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Background: Abdominal sarcomas are a heterogeneous group of rare soft tissue tumors and can be localized intraperitoneally or retroperitoneally. A pretherapeutic differentiated subtyping is essential for planning an individual, multimodal treatment concept in an interdisciplinary team of experts., Objective: The central aspects of histology acquisition, imaging diagnostics and (molecular) pathological subtyping of abdominal soft tissue sarcomas are described in detail., Material and Methods: Imaging and pathological diagnostics are depicted based on the German S3 guidelines on adult soft tissue sarcomas, a current literature search and personal experiences at the Sarcoma Center at the National Center for Tumor Diseases in Dresden (NCT/UCC)., Results: Preoperative imaging and (molecular) pathological subtyping of abdominal soft tissue sarcomas place high demands on surgeons, radiologists and pathologists. Genome analyses of sarcomas have the potential to identify points of attack for individualized treatment options. The limitations of resectability can only be assessed by experienced sarcoma surgeons at specialized centers., Conclusion: The treatment of abdominal soft tissue sarcomas at an experienced center is associated with a better prognosis. Even at the first suspicion of an abdominal sarcoma, a referral to an experienced center should be made in order to guarantee optimal expertise in diagnostics and treatment., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: Postpancreatectomy hemorrhage (PPH) is one of the leading causes of mortality after pancreatic resection. Late onset PPH is most often treated using a transarterial approach. The aim of this study was to analyze risk factors for in-hospital mortality after endovascular treatment., Methods: Between 2012 and 2017, patients who were treated endovascular due to PPH were identified from a retrospective analysis of a database. Risk factors for mortality were identified by univariate analysis., Results: In total, 52 of the 622 patients (8.4%) underwent endovascular treatment due to PPH. The primary technical success achieved was 90.4%. In 59.6% of patients, bleeding control was achieved by placing a stent graft and in 40.4% by coil embolization. The primary 30-day and 1-year patency of the placed covered stents was 89.3% and 71.4%, respectively. The 60-day mortality was 34.6%. The reintervention rate was higher after stent graft placement compared to coiling (39.3% vs. 21.1%, P = 0.012). In the univariate analysis the need for reintervention was associated with a higher in-hospital mortality (21.2% vs. 7.7%, P = 0.049). The use of an antiplatelet agent was associated with a decreased in-hospital mortality in the univariate (11.5% vs. 25%, P = 0.024) and multivariate analysis (HR 3.1, 95% CI 1.1-9, P = 0.034), but did not increase the risk of rebleeding., Conclusion: Endovascular management of delayed PPH has a high technical success rate. Stent graft placement showed a higher reintervention rate. The need for reintervention was associated with a higher in-hospital mortality but did not differ between coiling and stent graft placement.

Purpose: To investigate the outcome of local intra-arterial papaverine infusion therapy in patients with non-occlusive mesenteric ischemia (NOMI), and factors influencing survival, in comparison with a conservative approach., Methods: From 2013 to 2019, patients with NOMI confirmed by imaging were included in a retrospective two-center study. According to different in-house standard procedures, patients were treated in each center either conservatively or interventionally by a standardized local infusion of intra-arterial papaverine into the splanchnic arteries. Thirty-day mortality and factors influencing the outcome, such as different demographics and laboratories, were compared between groups using Kaplan-Meier survival analysis and Cox regression, respectively., Results: A total of 66 patients with NOMI were included, with n = 35 treated interventionally (21 males, mean age 67.7 ± 12.3 years) and n = 31 treated conservatively (18 females, mean age 71.6 ± 9.6 years). There was a significant difference in 30-day mortality between the interventional (65.7%; 12/35 survived) and the conservative group (96.8%; 1/31 survived) (hazard ratio 2.44; P = 0.005). Thresholds associated with a worse outcome of interventional therapy are > 7.68 mmol/l for lactate, < 7.31 for pH and <  - 4.55 for base excess., Conclusion: Local intra-arterial papaverine infusion therapy in patients with NOMI significantly increases survival rate in comparison with conservative treatment. High lactate levels, low pH and high base excess, and high demand for catecholamines are associated with a poor outcome., Level of Evidence: Level III.

Background: Evidence from multiple studies have shown the potential of thermal ablative therapies to induce regression of metastases and tumors which are distant from the treated metastases-within the same organ or even in other organs-the so-called abscopal effect. Unfortunately, this effect is most often weak and not always reproducible. Recent developments in systemic therapies showed that immunomodulating drugs are of major interest in patient-tailored tumor therapy due to the fact that they are able to enhance the treatment effect of conventional chemotherapy. Furthermore, several studies and reports showed that these immunomodulating therapies are also able to enhance the response of the immune system to the tumor-if combined with local ablative therapies-and trigger a systemic antitumor response. Unfortunately, there is also evidence that effects caused by thermal ablation can hamper the immune system and, therefore, increase tumor growth and tumor spread., Objectives: In this article, the effects of thermal ablation in general are described, different (thermo-)ablative techniques are presented and a perspective of combination therapies is given.

Clinical Issue: Percutaneous transhepatic biliary and gall bladder interventions play an important role in the diagnosis and therapy of biliary tract diseases., Performance: With technical success rates up to 99% as well as complications rates up to a maximum of 26% they showed good results. Indications were opacification of the biliary tree as well as treatment of biliary system pathologies, such as drainage and stents., Achievements: Interventions were used if endoscopic approaches are not possible or exploited. We describe the current state of knowledge and the range for percutaneous biliary/gall bladder interventions and give an overview of technical approaches for fundamental interventional procedures, including percutaneous transhepatic biliary drainage., Practical Recommendations: Percutaneous transhepatic biliary and gall bladder interventions are safe and effective treatments for benign and malignant stenosis, postoperative complications and risk patients with cholecystitis.

