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PURPOSE: To evaluate the opinions of gynecologists and interventional radiologists regarding uterine fibroid embolization (UFE). METHODS: We mailed surveys to all gynecologists and interventional radiologists practising in Toronto, Ontario. Study criteria excluded those physicians who did not assess or treat patients with uterine fibroids. We evaluated whether they educated patients regarding UFE, together with their opinion of current and future effectiveness of UFE, self-rated knowledge of fibroid treatment options, and recommendations for treatment in several clinical scenarios. RESULTS: A total of 102 gynecologists (46.4% response rate) and 28 interventional radiologists (51.9% response rate) completed the survey. After applying the exclusion criteria, the final study population was 82 gynecologists and 17 interventional radiologists. Both groups reported high rates of patient education regarding UFE (gynecologists 100% and interventional radiologist 88.2%, P > 0.05). Interventional radiologists had higher self-rated knowledge of UFE (P = 0.05), and gynecologists had higher self-rated knowledge of all other treatment options (P = 0.00). Interventional radiologists had a more favourable opinion of the current effectiveness (P < 0.05) and future use (P > 0.05) of UFE. In 5 of the 7 clinical scenarios, interventional radiologists chose UFE, whereas gynecologists chose other treatment options (P < 0.05). CONCLUSIONS: Although most gynecologists and intterventional radiologists educate their patients regarding UFE as a treatment option for uterine fibroids, interventional radiologists have greater self-rated knowledge and a higher opinion of current effectiveness and future use and recommend UFE more often for uterine fibroid scenarios. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the roles of noncontrast and delayed phases of computed tomography angiography (CTA) for optimization of the CTA protocol in endoleak detection. METHODS: CTAs of patients who underwent abdominal aortic endovascular stent-graft placement were retrospectively reviewed. CTA comprised noncontrast, arterial, and delayed phase (2 minutes postcontrast). The arterial phase was compared with a combined arterial and delayed phase and followed by the noncontrast phase to see whether additional information was obtained. RESULTS: Thirty-eight CTA studies demonstrated endoleak. In 30 studies (79%; 95%CI 64% to 89%), endoleak was detected in the arterial phase. Eight studies (21%; 95%CI 11% to 36%) demonstrated an endoleak only in the delayed phase. No additional information was obtained in the noncontrast phase when compared with a combined reading of the arterial and delayed phases (95%CI 0% to 9%). CONCLUSION: Delayed-phase imaging is necessary for endoleak detection and obviates a noncontrast phase. Identical parameters should be used for arterial and delayed phases. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the percentage of interventional radiologists who currently perform 3 interventional procedures: carotid stenting, vertebroplasty, and endovascular aneurysm repair (EVAR) in Canada, and impediments to their future performance by other interventional radiologists. METHODS: An anonymous online survey was emailed to all members of the Canadian Interventional Radiology Association (CIRA). The survey was open for a period of 2 months. RESULTS: A total of 75 survey responses were received (of an estimated 247). Carotid stenting, vertebroplasty, and EVAR were performed at 40%, 59%, and 46% of respondents' centres respectively. Wait times, from referral to consultation, and from consultation to procedure, were both typically between 2 to 4 weeks, longer for EVAR. Of respondents currently not performing these procedures, 26%, 28%, and 16% anticipated beginning to perform carotid stenting, vertebroplasty, and EVAR, respectively, in the proceeding year from time of survey. Of respondents who wished to perform the procedure, the greatest impediments were a lack of training, lack of a referral base, and lack of support from their radiology department and (or) colleagues. CONCLUSIONS: Although carotid stenting, vertebroplasty, and EVAR were being performed at about one-half of respondent's centres, and there will likely be greater adoption of the procedures in the near future, there remain substantial impediments. The greatest impediments to additional radiologists performing these procedures were a lack of training, lack of referral base, and lack of support from their radiology department and (or) colleagues. The former impediment suggested an unmet need for additional training courses. [ABSTRACT FROM AUTHOR]

Objectives: Determine if a large language model (LLM, GPT-4) can label and consolidate and analyze interventional radiology (IR) microwave ablation device safety event data into meaningful summaries similar to humans. Methods: Microwave ablation safety data from January 1, 2011 to October 31, 2023 were collected and type of failure was categorized by human readers. Using GPT-4 and iterative prompt development, the data were classified. Iterative summarization of the reports was performed using GPT-4 to generate a final summary of the large text corpus. Results: Training (n = 25), validation (n = 639), and test (n = 79) data were split to reflect real-world deployment of an LLM for this task. GPT-4 demonstrated high accuracy in the multiclass classification problem of microwave ablation device data (accuracy [95% CI]: training data 96.0% [79.7, 99.9], validation 86.4% [83.5, 89.0], test 87.3% [78.0, 93.8]). The text content was distilled through GPT-4 and iterative summarization prompts. A final summary was created which reflected the clinically relevant insights from the microwave ablation data relative to human interpretation but had inaccurate event class counts. Conclusion: The LLM emulated the human analysis, suggesting feasibility of using LLMs to process large volumes of IR safety data as a tool for clinicians. It accurately labelled microwave ablation device event data by type of malfunction through few-shot learning. Content distillation was used to analyze a large text corpus (>650 reports) and generate an insightful summary which was like the human interpretation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

During the hands-on teaching of Interventional Radiology (IR) to Residents and Fellows, certain learning tips or guiding statements are often repeated. Over the past two decades, these tips have evolved into the "Rules for Interventional Radiology." Relying on humour and the technical and foundational principles of our subspeciality, it is hoped that these Rules for IR provide helpful guidance to learners and practising Interventionalists in their daily work.

Purpose: To provide a comprehensive overview of the literature assessing the safety and efficacy of uterine artery embolization (UAE) for patients with pedunculated subserosal fibroids., Materials and Methods: MEDLINE and Embase databases were searched without language or publication type restrictions for observational studies to estimate safety (adverse events) and efficacy (devascularization, fibroid volume reduction, and uterine volume reduction) outcomes. Case reports were included to qualitatively report adverse events. Meta-analysis was performed for single proportions and mean changes with random-effects modeling., Results: Of 98 eligible articles, 11 studies were included in the final analysis. Of the adverse events detailed in these cases, 5 events were mild, 2 were moderate (torsion of pedunculated fibroid requiring laparoscopic myomectomy and persistent bleeding after embolization requiring hysterectomy), and 1 was severe (fibroid necrosis causing bowel obstruction requiring bowel resection and hysterectomy). There were no deaths reported in the literature. The pooled risk of adverse events was 1.7% (95% confidence interval [CI], 0.29%-9.2%; 4 of 181; I 2  = 0%). The pooled devascularization rate was 75.9% (95% CI, 62.4%-85.6%; 140 of 189; I 2  = 75%) at 3.91 months of follow-up. The percent volume reduction of the dominant pedunculated fibroid was 38.6% (95% CI, 33.0%-44.2%; I 2  = 0%) at 4.3 months of follow-up. The percent uterine volume reduction was 36.7% (95% CI, 30.3%-43.0%; I 2  = 47%) at 3.5 months of follow-up., Conclusions: UAE for pedunculated subserosal fibroids has a low risk of adverse events and effectively reduces fibroid and uterine size., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

