Direct translumbar inferior vena cava ports for long-term central venous access in patients with cancer.

PURPOSE: To evaluate the indications, complications, and long-term results of translumbar port placements to the inferior vena cava for long-term central venous access in a single tertiary center. MATERIALS AND METHODS: This retrospective study included all patients with cancer who underwent translumbar port placement from January 2000 to July 2012; 31 patients (all women) with an average age of 53.1 years ± 11.1 (range, 30-77 y) were included in the study. Of these patients, 26 (81%) had breast cancer, 3 had lung cancer, 1 had ovarian cancer, and 1 had rectal cancer. Indications included central venous occlusion in 9 patients (29%) and bilateral mastectomy and lymph node dissection in 22 patients (71%). RESULTS: All procedures were technically successful. The overall 30-day complication rate was 9.7% (n = 3). Average catheter use was 14.1 months ± 21 (range, 0.75-108 mo). Thirteen (41.9%) ports were removed because they were no longer needed; 4 (12.9%) ports required removal for port malfunction; 12 (38.7%) patients died with their ports still in place; 2 (6.5%) ports remain in use. Three (9.7%) ports required delayed secondary intervention to remain functional. One patient had a systemic infection attributed to the port, resulting in an overall infection rate of 0.08 per 1,000 catheter days. CONCLUSIONS: Translumbar inferior vena cava port placement is a technically feasible and safe alternative method for long-term central venous access.

Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices.

OBJECTIVE: Stomal varices can cause life-threatening gastrointestinal hemorrhage in patients with portal hypertension. Optimal therapy is not well defined. The purpose of this study was to determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of hemorrhagic stomal varices. MATERIALS AND METHODS: All patients who underwent TIPS creation for hemorrhagic stomal varices refractory to medical or endoscopic therapy over a 20-year period (1992-2012) were included. Ten patients (mean age, 63 ± 12 years) were identified. Retrospective chart review was used to document demographic characteristics, procedure details, technical and clinical success, complications, recurrent hemorrhage, and need for repeat interventions. Patients underwent follow-up for an average of 2 years (range, 22 days-9.6 years). RESULTS: All patients had cirrhosis and portal hypertension. Average corrected sinusoidal pressures were 11 ± 2.4 mm Hg (range, 6-15 mm Hg) before TIPS placement and 4.3 ± 1.8 mm Hg (range, 2-8 mm Hg) after TIPS placement. Five patients (50%) underwent adjunctive embolization of stomal varices through the TIPS, which did not affect outcome. Complications included one patient each with a contrast allergy and renal failure. Six patients experienced complete resolution of bleeding without further intervention (60%). Four patients had recurrent stomal hemorrhage. Two of the four needed TIPS revision for occlusion; one underwent oversewing of the ostomy; and in one the hemorrhage resolved with conservative measures after confirmation of TIPS patency. CONCLUSION: TIPS creation, with or without adjunctive variceal embolization, is a safe and effective treatment of refractory hemorrhagic stomal varices. Reintervention for recurrent bleeding may be required and appears effective.

Catheter-directed thrombolysis of deep venous thrombosis.

Venous thrombosis is a major public health problem associated with significant morbidity and mortality and has a substantial impact on the quality of life. Over the years, it has become more apparent that anticoagulation alone in the treatment of deep venous thrombosis (DVT) is insufficient in the prevention of postthrombotic syndrome, which adversely impacts the quality of life of the patient, and it is insufficient in preventing recurrence of DVT. With the advent of innovative catheter designs to deliver thrombolytic therapies in the treatment of DVT, there have been significant advances in the management of DVT. We review the management of DVT with emphasis on catheter-directed interventions.

Catheter-directed thrombolysis of arterial thrombosis.

Thrombotic or embolic arterial occlusive disease can lead to profound ischemia and, without emergent revascularization, is associated with significant morbidity and mortality. Significant advances in the management of arterial occlusive disease range from newer thrombolytic agents to innovative catheter designs to enhance thrombolysis and thrombectomy. Most of these advances have been directed toward the management of acute limb ischemia; therefore, we review the management of limb ischemia with emphasis on endovascular interventions.

Barriers to drug delivery in interventional oncology.

Although much attention has been paid to mechanisms of anticancer drug resistance that focus on intracellular processes that protect tumor cells, it has recently become increasingly evident that the unique features of the tumor microenvironment profoundly impact the efficacy of cancer therapies. The properties of this extracellular milieu, including increased interstitial pressure, decreased pH, hypoxia, and abnormal vascularity, result in limited drug efficacy; this finding is true not only for systemic chemotherapy but also for catheter-based therapies, including chemoembolization and radioembolization. The present review summarizes the barriers to drug delivery imposed by the tumor microenvironment and provides methods to overcome these hurdles.

