Burnout among Interventional Radiologists.

PURPOSE: To characterize burnout, as defined by high emotional exhaustion (EE) or depersonalization (DP), among interventional radiologists using a validated assessment tool. MATERIALS AND METHODS: An anonymous 34-question survey was distributed to interventional radiologists. The survey consisted of demographic and practice environment questions and the 22-item Maslach Burnout Inventory-Human Services Survey (MBI). Interventional radiologists with high scores on EE (≥ 27) or DP (≥ 10) MBI subscales were considered to have a manifestation of career burnout. RESULTS: Beginning on January 7, 2019, 339 surveys were completed over 31 days. Of respondents, 263 (77.6%) identified as male, 75 (22.1%) identified as female, and 1 (0.3%) identified as trans-male. The respondents were interventional radiology attending physicians (298; 87.9%), fellows (20; 5.9%), and residents (21; 6.2%) practicing at academic (136; 40.1%), private (145; 42.8%), and hybrid (58; 17.1%) centers. Respondents worked < 40 hours (15; 4.4%), 40-60 hours (225; 66.4%), 60-80 hours (81; 23.9%), and > 80 hours (18; 5.3%) per week. Mean MBI scores for EE, DP, and personal achievement were 30.0 ± 13.0, 10.6 ± 6.9, and 39.6 ± 6.6. Burnout was present in 244 (71.9%) participants. Identifying as female (odds ratio 2.4; P = .009) and working > 80 hours per week (odds ratio 7.0; P = .030) were significantly associated with burnout. CONCLUSIONS: Burnout is prevalent among interventional radiologists. Identifying as female and working > 80 hours per week were strongly associated with burnout.

Stent Placement Across the Renal Vein Inflow in Patients Undergoing Venous Reconstruction Preserves Renal Function and Renal Vein Patency: Experience in 93 Patients.

PURPOSE: To determine if stent placement across the renal vein inflow affects kidney function and renal vein patency. METHODS: Between June 2008 and September 2016, 93 patients (mean age 39 years, range 15-70; 54 women) with iliocaval occlusion underwent venous stent placement and were retrospectively reviewed. For this analysis, the patients were separated into treatment and control groups: 51 (55%) patients had suprarenal and infrarenal iliocaval venous disease requiring inferior vena cava stent reconstruction across the renal vein inflow (treatment group) and 42 (45%) patients had iliac vein stenting sparing the renal veins (control group). Treatment group patients received Wallstents (n=15), Gianturco Z-stents (n=24), or suprarenal and infrarenal Wallstents such that the renal veins were bracketed with a "renal gap" (n=12). Stenting technical success, stent type, glomerular filtration rate (GFR), and creatinine before and after stent placement were recorded, along with renal vein patency and complications. RESULTS: All procedures were technically successful. In the 51-patient treatment group, 15 (29%) patients received Wallstents and 24 (47%) received Gianturco Z-stents across the renal veins, while 12 (24%) were given a "renal gap" with no stent placement directly across the renal vein inflow. In the control group, 42 patients received iliac vein Wallstents only. Mean prestent GFR was 59±1.8 mL/min/1.73 m2 and mean prestent creatinine was 0.8±0.2 mg/dL for the entire cohort. Mean prestent GFR and creatinine values in the Wallstent, Gianturco Z-stent, and "renal gap" subgroups did not differ from the iliac vein stent group. Mean poststent GFR and creatinine values were 59±3.3 mL/min/1.73 m2 and 0.8±0.3 mg/dL, respectively. There were no differences between mean pre- and poststent GFR (p=0.32) or creatinine (p=0.41) values when considering all patients or when comparing the treatment subgroups and the control group. There were no differences in the poststent mean GFR or creatinine values between the Wallstent (p=0.21 and p=0.34, respectively) and Gianturco Z-stent (p=0.43 and p=0.41, respectively) groups and the "renal gap" group. One patient with a Wallstent across the renal veins developed right renal vein thrombosis 7 days after the procedure. CONCLUSION: Stent placement across the renal vein inflow did not compromise renal function. A very small risk of renal vein thrombosis was seen.

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.

