Nationwide Trends in Catheter-Directed Therapy Utilization for the Treatment of Lower Extremity Deep Vein Thrombosis in Medicare Beneficiaries

PurposeTo determine overall and provider specialty trends in the use of catheter-directed therapy for lower extremity deep vein thrombosis (DVT) treatment in the Medicare population.Materials and MethodsUsing data obtained from 2007–2017 Centers for Medicare & Medicaid Services 5% research identifiable files, all claims associated with acute and chronic lower extremity DVT were identified. The annual volume of 2 services—venous percutaneous transluminal thrombectomy (current procedural terminology [CPT] code 37187) and venous infusion for thrombolysis (CPT code 37201 from 2007 to 2012 and CPT code 37212 from 2013 to 2017)—was examined for trends in DVT intervention. Utilization rates based on region and the place of service were calculated. The results were further categorized based on primary operator type (radiology, cardiology, surgery, and other).ResultsThe total number of DVT interventions increased over time, with 4.27 service counts per 100,000 beneficiaries in 2007 increasing to 13.4 by 2017, a growth rate of 12.09%. Radiologists performed the majority of interventions each year, except in 2013, in which they performed 46.6% of interventions, whereas surgeons and cardiologists combined performed the other 53.4%. In 2017, radiologists performed 7.56 services per 100,000 beneficiaries, which was 56.8% of the total count, more than those performed by surgeons, cardiologists, and unspecified providers combined.ConclusionsCatheter-directed therapy is increasingly being used for the treatment of DVT, with its use undergoing a nearly 12-fold increase from 2007 to 2017 in the Medicare population. Radiologists remained the dominant provider of these services throughout the majority of study period, with a relative reduction in market share from 72% in 2007 to 57% in 2017.     

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology

PurposeTo assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice.Materials and MethodsBilling and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures—(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement—were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals).ResultsDepartmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%.ConclusionsDepartmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.     

Utilization of and Outcomes Associated with Intravascular Ultrasound during Deep Venous Stent Placement among Medicare Beneficiaries

PurposeTo evaluate temporal trends, practice variation, and associated outcomes with the use of intravascular ultrasound (US) during deep venous stent placement among Medicare beneficiaries.Materials and MethodsAll lower extremity deep venous stent placement procedures performed between January 1, 2017, and December 31, 2019 among Medicare beneficiaries were included. Temporal trends in intravascular US use were stratified by procedural setting and physician specialty. The primary outcome was a composite of 12-month all-cause mortality, all-cause hospitalization, or repeat target vessel intervention. The secondary outcome was a composite of 12-month stent thrombosis, embolization, or restenosis.ResultsAmong the 20,984 deep venous interventions performed during the study period, 15,184 (72.4%) utilized intravascular US. Moderate growth in intravascular US use was observed during the study period in all clinical settings. There was a variation in the use of intravascular US among all operators (median, 77.3% of cases; interquartile range, 20.0%–99.2%). In weighted analyses, intravascular US use during deep venous stent placement was associated with a lower risk of both the primary (adjusted hazard ratio, 0.72; 95% confidence interval [CI], 0.69–0.76; P < .001) and secondary (adjusted hazard ratio, 0.32; 95% CI, 0.27–0.39; P < .001) composite end points.ConclusionsIntravascular US is frequently used during deep venous stent placement among Medicare beneficiaries, with further increase in use from 2017 to 2019. The utilization of intravascular US as part of a procedural strategy was associated with a lower cumulative incidence of adverse outcomes after the procedure, including venous stent thrombosis and embolization.     

Recent Trends in Clinical Setting and Provider Specialty for Endovascular Peripheral Artery Disease Interventions for the Medicare Population

