RESUMO
A pulmonary arteriovenous malformation (PAVM) is a fistulous connection between a pulmonary artery and a pulmonary vein that bypasses the normal pulmonary capillary bed resulting in a right-to-left shunt. Because of the potential for paradoxical emboli, PAVMs are treated when their feeding arteries exceed 3 mm or patients are symptomatic. PAVMs are often encountered in patients with suspected hereditary hemorrhagic telangiectasia (HHT). Sporadic cases are uncommon. The radiologist may be called on to diagnose a PAVM after positive transthoracic contrast-enhanced echocardiography in a patient with suspected HHT to direct patient management and avoid potential complications. The radiologist may also be required to evaluate a potential PAVM detected at CT performed for other reasons. Through the authors' experiences at an HHT Center of Excellence in an area endemic with histoplasmosis, the authors have gained a unique perspective on the diagnosis of PAVMs and differentiation of PAVMs from their mimics. Understanding the CT appearance of PAVMs limits misdiagnosis, directs appropriate treatment, and allows subsequent family screening for HHT (and avoidance of unnecessary screening when a PAVM mimic is encountered). Both vascular and nonvascular pulmonary lesions can mimic PAVMs. Vascular mimics include fibrosing mediastinitis, venovenous collaterals, arterial collaterals, pulmonary artery pseudoaneurysms, hepatopulmonary vessels, Sheehan vessels, meandering pulmonary veins, and pulmonary vein varices. Nonvascular mimics include granulomas, nodules, mucoceles, bronchoceles, ground-glass opacities, and atelectasis. The authors review the CT technique for evaluating PAVMs and the appearance of PAVMs and their mimics. ©RSNA, 2022.
Assuntos
Malformações Arteriovenosas , Embolização Terapêutica , Veias Pulmonares , Telangiectasia Hemorrágica Hereditária , Malformações Arteriovenosas/diagnóstico por imagem , Humanos , Artéria Pulmonar/diagnóstico por imagem , Veias Pulmonares/anormalidades , Veias Pulmonares/diagnóstico por imagem , Telangiectasia Hemorrágica Hereditária/complicações , Telangiectasia Hemorrágica Hereditária/diagnóstico , Telangiectasia Hemorrágica Hereditária/terapia , Tomografia Computadorizada por Raios XRESUMO
Hemoptysis, which is defined as expectoration of blood from the alveoli or airways of the lower respiratory tract, is an alarming clinical symptom with an extensive differential diagnosis. CT has emerged as an important noninvasive tool in the evaluation of patients with hemoptysis, and the authors present a systematic but flexible approach to CT interpretation. The first step in this approach involves identifying findings of parenchymal and airway hemorrhage. The second step is aimed at determining the mechanism of hemoptysis and whether a specific vascular supply can be implicated. Hemoptysis can have primary vascular and secondary vascular causes. Primary vascular mechanisms include chronic systemic vascular hypertrophy, focally damaged vessels, a dysplastic lung parenchyma with systemic arterial supply, arteriovenous malformations and fistulas, and bleeding at the capillary level. Evaluating vascular mechanisms of hemoptysis at CT also entails determining if a specific vascular source can be implicated. Although the bronchial arteries are responsible for most cases of hemoptysis, nonbronchial systemic arteries and the pulmonary arteries are important potential sources of hemoptysis that must be recognized. Secondary vascular mechanisms of hemoptysis include processes that directly destroy the lung parenchyma and processes that directly invade the airway. Understanding and employing this approach allow the diagnostic radiologist to interpret CT examinations accurately in patients with hemoptysis and provide information that is best suited to directing subsequent treatment. ©RSNA, 2021.
Assuntos
Embolização Terapêutica , Hemoptise , Artérias Brônquicas , Hemoptise/diagnóstico por imagem , Hemoptise/etiologia , Hemoptise/terapia , Humanos , Pulmão , Artéria Pulmonar , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. METHODS: The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of "patency" and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. RESULTS: The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. CONCLUSIONS: A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.