Total endovenous recanalization and stent reconstruction for naïve non-inferior vena cava filter-associated chronic iliocaval occlusive disease: Placement of 352 venous stents in 69 debilitated patients.

The aim of this study was to report the technical success, adverse events, clinical outcomes, and long-term stent patency of iliocaval stent reconstruction for naïve, non-inferior vena cava (IVC) filter-related, chronic iliocaval thrombosis. A total of 69 patients, including 47 (68%) men, with a mean age of 36 years (range: 8-71 years), underwent first-time iliocaval stent reconstruction for non-IVC filter-associated iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.2 (range: 0-5), including 30 (43%) patients with IVC atresia. Upon initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification was C3 in 55 (80%) patients, C4 in four (5.8%) patients, C5 in one (1.4%) patient, and C6 in seven (10%) patients. Technical aspects of stent reconstruction, technical success, adverse events, 2-week and 6, 12, and 24-month clinical response, and 6, 12, and 24-month primary, primary-assisted, and secondary stent patency rates were recorded. Technical success was defined as recanalization and stent deployment. Adverse events were reported according to the Society of Interventional Radiology classification system. Clinical success was defined as a 1-point decrease in CEAP classification and stent patency was defined by the Cardiovascular and Interventional Radiological Society guidelines. The technical success rate was 100%. There were 352 venous stents deployed during stent reconstructions. One (1.4%) severe, four (5.8%) moderate, and four (5.8%) minor adverse events occurred and median post-procedure hospitalization was 1 day (range: 1-45 days). Clinical success at 2 weeks and 6, 12, and 24 months was 76%, 85%, 87%, and 100%, respectively. The estimated 6, 12, and 24-month primary patency rates were 91%, 88%, and 62%, respectively. The estimated 6, 12, and 24-month primary-assisted patency rates were 98%, 95%, and 81%, respectively. The estimated 6, 12, and 24-month secondary-assisted patency rates were all 100%. In conclusion, iliocaval stent reconstruction is an effective treatment for non-IVC filter-associated chronic iliocaval thrombosis with high rates of technical success, clinical responses, and stent patency.

Endobronchial Forceps-Assisted Removal of Gianturco Z-Stents from the Right Atrium.

Endovascular treatment of malignant intrahepatic inferior vena cava stenosis involves venoplasty and stenting. Intravascular migration is a complication associated with stents. This technical report describes the retrieval of migrated intracardiac Gianturco Z-stents using rigid endobronchial forceps.

Endovascular Transpulmonary Retrieval of a Migrated Amplatzer Vascular Plug Following Balloon-Occluded Retrograde Transvenous Obliteration.

Gastric varices are a common manifestation of portal hypertension and are associated with a high rate of mortality and rebleeding. Balloon-occluded retrograde transvenous obliteration (BRTO) is a commonly used method to sclerose gastric varices and has a high clinical success. Common complications following BRTO include portal or splenic vein thrombosis, systemic sclerosant extravasation, pulmonary emboli, and inferior vena cava thrombosis. This report describes a patient with vascular plug migration into the left pulmonary artery with subsequent endovascular retrieval.

Lower extremity endovenous reconstruction for symptomatic occlusive disease in pediatric patients: techniques, clinical outcomes, and long-term stent patencies.

