Predictors of Disease Recurrence after Venoplasty and Stent Placement for May-Thurner Syndrome.

PURPOSE: To identify factors independently associated with disease recurrence after venoplasty and stent placement for May-Thurner syndrome (MTS). MATERIALS AND METHODS: Fifty-nine consecutive patients (age, 47 y ± 15; 93% female) were identified who had undergone endovascular stent placement for MTS. Patient charts were reviewed for demographic data, risk factors for venous thrombosis, comorbidities, and venous inflow or outflow at first follow-up (3 wk to 6 mo after treatment). Logistic regression was used to identify independent predictors of symptom recurrence or repeat intervention, and multivariate analysis of variance and receiver operator characteristic curve analysis were used to assess relationships between degrees of in-stent stenosis and other variables in the 73% of patients with available cross-sectional imaging. Median follow up was 20.7 months (interquartile range, 4.7-49.5 mo). RESULTS: All procedures were technically successful. Disease recurrence, defined as symptom recurrence following initial postprocedural resolution, was observed in 38% of patients. No preprocedural variable was found to be independently predictive of disease recurrence; however, poor venous inflow or outflow were both strongly associated with recurrent disease, with adjusted odds ratios and 95% confidence intervals of 38.02 (3.76-384.20; P = .002) and 7.00 (1.15-42.71; P = .04), respectively. Higher degrees of in-stent stenosis were also associated with symptom recurrence, with an area under the curve of 0.93 (P = .000002) and 39%-41% stenosis being 78%-83% sensitive and 88%-92% specific for symptom recurrence. CONCLUSIONS: These results suggest that cross-sectional imaging can help differentiate patients in whom closer follow-up may be warranted after venoplasty and stent placement for MTS and also guide counseling regarding prognosis.

Transient and Regional Ischemia Related to Continuous Saline Solution Infusion during Radial Artery Access.

This case series illustrates a radial access complication seen in 7 of 9 consecutive patients (age range, 44-53 y) undergoing uterine artery embolization in May and June 2017. Demonstrative images and videos identify a transient and clinically consequential skin ischemia caused by intraprocedural saline solution infusion through the occlusive radial artery sheath. All complications documented were classified as mild adverse events (class A) according to Society of Interventional Radiology criteria. Complication severity ranged from transient blanching to ischemic necrosis of the skin. Operator cognizance of this phenomenon with appropriate adjustment of saline solution infusion rates will prevent tissue ischemia and necrosis in radial access cases.

Single-Center Retrospective Review of Radiofrequency Wire Recanalization of Refractory Central Venous Occlusions.

PURPOSE: To retrospectively review the effectiveness and safety of radiofrequency (RF) wire recanalization of refractory central venous occlusions (CVOs) and compare recurrent and nonrecurrent CVOs in terms of patient and occlusion characteristics. MATERIALS AND METHODS: Twenty CVOs were treated in 18 patients (age 40 y ± 13; 9 women) with 11 superior vena cava (SVC) or brachiocephalic vein occlusions (ie, supradiaphragmatic) and 9 inferior vena cava or iliac vein occlusions (ie, infradiaphragmatic). Indications included pain, edema, ulceration, and/or dialysis arteriovenous fistula dysfunction peripheral to the CVO(s). All patients had multiple venous thrombotic risk factors, including mechanical venous compression, endothelial injury, and/or coagulopathies. CVO traversal was first attempted with standard and advanced techniques before RF wire recanalization and followed up with computed tomographic venography and clinic visits approximately 1, 3, 6, and 12 months after treatment. RESULTS: Sixteen CVOs (80%) were successfully transversed and associated with symptom relief. One major complication occurred involving SVC perforation into the pericardial space. Primary CVO patency rate was 56% at a median follow-up of 14.1 months (interquartile range [IQR], 9.2-20.0 mo). Recurrent CVOs tended to be infradiaphragmatic (71% vs 12% for supradiaphragmatic; P = .02), longer (12.9 cm ± 10.0 vs 2.3 cm ± 1.3; P < .01), and associated with implanted venous stents, filters, or cardiac pacer/defibrillator leads (86% vs 22%; P = .01). Median time to restenosis/occlusion was 1.5 months (IQR, 1.1-6.1 mo). CONCLUSIONS: RF wire recanalization is a relatively effective and safe option for refractory CVOs. Patients with longer, infradiaphragmatic CVOs associated with indwelling devices may require closer follow-up for CVO recurrence.

