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Evidence supporting interventional pulmonary embolism (PE) treatment is needed.We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population.FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement.Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p0.0001) and a 0.3 L/min/mMechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE.

Pain is a complex syndrome that is difficult to treat. The increasing numbers of patients living with chronic diseases has led to increasing pain management needs and the rise of opioid use disorder (OUD) as a major and potentially lethal public health concern. Treatment of chronic pain with prescription opioids alone is not always successful, and a multidisciplinary approach is paramount to address the needs of patients at risk of developing or suffering from OUD. Interventional radiologists trained to perform minimally invasive procedures with negligible downtime and postprocedure pain can help stem the tide of opioid-related deaths and disability. This article reviews a wide range of minimally invasive procedures, including vertebral augmentation, sacroplasty, thermal ablation of osseous metastasis, nerve blocks, and gonadal vein embolization, that interventional radiologists are now using successfully to treat chronic pain. The evidence to support use of such procedures is highlighted. This article also briefly discusses emerging techniques such as arterial embolization and ablation for knee and shoulder osteoarthritis that have not yet been fully tested but exhibit strong potential in chronic pain management. By reducing opioid use in patients suffering from chronic pain, these minimally invasive procedures can potentially prevent escalation to OUD.

Cephalic arch stenosis causes repeated dysfunction and failure of arteriovenous access. Outcomes following balloon angioplasty alone in this location are unsatisfactory. Stent grafts have very good patency rates in this location. However, stent graft placement is technically challenging in this location due to the adverse angles and vectors of the cephalic arch. Stent graft deployment in this location is associated with a real risk of jailing the axillary vein, thereby precluding the use of that arm for future accesses and/or predisposes to venous edema. We describe a technique that was used to safely and effectively deploy a stent graft in the cephalic arch of a 65-year-old male patient.

Recurrent or metastatic peri-urethral pelvic malignancies are a difficult-to-treat entity. Re-resection is recommended when possible but is frequently unfavorable due to scar tissue, fibrosis, and obliteration of tissue planes following previous interventions such as surgical resection and/or radiation therapy. Curative options for patients that have unresectable cancer are limited. Cryo-ablation has been extensively studied in the treatment of unresectable renal, liver and lung malignancies and has the potential to provide definitive treatment for recurrent pelvic malignancy. There is a paucity of reports of salvage cryo-ablation in patients with recurrent pelvic malignancies, as most of these tumors are located close to critical structures that could be irreversibly injured by thermal ablation and are hence treated with some form of radiation therapy. But, for patients who fail surgical and radiation treatments, options are limited. Here, we describe two cases of regional tumor recurrence in the pelvis treated with percutaneous cryoablation using protective techniques to avoid thermal injury to adjacent structures. In each case, cryo-ablation was performed successfully despite extensive previous surgical and radiation interventions. Salvage cryo-ablation resulted in a positive clinical and imaging response with an improvement in quality of life and absence of recurrence on follow-up imaging which continues to persist at the writing of this manuscript about 8 and 12-months following treatment.

Extraosseous Ewing’s sarcoma (EES), first described in 1969, is a malignant mesenchymal tumor just like its intraosseous counterpart. Although Ewing’s sarcomas are common bone tumors in young children, EESs are rarer and more commonly found in older children/adults, often carrying a poorer prognosis. We discuss the multimodality imaging features of EES and the differential diagnosis of an aggressive appearing mass in proximity to skeletal structures, with pathologic correlates. This review highlights the need to recognize the variability of radiologic findings in EES such as the presence of hemorrhage, rich vascularity, and cystic or necrotic regions and its imaging similarity to other neoplasms that are closely related pathologically.

