Richard B. Towbin

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 Percutaneous Management of the Thrombosed or Dysfunctional Dialysis Access

John E. Aruny, MD, Curtis A. Lewis, MD, John F. Cardella, MD, Patricia E. Cole, PhD, MD, Andrew Davis, MD, Alain T. Drooz, MD, Clement J. Grassi, MD, Richard J. Gray, MD, James W. Husted, MD, Michael Todd Jones, MD, Timothy C. McCowan, MD, Steven G. Meranze, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD, Reed A. Omary, MD, Nilesh H. Patel, MD, Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Mark I. Silverstein, MD, Harjit Singh, MD, Timothy L. Swan, MD, Richard B. Towbin, MD, Scott O. Trerotola, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

Hemodynamic disturbances in premature infants born after chorioamnionitis: Association with cord blood cytokine concentrations

Chorioamnionitis and elevated cord blood inflammatory cytokine concentrations are associated with detectable disturbances of systemic and cerebral hemodynamics in premature newborns. Fifty-five infants (25–31 wk gestation) were enrolled. Chorioamnionitis was defined by placental histology. IL-6, IL-1β, and tumor necrosis factor-α were quantified by ELISA. Blood pressure, heart rate, cardiac output, stroke volume, fractional shortening, and middle cerebral artery blood flow velocities were measured at 3 ± 1 h after birth. Chorioamnionitis was evident in 22 placentas and was associated with increased IL-6 (p < 0.001), IL-1β (p = 0.035), and heart rate (p = 0.027); and with decreased mean and diastolic blood pressure (p = 0.026 and p = 0.019, respectively). IL-6 concentration correlated inversely with systolic, mean, and diastolic blood pressures. Right ventricular cardiac output was elevated (p = 0.028) in infants with fetal vessel inflammation. Maternal temperature ≥38.0°C and newborn immature-to-total white blood cell ratio ≥0.4 were associated with significant decreases in left ventricular fractional shortening (p = 0.001 and p = 0.005, respectively). Neither chorioamnionitis nor elevated cytokine concentrations were associated with changes in middle cerebral artery Doppler blood flow velocities. Chorioamnionitis and elevated cord blood IL-6 concentrations are associated with decreased blood pressure in premature newborns. Inflammation of the fetal vessels and nonspecific indicators of infection are associated with disturbances in cardiac function. Infants with chorioamnionitis and elevated cytokine concentrations do not manifest changes in cerebral Doppler indices within the first few postnatal hours. We speculate that cytokine-associated systemic hemodynamic disturbances in premature infants born after chorioamnionitis predispose such infants to perinatal brain injury.

Quality Improvement Guidelines for Percutaneous Permanent Inferior Vena Cava Filter Placement for the Prevention of Pulmonary Embolism

PULMONARY embolism (PE) continues to be a major cause of morbidity and mortality in the United States. Estimates of the incidence of nonfatal PE range from 400,000 to 630,000 cases per year, and 50,000 to 200,000 fatalities per year are directly attributable to PE (1–4). The current preferred treatment for deep venous thrombosis and PE is anticoagulation therapy. However, as many as 20% of these patients will have recurrent PE (1,5,6). Interruption of the inferior vena cava (IVC) for the prevention of PE was first performed in 1893 with use of surgical ligation (7). Over the years, surgical interruption took many forms (ligation, plication, clipping, or stapling) but IVC thrombosis was a frequent complication after these procedures. Endovascular approaches to IVC interruption became a reality in 1967 after the introduction of the Mobin-Uddin filter (8). Many devices have since been developed for endoluminal caval interruption but, currently, there are six devices commercially available in the United States. These devices are designed for permanent placement. For detailed information regarding each of these filters, the reader is referred to several published reviews (9–12). Selection of a device requires knowledge of the clinical settings in which filters are used, evaluation of the clot trapping efficiency of the device, occlusion rate of the IVC and access vein, risk of filter migration, filter embolization, structural integrity of the device, and ease of placement. Percutaneous caval interruption can be performed as an outpatient or inpatient procedure. However, practically speaking, most filter placements will occur in the inpatient population because of ongoing medical therapy for acute thromboembolic disease or underlying illness. The IVC should be assessed with imaging before placement of a filter, and the current preferred imaging method is vena cavography. Before filter selection and placement, the infrarenal IVC length and diameter should be measured, the location and number of renal veins determined, IVC anomalies (eg, duplication) defined, and intrinsic IVC disease such as preexisting thrombus or extrinsic compression excluded. The ideal placement for the prevention of lower extremity and pelvic venous thromboembolism is the infrarenal IVC. The apex or superior aspect of any filtration device should be at or immediately inferior to the level of the renal veins according to the manufacturers’ recommendations. In specific clinical circumstances, other target locations may be appropriate. Percutaneous caval interruption is commonly accomplished through right femoral and right internal jugular vein approaches; however, other peripheral and central venous access sites can be used. Filters can be placed in veins other than the vena cava to prevent thromboembolism. Implant sites have included iliac veins, subclavian veins, superior vena cava, and IVC (suprarenal and infrarenal). This document will provide quality improvement guidelines for filter placement within the inferior vena cava because of the limited data available for implantation sites other than the IVC. The patient’s clinical condition, the type of filter available, the alternative access sites available, and the expertise of the treating physician should always be considered when the decision to place an IVC filter has been made. These guidelines are written to be used in quality improvement programs to assess percutaneous interruption of the IVC to prevent pulmonary embolism. The most important processes of care are (a) patient selecThis article first appeared in J Vasc Interv Radiol 2001; 12:137–141.

