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Purpose To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. Materials and Methods All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US–guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. Results All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2–47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3–10 months). Conclusions TDE via US–guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.

Purpose To evaluate technical details, clinical outcomes, and complications in patients undergoing geniculate artery embolization for treatment of spontaneous hemarthrosis after knee surgery. Materials and Methods During 2009–2014, 10 consecutive patients (seven women; mean age, 57.4 y) underwent geniculate artery embolization at a single tertiary care center. All patients except one had hemarthrosis after total knee replacement (TKR). One patient presented with hemarthrosis after cartilage surgery. Two patients in the TKR group had a history of TKR revisions before the embolization. Embolization was performed with polyvinyl alcohol particles (range, 300–700 µm). In one patient requiring repeat embolization, N -butyl cyanoacrylate/ethiodized oil was used. The endpoint for embolization was stasis in the target artery and elimination of the hyperemic blush. Results In 10 patients, 14 embolizations were performed with 100% technical success. Hemarthrosis resolved in six patients. Four patients required repeat embolization for recurrent hemarthrosis, which subsequently resolved in two of four patients. Three of the four patients who required repeat embolization had serious comorbidities, either blood dyscrasias or therapeutic anticoagulation. There were two minor skin complications that resolved with conservative management. The average length of follow-up after embolization was 545 days (range, 50–1,655 d). One patient was lost to follow-up. Conclusions Geniculate artery embolization is a safe, minimally invasive treatment option for spontaneous and refractory knee hemarthrosis after knee surgery with 100% technical success. However, limited clinical success and higher repeat embolization rates were noted in patients with serious comorbidities.

To prospectively assess the safety of the PleurX catheter in the management of recurrent ascites in patients with advanced abdominal malignancy and the consequent quality of life among these patients.This was a multicenter, prospective study of PleurX catheters implanted between March 2004 and April 2005 for control of nonhepatic abdominal ascites associated with malignancy. A total of 34 subjects were included (age range, 40-81 years; mean age, 64.3 y) who underwent 440 drainage sessions. Subjects kept records of volume and frequency of ascites drainage and recorded any difficulties encountered with use of the device. Subjects assessed symptoms before device insertion and weekly for as long as 12 weeks. Serum laboratory values reflecting overall volume status were tracked.All catheter insertions were successful without major procedural complications. Twenty-nine (85%) required no catheter intervention or separate therapeutic paracentesis during 12 weeks observation or until the patient's death. Three needed a total of 13 interventions to restore catheter function. Before 12 weeks, 26 subjects died. Five discontinued catheter use as a result of catheter function despite the presence of ascites. Ascites resolved in five patients. Bloating and abdominal discomfort were significantly reduced at 2 and 8 weeks (P.05). At weekly follow-up, 83%-100% of subjects reported their ascites to be well controlled. There were no significant changes in blood chemistry results between baseline and 12 weeks. One case of peritonitis at 10 weeks resolved with antibiotic treatment.In terminally ill patients, PleurX catheter use resulted in improvement of ascites-related discomfort and was associated with low rates of serious adverse clinical events and catheter failure.

