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Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common form of neuroendocrine neoplasia, but there is no current consensus for the sequencing of approved therapies, particularly with respect to peptide receptor radionuclide therapy (PRRT). This comprehensive review evaluates the data supporting approved therapies for GEP-NETs and recommendations for therapeutic sequencing with a focus on how PRRT currently fits within sequencing algorithms. The current recommendations for PRRT sequencing restrict its use to metastatic, inoperable, progressive midgut NETs; however, this may change with emerging data to suggest that PRRT might be beneficial as neoadjuvant therapy for inoperable tumors, is more tolerable than other treatment modalities following first-line standard dose somatostatin analogs, and can be used as salvage therapy after disease relapse following prior successful cycles of PRRT. PRRT has also been shown to reduce tumor burden, improve quality of life, and prolong the time to disease progression in a broad spectrum of patients with GEP-NETs. As the various potential benefits of PRRT in GEP-NET therapy continues to expand, it is necessary to review and critically evaluate our treatment algorithms for GEP-NETs.

Colorectal liver metastasis (CRLM) is a leading cause of morbidity and mortality in patients with colorectal cancer. Hepatic arterial infusion (HAI) chemotherapy has been demonstrated to improve survival in patients with resected CRLM and to facilitate conversion of technically unresectable disease.Between 2016 and 2018, n = 22 HAI pumps were placed for CRLM. All patients received systemic chemotherapy concurrently with HAI floxuridine/dexamethasone. Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method.HAI pumps were placed in seven patients with completely resected CRLM and 15 patients with unresectable disease. Twenty-one patients received HAI floxuridine with a median of 5 total HAI cycles (interquartile range: 4-7). Biliary sclerosis was the most common HAI-related complication (n = 5, 24%). Of the 13 patients treated to convert unresectable CRLM, 3 (23%) underwent hepatic resection with curative intent after a median of 7 HAI cycles (range: 4-10). For all HAI patients, the mean OS was 26.7 months from CRLM diagnosis, while the median PFS and hepatic PFS from pump placement were 9 and 13 months, respectively.Concomitant HAI and systemic therapy can be utilized at multidisciplinary programs for patients with advanced CRLM, both in the adjuvant setting and to facilitate conversion of unresectable disease.

Variant hepatic arterial anatomy (vHAA) is thought to occur in 20-30% of patients. Hepatic arterial infusion (HAI) pump placement for liver cancers requires thorough hepatic artery dissection; we sought to compare vHAA identified during pump placement with established dogma.Between 2016 and 2020, n = 30 patients received a HAI pump. Intra-operatively identified vHAA was characterized and compared with published data.vHAA was identified in 60% (n = 18) of patients, significantly higher than 19% (3671 of 19013) in the largest published series (P 0.001). The most common variations were accessory left (n = 12; 40%) and replaced right (n = 6; 20%) hepatic arteries; six (20%) had ≥2 variants. Pre-operative imaging correctly identified 67% of variant hepatic arteries.Meticulous operative dissection of the hepatic arterial tree reveals vHAA not captured by imaging or cadaveric dissection. vHAA likely has a higher prevalence than previously reported and should be addressed to optimize therapeutic efficacy of HAI pump therapy.

Background: Hepatocellular carcinoma (HCC) with portal vein invasion (PVI) has a poor prognosis with limited treatment options. Intra-arterial brachytherapy (IAB) and transarterial chemoembolization (TACE) yield local control but risk accelerating liver dysfunction. The outcomes, survival, and safety of selective liver-directed treatment are reported. Methods: Thirty-seven consecutive patients with HCC and PVI treated between 2009 and 2015 were reviewed from a prospectively collected database. Univariate analysis, Kaplan-Meier plots using the log-rank method, and multivariate analyses were performed. Statistical significance was defined as P Results: Most patients (59%) had PVI identified at initial HCC diagnosis. The liver-directed therapy group (n=22) demonstrated a survival advantage versus the systemic/supportive care group (n=14) [23.6 (5.8, 30.9) vs . 6.0 (3.5, 8.8) months]. Patients indicated for liver directed therapy had unilateral liver involvement (100% vs . 43%, P vs . 208.0, P=0.002), and lower mean Child-Turcotte-Pugh (CTP) score (5.9 vs . 7.2, P=0.04) and tolerated treatment without serious complications. Conclusions: In HCC patients presenting with PVI, liver-directed therapy was safely performed in patients with limited venous involvement and preserved liver function. Liver-directed therapy extended survival for these patients indicated for palliative chemotherapy by traditional guidelines.

