Applications of Vascular Imaging and Interventional Radiology Modalities in the Upper Extremity: A Review.

Hand and upper extremity (HUE) vascular disorders are encountered frequently by hand surgeons in clinical practice. A wide array of imaging and vascular interventional radiology modalities exists for the diagnosis and treatment of HUE vascular disorders, some of which may not be familiar to the HUE surgeons. In this review article, we summarize the vascular imaging and vascular interventional radiology modalities and their relative advantages, disadvantages, and indications with respect to HUE pathology. We aim to familiarize HUE surgeons with the available types of diagnostic and therapeutic options for HUE vascular pathologies and aid interdisciplinary communication with vascular interventional radiology specialists during the clinical decision-making process.

Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy.

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Balloon-Occluded Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma: A Single-Center US Preliminary Experience.

This report describes a single-center experience with balloon-occluded transarterial chemoembolization for liver-directed therapy. A total of 26 patients (11 male, 4 female; mean age, 65 y ± 7) with 28 tumors (mean diameter, 2.7 cm; range, 1.1-5.9 cm) were treated. Technical success rate was 100% (28 of 28 cases), with 1 minor complication of left portal vein thrombosis and small liver infarct. Of the 15 tumors analyzed for response, 60% (9 of 15) exhibited complete response, 33.3% (5 of 15) exhibited partial response, and 6.6% (1 of 15) had stable disease on follow-up. Eight patients exhibited overall progression with a new hepatic lesion and a median time to progression of 7.9 months (range, 5-11 mo).

Aspiration Thrombectomy-Assisted Endovascular Retrieval of an Embolized Angio-Seal Device Causing Claudication.

The Angio-Seal vascular closure device is used to reduce time to hemostasis after femoral artery puncture. Although rare, complications associated with Angio-Seal are significant, including infection, pseudoaneurysm formation, symptomatic femoral artery stenosis, and separation and embolization, leading to limb-threatening ischemia. This report describes Angio-Seal polymer anchor embolization to the tibioperoneal trunk successfully retrieved using the 8-French Indigo Aspiration System.

Current Concepts and Future Directions of Minimally Invasive Treatment for Knee Pain.

PURPOSE OF REVIEW: The purpose of this paper is to review the percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty. RECENT FINDINGS: Corticosteroid injection and viscosupplementation have been the most studied, but there is still no consensus about their value. Thermal nerve ablation, including both radiofrequency ablation and cryoneurolysis, is a promising new modality of therapy that may increase in clinical use given current data showing favorable outcomes. Of the future therapies that are currently under investigation, synovial embolization via the geniculate arteries represents an exciting new approach that may soon be available clinically. There are various percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.

Vein of Galen Malformations.

Significant efforts have been made over the last few decades to improve the diagnosis and management of patients with vein of Galen malformations (VOGMs). The mainstays of treatment remain focused on primary endovascular management by staged transarterial embolizations with adjunctive use of transvenous embolization, medical therapy, and neurosurgical intervention for symptom control in select patients. Innovation in endovascular technology and techniques as well as promising new genomic research elucidating potential therapeutic targets hold significant promise for the future of VOGM treatment.

Safety and Efficacy of Conscious Sedation Versus General Anesthesia for Distal Vessel Thrombectomy.

BACKGROUND AND OBJECTIVES: Anesthesia modality for endovascular thrombectomy (EVT) for distal and medium vessel occlusions remains an open question. General anesthesia (GA) may offer advantages over conscious sedation (CS) because of reduced patient movement facilitating catheter navigation, but concerns persist about potential delays and hypotension affecting collateral circulation. METHODS: In our prospectively maintained stroke registry from December 2014 to July 2023, we identified patients with distal and medium vessel occlusions defined as M2, M3, or M4 occlusion; A1 or A2 occlusion; and P1 or P2 occlusion, who underwent EVT for acute ischemic stroke. We compared patients who received CS with those who received GA. Primary outcomes were early neurological improvement (ENI), successful reperfusion, first-pass effect, and good outcome at 90 days. Secondary outcomes included intracerebral hemorrhage, subarachnoid hemorrhage, and 90-day mortality. RESULTS: Of 279 patients, 69 (24.7%) received GA, whereas 193 (69.2%) received CS. CS was associated with higher odds of ENI compared with GA (odds ratio [OR] 2.59, 95% CI [1.04-6.98], P < .05). CS was also associated with higher rates of successful reperfusion (OR 2.33, 95% CI [1.11-4.93], P < .05). CS nonsignificantly trended toward lower rates of mortality (OR 0.51, 95% CI [0.2-1.3], P = .16). No differences in good outcome at 90 days, intracerebral hemorrhage, subarachnoid hemorrhage, or first-pass effect were seen. CONCLUSION: The use of CS during EVT seems to be safe and feasible with regard to successful recanalization, hemorrhagic complications, clinical outcome, and mortality. In addition, it may be associated with a higher rate of ENI. Further randomized studies in this specific EVT subpopulation are warranted.

