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PURPOSE: To evaluate the correlation between clot burden and pulmonary artery pressures in patients undergoing suction thromboembolectomy for high-risk and intermediate-high-risk pulmonary embolism with secondary outcomes of 30-day morality and intensive care unit (ICU) length of stay. MATERIALS AND METHODS: Institutional review board (IRB) exemption was granted for this retrospective study. The charts of 120 consecutive patients who underwent mechanical thromboembolectomy using the Flowtriever system (Inari Medical, Irvine, California) between February 2020 and August 2022 were retrospectively reviewed, and the following data were collected: (a) preprocedural B-type natriuretic peptide and creatinine levels, (b) echocardiographic findings, (c) preprocedural and postprocedural pulmonary artery pressures, (d) ICU length of stay, and (e) 30-day mortality. Clot burden was scored using Qanadli and Miller indices and correlated with the clinical outcomes. RESULTS: Of the 120 patients who underwent thromboembolectomy, pulmonary artery pressures and diagnostic-quality angiograms were available in 109 patients. In the 109 patients with adequate data, Qanadli, preprocedural Miller, and postprocedural Miller scores correlated with pulmonary artery pressures. Neither was independently associated with ICU length of stay. Freedom from 30-day mortality was 91%, and embolism-specific mortality was 92%. All-risk and high-risk patients who survived demonstrated a significantly lower preprocedural and postprocedural Miller score, respectively. CONCLUSIONS: Thrombus burden as measured by the Qanadli and Miller scores appeared to be correlated with pulmonary artery pressures. Furthermore, catheter-directed thromboembolectomy led to a reduction in Miller scores, which appeared to be correlated with a reduction in pulmonary pressures. In high-risk patients, a reduced postprocedural Miller score and pulmonary pressure demonstrated improved 30-day survival. Further investigation into the association between Miller scores and patient mortality is warranted to stratify patients who would benefit from emergency intervention.
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OBJECTIVES: To assess the effects of filtered blood reinfusion (FBR) on procedural outcomes of aspiration thrombectomy for pulmonary embolism (PE). MATERIALS AND METHODS: A total of 171 patients who underwent aspiration thrombectomy for intermediate-high-risk or high-risk PE between December 2018 and September 2022 were included, 84 of whom underwent thrombectomy with FBR and 87 without. Demographic data, vital signs, laboratory values, procedural details, pulmonary arterial pressures, transfusion needs, length of hospital stay, and procedure-related adverse events were recorded. RESULTS: The groups did not differ at baseline, other than the FBR cohort having a higher percentage of women. There was no significant difference in postprocedural vital signs or pulmonary arterial pressure. Mean fluoroscopy time and volume of contrast medium used were lower in the FBR cohort. The drop in hemoglobin level was lower in the FBR group at both 12 (FBR, -1.065; No FBR, -1.742; P > .001) and 24 hours (FBR, -1.526; No FBR, -2.380; P > .001) after procedure; accordingly, fewer patients required transfusions in the FBR cohort (FBR, 8 (9.5%); No FBR, 20 (23.0%); P = .016). There was no difference in the number or severity of adverse events or duration of intensive care unit or hospital admission. CONCLUSIONS: FBR use during aspiration pulmonary thrombectomy reduced blood loss and transfusion requirements but had no significant effect on procedural success or adverse event rates.
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Despite considerable advances in surgical technique, many patients with hepatic malignancies are not operative candidates due to projected inadequate hepatic function following resection. Consequently, the size of the future liver remnant (FLR) is an essential consideration when predicting a patient's likelihood of liver insufficiency following hepatectomy. Since its initial description 30 years ago, portal vein embolization has become the standard of care for augmenting the size and function of the FLR preoperatively. However, new minimally invasive techniques have been developed to improve surgical candidacy, chief among them liver venous deprivation and radiation lobectomy. The purpose of this review is to discuss the status of preoperative liver augmentation prior to resection of hepatocellular carcinoma with a focus on these three techniques, highlighting the distinctions between them and suggesting directions for future investigation.
