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Fluoroscopic placement of gastrostomy tubes requires creation and dilation of a percutaneous tract through which the tube is placed. Given the relatively large caliber of these tubes, aggressive dilation of the percutaneous tract is necessary prior to their insertion. Tract dilation is most commonly performed via the use of several sequential dilators or a single telescoping serial dilator. These methods are cumbersome and relatively time-consuming, and as a result this portion of the procedure can result in considerable patient discomfort as well as technical complications. This chapter describes the use of a balloon catheter for gastrostomy creation. It describes clinical scenarios that would benefit from gastrostomy tube placement. The procedure is described in a step-by-step manner with a focus on gastrostomy tract dilatation.

Purpose To assess the readability of online patient education materials (OPEM) related to common diseases treated by and procedures performed by interventional radiology (IR). Materials and Methods The following websites were chosen based on their average Google search return for each IR OPEM content area examined in this study: Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), National Library of Medicine, RadiologyInfo, Mayo Clinic, WebMD, and Wikipedia. IR OPEM content area was assessed for the following: peripheral arterial disease, central venous catheter, varicocele, uterine artery embolization, vertebroplasty, transjugular intrahepatic portosystemic shunt, and deep vein thrombosis. The following algorithms were used to estimate and compare readability levels: Flesch-Kincaid Grade Formula, Flesch Reading Ease Score, Gunning Frequency of Gobbledygook, Simple Measure of Gobbledygook, and Coleman-Liau Index. Data were analyzed using general mixed modeling. Results On average, online sources that required beyond high school grade–level readability were Wikipedia (15.0), SIR (14.2), and RadiologyInfo (12.4); sources that required high school grade–level readability were CIRSE (11.3), Mayo Clinic (11.0), WebMD (10.6), and National Library of Medicine (9.0). On average, OPEM on uterine artery embolization, vertebroplasty, varicocele, and peripheral arterial disease required the highest level of readability (12.5, 12.3, 12.3, and 12.2, respectively). Conclusions The IR OPEM assessed in this study were written above the recommended sixth-grade reading level and the health literacy level of the average American adult. Many patients in the general public may not have the ability to read and understand health information in IR OPEM.

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.

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.

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.

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", 1 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 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.

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.

Several renal vascular pathological processes have been associated with hematuria. These include renal artery aneurysm (RAA), fibromuscular dysplasia (FMD), renal nutcracker syndrome (RNS), renal arteriovenous malformation, renal vasculitis, and renal artery or vein thrombosis. We present an unusual case of hematuria in a patient eventually diagnosed with RAA, FMD, and RNS. Percutaneous therapy, including endovascular coiling, percutaneous transluminal angioplasty, and stent placement were used to address the underlying pathology. The differential diagnosis, pathophysiology, and surgical and interventional management of these renal vascular disorders are reviewed.

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.

To determine the effect of aortoiliac stent placement on walking ability and health-related quality of life (QOL) for elderly individuals with moderate to severe intermittent claudication.A prospective single-center study was performed in 35 consecutive patients (46 symptomatic limbs) with intermittent claudication and aortoiliac insufficiency (mean age+/-SD, 61.1 years+/-9.5). Baseline and follow-up data to 12 months included clinical status, ankle-brachial index (ABI), exercise performance according to a standardized treadmill exercise protocol, and self-reported health-related QOL according to the Walking Impairment Questionnaire (WIQ) and the Short Form 36 (SF-36).Comparing baseline with 12-month data, mean ABI significantly improved from 0.64+/-0.15 to 0.89+/-0.19 (P.01). Similarly, mean initial claudication duration improved from 1.7 minutes+/-1.0 to 4.7 minutes+/-3.3 and maximum walking duration on the treadmill test improved from a mean of 3.3 minutes+/-1.8 to 8.7 minutes+/-4.4. All WIQ subscales showed significant improvement, and the SF-36 physical component scale as well as subscales of physical functioning, bodily pain, role physical, and vitality showed significant improvement. There was no 30-day mortality. Complications in the perioperative period that required treatment were observed in three patients (9%), but surgery was not required for any complications. Importantly, urgent or emergent surgery was not required for any complication and no permanent disability related to complications occurred.A high technical success rate (97%) and low complication rate were observed. Exercise performance and health-related QOL results improved significantly after stent placement. Revascularization with stent placement should be strongly considered in addition to conservative management for moderate to severe claudication with aortoiliac obstruction. A randomized clinical trial would be needed to gauge the relative effectiveness of stent implantation and conservative therapy.

