Potential risk assessment: a model for quality evaluation in fluoroscopy-guided interventional procedures.

This study presented a model applied for potential risk assessment in an interventional radiology setting. The model of potential risk assessment (MARP) consisted of the creation of a scale of indicators ranging from 0 to 5. The radiation levels were categorized according to gender, kind of procedure, value of kerma air product (Pka), and accumulated radiation dose (mGy). The MARP model was applied in 121 institutions over 8 y. A total of 201 656 patient radiation doses (Dose-area product and accumulated kerma) data were launched into the system over time, with an average of 22 406 doses per year. In the context of the workers (cardiologists, radiographers, and nurses) monitored during the MARP application, 8007 cases (with an average of 890 per year) of occupational radiation doses were recorded. This study showed a strategy for quality evaluation in fluoroscopy using a model with a compulsory information system for monitoring safety.

Computed Tomography-Guided Microwave Ablation of Cystic Renal Cell Carcinoma: Assessment of Technique and Complications.

This report evaluates the techniques and complications of microwave ablation of cystic renal cell carcinoma. Five patients with cystic renal cell carcinoma were treated with microwave ablation between October 2015 and June 2020. Medical records were reviewed to evaluate technique and complications. Technical success and primary technique efficacy both were 100%. There were no complications. Mean follow-up time was 18 months (range, 6-36 months). No local recurrence was identified during the follow-up period. Renal function remained stable at 1 month and the last follow-up. Percutaneous microwave ablation is promising for the nonsurgical management of cystic renal cell carcinoma.

Optimization of resources and modifications in acute ischemic stroke care in response to the global COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has presented unprecedented challenges to healthcare organizations worldwide. A steadily rising number of patients requiring intensive care, a large proportion from racial and ethnic minorities, demands creative solutions to provide high-quality care while ensuring healthcare worker safety in the face of limited resources. Boston Medical Center has been particularly affected due to the underserved patient population we care for and the increased risk of ischemic stroke in patients with COVID-19 infection. METHODS: We present protocol modifications developed to manage patients with acute ischemic stroke in a safe and effective manner while prioritizing judicious use of personal protective equipment and intensive care unit resources. CONCLUSION: We feel this information will benefit other organizations facing similar obstacles in caring for the most vulnerable patient populations during this ongoing public health crisis.

Assessment of Eye Lens Dose Reduction When Using Lateral Lead Shields on the Patient's Head during Neurointerventional Fluoroscopic Procedures and Cone-beam Computed Tomography (CBCT) Scans.

The purpose of this study was to evaluate the effect of placing small lead shields on the temple region of the skull to reduce radiation dose to the lens of the eye during interventional fluoroscopically-guided procedures and cone-beam computed tomography (CBCT) scans of the head. EGSnrc Monte-Carlo code was used to determine the eye lens dose reduction when using lateral lead shields for single x-ray projections, CBCT scans with different protocols, and interventional neuroradiology procedures with the Zubal computational head phantom. A clinical C-Arm system was used to take radiographic projections and CBCT scans of anthropomorphic head phantoms without and with lead patches, and the images were compared to assess the effect of the shields. For single lateral projections, a 0.1 (0.3)-mm-thick lead patch reduced the dose to the left-eye lens by 40% to 60% (55% to 80%) from 45° to 90° RAO and to the right-eye lens by around 30% (55%) from 70° to 90° RAO. For different CBCT protocols, the reduction of lens dose with a 0.3-mm-thick lead patch ranged from 20% to 53% at 110 kVp. For CBCT scans of the anthropomorphic phantom, the lead patch introduced streak artifacts that were mainly in the orbital regions but were insignificant in the brain region where most neurointerventional activity occurs. The dose to the patient's eye lens can be reduced considerably by placing small lead shields over the temple region of the head without substantially compromising image quality in neuro-imaging procedures.

Assessment of the Annual Eye Lens Dose for Cardiologists During Interventional Procedures Using Anthropomorphic Phantoms and mEyeDose_X Tool.

