Nishita Kothary, MD

All Publications

• Single-shot quantitative x-ray imaging using a primary modulator and dual-layer detector. Medical physics Shi, L., Bennett, N. R., Vezeridis, A., Kothary, N., Wang, A. S. 2023

  Abstract

  Conventional x-ray imaging and fluoroscopy have limitations in quantitation due to several challenges, including scatter, beam hardening, and overlapping tissues. Dual-energy (DE) imaging, with its capability to quantify area density of specific materials, is well-suited to address such limitations, but only if the dual-energy projections are acquired with perfect spatial and temporal alignment and corrected for scatter.In this work, we propose single-shot quantitative imaging (SSQI) by combining the use of a primary modulator (PM) and dual-layer (DL) detector, which enables motion-free DE imaging with scatter correction in a single exposure.The key components of our SSQI setup include a PM and DL detector, where the former enables scatter correction for the latter while the latter enables beam hardening correction for the former. The SSQI algorithm allows simultaneous recovery of two material-specific images and two scatter images using four sub-measurements from the PM encoding. The concept was first demonstrated using simulation of chest x-ray imaging for a COVID patient. For validation, we set up SSQI geometry on our tabletop system and imaged acrylic and copper slabs with known thicknesses (acrylic: 0-22.5 cm; copper: 0-0.9 mm), estimated scatter with our SSQI algorithm, and compared the material decomposition (MD) for different combinations of the two materials with ground truth. Second, we imaged an anthropomorphic chest phantom containing contrast in the coronary arteries and compared the MD with and without SSQI. Lastly, to evaluate SSQI in dynamic applications, we constructed a flow phantom that enabled dynamic imaging of iodine contrast.Our simulation study demonstrated that SSQI led to accurate scatter correction and MD, particularly for smaller focal blur and finer PM pitch. In the validation study, we found that the root mean squared error (RMSE) of SSQI estimation was 0.13 cm for acrylic and 0.04 mm for copper. For the anthropomorphic phantom, direct MD resulted in incorrect interpretation of contrast and soft tissue, while SSQI successfully distinguished them quantitatively, reducing RMSE in material-specific images by 38%-92%. For the flow phantom, SSQI was able to perform accurate dynamic quantitative imaging, separating contrast from the background.We demonstrated the potential of SSQI for robust quantitative x-ray imaging. The integration of SSQI is straightforward with the addition of a PM and upgrade to a DL detector, which may enable its widespread adoption, including in techniques such as radiography and dynamic imaging (i.e., real-time image guidance and cone-beam CT).

  View details for DOI 10.1002/mp.16789

  View details for PubMedID 37843975

• Patient Decision Aids Before Informed Consent Conversations for Image-Guided Procedures: Controlled Trials at Two Institutions. AJR. American journal of roentgenology Srinivas, S., Newton, I. G., Waradzyn, M., Kothary, N., Keller, E. J. 2022

  Abstract

  Background: Patient decision aids (PDAs) improve informed consent practices. Available PDAs for image-guided procedures are of limited quality. Objective: To evaluate the impact of PDAs on understanding and satisfaction among patients undergoing informed consent conversations before outpatient image-guided procedures. Methods: This prospective study included patients awaiting an interventional radiology clinic visit to discuss and obtain informed consent for an image-guided procedure. The study was conducted at two academic medical centers (site A: visits from August, 2020 to July, 2021; site B: January, 2021 to October, 2021). Patients were assigned systematically at site A, and randomly at site B, to electronically receive or not receive a 2-page PDA before the visit. PDAs described procedures and their benefits, risks, and alternatives at a 6th-8th grade health literacy level, and vetted by diverse patient focus groups. Patients completed a postvisit survey (site A: phone; site B: online) assessing understanding of the procedure and satisfaction with the consent conversation using 5-point scales. Data were pooled between sites. Results: The study included 105 patients (59 male, 46 female; median age, 67 years; 51 from site A, 54 from site B; 53 who received PDA, 52 who did not). Survey response rate was 100% (51/51) at site A and 67% (62/92) at site B. Patients who received, versus not received, a PDA reported greater understanding of benefits (4.5 vs 4.0, p<.001), risks (4.4 vs 3.6, p<.001), and alternatives (4.0 vs 3.3, p<.001), and of what procedures involved (4.4 vs 4.1, p=.02); and were more likely to feel that they were provided with enough time with the clinician (4.7 vs 4.5, p=.03), listened to carefully (4.8 vs 4.4, p<.001), free to choose any option including not to have the procedure (4.7 vs 4.3, p<.001), given enough time to make a decision (4.8 vs 4.3, p<.001), encouraged to ask questions (4.8 vs 4.5, p<.001), and had questions answered (4.8 vs 4.4, p=.001). Conclusion: Well-vetted plain-language PDAs provided before image-guided procedure consent conversations improve patients' self-perceived understanding of the procedure and satisfaction with the conversation. Clinical Impact: PDAs can be implemented effectively without requiring additional clinician time or effort.

  View details for DOI 10.2214/AJR.22.28165

  View details for PubMedID 36129221

• Radiologists staunchly support patient safety and autonomy, in opposition to the SCOTUS decision to overturn Roe v Wade. Clinical imaging Karandikar, A., Solberg, A., Fung, A., Lee, A. Y., Farooq, A., Taylor, A. C., Oliveira, A., Narayan, A., Senter, A., Majid, A., Tong, A., McGrath, A. L., Malik, A., Brown, A. L., Roberts, A., Fleischer, A., Vettiyil, B., Zigmund, B., Park, B., Curran, B., Henry, C., Jaimes, C., Connolly, C., Robson, C., Meltzer, C. C., Phillips, C. H., Dove, C., Glastonbury, C., Pomeranz, C., Kirsch, C. F., Burgan, C. M., Scher, C., Tomblinson, C., Fuss, C., Santillan, C., Daye, D., Brown, D. B., Young, D. J., Kopans, D., Vargas, D., Martin, D., Thompson, D., Jordan, D. W., Shatzkes, D., Sun, D., Mastrodicasa, D., Smith, E., Korngold, E., Dibble, E. H., Arleo, E. K., Hecht, E. M., Morris, E., Maltin, E. P., Cooke, E. A., Schwartz, E. S., Lehrman, E., Sodagari, F., Shah, F., Doo, F. X., Rigiroli, F., Vilanilam, G. K., Landinez, G., Kim, G. G., Rahbar, H., Choi, H., Bandesha, H., Ojeda-Fournier, H., Ikuta, I., Dragojevic, I., Schroeder, J. L., Ivanidze, J., Katzen, J. T., Chiang, J., Nguyen, J., Robinson, J. D., Broder, J. C., Kemp, J., Weaver, J. S., Conyers, J. M., Robbins, J. B., Leschied, J. R., Wen, J., Park, J., Mongan, J., Perchik, J., Barbero, J. P., Jacob, J., Ledbetter, K., Macura, K. J., Maturen, K. E., Frederick-Dyer, K., Dodelzon, K., Cort, K., Kisling, K., Babagbemi, K., McGill, K. C., Chang, K. J., Feigin, K., Winsor, K. S., Seifert, K., Patel, K., Porter, K. K., Foley, K. M., Patel-Lippmann, K., McIntosh, L. J., Padilla, L., Groner, L., Harry, L. M., Ladd, L. M., Wang, L., Spalluto, L. B., Mahesh, M., Marx, M. V., Sugi, M. D., Sammer, M. B., Sun, M., Barkovich, M. J., Miller, M. J., Vella, M., Davis, M. A., Englander, M. J., Durst, M., Oumano, M., Wood, M. J., McBee, M. P., Fischbein, N. J., Kovalchuk, N., Lall, N., Eclov, N., Madhuripan, N., Ariaratnam, N. S., Vincoff, N. S., Kothary, N., Yahyavi-Firouz-Abadi, N., Brook, O. R., Glenn, O. A., Woodard, P. K., Mazaheri, P., Rhyner, P., Eby, P. R., Raghu, P., Gerson, R. F., Patel, R., Gutierrez, R. L., Gebhard, R., Andreotti, R. F., Masum, R., Woods, R., Mandava, S., Harrington, S. G., Parikh, S., Chu, S., Arora, S. S., Meyers, S. M., Prabhu, S., Shams, S., Pittman, S., Patel, S. N., Payne, S., Hetts, S. W., Hijaz, T. A., Chapman, T., Loehfelm, T. W., Juang, T., Clark, T. J., Potigailo, V., Shah, V., Planz, V., Kalia, V., DeMartini, W., Dillon, W. P., Gupta, Y., Koethe, Y., Hartley-Blossom, Z., Wang, Z. J., McGinty, G., Haramati, A., Allen, L. M., Germaine, P. 2022

  View details for DOI 10.1016/j.clinimag.2022.07.011

  View details for PubMedID 36064645

• Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel on Artificial Intelligence in Interventional Radiology: From Code to Bedside. Journal of vascular and interventional radiology : JVIR Chapiro, J., Allen, B., Abajian, A., Wood, B., Kothary, N., Daye, D., Bai, H., Sedrakyan, A., Diamond, M., Simonyan, V., McLennan, G., Abi-Jaoudeh, N., Pua, B. 2022

  Abstract

  Artificial intelligence (AI)-based technologies are the most rapidly growing field of innovation in healthcare with the promise to achieve substantial improvements in delivery of patient care across all disciplines of medicine. Recent advances in imaging technology along with marked expansion of readily available advanced health information, data offer a unique opportunity for interventional radiology (IR) to reinvent itself as a data-driven specialty. Additionally, the growth of AI-based applications in diagnostic imaging is expected to have downstream effects on all image-guidance modalities. Therefore, the Society of Interventional Radiology Foundation has called upon 13 key opinion leaders in the field of IR to develop research priorities for clinical applications of AI in IR. The objectives of the assembled research consensus panel were to assess the availability and understand the applicability of AI for IR, estimate current needs and clinical use cases, and assemble a list of research priorities for the development of AI in IR. Individual panel members proposed and all participants voted upon consensus statements to rank them according to their overall impact for IR. The results identified the top priorities for the IR research community and provide organizing principles for innovative academic-industrial research collaborations that will leverage both clinical expertise and cutting-edge technology to benefit patient care in IR.

  View details for DOI 10.1016/j.jvir.2022.06.003

  View details for PubMedID 35871021

• Limitations of Fluorine 18 Fluoromisonidazole in Assessing Treatment-induced Tissue Hypoxia after Transcatheter Arterial Embolization of Hepatocellular Carcinoma: A Prospective Pilot Study. Radiology. Imaging cancer Shah, R. P., Laeseke, P. F., Shin, L. K., Chin, F. T., Kothary, N., Segall, G. M. 2022; 4 (3): e210094

  Abstract

  Purpose To determine the variance and correlation with tumor viability of fluorine 18 (18F) fluoromisonidazole (FMISO) uptake in hepatocellular carcinoma (HCC) prior to and after embolization treatment. Materials and Methods In this single-arm, single-center, prospective pilot study between September 2016 and March 2017, participants with at least one tumor measuring 1.5 cm or larger with imaging or histologic findings diagnostic for HCC were enrolled (five men; mean age, 68 years; age range, 61-76 years). Participants underwent 18F-FMISO PET/CT before and after bland embolization of HCC. A tumor-to-liver ratio (TLR) was calculated by using standardized uptake values of tumor and liver. The difference in mean TLR before and after treatment was compared by using a Wilcoxon rank sum test, and correlation between TLR and tumor viability was assessed by using the Spearman rank correlation coefficient. Results Four participants with five tumors were included in the final analysis. The median tumor diameter was 3.2 cm (IQR, 3.0-3.9 cm). The median TLR before treatment was 0.97 (IQR, 0.88-0.98), with a variance of 0.02, and the median TLR after treatment was 0.85 (IQR, 0.79-1), with a variance of 0.01; both findings indicate a narrow range of 18F-FMISO uptake in HCC. The Spearman rank correlation coefficient was 0.87, indicating a high correlation between change in TLR and nonviable tumor. Conclusion Although there was a correlation between change in TLR and response to treatment, the low signal-to-noise ratio of 18F-FMISO in the liver limited its use in HCC. Keywords: Molecular Imaging-Clinical Translation, Embolization, Abdomen/Gastrointestinal, Liver Clinical trial registration no. NCT02695628 ©RSNA, 2022.

  View details for DOI 10.1148/rycan.210094

  View details for PubMedID 35485937

• Cost-effectiveness of tunneled peritoneal catheters versus repeat paracenteses for recurrent ascites in gynecologic malignancies. Gynecologic oncology Wu, X., Keller, E. J., Rabei, R., Rockwell, H., Beeson, S., Heller, M., Kothary, N. 1800

  Abstract

  OBJECTIVE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LVP) for patients with recurrent ascites secondary to gynecological malignancy.METHODS: A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses.RESULTS: There were no significant differences between the cohorts in the average number of hospital days (p = 0.21) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 0.22982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was >0.81% per 22 days or its procedural cost of TPC insertion was >$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202.CONCLUSIONS: TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy.

  View details for DOI 10.1016/j.ygyno.2022.01.011

  View details for PubMedID 35086684

• Tunneled Peritoneal Catheter vs Repeated Paracenteses for Recurrent Ascites: A Cost-Effectiveness Analysis. Cardiovascular and interventional radiology Wu, X., Rabei, R., Keller, E. J., King, B., Kothary, N., Kohi, M., Taylor, A., Heller, M. 2022

  Abstract

  To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus serial large-volume paracenteses (LVP) for patients with recurrent ascites.Retrospective, single-institution analysis of 100 consecutive patients undergoing LVP and eventual TPC placement (2015-2018) was performed with extraction of procedural complications and hospital admissions. LVPs were associated with 17 adverse events (AEs) while only 9 AEs occurred after TPC placement. While undergoing routine LVP, the patients had 30 hospitalizations monthly (177 days in total) and 10 hospitalizations monthly (51 days) after TPC placement. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Costs were based on Medicare reimbursement rates. Statistical analyses include base case calculation, Monte Carlo simulations, and deterministic sensitivity analyses.TPC placement was the dominant strategy with a comparable health benefit of 0.08060 quality-adjusted life-years (QALY) (LVP: 0.08057 QALY) at a lower cost of $4151 (LVP: $8401). Probabilistic sensitivity analysis showed TPC was superior in 97.49% of simulations. Deterministic sensitivity analysis demonstrated the superiority of TPC compared to LVP if the TPC complication rate was < 9.47% per week and the complication rate for LVP was > 1.32% per procedure. TPC was more cost-effective when its procedural cost was < $5427 (base case: 1174.5), and remained as such when the cost of LVP was varied as much as $10,000 (base case: $316.48).In this study, TPC was more cost-effective than LVP in patients with recurrent ascites due to the reduced risk of infection, emergency department visits, and length of hospitalization stays.

  View details for DOI 10.1007/s00270-022-03103-4

  View details for PubMedID 35292833

• Perceptions of Ethics in Interventional Radiology. Current problems in diagnostic radiology Rockwell, H. D., Beeson, S. A., Keller, E. J., Kothary, N., Dickey, K. 1800

  Abstract

  PURPOSE: To characterize perceptions of ethics among interventional radiologists to guide the development of an applied, specialty-specific approach to ethics.MATERIALS AND METHODS: A 17-question survey on perceptions of ethics and use of ethics resources was developed and vetted via cognitive interviewing of 15 diverse, representative members of the target population. The survey was distributed via the Society of Interventional Radiology, receiving 685 responses (48% participation and 90% completion rates). Responses were compared between different demographics, and common themes from free text responses were identified via content analysis.RESULTS: Most respondents indicated ethics is important for IR (93%) and more focus on practical approaches to ethical issues is needed (73%). Various ethical issues were perceived to be important for IR, but differentiating palliative from futile care was ranked as the top ethical issue. Trainees had more ethics training (P=0.05) but less confidence in navigating ethical issues (P<0.01). Regardless of career stage, those with ethics training (44%) were more confident in navigating ethical issues (P<0.01). Use of resources such as information sheets for patients and resources for coping with complications were variable and limited by lack of availability or knowledge of such resources in IR.CONCLUSIONS: Interventional radiologists believe ethics is important and face diverse ethical issues, but they are challenged by variable experiences and access to practical tools to navigate these challenges.

  View details for DOI 10.1067/j.cpradiol.2021.11.002

  View details for PubMedID 34955285

• Reimagining the IR Workflow for a Better Work-Life Balance. Journal of vascular and interventional radiology : JVIR Foo, E. T., Cianfichi, L. J., Guzman, E., Kerr, P. M., Krumm, J., Hofmann, L. V., Kothary, N. 2021; 32 (10): 1488-1491

  Abstract

  Several workflow changes were implemented in a large academic interventional radiology practice, including separation of inpatient and outpatient services, early start times, and using an adaptive learning system to predict case length tailored to individual physicians. Metrics including procedural volume, on-time start, accuracy at predicting case length, and room shutdown time were assessed before and after the intervention. Considerable improvements were seen in accuracy of first case start times, predicting block times, and last case encounter ending times. It is proposed that with improved role clarity, interventional radiologists can regain control over their schedules, utilize work hours more efficiently, and improve work-life balance.

  View details for DOI 10.1016/j.jvir.2021.07.004

  View details for PubMedID 34602161

• The Need to Mitigate Unconscious Bias to Improve Sponsorship Opportunities for Underrepresented Faculty in Academic Radiology. AJR. American journal of roentgenology Jerome, B., Fassiotto, M., Kothary, N. 2021

  Abstract

  Women physicians and those from racial and ethnic groups underrepresented in medicine face unique barriers to career advancement in academic medicine, especially in specialties that lack diversity such as radiology. One such barrier is the effect of unconscious bias on the ability of faculty from these groups to find effective sponsors. Given the central role of sponsorship in career advancement, departments are called upon to implement formal sponsorship programs to address inequities stemming from bias.