Purpose: To investigate clinical feasibility, technical success and toxicity of 166 Ho-radioembolization ( 166 Ho-RE) as new approach for treatment of hepatocellular carcinomas (HCC) and to assess postinterventional calculation of exact dosimetry through quantitative analysis of MR images., Materials and Methods: From March 2017 to April 2018, nine patients suffering from HCC were treated with 166 Ho-RE. To calculate mean doses on healthy liver/tumor tissue, MR was performed within the first day after treatment. For evaluation of hepatotoxicity and to rule out radioembolization-induced liver disease (REILD), the Model for End-Stage Liver Disease (MELD) Score, the Common Terminology Criteria for Adverse Events and specific laboratory parameters were used 1-day pre- and posttreatment and after 60 days. After 6 months, MR/CT follow-up was performed., Results: In five patients the right liver lobe, in one patient the left liver lobe and in three patients both liver lobes were treated. Median administered activity was 3.7 GBq (range 1.7-5.9 GBq). Median dose on healthy liver tissue was 41 Gy (21-55 Gy) and on tumor tissue 112 Gy (61-172 Gy). Four patients suffered from mild postradioembolization syndrome. No significant differences in median MELD-Score were observed pre-, posttherapeutic and 60 days after 166 Ho-RE. No deterioration of liver function and no indicators of REILD were observed. One patient showed a complete response, four a partial response, three a stable disease and one a progressive disease at the 6 months follow-up., Conclusion: 166 Ho-RE seems to be a feasible and safe treatment option with no significant hepatotoxicity for treatment of HCC.

Introduction: Surgical creation of a radiocephalic fistula is the gold standard of vascular access for hemodialysis. Recently, an endovascular approach for upper arm fistula creation (endoAVF) has been developed, which may be an alternative to open surgery. We describe a case series of eight cases showing feasibility, early complications and outcome of this novel treatment option., Materials and Methods: Between July 2015 and February 2016, we created an endoAVF in eight patients. Indications for endoAVF were confirmed by a multidisciplinary vascular board upon the exclusion for Cimino fistula candidates. Patients were suitable for the procedure after a pre-therapeutic ultrasound showed adequate brachial and ulnar vessels and no ipsilateral central venous stenosis. Patient characteristics, technical success, total patient radiation dose, complication rates, time to maturation of endoAVF and clinical effectiveness at six months were assessed retrospectively., Results: Creation of endoAVF using the everlinQ endoAVF system (TVA Medical Inc., Austin, TX, USA) was successful in all eight cases. There were one minor intraprocedural complication and no postoperative complications. Median time to endoAVF maturation was 63 days (range 26-137 days). One patient was lost to follow-up after the first monitoring visit. In the remaining seven patients, hemodialysis was started without problems. Patency after 6 months was 100%., Discussion: The endoAVF demonstrated to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Further studies with more patients and longer follow-up periods are needed to assess long-term outcomes and comparability to surgical dialysis access creation.

Interventional radiology provides a wide variety of vascular, nonvascular, musculoskeletal, and oncologic minimally invasive techniques aimed at therapy or palliation of a broad spectrum of pathologic conditions. Outcome data for these techniques are globally evaluated by hospitals, insurance companies, and government agencies targeting in a high-quality health care policy, including reimbursement strategies. To analyze effectively the outcome of a technique, accurate reporting of complications is necessary. Throughout the literature, numerous classification systems for complications grading and classification have been reported. Until now, there has been no method for uniform reporting of complications both in terms of definition and grading. The purpose of this CIRSE guideline is to provide a classification system of complications based on combining outcome and severity of sequelae. The ultimate challenge will be the adoption of this system by practitioners in different countries and health economies within the European Union and beyond.

Liver metastases are the most common cause of death in colorectal cancer patients. Nowadays, complete resection is considered to be the only curative treatment but only approximately 25% of patients are suitable candidates for surgery; therefore, many different interventional oncology techniques have been developed in recent years for the treatment of secondary liver metastases. The aim of interventional oncological procedures is either to provide a potentially curative treatment option for locally limited metastases with local ablative techniques, to enable nonresectable tumors to become accessible to surgical or local ablative techniques using transarterial procedures or to achieve improved survival in a palliative setting. These interventional therapies include transarterial approaches, such as chemoembolization and radioembolization as well as a multitude of different ablative techniques, such as radiofrequency and microwave ablation as well as irreversible electroporation (IRE). This article describes the indications for the various procedures and the clinical results of each of these techniques are reviewed based on the currently available literature.

