Comparison of anticoagulation vs mechanical thrombectomy for the treatment of iliofemoral deep vein thrombosis.

OBJECTIVE: To compare the comparative effects of treatment with contemporary mechanical thrombectomy (MT) or anticoagulation (AC) on Villalta scores and post-thrombotic syndrome (PTS) incidence through 12 months in iliofemoral deep vein thrombosis (DVT). METHODS: Patients with DVT in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) randomized trial and the ClotTriever Outcomes (CLOUT) registry were included in this analysis. Both studies evaluated the effects of thrombus removal on the incidence of PTS. Patients with bilateral DVT, isolated femoral-popliteal DVT, symptom duration of >4 weeks, or incomplete case data for matching covariates were excluded. Propensity scores were used to match patients 1:1 who received AC (from ATTRACT) with those treated with mechanical thrombectomy (from CLOUT) using nearest neighbor matching on nine baseline covariates, including age, body mass index, leg treated, provoked DVT, prior venous thromboembolism, race, sex, Villalta score, and symptom duration. Clinical outcomes, including Villalta score and PTS, were assessed. Logistic regression was used to estimate the likelihood of developing PTS at 12 months. RESULTS: A total of 164 pairs were matched, with no significant differences in baseline characteristics after matching. There were fewer patients with any PTS at 6 months (19% vs 46%; P < .001) and 12 months (17% vs 38%; P < .001) in the MT treatment group. Modeling revealed that, after adjusting for baseline Villalta scores, patients treated with AC had significantly higher odds of developing any PTS (odds ratio, 3.1; 95% confidence interval, 1.5-6.2; P = .002) or moderate to severe PTS (odds ratio, 3.1; 95% confidence interval, 1.1-8.4; P = .027) at 12 months compared with those treated with MT. Mean Villalta scores were lower through 12 months among those receiving MT vs AC (3.3 vs 6.3 at 30 days, 2.5 vs 5.5 at 6 months, and 2.6 vs 4.9 at 12 months; P < .001 for all). CONCLUSIONS: MT treatment of iliofemoral DVT was associated with significantly lower Villalta scores and a lower incidence of PTS through 12 months compared with treatment using AC. Results from currently enrolling clinical trials will further clarify the role of these therapies in the prevention of PTS after an acute DVT event.

Bladder-Induced Compression of the External Iliac Veins: Recognition and Implications for Treatment.

The effect of changes in bladder volume on the caliber of adjacent veins is underappreciated but essential to recognize to avoid complications such as unnecessary stenting or clot migration causing pulmonary embolism. Here the authors illustrate the importance of this finding in 3 cases using venographic and endovascular sonographic imaging: the first in which BPH-induced chronic bladder outlet obstruction resulted in DVT formation, the second in which the cause was unrecognized and unnecessary stenting performed, and the third in which inappropriate treatment was avoided by decompressing the bladder.

Mechanical Thrombectomy vs. Pharmacomechanical Catheter Directed Thrombolysis for the Treatment of Iliofemoral Deep Vein Thrombosis: A Propensity Score Matched Exploratory Analysis of 12 Month Clinical Outcomes.

OBJECTIVE: To compare thrombus removal and residual venous symptoms and signs of disease following interventional treatment of iliofemoral deep vein thrombosis (DVT) with mechanical thrombectomy (MT) and pharmacomechanical catheter directed thrombolysis (PCDT). METHODS: Retrospective cohort analysis of propensity score matched subgroups from the multicentre prospective MT ClotTriever Outcomes registry and the PCDT arm of the randomised Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter Directed Thrombolysis trial. Patients with bilateral DVT, symptom duration greater than four weeks, isolated femoral-popliteal disease, or incomplete case data were excluded. Patients with iliofemoral DVT were propensity score matched (1:1) on 10 baseline covariables, including race, sex, age, body mass index, leg treated, prior thromboembolism, Marder score, symptom duration, provoked deep vein thrombosis status, and Villalta score. Reduction in post-procedure thrombus burden (i.e., Marder scores), assessment of venous symptoms and signs (i.e., Villalta scores) at 12 months, and healthcare resource utilisation were compared between subgroups. RESULTS: Propensity score matching resulted in 130 patient pairs with no significant differences in baseline characteristics between the MT and PCDT groups. MT was associated with a greater reduction in Marder scores (91.0% vs. 67.7%, p < .001), and a greater proportion of patients at 12 months with no post-thrombotic syndrome (83.1% vs. 63.6%, p = .007) compared with matched patients receiving PCDT. No differences in rates of adjunctive stenting or venoplasty were identified (p = .27). Higher rates of single session treatment were seen with MT (97.7% vs. 26.9%, p < .001), which also showed shorter mean post-procedure hospital stays (1.81 vs. 3.46 overnights, p < .001), and less post-procedure intensive care unit utilisation (2.3% vs. 52.8%, p < .001). CONCLUSION: Compared with PCDT, MT was associated with greater peri-procedural thrombus reduction, more efficient post-procedure care, and improved symptoms and signs of iliofemoral vein disease at 12 months.

