Suvranu Ganguli

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

i PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constituency of the subject matter under consideration for standards production. Technical documents specifying the exact consensus and literature review methodologies as well as the institutional affiliations and professional credentials of the authors of this document are available upon request from SIR, 3975 Fair Ridge Dr., Suite 400 N., Fairfax, VA 22033.

Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal.

Suresh Vedantham, MD, Patricia E. Thorpe, MD, John F. Cardella, MD, Chair, Clement J. Grassi, MD, Nilesh H. Patel, MD, Hector Ferral, MD, Lawrence V. Hofmann, MD, Bertrand M. Janne d’Othée, MD, Vittorio P. Antonaci, MD, Elias N. Brountzos, MD, Daniel B. Brown, MD, Louis G. Martin, MD, Alan H. Matsumoto, MD, Steven G. Meranze, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert J. Min, MD, Calvin D. Neithamer Jr., MD, Dheeraj K. Rajan, MD, Kenneth S. Rholl, MD, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Richard B. Towbin, MD, Bret N. Wiechmann, MD, and David Sacks, MD, for the CIRSE and SIR Standards of Practice Committees

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.

Venous compression syndromes: clinical features, imaging findings and management

Extrinsic venous compression is caused by compression of the veins in tight anatomic spaces by adjacent structures, and is seen in a number of locations. Venous compression syndromes, including Paget-Schroetter syndrome, Nutcracker syndrome, May-Thurner syndrome and popliteal venous compression will be discussed. These syndromes are usually seen in young, otherwise healthy individuals, and can lead to significant overall morbidity. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, CT, or MR conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method.

Fracture and migration of a suprarenal inferior vena cava filter in a pregnant patient.

Placement of retrievable inferior vena cava (IVC) filters as prophylaxis for pulmonary embolism (PE) is an increasingly attractive option for patients who require temporary IVC filtration. However, experience thus far with retrievable filters in pregnant patients is limited. This report describes a suprarenally placed Recovery IVC filter in a pregnant woman with PE despite therapeutic anticoagulation. After failed induction of labor and uneventful cesarean section, the patient returned for filter retrieval 167 days after initial placement. Fracture and inferior migration of the filter was observed, and subsequent attempts at filter retrieval were unsuccessful.

Optimal Strategies for Combining Transcatheter Arterial Chemoembolization and Radiofrequency Ablation in Rabbit VX2 Hepatic Tumors

PURPOSE To determine the optimum combination strategy of transcatheter arterial chemoembolization and radiofrequency (RF) ablation in an experimentally induced hepatic tumor model. MATERIALS AND METHODS Twenty-five New Zealand White rabbits with VX2 carcinoma-induced hepatic tumors were randomly divided into five treatment groups, which received (i) chemoembolization followed 15 minutes later by RF ablation; (ii) RF ablation followed by chemoembolization; (iii) chemoembolization alone; (iv) RF ablation alone; and (v) bland embolization followed by RF ablation. Animals were euthanized at 48 hours to determine tumor infarction and coagulation, which were compared with analysis of variance. Representative histopathologic slides were compared. RESULTS Significantly larger areas of coagulation were produced by chemoembolization followed by RF ablation (22.0 cm(3) +/- 7.7) compared with RF ablation followed by chemoembolization (13.1 cm(3) +/- 3.2) and RF ablation alone (10.0 cm(3) +/- 4.5; P < .05). RF ablation followed by chemoembolization showed larger treatment areas than chemoembolization alone (25.0 cm(3) +/- 9.6 vs 12.1 cm(3) +/- 4.6; P < .001), with chemotherapeutic agent preferentially depositing around the coagulation zone. Histopathologic analysis revealed greater vascular thrombosis and necrosis and reduced islands of viable tumor cells in the chemoembolization/RF ablation group versus the groups treated with chemoembolization alone or bland embolization/RF ablation. CONCLUSIONS Larger treatment volumes were produced when chemoembolization was performed before RF ablation than when RF ablation preceded chemoembolization or when RF ablation or chemoembolization were performed alone. Larger treatment volumes were also produced when chemoembolization rather than bland embolization was performed before RF ablation, indicating the importance and synergy of the chemotherapeutic regimen. These results suggest that the reduction of tumor blood flow combined with the effect of hyperthermia and local chemotherapy creates the largest dimensions of treatment.

Immediate renal tumor involution after radiofrequency thermal ablation.

