Charges for Shoppable Musculoskeletal Imaging Examinations: CMS Transparency Compliance and Variability Among 250 U.S. Hospitals.

As of January 2021, among other transparency requirements, the Centers for Medicare & Medicaid Services require that hospitals publish consumer-friendly displays of charges for shoppable health care services, including four musculoskeletal imaging examinations. Of 250 selected U.S. hospitals, all published charges for these four examinations, although 21% did not provide charges within consumer-friendly displays. Bed count was larger for compliant hospitals than for noncompliant hospitals (500 vs 384 beds). All four examinations had widely variable charges (representing a 73.8-fold difference).

Laser-Assisted Removal of Embedded Vena Cava Filters: A First-In-Human Escalation Trial in 500 Patients Refractory to High-Force Retrieval.

Background Many patients are subject to potential risks and filter-related morbidity when standard retrieval methods fail. We evaluated the safety and efficacy of the laser sheath technique for removing embedded inferior vena cava filters. Methods and Results Over an 8.5-year period, 500 patients were prospectively enrolled in an institutional review board-approved study. There were 225 men and 275 women (mean age, 49 years; range, 15-90 years). Indications for retrieval included symptomatic acute inferior vena cava thrombosis, chronic inferior vena cava occlusion, and/or pain from filter penetration. Retrieval was also offered to prevent risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After retrieval failed using 3X standard retrieval force (6-7 lb via digital gauge), treatment escalation was attempted using laser sheath powered by 308-nm XeCl excimer laser system (CVX-300; Spectranetics). We hypothesized that the laser-assisted technique would allow retrieval of >95% of embedded filters with <5% risk of major complications and with lower force. Primary outcome was successful retrieval. Primary safety outcome was any major procedure-related complication. Laser-assisted retrieval was successful in 99.4% of cases (497/500) (95% CI, 98.3%-99.9%) and significantly >95% (P<0.0001). The mean filter dwell time was 1528 days (range, 37-10 047; >27.5 years]), among retrievable-type (n=414) and permanent-type (n=86) filters. The average force during failed attempts without laser was 6.4 versus 3.6 lb during laser-assisted retrievals (P<0.0001). The major complication rate was 2.0% (10/500) (95% CI, 1.0%-3.6%), significantly <5% (P<0.0005), 0.6% (3/500) (95% CI, 0%-1.3%) from laser, and all were successfully treated. Successful retrieval allowed cessation of anticoagulation in 98.7% (77/78) (95% CI, 93.1%-100.0%) and alleviated filter-related morbidity in 98.5% (138/140) (95% CI, 96.5%-100.0%). Conclusions The excimer laser sheath technique is safe and effective for removing embedded inferior vena cava filters refractory to high-force retrieval. This technique may allow cessation of filter-related anticoagulation and can be used to prevent and alleviate filter-related morbidity. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01158482.

Combined 5-minute double-echo in steady-state with separated echoes and 2-minute proton-density-weighted 2D FSE sequence for comprehensive whole-joint knee MRI assessment.

BACKGROUND: Clinical knee MRI protocols require upwards of 15 minutes of scan time. PURPOSE/HYPOTHESIS: To compare the imaging appearance of knee abnormalities depicted with a 5-minute 3D double-echo in steady-state (DESS) sequence with separate echo images, with that of a routine clinical knee MRI protocol. A secondary goal was to compare the imaging appearance of knee abnormalities depicted with 5-minute DESS paired with a 2-minute coronal proton-density fat-saturated (PDFS) sequence. STUDY TYPE: Prospective. SUBJECTS: Thirty-six consecutive patients (19 male) referred for a routine knee MRI. FIELD STRENGTH/SEQUENCES: DESS and PDFS at 3T. ASSESSMENT: Five musculoskeletal radiologists evaluated all images for the presence of internal knee derangement using DESS, DESS+PDFS, and the conventional imaging protocol, and their associated diagnostic confidence of the reading. STATISTICAL TESTS: Differences in positive and negative percent agreement (PPA and NPA, respectively) and 95% confidence intervals (CIs) for DESS and DESS+PDFS compared with the conventional protocol were calculated and tested using exact McNemar tests. The percentage of observations where DESS or DESS+PDFS had equivalent confidence ratings to DESS+Conv were tested with exact symmetry tests. Interreader agreement was calculated using Krippendorff's alpha. RESULTS: DESS had a PPA of 90% (88-92% CI) and NPA of 99% (99-99% CI). DESS+PDFS had increased PPA of 99% (95-99% CI) and NPA of 100% (99-100% CI) compared with DESS (both P < 0.001). DESS had equivalent diagnostic confidence to DESS+Conv in 94% of findings, whereas DESS+PDFS had equivalent diagnostic confidence in 99% of findings (both P < 0.001). All readers had moderate concordance for all three protocols (Krippendorff's alpha 47-48%). DATA CONCLUSION: Both 1) 5-minute 3D-DESS with separated echoes and 2) 5-minute 3D-DESS paired with a 2-minute coronal PDFS sequence depicted knee abnormalities similarly to a routine clinical knee MRI protocol, which may be a promising technique for abbreviated knee MRI. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018.

