Publications by authors named "Nariman Nezami"

97 Publications

Laser Ablation of the Cystic Duct Followed with Cryoablation of Gallbladder: Leave Nothing Behind.

J Vasc Interv Radiol 2021 Jul 19. Epub 2021 Jul 19.

Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.

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http://dx.doi.org/10.1016/j.jvir.2021.07.006DOI Listing
July 2021

Identifying enhancement-based staging markers on baseline MRI in patients with colorectal cancer liver metastases undergoing intra-arterial tumor therapy.

Eur Radiol 2021 Jun 1. Epub 2021 Jun 1.

Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA.

Objectives: To determine if three-dimensional whole liver and baseline tumor enhancement features on MRI can serve as staging biomarkers and help predict survival of patients with colorectal cancer liver metastases (CRCLM) more accurately than one-dimensional and non-enhancement-based features.

Methods: This retrospective study included 88 patients with CRCLM, treated with transarterial chemoembolization or Y90 transarterial radioembolization between 2001 and 2014. Semi-automated segmentations of up to three dominant lesions were performed on pre-treatment MRI to calculate total tumor volume (TTV) and total liver volumes (TLV). Quantitative 3D analysis was performed to calculate enhancing tumor volume (ETV), enhancing tumor burden (ETB, calculated as ETV/TLV), enhancing liver volume (ELV), and enhancing liver burden (ELB, calculated as ELV/TLV). Overall and enhancing tumor diameters were also measured. A modified Kaplan-Meier method was used to determine appropriate cutoff values for each metric. The predictive value of each parameter was assessed by Kaplan-Meier survival curves and univariable and multivariable cox proportional hazard models.

Results: All methods except whole liver (ELB, ELV) and one-dimensional/non-enhancement-based methods were independent predictors of survival. Multivariable analysis showed a HR of 2.1 (95% CI 1.3-3.4, p = 0.004) for enhancing tumor diameter, HR 1.7 (95% CI 1.1-2.8, p = 0.04) for TTV, HR 2.3 (95% CI 1.4-3.9, p < 0.001) for ETV, and HR 2.4 (95% CI 1.4-4.0, p = 0.001) for ETB.

Conclusions: Tumor enhancement of CRCLM on baseline MRI is strongly associated with patient survival after intra-arterial therapy, suggesting that enhancing tumor volume and enhancing tumor burden are better prognostic indicators than non-enhancement-based and one-dimensional-based markers.

Key Points: • Tumor enhancement of colorectal cancer liver metastases on MRI prior to treatment with intra-arterial therapies is strongly associated with patient survival. • Three-dimensional, enhancement-based imaging biomarkers such as enhancing tumor volume and enhancing tumor burden may serve as the basis of a novel prognostic staging system for patients with liver-dominant colorectal cancer metastases.
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http://dx.doi.org/10.1007/s00330-021-08058-7DOI Listing
June 2021

Lipiodol as an intra-procedural imaging biomarker for liver tumor response to transarterial chemoembolization: Post-hoc analysis of a prospective clinical trial.

Clin Imaging 2021 May 18;78:194-200. Epub 2021 May 18.

Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 330 Cedar Street, New Haven, CT 06520, USA. Electronic address:

Background: The use of the ethiodized oil- Lipiodol in conventional trans-arterial chemoembolization (cTACE) ensures radiopacity to visualize drug delivery in the process of providing selective drug targeting to hepatic cancers and arterial embolization. Lipiodol functions as a carrier of chemo drugs for targeted therapy, as an embolic agent, augmenting the drug effect by efflux into the portal veins as well as a predictor for the tumor response and survival.

Purpose: To prospectively evaluate the role of 3D quantitative assessment of intra-procedural Lipiodol deposition in liver tumors on CBCT immediately after cTACE as a predictive biomarker for the outcome of cTACE.

Materials & Methods: This was a post-hoc analysis of data from an IRB-approved prospective clinical trial. Thirty-two patients with hepatocellular carcinoma or liver metastases underwent contrast enhanced CBCT obtained immediately after cTACE, unenhanced MDCT at 24 h after cTACE, and follow-up imaging 30-, 90- and 180-days post-procedure. Lipiodol deposition was quantified on CBCT after cTACE and was characterized by 4 ordinal levels: ≤25%, >25-50%, >50-75%, >75%. Tumor response was assessed on follow-up MRI. Lipiodol deposition on imaging, correlation between Lipiodol deposition and tumor response criteria, and correlation between Lipiodol coverage and median overall survival (MOS) were evaluated.

