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Prompt drainage and accurate targeting of pathogenic organisms are the keys to reducing mortality from these serious infections. The increasing use of image-guided diagnosis and therapy makes it easier to achieve this goal. [ABSTRACT FROM AUTHOR]

Genicular artery embolization (GAE) is an emerging, minimally invasive therapy to address the global burden of knee osteoarthritis (OA) and the unmet needs for medically refractory disease. Although total knee arthroplasty has been a standard intervention for severe cases, GAE is developing into a promising alternative, particularly for patients ineligible for or unwilling to undergo surgery. GAE targets the inflammatory cascade underlying OA pathophysiology by arresting neoangiogenesis and preventing pathological neoinnervation, offering potential pain relief. Although early studies have established safety and short-term effectiveness, ensuing studies are needed to validate long-term safety, durability, and comparative effectiveness and to optimize patient selection, embolic agent selection, and administration techniques. Standardized reporting guidelines are therefore essential to enhance transparency and reproducibility across clinical trials, facilitating data aggregation and comparison. This Society of Interventional Radiology (SIR)-endorsed reporting standards consensus document provides a framework to harmonize future research efforts and to improve the interpretation of outcomes., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

The model for end-stage liver disease (MELD) score is an established indicator of cirrhosis severity and a predictor of morbidity and mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation and for allocation in liver transplantation. Since the adoption of the score, its use has been expanded to multiple new indications requiring model modifications, including relevant clinical and demographic variables, to increase predictive accuracy. The purpose of this report is to provide an update on the modifications made to the MELD score, comparing their performance with C statistics, advantages and disadvantages, and impact on mortality at 3 months after placing a TIPS or awaiting liver transplantation., (Published by Elsevier Inc.)

