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Background The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted outpatient radiology practices, necessitating change in practice infrastructure and workflow. Objective The purpose of this study was to assess the consequences of social distancing regulations on 1) outpatient imaging volume and 2) no-show rates per imaging modality. Methods Volume and no-show rates of a large, multicenter metropolitan healthcare system outpatient practice were retrospectively stratified by modality including radiography, CT, MRI, ultrasonography, PET, DEXA, and mammography from January 2 to July 21, 2020. Trends were assessed relative to timepoints of significant state and local social distancing regulatory changes. Results The decline in imaging volume and rise in no-show rates was first noted on March 10, 2020 following the declaration of a state of emergency in New York State (NYS). Total outpatient imaging volume declined 85% from baseline over the following 5 days. Decreases varied by modality: 88% for radiography, 75% for CT, 73% for MR, 61% for PET, 80% for ultrasonography, 90% for DEXA, and 85% for mammography. Imaging volume and no-show rate recovery preceded the mask mandate of April 15, 2020, and further trended along with New York City's reopening phases. No-show rates recovered within 2 months of the height of the pandemic, however, outpatient imaging volume has yet to recover to baseline after 3 months. Conclusion The total outpatient imaging volume declined alongside an increase in the no-show rate following the declaration of a state of emergency in NYS. No-show rates recovered within 2 months of the height of the pandemic with imaging volume yet to recover after 3 months. Clinical impact Understanding the impact of social distancing regulations on outpatient imaging volume and no-show rates can potentially aid other outpatient radiology practices and healthcare systems in anticipating upcoming changes as the COVID-19 pandemic evolves.

Hand and upper extremity (HUE) vascular disorders are encountered frequently by hand surgeons in clinical practice. A wide array of imaging and vascular interventional radiology modalities exists for the diagnosis and treatment of HUE vascular disorders, some of which may not be familiar to the HUE surgeons. In this review article, we summarize the vascular imaging and vascular interventional radiology modalities and their relative advantages, disadvantages, and indications with respect to HUE pathology. We aim to familiarize HUE surgeons with the available types of diagnostic and therapeutic options for HUE vascular pathologies and aid interdisciplinary communication with vascular interventional radiology specialists during the clinical decision-making process.

Study design Retrospective review. Objective To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures. Summary of background data Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities. Methods Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study. Results Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients. Conclusion MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone. Level of evidence 3.

Rationale and Objectives Requests for gastrostomy tube placement in patients on aspirin (ASA) 325 mg are common, particularly in patients following reconstructive surgery for head and neck cancer, but periprocedural guidelines and recommendations regarding management of high dose aspirin are inconsistent. The purpose of this study was to assess the bleeding risk of percutaneous gastrostomy tube placement in patients on ASA 325 mg. Materials and Methods This retrospective study of 213 patients who underwent image-guided “push” percutaneous gastrostomy tube placement compared rates of significant bleeding and other secondary outcomes (including all-cause mortality within 30 days, procedure-related mortality, bowel perforation, abdominal abscess, peritonitis, aspiration pneumonia, intraprocedural airway complications, and tube dislodgement) between patients maintained on ASA 325 mg and patients not on antiplatelet or anticoagulation therapy. Results No significant bleeding episodes occurred in patients on ASA 325 mg, compared to three episodes in patients not on ASA 325 mg (p = 0.37). A patient in each group had aspiration pneumonia possibly related to tube placement. There were no other notable secondary outcomes, including intraprocedural airway complications in this population with complex head and neck anatomy. Conclusion These findings suggest that holding ASA 325 mg in patients undergoing percutaneous gastrostomy tube placement is not necessary, especially in patients in whom holding ASA would pose considerable risk. Further multi-institutional longitudinal study is warranted to validate these results.

Objective Lung shunt fraction studies using technetium-99 m macro aggregated albumin are routinely performed before yttrium-90 radioembolization regardless of underlying liver malignancy type. This study evaluates the role of lung shunt fraction studies in hepatocellular carcinoma compared to non-hepatocellular carcinoma liver tumors. Methods A single-institution retrospective analysis of all pre-yttrium-90 technetium-99 m macro aggregated albumin lung shunt fraction studies between November 2012 to March 2018 was performed. Patient variables including age, underlying malignancy, laboratory values, lung shunt fraction, and severity of liver disease were compared between hepatocellular carcinoma and non-hepatocellular carcinoma cases. Results A total of 734 technetium-99 m macro aggregated albumin studies were identified in 653 patients. Among these cases, the liver tumor was hepatocellular carcinoma in 368 (50.1%), colorectal cancer in 112 (15.3%), neuroendocrine tumor in 89 (12.1%), cholangiocarcinoma in 59 (8.0%), breast cancer in 27 (3.7%), and other metastatic malignancies in 79 (10.7%). The mean lung shunt fraction for non-hepatocellular carcinoma cases was 7.4%, which was significantly lower than the mean lung shunt fraction, 11.7%, for hepatocellular carcinoma cases (P = 0.0001). In only one non-hepatocellular carcinoma case was yttrium-90 radioembolization not pursued due to high lung shunt fraction (69.3%), wherein large scale shunting was grossly apparent on angiography in a patient with metastatic gastrointestinal stromal tumor. In comparison, the lung shunt fraction was too high to pursue radioembolization in 37 hepatocellular carcinoma cases (mean lung shunt fraction 35.1%). Conclusion Lung shunt fraction appears low among patients with non-hepatocellular carcinoma liver malignancies. Further analysis examining the necessity of pre-Y90 technetium-99 m macro aggregated albumin lung shunt fraction studies in patients with non-hepatocellular carcinoma malignancies is warranted, since a consolidated yttrium-90 radioembolization without prior lung shunt fraction evaluation could reduce resource consumption, improve workflows, and patient access.

