Publications by authors named "Jonathan G Martin"

36 Publications

Quantifying the Financial Impact of Delayed Adoption of CPT Code Changes in Radiology.

Curr Probl Diagn Radiol 2021 Mar 13. Epub 2021 Mar 13.

Division of Interventional Radiology, Department of Radiology, Duke Health, Durham, NC. Electronic address:

Purpose: To quantify the financial effect of delayed reporting of new moderate sedation (MS) Current Procedural Terminology (CPT) codes at an academic radiology practice, and to identify barriers to timely reporting.

Materials And Methods: Billing and reimbursement data was collected for a 28-month period (January 1, 2017-April 30, 2019). Reporting of new MS codes was identified and compared to the number of procedures performed by radiology over the study period. Using the number of procedures performed and payment data, losses were estimated. A root cause analysis was then performed to further understand delayed reporting.

Results: MS was reported with 2.5% of cases in 2017, 47.8% of cases in 2018 and 69.1% of cases in 2019. Appropriate coding was not achieved until June 2018, equating to a 17-month lag in implementation. Lost revenue from inaccurate reporting of MS alone was $21,357 ± $3,945 per month. Primary barriers to an efficient transition included (1) updating billing systems, (2-5) coder, nursing, technologist, and operator education and coordination, and (6) drafting and vetting new procedural report templates.

Conclusions: Delayed reporting of the new moderate sedation codes resulted in a $363,069 ± $67,065 loss of procedural revenue at an academic radiology practice. Primary drivers of the delay were lags in education and coordination at multiple points in the reporting chain. As healthcare policy shifts and changes to coding become more frequent and significant, timely adoption becomes more salient for radiologists.
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http://dx.doi.org/10.1067/j.cpradiol.2021.03.014DOI Listing
March 2021

Socioeconomic Status is Associated with the Risk of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

J Vasc Interv Radiol 2021 Mar 1. Epub 2021 Mar 1.

Division of Vascular and Interventional Radiology, Department of Radiology, Duke University School of Medicine, Durham. Electronic address:

Purpose: To determine whether socioeconomic status (SES) is associated with hepatic encephalopathy (HE) risk after transjugular intrahepatic portosystemic shunt (TIPS) creation.

Materials And Methods: This single-institution retrospective study included 368 patients (mean age = 56.7 years; n = 229 males) from 5 states who underwent TIPS creation. SES was estimated using the Agency for Healthcare Research and Quality SES index, a metric based on neighborhood housing, education, and income statistics. Episodes of new or worsening HE after TIPS, defined as hospitalization for HE or escalation in outpatient medical therapy, were identified from medical records. Multivariable ordinal regression, negative binomial regression, and competing risks survival analysis were used to identify factors associated with SES quartile, the number of episodes of new or worsening HE per unit time after TIPS, and mortality after TIPS, respectively.

Results: There were 83, 113, 99, and 73 patients in the lowest, second, third, and highest SES quartiles, respectively. In multivariable regression, only older age (β = 0.04, confidence interval [CI] = 0.02-0.05; P < .001) and white non-Hispanic ethnicity (β = 0.64, CI = 0.07-1.21; P = .03) were associated with higher SES quartile. In multivariable regression, lower SES quartile (incidence rate ratio [IRR] = 0.80, CI = 0.68-0.94; P = .004), along with older age, male sex, higher model for end-stage liver disease score, nonalcoholic steatohepatitis, and proton pump inhibitor use were associated with higher rates of HE after TIPS. Ethnicity was not associated with the rate of HE after TIPS (IRR = 0.77, CI = 0.46-1.29; P = .28). In multivariable survival analysis, neither SES quartile nor ethnicity predicted mortality after TIPS.

Conclusion: Lower SES is associated with higher rates of new or worsening HE after TIPS creation.
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http://dx.doi.org/10.1016/j.jvir.2020.11.022DOI Listing
March 2021

Vivid biofluorescence discovered in the nocturnal Springhare (Pedetidae).

