Kriegshauser, J. Scott

Tumors of the lung, including primary cancer and metastases, are notoriously common and difficult to treat. Although surgical resection of lung lesions is often indicated, many conditions disqualify patients from being surgical candidates. Percutaneous image-guided lung ablation is a relatively new set of techniques that offers a promising treatment option for a variety of lung tumors. Although there have been no clinical trials to definitively compare its efficacy to those of traditional treatments, lung ablation is widely practiced and generally accepted to be safe and effective. Especially encouraging results have recently emerged for cryoablation, one of the newer ablative techniques. This article reviews the indications, techniques, contraindications, and complications of percutaneous image-guided ablation of lung tumors with special attention to cryoablation and its recent developments in protocol optimization.

ObjectivesTo determine whether renal transplant diagnoses substantially change when 2 biopsy sites are chosen and whether contrast‐enhanced ultrasound (CEUS) has value for targeting the second site.MethodsWe prospectively enrolled 40 patients undergoing ultrasound‐guided renal transplant biopsy within 2 years of transplant: 20, surveillance; and 20, for cause. A CEUS examination was performed to identify cortical regions with subjectively altered flow. One biopsy was performed at the operator‐preferred (primary) site regardless of CEUS findings. Another biopsy was done at a second location, either targeted to an area in which CEUS perfusion findings differed from the primary site (targeted) or at a random location (secondary) if no other area differed. Specimens were randomly labeled A or B; pathologists were blinded to the CEUS result and biopsy location. Location‐specific CEUS assessments were recorded. Pathologic results were compared, including acute and chronic Banff scores and any new findings from the targeted or secondary biopsy.ResultsForty patients were enrolled between January 2016 and December 2018. No location‐specific pathologic differences correlated with differences in CEUS assessments. The second biopsy provided additional information that changed management in 4 of 40 patients (10.0% [95% confidence interval, 2.8%–23.7%]). Major bleeding complications occurred in 3 of 40 (7.5%) patients.ConclusionsContrast‐enhanced ultrasound targeting was not useful. Major bleeding complications were higher than expected, possibly due to the additional biopsy away from the operator‐preferred location. Obtaining a second renal transplant biopsy from a substantially different area than the initial operator‐preferred location provided additional clinically useful information in 10% of patients.

The clinical significance of valves within gonadal veins is controversial. In males, the absence of valves in the left testicular vein (compared to the right) has been cited as a potential mechanism for varicocele formation in the pampiniform plexus in the scrotum. In females, ovarian vein valve absence or incompetence may lead to pelvic congestion syndrome, a disputed explanation for pelvic, abdominal, and/or flank pain of unknown etiology. One study suggests that females have incompetent valves in dilated veins more frequently than males due to past pregnancies. Furthermore, inconsistencies exist in the reported incidence of gonadal vein valves, though pelvic insufficiency is more thoroughly documented and diagnosed in males than in females. This study assesses the presence, number, and location of gonadal vein valves in male and females. The right and left gonadal veins were evaluated in 13 embalmed cadavers (7 males, 6 females; mean age = 86.3 +/− 6.2 years). Twenty‐four veins were available for dissection; two veins were lost to dissection and therefore omitted. The veins were dissected from the ovary (females) or deep inguinal ring (males) to the point of drainage into the inferior vena cava (right gonadal vein) or left renal vein (left gonadal vein). The veins were incised along the entire length of this course, and the number and location of valves was noted and photographed. Anatomical variation and pathological dilation in the vasculature was also documented. A total of 8 valves were found among the 24 dissections. Valves were present in four of the six females (67%) compared to one out of seven males (14%). The valve in the male was located in the left gonadal vein; the bilateral distribution in females was more randomly patterned. The majority of the valves (87.5%) in females were located distally, adjacent to the ovary, while a single valve was located adjacent to the left renal vein confluence. No dilation was noted in any of the specimens. The male population in this study had a lower incidence of gonadal vein valves than in previous studies. However, the number of valves in female gonadal veins was considerably greater than in males. This finding has not been reported previously, perhaps due to the emphasis on male pelvic congestion as a risk for infertility versus attributing the condition in females to a psychosomatic etiology. The primary limitation of this research is the small sample size. Future work will explore the clinical implications of these preliminary findings in a patient population. Clinical correlation with patients who are suspected or known to suffer from pelvic congestion syndrome may shed further light on the role of gonadal vein valves in vein sufficiency and inform more effective treatment for this poorly understood condition in the female patient population.

Arteriovenous malformations (AVMs) are a subset of congenital vascular malformations (CVMs). They comprise abnormal connections between arterial and venous circulation; treatment approaches are dependent on the angioarchitecture of the AVM, specifically the number and arrangement of the feeder arteries and outflow veins. Various imaging modalities can be used to diagnose and plan treatment. Here we will review the use of transarterial approaches to treat AVMs.

Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.

We created, posted, and updated radiology department anticoagulation guidelines and identified various steps in the process, including triggering events, consensus building, legal analysis, education, and distribution of the guidelines to nurses and clinicians. Supporting data collected retrospectively, before and after implementation, included nursing satisfaction survey results and the number of procedure cancellations. After the guidelines were developed and posted, significantly fewer procedures were cancelled, nursing satisfaction was higher, and radiologists performed procedures with less variability. Anecdotally, radiologists had fewer queries about anticoagulation. The development and dissemination of radiologic procedure anticoagulation guidelines should be considered as a departmental quality improvement project.