Sequential Pneumatic Compression in the Arm in Neurocritical Patients with a Peripherally Inserted Central Venous Catheter: A Randomized Trial.

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are increasingly used for parenteral access in critically ill hospitalized patients, but they increase the incidence of upper extremity deep venous thrombosis (UE DVT). Sequential compression devices (SCDs) applied to the legs effectively reduce lower extremity DVT, but have not been tested in the arms. Our objective was to determine whether SCDs applied to the arm may reduce the risk of PICC-associated UE DVT. METHODS: This was a retrospective study of randomized, single-center, controlled clinical trial on patients hospitalized in the intensive care unit with critical neurological illness who had a PICC and were not receiving anticoagulants. Between January 2014 and October 2016, patients were randomized 1:1 to an intervention group having a custom SCD applied to the arm harboring the PICC or to a control group. The primary endpoint was ultrasound-detected UE DVT. RESULTS: Following randomization of 77 subjects, the study was terminated due to excess DVT in the treatment arm. UE DVT was detected in 18 subjects (29.0%), and it was more frequent among those in the SCD group (13/31 [41.9%] vs. the control group 5/31 [16.1%]; p = 0.049). After accounting for crossovers, the difference was still significant (12/28 [43.0%] vs. 6/34 [17.6%]; p = 0.048). Yet, symptomatic UE DVT (n = 3) and pulmonary embolism without evidence of lower extremity DVT (n = 2) were only observed in patients who were not wearing the SCD on the arm. CONCLUSIONS: Although UE DVT is commonly associated with PICC use, the results of this trial do not support the use of SCD on the arm for DVT prevention. Further research on this strategy may nonetheless be justified. TRIAL REGISTRATION: This trial was registered in ClinicalTrials.gov under the identifier NCT01670188.

Outcomes of Ultrasound-Guided Thrombin Injection of Nongroin Arterial Pseudoaneurysms.

PURPOSE: To evaluate success and complication rates of percutaneous ultrasound-guided thrombin injection of nongroin pseudoaneurysms (PSAs). MATERIALS AND METHODS: Retrospective review of a prospectively maintained institutional database yielded 39 cases of arterial PSAs occurring at nongroin sites that were treated with percutaneous ultrasound-guided thrombin injection between 2000 and 2016 (average patient age 69.2 y ± 14.0). Of PSAs, 74.4% (29/39) arose in the upper extremities, and 92.3% (36/39) were iatrogenic. The brachial artery was the most commonly affected vessel (51.3% [20/39]), and arterial access was the most common cause (56.4% [22/39]). Average overall PSA size was 2.4 cm (range, 0.5-7.2 cm); average amount of thrombin injected was 320 IU (range, 50-2,000 IU). Technical success was defined as absence of flow within the PSA immediately after thrombin injection. Treatment success was defined as sustained thrombosis on follow-up imaging obtained at 1-3 days after treatment. RESULTS: Technical and treatment success rates of thrombin injections were 100% (39/39) and 84.8% (28/33), respectively. Longer term follow-up imaging (average 71 d; range, 12-201 d) was available for 7 of the treatment successes with 100% (7/7) showing sustained thrombosis. Comparing treatment successes and failures, there was no significant difference in average PSA size (2.3 cm vs 2.0 cm, P = .51) or average amount of thrombin injected (360 IU vs 180 IU, P = .14). There were no complications. CONCLUSIONS: Ultrasound-guided thrombin injection is a safe, efficacious treatment option for PSAs arising in nongroin locations.

Radiation dose reduction for CT-guided renal tumor cryoablation.