The hepatic venous pressure gradient (HVPG) is currently considered the gold standard to assess portal hypertension (PH) in patients with cirrhosis. A meticulous technique is important to achieve accurate and reproducible results, and values obtained during measurement are applied in risk stratification of patients with PH, allocating treatment options, monitoring follow-up, and deciding management options in surgical patients. The use of portosystemic pressure gradients in patients undergoing placement of transjugular intrahepatic portosystemic shunts has been studied extensively and has great influence on decisions on shunt diameter. The purpose of this study was to describe the recommended technique to measure HVPG and portosystemic pressure gradient and to review the existing literature describing the importance of these hemodynamic measurements in clinical practice., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To create a nonsurgical animal model of osteoarthritis (OA) to evaluate the effects of embolotherapy during geniculate artery embolization (GAE)., Materials and Methods: Fluoroscopy-guided injections of 700 mg of sodium monoiodoacetate were performed into the left stifle in 6 rams. Kinematic data were collected before and after induction. At 10 weeks after induction, Subjects 1 and 4-6 underwent magnetic resonance (MR) imaging with dynamic contrast enhancement (DCE) and Subjects 1, 3, and 4-6 underwent angiography with angiographic scoring to identify regions with greatest disease severity for superselective embolization (75-250-μm microspheres). Target vessel size was measured. At 24 weeks after angiography, DCE-MR imaging, angiography, and euthanasia were performed, and bilateral stifles were harvested. Medial/lateral tibial and femoral condylar, patellar, and synovial samples were cut, preserved, decalcified, and scored using the Osteoarthritis Research Society International criteria. The stifle and synovium Whole-Organ Magnetic Resonance Imaging Score and Multicenter Osteoarthritis Study score were determined. The volume transfer constant (K trans ) and extracellular volume fraction (v e ) were calculated from DCE-MR imaging along the lateral synovial regions of interest., Results: The mean gross and microscopic pathological scores were elevated at 38 and 61, respectively. Mean synovitis score was elevated at 9.2. Mean pre-embolization and postembolization angiographic scores were 5 and 3.8, respectively. Mean superior, transverse, and inferior geniculate artery diameters were 3.1 mm ± 1.21, 2.0 mm ± 0.50, and 1.6 mm ± 0.41 mm, respectively. Mean pre-embolization and postembolization cartilage and synovitis scores were elevated at 35.13 and 73.3 and 5.5 and 9.2, respectively. The K trans /v e values of Subjects 4, 5, and 6 were elevated at 0.049/0.38, 0.074/0.53, and 0.065/0.51, respectively. Altered gait of the hind limb was observed in all subjects after induction, with reduced joint mobility. No skin necrosis or osteonecrosis was observed., Conclusions: A nonsurgical ovine animal knee OA model was created, which allowed the collection of angiographic, histopathological, MR imaging, and kinematic data to study the effects of GAE., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63-2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment. In-hospital mortality for patients with acute massive pulmonary embolism was not significantly different (OR of 1.24, p = 0.54) between those treated with and without venoarterial ECMO., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To compare the utility of low-dose versus standard cone-beam computed tomography (CT) angiography protocols in identifying nontarget embolization (NTE) during prostatic artery embolization (PAE)., Materials and Methods: A prospective, single-center, Phase-1 study (NCT02592473) was conducted for lower urinary tract symptoms in benign prostatic hyperplasia. Prostate volume, international prostate symptom score (IPSS), quality of life score (QoL), International Index of Erectile Function (IIEF), peak flow rate, UCLA Prostate Cancer Index (UCLA-PCI), and postvoid residual were recorded at baseline and 1, 3, 6, 12, and 24-months after PAE. Six-second (standard protocol, n = 29) or 5-second (low-dose protocol n = 45) rotations were made. Images were selected and matched in pairs by areas of NTE and compared by readers using a binomial generalized estimating equation model. Procedural outcomes were analyzed using a linear mixed model., Results: Seventy-four cone-beam CT angiographies were performed in 21 patients. IPSS and QoL scores significantly improved (P <.05). There was no change in UCLA-PCI or IIEF scores. Dose area product of the low- and standard-dose protocol were 37,340.82 mGy·cm 2 ± 104.66 and 62,645.66 mGy·cm 2 ± 12,711.48, respectively, representing a dose reduction of 40.4%. A total of 120 comparisons showed no preference between the 2 protocols (P =.24). Observers identified 76 and 69 instances of NTE in the standard- and low-dose protocols, respectively (P =.125)., Conclusions: Low-dose cone-beam CT angiography achieved equivalent clinical utility in identifying NTE during PAE, with the advantage of a lower radiation dose., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: Thoracic central venous obstruction is commonly associated with the use of central venous catheters. The Surfacer System to Facilitate Access in Venous Occlusions Study was an Food and Drug Administration-approved US Investigational Device Exemption study designed to evaluate the performance and safety of the Surfacer System when used to facilitate central venous access in patients with thoracic central venous obstruction., Methods: Thirty patients were enrolled in this prospective, multicenter, single-arm study between December 2017 and May 2019. Device performance and adverse events were collected peri-procedurally and at discharge. Enrollment included 15 female and 15 male subjects with a mean age of 55.5 ± 12.9 (range: 30-79) years. Twenty-eight patients (93.3%) required central venous access for hemodialysis access. Locations of thoracic central venous obstruction were graded from 1 to 4 based on severity and extension of venous occlusions. Seven patients (23.3%) had type 1, 6 (20.0%) type 2, 16 (53.3%) type 3, and 1 (3.3%) type 4 obstruction., Results: Successful central venous catheter placement was achieved in 27 of 30 patients (90.0%). The procedure was discontinued in three (10.0%) due to tortuous anatomy discovered intraprocedurally. All 27 patients with successful CVC placement achieved adequate catheter patency and tip positioning with a mean overall procedural time and time to achieve central venous access with the Surfacer System being 44.1 ± 30.6 and 19.1 ± 25.1 min, respectively. There were no device-related adverse events or catheter malposition., Conclusion: The results of the SAVEUS Study confirm the safety and efficacy of the Surfacer System and the Inside-Out procedure when used for the placement of right-sided central venous access in patients with thoracic central venous obstruction.

