Role of interventional radiologists in the management of lower extremity venous insufficiency

Venous ablation procedures by provider type, including advanced practice providers

OBJECTIVE

The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types.

METHODS

We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends.

RESULTS

Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95).

CONCLUSIONS

The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Infectious complications of endoarterial interventional radiology: protocol for an observational study of a longitudinal national cohort of patients assessed in the French hospital discharge database (MOEVA study)

Around seven million patients undergo endoarterial interventional radiology procedures (EAIRP) annually worldwide. These procedures have become part of the standard repertoire of vascular surgery. However, the healthcare-associated infections related to these procedures are relatively unknown. Prevalence and adverse outcome of infectious complication (IC) post-EAIRP may be underestimated. We aim to provide national trend estimation of EAIRP incidence and outcome in France. METHODS AND ANALYSIS: From the French Common Classification of Medical Acts, we will define four categories of EAIRP. We will collect procedures via the French nationwide hospital discharge database, called Programme de Médicalisation des Systèmes d'Information (PMSI) and derived from the Diagnosis Related Group system. Various combinations to identify the numerator will be employed according to a pre-established algorithm. Technical data wrangling tools facilitating the use of PMSI will be developed to obtain a clean and well-structured database ready for statistical analysis. This protocol will require competences in medicine, epidemiology, statistics, data processing and techniques through various stages of the study. The cohort will contain the denominator (the first act of the first stay of each patient) and the corresponding numerator (the IC which will occur during the first stay). ETHICS AND DISSEMINATION: No nominative, sensitive or personal data on patients have been collected. The study of the MOrtality and infectious complications of therapeutic EndoVAscular interventional radiology (MOEVA) study does not involve humans, and falls within the scope of the French Reference Methodology MR-004 according to 2016-41 law dated 26 January 2016 on the modernisation of the French health system. Our study involves the reuse of already recorded data, which require neither information or non-opposition of the included individuals. Access to linked ANOnymous (ANO) file in the PMSI databases was approved by the French National Commission for Data Protection and Liberties (CNIL number 1564135). The results will be disseminated through a peer-reviewed publication.

Management of Chronic Deep Vein Thrombosis in Women

Chronic deep vein thrombosis (DVT) affects hundreds of thousands of women in the United States. Chronic DVT can lead to pain, edema, venous ulcers, and varicosities. While there are limited data regarding the management of chronic DVT, several interventional radiology groups aggressively treat chronic DVT to aid patient symptom resolution. Recanalization of occluded veins and venous stenting re-establishes deep vein flow and decreases venous hypertension.

Fluoroscopy-guided endovenous sclerotherapy using a microcatheter prior to endovenous laser ablation: comparison between liquid and foam sclerotherapy for varicose tributaries

OBJECTIVE

To compare the efficacy and adverse effects of endovenous foam sclerotherapy (EFS) and liquid sclerotherapy (ELS) using a microcatheter for the treatment of varicose tributaries.

MATERIALS AND METHODS

From December 2007 to January 2009, patients with venous reflux in the saphenous vein were enrolled. The foam or liquid sclerosant was injected through a microcatheter just before endovenous laser ablation (EVLA). Patients were evaluated for the technical success, clinical success, and procedure-related complications during the procedure and follow-up visits.

RESULTS

A total of 94 limbs were included: 48 limbs (great saphenous vein [GSV], 35; small saphenous vein [SSV], 13) were managed using EFS and EVLA (foam group; FG), and 46 limbs (GSV, 37; SSV, 9) were treated by ELS and EVLA (liquid group; LG). Varicose tributaries demonstrated complete sclerosis in 92.7% with FG and in 71.8% with LG (p = 0.014). Bruising (78.7% in FG vs. 73.2% in LG, p > 0.05), pain or tenderness (75.6% in FG vs. 51.2% in LG, p = 0.0237) were noted. Hyperpigmentation (51.2% in FG vs. 46.2% in LG, p > 0.05) was found.

CONCLUSION

Endovenous foam sclerotherapy using a microcatheter is more effective than ELS for eliminating remnant varicose tributaries prior to EVLA. However, EFS is more commonly associated with local complications such as pain or tenderness than ELS. Furthermore, both techniques seem to prolong the duration of hyperpigmentation along with higher costs.