Comparison of Outcomes of Drug-Coated Balloons versus Plain Balloons in Secondary Interventions on Percutaneous Arteriovenous Fistulae.

PURPOSE: To compare patency and reintervention outcomes after either plain old balloon angioplasty (POBA) or drug-coated balloon angioplasty (DCBA) for venous stenoses after percutaneous arteriovenous fistula (pAVF) creation. MATERIALS AND METHODS: One-hundred ninety-five pAVFs were successfully created during the study period, 141 using Ellipsys and 54 using Wavelinq. After pAVF creation, 95 patients (48.7%) required secondary percutaneous transluminal angioplasty (PTA) with either POBA (n = 55, 58%) or DCBA (n = 40, 42.1%). The most common site for PTA was the juxta-anastomotic segment (75.5%; 74/98). Univariate and multivariate Cox regression analyses were used to compare target lesion primary patency, access circuit primary patency, secondary patency, and reintervention rates in the POBA and DCBA cohorts. RESULTS: Thirty-four of 55 (62%) patients in the POBA cohort and 14 of 40 (35%) patients in the DCBA cohort required reinterventions for pAVF restenosis. Mean number of follow-up days among patients treated with POBA was 1,030.4 (SD ± 342.9) and among those treated with DCBA was 744.4 (SD ± 403.5). The use of POBA compared with DCBA was not associated with target lesion and access circuit primary patency loss in multivariate analysis (hazard ratio [HR], 1.81; 95% CI, 0.93-3.51; P = .080; and HR, 1.77; 95% CI, 0.73-4.28; P = .210, respectively). However, time from fistula creation to the first PTA (days) was statistically significantly associated with both outcomes (HR, 0.997; 95% CI, 0.994-0.999; P = .009; and HR, 0.997; 95% CI, 0.992-0.999; P = .021, respectively). There were no major adverse events. CONCLUSIONS: In this retrospective single-center analysis of pAVFs, considerably more patients who underwent PTA with POBA after pAVF creation required reinterventions compared with PTA using DCBA, although the follow-up time of POBA was longer. In multivariate analysis, no differences were noted in the hazard of patency loss between POBA and DCBA.

Percutaneous Arteriovenous Fistula Creation with Intended Brachial Vein Outflow and Secondary Brachial Vein Transposition Using the WavelinQ EndoAVF System.

PURPOSE: To assess percutaneous arteriovenous fistula (pAVF) creation with subsequent brachial vein transposition (BVT) using the WavelinQ endoAVF system. MATERIALS AND METHODS: A pre-existing database was retrospectively reviewed. Nine patients underwent attempted pAVF-BVT creation between December 2017 and November 2021. Study outcomes included technical success, time to maturation, patency rates, adverse events, and secondary interventions. Maturation was defined as a pAVF flow of ≥500 mL/min, outflow vein diameter ≥5 mm, and successful 2-needle cannulations in patients on active hemodialysis (HD). RESULTS: pAVF-BVT creation was technically successful in 8 of 9 patients (89%). Six of 8 created pAVFs remained patent and matured at 4 weeks, subsequently undergoing secondary BVT. Primary patency rates at 6, 12, and 24 months were 37.5%, 12.5%, and 12.5%, respectively. Secondary patency rates at 6, 12, and 24 months were 75%, 37.5%, and 37.5%, respectively. One patient had postprocedural access site bleeding, and 4 required secondary interventions to maintain patency. Two patients with failed pAVFs with BVT were successfully converted to surgical AVFs, probably facilitated by sufficient enlargement of superficial veins following pAVF creation. CONCLUSIONS: Off-label use of the WavelinQ system to create brachial vein outflow pAVF with BVT may be an alternative procedure for HD access creation in select patients with exhausted superficial veins.

Bowel Penetration by Inferior Vena Cava Filters: Feasibility and Safety of Percutaneous Retrieval.