Purpose The role of computed tomography (CT)-guided gastrostomy tube placement is still evolving. It is a valuable alternative to guide gastrostomy tube placement in a few selected patients, who are not candidates for the established endoscopy- or fluoroscopy-guided gastrostomy tube placement. Our objective was to describe our institutional experience placing gastrostomy tubes using CT guidance and to conduct a review of literature for similar studies to provide the best current evidence on success rates and complications. Methods We identified gastrostomy tubes placed under CT guidance at our institution using a comprehensive case log. We also identified studies in the literature, through a systematic search of PubMed. In both the local and literature analyses, we recorded success and complication rates. Results A total of 31 patients underwent 33 attempted CT-guided gastrostomy tube placements at our institution, with 32 successful procedures yielding a success rate of 97%. The overall rate of successful gastrostomy tube placement using CT-guidance was 94.9% (634/668), as reported in the existing literature. Conclusion CT-guidance is an effective method for gastrostomy tube placement and may play an important role in patients for whom endoscopic or fluoroscopic gastrostomy tube placement is not feasible.

Birt-Hogg-Dube syndrome (BHD) is a rare autosomal dominant disorder that predisposes patients to cutaneous tumors, pulmonary cysts with recurrent spontaneous pneumothoraces, and a variety of renal neoplasms including hybrid oncocytic and chromophobe renal cell carcinomas. There has been much debate regarding the genetic link with the occurrence of colorectal cancer and other colonic anomalies. Associations between BHD and intestinal adenomatous polyposis and sigmoid diverticulosis have been described in the literature, but there have been no prior reports of appendiceal diverticulosis in patients with BHD. Here, we present a 40-year-old female patient with a known family history of BHD, who was found to have diverticulosis of the appendix and pulmonary blebs on computed tomography upon routine screening for renal and pulmonary abnormalities, suggesting additional focus be given to the gastrointestinal tract (including the appendix) at the time of CT assessment.

Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.

Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.

Persistent eating of non-nutritive, nonfood substances (Pica) is seen in children and adult patients with psychiatric problems. Ingestion of multiple metallic FBs with resultant bezoar formation is rare. While many FBs are passed without complication, mucosal injury, bleeding, obstruction or perforation can occur in some cases. Endoscopic FB removal is performed in 20% of patients following FB ingestion. Generally, these are safe procedures, and very effective in extracting ingested FBs. We report, a 25-year-old male patient with a metal ingestion predominant Pica, requiring multiple prior extraction procedures (including open gastrostomy). He developed a splenic artery pseudoaneurysm following his latest endoscopic FB removal, that was successfully treated with transarterial coil embolization. The unique circumstances leading to this rare complication and its successful endovascular management make this case worthy of report.

To propose minimally invasive percutaneous techniques in the management of high output chylous ascites, a known potential complication of retroperitoneal surgery associated with significant morbidity and mortality. Management has traditionally been based on successful treatment reported in the literature. However, refractory or high-output leaks often prove difficult to treat and there is little evidence on superior management. We report percutaneous maceration and embolization for the management of high-volume abdominal chyle leak after robot-assisted laparoscopic (RAL) radical nephrectomy and lymph node dissection for renal cell carcinoma. A 68-year-old male with incidentally found renal cell carcinoma underwent RAL radical nephrectomy with paraaortic lymph node dissection. He initially improved after surgery but developed significant abdominal pain and distension approximately 7 weeks postoperative. This proved to be chyloperitoneum. Conservative management was initiated, but after continued high-output (>1 L) fluid drainage, we pursued adjunct intervention involving Interventional Radiological percutaneous procedures. This included lymphatic maceration and glue embolization of leaking lymphatics. The patient tolerated the percutaneous procedures well with significant improvement in drain output ultimately leading to complete resolution of ascites without further complication. Similar interventions have previously been reported in the literature for cases of chylothorax with success. However, there is a lack of reports on utilizing this minimally invasive procedure for chyloperitoneum after retroperitoneal urologic surgery. We report our successful experience with percutaneous lymphatic maceration and embolization for high output chylous ascites after RAL radical nephrectomy with lymphadenectomy. We believe that early initiation utilizing these percutaneous techniques can achieve timely resolution and should be considered in the management of these patients.

