Gregory M. Soares

Use of a puncture needle for recanalization of an occluded right subclavian vein

We report a patient in whom we used a puncture needle to initiate percutaneous recanalization of a chronic occlusion of the junction between the right subclavian vein and the right brachiocephalic vein. Under fluoroscopic guidance, an 18-gauge needle was used to puncture the right subclavian vein. When contrast material injected through the needle confirmed intravascular location, the needle was advanced until it deflected and perforated an occlusion balloon target positioned within the right brachiocephalic vein. This technique may be useful in patients with central venous occlusions that are refractory to traversal using traditional catheter and guidewire techniques.

Renal Artery Duplex Ultrasonography as a Screening and Surveillance Tool to Detect Renal Artery Stenosis A Comparison With Current Reference Standard Imaging

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 greater than 100 cm/s.

Quality of life and exercise performance after aortoiliac stent placement for claudication

PURPOSE 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. MATERIALS AND METHODS 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). RESULTS 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. CONCLUSIONS 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.

Clinical Services Provided by Interventional Radiologists to Medicare Beneficiaries in the United States, 2000-2003

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.

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.

Fenoldopam for the prevention of contrast-induced nephropathy (CIN)—do we need more trials? A meta-analysis

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.

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.

A previously unrecognized connection between occipital condyle fractures and internal carotid artery injuries (carotid and condyles)

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

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.

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.