Direct aneurysm sac catheterization and embolization of an enlarging internal iliac aneurysm using cone-beam CT

Since cone-beam computed tomography (CT) has been adapted for use with a C-arm system it has brought volumetric CT capabilities in the interventional suite. Although cone-beam CT image resolution is far inferior to that generated by traditional CT scanners, the system offers the ability to place an access needle into position under tomographic guidance and use the access to immediately begin a fluoroscopic procedure without moving the patient. We describe a case of a “jailed” enlarging internal iliac artery aneurysm secondary to abdominal aortic aneurysm repair, in which direct percutaneous puncture of the internal iliac artery aneurysm sac was performed under cone-beam CT guidance.When planning for successful abdominal endovascular aneurysm repair (EVAR), it is important to evaluate if there are associated internal iliac artery (IIA) aneurysms and the potential for type II endoleaks via retrograde IIA flow. In cases of short, ectatic, or aneurysmal common iliac arteries, placement of the distal limb of the stent graft into the external iliac artery may be necessary to ensure safe graft limb positioning and an adequate seal. In situations such as this, where there is not an associated IIA aneurysm, standard therapy is to embolize the origin of the IIA prior to stent graft placement in order to prevent type II endoleaks (1).The situation should be differentiated from the setting in which the IIA is not just a potential source of a type II endoleak, but is also aneurysmal. In this setting, embolization of the affected IIA origin is insufficient to protect the IIA aneurysm from retrograde perfusion and potential rupture (Fig. 1). This retrograde perfusion can lead to persistent aneurysm sac pressurization with subsequent aneurysm enlargement and increased risk of rupture. Furthermore, proximal embolization precludes future antegrade access into the aneurysm if an additional intervention is needed. The standard endovascular treatment of an isolated IIA aneurysm consists of embolic occlusion of all inflow and outflow branches (2). Hence, when an IIA aneurysm is associated with an abdominal aortic aneurysm (AAA), it should be treated in a similar manner prior to endograft placement (3).Open in a separate windowFigure 1.Illustration demonstrates endovascular aneurysm repair of an abdominal aortic aneurysm extending into the common iliac arteries and internal iliac arteries (IIA), with embolization of all inflow and outflow branches of the IIA to prevent enlargement of the IIA aneurysms. (Illustration by D.C. Botos)We present a case of cone-beam computed tomography (CBCT) guided direct puncture of a “jailed” enlarging IIA aneurysm. The IIA aneurysm was not directly accessible through an antegrade endovascular approach secondary to prior IIA origin coil occlusion and stent graft exclusion of the IIA orifice.     

Proximal iliac limb extension and embolization: a new technique of complete endovascular management of an unfavorably sited type III endoleak

Type III endoleak is an uncommon but life-threatening complication of endovascular aortic repair, and such leaks at certain sites can be challenging to treat through an endovascular route. A 77-year-old man presented with severe abdominal pain and was found to have an abdominal aortic aneurysm with contained rupture due to an unfavorably cited type IIIb endoleak. He was successfully treated with an endovascular approach using bilateral iliac limb proximal extension combined with embolization of endoleak sac, endoleak site and the feeding recess, preserving flow through both the iliac limbs obviating the need for an additional femorofemoral bypass. The patient improved clinically and had a favorable long-term follow-up profile.

Endoleak is the most common complication of endovascular aortic repair requiring re-intervention (1). There are five types of endoleak; type III is a less common but the most dangerous variety (2, 3). Endovascular repair is preferred over surgical repair and different treatment options exist depending on the site of endoleak (4). Because of its location, a type IIIb endoleak from a defect in the graft at or close to the endograft bifurcation cannot be treated by simple relining with an aortic extender cuff or an iliac limb, and is usually endovascularly treated by insertion of an aorto-uni-iliac stent graft along with occlusion of contralateral limb and a surgical femorofemoral bypass; the other option being insertion of a bifurcated stent graft if there is sufficient length between renal artery origin and endograft bifurcation (1, 4, 5). We describe the first case of a successfully treated unfavorable type IIIb endoleak using proximal extension of iliac limbs, endoleak sac and feeding recess embolization.     

Unidentified bright objects of spleen on arterial phase CT: mimicker of splenic vascular injury in blunt abdominal trauma

PURPOSEWe have described unidentified bright objects of spleen (UBOS), a hitherto undescribed entity, as hyperdense areas on arterial phase (AP) computed tomography (CT) seen in relation to splenic lacerations and are isodense to the normal parenchyma on portal venous phase with no correlate on digital subtraction angiography (DSA). UBOS mimic splenic vascular injuries like active contrast extravasation and pseudoaneurysm and need to be differentiated from them as it would have implications on patient management. We undertook this study to identify CT features of UBOS that can differentiate them from splenic vascular injuries and to calculate their diagnostic accuracy.METHODSThis retrospective study was approved by the institutional ethical committee and the need for informed consent was waived. Patients with splenic injury who had undergone dual-phase CT and DSA were included. All the lesions that were hyperdense on AP were evaluated for their outline, their relation to the adjacent/parallel margins of a laceration (margin sign), string of beads appearance, and the presence of adjacent normal parenchyma (adjacent parenchyma sign). The Hounsfield unit (HU) of the lesion and the aorta on the AP were also noted. The diagnostic accuracy of various signs for distinguishing UBOS from splenic vascular injuries was calculated using DSA as the reference standard.RESULTSOf 48 patients, 5 were excluded due to suboptimal quality of the examination or a time difference of more than 6 hours between the CT and DSA. A total of 54 hyperdense lesions were detected on AP in 43 patients. These were classified as vascular injuries (pseudoaneurysm, n=11; active contrast extravasation, n=11) and UBOS (n=32) based on DSA. The margin sign, string of beads appearance, and ill-defined outline had high specificity (95%, 86%, and 82%, respectively) but low sensitivity (50%, 65%, and 63%, respectively). The adjacent parenchyma sign had a moderate sensitivity and specificity of 84% and 77%, respectively. ROC analysis showed that a difference of 50 HU between the aorta and the lesion had a high sensitivity and specificity of 88.9% and 90.6%, respectively, with an area under the curve of 0.90.CONCLUSIONAn attenuation difference of over 50 HU between the aorta and the lesion and the presence of normal adjacent parenchyma had the highest diagnostic accuracy, while an ill-defined outline, string of beads appearance, and margin sign had high specificity but low sensitivity for differentiating UBOS from splenic vascular injuries.

