Disparities in access to and timing of interventional therapies for pulmonary embolism across the United States.

BACKGROUND: Interventional therapies (ITs) are an emerging treatment modality for pulmonary embolism (PE); however, the degree of racial, sex-based, and sociodemographic disparities in access and timing is unknown. OBJECTIVES: To investigate barriers to access and timing of ITs for PE across the United States. METHODS: A retrospective cohort study utilizing the Nationwide Inpatient Sample from 2016-2020 included adult patients with PE. The use of ITs (mechanical thrombectomy and catheter-directed thrombolysis) was identified via International Classification of Diseases 10th revision codes. Early IT was defined as procedure performed within the first 2 days after admission. RESULTS: A total of 27 805 273 records from the 2016-2020 Nationwide Inpatient Sample database were examined. There were 387 514 (1.4%) patients with PE, with 14 249 (3.6%) of them having undergone IT procedures (11 115 catheter-directed thrombolysis, 2314 thrombectomy, and 780 both procedures). After multivariate adjustment, factors associated with less use of IT included Black race (odds ratio [OR], 0.90; 95% CI, 0.86-0.94; P < .01), Hispanic race (OR, 0.73; 95% CI, 0.68-0.79; P < .01), female sex (OR, 0.88; 95% CI, 0.85-0.91; P < .01), treatment in a rural hospital (OR, 0.49; 95% CI, 0.44-0.54; P < .01), and lack of private insurance (Medicare OR, 0.77; 95% CI, 0.73-0.80; P < .01; Medicaid OR, 0.65; 95% CI, 0.61-0.69; P < .01; no coverage OR, 0.87; 95% CI, 0.82-0.93; P < .01). Among the patients who received IT, 11 315 (79%) procedures were conducted within 2 days of admission and 2934 (21%) were delayed. Factors associated with delayed procedures included Black race (OR, 1.12; 95% CI, 1.01-1.26; P = .04), Hispanic race (OR, 1.52; 95% CI, 1.28-1.80; P < .01), weekend admission (OR, 1.37; 95% CI, 1.25-1.51; P < .01), Medicare coverage (OR, 1.24; 95% CI, 1.10-1.40; P < .01), and Medicaid coverage (OR, 1.29; 95% CI, 1.12-1.49; P < .01). CONCLUSION: Significant racial, sex-based, and geographic barriers exist in overall access to IT for PE in the United States.

Intrahepatic inferior vena cava interruption with transhepatic venous continuation initially misdiagnosed as a congenital portosystemic shunt.

We report a case of intrahepatic inferior vena cava interruption with azygos and transhepatic venous continuation discovered incidentally on CT angiography for acute aortic syndrome. The lesion was initially misdiagnosed as a congenital portosystemic shunt on multiphase CT of the liver but subsequent fluoroscopic venogram revealed no evidence of portosystemic shunting. While intrahepatic IVC interruption with azygos continuation is an uncommon but well-known anatomical variant, transhepatic venous continuation is extremely rare and only a few cases have been published. Excluding portosystemic shunting is important for determining management as persistent congenital portosystemic shunts can be associated with significant morbidity.

Anterograde venous bullet embolism from the left facial vein to the right ventricle.

A young man presented to the emergency department reporting he had been recently shot in the face and chest with an unknown weapon. Initial physical examination only found bruising by the left hemimandible, but CT angiography of the thorax revealed a BB in the right ventricle. A subsequent CT angiography of the head and neck showed no major arterial injury but noted stranding and irregularity of the left facial vein directly deep to the injury site. The findings favoured anterograde venous bullet embolism from the left facial vein to the right ventricle. To our knowledge, this is the first report of a relatively small diameter and superficial vein of the face resulting in this phenomenon.