Minimally Invasive Ventriculo-Cholecystic Shunt Placement Utilizing Combined Ultrasound and Fluoroscopic Guidance.

For the management of hydrocephalus with ventricular cerebrospinal fluid (CSF) shunting, multiple therapeutic options are available. Among these routes, the most commonly used are ventriculo-peritoneal, ventriculo-atrial, and ventriculo-pleural, while ventriculo-cholecystic is a less common option. Although ventriculo-peritoneal is accepted as the first option, ventriculo-cholecystic shunting may be performed in patients who are poor candidates for other routes of shunt placement. Open cholecystic shunt placement may be contraindicated in patients who have undergone previous surgeries or other comorbidities. Here, we present the case of a 25-year-old female with a complex medical history who presented with a posterior fossa intraparenchymal hemorrhage and subsequent hydrocephalus. She was unable to undergo a ventriculo-peritoneal, atrial, or pleural shunt placement, and thus, a cholecystic shunt placement was chosen. Due to a history of previous surgeries and comorbidities as well as a large volume of idiopathic and recurrent ascites, open placement was contraindicated in this patient. To the best of our knowledge, we present the first successful adult case of a minimally invasive ventriculo-cholecystic shunt placement under ultrasound and fluoroscopic guidance.

The Effect of Immediate Versus Delayed Port Access on 30-Day Infection Rate.

This study compared the 30-day infection risk of chest ports accessed on the same day as placement and chest ports with delayed initial access. The aim was to evaluate a larger data set that provided evidence for the development of port access guidelines. A retrospective chart review of 3322 chest port placement procedures performed between October 15, 2003, and June 10, 2015, was conducted at the interventional radiology department of a single institution. Procedure notes and health records were reviewed to determine time of initial port access, evidence of infection within a 30-day window of port placement, and causal organism(s) of infection. The results demonstrated that 64 ports (1.93%) met infection criteria within 30 days of placement, including 30 of the 945 ports immediately accessed and 34 of the 2377 ports not immediately accessed (3.17% vs 1.43%; P < .005). Dual lumen devices had a statistically significant higher rate of infection compared with single lumen devices (P = .006). This study concluded that there is a statistically significant higher rate of infection if a port is accessed immediately versus when access is deferred to later than 24 hours after placement.

Computational predictions of the embolus-trapping performance of an IVC filter in patient-specific and idealized IVC geometries.

Embolus transport simulations are performed to investigate the dependence of inferior vena cava (IVC) filter embolus-trapping performance on IVC anatomy. Simulations are performed using a resolved two-way coupled computational fluid dynamics/six-degree-of-freedom approach. Three IVC geometries are studied: a straight-tube IVC, a patient-averaged IVC, and a patient-specific IVC reconstructed from medical imaging data. Additionally, two sizes of spherical emboli (3 and 5 mm in diameter) and two IVC orientations (supine and upright) are considered. The embolus-trapping efficiency of the IVC filter is quantified for each combination of IVC geometry, embolus size, and IVC orientation by performing 2560 individual simulations. The predicted embolus-trapping efficiencies of the IVC filter range from 10 to 100%, and IVC anatomy is found to have a significant influence on the efficiency results ([Formula: see text]). In the upright IVC orientation, greater secondary flow in the patient-specific IVC geometry decreases the filter embolus-trapping efficiency by 22-30 percentage points compared with the efficiencies predicted in the idealized straight-tube or patient-averaged IVCs. In a supine orientation, the embolus-trapping efficiency of the filter in the idealized IVCs decreases by 21-90 percentage points compared with the upright orientation. In contrast, the embolus-trapping efficiency is insensitive to IVC orientation in the patient-specific IVC. In summary, simulations predict that anatomical features of the IVC that are often neglected in the idealized models used for benchtop testing, such as iliac vein compression and anteroposterior curvature, generate secondary flow and mixing in the IVC and influence the embolus-trapping efficiency of IVC filters. Accordingly, inter-subject variability studies and additional embolus transport investigations that consider patient-specific IVC anatomy are recommended for future work.

