Identifying and Managing Patients with Elevated Breast Cancer Risk Presenting for Screening Mammography

BackgroundIdentifying the prevalence and management of patients at high-risk for breast cancer can improve resource utilization and provide individualized screening strategies.ObjectiveThe purpose of this study was to identify the prevalence of high-risk patients in our institution who presented for screening mammography and to understand how they utilized downstream resources offered to them.Materials and MethodsThis single institution retrospective study utilized the Tyrer-Cuzick risk assessment model to provide lifetime risk of breast cancer of patients presenting for screening mammography over a one-year period. Their subsequent management and resource utilization were collated.ResultsHigh-risk patients comprised 7.7% (701/9061) of our screening population. Of those high-risk women offered a Breast Center (BC) consultation, 75.2% (276/367) participated in the consultation, with 51.1% (141/276) of those patients completing MRI for supplemental screening. Risk reducing medication was adopted by 7.6% (6/79) of those offered. Of patients offered a genetics consultation, 66.3% (53/80) participated in the consultation, and 50.0% (40/80) completed genetic testing.ConclusionsIdentifying and understanding high-risk patient cohorts, whether locally or in a population-based context, is important for individualized patient care and practice efficiency.     

Racial and Ethnic Disparities among Participants in Hepatocellular Carcinoma Clinical Studies Evaluating Transarterial Therapies

PurposeTo evaluate the racial and ethnic representation of transarterial therapy for hepatocellular carcinoma (HCC) clinical trials in the United States.Materials and MethodsThe ClinicalTrials.gov database was examined to identify all completed studies with transarterial therapies for the management of HCC in the United States and extract information about the observed number of participants for each racial and ethnic group (based on the Office of Management and Budget definitions). The expected number of participants was calculated by multiplying the total number of participants in a trial with the U.S.-population HCC-based proportion for each group. The effects of the study phase, funding source, number of centers involved in the study, and the location of the participating center on racial and ethnic distribution were explored.ResultsSeventy-nine relevant studies were identified, of which 27 (34.2%) and 18 (22.8%) reported ethnic and race characteristics, respectively. Most study participants were White (81%, 1,591/1,964) by ethnicity and not Hispanic or Latino (93%, 937/1,008) by race. In terms of the observed-to-expected ratios by race and ethnicity in all trials, White and not Hispanic or Latino participants were overrepresented with a ratio of 1.22 (1.10–1.37) and 1.33 (1.26–1.41), respectively, and all other racial and ethnic groups were underrepresented. The enrollment of African Americans and Asian Americans varied by the study phase, and a higher enrollment of African Americans was noted in the National Institutes of Health–funded and multicenter studies (P < .05).ConclusionsThis cross-sectional study demonstrates that in HCC transarterial therapy clinical trials, racial and ethnic minorities were underrepresented and the majority of the studies identified failed to report this demographic information.     

Comparison of professional medical society guidelines for appropriate use of coronary computed tomography angiography

BackgroundMultiple appropriate use criteria (AUC) exist for the evaluation of coronary artery disease (CAD), but there is little data on the agreement between AUC from different professional medical societies. The aim of this study is to compare the appropriateness of coronary computed tomography angiography (CCTA) exams assessed using multimodality AUC from the American College of Cardiology Foundation (ACCF) versus the American College of Radiology (ACR).MethodsIn a single-center prospective cohort study from June 2014 to 2016, 1005 consecutive subjects referred for evaluation of known or suspected CAD received a contrast-enhanced CCTA. The primary outcome was the agreement of appropriateness ratings using ACCF and ACR guidelines, measured by the kappa statistic. A secondary outcome was the rate of obstructive CAD by appropriateness rating.ResultsAmong 1005 subjects, the median (5–95th percentile) age was 59 (37–76) years with 59.0% male. The ACCF criteria classified 39.6% (n = 398) appropriate, 24.2% (n = 243) maybe appropriate, and 36.2% (n = 364) rarely appropriate. The ACR guidelines classified 72.3% (n = 727) appropriate, 2.6% (n = 26) maybe appropriate, and 25.1% (n = 252) rarely appropriate. ACCF and ACR appropriateness ratings were in agreement for 55.0% (n = 553). Overall, there was poor agreement (kappa 0.27 [95% confidence interval 0.23–0.31]). By both AUC methods, a low rate of obstructive CAD was observed in the rarely appropriate exams (ACCF 7.1% [n = 26 of 364] and ACR 13.5% [n = 34 of 252]).ConclusionsCompared to ACCF criteria, the ACR guidelines of appropriateness were broader and classified significantly more CCTA exams as appropriate. The poor agreement between appropriateness ratings from the ACCF and ACR AUC guidelines evokes implications for reimbursement and future test utilization.     