Embolization of angiographically visible type I and II utero-ovarian anastomoses during uterine artery embolization for fibroid tumors: impact on symptom recurrence and permanent amenorrhea.

PURPOSE: To compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE). MATERIALS AND METHODS: A retrospective, institutional review board-approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05. RESULTS: Twenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1). CONCLUSIONS: There were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.

The impact of transvenous cardiac devices on vascular access patency in hemodialysis patients.

Creating a vascular access in the presence of a cardiovascular implantable electronic device (CIED) in a patient with or approaching end-stage renal disease can be challenging. In this study, we aimed to evaluate the impact of a CIED on the outcomes of vascular access creation in hemodialysis patients and determine their effects on vascular access patency. This is a single-center retrospective review of hemodialysis patients who underwent vascular access creation after CIED placement. Outcomes of vascular access creation and need for endovascular interventions were compared between patients with vascular access created ipsilateral and contralateral to the site of CIED. Comparing patients with arteriovenous (AV) access created ipsilateral to CIED placement (n=19) versus the contralateral side (n=17), the primary failure rate was 78.9% versus 35.3% (p=0.02). For AV accesses that were matured, the median primary patency durations for AV accesses created ipsilateral to the CIED was 11.2 months compared to 7.8 months for AV accesses created contralateral to the CIED (p=1.00). AV accesses created ipsilateral to a CIED have a higher primary failure rate compared with the contralateral arm and should be avoided as much as possible.

Detection of extracellular genomic DNA scaffold in human thrombus: implications for the use of deoxyribonuclease enzymes in thrombolysis.

PURPOSE: Mechanisms underlying transition of a thrombus susceptible to tissue plasminogen activator (TPA) fibrinolysis to one that is resistant is unclear. Demonstration of a new possible thrombus scaffold may open new avenues of research in thrombolysis and may provide mechanistic insight into thrombus remodeling. MATERIALS AND METHODS: Ten human thrombus samples were collected during cases of thrombectomy and open surgical repair of abdominal aortic aneurysms (five samples < 3 d old and five samples > 1 y old). Additionally, an acute murine hindlimb ischemia model was created to evaluate thrombus samples in mice. Human sections were immunostained for the H2A/H2B/DNA complex, myeloperoxidase, fibrinogen, and von Willebrand factor. Mouse sections were immunostained with the H2A antibody. All samples were further evaluated after hematoxylin and eosin and Masson trichrome staining. RESULTS: An extensive network of extracellular histone/DNA complex was demonstrated in the matrix of human ex vivo thrombus. This network is present throughout the highly cellular acute thrombus. However, in chronic thrombi, detection of the histone/DNA network was predominantly in regions of low collagen content and high cell density, which were mostly near the lumen. These regions of high cell density contained neutrophils and monocytes. Similarly, sections from the acute murine hindlimb ischemia model also exhibited extensive immunoreactivity to the histone antibody in the extracellular space within murine thrombi. CONCLUSIONS: Extensive detection of genomic DNA associated with histones in the extracellular matrix of human and mouse thrombi suggest the presence of a new thrombus-associated scaffold.

Pathogenesis of varicose veins.

Despite the high prevalence of varicose veins and the recent surge in research on the condition, the precise mechanisms underlying their development remain uncertain. In the past decade, there has been a shift from initial theories based on purely mechanical factors to hypotheses pointing to complex molecular changes causing histologic alterations in the vessel wall and extracellular matrix. Despite progress in understanding the molecular aspects of venous insufficiency, therapies for symptomatic varicose veins are directed toward anatomic and physical interventions. The present report reviews current evidence identifying the underlying biochemical alterations in the pathogenesis of varicose veins.

Image optimization during endovascular aneurysm repair.

OBJECTIVE: The purposes of this review are to examine various properties of the fluoroscopic imaging equipment used during endovascular aneurysm repair (EVAR) that can be modified to reduce radiation dose while optimizing image acquisition and display, to detail geometric aspects of EVAR intraprocedural imaging used to achieve consistently optimal EVAR results, and to describe acquisition parameters and strategies for minimizing contrast-induced nephropathy. CONCLUSION: The outcome of EVAR is strongly linked to image acquisition and interpretation, including the preprocedural, intraprocedural, and postprocedural display of relevant vascular anatomy, positions and configurations of the endograft components, and documentation of successful aneurysm exclusion. Operator familiarity with the imaging equipment, radiation and contrast dose reduction strategies, and image optimization techniques strongly influence the outcome of EVAR.

