Interventional Radiology Service Research Articles

Resource requirements for interventional radiologic management of long-term ambulatory hemodialysis patients.

The purpose of this study was to determine how many and what type of procedures a vascular and interventional radiology service should provide for patients at ambulatory-patient dialysis centers and to determine the necessary resource requirements. These data may provide a realistic starting point for those engaged in the planning and provision of contractual services to dialysis centers. Patient records at three dialysis centers for a recent 3-year period were examined, and demographic and clinical data were recorded. Records were cross-correlated with records from the vascular and interventional radiology service that had contractually provided all dialysis-related procedures. These data generated a monthly procedure volume and case mix per 100 dialysis patients. Facility usage times for 121 dialysis-related procedures were obtained prospectively and used to calculate the expected resources needed to service the dialysis patients. The three centers provided 5795 hemodialysis-months to 386 patients. Of the 386 patients over the 36-month period, 101 died and 92 transferred from the centers. Three hundred and sixteen patients required 1580 interventional procedures. Monthly procedure volume per 100 dialysis patients averaged 27.1 procedures. Observed procedure times were used to calculate expected room-time hours required to service the monthly procedural volume and case mix per 100 dialysis patients. On average, 500 ambulatory dialysis patients will require the full-time use of an interventional suite and the services of a full-time technologist, nurse, and physician to provide necessary dialysis-related procedures. If resources cannot accommodate this volume, the quality and timeliness of care for these patients is jeopardized.

Air Embolism during Tunneled Central Catheter Placement Performed without General Anesthesia in Children: A Potentially Serious Complication

Central venous catheters have had an increasingly important role in a variety of patient care situations, including long-term antibiotic therapy, chemotherapy, and nutritional support. The recent past has seen a gradual transition from placement of vascular access catheters by surgeons to placement by interventional radiologists. The interventional radiology service places a majority of the vascular access devices at our children's hospital, including peripherally inserted central catheters, tunneled central venous catheters, temporary and permanent hemodialysis catheters, and subcutaneous ports. Most procedures performed by our interventional radiology service in children can be successfully completed with use of intravenous (i.v.) sedation, and a few require general anesthesia (GA). Key advantages of GA over i.v. sedation include the ability to have positive pressure ventilation (PPV) or controlled apnea during the procedure. We report our experience of venous air embolism in three small children during placement of tunneled central venous catheters when GA was not used.

Bedside placement of peripherally inserted central catheters: a cost-effectiveness analysis.

To compare two strategies for placement of peripherally inserted central catheters (PICCs). In strategy A, all PICC placements were initially attempted at the patient's bedside by trained intravenous (i.v.) nurses, with failures referred to the interventional radiology (IR) service. In strategy B, all PICCs were placed by interventional radiologists under fluoroscopic and/or venographic guidance. Decision analysis and cost-effectiveness models were constructed with commercially available software. Data used in the model were obtained from a review of the authors' experience with bedside placement of PICCs by an i.v. team and data obtained from the literature. The cost-effectiveness of strategy A relative to strategy B depends on (a) the ability of the i.v. team to access a vein at the patient's bedside, (b) the cost of fluoroscopy or the IR suite, and (c) the intended use of the PICC. If the cost of fluoroscopy or the IR suite exceeds $100, strategy A is more cost-effective for most intended PICC uses. If the cost is less than $75, strategy B is more cost-effective for all intended PICC uses. If the cost is between $75 and $100, the most cost-effective strategy depends on the intended use of the PICC and the need to have the tip placed at the junction of the superior vena cava and right atrium.

Case report - oesophageal anastomotic leak complicated by bilateral empyemas: Non-operative management by an interventional radiology service

SummaryComplicated oesophageal perforation is considered a life-threatening surgical emergency for which open thoracotomy and primary repair are indicated. However, several reports of successful conservative management consisting of non-operative drainage exist in the literature. The various imaging modalities and catheter techniques available through an interventional radiology service make interventional radiologists ideally suited for management of this complex problem. We present a case successfully managed by image-guided catheter placement and manipulations.

