Workforce Diversity of Interventional Radiology Physicians in North America: Reflections on the U.S. Experience.

Achieving parity in representation within the field of Interventional Radiology (IR) across women and specific subsets of minority groups has been a challenge. The lack of a strongly diverse physician workforce in gender, race, and ethnicity suggests suboptimal recruitment after, during as well prior to IR training. There is a dearth of studies which effectively characterize the national demographic trends of the evolving IR workforce. This has prevented an accurate appraisal of continuing efforts to narrow the gaps in physician workforce diversity across the field of IR. To support these needs, this article illustrates historic trends while providing contemporary data that canvasses the status of diversity within the current IR physician and IR trainee workforce. It highlights the representation of those individuals historically underrepresented in medicine as well as women. It also highlights current obstacles to achieving equity, diversity, and inclusion within the field of IR as well as existing efforts that have been employed to mitigate this gap.

Closing the Gaps in Racial Disparities in Critical Limb Ischemia Outcome and Amputation Rates: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel.

Minority patients such as Blacks, Hispanics, and Native Americans are disproportionately impacted by critical limb ischemia and amputation due to multiple factors such as socioeconomic status, type or lack of insurance, lack of access to health care, capacity and expertise of local hospitals, prevalence of diabetes, and unconscious bias. The Society of Interventional Radiology Foundation recognizes that it is imperative to close the disparity gaps and funded a Research Consensus Panel to prioritize a research agenda. The following research priorities were ultimately prioritized: (a) randomized controlled trial with peripheral arterial disease screening of at-risk patients with oversampling of high-risk racial groups, (b) prospective trial with the introduction of an intervention to alter a social determinant of health, and (c) a prospective trial with the implementation of an algorithm that requires criteria be met prior to an amputation. This article presents the proceedings and recommendations from the panel.

Ergonomics in IR.

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

Endovascular Removal of Thrombus and Right Heart Masses Using the AngioVac System: Results of 234 Patients from the Prospective, Multicenter Registry of AngioVac Procedures in Detail (RAPID).

PURPOSE: To assess device and procedural safety and technical success associated with the use of the AngioVac System to remove vascular thrombi and cardiac masses. MATERIALS AND METHODS: The Registry of AngioVac Procedures in Detail (RAPID) study prospectively collected data for 234 patients receiving treatment with AngioVac at 21 sites between March 2016 and August 2019: 84 (35.9%) with caval thromboemboli (CTEs), 113 (48.3%) with right heart masses (RHMs), 20 (8.5%) with catheter-related thrombi (CRTs), and 4 (1.7%) with pulmonary emboli (PEs). Thirteen patients had a combination of procedures during the same admission. RESULTS: Using the AngioVac system, 70%-100% thrombus or mass removal was achieved in 73.6% of patients with CTEs, 58.5% of patients with RHMs, 60% of patients with CRTs, and 57.1% of patients with PEs. Extracorporeal bypass time was < 1 hour for 176 (75.2%) procedures. Estimated blood loss was < 250 mL for 179 procedures (76.5%). Mean hemoglobin decreased from 10.4 g/dL ± 2.9 preoperatively to 9.4 g/dL ± 2.6 postoperatively. Transfusions were administered in 59 procedures (25.2%) with 47 transfusions (78.2%) being ≤ 2 U. There were 36 procedure-related complications, including 1 death. CONCLUSIONS: The RAPID registry data demonstrate that the AngioVac System can be safely and effectively used to remove vascular thrombi and cardiac masses across a broad range of patient populations. The limited use of the device to remove pulmonary emboli in the present series precludes recommending the use of the AngioVac device for this indication.

Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia.

DESCRIPTION: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications. METHODS: The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved. RECOMMENDATIONS: The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.

Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare Beneficiaries.

