Stephen P. Reis

Improving Inferior Vena Cava Filter Retrieval Rates with the Define, Measure, Analyze, Improve, Control Methodology

PURPOSE To design a sustainable process to improve optional inferior vena cava (IVC) filter retrieval rates based on the Define, Measure, Analyze, Improve, Control (DMAIC) methodology of the Six Sigma process improvement paradigm. MATERIALS AND METHODS DMAIC, an acronym for Define, Measure, Analyze, Improve, and Control, was employed to design and implement a quality improvement project to increase IVC filter retrieval rates at a tertiary academic hospital. Retrievable IVC filters were placed in 139 patients over a 2-year period. The baseline IVC filter retrieval rate (n = 51) was reviewed through a retrospective analysis, and two strategies were devised to improve the filter retrieval rate: (a) mailing of letters to clinicians and patients for patients who had filters placed within 8 months of implementation of the project (n = 43) and (b) a prospective automated scheduling of a clinic visit at 4 weeks after filter placement for all new patients (n = 45). The effectiveness of these strategies was assessed by measuring the filter retrieval rates and estimated increase in revenue to interventional radiology. RESULTS IVC filter retrieval rates increased from a baseline of 8% to 40% with the mailing of letters and to 52% with the automated scheduling of a clinic visit 4 weeks after IVC filter placement. The estimated revenue per 100 IVC filters placed increased from

Utility of Intravascular US-Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients.

2,249 to

Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease

10,518 with the mailing of letters and to

Interpretation of Outside Imaging Studies: Solutions From a Tertiary Care Trauma Center

17,022 with the automated scheduling of a clinic visit. CONCLUSIONS Using the DMAIC methodology, a simple and sustainable quality improvement intervention was devised that markedly improved IVC filter retrieval rates in eligible patients.

Tumor Enhancement and Heterogeneity Are Associated With Treatment Response to Drug-Eluting Bead Chemoembolization for Hepatocellular Carcinoma

PURPOSE To compare safety and effectiveness of intravascular ultrasound (US)-guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. MATERIALS AND METHODS In this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass-related capsular perforation were recorded. RESULTS Baseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US-guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass-related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US-guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US-guided TIPS (P = .004). CONCLUSIONS Intravascular US-guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass-related capsular perforations, and reduced radiation dose.

The Utility of Viscoelastic Testing in Patients Undergoing IR Procedures

Noninvasive physiologic vascular studies play an important role in the diagnosis and characterization in peripheral arterial disease (PAD) of the lower extremity. These studies evaluate the physiologic parameters of blood flow through segmental arterial pressures, Doppler waveforms, and pulse volume recordings. Collectively, they comprise a powerful toolset for defining the functionality of the arterial system, localizing the site of disease, and providing prognostic data. This technology has been widely adopted by diverse medical specialty practitioners, including radiologists, surgeons, cardiologists, and primary care providers. The use of these studies increased substantially between 2000 and 2010. Although they do not employ imaging, they remain a critical component for a comprehensive radiologic vascular laboratory. A strong presence of radiology in the diagnosis of PAD adds value in that radiologists have shifted to noninvasive alternatives to diagnostic catheter angiography (DCA), such as computed tomography (CT) and magnetic resonance (MR) angiography, which provide a more efficient, less-expensive, and lower-risk alternative. Other specialties have increased the use of DCA during the same period. The authors provide a review of the relevant anatomy and physiology of PAD as well as the associated clinical implications. In addition, guidelines for interpreting the ankle-brachial index, segmental pressures, Doppler waveforms, and pulse volume recordings are reviewed as well as potential limitations of these studies. Noninvasive physiologic vascular studies are provided here for review with associated correlating angiographic, CT, and/or MR findings covering the segmental distribution of PAD as well as select nonatherosclerotic diagnoses. ©RSNA, 2016.

