Arteriovenous fistulas for hemodialysis: Brief review and current problems.

The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.

Benign Prostatic Hyperplasia: A Brief Overview of Pathogenesis, Diagnosis, and Current State of Therapy.

As prostatic artery embolization is assuming an increasingly important role in the management of benign prostatic hyperplasia, it is important for the practicing interventional radiologist to have a deep understanding of all aspects of the disease process and the available treatment options. This paper provides a comprehensive overview of the pathophysiology, diagnosis and management options for benign prostatic hyperplasia with an emphasis on the surgical and medical treatments.

Percutaneous Retrieval of IVC Filters With Struts Penetrating the Vertebral Body.

INTRODUCTION: Inferior vena cava (IVC) filter penetration of the caval wall is a well-documented complication. Less frequently, the struts of an IVC filter can penetrate a vertebral body that can lead to symptoms of abdominal pain. Vertebral penetration poses a management challenge, and characteristics for successful endovascular retrieval of such filters has not been reported. CASE DESCRIPTION: We present 2 cases of IVC filters with vertebral body penetration that were successfully retrieved through an endovascular approach. On preprocedure computed tomography, both patients had a small zone of osteolysis surrounding the penetrated struts into the vertebral body. The procedures were done via right internal jugular access using an Ensnare device. In one of the cases, the hangman technique was used to release the filter apex from the vessel wall. Both filters were able to be retrieved without using excessive force, follow-up venacavograms showed no sign of extravasation, and no postprocedure complications developed. DISCUSSION: Preprocedure CT imaging is essential prior to IVC filter removal if vertebral penetration is suspected. The zone of osteolysis seen around the struts in both cases are likely the result of constant cardiorespiratory motion of the filter. Based on the fact that in both cases the filter legs were able to be disengaged from the vertebral body without the use of excessive force, we hypothesize that if a zone of osteolysis surrounding the struts can be confirmed on preprocedural CT, the filter removal can be safely attempted by the standard percutaneous endovascular approach.

Colorectal Liver Metastasis: Overview of Treatment Paradigm Highlighting the Role of Ablation.

OBJECTIVE: The objective of this article is to discuss the current treatment options for colorectal cancer (CRC) liver metastases and the role of ablation. CONCLUSION: A randomized control trial of ablation combined with chemotherapy showed improved overall survival compared with chemotherapy alone. Local recurrence rates are comparable to those associated with resection when ablative margins of more than 5 mm are achieved and target lesions are smaller than 3 cm. In patients with unresectable disease, ablation for curative intent should be considered.

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism.

PURPOSE: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. METHODS: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. RESULTS: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. CONCLUSION: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Transjugular intrahepatic portosystemic shunt for chylous ascites in a patient with recurrent cirrhosis following liver transplantation.

Chylous ascites (CA) is the extravasation of lipid-rich lymphatic fluid into the peritoneal space following trauma or obstruction of the lymphatic system. Refractory cases of cirrhosis-related CA may be amendable to transjugular intrahepatic portosystemic shunting (TIPS). We present a case of TIPS in the setting of refractory CA secondary to cirrhosis of a transplanted liver graft. Following TIPS, the patient reported immediate improvement in abdominal pain and no longer requires paracentesis. Our case suggests TIPS to be a safe and effective treatment option for CA in liver transplant patients with cirrhosis.

Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade.

PURPOSE: The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010. METHODS: The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes. RESULTS: There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p < 0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p < 0.001) and shorter hospital stay (10.4 vs. 13.7 days, p < 0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p < 0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p < 0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p < 0.001) and OAR (46.2 vs. 36.9%, p < 0.001). The hospital mortality (41.3-25.8%, p < 0.001) and mean length of stay (11.8-9.7 days, p < 0.01) of EVAR steadily improved over the study period. CONCLUSIONS: National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.

Uterine artery embolization and its effect on fertility.

A systematic review of literature analyzing fertility following uterine artery embolization (UAE) is presented. Twenty-one studies describing pregnancy and complications of pregnancy following UAE were included. Low-level evidence from these studies suggests that pregnancy rates following UAE are comparable to the age-adjusted rates in the general population. Although pregnancy complication rates were similar to those in patients with untreated fibroid tumors, a few studies have reported higher miscarriage rates following UAE. Further randomized controlled trials comparing UAE versus other fertility-preserving treatments are necessary to confirm these findings.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting.

PURPOSE: To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting. MATERIALS AND METHODS: Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared. RESULTS: The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01). CONCLUSIONS: There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Management of Hinchey II diverticulitis.

Colonic diverticulosis can either be asymptomatic or present with complications resulting in significant morbidity and mortality. A key presentation of complicated disease is abscess formation (Hinchey type II). The natural course of this is unclear and therefore treatments range from conservative approach with antibiotics and percutaneous guided drainage (PCD) to surgery. There is no clear consensus on the exact management strategy. A Medline based literature search specifically looking at studies dealing with Hinchey type II diverticulitis and its management was carried out. For comparison, five-year retrospective data of diverticular abscesses from our institution was collected and the outcome analysed. Various studies have looked into this aspect of the disease, elaborating on the significance of the size and location of the abscesses, the role of PCD, recurrence rates and the controversies regarding the need for elective surgery. Conservative treatment with antibiotics alone is effective in a majority of cases with a role for PCD in large safely accessible abscesses. Variable recurrence rates have been reported in literature and elective surgery should be planned for selected groups of patients.