Assuntos
Ductos Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar/classificação , Endoscopia do Sistema Digestório/classificação , Radiografia Intervencionista/classificação , Terminologia como Assunto , Ferimentos e Lesões/terapia , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/lesões , Procedimentos Cirúrgicos do Sistema Biliar/normas , Consenso , Endoscopia do Sistema Digestório/normas , Humanos , Radiografia Intervencionista/normas , Índice de Gravidade de Doença , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico por imagemRESUMO
OBJECTIVE: The objective of our study was to evaluate our experience with the use of endovascular treatments for superior mesenteric artery (SMA) pseudoaneurysms using covered stents. MATERIALS AND METHODS: Between 2002 and 2011, six patients (mean age, 41.7 years; range, 23-65 years) with SMA pseudoaneurysms were treated percutaneously with the placement of covered stents at our institution. The causes of SMA pseudoaneurysms were penetrating trauma (n = 2), blunt trauma (n = 1), and previous surgical procedures (n = 3). The mean diameter of the SMA pseudoaneurysms was 16 mm (range, 4-24 mm). Technical success and clinical success were retrospectively analyzed. RESULTS: Immediate technical success, defined as exclusion of the pseudoaneurysm and lack of active extravasation, was achieved in all six patients. Secondary balloon angioplasty was needed in one patient with residual narrowing. There was a small dissection of the proximal SMA necessitating placement of a second bare stent across the dissection. A second covered stent (Fluency stent, 8 mm) was placed in the same patient because of recurrent bleeding due to a type II endoleak 5 days after the first covered stent had been placed. This patient had no subsequent episodes of bleeding or bowel ischemia. Follow-up CT in the remaining five patients (mean, 21 months; range, 1-58 months) confirmed stent patency and preserved distal arterial flow to the bowel without episodes of bleeding or bowel ischemia during follow-up (mean, 27 months; range, 11-58 months). CONCLUSION: Percutaneous endovascular treatment using a covered stent may be a safe and feasible tool for SMA pseudoaneurysms.
Assuntos
Falso Aneurisma/cirurgia , Procedimentos Endovasculares/métodos , Artéria Mesentérica Superior , Stents , Adulto , Idoso , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Angiografia , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia Intervencionista , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.
Assuntos
Doenças dos Ductos Biliares/cirurgia , Ductos Biliares/lesões , Doenças Biliares/cirurgia , Papel do Médico , Complicações Pós-Operatórias/cirurgia , Radiografia Intervencionista , Ferimentos e Lesões/cirurgia , Doenças dos Ductos Biliares/diagnóstico , Humanos , Doença Iatrogênica , Complicações Pós-Operatórias/diagnóstico , Ferimentos e Lesões/diagnósticoRESUMO
BACKGROUND: The presence of left renal vein (LRV) variants can increase the complexity of adrenal vein sampling (AVS), an already technically demanding procedure. While AVS literature often focuses on the right adrenal vein, an understanding of common LRV variants, their relationship with the left adrenal vein, and principles for successful catheterization can facilitate AVS. This guide provides practical, technical tips for AVS for duplicated (Du), circumaortic (Ca), and retroaortic (Ra) LRVs. METHODS: AVS cases were identified at a single institution (June 2009-March 2023) based on adrenophrenic trunk drainage relative to variant LRVs. Available cross-sectional imaging was reviewed to evaluate LRV anatomy pre-procedure. Twenty-seven cases (1 DuLRV, 13 CaLRVs, and 13 RaLRVs) were identified. Diagnostic AVS was confirmed by a threshold selectivity index. Literature on LRV anatomic variants was also reviewed. RESULTS: Based on the authors' experience and literature review, the following principles can guide AVS in the setting of LRV variants. In the presence of DuLRV or CaLRV, the left adrenal vein invariably drains into a normally positioned, pre-aortic LRV limb, so AVS can proceed as expected with a Simmons as the catheter of choice. In contrast, a LAV draining into a RaLRV may require a hockey stick-like catheter, or in rare cases a microcatheter, for selecting and sampling, due to the longer RaLRV course, which usually drains into the IVC more inferiorly and can be stenotic where the aorta crosses. CONCLUSION: Knowing the presence and understanding the anatomy of LRV variants can facilitate an efficient AVS.
