Michael C. Brunner

Biliary Strictures in Hepatic Transplantation

Between August 1985 and December 1990, 198 liver transplantations were performed. Among 18 patients, 20 biliary strictures were identified, which were categorized as anastomotic (n = 6), nonanastomotic central hilar (n = 8), and nonanastomotic peripheral (n = 6). Pretransplant disease, hepatic artery patency, presence of acute or chronic rejection, and donor cold ischemia times were tabulated for each case. Among the six patients with peripheral strictures, three had sclerosing cholangitis prior to transplantation. Three patients with nonanastomotic strictures experienced chronic rejection. The mean cold ischemia time for patients with nonanastomotic strictures was 9.75 hours versus 8.1 hours for nonstrictured transplants (P = .025). Balloon dilation was performed in 13 patients; follow-up longer than 6 months was available for nine patients. Dilation was successful in four cases. Among the five failures, only one patient has needed surgery. An association was noted between nonanastomotic biliary strictures and prolonged donor cold ischemia time, between peripheral nonanastomotic strictures and pretransplant sclerosing cholangitis, and between nonanastomotic strictures and chronic rejection. Percutaneous balloon dilation was found useful in the treatment of the strictured transplant.

Ultrarapid urokinase in hemodialysis access occlusion.

Over a 3-month period, 14 consecutive hemodialysis access occlusions were treated with 1-1.25 million IU of urokinase (UK) delivered at a rate of 20,000 IU/min. After systemic heparin administration, lytic infusion via the crossed-catheter technique was performed with use of pediatric microdrip pumps, with determination of success within 1 hour. Patency was established radiographically in 11 of 14 occlusions, for a 79% immediate success rate. At 285-day mean follow-up, 9% (one of 11) remained patent without further radiologic or surgical intervention; graft survival was 64% (seven of 11). No significant complications occurred with use of ultrarapid UK. The 1-hour outpatient procedure safely allowed for rapid triage between surgical and radiologic intervention, minimal catheter manipulation or physician dependency, shorter duration compression of any bleeding venipuncture sites during UK administration, and greater patient comfort because of shortened procedure times.

Bleeding Stomal Varices: Treatment with a Transjugular Intrahepatic Portosystemic Shunt in Two Pediatric Patients

JVIR 1995; 6:233-236 PmENTs with enterostomies and coexistent portal hypertension occasionally develop varices at the mucocutaneous junction of their stoma. These portosystemic collateral vessels are prone to recurrent episodes of bleeding despite local interventions including manual compression, sclerotherapy, percutaneous embolization, and stoma1 revision (1-6). Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently under investigation for control of variceal bleeding at the gastroesophageal junction and has recently been reported to be promising in treating intraabdominal intestinal varices (7,8). We report two pediatric cases in which bleeding stomal varices were successfully managed with TIPS placement.

Interventional care of the hemodialysis patient: it's about quality.