Analysis of the Final DENALI Trial Data: A Prospective, Multicenter Study of the Denali Inferior Vena Cava Filter.

PURPOSE: To report the final 2-year data on the efficacy and safety of a nitinol retrievable inferior vena cava (IVC) filter for protection against pulmonary embolism (PE). MATERIALS AND METHODS: This was a prospective multicenter trial of 200 patients with temporary indications for caval filtration who underwent implantation of the Denali IVC filter. After filter placement, all patients were followed for 2 years after placement or 30 days after filter retrieval. The primary endpoints were technical success of filter implantation in the intended location and clinical success of filter placement and retrieval. Secondary endpoints were incidence of clinically symptomatic recurrent PE, new or propagating deep vein thrombosis (DVT), and filter-related complications including migration, fracture, penetration, and tilt. RESULTS: Filter placement was technically successful in 199 patients (99.5%). Filters were clinically successful in 190 patients (95%). The rate of PE was 3% (n = 6), with 5 patients having a small subsegmental PE and 1 having a lobar PE. New or worsening DVT was noted in 26 patients (13%). Filter retrieval was attempted 125 times in 124 patients and was technically successful in 121 patients (97.6%). The mean filter dwell time at retrieval was 200.8 days (range, 5-736 d). There were no instances of filter fracture, migration, or tilt greater than 15° at the time of filter retrieval or during follow-up. CONCLUSIONS: The Denali IVC filter exhibited high success rates for filter placement and retrieval while maintaining a low complication rate in this clinical trial.

The Importance of Hemorheology and Patient Anatomy on the Hemodynamics in the Inferior Vena Cava.

Inferior vena cava (IVC) filters have been used for nearly half a century to prevent pulmonary embolism in at-risk patients. However, complications with IVC filters remain common. In this study, we investigate the importance of considering the hemorheological and morphological effects on IVC hemodynamics by simulating Newtonian and non-Newtonian blood flow in three IVC models with varying levels of geometric idealization. Partial occlusion by an IVC filter and a thrombus is also considered. More than 99% of the infrarenal IVC volume is found to contain flow in the nonlinear region of the shear rate-viscosity curve for blood (less than 100 s-1) in the unoccluded IVCs. Newtonian simulations performed using the asymptotic viscosity for blood over-predict the non-Newtonian Reynolds numbers by more than a factor of two and under-predict the mean wall shear stress (WSS) by 28-54%. Agreement with the non-Newtonian simulations is better using a characteristic viscosity, but local WSS errors are still large (up to 50%) in the partially occluded cases. Secondary flow patterns in the IVC also depend on the viscosity model and IVC morphological complexity. Non-Newtonian simulations required only a marginal increase in computational expense compared with the Newtonian simulations. We recommend that future studies of IVC hemodynamics consider the effects of hemorheology and IVC morphology when accurate predictions of WSS and secondary flow features are desired.

The DENALI Trial: an interim analysis of a prospective, multicenter study of the Denali retrievable inferior vena cava filter.

PURPOSE: To assess safety and effectiveness of a nitinol retrievable inferior vena cava (IVC) filter in patients who require caval interruption to protect against pulmonary embolism (PE). MATERIALS AND METHODS: Two hundred patients with temporary indications for an IVC filter were enrolled in this prospective, multicenter clinical study. Patients undergoing filter implantation were to be followed for 2 years or for 30 days after filter retrieval. At the time of the present interim report, all 200 patients had been enrolled in the study, and 160 had undergone a retrieval attempt or been followed to 6 months with their filter in place. Primary study endpoints included technical and clinical success of filter placement and retrieval. Patients were also evaluated for recurrent PE, new or worsening deep vein thrombosis, and filter migration, fracture, penetration, and tilt. RESULTS: Clinical success of placement was achieved in 94.5% of patients (172 of 182), with a one-sided lower limit of the 95% confidence interval of 90.1%. Technical success rate of filter placement was 99.5%. Technical success rate of retrieval was 97.3%; 108 filters were retrieved in 111 attempts. In two cases, the filter apex could not be engaged with a snare, and one device was engaged but could not be removed. Filter retrievals occurred at a mean indwell time of 165 days (range, 5-632 d). There were no instances of filter fracture, migration, or tilt greater than 15° at the time of retrieval or 6-month follow-up. CONCLUSIONS: In this interim report, the nitinol retrievable IVC filter provided protection against pulmonary embolism, and the device could be retrieved with a low rate of complications.

