Non Target Shunting of Tc-99m Macroaggregates of Albumin and Radiolabeled Yttrium-90 Microspheres into Hepatic Falciform Artery - Less Observed Arterial Variant not to be Overlooked

Identification of nontarget arteries is crucial prior to Yttrium-90 microspheres radioembolization. We present a case where an uncommon nontarget artery, the hepatic falciform artery was identified during work up for radioembolization and necessary preventive measures were taken to minimize the complications.

MagicTouch PTA Sirolimus Coated Balloon for Femoropopliteal and Below the Knee Disease: Results From XTOSI Pilot Study Up To 12 Months

INTRODUCTION

Sirolimus coated balloon (SCB) is a promising treatment option to prevent restenosis for peripheral arterial occlusive disease (PAOD). This is a pilot first-in-human study of MagicTouch percutaneous transluminal angioplasty (PTA) SCB for treatment of PAOD for both femoropopliteal and below the knee arteries (BTK).

MATERIAL AND METHODS

Xtreme Touch-Neo [MagicTouch PTA] Sirolimus Coated Balloon (XTOSI) pilot study is a prospective, single-arm, open-label, single-center trial evaluating MagicTouch PTA SCB for symptomatic PAOD. Primary endpoint was defined as primary patency at 6 months (duplex ultrasound peak systolic velocity ratio ≤2.4). Secondary endpoints included clinically driven target lesion revascularization (CD-TLR), amputation free survival (AFS), all-cause mortality, and limb salvage success.

RESULTS

Fifty patients were recruited. The mean age was 67 (n=31 [62%] males). SCB was applied to femoropopliteal in 20 patients (40%) and BTK in 30 patients (60%). Majority of treatments (94%) were performed for limb salvage indications (Rutherford scores 5 or 6). This was a high risk cohort, in which 90% had diabetes, 36% had coronary artery disease, 20% had end stage renal failure, and American Society of Anaesthesiologists (ASA) score was 3 or more in 80%. Mean lesion length treated was 227±81 mm, of which 36% were total occlusions. Technical and device success were both 100%. At 30 days, mortality was 2% and major limb amputation was also 2%. Six-month primary patency was 80% (88.2% for femoropopliteal; 74% for BTK). At 12 months, freedom from CD-TLR was 89.7% (94.1% for femoropopliteal; 86.3% for BTK), AFS was 81.6% (90.0% for femoropopliteal; 75.9% for BTK), all-cause mortality was 14.3% (10.0% for femoropopliteal; 17.2% for BTK), and limb salvage success was 92.9% (94.4% for femoropopliteal; 91.7% for BTK). There was a statistically significant increase between baseline and 6-month toe pressures for both femoropopliteal (57.3±23.3 mm Hg vs 82.5±37.8 mm Hg; p<.001) and BTK lesions (52.8±19.2 mm Hg vs 70.7±37 mm Hg; p<.037). At 12 months, wound healing rate was 33/39 (84.6%).

CONCLUSIONS

MagicTouch PTA SCB in the XTOSI study showed promising 6-month primary patency and encouraging 12-month freedom from CD-TLR, AFS, and limb salvage rates. No early safety concerns were raised. Randomized trials are needed to investigate the safety and efficacy of SCB for treatment of PAOD.

Combined utility of one lung ventilation and artificial pneumothorax in thermal ablation of hepatic dome tumor: a technical note

Radiofrequency ablation and microwave ablation are established treatment modalities for smaller (<3 cm) or isolated hepatic tumors. Transthoracic ablation of hepatic dome lesions is a well described technique. We report the use of one lung ventilation to facilitate the successful percutaneous transthoracic microwave ablation of a segment 8 hepatic dome lesion after induction of artificial pneumothorax. This involved the use of general anesthesia and insertion of a double lumen endotracheal tube to allow isolated ventilation of one lung, followed by creation of an artificial pneumothorax under computed tomography (CT) guidance. Complete ablation of the lesion was confirmed on CT liver at 1 and 7 months with no local recurrence. The combined techniques of one lung ventilation and artificial pneumothorax enabled a safe and accurate transthoracic targeting of the hepatic dome lesion.

Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

Computed tomography venography versus intravascular ultrasound in the diagnosis of iliofemoral vein stenosis

Summary: Background: Iliofemoral vein stenosis can cause debilitating chronic venous disease. Diagnostic tools include both computed tomography venography (CTV) and intravascular ultrasonography (IVUS). We aim to compare the diagnostic performance of CTV and IVUS. Patients and methods: We performed a retrospective study of patients with chronic venous disease presenting with iliac vein compression or post-thrombotic limb symptoms, excluding those with acute deep vein thrombosis, high anaesthesia risk, or who had contrast allergy. All patients received CTV before IVUS, as part of the diagnostic work-up and intervention. The cross-sectional area (CSA) of iliofemoral vein segments obtained from both studies were compared against reference CSAs to derive percentage stenosis. A 50% reduction in CSA was considered significant. Results: We studied 50 patients between May 2018 and April 2019. 58% of patients had severe disease CEAP C5-6. 48% of patients had at least one vein segment with significant stenosis. The left proximal common iliac vein was the most commonly stenosed vein segment (n = 12, 24% on IVUS). CSA measurements from CTV were greater than those of IVUS, with a correlation coefficient of 0.57 (p < 0.005). Conversely, percentage stenosis measured on CTV was lower than on IVUS, with approximately one-third of significant stenosis missed on CTV (58 veins from CTV vs. 78 from IVUS, p < 0.005). With IVUS as the gold standard, CTV has low sensitivity (37.2%, 95% CI 26.5–48.9) and high specificity (92.5%, 95% CI 89.3–94.9) in detecting significant stenosis. Conclusions: CTV has limited diagnostic performance in identifying iliofemoral vein stenosis. Patients with normal CTV findings should proceed with IVUS imaging if the clinical features are supportive of iliofemoral vein stenosis.

"Angioplasty-First" Approach for Limb Salvage in Asian Patients with Critical Limb Ischemia: Outcomes from 3,303 Angioplasties on 2,402 Limbs in a Single Tertiary Hospital

PURPOSE

To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization.

MATERIALS AND METHODS

Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome.

RESULTS

Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001).

CONCLUSIONS

PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.

Use of the VENOVO™ and Sinus Obliquus™ venous stents in the treatment of non-thrombotic or post-thrombotic iliac vein lesions - Short-term results from a multi-centre Asian cohort

OBJECTIVES

Deep venous stenting with intravascular ultrasound (IVUS) guidance is gaining favour as the treatment modality of choice for symptomatic ilio-femoral venous occlusive disease. The aim was to determine the short-term patency and symptomatic relief gained using the Bard Venovo™ and Optimed Sinus Obliquus™ stents in the endovascular treatment of non-thrombotic iliac vein lesions (NIVL) and post-thrombotic venous obstruction (PTO) from two Asian tertiary vascular centres.

METHODS

Sixty patients (males = 21/60 (35.0%); median age 67 years (interquartile range 54-77)) who underwent IVUS interrogation and ilio-femoral stenting (June 2018-May 2019) in two Asian centres were prospectively followed. Clinical improvement was determined by the revised Venous Clinical Severity Score (rVCSS), pain using the Visual Analogue Scale (VAS) and ulcer healing rate. Patency rates were evaluated using Duplex ultrasound and computer tomography venogram.

RESULTS

Seventy-one legs were interrogated and stented; 11/60 (18.3%) patients had a bilateral procedure. Indications for surgery were PTO (n = 11/71 (15.5%)) and NIVL (n = 60/71 (84.5%)). Twenty-seven of 71 (38.0%) patients had CEAP 6 disease. The median follow-up was 283 (interquartile range 211-370) days. Technical and procedural success was both 100%. Twenty-one of 71 (29.6%) legs had a combination of Venovo™ and Sinus Obliquus™ stents inserted for concurrent ilio-caval and iliac lesions. There were no major post-operative complications. Six-month primary, assisted primary and secondary patency rates were 94.1, 97.1 and 100%, respectively. There were no stent fractures. Mean rVCSS and VAS improved from 12.26 (±3.31) to 4.33 (±2.78) and 6.97 (±1.38) to 2.03 (±1.65), respectively, at three months (p < 0.01). Complete ulcer healing was seen in 27/27 (100%) patients at three months.