This study assessed the safety profile of high-volume (>10 mL) 3% sodium tetradecyl sulfate (STS) sclerotherapy for the treatment of renal cysts in patients with autosomal dominant polycystic kidney disease. A total of 211 sclerotherapy treatments were performed in 169 patients over a 5-year period, with a comparison of 2 patient cohorts based on the STS volumes used. The first cohort (n = 112) received a high volume (greater than 10 mL) of STS, and the second cohort (n = 57) received a low volume (less than 10 mL). The minor adverse event rate for the cohorts was 14.5% and 9.6%, respectively (P = .310), with postprocedure pain being the most common event. One major adverse event occurred, for which the patient required hospitalization for infection after low-volume STS treatment. Doses of STS higher than those currently recommended by the Food and Drug Administration for intravascular use allow large renal cysts to be treated safely in the setting of autosomal dominant polycystic kidney disease., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada., Methods: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics., Results: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%)., Conclusion: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

Background: Most reports of active surveillance (AS) of small renal masses (SRMs) lack biopsy confirmation, and therefore include benign tumors and different subtypes of renal cell carcinoma (RCC)., Objective: We compared the growth rates and progression of different histologic subtypes of RCC SRMs (SRM RCC ) in the largest cohort of patients with biopsy-characterized SRMs on AS., Design, Setting, and Participants: Data from patients in a multicenter Canadian trial and a Princess Margaret cohort were combined to include 136 biopsy-proven SRM RCC lesions managed by AS, with treatment deferred until progression or patient/surgeon decision., Outcome Measurements and Statistical Analysis: Growth curves were estimated from serial tumor size measures. Tumor progression was defined by sustained size ≥4 cm or volume doubling within 1 yr., Results and Limitations: Median follow-up for patients who remained on AS was 5.8 yr (interquartile range 3.4-7.5 yr). Clear cell RCC SRMs (SRM ccRCC ) grew faster than papillary type 1 SRMs (0.25 and 0.02 cm/yr on average, respectively, p =  0.0003). Overall, 60 SRM RCC lesions progressed: 49 (82%) by rapid growth (volume doubling), seven (12%) increasing to ≥4 cm, and four (6.7%) by both criteria. Six patients developed metastases, and all were of clear cell RCC histology. Limitations include the use of different imaging modalities and a lack of central imaging review., Conclusions: Tumor growth varies between histologic subtypes of SRM RCC and among SRM ccRCC , which likely reflects individual host and tumor biology. Without validated biomarkers that predict this variation, initial follow-up of histologically characterized SRMs can inform personalized treatment for patients on AS., Patient Summary: Many small kidney cancers are suitable for surveillance and can be monitored over time for change. We demonstrate that different types of kidney cancers grow at different rates and are at different risks of progression. These results may guide better personalized treatment., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: To compare the psychological distress throughout several predefined disease time points in patients younger than 70 with small renal masses (SRMs) treated with either active surveillance (AS) or ablative/surgical therapy., Methods: Using the Edmonton Symptom Assessment System - revised (ESAS-r) questionnaire, we focused on psychological distress symptoms in all consecutive patients with an SRM between 2014 and 2017. We further evaluated the psychological distress sub-score (PDSS) of ESAS-r, consisting of the sum scores of anxiety, depression, and well-being. PDSS of patients treated with AS or ablation/surgery were compared at 4 distinct time points (before and after diagnosis, after a biopsy is performed, and at last follow-up). Multivariable linear regression models were performed to assess factors associated with worse PDSS (1-point score increase)., Results: We examined 477 patients, of whom 217 and 260 were treated with AS and surgery/ablation, respectively. Similar ESAS-r and PDSS scores were shown at all predefined disease time points except following an SRM biopsy and at last, follow-up, where AS-treated patients with a biopsy-proven malignancy had significantly worse PDSS (11.4 vs. 6.1, P = 0.035), and (13.2 vs. 5.4, P = 0.004), respectively. At last follow-up, multivariable linear models demonstrated that a biopsy-proven malignancy (B = 2.630, 95% CI 0.024-5.236, P = 0.048) and AS strategy (B = 6.499, 95% CI 2.340-10.658, P = 0.002) were associated with worse PDSS in all patients, and in those who underwent a biopsy, respectively., Conclusions: Offering standardized psychological supportive care may be required for patients younger than 70 years on AS for SRM, especially for those with a biopsy-proven tumor., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Radiology is a finite health care resource in high demand at most health centers. However, anticipating fluctuations in demand is a challenge because of the inherent uncertainty in disease prognosis. The aim of this study was to explore the potential of natural language processing (NLP) to predict downstream radiology resource utilization in patients undergoing surveillance for hepatocellular carcinoma (HCC)., Materials and Methods: All HCC surveillance CT examinations performed at our institution from January 1, 2010, to October 31, 2017 were selected from our departmental radiology information system. We used open source NLP and machine learning software to parse radiology report text into bag-of-words and term frequency-inverse document frequency (TF-IDF) representations. Three machine learning models-logistic regression, support vector machine (SVM), and random forest-were used to predict future utilization of radiology department resources. A test data set was used to calculate accuracy, sensitivity, and specificity in addition to the area under the curve (AUC)., Results: As a group, the bag-of-word models were slightly inferior to the TF-IDF feature extraction approach. The TF-IDF + SVM model outperformed all other models with an accuracy of 92%, a sensitivity of 83%, and a specificity of 96%, with an AUC of 0.971., Conclusions: NLP-based models can accurately predict downstream radiology resource utilization from narrative HCC surveillance reports and has potential for translation to health care management where it may improve decision making, reduce costs, and broaden access to care., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Aims: Renal tumour biopsy (RTB) is increasingly recognised as a useful diagnostic tool in the management of small renal masses, particularly those that are incidentally found. Intratumoural heterogeneity with respect to morphology, grade and molecular features represents a frequently identified limitation to the use of RTB. While previous studies have evaluated pathological correlation between RTB and nephrectomy, no studies to date have focused specifically on the role of RTB for the diagnosis of papillary renal cell carcinoma (PRCC) and its further subclassification into clinically relevant subtypes., Methods: This single-institution study evaluated 60 cases of PRCC for concordance between RTB and nephrectomy with respect to diagnosis, grading and subtyping (type 1/type 2)., Results: We observed 93% concordance (55 of 59 evaluable cases) between RTB and nephrectomy for the diagnosis of PRCC, although seven tumours (12%) were undergraded on RTB. Subtyping of PRCC on RTB was concordant with nephrectomy in 89% of cases reported as type 1 PRCC on RTB (31/35), but only 40% of cases reported as type 2 PRCC on RTB (4/10). Morphological misclassification of PRCC on RTB was most likely to occur in tumours showing a solid growth pattern. Discordant PRCC subtyping most often occurred in tumours with eosinophilia/oncocytic change., Conclusion: There was good concordance between RTB and nephrectomy for the primary diagnosis of PRCC. Although further subtyping of PRCC can aid therapeutic stratification, this can be challenging on RTB and tumours with overlapping or ambiguous features are best reported as PRCC not otherwise specified pending development of more robust methods to facilitate definitive subclassification., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Pulled or dislodged gastrostomy catheters represent a common complication associated with percutaneous gastrostomy and are a common cause of recurrent visits in patients with altered mental status. We intended to perform an experiment to compare the pull forces required to dislodge different commonly used gastrostomy catheters., Materials and Methods: We used a digital force gauge device to measure the pull forces required to dislodge three types of 20 French gastrostomy catheters in double-layer skin models. These included the Flow 20 Pull Method (Cook Medical, Bloomington, IN, USA), Entuit Gastrostomy BR Balloon Retention feeding tube (Cook Medical, Bloomington, IN, USA), and Ponsky Non-Balloon Replacement Gastrostomy Tube (CR Bard Inc, Salt Lake City, Utah, USA). The catheters were inserted into the skin model using the same technique as would be utilized in a patient., Results: The mean forces measured to dislodge the per-oral Flow 20 Pull Method, Entuit Thrive Balloon Retention, and button-type retention Ponsky replacement catheters were 35.6, 22.8, and 20.6 Newtons, respectively. The pull method per-oral gastrostomy catheter required significantly more pull force to dislodge than both the Ponsky button-type retention catheter and the Entuit balloon retention catheters. There was no significant difference in the pull force required to dislodge the Ponsky replacement catheter and the Entuit balloon retention catheter., Conclusions: Per-oral image-guided gastrostomy with pull-method button-type retention catheters may be the ideal choice in patients at high risk of tube dislodgment.