Endovascular Alternatives to Transhepatic Shunt Creation.

Portomesenteric decompression is often necessary to treat patients with refractory symptoms of portal hypertension. When transjugular or direct intrahepatic portosystemic shunt creation is not feasible or is inadequate, surgical portosystemic shunt creation is considered, which carries significant morbidity and mortality in these high-risk patients. Surgery is further complicated in patients with portomesenteric thrombosis who require concurrent thrombectomy and long-term anticoagulation. In this article, we outline the technique for performing advanced endovascular alternatives to intrahepatic portosystemic shunt creation including mesocaval and splenorenal shunting. We will also discuss some of the clinical considerations for treating these patients with symptomatic portal hypertension and portomesenteric thrombosis.

Advanced Techniques for Accessing the Portal Vein during Transjugular Intrahepatic Portosystemic Shunt Creation.

Transjugular portosystemic shunt (TIPS) placement is a widely accepted method for reducing portal pressures in conditions including symptomatic varices, refractory ascites, hepatic hydrothorax, portomesenteric thrombosis, and Budd-Chiari syndrome. The traditional method for performing TIPS involves "blind" access into a portal vein branch from a hepatic vein, typically right portal vein to right hepatic vein, using preoperative imaging and intraoperative wedged portography for guidance. However, standard access technique may not always be feasible due to occluded portal or hepatic veins, distorted anatomy, or prior TIPS. In this article we discuss alternative techniques for accessing the portal vein for TIPS placement when standard methods are not sufficient.

Leveraging the virtual learning environment to enhance medical student engagement with interventional radiology.

PURPOSE: To evaluate medical student engagement with Interventional Radiology (IR) before and after a virtual elective course. METHODS: The elective was nine, one-hour lectures over ten weeks. An anonymous pre and post-course survey was administered to students. The hypothesis was that this course would increase student engagement with IR. Respondents answered nine questions to score their interest in, exposure to, familiarity with, and understanding of IR using a five-point Likert scale. Demographics were reported for the pre-course group only. A Wilcoxon signed-ranked test was performed to assess for significant mean change in pre and post-course responses. Among the 276 registered students, there were 144 individual, complete responses for the pre-course survey, and 60 paired responses for both surveys. RESULTS: Thirty-seven percent of respondents were first or second year medical students. Thirty percent of participants were enrolled at an institution outside of the United States, 26% are the first in their family to attend college, and 41% identified as female. Thirty-six percent reported this virtual course was one of their earliest experiences with IR. There was a significant increase in student exposure to IR generally, familiarity with IR compared to other specialties, familiarity with the IR training pathway(s), understanding of what an Interventional Radiologist does, understanding of the difference between IR and Diagnostic Radiology, and understanding of when to consult IR for patient care after completion of the course. CONCLUSION: A virtual IR elective is an effective means to increase exposure to, familiarity with, and understanding of IR.

Transradial access for cerebral angiography and neurointerventional procedures: A meta-analysis and systematic review.

PURPOSE: Transradial access (TRA) for diagnostic and interventional neurointerventional procedures has recently gained traction over transfemoral access (TFA) in the neurointerventional community. This meta-analysis aims to assess and summarize the utility of TRA in cerebral angiography and neurointerventional procedures. METHODS: A systematic literature review was performed utilizing Pubmed, Embase, and Scopus databases. Using PRISMA guidelines, records were extracted with the following search terms: transradial approach, transradial access, radial access, cerebral angiogram, cerebral angiography, neurointervention, and neuroendovascular. The primary outcomes assessed were case success rate, complication rate, and crossover rate from TRA to TFA. Secondary analysis was performed on procedure time, fluoroscopy time, fluoroscopy time per vessel (diagnostic procedures only), contrast dose, radial artery diameter, distal radial artery diameter, and patient preference for TRA over TFA. RESULTS: Sixty-two full-text articles were analyzed for this meta-analysis, representing 12,927 diagnostic and interventional TRA access patients. Our analysis revealed a combined diagnostic and interventional case success rate of 95.9% and complication rate of 3.5%, with crossover to TFA occurring in 4.9% of cases. CONCLUSION: This meta-analysis demonstrates that TRA access for diagnostic angiography and neurointerventional procedures is a safe and effective approach, though determining a true complication rate is challenging as the definition of TRA complications has changed in various publications over time.

A Citizen of Two Worlds: The IR/DR Residency.