CONCLUSION

Use of Venovo™ and Sinus Obliquus™ stents for symptomatic ilio-femoral venous disease showed excellent six-month primary patency rate with no stent fractures. There were significant clinical improvement and low-device-related complications. Longer follow-up is awaited to see how these dedicated venous stents perform.

Endovascular Deep Vein Stenting of Symptomatic Post-Thrombotic and Non-Thrombotic Iliac Vein Stenotic Lesions: A Multicentre Cohort Experience from Singapore

INTRODUCTION

This paper presents our experience with deep venous stenting in a multi-ethnic Asian cohort of patients with symptomatic Non-Thrombotic Iliac Vein Lesions (NIVL) and Post-Thrombotic Syndrome (PTS).

MATERIALS AND METHODS

This was a multicentre retrospective cohort study of patients who had symptomatic deep venous disease. Stent patency rate was evaluated using Duplex ultrasonography immediately post-intervention and at 3, 6 and 12 months. Clinical outcomes were evaluated using the revised Venous Clinical Severity Score (rVCSS) and Visual Analogue Scale (VAS) pain score at baseline and 3 months post-procedure.

RESULTS

87 patients (males = 47/87 (54.0%)); median age = 62 years (IQR 55 - 70)) and 115 limbs were analysed (left = 76/115 (66.1%)). Median follow-up time was 175 (IQR 57 - 257) days. 97/115 (84.3%) had NIVLs and 55/115 (47.8%) had May-Thurner-Syndrome. 43/115 (37.4%) had Clinical, Etiology, Anatomy and Pathophysiology (CEAP) 6 disease. Primary stent patency rates were 98.2% (112/114), 97.9% (93/95), 95.7% (89/93) and 92.8% (64/69) immediately post-intervention, 3, 6 and 12 months, respectively. The 6-month secondary patency rate was 99.1% (114/115). Mean rVCSS and VAS improved from 11.52 (±3.54) to 5.77 (±2.36) (P < 0.01) and 6.62 (±1.93) to 2.92 (±1.50) (P < 0.01) respectively, at 3 months. 41/43 (95.3%) venous ulcers healed over a median time of 169 days (IQR 120 - 253).

CONCLUSIONS

Short term primary patency rates following deep venous stenting are excellent, with few re-interventions. Patients presented with NIVLs rather than PTS. There was excellent clinical improvement at 3 months, with a high and expedient venous ulcer healing rate.

Preparing IR for COVID-19: The Singapore Experience

This paper describes country-wide special measures undertaken for interventional radiology staff during the current coronavirus disease 2019 (COVID-19) pandemic. Although each interventional radiology service around the world faces unique challenges, the principles outlined in this article will be useful when designing or strengthening individual practices and integrating them within wider hospital and national measures. Moving beyond the current outbreak, these measures will be useful for any future infectious diseases which are likely to arise.

Type 2 Endoleaks: Common and Hard to Eradicate yet Benign?

PURPOSE

The exact significance of type 2 endoleaks (T2ELs) and the indication and efficacy of treatment are widely debated. We report our experience with managing T2ELs in a tertiary Asian centre.

MATERIALS AND METHODS

This was a retrospective study of patients who underwent endovascular abdominal aortic aneurysm repair (EVAR) between February 2006 and December 2016. Patients with T2ELs were identified, and their data were analysed.