Background Dialysis maintenance interventions account for billions of dollars in U.S. Medicare spending and are performed by multiple medical specialties. Whether Medicare costs differ by physician specialty is, to the knowledge of the authors, not known. Purpose To assess patency-adjusted costs of endovascular dialysis access maintenance by physician specialty. Materials and Methods In this retrospective longitudinal cohort study, patients who were beneficiaries of Medicare undergoing their first arteriovenous access placement in 2009 were identified by using billing codes in the 5% Limited Data Set. By tracking their utilization data through 2014, postintervention primary patency and aggregate payments associated with maintenance interventions were calculated. Unadjusted payments per year of access patency gain were compared across physician specialty. A general linear mixed-effects model adjusted for covariates was used, as follows: patient characteristics, access type (fistula vs graft), clinical severity, type of intervention (angioplasty, stent, thrombolysis), clinical location (hospital outpatient vs office-based laboratory), and resource utilization (operating room use, anesthesia use). Results First arteriovenous access was performed in 1479 beneficiaries (mean age, 63 years ± 15 [standard deviation]; 820 men) in 2009. Through 2014, 8166 maintenance interventions were performed in this cohort. Unadjusted mean Medicare payments for each incremental year of patency were as follows: $71 000 for radiologists, $89 000 for nephrologists, and $174 000 for surgeons. Billing for operating room (41.8% [792 of 1895], surgery; 10.2% [277 of 2709], nephrology; and 31.1% [1108 of 3562], radiology) and anesthesia (19.9% [377 of 1895], surgery; 2.6% [70 of 2709], nephrology; 4.7% [170 of 3562], radiology) varied by specialty and accounted for 407% and 132% higher payments, respectively. After adjusting for clinical severity and location, type of intervention, and resource utilization, nephrologists and surgeons had 59% (95% confidence interval: 44%, 73%; P < .001) and 57% (95% confidence interval: 43%, 72%; P < .001) higher payments, respectively, for the same patency gain compared with radiologists. Operating room use and anesthesia services were major drivers of higher cost, with 407% (95% confidence interval: 374%, 443%; P < .001) and 132% (95% confidence interval: 116%, 150%; P < .001) higher costs, respectively. Conclusion Patency-adjusted payments for hemodialysis access maintenance differed by physician specialty, driven partly by discrepant rates of billing for operating room and anesthesia use. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by White in this issue.

Recent Trends in Clinical Setting and Provider Specialty for Endovascular Peripheral Artery Disease Interventions for the Medicare Population.

PURPOSE: To describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment of disease, and clinical location of service. MATERIALS AND METHODS: Current Procedural Terminology codes were used to identify claims for peripheral vascular interventions (PVIs) in 2011-2017 Physician Supplier Procedure Summary master files, which contain 100% Part B Medicare billing. Market share was defined as enrollment-adjusted proportion of billed PVI services for each specialty. Annual volume of billed services was additionally evaluated by clinical location (inpatient, outpatient, office-based laboratories) and anatomic segment of disease (iliac, femoral/popliteal, infrapopliteal). RESULTS: Aggregate PVI claims increased 31.3%, from 227,091 in 2011 to 298,127 in 2017. Annual market share remained relatively stable for all specialties: surgery, 48.3%-49.6%; cardiology, 37.2%-35.1%; radiology, 12.8%-13.3%. Accounting for Medicare enrollment, the volume of iliac interventions decreased by 18% over the study period, while femoral/popliteal interventions increased modestly (+7.5%) and infrapopliteal interventions increased (+46%). The greatest proportional increase in infrapopliteal claims occurred among radiologists (surgeons +40.4%, cardiologists +32.1%, radiologists +106.6%). Adjusting for enrollment, claims from office-based laboratories increased substantially (+305.7%), while hospital-based billing decreased (inpatient -25.7%, outpatient -12.9%). Office-based laboratory utilization increased dramatically with all specialties (surgery +331.8%, cardiology +256.0%, radiology +475.7%). CONCLUSIONS: Utilization of PVIs continues to increase, while specialty market shares have stabilized since 2011, leaving surgeons and cardiologists as the major providers of endovascular peripheral artery disease care. The greatest relative increases are occurring in infrapopliteal interventions and office-based laboratory procedures, where radiologist involvement has increased dramatically.

