Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. METHODS: The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. RESULTS: Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01). CONCLUSION: Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.

Tunneled Dialysis Catheters: Perspective from a Single Interventional Radiology Center.

Tunneled dialysis catheters (TDCs) serve as vascular access for hemodialysis (HD) or plasmapheresis. This study examines the frequency and indications for TDC placement and removal by an interventional radiology service over a 5-year period. Indications for catheter placement (n = 289) included HD for patients with end stage kidney disease (65%) or acute kidney injury (AKI, 24%), and plasmapheresis (11%). Indications for catheter removal included infection (20%), dysfunction (33%), no longer needed (40%), and patient issues (7%). TDCs provide access for HD when a functioning arteriovenous access does not exist. Using a TDC in patients with AKI reduces catheter complications, such as mechanical dysfunction and infection, and provides better dialysis delivery. TDC placement in patients with AKI, despite its time and resource intensity, provides medical and financial benefits.

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians.

PURPOSE: To test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. MATERIALS AND METHODS: Eight hospitals providing EVT performed by IRs and NI physicians at the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcomes (a 90-day modified Rankin score [mRS] of 0-2) and technically successful revascularization (a modified thrombolysis in cerebral infarction score of ≥2b) were compared between the specialties after adjusting for treating hospital, patient age, stroke severity, Alberta stroke program early computed tomography score, time from symptom onset to door, and clot location. Propensity score matching was used to compare the outcomes. A total of 1,009 patients were evaluated (622 treated by IRs and 387 treated by NI physicians). RESULTS: The median time from stroke onset to puncture was 245 versus 253 minutes (P = .49), the technically successful revascularization rate was 81.8% versus 82.4% (P = .81), and the good clinical outcome rate was 45.5% versus 50.1% (P = .16). After adjusting, the physician specialty was not a significant predictor of good clinical outcomes (odds ratio, 1.028; 95% confidence interval, 0.760-1.390; P = .86). After matching, an mRS of 0-2 was present in 47.7% of IR treated patients and 51.1% of NI treated patients (P = .366). CONCLUSIONS: There were no significant differences in the successful revascularization rate and good clinical outcomes between IRs and NI physicians. The outcomes of EVT performed by IRs were similar to those of EVT performed by NI physicians, as determined using previously published trials and registries. This may be useful for addressing coverage and access to stroke interventions.

Hybrid Repair of Chronic Stanford Type B Aortic Dissection with Expanding Arch Aneurysm.

PURPOSE: The management of patients with chronic Stanford type B aortic dissection who develop complications requires intervention without clear guidelines. Chronic aortic dissection is difficult to treat and often leads to significant morbidity and mortality. We report a complex case of chronic Stanford type B aortic dissection (TBAD) with an expanding false lumen aneurysm and distal fenestrations that required a multi-stage hybrid repair. TECHNIQUE: The patient first underwent a median sternotomy for the ascending aorta to the innominate artery and innominate artery to the left carotid artery bypass, followed by a left carotid to left axillary artery bypass. Due to continued aneurysmal growth, the patient ultimately underwent total cervical and abdominal aortic debranching as well as thoracic and abdominal endovascular grafting with iliac excluders. The patient recovered well after the surgery and had no further expansion of the aneurysm at 12-month follow up. CONCLUSION: Endovascular repairs have been the mainstay of chronic TBAD repair, but hybrid approaches may be necessary for difficult repairs. A multi-stage hybrid repair approach has been successful in a patient who had a chronic type B aortic dissection with aneurysmal degeneration that failed medical management.

Complications and Perioperative Management of Patients Undergoing Thoracic Endovascular Aortic Repair.

Endovascular treatments have become increasingly common for patients with a variety of thoracic aortic pathologies. Although considered less invasive than traditional open surgical approaches, they are nonetheless complex procedures. Patients undergo manipulation of an often calcified aorta near the origin of the carotid and subclavian vessels and have stents placed in a curved vessel adjacent to a perpetually beating heart. These stents can obstruct blood flow to the spinal cord, induce an inflammatory response, and in rare cases erode into the adjacent trachea or esophagus. Renal complications range from contrast-induced nephropathy to hypotension and ischemia to dissection. Emboli can lead to strokes and mesenteric ischemia. These patients have complex medical histories, and skilled perioperative management is critical to achieving the best clinical outcomes. Here, we review the medical management of the most common complications in these patients including stroke, spinal cord ischemia, renal injury, retrograde dissections, aortoesophageal and aortobronchial fistulas, postimplantation syndrome, mesenteric ischemia, and endograft failure.

