Inferior Pancreaticoduodenal Artery Pseudoaneurysm Causing Biliary Obstruction: A Case Report.

Introduction: Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01-0.2% of the worldwide population, as found on autopsy. Pancreaticoduodenal artery pathology accounts for approximately 2% of all visceral aneurysms; it is commonly caused by chronic inflammatory processes, such as pancreatitis or adjacent pseudocysts. Morbidity and mortality commonly result from rupture of the aneurysm itself, leading to life-threatening hemorrhage into the peritoneum or gastrointestinal tract. Case Report: Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia. Conclusion: Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and need urgent endovascular management to prevent morbidity and mortality.

Percutaneous kidney biopsy trends in the Medicare population by specialty from 2011 to 2021: implications for nephrology training requirements and radiology referral patterns.

PURPOSE: To study trends in volume and reimbursement for percutaneous kidney biopsy (PKB) by physicians and advanced practice providers (APPs) for Medicare enrollees from 2011-2021. METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Master File (a national Medicare database) for 2011-2021 were extracted using Current Procedural Terminology codes for PKB. Total volumes were compared by provider specialty. Non-facility reimbursement, work Relative Value Unit (RVU) non-facility practice expense RVU, and malpractice RVU were compared. RESULTS: Between 2011 and 2021, total volume of PKB by physicians and APPs increased from 30,753 to 34,090 (10.9%), with a peak of 37,882 in 2019 prior to the COVID 19 pandemic. Radiology performed the majority of procedures during the study period. Relative share for radiology increased from 67.6% to 81.1% while the relative share for internal medicine/nephrology decreased from 24.3% to 14.3%, accelerating between 2019 and 2020. Volume and relative share for APPs marginally increased (from 0.9% to 1.2%). Non-facility reimbursement decreased from $578.96 in 2010 to $568.76 in 2021 (1.7%), work RVU decreased from 2.63 to 2.38 (9.5%), non-facility practice expense RVU decreased from 14.10 to 13.71 (2.8%), and malpractice RVU decreased from 0.31 to 0.21 (32.3%). CONCLUSION: Volume and total share of PKB performed by radiology increased over the study period. Conversely, internal medicine/nephrology performed fewer kidney biopsies. Despite the expanding role for APPs in other image-guided procedures, very few PKBs were performed by APPs throughout the study period. Reimbursement and RVU for PKB declined over the study period.

Reductions in Reimbursement and Relative Value Units for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared with Those for Other Physician Specialties.

PURPOSE: To compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties. MATERIALS AND METHODS: Data from the Centers for Medicare and Medicaid Services Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single Current Procedural Terminology IR procedures were compared with similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021. RESULTS: The work RVU component decreased in 18 of 23 (78.3%) IR procedures compared with 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared with a 16.5% reduction for similar procedures performed by non-IR specialties. CONCLUSIONS: As a specialty, IR experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.

Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018.

PURPOSE: To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image guidance. METHODS: Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS: For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION: A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.

Percutaneous ablation of renal tumors versus surgical ablation and partial nephrectomy: Medicare trends and reimbursement cost comparison from 2010 to 2018.

