96% (43/45) for hepatic veins. CONCLUSIONS Midterm vessel occlusion after liver IRE could be predicted with relatively high accuracy by assessing ablation location and vessel diameter.
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Affiliation(s)
- Masashi Tamura
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany; Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany; Department of Radiology, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Markus Zimmerman
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
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Pedersoli F, Schröder A, Zimmermann M, Schulze-Hagen M, Keil S, Ulmer TF, Neumann UP, Kuhl CK, Bruners P, Isfort P. Percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts: technical considerations and complications. Eur Radiol 2020; 31:3035-3041. [PMID: 33051733 PMCID: PMC8043937 DOI: 10.1007/s00330-020-07368-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 12/20/2022]
Abstract
Objectives The aim of this study was to compare success, technical complexity, and complication rates of percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts. Methods In a retrospective analysis, we evaluated all consecutive PTBD performed in our department over a period of 5 years. Technical success, technical data (side, fluoroscopy time, radiation dose, amount of contrast media, use of disposable equipment), procedure-related complications and peri-interventional mortality were compared for patients with dilated vs. non-dilated bile ducts. Independent t test and χ2 test were used to evaluate the statistical significance. Results A total of 253 procedures were performed on 187 patients, of whom 101/253 had dilated bile ducts and 152/253 not. In total, 243/253 procedures were successful. PTBD was significantly more often successful in patients with dilated vs. nondilated bile ducts (150/153 vs. 93/101; p 0.02). Overall complication rate (13%) did not differ significantly between patients with dilated vs. nondilated bile ducts. Procedures in patients with normal, nondilated bile ducts were associated with a significantly higher rate of post-interventional bleeding (5/101 vs. 0/152). Mean fluoroscopy time (42:36 ± 35:39 h vs. 30:28 ± 25:10 h; p 0.002) and amount of contrast media (66 ± 40 ml vs. 52 ± 24 ml; p 0.07) or use of disposables were significantly higher in patients with nondilated ducts. A significantly lower fluoroscopy time and amount of contrast medium were used in left hepatic PTBD. Conclusion Despite the higher technical complexity, PTBD with nondilated bile ducts was associated with similar overall complication rates but higher bleeding complications compared with PTBD with dilated bile ducts. Key Points • PTBD was associated with similar overall complication rates in patients with dilated vs. nondilated bile ducts. • Although overall complication rates were low, PTBD in patients with nondilated bile ducts was associated with a higher incidence of post-interventional bleeding. • PTBD in patients with nondilated bile ducts is technically more complex.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Anja Schröder
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Tom Florian Ulmer
- Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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Schulze-Hagen M, Truhn D, Duong F, Keil S, Pedersoli F, Kuhl CK, Lurje G, Neumann U, Isfort P, Bruners P, Zimmermann M. Correlation Between Sarcopenia and Growth Rate of the Future Liver Remnant After Portal Vein Embolization in Patients with Colorectal Liver Metastases. Cardiovasc Intervent Radiol 2020; 43:875-881. [PMID: 31974746 PMCID: PMC7225189 DOI: 10.1007/s00270-020-02416-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate whether sarcopenia and myosteatosis correlate with the degree of hypertrophy (DH) and kinetic growth rate (KiGR) of the future liver remnant (FLR) in patients with colorectal liver metastases undergoing portal vein embolization (PVE) in preparation for right hepatectomy. MATERIALS AND METHODS Forty-two patients were included. Total liver volume and FLR volume were measured before and 2-4 weeks after PVE. KiGR of the FLR was calculated. Sarcopenia was assessed using the total psoas muscle volume (PMV), the psoas muscle cross-sectional area (PMCS) and the total skeletal muscle index (L3SMI) at the level of 3rd lumbar vertebra. Degree of myosteatosis was assessed by mean muscle attenuation at L3 (L3MA). Correlations between muscle indices and DH and KiGR were assessed using simple linear regression analyses. RESULTS Mean DH was 8.9 ± 5.7%, and mean KiGR was 3.6 ± 2.3. Mean PMV was 55.56 ± 14.19 cm3/m3, mean PMCS was 8.76 ± 2.3 cm2/m2, mean L3SMI was 45.6 ± 9.89 cm2/m2, and mean L3MA was 27.9 ± 18.6 HU. There was a strong positive correlation between PMV and DH (R = 0.503, p = 0.001) and PMV and KiGR (R = 0.545, p < 0.001). Furthermore, there was a moderate correlation between PMCS and KiGR (R = 0.389, p = 0.014). L3SMI and L3MA were neither associated with DH (p = 0.390 and p = 0.768, respectively) nor with KiGR (p = 0.188 and p = 0.929, respectively). CONCLUSION We identified a positive correlation between PMV and PMCS, as markers for sarcopenia, and the KiGR of the FLR after PVE. PMV and PMCS might therefore aid to identify patients who are poor candidates for FLR augmentation using PVE alone.
