Interventional radiology delivers high-value health care and is an Imaging 3.0 vanguard.

Given the changing climate of health care and the imperative to add value, radiologists must join forces with the rest of medicine to deliver better patient care in a more cost-effective, evidence-based manner. For several decades, interventional radiology has added value to the health care system through innovation and the provision of alternative and effective minimally invasive treatments, which have decreased morbidity, mortality, and overall cost. The clinical practice of interventional radiology embodies many of the features of Imaging 3.0, the program recently launched by the ACR. We provide a review of some of the major contributions made by interventional radiology and offer general principles from that experience, which are applicable to all radiologists.

Fundamentals of the neurologic examination for patients undergoing central nervous system interventional procedures.

The basic neurologic history and exam for the interventional radiologist performing intracranial procedures need not be exhaustive and will not supplant that by neurologic specialist. It should include a pertinent history, focused neurologic exam, and a brief physical exam. The interventional radiologist should be familiar with the grading scales commonly used for patients with intracranial pathology to understand the severity and prognosis of various pathologies. The goal of the examination is to mitigate risk, direct the evaluation, aid in medical decision making, and allow the establishment of an appropriate physician-patient relationship.

Transcatheter embolization in the management of epistaxis.

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

Contemporary endovascular embolotherapy for meningioma.

Preoperative endovascular tumor embolization has been used for 40 years. Meningiomas are the most common benign intracranial tumor in which preoperative embolization has been most extensively described in the literature. Advocates of embolization report that it reduces operative blood-loss, and softens the tumor, thus making surgery safer and easier. Opponents suggest that it adds additional risk and cost for patients without controlled studies showing conclusive benefit. The literature suggests a 3 to 6% neurological complication rate related to embolization. The combined external and internal carotid artery blood supply and complex anastomoses of the meninges can make embolization challenging. Positive outcomes require thorough knowledge of the pertinent vascular anatomy, familiarity with the neurovascular equipment and embolics, and meticulous technique. There remains debate on several aspects of embolization, including tumors most appropriate for embolization, embolic agent of choice, ideal size of embolic, and the choice of vessel(s) to embolize. This detailed review of pertinent vascular anatomy, embolization technique, results, and complications should allow practitioners to maximize treatment outcomes in this setting.

Intra-arterial Stroke Management.

Acute ischemic stroke is a leading cause of death and the leading cause of disability in the United States. Cerebral neuronal death begins within minutes after threshold values of blood oxygen saturation are crossed. Prompt restoration of oxygenated blood flow into ischemic tissue remains the common goal of reperfusion strategies. This article provides a brief overview of acute ischemic stroke, a summary of the major intra-arterial stroke therapy trials, and comments on current training requirements for the performance of intra-arterial therapies.

Interventional spine procedures for management of chronic low back pain-a primer.

Chronic low back pain is a common clinical condition. Percutaneous fluoroscopic-guided interventions are safe and effective procedures for the management of chronic low back pain, which can be performed in an outpatient setting. Interventional radiologists already possess the technical skills necessary to perform these interventions effectively so that they may be incorporated into a busy outpatient practice. This article provides a basic approach to the evaluation of patients with low back pain, as well as a review of techniques used to perform the most common interventions using fluoroscopic guidance.

Reported outcomes after the endovascular treatment of chronic cerebrospinal venous insufficiency.

Chronic cerebrospinal venous insufficiency (CCSVI) has recently been implicated as a potential causal factor in the development of multiple sclerosis (MS). The treatment of jugular and azygous vein stenoses, characteristic of CCSVI, has been proposed as a potential component of therapy for MS. In the few short years since Dr. Paulo Zamboni published "A Prospective Open label Study of Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency", there has been tremendous patient-driven demand for treatment. Concurrently, there have been numerous publications since 2009 addressing CCSVI and its association with MS. The purpose of this article is to present a brief review of CCSVI and its association with MS and to review the available literature to date with a focus on outcomes data.