PURPOSE: The purpose of this study is to analyze trends in Medicare volume and reimbursement for percutaneous and surgical ablation as well as laparoscopic and open partial nephrectomy for treatment of small renal tumors from 2010 to 2018. METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Summary from 2010 to 2018 were extracted using CPT codes for percutaneous and surgical renal ablation and surgical and laparoscopic partial nephrectomy. Facility reimbursement and relative value units (RVUs) were obtained using the Centers for Medicare & Medicaid Services physician fee schedule look-up tool. RESULTS: Volume of percutaneous ablation increased from 2539 to 4571 procedures (80.0%). Specifically, percutaneous cryoablation became the dominant technique, increasing from 1434 to 2981 procedures (107.9%). Overall, volume of partial nephrectomy also increased by 40.4%, driven by an increase in laparoscopic partial nephrectomy from 3227 to 7770 procedures (140.8%) with a decrease in open partial nephrectomy from 3489 to 1661 (- 52.4%). Volume of surgical ablations also decreased 72.7% from 1260 to 344 procedures. In 2018, reimbursement was $358.56 for percutaneous radiofrequency ablation, $481.32 for percutaneous cryoablation, $1216.43 for surgical radiofrequency ablation, $1269.35 for surgical cryoablation, $1381.67 for open partial nephrectomy, and $1552.66 for laparoscopic partial nephrectomy. CONCLUSION: There has been a trend toward minimally invasive techniques for treatment of small renal tumors among Medicare patients. Laparoscopic partial nephrectomy has become the dominant treatment. In the setting of evidence showing comparable outcomes with surgery as well as lower costs to insurers, the volume of percutaneous ablation has also markedly increased.

Percutaneous ablation versus surgical ablation and resection of liver tumors: medicare volume and physician reimbursement trends from 2010 to 2018.

PURPOSE: The purpose of this study is to analyze trends in Medicare volume and physician reimbursement for percutaneous ablation, surgical ablation, and resection of liver tumors from 2010 to 2018. METHODS: Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the CPT codes for percutaneous and surgical ablation of liver tumors and surgical liver resection. Total procedural volume and physician payment were analyzed by procedure and physician specialty. RESULTS: From 2010 to 2018, the volume of percutaneous ablation of liver tumors increased 94.3% from 1630 to 3168 procedures, and the volume of surgical ablations increased 86.2% from 593 to 1104 procedures. In contrast, there was a 16.8% decrease in liver resections from 10,807 to 8994 procedures. Physician reimbursement for percutaneous ablation decreased from $702.41 to $610.11 (- 13.1%). Conversely, reimbursement for resection increased from $849.18 to $1015.06 (19.5%). Reimbursement for surgical ablation also increased from $722.36 to $744.25 (3.0%). In 2018, physician reimbursement for resection and surgical ablation were 66% and 22% more than that for percutaneous ablation. CONCLUSION: An increasing number of patients with liver tumors were treated with percutaneous ablation from 2010 to 2018. Despite higher morbidity, a dwindling set of theoretical advantages over percutaneous ablation, and higher overall costs, the volume of surgical ablation also increased over this time period. The findings of this study suggest that a reevaluation of practice and referral patterns for surgical ablation of liver tumors is warranted in many institutions.

Effects of the MAGIC Guidelines on PICC Placement Volume: Advanced Practice Provider and Physician Trends Among Medicare Beneficiaries From 2010 to 2018.

BACKGROUND. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was published in 2015, recommending more restricted indications for peripherally inserted central catheter (PICC) placement, particularly for those placed by physicians. Changes in PICC placement volume since the publication of MAGIC is largely unknown. OBJECTIVE. The purpose of this article was to study the trends in volume and reimbursement for PICC placement by physicians and advanced practice providers (APPs) for Medicare enrollees from 2010 to 2018 with specific attention to the changes in volume after the publication of MAGIC in 2015. METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010-2018 were extracted using the Current Procedural Terminology code for PICC placement. Total volume and payment amounts (for the professional component) were analyzed. Trendline slopes for volume per 100,000 Medicare beneficiaries before and after the 2015 publication of MAGIC were compared. RESULTS. Volume for PICC placement by physicians and APPs steadily declined from 243,837 in 2010 to 130,361 in 2018 (46.5%). The PICC placement volume decreased sharply after the 2015 publication of the MAGIC guidelines. The slope of the trendline for all providers from 2010 to 2015 was -3.4 compared with -7.3 from 2015 to 2018. The change in slope was more pronounced for radiologists (-3.1 to -5.6) than for APPs (0.0 to -1.1). Professional payment per procedure for radiologists decreased from $78.04 in 2010 to $70.17 in 2018, and reimbursement for APPs proportionally decreased from $65.76 to $60.66 during this time. The relative share of PICC placement by radiologists declined from 77.0% in 2010 to 70.6% in 2018, with a corresponding increase in relative share by APPs from 13.5% to 18.4%. The percentage placed in outpatient procedures increased from 15.1% to 18.2%. CONCLUSION. The volume of PICC placements has steadily decreased since 2010, with a sharper decline between 2015 and 2016 corresponding with the publication of the MAGIC evidence-based guidelines. The role of APPs in PICC placement has increased over this time period. CLINICAL IMPACT. The findings of this study suggest that evidence-based guidelines impact clinical practice on a national level.