Perceptions of Quality in Interventional Oncology.

PURPOSE: To inductively characterize perceptions of quality in interventional oncology (IO) based on values and experiences of patients and referring providers. MATERIALS AND METHODS: Brief ethnographic interviews were completed with referring providers and patients before and after a variety of liver-directed procedures about their experiences, concerns, and perceptions of IO services at a single institution. Constructivist grounded theory was used to systematically analyze interview transcripts for themes until thematic saturation was achieved. All transcripts were analyzed by a reviewer with 3-years of experience performing such analyses, and 50% were randomly selected to be coded by 2 additional blinded reviewers. Interreviewer agreement was assessed via Cohen κ. RESULTS: Interviews with 22 patients (mean age, 65 y ± 13; 9 women) and 12 providers (mean age, 54 y ± 9; 6 women) were required to reach and confirm thematic saturation. Interreviewer agreement for interview themes was excellent (κ = 0.78; P < .001). Perceptions of high-quality IO care relied on interventional radiologists being responsive, friendly, and open; engaging in multidisciplinary collaboration; having thoughtful, dedicated support staff; and facilitating well-coordinated care after procedures and follow-up more than technical expertise and periprocedural comfort. Patient and provider perceptions of quality differed, but disjointed care after procedures was the most common critique among both groups. CONCLUSIONS: An inductive qualitative approach effectively characterized specific aspects of perceptions of high-quality IO care among patients and referring providers.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids.

PURPOSE: To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids. METHODS: Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years. RESULTS: Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests. CONCLUSIONS: Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

Who We Are and What We Can Become: An Analysis of Professional Identity Formation in IR.

PURPOSE: To characterize the unique experiences, values, and perspectives of interventional radiology (IR) fellows. MATERIALS AND METHODS: Sixteen fellows from 4 US vascular and IR programs were interviewed within 2 months of beginning and 2-3 months following their 2015-2016 fellowships about patient interactions, training experiences, and views of IR and other specialties. Interviews were systematically analyzed for dominant themes by using constructivist grounded theory. Four interviews with 2015-2016 interventional cardiology fellows, 16 interviews with IR attending physicians, and online descriptions of IR were also analyzed for context. Themes were compared qualitatively and quantitatively. RESULTS: Interobserver agreement was good for interview themes (κ = 0.70; P < .0001). IR fellows' professional identity emerged primarily from radiologic and surgical interests, with distinct emphasis on being "innovators," "thinking differently," and "needing to adapt and advertise abilities to survive." Fellows' descriptions of patient care were more clinically focused than past interviews with attending physicians (P = .05), but clinical interests common in medical specialties were limited, and descriptions of "nonprocedural patient care" were primarily periprocedural (81%). Descriptions of the future of the field conveyed competing pressures, loose role definition, and disconnect between academic and private-practice IR. CONCLUSIONS: IR fellows share professional interests, views of their field and others, and descriptions of patient care, but there is uncertainty regarding future roles of the specialty and a need for more specific and unified definitions of nonprocedural patient care in IR.

Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging.

BACKGROUND: Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized. MATERIALS AND METHODS: 15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results. RESULTS: Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility). CONCLUSIONS: Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."

Portal vein recanalization-transjugularintrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis.

