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SIR Foundation
18 2013
A to Z
30 Stroke
FALL 2013
VOL. 1
NO. 4
The Informational Resource for
Vascular and Interventional Radiology
p. 34
Clinical Practice:
Elements to Success
p. 16
p. 22
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FALL 2013
medical editor
VOL . 1
NO. 4
Hyun S. “Kevin” Kim, MD, FSIR
deputy editor
Meghal Antani, MD, MBA
consulting editor
Laura Findeiss, MD, FSIR
staff consultants
Tricia McClenny
Cheryl Sadowski
managing editor
Brian Haefs
editorial board
R. Torrance Andrews, MD, FSIR
Jonathan Barker, MD
James F. Benenati, MD, FSIR
Erik Cressman, MD
Joseph Erinjeri, MD
Ripal Gandhi, MD
Suvranu Ganguli, MD
Kevin Henseler, MD
Warren Krackov, MD
J. Keven McGraw, MD, FSIR
Gerald A. Niedzwiecki, MD, FSIR
Martin Radvany, MD, FSIR
William S. Rilling, MD, FSIR
Anthony Ryan, MD
Aaron Shiloh, MD
Manrita Sidhu, MD, FSIR
Alda Lui Tam, MD
executive director
Susan E. Sedory Holzer, MA, CAE
graphic design
Blue House
IR Quarterly (ISSN 2325-4092)
published by the Society of
Interventional Radiology
3975 Fair Ridge Drive
Suite 400 North
Fairfax, VA 22033.
Periodicals postage paid at
Fairfax, Virginia, USPS No. 006-339.
Copyright © 2013 Society of
Interventional Radiology
Send address changes to
IR Quarterly,
3975 Fair Ridge Drive
Suite 400 North,
Fairfax, VA 22033.
Send your articles, letters
and comments to
Hyun S. Kim, MD, FSIR, IR Quarterly
c/o Brian Haefs
3975 Fair Ridge Drive
Suite 400 North,
Fairfax, VA 22033
(703) 691-1805
Fax (703) 691-1855
16practice makes perfect...
Just entering the field?
Considering relocation?
Learn what type of IR
practice is right for you.
04president's column
Scott C. Goodwin,
07 ir up front
• New Category III CPT Codes
for Renal Denervation and
Pulmonary Cryoablation
22hire education
An overview of physician
extenders in interventional
34sir clinical practice
resources and materials
Learn about the wealth of
clinical practice resources
SIR provides for its
members and the broader
IR community.
38pieces of the past
How well do you know
your IR history? Identify
these tools and devices that
formed the foundations for
today’s IR innovations.
The views and opinions of authors
and advertisers expressed herein are
not necessarily those of the Society of
Interventional Radiology. The Society
does not endorse any companies or
06executive director's
Susan E. Sedory Holzer,
18trainees column
Daniel A. Siragusa, MD, FSIR
20sir foundation
research forum
Jeremy Collins, MD
26quality/reporting column
Stephen L. Ferrara, MD, FSIR
28coding q&a
Aaron Shiloh, MD
David Sacks, MD, FSIR
advertiser index
• Bard: 2, 39
• Cook: 5
• CareFusion: 9, 40
Interested in advertising? Visit
www.SIRweb.org/advertise/ or call
Beth Allgaier at (703) 460-5564.
ew Registry for Vertebroplasty/
Kyphoplasty Open to IRs in
Many Western States
ual Primary Certificate
Celebrates First Anniversary
• F
ederal Government
Releases Proposed 2014
Rules for MPFS and HOPPS
• JVIR Seeks Multimedia
• Call for Tips and Tricks
• 2013 SIR Foundation Grant
• ARIN Update: The Value of
Nurses in Radiology
• Call for Applications:
Executive Director, American
Board of Radiology
32annual scientific meeting
chair's column
Daniel B. Brown, MD FSIR
36abstracts in the
Current literature
Ripal T. Gandhi, MD, and
Suvranu Ganguli, MD
33international ir column Brian F. Stainken, MD, FSIR IR Quarterly is mailed to members and
other subscribers four times a year.
Archived issues of IR Quarterly and
other Society newsletters can be
found under Publications in the
Members section of www.SIRweb.org.
• 2013 Fellows Spring
Practicum Highlights
• Transitions
• LEARN “Recap”
13 corporate corner
by Scott C. Goodwin, MD, FSIR
Cultivating Clinical Practice
Interventional radiologists routinely provide longitudinal care, engage in
multidisciplinary quality initiatives and integrate disease-specific knowledge
and expertise to provide outstanding patient care.
his is SIR’s strategic goal when it comes to you—
our members—and clinical care. We know that
we want all health care providers to routinely and
directly rely on and value our expertise as clinical
care experts, leaders and providers of image-guided therapy.
We want to be recognized as a critical component of the health
care system, playing an integral part as leaders in hospital
decision-making at all levels. We want robust admitting
services and mature office practices. How do we reach this
envisioned future? How do we ensure that IR becomes the first
choice for image-guided therapy?
One way we are answering these questions is by engaging
in strategic collaborations with health care professionals.
Specifically, SIR is working with the American College of
Radiology (ACR), which over the years has endorsed IR’s
clinical patient-centered nature—recognizing that we need
an office presence, time allocated to see patients, time to
consult with referring physicians and time to see patients on
the ward. Last year, SIR was instrumental in the passage of
an ACR resolution to develop implementation and marketing
tactics to help optimize the clinical practices of IR and
interventional neuroradiology (INR). An educational campaign
to promote and demonstrate the value of IR and INR
clinical practices to all important stakeholders is a principal
component of the multipronged effort.
The Interventional Radiology (IR) and Interventional
Neuroradiology (INR) Clinical Practice Task Force was formed
last summer with a diverse set of medical professionals,
representing SIR, ACR and the Society of NeuroInterventional
Surgery (SNIS). The task force, which is chaired by Philip
Cook, MD, FACR, FSIR, has a steering committee and six
subcommittees (INR/IR Spine, MSK and Pain Management;
Neurointerventional Vascular; General IR and Interventional
Oncology; Clinical IR Vascular; Education and Training; and
Finance and IT).
Task force members have explored these questions: What are
barriers to the clinical practice of IR/INR? What can be done
to ensure the successful future of IR and INR? Forty national
FA L L 2 0 1 3
IR and INR thought leaders examined topics such as the
adequacy of the clinical training model, the resistance of
IR physicians to be more involved in longitudinal patient
care, and the need to be seen as drivers of new health care
delivery models and as part of the clinical infrastructure
future. They crafted a draft multiphase action plan, which is
being submitted to the Board of Chancellors, ACR’s executive
body, for review and revision this fall. Once implemented,
the action plan will first add clarity to the definition of IR
clinical practice. It will then address the further establishment
of the value of IR, clinical education, the creation of financial
models to address financial sustainability and patient access
to IR, and increasing the awareness of the importance of IR
and INR to major stakeholders.
I want to thank all the members of this important task
force and subcommittees who have been involved with this
ambitious undertaking. While we are members of the medical
house of radiology, we are also
hands-on clinicians who are
While we are
known as innovative problem
members of the
solvers and critical resources
medical house of
in tough medical situations.
radiology, we are
We have a unique skill set
comprised of competency in
also hands-on
diagnostic imaging, imageclinicians who are
guided procedures and
known as innovative
periprocedural care. ACR’s
problem solvers
support comes at an important
and critical resources
time—it comes on the heels of
the ABMS’s recognition of IR as
in tough medical
a primary specialty in medicine,
which was a very important
step in the formalization of
the interventionalist’s clinical role. Forty years ago we worked
as the “specialists’ specialist,” helping other doctors manage
their patients with the most difficult problems. While those
physician relationships remain strong, we have now taken a
position in the front line of medical care.
That’s where we need to be for patients.
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E X E C U T I V E D I R E C TO R ’ S C O L U M N
by Susan E. Sedory Holzer, MA, CAE
Success and Courage:
Two Sides of the Same Coin
This fall issue of IRQ centers on elements of
success for IR as a clinical specialty. I hope you
read and enjoy the articles about the value of
strategic collaboration, the role of physician
extenders, even the importance of making a sound fellowship
match—all actions that clearly have an impact on the overall
success of the specialty.
Some common intrinsic attributes underlying these
successes--vision, action, perseverance and courage--are as
essential to SIR’s organizational success as they are to each of
us individually.
The vision put forth in our five-year strategic plan forged
last summer ties IR more closely than ever to clinical
success—IR as the first choice in image-guided therapy will
not happen just because IRs are a profession of skilled and
innovative proceduralists. The action plan underlying that
vision requires definable, incremental goals to get the data we
need, demonstrate our clinical expertise, leverage strategic
partnerships and rebrand the way everyone talks about IR,
SIR and SIR Foundation.
We are making excellent progress, though the best vision
and action plans require perseverance to reach success.
Perseverance enabled SIR to finally achieve recognition of
interventional radiology as its own specialty through the
creation of the dual certificate and guides our volunteer
advisers each time they advocate on your behalf at coding
and reimbursement forums. And the labor of perseverance is
helping us launch a structured report-based registry that will
soon enable IRs to commit to improving patient quality and
outcomes through evidence-based clinical practice.
Which brings me to courage. I recently read a business article
on the topic of courage–typically defined not as fearlessness,
but action in spite of fear. We all know institutions that have
failed under the inertia of fear--they create bureaucratic walls
and forget that even the most inspiring individual courage
must be aligned with the moral courage to pursue a common
good despite opposition, difficulty or rejection.
Of all the attributes required for success, courage can be the
hardest to summon, yet it’s what often reaps the biggest
rewards. While mega-achievers like Steve Jobs, Christine
Lagarde and, yes, Charles Dotter clearly emanate vision,
action and persistence, it’s their courage amid obstacles that
is the key factor in their success.
But how do we create a culture of courage for IR and for
SIR? When I think about the struggles many IRs still have
in establishing a clinical practice, I see a clear desire to do
the right thing for patients amidst obstacles–local politics,
financial and contractual hassles, even the fear of failure. Yet,
day after day, individual IRs muster the courage to take that
risk--to know more, try more pioneering things, trust more,
and speak up more to achieve success. And each time you
further your personal goals or better your local situation, you
collectively help all of IR accomplish its vision.
With an engaged and informed membership as the backbone
of our Society, SIR can indeed position IR in the health
care landscape as a catalyst of courage. IRs are the kind
of professionals who take risks responsibly or go the extra
mile for patients—not because it benefits himself or herself
personally, but because it’s best for the entire system.
Similarly, SIR’s goal is to keep ensuring that all members
find opportunities here to grow your strengths as leaders–as
educators among your peers, as team players within your
workplace, as innovators and on behalf of patients.
Even though it’s nearly 6 months away, I am already thinking
about next year’s Annual Scientific Meeting and how it is far
more than a not-to-miss educational opportunity. When SIR
members from all over the world gather as they will in San
Diego to share their knowledge and confirm their vision for
the specialty, they also fortify their individual courage and
commitment to the specialty. In doing so, they return home
equipped with new skills and facts, energy and a renewed
commitment to success for the profession.
That’s how a strong, unified membership provides the energy
that fuels our workplace–to bolster courage–to succeed.
Interested in that article about courage? Read it at http://chiefexecutive.net/4-ways-to-create-a-cultureof-courage#sthash.CzT52KSd.dpuf. I’d love to know what you think.
FA L L 2 0 1 3
IR Up Front
New Category
III CPT Codes for
Renal Denervation
and Pulmonary
In July, the American Medical
Association (AMA) Current Procedural
Terminology (CPT) Editorial Panel
made available three new Category
III CPT Codes that pertain to SIR
members. Two codes will be established
to describe transcatheter renal
sympathetic denervation (unilateral
and bilateral), as well as a code for
percutaneous pulmonary cryoablation.