To examine the effectiveness of antithrombotic medications to prevent venous stent malfunction for iliocaval occlusive disease. A retrospective analysis was performed on 62 patients who underwent technically successful endovascular iliocaval stent placement between May 2008 and April 2017. Clinical records were reviewed for demographic information, procedure details, post-stenting antithrombotic prophylaxis and stent patency on follow-up. Stent malfunction was defined as > 50% stenosis or occlusion at follow-up. Risk factors for stent malfunction were assessed with univariable and multiple Cox proportional hazard models. The median follow-up period was 11.6 months (range 0.1–76.4). Overall primary and secondary cumulative patency rates at 12 months were 70.0% and 92.4%, respectively. After stent placement, 97% of patients received anticoagulation with warfarin, enoxaparin or a factor Xa inhibitor. In addition, 61% received antiplatelet prophylaxis with aspirin, clopidogrel or a combination. In multiple Cox regression analysis, post-stenting antiplatelet use remained significantly associated with primary stent patency (HR = 0.28, P = 0.022). After iliocaval venous stenting, stent patency was best predicted by concomitant antiplatelet and anticoagulation therapy rather than anticoagulation alone. This novel finding warrants further research underlying mechanisms leading to venous stent thrombosis, and has implications for optimal medical management after venous stenting.

Purpose To evaluate long-term effects of yttrium-90 (90Y) transarterial radioembolization (TARE) for unresectable hepatic metastases of neuroendocrine tumors (NETs). Materials and Methods Retrospective analysis of 93 patients (47 women, 46 men; mean age 59 y) who underwent resin-based 90Y TARE was performed. Variables associated with overall survival were analyzed using univariate and multivariate models. Changes in serologic values and imaging characteristics were assessed with long-term follow-up. Results Unilobar TARE was performed in 48 patients, and staged bilobar TARE was performed in 45 patients. In multivariate analysis, ascites (P = .002) and extrahepatic metastases (P = .038) at baseline were associated with poor survival. Among 52 patients who had > 1 year of follow-up, significant increases in alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were observed; however, only 4 patients experienced grade 3 serologic toxicities. Imaging signs of cirrhosis-like morphology and portal hypertension were observed in 15 of 52 patients, more frequently in patients treated with bilobar TARE compared with unilobar TARE. Patients treated with bilobar TARE exhibited significantly increased hepatobiliary enzymes and decreased platelet count. Sustained increases in liver enzymes were observed in patients with > 4 years of follow-up. No radioembolization-related liver failure or grade 4 toxicity was observed. Conclusions 90Y radioembolization using resin microspheres demonstrated a high safety profile for NET liver metastases, with low-grade, although sustained, long-term liver toxicity evident > 4 years after treatment. Bilobar treatment suggested a trend for treatment-related portal hypertension. Ongoing research will help define parameters for optimizing durable safety and efficacy of radioembolization in this setting.

PURPOSE/OBJECTIVES To describe the presence, frequency, severity, and distress of symptoms in outpatients with advanced hepatocellular carcinoma toward the end of life, and the variability in psychological and physical symptom distress between and within patients over time. . DESIGN A prospective, longitudinal, descriptive design. . SETTING Outpatient clinics at two healthcare institutions. . SAMPLE 18 patients (15 men and 3 women) with hepatocellular carcinoma and a mean age of 63.3 years (range = 54-81 years). . METHODS Data were collected monthly for six months. Patients completed the Memorial Symptom Assessment Scale, which reports a total score, and three subscales that provide global distress, psychological distress, and physical distress scores. . MAIN RESEARCH VARIABLES Global, psychological, and physical distress. . FINDINGS Patients reported lack of energy and pain as the most frequent and distressing symptoms. Problems with sexual interest or activity was the fourth most present symptom after drowsiness. Global Distress Index mean scores had notable variability between and within patients over time. During data collection, six patients died. None were referred to palliative care. . CONCLUSIONS Gaining knowledge about symptom distress and prevalent symptoms experienced by patients with advanced hepatocellular carcinoma is critical for designing symptom management strategies that are comprehensive and tailored to patients to optimize their quality of life as they approach death. . IMPLICATIONS FOR NURSING Nurses play a vital role in advocating for, initiating, and providing comprehensive holistic care based on individual patient needs by facilitating discussions about apparent and less apparent distressing symptoms, including those related to sexuality.