Sci Rep 2021 Feb 18;11(1):4125. Epub 2021 Feb 18.

Departments of Environmental Sciences and Natural Resources, Northland College, 1411 Ellis Avenue, Ashland, WI, 54806, USA.

Biofluorescence has been detected in several nocturnal-crepuscular organisms from invertebrates to birds and mammals. Biofluorescence in mammals has been detected across the phylogeny, including the monotreme duck-billed platypus (Ornithorhyncus anatinus), marsupial opossums (Didelphidae), and New World placental flying squirrels (Gluacomys spp.). Here, we document vivid biofluorescence of springhare (Pedetidae) in both museum specimens and captive individuals-the first documented biofluorescence of an Old World placental mammal. We explore the variation in biofluorescence across our sample and characterize its physical and chemical properties. The striking visual patterning and intensity of color shift was unique relative to biofluorescence found in other mammals. We establish that biofluorescence in springhare likely originates within the cuticle of the hair fiber and emanates, at least partially, from several fluorescent porphyrins and potentially one unassigned molecule absent from our standard porphyrin mixture. This discovery further supports the hypothesis that biofluorescence may be ecologically important for nocturnal-crepuscular mammals and suggests that it may be more broadly distributed throughout Mammalia than previously thought.
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http://dx.doi.org/10.1038/s41598-021-83588-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892538PMC
February 2021

Sharp Recanalization of Chronic Central Venous Occlusions of the Thorax Using a Steerable Coaxial Needle Technique from a Supraclavicular Approach.

Cardiovasc Intervent Radiol 2021 Jan 3. Epub 2021 Jan 3.

Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Durham, NC, 27710, USA.

Purpose: To evaluate the technical success and safety of a steerable coaxial sharp recanalization technique that utilizes routine needles in patients with refractory thoracic central venous occlusions.

Materials And Methods: This retrospective study was performed on 36-attempted sharp recanalizations in 35 patients (mean age 50 years, 23 male) performed via a supraclavicular approach. In all cases, an 18-gauge trocar needle was custom curved to provide directional control during fluoroscopic triangulation. A 22-gauge Chiba needle was then advanced coaxially across the occlusion. A tractogram was performed to assess for traversal of unintended structures. Procedures were completed by catheter placement, angioplasty, or stenting follow successful recanalizations.

Results: Sharp recanalization using this steerable coaxial needle technique demonstrated a technical success rate of 94% (34/36). The mean occlusion length was 30 mm (range 3-53 mm). In 11 patients, success was achieved using this technique after failure of other advanced techniques. In five procedures, stent interstices were traversed. Sharp recanalization was the direct cause of one major complication consisting of pleural transgression causing mild hemothorax treated successfully with a stent graft.

Conclusion: The proposed technique is effective and safe for patients who have failed traditional blunt recanalization techniques.

Level Of Evidence: Level 4, Case Series.
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http://dx.doi.org/10.1007/s00270-020-02728-7DOI Listing
January 2021

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability.

J Vasc Interv Radiol 2021 02 5;32(2):277-281. Epub 2020 Nov 5.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.
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http://dx.doi.org/10.1016/j.jvir.2020.10.001DOI Listing
February 2021

Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach.

Clin Imaging 2021 Feb 26;70:93-96. Epub 2020 Oct 26.

Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America.

Purpose: To identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach.

Materials And Methods: Retrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis.

Results: A total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13-0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16-0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure.

Conclusion: To minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.
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http://dx.doi.org/10.1016/j.clinimag.2020.10.036DOI Listing
February 2021

The Prevalence of Uterine Fibroids in African American Women with Hemoglobin SS Sickle Cell Disease as Determined by Pelvic Magnetic Resonance Imaging.

Acad Radiol 2020 Aug 17. Epub 2020 Aug 17.

