Aortic Remodeling and Clinical Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

BACKGROUND: There is currently limited data assessing the long-term consequences of thoracic endovascular aortic repair (TEVAR) in otherwise healthy aortic segments remote from the site of endograft coverage. The aim of this study is to retrospectively evaluate aortic remodeling and long-term outcomes of blunt thoracic aortic injury (BTAI) patients treated with TEVAR. Our hypothesis is that significant changes to the aorta proximal to the graft-covered segment are suspected following TEVAR. METHODS: An institutional review board-approved retrospective review of patients who underwent TEVAR for BTAI at a level I trauma center from 2004 to 2018 was performed. Forty-six patients were identified and of these, 32 patients with high-resolution computed tomographic angiography imaging follow-up were included in the study. Computed tomographic angiography measurements of aortic dimensions and branch vessels proximal, distal, and adjacent to the stent grafted segment were recorded preprocedure and postprocedure and analyzed. Primary device-related outcomes such as birdbeaking, mural thrombus, stent migration, and persistent endoleak were assessed. Patient outcomes including mortality, graft-related morbidity, and need for secondary interventions were also analyzed. RESULTS: Mean follow-up of the selected patients in the study was 1.52 y (range, 0.06-8.0 y). Following TEVAR, the ascending aortic length increased significantly (mean 5.7 ± 4.6 mm, P < 0.001). The mean diameters of the ascending aorta (1.5 ± 1.5, P < 0.001 mm), the midaortic arch (1.3 ± 1.7 mm, P < 0.001), and proximal and the distal endograft landing zones (1.9 ± 2.1 mm and 2.2 ± 1.6 mm, respectively, P < 0.001) also increased significantly following TEVAR. Clinically relevant device-related outcomes occurred with the presence of endograft infolding and subsequent development of endograft mural thrombus (P < 0.001). The need for secondary intervention following TEVAR for BTAI was associated with endograft mural thrombus (P < 0.05). CONCLUSIONS: TEVAR for BTAI causes significant geometric changes in the aorta proximal to the stented grafted segment of the aorta. Direct consequences of the graft at the stented segment includes mural thrombus development within the endograft which was associated with the need for secondary intervention. Although clinical significance is yet to be determined, post-TEVAR changes in aortic architecture warrant continued aortic surveillance following BTAI.

Outcomes and Cost Comparison of Percutaneous Endovascular Aortic Repair versus Endovascular Aortic Repair With Open Femoral Exposure.

BACKGROUND: The objective of this study was to assess cost differences between patients who underwent percutaneous endovascular aortic repair (PEVAR) and open surgical femoral exposure in elective endovascular aortic repair (EVAR) of abdominal aortic aneurysms. MATERIALS AND METHODS: An IRB-approved single center retrospective analysis of patients who underwent elective EVAR for abdominal aortic aneurysms from 2009 to 2016 was performed. One hundred patients were selected with 50 patients who underwent PEVAR and 50 patients who underwent open surgical femoral exposure. Patient demographics, procedural variables, and hospital outcomes were collected and compared. Primary outcomes assessed used in cost calculations included operating time (OR time), hospital length of stay (LOS), and intensive care unit stay (ICU LOS). Extrapolated cost differences were based on known, published cost multipliers for the primary outcomes observed. RESULTS: Patients undergoing PEVAR had significant reduction in mean OR time (113.9 min versus 144.9 min, P < 0.001), mean ICU LOS (19.7 h versus 28.9 h, P = 0.094), and overall LOS (28.3 h versus 33.1 h, P = 0.020). There was no statistically significant difference in access related complications, although there was a trend toward less complication rates with PEVAR (0% versus 5%, P = 0.056). Calculated cost of procedures based on mean ICU LOS, hospital LOS, and OR time, showed significant reduction in mean hospital costs with PEVAR ($16,628.5 versus $21,705.8, P < 0.001). Multiple linear regression analysis demonstrated an overall 23% cost reduction with PEVAR. CONCLUSIONS: Prior reports comparing PEVAR versus EVAR with open femoral exposures have shown improvement in overall patient time to ambulation and other hospital metrics such as LOS with PEVAR. There is, however, a paucity of overall cost comparison data regarding PEVAR. In this study, adoption of PEVAR was seen to significantly reduce OR times (19%) and overall hospital LOS (50%). The outcomes observed ultimately translated into significant reduction in hospital costs.

Diagnostic workup and endovascular treatment of popliteal artery trauma.

Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.

Sex-dependent outcomes following elective endovascular aortic repair.