Results: Image analysis demonstrated a high degree of agreement between the Lipiodol deposition on CBCT and the 24 h post-TACE CT, with a Bland-Altman plot of Lipiodol deposition on imaging demonstrated a bias of 2.75, with 95%-limits-of-agreement: -16.6 to 22.1%. An inverse relationship between Lipiodol deposition in responders versus non-responders for two-dimensional EASL reached statistical significance at 30 days (p = 0.02) and 90 days (p = 0.05). Comparing the Lipiodol deposition in Modified Response Evaluation Criteria in Solid Tumors (mRECIST) responders versus non-responders showed a statistically significant higher volumetric deposition in responders for European Association for the Study of the Liver (EASL)-30d, EASL-90d, and quantitative EASL-180d. The correlation between the relative Lipiodol deposition and the change in enhancing tumor volume showed a negative association post-cTACE (30-day: p < 0.001; rho = -0.63). A Kaplan-Meier analysis for patients with high vs. low Lipiodol deposition showed a MOS of 46 vs. 33 months (p = 0.05).

Conclusion: 3D quantification of Lipiodol deposition on intra-procedural CBCT is a predictive biomarker of outcome in patients with primary or metastatic liver cancer undergoing cTACE. There are spatial and volumetric agreements between 3D quantification of Lipiodol deposition on intra-procedural CBCT and 24 h post-cTACE MDCT. The spatial and volumetric agreement between Lipiodol deposition on intra-procedural CBCT and 24 h post-cTACE MDCT could suggest that acquiring MDCT 24 h after cTACE is redundant. Importantly, the demonstrated relationship between levels of tumor coverage with Lipiodol and degree and timeline of tumor response after cTACE underline the role of Lipiodol as an intra-procedural surrogate for tumor response, with potential implications for the prediction of survival.
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http://dx.doi.org/10.1016/j.clinimag.2021.05.007DOI Listing
May 2021

Role of 3D quantitative tumor analysis for predicting overall survival after conventional chemoembolization of intrahepatic cholangiocarcinoma.

Sci Rep 2021 Apr 29;11(1):9337. Epub 2021 Apr 29.

Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.

This study was designed to assess 3D vs. 1D and 2D quantitative tumor analysis for prediction of overall survival (OS) in patients with Intrahepatic Cholangiocarcinoma (ICC) who underwent conventional transarterial chemoembolization (cTACE). 73 ICC patients who underwent cTACE were included in this retrospective analysis between Oct 2001 and Feb 2015. The overall and enhancing tumor diameters and the maximum cross-sectional and enhancing tumor areas were measured on baseline images. 3D quantitative tumor analysis was used to assess total tumor volume (TTV), enhancing tumor volume (ETV), and enhancing tumor burden (ETB) (ratio between ETV and liver volume). Patients were divided into low (LTB) and high tumor burden (HTB) groups. There was a significant separation between survival curves of the LTB and HTB groups using enhancing tumor diameter (p = 0.003), enhancing tumor area (p = 0.03), TTV (p = 0.03), and ETV (p = 0.01). Multivariate analysis showed a hazard ratio of 0.46 (95%CI: 0.27-0.78, p = 0.004) for enhancing tumor diameter, 0.56 (95% CI 0.33-0.96, p = 0.04) for enhancing tumor area, 0.58 (95%CI: 0.34-0.98, p = 0.04) for TTV, and 0.52 (95%CI: 0.30-0.91, p = 0.02) for ETV. TTV and ETV, as well as the largest enhancing tumor diameter and maximum enhancing tumor area, reliably predict the OS of patients with ICC after cTACE and could identify ICC patients who are most likely to benefit from cTACE.
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http://dx.doi.org/10.1038/s41598-021-88426-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085245PMC
April 2021

Iatrogenic abdominal aortic pseudoaneurysm repaired by percutaneous image-guided translumbar embolization.

J Vasc Surg Cases Innov Tech 2021 Mar 10;7(1):35-39. Epub 2020 Nov 10.

Larner College of Medicine, University of Vermont Medical Center, Burlington, Vt.

Aortic injury is a frequently encountered condition that can present as a life-threatening emergency. When this injury occurs in the retroperitoneal portion of the aorta, it can be difficult to diagnose and treat because of the location. Although surgical repair remains the mainstay of treatment, surgery might not be an option for some patients. We have presented a case of a 54-year-old nonoperative candidate who had experienced iatrogenic retroperitoneal abdominal aortic rupture with pseudoaneurysm formation. The patient was successfully treated with the novel use of a proven technique: direct percutaneous embolization of the pseudoaneurysm sac via a translumbar approach under image guidance.
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http://dx.doi.org/10.1016/j.jvscit.2020.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903189PMC
March 2021

Mechanical thrombectomy for pulmonary embolism in patients with patent foramen Ovale.

