Adrenal Vein Sampling Results and Surgical Outcomes in Patients with Nonsuppressed Plasma Renin Activity.

PURPOSE: To determine adrenal vein sampling (AVS) and postadrenalectomy outcomes in patients with a nonsuppressed plasma renin activity (PRA) and elevated aldosterone-to-renin ratio (ARR). MATERIALS AND METHODS: The study sample included 23 patients with an ARR of >20 and PRA of >1 ng/mL/h (nonsuppressed group) and 69 patients with an ARR of >20 and PRA of <0.6 ng/mL/h (suppressed group) who underwent AVS from 2006 to 2023. Data regarding baseline clinical characteristics, AVS results, and outcomes after adrenalectomy were analyzed. RESULTS: The proportion of patients in the nonsuppressed group who had a lateralization index of >4 was lower than that in the suppressed group, although this was nonsignificant (43% vs 62%; P = .15). The mean lateralization index in the nonsuppressed group was lower compared with that in the suppressed group (8.7 vs 17.4; P = .05). The proportion of patients in the nonsuppressed group with improved or cured hypertension following adrenalectomy was similar to that of patients in the suppressed group who also underwent surgery (6/8, 75%, vs 25/32, 78%; P = .71). All hypokalemic patients (32/32) who underwent adrenalectomy had normalization of their potassium levels following procedure. CONCLUSIONS: Nearly half of patients with nonsuppressed PRA lateralized with AVS. The patients who did lateralize had similar blood pressure response and correction of hypokalemia following adrenalectomy, regardless of PRA. Therefore, patients with a nonsuppressed PRA (>1 ng/mL/h) should still be considered for AVS provided the ARR is elevated.

Supply Costs in Complex and Routine Inferior Vena Cava Filter Retrieval: 10 Years' Data from a Single Center.

PURPOSE: To characterize the medical supply costs associated with inferior vena cava filter retrieval (IVCFR) using endobronchial forceps (EFs), a snare, or Recovery Cone (RC). MATERIALS AND METHODS: In total, 594 of 845 IVCFRs attempted at a tertiary referral hospital between October 1, 2012, and June 20, 2022 were categorized by intended retrieval strategy informed by, rotational cavography as follows: (a) EF (n = 312) for tilted or tip-embedded/strut-embedded filters and for long-dwelling closed-cell filters and (b) a snare (n = 255) or (c) RC (n = 27) for other well-positioned filters with or mostly without hooks, respectively. List prices of relevant supplies at time of retrieval were obtained or, rarely, estimated using a standard procedure. Contrast use, fluoroscopic time, filter type, dwell time, and patient age and sex were recorded. Mean between-group cost differences were estimated by linear regression, adjusting for date. Additional models evaluated filter type, dwell time, and patient-level effects. RESULTS: Of the 594 IVCFRs, 591 were successful, whereas 2 EF and 1 snare retrievals failed. Moreover, 4 EF retrievals were successful with a snare and 2 with smaller EF, 12 snare retrievals were successful with EF, 1 RC retrieval was successful with a snare and 2 with EF. Principal model indicated a significantly lower mean cost of EF ($564.70, SE ± 9.75) than that of snare ($811.29, SE ± 10.83; P < .0001) and RC ($1,465.48, SE ± 47.12; P < .0001) retrievals. Adjusted models yielded consistent results. Had all retrievals been attempted with EF, estimated undiscounted full-period supplies savings would be $87,201.51. CONCLUSIONS: EFs are affordable for complex IVCFR, and extending their use to routine IVCFR could lead to considerable cost savings.

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience.

PURPOSE: To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS). MATERIALS AND METHODS: A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions. RESULTS: Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups. CONCLUSIONS: In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Endobronchial Forceps Retrieval of Embedded Inferior Vena Cava Filters: Retrieval of 535 Filters at a Single Center.