RESUMO
OBJECTIVE: Type II endoleak (T2EL) with aneurysm expansion is believed to place patients at risk for aneurysm-related mortality (ARM). Treatment with glue and/or coil embolization of the aneurysm sac, inferior mesenteric artery (IMA), and lumbar branches via translumbar or transarterial approaches has been utilized to ablate such endoleaks, and thus decrease ARM. We evaluated the midterm results of percutaneous endovascular treatment of T2EL with aneurysm expansion. METHODS: Single-institution, 5-year (January 2003 to August 2008) retrospective study of all endovascular interventions for T2EL with sac expansion. Blinded, independent review of all available pre- and post-T2EL intervention computed tomography (CT) scans was performed. Aneurysm sac maximal transverse diameters and aneurysm sac growth rates prior to and following T2EL intervention were analyzed. RESULTS: Forty-two patients (34 male, eight female; mean age, 75) underwent T2EL intervention at 26 ± 20 months after endovascular aneurysm repair (EVAR) and were subsequently followed for 23 ± 20 months. Seven out of 42 patients (17%) underwent repeat T2EL intervention. Interventions included 44 translumbar sac embolizations, and transcatheter embolizations of nine IMAs and seven lumbar/hypogastric arteries. Aneurysm diameter was 6.1 ± 1.6 cm at EVAR, 6.6 ± 1.5 cm at initial T2EL treatment, and 6.9 ± 1.7 cm at last follow-up. There were no significant differences in the rates of aneurysm sac growth pre- and post-T2EL treatment. At last follow-up imaging, recurrent or persistent T2EL was noted in 72% of patients. Of 42 patients, nine (21%) received operative endoluminal correction of occult type I or type III endoleaks that were diagnosed during the T2EL angiographic intervention. There were no aneurysm ruptures or ARMs during follow-up; overall mortality for the 5-year study period was 24%. CONCLUSIONS: In this series, percutaneous endovascular intervention for type II endoleak with aneurysm sac growth does not appear to alter the rate of aneurysm sac growth, and the majority of patients display persistent/recurrent endoleak. However, diagnostic angiographic evaluation may reveal unexpected type I and III endoleaks and is therefore recommended for all patients with T2EL and sac growth. While coil and glue embolization of aneurysm sac and selected branch vessels does not appear to yield benefit in our series, the diagnosis and subsequent definitive treatment of previously occult type I and III endoleaks may explain the absence of delayed rupture and ARM in our series.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia , Implante de Prótese Vascular/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Endoleak/cirurgia , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Incidência , Masculino , Missouri , Desenho de Prótese , Recidiva , Análise de Regressão , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Falha de TratamentoRESUMO
PURPOSE: To determine outcomes after successful fallopian tube recanalization (FTR) in women who suffer infertility with documented tubal occlusion on hysterosalpingogram. METHODS: A retrospective review of consecutive successful FTR procedures from January 2010 to December 2016 was performed. 53 women who had hysterosalpingogram confirmed unilateral or bilateral tubal occlusion from a single tertiary academic medical center and successful FTR were eligible for inclusion. 35 (66.0%) patients had follow up at 12 months after FTR, with 13 conceiving within 1 year of the procedure. Data was collected from the medical record. Complication, conception, and take-home-baby (THB) rates were recorded. The average age of patients was 32.3 years (range 26-42 years). All patients received peri- and post-procedure antibiotics. The study was conducted with institutional IRB approval. RESULTS: Average follow-up after FTR was 1335 days. All patients tolerated the procedure well with no immediate complications. One patient had a urinary tract infection a week after FTR. 13 (37.1%) became pregnant after FTR. Of these women, 2 had ectopic pregnancies and 2 patients had spontaneous abortions. The THB rate after FTR for all patients was 25.7%. The THB rate in women who became pregnant after FTR was 69.2%. Of those women who did not become pregnant after FTR, 19 (84.6%) went to assisted reproductive techniques, and of those, 8 (42.1%) became pregnant. CONCLUSION: Infertility affects 8.4% of U.S. women, with tubal disease a major causative factor. In our study, successful FTR led to pregnancy in over a third of the patients with the majority giving birth to healthy babies. Given the success of obtaining pregnancy in combination with a low complication rate, FTR is a viable option in women who suffer from tubal infertility.
