Michael S. Stecker

Guidelines for Patient Radiation Dose Management

Michael S. Stecker, MD, Stephen Balter, PhD, Richard B. Towbin, MD, Donald L. Miller, MD, Eliseo Vano, PhD,Gabriel Bartal, MD, J. Fritz Angle, MD, Christine P. Chao, MD, Alan M. Cohen, MD, Robert G. Dixon, MD,Kathleen Gross, MSN, RN-BC, CRN, George G. Hartnell, MD, Beth Schueler, PhD, John D. Statler, MD,Thierry de Baere, MD, and John F. Cardella, MD, for the SIR Safety and Health Committee and the CIRSEStandards of Practice Committee

Quality Improvement Guidelines for Recording Patient Radiation Dose in the Medical Record for Fluoroscopically Guided Procedures

ACR American College of Radiology, CRCPD Conference of Radiation Control Program Directors, FDA Food and Drug Administration, ICRU International Commission on Radiation Units and Measurements, IEC International Electrotechnical Commission, IRP interventional reference point, Ka,r total air kerma at the interventional reference point, NCRP National Council on Radiation Protection and Measurements, PKA kerma–area product, PSD peak skin dose, RDSR Radiation Dose Structured Report

Uterine Artery Embolization in the Treatment of Postpartum Uterine Hemorrhage

PURPOSE To evaluate the clinical effectiveness and safety of uterine artery embolization (UAE) in the treatment of primary postpartum hemorrhage (PPH), secondary PPH, and PPH associated with cesarean section. MATERIALS AND METHODS All women who underwent UAE for obstetric-related hemorrhage during a 52-month period culminating in April 2009 were included. Clinical success was defined as obviation of hysterectomy. Blood product requirements before and after UAE were calculated. Statistically significant associations between subject characteristics and clinical success were evaluated. The two subgroups of women with uterine artery pseudoaneurysms and women who underwent cesarean section were examined separately as well. RESULTS Sixty-six women (mean age, 33 years; range, 17-47 y) underwent UAE, with an overall clinical success rate of 95% (98% for primary PPH, 88% for secondary PPH, and 94% for PPH associated with cesarean section) and an overall complication rate of 4.5%. Mean pre- and postembolization transfusion requirements were 3.1 U and 0.4 U of packed red blood cells, respectively. The only significant characteristic identified for the cases that necessitated hysterectomy was an increased transfusion requirement after UAE (increase of 1.0 U ± 0.5; P = .02). Uterine artery pseudoaneurysms were associated with secondary PPH (P = .01) and cesarean section (P = .03). CONCLUSIONS The threshold for UAE in women with PPH should be low, as it is associated with a high clinical effectiveness rate and a low complication rate. Uterine artery pseudoaneurysms should be suspected in women presenting with secondary PPH after cesarean section.

The safety and effectiveness of the retrievable option inferior vena cava filter: A United States prospective multicenter clinical study

PURPOSE To evaluate the safety and effectiveness of the retrievable Option inferior vena cava (IVC) filter in patients at risk for pulmonary embolism (PE). MATERIALS AND METHODS This was a prospective, multicenter, single-arm clinical trial. Subjects (N = 100) underwent implantation of the IVC filter and were followed for 180 days; subjects whose filters were later removed were followed for 30 days thereafter. The primary objective was to determine whether the one-sided lower limit of the 95% CI for the observed clinical success rate was at least 80%. Clinical success was defined as technical success (deployment of the filter such that it was judged suitable for mechanical protection from PE) without subsequent PE, significant filter migration or embolization, symptomatic caval thrombosis, or other complications. RESULTS Technical success was achieved in 100% of subjects. There were eight cases of recurrent PE, two cases of filter migration (23 mm), and three cases of symptomatic caval occlusion/thrombosis (one in a subject who also experienced filter migration). No filter embolization or fracture occurred. Clinical success was achieved in 88% of subjects; the one-sided lower limit of the 95% CI was 81%. Retrieval was successful at a mean of 67.1 days after implantation (range, 1-175 d) for 36 of 39 subjects (92.3%). All deaths (n = 17) and deep vein thromboses (n = 18) were judged to have resulted from preexisting or intercurrent illnesses or interventions and unrelated to the filter device; all deaths were judged to be unrelated to PE. CONCLUSIONS Placement and retrieval of the Option IVC filter were performed safely and with high rates of clinical success.

Improved outcomes in postoperative and pancreatitis-related visceral pseudoaneurysms.

Pseudoaneurysm (PSA) of the visceral arterial tree is an uncommon but highly lethal complication of pancreatic surgery and pancreatitis. Surgical and angiographic interventions are used in treatment; however, optimal therapy remains unclear. We hypothesized that the natural history of PSA is different in these discrete clinical settings. From 1995–2005, 37 patients with PSA were treated: 13 after pancreatic surgery and 24 in the setting of pancreatitis. Postoperative patients most frequently presented with bleeding (92%), either from the gastrointestinal (GI) tract or a surgical drain. In this group, the diagnosis was most commonly made by angiography (77%), and 62% had a pancreatic fistula. In patients with pancreatitis, abdominal pain was the only presenting symptom in 62%, and GI bleeding was present in 29%. Eighty-seven percent had an associated pseudocyst or fluid collection. Interventional radiologic therapy successfully arrested hemorrhage in all 35 patients in whom it was employed. There were four false negative angiograms, and two patients required repeated interventions for rebleeding. The overall mortality was 14%. Pseudoaneurysms present differently in these two clinical settings, but transcatheter intervention is the first treatment of choice in clinically stable patients. Early recognition and prompt angiographic occlusion leads to improved outcomes.

