Louis G. Martin

Reporting Standards for Percutaneous Interventions in Dialysis Access

THE traditional treatment for failing arteriovenous dialysis access has been thrombectomy and/or surgical revision as needed (1–3). Over the past 2 decades, percutaneous methods for thrombus dissolution and/or correction of anatomic abnormalities have become accepted alternate treatment modalities (4). The results of thrombolysis (5–9), angioplasty (10–14), directional atherectomy (15,16), and endoluminal stent deployment (17–22) have been reported widely; nevertheless, comparison and interpretation of results are difficult because of differing methods of patient selection, treatment, and follow-up. For example, some thrombolysis series report success as establishment of flow immediately after the procedure (5), whereas others require at least three dialysis sessions after treatment for success (8). In addition, different reporting methods (life-table mean patency, life-table 50% patency, arithmetic mean patency, etc) applied to the exact same database can result in dramatically different conclusions; Hodges et al (23) showed that autogenous fistulas could be interpreted to have patencies equal to those of polytetrafluoroethylene (PTFE) grafts, shorter than PTFE grafts, or twice as long as PTFE grafts, depending on the method of data analysis. Suggested standards for reporting the results of arterial revascularization have been published previously by the Journal of Vascular Surgery (24,25) and the Journal of Vascular and Interventional Radiology (26,27). Reporting standards for acute and chronic thromboembolic venous disease have also been suggested (28). These reporting standards are obviously an imperfect fit for dialysis access interventions. To our knowledge, there has been no publication suggesting uniform reporting standards for dialysis access revascularization despite calls for their establishment (23,29). The purpose of this document is to recommend standards to be used for study design and reporting of percutaneous interventions for permanent hemodialysis access. The Table summarizes these standards in an abbreviated format.

Nonoperative management of visceral aneurysmsand pseudoaneurysms

During the period from 1975 to 1991, 41 patients with 60 visceral artery aneurysms were treated at the Affiliated Hospitals of Emory University. The total included 13 patients in whom 16 aneurysms were treated primarily by transarterial embolization. There were seven hepatic artery aneurysms, three splenic artery aneurysms, three gastroduodenal artery aneurysms, two left gastric artery aneurysms, and one right gastroepiploic artery aneurysm. Average age of these patients was 50 years; there were eight males and five females. Seven patients presented with gastrointestinal bleeding, and two patients presented with abdominal pain. In four patients, the aneurysm was an incidental finding. Etiology of the true or false aneurysms consisted of pancreatitis in two patients, trauma in three patients, connective tissue disease in one, and was unknown in the remainder. Embolization was performed in seven cases with Gianturco coils and Gelfoam, with coils alone in four, with Gelfoam alone in four, and with detachable balloons in one instance. Complete occlusion was achieved initially in 13 cases. Recanalization occurred in two patients over a mean follow-up period of 8.6 months, requiring re-embolization in one patient, whereas the other patient was managed expectantly. In three cases, embolization was unsuccessful: two cases required surgical correction, and one case was managed expectantly. Only one complication was related to the embolization procedure, which was a common hepatic arterial dissection that proceeded to the formation of a false aneurysm. Embolization as the primary treatment modality for visceral artery aneurysms should be considered in patients with the following diagnoses: pseudoaneurysms associated with pancreatitis, intrahepatic aneurysms, most splenic artery aneurysms, and gastric, gastroduodenal, and gastroepiploic aneurysms. The procedure has a low risk and may obviate a difficult surgical procedure, but it does not preclude surgical intervention should the need arise.

Prophylactic balloon angioplasty fails to prolong the patency of expanded polytetrafluoroethylene arteriovenous grafts: results of a prospective randomized study.

PURPOSE Maintenance of hemodialysis access grafts represents an enormous social and clinical problem. Current grafts and graft salvage techniques are inadequate. Consequently, there has been increasing interest in the use of minimally invasive catheter techniques to prophylactically treat stenoses in functioning arteriovenous grafts. Prophylactic balloon angioplasty has been widely suggested as prolonging assisted primary patency. We have performed a prospective randomized trial to compare patients who underwent percutaneous transluminal angioplasty (PTA) for graft stenoses > 50% with a control group that received no intervention. Our hypothesis was that to be efficacious a minimal benefit of 20% prolongation in patency would be necessary. METHODS Color flow duplex scanning was used to detect > 50% stenoses in functioning expanded polytetrafluoroethylene grafts. Patients were then subjected to confirmatory angiographic evaluation. Those who had angiographic stenoses > 50% were randomized to balloon angioplasty or observation. Patients were followed-up with duplex scanning every 2 months. Statistical analysis was performed using the Kaplan-Meier technique. Although demographically the patient groups were well matched, there were more prior interventions and concurrent central stenoses in the treatment group. Outcomes were graft thrombosis, graft dysfunction that precluded dialysis, and six or more PTA procedures within 18 months. RESULTS In the treatment and observation groups, the 6-month patency rates were 69% +/- 7% and 70% +/- 7%, respectively. The 12-month patency rates for the treatment and observation groups were 51% +/- 6% and 47% +/- 4%, respectively. There was no significant difference between these two groups (p = 0.97), with an 80% confidence limit for detection of a difference greater than 20%. CONCLUSIONS This study demonstrates that a generic approach of PTA to treat all polytetrafluoroethylene grafts with stenoses > 50% does not prolong patency and cannot be supported.

Quality improvement guidelines for transjugular intrahepatic portosystemic shunts.