PURPOSE: To report results of 16 years of using the endobronchial forceps technique to remove embedded inferior vena cava (IVC) filters. MATERIALS AND METHODS: Between January 2005 and June 2021, 534 patients (310 women and 224 men) with a mean age of 52 years (standard deviation [SD] ± 16 years) presented for complex filter retrieval of 535 tip- or strut-embedded IVC filters. Tip-embedded filters were diagnosed on rotational venography. Filters were considered strut-embedded if they were closed-cell filters with dwell times of >6 months. The filter was dissected from the IVC using rigid bronchoscopy forceps and removed through a vascular sheath. RESULTS: The endobronchial forceps technique was successful in 530 of 537 retrieval attempts on an intention-to-treat basis (98.7%); a total of 530 filters were retrieved. There were 7 failures: (a) 5 failed retrieval attempts (2 that were retrieved successfully in subsequent procedures) and (b) 2 for which retrieval was not attempted. The mean filter dwell time was 1,459 days (SD ± 1,617 days). Laser sheaths were not used for any removal. Filters included herein were 137 Celect (94 Celect and 43 Celect Platinum), 99 Günther Tulip, 72 Option (48 Option and 24 Option Elite), 68 G2, 45 G2X/Eclipse, 42 Denali, 30 OptEase, 29 Recovery, 7 Meridian, and 6 ALN with Hook filters. Thirty-four minor (6.3%) and 11 major (2%) adverse events (AEs) occurred, which did not result in permanent sequelae. CONCLUSIONS: Use of endobronchial forceps for removal of tip- and strut-embedded retrievable IVC filters is effective and has low AE rates.

Grasp-and-Fold Technique for Complex Inferior Vena Cava Filter Retrieval.

This study evaluated the use of the grasp-and-fold technique for complex forceps retrieval of inferior vena cava (IVC) filters. A retrospective study of 14 patients (12 women and 2 men) who had either deeply tip-embedded or severely distorted IVC filters was performed at a single institution over 10 years. In this technique, endobronchial forceps were used to fold the filter in half to remove it through the sheath because the filter tip could not be accessed by dissection. The grasp-and-fold technique successfully removed all 14 filters. One patient had retained filter struts, which were present before the procedure. One mild and 5 moderate adverse events (AEs), including fracture fragment embolization requiring retrieval and self-limited IVC extravasation, occurred. No severe AEs occurred. In this small patient cohort, the grasp-and-fold forceps technique successfully retrieved deeply tip-embedded or distorted IVC filters with inaccessible tips.

Adrenal Vein Sampling Results and Surgical Outcomes in Patients with a Normal Plasma Aldosterone Concentration.

PURPOSE: To determine the utility of adrenal vein sampling (AVS) and outcomes after adrenalectomy in patients with normal plasma aldosterone concentration (PAC) and elevated aldosterone-to-renin ratio (ARR). MATERIALS AND METHODS: The study sample included 106 patients with ARR greater than 20 and PAC between 5 and 15 ng/dL (normal PAC group) who underwent AVS from 2005 to 2021. These patients were compared with a cohort of 106 patients with ARR >20 and PAC >15 ng/dL (high PAC group) who underwent AVS during the same period. Data regarding baseline clinical characteristics, lateralization indices from AVS, and outcomes after adrenalectomy were analyzed. RESULTS: AVS was technically successful in 210 patients (210/212, 99%). A smaller proportion of patients in the normal PAC group showed a lateralization index of >4 compared with those in the high PAC group (44% vs 64%, P <.01). A similar proportion of patients in the normal PAC group experienced improved or cured hypertension after adrenalectomy compared with that in the high PAC group (94% vs 88%, P =.31). Hypokalemia was cured in all patients in the normal PAC group after adrenalectomy compared with 98% of patients in the high PAC group (100% vs 98%, P = 1). CONCLUSIONS: Although lateralization is less frequent for patients with normal PAC, patients who do lateralize show similar blood pressure response and correction of hypokalemia after adrenalectomy, regardless of initial plasma aldosterone levels. Therefore, patients with PAC <15 ng/dL should still be considered for AVS provided the ARR is elevated.

Comparison of Fibered versus Nonfibered Coils for Venous Embolization in an Ovine Model.

