Linch, Forrest B

Purpose The purpose of this study was to identify risk factors and evaluate clinical outcomes associated with incidental left common iliac vein compression on CT imaging. Methods This is a retrospective study that reviewed venous-phase abdomen and pelvis CT scans to identify patients with incidental extrinsic compression of the left common iliac vein due to an overlying right common iliac artery. A total of 726 patients were included (364 females, 362 males; mean patient age: 61.9 ± 15.9 years). Board-certified radiologists reviewed all CT scans. Significant left iliac vein compression was defined as >50% luminal narrowing. Results Significant iliac vein compression was identified in 114 (15.7%) patients and was more common in females (19.5%) versus males (11.9%) ( p < 0.01). Patients with iliac vein compression >50% had significantly lower BMI than those without compression (24.8 ± 6.2 vs 28.7 ± 7.2 kg/m 2 , p < 0.01). Patients with incidental left iliac vein compression had a higher rate of prior left lower extremity DVT ( p = 0.02). Conclusion Incidental left common iliac vein compression was present in approximately 16% of patients and was more frequent among females. Compression was associated with lower BMI and more than twice the rate of ipsilateral DVT, despite no prior diagnosis of MTS. These findings suggest that incidental iliac vein compression could have more clinical significance than previously recognized.

Abstract Background: Prostate artery embolization (PAE) requires a careful understanding of pelvic arterial anatomy and identifying prostatic artery variants. Pre-procedure CTA and intra-procedural cone beam CT are traditional means of planning and performing PAE, with the latter providing guidance for embolization. Photon counting detector (PCD) CT is a novel technology enabling ultra-high spatial resolution (UHR) whole-body imaging, with reconstructed slices as thin as 200 um. For PAE, we obtain a single UHR PCD CT acquisition, which provides both detailed pre-procedure pelvic arterial anatomy information and a registration reference for intra-procedural embolization guidance. Case Presentation: In five patients who underwent technically successful PAE via a left transradial approach, the pre-procedure diagnostic UHR PCD prostate CTA delineated bilateral prostatic artery origins and course in all cases, as confirmed with conventional angiograms. Further, registration of the UHR PCD CT for embolization guidance was successful in all cases, augmenting vessel selection. No complication occurred. Conclusion: UHR PCD CT is a novel acquisition option that is well suited to PAE due to its ability to delineate small vessels. Further, our experience has shown that a single pre-procedure scan can also be utilized for intra-procedural embolization guidance, obviating the need for a traditional cone beam CT angiogram. Further research is needed to assess reductions in radiation dose, contrast use, and intra-procedural time with these techniques.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a median survival of about 3 years. An ALS multidisciplinary team can provide primary palliative care and improve outcomes and quality of life for patients. Feeding tube insertion may be considered for patients with significant weight loss, or respiratory insufficiency. While radiologically inserted gastrostomy (RIG) tube placement may be an option, further studies are required to determine its best timing and appropriateness. This study’s objectives were to evaluate the feasibility and outcomes of RIG tube placement in ALS patients over a 90-day follow-up period through the assessment and primary palliative care provided by the multidisciplinary team. This retrospective study reviewed the placement of 16 or 18 French RIG-tube without intubation or endoscopy for 36 ALS patients at a single center between April 2019 and December 2021. Measures included ALS Functional Rating Scale-Revised (ALSFRS-R) scores to determine the ALS stage. Demographic, clinical, procedural, and follow-up data were reviewed. Results showed that the RIG tube placement had a low rate of minor adverse events (11%) and no major procedure-related adverse events. The mean ALSFRS-R score at the time of procedure in subjects who died within 90 days was lower than of those alive beyond 90 days ( P = .04). This study found that RIG-tube placement is a safe and effective way to manage dysphagia in ALS patients and highlights the importance of educating members of the multidisciplinary clinic in palliative care principles to determine the appropriateness of RIG tube placement.

AbstractBackgroundGastrostomy tubes placed radiologically, endoscopically or surgically facilitate long‐term home enteral nutrition (HEN). Patient‐specific clinical factors may affect placement techniques, confounding direct comparisons between radiologically inserted gastrostomy (RIG) and percutaneous endoscopic gastrostomy (PEG) outcomes. This study sought to evaluate the differences in clinical outcomes in patients undergoing gastrostomy tube placement by interventional radiologists or gastroenterologists.MethodsA single‐center prospective trial randomizing patients initiating HEN to RIG or PEG was conducted between March 2018 and June 2021. Patients were followed until the time of gastrostomy removal or until 9 months after tube placement. Tracked complications included peritonitis, abscess, bleeding, bowel perforation, and tube occlusion, malposition, or damage. Periprocedural pain rating and quality of life (QoL) surveys were collected.ResultsForty‐two patients were randomized to RIG or PEG. Twenty patients underwent RIG (mean age, 63.0 ± 11.7 years; 85% male; 95% with head and neck cancer) and 22 patients underwent PEG (mean age, 66.3 ± 10.9 years; 81.8% male; 90.9% with head and neck cancer). RIG and PEG groups had 4.18 ± 5.49 and 2.80 ± 5.82 complications per 1000 HEN days, respectively (P = 0.357). The most frequent complications were tube malposition and abscess formation for the RIG and PEG groups, respectively. No major complications occurred in either group. There was no difference in the average of pain ratings in all pain inventory components across both groups. Both groups reported improvement in overall QoL after gastrostomy tube placement (P = 0.532).ConclusionRIG is noninferior to PEG regarding complication rates, pain, and QoL when compared in a prospective randomized fashion.

Abstract Context Insulinoma is a pancreatic neuroendocrine tumor that causes hyperinsulinemic hypoglycemia. Symptomatic hypoglycemia related to hepatic insulinoma metastases may be addressed with liver-directed therapies such as hepatic artery embolization. Objective This work aimed to determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management. Methods An institutional review board–approved retrospective review was undertaken of all patients with a tissue (n = 18) or imaging (n = 2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland HAE at a single center between January 1, 1998 and November 1, 2020. Twenty patients (10 women, 10 men; mean age, 56 years; range, 18-84 years) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (eg, sweating, weakness, tremor), neuroglycopenic symptoms (eg, confusion, loss of consciousness), and/or documented serum glucose of less than 50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method. Results Before HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose of less than 50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 months; range, 0.1-190 months). Postprocedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients before discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 months; range, 0.2-60 months). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile postprocedure blood glucose levels requiring intensive care unit admission for intravenous dextrose. Otherwise, no major procedure-related complications occurred. Conclusion Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.