Interventional Radiology Cases Research Articles

Migrating appendicolith: A retained appendicolith causing recurrent infection and migrating to the skin

A retained appendicolith is an uncommon complication that can arise from appendix rupture and can lead to recurrent abscess formation. We present a case of a retained appendicolith causing recurrent infection over a 12-month period in a paediatric patient. The appendicolith migrated to the left side of the abdomen and then through the abdominal wall into the subcutaneous tissues. The appendicolith was finally retrieved in a joint surgical and interventional radiology case using ultrasound guidance.

Retrospective evaluation of image-guided cholecystostomy tube utilization and outcomes during the first wave of the COVID-19 pandemic

Objectives: During the COVID-19 pandemic, there was a perceived increase in the number of cholecystostomy tube placements. We have retrospectively analyzed the incidence and outcomes of cholecystostomy tube placement during the COVID-19 pandemic surge. Material and Methods: Cholecystostomy tube placement and overall interventional radiology (IR) case volume were analyzed at our tertiary care center during the pandemic (March 15, 2020–July 30, 2020) and compared to the same time period in 2019. In addition, an age- and gender-matched control study of outcomes for 40 patients (25 from our home institution and 15 from our affiliated hospitals) grouped by COVID-19 status who received percutaneous cholecystostomy tubes between March 15, 2020, and July 30, 2020, was performed. Results: We observed a significant increase in relative cholecystostomy tube volume during the pandemic, despite a decrease in total IR case volume. There was no significant difference in pre- or post-procedural laboratory data, vital signs, imaging, or mortality between COVID-positive and COVID-negative patients who received cholecystostomy tubes. Conclusion: Percutaneous cholecystostomy tube placement is likely a safe treatment for acalculous cholecystitis in patients with COVID-19 with equivalent outcomes to patients without COVID-19.

Abstract No. 156 Incidence and outcomes of cholecystostomy tubes in COVID-19 patients

Purpose: Our goal was to review the incidence and outcomes of cholecystostomy tube placement during the COVID pandemic as compared to matched controls. Materials and Methods: Monthly interventional radiology (IR) case volume was evaluated during the COVID pandemic through July 30, 2020, and was compared to monthly IR case volume during the same time period in 2019. A retrospective review of 40 patients who received percutaneous cholecystostomy tubes between March 2020 and July 2020 (first COVID pandemic peak in Boston, MA) was compared in a propensity matched controlled study. 14 COVID-positive patients were matched to 26 control patients who received a cholecystostomy tube. Outcomes such as positive cholecystostomy tube microbiology, pre-procedural ICU status, and death were evaluated. Results: During March to July 30, 2020, cholecystostomy tube placement constituted 0.43%, average 6 (range 2-10) cases/month of 1389 (range 672-1777) cases/month, whereas in the year prior for the same period it constituted 0.28%, 5.8 (range 4-8) cases/month of 2103 (range 1998-2146) cases/month. We find the average age was 66.5 ± 17.7 (SD) for COVID-negative and 66.0 ± 17.7 (SD) years for COVID-positive patients. Pre-procedure 19% (5/26) of COVID-negative patients and 50% (7/14) of COVID-positive patients were intubated at the time of placement, P = 0.04. Post-procedure, 54% (14/26) of COVID-negative patients and 50% (7/14) of COVID-positive patients had positive cholecystostomy tube fluid microbiology cultures, P = 0.82. 38% (10/26) of COVID-negative patients and 57% (8/14) of COVID-positive patients were in the ICU at the time of placement, P = 0.26. 23% (6/26) of the COVID-negative patients and 36% (5/14) of COVID-positive patients died post-procedure, P = 0.41. 15.4% (4/26) COVID-negative and 14.3% (2/14) of COVID-positive patients had any complications reported, P = 0.93. Conclusions: During the COVID-19 pandemic, we observed a relative increase in the number of cholecystostomy tube referrals despite a drop in total IR case volume. There were no significant differences in post-procedure long-term outcomes and the microbial culture results in our matched control review. Our study suggests that this perceived increase in cholecystostomy tube placements is not secondary to unique COVID pathophysiology, but rather a persistent incidence of acalculous cholecystitis in the setting of chronic ICU stays seen during the COVID pandemic. With the continuation of the pandemic, cholecystostomy tube placement incidence may increase with continued COVID patient care and chronic ICU stays for these patients.