PURPOSE: To present the transsplenic route as an alternative approach for portal vein recanalization-transjugular portosystemic shunt (PVR-TIPS) for chronic main portal vein thrombosis (PVT) in potential transplant candidates. MATERIALS AND METHODS: In 2013-2014, 11 consecutive patients with cirrhosis-induced chronic main PVT underwent transsplenic PVR-TIPS. All patients had been denied listing for transplant because of the presence of main PVT, a relative contraindication in this center. The patients were followed for adverse events. Portal vein patency was assessed at 1 month by splenoportography and every 3 months subsequently by ultrasound or magnetic resonance imaging. After PVR-TIPS, patients were reviewed (and subsequently listed for transplant) at a weekly multidisciplinary conference. RESULTS: PVR-TIPS using the transsplenic approach was successful in all 11 patients with no major complications. Median age was 61 years (range, 33-67 y) and 9 of 11 patients (82%) were men. Nonalcoholic steatohepatitis was the leading cause of liver disease in 4 of 11 patients (36%), and hepatitis C was present in 4 of 11 patients (36%). Complete main PVT was found in 8 of 11 patients (73%). Of 11 patients, 4 (36%) had a Model for End-Stage Liver Disease score > 18, and 8 (73%) had a baseline Child-Pugh score of 7-10. Minor adverse events occurred in 2 of 11 patients (fever, encephalopathy). At the end of the procedure, 5 of 11 patients (45%) exhibited some minor remaining thrombus in the portal vein; 3 of the 5 patients (60%) had complete thrombus resolution at 1 month, with the remaining 2 patients having resolution at 3 months (no anticoagulation was needed). Three patients underwent successful liver transplant with end-to-end anastomoses. CONCLUSIONS: Transsplenic PVR-TIPS is a potentially safe and effective method to treat PVT and improve transplant candidacy.

Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database.

PURPOSE: To compare the safety of permanent and retrievable inferior vena cava (IVC) filters by reviewing the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. MATERIALS AND METHODS: The MAUDE database was reviewed from January 1, 2009, to December 31, 2012. Product class search criteria were "filter, intravascular, cardiovascular." Type of device used and specific adverse events (AEs) were recorded. RESULTS: For the period January 2009-December 2012, 1,606 reported AEs involving 1,057 IVC filters were identified in the MAUDE database . Of reported AEs, 1,394 (86.8%) involved retrievable inferior vena cava filters (rIVCFs), and 212 (13.2%) involved permanent inferior vena cava filters (pIVCFs) (P < .0001). Reported AEs included fracture, migration, limb embolization, tilt, IVC penetration, venous thromboembolism and pulmonary embolism, IVC thrombus, and malfunctions during placement. Each specific AE was reported with significantly higher frequency in rIVCFs compared with pIVCFs. The most common reported complication with rIVCFs was fracture, whereas the most commonly reported complications with pIVCFs were placement malfunctions. For rIVCFs, the most commonly reported AE varied depending on filter brand. CONCLUSIONS: The MAUDE database reveals that complications occur with significantly higher frequency with rIVCFs compared with pIVCFs. This finding suggests that the self-reported complication rate with rIVCFs is significantly higher than the self-reported complication rate with pIVCFs.

Ethanol embolotherapy of vascular malformations: clinical outcomes at a single center.

PURPOSE: To retrospectively evaluate the results of endovascular therapy of vascular malformations principally treated with ethanol embolization at a single center. MATERIALS AND METHODS: From May 1999 to December 2012, 46 patients (28 female, 18 male) with vascular malformations (31 venous malformations, 15 arteriovenous malformations [AVMs]) throughout the body (nine upper extremity, 31 lower extremity, and six truncal) who underwent ethanol embolization were studied and followed up. Demographic factors, clinical findings, imaging data, and patient-reported changes in symptoms were collected and analyzed. Follow-up data were obtained by office visits, repeat imaging, and telephone contact. RESULTS: Twenty-four patients (52.2%) were considered cured, 12 (26.1%) showed improvement, and 10 (21.7%) had no change or showed worsening. Similar rates of cure or improvement were seen for AVMs and venous malformations (P = 0.67). Lesion location, depth, and size were not associated with differences in outcomes (P = .87, P = .37, and P = .61, respectively). Type 1 and type 2 AVMs were cured more often than other AVM types. The overall complication rate was 24% (11 of 46 patients). Minor complications were seen in six individuals (13%), and major complications developed in five patients (11%). CONCLUSIONS: Ethanol embolization of vascular malformations produces good outcomes, with control or relief of symptoms in a majority of patients.

Uterine artery embolization and its effect on fertility.