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

BACKGROUND Primary appendiceal cancers are rare, and they generally present with liver and/or peritoneal metastases. Currently there are no guidelines to treat metastatic appendiceal cancer, and hence they are treated as metastatic colorectal cancer. Combining Yttrium 90 (Y-90) radioembolization (RE) with systemic chemotherapy early in the treatment of right sided colon cancers has been shown to improve survival. Based on this data, a combination of systemic chemotherapy and Y-90 RE was used to treat a case of metastatic appendiceal cancer. CASE SUMMARY A 76-year-old male presented to the emergency room with progressive right lower quadrant pain. A Computed Tomography of the abdomen and pelvis was performed which showed acute appendicitis and contained perforation. Urgent laparoscopic appendectomy was then followed by histological analysis, which was significant for appendiceal adenocarcinoma. After complete workup he underwent right hemicolectomy and lymph node dissection. He received adjuvant chemotherapy as the local lymph nodes were positive. Follow-up imaging was significant for liver metastasis. Due to rapid growth of the liver lesions and new peritoneal nodules, the patient was treated with a combination of Y-90 RE and folinic acid, fluorouracil, and irinotecan with bevacizumab and not microwave ablation as previously planned. Follow up imaging demonstrated complete response of the liver lesions. At 12-mo follow-up, the patient continued to enjoy good quality of life with no recurrent disease. CONCLUSION Utilization of Y-90 RE concomitantly with systemic chemotherapy early in the treatment of appendiceal cancer may provide improved control of this otherwise aggressive cancer.

Imaging is needed for diagnosis, treatment planning, and follow-up of patients with pathologies affecting upper extremity vasculature. With growth and evolution of imaging modalities [especially CT angiography (CTA) and MR angiography (MRA)], there is need to recognize the advantages and disadvantages of various modalities and obtain the best possible imaging diagnostic test. Understanding various limitations and pitfalls as well as the best practices to minimize and manage these pitfalls is very important for the diagnosis. This article reviews the upper extremity arterial vascular anatomy, discusses the CTA and MRA imaging, various pitfalls, and challenges and discuss imaging manifestations of upper extremity arterial pathologies.

Ectopic varices are complex and highly variable entities that are not fully understood. Duodenal varices from pancreatitis have rarely been reported. Ectopic varices have much higher bleeding rates than the more common gastro-esophageal varices, and are associated with higher mortality. The ideal management of this difficult problem is not only to ensure prompt hemostasis, but also address the etiology or hemodynamics of the ectopic varices. We discuss the endovascular management of bleeding duodenal varices, which developed from superior mesenteric vein occlusion, following repeated attacks of pancreatitis. This unusual case was managed by a multidisciplinary collaborative approach between the gastrointestinal service and Interventional radiology. The classification system for ectopic varices and management options has been discussed in some detail. Medium term follow-up (8 months), at the time of this writing, showed that the patient is doing well, without interval hematemesis, imaging findings of recurrent/new varices or stent occlusion.

Ultrasonographic (US) guided procedures have wide range of application in the abdomen and pelvis, however their role is somewhat limited in the chest due to complete reflection of the ultrasound beam by the air in the lungs, preventing the direct imaging of the tissues deep to the air-sound interface. Most of the chest procedures, other than the exception of thoracentesis, rely on the use of CT (computed tomography) scan. The disadvantages of using CT scan is the cost, lack of portability, and most importantly the radiation involved, particularly in case of infants and children, whose tissues are more radiosensitive than the adults. Identification of air by Ultrasonography can help direct needles and wires, to accomplish procedures which may otherwise need CT. A 1-day-old infant with respiratory distress syndrome (RDS) on a ventilator, developed an expanding symptomatic pneumopericardium/pneumomediastinum. The patient was too unstable to leave the neonatal intensive care unit (NICU), so a pericardial/mediastinal drain was placed under ultrasonographic and radiographic guidance. This case, highlights a method for bedside treatment of pneumopericardium/pneumomediastinum in an unstable neonate. This procedure may be equally effective in older children and adults.

Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.

