Percutaneous Ultrasound Guided Gastrostomy Tube Placement: A Prospective Cohort Trial.

BACKGROUND: To compare the safety and efficacy of percutaneous ultrasound guided gastrostomy (PUG) tube placement with traditional fluoroscopic guided percutaneous gastrostomy tube placement (PRG). METHODS: A prospective, observational, non-randomized cohort trial was performed comparing 25 consecutive patients who underwent PUG placement between April 2020 and August 2020 with 25 consecutive patients who underwent PRG placement between February 2020 and March 2020. Procedure time, sedation, analgesia requirements, and complications were compared between the two groups in non-inferiority analysis. RESULTS: Technical success rates were 96% in both groups (24/25) of procedures. Ninety-two percent of patients in the PUG cohort were admitted to the ICU at the time of G-tube request. Aside from significantly more COVID-19 patients in the PUG group (P < .001), there was no other statistically significant difference in patient demographics. Intra-procedure pain medication requirements were the same for both groups, 50 micrograms of IV fentanyl (P = 1.0). Intra-procedure sedation with IV midazolam was insignificantly higher in the PUG group 1.12 mg vs 0.8 mg (P = .355). Procedure time trended toward statistical significance (P = .076), with PRG being shorter than PUG (30.5 ± 14.1 minutes vs 39.7 ± 17.9 minutes). There were 2 non-device related major complications in the PUG group and 1 major and 1 minor complication in the PRG group. CONCLUSION: PUG is similar in terms of complications to PRG gastrostomy tube placement and a safe method for gastrostomy tube placement in the critically ill with the added benefits of bedside placement, elimination of radiation exposure, and expanded and improved access to care.

Thoracic Trauma, Nonaortic Injuries.

Trauma is one of the leading causes of death worldwide. Approximately two-thirds of trauma patients have thoracic injuries. Nonvascular injury to the chest is most common; however, while vascular injuries to the chest make up a small minority of injuries in thoracic trauma, these injuries are most likely to require intervention by interventional radiology (IR). IR plays a vital role, with much to offer, in the evaluation and management of patients with both vascular and nonvascular thoracic trauma; in many cases, IR treatments obviate the need for these patients to go to the operating room. This article reviews the role of IR in the treatment of vascular an nonvascular traumatic thoracic injuries.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients.

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

ACR Appropriateness Criteria® Nonatherosclerotic Peripheral Arterial Disease.

A broad range of nonatherosclerotic diseases affect the peripheral arteries. The appropriate initial diagnostic imaging studies vary, depending upon the clinical presentation and suspicion of disease. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome or guiding surgical management. The scenarios discussed in this document include the initial evaluation of suspected popliteal entrapment syndrome, external iliac artery endofibrosis, lower-extremity inflammatory vasculitides, dissection or connective tissue disease, noninflammatory vascular disease, and vascular trauma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Abdominal Aortic Aneurysm Follow-up (Without Repair).

Abdominal aortic aneurysm (AAA) is defined as aneurysmal dilation of the abdominal aorta to 3 cm or greater. A high degree of morbidity and mortality is associated with AAA rupture, and imaging surveillance plays an essential role in mitigating the risk of rupture. Aneurysm size and growth rate are factors associated with the risk of rupture, thus surveillance imaging studies must be accurate and reproducible to characterize aneurysm size. Ultrasound, CT angiography, and MR angiography provide an accurate and reproducible assessment of size, while radiographs and aortography provide limited evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute pulmonary embolism: endovascular therapy.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

ACR Appropriateness Criteria® Lower Extremity Arterial Revascularization-Post-Therapy Imaging.

Peripheral arterial disease (PAD) affects millions across the world and in the United States between 9% to 23% of all patients older than 55 years. The refinement of surgical techniques and evolution of endovascular approaches have improved the success rates of revascularization in patients afflicted by lower extremity PAD. However, restenosis or occlusion of previously treated vessels remains a pervasive issue in the postoperative setting. A variety of different imaging options are available to evaluate patients and are reviewed within the context of asymptomatic and symptomatic patients with PAD who have previously undergone endovascular or surgical revascularization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Iliac Artery Occlusive Disease.

Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chylothorax Treatment Planning.

Chylothorax is an uncommon but serious medical condition, which arises when intestinal lymphatic fluid leaks into the pleural space. Treatment strategies depend on the daily output and underlying etiology, which may be due to direct injury to lymphatic vessels or a nontraumatic disorder. Chest radiographs confirm the presence of pleural fluid and lateralize the process. In the setting of direct injury, lymphangiography can often be both diagnostic and facilitate a minimally invasive attempt at therapy. CT and MRI in this setting may be appropriate for cases when lymphangiography is not diagnostic. When the etiology is nontraumatic or unknown, CT or MRI can narrow the differential diagnosis, and lymphangiography is useful if a minimally invasive approach to treatment is desired. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pulsatile Abdominal Mass Suspected Abdominal Aortic Aneurysm.

Clinical palpation of a pulsating abdominal mass alerts the clinician to the presence of a possible abdominal aortic aneurysm (AAA). Imaging studies are important in diagnosing and categorizing the extent of the aneurysm and may aid in treatment planning. The consensus of the literature supports the use of ultrasound as the initial screening test in patients with suspected AAA. Population-based ultrasound screening studies have been recommended and have proved effective for male patients > 65 years of age. For diagnosis and pre-intervention evaluation, either multidetector CT or CT angiography is the optimal choice for detailed characterization of the aneurysm. MR angiography may be substituted if CT cannot be performed (for example, because the patient is allergic to iodinated contrast material). Invasive angiography has little role in the diagnosis of AAA and PET and CT remain experimental in patients with suspected aneurysms. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg.

