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   Table of Contents - Current issue
July-December 2020
Volume 4 | Issue 2
Page Nos. 53-140

Online since Tuesday, August 25, 2020

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Interventional oncology: A key part of mainstream cancer care p. 53
Andreas Adam
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Fellowship training in interventional radiology in the Middle and Near East p. 57
Aghiad Al-Kutoubi
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How to deal with infrainguinal arterial calcifications: Atherectomy and lithoplasty devices p. 60
Dierk Vorwerk
This overview article should describe current technical problems of severe infrainguinal calcifications, outline solutions for challenging and complex lesions and give an overview over currently available debulking devices which are meant to deal with calcified lesions. As a relatively new device, arterial lithoplasty is discussed.
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Vascular and interventional radiology workflow management during the COVID-19 pandemic: Position statement by the saudi interventional radiology society p. 67
Majed A Ashour, Mohammad Arabi, Almamoon I Justaniah
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Stimulan® Antibiotic impregnated beads for the treatment of diabetic foot infection p. 73
Hazel Ting Wai Chon, Maher Hamish, Piranavan Kirupananthan, Aimen Gmati, Hiba Abdalla, Robert Hicks
Context: Limited evidence has been found on the effectiveness of Stimulan® antibiotic beads for the treatment of diabetic foot ulcer. Aims: The aim of the study was to evaluate the safety and efficacy of Stimulan® antibiotic beads in treating diabetic foot infection and review the healing rate, infection recurrence rate, and the length of postoperative hospital stay. Settings and Design: It was a retrospective review of patients implanted with Stimulan® antibiotic beads at a district general hospital in England from 2017 to 2019. Subjects and Methods: Nineteen patients with Wagner Grade 3 and 4 ulcers were included, with a mean age of 62.3 years. Stimulan®, an antibiotic loaded absorbable calcium sulfate biocomposite, was used to treat persistent diabetic foot infection with chronic osteomyelitis. Staphylococcus aureus was the most common bacteria isolated. Exclusion criteria consisted of those with Wagner Grade 1 or 2 ulcers and infections that had clinically responded to long courses of systemic antibiotics treatment. Results: All patients underwent local wound debridement with the application of Stimulan® beads and received intravenous antibiotics for 48 h postoperatively. The average postoperative hospital stay was 2 days. After 1 month of follow-up, 16 wounds (84%) fully healed, two wounds (11%) had partially healed, and one wound (5%) showed no sign of healing. Two patients (11%) had shown recurrence of diabetic foot infection in a different foot after 24 months. Amputation rate was 0% over 24 months. Conclusions: This study recorded the clinical efficacy of Stimulan® antibiotic beads by demonstrating 0% amputation rate after two years and shortened hospital stay. With a low recurrence rate (16%), Stimulan® beads could be considered as one of the alternative treatments in managing diabetic foot infection.
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Awareness of uterine artery embolization as a treatment for fibroids among Saudi women p. 79
Meshael Nazzal Alreshidi, Dalal Alshubrmi, Ibrahim Alrashidi, Mohammad Arabi
Context: No study has investigated the awareness of uterine artery embolization (UAE) as a treatment option for uterine fibroids among Saudi women. Aims: The aim of this study was to investigate Saudi women's awareness of UAE as a therapeutic modality for uterine fibroids Settings and Design: This was a cross-sectional study conducted in Hail and Riyadh. Subjects and Methods: In 2019, an anonymous online questionnaire was sent via social media to women residing in Hail and Riyadh. The questionnaire contained 11 multiple-choice questions divided into two parts. The first part contained questions about demographic characteristics and one question about their history of fibroids. The second part contained items pertaining to awareness of treatment options for uterine fibroids and whether they were aware of UAE. Statistical Analysis Used: The Chi-square test was used for statistical analysis. Results: Eight hundred and forty-five responses have been received. Overall, 76.1% of the respondents had never heard of UAE. Awareness of treatment options for uterine fibroids was significantly associated with education level and participants' involvement in a medical field (P < 0.05; Chi-squared test). 9.2% were from respondents who reported a history of fibroids. Among them, 71.7% had never heard of UAE; 9% had heard about it from an obstetrician or gynecologist. Only 6.4% of the participants were aware of all the treatment options for uterine fibroids; 28.2% believed that hysterectomy was the only treatment for uterine fibroids. Conclusions: This study highlights the need for public awareness of the treatment options for uterine fibroids to appropriate candidates.