OBJECTIVE. The purpose of this study was to evaluate the safety and technical feasibility of inferior vena cava filter (IVCF) removal when filter elements penetrate adjacent bowel. MATERIALS AND METHODS. A multicenter retrospective review of IVCF retrievals between 2008 and 2018 was performed. Adult patients with either CT or endoscopic evidence of filter elements penetrating bowel before retrieval were included. Technical success of IVCF retrieval was recorded. Patient records were assessed for immediate, 30-day, and 90-day complications after retrieval. RESULTS. Thirty-nine consecutive adult patients (11 men and 28 women; mean age, 51.2 years; age range, 18-81 years) qualified for inclusion. Filter dwell time was a median of 148 days (range, 32-5395 days). No IVCFs were known to have migrated or caused iliocaval thrombosis. Five IVCFs (12.8%) had more than 15° tilt relative to the inferior vena cava (IVC) before retrieval. Three IVCFs (7.7%) had fractured elements identified at the time of retrieval. Mean international normalized ratio (INR) was 1.24 ± 0.53 (SD), and mean platelet count was 262 ± 139 × 103/µL. Ten patients (25.6%) were on antibiotics at the time of retrieval. All 39 IVCFs were successfully retrieved (technical success = 100%). Two patients experienced minor complications in the immediate postprocedural period, which resulted in a minor complication rate of 5.1%. There were no complications (major or minor) identified in any patient at 30 or 90 days after retrieval. The overall major complication rate was 0%. CONCLUSION. Endovascular retrieval of IVCFs with CT evidence of filter elements that have penetrated adjacent bowel is both safe and technically feasible.

Three-Dimensional Quantitative Assessment of Uterine Fibroid Response after Uterine Artery Embolization Using Contrast-Enhanced MR Imaging.

PURPOSE: To evaluate the clinical feasibility and diagnostic accuracy of three-dimensional (3D) quantitative magnetic resonance (MR) imaging for the assessment of total lesion volume (TLV) and enhancing lesion volume (ELV) before and after uterine artery embolization (UAE). MATERIALS AND METHODS: This retrospective study included 25 patients with uterine fibroids who underwent UAE and received contrast-enhanced MR imaging before and after the procedure. TLV was calculated using a semiautomated 3D segmentation of the dominant lesion on contrast-enhanced MR imaging, and ELV was defined as voxels within TLV where the enhancement exceeded the value of a region of interest placed in hypoenhancing soft tissue (left psoas muscle). ELV was expressed in relative (% of TLV) and absolute (in cm(3)) metrics. Results were compared with manual measurements and correlated with symptomatic outcome using a linear regression model. RESULTS: Although 3D quantitative measurements of TLV demonstrated a strong correlation with the manual technique (R(2) = 0.93), measurements of ELV after UAE showed significant disagreement between techniques (R(2) = 0.72; residual standard error, 15.8). Six patients (24%) remained symptomatic and were classified as nonresponders. When stratified according to response, no difference in % ELV between responders and nonresponders was observed. When assessed using cm(3) ELV, responders showed a significantly lower mean ELV compared with nonresponders (4.1 cm(3) [range, 0.3-19.8 cm(3)] vs 77 cm(3) [range, 11.91-296 cm(3)]; P < .01). CONCLUSIONS: The use of segmentation-based 3D quantification of lesion enhancement is feasible and diagnostically accurate and could be considered as an MR imaging response marker for clinical outcome after UAE.

Abdominopelvic and lower extremity deep venous thrombosis: evaluation with contrast-enhanced MR venography with a blood-pool agent.

OBJECTIVE: The purpose of this article is to evaluate contrast-enhanced (CE) MR venography (MRV) with a blood-pool agent for detection of abdominopelvic and lower extremity deep venous thrombosis (DVT) compared with a conventional unenhanced gradient-recalled echo (GRE) MRV technique. MATERIALS AND METHODS: This retrospective study was performed on 30 patients (mean age, 52.7 years; 15 men and 15 women) referred for MRV between March 2010 and November 2010 for evaluation of lower extremity or abdominopelvic DVT. All patients underwent a GRE sequence followed by a CE T1-weighted sequence with gadofosveset, a blood-pool agent. The abdominopelvic and lower extremity venous system was divided into 13 segments. The presence of acute or chronic DVT was assessed by six radiologists, as well as qualitative and quantitative assessments of each venous segment. Image acquisition and interpretation times were also tabulated. RESULTS: The sensitivity and specificity for acute DVT were 91.0% and 99.8%, respectively, on CE MRV compared with 80.8% and 95.8%, respectively, on GRE MRV (p = 0.077 and p < 0.001). The sensitivity and specificity for chronic DVT were 84.4% and 98.4%, respectively, on CE MRV and 64.5% and 95.6%, respectively, on GRE MRV (p < 0.001 for both). Subjective ratings of vein visualization, signal homogeneity, and confidence pertaining to DVT diagnosis were significantly higher with the CE images (p < 0.001). The contrast-to-noise ratio for CE images was similar or significantly higher for all venous segments. Image acquisition and radiologist interpretation times on the CE studies were decreased (p < 0.001). CONCLUSION: Gadofosveset-enhanced MRV had equal or higher sensitivity and specificity for detection of DVT than did GRE MRV, with decreased time for image acquisition and interpretation.

Fatal reperfusion injury after thrombolysis for phlegmasia cerulea dolens.