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Affiliation(s)
- M Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany.
| | - D Truhn
- Institute of Imaging and Computer Vision, RWTH Aachen University, Aachen, DE, Germany
| | - F Duong
- Institute of Imaging and Computer Vision, RWTH Aachen University, Aachen, DE, Germany
| | - S Keil
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - F Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - C K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - G Lurje
- Department of Surgery and Transplantation, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - U Neumann
- Department of Surgery and Transplantation, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - P Isfort
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - P Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
| | - M Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, DE, Germany
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Pedersoli F, Zimmermann M, Schulze-Hagen M, Sieben P, Barzakova E, Goerg F, Keil S, Gombert A, Kuhl CK, Isfort P, Bruners P. Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access. Vasc Endovascular Surg 2020; 54:477-481. [PMID: 32419653 DOI: 10.1177/1538574420927132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. METHODS We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. RESULTS Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. CONCLUSIONS The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Paul Sieben
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Emona Barzakova
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Fabian Goerg
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Alexander Gombert
- Clinic for Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
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Liebl M, Schulze-Hagen M, Zimmermann M, Pedersoli F, Kuhl C, Bruners P, Isfort P. Microwave Ablation in the Proximity of Surgical Clips: Is there a Safety Issue? Cardiovasc Intervent Radiol 2020; 43:918-923. [PMID: 32236668 PMCID: PMC7225190 DOI: 10.1007/s00270-020-02453-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/12/2020] [Indexed: 12/22/2022]
Abstract
Purpose The purpose of this study was to evaluate the heat generation of surgical clips within the target area of MWA and the influences on the ablation volume. Materials and Methods In bovine liver tissue, 42 ex vivo microwave ablations (60 W; 180 s) were performed. During ablation, the temperature was measured continuously at 4 points of interest (POI), in a distance of 7.5 and 15 mm on each side of the microwave antenna, with a titanium surgical placed at one 7.5-mm POI. Ablation volumes containing large vessels (n = 10) were excluded. For every POI, the mean temperature of 32 ablations was calculated. The mean temperatures were compared between the 4 POI and statistically analyzed using the Student’s t test. Results The mean maximum temperatures at the side of the clip were 88.76 °C/ 195 s and 52.97 °C/ 195 s and at the side without clip 78.75 °C/ 195 s and 43.16 °C/ 195 s, respectively, at POI 7.5 mm and POI 15 mm. The maximum difference of mean temperatures for POI 7.5 mm was 12.91 °C at 84 s (p = 0.022) and for POI 15 mm 9.77 °C at 195 s (p = 0.009). No significant changes in size and shape of the ablation zone could be determined. Conclusions Our study demonstrated significantly higher temperatures adjacent to surgical clips. Also, the temperatures distal to the titanium clip were higher compared to the control location without clip. These findings suggest an increased risk of thermal damage to surrounding tissues during MWA, especially in case of immediate contact to surgical clips.
