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We sought to evaluate differences in outcomes between double versus triple transarterial chemoembolization (TACE). TACEs over a 1-year period were retrospectively reviewed and divided into two groups: double and triple. Imaging response and complications were made on a per-procedure basis. Student's t-test was used to calculate differences in continuous variables, and chi-square test was used to calculate differences in categorical values.Overall tumor response was similar between the two groups, and there were no significant differences in complications between groups. Outcomes are similar between double and triple conventional TACE, suggesting that adding a third drug may only contribute to cost.

Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Purpose To report device-related adverse events 6 months after placement or conversion of the VenaTech convertible vena cava filter (VTCF). Materials and Methods A review of 6-month follow-up data of an investigational device exemption multicenter, prospective, single-arm study was performed. The VTCF was implanted in 149 patients. Conversion was attempted in 64.4% of those patients (n = 96) and successfully in 96.9% of the patients (n = 93). A total of 76 patients completed imaging evaluation at 6 months after filter conversion. Patients who required continued venous thromboembolism prophylaxis at 6 months did not undergo a conversion attempt and were designated as nonconverted filter subjects. A total of 28 nonconverted filter subjects completed imaging evaluation at 6 months after implantation. Results Evaluation of patients at 6 months after conversion demonstrated 1 of 76 (1.3%) inferior vena cava (IVC) perforations with a filter strut greater than 3 mm outside of the caval lumen. No cases of recurrent PE, clinically significant filter migration, filter fracture, or IVC thrombosis were reported in the converted subjects. In the nonconverted filter subjects, there was a 14.3% (4 of 28) complete or nearly complete rate of IVC thromboses. There were no cases of recurrent pulmonary embolism, penetration, fracture, or spontaneous conversion in the nonconverted filter subjects. There was a significant reduction in the rate of IVC thrombosis and migration in the converted cohort compared to that in the nonconverted cohort. Conclusions At 6 months, the VTCF demonstrated low adverse event rates in the converted configuration, whereas a minority of patients with the nonconverted configuration demonstrated a high risk of IVC thrombosis.

Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Iliofemoral venous thrombosis carries a high risk for pulmonary embolism, recurrent deep vein thrombosis, and post-thrombotic syndrome complicating 30% to 71% of those affected. The clinical scenarios in which iliofemoral venous thrombosis is managed may be diverse, presenting a challenge to identify optimum therapy tailored to each situation. Goals for management include preventing morbidity from venous occlusive disease, and morbidity and mortality from pulmonary embolism. Anticoagulation remains the standard of care for iliofemoral venous thrombosis, although a role for more aggressive therapies with catheter-based interventions or surgery exists in select circumstances. Results from recent prospective trials have improved patient selection guidelines for more aggressive therapies, and have also demonstrated a lack of efficacy for certain conservative therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Purpose To demonstrate rates of successful filter conversion and 6-month major device-related adverse events in subjects with converted caval filters. Materials and Methods An investigational device exemption multicenter, prospective, single-arm study was performed at 11 sites enrolling 149 patients. The VenaTech Convertible Vena Cava Filter (B. Braun Interventional Systems, Inc, Bethlehem, Pennsylvania) was implanted in 149 patients with venous thromboembolism and contraindication to or failure of anticoagulation (n = 119), with high-risk trauma (n = 14), and for surgical prophylaxis (n = 16). When the patient was no longer at risk for pulmonary embolism as determined by clinical assessment, an attempt at filter conversion was made. Follow-up of converted patients (n = 93) was conducted at 30 days, 3 months, and 6 months after conversion. Patients who did not undergo a conversion attempt (n = 53) had follow-up at 6 months after implant. Results All implants were successful. One 7-day migration to the right atrium required surgical removal. Technical success rate for filter conversion was 92.7% (89/96). Mean time from placement to conversion was 130.7 days (range, 15–391 d). No major conversion-related events were reported. The mean conversion procedure time was 30.7 minutes (range, 7–135 min). There were 89 converted and 32 unconverted patients who completed 6-month follow-up with no delayed complications. Conclusions The VenaTech Convertible filter has a high conversion rate and low 6-month device-related adverse event rate. Further studies are necessary to determine long-term safety and efficacy in both converted and unconverted patients.

