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Objective This study aims to assess the regional variation and overall longitudinal prevalence of approaches to gastrostomy tube placement in patients covered by Medicare or Medicaid. Background Gastrostomy tubes are most commonly inserted endoscopically given the approaches’ demonstrated safety, success, and patient outcomes as compared with laparoscopic approaches. Recently, the growth of interventional radiology services has provided patients with an alternative percutaneous approach. The safety and efficacy of this approach as opposed to endoscopic approaches has yet to be determined. Methods From 2005 to 2014, Medicare Standard Analytic Files derived from Medicare parts A and B, which contain 100% of inpatient and outpatient facility records billed to Medicare, were retrospectively analyzed. Age, sex, year of placement, region, comparative quarterly ratio, regional cost variation, and overall financial cost were compared between both cohorts. Results Our population included a total of 336,021 patients; of those, 30,327 patients underwent fluoroscopic guided procedures, and 305,694 patients underwent endoscopic procedures. Age (p < 0.001), region (p = 0.043), and year of placement (p < 0.001) varied significantly between these populations. Fluoroscopic-guided procedures were found to have a statistically significantly lower average cost of treatment compared with endoscopic gastrostomies ($2,018.62 vs. $2,471.33, respectively, p = 0.03). Conclusion This study demonstrates an increasing prevalence of fluoroscopically placed gastrostomy tubes as compared with those placed endoscopically.

Objectives This study aims to report the technical results of below-the-elbow arterial revascularization in patients with critical hand ischemia. Methods We retrospectively identified upper extremity critical limb ischemia patients treated with below-the-elbow arterial intervention between 2013 and 2017. Patient demographics, comorbidities, and procedural data were reviewed and technical success was evaluated. Results Seven patients with 12 arteries that were affected by critical hand ischemia were treated. All patients had a history of end-stage renal disease. The technical success rate was 83.3%. There were no major or minor complications. The average follow-up duration was 9 months (2–26 months). One patient underwent a digital amputation at 8 months. Conclusion Arterial revascularization of the below-the-elbow arteries for critical hand ischemia is safe and technically feasible.

Objective: Previous studies show good technical success rates for fallopian tube recanalization. Scarce literature exists regarding advance techniques currently used by interventional radiologists during fallopian tube recanalization procedures. This study investigates the level of intervention and tubal patency and its association with technical success and associated pregnancy outcomes. Methods: We retrospectively evaluated fallopian tube recanalization procedures performed at a single center in a 24-year period. A total of 160 couples undergoing a basic infertility evaluation were included. Hysterosalpingography with high pressure contrast injection followed by selective contrast, guidewire catheterization at the tubal ostium, and/or microcatheter/microwire recanalization were performed. Comparisons of the tubal fertilization rate by relevant characteristics were tested for statistical significance with t tests for continuous data or with Pearson chi-square tests for categorical data. Results: Technical success rate was 94% (319 of 341 tubes). High pressure contrast injection alone (184 of 341, 54%), selective catheterization (40%), and microcatheter/microwire (6%) interventions yielded technical success rates of 98%, 90%, and 73%, respectively. The overall rate of conception was 35% (17 of 48). Conclusion: Current techniques of fallopian tube recanalization offer a desirable and safe option with high technical success for patients seeking treatment for infertility due to proximal fallopian tube obstruction.

Background/objectives The purpose of this research is to analyze the past and forecast the future prevalence of Hepatitis C Virus (HCV) and Nonalcoholic Steatohepatitis (NASH) and their respective contribution to Hepatocellular Carcinoma (HCC) incidence in the setting of novel anti-viral agents and rising obesity rates in the United States. Methods Existing data of HCV and NASH prevalence in the United States utilizing the National Health and Nutrition Examination Survey (NHANES) and Organ Procurement and Transplantation Network (OPTN) was collected and analyzed to project future prevalence trends. Results Prevalence of NASH and HCV are expected to increase and decline respectively over the next two decades with alcoholic cirrhosis expected to stay relatively unchanged. The estimated prevalence of NASH equaled and overtook the projected prevalence of HCV in 2007 at approximately 3 million persons. Estimates of NASH's contribution to HCC overtook HCV-HCC in 2015 at an approximately 25 million persons. Projection models suggest HCV prevalence declining to 1 million active cases by 2025, while NASH potentially increases to 17–42 million depending on a linear or exponential trendline. Projections of NASH-HCC similarly outpace HCV-HCC by 2025 with 45 million or 106 million (linear, exponential) versus 18 million persons respectively. Conclusions The future prevalence of HCV and NASH are expected to become further divergent with NASH emerging as the major contributor of cirrhosis and HCC in the United States.