Quantification of Activity Lost to Delivery-System Residual and Decay in Yttrium-90 Radioembolization.

PURPOSE: To measure the decay activity loss and delivery system residual activity loss of yttrium-90 (Y90) radioembolization treatments across resin and glass microsphere activities. MATERIALS AND METHODS: For Y90 administrations between December 2009 and June 2017 at the study institution, the prescribed activity, prepared activity, and delivered activity were recorded. Six hundred sixty-two administrations were reviewed-345 glass (0.21-8.52 GBq) and 317 resin (0.18-3.28 GBq). Twenty-five patients (all resin) were excluded for arterial stasis or catheter clogging. The percentage and actual losses of activity lost to decay and to delivery system residual were calculated for glass and resin microspheres. RESULTS: The median time between activity premeasurement and administration was 2.20 hours, resulting in a median activity lost to decay of 0.030 GBq or 2.35%, with no significant difference observed between glass and resin despite differences in preparation (P = .0697). Resin showed significantly higher activity lost to delivery system residual than glass (0.039 GBq vs 0.010 GBq, 3.01% vs 0.61%, P < .001). The percent activity lost to residual varied with activity prepared, with a maximum of 20.1% and 16.2% for the smallest activities of resin and glass, respectively. CONCLUSIONS: Residual activity loss differs between glass and resin microspheres. For resin microspheres in particular, percent residual activity loss increases with lower prepared activities. Protocols for activity calculation and preparation, patient dosimetry, and regulatory compliance must take these losses into consideration prospectively.

Prophylactic IVC filter placement in bariatric surgery patients: results from a prospective filter registry.

BACKGROUND: Bariatric surgery patients are at increased risk for VTE, but potential risks versus benefits of IVC filters in this group remain unclear. Indwelling filters may increase risk of VTE, and removal of filters in obese patients can be challenging. This study evaluated the incidence of VTE in select bariatric patients receiving prophylactic IVC filters, their risk of filter-related complications, and outcomes from attempted filter retrieval. RESULTS: Postsurgical DVT occurred in 3 patients within 3 months postoperatively (3%)(95%CI:1-9%), and 1 patient(1%)(95%CI:0-5%) developed acute low-risk PE at 31 days postoperatively, prior to filter removal. All VTE patients were successfully managed with therapeutic anticoagulation alone except one who required thrombolysis. Median filter dwell time was 54 days (range:22-1548), and there were no major filter-related complications (0%)(95%CI:0-3%). Retrieval was attempted in 104 cases (97%)(95%CI:92-99%) and successful in 104 cases (100%)(95%CI:97-100%). Thirty-three patients (32%)(95%CI:23-42%) required advanced techniques for filter removal, and there were no major procedural complications (0%)(95%CI:0-3%). Median follow-up occurred at 344 days (range:3-1570) days after filter retrieval. CONCLUSIONS: No cases of life-threatening post-op PE occurred in this cohort of high-risk bariatric surgery patients receiving prophylactic IVC filters in combination with mechanical and chemoprophylaxis. The risk of filter-related complications was low and retrieval success was high with adjunctive use of advanced techniques. CLINICAL TRIAL REGISTRATION: NCT01158482.