Category III codes have no relative
value units (RVUs) associated with them
and are intended primarily for research
and data collection purposes. However,
IRs should verify with their specific
carrier medical directors (CMDs) to
determine possible reimbursement
when these codes are used. Insurance
carriers can elect to use the new codes
but are not required to do so until
Jan. 1, 2014. If you have any questions,
contact Robert White, SIR director of
reimbursement and hospital affairs,
at [email protected]
It’s Not Too Late
to Renew Your
New Registry for Vertebroplasty/
Kyphoplasty Open to IRs in
Many Western States
SIR members who perform vertebral procedures (vertebroplasty/kyphoplasty)
may want to examine a new registry that could facilitate documentation
requirements and reduce payment denials. Difficulty with authorizations,
treatment denials and failure of reimbursement for vertebral compression
fracture (VCF) procedures have been common across the states whose
Medicare services are administered by Noridian Healthcare Solutions
(Ala., Ariz., Idaho, Mont., Wyo., Wash., Minn., N.D., S.D., Ore., Utah, and soon
Nev. and Calif.). The BenchMarket Medical (BMM) VCF Registry addresses
these problems and is organized to provide evidence of safety, efficacy, and
patient outcomes following VCF procedures (http://benchmarketmedical.com/
Noridian Healthcare Solutions now requires compliance with authorization
and tracking of patient outcomes as a prerequisite to secure reimbursement.
The BMM VCF Registry addresses this variability by using common metrics for
all VCF procedures, no matter what technique is chosen. The BMM metrics are
the metrics most relative to the patient and these metrics satisfy the Noridian
LCD for authorization and provide a mechanism for tracking patient outcomes
and submitting that data to Noridian.
SIR has been in communication with Noridian’s Carrier Medical Director
and BenchMarket Medical on the registry. SIR has concerns that the costs
of participating in the registry may make widespread physician participation
problematic, though we are supportive of the registry’s objectives.
We encourage any member who wants to enroll in the registry to coordinate
with your hospital to explore cost-sharing arrangements and to conduct an
analysis of your own financial environment.
Even if you’ve missed the July 1 deadline, renew your 2013–2014 membership
today and stay connected to IR education, advocacy and leadership
opportunities for every stage of your career. The Society continues to be the
premier resource for lifelong learning in IR. As an SIR member, you benefit
from discounted rates on the Annual Scientific Meeting, highly specialized,
interactive learning, and member-only resources and publications. Continue your
professional development by renewing your membership today.
Invoices were recently mailed to all members, or members can renew online
by logging into the Members section of www.SIRweb.org and clicking the
Pay Your Dues link.
While you are online, please consider a gift to SIR Foundation’s Annual Fund to
support research in IR.
FA L L 2 0 1 3
Dual Primary Certificate
Celebrates First Anniversary
One year ago, the American Board of Medical Specialties (ABMS)
approved the American Board of Radiology (ABR) application
for a Dual Primary Certificate in Interventional Radiology and
Diagnostic Radiology. Although much progress has been made
since that time, many questions remain within the community.
In the winter 2014 issue of IR Quarterly, John A. Kaufman, MD,
MS, FSIR, and Jeanne Laberge, MD, FSIR, will discuss the current
status of the certificate, where it’s headed and how SIR and ABR
plan to engage the community in its development. If you have
specific questions for them about the certificate, contact the
Society at [email protected]; the most frequent questions will
be addressed by Drs. Kaufman and Laberge in their article.
SIR Expresses Urgent
Concerns to CMS on
Proposed 2014 Medicare
Physician Fee Schedule
and HOPPS Rules
On Sept. 6, 2013, SIR submitted detailed comments to the Centers
for Medicare and Medicaid Services (CMS) on the agency’s 2014 draft
rules for the Physician Fee Schedule and the Hospital Outpatient
Prospective Payment System (HOPPS). The SIR Economics
Committee had worked for more than a month to closely analyze
the provisions of both rules, received member feedback and also
received helpful input from SIR’s industry partners.
The central theme of the SIR MFS letter is disagreement with the
CMS proposal to cap payment in the non-facility based on the
ASC or HOPPS rates. In SIR’s HOPPS comments, SIR is opposed
to the “packaging” methodology that CMS proposes, as it will
underreport costs associated with many procedures. SIR will
continue to advocate with federal agencies in the coming weeks
to illuminate how these drastic cuts would impact care delivery to
Medicare beneficiaries.
Links to both comment letters can be found in the Members
Section of www.SIRweb.org.
FA L L 2 0 1 3
JVIR Seeks
Journal of Vascular and Interventional
Radiology (JVIR) Editor-in-chief Ziv J Haskal,
MD, FSIR, is seeking new contributors
and editors to serve the journal’s
expanding multimedia content plans.
Among opportunities, these volunteers
could serve as correspondents planning
and conducting interviews, propose and
manage online, Web, Podcast, and cloud
projects, and work closely with Dr. Haskal
and Deputy Editor Tony P. Smith, MD, FSIR.
There are possibilities for advancement
to larger editorial positions. Candidates
are encouraged to submit a resume,
brief statement of interest, and ideas or
possible examples of relevant work. Other
requirements include good organizational
skills and ability to meet publishing
deadlines. To nominate yourself or a
colleague, please forward the applicant’s
name and CV to [email protected], along
with a brief introduction.
Submit a Video
Article to JVIR
JVIR announces a new submission category,
the Video Article. The initial purpose of this
category is to illustrate specific aspects of
procedures, anatomy, or new or less widely
used techniques that will be of particular
and timely interest to the readership.
Interested authors are encouraged to
discuss their potential projects or ideas
directly with Editor-in-chief Ziv J Haskal at
[email protected] org. Once Dr. Haskal has
approved the idea, video submissions can
be made via www.JVIR.org.
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In Gratitude . . .
SIR FOUNDATION supports programs that perpetuate a strong and vibrant future for IR. We are grateful to make
a difference in many professional and personal lives, including yours. This holiday season, we are especially grateful for . . .
Young IR investigators who are creating the future of IR in collaboration with SIR Foundation
Innovative researchers and scientists, who are pioneering new techniques in IR
Patients and the IRs who treat them for contributing to data registries and helping to advance IR care
Dedicated SIR and SIR Foundation leaders and grant recipients, some of whom have been recognized through
our awards program, shedding light on the importance of continued IR innovation
Most importantly, we are grateful to the hundreds of SIR Foundation Discovery Campaign, Annual Fund and
Gala donors for their investment in the specialty’s future
Please help us continue making a difference in IR through a gift to the Annual Fund today. When you give a gift of $1,000 or
more, we will honor you as a distinguished Founding Donor of SIR Foundation’s Pioneer Circle, a new development program
that acknowledges the Foundation’s most generous and loyal donors (please see
www.SIRFoundation.org/pioneer for details).
Donations made on or before Dec. 31, 2013, are tax deductible in 2013 to the
extent of current IRS regulations. Thank you for considering a gift today!
SIR Foundation | 3975 Fair Ridge Drive, Suite 400 N, Fairfax, VA 22033 | (703) 460-5598 | [email protected]SIRFoundation.org
FA L L 2 0 1 3
New 2013 Grant Recipients
The Summer 2013 IRQ listed the SIR Foundation 2013 grant recipients.
This summer, SIR Foundation awarded an additional seven grant recipients,
bringing the total to 23 grant recipients. SIR and the Foundation congratulate
these grant recipients.
Allied Scientist Grant
Andrew Gordon, Northwestern University
Image-Guided Transcatheter Thermoradiotherapy of Liver Tumors
Nivethan Velauthapillai, University of Toronto
Oral and Cutaneous Antioxidants for Radioprotection During Medical
Imaging Examinations
Pilot Research Grant Supported by C.R. Bard
Shivank Bhatia, MD, University of Miami Miller School of Medicine
Phase II Open Label Investigation of the Safety and Efficacy of Preoperative Prostate Artery Embolization (PAE) Before Radical Prostatectomy
in Prostate Cancer Patients
Joshua Dowell, MD, PhD, Ohio State University
Magnetic Resonance Elastography: A Novel Method to Estimate Wall
Stiffness in Abdominal Aortic Aneurysms and Its Relationship to
Aneurysm Diameter
Radiology Resident Research Grant
Anand Patel, MD, University of California, San Francisco
Intravenous Chemotherapy Filter: A Novel Device for High-dose
Chemotherapy Delivery During Transarterial Chemoembolization
Student Research Grant
Andrew Lee, University of California, San Francisco
Effectiveness of Minimally Invasive Management of Biliary Complications
after Liver Transplantation in Pediatric Patients
Mikhail Silk, Memorial Sloan-Kettering Cancer Center
Core Biopsy Adequacy Assessment Using Rapid Light Spectroscopic Scatter
Analysis: Correlation with Molecular Assays and Histopathologic Diagnosis
ARIN Update:
The Value
of Nurses in
The Patient Protection and Affordable
Care Act has led to an integrated health
care unit that lowers cost for health care.
The effect has left radiologists to shoulder
a good portion of this cost savings.
This has occurred through a reduction
in Medicare payments, an excise tax
on equipment, and increased federal
control over advanced imaging in clinical
practice. It is important that all radiology
staff understand the underpinnings of
reimbursement and the relationship
between reimbursement and quality of
care (value-based healthcare).
The Association for Radiologic and
Imaging Nursing (ARIN) Board has
realized the need to educate its nurses
on the present healthcare environment.
ARIN recently became an affiliate
organization (OA) of the American Nurses
Association (ANA) which will allow us
to remain abreast of federal legislative
and regulatory issues and provide us
the ability to be engaged in political and
patient safety issues.
In this climate of value-based care,
radiology nursing can play a fundamental
role. Preprocedural assessment is vital to
maintaining patient safety throughout the
continuum of care, providing seamless
patient care. Their role includes: providing
patient assessment and care prior to and
subsequent to procedures/examinations
and medication administration pre-,
intra-, and postprocedure/examinations.
The utilization of advanced nursing skills
maintains patient safety pre-, intra-, and
postprocedure and patient assessment
during clinical changes in the radiology
department ensures optimal care. Nursing
acts as liaisons for quality patient care
between inpatient nursing and radiology.
Additionally, imaging nurses advocate
and are instrumental in issues of infection
control, patient safety, setting practice
guidelines and interdepartmental quality
assurance. Radiology nurses plan an
integral role in offering value-based care in
this climate of cost containment.
FA L L 2 0 1 3
IRs Stay Current at LEARN
In September, SIR held its third Lower Extremity Arterial
RevascularizatioN (LEARN) course, featuring a case-based, panel
discussion format that included live video cases with interactive
review, the opportunity to hear insights from experienced
endovascular specialists on the various methods to accomplishing
a successful intervention (ranging from basic to complex skills and
techniques) as well as a detailed review of the latest technologic
advances available today in peripheral intervention.
George A. Fueredi, MD, FSIR, who has served as
SIR’s Health Policy and Economics Division councilor
since 2010, announced his resignation in early June.
Donald F. Denny Jr., MD, FSIR, was appointed at the
June Executive Council meeting to serve the rest of
his term. SIR thanks Dr. Fueredi for his service. Dr.
Fueredi has been instrumental in SIR’s advocacy
strategy and in the growth of SIRPAC to the secondlargest PAC in radiology. He represented interventional
radiology at the AMA, and he has ensured the
Society has a strong team fighting for appropriate
reimbursement and coverage.
The course, developed by Robert A. Lookstein, MD, FSIR, Sanjay
Misra, MD, FSIR, and Bret N. Wiechmann, MD, was designed
to be useful for even the most-well-trained specialists, including
interventional radiologists, vascular medicine physicians, vascular
surgeons and interventional cardiologists. LEARN meeting
attendees were able to review the overall management of PAD
patients—including claudication and critical limb ischemia (CLI)—
from diagnosis through treatment and follow-up. In dedicated
hands-on workshops, attendees test drove the latest devices under
the instruction of experienced specialists and used simulators to
fine-tune their skills. SIR thanks the course developers as well as its
Steering Committee: James F. Benenati, MD, FSIR, Jafar Golzarian,
MD, and Mahmood K. Razavi, MD, FSIR.
J. Mark McKinney, MD, the IR fellowship program
director and IR section chief at Mayo Clinic in
Jacksonville, Fla., has been named president of the
Association of Program Directors in Radiology. In
addition to being an SIR member, Dr. McKinney is a
member of RSNA and serves as councilor to ACR. As
president, he will help shape and implement APDR’s
strategic priorities in the coming year.
Apply Now—SIR Foundation
Research Award and Grant
Deadlines Approaching
Register for Legs For Life,
Offer Year-round
PAD Screening
Research Award Application Deadline
Friday, Nov. 15, 2013
Legs For Life® (www.LegsForLife.org) showcases your
ability to identify at-risk patients and creates community
involvement that can lead to collaborative relationships with
health care professionals who treat these conditions. Register
today at www.LegsForLife.org to become a screening site.