CVIR Endovasc 2020 Nov 28;3(1):89. Epub 2020 Nov 28.

Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.

Background: The current level of evidence for mechanical thrombectomy (MT) of pulmonary embolism (PE) in patients with patent foramen ovale (PFO) is limited.

Results: This was a retrospective analysis of 9 patients with PFO and acute high-risk or intermediate-high-risk PE, 6 with intermediate-high risk and 3 with high-risk PE. All underwent MT using the Inari FlowTriever System from Dec 2018 to November 2019. Six of these patients had confirmed deep venous thrombosis. The technical and clinical success rate for MT in all patients was 100% and 77.8%, respectively. Right-heart strain improved in 6/8 patients on follow-up echocardiography. Mean main pulmonary artery (MPA) pressure significantly decreased after MT (p < 0.012). One patient presented with altered mental status (somnolence and disorientation) prior to coronary artery angiogram and thrombectomy, developed a middle cerebral artery embolic stroke 1 day after MT, and recovered with minor sequalae and later was discharged. There was no in-hospital mortality.

Conclusions: MT using FlowTriever was feasible and safe, successfully improving MPA pressure in patients presenting with concurrent PFO and PE.
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http://dx.doi.org/10.1186/s42155-020-00180-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695793PMC
November 2020

A Solution to Academic Radiology's Experience With Solicitation E-mails From Predatory Journals.

AJR Am J Roentgenol 2021 01 28;216(1):233-240. Epub 2020 Oct 28.

Division of Vascular and Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 1800 Orleans St, Zayed Tower 7203, Baltimore, MD 21287.

The objective of our study was to help academic researchers avoid predatory publishers by characterizing the problem with respect to radiology and medical imaging and to test an intervention to address aggressive e-mail solicitation. In total, 803 faculty from 10 U.S. academic radiology departments and 193 faculty in the senior author's department were surveyed about their experiences with soliciting journals. To document the characteristics of these journals and their publishers, we retrospectively reviewed the academic institutional e-mail box of one radiologist over 51 days. Journals' bibliometric parameters were compared with those of established medical imaging journals offering open access publishing. We tested filters for selected syntax to identify spam e-mails during two time periods. Of 996 faculty, 206 responded (16% nationally, 42% locally). Most (98%) received e-mails from soliciting publishers. Only 7% published articles with these publishers. Submission reasons were invitations, fee waivers, and difficulty publishing elsewhere. Overall, 94 publishers sent 257 e-mails in 51 days, 50 of which offered publishing opportunities in 76 imaging journals. Six journals were indexed in PubMed, and two had verifiable impact factors. The six PubMed-indexed journals had a lower mean publication fee ($824) than top medical imaging journals ($3034) ( < 0.001) and had a shorter mean duration of existence (9.5 vs 49.0 years, respectively; = 0.005). The e-mail filters captured 71% of soliciting e-mails during the initial 51-day period and 85% during the same period 1 year later. Soliciting publishers have little impact on scientific literature. Academicians can avoid soliciting e-mails with customized e-mail filters.
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http://dx.doi.org/10.2214/AJR.20.22923DOI Listing
January 2021

Bland embolization of a ruptured hepatoblastoma with massive intraperitoneal hemorrhage.

Radiol Case Rep 2020 Nov 17;15(11):2367-2370. Epub 2020 Sep 17.

Division of Vascular and Interventional Radiology, Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed Tower 7203, Baltimore, MD 21287, USA.

Purpose: Hepatoblastoma is the most common primary neoplasm of the liver in the pediatric population, usually diagnosed during the first 5 years of life. Patients with large or peripheral hepatoblastomas are at risk for rupture and peritoneal hemorrhage. Image-guided, minimally invasive interventions are offered for controlling hemorrhage.

Case Presentation: We present a 2-year-old female with an 11.8 cm hepatoblastoma in the right hepatic lobe involving segment 4A, who developed hemodynamic instability on day 8 of induction chemotherapy. Imaging revealed intraperitoneal hemorrhage secondary to her ruptured hepatoblastoma. The patient was successfully treated by celiac artery angiogram and transarterial bland embolization.