Laser-Assisted Removal of Embedded Vena Cava Filters: A 5-Year First-in-Human Study.

BACKGROUND: Many patients are subjected to the potential risks and morbidity associated with an indwelling inferior vena cava (IVC) filter when standard methods fail to remove the filter. We evaluated the safety and effectiveness of the excimer laser sheath technique for removing embedded IVC filters. METHODS: Over a 5-year period, 251 consecutive patients undergoing laser-assisted filter retrieval were prospectively enrolled. There were 103 men and 148 women (mean, 46 years; range, 15-82 years). Indications for retrieval included symptomatic acute IVC thrombosis, chronic IVC occlusion, and/or pain from filter penetration. Retrieval was also performed to prevent risks from prolonged implantation and potentially to eliminate the need for lifelong anticoagulation. After retrieval failed using three times the standard retrieval force (digitally measured), treatment escalation was attempted using a laser sheath powered by a 308-nm XeCl laser. Success was defined as complete filter detachment and removal from the body. Primary safety outcomes were major procedure-related complications. RESULTS: Laser-assisted retrieval was successful in 249 of 251 patients (99.2%) (95% CI, 97.2%-99.9%), with a mean implantation of 979 days, range: 37-7,098 days (> 19 years), among retrievable-type filters (n = 211) and permanent-type filters (n = 40). Average force during failed attempts without laser was 6.7 vs 3.8 lbs during laser-assisted retrievals (P < .0001). The major complication rate was 1.6% (95% CI, 0.4%-4.0%), and all were successfully treated. Successful retrieval allowed cessation of anticoagulation in 45 of 46 patients (98%) (95% CI, 88%-99%) and alleviated filter-related morbidity in 55 of 57 patients (96%) (95% CI, 88%-99%). CONCLUSIONS: The excimer laser sheath technique is safe and effective for removing embedded IVC filters refractory to standard retrieval and high force. This technique can be used to alleviate or prevent filter-related morbidity and may allow cessation of filter-related anticoagulation. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01158482; URL: www.clinicaltrials.gov.

Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction.

PURPOSE: To evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success. MATERIALS AND METHODS: A total of 57 patients (37 male, 20 female; age range, 22-86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively. RESULTS: Stent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post-stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors. CONCLUSIONS: Stent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): Initial Results From a Prospective Multicenter Registry.

BACKGROUND: Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20% risk of major bleeding, including a 2% to 5% risk of hemorrhagic stroke. We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PE. METHODS: One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry. Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy and/or catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase. Clinical success was defined as meeting all the following criteria: stabilization of hemodynamics; improvement in pulmonary hypertension, right-sided heart strain, or both; and survival to hospital discharge. Primary safety outcomes were major procedure-related complications and major bleeding events. RESULTS: Fifty-three men and 48 women (average age, 60 years [range, 22-86 years]; mean BMI, 31.03 ± 7.20 kg/m2) were included in the study. The average thrombolytic doses were 28.0 ± 11 mg tPA (n = 76) and 2,697,101 ± 936,287 International Units for urokinase (n = 23). Clinical success was achieved in 24 of 28 patients with massive PE (85.7%; 95% CI, 67.3%-96.0%) and 71 of 73 patients with submassive PE (97.3%; 95% CI, 90.5%-99.7%). The mean pulmonary artery pressure improved from 51.17 ± 14.06 to 37.23 ± 15.81 mm Hg (n = 92) (P < .0001). Among patients monitored with follow-up echocardiography, 57 of 64 (89.1%; 95% CI, 78.8%-95.5%; P < .0001) showed improvement in right-sided heart strain. There were no major procedure-related complications, major hemorrhages, or hemorrhagic strokes. CONCLUSIONS: CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding. At experienced centers, CDT is a safe and effective treatment of both acute massive and submassive PE. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01097928; URL: www.clinicaltrials.gov.

Optimizing isotropic three-dimensional fast spin-echo methods for imaging the knee.