Purpose Transradial access (TRA) for diagnostic and interventional neurointerventional procedures has recently gained traction over transfemoral access (TFA) in the neurointerventional community. This meta-analysis aims to assess and summarize the utility of TRA in cerebral angiography and neurointerventional procedures. Methods A systematic literature review was performed utilizing Pubmed, Embase, and Scopus databases. Using PRISMA guidelines, records were extracted with the following search terms: transradial approach, transradial access, radial access, cerebral angiogram, cerebral angiography, neurointervention, and neuroendovascular. The primary outcomes assessed were case success rate, complication rate, and crossover rate from TRA to TFA. Secondary analysis was performed on procedure time, fluoroscopy time, fluoroscopy time per vessel (diagnostic procedures only), contrast dose, radial artery diameter, distal radial artery diameter, and patient preference for TRA over TFA. Results Sixty-two full-text articles were analyzed for this meta-analysis, representing 12,927 diagnostic and interventional TRA access patients. Our analysis revealed a combined diagnostic and interventional case success rate of 95.9% and complication rate of 3.5%, with crossover to TFA occurring in 4.9% of cases. Conclusion This meta-analysis demonstrates that TRA access for diagnostic angiography and neurointerventional procedures is a safe and effective approach, though determining a true complication rate is challenging as the definition of TRA complications has changed in various publications over time.

The integrated interventional radiology (IR) residency accepted its first applicants in 2017. Achieving specialty status represents a significant milestone for IR; recognizing the expanding role of IR as part of an interdisciplinary team. However, this transition has had challenges that were well predicted by Heitkamp and Gunderman in 2014 and are reflected in the history of many specialties. New specialties often have complex relationships with their “parent” specialties, creating debates and tension regarding training, licensure, and scope of practice. Many of these factors have been discussed in opinion pieces by leaders in the field, reflecting upon the transition. There have also been surveys of matched IR/DR residents. However, there are few firsthand accounts of the challenges faced by trainees during such a transition, challenges that often are not well captured by an online survey.

Rationale and Objectives This study seeks to quantify the financial impact of COVID-19 on radiology departments, and to describe the structure of both volume and revenue recovery. Materials and Methods Radiology studies from a large academic health system were retrospectively studied from the first 33 weeks of 2020. Volume and work relative value unit (wRVU) data were aggregated on a weekly basis for three periods: Presurge (weeks 1–9), surge (10–19), and recovery (20–33), and analyzed compared to the pre-COVID baseline stratified by modality, specialty, patient service location, and facility type. Mean and median wRVU per study were used as a surrogate for case complexity. Results During the pandemic surge, case volumes fell 57%, while wRVUs fell by 69% relative to the pre-COVID-19 baseline. Mean wRVU per study was 1.13 in the presurge period, 1.03 during the surge, and 1.19 in the recovery. Categories with the greatest mean complexity declines were radiography (−14.7%), cardiothoracic imaging (−16.2%), and community hospitals overall (−15.9%). Breast imaging (+6.5%), interventional (+5.5%), and outpatient (+12.1%) complexity increased. During the recovery, significant increases in complexity were seen in cardiothoracic (0.46 to 0.49), abdominal (1.80 to 1.91), and neuroradiology (2.46 to 2.56) at stand-alone outpatient centers with similar changes at community hospitals. At academic hospitals, only breast imaging complexity remained elevated (1.32 from 1.17) during the recovery. Conclusion Reliance on volume alone underestimates the financial impact of the COVID-19 pandemic as there was a disproportionate loss in high-RVU studies. However, increased complexity of outpatient cases has stabilized overall losses during the recovery.

Purpose To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. Methods Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. Results In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. Conclusion Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Early detection of acute pulmonary embolism (PE) in patients with SARS‐CoV‐2 infection is integral to the clinical management of these patients. Many recently published studies have evaluated incidence of PE in hospitalized patients with COVID‐191‐9, however there is relatively limited data describing patients with SARS‐CoV‐2 infection and concomitant diagnosis of acute PE upon initial presentation. Therefore, the purpose of this study is to (i) evaluate the incidence of acute pulmonary embolism (PE) in patients undergoing computed tomography pulmonary angiography (CTPA) in the emergency department (ED) across six hospitals in New York City during the height of the COVID‐19 pandemic compared to a non‐pandemic period, and (ii) compare the characteristics and early outcomes of patients presenting with PE during the pandemic (n=87) to patients presenting with PE during a non‐pandemic period (n=34).