Purpose: To assess the safety and efficacy of percutaneous thermal ablation for the treatment of hepatocellular adenomas., Materials and Methods: This is an ethics board-approved, single-arm, retrospective, cohort study of patients with pathologically proven hepatocellular adenomas treated with percutaneous thermal ablation at a tertiary referral center from 1999 to 2016. Demographic, procedural, and outcome data were collected and summarized with appropriate measures of central tendency and dispersion. Complications were graded per the Society of Interventional Radiology reporting guidelines. Determination of primary and secondary technique efficacies was based on post-procedural imaging., Results: Thirty-six patients (4 male, 32 female) with a median age of 35 years had 44 procedures for the treatment of 58 tumors. Twenty-two percent of patients had prior history of adenoma-related hemorrhage. The median tumor size was 2.1 cm (range 0.6-6.0). The majority of treatments were done on an outpatient basis, under moderate sedation, using radiofrequency ablation with ultrasound guidance. The median procedure time was 85 min. There were two immediate post-procedural hemorrhages (4.5% per procedure). During a median follow-up of 1.7 years (95% CI 0.2-8.0), there were no instances of malignant transformation, adenoma-related hemorrhages, or deaths. The primary and secondary technique efficacy rates were 88 and 100%, respectively., Conclusion: Thermal ablation for the treatment of hepatocellular adenoma had a primary and secondary efficacy of 88 and 100%, respectively. The major complication rate was 4.5%. The clinical efficacy during a median follow-up of 1.7 year was 100%.