Although there is a wide variation in the computed tomography (CT) protocol for the evaluation of blunt abdominal trauma across centers, arterial phase (AP) CT is increasingly being used as part of the evaluation (1–3). AP is usually acquired as a part of whole-body (chest and abdomen) CT angiography followed by a portal venous phase (PVP) acquisition of the abdomen (4–7). AP has been shown to increase the sensitivity of CT for the detection of splenic vascular injuries like pseudoaneurysms (6–9). These appear hyperdense relative to the surrounding parenchyma on AP, leading to better detection rates on AP. However, due to poorly understood mechanisms, the splenic parenchyma shows heterogeneous enhancement in the arterial phase (10–14). This is further exaggerated in the presence of parenchymal injuries like laceration following blunt abdominal trauma leading to the appearance of hyperdense areas on AP which may masquerade as intraparenchymal pseudoaneurysms or active extravasations.We describe unidentified bright objects of spleen (UBOS) as hyperdense areas seen in relation to splenic lacerations on AP CT which are isodense to the normal parenchyma on PVP with no abnormal correlate on digital subtraction angiography (DSA). As most splenic vascular injuries are hyperdense on AP and some of them isodense on PVP, these UBOS closely mimic splenic vascular injuries (Fig. 1).Open in a separate windowFigure 1. a, bIllustration depicting the imaging features of unidentified bright objects of spleen (UBOS) and pseudoaneurysm: UBOS (a, asterisk) show ill-defined outline, normal adjacent parenchyma, string of beads appearance due to multiple adjacent lesions, the presence of lesions on adjacent/parallel margins of laceration. Also, UBOS show no communication with the arterial and is less bright than the adjacent arteries (depicting lesser HU). Pseudoaneurysm (b, asterisk) shows a well-defined lesion with no adjacent normal parenchyma in direct communication with an artery. Brown shaded area represents a laceration with intraparenchymal hematoma.The 2018 revision of the organ injury scale for splenic injuries by the American Association for Surgery in Trauma (AAST) has incorporated CT-diagnosed vascular injuries into the grading system. The grade of injury is upgraded to grade 4/grade 5 if there are associated splenic vascular injuries irrespective of the grade of parenchymal injuries (15–17). Hence, it is imperative to accurately diagnose the splenic vascular injuries on CT and to differentiate UBOS, a previously undescribed entity, from splenic vascular injuries, as it would have implications on the grading of injury and further management.There are no studies describing such an entity or its imaging features. We undertook this retrospective study to describe CT features of UBOS and to identify features that can differentiate UBOS from pseudoaneurysms or active extravasations and test their diagnostic accuracy.     

Increased x-ray attenuation in malignant vs. benign mediastinal nodes in an orthotopic model of lung cancer

PURPOSE

Staging of lung cancer is typically performed with fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET/CT); however, false positive PET scans can occur due to inflammatory disease. The CT scan is used for anatomic registration and attenuation correction. Herein, we evaluated x-ray attenuation (XRA) within nodes on CT and correlated this with the presence of malignancy in an orthotopic lung cancer model in rats.

METHODS

1×10⁶ NCI-H460 cells were injected transthoracically in six National Institutes of Health nude rats and six animals served as controls. After two weeks, animals were sacrificed; lymph nodes were extracted and scanned with a micro-CT to determine their XRA prior to histologic analysis.

RESULTS

Median CT density in malignant lymph nodes (n=20) was significantly higher than benign lymph nodes (n=12; P = 0.018). Short-axis diameter of metastatic lymph nodes was significantly different than benign nodes (3.4 mm vs. 2.4 mm; P = 0.025). Area under the curve for malignancy was higher for density-based lymph node analysis compared with size measurements (0.87 vs. 0.7).

CONCLUSION

XRA of metastatic mediastinal lymph nodes is significantly higher than benign nodes in this lung cancer model. This suggests that information on nodal density may be useful when used in combination with the results of FDG-PET in determining the likelihood of malignant adenopathy.Lung cancer is the leading cause of cancer deaths in the United States and Europe (1). Choice of therapy and prognosis is determined by the stage at which lung cancer is detected. Mediastinal nodal involvement is a significant negative prognostic sign and portends a shorter time to progression (2). Fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET/CT) has emerged as the leading noninvasive staging method as both primary tumor and mediastinal nodes can be assessed (2, 3). Precise mediastinal N-staging is mandatory since patients with contralateral or multiregional mediastinal lymph node metastases are often excluded from primary surgery (4). The PET component of the FDG-PET/CT examination is typically assessed by measuring the maximum standardized uptake value (SUV_max) in the primary tumor and nodes. However, the FDG-PET component is sometimes equivocal due to false positive uptake in inflammatory nodes (5). The CT component is typically assessed using Response Evaluation Criteria In Solid Tumors (RECIST 1.1) criteria in the primary and nodes, and it is based on the node’s short-axis diameter (3). However, size changes are notoriously unreliable in assessing disease status. Therefore, staging often requires additional invasive methods such as transbronchial biopsy or mediastinoscopy for histologic verification (6), especially in patients that might benefit from primary surgery.Previous reports have suggested that nodes exhibit increases in x-ray attenuation (XRA) density when they become malignant due to replacement of the fatty nodal hilum with cancer cells (5). For instance, malignant lymph nodes obtained from patients with breast cancer showed increased density on grating-based phase-contrast x-ray tomography (7–10). However, this observation is not routinely incorporated into clinical interpretation of PET/CT despite the ready availability of such information. In order to further investigate potential density changes in metastatic and nonmetastatic mediastinal and hilar lymph nodes, we utilized an orthotopic lung cancer model in nude rats (11), which included ex vivo micro-CT XRA of extracted lymph nodes two weeks after transthoracic tumor cell implantation (Fig. 1). Findings were correlated with histology.Open in a separate windowFigure 1Study design with in vivo and ex vivo measurements. Step 1: Transthoracic tumor cell transplantation in the 5th intercostal space. Step 2: Within the first two weeks after transthoracic tumor cell transplantation tumor spreads in mediastinal and hilar lymph nodes (small yellow dots). Primary tumor is seen in the right lower lobe (big yellow dot). Step 3: Micro-CT examination of extracted mediastinal lymph nodes.     

The potential role of modern US in the follow-up of patients with retroperitoneal fibrosis

PURPOSE

We aimed to evaluate a standardized ultrasonography (US) algorithm for the visualization of pathologic para-aortic tissue in retroperitoneal fibrosis (RPF).

MATERIALS AND METHODS

Thirty-five patients with lumbar RPF of typical extent, as determined by abdominal magnetic resonance imaging, were included. Examinations were conducted using standardized abdominal US with axial sections obtained at the levels of the renal arteries, aortic bifurcation, and both common iliac arteries. Imaging of each section was acquired with fundamental B-mode (US) and tissue harmonic imaging, respectively. In addition, we examined RPF visualized using extended field-of-view US.