Varicose vein management presents an exciting opportunity for the expansion of the interventional components of many practices. Although vein practice development has been addressed by other specialists, concerns unique to radiologists have only lately become important. Radiology groups are well suited to support the addition of this service line, and it may serve as a showcase for further clinical growth. Success depends on appropriate business planning, clinical and administrative infrastructure, and intelligent marketing. This article describes requisites for the successful development of a phlebology practice by a radiology group.

It is clear that interventional radiology contributes substantially to the status of radiology departments in the hospital as well as in the community. Experience has shown that clinical management is the key to well-reimbursed procedure volume and increased referrals for those services. Additionally, it allows the opportunity for interventionalists to participate in technological changes that we can envision right now, which could have significant impact on the management of numerous diseases. If treatment is “clearly indicated,” then the interventionalist has an obligation to present that opinion to the patient and to implement that care if the patient desires. Interventional radiologists have recognized that clinical care requires service to the patient first and foremost.

The business strategy for establishing a clinical office involves three key components: fundamental change from the traditional technical model in processes for accepting referrals; establishment of a high-quality clinical operation; and changing the perception of interventionalist radiology among the referring community and the public. The costs and revenues used to derive profit and loss statements will vary considerably across regions and practice set-ups. Some of the considerations are outlined in this article, but it will be up to interventionalists and their business managers to make these factors conform to their individual practices and locations.

The purpose of this brief article is to suggest some specific considerations that diagnostic radiology groups must make prior to embarking upon a varicose veins practice component. There are many excellent sources for further information, including the Web sites and practice management components of organizations such as the Society of Interventional Radiology, American College of Phlebology, International Vein Congress, and Union Internationale Phlebologie, all of which also hold excellent meetings or sections. Major points addressed in the article will include business plans, physician and group requirements, physical space and equipment requirements, and personnel issues. Though vein practice is clearly a major undertaking, the nature of varicose venous disease is such that there is a serendipitous overlap between the skill sets of the interventional radiologists and those required of the treating phlebologist. Consequently, with the proper motivation, self-education, and ongoing training, the addition of a varicose vein practice component can be extremely gratifying and rewarding for the physician, his radiology group, and most importantly the patients whom they serve.

Interventional radiology was once considered “angiography,” or in some hospitals, “special procedures.” Angiographers usually did not perform evaluation and management services. In 1963, Dr. Charles T. Dotter recognized the potential of catheters to be used in performing intravascular surgery. By the mid-1980s a wide array of therapeutic interventions and devices had been developed. The emergence of interventional radiology as a dedicated specialty, where interventionalists practice solely interventional radiology, has been a tremendous boost to referrals for therapeutic interventions. However, the possibility for change depends on the practice environment in which interventionalists work. This may serve as a note of caution to young interventionalists just out of fellowship; they have the most to lose if a practice doesn't support interventional clinical practice over the long haul in terms of time and resources.

If interventionalists are able to set up clinical practices and promote themselves along service lines, especially peripheral arterial disease, it is likely that they will have some market share and that market share will grow as new devices and technologies become available. The key to success will be changing the impression of the referring community that interventional radiologists are technical specialists and don't see patients. Marketing experts tell us that several impressions are required for a concept to stick with the target audience. One of the most important points that an interventionalist can make to establish themselves as a clinical specialty is high-quality work and effective communications.

It is unfortunate that in the peripheral arena surgeons often get the first referral for patients with peripheral arterial disease. Interventionalists should present themselves as vascular specialists to the referring community. Peripheral vascular disease in the future will be primarily an interventional specialty. Endovascular interventions are safe for people with claudication and interventionalists should offer them. If interventionalists provide comprehensive care and thoughtfully enter a market with the will to compete, it is very likely that they will succeed.

The purpose of this study was to describe the findings of MR imaging and radiographic changes that occur in osseous structures adjacent to soft-tissue hemangiomas of the extremities and to correlate them with patient symptomatology, the size of the hemangiomas, and their proximity to adjacent bone.We retrospectively reviewed the radiographs and MR images of 35 patients with soft-tissue hemangiomas of the extremities. The pattern and extent of the osseous change were categorized as periosteal, cortical, or medullary. Symptomatology, size, and proximity of the hemangioma to the adjacent bone were compared with the presence or absence of osseous change. Statistical analysis was performed using the Student's t test.Osseous change was noted on radiographs in 13 (37%) of 35 patients and on MR images in 11 (31%) of 35 patients with a total of 14 patients (40%) showing osseous change on at least one study. Periosteal change was present in eight (23%) of 35 patients; cortical change, in 11 (31%) of 35 patients; and medullary change, in 10 (29%) of 35 patients. Direct contact between the soft-tissue hemangioma and the adjacent bone was seen in 13 of 14 patients with osseous change. In those patients without osseous change, the average distance between the soft-tissue hemangioma and bone was 1.06 cm (range, 0-4 cm). No correlation was found between symptoms and the presence of osseous change.Soft-tissue hemangiomas of the extremities frequently result in adjacent osseous change that can be categorized as either periosteal, cortical, or medullary. Only medullary changes correspond with hemangioma size, whereas all three categories of change correlate with the proximity of the hemangioma to the adjacent bone. The presence of osseous change does not correlate with patient symptomatology.

