Publications by authors named "Waleska Pabon-Ramos"

33 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

Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel.

J Vasc Interv Radiol 2021 Feb 17. Epub 2021 Feb 17.

Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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http://dx.doi.org/10.1016/j.jvir.2021.01.269DOI Listing
February 2021

The Symptoms-Varices-Pathophysiology (SVP) Classification of Pelvic Venous Disorders A Report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

J Vasc Surg Venous Lymphat Disord 2021 Jan 30. Epub 2021 Jan 30.

Fairfield, CT.

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the "May-Thurner," "pelvic congestion," and "nutcracker" syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based upon a perceived need, the American Vein and Lymphatic Society (AVLS) convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the "SVP" classification for PeVD, includes three domains - Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with CEAP. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.
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http://dx.doi.org/10.1016/j.jvsv.2020.12.084DOI Listing
January 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

Complications during Lymphangiography and Lymphatic Interventions.

Semin Intervent Radiol 2020 Aug 31;37(3):309-317. Epub 2020 Jul 31.

Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia.

Lymphangiography as a diagnostic procedure dates back to the 1950s and was widely performed for several decades until being supplanted by other advanced imaging techniques. With the advent of thoracic duct embolization to treat chylothorax, Constantin Cope ushered in a transition from lymphangiography as a diagnostic procedure to a precursor for lymphatic intervention. Subsequently, technical modifications and applications of lymphatic embolization to other medical conditions have greatly expanded the scope and application of lymphangiography and lymphatic intervention. Although there is increasing familiarity with lymphatic interventions, few interventionalists have performed a high enough volume to be aware of potential complications and their management. Potential complications of lymphangiography and those encountered while performing lymphatic interventions are discussed along with approaches to minimize their risk and management strategies should they occur.
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http://dx.doi.org/10.1055/s-0040-1713448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394574PMC
August 2020

Lymphatic Imaging: Current Noninvasive and Invasive Techniques.

Semin Intervent Radiol 2020 Aug 31;37(3):237-249. Epub 2020 Jul 31.

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

After nearly disappearing, invasive lymphangiography not only has resurged, but new approaches have been developed to guide lymphatic interventions. At the same time, noninvasive lymphatic imaging is playing a larger role in the evaluation of lymphatic pathologies. Lymphangioscintigraphy, computed tomography lymphangiography, and magnetic resonance lymphangiography are increasingly being used as alternatives to invasive diagnostic lymphangiography. The purpose of this article is to review current invasive and noninvasive lymphatic imaging techniques.
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http://dx.doi.org/10.1055/s-0040-1713441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394578PMC
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

Magnetic Resonance Lymphangiography of the Central Lymphatic System: Technique and Clinical Applications.

J Magn Reson Imaging 2021 02 11;53(2):374-380. Epub 2020 Feb 11.

Division of Cardiothoracic Imaging, Duke University Medical Center, Durham, North Carolina, USA.

Magnetic resonance lymphangiography (MRL) is a noninvasive imaging technique that can be used in the management of lymphatic disorders to delineate the central lymphatic system for treatment planning. This article reviews the MRL technique, its advantages, limitations, indications, and impact on patient management. Level of Evidence 5 Technical Efficacy Stage 3 J. MAGN. RESON. IMAGING 2021;53:374-380.
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http://dx.doi.org/10.1002/jmri.27069DOI Listing
February 2021

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

Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment.

J Vasc Interv Radiol 2020 Feb 6;31(2):243-250. Epub 2019 Nov 6.

Division of Interventional Radiology, Duke University Medical Center, Durham, North Carolina. Electronic address:

Purpose: To compare outcomes after conversion of arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling owing to ipsilateral central vein stenosis.

Materials And Methods: This single-center retrospective study comprised 48 patients (19 men, mean age 58 y) with arm swelling ipsilateral to AV access and central vein stenosis over a 13-year period who had clinical follow-up and without prior central stents. Twenty-one patients underwent placement of a HeRO graft with anastomosis of the HeRO graft to the existing graft or fistula, and 27 patients underwent central venous stent deployment. Symptomatic improvement in arm swelling and access patency rates after intervention were ascertained from medical records.