Department of Radiology, Division of Interventional Radiology, Duke University School of Medicine, DUMC 3808, 2301 Erwin Rd, 1502 Duke North, Durham, NC 27710. Electronic address:

Rationale And Objectives: This study explores the relationship between the development of uterine fibroids and hemoglobin SS sickle cell disease (SCD) by examining the prevalence of uterine fibroids as detected by pelvic magnetic resonance imaging (MRI) in African American (AA) women with and without SCD.

Materials And Methods: A single-center, retrospective review was performed of all adult AA women at a large, academic medical center who received pelvic MRI from January 1, 2007 to December 31, 2018. Propensity score matching conditional on age and ZIP code evaluated the differences in fibroid prevalence between the two groups. Subanalyses by age in 10-year intervals were also performed.

Results: Twenty-one (23.9%) of 88 patients with SCD had fibroids on pelvic MRI versus 1493 (52.1%) of 2868 patients without SCD (p value <0.001). After propensity score matching, 21 (24.7%) of 85 patients with SCD compared to 52 (61.2%) of 85 patients without SCD had fibroids (p value <0.001). Subanalyses in 10-year age intervals showed significance for patients between 30 and 39 years old in which 4 (13.8%) of 29 SCD patients versus 374 (65.3%) of 573 no SCD patients had fibroids (p value <0.001), and for patients between 40 and 49 years old in which 9 (42.9%) of 21 SCD patients versus 667 (73.8%) of 904 no SCD patients had fibroids (p value = 0.002).

Conclusion: These findings indicate an overall significantly lower prevalence of uterine fibroids in AA women with SCD, suggesting that SCD may be protective against the development of uterine fibroids in these patients.
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http://dx.doi.org/10.1016/j.acra.2020.07.032DOI Listing
August 2020

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

J Vasc Interv Radiol 2020 Aug;31(8):1302-1307.e1

Division of Interventional Radiology, Duke Health, DUMC Box 3808, Durham, NC, 27710.

Purpose: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice.

Materials And Methods: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals).

Results: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%.

Conclusions: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.
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http://dx.doi.org/10.1016/j.jvir.2020.04.034DOI Listing
August 2020

Knowledge Retention in Radiology Residents for Audience Response System Versus Traditional Hot-Seat Conference.

J Am Coll Radiol 2021 Feb 28;18(2):305-308. Epub 2020 Jul 28.

Vice Chair of Education, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1016/j.jacr.2020.07.008DOI Listing
February 2021

Additional Magnetic Resonance or Nuclear Scintigraphy Imaging Influences Approach to Vertebral Augmentation: A Single Institution Experience.

Spine (Phila Pa 1976) 2020 Aug;45(15):E927-E932

Radiology Associates of Atlanta, Piedmont Healthcare, Atlanta, GA.

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.
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http://dx.doi.org/10.1097/BRS.0000000000003420DOI Listing
August 2020

Comparing the Safety and Cost of Image-Guided Percutaneous Gastrostomy Tube Placement in the Outpatient Versus Overnight Observation Setting in a Single-Center Retrospective Study.

Acad Radiol 2020 Jun 8. Epub 2020 Jun 8.

Emory University Department of Radiology, Emory University Hospital, 1364 Clifton Road NE, Suite D112, Atlanta, GA 30322.

Rationale And Objectives: Historically, patients undergoing image-guided percutaneous gastrostomy tube placement have been admitted overnight with feeds commencing 12-24 hours postprocedure. With new expedited feeding protocols starting 3-4 hours postprocedure, same-day discharge is now possible. The purpose of this study was to evaluate the safety and cost of image-guided percutaneous gastrostomy tube placement as an outpatient procedure.

Materials And Methods: In this retrospective study, 131 patients (age 63.9 ± 11.6; 34% female) underwent gastrostomy tube placement as an outpatient procedure with expedited feeding protocol versus 40 patients (age 61.3 ± 12.6; 38% female) who were hospitalized overnight with feeds starting at 12-24 hours, primarily based on operator preference. The two groups were compared regarding complications within 90 days of procedure. Using a subgroup of 33 consecutive patients, procedural costs (total combined insurer and patient payments for professional and hospital services) for outpatients vs. hospitalized patients were compared.

