Accreditation: RPVI, RVT, IAC Accreditation, and ACR Accreditation.

Personnel and department accreditation are means by which institutions can evaluate, demonstrate, and maintain the highest level of patient care. In this article, we will discuss the certification and the resources for physicians (RPVI) and technologists (RVT) who provide care to patients in the vascular lab (VL) as well as information about certification by the two accrediting bodies - the Intersocietal Accreditation Commission (IAC) and the American College of Radiology (ACR) - that accredit VLs. Noninvasive vascular testing provides timely delivered valuable information to healthcare providers. Accreditation recognizes quality vascular testing services, but also facilitates a process of education and the quality assurance to improve the overall quality of vascular labs (VL).

Anti-Restenotic Technologies in the SFA: Balloons and Stents.

Peripheral arterial disease (PAD) is a common condition, which significantly impacts the quality and length of life. In recent years, drug-eluting devices have demonstrated improved clinical effectiveness for treating peripheral arterial disease in the femoropopliteal arteries compared to traditional stents and angioplasty balloons. However, recent controversial studies have called the safety of this technology into question, leading to confusion as to if, when, and how these devices should be used. This article focuses on the underlying pathophysiology and pharmacology, the clinical benefits and potential harms, as well as expected future developments affecting the use of these drug-eluting technologies in treating peripheral arterial disease of the superficial femoral arteries.

"Catch, Flip, and Remove" Technique for Retrieval of a Hypermobile Detached Leadless Pacemaker: A Case Report and Literature Review.

Leadless pacemaker (LP) detachment is a rare but life-threatening complication that may occur during implantation. While different snaring techniques have been described to remove partially or completely detached LPs, there are currently no reports of snaring a hypermobile LP that travels between different cardiac chambers. This report describes a technique to successfully snare a hypermobile detached LP by first "catching" onto the tines for stabilization with the help of a multi-loop snare, followed by using a second snare for the proximal retrieval feature.

Imaging of Patellofemoral Instability.

Patellar instability is a broad term that encompasses patellar dislocation, patellar subluxation, and patellar instability. Although both functional and anatomic considerations contribute to symptoms of patellar instability, the most important are thought to be patella alta, trochlear dysplasia, and lateralization of the tibial tubercle. In patients with a history suspicious for prior patellar dislocation, careful evaluation of MRI and radiographic studies can reveal characteristic findings. The most common methods to address patellofemoral instability are medial patellofemoral ligament reconstruction and tibial tubercle osteotomy with either anteromedialization or medialization. Less commonly trochleoplasty is indicated as well. Patients may be treated with one of or a combination of these techniques, each of which has specific indications and complications.

Computational Prediction of All Lanthanide Aqua Ion Acidity Constants.

The protonation state of lanthanide-ligand complexes, or lanthanide-containing porous materials, with many Brønsted acid sites can change due to proton loss/gain reactions with water or other heteroatom-containing compounds. Consequently, variations in the protonation state of lanthanide-containing species affect their molecular structure and desired properties. Lanthanide(III) aqua ions undergo hydrolysis and form hydroxides; they are the best characterized lanthanide-containing species with multiple Brønsted acid sites. We employed constrained ab initio molecular dynamics simulations and electronic structure calculations to determine all acidity constants of the lanthanide(III) aqua ions solely from computation. The first, second, and third acidity constants of lanthanide(III) aqua ions were predicted, on average, within 1.2, 2.5, and 4.7 absolute pKa units from experiment, respectively. A table includes our predicted pKa values alongside most experimentally measured pKa values known to date. The approach presented is particularly suitable to determine the Brønsted acidity of lanthanide-containing systems with multiple acidic sites, including those whose measured acidity constants cannot be linked to specific acid sites.

Retrieval of Bard Simon Nitinol inferior vena cava filters: Approaches, technical successes, complications, and clinical outcomes.