Comparison of Transjugular and Surgical Portosystemic Shunts on the Outcome of Liver Transplantation

To analyze the effect of previous transjugular intrahepatic portosystemic shunt (TIPS) vs surgical portosystemic shunt (SPS) on the outcome of orthotopic liver transplantation (OLT). A case series of 38 patients who underwent OLT: 25 with a previous TIPS and 13 with a previous SPS. A liver transplant center and interventional radiology service in a private, tertiary referral medical center. Eighteen men and seven women who had a TIPS before OLT were compared with nine men and four women who had an SPS before OLT. Operative transfusion requirements, operative time, length of hospital stay, postoperative liver chemistry studies, and graft and patient survival. Compared with patients who had an SPS, patients who had a TIPS had significantly less median transfusion requirements for packed red blood cells (5 vs 12 U), fresh-frozen plasma (0 vs 8 U), and thrombocytes (0 vs 1 U). The median operative time (9 vs 13 hours), length of intensive care unit stay (3 vs 5 days), and length of hospital stay (12 vs 24 days) were also significantly less in patients who had a TIPS. The 2-year actuarial patient survival rate was 92% in both groups. In patients undergoing OLT, TIPS is associated with reduced operative transfusion requirements, operative time, and length of intensive care unit and hospital stays compared with SPS. In the potential liver transplant candidate with refractory complications of portal hypertension, TIPS is preferred to SPS.

Interventional Radiologic Placement of Hohn Central Venous Catheters: Results and Complications in 100 Consecutive Patients

Hohn catheters are single- or double-lumen catheters used for intermediate-length central venous access. The authors report their technique, results, and long-term follow-up in a prospective study of their first 100 consecutive patients. Indications for Hohn subclavian catheter placement included chemotherapy in 53%, antibiotic therapy in 30%, and total parenteral nutrition in 8%. Patients' ages ranged from 21 to 82 years, and 80% of catheters were placed in inpatients. Hohn catheters were placed with fluoroscopic and/or ultrasound guidance. Patients were followed up for the duration of the study or until their catheters were removed. The technical success rate for catheter placement was 100%. No major procedural complications occurred. Duration of catheter placement varied between 5 and 276 days (mean, 70 days). The catheter infection rate was 8%, which corresponds to 1.1 infections per 1,000 catheter days. Catheter thrombosis occurred in nine cases (9%) and was successfully treated with urokinase in six of these nine. Subclavian vein thrombosis occurred in 3% of patients. Technical success, complication, and long-term patency rates for the Hohn catheter are comparable to or better than those in most surgical series involving tunneled external catheters. The Hohn catheter is an excellent alternative for intermediate-length central venous access. Hohn subclavian catheter placement has become a standard part of the authors' interventional radiology service and is easily adaptable to all interventional practices.

Grading for angioplasty

An increasing proportion of patients with lower limb arterial disease are being treated by transluminal angioplasty. There have been various estimates of the numbers of potentially treatable patients, but none have been accompanied by detailed selection criteria. Based on patients' arteriograms, we present a clear grading system of suitability for angioplasty aimed at allowing ready interpretation and comparison of data. We have used these grades to examine prospectively the suitability for angioplasty of 118 consecutive patients undergoing arteriography for the first time. Thirty-five per cent of patients with claudication, and 30% of those with rest pain or trophic lesions appeared suitable for angioplasty. Forty-five per cent of claudicants and 40% patients with rest pain or trophic lesions could have their symptoms relieved by appropriate angioplasty of aortoiliac disease alone in the presence of distal disease, or of isolated femoropopliteal lesions. These figures have important implications for the provision of interventional radiological services throughout the United Kingdom.

Abdominal abscess drainage under radiologic guidance: causes of failure.

The results of percutaneous drainage of abdominal abscesses in 136 patients are analyzed, revealing a failure rate of 23% (31 patients). The mortality rate was 1.4% (two patients); the rate of serious complications was 5% (seven patients). Failure rate was lowest in critically ill patients having palliative drainage only (12%), emphasizing the importance of immediate drainage to stabilize such patients. The low mortality rate is also attributed to prompt palliative drainage. Technical errors were most commonly responsible for failure of procedures (14%), especially failure to recognize and respond to loculation or subseptation, premature withdrawal of drains (12 patients), and inappropriate approach to the abscess (nine patients). Assignment of patients to a clinical interventional radiology service for the duration of this treatment may greatly facilitate management.

Inpatient management: a new role for interventional radiologists.

A new role for interventional radiologists, which allows them greater control over patient management, is discussed. The development of interventional radiology services that provide inpatient and outpatient care will establish interventional radiology as an important primary service and improve patient care.