Lack of Growth of Small (≤2 mm Feeding Artery) Untreated Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia

PurposeTo assess pulmonary arteriovenous malformation (PAVM) growth among patients with untreated PAVMs using imaging from long-term follow-up per hereditary hemorrhagic telangiectasia international guidelines.Materials and MethodsAnalysis included 88 untreated PAVMs from 21 patients (6 male;15 female; mean age at presentation 47 y; range, 12–68 y). Two CT studies with the longest interval between were evaluated (mean 8.4 y; median 8.8 y; range, 3.1–14.1 y). Measurement of feeding artery diameter and anteroposterior (AP) and mediolateral (ML) sac dimensions for each PAVM was performed separately by 2 radiologists blinded to patient and CT order. Statistical analysis was performed to determine change in size between earliest and follow-up imaging.ResultsMean feeding artery diameter, AP sac dimension, and ML sac dimension were 1.4 mm (range, 0.8–3.7 mm), 4.3 mm (range, 2.1–11.1 mm), and 4.1 mm (range, 1.8–9.2 mm) on earliest imaging and 1.4 mm (range, 0.9–2.6 mm), 4.5 mm (range, 2.2–12.2 mm), and 4.3 mm (range, 2.0–9.6 mm) on follow-up. Model-based mean analysis showed no statistically significant change in dimension of any variable between earliest and follow-up imaging. Secondary analysis including age also found no statistically significant difference (feeding diameter, P = .09; AP sac dimension, P = .9; ML sac dimension, P = .1). Analysis including time between measurements found no significant relationship between change in variables and time (feeding artery diameter, P = .4; AP sac dimension, P = .3; ML sac dimension, P = .06).ConclusionsUntreated PAVMs grew slowly, if at all, in a near-decade span, and any demonstrated growth was minimal. These findings challenge the current recommendation of 3- to 5-year CT follow-up.     

Radiation Dose during Transarterial Radioembolization: A Dosimetric Comparison of Cone-Beam CT and Angio-CT Technologies

PurposeTo evaluate the radiation dose differences for intraprocedural computed tomography (CT) imaging between cone-beam CT and angio-CT acquired during transarterial radioembolization (TARE) therapies for hepatocellular carcinoma.Materials and MethodsA retrospective cohort of 22 patients who underwent 23 TARE procedures were selected. Patients were imaged in both cone-beam CT and angio-CT rooms as a part of their conventional treatment plan. Effective dose contributions from individual CT acquisitions as well as the cumulative dose contributions from procedural 3D imaging were evaluated. Angiography dose contributions were omitted. Cone-beam CT images were acquired on a C-arm Philips Allura system. Effective doses were evaluated by coupling previously published conversion factors (effective dose per dose-area product) to patient’s dose-area product meter readings after the procedure. Angio-CT images were acquired on a hybrid Canon Infinix-i Aquilion PRIME system. Effective doses from angio-CT scans were estimated using Radimetrics. Comparisons of a single patient’s dose differential between the 2 technologies were made.ResultsThe mean effective dose from a single CT scan was 6.42 mSv and 5.99 mSv in the cone-beam CT room and the angio-CT room, respectively (P = .3224), despite the greater field of view and average craniocaudal scan coverage in angio-CT. The mean effective dose summed across all CTs in a procedure was 12.89 mSv and 34.35 mSv in the cone-beam CT room and the angio-CT room, respectively (P = .0018).ConclusionsThe mean effective dose per CT scan is comparable between cone-beam CT and angio-CT when considered in direct comparison for a single patient.     