Purpose: To evaluate technical success, complications, and effective dose in patients undergoing CT fluoroscopy-guided iliosacral screw placement for the fixation of unstable posterior pelvic ring injuries., Materials and Methods: Our retrospective analysis includes all consecutive patients with vertical sacral fractures and/or injury of the iliosacral joint treated with CT fluoroscopy-guided screw placement in our department from 11/2005 to 03/2013. Interventions were carried out under general anesthesia and CT fluoroscopy (10-20 mAs; 120 kV; 16- or 128-row scanner, Siemens Healthcare, Erlangen, Germany). Technical outcome, major and minor complications, and effective patient dose were analyzed., Results: We treated 99 consecutive patients (mean age 53.1 ± 21.7 years, 50 male, 49 female) with posterior pelvic ring instability with CT fluoroscopy-guided screw placement. Intervention was technically successful in all patients (n = 99). No major and one minor local complication occurred (1 %, secondary screw dislocation). General complications included three cases of death (3 %) due to pulmonary embolism (n = 1), hemorrhagic shock (n = 1), or cardiac event (n = 1) during a follow-up period of 30 days. General complications were not related to the intervention. Mean effective patient radiation dose per intervention was 12.28 mSv ± 7.25 mSv. Mean procedural time was 72.1 ± 37.4 min., Conclusions: CT fluoroscopy-guided screw placement for the treatment of posterior pelvic ring instabilities can be performed with high technical success and a low complication rate. This method provides excellent intrainterventional visualization of iliac and sacral bones, as well as the sacral neuroforamina for precise screw placement by applying an acceptable effective patient dose.

Hepatocellular carcinoma (HCC) is one of the most frequent malignancies worldwide. Besides liver transplantation, which is only feasible in few patients and surgical resection, the scope of potential treatment options has considerably expanded in recent years. Thermoablative therapies are now well established in early HCC due to the low rate of complications and short hospital stay. The disadvantage of higher relapse rates compared to surgical resection will be further diminished through technical advances regarding radiofrequency ablation and microwave ablation, as well as growing experience of users and thorough multidisciplinary selection of potential candidates for thermoablative therapy.

Background: For patients with non-resectable liver metastases a response to chemotherapy is necessary in order to be able to achieve resection. Studies have shown that the response rate during neoadjuvant conversion chemotherapy is closely correlated with the frequency of resection of metastases., Methods: Assessment of the response in clinical studies is based on the RECIST criteria. These criteria are supplemented by questions on the prognosis, tumor symptoms and toxicity for decisions on therapy. For assessment of resectability, the functional residual liver tissue and prognostic factors are important., Results and Discussion: Regular imaging controls are necessary for guiding therapy in order to avoid a continuation of chemotherapy in cases of tumor progression. Chemotherapy is normally terminated when resectability has been achieved in order to avoid additional (liver) toxicity. Morphological criteria for response to therapy (e.g. mRECIST) can be more sensitive for assessing the effects of individual therapeutic procedures but are not established for guiding systemic therapy or for comparison with other therapeutic procedures.

Unlabelled: CLINICAL ISSUE OF THORACIC ANEURYSMS: Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice., Standard Radiological Methods: CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging. THRESHOLD FOR TREATMENT: In the ascending aorta a diameter larger than 5-5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment. THORACIC ENDOVASCULAR AORTIC REPAIR: The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years., Practical Recommendations: Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.

Objective: To assess the technical results of CT fluoroscopy-guided, radiofrequency-induced vertebral augmentation (StabiliT®) in terms of vertebral height restoration and polymethylmethacrylate (PMMA) leakages, occurring in 25 individual patients with vertebral compression fractures and osteolysis., Materials and Methods: From 07/2010 to 08/2011, 25 patients (16 women, nine men; age 71 ± 14; range 41-89) with painful vertebral compression fractures due to osteoporosis (n = 19), metastases (n = 2) or multiple myeloma (n = 4) underwent vertebral augmentation with a radiofrequency-activated, high-viscosity polymethylmethacrylate (PMMA) bone cement (StabiliT® Vertebral Augmentation system; DFINE Europe GmbH, Mannheim) under local anesthesia. Thirty-four vertebrae (Th5-L5) were treated in 27 sessions under CT fluoroscopy guidance (128-row CT, Somatom Definition AS, Siemens, Erlangen) using a unilateral access and a cavity-creating osteotome prior to remote-controlled, hydraulically driven cement injection. 1/2/3 levels were treated in 21/5/1 session(s). Vertebral height change in the midsagittal plane (anterior, midvertebral, posterior endplate distance) and PMMA leaks were retrospectively evaluated using the postinterventional CT., Results: All patients were successfully treated in the first session. Mean (MV ± SD) procedure time and amount of injected PMMA were 56 ± 14 min and 4.5 ± 1.4 ml, respectively. Mean anterior/midvertebral/posterior height gain was +7.1/+9.7/+0.4%. Small local vertebral leaks were observed in 18/34 vertebrae (53%) without any clinical sequelae. No major complications occurred., Conclusions: CT fluoroscopy-guided, RF-induced vertebral augmentation with a high-viscosity bone cement (StabiliT®) was safe and technically successful in all patients. Using a hydraulic cement injection technique, a moderate restoration of anterior and midvertebral height was seen while the system was not markedly superior to standard vertebroplasty regarding the frequency of minor asymptomatic PMMA leaks.