Conclusion: Transarterial bland embolization of large hepatoblastomas may control and even prevent intraperitoneal/intracapsular hemorrhage, and may also enhance the efficacy of systematic chemotherapy in the pediatric patients with advanced hepatoblastoma.
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http://dx.doi.org/10.1016/j.radcr.2020.08.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502784PMC
November 2020

The Cholangioscopy Expander: A Handmade Device to Improve Visualization and Minimize Mucosal Injury during Percutaneous Cholangioscopy.

J Vasc Interv Radiol 2020 11 22;31(11):1956-1958. Epub 2020 Sep 22.

Department of Vascular and Interventional Radiology, The Johns Hopkins School of Medicine, 601 N. Caroline St., Baltimore, MD 21205.

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http://dx.doi.org/10.1016/j.jvir.2020.04.024DOI Listing
November 2020

One Step Closer to Precision Medicine for Transarterial Therapy of HCC.

Radiology 2020 10 11;297(1):235-236. Epub 2020 Aug 11.

From the Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, 1800 Orleans St, Zayed Tower 7203, Baltimore, MD 21287.

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http://dx.doi.org/10.1148/radiol.2020202843DOI Listing
October 2020

Combining Chemotherapy and Radiation Therapy for Liver Cancer: Is the Solution an Intraarterial Approach?

Cardiovasc Intervent Radiol 2020 10 11;43(10):1538-1539. Epub 2020 Aug 11.

Section of Vascular and Interventional Radiology, Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA.

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http://dx.doi.org/10.1007/s00270-020-02592-5DOI Listing
October 2020

Predictors of coronavirus disease 19 (COVID-19) pneumonitis outcome based on computed tomography (CT) imaging obtained prior to hospitalization: a retrospective study.

Emerg Radiol 2020 Dec 8;27(6):653-661. Epub 2020 Aug 8.

Department of Radiology, Neuro-Intervention and Neurologic Surgery, Urmia University of Medical Sciences, Urmia, Iran.

Purpose: Computed tomography (CT) has been utilized as a diagnostic modality in the coronavirus disease 19 (COVID-19), while some studies have also suggested a prognostic role for it. This study aimed to assess the diagnostic and prognostic value of computed tomography (CT) imaging in COVID-19 patients.

Methods: This was a retrospective study of fifty patients with COVID-19 pneumonia. Twenty-seven patients survived, while 23 passed away. CT imaging was performed in all of the patients on the day of admission. Imaging findings were interpreted based on current guidelines by two expert radiologists. Imaging findings were compared between surviving and deceased patients. Lung scores were assigned to patients based on CT chest findings. Then, the receiver operating characteristic curve was used to determine cutoff values for lung scores.

Results: The common radiologic findings were ground-glass opacities (82%) and airspace consolidation (42%), respectively. Air bronchogram was more commonly seen in deceased patients (p = 0.04). Bilateral and multilobar involvement was more frequently found in deceased patients (p = 0.049 and 0.014, respectively). The mean number of involved lobes was 3.46 ± 1.80 lobes in surviving patients and 4.57 ± 0.60 lobes in the deceased patients (p = 0.009). The difference was statistically significant. The area under the curve for a lung score cutoff of 12 was 0.790.

Conclusion: Air bronchogram and bilateral and multilobar involvement were more frequently seen in deceased patients and may suggest a poor outcome for COVID-19 pneumonia.
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http://dx.doi.org/10.1007/s10140-020-01833-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414287PMC
December 2020

Catheter-directed therapies for pulmonary embolism: considerations for patients with patent foramen ovale.

J Thromb Thrombolysis 2021 Feb;51(2):516-521

Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed Tower 7203, Baltimore, MD, 21287, USA.

Pulmonary embolism can be fatal, especially in high-risk patients who have contraindications to systemic thrombolysis or surgical embolectomy. For this population, interventionalists can provide catheter-directed therapies, including catheter-directed thrombolysis and thrombectomy, using a wide array of devices. Endovascular treatment of pulmonary embolism shows great promise through fractionated thrombolytic drug delivery, fragmentation, and aspiration mechanisms with thrombectomy devices. Although successful outcomes have been reported after using these treatments, evidence is especially limited in patients with both a patent foramen ovale (PFO) and acute pulmonary embolism. In patients with PFO, it is important to consider whether catheter-directed therapy is appropriate or whether surgical embolectomy should instead be performed. An increased risk of paradoxical embolus in these patients supports the use of diagnostic echocardiography with possible surgical closure of PFO after one episode of pulmonary embolism. Percutaneous PFO closure, which can be performed at the time of catheter-based therapy, theoretically reduces risk of future paradoxical embolization, although more data are needed before making a recommendation for this specific group of patients.
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http://dx.doi.org/10.1007/s11239-020-02189-2DOI Listing
February 2021

Dual-chambered venous access port as alternative access for extracorporeal apheresis therapy.

