A Single Center 9-Year Experience in IVC Filter Retrieval - The Importance of an IVC Filter Registry.

Background:To evaluate Inferior vena cava (IVC) filter retrieval practices over a 9-year period at an academic hospital with a prospectively maintained IVC filter registry. Method:An IVC filter registry was maintained prospectively within our institution. We reviewed cases between August 2011 and June 2020, following filter status, retrieval plans, and eventual retrieval date. The validity of the database was cross referenced with a Picture Archiving and Communication System and patient records. Results:343 patients had IVC filters inserted. Three filter types were used, Celect (Cook Medical) in 189, Gunther Tulip (GT) (Cook Medical) in 65, ALN (ALN) in 89. 196 filters were retrieved, 108 were made permanent, 36 died before retrieval, and 3 were yet to be retrieved. Retrieval rates were 92.5% overall (86% for GT, 93% for Celect and 94.5% for ALN). The mean dwell time for successful retrieval was 59 days with the majority of insertions (85%) removed in under 100 days. Failed initial retrieval occurred in 23 patients, 10 (43%) were retrieved at second attempt, 13/23 filters remained in-situ and were deemed permanent after discussion with the patient and referring team. Conclusion:The removal of IVC filters, when indication for insertion has past, is no longer the sole responsibility of the referring physician but also the responsibility of the Interventionalist. Our retrieval rates of 92.5% of eligible IVC filters highlights the value of maintaining a prospective IVC filter registry.

Measurement of Medial Tibial Eminence Dimensions for the Clinical Evaluation of ACL-Injured Knees: A Comparison between CT and MRI

Anterior cruciate ligament (ACL) injuries commonly lead to translational and rotational tibiofemoral instability. The morphology of the medial tibial eminence (MTE) has received increased attention regarding its role in tibiofemoral stability in ACL-injured knees. Therefore, quantification of MTE dimensions on clinical imaging may help clinicians predict knee stability after ACL injury. Although magnetic resonance imaging (MRI) is routinely obtained in patients with ACL injuries, whether the dimensions of the MTE can be accurate quantified on MRI is unknown. The purpose of this study was to assess the degree of correlation between measurements of MTE height and width on computed tomography (CT) versus MRI. An institutional picture archiving and communication system imaging database was used to identify patients aged between 15 and 60 years who received concurrent MRI and CT of the same knee within a 1-year interval. Knees with significant arthrosis, deformity, intraarticular fracture, or hardware-related artifact that obscured visualization of the MTE were excluded. Mean differences and interstudy agreement between CT and MRI MTE measurements were compared using concordance correlation coefficient (r c) and Bland–Altman analysis. A total of 41 knees in 38 patients (mean age, 37 years; 82% male) were analyzed. Interrater reliability for CT and MRI measurements was high (intraclass correlation coefficient = 0.740–0.954). On coronal CT and MRI, mean MTE height measurements were 10.4 ± 1.9 and 10.4 ± 1.8 mm, respectively; mean MTE width measurements were 14.6 ± 3.6 and 14.2 ± 3.0 mm, respectively. On sagittal CT and MRI, mean MTE height measurements were 11.6 ± 1.7 and 11.7 ± 1.7 mm, respectively; mean MTE width measurements were 36.5 ± 4.8 and 36.2 ± 5.0 mm, respectively. Good agreement was observed between CT and MRI measurements of MTE height and width on coronal and sagittal planes (r c = 0.947–0.969). Measurements of MTE height and width were similar on MRI relative to CT on both coronal and sagittal planes. MRI may be suitable for characterizing the dimensions of the MTE when clinically evaluating patients with ACL injuries, potentially allowing for individualized patient care.

Automated Angiographic Labeling Pipeline

Background & Hypothesis: Treatment decisions for medical management, endovascular therapy, open surgery, and hybrid approaches for peripheral artery disease (PAD) are largely driven by imaging. While catheter-directed angiography remains the gold-standard for endoluminal vessel analysis, currently, there is not widespread clinical use of machine learning to provide automated segmentation. This project aims to develop an active learning pipeline to automate the labeling of vascular structures in angiographic images. Methods: We queried the picture archiving and communication system (PACS) database for Indiana University Health and Eskenazi Health to identify studies with catheter-directed angiograms of the extremities. From this dataset we randomly selected an initial convenience sample of 50 angiograms to manually label using the 3D Slicer software. We compared three workflow approaches for labeling this training data - (1) human-only single-pass labelling whereby one person labels each image; (2) human-only multi-pass labelling whereby three humans label a vessel with increasing precision; (3) “human-in-the-middle” approach using NVIDIA’s AI-Assisted Annotation client whereby the image is auto-segmented and then manually checked for accuracy. Results: We are currently evaluating speed and accuracy for each of these approaches. However, our preliminary data suggests that human-only multi-pass labeling is most efficientappreac We will be validating the following three-step process. First, thresholding tool was used to leverage differences in contrast gradations to approximate the location of vascular structure. Second, the eraser tool was utilized to refine the vessel boundaries. Finally, major blood vessels contributing to axial flow to the foot were manually labeled. These labeled angiograms will be used to develop an active learning algorithm to automate future labeling of the remaining dataset. Conclusion: A machine learning approach to interpreting lower extremity images can dramatically improve the efficiency of triaging patients with PAD. Further work is underway to develop and implement this program clinically.