Results: Complication rates were similar (p = 0.64) for gastrostomy tubes placed on outpatients (0.17 complications/procedure: 4 bleeding, 2 aspiration pneumonia, 1 abdominal abscess, 4 significant pain, 6 cellulitis, 1 surgical consult, 4 malpositioned/fractured tubes) and hospitalized patients (0.20 complications/procedure: 1 aspiration pneumonia, 1 significant pain, 3 cellulitis, 1 surgical consult, 2 fractured tubes). Total combined insurer and patient payments were similar ($2193/outpatient vs $2701/hospitalized patient; p= 0.52).

Conclusion: Outpatient image-guided percutaneous gastrostomy tube placement with an expedited feeding protocol is a safe and cost-comparable alternative to historic overnight hospitalization. Further prospective investigation with a larger sample is warranted.
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http://dx.doi.org/10.1016/j.acra.2020.04.044DOI Listing
June 2020

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial.

J Vasc Interv Radiol 2020 Jul 23;31(7):1143-1147. Epub 2020 May 23.

Department of Radiology, Division of Vascular & Interventional Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Purpose: To determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement.

Methods: This prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965).

Results: Of 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3-10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2-27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5-16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8-29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13-354 mGy) for the metoclopramide group versus 130 mGy (range, 24-525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8-51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6-53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications.

Conclusions: A single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.
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http://dx.doi.org/10.1016/j.jvir.2020.02.028DOI Listing
July 2020

Length of Stay Predicts Risk of Early Infection for Hospitalized Patients Undergoing Central Venous Port Placement.

J Vasc Interv Radiol 2020 Mar 29;31(3):454-461. Epub 2020 Jan 29.

Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Purpose: To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.

Materials And Methods: In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.

Results: The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P < .001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was < 7 days and time to discharge was > 3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was < 7 days and time to discharge was ≤ 3 days (P < .001).

Conclusions: Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.
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http://dx.doi.org/10.1016/j.jvir.2019.10.017DOI Listing
March 2020

Uterine artery embolisation for IVC syndrome and severe lower extremity oedema secondary to IVC compression from massive fibroids.

BMJ Case Rep 2019 Nov 24;12(11). Epub 2019 Nov 24.

Department of Radiology, Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina, USA.

A 66-year-old woman was admitted to an outside facility with leg swelling and dyspnea on exertion. Initial workup revealed severe aortic stenosis and congestive heart failure (CHF) thought to be the culprit; however, a CT performed in the emergency department revealed massive uterine mass resulting in significant inferior vena cava (IVC) compression. Her cardiac status precluded hysterectomy, due to concerns regarding intraoperative fluid shifts decreasing preload in the setting of preload dependence in severe aortic stenosis. Similarly, her degree of IVC compression was thought to make valve replacement unacceptably dangerous, so she was referred to interventional radiology for consideration of uterine artery embolisation (UAE) to relieve IVC compression. She underwent UAE without complication, and her leg swelling nearly completely resolved at follow-up.
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http://dx.doi.org/10.1136/bcr-2019-231718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887409PMC
November 2019

Relative Sarcopenia With Excess Adiposity Predicts Survival After Transjugular Intrahepatic Portosystemic Shunt Creation.

AJR Am J Roentgenol 2020 01 31;214(1):200-205. Epub 2019 Oct 31.

Department of Radiology, Division of Abdominal Imaging, Duke University Medical Center, Durham, NC.