Objectives: The objective of the study was to retrospectively investigate the safety and efficacy of computerized tomography-guided microwave ablation (MWA) in the treatment of Stage I non-small cell lung cancers (NSCLCs). Material and Methods: This retrospective, single-center study evaluated 21 patients (10 males and 11 females; mean age 73.8 ± 8.2 years) with Stage I peripheral NSCLCs treated with MWA between 2010 and 2020. All patients were surveyed for metastatic disease. Clinical success was defined as absence of FDG avidity on follow-up imaging. Tumor growth within 5 mm of the original ablated territory was defined as local recurrence. Welch t-test and Fisher’s exact test were used for univariate analysis. Hazard ratio (HR) and odds ratio (OR) were determined using Cox regression and Firth logistic regression. Significance was P < 0.05. Data are expressed as mean ± standard deviation. Results: Ablated tumors had longest dimension 17.4 ± 5.4 mm and depth 19.7 ± 15.1 mm from the pleural surface. Median follow-up was 20 months (range, 0.6–56 months). Mean overall survival (OS) following lung cancer diagnosis or MWA was 26.2 ± 15.4 months (range, 5–56 months) and 23.7 ± 15.1 months (range, 3–55 months). OS at 1, 2, and 5 years was 67.6%, 61.8%, and 45.7%, respectively. Progression-free survival (PFS) was 19.1 ± 16.2 months (range, 1–55 months). PFS at 1, 2, and 5 years was 44.5%, 32.9%, and 32.9%, respectively. Technical success was 100%, while clinical success was observed in 95.2% (20/21) of patients. One patient had local residual disease following MWA and was treated with chemotherapy. Local control was 90% with recurrence in two patients following ablation. Six patients (28.6%) experienced post-ablation complications, with pneumothorax being the most common event (23.8% of patients). Female gender was associated with 90% reduction in risk of death (HR 0.1, P = 0.014). Tumor longest dimension was associated with a 10% increase in risk of death (P = 0.197). Several comorbidities were associated with increased hazard. Univariate analysis revealed pre-ablation forced vital capacity trended higher among survivors (84.7 ± 15.2% vs. 73 ± 21.6%, P = 0.093). Adjusted for age and sex, adenocarcinoma, and neuroendocrine histology trended toward improved OS (OR: 0.13, 0.13) and PFS (OR: 0.88, 0.37) compared to squamous cell carcinoma. Conclusion: MWA provides a safe and effective alternative to stereotactic brachytherapy resulting in promising OS and PFS in patients with Stage I peripheral NSCLC. Larger sample sizes are needed to further define the effects of underlying comorbidities and tumor biology.

Objectives: Computed tomography pulmonary angiogram (CTPA) is one of the most commonly ordered and frequently overused tests. The purpose of this study was to evaluate the mean radiation dose to patients getting CTPA and to identify factors that are associated with higher dose. Material and Methods: This institutionally approved retrospective study included all patients who had a CTPA to rule out acute pulmonary embolism between 2016 and 2018 in a tertiary care center. Patient data (age, sex, body mass index [BMI], and patient location), CT scanner type, image reconstruction methodology, and radiation dose parameters (dose-length product [DLP]) were recorded. Effective dose estimates were obtained by multiplying DLP by conversion coefficient (0.014 mSv•mGy−1•cm−1). Multivariate logistic regression analysis was performed to determine the factors affecting the radiation dose. Results: There were 2342 patients (1099 men and 1243 women) with a mean age of 58.1 years (range 0.2–104.4 years) and BMI of 31.3 kg/m2 (range 12–91.5 kg/m2). The mean effective radiation dose was 5.512 mSv (median – 4.27 mSv; range 0.1–43.0 mSv). Patient factors, including BMI >25 kg/m2, male sex, age >18 years, and intensive care unit (ICU) location, were associated with significantly higher dose (P < 0.05). CT scanning using third generation dual-source scanner with model-based iterative reconstruction (IR) had significantly lower dose (mean: 4.90 mSv) versus single-source (64-slice) scanner with filtered back projection (mean: 9.29 mSv, P < 0.001). Conclusion: Patients with high BMI and ICU referrals are associated with high CT radiation dose. They are most likely to benefit by scanning on newer generation scanner using advance model-based IR techniques.