Abstract No. 158 Changes in interventional radiology case volumes during the COVID-19 pandemic

Abstract No. 158 Changes in interventional radiology case volumes during the COVID-19 pandemic

Abstract No. 234 Interventional radiology case mix changes due to the COVID-19 pandemic

The COVID-19 pandemic led to unprecedented radiology volume loss and substantial changes in case mix. This study seeks to identify the specific sources of procedural volume loss and recovery in a large academic system at the epicenter of the pandemic.

Abstract No. 565 Smartphone and web-based interventional radiology case logging system to facilitate recording of procedures performed by interventional radiology residents

The integrated and independent IR residency programs require the tracking and reporting of procedure volumes for both reporting to the Accreditation Council of Graduate Medical Education and the American Board of Radiology for both program and trainee certification. The Society of Interventional Radiology (SIR) and Association of Program Directors in Interventional Radiology (APDIR) have formalized the case tracking process to in the form of a templated electronic spreadsheet to aid in collecting this data. Despite the ability to capture all pertinent information, data entry can be time consuming, though much of the data necessary to populate a case log already exists in a structured format within the Picture Archive and Communications System (PACS). Previous efforts have been made to develop mobile and web applications within interventional radiology (IR) to facilitate peer-review data entry during morning rounds. This study aims to compare conventional case logging in the current approved APDIR spreadsheet with a novel responsive web application case logging system integrated to PACS. A responsive web application optimized for both desktop and touch screen use was created to facilitate logging of cases. The application connects to our institutional PACS via standard DICOM networking protocols to populate a list of recent cases and their associated metadata. Two IR residents accessed the case logging app and used it to log their 25 most recent cases, recording the number of screen taps and keystrokes. They then logged the same 25 cases on the SIR-APDIR approved IR resident spreadsheet, recording keystrokes and mouse clicks. There was a significant difference in the manual logging of cases in the SIR-APDIR spreadsheet versus keystroke logging of cases via the web-based smartphone app, with an average of 89.9 keystrokes (± 9.5) versus 21.3 keystrokes (± 6.4), respectively (P < 0.001). Similarly, there was a significant difference in mouse clicks and screen taps between the spreadsheet case logging and the smartphone app, with an average of 8.3 screen clicks (± 0.9) versus an average of 5.7 screen taps (± 0.7), respectively (P < 0.001). The smartphone-based case logging app required fewer screen clicks and keystrokes than the approved APDIR spreadsheet, resulting in less time spent logging cases. This novel web-based app may serve as a model for other programs to develop similar tools, integrating with PACS using industry standard protocols. A web-based smartphone app may provide a means to facilitate increased case logging adherence throughout the IR residency, providing a more accurate snapshot of procedural experience gained.

Diagnostic and Interventional Radiology Case Volume and Education in the Age of Pandemics: Impact Analysis and Potential Future Directions

Rationale and ObjectivesTo assess the immediate impact of the COVID-19 pandemic on Diagnostic and Interventional Radiology education, and to propose measures to preserve and augment trainee education during future crises.Materials and MethodsDiagnostic Radiology (DR) studies and Interventional Radiology (IR) procedures at a single tertiary-care teaching institution between 2015 and 2020 were reviewed. DR was divided by section: body, cardiothoracic, musculoskeletal (MSK), neuroradiology, nuclear medicine, pediatrics, and women's imaging. IR was divided by procedural types: arterial, venous, lymphatic, core, neuro, pediatrics, dialysis, cancer embolization or ablation, noncancer embolization, portal hypertension, and miscellaneous. Impact on didactic education was also assessed. ANOVA, t test, and multiple comparison correction were used for analysis.ResultsDR and IR caseloads decreased significantly in April 2020 compared to April of the prior 5 years (both p < 0.0001). Case volumes were reduced in body (49.2%, p < 0.01), MSK (54.2%, p < 0.05), neuro (39.3%, p < 0.05), and women's imaging (75.5%, p < 0.05) in DR, and in arterial (62.6%, p < 0.01), neuro IR (57.6%, p < 0.01) and core IR (42.6%, p < 0.05) in IR. IR trainee average caseload in April 2020 decreased 51.9% compared to April of the prior 5 years (p < 0.01). Utilization of online learning increased in April. Trainees saw significant increases in overall DR didactics (31.3%, p = 0.02) and no reduction in IR didactics, all online. Twelve major national and international DR and IR meetings were canceled or postponed between March and July.ConclusionDecreases in caseload and widespread cancellation of conferences have had significant impact on DR/IR training during COVID-19 restrictions. Remote learning technologies with annotated case recording, boards-style case reviews, procedural simulation and narrated live cases as well as online lectures and virtual journal clubs increased during this time. Whether remote learning can mitigate lost opportunities from in-person interactions remains uncertain. Optimizing these strategies will be important for potential future restricted learning paradigms and can also be extrapolated to augment trainee education during unrestricted times.

