Results of an American College of Radiology-Society of Interventional Radiology Membership Survey on Exclusive Contracts and the Attitudes of Interventional Radiologists.

PURPOSE: To assess the attitudes of interventional radiologists (IRs) and diagnostic radiologists (DRs) toward exclusive contracts and independently practicing IRs who may request privileges at a hospital where an exclusive contract exists with a different group of radiologists. MATERIALS AND METHODS: A total of 22,400 survey instruments were distributed to 4,490 IRs and 17,910 DRs in the United States. Statistical evaluation included multivariate ordinal logistic regression analysis with calculation of the odds ratios and forest plots. RESULTS: Completed surveys were received from 525 (11.69%) IRs and 401 (2.23%) DRs. Given the low response rate of DRs, data analysis was focused on IRs. Early-career IRs and those in outpatient practices had a more positive attitude toward independent IRs who requested admitting and/or procedural privileges. A supermajority of both IRs and DRs who responded to the survey agreed that the importance of IR to hospital and health system contracts will increase. CONCLUSIONS: This survey identified many interrelated and complex variables that significantly affected the attitudes of IRs in various practice settings toward independent IRs requesting hospital admitting and/or procedural privileges. It will benefit independent IRs seeking admitting privileges to better understand some of the factors that impact the potential willingness of the radiology groups and other IRs with exclusive hospital contracts to work toward mutually beneficial practice paradigms, especially as more clinically oriented IRs complete their training in the new, integrated residency programs.

Alternate Cervical Venous Access Sites for Implantable Port Catheters: Experience at a Single Quaternary Care Institution.

INTRODUCTION: Clinical outcomes of implantable port catheters (IPCs) placed via alternative veins such as the external jugular and cervical collaterals have not been well established. This investigation evaluates the short- and long-term outcomes of IPCs inserted via alternate cervical veins (ACV) compared to traditionally inserted IPCs via the internal jugular vein (IJV). MATERIALS AND METHODS: A total of 24 patients who received an IPC between 2010 and 2020 via an ACV-defined as the external jugular vein, superficial cervical vein, or unnamed collateral veins-were identified. Based on power analysis, a matched control group of 72 patients who received IPCs via the IJV was identified. Non-inferiority analysis for port complications was performed between the two groups based on the selected non-inferiority margin of 20%. Secondary end points included complication-free survival and comparison of complications by the time at which they occurred. RESULTS: ACV access was non-inferior to traditional access for overall complications. Alternate access resulted in fewer complications than traditional access with an estimated reduction of - 7.0% [95% CI - 23.6%, 39.7%]. There was no significant difference in peri-procedural and post-procedural complications between the two groups. Complication-free survival was also equivalent between the two groups. CONCLUSION: IPC placement via ACVs was non-inferior to IPCs placed via traditional access through the IJV. When abnormal pathology obviates the use of IJV access, other cervical veins may be considered prior to seeking alternate locations such as femoral, translumbar, inferior vena cava, and hepatic veins.

A Survey of Interventional Radiologists Regarding the Use of Morbidity and Mortality Conferencing in Departmental Quality Improvement Programs.

PURPOSE: To investigate the degree to which morbidity and mortality (M&M) conferencing is utilized in interventional radiology (IR), identify impediments to its adoption, and assess the experience of those using this tool. MATERIALS AND METHODS: Members of the Society of Interventional Radiology (SIR) were offered a 9-question survey of practices and experiences regarding M&M conferencing within their quality assessment (QA) programs. RESULTS: Among 604 respondents, 37.8% were university-based practitioners and 60% were from outside of university practices. Of all respondents, 43% reported practicing 100% IR, with 28.5% practicing IR 75%-99% and 11% practicing IR <50% of the time. The use of M&M conferencing was significantly greater in university practices (90.7%) than in nonuniversity practices (37.1%) and among practitioners performing at least 75% IR (71.2%) than among those practicing <75% (28.8%). The conferences were held monthly (66.6%) or more often, and the majority (56%) of the events identified were scored using the SIR severity score. Approximately 20% of M&M conferences were multidisciplinary, shared most commonly with vascular surgery. The reasons cited for not using M&M included the lack of time and the logistical challenges of the process. However, among those who participate in M&M conferences, the QA goals of the conference were met at very high rates. CONCLUSIONS: M&M conferencing is well established in university IR programs and among full-time practitioners but much less so elsewhere. For those sites that do not utilize M&M conferencing, there may be a considerable benefit to addressing the obstacles that are limiting their implementation of this tool.