Prognostic value of CT myocardial perfusion imaging and CT-derived fractional flow reserve for major adverse cardiac events in patients with coronary artery disease

ObjectivesThe purpose of this study was to analyze the prognostic value of dynamic CT perfusion imaging (CTP) and CT derived fractional flow reserve (CT-FFR) for major adverse cardiac events (MACE).Methods81 patients from 4 institutions underwent coronary computed tomography angiography (CCTA) with dynamic CTP imaging and CT-FFR analysis. Patients were followed-up at 6, 12, and 18 months after imaging. MACE were defined as cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or revascularization. CT-FFR was computed for each major coronary artery using an artificial intelligence-based application. CTP studies were analyzed per vessel territory using an index myocardial blood flow, the ratio between territory and global MBF. The prognostic value of CCTA, CT-FFR, and CTP was investigated with a univariate and multivariate Cox proportional hazards regression model.Results243 vessels in 81 patients were interrogated by CCTA with CT-FFR and 243 vessel territories (1296 segments) were evaluated with dynamic CTP imaging. Of the 81 patients, 25 (31%) experienced MACE during follow-up. In univariate analysis, a positive index-MBF resulted in the largest risk for MACE (HR 11.4) compared to CCTA (HR 2.6) and CT-FFR (HR 4.6). In multivariate analysis, including clinical factors, CCTA, CT-FFR, and index-MBF, only index-MBF significantly contributed to the risk of MACE (HR 10.1), unlike CCTA (HR 1.2) and CT-FFR (HR 2.2).ConclusionOur study provides initial evidence that dynamic CTP alone has the highest prognostic value for MACE compared to CCTA and CT-FFR individually or a combination of the three, independent of clinical risk factors.     

Percutaneous MR Imaging–Guided Laser Ablation for the Treatment of Symptomatic Cervicofacial Vascular Malformations

PurposeTo evaluate the safety and effectiveness of percutaneous magnetic resonance (MR) imaging–guided laser ablation for the treatment of symptomatic soft tissue vascular malformations (VMs) in the face and neck.Materials and MethodsAn institutional review board–approved retrospective review was undertaken of all consecutive patients who underwent MR imaging–guided and monitored laser ablation for treatment of symptomatic, cervicofacial soft tissue VM. Preablation and postablation MR imaging findings were independently reviewed. Preablation and postablation VM sizes were documented. Preablation T2 signal characteristics and enhancement patterns as well as postablation change in both signal and enhancement were semiquantitatively assessed. Changes in VM size were compared using a paired t test.ResultsThirteen patients (women, 9; age, 14.5–69.5 years) with 13 VMs were treated for moderate-to-severe pain (n = 4), swelling/mass effect (n = 8), or predominantly cosmesis (n = 1) with 22 total ablation sessions. The baseline maximum VM diameter was 5.7 cm ± 4.2. At baseline, all VMs (100%) demonstrated variable T2-weighted signal hyperintensity and enhancement. For painful VM, the baseline pain score was 8 ± 1. Clinical follow-up was available for 10 patients. Of patients with available follow-up, 3 (100%) treated for moderate-to-severe pain and 7 (100%) treated for swelling/mass effect reported subjective complete or partial symptomatic relief. The patient treated predominantly for cosmetic reasons was lost to follow-up. Two patients (15.4%) experienced minor adverse events by the Society of Interventional Radiology standards. There were no major adverse events.ConclusionsMR imaging–guided and monitored percutaneous laser ablation is safe and effective for the treatment of symptomatic, cervicofacial VMs.     

Preintervention Computed Tomography Improves the Performance of Endovascular Intervention in Patients with Abdominopelvic Trauma