Objectives: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. Material and Methods: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. Results: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28–32.30) and 15 times higher with >2 AAs (95% CI, 1.41–169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. Conclusion: There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.

COVID-19 (Corona Virus Disease-19) is a zoonotic illness first reported in the city of Wuhan, China in December 2019, and is now officially a global pandemic as declared by the World Health Organization. The infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 infected patients can be asymptomatic carriers or present with mild-to-severe respiratory symptoms. Imaging, including computed tomography is not recommended to screen/diagnose COVID-19 infections, but plays an important role in management of these patients, and to rule out alternative diagnoses or coexistent diseases. In our multicenter case series, we outline the clinical presentations and illustrate the most common imaging manifestations in patients hospitalized with COVID-19.

PURPOSE: Post-thoracotomy pain syndrome is a common condition affecting up to 50% of post-thoracotomy patients. However, percutaneous computed tomography (CT)-guided intercostal nerve cryoablation may provide symptomatic benefit in chronic and/or refractory cases. METHODS: A retrospective review of our institution’s comprehensive case log from October 2017 to September 2018 for patients who underwent cryoablation was analyzed. Thirteen patients with post-thoracotomy pain syndrome, refractory to medical management, were treated with CT-guided intercostal nerve cryoablation. Most patients had treatment of the intercostal nerve at the level of their thoracotomy scar, two levels above and below. The safety and technical success of this technique and the clinical outcomes of the study population were then retrospectively reviewed. RESULTS: Of the patients, 69% experienced significant improvement in their pain symptoms with a median pain improvement score of 3 points (range, −1 to 8 points) over a median follow-up of 11 months (range, 2–18.6 months). Complications included pneumothorax in 8% and pseudohernia in 23% of patients. CONCLUSION: CT-guided intercostal nerve cryoablation may be an effective technique in the treatment of post-thoracotomy pain syndrome and requires further study.

Solitary fibrous tumors are primary mesenchymal tumors, which may occur in any part of the body. Overall, these tumors are considered to have intermediate malignant potential with 5- and 10-year metastasis-free and overall disease-specific survival rates of 74% and 55%, and 89% and 73%, respectively (Demicco et al, 2012). Herein we present an unusual case of solitary fibrous tumors involving the ischioanal fossa in a 19-year-old woman with radiologic-pathologic correlation. This case was complicated by extensive tumor vascularity and was thus managed with preoperative embolization followed by en bloc surgical resection. Keywords: Solitary fibrous tumor, Embolization, Ischioanal, Hemangiopericytoma

Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap. Traditionally, these reconstructions were performed with the transverse rectus abdominis myocutaneous (TRAM) flap, but autologous breast reconstruction using muscle sparing free flaps has become steadily more popular in recent years. Preoperative imaging to locate and evaluate candidate perforators has become an essential step before patients undergo the microsurgical procedure. Preoperative mapping assists with operative planning, reduces operating times, and brings anatomical variations to their attention. Pre-operative imaging also assists in choosing the appropriate donor site for harvesting flaps. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been widely used for this type of preoperative imaging. Both MRA and CTA have their inherent advantages and disadvantages, and the preferred modality for this purpose varies by institution based on factors such as scanner availability, radiologist and surgeon experience, and comfort in interpreting the images. Concerns over excessive exposure to ionizing radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made MRA the first-choice imaging modality in many centers. The purpose of the article is to review technique and protocols for the pre-operative CTA/MRA in patients who are being considered for a deep inferior epigastric artery perforator (DIEP) or profunda artery perforator (PAP) flap and to familiarize the reader with the normal and variant anatomic features of the deep inferior epigastric and PAP vessels along with the anatomic and surgical considerations used in the selection of perforator flap donor site for breast reconstruction post mastectomy.