  View details for DOI 10.2214/AJR.21.26481

  View details for PubMedID 34467782

• The Role of Physician-Driven Device Preference in the Cost Variation of Common Interventional Radiology Procedures. Journal of vascular and interventional radiology : JVIR Shivakumar, V., Bundorf, M. K., Vezeridis, A. M., Kothary, N. 2021

  Abstract

  PURPOSE: To analyze the impact of physician-specific equipment preference on cost variation for procedures typically performed by interventional radiologists at a tertiary care academic hospital.MATERIALS AND METHODS: From October 2017 to October 2019, data on all expendable items used by 9 interventional radiologists for 11 common interventional radiology procedure categories were compiled from the hospital analytics system. This search yielded a final dataset of 44,654 items used in 2,121 procedures of 11 different categories. The mean cost per case for each physician as well as the mean, standard deviation, and coefficient of variation (CV) of the mean cost per case across physicians were calculated. The proportion of spending by item type was compared across physicians for 2 high-variation, high-volume procedures. The relationship between the mean cost per case and case volume was examined using linear regression.RESULTS: There was a high variability within each procedure, with the highest and the lowest CV for radioembolization administration (56.6%) and transjugular liver biopsy (4.9%), respectively. Variation in transarterial chemoembolization cost was mainly driven by microcatheters/microwires, while for nephrostomy, the main drivers were catheters/wires and access sets. Mean spending by physician was not significantly correlated with case volume (P=.584).CONCLUSIONS: Physicians vary in their item selection even for standard procedures. While the financial impact of these differences vary across procedures, these findings suggest that standardization may offer an opportunity for cost savings.

  View details for DOI 10.1016/j.jvir.2021.01.275

  View details for PubMedID 33781687

• Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: a systematic review Trauma Surgery & Acute Care Open Cha, P. I., Min, J. G., Patil, A., Choi, J., Kothary, N. N., Forrester, J. D. 2021: e000690

  View details for DOI 10.1136/tsaco-2021-000690

• Comparison of Drug-Eluting Embolics versus Conventional Transarterial Chemoembolization for the Treatment of Patients with Unresectable Hepatocellular Carcinoma: A Cost-Effectiveness Analysis. Journal of vascular and interventional radiology : JVIR Wu, X., Chapiro, J., Malhotra, A., Kothary, N. 2020

  Abstract

  PURPOSE: To compare the cost-effectiveness of using doxorubicin-loaded drug-eluting embolic (DEE) transarterial chemoembolization versus that of using conventional transarterial chemoembolization for patients with unresectable hepatocellular carcinoma (HCC).MATERIALS AND METHODS: A decision-analysis model was constructed over the lifespan of a payer's perspective. The model simulated the clinical course, including periprocedural complications, additional transarterial chemoembolization or other treatments (ablation, radioembolization, or systemic treatment), palliative care, and death, of patients with unresectable HCC. All clinical parameters were derived from the literature. Base case calculations, probabilistic sensitivity analyses, and multiple two-way sensitivity analyses were performed.RESULTS: In the base case calculations for patients with a median age of 67 years (range for conventional transarterial chemoembolization: 28-88 years, range for DEE-transarterial chemoembolization: 16-93 years), conventional transarterial chemoembolization yielded a health benefit of 2.11 quality-adjusted life years (QALY) at a cost of $125,324, whereas DEE-transarterial chemoembolization yielded 1.71 QALY for $144,816. In 10,000 Monte Carlo simulations, conventional transarterial chemoembolization continued to be a more cost-effective strategy. conventional transarterial chemoembolization was cost-effective when the complication risks for both the procedures were simultaneously varied from 0% to 30%. DEE-transarterial chemoembolization became cost-effective if the conventional transarterial chemoembolization mortality exceeded that of DEE-transarterial chemoembolization by 17% in absolute values. The two-way sensitivity analyses demonstrated that conventional transarterial chemoembolization was cost-effective until the risk of disease progression was >0.4% of that for DEE-transarterial chemoembolization in absolute values. Our analysis showed that DEE-transarterial chemoembolization would be more cost-effective if it offered >2.5% higher overall survival benefit than conventional transarterial chemoembolization in absolute values.CONCLUSIONS: Compared with DEE-transarterial chemoembolization, conventional transarterial chemoembolization yielded a higher number of QALY at a lower cost, making it the more cost-effective of the 2 modalities.

  View details for DOI 10.1016/j.jvir.2020.09.022

  View details for PubMedID 33160827

• Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis. Cardiovascular and interventional radiology Keller, E. J., Rabei, R., Heller, M., Kothary, N. 2020

  Abstract

  PURPOSE: To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement.METHODS: Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39years of experience) and 7 referring physicians (3 males, 4 females, 6-14years of experience) were analyzed.RESULTS: Many IRs (75%) perceived futility as an important issue. Years of experience (r=0.60, p=0.03) and being in academics (r=0.62, p=0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility.CONCLUSION: This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.

  View details for DOI 10.1007/s00270-020-02675-3

  View details for PubMedID 33078233

• Emergency General Surgery Quality Improvement Efforts for the Elderly: Are Needs Different from the Young? Staudenmayer, K., Burlew, C., Kothary, N., Tennakoon, L., Coimbra, R. ELSEVIER SCIENCE INC. 2020: E16

  View details for Web of Science ID 000582798100031

• The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development. Journal of the American College of Radiology : JACR Shah, S. S., Tennakoon, L., O'Beirne, E., Staudenmayer, K. L., Kothary, N. 2020

  Abstract

  PURPOSE: Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost.METHODS: The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, tenth rev, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates.RESULTS: Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 vs 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme vs 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% vs 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 vs $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group.CONCLUSIONS: Approximately 1 in 10 US inpatients are treated with IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.

  View details for DOI 10.1016/j.jacr.2020.07.038

  View details for PubMedID 32918863

• Comparison of Opioid Medication Use after Conventional Chemoembolization versus Drug-Eluting Embolic Chemoembolization. Journal of vascular and interventional radiology : JVIR Khalaf, M. H., Shah, R. P., Green, V., Vezeridis, A. M., Liang, T., Kothary, N. 2020

  Abstract

  PURPOSE: To assess the use of opioid analgesics and/or antiemetic drugs for pain and nausea following selective chemoembolization with doxorubicin-based conventional (c)-transarterial chemoembolization versus drug-eluting embolic (DEE)-transarterial chemoembolization for hepatocellular carcinoma (HCC).MATERIALS AND METHODS: From October 2014 to 2016, 283 patients underwent 393 selective chemoembolization procedures including 188 patients (48%) who underwent c-transarterial chemoembolization and 205 (52%) who underwent DEE-transarterial chemoembolization. Medical records for all patients were retrospectively reviewed. Administration of postprocedural opioid and/or antiemetic agents were collated. Time of administration was stratified as phase 1 recovery (0-6 hours) and observation (6-24 hours). Logistic regression model was used to investigate the relationship of transarterial chemoembolization type and use of intravenous and/or oral analgesic and antiemetic medications while controlling for other clinical variables.RESULTS: More patients treated with DEE-transarterial chemoembolization required intravenous analgesia in the observation (6-24 hours) phase (18.5%) than those treated with c-transarterial chemoembolization (10.6%; P= .033). Similar results were noted for oral analgesic agents (50.2% vs. 31.4%, respectively; P < .001) and antiemetics (17.1% vs. 7.5%, respectively; P= .006) during the observation period. Multivariate regression models identified DEE-transarterial chemoembolization as an independent predictor for oral analgesia (odds ratio [OR], 1.84; P= .011), for intravenous and oral analgesia in opioid-naive patients (OR, 2.46; P= .029) and for antiemetics (OR, 2.56; P= .011).CONCLUSIONS: Compared to c-transarterial chemoembolization, DEE-transarterial chemoembolization required greater amounts of opioid analgesic and antiemetic agents 6-24 hours after the procedure. Surgical data indicate that a persistent opioid habit can develop even after minor surgeries, therefore, caution should be exercised, and a regimen of nonopiate pain medications should be considered to reduce postprocedural pain after transarterial chemoembolization.

  View details for DOI 10.1016/j.jvir.2020.04.018

  View details for PubMedID 32654960

• Interreader Variability in Semantic Annotation of Microvascular Invasion in Hepatocellular Carcinoma on Contrast-enhanced Triphasic CT Images. Radiology. Imaging cancer Bakr, S., Gevaert, O., Patel, B., Kesselman, A., Shah, R., Napel, S., Kothary, N. 2020; 2 (3): e190062

  Abstract

  Purpose: To evaluate interreader agreement in annotating semantic features on preoperative CT images to predict microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC).Materials and Methods: Preoperative, contrast material-enhanced triphasic CT studies from 89 patients (median age, 64 years; age range, 36-85 years; 70 men) who underwent hepatic resection between 2008 and 2017 for a solitary HCC were reviewed. Three radiologists annotated CT images obtained during the arterial and portal venous phases, independently and in consensus, with features associated with MVI reported by other investigators. The assessed factors were the presence or absence of discrete internal arteries, hypoattenuating halo, tumor-liver difference, peritumoral enhancement, and tumor margin. Testing also included previously proposed MVI signatures: radiogenomic venous invasion (RVI) and two-trait predictor of venous invasion (TTPVI), using single-reader and consensus annotations. Cohen (two-reader) and Fleiss (three-reader) kappa and the bootstrap method were used to analyze interreader agreement and differences in model performance, respectively.Results: Of HCCs assessed, 32.6% (29 of 89) had MVI at histopathologic findings. Two-reader agreement, as assessed by pairwise Cohen kappa statistics, varied as a function of feature and imaging phase, ranging from 0.02 to 0.6; three-reader Fleiss kappa varied from -0.17 to 0.56. For RVI and TTPVI, the best single-reader performance had sensitivity and specificity of 52% and 77% and 67% and 74%, respectively. In consensus, the sensitivity and specificity for the RVI and TTPVI signatures were 59% and 67% and 70% and 62%, respectively.Conclusion: Interreader variability in semantic feature annotation remains a challenge and affects the reproducibility of predictive models for preoperative detection of MVI in HCC.Supplemental material is available for this article.© RSNA, 2020.

  View details for DOI 10.1148/rycan.2020190062

  View details for PubMedID 32550600

• Genomic analysis of Vascular Invasion in Hepatocellular Carcinoma (HCC) Reveals Molecular Drivers and Predictive Biomarkers. Hepatology (Baltimore, Md.) Krishnan, M. S., Rajan Kd, A. n., Park, J. n., Arjunan, V. n., Garcia Marques, F. J., Bermudez, A. n., Girvan, O. A., Hoang, N. S., Yin, J. n., Nguyen, M. H., Kothary, N. n., Pitteri, S. n., Felsher, D. W., Dhanasekaran, R. n. 2020

  Abstract

  Vascular invasion is a critical risk factor for hepatocellular carcinoma (HCC) recurrence and poor survival. The molecular drivers of vascular invasion in HCC are largely unknown. Deciphering the molecular landscape of invasive HCC will help identify novel therapeutic targets and noninvasive biomarkers. To this end, we undertook this study to evaluate the genomic, transcriptomic, and proteomic profile of tumors with vascular invasion using the multi-platform cancer genome atlas (TCGA) data (n=373). In the TCGA liver hepatocellular carcinoma (LIHC) cohort, macrovascular invasion was present in 5% (n=17) of tumors and microvascular invasion in 25% (n=94) of tumors. Functional pathway analysis revealed that the MYC oncogene was a common upstream regulator of the mRNA, miRNA and proteomic changes in vascular invasion. We performed comparative proteomic analyses of invasive human HCC and MYC driven murine HCC and identified fibronectin to be proteomic biomarker of invasive HCC (mouse Fn1 p= 1.7 X 10-11 ; human FN1 p=1.5 X 10-4 ) conserved across the two species. Mechanistically, we show that FN1 promotes the migratory and invasive phenotype of HCC cancer cells. We demonstrate tissue overexpression of fibronectin in human HCC using a large independent cohort of human HCC tissue microarray (n=153; p<0.001). Lastly, we showed that plasma fibronectin levels were significantly elevated in patients with HCC (n=35, mean=307.7 μg/ml, SEM=35.9) when compared to cirrhosis (n=10, mean=41.8 μg/ml, SEM=13.3; p<0.0001). CONCLUSION: Our study evaluates the molecular landscape of tumors with vascular invasion, identifying distinct transcriptional, epigenetic and proteomic changes driven by the MYC oncogene. We show that MYC upregulates fibronectin expression which promotes HCC invasiveness. In addition, we identify fibronectin to be a promising non-invasive proteomic biomarker of vascular invasion in HCC.

  View details for DOI 10.1002/hep.31614

  View details for PubMedID 33140851

• Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis JOURNAL OF VASCULAR SURGERY-VENOUS AND LYMPHATIC DISORDERS Kahn, S. R., Julian, J. A., Kearon, C., Gu, C., Cohen, D. J., Magnuson, E. A., Comerota, A. J., Goldhaber, S. Z., Jaff, M. R., Razavi, M. K., Kindzelski, A. L., Schneider, J. R., Kim, P., Chaer, R., Sista, A. K., McLafferty, R. B., Kaufman, J. A., Wible, B. C., Blinder, M., Vedantham, S., ATTRACT Trial Investigators 2020; 8 (1): 8-+

  Abstract

  After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P < .0001) and 6 months (8.8; P < .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

  View details for DOI 10.1016/j.jvsv.2019.03.023

  View details for Web of Science ID 000518221600003

  View details for PubMedID 31843251

  View details for PubMedCentralID PMC7681916

• Gender Differences in Patient Perceptions of Physicians' Communal Traits and the Impact on Physician Evaluations. Journal of women's health (2002) Chen, H. n., Pierson, E. n., Schmer-Galunder, S. n., Altamirano, J. n., Jurafsky, D. n., Leskovec, J. n., Fassiotto, M. n., Kothary, N. n. 2020

  Abstract

  Background: Communal traits, such as empathy, warmth, and consensus-building, are not highly valued in the medical hierarchy. Devaluing communal traits is potentially harmful for two reasons. First, data suggest that patients may prefer when physicians show communal traits. Second, if female physicians are more likely to be perceived as communal, devaluing communal traits may increase the gender inequity already prevalent in medicine. We test for both these effects. Materials and Methods: This study analyzed 22,431 Press Ganey outpatient surveys assessing 480 physicians collected from 2016 to 2017 at a large tertiary hospital. The surveys asked patients to provide qualitative comments and quantitative Likert-scale ratings assessing physician effectiveness. We coded whether patients described physicians with "communal" language using a validated word scale derived from previous work. We used multivariate logistic regressions to assess whether (1) patients were more likely to describe female physicians using communal language and (2) patients gave higher quantitative ratings to physicians they described with communal language, when controlling for physician, patient, and comment characteristics. Results: Female physicians had higher odds of being described with communal language than male physicians (odds ratio 1.29, 95% confidence interval 1.18-1.40, p < 0.001). In addition, patients gave higher quantitative ratings to physicians they described with communal language. These results were robust to inclusion of controls. Conclusions: Female physicians are more likely to be perceived as communal. Being perceived as communal is associated with higher quantitative ratings, including likelihood to recommend. Our study indicates a need to reevaluate what types of behaviors academic hospitals reward in their physicians.

  View details for DOI 10.1089/jwh.2019.8233

  View details for PubMedID 32857642

• The Treatment of Hepatocellular Carcinoma With Portal Vein Tumor Thrombosis. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting Qadan, M. n., Kothary, N. n., Sangro, B. n., Palta, M. n. 2020; 40: 1–8

  Abstract

  Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death worldwide. HCC is also is a tumor with a distinct ability to invade and grow within the hepatic vasculature. Approximately 20% of patients with HCC have macrovascular invasion (MVI) at the time of diagnosis. MVI is associated with dismal prognosis, with median survival ranging from 2 to 5 months. Current staging systems designate MVI as advanced disease. Recent advances in multimodal approaches, including systemic therapies, radiation therapy, liver-directed therapies, and surgical approaches, in the treatment of HCC with MVI have rendered this disease process more treatable with improved outcomes and are discussed here.

  View details for DOI 10.1200/EDBK_280811

  View details for PubMedID 32213090

• Achieving Speaker Gender Equity at the SIR Annual Scientific Meeting: The Effect of Female Session Coordinators. Journal of vascular and interventional radiology : JVIR Ghatan, C. E., Altamirano, J., Fassiotto, M., Perez, M. G., Maldonado, Y., Josephs, S., Sze, D. Y., Kothary, N. 2019

  Abstract

  PURPOSE: To examine the impact of targeted efforts to increase the number of female speakers at the Society of Interventional Radiology (SIR) Annual Scientific Meeting (ASM) by reporting gender trends for invited faculty in 2017/2018 vs2016.MATERIALS AND METHODS: Faculty rosters for the 2016, 2017, and 2018 SIR ASMs were stratified by gender to quantify female representation at plenary sessions, categorical courses, symposia, self-assessment modules, and "meet-the-expert" sessions. Keynote events, scientific abstract presentations, and award ceremonies were excluded. In 2017, the SIR Annual Meeting Committee issued requirements for coordinators to invite selected women as speakers. Session coordinators are responsible for issuing speaker invitations, and invited speakers have the option to decline.RESULTS: Years 2017 and 2018 showed increases in female speaker representation, with women delivering 13% (89 of 687) and 14% (85 of 605) of all assigned presentations, compared with 9% in 2016 (46 of 514; P= .03 and P= .01, respectively). Gender diversity correlated with the gender of the session coordinator(s). When averaged over a 3-year period, female speakers constituted 7% of the speaker roster (112 of 1,504 presentations) for sessions led by an all-male coordinator team, compared with 36% (108 of 302) for sessions led by at least 1 female coordinator (P < .0001). Results of the linear regression model confirmed the effect of coordinator team gender composition (P < .0001).CONCLUSIONS: Having a woman as a session coordinator increased female speaker participation, which suggests that the inclusion of more women as coordinators is one mechanism for achieving gender balance at scientific meetings.