OBJECTIVE: The purpose of this article is to retrospectively determine the image quality and degree of radiation dose reduction that is clinically acceptable for CT-guided renal tumor cryoablation. MATERIALS AND METHODS: A total of 15 patients (17 procedures; mean age, 67 years; range, 38-85 years) undergoing clinically indicated CT-guided renal tumor cryoablation procedures were included in this retrospective study. A previously validated noise-insertion tool was used to simulate reduced-dose scans at 75%, 50%, 25%, and 10% of the original dose at four representative phases of the cryoablation procedure. Images obtained at different dose levels were randomized and reviewed by three radiologists blinded to the level of dose reduction, who scored them independently with a 5-point scale (1-5, with 5 the best). Images with a mean score of 3 or higher were considered diagnostically acceptable. The minimal acceptable dose was that at which 90% of images were considered diagnostically acceptable. Interrater agreement was assessed using the weighted kappa statistic. RESULTS: The weighted kappa value was 0.68, indicating substantial agreement among the reviewers. The averaged percentage of diagnostically acceptable images for the four series was 100% for a full dose, 98-100% for the 75% dose level, 94-98% for the 50% dose level, and less than 90% for images obtained at the 25% and 10% dose levels, which was considered unacceptable. CONCLUSION: On the basis of results from 15 patients (17 procedures), images obtained from CT acquisitions at 50% (volume CT dose index, 12.2 mGy) of the original dose level (volume CT dose index, 24.4 mGy) were acceptable for the purpose of CT monitoring of renal cryoablation procedures.

Subfascial endoscopic perforator vein surgery in patients with post-thrombotic venous insufficiency--is it justified?

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with post-thrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p = 0.001), and median outcome score was +2 (mean 1.9; range, -1 to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.

Carotid Doppler ultrasound findings in patients with left ventricular assist devices.

Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory to medical management, as bridge therapy to myocardial recovery, as bridge therapy to cardiac transplantation, or as destination therapy for patients with unfavorable transplant candidacy. Neurologic complications are some of the most common and devastating complications in these patients. Preoperative carotid ultrasound is, therefore, a standard evaluation in patients at risk for cerebrovascular disease. Postoperative carotid artery Doppler sonography is performed in those patients with neurologic symptoms. It is likely, therefore, that sonographers, radiologists, and other physicians working in a center where LVADs are implanted will likely encounter a carotid artery Doppler study in this patient group. To our knowledge, the carotid Doppler findings in these patients have never been published. We review the Doppler ultrasound findings in 6 patients after LVAD insertion.

Intraoperative use of a new angle-independent Doppler system to measure arterial velocities after carotid endarterectomy.

OBJECTIVE: The purpose of this study was to assess the intraoperative use of a new angle-independent ultrasound scan device (EchoFlow [EF]) in measurement of carotid artery velocities after endarterectomy. Specifically, the purpose was to determine the reproducibility of velocity measurements obtained with EF and to compare these measurements with the velocity measurements obtained with duplex ultrasound scan. METHODS: Velocity measurements of the common, internal, and external carotid arteries were performed by the operative surgeon with EF in 65 consecutive patients after carotid endarterectomy (36 female, 29 male; mean age, 71 years). Three velocity measurements were obtained from each of the arteries with EF and compared with the velocity measurements obtained with duplex ultrasound scan performed by a radiologist. RESULTS: Velocity measurements obtained with the EF device were reproducible in the common, internal, and external carotid arteries (intrapatient correlation coefficients, 0.95, 0.96, and 0.95, respectively). Seventy-five percent of common, 88% of internal, and 78% of external carotid velocity measurements obtained with the angle-independent ultrasound scan device were within 25 cm/s of the velocities measured with duplex ultrasound scan. The mean differences in velocity measurements between EF and duplex scan were -12 cm/s in the common, -8 cm/s in the internal, and -11 cm/s in the external carotid arteries. Differences between the EF device and duplex scan velocity measurements correlated with increasing arterial velocities in each of the three arteries measured (P <.05). CONCLUSION: Reproducible measurements of carotid artery velocity may be obtained with a new angle-independent Doppler system after endarterectomy. Most measurements obtained with the EF system are clinically comparable with those obtained with standard duplex ultrasound scan. This novel low-cost device may be useful in the intraoperative assessment of hemodynamic adequacy of carotid endarterectomy.

Computed tomography and ultrasound in follow-up of patients after endovascular repair of abdominal aortic aneurysm.