RESULTS

Tissue harmonic imaging adequately visualized RPF of typical extent in 33 patients (94.2%). Excellent and good visualization with mild artifacts were achieved in 25 (71.4%) and six (17.1%) patients, respectively. When RPF spread along the iliac arteries, excellent visualization was achieved in 38.7% for the left side and 34.5% for the right side. There were significantly fewer diagnostic examinations for the right iliac (27.6%) than for the left one (9.7%) (P = 0.016). Overall, harmonic imaging achieved significantly better visualization than fundamental B-Mode (P < 0.001).

CONCLUSION

We described the first systematic evaluation of RPF visualization by modern US techniques. The best imaging quality was found in the typical RPF location, at the level of the aortic bifurcation. These results advocate for the presented US algorithm as an efficient follow-up alternative to cross-sectional imaging in RPF patients.Chronic periaortitis or retroperitoneal fibrosis (RPF) is a rare fibrosing disease that affects para-aortic tissues (1–3). It typically presents as a proliferating lumbar process surrounding the ureters and retroperitoneal vascular structures (Fig. 1) (2, 4). Sporadic, atypical manifestations in pelvic and mesenteric regions are also possible (5).Open in a separate windowFigure 1. a–c.Typical extent of the retroperitoneal fibrosis surrounding the infrarenal aorta (a). Spreading of the fibrosis to the renal arteries and along the common iliac arteries (b). Standardized US examination with four transverse sections (c). AO, aorta; AIC, common iliac artery; RA, renal artery; RPF, retroperitoneal fibrosis.Magnetic resonance imaging (MRI) allows precise evaluation of the extent and complications (6). RPF presents as hypointense (often isointense to striated muscle) plaques in native T1-weighted magnetic resonance (MR) images with significant gadolinium contrast enhancement of active and untreated retroperitoneal fibrosis (7–9).Ultrasonography (US) is primarily used in patients with RPF for a rapid and practical diagnosis of consecutive hydronephrosis (6). RPF presents as a smooth-bordered mass with either an echo-poor or echo-free signal (10, 11). Two studies in the 1980s indicated that US revealed only a poor overall sensitivity in the detection of RPF (12, 13). Feinstein et al. (14) reported that only 25% of affected patients with computed tomography (CT)-mediated diagnosis of RPF showed corresponding ultrasonographic abnormalities. Since that time the quality of US scanners has improved dramatically, and modern techniques, such as tissue harmonic imaging (THI) and extended field-of-view US, have significant advantages for routine clinical diagnosis (15–17). Today, US has established itself as an effective and cost-efficient imaging method for the screening and follow-up of infrarenal aortic aneurysms (18, 19). US, however, is not used routinely for RPF follow-up, nor has a systematic evaluation of modern ultrasonographic methods been available to date.The aim of the present study was to evaluate the potential role of modern ultrasonographic techniques for the visualization of fibrous tissue in patients with prediagnosed RPF.     

Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair

PURPOSE

We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation).

RESULTS

Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all).

CONCLUSION

Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.The aim of endovascular abdominal aortic aneurysm repair (EVAR) is to prevent rupture of an abdominal aortic aneurysm (AAA) by depressurizing the aneurysm and excluding it from the systemic circulation using a stent-graft. Aneurysmal sac reduction is a reliable marker for the long-term prognosis after EVAR. Although most aneurysmal sacs shrink after EVAR, some sacs continue to expand. A relationship between aneurysm size and endoleaks was previously reported (1, 2). Most type II endoleaks spontaneously disappear over time, but 10%–25% persist for more than six months after EVAR (3–6). Persistent endoleaks with aneurysmal sac expansion are at high risk of rupture because of the continuously elevated intra-aneurysmal pressure and require a second intervention, such as embolization (7–11). However, it is difficult to predict sac expansion and persistent endoleak before performing EVAR. Although intraoperative intrasac thrombin injection and prophylactic embolization of aortic branches such as the inferior mesenteric artery and lumbar artery are reported to reduce the incidence of type II endoleak, the efficacy and clinical benefit of these procedures in terms of late postoperative aneurysm shrinkage have not been fully evaluated (12–15). Therefore, the purpose of this study was to identify the risk factors associated with late aneurysmal sac expansion after EVAR to determine possible indications for intrasac embolization and prophylactic embolization of aortic branches.     

