Correlation of intravascular ultrasound and computed tomography scan measurements for placement of intravascular ultrasound-guided inferior vena cava filters.

OBJECTIVE: The single puncture intravascular ultrasound (IVUS)-guided bedside placement of inferior vena cava (IVC) filters has been shown to be an effective technique. The major disadvantage of this procedure is a steep learning curve that can lead to an increased risk of filter malposition. In an effort to increase the safety and efficacy of IVUS-guided bedside IVC filter placement, we proposed that preoperative planning could reduce the incidence of IVUS-guided filter malpositions. As a first step, we examined the correlation between preoperative abdominal computed tomography (CT) scan measurements and intraprocedural IVUS derived measurements of vena cava anatomy and its surrounding structures. As a second step, we attempted to determine the safety of this protocol by assessing the incidence of malposition. METHODS: A retrospective review of prospectively collected data was performed on all patients receiving bedside IVUS-guided filters from July 1, 2010 to August 31, 2011. Measurements of the IVC length from the atrial-IVC junction to the midportion of the crossing right renal artery, the lowest renal vein, and iliac vein confluence were obtained prior to IVC filter placement by both CT-based measurement, as well as intraprocedural IVUS pullback lengths. Regression analysis (significant for P < .05) was used to determine the correlation between these imaging modalities. RESULTS: Forty-six patients had adequate CT scans available to perform the analysis and were candidates for bedside IVUS-guided IVC filter placement. All IVUS-guided filters were placed using a single puncture technique with the Cook Celect Filter. This study found there was a close correlation between IVUS and CT derived measurements of the right atrium to right renal artery distance, lowest renal vein distance, and iliac confluence distance. In addition, we found that the IVUS distances from the atrial-IVC junction to the right renal artery and lowest renal vein were statistically similar. Nine patients had 10 vascular anatomic variations, all identified by both IVUS and CT. There were no complications or malpositions of IVC filters using this protocol. CONCLUSIONS: These data suggest that IVUS pullback measurements from the right atrium used in combination with preprocedure CT derived measurements of the distance from the right atrium to the lowest renal vein and iliac vein confluence provide an accurate roadmap for the placement of bedside IVC filters under IVUS guidance. We provide a method for organizing this information in a preplanning document to aid this procedure. We suggest this easily employed technique be more fully utilized to help decrease the incidence of malpositioned filters using single puncture IVUS guidance.

Carotid artery stenting compared to carotid endarterectomy performed exclusively in a veteran population: one center's experience with midterm results.

OBJECTIVE: To evaluate a single center's experience with carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed by vascular surgeons in an entirely veteran population. METHODS: Data from the Lakeside and Jesse Brown Veterans Affairs Medical Centers (VAMC) from September 1997 to December 2006 were retrospectively reviewed. Indications for CAS or CEA included asymptomatic carotid stenosis >70% or symptomatic stenosis >50%. Demographic data, procedural details, and clinical outcomes are reported. RESULTS: A cohort of 104 patients (98% men) underwent 113 CAS procedures with 100% technical success. Cerebral protection was used in 98% of the procedures. Average age was 70 years (15 patients >or=80 years old); 30% were symptomatic. Previous ipsilateral CEA, neck dissection or irradiation was present in 10.6% of procedures. The 30-day transient ischemic attack, stroke, and death rates were 2.7%, 3.5%, and 0.0% respectively. The 1-year all cause death rate was 6.2%. During the same time period, 79 patients (98% male) underwent 91 CEA procedures. Average age was 67 years (9 patients >or=80 years old); 45% were symptomatic. The 30-day transient ischemic attack, stroke, and death rates were 1%, 2.2%, and 1% respectively. The 1-year all cause death rate was 5.5%. There were no statistically significant differences in outcome within asymptomatic and symptomatic patient groups between CAS and CEA, respectively. CONCLUSIONS: CAS is a safe and efficacious alternative for the treatment of carotid artery stenosis in a veteran population and outcomes compare favorably to contemporary CAS and CEA trials. Veterans should be offered CAS as a treatment option for carotid artery stenosis by vascular surgeons or interventionalists who are trained to perform this procedure and have the appropriate resources.