PurposeTo evaluate the role of computed tomography (CT) and CT angiography in guiding endovascular arteriography (EA) and embolization in hemodynamically (HD) stable and unstable patients with abdominal and/or pelvic (AP) trauma.Materials and MethodsA retrospective review was performed of patients with AP trauma who underwent EA with or without embolization (from January 2012 to August 2020) at an urban, level I trauma center. Patients aged <18 years or those undergoing EA outside of the abdomen and/or pelvis were excluded. Demographics, imaging findings, procedure length, contrast agent administration, laboratory values, and outcomes were compared on the basis of preprocedural imaging technique and hemodynamic status.ResultsA total of 190 patients with AP trauma underwent EA with or without embolization; among them, 123 were HD stable and underwent CT/CT angiography, whereas 67 were initially HD unstable and underwent operative management prior to EA. Of these patients, 38 underwent CT/CT angiography after hemodynamic stability was achieved prior to postoperative EA. The incidence of therapeutic embolization for arterial injury on EA was significantly higher in patients with preprocedural CT/CT angiography (65.8% vs 44.8%, P = .04). The positive and negative predictive values of CT angiography for arterial injury at the time of EA were 92.3% and 100%, respectively. Prior imaging was associated with a reduced contrast agent requirement at the time of EA and reduced transfusion requirement (P = .05 and P = .02). No significant differences were observed in adverse outcomes for patients undergoing preprocedural imaging.ConclusionsCT or CT angiography prior to EA for HD stable and unstable patients with AP trauma may improve the likelihood of therapeutic embolization and enable improved procedure metrics without increasing adverse outcomes.     

Predictors for Nonhome Patient Discharge following Lower Extremity Arterial Interventions

PurposeTo identify the variables associated with patient discharge disposition to optimize postprocedural care and discharge planning following lower extremity arterial interventions for peripheral artery disease (PAD).Materials and MethodsThe 2014–2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using current procedural terminology codes for endovascular infrainguinal interventions for PAD. The main outcome variable of interest was nonhome discharge. Covariates included patient sociodemographic variables, age quartile (upper quartile, ≥77 years), comorbidities (diabetes, renal disease, bleeding disorder, congestive heart failure [CHF], and chronic obstructive pulmonary disease), presence of an open wound before a procedure, type of procedure, operative time, symptom severity, American Society of Anesthesiologists class, and baseline functional status. Univariate analysis and multivariate logistic regression were performed on Stata/SE 15.1.ResultsA total of 3,190 patients met the inclusion criteria, of whom 664 (20.8%) had nonhome discharge. Multivariate regression revealed that age (odds ratio [OR], 1.9 for the upper age quartile [>77 years]; 95% confidence interval [CI], 1.46–2.50), operative time (OR, 1.2 per increase in quartile; 95% CI, 1.09–1.30), preoperative wound (OR, 1.5; 95% CI, 1.24–1.90), renal failure (OR, 1.7; 95% CI, 1.30–2.14), CHF (OR, 2.2; 95% CI, 1.51–3.24), symptom severity (OR, 1.7; 95% CI, 1.46–1.98), and independent functional status (OR, 0.74; 95% CI, 0.59–0.92; P = .007) were associated with nonhome discharge. All P values were ≤.001 unless otherwise stated.ConclusionsProlonged procedural time, the presence of preprocedural wound and patient comorbidities, symptomatology, and baseline functional status may be used to identify patients who will require a nonhome discharge and early discharge planning.     

Socioeconomic Status Is Associated with the Risk of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo determine whether socioeconomic status (SES) is associated with hepatic encephalopathy (HE) risk after transjugular intrahepatic portosystemic shunt (TIPS) creation.Materials and MethodsThis single-institution retrospective study included 368 patients (mean age = 56.7 years; n = 229 males) from 5 states who underwent TIPS creation. SES was estimated using the Agency for Healthcare Research and Quality SES index, a metric based on neighborhood housing, education, and income statistics. Episodes of new or worsening HE after TIPS creation, defined as hospitalization for HE or escalation in outpatient medical therapy, were identified from medical records. Multivariable ordinal regression, negative binomial regression, and competing risks survival analysis were used to identify factors associated with SES quartile, the number of episodes of new or worsening HE per unit time after TIPS creation, and mortality after TIPS creation, respectively.ResultsThere were 83, 113, 99, and 73 patients in the lowest, second, third, and highest SES quartiles, respectively. In multivariable regression, only older age (β = 0.04, confidence interval [CI] = 0.02–0.05; P < .001) and white, non-Hispanic ethnicity (β = 0.64, CI = 0.07–1.21; P = .03) were associated with higher SES quartile. In multivariable regression, lower SES quartile (incidence rate ratio [IRR] = 0.80, CI = 0.68–0.94; P = .004), along with older age, male sex, higher model for end-stage liver disease score, nonalcoholic steatohepatitis, and proton pump inhibitor use were associated with higher rates of HE after TIPS creation. Ethnicity was not associated with the rate of HE after TIPS creation (IRR = 0.77, CI = 0.46–1.29; P = .28). In multivariable survival analysis, neither SES quartile nor ethnicity predicted mortality after creation of a TIPS.ConclusionLower SES is associated with higher rates of new or worsening HE after TIPS creation.     