MRI in local staging of rectal cancer: an update

Preoperative imaging for staging of rectal cancer has become an important aspect of current approach to rectal cancer management, because it helps to select suitable patients for neoadjuvant chemoradiotherapy and determine the appropriate surgical technique. Imaging modalities such as endoscopic ultrasonography, computed tomography, and magnetic resonance imaging (MRI) play an important role in assessing the depth of tumor penetration, lymph node involvement, mesorectal fascia and anal sphincter invasion, and presence of distant metastatic diseases. Currently, there is no consensus on a preferred imaging technique for preoperative staging of rectal cancer. However, high-resolution phased-array MRI is recommended as a standard imaging modality for preoperative local staging of rectal cancer, with excellent soft tissue contrast, multiplanar capability, and absence of ionizing radiation. This review will mainly focus on the role of MRI in preoperative local staging of rectal cancer and discuss recent advancements in MRI technique such as diffusion-weighted imaging and dynamic contrast-enhanced MRI.Colorectal cancer is the second most common cancer in women and the third most common cancer in men with 570 100 and 663 600 estimated new cases per year worldwide, respectively (1). Rectal cancer accounts for approximately 42% of colorectal cancers with 45 000 estimated new cases per year in the United States (2). Prognosis of rectal cancer is determined by depth of invasion, number of involved lymph nodes, and involvement of circumferential resection margin. Management of rectal cancer has evolved over the years with preoperative imaging playing an increasingly prominent role. Initial strategy of clinical diagnosis followed by surgery and postoperative chemotherapy had a high local recurrence rate (27%) and poor survival (48% 5-year survival) (3). Later studies showed that neoadjuvant chemoradiation improves survival and decreases local recurrence rates significantly (4). In addition, it reduces tumor size, facilitates curative resection (5), and may enable sphincter sparing surgery in cancers close to the anorectal junction (6). Neoadjuvant chemoradiotherapy is not indicated in stage I tumors (confined to rectal wall with no nodal involvement), but is recommended for stage II (extends beyond the rectal wall, no nodal involvement) and stage III tumors (regional lymph node involvement). Therefore, in order to avoid unnecessary chemoradiation in stage I cancers, a reliable imaging modality is crucial to precisely define depth of invasion and to identify lymph node involvement (7). Current approach in the management of rectal cancer includes preoperative staging with different imaging modalities followed by neoadjuvant chemoradiotherapy (for stage II/III cancers). This approach has lowered the local recurrence rate (11%) and improved survival (58% 5-year survival) (3).Preoperative imaging for rectal cancer staging is also useful to determine which surgical technique would be more appropriate: recently-developed local excision method of transanal resection or traditional radical resections such as low anterior resection or abdominoperineal resection. Physical examination, endoscopic evaluation, and imaging modalities are used for preoperative staging of rectal cancer. Ideal imaging modality should accurately assess the depth of tumor penetration (T), lymph node involvement (N), presence of distant metastatic disease (M), mesorectal fascia involvement, and anal sphincter involvement. Currently, there is no consensus on a preferred imaging technique for preoperative staging of rectal cancer.Endoscopic ultrasonography, one of the oldest and most widely used imaging modalities, is reported to assess T staging with 67%–97% accuracy and nodal involvement with 64%–88% accuracy (8–11). Although it has a role in staging of early cancers confined to the wall of the rectum, endoscopic ultrasonography may not assess deeper or higher nodes in the mesorectum and can misinterpret inflammatory or fibrotic changes as metastasis (12). Its value is also limited in the evaluation of near-obstructing tumors, tumors in the upper rectum, and mesorectal fascia involvement (12, 13).Computed tomography (CT) is commonly used in rectal cancer because of its ability to assess entire pelvic anatomy and presence or absence of distant metastasis. However, CT has limited soft tissue contrast for local staging. A meta-analysis of 83 studies showed that CT has 73% accuracy for T staging and 22%–73% accuracy for nodal staging (14). In a recent study, Sinha et al. (15) showed T stage accuracy of 87.1% and N stage accuracy of 87.1%. Although newer multidetector CT technology with multiplanar reformations has improved the accuracy, soft tissue resolution of CT is still inadequate to evaluate early rectal cancers.On the other hand, high-resolution phased-array MRI is recommended as a standard imaging modality for pre-operative local staging of rectal cancer, with excellent soft tissue contrast, functional imaging ability, and multi-planar capability (Figs. 1 and ​and2).2). With these inherent proprieties, MRI fills a gap in clinical practice and helps accurate local staging of rectal cancer prior to management decisions. This review will mainly focus on the role of MRI in preoperative local staging of rectal cancer and discuss recent advancements in MRI technique.Open in a separate windowFigure 1. a, b.Axial (a) and coronal (b) fast spin-echo T2-weighted MR images obtained with a phased-array coil on a 3.0 T magnet show the normal anatomy of the pelvis. The rectum (a, arrowhead) is distended with water. Note uterus (a, arrow), and oval-shaped fatty-centered left iliac node (a, curved arrow), which is likely reactive. The iliococcigeal part of the levator ani muscle (b, arrows) extends from the pelvic sidewalls to the anus and joins with the puborectalis muscle (b, arrowheads) to form the external sphincter of the anus (b, curved arrow).Open in a separate windowFigure 2.Axial T2-weighted MR image obtained with an endorectal coil shows the layers of the rectum. Hyperintense submucosa (curved arrows) is surrounded by hypointense muscularis propria (arrows). The mucosa cannot be differentiated from the submucosa, and both layers appear as a single hyperintense layer. Note the levator ani muscle (curved arrows).     

Outcomes of endovascular treatment of thoracic aorta pathologies: 10-year single-center results

PURPOSE Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment method for a variety of thoracic aortic pathologies. We aimed to investigate the mortality and complication outcomes and associated factors of TEVAR treatment in Turkey.METHODS In this single-centered retrospective study, patients with thoracic aorta pathologies treated with TEVAR at Gazi University School of Medicine, Department of Radiology, between January 2009 and January 2020 were included. Perioperative, early, and late mortality, complications, and technical success were the outcomes.RESULTS The sample comprised 58 patients with 68 TEVAR interventions. Eleven (16.2%) patients were female, the mean age was 60.1 ± 13.4 years. Emergent TEVAR was required in 20.7% of the patients. The main indications of TEVAR were intact descending aorta aneurysms in 37.9% of the sample, 31.0% Stanford type-B dissection, and 12.1% traumatic transections. The technical success rate of primary and secondary interventions was 98.3% and 100%, respectively. The mortality rate in the first 30 days was 8.6%. Seventeen (29.3%) cases had at least 1 complication related to TEVAR treatment. The most common complication was type-1A endoleak (10.3%). Having acute symptoms, stroke, and acute renal failure were significantly associated with mortality (P = .020, .049, and .009, respectively).CONCLUSION This study reported the outcomes of TEVAR treatment from a tertiary medical center in Turkey over a decade. Patients presenting with acute symptoms and who developed stroke and acute renal failure after the procedure should be carefully followed up as these factors were found to be associated with mortality.

Main points

• Thoracic endovascular aortic repair (TEVAR) procedure is associated with increased mortality.
• This study showed the mortality and complication outcomes of TEVAR treatment for various aortic pathologies in a single tertiary center in Turkey over a 10-year period.
• Presenting with acute symptoms and developing stroke and acute renal failure after the TEVAR procedure were associated with mortality.

Thoracic aorta pathologies are a spectrum of diseases composed of aneurysms, dissections, traumatic injuries, penetrating atherosclerotic ulcers (PAU), and intramural hematomas. Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment method described and used with increased frequency. Lower rates of complications like renal failure, paraplegia, stroke, lower blood transfusion requirement, and lower mortality rates, as well as shorter hospitalization time, make TEVAR a successful treatment alternative to open surgery regarding thoracic aortic pathologies.^1-3 TEVAR has become the treatment of choice for descending aortic aneurysm,^4-6 complicated type-B dissections,⁷ and traumatic transections.⁸While TEVAR has been used widely around the world, mortality and complications such as endoleak, stroke, renal failure, myocardial infarction, hemorrhage, thrombus, migration, and loss of graft integrity have been reported during follow-up.^4-6,9-14 This study aimed to investigate the mortality and complication outcomes in the first year after the TEVAR procedure and associated factors in patients with a variety of thoracic aorta pathologies.     

Balloon-occluded middle adrenal artery embolization and percutaneous microwave ablation of a metastatic adrenal tumor from renal cell carcinoma

Renal cell carcinomas present with locally advanced or metastatic disease in 25% of patients. Thermal ablation may be considered in selected patients with single-site or oligometastatic disease. In the study, we describe single-session transarterial particle embolization with the assistance of a balloon-occlusion catheter and microwave ablation of a large hypervascular adrenal metastasis using cone-beam computed tomography and fluoroscopic XperGuide needle guidance.

Main points

• Interventional treatment options for hypervascular metastases include direct percutaneous ablation and transarterial embolization.
• Single-session transarterial particle embolization and microwave ablation using cone-beam computed tomography and fluoroscopic XperGuide needle guidance may be considered for patients with hypervascular metastases.