Retrieval of TRAPEASE and OPTEASE Inferior Vena Cava Filters with Extended Dwell Times.

PURPOSE: To demonstrate that OPTEASE and TRAPEASE filters can be removed after dwell times greater than 60 days. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent an attempted removal of a TRAPEASE or OPTEASE filter with a greater than 60-day dwell time between 2009 and 2015 at a single institution. Eleven patients within that time span were identified, and 10 were included in the review. One patient was excluded from the study because the date of filter placement was unknown. RESULTS: All filters were successfully retrieved. The average dwell time for removed TRAPEASE filters was 1,273 days (range, 129-3,582 d), with a median of 492 days (n = 5). The average dwell time for OPTEASE filters was 977 days (range, 123-2,584 d), with a median of 661 days (n = 5). The average dwell time of all filters was 1,125 days (range, 123-3,582 d), with a median of 577 days (n = 10). All patients exhibited inferior vena cava (IVC) stenosis after filter retrieval. An IVC pseudoaneurysm was present following retrieval in one case and resolved. In one case, a fractured filter strut was left completely embedded in the caval wall. Two patients reported unilateral leg swelling on clinical follow-up, and the remainder reported no leg swelling or tightness. CONCLUSIONS: Initial experience suggests that TRAPEASE and OPTEASE filters can be removed after extended dwell times.

The smoker's paradox in transjugular intrahepatic portosystemic shunt procedure: A national inpatient sample analysis from 2015 to 2020.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Smoking can adversely impact liver function and has been shown to influence liver-related outcomes. This study aimed to examine the impact of smoking on the immediate outcomes of TIPS procedure. MATERIALS AND METHOD: The study compared smokers and non-smokers who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015 to 2020. Multivariable analysis was used to compare the in-hospital outcomes post-TIPS. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, indications for TIPS, liver disease etiologies, comorbidities, and hospital characteristics. RESULTS: Compared to non-smokers, smokers had lower risks of in-hospital mortality (7.36% vs 9.88 %, aOR 0.662, p < 0.01), acute kidney injury (25.57% vs 33.66 %, aOR 0.68, p < 0.01), shock (0.45% vs 0.98 %, aOR 0.467, p = 0.02), and transfer out to other hospital facilities (11.35% vs 14.78 %, aOR 0.732, p < 0.01). There was no difference in hepatic encephalopathy or bleeding. Also, smokers had shorter wait from admission to operation (2.76±0.09 vs 3.17±0.09 days, p = 0.01), shorter length of stay (7.50±0.15 vs 9.89±0.21 days, p < 0.01), and lower total hospital cost (148,721± 2,740.7 vs 204,911±4,683.5 US dollars, p < 0.01). Subgroup analyses revealed consistent patterns among both current and past smokers. CONCLUSION: This study compared the immediate outcomes of smokers and non-smokers after undergoing the TIPS procedure. Interestingly, we observed a smokers' paradox, where smoker patients had better outcomes following TIPS. The underlying causes for this smoker's paradox warrant further in-depth exploration.

Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US. METHODS: The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression. RESULTS: A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P  = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P  < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P  < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P  < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P  = 0.42). CONCLUSION: Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.

