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Interventional radiology is at a crossroads. Two possible futures exist. In one direction, advances in technology are providing exciting opportunities for interventional radiology. Promising new treatments in tumor and cancer therapy, the treatment of fibroids, venous access, and spine interventions, as well as advances in noninvasive vascular imaging, pharmacologic therapies, and peripheral interventions are revitalizing our specialty, attracting significant patient interest and promising tremendous public benefit. In the other direction, interventional radiology is losing market share in vascular interventions to other specialties and suffering a crisis of confidence. One road leads to success, the other to failure. The only problem is that the roads aren’t clearly marked. Which road is which? The burden falls upon all of us, the leaders, staff, and members of the Society to choose the right path, to choose our future, and to make our continued success a reality. Fortunately, we have the tool to create a map; this tool is strategic planning, a business discipline that helps organizations determine and achieve desired futures. Strategic planning can provide direction and help focus organizational activities. Without it, entropy can set in and organizations can fail. Last year, SCVIR launched a strategic planning process to set directions for both the specialty and the Society. It was clearly time; the Society’s thencurrent plan was more than 5 years old—a millennium in today’s rapidly changing world. In addition, the Society and its members were facing increasing challenges from competing specialties, ever-tightening reimbursement, new technologies, evolving practice patterns, and changing consumer expectations. This paper is the first of a series in JVIR to convey a significant depth of information about the strategic plan; to provide an understanding of its foundations, our goals and objectives, and issues that will still need to be debated as the plan moves forward. This first article describes the strategic planning process, the vision, timeline and goals, and early successes of the new plan. Subsequent articles will include the following topics: • Results of strategic plan research: the environmental/economic assessment, leadership, staff and external interviews, and member polling; • Workforce projections and employment market for interventional radiologists; • Becoming “clinical,” and what this will mean for the interventional radiologist; • Practice and volume trends in interventional radiology; • “Branding” of interventional radiology, what our customers are telling us about who we are; • Future of interventional radiology and the implications for training and practice; the report of the SCVIR Specialty Development Task Force; and • A series on innovation and research.

Part I: Basic principles and techniques: Introduction Catheters and Guidewires Filming and Injection Techniques Patient Selection Cross-sectional Imaging Peripheral Vascular Disaease Vascular Recanalization General Principles of Embolization and Chemoembolization Organ Access Techniques Techniques for Fluid Aspiration, Abscess Drainage, Stents GI Interventions Radiation Protection MD Health and Safety in the Angio Suite. Part II: A systems approach to diagnosis and management: Section 1: Vascular Disease Above the Diaphragm: Vascular Anatomy Pulmonary and Bronchial Circulation Thoracic Aorta Thoracic Outlet and Upper Extremities Carotid, Vertebral, and Spinal Arteriography. Section 2: Vascular Diseases of the Abdomen, Pelvis, and Lower Extremities: Vascular Anatomy Arterial Diseases Venous Diseases. Section 3: The Kidneys and Genitourinary Tract: Anatomy Vascular Diseases of the Kidney Obstructive Uropathy and Renal Calculus Disease Pelvic and Obstetric Hemorrhage Vasculogenic Impotence Varicocele and Female Infertility. Section 4: The Gastrointestinal Tract, Liver, and Biliary System: Anatomy Interventional Management of GI Strictures Upper GI Bleeding Liver and Spleen Pancreas and Biliary Tree Vascular Diseases of the Lower GI Tract. Section 5: Endocrine System: Angiography and Sampling of the Pancreas, Parathyroid, and Adrenal Glands. Section 6: Vascular Access: Central Venous Access Dialysis Shunt and Management.

Society of Interventional Radiology Standards of Practice Committee: James B. Spies, MD, Chairman, Curtis W.Bakal, MD, Dana R. Burke, MD, John F. Cardella, MD, Alain Drooz, MD, Michael E. Edwards, MD, James W.Husted, MD, Aubrey M. Palestrant, MD, Michael J. Pentecost, MD, Anne C. Roberts, MD, William F. Rogers,MD, Millard C. Spencer, MD, Phillip J. Weyman, MD

The aim of this study was to evaluate our early experience with the Corvita endoluminal graft for the treatment of a variety of arterial injuries. Ten patients with arterial pseudoaneurysms (8) or arteriovenous fistulas (2) due to arterial injuries were followed prospectively after undergoing treatment with the endovascular graft. Our results showed that the Corvita low-profile endoluminal graft can be successfully used to treat arterial injuries but that it sometimes requires the placement of additional stents in patients with tortuous or tapering vessels. These grafts are extremely useful for the safe treatment of difficult and high-risk patients. Further improvements in available endovascular grafts and good long-term results will be necessary before considering these grafts the best treatment available for most patients with significant arterial injuries.