OBJECTIVES: In this study, eye lens dose measurements were performed using two anthropomorphic phantoms simulating the cardiologist and patient during interventional procedures. BACKGROUND: Interventional procedures known as areas with high potential risk and the cardiologists can receive relatively high doses to their eyes. METHODS: This study was comprised of both phantom and computer simulations. Thermoluminescent dosimeters (TLDs) and mEyeDose_X tool were used to measure and calculate eye lens doses for the cardiologist. 144 TLDs measurements were performed using cardiac protocol for three angiographic projections: anterior-posterior (AP), left anterior oblique 90° (LAO90) and left anterior oblique 45° with cranial 30° (spider) angulations. All cine and fluoroscopy modes including the projections used in this study performed with and without protection tools. RESULTS: The annual equivalent doses with protective tools using mEyeDose_X were found to be 1.831 and 1.424 mSv/year, whereas the values using phantom were found to be 2.204 and 1.802 mSv/year for the lens of lift and right eye respectively. CONCLUSION: The annual doses reported in this study are almost comparable to other studies performed on interventional cardiology (IC) procedures. The highest dose rate in the lens was 20.21 ±â€¯0.015 mSv/h without protective tools in cine mode for spider projection. Cardiologists may therefore easily exceed the lens dose limit if protective tools are not used.

ASDIN white paper: Assessment and management of hemodialysis access-induced distal ischemia by interventional nephrologists.

Although not common, hemodialysis access-induced distal ischemia is a serious condition resulting in significant hemodialysis patient morbidity. Patients with signs and symptoms suggestive of hand ischemia frequently present to the general and interventional nephrologist for evaluation. In order to care for these cases, it is necessary to understand this syndrome and its management. Most cases can be managed conservatively without intervention. Some cases requiring intervention may be treated using techniques within the scope of practice of the interventional nephrologists while other cases require vascular surgery. In order for the interventional nephrologists to evaluate and manage these cases in a timely and appropriate manner, practice guidelines are presented.

Medical Malpractice in Image-Guided Procedures: An Analysis of 184 Cases.

PURPOSE: To report types and outcomes of a small subset of malpractice lawsuits filed against physicians performing image-guided interventions in the United States. MATERIALS AND METHODS: In total, 1,312 cases involving common image-guided procedures were reviewed from the Westlaw and LexisNexis databases in the United States from 1963 to 2018. Social Security, disability, employment contract, product liability, criminal, and government employment claims were excluded. The final legal cohort comprised 184 (14.0%) cases. They were categorized into vascular (113/184; 61.4%), inferior vena cava filter (n = 22; 12.0%), neurointerventional (n = 13; 7.1%), gastrointestinal and genitourinary (n = 17; 9.2%), foreign body (n = 7; 3.8%), biopsy related (n = 9; 4.9%), and oncologic (n = 3; 1.6%) interventions. Claims were also organized by defendant type and by specialty, complication stage, verdict, and year. RESULTS: From 2001 to 2018, 58.7% of claims (n = 108) were reported. Procedural complications related to arteriography were most commonly litigated (63/113; 55.8%). Claims arising from intra-procedural and early post-procedural complications were common (84/184; 45.7%). Community hospitals were most often named as defendants (61/184; 33.2%). In reported outcomes, courts sided with defendants in 81.9% (104/127) of the cases, similar to national malpractice trends. Unreported outcomes comprised 31% (57/184) of the data. CONCLUSIONS: For the small subset of claims published within national legal databases, intra-procedural and early post-procedural complications after diagnostic arteriography were most commonly litigated. Most (81.9%) claims with reported outcomes sided with the defendant physician.

Comparison of the value of superficial mark guided localization and hook-wire guided localization techniques for non-palpable breast microcalcifications: A retrospective clinical research.

AIM: The present study compares the effect and accuracy of the superficial mark guided localization (SGL) and hook-wire guided localization (WGL) techniques for non-palpable breast microcalcifications. METHODS: This retrospective study was conducted to compare SGL and WGL techniques. These techniques were performed on 51 patients with non-palpable breast microcalcifications from January 2015 to May 2016. RESULTS: Among these 51 patients, 25 (49.01%) patients were subjected to WGL and 26 patients (50.99%) were subjected to SGL. The SGL technique had a higher rate of malignant cancer detection (WGL = 12.0% and SGL = 23.0%). Furthermore, no significant differences were found with regard to average age, the rate of a second excision and the diameter of the excised tissue. Moreover, no complications were observed in the SGL group, while four (16.0%) patients in the WGL group experienced problems. CONCLUSION: The SGL technique is as accurate as the WGL technique. Furthermore, the procedure has advantages of being less expensive and causing less complications.

Contemporary use of and outcomes associated with ultra-low contrast volume in patients undergoing percutaneous coronary interventions.