Background The aim of the study was to evaluate the association between baseline Lipiodol uptake in hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE) with early tumor recurrence, and to identify a threshold baseline uptake value predicting tumor response. Patients and methods A single-institution retrospective database of HCC treated with Lipiodol-TACE was reviewed. Forty-six tumors in 30 patients treated with a Lipiodol-chemotherapy emulsion and no additional particle embolization were included. Baseline Lipiodol uptake was measured as the mean Hounsfield units (HU) on a CT within one week after TACE. Washout rate was calculated dividing the difference in HU between the baseline CT and follow-up CT by time (HU/month). Cox proportional hazard models were used to correlate baseline Lipiodol uptake and other variables with tumor response. A receiver operating characteristic (ROC) curve was used to identify the optimal threshold for baseline Lipiodol uptake predicting tumor response. Results During the follow-up period (mean 5.6 months), 19 (41.3%) tumors recurred (mean time to recurrence = 3.6 months). In a multivariate model, low baseline Lipiodol uptake and higher washout rate were significant predictors of early tumor recurrence (P = 0.001 and < 0.0001, respectively). On ROC analysis, a threshold Lipiodol uptake of 270.2 HU was significantly associated with tumor response (95% sensitivity, 93% specificity). Conclusions Baseline Lipiodol uptake and washout rate on follow-up were independent predictors of early tumor recurrence. A threshold value of baseline Lipiodol uptake > 270.2 HU was highly sensitive and specific for tumor response. These findings may prove useful for determining subsequent treatment strategies after Lipiodol TACE.

e16119 Background: Assessment of the clinical outcomes and prognostic value of genomic mutations in colorectal liver metastases treated with Y90 radioembolization. Methods: Multi-institution retrospective study of patients who underwent Y-90 radioembolization treatment after tumor genotyping was completed for CRLM. Patients treated between 2008 and 2019 were included from 7 institutions within the United States and Europe. Patient demographics, tumor characteristics, pre- and post- treatment regimens, serum laboratory evaluation and overall survival were analyzed between patients with differing histopathologic and genomic status. Tumor genotyping was obtained for KRAS, BRAF, PIK3CA, AKT, MEK, NRAS and MMR genes. Kaplan-Meier survival estimation and multivariate Cox regression were analyzed. Results: 434 patients treated with Y90 radioembolization fulfilled the inclusion criteria. Of the total cohort, 399 patients were available who had sufficient documented tumor profiling data. Average age at diagnosis was found to be 58.8 years for all patients (60.1% male, 39.9% female). Decreased survival post Y-90 treatment was shown in those patients with increased number of documented tumor mutations (n = 0,1 or ≥2 mutations: median OS 9.63 mos vs. 6.2 mos vs. 5.3 mos; p < 0.0001). Additionally, the median survival in patients with mutated BRAF was 5.0 months, as compared to 9.4 months in those patients with wild-type BRAF (p = 0.0009). Primary colon cancer sidedness was also shown to demonstrate significant difference in survival post-Y90 treatment with left sided primaries showing improved median overall survival (left = 7.5 mos vs. right = 6.3 mos; p = 0.04.) Patient demographics including gender, age and race were not shown to be significant in overall survival post-Y90 treatment (p-values > 0.05). Number of tumor mutations (p < 0.0001, HR = 1.69 CI: 1.39-2.05), BRAF status (p = 0.02, HR = 2.6 CI:1.20-4.9), primary sidedness (p = 0.01, HR = 0.65 CI:0.47-0.90), pre-treatment neutrophil-lymphocyte ratio (p = 0.04, HR = 1.42 CI: 1.02-1.98) and KRAS mutation status (p < 0.0001, HR = 1.81 CI: 1.45-2.26) all persisted as significant predictors of survival on multivariate analysis. Conclusions: Number of tumor mutations, BRAF mutation status, primary tumor sidedness, neutrophil-lymphocyte ratio and KRAS mutation status are all shown to be significant prognostic factors in patients with colorectal liver metastases receiving Y90 radioembolization.