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

PurposeTo assess changes in operational utilization following conversion of a single IR suite to a hybrid CT/angiography (Angio-CT) system at an academic tertiary care center.Materials and MethodsThe total number of interventional procedures and diagnostic CT examinations performed in 29 rooms (20 diagnostic radiology, 7 IR, 2 shared between divisions) was calculated in the 24 months before conversion of an IR suite to Angio-CT and 12 months after conversion. The total number of IR procedures (global IR/month) and diagnostic CT scans per month (global CT/month) in both before and after conversion periods was calculated and defined as baseline institutional growth. This was compared against the change in the number of IR procedures performed in the before and after periods in the converted room (Angio-CT/month) as well as the number of diagnostic CT scans performed in the shared rooms (shared CT/month).ResultsThe percent change in global CT and global IR from the before to the after periods was 39.2% and 3.1%, respectively. Shared CT per month and Angio-CT per month increased by 46.7% and 12.0% across the same time periods, respectively. The ratio of the percent increase in Angio-CT per month to percent increase in global IR per month was 3.87. The ratio of the percent increase in shared CT per month to percent increase in global CT per month was 1.19.ConclusionsOperational utilization improved in both diagnostic radiology and IR sections following conversion of a conventional fluoroscopic IR suite to an Angio-CT room.     

Nationwide Outcomes following Percutaneous Cholecystostomy for Acute Calculous Cholecystitis and the Impact of Coronavirus Disease 2019: Results of the Multicentre Audit of Cholecystostomy and Further Interventions (MACAFI study)

PurposeTo assess the mortality, readmission rates, and practice variation of percutaneous cholecystostomy (PC) in patients with acute calculous cholecystitis in the United Kingdom (UK).Materials and MethodsA total of 1,186 consecutive patients (636 men [53.6%]; median age, 75 years; range, 24–102 years) who underwent PC for acute calculous cholecystitis between January 1, 2019, and December 31, 2020, were included from 36 UK hospitals. The exclusion criteria were diagnostic aspirations, absence of acute calculous cholecystitis, and age less than 16 years. The coronavirus disease 2019 (COVID-19) lockdown was declared on March 26, 2020, in the UK, which served to distinguish among groups.ResultsMost patients (66.3%) underwent PC as definitive treatment, whereas 31.3% underwent PC as a bridge to surgery. The overall 30-day readmission rate was 42.2% (500/1,186), and the 30-day mortality was 9.1% (108/1,186). Centers performing fewer than 30 PCs per year had higher 90-day mortality than those performing more than 60 (19.3% vs 11.0%, respectively; P = .006). A greater proportion of patients presented with complicated acute calculous cholecystitis during the COVID-19 pandemic compared to prior (49.9% vs 40.9%, respectively; P = .007), resulting in more PCs (61.3 vs 37.9 per month, respectively; P < .001). More PCs were performed in tertiary hospitals than in district general hospitals (9 vs 3 per 100 beds, respectively; P < .001), with a greater proportion performed as a bridge to surgery (50.5% vs 22.8%, respectively; P < .001).ConclusionsThe practice of PC is highly variable throughout the UK. The readmission rates are high, and there is significant correlation between mortality and PC case volume.     

Sodium Cholate Bile Acid-Stabilized Ferumoxytol-Doxorubicin-Lipiodol Emulsion for Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