The purpose of this study was to assess the impact of relative sarcopenia with excess adiposity on mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation. In this single-institution retrospective study, patients underwent abdominal CT scans within 100 days before or 30 days after TIPS creation. Subcutaneous and visceral adipose tissue and muscle were segmented at the L3 vertebral level. Relative sarcopenia with excess adiposity was defined as the lowest sex-specific quartile of muscle area divided by muscle plus adipose. Dates of death, liver transplantation, TIPS occlusion, and hepatic encephalopathy (HE) after TIPS creation were identified. Mortality was evaluated using competing risks survival analysis. Number of HE episodes and time to first episode were analyzed using negative binomial regression and competing risks survival analysis, respectively. A total of 141 patients (91 men; mean age, 56 years) were included in this study. In univariate analyses, Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.09 per point; CI, 1.05-1.13; < 0.001) and relative sarcopenia with excess adiposity (HR, 2.70; CI, 1.55-4.69; < 0.001) were significant risk factors for shorter survival after TIPS. In multivariate analysis, both MELD score (HR, 1.09; CI, 1.03-1.15; = 0.003) and relative sarcopenia with excess adiposity (HR, 2.65; CI, 1.56-4.51; < 0.001) were significant predictors of worse survival. The C-index at 30 days was 0.71 for MELD score, 0.72 for relative sarcopenia with excess adiposity, and 0.80 for a model including both. There was no association between relative sarcopenia with excess adiposity and number of HE episodes (incidence rate ratio, 1.08; CI, 0.49-2.40; = 0.84) or time to first HE episode (HR, 0.89; CI, 0.51-1.54; = 0.67). Relative sarcopenia with excess adiposity is a risk factor for mortality after TIPS and contributes additional prognostic information beyond MELD score.
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http://dx.doi.org/10.2214/AJR.19.21655DOI Listing
January 2020

Tc-99m-MAA lung shunt fraction before Y-90 radioembolization is low among patients with non-hepatocellular carcinoma malignancies.

Nucl Med Commun 2019 Nov;40(11):1154-1157

Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

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.
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http://dx.doi.org/10.1097/MNM.0000000000001089DOI Listing
November 2019

Postpartum haemorrhage requiring embolisation of a hypertrophied round ligament artery.

BMJ Case Rep 2019 Aug 30;12(8). Epub 2019 Aug 30.

Interventional Radiology, Duke University School of Medicine, Durham, North Carolina, USA.

A gravida 4 para 1021, 41-year-old woman postcaesarean section at 39 weeks and 1 day with clinically significant haemorrhage required embolisation of unique uterine arterial collaterals. She had persistent haemorrhage after initial bilateral uterine artery embolisation, and on further investigation she was found to have a hypertrophied right round ligament artery. Once successful embolisation of this abnormal right round ligament artery was completed using a combination of Gelfoam and coils, haemostasis was achieved. She had rapid clinical improvement, no complications and no further admissions on postprocedural follow-up over a year and a half later.
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http://dx.doi.org/10.1136/bcr-2019-230071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6720571PMC
August 2019

Correlation of CT Angiography and Technetium-Labeled Red Blood Cell Scintigraphy to Catheter Angiography for Lower Gastrointestinal Bleeding: A Single-Institution Experience.

J Vasc Interv Radiol 2019 Nov 3;30(11):1725-1732.e7. Epub 2019 Jul 3.

Department of Radiology, Division of Interventional Radiology, Duke University, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Purpose: To investigate the correlation of computed tomography (CT) angiography and Technetium-labeled red blood cell (RBC) scintigraphy to catheter angiography (CA) in the management of lower gastrointestinal bleeding (LGIB) while considering potential nephrotoxic effects of iodinated contrast.

Materials And Methods: From November 2012 to August 2017, 223 CAs performed for LGIB, including massive, ongoing, and obscure bleeding, were retrospectively identified in patients with pre-procedural CT angiography or RBC scintigraphy. Positive correlations and sensitivities were calculated for CT angiography and RBC scintigraphy using CA results as reference. Correlations were then compared while considering certain clinical presentations of LGIB. Contrast dose was compared with maximum creatinine recorded 48-72 hours after.