Significant unfavorable geometrical changes in ascending aorta despite stable diameter at follow-up.

OBJECTIVE: The clinical importance of following up on the ascending aortic diameter lies in the fundamental presumption that wall pathology eventually manifests as a change in shape. However, the diameter describes the vessel locally, and the 55 mm criterion fails to prevent most dissections. We hypothesized that geometric changes across the ascending aorta are not necessarily imprinted on its diameter; i.e. the maximum diameter correlates weakly and insignificantly with elongation, surface stretching, engorgement, and tortuosity. METHODS: Two databases were interrogated for patients who had undergone at least 2 ECG-gated CT scans. The absence of motion artifacts permitted the generation of exact copies of the ascending aorta which then underwent three-dimensional analysis producing objective and accurate measurements of the centreline length, surface, volume, and tortuosity. The correlations of these global variables with the diameter were explored. RESULTS: Twenty-two patients, 13 male and 9 female, were included. The mean age at the first and last scan was 63.7 and 67.1 y, respectively. The mean diameter increase was approximately 1 mm/y. There were no dissections, while 7 patients underwent preemptive surgery. The yearly change rate of the global variables, normalized to height if applicable, showed statistically insignificant, weak, or negligible correlation with diameter increments at follow-up. Most characteristically, a patient's aorta maintained its diameter, while undergoing 1 mm/y elongation, 151 mm2/(y·m) stretching, 2366 mm3/(y·m) engorgement, and 0.02/y tortuosity. CONCLUSION: Maximum diameter provides a local description of the ascending aorta and cannot fully portray the pathological process across this vessel. Following up the diameter is not suggestive of length, surface, volume, and tortuosity changes.

Case report: Coronary atherosclerosis in a patient with long-standing very low LDL-C without lipid-lowering therapy.

Background: ApoB-containing lipoproteins including low-density lipoprotein cholesterol (LDL-C) are necessary for the development of atherosclerosis, and lifelong exposure to low serum levels of LDL-C have been associated with a substantial reduction of cardiovascular risk. Although plaque regression has been observed in patients with serum LDL-C less than 70-80 mg/dl on lipid-lowering therapy, an LDL-C level under which atherosclerosis cannot develop has not been established. Case presentation: In this case we describe a 60-year-old man with well-controlled diabetes mellitus and hypertension who presented to the hospital after an acute stroke likely due to an atrial myxoma discovered on imaging. A coronary computed tomography angiography scan performed in preparation for the planned surgical myxoma resection revealed an anomalous origin of the right coronary artery as well as evidence of nonobstructive coronary atherosclerosis in the right coronary and non-anomalous left coronary system. Despite not having ever been on any lipid-lowering therapy, this patient was found to have low LDL-C levels (<40 mg/dl) during this admission and on routine laboratory data collected over the prior 16 years. His family history strongly suggested heterozygous familial hypobetalipoproteinemia as a possible diagnosis. Conclusions: This case illustrates that even long-standing, very low levels of LDL-C may be insufficient to completely prevent atherosclerosis and emphasizes the importance of primordial prevention of all cardiovascular risk factors.

Effect of inferior vena cava filter placement position on device complications.