A ten-year, single institution experience with percutaneous nephrostomy during pregnancy.

PURPOSE: To evaluate the safety and efficacy of percutaneous nephrostomy (PCN) in pregnancy. MATERIALS AND METHODS: PCN tubes were placed during 52 pregnancies in 49 patients from 2008 to 2018. The medical records during pregnancies were retrospectively reviewed for imaging findings, procedural parameters, outcomes of delivery, and complications. RESULTS: The mean gestational age on percutaneous nephrostomy placement was 27 weeks (range, 8-36 weeks). PCN catheters were placed for the following indications: 1) flank or lower abdominal pain (42%), 2) obstructing calculi (37%), 3) pyelonephritis (20%), and 4) obstructing endometrioma (2%). Prior to PCN, retrograde ureteric stenting was performed in 17 of 49 patients (34%) and attempted but failed in 4 patients (8%). Nephrostomy drainage relieved pain completely or significantly in all 12 patients without prior ureteral stenting, but in only 4 of 10 with retrograde ureteric stents. In one patient in whom the ureteral stent had been removed, PCN relieved her flank pain. The mean number of PCN catheter exchanges was 1.6, ranging from 0 to 9, with a mean time interval of 21.3 days between exchanges. There were 29 difficult exchanges due to encrustation in 15 patients with a mean of 20.5 days between exchanges. CONCLUSIONS: PCN drainage is a safe and effective treatment for managing symptomatic hydronephrosis in pregnant patients but is less effective in treating pain when retrograde ureteral stents are in place. Rapid encrustation, seen more commonly in pregnancy, tends to recur in the same patients and requires more frequent exchanges than the general population.

Bundled Medicare Payments: Trends in Utilization and Physician Payments for Dialysis Arteriovenous Fistula and Graft Maintenance Procedures From 2010 to 2018.

OBJECTIVE. The purposes of this study were to evaluate the volume of and payments for dialysis arteriovenous fistula and arteriovenous graft maintenance procedures among Medicare beneficiaries from 2010 to 2018 and analyze trends by physician specialty and practice setting after the introduction of bundled Current Procedural Terminology (CPT) codes in 2017. MATERIALS AND METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010 through 2018 were extracted by use of the CPT codes for arteriovenous fistula and arteriovenous graft maintenance procedures. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty and practice setting. RESULTS. From 2010 to 2018, the volume of dialysis circuit maintenance procedures increased 25%, from 308,140 to 385,440 procedures. This increase was driven by increased volumes among nephrologists (30.0%) and surgeons (30.5%) with only a modest increase for interventional radiologists (1.5%). Total physician payments increased 20%, from $333.8 million to $399.5 million. After the introduction of bundled CPT codes in 2017, per-procedure physician payment decreased from $1073 in 2016 to $1025 in 2017 (4.5%). The true decrease in per-procedure payment was underestimated owing to inclusion of higher-cost stenting and embolization procedures in the dialysis-specific codes beginning in 2017. CONCLUSION. The volume of dialysis access maintenance procedures and total physician payments increased from 2010 to 2018 in keeping with the Centers for Medicare & Medicaid Services Fistula First Breakthrough Initiative. Introduction of bundled CPT codes in 2017, designed to reduce redundant payments, correlated with a decrease in average per-procedure physician payment.

Trends of utilization and physician payments for vertebroplasty and kyphoplasty procedures by physician specialty and practice setting: 2010 to 2018.