Higher risk of in-hospital mortality and hepatic encephalopathy during weekend admission in Transjugular Intrahepatic Portosystemic Shunt procedure.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. The weekend effect refers to a higher risk of adverse outcomes associated with procedures performed on weekends compared to weekdays. The goal of this study is to determine whether a weekend effect is evident in TIPS procedures. MATERIALS AND METHOD: The study identified patients who underwent TIPS procedures in the NIS database from 2015 to 2020. Patients who were admitted on the weekday or weekends were classified into two cohorts. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were noted. Multivariable analysis was used to assess outcomes. RESULTS: Compared to patients admitted on the weekdays, weekend patients had higher in-hospital mortality (12.87 % vs. 7.96 %, aOR = 1.62, 95 CI 1.32-1.00, p < 0.01), hepatic encephalopathy (33.24 % vs. 26.18 %, aOR = 1.41, 95 CI 1.23-1.63, p < 0.01), acute kidney injury (39.03 % vs. 28.36 %, aOR = 1.68, 95 CI 1.46-1.93, p < 0.01), and transfer out (15.91 % vs. 12.76 %, aOR=1.33, 95 CI 1.11-1.60, p < 0.01). It was also found that weekend patients had longer wait from admission to operation (3.83 ± 0.15 days vs 2.82 ± 0.07 days, p < 0.01), longer LOS (11.22 ± 0.33 days vs 8.38 ± 0.15 days, p < 0.01), and higher total hospital charge (219,973 ± 7,352 dollars vs 172,663 ± 3,183 dollars, p < 0.01). CONCLUSION: Our research unveiled a significant relationship between weekend admission and a higher risk of mortality and morbidity post-TIPS procedure. Eliminating delays in treatment associated with the weekend effect may mitigate this gap to deliver consistent and high-quality care to all patients.

Endovascular Repair of Zone 0 Ascending Aortic Pseudoaneurysm: A Case Report.

Although open surgery is standard of care for ascending aortic pathology, endovascular approaches can be viable options. We report the case of a 77-year-old man with a 5.7-cm ascending aorta penetrating ulcer. Given his age and clinical profile, the patient underwent Zone 0 thoracic endovascular aortic repair.

Reintervention Rate After Pigtail Catheter Insertion Compared to Surgical Chest Tubes.

BACKGROUND: Prior studies suggest similar efficacy between large-bore chest tube (CT) placement and small-bore pigtail catheter (PC) placement for the treatment of pleural space processes. This study examined reintervention rates of CT and PC in patients with pneumothorax, hemothorax, and pleural effusion. METHODS: This retrospective study examined patients from September 2015 through December 2020. Patients were identified using ICD codes for pneumothorax, hemothorax, or pleural effusion. Use of a pigtail catheter (≤14Fr) or surgical chest tube (≥20Fr) was noted. The primary outcome was overall reintervention rate within 30 days of tube insertion. Patients who died with a pleural drainage catheter in place, unrelated to complications from chest tube placement, were excluded. RESULTS: There were 1032 total patients in the study: 706 CT patients and 326 PC patients. The PC group was older with more comorbidities and more likely to have effusion as the indication for pleural drainage. Patients with PC were 2.35 times more likely to have the tube replaced or repositioned (P < .0001), 1.77 times more likely to require any reintervention (P = .001) and 2.09 times more likely to remain in the hospital >14 days (P < .0001) compared to patients with CT. CONCLUSION: PCs have a significantly higher reintervention rate compared to CT for the treatment of pneumothorax, hemothorax, and pleural effusion. Although PC are believed to cause less pain and tissue trauma, they do not necessarily drain the pleural space as well as CT. Decisions on which method of draining the chest should be made on a case-by-case basis.

Use of the 8-F angio-seal vascular closure device in large-caliber arteriotomies.

PURPOSE: To evaluate the feasibility and safety of using the 8-F Angio-Seal vascular closure device (VCD) to seal large-caliber (>8-F) access sites during percutaneous endovascular interventions. METHODS: A retrospective review was undertaken of 42 consecutive patients (34 men; mean age 67.8 years, range 36-94) undergoing percutaneous peripheral interventions with sheaths ranging from 9-F to 12-F and subsequent closure using 8-F Angio-Seal VCDs. Single-wall puncture (n = 48) of the common femoral artery was guided by ultrasound in 46 cases and palpation in 2. Forty procedures required therapeutic heparinization during the interventional procedure; protamine was administered in only 5. Per protocol, manual pressure was held for 15 minutes. Clinical and/or imaging follow-up was available in all cases within 3 months after the procedure. RESULTS: Immediate technical success was achieved in all cases, with hemostasis obtained within 5 minutes (no oozing or hematoma). The overall complication rate was 4.1% (2/48); one hematoma requiring surgical repair occurred 10 hours after VCD deployment. An asymptomatic pseudoaneurysm was discovered on follow-up imaging and was treated with ultrasound-guided thrombin injection with complete resolution. CONCLUSION: The use of the 8-F Angio-Seal VCD to close large-caliber arteriotomies ranging from 9-F to 12-F is feasible and safe, with a low complication rate.