J Vasc Access 2021 Mar 15;22(2):173-177. Epub 2020 Jun 15.

Division of Interventional Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Purpose: To evaluate the use of a dual-chambered venous access port for extracorporeal apheresis therapy.

Methods: This was a single-center retrospective analysis of all patients who received a dual-chambered venous access port for apheresis therapy over a 36-month period. Clinical success was defined as successful completion of at least one round of apheresis via the venous access port. Major complications were defined as any event requiring elevation of patient care and/or venous access port removal or repositioning. Minor complications were defined as venous access port issues resolved with clinical intervention.

Results: Forty-four patients had a venous access port placed at the time of this study. Patients underwent red cell exchange (n = 33), therapeutic plasma exchange (n = 6) or extracorporeal photopheresis (n = 5). Forty (90%) patients had autoimmune diseases and four (10%) had neoplastic processes. Clinical success was achieved in 42 (95.5%) patients. Average venous access port dwell time was 632 days (range = 42-1191 days). All therapies through the venous access ports were well tolerated and no patients reported pain or discomfort. Major complications were seen in nine (20.5%) patients-the majority (n = 7) of which were due to venous access port malfunction-and resolved with catheter revision. One (2.27%) major complication involved an infected venous access port, and one involved a large hematoma at the venous access port site. Minor complications were seen in eight (18.2%) patients, where simple flushing of the catheter with saline or tissue plasminogen activator resolved the issue.

Conclusion: The dual-chambered venous access port was successfully used for sustained blood flow in apheresis therapy with a moderate, yet correctable complication rate.
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http://dx.doi.org/10.1177/1129729820932425DOI Listing
March 2021

Predicting Patient Survival in Oncology: Is it Time to Take a New Path?

Cardiovasc Intervent Radiol 2020 08;43(8):1173-1174

USA Vein Clinics and Oncology Centers, 304 Wainwright Drive, Northbrook, IL, 60062, USA.

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http://dx.doi.org/10.1007/s00270-020-02553-yDOI Listing
August 2020

Median Arcuate Ligament Syndrome With Celiac Artery Aneurysm and Dissection.

Vasc Endovascular Surg 2020 Aug 21;54(6):525-527. Epub 2020 May 21.

Department of Radiology, University of Vermont Medical Center, Burlington, VT, USA.

Median arcuate ligament syndrome (MALS) is the chronic symptomatic compression of the celiac artery by the median arcuate ligament. A known potential sequela of MALS is celiac artery aneurysm, which could predispose the diseased artery to dissection. However, the presence of celiac artery dissection and MALS is yet to be reported. Here, we present a case of MALS with a coincident celiac artery aneurysm and dissection.
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http://dx.doi.org/10.1177/1538574420927866DOI Listing
August 2020

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios as predictors of tumor response in hepatocellular carcinoma after DEB-TACE.

Eur Radiol 2020 Oct 19;30(10):5663-5673. Epub 2020 May 19.

Department of Radiology and Biomedical Imaging, Yale School of Medicine, 300 Cedar Street, New Haven, CT, 06520, USA.

Objectives: To investigate the predictive value of quantifiable imaging and inflammatory biomarkers in patients with hepatocellular carcinoma (HCC) for the clinical outcome after drug-eluting bead transarterial chemoembolization (DEB-TACE) measured as volumetric tumor response and progression-free survival (PFS).

Methods: This retrospective study included 46 patients with treatment-naïve HCC who received DEB-TACE. Laboratory work-up prior to treatment included complete and differential blood count, liver function, and alpha-fetoprotein levels. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were correlated with radiomic features extracted from pretreatment contrast-enhanced magnetic resonance imaging (MRI) and with tumor response according to quantitative European Association for the Study of the Liver (qEASL) criteria and progression-free survival (PFS) after DEB-TACE. Radiomic features included single nodular tumor growth measured as sphericity, dynamic contrast uptake behavior, arterial hyperenhancement, and homogeneity of contrast uptake. Statistics included univariate and multivariate linear regression, Cox regression, and Kaplan-Meier analysis.

Results: Accounting for laboratory and clinical parameters, high baseline NLR and PLR were predictive of poorer tumor response (p = 0.014 and p = 0.004) and shorter PFS (p = 0.002 and p < 0.001). When compared to baseline imaging, high NLR and PLR correlated with non-spherical tumor growth (p = 0.001 and p < 0.001).