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Radiation exposure during varicocele embolization: Does access site and treated side matter? p. 83
Abdulaziz Alqubaisi, Ali S Alsaadi, Omar Bashir, Mohammad Arabi
Purpose: The purpose of the study was to evaluate radiation exposure during varicocele embolization and correlate it with access site, embolized side, and complexity of varicoceles. Materials and Methods: This retrospective study included 39 adults who underwent varicocele embolization with a combination of coils and sclerosing agents between January 2015 and December 2018. Left-sided embolization was done in 26 patients and bilateral embolization in 13 patients. Jugular access was used in ten patients, whereas upper limb access was done in 29 patients. Dose area product (DAP) and total fluoroscopy time were collected and correlated to the treated side, access site, and complexity of varicoceles. Results: The mean fluoroscopy time for left varicocele embolization was 26.76 min, which was not statistically different (P = 0.16) compared to bilateral embolization (33.2 min). There was no statistical difference (P = 0.37) between the mean DAP for left embolization of 106,239 mGy.cm2 compared to bilateral DAP of 107,153 mGy.cm2. There was no difference in the mean DAP or fluoroscopy time between jugular vein access (DAP = 87,569 mGy.cm2, time = 34 min) and upper limb venous access (DAP = 113,086.8534 mGy.cm2, time = 28 min) with P = 0.64 and P = 0.14, respectively. There was no statistically significant correlation between the left varicocele Bähren classification and the fluoroscopy time (P = 0.52) or DAP (P = 0.76). Conclusion: This study finds no significant difference in DAP or fluoroscopy time between jugular and upper limb venous access or between left and bilateral embolization.
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Dialysis shunt thrombectomy utilizing a rotational thrombectomy device in patients with pseudoaneurysms p. 87
Anderson Webb, Kurt Zacharias, Paul Ciolek, Thomas Webb, Osman Ahmed
Aims: To assess the safety and efficacy of dialysis shunt thrombectomy utilizing a rotational thrombectomy device in patients with pseudoaneurysms refractory to declot by conventional treatments. Methods: Between July 2016 and August 2019, 34 dialysis shunt thrombectomies were retrospectively examined in 29 individual patients. All patients presented with pseudoaneurysms and clotted accesses that were refractory to angioplasty balloon sweeps (“push–pull”) to restore patency. The Cleaner® rotational thrombectomy device was used as a bail-out in an attempt to restore patency to the clotted shunt. Procedure success, complications, primary patency, primary-assisted patency, secondary patency, average number of shunt pseudoaneurysms, and average pseudoaneurysm size were documented and analyzed. Results: Thirty-three of the 34 (97%) thrombectomies were successful in restoring patency and facilitating same-day hemodialysis. An average of 1.5 pseudoaneurysms were present per patient (range 1–3 pseudoaneurysms, standard deviation [SD] 0.65 pseudoaneurysms), with an average size of 15.0 mm (range 9.4–31.1 mm, SD 4.87 mm). Postprocedural complications occurred in 14.7% of the cases, none of which were definitively device related. Primary patency to the time of data collection was achieved in 29% of the cases, and the average primary patency for these cases was 124.5 days (range 10–946 days, SD 186.9 days). The average primary-assisted patency was 126.8 days (range 1–564 days, SD 169.8 days). Dialysis accesses were eventually abandoned or surgically revised in ten instances, resulting in an average secondary patency of 157.5 days (range 6–712 days, SD 257 days). Conclusions: In patients with pseudoaneurysms, rotational thrombectomy with the Cleaner® device appeared to be a safe and effective option for restoring patency to thrombosed dialysis accesses refractory to standard push–pull techniques with angioplasty balloons.