PURPOSE: To compare nylon fibered (F) with nonfibered (NF) coils for embolization in an ovine venous model. MATERIALS AND METHODS: Four- to 8-mm-diameter, 0.035-inch F and NF coils were deployed in 24 veins in 6 sheep. The number of coils, total length of the coils, and length of implanted coil pack required to achieve complete stasis were recorded, as were vessel diameter, radiation dose, ease of packing, damage to embolized vessel, and time to stasis. Venography at 1 and 3 months was used to assess the migration and durability of vessel occlusion. Veins were harvested at 3 months. RESULTS: F and NF coils were deployed in 24 veins, and stasis was achieved, without immediate coil migration or vessel damage. The mean numbers of F and NF coils per vein were 5 and 8.75, respectively (P = .007). The vessel diameter between the groups was not statistically different. The total coil length (F, 70 cm vs NF, 122.5 cm; P = .0007), coil pack length (F, 29.3 mm vs NF, 39.4 mm; P = .003), time to stasis (F, 5.3 minutes vs NF, 9.0 minutes; P = .008), and radiation dose (F, 25.3 mGy vs NF, 34.9 mGy; P = .037) were significantly different between the groups. Challenges with the animal model prevented conclusive long-term results. Migration occurred with 8 of 11 (72%) coil packs in the femoral veins and 0 of 13 (0%) coil packs in the internal iliac and deep femoral veins. Venography demonstrated that of 16 remaining coil packs, 11 were occluded at 1 month and 10 remained occluded at 3 months. CONCLUSIONS: Fibers allow for significantly fewer coils to achieve immediate venous occlusion.

Outcomes following Exchange and Upsizing of Malfunctioning Small-Caliber Double-J Ureteral Stents.

PURPOSE: To determine the effectiveness of exchange and upsizing of malfunctioning small-caliber double-J (JJ) ureteral stents. MATERIALS AND METHODS: Thirty-one patients with malfunctioning cystoscopically placed small-caliber (6 or 7 F) JJ stents underwent transurethral (n = 28) or transrenal (n = 3) exchange and upsizing to a large-caliber (10 F) JJ stent from 2013 to 2022. Ureteral obstruction was malignant in 20 patients (65%) and benign in 11 (35%). Fifteen patients (48%) presented with persistent hydroureteronephrosis and 16 patients (52%) with worsening hydronephrosis. Acute kidney injury (AKI) was present in 19 patients (61%) at the time of stent malfunction. Therapeutic success was defined as resolution of hydronephrosis and AKI, if present. RESULTS: JJ stent exchange and upsizing was technically successful in 31 patients (100%) with no immediate adverse events. Therapeutic success was achieved in 27 patients (87%). During follow-up (median, 97 days; IQR, 32-205 days), 2 patients who initially achieved therapeutic success had stent malfunction, requiring conversion to percutaneous nephrostomy drainage (2/27, 7%). CONCLUSIONS: Exchange and upsizing to large-caliber JJ stents can relieve urinary obstruction and resolve AKI in patients with malfunctioning small-caliber JJ stents. Large-caliber JJ stents should be considered as a salvage option for patients who wish to continue internal drainage and avoid percutaneous nephrostomy.

Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding.

PURPOSE: To evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI). MATERIALS AND METHODS: Patients at the authors' institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test. RESULTS: Ninety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week. CONCLUSIONS: Despite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.

Comparison of Transthoracic Contrast Echocardiography with High-Resolution Chest CT after Embolization of Pulmonary Arteriovenous Malformation.

PURPOSE: To compare postembolotherapy follow-up graded transthoracic contrast echocardiography (TTCE) and high-resolution computed tomography (CT) of the chest and to evaluate the use of graded TTCE in the early postembolic period. MATERIALS AND METHODS: Thirty-five patients (6 men and 29 women; mean age, 56 years; range, 27-78 years) presenting for postembolotherapy follow-up between 2017 and 2021 with concurrent high-resolution CT and graded TTCE were analyzed retrospectively. Untreated pulmonary arteriovenous malformations (PAVMs) with a feeding artery of ≥2 mm were considered treatable. RESULTS: Ninety-four percent of patients (33 of 35) did not have treatable PAVMs on high-resolution CT. TTCE was negative for shunts (Grade 0) in 34% of patients (n = 12). Of patients with a TTCE positive for shunts (23 of 35, 66%), 83% had a Grade 1 shunt, 13% had a Grade 2 shunt, and 4% had a Grade 3 shunt. No patient with a Grade 0 or 1 shunt had a treatable PAVM on high-resolution CT. Of the 2 patients with PAVMs requiring treatment, one had a Grade 2 shunt and one had a Grade 3 shunt. TTCE grade was significantly associated with the presence of a treatable PAVM on high-resolution CT (P < .01). CONCLUSIONS: Graded TTCE predicts the need for repeat embolotherapy and does so reliably in the early postembolotherapy period. This suggests that graded TTCE can be utilized in the postembolotherapy period for surveillance, which has the potential to lead to a decrease in cumulative radiation in this patient population.

