Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee.

PURPOSE: To develop a new adverse event (AE) classification for the interventional radiology (IR) procedures and evaluate its clinical, research, and educational value compared with the existing Society of Interventional Radiology (SIR) classification via an SIR member survey. MATERIALS AND METHODS: A new AE classification was developed by members of the Standards of Practice Committee of the SIR. Subsequently, a survey was created by a group of 18 members from the SIR Standards of Practice Committee and Service Lines. Twelve clinical AE case scenarios were generated that encompassed a broad spectrum of IR procedures and potential AEs. Survey questions were designed to evaluate the following domains: educational and research values, accountability for intraprocedural challenges, consistency of AE reporting, unambiguity, and potential for incorporation into existing quality-assurance framework. For each AE scenario, the survey participants were instructed to answer questions about the proposed and existing SIR classifications. SIR members were invited via online survey links, and 68 members participated among 140 surveyed. Answers on new and existing classifications were evaluated and compared statistically. Overall comparison between the two surveys was performed by generalized linear modeling. RESULTS: The proposed AE classification received superior evaluations in terms of consistency of reporting (P < .05) and potential for incorporation into existing quality-assurance framework (P < .05). Respondents gave a higher overall rating to the educational and research value of the new compared with the existing classification (P < .05). CONCLUSIONS: This study proposed an AE classification system that outperformed the existing SIR classification in the studied domains.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques.

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

Checklists for Image-Guided Interventions.

OBJECTIVE: Checklists are tools commonly used to help confirm that certain tasks of a process are completed. Within the health care industry, medical checklists are recognized as a means to improve patient safety. CONCLUSION: Recent application of checklists to image-guided interventions has shown positive outcomes; however, there are limited published studies. We review the literature regarding checklist use as a safety measure and focus on implementation of checklists for image-guided interventions.

Ethylene vinyl alcohol copolymer (onyx) embolization for acute hemorrhage: a systematic review of peripheral applications.

PURPOSE: To evaluate the endovascular use of ethylene vinyl alcohol (EVOH) copolymer (Onyx; ev3 Endovascular, Inc, Plymouth, Minnesota) for the treatment of acute peripheral nonneurologic hemorrhage. MATERIALS AND METHODS: MEDLINE and PubMed databases were searched for articles published in English from 1946 to August 2014 describing patients treated for hemorrhage with EVOH copolymer outside of its usual neurovascular applications. Additional cases were collected from the bibliographies of relevant articles. Full-text articles were obtained. Demographic data, clinical presentation, underlying etiology, culprit vessel, endovascular treatment, outcomes, and follow-up times were obtained. RESULTS: The literature search yielded 19 relevant articles. Cases of 131 patients (87 men, 44 women; mean age, 61 y ± 19.2) describing the treatment of 151 lesions were reviewed. The most common categories of arterial lesions were gastrointestinal (n = 53) and bronchial (n = 40) in origin. In 14 cases, EVOH copolymer was employed after failure or rebleeding following the use of a different embolic agent. Average follow-up time was 12.0 months. EVOH copolymer was the sole embolic agent used in 105 patients. Rebleeding after treatment with EVOH copolymer occurred in 10 patients. There were 2 technical failures. One patient died of multiorgan failure in the setting of persistent hemoptysis. Complications included 2 nerve injuries and 2 minor strokes. CONCLUSIONS: Embolization of acute hemorrhage in the peripheral vasculature was safe and effective with EVOH copolymer.

Reduction of operator radiation dose by an extended lower body shield.

