Purpose: To describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment segment of disease,and clinical location of service. Materials and Methods: Current 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). Results: Aggregate 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%). Conclusions: Utilization 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.

Whereas medical treatment remains the “gold standard” for acute aortic syndrome (AAS), mortality remains high. Thoracic endovascular aortic repair (TEVAR) is increasingly used for AAS, a spectrum of disease that includes complicated type B aortic dissection, penetrating aortic ulcer, and intramural hematoma (IMH). We report our institutional outcomes after TEVAR for AAS. An Institutional Review Board-approved study of patients undergoing TEVAR for complicated AAS (ie, refractory to medical treatment, rapid aortic degeneration, malperfusion, and rupture) from 2007 through 2017 was performed. Clinical outcomes and imaging results were analyzed. Positive aortic remodeling (regression of false lumen and resolution of IMH) was assessed. Appropriate statistical analyses were performed on the data collected, and P value < .05 was considered significant. Forty patients (20 penetrating aortic ulcers, 19 complicated type B aortic dissections, 1 IMH) were identified who underwent TEVAR for AAS. The majority (22 [55%]) were female. Mean age of the patients was 62.4 years (range, 30-88 years). Mean follow-up was 13.2 months (range, 1-68 months). Most (31 [77.5%]) patients were treated in the acute phase (<14 days) of the disease. There were two (5%) immediate deaths after the procedure. The 30-day mortality was 10%. There were 14 (35%) postoperative complications, including spinal cord ischemia (2 [5%]), stroke (4 [10%]), congestive heart failure (1 [2.5%]), pneumonia (2 [5%]), and retrograde type A dissection (RTAD; 5 [12.5%]). Development of RTAD after TEVAR was significantly associated with presence of IMH in addition to the primary AAS (P = .001) and zone 3 TEVAR (P = .02). Cumulative 1-year and 5-year survival after TEVAR for AAS was 77.5% and 47%. Survival was significantly reduced by postoperative complications (P = .037) and negative aortic remodeling (P = .003). Nine patients (22.5%) required secondary interventions after TEVAR. Twenty-eight patients (70%) demonstrated positive aortic remodeling on follow-up imaging. Need for secondary interventions was significantly associated with negative aortic remodeling (P = .002). TEVAR is an acceptable option for the treatment of refractory AAS. Perioperative complications, however, are not insignificant, and overall patient survival is dependent on favorable aortic remodeling. Patients with an IMH component to their AAS and having zone 3 TEVAR appear to have higher incidence of RTAD.

The drug-coated balloon (DCB) is widely employed in treatment of peripheral arterial disease. Treatment outcomes of DCB in patients with critical limb ischemia (CLI) are still lacking. The objective of this study was to compare and to assess clinical outcomes of DCB treatment vs standard angioplasty and stenting (SAS) in patients with CLI. Patients with CLI who have undergone endovascular interventions for femoropopliteal artery occlusive disease between 2013 and 2017 were identified retrospectively from an institutional database. Relevant patient data and clinical outcomes were collected and compared between DCB and SAS. Primary outcomes assessed and compared included target limb salvage rates, patency, and frequency of secondary interventions (SIs). Univariate and multivariate analyses were used to determine predictors of major amputations and SI. During the study period, 122 patients with CLI were identified who underwent endovascular treatment of primary femoropopliteal disease (DCB, 58; SAS, 64). Mean lesion length treated was 14.7 cm (standard deviation, 8.9 cm) in the SAS group vs 13.7 cm (standard deviation, 7.8 cm) in the DCB group (P = .317). Overall 12-month target limb salvage rate was not statistically different between DCB (87%) and SAS (83%; P = .168). The 6-month and 12-month freedom from SI was 84% and 75%, respectively, with DCB vs 85% and 70%, respectively, for SAS (P = .651). Female sex (hazard ratio, 2.1; P = .02) and higher TransAtlantic Inter-Society Consensus classifications (hazard ratio, 1.8; P = .035) were significant risk factors for reintervention. One-year mortality in the cohort was 48%. DCB treatment demonstrates noninferiority compared with SAS in CLI patients, but definitive efficacy cannot be supported by these data. Female sex and higher TransAtlantic Inter-Society Consensus classification of lesions were associated with higher risk of reinterventions after DCB or SAS.

