Increasing Volume of Bone Marrow Biopsies by Radiology Providers: Evaluation of Trends by Physician Specialty and Practice Setting.

PURPOSE: The aim of this study was to evaluate trends in bone marrow biopsies performed in the United States by physician specialty and practice setting. METHODS: The CMS Medicare Physician Supplier Procedure Summary database was queried from 2005 to 2016 for bone marrow biopsies and aspirations (BMBs). Data were categorized according to the largest subspecialty groups (medicine, surgery, radiology, pathology, and other) and encounter setting (office, inpatient hospital, and outpatient hospital). Trends in procedure volume by specialty and practice setting were evaluated. RESULTS: Between 2005 and 2016, an annual average of 11,417 BMBs were performed (range, 10,380-14,204), with no significant year-over-year change in volume. Medicine was the largest provider of BMBs by specialty, although their market share over this time period declined from 60.2% to 36.6%. Radiology saw the greatest growth in BMB market share from 4.1% to 16.2%. The compound annual growth rate (CAGR) of BMBs performed by medicine subspecialists demonstrated a decrease in year-over-year procedural volume at -5.16% (P < .001). Both surgery and radiology demonstrated positive trends in the number of BMBs performed, with CAGRs of 6.20% (P < .001) and 12.43% (P < .001), respectively. Independent of physician specialty, there was a decrease in the number of biopsies performed in the office setting, decreasing by a CAGR of -5.59% (P < .001). CONCLUSIONS: From 2005 to 2016, medicine has remained the primary provider of BMBs, although their market share has declined. Radiology has experienced the greatest rate of growth in this time period and now represents the third largest individual specialty providing this service.

Percutaneous Vertebral Augmentation for Vertebral Compression Fractures: National Trends in the Medicare Population (2005-2015).

STUDY DESIGN: Retrospective analysis of Medicare data OBJECTIVE.: To analyze trends of vertebral augmentation in the elderly Medicare population in the context of evolving evidence and varied medical society opinions. SUMMARY OF BACKGROUND DATA: Percutaneous vertebral augmentation offers a minimally invasive therapy for vertebral compression fractures. Numerous trials have been published on this topic with mixed results. The impact of these studies and societal recommendations on physician practice patterns is not well understood. METHODS: The Centers for Medicare and Medicaid Services annual Medicare Physician Supplier Procedure Summary database was examined for kyphoplasty and vertebroplasty procedures from 2005 through 2015. Top provider specialties were determined based on annual procedural volume, and grouped into the three broad categories of radiology, surgery, and anesthesia/pain medicine. Data entries were independently analyzed by provider type, site of service, submitted charges, and reimbursement rates for interventions during the study period. RESULTS: Between 2005 and 2015 total annual claims for vertebral augmentation procedures in the Medicare population increased from 108.11% (37,133-77,276) peaking in 2008 and declining by 15.56% in 2009. Radiology is the largest provider of vertebral augmentation by specialty with declining market shares from 71% in 2005 to 43% in 2015. The frequency of vertebroplasty declined by 61.7% (35,409-13,478) from 2005 to 2015 with reduction in Medicare reimbursement. Annual volume of kyphoplasty grew by 18.3% (48,725-57,646) with significant increase in reimbursement for office-based procedures ($728.50/yr, P < 0.001, R = 0.69). CONCLUSION: The annual volume of vertebral augmentation declined in 2009 following two negative trials on vertebroplasty. Although these publications had a persistent negative impact on practice of vertebroplasty, the overall frequency of vertebral augmentation in the Medicare population has not changed significantly between 2005 and 2015. Instead, there has been a significant shift in provider practice patterns in favor of kyphoplasty in increasingly outpatient and office-based settings. LEVEL OF EVIDENCE: 3.

ACR Appropriateness Criteria® Imaging of Mesenteric Ischemia.