RESULTS

A total of 156 patients underwent EVAR, of which 67 (42.9%) developed T2ELs. Seven were lost to follow-up. The remaining 60 patients had a mean follow-up period of 50.3 ± 33.9 months-34 (56.7%) experienced T2ELs early and the rest (43.3%) had late T2ELs. Forty-one patients had isolated T2EL, whilst 19 had concomitant T1EL and/or T3EL. Spontaneous resolution occurred in 25 patients (41.7%). All T2ELs with stable sac size were on continued surveillance. Amongst those with persistent T2ELs associated with sac growth (n = 17), 14 underwent intervention, of which 7 (50%) received > 1 embolisation procedure. A total of 16 transarterial embolisation and 8 translumbar embolisation procedures were performed. Technical success rate was 75%. In the intervention group, 5 (35.7%) had complete and sustained resolution, 7 had persistent/recurrent T2ELs but stable sac size, and 2 had progressive sac expansion. Overall mortality due to sac rupture occurred in 2 patients with concomitant T2EL and T1EL/T3EL.

CONCLUSION

T2ELs are common, albeit mostly benign if occurring in isolation and not in association with sac growth. Achieving complete T2EL resolution with embolisation is difficult even with reinterventions.

LEVEL OF EVIDENCE

Level 2B, retrospective study.

Review of imaging and endovascular intervention of iliocaval venous compression syndrome

Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.

Radiological retrograde ureteric stent exchange in women: a single-centre review

AIM

To evaluate the safety and efficacy of modified wire loop technique for retrograde stent exchange.

MATERIALS AND METHODS

All patients were from the KK Women and Children's Hospital where there is no on-site urology service. Patients were identified retrospectively from the institutional radiological information system (RIS) database. In total, 270 stents were removed and 238 replaced for 79 patients between January 2012 to December 2016. Success rates for stent removal and exchange as well as skin dose and fluoroscopy time were assessed.

RESULTS

Stent exchange was successful in 234/238 (98%) of cases. Failure was due to loss of access (one case), inability to snare stent due to distorted anatomy (two cases), and extensive encrustation of stent (one case). In 252/270 (93%) cases, stent was removed using modified snare while in 18 (7%) cases, other snare devices were used. Average fluoroscopy time per stent for stent exchange was 573 seconds and average skin dose was 12,494 DAP/mGy•cm².

CONCLUSION

Fluoroscopy-guided retrograde ureteric stent exchange using the modified snare loop technique is effective, quick, and can be performed easily with equipment used in daily intervention practice. It may also be coupled with ureteroplasty, which may help the patient achieve eventual stent-free status.

Subcentimetre thyroid nodules: Sonographic features associated with malignancy

Introduction

The aim of this study was to identify the ultrasound features which are associated with malignancy in subcentimetre thyroid nodules.

Methods

This retrospective study included 454 thyroid nodules <10 mm in size in 413 patients from 2012 to 2016, which were subjected to fine needle aspiration cytology. Each nodule was classified according to the ultrasound patterns of the 2015 American Thyroid Association guidelines and the high suspicion ultrasound features (solid, hypo-echogenicity, irregular margins, microcalcifications, taller-than-wide, interrupted rim calcifications, and extrathyroidal extension) were identified for evaluation of their diagnostic performance.

Results

Of the American Thyroid Association high suspicion ultrasound features, univariate analysis showed that hypo-echogenicity (sensitivity 81.6% (95% CI 65.7-92.3%), specificity 50.0% (95% CI 43.4-56.6%)), irregular margins (sensitivity 34.2% (95% CI 19.6-51.4%), specificity 92.2% (95% CI 88.0-95.3%)), microcalcifications (sensitivity 23.7% (95% CI 11.4-40.2%), specificity 91.0% (95% CI 86.5-94.3%)), and taller-than-wide (sensitivity 23.7% (95% CI 11.4-40.2%), specificity 92.2% (95% CI 88.0-95.3%)) were significantly associated with a malignant diagnosis. Amongst the above features, subsequent multivariate analysis identified a combination of hypo-echogenicity and irregular margins as significantly associated with malignancy. Our malignancy rates based on American Thyroid Association ultrasound patterns from benign to high suspicion were 0.0, 8.3, 3.9, 15.7, and 40.4%, respectively. The American Thyroid Association high suspicion ultrasound pattern had a sensitivity of 50.0% (95% CI 33.4-66.7%) and specificity of 84.5% (95% CI 79.2-88.9%).