PURPOSE:Prior studies have reported infection rates of converting non-tunneled dialysis catheters (NTDCs) to tunneled dialysis catheters (TDCs) versus de novo placement of TDCs using povidone-iodine. Chlorhexidine, per the Center of Disease Control guidelines, has been exclusively used in our institution since 2005. Therefore, our study aims to determine whether there is a difference in infection rates between conversion and de novo placement when utilizing chlorhexidine.MATERIALS AND METHODS:A retrospective analysis from 1/1/2009 to 8/10/2012 was performed of patients who underwent placement of NTDCs, which were subsequently converted to TDCs and those who underwent de novo TDC placement. To assess the rate of infection, the following data points were collected: date of procedure(s), indication, outcomes, site of catheter insertion, pre- and post-procedure laboratory values, complications, infection rates within the life of the initially placed catheter, catheter days, and survival.RESULTS:The conversion cohort was composed of 205 patients, 135 of whom were lost to follow-up, leaving 70 patients. The de novo cohort included 70 randomly selected patients. Of the 70 patients who underwent conversion, 23 developed a catheter-related infection, with an infection rate of 0.26 events per 100 catheter days. Of the 70 de novo catheters, 20 developed infection with an infection rate of 0.25 events per 100 catheters days.CONCLUSION:In this series, there is no difference in infection rates between conversion and de novo TDC placement when utilizing chlorhexidine as the sterilization agent. However, these infection rates are superior to those reported when using povidone-iodine.

To evaluate and analyze aortic remodeling following endovascular repair of blunt traumatic aortic injury (BTAI) patients and correlate relevance to overall clinical outcomes. An IRB approved institutional review of thoracic endovascular aortic repair (TEVAR) for BTAI between 2006-2014 was performed from a prospectively maintained database. Pre-procedure and post-procedure computed tomographic angiograms (CTA) were analyzed for significant anatomic remodeling including mean aortic diameter change and unfavorable endograft configurations such as “bird-beaking,” in-folding, migration, and endoleak. These variables were correlated with endograft type and need for secondary interventions. 29 patients underwent TEVAR for BTAI between 2006 and 2014. Of the 29 patients, 17 had follow up imaging (ranging 30 days to 5.7 years). Six of the 17 patients (35%) had coverage of left subclavian artery. One patient required carotid to subclavian artery bypass. Despite mean endograft oversizing of 18%, aortic diameters in the proximal and distal seal zones showed minimal increase in size from baseline (1.7+/- 1 mm). One patient had significant increase in aortic diameter post procedure (> 5 mm) with development of a penetrating aortic ulcer above the endografted segment. Bird’s beak configuration was seen in 3 of 17 patients (17%); non-conformable type endografts (not Gore ® C-TAG or Medtronic ® Valiant Captivia) were involved in all cases. Two patients had persistent type I endoleaks, both with non-conformable grafts. One patient required conversion to open repair due to aneurysm expansion. There were no instances of graft infolding or graft migration. Mural thrombus in the endografted segment of the aorta was seen in 7 patients (41%) without clinical sequelae in the follow up period. Aortic remodeling is an expected occurrence following TEVAR for BTAI. Unfavorable clinical outcomes were associated with older generation non-conformable endografts. Further evaluation of post TEVAR aortic remodeling in BTAI is needed as potentially clinically relevant changes such as mural thrombus development is seen in a significant number of these patients regardless of graft type.

BACKGROUNDTransarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS.METHODSA retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed.RESULTSFrom 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5-67.5] with the majority being male (n = 12, 75%) and Childs-Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months).CONCLUSIONTACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.