Artifacts in MRI: Villain or Hero? Using Artifacts for Diagnosing Central Nervous System Diseases

An artifact is a feature present in an image which is not part of the original structure. It can occur as a consequence of several factors. It may be mistaken for pathologic conditions, leading to adverse consequences for the patients. The aim of the present study is to present a selection of the main artifacts described in brain and spinal magnetic resonance images to improve the ability of the physicians to recognize them and to reduce their interference on the final interpretation of a scan. The authors searched the scientific community for artifacts in magnetic resonance imaging (MRI), which were selected to focus on central nervous system (CNS) findings. With the Picture Archiving and Communication System (PACS) database from the center where this study was conducted, the authors designated brain and spine MRI scans with conspicuous artifacts to compose the present study. The artifacts were then classified as those that contribute to the diagnosis and those that must be distinguished from pathologic lesions. Considering the novel classification proposed by the present study, physicians might be stimulated to reevaluate their opinions regarding artifacts, perhaps considering them helpful to evaluate certain conditions even if they cannot be fully corrected, as shown by this distinct approach to artifacts with specific findings concerning differential diagnosis of CNS conditions.

Clinical Presentation, Imaging, and Management of Segmental Arterial Mediolysis: A Rare Vascular Disorder

Objectives Our objective was to analyze the clinical presentation, imaging findings, and the management of segmental arterial mediolysis (SAM) in different case scenarios within our medical institution. Materials and Methods We retrospectively analyzed 13 cases of SAM in our institution from July 2017 to March 2020. The images from the cases were collected from picture archiving and communication system (PACS) along with other pertinent clinical information from the hospital's information system. All the patients we studied underwent contrast-enhanced computed tomography (CT) using a third-generation Siemens SOMATOM Force dual-source CT scanner. Once the dual-phase scanning was completed, the images were analyzed using the workstation's syngo.via software. Results Three out of the 13 cases required stent-grafting of the renal/celiac artery, and the involved branch of the superior mesenteric artery was embolized in one case. The rest of the cases were managed conservatively with antiplatelets/anticoagulants. Subsequent follow-ups of the patients were conducted and showed stabilization/regression of the initial findings without finding any evidence of worsening. Conclusion SAM should be considered when making a differential diagnosis of acute abdominal pain when associated with dissection or aneurysms in splanchnic arteries, and in cases of unexplained intra-abdominal hemorrhaging. The radiologist needs to be aware of this possibility to raise suspicion, alert the clinician, and guide appropriate management.

Volumetric change of the latissimus dorsi muscle after postoperative chemotherapy and radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap: final results from serial studies

Background Breast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy—both separately and jointly—need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap.Methods This study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7–10 days after surgery and 10–14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance.Results The average volume reduction of LD at 10–14 months after completing POCTx and PORTx was 64.5% (range, 42.8%–81.4%) in comparison to the volume measured 7–10 days after surgery. This change was statistically significant (P<0.05).Conclusions Based on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap.

Usefulness of Grayscale Values of Hypoechoic Lesions Matched with Target Lesions Observed on Magnetic Resonance Imaging for the Prediction of Clinically Significant Prostate Cancer

Background: To analyze grayscale values for hypoechoic lesions matched with target lesions evaluated using prebiopsy magnetic resonance imaging (MRI) according to the Prostate Imaging-Reporting and Data System (PI-RADS).Methods: We collected data on 420 target lesions in patients who underwent MRI/transrectal ultrasound fusion-targeted biopsies between January 2017 and September 2020. Images of hypoechoic lesions that matched the target lesions on MRI were stored in a picture archiving and communication system, and their grayscale values were estimated using the red/green/blue scoring method through an embedded function. We analyzed imaging data using grayscale values.Results: Of the 420 lesions, 261 (62.1%) were prostate cancer lesions. There was no difference in the median grayscale values between benign and prostate cancer lesions. However, grayscale ranges (41.8–98.5 and 42.6–91.8) were significant predictors of prostate cancer and clinically significant prostate cancer (csPC) in multivariable logistic regression analyses. Area under the curve for detecting csPC using grayscale values along with conventional variables (age, prostate-specific antigen levels, prostate volume, previous prostate biopsy results, and PI-RADS scores) was 0.839, which was significantly higher than that for detecting csPC using only conventional variables (0.828; p=0.036). Subgroup analysis revealed a significant difference for PI-RADS 3 lesions between grayscale values for benign and cancerous lesions (74.5 vs. 58.8, p=0.008). Grayscale values were the only significant predictive factor (odds ratio=4.46, p=0.005) for csPC.Conclusions: Distribution of grayscale values according to PI-RAD 3 scores was useful, and the grayscale range (42.6–91.8) was an important factor for csPC diagnosis.

The variation in hip stability measurements between supine and standing radiographs of dysplastic hips

Aims The aims of this study were to compare clinically relevant measurements of hip dysplasia on radiographs taken in the supine and standing position, and to compare Hip2Norm software and Picture Archiving and Communication System (PACS)-derived digital radiological measurements. Methods Preoperative supine and standing radiographs of 36 consecutive patients (43 hips) who underwent periacetabular osteotomy surgery were retrospectively analyzed from a single-centre, two-surgeon cohort. Anterior coverage (AC), posterior coverage (PC), lateral centre-edge angle (LCEA), acetabular inclination (AI), sharp angle (SA), pelvic tilt (PT), retroversion index (RI), femoroepiphyseal acetabular roof (FEAR) index, femoroepiphyseal horizontal angle (FEHA), leg length discrepancy (LLD), and pelvic obliquity (PO) were analyzed using both Hip2Norm software and PACS-derived measurements where applicable. Results Analysis of supine and standing radiographs resulted in significant variation for measurements of PT (p < 0.001) and AC (p = 0.005). The variation in PT correlated with the variation in AC in a limited number of patients (R2 = 0.378; p = 0.012). Conclusion The significant variation in PT and AC between supine and standing radiographs suggests that it may benefit surgeons to have both radiographs when planning surgical correction of hip dysplasia. We also recommend using PACS-derived measurements of AI and SA due to the poor interobserver error on Hip2Norm. Cite this article: Bone Joint J 2021;103-B(11):1662–1668.