Segmental arterial mediolysis: clinical and imaging features at presentation and during follow-up.

PURPOSE: To review clinical and imaging features at presentation and during follow-up of patients with a suspected diagnosis of segmental arterial mediolysis (SAM). MATERIALS AND METHODS: All cases of SAM diagnosed at a single institution from 2000 to 2010 were included. Diagnosis was based on characteristic radiologic features in the absence of other plausible diagnoses. Medical records were reviewed for demographics, presenting symptoms, and laboratory and imaging findings at presentation and during follow-up. RESULTS: Fourteen patients (nine men; mean age, 53 y ± 15) were diagnosed with SAM. Initial presentation included abdominal or flank pain (n = 8) and chest pain, headache, stroke, or suprapubic fullness (n = 1 each). Two patients were asymptomatic. Inflammatory markers were negative in all cases. Imaging at presentation revealed involvement of celiac (n = 7), common hepatic (n = 3), splenic (n = 2), superior mesenteric (n = 5), renal (n = 5), and iliac (n = 2) arteries and the abdominal aorta (n = 1). Imaging demonstrated arterial dissections (n = 10), fusiform aneurysms (n = 6), arterial wall thickening (n = 2), and artery occlusion (n = 1). Clinical follow-up was available in 13 patients (median, 25 mo). Symptoms improved (n = 4), resolved (n = 3), or remained stable (n = 2), and four patients experienced new symptoms. Follow-up imaging, available in 10 patients at a median of 33 months, demonstrated new dissections, aneurysms, or arterial occlusions in five patients, including carotid artery dissection in three. Imaging findings remained stable (n = 3), improved (n = 1), or resolved (n = 1). CONCLUSIONS: SAM affects middle-aged and elderly patients. Visceral artery dissections and aneurysms are common. The disease progresses in nearly half the patients. Serial follow-up with computed tomographic angiography and/or magnetic resonance angiography may be necessary to monitor disease progression.

Localization of latent transforming growth factor-ß binding protein-1 in human coronary atherosclerotic plaques.

BACKGROUND: Transforming growth factor-ß (TGFß) and its receptors have been detected by immunohistochemistry in the normal vessel wall and in atherosclerotic lesions of human coronary arteries. However, TGFß is normally secreted as an inactive complex associated with a latent TGFß-binding protein (LTBP). Therefore, detection of TGFß antigen only in the arterial wall does not imply the activated form of the growth factor. METHODS AND RESULTS: In situ hybridization and immunohistochemistry demonstrated LTBP1 mRNA and protein expression throughout the media and intima of early coronary artery lesions, with the highest levels of protein at the luminal surface. In advanced lesions, LTBP1 mRNA and protein were detected mainly in regions of high cell density, such as the fibrous cap. CONCLUSIONS: Assays of the TGFß signalling pathway will be required to determine the activity associated with TGFß antigen in the vessel wall.

Expression of mRNA isoforms of latent transforming growth factor-ß binding protein-1 in coronary atherosclerosis and human tissues.

Latent transforming growth factor-ß binding protein-1 (LTBP1) has been implicated in the control of secretion, localization, and activation of TGFß (transforming growth factor-ß). We developed a quantitative reverse-transcriptase polymerase chain reaction (Q-RT-PCR) assay using an RNA internal standard to examine the expression of three alternatively spliced isoforms of LTBP1 (LTBP1Δ41, LTBP1Δ53, and LTBP1Δ55) in a variety of human tissues. The assays were also used to determine the expression of LTBP1L and LTBP1S isoforms and total LTBP1. The Q-RT-PCR assays were highly reproducible and showed that in most tissues LTBP1Δ55 and LTBP1L were minor components of LTBP1. The proportion of LTBP1Δ41 ranged from 2% of total LTBP1 mRNA in early coronary atherosclerotic lesions to 54% in advanced lesions.

Percutaneous transcatheter arterial embolization of inferior pancreatico-duodenal artery aneurysms associated with celiac artery stenosis or occlusion.