BACKGROUND CONTEXT: In 2010, the American Academy of Orthopedic Surgeons published guidelines strongly recommending against the use of vertebroplasty following the publication of randomized control trials that failed to show significant improvement in pain. Vertebroplasty has remained controversial since those findings. PURPOSE: To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries by physician specialty and practice setting following publication of recommendations against vertebroplasty in 2010. STUDY DESIGN/SETTING: This study uses Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 to determine trends in volume and reimbursement by physician specialty and practice setting. PATIENT SAMPLE: All vertebral augmentation procedures with a physician reimbursement claims approved by Medicare Part B from 2010 to 2018. OUTCOME MEASURES: This study analyzes trends in volume and physician payment of vertebroplasty and kyphoplasty procedures by physician specialty for the time period 2010 to 2018. METHODS: Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty. RESULTS: Between 2010 and 2018, the total volume of vertebroplasties decreased by 61.2% (29,995 to 11,654), whereas the volume of kyphoplasties increased modestly by 14.4% (59,691 to 68,294). Radiologists performed an increasing share of both procedures over this time period, from 68.5% to 75.1% for vertebroplasties and 28.9% to 37.1% for kyphoplasties. Total payment for vertebroplasties decreased by 74.3% from $14.8 million in 2010 to $3.8 million in 2018; whereas it increased by 235.3% for kyphoplasty procedures from $26.7 million to $89.7 million. This is driven in large part by a 6,833% increase in office based kyphoplasties which bill at the higher nonfacility rate that incorporates overhead, staff, and equipment. CONCLUSIONS: Previous studies have demonstrated mixed evidence for benefits of vertebroplasty procedures and decreasing volumes over time. Data show continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, the growing number of kyphoplasties correlated with a sharp rise in volume and increased reimbursement for office-based procedures. Radiologists have been performing an increasing share of both procedures.

Percutaneous thermal ablation for treatment of osteoid osteoma: a systematic review and analysis.

OBJECTIVE: Although radiofrequency ablation is well validated for treatment of osteoid osteoma, newer technologies, namely cryoablation, have been less thoroughly studied. The purpose is to perform a systematic review and pooled analysis of percutaneous ablation technologies for treatment of osteoid osteoma with subset analysis of intra-articular and spinal tumors. MATERIAL AND METHODS: A total of 36 of 79 identified manuscripts met inclusion criteria, comprising 1863 ablations in 1798 patients. Inclusion criteria were (1) retrospective or prospective analysis of thermal ablation of osteoid osteomas in any location, (2) at least 6 months of clinical follow-up, (3) 10 or more patients, (4) patients not included in a second study included in this review, and (5) English language or English translation available. Success rate was defined as all ablations minus technical failures, clinical failures, and recurrences. Subset analysis of intra-articular and spinal tumors was performed. RESULTS: Overall success rate was 91.9% (95% CI 91-93%). Technical failure, clinical failure, and recurrence rates were 0.3%, 2.1%, and 5.6% respectively. Complications were seen in 2.5% (95% CI 1.9-3.3%) patients. There was no significant difference when comparing radiofrequency ablation and cryoablation (p = 0.92). Success rates for intra-articular (radiofrequency ablation) and spinal tumors (radiofrequency and cryoablation) were 97% and 91.6% respectively. CONCLUSION: Percutaneous ablation of osteoid osteomas was highly successful with low complication rates. Efficacy of radiofrequency ablation and cryoablation is similar, which is consequential because cryoablation is associated with decreased pain, predictable nerve regeneration, and theoretical immunotherapy benefits. Treatment of more challenging intra-articular and spinal lesions demonstrated similarly high success and low complication rates.

Hepatic Venous Pressure Gradient Measurements in Children: Correlation With Hepatic Histology and Clinical Indicators of Portal Hypertension.