OBJECTIVE: The Simon Nitinol filter is a bi-level filtration device designed for permanent implantation that is no longer commercially available, but may result in similar complications to current commercially available long term indwelling temporary or permanent filters. Complications related to indwelling inferior vena cava filters include inferior vena cava thrombosis, inferior vena cava penetration, filter migration, and filter fracture. There is a paucity of reports describing the technical aspects related to retrieval of Simon Nitinol filters. MATERIALS AND METHODS: This study consisted of five patients with Simon Nitinol filters and describes the indication for retrieval, the retrieval techniques used to remove the filters, technical success, complications, and clinical course. RESULTS: The indications for retrieval included: abdominal pain (n = 2; 40%), iliocaval thrombosis (n = 1; 20%), identification of an intracardiac filter fragment (n = 1; 20%), and recurrent venous thromboembolic events (n = 1; 20%). Retrieval techniques included: biopsy forceps (n = 3; 60%), excimer laser extraction sheaths (n = 3; 60%), hangman modified loop snares (n = 3; 60%), rigid endobronchial forceps (n = 2; 40%), and balloon deflection (n = 2; 40%). All filters were successfully retrieved. One patient developed a post-procedural intramuscular hematoma near the site of right internal jugular sheath placement. CONCLUSIONS: Simon Nitinol filters may be retrieved safely and effectively using advanced inferior vena cava filter retrieval techniques.

Nicotine Induces IL-8 Secretion from Pancreatic Cancer Stroma and Worsens Cancer-Induced Cachexia.

Smoking is highly associated with pancreatic cancer. Nicotine, the addictive component of tobacco, is involved in pancreatic cancer tumorigenesis, metastasis, and chemoresistance. This work aimed to describe the role of nicotine within the pancreatic cancer tumor microenvironment. Nicotine treatment was used in vitro to assess its effect on tumor-associated stromal cells and pancreatic cancer cells. Nicotine treatment was then used in a pancreatic cancer patient-derived xenograft model to study the effects in vivo. Nicotine induced secretion of interleukin 8 (IL-8) by tumor-associated stroma cells in an extracellular signal-regulated kinase (ERK)-dependent fashion. The secreted IL-8 and nicotine acted on the pancreatic cancer cell, resulting in upregulation of IL-8 receptor. Nicotine treatment of mice bearing pancreatic cancer patient-derived xenografts had significantly increased tumor mass, increased tumor-free weight loss, and decreased muscle mass. These represent important pathways through which nicotine acts within the tumor microenvironment and worsens pancreatic cancer-induced cachexia, potentially representing future therapeutic targets.

Interventional Radiology-Operated Endoscopy as an Adjunct to Image-Guided Interventions.

PURPOSE: Interventional radiology-operated endoscopy is an underused technique, which may have a significant impact on the ability to treat patients with a variety of conditions. The purpose of this article is to discuss the setup, equipment, and potential clinical uses of interventional radiology-operated endoscopy. METHODS: A number of new and innovative interventions may be performed in the biliary, genitourinary, and gastrointestinal systems through percutaneous access that interventional radiologists already create. When used in combination, endoscopy adds an entirely new dimension to the fluoroscopic-guided procedures of which interventional radiologists are accustomed. RESULTS: Interventional radiologists are in a unique position to implement endoscopy into routine practice given the manual dexterity and hand-eye coordination already required to perform other image-guided interventions. CONCLUSION: Although other specialists traditionally have performed endoscopic interventions and local politics often dictate referral patterns, a collaborative relationship among these specialists and interventional radiology will allow for improved patient care. A concerted effort is needed by interventional radiologists to learn the techniques and equipment required to successfully incorporate endoscopy into practice.

Endobronchial Forceps-Assisted Removal of Gianturco Z-Stents from the Right Atrium.

Endovascular treatment of malignant intrahepatic inferior vena cava stenosis involves venoplasty and stenting. Intravascular migration is a complication associated with stents. This technical report describes the retrieval of migrated intracardiac Gianturco Z-stents using rigid endobronchial forceps.