BACKGROUND: The risk of contrast-induced acute kidney injury (CI-AKI) increases in a nonlinear fashion with increasing volume of contrast media. Prior studies recommend limiting contrast volume to less than three times the estimated creatinine clearance (CC). Recently, a number of operators have reported successful percutaneous coronary intervention (PCI) using even lower volumes of contrast. OBJECTIVES: To evaluate the prevalence and outcomes associated with ultra-low contrast volume among patients undergoing PCI. METHODS: We assessed the prevalence and outcomes associated with use of ultra-low contrast volume among 75 393 patients undergoing PCI in Michigan between July 2014 and June 2017 in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry. Ultra-low contrast volume was defined as contrast volume less than or equal to the patient's estimated CC. Patients receiving dialysis at the time of the procedure were excluded. RESULTS: Ultra-low contrast volume was used in 13% of procedures with the majority of these patients being at low risk of renal complications. Compared with patients who received a contrast volume between one and three times the CC, use of ultra-low volume of contrast was associated with a significantly lower incidence of AKI (aOR 0.682, 95% CI 0.566-0.821, P < 0.001) and a lower incidence of need for dialysis (aOR = 0.341, 95% CI 0.165-0.704, P = 0.003). These benefits were most evident in the patients with a high baseline predicted risk of AKI. CONCLUSIONS: A small but clinically significant number of patients are treated with ultra-low contrast volume. Ultra-low contrast volume use is associated with a significant reduction in the incidence of AKI or need for dialysis. It may be prudent to consider this new threshold when performing PCI on patients who are at an increased risk of AKI.

Risk Assessment of Chronic Kidney Disease following Microwave Ablation for Stage T1 Renal Cell Carcinoma.

PURPOSE: To assess safety and renal-function outcomes after microwave (MW) ablation of localized stage T1 renal cell carcinoma (RCC). MATERIALS AND METHODS: A retrospective review was conducted of 38 patients (28 men; mean age, 69 y; range, 51-88 y) who underwent computed tomography (CT)-guided MW ablation for stage T1N0M0 RCC. Baseline and follow-up renal function surrogates including creatinine level and estimated glomerular filtration rate (eGFR) were statistically compared. Peri- and postoperative complication rates, technical success, and treatment response were also assessed. RESULTS: A total of 44 biopsy-proven stage T1N0M0 RCCs measuring 1.2-6.9 cm (mean, 2.5 cm) were treated, and renal function was measured 1 mo after treatment. Mean eGFRs were 60 mL/min/1.73 m2 at baseline and 59 mL/min/1.73 m2 at 1 month after ablation. At 1-year and last follow-ups, the means of difference were 3.3% (95% confidence interval, -4.4 to 4.3; P = .99) and 3.3% (95% confidence interval, -4.3 to 4.8; P = .91), respectively. The 2-years freedom from eGFR decrease to < 60 mL/min/1.73 m2 was 2% (P = .91). Among the 5 patients (13%) with preexisting stage 4 chronic kidney disease (CKD; eGFR < 30 mL/min/1.73 m2) before ablation, there was no significant postablative onset of decline or CKD upstaging (P = .001). There were no major complications, and 5 patients (13%) had small asymptomatic perinephric hematomas (Society of Interventional Radiology minor complication, class A/B) that were managed conservatively. CONCLUSIONS: At 2-year follow-up, CT-guided percutaneous MW ablation is safe and well-tolerated and achieves nephron preservation similar to existing ablative modalities.

Eye lens dose levels in interventional rooms using simple phantom simulation, dose management software and Monte Carlo method of uncertainty assessment.

This paper presents a fast method to estimate the annual eye lens dose levels for interventional practitioners applying the Monte Carlo method of uncertainty assessment. The estimation was performed by placing an anthropomorphic phantom in the typical working position, and applying the habitually employed protocol. No radiation protection devices were considered in the simulation. The results were compatible with the measurements performed during interventions by placing dosimeters in the vicinity of the eyes of two paediatric interventional cardiologists working with a fluoroscopic biplane system.

Variability in radiation dose and image quality: A comparison across fluoroscopy-system vendors, generations of equipment and institutions.