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objective This report summarizes the findings of the consensus panel based on the results of the comprehensive questionnaire of US American College of Phlebology annual congress attendees and results of the systematic meta-analysis of the literature and provides quality improvement guidelines for the use of endovenous foam sclerotherapy (EFS) for the treatment of venous disorders, as well as identifies areas of needed research. Methods Based on the above data, quality improvement guidelines were developed and reviewed by the ten US consensus panel members and approved by their respective societies. Results EFS is effective for the treatment of truncal and tributary varicose veins, both as primary treatment and for treatment of recurrence. It may improve the signs and symptoms associated with varicose veins including pain and swelling. EFS is contraindicated in patients who have experienced an allergic reaction to previous treatment with foam or liquid sclerosant, and in patients with acute venous thrombosis events secondary to EFS. Conclusion These guidelines for the use of EFS in the treatment of venous disorders provide an initial framework for the safe and efficacious use of this therapy, and the impetus to promote the evaluation of the questions remaining regarding the use of EFS through well-designed randomized and cohort studies.

Chronic mesenteric ischemia is a rare condition, generally characterized by postprandial abdominal pain. Although chronic mesenteric ischemia accounts for only a small percentage of all mesenteric ischemic events, it can have significant clinical consequences. There are multiple etiologies; however, the most common cause is atherosclerosis. The diagnosis of chronic mesenteric ischemia requires a high clinical index of suspicion. An imaging study can confirm the presence of a stenosis or occlusion involving the mesenteric vessels in patients who are suspected of having chronic mesenteric ischemia. The diagnosis is usually late in its course due to the slow progression of disease and the abundance of mesenteric collaterals. Because of the extensive collateral network, usually at least two of the three visceral vessels need to be affected before patients develop symptoms. Treatment is necessary to avoid progression to bowel ischemia and infarction. Once a diagnosis of chronic mesenteric ischemia is made, treatment options include open surgical revascularization and endovascular revascularization.

Purpose To retrospectively evaluate the safety and effectiveness of the use of the AngioSeal device for repeat arterial closure in patients with hepatic malignancy. Materials and Methods A retrospective analysis of patients with hepatic malignancy who had undergone repeated arterial closure with the AngioSeal device was performed. All charts for patients undergoing transarterial chemoembolization or TheraSphere radioembolization were reviewed for the method of hemostasis and the number of arterial closures. A total of 53 patients (58.5% men, 41.5% women; mean age, 58.7 years) had repeat AngioSeal arterial puncture closure after chemoembolization or TheraSphere treatment. Percutaneous closure of the common femoral artery with the AngioSeal device was performed in accordance with the manufacturer's recommendations. The patients were examined for complications on follow-up. Effectiveness was defined by the ability to obtain satisfactory hemostasis. Safety was assessed by the absence of groin complications and by vessel patency on follow-up angiograms of the puncture site obtained at subsequent liver-directed therapy sessions. Results Fifty-three patients in this study group had a total of 203 common femoral artery punctures. There were a total of 161 closures with the AngioSeal device (79.3%): 58 (36%) single closures and 103 (64.0%) repeat closures. Of the 161 attempts at AngioSeal closure, there was one closure failure in the single-puncture group, yielding a success rate of 98.3%; and one closure failure in the repeat-puncture group, yielding a success rate of 99%. In these two patients, hemostasis was achieved with traditional manual compression without the need for any other device, and no complications were noted. The overall success rate of AngioSeal device closure was 98.7%. Conclusions The repeat use of the AngioSeal closure device is safe and effective in patients with hepatic malignancy undergoing regional oncologic interventional procedures.

Background Endovascular revascularization of the femoral-politeal arterial segment has gained acceptance despite lower patency than surgical bypass due to lower morbidity. Choosing patients that are ideal candidates for endovascular therapy remains controversial. We have assessed hemodynamic factors that might predict longer primary patency after endovascular therapy. Methods Ninety-nine limbs were treated with endovascular therapy from January 2001 to January 2005 with a mean and median follow-up of 338 and 293 days. Primary patency was considered lost when recurrent symptoms developed, ankle-brachial index (ABI) decreased following initial improvement, or a subsequent procedure was required. Kaplan-Meier analysis was used to evaluate patency. Results Patients with an ABI ≥.5 prior to intervention had longer primary patency compared to those with an ABI less than .5 (P = .043). Having 1 or more patent tibial runoff vessels was associated with improved patency for the first 24 months post-procedure (P = .001). Conclusions Patients with an ABI ≥.5 or at least 1 patent tibial vessel runoff have significantly higher hemodynamic and clinical success following endovascular therapy of the femoral-popliteal arterial segment.

