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BACKGROUND: Transbronchial microwave ablation (MWA) is a promising novel therapy. Despite advances in bronchoscopy and virtual navigation, real time image guidance of probe delivery is lacking, and distal maneuverability is limited. Cone-beam computed tomography (CBCT) based augmented fluoroscopy guidance using steerable sheaths may help overcome these shortcomings. The aim of this study was to evaluate feasibility and accuracy of augmented fluoroscopy guided transbronchial MWA with a steerable sheath and without a bronchoscope. METHODS: In this prospective study, procedures were performed under general anesthesia. Extra-bronchial lung synthetic targets were placed percutaneously. Target and airways extracted from CBCT, with planned bronchial parking point close to the target were overlaid on live fluoroscopy. Endobronchial navigation was solely performed under augmented fluoroscopy guidance. A 6.5 Fr steerable sheath was parked in the bronchus per plan, and a flexible MWA probe was inserted coaxially then advanced through the bronchus wall towards the target. Final in-target position was confirmed by CBCT. Only one ablation of 100 W-5 min was performed per target. Animals were euthanized and pathology analysis of the lungs was performed. RESULTS: Eighteen targets with a median largest diameter of 9 mm (interquartile range, 7–11 mm) were ablated in 9 pigs. Median needle-target center distance was 2 mm (interquartile range, 0–4 mm), and was higher for lower/middle than for upper lobes [0 mm (interquartile range, 0–4 mm) vs. 4 mm (interquartile range, 3–8 mm), P=0.04]. No severe complications or pneumothorax occurred. Two cases of rib fractures in the ablation zone resolved after medical treatment. Median longest axis of the ablation zone on post-ablation computed tomography was 38 mm (interquartile range, 30–40 mm). Histology showed coagulation necrosis of ablated tissue. CONCLUSIONS: Transbronchial MWA under augmented fluoroscopy guidance using a steerable sheath is feasible and accurate.

Transarterial chemoembolization (TACE) is a therapeutic procedure often performed for hepatocellular carcinoma (HCC). Local complications, though generally uncommon, can arise from arterial ischemia and local cytotoxicity from the chemotherapeutic delivery. We present a case of acute pancreatitis as a rare complication of the TACE procedure along with a review of literature of this uncommon adverse effect.

We present the case of a 56-year-old double lung transplant recipient with chest pain who underwent an attempted endovascular retrieval of what was described as a retained guide wire in the azygos vein. After successfully grasping the tip, the object further migrated to the right pulmonary artery complicating the retrieval. It was realized that the “wire” was extravasated methyl methacrylate from a recent percutaneous kyphoplasty. This is believed to be the first report of attempted endovascular retrieval of extravasated methyl methacrylate in the azygos system. We include the details of this case and briefly review the current literature on the management of extravasated methyl methacrylate from vertebral augmentation procedures. Extravasated methyl methacrylate in the venous system is a common finding after vertebral augmentation procedures and any radiopaque stripe arising from a cemented vertebral body should be first described as probable cement leakage.

Interventional radiologic techniques have become a mainstay in the management of trauma ranging from hemorrhage control (i.e., endovascular balloon occlusion, stenting, and embolization) to the management of complications (i.e., drainage of abscesses and placement of inferior vena caval filters). This chapter will provide a broad overview of the diagnostic assessment, equipment, techniques, and their specific applications in the care of the injured patient as it relates to solid organ injury, pelvic bleeding, and resuscitation assisted by aortic balloon occlusion. Endovascular techniques specifically applicable for great vessel injury will be covered elsewhere in this handbook.