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Purpose: Factors affecting tumor-to-normal tissue ratio (T:N) have implications for patient selection, dosimetry, and outcomes when considering radioembolization for HCC. This study sought to evaluate patient, disease specific, and technical parameters that predict T:N as measured on planning pre-90Y radioembolization 99mTc-MAA scintigraphy for hepatocellular carcinoma (HCC). Methods: 99mTc-MAA hepatic angiography procedures with SPECT/CT over a 4-year period were reviewed. Data recorded included patient demographics, details of underlying liver disease, tumor size, history of prior treatments for HCC and technical parameters from angiography. Anatomic-based segmentation was performed in 93 cases for measurement of tumor and perfused liver volumes and SPECT counts. T:N were calculated and correlated with collected variables. Results: Mean calculated T:N was 2.52. History of prior ablation was significantly correlated with higher T:N (mean 3.39 vs 2.24, p = 0.003). Cases in which mapping was being performed for treatment of disease progression was significantly correlated with higher T:N (mean 3.35 vs 2.14, p = 0.001). Larger tumor size trended toward lower T:N (p = 0.052). Conclusion: Patients with history of ablation and those undergoing treatment for disease progression have higher T:N and, therefore, could be considered for radioembolization preferentially over alternative treatments. [ABSTRACT FROM AUTHOR]

To assess the cost-effectiveness of transarterial radioembolization (TARE) versus conventional transarterial chemoembolization (cTACE) and drug-eluting beads chemoembolization (DEE-TACE) for patients with unresectable early- to intermediate-stage hepatocellular carcinoma (HCC). A cohort-based Markov model with a five-year time horizon was developed to evaluate the cost-effectiveness of the three embolization treatments. Upon entering the model, patients with HCC received either TARE or one of the two other embolization treatments. Patients remained in a "watch and wait" state for tumor downstaging that allowed them to move to health states such as liver transplant, resection, systemic therapies, or cure. Clinical input parameters were retrieved from the published literature, and where values could not be sourced, assumptions were made and validated by clinical experts. Health benefits were quantified using quality-adjusted life years (QALYs). Cost input parameters were obtained from various sources, including the Medicare Cost Report, IBM® Micromedex RED BOOK, and published literature. At five years, TARE was found to be cost-saving (saving $15,779 per person compared to cTACE) and produced 0.33 more QALYs per person than cTACE. TARE cost $13,696 more but produced 0.33 more QALYs than DEE-TACE, with an incremental cost-effectiveness ratio of $41,474 per QALY gained at five years. After accounting for parameter uncertainty, the likelihood of TARE being cost-effective was at least 90% against all comparators at a cost-effectiveness threshold of $100,000 per QALY gained. TARE produces more QALYs than cTACE and DEE-TACE, with a high probability of being cost-effective against both comparators. The Barcelona Clinic Liver Cancer guideline recommends the use of transarterial radioembolization (TARE), conventional (cTACE), or drug-eluting bead transarterial chemoembolization (DEE-TACE) for treating hepatocellular carcinoma (HCC). This study evaluated the cost-effectiveness of TARE versus two alternative embolization treatments (cTACE and DEE-TACE) in treating patients with unresectable early- to intermediate-stage HCC. A cohort-based Markov model was developed to analyze the costs and benefits of these treatments from a US healthcare perspective within a 5-year time horizon. A 20-year time horizon was assessed as a scenario. In the model, patients were assigned to receive TARE, cTACE, or DEE-TACE and remained in the "watch and wait" stage for tumor downstaging. Data used in the model was taken from previous studies and in consultation with clinical experts. The benefits of the treatments were measured by considering the impact on the patient's quality of life. The costs associated with the treatments were obtained from various sources, including reports, publicly available databases, and published literature. The findings show that TARE is not only cost-saving compared to cTACE but also results in a higher number of quality-adjusted life years (QALYs) per person. While TARE was more expensive than DEE-TACE, it produced more QALYs, further indicating more favorable patient outcomes and overall treatment effectiveness. These findings could potentially impact resource allocation and decision-making for the treatment of HCC. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to assess the association between complication rate and time to feeding in a cohort of patients undergoing radiologically guided placement of gastrostomy tubes.Methods: A retrospective study was conducted of all patients receiving pull-type and push-type gastrostomy tubes placed by interventional radiologists between January 1st, 2017 and December 31st, 2018 at a single institution. Primary outcomes included procedural and tube-related complications per medical chart review with a follow-up interval of 30 days. Exclusion criteria were enteral nutrition delayed more than 48 hours, no feeding information, and tubes placed for venting (n=20). Overall, 303 gastrostomy tubes (pull-type, n=184; push-type, n=119) were included. The most common indications for placement included head and neck carcinoma for push-type tubes (n=76, 63.9%) and cerebral vascular accident for pull-type tubes (n=78, 42.4%).Results: In a multiple regression analysis, there was no statistically significant association between complications and time to feeding (p = 0.096), age (p = 0.758), gender (p = 0.127), indication for tube placement (p = 0.206), or type of tube placed (p = 0.437). Average time to initiation of enteral nutrition was 12.3 hours for the pull-type and 21.7 hours for the push-type cohort (p < 0.001). Additional multiple regression analyses of pull-type tubes and push-type tubes separately also did not find any significant association between complications and the above factors (p > 0.05).Conclusion: There was no statistically significant correlation between time to feed and complications, suggesting that there is no clinical difference between early and late feeding following gastrostomy tube placement. [ABSTRACT FROM AUTHOR]