Objective: To retrospectively evaluate the incidence and clinical impact of local polymethylmethacrylate (PMMA) leaks and pulmonary cement embolisms occurring under CT fluoroscopy-guided vertebroplasty of symptomatic malignant vertebral osteolyses., Materials and Methods: From December 2001 to June 2009, 202 cancer patients (116 women, 86 men; age 63.2±8.6 years) with painful malignant vertebral osteolyses underwent vertebroplasty, with or without vertebral compression fracture. A total of 331 vertebrae were treated in 231 sessions under CT fluoroscopy guidance (120 kV; 10–25 mA; single slice, 4-, 16-, and 128-row CT). In the pre-vertebroplasty CT, the following items were assessed: osteolytic destruction (0, ≤25, ≤50, ≤75, or ≤100%) of vertebral cross-sectional area, posterior wall, and circumference; presence of perivertebral and degree of epidural (no, mild, moderate) soft tissue involvement. Local PMMA leaks were analyzed using the post-vertebroplasty CT. Pulmonary cement embolisms were evaluated in all patients having undergone radiography (CR; n053) or CT (n088) of the chest after vertebroplasty due to their underlying disease. Patient charts were reviewed regarding adverse events., Results: Of 331 treated vertebrae, 32, 20.2, and 15.7% showed more than 50% osteolytic involvement of the vertebral cross-sectional area, posterior wall, and circumference, respectively. Mild or moderate epidural involvement was seen in 13.0 and 8.4%. Local PMMA leakage rate was 58.6% (194 of 331 vertebrae). Pulmonary cement embolisms (segmental, n010; central, n01) were seen after 7.8% of the procedures with follow-up imaging of the chest. No major complications occurred within a 30-day period after vertebroplasty., Conclusion: Vertebroplasty of spinal malignancy can be safely performed under CT fluoroscopy guidance even in patients with substantial osteolytic involvement. In our patient collective, PMMA leaks and pulmonary cement embolisms visualized in post-procedural radiography and CT images had no clinical impact.

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.

Purpose: To evaluate safety, efficacy, and symptom-control of radioembolization in patients with unresectable liver metastases from neuroendocrine tumors (NETLMs)., Materials and Methods: Forty-two patients (mean age of 62 years) with treatment-refractory NETLMs underwent radioembolization using yttrium-90 ((90)Y) resin microspheres. Posttreatment tumor response was assessed by cross-sectional imaging using the Response Evaluation Criteria in Solid Tumors (RECIST) and tumor-marker levels. Laboratory and clinical toxicities and clinical symptoms were monitored., Results: The median activity delivered was 1.63 GBq (range 0.63-2.36). Imaging follow-up using RECIST at 3-month follow-up demonstrated partial response, stable disease, and progressive disease in 22.5, 75.0, and 2.5% of patients, respectively. In 97.5% of patients, the liver lesions appeared hypovascular or partially necrotic. The mean follow-up was 16.2 months with 40 patients (95.2%) remaining alive. The median decrease in tumor-marker levels at 3 months was 54.8% (chromogranin A) and 37.3% (serotonin), respectively. There were no acute or delayed toxicities greater than grade 2 according to Common Terminology Criteria for Adverse Events [CTCAE (v3.0)]. No radiation-induced liver disease was noted. Improvement of clinical symptoms 3 months after treatment was observed in 36 of 38 symptomatic patients., Conclusion: Radioembolization with (90)Y-microspheres is a safe and effective treatment option in patients with otherwise treatment-refractory NETLMs. Antitumoral effect is supported by good local tumor control, decreased tumor-marker levels, and improved clinical symptoms. Further investigation is warranted to define the role of radioembolization in the treatment paradigm for NETLMs.

Introduction: In unresectable intrahepatic cholangiocarcinoma (ICC), systemic chemotherapy often is viewed as the only option, although efficacy is limited. Radioembolization (RE) using yttrium-90 ((90)Y) microspheres is an accepted therapy for patients with hepatocellular-carcinoma or metastatic liver tumors. However, there are limited data on the value of RE in patients with ICC and few data on factors influencing prognosis. The purpose of our retrospective analysis was to establish which factors influenced time-to-progression (TTP) and overall survival (OS)., Methods: Patients with unresectable ICC were treated with (90)Y resin-microspheres and assessed at 3-monthly intervals. Radiologic response was evaluated by using Response Criteria in Solid Tumors (RECIST). Baseline characteristics, biochemical/clinical toxicities, and response were examined for impact on TTP and OS., Results: Thirty-four treatments were administered to 33 patients without major complications. By RECIST, 12 patients had a partial response, 17 had stable disease, and 5 had progressive disease after 3 months. The median OS was 22 months posttreatment and 43.7 months postdiagnosis. Median TTP was 9.8 months. Survival and TTP were significantly prolonged in patients with ECOG 0 (vs. ECOG 1 or 2; median OS: 29.4, 10, and 5.1 months; TTP: 17.5, 6.9, and 2.4 months), tumor burden ≤25% (OS: 26.7 vs. 6 months; TTP: 17.5 vs. 2.3 months), or tumor response (PR or SD vs. PD; OS: 35.5, 17.7 vs. 5.7 months; TTP: 31.9, 9.8 vs. 2.5 months), respectively (P < 0.001)., Conclusions: Radioembolization is an effective and safe option for patients with unresectable ICC. Predictors for prolonged survival are performance status, tumor burden, and RECIST response.