Immediate and delayed migration of Onyx embolisation into the renal collecting system.

We present a case of Onyx embolisation of a renal pseudoaneurysm following partial nephrectomy with collecting system involvement with subsequent migration of Onyx into the renal collecting system resulting in renal obstruction. This occurred both immediately after embolisation and again 8 years after embolisation. Both cases required ureteroscopic surgical intervention. In the first instance, the pieces were removed using basket extraction. In the second, laser lithotripsy was used in addition to basket extraction. While there are a few cases of embolisation coils eroding into the renal collecting system, this is the second reported case of Onyx migration and the first where ureteroscopy with laser lithotripsy was used. The patient is doing well and undergoing surveillance ultrasounds to ensure there is no further Onyx migration. This may be a consideration for patients with pseudoaneurysm embolisation especially in the setting of prior collecting system damage.

Comparison of Smartphone Augmented Reality, Smartglasses Augmented Reality, and 3D CBCT-guided Fluoroscopy Navigation for Percutaneous Needle Insertion: A Phantom Study.

PURPOSE: To compare needle placement performance using an augmented reality (AR) navigation platform implemented on smartphone or smartglasses devices to that of CBCT-guided fluoroscopy in a phantom. MATERIALS AND METHODS: An AR application was developed to display a planned percutaneous needle trajectory on the smartphone (iPhone7) and smartglasses (HoloLens1) devices in real time. Two AR-guided needle placement systems and CBCT-guided fluoroscopy with navigation software (XperGuide, Philips) were compared using an anthropomorphic phantom (CIRS, Norfolk, VA). Six interventional radiologists each performed 18 independent needle placements using smartphone (n = 6), smartglasses (n = 6), and XperGuide (n = 6) guidance. Placement error was defined as the distance from the needle tip to the target center. Placement time was recorded. For XperGuide, dose-area product (DAP, mGy*cm2) and fluoroscopy time (sec) were recorded. Statistical comparisons were made using a two-way repeated measures ANOVA. RESULTS: The placement error using the smartphone, smartglasses, or XperGuide was similar (3.98 ± 1.68 mm, 5.18 ± 3.84 mm, 4.13 ± 2.38 mm, respectively, p = 0.11). Compared to CBCT-guided fluoroscopy, the smartphone and smartglasses reduced placement time by 38% (p = 0.02) and 55% (p = 0.001), respectively. The DAP for insertion using XperGuide was 3086 ± 2920 mGy*cm2, and no intra-procedural radiation was required for augmented reality. CONCLUSIONS: Smartphone- and smartglasses-based augmented reality reduced needle placement time and radiation exposure while maintaining placement accuracy compared to a clinically validated needle navigation platform.

Correction to: Thoracic endovascular repair of a rare case of leaking aortic arch intramural hematoma secondary to Giant cell arteritis.

'In the published article (Salaskar et al. 2019) the statement under the subheading 'Consent for publication' is incorrect.

Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer.

OBJECTIVE: To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies. RESULTS: Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days). CONCLUSION: The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

Complications and Management of the Thoracic Endovascular Aortic Repair.

Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be "strongly considered" when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.

Pseudoaneurysm: a rare complication of distal transradial access in the anatomical snuffbox.

BACKGROUND: This report presents a case of distal radial artery pseudoaneurysm following cardiac catheterization and its successful endovascular management. Due to its novelty as a catheterization site, few to no reports exist regarding the complications associated with distal radial access. CASE PRESENTATION: A patient presented to the emergency department with severe wrist and hand swelling 48 h after successful cardiac catheterization via distal radial artery access. Angiography revealed a pseudoaneurysm which was embolized with Onyx™. Post intervention angiogram showed exclusion of the pseudoaneurysm and preservation of the left palmar arch vasculature. CONCLUSION: The case presented herein demonstrates a rare complication of distal radial access at the anatomical snuffbox.