Safety, Efficacy and Mid-Term Outcome for Transarterial Embolization (TAE) of Renal Angiomyolipoma (AML) Using Ethylene Vinyl Alcohol Copolymer Liquid Embolic Agent (EVOH).

Transarterial embolization (TAE) of renal angiomyolipoma (AML) is effective in treating and preventing hemorrhage. We report our experience using EVOH with a single-center retrospective study of all AML embolized with EVOH between June 2013 and March 2022 at the Montpellier University Hospital. A total of 29 embolizations were carried out in 24 consecutive patients (mean age: 53.86 years; 21 women and 3 men) with 25 AMLs for severe bleeding, symptomatic AML, tumor size > 4 cm, or presence of aneurysm(s) > 5 mm. Data collected included imaging and clinical outcomes, tuberous sclerosis complex status, change in AML volume, rebleeding, renal function, volume and concentration of EVOH used, and complications. Out of 29 embolizations performed for 25 AMLs, four were performed in an emergency. Technical success was achieved for 24/25 AMLs. Mean AML volume reduction was 53.59% after a mean follow-up time of 446 days using MRI or CT scan. Aneurysms on angiogram and the symptomatological nature of AML, as well as secondary TAE and multiple arterial pedicles, were statistically associated (p < 0.05). Two patients (8%) underwent nephrectomy after TAE. Four patients had a second embolization. Minor and major complication rates were 12% and 8%, respectively. Neither rebleeding nor renal function impairment was noticed. TAE of AML using EVOH is, thus, highly effective and safe.

CYP2C19 genotype-directed P2Y12 inhibitor antiplatelet therapy normalizes risk for major adverse cardiovascular events after percutaneous coronary intervention.

OBJECTIVE: To study the use of CYP2C19 genotyping to guide P2Y12 inhibitor selection to maximize efficacy, and attenuate risk in appropriate patients who underwent PCI for CAD. METHODS: We performed a retrospective analysis of 868 patients with CAD who received CYP2C19 genotyping after PCI and changed P2Y12 inhibitor based on the results. Patients were divided into two groups based on clopidogrel metabolizer status. Group I: Intermediate (IM) and poor metabolizers (PM). Group II: Ultra-rapid (UM), rapid (RM) and normal metabolizers (NM). Each group was then categorized to one of two treatment arms guided by CYP2C19 genotype. Category 1: IM/PM started on clopidogrel, switched to ticagrelor or prasugrel; 2:IM/PM started on ticagrelor/prasugrel, continued these medications; 3: UM/RM/NM started on ticagrelor/prasugrel, switched to clopidogrel; 4: UM/RM/NM started on clopidogrel, continued clopidogrel. Death due to cardiac causes, bleeding events, non-fatal MI, target vessel revascularization (TVR), and MACE in all four categories were considered at 1, 6 and 12 months. RESULTS: We did not observe significant difference between phenotypes for MACE at 1 (p = 0.274), 6 (p = 0.387), and 12 months (p = 0.083). Death due to cardiac causes, MI, and bleeding events were not significant at 1, 6, and 12 months. There was no significant difference in TVR at 6 (p = 0.491), and 12 months (p = 0.423) except at 1 month (p = 0.012). CONCLUSION: CYP2C19 genotype-based intervention can be implemented effectively and reliably to guide selection of P2Y12 inhibitor to optimize patient quality and safety when appropriate in post PCI patients.

Combination of mural thrombus and age improves the identification of all-cause mortality following branched endovascular repair.

BACKGROUND: In-hospital and 30-day mortality rates of endovascular repair of thoracoabdominal aortic aneurysms shows a significant improvement over open surgery, although we are not seeing a significant difference at 1 year. We assess the hypothesis that a greater mural thrombus ratio within the aorta could function as an indicator of postoperative mortality. METHODS: The mural thrombus ratio and preoperative comorbidities of 100 consecutive patients from a single center undergoing endo-debranching between 2012 and 2019 were evaluated. Logistic regression, survival analysis, and decision tree methods were used to examine each variable's association with death at 1 year. RESULTS: At the time of analysis, 73 subjects had 1-year outcomes and adequate imaging to assess the parameters. At 1 year, the overall survival for all subjects was 71.2% (21 died, 52 survived). For patients with a favorable mural thrombus ratio (n = 36), the overall 1-year survival was 86.1% (5 died, 31 survived). The subjects with an unfavorable mural thrombus ratio (n = 37), had an overall 1 year survival of 56.8% (16 died, and 21 survived). The only preoperative mortality factor that was statistically significant between the subjects with an unfavorable mural thrombus ratio was age of the patient. The survival for subjects 75 years and older with an unfavorable mural thrombus ratio was 90% (one died, nine survived) vs only 44.4% survival for subjects less than 75 years with an unfavorable mural thrombus ratio (15 died, 12 survived). CONCLUSIONS: This study examined whether a patient's mural thrombus ratio may be an indicator of 1-year survival. These findings suggest that the combination of a patient's aortic mural thrombus ratio and age can function as a preoperative indicator of their underlying cardiac reserve. Identifying patients with low cardiac reserve and fitness to handle the increased cardiac demands owing to the physiologic response to extensive aortic stent grafting before undergoing aortic repair may allow for modification of preoperative patient counseling and postoperative care guidelines to better treat this patient population.

Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial.

Importance: Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective: To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants: In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions: Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures: The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results: A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance: Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration: ClinicalTrials.gov Identifier: NCT02021396.

Improving Hepatitis C Screening in the Baby Boomer Birth Cohort in Rural South Dakota: A Medical Student HQIP Project.

Hepatitis C is a bloodborne viral infection that often leads to liver disease. Individuals born between 1945-1965 (baby boomer birth cohort) are five times more likely to have hepatitis C than other age groups due to blood transfusions and medical procedures performed before the discovery of the virus. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend a one-time screening for individuals in the baby boomer birth cohort. Even with these recommendations, national screening rates remain low at around 13 percent, suggesting a need for improvement. In this study we reviewed the electronic medical record (EMR) data for a rural primary care clinic and determined the percentage of individuals screened in the baby boomer birth cohort in a one-year time period. Interventions (provider/nursing education, community education) were implemented over a four-month period. We compared the EMR data from before, during, and after interventions. Pearson's chi-squared analysis was used to evaluate differences in proportions. The results showed no statistical significance between the three timeframes measured (p-value 0.6164). We can conclude that the interventions used in this study were not adequate in producing a statistically significant change in the percentage of baby boomers screened at our local clinic. These results could be due to interventions not being implemented simultaneously, lack of follow-up with staff regarding interventions, and a short time frame for measuring post-intervention changes. Future projects may benefit from modifying interventions and their implementation.

Systemic air embolism depicted on systematic whole thoracic CT acquisition after percutaneous lung biopsy: Incidence and risk factors.

OBJECTIVES: To evaluate the incidence and risk factors of systemic air embolism (SAE) depicted on systematic whole thoracic CT performed after percutaneous lung biopsy. METHODS: A total of 559 CT-guided lung biopsies performed between April 2014 and May 2016 were retrospectively evaluated. SAE was defined by the presence of air in the aorta or left cardiac cavities seen on whole thorax CT images acquired after needle withdrawal. Analyzed data focused on patient (age, sex, spirometry data, emphysema on CT, therapeutics received), target lesion (location, depth, size and feature) and procedure (patient position, length of intrapulmonary needle path, number of pleural passes and of biopsy samples, operator's experience). A regression logistic model was used to identify risk factors of SAE. RESULTS: SAE was observed after 27 of the 559 lung biopsies, corresponding to a radiological incidence of 4.8% (95%CI: 3.3-7.0). Clinical incidence was 0.17% (n = 1). For 21/27 patients (78%), a targeted acquisition in the nodule area would not have included the cardiac cavities meaning SAE would have been missed. On multivariate analysis, the independent risk factors were needle path length through ventilated lung (OR: 1.13, 95%CI: 1.02-1.25, p = 0.024), number of samples (OR: 1.48, 95%CI: 1.01-2.17, p = 0.046) and prone position (OR: 3.12, 95%CI: 1.11-8.31, p = 0.031) or right-sided lateral decubitus (OR: 6.15, 95%CI: 1.66-22.85, p = 0.005). CONCLUSIONS: Asymptomatic systemic air embolism can be depicted in almost 5% of post biopsy CT examinations, when they are not limited to the targeted nodule area but include the entire thorax.

Diaphragmatic hernia after lung percutaneous radiofrequency ablation: incidence and risk factors.

PURPOSE: To evaluate diaphragmatic hernias (DH) after percutaneous radiofrequency ablation (PRFA) for basal lung nodules and to detect risk factors. MATERIALS AND METHODS: Between January 2009 and December 2012, the presence of DH was retrospectively recorded in all of the patients who underwent PRFA with multitine expandable electrodes for ablation of nodules in the lower lobe. All nodules were classified into three groups according to the location of the tines after deployment relative to the diaphragm: In group 1, the tines were at a distance of >1 cm from the diaphragm; in group 2, at least one tine was in contact with the diaphragm without perforation; and in group 3, at least one tine was perforating the diaphragm. RESULTS: We recorded 4 cases of DH (3 on the left side, 1 on the right side) in 156 patients (2.3% of procedures). The delay of onset was 7.8 months. DH occurred in groups 2 (n = 1) and 3 (n = 3). Only the 3 cases that occurred on the left side were symptomatic (2 intussusceptions and 1 gastroesophageal reflux) and were surgically repaired. The electrode was positioned in the center of the diaphragm in all cases. CONCLUSION: The central position of the electrode and the contact of at least one tine with the diaphragm after deployment seem to be a risk factor to develop DH.