To evaluate yttrium-90 (Y90) radioembolization outcomes across Child-Pugh scores in patients with advanced hepatocellular carcinoma (HCC).From April 2005 to December 2018, 106 consecutive patients with BCLC Stage C HCC who underwent Y90 radioembolization were retrospectively analyzed. Exclusion criteria included additional malignancy (n = 7), death unrelated to liver disease (n = 2), metastases (n = 2), or lack of follow-up data (n = 4). Ninety-one patients were analyzed. Overall survival (OS) was calculated using the Kaplan-Meier method and compared between groups with the log-rank test. Cox regression modeling was used to evaluate the prognostic factors for survival.Mean age was 63 years and 85.7% were male. HCV infection was the most common etiology of liver disease (58.2%). Sixty-four (70.3%) patients were Child-Pugh A, 19 (20.9%) patients were B7, and eight (8.8%) patients were B8-9. Median OS after radioembolization was 20.2 [95% confidence interval (CI) 13.0-27.4], 6.0 (95% CI 4.4-7.6), and 5.5 (95% CI 2.5-8.5) months for Child-Pugh A, B7, and B8/9 groups, respectively (P 0.001 for B7 vs. A; P = 0.537 for B7 vs. B8/9). The multivariable Cox regression analysis showed that Eastern Cooperative Oncology Group (ECOG) score (P 0.001), Child-Pugh class (P = 0.005), tumor morphology pattern (P = 0.012), and Y90 delivery location (P = 0.020) were significant independent predictors of overall survival.Outcomes from Y90 for BCLC C HCC for Child-Pugh B7 patients were equivalent to B8/9 patients and significantly worse compared to Child-Pugh A patients. Although further research is warranted, these results suggest continued cautious patient selection for radioembolization in advanced HCC.

Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

239 Background: Assessment of the clinical outcome and prognostic factors of patients receiving Y90 radioembolization to treat colorectal liver metastases. Methods: Multi-institution retrospective study of patients with CRLM who received Y-90 radioembolization after undergoing molecular testing was performed. Patients treated between 2008 and 2019 were included from 7 institutions within the United States and Europe. Patient demographics, systemic therapy regimens, tumor characteristics, laboratory values and overall survival were analyzed between patients with differing histopathologic and genomic status. Genomic profiling was obtained for KRAS, BRAF, PIK3CA, AKT, MEK, NRAS and MMR genes. Kaplan-Meier survival estimation and multivariate Cox regression were analyzed. Results: 445 patients treated with Y90 radioembolization fulfilled the inclusion criteria. Of the total cohort, 430 patients were available who had documented KRAS mutation status. Average age at diagnosis was found to be 58.4 years for all patients (57.6% male, 42.4% female). Decreased survival post Y90 treatment was shown in those patients with mutant KRAS. The median survival in patients with mutated KRAS was 5.7 months, as compared to 8.0 months in those patients with wild-type KRAS (p< 0.0001). Patient demographics including age, gender and race were not shown to be significant in overall survival post-Y90 treatment (p-values >0.05). The average number of systemic chemotherapy treatments prior to Y90 was 2.15 and was similar between KRAS groups (mutant vs wild type.) KRAS status persisted as a significant predictor of survival on multivariate analysis (p< 0.0001; HR 2.1 CI: 1.54-2.85). Conclusions: KRAS status is shown as a significant prognostic factor in patients with colorectal liver metastases receiving Y90 radioembolization.

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE. Transjugular intrahepatic portosystemic shunt (TIPS) creation increases the risk of hepatic encephalopathy due to overshunting. Techniques exist to secondarily reduce the shunt for refractory encephalopathy. The purpose of this article is to describe a technique for primary TIPS restriction using a balloon-expandable stent within the transvenous hepatic track followed by deployment of a self-expanding polytetrafluoroethylene–lined stent-graft within the balloon-expandable stent to create the TIPS. CONCLUSION. This technique enables control over the degree of portosystemic shunting in elective TIPS creation.

Inferior vena cava filters are placed in selected patients to protect against potentially fatal pulmonary embolism. Generally, filter placement is regarded as a safe procedure although rare complications may arise. Recurrent thromboembolic events are the most common complications assoiated with inferior vena cava filters; however, there are multiple reports of filter fracture, migration, embolization, penetration and perforation. The aim of this report is to illustrate a serious potential complication of inferior vena cava filters. We report a rare case of symptomatic retroperitoneal hemorrhage occurring 3 weeks after filter placement treated successfully with selective arterial embolization of a lumbar artery laceration. This case serves to highlight the importance of retrieving filters when they are no longer beneficial.

