Hicham Kobeiter

Purpose: To describe the outcomes of a survey conducted among CIRSE members on endovascular aortic repair and to outline the future practice and needs of CIRSE members in this area. Materials and methods: An anonymous online survey with 21 questions was designed by the authors and sent to CIRSE members worldwide; data were collected for 12 weeks. Results: The survey collected 326 complete responses, with most respondents practicing in Europe. Two-thirds of respondents indicated that aortic repair is performed by multidisciplinary teams including IRs, with more than half reporting that they are equal partners in performing the procedure, and 27% acting as primary operators. In their practice, the most frequently performed endovascular aortic procedures were EVAR and embolisation of endoleaks, followed by FEVAR and TEVAR. A majority of 64% of respondents predict a growth in their endovascular aortic practice in the next 5 to 10 years that could further be supported by training, an increase in the workforce, societal guidelines, and additional qualifications. Hindrances for growth include turf competition as well as hospital management decisions. Conclusion: The survey indicates that Interventional Radiologists continue to play a significant role in endovascular aortic procedures and identifies challenges and opportunities to further increase the role of IR in endovascular aortic aneurysm procedures for the benefit of patients. The authors consider it essential for national societies as well as CIRSE to facilitate and encourage the clinical role of IRs in standard and complex EVAR to best guide future developments for optimal patient management in aortic disease.

Purpose: To describe the outcomes of a survey on the provision of interventional radiology procedures for the treatment of acute pulmonary embolism (PE) in Europe and beyond. Methods: An online survey with 14 structured items was designed by the authors and was sent to 7116 CIRSE members via email. The anonymous online survey collected data for eight weeks; only complete responses were statistically analysed. Results: The survey was completed by 373 members (5.24%). Among these, 75.1% worked at centres offering catheter-directed thrombolysis or thrombectomy, in which 89.3% (250) personally perform endovascular treatment techniques for pulmonary embolism and the IR department is primarily responsible for the endovascular treatment techniques of PE in 83.2% of cases. The most frequently used endovascular techniques were (large bore) aspiration thrombectomy (85%) and catheter-directed thrombolysis (58.9%). The most common indications for intervention were sub-massive and massive PE (69.9%) and massive PE only (28%). In 70% of centres offering catheter-directed thrombolysis or thrombectomy, three or more Interventional Radiologists (IRs) are involved in PE treatment. Multidisciplinary rapid response teams for PE were available in 40.8% of centres, and included IRs in 91.4%. Conclusion: IRs are heavily involved in the management of patients with massive and sub-massive pulmonary embolism; further research is mandated to address clinical questions including patient selection and the timing for transcatheter therapies of PE provided by IR. Graphical

Background/Objectives: This multicentric study aimed to evaluate the efficacy and safety of prostatic artery embolization (PAE) to remove indwelling urinary catheter (IUC) in patients with symptomatic benign prostatic hyperplasia (BPH). Secondary objectives were to identify features associated with post-PAE catheter-free survival (PCFS). Methods: All consecutive patients who underwent PAE for IUC related to BPH with a follow-up of at least 2 years (except for early death) in 6 French University Hospitals were retrospectively included. Clinical efficacy was defined as the removal of the IUC after PAE (through a trial without catheter [TWOC]) and evaluated at regular intervals. Chi-square tests, Wilcoxon tests and multivariable binary logistic regressions were utilized to investigate predictors of TWOC success. Univariable and multivariable Cox regressions were utilized to investigate predictors of PCFS in patients with TWOC success. Results: 140 men with IUC (median age: 82.5 years, interquartile range [IQR] = 73–88.2 years, range: 46–100) who underwent PAE between January 2017 and March 2021 were included. Initial successful catheter removal (TWOC success) following PAE occurred in 113/140 (80.7%) patients, and 3/140 (2.1%) patients encountered major complications. In patients with TWOC success, PCFS at 6 months, 1 year and 2 years were 87.5% (95%CI: 81.4–94.1), 84.4% (95%CI: 77.7–91.7) and 79% (71.3–87.4), respectively. No independent predictive factors for TWOC success and PCFS were identified. Conclusions: PAE should be considered as a safe option with good clinical efficacy in the short and long term for elderly and inoperable patients with IUC due to symptomatic BPH.

Background and Objective: High-flow pancreaticoduodenal artery (PDA) aneurysms secondary to celiac trunk occlusion or stenosis have a high risk of rupture. Embolization offers a less invasive alternative to surgery. We evaluated the effectiveness and safety of retrograde embolization via the superior mesenteric artery of high-flow PDA aneurysms without celiac trunk revascularization. Methods: This retrospective bicentric study included patients who underwent embolization of high-flow PDA aneurysms due to significant celiac trunk stenosis or occlusion. All patients underwent pre-interventional dynamic contrast-enhanced computed tomography. Retrograde embolization was performed using microcoils and/or liquid agents without celiac trunk revascularization. Follow up involved clinical and radiological assessment at one month. Technical and clinical success were evaluated, and complications were categorized as minor or major. Results: Twenty-three patients (mean age 65 ± 14 years; 52% male) were included. Emergency embolization was required in 12 patients (52%). The technical success rate was 100%. Patients were monitored for a median of 16 months. Clinical success was 87%. No hemorrhagic recurrences were observed. Minor complications occurred in two cases. One major complication involved splenic infarction due to glue migration, requiring splenectomy and intensive unit care admission. Conclusions: Retrograde embolization of high-flow PDA aneurysms is effective and safe without needing celiac trunk revascularization.