PurposeTo develop bile acid-stabilized multimodal magnetic resonance (MR) imaging and computed tomography (CT)-visible doxorubicin eluting lipiodol emulsion for transarterial chemoembolization of hepatocellular carcinoma (HCC).Materials and MethodsFerumoxytol, a US Food and Drug Administration-approved iron oxide nanoparticle visible under MR imaging was electrostatically complexed with doxorubicin (DOX). An amphiphilic bile acid, sodium cholate (SC), was used to form a stable dispersion of ferumoxytol-DOX complex in lipiodol emulsion. Properties of the fabricated emulsion were characterized in various component ratios. Release kinetics of DOX were evaluated for the chemoembolization applications. Finally, in vivo multimodal MR imaging/CT imaging properties and potential therapeutic effects upon intra-arterial (IA) infusion bile acid-stabilized ferumoxytol-DOX-lipiodol emulsion were evaluated in orthotopic McA-Rh7777 HCC rat models.ResultsDOX complexed with ferumoxytol through electrostatic interaction. Amphiphilic SC bile acid at the interface between the aqueous ferumoxytol-DOX complexes and lipiodol enabled a sustained DOX release (17.2 ± 1.6% at 24 hours) at an optimized component ratio. In McA Rh7777 rat HCC model, IA-infused emulsion showed a significant contrast around tumor in both T2-weighted MR imaging and CT images (P = .044). Hematoxylin and eosin and Prussian blue staining confirmed the local deposition of IA-infused SC bile acid-stabilized emulsion in the tumor. The deposited emulsion induced significant increases in TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling) stain-positive cancer cell apoptosis compared to those in a group treated with the nonstabilized emulsion.ConclusionsSC bile acid-stabilized ferumoxytol-DOX-lipiodol emulsion demonstrated sustained drug release and multimodal MR imaging/CT imaging capabilities. The new lipiodol-based formulation may enhance the therapeutic efficacy of chemoembolization in HCC.     

Predictors of Progression-Free Survival and Local Tumor Control after Percutaneous Thermal Ablation of Oligometastatic Breast Cancer: Retrospective Study

PurposeTo describe ablation of bone, liver, lung, and soft tissue tumors from oligometastatic breast cancer and to define predictors of local progression and progression-free survival (PFS).Materials and MethodsA total of 33 women (mean age 52 ± 12 years old; range, 28–69 years), underwent 46 thermal ablations of liver (n = 35), lung (n = 7), and bone/soft tissue (n = 4) metastases. Mean tumor diameter was 18 ± 15 mm (range, 6–50 mm). Ablations were performed to eradicate all evident sites of disease (n = 24) or to control growing sites in the setting of other stable or responding sites of disease (n = 22). Patient characteristics, ablation margins, imaging responses, and cases of PFS were assessed. Follow-up imaging was performed using contrast-enhanced computed tomography (CT), magnetic resonance (MR) imaging, or positron-emission tomography/ CT.ResultsMedian PFS was 10 months (95% confidence interval [CI], 6.2 –14.5 months), and time to local progression was 11 months (95% CI, 5–16 months). Eight patients (24%) maintained no evidence of disease during a median follow-up period of 39 months. Ablation margin ≥5 mm was associated with no local tumor progression. Longer PFS was noted in estrogen receptor-positive patients (12 vs 4 months; P = .037) and younger patients (12 vs 4 months; P = .039) treated to eradicate all sites of disease (13 vs 5 months; P = .05). Eighteen patients (55%) developed new metastases during study follow-up.ConclusionsThermal ablation of oligometastatic pulmonary, hepatic, bone, and soft tissue tumors can eliminate local tumor progression if margins are ≥5 mm. Longer PFS was observed in patients who were estrogen receptor-positive and patients who were younger and in whom all sites of disease were eradicated.     

Recent Trends in Clinical Setting and Provider Specialty for Endovascular Peripheral Artery Disease Interventions for the Medicare Population

PurposeTo describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment of disease, and clinical location of service.Materials and MethodsCurrent Procedural Terminology codes were used to identify claims for peripheral vascular interventions (PVIs) in 2011–2017 Physician Supplier Procedure Summary master files, which contain 100% Part B Medicare billing. Market share was defined as enrollment-adjusted proportion of billed PVI services for each specialty. Annual volume of billed services was additionally evaluated by clinical location (inpatient, outpatient, office-based laboratories) and anatomic segment of disease (iliac, femoral/popliteal, infrapopliteal).ResultsAggregate PVI claims increased 31.3%, from 227,091 in 2011 to 298,127 in 2017. Annual market share remained relatively stable for all specialties: surgery, 48.3%–49.6%; cardiology, 37.2%–35.1%; radiology, 12.8%–13.3%. Accounting for Medicare enrollment, the volume of iliac interventions decreased by 18% over the study period, while femoral/popliteal interventions increased modestly (+7.5%) and infrapopliteal interventions increased (+46%). The greatest proportional increase in infrapopliteal claims occurred among radiologists (surgeons +40.4%, cardiologists +32.1%, radiologists +106.6%). Adjusting for enrollment, claims from office-based laboratories increased substantially (+305.7%), while hospital-based billing decreased (inpatient −25.7%, outpatient −12.9%). Office-based laboratory utilization increased dramatically with all specialties (surgery +331.8%, cardiology +256.0%, radiology +475.7%).ConclusionsUtilization of PVIs continues to increase, while specialty market shares have stabilized since 2011, leaving surgeons and cardiologists as the major providers of endovascular peripheral artery disease care. The greatest relative increases are occurring in infrapopliteal interventions and office-based laboratory procedures, where radiologist involvement has increased dramatically.     

