What’s new in Interventional Radiology – April 2021

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Bariatric Embolization in the Treatment of Patients with a Body Mass Index Between 30 and 39.9 kg/m2 (Obesity Class I and II) and Metabolic Syndrome, a Pilot Study 

Raphael Braz Levigard, Henrique Serrão, Camille Castro, Priscila Matos, Fernanda Mattos, Eduardo Madeira, Camila Lüdke Rosseti, Denise Pires de Carvalho, Joana Rodrigues Dantas, Lenita Zajdenverg & Miguel Madeira 

Cardiovasc Intervent Radiol. 2021 Feb 1. doi: 10.1007/s00270-021-02776-7. Epub ahead of print. PMID: 33527186.  

Obesity is one of the leading causes of morbidity and mortality worldwide and is often coexistent with Metabolic Syndrome (MS). Treatment options include bariatric surgery with complication rates up to 25%, and most recently bariatric arterial embolization (BAE), a minimally invasive alternative capable of reducing serum levels of ghrelin, the “hunger hormone” through ischemia of the gastric fundus.  

This study’s purpose was to study the safety and efficacy of BAE in a female cohort with class I (BMI of 30.0 to 34.9) and II (BMI of 35.0 to 39.9) obesity and MS. 10 female participants between 21 and 48-years-old, median BMI of 36.37 ± 2.58 kg/m2 and MS were enrolled in this prospective single-center trial.  

The procedure entailed angiographic studies of left gastric artery (LGA), gastroduodenal and splenic arteries followed by targeted embolization of the LGA, the dominant artery feeding the fundus, and in certain cases, additional feeding vessels (accessory left gastric artery, gastroepiploic artery, and short gastric artery ) with Embospheres 300-500 μm.   

All participants were discharged on a liquid diet followed by a bland and hypocaloric low fat and low carbohydrate diet. Gastric protection was initiated with pantoprazole followed by omeprazole. Patients were screened by gastrointestinal endoscopy, performed before and one week and one month after BAE. 6 months after BAE, efficacy was assessed by changes in total body weight (TBW), ghrelin and Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) levels and by changes in quality of life (QOL) and in binge eating scale (BES) scores.  

Six months after embolization, TBW decreased by 6.8% (6.22 kg ± 3.6;p = .01), serum ghrelin dropped from 25.39 pg/ml ± 10.63 to 17.1 ± 8.07 (p = 0.01), and HOMA-IR decreased from 7.29 ± 5.66 to 3.73 ± 1.99 (p = 0.01). The QOL scores improved from 59.64 ± 5.59 to 69.02 ± 11.97 (p < 0.05) and in the BES from 21.50 ± 8.89 to 9.60 ± 4.40 (p = 0.01). In total, there were two Grade 1 (deep gastric ulcers) complications and one Grade 2 (puncture site thrombosis) complication according to the Clavien-Dindo scale. 9 out of 10 patients did not follow the proposed low-calorie diet after the first month following the procedure, with a consumption of 300 kilocalories more than the prescribed amount.  

This study demonstrated that for a small population of obese women with class I and II obesity and MS, BAE efficiency reduced weight, insulin resistance, and ghrelin levels and improved BES and QOL scores without major complications. 

Fig. 1 A Left gastric digital arteriogram (non-subtracted) in the supine position from the left radial approach showing arterial branches to the gastric fundus (*) and proximal body. B Left gastric digital subtraction arteriogram after embolization with Embospheres showing occlusion of the distal branches of the left gastric artery 

 

Prostatic Artery Embolization for the Treatment of Recurrent Lower Urinary Tract Symptoms following Transurethral Resection of the Prostate 

Xu ZW, Tian W, Zhou CG, Leng B, Shi HB, Liu S.  

J Vasc Interv Radiol. 2021 Feb;32(2):242-246. doi: 10.1016/j.jvir.2020.09.004. Epub 2020 Nov 25. PMID: 33248915. 

Benign prostatic hyperplasia (BPH) is responsible for lower urinary tract symptoms (LUTS). Following a transurethral resection of the prostate (TURP), up to 11.2% of patients need repeated treatment after intolerance of medical therapy or failure of primary TURP. Repeated surgery is associated with an increased risk of surgical morbidity and severe complications. Prostate artery embolization (PAE) has therefore emerged as a viable minimally invasive modality for the efficient management of LUTS in patients with BPH. 

The purpose of this single-center retrospective study was to evaluate the safety and efficacy of PA in patients with recurrent LUTS secondary to BPH who underwent a previous TURP. This study included 15 patients who had severe LUTS (International Prostate Symptom Score [IPSS] ≥ 18 and quality of life [QoL] score ≥ 3) refractory to medical treatment for at least 6 months from February 2014 and April 2019. 

The procedure consisted of digital subtraction angiography of the prostatic arteries (PA) and  its pelvic anastomoses followed by Polyvinyl alcohol (PVA) particle complete embolization of both prostate arteries (90–180 μm (n=9) or 180–300 μm (n=6)).  A foley balloon was placed in the bladder to obtain optimal visualization.  

After the PAE, patients were asked on a questionnaire to record their perceived pain severity and to stay in the hospital for observation. Patients were followed by telephone or as outpatients, and PV was measured on MRI or US at 3 and 12 months after PAE. There were no major complications. 5 patients had minor complications which resolved spontaneously, including mild urethral pain during voiding, urinary frequency, pelvic pain, and fever. 