BACKGROUND: Endovascular stent reconstruction is the standard of care for chronic venous occlusive disease in adults, but it has not been reported in pediatric patients. OBJECTIVE: This study reports the technical success, complications, clinical outcomes, and stent patency of iliocaval stent reconstruction for chronic iliocaval thrombosis in pediatric patients. MATERIALS AND METHODS: Fourteen patients, 13 (93%) male with a mean age of 16.4 years (range: 8-20 years), underwent iliocaval stent reconstruction for chronic iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.5 (range: 0-4), including 7 (50%) patients with inferior vena cava atresia. At initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology classification (CEAP) score was C3 in 2 (14%) patients, C4 in 11 (79%) patients, and C6 in 1 (7.1%) patient. Time course of presenting symptoms included chronic (>4 weeks) (n=7; 50%) and acute worsening of chronic symptoms (2-4 weeks) (n=7; 50%). Aspects of recanalization and reconstruction, stenting technical success, complications, clinical outcomes and stent patency were recorded. Clinical success was defined as a 1-point decrease in the CEAP. Primary, primary-assisted, and secondary patency were defined by Cardiovascular and Interventional Radiological Society of Europe guidelines. RESULTS: Most procedures employed three access sites (range: 2-4). Intravascular ultrasound was employed in 11 (79%) procedures. Blunt and sharp recanalization techniques were used in 12 (86%) and 2 (14%) patients, respectively. Stenting technical success was 100%. Two (14%) minor adverse events occurred and mean post-procedure hospitalization was 2.8 days (range: 1-8 days). Clinical success rates at 2 weeks, 6 months and 12 months were 85%, 82%, and 83%, respectively. At a mean final clinical follow-up of 88 months (range: 16-231 months), clinical success was 93%. Estimated 6- and 12-month primary stent patencies were 86% and 64%, respectively. Six- and 12-month primary-assisted and secondary stent patency rates were both 100%. CONCLUSION: Iliocaval stent reconstruction is an effective treatment for symptomatic chronic iliocaval thrombosis in pediatric patients with high rates of technical success, 6- and 12-month clinical success, and 6- and 12-month primary-assisted and secondary patency rates.

#VascularSurgery.

BACKGROUND: To characterize the vascular surgery Twitter network. METHODS: A total of 20,841 consecutive tweets by 8,282 unique Twitter accounts regarding vascular surgery from October 23, 2014 to January 15, 2018 were analyzed. Twitter analytics, including activity metrics, content analysis, user characteristics, engagement, and network analysis were performed using Symplur Signals, a health care social media analytics platform. RESULTS: Vascular surgery tweets, the number of users tweeting about vascular surgery, and vascular surgery tweet impressions have increased by an annual average of 77.8%, 55.3%, and 209.1% from 2015 to 2017, respectively. Twitter activity trend analysis showed consistent growth over the study period with an average of 25.7 ± 2.6 additional tweets per month (P < 0.001). As for tweet content, 2,220 tweets (10.7%) were pertaining to patients, and 2,198 tweets (10.5%) were regarding new or innovative topics. 15,422 tweets (74.0%) included links to journals or websites and 6,826 tweets (32.8%) contained at least 1 image. Deep venous thrombosis, pulmonary embolism, diabetes, endovascular interventions, trauma, and practice guidelines were among the most commonly discussed health topics. Physicians composed 5,618 tweets (27%), while patients submitted 2,447 tweets (11.7%). As for engagement, 8,886 tweets (42.6%) were retweets, 11,816 tweets (56.7%) mentioned at least 1 other user, and 786 tweets (3.8%) were replies. Network analysis revealed central hubs to be vascular surgery societies, academic institutions, academic journals, and physicians. CONCLUSIONS: The use of Twitter to discuss vascular surgery is growing rapidly with increasing use by vascular surgeons and vascular medicine physicians. An effort to involve more patients in the vascular surgery Twitter social network may allow for more opportunities to educate, and garner interest and support for vascular surgery.

Retrieval of Bard Simon Nitinol inferior vena cava filters: Approaches, technical successes, complications, and clinical outcomes.

OBJECTIVE: The Simon Nitinol filter is a bi-level filtration device designed for permanent implantation that is no longer commercially available, but may result in similar complications to current commercially available long term indwelling temporary or permanent filters. Complications related to indwelling inferior vena cava filters include inferior vena cava thrombosis, inferior vena cava penetration, filter migration, and filter fracture. There is a paucity of reports describing the technical aspects related to retrieval of Simon Nitinol filters. MATERIALS AND METHODS: This study consisted of five patients with Simon Nitinol filters and describes the indication for retrieval, the retrieval techniques used to remove the filters, technical success, complications, and clinical course. RESULTS: The indications for retrieval included: abdominal pain (n = 2; 40%), iliocaval thrombosis (n = 1; 20%), identification of an intracardiac filter fragment (n = 1; 20%), and recurrent venous thromboembolic events (n = 1; 20%). Retrieval techniques included: biopsy forceps (n = 3; 60%), excimer laser extraction sheaths (n = 3; 60%), hangman modified loop snares (n = 3; 60%), rigid endobronchial forceps (n = 2; 40%), and balloon deflection (n = 2; 40%). All filters were successfully retrieved. One patient developed a post-procedural intramuscular hematoma near the site of right internal jugular sheath placement. CONCLUSIONS: Simon Nitinol filters may be retrieved safely and effectively using advanced inferior vena cava filter retrieval techniques.