PurposeTo describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment of disease, and clinical location of service.Materials and MethodsCurrent Procedural Terminology codes were used to identify claims for peripheral vascular interventions (PVIs) in 2011–2017 Physician Supplier Procedure Summary master files, which contain 100% Part B Medicare billing. Market share was defined as enrollment-adjusted proportion of billed PVI services for each specialty. Annual volume of billed services was additionally evaluated by clinical location (inpatient, outpatient, office-based laboratories) and anatomic segment of disease (iliac, femoral/popliteal, infrapopliteal).ResultsAggregate PVI claims increased 31.3%, from 227,091 in 2011 to 298,127 in 2017. Annual market share remained relatively stable for all specialties: surgery, 48.3%–49.6%; cardiology, 37.2%–35.1%; radiology, 12.8%–13.3%. Accounting for Medicare enrollment, the volume of iliac interventions decreased by 18% over the study period, while femoral/popliteal interventions increased modestly (+7.5%) and infrapopliteal interventions increased (+46%). The greatest proportional increase in infrapopliteal claims occurred among radiologists (surgeons +40.4%, cardiologists +32.1%, radiologists +106.6%). Adjusting for enrollment, claims from office-based laboratories increased substantially (+305.7%), while hospital-based billing decreased (inpatient −25.7%, outpatient −12.9%). Office-based laboratory utilization increased dramatically with all specialties (surgery +331.8%, cardiology +256.0%, radiology +475.7%).ConclusionsUtilization of PVIs continues to increase, while specialty market shares have stabilized since 2011, leaving surgeons and cardiologists as the major providers of endovascular peripheral artery disease care. The greatest relative increases are occurring in infrapopliteal interventions and office-based laboratory procedures, where radiologist involvement has increased dramatically.     

Changes in the National Endovascular Management of Femoropopliteal Arterial Disease: An Analysis of the 2011–2019 Medicare Data

PurposeTo describe national trends in the utilization of endovascular approaches (including balloon angioplasty, atherectomy, and stent placement) for the management of femoropopliteal peripheral arterial disease (PAD).Materials and MethodsThe Medicare Physician/Supplier Procedure Summary dataset containing 100% of Part B claims was interrogated for years 2011–2019. The Current Procedural Terminology codes specific for femoropopliteal angioplasty, stent placement, and atherectomy were used to create summary statistics for utilization by year, place of service (hospital inpatient, hospital outpatient, and office-based laboratory), and provider specialty (cardiology, radiology, and surgery).ResultsThe use of atherectomy increased from 34,732 (33%) procedures in 2011 to 75,435 (53%) procedures in 2019, and atherectomy became the dominant treatment strategy for femoropopliteal PAD. The relative utilization of stent placement (36,793 [35%] to 28,899 [20%]) and angioplasty only (34,398 [32%] to 38,228 [27%]) decreased concomitantly from 2011 to 2019. By 2019, the use of atherectomy was twofold higher in office-based laboratories than in the outpatient hospital setting (44,767 and 20,901, respectively). Treatment strategy varied by provider specialty in 2011 when cardiologists used atherectomy most frequently (17,925 [43%]), whereas radiologists used angioplasty alone (5,928 [6%]) and surgeons stented (18,009 [37%]) most frequently. By 2019, all specialties utilized atherectomy most frequently (29,564 [59%] for cardiology, 10,912 [58%] radiology, and 33,649 [47%] surgery).ConclusionsThe national approach to endovascular management of femoropopliteal PAD has changed since 2011 toward an implant-free strategy, including a multifold increase in the use of atherectomy. Discordant rates of atherectomy use between the ambulatory hospital and office-based settings highlight the need for comparative effectiveness studies to guide management.     

Reductions in Reimbursement and Relative Value Units for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared with Those for Other Physician Specialties

PurposeTo compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties.Materials and MethodsData from the Centers for Medicare and Medicaid Services Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single Current Procedural Terminology IR procedures were compared with similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021.ResultsThe work RVU component decreased in 18 of 23 (78.3%) IR procedures compared with 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared with a 16.5% reduction for similar procedures performed by non-IR specialties.ConclusionsAs a specialty, IR experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.     

Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020

PurposeTo investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020.Materials and MethodsReimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020.ResultsFrom 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by ?6.9% (95% confidence interval [CI], ?13.5% to ?0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of ?18.7% (95% CI, ?24.4% to ?12.9%) during the study period, with a mean yearly decline of ?2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R² = 0.97), indicating a steady decline in reimbursement over time.ConclusionsIn just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.     

Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding

PurposeTo assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for the treatment of acute lower gastrointestinal bleeding (LGIB).Materials and MethodsThe single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 men; mean age, 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as the absence of recurrent bleeding within 30 days of embolization.ResultsTechnical success for embolization of LGIB was achieved in 87% of the cases (134/154); clinical success rate was 76.1% (102/134) among the technically successful cases. Clinical success was 82.2% (60/73) for coils alone and 68.9% (42/61) for particles with or without coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 (5.3%) patients who underwent particle embolization with or without coils versus zero of 66 patients when coils alone were used (P = .09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the procedure were found in 3 of the 15 who underwent embolization with coils alone versus 8 of 18 who underwent embolization with particles with or without coils (P = .27).ConclusionsParticle embolization for the treatment of LGIB as second-line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.     