Effort Thrombosis Presenting as Unilateral "Pumped" Arm in a Climber.

Upper extremity injuries are common among the growing population of climbers. Although conditions affecting musculoskeletal structures are the most common causes of symptoms, a comprehensive differential diagnosis is necessary to avoid the misdiagnosis of high-morbidity conditions in this patient population. We present a case of a climber with acute edema, erythema, and pain of the entire right upper extremity. After confirmation of an upper extremity deep vein thrombosis by ultrasound, and in the absence of secondary causes for his thrombotic process, he was diagnosed with effort thrombosis. The patient was treated acutely with anticoagulation, catheter thrombectomy, direct thrombolysis, and balloon angioplasty followed by surgical decompression of the subclavian vein. Owing to the importance of early diagnosis and initiation of treatment, it is critical to keep disorders affecting the upper thoracic vascular structures in consideration.

Bowel Penetration by Inferior Vena Cava Filters: Feasibility and Safety of Percutaneous Retrieval.

OBJECTIVE. The purpose of this study was to evaluate the safety and technical feasibility of inferior vena cava filter (IVCF) removal when filter elements penetrate adjacent bowel. MATERIALS AND METHODS. A multicenter retrospective review of IVCF retrievals between 2008 and 2018 was performed. Adult patients with either CT or endoscopic evidence of filter elements penetrating bowel before retrieval were included. Technical success of IVCF retrieval was recorded. Patient records were assessed for immediate, 30-day, and 90-day complications after retrieval. RESULTS. Thirty-nine consecutive adult patients (11 men and 28 women; mean age, 51.2 years; age range, 18-81 years) qualified for inclusion. Filter dwell time was a median of 148 days (range, 32-5395 days). No IVCFs were known to have migrated or caused iliocaval thrombosis. Five IVCFs (12.8%) had more than 15° tilt relative to the inferior vena cava (IVC) before retrieval. Three IVCFs (7.7%) had fractured elements identified at the time of retrieval. Mean international normalized ratio (INR) was 1.24 ± 0.53 (SD), and mean platelet count was 262 ± 139 × 103/µL. Ten patients (25.6%) were on antibiotics at the time of retrieval. All 39 IVCFs were successfully retrieved (technical success = 100%). Two patients experienced minor complications in the immediate postprocedural period, which resulted in a minor complication rate of 5.1%. There were no complications (major or minor) identified in any patient at 30 or 90 days after retrieval. The overall major complication rate was 0%. CONCLUSION. Endovascular retrieval of IVCFs with CT evidence of filter elements that have penetrated adjacent bowel is both safe and technically feasible.

Race and Sex Disparities in Outcomes of Dialysis Access Maintenance Interventions.

PURPOSE: To determine whether utilization and outcomes of dialysis access maintenance interventions vary by patient race or sex. MATERIALS AND METHODS: Data for this retrospective cohort study of first-time arteriovenous (AV) access recipients were drawn from a 5% sample of Medicare beneficiaries, containing claims from all clinical settings (2009-2014) in 2,693 patients who received their first AV fistula/graft in 2009. Maintenance interventions-angiography, angioplasty, thrombolysis, stent placement, and venous embolization-were identified by corresponding Current Procedural Terminology codes. Outcomes of primary patency (PP), postinterventional primary patency (PIPP), and postinterventional secondary patency (PISP) were calculated with utilization records. Associations between demographic data and patency times were evaluated by a multivariate survival approach, controlling for baseline differences in patient age, comorbid disease, type of dialysis access, and interventionist specialty. RESULTS: AV grafts (AVGs) were created with greater frequency in women (32% vs 23% in men; P < .001) and minority patients (39% in black, 32% in Hispanic, and 29% in Asian patients vs 21% in white patients; P < .001). Women were at greater hazards for loss of PP (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.14) and PIPP (HR, 1.42; 95% CI, 1.01-2.00). Black patients were at greater hazards for loss of PP (HR, 1.37; 95% CI, 1.23-1.54) and PISP (HR, 1.29; 95% CI, 1.01-1.65). AVG creation predisposed patients to patency loss in all models (P < .001). CONCLUSIONS: Dialysis access patency rates are lower for women and black patients. More frequent primary AVG creation in women and minority patients additionally predisposes these patients to patency loss.