Type A acute aortic dissection: why does the false channel remain patent after surgery?

PURPOSE: To understand why the false channel (FC) remains patent after surgery of type A acute aortic dissection (TAAAD). MATERIALS AND METHODS: Postoperative contrast-enhanced computed tomography scans of 129 patients operated for TAAAD were analyzed, and a color-Doppler ultrasound examination (CDUS) of the supra-aortic vessels (SAVs) was performed in 12 patients. RESULTS: The FC remained patent in 107 (82.9%) patients. The entry site was situated near the distal anastomosis in 43 (40.2%) patients and far from it in 44 (41.1%) patients. In 10 (9.35%) patients, an entry site was observed only in the SAVs. In 10 (9.35%) patients, no entry site was seen. Of the 12 patients explored with CDUS, a retrograde filling of the FC was observed in 11 patients. CONCLUSION: The frequent postoperative circulating aortic FC can be explained by the persistence of the primary entry tear, the presence of iatrogenic tears, and/or a retrograde filling in the SAVs.

Endovascular treatment of malignant superior vena cava syndrome: results and predictive factors of clinical efficacy.

PURPOSE: To demonstrate the effectiveness of endovascular treatment (EVT) with self-expandable bare stents for malignant superior vena cava syndrome (SVCS) and to analyze predictive factors of EVT efficacy. METHODS: Retrospective review of the 164 patients with malignant SVCS treated with EVT in our hospital from August 1992 to December 2007 and followed until February 2009. Endovascular treatment includes angioplasty before and after stent placement. We used self-expandable bare stents. We studied results of this treatment and looked for predictive factors of clinical efficacy, recurrence, and complications by statistical analysis. RESULTS: Endovascular treatment was clinically successful in 95% of cases, with an acceptable rate of early mortality (2.4%). Thrombosis of the superior vena cava was the only independent factor for EVT failure. The use of stents over 16 mm in diameter was a predictive factor for complications (P = 0.008). Twenty-one complications (12.8%) occurred during the follow-up period. Relapse occurred in 36 patients (21.9%), with effective restenting in 75% of cases. Recurrence of SVCS was significantly increased in cases of occlusion (P = 0.01), initial associated thrombosis (P = 0.006), or use of steel stents (P = 0.004). Long-term anticoagulant therapy did not influence the risk of recurrence or complications. CONCLUSION: In malignancy, EVT with self-expandable bare stents is an effective SVCS therapy. These results prompt us to propose treatment with stents earlier in the clinical course of patients with SVCS and to avoid dilatation greater than 16 mm.

Transarterial ethylene vinyl alcohol copolymer visualization and penetration after embolization of life-threatening hemoptysis: technical and clinical outcomes.

OBJECTIVES: This study was designed to evaluate the feasibility of using ethylene vinyl alcohol copolymer (EVAC) for bronchial artery embolization (BAE) in patients with life-threatening hemoptysis and to compare the visualization and transarterial penetration of EVAC under fluoroscopy and computed tomography (CT). METHODS: Fifteen patients (mean age, 62.9 (range, 24-82) years) who were referred for life-threatening hemoptysis (27 month period) underwent BAE using EVAC. All patients had thoracic CT examination before and after BAE. Technical and clinical results were evaluated. Visibility and extent of cast penetration (graded 1-4) on fluoroscopy and postprocedure CT were assessed and compared. RESULTS: BAE was feasible in all but one artery (due to spasm; n=27; 96.4%). No procedure-related complications or deaths were detected. Two patients had recurrent bleeding in the following day (13.3%). Immediate clinical success was achieved in 14 cases (93.3%) after reembolization of pulmonary artery pseudoaneurysm in one patient (mean follow-up, 43.5 (range, 14-148) days). Visibility of the cast was possible in 73.3% of patients (n=11) under fluoroscopy (mean cast penetration 1.66) and in all patients under CT (mean cast penetration 2.06). The postinjection fluoroscopic visibility in 6 of 15 (40%) patients was inferior to CT (P<0.02). CONCLUSIONS: BAE with EVAC seems to be feasible and safe with immediate control of hemoptysis in most patients. The postinjection fluoroscopic visibility of EVAC under fluoroscopy was inferior to CT.

Endovascular stent-graft management of aortic intramural hematomas.

PURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.