Cost drivers in endovascular pulmonary embolism interventions.

AIM: To determine the costs associated with endovascular pulmonary embolism (PE) interventions. MATERIALS AND METHODS: Procedural costs were determined utilising time-driven activity-based costing (TDABC). A multidisciplinary team created process maps describing personnel, space, equipment, materials, and time required for each procedural step. Costs and capacity cost rates were determined using institutional and publicly available financial data. RESULTS: Process maps were developed for catheter-directed thrombolysis (CDT), ultrasound-assisted thrombolysis (USAT), pharmaco-mechanical thrombectomy (PMT), mechanical-aspiration thrombectomy (MAT), and aspiration thrombectomy (AT). Total costs were CDT $3,889, USAT $9,017.10, PMT $9,565.98, AT $12,126.42, and MAT $13,748.01. Tissue plasminogen activator costs represented 46.4% of the total materials cost for CDT, 13.1% for PMT, and 10.8% for USAT. Intensive care unit costs constitute 33.4% in CDT, 13.5% in USAT, and 13.1% in PMT of the total procedure costs. Highest total procedural costs were AT and MAT with materials cost comprising 82.6% and 80.3% of total costs, respectively. CONCLUSION: Costs were greatest with large-bore mechanical aspiration and least with catheter-directed thrombolysis using a multi-side hole infusion catheter. In the absence of a reference standard technique, physician-driven device selection can substantially impact the price of a procedure. Device choice and costs must be weighed against long-term technical and clinical success to maximise the healthcare value equation.

Percutaneous fluoroscopically-guided transcervical retrograde access facilitates successful thoracic duct embolization after failed antegrade transabdominal access.

The purpose of this study was to demonstrate the feasibility of percutaneous fluoroscopically-guided transcervical retrograde access into the thoracic duct following unsuccessful transabdominal cisterna chyli cannulation to perform thoracic duct embolization for the treatment of chylothorax. Five patients, including three (60%) women and two (40%) men, with median age of 62 years, underwent percutaneous transcervical thoracic duct access and embolization after failed transabdominal cisterna chyli cannulation for the treatment of chylothorax. In all patients, fluoroscopically-guided percutaneous transcervical retrograde access into the distal thoracic duct was achieved using a 21-gauge needle and an 0.018-inch wire. Following advancement of a microcatheter, retrograde lymphangiography was performed to identify the location of thoracic duct injury. A combination of 2:1 ethiodized oil to cyanoacrylate mixtures, platinum microcoils, or stent-grafts were used to treat the chylous leaks. Technical successes, procedure durations, fluoroscopy times, blood losses, immediate adverse events, clinical successes, and follow-up durations were recorded. Technical success was defined as cannulation of the distal thoracic duct using a transcervical approach followed by treatment of the thoracic duct injury. Adverse events were classified according to the Society of Interventional Radiology guidelines. Clinical success was defined as resolution of the presenting chylothorax. Percutaneous transcervical retrograde thoracic duct access and treatment was technically successful in all patients (n=5). Median procedure duration was 173 minutes (range: 136-347 minutes) with a median fluoroscopy time of 94.7 minutes (range: 47-125 minutes). Median blood loss was 10 mL (range: 5-20 mL). No minor or major adverse occurred. Clinical success was achieved in all patients (n=5). Median follow-up was 372 days (range: 67-661 days). Percutaneous fluoroscopically- guided transcervical retrograde thoracic duct access is an effective and safe method to perform thoracic duct embolization following unsuccessful transabdominal cisterna chyli cannulation for the treatment of chylothorax.

Transfemoral Venous Access Facilitates Upper Extremity Dialysis Interventions: Procedural Success and Clinical Outcomes.

PURPOSE: To report technical success and clinical outcomes of transfemoral venous access for upper extremity dialysis interventions. MATERIALS AND METHODS: A total of 15 patients underwent a transfemoral venous approach for fistulography (n = 4; 27%) or thrombectomy (n = 11; 73%) over a 14-month period. Access characteristics, sheath size, thrombectomy method, angioplasty site, fluoroscopy time, radiation dose, technical and clinical success, complications, and post-intervention primary and secondary patency rates were recorded. RESULTS: Access type included arteriovenous fistulas (n = 10; 67%) and grafts (n = 5; 33%). The most common configuration was brachio-brachial (n = 6; 38%). Mean age of access was 37 months. Mean prior interventions were 4. Right CFV access was used in all patients using 6-8-French (most common: 7-French [n = 10; 67%]) sheaths. Most thrombectomies (n = 11; 73%) required both pharmacologic and mechanical maceration (n = 9; 82%). All accesses required angioplasty to treat underlying stenosis at the outflow vein (n = 12; 80%) or arteriovenous anastomosis (n = 9; 90%). Mean fluoroscopy time was 26.43 min. Air kerma and dose area product were 178.06 ± 225.77 mGy and 57,768.83 ± 87,553.29 µGym2, respectively. Procedural and clinical success rates were 93% and 80%, respectively. Technical failure was due to persistent stenosis in one patient. Clinical failure was due to unsuccessful dialysis immediately following intervention in three patients. Mean post-intervention primary patency and secondary patency durations were 2.8 and 4.8 months, respectively. Primary patency rates at 1 and 3 months were 50% and 35%, respectively. Secondary patency rates at 1 and 3 months were 58% and 30%, respectively. CONCLUSION: A transfemoral venous approach for intervention of upper extremity dialysis accesses may be a valuable adjunct to traditional approaches.