Results: Improvement in swelling within 1 month after HeRO conversion and stent deployment was found in 95% and 89%, respectively (P = .62). Swelling eventually recurred in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Primary access patency was statistically significantly longer after HeRO conversions than stent deployments, with 6- and 12-month primary patency rates of 89% and 72% vs 47% and 11% (P < .001). HeRO conversions also resulted in longer 6- and 12-month secondary access patency rates (95% and 95% vs 79% and 58%, P = .006). Mean number of interventions per 1,000 access days to maintain secondary patency was 2.7 for the HeRO group vs 6.3 for the stent group.

Conclusions: Although stent deployment and HeRO graft conversion are effective for alleviating arm swelling in the short term in patients receiving hemodialysis with clinically significant arm swelling and functioning AV access, the HeRO graft has more durable results.
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http://dx.doi.org/10.1016/j.jvir.2019.06.010DOI Listing
February 2020

Management of Port Occlusions in Adults: Different-Site Replacement versus Same-Site Salvage.

J Vasc Interv Radiol 2019 Jul 24;30(7):1069-1074. Epub 2019 May 24.

Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

Purpose: To compare the safety and effectiveness of different-site port placement versus same-site port salvage in adult patients with occluded ports.

Materials And Methods: Ninety-five occluded subcutaneous infusion ports (ports) in 95 patients presenting between July 1, 2002, and June 30, 2017, were retrospectively reviewed: 48 (51%) different-site placements (replacements; same-day indwelling port removal and different-site new port placement) and 47 (49%) same-site salvages (salvages; 35 fibrin sheath strippings, 12 over-the-wire exchanges). Demographic information, indication for initial placement and replacement or salvage, procedural details, post-intervention primary catheter patency, and post-intervention port sequelae were recorded. Post-intervention primary catheter patency, and malfunction and infection rates were compared with Kaplan-Meier estimation and the log-rank test, and Fisher exact test, respectively. The association of patient risk factors and port patency was assessed with Cox regression.

Results: Median primary catheter patency after replacement was 254 days (interquartile range [IQR], 297) and after salvage was 391 days (IQR, 906) (P = .25). Within the salvage group, median primary catheter patency after stripping was 391 days (IQR, 658) and after exchange was 666 days (IQR, 1412) (P = .08). There was no statistical difference in malfunction (P = .12) and infection (P = .74) rates between the replaced and salvaged groups or in malfunction (P = .09) and infection (P = .1) rates between the exchanged and stripped subgroups. None of the patient or catheter characteristics assessed were significantly associated with primary catheter patency.

Conclusions: There was no statistical difference between patency, malfunctions, or infections after replacement and salvage, or after stripping and exchange, so technique selection should be based on the patient's estimated lifetime venous access requirements, cost, and physician preference.
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http://dx.doi.org/10.1016/j.jvir.2019.02.027DOI Listing
July 2019

Proton Pump Inhibitor Use Is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

J Vasc Interv Radiol 2019 02 11;30(2):163-169. Epub 2019 Jan 11.

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

Purpose: To determine whether proton pump inhibitor (PPI) use increases the rate of new or worsening hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation.

Materials And Methods: In this retrospective study, 284 of 365 patients who underwent TIPS creation from January 1, 2005, to December 31, 2016, were analyzed (186 male, mean age 56 y, range 19-84 y). Dates of PPI use and dates of new or worsening HE, defined as hospitalization or escalation in outpatient medical management, were extracted from medical records. Mixed-effects negative binomial regression was used to test for an association between PPI usage and HE.

Results: After TIPS creation, among 168 patients on PPIs chronically, there were 235 episodes of new or worsening HE in 106,101 person-days (0.81/person-year). Among 55 patients never on PPIs, there were 37 episodes in 31,066 person-days (0.43/person-year). Among 61 patients intermittently taking PPIs, there were 78 episodes in 37,710 person-days while on PPIs (0.75/person-year) and 25 episodes in 35,678 person-days while off PPIs (0.26/person-year). In univariate regression, PPI usage was associated with a 3.34-fold increased rate of new or worsening HE (incidence rate ratio [IRR] 3.34; P < .001). In multivariate regression, older age (IRR 1.05; P < .001), male sex (IRR 1.58; P = .023), higher Model for End-Stage Liver Disease score (IRR 1.06; P = .015), previous HE or HE-preventive medication use (IRR 1.51; P = .029), and PPI use (IRR 3.19; P < .001) were significant risk factors. Higher PPI doses were associated with higher rates of HE (IRR 1.16 per 10 mg omeprazole equivalent; P = .046).