Assuntos
Doenças das Tubas Uterinas , Infertilidade Feminina , Adulto , Doenças das Tubas Uterinas/diagnóstico por imagem , Doenças das Tubas Uterinas/cirurgia , Tubas Uterinas/diagnóstico por imagem , Tubas Uterinas/cirurgia , Feminino , Humanos , Histerossalpingografia , Infertilidade Feminina/diagnóstico por imagem , Infertilidade Feminina/terapia , Gravidez , Estudos RetrospectivosRESUMO
PURPOSE: To report outcomes of percutaneous cholecystostomy (PC) catheter placement in patients with acute cholecystitis (AC) and propose management algorithm of AC after PC catheter placement based on the outcomes. METHOD AND MATERIALS: Retrospective study was performed. 419 patients who underwent PC between July 2010 and September 2016 were included. Patients who underwent PC for indication other than AC were excluded. The primary outcome was definitive treatment of AC following PC, including cholecystectomy or percutaneous cholecystolithotomy. Secondary outcomes include removal of drainage catheter without further management or death with catheter in place. Based on outcomes, we proposed management algorithm of AC after PC catheter placement. RESULTS: 377 of 419 patients underwent PC for treatment of AC (median age, 66 years; range 18-100 years). Technical success rate was 100% with 2.4% major complications rate and 1.6% minor complications rate. Following PC, 118 patients (31%) underwent definitive treatment with cholecystectomy. Sixty-one patients (16%) underwent definitive treatment with percutaneous cholecystolithotomy with removal of catheters. Seventy-four patients (20%) had their catheters removed upon resolution of cholecystitis without undergoing surgery or stone removal. Fifty patients (13%) died with catheters in place due to other comorbidities. Five patients (1%) still had their catheters in place at the end of the study. CONCLUSION: PC remains a viable option for treatment of AC with low complication rate and can be used as bridge to definitive therapy. Our proposed management algorithm can be a guideline for the management of AC after PC catheter placement.
Assuntos
Algoritmos , Colecistite Aguda/terapia , Colecistostomia/métodos , Complicações Pós-Operatórias/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateteres de Demora , Colangiografia , Colecistite Aguda/diagnóstico por imagem , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos RetrospectivosRESUMO
BACKGROUND: The Hepp-Couinaud technique describes side-to-side HJ to the main left hepatic duct but a side-to-side approach is not consistently used when repairing other ducts. Compared with end-to-side repairs, side-to-side anastomoses require less dissection, theoretically preserving blood supply to the bile ducts, and usually permit wider anastomoses. METHODS: We report the treatment results of 113 consecutive biliary injuries, with intention to perform side-to side anastomosis in all. RESULTS: 113 biliary injuries, 109 associated with cholecystectomy, were treated from 1992-2006. Injury types were B (7 patients, 6%); C (11 patients, 10%); E1 (8 patients, 7%); E2 (37 patients, 33%); E3 (20 patients, 18%); E4 (24 patients, 21%); E5 (6 patients, 5%). 19% of repairs were early (within 1 week after cholecystectomy), 58% were delayed (at least 6 weeks after cholecystectomy), and 22% were reoperations for recurrent strictures. In 92% of cases, side-to-side repair was accomplished. 23/113 (20%) developed postoperative complications, with one postoperative death. Mean follow-up was 4.9 years. Excellent anastomotic function was achieved in 107/112 (95%). "Poor" anastomotic results occurred in 5 patients: 2 patients with E4 injuries had postoperative anastomotic stenting >3 months, and 3 developed strictures requiring percutaneous dilation. There have been no reoperations for biliary strictures. CONCLUSIONS: HJ using side-to-side anastomosis has theoretical advantages and is usually possible. In some high right-sided injuries it could not be achieved. 95% excellent anastomotic function without intervention attests to the benefit of the method, especially as postoperative stenting >3 months was considered to be a "poor" result.