BACKGROUND: Evidence has shown that women derive less benefit from endovascular aortic repair (EVAR) in large part due to more challenging aortoiliac anatomy. This study sought to examine whether sex-dependent outcomes exist following elective EVAR cases. METHODS: An institutional retrospective review was performed on patients who underwent elective EVAR procedures between 2008 and 2014. Outcome data collected included procedural and hospital morbidity, mortality, and overall EVAR durability based on the incidence of unplanned graft-related secondary interventions (SIs) (e.g., open conversion, proximal or distal extensions, and coil embolizations). RESULTS: One hundred eighty-one patients (150 men, 31 women) met the study inclusion criteria. Median follow-up was 40.3 mo. Women had more challenging anatomy compared to men including smaller overall iliac diameters (6.8 mm versus 8.0 mm, P < 0.001) and more severe iliac angulation (77% moderate to severe versus 44%, P < 0.001). Women had increased risk of postoperative complications compared to men (41.9% versus 11.3%, P = 0.003). There was no perioperative mortality in our series of elective EVAR cases. Median 5-y survival following EVAR was 64.4% for men and 76.3% for women (P = 0.599). Late SI rates following EVAR was 10.5% with 16 (10.7%) men and 3 (9.7%) women needing interventions (P = 0.870). Overall durability of EVAR extrapolated as time to SIs was 91% at 2 y and 85% at 5 y. Factors predisposing SIs were iliac tortuosity (P = 0.046), aortic neck angle (P = 0.022), and endoleak at the follow-up (P = 0.030). CONCLUSIONS: In this study, immediate outcomes following EVAR were different between men and women, with women having increased rates of postoperative complications. Mortality and overall long-term durability of EVAR, however, were the same between sexes despite anatomical differences. EVAR durability was significantly dependent on the severity of iliac tortuosity, aortic neck angulation, and presence of endoleak at the follow-up.

A Cross-Sectional Survey of Interventional Radiologists and Vascular Surgeons Regarding the Cost and Reimbursement of Common Devices and Procedures.

PURPOSE: To evaluate knowledge of interventional radiologists (IRs) and vascular surgeons (VSs) on the cost of common devices and procedures and to determine factors associated with differences in understanding. MATERIALS AND METHODS: An online survey was administered to US faculty IRs and VSs. Demographic information and physicians' opinions on hospital costs were elicited. Respondents were asked to estimate the average price of 15 commonly used devices and to estimate the work relative value units (wRVUs) and average Medicare reimbursements for 10 procedures. Answer estimates were deemed correct if values were ± 25% of the actual costs. Multivariate logistical regression was used to calculate odds ratios and 95% confidence intervals. RESULTS: Of the 4,926 participants contacted, 1,090 (22.1%) completed the questionnaire. Overall, 19.8%, 22.8%, and 31.9% were accurate in price estimations of devices, Medicare reimbursement, and wRVUs for procedures. Physicians who thought themselves adequately educated about wRVUs were more accurate in predicting procedural costs in wRVUs than physicians who responded otherwise (odds ratio = 1.40, 95% confidence interval, 1.29-1.52; P < .0001). Estimation accuracies for procedures showed a positive trend in more experienced physicians (≥ 16 y), private practice physicians, and physicians who practice in rural areas. CONCLUSIONS: This study suggests that IRs and VSs have limited knowledge regarding device costs. Given the current health care environment, more attention should be placed on cost education and awareness so that physicians can provide the most cost-effective care.

A single-center experience in capturing inpatient evaluation and management for an IR practice.

PURPOSE: To demonstrate that interventional radiologists can capture work relative value units (wRVUs) for the work that is already being performed providing evaluation and management (E&M) clinical services. MATERIALS AND METHODS: A team approach was implemented to optimize revenue capture for inpatient E&M. Structured templates were created for inpatient documentation to ensure that maximum wRVUs were captured. Inpatient billing was audited from fiscal year 2011 (1 year before meeting and structured template creation) through fiscal year 2014. Specifically, data were collected on total charges, collections, wRVUs and total number of inpatient E&M encounters, and the level of the billed encounter. RESULTS: Retrospective annual audits revealed that overall inpatient E&M billing charges increased by 722%, whereas collections increased by 831% from 2011 to 2014. The wRVUs increased in 2011 from 181.74 to 1,396.9 (669% increase) in 2014, and the number of inpatient E&M encounters billed increased from 130 to 693 (433% increase) over that same time period. Lower level billing (level I) declined from 30% to 19%, and complex billing levels (level II or higher) increased from 70% to 81%. CONCLUSIONS: By implementing a systems approach to revenue management, which includes physician and billing staff meetings and the use of structured templates, billing capture from inpatient E&M services can be improved.

Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts.

BACKGROUND: Transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS. METHODS: A retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed. RESULTS: From 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5-67.5] with the majority being male (n = 12, 75%) and Childs-Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months). CONCLUSION: TACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.

Aortoiliac: Covered, Uncovered, CERAB as It Relates to Peripheral Arterial Disease.