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Carcinoma Hepatocelular , Embolización Terapéutica , Hepatectomía , Neoplasias Hepáticas , Vena Porta , Humanos , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/diagnóstico por imagen , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/radioterapia , Embolización Terapéutica/métodos , Hepatectomía/métodos , Cirugía Asistida por Computador/métodosRESUMEN
The Inari ClotTriever system (Inari Medical, Irvine, California) is safe and effective for the treatment of DVT. However, because it consists of a 31 cm coring device and collection bag that must be extended for use, application may be precluded by available intravascular "running room", such as in the presence of an IVC filter. Here we present a technique for bypassing IVC filters via retrograde deployment of the ClotTriever within a sheath, as illustrated in three cases. This technique extends the applicability of the ClotTriever to locations in which its length would otherwise preclude use.
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The effect of changes in bladder volume on the caliber of adjacent veins is underappreciated but essential to recognize to avoid complications such as unnecessary stenting or clot migration causing pulmonary embolism. Here the authors illustrate the importance of this finding in 3 cases using venographic and endovascular sonographic imaging: the first in which BPH-induced chronic bladder outlet obstruction resulted in DVT formation, the second in which the cause was unrecognized and unnecessary stenting performed, and the third in which inappropriate treatment was avoided by decompressing the bladder.
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Embolia Pulmonar , Obstrucción del Cuello de la Vejiga Urinaria , Humanos , Vena Ilíaca/diagnóstico por imagen , Vejiga Urinaria/diagnóstico por imagen , Resultado del Tratamiento , Embolia Pulmonar/complicaciones , Obstrucción del Cuello de la Vejiga Urinaria/etiologíaRESUMEN
Inferior vena cava (IVC) filters should be removed when no longer needed, given their association with complications such as thrombosis of the IVC and lower extremities, fracture, migration, and growth into adjacent structures. While this is generally straightforward in the setting of retrievable filters, permanent filters present more of a challenge. In fact, many operators will not attempt to do so for fear of intraprocedural complications, among them, filter fracture and fragment embolization. Despite this, leaving the filters in situ places patients at risk of the complications described above. Here, the authors illustrate a novel technique for retrieving permanent filters using a funneled sheath to protect against embolization.
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Embolización Terapéutica , Trombosis , Filtros de Vena Cava , Humanos , Trombosis/diagnóstico por imagen , Extremidad InferiorAsunto(s)
Anomalías Cardiovasculares , Várices Esofágicas y Gástricas , Várices , Humanos , Vena Porta/diagnóstico por imagen , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/diagnóstico por imagen , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/cirugía , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Scrotal swelling from varicocele is a common complaint in adult men. Varicocele due to portosystemic collaterals is a rare presentation of portal hypertension. Imaging workup and intervention for varicocele in this case is more complex than varicocele due to absent or incompetent valves in the testicular veins and pampiniform plexus. CASE PRESENTATION: We present the case of a 53-year-old man with alcohol-related cirrhosis presented with persistent left scrotal heaviness, pain, and swelling found to have a large left varicocele. Given his history of cirrhosis, a contrast-enhanced CT of the abdomen and pelvis was obtained showing that the varices were supplied by a vessel arising from the splenic vein and draining into the left renal vein as well as gastric varices. Varicocele embolization alone is not sufficient in this case, and we treated with transjugular intrahepatic portosystemic shunt, variceal and varicocele embolization. CONCLUSION: In patients presenting with a varicocele with a history of cirrhosis/portal hypertension, cross sectional imaging of the abdomen and pelvis should be obtained prior to treatment to evaluate for the presence of varices which may be pressured by varicocele embolization. If present, consideration should be given to referral to an interventional radiologist for possible concurrent variceal embolization and TIPS placement.
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Hipertensión Portal , Derivación Portosistémica Intrahepática Transyugular , Varicocele , Várices , Adulto , Masculino , Humanos , Persona de Mediana Edad , Derivación Portosistémica Intrahepática Transyugular/métodos , Varicocele/complicaciones , Varicocele/diagnóstico por imagen , Varicocele/cirugía , Hemorragia Gastrointestinal , Hipertensión Portal/complicaciones , Hipertensión Portal/terapia , Cirrosis Hepática , Fibrosis , Resultado del TratamientoAsunto(s)
Várices Esofágicas y Gástricas , Hipertensión Portal , Várices , Humanos , Várices/diagnóstico por imagen , Várices/cirugía , Procedimientos Quirúrgicos Vasculares , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/cirugía , Derivación Portosistémica QuirúrgicaRESUMEN
Most inferior vena cava (IVC) filters are designed for retrieval from a superior approach. Retrieval becomes technically challenging when the central veins in the chest are occluded. In a patient with thrombosis of the bilateral brachiocephalic veins, the authors describe direct puncture of the superior vena cava (SVC) under fluoroscopy, followed by the successful retrieval of a fractured IVC filter using forceps. A snare inserted into the SVC via the common femoral vein was used as a radiopaque target for direct SVC puncture from the lower neck. Cone beam computed tomography and pullback tractography were used to confirm a safe access trajectory. Thus, direct SVC access may be used for filter retrieval in similar clinical scenarios.
