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Although infectious complications are rare in interventional radiology (IR), their occurrence can have serious consequences. Considerations for antibiotic prophylaxis and selection of an appropriate antibiotic agent and dosing regimen are essential components of the preprocedural evaluation of patients presenting for IR procedures. As the breadth and complexity of patients and procedures expand, it is critical for the interventional radiologist to have a thorough knowledge of the pathogenesis of infection, the rationale behind prophylaxis in specific clinical scenarios, and the appropriate use of antibiotic agents. The goal of this chapter is to provide the trainee with a comprehensive overview of antibiotic prophylaxis for the most commonly performed procedures in interventional radiology.

Subclavian artery occlusive disease (SAOD) is often associated with cerebrovascular symptoms such as subclavian steal syndrome and stroke. We conducted a systematic review and meta-analysis to compare percutaneous transluminal angioplasty (PTA) and stent placement for the treatment of SAOD. We searched Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through October 16, 2014. From each study, we abstracted baseline patient characteristics, study design variables, and outcome data including rates of technical success, primary patency (≤2 and >2 years follow-up), symptom resolution, and complications. Meta-analysis was performed using a random-effects model. A total of 35 non-comparative studies with 1726 patients were included. Technical success rate was significantly higher in the stent group than the PTA group (92.8 vs 86.8 %, p = 0.007). Long-term primary patency rates (76.9 vs 79.6 %, p = 0.729) and symptom resolution rates (82.2 vs 73.0 %, p = 0.327) were not statistically different. There was no statistically significant difference in the rates of stroke or death. Stent placement for treatment of SAOD may be associated with higher rates of technical success but similar rates of symptom resolution and long-term outcomes. The confidence in the available estimates is low. Further comparative studies are needed to guide patients and clinicians in shared decision making.

Magnetic resonance enterography (MRE) plays a critical role in the management of Crohn's disease in the pediatric population. The ability to provide dynamic assessment of disease burden, complications, and therapeutic response without ionizing radiation makes it an ideal tool for younger patients requiring frequent follow-up. With a growing array of available treatment options, a sound understanding of MRE is critical in directing management aimed at curbing the physical and emotional morbidity associated with the lifelong condition. The goal of this article is to provide a practical overview of MRE in the pediatric population. This includes a review of our technique, approach to interpretation, pictorial collection of findings, and discussion of the role MRE plays in management.

To describe the techniques, outcomes and complications of CT-guided transosseous biopsy of soft tissue lesions via multiple different routes. Clinical and radiologic data from all consecutive soft tissue biopsies performed via a transosseous approach between April 2009 and July 2015 were retrospectively compiled. Fifty biopsies performed in 50 patients (n = 17 males, n = 33 females) were included. Biopsies were performed using a 13-gauge biopsy needle which was advanced through the selected bone to the lesion margin followed by coaxial placement of either an 18- or 20-gauge biopsy gun. Sampling accuracy was determined from the final pathology report as diagnostic or non-diagnostic. Complications included rates of pneumothorax, pneumomediastinum, hemoptysis, immediate admission, chest tube insertion, surgical consultation, 30-day readmission, fracture, osteomyelitis or tract seeding. Number of diagnostic samples per bone included: sternum (n = 17, 34%), rib (n = 7, 14%), scapula (n = 6, 12%), transverse process (n = 4, 8%), vertebral body (n = 4, 8%), spinous process (n = 1, 2%), ilium (n = 7, 14%), sacrum (n = 4, 8%). Complications included 10 pneumothoraces in 39 cases that crossed the pleura, 8 pneumomediastinum in 17 transsternal cases, one immediate surgical consultation and one 30-day readmission. Transosseous biopsy approach is a technically feasible means of obtaining core needle samples of soft tissue lesions. Case series, IV.