Renal cell carcinomas (RCC) represent 80%-85% of primary renal neoplasms and present with locally advanced or metastatic disease in 25% of patients.¹ In patients with advanced or metastatic clear cell RCC, systemic therapy is the mainstay of treatment.¹ Surgical metastasectomy and thermal ablation may be considered in selected patients with single-site or oligometastatic disease during or after targeted systemic therapy, particularly for refractory tumors.¹ This report describes techniques and outcomes for a patient undergoing embolization and ablation of a large RCC metastasis.Institutional review board approval was not required for this report. A 59-year-old man with a history of stage 2 clear cell RCC status post total nephrectomy 13 years prior presented with cough, underwent computed tomography (CT) of the chest, and was found to have biopsy-proven metastatic disease in mediastinal lymph nodes. Additional sub-centimeter pulmonary nodules, hyper enhancing pancreatic lesions, and bilateral adrenal masses were discovered. The patient was started on axitinib and pembrolizumab, and over an 8-month period of observation on systemic therapy, there was interval stability of all sites of metastatic disease except for a growing left adrenal mass which now measured 8.6 cm (Figure 1). Interventional radiology was consulted for minimally invasive treatment of the left adrenal metastasis.Open in a separate windowFigure 1.Axial and coronal image from pre-procedure CT scan demonstrating heterogeneously enhancing left adrenal RCC metastasis, measuring 8.6 cm. CT, computed tomography; RCC, renal cell carcinoma.     

Single-center experience with routine clinical use of 3D technologies in surgical planning for pediatric patients with complex congenital heart disease

PURPOSEThis study was planned to assess the application of three-dimensional (3D) cardiac modeling in preoperative evaluation for complex congenital heart surgeries.METHODSFrom July 2015 to September 2019, 18 children diagnosed with complex congenital heart diseases (CHDs) were enrolled in this study (double outlet right ventricle in nine patients, complex types of transposition of the great arteries in six patients, congenitally corrected transposition of the great arteries in two patients, and univentricular heart in one patient). The patients’ age ranged from 7 months to 19 years (median age, 14 months). Before the operation, 3D patient-specific cardiac models were created based on computed tomography (CT) data. Using each patient’s data, a virtual computer model (3D mesh) and stereolithographic (SLA) file that would be printed as a 3D model were generated. These 3D cardiac models were used to gather additional data about cardiac anatomy for presurgical decision-making.RESULTSAll 18 patients successfully underwent surgeries, and there were no mortalities. The 3D patient-specific cardiac models led to a change from the initial surgical plans in 6 of 18 cases (33%), and biventricular repair was considered feasible. Moreover, the models helped to modify the planned biventricular repair in five cases, for left ventricular outflow tract obstruction removal and ventricular septal defect enlargement. 3D cardiac models enable pediatric cardiologists to better understand the spatial relationships between the ventricular septal defect and great vessels, and they help surgeons identify risk structures more clearly for detailed planning of surgery. There was a strong correlation between the models of the patients and the anatomy encountered during the operation.CONCLUSION3D cardiac models accurately reveal the patient’s anatomy in detail and are therefore beneficial for planning surgery in patients with complex intracardiac anatomy.

Congenital heart diseases (CHDs), especially complex ventricular–arterial (VA) relationships (double outlet right ventricle [DORV], complex types of transposition of the great arteries [TGA], and congenitally corrected TGA [c-TGA]) are a heterogeneous and complex group of cardiac malformations. The planning of an optimal surgical repair of some of these pathologies requires a clear and complete understanding of spatial relationships; hence, they sometimes require advanced diagnostic imaging (1). It is important to reveal the anatomy and three-dimensional (3D) spatial relationships of cardiac structures before the ultimate decision is reached on whether to perform a single ventricular or biventricular repair.Before surgical procedures, the primary noninvasive and widely used diagnostic tool is echocardiography (2–4). While most decisions for treatment can be made with echocardiography (5), it may not be sufficient for decision-making in some complex CHDs, especially with complex VA relationships. In particular, the spatial relationship of great vessels and ventricular septal defects (VSD) is difficult to determine with echocardiography (6). Computed tomography angiography (CTA) has been widely used for the diagnosis of CHDs, and in some instances, it may eliminate the anatomical shortcomings of echocardiography (7). However, even CTA may not provide sufficient data on intracardiac anatomy, particularly regarding the relationship of VSD with great arteries (6). This, in turn, has resulted in an increased need for advanced diagnostic imaging and additional engineering techniques to achieve adequate presurgical planning, particularly before biventricular surgical repair.3D cardiac modeling (i.e., 3D virtual intracardiac modeling and printing techniques) is an innovative technology that involves computer-aided processing of 3D imaging data for physical outputs of virtual objects (8–10). More advanced 3D imaging can provide significant information on complex VA relationships and help to select the appropriate surgical procedure considering the complexity of the spatial planes in complex CHDs (11). The relationship between great vessels, VSDs, and semilunar valves can be clearly identified and the suitability of a left ventricular (LV)–aortic tunnel can be confirmed with 3D cardiac modeling (12). Numerous authors have reported the benefits of 3D cardiac modeling, and this approach has been a helpful diagnostic tool for presurgical decision-making in many centers worldwide (1, 13, 14). However, to our knowledge, there have been no studies conducted in our country examining the use of 3D cardiac model techniques (i.e., 3D virtual intracardiac modeling and printing techniques) for presurgical decision-making with complex CHDs. In this retrospective study, we share our experience with surgical planning based on 3D cardiac modeling for complex CHDs and introduce 3D cardiac modeling as a valuable tool in presurgical decision-making in complex CHDs to be adopted throughout the country.     

Chest X-ray in intensive care unit patients: what there is to know about thoracic devices

Critically ill patients admitted to the intensive care unit require continuous monitoring of vital functions as well as mechanical and pharmacological support, provided through different devices. Chest radiographs play a fundamental role in monitoring the conditions of these patients and assessing the intensive-care devices after their insertion; therefore, the radiologist needs to know their normal appearance and their correct position and should be aware of the possible complications that may occur after their placement. This pictorial review illustrates the radiographic appearance of non-cardiological devices commonly used in clinical practice (central venous catheters, tunneled catheters, Swan-Ganz catheters, chest tubes, endotracheal tubes, and nasogastric tubes), their correct position and the most common complications that may occur after their placement.