We present a case of successful treatment of chemoresistant hepatic lymphoma using yttrium-90 micropheres. A 41 year-old male with a history of hepatitis C presented with fatigue, night sweats, right upper quadrant pain, a 20 pound weight loss, and hypercalcemia. CT scan of the abdomen revealed a 13.4 x 10.0 cm mass involving the right hepatic lobe, along with portohepatic, celiac, and retroperitoneal lymphadenopathy. Ultrasound-guided core biopsy of the portohepatic mass showed diffuse large B-cell lymphoma (DLBCL). The patient had a partial response to R-CHOP, and was subsequently treated with 3 additional chemotherapeutic regimens. Despite this extensive therapy, as well as surgical resection of hepatic lesions, he had residual lymphoma within the liver. Due to inadequate chemosensitivity, he was not a candidate for stem cell transplantation. Repeat biopsy showed loss of CD20 expression, eliminating radioimmunotherapy as an option. Because the residual lymphoma was confined to the liver, the patient was treated with yttrium-90 microspheres (TheraSphere®). The patient had a significant improvement in his abdominal pain. Furthermore, six weeks after treatment, a complete response in the hepatic lesions was documented by PET/CT scan. Although the patient later developed recurrent disease outside of the liver, the case clearly demonstrates the potential clinical utility of this approach in properly selected lymphoma patients. To our knowledge, this is the first reported case documenting clinical activity of yttrium-90 microspheres for lymphoma.

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.

Aberrant right subclavian artery (ARSA) aneurysms are rare but carry a high risk of rupture and require early elective treatment. The present report describes a 60-year-old man with an asymptomatic ARSA aneurysm for whom surgical treatment would have been associated with a high degree of risk. The ARSA aneurysm was occluded with use of Amplatzer septal occluders, which avoided high-risk surgery and preserved antegrade flow into the left common carotid, subclavian, and vertebral arteries and perfusion of the right upper extremity through an induced right subclavian steal. The eventual need for bypass surgery for perfusion of the right upper extremity was assessed after the procedure.

Purpose To demonstrate that interventional radiologists can capture work relative value units (wRVUs) for the work that is already being performed providing evaluation and management (E&M) clinical services. Materials and Methods A team approach was implemented to optimize revenue capture for inpatient E&M. Structured templates were created for inpatient documentation to ensure that maximum wRVUs were captured. Inpatient billing was audited from fiscal year 2011 (1 year before meeting and structured template creation) through fiscal year 2014. Specifically, data were collected on total charges, collections, wRVUs and total number of inpatient E&M encounters, and the level of the billed encounter. Results Retrospective annual audits revealed that overall inpatient E&M billing charges increased by 722%, whereas collections increased by 831% from 2011 to 2014. The wRVUs increased in 2011 from 181.74 to 1,396.9 (669% increase) in 2014, and the number of inpatient E&M encounters billed increased from 130 to 693 (433% increase) over that same time period. Lower level billing (level I) declined from 30% to 19%, and complex billing levels (level II or higher) increased from 70% to 81%. Conclusions By implementing a systems approach to revenue management, which includes physician and billing staff meetings and the use of structured templates, billing capture from inpatient E&M services can be improved.

The optimal treatment for patients with biliary obstruction varies depending on the underlying cause of the obstruction, the clinical condition of the patient, and anticipated long-term effects of the procedure performed. Endoscopic and image-guided procedures are usually the initial procedures performed for biliary obstructions. Various options are available for both the radiologist and endoscopist, and each should be considered for any individual patient with biliary obstruction. This article provides an overview of the current status of radiologic procedures performed in the setting of biliary obstruction and describes multiple clinical scenarios that may be treated by radiologic or other methods. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Analogs of the immunosuppressive cyclic undecapeptide cyclosporin A (CsA) with substitutions in positions 1, 4, 6, and/or 11 were rationally designed to possess substantially diminished or no immunosuppressive activity. When these compounds were assayed for their capacity to interfere with the replication of human immunodeficiency virus, some displayed a potent antiviral activity in newly infected cells. However, only CsA could interfere with virus replication in persistently infected cells. One CsA analog with antiviral activity costimulated the phytohemagglutinin-induced production of interleukin 2 by human lymphocytes. Human immunodeficiency virus particles from drug-exposed cells showed lower infectivity than virions from untreated cells. Thus, these nonimmunosuppressive analogs of CsA constitute a promising class of lead compounds to develop drugs for effective treatment of the acquired immunodeficiency syndrome.