We conducted a pooled analysis of clinical trials comparing intravenous Fenoldopam (FP) with Saline/Placebo/N-acetyl cysteine (NAC) for the prevention of contrast-induced nephropathy (CIN). Five studies were eligible. Quantitative analyses were done with Review Manager (RevMan version 5.2.). A total of 85 out of 353 patients in Fenoldopam group while 73 among 366 in the control group were affected due to CIN. The risk ratio for the development of CIN in the Fenoldopam group was 1.19 compared to the control group. This was not statistically significant. Fenoldopam is no better than Placebo/Saline or NAC in preventing CIN, but more studies are required.

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.

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.

The authors describe a novel fluoroscopically guided transnasal technique for removal of an endoscopically placed endobiliary prosthesis (EBP). A case in which the approach was applied is used to demonstrate its indications, clinical utility and possible benefits. The procedure entails simultaneous percutaneous replacement of the EBP with an internal/external biliary catheter over a through-and-through transhepatic/transnasal access wire. A comparison of the technique's limitations with those of traditional approaches for endoscopic or percutaneous EBP removal and replacement is presented.

Once the clinical practice model is established, transitioning is fairly easy. Office staff such as schedulers and nurse practitioners should understand that all elective therapeutic interventions are to be booked only by interventional radiologists once the interventionalist has done a thorough diagnostic evaluation, including a history and physical in an office environment. To optimize the interventionalist's workload and efficiency, some triaging of patients in the clinical office is necessary. Also, noninvasive testing will need to be made available in the clinical office.

It's a Tuesday afternoon. A local orthopedic spine surgeon calls your office, “I have this patient with a T10 RCC met. I need to stabilize the spine, and it will be a bloody mess. Can you help us out?” You are not a fellowship-trained neurointerventional radiologist (NIR). Your answer is: Sure, I did vertebral body embolizations in fellowship; I do it all the time. No way man! I'm not a NIR. I'd love to help. I did vertebral body embolizations in fellowship, but it may be a little too risky now. Let me think about it. Never did it. But, I do trauma embolizations in same anatomic region. Let me think about it. If you answered B, put this journal down. Politely demure and suggest your orthopedic surgeon consider a transfer of the patient or perhaps an attempt at the surgery without pretreatment. You should not perform interventions that could be considered NIR. You should also be lauded for your honesty, compassion, and self-knowledge. You should NOT feel that you are somehow a failure. You might consider discussing with your hospital or group the potential value of adding a staff member with the skillset your local orthopedic surgeon seeks. If you answered A, read on. We're hoping to refresh your memory and maybe even provide you a few pearls. If you answered C or D, this Seminars issue is designed for you! You were trained to do this sort of work. You can and you should use your knowledge and skillset to help as many patients as possible. Your work will make this patient's surgery much safer. You can really help this patient and the referring surgeon and will almost certainly further cement your already strong relationship with this referring provider. Before you perform your T10 embolization, and after reading this issue, you will probably begin by reviewing everything you can about spinal cord vascular anatomy. You should and probably will continue by rereading any texts or journal articles you can about safe vertebral body embolization. You might even talk to a few IR colleagues about their experiences in this clinical arena. You will plan diligently, prepare meticulously, and perform a safe and effective arteriogram and embolization. You will follow up your patient after the spine surgery. You will also see your patient in follow-up in your office. You are an excellent IR and have added value to your health-care system. Regardless of your answer, what you are NOT is a NIR. Though NIR is defined as “physicians providing neurointerventional management of patients with diseases of the brain, spine, head, and neck” by the vision statement of the Society of Neurointerventional Surgery (www.snisonline.org/mission), this edition does NOT propose to make you a NIR; reading it should not inspire you to begin coiling anterior communicating artery (ACOM) aneurysms or gluing cerebral arteriovenous malformation (AVMs) or spinal dural arteriovenous fistula (AVFs). It should rekindle your desire to help manage some clinical problems that share anatomic or pathologic features in common with those problems managed by our NIR brethren. These are the sort of issues that happen frequently and may go either untreated or treated in a delayed fashion if you don't help. Acute ischemic stroke, refractory epistaxis, arterial injuries from head and neck trauma, and severe back pain from compression fractures are diagnoses made every day at community hospitals and Level I trauma centers alike. Unfortunately, the former facility (and even some of the latter) may not have a NIR as readily available as you! Intra-arterial (IA) acute stroke management is a great example of a “neuro IR” area in which IRs can really have more impact. At our institution, more stroke interventions are performed by IR than by our superb NIR team. Although our NIR section is well staffed, there are still only two NIRs available and they are essentially on call every other night for extremely complex clinical issues such as subarachnoid hemorrhage due to aneurysms, dural AVFs, and AVMs. Our system of on-call coverage entails IR performing initial diagnostic cerebral angiography and calling in the NIR if and when they are needed for management. If the eight non-NIRs at our institution didn't do IA stroke care, either many folks would simply not benefit from catheter-directed approaches or our NIRs would likely burn out and look for a better gig! Couple this with the fact that our stroke outcomes between the IRs and NIRs are equal, and, at least for our institution, the math becomes pretty simple. Unofficial results of a recent Society of Interventional Radiology (SIR) stroke survey are interesting. The survey had 486 overall responders, all SIR members: 62% reported working in an accredited (primary or comprehensive) stroke center; 88% report that neurologists and 71% report that emergency department providers offer IV thrombolysis at their centers. Since only 64% of respondents report that their centers offer IA therapy, 36% of respondents' patients appear to be deprived of IA stand-alone or salvage approaches (which we find increasingly useful with drip and ship protocols and in the setting of failed IV therapy). Also, though 64% reported that their centers offer IA stroke care, 54% reported working in a setting with available NIR and only 35% reported that they provided IA stroke care themselves. This suggests that a significant amount of IA stroke management is done by services other than IR or NIR. Although drawing conclusions from this sort of survey may not be possible, keeping in mind the public health impact of acute stroke, it appears that non-NIR specialists are willing, capable, and indispensable in the management of this disease. Given our skillset and clinical acumen, shouldn't IR be one of these non-NIR specialties? In the end, there's no reason why IRs can't have a positive effect in stroke management and a similar impact in other areas involving CNS anatomy. Certainly, assuming this mantle will take effort, education, and—let's face it—some risk. But, I wouldn't want myself or any of my family members to be the patient who needs that vertebral surgery done without an IRs help. Would you?