Purpose To evaluate dose-response relationship in yttrium-90 ( 90 Y) resin microsphere radioembolization for neuroendocrine tumor (NET) liver metastases using a tumor-specific dose estimation based on technetium-99m–labeled macroaggregated albumin ( 99m Tc MAA) single photon emission computed tomography (SPECT)-CT. Materials and Methods Fifty-five tumors (mean size 3.9 cm) in 15 patients (10 women; mean age 57 y) were evaluated. Tumor-specific absorbed dose was estimated using a partition model. Initial (median 2.3 months) follow-up data were available for all tumors; last (median 7.6 months) follow-up data were available for 45 tumors. Tumor response was evaluated using Modified Response Evaluation Criteria in Solid Tumors (mRECIST) on follow-up CT. Tumors with complete or partial response were considered responders. Mean tumor absorbed dose was 231.4 Gy ± 184.3, and mean nontumor liver absorbed dose was 39.0 Gy ± 18.0. Results Thirty-six (65.5%) and 30 (66.7%) tumors showed response at initial and last follow-up, respectively. Mean absorbed doses in responders and nonresponders at initial and last follow-up were 285.8 Gy ± 191.1 and 128.1 Gy ± 117.1 ( P = .0004) and 314.3 Gy ± 195.8 and 115.7 Gy ± 117.4 ( P = .0001). Cutoff value of ≥ 191.3 Gy for tumor-specific absorbed dose predicted tumor response with 93% specificity, whereas P = .007). Conclusions Tumor-specific absorbed dose, estimated with a partition model, was significantly associated with tumor response in NET liver metastases. An estimated dose ≥ 191.3 Gy predicted treatment response with high sensitivity and specificity.

OBJECTIVE. The purpose of this article is to highlight the clinical and radiologic evaluation of patients referred for transjugular intrahepatic portosystemic shunt (TIPS) creation. CONCLUSION. TIPS creation is an effective procedure for portal diversion in the setting of recurrent variceal bleeding or diuretic refractory ascites secondary to portal hypertension. Close collaboration between hepatologists and interventional radiologists is important for appropriate patient selection. Pre-procedural clinical and radiologic evaluation is fundamental for successful management of these patients.

OBJECTIVE. The purpose of this article is to present our experience in treating patients with hepatic metastases from a neuroendocrine primary malignancy. CONCLUSION. The tumor and patient characteristics, vascular access, and features of treatment all play a role in the long-term management of patients with metatastic neuroendocrine tumors. Routine prophylactic measures are recommended to reduce the frequency and severity of crisis events related to hormone release in patients with neuroendocrine tumors.

Patients with Barrett's esophagus (BE) and cirrhosis who develop high-grade dysplasia (HGD) or adenocarcinoma in the setting of esophageal varices present a unique therapeutic dilemma. There is limited literature regarding the optimal management of varices prior to invasive procedures or surgery involving the distal esophagus. We present a case of variceal decompression with a transjugular intrahepatic portosystemic shunt (TIPS) allowing for successful endoscopic mucosal resection (EMR) of BE with HGD overlying esophageal varices.

443 Background: To assess the relative efficacy and toxicity associated with TACE+Ablation (Ablation) or TACE+SBRT (SBRT) in a large cohort of patients with unresectable HCC. Methods: Patients with HCC undergoing Ablation or SBRT from 2006-2016 with available follow up were included. Treatment groups were different at baseline regarding tumor stage (BCLC A, B and C: 96%, 4%, 0% (Ablation) vs. 73%, 14% and 13% (SBRT), P < 0.001) and severity of liver disease (CTP A, B, and C: 55%, 45% and 0% (Ablation) vs. 50%, 41%, and 9% (SBRT), P = 0.007). Propensity scores were calculated with age, sex, BCLC stage, CTP class, etiology of liver disease, tumor number, and diameter to balance the cohorts. Average treatment effects on survival with multivariable propensity score-weighted competing risk Cox regression models were evaluated, with BCLC stage, number of treated tumors and liver transplant as additionally controlled variables. Primary outcome was overall survival (OS). Secondary outcomes were progression-free survival (PFS), local tumor control and hepatotoxicity. Treatment-related hepatotoxicity was defined as a two point change in CTP within six months after treatment. Results: 192 subjects were included (101 Ablation, 91 SBRT; median age=60 years, 75% men). Liver disease included HCV (78%), alcohol (35%) and NASH (8%). Liver transplant-adjusted 1- and 2-year OS rates were significantly greater for Ablation vs SBRT (88% vs. 75% and 77% vs. 50%, P

Purpose To describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans. Materials and Methods The initial 25 cases of intravascular US–guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass–related complications. Results Intravascular US–guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass–related complications between TIPS techniques. Intravascular US–guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd–Chiari syndrome and in a patient with intrahepatic tumors. Conclusions Intravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd–Chiari syndrome, or hepatic tumors.