Learning ObjectivesHistorically, although countless hours were spent on inpatient care and consultations with hundreds of written documents recording these services, only a small fraction of these notes were assigned an E&M billing code by the hospital billing staff. The purpose of this project is to educate interventional radiology providers on how E&M billing is performed and how it can be improved in order to capture appropriate billing for inpatient services.BackgroundIn July 2011, members of our interventional radiology department met with hospital billing and coding divisions to examine the relatively low monthly billing rate for our inpatient E&M services. After clarifying our clinical role as an admitting, consultative and patient management service, it became obvious that billing for inpatient IR E&M services was more than appropriate. Next, we created templates for our inpatient documentation to ensure that the proper verbiage was utilized and appropriate elements were included in order to capture and meet criteria and maximize the applicable billing codes.Clinical Findings/Procedure DetailsAfter meeting with the appropriate coding staff (abstractors) and discussing the clinical role of IR physicians and the necessary documentation to accompany patient management, inpatient documentation was audited and categorized into the appropriate billing tier for initial hospital care, hospital visit, consultation and discharge day management. Not only were more studies billed (increase of 502%), but overall billing increased per encounter by 18%. Lower level I billing levels declined from 35% to 27% and complex billing levels (II,III,IV, V) increased by 8%.Overall billing charges increased by 580%.Conclusion and/or Teaching PointsA large portion of clinical IR work goes largely unbilled as many hospital abstractors are unaware of the decision-making process and time spent by the specialty in the management of inpatients. By actively meeting with abstractors and discussing the clinical role of the specialty and using templates (with verbiage approved by abstractors) it is possible to improve billing capture from services that are routinely provided. Learning ObjectivesHistorically, although countless hours were spent on inpatient care and consultations with hundreds of written documents recording these services, only a small fraction of these notes were assigned an E&M billing code by the hospital billing staff. The purpose of this project is to educate interventional radiology providers on how E&M billing is performed and how it can be improved in order to capture appropriate billing for inpatient services. Historically, although countless hours were spent on inpatient care and consultations with hundreds of written documents recording these services, only a small fraction of these notes were assigned an E&M billing code by the hospital billing staff. The purpose of this project is to educate interventional radiology providers on how E&M billing is performed and how it can be improved in order to capture appropriate billing for inpatient services. BackgroundIn July 2011, members of our interventional radiology department met with hospital billing and coding divisions to examine the relatively low monthly billing rate for our inpatient E&M services. After clarifying our clinical role as an admitting, consultative and patient management service, it became obvious that billing for inpatient IR E&M services was more than appropriate. Next, we created templates for our inpatient documentation to ensure that the proper verbiage was utilized and appropriate elements were included in order to capture and meet criteria and maximize the applicable billing codes. In July 2011, members of our interventional radiology department met with hospital billing and coding divisions to examine the relatively low monthly billing rate for our inpatient E&M services. After clarifying our clinical role as an admitting, consultative and patient management service, it became obvious that billing for inpatient IR E&M services was more than appropriate. Next, we created templates for our inpatient documentation to ensure that the proper verbiage was utilized and appropriate elements were included in order to capture and meet criteria and maximize the applicable billing codes. Clinical Findings/Procedure DetailsAfter meeting with the appropriate coding staff (abstractors) and discussing the clinical role of IR physicians and the necessary documentation to accompany patient management, inpatient documentation was audited and categorized into the appropriate billing tier for initial hospital care, hospital visit, consultation and discharge day management. Not only were more studies billed (increase of 502%), but overall billing increased per encounter by 18%. Lower level I billing levels declined from 35% to 27% and complex billing levels (II,III,IV, V) increased by 8%.Overall billing charges increased by 580%. After meeting with the appropriate coding staff (abstractors) and discussing the clinical role of IR physicians and the necessary documentation to accompany patient management, inpatient documentation was audited and categorized into the appropriate billing tier for initial hospital care, hospital visit, consultation and discharge day management. Not only were more studies billed (increase of 502%), but overall billing increased per encounter by 18%. Lower level I billing levels declined from 35% to 27% and complex billing levels (II,III,IV, V) increased by 8%.Overall billing charges increased by 580%. Conclusion and/or Teaching PointsA large portion of clinical IR work goes largely unbilled as many hospital abstractors are unaware of the decision-making process and time spent by the specialty in the management of inpatients. By actively meeting with abstractors and discussing the clinical role of the specialty and using templates (with verbiage approved by abstractors) it is possible to improve billing capture from services that are routinely provided. A large portion of clinical IR work goes largely unbilled as many hospital abstractors are unaware of the decision-making process and time spent by the specialty in the management of inpatients. By actively meeting with abstractors and discussing the clinical role of the specialty and using templates (with verbiage approved by abstractors) it is possible to improve billing capture from services that are routinely provided.