Quality Improvement Report: Design and Implementation of a Radiology E-Consult Service.

Electronic consultations (e-consults) mediated through an electronic health record system or web-based platform allow synchronous or asynchronous physician-to-physician communication. E-consults have been explored in various clinical specialties, but relatively few instances in the literature describe e-consults to connect health care providers directly with radiologists.The authors outline how a radiology department can implement an e-consult service and review the development of such a service in a large academic health system. They describe the logistics, workflow, turnaround time expectations, stakeholder management, and pilot implementation and highlight challenges and lessons learned.

Stability of Retained Inferior Vena Cava Filter Fragments after Filter Removal.

PURPOSE: To assess the stability and outcome of fractured inferior vena cava (IVC) filter fragments that are retained in patients after IVC filter removal. MATERIALS AND METHODS: A retrospective analysis was conducted on all patients at a single tertiary referral center between May 2005 and June 2020 with fractured IVC filters where fragment(s) were retained after removal of the main filter body. IVC filter fragment stability was assessed by a clinician review of computed tomography images, chosen from available radiologic studies, to best visualize the fragments. Data collected included filter type, fragment location, duration of fragment follow-up, fragment stability in location, and further fragment fracture or clinical sequelae. RESULTS: Seventy-seven patients with retained IVC filter fragment(s) after complex filter removal were identified. Of this, 37 patients (14 men, 23 women) were deemed to have adequate imaging follow-up to assess positional stability of the retained fragments, whereas the remainder were excluded from further analysis. Excluding fractured foot processes, 51 separate filter fragments were retrospectively identified and followed for a median duration of 726 days (interquartile range, 843 days; range, 28-3353 days). Filter designs producing the studied fragments included Celect, G2, Recovery, Günther, OptEase, Meridian, and G2X/Eclipse. In all, 50 of 51 (98%) fragments were found to be unchanged in position during their respective intervals of observation. One fragment displayed a rotational change without migrating from its original location. No further fragment fractures or clinical sequelae were observed among the group. CONCLUSIONS: When asymptomatic, retained IVC filter fragments are predominantly stable and can be safely followed on an intermediate-term basis.

Infectious Recidivism in Tunneled Dialysis Catheters Removed for Bloodstream Infection in the Intensive Care Unit.

PURPOSE: To determine the rate of recurrent infection of ICU patients who underwent tunneled dialysis catheter (TDC) exchange or removal for bloodstream infection. MATERIALS AND METHODS: Forty seven patients, with a total of 61 TDCs removed for bloodstream infection while admitted in an ICU from 2017-2020, were identified. TDCs were exchanged over a wire or removed and replaced. Thirteen patients (21%) were managed with non-tunneled dialysis catheters (NTDCs) until delayed TDC replacement at ICU departure. Forty seven TDCs were removed for bacteremia (77%), 13 for fungemia (21%), and 1 for both (2%). Thirty TDCs (49%) were exchanged over-the-wire (ICU-exchanged TDCs), and 31 (51%) were removed. Of the patients who underwent TDC removal, 9 had a new TDC placed while still admitted in the ICU (ICU-replaced TDCs), and 7 underwent delayed TDC replacement at ICU departure. Data regarding infection, removal technique, catheter replacement, and patient outcomes were analyzed. RESULTS: There were 10 instances of recurrent bloodstream infection (infectious recidivism), occurring in 7 ICU-exchanged TDCs (7/30, 23%) and 3 ICU-replaced TDCs (3/9, 33%). Bloodstream infection complicated 22% of NTDCs used in patients undergoing delayed TDC replacement. No cases of TDC infectious recidivism were observed in patients who underwent delayed TDC replacement (0/7, 0%) after ICU departure. CONCLUSIONS: High rates of infectious recidivism exist in the ICU, meriting further investigation into how to optimally manage these patients. In those in whom TDCs are removed, withholding TDC replacement until ICU departure may help to minimize the rate of recurrent infection.

"Double-Down" Adrenal Vein Sampling Results in Patients with Apparent Bilateral Aldosterone Suppression: Utility of Repeat Sampling including Super-Selective Sampling.

