Diagnostic reference levels for fluoroscopically guided procedures in a South African tertiary hospital

Background The burgeoning usage and complexity of fluoroscopically guided procedures (FGPs) contribute to extended examination times and increased risk of adverse radiation effects. Diagnostic reference levels (DRLs) play a pivotal role in dose optimization. There are limited DRL data for FGPs in low- and middle-income countries (LMICs). Purpose To determine local DRLs (LDRLs) for common FGPs in the South African (SA) context and compare these with published international data. Material and Methods A three-year, retrospective study of the 15 most frequently performed FGPs at a SA institution. For each procedure, the 50th and 75th percentiles of kerma area product (KAP), reference point air kerma (Ka,r), and fluoroscopy time data were derived. Published international FGP DRL data were collated and compared with the 75th percentiles of local institutional dosage parameters. Results The commonest FGPs were aorto-bifemoral diagnostic angiography (n = 590), aorto-bifemoral interventional angiography (n = 287), nephrostomy (n = 265), and bronchial arterial embolization (BAE) (n = 208). Selective abdominal vessel interventional angiography (KAP = 170 Gy . cm2; Ka,r = 877 mGy) recorded the highest LDRL dosages; BAE was the longest procedure (LDRL = 38 min). Nephrostomies achieved the lowest LDRLs across all parameters (KAP = 10 Gy . cm2; Ka,r = 63 mGy, fluoroscopy time = 4.3 min). All Tygerberg Hospital LDRLs with comprehensive comparable data were within or below published ranges. Conclusion This study advances international radiation protection initiatives, addresses the paucity of LMIC DRL data, demonstrates broad alignment of Tygerberg Hospital FGP practice with international norms and highlights areas for optimization of institutional practice.

ENDOVASCULAR METHODS OF TREATMENT POSTPANCREATECTOMY HEMORRHAGE AFTER PANCREATIC RESECTIONS

Summary. Aim. To evaluate of the endovascular treatment of patients with postpancreatectomy hemorrhage after pancreatic resections. Matherials and Methods. In the period 2009-2018 we performed 728 radical pancreatic resections in patients with pancreatic cancer. Postpancreatectomy hemorrhage was occurred in 38 (5,2 %) patients. Mortality was 6 (15,8 %). Postpancreatectomy hemorrhage gr. A st. А was occurred in 3 patients and was treatment concervatively. Hemorrhage gr. B or C were occurred in 35 patients. Results. Angiography was performed in 17 (48,6 %) patients among 35. In 14 patients postpancreatectomy hemorrhage was diagnosed. In 3 (17,6 %) patients the source of the bleeding wasn’t identified, this patients underwent a laparotomy with a subsequent treatment. Interventional angiography and treatment of hemorrhage were performed in 14 (82,4 %) patients: embolization was performed in 9, stenting in 5. Mortality was occurred in 1 (7 %) patient. There were no complications after stent grafting. Open surgery was performed in 18 (51.4 %) patients. Of the 18 patients, 6 (33.3 %) died of further septic complications. Conclusions. Endovascular techniques to treatment of postpancreatectomy haemorrhage have proven to be highly effective and safe with good technical and clinical results. Endovascular treatment of bleeding should be the first step in the treatment of postpancreatectomy haemorrhage with stent graft placement in haemorrhage of the main vessels.

Comparison between C-arm cone beam computed tomography and interventional angiography in transarterial chemoembolization of hepatocellular carcinoma

Background Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy of adults. One of the established treatment procedures performed worldwide for HCC is transcatheter arterial chemoembolization (TACE). By using conventional angiography in TACE, we can detect and identify the vascular anatomy of the liver through obtaining 2D images. Recently C-arm cone beam computed tomography (CBCT) is introduced for obtaining cross-sectional and three-dimensional (3D) images for better visualization of small tumors and their feeding arteries. Results The number of detected focal lesions by angiography was 51 compared to 87 focal lesion detected by CBCT; of those, 45 and 77 were active lesions by both procedures respectively. For lesions, less than 1 cm CBCT detected 23 lesions while angiography detected only one lesion. Angiography detected 87 feeding arterial branch while cone beam CT-HA detected 130 branches to the same number of target lesion. Feeder tractability and confidence were better by CBCT. Conclusion CBCT is superior to angiography in tumor detectability, detection of lesions less than 1 cm, feeder detection, and feeder traction; however, conventional angiography and DSA are irreplaceable. Thus, combination of CBCT with angiography during TACE produces better results and less complication.

Simulation in Angiography – Experiences from 5 Years Teaching, Training, and Research

Purpose The example of university radiology/neuroradiology illustrates how high-tech angiography simulators can be used meaningfully in teaching, clinical training and research. Materials and Methods/Technical Basics A VIST LAB simulator (Mentice, Gothenburg, Sweden), which has been continuously developed both in terms of software and hardware, has been in use since 2013. Recently, the simulator has been integrated into the angiography suite Azurion (Philips, Amsterdam, Netherlands). Results/Areas of Application In student education there is the possibility for intensive examination of cerebrovascular diseases and their therapy in small group lessons. The training of beginners in diagnostic and interventional angiography begins mandatorily on the simulator. Research questions are the proof of validity and the training effect, but also the influence on patient safety and the possible cost reduction of an intervention. Conclusion As a result of continuous further development in recent years, simulators are now very well suited for both student teaching and beginner medical training. In the future, even experienced interventionalists could benefit from further technical advances, which should also be driven by academic research. Possible effects would be the reduction of examination times, complications and costs. Key Points: Citation Format

Transoral Penetrating Knife Injury in the Oral, Maxillofacial Region: A Case Report

Penetrating injuries are a rare yet complex variety of oral and maxillofacial trauma and often require a multidisciplinary approach to treatment. The primary survey is always the first step in trauma management prior to proceeding with further evaluation and treatment. The following case report discusses the clinical strategy for a rare transoral and trans-spinal penetrating injury. A 42-year-old man presented with a penetrating metal injury through the oral cavity. A computed tomography scan revealed a 12.8-cm-long knife penetrating through the tongue, floor of the mouth, and hypopharynx reaching the spinal cord in close proximity to the right vertebral artery. The patient did not present with any neurological malfunctions. An emergency tracheotomy was performed for airway protection. A balloon catheter was inserted into the right vertebral artery using interventional angiography to prevent massive bleeding prior to extraction. The knife was then surgically removed, and soft tissue reconstruction was performed without major bleeding. Postoperative magnetic resonance imaging angiography showed no bleeding of the right vertebral artery, but there was mild cerebellar infarction. Early isolated paresis of the right arm returned to nearly normal function within 1 week. This case demonstrates that complex penetrating injuries of the oral and maxillofacial region require a structured and multidisciplinary approach to prevent further side effects and obtain an ideal clinical outcome.