BACKGROUND AND PURPOSE: In recent years, the transradial approach has become more widely adopted for neuroendovascular procedures. The purpose of this study was to evaluate the safety and feasibility of a transradial approach and distal transradial access for neuroendovascular procedures in a single center. MATERIALS AND METHODS: Retrospective analysis was performed for all patients who underwent transradial approach or distal transradial access neuroendovascular procedures from January 2016 to August 2019 at a single center. Exclusion criteria included a Barbeau D waveform, a radial artery of

The purpose of this study is to compare the motivations of interventional radiology (IR) residency, IR fellowship, and diagnostic radiology (DR) applicants.A questionnaire was distributed to IR integrated residency and IR fellowship applicants for the 2018 National Resident Matching Program (NRMP) Match. Survey respondents scored the influence of 13 aspects of IR on their career decision. These results were combined with a previously published survey of DR residency applicants from 2016 who were asked the same questions. Pairwise comparisons to survey responses were made between IR residency and IR fellowship as well as IR residency and DR residency respondents.There were 202 of 657 DR residency respondents (response rate 30.7%), 114 of 295 IR residency respondents (response rate 38.6%), and 70 of 169 IR fellowship respondents (response rate 41.4%). Compared with DR respondents, IR residency respondents rated the following factors more positively: influence of a mentor (P = .030), perceived job satisfaction (P.001), job market (P .001), salary (P.001), intellectual stimulation (P = .030), the use of emerging or advanced technology (P.001), and the visual nature of the field (P .001). In contrast, DR residency respondents rated flexible work hours (P.001), physics (P.001), and competitiveness of the application process (P.001) more positively than IR respondents. Compared with IR fellowship respondents, IR residency respondents rated flexible work hours (P = .002), the job market (P = .020), physics (P.001), and salary (P.001) more positively, and competitiveness (P = .002) was felt to be more negative for residency applicants.The motivations for pursuing IR residency differ from both DR residency and IR fellowship. Understanding these motivations can help to recruit top quality IR residency applicants.

The purpose of this paper is to review the percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty. Corticosteroid injection and viscosupplementation have been the most studied, but there is still no consensus about their value. Thermal nerve ablation, including both radiofrequency ablation and cryoneurolysis, is a promising new modality of therapy that may increase in clinical use given current data showing favorable outcomes. Of the future therapies that are currently under investigation, synovial embolization via the geniculate arteries represents an exciting new approach that may soon be available clinically. There are various percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.

This report describes a single-center experience with balloon-occluded transarterial chemoembolization for liver-directed therapy. A total of 26 patients (11 male, 4 female; mean age, 65 y ± 7) with 28 tumors (mean diameter, 2.7 cm; range, 1.1-5.9 cm) were treated. Technical success rate was 100% (28 of 28 cases), with 1 minor complication of left portal vein thrombosis and small liver infarct. Of the 15 tumors analyzed for response, 60% (9 of 15) exhibited complete response, 33.3% (5 of 15) exhibited partial response, and 6.6% (1 of 15) had stable disease on follow-up. Eight patients exhibited overall progression with a new hepatic lesion and a median time to progression of 7.9 months (range, 5-11 mo).

Introduction The formation of integrated interventional radiology (IR) residency programs has changed the training paradigm. This change mandates the need to provide adequate exposure to allow students to explore IR as a career option and to allow programs to sufficiently evaluate students. This study aims to highlight the availability of medical student education in IR and proposes a basic framework for clinical rotations. Materials and Methods The Liaison Committee on Medical Education (LCME) website was utilized to generate a list of accredited medical schools in the United States. School websites and course listings were searched for availability of IR and diagnostic radiology rotations. The curricula of several well-established IR rotations were examined to identify and categorize course content. Results In all, 140 LCME-accredited medical schools had course information available. Of those schools, 70.5% offered an IR rotation; 84.6% were only available to senior medical students and only 2% were offered for preclinical students; and 8.1% of courses were listed as subinternships. Well-established IR clerkships included a variety of clinical settings, including preprocedure evaluation, experience performing procedures, postprocedure management, and discharge planning. Conclusion Medical student exposure to IR is crucial to the success of integrated IR residency programs. Current research shows few institutions with formal IR subinternship rotations. Although 70.5% of institutions have some form of nonstandardized IR course, 84.6% are available only to fourth-year students, and 2% are offered to preclinical students. This suggests there is a significant opportunity for additional formal exposure to IR through increasing availability of IR rotations and exposure during the clinical and preclinical years.

The Angio-Seal vascular closure device is used to reduce time to hemostasis after femoral artery puncture. Although rare, complications associated with Angio-Seal are significant, including infection, pseudoaneurysm formation, symptomatic femoral artery stenosis, and separation and embolization, leading to limb-threatening ischemia. This report describes Angio-Seal polymer anchor embolization to the tibioperoneal trunk successfully retrieved using the 8-French Indigo Aspiration System.