Assuntos
Ductos Biliares/lesões , Colecistectomia/efeitos adversos , Ducto Hepático Comum/cirurgia , Jejuno/cirurgia , Portoenterostomia Hepática/métodos , Traumatismos Abdominais/complicações , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
The aim of this study is to develop a secure, Google-based data-mining tool for radiology reports using free and open source technologies and to explore its use within an academic radiology department. A Health Insurance Portability and Accountability Act (HIPAA)-compliant data repository, search engine and user interface were created to facilitate treatment, operations, and reviews preparatory to research. The Institutional Review Board waived review of the project, and informed consent was not required. Comprising 7.9 GB of disk space, 2.9 million text reports were downloaded from our radiology information system to a fileserver. Extensible markup language (XML) representations of the reports were indexed using Google Desktop Enterprise search engine software. A hypertext markup language (HTML) form allowed users to submit queries to Google Desktop, and Google's XML response was interpreted by a practical extraction and report language (PERL) script, presenting ranked results in a web browser window. The query, reason for search, results, and documents visited were logged to maintain HIPAA compliance. Indexing averaged approximately 25,000 reports per hour. Keyword search of a common term like "pneumothorax" yielded the first ten most relevant results of 705,550 total results in 1.36 s. Keyword search of a rare term like "hemangioendothelioma" yielded the first ten most relevant results of 167 total results in 0.23 s; retrieval of all 167 results took 0.26 s. Data mining tools for radiology reports will improve the productivity of academic radiologists in clinical, educational, research, and administrative tasks. By leveraging existing knowledge of Google's interface, radiologists can quickly perform useful searches.
Assuntos
Armazenamento e Recuperação da Informação , Sistemas de Informação em Radiologia , Interface Usuário-Computador , Humanos , Radiologia/métodos , Estados UnidosRESUMO
We describe a rare case of a large renal arteriovenous malformation in a patient with von Willebrand disease. Initial attempts at technically challenging embolization failed requiring a nephrectomy. Extra-intestinal vascular malformations are rare in von Willebrand disease. However, there is more recent evidence of von Willebrand factor's regulatory role in angiogenesis and vascular malformations.
Assuntos
Anormalidades Múltiplas/cirurgia , Malformações Arteriovenosas/complicações , Artéria Renal/anormalidades , Veias Renais/anormalidades , Doenças de von Willebrand/complicações , Malformações Arteriovenosas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Renal/cirurgia , Veias Renais/cirurgia , Doenças de von Willebrand/cirurgiaRESUMO
The morbidity and mortality of cholecystectomy can increase to 10% in high surgical risk patients. The technique for percutaneous cholecystolithotomy consists of 3 steps: (1) percutaneous cholecystostomy, (2) tract dilation and cholecystolithotomy, and (3) tract evaluation and catheter removal. Cholecystoscopy is critical in guiding the lithotripsy probe for fragmentation of large stones and is useful for locating small stone fragments not seen in cholangiography. Cholecystoscopy is also useful for assessing ambiguous lesions and in distinguishing between stone vs debris or mass. Technical success rate of percutaneous cholecystolithotomy using cholecystoscopy ranges from 93% to 100%. Procedure related complication rate has been reported as 4%-15%. The most common complication is bile leak during the procedure or after catheter removal. Although recurrence rate of gallstones has been reported up to 40%, the symptom recurrence rate is much lower. Therefore, percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with symptomatic gallstones.