Spontaneous Extraperitoneal Hemorrhage with Hemodynamic Collapse in Patients Undergoing Anticoagulation: Management with Selective Arterial Embolization

The authors report their experience with management of unstable spontaneous extraperitoneal hemorrhage (SEH) with selective transcatheter embolization. Five consecutive patients underwent angiographic evaluation for SEH complicated by hemodynamic collapse while undergoing anticoagulation therapy. Bleeding occurred via one or two lumbar arteries in psoas hematomas. Two abdominal wall hematomas were supplied by the inferior epigastric artery, with additional supply via the deep circumflex iliac artery in one. Microcoil embolization successfully controlled extravasation in all patients, with stabilization of hemodynamic parameters. Four of the five patients survived the immediate postprocedural interval. Selective transcatheter embolization may be a viable life-saving option in SEH-associated hemodynamic collapse.

Safety and effectiveness of the celect inferior vena cava filter: preliminary results.

PURPOSE To evaluate the safety and effectiveness of the Celect inferior vena cava (IVC) filter during implantation, retrieval, and short-term follow-up. MATERIALS AND METHODS The clinical data of 73 patients (46 men; age range, 22-89 years) who had a Celect IVC filter implanted between August 2007 and June 2008 were reviewed. Twenty-one (28.8%) presented with pulmonary embolism (PE), 15 (20.54%) with deep vein thrombosis (DVT), 12 (16.4%) with both, and the rest (34.26%) with other symptoms. Indications for filter placement were contraindication to anticoagulation (n = 38; 52%), prophylaxis/added protection (n = 22; 30%), failure of anticoagulation (n = 11; 15%), and complications of anticoagulation (n = 2; 3%). Filters were placed in the infrarenal (n = 71) or suprarenal (n = 2) IVC. Follow-up data were reviewed for filter-related complications and recurrent PE. RESULTS All filters were successfully deployed. Immediately after fluoroscopy-guided filter deployment in 61 patients, four filters (6.5%) showed significant tilt. During follow-up (mean, 68 days +/- 73), three patients developed symptoms of PE after filter placement; however, computed tomographic (CT) pulmonary angiography demonstrated new PE in only two. Imaging follow-up with radiography (n = 32), CT (n = 11), and/or angiography (n = 4) in 47 patients (at a mean of 62 days +/- 75) showed no filter migration. Follow-up abdominal CT (at a mean of 69 days +/- 58) was available in 18 patients and demonstrated filter-related problems in seven (39%). These included penetration of filter legs in four and fracture/migration of filter components in one. Fourteen filters were successfully retrieved after a median period of 84 days. CONCLUSIONS The Celect IVC filter can be safely placed but is related to a high incidence of caval filter leg penetration. Symptomatic PE after filter placement confirmed by CT occurred in 2.8% of patients.

Thoracic Duct Embolization and Disruption for Treatment of Chylous Effusions: Experience with 105 Patients

PURPOSE To review the indications, technical approach, and clinical outcomes of thoracic duct embolization (TDE) and thoracic duct disruption (TDD) in patients with symptomatic chylous effusions. MATERIALS AND METHODS A total of 105 patients who underwent 120 consecutive TDE/TDD procedures were retrospectively reviewed. Data including cause of effusion, procedural technique, and pre- and postprocedural effusion volume were analyzed. Technical and clinical success were evaluated for each procedure, with technical success defined as successful interruption of the thoracic duct by embolization or needle disruption and clinical success defined as resolution of effusion without surgical intervention. RESULTS The technical success rate was 79% (95 of 120); 53 TDEs were performed, resulting in a 72% clinical success rate (n = 38), whereas 42 TDDs showed a 55% clinical success rate (n = 23; P = .13). Procedures to treat postpneumonectomy chylous effusions had a success rate of 82% (14 of 17), compared with 47% (nine of 19) in postpleurectomy subjects (P < .05). Clinically successful cases had lower 24-, 48-, and 72-hour postprocedural effusion volumes versus clinically unsuccessful cases (P < .05), as well as greater rates of reduction in effusion volume at these time points (P < .05). Clinical success rate in subjects with traumatic effusions was higher than in subjects with nontraumatic effusions (62% [60 of 97] vs 13% [one of eight]; P < .05), and 6.7% of subjects (n = 7) experienced minor complications. CONCLUSIONS TDE and TDD are safe and effective minimally invasive treatments for traumatic thoracic duct injuries. In the present series, factors affecting procedural success included etiology of effusion, postprocedural effusion volume, and rate of postprocedural effusion volume reduction.

Physician assistants in interventional radiology practice.

Interventional radiology (IR) is a clinical subspecialty; as such, there is a large amount of direct patient care. However, until recently, this topic has not been a major focus in radiology training programs. Additionally, as interventional radiologists develop busier and busier practices, there is less time to spend with individual patients. Physician extenders such as physician assistants (PAs) represent an excellent way to improve clinical patient care. This article describes what PAs are and how they work together with physicians. It illustrates differences between PAs and other physician extenders and describes the duties that may be delegated to PAs in the IR setting.

Occupational radiation protection of pregnant or potentially pregnant workers in IR: A joint guideline of the society of interventional radiology and the cardiovascular and interventional radiological society of europe

Lawrence T. Dauer, PhD, Donald L. Miller, MD, Beth Schueler, PhD, James Silberzweig, MD, Stephen Balter, PhD, Gabriel Bartal, MD, Charles Chambers, MD, Jeremy D. Collins, MD, John Damilakis, PhD, Robert G. Dixon, MD, M. Victoria Marx, MD, Michael S. Stecker, MD, Eliseo Vano, PhD, Aradhana M. Venkatesan, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology Safety and Health Committee and the Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committee