PURPOSE: To optimize acquisition parameters for three dimensional fast spin-echo (3D FSE) imaging of the knee. MATERIALS AND METHODS: The knees of eight healthy volunteers were imaged in a 3 Tesla MRI scanner using an eight-channel knee coil. A total of 146 intermediate weighted isotropic resolution 3D FSE (3D-FSE-Cube)images with varied acquisition parameter settings were acquired with an additional reference scan performed for subjective image quality assessment. Images were graded for overall quality, parallel imaging artifact severity and blurring. Cartilage, muscle, and fluid signal-to-noise ratios and fluid-cartilage contrast-to-noise ratios were quantified by acquiring scans without radio frequency excitation and custom-reconstructing the k-space data.Mixed effects regression modeling was used to determine statistically significant effects of different parameters on image quality. RESULTS: Changes in receiver bandwidth, repetition time and echo train length significantly affected all measurements of image quality (P < 0.05). Reducing band width improved all metrics of image quality with the exception of blurring. Reader agreement was slight to fair for subjective metrics, but overall trends in quality ratings were apparent. CONCLUSION: We used a systematic approach to optimize 3D-FSE-Cube parameters for knee imaging. Image quality was overall improved using a receiver bandwidth of 631.25 kHz, and blurring increased with lower band width and longer echo trains.

Excimer laser-assisted removal of embedded inferior vena cava filters: a single-center prospective study.

BACKGROUND: Although chronically implanted inferior vena cava filters may result in filter-related morbidity, there is currently no routine option for removing such filters when they become firmly embedded along the vena cava endothelium. METHODS AND RESULTS: During a 3-year period, 100 consecutive patients were prospectively enrolled in a single-center study. There were 42 men and 58 women (mean age, 46 years; limits, 18-76 years). Retrieval indications included filter-related acute inferior vena cava thrombosis, chronic inferior vena cava occlusion, and pain from retroperitoneal or bowel penetration. Filter retrieval was also performed to prevent risks from prolonged implantation and to potentially eliminate the need for lifelong anticoagulation. After standard methods failed, photothermal tissue ablation was attempted with a laser sheath powered by a 308-nm xenon chloride excimer laser. Applied forces were recorded with a digital tension meter before and during laser activation. Laser-assisted retrieval was successful in 98.0% (95% confidence interval [CI], 93.0%-99.8%) with mean implantation of 855 days (limits, 37-6663 days; >18 years). The following filter types were encountered in this study: Günther-Tulip (n=34), Celect (n=12), Option (n=17), Optease (n=20, 1 failure), TrapEase (n=6, 1 failure), Simon-Nitinol (n=1), 12F Stainless Steel Greenfield (n=4), and Titanium Greenfield (n=6). The average force during failed standard retrievals was 7.2 versus 4.6 pounds during laser-assisted retrievals (P<0.0001). The major complication rate was 3.0% (95% CI, 0.6%-8.5%), the minor complication rate was 7.0% (95% CI, 0.3%-13.9%), and there were 4 adverse events (2 coagulopathic hemorrhages, 1 renal infarction, and 1 cholecystitis; 4.0%; 95% CI, 1.1%-9.9%) at mean follow-up of 500 days (limits, 84-1079 days). Scar tissue ablation was histologically confirmed in 96.0% (95% CI, 89.9%-98.9%). Successful retrieval allowed cessation of anticoagulation in 30 of 30 (100%) patients and alleviated morbidity in 23 of 24 patients (96%). CONCLUSIONS: Excimer laser-assisted removal is effective in removing embedded inferior vena cava filters refractory to standard retrieval and high force. This method can be safely used to prevent and alleviate filter-related morbidity. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01158482.

Uncluttered Single-Image Visualization of Vascular Structures Using GPU and Integer Programming.

Direct projection of 3D branching structures, such as networks of cables, blood vessels, or neurons onto a 2D image creates the illusion of intersecting structural parts and creates challenges for understanding and communication. We present a method for visualizing such structures, and demonstrate its utility in visualizing the abdominal aorta and its branches, whose tomographic images might be obtained by computed tomography or magnetic resonance angiography, in a single 2D stylistic image, without overlaps among branches. The visualization method, termed uncluttered single-image visualization (USIV), involves optimization of geometry. This paper proposes a novel optimization technique that utilizes an interesting connection of the optimization problem regarding USIV to the protein structure prediction problem. Adopting the integer linear programming-based formulation for the protein structure prediction problem, we tested the proposed technique using 30 visualizations produced from five patient scans with representative anatomical variants in the abdominal aortic vessel tree. The novel technique can exploit commodity-level parallelism, enabling use of general-purpose graphics processing unit (GPGPU) technology that yields a significant speedup. Comparison of the results with the other optimization technique previously reported elsewhere suggests that, in most aspects, the quality of the visualization is comparable to that of the previous one, with a significant gain in the computation time of the algorithm.