The Role of Physician-Driven Device Preference in the Cost Variation of Common Interventional Radiology Procedures

PurposeTo analyze the impact of physician-specific equipment preference on cost variation for procedures typically performed by interventional radiologists at a tertiary care academic hospital.Materials and MethodsFrom October 2017 to October 2019, data on all expendable items used by 9 interventional radiologists for 11 common interventional radiology procedure categories were compiled from the hospital analytics system. This search yielded a final dataset of 44,654 items used in 2,121 procedures of 11 different categories. The mean cost per case for each physician as well as the mean, standard deviation, and coefficient of variation (CV) of the mean cost per case across physicians were calculated. The proportion of spending by item type was compared across physicians for 2 high-variation, high-volume procedures. The relationship between the mean cost per case and case volume was examined using linear regression.ResultsThere was a high variability within each procedure, with the highest and the lowest CV for radioembolization administration (56.6%) and transjugular liver biopsy (4.9%), respectively. Variation in transarterial chemoembolization cost was mainly driven by microcatheters/microwires, while for nephrostomy, the main drivers were catheters/wires and access sets. Mean spending by physician was not significantly correlated with case volume (P =.584).ConclusionsPhysicians vary in their item selection even for standard procedures. While the financial impact of these differences vary across procedures, these findings suggest that standardization may offer an opportunity for cost savings.     

Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding

PurposeTo evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI).Materials and MethodsPatients at the authors’ institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test.ResultsNinety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week.ConclusionsDespite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.     

Liver Tumor Ablation Procedure Duration and Estimated Patient Radiation Dose: Comparing Positron Emission Tomography/CT and CT Guidance

PurposeTo compare procedure duration and patient radiation dose in positron emission tomography/computed tomography (PET/CT) and CT-guided liver tumor ablation procedures.Materials and MethodsIn this retrospective, case-control study, 275 patients underwent 368 image-guided ablation procedures to treat 537 tumors. Radiologists used PET/CT guidance for 117 procedures and CT guidance for 251 procedures. PET/CT-guided procedures were performed by one radiologist (C: P.B.S.). All 3 radiologists (A: J.G.S., B: a radiologist who is not an author on this article, and C: P.B.S.) performed CT-guided procedures. Potential confounders included patient demographics, clinical and tumor characteristics, and procedural variables.ResultsThe mean duration and estimated patient radiation dose of PET/CT-guided procedures performed by radiologist C were 21.5 ± 4.9 minutes longer and 0.7 ± 2.8 mSv higher than CT-guided procedures performed by all radiologists in an unadjusted comparison. Adjusting for confounding, mean duration and estimated dose of PET/CT-guided procedures performed by radiologist C were 28.3 ± 3.8 minutes longer (P < .0001) and 6.2 ± 2.9 mSv higher (P = .03) than CT-guided procedures performed by the same radiologist. Comparing CT-guided procedures performed by all 3 radiologists, adjusted mean durations and estimated patient doses of procedures by the least experienced radiologist, radiologist A, and the second most experienced radiologist, radiologist B, were 24.2 ± 5.1 (P < .0001) and 18.1 ± 8.9 (P = .04) minutes longer and 13.1 ± 3.7 (P < .001) and 14.5 ± 6.4 (P = .02) mSv higher, respectively, than procedures performed by the most experienced radiologist, radiologist C.ConclusionsPET/CT-guided liver ablations had a slightly longer duration with slightly higher estimated patient radiation dose than similar CT-guided liver ablations. Procedure duration and patient dose do not appear to be major impediments to the emerging field of PET/CT-guided tumor ablation.     