Conclusion

The presence of both hypo-echogenicity and irregular margins was significantly associated with malignancy in subcentimetre thyroid nodules in our study. Hence, subcentimetre nodules which are hypoechoic with irregular margins may warrant further follow-up.

Case Report: An Unusual Presentation of Bilateral Subclavian Stenosis in a Patient with Asymptomatic Hypotension

Patient: Male, 63

Final Diagnosis: Bilateral subclavian artery stenosis

Symptoms: Hypotension

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Should we perform fine needle aspiration cytology of subcentimetre thyroid nodules? A retrospective review of local practice

In light of the rising rate of incidentally detected subcentimetre thyroid nodules due to improved surveillance and diagnostic imaging, the decision of whether to perform fine needle aspiration cytology is increasingly pertinent. We aim to assess (1) the sampling adequacy of fine needle aspiration cytology, (2) malignancy rate, (3) thyroidectomy rate and (4) diagnostic accuracy of fine needle aspiration cytology. A total of 245 subcentimetre nodules in 220 patients underwent fine needle aspiration cytology between 2011 and 2014. Medical records were reviewed for cytology results, subsequent management and histopathological results in the event the patient underwent thyroidectomy. Sampling adequacy was calculated as the percentage of diagnostic results (Bethesda II-VI). Malignancy rate was defined as the percentage of Bethesda IV-VI diagnoses. Amongst patients with Bethesda IV-VI diagnoses who underwent thyroidectomy, their cytology reports were correlated with post-operative histopathological findings. The sampling adequacy of fine needle aspiration cytology was 77.1%. Malignancy rate (Bethesda IV-VI) was 9.7%. The respective malignancy rates in the < 5 mm nodule group and ≥ 5 mm nodule group were 6.67 and 10.0%. In total, 79.2% (19/24) of the malignant nodules underwent surgical excision. The rest declined surgery and/or were lost to follow-up. Amongst the malignant nodules which were surgically resected, 84.2% (16/19) had definitive malignant histology. Five of these demonstrated multifocal carcinoma and/or extrathyroidal extension of carcinoma on histology. Initial fine needle aspiration cytology and subsequent histopathological diagnoses matched in all cases except for three that had false-positive fine needle aspiration cytology results. Majority of our patients with suspicious cytology results subsequently underwent thyroidectomy, notwithstanding the relatively lower diagnostic accuracy of fine needle aspiration cytology in subcentimetre thyroid nodules.

Type B Aortic Dissection after Nellix Endovascular Aneurysm Sealing

BACKGROUND

Endovascular aneurysm sealing (EVAS) was developed with the intention of expanding the anatomical limitations of conventional endovascular aneurysm repair devices and decrease rates of reintervention secondary to migration and type II endoleaks in treatment of abdominal aortic aneurysms.¹ Since its inception, EVAS has gained much popularity especially for patients with concomitant common iliac aneurysms, with good long-term durability suggested by several studies. Currently, the known complications of EVAS, while considered uncommon, include endoleaks, renal artery, and limb thrombosis.² This report emphasizes the importance of vigilance in terms of early recognition of unusual complications after EVAS and describes the successful management of type B aortic dissection after EVAS, which is a novel complication of EVAS not previously described.

METHOD

We describe a rare case of type B aortic dissection after EVAS and discuss the possible causes.

RESULT

After diagnosis of progressive type B aortic dissection after EVAS, patient underwent emergency thoracic endovascular aortic repair with carotid to subclavian bypass for the aortic dissection with good results. He was discharged well with return to his baseline function.

CONCLUSIONS

Aortic dissection is a potentially catastrophic complication of EVAS and with prompt recognition and monitoring, adverse complications may be averted.

Catheter-directed thrombolysis versus percutaneous mechanical thrombectomy in the management of acute limb ischemia: a single center review

Background

Acute limb ischemia is associated with significant mortality and amputation rate. Early restoration of flow can be obtained by various treatment methods that include catheter-directed thrombolysis (CDT) and percutaneous mechanical thrombectomy (PMT). These treatments have been shown to be effective but associated with various complications. There is lack of data comparing these two treatments. We aim to review our experience in the treatment of acute limb ischemia (ALI) and compare CDT with PMT.