The integrated interventional radiology (IR) residency accepted its first applicants in 2017. Achieving specialty status represents a significant milestone for IR; recognizing the expanding role of IR as part of an interdisciplinary team. However, this transition has had challenges that were well predicted by Heitkamp and Gunderman in 2014 and are reflected in the history of many specialties. New specialties often have complex relationships with their "parent" specialties, creating debates and tension regarding training, licensure, and scope of practice. Many of these factors have been discussed in opinion pieces by leaders in the field, reflecting upon the transition. There have also been surveys of matched IR/DR residents. However, there are few firsthand accounts of the challenges faced by trainees during such a transition, challenges that often are not well captured by an online survey.

Sources of Revenue Loss and Recovery in Radiology Practices During the Coronavirus Disease 2019 (COVID-19) Pandemic.

RATIONALE AND OBJECTIVES: This study seeks to quantify the financial impact of COVID-19 on radiology departments, and to describe the structure of both volume and revenue recovery. MATERIALS AND METHODS: Radiology studies from a large academic health system were retrospectively studied from the first 33 weeks of 2020. Volume and work relative value unit (wRVU) data were aggregated on a weekly basis for three periods: Presurge (weeks 1-9), surge (10-19), and recovery (20-33), and analyzed compared to the pre-COVID baseline stratified by modality, specialty, patient service location, and facility type. Mean and median wRVU per study were used as a surrogate for case complexity. RESULTS: During the pandemic surge, case volumes fell 57%, while wRVUs fell by 69% relative to the pre-COVID-19 baseline. Mean wRVU per study was 1.13 in the presurge period, 1.03 during the surge, and 1.19 in the recovery. Categories with the greatest mean complexity declines were radiography (-14.7%), cardiothoracic imaging (-16.2%), and community hospitals overall (-15.9%). Breast imaging (+6.5%), interventional (+5.5%), and outpatient (+12.1%) complexity increased. During the recovery, significant increases in complexity were seen in cardiothoracic (0.46 to 0.49), abdominal (1.80 to 1.91), and neuroradiology (2.46 to 2.56) at stand-alone outpatient centers with similar changes at community hospitals. At academic hospitals, only breast imaging complexity remained elevated (1.32 from 1.17) during the recovery. CONCLUSION: Reliance on volume alone underestimates the financial impact of the COVID-19 pandemic as there was a disproportionate loss in high-RVU studies. However, increased complexity of outpatient cases has stabilized overall losses during the recovery.

Impact of COVID-19 social distancing regulations on outpatient diagnostic imaging volumes and no-show rates.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted outpatient radiology practices, necessitating change in practice infrastructure and workflow. OBJECTIVE: The purpose of this study was to assess the consequences of social distancing regulations on 1) outpatient imaging volume and 2) no-show rates per imaging modality. METHODS: Volume and no-show rates of a large, multicenter metropolitan healthcare system outpatient practice were retrospectively stratified by modality including radiography, CT, MRI, ultrasonography, PET, DEXA, and mammography from January 2 to July 21, 2020. Trends were assessed relative to timepoints of significant state and local social distancing regulatory changes. RESULTS: The decline in imaging volume and rise in no-show rates was first noted on March 10, 2020 following the declaration of a state of emergency in New York State (NYS). Total outpatient imaging volume declined 85% from baseline over the following 5 days. Decreases varied by modality: 88% for radiography, 75% for CT, 73% for MR, 61% for PET, 80% for ultrasonography, 90% for DEXA, and 85% for mammography. Imaging volume and no-show rate recovery preceded the mask mandate of April 15, 2020, and further trended along with New York City's reopening phases. No-show rates recovered within 2 months of the height of the pandemic, however, outpatient imaging volume has yet to recover to baseline after 3 months. CONCLUSION: The total outpatient imaging volume declined alongside an increase in the no-show rate following the declaration of a state of emergency in NYS. No-show rates recovered within 2 months of the height of the pandemic with imaging volume yet to recover after 3 months. CLINICAL IMPACT: Understanding the impact of social distancing regulations on outpatient imaging volume and no-show rates can potentially aid other outpatient radiology practices and healthcare systems in anticipating upcoming changes as the COVID-19 pandemic evolves.

Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients.

PURPOSE: To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. METHODS: Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. RESULTS: In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. CONCLUSION: Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Additional Magnetic Resonance or Nuclear Scintigraphy Imaging Influences Approach to Vertebral Augmentation: A Single Institution Experience.

STUDY DESIGN: Retrospective review. OBJECTIVE: To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures. SUMMARY OF BACKGROUND DATA: Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities. METHODS: Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study. RESULTS: Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients. CONCLUSION: MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone. LEVEL OF EVIDENCE: 3.

Extreme obesity is associated with angulation during inferior vena cava filter placement.