Assuntos
Colecistite Acalculosa/terapia , Colecistite Aguda/terapia , Colecistostomia/métodos , Endoscopia do Sistema Digestório/métodos , Cálculos Biliares/terapia , Radiografia Intervencionista/métodos , Colecistite Acalculosa/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Catéteres , Colecistite Aguda/diagnóstico por imagem , Colecistostomia/efeitos adversos , Colecistostomia/instrumentação , Dilatação , Endoscopia do Sistema Digestório/efeitos adversos , Endoscopia do Sistema Digestório/instrumentação , Feminino , Cálculos Biliares/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/instrumentação , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: We present our experience in image-guided percutaneous nephrolithotomy (PCNL) access in 591 patients. MATERIALS AND METHODS: An IRB-approved review of all adult PCNL cases from 2009 to 2014 was performed. Patient data, information regarding stone size and location, procedural details, clinical success, complications by access site (upper pole versus middle or lower pole) and puncture location (supracostal versus infracostal) were recorded. RESULTS: In this study, 591 patients (314 males, 278 females, mean stone size: 23 mm, range: 4-100 mm) were included. Stone clearance was achieved in 66% of patients. There were 174 total complications (29.3%). Upper pole access was less likely to require a secondary access to achieve stone clearance (p = 0.02) and was preferentially used for both larger stones (p = 0.006) and staghorn calculi (p = 0.001). If a supracostal approach to the upper pole was used, there were significantly more complications compared to an infracostal approach (p = 0.002). CONCLUSION: Upper pole access for PCNL provides anatomic advantages for stone clearance but significantly increases the risk for complications when a supracostal puncture is required.
RESUMO
Ruptured abdominal aortic aneurysm (rAAA) with an associated Type II endoleak is rare. Emergent surgical repair is often necessary and may be associated with high morbidity and mortality. We report an alternative unique trans-luminal repair strategy in an 84-year-old male who presented with a rAAA with prior EVAR, and Type Ia and Type II endoleaks. The operative strategy consisted of proximal endograft extension into the para-renal aorta, followed by staged sac embolization using glue. Postoperatively, the patient recovered well from the repair, and follow-up imaging demonstrated a stable repair.
RESUMO
PURPOSE: To report discrepancy rates for examinations interpreted by on-call residents overall and by resident training level, and to describe a novel discrepancy classification system based on patient location and severity that facilitates recording of discrepancy data, helps ensure proper communication of report changes, and allows our radiology department to assume responsibility for contacting discharged patients with non-time-dependent results. METHODS: A HIPAA-compliant, institutional review board-exempt review of two years (January 2013 to December 2014) of discrepancy data was retrospectively performed for total number of examination interpreted, discrepancy rates, resident training level, and discrepancy categories. Most common diagnoses and means of results communication for discharged patients were also recorded. RESULTS: Radiology residents interpreted 153,420 examinations after hours and had 2169 discrepancies, for an overall discrepancy rate of 1.4%. Discrepancy rates for postgraduate year (PGY)-3, PGY-4, and PGY-5 residents were 1.31%, 1.65%, and 1.88%, respectively. The rate of critical discrepancies was extremely low (10/153,420 or 0.007%). A total of 502 patients (23.2% of all discrepancies) were discharged at the time their discrepancy was identified, 60% of whom had non-time-dependent discrepancies that were communicated by radiologists; 32.4% of these had addended results telephoned to a PCP, 43.4% had addended results telephoned to the patient, and the remaining 24.2% required a registered letter. Eight percent of patients with non-time-dependent findings were lost to follow-up. CONCLUSIONS: Our resident discrepancy rates were comparable to those published previously, with extremely low rates of critical discrepancies. Radiologists assumed responsibility for contacting the majority of discharged patients with discrepant results, a minority of whom were lost to follow-up.