OBJECTIVES: To evaluate differences in radiation dose and image quality across institutions, fluoroscope vendors and generations of fluoroscopes for pediatric cardiac catheterization. BACKGROUND: Increased recognition of the potentially harmful effects of ionizing radiation has spurred technological advances in fluoroscopes, as well as increased focus on optimizing fluoroscope performance. There is currently little understanding of variability in the dose-image quality relationship across institutions, fluoroscope vendor and/or generation of equipment. METHODS: We evaluated latest generation fluoroscopes from Phillips, Siemens, GE, and Toshiba, and an older generation Phillips fluoroscope (release date 2003) at three different institutions. Radiation dose was measured using an anthropomorphic dose-assessment phantom with effective dose in mSv estimated from Monte Carlo simulations. Image quality phantom images were scored on a 12-point scale by three blinded reviewers. RESULTS: Fluoroscope effective doses ranged from 0.04 to 0.14 mSv/1,000 pulses for fluoroscopy with associated composite image quality scores ranging from 8.0 ± 0.6 to 10.4 ± 1.3. For cineangiography, effective doses ranged from 0.17 to 0.57 mSv/1,000 frames with image quality scores ranging from 10.1 ± 0.3 to 11.1 ± 0.3. There was modest correlation between effective dose and image quality (r = 0.67, P = 0.006). The older generation fluoroscope delivered consistently higher doses than the newer generation systems (2.3- to 3.5-fold higher for fluoroscopy; 1.1- to 3.4-fold higher for cineangiography) without appreciable differences in image quality. CONCLUSION: Technological advances have markedly improved fluoroscope performance. Comparing latest generation systems across vendors and institutions, we found variability in the dose-IQ relationship and speculate that this reflects both equipment and institutional optimization practices.

IMPORTANCE OF CONTEXTUAL DATA IN PRODUCING HEALTH TECHNOLOGY ASSESSMENT RECOMMENDATIONS: A CASE STUDY.

OBJECTIVES: Contextual data and local expertise are important sources of data that cannot be ignored in hospital-based health technology assessment (HTA) processes. Despite a lack of or unconvincing evidence in the scientific literature, technology can be recommended in a given context. We illustrate this using a case study regarding biplane angiography for vascular neurointervention. METHODS: A systematic literature review was conducted, along with an analysis of the context in our setting. The outcomes of interest were radiation doses, clinical complications, procedure times, purchase cost, impact on teaching program, the confidence of clinicians in the technology, quality of care, accessibility, and the volume of activity. A committee comprising managers, clinical experts, physicians, physicists and HTA experts was created to produce a recommendation regarding biplane technology acquisition to replace a monoplane device. RESULTS: The systematic literature review yielded nine eligible articles for analysis. Despite a very low level of evidence in the literature, the biplane system appears to reduce ionizing radiation and medical complications, as well as shorten procedure time. Contextual data indicated that the biplane system could improve operator confidence, which could translate into reduced risk, particularly for complex procedures. In addition, the biplane system can support our institution in its advanced procedures teaching program. CONCLUSIONS: Given the advantages provided by the biplane technology in our setting, the committee has recommended its acquisition. Contextual data were of utmost importance in this recommendation. Moreover, this technology should be implemented alongside a responsibility to collect outcome data to optimize clinical protocol in the doses of ionizing delivered.

Patient Exposure during Fluoroscopy-guided Pacemaker Implantation Procedures.

A pacemaker, which is used for heart resynchronization with electrical impulses, is used to manage many clinical conditions. Recently, the frequency of pacemaker implantation procedures has increased to more than 50% worldwide. During this procedure, patients can be exposed to excessive radiation exposure. Wide range of doses has been reported in previous studies, suggesting that optimization of this procedure has not been fulfilled yet. The current study evaluated patient radiation exposure during cardiac pacemaker procedures and quantified the patient effective dose. A total of 145 procedures were performed for five pacemaker procedures (VVI, VVIR, VVD, VVDR, and DDDR) at two hospitals. Patient doses were measured using the kerma-area product meter. Effective doses were estimated using software based on Monte Carlo simulation from the National Radiological Protection Board (NRPB, now The Health Protection Agency). The effective dose values were used to estimate cancer risk from the pacemaker procedure. Patient demographic data and exposure parameters for fluoroscopy and radiography were quantified. The mean patient doses ± SD per procedure (Gycm2) for VVI, VVIR, VVD, VVDR, and DDDR were 1.52 ± 0.13 (1.43-1.61), 3.28 ± 2.34 (0.29-8.73), 3.04 ± 1.67 (1.57-4.86), 6.04 ± 2.326 3.29-8.58), and 8.8 ± 3.6 (4.5-26.20), respectively. The overall patient effective dose was 1.1mSv per procedure. It is obvious that the DDDR procedure exposed patients to the highest radiation dose. Patient dose variation can be attributed to procedure type, exposure parameter settings, and fluoroscopy time. The results of this study showed that patient doses during different pacemaker procedures are lower compared to previous reported values. Patient risk from pacemaker procedure is low, compared to other cardiac interventional procedures. Patients' exposures were mainly influenced by the type of procedures and the clinical indication.

