Chest radiography in the ICU: Part 2, Evaluation of cardiovascular lines and other devices.

AJR Am J Roentgenol. 2012 Mar;198(3):572-81

Authors: Godoy MC, Leitman BS, de Groot PM, Vlahos I, Naidich DP

Abstract
OBJECTIVE: In this pictorial essay, we discuss and illustrate normal and aberrant positioning of the cardiovascular support and monitoring devices frequently used in critically ill patients, including central venous catheters, pulmonary artery catheters, left atrial catheters, transvenous pacemakers, automatic implantable cardioverter defibrillators, intraaortic counterpulsation balloon pump, and ventricular assist devices, as well as their inherent complications. CONCLUSION: The radiographic evaluation of the support and monitoring devices used in patients in the ICU is important, because the potentially serious complications arising from their introduction and use are often not clinically apparent. Familiarity with normal and abnormal radiographic findings is critical for the detection of these complications.

PMID: 22357995 [PubMed - indexed for MEDLINE]

Nonthrombotic pulmonary embolism.

AJR Am J Roentgenol. 2012 Feb;198(2):W152-9

Authors: Khashper A, Discepola F, Kosiuk J, Qanadli SD, Mesurolle B

Abstract
OBJECTIVE: The purpose of this essay is to highlight the clinical features and imaging findings associated with different types of nonthrombotic pulmonary embolism. CONCLUSION: Nonthrombotic pulmonary embolism is an infrequent condition with various causes that can be life-threatening pathologic conditions. The entity presents a diagnostic challenge because of the low specificity of clinical symptoms and imaging signs. Awareness of the imaging features of nonthrombotic pulmonary embolism facilitates correct diagnosis and leads to appropriate patient care.

PMID: 22268205 [PubMed - in process]

A novel double stent system for palliative treatment of malignant extrahepatic biliary obstructions: a pilot study.

AJR Am J Roentgenol. 2011 Nov;197(5):W942-7

Authors: Gwon DI, Ko GY, Sung KB, Yoon HK, Shin JH, Kim JH, Kim J, Oh JY, Song HY

Abstract
OBJECTIVE: The purpose of this study is to investigate the efficacy and safety of a novel double stent in patients with malignant extrahepatic biliary obstruction.
SUBJECTS AND METHODS: This prospective pilot study enrolled 45 consecutive patients with malignant extrahepatic biliary obstructions from January 2008 to December 2009. All patients were treated with a novel double stent system (covered stent in uncovered stent).
RESULTS: The double stents were successfully placed in all patients. Bilirubin levels decreased significantly after stent placement (p < 0.001). Median patient survival and stent patency times were 149 days (95% CI, 126-172 days) and 439 days (95% CI, 123-755 days), respectively. Cumulative stent patency rates at 3, 6, 9, and 12 months were 91%, 89%, 82%, and 82%, respectively. Five patients (11.1%) presented with stent occlusion due to tumor overgrowth (n = 3) or sludge incrustation (n = 2) and required repeat intervention. Tumor ingrowth, acute cholecystitis, pancreatitis, or stent migration was not observed in any of these patients.
CONCLUSION: Preliminary results indicate that percutaneous treatment of malignant extrahepatic biliary obstructions using a novel double stent is feasible, safe, and effective in achieving internal biliary drainage.

PMID: 22021547 [PubMed - in process]

The Negative Appendectomy Rate: Who Benefits From Preoperative CT?