A traumatic thoracic aortic injury is fatal in the majority of cases. Surviving the aortic injury in addition to the myriad of associated trauma requires comprehensive medical management from many medical services. Balancing these services and coordinating the medical care requires free and open communication between services. Although one might assume a thoracic aortic injury takes precedence over other injuries, an organized plan of care in which the morbidity of the injury as well as the consequences of treatment of each injury helps provide an appropriate "rank order" in the treatment process. A patient with a thoracic aortic injury can be observed for several days while additional injuries are treated, as long as appropriate blood pressure controls are observed. The treatment order for multiple injuries must be reevaluated on a regular basis to adjust for changes in the overall clinical condition. This rank order to treatment and scheduled treatment plan allows for appropriate imaging, evaluation, and coordination of services in preparation for the placement of a thoracic aortic stent graft. The goal of treatment is to reduce the risk of aortic rupture and subsequent fatal hemorrhage. Choosing an open surgical repair versus an endovascular stent graft depends upon physician expertise and clinical status of the patient. In the appropriate clinical setting, endovascular repair of the thoracic aortic injury has become the treatment of choice at the authors' institution in patients with significant operative risks and extensive comorbid injuries. Specific characteristics of the injured aorta also dictate the type of endovascular device required for repair. Case reviews of a patient with blunt trauma and a patient with penetrating trauma used to demonstrate clinical parameters, imaging options, and details of stent graft choice and placement, are presented followed by a review of the literature.

A ruptured abdominal aortic aneurysm is an emergency anywhere in the world. Physician expertise and clinical status of the patient drive the treatment modalities in the majority of cases. Independent of treatment choice, the goal of therapy is to stabilize the patient as quickly as possible in a manner that establishes maximum survival and minimum morbidity and provides a long-lasting, durable result. Endovascular aortic repair has become an acceptable alternative to open surgical repair in a subset of patients presenting with ruptured aortoiliac aneurysms. Patient selection, physician preference, institutional experience, and availability of appropriate equipment make up a majority of factors influencing treatment choices. Once the decision has been made to treat the patient via endovascular techniques, then experience, planning, and the ability to improvise solutions "on the fly" become vital components to the success of the procedure. Two separate cases, requiring intraprocedural improvisation, are presented followed by a review of the literature.

Purpose This study evaluated the aerostatic properties of the catheter clamp during over-the-wire catheter exchanges and determined if protective devices reduce volumes of air emboli (AE). Materials and Methods A cuffed catheter was placed in an AE model in physiologic conditions and the volume of AE was recorded during 60 seconds ( n = 10). Similarly, the volume of AE entering the model during 30 seconds was recorded with the catheter clamp open ( n = 10) or closed over the wire ( n = 10), and with the sliding clamp in the open position ( n = 10). The volume of AE during 60 seconds was recorded with the sliding clamp closed over the wire ( n = 10) and with the aerostatic valve with ( n = 10) and without ( n = 10) a wire in place. Results Without a wire, no AE occurred with the catheter clamp closed (60 seconds, n = 10). There was no statistically significant difference between the volumes of AE with the catheter clamp open or closed over the wire during 30 seconds (43 mL ± 4 and 32 mL ± 11, respectively). With the protective devices in place and the wire unchanged in position, no AE occurred during 60 seconds. A positive control (sliding clamp and catheter clamp open, n = 10) yielded AE volumes of 44 mL ± 5 in 30 seconds. Conclusions AE can occur with the catheter clamp closed over a wire. Protective devices reduce the volume of AE under simulated physiologic conditions and are recommended with over-the-wire catheter exchanges.