Transvenous Biopsy in the Diagnosis of Intravascular or Perivascular Neoplasm: A Single-Center Retrospective Analysis of 36 Patients.

Between September 2008 and August 2017, 36 patients (mean age 56 y; range, 30-89 y) underwent transvenous biopsy of suspected tumor thrombus or perivascular tumor. Intravascular biopsy was pursued because of inaccessible percutaneous access in 9 patients (25%) and as part of a planned revascularization procedure in 27 patients (75%). Histopathologic results showed malignancy in 26 patients (72%) and benign etiologies in 10 patients (28%). No patients required repeat biopsy. There were no complications related to the biopsy procedure. The present series suggests that transvenous biopsy is a safe and accurate method of intravascular and perivascular mass tissue sampling.

Endovascular Management of Acute Traumatic Aortic Injury.

Acute traumatic injury of the thoracic aorta is a highly lethal condition, with many afflicted patients expiring before hospital arrival. While previously these conditions were managed with open surgery, endovascular repair has rapidly evolved and is now considered the standard of care for certain patterns of aortic injury at centers with appropriate expertise. The development of newer branched devices has allowed these techniques to be utilized further and further proximally into the aorta. Through minimally invasive techniques, many aortic injuries can now be treated percutaneously with shorter recovery time and less perioperative complications.

Step-by-Step Approach to Management of Type II Endoleaks.

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.

Removal of T-Fasteners Immediately After Percutaneous Gastrostomy Tube Placement: Experience in 488 Patients.

OBJECTIVE: The purpose of this article is to evaluate the safety of T-fastener removal immediately after percutaneous gastrostomy tube placement by assessing difference in complication rates between early and delayed gastropexy removal. MATERIALS AND METHODS: A retrospective review was performed of the electronic medical records of all patients who underwent percutaneous gastrostomy at our institution from January 2015 to June 2017. A total of 722 patients successfully underwent gastrostomy tube insertion during this period. Two hundred twenty-two patients were excluded from analysis on the basis of our exclusion criteria. Twelve patients were lost to follow-up. The remaining patients were divided into two groups: group 1 included 350 patients who had their T-fasteners released immediately after gastrostomy, and group 2 included 138 patients whose T-fasteners were left in place for 2 weeks. Electronic medical records were reviewed for postprocedure complications for up to 1 month. Complications were classified according to Society of Interventional Radiology classification. Statistical analysis was performed using a logistic regression model with calculation of odds ratios, power, p values, and 95% CIs. RESULTS: Seven (2.0%) major and 24 (6.8%) minor complications occurred in group 1. Two (1.4%) major and 11 (7.9%) minor complications occurred in group 2. There was no statistically significant difference in complication rates between immediate and delayed gastropexy removal. CONCLUSION: In our study, immediate removal of T-fasteners was not associated with a higher complication rate.

Endovascular management of acute aortic dissection.

Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.

Type II endoleaks: diagnosis and treatment algorithm.

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.

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.

Endovascular Iliocaval Reconstruction for Chronic Iliocaval Thrombosis: The Data, Where We Are, and How It is Done.

Iliocaval thrombosis, or thrombosis of the inferior vena cava and iliac veins, is associated with significant morbidity in the form of limb-threatening compromise from phlegmasia cerulean dolens, development of post-thrombotic syndrome, and death secondary to pulmonary embolism. Endovascular iliocaval reconstruction is an effective treatment for iliocaval thrombosis with high levels of technical success, favorable clinical outcomes and stent patency rates, and few complications. It is often able to relieve the debilitating symptoms experienced by affected patients and is a viable option for patients who fail conservative management. This article presents an approach to endovascular iliocaval stent reconstruction in patients suffering from chronic iliocaval thrombosis that takes into consideration background, patient selection and indications, timing of intervention, procedural steps, technical considerations, postprocedural care, and outcomes, along with providing schematic illustrations that serve to outline iliocaval stent reconstruction and management of chronic venous occlusions.