Purpose: To evaluate feasibility, procedural outcomes, and safety aspects of implantation of the alfapump system for management of refractory ascites by interventional radiology (IR) methods., Materials and Methods: The multicenter open-label prospective MOSAIC study included 29 patients (mean age 60.0 y ± 9.9; range, 32-72 y, 17 [56.7%] male) with cirrhotic refractory ascites who received an alfapump system implanted by IR. The fully subcutaneous alfapump system consists of a pump and 2 silicone catheters, whose distal ends are inserted in the peritoneum and the bladder, respectively. The device moves ascites from the peritoneum to the bladder, reducing the requirement of paracentesis. Pumped volume and speed can be customized as required. The implant procedure was performed under general or local anesthesia. Both catheters were placed under ultrasound guidance. The pump was inserted in a subcutaneous pocket on the upper abdomen. Incidence and severity of procedure-related serious adverse events up to 3 months after implantation were recorded., Results: Technical success was achieved in 29 (100%) IR implant procedures. The pump was usually implanted on the right abdomen (76.7%). In 5 patients, deviation from the Instructions for Use was required. Adverse events (requirement of additional incisions, postoperative bleed) occurred in 3 patients. At 3 months after implantation, 3 possibly procedure-related serious adverse events (ascites leakage, bacterial peritonitis, postoperative bleeding) had occurred. Two explantations (2/29; 6.8%) (cellulitis, pump pocket infection) and 4 reinterventions (pump or catheter replacement) were required, corresponding to an adverse event incidence rate of 9/29 (31.0%)., Conclusions: Placement of the alfapump using IR methods is both feasible and technically successful., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established., Methods: To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data., Results: 317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications., Conclusions: At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.

The automated low-flow ascites pump (alfapump) is an implantable device that drains ascites directly into the urinary bladder. We studied its safety (absence of serious complications) and efficacy (decreased large-volume paracentesis [LVP] requirement and improved quality of life [QoL]) in the management of ascites in a cohort of North American patients with cirrhosis and recurrent ascites ineligible for transjugular intrahepatic portosystemic shunt (TIPS). QoL was measured by the Chronic Liver Disease Questionnaire (CLDQ) and Ascites Questionnaire (Ascites Q). Following alfapump implantation, patients were monitored for ascites control, laboratory abnormalities, QoL, adverse events, and survival at 12 months. A total of 30 patients (60.0 ± 9.9 years; 57% male; Model for End-Stage Liver Disease score, 11.4 ± 2.7) received an alfapump, mostly by an interventional radiology approach (97%), followed by longterm prophylactic antibiotics. The alfapump removed a mean ascites volume of 230.6 ± 148.9 L/patient at 12 months, dramatically reducing the mean LVP frequency from 2.4 ± 1.4/patient/month before pump implantation to 0.2 ± 0.4/patient/month after pump implantation. All surviving patients had improved QoL (baseline versus 3 months; CLDQ, 3.9 ± 1.21 versus 5.0 ± 1.0; Ascites Q, 51.7 ± 21.9 versus 26.7 ± 18.6; P < 0.001 for both) and a better biochemical index of nutritional status (prealbumin 87.8 ± 37.5 versus 102.9 ± 45.3 mg/L at 3 months; P = 0.04). Bacterial infections (15 events in 13 patients), electrolyte abnormalities (11 events in 6 patients), and renal complications (11 events in 9 patients) were the most common severe adverse events. By 12 months, 4 patients died from complications of cirrhosis. Alfapump insertion may be a definitive treatment for refractory ascites in cirrhosis, especially in patients who are not TIPS candidates., (Copyright © 2020 The Authors. Liver Transplantation published by Wiley Periodicals, Inc., on behalf of American Association for the Study of Liver Diseases.)

Patients with pulmonary embolism who are in hemodynamically unstable condition present a special challenge to the interventionalist. When treating such patients, extracorporeal membranous oxygenation (ECMO) can help to stabilize these patients' condition; however, specific criteria for its use do not exist. Two patients are presented here to familiarize the reader with the use of ECMO and to demonstrate its utility for the interventional radiologist., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)