BackgroundMany CT angiography (CTA) collateral scoring systems are either subjective or complex and time consuming.ObjectiveTo evaluate the correlation between a CTA collateral scoring system—the Opercular Index Score (OIS)—with neurological outcomes at 90 days following endovascular treatment for acute ischemic stroke (AIS) secondary to large vessel occlusion.MethodsFifty-five patients with AIS due to distal internal carotid artery, M1, or proximal M2 occlusions who underwent endovascular treatment were included. OIS was retrospectively calculated from CTA images, reconstructed from CT perfusion imaging, as the ratio of opacified M3 opercular branches in the Sylvian fissure on the unaffected side to those on the stroke side and dichotomized into favorable (OIS≤2) and poor (OIS>2). The ability of OIS to predict good neurological outcomes (modified Rankin Scale score ≤2 at 90 days) was assessed using sensitivity, specificity, and area under the curve (AUC) with receiver operating characteristic analysis.ResultsThirty-five patients had a favorable OIS and 20 patients had a poor OIS. Patients with favorable OIS had an 80.0% (n=28) rate of good neurological outcomes compared with 15.0% (n=3) of patients with a poor OIS (pConclusionsOIS is a simple and practical non-invasive scoring system that can be used to predict collateral robustness and good neurological outcome among patients with AIS undergoing endovascular treatment.

Image-guided high-intensity focused ultrasound (HIFU) is an innovative therapeutic technology, permitting extracorporeal or endocavitary delivery of targeted thermal ablation while minimizing injury to the surrounding structures. While ultrasound-guided HIFU was the original image-guided system, MR-guided HIFU has many inherent advantages, including superior depiction of anatomic detail and superb real-time thermometry during thermoablation sessions, and it has recently demonstrated promising results in the treatment of both benign and malignant tumors. HIFU has been employed in the management of prostate cancer, hepatocellular carcinoma, uterine leiomyomas, and breast tumors, and has been associated with success in limited studies for palliative pain management in pancreatic cancer and bone tumors. Nonthermal HIFU bioeffects, including immune system modulation and targeted drug/gene therapy, are currently being explored in the preclinical realm, with an emphasis on leveraging these therapeutic effects in the care of the oncology patient. Although still in its early stages, the wide spectrum of therapeutic capabilities of HIFU offers great potential in the field of image-guided oncologic therapy.

The interventional radiologist is increasingly called upon to successfully access challenging biopsy and ablation targets, which may be difficult based on poor visualization, small size, or the proximity of vulnerable regional anatomy. Complex therapeutic procedures, including tumor ablation and transarterial oncologic therapies, can be associated with procedural risk, significant procedure time, and measurable radiation time. Navigation tools, including electromagnetic, optical, laser, and robotic guidance systems, as well as image fusion platforms, have the potential to facilitate these complex interventions with the potential to improve lesion targeting, reduce procedure time, and radiation dose, and thus potentially improve patient outcomes. This review will provide an overview of currently available navigational tools and their application to interventional radiology and oncology. A summary of the pertinent literature on the use of these tools to improve safety and efficacy of interventional procedures compared with conventional techniques will be presented.

To compare cost of percutaneous cryoablation vs open and robot-assisted partial nephrectomy of T1a renal masses from the hospital perspective.We retrospectively compared cost, clinical and tumor data of 37 percutaneous cryoablations to 26 open and 102 robot-assisted partial nephrectomies. Total cost was the sum of direct and indirect cost of procedural and periprocedural variables. Clinical data included demographics, Charlson Comorbidity Index (CCI), hospitalization time, complication rate, ICU admission rate, and 30-day readmission rates. Tumor data included size, RENAL nephrometry score, and malignancy rate. Student's t-test was used for continuous variables and Fisher's exact or chi-square tests for categorical data.Mean total cost was lower for percutaneous cryoablation than open or robot-assisted partial nephrectomy: $6067 vs $11392 or $11830 (p0.0001) with lower cost of procedure room: $1516 vs $3272 or $3254 (p0.0001), room and board: $95 vs $1907 or $1106 (p0.0001), anesthesia: $684 vs $1223 or $1468 (p0.0001), and laboratory/pathology fees: $205 vs $804 or $720 (p0.0001). Supply and device cost was higher than open: $2596 vs $1352 (p0.0001), but lower than robot-assisted partial nephrectomy: $3207 (p=0.002). Mean hospitalization times were lower for percutaneous cryoablation (p0.0001), while age and CCI were higher (p0.0001). No differences in tumor size, nephrometry score, malignancy rate complication, ICU, or 30-day readmission rates were observed.Percutaneous cryoablation can be performed at significantly lower cost than open and robotic partial nephrectomies for similar masses.