*To be considered for the Resident/Fellow
or Medical Student Research Awards, your
scientific abstract must have been submitted
to the 2014 SIR Annual Scientific Meeting by
Tuesday, Oct. 8, 2013, at 5 p.m. ET.
The Legs For Life® website provides you with all you need to
spread the word, including:
SIR Foundation Grant Application Deadline
Saturday, Dec. 14, 2013
Dr. Gary J. Becker Young Investigator Award
Resident/Fellow Research Award*
Dr. Constantin Cope Medical Student
Research Award*
• Patient brochures
Dr. Ernest J. Ring Academic Development Grant
• Media factsheets
Allied Scientist Training Grant
• Updated statistics about PAD, AAA, carotid stenosis
and venous disease
Academic Transition Grant
Visit www.LegsForLife.org to get started.
Pilot Research Grant
Legs For Life® is an online-based program for SIR members
only. Once registered, you’ll gain access to customizable,
downloadable PDFs of necessary forms and related materials.
FA L L 2 0 1 3
Funding Source Development Grant
Saturday, Feb. 1, 2014
Radiology Resident Research Grant
Student Research Grant
2013 Fellows Spring Practicum Highlights
The SIR 8th Annual Fellows Spring Practicum took place May 30–June 1 in Evanston, Ill. Participating
in this meeting were 60 fellows, 22 faculty and 15 companies. The meeting was coordinated by
Parag J. Patel and Thuong G. Van Ha.
by venkatesh p. “kavi” krishnasamy, md, sir fellow-in-training member
As an IR fellow completes fellowship and prepares for future
endeavors, questions about IR practice inevitably arise,
especially after an intense year of call, cases and clinical
management of patients. The 2013 SIR Fellows Spring
Practicum was an incredibly valuable educational experience
that tied it all together.
Day one was primarily focused on interventional oncology and
practice development. The comprehensive overview coordinated
by Thuong G. Van Ha, MD, including “how-to” sessions covering
percutaneous ablation and intra-arterial oncologic therapy,
discussed the finer points of these interventions.
The practice development session provided insight into CPT
and E&M coding among other topics. As Sarah B. White, MD,
enthusiastically demonstrated, the effects of simple changes
to daily practice can have astonishing changes in billing and
reimbursement. My two favorite lectures of the day were
“Tips for TIPS” by Hector Ferral, MD, and “Nonvascular
Interventions: What Not to Do” by Brian Funaki, MD, FSIR.
Both provided excellent information and important learning
points for any junior IR.
The second day opened with a comprehensive overview on
arterial disease coordinated by Parag J. Patel, MD. As we know,
arterial disease exposure is variable among IR fellowships
around the country. The evidence-based lectures from carotid
interventions to infrapopliteal disease provided knowledge
as well as tips and techniques for interventions in the various
vascular beds. Arguably the most valuable part of the day related
to clinical management of PAD patients. One of these lectures,
“Pharmacology for PAD Interventions” provided by Shawn N.
Sarin, MD, gave us an intricate understanding of the medications
we use in everyday practice. These topics are essential for
current IR fellows transitioning to a clinical IR practice.
Finally, the practicum wrapped up with an examination of
venous intervention and aneurysmal disease. Discussions
on management of acute and chronic deep vein thrombosis,
pulmonary embolism and inferior vena cava filters gave fellows
an in-depth review of current therapeutic options and insight
into how other practices approach and treat these diseases.
The day concluded with talks on aortic pathology and therapy.
“Evaluation and Management of AAA” by Geogy Vatakencherry,
MD, provided the fellows with an extensive review of landmark
trials. As Dr. Vatakencherry mentioned, “Becoming disease
experts is paramount to clinical IR success in a competitive
environment.” Case conferences, hands-on workshops, and the
presence of numerous companies also added to the experience.
My mentors remind me often that fellows are always more
ready than we believe we are. Experience will come with time
and the learning never ends. With the excellent faculty who
dedicated their time at the 2013 SIR Fellows Spring Practicum,
we as fellows will undoubtedly be using the knowledge we
gained over the duration of our careers.
Corporate Corner
Thank you, SIR Corporate Partners
Do you miss the excitement of the SIR Annual Meeting Technical
Exhibit Hall and wonder what all those companies do the rest
of the year? When the booths are taken down, is that the
last we see of our industry partners? The answer here at SIR
headquarters and around the country is a resounding, “No!”
and Society leaders can be found at roundtables discussing
the future of the specialty during the SIR Foundation Summer
Strategy Session. Hands-on workshops at SIR meetings are
staffed and stocked by generous corporate donations of
models, simulators and devices.
SIR’s corporate partners continue to work with us throughout
the year and can be found providing educational support
and advertising funding that make meetings like the Fellows
Spring Practicum, LEARN and Y-90: The Advanced Course
and events like the SIR Foundation Gala possible. Industry
As we say on our banners and signs, we at SIR and SIR
Foundation are truly grateful for the generosity of our
corporate partners. Please take a moment to thank your
industry contacts for all they do to support IR, its trainees,
and its Society and Foundation.
FA L L 2 0 1 3
2013 Calendar
October 1
IR 2014 Annual Scientific
Meeting online registration opens
IR 2014 Resident-in-training
International Day of Radiology
November 15
Scholarship deadline
r. Gary J. Becker Young Investigator
IR 2014 Medical Student
Award applications due
Scholarship deadline
esident/Fellow SIR Annual
Scientific Meeting Research
November 8
October 4
Award applications due
r. Constantin Cope Medical
Nominating Committee nominations
deadline; for questions or more
information, contact Tricia McClenny
at [email protected]
8 9 1011121314
Student SIR Annual Scientific
Meeting Research Award
applications due
October 8
December 14
eaders in Innovation Award
Allied Scientist Grant
nominations due
applications due
World Osteoporosis Day
Academic Transition Grant
IR 2014 Annual Scientific
applications due
Meeting abstract submissions
r. Ernest J. Ring Academic
due, 5.p.m. EDT
Development Grant
applications due
October 10-12
unding Source Development
3rd SPIR Meeting, Santa Fe, N.M.
Grant applications due
ilot Research Grant
October 23
Details on the SIR Annual
Scientific Meeting
SIR International Scholarship
Program applications due
Details on other SIR
educational opportunities
Details on SIR Foundation
grants and awards
Contact [email protected]
to make a year end donation
applications due
December 31
eadline for SIR Fellow Applications
ast day to invest in SIR
Foundation for a 2013 tax benefit
FA L L 2 0 1 3
Practice Makes
but what practice setting is right for you?
by meghal antani, md
In today’s health care environment,
interventional radiologists can
choose between multiple different
practice settings, all with their own
unique advantages and challenges.
One’s choice of a practice setting
will depend on how comfortable one
might feel in a specific setting, with
those particular characteristics. In this
article, we will investigate some of the
advantages and challenges inherent
to three common practice models in
which IRs practice:
• Large private radiology groups
• Direct employment by nonacademic
hospitals and health systems
• Freestanding interventional
outpatient centers
Large Private
Radiology Groups
During the past decade, the
average size of radiology groups
grew substantially, and the largest
increase has been in groups with
30 or more radiologists.1 This
trend applies to both private and
academic groups. Advantages of
the increased group size include
more effective economies of scale
relative to smaller groups, resulting in
reduced unit costs of operation, and
stronger market power, resulting in
improved negotiating abilities with
insurance companies. These factors
have allowed larger groups to more
effectively manage their cash flows
compared to smaller groups, which
may not have the same ability to
control costs or improve revenue.
FA L L 2 0 1 3
Larger groups may also help keep
the IR in the group by allowing for
greater subspecialization. According
to R. Torrance Andrews MD, FSIR, a
Seattle, Wash., IR in a large hospitalbased group, you have the “freedom
to chase down whatever aspect of
IR happens to catch your interest.”
For example, you may subspecialize
in interventional oncology, or
peripheral vascular disease, because
there are usually a greater number
of patients with the condition than
may be seen by an IR who is part of
a smaller group.
A large group facilitates marketing
as well: branding one’s IR practice
can be made easier by the group’s
existing name recognition within
the patient community as well as
among referring physicians. Also, a
large group may have a significant
marketing budget and dedicated
marketing staff to assist the IR division
with its own marketing efforts.
On the other hand, marketing the IR
division may be dictated to varying
degrees by the group’s hierarchy, who
may not always agree with certain
strategies. Another challenge for a
large group may be greater difficulty
with physician retention because the
groups may be seen as being less
personal; the physicians within the
larger groups may feel less loyalty to
those groups and therefore may be
more likely to leave the group.1
Additionally, according to Bret
Wiechmann, MD, FSIR, an IR in
Tampa, Fla., an IR section within
a larger group may “require buy-in
from the majority of the main group”
in order to “develop consensus within
the traditional radiology group that
IR is a distinct clinical specialty, and
therefore requires a totally different
infrastructure [including] dedicated
space for patient examination,
retraining administrative personnel”
and marketing.
Employment by
Nonacademic Hospitals
In the early 1990s, hospital
employment by physicians reached a
plateau but then declined. Many felt
that one reason was that hospitals
and health systems did a poor job of
managing the private practices that
they acquired.2
Today, the integrated health system
(IHS) is contributing to an increase
in physician employment directly
by hospitals and health systems. An
IHS, also known as an organized
delivery system, may be defined
as “a network of organizations that
provides or arranges to provide a
coordinated continuum of services
to a defined population and is willing
to be held clinically and fiscally
accountable for the outcomes and
health status of the population
served.”3 A main goal of an IHS is to
reduce waste by coordinating care
between many different providers
and using economies of scale to
further reduce costs.4 Presently,
about 10 percent of radiologists are
employed directly by nonacademic
hospitals and health systems.2
Employment certainly carries its
advantages: financial stability by
way of a regular paycheck, not
having to worry about running a
business in the form of a private
group, billing done by the hospital’s
billing department, and the hospital
covering large expenses such as
equipment and electronic medical
records. In addition, physician
recruitment may be primarily
handled by the hospital’s HR
department, relieving the individual
physicians of having to find a
qualified associate physician to fill
a vacancy. Geogy Vatakencherry,
MD, an IR with Kaiser Permanente
in Los Angeles, Calif., agrees, and
cites another advantage that is
more patient-centered: a stronger
focus on preventive care. The fact
that it is not fee-for-service may
take out some of the incentives
that foster unnecessary procedures.
In this environment, there seems
to be more collaboration between
the various practitioners as they
work for an end goal of providing
cost-effective, evidence-based
comprehensive quality care.
But some challenges are associated
with hospital employment as well. Dr.
Vatakencherry states that, historically,
relative to traditional private group
practice, salaries in the employed
setting may not be as high, and
scheduling personal time may be
more restricted; for example, vacation
days may need to be scheduled several
months in advance and there is less
flexibility in physician scheduling.
Outpatient Centers
Interventional radiologists in
independently owned freestanding
facilities are directly responsible
for making financial decisions that
affect their practice. Some are
entrepreneurs running their own
businesses; others are employed by
regional or national companies. Those
who are owners of outpatient centers
directly feel the effects of declining
reimbursements and increasing costs.
As such, they must be exceptionally
good businesspeople, or have access
to good business managers, and make
sound strategic decisions to carefully
maximize revenue and manage costs.
In addition, when it is time to hire
an associate physician, independent
IRs are on their own to find a partner
who fits in the uniquely demanding
environment of outpatient IR.
Join a Team, Build
a Team With SIR’s
Career HQ
Online Job Board Serves
Up New Features, Ease
of Navigation
While these may seem like
disadvantages, IRs in outpatient
practice also enjoy a relatively higher
level of control over their business—
e.g., with marketing and branding.
Physicians who own their own facilities
can brand themselves and their
practice exactly as they desire and
appeal to a specific patient population
or group of referring physicians.
Career HQ, which connects
job seekers and employers
in interventional radiology,
continuously generates job seeking
and job posting traffic. Last year,
nearly 45,000 job seekers explored
posted positions. Whether you’re
looking for a job or need that
perfect candidate, Career HQ is
your team-building resource.
In the author’s experience, owning
and operating an outpatient IR center
brings challenges and rewards—
such as financial risks, personal
scheduling flexibility and ability to
do a variety of procedures—that
must be considered carefully before
undertaking such a venture.