Are We Doing Enough to Reduce Ionizing Radiation Exposure in Children?: An Analysis of Current Approaches to Pediatric Appendicitis Imaging at a Major Urban Medical Center.

The aim of this study was to evaluate current imaging approaches in children with suspected appendicitis (AP) in the pediatric emergency department (ED) of a major urban medical center. Children aged 6 to 18 years who presented to a pediatric ED in 2016 with possible AP were identified by a keyword search. Charts were reviewed for the following: age, sex, time of evaluation, imaging study, results of imaging study, disposition, and outcome. We calculated mean values and SD for continuous data. Initially, 503 charts were identified. Of these 503, 292 children were identified as having possible AP. Mean age was 10.7 years (SD, 2.7); 50.6% presented between 5:00 PM and 8:00 AM the next morning. Of the 287 US studies performed, 114 (39.7%) were definitively positive or negative. Of these, 46 (16.0%) were negative for AP and 68 (23.7%) were positive. There were 173 (60.3%) ultrasounds that were equivocal. Computed tomography scans were performed in 41 (13.9%) of the total 292 patients, and 2 (0.7%) of the 292 received magnetic resonance imaging. Patient dispositions were as follows: discharged home, 163 (55.8%); admitted for appendectomy, 69 (23.6%); admitted for observation, 37 (12.7%); and extended observation in ED, 10 (3.4%). There were 83 (28.4%) total surgical and interventional radiology cases and 209 (71.6%) nonsurgical cases. Of the 81 appendectomies, 79 (97.5%) had an abnormal appendix, and 2 (2.5%) had no AP. Of the 79 abnormal appendices, 22 (27.8%) were perforated, 55 (69.6%) were not, and 2 (2.6%) were unclear. Computed tomography scans were performed in 13.9% of patients with suspected AP. The overall AP rate was 28.4%. We plan to increase the use of magnetic resonance imaging and other modalities to reduce overall computed tomography usage.

The Administration of Moderate Sedation and the Role of the Radiology Nurse

BackgroundModerate sedation administration is an assumed role of the nurse in interventional radiology. There remains limited documentation to define this practice and its relationship to the radiology nurse. The use of moderate sedation is common for patients receiving interventional radiology procedures, and therefore, defining the administrative parameters for this variable will allow for the future study of outcomes for this patient population. The primary aim of this article is to describe moderate sedation parameters in interventional radiology in hospitals offering adult interventional radiology services. Parameters included total case volumes, presence of provider type during interventional radiology cases using moderate sedation, existence of moderate sedation privileges, and the total percentage of moderate sedation administration by provider type. The results of this study are part of a larger nationwide survey that described administratively mediated variables in interventional radiology. MethodsA 26-question survey was developed and sent to a sample of radiologic administrators (n = 510) across the United States. The survey was developed using the Minnick and Roberts Outcomes Production Model, which identifies the relationship among essential health services concepts and their influence on patient outcomes. Recipients could answer via paper survey or by electronic link. Completion of the survey constituted consent. ResultsA total of 82 individuals responded to the survey (response rate = 16.8%). Respondents reported a median value of 2656.5 (n = 74, IQR: 1175.0, 5833.0) interventional radiology cases completed in the last year and a median value of 1500 patients receiving moderate sedation (n = 82, IQR: 600.0, 2725.0). Respondents reported that the registered nurse was responsible for a median of 90.0% of the sedation administered for adult patients (IQR: 80.0, 98.0). ConclusionsBased on the results of the survey, it is determined that moderate sedation is primarily administered by the registered nurse in interventional radiology. Future studies can include relational designs that focus on aspects of the registered nurse as a highly influential factor in moderate sedation patient outcomes.