AJR Am J Roentgenol. 2011 Oct;197(4):861-866

Authors: Webb EM, Nguyen A, Wang ZJ, Stengel JW, Westphalen AC, Coakley FV

Abstract
OBJECTIVE: The purpose of this article is to determine the negative appendectomy rates of patients who did and did not undergo preoperative CT and to determine, more specifically, whether men benefit from preoperative CT. MATERIALS AND METHODS: We identified 512 patients who had a nonincidental appendectomy between July 1, 2002, and June 30, 2007. Pathology records were compared with a radiology records search to determine which patients underwent preoperative CT. Proportions of patients were compared between groups using the Fisher exact test. RESULTS: Of 512 patients who had a nonincidental appendectomy, 465 (91%) underwent preoperative CT, and 47 (9%) underwent appendectomy only on the basis of clinical findings. Overall, 22 of 465 patients (4.7%) who underwent preoperative CT had a negative appendectomy compared with six of 47 patients who did not undergo preoperative imaging (negative appendectomy rate, 12.7%; p = 0.03). Among men, six of 237 (2.5%) with preoperative CT had a negative appendectomy, versus five of 42 without imaging (negative appendectomy rate, 11.9%; p = 0.01). CONCLUSION: The negative appendectomy rate was decreased for adult patients who underwent preoperative CT compared with patients who did not undergo preoperative imaging. Although most prior studies have suggested that CT is efficacious only in decreasing the negative appendectomy rate among women, we found that men benefit from CT as well.

PMID: 21940573 [PubMed - as supplied by publisher]

Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased bleeding complications after ultrasound-guided thoracentesis.

AJR Am J Roentgenol. 2011 Jul;197(1):W164-8

Authors: Patel MD, Joshi SD

The objective of our study was to identify differences in hemorrhagic complications after ultrasound-guided thoracentesis on the basis of patient coagulation parameters.

PMID: 21700980 [PubMed - in process]

Incidental Finding of Renal Masses at Unenhanced CT: Prevalence and Analysis of Features for Guiding Management.

AJR Am J Roentgenol. 2011 Jul;197(1):139-45

Authors: O'Connor SD, Pickhardt PJ, Kim DH, Oliva MR, Silverman SG

The purposes of this study were to investigate the frequency and clinical relevance of the incidental finding of renal masses at low-dose unenhanced CT and to analyze the results for features that can be used to guide evaluation.

PMID: 21701022 [PubMed - in process]

Urgent findings on portable chest radiography: what the radiologist should know--review.

AJR Am J Roentgenol. 2011 Jun;196(6 Suppl):S45-61

Authors: Asrani A, Kaewlai R, Digumarthy S, Gilman M, Shepard JA

PMID: 21606235 [PubMed - in process]

Phase I/II Study of Transjugular Transhepatic Peritoneovenous Venous Shunt, a New Procedure to Manage Refractory Ascites in Cancer Patients: Japan Interventional Radiology in Oncology Study Group 0201.

AJR Am J Roentgenol. 2011 May;196(5):W621-W626

Authors: Arai Y, Inaba Y, Sone M, Saitoh H, Takeuchi Y, Shioyama Y, Nakajima Y

OBJECTIVE: This multicenter phase I/II study evaluated the safety and the efficacy of transjugular transhepatic peritoneovenous shunt (PVS), a new palliative treatment for malignant refractory ascites. SUBJECTS AND METHODS: Patients with refractory malignant ascites and patent hepatic veins and vena cava were included in this study. Eligible patients underwent the placement of transjugular transhepatic PVS catheter via the jugular vein into the abdominal cavity through the hepatic vein. In phase I, a step-by-step analysis of the safety was performed. The safety and the efficacy were determined through phases I and II. RESULTS: Thirty-three patients were entered in this study, nine in phase I and 24 in phase II. Transjugular transhepatic PVS was technically successful in all patients. No severe adverse events were observed during the placement procedure. After the placement, 22 adverse events (grade 2 or higher) occurred. Frequent adverse events were hypoalbuminemia (24%) and decrease in hemoglobin (18%), which resolved within 1 week without additional treatment. The clinical efficacy rate at 1 week after the procedure was 67%. Occlusion of the catheter due to fibrin sheath was observed in seven patients, and the revision of the system was performed. CONCLUSION: Transjugular transhepatic PVS is a safe and feasible procedure for managing refractory ascites in patients with cancer. Sufficient efficacy was observed in our initial experience, but a larger clinical trial is warranted.

