Steven B. Oglevie

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

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 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

Pulmonary Embolism from PulseSpray Pharmacomechanical Thrombolysis of Clotted Hemodialysis Grafts: Urokinase versus Heparinized Saline

PURPOSE To compare the frequency and extent of pulmonary embolism (PE) occurring during pulse-spray pharmacomechanical thrombolysis (PSPMT) of clotted hemodialysis grafts with use of either urokinase (UK) or heparinized saline (HS). Postintervention primary patency and complication rates were compared for each method of thrombolysis. METHODS AND MATERIALS Twenty-seven patients were enrolled in this prospective, randomized, double-blind study evaluating PE with two PSPMT agents. The doses of heparin were similar between groups. The only variable was that one group of patients received UK and the other received HS. In two cases, the venous anastomosis could not be crossed. Eleven patients were treated with UK and 14 with HS. Nuclear medicine perfusion lung scans were performed before treatment and after graft declotting procedures. Lung perfusion was quantified to 10% of a pulmonary segment (0 = normal perfusion, 1 = segmental perfusion defect), with nine segments counted for each lung. RESULTS Baseline nuclear medicine perfusion lung scan results were abnormal (> or = 20% segmental perfusion defect) in 19 patients (70.4%). New PE (one or more pulmonary segments) occurred in two patients treated with UK (18.2%) and nine patients treated with HS (64.3%; P = .04). All cases of PE were asymptomatic. Quantitative global pulmonary perfusion analyses revealed that treatment with UK improved flow to 0.2 +/- 2.0 pulmonary segments, whereas treatment with HS decreased perfusion to 1.0 +/- 1.7 segments (P = .16, NS). Although postintervention primary patency rates were similar according to life-table analysis (P = .76, NS), complication rates were higher with use of HS (n = 4, 28.6%) than with use of UK (n = 2, 18.2%) (P = .6, NS). CONCLUSIONS All PE were asymptomatic during PSPMT, but treatment with UK reduced the rate of PE and tended to result in smaller defects in lung scan results. Most patients undergoing hemodialysis have abnormal baseline perfusion scan results, but PSPMT with UK improved many of them. The postintervention primary patency rates were similar between groups, but complications were more frequent after treatment with HS.

Spontaneous Dissection of the Superior Mesenteric Artery

Spontaneous dissection of the superior mesenteric artery (SMA) is a rare occurrence, especially when not associated with aortic dissection [1]. Currently, only 28 cases appear to have been reported. Due to the scarcity of cases in the literature, the natural history of isolated, spontaneous SMA dissection is unclear. CT has been reported to be useful for the initial diagnosis of SMA dissection [2–5]. We present two recent cases of spontaneous SMA dissection in which enhanced spiral CT was instrumental in following the disease process and guiding clinical decision making.

Quality Improvement Guidelines for Image-guided Percutaneous Biopsy in Adults

PERCUTANEOUS biopsy has become established as a safe, effective procedure. Successful percutaneous needle biopsy has been applied in most organ systems with excellent results and few complications (1–19). The key to these procedures has been the use of imaging guidance, which allows for the safe passage of a needle into an organ or mass, to obtain tissue for cytologic or histologic examinations. Imageguided percutaneous biopsy is less invasive than open exploration to obtain these same tissues. Because of the lower morbidity and mortality of the noninvasive procedures, they can be applied to patients who are too ill to undergo surgery or who wish to avoid convalescence from large diagnostic laparotomy procedures. In most settings percutaneous biopsy is the first approach to diagnosis. Follow-up, with postprocedure monitoring and management of the patient, is appropriate for the radiologist and will increase the effectiveness of the procedure. These guidelines are written for use in a quality improvement program that monitors percutaneous biopsy procedures (20). The most important processes of care in this area 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 rate.

IVC Filter Tilt and Asymmetry: Comparison of the Over-the-Wire Stainless-Steel and Titanium Greenfield IVC Filters☆

PURPOSE A comparison of tilting, caval coverage, asymmetry, and insertion problems with the over-the-wire stainless-steel and titanium versions of the Greenfield filter. MATERIALS AND METHODS The study compared 104 stainless-steel and 141 titanium Greenfield inferior vena cava (IVC) filter insertions. The angle the sheath and deployed filter made relative to the cava, as well as filter strut distribution, were determined from spot films. The proportionate caval coverage was computed from the cavogram (anteroposterior projection). Mean filter tilts, subgrouped by insertion site, and caval coverage were compared with the Student t test, whereas strut patterns were analyzed with a contingency table. RESULTS The filter caval and sheath caval angles correlated. The filter caval angles varied with insertion site, but were lowest with a right jugular approach. Caval coverage was identical with both designs. The stainless-steel version resulted in a more uniform distribution of struts in comparison with the titanium version. The incidence of insertion problems was not significantly different between the filter types. CONCLUSIONS While IVC filter tilting was not improved with the newer design, the pattern of struts was more uniformly symmetric with the stainless-steel device. The right jugular insertion site was associated with the lowest filter caval angles and the most symmetric pattern of struts.

Treatment of postoperative lymphoceles with percutaneous drainage and alcohol sclerotherapy.

PURPOSE To assess the efficacy and safety of percutaneous catheter drainage combined with alcohol sclerosis in the treatment of postoperative lymphoceles. PATIENTS AND METHODS Thirteen patients with 14 postoperative symptomatic lymphoceles were treated. Drainage catheters were inserted under ultrasound (n = 13) or computed tomographic (n = 1) guidance. Lymphocele sclerosis was performed by instilling 10-100 mL of absolute alcohol into the lymphocele cavity and aspirating the alcohol after 30 minutes. Sclerosis sessions were carried out one to three times per day, usually three times per week. Catheter sinograms were obtained and prophylactic antibiotics administered. Imaging was repeated if symptoms or signs of recurrence developed. RESULTS Successful drainage and sclerosis were achieved in all 13 patients. One patient with a recurrence was successfully treated with repeated drainage and alcohol ablation. No adverse effects of alcohol instillation were seen. The mean duration of catheterization was 36 days (range, 17-65 days; median, 30 days). CONCLUSION Percutaneous drainage combined with alcohol ablation is a safe and effective treatment of postoperative lymphoceles.

Adjunctive 3D US for Achieving Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Procedures

PURPOSE To evaluate the usefulness of information provided by three-dimensional ultrasound (3D US) and to determine whether 3D US decreased the number of passes required to obtain portal vein (PV) access during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Intermittent 3D US volume acquisitions were obtained during creation of TIPS in 20 patients. Useful information provided by 3D US was tabulated. The number of passes required to achieve PV access was recorded and results were compared retrospectively to 25 patients who underwent TIPS without 3D US. RESULTS 3D US documented that the operators opinion of which hepatic vein had been selected was incorrect in nine patients (45%), detected unfavorable PV anatomy that required modification of equipment or technique in seven patients (35%), permitted estimation of the trajectory required to access the targeted PV in all patients (100%), assisted in selecting the optimal point along the hepatic vein for origination of the needle pass in 11 patients (55%), allowed avoidance of a large hepatocellular carcinoma in one patient (5%), and confirmed that access into the main PV was intrahepatic in four patients (20%). The mean number of needle passes decreased from 10.4 in the historic control group to 4.6 in the 3D US group (P = .0001). CONCLUSION 3D US provided imaging information that detected technical errors and altered anatomy, and provided positional and directional information to significantly improve needle pass efficiency.