Results: Thirty-eight patients underwent CT angiography; 173 patients underwent RBC scintigraphy; and 12 patients completed both studies. CT angiography had a positive correlation of 67.7% (95% confidence interval [CI]: 57.0, 76.7) and sensitivity of 85.2% (95% CI: 66.3, 95.8), whereas RBC scintigraphy had a positive correlation of 29.3% (95% CI: 27.7, 31.0) and sensitivity of 94.4% (95% CI: 84.6, 98.8). CT angiography had higher positive correlation across all clinical presentations. No dose-toxicity relationship was observed between contrast and renal function (R: 0.008), nor was there a difference in incidence of contrast-induced nephropathy between CT angiography and RBC scintigraphy (P = .30).

Conclusions: CT angiography has greater positive correlation to CA than RBC scintigraphy for assessing LGIB in active stable as well as hemodynamically unstable LGIB. As such, greater adoption of CT angiography may reduce the number of nontherapeutic CAs performed. Additional contrast associated with CT angiography does not result in increased nephrotoxicity.
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http://dx.doi.org/10.1016/j.jvir.2019.04.019DOI Listing
November 2019

Image-Guided Percutaneous Gastrostomy Tube Placement is Safe in Patients Requiring Aspirin 325 mg.

Acad Radiol 2019 11 14;26(11):1483-1487. Epub 2019 Mar 14.

Department of Radiology, Duke University School of Medicine, Durham, North Carolina.

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.
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http://dx.doi.org/10.1016/j.acra.2019.02.008DOI Listing
November 2019

Best Practices From the APDR: Improving Medical Student Exposure to Interventional Radiology.

Acad Radiol 2018 06 19;25(6):789-791. Epub 2018 Jan 19.

Indiana University School of Medicine, Department of Radiology and Imaging Sciences, Indiana University Hospital, 550 N. University Blvd., Room 0641, Indianapolis, IN 46202. Electronic address:

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http://dx.doi.org/10.1016/j.acra.2017.11.021DOI Listing
June 2018

No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites.

Cardiovasc Intervent Radiol 2019 May 2;42(5):720-728. Epub 2019 Jan 2.

Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA.

Purpose: To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.

Materials And Methods: In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.

Results: In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).

Conclusion: Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.
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http://dx.doi.org/10.1007/s00270-018-02155-9DOI Listing
May 2019

The State of Medical Student Teaching of Interventional Radiology: Implications for the Future.

J Am Coll Radiol 2018 Dec 21;15(12):1761-1764. Epub 2018 Sep 21.

Icahn School of Medicine at Mount Sinai, New York, New York.

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.
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http://dx.doi.org/10.1016/j.jacr.2018.07.016DOI Listing
December 2018

Modifying Institutional Guidelines Reduces the Likelihood of Oversedation During Interventional Procedures.

J Am Coll Radiol 2018 Aug 8;15(8):1185-1187. Epub 2018 May 8.

Division of Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

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http://dx.doi.org/10.1016/j.jacr.2018.03.050DOI Listing
August 2018

Quality Improvement Project to Increase Patients' Knowledge About Their Impending Procedures During the Consent Process.

J Am Coll Radiol 2018 Apr 18;15(4):652-654. Epub 2017 Dec 18.

Division of Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital Midtown, Atlanta, Georgia.

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http://dx.doi.org/10.1016/j.jacr.2017.10.033DOI Listing
April 2018

Obstruction of the Biliary and Urinary System.

Tech Vasc Interv Radiol 2017 Dec 9;20(4):288-293. Epub 2017 Oct 9.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.

Biliary and urinary obstructions can be managed endoscopically or cystoscopically, surgically or by percutansous intervention or drainage. If the obtructed system is infected, emergent decompression is needed. Early recognition and treatment is paramount in both conditions. Acute cholangitis can present many different ways, from mild symptoms to fulminant sepsis. It is usually a result of ascending bacterial colonization and biliary obstruction resulting in bacterial overgrowth. Therefore, those patients with recent biliary instrumentation or previous biliary modification are at higher risk. Charcot's triad of fever, right upper quadrant abdominal pain, and jaundice is only seen in 50%-70% of patients. Fever is seen in over 90% of cases, pain is seen in 70% of cases, and jaundice is seen in 60% of cases. Altered mental status and hypotension are associated with severe cases. All 5 symptoms of fever, right upper quadrant abdominal pain, jaundice, altered mental status, and hypotension are referred to as Reynold's Pentad. Acute pyonephrosis can also present many different ways, from minimal symptoms to fulminant sepsis. Fever, chills, and flank pain are the classic symptoms, although some patients may be relatively asymptomatic. Pyonephrosis may present with a classic triad of fever, flank pain, and hydronephrosis, or simply hydronephrosis and sepsis. Pyonephrosis usually occurs as a result of urinary obstruction with either an ascending infection of the urinary tract or hematogenous spread of a bacterial pathogen as the culprit. Up to 75% of cases are related to urinary stone disease. Patients are at increased risk for pyonephrosis when they haven anatomic urinary tract obstruction, certain chronic diseases (diabetes meliitus and AIDS), or are immunosuppressed due to immunodeficiency or medications, (chronic steroid therapy).
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http://dx.doi.org/10.1053/j.tvir.2017.10.010DOI Listing
December 2017

Acute Limb Ischemia.

Tech Vasc Interv Radiol 2017 Dec 12;20(4):274-280. Epub 2017 Oct 12.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.

Acute limb ischemia is technically defined as ischemia of the lower extremities lasting 14 days or less. The condition affects between 15 and 26 persons per 100,000 each year in the United States. The associated morbidity and mortality is extremely high, with 1-year mortality rates reported at over 40%. Acute limb ischemia is 20 times more common in the lower extremities than the upper extremities. Both interventional radiologists and vascular surgeons bring unique skills to the table in caring for these patients, and therefore should approach the care of these patients in a multidisciplinary manner to ensure the best outcomes for each patient. Patients should be classified according to the Rutherford classification scale for acute limb ischemia. Catheter-directed thrombolysis can be a viable treatment alternative for these patients, offering a minimally invasive option to patients with outcomes similar to surgery. It is important to know the presentation, physical examination, risks and benefits, as well as the techniques and equipment required to treat patients with acute lower limb ischemia.
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http://dx.doi.org/10.1053/j.tvir.2017.10.008DOI Listing
December 2017

Postpartum Hemorrhage.

Tech Vasc Interv Radiol 2017 Dec 10;20(4):266-273. Epub 2017 Oct 10.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.

Interventional radiologists are often called for emergent control of abnormal uterine bleeding. Bleeding, even heavy bleeding as a result of uterine fibroids is not a common emergent procedure; instead, pregnancy and pregnancy related conditions, trauma and malignancy associated with bleeding can be the source of many interventional radiology on call events or procedures. Postpartum hemorrhage (PPH) is the most common cause, and is defined as blood loss of 500mL after vaginal delivery or 1000mL after cesarean section. Several authors have suggested a simpler definition of any amount of blood loss that creates hemodynamic instability in the mother. Regardless, PPH can be a life-threatening emergency and is a leading cause of maternal mortality requiring prompt action. Primary PPH is bleeding within the first 24 hour of delivery and secondary PPH is hemorrhage that occurs more than 24 hour after delivery. In addition to death, other serious morbidity resulting from postpartum bleeding includes shock, adult respiratory distress syndrome, coagulopathy, and loss of fertility due to hysterectomy. Transcatheter uterine artery embolization was first introduced as a treatment for PPH in 1979. It is a nonsurgical, minimally invasive, extremely safe and effective treatment for controlling excessive bleeding of the female reproductive track usually after conservative measures have failed, yet somewhat underused. Referring providers have limited awareness of the procedure. In hospitals where interventional radiologists have the experience and technical expertise to perform pelvic arteriography and embolization, this therapeutic option can play a pivotal role in the management of emergent obstetric hemorrhage.
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http://dx.doi.org/10.1053/j.tvir.2017.10.007DOI Listing
December 2017

Management of Acute Lower Gastrointestinal Bleeding.