Purpose: In clinical trials with yttrium-90-resin-microspheres for the management of colorectal cancer liver metastases, it was observed that radioembolization might result in splenomegaly and an increase in portal vein size. Subclinical hepatitis in normal liver tissue as well as the effects of radioembolization and prior chemotherapy are suspected to be responsible for this phenomenon. The purpose of this study was to quantify the changes in liver and spleen volume and portal vein diameter after radioembolization., Methods: Twenty-seven patients with liver-dominant metastatic disease from breast cancer who had not responded to chemotherapy or had to abandon chemotherapy because of its toxic effects were evaluated. Changes in liver and spleen volume and portal vein diameter as well as liver tumor volume and diameter were quantified using computed tomography scans., Results: Radioembolization was associated with a significant mean decrease in the whole liver volume of 10.2% (median 16.7%; P = 0.0024), mainly caused by a reduction in the right lobe volume (mean 16.0%; P < 0.0001). These changes were accompanied by a significant increase in the diameter of the main portal vein (mean 6.8%; P < 0.0001) as well as splenic volume (mean 50.4%; P < 0.0001). Liver-tumor volume and diameter decreased by a median of 24 and 39.7%., Conclusions: Radioembolization is an effective treatment for tumor size reduction in patients with breast cancer liver metastases. Treatment is associated with changes of hepatic parenchymal volume, splenic volume, and portal vein size that appear not to represent clinically important sequelae in this patient cohort.

The purpose of this study was to determine whether rotational C-arm computed tomography (CT) allows visualization of liver metastases and adds relevant information for radioembolization (RE) treatment planning. Technetium angiography, together with C-arm CT, was performed in 47 patients to determine the feasibility for RE. C-arm CT images were compared with positron emission tomography (PET)/CT images for the detection of liver tumors. The images were also rated according one of the following three categories: (1) images that provide no additional information compared with DSA alone; (2) images that do provide additional information compared with DSA; and (2) images that had an impact on eligibility determination for and planning of the RE procedure. In all patients, 283 FDG-positive liver lesions were detected by PET. In venous contrast-phase CT, 221 (78.1%) and 15 (5.3%) of these lesions were either hypodense or hyperdense, respectively. In C-arm CT, 103 (36.4%) liver lesions were not detectable because they were outside of either the field of view or the contrast-enhanced liver segment. Another 25 (8.8%) and 98 (34.6%) of the liver lesions were either hyperdense or presented primarily as hypodense lesions with a rim enhancement, respectively. With PET/CT as the standard of reference, venous CT and C-arm CT failed to detect 47 (16.6%) and 57 (20.1%) of all liver lesions, respectively. For RE planning, C-arm CT provided no further information, provide some additional information, or had an impact on the procedure in 20 (42.5%), 15 (31.9%) and 12 (25.6%) of patients, respectively. We conclude that C-arm CT may add decisive information in patients scheduled for RE.

We present a case of combined surgical screw placement and osteoplasty guided by computed tomography-fluoroscopy (CTF) in a 68-year-old man with unilateral osteolytic destruction and a pathological fracture of the iliosacral joint due to a metastasis from renal cell carcinoma. The patient experienced intractable lower back pain that was refractory to analgesia. After transarterial particle and coil embolization of the tumor-feeding vessels in the angiography unit, the procedure was performed under general anesthesia by an interdisciplinary team of interventional radiologists and trauma surgeons. Under intermittent single-shot CTF, two K wires were inserted into the left iliosacral joint from a lateral transiliac approach at the S1 level followed by two self-tapping surgical screws. Continuous CTF was used for monitoring of the subsequent polymethylmethacrylate injection through two vertebroplasty cannulas for further stabilization of the screw threads within the osteolytic sacral ala. Both the screw placement and cement injection were successful, with no complications occurring during or after the procedure. With additional nonsteroidal anti-inflammatory and opioid medication, the patient reported a marked decrease in his lower back pain and was able to move independently again at the 3-month follow-up assessment. In our patient with intolerable back pain due to tumor destruction and consequent pathological fracture of the iliosacral joint, CTF-guided iliosacral screw placement combined with osteoplasty was successful with respect to joint stabilization and a reduction in the need for analgesic therapy.

In patients with acute thrombo-embolic occlusion of the superior mesenteric artery, catheter-assisted thrombolytic therapy represents a procedure of increasing importance in addition to surgery and intensive care treatment. The thrombolytic drugs utilized for this purpose are urokinase, streptokinase and recombinant tissue plasminogen activator (rtPA).Therapeutic embolization is predominantly used in the treatment of arterial bleeding from the gastro-intestinal tract, the liver, the intestines (due to an aneurysm or vascular malformation) and in bleeding from intestinal anastomoses. Polyvinyl alcohol particles, embospheres, gelfoam and microcoils can be utilized as embolic agents. Percutaneous transhepatic cholangiodrainage and stent implantation are applied in patients with biliary obstructions caused by inoperable tumors of the gall bladder or bile ducts, of the pancreatic head or duodenum and by metastases located in the liver parenchyma or hepatic hilum.Image-guided percutaneous drainage is a valuable option in the management of abscesses in the peritoneal cavity; less common indications are lymphoceles, biliomas, urinomas, hematomas, necrosis and pseudocysts.

The purpose of this study was to evaluate technical success, technique effectiveness, and survival following radiofrequency ablation for breast cancer liver metastases and to determine prognostic factors. Forty-three patients with 111 breast cancer liver metastases underwent CT-guided percutaneous radiofrequency (RF) ablation. Technical success and technique effectiveness was evaluated by performing serial CT scans. We assessed the prognostic value of hormone receptor status, overexpression of human epidermal growth factor receptor 2 (HER2), and presence of extrahepatic tumor spread. Survival rates were calculated using the Kaplan-Meier method. Technical success was achieved in 107 metastases (96%). Primary technique effectiveness was 96%. During follow-up local tumor progression was observed in 15 metastases, representing a secondary technique effectiveness of 86.5%. The overall time to progression to the liver was 10.5 months. The estimated overall median survival was 58.6 months. There was no significant difference in terms of survival probability with respect to hormone receptor status, HER2 overexpression, and presence of isolated bone metastases. Survival was significantly lower among patients with extrahepatic disease, with the exception of skeletal metastases. We conclude that CT-guided RF ablation of liver metastases from breast cancer can be performed with a high degree of technical success and technique effectiveness, providing promising survival rates in patients with no visceral extrahepatic disease. Solitary bone metastases did not negatively affect survival probability after RF ablation.

