Cephalic arch stenosis in the arteriovenous fistula: A retrospective analysis of predisposing factors

Background: Cephalic Arch Stenosis (CAS) is a frequently observed complication in brachiocephalic and radiocephalic arteriovenous fistulae (AVF) associated with high morbidity and healthcare expenditure. The predisposing factors and preventative strategies for CAS remain unclear. Our aim was to examine predisposing factors for CAS development in the AVF. Methods: A retrospective case-control study was performed at Gold University Coast Hospital on patients with AVFs created from 2009 to 2018 with ⩾18 months follow-up. CAS was defined as a >50% narrowing on angiographic assessment with clinically significant symptoms (dialysis dysfunction, arm swelling, prolonged bleeding after access). Results: About 187 patients with AVF were included in the analysis (36 brachiocephalic, 151 radiocephalic). CAS developed in 22 of 36 (61%) of brachiocephalic AVF and 9 of 151 (6%) of radiocephalic AVFs. Brachiocephalic AVF were ⩾12 times more likely to develop CAS than radiocephalic AVF (Hazard Ratio (HR) 12.7, 95% CI [5.6–28.3], p < 0.001). Each 1 mL/min increase in flow rate through the AVF, correlated with a 0.07% increase in the probability of development of CAS (HR 1.0007, 95% CI [1.0001–1.0012], p = 0.011). Brachiocephalic AVFs with CAS were associated with a higher number of interventional procedures per access-year compared with their non-CAS counterparts (Median [Interquartile range]: 1.76 [0.74, 3.97] vs 0.41 [0.27, 0.67], p = 0.003). Conclusion: Brachiocephalic AVF with higher access flow rates are more likely to develop CAS and earlier than radiocephalic AVF, and in a dose dependent fashion. AVF flow rate is a major factor in CAS development within brachiocephalic AVF and has potential utility in surveillance thresholds for prophylactic blood flow reduction procedures. AVFs with CAS are associated with a greater number of interventional procedures per access-year, heralding higher patient morbidity and healthcare expenditure. Further prospective studies will help define an AVF access flow rate threshold in the implementation of prophylactic strategies for CAS.

A study of variations in branching pattern of axillary artery in cadavers

The knowledge of variable branching pattern of Axillary artery is needed for vascular surgeons, onco surgeons, anaesthesiologists, orthopedic surgeons and radiologists due to increased use of invasive diagnostic, interventional procedures. The aim was to study the variable branching pattern of Axillary artey in cadavers. 15 cadavers (30 upper limbs) - 12 male and 3 female embalmed with 10% formalin were dissected for this study. Variable branching pattern was observed in 6.6% of the cases on right side and 6.6% of the cases on left side in first part of axillary artery, 40% of the cases on right side and 53.3% of the cases on left side in second part and 53.3% of the cases on right side and 26.6% of the cases on left side in third part. The anatomical knowledge of the normal and variant anatomy of the Axillary artery is of importance for anatomists, surgeons, radiologists and clinicians during various interventional, diagnostic, therapeutic and surgical procedures on pectoral and axillary regions.

EULAR Points to Consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

ObjectivesTo develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).MethodsEuropean Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.ResultsA total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.ConclusionThese are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

Radiation exposure in 101 non-coronary fluoroscopically guided interventional procedures: reference levels of air kerma at the reference point and air kerma-area product

Objectives: To present the median value and 75th percentile of air kerma at the reference point (Ka,r), air kerma-area product (KAP), and fluoroscopic time for a large number of fluoroscopically-guided interventional (FGI) procedures. Methods: This retrospective study included the consecutive non-coronary FGI procedures from a Radiology department between May 2016 and October 2018 at a large tertiary care hospital in the U.S. An in-house developed, semi-automated software, integrated with a dictation system, was used to record patient examination information, including Ka,r, KAP and fluoroscopic time. The included patient procedures were categorized into procedure types. A software package R (version 3.5.1, R Foundation) was used to calculate procedure-specific quartiles of radiation exposure. Results: Based on analysis of 24,911 FGI cases, median value and 75th percentile are presented for each of Ka,r, KAP and fluoroscopic time for 101 procedures that can act as benchmark for comparison for dose optimization studies. Conclusion: This study provides reference levels (50th and 75th percentiles) for a comprehensive list of FGI procedures, reflecting an overall picture of the latest FGI studies for diagnosis, targeted minimally invasive intervention, and therapeutic treatment. Advances in knowledge: This study provides reference levels (50th and 75th percentiles) for the largest number of fluoroscopically-guided interventional procedures reported to-date (101 procedures), in terms of air kerma at the reference point, air kerma-area product, and fluoroscopic time, among which these quartiles for ≥50 procedures are presented for the first time.

Current Practice of Imaging-Guided Interventional Procedures in Rheumatic and Musculoskeletal Diseases: Results of a Multinational Multidisciplinary Survey

Objectives: To investigate opinion and routine practice of specialists from different disciplines on imaging techniques for interventional procedures related to rheumatic and musculoskeletal diseases (RMDs).Methods: An English-language questionnaire was developed by an international working group and distributed to health care providers of various disciplines involved in the care of people with RMDs via an online survey tool (SoSci Survey®) from December 2019 to May 2020.Results: A total of 1,105 respondents from 56 countries completed the survey, over 60% of participants were rheumatologists. The majority of respondents (88%) performed interventional procedures in RMDs patients and 90% of them used imaging guidance. Ultrasonography was the most frequently used technique, particularly among rheumatologists. X-ray and computed tomography were mainly used by radiologists. A discrepancy emerged between the importance assigned to certain items such as the availability of a second operator and their actual implementation in clinical practice. Local barriers, lack of resources and facilities were mentioned as the most relevant obstacles in this regard. Lack of training on imaging and/or imaging guided procedures did not emerge as a barrier to perform such interventions; in fact, 19% of respondents performing the procedures indicated not to have received adequate training in this field.Conclusions: This is the first multinational multidisciplinary survey exploring in detail the opinions and practice on imaging guidance for interventional procedures in RMDs. A harmonization of protocols based on international guidelines, along with adequate training programmes and interventions on barriers at national/local levels are the main unmet needs requiring attention.

Interventional Procedures for Vertebral Diseases: Spinal Tumor Ablation, Vertebral Augmentation, and Basivertebral Nerve Ablation—A Scoping Review

Low back pain is consistently documented as the most expensive and leading cause of disability. The majority of cases have non-specific etiologies. However, a subset of vertebral diseases has well-documented pain generators, including vertebral body tumors, vertebral body fractures, and vertebral endplate injury. Over the past two decades, specific interventional procedures targeting these anatomical pain generators have been widely studied, including spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation. This scoping review summarizes safety and clinical efficacy and discusses the impact on healthcare utilization of these interventions. Vertebral-related diseases remain a top concern with regard to prevalence and amount of health care spending worldwide. Our study shows that for a subset of disorders related to the vertebrae, spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation are safe and clinically effective interventions to decrease pain, improve function and quality of life, and potentially reduce mortality, improve survival, and overall offer cost-saving opportunities.