Conclusions: PPI usage is associated with increased rates of new or worsening HE after TIPS creation.
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http://dx.doi.org/10.1016/j.jvir.2018.10.015DOI Listing
February 2019

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

Identification and Management of Abdominal Wall Varices in Pregnancy.

Obstet Gynecol 2018 10;132(4):882-887

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, the Department of Radiology, Division of Interventional Radiology, the Department of Anesthesia, Division of Women's Anesthesia, the Department of General Surgery, Division of Abdominal Transplant Surgery, the Department of Medicine, Division of Hematology and Oncology, the Department of Radiology, Division of Cardiothoracic Imaging, and the Department of Medicine, Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina.

Background: Portal hypertension in pregnancy is associated with elevated risk of variceal hemorrhage. Ectopic varices, those located outside the esophagus or stomach, are rare but have a high risk of associated maternal morbidity or mortality.

Case: A 31-year-old woman, gravida 2 para 0010, with cirrhosis and portal hypertension was found to have abdominal wall ectopic varices on third-trimester obstetric ultrasonography. Computed tomography angiography confirmed these findings. Given concern for catastrophic hemorrhage during delivery, she underwent transjugular intrahepatic portosystemic shunt placement at 35 weeks of gestation, with reduction in the pressure gradient within the portosystemic circulation. She subsequently underwent an uncomplicated cesarean delivery.

Conclusion: Identification of ectopic varices on obstetric ultrasonography may allow for treatment before delivery, decreasing the risk of serious maternal morbidity or mortality.
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http://dx.doi.org/10.1097/AOG.0000000000002805DOI Listing
October 2018

Pilot Evaluation of Angiogenesis Signaling Factor Response after Transcatheter Arterial Embolization for Hepatocellular Carcinoma.

Radiology 2017 10 8;285(1):311-318. Epub 2017 Aug 8.

From the Department of Radiology, Division of Vascular & Interventional Radiology (J.R., D.M., R.T.G., G.J., W.C., P.V.S., W.P.R., D.R.S., C.Y.K.), and Department of Medicine (A.B.N., M.D.S., J.C.B., H.I.H.), Duke University Medical Center, Box 3808 Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710.

Purpose To identify changes in a broad panel of circulating angiogenesis factors after bland transcatheter arterial embolization (TAE), a purely ischemic treatment for hepatocellular carcinoma (HCC). Materials and Methods This prospective HIPAA-compliant study was approved by the institutional review board. Informed written consent was obtained from all participants prior to entry into the study. Twenty-five patients (21 men; mean age, 61 years; range, 30-81 years) with Liver Imaging Reporting and Data System category 5 or biopsy-proven HCC and who were undergoing TAE were enrolled from October 15, 2014, through December 2, 2015. Nineteen plasma angiogenesis factors (angiopoietin 2; hepatocyte growth factor; platelet-derived growth factor AA and BB; placental growth factor; vascular endothelial growth factor A and D; vascular endothelial growth factor receptor 1, 2, and 3; osteopontin; transforming growth factor β1 and β2; thrombospondin 2; intercellular adhesion molecule 1; interleukin 6 [IL-6]; stromal cell-derived factor 1; tissue inhibitor of metalloproteinases 1; and vascular cell adhesion molecule 1 [VCAM-1]) were measured by using enzyme-linked immunosorbent assays at 1 day, 2 weeks, and 5 weeks after TAE and were compared with baseline levels by using paired Wilcoxon tests. Tumor response was assessed according to modified Response Evaluation Criteria in Solid Tumors (mRECIST). Angiogenesis factor levels were compared between responders and nonresponders by mRECIST criteria by using unpaired Wilcoxon tests. Results All procedures were technically successful with no complications. Fourteen angiogenesis factors showed statistically significant changes following TAE, but most changes were transient. IL-6 was upregulated only 1 day after the procedure, but showed the largest increases of any factor. Osteopontin and VCAM-1 demonstrated sustained upregulation at all time points following TAE. At 3-month follow-up imaging, 11 patients had responses to TAE (complete response, n = 6; partial response, n = 5) and 11 patients were nonresponders (stable disease, n = 9; progressive disease, n = 2). In nonresponders, the percent change in IL-6 on the day after TAE (P = .033) and the mean percent change in osteopontin after TAE (P = .024) were significantly greater compared with those of responders. Conclusion Multiple angiogenesis factors demonstrated significant upregulation after TAE. VCAM-1 and osteopontin demonstrated sustained upregulation, whereas the rest were transient. IL-6 and osteopontin correlated significantly with radiologic response after TAE. RSNA, 2017.
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http://dx.doi.org/10.1148/radiol.2017162555DOI Listing
October 2017