Purpose: To investigate the current status and evolution of both the interventional radiologist's role as a clinician and the practice of interventional radiology (IR) over the past decade in Canada., Materials and Methods: In 2015, an online survey was e-mailed to 210 interventional radiologists, including all Canadian active members of the Canadian Interventional Radiology Association (CIRA) and nonmembers who attended CIRA's annual meeting. Comparisons were made between interventional radiologists in academic versus community practice. The results of the 2015 survey were compared with CIRA's national surveys from 2005 and 2010., Results: A total of 102 interventional radiologists responded (response rate 49%). Significantly more academic versus community interventional radiologists performed chemoembolization, transjugular intrahepatic portosystemic shunt, aortic interventions, and arteriovenous malformation embolization (P < .05). Ninety percent of respondents were involved in longitudinal patient care, which had increased by 42% compared with 2005; 46% of interventional radiologists had overnight admitting privileges, compared with 39% in 2010 and 29% in 2005. Eighty-six percent of interventional radiologists accepted direct referrals from family physicians, and 83% directly referred patients to other consultants. Sixty-three percent participated in multidisciplinary tumor board. The main challenges facing interventional radiologists included a lack of infrastructure, inadequate remuneration for IR procedures, and inadequate funding for IR equipment. Significantly more community versus academic interventional radiologists perceived work volume as an important issue facing the specialty in 2015 (60% vs 34%; P = .02)., Conclusions: Over the past decade, many Canadian interventional radiologists have embraced the interventional radiologist-clinician role. However, a lack of infrastructure and funding continue to impede more widespread adoption of clinical IR practice., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate oncologic outcomes and graft viability after percutaneous radiofrequency (RF) ablation of renal cell carcinoma (RCC) developing within renal transplant allografts., Materials and Methods: A single-institution, retrospective study reviewed all patients treated with RF ablation for RCC between February 2004 and May 2016. Ten patients were identified (age 49.6 y ± 12.6; 9 men, 1 woman) with 12 biopsy-confirmed RCC tumors within the allograft (all T1a, mean diameter 2.0 cm ± 0.7). Mean time from transplant to RCC diagnosis was 13.2 years ± 6.3. RF ablation was performed on an outpatient basis using conscious sedation. Procedural efficacy, complications, oncologic outcomes, and allograft function were evaluated. Statistical analysis with t tests and Pearson correlation compared allograft function before and after RF ablation and impact of proportional ablation size to allograft volume on function after ablation., Results: Technical success rate and primary technique efficacy were 100% (12/12). No local or distant RCC progression was seen at mean follow-up of 54.3 months ± 38.7 (range, 9-136 months). Graft failure requiring hemodialysis or repeat transplantation occurred in 3 patients (26, 354, and 750 d after RF ablation), all of whom had glomerular filtration rate (GFR) < 30 mL/min/1.73 m 2 before ablation. For all patients, mean GFR 6 months after RF ablation (35.8 mL/min/1.73 m 2 ± 17.7) was not significantly different (P = .8) from preprocedure GFR (36.2 mL/min/1.73 m 2 ± 14.3). Proportional volume of allograft that was ablated did not correlate with immediate or long-term GFR changes. One patient died of unrelated comorbidities 52 months after ablation. No major complications occurred., Conclusions: RF ablation of renal allograft RCC provided effective oncologic control without adverse impact on graft viability., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare survival outcomes of small solitary hepatocellular carcinomas (HCCs) treated with thermal ablation vs resection in the Surveillance, Epidemiology, and End Results (SEER) cohort., Materials and Methods: SEER data (November 2014 submission) were searched for histologic diagnoses of HCC and stage T1 disease (≤ 5-cm solitary tumor without vascular invasion). Comparison was made between thermal ablation and resection as the primary treatment. Overall and disease-specific survival were compared by log-rank tests (stratified for presence of fibrosis) and Cox regression (with tumor size and presence of fibrosis covariates)., Results: Of 264 patients with ≤ 2-cm HCCs, 185 underwent thermal ablation and 79 underwent resection. Patients undergoing ablation had higher Ishak scores (P = .0002). There was no difference in survival (observed P = .698, disease-specific P = .446). Of 544 patients with 2.1-4-cm HCCs, 335 underwent thermal ablation and 209 underwent resection. Patients undergoing ablation were more likely to have higher Ishak scores (P < .001), but had slightly smaller tumors (2.9 vs 3.1 cm; P < .001). There was no difference in survival (observed P = .174, disease-specific P = .609). Of 112 patients with 4.1-5-cm HCCs, 46 underwent thermal ablation and 66 underwent resection. Patients undergoing ablation had higher Ishak scores (P = .0002). Surgical resection was associated with improved survival (observed P = .009, disease-specific P = .046)., Conclusions: There was no difference in overall or disease-specific survival between surgical resection and thermal ablation for T1 HCCs ≤ 4 cm after adjusting for the presence of histologic fibrosis and tumor size in the SEER cohort. Significant benefit was observed with surgery for tumors measuring 4.1-5 cm., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group)., Materials and Methods: Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ 2 tests., Results: Technical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE., Conclusions: PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies have demonstrated that elevated neutrophil-to-lymphocyte ratios and platelet-to-lymphocyte ratios (PLRs) are associated with the presence of various malignancies. The present study evaluated various hematologic parameters and their association with renal tumor biopsy pathology., Materials and Methods: The clinical, hematologic, and pathologic parameters were obtained through a retrospective review of 475 diagnostic biopsy specimens of small renal masses from January 2001 to December 2013. The complete blood counts closest to and before the biopsies were obtained. The biopsy pathologic findings were divided into 3 groups: benign, primary renal malignancy, and nonrenal malignancy. The hematologic parameters were compared among the 3 groups. Receiver operating characteristic curves were constructed for the parameters that were significantly different among the groups. Multiple logistic regression models were used to assess whether the clinical and hematologic parameters were associated with benign or malignant pathologic findings., Results: Hematologic parameters were available for 462 cases (97%). Pathologic examination of the biopsy specimens demonstrated benign, primary renal malignancy, and nonrenal malignancy in 114 (25%), 337 (73%), and 11 (2%) patients, respectively. The PLR was significantly (P = .010) different among the 3 groups and was significantly (P = .013) greater in those with nonrenal malignancies than in those with primary renal malignancies. Using a cutoff for the PLR of 202.9 gave a sensitivity of 63.6% and specificity of 82.2% for detecting a nonrenal malignancy., Conclusion: The hematologic parameters did not differ significantly between benign and primary renal malignant masses undergoing biopsy. The PLR might be useful as a simple and inexpensive marker to help distinguish nonrenal malignancies in the workup of a small renal mass., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Renal tumor biopsy (RTB) for the characterization of small renal masses (SRMs) has not been widely adopted despite reported safety and accuracy. Without pretreatment biopsy, patients with benign tumors are frequently overtreated., Objective: To assess the diagnostic rate of RTBs, to determine their concordance with surgical pathology, and to assess their impact on management., Design, Setting, and Participants: This is a single-institution retrospective study of 529 patients with biopsied solid SRMs ≤4 cm in diameter. RTBs were performed to aid in clinical management., Outcome Measurements and Statistical Analysis: Diagnostic and concordance rates were presented using proportions. Factors that contributed to a diagnostic biopsy were identified using a multivariable logistic regression., Results and Limitations: The first biopsy was diagnostic in 90% (n=476) of cases. Of the nondiagnostic biopsies, 24 patients underwent a second biopsy of which 83% were diagnostic. When both were combined, RTBs yielded an overall diagnostic rate of 94%. Following RTB, treatment could have been avoided in at least 26% of cases because the lesion was benign. Tumor size and exophytic location were significantly associated with biopsy outcome. RTB histology and nuclear grade were highly concordant with final pathology (93% and 94%, respectively). Adverse events were low (8.5%) and were all self-limited with the exception of one. Although excellent concordance between RTB and final pathology was observed, only a subset of patients underwent surgery following biopsy. Thus it is possible that some patients were misdiagnosed., Conclusions: RTB of SRMs provided a high rate of diagnostic accuracy, and more than a quarter were benign. Routine RTB for SRMs informs treatment decisions and diminishes unnecessary intervention. Our results support its systematic use and suggest that a change in clinical paradigm should be considered., Patient Summary: Renal tumor biopsy (RTB) for pretreatment identification of the pathology of small renal masses (SRMs) is safe and reliable and decreases unnecessary treatment. Routine RTB should be considered in all patients with an indeterminate SRM for which treatment is being considered., (Crown Copyright © 2015. Published by Elsevier B.V. All rights reserved.)