Background: High-flow pancreaticoduodenal artery (PDA) aneurysms secondary to celiac trunk occlusion or stenosis have a high risk of rupture. Embolization offers a less invasive alternative to surgery. Objective: To evaluate the effectiveness and safety of retrograde embolization via the superior mesenteric artery of high-flow PDA aneurysms without celiac trunk revascularization. Methods: This retrospective bicentric study included patients who underwent embolization of high-flow PDA aneurysms due to significant celiac trunk stenosis or occlusion. All patients underwent pre-interventional dynamic contrast-enhanced computed tomography. Retrograde embolization was performed using microcoils and/or liquid agents without celiac trunk revascularization. Follow-up involved clinical and radiological assessment at one month. Technical and clinical success were evaluated, and complications were categorized as minor or major. Results: Twenty-three patients (mean age: 65 ±14 years; 52% male) were included. Emergency embolization was required in 12 patients (52%). The technical success rate was 100%. Patients were monitored for a median of 16 months. Clinical success was 87%. No hemorrhagic recurrences were observed. Minor complications occurred in two cases. One major complication involved splenic infarction due to glue migration, requiring splenectomy and intensive unit care admission. Conclusion: Retrograde embolization of high-flow PDA aneurysms is effective and safe without needing celiac trunk revascularization.

Background: Selective internal radiation therapy (SIRT) is recommended as a downstaging (DS) strategy for solitary unresectable HCC p < 0.001). In patients who achieved DS, progression-free survival was higher in patients who underwent surgery: 47 versus 11 months (p < 0.001). Four variables were independently associated with DS: age (OR: 0.96, 95% CI: [0.92, 0.99]; p = 0.032), baseline α-fetoprotein (OR: 1.00, 95% CI: [1.00, 1.00]; p = 0.034), HCC distribution (OR: 0.3, 95% CI: [0.11, 0.75]; p = 0.012), and ALBI grade (OR: 0.34. 95% CI: [0.14, 0.80]; p = 0.014). Conclusions: These results suggest that SIRT in patients with unresectable HCC could be an effective treatment: DS was achieved for around 39% of the patients and more than half of these then underwent curative treatment.

Background: Current guidelines do not indicate any comprehensive management of hepatic hypervascular incidentalomas (HVIs) discovered in hepatocellular carcinoma (HCC) patients during intra-arterial therapies (IATs). This study aims to evaluate the prognostic value of HVIs detected on per-interventional cone beam computed tomography (CBCT) during IAT for HCC in patients waiting for liver transplantation (LT). Material and methods: In this retrospective single-institutional study, all liver-transplanted HCC patients between January 2014 and December 2018 who received transarterial chemoembolization (TACE) or radioembolization (TARE) before LT were included. The number of ≥10 mm HCCs diagnosed on contrast-enhanced pre-interventional imaging (PII) was compared with that detected on per-interventional CBCT with a nonparametric Wilcoxon test. The correlation between the presence of an HVI and histopathological criteria associated with poor prognosis (HPP) on liver explants was investigated using the chi-square test. Tumor recurrence (TR) and TR-related mortality were investigated using the chi-square test. Recurrence-free survival (RFS), TR-related survival (TRRS), and overall survival (OS) were assessed according to the presence of HVI using Kaplan–Meier analysis. Results: Among 63 included patients (average age: 59 ± 7 years, H/F = 50/13), 36 presented HVIs on per-interventional CBCT. The overall nodule detection rate of per-interventional CBCT was superior to that of PII (median at 3 [Q1:2, Q3:5] vs. 2 [Q1:1, Q3:3], respectively, p < 0.001). No significant correlation was shown between the presence of HVI and HPP (p = 0.34), TR (p = 0.095), and TR-related mortality (0.22). Kaplan–Meier analysis did not show a significant impact of the presence of HVI on RFS (p = 0.07), TRRS (0.48), or OS (p = 0.14). Conclusions: These results may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection.

Pre-op spinal arterial mapping is crucial for complex aortic repair. This study explores the utility of non-selective cone beam computed tomography (CBCT) for pre-operative spinal arterial mapping to identify the Adamkiewicz artery (AKA) in patients undergoing open or endovascular repair of the descending thoracic or thoracoabdominal aorta at risk of spinal cord ischemia. Pre-operative non-selective dual-phase CBCT after intra-aortic contrast injection was performed in the aortic segment to be treated. The origin of detected AKA was assessed based on image fusion between CBCT and pre-interventional computed tomography angiography. Then, the CBCT findings were compared with the incidence of postoperative spinal cord ischemia (SCI). Among 21 included patients (median age: 68 years, 20 men), AKA was detected in 67% within the explored field of view, predominantly from T7 to L1 intercostal and lumbar arteries. SCI occurred in 14%, but none when AKA was not detected (p < 0.01). Non-selective CBCT for AKA mapping is deemed safe and feasible, with potential predictive value for post-surgical spinal cord ischemia risk. The study concludes that non-selective aortic CBCT is a safe and feasible method for spinal arterial mapping, providing promising insights into predicting post-surgical SCI risk.