Conclusions: This study establishes the prognostic value of quantitative inflammatory biomarkers associated with aggressive non-spherical tumor growth and predictive of poorer tumor response and shorter PFS after DEB-TACE.

Key Points: • In treatment-naïve hepatocellular carcinoma (HCC), high baseline platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are associated with non-nodular tumor growth measured as low tumor sphericity. • High PLR and NLR are predictive of poorer volumetric enhancement-based tumor response and PFS after DEB-TACE in HCC. • This set of readily available, quantitative immunologic biomarkers can easily be implemented in clinical guidelines providing a paradigm to guide and monitor the personalized application of loco-regional therapies in HCC.
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http://dx.doi.org/10.1007/s00330-020-06931-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483919PMC
October 2020

Simultaneous proximal embolic protection and inferior vena cava mechanical thrombectomy using the FlowTriever system.

Diagn Interv Radiol 2020 Jul;26(4):345-348

Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, United States.

Interventional radiologists have the unique ability to apply their imaging knowledge, wide scope of technical skills, and use of innovative technologies to comprehensively address the percutaneous management of the thromboembolic disease processes. This report illustrates successful management of a thrombosed IVC, while protecting against possible pulmonary embolism. Here, we present a 49-year-old female with stage IIIB ovarian cancer who presented with severe bilateral lower extremity edema and anasarca in setting of occlusive thrombus of IVC. The thrombus was the result of compressionfrom a large hepatic hematoma which gradually developed after radical hysterectomy. A new mechanical thrombectomy device approved for use in pulmonary embolism, Inari FlowTriever catheter, was used off-label to remove the clot. The self-expanding mesh discs in the Inari FlowTriever catheter were utilized to protect against pulmonary embolism while percutaneously draining the hepatic hematoma and alleviating the IVC compression. The IVC was largely patent at the end of the procedure, and the patient experienced complete resolution of her symptoms. This case report demonstrates the successful and safe off-label use of a new mechanical thrombectomy device approved for pulmonary embolism thrombectomy in the IVC and illustrates a novel application of the nitinol mesh discs in the device as proximal embolic protection.
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http://dx.doi.org/10.5152/dir.2019.19458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360082PMC
July 2020

Oligometastatic Disease and Interventional Oncology: Rationale and Research Directions.

Cancer J 2020 Mar/Apr;26(2):166-173

Division of Vascular and Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, MD.

Oligometastatic disease (OMD) is generally defined as a stage of clinically or radiographically demonstrated metastatic disease limited in total disease burden and without rapid spread. Interventional oncology performs local therapies for primary and metastatic cancers, including OMD. Interventional oncology treatments can be pursued both as definitive therapy and for palliative purposes. Applied to OMD, these interventions can offer patients a decreasing overall tumor burden, minimizing cancer morbidity, and early evidence suggests a survival benefit. Here, we discuss the range of interventional oncology treatments, including ablation, chemoembolization, radioembolization, and irreversible electroporation. We describe the rationale for their application to OMD and discuss future directions for research.
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http://dx.doi.org/10.1097/PPO.0000000000000442DOI Listing
April 2021

Contemporary Management of Hepatic Trauma: What IRs Need to Know.

Semin Intervent Radiol 2020 Mar 4;37(1):35-43. Epub 2020 Mar 4.

Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.
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http://dx.doi.org/10.1055/s-0039-3401838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056342PMC
March 2020

Hyoid bone impingement contributing to symptomatic atherosclerosis of the carotid bifurcation.

J Vasc Surg Cases Innov Tech 2020 Mar 20;6(1):89-92. Epub 2020 Feb 20.

Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University, New Haven, Conn.

Symptomatic carotid artery disease caused by hyoid bone compression is rare, although scant reports describe cerebrovascular events due to this mechanical interference leading to entrapment, embolism, dissection, atherosclerotic stenosis, and pseudoaneurysm formation. This report describes a patient presenting with left-sided paresis and paresthesia who was found to have focal right carotid stenosis secondary to impingement of the carotid bulb by an elongated hyoid bone. Whereas previous cases describe hyoid bone resection, we describe successful management with endarterectomy and carotid mobilization without hyoid resection, with long-term follow-up demonstrating a widely patent carotid system without recurrent impingement.
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http://dx.doi.org/10.1016/j.jvscit.2020.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7033462PMC
March 2020

Vertebroplasty-associated cement leak leading to iatrogenic venous compression and thrombosis.

J Vasc Surg Cases Innov Tech 2019 Dec 22;5(4):561-565. Epub 2019 Nov 22.

