Mary E. Meek

Management of Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations are rare lesions with significant clinical complications. These lesions are commonly seen in patients with hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome). Interventional radiologists are a key part of the treatment team in this complex disease, and a thorough understanding of the disease process is critical to providing good patient care. In this article, the authors review the disease course and its association with hereditary hemorrhagic telangiectasia, discusses the clinical evaluation and treatment of these complex patients, and outlines complications and follow-up.

The Interventional Radiology Business Plan

Strategic planning and business planning are processes commonly employed by organizations that exist in competitive environments. Although it is difficult to prove a causal relationship between formal strategic/business planning and positive organizational performance, there is broad agreement that formal strategic and business plans are components of successful organizations. The various elements of strategic plans and business plans are not common in the vernacular of practicing physicians. As health care becomes more competitive, familiarity with these tools may grow in importance. Herein we provide an overview of formal strategic and business planning, and offer a roadmap for an interventional radiology-specific plan that may be useful for organizations confronting competitive and financial threats.

Radiology Boot Camp: Facilitating the Transition of Interns into Residents

It is no secret that transitions inmedical education are challengingand inherently stressful. New in-ternsstrugglewithalackofmedicalknowledge, poor organizationalskills, inadequate ability to reflectand self-assess, and underdevelo-ped professionalism, most oftenattributed to a lack of thoroughpreparation in medical school [1-3]. Then, after a year of clinicalpracticeinmedicineorsurgeryoratransitional year, the transition toradiology residency presents a newsetofchallenges.Theradiologyres-ident is no longer the the primarycontact in direct patient care anddecisionmaking,butisexpectedtobe an imaging consultant, operat-ing largely behind the scenes in anunfamiliar specialty [4-6]. Few res-idents gain skills and experienceswith imaging modalities and stud-ies during medical school and in-ternship, so they find themselves asnovices once again [7]. Additionalstresses are created by having toadapt to a hospital-based learningenvironmentand,often,anewpro-gram director and set of peers. Ourspecialty’s reliance on the internetanddigitaldevicesforaccessinged-ucational material requires a highlevel of technological savvy [8,9].Thevolumeandcomplexityofnewinformation to be assimilated canparalyze and demoralize any newradiology resident.Research on “resident readiness”suggests the usefulness of focusededucationalinterventionstoimprovethe clinical orientation process andincrease residents’ confidence [2,6,7,10-13].Asmallbutgrowingcollec-tion of literature has focused on“boot camps,” which are being usedin graduate medical education tomaximize fundamental teachingtime while fostering team building[5,11].Colloquially, “boot camp” refersto military recruit training as anabrupt,oftenshockingtransitiontoanew way of life, with strict disciplineand an emphasis on hard work andphysical conditioning. Companiesalso use boot camps to immerse re-cruitsinbothtechnicalskillsandcor-porateculture.Asaresult,therecruitsdevelop strong bonds to their peersand the organization [14]. Havingpeerstheycanrelyonhelpsresidentscopeandalleviatessomeofthenega-tive effects of high stress levels.The literature on preparation andreadiness for radiology is sparse butemerging. One program’s lecture se-ries designed specifically for incom-ing residents resulted in an increasein residents’ confidence (althoughclinical performance improvementcould not be demonstrated) [7].Inanotherprogram,theadditionofres-ident-to-resident role-oriented pre-sentations decreased anxiety andincreased role awareness more thanlectures alone [6].

Effective Use of Low-Dose Computed Tomography Lung Cancer Screening

Lung cancer screening programs for high-risk populations using low-dose computed tomography (LDCT) have been shown by a class I clinical trial to reduce lung cancer mortality by 20%. We present an overview of randomized and nonrandomized lung cancer screening trials and review some of the arguments advocating for or against the widespread implementation of such a screening program. Concerns regarding the use of LDCT screening for lung cancer include increased risk from radiation exposure, overdiagnosis of indolent tumors, and high numbers of false-positive results, which may increase patient anxiety and result in unnecessary procedures with potential complications. Current recommendations regarding diagnostic criteria and workup of positive screens as well as the risks and benefits of using LDCT for lung cancer screening are provided.

Diagnosis and Treatment of Central Venous Access–Associated Infections

This paper provides readers with a basic understanding of the types of central venous access-associated infections as well as appropriate diagnostic techniques. Preventive measures are the most effective way to reduce rates of catheter-associated infection and are discussed in detail. Diagnosis and treatment of each type of infection are reviewed for nontunneled central venous catheters, tunneled dialysis catheters, and venous access ports. Readers should be able to employ the methods described in this paper to reduce the rate of central venous access-associated infections at their hospitals.

Lightly Embalmed Cadavers as a Training Tool for Ultrasound-Guided Procedures Commonly Used in Interventional Radiology

RATIONALE AND OBJECTIVES Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care. MATERIALS AND METHODS Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access. RESULTS The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient. CONCLUSION Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Percutaneous rendezvous technique for the management of a bile duct injury

The rendezvous technique typically involves combined efforts of interventional radiology, endoscopy, and surgery. It can be done solely percutaneously, whereby the interventionalist gains desired access to one point in the body by approaching it from two different access sites. We present the case of a woman who underwent cholecystectomy complicated by a bile duct injury. A percutaneous rendezvous procedure enabled placement of an internal-external drain from the intrahepatic ducts through the biloma and distal common bile duct and into the duodenum. Thus, a percutaneous rendezvous technique is feasible for managing a bile duct injury when endoscopic retrograde cholangio-pancreatography or percutaneous transhepatic cholangiogram alone has been unsuccessful.

Use of a mechanical thrombectomy device to treat early hepatic artery thrombosis after orthotopic liver transplant

Hepatic artery thrombosis (HAT) is a major cause of morbidity and mortality after orthotopic liver transplantation, occurring in 5% of cases (Piardi et al, 2016). HAT is the second main cause of graft loss after primary nonfunction, the leading cause of graft failure in the immediate postoperative period (<1 month), and is associated with a mortality rate of up to 60% without intervention (Piardi et al, 2016; Pareja et al., 2010; Crossin et al., 2003). Although retransplantation is the preferred therapy, the limited availability of donor organs can necessitate urgent, alternative treatment. These patients present physicians with an often-severe clinical picture, which requires consideration of endovascular approaches as opposed to the more traditional, invasive surgical interventions. The following case study presents a novel mechanical therapy that uses an endovascular approach for revascularization—a stent retriever device.

Percutaneous Transsternal Cryoablation of Ectopic Parathyroid Adenoma in the Anterior Mediastinum

Ectopic parathyroid adenomas are common in the context of hyperparathyroidism and represent a unique challenge in terms of localization and treatment. Often they are related to higher serum calcium levels than those associated with parathyroid adenomas in typical locations. Additionally, ectopic adenomas often lead to higher morbidity due to failed parathyroid exploration and multiple attempts at surgical removal. We present two cases of computed tomography–guided percutaneous transsternal cryoablation of ectopic parathyroid adenomas in the anterior mediastinum, one after failed surgical resection and the other after failed transarterial embolization. Cryoablation may represent a safe and effective alternative to surgery or embolization and should be included in the therapeutic algorithm in patients with percutaneously accessible lesions.

Smartphone Apps as a Source of Information About Interventional Radiology

To the Editor, Smartphone applications (apps) have been studied as a potential source of information for various medical specialties, including neurology [1], dermatology [2] and oncology [3]. There are over 2 million apps on the Apple App Store, and 2.4 million apps on the Google Play Store as of September 2016. As the use of smartphones increases across the world, the number of patients and medical professionals utilizing smartphone apps for accessing health care-related information through apps is also expected to rise. However, there is a concern about scientific accuracy and relevance of apps [4], since they are not screened for quality and validity of information, but are only screened for technical efficiency by the app store owners (i.e., Apple Inc, Google Inc, etc). No studies have been done yet to evaluate the availability and content of apps related to Interventional Radiology (IR). The purpose of this study was to identify and analyze the presently available IR-related applications on the Apple App Store. The Apple App Store was searched for IR-related applications on September 12, 2016, using 48 keywords associated with IR procedures. Only apps in English were included. Apps that were primarily targeted toward other specialties (vascular surgery, interventional cardiology or neurosurgery) were excluded. The content of the apps was reviewed and analyzed by two radiology residents (VW, BBJ) in consensus. The parameters included cost (free vs. paid), uploading agency (health care vs. non-health care), target audience (healthcare professional vs. general public), based on scientific evidence or studies (i.e., cited scientific literature) and usefulness. The usefulness of an app was defined by the user reviews and star rating on the app store and classified as not useful (1 star), moderately useful (2–3 stars) and very useful (4–5 stars). If an app did not have a star rating due to too few user reviews, the app reviewers gave their own star rating based on the content and description of the app. The apps were also classified by the type of information (Table 1). Univariate analysis was performed using Pearson’s Chi-squared test for categorical variables, and p value of\0.05 was considered significant. A total of 85 IR-related applications were identified and included in the study. A majority of the apps (84.7%) were available free of cost and rated moderate to very useful (65.8%). Most of the apps were based on scientific studies (89.4%), targeted healthcare professionals (88.2%) and were published by healthcare agencies (70.6%). There was clear trend toward recent increase in the number of apps, as 63.5% were released in years 2015/2016. Significantly higher proportion of scientifically valid apps (65.9%) were Electronic supplementary material The online version of this article (doi:10.1007/s00270-017-1608-2) contains supplementary material, which is available to authorized users.