To evaluate minimally invasive acetabular stabilization (MIAS) with thermal ablation and augmented screw fixation for impending or minimally displaced fractures of the acetabulum secondary to metastatic disease.Between February 2011 and July 2014, 13 consecutive patients underwent thermal ablation, percutaneous screw fixation, and polymethyl methacrylate augmentation for impending or nondisplaced fractures of the acetabulum secondary to metastatic disease. Functional outcomes were evaluated before and after the procedure using the Musculoskeletal Tumor Society (MSTS) scoring system. Complications, hospital length of stay, and eligibility for chemotherapy and radiation therapy were assessed.All procedures were technically successful with no major periprocedural complications. The mean total MSTS score improved from 23% ± 11 before MIAS to 51% ± 21 after MIAS (P.05). The mean MSTS pain scores improved from 0% (all) to 32% ± 22 after MIAS (P.05). The mean MSTS walking ability score improved from 22% ± 19 to 55% ± 26 after MIAS (P.05). Two complications occurred; a patient had a minimally displaced fracture of the superior pubic ramus at the site of repair but remained ambulatory, and septic arthritis was diagnosed in another patient 12 months after repair. The average length of hospital stay was 2 days ± 3.6; six patients were discharged within 24 hours of the procedure. All patients were eligible for chemotherapy and radiation therapy immediately after the procedure.MIAS is feasible, improves pain and mobility, and offers a minimally invasive alternative to open surgical reconstruction.

Image-guided drainage of abscesses and fluid collections is a valuable tool in the treatment of pediatric patients. It may obviate surgery or optimize the child’s clinical condition for subsequent surgery. Compared with adults, several differences exist in terms of etiology, risks (especially radiation exposure), preprocedural imaging and planning, technical considerations, support issues such as sedation, and complications. Knowledge of these differences is important in the planning and treatment of these patients. In addition, a quality improvement plan can be used to assess practice performance.

Purpose To assess practice patterns of endovenous foam sclerotherapy (EFS) use in the USA. Methods A multidisciplinary panel of US experts was convened and developed a questionnaire to assess use of EFS. US attendees at the American College of Phlebology 2009 Annual Congress were asked to complete the questionnaire. Results Of 776 questionnaires distributed, 239 were completed (31%). The majority of respondents (87%) reported using EFS for the treatment of venous disorders. Foam sclerotherapy was used by a wide variety of specialists in every region of the USA. The most common indication was sclerosis of recurrent truncal or tributary veins of the leg. There was variation among practitioners in the indications for use, pre- and postprocedural evaluation and procedure methodology. Conclusions The results of this questionnaire show widespread usage of EFS and are important in the development of national quality improvement guidelines for the performance of EFS.

• Bone tumor embolizations can be performed for palliation of pain/symptoms, or pre-operatively to reduce blood loss during surgery.

database, all patients with stage T1aN0M0 RCC (r4cm) diagnosed in 2004 to 2011 were identified. Sociodemographic trends in use of surgery vs. TA were evaluated by chi-square and logistic regression. Overall survival (OS) was estimated using Kaplan-Meier from the time of diagnosis. Difference in utilization rate of TA in 2004-2007 vs. 2008-2011 was observed. Results: Of 28351 patients with T1a lesion, 2133 (7.5%) did not receive curative therapy. Of 26218 patients who received curative therapy, the majority underwent surgical resection: 24992 (95.3%) surgical resection, 671(2.6%) CRA, 553(2.1%) (po0.001). While mean overall survival was similar between the surgery (81.1 months) and TA (81.0 months) group (p1⁄40.612). Those who did not receive curative therapy had a significantly shorter mean OS (70.4 mo; po0.001) when compared to curative group as a whole. Furthermore, mean OS for TA group was also significantly prolonged compared to no curative therapy group (po0.001). Being unmarried, Z65 years of age, being insured, living in metropolitan areas, in Pacific Coast region, and residing in areas with higher median family income demonstrated higher likelihoods of receiving TA when compared to surgery (po0.001). There was a significant increase in the rate of use of TA compared to surgery in more recent years (3.2% in 2004-2007 vs. 5.3% in 2008-2011 (po0.001)). Older age, being unmarried, living in rural areas with lower median family income and lower educational status were found to be predictor of not receiving therapy. Conclusion: There was significant disparity in the management of T1a RCC lesions, in part affected by patient’s sociodemographic determinants. In addition, there was significant underutilization of less invasive thermal ablation which demonstrated similar survivorship compared to surgery and significantly prolonged survival compared to no therapy.

Hepatocellular carcinoma and metastatic colon cancer have proven to be challenging problems in oncology today. Currently multiple treatment options are available for treating patients with these diseases, and for this reason, a multimodality and multidisciplinary approach is needed to optimize the effectiveness of treatment. Local ablation techniques along with intra-arterial therapy may be complementary and therefore increase survival in patients being treated for hepatocellular carcinoma and metastatic colon cancer. With proper patient selection, further improvement in treatment outcomes can be achieved when these techniques are combined with surgical resection and multidrug systemic chemotherapy. Therefore, it is imperative that interventional radiologists work closely with our colleagues in other medical and surgical specialties to provide our patients with the best possible treatment options.