The purpose of this study was to compare our experience with duplex ultrasonography (US) and computed tomography (CT) for the routine follow-up of patients after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). We reviewed the electronic charts and radiologic exams of the first 125 patients (113 males, 12 females, median age of 76 years, range 48-98 years) with AAA treated by EVAR from June 1996 to November 2001. Our follow-up protocol included serial CT and US at regular intervals after the procedure (before discharge, at 1 month, and then every 6 months). Adequacy of each exam, ability to detect endoleaks, measurements of AAA diameter, and ability to determine graft patency were compared. For endoleak detection, comparison between CT and US was done using CT as the gold standard. A total of 608 exams, 337 CTs and 271 US, were performed 1 day to 5 years after endovascular aneurysm repair; 98% of CT and 74% of US were technically adequate. Contrary to CT, the proportion of adequate US exam was significantly less in patients with higher body mass index (BMI > or = 30 = 54% vs. BMI < 30 = 81%, p < 0.001) and for pre-discharge US compared to the post-discharge US (54% vs. 88%, p = 0.0005). Concurrent scan pairs were obtained in 252 instances in 107 patients (1-8 pairs per patient). Excellent correlation between AAA diameter measured on CT and US was noted (correlation coefficient of 0.9, p < 0.0001). However, agreement was poor. CT anteroposterior (AP) and transverse measurements were on average 2.9 mm (95% limits of agreement = -7 to 13 mm) and 1.8 mm (95% limits of agreement = -9 to 12 mm) greater than US. For AAA diameter change, there was no case of increase AP diameter on CT. However, in 23% (29/128 pairs of sets) of US, an increase in AAA size that could have influenced patient management (> or = 4 mm) was reported despite no change demonstrated on CT. For endoleak detection, sensitivity and specificity of US compared to that of CT was 25% and 89%. Similar sensitivity and specificity were noted when we excluded the first set (25% and 95%), sets done prior to 2000 (30% and 89%), inadequate CT or US scans (31% and 98%), or duplicate sets of results for each patient (28% and 81%). Of the 27 endoleaks missed on US in 17 patients, 2 were type I endoleaks. None of the four endoleaks seen only on US were type I endoleak. US usefulness prior to discharge was reduced by the high rate of inadequate exam, especially in obese patients. Despite the excellent correlation in AAA diameter between US and CT, there was significant disagreement in AAA diameter measurement and diameter change. Sensitivity of nonstandardized US for endoleak was low compared to CT. CT remains our primary imaging study after EVAR, but standardization of post-EVAR US technique may improve its accuracy.

Painful metastases involving bone: feasibility of percutaneous CT- and US-guided radio-frequency ablation.

PURPOSE: To determine the safety and efficacy of radio-frequency (RF) ablation for pain reduction, quality of life improvement, and analgesics use reduction in patients with skeletal metastases. MATERIALS AND METHODS: Over 10 months, 12 adult patients with a single painful osteolytic metastasis in whom radiation therapy or chemotherapy had failed and who reported severe pain (pain score > or = 4 [scale of 0-10]) over a 24-hour period were treated with percutaneous imaging-guided RF ablation with a multi-tined electrode while under general anesthesia. Patient pain was measured with a Brief Pain Inventory 1 day after the procedure, every week for 1 month, and thereafter every other week (total follow-up, 6 months). Patient analgesics use was also recorded at these follow-up intervals. Follow-up contrast material-enhanced computed tomography was performed 1 week after the procedure. Complications were monitored. Analysis of the primary end point was undertaken with paired comparison procedures. RESULTS: Lesion size was 1-11 cm. Before RF ablation, mean worst pain score in a 24-hour period in 12 patients was 8.0 (range, 6-10). At 4 weeks after treatment, mean worst pain decreased to 3.1 (P =.001). Mean pain before treatment was 6.5 and decreased to 1.8 (P <.001) 4 weeks after treatment. Mean pain interference in general activity decreased from 6.6 to 2.7 (P =.002) 4 weeks after treatment. Eight of 10 patients using analgesics reported reduced use at some time after RF ablation. No serious complications were observed. CONCLUSION: RF ablation of painful osteolytic metastases is safe, and the relief of pain is substantial.