BACKGROUND: Placement of inferior vena cava (IVC) filters can be complicated by venous injury, filter misplacement, angulation, insertion site injury, and procedure-related death. Currently, no studies exist evaluating the correlation between obesity and adverse outcomes of IVC filters. We aimed to assess the outcomes of IVC filter placement in the obese population using the Vascular Quality Initiative database. METHODS: The Vascular Quality Initiative registry identified 7258 patients who underwent IVC filter placement from January 2013 to June 2017. Patients were divided into three groups based on their body mass index (BMI): normal/overweight (BMI <30), obese (BMI 30-40), and extremely obese (BMI >40). Periprocedural outcomes were analyzed. RESULTS: The mean age was 63.6 ± 16.6 years and 3444 patients (47%) were female. BMI was less than 30 in 4115 (56.7%), 30 to 40 in 2148 (29.6%), and greater than 40 in 995 (13.7%) patients. A complication or IVC filter-related death occurred in 142 patients (2.6%). Adverse events included angulation (1.3%), IVC filter misplacement (0.5%), insertion site injury (0.3%), IVC filter-related death (0.1%), and venous injury (0.06%). In multivariable analysis, increased BMI was found to be associated with angulation (P = .03), but was not associated with IVC filter misplacement (P = .43), or any complication or IVC filter-related death (P = .22). A subgroup analysis of IVC filter placements using only fluoroscopy demonstrated that the risk of angulation was significantly higher in patients with a BMI of greater than 40 compared with a BMI of less than 30 (odds ratio, 2.12; 95% confidence interval, 1.07-4.21; P = .03). There was not enough evidence to conclude that BMI was associated with any other outcome. CONCLUSIONS: IVC filter insertion has low complication rates. Increased BMI is associated with an increased risk of IVC filter angulation; there is no evidence of association between BMI and other periprocedural complications.

Differential Motivations for Pursuing Interventional Radiology: Implications for Residency Recruitment.

PURPOSE: The purpose of this study is to compare the motivations of interventional radiology (IR) residency, IR fellowship, and diagnostic radiology (DR) applicants. MATERIALS AND METHODS: A questionnaire was distributed to IR integrated residency and IR fellowship applicants for the 2018 National Resident Matching Program (NRMP) Match. Survey respondents scored the influence of 13 aspects of IR on their career decision. These results were combined with a previously published survey of DR residency applicants from 2016 who were asked the same questions. Pairwise comparisons to survey responses were made between IR residency and IR fellowship as well as IR residency and DR residency respondents. RESULTS: There were 202 of 657 DR residency respondents (response rate 30.7%), 114 of 295 IR residency respondents (response rate 38.6%), and 70 of 169 IR fellowship respondents (response rate 41.4%). Compared with DR respondents, IR residency respondents rated the following factors more positively: influence of a mentor (P = .030), perceived job satisfaction (P < .001), job market (P < .001), salary (P < .001), intellectual stimulation (P = .030), the use of emerging or advanced technology (P < .001), and the visual nature of the field (P < .001). In contrast, DR residency respondents rated flexible work hours (P < .001), physics (P < .001), and competitiveness of the application process (P < .001) more positively than IR respondents. Compared with IR fellowship respondents, IR residency respondents rated flexible work hours (P = .002), the job market (P = .020), physics (P < .001), and salary (P < .001) more positively, and competitiveness (P = .002) was felt to be more negative for residency applicants. CONCLUSION: The motivations for pursuing IR residency differ from both DR residency and IR fellowship. Understanding these motivations can help to recruit top quality IR residency applicants.

Image-Guided Percutaneous Gastrostomy Tube Placement is Safe in Patients Requiring Aspirin 325 mg.

RATIONALE AND OBJECTIVES: Requests for gastrostomy tube placement in patients on aspirin (ASA) 325 mg are common, particularly in patients following reconstructive surgery for head and neck cancer, but periprocedural guidelines and recommendations regarding management of high dose aspirin are inconsistent. The purpose of this study was to assess the bleeding risk of percutaneous gastrostomy tube placement in patients on ASA 325 mg. MATERIALS AND METHODS: This retrospective study of 213 patients who underwent image-guided "push" percutaneous gastrostomy tube placement compared rates of significant bleeding and other secondary outcomes (including all-cause mortality within 30 days, procedure-related mortality, bowel perforation, abdominal abscess, peritonitis, aspiration pneumonia, intraprocedural airway complications, and tube dislodgement) between patients maintained on ASA 325 mg and patients not on antiplatelet or anticoagulation therapy. RESULTS: No significant bleeding episodes occurred in patients on ASA 325 mg, compared to three episodes in patients not on ASA 325 mg (p = 0.37). A patient in each group had aspiration pneumonia possibly related to tube placement. There were no other notable secondary outcomes, including intraprocedural airway complications in this population with complex head and neck anatomy. CONCLUSION: These findings suggest that holding ASA 325 mg in patients undergoing percutaneous gastrostomy tube placement is not necessary, especially in patients in whom holding ASA would pose considerable risk. Further multi-institutional longitudinal study is warranted to validate these results.