PURPOSE To retrospectively evaluate solid renal tumor sizes before and after treatment with radiofrequency (RF) thermal ablation to assess for immediate changes on cross-sectional imaging. MATERIALS AND METHODS Medical records were retrospectively reviewed in consecutive patients who underwent percutaneous image-guided RF thermal ablation for solid renal tumors between December 12, 2000, and December 13, 2006. All patients underwent noncontrast computed tomography (CT) immediately before and after RF ablation. Maximum renal tumor diameters were measured before and after ablation. Statistical analysis of tumor sizes before and after ablation and change in tumor sizes was performed with the paired Student t test with confidence intervals calculated. RESULTS Seventy-two renal tumors were treated with RF ablation in 66 patients (42 men, 24 women; mean age, 68.4 years; range, 25-88 y). Mean tumor sizes were 27.5 mm (range, 9.8-64.8 mm; 95% CI, 24.9-30.1 mm) before ablation and 22.1 mm (range, 5.3-67.3 mm; 95% CI, 19.4-24.8 mm) immediately after ablation. An average decrease in renal tumor size of 21% (range, -10% to 50%) was identified, with a mean tumor diameter decrease of 5.4 mm (P < .05; 95% CI, 4.4-6.4 mm). No relationship between size or location of tumors and percentage decrease in size after RF ablation was identified. Measurement of tumors on 1-month follow-up CT showed no appreciable change compared with immediate postprocedural measurements. CONCLUSIONS Renal tumors decrease in size immediately after treatment with RF thermal ablation. Immediate tumor involution after RF ablation should be anticipated and follow-up imaging studies should ideally be compared to a baseline tumor size measured as soon as possible after ablation.

Quality improvement guidelines for vascular access and closure device use

PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constituency of the subject matter under consideration for standards production. Technical documents specifying the exact consensus and literature review methodologies as well as the institutional affiliations and professional credentials of the authors of this document are available upon request from SIR, 3975 Fair Ridge Dr., Suite 400 N., Fairfax, VA 22033.

Safety and Efficacy of 70–150 μm and 100–300 μm Drug-Eluting Bead Transarterial Chemoembolization for Hepatocellular Carcinoma

PURPOSE To compare the safety and efficacy of using 70-150 μm drug-eluting beads (DEBs) (LC BeadM1; Biocompatibles UK Ltd, Farnham, Surrey, United Kingdom) in addition to 100-300 μm DEBs with 100-300 μm DEBs alone in transarterial chemoembolization for treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS A cohort of patients with HCC who underwent transarterial chemoembolization with two vials of 100-300 μm DEBs (group 1, 55 procedures among 42 patients, 33 men, average Model for End-Stage Liver Disease score 10 ± 0.6, 67% Child-Pugh A, 33% Child-Pugh B) was retrospectively compared with a cohort of patients who underwent transarterial chemoembolization with one vial of 70-150 μm DEBs followed by one vial of 100-300 μm DEBs (group 2, 51 procedures among 42 patients, 29 men, average Model for End-Stage Liver Disease score 9 ± 0.6, 73% Child-Pugh A, 27% Child-Pugh B) in regard to adverse events and response on 1-month follow-up imaging using modified Response Evaluation Criteria In Solid Tumors criteria. RESULTS There was no difference in 1-month imaging response (P = .3). Patients in group 2 were readmitted more often within 1 month for hepatobiliary adverse events (group 2, 25%; group 1, 9%; P < .0001), including ascites, gastrointestinal hemorrhage, biliary dilatation, and cholecystitis. CONCLUSIONS Despite similar efficacy based on short-term follow-up imaging, transarterial chemoembolization with smaller DEBs (70-150 μm) followed by larger DEBs (100-300 μm) may cause more hepatobiliary adverse events.

Quality Improvement Guidelines for Percutaneous Management of Acute Lower-extremity Ischemia

ALI = acute limb ischemia, APSAC = antistreplase, MTD = mechanical thromboembolectomy device, PAT = percutaneous aspiration thromboembolectomy, pro-UK = prourokinase, RPA = reteplase, r-UK = recombinant urokinase, SK = streptokinase, STILE = Surgery versus Thrombolysis for Ischemia of the Lower Extremity [study], tPA = tissue plasminogen activator, TOPAS = Thrombolysis or Peripheral Arterial Surgery [study], TNK = tenecteplase, TPA = alteplase, UK = urokinase