Timothy L. Swan

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 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 Following Hemodialysis Access Thrombolysis/Thrombectomy

PURPOSE The increased use of thrombectomy with deliberate pulmonary embolization of thrombus following initial thrombolysis for occluded hemodialysis fistulas prompted the authors to measure the prevalence of pulmonary embolism (PE) due to the procedure. PATIENTS AND METHODS Thirty-one patients with 43 acutely thrombosed polytetrafluoroethylene hemodialysis fistulas were treated with thrombolysis/thrombectomy. Perfusion lung scans were obtained in 22 patients. Patients were also continuously monitored for clinical signs or symptoms of PE. RESULTS Perfusion scans were interpreted as consistent with PE in 59% of those studied, but no clinical signs or symptoms were present in 41 of the 43 cases (95%). However, two patients developed both signs and symptoms of acute PE in the postprocedural period and died. One had underlying pulmonary disease and had undergone thrombectomy before. The other had chronic heart disease. CONCLUSION Thrombolysis/thrombectomy is usually safe and effective, even though many patients develop subclinical PE. The authors urge extreme caution in patients who have underlying pulmonary or cardiac disease and/or have undergone the procedure before.

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.

Multi-society consensus quality improvement guidelines for the treatment of lower-extremity superficial venous insufficiency with endovenous thermal ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association.

Neil M. Khilnani, MD, Clement J. Grassi, MD, Sanjoy Kundu, MD, FRCPC, Horacio R. D’Agostino, MD, Arshad Ahmed Khan, MD, J. Kevin McGraw, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert B. Osnis, MD, Darren Postoak, MD, Cindy Kaiser Saiter, NP, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Suresh Vedantham, MD, Bret N. Wiechmann, MD, Laura Crocetti, MD, John F. Cardella, MD, and Robert J. Min, MD, for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees

Multidisciplinary Practical Guidelines for Gastrointestinal Access for Enteral Nutrition and Decompression From the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, With Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE)

J INTRODUCTION Tube feeding has been practiced for more than 400 years (1). In addition to feeding, gastrointestinal (GI) access can be used for decompression in cases of enteral obstruction. Temporary access can be achieved with a nasogastric (NG), oral gastric (OG), nasojejunal (NJ), or oral jejunal (OJ) feeding tube. These tubes can be placed “blindly” at the bedside, with the use of image guidance (eg, fluoroscopy, ultrasound), or with the use of endoscopic guidance. Unfortunately, natural orifice tubes often fail because of clogging as a result of their relatively small diameter or inadvertent dislodgement (2). More permanent enteral access can be obtained

Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of the Joint Commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" to the Practice of Interventional Radiology

From the Department of Radiology (J.F.A.), Univ sity of Virginia Health System, Charlottesville, V ginia; Department of Radiology (A.A.N.), Nor western Memorial Hospital, Chicago, Illino Department of Vascular and Interventional Radi ogy (A.M.C.), University of Texas–Houston; Depa ment of Interventional Radiology (M.J.W.), The U versity of Texas M. D. Anderson Cancer Cen Houston, Texas; Department of Radiology (D.L.M Uniformed Services University, Bethesda, Mar land; Department of Radiology (C.J.G.), Bost Healthcare System/Veterans Affairs Medical Ce ter, Boston; Department of Radiology (J.F.C.), B state Health System, Springfield, Massachusetts; D partment of Radiology (H.A.D.), Louisiana Sta University Health Sciences Center, Shreveport, Lo isiana; Department of Interventional Radiolog (A.A.K.), Washington Hospital, Bethesda, Mar land; Department of Medical Imaging (S.K.), Scarborough General Hospital, Richmond Hill; Division represent a valid broad expert consti ency of the subject matter under cons eration for standards production. Technical documents specifying th exact consensus and literature revie methodologies as well as the insti tional affiliations and professional cr dentials of the authors of this do ment are available upon request fro SIR, 3975 Fair Ridge Dr., Suite 4 Fairfax, VA 22033.

Joint Practice Guideline for Sterile Technique during Vascular and Interventional Radiology Procedures: From the Society of Interventional Radiology, Association of periOperative Registered Nurses, and Association for Radiologic and Imaging Nursing, for the Society of Interventional Radiology (Wael Saad, MD, Chair), Standards of Practice Committee, and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

Joint Practice Guideline for Sterile Technique during Vascular and Interventional Radiology Procedures: From the Society of Interventional Radiology, Association of periOperative Registered Nurses, and Association for Radiologic and Imaging Nursing, for the Society of Interventional Radiology (Wael Saad, MD, Chair), Standards of Practice Committee, and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

Commentary on ‘Culture Shift’–Radiologists and Radiation Oncologists Adding Value to the Health Care System

o e t p h o p t a p w On behalf of the ACR Council Steering Committee, we are providing a commentary based on the “value-added” presentations and open-microphone session comments by ACR Council members at the 2012 AMCLC. The intent of this commentary is to complement the article “Culture Shift: An Imperative for Future Survival,” by Lawrence Muroff, MD, in this issue of JACR [1]. The article by Dr Muroff represents a summary of his very insightful, inspiring, and well-articulated presentation at the 2012 AMCLC. On the basis of the presentations and comments at the value-added session at the 2012 AMCLC, there is definite concern that too many radiologists and radiation oncologists are continuing an “old-world” practice rather than adapting to the challenges and changes of the “new world” of health care expectations, economics, and reform. Years ago, the common advice given to young radiologists or radiation oncologists entering practice was to be mindful of the “3 A’s” vital to a successful career: being available, able, and affable. If one could provide the 3 A’s, success in medicine would likely follow. However, times have changed, and these 3 A’s are no longer sufficient to ensure success. Indeed, the expectations for physicians have escalated. Availability is translating into 24/7 coverage with rapid report turnaround times. Ability is evolving into demands for subspecialized interpretation of all advanced imaging studies. The growth in medib