Ruptured aortic aneurysms uniformly require emergent attention. Historically, urgent surgical repair or medical management was the only treatment options. The development of covered stent grafts has introduced a third approach in the care of these critical patients. The clinical status of the patient and local physician expertise drive the treatment modalities in the majority of cases. The goal of therapy in these patients is to stabilize the patient as quickly as possible, establish maximum survival with minimum morbidity, and provide a long lasting result. The endovascular approach has become an acceptable treatment option in an increasing number of patients presenting with ruptured aneurysmal disease of both the descending thoracic and abdominal aorta. Major factors influencing treatment include patient clinical status, characteristics of the aorta, physician preference, institutional experience, and availability of appropriate equipment. Planning, experience, and the ability to improvise effective solutions are keys to the success of the procedure when endovascular techniques are utilized. Three separate cases, requiring intraprocedural improvisation, are presented followed by a review of the literature.

Retrieval of an optional inferior vena cava (IVC) filter with retained thrombus may result in pulmonary emboli if the trapped thrombus is not removed along with the filter. An in vitro model was developed to determine the fate of trapped thrombus during filter removal.An in vitro IVC flow model was created with 25-mm inner diameter tubing and a 50% glycerol/water solution. Three different optional filters-Recovery (Bard, Tempe, AZ), Günther-Tulip (Cook Inc., Bloomington IN), and OptEase (Cordis Endovascular/JohnsonJohnson, Warren, NJ)-were evaluated in the study. A known mass of mature thrombus (porcine, aged 1 wk) was trapped within the optional filters. The filters were then retrieved according to the manufacturers' protocol, and the mass of thrombus recovered with the filter was determined. For each filter, five iterations were performed with initial thrombus sizes less than 1 g (group A) and an additional five iterations with initial thrombus sizes greater than 1 g (group B).Thrombi from group A were statistically significantly smaller than those from group B (P.0001). Retrieval of the Recovery filter resulted in an average of 25% (range, 0%-53%) and 4% (range, 0%-7%) of the clot being removed in group A and group B, respectively. Retrieval of the Günther-Tulip filter resulted in an average of 22% (group A) and 13% (group B) of the clot being removed. Retrieval of the OptEase filter resulted in an average of 43% (group A) and 0% (group B) of the clot being removed.In our in vitro model, we have established that the mass of thrombus retrieved with optional filters is only a fraction of the initial clot burden. Because of the risk of pulmonary emboli, care should be taken when IVC filters with large amounts of trapped thrombus are removed from patients.

Acoustic cavitation is responsible for both sonochemistry and sonoluminescence. Bubble collapse in liquids results in an enormous concentration of energy from the conversion of the kinetic energy of liquid motion into heating of the contents of the bubble. The high local temperatures and pressures, combined with extraordinarily rapid cooling, provide a unique means for driving chemical reactions under extreme conditions. A diverse set of applications of ultrasound to enhance chemical reactivity has been explored, with important applications in mixed–phase synthesis, materials chemistry, and biomedical uses. For example, the sonochemical decomposition of volatile organometallic precursors in low–volatility solvents produces nanostructured materials in various forms with high catalytic activities. Nanostructured metals, alloys, carbides and sulphides, nanometre colloids, and nanostructured supported catalysts can all be prepared by this general route. Another important application of sonochemistry to materials chemistry has been the preparation of biomaterials, most notably protein microspheres. Such microspheres have a wide range of biomedical applications, including their use as echo contrast agents for sonography, magnetic resonance imaging contrast enhancement, and oxygen or drug delivery.

The optimal treatment for patients with biliary obstruction varies depending on the underlying cause of the obstruction, the clinical condition of the patient, and anticipated long-term effects of the procedure performed. Endoscopic and image-guided procedures are usually the initial procedures performed for biliary obstructions. Various options are available for both the radiologist and endoscopist, and each should be considered for any individual patient with biliary obstruction. This article provides an overview of the current status of radiologic procedures performed in the setting of biliary obstruction and describes multiple clinical scenarios that may be treated by radiologic or other methods. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The ability to make localized temperature measurements in tissue during hyperthermia treatment of cancer is an essential factor in optimizing its efficacy. To this end we have developed and evaluated the complex tris(ethylenediamine) cobalt(III) trichloride as a temperature sensor by determining the temperature dependence of it 59Co nuclear magnetic resonance chemical shift. Encapsulating this complex within liposomes targets the agent to the reticuloendothelial system. Temperature changes of the order of 0.1 degrees C have been measured in vivo on rats, and the half-life of the complex within the body determined by plasma emission spectroscopy.