Selective internal radiation therapy (SIRT) is used for the treatment of patients with liver tumors, especially for those with hepatocellular carcinoma (HCC) or liver metastases from various primary tumors. Currently this innovative treatment concept is recommended when established state-of-the-art treatment regimes have failed and tumor progression is noted or if the treatment has to be abandoned because of intolerable toxic effects. For SIRT small biocompatible microspheres (SIR-Spheres(R)) are labelled with the radioactive isotope 90Yttrium, a pure beta emitter, and are superselectively infused into the hepatic arteries. The microspheres are collected in the precapillary vessels in and surrounding the tumor. The beta radiation of 90Yttrium has an average penetration in tissue of approximately 2.5 mm and results in very high doses of radiation being selectively targeted to metastases providing protection to the surrounding healthy liver tissue. In this paper we review the results of SIRT in patients with hepatic metastases from colorectal cancer, breast cancer, neuroendocrine tumors and primary liver cancer (HCC).

The encouraging preliminary results of radioembolization therapy in hepatocellular carcinoma and liver metastases from colorectal cancer have suggested that this mode of therapy could also be successful in breast and neuroendocrine metastases from colorectal cancer. (90)Yttrium microspheres in combination with radiosensitizing agents and growth factor inhibitors present opportunities to evaluate its application in combinatorial treatment paradigms with modern chemotherapy regimens. Other randomized trials are needed in hepatocellular carcinoma, to compare radioembolization with (90)yttrium against transarterial chemoembolization, bland embolization, drug-eluting beads, and best supportive care. A further potential research area besides the application of radioembolization for extrahepatic tumors is the determination of quality of life in randomized studies comparing radioembolization with systemic chemotherapy regimens with or without percutaneous radiation therapies.

Lung tumors and pulmonary metastases together are the most common cause of cancer-related death in men and the second most frequent in women. Up to now, surgical resection has remained the gold standard in the treatment of pulmonary tumors, being the only treatment option that was potentially curative and offered the possibility of a significant increase in life expectancy after successful therapy. Over the past decade, percutaneous radiofrequency ablation (RFA) has gained worldwide acceptance in the treatment of primary and secondary tumors of the liver with curative intent, so that indications for RFA have been extended to embrace tumors in other organs, e.g. the lung. Since the first case results were described, the number of publications dealing with the treatment of lung tumors using thermal ablative therapies has increased significantly. The aims of the present article are to give a short overview of emerging therapies such as cyberknife surgery and also, especially, to describe the indications for and technique of RFA, to discuss the ideal method of follow-up, and to highlight possible complications of the therapy and the current results of RFA of primary and secondary lung tumors. In addition, the value of combining RFA with other therapy modes (especially chemotherapy and radiation therapy)is briefly treated.

In the last two decades image-guided interventional catheterizations and percutaneous ablative regional treatment procedures have revolutionized the therapy of nonresectable primary and secondary liver tumours. A distinction is made between chemoablative procedures and thermo- and radioablative procedures. The main chemoablative interventions are transarterial infusion chemotherapy (HAIC; hepatic arterial infusion chemotherapy) and transarterial (chemo-)embolization (TACE/TAE). The object of the transarterial treatment procedures is to deliver the highest possible concentration of a chemotherapy agent or combination of chemotherapy agents directly into the tumour by way of the blood vessels supplying it, while at the same time keeping the systemic effects of the drugs as small as possible. Transarterial chemoperfusion to the liver can be applied in the treatment of all primary and secondary hepatic tumours, but the main indications are hepatocellular carcinoma (HCC) and metastases from colorectal primary tumours.

Ventricular free wall rupture remains the most serious complication after acute myocardial infarction. In early-recognized, subacute cases a surgical intervention using patches can be lifesaving. However, in the rare case of postoperative patch leakage, a relapse of a pseudoaneurysm may occur. This is the first case in the literature--to the best of our knowledge--describing a minimally invasive strategy using CT fluoroscopic guidance to perform an injection of thrombin into the perfused pseudoaneurysm to seal a leakage. This therapeutical regimen was chosen--in accordance with cardiac surgeons, cardiologists, and interventional radiologists--due to the high risk of adverse event after repeated surgery in this particular patient. The follow-up images showed complete occlusion of the pseudoaneurysm after the thrombin injection. This approach could be discussed in a multidisciplinary setting in similar cases, especially due to the described negligible recurrence rate after successful initial thrombosis after treating femoral pseudoaneurysms, pseudoaneurysms of the pancreatic artery, or even endoleaks after stenting of aneurysms of the aorta.

Percutaneous catheter interventions are performed increasingly often for the purposes of both diagnosis and therapy. The incidence of local complications reported after transfemoral catheterization in the literature is 0.1-9%. Such complications should be detected as early and reliably as possible, and sonography is a good means of finding them during follow-up, not least because it is suitable for use in examinations at the bedside. The clinical value of sonography compared with other examination techniques is made clear with reference to specimen cases.