Critically ill patients in the intensive care unit require continuous monitoring of vital functions and mechanical and pharmacological support, provided through different devices. Inserting intensive-care devices is a common medical practice but complications may occur and a chest X-ray radiography (CXR) should be performed immediately after placement (1). The widespread availability along with low radiation exposure and low costs, give CXR a decisive role in these settings to assess the position of the device, the response to therapy and the occurrence of any complications (2) (Fig. 1). Radiologists should be aware of the normal appearance of these devices and promptly recognize any abnormal findings.Open in a separate windowFigure 1A technically correct bedside chest X-ray performed in the intensive care unit. The exam allows to evaluate the position of inserted chest devices (chest tubes, black asterisks; endotracheal tube, white asterisk; pulmonary artery catheter, black arrowhead; nasogastric tube – proximal portion, white arrowhead) and to detect the presence of bilateral pleural effusions (white arrows) and the occurrence of soft tissue emphysema (black arrow). The patient underwent heart surgery and prosthetic valves, median sternotomy wires and external cardiac monitor wires are also present.This pictorial review illustrates the radiographic appearance of commonly used non-cardiological devices (

Correlation of 18F-FDG PET/CT uptake with severity of MRI findings and epidural steroid injection sites in patients with symptomatic degenerative disease of the lumbar spine: a retrospective study

PURPOSEWe aimed to retrospectively correlate ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) metabolic activity with lumbar spine magnetic resonance imaging (MRI) findings and epidural steroid injection sites in patients with symptomatic degenerative disease of the lumbar spine.METHODSA database search was conducted for patients receiving epidural injections <12 months after a positron emission tomography/computed tomography (PET/CT). Maximum standard uptake values (SUVmax) were measured at the facet joints, neural foramina, and spinal canal. Severity of facet arthrosis, disc degeneration, neuroforaminal, and canal stenosis was determined on MRI using previously described grading scales. Spearman rank coefficient assessed association between PET/CT FDG uptake and severity of MRI findings. The SUVmax was also compared with injection sites.RESULTSTwenty-five patients were included, comprising MRI (n=19) and injection (n=22 patients; 18 interlaminar, 8 transforaminal) groups. Injections were performed an average of 2.6 months after PET/CT. The greatest SUVmax occurred at the L5-S1 spinal canal (mean SUVmax = 2.25). A statistically significant, positive correlation between uptake and grade of spinal canal stenosis was seen only at L4-L5 (r=0.60, p = 0.007). No other significant association was found with spinal canal or neuroforaminal stenosis, or grade of facet joint or disc degeneration. All patients reported symptomatic improvement after injections with mean pain score improvement of 4.4 on a 10-point scale (SD, 2.9). There was moderate agreement between sites of epidural injection and highest SUVmax (κ= 0.591, p < 0.001).CONCLUSION¹⁸F-FDG metabolic activity on PET/CT corresponds with MRI findings about the lumbar spinal column, but there is no significant correlation between severity of MRI findings and radiotracer uptake. Given the moderate agreement between metabolic activity and levels of symptomatic spinal stenosis, further studies are warranted to fully evaluate the diagnostic potential of FDG PET/CT as a surrogate for guiding epidural injections.

¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is useful to detect osseous metastases; however, uptake within the musculoskeletal system is frequently incidentally observed related to non-malignant degenerative or inflammatory disease 1–4). Chronic low back pain is extremely common worldwide, with a prevalence of 19.6% among people 20–59 years of age. Image-guided epidural steroid injections can be targeted to address symptomatic focal spinal stenosis (5, 6).Previous studies have examined incidental FDG uptake in the musculoskeletal system in general (1, 7–9) and the spine in particular (10–13), although few have systematically evaluated non-neoplastic uptake as it pertains to patient symptoms. Incidental FDG metabolic activity in the spine is most frequently due to degenerative etiologies involving the intervertebral discs or facet joints (11) with the most common site of uptake at the thoracolumbar junction (10, 13). Despite this, to our knowledge, no study has correlated patterns of radiotracer uptake with MRI findings and patient symptoms.The purpose of our study was therefore to detect possible correlations between FDG metabolic activity and severity of lumbar spine MRI findings as well as epidural injection sites among symptomatic patients.     

Iatrogenic arterio-biliary fistula and peripheral hepatic artery pseudoaneurysm after transjugular liver biopsy: complication management using a microvascular plug

This study aimed to report on complication management in a 58-year-old woman referred for transjugular biopsy for the evaluation of unknown liver disease. After an initial uneventful biopsy procedure, the patient complained of severe upper abdominal pain. Laboratory tests revealed increasing liver enzymes. Imaging studies depicted an iatrogenic pseudoaneurysm associated with an arterio-biliary fistula originating from the right peripheral hepatic artery. Angiography and percutaneous transarterial superselective embolotherapy was performed by means of a microcatheter and microvascular plug. Precise device positioning allowed for successful closure of the bleeding site without compromising the hepatic vasculature.

Main points

• Pseudoaneurysms or arterio-biliary fistulae are rare complications after transjugular liver biopsy or transjugular intrahepatic portosystemic shunt.
• Microcatheter-directed embolotherapy using a microvascular plug allows for immediate and effective superselective occlusion of complex, small vasculature.
• Microvascular plug warrants precise and compact delivery straight to the point without sacrificing the parent vessel.