Hypersensitivity Reactions to Transarterial Chemoembolization with Cisplatin and Ethiodized Oil: A Retrospective Cohort Study

PurposeTo assess the incidence of hypersensitivity reactions (HSRs) and risk factors in patients with unresectable hepatocellular carcinoma (HCC) who have undergone transarterial chemoemblization (TACE) with cisplatin–ethiodized oil emulsion.Materials and MethodsBetween September 2014 and December 2019, patients with HCC in the authors’ institution undergoing TACE with cisplatin–ethiodized oil emulsion were retrospectively reviewed. Clinical, laboratory, and imaging data (including age, sex, etiology of HCC, serum bilirubin, albumin, alpha-fetoprotein, prothrombin time, dose of cisplatin, and details of TACE procedure) and data on procedural complications were retrieved from the registry of TACE. The incidence of HSRs was calculated, and variables were compared between the patient groups with and without HSRs. Predictive factors were analyzed using binary logistic regression.ResultsA total of 882 TACE procedures were involved in 257 patients with HCC. The median number of TACE procedures performed per patient was 3 (range, 1–23). The median dose of cisplatin per TACE session was 4.58 mg (range, 0.42–21 mg), and the median accumulated dose of cisplatin per patient was 15.42 mg (range, 0.52–125 mg). HSRs were identified in 22 (2.49%) of 882 procedures (17 [6.61%] of 257 patients). The median number of TACE procedures performed in these patients was 2.5 (range, 1–17). The median dose of cisplatin per TACE session was 5.42 mg (range, 0.63–20 mg), and the median accumulated dose of cisplatin per patient was 18.44 mg (range, 3.33–47.99 mg). Upon binary logistic regression analysis, parameters that showed statistically significant and independent association with HSRs included performance of ≥6 TACE procedures (odds ratio, 3.773; P = .012).ConclusionsPerformance of ≥6 TACE procedures was found to be independently associated with the incidence of HSRs. Patients undergoing multiple TACE procedures should be monitored closely for HSRs.     

Correlation and Agreement of Yttrium-90 Positron Emission Tomography/Computed Tomography with Ex Vivo Radioembolization Microsphere Deposition in the Rabbit VX2 Liver Tumor Model

PurposeTo demonstrate a stronger correlation and agreement of yttrium-90 (⁹⁰Y) positron emission tomography (PET)/computed tomography (CT) measurements with explant liver tumor dosing compared with the standard model (SM) for radioembolization.Materials and MethodsHepatic VX2 tumors were implanted into New Zealand white rabbits, with growth confirmed by 7 T magnetic resonance imaging. Seventeen VX2 rabbits provided 33 analyzed tumors. Treatment volumes were calculated from manually drawn volumes of interest (VOI) with three-dimensional surface renderings. Radioembolization was performed with glass ⁹⁰Y microspheres. PET/CT imaging was completed with scatter and attenuation correction. Three-dimensional ellipsoid VOI were drawn to encompass tumors on fused images. Tumors and livers were then explanted for inductively coupled plasma (ICP)-optical emission spectroscopy (OES) analysis of microsphere content. ⁹⁰Y PET/CT and SM measurements were compared with reference standard ICP-OES measurements of tumor dosing with Pearson correlation and Bland-Altman analyses for agreement testing with and without adjustment for tumor necrosis.ResultsThe median infused activity was 33.3 MBq (range, 5.9–152.9). Tumor dose was significantly correlated with ⁹⁰Y PET/CT measurements (r = 0.903, P < .001) and SM estimates (r = 0.607, P < .001). Bland-Altman analyses showed that the SM tended to underestimate the tumor dosing by a mean of ?8.5 Gy (CI, ?26.3–9.3), and the degree of underestimation increased to a mean of ?18.3 Gy (CI, ?38.5–1.9) after the adjustment for tumor necrosis.Conclusions⁹⁰Y PET/CT estimates were strongly correlated and had better agreement with reference measurements of tumor dosing than SM estimates.     