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Filtros de Vena Cava , Vena Cava Superior , Humanos , Punciones , Vena Cava Inferior , Remoción de Dispositivos/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Catheter associated right atrial thrombus (CRAT) is an uncommon but potentially life-threatening condition. There are no established guidelines for management, and treatment ranges from systemic anticoagulation and thrombolysis to open surgery. While there have been reports on use of suction thrombectomy for right atrial thrombi, the feasibility and outcomes of suction thrombectomy in CRAT have not been described. These two cases describe a successful off-label use of two devices (Triever 20, Inari Medical, Irvine, CA, and AlphaVac, AngioDynamics, Latham, NY) for thrombectomy in CRAT. Both patients had near complete extraction of chronic appearing thrombus, with follow up imaging demonstrating complete resolution. Suction thrombectomy may have a unique role in management in CRAT, especially in cases of infected thrombi. A formal exemption from the institutional review board was obtained for publication.
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Paravertebral pseudoaneurysms are infrequent following vertebral augmentation but can be difficult to manage due to their proximity to the arterial supply of the spinal cord. Here, we present two distinct manifestations of this complication with associated anatomy and management. In the first, a pseudoaneurysm developed following radiofrequency ablation and kyphoplasty at the L2 and L4 levels. Direct puncture embolization initially failed to close the pseudoaneurysm, but stasis was ultimately achieved via trans-arterial embolization. In the second, vertebral augmentation at the T9 and T11-L3 levels was complicated by formation of a pseudoaneurysm fed by a segmental artery and a long paravertebral anastomotic vein. Due to the patient's poor medical status, intervention was not performed. Understanding vertebral arterial anatomy is crucial for preventing and treating vascular injury in vertebral augmentation.
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Aneurisma Falso , Fracturas por Compresión , Cifoplastia , Fracturas de la Columna Vertebral , Vertebroplastia , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/terapia , Fracturas por Compresión/complicaciones , Fracturas por Compresión/cirugía , Humanos , Cifoplastia/efectos adversos , Vértebras Lumbares/cirugía , Resultado del Tratamiento , Vertebroplastia/efectos adversosRESUMEN
Although COVID-19 coagulopathy typically manifests with thrombotic complications, hemorrhagic complications also occur and must be considered when making decisions about anticoagulation in these patients. Here, we report a case of massive hemoptysis occurring in a recently post-partum woman via Cesarean section with COVID-19 who was managed via bronchial artery embolization while on extracorporeal membrane oxygenation.
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COVID-19 , Embolización Terapéutica , Oxigenación por Membrana Extracorpórea , Arterias Bronquiales/diagnóstico por imagen , Cesárea/efectos adversos , Embolización Terapéutica/efectos adversos , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Hemoptisis/diagnóstico por imagen , Hemoptisis/etiología , Hemoptisis/terapia , Humanos , Periodo Posparto , Embarazo , SARS-CoV-2RESUMEN
Although yttrium-90 (90Y) transarterial radioembolization (TARE) is an effective treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), inability to cannulate tumor-feeding vessels can preclude its use. In this case we demonstrate the feasibility of employing balloon occlusion within the proper hepatic artery to treat a left lobar HCC and PVTT with an inaccessible left hepatic artery. Vessel angulation prevented subselection of the left hepatic artery, and subsequent mapping studies indicated significant non-target radiotracer activity. Through occlusion of the proper hepatic artery by a balloon microcatheter, flow alterations were created that led to uptake of the 90Y microspheres by the tumor while sparing the non-diseased liver parenchyma. Thus, this innovative approach may permit the use of TARE in patients when proximal tumor vessels are inaccessible.