Academic vs. Private Practice: An Indistinct Distinction.

Interventional radiology (IR) practices take many forms, but often are distinguished as following either an academic or private practice model. Both differences and similarities are seen when comparing these two general practice categories, and often the line between the two models is unclear. This article reviews some of the commonalities and differences between academic and private practice IR, and provides personal insights from an author who has significant experience in both practice models.

Midterm follow-up of transjugular intrahepatic portosystemic shunts using polytetrafluoroethylene endografts in children.

PURPOSE: To report the initial experience of a pediatric center's use of expanded polytetrafluoroethylene (ePTFE) endografts for the creation of transjugular intrahepatic portosystemic shunts (TIPSs) in children. MATERIALS AND METHODS: Twelve consecutive patients had a TIPS created, all with ePTFE endografts. Nine were children younger than 18 years of age: one infant (age 18 mo) and eight adolescent children with a median age of 14 years, 3 months (range, 10 y, 1 mo, to 17 y, 2 mo). All had gastric or esophageal varices. Acute variceal bleeding was the primary indication in four of nine cases (44%). Mean follow-up was 20 months (range, 4 d to 32 mo). RESULTS: Technical success rate was 100%. Seven TIPSs (78%) were created with a 10-mm-diameter endograft and two (22%) were created with an 8-mm-diameter endograft. Mean portosystemic gradient was reduced from 15.9 mm Hg to 5.8 mm Hg after TIPS creation. The devices were not dilated to their nominal diameter in seven of nine cases (78%). There were no major complications or mortalities associated with TIPS creation. There was one minor complication during follow-up in which a child developed progressively increasing lethargy. Primary patency rate by ultrasound during follow-up was 100%. There were no shunt dysfunctions or repeat interventions required, and no clinical recurrences. One child received a liver transplant 4 days after TIPS creation. CONCLUSIONS: TIPSs can be created in children with the use of ePTFE endografts with an excellent midterm primary patency rate and a low complication rate.

Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study.

BACKGROUND: The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. DESIGN: Multicenter, prospective, single-arm phase 2 study. SETTING: Six academic medical centers. PATIENTS: We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. INTERVENTIONS: Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. MAIN OUTCOME MEASURES: Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. RESULTS: We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. CONCLUSIONS: This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.

Thermal osteonecrosis of the rib after radiofrequency ablation in the thorax.

A patient underwent radiofrequency (RF) ablation of a pleural-based pulmonary metastasis from treated hepatocellular carcinoma. Ten months after the procedure, computed tomography and positron emission tomography findings raised the concern of tumor recurrence with invasion of the chest wall, for which the patient underwent thoracotomy with resection. Pathologic evaluation demonstrated osteonecrosis of the rib but no malignancy. This case illustrates that thermal osteonecrosis may occur after RF ablation of a pleural-based lesion.

Ultrasound-based elastography: a novel approach to assess radio frequency ablation of liver masses performed with expandable ablation probes: a feasibility study.

OBJECTIVE: The purpose of this study was to evaluate the technical feasibility of ultrasound-based elastography as a tool for assessing the size and shape of the coagulation necrosis caused by radio frequency ablation (RFA) probes using expandable electrodes ex vivo as well as in a patient with a liver metastasis. METHODS: A commercially available expandable RFA probe was used to create a 3-cm ablation in a piece of bovine liver. The ablation probe was used in situ to induce tissue deformation for elastography before and after ablation. Ultrasonic radio frequency data were processed to generate elasticity strain images. The appearance of the ablation zone was compared with magnetic resonance imaging and a gross section specimen. One patient with malignant metastatic disease to the liver and a clinical indication for RFA was investigated for the feasibility of percutaneous elastography of RFA using the same technique. Sonographic strain images were compared with the appearance of the nonenhancing ablation zone on contrast-enhanced computed tomography. RESULTS: Ex vivo, the ablation zone on ultrasound-based elastography was represented by an area of increased stiffness and was well demarcated from the nonablated surrounding tissue. The size and shape of the ablated zone on the strain image correlated well with the gross specimen and the magnetic resonance imaging appearance. Strain images obtained from the patient showed results similar to those of the ex vivo experiment and correlated well with the nonenhancing area of ablation on contrast-enhanced computed tomography. CONCLUSIONS: Ultrasound-based elastography may be a promising tool for displaying the ablation zone created by expandable RFA probes.