  View details for DOI 10.1016/j.jvir.2019.07.006

  View details for PubMedID 31587951

• CROSS-SPECIES COMPREHENSIVE PROTEOMIC ANALYSIS OF HEPATOCELLULAR CARCINOMA (HCC) TO IDENTIFY PLASMA BIOMARKERS OF VASCULAR INVASION Krishnan, M., Arjunan, V., Kothary, N., Felsher, D., Dhanasekaran, R. WILEY. 2019: 74A

  View details for Web of Science ID 000488653500112

• Drs. Kothary et al respond. Journal of vascular and interventional radiology : JVIR Kothary, N., Fassiotto, M., Altamirano, J. 2019

  View details for DOI 10.1016/j.jvir.2019.04.008

  View details for PubMedID 31126787

• Untapped Resources: Attaining Equitable Representation for Women in IR JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Perez, M. G., Fassiotto, M., Altamirano, J., Hwang, G. L., Maldonado, Y., Josephs, S., Sze, D. Y., Kothary, N. 2019; 30 (4): 579–83

  View details for DOI 10.1016/j.jvir.2018.10.028

  View details for Web of Science ID 000464772000015

• Untapped Resources: Attaining Equitable Representation for Women in IR. Journal of vascular and interventional radiology : JVIR Perez, M. G., Fassiotto, M., Altamirano, J., Hwang, G. L., Maldonado, Y., Josephs, S., Sze, D. Y., Kothary, N. 2019

  Abstract

  PURPOSE: To investigate the current state of gender diversity among invited coordinators at the Society of Interventional Radiology (SIR) Annual Scientific Meeting and to compare the academic productivity of female interventional radiologists to that of invited male coordinators.MATERIALS AND METHODS: Faculty rosters for the SIR Annual Scientific Meetings from 2015 to 2017 were stratified by gender to quantify female representation among those asked to lead and coordinate podium sessions. To quantify academic productivity and merit, H-index, publications, and authorship by females over a 6-year period (2012-2017) were statistically compared to that of recurring male faculty.RESULTS: From 2015 to 2017, women held 7.1% (9/126), 4.3%, (8/188), and 13.7% (27/197) of the available coordinator positions for podium sessions, with no representation at the plenary sessions, and subject matter expertise was concentrated in economics and education. Academic productivity of the top quartile of published female interventional radiologists was statistically similar to that of the invited male faculty (H-index P= .722; total publications P= .689; and authorship P= .662).CONCLUSIONS: This study found that senior men dominate the SIR Annual Scientific Meeting, with few women leading or coordinating the podium sessions, despite their established academic track record.

  View details for PubMedID 30772166

• A Predictive Model for Postembolization Syndrome after Transarterial Hepatic Chemoembolization of Hepatocellular Carcinoma RADIOLOGY Khalaf, M. H., Sundaram, V., Mohammed, M., Shah, R., Khosla, A., Jackson, K., Desai, M., Kothary, N. 2019; 290 (1): 254–61

  View details for DOI 10.1148/radiol.2018180257

  View details for Web of Science ID 000453784400045

• Quantitative Ultrasound Spectroscopy for Differentiation of Hepatocellular Carcinoma from At-risk and Normal Liver Parenchyma. Clinical cancer research : an official journal of the American Association for Cancer Research Durot, I. n., Sigrist, R. n., Kothary, N. n., Rosenberg, J. n., Willmann, J. K., El Kaffas, A. n. 2019

  Abstract

  Quantitative ultrasound approaches can capture tissue morphological properties to augment clinical diagnostics. This study aims to assess whether quantitative ultrasound spectroscopy (QUS) parameters measured in HCC tissues can be differentiated from those measured in at risk or healthy liver parenchyma.This prospective HIPAA-compliant study was approved by the IRB. Fifteen HCC patients, 15 non-HCC patients with chronic liver disease and 15 healthy volunteers were included (31.1% women; 68.9% men). Ultrasound radiofrequency (RF) data were acquired in each patient in both liver lobes at 2 focal depths. Region of interests (ROI) were drawn on HCC and liver parenchyma. The average normalized power spectrum for each ROI was extracted and a linear regression was fit within the -6dB bandwidth, from which the mid-band fit (MBF), spectral intercept (SI) and spectral slope (SS) were extracted. Differences in QUS parameters between the ROIs were tested by a mixed-effects regression.There was a significant intra-individual difference in MBF, SS and SI between HCC and adjacent liver parenchyma (P<0.001), and a significant inter-individual difference between HCC and at-risk and healthy non-HCC parenchyma (P<0.001). In HCC patients, cirrhosis (n=13) did not significantly change any of the three parameters (P>0.8) in differentiating HCC from non-HCC parenchyma. MBF (P=0.12), SI (P=0.33), and SS (P=0.57) were not significantly different in non-HCC tissue among the groups.The QUS parameters are significantly different in HCC vs. non-HCC liver parenchyma, independent of underlying cirrhosis. This could be leveraged for improved HCC detection with ultrasound in the future.

  View details for DOI 10.1158/1078-0432.CCR-19-1030

  View details for PubMedID 31444249

• Albumin-Bilirubin Score: An Accurate Predictor of Hepatic Decompensation in High-Risk Patients Undergoing Transarterial Chemoembolization for Hepatocellular Carcinoma JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Mohammed, M., Khalaf, M. H., Liang, T., Wang, D. S., Lungren, M. P., Rosenberg, J., Kothary, N. 2018; 29 (11): 1527–34

  View details for DOI 10.1016/j.jvir.2018.06.016

  View details for Web of Science ID 000450542400005

• A Predictive Model for Postembolization Syndrome after Transarterial Hepatic Chemoembolization of Hepatocellular Carcinoma. Radiology Khalaf, M. H., Sundaram, V., AbdelRazek Mohammed, M. A., Shah, R., Khosla, A., Jackson, K., Desai, M., Kothary, N. 2018: 180257

  Abstract

  Purpose To develop and validate a predictive model for postembolization syndrome (PES) following transarterial hepatic chemoembolization (TACE) for hepatocellular carcinoma. Materials and Methods In this single-center, retrospective study, 370 patients underwent 513 TACE procedures between October 2014 and September 2016. Seventy percent of the patients were randomly assigned to a training data set and the remaining 30% were assigned to a testing data set. Variables included demographic, laboratory, clinical, and procedural details. PES was defined as pain and/or nausea beyond 6 hours after TACE that required intravenous medication for symptom control. The predictive model was developed by using conditional inference trees and Lasso regression. Results Demographics, laboratory data, performance, tumor characteristics, and procedural details were statistically similar for the training and testing data sets. Overall, 83 of 370 patients (22.4%) after 107 of 513 TACE procedures (20.8%) met the predefined criteria. Factors identified at univariable analysis included large tumor burden (P = .004), drug-eluting embolic TACE (P = .03), doxorubicin dose (P = .003), history of PES (P < .001) and chronic pain (P < .001), of which history of PES, tumor burden, and drug-eluting embolic TACE were identified as the strongest predictors by the multivariable analysis and were used to develop the predictive model. When applied to the testing data set, the model demonstrated an area under the curve of 0.62, sensitivity of 79% (22 of 28), specificity of 44.2% (53 of 120), and a negative predictive value of 90% (53 of 59). Conclusion The model identified history of postembolization syndrome, tumor burden, and drug-eluting embolic chemoembolization as predictors of protracted recovery because of postembolization syndrome. © RSNA, 2018.

  View details for PubMedID 30299233

• Albumin-Bilirubin Score: An Accurate Predictor of Hepatic Decompensation in High-Risk Patients Undergoing Transarterial Chemoembolization for Hepatocellular Carcinoma. Journal of vascular and interventional radiology : JVIR Mohammed, M. A., Khalaf, M. H., Liang, T., Wang, D. S., Lungren, M. P., Rosenberg, J., Kothary, N. 2018

  Abstract

  PURPOSE: To evaluate validity of albumin-bilirubin (ALBI) grade as a predictor of acute-on-chronic liver failure (ACLF) after transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with baseline moderate to severe liver dysfunction.MATERIALS AND METHODS: In this retrospective study, serum albumin and bilirubin levels measured before chemoembolization were used to calculate ALBI score in 123 patients treated with 187 high-risk chemoembolizations. Procedures were considered high risk if Child-Turcotte-Pugh score before chemoembolization was ≥ 8. ACLF was objectively measured using chronic liver failure-sequential organ failure assessment score at 30 and 90 d. The 30-day mortality and morbidity from new or worsening ascites and/or hepatic encephalopathy (HE) were assessed. Univariate and multivariate analyses were used to identify clinical and procedural predictors of ACLF in this high-risk population.RESULTS: ACLF occurred after 15 (8%) high-risk chemoembolizations within 30 days and an additional 9 (5%) procedures between 30 and 90 days. Overall 30-day mortality was 2.7%. New or worsened ascites and/or HE occurred after 52 (28%) procedures within 30 days. Significant prognosticators of ACLF at 90 days revealed by univariate analysis were bilirubin (P= .004), albumin (P= .007), and ALBI score (P= .002), with ALBI score remaining statistically significant on multivariate regression analysis (OR= 3.99; 95% CI, 1.70-9.40; P= .002).CONCLUSIONS: Chemoembolization for HCC can be performed safely in patients with moderate to severe liver dysfunction. ALBI score before chemoembolization provides objective prognostication for ACLF after chemoembolization in this cohort and may be used for risk stratification.

  View details for PubMedID 30274856

• Comparison of Transjugular Liver Biopsy and Percutaneous Liver Biopsy With Tract Embolization in Pediatric Patients JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Tulin-Silver, S., Obi, C., Kothary, N., Lungren, M. P. 2018; 67 (2): 180–84

  Abstract

  The aim of the study was to compare safety and efficacy of transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) with tract embolization in pediatric patients with liver disease.TJLB and PLB between December 2009 and October 2015 were retrospectively reviewed. Primary endpoints were adequate sampling and complication rate. Patient age, weight, coagulation factors, ascites, blood transfusions, adequacy of biopsy sample, number of biopsy samples, and complications were compared.There were 39 TJLB (average age 10.6 years) and 120 PLB (average age 7.1 years) (P value <0.05). Average weight was 40.2 kg for TJLB and 26.8 kg for PLB (P value <0.05). Average platelets were 155 for TJLB and 252 for PLB (P value <0.05). Average international normalized ratio was 1.7 for TJLB and 1.3 for PLB (P value <0.05). Mean postbiopsy hematocrit decrease was 0.8 and 0.9, for TJLB and PLB, respectively. Mean postbiopsy hemoglobin decrease was 0.3 in both groups. Number of core biopsy samples was 4.5 and 4.3, for TJLB and PLB, respectively. There was 1 biopsy yielding insufficient sample in each group. TJLB had 1 (2.6%) complication of supraventricular tachycardia. PLB had 4 (3.3%) complications, with 1 hemoperitoneum, 1 hypotension, 1 patient with decreased hemoglobin, and 1 patient with bilious drainage from the biopsy site.TJLB and PLB with gelatin sponge pledget tract embolization are both safe and effective for the diagnosis of hepatic disease in pediatric patients. To avoid radiation, PLB may be considered as first-line approach in the pediatric population, even in the setting of coagulopathy.

  View details for DOI 10.1097/MPG.0000000000001951

  View details for Web of Science ID 000442250800015

  View details for PubMedID 29509634

• A Role for Virtual Reality in Planning Endovascular Procedures JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Mohammed, M., Khalaf, M. H., Kesselman, A., Wang, D. S., Kothary, N. 2018; 29 (7): 971–74

  View details for DOI 10.1016/j.jvir.2018.02.018

  View details for Web of Science ID 000438179300010

• Transarterial chemoembolization in children to treat unresectable hepatocellular carcinoma PEDIATRIC TRANSPLANTATION Weiss, K. E., Sze, D. Y., Rangaswami, A. A., Esquivel, C. O., Concepcion, W., Lebowitz, E. A., Kothary, N., Lungren, M. P. 2018; 22 (4)

  View details for DOI 10.1111/petr.13187

  View details for Web of Science ID 000433590800016

• Transarterial chemoembolization in children to treat unresectable hepatocellular carcinoma. Pediatric transplantation Weiss, K. E., Sze, D. Y., Rangaswami, A. A., Esquivel, C. O., Concepcion, W., Lebowitz, E. A., Kothary, N., Lungren, M. P. 2018: e13187

  Abstract

  Children with unresectable HCC have a dismal prognosis and few approved treatment options. TACE is an effective treatment option for adults with HCC, but experience in children is very limited. Retrospective analysis was performed of 8 patients aged 4-17years (4 male, mean 12.5years) who underwent TACE for unresectable HCC. Response to TACE was evaluated by change in AFP, RECIST and tumor volume, PRETEXT, and transplantation eligibility by UCSF and Milan criteria. Post-procedure mean follow-up was 8.2years. Mean overall change in tumor volume for the 8 patients was 51%. Percent change in AFP ranged from a decrease of 100% to an increase of 89.3%, with a mean change of -49.6%. Two patients did not undergo resection or transplantation and died of progressive disease. Six patients underwent orthotopic liver transplantation with mean first TACE-to-transplant interval of 141days (range 11-514). Following transplantation, 5 patients were alive at the end of the follow-up period and one died of recurrent disease. Based on our initial experience, TACE for children with unresectable HCC appears to be a safe and effective method for managing hepatic tumor burden and for downstaging and bridging to liver transplantation.

  View details for PubMedID 29707868

• Female Surgeons as Counter Stereotype: The Impact of Gender Perceptions on Trainee Evaluations of Physician Faculty. Journal of surgical education Fassiotto, M., Li, J., Maldonado, Y., Kothary, N. 2018

  Abstract

  Similar to women in Science, Technology, Engineering and Mathematics disciplines, women in medicine are subject to negative stereotyping when they do not adhere to their sex-role expectations. These biases may vary by specialty, largely dependent on the gender's representation in that specialty. Thus, females in male-dominated surgical specialties are especially at risk of stereotype threat. Herein, we present the role of gender expectations using trainee evaluations of physician faculty at a single academic center, over a 5-year period (2010-2014).Using Graduate Medical Education evaluation data of physician faculty from MedHub, we examined the differences in evaluation scores for male and female physicians within specialties that have traditionally had low female representation (e.g., surgical fields) compared to those with average or high female representation (e.g., pediatrics).Stanford Medicine residents and fellows' MedHub ratings of their physician faculty from 2010 to 2014.A total of 3648 evaluations across 1066 physician faculty.Overall, female physicians received lower median scores than their male counterparts across all specialties. When using regression analyses controlling for race, age, rank, and specialty-specific characteristics, the negative effect persists only for female physicians in specialties with low female representation.This finding suggests that female physicians in traditionally male-dominated specialties may face different criteria based on sex-role expectations when being evaluated by trainees. As trainee evaluations play an important role in career advancement decisions, dictate perceptions of quality within academic medical centers and affect overall job satisfaction, we propose that these differences in evaluations based merely on gender stereotypes could account, in part, for the narrowing pipeline of women promoted to higher ranks in academic medicine.

  View details for DOI 10.1016/j.jsurg.2018.01.011

  View details for PubMedID 29402668

• A Role for Virtual Reality in Planning Endovascular Procedures. Journal of vascular and interventional radiology : JVIR Mohammed, M. A., Khalaf, M. H., Kesselman, A., Wang, D. S., Kothary, N. 2018; 29 (7): 971–74

  Abstract

  Current imaging technologies are capable of acquiring volumetric data, but they are limited by the flat 2-dimensional representation of complex 3-dimensional data. This pictorial report illustrates the potential role of interactive virtual reality (VR) that enables physicians to visualize and interact with image data as if they were real physical objects. Increasing availability of tools that make the VR environment a possibility could potentially be valuable in the interventional radiology suite.

  View details for PubMedID 29935787

• Female Surgeons as Counter Stereotype: The Impact of Gender Perceptions on Trainee Evaluations of Physician Faculty Journal of Surgical Education Fassiotto, M., Li, J., Maldonado, Y., Kothary, N. 2018

  View details for DOI 10.1016/j.jsurg.2018.01.011

• Administering Blood Products Before Selected Interventional Radiology Procedures: Developing, Applying, and Monitoring a Standardized Protocol JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Hoang, N. S., Kothary, N., Saharan, S., Rosenberg, J., Tran, A. A., Brown, S. B., Hovsepian, D. M. 2017; 14 (11): 1438–43

  Abstract

  To apply and monitor a single institution's adherence to internally established guidelines for the preoperative administration of platelets and/or fresh frozen plasma (FFP) before a specified subset of minimally invasive interventional radiology (IR) procedures.Beginning in December 2008, we implemented a set of restrictive guidelines for preoperative platelet and/or FFP administration before IR procedures at a single academic hospital. Basing our program on the methodology of Lean Six Sigma, we compared the number and appropriateness of transfusions between the months of January and October in 2008 (prepolicy), again in 2010 (postpolicy), and finally in 2015 (follow-up). Patients with a platelet count less than or equal to 50,000 or an international normalized ratio greater than or equal to 1.7 met criteria for receiving platelets or FFP, respectively, before their IR procedure. For all three periods, we compared the rates of transfusion, hemorrhagic complications, and proportion of appropriate versus inappropriate blood product administration (BPA) per our guidelines.There was a significant increase in the number of appropriate BPAs between 2008 and 2010 from 58% to 76% (P = .021). Between 2010 and 2015, the rate trended up further, from 76% to 88% (P = .051). Overall, between 2008 and 2015, the improvement from 58% to 88% was significant (P < .001). The rate of hemorrhagic complications was extremely low in all three groups.Restrictive guidelines for receiving platelets and FFP administrations before IR procedures can sustainably decrease the rate of overall BPA while increasing the proportion of appropriate BPA without impacting the rate of hemorrhagic complications.