1. Understand the potential impact of EMR data mining on the practice of interventional radiology. 2. Describe the process of data extraction in EpicCare EMR .3. Understand the current limitations of data mining with EMRs Data mining is the process of discovering patterns in sets of data. Its use in medicine has uncovered correlations not seen by physicians that affect large numbers of patients. For example, in 2011 the previously unnoticed increase of blood sugar by the combination of pravastatin and paroxetine was found by data mining, a result that was unexpected by researchers.Over 500,000 patients in the US take this drug combination. With the increasing importance of quality metric reporting, it is in Interventional Radiologists' interest to find these unnoticed correlations between their practice environment and outcomes. Most EMRs have the ability to extract data for quality metrics and research, which is useful for known quality metrics and for retrospective research. EpicCare provides several ways of accessing the data from the EMR in an automated way. The first is Reporting Workbench, which allows for static report generation. The second is Clarity reporting, which involves making SQL queries on a relational database built on top of EpicCare's underlying database. Discovering potential correlations with variables such as other disease states, medications, socioeconomic data, the operator who placed the stent, or the day of the week the stent was placed would require analysis outside of EpicCare using specialized software. Several data mining applications were evaluated and we present the pros and cons of each one. Of note, we found several previously unknown correlations with complication rates of procedures. Trials are under way to determine if there is a causal relationship as well. 1. Automated data extraction is an invaluable tool for quality improvement and research. 2. EpicCare has tools that can be used for basic data extraction by physicians for quality improvement and research. 3. Data mining has the potential to improve the practice of IR. 4. Data mining currently requires extracting the data from EpicCare to data mining applications.

Purpose The purpose of this study was to identify factors that may contribute to increased infection rates in implanted chest ports (CP). Specifically, the aim of our study was to determine whether accessing a CP within 7 days of insertion affects the risk of infection. Materials and Methods A query of our QI database was performed to determine a cohort of patients that had undergone CP placement between 5/13/2008 and 4/4/2012. During this time period, 1,352 chest ports were implanted. Patients were evaluated for infections occurring both within and after 30 days of implantation. Infections are defined as positive blood cultures, positive tip cultures, or pus/cellulitis at the site of CP insertion. To assess risk factors for infection, we collected the following data: age, indication for procedure, diagnosis, inpatient vs. outpatient status at the time of CP insertion, site of CP placement, device inserted (single vs. double lumen), date of initial access, type of initial infusion and laboratory data including, WBC, ANC, platelet count and INR. Results Of the 1,352 CPs implanted, 15 infections were seen within 30 days of insertion (infection rate 0.01%) and 43 infections were observed after 30 days. Statistical comparisons of categorical variables were made in patients with infections occurring within 30 days using Fisher's Test or the Exact Pearson Chi-Square test. Of the variables examined, differences in age, indication for procedure, diagnosis, WBC, ANC, platelet count, INR, site of access and date of initial access were not found to be statistically significant. Single vs. double lumen CP approached statistical significance (p Conclusion Accessing a CP within 7 days of insertion did not result in a higher rate of infection. However, when CP were implanted in the inpatient setting, the odds of infection increased 18 fold.

Many patients with severe intermittent claudication (IC) or critical limb ischemia (CLI) have chronic total occlusions (CTO) in their lower extremity vascular bed. The successful treatment of these lesions is becoming increasingly more important as the population ages and the prevalence of diseases such as diabetes mellitus and its consequences increases. Many of these patients have significant comorbidities and may benefit from less invasive treatment options. Several endovascular techniques have now become well established in the treatment of these lesions. Additionally, several new adjunctive tools have been developed to enhance the technical success of CTO revascularization. These tools and techniques offer a minimally invasive alternative for limb salvage in this compromised patient population and have become an established practice in many centers. Although some concerns about procedure durability and lower rates of primary patency exist, particularly when compared to surgical bypass, the limb salvage and amputation-free survival rates are much more encouraging. Advantages of these techniques compared to surgical bypass are reduced morbidity and mortality, reduced anesthesia requirements, and potential reductions in length of hospital stay and cost. In addition, bypass options are typically preserved after endovascular treatment. The more conventional and some newer endovascular treatment approaches, some of the adjunctive tools and techniques used in CTO revascularization as well as their clinical results will be discussed in this review.

