Diagnostic reference levels and complexity indices in interventional radiology: a national programme.

OBJECTIVES: To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses. METHODS: Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values. RESULTS: The KAP (3rd quartile) in Gy cm2 for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4. CONCLUSIONS: The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology. KEY POINTS: • National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

Early detection and treatment of hemodialysis access dysfunction.

PURPOSE: To assess the usefulness of a program for the early detection of hemodialysis graft dysfunction and the impact on graft survival of percutaneous transluminal angioplasty (PTA) and stent implantation to correct venous stenosis. METHODS: A program for the early detection of hemodialysis access graft dysfunction was carried out in 110 patients over a period of 80 months. Detection was based on physical examination, flow rate measurements, venous pressure, and analytical determinations performed at dialysis. The stenoses detected were treated by PTA or PTA plus stent deployment. Survival curves compared primary and assisted patency rates for the different graft types. RESULTS: The most important indicators of dysfunction were increased venous pressure and difficulty in cannulation of the graft. Significant stenoses were revealed by 227 (92.2%) of the 246 fistulography procedures performed. PTA results were satisfactory in 100% of the Thomas grafts, 74% of the Brescia-Cimino (BC) grafts, and 53% of the polytetrafluoroethylene (PTFE) grafts. Technical success rates for stent deployment were 92% for BC grafts and 100% for PTFE grafts, while functional success rates were 96% and 97%, respectively. The difference in the primary patency (P1) and assisted patency (AP) values was statistically significant for all three graft types. There was no significant difference in the patency rates for grafts treated by PTA alone or by PTA and stent deployment. CONCLUSION: A surveillance program helped prevent graft thrombosis, and intervention as required achieved excellent primary and assisted patency rates. Stent deployment salvaged a considerable number of accesses but did not significantly extend access survival time.

[Addition of ritanserin to the treatment with propranolol in cirrhotic patients: effects on portal pressure]. / Adición de ritanserina al tratamiento con propranolol en enfermos cirróticos: efectos sobre la presión portal.

The use of vasodilators to prevent the rupture of esophagic varices (EV) due to portal hypertension (PH) would reduce the portal pressure (PP) as the result of increased portocolateral flow. Rinsaterine, a 5-HT2 receptor blocker, reduces PP in experimental models of PH. This pilot study was designed to verify if ritanserine has a sustained and additive effect to propranolol on PP in cirrhotic patients with PH. Ten chronic patients with EV, under prophylactic therapy with propranolol and with a suprahepatic venous pressure gradient (SVPG) > 12 mm Hg, received ritanserine (0.11-0.14 mg/kg/day). One patients completed one month of treatment due to drug intolerance. Nine patients completed one month of treatment; SVPG did not show any significant variation in four patients and decreased 3 mm Hg in five patients, which were treated during 70 days more. After then, HVPG returned to its previous values except in one patient. The long-term association between ritanserine and propranolol does not improve the results of propranolol. However, the initial response observed in all of these patients supports the role of the serotoninergic system in the PH and states the need for further studies on 5-HT2 blocking for the prophylaxis of EV rupture.

[Effort thrombosis of the subclavian-axillary vein: a report of 3 cases and the individualization of treatment]. / Trombosis de esfuerzo de la vena subclavioaxilar: descripción de tres casos e individualización del tratamiento.

The previous history, clinical evolution, diagnostic procedure and treatment in three cases of effort thrombosis of the subclavian-axillary vein are described. Only one patient presented on admittance signs compatible with thoracic outlet syndrome. We insist on the importance of individualizing treatment. A patient presented on admittance an advanced clinical picture and underwent anticoagulant treatment for six months, showing important clinical and phlebographic alterations during this time. The other two patients presented an acute picture of a few hours of evolution and initially underwent fibrinolytic treatment followed by anticoagulant treatment during three months. The clinical data as well as phlebography was normal in these patients six months after admission.