A computational method for predicting inferior vena cava filter performance on a patient-specific basis.

A computational methodology for simulating virtual inferior vena cava (IVC) filter placement and IVC hemodynamics was developed and demonstrated in two patient-specific IVC geometries: a left-sided IVC and an IVC with a retroaortic left renal vein. An inverse analysis was performed to obtain the approximate in vivo stress state for each patient vein using nonlinear finite element analysis (FEA). Contact modeling was then used to simulate IVC filter placement. Contact area, contact normal force, and maximum vein displacements were higher in the retroaortic IVC than in the left-sided IVC (144 mm(2), 0.47 N, and 1.49 mm versus 68 mm(2), 0.22 N, and 1.01 mm, respectively). Hemodynamics were simulated using computational fluid dynamics (CFD), with four cases for each patient-specific vein: (1) IVC only, (2) IVC with a placed filter, (3) IVC with a placed filter and model embolus, all at resting flow conditions, and (4) IVC with a placed filter and model embolus at exercise flow conditions. Significant hemodynamic differences were observed between the two patient IVCs, with the development of a right-sided jet, larger flow recirculation regions, and lower maximum flow velocities in the left-sided IVC. These results support further investigation of IVC filter placement and hemodynamics on a patient-specific basis.

Modified loop snare technique for the removal of bard recovery, G2, G2 express, and eclipse inferior vena cava filters.

The present work describes the preliminary results of the use of a novel technique for the removal of tilted and apex-embedded Recovery, G2, G2 Express, and Eclipse inferior vena cava filters. A retrospective review was performed of 33 filters removed in 32 patients by using the described modified loop snare technique. All filters were successfully removed with the use of the technique. The average duration of filter implantation for the devices removed with the technique was 556 days (range, 11-2,437 d; median, 268 d). No filter fractures occurred related to the removal technique. No procedure-related complications occurred.

Fractured Bard Recovery, G2, and G2 express inferior vena cava filters: incidence, clinical consequences, and outcomes of removal attempts.

PURPOSE: To increase the understanding of risks of inferior vena cava (IVC) filter fracture and embolization and the safety of removing fractured filters via retrospective review of a prospectively collected database of fractured IVC filters. MATERIALS AND METHODS: A total of 63 fractured IVC filters were discovered among 548 patients presenting for retrievable filter removal between April 2004 and November 2010 at a single institution. Device type, duration of implantation, component fracture, and embolization events were recorded. Success rates and techniques for removal of components were recorded. RESULTS: A total of 63 fractured Recovery, G2, and G2 Express IVC filters were identified, for an overall fracture rate of 12%. Excluding foot process fractures, the fracture rate for only filter arms and/or legs was 6%. The incidence of fracture increased with longer filter dwell times. Success rates for removal of the nonfractured component (ie, main body) and fractured components (ie, arm or leg) were 98.4% and 53.4%, respectively. The distal embolization rate of fractured filter components was 13%. There were no immediate clinically significant complications associated with fracture component embolization or filter removal. A single patient was encountered with symptoms related to their fractured filter. CONCLUSIONS: IVC filter fracture rates increase with longer dwell times; however, removal of fractured filters and fractured components (ie, arms and legs) can be achieved safely and effectively. Clinically significant complications of IVC filter fracture are rare, and there were no immediate clinical sequelae related to embolization of fracture components.

A method for following patients with retrievable inferior vena cava filters: results and lessons learned from the first 1,100 patients.