Purpose: In this study, protein-shell microspheres filled with a suspension of iron oxide nanoparticles in oil are demonstrated as multimodal contrast agents in magnetic resonance imaging (MRI), magnetomotive optical coherence tomography (MM-OCT), and ultrasound imaging. The development, characterization, and use of multifunctional multimodal microspheres are described for targeted contrast and therapeutic applications. Procedures: A preclinical rat model was used to demonstrate the feasibility of the multimodal multifunctional microspheres as contrast agents in ultrasound, MM-OCT and MRI. Microspheres were functionalized with the RGD peptide ligand, which is targeted to α vβ 3 integrin receptors that are over-expressed in tumors and atherosclerotic lesions. Results: These microspheres, which contain iron oxide nanoparticles in their cores, can be modulated externally using a magnetic field to create dynamic contrast in MM-OCT. With the presence of iron oxide nanoparticles, these agents also show significant negative T2 contrast in MRI. Using ultrasound B-mode imaging at a frequency of 30 MHz, a marked enhancement of scatter intensity from in vivo rat mammary tumor tissue was observed for these targeted protein microspheres. Conclusions: Preliminary results demonstrate multimodal contrast-enhanced imaging of these functionalized microsphere agents with MRI, MM-OCT, ultrasound imaging, and fluorescence microscopy, including in vivo tracking of the dynamics of these microspheres in real-time using a high-frequency ultrasound imaging system. These targeted oil-filled protein microspheres with the capacity for high drug-delivery loads offer the potential for local delivery of lipophilic drugs under image guidance

Aqueous suspensions of albumin and haemoglobin microspheres can be synthesized using high-intensity ultrasound. The particle size distributions are Gaussian with mean diameters of a few micrometers. These microspheres can contain either nonaqueous liquids (i.e. microcapsules) of air (i.e. microbubbles). The chemical processes involved in the synthesis and some physical properties of the microspheres have been elucidated. Yields and size distributions of albumin microbubbles as a function of experimental parameters indicate that the microspheres are held together primarily by disulphide cross-linking of cysteine residues between protein molecules. The primary oxidizing agent is superoxide (HO 2 ), which is generated from water and oxygen during acoustic cavitation. Physically, the protein within the microsphere shell is not significantly denatured; the heme held within haemoglobin, for example, is fully retained. Optical, scanning electron, and transmission electron microscopy reveals spherical particles with diameters between 1 and 3 μm, and an approximate shell thickness of roughly 30 nm.

BackgroundRight portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis.MethodsRecords of patients who underwent RPVE during 2006–2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported.ResultsA total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE.ConclusionsRight portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.

Historically less aggressive than gastrointestinal adenocarcinoma, thus the term carcinoid. Primary tumor can be from many locations: foregut (lungs, bronchi, and stomach), midgut (small intestine, appendix, and proximal colon), or hindgut (distal colon, rectum). Majority of cell types originate from neural crest during fetal development. Secretory/functional tumors release physiologically active compounds; nonsecretory/non-functional tumors do not. Symptoms frequently related to hormone (peptides, steroids, and neuroamines) production and release.

Background: Endografts originally designed and approved for the treatment of thoracic aortic aneurysms have rapidly been adopted for nonapproved use in the treatment of disorders of the thoracic aorta, including aortic transection, dissection, pseudoaneurysms, and thoracoabdominal aneurysms. The purpose of this study was to evaluate the early outcomes of patients treated with thoracic endografts for nonapproved indications at our institution. Methods: The medical records of patients undergoing thoracic endografting at our institution from August 2005 until March 2008 were reviewed. Patients undergoing endografting for uncomplicated thoracic aortic aneurysms were excluded. The outcomes of patients with extended indications for thoracic endografting were studied. Results: During the study period, endografting was performed in 31 patients for nonapproved aortic conditions. Patients underwent endografting for a spectrum of indications, including aortic transection (n = 12), complications of type B aortic dissection including rupture (n = 9), thoracoabdominal aneurysm with visceral debranching (n = 6), aortic arch debranching (n = 2), and pseudoaneurysm associated with prior coarctation repair (n = 2). Early outcomes were favorable. All patients had successful endograft repair of their anatomic lesion. There were no endoleaks. There was no hospital mortality. Average hospitalization was 15 days for patients with aortic transection and 9 days for all other patients. Conclusions: Thoracic endografts are versatile devices that with appropriate expertise can be used effectively to treat a spectrum of disorders of the thoracic aorta, including acute emergencies. Early outcomes of patients with extended indications for thoracic endografting compare favorably to published series of patients treated with open procedures. Further study is required to assess the long-term efficacy of these devices.