MRI of the Central Lymphatic System: Indications, Imaging Technique, and Pre-Procedural Planning.

Top Magn Reson Imaging 2017 Aug;26(4):175-180

Duke University Medical Center, Durham, NC.

Magnetic resonance imaging is increasingly being used to evaluate the lymphatic system. Advances in magnetic resonance (MR) software and hardware allow improved visualization of lymph nodes and lymphatic vessels. We describe how MR lymphangiography can be used to diagnose central lymphatic system anatomy and pathology, which can be used for diagnostic purposes or for pre-procedural planning.
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http://dx.doi.org/10.1097/RMR.0000000000000130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548502PMC
August 2017

Treatment of central venous in-stent restenosis with repeat stent deployment in hemodialysis patients.

J Vasc Access 2017 May 20;18(3):214-219. Epub 2017 Apr 20.

 Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, NC - USA.

Purpose: To report patency rates for stent deployment for treatment of in-stent stenosis of the central veins of the chest in hemodialysis patients.

Materials And Methods: A retrospective analysis was performed on 29 patients who underwent 35 secondary percutaneous transluminal stent (PTS) deployments for in-stent stenosis within the central veins that were refractory to angioplasty and ipsilateral to a functioning hemodialysis access (in-stent PTS group). For comparison, patency data were acquired for 47 patients who underwent 78 successful percutaneous transluminal angioplasty (PTA) procedures for in-stent stenosis (in-stent PTA group) and 55 patients who underwent 55 stent deployments within native central vein stenosis refractory to angioplasty (native vein PTS group).

Results: The 3-, 6-, and 12-month primary lesion patency for the in-stent PTS group was 73%, 57%, and 32%, respectively. The 3-, 6-, and 12-month primary patency for the in-stent PTA group was 70%, 38%, and 17% and for the native vein PTS group was 78%, 57%, and 26%, which were similar to the in-stent PTS group (p = 0.20 and 0.41, respectively). The 3-, 6-, and 12-month secondary access patency was 91%, 73%, and 65% for the in-stent PTS group. Sub-analysis of the in-stent PTS group revealed no difference in primary (p = 0.93) or secondary patency rates (p = 0.27) of bare metal stents (n = 23) compared with stent grafts (n = 12).

Conclusions: Stent deployment for central vein in-stent stenosis refractory to angioplasty was associated with reasonable patency rates, which were similar to in-stent PTA and native vein PTS.
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http://dx.doi.org/10.5301/jva.5000705DOI Listing
May 2017

Morbidity and healthcare costs of vascular anomalies: a national study.

Pediatr Surg Int 2017 Feb 22;33(2):149-154. Epub 2016 Nov 22.

Duke University Medical Center, Box 3443, Durham, NC, 27710, USA.

Purpose: This study aimed to define morbidities and costs related to modern-day medical care for children with vascular anomalies.

Methods: We reviewed the 2003-2009 Kids' Inpatient Database for pediatric patients (age < 21 years) hospitalized with hemangioma, arteriovenous malformation (AVM), or lymphatic malformation (LM). Patient characteristics, hospital complications, and hospital charges were compared by vascular anomaly type. Multivariable linear regression modeling was used to determine predictors of increasing hospital costs for patients with AVMs.

Results: In total, 7485 pediatric inpatients with vascular anomalies were identified. Frequently associated complications included chronic anemia (4.0%), sepsis (4.6%), and hypertension (2.4%). Children with AVM had the highest rate of in-hospital mortality, compared to those with hemangiomas or LM (1.0% vs. 0.1% vs. 0.3%, p < 0.001). AVMs were also associated with the highest median hospital charge, more than twice the cost for hemangiomas or LM ($45,875 vs. $18,909 vs. $18,919; p < 0.001).

Conclusions: There is a significant rate of morbidity in children with vascular anomalies, most often from blood loss and infection. The greater cost of AVM care may be related to the higher mortality rate, associated complications, and complexity of procedures required treating them. Cost-effective management of vascular anomalies should target prevention and the early recognition of both chronic comorbidities and acute complications.
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http://dx.doi.org/10.1007/s00383-016-4007-xDOI Listing
February 2017

Randomized Controlled Trial of Octyl Cyanoacrylate Skin Adhesive versus Subcuticular Suture for Skin Closure after Implantable Venous Port Placement.

J Vasc Interv Radiol 2017 Jan 9;28(1):111-116. Epub 2016 Nov 9.

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

Purpose: To compare early outcomes of skin closure with octyl cyanoacrylate skin adhesive versus subcuticular suture closure.

Materials And Methods: Over a 7-month period, 109 subjects (28 men and 81 women; mean age, 58.6 y) scheduled to undergo single-lumen implantable venous port insertion for chemotherapy were randomly assigned to skin closure with either octyl cyanoacrylate skin adhesive or absorbable subcuticular suture after suturing the deep dermal layer. Subjects were followed for episodes of infection or dehiscence within 3 months of port implantation. At 3 months, photographs of the healed incision were obtained and reviewed by a plastic surgeon in a blinded fashion who rated cosmetic scar appearance based on a validated 10-point cosmesis score.

Results: Of subjects, 54 were randomly assigned to skin adhesive, and 55 were randomly assigned to subcuticular suture. No subjects had incision dehiscence. Infection rates at 3 months were similar between groups (2.1% vs 4.0%; P = 1.0). The mean cosmesis scores were 4.40 for skin adhesive and 4.46 for subcuticular suture (P = .898). The superficial skin closure time was 8.6 minutes for suture versus 1.4 minutes for skin adhesive (P < .001).

Conclusions: Scar cosmesis and patient outcomes did not significantly vary between skin adhesive versus subcuticular suture, although skin closure time was significantly less with skin adhesive.
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http://dx.doi.org/10.1016/j.jvir.2016.08.009DOI Listing
January 2017

Quality Improvement Guidelines for Percutaneous Nephrostomy.

J Vasc Interv Radiol 2016 Mar 21;27(3):410-4. Epub 2016 Jan 21.

Department of Radiology, Stratton Medical Center, Albany, New York.

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http://dx.doi.org/10.1016/j.jvir.2015.11.045DOI Listing
March 2016

Effectiveness of Transarterial Embolization of Hepatocellular Carcinoma as a Bridge to Transplantation.

J Vasc Interv Radiol 2016 Jan 21;27(1):39-45. Epub 2015 Oct 21.

Divisions of Vascular and Interventional Radiology, Duke University Medical Center, Box 3808, 2311 Erwin Rd., Durham, NC 27710. Electronic address:

Purpose: To assess the effectiveness of bland transarterial embolization of hepatocellular carcinoma (HCC) as a "bridge" to transplantation.

Materials And Methods: In this retrospective study, 117 patients with HCC that met Milan criteria underwent bland embolization as their initial and sole therapy for treatment of HCC (88 men and 29 women; mean age, 60.4 y; range, 35-88 y). Subsequent postembolization contrast-enhanced computed tomography or magnetic resonance imaging studies were reviewed to determine whether Milan criteria were met in an intent-to-transplant analysis. Freedom from progression beyond Milan criteria and survival were calculated by Kaplan-Meier technique. Predictors of progression and survival were also assessed.

Results: After embolization, 87% and 78% of patients' disease still met Milan criteria at 6 and 12 months, respectively. The median time until disease progression beyond Milan criteria was 22.6 months (95% confidence interval, 16.2-29 mo). α-Fetoprotein levels, number of lesions, United Network for Organ Sharing stage, Model for End-stage Liver Disease score, and cirrhosis etiology did not correlate significantly with stability within Milan criteria. A total of 34 patients (29%) underwent eventual liver transplantation at a median of 3.3 months (range, 0.5-20.9 mo). Liver transplantation was a significant independent predictor of longer survival (6.9 y vs 2.6 y; P < .001). The major complication rate within 30 days of embolization was 2.6%, including one mortality.

Conclusions: Bland transarterial embolization as a bridging strategy to maintain HCC within Milan criteria was successful in 78% of patients at 1 year, which compares favorably with other locoregional embolotherapies.
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http://dx.doi.org/10.1016/j.jvir.2015.08.032DOI Listing
January 2016

Postintervention Patency Rates and Predictors of Patency after Percutaneous Interventions on Intragraft Stenoses within Failing Prosthetic Arteriovenous Grafts.

J Vasc Interv Radiol 2015 Nov 26;26(11):1673-9. Epub 2015 Sep 26.

Division of Vascular and Interventional Radiology, Duke University Medical Center, Box 3808, 2311 Erwin Rd., Durham, NC 27710. Electronic address:

Purpose: To determine postintervention patency rates after endovascular interventions on intragraft stenosis within failing prosthetic arteriovenous (AV) grafts, as well as predictors of patency.

Materials And Methods: Retrospective review of percutaneous interventions on prosthetic AV grafts presenting with first-time intragraft stenoses over a 7-year period revealed 183 patients (81 male; mean age, 59.7 y). "Intragraft" was defined as 2 cm or more from the arterial or venous anastomosis. Procedural imaging was retrospectively reviewed. Patency rates were estimated by Kaplan-Meier test. Predictors of patency were calculated by Cox proportional-hazards model.

Results: Two-hundred twenty-nine intragraft stenoses were identified in 183 grafts. Intragraft stenoses were treated at a median of 20.7 months (interquartile range, 12.0-33.9 mo) after graft creation. Graft thrombosis was present in 62%. The anatomic success rate of angioplasty was 85%. Fifteen percent required stent or stent-graft deployment because of inadequate response to angioplasty. A concurrent nonintragraft stenosis within the access circuit was identified in 76% of grafts. At 3, 6, and 12 months, postintervention primary patency rates were 56%, 40%, and 23%, respectively. Secondary patency rates were 84%, 77%, and 67%, respectively. The lesion-specific patency rates were 89, 75%, and 63%, respectively. Graft thrombosis (hazard ratio [HR], 1.43; P = .048) and concurrent nonintragraft lesion (HR, 1.51; P = .047) were independent negative predictors of primary patency. Graft thrombosis (HR, 1.81; P = .029) was a negative predictor of lesion patency, and stent or stent-graft deployment (HR, 0.42; P = .045) was a positive predictor of lesion patency.

Conclusions: Endovascular interventions on intragraft stenoses resulted in primary, secondary, and lesion-specific patency rates of 40%, 77%, and 75%, respectively, at 6 months. Stent or stent-graft deployment may prolong lesion patency.
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http://dx.doi.org/10.1016/j.jvir.2015.08.008DOI Listing
November 2015

Assessing medical students' knowledge of IR at two American medical schools.

J Vasc Interv Radiol 2014 Nov 22;25(11):1801-6, 1807.e1-5. Epub 2014 Jul 22.

Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 107 Old Clinic Building, CB# 7510, Chapel Hill, North Carolina 27599.

Purpose: To determine if there was a difference in the level of knowledge about interventional radiology (IR) between medical students in preclinical years of training compared with medical students in clinical years of training at two medical schools and to compare awareness of IR based on the curriculum at each school: one with required radiology education and one without such a requirement.