Mesenteric ischemia is an uncommon condition resulting from decreased blood flow to the small or large bowel in an acute or chronic setting. Acute ischemia is associated with high rates of morbidity and mortality; however, it is difficult to diagnose clinically. Therefore, a high degree of suspicion and prompt imaging evaluation are necessary. Chronic mesenteric ischemia is less common and typically caused by atherosclerotic occlusion or severe stenosis of at least two of the main mesenteric vessels. While several imaging examination options are available for the initial evaluation of both acute and chronic mesenteric ischemia, CTA of the abdomen and pelvis is overall the most appropriate choice for both conditions. 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.

ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis.

Suspected lower extremity deep venous thrombosis is a common clinical scenario which providers seek a reliable test to guide management. The importance of confidently making this diagnosis lies in the 50% to 60% risk of pulmonary embolism with untreated deep vein thrombosis and subsequent mortality of 25% to 30%, balanced with the risks of anticoagulation. The ACR Appropriateness Criteria Expert Panel on Vascular Imaging reviews the current literature regarding lower extremity deep venous thrombosis and compared various imaging modalities including ultrasound, MR venography, CT venography, and catheter venography. 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.

ACR Appropriateness Criteria® Suspected Thoracic Aortic Aneurysm.

Although the incidence of thoracic aortic aneurysm is on the rise, initial imaging diagnosis can present a challenge for many clinicians. Providers are faced with many imaging choices as part of the initial workup. Considering level of invasiveness, relative radiation level, and quality of associated diagnostic data, CT angiography and MR angiography are believed to be the most appropriate options for radiological diagnosis of suspected thoracic aortic aneurysm. 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.

Hemodialysis Access Maintenance in the Medicare Population: An Analysis Over a Decade of Trends by Provider Specialty and Site of Service.

PURPOSE: To evaluate annual national trends in hemodialysis access maintenance procedures in the Medicare population by specialty and setting. METHODS: Medicare Physician Supplier Procedure Summary Master Files between 2005 and 2015 were analyzed for procedure codes of hemodialysis access angiography and percutaneous thrombectomy. Using physician specialty codes, component procedure volume for endovascular services were queried for radiology, medicine, and surgery. Data entries were analyzed by provider specialty and place of service. Average submitted and allowed charges per intervention were extracted. Linear regression modeling was used to identify trends in number of and allowed charges by specialty and practice setting. RESULTS: Between 2005 and 2015, the frequency of dialysis access angiography for Medicare fee-for-service beneficiaries increased by a total of 74.71% (211,181 to 368,955). Specialty-specific analysis demonstrated volume increases of 220.21% (22,128 to 101,109) for surgery, 249.02% (32,690 to 114,094) for medicine, and 2.81% (135,564 to 139, 367) for radiology. By 2015, an increased trend from hospital-based to non-hospital-based procedures associated with significantly higher reimbursement rates to providers (+18,798 non-hospital-based cases/year, $46.95/year, P ≤ .001) was also observed, with medicine performing the highest volume of non-hospital-based procedures. In this period, there was also a modest total overall increase of percutaneous thrombectomy procedures by 7.75% (61,485 to 66,250). CONCLUSIONS: The frequency of endovascular hemodialysis access maintenance procedures in the Medicare fee-for-service program has increased from 2005 to 2015, with the majority market share transitioning from radiologists to non-radiologists. Similarly, most access maintenance in this time period changed from hospital-based to non-hospital-based interventions.

ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery).

Breast cancer is the most common malignancy in women in the United States. Breast reconstruction surgery is a commonly used therapy for patients with breast cancer. The technique for the deep inferior epigastric perforator flap uses a preserved rectus muscle, which decreases donor site morbidity. Accurate identification and measurement of the perforator branches of the deep inferior epigastric artery is pivotal during pre-operative planning so that the surgeon can prioritize the best vessel to use and ultimately improve clinical outcome. 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.

ACR Appropriateness Criteria® Penetrating Neck Injury.

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR 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.

ACR Appropriateness Criteria® Vascular Claudication-Assessment for Revascularization.

