Left Common Iliac Vein Stenting in a Case of Postural Orthostatic Tachycardia Syndrome/Pelvic Pain Overlap.

Postural orthostatic tachycardia syndrome (POTS) is mainly characterized by orthostatic intolerance and positional tachycardia although it frequently involves a myriad of non-specific symptoms that seem to overlap with existing medical conditions. Recent efforts have been made to further classify subtypes of POTS and associated conditions to better delineate underlying pathophysiology in an effort to guide diagnosis and tailor treatment. Here, we present a 22-year-old female with debilitating symptoms of POTS who reported pelvic pain on review of systems and underwent vascular ultrasound of the inferior vena cava, iliac veins, and bilateral lower extremities which revealed the characteristic left common iliac vein compression of May-Thurner syndrome prompting venous stenting which provided systemic symptomatic relief.

Preoperative Computed Tomography-Guided Pulmonary Lesion Marking in Preparation for Fluoroscopic Wedge Resection-Rates of Success, Complications, and Pathology Outcomes.

PURPOSE: In this study, we describe our experience of lesion marking with fiducial markers (FM) and microcoils (MC) facilitating same-day surgical wedge resection, including success rates, pathology outcomes, and complications. We also explored patient/nodular characteristics associated with developing complications. MATERIALS AND METHODS: An IRB-approved single-institutional retrospective study of 136 patients who had 148 pulmonary nodules was conducted. All patients had CT-guided pulmonary nodule labeling with either FM (121) or MC (15) patients with plan for same-day fluoroscopic-guided wedge resection. RESULTS: Of 136 (98%) patients, 133 had successful same-day wedge resection as planned; 2 had delayed but successful wedge resection surgery due to complications at the time of marker placement (fiducial embolization and hemorrhage/pneumothorax, respectively). A third patient ultimately needed lobectomy due to deep lesion location. Eighty percent [118/148] of resected nodules were malignant. Further, 68% of the total group of patients [93/136] had mild complications of various types including hemorrhage [44/136, 32%], pneumothorax [35/136, 26%], a combination of both hemorrhage and pneumothorax [10/136, 7%], or migration/embolization [4/136, 3%]. Depth of nodule from skin (P = 0.011) and pleura (P = 0.027) was significantly associated with complications. CONCLUSION: CT-guided marking of small or deep pulmonary lesions using either fiducial markers or microcoils provides an effective means to aid surgeons to accomplish minimally invasive wedge resection. The importance of the success of this technique is supported by the high incidence (80%) of malignant lesion etiology found at postresection pathology. Although complications occurred, the vast majority were mild and did not alter planned same-day resection.

Managing Venous Thromboembolic Disease On-Call.

Managing venous thromboembolic disease on-call requires the interventional radiologist consider not only potential risk and benefit to the patient but also available resources in the IR suite as well as throughout the hospital, such as intensive care monitoring during treatment. We demonstrate how our practice manages these on-call cases ranging from deep venous thrombosis to acute pulmonary embolism and decide which patients need emergent treatment and which can undergo delayed intervention during working hours. In all cases, an adequate preprocedural clinical assessment is crucial.

Percutaneous Image-Guided Cryoablation for the Treatment of Phantom Limb Pain in Amputees: A Pilot Study.

PURPOSE: To prospectively evaluate percutaneous image-guided nerve cryoablation for treatment of refractory phantom limb pain (PLP) in a pilot cohort for purposes of deriving parameters to design a larger, randomized, parallel-armed, controlled trial. MATERIALS AND METHODS: From January 2015 to January 2016, 21 patients with refractory PLP underwent image-guided percutaneous cryoneurolysis procedures. Visual analog scale scores were documented at baseline and 7, 45, and 180 days after the procedure. Responses to a modified Roland Morris Disability Questionnaire were documented at baseline and 7 and 45 days after the procedure. RESULTS: Technical success rate of the procedures was 100%. There were 6 (29%) minor procedure-related complications. Disability scores decreased from a baseline mean of 11.3 to 3.3 at 45-day follow-up (95% confidence interval 5.8, 10.3; P < .0001). Pain intensity scores decreased from a baseline mean of 6.2 to 2.0 at long-term follow-up (95% confidence interval 2.8, 5.6; P < .0001). CONCLUSIONS: Image-guided percutaneous nerve cryoablation is feasible and safe and may represent a new efficacious therapeutic option for patients with phantom pains related to limb loss.

Standardized Reporting in IR: A Prospective Multi-Institutional Pilot Study.

PURPOSE: To assess adoption and survey-based satisfaction rates following deployment of standardized interventional radiology (IR) procedure reports across multiple institutions. MATERIALS AND METHODS: Standardized reporting templates for 5 common interventional procedures (central venous access, inferior vena cava [IVC] filter insertion, IVC filter removal, uterine artery embolization, and vertebral augmentation) were distributed to 20 IR practices in a prospective quality-improvement study. Participating sites edited the reports according to institutional preferences and deployed them for a 1-year pilot study concluding in July 2015. Study compliance was measured by sampling 20 reports of each procedure type at each institution, and surveys of interventionalists and referring physicians were performed. Modifications to the standardized reporting templates at each site were analyzed. RESULTS: Ten institutions deployed the standardized reports, with 8 achieving deployment of 3-12 months. The mean report usage rate was 57%. Each site modified the original reports, with 26% mean reduction in length, 18% mean reduction in wordiness, and 60% mean reduction in the number of forced fill-in fields requiring user input. Linear-regression analysis revealed that reduced number of forced fill-in fields correlated significantly with increased usage rate (R2 = 0.444; P = .05). Surveys revealed high satisfaction rates among referring physicians but lower satisfaction rates among interventional radiologists. CONCLUSIONS: Standardized report adoption rates increased when reports were simplified by reducing the number of forced fill-in fields. Referring physicians preferred the standardized reports, whereas interventional radiologists preferred standard narrative reports.