Purpose: To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured., Materials and Methods: Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined., Results: Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 μg, respectively, for PG vs 1.9 mg and 105 μg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation., Conclusions: Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery., Methods: Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity., Results: All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%., Conclusion: Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery., (Copyright © 2015 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose: The objective of the study was to assess the efficacy of ovarian artery embolization (OAE) treatment for symptomatic uterine leiomyomas., Methods: A retrospective review of 17 patients who underwent OAE in conjunction with uterine artery embolization in a 6-year period (2006-2012) was performed. Ten patients had previous failed embolization, while 7 had not received any embolization therapy before. Percent uterine volume change, percent dominant fibroid volume change, and percent dominant fibroid infarction were assessed with magnetic resonance (MR) imaging. Resolution of menorrhagia, dysmenorrhea/pain, and bulk and/or pressure symptoms including urinary frequency were evaluated clinically. Change in menopausal state was also an outcome of interest., Results: Mean MR imaging follow-up was performed 3 months post-OAE. MR images showed complete infarction in the majority of cases (64.7%; n = 11), with infarction rates of 90%-100% in 3 cases, 1 case with 30%-50% infarction, and 2 cases with 0%-10% infarction. Average uterine size reduction on MR was 32.3% (95% confidence interval [CI]: 22.5%-42.2%; P < .001). The average size reduction for the dominant fibroid was 42.4% (95% CI: 27.7%-57.0%; P = .01). The mean time to final follow-up visit was 11 months. At this point complete symptom resolution (menorrhagia, dysmenorrhea and bulk-related) was achieved in 82.4% (n = 14) of cases. At the final follow-up 11.8% (n = 2) of cases reported menopause., Conclusions: We observed OAE to be an effective and safe adjunct to uterine artery embolization when hypertrophic ovarian artery(ies) require intervention. However, incomplete fibroid infarction of 23% remains a concern with a potential for long-term treatment failure. In addition, long-term effect on ovarian function is uncertain., (Copyright © 2015 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops., Methods: Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed., Results: Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization., Conclusions: The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Purpose: To determine whether patients with venous aneurysms in their arteriovenous fistulas (AVFs) have associated venous outflow stenoses., Materials and Methods: A retrospective study was performed, which included all patients presenting with dysfunction and had venous aneurysms in their AVFs. Patient's medical records and imaging studies were examined and data collected including access characteristics, patient demographics and imaging findings. Data were analyzed using Fisher's exact test., Results: A total of 89 patients (58 men, 31 women; mean age 60) presented for intervention related to access dysfunction with incident venous aneurysms over the study period. Of the 89 patients with venous aneurysms (mean diameter 2.3 cm) of their AVF's, 69 (78%) patients had an associated venous outflow stenosis. The stenoses were present most commonly in the outflow cephalic vein (57%), followed by the cephalic arch (20%), brachiocephalic vein (10%) and subclavian vein (6%). Outflow stenoses in AVFs with venous aneurysms were observed in 87% of brachiocephalic AVFs, 60% of radiocephalic AVFs and 80% of brachiobasilic AVFs. Brachiocephalic AVFs with venous aneurysms were significantly more likely to have an associated outflow stenosis than radiocephalic AVFs with venous aneurysms (P=0.007). AVFs with outflow stenosis were on average 1502 days old while AVFs without outflow stenosis were on average 2351 days old, which was a statistically significant difference (P=0.031). No statistically significant differences were observed for sex and side of the fistula., Conclusions: Outflow stenosis was observed to be associated with venous aneurysms in AVFs with a more statistically significant association in brachiocephalic AVFs compared to other AVFs.

Purpose: Various radiofrequency (RF) ablation electrode designs have been developed to increase ablation volume. Multiple heating cycles and electrode positions are often required, thereby increasing treatment time. The objective of this study was to evaluate the performance of a high-frequency monopolar induction coil designed to produce large thermal lesions (>3 cm) with a single electrode insertion in a treatment time of less than 10 minutes., Materials and Methods: A monopolar nitinol interstitial coil operated at 27.12 MHz and 200 W was evaluated. Ex vivo performance was tested in excised bovine liver (n = 22). In vivo testing (n = 10) was conducted in livers of seven Yorkshire pigs. Visual inspection, contrast-enhanced computed tomography (CT), and pathologic evaluation of ablation zones were performed., Results: Average ablation volumes in ex vivo and in vivo tests were 60.5 cm(3) ± 14.1 (5.9 × 4.4 × 4.4 cm) and 57.1cm(3) ± 13.8 (6.1 × 4.5 × 4.1cm), with average treatment times of 9.0 minutes ± 3.0 and 8.4 minutes ± 2.7, respectively. Contrast-enhanced CT ablation volume measurements corresponded with findings of gross inspection. Pathologic analysis showed morphologic and enzymatic changes suggestive of tissue death within the ablation zones., Conclusions: The RF ablation coil device successfully produced large, uniform ablation volumes in ex vivo and in vivo settings in treatment times of less than 10 minutes. Ex vivo and in vivo lesion sizes were not significantly different (P = .53), suggesting that the heating efficiency of this higher-frequency coil device may help to minimize the heat-sink effect of perfusion., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.