Job seekers at all stages of
their careers
IR physicians work in a range of
different practice settings today. Each
practice setting may be affected
differently by outside forces in the
current healthcare environment.
After a careful consideration of the
advantages and disadvantages of these
different practice settings, one will
hopefully identify a practice setting that
ideally matches his or her professional
aspirations and personal lifestyle.
Bhargavan and Sunshine. The Growing Size of
Radiology Practices. J Am Coll Radiol 2008;5:801-805.
2. Medverd et al. ACR White Paper: New Practice
Models—Hospital Employment of Radiologists: A
Report From the ACR Future Trends Committee. J Am
Coll Radiol 2012;9:782-787.
• Launch targeted searches and
• Post resumes and job
applications anonymously
• Tailor alerts for new
opportunities matching
preselected criteria
Employers and others recruiting for
hospital, freestanding practice and
academic interventional radiology
and related professional positions
• Post industry-specific jobs, often
not seen on large, broadlyfocused job boards
• Gain quality candidates
• Promote via upgrades, which
come with the added value
of promotion on SIR’s social
media sites
To visit Career HQ, log on now at
3. S.M. Shortell, R.R. Gillies, and D.A. Anderson, et al.
Remaking Health Care in America, San Francisco:JoseyBass (1996) , p. 7.
4. Maggar M. Integrated Systems Put Patients’ Health
First. The New York Times, March 26, 2-13. From:
Meghal Antani, MD,
is an interventional
radiologist practicing
with the Center for
Interventional Medicine
in the Washington, D.C.,
region, and is IRQ deputy editor.
FA L L 2 0 1 3
by Daniel A. Siragusa, MD, FSIR
Interventional Radiology
Match Has Another
Record-breaking Year
he official National Resident Matching Program (NRMP) Match Day for
the Accreditation Council for Graduate Medical Education (ACGME)accredited vascular and interventional radiology fellowships took
place on June 19, and what a day it was! This year’s Match was for
positions starting in July 2014. For the ninth consecutive year, the IR Match
has seen an increase in both numbers of applicants and in the number of
positions filled via the Match. This year, 219 of 227 fellowship positions were
filled via the Match (96 percent) and 73 of 81 programs filled all of their
positions via the Match (90 percent). Compared to the 2006 Match, numbers
of applicants have increased by 304 percent and the number of positions filled
via the Match is up 308 percent.
8 unfilled programs
73 filled programs
IR Fellowship
At the Association of Program Directors in Interventional Radiology (APDIR)
business meeting in New Orleans, La., all of the program directors were
commenting on how impressive the applicants were this year. This trend of
continued year-over-year growth in demand for IR fellowships demonstrates
the promising future ahead for the field of IR. Congratulations to all of the
matched applicants and programs!
8 unfilled programs
219 filled programs
Much of this would not have been possible without the efforts of the Residents
and Fellows Section (RFS) of SIR. Their past few years’ efforts to communicate
to medical students and residents about the amazing the field of IR have been
tremendous. Many thanks to the leadership and members of the RFS—keep up
the good work.
IR Fellowship
IR Fellowship Applicant Trends
IR Applicants (Lt Axis)
IR Matched (Lt Axis)
IR Apps/Pos (Rt Avis)
FA L L 2 0 1 3
Have You Met Your Match?
An Applicant’s Perspective on the 2013 IR Fellowship Match
by Sampson K. Kyere, md, phd, and Olaguoke Akinwande, md
s we reflect on the past
match cycle with a record
number of applicants,
we continue to witness
the increasing competitiveness for a
fellowship position in IR. In 2008, there
were 97 applicants for 178 certified
positions (~0.6 applicants per position).
This year, the number of applicants
exploded to 271 for 227 certified
positions (1.2 applicants per position). It
is important to note that these numbers
are an underestimation when taking into
account the number of direct pathway
residents and in-house candidates
guaranteed a position in their home
programs, thereby decreasing the total
number of available seats for external
applicants. This year, 52 applicants did
not match into an IR fellowship. We
estimate, then, that almost 25 percent
of our 2014 graduating class pursued
training in IR out of nine possible
radiology subspecialties.
In order to understand the effect of an
increasingly competitive and desirable
fellowship from an applicant’s perspective,
we conducted a short, anonymous
nonscientific survey on Auntminnie.com
from June 9 to June 20, 2013. There were
65 respondents out of the 271 known
match applicants. Of the respondents,
43.1 percent (n=28) reported that they
did not have an IR fellowship program at
their institution, 41.5 percent had a home
program but wanted to go elsewhere, 6.2
percent were definitely staying at their
home program and 4.6 percent wanted to
stay at their home program but were not
guaranteed a position due to increased
interest, forcing them to apply elsewhere.
The remaining three applicants (4.6
percent) intended to stay at their home
program but were testing the waters by
applying to other programs.
We next sought to evaluate the
competitiveness of the application pool.
Of the respondents, 63 percent chose
radiology as a specialty because of IR,
37 percent attended resident-in-training
content at the SIR Annual Scientific
Meeting, 43 percent presented IR
research at a conference and 46 percent
had published research work in IR.
Seventeen applicants (26 percent) had
what they considered to be a wellknown IR attending write a letter of
recommendation on their behalf.
We found that many candidates apply
very early for a selection process that
can last until May. Of the respondents,
12 percent (n=8) had sent a portion of
their application (with or without letters
of recommendation) in October and
29 percent sent their applications in
November prior to Thanksgiving, while
37 percent had sent their applications
between Thanksgiving and Christmas.
The remaining 22 percent of respondents
sent their applications in January.
Of the 81 certified fellowship programs,
the majority of applicants (29.2 percent)
applied to more than 25 programs and
attended either 6-10 (35.4 percent) or
11-15 (36.9 percent) interviews. A small
minority (5; 7.7 percent) attended 16 or
more interviews. Of the respondents, 55
percent (n=33) had an attending within
their residency program call a fellowship
program director to convey their interest
prior to submitting rank lists.
We next asked the respondents to rank
the most important factors in creating
their rank lists. Perceived prestige of
the program and the types of cases the
respective programs performed were
virtually tied for highest average rank.
While we believe that the increased
number of applications may in part be
attributed to the tightening job market,
the majority is probably due to genuine
interest in the field, which could reflect
the rapid growth of interventional
oncology over the last couple of years
and the transition of IR into a clinical
specialty. Or, perhaps, the interest stems
from the approval of the Dual Primary
Certificate in Interventional Radiology
and Diagnostic Radiology and the
eventual end of the IR fellowship (which
would presumably hinder the possibility
of IR training later in one’s career).
What we do know is that growing interest
in the field has been catalyzed by SIR
through the IR-in-training education
pathway at the Annual Scientific Meeting,
free SIR membership for medical
students and the mission to increase
early exposure to the field. As a result,
many medical students are now entering
radiology to become IRs. In fact, the start
of the new Dual Primary Certificate may
potentially attract a new subset of medical
students who are interested in minimally
invasive surgical specialties rather than
those interested in being diagnosticians.
Going forward, the challenge for potential
applicants is to get hands-on experience
in IR through medical school electives
and residency rotations and to build up
their CV in order to get a position at an
institution they favor. This would show
long-standing interest in the field. The
challenge for programs is how to deal
with the growing interest and resultant
larger pool of applicants. We have shown
that with increasing competition for
a fellowship position, applicants have
responded by getting involved in SIR,
presenting and publishing research within
IR and applying early and more broadly.
As we await the start of the IR/DR
pathway, competition for fellowship
positions through the Match will likely
remain high. The prospect of not
matching can be nerve-racking since
the Match for radiology (neuroradiology
and IR) takes place after the majority of
other radiology subspecialty fellowship
positions have been filled, thus making
the Match “all or nothing.” This stress
can be be further compounded by
simultaneous preparation for the
American Board of Radiology Core
Exam. It would be beneficial to
applicants if all radiology subspecialties
were to have a common set of interview
and match dates in the future.
FA L L 2 0 1 3
Interview With Clifford R. Weiss, MD,
SIR Foundation and NIH Grant Recipient
lifford R. Weiss, MD, an
interventional radiologist from
Johns Hopkins University,
Baltimore, Md., received a Dr.
Ernest J. Ring Academic Development
Grant from SIR Foundation in 2009 for
his project, “MR-guided Transplantation
of Magneto-encapsulated Human
Pancreatic Islet Cells in a Diabetic Swine
Model.” He has recently been awarded
a National Institutes of Health (NIH)
R01 based in part on preliminary work
funded by the Ring Grant. Dr. Weiss and
his co-primary investigator on the R01,
Dara L. Kraitchman, VMD, PhD, FACC,
recently joined me for an interview.
COLLINS: Can you briefly summarize
your research that was funded by SIR
Foundation’s Ernest J. Ring Academic
Development Grant?
WEISS: Its purpose was to demonstrate
the possibility of encapsulating islet
cells in magnetocapsules that are
visible on MRI and then delivering
them into the livers of pigs. Our work
showed that we could indeed have
those cells survive and produce insulin.
COLLINS: Excellent research ideas
often grow out of clinical practice.
Did an initial IR experience lead to
this research idea?
WEISS: About five or six years before
my Ring Grant was awarded, Jeff W.M.
Bulte, PhD, and Aravind Arepally,
MD, FSIR, originated the idea of
encapsulating islets using MRI-visible
particles, for which they received an R01
grant. Dr. Arepally was my mentor when
I was a medical student, and he was my
research mentor on the Ring Grant. I
was focusing on a piece of their project.
COLLINS: Was there anything in your
clinical practice that led you to want to
pursue this topic under the Ring Grant?*
WEISS: It was more my view of the
role of the interventional radiologist
and interventional radiology scientist
to bridge the translational gap between
basic and clinical science, as it relates
to minimally invasive procedures.
I was very interested in developing
MR-guided interventions in clinical
practice. The Ring Grant project was a
great way to bring some advanced MRI
techniques into the clinic.
COLLINS: How did you turn your idea into
preliminary data to support an application
for the SIR Foundation Ring Grant?
WEISS: My mentors and collaborators,
Drs. Arepally, Bulte and Kraitchman,
had performed extensive work in
this area. In terms of the Ring Grant,
there was a lot of data that had been
collected already by our group, under
the leadership of Dr. Arepally. I was
SIR Foundation is the best place to
go as an interventional radiologist
to obtain preliminary data that you
are going to need to apply for the
next round of grants.
very lucky to have a strong clinical and
research mentor to guide me through
the process of applying for grants and
make sure that we had enough data
to apply for a Ring Grant. I cannot
underscore enough the need for great
mentorship as a junior faculty member.
COLLINS: Congratulations on your
recently funded R01 application!
Applying for an R01 grant is a substantial
undertaking. Did you find the application
process for and research support enabled
by the SIR Foundation Ring Grant helpful
in the NIH R01 application process?
WEISS: The Ring Grant is essentially
in the format of an NIH grant, whether
it’s an R01 or R21. The Foundation’s
application process is designed to
prepare you to go for the [NIH] grant
process. The application process
provides feedback and experience in a
less competitive environment, where
you know that your grant is being
reviewed by colleagues rather than by
a committee of people who may not
understand your work. The concept of
how to approach the R01 application—
how to keep ideas focused and clear—
that really came from the Ring Grant
application process.
KRAITCHMAN: Also, as a result of
the Ring Grant, Dr. Weiss had some
publications that were directly relevant
for the R01 that we applied for and that
gave him more standing as well for his
first R01. Of the awards that I see that
are for young or early investigators,
it seems to me that the Ring Grant
provides a particularly excellent
opportunity to obtain preliminary data
for subsequent grants.
for more information on sir foundation grants
and awards, go to www.SIRFoundation.org/grants-awards.
by Jeremy Collins, MD
WEISS: I agree. SIR Foundation is the
best place to go as an interventional
radiologist to obtain preliminary data
that you are going to need to apply for
the next round of grants.
COLLINS: I understand that Ben E. Paxton,
MD, a recent SIR Foundation pilot grant
and resident research award recipient,
is a collaborator on your R01 grant. Can
you describe how such collaboration has
advanced your research?
WEISS: In any modern research
program where you are trying to get
funding, the more expertise you bring
to the table from different players the
better, so collaboration is absolutely
essential. The close collaboration
of the obesity research programs at
Duke University and Johns Hopkins
University has been crucial to the
success of the recent R01 application.