Which Arteries Are Expendable? The Practice and Pitfalls of Embolization throughout the Body.

This article outlines general concepts of, and strategies for, therapeutic embolization throughout the body, touching on all major arterial distributions. Clinical scenarios that allow or prevent safe embolization of vessels are presented. Specific agents are recommended where appropriate, as are alternate approaches when embolization is not an option. Pre-embolization precautions and adjunctive measures are described in high-risk areas.

Uterine artery embolization: a safe and effective, minimally invasive, uterine-sparing treatment option for symptomatic fibroids.

Leiomyomas (or fibroids) are exceedingly common lesions. The indications to initiate treatment are based on the symptoms that can arise from their presence. In general, medical therapy should be considered the first line of treatment. Currently, the treatment of fibroids is in evolution. Since uterine artery embolization (UAE) was first described by Ravina et al in 1995, it has been shown to be a safe, efficacious, and cost-effective alternative to traditional surgical options, with data from long-term studies now available. Appropriate patient evaluation and selection are vital; the ideal candidate is one who is premenopausal, has symptomatic fibroids resistant to medical therapy, no longer desires fertility, and wishes to maintain her uterus. Uterine artery embolization is primarily an angiographic procedure, but periprocedural clinical management is critical for patient satisfaction. This article discusses the various embolic materials that are commonly used and available for UAE; understanding the technical nuances is critical for long-term success.

The use of paired optionally retrievable günther tulip filters in trauma patients with anatomical variants.

Inferior vena cava (IVC) filtration is commonly performed to protect against pulmonary embolism in acutely injured patients with contraindications for anticoagulation therapy. Increasingly, optionally retrievable IVC filters are utilized, particularly in younger patients with longer life expectancies. There are well-described anatomical variants that preclude the typical infrarenal deployment of IVC filters. We describe three cases in which trauma patients with congenital anomalies required temporary prophylaxis with IVC filters. One patient had a duplication of the IVC requiring filter deployment in each IVC limb. The second patient had a low inserting accessory left renal vein, and a third patient had a megacava. Both of these patients required filter deployment in each common iliac vein. In each case, a pair of optionally retrievable Günther Tulip filters was deployed and subsequently retrieved.

Ultrasound-guided endovenous diode laser in the treatment of congenital venous malformations: preliminary experience.

The authors present their experience in treating congenital venous malformations with ultrasound (US)-guided endovenous diode laser. Six patients underwent treatment of eight venous malformations for complaints including pain, activity limitation, or cosmetic defect. At a mean follow-up interval of 14.5 months, all had either resolution of (five patients) or marked decrease in (one patient) pain, allowing them to resume previously limited activities. There were no instances of nerve damage or skin necrosis. One patient had a self-limited mucosal tongue base ulcer. In this small series of patients, endovenous laser treatment of venous malformations was effective during short-term follow-up.

Contrast peripheral phlebography and pulmonary angiography for diagnosis of thromboembolism.

At one time, direct intravascular contrast angiography was the standard method for confirmatory diagnosis of venous or pulmonary arterial thromboembolism. Although sensitive and specific, conventional catheter-based contrast imaging is invasive and associated with a risk of phlebitis and thrombosis. These procedures require specialized training and experience in catheter manipulation, as well as specialized vascular imaging equipment. In current practice, less invasive techniques have largely superceded conventional angiography because they can be performed by technologists using widely available, multifunctional apparatus under physician supervision. When results using these newer approaches are inconclusive or impractical, however, catheter-based techniques are still relied on for definitive diagnosis. The purpose of this article is to review the indications, techniques, and interpretations of contrast angiography as applied to venous thromboembolic disease.