Vascular claudication is a symptom complex characterized by reproducible pain and weakness in an active muscle group due to peripheral arterial disease. Noninvasive hemodynamic tests such as the ankle brachial index, toe brachial index, segmental pressures, and pulse volume recordings are considered the first imaging modalities necessary to reliably establish the presence and severity of arterial obstructions. Vascular imaging is consequently used for diagnosing individual lesions and triaging patients for medical, percutaneous, or surgical intervention. Catheter angiography remains the reference standard for imaging the peripheral arteries, providing a dynamic and accurate depiction of the peripheral arteries. It is particularly useful when endovascular intervention is anticipated. When combined with noninvasive hemodynamic tests, however, noninvasive imaging, including ultrasound, CT angiography, and MR angiography, can also reliably confirm or exclude the presence of peripheral arterial disease. All modalities, however, have their own technical limitations when classifying the location, extent, and severity of disease. 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.

Radiofrequency and microwave ablation in combination with transarterial chemoembolization induce equivalent histopathologic coagulation necrosis in hepatocellular carcinoma patients bridged to liver transplantation.

BACKGROUND: Bridging therapy plays an increasingly important role in the management of patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). Combination therapy with drug-eluting bead transarterial chemoembolization (DEB-TACE) and percutaneous thermal ablation, such as radiofrequency ablation (RFA) or microwave ablation (MWA), has shown success at prolonging survival and bridging patients to LT. However, few studies have evaluated the two combination therapy regimens head-to-head at a single institution, and fewer have compared histopathology. This retrospective study compares tumor coagulation on explanted livers in patients with HCC treated with DEB-TACE sequentially combined with RFA versus MWA. METHODS: From 2005 to 2015, 42 sequential patients underwent combination therapy prior to LT by Milan criteria, with 11 patients (11 tumors; mean, 2.9 cm; range, 1.8-4.3 cm) in the DEB-TACE/RFA cohort and 31 patients (40 tumors; mean, 2.4 cm; range, 1.1-5.4 cm) in the DEB-TACE/MWA cohort. The mean TACE procedures in the RFA and MWA cohorts were 1.3 (range, 1-2) and 1.3 (range, 1-3), respectively. The mean thermal ablations in the RFA and MWA cohorts were 1.2 (range, 1-2) and 1.3 (range, 1-3), respectively. Tumor coagulation was evaluated on explanted livers. RESULTS: Mean tumor coagulation in the RFA and MWA cohorts were 88.9% (range, 0-100%) and 90.5% (range, 30-100%), respectively (P=0.82). Rates of complete tumor coagulation in the RFA and MWA cohorts were 45% and 53%, respectively (P=0.74). No difference in tumor coagulation was found between the cohorts when separating tumors <3 cm (P=0.21) and >3 cm (P=0.09). Among all 51 tumors, the 36 in complete response (CR) on imaging at LT demonstrated mean tumor coagulation of 95.8%. No correlation was found between tumor coagulation and initial tumor size or time interval to LT. No tumor seeding was seen along the ablation tracts. CONCLUSIONS: RFA and MWA in sequential combination with DEB-TACE, used as a bridge to LT, are equally efficacious at inducing HCC tumor coagulation.

ACR Appropriateness Criteria Clinically Suspected Pulmonary Arteriovenous Malformation.

Pulmonary arteriovenous malformations are often included in the differential diagnosis of common clinical presentations, including hypoxemia, hemoptysis, brain abscesses, and paradoxical stroke, as well as affecting 30% to 50% of patients with hereditary hemorrhagic telangiectasia (HHT). Various imaging studies are used in the diagnostic and screening settings, which have been reviewed by the ACR Appropriateness Criteria Vascular Imaging Panel. Pulmonary arteriovenous malformation screening in patients with HHT is commonly performed with transthoracic echocardiographic bubble study, followed by CT for positive cases. Although transthoracic echocardiographic bubble studies and radionuclide perfusion detect right-to-left shunts, they do not provide all of the information needed for treatment planning and may remain positive after embolization. Pulmonary angiography is appropriate for preintervention planning but not as an initial test. MR angiography has a potential role in younger patients with HHT who may require lifelong surveillance, despite lower spatial resolution compared with CT. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Strut penetration: local complications, breakthrough pulmonary embolism, and retrieval failure in patients with Celect vena cava filters.