The value of clinical interventional radiology.

Interventional radiology (IR) is a vital component of diagnostic imaging (DI). The Society of Interventional Radiology has long held that the practice of IR should be clinical in nature, with dedicated clinical time, space, and infrastructure. The ACR has recognized the necessity of the clinical practice of IR. The cost to DI groups and hospitals of providing clinical IR is substantial. A willingness to invest in the creation or maintenance of a clinical IR service should be based on the value such an investment may provide. The author presents a 2-fold assessment of the value of IR. A review of the intangible value of IR to DI groups and facilities follows the presentation of an algorithm that ascribes a tangible, financial value to the provision of clinical IR services. The author provides an example of this algorithm applied to a mature, clinical IR practice. The author's assertion is that this value is compelling justification to warrant support of clinical IR. Additionally, the author's hope is that the utilization of this algorithm may allow DI groups to determine the financial value of clinical IR in their own settings.

Impact of laser fiber design on outcome of endovenous ablation of lower-extremity varicose veins: results from a single practice.

The design of laser fibers used for endovenous laser ablation (EVLA) in the management of lower-extremity varicose vein disease may affect treatment success. The purpose of this investigation is to report our experience using the gold-tip NeverTouch VenaCure laser fiber (AngioDynamics, Queensbury, NY) and to compare that to our experience with standard bare-tip fibers. A retrospective chart review of 363 consecutive EVLA treatments using the gold-tip laser fiber was performed. Demographic data including patient age, sex, history of previous varicose vein stripping, vein identity, laterality, treatment length, total applied energy in joules (J), use of adjuvant sclerotherapy and ambulatory phlebectomy, treatment-related complications, and treatment failure, which was defined as recanalization of any portion of the treated vein during follow-up as assessed by duplex ultrasound examination-were entered into a spreadsheet. These data were compared with a control group of 471 EVLA treatments performed with a standard bare-tip laser fiber. Data were analyzed using independent-samples Student's t test, chi-square test, and multivariate analysis. Demographic data were similar between the two groups. Treatments with the gold-tip fiber had a failure rate of 11.1%, whereas treatment with a bare-tip fiber had a failure rate of 2.3% during a similar follow-up period. This difference was highly statistically significant (p<0.0001). Multivariate analysis showed fiber type as the most significant factor associated with treatment failure. We conclude that laser fiber design has a significant effect on treatment success in the performance of EVLA.

Acute deep vein thrombosis (DVT): evolving treatment strategies and endovascular therapy.

DVT and PE contribute to at least 100,000 deaths each year. In addition, 4% of patients with PE will progress to CTEPH and PTS will affect nearly 30%. Anticoagulation alone appears inadequate to prevent PTS in many patients. Newer treatment strategies, including PCDT, appear to offer the possibility of reducing the pain, suffering and expense of PTS especially in the most severe cases. The NIH/NHLBI sponsored the ATTRACT trial, which will compare PCDT plus standard anticoagulation versus standard anticoagulation alone in patients with proximal DVT. The ATTRACT trial will enroll patients at both Miriam and RI Hospitals and is expected to add significantly to the research in this area. When successfully completed, results from the trial may guide therapy in the years ahead.

An investigation of the relationship between energy density and endovenous laser ablation success: does energy density matter?