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Purpose To evaluate the incidence, cause, and management of delivery system occlusions during yttrium-90 ( 90 Y) microsphere infusions and to identify techniques to prevent occlusions. Materials and Methods A retrospective review was conducted of 885 consecutive radioembolization deliveries during 820 procedures (some with multiple deliveries) in 503 patients (mean age, 65 y; 293 male) performed between June 2001 and July 2013 at a single academic tertiary care hospital. Occlusions were reported prospectively, and procedural details were reviewed. Statistical analysis assessed associations between catheter occlusions and patient and procedural characteristics. Results Of 885 90 Y microsphere deliveries, 11 resulted in occlusion (1.2%). Five occlusions were associated with contained leakage of radioactive material, and one was associated with a spill. Treatment was completed in the same day in 10 patients; repeat catheterization was required in five patients. One patient returned 1 week later to complete treatment. Occlusions were more frequent with deliveries of resin (11/492; 2.2%) versus glass (0/393; 0%) microspheres ( P = .002). Occlusions were more likely to occur within the proximal portion of the delivery apparatus ( P = .002). There was no significant relationship with any patient characteristics, and there was no improvement with operator experience. The most common cause of occlusion was resin microsphere delivery device failure. Conclusions 90 Y microsphere delivery device occlusion is uncommon but does occur with resin microspheres. Understanding causes and how to troubleshoot can limit the incidence and detrimental effects.

We present the case of a 59-year-old male with massive hemoptysis secondary to a bronchopulmonary artery fistula formed as the result of a perihilar lung cancer. The hemoptysis was successfully treated by Amplatzer Plug (St. Jude Medical) embolization of the supplying pulmonary artery branch. At the same time, bronchoscopy was performed to tamponade the patients bleeding and avoid exsanguination. Biopsy of the mass demonstrated poorly differentiated non small cell carcinoma. Post procedure day 13 the patient underwent staging with PET CT which showed localized disease. His hemoptysis resolved.

Purpose To describe technical feasibility and safety of perforating vein ablation with the use of a 1,470-nm laser and bare-tip fiber in the management of chronic venous insufficiency (CVI). Materials and Methods A total of 171 perforating veins were ablated in 101 limbs of 87 patients (mean age, 54.4 y; 79% female). Outcomes included sonographic occlusion of ablated perforator, subjective changes of insufficiency symptoms, incidence of procedure-related side effects (pain, hyperpigmentation), and complications (burn, infection, deep vein thrombosis, paresthesia). Correlation between perforator closure and patient symptoms was assessed by Pearson χ 2 test. Factors influencing failure of perforator closure were analyzed by analysis of variance. Results Forty-nine perforating veins had previous great saphenous vein (GSV) interruption, 25 had previous small saphenous vein (SSV) interruption, 88 had previous GSV and SSV interruption, and 9 had competent saphenous systems. Ninety-one ablations were combined with microphlebectomy, 55 were combined with sclerotherapy, and 25 were performed alone. At 1 and 3 months' follow-up, 94% and 98% of ablated perforators were sonographically occluded, and 82% and 96% of patients noted complete symptom resolution, respectively. Complications included 5 cases of new-onset paresthesia and 1 case of nonocclusive deep vein thrombosis. Ablation failed in 10 perforators, and treatment failure showed significant correlations with higher clinical, etiology, anatomy, and physiology score ( P = .002) and history of GSV/SSV interruption ( P = .042). Conclusions Three-month closure of perforating veins is achievable by using a 1,470-nm laser and bare-tip fiber and can be safely performed alone or in combination with microphlebectomy or sclerotherapy at all stages of CVI severity.