Tech Vasc Interv Radiol 2017 Dec 9;20(4):258-262. Epub 2017 Oct 9.

Department of Radiology and Imaging Sciences, Emory University Hospital, Emory University School of Medicine, Atlanta, GA.

Acute lower gastrointestinal bleeding (LGIB), defined as hemorrhage into the gastrointestinal tract distal to the ligament of Treitz, is a major cause of morbidity and mortality among adults. Overall, mortality rates are estimated between 2.4% and 3.9%. The most common etiology for LGIB is diverticulosis, implicated in approximately 30% of cases, with other causes including hemorrhoids, ischemic colitis, and postpolypectomy bleeding. Transcatheter visceral angiography has begun to play an increasingly important role in both the diagnosis and treatment of LGIB. Historically, transcatheter visceral angiography has been used to direct vasopressin infusion with embolization reserved for treatment of upper gastrointestinal bleeding. However, advances in microcatheter technology and embolotherapy have enabled super-selective embolization to emerge as the treatment of choice for many cases of LGIB.
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http://dx.doi.org/10.1053/j.tvir.2017.10.005DOI Listing
December 2017

CTA As an Adjuvant Tool for Acute Intra-abdominal or Gastrointestinal Bleeding.

Tech Vasc Interv Radiol 2017 Dec 9;20(4):248-257. Epub 2017 Oct 9.

Department of Radiology, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA.

Hematemesis and acute postsurgical upper gastrointestinal hemorrhage are common emergent on-call consultations for the interventional radiologist. Upper GI bleleding (UGIB) is a relatively frequent problem. The incidence and mortality vary among patient populations, but studies have shown an overall incidence ranging from 36-172 cases per 100,000 adults per year, with a mortality rate of 5%-14%. The incidence is significantly higher in men. Peptic ulcer disease is the predominant etiology, responsible for 28%-59% of UGIB. Other causes include varices, mucosal erosive disease, Mallory-Weiss syndrome, and malignancy. After assessment of hemodynamic status and airway stability with resuscitative efforts as needed, initial consultation with gastroenterology for endoscopic evaluation and treatment is well regarded as the initial therapeutic strategy. Angiography with embolization and interventional techniques directed at managing variceal hemorrhage have emerged as very capable second-line strategies for patients who have failed endoscopic therapy. In certain circumstances, the interventional radiologist may be called upon as the first line, notably for patients who have had recent surgical intervention or who have extraluminal hemorrhage. As the role of the interventional radiologist in the evaluation and treatment of UGIB continues to evolve, familiarity and knowledge of how to deal with these urgent and emergent clinical scenarios becomes paramount.
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http://dx.doi.org/10.1053/j.tvir.2017.10.004DOI Listing
December 2017

Emergent Endovascular Treatment of Penetrating Trauma: Solid Organ and Extremity.

Tech Vasc Interv Radiol 2017 Dec 7;20(4):243-247. Epub 2017 Oct 7.

Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, GA.

Penetrating injuries can result in acute or subacute arterial injuries of the solid organs or extremities. Although most penetrating injuries are managed conservatively, some patients require endovascular or surgical treatment. Often, the best method for management is controversial and the level of urgency for clinical decision-making is high. Once the decision has been made to intervene, the operator must also determine the best embolization material and technique to use. Not unfrequently, these decisions are made during the course of the procedure. There are numerous embolization agents, each of which serves a very specific purpose, depending on the clinical scenario. Within this article, we will review endovascular treatment indications, contraindications, and endovascular techniques for the treatment of penetrating trauma of the solid organs or extremities.
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http://dx.doi.org/10.1053/j.tvir.2017.10.003DOI Listing
December 2017