Results

A total of 94 patients [mean age 65 years, 67% male (n = 63)] presented with ALI between 2006 and 2015 and were treated with either CDT or PMT. Outcomes were retrospectively reviewed. Primary outcomes were technical and clinical success; secondary outcomes were amputation rate at 30 days, duration of hospitalization and 30-day mortality. A total of 117 procedures were performed in 94 patients: 27 surgical bypass grafts, 31 previously stented arteries and 59 native vessels. Twenty eight procedures (24%) were performed with PMT, and 89 (76%) procedures were performed with CDT. Higher technical success was achieved in the PMT group (68%, 19/28) compared to the CDT group (47%, 42/89), p = 0.056. Clinical success was similar in both groups (75%, 21/28 in the PMT group and 73%, 65/89) in the CDT group (p = 0.837). There was no statistically significant difference in 30-day mortality between the PMT vs CDT groups (4% vs 8%, p = 0.425). The length of post-procedural hospital stay was shorter in patients with PMT (6.0 vs 12.6 days, p = 0.001). The absence of end-stage renal failure appears to be a predictor for clinical succes (HR 3.3, 95% CI 0.809–13.592).

Conclusion

PMT is associated with higher technical success and significantly shorter length of stay compared to CDT; however, clinical success is similar across both treatment entities. The safety profile is comparable.

Diagnosis and Management of Complications from Percutaneous Biliary Tract Interventions

Complications related to percutaneous biliary tract interventions (PBTIs) can range from access site discomfort to life-threatening vascular complications. These complications are relatively uncommon, and most of them are self-limiting. However, major complications for which an increased level of patient care and/or a prolonged hospital stay are required and that may lead to death-albeit rarely-can occur. Some of the most common complications related to PBTI include pain, infection, bile leakage, and catheter blockage. These conditions can be easily recognized by using the patient's clinical history and laboratory examination results. However, the more uncommon complications, such as life-threatening hemobilia, acute pancreatitis, and catheter and stent fractures, may have nonspecific clinical manifestations, and the underlying pathologic condition may be found only when it is being sought specifically. It is important that diagnostic and interventional radiologists be aware of the wide spectrum of PBTI-related complications, as early recognition and treatment may prevent catastrophic situations. In addition, knowledge of the different treatment options is essential for guidance in interventional radiology procedures such as transarterial control of hemobilia, imaging-guided direct percutaneous embolization of pseudoaneurysms, and percutaneous treatment of catheter- and stent-related complications such as fractures. The authors review a wide spectrum of complications associated with PBTI and the percutaneous management of these conditions. They also highlight valuable lessons learned from morbidity and mortality rounds at a high-volume tertiary care center. ^©RSNA, 2017.

Radioembolisation of hepatocellular carcinoma: a primer

Transarterial radioembolisation (TARE) has gained increasing acceptance as an additional/alternative locoregional treatment option for hepatocellular carcinoma, and colorectal hepatic metastases that present beyond potentially curative options. This is a catheter-based transarterial selective internal brachytherapy that involves injection of radioactive microspheres (usually Y-90) that are delivered selectively to the liver tumours. Owing to the combined radioactive and microembolic effect, the findings at follow-up imaging are significantly different from that seen with other transarterial treatment options. Considering increasing confidence among clinicians, refinement in techniques and increasing number of ongoing trials, TARE is expected to gain further acceptance and become an important tool in the armamentarium for the treatment of liver malignancies. So it is imperative that all radiologists involved in the management of liver malignancies are well versed with TARE to facilitate appropriate discussion at multidisciplinary meetings to direct further management. In this article, we provide a comprehensive review on various aspects of radioembolisation with Y-90 for hepatocellular carcinoma including the patient selection, treatment planning, radiation dosimetry and treatment, side effects, follow-up imaging and future direction.