  View details for PubMedID 28964688

• Dynamic Measurement of Arterial Liver Perfusion With an Interventional C-Arm System. Investigative radiology Datta, S., Müller, K., Moore, T., Molvin, L., Gehrisch, S., Rosenberg, J., Saenz, Y., Manhart, M., Deuerling-Zheng, Y., Kothary, N., Fahrig, R. 2017

  Abstract

  Objective intraprocedural measurement of hepatic blood flow could provide a quantitative treatment end point for locoregional liver procedures. This study aims to validate the accuracy and reproducibility of cone-beam computed tomography perfusion (CBCTp) measurements of arterial liver perfusion (ALP) against clinically available computed tomography perfusion (CTp) measurements in a swine embolization model.Triplicate CBCTp measurements using a selective arterial contrast injection were performed before and after complete embolization of the left lobe of the liver in 5 swine. Two CBCTp protocols were evaluated that differed in sweep duration (3.3 vs 4.5 seconds) and the number of acquired projection images (166 vs 248). The mean ALP was measured within identical volumes of interest selected in the embolized and nonembolized regions of the perfusion map generated from each scan. Postembolization CBCTp values were also compared with CTp measurements.The 2 CBCTp protocols demonstrated high concordance correlation (0.90, P < 0.001). Both CBCTp protocols showed higher reproducibility than CTp in the nontarget lobe, with an intraclass correlation of 0.90 or greater for CBCTp and 0.83 for CTp (P < 0.001 for all correlations). The ALP in the embolized lobe was nearly zero and hence excluded for reproducibility. High concordance correlation was observed between the CTp and each CBCTp protocol, with the shorter CBCTp protocol reaching a concordance correlation of 0.75 and the longer achieving 0.87 (P < 0.001 for both correlations).Dynamic blood flow measurement using an angiographic C-arm system is feasible and produces quantitative results comparable to CTp.

  View details for DOI 10.1097/RLI.0000000000000368

  View details for PubMedID 28306699

• The Role of Cone-Beam CT in Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis. Journal of vascular and interventional radiology Pung, L., Ahmad, M., Mueller, K., Rosenberg, J., Stave, C., Hwang, G. L., Shah, R., Kothary, N. 2017; 28 (3): 334-341

  Abstract

  To review available evidence for use of cone-beam CT during transcatheter arterial chemoembolization in hepatocellular carcinoma (HCC) for detection of tumor and feeding arteries.Literature searches were conducted from inception to May 15, 2016, in PubMed (MEDLINE), Scopus, and Cochrane Central Register of Controlled Trials. Searches included "cone beam," "CBCT," "C-arm," "CACT," "cone-beam CT," "volumetric CT," "volume computed tomography," "volume CT," AND "liver," "hepatic*," "hepatoc*." Studies that involved adults with HCC specifically and treated with transcatheter arterial chemoembolization that used cone-beam CT were included.Inclusion criteria were met by 18 studies. Pooled sensitivity of cone-beam CT for detecting tumor was 90% (95% confidence interval [CI], 82%-95%), whereas pooled sensitivity of digital subtraction angiography (DSA) for tumor detection was 67% (95% CI, 51%-80%). Pooled sensitivity of cone-beam CT for detecting tumor feeding arteries was 93% (95% CI, 91%-95%), whereas pooled sensitivity of DSA was 55% (95% CI, 36%-74%).Cone-beam CT can significantly increase detection of tumors and tumor feeding arteries during transcatheter arterial chemoembolization. Cone-beam CT should be considered as an adjunct tool to DSA during transcatheter arterial chemoembolization treatments of HCC.

  View details for DOI 10.1016/j.jvir.2016.11.037

  View details for PubMedID 28109724

• The Role of Dual-Phase Cone-Beam CT in Predicting Short-Term Response after Transarterial Chemoembolization for Hepatocellular Carcinoma. Journal of vascular and interventional radiology Müller, K., Datta, S., Gehrisch, S., Ahmad, M., Mohammed, M. A., Rosenberg, J., Hwang, G. L., Louie, J. D., Sze, D. Y., Kothary, N. 2017; 28 (2): 238-245

  Abstract

  To identify computational and qualitative features derived from dual-phase cone-beam CT that predict short-term response in patients undergoing transarterial chemoembolization for hepatocellular carcinoma (HCC).This retrospective study included 43 patients with 59 HCCs. Six features were extracted, including intensity of tumor enhancement on both phases and characteristics of the corona on the washout phase. Short-term response was evaluated by modified Response Evaluation Criteria in Solid Tumors on follow-up imaging, and extracted features were correlated to response using univariate and multivariate analyses.Univariate and multivariate analyses did not reveal a correlation between absolute and relative tumor enhancement characteristics on either phase with response (arterial P = .21; washout P = .40; ∆ P = .90). On multivariate analysis of qualitative characteristics, the presence of a diffuse corona was an independent predictor of incomplete response (P = .038) and decreased the odds ratio of objective response by half regardless of tumor size.Computational features extracted from contrast-enhanced dual-phase cone-beam CT are not prognostic of response to transarterial chemoembolization in patients with HCC. HCCs that demonstrate a diffuse, patchy corona have reduced odds of achieving complete response after transarterial chemoembolization and should be considered for additional treatment with an alternative modality.

  View details for DOI 10.1016/j.jvir.2016.09.019

  View details for PubMedID 27914917

• Cost-effectiveness of Stereotactic Body Radiation Therapy versus Radiofrequency Ablation for Hepatocellular Carcinoma: A Markov Modeling Study. Radiology Pollom, E. L., Lee, K., Durkee, B. Y., Grade, M., Mokhtari, D. A., Wahl, D. R., Feng, M., Kothary, N., Koong, A. C., Owens, D. K., Goldhaber-Fiebert, J., Chang, D. T. 2017: 161509-?

  Abstract

  Purpose To assess the cost-effectiveness of stereotactic body radiation therapy (SBRT) versus radiofrequency ablation (RFA) for patients with inoperable localized hepatocellular carcinoma (HCC) who are eligible for both SBRT and RFA. Materials and Methods A decision-analytic Markov model was developed for patients with inoperable, localized HCC who were eligible for both RFA and SBRT to evaluate the cost-effectiveness of the following treatment strategies: (a) SBRT as initial treatment followed by SBRT for local progression (SBRT-SBRT), (b) RFA followed by RFA for local progression (RFA-RFA), (c) SBRT followed by RFA for local progression (SBRT-RFA), and (d) RFA followed by SBRT for local progression (RFA-SBRT). Probabilities of disease progression, treatment characteristics, and mortality were derived from published studies. Outcomes included health benefits expressed as discounted quality-adjusted life years (QALYs), costs in U.S. dollars, and cost-effectiveness expressed as an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analysis was performed to assess the robustness of the findings. Results In the base case, SBRT-SBRT yielded the most QALYs (1.565) and cost $197 557. RFA-SBRT yielded 1.558 QALYs and cost $193 288. SBRT-SBRT was not cost-effective, at $558 679 per QALY gained relative to RFA-SBRT. RFA-SBRT was the preferred strategy, because RFA-RFA and SBRT-RFA were less effective and more costly. In all evaluated scenarios, SBRT was preferred as salvage therapy for local progression after RFA. Probabilistic sensitivity analysis showed that at a willingness-to-pay threshold of $100 000 per QALY gained, RFA-SBRT was preferred in 65.8% of simulations. Conclusion SBRT for initial treatment of localized, inoperable HCC is not cost-effective. However, SBRT is the preferred salvage therapy for local progression after RFA. (©) RSNA, 2017 Online supplemental material is available for this article.

  View details for DOI 10.1148/radiol.2016161509

  View details for PubMedID 28045603

• Noninvasive radiomics signature based on quantitative analysis of computed tomography images as a surrogate for microvascular invasion in hepatocellular carcinoma: a pilot study. Journal of medical imaging (Bellingham, Wash.) Bakr, S. n., Echegaray, S. n., Shah, R. n., Kamaya, A. n., Louie, J. n., Napel, S. n., Kothary, N. n., Gevaert, O. n. 2017; 4 (4): 041303

  Abstract

  We explore noninvasive biomarkers of microvascular invasion (mVI) in patients with hepatocellular carcinoma (HCC) using quantitative and semantic image features extracted from contrast-enhanced, triphasic computed tomography (CT). Under institutional review board approval, we selected 28 treatment-naive HCC patients who underwent surgical resection. Four radiologists independently selected and delineated tumor margins on three axial CT images and extracted computational features capturing tumor shape, image intensities, and texture. We also computed two types of "delta features," defined as the absolute difference and the ratio computed from all pairs of imaging phases for each feature. 717 arterial, portal-venous, delayed single-phase, and delta-phase features were robust against interreader variability ([Formula: see text]). An enhanced cross-validation analysis showed that combining robust single-phase and delta features in the arterial and venous phases identified mVI (AUC [Formula: see text]). Compared to a previously reported semantic feature signature (AUC 0.47 to 0.58), these features in our cohort showed only slight to moderate agreement (Cohen's kappa range: 0.03 to 0.59). Though preliminary, quantitative analysis of image features in arterial and venous phases may be potential surrogate biomarkers for mVI in HCC. Further study in a larger cohort is warranted.

  View details for PubMedID 28840174

• Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival. Cardiovascular and interventional radiology Chen, J. X., Rose, S., White, S. B., El-Haddad, G., Fidelman, N., Yarmohammadi, H., Hwang, W., Sze, D. Y., Kothary, N., Stashek, K., Wileyto, E. P., Salem, R., Metz, D. C., Soulen, M. C. 2017; 40 (1): 69-80

  Abstract

  The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases.This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models.Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p < 0.05). Tumor burden >50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p < 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE.Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.

  View details for DOI 10.1007/s00270-016-1478-z

  View details for PubMedID 27738818

• Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Chen, J. X., Rose, S., White, S. B., El-Haddad, G., Fidelman, N., Yarmohammadi, H., Hwang, W., Sze, D. Y., Kothary, N., Stashek, K., Wileyto, E. P., Salem, R., Metz, D. C., Soulen, M. C. 2017; 40 (1): 69-80

  Abstract

  The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases.This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models.Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p < 0.05). Tumor burden >50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p < 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE.Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.

  View details for DOI 10.1007/s00270-016-1478-z

  View details for Web of Science ID 000391430800010

• Endovascular Management of May-Thurner Syndrome in Adolescents: A Single-Center Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Goldman, R. E., Arendt, V. A., Kothary, N., Kuo, W. T., Sze, D. Y., Hofmann, L. V., Lungren, M. P. 2017; 28 (1): 71-77

  Abstract

  To report a single-center experience in regard to the technique, safety, and clinical outcomes of endovascular therapy for treatment of May-Thurner syndrome (MTS) in adolescent patients.A retrospective review identified 10 patients (6 female; mean age, 16 y; range, 12-18 y; mean weight, 73 kg; range, 50-116 kg) treated by endovascular therapy for MTS from 1998 to 2015. Clinical presentations consisted of acute thrombotic MTS (n = 6) and nonthrombotic MTS (n = 4). Catheter-directed thrombolysis was performed in all cases of thrombosis. Venoplasty and stent placement were performed in all cases. Self-expanding stents 12-16 mm in diameter and 4-9 cm in length were deployed.No major periprocedural complications were observed. Median follow-up was 32 months (range, 6-109 mo). Primary and secondary patency rates were 79% and 100% at 12 months and 79% and 89% at 36 months, respectively. In a single patient with permanent loss of flow in the treated segment, multiple risk factors for thrombosis were identified. Rates of posttreatment symptoms were 0% by Villalta score and 60% (n = 6; mild symptoms) by modified Villalta score at the last clinical follow-up.Endovascular therapy for the treatment of MTS in our adolescent cohort was safe and effective in relieving venous obstruction. Stent placement in patients with underlying thrombophilic disorders is associated with loss of secondary patency, suggesting the need for further consideration in this population.

  View details for DOI 10.1016/j.jvir.2016.09.005

  View details for Web of Science ID 000392465200010

• Endovascular Management of May-Thurner Syndrome in Adolescents: A Single-Center Experience. Journal of vascular and interventional radiology Goldman, R. E., Arendt, V. A., Kothary, N., Kuo, W. T., Sze, D. Y., Hofmann, L. V., Lungren, M. P. 2016

  Abstract

  To report a single-center experience in regard to the technique, safety, and clinical outcomes of endovascular therapy for treatment of May-Thurner syndrome (MTS) in adolescent patients.A retrospective review identified 10 patients (6 female; mean age, 16 y; range, 12-18 y; mean weight, 73 kg; range, 50-116 kg) treated by endovascular therapy for MTS from 1998 to 2015. Clinical presentations consisted of acute thrombotic MTS (n = 6) and nonthrombotic MTS (n = 4). Catheter-directed thrombolysis was performed in all cases of thrombosis. Venoplasty and stent placement were performed in all cases. Self-expanding stents 12-16 mm in diameter and 4-9 cm in length were deployed.No major periprocedural complications were observed. Median follow-up was 32 months (range, 6-109 mo). Primary and secondary patency rates were 79% and 100% at 12 months and 79% and 89% at 36 months, respectively. In a single patient with permanent loss of flow in the treated segment, multiple risk factors for thrombosis were identified. Rates of posttreatment symptoms were 0% by Villalta score and 60% (n = 6; mild symptoms) by modified Villalta score at the last clinical follow-up.Endovascular therapy for the treatment of MTS in our adolescent cohort was safe and effective in relieving venous obstruction. Stent placement in patients with underlying thrombophilic disorders is associated with loss of secondary patency, suggesting the need for further consideration in this population.

  View details for DOI 10.1016/j.jvir.2016.09.005

  View details for PubMedID 27818112

• Reproducibility of Parenchymal Blood Volume Measurements Using an Angiographic C-arm CT System. Academic radiology Mueller, K., Fahrig, R., Manhart, M., Deuerling-Zheng, Y., Rosenberg, J., Moore, T., Ganguly, A., Kothary, N. 2016; 23 (11): 1441-1445

  Abstract

  Intra-procedural measurement of hepatic perfusion following liver embolization continues to be a challenge. Blood volume imaging before and after interventional procedures would allow identifying the treatment end point or even allow predicting treatment outcome. Recent liver oncology studies showed the feasibility of parenchymal blood volume (PBV) imaging using an angiographic C-arm system. This study was done to evaluate the reproducibility of PBV measurements using cone beam computed tomography (CBCT) before and after embolization of the liver in a swine model.CBCT imaging was performed before and after partial bland embolization of the left lobe of the liver in five adult pigs. Intra-arterial injection of iodinated contrast with a 6-second x-ray delay was used with a two-sweep 8-second rotation imaging protocol. Three acquisitions, each separated by 10 minutes to allow for contrast clearance, were obtained before and after embolization in each animal. Post-processing was carried out using dedicated software to generate three-dimensional (3D) PBV maps. Two region-of-interest measurements were placed on two views within the right and left lobe on each CBCT 3D PBV map. Variation in PBV for scans acquired within each animal was determined by the coefficient of variation and intraclass correlation. A Wilcoxon signed-rank test was used to test post-procedure reduction in PBV.The CBCT PBV maps showed mean coefficients of variation of 7% (range: 2%-16%) and 25% (range:  13%-34%) for baseline and embolized PBV maps, respectively. The intraclass correlation for PBV measurements was 0.89, demonstrating high reproducibility, with measurable reduction in PBV displayed after embolization (P = 0.007).Intra-procedural acquisition of 3D PBV maps before and after liver embolization using CBCT is highly reproducible and shows promising application for obtaining intra-procedural PBV maps during locoregional therapy.

  View details for DOI 10.1016/j.acra.2016.08.001

  View details for PubMedID 27745815

• The Angiomyolipoma Conundrum JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N. 2016; 27 (10): 1550–51

  View details for PubMedID 27670990

• Ultrasound Guided Liver Biopsy with Gelatin Sponge Pledget Tract Embolization in Infants Weighing Less Than 10 kg. Journal of pediatric gastroenterology and nutrition Lungren, M. P., Lindquester, W. S., Seidel, F. G., Kothry, N., Monroe, E. J., Shivaram, G., Gill, A. E., Hawkins, M. C. 2016: -?

  Abstract

  The aim of the study was to describe and assess the technical success and safety of ultrasound-guided liver biopsy with gelatin sponge pledget tract embolization technique in infants <10 kg across 3 tertiary pediatric hospitals.There were 67 pediatric patients weighing <10 kg (36 boys; 31 girls; average age 202 days; average weight 6 kg, range 1.5-9.9 kg) referred for liver biopsy performed with ultrasound guidance and gelatin sponge pledget tract embolization during a 2-year period. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed.A total of 67 procedures were included. There was 100% technical success rate and all samples obtained provided adequate tissue for histological assessment. Average number of 18 G biopsy passes was 3 (range 1-6). There were no procedure-related deaths. There was 1 complication (1%) in a 5-kg infant who was readmitted 36 hours after biopsy with a fever and fully recovered after antibiotics were administered. Biliary atresia was the most common underlying diagnosis (20%), whereas others included acute rejection (16%) and biliary obstruction (7%).Ultrasound-guided percutaneous liver biopsy with gelatin sponge pledget tract embolization technique in children weighing <10 kg is safe, effective, and use of this technique may lead to a reduction in rates of adverse events reported in other pediatric series.