The intervals from TURP to recurrent symptoms and from TURP to PAE were 4.3 y ± 3.2 and 5.6 y ± 3.8, respectively. Technical success was achieved in all patients. The clinical success rate for LUTS relief at 12 mo was 93.3% (14 of 15). IPSS significantly reduced from 22.5 ± 4.1 at baseline to 9.9 ± 4.9 at 12-mo follow-up, and QoL score improved from 4.7 ± 1.0 to 2.1 ± 1.1 (P < .05 for both). There was a significant mean reduction of 26.6% in PV at 12 mo, improving from 100.7 cm3 ± 38.5 to 73.9 cm3 ± 29.4 (P < .05).  

The percentage of PV reduction was lower than reported by Wang et al (41.9%), Kurbatov et al (44.9%), and Bhatia et al (39.3%). One patient experienced recurrent LUTS at 12 months despite a marked reduction in PV, which indicates that symptom improvement could not be entirely determined by a decrease in PV. 

In sum, this study reveals that PAE is a safe and effective procedure for recurrent LUTS post TURP.   

Fig. 2. MR imaging and DSA in an 83-year-old man. (a) Axial imaging revealed an enlarged prostate gland with a prostatic resection cavity before PAE. (b) Sagittal imaging revealed a vertical diameter of the prostate (PV, 135.2 cm3). (c) Right iliac artery angiography showed the PA arising from the internal pudendal artery. (d) Postembolization angiography showed occlusion of the right PA. (e) Axial MR image at 3 months after PAE revealed a reduction of PV. (f) Sagittal MR image at 3 months after PAE revealed a vertical diameter (PV, 112.7 cm3; change from baseline, 16.6%). 

 

Ergonomics in IR 

Knuttinen MG, Zurcher KS, Wallace A, Doe C, Naidu SG, Money SR, Rochon PJ.  

J Vasc Interv Radiol. 2021 Feb;32(2):235-241. doi: 10.1016/j.jvir.2020.11.001. Epub 2020 Dec 24. PMID: 33358387 

This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas. 

Applying ergonomic principles is meant to maximize performance by reducing work-related injuries, performance errors, and lost productivity. There is a large body of research demonstrating high rates of musculoskeletal disorders (MSDs) in procedural fields such as interventional cardiology, endoscopy, and surgery; however, there is a paucity of research in IR. A 2019 survey by Wells et al redemonstrated the increased need for leaves of absence or short-term disability related to MSDs in endoscopic/minimally invasive surgeons. Further, physicians in endoscopic/minimally invasive fields suffering from MSDs are at higher risk for burnout, with women in at-risk specialties demonstrating an increased risk for certain MSDs compared to their male counterparts. 

To avoid the risk factors associated with the development of MSDs, procedure rooms and equipment should be designed and operated in a manner that optimizes the ergonomic considerations of the operator. Some of these ergonomic principles are depicted in Figure 3. Techniques, such as the use of insoles or cushioned floor mats, are yet to demonstrate any definite preventative or therapeutic effects on lower back pain.  Moreover, more studies are required to assess the ergonomic benefits or protective effects of 2- versus 1-piece lead garments, and the long-term benefits of lumbar support belts. 

There are a few solutions to reducing MSDs. An exercise regimen with strength/resistance training as well as coordination/stabilization exercises have been shown to be effective in alleviating chronic back pain. Microbreaks, for instance, 1-2 mins every 20-40 min, have also been used across many workplaces to improve worker productivity and prevent work-related discomfort.  

There is currently no research that specifically delineates the types of MSDs experienced by female interventional radiologists compared to their male counterparts and the impacts of ergonomics and MSDs on physician wellness and burnout in interventional radiologists. Special considerations in female interventional radiologists include the differences in objective upper body strength when compared to males, and the design of laparoscopic or general surgical instruments, including the table height and grip-size, which were historically designed for a taller and larger-handed male demographic. 

It is also important to note that optimal ergonomics are also beneficial for in-training physicians. Incorporating ergonomics education into interventional radiology residency training curricula may help to reinforce the importance of ergonomic principles among educators and trainees, particularly with regards to physician well-being and career longevity.  

 

Interventional Radiology’s Evolution Into a Clinically Based Specialty 

Tai E, Graham T, Wong J, Mujoomdar A. 

Can Assoc Radiol J. 2020 Dec 1:846537120975214. doi: 10.1177/0846537120975214. Epub ahead of print. PMID: 33259225. 

“If my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities attendant on transluminal angioplasty, they will become high-priced plumbers facing forfeiture of territorial rights based solely on imaging equipment others can obtain and skill still others can learn.”  

Dr. Charles Dotter, the father of interventional radiology (1968) 

In Canada, the developing field of IR is supported by The Canadian Association for Interventional Radiology (CAIR). In 2016, IR was recognized as a distinct subspecialty of Diagnostic Radiology by the Royal College of Physicians and Surgeons of Canada. This was followed by the recent development of a separate interventional radiology residency program and licensing examination.  

IR has gradually evolved into a clinical practice. Clinical responsibilities include accepting referrals, performing a consultation before elective, urgent or emergent interventions, post-treatment follow-up, and educating patients and providers about therapeutic options that may be beneficial for patient care. Admitting privileges have been a cornerstone in many practices. In 2015, the number of interventional radiologists with admitting privileges was 46%, also increased from 29% in 2005. It demonstrates that IR is able and willing to be the most responsible physician while the patient is in hospital.  

Advantages of this clinical progression have resulted in improvements in patient care due to increased inpatients and outpatients follow-up, and increased IR visibility with patients. It has also led to enhanced collaboration with clinicians, and in turn, increased referrals. Based on results of Canadian surveys of interventional radiologists in 2015, 90% of respondents were involved in longitudinal patient care which had increased compared to 42% in 2005.  In turn, interventional radiologists must be allocated additional time for clinical duties and patient care. Radiology departments and hospitals should allow for such schedule flexibility. 

Clinical interventional radiology is the new standard of care that should be adopted in IR practices.  The model of the interventional radiologist solely as a technician is extinct.  

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