OVER the past two decades, Interventional Radiology has developed into an essential provider of percutaneous creation and management of access in hemodialysis patients. The role of interventional radiology in this patient population has developed into a broad range of procedures, including catheter placement and management, preoperative imaging for access, screening of and prophylactic intervention for failing hemodialysis conduits and fistulas, treatment of thrombosed conduits and fistulas, and salvage procedures designed to enhance the maturation of native fistulas. The development and proliferation of these interventions has been accomplished almost exclusively by interventional radiologists. These interventions are so integral to the care of the patient receiving hemodialysis treatment that they are strongly supported by the Dialysis Outcomes Quality Initiative (DOQI) Vascular Access Guidelines, published in 1997 (1) and updated in 2001 (2). Undoubtedly, the last thing interventional radiologists want to hear is the rumbling of another turf battle, but that is precisely what is happening in the area of hemodialysis access interventions. For many years, a very small group of nephrologists “borrowed” from our well-recognized name and began calling themselves “interventional nephrologists.” Until recently, the “interventional nephrology” movement was a small blip on the radar screen, but now, for a variety of reasons discussed herein, there is increased interest in this area from the nephrology community. Gradually, throughout the late 1990s, manuscripts published by “interventional nephrologists” became more frequent, billing for percutaneous procedures by the same specialists increased, and attention to this subject at nephrology meetings increased dramatically. In fact, there has been a hands-on course in “interventional nephrology” at the American Society of Nephrology meeting for the past three years. The year 2000 marked a turning point, and arguably the true onset of the “turf battle” over hemodialysis access interventions. In January of that year, the American Society of Nephrology and Renal Physicians Association published a document outlining training guidelines for nephrology fellowships, which include “interventional nephrology,” clearly defined and covering the entire spectrum of interventions currently performed by interventional radiologists in this patient population (3). Later in the year, the formation of the American Society of Interventional Nephrology was announced. Also during 2000, a proliferation of freestanding “interventional nephrology” centers, largely Baxter’s RMS Lifelines, allowed nephrologists to bypass hospital credentials committees by performing interventions outside of the hospital setting. Until this point, nephrologists had largely been unable to receive credentials for percutaneous interventions precisely because of their lack of training, which was obvious to even the most liberal credentials committee. “Training centers” are now available to nephrologists in several places throughout the country (4,5) where a 2-week course is considered “acceptable training” to allow performance of these procedures. The quote at the beginning of this Commentary reflects this sentiment. To make matters worse, medical device manufacturers are promoting the concept, offering 1and 2-day “training courses” to nephrologists, cardiologists, and surgeons; one of the authors of this article has been approached repeatedly to provide such “training.” If this sounds far-fetched, or if the reader is thinking, “this won’t happen here,” consider the following: Late this year, the Society of Cardiovascular & Interventional Radiology (SCVIR) From the Department of Radiology (S.O.T.), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; Department of Radiology (R.D.G.), Washington Hospital Center, Washington, DC; Department of Radiology (M.B.), Swedish Covenant Hospital, Chicago, Illinois, and Department of Radiology (S.A.), Open Access Vascular Access Center, Miami, Florida. Address correspondence to S.O.T., Department of Radiology, Hospital of the University of Pennsylvania, 1 Silverstein, 3400 Spruce St., Philadelphia, PA 19104; E-mail: streroto@uphs.upenn.edu

Percutaneous Vertebroplasty and Kyphoplasty for Pathologic Vertebral Fractures in the Medicare Population: Safer and Less Expensive than Open Surgery

PURPOSE To compare cost and outcomes of surgical and percutaneous treatments of pathologic vertebral fractures. MATERIALS AND METHODS Standard Medicare 5% anonymized inpatient files (1999-2009) were retrospectively reviewed. Patients with a diagnosis of vertebral fracture without spinal cord injury and primary or metastatic bony malignancy were divided into percutaneous or surgical groups based on whether they received vertebroplasty/kyphoplasty or surgical treatment. Patients who had no intervention or both interventions were excluded. Cost, length of stay, and type of discharge were examined while controlling for demographic and comorbidity variables. RESULTS A total of 451 patients were included; 52% received percutaneous treatment and 48% received surgery. Patients treated percutaneously were older (P < .001) and more likely to be female (P = .04). Percutaneous therapy predicted

Strategic Initiatives in Interventional Radiology: A New Vision1

14,862 less Medicare cost and

Strategic initiatives in interventional radiology: the clinical imperative.

13,565 less overall cost (P < .001 for both), and 4.1 fewer inpatient days (P < .001). Patients who underwent surgery had higher odds of death (odds ratio = 3.38, P = .016), discharge to a rehabilitation facility (odds ratio = 3.3, P = .003), and transfer to another inpatient facility (odds ratio = 8.53, P < .001), and lower odds of discharge to home (odds ratio = 0.42, P < .001) and hospice (odds ratio = 0.08, P = .002). CONCLUSIONS In a Medicare population with bony malignancy and vertebral fractures, percutaneous therapy predicted significantly reduced cost and length of stay versus surgery. Patients who underwent percutaneous therapy were significantly less likely to die, be transferred, or be discharged to rehabilitation facilities, and were more likely to be discharged to home or hospice.