Acute limb ischemia (ALI) requires urgent diagnosis and treatment to prevent limb loss. Invasive digital subtraction arteriography (DSA) is the gold standard for diagnosing ALI. DSA is the only diagnostic modality that permits simultaneous treatment of acute arterial occlusion. Noninvasive imaging with MRA or CT angiography may also be appropriate before treatment, especially when the diagnosis of ALI is in doubt or where DSA is unavailable. Other imaging and noninvasive physiologic tests may prove important for longer term management but are less recommended in the acute setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease.

Noninvasive physiologic vascular studies play an important role in the diagnosis and characterization in peripheral arterial disease (PAD) of the lower extremity. These studies evaluate the physiologic parameters of blood flow through segmental arterial pressures, Doppler waveforms, and pulse volume recordings. Collectively, they comprise a powerful toolset for defining the functionality of the arterial system, localizing the site of disease, and providing prognostic data. This technology has been widely adopted by diverse medical specialty practitioners, including radiologists, surgeons, cardiologists, and primary care providers. The use of these studies increased substantially between 2000 and 2010. Although they do not employ imaging, they remain a critical component for a comprehensive radiologic vascular laboratory. A strong presence of radiology in the diagnosis of PAD adds value in that radiologists have shifted to noninvasive alternatives to diagnostic catheter angiography (DCA), such as computed tomography (CT) and magnetic resonance (MR) angiography, which provide a more efficient, less-expensive, and lower-risk alternative. Other specialties have increased the use of DCA during the same period. The authors provide a review of the relevant anatomy and physiology of PAD as well as the associated clinical implications. In addition, guidelines for interpreting the ankle-brachial index, segmental pressures, Doppler waveforms, and pulse volume recordings are reviewed as well as potential limitations of these studies. Noninvasive physiologic vascular studies are provided here for review with associated correlating angiographic, CT, and/or MR findings covering the segmental distribution of PAD as well as select nonatherosclerotic diagnoses. ©RSNA, 2016.

The Utility of Viscoelastic Testing in Patients Undergoing IR Procedures.

Whole-blood viscoelastic testing can identify patient-specific coagulation disturbances, allowing for targeted repletion of necessary coagulation factors and differentiation between coagulopathy and surgical bleeding that requires intervention. Viscoelastic testing complements standard coagulation tests and has been shown to decrease transfusion requirements and improve survival in bleeding patients. Viscoelastic testing also can be used to predict bleeding and improve the care of patients undergoing interventional radiology (IR) procedures.

Tumor Enhancement and Heterogeneity Are Associated With Treatment Response to Drug-Eluting Bead Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: Treatment response to drug-eluting bead chemoembolization (DEB-TACE) is well established for patients with hepatocellular carcinoma (HCC); however, few studies have evaluated tumor imaging characteristics associated with treatment responses. The aim of our study was to identify imaging characteristics associated with treatment responses and overall survival after DEB-TACE of HCC. METHODS: This is a retrospective cohort study of 33 tumors in 32 patients who underwent DEB-TACE for inoperable HCC in a single, large academic medical center. Arterial phase computed tomography data were reviewed to assess tumor size, edge characteristics, tumor enhancement on pixel density histogram, and heterogeneity using coefficient of variation. We assessed correlation between these markers of tumor morphology and response to DEB-TACE using mRECIST criteria, progression-free survival, and overall survival. RESULTS: Tumor heterogeneity (P = 0.01) and tumor enhancement greater than 50% (P = 0.05) were significantly associated with complete response to DEB-TACE in patients with HCC; however, neither was associated with overall or progression-free survival. Tumor size and edge characteristics were not associated with complete response to DEB-TACE, although tumor size greater than 6 cm was associated with worse overall survival (hazard ratio, 3.349; P = 0.02). CONCLUSIONS: Tumor heterogeneity and enhancement on arterial phase imaging may be predictive markers of treatment response to DEB-TACE among patients with HCC.

Safety and Effectiveness of the Denali Inferior Vena Cava Filter: Intermediate Follow-Up Results.

PURPOSE: The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS: In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed. RESULTS: Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs. CONCLUSION: The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.

Utility of Intravascular US-Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients.

PURPOSE: To compare safety and effectiveness of intravascular ultrasound (US)-guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. MATERIALS AND METHODS: In this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass-related capsular perforation were recorded. RESULTS: Baseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US-guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass-related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US-guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US-guided TIPS (P = .004). CONCLUSIONS: Intravascular US-guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass-related capsular perforations, and reduced radiation dose.

Approaching the Practice Quality Improvement Project in Interventional Radiology.

An important component of maintenance of certification and quality improvement in radiology is the practice quality improvement (PQI) project. In this article, the authors describe several methodologies for initiating and completing PQI projects. Furthermore, the authors illustrate several tools that are vital in compiling, analyzing, and presenting data in an easily understandable and reproducible manner. Last, they describe two PQI projects performed in an interventional radiology division that have successfully improved the quality of care for patients. Using the DMAIC (define, measure, analyze, improve, control) quality improvement framework, interventional radiology throughput has been increased, to lessen mediport wait times from 43 to 8 days, and mediport infection rates have decreased from more than 2% to less than 0.4%.