Two-year outcomes of balloon-occluded retrograde transvenous obliteration of gastric varices in liver transplant recipients: A multi-institutional study.

PURPOSE: To assess the 2-year effectiveness and safety of balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices (GVs) in liver transplant recipients. MATERIALS AND METHODS: Eleven liver transplant recipients underwent consecutive BRTO for GVs at four institutions. Patients included eight (73%) men and three (27%) women with mean age of 56 years±12 (SD) (range: 26-67 years). Underlying cause of liver transplantation was hepatitis C virus (HCV)-related cirrhosis in five (45%), alcohol- and HCV-related cirrhosis in three (27%), primary biliary cirrhosis in two (18%), and alcoholic cirrhosis in one (9%). Five (45%) patients underwent BRTO for actively bleeding GVs, three (17%) for high-risk GVs, and three (17%) for augmentation of portal venous flow through obliteration of gastrorenal shunts. Mean time between liver transplantation and BRTO was 78 months (range: 0.1-276 months). Technical success, GVs obliterative rates, and immediate complications were recorded. Post-BRTO hemorrhagic, transplant, and overall survival rates were evaluated at 6, 12, and 24 months. RESULTS: All (100%) procedures were technically successful. Complete GVs obliteration was achieved in ten patients (91%). Two major complications (18%) occurred in the immediate post-procedure period. One patient developed complete portal vein thrombosis, and another patient developed consumptive coagulopathy, ultimately leading to death. No post-BRTO hemorrhagic recurrences were seen at 6, 12, or 24 months. One patient (9%) had delayed upper gastrointestinal bleeding at 34 months after the procedure which was managed conservatively. Transplant and overall survival rates were 91% at 6, 12, and 24 months. CONCLUSION: BRTO has high technical success and complete GVs obliterative rates in liver transplant recipients with few complications and high graft survival rates.

Biodistribution of 99mTc-MAA on SPECT/CT performed for 90Y radioembolization therapy planning: a pictorial review.

Purpose: To evaluate the frequency of 99mTc-MAA uptake in extrahepatic organs during 90Y radioembolization therapy planning. Methods: This retrospective case series of 70 subjects who underwent 99mTc-MAA hepatic artery perfusion studies between January 2014 and July 2016 for 90Y radioembolization therapy planning at our institution involved direct image review for all subjects, with endpoints recorded: lung shunt fraction, extrahepatic radiotracer uptake, time from MAA injection to imaging. Results: Combined planar and SPECT/CT imaging findings in the 70 subjects demonstrated lung shunt fraction measurements of less than 10% in 53 (76%) subjects and greater than 10% in 17 (24%) subjects. All patients demonstrated renal cortical uptake, 23 (33%) demonstrated salivary gland uptake, 23 (33%) demonstrated thyroid uptake, and 32 (46%) demonstrated gastric mucosal uptake, with significant overlap between these groups. The range of elapsed times between MAA injection and initial imaging was 41-138 min, with a mean of 92 min. There was no correlation between time to imaging and the presence of extrahepatic radiotracer uptake at any site. Conclusions: During hepatic artery perfusion scanning for 90Y radioembolization therapy planning, extrahepatic uptake is common, particularly in the kidney, salivary gland, thyroid and gastric mucosa, and is hypothesized to result from breakdown of 99mTc-MAA over time. Given the breakdown to smaller aggregates and ultimately pertechnetate, this should not be a contraindication to actual Y-90 microsphere therapy. Although we found no correlation between time to imaging and extrahepatic uptake, most of our injection to imaging times were relatively short.

Genitourinary trauma: a pictorial essay.

Genitourinary trauma is often overlooked in the setting of acute trauma. Usually other more life-threatening injuries take precedence for immediate management. When the patient is stabilized, radiologic imaging often plays a key role in diagnosing insults to the upper and lower genitourinary tract in the setting of trauma. Our aim is to provide a pictorial assay of imaging findings in upper and lower tract genitourinary trauma from a variety of mechanisms including blunt trauma, penetrating trauma, and iatrogenic trauma. A patient archiving and communication system will be used to review imaging studies of patients at our institution with genitourinary tract trauma. Cases of renal, ureteral, bladder, urethral, penile, and scrotal trauma will be considered for inclusion in our study. Multimodality imaging techniques will be reviewed. The imaging and pertinent findings that occur in various types of genitourinary trauma are outlined. Genitourinary trauma is often missed in the frenzy of acute trauma. It is important to have a high suspicion for injury especially in severe trauma, and in particular clinical settings. Although often not life threatening, recognizing the diagnostic imaging findings quickly is the realm of the astute radiologist so appropriate urologic management can be made.

Dural arteriovenous malformation in a child with Bannayan-Riley-Ruvalcaba Syndrome.

Intracranial arteriovenous malformations (AVM) are a rare feature of Bannayan-Riley-Ruvalcaba syndrome (BRRS). Palencia et al reported a case of intracranial arteriovenous malformation in a child with BRRS in a Spanish journal in 1986. However, the occurrence of dural AVM in a patient with BRRS has not since been addressed in the literature. Advancements in imaging and therapeutic embolization, and the ability now to screen for phosphatase and tensin homologue (PTEN) mutations allow us to detect and manage these patients sooner. Early detection of intracranial AVMs is necessary because of the risk for progression to venous ischemia and resultant neurologic damage. We present the case of a child with headaches and periorbital venous congestion due to a dural AVM with bilateral venous outflow occlusion who was treated with multiple embolizations, now with interval remission of headache symptoms.