Steven G. Meranze

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.

Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement

BACKGROUND/AIMS Transjugular intrahepatic portosystemic shunt (TIPS) placement has been used for the treatment of recurrent variceal hemorrhage. The 1-year incidence of shunt stenosis or occlusion after TIPS placement was prospectively assessed, and the accuracy of Doppler ultrasonography to predict TIPS stenosis was evaluated. METHODS Twenty-two patients with recurrent variceal hemorrhage were selected for TIPS placement between April 1991 and May 1992. Preoperative and postoperative evaluation included clinical assessment, upper gastrointestinal endoscopy, portal angiography with pressure measurements, and Doppler ultrasonography. Follow-up was performed at 3 and 12 months post-TIPS and when patients developed recurrent bleeding. RESULTS Twenty-one of 22 patients (Child-Pugh class A-1, B-11, C-9) had successful TIPS placement. Seventeen of 21 patients have completed follow-up for at least 12 months. Of these 17 patients, 2 of 17 (12%) developed TIPS occlusion, 7 of 17 (41%) developed shunt stenosis, and 8 of 17 (47%) showed no stenosis on follow-up angiography. Doppler ultrasonographic assessment of the TIPS predicted shunt stenosis or occlusion with 100% sensitivity, 98% specificity, and 90% positive predictive value. CONCLUSIONS Shunt occlusion or stenosis develops frequently within 12 months after TIPS placement, and Doppler ultrasonography is accurate in the noninvasive assessment of shunt stenosis. TIPS placement without careful follow-up and shunt revision cannot be considered a long-term treatment of variceal hemorrhage.

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 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.

Transcatheter arterial chemoembolization as primary treatment for hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma (HCC) in Western populations has historically been associated with poor survival. METHODS In this study, we conducted a 7-year retrospective analysis of patients with HCC undergoing transcatheter arterial chemoembolization (TACE) at our institution and examined demographics, outcomes, and complications. RESULTS During the period of study, 39 patients (25 male [64%], mean age 58 [range 17 to 86]) underwent a total of 78 chemoembolization treatments. During the same time period, an additional 31 patients received supportive care only. The majority of patients had late stage disease (American Joint Committee on Cancer stage III, IVa, or IVb) with no statistical difference noted between the two groups (P = 0.2). However, patients receiving supportive care only had significantly worse hepatic dysfunction by Childs classification (P = 0.005). Twenty-nine patients (74%) had documented cirrhosis, with hepatitis C being the most common cause in 11 of 29 (38%). In patients undergoing TACE, overall actuarial survival was 35%, 20%, and 11% at 1, 2, and 3 years with a median survival of 9.2 months, significantly improved over the group receiving supportive care only (P < 0.0001). Median survival for the group receiving supportive care was less than 3 months. Neither age nor stage had a significant impact on survival. The most common complications of TACE included transient nausea, abdominal pain, vomiting, and fever. CONCLUSIONS TACE is a safe and effective therapeutic option for selected patients with HCC not amenable to surgical intervention.

Quality Improvement Guidelines for Adult Percutaneous Abscess and Fluid Drainage

Curtis W. Bakal, MD, MPH, Chairman, David Sacks, MD, Dana R. Burke, MD, John F. Cardella, MD, Paramjit S. Chopra, MD, Steven L. Dawson, MD, Alain T. Drooz, MD, Neil Freeman, MD, Steven G. Meranze, MD, A. Van Moore, Jr, MD, Aubrey M. Palestrant, MD, Anne C. Roberts, MD, James B. Spies, MD, Eric J. Stein, MD, Richard Towbin, MD, for the Society of Interventional Radiology Standards of Practice Committee

Quality Improvement Guidelines for Percutaneous Management of Acute Limb Ischemia

Dheeraj K. Rajan, MD, FRCPC, Nilesh H. Patel, MD, Karim Valji, MD, John F. Cardella, MD, Curtis Bakal, MD, Daniel Brown, MD, Elias Brountzos, MD, Timothy W.I. Clark, MD, Clement Grassi, MD, MSc, Steven Meranze, MD, Donald Miller, MD, Calvin Neithamer, MD, Kenneth Rholl, MD, Anne Roberts, MD, Marc Schwartzberg, MD, Timothy Swan, MD, Patricia Thorpe, MD, Richard Towbin, MD, and David Sacks, MD, for the CIRSE and SIR Standards of Practice Committees

Percutaneous Transluminal Angioplasty of the Abdominal Aorta

PURPOSE To determine the long-term results of percutaneous transluminal angioplasty (PTA) of focal infrarenal abdominal aortic stenoses. PATIENTS AND METHODS Over a 10-year period, 15 focal infrarenal abdominal aortic stenoses were treated with PTA in 14 patients (13 women and one man; mean age, 53.2 years; range, 43-78 years). RESULTS The initial technical success rate was 100%. Clinical patency, as defined by continued absence or improvement in symptoms after PTA, was achieved in 14 of the 15 angioplasty procedures (93%) with a mean duration of clinical follow-up of 4.3 years (range, 0.6-9.8 years) in the 14 patients. Long-term noninvasive follow-up demonstrated continued patency of the angioplasty site in 11 of 11 patients available for study. The mean ankle-arm index in these 11 patients was 0.95 (range, 0.9-1.0) at a mean follow-up of 4.8 years (range, 0.6-9.8 years). There was no significant morbidity or mortality associated with the angioplasty procedures. CONCLUSION In view of the high degree of technical success and the excellent long-term patency, we believe that PTA should be considered a primary method of treatment in properly selected patients with focal abdominal aortic stenoses.

Quality Improvement Guidelines for Image-guided Percutaneous Biopsy in Adults: Society of Cardiovascular & Interventional Radiology Standards of Practice Committee

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.