Acute ischemic pancreatitis: A rare complication of empirical gastroduodenal artery embolization

Empirical embolization of the gastroduodenal artery (GDA) is accepted as a safe and effective treatment option for endoscopy-refractory nonvariceal upper gastrointestinal bleeding (UGIB) in patients with high surgical risk. Nontarget embolization is a recognized complication of transarterial embolization, however, symptomatic pancreatic injury is extremely rare. We report a patient who developed acute ischemic pancreatitis immediately after embolization of the GDA, which was confirmed intraoperatively. Interventionists as well as referring clinicians need to be aware of this rare but life threatening complication.

Endovascular Retrieval of Entrapped Elephant Trunk Graft During Complex Hybrid Aortic Arch Repair

Entrapment of the elephant trunk graft within the false lumen is a rare complication of surgical repair of an aortic dissection. This is normally retrieved by emergent open surgery. We describe a technique of endovascular retrieval of the dislodged graft, during hybrid aortic arch repair. The elephant trunk was cannulated through and through from a femoral access and the free end of the wire was snared and retrieved from a brachial access. The wire was externalised from both accesses and was used to reposition the graft into the true lumen using a body flossing technique.

Transmural coil embolization—alternative technique for management of arterial perforation during subintimal angioplasty

Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA) after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.

CT diagnosis and endovascular management of spontaneous rupture of uterine artery in pregnancy

Spontaneous rupture of the uterine artery during pregnancy is an extremely uncommon condition, which presents as an acute emergency, associated with high rates of maternal and foetal mortality. This condition is challenging to diagnose and treat, as it is an uncommon entity having an acute nature of presentation. They are usually managed by emergency laparotomy and the diagnosis is rarely made preoperatively. We describe a case with CT angiographic images clearly demonstrating the uterine artery pseudoaneurysm with associated extensive haemoperitoneum, which helped us confirm this rare diagnosis. We successfully treated the patient by an endovascular approach, which has not been reported previously.

Streptomyces sp. strain PGPA39 alleviates salt stress and promotes growth of 'Micro Tom' tomato plants

AIMS

To identify an actinobacterial strain that can promote growth and alleviate salinity stress in tomato plants.

METHODS AND RESULTS

Actinobacteria were isolated from agricultural soil and screened for ACC deaminase activity, production of indole acetic acid (IAA), solubilization of tricalcium phosphate and sodium chloride (NaCl) salinity tolerance. Among the several strains tested, one strain designated PGPA39 exhibited higher IAA production, and phosphate solubilization in addition to ACC deaminase activity, and tolerance to 1 mol l(-1) NaCl. Strain PGPA39 was identified as a Streptomyces strain based on 16S rDNA sequence and designated Streptomyces sp. strain PGPA39. It promoted the growth of Arabidopsis seedlings in vitro as evidenced by a significant increase in plant biomass and number of lateral roots. Salinity stress-alleviating activity of PGPA39 was evaluated using 'Micro Tom' tomato plants with 180 mmol l(-1) NaCl stress under gnotobiotic condition. A significant increase in plant biomass and chlorophyll content and a reduction in leaf proline content were observed in PGPA39-inoculated tomato plants under salt stress compared with control and salt-stressed noninoculated plants.

CONCLUSIONS

Streptomyces sp. strain PGPA39 alleviated salt stress and promoted the growth of tomato plants.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows the potential of Streptomyces sp. strain PGPA39 in alleviating salinity stress in tomato plants and could be utilized for stress alleviation in crop plants under field conditions.

Hospital-based evaluation of two rapid human immunodeficiency virus antibody screening tests

Two rapid human immunodeficiency virus (HIV) screening assays, HIV TRI-DOT and HIV-SPOT were compared with standard enzyme-linked immunosorbent assays according to a testing algorithm. Sensitivities and specificities in the real-time evaluation were 99.5 and 99.9% for TRI-DOT and 98.2 and 99.7% for HIV-SPOT, respectively. These two tests are suitable for use where facilities and laboratory expertise are limited.