Reperfusion injury after venous thrombolysis for phlegmasia cerulea dolens (PCD), despite its potentially rapid, fatal course, has not been well described in the literature. Two cases of fatal reperfusion injury after venous thrombolysis are reported, and the clinical manifestations and treatment strategies of PCD and the aspects of reperfusion injury relevant to the interventionalist are reviewed.

Does Intraprocedural CT Improve the Success Rate of Adrenal Venous Sampling? A Systematic Review and Meta-Analysis of Data from 809 Patients.

PURPOSE: To perform a systematic review and meta-analysis to quantify the technical success rate of adrenal venous sampling (AVS) with and without intraprocedural computed tomography (CT). METHODS: A systematic search of the Medline, Scopus, EMBASE, and Web of Science databases for comparative studies using intraprocedural CT was undertaken. More than 1,000 records were screened using titles and abstracts. Full texts of 121 studies were reviewed and 14 eligible studies were identified. Nine studies had adequate comparative data and were included in the meta-analysis. RESULTS: A research synthesis was performed and data from 809 patients were pooled in multiple random effect models. Overall success rate of AVS without and with intraprocedural CT was 72.7% (59.3-83.0%) and 92.5% (86.6-95.9), respectively. The addition of intraprocedural CT increased the technical success rate by 19.8% (P < 0.001), with an odds ratio (OR) of 5.5 (3.3-9.2; P < 0.01). In meta-regression, odds of success with intraprocedural CT was associated with younger age (beta: 0.16 ± 0.05; P:0.001), higher body mass index (BMI; beta:0.08 ± 0.03; P:0.002), and higher selectivity index (defined as the ratio of cortisol in the adrenal vein to that in the inferior vena cava; beta:0.35 ± 0.08, P < 0.001). We found a linear inverse association between operator's success without CT and improved success with intraprocedural CT (R2: 0.86). CONCLUSIONS: Intraprocedural CT is not required for every case, but can be performed in difficult cases or when operators' success is limited. The benefit was more pronounced in younger patients with higher BMI, female gender, and with higher selectivity. LEVEL OF EVIDENCE: III Systematic review and meta-analysis of non-randomized clinical trials.

Safe endovascular retrieval of a vena cava filter after duodenal perforation.

The use of vena cava filters (VCF) is a common procedure utilized in the prevention of pulmonary embolism (PE), yet VCFs have some significant and known complications, such as strut penetration and migration. Deep vein thrombosis (DVT) and PE remain a major cause of morbidity and mortality in the United States. It is estimated that as many as 900,000 individuals are affected by these each year with estimates suggesting that nearly 60,000-100,000 Americans die of DVT/PE each year. Currently, the preferred treatment for DVT/PE is anticoagulation. However, if there are contraindications to anticoagulation, an inferior vena cava (IVC) filter can be placed. These filters have both therapeutic and prophylactic indications. Therapeutic indications (documented thromboembolic disease) include absolute or relative contraindications to anticoagulation, complication of anticoagulation, failure of anticoagulation, propagation/progression of DVT during therapeutic anticoagulation, PE with residual DVT in patients with further risk of PE, free-floating iliofemoral IVC thrombus, and severe cardiopulmonary disease and DVT. There are also prophylactic indications (no current thromboembolic disease) for these filters. These include severe trauma without documented PE or DVT, closed head injury, spinal cord injury, multiple long bone fractures, and patients deemed at high risk of thromboembolic disease (immobilized or intensive care unit). Interruption of the IVC with filters has long been practiced and is a procedure that can be performed on an outpatient basis. There are known complications of filter placement, which include filter migration within the vena cava and into various organs, as well as filter strut fracture. This case describes a 66-year-old woman who was found to have a filter migration and techniques that were utilized to remove this filter.

Percutaneous removal of a precariously placed pericardial peripherally inserted central catheter.

Peripherally inserted central catheters provide access to the central chest veins and allow administration of long-term antibiotics, chemotherapy, blood products, fluids, and parenteral nutrition. Peripherally inserted central catheters provide an essential function and are routinely placed safely, but are not without risks. This case describes an unusual complication of peripherally inserted central catheter perforation into the pericardial space with subsequent successful percutaneous removal.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline.

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Inferior Vena Cava Filters: Why, Who, and for How Long?

Vena cava filters are implantable devices that are placed to trap thrombus originating in the lower extremities and prevent it from migrating to the lungs. In general, inferior vena cava (IVC) filters are indicated for patients who cannot receive anticoagulation. Other indications for IVC filtration are less clear, and guidelines vary. All patients who have a retrievable IVC filter should be followed, and the removal of the IVC filter should be considered once its indication is lost.