Gunther Tulip Filter Strut Penetration: Benign Long-Term Follow-up

PurposeTo describe the natural history of Gunther Tulip filter (GTF) strut penetration based on the computed tomography (CT)–documented distance penetrated over time and any clinical manifestations.Materials and MethodsThe records of 203 patients (mean age, 59.1 years; 59.4% men) who had had an infrarenal GTF placed for venous thromboembolism (84.2%) with contraindications to anticoagulation (95.1%) and had CT follow-up were reviewed retrospectively for clinical or imaging evidence of complications. Filter strut penetration was measured on axial images from the outer caval wall to the inner edge of the distal end of each strut. Filter strut behavior over time was modeled using a linear mixed model.ResultsThe extent of penetration correlated positively with filter dwell time (P < .001) but plateaued at 3.3 mm at 10-year follow-up. At median 4.7-year follow-up 79.3% of patients had at least 1 strut that was >0.2 mm and 31% had a strut >3 mm from the inferior vena caval wall. The extent of strut penetration was greater at all time points for women (P = .002). Abutment or entry into an adjacent structure was identified in 183 struts of 105 (52.7%) filters; of the 80 filters with CT follow-up, 47% showed progression and 19% regressed. There were no symptoms referable to filter strut penetration.ConclusionsGTF struts often penetrate the inferior vena cava progressively; however, this tends to plateau by 10 years. The limited long-term progression and a very low incidence of symptomatic complications together support a noninterventional approach to the finding of an asymptomatic GTF strut penetration.     

Survival and Toxicities after Yttrium-90 Transarterial Radioembolization of Cholangiocarcinoma in the RESiN Registry

PurposeTo report outcomes in patients with intrahepatic cholangiocarcinoma treated with yttrium-90 resin microspheres (transarterial radioembolization [TARE]) from a multicenter, prospective observational registry.Materials and MethodsNinety-five patients (median age, 67 years [interquartile range {IQR}, 59–74]; 50 men) were treated in 27 centers between July 2015 and August 2020. Baseline demographic characteristics included imaging findings, performance status, and previous systemic or locoregional treatments. Dosimetry method was tracked. Overall survival (OS) and progression-free survival were calculated using the Kaplan-Meier method. The best imaging response was calculated using the Response Evaluation Criteria in Solid Tumors v1.1. Grade ≥3 toxicities were assessed using Common Terminology Criteria for Adverse Events v5. Cox regression analysis was performed.ResultsFifty-two of 86 (60%) patients had multifocal tumors, and 24/89 (27%) had extrahepatic tumors. The median index tumor diameter was 7.0 cm (IQR, 4.9–10 cm). The activity calculation method was reported in 59/95 (62%) patients, with body surface area being the most frequently used method (45/59, 76%). Median OS for the cohort was 14 months (95% confidence interval, 12–22). OS at 3, 6, 12, and 24 months was 94%, 80%, 63%, and 34%, respectively. Median OS was longer in patients without cirrhosis (19.1 vs 12.2 months, P = .05). Cirrhosis, previous chemotherapy (OS, 19.1 vs 10.6 months for treatment-naïve; P = .07), and imaging response at 6 months (OS, 16.4 vs 9.5 months for no response; P = .06) underwent regression analysis. Imaging response predicted OS at regression (hazard ratio, 0.39; P = .008). Grade 3–4 bilirubin toxicities were noted in 5 of 72 (7%) patients. Grade 3 albumin toxicity was noted in 1 of 72 (1.4%) patients.ConclusionsObjective response at 6 months predicted longer OS after TARE for intrahepatic cholangiocarcinoma. The incidence of liver function toxicity was <10%.