Dana R. Burke

Quality Improvement Guidelines for Percutaneous Transhepatic Cholangiography and Biliary Drainage

PERCUTANEOUS transhepatic cholangiography is a safe and effective technique for evaluating biliary abnormalities. It reliably demonstrates the level of abnormalities and sometimes can help diagnose their etiologies. Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary abnormalities demonstrated with cholangiography. Participation by the radiologist in patient follow-up is an integral part of percutaneous transhepatic biliary drainage and will increase the effectiveness of the procedure. Close follow-up, with monitoring and management of the patients’ drainage-related problems, is appropriate for the interventional radiologist. These guidelines are written to be used in quality improvement programs to assess percutaneous biliary procedures. The most important processes of care are (a) patient selection, (b) performing the procedure, and (c) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rates. Outcome measures are assigned threshold levels.

Percutaneous transluminal angioplasty. The procedure of choice in the hypertensive renal allograft recipient with renal artery stenosis.

A retrospective review of 547 renal transplants performed over a six-year period revealed allograft renovascular hypertension secondary to RTAS in 39 (7.1%) patients. Percutaneous transluminal angioplasty (PTA) resulted in immediate cure or improvement in 76% of the patients, increasing to 83% in patients with functioning kidneys at a mean follow-up period of 30 months (1–72 months). The renal artery stenosis (RTAS) was equally distributed between living-related and cadaver kidney recipients and did not appear to be more prevalent in end-to-end or end-to-side anastomoses. The blood pressures fell from pre-PTA levels of 167 ± 22 mmHg systolic to 141 ± 23.7 post-PTA and 102 ± 11 mmHg diastolic pre-PTA to 88 ± 12 mmHg post-PTA (P < 0.01). Of 25 cured or improved patients, 24 are on significantly less hypertensive medication. Two patients died of causes unrelated to the PTA and only one patient lost a kidney because of the procedure. Compared with operation, PTA is a safer and more effective procedure for the initial treatment of RTAS.

The Fibrolamellar Variant of Hepatocellular Carcinoma Its Association With Focal Nodular Hyperplasia

A case of fibrolamellar hepatocellular carcinoma (FL‐HCC) associated with adjacent focal nodular hyperplasia (FNH) is described. These two regions were adjacent but distinct, both on gross and microscopic examination. Currently, it is unclear whether FL‐HCC rarely arises in preexisting FNH, or whether FNH is a typical response to this vascular variant of hepatocellular carcinoma (HCC). The FNH region, which is peripheral, may be biopsied to exclude the underlying carcinoma, and thus lead to inadequate therapy. Previous reports of this association are reviewed.

Quality Improvement Guidelines for Image-guided Percutaneous Biopsy in Adults

PERCUTANEOUS biopsy has become established as a safe, effective procedure. Successful percutaneous needle biopsy has been applied in most organ systems with excellent results and few complications (1–19). The key to these procedures has been the use of imaging guidance, which allows for the safe passage of a needle into an organ or mass, to obtain tissue for cytologic or histologic examinations. Imageguided percutaneous biopsy is less invasive than open exploration to obtain these same tissues. Because of the lower morbidity and mortality of the noninvasive procedures, they can be applied to patients who are too ill to undergo surgery or who wish to avoid convalescence from large diagnostic laparotomy procedures. In most settings percutaneous biopsy is the first approach to diagnosis. Follow-up, with postprocedure monitoring and management of the patient, is appropriate for the radiologist and will increase the effectiveness of the procedure. These guidelines are written for use in a quality improvement program that monitors percutaneous biopsy procedures (20). The most important processes of care in this area are: (a) patient selection, (b) performing the procedure, and (c) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rate.