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The pattern of publications on cerebral arteriovenous malformations and cavernomas in the Middle East and North Africa p. 92
Amira Alolyani, Horia Alotaibi, May Adel AlHamid, Faisal Alabbas, Hosam Al-Jehani
Background: Cerebrovascular malformations are encountered frequently in clinical practice, but not much is known about the pattern of publication in the Middle East and North Africa (MENA) countries. We aim to evaluate the status and pattern of publications of cerebral arteriovenous malformations (AVM) and cavernomas in the MENA. Materials and Methods: PubMed database was searched for publications on cerebral AVM and cavernomas in the MENA between 2009 and 2019. Results: We found only 94 publications in the MENA region out of 31,333 publications pertaining to AVMs (0.3%). The highest publishing country was Turkey, with 50 (53.1%) studies. The case report was the study design used most by authors with 59 (62.7%) studies. The majority of publications were by neurosurgeons with 42 of 94 (42.4%) papers. European journals ranked first in the number of published articles with 42 of 94 (46.1%) articles. Conclusions: We found a limited number of publications on cerebral AVMs and cavernomas by MENA countries in the past decade. Research support and national/regional registries are important factors to improve the academic output on AVMs and cavernomas in the MENA region.
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Foundation doctors' exposure to interventional radiology in two large teaching hospitals in the United Kingdom p. 96
Zaid Alsafi, Sanjeev Ramachandran, Vamsee Bhrugubanda, Alison Graham, Ali Alsafi
Background: Significant efforts have been made to improve medical students' exposure to interventional radiology (IR). Foundation doctors in the UK, however, are a neglected group, with little being done engage these doctors who are at a crucial juncture in their training. Objectives: The objective of the study is to assess Foundation Year 1 (FY1) doctors' understanding of and exposure to IR. Methods: FY1s from two teaching hospitals in the UK at the end of their first year of Foundation training were invited to take part in an 18-question survey, including 14 single-best-answer (SBA) questions. The questions examined knowledge of IR and other specialties. The SBAs were scored out 14 and the Student's t-test was used to compare IR and non-IR scores. Results: Questionnaires were given to 72 FY1 doctors and 52 (72.2%) were completed. The median score was 9/14 (64.3%) [4.5/14–12/14]. Questions relating to coronary intervention and neurosurgery scored best (96.2% and 94.3%, respectively). The mean score for IR-related questions was significantly lower than that for non-IR questions (51.5% vs. 81.1%, respectively, P < 0.0001). Participants who referred patients to IR at least once per month scored higher than those who rarely referred (60.5% vs. 47.2%, respectively, P < 0.0084). Nearly 83.0% of participants expressed a desire to gain more exposure to IR. Conclusion: Although Foundation doctors have some understanding of IR, reflecting some exposure to the specialty, this remains deficient when compared with their knowledge of other specialties. This may be improved by the introduction of IR specific teaching during the Foundation program.