ACR Appropriateness Criteria® Chylothorax Treatment Planning

p S a C ( b r r m s i c o d h c e u d T l i t m a INTRODUCTION There has been increasing public awareness of radiation safety since the Fukushima nuclear crisis and reports in the media suggesting that patients are being overly irradiated at hospitals across the country [1,2]. As radiologists, we must be increasingly aware of the appropriateness of the examinations we perform. Many radiology departments will only interpret studies performed at their institutions, resulting in a significant number of unnecessary repeat examinations. Providing interpretations of outside imaging studies, as opposed to repeating examinations, may be the more appropriate course of action. Referring physicians are also feeling increased pressure to request fewer repeat examinations. At our institution alone, there was a 1,400% annual increase in requests for interpretations of outside imaging studies from 2010 to 2011 (Table 1). There has also been a significant increase in pressure for these studies to be interpreted by attending radiologists during off hours (9 PM to 8 AM). We currently have 24/7 coverage by postgraduate year 3 or higher radiology residents, with attending radiologist backup from home between 9 PM and 8 AM. Our institution is a 640ed, tertiary care referral center in the udson Valley, with nearly 7,000 ransfer patients per year. Several authors have discussed the ncreased workload from interpreting utside imaging studies [3,4] and liaility implications, along with logisical problems with interpreting outide imaging studies [5]. At estchester Medical Center, we ave developed a streamlined process or uploading and interpreting out-

Direct Percutaneous Access to the Cervical Portion of the Thoracic Duct, an Alternative to Traditional Access through the Cisterna Chyli.

Purpose Treatment response to drug-eluting bead chemoembolization (DEB-TACE) is well established for patients with hepatocellular carcinoma (HCC); however, few studies have evaluated tumor imaging characteristics associated with treatment responses. The aim of our study was to identify imaging characteristics associated with treatment responses and overall survival after DEB-TACE of HCC. Methods This is a retrospective cohort study of 33 tumors in 32 patients who underwent DEB-TACE for inoperable HCC in a single, large academic medical center. Arterial phase computed tomography data were reviewed to assess tumor size, edge characteristics, tumor enhancement on pixel density histogram, and heterogeneity using coefficient of variation. We assessed correlation between these markers of tumor morphology and response to DEB-TACE using mRECIST criteria, progression-free survival, and overall survival. Results Tumor heterogeneity (P = 0.01) and tumor enhancement greater than 50% (P = 0.05) were significantly associated with complete response to DEB-TACE in patients with HCC; however, neither was associated with overall or progression-free survival. Tumor size and edge characteristics were not associated with complete response to DEB-TACE, although tumor size greater than 6 cm was associated with worse overall survival (hazard ratio, 3.349; P = 0.02). Conclusions Tumor heterogeneity and enhancement on arterial phase imaging may be predictive markers of treatment response to DEB-TACE among patients with HCC.

Acute pulmonary embolism: Endovascular therapy

Whole-blood viscoelastic testing can identify patient-specific coagulation disturbances, allowing for targeted repletion of necessary coagulation factors and differentiation between coagulopathy and surgical bleeding that requires intervention. Viscoelastic testing complements standard coagulation tests and has been shown to decrease transfusion requirements and improve survival in bleeding patients. Viscoelastic testing also can be used to predict bleeding and improve the care of patients undergoing interventional radiology (IR) procedures.

ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg

Chylothorax is an uncommon but serious medical condition, which arises when intestinal lymphatic fluid leaks into the pleural space. Treatment strategies depend on the daily output and underlying etiology, which may be due to direct injury to lymphatic vessels or a nontraumatic disorder. Chest radiographs confirm the presence of pleural fluid and lateralize the process. In the setting of direct injury, lymphangiography can often be both diagnostic and facilitate a minimally invasive attempt at therapy. CT and MRI in this setting may be appropriate for cases when lymphangiography is not diagnostic. When the etiology is nontraumatic or unknown, CT or MRI can narrow the differential diagnosis, and lymphangiography is useful if a minimally invasive approach to treatment is desired. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.