KRAITCHMAN: We are very thankful
for our collaboration with Dr. Arepally,
Dr. Paxton and Charles Y. Kim, MD,
because some of the data from our
collaborators at Duke University and
specifically data from Dr. Paxton’s SIR
Foundation Resident Research Grant
provided additional data to answer
questions we knew would be posed on
our R01 application. Subsequently, our
preliminary data as well as data from
Dr. Paxton’s resident grant assisted
with his pilot grant application.
COLLINS: Would you like to share
with IRQ readers anything regarding
the unique components of the novel
embolic agent you are studying for
the treatment of obesity?
KRAITCHMAN: We’re pretty excited. We
weren’t looking to make an embolic;
my work is primarily cardiovascular
where we are not trying to cause
ischemia. This work originated from a
focus on individual cell encapsulation
and we were trying to miniaturize that
technology. It was developed using a
device similar to a computer chip, but
instead of moving electrons it allows
you to move fluids and create uniformsized embolic particles, with a very
high throughput. On top of that we
applied our expertise to improve bead
X-ray visibility. We are pretty excited
about it since it lets us see where we
are putting the beads initially, but we
can also follow up with cone beam CT,
c-arm CT, conventional CT, to see if that
embolic is still there.
WEISS: I think the concept of
knowing where you are embolizing
and knowing where you embolized
previously is critical to this grant
and critical to the embolic treatment
of obesity knowing that these are
otherwise healthy patients.
To support the SIR Foundation
grants and awards program,
go to www.SIRFoundation.org/
COLLINS: What other applications
do you foresee for this embolic
technology in IR?
WEISS: I think that this agent would
be useful for any embolic application.
Rather than looking at the dynamic
state during particle embolization using
contrast, you can look at a static state
of where this embolic is sitting in the
body. When you think about it, there
aren’t many applications where an
X-ray- and MRI-visible, highly precisely
sized agent wouldn’t be very useful. To
be fair, the concept of a visible embolic
agent is the holy grail of embolics.
These beads are unique in that they,
themselves, are the contrast agent.
WEISS: That’s a difficult
dilemma commonly faced in
academic practice. Realistically, early
research success requires a division that
supports research and is willing to let
you take the time to do it. At this point I
pay for my time. The Ring Grant helped
to pay for my time to be able to do this
research. Now my R01 and my other
duties in research and administration
pay for my time. Otherwise, even if your
time is paid for it can be a challenging
balance. Reed A. Omary, MD, MS, FSIR,
gave me a very useful piece of advice:
“When you have an academic day, it’s
an academic day. Academic time is for
academic pursuits; clinical time is for
clinical pursuits.”
COLLINS: What advice would you give
to residents and fellows considering
an academic research career in
interventional radiology?
WEISS: First, don’t hesitate to get
involved in research. Ask what
research is going on in or outside of
your department. Second, take time
to do research, with dedicated time
without or outside of your training
program. Finally, the most important
thing I can say to any young physician
looking to get involved with research
is to find a mentor who has the
perspective to guide you along the
steps of your career. Mentorship
involvement and time gets you 90
percent of the way there.
KRAITCHMAN: We could use X-ray for
bead delivery and then monitor their
location over time with nonionizing
radiation imaging such as MRI.
COLLINS: How do you balance a
busy clinical practice with your
research program?
Of the awards that I see that are
for young or early investigators,
it seems to me that the Ring Grant
provides a particularly excellent
opportunity to obtain preliminary
data for subsequent grants.
*The Dr. Ernest J. Ring Academic Development Grant is made possible, in part, through
generous support from AngioDynamics, an SIR Foundation Discovery Campaign donor
(see www.SIRFoundation.org/discovery for more information).
FA L L 2 0 1 3
an overview of PAs, NPs, and RAs
in interventional radiology
by r. torrance andrews, md, fsir
longitudinal care and referrals to
other providers; consult and round on
inpatients (yours and others’); and, in
many facilities, independently perform
IR procedures.
As a result of these pressures,
many IR groups are turning to
physician extenders (also referred
to as midlevel providers or clinical
associates) to keep the wheels
turning. A recent survey of the five
hospitals in Seattle, Wash. (excluding
the Puget Sound VA) found at least
one IR physician extender at each,
with two facilities each employing
two of these individuals. A single
practice group in Spokane, Wash.,
employs four.
For IR practices that are already
performing the evaluation and
management (E&M) services listed
above, shifting that responsibility
to a physician extender gives the
physicians more time for their
procedures, which can improve
throughput and increase both case
volume and the quality of procedural
care. Practices that do not currently
perform and bill for E&M service
can, with the addition of a physician
extender, recognize an incremental
increase in billing revenue while at
the same time improving the quality
of patient care and satisfaction
among both patients and their
referring providers. Furthermore,
having dedicated clinical
management can result in the capture
of procedural and imaging studies
that might otherwise be overlooked
or forgotten (such as filter retrieval or
follow-up MRI after UFE).
Depending on the needs of the practice
and the laws of the state in which
they reside, physician extenders can
dramatically increase the efficiency of
an IR service. Physician extenders can
see patients in clinic before and after
treatment; review medical records
and study results; provide patient
education; dictate letters, reports
and insurance appeals; coordinate
Very busy practices may opt to use
physician extenders as proceduralists
for certain routine cases, such as
vascular access or drainage. Doing
so can improve departmental
throughput, allow the physicians
to focus on more complex cases,
or allow the physicians to dictate
imaging procedures while the
physician extender handles cases
s interventional radiology
continues its evolution
to a clinical specialty, the
responsibilities of the IR
service also continue to change.
Preprocedure consultation, patient
education, inpatient rounding and
postprocedural follow-up are no
longer beyond the scope of practice;
in fact, they are an imperative. At the
same time, changes in health care
finance are creating a tremendous
incentive in hospitals to shorten
length of stay and improve the quality
of care—both of which goals rely
heavily on the IR service.
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that would generate lower RVUs than
those imaging studies. The specific
nature of procedural work available
to a physician extender is subject
to each institution’s credentialing
body as well as state practice law, as
further discussed below.
Physician Extender Types
Three groups of physician extender
lend themselves to an IR practice:
nurse practitioners (NPs), physician
assistants (PAs) and radiology
assistants (RAs). These groups vary
greatly in their background, training
pathways and practice paradigms, and
there are still further variations within
each practitioner group by state of
licensure. (See table on p. 24.)
Nurse Practitioners
The first formal training program for
clinical NPs was launched in 1965.
There are now more than 350 NP
programs in the United States offering
master’s and doctoral degrees, with
approximately 150,000 NPs practicing
in this country. Enrollment requires
a registered nurse (RN) degree
and most programs also require a
period of clinical experience prior to
matriculation. Since their students
have already had exposure to a broad
range of clinical issues, NP programs
are specialty-specific and weighted
toward classroom didactics. The
national average of clinical (e.g.,
bedside) training hours for a master’slevel NP program is reported to be 686
(17 weeks), whereas the minimum
number required for accreditation is
500 (13 weeks). This clinical exposure,
like the training itself, is specialtyspecific and is distributed over the
entire period of training.
NPs are independently licensed
and have prescriptive authority
in all 50 states and the District of
Columbia, though many states require
a “collaborative relationship” or
physician supervision for prescriptions
to be honored. NPs have the ability to
prescribe controlled substances under
the same restrictions in all states but
Alabama and Florida, where they
have no such ability. In 17 states, NPs
can operate independent practices
without physician oversight; the others
require varying degrees of physician
supervision. An interactive summary
of NP scope of practice by state is
available at www.bartonassociates.
NPs qualify for National Practitioner
Identification (NPI) numbers and bill
CMS under their own numbers for their
work. When doing so, their Medicare
reimbursement rate is fixed at 85
percent of that of a physician.
substances in all states but Kentucky
and Florida. Unlike NPs, who offer fully
independent services in some states,
PAs in all states require oversight by a
physician. The specific obligations of
that oversight vary by state, but direct,
on-site supervision and cosignature
of notes and orders are not required.
Rather, there is an expectation that the
PA and physician will have a shared
approach to management and will
regularly confer and that complex or
unusual cases will be managed with
direct interaction. This arrangement
may require a formal written practice
plan in some states. Some states
also specify an “on-site” requirement
under which the supervising physician
must be physically present at the PA’s
practice location for a minimum fixed
percentage of time. A summary of state
law regarding PA practice is available
at www.aapa.org/the_pa_profession/
Like NPs, PAs have unique NPI
numbers and bill CMS at 85 percent of
the rate of a physician for the
same work.
Radiology Assistants
The first group of PAs, which
coincidentally also began training in
1965, was made up of former navy
corpsmen. This pathway from military
medic to PA continued for many years
and initially a large number of PAs
were former medics or corpsmen.
PA training programs—of which
there are currently more than 150
conferring either bachelor’s or master’s
degrees—are modeled on the training
of physicians and consist of a year
of preclinical classroom education
followed by a year of broad-based
formal clinical rotations much like
those of medical students. The number
of clinical (e.g., bedside) training hours
for a PA is approximately 2,000. There
are approximately 90,000 PAs in
practice in the United States.
Radiology assistant is the generalized
phrase used to describe an advanced
practice radiologic technologist whose
additional training allows him or
her to operate semi-autonomously
within a radiology environment.
More specifically, these individuals
are either radiology practitioner
assistants (RPAs, not to be confused
with “registered physician assistants,”
who are also sometimes called RPAs) or
registered radiology assistants (RRAs),
a designation that reflects some
variations in their training paradigms
and prerequisites that are beyond the
scope of this article. RAs in either group
complete a two-year program that
culminates in a bachelor’s or master’s
degree. There are at present 10 RPA
or RRA programs in the United States,
with approximately 700 graduates
in practice.
PAs are licensed to practice and to
prescribe medications in all 50 states
and the District of Columbia, as well
as all offshore territories but Puerto
Rico. They can prescribe controlled
Although the RA training paradigm
requires “clinical preceptorships,”
these are rotations through different
areas of the imaging department
rather than medical/surgical rotations
Physician Assistants
as experienced by the other trainee
groups. The RPA curriculum includes
two courses in which students are
presented with patient histories, lab
values, images and other clinical
information and are required to predict
imaging findings and the likely clinical
pathway. However, in general, RAs
have no specific training in clinical
management beyond that which
occurs in the radiology department.
Therefore, while an RA may interview
a patient and aggregate data regarding
that patient’s history, he or she
would not be expected to generate or
document billable history and physical
examinations (H&Ps), consult notes or
rounding notes. Similarly, while an RA
might maintain a database of patients
requiring follow-up imaging, lab studies
or clinic visits, he or she would not
order those studies or visits. Because
they do not have prescriptive authority,
RAs cannot supervise or administer
medications and are therefore
unable to independently perform any
procedures that require sedation.
However, they can, within a given
institution, be credentialed to perform
other invasive procedures that do
not require sedation (joint injections,
lumbar punctures, catheter checks,
PICC line placements, etc.).
RPAs, but not RRAs, are able to obtain
NPI numbers. However, neither
category of RA is recognized by
CMS for billing purposes. In some
very specific situations the work
of an RA can be billed under the
physician’s NPI, but his or her work
is otherwise not billable. A very
detailed discussion of these issues
is available at http://cbrpa.org/
One unique characteristic of the
radiology assistant approach is the
opportunity for on-site training. Some
RA programs offer distance learning
pathways that allow the candidate to
obtain his or her practical training
at the institution in which he or she
already works. It is therefore possible
for a highly qualified and motivated
technologist to advance his or her
training and career without having to
leave the job site that has nurtured
that motivation. As long as certain
FA L L 2 0 1 3
criteria are met (such as the number
of specific procedures that must be
performed), training can be tailored
to meet the needs of the practice
group rather than conforming to a
national standard that might not
be entirely relevant. And because
the training covers all aspects of a
radiology practice, rather than just IR,
an RA might be utilized more broadly
in the department than would an NP
or PA. This might be advantageous in
a smaller radiology department with
limited subspecialization.