Scholarly Activities and Indices Among Academic Endovascular Specialists: A Comparative Analysis Between Interventional Radiologists and Vascular Surgeons.

PURPOSE: To report scholarly metrics amongst academic endovascular specialists. MATERIAL AND METHODS: Faculty pages identified interventional radiologists and vascular surgeons at academic institutions. Members were classified as assistant, associate, or full professors. Scopus was used to extract publication and citation records. Data extracted included: number of publications, number of citations, h-index, i-10 index, hc-index, m-quotient, e-index, and g-index. RESULTS: Two hundred seventy six interventional radiologists and 266 vascular surgeons were included. Mean publications for interventional radiology assistant, associate, and full professors were 17.81, 48.77, and 131.65 and the citation counts were 311.45, 1051.08, and 3981.71, respectively. Mean publications for vascular surgeon assistant, associate, and full professors were 24.00, 48.7, and 161.37 and the citation counts were 414.33, 1147.89, and 5747.00, respectively. Multivariable proportional odds model for interventional radiologists showed a positive correlation between the academic rank and publication count (c = 0.028), h-index (c = 0.090), i10-index (c = 0.014), hc-index (c = 0.052), e-index (c = 0.016), and g-index (0.037). There was a negative correlation between m-quotient (c = -1.745) and citations (c = -0.001) and academic rank. Multivariable proportional odds model for vascular surgeons showed a positive correlation between the academic rank and publication count (c = 0.037) and g-index (c = 0.083). There was a negative correlation between m-quotient (c = -2.232) and hc-index (c = -0.065) and academic rank. CONCLUSION: Citation count and h-index are positively correlated while m-quotient is negatively correlated with academic performance for endovascular specialists.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience.

PURPOSE: To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods. MATERIALS AND METHODS: This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers. RESULTS: Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case. CONCLUSIONS: The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

Thoracic duct embolization in kaposiform lymphangiomatosis.

An 11-year-old girl with kaposiform lymphangiomatosis presented with recurrent chylous pericardial effusions that were refractory to pericardial drainage and medical therapy. Magnetic resonance imaging demonstrated a prominent lymphatic duct with anterior mediastinal extension into the left clavicular region and a region of high signal that was favored to represent a low-flow lymphatic malformation. The patient underwent direct access thoracic duct lymphangiography with thoracic duct embolization and sclerotherapy of the large left-sided neck and pericardial lymphatic malformation. After the procedure, her pericardial effusions resolved, and she has remained asymptomatic for 15 months.

Fluoroscopically-guided interventions with radiation doses exceeding 5000 mGy reference point air kerma: a dosimetric analysis of 89,549 interventional radiology, neurointerventional radiology, vascular surgery, and neurosurgery encounters.