PURPOSE: Patients who have undergone implantation of a retrievable inferior vena cava (IVC) filter require continued follow-up to have the device removed when clinically appropriate and in a timely fashion to avoid potential long-term filter-related complications. The efficacy of a method for patient follow-up was evaluated based on a retrospective review of a single-institutional retrievable IVC filter experience. MATERIALS AND METHODS: Patients with retrievable IVC filters were tracked via a prospectively collected database designed specifically for patient follow-up. Follow-up consisted of periodic review of the electronic medical record. Patients were contacted by mail (at regular intervals one or more times) when removal of the filter was deemed appropriate. A retrospective review of the ultimate fate of the first 1,127 retrievable IVC filters placed at a single institution was performed. Retrieval rates were compared with those seen in the initial experience, during which no structured follow-up was performed. RESULTS: Of 1,127 filters placed, 658 (58.4%) were removed. Filter removal or declaration of the device as permanent was achieved in 860 patients (76.3%). Filter removal, declaration of the device as permanent, or establishment of the need for continued follow-up was achieved in 941 patients (83.5%). Only 186 patients (16.5%) were lost to follow-up. CONCLUSIONS: The follow-up method described in the present study resulted in a statistically significant difference (P < .001) in the likelihood of a patient returning for IVC filter removal compared with a lack of follow-up (59% vs 24%).

Optional vena cava filter use in the elderly population.

PURPOSE: To review utility, safety, and efficacy of optional inferior vena cava (IVC) filters in patients 65 years or older at a single institution over a 6-year period. MATERIALS AND METHODS: Retrospective review of permanent and optional IVC filters placed in elderly patients was performed. Older and younger groups were compared based on technical success of filter placement and clinical success measured by recurrent pulmonary embolism (PE) or thrombotic complications. The rate of successful filter removal was compared with that in the cohort of patients of all ages who received optional filters. RESULTS: Fifty-three patients received an optional filter and 445 received a permanent filter. Technical success rates for filter placement in the permanent and optional filter groups were 99.8% (447 of 448) and 98.1% (53 of 54), respectively (P = .51). Rates of PE after filter placement were 0% and 1.4% (five of 359) in the optional and permanent filter groups, respectively (P = .87). Incidences of deep vein thrombosis were 12% (six of 50) and 4.5% (16 of 359) in optional and permanent filter recipients, respectively (P = .06). Filter retrieval was attempted in 55.6% of optional filter recipients (30 of 54), similar to that seen in patients of any age with optional filters. Retrieval was unsuccessful in one patient in whom a suprarenal IVC filter was placed. CONCLUSIONS: Optional filters are safe and effective in patients aged 65 years or older. Age alone is a poor predictor of a clinical opportunity to remove a filter. With appropriate patient selection and aggressive follow-up, retrieval rates comparable with those in younger populations can be achieved.

Angiographic embolization of nonvariceal upper gastrointestinal bleeding: predictors of clinical failure.

BACKGROUND: Angiographic embolization (AE) has emerged as an important therapy for patients with nonvariceal upper gastrointestinal bleeding (UGIB). We hypothesized that discrete factors predictive of AE failure could be identified. METHODS: A retrospective review was performed for patients with nonvariceal UGIB who underwent AE from 1999 to 2009 at Penn State Milton S. Hershey Medical Center. AE clinical failure was defined as requirement for another intervention (surgery, endoscopic therapy, or another AE) for nonvariceal UGIB and/or death from bleeding after AE. Statistical analysis was performed using Fisher's exact test and Student's t test to explore the risk of AE failure. RESULTS: Of 48 total AE cases, 17 patients (35.4%) had clinically failed AE. Mortality rate was significantly higher in patients with AE clinical failure than in patients with AE clinical success (64.7% vs. 12.9%, p=0.001). Factors associated with AE clinical failure include anticoagulant use before admission (p=0.001), use of corticosteroids before admission (p=0.045), pre-AE vasopressor use (p=0.038), and embolization using either coils alone (p=0.05) or using coils with or without additional embolic materials (p=0.018). CONCLUSIONS: AE clinical failure portends poor prognosis. Caution should be exercised when considering AE, particularly AE using coils, in patients with a history of anticoagulant, corticosteroid, or vasopressor use.

Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability.

BACKGROUND: This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. METHODS: We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. RESULTS: There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). CONCLUSIONS: IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.

Removal of a Günther Tulip filter after 3,006 days.

Patients may be denied the opportunity to have their inferior vena cava (IVC) filters removed because of a perception that retrievable filters that have been in place for a long period of time may be more technically difficult or hazardous to remove. A case report on the removal of a Günther Tulip filter that was implanted for a total of 3,006 days is presented. This case report adds to the literature that suggests that no time limits may exist after which many retrievable IVC filters can no longer be safely removed.

Technical success and safety of retrieval of the G2 filter in a prospective, multicenter study.

PURPOSE: To assess the technical success and safety for retrieval of the G2 filter. MATERIALS AND METHODS: The authors performed a prospective, multicenter study of 100 patients with temporary indication for caval interruption. Patients were enrolled consecutively between December 2005 and July 2006. There were 67 men and 33 women with a mean age of 52.1 years (range, 19-82 years). Indications for filter placement were trauma (n = 56), perioperative risk (n = 16), and medical indications (n = 28). Forty-two patients had venous thromboembolism at filter placement. Fifty-eight filters were placed prophylactically. RESULTS: Retrieval was attempted in 61 patients. Fifty-eight of the 61 filters (95%) were successfully retrieved after a mean dwell time of 140 days (range, 5-300 days). In all failed retrievals, the filter tip was against the caval wall. There was no difference in dwell times between successful and unsuccessful retrievals. Although there were no cases of cranial migration, caudal migrations were observed in 12% of cases (10 of 85 patients with a complete data set). Other device-related complications included filter fracture (1/85, 1.2%), filter tilt of more than 15 degrees (15/85, 18%), and leg penetration (16/61, 26%). The recurrent pulmonary embolism (PE) rate was 2%, with no PE in the 30-day period after filter retrieval. CONCLUSIONS: Retrieval of the Recovery G2 filter was safe and successful in most patients. Caudal migration was observed as an unexpected phenomenon.

Balloon-assisted removal of tilted inferior vena cava filters with embedded tips.

PURPOSE: The successful removal of most retrievable inferior vena cava (IVC) filters requires the capture of the filter apex. The severely tilted filter with an apex in contact with the caval wall and covered by an endothelial cap represents a major technical challenge to removal. While a variety of techniques to deal with this problem have been reported, most require complex wire manipulations or the use of rigid endobronchial forceps. This article describes the successful use of a standard angioplasty balloon to free the apex of severely tilted filters with endothelial apical caps. MATERIALS AND METHODS: A retrospective review of those patients who presented for removal of their Bard Recovery or G2 IVC filter between June 2005 and August 2008 was performed. Imaging studies and medical records were reviewed for those patients who had their IVC filters removed using the balloon-assisted technique. The presence of filter tilt and movement as well as the outcome of the technique was recorded for each case. RESULTS: Forty-eight Recovery and 209 G2 filters presented for removal. Ten of these 257 filters (3.6%) were found to be severely tilted with filter apex embedded into the wall of the cava. Eight of these filters were successfully removed using the balloon-assisted technique. No complications resulting from the technique occurred. CONCLUSIONS: Balloon-assisted removal of severely tilted embedded G2 and Recovery filters is an effective technique that can be performed using tools commonly available and familiar to most interventionists.

Comparison of the recovery and G2 filter as retrievable inferior vena cava filters.