  View details for PubMedID 27749391

• CT-Guided Wire Localization for Involved Axillary Lymph Nodes After Neo-adjuvant Chemotherapy in Patients With Initially Node-Positive Breast Cancer BREAST JOURNAL Long Trinh, L., Miyake, K. K., Dirbas, F. M., Kothary, N., Horst, K. C., Lipson, J. A., Carpenter, C., Thompson, A. C., Ikeda, D. M. 2016; 22 (4): 390-396

  Abstract

  Resection of biopsy-proven involved axillary lymph nodes (iALNs) is important to reduce the false-negative rates of sentinel lymph node (SLN) biopsy after neo-adjuvant chemotherapy (NAC) in patients with initially node-positive breast cancer. Preoperative wire localization for iALNs marked with clips placed during biopsy is a technique that may help the removal of iALNs after NAC. However, ultrasound (US)-guided localization is often difficult because the clips cannot always be reliably visible on US. Computed tomography (CT)-guided wire localization can be used; however, to date there have been no reports on CT-guided wire localization for iALNs. The aim of this study was to describe a series of patients who received CT-guided wire localization for iALN removal after NAC and to evaluate the feasibility of this technique. We retrospectively analyzed five women with initially node-positive breast cancer (age, 41-52 years) who were scheduled for SLN biopsy after NAC and received preoperative CT-guided wire localization for iALNs. CT visualized all the clips that were not identified on post-NAC US. The wire tip was deployed beyond or at the target, with the shortest distance between the wire and the index clip ranging from 0 to 2.5 mm. The total procedure time was 21-38 minutes with good patient tolerance and no complications. In four of five cases, CT wire localization aided in identification and resection of iALNs that were not identified with lymphatic mapping. Residual nodal disease was confirmed in two cases: both had residual disease in wire-localized lymph nodes in addition to SLNs. Although further studies with more cases are required, our results suggest that CT-guided wire localization for iALNs is a feasible technique that facilitates identification and removal of the iALNs as part of SLN biopsy after NAC in situations where US localization is unsuccessful.

  View details for DOI 10.1111/tbj.12597

  View details for PubMedID 27061012

• Occupational Radiation Exposure during Pregnancy: A Survey of Attitudes and Practices among Interventional Radiologists JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ghatan, C. E., Fassiotto, M., Jacobsen, J. P., Sze, D. Y., Kothary, N. 2016; 27 (7): 1013-1020

  Abstract

  To assess attitudes of interventional radiologists toward occupational ionizing radiation exposure in pregnancy and to survey practice patterns and outcomes.A 34-question anonymous online survey on attitudes and work practices toward interventional radiologists who worked during pregnancy was sent to active SIR members, including 582 women.There were 534 (10%) respondents, including 142 women and 363 men. Among respondents, men were statistically older than women (P < .001) and had practiced interventional radiology (IR) longer (P < .001). Of female interventional radiologists, 55% had worked during pregnancy and reported no specific mutagenic events in their offspring. Spontaneous abortions (11%) and use of reproductive technology (17%) matched that of women with similar age and socioeconomic background. Although more women changed their work practice because of concerns of occupational exposure than men (23% vs 13%), this change was largely limited to the duration of a pregnancy. Among pregnant interventional radiologists, 4 (6%) completely abstained from performing fluoroscopically guided interventions (FGIs), whereas 31 (46%) continued to spend > 80% of their work week doing FGIs with additional protection. Perceptions of impact of pregnancy on daytime work redistribution varied significantly with gender (P < .001); however, perceptions regarding impact of pregnancy on on-call hours, distribution of complex cases, and need to hire for temporary coverage were similar between the genders.Most pregnant interventional radiologists continue to practice IR while pregnant. Pregnancy and fetal outcomes parallel that of the general population when matched for demographics. However, perceptions of impact of pregnancy on work lives of colleagues vary notably.

  View details for DOI 10.1016/j.jvir.2016.03.040

  View details for PubMedID 27236211

• Assessing the Risk of Hemorrhagic Complication following Transjugular Liver Biopsy in Bone Marrow Transplantation Recipients JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ahmed, O., Ward, T. J., Lungren, M. P., Mohammed, M. A., Hofmann, L. V., Sze, D. Y., Kothary, N. 2016; 27 (4): 551-557

  Abstract

  To determine if recipients of bone marrow transplants (BMTs) are at increased risk of hemorrhagic complications following transjugular liver biopsy (TJLB).TJLBs in BMT and non-BMT patients between January 2007 and July 2014 were reviewed. Patient demographic and pre- and postprocedural laboratory data were reviewed. Mean platelet count and International Normalized Ratio were 174,300 × 10(3)/µL ± 107.3 (standard deviation) and 1.2 ± 0.4, respectively, for BMT recipients, compared with 88,100 × 10(3)/µL ± 70.9 and 1.2 ± 0.5, respectively, for non-BMT. Patients in whom hemoglobin level decreased by > 1 g/dL and/or required transfusion within 15 days of TJLB were reviewed to determine the presence of a biopsy-related hemorrhagic complication.A total of 1,600 TJLBs in 1,120 patients were analyzed. Of these, 183 TJLBs in 159 BMT recipients and 1,417 TJLBs in 961 patients non-BMT patients were performed. Thirteen TJLBs were complicated by hemorrhage: five in BMT (2.9%) and eight in the non-BMT cohorts (0.6%; P < .01). Preprocedural platelet counts were within normal range (57-268 × 10(3)/µL) in all but one patient (8 × 10(3)/µL). BMT recipients had an odds ratio of 4.9 (95% confidence interval, 1.25-17.3) for post-TJLB bleeding/hemorrhage compared with those without BMTs (P < .01).TJLB continues to be a safe procedure in the vast majority of patients. However, hemorrhagic complications occurred at a rate of 2.9% in BMT recipients, compared with 0.6% in patients without BMTs, and therefore caution should be exercised when performing TJLB in this group.

  View details for DOI 10.1016/j.jvir.2016.01.007

  View details for Web of Science ID 000373753900013

• Assessing the Risk of Hemorrhagic Complication following Transjugular Liver Biopsy in Bone Marrow Transplantation Recipients. Journal of vascular and interventional radiology Ahmed, O., Ward, T. J., Lungren, M. P., Abdelrazek Mohammed, M. A., Hofmann, L. V., Sze, D. Y., Kothary, N. 2016; 27 (4): 551-557

  Abstract

  To determine if recipients of bone marrow transplants (BMTs) are at increased risk of hemorrhagic complications following transjugular liver biopsy (TJLB).TJLBs in BMT and non-BMT patients between January 2007 and July 2014 were reviewed. Patient demographic and pre- and postprocedural laboratory data were reviewed. Mean platelet count and International Normalized Ratio were 174,300 × 10(3)/µL ± 107.3 (standard deviation) and 1.2 ± 0.4, respectively, for BMT recipients, compared with 88,100 × 10(3)/µL ± 70.9 and 1.2 ± 0.5, respectively, for non-BMT. Patients in whom hemoglobin level decreased by > 1 g/dL and/or required transfusion within 15 days of TJLB were reviewed to determine the presence of a biopsy-related hemorrhagic complication.A total of 1,600 TJLBs in 1,120 patients were analyzed. Of these, 183 TJLBs in 159 BMT recipients and 1,417 TJLBs in 961 patients non-BMT patients were performed. Thirteen TJLBs were complicated by hemorrhage: five in BMT (2.9%) and eight in the non-BMT cohorts (0.6%; P < .01). Preprocedural platelet counts were within normal range (57-268 × 10(3)/µL) in all but one patient (8 × 10(3)/µL). BMT recipients had an odds ratio of 4.9 (95% confidence interval, 1.25-17.3) for post-TJLB bleeding/hemorrhage compared with those without BMTs (P < .01).TJLB continues to be a safe procedure in the vast majority of patients. However, hemorrhagic complications occurred at a rate of 2.9% in BMT recipients, compared with 0.6% in patients without BMTs, and therefore caution should be exercised when performing TJLB in this group.

  View details for DOI 10.1016/j.jvir.2016.01.007

  View details for PubMedID 26948328

• Superselective Chemoembolization of HCC: Comparison of Short-term Safety and Efficacy between Drug-eluting LC Beads, QuadraSpheres, and Conventional Ethiodized Oil Emulsion. Radiology Duan, F., Wang, E. Q., Lam, M. G., Abdelmaksoud, M. H., Louie, J. D., Hwang, G. L., Kothary, N., Kuo, W. T., Hofmann, L. V., Sze, D. Y. 2016; 278 (2): 612-621

  Abstract

  Purpose To study the comparative short-term safety and efficacy of transcatheter arterial chemoembolization (TACE) with drug-eluting LC Beads loaded with doxorubicin (DEBDOX), doxorubicin-eluting QuadraSpheres (hqTACE), and conventional TACE using ethiodized oil for superselective C-arm computed tomography (CT)-guided treatment of hepatocellular carcinoma (HCC) after the onset of drug shortages. Materials and Methods From March 2010 to March 2011, 166 patients with HCC were treated with 232 superselective TACE procedures using C-arm cone-beam CT at one institution. Patients underwent treatment depending on the availability of materials after the onset of drug shortages. Conventional TACE with doxorubicin, cisplatin, and Ethiodol was performed for 159 procedures, DEBDOX TACE was performed for 47, and hqTACE was performed for 26. Toxicity and objective response were compared at 3 months after treatment. Data were stratified for the high-risk population (Child-Pugh class B, performance status 1, bilobar disease, and/or post-resection recurrence) and initial versus repeat treatment. Kruskal-Wallis H test, Mann-Whitney U test, and Fisher exact test were used to compare the groups, with Bonferroni correction where needed. Results Whole liver response rates trended higher for conventional TACE (conventional TACE, 65.4%; DEBDOX, 63.8%; hqTACE, 53.8%) (P = .085). Only minor trends for differences in toxicity were observed between the three groups. Low-risk patients had higher whole liver (P = .001) and treated lesion (P = .007) response rates when treated with conventional TACE, but no significant differences were seen for DEBDOX and hqTACE. Treatment-naive patients also had higher whole liver (P = .012) and treated lesion (P = .056) response rates. No advantages for drug-eluting microspheres were found. Conclusion Within statistical power limitations, overall toxicity and efficacy were equivalent in patients treated with LC Beads, QuadraSpheres, or ethiodized oil emulsions, including in high-risk patients, when performed superselectively with cone-beam C-arm CT guidance. (©) RSNA, 2015.

  View details for DOI 10.1148/radiol.2015141417

  View details for PubMedID 26334787

• Cost Accounting as a Tool for Increasing Cost Transparency in Selective Hepatic Transarterial Chemoembolization. Journal of vascular and interventional radiology Ahmed, O., Patel, M., Ward, T., Sze, D. Y., Telischak, K., Kothary, N., Hofmann, L. V. 2015; 26 (12): 1820-1826 e1

  Abstract

  To increase cost transparency and uncover potential areas for savings in patients receiving selective transarterial chemoembolization at a tertiary care academic center.The hospital cost accounting system charge master sheet for direct and total costs associated with selective transarterial chemoembolization in fiscal years 2013 and 2014 was queried for each of the four highest volume interventional radiologists at a single institution. There were 517 cases (range, 83-150 per physician) performed; direct costs incurred relating to care before, during, and after the procedure with respect to labor, supply, and equipment fees were calculated.A median of 48 activity codes were charged per selective transarterial chemoembolization from five cost centers, represented by the angiography suite, units for care before and after the procedure, pharmacy, and observation floors. The average direct cost of selective transarterial chemoembolization did not significantly differ among operators at $9,126.94, $8,768.77, $9,027.33, and $8,909.75 (P = .31). Intraprocedural costs accounted for 82.8% of total direct costs and provided the greatest degree in cost variability ($7,268.47-$7,691.27). The differences in intraprocedural expense among providers were not statistically significant (P = .09), even when separated into more specific procedure-related labor and supply costs.Cost accounting systems could effectively be interrogated as a method for calculating direct costs associated with selective transarterial chemoembolization. The greatest source of expenditure and variability in cost among providers was shown to be intraprocedural labor and supplies, although the effect did not appear to be operator dependent.

  View details for DOI 10.1016/j.jvir.2015.09.004

  View details for PubMedID 26521766

• Core samples for radiomics features that are insensitive to tumor segmentation: method and pilot study using CT images of hepatocellular carcinoma. Journal of medical imaging (Bellingham, Wash.) Echegaray, S., Gevaert, O., Shah, R., Kamaya, A., Louie, J., Kothary, N., Napel, S. 2015; 2 (4): 041011-?

  Abstract

  The purpose of this study is to investigate the utility of obtaining "core samples" of regions in CT volume scans for extraction of radiomic features. We asked four readers to outline tumors in three representative slices from each phase of multiphasic liver CT images taken from 29 patients (1128 segmentations) with hepatocellular carcinoma. Core samples were obtained by automatically tracing the maximal circle inscribed in the outlines. Image features describing the intensity, texture, shape, and margin were used to describe the segmented lesion. We calculated the intraclass correlation between the features extracted from the readers' segmentations and their core samples to characterize robustness to segmentation between readers, and between human-based segmentation and core sampling. We conclude that despite the high interreader variability in manually delineating the tumor (average overlap of 43% across all readers), certain features such as intensity and texture features are robust to segmentation. More importantly, this same subset of features can be obtained from the core samples, providing as much information as detailed segmentation while being simpler and faster to obtain.

  View details for DOI 10.1117/1.JMI.2.4.041011

  View details for PubMedID 26587549

• Watershed Hepatocellular Carcinomas: The Risk of Incomplete Response following Transhepatic Arterial Chemoembolization. Journal of vascular and interventional radiology Kothary, N., Takehana, C., Mueller, K., Sullivan, P., Tahvildari, A., Sidhar, V., Rosenberg, J., Louie, J. D., Sze, D. Y. 2015; 26 (8): 1122-1129

  Abstract

  Hepatocellular carcinomas (HCCs) bridging two or more Couinaud-Bismuth segments of the liver ("watershed tumors") can recruit multiple segmental arteries. The primary hypothesis of this study was that fewer watershed tumors show complete response (CR) after chemoembolization, with shorter time to local recurrence. Secondary analysis on the impact on transplantation eligibility in the presence of progressive disease was also performed.A total of 155 transplantation-eligible patients whose HCC met Milan criteria (watershed, n = 83; nonwatershed, n = 72) and was treated with chemoembolization were included. Cone-beam computed tomography (CT) was used for guidance and for confirmation of circumferential uptake. Local response to chemoembolization per modified Response Evaluation Criteria In Solid Tumors and local disease-free survival (DFS) for the index tumor were calculated. Differences were assessed by univariate and multivariate analyses.CR after a single of chemoembolization was observed in 55.4% of watershed tumors and in 72.2% of nonwatershed tumors (P = .045). Estimated DFS intervals were 151 days (95% confidence interval [CI], 93-245 d) and 336 days (95% CI, 231-747 d; P = .040) in the watershed and nonwatershed groups, respectively. Worse DFS was observed with a Model for End-Stage Liver Disease score > 20 (P = .0001), higher Child-Pugh-Turcotte score (P = .049), and watershed location (P = .040). Waiting list drop-off rates were statistically similar between groups.Hepatocellular carcinomas located in the watershed region of the liver have a poorer response to chemoembolization than those located elsewhere. These tumors are associated with worse DFS and require additional treatments to maintain transplantation eligibility per Milan criteria. Cone-beam CT can identify crossover supply and confirm complete geographic drug uptake, possibly reducing (but not eliminating) the risk of incomplete response.

  View details for DOI 10.1016/j.jvir.2015.04.030

  View details for PubMedID 26091800

• Optimal imaging surveillance schedules after liver-directed therapy for hepatocellular carcinoma. Journal of vascular and interventional radiology Boas, F. E., Do, B., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hovsepian, D. M., Kantrowitz, M., Sze, D. Y. 2015; 26 (1): 69-73

  Abstract

  To optimize surveillance schedules for the detection of recurrent hepatocellular carcinoma (HCC) after liver-directed therapy.New methods have emerged that allow quantitative analysis and optimization of surveillance schedules for diseases with substantial rates of recurrence such as HCC. These methods were applied to 1,766 consecutive chemoembolization, radioembolization, and radiofrequency ablation procedures performed on 910 patients between 2006 and 2011. Computed tomography or magnetic resonance imaging performed just before repeat therapy was set as the time of "recurrence," which included residual and locally recurrent tumor as well as new liver tumors. Time-to-recurrence distribution was estimated by Kaplan-Meier method. Average diagnostic delay (time between recurrence and detection) was calculated for each proposed surveillance schedule using the time-to-recurrence distribution. An optimized surveillance schedule could then be derived to minimize the average diagnostic delay.Recurrence is 6.5 times more likely in the first year after treatment than in the second. Therefore, screening should be much more frequent in the first year. For eight time points in the first 2 years of follow-up, the optimal schedule is 2, 4, 6, 8, 11, 14, 18, and 24 months. This schedule reduces diagnostic delay compared with published schedules and is cost-effective.The calculated optimal surveillance schedules include shorter-interval follow-up when there is a higher probability of recurrence and longer-interval follow-up when there is a lower probability. Cost can be optimized for a specified acceptable diagnostic delay or diagnostic delay can be optimized within a specified acceptable cost.

  View details for DOI 10.1016/j.jvir.2014.09.013

  View details for PubMedID 25446423

• Introduction TECHNIQUES IN VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N. 2013; 16 (3): 135

  View details for DOI 10.1053/j.tvir.2013.02.007

  View details for Web of Science ID 000421865300002

  View details for PubMedID 23993074

• Prophylactic Topically Applied Ice to Prevent Cutaneous Complications of Nontarget Chemoembolization and Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Wang, D. S., Louie, J. D., Kothary, N., Shah, R. P., Sze, D. Y. 2013; 24 (4): 596-600

  Abstract

  Cutaneous complications can result from nontarget deposition during transcatheter arterial chemoembolization or radioembolization. Liver tumors may receive blood supply from parasitized extrahepatic arteries (EHAs) that also perfuse skin or from hepatic arteries located near the origin of the falciform artery (FA), which perfuses the anterior abdominal wall. To vasoconstrict cutaneous vasculature and prevent nontarget deposition, ice packs were topically applied to at-risk skin in nine chemoembolization treatments performed via 14 parasitized EHAs, seven chemoembolization treatments near the FA origin, and five radioembolization treatments in cases in which the FA could not be prophylactically coil-embolized. No postprocedural cutaneous complications were encountered.

