A.K. Pillai

Improving Inferior Vena Cava Filter Retrieval Rates with the Define, Measure, Analyze, Improve, Control Methodology

PURPOSE To design a sustainable process to improve optional inferior vena cava (IVC) filter retrieval rates based on the Define, Measure, Analyze, Improve, Control (DMAIC) methodology of the Six Sigma process improvement paradigm. MATERIALS AND METHODS DMAIC, an acronym for Define, Measure, Analyze, Improve, and Control, was employed to design and implement a quality improvement project to increase IVC filter retrieval rates at a tertiary academic hospital. Retrievable IVC filters were placed in 139 patients over a 2-year period. The baseline IVC filter retrieval rate (n = 51) was reviewed through a retrospective analysis, and two strategies were devised to improve the filter retrieval rate: (a) mailing of letters to clinicians and patients for patients who had filters placed within 8 months of implementation of the project (n = 43) and (b) a prospective automated scheduling of a clinic visit at 4 weeks after filter placement for all new patients (n = 45). The effectiveness of these strategies was assessed by measuring the filter retrieval rates and estimated increase in revenue to interventional radiology. RESULTS IVC filter retrieval rates increased from a baseline of 8% to 40% with the mailing of letters and to 52% with the automated scheduling of a clinic visit 4 weeks after IVC filter placement. The estimated revenue per 100 IVC filters placed increased from

Yttrium-90 radioembolization of hepatic metastases from colorectal cancer

2,249 to

Thrombolysis and Transjugular Intrahepatic Portosystemic Shunt Creation for Acute and Subacute Portal Vein Thrombosis

10,518 with the mailing of letters and to

Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions

17,022 with the automated scheduling of a clinic visit. CONCLUSIONS Using the DMAIC methodology, a simple and sustainable quality improvement intervention was devised that markedly improved IVC filter retrieval rates in eligible patients.

Interventional radiology in the management of thoracic duct injuries: Anatomy, techniques and results

Liver metastases from colorectal cancer (CRC) result in substantial morbidity and mortality. The primary treatment is systemic chemotherapy, and in selected patients, surgical resection; however, for patients who are not surgical candidates and/or fail systemic chemotherapy, liver-directed therapies are increasingly being utilized. Yttrium-90 (Y-90) microsphere therapy, also known as selective internal radiation therapy (SIRT) or radioembolization, has proven to be effective in terms of extending time to progression of disease and also providing survival benefit. This review focuses on the use of Y-90 microsphere therapy in the treatment of liver metastases from CRC, including a comprehensive review of published clinical trials and prospective studies conducted thus far. We review the methodology, outcomes, and side effects of Y-90 microsphere therapy for metastatic CRC.

Utility of Intravascular US-Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients.

Catheter-based interventional therapy offers a safe and effective option for treatment of symptomatic portomesenteric venous thrombosis refractory to medical therapy. Various techniques and approaches have been described for thrombolysis and thrombectomy and re-establishing the portal venous flow for select populations. Early diagnosis and prompt treatment based on clinical presentation, imaging, and underlying anatomy are necessary to prevent long-term complications. This article describes various catheter-based approaches for treatment of acute and subacute portal vein thrombosis.

Anatomic and radiologic review of chronic mesenteric ischemia and its treatment

The portal vein is formed at the confluence of the splenic and superior mesenteric vein behind the head of the pancreas. Normal blood pressure within the portal system varies between 5 and 10 mmHg. Portal hypertension is defined when the gradient between the portal and systemic venous blood pressure exceeds 5 mmHg. The most common cause of portal hypertension is cirrhosis. In cirrhosis, portal hypertension develops due to extensive fibrosis within the liver parenchyma causing increased vascular resistance. In addition, the inability of the liver to metabolise certain vasodilators leads to hyperdynamic splanchnic circulation resulting in increased portal blood flow. Decompression of the portal pressure is achieved by formation of portosystemic collaterals. In this review, we will discuss the pathophysiology, anatomy, and imaging findings of spontaneous portosystemic collaterals and clinical manifestations of portal hypertension with emphasis on the role of interventional radiology in the management of complications related to portal hypertension.

Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts

Disruption of the thoracic duct can have devastating consequences and be associated with a high morbidity and mortality. Conservative therapies have been attempted to treat chylothorax without much success. Surgical management has traditionally been necessary to provide definitive treatment at the expense of increased morbidity. Lymphatic interventions have recently emerged as a new frontier for interventional radiologists to add value and provide minimally invasive therapies for debilitating conditions. The goal of this manuscript is to review the anatomy of the thoracic duct, describe various percutaneous techniques for accessing the duct, and briefly discuss outcomes as reported in the literature.

Transient Bacteremia after a Percutaneous Liver Biopsy

PURPOSE To compare safety and effectiveness of intravascular ultrasound (US)-guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. MATERIALS AND METHODS In this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass-related capsular perforation were recorded. RESULTS Baseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US-guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass-related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US-guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US-guided TIPS (P = .004). CONCLUSIONS Intravascular US-guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass-related capsular perforations, and reduced radiation dose.

Direct Percutaneous Access to the Cervical Portion of the Thoracic Duct, an Alternative to Traditional Access through the Cisterna Chyli.

Chronic mesenteric ischemia (CMI) is a vascular occlusive disease process that generally affects the elderly population. Clinical presentation occurs when two of the three mesenteric arteries are affected and includes non-specific abdominal pain and weight loss. The most common cause of CMI is atherosclerotic arterial occlusion. The aim of this review is to present the vascular anatomy of the mesenteric arterial circulation including the different collateral pathways. The imaging findings and the different treatment options with a brief review of the literature is presented.