Cost Burden and Cost Influencers of Inferior Vena Cava Filter Placement and Retrieval among Medicare Beneficiaries with Acute Venous Thromboembolism

PurposeTo examine the frequency, costs, and cost influencers of inferior vena cava filters (IVCFs) placements and retrievals among a national sample of patients using Medicare data.Materials and MethodsThis retrospective cohort study used the U.S. Medicare 100% database, a nationally representative sample of all U.S. patients aged ≥65 years, from 2014 through 2020. Procedures and clinical characteristics were identified from the diagnosis and procedure codes on Medicare claims. Beneficiaries aged ≥65 years with newly diagnosed venous thromboembolism (VTE) were identified and followed to obtain data on IVCF placements and retrievals. Data on the costs of the index IVCF procedures and any subsequent IVCF placements and retrievals were obtained. Multivariate models were used to estimate the impact of patient and clinical characteristics on costs.ResultsAmong 501,216 patients with newly diagnosed VTE, 4,995 (1%) received an IVCF placement; of these, 1,215 (24.3%) had a retrieval procedure. Beneficiaries with IVCF placements and retrievals differed from a demographic and clinical perspective than from those without. Costs varied by the site of service, VTE acuity, and VTE type. Cost influencers included age, race, census region, service location, and VTE type.ConclusionsIVCF placement costs were driven by baseline patient characteristics (age, race, geographic residence, acute VTE diagnosis, and inpatient site of service), whereas retrieval costs were driven by age and deep vein thrombosis diagnosis. Strategies to mitigate the retrieval costs or the need to retrieve IVCFs may reduce the overall cost burden of IVCFs.     

Endovascular Therapy for Ischemic Stroke Can Be Successfully Performed by Peripheral Vascular Interventionalists

PurposeTo describe interventionalist and workflow characteristics of an acute stroke endovascular thrombectomy (EVT) center without a dedicated interventional neuroradiology service and report clinical and radiologic outcomes.Materials and MethodsRetrospective review was performed of all patients receiving EVT at Christchurch Hospital, New Zealand, from June 2014 to the end of December 2019 from a prospective reperfusion registry. During the study period, 5 peripheral vascular interventional radiologists, 2 of whom had experience in other neuroendovascular procedures, performed 210 EVT procedures. Median age of patients was 76 years (interquartile range: 64–83 y), and 107 (51%) were men.ResultsThe most commonly occluded vessel was the M1 middle cerebral artery (n = 114; 54%). Successful reperfusion (Modified Treatment In Cerebral Ischemia score 2b–3) was achieved in 180 (86%) procedures. Favorable 90-day outcome (modified Rankin Scale score 0–2) was achieved in 102 (54%) patients with no disability before stroke. Symptomatic intracranial hemorrhage occurred in 3 (1.4%) patients. Treatment rates in the local catchment area increased from 6 per 100,000 population in 2017 to 15 per 100,000 in 2019.ConclusionsThe results of this study suggest peripheral vascular interventional radiologists with specific training can successfully perform EVT resulting in a significant increase in EVT provision.     

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract

PurposeTo retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA).Materials and MethodsData of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT).ResultsIn 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1–5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11–117 weeks). There were no procedure-related complications.ConclusionsPercutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.     

Venous Sac and Feeding Artery Embolization versus Feeding Artery Embolization Alone for Treating Pulmonary Arteriovenous Malformations: Draining Vein Size Outcomes

PurposeTo investigate and compare venous sac and feeding artery embolization (VFE) with feeding artery embolization (FAE) alone for treatment of pulmonary arteriovenous malformations (PAVMs), based on difference in outcomes in decrease of the size of the draining vein.Materials and MethodsTwenty-six patients (7 male and 19 female; median age [interquartile range], 58 years [46–65 years]) with 42 simple PAVMs treated with coil embolization between August 2005 and December 2018 were retrospectively evaluated. Twenty PAVMs were treated with FAE early in the study period and compared with 22 PAVMs treated with VFE later in the study period. Follow-up computed tomography images obtained 8–20 months after embolotherapy were used for outcome analysis. Data related to patient demographics; follow-up period; baseline diameters of the feeding artery, venous sac, and draining vein; draining vein diameter after treatment; and decrease in the size of the draining vein, including the number reaching a threshold of 70% decrease, were compared between the 2 groups.ResultsThe draining vein decreased in size by a median of 46.4% in the FAE group and 66.3% in the VFE group, and the difference between the 2 groups was statistically significant (P = .009). There were no significant differences in the other parameters.ConclusionsVFE leads to a greater decrease in the size of the draining vein than FAE, suggesting that VFE results in more complete occlusion than FAE for treatment of PAVMs.     