Section of Vascular and Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.

A 91-year-old woman presented with left lower extremity swelling and pain diagnosed as phlegmasia cerulea dolens. Doppler ultrasound and venography revealed extensive left lower extremity deep venous thrombosis. Review of prior images revealed cement leakage causing compression of the left common iliac vein. She underwent successful mechanical thrombectomy using the ClotTriever device (Inari Medical, Irvine, Calif) and subsequent stent placement. Phlegmasia cerulea dolens resolved on the following day, and the stent remained patent at the 1-month follow-up appointment. Cement leakage from L5 vertebroplasty can cause extrinsic compression on the left common iliac vein, resulting in iatrogenic venous compression syndrome and the development of deep venous thrombosis in the affected lower extremity.
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http://dx.doi.org/10.1016/j.jvscit.2019.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911956PMC
December 2019

Right Atrial and Massive Pulmonary Artery Mechanical Thrombectomy Under Echocardiography Guidance Using the FlowTriever System.

EJVES Short Rep 2019 7;45:22-25. Epub 2019 Nov 7.

Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.

Introduction: Management of clot in transit in patients with pulmonary embolism, who are candidates for percutaneous intervention, can be challenging. This is a case report of simultaneous right atrial mechanical thrombectomy under echocardiography guidance and pulmonary artery embolectomy under fluoroscopy guidance, using the recently introduced FlowTriever system (Inari Medical Inc., Irvine, CA, USA).

Report: An 88 year old female, resuscitated from cardiopulmonary arrest near the end of a total right hip arthroplasty, presented for management of suspected massive pulmonary embolism. Her right atrial thrombus was removed under transthoracic echocardiography guidance, and her pulmonary arterial thrombus was subsequently successfully treated under fluoroscopy.

Discussion: The FlowTriever system can be safely and effectively used under real time transthoracic echocardiography guidance to retrieve clot in transit from the cardiac chambers, in addition to its standard application for the pulmonary artery under fluoroscopy guidance.
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http://dx.doi.org/10.1016/j.ejvssr.2019.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6888743PMC
November 2019

Cholangiolithiasis postliver transplantation: Successful treatment utilizing percutaneous transhepatic cholangioscopy and laser lithotripsy.

Radiol Case Rep 2019 Dec 8;14(12):1459-1466. Epub 2019 Oct 8.

Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven 06520, CT, USA.

Liver transplant is a risk factor for the development of cholangiolithiasis and choledocholithiasis. While usually addressed by endoscopic techniques, percutaneous transhepatic cholangioscopy combined with laser lithotripsy can be considered a suitable alternative option in select patients. A 29-year-old male with a 27-year history of liver transplant presented with new onset of persistent pain localized to the lower abdomen 9 days after a liver biopsy. Abdominal CT scan and MRCP showed large calculi expanding intra- and extrahepatic bile ducts. All intrahepatic ductal calculi were removed after 2 sessions of laser lithotripsy and basket retrieval, while common hepatic duct calculi were anterogradely swept into the jejunum after balloon cholangioplasty of the hepaticojejunal anastomosis. No major procedure-related complications were seen. Percutaneous transhepatic cholangioscopy and choledochoscopy with laser lithotripsy is a minimally invasive and efficient technique for removal of intra- and extrahepatic bile duct stones postliver transplantation.
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http://dx.doi.org/10.1016/j.radcr.2019.09.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796643PMC
December 2019

Phase Ib trial of gemcitabine with yttrium-90 in patients with hepatic metastasis of pancreatobiliary origin.

J Gastrointest Oncol 2019 Oct;10(5):944-956

Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.

Background: Gemcitabine, a chemotherapy for hepatic metastasis with pancreatic cancer (PC) or intrahepatic cholangiocarcinoma (ICC) origin, may radiosensitize the targeted tumor cells for yttrium-90 radioembolization (90Y-RE). This clinical trial was designed to investigate the effects of a combination of 90Y-RE and gemcitabine in hepatic metastasis of PC or ICC origin.

Methods: Fourteen patients who had histopathologic diagnosis of unresectable hepatic metastasis of PC or ICC origin were enrolled into the open-label phase Ib clinical trial. Induction dose of gemcitabine on day 1 was followed by 90Y-RE on day 2 with predetermined doses of gemcitabine to follow till week 12. Maximal tolerated dose (MTD) of gemcitabine in combination with 90Y-RE, associated toxicities and hepatic progression free survival (HPFS) were assessed. The tumor response rate was evaluated using both RECIST and PERCIST criteria.