IN an editorial in this issue of JVIR, Hirsch and coauthors (1) report the outcome of a 2-day Peripheral Arterial Disease (PAD) Public Education Strategy Meeting held in January of 2003. This meeting, organized by the Vascular Disease Foundation and hosted by the National Heart, Lung, and Blood Institute, was preceded by the Society of Interventional Radiology (SIR)– sponsored Peripheral Vascular Health Summit in August of 2002. SIR initiated and hosted the Peripheral Vascular Health Summit 2002 to address several issues. It was recognized that there was a compelling need for increased public education regarding PAD and peripheral vascular disease, and it was believed that a unified effort would be more successful and more cost-effective than multiple smaller competing programs and efforts. The SIR also recognized that, although Legs For Life® was quite successful, it had grown to the point at which SIR would have difficulty sustaining the effort to further increase awareness with its resources alone. A greater long-term sustained nationwide educational effort was needed to create the impact proven possible by other national campaigns. The 2002 Peripheral Vascular Health Summit brought together for the first time the nation’s leading medical organizations, advocacy groups, and government agencies to address these issues. The 17 organizations attending the 2-day Summit began the first stages of developing a framework for a collaborative approach toward public education, public awareness, and improved detection of peripheral vascular disease and abdominal aortic aneurysm (see Appendix). The Secretary of Health and Human Services was impressed with this effort, and Assistant Secretary of Health and Human Services, Eve Slater, MD, made an address early in the meeting encouraging the group to speak with one voice. The Summit concluded with the commitment of all present to proceed with a PAD public awareness campaign under the direction of an organization that would have representation from all specialties interested in vascular disease. Becker et al (2), in a 2002 JVIR commentary, defended the position for such a campaign based on scientific data that confirm the cardiovascular risk present in patients with PAD. Analysis of 3-year benchmark consumer survey data on awareness of peripheral vascular disease from the Legs For Life® screening and awareness program indicated that patients had a similar level of awareness as primary care physicians and that it could be greatly increased. Becker et al (2) called for a consistent and uniform message to primary care providers and to the public with the goal of reducing cardiovascular risk. He concluded that this would be best accomplished by working “in harmony with other medical specialties representing health care professionals who treat the disease, organizations representing patients at risk, private philanthropies, nonprofit and public entities, and with all parties having an express interest in the field.” In their article, Hirsch et al (1) echo many of these same arguments. SIR has had a long history of supporting PAD public awareness. Legs For Life®, a program dedicated to improving the cardiovascular health of the community, was devised in 1998 and launched nationally in September 1999 with three primary goals: to educate the public and medical community regarding PAD, to provide for early detection when appropriate, and to strengthen collaborative relationships among health care professionals. This program, now in its sixth year, was evaluated by an independent health research firm, which concluded that the program met its proposed goals (3). Eighty percent of the surveyed participants identified the ankle-brachial index given during the screening program and half reported that leg pain when walking was a symptom of PAD. In addition, just fewer than half were able to identify individuals at the highest risk for the disease, and a majority of respondents could identify ways to prevent or slow progression of the disease. This program has grown into the From the Mallinckrodt Institute of Radiology (M.D.D.), Washington University School of Medicine, St. Louis, Missouri; Department of Radiology (J.D.D.), University of Colorado Heath Sciences Center, 4200 East Ninth Avenue, A030, Denver, Colorado 80262; and Society of Interventional Radiology (T.E.M.), Fairfax, Virginia. Received April 13, 2004; accepted April 13. Address correspondence to J.D.D.; E-mail: janette.durham@uchsc.edu

Traditionally, embolization has been reserved for treatment of upper gastrointestinal bleeding whereas lower gastrointestinal (LGI) bleeding has been controlled with vasopressin infusion. This is based on findings in older literature in which infarction frequently complicated LGI embolization. With modern embolization techniques, clinically significant bowel ischemia has become an uncommon complication. Although the efficacies of vasopressin and embolization are fairly comparable, embolotherapy has advantages in terms of quicker completion of therapy and decreased likelihood of systemic complications. Although vasopressin is still probably preferable for diffuse lesions and cases in which superselective catheterization is not technically possible, embolization should be considered a primary option for treating LGI bleeding.

PURPOSE To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis. MATERIALS AND METHODS Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded. RESULTS Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours ± 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U ± 1.60 urokinase, 18.4 mg ± 10.7 tissue plasminogen activator, and 13.8 U ± 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% ± 24.1) when using MT alone, compared with substantial thrombus removal (62.0% ± 24.9) when using MT after pharmacologic thrombolytic agents had been administered ( P = .006). CONCLUSION The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

Interventional radiology is at a crossroads. Two possible futures exist. In one direction, advances in technology are providing exciting opportunities for interventional radiology. Promising new treatments in tumor and cancer therapy, the treatment of fibroids, venous access, and spine interventions, as well as advances in noninvasive vascular imaging, pharmacologic therapies, and peripheral interventions are revitalizing our specialty, attracting significant patient interest and promising tremendous public benefit. In the other direction, interventional radiology is losing market share in vascular interventions to other specialties and suffering a crisis of confidence. One road leads to success, the other to failure. The only problem is that the roads aren’t clearly marked. Which road is which? The burden falls upon all of us, the leaders, staff, and members of the Society to choose the right path, to choose our future, and to make our continued success a reality. Fortunately, we have the tool to create a map; this tool is strategic planning, a business discipline that helps organizations determine and achieve desired futures. Strategic planning can provide direction and help focus organizational activities. Without it, entropy can set in and organizations can fail. Last year, SCVIR launched a strategic planning process to set directions for both the specialty and the Society. It was clearly time; the Society’s thencurrent plan was more than 5 years old—a millennium in today’s rapidly changing world. In addition, the Society and its members were facing increasing challenges from competing specialties, ever-tightening reimbursement, new technologies, evolving practice patterns, and changing consumer expectations. This paper is the first of a series in JVIR to convey a significant depth of information about the strategic plan; to provide an understanding of its foundations, our goals and objectives, and issues that will still need to be debated as the plan moves forward. This first article describes the strategic planning process, the vision, timeline and goals, and early successes of the new plan. Subsequent articles will include the following topics: • Results of strategic plan research: the environmental/economic assessment, leadership, staff and external interviews, and member polling; • Workforce projections and employment market for interventional radiologists; • Becoming “clinical,” and what this will mean for the interventional radiologist; • Practice and volume trends in interventional radiology; • “Branding” of interventional radiology, what our customers are telling us about who we are; • Future of interventional radiology and the implications for training and practice; the report of the SCVIR Specialty Development Task Force; and • A series on innovation and research.