1098. Perioperative Antibiotic Stewardship for Interventional Radiology Cases Improves Antibiotic Decision-Making

BackgroundAppropriate periprocedural antibiotic prophylaxis is critical to optimize in order to reduce excessive antibiotics exposure for patients and to minimize the risk for procedure-related infection. Wrong antibiotic or excess antibiotics increase the risk for development of antimicrobial resistance, Clostridium difficile infection, adverse side effects. Incorrect or missed antibiotic can put the patient at risk for an infection.MethodsInterventions included education of vascular and interventional radiology (IR) consult RN and physicians regarding updated institutional antimicrobial prophylaxis guidelines for vascular and IR procedures, creation of a consulting template that incorporated ongoing antibiotics. Review of recent cultures was incorporated into workflow and consult evaluation. Handoff between the IR RN and IR attendings was expanded to include a review of antimicrobials.ResultsAll IR cases were reviewed for antibiotic administration for 3 months pre- and post-intervention. In the pre-intervention timeframe, 23 of 290 procedures (7.9%) were associated with inappropriate antibiotic administration, further delineated as 6 cases where no antibiotics were given, 7 cases of inappropriate antibiotics administered, and 10 cases where extraneous antibiotics were administered. Of the 39 total procedures where antibiotics were indicated, 17 (43.6%) were associated with antibiotic errors. In the post-intervention period, only 9 of 309 total procedures (10.3%) were associated with inappropriate antibiotic administration: missed antibiotics in 3 cases, inappropriate antibiotics in 4 cases, and unnecessary antibiotics in 2 cases. Of the 32 cases where antibiotics were indicated, only 7 (21.9%) were associated with antibiotic errors.ConclusionIncorporating current antibiotics and review of culture data in a preoperative review and template for patients who need a surgical procedure helps guide appropriate antibiotic decision-making and greatly decreases administration of unnecessary antibiotics.Disclosures All authors: No reported disclosures.

Experimental Assessment of a Novel Touchless Interface for Intraprocedural Imaging Review.

To examine the feasibility of a novel technology platform that enables real-time touchless interaction with radiology images in both a simulated and an actual clinical setting. This platform offers three different modes for image interaction. The gesture recognition mode uses a depth camera to detect the user's hand gestures which are translated to image manipulation commands. The light projection mode uses the same camera to detect finger point-and-tap movements above the icons which are projected on a surface to activate the commands. The capacitive sensing mode is enabled by a handheld, portable device, over which finger movements are detected by capacitive sensors to control the image review. Following initial feedback, light projection and capacitive sensing modes were selected for further testing by comparing with the conventional mode of image interaction in time trials for performing a series of standardized image manipulation tasks. Finally, the usability of the technology platform was examined in actual clinical procedures. The light projection and the capacitive sensing modes were evaluated in the time trials and exhibited 60% and 71% reduction in time, respectively, relative to the control mode (p < 0.001). Clinical feasibility for this platform was demonstrated in three actual interventional radiology cases. Accessing, navigating, and extracting relevant information from patient images intraprocedurally are cumbersome and time-consuming tasks that affect safety, efficiency, and decision-making during image-guided procedures. This study demonstrated that the novel technology addressed this issue by allowing touchless interaction with these images in the sterile field.

3:00 PMAbstract No. 316 - ▪ FEATURED ABSTRACT Radiation exposure in radial versus femoral artery access in interventional radiology

Radial artery access has slowly been gaining popularity due to reduced complication rates and improved patient comfort compared to femoral artery access. However, studies have demonstrated a substantial increase (up to 100% [1]) in operator radiation exposure for radial access. We implemented a unique radial approach using a mobile lead wall placed between the operator and patient. Operator exposure with this shielded radial approach was compared to a standard femoral approach. Dose data for the principal operator and scrub technologist were measured using the RaySafe i2 staff dosimetry system for 25 interventional radiology cases: 11 radial and 14 femoral artery access. Standard radiation protection including lead aprons, table drapes, and a “floating” acrylic shield were used for all cases. For radial cases, a 1.5 mm lead equivalent mobile wall further protected the operator. For each case, staff doses (in μSv) were normalized by the total fluoroscopy reference point dose (in mGy) in order to account for differences in case complexity. Normalized staff doses were averaged for radial and femoral cases. A t-test was used for statistical significance. Radial and femoral approaches were also simulated by irradiating an anthropomorphic phantom. Dosimeters were placed at typical staff positions both with and without shielding. For each approach, shielding efficacy was determined via the ratio of shielded to unshielded doses. Operator exposure was reduced by 78% for radial access with a mobile lead wall compared to femoral access (0.009 μSv/mGy vs 0.041 μSv/mGy, p=0.03). However, there was no significant difference in radiation exposure for the scrub technologist (0.032 μSv/mGy vs 0.023 μSv/mGy, p=0.42). Phantom data revealed an average dose reduction of 99% for shielded radial cases with the addition of a mobile lead wall, versus 53% for femoral cases utilizing standard shielding. Radial artery access allows the placement of a mobile lead wall between the operator and patient, which can substantially reduce operator exposure compared to femoral access. Interventional radiologists should consider the benefits of radial access to both patients and staff when appropriate.