OBJECTIVES: To report our experience with percutaneous TAE of true IPDA aneurysms. BACKGROUND: Most IPDA aneurysms are ruptured at presentation causing a high mortality risk. Minimally invasive treatment approaches may improve overall outcomes in such patients. METHODS: Between 1996 and 2007, seven patients (5 Males; mean age 55 y) with symptomatic IPDA aneurysms and severe degree (>75%) celiac artery stenosis were treated with percutaneous TAE. The medical and imaging records were reviewed for demographics, clinical presentation, treatment, complications and follow-up. Patients presented with epigastric pain (7/7), hemodynamic shock (2/7) and rectal bleeding (2/7). Selective catheter angiography was performed in all patients with the intent to embolize the aneurysms. RESULTS: A total of nine aneurysms were seen in seven patients. Two patients had two aneurysms each. The aneurysms ranged in size from 0.5 to 4.0 cm (mean 1.9 cm). Trans-catheter coil embolization was successful in 8/9 (89%) aneurysms in 6 patients. Following unsuccessful TAE of one aneurysm in one of the patient, the aneurysm was treated successfully with direct CT-guided percutaneous transabdominal injection of N-butyl-2-cyanoacrylate. There were no complications on follow up. Angioplasty and stenting of the celiac artery were performed in one patient for complete occlusion. None of the patients developed clinical or imaging evidence of visceral ischemia following embolization. None had recurrent symptoms during clinical follow-up (median 3 years, range 0.5-13.5 years). Follow-up CT (Median 6.6 months, range 4 days-11.5 years) in all patients showed no recurrence of the aneurysm. CONCLUSION: IPDA aneurysms associated with celiac axis stenosis can be successfully treated with percutaneous embolization with minimal recurrence.

Angiogenesis and current antiangiogenic strategies for the treatment of cancer.

Angiogenesis is a complex process critical for embryonic development and for survival. It is also a critical player in many pathologic processes, most notably in neoplasia. The cell signaling pathways involved in angiogenesis have become key targets for drug design, with more than 2,500 clinical trials currently under way. This review summarizes the essential features of angiogenesis and discusses therapeutic strategies that have been applied to specific diseases known to be associated with perturbation of normal angiogenic control.

Safety and effectiveness of the celect inferior vena cava filter: preliminary results.

PURPOSE: To evaluate the safety and effectiveness of the Celect inferior vena cava (IVC) filter during implantation, retrieval, and short-term follow-up. MATERIALS AND METHODS: The clinical data of 73 patients (46 men; age range, 22-89 years) who had a Celect IVC filter implanted between August 2007 and June 2008 were reviewed. Twenty-one (28.8%) presented with pulmonary embolism (PE), 15 (20.54%) with deep vein thrombosis (DVT), 12 (16.4%) with both, and the rest (34.26%) with other symptoms. Indications for filter placement were contraindication to anticoagulation (n = 38; 52%), prophylaxis/added protection (n = 22; 30%), failure of anticoagulation (n = 11; 15%), and complications of anticoagulation (n = 2; 3%). Filters were placed in the infrarenal (n = 71) or suprarenal (n = 2) IVC. Follow-up data were reviewed for filter-related complications and recurrent PE. RESULTS: All filters were successfully deployed. Immediately after fluoroscopy-guided filter deployment in 61 patients, four filters (6.5%) showed significant tilt. During follow-up (mean, 68 days +/- 73), three patients developed symptoms of PE after filter placement; however, computed tomographic (CT) pulmonary angiography demonstrated new PE in only two. Imaging follow-up with radiography (n = 32), CT (n = 11), and/or angiography (n = 4) in 47 patients (at a mean of 62 days +/- 75) showed no filter migration. Follow-up abdominal CT (at a mean of 69 days +/- 58) was available in 18 patients and demonstrated filter-related problems in seven (39%). These included penetration of filter legs in four and fracture/migration of filter components in one. Fourteen filters were successfully retrieved after a median period of 84 days. CONCLUSIONS: The Celect IVC filter can be safely placed but is related to a high incidence of caval filter leg penetration. Symptomatic PE after filter placement confirmed by CT occurred in 2.8% of patients.

TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts.