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Affiliation(s)
- Martin Liebl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.,Hôpital Kirchberg (Hôpitaux Robert Schuman), 9, Rue Edward Steichen, 2540, Luxembourg, Luxembourg
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
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Barzakova ES, Schulze-Hagen M, Zimmermann M, Lurje G, Bednarsch J, Pedersoli F, Isfort P, Kuhl C, Bruners P. Monitoring Liver Function of Patients Undergoing Transarterial Chemoembolization (TACE) by a 13C Breath Test (LiMAx). Cardiovasc Intervent Radiol 2019; 42:1702-1708. [PMID: 31535181 DOI: 10.1007/s00270-019-02325-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/23/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Transarterial chemoembolization (TACE) is associated with the risk of deteriorating liver function, especially in patients with preexisting liver damage. Current liver function tests may fail to accurately predict the functional liver reserve. Aim of this study was to investigate whether changes of liver function caused by TACE are associated with detectable changes of LiMAx values. METHODS AND MATERIALS Forty patients with primary or secondary liver cancer underwent TACE and LiMAx test on the day before, the day after, and 4 weeks after TACE. LiMAx results were evaluated, referenced to liver volume (CT/MR volumetry), correlated with the respective TACE volume (subsegmental vs. segmental vs. lobar), established liver function tests, and Child-Pugh and ALBI scores. RESULTS The individual LiMAx values were significantly reduced by 10% (p = 0.01) on the day after TACE and fully recovered to baseline 1 month after treatment. Similar changes were observed regarding levels of bilirubin, transaminases, albumin, INR, and creatinine. LiMAx did not correlate significantly with the treated liver volume, but did correlate with the baseline liver volume (< 1200 ml vs. > 1200 ml; p < 0.01). No significant changes were observed in the Child-Pugh score or ALBI score. CONCLUSION LiMAx is capable of detecting changes in liver function, even modulations caused by superselective TACE procedures. Accordingly, it could be used as a tool for patient selection and monitoring of transarterial therapy. In comparison, Child-Pugh and ALBI scores did not reflect any of these changes. Some biochemical parameters also changed significantly after TACE, but they tend to be less specific in providing sufficient information on actual cellular dysfunction.
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Affiliation(s)
- Emona S Barzakova
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany.
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
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Thüring J, Zimmermann M, Bruners P, Pedersoli F, Schulze-Hagen M, Barzakova E, Kuhl CK, Isfort P. Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment. Cardiovasc Intervent Radiol 2019; 42:1494-1499. [PMID: 31363899 PMCID: PMC6715807 DOI: 10.1007/s00270-019-02294-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC. MATERIALS AND METHODS Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA. RESULTS All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand-foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively. CONCLUSION Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.
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Affiliation(s)
- J Thüring
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany.
| | - M Zimmermann
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - P Bruners
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - F Pedersoli
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - M Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - E Barzakova
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - C K Kuhl
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
| | - P Isfort
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, Pauwelsstreet 30, 52072, Aachen, Germany
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Zimmermann M, Schulze-Hagen M, Pedersoli F, Isfort P, Heinzel A, Kuhl C, Bruners P. Y90-radioembolization via variant hepatic arteries: Is there a relevant risk for non-target embolization? World J Radiol 2019; 11:102-109. [PMID: 31396373 PMCID: PMC6682496 DOI: 10.4329/wjr.v11.i7.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/03/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The hepatic arterial anatomy is highly variable, with the two most common variants being a replaced right hepatic artery (RHA) originating from the superior mesenteric artery (SMA) and a left hepatic artery (LHA) originating from the left gastric artery (LGA). These anatomical variants could potentially increase the risk for non-target embolization during Y90-Radioembolization due to the close proximity between hepatic and enteric vessel branches.
AIM To evaluate the safety of Yttrium-90 radioembolization (90Y-RE) with resin microspheres in patients with a variant hepatic arterial anatomy.
METHODS In this retrospective single-center observational study, 11 patients who underwent RE with 90Y-resin microspheres via a LHA originating from the LGA, and 13 patients via a RHA originating from the SMA were included. Patient and treatment data were reviewed regarding clinical and imaging evidence of non-target embolization of 90Y-resin microspheres to the GI tract. Positioning of the tip of the microcatheter in relationship to the last hepatoenteric side branch was retrospectively analyzed using angiographic images, cone-beam CT and pre-interventional CT-angiograms.
RESULTS None of the 24 patients developed clinical symptoms indicating a potential non-target embolization to the GI tract within the first month after 90Y-RE. On the postinterventional 90Y-bremsstrahlung images and/or 90Y-positron emission tomographies, no evidence of extrahepatic 90Y-activity in the GI tract was noted in any of the patients. The mean distance between the tip of the microcatheter and the last enteric side branch during delivery of the 90Y microspheres was 3.2 cm (range: 1.9-5 cm) in patients with an aberrant LHA originating from a LGA. This was substantially shorter than the mean distance of 5.2 cm (range: 2.9-7.7 cm) in patients with an aberrant right hepatic originating from the SMA.