Ziv J. Haskal, MD, Louis Martin, MD, John F. Cardella, MD, Patricia E. Cole, PhD, MD, Alain Drooz, MD,Clement J. Grassi, MD, Timothy C. McCowan, MD, Steven G. Meranze, MD, Calvin D. Neithamer, MD,Steven B. Oglevie, MD, Anne C. Roberts, MD, David Sacks, MD, Mark I. Silverstein, MD,Timothy L. Swan, MD, Richard B. Towbin, MD, and Curtis A. Lewis, MD, MBA, for the Society ofInterventional Radiology Standards of Practice Committee

Reporting Standards for Endovascular Treatment of Pulmonary Embolism

From the Division of Interventional Radiology (F.B.) and the Departments of Radiology (D.C.B.) and Surgery (D.M.L.), Georgetown University Hospital, 3800 Reservoir Rd, NW, Washington, DC 20007; the Division of Vascular and Interventional Radiology, Stanford University Medical Center, Stanford, California (W.T.K.); the Department of Radiology, Division of Interventional Radiology, Emory University School of Medicine, Emory University Hospital, Atlanta, Georgia (L.G.M.); the Department of Radiology, University of Western Ontario, London, and Peterborough Regional Health Centre, Peterborough, Ontario, Canada (S.F.M.); the Department of Interventional Radiology, New York University School of Medicine, NYU Medical Center, New York, New York (T.W.I.C.); Scarborough General Hospital, Toronto, Ontario, Canada (S.K.); the Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada (D.K.R.); The Reading Hospital and Medical Center, Advanced Interventional Radiology, West Reading, Pennsylvania (D.S.); and Geisinger Health System, Danville, Pennsylvania (J.F.C.). Received September 1, 2009; accepted September 28, 2009. Address correspondence to F.B.; E-mail: banovac@isis.georgetown.edu

Quality Improvement Guidelines for Diagnostic Arteriography

PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee member dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid, broad expert constituency of the subject matter under consideration for standards production.

Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

Alain T. Drooz, MD, Curtis A. Lewis, MD, Timothy E. Allen, MD, Steven J. Citron, MD, Patricia E. Cole, PhD, MD, Neil J. Freeman, MD, James W. Husted, MD, Patrick C. Malloy, MD, Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony C. Venbrux, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

Long-term Results of Angioplasty in 110 Patients with Renal Artery Stenosis☆

Percutaneous transluminal renal angioplasty (PTRA) is generally considered of little benefit in the treatment of ostial renal artery stenosis. This report contains long-term follow-up (> 12 months in all patients; mean follow-up, 38 months) for 110 patients who underwent PTRA for treatment of ostial renal artery stenosis. There was no significant difference in patient benefit related to bilaterality or multiplicity of lesions treated or to renal function before angioplasty (P > .1). Although there was no statistically significant difference in benefit among groups of patients who received treatment, certain trends were apparent. The least benefit occurred in patients with insulin-dependent diabetes and those with symptoms or history of vascular disease in another organ system. Treatment of lesions with proportionately larger balloons did not result in greater benefit. Restenoses were redilated in 16 patients for whom initial treatment failed. Eleven of these were ostial restenoses. The ostial stenosis in one patient was redilated a second time. At the end of follow-up, primary, secondary, and tertiary clinical benefits were 48%, 57%, and 58%, respectively. This was not statistically different (P = .14) from a control group of 94 patients with nonostial stenoses who had 68% long-term benefit. The authors conclude that ostial renal artery stenosis is not a contraindication to PTRA, and balloon angioplasty can play an important role in blood pressure control in this patient population.

Transjugular Intrahepatic Portosystemic Shunt for Symptomatic Refractory Hepatic Hydrothorax in Patients With Cirrhosis

OBJECTIVES:We sought to study effectiveness, survival, and complications after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and symptomatic refractory hepatic hydrothorax.METHODS:Consecutive patients who underwent TIPS between January 1992 and December 2008 for refractory hydrothorax were reviewed retrospectively. Clinical, laboratory, and procedural data were collected for all patients by retrospective chart review. Chi-square test was used to compare categorical variables and t-test to compare continuous variables. The Kaplan–Meier method was used for survival analysis. Survival curves were compared using the log-rank test.RESULTS:Seventy-three patients were included in the study, and their mean age at TIPS creation was 55.62 years (s.d. 11.65). The mean pre- and post-TIPS portosystemic gradients were 18.9 (s.d. 4.7) mm Hg and 5.7 (s.d. 2.4) mm Hg (P<0.001), respectively. The rates of favorable clinical response within 1 month and at 6 months after TIPS were 79% (58/73) and 75% (30/40), respectively. Median survival of the study group was 517 days (95% CI 11–626). The short-term survival rates at 30, 60, and 90 days were 81, 78, and 72%, respectively. The long-term survival rates at 1, 3, and 5 years were 48, 26, and 15%, respectively. Multivariate analysis by Cox proportional hazards method showed that pre-TIPS model for end-stage liver disease (MELD) score (P=0.039, HR 1.9 (95% CI 1.0–3.7)) and clinical response (P=0.003, HR 2.5 (95% CI 1.4–4.5)) were significantly and independently associated with overall survival. The 30-day mortality rate was 19%. Pre-TIPS creatinine levels (P=0.024, HR 3.42 (95% CI 1.2–9.9)) were significantly associated with 30-day mortality.CONCLUSIONS:TIPS can be successfully used to achieve symptomatic relief in patients with refractory hepatic hydrothorax. Better clinical response after TIPS and pre-TIPS MELD score less than 15 were associated with longer survival after TIPS.

ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability. Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas (Table 1). The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts. When appropriate, these committees have included representation from other organizations involved in the care of patients with the condition of focus. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, to rely upon easily documented clinical criteria, and where appropriate, to incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of cardiovascular care. The writing committees are also instructed to evaluate the extent to which existing nationally recognized performance measures conform to the attributes of performance measures described by the ACCF/AHA and to strive to create measures aligned with acceptable existing measures …