TACE is well-established as a treatment modality for a variety of primary and metastatic liver tumors, but results in metastatic genitourinary (GU) malignancies have not previously been reported. The purpose of this study is to evaluate the safety and efficacy of transarterial chemoembolization (TACE) in patients with hepatic metastases from urothelial (TCC), renal cell (RCC), and prostate malignancies, following failed systemtic therapy. With IRB approval, a retrospective review was conducted of 14 patients who had TACE performed for liver dominant metastases of GU malignancies with disease progression during standard systemic therapy. Twelve of 14 patients had extra-hepatic disease at the time of treatment. Primary tumors included urothelial (n=8), prostate (n=4), and renal (n=2). Standard triple drug TACE was performed. Tumor response was evaluated by volume measurements on sequential CT scans. Survival time from first known hepatic metastases and from first TACE procedure were determined. Twenty-nine lobar TACE procedures were performed in 14 patients. Two TCC patients with ECOG scores of 2 died within 30 days, related to extrahepatic disease progression. There were no other major complications. Average tumor response was 28% decrease in volume in the 9 patients (64%) who had one month follow-up CT imaging. Prostatic hepatic metastases responded most favorably (45% volume reduction), followed by urothelial (-34%), then RCC (-9%). Mean survival from the first TACE averaged 11.1 months. Survival for TCC, prostate, and RCC were 2.5, 7.2, and 53.1 months, respectively. Five of the 14 patients are currently alive. TACE of hepatic metastases in patients with primary GU malignancies is generally well-tolerated with fairly high tumor response rates. In this series, patients with metastatic TCC had a very poor prognosis and may not benefit from the procedure due to progression of extra-hepatic disease. Long-term survival can be achieved in well-selected metastatic RCC patients.

PURPOSE:Transarterial chemoembolization (TACE) has become a standard treatment option for unresectable hepatocellular carcinoma (HCC) and is often used to palliate hepatic metastases. Many patients who are candidates for TACE present with poor hepatic reserve, advanced tumor stage with major portal vein (PV) invasion or thrombosis, and/or biliary dilation. These factors have been associated with a poor prognosis and increased complications after chemoembolization. Accordingly, these patients are classified as being at high risk and may not be considered for therapy. The aim of this study is to evaluate the results of TACE in these patients.MATERIALS AND METHODS:Over a period of 5 years, 141 patients underwent 355 TACE procedures. Thirty-six patients (26%) were in the high-risk group as a result of major PV thrombosis, increased serum bilirubin level (>2 mg/dL), and/or intrahepatic biliary dilation. HCC was the underlying tumor in 60% of patients. Thirty-seven percent of patients had Child-Pugh class B/C disease. Patients in the high-risk group received more selective embolization with fewer particles and fewer procedures (2.0 vs 2.7; P < .04).RESULTS:Patients in the high-risk group were more likely to have HCC (83% vs 51%; P < .01) and were also more likely to have advanced disease according to Child-Pugh classification versus patients in the low-risk group (49% vs 20%; P < .01). The overall complication rate was 4.3%, with no significant difference in complication rate between groups (3.2% vs 8.2%; P = .12). The overall 30-day mortality rate was 2.3%, and no significant difference in 30-day mortality rate was observed between the high- and low-risk groups (5.5% vs 1.4%; P = .11). A trend toward increased survival in the low-risk group did not reach statistical significance.CONCLUSIONS:These data suggest that patients with advanced disease and decreased hepatic reserve who are treated with TACE exhibit no significant increase in morbidity or mortality and no significant decrease in survival. With variations in technique, TACE can be performed safely in patients with the relative risk factors that may classify them in high-risk groups.

INTRODUCTION: Vascular invasion of tumor is well described in Lung cancer. We wish to report a case of lung cancer which was extending intravascularly into the pulmonary artery masquerading as a pulmonary thrombus. Pulmonary endoarterial biopsy was obtained via a percutaneous transvenous catheter which confirmed the diagnosis of recurrent lung adenocarcinoma. To the best of our knowledge, this is first reported case of lung cancer diagnosed with this novel approach.

Continuations have proven to be useful for implementing a variety of control structures, including exception handling facilities and breadth-first searching algorithms. However, traditional continuations are not useful in the presence of concurrency, because the notion of the rest of the computation represented by a continuation does not in general make sense. This paper presents a new type of continuation, called a process continuation , that may be used to control tree-structured concurrency. Just as a traditional continuation represents the rest of a computation from a given point in the computation, a process continuation represents the rest of a subcomputation , or process , from a given point in the subcomputation . Process continuations allow nonlocal exits to arbitrary points in the process tree and allow the capture of a subtree of a computation as a composable continuation for later use. Even in the absence of multiple processes, the precise control achievable with process continuations makes them more useful than traditional continuations.