PURPOSE: To investigate strut penetration in patients with Celect filters, specifically local complications and association with breakthrough pulmonary embolism (PE) or retrieval failure. MATERIALS AND METHODS: A retrospective single-center study was conducted to evaluate patients who received Celect filters between January 2007 and May 2013. A total of 595 filters were placed during the study period. Primary indications included thromboembolic disease (93%) and primary surgical prophylaxis (7%). Complications and retrieval data were assessed by computed tomography (CT) and electronic medical records. RESULTS: A total of 193 patients underwent follow-up abdominal CT at a mean follow-up interval of 176.2 days (range, 0-1,739 d). The rate of strut penetration more than 3 mm outside the caval wall was 28.5% (n = 55). One patient had CT evidence of clinically major strut penetration (1.8%) with strut compression of the right ureter causing hydronephrosis. Indwelling filter time longer than 100 days was associated with strut penetration (P < .001). Age, sex, and history of thromboembolic disease were not associated with strut penetration (P = .51, P = .81, and P = .89). Sixty-three patients presented for follow-up CT pulmonary angiography at a mean of 128.1 days (range, 1-895 d). The rate of breakthrough PE was 12.7%. The overall retrieval success rate was 96.7% (n = 150). Strut penetration was not associated with breakthrough PE or retrieval failure (P = .49 and P = .22). CONCLUSIONS: Although strut penetration is a common complication with Celect filters, there is no association with breakthrough PE or retrieval failure. CT evidence of local complications associated with strut penetration is rare.

Comparison of combination therapies in the management of hepatocellular carcinoma: transarterial chemoembolization with radiofrequency ablation versus microwave ablation.

PURPOSE: To compare retrospectively the outcomes and complications of transcatheter arterial chemoembolization with drug-eluting embolic agents combined with radiofrequency (RF) ablation or microwave (MW) ablation in treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From 2003-2011, 89 patients with HCC received a combination therapy-transcatheter arterial chemoembolization plus RF ablation in 38 patients and transcatheter arterial chemoembolization plus MW ablation in 51 patients. Local tumor response, tumor progression-free survival (PFS), overall PFS, overall survival (OS), and complications were compared. Overall PFS and OS were compared between the two treatment groups in multivariate analysis controlling for Child-Pugh class, Barcelona Clinic Liver Classification stage, and index tumor size. RESULTS: Complete local tumor response was achieved in 37 (80.4%) of the tumors treated with transcatheter arterial chemoembolization plus RF ablation and 49 (76.6%) of the tumors treated with transcatheter arterial chemoembolization plus MW ablation (P = .67). The median tumor PFS and overall PFS were 20.8 months and 9.3 months (P = .72) for transarterial chemoembolization plus RF ablation and 21.8 months and 9.2 months for transarterial chemoembolization plus MW ablation (P = .32). The median OS of the transcatheter arterial chemoembolization plus RF ablation group was 23.3 months, and the median OS of the transcatheter arterial chemoembolization plus MW ablation group was 42.6 months, with no significant difference in the survival experience between the two groups (log-rank test, P = .10). In the multivariate analysis, Barcelona Clinic Liver Classification stage was the only factor associated with overall PFS and OS. One patient in the transcatheter arterial chemoembolization plus RF ablation cohort (3%) and two patients in the transcatheter arterial chemoembolization plus MW ablation cohort (4%) required prolonged hospitalization (< 48 h) for pain management after the procedure (P = 1.00). CONCLUSIONS: Based on similar safety and efficacy outcomes, both combination therapies, transcatheter arterial chemoembolization plus RF ablation and transcatheter arterial chemoembolization plus MW ablation, are effective treatments for HCC.