CONCLUSION 90Y-RE via aberrant hepatic arteries appears to be safe; at least with positioning of the microcatheter tip no less than 1.9 cm distal to the last hepatoenteric side branch vessel.
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Affiliation(s)
- Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
| | - Alexander Heinzel
- Department of Nuclear Medicine, RWTH Aachen University Hospital, Pauwelsstrasse 30, Aachen 52074, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
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Abstract
BACKGROUND Carbon dioxide (CO2) is a very good and validated alternative to iodine-containing contrast media in diagnostic and interventional angiography. Nevertheless, its routinely use is still limited to specialized centers. OBJECTIVE The presentation of the current role and limitations of CO2 in diagnostic and interventional angiography (venous and arterial). MATERIAL AND METHODS A comprehensive review of the literature regarding CO2 angiography (physical features, indications, contraindications, applications) was carried out. RESULTS The results show that CO2 can be used as a reliable alternative for diagnostic angiography and to support interventions in many arterial and venous vascular territories. An exception is the intra-arterial use of CO2 above the diaphragm due to the risk of severe myocardial and cerebral complications, which represents the most important contraindication. Moreover, due to its very low viscosity, CO2 is more effective than iodine-containing contrast media in detecting bleeding arising from small vessels. CONCLUSION The CO2 angiography is a safe and effective technique and can be used as valid alternative. In several clinical cases it even offers some advantages compared to iodine-containing contrast media.
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Affiliation(s)
- F Pedersoli
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - P Bruners
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - C K Kuhl
- Klinik für Diagnostische und Interventionelle Radiologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - T Schmitz-Rode
- Institut für Angewandte Medizintechnik, RWTH Aachen, Pauwelsstraße 20, 52074, Aachen, Deutschland
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Ritter A, Bruners P, Isfort P, Barabasch A, Pfeffer J, Schmitz J, Pedersoli F, Baumann M. Electroporation of the Liver: More Than 2 Concurrently Active, Curved Electrodes Allow New Concepts for Irreversible Electroporation and Electrochemotherapy. Technol Cancer Res Treat 2019; 17:1533033818809994. [PMID: 30411673 PMCID: PMC6259055 DOI: 10.1177/1533033818809994] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Irreversible electroporation and electrochemotherapy are 2 innovative electroporation-based minimally invasive therapies for the treatment of cancer. Combining nonthermal effects of irreversible electroporation with local application of chemotherapy, electrochemotherapy is an established treatment modality for skin malignancies. Since the application of electrochemotherapy in solid organs is a promising approach, this article describes a novel electrode configuration and field generating method. For the treatment of hepatic malignancies, the shape of the electric field should resemble a spherical 3-dimensional geometry around the target tissue inside the liver. To adapt the actual shape of the field, the probe is designed in computer-aided design with a live link to a computer simulation software: Changes in design can be revalued quickly, regarding different quality criteria for field strength inside and outside the tumor. To rate these criteria, a set of formulas with weighting coefficients has been included. As a result of this design process, a needle-shaped prototype applicator has been built, designed for an intracorporal electroporation-based treatment. It can be used as percutaneous, image-guided, minimally invasive treatment option for malignant liver tumors. The shaft of the probe is used as central electrode and fitted with additional 4 expandable electrodes. These satellite electrodes are hollow, thus serving as injectors for chemotherapeutic agents within the area of the electric field. This configuration can be used for electrochemotherapy as well as irreversible electroporation. By placing 5 electrodes with just one needle, the procedure duration as well as the radiation dose can be reduced tremendously. Additionally, the probe offers an option to adapt the field geometry to the tumor geometry by connecting the 5 electrodes to 5 individually chosen electric potentials: By fine-tuning the ablation zone via the potentials instead of adjusting the location of the electrode(s), the procedure duration as well as the radiation dose will decrease further.