Parallels between the evolution of surgery into an accepted clinical specialty and changes in the practice of interventional radiology (IR) have been drawn. Technical advances have mandated a change in the role of interventional radiologists from diagnostic radiologist to that of the treating physician. The development of “modern” IR is an accelerated repetition of the evolution of “modern” clinical surgery. The resistance or delay of some to accept IR as a clinical specialty is a duplication of the resistance to accept surgery as a clinical specialty by medicine in general. It is clearly time to understand that the benefits the interventional radiologist brings to the patient far exceed his ability to synthesize imaging data with catheter skills. Those of us who have accepted this can take some comfort in the fact that we now tread a path already proven in its destination.

We describe three cases of acute pericardial effusion during endovascular treatment of superior vena cava (SVC) syndrome, one of which resulted in fatal pericardial tamponade. SVC syndrome results from impaired venous return from the head and upper extremities to the right atrium. Malignancy and catheter-induced SVC stenosis accounts for the majority of cases of SVC syndrome. Endovascular therapy is the treatment of choice for SVC syndrome due to its rapid relief of symptoms and low morbidity. Acute pericardial effusion and pericardial tamponade may result from inadvertent extraluminal traversal of the SVC in the so-called danger zone above the right atrium, as well as secondary to dissection of wires in a location where fascial planes have been altered by neoplasia or inflammation.

The lack of clinical office space is the biggest Achilles' heel of interventional radiology and establishing an office eliminates that weakness immediately. Many interventionalists practice within a hospital setting; however, setting up a clinical office outside the hospital offers more flexibility. There are several reasons why interventionalists who set up clinical practices will succeed well into the future. Also, the American Board of Medical Specialties offers the fully trained interventional radiologist board certification in interventional disease management.

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.

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.

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.

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 χ 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.

This article reviews the existing literature on the use of partial splenic embolization in patients with portal hypertension. All articles published in the English language on splenic embolization or partial splenic embolization as a treatment for portal hypertension were identified with a PubMed search from 1973 through 2005. Partial splenic embolization appears to be efficacious in reducing episodes of variceal bleeding, improving hematologic parameters, enhancing hepatic protein synthesis, and reducing the severity of hepatic encephalopathy. Associated morbidity and mortality appear to be acceptable. The literature, however, is limited in quality. Given the potential benefits of partial splenic embolization, further investigation is warranted to allow evidence-based evaluation of its use.