Quality Improvement Guidelines for Percutaneous Transhepatic Cholangiography and Biliary Drainage

PERCUTANEOUS transhepatic cholangiography is a safe and effective technique for evaluating biliary abnormalities. It reliably demonstrates the level of abnormalities and sometimes can help diagnose their etiologies. Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary abnormalities demonstrated with cholangiography. Participation by the radiologist in patient follow-up is an integral part of percutaneous transhepatic biliary drainage and will increase the effectiveness of the procedure. Close follow-up, with monitoring and management of the patients’ drainage-related problems, is appropriate for the interventional radiologist. These guidelines are written to be used in quality improvement programs to assess percutaneous biliary procedures. The most important processes of care are (a) patient selection, (b) performing the procedure, and (c) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rates. Outcome measures are assigned threshold levels.

Quality improvement guidelines for central venous access.

Curtis A. Lewis, MD, Timothy E. Allen, MD, Dana R. Burke, MD, John F. Cardella, MD, Steven J. Citron, MD, Patricia E. Cole, MD, PhD, Alain T. Drooz, MD, Elizabeth A. Drucker, MD, JD, Ziv J. Haskal, MD, Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD, Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony Venbrux, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

Hepatic hemangioendothelioma: Clinical experience and management strategy

PURPOSE This study sought to define management strategies based on clinical experience in treating infantile hepatic hemangioendothelioma. METHODS A retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was performed. RESULTS Thirteen patients (median age, 14 days) with hemangioendothelioma were identified. Congestive heart failure (P<.03) and abdominal mass (P<.081) were predictive of 5-month mortality rates. Ultrasonography and computerized axial tomography were the diagnostic modalities most commonly used. Treatment strategies consisted of medical management (steroids and alpha-interferon) and interventional modalities (hepatic artery ligation or embolization, resectional surgery, or orthotopic liver transplantation). Patients who underwent resectional surgery, with or without orthotopic liver transplantation, had a lower 5-month mortality rate (P<.02) and a greater 2-year survival rate (P<.003) than did those who underwent hepatic artery ligation or embolization. Early morbidity and mortality tended to be a consequence of the primary lesion, whereas late morbidity and mortality were reflective of the treatment modality used. CONCLUSIONS In cases of failed medical management, resectional therapy should be used when possible. If partial hepatectomy is not technically achievable, hepatic artery embolization should be used either as definitive therapy or as a temporizing measure until orthotopic liver transplantation is possible.

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

Quality improvement guidelines for recording patient radiation dose in the medical record.

From the Department of Interventional Radiology (D.L.M.), National Naval Medical Center, Bethesda, Maryland; Department of Medicine (S.B.), Lenox Hill Hospital, New York; Department of Radiology (L.K.W.), University of Texas Houston Medical School, Houston, Texas; Department of Radiology (J.F.C.), SUNY–Upstate Medical University, Syracuse, New York; Section of Vascular and Interventional Radiology (T.W.I.C.), Department of Radiology, Hospital of the University of Pennsylvania; Department of Radiology (R.B.T.), Children’s Hospital of Philadelphia, Philadelphia; Department of Radiology (D.S.), Reading Hospital and Medical Center, Reading, Pennsylvania; Department of Radiology (C.D.N.), Inova Mount Vernon Hospital; Department of Radiology (K.S.R.), Inova Alexandria Hospital, Alexandria, Virginia; Radiology Associates of Central Florida (M.S.S.) Leesburg, Florida; and Department of Radiology (T.L.S.), Marshfield Clinic, Marshfield, Wisconsin. Received January 23, 2004; accepted January 23. Address correspondence to SIR, 10201 Lee Highway, Suite 500, Fairfax, VA 22030.

Cavoatrial Junction and Central Venous Anatomy: Implications for Central Venous Access Tip Position

PURPOSE To quantify the anatomic relationships of the cavoatrial junction and propose a system for describing central venous access device tip location on the basis of structures visible on chest radiographs. MATERIALS AND METHODS The authors performed a retrospective study of 100 consecutive computed tomographic (CT) studies from a predominantly pediatric population consisting of 52 male and 48 female patients aged 12-28 years (mean age, 16 years). With use of multiplanar and scout images, relevant mediastinal structures were marked, vertebral levels were noted, and measurements were made electronically. Catheter tip positions were recorded in the 26 children who had central catheters. RESULTS A vertebral body unit was defined as the distance between the inferior endplate of one vertebra to the inferior endplate of the next, with the upper intervertebral disk included. The most reliable estimate of cavoatrial junction position is a point two vertebral body units below the carina; there was no association with patient age or other parameters. CONCLUSIONS A more accurate understanding of the superior vena cava anatomy is essential for the correct interpretation of central venous access device position. The true cavoatrial junction is located more inferiorly than commonly believed and is not accurately estimated with commonly used imaging landmarks. A point two vertebral body units below the carina enables the reliable estimate of the position of the cavoatrial junction. Catheter tip position can be most reliably described in vertebral body units below the carina, with use of the thoracic spine as an internal ruler.