Assuntos
Plantão Médico/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Erros de Diagnóstico/estatística & dados numéricos , Diagnóstico por Imagem/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Serviço Hospitalar de Radiologia/normas , Carga de Trabalho/estatística & dados numéricos , Humanos , Perda de Seguimento , Variações Dependentes do Observador , Relações Médico-Paciente , Radiologia/educação , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
PURPOSE: The ionizing radiation used during fluoroscopically guided medical interventions carries risk. The teams performing these procedures seek to minimize those risks while preserving each procedure's benefits. This report describes a data-driven optimization strategy. METHODS: Manual and automated data capture systems were used to collect a series of different metrics, including fluoroscopy time, kerma area product, and reference point air kerma, from both adult and pediatric interventional radiologic procedures. Tools from statistical process control were used to identify opportunities for improvement and assess which changes led to improvement. RESULTS: Initial efforts focused on creating a system capable of reliably capturing fluoroscopy time from all interventional radiologic procedures. Ongoing data analysis and feedback to frontline teams led to the development of a manual workflow that reliably captured fluoroscopy time. Data capture was later supplemented by automatic capture of electronic records. This process exploited the standardized format (DICOM Structured Reporting) that newer fluoroscopy units use to record the radiation metrics. Data analysis found marked differences between the imaging protocols used for adults and children. Revision of the adult protocols led to a stable twofold reduction in average exposure per adult procedure. Analysis of balancing measures found no impact on workflow. CONCLUSIONS: A systematic approach to improving radiation use during procedures led to a substantial and sustained reduction in risk with no reduction in benefits. Data were readily captured by both manual and automated processes. Concepts from cognitive psychology and information theory provided a theoretical basis for both data analysis and improvement opportunities.
Assuntos
Fluoroscopia/normas , Segurança do Paciente/normas , Melhoria de Qualidade/normas , Doses de Radiação , Proteção Radiológica/normas , Adulto , Fluoroscopia/estatística & dados numéricos , Humanos , Missouri , Segurança do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Proteção Radiológica/estatística & dados numéricosRESUMO
PURPOSE: The aim of this study was to evaluate national trends in central venous access (CVA) procedures over 2 decades with regard to changing specialty group roles and places of service. METHODS: Aggregated claims data for temporary central venous catheter and long-term CVA device (CVAD) procedures were extracted from Medicare Physician/Supplier Procedure Summary Master Files from 1992 through 2011. Central venous catheter and CVAD procedure volumes by specialty group and place of service were studied. RESULTS: Between 1992 and 2011, temporary and long-term CVA placement procedures increased from 638,703 to 808,071 (+27%) and from 76,444 to 316,042 (+313%), respectively. For temporary central venous catheters, radiology (from 0.4% in 1992 to 32.6% in 2011) now exceeds anesthesiology (from 37% to 22%) and surgery (from 30.4% to 11.7%) as the dominant provider group. Surgery continues to dominate in placement and explantation of long-term CVADs (from 80.7% to 50.4% and from 81.6% to 47.7%, respectively), but radiology's share has grown enormously (from 0.7% to 37.6% and from 0.2% to 28.6%). Although volumes remain small (<10% of all procedures), midlevel practitioners have experienced >100-fold growth for most services. The inpatient hospital remains the dominant site for temporary CVA procedures (90.0% in 1992 and 81.2% in 2011), but the placement of long-term CVADs has shifted from the inpatient (from 68.9% to 45.2%) to hospital outpatient (from 26.9% to 44.3%) setting. In all hospital settings combined, radiologists place approximately half of all tunneled catheters and three-quarters all peripherally inserted central catheters. CONCLUSIONS: Over the past 2 decades, CVA procedures on Medicare beneficiaries have increased considerably. Radiology is now the dominant overall provider.