Results: Eight patients met the study criteria; three with PC and five with ICC. The mean age of the patients was 69.4 years. Seven out of 8 patients tolerated predetermined gemcitabine regime (dose level 1 at 400 mg/m and dose level 2 at 600 mg/m). All of the patients developed grade 1 toxicities. Three patients (37.5%) had grade 2 hepatobiliary toxicity and one patient (12.5%) had grade 3 hepatobiliary toxicity, who was hospitalized for a short-term. The median HPFS was 8.7 months for all patients. The objective response rate was 62%.

Conclusions: A combination of 90Y-RE and gemcitabine at 600 mg/m is a safe and potential treatment option for hepatic metastasis of pancreaticobiliary origin.
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http://dx.doi.org/10.21037/jgo.2019.05.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776801PMC
October 2019

The resuscitative endovascular balloon occlusion of aorta (REBOA) device-what radiologists need to know.

Emerg Radiol 2019 Dec 12;26(6):691-694. Epub 2019 Sep 12.

Emory University Department of Radiology and Imaging Services, 550 Peachtree St NE, Atlanta, GA, 30308, USA.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel device approved by the Food and Drug administration (FDA) in 2017 as an alternative to resuscitative emergent thoracotomy (RET). Due to advancements in placement of REBOA, including newly validated placement using anatomic landmarks, REBOA is now widely used by interventional radiologists and emergency physicians in acute subdiaphragmatic hemorrhage. Increased use of REBOA necessitates that radiologists are familiar with verification of proper REBOA placement to minimize complications. This review describes the REBOA device, indications, placement, and complications, summarizing the current available literature.
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http://dx.doi.org/10.1007/s10140-019-01724-wDOI Listing
December 2019

Modeling of implementation of the new Organ Procurement and Transplantation Network/United Network for Organ Sharing policy for patients with hepatocellular carcinoma.

J Comp Eff Res 2019 09 12;8(12):993-1002. Epub 2019 Sep 12.

Section of Interventional Radiology, Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, USA.

To simulate effects of the new Organ Procurement and Transplantation Network/United Network for Organ Sharing policy on the patients' characteristics and post orthotopic liver transplantation (OLT) outcome. The United Network for Organ Sharing database was used to identify patients with hepatocellular carcinoma who were listed for OLT 2002-2014. All patients (actual group) versus simulated group with new 6-month delay in assigning Model for End-Stage Liver Disease score exception and Model for End-Stage Liver Disease exception cap of 34 were compared. With the new policy, 7,745 (30.4%) of the transplanted patients would have received a delayed transplantation or not be transplanted. The simulated group also showed significantly higher mean overall survival after OLT (p < 0.002) and received more locoreginal treatments (p < 0.001).
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http://dx.doi.org/10.2217/cer-2019-0076DOI Listing
September 2019

The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia.

Abdom Radiol (NY) 2020 10;45(10):2960-2979

Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.

Objective: This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications.

Results: Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of "imaging wisely" raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia.

Conclusion: Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.
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http://dx.doi.org/10.1007/s00261-019-02165-2DOI Listing
October 2020

Optimizing Image Quality When Evaluating Blood Flow at Doppler US: A Tutorial.

Radiographics 2019 Sep-Oct;39(5):1501-1523. Epub 2019 Aug 9.

From the Department of Diagnostic Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R., A.I., S.P., A.M., N.N., M.S.); Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (C.M.); and Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.).

Doppler US is an essential component of nearly all diagnostic US procedures. In this era of increased awareness of the effects of ionizing radiation and the side effects of iodine- and gadolinium-based contrast agents, Doppler US is poised to play an even bigger role in medical imaging. It is safe, cost-effective, portable, and highly accurate when performed by an experienced operator. The sensitivities and specificities of Doppler US for detecting blood flow and determining the direction and velocity of blood flow in various organs and vascular systems have increased dramatically in the past decade. With use of advanced flow techniques that are available for use with most modern equipment, US can provide vascular information that is comparable to or even more accurate than that obtained with other cross-sectional and interventional modalities. However, there remains concern that US (including newer more advanced flow-evaluating techniques) will not be used to its full potential owing to dependence on operator skill and expertise. Thorough understanding of image optimization techniques and expanded knowledge of the physical principles, instrumentation, application, advantages, and limitations of this modality are of utmost importance. The authors provide a simple practical guide for optimizing images for vascular flow detection by reviewing various cases and focusing on the parameters that should be optimized. RSNA, 2019 See discussion on this article by Pellerito.
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http://dx.doi.org/10.1148/rg.2019180055DOI Listing
May 2020
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