A systematic review of literature analyzing fertility following uterine artery embolization (UAE) is presented. Twenty-one studies describing pregnancy and complications of pregnancy following UAE were included. Low-level evidence from these studies suggests that pregnancy rates following UAE are comparable to the age-adjusted rates in the general population. Although pregnancy complication rates were similar to those in patients with untreated fibroid tumors, a few studies have reported higher miscarriage rates following UAE. Further randomized controlled trials comparing UAE versus other fertility-preserving treatments are necessary to confirm these findings.

Cancer concepts and principles: primer for the interventional oncologist-part I.

A sophisticated understanding of the rapidly changing field of oncology, including a broad knowledge of oncologic disease and the therapies available to treat them, is fundamental to the interventional radiologist providing oncologic therapies, and is necessary to affirm interventional oncology as one of the four pillars of cancer care alongside medical, surgical, and radiation oncology. The first part of this review intends to provide a concise overview of the fundamentals of oncologic clinical trials, including trial design, methods to assess therapeutic response, common statistical analyses, and the levels of evidence provided by clinical trials.

Cancer concepts and principles: primer for the interventional oncologist-part II.

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma.

BACKGROUND & AIMS: Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC. METHODS: We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed. RESULTS: Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P < .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42). CONCLUSIONS: Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies.

The power of proximity: Effects of a multidisciplinary fibroid clinic on inter-specialty perceptions and practice patterns.

BACKGROUND: Multidisciplinary collaboration has generally been shown to have positive effects on healthcare but can be difficult to facilitate. This study assessed the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions to better understand drivers of interspecialty collaboration. MATERIALS AND METHODS: Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) performed in an urban healthcare system were collected from 2012-2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The gynecologists and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (κ = 0.80). RESULTS AND DISCUSSION: Annual rates of fibroid procedures increased over time (p<0.01) but the relative number of UFEs decreased (p = 0.01). UFE referrals by the clinic gynecologists significantly increased as did the number of combined fibroid procedures (p<0.01). However, the rates of one fibroid procedure relative to others were not different between the clinic and rest of the healthcare system (p = 0.55). Specialty-specific perceptions of fibroid treatments and inter-specialty dynamics did not change. Despite this, clinicians unanimously perceived the clinic and post-clinic practice patterns as positive and distinct from their previous work and relationships between gynecology and IR elsewhere. Limitations of this study included its single clinic design and potential confounder of differences in advertising pre- versus post-clinic. CONCLUSION: Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.

Chemoembolization for hepatocellular carcinoma: comprehensive imaging and survival analysis in a 172-patient cohort.

PURPOSE: To determine comprehensive imaging and long-term survival outcome following chemoembolization for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: One hundred seventy-two patients with HCC treated with chemoembolization were studied retrospectively in an institutional review board approved protocol; this study was HIPAA compliant. Baseline laboratory and imaging characteristics were obtained. Clinical and laboratory toxicities following treatment were assessed. Imaging characteristics following chemoembolization were evaluated to determine response rates (size and necrosis) and time to progression (TTP). Survival from the time of first chemoembolization treatment was calculated. Subanalyses were performed by stratifying the population according to Child-Pugh, United Network for Organ Sharing, and Barcelona Clinic for Liver Cancer (BCLC) staging systems. RESULTS: Cirrhosis was present in 157 patients (91%); portal hypertension was present in 139 patients (81%). Eleven patients (6%) had metastases at baseline. Portal vein thrombosis was present in 11 patients (6%). Fifty-five percent of patients experienced some form of toxicity following treatment; 21% developed grade 3 or 4 bilirubin toxicity. Post-chemoembolization response was seen in 31% and 64% of patients according to size and necrosis criteria, respectively. Median TTP was 7.9 months (95% confidence interval: 7.1, 9.4) but varied widely by stage. Median survival was significantly different between patients with BCLC stages A, B, and C disease (stage A, 40.0 months; B, 17.4 months; C, 6.3 months; P < .0001). CONCLUSION: The determination of TTP and survival in patients with HCC is confounded by tumor biology and background cirrhosis; chemoembolization was shown to be a safe and effective therapy in patients with HCC.