Background: Percutaneous needle core biopsy has become established in the management of small renal masses ≤ 4 cm (SRMs). Recent series have reported success rates of ≥ 80%. Nondiagnostic results continue to be problematic., Objective: To determine the results of SRM biopsy and the outcomes of nondiagnostic biopsy and repeat biopsy., Design, Setting, and Participants: Patients undergoing renal tumor biopsy (RTB) for suspected renal cell carcinoma (RCC) were included in a prospectively maintained database., Measurements: The database was analyzed retrospectively to determine the pathology and outcomes of SRM biopsy. Outcomes of patients with nondiagnostic biopsy were determined. Patients undergoing repeat biopsy were identified and their outcomes analyzed., Results and Limitations: Three hundred forty-five biopsies were performed (mean diameter: 2.5 cm). Biopsy was diagnostic in 278 cases (80.6%) and nondiagnostic in 67 cases (19.4%). Among diagnostic biopsies, 221 (79.4%) were malignant, 94.1% of which were RCC. Histologic subtyping and grading of RCC was possible in 88.0% and 63.5% of cases, respectively. Repeat biopsy was performed in 12 of the 67 nondiagnostic cases, and a diagnosis was possible in 10 (83.3%). Eight lesions were malignant and two were oncocytic neoplasms. Pathology was available for 15 masses after initial nondiagnostic biopsy; 11 (73%) were malignant. Larger tumor size and a solid nature on imaging predicted a successful biopsy on multivariate analysis. Grade 1 complications were experienced in 10.1% of cases, with no major bleeding and no seeding of the biopsy tract. There was one grade 3a complication (0.3%). This is a retrospective study and some data are unavailable on factors that may affect biopsy success rates. Repeat biopsy was not standard practice prior to this analysis., Conclusions: RTB can be performed safely and accurately in the investigation of renal masses ≤ 4 cm. A nondiagnostic biopsy should not be considered a surrogate for the absence of malignancy. Repeat biopsy can be performed with similar accuracy, providing a diagnosis for most patients., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Most early stage kidney cancers are renal cell carcinomas (RCCs), and most are diagnosed incidentally by imaging as small renal masses (SRMs). Indirect evidence suggests that most small RCCs grow slowly and rarely metastasize., Objective: To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology., Design, Setting, and Participants: A multicenter prospective phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and/or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression., Intervention: Patients underwent serial imaging and needle core biopsies., Measurements: We measured rates of change in tumor diameter (growth measured by imaging) and progression to ≥ 4 cm, doubling of tumor volume, or metastasis with histology on biopsy., Results and Limitations: Local progression occurred in 25 patients (12%), plus 2 progressed with metastases (1.1%). Of the 178 subjects with 209 SRMs, 127 with 151 SRMs had>12 mo of follow-up with two or more images, with a mean follow-up of 28 mo. Their tumor diameters increased by an average of 0.13 cm/yr. Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate. Limitations included no central review of imaging and pathology and a short follow-up., Conclusions: This is the first SRM active surveillance study to correlate growth with histology prospectively. In the first 2 yr, the rate of local progression to higher stage is low, and metastases are rare. SRMs appear to grow very slowly, even if biopsy proven to be RCC. Many patients with SRMs can therefore be initially managed conservatively with serial imaging, avoiding the morbidity of surgical or ablative treatment., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Aim: To compare the diagnostic utility of pelvic ultrasound (US) and magnetic resonance imaging (MRI) on the clinical decision to proceed with uterine artery embolization (UAE)., Materials and Methods: Over 2 years, 180 consecutive women (mean age 43) sought consultation for UAE, 116 underwent pelvic US and MRI before possible UAE. US was performed prior to MRI. Imaging was analysed for leiomyoma quantity, size and location, uterine volume, and the presence of potential contraindications to UAE. Discrepancies between imaging methods and cases where discrepancies could have altered management, were recorded., Results: For the 116 patients who completed imaging, the average uterine volume was 701 cm(3) using MRI versus 658 cm(3) using US (p=0.48). The average dominant leiomyoma volume was 292 cm(3) using MRI versus 253 cm(3) using US (p=0.16). In 14 (12.1%) patients US did not correctly quantify or localize leiomyomas compared with MRI (p=0.0005). Thirteen patients did not undergo UAE (patient preference n=9, pre-procedural imaging findings n=4). In the four cases where UAE was not performed due to imaging findings, relevant findings were all diagnosed by MRI compared with two by US (p=0.5). The two cases not detected by ultrasound were adenomyosis and a pedunculate subserosal leiomyoma. Of the 103 patients who underwent UAE, 14 were treated (without complication) despite the presence of a relative contraindication; all 14 relative contraindications were identified by MRI compared with 13 by US (p=1.0)., Conclusion: MRI is more accurate than US for characterizing uterine leiomyomas. In a small but statistically insignificant number of cases, MRI identified findings that were missed by US, which changed management. For patients that are unsuitable to be assessed with MRI, ultrasound alone is sufficient for pre-UAE assessment., (Copyright © 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: Radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) is widely utilized as a bridge to liver transplant with limited evidence to support efficacy. The purpose of the present study was to measure the effect of RFA on time to drop-off in HCC-listed patients., Methods: Patients with Milan criteria tumours listed between January 1999 and June 2007 were stratified into RFA (n= 77) and No Treatment groups (n= 93)., Results: The primary effectiveness of RFA was 83% (complete radiographic response). RFA was associated with a longer median wait time to transplant (9.5 vs. 5 months). Tumour-specific drop-off events were equivalent between RFA (21%) and No Treatment (12%) groups (P= 0.11). Controlling for wait time, there was no difference in overall (P= 0.56) or tumour-specific drop-off (P= 0.94). Furthermore, there were no differences in 5-year overall or tumour-free survivals from list date or transplant. Using multivariate analysis, the likelihood of receiving a transplant and patient survivals were associated with tumour characteristics (AFP, tumour number and size) and not with bridge therapy or waiting time., Discussion: RFA allows patients to be maintained longer on the waiting list without negative consequences on drop-off or survival compared with no treatment. Post-transplant outcomes are affected more by tumour characteristics than RFA or wait time., (© 2010 International Hepato-Pancreato-Biliary Association.)

Purpose: To evaluate pathologically the effectiveness of radiofrequency (RF) ablation in the treatment of pulmonary metastases., Materials and Methods: Patients with multiple pulmonary metastases scheduled for surgical resection were prospectively enrolled. Patients underwent RF ablation of one percutaneously accessible tumor and within 2-4 weeks underwent surgical resection of the ablated tumor and any additional lesions. Resected tumors all were assessed by routine light microscopy, and selected tumors were assessed by immunohistochemistry with MIB1 and proliferative cell nuclear antigen (PCNA). Relationship of ablation zone to the tumor and viability of the ablated tumors were assessed., Results: Nine patients (four men and five women) 46-76 years of age were included in the study. Four patients had metastatic colorectal carcinoma, and five patients had metastases from soft tissue sarcomas. Ablated tumors ranged from 1.0-3.0 cm in diameter. Each target lesion was completely encompassed by the ablation zone. All tumor tissue within the ablation zone showed characteristic changes of coagulative necrosis with hematoxylin and eosin staining. Tumors showed preservation of MIB1 staining but loss of PCNA protein staining. RF ablation resulted in complete coagulative necrosis of all the pulmonary metastases treated in the study., Conclusions: Although this series is small, it provides histologic support for RF ablation as an effective treatment for selected pulmonary metastases., (Copyright © 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Interventional ablative technologies have played an increasingly important role in the management of patients with primary or secondary liver malignancies. Ethanol and acetic acid ablation were the primary modalities available 2 decades ago. Today, several new technologies are available, including radiofrequency ablation, cryoablation, and microwave ablation. Radiofrequency ablation is the most widely practiced, however, cryoablation and microwave ablation are reasonable choices in certain situations. Irreversible electroporation is a newer technique, which has yet to enter clinical practice, but shows promising preliminary results. Herein, we provide a brief overview of the above-mentioned technologies with a focus on principles of ablation and technique. We also describe the use of these techniques in the context of cytoreduction, a noncurative approach aimed at reducing the overall tumour burden and providing concomitant survival benefit., (Copyright © 2010. Published by Elsevier Inc.)