Comparison of Physician Extender Training
and Practice Variables
Nurse Practitioner
RN; most also
require work
Two years of
prior to starting
a bachelorlevel program;
bachelor’s degree
prior to starting
a master-level
Two years for
master’s, four
years for doctorate
Two years
Two years
MD oversight
Varies by state
Varies by state
85% CMS
85% CMS
Mean Salary
$ 93,000*
Financial Considerations
According to the Medical Group
Management Association’s “Physician
Compensation and Production Survey
2009 Report Based on 2008 Data,”
the median salary for a full-time NP
or PA in 2008 was between $80,000
and $88,000 (current salary levels
are higher; see table at right). Median
collections by those individuals were
between $200,000 and $250,000, for
a compensation-to-collections ratio of
0.35–0.38. Thus, the addition of an NP
or PA could reasonably be expected
to be revenue-neutral or better even
if his or her work is limited solely
to E&M billing. However, since a
physician extender is likely to generate
additional imaging and procedural
studies, his or her contribution to the
revenue stream of an imaging practice
is likely to be much greater.
As previously noted, RAs cannot bill
independently, so their value lies in
allowing the physician to focus upon
activities that do generate revenue.
Unpublished data from the cbrpa.org
link cited previously report that use
of an RA produced a time savings
for the typical diagnostic radiologist
of 3.5 hours/day, which the authors
correlated to a total of $2,548.74
per day and $637,185.00 per year in
increased revenue.
As the landscape of medical care
in the United States changes, ever
more is expected of the IR service.
Yet, at the same time, the increasing
visibility of IR and its growing
FA L L 2 0 1 3
Physician Assistant Radiology Assistant
Program duration
practicing in the
United States
*ADVANCE for NPs and PAs: 2012 NP & PA Salary Survey Results.
**American Society of Radiologic Technologists: 2008 Radiologist Extender Salaries and
Functions Survey.
recognition as a clinical specialty
present new opportunities. Physician
extenders can help in both areas by
being “the face” of the IR service in
the clinic and on the hospital wards,
by improving the flow of patients
through their IR experience and by
ensuring that the IR physicians meet
their longitudinal care obligations
and also realize the follow-up imaging
and procedural opportunities that
might otherwise be missed. Far from
representing an additional cost to the
IR service, these individuals can not
only cover their own salaries but also
generate incremental new revenue.
Local needs and state regulations will
play a significant role in determining
which physician extender group will
fit best into any given practice.
Additional Information
American Association of Nurse
Practitioners: www.aanp.org
American Academy of Physician
Assistants: www.aapa.org
Certification Board of Radiology
Practitioner Assistants: www.cbrpa.org
American Registry of Radiologic
Technologists: www.arrt.org
American Society of Radiologic
Technologists: www.asrt.org.
The author thanks the following
individuals for their assistance in the
preparation of this article: Kathy Taylor,
MS, FNP-C, chair, SIR Clinical Associates
Committee; Ann Davis, PA-C, MS; and
Jane Van Valkenburg, PhD, RPA.
R. Torrance Andrews, MD,
FSIR, is an interventional
radiologist at the Seattle
Radiologists division
of Integra Imaging in
Updates in
Radiology 2013
Charles E. Ray Jr., MD, PhD, FSIR
Brian Funaki, MD, FSIR
Chapters offer brief synopses of the
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opinion statement with recommendations
for changes in clinical practice.
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Q UA L I T Y / R E P O R T I N G C O L U M N
By Stephen L. Ferrara, MD, FSIR
PQRS From A to Z
he Physician Quality
Reporting System, more
commonly known simply
as PQRS (formerly PQRI), is
a voluntary pay-for-reporting program
that phased in a series of payment
adjustments (bonuses becoming
penalties over time) in order to
promote reporting of quality data.
Since it launched in 2007, physicians
have only seen the positive incentive
payments: a 2 percent bonus added
to all eligible Medicare payments for a
compliant physician in 2009 and 2010.
This bonus has been reduced to 0.5
percent for the 2012 performance year
(bonus applied in 2014). Beginning in
2015, however, eligible professionals
who fail to report on quality data in
2013 will begin to receive penalties
of -1.5 percent of their total Medicare
charges, progressing to -2 percent in
2016 (there is a lag between reporting
and payment due to Centers for
Medicare and Medicaid Services [CMS]
administrative constraints). Considering
the anemic PQRS participation rates in
interventional radiology and throughout
the larger medical community, this is
ominous news.
A recent article (Duszak et al.,
“Medicare’s Physician Quality
Reporting System: Early National
Radiologist Experience and Near-future
Performance Projections,” J Am Coll
Radiol 2013;10:114–121) reviewed
the early experience with PQRS and
offered a glimpse into the near future.
The study examined CMS claims data,
revealing that in the program’s first
year, 160 interventional radiologists
participated in PQRS (16.7 percent)
with 59 (36.9 percent) qualifying
for a bonus; and, in 2010, 537 IRs
participated (39.4 percent) with 306
(57 percent) qualifying for a bonus
(mean annual bonus = $3,973.06). To
provide context, corresponding values
in radiology overall (diagnostic radiology
FA L L 2 0 1 3
+ interventional radiology + nuclear
medicine +radiation oncology) were as
• 2007: 21.6 percent participation/32.5
percent qualifying for a bonus
• 2010: 38.1 percent participation/62.3
percent qualifying for a bonus
Thus, the interventionalist participation
and qualification tracks fairly
synchronously with radiology as a
whole, with both cohorts more active
in the PQRS program than most other
medical specialties.
While IR participation is respectable
compared to the greater medical
community, as carrots turn into sticks
beginning in 2015 (based on the
2013 reporting year) the landscape
may begin to change. Assuming
participation rates and payment
rates remain static, 78 percent of
IRs will see a $2,802 annual penalty
in 2015, increasing to $3,735 in
2016. Some will dismiss these losses
as too small to justify a change in
behavior. An even more interesting
question (where data are lacking)
is whether the administrative costs
of participation approach or even
exceed the costs of nonparticipation.
The answer likely varies on the basis
of a practice’s ability to scale the
administrative cost burden over a large
number of providers and whether
an infrastructure such as a modern
electronic health record is already in
place. Thus, hospital-based specialties,
including most IR practices, likely
enjoy some infrastructure advantage
over predominantly outpatient-based
Online Resources
PQRS Home:
Getting Started:
Tip Sheet and Decision Tree:
PQRS Main Page:
Sample PQRS Interventional Measure
Codes Charge Sheets
specialties. Regardless, the penalties
become meaningful for any
economically minded physician as
the cost of nonparticipation begins
to stack up: other potentially erosive
CMS mandates include Meaningful Use
and the Value-based Modifier. And, of
course, there is always the potential of
budget sequester.
Clearly then, most IRs will want to
avoid the penalties and public reporting
consequences of nonparticipation in
PQRS. What measures are there to
report on, and what are the methods
of reporting? Historically, there has
been a great deal of justifiable criticism
that the PQRS measures do not have
a meaningful impact on patient care,
which has been a major factor in the
low participation rates. While a great
deal of work remains to be done in
terms of improving the clinical impact
of quality measures, several are
currently available that are germane
to most IR practices. The CMS Web
site has a comprehensive list of all the
approved measures and the SIR Web
site lists the ones that are most relevant
to interventional radiology. These
largely fall into categories including
antibiotic prophylaxis, central venous
catheter placement, fluoroscopy and
hemodialysis to name a few (for a
complete list, see the links on page 26).
There are several methods of reporting
to CMS: claims, registries, electronic
health records or the group practice
reporting option (GPRO). In order to
avoid the 2015 penalty applied to those
who fail to satisfactorily report in 2013,
CMS has made a reporting allowance
that exempts providers who sign up by
Oct. 15 and elect the administrative
claims option. Use of this option
makes a physician ineligible for the 0.5
percent bonus in 2015, however. For
help with navigating this administrative
maze and avoiding financial penalties,
CMS offers a tip sheet and decision tree
to assist providers in determining how
PQRS applies to their practice (see link
on page 26).
Whether through PQRS, new payment
models or a replacement of the
sustainable growth rate, quality reporting
has become embedded in both public
PQRS Measures
Are you treating patients with
peripheral arterial disease or
vertebral compression fractures?
Are you documenting fluoroscopy
time? These and other measures
might be applicable to your
practice. SIR has compiled many
of the applicable PQRS measures
at http://members.SIRweb.org/
cfm. SIR encourages all members
to report on PQRS this year and
avoid the 2015 penalty. See www.
for more details.
and private payer systems and is
here to stay. Engagement with SIR,
particularly through development and
contribution to registries, offers practicing
IRs the opportunity to make quality
measures more clinically relevant, less
administratively burdensome and more
financially rewarding.
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FA L L 2 0 1 3
For external carotid angiography
(ECA), is code 36227 reported once for
all diagnostic angiography performed
for the ECA, including the selection
of the main trunk of ECA and/or
the superselection of any number of
branches for diagnostic imaging?
by Aaron Shiloh, MD
Answer: CPT code 36227 (Selective catheter
placement, external carotid artery, unilateral, with
angiography of the ipsilateral external carotid
circulation and all associated radiological supervision
and interpretation (List separately in addition to
code for primary procedure)) includes all selective
catheterizations in the external carotid artery
territory; therefore, additional catheterizations
and angiograms are not reported separately. Code
75774 is not reported for additional superselective
diagnostic imaging in the ECA territory.
Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind
of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2013/CPT®). It is not comprehensive and
does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the
appropriate services associated with each code is mandatory for proper coding of physician service.
Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation,
warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication
is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a
particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct
use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who
utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any
Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.
2014 CPT Coding Change Alert
The SIR Economics Committee will soon reach out to members with detailed information about several major
coding changes that will take effect Jan. 1, 2014. A new family of four Current Procedural Terminology (CPT) codes
covering embolization procedures will permit greater coding specificity and anatomical precision. These four new
codes (37241-37244) were approved by the American Medical Association (AMA) CPT Editorial Panel and were
presented to the RBRVS Update Committee (RUC) in April. These new codes will replace the existing CPT code for
embolization, 37204, as well as the existing uterine fibroid embolization code, 37210. The final RVU values for these
new codes will be assigned when CMS issues the 2014 Medicare Physician Fee Schedule Final Rule in November.
Additionally, four new codes (37236-37239) for endovascular revascularization have been approved. These new codes
are for vessels other than lower extremity, cervical carotid, intracranial, intracoronary, or extracranial vertebral or
intrathoracic carotid. New codes 37236 and 37237 will be used for arterial stent insertion, while 37238 and 37239 will
be used for venous stenting.
SIR will continue to provide updates and education opportunities regarding these and other 2014 CPT changes as
they develop.
FA L L 2 0 1 3
ct o
h Anniv
The 118t
You, your local radiology association, and your
institution can build greater awareness of radiology
and its contribution to patient care.
Help spread the word in your community with
ready-to-use promotional materials available at
New Commission
to Accredit Carotid
Stenting Facilities
by david sacks, md, fsir
IR is one of the founding societies
of the Intersocietal Commission
for the Accreditation of Carotid
Stenting Facilities (IAC Carotid
Stenting|ICACSF). The IAC Carotid
Stenting program accredits a facility
on the basis of outcomes for 30-day
periprocedure stroke or death meeting
accepted national benchmarks of 3
percent for asymptomatic patients and
6 percent for symptomatic patients.
The program standards also include
assessment of infrastructure and
processes of care that contribute to
patient outcomes.
Currently the Centers for Medicare
and Medicaid Services (CMS) require
a facility to be certified through CMS
as a prerequisite for reimbursement
for carotid artery stenting procedures.
However, the CMS certification does not
require that outcomes meet established
benchmarks. As a consequence,
although CMS has accredited more than
1,000 facilities, there is wide variation
in the quality of carotid stenting
procedures, which has led to skepticism
that good outcomes from major carotid
stent trials can be generalized to routine
clinical practice.
The IAC Carotid Stenting program has
currently accredited five facilities, with
more applications in process. Applicant
sites supply patient procedure logs with
outcome data, descriptions of processes
of care, neurological assessment
information and procedure imaging
reports to confirm clinical necessity. In
FA L L 2 0 1 3
addition, randomly selected procedures
are evaluated for appropriateness of
patient selection, image quality, technical
expertise, outcome and quality of
documentation. Random audits and site
visits are also part of the program.
The IAC Carotid Stenting accreditation
process so far has revealed that most
facilities do not accurately track
outcomes. Thirty-day patient follow-up
assessments are not the rule, and
rigorous neurologic evaluation at the
follow-up visit is the exception. Facilities
that believe they have low stroke rates
do not have the information to confirm
this assumption. Without assessment
of patient outcome postprocedure, it
is not possible to assess the quality
of the facility in the performance of
carotid stenting. As a result of the IAC
accreditation program, facilities have
improved processes and assessment
of patients, and reliable data is now
being obtained. The approach of the IAC
Carotid Stenting accreditation program
is to serve as an independent agency to
accredit facilities that meet established
benchmarks and demonstrate
quality patient care and to provide a
mechanism for continuous process
improvement, which should lead to
improved patient outcomes.