PURPOSE: To assess the relationship between energy density and the success of endovenous laser ablation (EVLA) treatment. MATERIALS AND METHODS: A total of 586 EVLAs were performed in a period of 35 months. Retrospective chart review was performed, and data collected included the patients' age, sex, and history of venous stripping procedures, as well as the name, laterality, and length of the treated vein segment(s) and the total energy delivered. Energy density was calculated by dividing total energy delivered (in J) by the length of vein (in cm). Energy density selection was based on the treating interventionalist's preference. Ablated segments were grouped into those treated with less than 60 J/cm, 60-80 J/cm, 81-100 J/cm, and more than 100 J/cm. Failure of EVLA was defined by recanalization of any portion of the treated vein during follow-up as assessed by duplex Doppler ultrasound examination. Failure rates were compared with the chi(2) test and Wilcoxon rank-sum test. RESULTS: A total of 471 segments were included in the analysis with an average follow-up period of 5 months (range, 0.2-28.7 months). Overall, 11 failures were encountered, including four in the group treated with less than 60 J/cm (n = 109; 4%), two in the 60-80-J/cm group (n = 77; 3%), four in the 81-100-J/cm group (n = 169; 3%), and one in the group treated with more than 100 J/cm (n = 116; 1%). There was no statistically significant difference in failure rates among energy density ranges. CONCLUSION: EVLA has a low failure rate that is not affected by energy density.

Regional infusion-radioembolization.

Selective internal radiation therapy involves the intra-arterial delivery of radioactive beads to the tumor while minimizing dosing to the adjacent organ. Because this technique invariably results in some degree of embolization, it has also been termed radioembolization. More than 8000 patients have been treated worldwide, with a large body of experience with primary hepatocellular carcinoma (HCC) and metastatic colorectal carcinoma (MCRC) and growing experience with other tumors (metastatic neuroendocrine, breast carcinoma, cholangiocarcinoma). Response rates by FDG-PET are 80% to 90%. Complications are uncommon and most often consist of self-limited malaise. More significant complications, including radiation-induced liver disease, ischemic cholecystitis, and gastrointestinal ulceration may be seen in up to 10% of patients. This underscores the critical importance of patient selection and meticulous technique. Median survival times in patients who have HCC and MCRC are significantly improved compared with historic controls. Further study is required to determine the appropriate role of radioembolization in the context of state-of-the-art chemotherapy and other liver-directed therapies.

Evaluation and management of patients with peripheral artery disease by interventional radiologists: current practices.

PURPOSE: Traditionally, surgeons have served as primary consultants for patients with peripheral vascular disease for whom revascularization is considered. An important component of care for patients with peripheral artery disease (PAD) is risk factor management. The present study was undertaken to determine current management practices of interventional radiologists for patients with PAD and compare them to published data for vascular surgeons. If PAD patient management practices are similar, this would support direct referral of PAD patients who are considered for revascularization from primary care doctors to interventional radiologists. MATERIALS AND METHODS: An online survey was administered to full members of the Society of Interventional Radiology with e-mail addresses on file. Filtering was done to examine and compare interactions among several responses. The margin of error for the survey was +/-2%, based on 95% CIs for the entire surveyed population (N=2,371). RESULTS: Seventy-five percent of respondents see PAD patients in ambulatory office settings. Only eight percent see themselves as the physician responsible for risk factor management, similar to reported results of vascular surgeons (10%). Other variables examined, such as frequency of inquiring about Framingham risk factors, indicate similar practices to those previously reported for vascular surgeons. CONCLUSIONS: For interventional radiologists who accept direct referrals for medical management of patients with PAD, disease management by interventional radiologists is similar to that previously reported for vascular surgeons. This supports the role of interventional radiologists who accept direct referrals of patients with PAD as primary consultants to primary care doctors.

Uterine artery embolization for control of life-threatening hemorrhage at menarche: brief report.

Uncontrolled acute menorrhagia resulting in hemodynamic instability in the adolescent is uncommon. We report a case of life-threatening menorrhagia upon first menses in a 12-year-old girl who was successfully treated with uterine artery embolization after failure of standard gynecologic and medical measures. Testing eventually revealed a coagulopathy that resulted from decreased plasminogen activator inhibitor-1 activity in combination with an immature hypothalamic-pituitary-ovarian axis. Coagulation disorders are more common in patients presenting with severe menorrhagia upon menarche. Interventional radiologists should be aware of such coagulation abnormalities and the differences between adults and adolescents when contemplating uterine artery embolization for adolescent patients.