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Adrenal vein sampling: Radiation dose reduction on new angiography platform p. 102
Ali Alsafi, Florian Wernig, Jeannie Todd, Tricia Tan, F Fausto Palazzo, Karim Meeran, James E Jackson
Objectives: Primary aldosteronism is one of the most common causes of secondary hypertension. Distinguishing unilateral from bilateral disease is essential as those with unilateral adrenal disease will benefit from adrenalectomy. This is best achieved by adrenal vein sampling (AVS) which may be a difficult procedure with significant radiation to both patient and operator. This study aims to measure the radiation dose during AVS before and after the installation of a new angiography platform. Materials and Methods: The dose area product (DAP), air kerma, and fluoroscopy time were collected retrospectively together with demographic data for the first ten patients who underwent AVS between April and September 2018 following the installation of the Philips Azurion 7 M20 interventional platform. These results were compared with those from ten patients who underwent AVS before the installation of the new machine using the Philips Allura Xper FD20 platform. Mann–Whitney test was used to compare DAP, air kerma, and fluoroscopy time. P < 0.05 was considered statistically significant. Results: Successful bilateral adrenal vein catheterization was achieved in all cases in both groups. There was no significant difference in fluoroscopy time: 5.5 (3.3–10.8) min (new) versus 5.3 (4.5–8.4) min (old) (P = 0.9502). The DAP and air kerma were both significantly lower on the new machine: 11.3 (5.2–26.7) Gy.cm2 versus 45.5 (17.2–56.5) Gy.cm2 (P = 0.0089) and 201.5 (88.1–464.0) mGy versus 682.5 (300.5–998.5) mGy (P = 0.0115), respectively. Conclusion: The installation of the Philips Azurion 7 M20 interventional platform has allowed a significant reduction in radiation dose during AVS.
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Percutaneous image-guided gastrostomy insertion with and without gastropexy p. 107
Nehal Alghamdi, Shaima Abdulrahman, Yousof Alzahrani, Hana Alfaleh, Fawziah Alorfi, Ali Rajeh, Mohammed Aljarie, Mohammad Arabi
Purpose: The objective was to compare the major and minor complications of percutaneous gastrostomy with and without gastropexy. Materials and Methods: This was a retrospective study of adult patients who underwent percutaneous gastrostomy with or without gastropexy between January 2015 and November 2018. A total of 830 patients (512 males [61.8%] and 318 females [38.2%]) were included in the study. Gastropexy was performed for 428 (51.6%) patients (343 pigtail and 85 balloon-type gastrostomies). The remaining 402 patients (48.4%) had no gastropexy (387 pigtail and 15 balloon-type gastrostomies). Major and minor complication rates were assessed within 30 days postprocedure. Results: Technical success was 100% with and without gastropexy. Complications were recorded in 143 patients (17.2%): six major complications in 6 patients and 155 minor complications in 137 patients. Major complications included peritonitis (n = 1) and severe skin infection (n = 1) in the gastropexy group, whereas the remaining four complications were without gastropexy and had tube malposition and peritonitis (n = 4). There was no significant difference in major (0.47% vs. 1%; P = 0.37) or minor complication rate (18.7% vs. 14.2%; P = 0.08) between the gastropexy and nongastropexy groups, respectively. Subgroup analysis showed significantly more superficial infections in the gastropexy group (28 vs. 14; P = 0.04), and pneumoperitoneum was significantly more common with pigtail gastrostomy compared to the balloon-type catheter (30 vs. 0; P = 0.04). There was no significant difference in complication rates in relation to the number of anchors (P = 0.32 for major complications and P = 0.57 for minor complications). Thirty patients (3.6%) died within 30 days after the procedure due to other comorbidities. Conclusion: Gastropexy does not reduce the incidence of major or minor complications following percutaneous gastrostomy and is associated with increased risk for superficial infections. The use of pigtail-type gastrostomy is associated with a higher incidence of pneumoperitoneum.