PURPOSE: To compare the technical success of the Recovery and G2 filters as retrievable inferior vena cava (IVC) filters. MATERIALS AND METHODS: Recovery (n = 128) and G2 (n = 113) filters were placed in the IVCs of 241 patients with the intent of retrieval. The referring physician and/or patient were contacted at 6-month intervals to ensure filter retrieval when indicated. The Recovery and G2 filter groups were compared regarding technical success of filter placement, technical success of attempted retrieval, filter tilt, filter migration, filter fracture, and filter efficacy. RESULTS: Filter placement was technically successful in 95% of Recovery filters (n = 122) and 100% of G2 filters (n = 113). Recovery filter retrieval was attempted in 55% of patients (n = 71) at a mean of 228 days (range, 0-838 d) after filter placement. G2 filter retrieval was attempted in 55% of patients (n = 62) at a mean of 230 days (range, 7-617 d) after filter placement. Technical success rates of filter retrieval were 94% (n = 67) and 97% (n = 60) in the Recovery and G2 filter groups, respectively. The G2 filter group had significantly fewer cases of (i) filter tilt at placement, (ii) filter tilt at attempted retrieval, and (iii) filter fracture than the Recovery filter group. In the G2 filter group, there was a significantly higher technical success rate of filter placement and there were more cases of caudal filter migration than in the Recovery filter group. CONCLUSIONS: Compared with the Recovery filter, the G2 filter is associated with significantly less filter fracture and tilt, greater technical success of filter placement, and more caudal filter migration.

Removal of the G2 filter: differences between implantation times greater and less than 180 days.

PURPOSE: To investigate whether filters implanted for longer periods are more difficult or hazardous to remove. MATERIALS AND METHODS: A retrospective review of G2 inferior vena cava filter removals was performed. Objective measures reflecting the difficulty of the removal procedure were evaluated for differences required to remove a filter with an implantation period greater or less than 180 days. RESULTS: One hundred seventy of 174 G2 filters were successfully removed (97.7% success rate). There was no significant difference in the success rate (P = .86), total procedure time (P = .87), fluoroscopy time (P = .13), or contrast medium use (P = .22) required to remove filters implanted for more than 180 days compared to those implanted for a shorter period of time. There was no significant difference in the frequency of filter movement (P = .90), tilt (P = .87), and caval penetration (P = .41) between the two groups. Six filter fractures were observed, all with implantation times greater than 180 days. CONCLUSIONS: The removal of a G2 filter that has been in place for more than 180 days can be performed as easily, as safely, and with a similar degree of success as one that has been in place for less time. Movement, tilt, and penetration are early events after implantation that may have an effect on successful filter removal.

Prophylactic inferior vena cava filters: do they make a difference in trauma patients?

BACKGROUND: Inferior vena cava filters (IVCF) are used in trauma patients to reduce the incidence of pulmonary embolism (PE). This study investigates the efficacy of prophylactic IVCF (PIVCF) placement from implantation through outpatient follow-up. METHODS: Data were prospectively collected on PIVCF placed in trauma patients > or =18-years old from 2004 to 2006. Exclusion criteria include therapeutic IVCF, major burns, deviated from a modified EAST protocol, and deaths. Data were collected on age, gender, Injury Severity Score (ISS), filter type, total implant days, PE, deep venous thrombosis (DVT), and filter-related complications. STATISTICAL ANALYSIS: p < 0.05*, chi square test, mean +/- SD. RESULTS: Of 4,936 patients, 280 had an IVCF with 244 meeting inclusion criteria. Study group demographics: 63.5% men; 98.8% blunt; mean age 43.8 +/- 20.3; ISS 26.7 +/- 12.8. There were 176 of 244 (72.1%) patients who met traditional EAST guidelines for PIVCF. PIVCF increased significantly from 29 in 2004 to 127 in 2006 with no difference in the PE rate (0.7% to 0.4%). There were 4 PEs (1.6%) on postprocedure days 7, 14, 18, and 23. Five technical complications occurred: two filter fractures, two caudal migrations, and one filter tilt. A total of 140 retrievable filters had the opportunity for outpatient follow-up for 18 months with 58.6% removed, 15.7% declared permanent, 12.1% lost to follow-up, and 13.6% still considered potential removal candidates. Days to implant: 0 to 32; 3.89 +/- 4.79. Implant days: 15 to 838; mean 231 +/- 162. CONCLUSIONS: PIVCF increased significantly without impacting the overall PE rate. There was a 1.6% PE rate among PIVCF, high retrieval rate (59%), low complication rate (0.1%), and satisfactory compliance with traditional EAST guidelines.