PMID: 21512054 [PubMed - as supplied by publisher]

Does a Clinical Decision Rule Using D-Dimer Level Improve the Yield of Pulmonary CT Angiography?

AJR Am J Roentgenol. 2011 May;196(5):1059-1064

Authors: Soo Hoo GW, Wu CC, Vazirani S, Li Z, Barack BM

OBJECTIVE: The objective of our study was to evaluate the impact of incorporating a mandatory clinical decision rule and selective d-dimer use on the yield of pulmonary CT angiography (CTA). MATERIALS AND METHODS: Guidelines incorporating a clinical decision rule (Wells score: range, 0-12.5) and a highly sensitive d-dimer assay as decision points were placed into a computerized order entry menu. From December 2006 through November 2008, 261 pulmonary CTA examinations of 238 men and 14 women (mean age ± SD, 65 ± 12 years; range, 31-92 years) were performed. Eight patients underwent more than one pulmonary CTA examination. Charts were reviewed. The results of pulmonary CTA, the clinical decision rule, and d-dimer level (if obtained) were analyzed with the Student t test, chi-square test, or other comparisons using statistical software (MedCalc, version 11.0). RESULTS: Of the pulmonary CTA examinations, 16.5% (43/261) were positive for pulmonary embolism (PE) compared with 3.1% (6/196) during the previous 2 years. The mean clinical decision rule score and mean d-dimer level were 5.5 ± 2.4 (SD) and 4956 ± 2892 ng/mL, respectively, for those with PE compared with 4.5 ± 2.1 and 2398 ± 2100 ng/mL for those without PE (both, p < 0.01). The negative predictive value of a clinical decision rule score of 4 or less and d-dimer level of less than 1000 ng/mL was 1.0. A clinical decision rule of greater than 4 and a higher d-dimer level were better predictors for PE, especially a d-dimer level of greater than 3000 ng/mL (odds ratio = 6.69; 95% CI = 2.72-16.43). CONCLUSION: Guidelines combining a clinical decision rule with d-dimer level significantly improved the utilization of pulmonary CTA and positive yield for PE.

PMID: 21512071 [PubMed - as supplied by publisher]

Incremental Value of CT Venography Combined With Pulmonary CT Angiography for the Detection of Thromboembolic Disease: Systematic Review and Meta-Analysis.

AJR Am J Roentgenol. 2011 May;196(5):1065-1072

Authors: Krishan S, Pandiratne N, Verma R, Robertson R

OBJECTIVE: The objective of our study was to assess the incremental role of CT venography (CTV) combined with pulmonary CT angiography (CTA) in detecting venous thromboembolic disease with a systematic review and meta-analysis of the literature. MATERIALS AND METHODS: MEDLINE, Embase, and Web of Science were searched for relevant original articles published from January 1, 1995, to December 31, 2009. A random-effects model was used to obtain the incremental value of CTV in detecting thromboembolic disease. RESULTS: Twenty-four studies, which included 17,373 patients, met our inclusion criteria. A meta-analysis showed that CTV increased detection rates of venous thromboembolic disease by identifying an additional 3% of cases (95% CI, 2-4%) of isolated deep venous thrombosis (DVT). A subgroup analysis of a high-risk group did not show any difference in the detection of isolated DVT. CONCLUSION: The addition of CTV results in the increased detection of thromboembolic disease. CTV combined with pulmonary CTA has a promising role as a quick and efficient test for venous thromboembolism.

PMID: 21512072 [PubMed - as supplied by publisher]

Central venous line placement in the superior vena cava and the azygos vein: differentiation on posteroanterior chest radiographs.