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Single-center experience in targeted prostate biopsy using multiparametric magnetic resonance imaging-transrectal ultrasound elastic fusion technique p. 111
Jennifer Farah, Gerard El-Hajj, Edward Assaf, Abdallah Noufaily, Abbas Chamsuddin, Michel Jabbour, Fatmeh Ghandour, Emilie Fayad, Raja Ashou
Introduction: Transrectal ultrasound (TRUS)-guided random biopsies are used to be the gold standard when diagnosing prostate cancer. A relatively new system with organ tracking that fuses real-time TRUS images with previously acquired multiparametric magnetic resonance imaging (mpMRI) images for prostate biopsy guidance is presented here. The primary goal of the study is to correlate (1) the mpMRI findings with the Gleason score grading of the prostate biopsies performed under mpMRI-TRUS elastic fusion and (2) the prostate-specific antigen (PSA) levels with the Gleason grading. Materials and Methods: Between January 2017 and August 2018, 58 patients had targeted prostate biopsy using mpMRI-TRUS elastic fusion technique (Urostation). These patients had previously the mpMRI of the prostate at our center using three-dimensional T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhanced imaging. Of all 58 patients, 32 patients were classified as having Prostate Imaging-Reporting And Data System (PI-RADS) 4/5, 21 patients as PI-RADS 3, and five as PI-RADS 2. Results: Twenty-seven patients had positive biopsies for prostate cancer. Positive results were found in 25 patients having PI-RADS 4/5 (25 out of 32). Of these patients, 20 had positive specimens from the dominant lesion, four from both the targeted lesion and nontargeted areas, and one from a nontargeted area. Positive results were found in two patients classified as PI-RADS 3 from targeted and nontargeted areas. These results show that 78% of the patients classified by mpMRI as PI-RADS 4/5 and 10% of the patients classified as PI-RADS 3 had positive biopsies for prostate cancer. The results also showed a correlation between the PI-RADS score on mpMRI, the Gleason score, and the PSA levels. Conclusion: mpMRI-TRUS fusion biopsy is a safe and accurate method for targeted prostate biopsies. Our preliminary results are comparable to the published international numbers and show a good correlation between the PI-RADS classification and histopathology, as well as correlation between PI-RADS, Gleason scores, and PSA levels of positive biopsies.
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Uterine artery embolization improves quality of life in patients with pure adenomyosis: A single-center experience p. 117
Ibrahim Alrashidi, Hayat Alharthy, Faisal Alahmari, Sultan Alammari, Hatim Alobaidi, Abdulwaeed Alruhaimi, Abdulaziz Almat'hami, Abdulrahman Alkhalifah, Fares Garad
Aim: The aim of the study was to assess clinical outcomes following uterine artery embolization (UAE) in the treatment of dysmenorrhea and menorrhagia related to pure adenomyosis. Materials and Methods: This was a retrospective analysis of 14 patients with dysmenorrhea and menorrhagia related to pure adenomyosis treated with UAE using polyvinyl alcohol (PVA) between January 2017 and September 2019. The baseline and 3-month and 12-month postintervention outcomes were assessed using Uterine Fibroid Symptom-Health-Related Quality of Life Questionnaire (UFS-QOL), Symptom Severity Score (SSS), and magnetic resonance imaging findings. The median age of the patients was 47 years (28–55). The main clinical presentation was dysmenorrhea and menorrhagia, with a median duration of symptom of 24 (12–84) months. All patients received combined estrogen-progestin and nonsteroidal anti-inflammatory drugs prior to UAE without clinical improvement. Results: According to UFS-QOL and SSS results, the score for distress level was statistically significantly reduced from baseline 4.6 (3.6–5) to 2.25 (1–3.37) (P = 0. 018) after 3 months, and remained stable 12 months later. The score of symptom level was statistically significantly reduced from 4 (3.6–5) at baseline to 1.6 (1–3.58) (P = 0. 018) after 3 months with maintained clinical satisfaction after 12-month follow-up. The junctional zone was statistically significantly reduced from baseline with a median of 33.5 mm (19–79 mm) to 25 mm (8–77 mm) after 3 and 12 months (P = 0.046). The incidence of post-UAE permanent amenorrhea is 71% with a mean age of 49 years. No patient underwent hysterectomy during the follow-up period. Conclusion: UAE using PVA can improve the quality of life in patients with menorrhagia and dysmenorrhea related to adenomyosis. However, larger prospective studies are needed to establish the long-term outcomes and risk of amenorrhea.