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Carcinoma Hepatocelular , Embolización Terapéutica , Neoplasias Hepáticas , Trombosis , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/radioterapia , Arteria Hepática/diagnóstico por imagen , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/radioterapia , Vena Porta/diagnóstico por imagen , Estudios Retrospectivos , Resultado del Tratamiento , Radioisótopos de Itrio/uso terapéuticoRESUMEN
PURPOSE: To investigate the safety and efficacy of genicular artery embolization for treatment of refractory hemarthrosis following total knee arthroplasty. MATERIAL AND METHODS: Patients who underwent genicular artery embolization with spherical embolics between January 2010 and March 2020 at a single institution were included if they had undergone total knee arthroplasty and subsequently experienced recurrent hemarthrosis. Technical success was defined as the significant reduction or elimination of the hyperemic blush. Clinical success was defined as the absence of clinical evidence of further hemarthrosis. Clinical follow-up was performed 7-14 days after the procedure and at 3-month intervals thereafter via a telephone interview. A total of 117 embolizations, comprising 82 initial, 28 first repeat, and 7 second repeat, were performed. RESULTS: An average of 2.5 arteries was treated per procedure. The superior lateral genicular artery was the most frequently embolized. The most utilized embolic size was 100-300 µm. Follow-up was available for all patients, with a median duration of 21.5 months. 65.9%, 25.6%, and 8.5% of patients underwent 1, 2, and 3 treatments, respectively. Complications occurred following 12.8% of treatments, of which the most common was transient cutaneous ischemia. Technical success was achieved in all cases. Clinical success was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively. 83% of patients reported being either satisfied or very satisfied with the overall result. CONCLUSIONS: Targeted genicular artery embolization with spherical embolics is an effective treatment for recurrent hemarthrosis with infrequent serious complications. Repeat embolization should be considered in cases of recurrence following initial therapy.
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Artroplastia de Reemplazo de Rodilla , Hemartrosis , Arterias , Artroplastia de Reemplazo de Rodilla/efectos adversos , Hemartrosis/etiología , Hemartrosis/terapia , Humanos , Medición de Resultados Informados por el Paciente , RecurrenciaRESUMEN
ABSTRACT: The incidence of pancreatic cystic neoplasms has grown because of increased detection. Among these lesions, serous cystadenoma was traditionally thought to be universally benign and indolent. However, there is an exceedingly rare malignant variant of serous cystadenoma known as serous cystadenocarcinoma (SCAC) that can exhibit local invasion into adjacent structures, hepatic implants, and metastatic spread to the abdominal viscera. Diagnosis of SCAC can be challenging as it is histologically identical to serous cystadenoma. To better understand this entity, a review of all published accounts of SCAC was performed in which tumor and patient factors were characterized. In addition, we present the case of a 49-year-old woman who was found to have a solitary hepatic metastasis due to SCAC, 11 years after a distal pancreatectomy for serous cystadenoma. She was successfully treated with percutaneous microwave ablation and has no evidence of recurrence 3 years later. This report details the first published account of percutaneous ablation in such a setting. Compared with hepatectomy, hepatic ablation may offer a less invasive but equally effective treatment option in well-selected patients.
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Técnicas de Ablación/métodos , Cistadenocarcinoma Seroso/diagnóstico , Neoplasias Hepáticas/diagnóstico , Microondas , Neoplasias Pancreáticas/diagnóstico , Cistadenocarcinoma Seroso/patología , Cistadenocarcinoma Seroso/cirugía , Femenino , Humanos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Persona de Mediana Edad , Pancreatectomía/métodos , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Esplenectomía/métodos , Resultado del TratamientoRESUMEN
Uterine artery embolization (UAE) for symptomatic uterine fibroids is accompanied by transcervical fibroid expulsion in 3-15% of cases. It can be a source of significant patient distress, may require reintervention for removal, and is the most common reason for hospital readmission following UAE. Conversely, the success of hysteroscopic resection decreases with increasing fibroid size while the risk of complications increases. Because certain fibroid features identifiable on preoperative imaging predict need for eventual hysteroscopic resection, it is possible to prospectively identify such patients and employ an alternative management strategy. We present such an approach, illustrated in the case of a woman with a pedunculated broad-based uterine fibroid successfully managed via combination UAE and immediate hysteroscopic resection.