Purpose: Catheter-directed thrombolysis (CDT) is an emerging, minimally invasive treatment for patients with massive and submassive pulmonary embolism (PE). The value of follow-up pulmonary angiography for evaluating improvement after CDT is limited by a paucity of large studies assessing its utility and role for additional intervention. The purpose of our study was to assess the role of next-day pulmonary angiography for CDT in patients with acute massive and submassive PE undergoing continuous pulmonary arterial pressure monitoring, and secondarily, determine factors that are correlated with a need for further therapy.Methods: Patients who underwent CDT from 2006 to 2016 for massive and submassive PE were reviewed. Patient demographics, comorbidities, preprocedural lab results, noninvasive hemodynamic studies, and technical variables were recorded. Among patients receiving next-day angiography, those requiring further therapy, defined as continued CDT beyond the standard 24 hours (with or without catheter repositioning or exchange) and/or mechanical or suction thrombectomy were contrasted with those not requiring additional therapy to assess for the role of angiography and patient factors that correlate with need for further therapy.Results: Thirty-two patients underwent CDT for massive (n=14) and submassive (n=18) PE. Eighteen (56.3%) were male, 14 (43.7%) were Caucasian, 18 (56.3%) were African-American, with a mean age of 66.2 years (range, 26-87 years). Of the 27 (84.4%) patients that underwent next-day pulmonary angiography, 16 (59.3%) did not require additional therapy and 11 (40.7%) did require additional therapy. Additional therapy included extended CDT beyond 24 hours (n=4), mechanical/suction thrombectomy (n=5), or both extended CDT and mechanical/suction thrombectomy (n=2). Younger age (50.1 vs. 62.2 years, P = 0.039) was correlated with a need for further therapy. Initial (40.7 vs. 34.8 mmHg, P = 0.248), next-day (31.5 vs. 26.3 mmHg, P = 0.259), and interval change (4.6 vs. 8.0 mmHg, P = 0.669) in pulmonary artery pressures were not statistically significant between patient subsets. Preprocedural right ventricular/left ventricular ratio (RV/LV) also did not differ significantly (1.74 vs. 1.75, P = 0.961). Thirty-day mortality was comparable (2 vs. 1, P = 0.332).Conclusion: Next-day pulmonary angiography is a useful method to identify patients needing additional therapy including extended CDT and/or mechanical or suction thrombectomy in acute PE management. Pulmonary arterial pressures and preprocedural RV/LV ratios were not found to be predicative of those requiring further intervention. [ABSTRACT FROM AUTHOR]

Purpose: Although recommended placement of IVC filters is with their tips positioned at the level of the renal vein inflow, in practice, adherence is limited due to clinical situation or IVC anatomy. We seek to evaluate the indwelling and retrieval complications of IVC filters based on their specific position within the infrarenal IVC.Materials and Methods: Retrospective, single institution study of 333 consecutive infrarenal vena cava filters placed by interventional radiologists in patients with an average age of 62.2 ± 15.7 years was performed between 2013 and 2015. Primary indication was venous thromboembolic disease (n = 320, 96.1%). Filters were classified based on location of the apex below the lowest renal vein inflow on the procedural venogram: less than 1 cm (n = 180, 54.1%), 1-2 cm (n = 96, 28.8%), and greater than 2 cm (n = 57, 17.1%). Denali (n = 171, 51.4%) and Celect (n = 162, 48.6%) filters were evaluated. CT follow-up, indwelling complications, and retrieval data were obtained.Results: Follow-up CT imaging performed for symptomatic indications occurred for 38.3% of filters placed < 1 cm below the lowest renal vein, 27.1% of filters placed 1-2 cm, and 36.8% placed > 2 cm (p = .16). There was no difference in caval strut penetration, penetration of adjacent viscera, time to penetration, filter migration, or tilt (p = .15, .27, .41, .57, .93). No filter fractures occurred. There was no difference in the incidence of breakthrough PE or complex filter retrieval (p = .83, .59). Only one retrieval failure occurred.Conclusions: This study suggests filter apex location within the infrarenal IVC, including placement > 2 cm below the level of the renal vein inflow, is not associated with differences in indwelling or retrieval complications.Level Of Evidence: Level 3 non-randomized controlled follow-up study. [ABSTRACT FROM AUTHOR]