AJR Am J Roentgenol. 2011 Apr;196(4):783-7

Authors: Haygood TM, Brennan PC, Ryan J, Yamal JM, Liles L, O'Sullivan P, Costelloe CM, Fitzgerald NE, Murphy WA

The purpose of this study was to determine, first, the accuracy with which radiologists reading posteroanterior chest radiographs differentiate whether a central venous line is in the superior vena cava or the azygos vein and, second, the circumstances in which radiologists may omit the lateral view to determine the position of a central venous line.

PMID: 21427325 [PubMed - in process]

The Lack of Growth in Use of Coronary CT Angiography: Is It Being Appropriately Used?

AJR Am J Roentgenol. 2011 Apr;196(4):862-7

Authors: Levin DC, Parker L, Halpern EJ, Julsrud PR, Rao VM

The purpose of this article is to study recent utilization trends in coronary CT angiography (CTA) and compare them with radionuclide myocardial perfusion imaging (MPI), a competing procedure.

PMID: 21427337 [PubMed - in process]

Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Medical Center.

AJR Am J Roentgenol. 2011 Feb;196(2):238-43

Authors: Abujudeh HH, Kaewlai R, McMahon PM, Binder W, Novelline RA, Gazelle GS, Thrall JH

The objective of our study was to prospectively determine how CT affects physicians' diagnostic certainty and management decisions in the setting of patients with nontraumatic abdominal complaints presenting to the emergency department.

PMID: 21257870 [PubMed - in process]

MRI of patients with cardiac pacemakers: a review of the medical literature.

AJR Am J Roentgenol. 2011 Feb;196(2):390-401

Authors: Zikria JF, Machnicki S, Rhim E, Bhatti T, Graham RE

OBJECTIVE: Numerous studies testing the use of pacemakers with MRI have been published. Our aim was to analyze these trials to determine the safety of MRI for patients with cardiac pacemakers. We performed a systematic search of peer-reviewed databases. A total of 31 articles were reviewed. CONCLUSION: The data are heterogeneous with regard to MRI being considered for patients with pacemakers, and the benefits of the imaging should outweigh the risks.

PMID: 21257892 [PubMed - in process]

Frequency of use of imaging tests in the diagnosis of pulmonary embolism: effects of physician specialty, patient characteristics, and region.

AJR Am J Roentgenol. 2010 Apr;194(4):1018-26

Authors: Bhargavan M, Sunshine JH, Lewis RS, Jha S, Owen JB, Vializ J

OBJECTIVE: The purpose of this study was to ascertain whether clinical practice in diagnosing pulmonary embolism is consistent with recommendations in the literature and to explore variations in practice across site of care (e.g., emergency department), physician and patient characteristics, and geographic location. MATERIALS AND METHODS: Medicare 5% research identifiable files were analyzed. The cases of patients with emergency department visits or inpatient stays for a diagnosis of pulmonary embolism or for symptoms related to pulmonary embolism (shortness of breath, chest pain, and syncope) were identified. We determined the number of patients who underwent each type of relevant imaging test and evaluated variations in the first non-chest-radiographic test by site of care and treating physician specialty. Using logistic regression, we studied variations in the use of common imaging tests, exploring variations associated with patient characteristics, physician specialty, site of care, and geographic location. RESULTS: For patients in whom pulmonary embolism might have been suspected, the most common tests were echocardiography (26% of the patients), CT or CT angiography of the chest (11%), cardiac perfusion study (6.9%), and duplex ultrasound (7.3%). For patients with an inpatient diagnosis of pulmonary embolism, the most common tests were chest CT or CT angiography (49%), duplex ultrasound (18%), echocardiography (10.9%), and ventilation-perfusion scintigraphy (10.9%). For patients for whom pulmonary embolism might have been suspected, many large variations were found in practice patterns among physician specialties and geographic locations. There were fewer variations among patients with the inpatient diagnosis of pulmonary embolism. CONCLUSION: Physician practice in the diagnosis of pulmonary embolism is broadly consistent with recommendations. However, variations by physician specialty and geographic location may be evidence of inappropriate imaging.

PMID: 20308505 [PubMed - in process]