OBJECTIVES: In adults, elevated hepatic venous pressure gradients (HVPGs) are correlated with the degree of liver fibrosis on histopathology and predict worse outcomes including variceal bleeding and death. We aimed to examine the association between HVPG measurements, histopathologic findings, and clinical indicators of portal hypertension in children. METHODS: Utilizing retrospective data from 2 pediatric centers between 2006 and 2015, we identified children who underwent simultaneous HVPG measurement and transjugular liver biopsy. Medical charts were reviewed for histopathology, imaging, endoscopic, and clinical data. RESULTS: Forty-one children (median age 11 years) were included in the analysis with diagnoses of acute hepatitis (n = 15), chronic liver disease (n = 12), hepatic noncirrhotic portal hypertension (n = 4), acute liver failure (n = 3), and nonhepatic causes of portal hypertension (n = 7). Elevated mean HVPG measurements were found in children with acute liver failure (10 mmHg, range 4-12) and chronic liver disease (7 mmHg, range 1-12). HVPG measurements did not correlate with the histological severity of fibrosis (ρ = 0.23, P = 0.14) or portal inflammation (ρ = 0.24, P = 0.29), and no difference was found in HVPG when comparing children with and without a history of variceal bleeding (P = 0.43). CONCLUSIONS: HVPG measurements do not correlate significantly with the degree of hepatic fibrosis on biopsy. Furthermore, HVPG measurements are not associated with the presence of varices or history of variceal bleeding, suggesting the possibility of intrahepatic shunting in children with advanced liver disease. Therefore, unlike in adults, HVPG measurements may not accurately predict children who are at risk of complications from portal hypertension.

Structured Protocol for Benign Biliary Anastomotic Strictures: Impact on Long-Term Clinical Effectiveness.

OBJECTIVE: The purpose of this study is to compare long-term clinical effectiveness before and after implementation of a structured protocol for percutaneous drainage of benign anastomotic biliary strictures. MATERIALS AND METHODS: Three hundred five adult patients undergoing percutaneous biliary drainage for biliary anastomotic strictures between 1994 and 2015 were identified using Current Procedural Terminology billing codes, with 234 undergoing intervention before implementation of a structured protocol and 71 undergoing intervention after implementation of the protocol. The frequency of surgical anastomotic revision was compared between patients treated before and after the implementation of the structured protocol. Patient characteristics and treatment variables were also analyzed with respect to the frequency of surgical revision. A Kaplan-Meier analysis was performed to determine the long-term probabilities of avoiding surgical revision and patency rates. RESULTS: Overall, 72.8% of patients avoided surgical revision, with 71.1% before and 81.7% after the protocol was implemented (p = 0.1052). A larger maximum drain size was significantly associated with a lower frequency of surgical revision (p = 0.0006). The rates of surgical avoidance 5 years after treatment before and after protocol implementation were 69.1% and 80.8%, respectively. Patency rates 5 years after treatment before and after protocol implementation were 73.8% and 76.8%, respectively. CONCLUSION: Percutaneous drainage and management of benign biliary anastomotic strictures is an effective treatment regardless of the presence of a structured protocol. Although there was no significant benefit in terms of avoidance of surgical revision, the time until surgical revision and patency rates were increased with the protocol. In addition, a larger maximum drain size was associated with a better outcome.

Single-stick tunneled central venous access using the jugular veins in infants weighing less than 5 kg.