National Trends and Outcomes of Transjugular Intrahepatic Portosystemic Shunt Creation Using the Nationwide Inpatient Sample.

PURPOSE: To elucidate trends in transjugular intrahepatic portosystemic shunt (TIPS) use and outcomes over the course of a decade, including predictors of inpatient mortality and extended length of hospital stay. MATERIALS AND METHODS: The Nationwide Inpatient Sample was interrogated for the most recent 10 years available: 2003-2012. TIPS procedures and associated diagnoses were identified via International Classification of Diseases (version 9) codes, with the latter categorized into primary diagnoses in a hierarchy of disease severity. Linear regression analysis was used to determine trends of TIPS use and outcomes over time. Independent predictors of mortality and extended length of stay were determined by logistic regression. RESULTS: A total of 55,145 TIPS procedures were captured during the study period. Annual procedural volume did not change significantly (5,979 in 2003, 5,880 in 2012). The majority of TIPSs were created for ascites and/or varices (84%). Inpatient mortality (12.5% in 2003, 10.6% in 2012; P < .05) decreased but varied considerably by diagnosis (from 3.7% to 59.3%), with a disparity between bleeding and nonbleeding varices (18.7% vs 3.8%; P < .01). Multivariate predictors of mortality (P < .001 for all) included primary diagnoses (bleeding varices, hepatorenal and abdominal compartment syndromes), patient characteristics (age > 80 y, black race), and sequelae of advanced cirrhosis (comorbid hepatocellular carcinoma, spontaneous bacterial peritonitis, encephalopathy, and coagulopathy). CONCLUSIONS: National TIPS inpatient mortality has decreased since 2003 while procedural volume has not changed. Postprocedural outcome is a function of patient demographic and socioeconomic factors and associated diagnoses. Independent predictors of poor outcome identified in this large national population study may aid clinicians in better assessing preprocedural risk.

Intravascular US-Guided Portal Vein Access: Improved Procedural Metrics during TIPS Creation.

PURPOSE: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) outcomes and procedure metrics with the use of three different image guidance techniques for portal vein (PV) access during TIPS creation. MATERIALS AND METHODS: A retrospective review of consecutive patients who underwent TIPS procedures for a range of indications during a 28-month study period identified a population of 68 patients. This was stratified by PV access techniques: fluoroscopic guidance with or without portography (n = 26), PV marker wire guidance (n = 18), or intravascular ultrasound (US) guidance (n = 24). Procedural outcomes and procedural metrics, including radiation exposure, contrast agent volume used, procedure duration, and PV access time, were analyzed. RESULTS: No differences in demographic or procedural characteristics were found among the three groups. Technical success, technical success of the primary planned approach, hemodynamic success, portosystemic gradient, and procedure-related complications were not significantly different among groups. Fluoroscopy time (P = .003), air kerma (P = .01), contrast agent volume (P = .003), and total procedural time (P = .02) were reduced with intravascular US guidance compared with fluoroscopic guidance. Fluoroscopy time (P = .01) and contrast agent volume (P = .02) were reduced with intravascular US guidance compared with marker wire guidance. CONCLUSIONS: Intravascular US guidance of PV access during TIPS creation not only facilitates successful TIPS creation in patients with challenging anatomy, as suggested by previous investigations, but also reduces important procedure metrics including radiation exposure, contrast agent volume, and overall procedure duration compared with fluoroscopically guided TIPS creation.