Purpose Assessment of collaterals is imperative in patient selection for endovascular reperfusion in acute ischemic stroke (AIS). The purpose of this study was to evaluate the correlation between a novel CTA based collateral scoring system: the Opercular IndexScore (OIS), with the capillary index score (CIS) at angiography and neurologic outcomes at 90 days following endovascular treatment of acute ischemic stroke. Materials and methods Data from 58 patients with AIS who underwent clinical assessment, institutional stroke based CT imaging (noncontrast CT, CT Perfusion with CTA reconstructions) and endovascular reperfusion were included in this study. OIS was retrospectively calculated from CTA images as the ratio of the number of opacified branches in the Sylvian fissure on the normal side to those on the affected side and dichotomized into favorable OIS (fOIS i.e. OIS ≤ 2) and poor OIS (pOIS i.e. OIS > 2). CIS was defined as favorable (CIS ≥ 2) or unfavorable (CIS Results Thirty-five patients had fOIS and 20 patients had pOIS. There was no difference in mean age (p = 0.96), gender (p = 0.31), side of occlusion (p = 0.11), use of IV-tPA (p = 0.73), ASPECTS (p = 0.61), door-to-puncture time (p = 0.49), door to recanalization time (p = 0.81), recanalization rate (0.32) or TICI scores (p = 0.78). There was a trend towards lower NIHSS in the fOIS group (p = 0.07). At angiography, 82.9% of patients (n = 29) with fOIS had a fCIS and 40.0% of patients (n = 14) with pOIS group had a fCIS (p = 0.002). Patients with fOIS had an 80.0% (n = 28) rate of good neurological outcomes compared to 15.0% (n = 3) in the pOIS group (p Conclusion OIS is a practical, noninvasive scoring system that can be used to predict collateral robustness and good clinical outcome among patients undergoing endovascular recanalization in the treatment of acute ischemic stroke. Disclosures A. Copelan: None. M. Chehab: None. S. Xli: None. W. Brinjikji: None. Z. Wilseck: None. D. Kallmes: None. J. Wilseck: None.

Introduction CT perfusion imaging is commonly used in evaluation of patients who present with symptoms of acute ischemic stroke. Numerous entities can simulate an acute cerebral infarct. Knowledge of the common imaging manifestations of non- ischemic entities can prevent misdiagnosis and can facilitate appropriate therapy. We present a review of findings of common non-ischemic entities on CT perfusion imaging. Materials and methods We present several cases of non-ischemic diagnosis and review their imaging findings on CTP. This includes: malignancy, Todd’s paralysis, Multiple Sclerosis, migraine headaches, Bell’s palsy, complex seizure disorder, hypertensive encephalopathy, herpes encephalitis and chronic subdural hematoma. Conclusion The radiologist should be aware of the imaging findings of etiologies which may mimic an acute ischemic stroke on CT perfusion imaging. Disclosures M. Chehab: None. J. Wilseck: None.

Purpose To determine the negative predictive value of CT perfusion (CTP) imaging in excluding lesions amenable to endovascular reperfusion in patients who present with symptoms of acute ischemic stroke. Materials and methods We retrospectively reviewed CTP studies performed between February 2013 and February 2015 who had follow up MRI imaging within 10 days. Patients who received intervenous thrombolysis were excluded. True negative was defined as a CTP study that had: no perfusion mismatch, a fixed matched defect or a small perfusion mismatch in a size (typically Results 461 CTP studies performed in 450 patients (mean age 69.1 years, 57% male) were reviewed. 400 were true negative, 55 were true positive, 6 were false positive and 0 was false negative. Negative predictive value was 100%. Conclusion CTP can confidently exclude lesions which are not amenable to endovascular reperfusion. Disclosures M. Chehab: None. J. Wilseck: None.

Percutaneous cryoablation vs open and robot assisted partial nephrectomy: cost and clinical analysis M. Chehab, S.A. Vartanian, J. Ciacci, X. Li, H. Korman, A. Krishnan; Radiology, Oakland University William Beaumont School of Medicine, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Royal Oak, MI; Urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI