Mehran Midia

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.

Vascular Complications of Pancreatitis: Imaging and Intervention

The objective of this study was to highlight technical challenges and potential pitfalls of diagnostic imaging, intervention, and postintervention follow-up of vascular complications of pancreatitis. Diagnostic and interventional radiology imaging from patients with pancreatitis from 2002 to 2006 was reviewed. We conclude that biphasic CT is the diagnostic modality of choice. Catheter angiography may (still) be required to diagnose small pseudoaneurysms. Endovascular coiling is the treatment of choice for pseudoaneurysms. Close clinical follow-up is required, as patients may rebleed/develop aneurysms elsewhere.

Pelvic Congestion Syndrome: Etiology of Pain, Diagnosis, and Clinical Management

Pelvic congestion syndrome is associated with pelvic varicosities that result in chronic pelvic pain, especially in the setting of prolonged standing, coitus, menstruation, and pregnancy. Although the underlying pathophysiology of pelvic congestion syndrome is unclear, it probably results from a combination of dysfunctional venous valves, retrograde blood flow, venous hypertension, and dilatation. Asymptomatic women may also have pelvic varicosities, making pelvic congestion syndrome difficult to diagnose. This article explores the etiologies of pain, use of imaging techniques, and clinical management of pelvic congestion syndrome. Possible explanations for the spectrum of pain among women with pelvic varicosities are also discussed.

Utility of MRI Before and After Uterine Fibroid Embolization: Why to Do It and What to Look For

The utility of magnetic resonance imaging (MRI) in the selection, procedure planning, and follow-up of patients undergoing arterial embolization for uterine fibroids is reviewed. Advantages of MRI over ultrasound include multiplanar imaging capability, a larger field of view, increased spatial resolution, improved anatomic detail, and the ability to detect other pelvic disorders. MRI can assess fibroid viability by detecting contrast agent enhancement. Magnetic resonance angiography has a useful role in evaluation of pelvic vasculature. Magnetic resonance parameters such as T1 and T2 relaxation times and diffusion-weighted characteristics have an emerging role in predicting outcome before and after embolization. MRI may be used to evaluate technical success and to image potential complications after embolization.

Image-guided Intervention in Management of Complications of Portal Hypertension: More than TIPS for Success

Management of clinically important sequelae of portal hypertension, such as variceal bleeding and ascites, may involve a combination of medical, endoscopic, surgical, and interventional approaches and procedures. Although clinically significant esophageal and rectal varices are typically visible endoscopically, ectopic varices may require multiplanar portal venous phase computed tomography or magnetic resonance imaging for diagnosis. A detailed understanding of individual vascular anatomy, flow dynamics, and patient-related factors such as cardiac and hepatic status is necessary for appropriate treatment selection in patients with complicated portal hypertension. The hepatic venous pressure gradient is the key indirect measurement of portal venous pressure. Transjugular intrahepatic portosystemic shunt (TIPS) placement is regarded as the archetypal intervention for treating complicated portal hypertension by reducing portal pressure. Various modifications, such as direct portocaval shunt, may be used in patients with challenging vascular anatomy. A subset of patients with obstructed hepatic venous outflow or portal venous inflow should be considered for recanalization. Splenic artery embolization may be considered for reduction of portal pressure in selected patients, particularly when hypersplenism or splenic vein occlusion is a prominent feature. Gastric and ectopic varices may bleed even when the portal pressure is low, and balloon-occluded retrograde transvenous obliteration (BRTO) in such patients may lead to equal or improved outcome compared with TIPS placement. BRTO is not limited by poor hepatic reserve or encephalopathy; however, it does not reduce portal pressure and may aggravate esophageal varices. Interventional radiology plays an important role in maintaining the patency of surgically created portosystemic shunts, and it remains at the forefront of new approaches in shunt design and placement. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.335125166/-/DC1.

Perivascular Spaces: Normal and Giant

The purpose of this paper is to discuss both normal perivascular spaces (PVSs) and pathological giant perivascular spaces (GPVSs). The anatomy and physiology of normal PVSs, including important immunological and lymphatic roles, are described. Special attention is given to the Magnetic Resonance Imaging (MRI) findings of both normal and GPVSs. Furthermore, the clinical features and pathogenesis of GPVSs are explored, with special emphasis on the pathological implications of these lesions, and their relevance. It is important that symptomatic GPVSs not be mistaken for more devastating disease processes. When the lesions in question occur in a characteristic location along the path of a penetrating vessel, are isointense with cerebrospinal fluid on all MRI sequences, do not enhance with contrast material, are not calcified, and have normal adjacent brain parenchyma, their appearance is pathognomonic of GPVSs. The clinician should realize that an extensive differential diagnosis is superfluous and that biopsy is unnecessary in these patients. Instead, the clinical focus should be aimed at neurosurgical intervention, as dictated by the symptoms of mass effect.