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Affiliation(s)
- Andreas Ritter
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany.,2 Institute of Applied Medical Engineering (AME), Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Philipp Bruners
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Isfort
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Alexandra Barabasch
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Joachim Pfeffer
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Jula Schmitz
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- 1 Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Baumann
- 2 Institute of Applied Medical Engineering (AME), Helmholtz Institute, RWTH Aachen University, Aachen, Germany
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Zimmermann M, Schulze-Hagen M, Liebl M, Pedersoli F, Goerg F, Ulmer TF, Heinzel A, Isfort P, Kuhl C, Bruners P. Safety and Efficacy of Y-90 Radioembolization After Prior Major Hepatic Resection. Cardiovasc Intervent Radiol 2017; 40:1206-1212. [DOI: 10.1007/s00270-017-1629-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
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Isfort P, Pedersoli F, Liebl M, Zimmermann M, Schulze-Hagen M, Scheck J, Kuhl C, Bruners P. Bildmorphologische Unterschiede nach irreversibler Elektroporation und Radiofrequenzablation im Follow-up mittels Mehrphasen-CT. ROFO-FORTSCHR RONTG 2017. [DOI: 10.1055/s-0037-1600278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- P Isfort
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - F Pedersoli
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - M Liebl
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - M Zimmermann
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - M Schulze-Hagen
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - J Scheck
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - C Kuhl
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
| | - P Bruners
- Universitätsklinikum RWTH Aachen, Klinik für Diagnostische und Interventionelle Radiologie, Aachen
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Zimmermann M, Liebl M, Schulze-Hagen M, Pedersoli F, Pfeffer J, Schmeding M, Isfort P, Kuhl CK, Bruners P. Preoperative Embolization of the Celiac Axis or Common Hepatic Artery before Distal Pancreatectomy with Resection of the Celiac Axis. J Vasc Interv Radiol 2017; 28:60-63. [DOI: 10.1016/j.jvir.2016.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 11/25/2022] Open
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Pedersoli F, Isfort P, Keil S, Goerg F, Zimmermann M, Liebl M, Schulze-Hagen M, Schmeding M, Kuhl CK, Bruners P. Stentgraft Implantation for the Treatment of Postoperative Hepatic Artery Pseudoaneurysm. Cardiovasc Intervent Radiol 2016; 39:575-81. [PMID: 26797022 DOI: 10.1007/s00270-015-1274-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 11/29/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE Hepatic artery pseudoaneurysms are a rare but potentially life-threatening complication of major pancreaticobiliary surgery. We evaluated the safety and efficacy of endovascular stentgraft implantation for the management of such vascular lesions. MATERIALS AND METHODS Between May 2013 and October 2015, ten patients with postoperative hepatic artery pseudoaneurysm, of which eight presented with active hemorrhage, were treated with endovascular stentgraft implantation. All patients had undergone major pancreatic or hepatic surgery before (pylorus-preserving pancreaticoduodenectomy, pancreatectomy, hemihepatectomy, extended hemihepatectomy). The pseudoaneurysms were diagnosed 13-202 days after surgery and were associated with postsurgical complications (e.g., leakage of pancreaticojejunal anastomosis). RESULTS In 9/10 patients, the pseudoaneurysm was completely excluded via stentgraft implantation. In 1/10 patient, the pseudoaneurysm ruptured during the procedure and was successfully treated by immediate open surgery. In 1/10 patient, a second intervention was performed after 6 days because of rebleeding; this was successfully treated by implantation of a second overlapping stentgraft. Mean follow-up time is 51 days. None of the patients died due to stentgraft- or aneurysm-related complications. Further episodes of hemorrhage were not observed. In one patient, clinically asymptomatic complete occlusion of the stentgraft was discovered at follow-up imaging. CONCLUSION Stentgraft implantation is a safe and effective technique to treat hepatic artery pseudoaneurysms related to major pancreatic or hepatic surgery, especially in the setting of acute hemorrhage.
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Affiliation(s)
- F Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - P Isfort
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - S Keil
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - F Goerg
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - M Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - M Liebl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - M Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - M Schmeding
- Clinic for General, Visceral and Transplant Surgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - C K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - P Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
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Pedersoli F, Pedersoli F, Isfort P, Zimmermann M, Liebl M, Schulze-Hagen M, Goerg F, Neumann U, Kuhl C, Bruners P. Sicherheit und Effektivität der Stentgraftimplantation für die Behandlung von iatrogener Aneurysmen der Arteria hepatica. ROFO-FORTSCHR RONTG 2015. [DOI: 10.1055/s-0035-1551094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Apostoli M, Fenotti A, Bravo M, Archetti AM, Magazza AR, Pedersoli F, Cosio R, Zappa S, Candiani A. [Notes on the epidemiology and prevention of decubitus ulcers in intensive care units]. Riv Inferm 1988; 7:18-22. [PMID: 3135574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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