PURPOSE To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd). MATERIALS AND METHODS Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with χ 2 tests and Kaplan-Meier analysis. RESULTS Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B ( n = 7) or C( n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response. CONCLUSION TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.

Although polycystic liver disease has long been listed as a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, two cases of TIPS placement in that particular clinical setting have been reported. Another case is reported in this article and the clinical course over 21 months of follow-up is examined. The discussion reviews the mechanics of TIPS creation in a polycystic liver and the vague premise of the polycystic liver as a contraindication to TIPS.

To use angioscopy to evaluate and compare the amount of residual thrombus and endoluminal wall damage in hemodialysis grafts after percutaneous thrombectomy procedures.Thirty-nine thrombectomy and angioscopy procedures were performed in 35 patients. Percutaneous thrombectomy methods included eight different mechanical thrombectomy devices and the "lyse and wait" technique. Videotaped images of 33 angioscopic examinations were independently reviewed by three radiologists. Two parameters-the amount of residual thrombus and degree of endoluminal wall damage-were scored on a scale of 1 to 5. Data were initially analyzed to validate the grading system and then further studied to compare the different thrombectomy techniques.The Spearman rank order analysis validated the data pertaining to the amount of residual thrombus (r = 0.71, P.0001), but there was poor correlation between reviewers regarding the degree of endoluminal wall damage. Combined scores from three reviewers revealed that the Cragg brush and Percutaneous Thrombectomy Device (PTD) left the smallest amounts of residual thrombus. The other methods tested, listed by increasing amount of residual thrombus, were the Endovac, Hydrolyser, Amplatz Thrombectomy Device, AngioJet, Oasis, and the lyse and wait technique. There were two complications related to angioscopy procedures.Subjective observations reveal that wall-contact thrombectomy devices leave less residual thrombus than hydrodynamic devices, aspiration devices, or the lyse and wait technique.

Purpose Hohn catheters are single- or double-lumen catheters used for intermediate-length central venous access. The authors report their technique, results, and long-term follow-up in a prospective study of their first 100 consecutive patients. Patients and Methods Indications for Hohn subclavian catheter placement included chemotherapy in 53%, antibiotic therapy in 30%, and total parenteral nutrition in 8%. Patients’ ages ranged from 21 to 82 years, and 80% of catheters were placed in inpatients. Hohn catheters were placed with fluoroscopic and/or ultrasound guidance. Patients were followed up for the duration of the study or until their catheters were removed. Results The technical success rate for catheter placement was 100%. No major procedural complications occurred. Duration of catheter placement varied between 5 and 276 days (mean, 70 days). The catheter infection rate was 8%, which corresponds to 1.1 infections per 1,000 catheter days. Catheter thrombosis occurred in nine cases (9%) and was successfully treated with urokinase in six of these nine. Subclavian vein thrombosis occurred in 3% of patients. Conclusion Technical success, complication, and long-term patency rates for the Hohn catheter are comparable to or better than those in most surgical series involving tunneled external catheters. The Hohn catheter is an excellent alternative for intermediate-length central venous access. Hohn subclavian catheter placement has become a standard part of the authors’ interventional radiology service and is easily adaptable to all interventional practices.

The authors reviewed their experience with percutaneous gastrostomy and gastrojejunostomy in 30 consecutive patients who had undergone prior gastric surgery consisting of either partial resections ( n = 24) or alteration of normal gastric anatomy ( n = 6). Parameters evaluated included indications for the procedure, procedural modifications, type of prior gastric surgery, major and minor procedural complications, tube efficacy, and follow-up data. Gastrostomy tubes were placed in 27 patients for enteral feeding and in three for decompression. The success rate (100%), as well as the prevalence of major (0%) and minor (23%) morbidity—transient fever, skin infection, and high gastric residuals—were similar to those reported in patients who had not undergone prior gastric surgery. Thirty-day mortality was 13% (four patients); no deaths were related to the gastrostomy tube placement. Minor procedural modifications such as an extra-long needle, a peel-away sheath, or additional rotational fluoroscopy were necessary in 18 patients (60%). Knowledge of the post-surgical gastric anatomy is crucial in this subset of patients. Prior gastric surgery is no longer a contraindication to percutaneous gastrostomy or gastrojejunostomy tube placement.