Common procedures and strategies for anaesthesia in interventional radiology.

This review describes the range of cases now available in the interventional radiology suite and summarizes suggestions for their anaesthetic and perioperative management. The type and complexity of interventional radiology cases being performed increases from year to year. Anaesthesiologists' presence in interventional radiology is increasing in turn, due to increasingly ill patients and intricate procedures requiring more than local anaesthesia for well tolerated completion. The literature available describing this is largely written by radiologists, with little attention paid to anaesthetic considerations. Cases in interventional radiology are complex in terms of the logistics of working in an unfamiliar area, frequency of patient comorbidity and unfamiliar procedures. Ensuring familiarity with the variety of interventional radiology procedures and their periprocedure requirements can increase anaesthesiologists' comfort in interventional radiology.

1:54 PM, Abstract No. 282 - Evaluation of the efficacy of an interactive interventional radiology case based electronic tablet application on the academic development of radiology residents

1:54 PM, Abstract No. 282 - Evaluation of the efficacy of an interactive interventional radiology case based electronic tablet application on the academic development of radiology residents

Educational ExhibitAbstract No. 378 - Academic development of radiology residents using interesting interventional radiology cases

Educational ExhibitAbstract No. 378 - Academic development of radiology residents using interesting interventional radiology cases

Retrospective Evaluation of Safety and Effectiveness of the EXOSEAL Vascular Closure Device for Single Vascular Closure and Closure after Repeat Puncture in Diagnostic and Interventional Radiology: Single-center Experience

PurposeTo retrospectively evaluate the safety and effectiveness of the EXOSEAL vascular closure device (VCD) for first or repeated closure after retrograde percutaneous femoral arterial access. Materials and MethodsA retrospective analysis of 417 patients (271 men; mean age, 64.1 y±12.8; age range, 22–94 y) who had undergone arterial closure with the EXOSEAL VCD was performed. Procedures with retrograde femoral access and closure with the 5-F, 6-F, or 7-F EXOSEAL VCD according to the manufacturer’s instructions were included. The clinical indications included the full procedural portfolio of a radiologic department with a focus on transarterial hepatic procedures. After EXOSEAL VCD closure, patients were restricted to bed rest for 4 hours. ResultsFrom August 2010 to March 2012, a total of 682 EXOSEAL VCDs (5-F, n = 276; 6-F, n = 394; 7-F, n = 12) were used in 659 procedures with a total of 404 repeated closures. The EXOSEAL VCD was used successfully in 676 of 682 procedures (99.1%). Hemostasis was achieved in 651 of 682 procedures (95.5%). No major complications were encountered. There were eight cases (1.17%) of minor complications despite a successful vascular closure procedure, none requiring further therapy. There were no complications in any of the 404 cases of repeated vascular closure. ConclusionsThe results of this study suggest that the EXOSEAL VCD is safe and effective in single and repeated closure of retrograde percutaneous femoral arterial access in interventional radiology cases.

Feasibility and safety of sequential research‐related tumor core biopsies in clinical trials