Purpose Significant disease or occlusion of the common femoral artery may preclude percutaneous therapy for aorto-iliac occlusive disease. In addition, aorto-iliac angioplasty may not reverse the ischemic symptoms when common femoral artery disease exists. The authors describe the feasibility of endoluminal stent-grafts to treat multilevel aortoiliofemoral occlusive disease. Materials and Methods The authors placed 18 stent-grafts for aorto-iliac occlusive disease in 17 patients with limb-threatening ischemia and significant common femoral artery disease. These procedures were performed as a joint effort between vascular surgery and interventional radiology staff in the operating room. The common femoral artery was occluded in 10 or severely diseased in eight, necessitating endoluminal bypass to the superficial femoral or popliteal artery ( n = 7) or to the deep femoral artery ( n = 7), or necessitating patch angioplasty of the common femoral artery ( n = 4). Stent-grafts were fabricated from 6-mm polytetrafluoroethylene and 29-mm Palmaz stents. Results All 18 grafts were placed successfully. Follow-up ranged from 3 to 38 months (mean, 21 months). Seven patients died of myocardial infarction; two grafts occluded and one required angioplasty during follow-up, resulting in a primary patency rate of 81% at 2 years. Conclusion Endoluminal stent-graft placement is a useful method of treatment for advanced atherosclerotic aorto-iliac disease, particularly in the presence of common femoral artery disease. This approach avoids an extra-anatomic bypass or a major transabdominal aortic bypass procedure. Longer follow-up with a larger series is needed to ensure the safety and late graft patency comparable to the traditional aortofemoral and iliofemoral bypass grafts.

Purpose: Although axillobifemoral bypass procedures have a lower mortality rate than aortobifemoral bypass procedures, they are limited by decreased patency, moderate hemodynamic improvement, and the need for general anesthesia. This report describes an alternative approach to bilateral aortoiliac occlusive disease using unilateral endovascular aortofemoral bypass procedures in combination with standard femorofemoral reconstructions. Methods: Seven patients who had bilateral critical ischemia and tissue necrosis in association with severe comorbid medical illnesses underwent implantation of unilateral aortofemoral endovascular grafts, which were inserted into predilated, recanalized iliac arteries. The proximal end of the endovascular graft was fixed to the distal aorta or common iliac artery with a Palmaz stent. The distal end of the graft was suture-anastomosed to the ipsilateral patent outflow vessel, and a femorofemoral bypass procedure was then performed. Results: All endovascular grafts were successfully inserted through five occluded and two diffusely stenotic iliac arteries under either local (1), epidural (5), or general anesthesia (1). The mean thigh pulse volume recording amplitudes increased from 9 ± 3 mm to 30 ± 7 mm and from 6 ± 2 mm to 26 ± 4 mm ipsilateral and contralateral to the aortofemoral graft insertion, respectively. In all cases the symptoms completely resolved. Procedural complications were limited to one local wound hematoma. No graft thromboses occurred during follow-up to 28 months (mean, 17 months). Conclusions: Endovascular iliac grafts in combination with standard femorofemoral bypass grafts may be an effective alternative to axillobifemoral bypass in high-risk patients who have diffuse aortoiliac occlusive disease, particularly when bilateral axillary-subclavian disease is present. (J Vasc Surg 1996;24;984-97.)

Occlusive disease of the aorta and iliac and femoral arteries may lead to limb-threatening ischemia when multiple levels of disease are present. The combined treatment of severe aortoiliac and infrainguinal disease using standard techniques may be hazardous or contraindicated in patients with multiple, previous reconstructions or severe co-morbid medical illnesses. This report summarizes the technical feasibility and early results of aortoiliac endovascular stented grafts (ESGs) in combination with conventional surgical reconstructions for the treatment of multilevel arterial occlusive disease. Forty-two patients with multilevel aortoiliofemoral limb-threatening occlusive disease had an ESG inserted to treat long-segment, multilevel, occlusive disease. ESGs originated from either the aorta or the common iliac artery and were inserted into one of the femoral arteries. ESG lengths ranged from 16 to 30 cm (mean 21 cm). Conventional surgical bypasses were constructed, when necessary, from polytetrafluoroethylene (PTFE) or saphenous vein and were extended using standard techniques to the popliteal, tibial, or contralateral femoral arteries. Technical success of graft insertion was achieved in 39 of 42 attempted ESG procedures (93%). The 18-month primary and secondary cumulative patency rates for ESGs were 89 +/- 9 (SE) and 100%, respectively. Limb salvage was achieved in 94% of patients at 24 months. Four patients had minor postprocedure complications (10%), and there was one death. Endovascular aortoiliac grafts, often in combination with conventional surgical infrainguinal bypasses, are a technically feasible, potentially safe option for the treatment of limb-threatening aortoiliofemoral occlusive disease and have demonstrated encouraging early patency. Long-term follow-up is necessary before widespread application of this technique is instituted.

We believe that a substantial experience demonstrating the effectiveness and safety of infrapopliteal artery PTA has been accumulated. It is clear that the results of tibial PTA and femoropopliteal PTA are closely associated for most patients undergoing limb salvage procedures. Anatomic selection is most important; patients with focal disease and restorable runoff will generally benefit, and interventional radiologists should concentrate on treating this group of patients. PTA and surgery for limb salvage patients are indeed complementary procedures, and patients will benefit most by a methodical team approach to treatment. Problems with reporting of data in the literature have obscured the true effectiveness of distal PTA, with such deficiencies leading to both overestimation and underestimation of clinical utility. Nevertheless, the preponderance of evidence (as we see it) suggests a clinical effectiveness of about 80% at 2 years in appropriately selected patients. Like Dr. Fraser and his co-authors, we would welcome randomized trials of tibial PTA versus surgery, but even in the absence of these, the reporting of indications and results needs to be standardized: severity of symptoms at presentation and the extent of conservative treatments employed before intervention; life-table methodology on an intent-to-treat basis with clear delineation of end points; stratification by important variables such as lesion length, runoff status, extent of preexisting tissue loss, presence of diabetes and ESRD, and ideally, functional outcome and quality-of-life measures. Finally, we should learn from our surgical colleagues that close surveillance and early reintervention will probably increase the effectiveness of our percutaneous treatment methods.