PURPOSE: To quantify the reduction in operator exposure to scatter radiation by using an extension component in addition to a commonly used lower body radiation shield attached to an interventional radiology procedure table. MATERIALS AND METHODS: An anthropomorphic pelvis phantom was exposed to fluoroscopy at varying C-arm angles to simulate a standard interventional procedure. A MAVIG UT60 lower body shield (MAVIG, Munich, Germany) (48 cm × 78 cm, 0.5 mm lead equivalent), with an attachable extension component (48 cm × 36 cm), was suspended from the edge of the table adjacent to the pelvic phantom. Using a handheld Geiger counter, scatter radiation exposure rates were measured at the level of an operator's eye, chest, waist, and knee, with various C-arm angles both with and without the attachable extension component. Mean exposure rates for each experimental setup were calculated and compared. RESULTS: Overall, scatter radiation exposures were lower with the addition of the extension component, with the largest reductions (> 80%) measured at the operator's waist and knee levels, for all C-arm angles. The highest reduction in scatter radiation exposure was measured at knee level, at 0 degrees left posterior oblique projection, where the use of the lower body shield extension component reduced the exposure rate from 4.80 mR/h to 0.44 mR/h (90.8% reduction, P < .001). Reductions in scatter radiation were less at eye and chest levels. CONCLUSIONS: The use of the additional extension component to the lower body radiation shield can result in large (> 80%) reductions in operator scatter radiation exposure, particularly to the lower body.

Survey of current status and physician opinion regarding ancillary staffing for the IR suite.

PURPOSE: To survey the status quo of ancillary staffing in predominantly hospital-based interventional radiology (IR) suites and to assess interventional radiologist attitudes toward current IR procedure room staffing availability and appropriateness. MATERIALS AND METHODS: Invitations to an online survey composed of 26 questions focused on levels of IR suite ancillary staffing as well as operators' opinions of current IR procedure room staffing were sent via email to 2,284 active Society of Interventional Radiology members. RESULTS: There were 777 survey responses. Nurse staffing count per IR room was at least one in 90% (n = 699) during regular hours and 93.6% (n = 730) during off-hours, respectively. A second technologist was frequently used during regular hours and, to a lesser extent, during on-call hours (n = 341 [43.9%] and n = 122 [15.7%]), respectively. Ten and 15% of IR respondents believe staffing support is inadequate for most interventional procedures requiring moderate sedation during normal business hours and off-hours/weekends, respectively, and 69% and 56% of IR respondents believe anesthesia support is inadequate during normal business hours and during off-hours, respectively. CONCLUSIONS: The number of technologists used per IR suite varies across practices and frequently exceeds that of earlier American College of Radiology recommendations, whereas use of IR suite nurse staffing is consistent with approximately one per suite and constant. However, there is dissatisfaction among surveyed interventional radiologists with availability and appropriateness of staffing of the IR procedure room, particularly during on-call hours and weekends, as well as with anesthesia support for emergent cases. No evidence-based guidelines for staffing the IR suite currently exist. This underscores the need for further investigation with the ultimate goal of creating such guidelines.

Radiation protection in interventional radiology: survey results of attitudes and use.

PURPOSE: To assess attitudes of interventional radiologists toward personal radiation protection and the use of radiation protection devices. MATERIALS AND METHODS: Invitations to an anonymous online survey that comprised eight questions focused on operator attitudes toward radiation protection devices were sent via e-mail to the active membership of the Society of Interventional Radiology (SIR): a total of 3,158 e-mail invitations. A single reminder e-mail was sent. RESULTS: There were 504 survey responders (16% response rate). Reported radiation safety device use included lead apron (99%), thyroid shield (94%), leaded eyeglasses (54%), ceiling-suspended leaded shield (44%), rolling leaded shields (12%), ceiling-suspended/rolling lead-equivalent apron (4%), radiation-attenuating sterile surgical gloves (1%), and sterile lead-equivalent patient-mounted drape (4%). Reasons commonly cited for not using certain devices were comfort (eyewear), ease of use (mounted shields), and lack of availability (rolling/hanging shields and patient-mounted shields). CONCLUSIONS: Interventionalists have an array of tools from which to choose for personal radiation protection; however, for a variety of reasons related to lack of availability or choice, these tools are not universally employed. Further study may be of value to clarify why comfort was cited most often as the primary barrier to the use of protective eyewear and difficulty of use was cited as the primary barrier to use of mounted shields (despite reporting that concern for radiation-induced injury to the eye is paramount). It may also be of interest to further study why certain devices with demonstrable protection effects are not readily available, such as rolling/hanging and patient-mounted shields.

Hysterosalpingography with selective salpingography.