Quality Improvement Guidelines for Adult Percutaneous Abscess and Fluid Drainage

Curtis W. Bakal, MD, MPH, Chairman, David Sacks, MD, Dana R. Burke, MD, John F. Cardella, MD, Paramjit S. Chopra, MD, Steven L. Dawson, MD, Alain T. Drooz, MD, Neil Freeman, MD, Steven G. Meranze, MD, A. Van Moore, Jr, MD, Aubrey M. Palestrant, MD, Anne C. Roberts, MD, James B. Spies, MD, Eric J. Stein, MD, Richard Towbin, MD, for the Society of Interventional Radiology Standards of Practice Committee

Angioplasty Standard of Practice

Society of Interventional Radiology Standards of Practice Committee: James B. Spies, MD, Chairman, Curtis W.Bakal, MD, Dana R. Burke, MD, John F. Cardella, MD, Alain Drooz, MD, Michael E. Edwards, MD, James W.Husted, MD, Aubrey M. Palestrant, MD, Michael J. Pentecost, MD, Anne C. Roberts, MD, William F. Rogers,MD, Millard C. Spencer, MD, Phillip J. Weyman, MD

Fibrolamellar hepatocellular carcinoma: MR appearance.

We report two cases of fibrolamellar hepatocellular carcinoma, each of which had lower signal intensity than normal liver on short repetition time (TR), short echo time (TE) spin-echo (SE) images and demonstrated a central scar-like area of low signal intensity which did not become hyperintense on long time TR/TE SE images.

Quality Improvement Guidelines for Image-guided Percutaneous Biopsy in Adults: Society of Cardiovascular & Interventional Radiology Standards of Practice Committee

PERCUTANEOUS biopsy has become established as a safe, effective procedure. Successful percutaneous needle biopsy has been applied in most organ systems with excellent results and few complications (1–19). The key to these procedures has been the use of imaging guidance, which allows for the safe passage of a needle into an organ or mass, to obtain tissue for cytologic or histologic examinations. Imageguided percutaneous biopsy is less invasive than open exploration to obtain these same tissues. Because of the lower morbidity and mortality of the noninvasive procedures, they can be applied to patients who are too ill to undergo surgery or who wish to avoid convalescence from large diagnostic laparotomy procedures. In most settings percutaneous biopsy is the first approach to diagnosis. Follow-up, with postprocedure monitoring and management of the patient, is appropriate for the radiologist and will increase the effectiveness of the procedure. These guidelines are written for use in a quality improvement program that monitors percutaneous biopsy procedures (20). The most important processes of care in this area are: (a) patient selection, (b) performing the procedure, and (c) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rate.

Percutaneous management of chronic pancreatic duct strictures and external fistulas with long-term results.

THE treatment of chronic pancreatitis with severe intermittent abdominal pain or chronic low-output pancreaticocutaneous fistulas remains a major challenge. The 20%–40% of patients who do not respond to intensive medical therapy, including abstinence from alcohol, are traditionally treated by surgical resection or drainage of the diseased pancreas; surgery leads to partial or complete pain relief in 60%– 90% of cases of ductal obstruction, but with a mortality rate of 2%–5% and a serious complication rate of 20%–40% (1–3). Evolving endoscopic pancreatic duct drainage and stent placement procedures (4–7) for treating pancreatic duct (PD) strictures, sealing PD disruptions, and draining PD pseudocysts can offer an alternative to surgery with low major morbidity and mortality. There remains a small group of patients for whom endoscopic and surgical treatment of PD obstruction or fistulas is not possible or advisable; it has been shown in a few case reports that the management of these patients by percutaneous PD drainage with or without stent placement can be effective (8–10). We describe a variety of interventional techniques that we have used to successfully treat five patients with chronic fistula or severe pancreatic pain syndrome, after both surgery and endoscopic catheterization had failed. A follow-up of 5–10 years was possible in most cases.

Assessment of Heparin Anticoagulation during Peripheral Angioplasty

The amount of heparin administered during peripheral angioplasty procedures is controversial and varies greatly among angiographers. Complications may result from both excessive and insufficient anticoagulation. The authors characterized the anticoagulant response to heparin in patients undergoing angioplasty by means of the activated clotting time (ACT). The ACT was measured in 64 patients who underwent lower extremity angioplasty. There was a linear relationship between heparin dose and ACT (P = .0001), but the slope of this relationship varied from patient to patient (R2 = .232). The response to heparin was blunted in one patient with thrombosis, but it was not exaggerated in patients with hematomas. Heparin anticoagulant response is highly variable, and heparin administration should be individualized according to ACT to produce a desired level of anticoagulation. Use of the ACT is a convenient and reproducible means of monitoring heparin administration and may increase safety and efficacy during peripheral angioplasty.