Safety and Effectiveness of Ethylene Vinyl Alcohol Copolymer Embolization of Peripheral High-Flow Arteriovenous Malformations: Results of a Prospective Study

PurposeTo prospectively evaluate the efficacy and safety of a new ethylene vinyl alcohol (EVOH) copolymer–based embolic agent in the treatment of symptomatic peripheral arteriovenous malformations (AVMs).Materials and MethodsThis prospective single-center study evaluated EVOH embolization with 3 different formulations of EVOH (Squid Peri 12 cP, 18 cP, and 34 cP; BALT Germany GmbH, Düsseldorf, Germany) in patients with symptomatic AVMs. Between April 2018 and October 2019, 36 embolization procedures in 21 patients (3 males and 18 females; mean age, 34.7 years) were performed (inclusion criteria: symptomatic peripheral AVM, ≥14 years of age, and elective embolization). Symptoms, technical aspects (transarterial, transvenous, or percutaneous approach; plug or balloon occlusion), clinical and technical success (defined as the improvement of symptoms and complete angiographic eradication of the AVM nidus), adverse events, and short-term outcomes were assessed.ResultsThe mean volume of the embolic agent used per session was 3.4 mL of EVOH 34 cP (standard deviation [SD], ± 5.4), 6.2 mL ± 8.1 of EVOH 18 cP, and 4.6 mL ± 10.1 of EVOH 12 cP. Angiographic success was achieved in 18 patients (85.7%). The mean follow-up was 190 days (range, 90–538 days; median, 182 days). In the follow-up assessment, findings of magnetic resonance imaging showed that 19 patients (90.5%) had a persistent state of devascularization compared with postinterventional angiography. Amelioration or complete elimination of pain was achieved in 90.0% of the patients. One patient experienced a major adverse event; minor adverse events developed in 2 patients.ConclusionsIn this study, EVOH appeared to be a safe and effective embolic agent in peripheral AVMs and had a low rate of adverse events in a limited number of patients.     

Inline Balloon Occlusion–Assisted Delivery of Ethylene Vinyl Alcohol Copolymer for Peripheral Arterial Applications: A Multicenter Case Series

PurposeTo assess the feasibility, safety, and efficacy of balloon-assisted delivery of ethylene vinyl alcohol copolymer (EVOH) for a range of peripheral arterial applications.Materials and MethodsSix academic medical centers entered retrospective data on 46 consecutive patients (27 men, 19 women; ages, 11–94 y; mean age, 50.3 y) who underwent 60 balloon-assisted EVOH procedures. The cohort was restricted to procedures involving peripheral, nonneural arteries 1–5.5 mm in diameter. Clinical indications included a wide range of vascular pathologic conditions (most commonly arteriovenous malformations [n = 20], renal angiomyolipomas [n = 8], and acute hemorrhage [n = 9]) and targeted visceral and musculoskeletal peripheral arteries. Data collected included sex, age, clinical indication, arterial pathology, arteries embolized, type of occlusion balloon microcatheter, type and concentration of EVOH agent, effectiveness as an embolic backstop, vessels protected, adequacy of EVOH cast penetration, catheter extraction, nontarget embolization, and complications.ResultsBalloon occlusion prevented EVOH reflux in 59 of 60 procedures (98.3%). Nontarget EVOH embolization occurred in 2 procedures (3.3%). Adequate EVOH cast penetration and complete filling of the target pathologic structure were seen in 57 of 60 procedures (95%). Balloon deflation and uneventful extraction occurred in all procedures; small EVOH fragments detached into target arteries in 2 cases. One major (1.7%) and 2 minor (3.3%) complications occurred.ConclusionsBalloon-assisted EVOH embolization of peripheral arteries is feasible, safe, effective, and versatile. The primary advantage of balloon-assisted EVOH embolization is the ability to apply more injection pressure to advance the EVOH cast assertively into the pathologic structure(s).     

Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients

PurposeThe purpose of this study was to determine the efficacy and safety of embolization treatment in pelvic venous disorders in women refluxing in the ovarian and or internal iliac veins in women with chronic pelvic pain.Materials and MethodsA retrospective study conducted from January 2000 to June 2017 in 617 patients diagnosed with pelvic venous disorders (PeVDs) with a mean age of 43.2 ± 7.2 years were treated using an embolization procedure. A total of 520 were included, and 97 patients were excluded. The main inclusion criteria were PeVD symptoms for more than 6 months and transvaginal Doppler ultrasonography (TV-DUS) diagnosis of varicose veins in the pelvis with a diameter greater than 6 mm. The main objective was to embolize the 4 main pelvic venous plexi (ovarian and internal iliac veins) whenever possible. Follow-up was performed using clinical symptoms (visual analog scale) and TV-DUS at 1, 3, 6, and 12 months and then every year up to 5 years.ResultsThe technical success (embolization of the 4 main pelvic veins) was achieved in 84.4% of the patients. The average follow-up was 58.7 ± 5.7 months. The visual analog scale was improved from 7.63 ± 0.9 points pretreatment to 0.91 ± 1.5 at 5 years. A total of 26 patients (5%) presented with symptom recurrence and pelvic varicose veins. There were 57 minor complications (10.9%) and 11 major complications (2.1%), with 7 cases (1.34%) of device migration to the lung.ConclusionsThe embolization of pelvic varicose veins is a safe and effective procedure. The selection of the embolic agents and the number of veins needed to be treated.     

Safety and Efficacy of Peripheral Embolization with EASYX Liquid Embolic Agent: A Multicenter Prospective Study

PurposeTo evaluate the clinical safety and efficacy of EASYX, a new nonadhesive precipitating liquid embolic agent based on a polyvinyl alcohol ether polymer labeled with iodine molecules, for peripheral embolization.Materials and MethodsThis open-label prospective multicenter study was conducted on 50 consecutive patients treated with embolization using EASYX in 3 academic hospitals from April 2018 to July 2019. Indications for embolization were symptomatic varicocele (n = 15), type II endoleak (n = 8), acute hemorrhage (n = 16), portal vein embolization (PVE; n = 9), or angiomyolipoma (AML; n = 2). Patient characteristics, technical and clinical success rates, pain at injection, and satisfaction of the interventional radiologists were assessed. Follow-up imaging was performed using ultrasound for varicoceles (at 1 month) and computed tomography (CT) for the other indications (at 3 or 6 months).ResultsThe immediate technical success rate was 98%. The clinical success rates were 100% for acute hemorrhage and type II endoleaks, 89% for PVE, 86% for varicoceles, and 50% for AMLs. Patients who underwent PVE showed significant hypertrophy of the future liver remnant at follow-up (P < .001), and 55.6% of patients proceeded to hepatectomy. The absence of artifacts on imaging allowed improved monitoring of the aneurysmal sac in patients with type II endoleaks. The satisfaction rate of the interventional radiologists was >90% for 5 of 7 items.ConclusionsEASYX as a novel copolymer liquid embolic agent was safe and efficient for peripheral embolization. The absence of tantalum allowed reduced CT artifacts on imaging follow-up, which was especially useful in patients with type II endoleaks.     

Outcomes of Postprocedural Closeout Checklist Implementation to Prevent Adverse Events during Interventional Radiology Procedures: An Initiative to Improve Outcomes

PurposeTo assess whether adherence to a postprocedural closeout (PPC) checklist decreases adverse events during image-guided procedures.Materials and MethodsBased on the analysis of prior adverse events related to image-guided procedures, the Radiology Quality Committee developed a PPC checklist. The rates of serious reportable events related to image-guided procedures performed in the radiology department were recorded annually from 2015 to 2021. The rate of adverse events was normalized to the procedure volume in the corresponding periods. The number of patients requiring repeat procedures was recorded. The severity of impact was classified according to the Society of Interventional Radiology Adverse Event Classification System. The annual rates before (2015 and 2016) and after (2017–2021) the implementation of PPC were compared.ResultsSeventy-seven safety reports were identified in image-guided procedures over the study period, of which 43 cases were not related to the PPC, leaving 34 cases for the analysis. Radiology adverse events decreased from 0.069% (14/20,218, 7/y) before PPC implementation to 0.034% (20/58,793, 4/y) after implementation (P = .05, 43% decrease). Radiology repeat procedures decreased from 0.040% (8/20,218, 4/y) before PPC implementation to 0.007% (4/58,793, 0.8/y) after implementation (P = .0033, 80% decrease). Moreover, severity of adverse events decreased (P = .009).ConclusionsImplementation of a PPC checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the end of image-guided procedures by 43%, need for repeat procedures by 80%, and severity of impact of errors.