Background: Percutaneous vertebroplasty (PVP) represents a minimally invasive option which is gaining in importance for the treatment of vertebral compression fractures (VCF) and osteolysis of the spine. This article describes the indications for its use, peri-interventional imaging, technique, and results of PVP., Material and Methods: The current guidelines for performance of PVP are explained in accordance with the "Interdisciplinary Consensus Paper on Vertebroplasty and Kyphoplasty" of the German Professional Associations and the 2005 CIRSE Guidelines. The results of our own study carried out in 2002 are compared to the complication rates and clinical outcomes reported in the literature., Results: Painful osteoporotic VCF and osteolysis within the vertebral body due to metastases and multiple myeloma are indications for PVP. Absolute contraindications are, in particular, asymptomatic VCF, alleviation of pain by drug treatment, therapy-refractory coagulopathies, allergies to cement components, and active infections. MRI or CT is indicated before undertaking PVP to assess the fracture age, to exclude other causes of pain, and to evaluate the posterior edge of the vertebral body. High-quality mono- or biplanar fluoroscopy--preferably in combination with CT (fluoroscopy)--is necessary for PVP to minimize the risk of cement leakage. A clear reduction in pain [mean reduction of 6.1 points (VAS)] is achieved in 86-92% of the patients with PVP. Our own study treating 58 patients (mean follow-up 323+/-99 days) revealed a clear alleviation of pain in 77% [-5.7 points (VAS)]., Conclusion: PVP constitutes a safe and effective minimally invasive treatment approach to stabilize and reduce acute and chronic back pain due to osteoporotic VCF and tumor-associated osteolysis.

Reimbursement for inpatient services rendered based on comparable daily care rates, case-based flat rates, and special fees as practiced until now has been replaced by the system of diagnosis-related groups. Up until 2004, operation and procedure system (OPS 301) codes could be processed completely automatically by appropriate adaptation of the radiology information system (RIS). Because of further differentiation of OPS codes in the 2005 version, it is no longer possible to unambiguously determine OPS codes automatically. Our goal was to fulfill these additional requirements with as little extra effort as possible. In 36 of 2138 procedures during an observation period of 12 days, i.e., 4/day, manual input on the part of the radiology technical assistant and quality assurance by the diagnosing physician were necessary. This is only needed in complicated procedures for which the minor added effort is negligible in comparison to the entire effort expended for the procedure. We were thus able to achieve the goal of near automation of ascertaining OPS codes.

Minimal-invasive techniques for ablation of primary and secondary hepatic tumors gain increasingly clinical importance. This is especially true since surgical resection and classic chemotherapy is successful only in a limited number of patients. Local ablative methods incorporate chemo- (percutaneous alcohol instillation, transarterial chemoembolization), thermo- (radiofrequency-, laser-, microwave-, cryoablation, high intensive focused ultrasound) and radio-ablative techniques (interstitial brachytherapy, selective internal radiotherapy). Regarding their implementation and specific effects these methods are varying widely, nevertheless all of them have a high therapeutical efficacy together with a low complication rate in common-correct application presumed. The knowledge on specific indications and contraindications is crucial to implement these methods into multimodality therapy concepts.

Background: The accurate evaluation of carotid artery stenoses is important for therapeutic decision making. Catheter digital subtraction angiography (DSA) still represents the gold standard, while the advent of multislice CT (MSCT) has led to improved temporal and spatial resolutions of CTA., Material and Methods: In a pilot study, we investigated 14 diseased vessels in 9 symptomatic patients (7m, 2f; mean age 60.7+/-10,9 years) comparing biplanar DSA with standardized 16-slice MS-CTA. The degree of stenosis was evaluated in a consensus reading following modified NASCET criteria., Results: DSA demonstrated 4 occlusions, 5 high-grade stenoses (>70%) and 5 lower-grade stenoses (<70%). One dissecting, infrapetrous stenosis was not adequately quantified by CTA due to a close topographic relation to the skull base. In the carotid bifurcation (n=13), an excellent correlation was demonstrated between DSA and CTA with a correlation coefficient of 0.99., Conclusion: MS-CTA has a good diagnostic potential in the evaluation of carotid artery stenoses. Larger studies will need to demonstrate the relative diagnostic value for different subtypes of stenosis and for different reader experience levels.

Radiofrequency ablation (RFA) of primary and secondary liver malignancies is a promising and rapidly evolving technique, which increasingly gains importance. A new field of RFA is the minimal invasive therapy of osseous and soft tissue tumors. In the management of osteoid-osteoma, RFA is a well established treatment option. Basic principles, indications, complications and results of RFA will be presented. A careful evaluation of indications for RFA in osseous or soft tissue neoplasms is mandatory. In patients who are neither candidates for surgical tumor resection nor respond to chemotherapy, there is a need for alternative treatment options. In these preselected patients a substantial improvement in quality of life with low associated morbidity can be provided by RFA. In malignancies of bone and soft-tissue tumors, RFA is a palliative treatment option. Therefore, the results can not be compared to those of surgical resection or chemotherapy which essentially are employed with curative intention. Our own experiences as well as data published in the literature indicate that RFA is a helpful tool in preserving patient's quality of life. The high technical and clinical success together with a low complication rate makes RFA of osseous and soft tissue neoplasms a valuable supportive tool for patients not referable for surgery or systemic therapy.

