Catheter Directed Thrombectomy and Other Deep Venous Interventions in Cancer Patients.

Treating cancer patients with deep venous thrombosis/venous thromboembolism (DVT/VTE) can be challenging as patients are frequently unable to receive the standard therapy of anticoagulation due to the increased risk of bleeding complications seen in this population. Similarly, the hesitation of interventionalists to use thrombolytic agents due to bleeding risks limits percutaneous intervention options as well. Further, outcome data and guidelines do not exist for oncologic patients and often treatment is tailored to patient-specific factors after multidisciplinary discussion. This article reviews specific factors to consider when planning percutaneous treatment of cancer patients with DVT/VTE, focusing on the iliocaval system.

Predictors for Nonhome Patient Discharge following Lower Extremity Arterial Interventions.

PURPOSE: To identify the variables associated with patient discharge disposition to optimize postprocedural care and discharge planning following lower extremity arterial interventions for peripheral artery disease (PAD). MATERIALS AND METHODS: The 2014-2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using current procedural terminology codes for endovascular infrainguinal interventions for PAD. The main outcome variable of interest was nonhome discharge. Covariates included patient sociodemographic variables, age quartile (upper quartile, ≥77 years), comorbidities (diabetes, renal disease, bleeding disorder, congestive heart failure [CHF], and chronic obstructive pulmonary disease), presence of an open wound before a procedure, type of procedure, operative time, symptom severity, American Society of Anesthesiologists class, and baseline functional status. Univariate analysis and multivariate logistic regression were performed on Stata/SE 15.1. RESULTS: A total of 3,190 patients met the inclusion criteria, of whom 664 (20.8%) had nonhome discharge. Multivariate regression revealed that age (odds ratio [OR], 1.9 for the upper age quartile [>77 years]; 95% confidence interval [CI], 1.46-2.50), operative time (OR, 1.2 per increase in quartile; 95% CI, 1.09-1.30), preoperative wound (OR, 1.5; 95% CI, 1.24-1.90), renal failure (OR, 1.7; 95% CI, 1.30-2.14), CHF (OR, 2.2; 95% CI, 1.51-3.24), symptom severity (OR, 1.7; 95% CI, 1.46-1.98), and independent functional status (OR, 0.74; 95% CI, 0.59-0.92; P = .007) were associated with nonhome discharge. All P values were ≤.001 unless otherwise stated. CONCLUSIONS: Prolonged procedural time, the presence of preprocedural wound and patient comorbidities, symptomatology, and baseline functional status may be used to identify patients who will require a nonhome discharge and early discharge planning.

Endobronchial forceps-assisted complex retrieval of inferior vena cava filters.

OBJECTIVE: The objective of this study was to assess the safety, feasibility, and effectiveness of endobronchial forceps-assisted retrieval of inferior vena cava (IVC) filters when standard retrieval techniques fail. METHODS: An Institutional Review Board-approved single-center retrospective review during a 6-year period identified 60 consecutive patients (23 men and 37 women; mean age, 49.3 years; range, 19-77 years) in whom rigid endobronchial forceps were required for IVC filter retrieval after standard techniques failed. Factors affecting retrieval success, including an embedded or tilted filter, overall dwell time, filter fracture, and caval penetration, were recorded, as were success rates, procedural details, and complications. RESULTS: Mean dwell time between filter placement and removal was 565 days (range, 15-7366 days). Various IVC filters were encountered: 33 Option (Argon Medical, Frisco, Tex), 8 Celect (Cook Medical, Bloomington, Ind), 9 Günther Tulip (Cook Medical), 4 G2 and 3 Eclipse (Bard, Murray Hill, NJ), 2 OptEase (Cordis, Bridgewater, NJ), and 1 Simon Nitinol (Bard). Imaging before retrieval showed grade 1 (3/60), grade 2 (44/60), and grade 3 (13/60) filter interaction with IVC wall. The degree of secondary tilt as assessed on images acquired before attempted retrieval was <10 degrees (n = 22; 36.7%), 10 to 20 degrees (n = 26; 43.3%), and >20 degrees (n = 12; 20%), with an average tilt of 13.8 degrees (range, 0-48.9 degrees). Of the 60 filters, 58 were retrieved successfully (96.7%). Two of these required a second attempt (one because of migration into the right atrium and the other because of extreme discomfort of the patient requiring subsequent general anesthesia). Five of 60 procedures were forceps-assisted loop snare retrievals in which the forceps were used to dissect the embedded hook free from surrounding hyperplastic caval venous endothelium. Mean fluoroscopy retrieval time was 33.2 minutes (range, 10-76.9 minutes). Intraprocedural inconsequential filter fracture was observed in 10 patients. There were four complications: one retroperitoneal hemorrhage, one IVC dissection flap, and two filter fractures with subsequent migration of filter components to the right side of the heart and to the right pulmonary artery. The first two complications required hospital admission and conservative management; in the last two, the fractured and migrated filter limbs were retrieved successfully using a snare device. CONCLUSIONS: Rigid endobronchial forceps can be safely and reliably used to remove embedded, fractured, or tilted retrievable IVC filters from patients in whom standard retrieval techniques are unsuccessful. There is a high success rate and minimal complications. We propose that the degree of filter tilt, caval penetration, and filter fracture are predictive of the need for the use of forceps as a first-line retrieval technique.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management.