Photothermal ablation with the excimer laser sheath technique for embedded inferior vena cava filter removal: initial results from a prospective study.

PURPOSE: To evaluate the safety and effectiveness of the excimer laser sheath technique for removing embedded inferior vena cava (IVC) filters. MATERIALS AND METHODS: Over 12 months, 25 consecutive patients undergoing attempted IVC filter retrieval with a laser-assisted sheath technique were prospectively enrolled into an institutional review board-approved study registry. There were 10 men and 15 women (mean age 50 years, range 20-76 years); 18 (72%) of 25 patients were referred from an outside hospital. Indications for retrieval included symptomatic filter-related acute caval thrombosis (with or without acute pulmonary embolism), chronic IVC occlusion, and bowel penetration. Retrieval was also performed to remove risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After failure of standard methods, controlled photothermal ablation of filter-adherent tissue with a Spectranetics laser sheath and CVX-300 laser system was performed. All patients were evaluated with cavography, and specimens were sent for histologic analysis. RESULTS: Laser-assisted retrieval was successful in 24 (96%) of 25 patients as follows: 11 Günther Tulip (mean 375 days, range 127-882 days), 4 Celect (mean 387 days, range 332-440 days), 2 Option (mean 215 days, range 100-330 days), 4 OPTEASE (mean 387 days, range 71-749 days; 1 failed 188 days), 2 TRAPEASE (mean 871 days, range 187-1,555 days), and 2 Greenfield (mean 12.8 years, range 7.2-18.3 years). There was one (4%) major complication (acute thrombus, treated with thrombolysis), three (12%) minor complications (small extravasation, self-limited), and one adverse event (coagulopathic retroperitoneal hemorrhage) at follow-up (mean 126 days, range 13-302 days). Photothermal ablation of filter-adherent tissue was histologically confirmed in 23 (92%) of 25 patients. CONCLUSIONS: The laser-assisted sheath technique appears to be a safe and effective tool for retrieving embedded IVC filters, including permanent types, with implantation ranging from months to > 18 years.

Imaging of the wrist at 1.5 Tesla using isotropic three-dimensional fast spin echo cube.

PURPOSE: To compare three-dimensional fast spin echo Cube (3D-FSE-Cube) with conventional 2D-FSE in MR imaging of the wrist. MATERIALS AND METHODS: The wrists of 10 volunteers were imaged in a 1.5 Tesla MRI scanner using an eight-channel wrist coil. The 3D-FSE-Cube images were acquired in the coronal plane with 0.5-mm isotropic resolution. The 2D-FSE images were acquired in both coronal and axial planes for comparison. An ROI was placed in fluid, cartilage, and muscle for SNR analysis. Comparable coronal and axial images were selected for each sequence, and paired images were randomized and graded for blurring, artifact, anatomic details, and overall image quality by three blinded musculoskeletal radiologists. RESULTS: SNR of fluid, cartilage and muscle at prescribed locations were higher using 3D-FSE-Cube, without reaching statistical significance. Fluid-cartilage CNR was also higher with 3D-FSE-Cube, but not statistically significant. Blurring, artifact, anatomic details, and overall image quality were significantly better on coronal 3D-FSE-Cube images (P < 0.001), but significantly better on axial 2D-FSE images compared with axial 3D-FSE-Cube reformats (P < 0.01). CONCLUSION: Isotropic data from 3D-FSE-Cube allows reformations in arbitrary scan planes, which may make multiple 2D acquisitions unnecessary, and improve depiction of complex wrist anatomy. However, axial reformations suffer from blurring, likely due to T2 decay during the long echo train, limiting overall image quality in this plane.

Creating a patient-centered imaging service: determining what patients want.