  View details for DOI 10.1016/j.jvir.2012.12.020

  View details for PubMedID 23522163

• Migration of implanted markers for image-guided lung tumor stereotactic ablative radiotherapy JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS Hong, J. C., Eclov, N. C., Yu, Y., Rao, A. K., Dieterich, S., Quynh-Thu Le, Q. T., Diehn, M., Sze, D. Y., Loo, B. W., Kothary, N., Maxim, P. G. 2013; 14 (2): 77-89

  View details for Web of Science ID 000315898300008

• Migration of implanted markers for image-guided lung tumor stereotactic ablative radiotherapy. Journal of applied clinical medical physics Hong, J. C., Eclov, N. C., Yu, Y., Rao, A. K., Dieterich, S., Le, Q., Diehn, M., Sze, D. Y., Loo, B. W., Kothary, N., Maxim, P. G. 2013; 14 (2): 4046-?

  Abstract

  The purpose of this study was to quantify postimplantation migration of percutaneously implanted cylindrical gold seeds ("seeds") and platinum endovascular embolization coils ("coils") for tumor tracking in pulmonary stereotactic ablative radiotherapy (SABR). We retrospectively analyzed the migration of markers in 32 consecutive patients with computed tomography scans postimplantation and at simulation. We implanted 147 markers (59 seeds, 88 coils) in or around 34 pulmonary tumors over 32 procedures, with one lesion implanted twice. Marker coordinates were rigidly aligned by minimizing fiducial registration error (FRE), the root mean square of the differences in marker locations for each tumor between scans. To also evaluate whether single markers were responsible for most migration, we aligned with and without the outlier causing the largest FRE increase per tumor. We applied the resultant transformation to all markers. We evaluated migration of individual markers and FRE of each group. Median scan interval was 8 days. Median individual marker migration was 1.28 mm (interquartile range [IQR] 0.78-2.63 mm). Median lesion FRE was 1.56 mm (IQR 0.92-2.95 mm). Outlier identification yielded 1.03 mm median migration (IQR 0.52-2.21 mm) and 1.97 mm median FRE (IQR 1.44-4.32 mm). Outliers caused a mean and median shift in the centroid of 1.22 and 0.80 mm (95th percentile 2.52 mm). Seeds and coils had no statistically significant difference. Univariate analysis suggested no correlation of migration with the number of markers, contact with the chest wall, or time elapsed. Marker migration between implantation and simulation is limited and unlikely to cause geometric miss during tracking.

  View details for DOI 10.1120/jacmp.v14i2.4046

  View details for PubMedID 23470933

• Correlation of the Diameter of the Left Common Iliac Vein with the Risk of Lower-extremity Deep Venous Thrombosis JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Carr, S., Chan, K., Rosenberg, J., Kuo, W. T., Kothary, N., Hovsepian, D. M., Sze, D. Y., Hofmann, L. V. 2012; 23 (11): 1467-1472

  Abstract

  Compression of the left common iliac vein (CIV; LCIV) is a known risk factor for lower-extremity deep vein thrombosis (DVT). This study was performed to model the probability of DVT based on LCIV diameter and apply this to a quantitative DVT risk factor scoring system.Medical records were used to identify female patients younger than 45 years of age who were diagnosed with lower-extremity DVT (n = 21) and age-matched control subjects (n = 26) who presented to the emergency department with abdominal pain. Minimum CIV diameters were measured on computed tomography. Based on published reporting standards, 13 risk factors were scored for patients diagnosed with left-sided DVT and for control subjects. The association between vein diameter and DVT was examined by Mann-Whitney test. Odds of DVT based on vein diameter was assessed by logistic regression.Mean minimum LCIV diameters were 4.0 mm for patients with DVT and 6.5 mm for patients without DVT (P = .001). The odds of left DVT increased by a factor of 1.68 for each millimeter decrease in LCIV diameter (odds ratio = 1.68; P = .006; 95% confidence interval, 1.16-2.43). As the risk factor score increased, the relationship between diameter and risk for DVT became stronger; identical LCIV diameters were associated wtih a higher probability of developing DVT if the risk factor score was higher.Stenosis of the LCIV was found to be a strong independent risk factor for development of DVT. Moreover, each millimeter decrease in CIV diameter increased the odds of DVT by a factor of 1.68.

  View details for DOI 10.1016/j.jvir.2012.07.030

  View details for PubMedID 23101919

• The diagnostic yield of CT-guided percutaneous lung biopsy in solid organ transplant recipients CLINICAL TRANSPLANTATION Hsu, J. L., Kuschner, W. G., Paik, J., Bower, N., Guillamet, M. C., Kothary, N. 2012; 26 (4): 615-621

  Abstract

  Despite the widespread use of computed tomography(CT)-guided percutaneous lung biopsy (PLB) in immunocompetent patients, the diagnostic yield and safety in solid organ transplant (SOT)recipients is unknown. The purpose of this investigation was to determine the test performance of CT-PLB in SOT recipients.We performed a 10-yr single-center, retrospective analysis among heart, lung, kidney, and liver transplant recipients. We included all adult patients who underwent a PLB of a parenchymal lung nodule following their transplantation.Within the study period, 1754 SOTs were performed, of which 45 biopsies met study criteria. Overall, the incidence of PLB in SOT was 3%.PLB established a diagnosis in 24 of 45 cases. The yield of PLB was better for combined biopsy technique (fine-needle aspiration biopsy [FNAB]) and core biopsy than for FNAB alone (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.2, 15.6), and for lesions that were malignant (OR: 10.0, 95%CI: 1.8, 75.4) or caused by an invasive fungal infection (OR: 5.0, 95% CI:1.1, 27.9). Complications occurred in 13% (6/45) of patients.CT-guided PLB is a safe modality that provides a moderate yield for diagnosing pulmonary nodules of malignant or fungal etiology in SOT recipients.

  View details for DOI 10.1111/j.1399-0012.2011.01582.x

  View details for Web of Science ID 000307344400032

  View details for PubMedID 23050274

  View details for PubMedCentralID PMC3473075

• Complex Retrieval of Embedded IVC Filters: Alternative Techniques and Histologic Tissue Analysis CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Cupp, J. S., Louie, J. D., Kothary, N., Hofmann, L. V., Sze, D. Y., Hovsepian, D. M. 2012; 35 (3): 588-597

  Abstract

  We evaluated the safety and effectiveness of alternative endovascular methods to retrieve embedded optional and permanent filters in order to manage or reduce risk of long-term complications from implantation. Histologic tissue analysis was performed to elucidate the pathologic effects of chronic filter implantation.We studied the safety and effectiveness of alternative endovascular methods for removing embedded inferior vena cava (IVC) filters in 10 consecutive patients over 12 months. Indications for retrieval were symptomatic chronic IVC occlusion, caval and aortic perforation, and/or acute PE (pulmonary embolism) from filter-related thrombus. Retrieval was also performed to reduce risk of complications from long-term filter implantation and to eliminate the need for lifelong anticoagulation. All retrieved specimens were sent for histologic analysis.Retrieval was successful in all 10 patients. Filter types and implantation times were as follows: one Venatech (1,495 days), one Simon-Nitinol (1,485 days), one Optease (300 days), one G2 (416 days), five Günther-Tulip (GTF; mean 606 days, range 154-1,010 days), and one Celect (124 days). There were no procedural complications or adverse events at a mean follow-up of 304 days after removal (range 196-529 days). Histology revealed scant native intima surrounded by a predominance of neointimal hyperplasia and dense fibrosis in all specimens. Histologic evidence of photothermal tissue ablation was confirmed in three laser-treated specimens.Complex retrieval methods can now be used in select patients to safely remove embedded optional and permanent IVC filters previously considered irretrievable. Neointimal hyperplasia and dense fibrosis are the major components that must be separated to achieve successful retrieval of chronic filter implants.

  View details for DOI 10.1007/s00270-011-0175-1

  View details for PubMedID 21562933

• Applying a Structured Innovation Process to Interventional Radiology: A Single-Center Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sista, A. K., Hwang, G. L., Hovsepian, D. M., Sze, D. Y., Kuo, W. T., Kothary, N., Louie, J. D., Yamada, K., Hong, R., Dhanani, R., Brinton, T. J., Krummel, T. M., Makower, J., Yock, P. G., Hofmann, L. V. 2012; 23 (4): 488-494

  Abstract

  To determine the feasibility and efficacy of applying an established innovation process to an active academic interventional radiology (IR) practice.The Stanford Biodesign Medical Technology Innovation Process was used as the innovation template. Over a 4-month period, seven IR faculty and four IR fellow physicians recorded observations. These observations were converted into need statements. One particular need relating to gastrostomy tubes was diligently screened and was the subject of a single formal brainstorming session.Investigators collected 82 observations, 34 by faculty and 48 by fellows. The categories that generated the most observations were enteral feeding (n = 9, 11%), biopsy (n = 8, 10%), chest tubes (n = 6, 7%), chemoembolization and radioembolization (n = 6, 7%), and biliary interventions (n = 5, 6%). The output from the screening on the gastrostomy tube need was a specification sheet that served as a guidance document for the subsequent brainstorming session. The brainstorming session produced 10 concepts under three separate categories.This formalized innovation process generated numerous observations and ultimately 10 concepts to potentially to solve a significant clinical need, suggesting that a structured process can help guide an IR practice interested in medical innovation.

  View details for DOI 10.1016/j.jvir.2011.12.029

  View details for Web of Science ID 000302396300009

  View details for PubMedID 22464713

• Yttrium-90 Radioembolization of Renal Cell Carcinoma Metastatic to the Liver JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Hwang, G. L., Kothary, N., Minor, D. R., Sze, D. Y. 2012; 23 (3): 323-330

  Abstract

  To investigate the safety and efficacy of yttrium-90 ((90)Y) hepatic radioembolization treatment of patients with liver-dominant metastatic renal cell carcinoma (RCC) refractory to immunotherapy and targeted therapies.Between March 2006 and December 2010, six patients with metastatic RCC underwent eight radioembolization treatments with (90)Y-labeled resin microspheres for unresectable liver-dominant metastases. All six patients had previous hepatic tumor progression despite targeted therapies or immunotherapies. All had bilobar disease and required whole-liver treatment. Clinical and biochemical toxicities were recorded, and tumor response was assessed every 2-3 months after treatment by cross-sectional imaging.The median dose delivered was 1.89 Gbq (range 0.41-2.03 Gbq). Grade 1 and 2 toxicities were noted in all patients, primarily fatigue. Follow-up imaging was available for five patients. In follow-up periods from 2-64 months (mean 25 months), three patients showed complete responses, and 1 patient showed a partial response by standard imaging criteria, and these patients are alive at 64 months, 55 months, 17 months, and 7 months after treatment. Two patients with rapid progression of disease died within 2 months of treatment, although hepatic malignancy or failure was not the cause of death in either patient.(90)Y radioembolization is a promising option for liver-dominant metastatic RCC with potential for providing long-term survival in patients refractory to or intolerant of targeted therapies.

  View details for DOI 10.1016/j.jvir.2011.11.007

  View details for PubMedID 22277275

• Percutaneous Cholecystostomy for Acute Cholecystitis: Ten-Year Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Joseph, T., Unver, K., Hwang, G. L., Rosenberg, J., Sze, D. Y., Hashimi, S., Kothary, N., Louie, J. D., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M. 2012; 23 (1): 83-88

  Abstract

  To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

  View details for DOI 10.1016/j.jvir.2011.09.030

  View details for PubMedID 22133709

• Common iliac vein stenosis: a risk factor for oral contraceptive-induced deep vein thrombosis 36th Annual Scientific Meeting of the Society-of-Interventional-Radiology Chan, K. T., Tye, G. A., Popat, R. A., Kuo, W. T., Unver, K., Kothary, N., Sze, D. Y., Hofmann, L. V. MOSBY-ELSEVIER. 2011

  Abstract

  The objective of the study was to determine whether women with significant left common iliac vein stenosis who also use combined oral contraceptives (COCs) have a combined likelihood of deep vein thrombosis (DVT) greater than each independent risk.This was a case-control study comparing 35 women with DVT against 35 age-matched controls. Common iliac vein diameters were measured from computed tomography and magnetic resonance imaging. Logistic regression modeling was used with adjustment for risk factors.DVT was associated with COC use (P = .022) and with increasing degrees of common iliac vein stenosis (P = .004). Compared with women without venous stenosis or COC use, the odds of DVT in women with a 70% venous stenosis who also use COCs was associated with a 17-fold increase (P = .01).Venous stenosis and COC use are independent risk factors for DVT. Women concurrently exposed to both have a multiplicative effect resulting in an increased risk of DVT. We recommend further studies to investigate this effect and its potential clinical implications.

  View details for DOI 10.1016/j.ajog.2011.06.100

  View details for PubMedID 21893308

• Imaging Guidance with C-arm CT: Prospective Evaluation of Its Impact on Patient Radiation Exposure during Transhepatic Arterial Chemoembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Abdelmaksoud, M. H., Tognolini, A., Fahrig, R., Rosenberg, J., Hovsepian, D. M., Ganguly, A., Louie, J. D., Kuo, W. T., Hwang, G. L., Holzer, A., Sze, D. Y., Hofmann, L. V. 2011; 22 (11): 1535-1544

  Abstract

  To prospectively evaluate the impact of C-arm CT on radiation exposure to hepatocellular carcinoma (HCC) patients treated by chemoembolization.Patients with HCC (N = 87) underwent digital subtraction angiography (DSA; control group) or combined C-arm CT/DSA (test group) for chemoembolization. Dose-area product (DAP) and cumulative dose (CD) were measured for guidance and treatment verification. Contrast agent volume and C-arm CT utility were also measured.The marginal DAP increase in the test group was offset by a substantial (50%) decrease in CD from DSA. Use of C-arm CT allowed reduction of DAP and CD from DSA imaging (P = .007 and P = .017). Experienced operators were more efficient in substituting C-arm CT for DSA, resulting in a negligible increase (7.5%) in total DAP for guidance, compared with an increase of 34% for all operators (P = .03). For treatment verification, DAP from C-arm CT exceeded that from DSA, approaching that of conventional CT. The test group used less contrast medium (P = .001), and C-arm CT provided critical or supplemental information in 20% and 17% of patients, respectively.Routine use of C-arm CT can increase stochastic risk (DAP) but decrease deterministic risk (CD) from DSA. However, the increase in DAP is operator-dependent, thus, with experience, it can be reduced to under 10%. C-arm CT provides information not provided by DSA in 33% of patients, while decreasing the use of iodinated contrast medium. As with all radiation-emitting modalities, C-arm CT should be used judiciously.

  View details for DOI 10.1016/j.jvir.2011.07.008

  View details for PubMedID 21875814

• Embolization of Parasitized Extrahepatic Arteries to Reestablish Intrahepatic Arterial Supply to Tumors before Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M., Sze, D. Y. 2011; 22 (10): 1355-1362

  Abstract

  To perform embolization of parasitized extrahepatic arteries (EHAs) before radioembolization to reestablish intrahepatic arterial supply to large, peripheral tumors, and to evaluate the technical and clinical outcomes of this intervention.Among 201 patients retrospectively analyzed, embolization of 73 parasitized EHAs in 35 patients was performed. Most embolization procedures were performed during preparatory angiography using large particles and coils. Digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy were used to evaluate the immediate perfusion via intrahepatic collateral channels of target tumor areas previously supplied by parasitized EHAs. Follow-up imaging of differential regional tumor response was used to evaluate microsphere distribution and clinical outcome.After embolization, reestablishment of intrahepatic arterial supply was confirmed by both DSA and C-arm CT in 94% of territories and by scintigraphy in 96%. In 32% of patients, the differential response of treatment could not be evaluated because of uniform disease progression. However, symmetric regional tumor response in 94% of evaluable patients indicated successful delivery of microspheres to the territories previously supplied by parasitized EHAs.Reestablishment of intrahepatic arterial inflow to hepatic tumors by embolization of parasitized EHAs is safe and effective and results in successful delivery of yttrium-90 microspheres to tumors previously perfused by parasitized EHAs.

  View details for DOI 10.1016/j.jvir.2011.06.007

  View details for PubMedID 21961979

• In Vitro Design and Characterization of the Nonviral Gene Delivery Vector lopamidol, Protamine, Ethiodized Oil Reagent JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Higgins, L. J., Hwang, G. L., Rosenberg, J., Katzenberg, R. H., Kothary, N., Sze, D. Y., Hofmann, L. V. 2011; 22 (10): 1457-1463

  Abstract

  To demonstrate cellular selectivity toward hepatoma cells and compare the efficiency of gene delivery of a novel nonviral vector of iopamidol, protamine, and ethiodized oil reagents (VIPER).Rat hepatocellular carcinoma (HCC) cells were transfected in triplicate under varying conditions by using firefly luciferase as a reporter gene. Conditions included variations of a protamine:DNA (P:D) complex (20:1, 50:1, 100:1, 200:1 mass ratios), iopamidol (0%, 10%, 33%), and ethiodized oil (0%, 1%, 2%, 4%, 8%, and 16%). The conditions affording efficient gene transfer and ease of translation to in vivo studies were selected for cell line comparison (HCC cells vs hepatocytes). Adenoviral transduction was compared with nonviral vector transfection.At low concentrations, ethiodized oil increased transfection efficiency regardless of P:D mass ratio. However, high concentrations resulted in significant attenuation. Unexpectedly, the addition of iopamidol to P:D complexes markedly improved transfection efficiency. When using an optimal P:D, iopamidol, and ethiodized oil solution, DNA transfection of normal liver and tumor cells showed significant selectivity for tumor cells. In the context of hepatoma cells, transfection efficiency with the nonviral vector was better than 10(4) pfu adenovirus.The development and characterization of the VIPER system provides a possible alternative to viral gene therapy of HCC.