PURPOSE: To quantify and categorize fluoroscopically-guided procedures with radiation doses exceeding 5000 mGy reference point air kerma (Ka,r). Ka,r > 5000 mGy has been defined as a "significant radiation dose" by the Society of Interventional Radiology. Identification and analysis of interventions with high radiation doses has the potential to reduce radiation-induced injuries. MATERIALS AND METHODS: Radiation dose data from a dose monitoring system for 19 interventional suites and 89,549 consecutive patient encounters from January 1, 2013 to August 1, 2019 at a single academic institution were reviewed. All patient encounters with Ka,r > 5000 mGy were included. All other encounters were excluded (n = 89,289). Patient demographics, medical specialty, intervention type, fluoroscopy time (minutes), dose area product (mGy·cm2), and Ka,r (mGy) were evaluated. RESULTS: There were 260 (0.3%) fluoroscopically-guided procedures with Ka,r > 5000 mGy. Of the 260 procedures which exceeded 5000 mGy, neurosurgery performed 81 (30.5%) procedures, followed by interventional radiology (n = 75; 28.2%), neurointerventional radiology (n = 55; 20.7%), and vascular surgery (n = 49; 18.4%). The procedures associated with the highest Ka,r were venous stent reconstruction performed by interventional radiology, arteriovenous malformation embolization performed by neurointerventional radiology, spinal hardware fixation by neurosurgery, and arterial interventions performed by vascular surgery. Neurointerventional radiology had the highest mean Ka,r (7,799 mGy), followed by neurosurgery (7452 mGy), vascular surgery (6849 mGy), and interventional radiology (6109 mGy). The mean Ka,r for interventional radiology performed procedures exceeding 5000 mGy was significantly lower than that for neurointerventional radiology, neurosurgery, and vascular surgery. CONCLUSIONS: Fluoroscopically-guided procedures with radiation dose exceeding 5000 mGy reference point air kerma are uncommon. The results of this study demonstrate that a large proportion of cases exceeding 5000 mGy were performed by non-radiologists, who likely do not receive the same training in radiation physics, radiation biology, and dose reduction techniques as radiologists.

Percutaneous Extra-Anatomic Lymphovenous Bypass Creation: Toward Treatment of Central Conducting Lymphatic Obstructions.

INTRODUCTION: Protein-losing enteropathy manifests as a loss of serum proteins through the gastrointestinal tract, resulting in hypoproteinemia, extravascular fluid retention, and edema. Management consists of nutritional maintenance in conjunction with interventions targeted at treating the underlying etiology. MATERIALS AND METHODS: This report describes a patient with protein-losing enteropathy from a central conducting lymphatic obstruction who was treated with percutaneous extra-anatomic lymphovenous bypass creation. RESULTS: A modified gun-sight technique was used to create a lymphovenous bypass between an occluded terminal thoracic duct and the left internal jugular vein. CONCLUSION: A percutaneous technique to reconstruct the terminal thoracic duct via lymphovenous bypass creation was feasible.

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.

PURPOSE: Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. MATERIALS AND METHODS: Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32 mm × 120 cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. RESULTS: The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56 days. CONCLUSION: The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Approach, Technical Success, Complications, and Stent Patency of Sharp Recanalization for the Treatment of Chronic Venous Occlusive Disease: Experience in 123 Patients.

PURPOSE: To report the technical success and complications following sharp recanalization of chronic venous occlusions. MATERIALS AND METHODS: A total of 123 patients, including 75 (61.0%) men and 48 (39.0%) women, with mean age of 50.5 ± 17.5 years (range 19-90 years), underwent sharp recanalization of chronic venous occlusions. The etiologies of occlusion were chronic deep venous thrombosis (n = 43; 35.0%), prior central venous access (n = 39; 31.7%), indwelling cardiac leads (n = 21; 17.1%), and occluded venous stents (n = 20; 16.3%). The sites of venous occlusion included 59/123 (48.0%) thoracic central veins, 37 (30.1%) non-thoracic central veins, and 27 (22.0%) peripheral veins. Median length of occlusion was 3.2 ± 1.4 cm (range 1.3-10.9 cm). RESULTS: Sharp recanalization was most commonly attempted with transseptal needles in 108/123 (87.8%), with a mean number of 1.2 ± 0.4 crossing devices per patient (range 1-4 devices). Targeting devices included a loop snare (n = 92; 74.8%), partially deployed Wallstent (n = 21; 17.1%), partially deployed Amplatzer vascular plug (n = 8; 6.5%), and an angioplasty balloon (n = 3; 2.4%). Technical success was achieved in 111 (90.2%) patients. There were 3 (2.4%) severe, 1 (0.8%) moderate, and 7 (5.7%) minor adverse events. Severe adverse events included 1 case each of pericardial tamponade, hemothorax, and inferior vena cava filter occlusion. 88 (71.5%) patients had venous stents placed; at the last follow-up examination, 68/86 (79.0%) stents were patent. CONCLUSION: Sharp recanalization has a high technical success and low rate of adverse events in the recanalization of chronic venous occlusions.