Purpose: To evaluate the efficacy and safety of arterial embolization (AE) for treatment of primary postpartum hemorrhage (PPH), and the factors associated with clinical success., Material and Methods: A retrospective analysis of all patients undergoing AE for primary PPH at three institutions (N = 43) from 1996 through 2007 was conducted. Patients with an antepartum diagnosis of invasive placenta were excluded from the study. Mean patient age was 31 years +/- 5 (range, 21-40 y). Eighteen women (42%) were primiparous. Delivery details, transfusion requirements, hematology and coagulation results, embolization details, and clinical outcomes were collected. Clinical success was defined as cessation of bleeding without the need for repeat embolization, laparotomy, or hysterectomy after embolization; or death. The Fisher exact test was used to analyze nonparametric data., Results: The clinical success rate was 79% (n = 34). Four patients underwent successful repeat embolization. Two of 35 patients who had not undergone hysterectomy before embolization underwent hysterectomy for continued bleeding (without repeat embolization). One underwent hysterectomy 2 weeks after AE for uterine necrosis. One of eight patients who had undergone hysterectomy before AE required a laparotomy for a large retroperitoneal hematoma, and one patient died from cerebral anoxia secondary to hypotension despite repeat embolization. Clinical success was not related to mode of delivery, cause of PPH, transfusion requirements, time from delivery to embolization, or hysterectomy before AE (P > .05). Patients with active extravasation visualized angiographically were more likely to require repeat embolization (five of 13 [38%] vs 0 of 30 without extravasation; P < .01)., Conclusions: AE for primary PPH is safe and effective. Repeat embolization may be necessary in patients with active extravasation on angiography.

Purpose: Percutaneous biopsy of small renal tumors has not been historically performed because of concern about complications and accuracy. We reviewed our experience with percutaneous needle biopsy of small renal masses to assess the safety and accuracy of the procedure, the potential predictors of a diagnostic result and the role of biopsy in clinical decision making., Materials and Methods: A total of 100 percutaneous needle biopsies of renal masses less than 4 cm were performed between January 2000 and May 2007 with 18 gauge needles and a coaxial technique under ultrasound and/or computerized tomography guidance. A retrospective chart review was performed to document the complication rate and the ability to obtain sufficient tissue for diagnosis. Tumor size, tumor type (solid vs cystic), image guidance, biopsy number and core length were assessed for the ability to predict a diagnostic biopsy., Results: No tumor seeding or significant bleeding was observed. Of the core biopsies 84 (84%) were diagnostic for a malignant (66) or a benign (18) tumor. Larger tumor size and a solid pattern were significant predictors of a diagnostic result. Histological subtyping and grading were possible on core biopsies in 93% and 68% of renal cell carcinomas, respectively. A total of 20 patients underwent surgery after a diagnostic biopsy. The histological concordance of biopsies and surgical specimens was 100%., Conclusions: Percutaneous needle biopsy of renal masses less than 4 cm is safe and provides adequate tissue for diagnosis in most cases. Larger tumor size and a solid pattern are significant predictors of a successful biopsy. Renal tumor biopsy decreases the rate of unnecessary surgery for benign tumors and can assist the clinician with treatment decision making, especially in elderly and unfit patients.

Purpose: To assess the safety and efficacy of uterine artery embolization (UAE) treatment of pedunculated subserosal leiomyomas., Materials and Methods: A review of patients undergoing UAE in a 30-month period (July 2004 to December 2006) was performed. Cases in which a pedunculated subserosal tumor (volume>or=4 cm3) was embolized were analyzed. The preprocedural volumes of the pedunculated tumor and uterus and the diameter and vascularity of the tumor and stalk were recorded. Posttreatment sizes of the pedunculated leiomyoma, stalk, and uterus were recorded, as was the presence or absence of complication(s)., Results: A total of 240 patients underwent embolization. Pedunculated subserosal leiomyomas were treated in 16 women, with a technical success rate of 100%. Preprocedural mean tumor and uterine volumes were 372 cm3 and 789 cm3, respectively. The mean stalk diameter was 2.7 cm (range, 0.8-7.8 cm). All pedunculated leiomyomas exhibited enhancement on contrast agent-enhanced magnetic resonance (MR) imaging (n=13) or vascularity on Doppler ultrasonography (US; n=3). Stalk vascularity was noted on MR imaging in 13 patients and was not assessed in the remaining three, who underwent US imaging. Imaging follow-up (mean, 5.9 months after UAE) demonstrated mean tumor volume reduction of 39.3% (95% confidence interval [CI], 28.2%-50.5%) and mean uterine volume reduction of 37.6% (95% CI, 26%-49.3%). There were no cases of continued tumor perfusion and no major complications. There was one minor complication of prolonged hospital stay (36 hours) for pain control., Conclusion: UAE was successfully and safely performed for pedunculated subserosal leiomyomas, with a tumor volume reduction of 39% and no unique complications related to these lesions.

Purpose: To describe the current state and limitations to interventional radiology (IR) in Canada through a large, national survey of Canadian interventional radiologists., Methods: An anonymous online survey was offered to members of the Canadian Interventional Radiology Association (CIRA). Only staff radiologists were invited to participate., Results: Seventy-five (75) responses were received from a total of 247, giving a response rate of 30%. Respondents were split approximately equally between academic centers (47%) and community practice (53%), and the majority of interventional radiologists worked in hospitals with either 200-500 (49%) or 500-1,000 (39%) beds. Procedures listed by respondents as most commonly performed in their practice included PICC line insertion (83%), angiography and stenting (65%), and percutaneous biopsy (37%). Procedures listed as not currently performed but which interventional radiologists believed would benefit their patient population included radiofrequency ablation (36%), carotid stenting (34%), and aortic stenting (21%); the majority of respondents noted that a lack of support from referring services was the main reason for not performing these procedures (56%). Impediments to increasing scope and volume of practice in Canadian IR were most commonly related to room or equipment shortage (35%), radiologist shortage (33%), and a lack of funding or administrative support (28%)., Conclusion: Interventional radiology in Canada is limited by a number of factors including funding, manpower, and referral support. A concerted effort should be undertaken by individual interventional radiologists and IR organizations to increase training capacity, funding, remuneration, and public exposure to IR in order to help advance the subspecialty.

Purpose: The incidence of renal cell carcinoma is increasing worldwide and there are new treatments for localized as well as metastatic tumors. The traditional role for percutaneous biopsy of renal masses has been limited, and so there is little general experience. There have been concerns about safety and accuracy. This review provides an update on the current techniques, indications and accuracy of needle biopsy of renal tumors., Materials and Methods: PubMed and MEDLINE were searched for English language reports of percutaneous needle core biopsy and fine needle aspiration of renal tumors that were published from 1977 to 2006., Results: With the development of new biopsy techniques and wider experience with percutaneous probe ablation therapies the risk of tumor seeding appears negligible. Significant bleeding is unusual and almost always self-limiting. At centers with expertise needle core biopsy with or without fine needle aspiration appears to provide adequate specimens for an accurate diagnosis in more than 90% of renal masses., Conclusions: Percutaneous biopsy of renal masses appears to be safe and it carries minimal risk of tumor spread. Urologists should consider increasing the indications for renal biopsy of small renal masses that appear to be renal cell carcinoma, especially in elderly and unfit patients. With more experience and followup preoperative biopsy has the potential to decrease unnecessary treatment since up to a third of small renal masses are now reported to be benign at surgery. Percutaneous biopsy may also allow a better selection of renal tumors for active surveillance and minimally invasive ablative therapies. Finally, there is potential for stratifying initial therapy for metastatic renal cell carcinoma by histological subtype and in the future molecular characteristics.