Supplemental material, Table_VM for Outcomes of subintimal arterial flossing with antegrade–retrograde intervention on patients with critical limb ischemia and tissue loss by Merve Ozen, Fang Zhu, Chen Ma, Shelly Bhanot, Bulent Arslan and Ulku Cenk Turba in Vascular Medicine

The role for stent grafting in the juxta-anastomotic segment for nonmaturing arteriovenous (AV) fistulas is not well understood. We report a case in which a long segment stent-graft of nearly the entire venous limb of a brachiocephalic AV fistula was stented to salvage an access that would likely otherwise have been abandoned. The patient went on to mature his fistula 3 months later and access it for hemodialysis through percutaneous puncture of the stent graft.

To report hepatic arterial-related complications encountered during planning and treatment angiograms for radioembolization and understand any potential-associated risk factors.518 mapping or treatment angiograms for 180 patients with primary or metastatic disease to the liver treated by Yttrium-90 radioembolization between 2/2010 and 12/2015 were retrospectively reviewed. Intra-procedural complications were recorded per SIR guidelines. Patient demographics, indication for treatment, prior exposure to chemotherapeutic agents, operator experience, and disease burden were reviewed. Technical variables including type of radioembolic (glass vs. resin microspheres), indication for angiography (mapping vs. treatment), variant anatomy, and attempts at coil embolization were also assessed.Thirteen (13/518, 2.5%) arterial-related complications occurred in 13 patients. All but two complications resulted during transcatheter coil embolization to prevent non-target embolization. Complications included coil migration (n = 6), arterial dissection (n = 2), focal vessel perforation (n = 2), arterial thrombus (n = 2), and vasospasm prohibiting further arterial sub-selection (n = 1). Transarterial coiling was identified as a significant risk factor of complications on both univariate and multivariate regression analysis (odds ratio 7.8, P = 0.004). Usage of resin microspheres was also a significant risk factor (odds ratio 9.5, P = 0.042). No other technical parameters or pre-procedural variables were significant after adjusting for confounding on multivariate analysis (P 0.05).Intra-procedural hepatic arterial complications encountered during radioembolization were infrequent but occurred mainly during coil embolization to prevent non-target delivery to extra-hepatic arteries.

STUDY DESIGN Retrospective analysis of Medicare data OBJECTIVE.: To analyze trends of vertebral augmentation in the elderly Medicare population in the context of evolving evidence and varied medical society opinions. SUMMARY OF BACKGROUND DATA Percutaneous vertebral augmentation offers a minimally invasive therapy for vertebral compression fractures. Numerous trials have been published on this topic with mixed results. The impact of these studies and societal recommendations on physician practice patterns is not well understood. METHODS The Centers for Medicare and Medicaid Services annual Medicare Physician Supplier Procedure Summary database was examined for kyphoplasty and vertebroplasty procedures from 2005 through 2015. Top provider specialties were determined based on annual procedural volume, and grouped into the three broad categories of radiology, surgery, and anesthesia/pain medicine. Data entries were independently analyzed by provider type, site of service, submitted charges, and reimbursement rates for interventions during the study period. RESULTS Between 2005 and 2015 total annual claims for vertebral augmentation procedures in the Medicare population increased from 108.11% (37,133-77,276) peaking in 2008 and declining by 15.56% in 2009. Radiology is the largest provider of vertebral augmentation by specialty with declining market shares from 71% in 2005 to 43% in 2015. The frequency of vertebroplasty declined by 61.7% (35,409-13,478) from 2005 to 2015 with reduction in Medicare reimbursement. Annual volume of kyphoplasty grew by 18.3% (48,725-57,646) with significant increase in reimbursement for office-based procedures ($728.50/yr, P

We aimed to investigate patients with lower gastrointestinal bleeding who presented to the emergency department requiring initial conventional angiography. We report risk-stratified and mesenteric conventional angiography outcomes.We retrospectively reviewed patients with lower gastrointestinal bleeding between 2001 and 2012. We included all consecutive patients with clinical lower gastrointestinal bleeding with a requirement of further angiography and possible embolization. Patients who had prior interventions or surgery were excluded.A total of 88 patients (35 women, 53 men) with a median age of 71 years (range, 23-99 years) were included in the analysis. Conventional angiography was positive and endovascular treatment was intended in 35 patients. Once the source of bleeding was found angiographically, endovascular treatment had a technical success rate of 90.3% and clinical success rate of 71.4%. Overall early rebleeding rate (30 days) was 14.8% and late rebleeding rate (30 days) was 13.6%.Identifying the source of lower gastrointestinal bleeding remains to be a clinical and angiographic challenge. Although we did not observe an association between mortality and clinical success, increased early rebleeding rates were associated with higher mortality rates.