Peripheral arterial disease (PAD) affects over 200 million worldwide and is the leading cause of major limb amputation, with individuals suffering from PAD being at three times greater risk of dying compared with matched controls. TASC-II guidelines provide a consensus on the management of PAD based on the collaboration between international vascular specialties. These guidelines previously outlined open surgery as the gold standard for treatment of aortoiliac disease and PAD as it has demonstrated consistent long-term results. However, this approach is also associated with high perioperative mortality, especially when compared with endovascular techniques. With recent developments in endovascular technology, user technique, and experience, this approach has become more widely used as primary intervention for aortoiliac disease. One of these novel techniques includes covered endovascular reconstruction of the aortic bifurcation, which has demonstrated excellent technical success and improved primary and secondary patency rates with follow-up. The aim of this review is to compare the efficacy of these approaches to the treatment of aortoiliac disease and demonstrate the benefits of the shift toward an endovascular-first approach to treatment of this disease, regardless of lesion complexity or severity.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease.

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. 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® Central Venous Access Device and Site Selection.

The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia: 2022 Update.

Mesenteric ischemia is a serious medical condition characterized by insufficient vascular supply to the small bowel. In the acute setting, endovascular interventions, including embolectomy, transcatheter thrombolysis, and angioplasty with or without stent placement, are recommended as initial therapeutic options. For nonocclusive mesenteric ischemia, transarterial infusion of vasodilators, such as papaverine or prostaglandin E1, is the recommended initial treatment. In the chronic setting, endovascular means of revascularization, including angioplasty and stent placement, are generally recommend, with surgical options, such as bypass or endarterectomy, considered alternative options. Although the diagnosis of median arcuate ligament syndrome remains controversial, diagnostic angiography can be helpful in rendering a diagnosis, with the preferred treatment option being a surgical release. Systemic anticoagulation is recommended as initial therapy for venous mesenteric ischemia with acceptable rates of recanalization. If anticoagulation fails, transcatheter thrombolytic infusion can be considered with possible adjunctive placement of a transjugular intrahepatic portosystemic shunt to augment antegrade flow. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Endovascular management of acute aortic syndromes.

The term "acute aortic syndrome" (AAS) refers to a spectrum of life-threatening thoracic aortic pathologies including intramural hematoma, penetrating atherosclerotic ulcer, and aortic dissection. Clinically, patients often present with characteristic aortic pain. AAS often leads to aortic rupture. Therefore, recognition of this condition, its prompt diagnosis, and timely treatment is crucial to obtain clinical success and improved overall survival. The management of AAS, however, remains a therapeutic challenge. Endovascular strategies have gained wide acceptance and now represent a minimally invasive alternative to traditional open surgery. Several studies have shown endovascular repair of varying thoracic aortic pathologies to be technically feasible with fewer complications than open surgery. In this review, the authors discuss AAS pathology and its management, with particular attention to the current role of endovascular aortic repair and its treatment.

Endovascular Management of Chronic Type B Aortic Dissection.

Acute uncomplicated type B aortic dissection (aTBAD) is often treated non operatively, with medical management primarily focused on blood pressure and heart rate control. After a 3 month period following the initial diagnosis, the dissection is considered chronic. Frequent clinical and imaging follow-up is performed to evaluate for dissection stability, aneurysmal degeneration, and visceral malperfusion, which would represent indication for surgical or endovascular repair. In this article we discuss four cases of chronic type B aortic dissection (cTBAD) managed with thoracic endovascular aortic repair (TEVAR) and varying techniques.

ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update.

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). 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.

The reentry catheter: a second chance for endoluminal reentry at difficult lower extremity subintimal arterial recanalizations.

From January 2005 to July 2008, a retrospective study was conducted at a single institution to investigate technical success of the use of a reentry device (Outback LTD reentry catheter) in aortoiliac and femoropopliteal artery recanalization in 34 patients (18 men; mean age +/- SD, 72 years +/- 11) in whom the conventional guide wires and catheters failed to reenter the true lumen. True lumen reentry was achieved in 87% (n = 23) and 91% (n = 11) of patients with femoropopliteal and aortoiliac occlusions, respectively. The overall technical success rate with the device was 88% (n = 34). The device success rate in Transatlantic Inter-Society Consensus II class D lesions was significantly lower than in lower lesion classes (71.4% vs 100%; P < .05). No procedure-related complications were encountered. In conclusion, the use of the reentry catheter enhances the likelihood of successful subintimal recanalization of chronic occlusions in femoropopliteal and aortoiliac arteries.

Endovascular repair of delayed traumatic aortocaval fistula.

Aortocaval fistula (ACF) is an uncommon condition that can result in a number of adverse clinical sequelae. We describe a case of an ACF that occurred several years after open repair of a penetrating injury of the abdominal aorta and inferior vena cava. Whereas ACF can have sudden and catastrophic presentations, our patient had a subacute presentation of high-output heart failure. We were able to fully correct the vascular injury and heart failure physiology and symptoms with endovascular therapy.