Currently CMS does not require
accreditation through IAC Carotid
Stenting|ICACSF and facilities therefore
apply voluntarily for the benefits of
improving and certifying quality. The
IAC Carotid Stenting board of directors
has had discussions with CMS staff to
suggest that the IAC Carotid Stenting
accreditation program replace CMS
accreditation as a requirement for
Sponsoring societies of IAC Carotid
Stenting|ICACSF include the Society
of Interventional Radiology, American
Academy of Neurology, American
Association of Neurological Surgeons/
Congress of Neurological Surgeons
Cerebrovascular Section, American
Association of Physicists in Medicine,
American Society of Neuroradiology,
Neurocritical Care Society, Society for
Vascular Medicine, Society for Vascular
Surgery, Society of NeuroInterventional
Surgery, and the Society of Vascular and
Interventional Neurology.
ICACSF is a division of the Intersocietal
Accreditation Commission (IAC). In
addition to IAC Carotid Stenting, the
IAC provides accreditation programs
for vascular testing, echocardiography,
nuclear/PET, MRI, diagnostic CT, dental
CT and vein centers. Applications for
accreditation for carotid stenting can
be accessed at www.intersocietal.org/
David Sacks, MD, FSIR,
FACR, is the president of
the IAC Carotid Stenting
board and a past
president of SIR.
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A N N UA L S C I E N T I F I C M E E T I N G C H A I R ’ S
by Daniel B. Brown, MD FSIR
SIR 2014:
Content and Convergence
More interactivity, more hands-on learning, more IR
Convergence will define SIR
2014. An incredible array of
scientific and clinical topics will
illustrate the multidimensional
nature of our specialty and reflect the diversity of materials
and members of the IR community when we converge to
share, network, learn and lead at SIR’s Annual Scientific
Meeting—March 22–27, 2014, in beautiful San Diego, Calif.
We’re excited to bring you a fresh program that affords more
interactivity, more hands-on learning and unparalleled access
to experts across the spectrum—all designed to enhance your
skills, increase your knowledge, and give you a competitive
edge in today’s health marketplace. SIR 2014 will feature
more than 400 scientific presentations and more than 250
hours of educational programming.
Plans are progressing rapidly. Based on member feedback
from past meetings, the Annual Scientific Meeting
Committee has clarified session structure in order to help
you craft a learning experience that is suited precisely to
your needs and interests.
As in the past, clinical symposia will bookend the Saturday–
Thursday meeting; however, rather than exploring one or
two subjects for four to six hours each, the 2014 Saturday
session will cover Morbidity and Mortality (M&M) with
focused sequential reviews of three topics: peripheral
arterial disease, oncology and embolization. Similarly, the
Thursday symposium will feature three sequential “How I
Do It” sessions highlighting venous disease, embolization
FA L L 2 0 1 3
and oncology. SIR 2014 workshops will feature even more
personalized discussion and case-based review, with some
sessions leveraging a more traditional question-and-answer
format. The number and quality of hands-on workshop
sessions is expanding as well.
Last year’s popular “In the Trenches” series will return
with three in-depth afternoon sessions geared toward
interventional radiologists in private practice and recent
graduates looking for reviews on core procedures and
guidance on practice development. Categorical courses
will drill down on a single topic within IR, ranging
from hemodialysis and portal hypertension to practice
management and women’s health, to name a few.
Three of the ever-popular Case-based Review courses are
scheduled, with learning via analysis of individual cases—
plus networking through “Meet the Professors,” which will
provide a special opportunity for informal, thought-provoking
discussion with current subspecialty leaders in IR.
Finally, each day will feature a plenary session that crosses
multiple service lines and serves as the daily centerpiece.
With the convergence of so many scientific sessions with
exploration of the latest advances from our partners in
industry, there is something for everyone at SIR 2014.
I look forward to seeing you in San Diego!
by Brian F. Stainken, MD, FSIR
The World Is Flat (Again)
oday, it is as easy to connect with China as it is to
Chicago. Opportunities to trade, learn and relate
happen literally at the speed of light. No corner is
inaccessible, no place unknown. We see it in our
lives—how familiar faraway places have become, how the
instantaneous flow of information has actually influenced
world events, how our ability to “link” has changed what we
say and do. It has also changed IR.
We began as angiographers, in a few centers in the United
States and in northern Europe. People actually traveled
back and forth to learn the trade and our meetings were in
person. We used to create abstract submissions by cutting
and pasting typed paper, not by creating word processor
documents. How quaint.
Fast forward to the present. Last year, SIR worked with the
Indian Society of Vascular and Interventional Radiology
to help develop its annual meeting program (see “Xtreme
Interventions in India,” Summer 2014 IRQ, p. 33). Our
meetings were on Skype, and we used Google Docs to develop
and modify a Microsoft Excel-based program—in real time
while we spoke. We reviewed scientific submissions together
online and even invited select posters for display at the SIR
2013 Annual Scientific Meeting in New Orleans. We then
Webcast select SIR meeting proceedings to India (and the rest
of the world) via live simultaneous Web-based blogging. It was
fast, fluid and mutually beneficial. It’s called “globalization.”
SIR began as an international society. We realized from
the beginning that the power of our discoveries, our new
way of healing, would grow as we shared. And it has. We
know of nearly 50 regional IR societies worldwide, each
doing important work to spread IR. The latest example of
this growth can be seen in Canada, where IR has achieved
subspecialty status. This past summer, the Royal College of
Physicians and Surgeons of Canada approved the application
spearheaded by the Canadian Interventional Radiology
Association (CIRA), and the Society congratulates CIRA on
this important accomplishment.
For 40 years, SIR has served as a resource for materials like
standards and educational programs and has helped partner
societies like CIRA mature into strong advocates for our field.
We have never wavered from our role as a good partner. But
we can do much more—we can globalize. We can accelerate
our interactions, improve communication, pursue new
international partnerships in the area of education, standards
and government relations. We can foster global accreditation
and certification. We know that industry sees tremendous
growth in international markets and we can serve as a resource
for developing these important markets. We want IR worldwide
to be known for quality innovation. We can make that happen.
To this end, in 2012, SIR created an International Task Force.
This group was tasked with advising the Society on its global
initiatives, and it has been kept very busy since its formation.
The Society has hosted more than 25 international scholars
at the SIR Annual Scientific Meeting. Each scholar is a young
IR sponsored by his or her national society based on interest,
performance and leadership potential. Now in its third year,
the task force is working to network these IRs together
through such efforts as the quarterly International Leadership
Update e-newsletter. We have carried SIR’s message to
meetings on nearly every continent. SIR hosted a strategic
planning session at last year’s meeting with the two primary
Latin American IR societies. We have helped standing
SIR committees and divisions to reach out to the global
IR community. We are working on Web sites, educational
programs and much more.
In coming issues of IRQ, this column will describe the
activities of the task force, international initiatives and stories
about our field from around the world. We invite those of you
with global connections to contribute and we always welcome
more volunteers.
International SIR Scholarship Program
Application deadline is Oct. 23.
Online application is now available for SIR’s International
Scholarship Program. This program is intended to enable
physicians within 10 years of completion of training who
are practicing outside North America an opportunity to
attend SIR’s Annual Scientific Meeting.
Apply online at www.tfaforms.com/296365. For more
information or questions, contact Tricia McClenny
at [email protected] Please forward program
information to international colleagues.
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Good news! For many years, SIR
has developed and made available
publications, patient resources,
educational opportunities and much
more to give IRs tools that will facilitate
the management of their practice—
many of which are complimentary
benefits of membership with the
Society. Below is just a small sample
of the tools and resources available
to you. Explore www.SIRweb.org
at the links cited below for more
details on these and other valuable
materials. The Society thanks all
those responsible for generating and
contributing to these documents.
Clinical Practice
The clinical practice guidelines of the
Society of Interventional Radiology
attempt to define practice principles
that generally should assist in
producing high quality patient care.
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• Occupational Radiation Protection in IR
• ACR, SIR, SNIS Practice Guideline for
IR Clinical Practice
• General Principles for Evaluation of
New Interventional Technologies and
• SIR Policy on Gainsharing
• SIR Policy on Off-label Use
• Position Statement: The Role of
Physician Assistants in IR
• Joint Practice Guideline for Sterile
Technique During Vascular and IR
• ACR-SIR Practice Guideline on
Informed Consent for Image-guided
Publications and
Materials on the IR Store
• Setting Up and Running an
Office-based Clinical Practice Manual
and Supplement
The clinical practice manual is a stepby-step blueprint that will guide you
through the process of implementing a
clinical practice in an existing setting.
• Socioeconomic Survey Booklet Set
(2006-2007 & 2000/2001)
The 2006–2007 SIR Socio-Economic
Survey was designed to capture
the various aspects of the practice
of interventional radiology. The
65-page survey report summarizes
the findings with particular focus
• Recommendations for the
Implementation of Joint Commission
Guidelines for Labeling Medications
SIR Clinical
Practice Resources
and Materials
ears of training have prepared you
to provide high-quality care for a
broad range of disease states and
conditions. In today’s economy,
however, meeting your patients’ needs
is just part of ensuring the success of an
interventional radiology clinical practice.
From developing a business plan, to
marketing your practice to referring
physicians and the general public, to the
logistical demands of setting up an office,
developing a strong clinical practice
provides a steady stream of logistical
and administrative challenges that IRs
typically aren’t trained to address.
on: practice information, trends in
services offered, trends in referral
patterns, employment issues and
freestanding centers.
• Interventional Radiology Sourcebook
This functional coffee table book
can help patients in your waiting
room and others learn more about
interventional radiology.
• Marketing Your UFE Practice
For those who want to enhance their
UFE practice or those starting a new
one, SIR’s UFE marketing manual is
essential. This manual will help you
assess your practice’s strengths and
guide you through areas needing
• IR Public Awareness Poster Series
These 16x20 posters can be
used to educate the public about
interventional radiologists and
the treatments they offer. The
topics included in the kit are PAD,
varicose veins, UFE, DVT, stroke,
vertebroplasty and liver cancer.
• 2013 Interventional Radiology
Coding Update (free for members)
2013 Interventional Radiology
Coding Update features include: New
and revised 2013 interventional
radiology codes; frequently asked
questions; individual coverage
request sample letters; sample 2013
charge sheets.
• Waiting Room DVD
This video is a compilation of 10
two-minute stories that discuss how
a sick patient finds an IR, has a
nonsurgical procedure and gets well.
Patient Information
(25 topics in all, including
some in Spanish):
These popular patient-oriented
brochures help patients and family
members and referring physicians
to understand IR procedures and the
special training you have as an IR.
• What You Need to Know About Cancer
• What You Need to Know about
Women and Vascular Disease
• What You Need to Know About Male
Infertility Caused by Varicoceles
• What You Need to Know About Venous
Insufficiency and Varicose Veins
• What You Need to Know About Stroke
• What You Need to Know About PAD
Archived IR News articles
Featuring excerpts from clinical
practice resources, expert commentary
and the perspectives of those who
have successfully met the challenges
of the clinical practice setting, archived
IR News articles remain relevant and
incredibly useful references.
• Freestanding IR—Seven Years Later,
Arash M. Padidar, MD
Clinical Practice/
Documents to Help Build
a Strong Practice
SIR Digital Video Library
• Employment Negotiating: “How
do you get the job you want?”
Professional Contracting
• Coding and Reimbursement
• Critical Components to a Successful
IR Practice: “How to do a good job?”
•Marketing: “How to let others know
what a great job you do?”
Practice Building/
PowerPoint Presentations
• “The Future of Modern Medicine”: An
SIR Presentation to Inform the Public
About Interventional Radiology
• “PAD Patient Information
Presentation”: Stay in Circulation/
NHLBI Campaign
• Varicocele Occlusion, Alan M.