Adenoma localization for recurrent or persistent primary hyperparathyroidism using dynamic four-dimensional CT and venous sampling.

PURPOSE: To determine if parathyroid venous sampling (PVS) combined with four-dimensional (4D) computed tomography (CT) improves sensitivity and accuracy of identification of parathyroid adenoma in patients with recurrent or persistent primary hyperparathyroidism (pHPT) and negative technetium-99m methoxyisobutyl isonitrile ((99m)Tc-MIBI) and ultrasound (US) scans. MATERIALS AND METHODS: Both PVS and 4D CT were performed in 28 patients with recurrent or persistent pHPT and negative (99m)Tc-MIBI and US examinations. Localization by 4D CT alone and in combination with PVS and lateralization by PVS alone were retrospectively assessed for correlation with surgical results. Suspected adenomas on 4D CT were said to correlate with PVS if venous drainage identified on CT corresponded to sites of elevated parathyroid hormone concentration on PVS. Lesions difficult to identify on 4D CT were lesions < 1 cm in longest dimension. Results of 4D CT were classified as positive, negative, or equivocal. RESULTS: Surgery was performed in 22 of 28 patients. Surgery identified 23 parathyroid adenomas, 1 carcinoma, and 2 hyperplastic glands in 20 patients. 4D-CT alone localized 11 lesions in 10 patients. PVS helped localize 13 additional lesions in nine more patients and clarified two lesions that were equivocal on 4D CT. Comparing 4D CT alone with 4D CT plus PVS, the sensitivity increased from 50% to 95% (P = .004), and accuracy increased from 55% to 91% (P = .022). PVS lateralization had a sensitivity of 93.3%, positive predictive value of 66.7%, and accuracy of 63.6%. CONCLUSIONS: PVS significantly improves 4D CT localization of parathyroid adenomas in patients undergoing repeat surgery for pHPT with negative (99m)Tc-MIBI and US.

Percutaneous transhepatic placement of a stent-graft to treat a delayed mesoportal hemorrhage after pancreaticoduodenectomy.

Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published. This article describes an unusual case of delayed post-pancreaticoduodenectomy hemorrhage detected on a fluoroscopic drain check and treated with percutaneous transhepatic covered stent placement.

Effectiveness of collateral vein embolization for salvage of immature native arteriovenous fistulas.

PURPOSE: To investigate the value of collateral vein embolization (CVE) as a salvage treatment for nonmaturing native arteriovenous fistulae (AVFs) in patients requiring hemodialysis. MATERIALS AND METHODS: A total of 49 patients undergoing CVE (N = 65) for immature native AVFs at a single institution were reviewed. The study included 42 patients treated by 56 embolizations. Average fistula age at time of intervention was 18.2 weeks. Each patient underwent angiographic evaluation for fistula immaturity, with clinical success defined by initiation of single-session hemodialysis through the native fistula. RESULTS: Fistula maturity was achieved in 32 of 42 patients (76.2%). No major complications occurred. Average time from CVE to fistula maturity was 38.4 days. Angioplasty done with CVE was found in a statistically higher percentage of patients with fistula success versus failure (31.3% vs 8.3%; P = .039). Radiocephalic fistulae were seen in a higher percentage of fistula failures compared with successes, but the results were not statistically significant (83.3% vs 59.4%; P = .054). Thirty-four patients underwent CVE without angioplasty, which resulted in successful fistula maturation in 22 cases (64.7%). Radiocephalic fistulae were again seen in a higher percentage of fistula failures compared with successes, but the findings did not meet statistical significance (81.8% vs 54.5%; P = .052). CONCLUSIONS: Coil embolization of competing collateral vessels as a salvage treatment for nonfunctioning autologous AVFs is a viable treatment option in the majority of patients. Patients with radiocephalic fistulae may be at higher risk for primary fistula failure, but the present data are inconclusive.