OBJECTIVE: The purpose of this study is to determine patients' preferences for how, from whom, and how soon they receive imaging results. MATERIALS AND METHODS: Hard copies of our survey were randomly distributed to patients at an academic medical center outpatient imaging facility for 9 weeks, during August through October 2008, to collect data regarding patient preferences for how they received results ("Method"), from whom ("Person"), and how quickly ("Speed"). RESULTS: A total of 129 (23%) of 557 patients (47.4% male; median age, 55 years) undergoing CT (62%) and MRI (38%) completed the survey. According to survey responses, results needed to be communicated within a few hours for an "acceptable" rating from 95% of patients. Thirty-one percent preferred to receive normal results by the fastest method, whereas 35% preferred to receive abnormal results by telephone. Patients did not show an overwhelming preference regarding which physician communicates the results. More than 25% of patients were indifferent as to who was giving the results and cared only about the speed of delivery. For normal results, 12% chose from the radiologist, 41% from the referring physician, 14% from both, and 33% from whoever is faster (p < 0.0001). For abnormal results, 6% chose from the radiologist, 41% from the referring physician, 27% from both, and 26% from whoever is faster (p < 0.0002). CONCLUSION: Patients in our study wanted their results communicated much sooner than is currently practiced. Optimizing patient satisfaction may require a new communication model.

Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques.

PURPOSE: Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE. MATERIALS AND METHODS: The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge. RESULTS: Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis. CONCLUSIONS: Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.

Transparent rendering of intraluminal contrast for 3D polyp visualization at CT colonography.

We developed a classifier that permits transparent rendering of both tagging material and air to facilitate interpretation of tagged computed tomographic (CT) colonography. With this technique, a reader can simultaneously appreciate polyps on endoluminal views both covered with tagging material and against air, along with unmodified 2-dimensional CT images. Evaluated with 49 polyps from 26 patients (data from public National Library of Medicine, Health Insurance Portability and Accountability Act compliant), 3 readers were able to determine the presence/absence of polyps in tagged locations with equivalent accuracy compared with polyps in air. This method offers an alternative way to visualize tagged CT colonography.

Hemorrhage rate in patients with Spetzler-Martin grades IV and V arteriovenous malformations: is treatment justified?

BACKGROUND AND PURPOSE: We sought to examine the prospective annual risk of hemorrhage in patients harboring Spetzler-Martin grades IV and V arteriovenous malformations (AVMs) before and after initiation of treatment. METHODS: Medical records of 61 consecutive patients presenting with Spetzler-Martin grades IV and V AVMs were retrospectively reviewed for demographics, angiographic features, presenting symptom(s), and time of all hemorrhage events, before or after treatment initiation. Pretreatment hemorrhage rates (excluding hemorrhages at presentation) and posttreatment rates were subsequently calculated. Modified Rankin Scale (mRS) scores before and after treatment were recorded. RESULTS: The annual pretreatment hemorrhage rate for all patients was 10.4% per year (95% CI, 2.2 to 15.4%), 13.9% (95% CI, 3.5 to 22.1%) in patients with hemorrhagic presentation and 7.3% (2.6 to 14.3%) in patients with nonhemorrhagic presentation. Posttreatment hemorrhage rates were 6.1% per year (95% CI, 2.5 to 13.2%) for all patients, 5.6% (95% CI, 2.1 to 11.8%) for patients presenting with hemorrhage and 6.4% (95% CI, 1.6 to 10.1%) in patients with nonhemorrhagic presentation. A noninferiority test showed that the posttreatment hemorrhage rate was less than or equal to the pretreatment hemorrhage rate (P<0.0001), with some indication that the reduction was greatest in patients with hemorrhagic presentation. Of the 62 patients, 51 (82%) had an mRS score of 0 to 2 before treatment, and 47 (76%) had an mRS score of 0 to 2 at the last follow-up after treatment. CONCLUSIONS: The annual rate of hemorrhage in grades IV and V AVMs is higher in this series than reported for all AVMs, which may reflect some referral bias in this single-center study. Nevertheless, initiation of treatment does not appear to increase the rate of subsequent hemorrhage. Treatment for these lesions may be warranted, given their poor natural history.