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Thoracic duct embolization using direct hybrid angiography/computed tomography-guided cisterna chyli access for the treatment of chylous leak secondary to partial glossectomy and neck dissection p. 121
Karan Nijhawan, Divya Kumari, Brian Funaki, Osman Ahmed
Thoracic duct embolization (TDE) is a minimally invasive alternative to surgery for the treatment of postoperative chylous leaks that fail conventional medical management. TDE can be a technically challenging procedure that requires real-time image guidance to visualize the thoracic duct. This case report describes using hybrid angiography/computed tomography technology to perform TDE through direct access of the cisterna chyli, potentially eliminating the need for intranodal lymphangiography, and reducing procedure length.
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Ureteroarterial fistula presenting as gross hematuria during routine nephroureteral stent exchange p. 124
Felipe Matsunaga, Mohammed Arabi, Sidhartha Tavri
Ureteroarterial fistula (UAF) is an uncommon entity and underrecognized etiology of hematuria in patients with a history of pelvic malignancy, irradiation, and surgery. Herein we report two cases of UAF unexpectedly identified during routine nephroureteral stent exchanges which highlight salient points regarding diagnosis and management.
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Uneventful sleeve gastrectomy post bariatric arterial embolization p. 127
Majed A Ashour, Ahmed Saliman Karsou, Adel A Bakhsh
We present the case of a 42-year-old female patient who successfully and uneventfully underwent gastric sleeve surgery 3-years after left gastric artery embolization, for the treatment of obesity. This case highlights that left gastric artery embolization may not preclude future bariatric surgeries in this subset of patients who initially fail to lose weight after bariatric arterial embolization (BAE).
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Partial splenic artery embolization for idiopathic warm autoimmune hemolytic anemia refractory to medical therapy p. 130
Mohamad Omar Hadied, Riyad Yazan Kherallah, Mariam Salman, Khalid Eteer, Scott Schwartz
Purpose: While Partial Splenic Artery Embolization (PSAE) is a useful procedure that has been performed for a variety of indications including trauma and hypersplenism, it has only been rarely described as a treatment for Idiopathic Warm Autoimmune Hemolytic Anemia. Previous reports in the literature are limited to case reports in situations that include the patient being a poor surgical candidate, the inability to transfuse blood during surgery because of autoantibodies, and a patient's refusal of blood products on religious grounds. Materials and Methods: A case report describing the case of a 27-year-old male diagnosed with idiopathic warm Autoimmune Hemolytic Anemia treated successfully with partial splenic artery embolization (PSAE) as a bridging therapy to definitive surgical splenectomy. Results: The patient's pre-procedure hemoglobin was 2.1 g/dl. The first hemoglobin post-procedure was 4.5 g/dl. After embolization, the patient remained in the inpatient setting for eight days for close observation. During the inpatient hospitalization the patient's hemoglobin continued to trend upwards until it stabilized around 6 g/dl. Inpatient laboratory workup also showed increasing haptoglobin, and decreasing LDH. After discharge, the patient developed persistent pain two months post-procedure. An elective splenectomy was scheduled three months after the embolization procedure to address the persistent pain. Six months' post embolization procedure and three months postoperatively, the patient is doing well clinically with a hemoglobin of 14 g/dl. Conclusion: In conclusion, this case demonstrates the utility of a Partial Splenic Artery Embolization (PSAE) as an acute life-saving intervention for poor surgical candidates with idiopathic warm Autoimmune Hemolytic Anemia (AIHA) refractory to medical therapy.
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Embolization of high-flow renal arteriovenous fistula p. 134
Omar J AlThaqufi, Abdullah Mohammed Almughir, Fadhel Mohsen Almolani
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Analysis of interventional radiology publications regarding COVID-19 p. 136
Tushar Garg, Apurva Shrigiriwar
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Angio-seal-assisted closure of femoral arterial pseudoaneurysm in a case of uncorrectable coagulation and potential allergy to thrombin p. 138
Abdulmajeed Bin Dahmash, Abdulrahman Al Qahtani, Shaker Alshehri
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