Effect of protective devices on the radiation dose received by the brains of interventional cardiologists.

AIMS: This study aimed to evaluate the effectiveness of ceiling suspended screens, lead glasses and lead caps in reducing radiation doses to the brains of interventional cardiologists. METHODS AND RESULTS: Interventional procedures where the thorax of the patient is irradiated with different beam projections were modelled. The dose reduction in the white matter and hippocampus of the Zubal head phantom was studied for two sizes of ceiling suspended screens, two types of lead glasses and lead caps of surgical and hood models, which cover different regions of the head. Ceiling screens were the most effective, reducing the dose to brain tissue by 74% or even as much as 94%. The dose reduction provided by lead glasses varies between 10% and 17%. For the lead caps, it strongly depends on the model, varying from 6% (surgical) up to 68% (hood that also covered lower parts of the head). CONCLUSIONS: The dose to the brain can be reduced by using appropriate radiation protection devices. This study has shown that lead caps are less protective than previously described and that the best protection is given by ceiling suspended screens, which are widely available in interventional theatres.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Preventive Strategies for Contrast-Induced Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Procedures: Evidence From a Hierarchical Bayesian Network Meta-Analysis of 124 Trials and 28 240 Patients.

BACKGROUND: The effectiveness of currently available effective preventive strategies for contrast-induced acute kidney injury (CIAKI) is a matter of debate. METHODS AND RESULTS: We performed a Bayesian random-effects network meta-analysis of 124 trials (28 240 patients) comparing a total of 10 strategies: saline, statin, N-acetylcysteine (NAC), sodium bicarbonate (NaHCO3), NAC+NaHCO3, ascorbic acid, xanthine, dopaminergic agent, peripheral ischemic preconditioning, and natriuretic peptide. Compared with saline, the risk of CIAKI was reduced by using statin (odds ratio [OR], 0.42; 95% credible interval [CrI], 0.26-0.67), xanthine (OR, 0.32; 95% CrI, 0.17-0.57), ischemic preconditioning (OR, 0.48; 95% CrI, 0.26-0.87), NAC+NaHCO3 (OR, 0.50; 95% CrI, 0.33-0.76), NAC (OR, 0.68; 95% CrI, 0.55-0.84), and NaHCO3 (OR, 0.66; 95% CrI, 0.47-0.90). The benefit of statin therapy was consistent across multiple sensitivity analyses, whereas the efficacy of all the other strategies was questioned by restricting the analysis to high-quality trials. Overall, high heterogeneity was observed for comparisons involving xanthine and ischemic preconditioning, although the impact of NAC and xanthine was probably influenced by publication bias/small-study effect. Hydration alone was the least effective preventive strategy for CIAKI. Meta-regressions did not reveal significant associations with baseline creatinine and contrast volume. In patients with diabetes mellitus, no strategy was found to reduce the incidence of CIAKI. CONCLUSIONS: In patients undergoing percutaneous coronary procedures, statin administration is associated with a marked and consistent reduction in the risk of CIAKI compared with saline. Although xanthine, NAC, NaHCO3, NAC+NaHCO3, ischemic preconditioning, and natriuretic peptide may have nephroprotective effects, these results were not consistent across multiple sensitivity analyses.

A Primer on Hemodialysis From an Interventional Radiology Perspective.

Interventional radiologists play a central role in the care of patients with end-stage renal disease receiving renal replacement therapy. Ensuring that a patient׳s dialysis access remains suitable for high-quality dialysis is of paramount importance. However, although much has been spoken and written about endovascular techniques and outcomes based on angiographic criteria, little is generally known regarding the function and therefore the requirements of hemodialysis. In this article, we provide a heuristic overview of the mechanics of hemodialysis, with an emphasis on the "breaking points" in the extracorporeal circuit that trigger a patient׳s referral to Interventional Radiology. We also describe how dialysis quality is increasingly becoming linked with dialysis reimbursements. It is thus becoming progressively incumbent on the interventional radiologist to not only ensure that a patient receives high-quality outpatient dialysis but also that the patient׳s dialysis center meets its performance metrics.