Background and Purpose: Radiofrequency ablation is increasingly used to treat tumors "beyond the liver". The aim of this article is to perform a structured and critical review of the current literature concerning RFA of the lung and to compare these results with our own experience., Material and Methods: 16 patients with tumors or metastases of the lung were treated in our institution within 18 months. 8 of these 16 patients were treated in a multicenter trial. For this article we compared our results to the results of all publications concerning RFA of the lung since 1995., Results: 8 of our 16 patients were not included in the international multicenter trial and were followed-up at least 15 months. Within this observation period, 2 of 8 patients had recurrence of the tumors while in 6 patients no recurrence was detected. Lee et al. published a study with 30 patients. In 10 of these 30 patients RFA was performed in a curative intention with a therapeutical success in 8 of 10 patients after one year., Discussion: Radiofrequency ablation of lung tumors smaller than 3 cm appears to be an alternative to surgical removal. Moreover, RFA offers a higher quality of life for the patients due to a low morbidity and mortality. However, more studies with longer observation periods are necessary for a definite conclusions.

Purpose: Percutaneous vertebroplasty (pv) is a worldwide increasingly performed interventional therapeutic procedure. This article addresses indications, patient preparation, technical requirements and approach as well as possible complications of percutaneous vertebroplasty., Technique: Percutaneous vertebroplasty is a technique consisting in an injection of bone cement into a vertebral body under imaging guidance. This procedure is performed to relief pain and support the mechanical stability in partially collapsed vertebral bodies., Results: In the management of spinal compression fractures secondary to osteoporosis, myeloma, osteolytic metastases and aggressive hemangiomas, percutaneous vertebroplasty yields analgesic effect, and provides additional fortification in weakened segments of the vertebral column. Contraindications include major bleeding disorders, radicular pain and pain caused by compression of the myelon., Discussion: Percutaneous vertebroplasty results in prompt pain relief and rapid rehabilitation. In experienced hands, using correct technique, pv is a safe and effective procedure for treating pain, caused either by osteoporotic or malignant vertebral compression fractures.

Background and Purpose: Osteoporotic vertebral compression fractures are a frequently encountered clinical problem. We aimed to perform a critical, structured review of the current literature and to compare the results with our own experiences., Material and Methods: A structured review of 7 studies about vertebroplasty in osteoporotic compression fractures was performed; each study assessed at least 16 patients and was published in English since 1997. The results were compared to our own experience in 22 patients treated in 2002., Results: Over the past decade, vertebroplasty has increasingly been performed for the treatment of painful osteoporotic vertebral body compression fractures. In good correlation with our own results, all authors reported a significant improvement of pain immediately after treatment and a reduction of pain of up to 90% within 24 h after vertebroplasty. Furthermore, a significant reduction in the use of analgetics and a substantial improvement of functional status has been described in recent studies. In our own evaluation, we were also able to demonstrate a significant improvement of pain after vertebroplasty in 17 of 22 (77%) of our patients. 18 of 22 (82%) patients were able to diminish or even discontinue their analgesic medication., Discussion: Reported results for vertebroplasty have demonstrated a rapid improvement in pain and physical functioning in patients with osteoporotic vertebral compression fractures. Percutaneous vertebroplasty has proven to provide a valuable treatment option for osteoporotic vertebral compression fractures.

Intracranial aneurysms are a common pathology faced by the diagnostic radiologist in daily practice. They can present as symptomatic aneurysms with a subarachnoid hemorrhage or as an incidental finding in another radiological study. Moreover, clipped or coiled aneurysms sometimes require a postinterventional work-up to exclude residual perfusion. Previous studies assessing the value of CT angiography in the diagnosis of intracranial aneurysms have been conducted using single slice spiral CT-scanners. They have shown a limited sensitivity in the diagnosis of small aneuryms with a diameter of equal to or smaller than 3 mm.Presently, there is only limited experience regarding the use of multi-detector row CT (MDCT) in the diagnosis of intracranial aneurysms. We have examined eight patients with a total of eleven aneurysms with MDCT technology, five patients with a 4-slice MDCT and three with a 16-slice MDCT. Of these, five were untreated aneurysms and six posttherapeutic with a status post surgical clipping. The mean diameter of the aneurysms was 5 mm (range 2 to 13 mm, median 3 mm). Of the treated aneuryms, two showed residual perfusion of the aneurysmal neck with a diameter of 2 and 6 mm respectively. In all cases, MDCT-angiography was in full agreement with the DSA diagnosis. Studies on larger patient populations will need to demonstrate the value of CTA in the diagnosis of intracranial aneurysms compared to the reference standard DSA.

Purpose: The newly developed 16-slice multi detector row computed tomography (MDCT) allows for isotropic imaging at rotation times under 500 ms. We aim to describe our first experiences with this novel technology in the diagnostic imaging of the craniocervical vascular system., Methods: The craniocervical vascular system of 8 consecutive patients was examined with a standardized protocol with the new 16-slice MDCT. The volume covered included the carotid arteries from their origin at the aortic arch and the intracranial arterial and venous vessels in their entirety. Homogeneity of contrast, contrast-to-parenchyma ratios, image quality and radiation doses were assessed., Results: A homogeneous vessel-to-parenchyma ratio was reached in the carotids as well as in the intracranial arterial and venous vessels. Image quality was rated as excellent in all patients. The estimated mean effective radiation dose amounted to 2.31 mSv +/-0.57, the mean dose length product to 608 mGy*cm +/-151., Conclusion: The newly developed 16-slice MDCT technology appears to be a promising tool in the diagnostic assessment of the cervicocranial vessels.