Transjugular liver biopsy (TJLB) is a safe, fast, and effective procedure for the sampling of liver tissue for a definitive histologic and virologic differentiation of a variety of liver diseases.¹ Especially, in the case of liver-associated bleeding disorders, TJLB reduces the procedure-associated bleeding risk because the biopsy specimen is acquired through the hepatic vein, resulting in drainage of any associated hemorrhage into the vessel lumen. In contrast to the percutaneous transabdominal route, there is no liver capsule passage.² Minimally invasive endovascular embolotherapy is an established treatment option for traumatic lesions of visceral arteries including pseudoaneurysms.³TechniqueA 58-year-old female patient (height: 159 cm and weight: 68 kg) with asymptomatic icterus was hospitalized for diagnostic workup of an unknown hepatopathy with elevated liver enzymes (initial gamma-glutamyltransferase, GGT, 312 U/L). At admission, her lab test verified increased GGT levels up to 543 U/L, while alanine aminotransferase (52 U/L) and aspartate aminotransferase (44 U/L) were only moderately elevated. Her total serum bilirubin level (1.0 mg/dL), coagulation parameters, and other routine laboratory parameters were within normal limits. Transient elastography (FibroScan^®) revealed liver tissue stiffness of 21.8 kPa, indicating an advanced stage of liver fibrosis. Magnetic resonance cholangiopancreatography demonstrated “beading” of the bile ducts inside the right liver lobe caused by alternating strictures and dilating up to 10 mm, while further diagnosis was inconsistent with primary sclerosing cholangitis. Liver-specific antibody testing including antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, antimitochondrial antibodies (AMA-M2), and hepatitis serology was negative, and there was no history of chronic inflammatory bowel disease. After interdisciplinary evaluation and patient’s written informed consent, TJLB was performed by a standard technique using an 18 G biopsy needle (Transjugular liver access and biopsy set LABS-100-J). Four liver tissue cylinders were circumferentially sampled along the central liver vein without periprocedural signs of potential complications.On the next day, the patient complained of increasing upper abdominal pain. The initial ultrasound examination was unremarkable. Due to persisting severe pain and increasing serum bilirubin levels up to 5.8 mg/dL on the second day, contrast-enhanced abdominal computed tomography (CT) was performed. A pseudoaneurysm originating from the right peripheral hepatic artery of segment VII measuring 12 × 7 mm in diameter adjacent to dilated bile ducts was depicted (Figure 1a, 1b). Increased density of the gallbladder indicated limited hemobilia, while there was no decrease in hemoglobin or clinical bleeding signs.Open in a separate windowFigure 1. a-c.3D reconstruction of a contrast-enhanced CT angiography in the arterial phase (a) demonstrates an intrahepatic pseudoaneurysm (arrow), originating from the superior branch of the right hepatic artery’s posterior sectoral branch, supplying liver segment VII with a diameter of 3 mm. Coronal reformation of a contrast-enhanced CT angiography (maximum intensity projection) showing the close proximity of the intrahepatic pseudoaneurysm to the parent hepatic artery branch of liver segment VII and the hepatic veins. (c), Selective digital subtraction angiography (DSA) confirms the intrahepatic pseudoaneurysm (arrow).Endovascular treatment was performed after multidisciplinary discussion and patient’s written informed consent. The institutional review board at the participating institution does not require approval for the type of research being performed, where a CE Mark- and FDA-cleared state-of-the-art medical product was used according to clinical indication during an emergency procedure.Transfemoral access was used to insert a flexible 5 F sheath into the celiac trunk. Selective catheterization of the right hepatic artery was performed by means of a 4 F Cobra catheter. Digital subtraction angiography confirmed the pseudoaneurysm, originating from a small side branch of the peripheral right hepatic artery of segment VII (Figure 1c).A 2.7 F microcatheter (Progreat^®) and, due to significant vessel elongation, another steerable 2.4 F microcatheter (SwiftNINJA^®) were used to gain access to the parent vessel. Superselective angiography additionally showed evidence of an arterio-biliary fistula (ABF), which was not identifiable on CT (Figure 2b, Online Supplementary Video 1).Open in a separate windowFigure 2. a-c.Photography (a) demonstrates the macrostructure of a microvascular plug (MVP-3Q^TM) consisting of a polytetrafluoroethylene (PTFE)-covered nitinol cage. Image by courtesy of the manufacturer modified by the author. Angiogram (b) after positioning and deployment a microvascular plug (MVP) into the arterio-biliary fistula (ABF) second to access using a steerable 2.4 F microcatheter (SwiftNINJA^®). Arrows indicate the MVP’s proximal and distal markers. Final DSA (c) shows occlusion of pseudoaneurysm and ABF with uncompromised perfusion of the parent hepatic artery branch after the release of MVP. Arrows indicate the MVP’s proximal and distal marker.In consideration of the impaired liver function, a combined occlusion of the fistula and pseudoaneurysm without compromising the biliary system and complete preservation of the parent arterial vessel was intended. For this purpose, a microvascular plug (MVP-3Q^TM; Medtronic, US-MN) was chosen (Figure 2a). A 2.7 F Progreat^®-microcatheter was positioned directly into the fistula to the adjacent biliary system. The MVP was advanced via the microcatheter in place. After positioning the MVP along the fistula using the proximal and distal plug markers, the microcatheter was gently pulled back to allow for partial expansion of the MVP. Another contrast injection was helpful in precisely identifying the fistula’s origin from the parent hepatic artery branch. Then, the microcatheter and MVP were gently pulled back with the proximal marker just to the fistula’s origin (Online Supplementary Video 2). Finally, the MVP was completely deployed by retracting the microcatheter and released from the delivery wire. The final angiogram confirmed the complete exclusion of the pseudoaneurysm and ABF with a patent parent hepatic branch vessel and uncompromised bile duct (Figure 2c, Online Supplementary Video 3).Abdominal pain was resolved and serum bilirubin levels were decreased to 2.0 mg/dL within 2 days. During a follow-up visit after 4 weeks, the patient revealed no complaints and showed no clinical or laboratory signs of intermittent or recurrent bleeding. Also, there was no indication of possible biliary complications, which are very important in the long term and should be considered during decision-making for the treatment of bleeding ABF in the acute phase.     

Iliorenal periscope graft to maintain blood flow to accessory renal artery

Parallel endografts such as “chimney” and “periscope” are being increasingly used to maintain blood flow to visceral and supra-aortic branches in patients with different aortic disorders. We present a new technique, “iliorenal periscope graft”, in a patient with abdominal aortic aneurysm undergoing endovascular aortic repair. In this case, left accessory renal artery flows were provided by an iliorenal periscope graft that extends from the left accessory renal artery to the right common iliac artery in a retrograde fashion.Fenestrated and branched endografts have been developed to extend proximal and/or distal landing zone in aortic diseases with short proximal and/or distal necks; however, the applicability of these devices are currently very limited (1, 2). Parallel endografts have been recently used for the same purpose (3). These grafts can also be used to maintain flow to the accessory renal arteries. We have successfully applied a new technique similar to periscope graft (PG), in which the PG is extended from the accessory renal artery (ARA) to the common iliac artery (CIA) and blood flow of the ARA is maintained by the iliorenal periscope graft (IRPG) in a retrograde fashion.     

Increased 99mTc MDP activity in the costovertebral and costotransverse joints on SPECT-CT: is it predictive of associated back pain or response to percutaneous treatment?

PURPOSE

Pain related to costovertebral and costotransverse joints is likely an underrecognized and potentially important cause of thoracic back pain. On combined single-photon emission computed tomography and computed tomography (SPECT-CT), increased technetium-99m methylene diphosphonate (99mTc MDP) activity at these articulations is not uncommon. We evaluated whether this activity corresponds with thoracic back pain and whether it predicts response to percutaneous injection.

METHODS

All 99mTc MDP SPECT-CT spine examinations completed at our institution from March 2008 to March 2014 were retrospectively reviewed to identify those with increased 99mTc MDP activity in the costovertebral or costotransverse joints. The presence of corresponding thoracic back pain, percutaneous injection performed at the relevant joint(s), and response to injection were recorded.

RESULTS

A total of 724 99mTc MDP SPECT-CT examinations were identified. Increased 99mTc MDP activity at costovertebral or costotransverse joints was reported in the examinations of 55 patients (8%). Of these, 25 (45%) had corresponding thoracic back pain, and nine of 25 patients (36%) underwent percutaneous injection of the joint(s) with increased activity. At clinical follow-up two days to 12 weeks after injection, one patient (11%) had complete pain relief, two (22%) had partial pain relief, and six (67%) had no pain relief.

