American Journal of Interventional Radiology

1-5

Authors: Thomas Pieters

Using intravenous tissue plasminogen activator (IV tPA), improved functional outcomes are seen with earlier initiation of treatment. Recent studies have shown endovascular revascularization to be a revolutionary and effective treatment. There have been many initiatives focused on improving public education and awareness of stroke symptoms. The concept of a mobile stroke unit (MSU) was created as a way of bringing treatment to patients. Earlier CT scans, delivery of tPA, proper triage and on-scene goal-directed care were the primary goals with these units. It was thought that rapid implementation would shorten hospital stay and improve outcomes. The University of Saarland found a decrease of 41 minutes from stroke alarm to therapeutic decision when an MSU was used. A second trial found a decrease of 25 minutes in time to treatment, an increase in the rate of thrombolysis utilization, and no change in the rates of intracranial hemorrhage or 7-day mortality when an MSU was employed. In 2016, a Lancet article showed that 3 month modified Rankin Scale (mRS) and 3-month mortality were improved in MSU patients. Finally, starting thrombolytic therapy in the MSU was associated with higher probability of mRS of 0-3 but not an improved 3-month survival rate. Long-term results are thus far not available precluding an effective cost-benefit analysis. Many study results are not generalizable as they compare a single hospital system and specialized MSU team to conventional care delivered by a multiple healthcare systems. Future studies will target these limitations.

1-12

Authors: Robert Elliott

Hepatocellular carcinoma (HCC) is an aggressive primary liver cancer that arises in a background of hepatic cirrhosis. In the United States, HCC has been increasing due to an increasing prevalence of the Hepatitis C virus which causes cirrhosis. Curative treatment of HCC is indicated when tumors are small and may include surgical resection, liver transplant, or radiofrequency ablation. Locoregional treatment includes transarterial chemoembolization and transarterial radioembolization which can be used as eithera an adjunct to surgical care or as primary therapy. This review article will examine the initial surveillance of patients at risk for HCC, the current guidelines related to diagnosis and staging of HCC, and will conclude with a review of best practices related to the treatment of HCC.

1-2

Authors: Shyamkumar Keshava

1-6

Authors: Shyamkumar N Keshava

Purpose: The purpose of this study was to study the effects of ankle position on Doppler measurements of popliteal artery (PA) and posterior tibial arteries (PTA) in healthy individuals. Materials and Methods: PA and PTAs of 20 healthy (questionnaire based and ankle brachial pressure index assessed) subjects (40 limbs) were studied with Doppler ultrasound in neutral and after active ankle joint movements. Results: The mean increase in the velocity of PA from neutral position was more with plantar flexion as compared to dorsiflexion (22 vs. 15 cm/s, respectively). PA showed a significant change in waveform, with the absence of diastolic flow, more with dorsiflexion than plantar flexion (46% and 33%, respectively). Similarly, mean increase in the velocity of PTA was more with plantar flexion as compared to dorsiflexion (mean 36.7 vs. 33.2 cm/s, respectively). PTA showed a significant change from triphasic to biphasic and monophasic on plantar flexion (up to 39.2%). Dorsiflexion also showed similar results, however, to a lesser degree. None of the PA or PTA showed complete absence of flow on these maneuvers. Conclusion: Predominantly, a pattern of increase is seen in the mean velocity on plantar flexion and dorsiflexion in both the arteries. The most common change in the Doppler waveforms was the absence of diastolic flow (biphasic pattern). Our study confirms that waveforms in the popliteal and PTA can even be monophasic depending on the position of the foot in normal healthy individuals, therefore, when biphasic/monophasic in appearance, they should not be interpreted as abnormal or diseased.

1-4

Authors: Scott P Patterson

This case report describes the chemoembolization of a small hepatocellular carcinoma employing a lipiodol drug delivery system utilizing a novel arterial pathway. Because the target lesion was precariously located adjacent to the inferior heart border and the diaphragm, it was unsuitable for imaging-guided microwave ablation. To achieve chemoembolization, several intraprocedural adaptations were necessary, given the variant anatomy encountered and difficulty accessing the left gastric artery through a celiac artery approach. The left gastric artery was selected from a superior mesenteric artery approach through the pancreaticoduodenal arcade (Rio Branco's arcade). This case illustrates the importance of a mastery of the vascular anatomy and variants of hepatic arterial flow.