Materials And Methods: An anonymous survey was distributed to students at two medical schools; the survey assessed knowledge of IR, knowledge of training pathways, and preferred methods to increase exposure. Responses of the preclinical and clinical groups were compared, and responses from the clinical groups at each school were compared.

Results: "Poor" or "fair" knowledge of IR was reported by 84% (n = 217 of 259) of preclinical students compared with 62% of clinical students (n = 110 of 177; P < .001). IR was being considered as a career by 11% of all students (15%, n = 40 of 259 preclinical; 5%, n = 9 of 177 clinical). The main reason respondents were not considering IR was "lack of knowledge" (65%, n = 136 of 210 preclinical; 20%, n = 32 of 162 clinical). Students in the clinical group at the institution with a required radiology rotation reported significantly better knowledge of IR than clinical students from the institution without a required clerkship (P = .017).

Conclusions: There are significant differences in knowledge of IR between preclinical and clinical students. Required radiology education in the clinical years does increase awareness of IR.
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http://dx.doi.org/10.1016/j.jvir.2014.06.008DOI Listing
November 2014

Alternative treatment for bleeding peristomal varices: percutaneous parastomal embolization.

Cardiovasc Intervent Radiol 2013 Oct 13;36(5):1399-404. Epub 2013 Mar 13.

Department of Radiology, Duke University Hospital, P.O. Box 3808, Durham, NC, 27710, USA,

Purpose: To describe how peristomal varices can be successfully embolized via a percutaneous parastomal approach.

Methods: The medical records of patients who underwent this procedure between December 1, 2000, and May 31, 2008, were retrospectively reviewed. Procedural details were recorded. Median fluoroscopy time and bleeding-free interval were calculated.

Results: Seven patients underwent eight parastomal embolizations. The technical success rate was 88 % (one failure). All embolizations were performed with coils combined with a sclerosant, another embolizing agent, or both. Of the seven successful parastomal embolizations, there were three cases of recurrent bleeding; the median time to rebleeding was 45 days (range 26-313 days). The remaining four patients did not develop recurrent bleeding during the follow-up period; their median bleeding-free interval was 131 days (range 40-659 days).

Conclusion: This case review demonstrated that percutaneous parastomal embolization is a feasible technique to treat bleeding peristomal varices.
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http://dx.doi.org/10.1007/s00270-013-0588-0DOI Listing
October 2013

Percutaneous interventions on the hemodialysis reliable outflow vascular access device.

J Vasc Interv Radiol 2013 Apr 23;24(4):543-9. Epub 2013 Feb 23.

Division of Vascular and Interventional Radiology, Duke University Medical Center, Box 3808, Duke North, Room 1502, Durham, NC 27710, USA.

Purpose: To determine the outcomes of percutaneous interventions for prolonging the patency of the Hemodialysis Reliable Outflow (HeRO) device.

Materials And Methods: Between January 2007 and August 2011, 73 percutaneous interventions were performed on 26 HeRO devices in 25 patients. The graft was implanted in the upper arm with the outflow catheter tip in the superior vena cava or right atrium. Procedural reports, angiographic images, and clinical notes were retrospectively reviewed. The primary and secondary patency rates after intervention were calculated using the Kaplan-Meier method.

Results: The mean time from HeRO implantation to initial dysfunction or thrombosis was 171 days. In 60 (82%) procedures, the HeRO device was thrombosed. An intragraft stenosis was the most common lesion identified (59%; n = 43) followed by an arterial anastomosis stenosis identified in 18% (n = 13). In 22% (n = 16) of procedures in which the HeRO device was thrombosed, an underlying cause was not identified after thrombectomy. The 3-, 6-, and 12-month primary patency rates after intervention were 47%, 37%, and 26% for first-time interventions. The secondary patency rates were 80%, 70%, and 64%. The only complication was pulmonary embolism resulting in death 2 days after HeRO thrombectomy.

Conclusions: Percutaneous interventions on thrombosed and failing HeRO devices yielded acceptable primary and secondary patency rates after intervention in these patients with few, if any, alternatives for hemodialysis access.
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http://dx.doi.org/10.1016/j.jvir.2012.12.027DOI Listing
April 2013