OBJECTIVE: To evaluate the use of selective salpingography to achieve tubal patency in patients with proximal fallopian tube occlusion on hysterosalpingography (HSG). STUDY DESIGN: We performed a retrospective cohort study on 116 infertile women (age 37.7 +/- 4.6 years) with proximal tubal obstruction treated with selective salpingography. Success was defined as opening at least 1 fallopian tube. Pregnancy was defined as having a positive beta-hCG level. RESULTS: A total of 151 tubes were blocked on HSG before tubal catheterization; 103 tubes were opened by selective salpingography. Of 116 patients, 84 (72.4%) had successful procedures with at least 1 tube opened by catheterization. Of the 116, 32 (27.6%) had failed procedures with no tubes opened. Of 83 patients, 30 (36.1%) with successful procedures achieved pregnancy. Of these pregnancies, 16 occurred spontaneously or following ovulation induction and 5 pregnancies occurred in the failure group, allfollowing in vitro fertilization. CONCLUSION: Selective salpingography is useful in demonstrating tubal patency, reducing the diagnosis of tubal disease and potentially minimizing surgery in infertile patients.

Endovascular graft placement for femoral artery erosion caused by recurrent vulvar carcinoma.

BACKGROUND: Advances in minimally-invasive endovascular therapy have offered an efficient alternative to conventional open surgery in patients with severe comorbidities. CASE: We report a case of severe hemorrhage resulting from recurrent vulvar carcinoma-associated erosion of the left common femoral and proximal left superficial femoral arteries which was successfully managed with percutaneous endovascular stent-graft placement, achieving immediate hemostasis and maintaining lower extremity perfusion while awaiting more invasive and definitive treatment. CONCLUSION: Endovascular stent-graft placement of eroded artery, in an infected field, is technically feasible in an emergency situation.

Outcomes of rejected Journal of Vascular and Interventional Radiology manuscripts.

PURPOSE: To track the publication fate of rejected Journal of Vascular and Interventional Radiology (JVIR) manuscript submissions. MATERIALS AND METHODS: All manuscripts submitted to JVIR for consideration in 2004, but subsequently rejected, were retrospectively evaluated. The PubMed database was searched for subsequent manuscript publication. Manuscript type, journal type and title, publication delay, journal publication volume, journal circulation volume, and journal impact factor were evaluated. RESULTS: Two hundred thirteen of the 366 rejected JVIR submissions (58%) were subsequently published in 72 different journals as of December 15, 2007. Fifty-five of the published manuscripts (26%) were revised resubmissions to JVIR and 45 (21%) were published in Cardiovascular and Interventional Radiology, with 113 manuscripts published in other journals. The mean time from manuscript rejection to subsequent publication was 15.5 months. Half of the 366 rejected manuscripts were ultimately published within 25 months. CONCLUSIONS: A majority of rejected JVIR mauscripts were ultimately published. Rejection of a manuscript by JVIR does not preclude publication.

Cesarean section scar diverticulum: appearance on hysterosalpingography.

OBJECTIVE: The purpose of this study was to characterize the frequency and appearance of hysterotomy defects on hysterosalpingography in patients with a history of cesarean section. MATERIALS AND METHODS: We reviewed the hysterosalpingograms of 150 women with a history of cesarean section. The incidence, location, and appearance of defects at the expected location of a hysterotomy scar were evaluated. RESULTS: Of the 148 patients with history of cesarean section and technically adequate hysterosalpingograms, 89 (60%) had defects that were in the expected location of a hysterotomy incision. Fifty-eight (65%) of the diverticula were focal outpouchings, and 31 (35%) were thin linear defects. Forty-eight (54%) of the diverticula were located at the lower uterine cavity, 32 (36%) at the uterine isthmus, and nine (10%) at the upper endocervical canal. CONCLUSION: A diverticulum at the lower uterine cavity, uterine isthmus, or upper endocervical canal is a common finding on hysterosalpingography in patients with a history of cesarean section.

Transarterial embolization for inferior epigastric artery injury.

The inferior epigastric artery represents a potentially overlooked source of pelvic arterial hemorrhage. The authors describe 3 patients with massive inferior epigastric artery bleeding following cesarean section, paracentesis, and blunt trauma that were successfully treated with transarterial embolization. The inferior epigastric artery should be considered as a possible source of arterial hemorrhage if arteriography of internal iliac artery branches does not yield a bleeding source.