Zuckerman, MD, FSIR
• Integrated Practices & IR: Opportunities
for Program Development
• Managing Overwhelm: Time
Management Strategies for Health
Care Professionals
• Practice Development II: IR
Outpatient Office and Optimal Use of
Clinical Associates
• Practice Development III: Marketing
• Strategies for Interventional
Radiology Practices: Developing IR as
a Profit Center
Special SIR Programs
Legs For Life®
Legs For Life® is a national screening
program for peripheral arterial disease
(PAD), abdominal aortic aneurysm
(AAA), carotid/stroke and venous
disease. The program is a community
health and public information program
founded in 1997 by the Society of
Interventional Radiology
• Clinical Practice: The Business Plan,
Jeremy L. Friese, MD, MBA, and
Jason G. Funderburk, MD, MBA
SIR Learning Center
Browse the Members Section of
www.SIRweb.org to find a wealth of
information and resources. Here are
just a few examples:
• In the Trenches: My Challenges:
• Carotid Artery Stenting, Randall T.
Higashida, MD, FSIR
• Credentials and Quality
Improvement for Peripheral Vascular
Procedures: David Sacks, MD, FSIR
• Freestanding IR: Economics, Politics,
and Business of IR: A Mini MBA
• Practice Organization and Operations,
Jeremy L. Friese, MD, MBA, and
Jason G. Funderburk, MD, MBA
Other Materials in
Members Section
• E&M Coding
• Chemoembolization, Eric A. Huettl, MD
• Evaluation/Management Coding,
Katharine L. Krol, MD, FSIR, and
Michael E. Edwards, MD, FSIR
• Get an Office and Save Your Practice,
Reza Malek, MD; A.M. Padidar, MD;
Carlo Ferrarone, MMS
• SIR Coding and Payment Update, 2013
• Practice Models: “Which practice
model is right for you?” Pros/Cons of
Various Practice Models
• Marketing Your IR Practice, Jason G.
Funderburk, MD, MBA, and Jeremy
L. Friese, MD, MBA
• Strategic Planning for a Clinical
Practice, Jeremy L. Friese, MD, MBA,
and Jason G. Funderburk, MD, MBA
Interventional Radiology (EBIR) and
Comparative Effectiveness, 2012
The SIR Learning Center provides you
with a growing library of educational
activities that offer the latest and
most important information regarding
interventional radiology. Dynamic and
informative, our accredited courses are
designed by the nation’s leading experts.
Learning Center On-demand
• So You’re Getting Called Up to the
Big Leagues or What They Didn’t
Teach You During Your Fellowship
SIR Content
Licensing Program
Save time, effort and money by
leveraging an expansive collection
of SIR-sanctioned content that
is accurate and targeted to your
patients’ needs. For more details,
see the ad on page 31.
• Research Education: Literature
Review, Evidence-based
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in the Current Literature
This column alerts SIR members to abstracts that may have
an impact on their practice and how they converse with
referring clinicians. If you would like to suggest abstracts you
feel should be included, email us at [email protected]
or [email protected]
20% (15/75) in the cilostazol group versus 49% (38/77) in the
noncilostazol group (P=0.0001) by intention-to-treat analysis.
The cilostazol group also had a significantly higher event-free
survival at 12 months (83% versus 71%, P=0.02), although
cardiovascular event rates were similar in both groups.
CONCLUSION: Cilostazol reduced angiographic restenosis
Cilostazol Reduces Angiographic
Restenosis After Endovascular Therapy
for Femoropopliteal Lesions in the
Sufficient Treatment of Peripheral
Intervention by Cilostazol Study.
Circulation. 2013 Jun 11;127(23):2307-15. doi: 10.1161/
CIRCULATIONAHA.112.000711. Epub 2013 May 7.
Iida O, Yokoi H, Soga Y, Inoue N, Suzuki K, Yokoi Y,
Kawasaki D, Zen K, Urasawa K, Shintani Y, Miyamoto
A, Hirano K, Miyashita Y, Tsuchiya T, Shinozaki N,
Nakamura M, Isshiki T, Hamasaki T, Nanto S; STOP-IC
SOURCE: Kansai Rosai Hospital, Cardiovascular Center,
3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan.
Email [email protected]
BACKGROUND: It remains unclear whether cilostazol,
which has been shown to improve the clinical outcomes
of endovascular therapy for femoropopliteal lesions, also
reduces angiographic restenosis.
METHODS AND RESULTS: The Sufficient Treatment
of Peripheral Intervention by Cilostazol (STOP-IC) study
investigated whether cilostazol reduces the 12-month
angiographic restenosis rate after percutaneous
transluminal angioplasty with provisional nitinol stenting
for femoropopliteal lesions. Two hundred patients with
femoropopliteal lesions treated from March 2009 to April
2011 at 13 cardiovascular centers were randomly assigned
1:1 to receive oral aspirin with or without cilostazol. The
primary end point was 12-month angiographic restenosis
rate. Secondary end points were the restenosis rate on
duplex ultrasound, the rate of major adverse cardiac
events, and target lesion event-free survival. Researchers
evaluated all follow-up data and assessed the end points in
a blinded fashion. The mean lesion length and reference
vessel diameter at the treated segment were 128±86 mm
and 5.4±1.4 mm, respectively. The frequency of stent
used was similar between groups (88% versus 90% in the
cilostazol and noncilostazol group, respectively, P=0.82).
During the 12-month follow-up period, 11 patients died and
152 patients (80%) had evaluable angiographic data at 12
months. The angiographic restenosis rate at 12 months was
FA L L 2 0 1 3
after percutaneous transluminal angioplasty with provisional
nitinol stenting for femoropopliteal lesions.
Aspiration and Sclerotherapy:
A Nonsurgical Treatment Option
for Hydroceles.
J Urol. 2013 May;189(5):1725-9. doi: 10.1016/j.
juro.2012.11.008. Epub 2012 Nov 6.
Francis JJ, Levine LA.
SOURCE: Department of Urology, Rush University Medical
Center, Chicago, Illinois 60612, USA.
PURPOSE: We demonstrated that hydrocele aspiration
and sclerotherapy with doxycycline is an effective and safe
nonsurgical treatment option for hydrocele correction.
MATERIALS AND METHODS: The medical records
of patients who underwent hydrocele aspiration and
sclerotherapy were analyzed in a retrospective cohort
study for success rates as well as improvement in scrotal
size and discomfort after a single hydrocele aspiration and
sclerotherapy treatment. Patients who reported decreased
scrotal size, improved physical symptoms and satisfaction
with the procedure were considered as having success with
hydrocele aspiration and sclerotherapy.
RESULTS: A total of 29 patients (mean age 52.8 years)
presenting with 32 nonseptated hydroceles underwent
hydrocele aspiration and sclerotherapy with doxycycline
between 2005 and 2012. Of the hydroceles 27 (84%) were
successfully treated with a single aspiration and sclerotherapy
procedure. Overall mean follow-up was 20.8 months. Three
patients reported moderate pain which resolved in 2 to 3
days. Of those patients in whom hydrocele aspiration and
sclerotherapy failed, 1 had hydrocele successfully resolved
with a second aspiration and sclerotherapy treatment, 3 did
not have success with a second procedure and underwent
hydrocelectomy, and 1 wanted immediate surgical correction.
CONCLUSIONS: Hydrocele aspiration and sclerotherapy
was successful in correcting 84% of simple nonseptated
hydroceles with a single treatment. This result is an increase
from previously reported success rates involving a single
hydrocele aspiration and sclerotherapy procedure with
by Ripal T. Gandhi, MD, and
Suvranu Ganguli, MD
tetracycline (75%). The success rate of a single hydrocele
aspiration and sclerotherapy procedure is similar to the
reported success rates involving hydrocelectomy while
avoiding the hospital expense and many other complications.
We conclude that the hydrocele aspiration and sclerotherapy
procedure is a reasonable, nonsurgical and underused
treatment option for nonseptated simple hydroceles.
Trauma Center Variation in Splenic Artery
Embolization and Spleen Salvage:
A Multicenter Analysis.
J Trauma Acute Care Surg. 2013 Jul;75(1):69-75. doi: 10.1097/
Banerjee A, Duane TM, Wilson SP, Haney S, O’Neill PJ,
Evans HL, Como JJ, Claridge JA.
SOURCE: From the MetroHealth Medical Center (A.B., J.J.C.,
J.A.C.), Case Western Reserve University, Cleveland, Ohio;
Virginia Commonwealth University Health System (T.M.D.,
S.P.W.), Richmond, Virginia; The Trauma Center at Maricopa
Medical Center (S.H., P.J.O.), Phoenix, Arizona; Harborview
Medical Center (H.L.E.), Seattle, Washington.
were more likely to leave the hospital with their spleen in situ
(odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01).
CONCLUSION: Significant practice variation exists in the
use of SAE in treating BSI at Level I trauma centers. Centers
with higher rates of SAE use have higher spleen salvage
and less NOM failure. SAE was shown to be an independent
predictor of spleen salvage.
Sorafenib Combined With Transarterial
Chemoembolization for the treatment
of advanced Hepatocellular Carcinoma:
A Large-scale Multicenter Study of 222
Ann Oncol. 2013 Jul;24(7):1786-92. doi: 10.1093/annonc/
mdt072. Epub 2013 Mar 18.
Zhao Y, Wang WJ, Guan S, Li HL, Xu RC, Wu JB, Liu JS, Li
HP, Bai W, Yin ZX, Fan DM, Zhang ZL, Han GH.
SOURCE: Department of Liver Disease and Digestive
Interventional Radiology, Xijing Hospital of Digestive
Diseases, Fourth Military Medical University, Xi’an.
BACKGROUND: This study aimed to evaluate if variation
in management of blunt splenic injury (BSI) among Level I
trauma centers is associated with different outcomes related
to the use of splenic artery embolization (SAE).
BACKGROUND: Data on the efficacy and safety of sorafenib
METHODS: All adult patients admitted for BSI from 2008
to 2010 at 4 Level I trauma centers were reviewed. Use of
SAE was determined, and outcomes of spleen salvage and
nonoperative management (NOM) failure were evaluated. A
priori, a 10% SAE rate was used to group centers into high- or
low-use groups.
PATIENTS AND METHODS: In this multicenter
retrospective study, 222 consecutive HCC patients receiving
combination therapy were enrolled between June 2008 and
July 2011.
RESULTS: There were 1,275 BSI patients. There were
intercenter differences in age, injury severity, and grade of
spleen injury (Spleen Injury Scale [SIS]). Mortality was similar
by center; however, BSI treatment varied significantly by
center. Overall, SAE use was highest at center A compared
with B, C, and D (19%, 11%, 1%, and 4%, respectively; p <
0.01). High SAE use centers had significantly higher spleen
salvage rates and fewer NOM failures. Differences in the use
of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs.
56%, p = 0.03) were most dramatic between high- and lowuse SAE centers for Grade 3 and 4 injured spleens. In patients
who received initial NOM, multivariate logistic regression
analysis showed that SAE was an independent predictor
of spleen salvage (odds ratio, 5; 95% confidence interval,
1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury
Severity Score (ISS). Patients treated at high SAE use centers
in combination with transarterial chemoembolization (TACE)
in patients with advanced hepatocellular carcinoma (HCC)
are lacking.
RESULTS: Chronic hepatitis B was the predominant cause
of HCC (86%). Eighty percent patients were at Barcelona
Clinic Liver Cancer (BCLC) stage C, and 86% patients
were in Child-Pugh (CP) A class. The overall median
survival was 12 months (95% CI 10.1-13.9). The overall
incidence of adverse events (AEs) was 87%. In 177
BCLC-C patients, performance status, the number of HCC
nodules, Child-Pugh score and macrovascular invasion
were significantly associated with overall survival (OS)
and were included in the final risk scores (R), where R
= 5 × (vascular invasion: 0 if no, 1 yes) + 6 × (CP: 0 if
A, 1 if B) + 7 × (no. of lesions: 0 if 1-2, 1 ≥3) + 8 × (
Eastern Cooperative Oncology Group, ECOG: 0 if 0, 1 ≥1).
CONCLUSIONS: Sorafenib in combination with TACE should
be considered a safe and effective therapy for advanced HCC.
Further validation of the new subgroup of BCLC-C stage is
warranted in an independent patient cohort.
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Pieces of the Past
As SIR celebrates its 40th anniversary, IRQ looks back
at some of the early innovative devices that formed the
foundation for today’s interventional radiology procedures.
Can you identify these devices?
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Answers will
appear in the
next issue
of IRQ.
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