Survival outcomes in patients with advanced hepatocellular carcinoma treated with drug-eluting bead chemoembolization.

OBJECTIVE. The purpose of this study was to determine the overall survival rates in patients with advanced hepatocellular carcinoma (HCC) who undergo treatment with drug-eluting bead (DEB) therapy. MATERIALS AND METHODS. A retrospective review of the clinical HCC database of a single institution was undertaken for patients treated between September 2008 and December 2011. Demographic information, laboratory and imaging findings, procedural details, and outcomes after treatment were obtained. The primary outcome was overall survival, which was stratified by Barcelona Clinic Liver Cancer (BCLC) stage, Child-Pugh class, Eastern Cooperative Oncology Group (ECOG) score, serum bilirubin level, and ethnicity. Multiple secondary independent variables were also measured. RESULTS. Of 239 consecutive patients treated during the prescribed time frame, 43 patients met the inclusion criteria. Thirty patients met the criteria for BCLC stage C, and 13 met the criteria for BCLC stage D based largely on ECOG score. Eight patients had venous invasion or portal venous thrombosis, and four had limited extrahepatic metastases. Eight patients had Child-Pugh class C liver disease but remained candidates for liver transplant based on the Milan criteria. The median overall survival was 596 days; 23 patients are still alive, 12 of whom underwent liver transplant. The only independent variables affecting survival were serum bilirubin value of 2.0 mg/dL or greater (hazard ratio [HR] = 3.96; 95% CI, 1.46-10.7; p = 0.007) and Child-Pugh class B or C disease (HR = 3.33; 95% CI, 1.07-10.34; p = 0.037). CONCLUSION. The use of DEBs for TACE therapy is safe and effective in carefully selected patients with advanced HCC.

Metaanalysis of survival, complications, and imaging response following chemotherapy-based transarterial therapy in patients with unresectable intrahepatic cholangiocarcinoma.

PURPOSE: Unresectable intrahepatic cholangiocarcinoma represents a devastating illness with poor outcomes when treated with standard systemic therapies. Several smaller nonrandomized outcomes studies have been reported for such patients undergoing transarterial therapies. A metaanalysis was performed to assess primary clinical and imaging outcomes, as well as complication rates, following transarterial interventions in this patient population. MATERIALS AND METHODS: By using standard search techniques and metaanalysis methodology, published reports (published in 2012 and before) evaluating survival, complications, and imaging response following transarterial treatments for patients with unresectable intrahepatic cholangiocarcinoma were identified and evaluated. RESULTS: A total of 16 articles (N = 542 subjects) met the inclusion criteria and are included. Overall survival times were 15.7 months ± 5.8 and 13.4 months ± 6.7 from the time of diagnosis and time of first treatment, respectively. The overall weighted 1-year survival rate was 58.0% ± 14.5. More than three fourths of all subjects (76.8%) exhibited a response or stable disease on postprocedure imaging; 18.9% of all subjects experienced severe toxicities (National Cancer Institute/World Health Organization grade ≥ 3), and most experienced some form of postembolization syndrome. Overall 30-day mortality rate was 0.7%. CONCLUSIONS: As demonstrated by this metaanalysis, transarterial chemotherapy-based treatments for cholangiocarcinoma appears to confer a survival benefit of 2-7 months compared with systemic therapies, demonstrate a favorable response by imaging criteria, and have an acceptable postprocedural complication profile. Such therapies should be strongly considered in the treatment of patients with this devastating illness.

Downstaging disease in patients with hepatocellular carcinoma outside of Milan criteria: strategies using drug-eluting bead chemoembolization.

PURPOSE: To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation. MATERIALS AND METHODS: A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging. RESULTS: After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child-Pugh class (P = .14), Child-Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62). CONCLUSIONS: T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease.

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.