CONCLUSION

The findings suggest that increased activity in costovertebral and costotransverse joints on 99mTc MDP SPECT-CT is only variably associated with the presence and location of thoracic back pain; it does not predict pain response to percutaneous injection.Back pain is a prevalent and costly medical problem in the United States that often presents a diagnostic and therapeutic challenge (1). In the thoracic spine, many potential pain generators exist, and the source of pain is frequently difficult to determine. Two of these potentially underrecognized pain generators are the costovertebral and costotransverse joints.Approximately 9% of technetium-99m methylene diphosphonate (^99mTc MDP) single-photon emission computed tomography (SPECT) combined with computed tomography (CT) studies ordered for an indication of back pain show increased ^99mTc MDP activity at costovertebral or costotransverse joints (2). The relationship of ^99mTc MDP activity to pain and the utility in directing percutaneous injection seems to vary at different sites throughout the axial skeleton (2). Therefore, it is important to evaluate each articulation independently. Several studies have evaluated the utility of ^99mTc MDP activity at facet joints (2–6), at sacroiliac joints (7), and in the pars interarticularis (8, 9), but the utility of this activity in the costovertebral and costotransverse joints needs further study. We evaluated whether increased ^99mTc MDP activity at the costovertebral and costotransverse joints corresponds with thoracic back pain and whether it predicts response to percutaneous injection.     

Female medical student impression of interventional radiology: what can we do to improve this?

PURPOSEThe number of female medical students has increased significantly in the last decade due to increased gender diversity. However, the number of female doctors going into interventional radiology (IR) does not reflect this trend on an international scale.METHODSA standardized set of questions was created looking into medical students’ demographics, awareness of IR, their general opinion, and whether they would consider IR as a potential career path. One-hundred female medical students from the United Kingdom, Germany, Poland, Spain, and New Zealand were approached either directly or via an online survey platform. The students ranged from first to final year study of Medicine and were between 18 and 30 years of age.RESULTSThe majority of medical students (68%) were unaware of what IR is and 98% denied having teaching about IR in their university. Influential factors to choosing IR were more exposure to IR in medical school (15%), more options to allow family life (15%), direct training pathway to IR rather than via diagnostic radiology (13%), options of private practice (13%), and understanding more about radiation protection during pregnancy (12%).CONCLUSIONA lack of awareness about what IR is and misconceptions, particularly regarding radiation exposure during pregnancy, play an important role in discouraging entry into IR. Additionally, some of the concerns raised were directed at IR training pathway. Female IR consultants should also take leadership initiative to act as role models. More lectures and direct clinical exposure are paramount to their understanding of IR.

Over the past decades, the number of female medical students has gradually increased equalizing the gender gap. The Royal College of Physicians suggest that more than 60% of new medical students in 2009 were female (1). This was increased by ten-fold in comparison to the late 20th century when medicine was a male dominated career (1). However, the number of female doctors going into interventional radiology (IR) training schemes or female IR consultants does not reflect this trend on an international scale. When compared with other specialties such as general surgery and vascular surgery, entrance of women into IR was substantially lower in proportion (2, 3). Even though female consultant radiologists make 35% of the IR workforce in the UK, it was estimated that only 10% of interventional radiology consultants were female (4, 5).Many factors have been perceived to contribute to this discrepancy. These include radiation exposure concerns (particularly those relating to pregnancy), the frequency of being on call, the lack of female role models, and an overwhelmingly male dominant culture in IR (3, 5). Methods to attract females into IR include early exposure to the specialty, preferably at the medical student stage to increase interest and address any misconceptions of the perceived work life imbalance and radiation exposure (5). The aim of our study was to evaluate and understand female medical students’ perception of the obstacles preventing them from entering this career path.     

Role of magnetic resonance spectroscopy in differential diagnosis of solitary pulmonary lesions

PURPOSEThe aim of our study was to evaluate the availability of magnetic resonance spectroscopy (MRS) for the differentiation of benign or malignant pulmonary nodules and masses.METHODSA total of 59 patients (45 male, 14 female) with pulmonary nodules and masses were included in this prospective study. MRS was applied to the pulmonary lesions of the patients and choline levels were determined. Afterwards CT-guided percutaneous needle biopsy was performed. According to the biopsy results, pulmonary lesions were benign in 25 patients and malignant in 34 patients.RESULTSCholine levels were significantly higher in malignant lesions compared with benign lesions (p < 0.001). When the other conditions were kept constant, the probability of malignancy significantly increased by 17.38-fold (95% CI, 3.78–79.93) in those with choline levels >1.65 μmol/g compared to those with choline levels ≤1.65 μmol/g (p < 0.001).CONCLUSIONMRS is a noninvasive method that can be used in the differential diagnosis of pulmonary nodules and masses.

The majority of the solitary pulmonary nodules have a benign character (1). However, all pulmonary nodules should be considered as malignant lesions unless proven otherwise (2). The differential diagnosis of these lesions may be an important problem in routine medical practice. Computed tomography (CT) is the standard method for the examination of the nodules and mass lesions (3). CT imaging of morphological features like size, margins, and calcification enables the investigation of malignancy (4). However, there is some overlap so that some malignant lesions may appear benign, while some benign nodules may show morphological features typical for malignancy (5). CT imaging for differantial diagnosis have problems like false-negative and false-positive results, over-diagnosis, benign nodule resections, and exposure to radiation (6). Biopsy is the most reliable and effective method for the diagnosis of the pulmonary nodules and mass lesions. However, it may cause serious complications such as pneumothorax, hemoptysis, air embolism, tumor cell seeding and death (7, 8). In addition, the tolerability of this invasive intervention is rather low among patients.Magnetic resonance imaging (MRI) provides information about the tumor morphology and magnetic resonance spectroscopy (MRS) provides biochemical information about the physiology and metabolism of the disease (9). MRS enables molecular analysis of the tissues based on the display of different chemical shifts of certain nuclei in the magnetic field (10). MRS was initially used in neuroradiology for characterization of tumor, stroke, epilepsy, infection, and neurodegenerative diseases. In recent years, it was also introduced in the evaluation of lesions in other organs like breast (11), liver (12), pancreas (13), and prostate (14). There are some in vitro studies in the literature on the use of MRS in lung cancer showing higher lactate and total choline peaks compared with normal tissues (15, 16). Also there is one case report in the literature regarding the feasibility of using MRS in lung cancer (17).The objective of this study was to demonstrate the value of MRS, which is a noninvasive method and does not require a contrast agent, in the differential diagnosis of pulmonary nodules and mass lesions.