Percutaneous gastrostomy was performed in 27 patients with ages ranging from 7 months to 18 years (mean, 8 years). Patient weights ranged from 4.7 to 73 kg (mean, 25 kg). Access to the stomach was planned and achieved with only fluoroscopic guidance. The technical success rate was 100%. Major procedure-related complications including death, sepsis, hemorrhage, peritonitis, or early tube removal did not occur. The minor complication of local skin infection occurred in six patients. Twenty-six patients (96%) tolerated tube feedings well. Mean follow-up was 184 days, and median follow-up was 103 days. At 30 days, 26 patients (96%) were alive. Percutaneous gastrostomy under fluoroscopic guidance is a safe and effective method of obtaining long-term nonparenteral nutritional access in pediatric patients.

An animal model was developed to study ureteral occlusion produced by steel coils and gelatin sponge. A coil nest was formed in the ureter, and in all but one pig, gelatin sponge pledgets were incorporated in the coil nest. Animals were killed at 2 hours, 1 week, 1 month, and 2 months. High-grade obstruction was present immediately following the procedure in all animals and was documented to be persistent by means of antegrade nephrostograms obtained just prior to death. At gross examination after death, ureteral thickening and strictures were evident. Histologic studies helped confirm the presence of acute and chronic inflammatory changes. In the in vivo model, gelatin sponge was not found necessary for acute ureteral occlusion. However, in an ancillary in vitro study in which a rigid plastic tube was used, gelatin sponge was necessary in addition to coil occlusion to provide acute total obstruction. The authors' findings suggest that in a compliant ureter, coil occlusion alone produces sufficient mechanical occlusion. Long-term obstruction is probably due to mechanical obstruction and stricture formation.

A new multilevel infusion catheter for administration of thrombolytic agents is described that provides near equal flow distribution through each of four infusion ports. Advantages of the catheter include fluoroscopically visible infusion length markers, small size (4.7 F), and secure positioning of the catheter within the occluded segment of graft or vessel. This catheter was used for infusion of urokinase in the treatment of 20 peripheral vascular occlusions. Complete or near complete thrombolysis was achieved in all cases.

Retained biliary stones remain a common clinical problem in patients after surgery. Since 1984, the authors have used choledochoscopy in the treatment of suspected retained biliary stones in 75 patients. These procedures were performed in the radiology department with use of local anesthesia supplemented by an intravenously administered sedative and analgesic. A 15-F flexible fiberoptic choledochoscope was used. Fifty-one of the 75 patients were treated as outpatients. Treatment was successful in 74 of 75 patients; in one patient, intrahepatic stones were not completely removed. Electrohydraulic lithotripsy was used to fragment calculi in 11 patients (15%). Biopsies were performed in four patients (5%). Five minor complications occurred; three required overnight admission. Choledochoscopic-assisted removal of retained biliary calculi is a highly effective and safe procedure. Advantages over standard fluoroscopic stone removal include the ability to directly visualize and fragment adherent or impacted stones and visualize noncalculous filling defects, such as air bubbles, mucus, and biliary tumors.

Bird's Nest vena caval filters were placed in 63 patients over a 6-month period by means of a transfemoral ( n = 62) or transjugular ( n = 1) approach. To determine the prevalence of access-site thrombosis, compression color Doppler flow imaging was performed 1–11 days after the procedure in 48 patients without suspected or documented preexisting thrombus. Clinical follow-up was from 5 to 289 days (mean, 100 days). Findings at ultrasound (US) examination were normal in 38 patients, and all of these patients remained clinically asymptomatic. Nonocclusive thrombus was seen in nine patients, eight of whom remained asymptomatic. A single patient had an occlusive thrombus at US. This patient had leg swelling. Nonocclusive thrombus did not predispose patients to the development of clinically evident occlusive thrombosis. The authors conclude that the transfemoral placement of the Bird's Nest vena caval filter is associated with a low prevalence (2%) of femoral vein occlusion documented at US follow-up. This contrasts with results from a similarly designed study demonstrating a 17% prevalence after percutaneous Greenfield filter placement.