PURPOSE: To report outcomes of patients undergoing adrenal vein sampling (AVS) for primary aldosteronism with results indicating apparent bilateral adrenal suppression (ABAS), in which the adrenal aldosterone-to-cortisol ratios are decreased bilaterally ("double-down") compared to the non-adrenal sample, and evaluate repeat AVS results. MATERIALS AND METHODS: Between 2003 and 2020, 762 patients underwent AVS. Twenty patients (2.6%; male, 12; female, 8; age 50.3 ± 9.7 years) with ABAS on initial AVS were identified. Ten underwent repeat AVS. Super-selective AVS (SS-AVS) was employed in 6 of 10 repeat AVS (60%). Outcomes after AVS were analyzed. A lateralization index (LI) >4 was considered an indication for adrenalectomy. RESULTS: Repeat AVS was diagnostic in 70% of patients (n = 7), with 6 of 7 lateralizing with LI >4 (median LI = 32.3; range 4.6-54.8) and 1 of 7 nearly lateralizing (LI = 3.5). All 7 patients underwent adrenalectomy. ABAS was redemonstrated in 3 patients (30%): 2 with unilateral adenomas on cross-sectional imaging underwent adrenalectomy despite ABAS results and 1 was lost to follow-up. Four of 6 patients (66%) who underwent SS-AVS were diagnosed with unilateral disease (median LI = 43.3; range 23.9-54.8), with one patient's diagnosis reliant upon a single super-selective sample. In total, 9 patients underwent adrenalectomy after repeat AVS, all of whom had improved blood pressure control postoperatively. Ten patients did not undergo repeat AVS: 6 were lost to follow-up, 3 underwent medical management, and 1 underwent adrenalectomy. CONCLUSIONS: AVS should be repeated when "double-down" ABAS results are encountered. Super-selective sampling may provide worthwhile diagnostic data when employed during repeat AVS.

Role of Venous Access Port Cultures in the Management of Port-Related Infections.

PURPOSE: To determine the impact of port and catheter tip cultures on the clinical management of port-related infections. MATERIALS AND METHODS: Patients whose ports were removed for infection between January 2016 and December 2019 were retrospectively identified. The study sample included 68 ports removed for suspected catheter-related bloodstream infection (CRBSI) and 27 ports removed for local infection. Port surface, catheter tip, and blood culture results were recorded. Antimicrobial therapy before and after port removal was recorded. The impact of culture results on port infection management was determined. RESULTS: Of the 68 ports removed from patients with CRBSI, 78% received empiric antibiotics. Of these patients, blood cultures led to a change in therapy in 77%. Catheter tip cultures were positive in 32% whereas port surface cultures were positive in 53% of patients. Culture results did not influence antimicrobial therapy in any patient with CRBSI. Of 27 port removals performed for local infection, catheter tip cultures were positive in 41% whereas port surface cultures were positive in 59% of patients. Port surface cultures led to a change in therapy in 33% of local infections. Port surface cultures were significantly more likely to impact management if removal was performed for local infection than for CRBSI (33% vs. 0%, respectively; P < .001). Port surface cultures were inclusive of all positive catheter tip cultures. CONCLUSIONS: For patients with suspected CRBSI, blood cultures alone are sufficient to guide therapy. Port cultures may be justified in the setting of local infection. Catheter tip cultures are unnecessary if port surface cultures are performed.

Magnification Spot Radiographs Improve Assessment for Inferior Vena Cava Filter Fractures prior to Removal Compared to CT.

PURPOSE: To determine if magnification spot radiographs acquired before attempting inferior vena cava (IVC) filter removal have value in the assessment for filter fractures. MATERIALS AND METHODS: A retrospective review of complex IVC filter removals performed at a tertiary referral center from October 2015 to May 2017 was performed. Magnification spot radiographs (frontal and at least 2 oblique views) were obtained with the fluoroscopic unit in the procedure suite prior to venous access for filter removal. Patients were included in the study if a computed tomography (CT) scan of the abdomen/pelvis before filter removal was available. Ninety-six patients (47 women and 49 men) were included. Most removed filters were the Recovery/G2/G2X/Eclipse/Meridian (n = 28), the Günther Tulip (n = 26), and the Celect/Celect Platinum (n = 22). Blinded review of the pre-procedural CT scans and spot radiographs for the presence of filter fractures was performed by 2 interventional radiologists. Accuracy of each modality was assessed using the status of the explanted filter as the gold standard. Agreement between the 2 readers was assessed with the kappa statistic. RESULTS: Fractures were present in 27 explanted filters (28%). Accuracy of CT was 88% and 68% for readers 1 and 2, respectively, which increased to 98% and 97% with magnification spot radiographs. The kappa statistic was 0.12 for CT and 0.97 for spot radiographs. CONCLUSIONS: Magnification spot radiographs acquired before attempting IVC filter removal improve detection of filter fractures and agreement among interventional radiologists. Therefore, these should be performed routinely to allow for optimal treatment planning.

The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis.

PURPOSE: To present final, 2-year results of a randomized trial comparing paclitaxel-coated vs uncoated balloon angioplasty following vessel preparation with ultra-high-pressure percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistulae (AVFs). MATERIALS AND METHODS: Twenty-three sites enrolled 285 subjects with dysfunctional AVFs located in the arm. Before 1:1 randomization, successful vessel preparation was achieved (full waist effacement, < 30% residual stenosis). Follow-up was clinically driven except for a 6-month office visit. RESULTS: Ninety-six of 141 subjects in the drug-coated balloon (DCB) arm and 111 of 144 in the control arm completed the study. Target lesion primary patency (TLPP) rates for the DCB and control groups were 58% ± 4 vs 46% ± 4 (P = .02) at 9 months, 44% ± 5 vs 36% ± 4 (P = .04) at 12 months, 34% ± 5 vs 28% ± 4 (P = .06) at 18 months, and 27% ± 4 vs 24% ± 4 (P = .09) at 24 months, respectively. Mean time to TLPP event for subjects with an event was longer for DCBs (322 vs 207 d; P < .0001). Fewer interventions were needed to maintain target lesion patency in the DCB group at 9 months (P = .02) but not at 12 (P = .08), 18 (P = .13), or 24 months (P = .19). The noninferiority safety target was met at all intervals (P < .01). Mortality did not differ between groups (P = .27). Post hoc analyses showed equivalent DCB effect in all subgroups. CONCLUSIONS: Two-year results demonstrate long-term safety and variable efficacy of DCB angioplasty in AVFs.

Retrospective Analysis of 77 Hemodialysis Patients Shows No Cases of Steal Syndrome from Graft Taper Reduction.

PURPOSE: To review the immediate flow response and incidence of steal syndrome after taper reduction of tapered dialysis grafts. MATERIAL AND METHODS: This was a retrospective review of a quality assurance database of all hemodialysis access interventions performed between 2005 and 2017. It identified 77 patients who underwent a taper reduction procedure, involving angioplasty of the arterial limb of the graft and the arterial anastomosis for graft thrombosis/poor flow. A subset of patients underwent 5-, 6-, or 7-mm balloon taper reduction angioplasty coupled with intravascular direct flow measurement (n = 15 with 16 dialysis grafts). A two-tailed Wilcoxon matched-pairs signed-rank test was used to compare pre- and post-taper reduction flows. Mean duration of follow-up was 3.5 years (range, 0-12.5 years). RESULTS: Mean access survival after taper reduction was 20.2 months (range, 0.10-94.4 months). Pre- and post-taper reduction access flows (mean Qb ± standard deviation) were 574 ± 315 ml/min and 929 ± 352 ml/min, respectively (P < .0001). The mean ratio of post- to pre-taper reduction flows was 1.6 (range, 1.1-10.2). No patients developed steal syndrome within 6 months after taper reduction. CONCLUSIONS: Dialysis graft arterial anastomotic taper reduction did not result in the development of steal syndrome within 6 months. In the subset of patients who underwent flow measurements, taper reduction was associated with nearly a 2-fold improvement in access flow, which is a key predictor of access function.

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement.

PURPOSE: To evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE). MATERIALS AND METHODS: Data were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis). RESULTS: In total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2-2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year). CONCLUSIONS: TDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Endovascular Treatment of an Anatomically Complex Iliac Lesion and a Review of Variant Iliac Venous Anatomy.

The diagnosis and treatment of pelvic venous disease is complicated by a number of potential venous anatomic variants. Stent-assisted recanalization of a chronically occluded left external iliac vein draining directly into the inferior vena cava, with absence of the left common iliac vein, is described here. Variant iliac venous anatomy is reviewed in 3 categories: additional iliac vessels, absence/shortening of iliac vessels, and deviations in the drainage pattern of iliac vessels. Additionally, variations of the ascending lumbar and iliolumbar veins, the identification of which can aid in the treatment of pelvic venous disease, are described.