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Bilateral inferior petrosal sinus sampling: experience in 327 patients.

OBJECTIVE: To describe findings and outcomes of 331 bilateral inferior petrosal sinus sampling (BIPSS) procedures performed in 327 patients evaluated for Cushing disease (CD). MATERIALS AND METHODS: The radiology department's electronic database was searched to identify all BIPSS procedures (1990-2013). Electronic medical records were used to identify demographics, laboratory, procedural, surgical and pathologic findings. RESULTS: A total of 331 BIPSS procedures were performed in 327 patients (254 F, 73 M), mean age 41 (range 7-81) years. The overall technical success rate was 88% for bilateral cannulation, though nearly two-thirds of the technical failures had unilateral sampling that diagnosed CD. Of the 331 BIPSS procedures, 40 were performed without, and 291 with stimulation by Acthrel or desmopressin. Sensitivity was 89-94% for unstimulated BIPSS, 96% for stimulated BIPSS, and 77% for MRI. BIPSS lateralization was accurate in about half of patients, compared with 75% accuracy for MRI. Mean inferior petrosal sinus (IPS):peripheral adrenocorticotropic hormone ratio was 17.3 (SE 1.8) at baseline, and 99.2 (SE 14.8) at 3 min, with decreasing values over time. All patients with follow-up after surgical resection for centralizing BIPSS were reported to be cured, with cortisol levels significantly decreased from 19 to 4 µg/dL (p<0.0001). Complications from BIPSS were rare, including groin hematoma (2.5%), but no thromboembolic complications were seen. CONCLUSIONS: BIPSS remains the 'gold standard' for diagnosing CD. Stimulation with Acthrel or desmopressin is key to increasing specificity. When only one IPS can be successfully cannulated, results may still be diagnostic. BIPSS findings cannot be used to accurately lateralize lesions within the pituitary.

Sporadic versus Tuberous Sclerosis Complex-Associated Angiomyolipomas: Predictors for Long-Term Outcomes following Transcatheter Embolization.

PURPOSE: To evaluate risk factors for long-term outcomes following embolization of sporadic versus tuberous sclerosis complex (TSC)-associated angiomyolipomas (AMLs). MATERIALS AND METHODS: A retrospective review of consecutive transcatheter embolizations of renal AMLs between 2002 and 2014 was performed. Tumor volumetrics including density analysis were obtained. Treatment outcomes were assessed at 1 year after embolization using Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 and volumetric RECIST criteria. A total of 56 patients, 70% (39/56) of whom had TSC, underwent embolization of 72 renal AMLs. Embolization was most commonly performed (70/72, 97%) using microspheres (300-500 µm or 500-700 µm Embosphere). RESULTS: Between the sporadic and TSC-associated populations, there was no difference in follow-up time (648 d vs 583 d, P = .78), initial tumor diameter (6.68 cm vs 5.71 cm, P = .09), or percent tumoral fat content (39.5% vs 8.6%, P = .35). Progressive disease was noted in 9 TSC-associated AMLs by volume and 3 TSC-associated AMLs by diameter but in no sporadic AMLs. Growth suppression curves were remarkable for rebound growth in TSC patients, particularly in TSC patients younger than 18 years. Patient age (P = .007) and tumor volume (P = .03) were found to correlate with tumor regrowth within the TSC population. No difference was found in median change in total volume after embolization based on fat content (-57.9% vs -54.2%, P = .68). CONCLUSIONS: TSC, patient age, and tumoral volume before embolization are risk factors for AML growth following embolization. Intratumoral fat content was not found to predict response to embolization.