BACKGROUND: Despite the demonstrated feasibility of the single-stick technique in the femoral vein, its use in neonates and infants for placing central lines in internal and external jugular veins has not been reported. OBJECTIVE: Describe and assess the safety and efficacy of tunneled jugular central venous catheter placement performed under ultrasound (US) and fluoroscopic guidance in neonates and infants weighing <5 kg using the single-stick technique at three tertiary pediatric hospitals. MATERIALS AND METHODS: Thirty-three children weighing less than 5 kg received tunneled central venous access in either internal or external jugular veins using the single-stick technique. Patient history, procedural records and clinical follow-up documents were retrospectively reviewed. Complication rates were compared to those of 41 patients receiving single-stick femoral central lines. RESULTS: Technical complications occurred during one (3.0%) jugular placement with the patient having a failed right-side attempt with subsequent successful left-side placement. The catheters did not last the entire course of treatment in three (9.1%) patients with jugular lines. One patient had the catheter removed due to concern for infection, one catheter was accidentally removed during dressing changes, and one catheter was displaced and subsequently exchanged. Of patients receiving femoral central lines, 1 (2.4%) had a technical complication and 5 catheters (12.2%) did not last the entire course of treatment. CONCLUSION: The placement of tunneled central venous catheters in neonates/infants <5 kg is safe and technically feasible using the internal/external jugular vein via the single-stick technique. By theoretically reducing the risks of catheter infection by avoiding the diaper area and thrombosis by using larger veins, it may be preferable in certain patient populations.

The effects of expanding outpatient and inpatient evaluation and management services in a pediatric interventional radiology practice.

BACKGROUND: Despite a continuing emphasis on evaluation and management clinical services in adult interventional radiology (IR) practice, the peer-reviewed literature addressing these services - and their potential economic benefits - is lacking in pediatric IR practice. OBJECTIVE: To measure the effects of expanding evaluation and management (E&M) services through the establishment of a dedicated pediatric interventional radiology outpatient clinic and inpatient E&M reporting system. MATERIALS AND METHODS: We collected and analyzed E&M current procedural terminology (CPT) codes from all patients seen in a pediatric interventional radiology outpatient clinic between November 2014 and August 2015. We also calculated the number of new patients seen in the clinic who had a subsequent procedure (procedural conversion rate). For comparison, we used historical data comprising pediatric patients seen in a general interventional radiology (IR) clinic for the 2 years immediately prior. An inpatient E&M reporting system was implemented and all inpatient E&M (and subsequent procedural) services between July 2015 and September 2015 were collected and analyzed. We estimated revenue for both outpatient and inpatient services using the Medicare Physician Fee Schedule global non-facility price as a surrogate. RESULTS: Following inception of a pediatric IR clinic, the number of new outpatients (5.5/month; +112%), procedural conversion rate (74.5%; +19%), estimated E&M revenue (+158%), and estimated procedural revenue from new outpatients (+228%) all increased. Following implementation of an inpatient clinic reporting system, there were 8.3 consults and 7.3 subsequent hospital encounters per month, with a procedural conversion rate of 88%. CONCLUSION: Growth was observed in all meaningful metrics following expansion of outpatient and inpatient pediatric IR E&M services.

Ultrasound-Guided Liver Biopsy With Gelatin Sponge Pledget Tract Embolization in Infants Weighing Less Than 10 kg.

OBJECTIVES: The aim of the study was to describe and assess the technical success and safety of ultrasound-guided liver biopsy with gelatin sponge pledget tract embolization technique in infants <10 kg across 3 tertiary pediatric hospitals. MATERIALS AND METHODS: There were 67 pediatric patients weighing <10 kg (36 boys; 31 girls; average age 202 days; average weight 6 kg, range 1.5-9.9 kg) referred for liver biopsy performed with ultrasound guidance and gelatin sponge pledget tract embolization during a 2-year period. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. RESULTS: A total of 67 procedures were included. There was 100% technical success rate and all samples obtained provided adequate tissue for histological assessment. Average number of 18 G biopsy passes was 3 (range 1-6). There were no procedure-related deaths. There was 1 complication (1%) in a 5-kg infant who was readmitted 36 hours after biopsy with a fever and fully recovered after antibiotics were administered. Biliary atresia was the most common underlying diagnosis (20%), whereas others included acute rejection (16%) and biliary obstruction (7%). CONCLUSIONS: Ultrasound-guided percutaneous liver biopsy with gelatin sponge pledget tract embolization technique in children weighing <10 kg is safe, effective, and use of this technique may lead to a reduction in rates of adverse events reported in other pediatric series.