There has been increasing interest in serial research biopsies in studies of targeted therapies. Definition of patient characteristics and optimal target tissue for safe research tumor biopsy in the era of antiangiogenic and targeted agents is needed. This institutional review board-approved, retrospective study included chart and interventional radiology case review from 6 phase 1/2 studies at the National Cancer Institute. One hundred forty-two of 150 protocol patients who were approached gave consent for research biopsies. Patients' median age was 56 years (range, 27-78 years), their median body mass index was 25.8 kg/m(2) (range, 14.4-46.2 kg/m(2) ), they had an Eastern Cooperative Oncology Group performance status of 0 or 1, and they had normal end-organ function. Baseline biopsies were collected from 138 of 142 patients (97%), and paired specimens were collected from 96 (70%). Most patients had metastatic gynecologic cancers (85%), and 78% had target disease below the diaphragm with a median size of 2.7 cm (range, 1-14.5 cm). Protocol therapies included kinase inhibitors (35%), angiogenesis inhibitors (54%), and olaparib/carboplatin (11%); therapy was not interrupted for biopsies. All adverse events were uncomplicated and were observed in 4 patients (liver subcapsular hematoma in 1 patient, vasovagal syncope in 2 patients, and pneumothorax in 1 patient). The complication rate in obese patients was similar to that in nonobese patients (3 of 108 patients vs 1 of 34 patients, respectively). Sixty-seven patients (48%) were receiving bevacizumab at the time of subsequent biopsies. The complication rate was not different between patients who were and were not receiving bevacizumab (3 of 67 patients vs 1 of 71 patients, respectively). Ninety-five percent of biopsies yielded useable material. Serial percutaneous core-needle biopsies can be obtained safely and yield material applicable for multiple translational applications. Obesity and/or concomitant antiangiogenic therapy and depth of disease did not increase the risk or preclude the successful acquisition of useful tissue.

Lead aprons: how protected are you?

Lead aprons: how protected are you?

Organ and effective dose estimates for patients undergoing hepatic arterial embolization for treatment of liver malignancy

Effective dose (E) is useful as a dose index for patient exposures in interventional radiology; therefore, the authors estimated E from the kerma-area product (P(KA)) utilized during hepatic embolization interventional radiology cases performed at a cancer center and determined the variation of such doses over a representative patient population. A single-center, IRB-approved retrospective study was performed to estimate doses from consecutive hepatic embolization procedures performed during 2006. Organ doses E and E/P(KA) were determined from patient height, weight, P(KA), procedure geometry factors, beam quality, the PCXMC Monte Carlo model, and the International Commission on Radiological Protection organ weighting factors. One hundred thirteen patients were included in the study population, 72 males and 41 females, with a median age of 63 yr (29-89 yr), weight of 79 kg (42-111 kg), height of 170 cm (147-188 cm), and P(KA) of 233 Gy cm2 (9-1020 Gy cm2). E was directly correlated with P(KA) r2 = 0.8 (p < 0.01), with a median E/P(KA) of 0.18 mSv Gy(-1) cm(-2) (0.12-0.33 mSv Gy(-1) cm(-2)). The E/P(KA) ratio was inversely and exponentially correlated with weight r2 = 0.9 (p < 0.001). The median E (mSv) for the study patient population was 44 mSv (2.0-255 mSv). Values of E can be estimated utilizing patient-specific and procedure-specific parameters. The strong inverse correlation of E/P(KA) with patient weight allows simple estimation of E from P(KA) and patient weight. There is a wide variation in effective dose in oncologic hepatic embolizations with doses up to an order of magnitude higher than diagnostic imaging of the abdomen by CT radiology. Variation is likely due to patient geometry, clinical technique factors, and procedure complexity.

Comparing coding between interventional radiologists and hospital coding departments

Comparing coding between interventional radiologists and hospital coding departments J Cox1, N Koutroumanos11Department of Radiology, University Hospital North Durham, Durham, UKPurpose: The purpose of this audit was to assess whether there was a difference in the health care resource groups coding and subsequent reimbursement of interventional radiology cases, depending on whether the coding was carried out by a clinician or an administrator in the coding departmentMethodology: A retrospective analysis was undertaken of 137 consecutive patients who had therapeutic endovascular procedures in our Trust from 2005&ndash;2007. Six patients were excluded due to lack of data. The audit was carried out at a single center. A single clinician, under the supervision of a consultant interventional radiologist, proceeded to code the procedure after referring to the patient&rsquo;s radiology report and notes.Findings: The error rate by part of the coding department in terms of assessing nonelective versus elective procedures was 7%. This had lead to a &pound;2,352 excess charge on the part of the coding department. Additionally, there were errors in a further 19 procedures (15%), in which vascular stents had been inserted during the procedure but had not been coded for. The stent usage had not been recognised by the coding administrators in their evaluation, and this equipment-based undercoding resulted in underpayment by the patient&rsquo;s primary care trust of &pound;11,153.Originality/value: This is the first published audit of coding in interventional radiology in the UK. Coding in complex subspecialties like vascular interventional radiology requires more clinical input and engagement to ensure the case complexity is accurately reflected in the codes assigned and in the subsequent reimbursement.Keywords: coding, interventional radiology, payment by results (PBR)