The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications.

The numbers of nurse practitioners (NPs) and physician assistants (PAs) are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. The use of radiologist assistants is growing in some radiology practices as well. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside radiology departments warrants closer review, particularly with regard to their potential influence on radiology education and medical imaging resource utilization. In this article (the second in a two-part series), the authors review recent literature and offer recommendations for radiology practices regarding the impact NPs, PAs, and radiologist assistants may have on interventional and diagnostic radiology practices. Their potential impact on medical education is also discussed. Finally, staffing for radiology departments, as a result of an enlarging nonradiology NP and PA workforce ordering diagnostic imaging, is considered.

The impact of nonphysician providers on diagnostic and interventional radiology practices: regulatory, billing, and compliance perspectives.

The numbers of nurse practitioners and physician assistants are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. Some practices have instead embraced radiologist assistants. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside of radiology departments warrants closer review. The authors evaluate the recent literature and offer recommendations to radiology practices regarding both regulatory and scope-of-practice issues related to these professionals. Additionally, billing and compliance issues for care provided by nurse practitioners, physician assistants, and radiologist assistants are detailed. An analysis of the integration of these professionals into interventional and diagnostic radiology practices, as well as potential implications for medical education, is provided in the second part of this series.

Characterizing cardiopulmonary arrest during interventional radiology procedures.

PURPOSE: Careful case selection and preparation can prevent most cardiopulmonary arrest (CPA) in the interventional radiology (IR) suite. A series of CPAs was analyzed to provide insight into risk factors for these events. MATERIALS AND METHODS: A single-institution CPA database was used to identify all code team activations from January 1, 2005, to May 30, 2011, in the IR department. Medical records were searched for medical history, American Society of Anesthesiologists (ASA) classification, moderate sedation, and outcomes. Procedural data and procedure classification was acquired from the HI-IQ database. RESULTS: There were 36,489 procedures and 23 CPAs during the study period. Of the 23 patients with CPAs, 12 (52%) were male and 11 (48%) female, and average age was 57 years ± 19 (standard deviation). Risk factors included a 56% incidence of diabetes mellitus, 48% incidence of hypertension, and 78% incidence of renal failure. Of the patients with kidney disease, 56% were chronically dialysis-dependent, and an additional 9% were undergoing central venous catheter placement for new hemodialysis. Seventy-eight percent had ASA status of III or greater, and 57% underwent moderate sedation during the procedure. Relative risk of a CPA during dialysis shunt interventions versus arterial interventions was 3.6 (95% confidence interval, 1.0-11.3; P = .045). Eight of 23 (35%) died: one (12%) during resuscitation and seven (88%) after resuscitation (P = .070). CONCLUSIONS: The most common comorbidity of patients with CPA in IR was kidney disease, and the most patients who had CPA underwent dialysis access-related procedures.

Incidence and management of inferior vena cava filter thrombus detected at time of filter retrieval.

PURPOSE: To evaluate inferior vena cava (IVC) venograms (ie, cavograms) before filter retrieval to determine the incidence and volume of filter thrombus relative to filter dwell time and evaluate subsequent changes in thrombus volume with additional anticoagulation. MATERIALS AND METHODS: IVC filter retrieval attempts between December 2002 and June 2010 were retrospectively reviewed to determine the incidence of filter thrombus and estimate thrombus volume on a preretrieval cavogram. Correlation between filter dwell times (assessed at 30-d intervals) and incidence and volume of thrombus was assessed. Follow-up images and management of filters with thrombus that were not initially removed were analyzed. RESULTS: A total of 463 retrieval attempts were performed in 440 patients, with a mean filter dwell time of 95 days ± 145 (SD; range, 0-1,762 d). Thirty (6.5%) had filter thrombus on initial cavograms, with a mean thrombus volume of 2.8 cm(3) ± 7.3 (range, 0.04-40.02 cm(3)). Incidence rate and estimated thrombus volume were highest in the 0-30-day dwell interval (8.0% and 6.3 cm(3), respectively) and decreased at subsequent time intervals. On linear regression analysis, incidence of filter thrombus was inversely related to dwell time (P < .05; correlation coefficient, -0.86). Seven patients with thrombus underwent additional anticoagulation for a mean of 48 days ± 25 (range, 14-90 d); thrombus resolved completely in five (71%) and partially in one (14%), and increased in one (14%). CONCLUSIONS: The incidence of filter thrombus at the time of filter retrieval appears to decrease with dwell time. If thrombus is detected, an additional period of anticoagulation is likely to reduce the thrombus burden and facilitate later retrieval.