Contrast enhanced magnetic resonance angiography (CE-MRA) is limited by long acquisition time and contrast exposure in aortic emergencies. To compare the effcacy of dark blood (DB) and bright blood (BB) noncontrast sequences with the gold standard CE-MRA using a novel protocol for performing consistent thoracic aortic measurements and thoracic aortic pathologies identifications. A total of 66 patients with suspected or known thoracic aortic pathology who underwent CE-MRA underwent DB and BB imaging prior to CE-MRA for planning purposes. Aortic dimension was measured at 10 standard reference points in the ascending, arch, and descending aorta. Detection of aortic pathologies was recorded individually for each noncontrast sequence. When comparing the CE-MRA to the DB images and CE-MRA to the BB images, a majority of the measurement differences were less than or equal to 2 mm or resulted in no change of diagnostic class (95% for CE-MRA vs. DB and 96% for CE-MRA vs. BB). Of the patients who had major changes in diagnostic class (e.g., changes in two or three classes), the absolute measurements were not clinically significant in any given patient to warrant a change in management. Individually, the DB and BB sequences allowed for accurate recognition of all 47 aortic pathologies. DB and BB sequences produced comparable and consistent measurements of the thoracic aorta when compared with CE-MRA. In a situation where CE-MRA is not readily available or contraindicated, noncontrast MRA using our protocol is a reliable alternative to CE-MRA for assessment of aortic pathologies.

Background: Inferior vena cava (IVC) filter placement still plays an essential role in preventing pulmonary embolism (PE) in patients with contraindications to anticoagulant therapy. However, IVC filter placement does have long-term risks which may be mitigated by retrieving them as soon as clinically acceptable. A dedicated IVC filter clinic provides a potential means of assuring adequate follow-up and retrieval. Aim: To assess the efficacy of our Inferior vena cava (IVC) filter retrieval clinic at improving the rate of patient follow-up, effective filter management, and retrieval rates. Materials and Methods: During the period of August 2017 through July 2018, 70 IVC filters were placed at our institution, and these patients were automatically enrolled into our IVC filter retrieval clinic for quarterly follow-up. We retrospectively reviewed data including appropriateness for removal at 3 months, overall retrieval rates, removal technique(s) employed, and technical success. Results: 62.9% of the potentially retrievable filters were removed during the study period. The technical success of extraction, using a combination of standard and advanced techniques, was 91.7%. Overall, 15% of the patients were lost to follow-up. Conclusion: Our findings add to the growing body of literature to support the need for a robust IVC filter retrieval clinic to ensure adequate follow-up and timely retrieval of IVC filters.

Objectives: Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN. Materials and Methods: One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy. Result: Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions Conclusion: CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions

Background: Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE. Materials and Methods: A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019–January 2020). Technical and clinical results, including complications, are reported. Results: Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE. Conclusions: The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

Many patients with severe intermittent claudication (IC) or critical limb ischemia (CLI) have chronic total occlusions (CTO) in their lower extremity vascular bed. The successful treatment of these lesions is becoming increasingly more important as the population ages and the prevalence of diseases such as diabetes mellitus and its consequences increases. Many of these patients have significant comorbidities and may benefit from less invasive treatment options. Several endovascular techniques have now become well established in the treatment of these lesions. Additionally, several new adjunctive tools have been developed to enhance the technical success of CTO revascularization. These tools and techniques offer a minimally invasive alternative for limb salvage in this compromised patient population and have become an established practice in many centers. Although some concerns about procedure durability and lower rates of primary patency exist, particularly when compared to surgical bypass, the limb salvage and amputation-free survival rates are much more encouraging. Advantages of these techniques compared to surgical bypass are reduced morbidity and mortality, reduced anesthesia requirements, and potential reductions in length of hospital stay and cost. In addition, bypass options are typically preserved after endovascular treatment. The more conventional and some newer endovascular treatment approaches, some of the adjunctive tools and techniques used in CTO revascularization as well as their clinical results will be discussed in this review.