Purpose: To determine if there is a difference in intervention patency for central venous stenosis (CVS) and occlusion between patients with autogenous hemodialysis fistulas and those with grafts., Material and Methods: A retrospective study was performed from March 1998 to September 2005 identifying all patients with autogenous fistulas and synthetic grafts who underwent percutaneous angioplasty and/or stent placement for CVS. This study cohort consisted of 38 patients (22 with fistulas and 16 with grafts). Age, sex, type of access, location and side of the access, location and side of the CVS, presence of diabetes, previous hemodialysis catheter placement, date and type of interventions, and outcomes were recorded. The patency of each intervention was estimated by using the Kaplan-Meier survival curves. Univariate and multivariate analysis of the variables were performed., Results: Eighty-nine interventions were performed; 83 were angioplasties and six were stent placements. Previous catheter placement on the side of the CVS occurred in 29 of the 38 patients (76%). Technical and clinical success of the interventions were 93.3% and 94.4% respectively. The intervention or primary patency rates +/- standard errors at 3, 6, and 9 months in the fistula group were 88.5% +/- 4.8, 59.4% +/- 7.6, and 46% +/- 7.9, respectively. In the graft group, the rates were 78.1% +/- 7.3, 40.7% +/- 9, and 16% +/- 7.3, respectively. With multivariate analysis, intervention patency remained significantly longer for fistulas (P .014) and in patients who did not have a previous catheter (P .001)., Conclusion: Longer intervention-free survival for CVS was observed in patients with autogenous fistulas compared with grafts and in patients who did not previously undergo hemodialysis catheter insertion.

Fine needles with an end hole or multiple side holes have traditionally been used for percutaneous ethanol injection (PEI) of hepatomas. This study retrospectively evaluates the safety and efficacy of PEI of unresectable medium-to-large (3.5-9 cm) hepatomas using a multipronged needle and with conscious sedation. Twelve patients, eight men and four women (age 51-77 years; mean: 69) received PEI for hepatomas, mostly subcapsular or exophytic in location with average tumor size of 5.6 cm (range: 3.5-9.0 cm). Patients were consciously sedated and an 18G retractable multipronged needle (Quadrafuse needle; Rex Medical, Philadelphia, PA) was used for injection under real-time ultrasound guidance. By varying the length of the prongs and rotating the needle, the alcohol was widely distributed within the tumor. The progress of ablation was monitored by contrast-enhanced ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) after each weekly injection and within a month after the final (third) injection and 3 months thereafter. An average total of 63 mL (range: 20-154 ml) of alcohol was injected per patient in an average of 2.3 sessions. Contrast-enhanced CT, ultrasound, or MRI was used to determine the degree of necrosis. Complete necrosis was noted in eight patients (67%), near-complete necrosis (90-99%) in two (16.7%), and partial success (50-89%) in two (16.7%). Follow-up in the first 9 months showed local recurrence in two patients and new lesions in another. There was no mortality. One patient developed renal failure, liver failure, and localized perforation of the stomach. He responded to medical treatment and surgery was not required for the perforation. One patient had severe postprocedural abdominal pain and fever, and another had transient hyperbilirubinemia; both recovered with conservative treatment. PEI with a multipronged needle is a new, safe, and efficacious method in treating medium-to-large-sized hepatocellular carcinoma under conscious sedation. Its survival benefits require further investigations.

Aims: In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population., Materials and Methods: This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response., Results: The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE., Conclusions: The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Four patients with symptomatic uterine fibroids measuring less than 6 cm underwent laparoscopic ultrasound-guided radiofrequency ablation (RFA) using multiprobe-array electrodes. Follow-up of the treated fibroids was performed with gadolinium-enhanced magnetic resonance imaging (MRI) and patients' symptoms were assessed by telephone interviews. The procedure was initially technically successful in 3 of the 4 patients and MRI studies at 1 month demonstrated complete fibroid ablation. Symptom improvement, including a decrease in menstrual bleeding and pain, was achieved in 2 patients at 3 months. At 7 months, 1 of these 2 patients experienced symptom worsening which correlated with recurrent fibroid on MRI. The third, initially technically successfully treated patient did not experience any symptom relief after the procedure and was ultimately diagnosed with adenomyosis. Our preliminary results suggest that RFA is a technically feasible treatment for symptomatic uterine fibroids in appropriately selected patients.

Purpose: To assess the efficacy and durability of percutaneous transluminal angioplasty (PTA)/stent placement for treatment of chronic mesenteric ischemia (CMI)., Materials and Methods: A retrospective review of patients treated from January 1986 to August 2003 was conducted. Twenty-nine patients (mean age, 62 years) were treated for clinical symptoms consistent with CMI. Clinical diagnosis was verified with angiographic assessment and PTA with or without stent placement was performed based on angiographic and/or pressure gradient findings. Outcomes were estimated with the Kaplan-Meier method., Results: A total of 63 interventions were performed in 29 patients during the study period. Of these 63 interventions, 46 PTA and 17 stent implantation procedures were performed. Thirty-four interventions were performed for SMA stenosis/occlusion, 17 interventions for celiac artery stenosis/occlusion, and four interventions were performed on aorto-mesenteric graft stenoses. Technical success was 97%, and clinical success (defined as clinical resolution of symptoms) was 90% (26 of 29 patients). Mean duration of follow-up was 28.3 months. Primary patency for all interventions at 3, 6, and 12 months was 82.7% (95% CI: 68.7-96.7), 78.9% (66.7-91.1), and 70.1% (55.1-85.6), respectively. Primary assisted patency for all interventions at 3, 6, and 12 months was 87.9% (79.0-95.3), 87.9% (79.2-95.1), and 87.9% (77.3-98.3), respectively. An average of 1.9 interventions per patient was required. One major complication occurred (3.4%). There were three minor complications (10.3%)., Conclusions: Percutaneous intervention for CMI is safe with durable early and midterm clinical success. However, repeated intervention is often required for improved primary assisted patency.