Table 1. Interventional radiology procedures prioritization Arterial Venous


Emergent


• Active bleeding with unstable vital signs or hemodynamic decompensation


• Arterial interventions for limb or bowel ischemia


• Large splenic aneurysms with impending rupture


• Vascular tumors at risk of impending rupture


• Arteriovenous malformation with cardiac decompensation


Schedule within 1 month


• Abdominal aortic aneurysm endoleak embolizations


• Interventional oncology procedures


• Splenic artery aneurysms


Elective, schedule in 3 months


• Prostatic/uterine artery, angiomyolipoma


• Arteriovenous malformation embolizations


• Deep venous interventions (embolization/recanalization/ stenting)


• Filter retrievals without acute venothromboembolic complication


• Venous sampling • Venous malformations


N/A


• Venography for dialysis access planning


• TIPS revision N/A


• Acute venous thromboembolic event with complicating features (e.g., PE with right heart strain)


• TIPS for acute bleeding • Arteriovenous graft declotting


• Acute central DVT with complicating features (phlegmasia cerulea dolens)


Non-vascular


• Percutaneous biliary and nephrostomy drainages for obstruction with sepsis


optimize imaging software (i.e., roadmap, overlay) during emergency procedures are being emphasized to reduce the amount of CM utilized per case. In addition, leadership committees to oversee institutional contrast use are being created to coordinate targeted use of CM on the basis of patient acuity in all procedural areas within the hospital that use CM, such as neurointerventional radiology, interventional cardiology, vascular surgery, urology, radiation oncology, orthopedic surgery and advanced gastroenterology.


As an example, for each area at our institution, leadership requested that clinical teams triage examinations into three categories:


1. Emergent—must be done 2. Can be delayed by up to 1 month 3. Can be delayed by 3 months


For the second and third categories, every effort has been taken to reschedule patients within the timeline determined. Table 1 lists an example of prioritization matrix on the use of iodinated CM stratification by patient acuity for IR procedures.


Minimizing waste and centralizing allocation of supply While case prioritization and use of alternative contrast agents are key to preserving CM use, there are still IR procedures that require CM. We therefore need mitigation strategies to reduce waste and conserve supply for emergency patient management.


The main step toward reducing waste is to centralize CM management across other procedural areas within the hospital. Another approach is central pharmacy distribution of CM in smaller aliquots. More broadly, in multihospital health care systems, centralized


inventory that subsequently allocates CM to affiliates based on acuity and need is actively being pursued. In addition, our institutions have approved implementation of multiuse valves equipment, which can extend the use of the contrast vials (multiuse vials) to preserve CM, and we are encouraging the use of 50% diluted contrast in emergent cases.


While supply may vary across institutions, a common approach is deferral of all elective procedures that require iodinated CM to a later time.


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