  View details for DOI 10.1016/j.jvir.2011.06.025

  View details for PubMedID 21856173

• Consolidation of Hepatic Arterial Inflow by Embolization of Variant Hepatic Arteries in Preparation for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M., Sze, D. Y. 2011; 22 (10): 1364-1372

  Abstract

  Before yttrium-90 ((90)Y) radioembolization administration, the authors consolidated arterial inflow by embolizing variant hepatic arteries (HAs) to make microsphere delivery simpler and safer. The present study reviews the technical and clinical success of these consolidation procedures.Preparatory and treatment angiograms were retrospectively analyzed for 201 patients. Variant HAs were coil-embolized during preparatory angiography to simplify arterial anatomy. Collateral arterial perfusion of territories previously supplied by variant HAs was evaluated by digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) scintigraphy, and by follow-up evaluation of regional tumor response.A total of 47 variant HAs were embolized in 43 patients. After embolization of variant HAs, cross-perfusion into the embolized territory was depicted by DSA and by C-arm CT in 100% of patients and by (99m)Tc-MAA scintigraphy in 92.7%. Uniform progressive disease prevented evaluation in 33% of patients, but regional tumor response in patients who responded supported successful delivery of microspheres to the embolized territories in 95.5% of evaluable patients.Embolization of variant HAs for consolidation of hepatic supply in preparation for (90)Y radioembolization promotes treatment of affected territories via intrahepatic collateral channels.

  View details for DOI 10.1016/j.jvir.2011.06.014

  View details for PubMedID 21961981

• HIGH RETENTION AND SAFETY OF PERCUTANEOUSLY IMPLANTED ENDOVASCULAR EMBOLIZATION COILS AS FIDUCIAL MARKERS FOR IMAGE-GUIDED STEREOTACTIC ABLATIVE RADIOTHERAPY OF PULMONARY TUMORS INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Hong, J. C., Yu, Y., Rao, A. K., Ditererich, S., Maxim, P. G., Le, Q., Diehn, M., Sze, D. Y., Kothary, N., Loo, B. W. 2011; 81 (1): 85-90

  Abstract

  To compare the retention rates of two types of implanted fiducial markers for stereotactic ablative radiotherapy (SABR) of pulmonary tumors, smooth cylindrical gold "seed" markers ("seeds") and platinum endovascular embolization coils ("coils"), and to compare the complication rates associated with the respective implantation procedures.We retrospectively analyzed the retention of percutaneously implanted markers in 54 consecutive patients between January 2004 and June 2009. A total of 270 markers (129 seeds, 141 coils) were implanted in or around 60 pulmonary tumors over 59 procedures. Markers were implanted using a percutaneous approach under computed tomography (CT) guidance. Postimplantation and follow-up imaging studies were analyzed to score marker retention relative to the number of markers implanted. Markers remaining near the tumor were scored as retained. Markers in a distant location (e.g., pleural space) were scored as lost. CT imaging artifacts near markers were quantified on radiation therapy planning scans.Immediately after implantation, 140 of 141 coils (99.3%) were retained, compared to 110 of 129 seeds (85.3%); the difference was highly significant (p<0.0001). Of the total number of lost markers, 45% were reported lost during implantation, but 55% were lost immediately afterwards. No additional markers were lost on longer-term follow-up. Implanted lesions were peripherally located for both seeds (mean distance, 0.33 cm from pleural surface) and coils (0.34 cm) (p=0.96). Incidences of all pneumothorax (including asymptomatic) and pneumothorax requiring chest tube placement were lower in implantation of coils (23% and 3%, respectively) vs. seeds (54% and 29%, respectively; p=0.02 and 0.01). The degree of CT artifact was similar between marker types.Retention of CT-guided percutaneously implanted coils is significantly better than that of seed markers. Furthermore, implanting coils is at least as safe as implanting seeds. Using coils should permit implantation of fewer markers and require fewer repeat implantation procedures owing to lost markers.

  View details for DOI 10.1016/j.ijrobp.2010.04.037

  View details for PubMedID 20675070

• Photothermal Ablation with the Excimer Laser Sheath Technique for Embedded Inferior Vena Cava Filter Removal: Initial Results from a Prospective Study JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Odegaard, J. I., Louie, J. D., Sze, D. Y., Unver, K., Kothary, N., Rosenberg, J. K., Hovsepian, D. M., Hwang, G. L., Hofmann, L. V. 2011; 22 (6): 813-823

  Abstract

  To evaluate the safety and effectiveness of the excimer laser sheath technique for removing embedded inferior vena cava (IVC) filters.Over 12 months, 25 consecutive patients undergoing attempted IVC filter retrieval with a laser-assisted sheath technique were prospectively enrolled into an institutional review board-approved study registry. There were 10 men and 15 women (mean age 50 years, range 20-76 years); 18 (72%) of 25 patients were referred from an outside hospital. Indications for retrieval included symptomatic filter-related acute caval thrombosis (with or without acute pulmonary embolism), chronic IVC occlusion, and bowel penetration. Retrieval was also performed to remove risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After failure of standard methods, controlled photothermal ablation of filter-adherent tissue with a Spectranetics laser sheath and CVX-300 laser system was performed. All patients were evaluated with cavography, and specimens were sent for histologic analysis.Laser-assisted retrieval was successful in 24 (96%) of 25 patients as follows: 11 Günther Tulip (mean 375 days, range 127-882 days), 4 Celect (mean 387 days, range 332-440 days), 2 Option (mean 215 days, range 100-330 days), 4 OPTEASE (mean 387 days, range 71-749 days; 1 failed 188 days), 2 TRAPEASE (mean 871 days, range 187-1,555 days), and 2 Greenfield (mean 12.8 years, range 7.2-18.3 years). There was one (4%) major complication (acute thrombus, treated with thrombolysis), three (12%) minor complications (small extravasation, self-limited), and one adverse event (coagulopathic retroperitoneal hemorrhage) at follow-up (mean 126 days, range 13-302 days). Photothermal ablation of filter-adherent tissue was histologically confirmed in 23 (92%) of 25 patients.The laser-assisted sheath technique appears to be a safe and effective tool for retrieving embedded IVC filters, including permanent types, with implantation ranging from months to > 18 years.

  View details for DOI 10.1016/j.jvir.2011.01.459

  View details for PubMedID 21530309

• Educational Course Therapy: Implanted Target Surrogates for Radiation Treatment Verification Wang, Z., Kothary, N. WILEY. 2011: 3791-+

  View details for DOI 10.1118/1.3613266

  View details for Web of Science ID 000411570300002

• Common Iliac Vein Stenosis and Risk of Symptomatic Pulmonary Embolism: An Inverse Correlation JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Chan, K. T., Popat, R. A., Sze, D. Y., Kuo, W. T., Kothary, N., Louie, J. D., Hovsepian, D. M., Hwang, G. L., Hofmann, L. V. 2011; 22 (2): 133-141

  Abstract

  To test the hypothesis that a common iliac vein (CIV) stenosis may impair embolization of a large deep venous thrombosis (DVT) to the lungs, decreasing the incidence of a symptomatic pulmonary embolism (PE).Between January 2002 and August 2007, 75 patients diagnosed with unilateral DVT were included in a single-institution case-control study. Minimum CIV diameters were measured 1 cm below the inferior vena cava (IVC) bifurcation on computed tomography (CT) images. A significant stenosis in the CIV ipsilateral to the DVT was defined as having either a diameter 4 mm or less or a greater than 70% reduction in lumen diameter. A symptomatic PE was defined as having symptoms and imaging findings consistent with a PE. The odds of symptomatic PE versus CIV stenosis were assessed using logistic regression models. The associations between thrombus location, stenosis, and symptomatic PE were assessed using a stratified analysis.Of 75 subjects, 49 (65%) presented with symptomatic PE. There were 17 (23%) subjects with a venous lumen 4 mm or less and 12 (16%) subjects with a greater than 70% stenosis. CIV stenosis of 4 mm or less resulted in a decreased odds of a symptomatic PE compared with a lumen greater than 4 mm (odds ratio [OR] 0.17, P = .011), whereas a greater than 70% stenosis increased the odds of DVT involving the CIV (OR 7.1, P = .047).Among patients with unilateral DVT, those with an ipsilateral CIV lumen of 4 mm or less have an 83% lower risk of developing symptomatic PE compared with patients with a CIV lumen greater than 4 mm.

  View details for DOI 10.1016/j.jvir.2010.10.009

  View details for PubMedID 21276911

• C-arm Computed Tomography for Hepatic Interventions: A Practical Guide JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Tognolini, A., Louie, J., Hwang, G., Hofmann, L., Sze, D., Kothary, N. 2010; 21 (12): 1817-1823

  Abstract

  With adoption of catheter-based techniques that require technically difficult catheterization, the need for imaging platforms that exploit the advantages of multiple modalities and offer three-dimensional visualization has correspondingly increased. At the authors' institution, C-arm computed tomography (CT) is routinely used to complement conventional digital subtraction angiography for transcatheter therapy. The goal of the present report is to share experience with the use of C-arm CT in hepatic interventions, with the aim to provide practical tips for optimizing image acquisition and postprocessing. Although the authors' direct experience is limited to the equipment of a single manufacturer, many of the principles and guidelines can be readily extrapolated to other C-arm CT systems.

  View details for DOI 10.1016/j.jvir.2010.07.027

  View details for PubMedID 20970354

• Renewing Focus on Resident Education: Increased Responsibility and Ownership in Interventional Radiology Rotations Improves the Educational Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Ghatan, C. E., Hwang, G. L., Kuo, W. T., Louie, J. D., Sze, D. Y., Hovsepian, D. M., Desser, T. S., Hofmann, L. V. 2010; 21 (11): 1697-1702

  Abstract

  To enhance the educational experience among residents rotating through interventional radiology (IR) by encouraging ownership and responsibility.In May 2006, the authors implemented changes in resident education in IR that included increased clinical responsibilities, structured didactics, and greater hands-on experience, including call. Residents were assigned as first assistants, ownership of cases was encouraged, and assignment to a week on the consult service was instituted to help residents better understand all aspects of IR practice. Additional faculty recruitment and program expansion ensured the same high level of training for the fellowship program. Evaluations were reviewed every year (July 1, 2007-June 30, 2009) for hands-on training, daily teaching, didactic conferences, and overall effectiveness of the clinical service. A graduated scale of 1-5 was used.In 2009, 3 years after the curricular changes were made, the quality of hands-on training, daily case reviews and consults, didactics, and overall education had markedly improved with 89%, 71%, 65%, and 82% of the residents rating these respective aspects of the training as "above expectations" (4 on a scale of 5) or "superior" (5 on a scale of 5) compared with 77%, 23%, 20%, and 60% in 2005-2006. Three years after the changes, the impact of these changes on recruitment patterns also showed improvement, with 28.6% of the class of 2010 pursuing a fellowship in IR.Increasing resident ownership, responsibility, and hands-on experience improves resident education in IR, which, in turn, promotes interest in the field.

  View details for DOI 10.1016/j.jvir.2010.07.009

  View details for PubMedID 20884234

• Development of New Hepaticoenteric Collateral Pathways after Hepatic Arterial Skeletonization in Preparation for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Hwang, G. L., Louie, J. D., Kothary, N., Hofmann, L. V., Kuo, W. T., Hovsepian, D. M., Sze, D. Y. 2010; 21 (9): 1385-1395

  Abstract

  Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization.One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization.Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038).Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.

  View details for DOI 10.1016/j.jvir.2010.04.030

  View details for PubMedID 20688531

• Computed Tomography-Guided Percutaneous Needle Biopsy of Indeterminate Pulmonary Pathology: Efficacy of Obtaining a Diagnostic Sample in Immunocompetent and Immunocompromised Patients CLINICAL LUNG CANCER Kothary, N., Bartos, J. A., Hwang, G. L., Dua, R., Kuo, W. T., Hofmann, L. V. 2010; 11 (4): 251-256

  Abstract

  We aimed to evaluate the efficacy of computed tomography (CT)-guided percutaneous lung biopsy of pulmonary nodules with indeterminate radiologic characteristics in patients at risk for malignant and nonmalignant processes such as infection or inflammation.From January 2003 to September 2008, 262 patients (mean age, 59 years; range, 18-92 years) with pulmonary nodules or a mass of uncertain etiology and with indeterminate radiologic characteristics underwent CT-guided percutaneous lung biopsy. Patients with discordant clinical history and imaging findings or immunocompromised patients at risk for both etiologies were included. Specimens were submitted for both cytology and microbiology.Of the entire cohort, 166 patients (63.4%) had a nonmalignant process, and 96 patients (36.6%) had a malignancy. CT-guided percutaneous lung biopsy established a diagnosis in 166 patients (63.4%). Of the 166 patients with a nonmalignant etiology and 96 patients with malignancy, it provided a definitive diagnosis in 91 patients (54.8%) and 75 patients (78.1%), respectively, a difference that was statistically significant (P = .0001). Overall diagnostic efficacy between immunocompetent and immunocompromised patients was comparable (P = .2); however, detection of infection or inflammation in individual groups was lower compared with detection of malignancy (P = .002 and P = .06, respectively).CT-guided percutaneous lung biopsy in patients who are clinically at risk for both nonmalignant and malignant processes continues to be a challenge. Although CT-guided percutaneous biopsy can establish an accurate diagnosis in a large majority of patients with malignancy, it is significantly less sensitive for infectious or inflammatory processes.

  View details for DOI 10.3816/CLC.2010.n.032

  View details for PubMedID 20630827

• Alternatives to Surgery for Early Stage Non-Small Cell Lung Cancer-Ready for Prime Time? CURRENT TREATMENT OPTIONS IN ONCOLOGY Das, M., Abdelmaksoud, M. H., Loo, B. W., Kothary, N. 2010; 11 (1-2): 24-35

  Abstract

  Surgery is the standard of care for early stage non-small cell lung cancer (NSCLC), with lobectomy being the most oncologically sound resection. Medically inoperable patients and high-risk surgical candidates require effective alternatives to surgery; even operable patients may opt for less invasive options if they are proven to achieve similar outcomes to surgery. Minimally invasive local treatment modalities including dose-intensified conformal radiation therapy, most notably stereotactic ablative radiotherapy (SABR; also known as stereotactic body radiation therapy), and thermal ablation methods such as radiofrequency ablation (RFA) and microwave ablation (MWA) are emerging as promising treatment options whose roles in the treatment of early stage lung cancer are being defined. Early clinical experience and a rapidly growing body of prospective clinical trials, primarily in medically inoperable patients, are demonstrating encouraging effectiveness and safety outcomes in some cases approaching historical results with surgery. Given the very poor prognosis of the medically inoperable patient population, these alternatives to surgery, particularly SABR, are starting to be considered appropriate first-line therapy in properly selected patients, and prospective cooperative group trials to evaluate and optimize RFA and SABR in specific patient subsets are being conducted. For operable patients, prospective multi-center and cooperative groups trials of SABR are ongoing or completed, and international randomized trials of SABR vs. surgery have been initiated. Thus, promising alternatives to surgery for early stage NSCLC are ready for prime time evaluation in the setting of clinical trials, and participation in ongoing trials for both operable and medically inoperable patients is strongly encouraged.

  View details for DOI 10.1007/s11864-010-0119-z

  View details for PubMedID 20577833

• Dose and Image Quality in C-Arm CT Rotational Angiography Fahrig, R., Girard-Hughes, E., Ganguly, A., Tognolini, A., Kothary, N. WILEY. 2010: 3413-3414

  View details for DOI 10.1118/1.3469339

  View details for Web of Science ID 000411472300039

• Making the Case for Early Medical Student Education in Interventional Radiology: A Survey of 2nd-year Students in a Single US Institution JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ghatan, C. E., Kuo, W. T., Hofmann, L. V., Kothary, N. 2010; 21 (4): 549-553

  Abstract

  To examine perceptions of interventional radiology (IR) among a group of second-year medical students and support the case for early exposure to the field in order to increase visibility and, ultimately, recruitment to this specialty.Sixty-five members of the class of 2011 from a single U.S. institution were anonymously surveyed about their opinions on IR before and after a 1-hour case-based introductory lecture.Sixty-four students completed the survey in its entirety. Perception about what IR entails varied, with 52% of the students aware of IR involvement in major and potentially life-saving procedures; however, 34% believed that an interventional radiologist primarily performed "minor" procedures or "read films." Previous interaction with interventional radiologists was uncommon. Following the single, case-based introductory IR lecture, 74% of the class was eager to learn more about the specialty, with 22% interested in enrolling in a dedicated hands-on elective in IR. The perception and impression of what IR entails changed significantly for the better for 75% of the students. Before the lecture, 19% were considering IR as a career (first or second choice); this increased to 33% after the introductory lecture.Although medical students are aware of IR, their exposure and understanding is limited. They are keen to learn more when exposed to it. Reaching out to the medical students early in their career may help in recruiting talent and securing the specialty's growth.

  View details for DOI 10.1016/j.jvir.2009.12.397

  View details for Web of Science ID 000276663700019

  View details for PubMedID 20189831

• Utility of C-arm CT in Patients with Hepatocellular Carcinoma undergoing Transhepatic Arterial Chemoembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Tognolini, A., Louie, J. D., Hwang, G. L., Hofmann, L. V., Sze, D. Y., Kothary, N. 2010; 21 (3): 339-347

  Abstract

  To evaluate the utility of C-arm computed tomography (CT) on treatment algorithms in patients undergoing transhepatic arterial chemoembolization for hepatocellular carcinoma (HCC).From March 2008 to July 2008, 84 consecutive patients with HCC underwent 100 consecutive transhepatic arterial chemoembolizations with iodized oil. Unenhanced and iodinated contrast medium-enhanced C-arm CT with planar and three-dimensional imaging were performed in addition to conventional digital subtraction angiography (DSA) in all patients. The effect on diagnosis and treatment was determined by testing the hypotheses that C-arm CT, in comparison to DSA, provides (a) improved lesion detection, (b) expedient identification and mapping of arterial supply to a tumor, (c) improved characterization of a lesion to allow confident differentiation of HCC from pseudolesions such as arterioportal shunts, and (d) an improved evaluation of treatment completeness. The effect of C-arm CT was analyzed on the basis of information provided with C-arm CT that was not provided or readily apparent at DSA.C-arm CT was technically successful in 93 of the 100 procedures (93%). C-arm CT provided information not apparent or discernible at DSA in 30 of the 84 patients (36%) and resulted in a change in diagnosis, treatment planning, or treatment delivery in 24 (28%). The additional information included, amongst others, visualization of additional or angiographically occult tumors in 13 of the 84 patients (15%) and identification of incomplete treatment in six (7.1%).C-arm CT is a useful collaborative tool in patients undergoing transhepatic arterial chemoembolization and can affect patient care in more than one-fourth of patients.