Angiographic and volumetric effects of mammalian target of rapamycin inhibitors on angiomyolipomas in tuberous sclerosis.

AIM: To investigate the angiographic and volumetric effects of mammalian target of rapamycin (mTOR) inhibitors on angiomyolipomas (AMLs) in a case series of patients with tuberous sclerosis complex. METHODS: All patients who underwent catheter angiography prior to and following mTOR inhibitor therapy (n = 3) were evaluated. All cross-sectional imaging studies were analyzed with three-dimensional volumetrics, and tumor volume curves for all three tissue compartments (soft tissue, vascular, and fat) were generated. Segmentation analysis tools were used to automatically create a region of interest (ROI) circumscribing the AML. On magnetic resonance images, the "fat only" map calculated from the in- and opposed-phase gradient recalled echo sequences was used to quantify fat volume within tumors. Tumor vascularity was measured by applying a thresholding tool within the ROI on post-contrast subtraction images. On computed tomography images, volume histogram analysis of Hounsfield unit was performed to quantify tumor tissue composition. The angiography procedures were also reviewed, and tumor vascularity based on pre-embolization angiography was characterized in a semi-quantitative manner. RESULTS: Patient 1 presented at the age of 15 with a 6.8 cm right lower pole AML and a 4.0 cm right upper pole AML. Embolization was performed of both tumors, and after a few years of size control, the tumors began to grow, and the patient was initiated on mTOR inhibitor therapy. There was an immediate reduction in the size of both lesions. The patient then underwent repeat embolization and discontinuation of mTOR inhibition, after which point there was a substantial regrowth in both tumors across all tissue compartments. Patient 2 presented at the age of 18 with a right renal AML. Following a brief period of tumor reduction after embolization, she was initiated on mTOR inhibitor therapy, with successful reduction in tumor size across all tissue compartments. As with patient 1, however, there was immediate rebound growth following discontinuation of inhibitor therapy, without sustained control despite repeat embolization. patient 3 presented at the age of 5 with a left renal AML and underwent two embolization procedures without lasting effect prior to starting mTOR inhibition. As with patients 1 and 2, following discontinuation of therapy, there was immediate rebound growth of the tumor. Repeat embolization, however, was notable for a substantial reduction in intratumoral aneurysms and vascularity. CONCLUSION: AML volume reduction as well as post-treatment rebound growth due to mTOR inhibitors involves all three tissue components of the tumor.

Renoduodenal fistula after transcatheter embolization of renal angiomyolipoma.

Transcatheter embolization of renal angiomyolipomas is a routinely performed, nephron-sparing procedure with a favorable safety profile. Complications from this procedure are typically minor in severity, with postembolization syndrome the most common minor complication. Abscess formation is a recognized but uncommon major complication of this procedure and is presumably due to superinfection of the infarcted tissue after arterial embolization. In this case report, we describe the formation of a renoduodenal fistula after embolization of an angiomyolipoma, complicated by intracranial abscess formation and requiring multiple percutaneous drainage procedures and eventual partial nephrectomy.

Outcomes of transcatheter arterial embolization for acute hemorrhage originating from gastric adenocarcinoma.