Objective. Digital subtraction angiography quantitative vessel analysis (QVA) to assess percent renal arterial stenosis (RAS) is the reference standard. Quantitative vessel analysis is not ideal for screening purposes. Renal artery duplex ultrasonography (RADUS) is a noninvasive method to screen for RAS using well-known parameters. We investigated the direct correlation between several RADUS parameters and QVA to evaluate the acceptability of RADUS as a RAS screening and surveillance tool. Methods. We performed a multicenter retrospective study. Stenoses were evaluated in all patients with arteriograms and RADUS examinations within 30 days of each other in the span of 1 year. Percent stenosis of each stenotic renal artery segment was calculated digitally with QVA and correlated with the corresponding peak systolic velocity (PSV) and renal-aortic ratio (RAR) obtained with RADUS. Descriptive statistics and receiver operating characteristic curves were calculated. Correlation of percent stenosis, PSV, and RAR was performed. Sensitivity, specificity, and accuracy of diagnostic cut points for each RADUS parameter were calculated. Results. Sixty-seven renal arteries were included. Thirty-three arteries had less than 60% stenosis; 34 had stenosis of 60% or greater. The mean values were PSV, 272.791 cm/s; RAR, 3.716; and angiographic percent stenosis, 51.731%. Receiver operating characteristic curves showed higher accuracy for RAR with stenoses of 60% or greater versus PSV. Conclusions. Renal artery duplex ultrasonographic parameters for 60% or greater RAS correlate well with QVA. For detecting stenosis of 60% or greater, RAR is the most accurate parameter at a threshold of 2.5. Renal-aortic ratio is more accurate than PSV. Peak systolic velocity may be a useful RADUS alternative parameter for hemodynamically important stenoses in the setting of aortic disease when aortic velocities are less than 40 or

To identify trends in Evaluation and Management (E&M) and non-E&M services of interventional radiologists (physician specialty type 94) from 2000 to 2003 for Medicare patients, Medicare Part B physician annual allowed services data from the Centers of Medicare and Medicaid Services (CMS) were analyzed for all interventional radiologists from 2000 to 2003. Because the number of interventional radiologists in the United States according to the Society of Interventional Radiology is, on average, 4.2 times the number of interventional radiologists who use physician specialty type 94, we extrapolated the E&M services for each year. During the period examined, the total number of E&M services by interventional radiologists increased 309%, from 9,698 in 2000 to 29,914 in 2003. The most commonly performed services were Office or Other Outpatient Visit (Current Procedural Terminology [CPT] codes 99211-99215) for established patients, followed by Subsequent Hospital Care (CPT 99231-99233) and Office or Other Outpatient Consultations (CPT 99241-99245). The extrapolated number of E&M services by interventional radiologists for Medicare patients in 2003 is approximately 107,853. The number of Office and Outpatient Visits for New Patients (CPT 99201-99205) increased 142%, whereas the number of Consultations for New Patients (CPT 99241-99245) increased 208%. The total number of codes reimbursed by CMS to interventional radiologists (type 94) increased from 2.8 million in 2000 to 3.8 million in 2003.

Occipital condyle fractures (OCF) were once considered rare, but are increasingly recognized with computed tomography [1]. Utilizing the classification scheme of Anderson and Montesano [2] proposed mechanisms include direct axial-loading of the skull onto the atlas (Type I), direct blow to the skull (Type II), or forced rotation (Type III). A fracture of the occipital condyles may suggest a specific pattern of injury to adjacent structures. The occipital condyles form the boundaries of the foramen magnum through which the medulla, vertebral arteries, and inferior cranial nerves pass. Injury to the occipital condyles places those structures at greatest risk. As the carotid arteries do not course near the occipital condyles, injury to them is generally unexpected in OCFs without concomitant craniocervical injuries. To date, there have been no published reports of carotid injuries associated with any type OCFs. We present two patients with isolated type III occipital condylar fractures in whom injury to the carotid arteries was present. Case 1

The Society of Interventional Radiology survey in 2000 to 2001 reported what appeared to be favorable results. However, closer scrutiny provides more information. The Society of Interventional Radiology's strategic plan calls for 80% of interventional radiologists to be clinical practitioners by the year 2006. Recent American College of Radiology practice guidelines support this goal. Interventionalists need to decide whether they are going to provide clinical care and those who chose to take on the clinical practice model will most likely be successful.