Endovascular Strategies for Management of Claudication and Lower Extremity Arterial Disease

Interventional radiology is at a crossroads. Two possible futures exist. In one direction, advances in technology are providing exciting opportunities for interventional radiology. Promising new treatments in tumor and cancer therapy, the treatment of fibroids, venous access, and spine interventions, as well as advances in noninvasive vascular imaging, pharmacologic therapies, and peripheral interventions are revitalizing our specialty, attracting significant patient interest and promising tremendous public benefit. In the other direction, interventional radiology is losing market share in vascular interventions to other specialties and suffering a crisis of confidence. One road leads to success, the other to failure. The only problem is that the roads aren’t clearly marked. Which road is which? The burden falls upon all of us, the leaders, staff, and members of the Society to choose the right path, to choose our future, and to make our continued success a reality. Fortunately, we have the tool to create a map; this tool is strategic planning, a business discipline that helps organizations determine and achieve desired futures. Strategic planning can provide direction and help focus organizational activities. Without it, entropy can set in and organizations can fail. Last year, SCVIR launched a strategic planning process to set directions for both the specialty and the Society. It was clearly time; the Society’s thencurrent plan was more than 5 years old—a millennium in today’s rapidly changing world. In addition, the Society and its members were facing increasing challenges from competing specialties, ever-tightening reimbursement, new technologies, evolving practice patterns, and changing consumer expectations. This paper is the first of a series in JVIR to convey a significant depth of information about the strategic plan; to provide an understanding of its foundations, our goals and objectives, and issues that will still need to be debated as the plan moves forward. This first article describes the strategic planning process, the vision, timeline and goals, and early successes of the new plan. Subsequent articles will include the following topics: • Results of strategic plan research: the environmental/economic assessment, leadership, staff and external interviews, and member polling; • Workforce projections and employment market for interventional radiologists; • Becoming “clinical,” and what this will mean for the interventional radiologist; • Practice and volume trends in interventional radiology; • “Branding” of interventional radiology, what our customers are telling us about who we are; • Future of interventional radiology and the implications for training and practice; the report of the SCVIR Specialty Development Task Force; and • A series on innovation and research.

Presidential Address: Like a Bridge Over Troubled Waters

INTERVENTIONAL radiologists have invented and reinvented their specialty, their practice, and their future since the specialty began in the 1960s. In the process, interventional radiology (IR) has dramatically revolutionized the practice of medicine, the standard of care, and the patient outcomes achieved for many disease processes. The Society of Interventional Radiology (SIR) Strategic Plan, launched in 2002, set a new vision for reinventing IR’s future (1). SIR’s leadership is swiftly and tenaciously moving to achieve this vision. One of the critical strategic goals in the plan is establishing IR as a clinically based specialty with direct patient referrals. Vital to this endeavor is the coordinated effort with diagnostic radiology to ensure that this is accomplished and that IR thrives as one of the three separate and distinct components within the house of radiology. The evolution to a clinically based specialty is already occurring, and there are many SIR members who have successfully established clinical officebased IR practices. A key milestone set by SIR is to have 80% of interventional radiologists meet SIR benchmarks for clinical practice by 2006. This article is the second in the Journal of Vascular and Interventional Radiology Strategic Initiatives in IR series. It will describe progress on SIR Strategic Plan goals since publication of the June 2002 “Strategic Initiatives in Interventional Radiology: A New Vision” (1) and will focus specifically on the goals related to clinical practice. This commentary includes why interventional radiologists should develop a clinical practice, the importance of diagnostic radiology’s proactive support, the rate of acceptance, and an update on new accomplishments and strategic milestones reached.

Special CommunicationsPresidential Address: Like a Bridge Over Troubled Waters: Presented at the 29th Annual Meeting of the Society of Interventional Radiology

In 1964, Dotter and Judkins introduced therapeutic percutaneous angioplasty of atherosclerotic peripheral plaques, a technique that used multiple coaxial catheters of various sizes to dilate the stenosis. In the mid-1970s, Andreas Gruentzig, at the University of Zurich, Switzerland, developed a double-lumen balloon catheter—used to dilate lesions in the iliac and femoral arteries safely and with a high rate of procedural success. The modern era of cardiovascular interventions had begun. Miniaturization of Gruentzig’s balloon catheters system led to the first percutaneous transluminal coronary angioplasty in 1977 in Zurich, performed by Gruentzig. Since the initial percutaneous interventions, there has been explosive growth in the field of interventional transcatheter therapeutics. This expansion has been fueled by the introduction of an array of new devices, adjuvant pharmacologic therapies, and novel imaging and physiologic measurement catheters designed to overcome some of the limitations of balloon angioplasty. Devices and techniques for lower extremity arterial disease (LEAD) are balloon angioplasty, rotational atherectomy, stents, rheolytic thrombectomy, and distal embolic protection devices. Table 1 lists their indications, potential advantages, limitations, and complications. See Fig. 1 for angiography examples.