Background To determine recent inferior vena cava filter (IVCF) retrieval volumes and rates in the Medicare population. Methods The summary Medicare claims data were searched for the years 2012 to 2016 to identify the frequency of IVCF placements and retrievals. The new Healthcare Common Procedure Coding System code for filter retrieval introduced in 2012, 37193, was used to track filter retrievals. Trends in number of IVCF placements and retrievals over the study period were evaluated, both of which were further stratified by physician specialty and site of service. Aggregate and compound annual growth rates for retrievals were also computed. Results A total of 255,034 filters were placed over the study period, with the filter placement volume declining from 61,889 in 2012 to 38,095 in 2016. Filter retrievals, however, increased from 4,327 in 2012 to 8,405 in 2016. The net filter retrieval rate per annual filters placed increased from 6.9% in 2012 to 22.1% in 2016, yielding an average filter retrieval rate and compound annual growth rate of 11.6% and 18.1% respectively. Radiologists placed and retrieved the majority of filters (60.4% placed, 63.5% retrieved) compared with nonradiologists. The inpatient setting was the dominant site for filter placement compared with the outpatient setting for filter retrieval across all years and specialties. Conclusions Since introduction of the unique Healthcare Common Procedure Coding System code for IVCF retrieval in 2012, IVCF placements in the Medicare population have been declining and net retrieval rates have risen. Radiologists continue to place and retrieve the majority of filters.

Introduction We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. Case Report A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. Comments Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.

Peripheral vascular disease (PVD) is a devastating medical problem that may lead to significant life alterations for patients, from simply limiting their daily activities to potential loss of limbs and eventual demise. Superficial femoral and popliteal arteries are significantly common locations for PVD sequelae to present itself, and owing to their length and mobile nature, treatment of these segments are quite challenging. Indications for PVD treatment include lifestyle-limiting claudication that is not responding to medical management, ischemic rest pain, nonhealing ulcers, and lower extremity gangrene. There is a wide variety of treatment options that include medical management, interventional, and surgical techniques. Interventional techniques include plain old balloon angioplasty, cryoplasty, drug-coated balloon angioplasty, self-expanding bare-nitinol stents, self-expanding covered stents, self-expanding drug-eluding stents, and a number of atherectomy devices (ie, laser, rotational, orbital, and excisional). The scope of this article is to review indications, patient selection, and deployment techniques of Viabahn and Supera self-expanding stents.

We report the case of a 34-year-old woman who developed delayed retrograde ascending aortic dissection after previous endovascular repair of her descending thoracic aorta. Preoperative computed tomography imaging specifically highlights the interaction of endograft springs with the dissection flap and surrounding aortic tissues. Intraoperative findings are presented for comparison and further discussion.

OBJECTIVE: To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS: All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child–Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS: All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION: Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. ADVANCES IN KNOWLEDGE: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.

Purpose: To compare our experience using paclitaxel-coated balloon angioplasty (PCBA) of femoropopliteal lesions in patients undergoing revascularization in the setting of CLI compared with current data in the literature. Materials: Angiography, diagnostic imaging, demographics, risk factors, and clinical notes of patients who underwent PCBA from October 2014 to September 2015 for treatment of CLI were reviewed. Study outcome measures include latest follow up study demonstrating luminal patency, amputation and death attributable to CLI. Patients were excluded if PCBA was used within a stent, the target lesion was stented in the same case, treatment was performed with a planned subsequent amputation, or there is lack of any follow up (defined as subsequent ankle-brachial index (ABI), arterial duplex ultrasound, angiography, or clinical exam). Results: A total of 58 stenoses in 41 patients (24 men; mean age 64.8) underwent PCBA during lower extremity revascularization in this interval. Of these, 19 patients (Rutherford class 4, 5, or 6) with 21 lesions met inclusion criteria. These lesions were pretreated with plain-old balloon angioplasty for predilation or atherectomy followed by PCBA. 5 patients were chronically occluded (26%), and 11 (58%) patients also underwent infrapopliteal disease treatment. Average target lesion length was 4.8 cm and luminal narrowing was 79.6%. Mean follow up was 131.7 days (range 8-339 days, median 108 days) and reintervention was performed only in 2 of 21 lesions (92%). Two patients died of other causes with last documented patency at 56 and 83 days follow up. In patients that have available pre and post PCBA ABIs, the average ratio was 0.61 compared to 0.80 following revascularization. Conclusions: Early follow up demonstrates promising patency rates of femoro-popliteal PCBA in the setting of CLI, as well as high rate of concurrent additional infrapopliteal intervention. Current PCBA data in the literature is comprised of significantly lower Rutherford class patients and minimal concurrent infra-popliteal interventions.