PURPOSE: To evaluate the indications, complications, and clinical outcomes of transcatheter embolization for acute hemorrhage associated with gastric adenocarcinoma. MATERIALS AND METHODS: Ten patients underwent catheter-directed arterial embolization at two institutions for acute gastrointestinal hemorrhage related to pathology-proven gastric adenocarcinoma from March 2002 to March 2012. The electronic medical record for each patient was reviewed for clinical presentation, endoscopy history, procedural complications, and long-term follow-up results. RESULTS: Between March 2002 and March 2012, 10 patients (eight men; mean age, 61.1 y ± 15.3) underwent transcatheter arterial embolization for gastrointestinal hemorrhage caused by gastric adenocarcinoma. Endoscopic therapy had failed in all patients before embolization. Embolization involving branches of the left gastric artery was performed in all patients. No deaths or complications related to the procedure were identified. Mean survival was 301 days, but with a wide range, from 1 day to 1,852 days and counting. Those with unresectable disease (n = 7; 70%) had a median survival time of 9 days, significantly worse (P < .01) than those with resectable disease (n = 3; 30%), who had a median survival of 792 days. Six patients, all with unresectable disease, did not live beyond 30 days. Two of the three patients with resectable disease had subsequent curative resection. CONCLUSIONS: Transcatheter arterial embolization can be considered for cases of acute hemorrhagic gastric adenocarcinoma, with improved outcomes in patients with localized disease compared with nonresectable gastric adenocarcinoma.

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.

Outcomes following "rescue" superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients.

BACKGROUND: Therapeutic angioembolization is a relatively new "rescue treatment" modality for gastrointestinal hemorrhage (GIH) for unstable patients who fail primary treatment approaches; however, the effectiveness of this treatment and the incidence of ischemic necrosis following embolization for acute GIH are poorly described. The purpose of this study was to evaluate the effectiveness and safety of "rescue" transcatheter superselective angioembolization (SSAE) for the treatment of hemodynamically unstable patients with GIH. METHODS: A 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure < 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. All patients with evidence of active contrast extravasation were included. Data were collected on demographics, comorbidities, clinical presentation, and type of intravascular angioembolic agent used. Outcomes included technical success (cessation of extravasation), clinical success (no rebleeding requiring intervention within 30 days), and incidence of ischemic complications. RESULTS: Ninety-eight patients underwent SSAE for GIH during the study period; 47 were excluded owing to lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority underwent embolization with a permanent agent (71%), while the remaining patients received either a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections. Only one patient had an ischemic complication (small bowel necrosis) requiring resection. CONCLUSION: SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications are extremely rare. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Intravascular ultrasound-guided inferior vena cava filter placement using a single-puncture technique in 99 patients.

PURPOSE: To assess the feasibility and safety of intravascular ultrasound (IVUS) to guide inferior vena cava (IVC) filter placement using a single venous puncture technique. MATERIALS AND METHODS: Medical records of all patients who had IVC filters placed under IVUS guidance between January 1, 2005 and December 31, 2011 were retrospectively reviewed for pertinent history, results, and complications. All filters were placed using a single venous puncture technique. RESULTS: Filters were successfully placed within the IVC in 94% of the patients with 6 malpositioned filters (4 in the iliac veins and 2 in the suprarenal IVC). Complications included groin hematoma (4%), deep venous thrombosis at the site of vascular access (2%), and filter tilt >15° along the long axis of the IVC (2%). CONCLUSIONS: The IVUS-guided IVC filter placement using a single venous puncture technique is technically feasible and safe when compared to case series using a double venous puncture technique.

Preliminary experience with Option inferior vena cava filter.

OBJECTIVES: To evaluate the safety and efficacy of Option inferior vena cava (IVC) filter during placement and short-term follow-up. METHODS: A total of 165 patients (mean age: 60-years) who received Option IVC filter from June 2009 to July 2011 were included. In all, 42 patients presented with deep vein thrombosis (DVT), 26 with pulmonary embolism (PE), and 17 with both. All outcomes were examined until April 30, 2012. RESULTS: The filters were successfully deployed in 161patients. During follow-up (mean, 9.5 ± 0.68months), 10 patients were diagnosed with post-filter PE and 13 patients with DVT. There were no instances of fatal PE. Follow-up abdominal computed tomography was available in 60 patients and demonstrated filter-related problems in 8 patients (2: penetration of filter legs, 5: asymptomatic nonocclusive thrombus, and 1: caval occlusion). There were no instances of filter migration or fracture. In total, 27 filters were successfully retrieved after a mean of 5.27 ± 0.76 months. CONCLUSION: The Option filter was effective and safe during implantation and short-term follow-up and associated with high technical success at retrieval.