PURPOSE: To compare shunt patency and clinical outcomes in two groups of patients who received a transjugular intrahepatic portosystemic shunt (TIPS): one group with bare stents and one with expanded polytetrafluoroethylene stent-grafts. MATERIALS AND METHODS: TIPS were created with bare stents (n = 41) or stent-grafts (n = 40). Overall TIPS patency rates were compared between these two groups, as were clinical outcomes in patients with variceal bleeding and those with ascites. RESULTS: In the bare stent group, primary shunt patency rates were 63%, 48%, and 24% at 3, 6, and 12 months, respectively. Secondary patency rates were 75% and 62% at 3 and 6 months, respectively. In the stent-graft group, primary patency rates were 94%, 67%, and 38% at 3, 6, and 12 months, respectively. Secondary patency rates were 100% and 92% at 3 and 6 months, respectively. All stent patency rates were higher in the stent-graft group, but only the difference in the 3-month primary patency rate (63% vs 94%) reached significance (P = .03). In patients with variceal bleeding as well as those with ascites, early and overall clinical success rates were higher in the stent-graft group, but only the 3-month and 12-month differences were statistically significant. CONCLUSIONS: TIPS created with stent-grafts had better 3-month primary patency rates and better 3-month and 12-month clinical success rates compared with those created with bare stents.

Wound dehiscence or failure to heal following venous access port placement in patients receiving bevacizumab therapy.

PURPOSE: To determine the incidence of wound dehiscence or failure to heal after port placement in patients receiving bevacizumab therapy. A hypothesis was tested that the mean interval between bevacizumab administration and port placement was shorter in patients who had dehiscence than in those who did not. MATERIALS AND METHODS: Medical records of all patients who had venous access ports placed from July 2006 through December 2007 were retrospectively reviewed. A total of 195 ports were placed in 189 patients (106 men) who were treated with bevacizumab within 120 days of port placement. The incidence of wound dehiscence and the significance of dose timing relative to port placement in these patients were calculated. RESULTS: Six of 195 ports (3.1%) were associated with wound dehiscence requiring port removal. The mean interval between bevacizumab dosing and port placement in patients without dehiscence (n = 189) was 16.9 days. The mean interval in patients with dehiscence (n = 6) was 10.8 days. A two-tailed Wilcoxon test was performed, which yielded a P value of .0150. A statistically significant difference in the mean interval between bevacizumab dosing and port placement exists between patients with dehiscence and those without. CONCLUSIONS: Wound dehiscence after port placement was related to timing of bevacizumab therapy. Patients receiving bevacizumab within 10 days of port placement had a higher incidence of wound dehiscence.

Arterial interventions for renovascular hypertension.

Renovascular hypertension is a major cause of secondary hypertension. It affects relatively younger patients. The unifying pathology is renal artery stenosis. The most common cause is atherosclerosis accounting for about 90% of cases with fibromuscular dysplasia being the second most common cause. Both of these are amenable to percutaneous interventional therapy. With the advent of new medical therapies, the control of blood pressure has improved significantly. In well-selected patients, renal arterial intervention has a good outcome. The intervention includes renal angioplasty and stenting. In this article, the authors review the role of percutaneous intervention and the techniques involved with renal angioplasty and stenting for the treatment of renovascular hypertension.

Venous thromboembolism: indirect CT venography during CT pulmonary angiography--should the pelvis be imaged?

PURPOSE: To retrospectively determine the relative contribution of pelvic and lower-extremity indirect computed tomographic (CT) venography to the diagnosis of venous thromboembolism (VTE) in patients undergoing CT for pulmonary embolism (PE). MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board, and informed consent was waived. The records of 2074 consecutive patients (890 men, 1184 women; mean age, 59 years; age range, 15-97 years) suspected of having PE who underwent combined CT pulmonary angiography and CT venography between May 2005 and March 2006 were reviewed. CT venograms from the iliac crests to the popliteal fossae were reviewed for presence and location of thrombi. Radiology reports were reviewed for CT pulmonary angiographic results. Thrombus detection rates with and without pelvic CT venography were compared by using the chi(2) test. Separate effective radiation doses for CT venography of pelvis and lower extremities were calculated. RESULTS: On CT images of the 2074 patients, VTE was detected in 283 (13.6%) patients; PE, in 237 (11.4%); and deep vein thrombosis (DVT), in 121 (5.8%). Forty-six patients had DVT but no PE. Addition of CT venography to CT pulmonary angiography increased the detection of VTE by 19.4% (46 of 237). Isolated pelvic DVT was seen in two (0.1%) patients. There was no difference in the detection of VTE whether or not the pelvis was included (P = .92). Effective radiation dose for CT venography was 5.2 mSv +/- 0.5 (standard deviation) for the pelvis and 0.6 mSv +/- 0.2 for the lower extremities. CONCLUSION: CT venography of the pelvis during CT pulmonary angiography does not significantly improve the detection of VTE. CT venography may be limited to the lower extremities, thus reducing radiation dose.