Effect of governmental intervention on appropriateness of lumbar MRI referrals: a Canadian experience.

PURPOSE In 2012, the Ontario government attempted to reduce inappropriate lumbar MRI referrals through guideline and decision-aid distributions to physicians as well as threats of financial penalties. The goals of this study were to determine if any change in lumbar MRI referral appropriateness occurred after this policy change at a tertiary care hospital in Ontario and to determine if any change in the number of new lumbar MRI referrals occurred after the policy change. METHODS Six hundred lumbar MRI referral forms were randomly selected; 300 before and 300 after the policy change. The ACR Appropriateness Criteria for low back pain imaging were used to evaluate the appropriateness of each referral and assign it a score from 1 to 9. The numbers of new referrals during 3-month periods both before and after the policy change were recorded. Students t test was performed to test for significant differences after the policy change. RESULTS Before the policy change, 50.4% of lumbar MRI referrals were appropriate, and 47.9% were not appropriate. After the policy change, appropriateness increased, with 62.6% of referrals being appropriate and 37.1% not appropriate. The mean appropriateness score before the policy change was 5.08 (95% confidence interval, 4.74-5.42) and increased significantly after the policy change to 5.79 (95% confidence interval, 5.46-6.12) (P = .004). No significant difference in the number of new lumbar MRI referrals before (246 ± 20.1 per month) and after (232.7 ± 38.3 per month) the policy change was noted (P > .05). CONCLUSIONS The Ontario governments interventions have significantly increased the appropriateness of lumbar MRI referrals. However, many referrals remain inappropriate, and no change in the number of new referrals has occurred.

Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee

PURPOSE To develop a new adverse event (AE) classification for the interventional radiology (IR) procedures and evaluate its clinical, research, and educational value compared with the existing Society of Interventional Radiology (SIR) classification via an SIR member survey. MATERIALS AND METHODS A new AE classification was developed by members of the Standards of Practice Committee of the SIR. Subsequently, a survey was created by a group of 18 members from the SIR Standards of Practice Committee and Service Lines. Twelve clinical AE case scenarios were generated that encompassed a broad spectrum of IR procedures and potential AEs. Survey questions were designed to evaluate the following domains: educational and research values, accountability for intraprocedural challenges, consistency of AE reporting, unambiguity, and potential for incorporation into existing quality-assurance framework. For each AE scenario, the survey participants were instructed to answer questions about the proposed and existing SIR classifications. SIR members were invited via online survey links, and 68 members participated among 140 surveyed. Answers on new and existing classifications were evaluated and compared statistically. Overall comparison between the two surveys was performed by generalized linear modeling. RESULTS The proposed AE classification received superior evaluations in terms of consistency of reporting (P < .05) and potential for incorporation into existing quality-assurance framework (P < .05). Respondents gave a higher overall rating to the educational and research value of the new compared with the existing classification (P < .05). CONCLUSIONS This study proposed an AE classification system that outperformed the existing SIR classification in the studied domains.

Quality Improvement Guidelines for Transarterial Chemoembolization and Embolization of Hepatic Malignancy

From the Division of In ment of Radiology, Un 1740 West Taylor Stree Interventional Radiolog Northwestern Memoria (D.B.B.), Vanderbilt Univ Interventional Radiolog Therapy (S.G.), Massa Boston, Massachusetts Israel, New York, New Hospital, Barrie, Onta (A.M.E.), University of ventional Radiology (M Interventional Radiolog University School of M Radiology (S.A.P.), Dep at University of Californ Radiology (T.J.W.), Flor Radiology (J.L.W.), Dep Center, Boston, Massa Medical Center, Albany 2017. Address corres Fair Ridge Dr., Suite 40

Major Bleeding after Percutaneous Image-Guided Biopsies: Frequency, Predictors, and Periprocedural Management

Major bleeding remains an uncommon yet potentially devastating complication following percutaneous image-guided biopsy. This article reviews two cases of major bleeding after percutaneous biopsy and discusses the frequency, predictors, and periprocedural management of major postprocedural bleeding.