  View details for DOI 10.1016/j.jvir.2009.11.007

  View details for PubMedID 20133156

• Computed Tomography-Guided Percutaneous Needle Biopsy of Pulmonary Nodules: Impact of Nodule Size on Diagnostic Accuracy CLINICAL LUNG CANCER Kothary, N., Lock, L., Sze, D. Y., Hofmann, L. V. 2009; 10 (5): 360-363

  Abstract

  This study was undertaken to compare the diagnostic accuracy and complication rate of computed tomography (CT)-guided percutaneous lung biopsies of lung nodules1.5 cm in diameter.A total of 139 patients (age range, 18-89 years; mean, 62.5 years) underwent CT-guided percutaneous fine-needle aspiration biopsy or 20-gauge core biopsy using an automated biopsy gun. In 37 patients, the lung nodule measured 1.5 cm (mean, 2.8 cm). Diagnostic accuracy was determined by cytopathology results. Major and minor complications were documented.Overall diagnostic accuracy, pneumothorax rate, and thoracostomy tube insertion rates were 67.6%, 34.5%, and 5%, respectively. Of the 98 patients with malignancy, 77 patients (78.6%) had a definite diagnostic biopsy. Overall, nodules>1.5 cm were statistically more likely to result in a diagnostic specimen (73.5%) than nodules1.5 cm than in those1.5 cm. However, the diagnostic accuracy for malignancy is high in both groups, with a low risk of complications.

  View details for DOI 10.3816/CLC.2009.n.049

  View details for PubMedID 19808195

• A Primer on Image-guided Radiation Therapy for the Interventional Radiologist JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Dieterich, S., Louie, J. D., Koong, A. C., Hofmann, L. V., Sze, D. Y. 2009; 20 (7): 859-862

  Abstract

  The use of image-guided radiation therapy in thoracic and abdominal tumors is increasing. Herein, the authors review the process of image-guided radiation therapy and describe techniques useful for optimal implantation of fiducial markers.

  View details for DOI 10.1016/j.jvir.2009.03.037

  View details for PubMedID 19481470

• Incorporating Cone-beam CT into the Treatment Planning for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Louie, J. D., Kothary, N., Kuo, W. T., Hwang, G. L., Hofmann, L. V., Goris, M. L., Iagaru, A. H., Sze, D. Y. 2009; 20 (5): 606-613

  Abstract

  To prepare for yttrium-90 ((90)Y) microsphere radioembolization therapy, digital subtraction angiography (DSA) and technetium- 99m-labeled macroaggregated albumin ((99m)Tc MAA) scintigraphy are used for treatment planning and detection of potential nontarget embolization. The present study was performed to determine if cone-beam computed tomography (CBCT) affects treatment planning as an adjunct to these conventional imaging modalities.From March 2007 to August 2008, 42 consecutive patients (21 men, 21 women; mean age, 59 years; range, 21-75 y) who underwent radioembolization were evaluated by CBCT in addition to DSA and (99m)Tc MAA scintigraphy during treatment planning, and their records were retrospectively reviewed. The contrast-enhanced territories shown by CBCT with selective intraarterial contrast agent administration were used to predict intrahepatic and possible extrahepatic distribution of microspheres.In 22 of 42 cases (52%), extrahepatic enhancement or incomplete tumor perfusion seen on CBCT affected the treatment plan. In 14 patients (33%), the findings were evident exclusively on CBCT and not detected by DSA. When comparing CBCT versus (99m)Tc MAA scintigraphy, CBCT showed eight cases of extrahepatic enhancement (19%) that were not evident on (99m)Tc MAA imaging. CBCT findings directed the additional embolization of vessels or repositioning of the catheter for better contrast agent and microsphere distribution. One case of gastric ulcer from nontarget embolization caused by reader error was observed.CBCT can provide additional information about tumor and tissue perfusion not currently detectable by DSA or (99m)Tc MAA imaging, which should optimize (90)Y microsphere delivery and reduce nontarget embolization.

  View details for DOI 10.1016/j.jvir.2009.01.021

  View details for PubMedID 19345589

• Percutaneous Implantation of Fiducial Markers for Imaging-Guided Radiation Therapy AMERICAN JOURNAL OF ROENTGENOLOGY Kothary, N., Dieterich, S., Louie, J. D., Chang, D. T., Hofmann, L. V., Sze, D. Y. 2009; 192 (4): 1090-1096

  Abstract

  The use of imaging-guided radiation therapy (IGRT) to treat thoracic and abdominal tumors is increasing. In this article, we review the process of IGRT and describe techniques to implant fiducial markers in the optimal geometry.Implantation of fiducial markers can be challenging. A better understanding of the physics of IGRT can help optimize fiducial marker placement for precise tumor targeting.

  View details for DOI 10.2214/AJR.08.1399

  View details for PubMedID 19304719

• Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Heit, J. J., Louie, J. D., Kuo, W. T., Loo, B. W., Koong, A., Chang, D. T., Hovsepian, D., Sze, D. Y., Hofmann, L. V. 2009; 20 (2): 235-239

  Abstract

  To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy.From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation.The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation.Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

  View details for DOI 10.1016/j.jvir.2008.09.026

  View details for PubMedID 19019700

• Radiologic Monitoring of Hepatocellular Carcinoma Tumor Viability after Transhepatic Arterial Chemoembolization: Estimating the Accuracy of Contrast-enhanced Cross-sectional Imaging with Histopathologic Correlation JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Hunt, S. J., Yu, W., Weintraub, J., Prince, M. R., Kothary, N. 2009; 20 (1): 30-38

  Abstract

  Cross-sectional diagnostic imaging studies such as contrast-enhanced quadruple-phase helical computed tomography (CT) and contrast-enhanced magnetic resonance (MR) imaging are routinely performed to evaluate tumor response to transhepatic arterial chemoembolization. However, the true correlation between imaging characteristics and histopathologic tumor viability is not known. The aim of the present retrospective study was to determine the sensitivity and specificity of contrast-enhanced CT and contrast-enhanced MR imaging with use of histopathologic analysis.Between February 2002 and October 2005, a total of 31 patients (age, 51-74 years; mean, 60 y) who had undergone chemoembolization underwent follow-up diagnostic cross-sectional imaging before transplantation. The mean time interval between the imaging study and transplantation was 32 days (range, 1-117 d). Imaging studies were assessed for residual or recurrent tumor and were then correlated to the findings of histopathologic analysis performed on the surgical specimens at the time of transplantation.The overall sensitivity and specificity rates of cross-sectional imaging studies were 35% and 64%, respectively. The overall accuracy rate of CT was 43%, with 36% sensitivity and 57% specificity. The overall accuracy rate of MR imaging was 55%, with 43% sensitivity and 75% specificity. Gross macroscopic disease was missed in one patient (9%) who underwent MR imaging and four patients (19%) who underwent CT.Contrast-enhanced CT and MR imaging after chemoembolization are associated with high error rates. Between the two modalities, MR has higher sensitivity and specificity and may be a preferable imaging tool for patients who have undergone chemoembolization.

  View details for DOI 10.1016/j.jvir.2008.09.034

  View details for PubMedID 19028117

• Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis CHEST Kuo, W. T., Van den Bosch, M. A., Hofmann, L. V., Louie, J. D., Kothary, N., Sze, D. Y. 2008; 134 (2): 250-254

  Abstract

  The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE.A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis.Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days).In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.

  View details for DOI 10.1378/chest.07-2846

  View details for PubMedID 18682455

• Complications of ablative therapies in lung cancer CLINICAL LUNG CANCER Padda, S., Kothary, N., Donington, J., Cannon, W., Loo, B. W., Kee, S., Wakelee, H. 2008; 9 (2): 122-126

  Abstract

  Two cases of complications secondary to the use of microwave ablation (MWA) in non-small-cell lung cancer (NSCLC) are discussed herein. The first case involves a 62-year-old man with stage IB NSCLC who declined surgery and pursued MWA. Within 7 months, he had residual disease at the MWA treatment site, and surgery was performed. The patient was found to have pleural and chest wall involvement, making complete resection impossible. The second case involves an 86-year-old woman with a second local recurrence of NSCLC and previous treatment including surgery and chemoradiation therapy. She was initially a surgical candidate but declined surgery and pursued MWA. Within 6 months, she had residual disease at the MWA treatment site. A second MWA was performed, and she developed a large cavitary abscess at the MWA site and had subsequent clinical decline. Less invasive ablation therapies and stereotactic radiosurgery are being developed for patients with inoperable lung cancer. Because these modalities have recently been developed, trials that clearly show efficacy and survival benefit are yet to be completed. Ablation procedures can result in complications, including residual disease and cavitary lesions susceptible to infection. These cases highlight the caution that should still be observed when recommending lung ablation strategies and the importance of selecting appropriate patients.

  View details for PubMedID 18501100

• Transarterial chemoembolization for primary hepatocellular carcinoma in patients at high risk JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Weintraub, J. L., Susman, J., Rundback, J. H. 2007; 18 (12): 1517-1526

  Abstract

  Transarterial chemoembolization (TACE) has become a standard treatment option for patients with unresectable hepatocellular carcinoma (HCC). This retrospective study evaluated the safety and efficacy of TACE in patients at high risk with increased serum bilirubin level, low serum albumin level, poor hepatic reserve, or compromised hepatopetal flow in the portal vein (PV).A total of 52 patients underwent 65 high-risk procedures. Thirty patients treated with 38 procedures (57.7% of patients and 58.5% of procedures) had serum bilirubin levels of 2-3 mg/dL (ie, moderate elevation) and 22 patients treated with 27 procedures (42.3% and 41.5%) had a serum bilirubin level of at least 3 mg/dL (ie, considerable elevation). Forty patients (76.9%) had serum albumin levels less than 3.5 mg/dL. Thirteen recipients of 15 procedures (25% and 20%) had portal diversion or obstruction. Twenty-four patients (46.2%) had a Child-Pugh (CP) score of 8 or less and 28 patients (53.8%) had a CP score of at least 9 at the time of TACE. Thirty patients (57.7%) had focal tumors and 22 patients (42.3%) had multifocal or infiltrative disease. Superselective chemoembolization could be performed in 37 procedures (56.9%); lobar chemoembolization was performed in the remaining 28 (43.1%).The 30-day mortality rate was 7.7% and the procedure-related morbidity rate was 10.8%. Patients with multifocal disease and lobar embolization had significantly higher mortality rates (P=.03). Individual factors such as serum bilirubin, serum albumin, and PV flow did not affect outcomes significantly. The 1- and 2-year survival rates in patients with focal disease were 67.9% and 37.7%, respectively, compared with 19.6% and 0% in patients with multifocal disease (P<.0001).TACE in patients considered at high risk does not necessarily incur a higher incidence of morbidity or mortality. Patient selection should be based on extent of disease, and these tumors should be treated selectively at a segmental level if possible.

  View details for DOI 10.1016/j.jvir.2007.07.035

  View details for PubMedID 18057286

• A novel endovascular adjustable polytetrafluoroethylene-covered stent for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Weintraub, J. L., Mobley, D. G., Weiss, M. E., Swanson, E., Kothary, N. 2007; 18 (4): 563-566

  Abstract

  Transjugular intrahepatic portosystemic shunt (TIPS) is frequently complicated by hepatic encephalopathy. When medical therapy fails, TIPS narrowing and resultant increase in the portosystemic pressure gradient and blood flow to the liver is performed in order to reverse the encephalopathy. We present a method for reducing the TIPS using a polytetrafluoroethylene-covered balloon expandable stent placed over a self-expanding stent. This results in a narrowed TIPS that not only rapidly increases the portosystemic gradient but also can be adjusted by dilating the balloon expandable stent. This method was successful in narrowing the patient's TIPS, acutely increasing the portosystemic gradient and reversing the hepatic encephalopathy.

  View details for DOI 10.1016/j.jvir.2007.02.004

  View details for Web of Science ID 000246008400012

  View details for PubMedID 17446548

• Re: Renal angiomyolipoma - Long-term results after arterial embolization - Response JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Soulen, M. C., Stavropoulos, S. W. 2005; 16 (8): 1154

  View details for DOI 10.1097/01.RVI.0000167798.10986.6A

  View details for Web of Science ID 000231292900018

• Heparin in interventional radiology: a therapy in evolution. Seminars in interventional radiology Resnick, S. B., Resnick, S. H., Weintraub, J. L., Kothary, N. 2005; 22 (2): 95-107

  Abstract

  Interventional radiology techniques made possible by the antithrombotic properties of heparin have revolutionized treatment for a myriad of disorders. Newer low-molecular-weight heparins (LMWHs) offer several advantages over unfractionated heparin (UFH), especially in chronic settings. They are increasing in popularity for use during vascular procedures. However, LMWH shares limitations with UFH such as heterogeneity, nonspecificity, and induction of thrombocytopenia. These drawbacks have led to a search for the next generation of antithrombotic agents. Homogeneous drugs targeting specific coagulation cascade molecules are now available. The number of alternative anticoagulant drug combinations presents clinicians with a confusing array of choices. The strengths and weaknesses of UFH, LMWH, and direct antithrombin agents are presented. The promising future of LMWH and hirudins is discussed.

  View details for DOI 10.1055/s-2005-871864

  View details for PubMedID 21326679

• Renal angiomyolipoma: Long-term results after arterial embolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Soulen, M. C., Clark, T. W., WEIN, A. J., Shlansky-Goldberg, R. D., Crino, P. B., Stavropoulos, S. W. 2005; 16 (1): 45-50

  Abstract

  Selective arterial embolization of renal angiomyolipomas (AMLs) was performed to prevent hemorrhage in patients with AMLs larger than 4 cm. This study was conducted to evaluate the long-term efficacy of AML embolization.Nineteen patients underwent embolization for 30 renal AMLs between July 1991 and June 2002. Of these, 10 patients had tuberous sclerosis (TS) with multiple AMLs and nine patients had a solitary sporadic AML. Embolization was performed with use of ethanol mixed with iodized oil (Ethiodol) in 29 tumors; coils were used in addition to the ethanol/Ethiodol mixture in one case. All tumors were completely embolized according to angiographic criteria including vascular stasis and absence of arterial feeders. The efficacy of embolization was determined over a mean follow-up period of 51.5 months (range, 6-132 months). Recurrence was defined as an increase in tumor size of greater than 2 cm on follow-up imaging and/or recurrent symptoms that required repeat embolization. An institutional review board exemption was obtained to perform this retrospective study.Embolization of the renal AMLs was technically successful in all 19 patients and for all 30 lesions. AML recurrence was noted in 31.6% of patients (n = 19) and for 30% of lesions overall (n = 9). Six of 10 patients in the TS group had AML recurrences. No recurrences occurred in the patients with sporadic AML. In the TS group of 10 patients, there was a total of 21 AMLs and the overall tumor recurrence rate was 42.9% (nine of 21). Six lesions in four patients had to be reembolized because of recurrent symptoms, including one hemorrhage, and three lesions in two patients required repeat embolization because of a greater than 2 cm increase in size. The median time interval from embolization to recurrence was 78.7 months (range, 13-132 months). Statistical testing with use of the Fisher exact test demonstrated that patients with TS were significantly more likely to develop recurrence than those without TS (P = .01).Transarterial embolization is effective in preventing hemorrhage in patients with renal AMLs. However, long-term follow-up revealed a high AML recurrence rate in patients with TS. Lifelong surveillance for recurrence after AML embolization is essential in patients with TS.

  View details for DOI 10.1079/01.RVI.0000143769.79774.70

  View details for Web of Science ID 000227679100008

  View details for PubMedID 15640409

• Interventional radiology: management of biliary complications of liver transplantation. Seminars in interventional radiology Kothary, N., Patel, A. A., Shlansky-Goldberg, R. D. 2004; 21 (4): 297-308

  Abstract

  Major advances in the field of liver transplantation have led to an increase in both graft and patient survival rates. Despite increased graft survival rate, biliary complications lead to significant postoperative morbidity and even mortality. A multidisciplinary approach to these complications is critical. As part of the team approach, less invasive techniques used by the interventional radiologist have an increasing role in the management of complications after liver transplantation. This paper will review the current role of the interventionalist in management of biliary complications.

  View details for DOI 10.1055/s-2004-861564

  View details for PubMedID 21331141

• Conventional and perfusion MR imaging of parafalcine chondrosarcoma AMERICAN JOURNAL OF NEURORADIOLOGY Kothary, N., Law, M., Cha, S., Zagzag, D. 2003; 24 (2): 245-248

  Abstract

  Intracranial chondrosarcomas have a predilection for the skull base, for which CT and MR imaging findings have been described. We present a rare case of primary chondrosarcoma arising from the falx in a young woman with no history of radiation. The CT, conventional MR imaging, perfusion MR imaging, and digital subtraction angiography findings are described.

  View details for Web of Science ID 000186306800015

  View details for PubMedID 12591641

  View details for PubMedCentralID PMC7974122

• Strongyloides stercoralis hyperinfection RADIOGRAPHICS Kothary, N. N., Muskie, J. M., Mathur, S. C. 1999; 19 (4): 1077-1081

  View details for DOI 10.1148/radiographics.19.4.g99jl171077

  View details for Web of Science ID 000081364000026

  View details for PubMedID 10464810