BACKGROUND: Indwelling inferior vena cava (IVC) filters can cause complications, including penetration into surrounding structures, migration, and thrombosis of the vena cava. Computational fluid dynamics suggests juxtarenal placement of IVC filters decreases the risk of thrombosis; however, this has not been explored clinically. The present study examines the effect of filter placement position on long-term device complications with an emphasis on IVC thrombosis. We hypothesized that IVC filters placed further caudal to the renal veins were more likely to develop long-term thrombosis. METHODS: A retrospective review of the medical records of patients receiving IVC filters at a single tertiary center between 2008 and 2016 was performed. Patients missing follow-up or procedural imaging data were excluded. The placement procedure venograms were reviewed, and the distance from the filter apex to the more inferior renal vein was measured using reported IVC filter lengths for calibration. The patients were divided into three groups according to the tip position relative to the more inferior renal vein: at or superior (group A), 1 to 20 mm inferior (group B), and >20 mm inferior (group C). The patient and procedural characteristics and outcomes were compared between the three groups. The primary end points were IVC thrombosis and device-related mortality. RESULTS: Of 1497 eligible patients, 267 (17.8%) were excluded. The most common placement position was group B (64.0%). The mean age was lowest in group C, followed by groups A and B (age, 59.5 years, 64.6 years, and 62.2 years, respectively; P = .003). No statistically significant differences were found in the distribution of sex or the measured comorbidities. Group C was the most likely to receive jugular access (group C, 71.7%; group A, 48.3%; group B, 62.4%; P < .001) and received more first-generation filters (group C, 58.5%; group A, 46.6%; group B, 52.5%; P = .045). The short-term (<30-day) and long-term (≥30-day) outcomes, including access site hematoma, deep vein thrombosis, and pulmonary embolism, were uncommon, with no differences between the groups. Cases of symptomatic filter penetration, migration, and fracture were rare (one, one, and three cases, respectively). Although a pattern of increasing thrombosis with more inferior placement was found, the difference between groups was not statistically significant (group A, 1.5%; group B, 1.8%; group C, 2.5%; P = .638). No cases of device-related mortality occurred. All-cause mortality after a mean follow-up of 2.6 ± 2.3 years was 41.3% and did not vary significantly between the groups (P = .051). Multivariate logistic regression revealed that placement position did not predict for short- or long-term deep vein thrombosis, pulmonary embolism, IVC thrombosis, or all-cause mortality after adjustment for the baseline patient characteristics. CONCLUSIONS: IVC filters have low rates of short- and long-term complications, including IVC thrombosis. The placement position did not affect the occurrence of device complications in this study.

Quantitative cardiovascular magnetic resonance findings and clinical risk factors predict cardiovascular outcomes in breast cancer patients.

BACKGROUND: Cardiac magnetic resonance (CMR) global longitudinal strain and circumferential strain abnormalities have been associated with left ventricular ejection fraction (LVEF) reduction and cardiotoxicity from oncologic therapy. However, few studies have evaluated the associations of strain and cardiovascular outcomes. OBJECTIVES: To assess CMR circumferential and global longitudinal strain (GLS) correlations with cardiovascular outcomes including myocardial infarction, systolic dysfunction, diastolic dysfunction, arrhythmias and valvular disease in breast cancer patients treated with and without anthracyclines and/or trastuzumab therapy. METHODS: Breast cancer patients with a CMR from 2013-2017 at Yale New Haven Hospital were included. Patient co-morbidities, medications, and cardiovascular outcomes were obtained from chart review. Biostatistical analyses, including Pearson correlations, competing risk regression model, and competing risk survival curves comparing the two groups were analyzed. RESULTS: 116 breast cancer with CMRs were included in our analysis to assess differences between Anthracycline/Trastuzumab (AT) (62) treated versus non anthracycline/trastuzumab (NAT) (54) treated patients in terms of imaging characteristics and outcomes. More AT patients 17 (27.4%) developed systolic heart failure compared to the NAT group 6 (10.9%), p = 0.025. Statin use was associated with a significant reduction in future arrhythmias (HR 0.416; 95% CI 0.229-0.755, p = 0.004). In a sub-group of 13 patients that underwent stress CMR, we did not find evidence of microvascular dysfunction by sub-endocardial/sub-epicardial myocardial perfusion index ratio after adjusting for ischemic heart disease. CONCLUSIONS: In our study, CMR detected signs of subclinical cardiotoxicity such as strain abnormalities despite normal LV function and abnormal circumferential strain was associated with adverse cardiovascular outcomes such as valvular disease and systolic heart failure. Thus, CMR is an important tool during and after cancer treatment to identity and prognosticate cancer treatment-related cardiotoxicity.

Major Adverse Limb Events Among Patients with Premature Peripheral Artery Disease Compared with Those at the Common Age Undergoing Revascularization in the Vascular Quality Initiative.

BACKGROUND: Premature peripheral artery disease (PAD), defined as ≤ 50 years of age, is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes of this group of patients compared to those at the common age undergoing revascularization have not been examined. The aim of this study is to compare patients with early versus late onset premature PAD undergoing LER focusing on major adverse limb events (MALEs). METHODS: All LER procedures (open and endovascular) in the Vascular Quality Initiative (VQI) were reviewed. A histogram of patient age at the time of initial LER (no prior LER) was used to define the common age, which included all patients within one standard deviation of the mean. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation undergoing LER. RESULTS: A histogram of all patients undergoing LER was used to define 60 to 80 years as the common age. Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age. Patients with premature PAD were also more likely to have insulin-dependent diabetes, be current smokers, on dialysis, and be treated for claudication. Patients with premature PAD were less likely to have Transatlantic Intersociety Consensus (TASC II) C or D disease and were less likely to be on antiplatelets and statins. These differences were more pronounced in patients with chronic limb-threatening ischemia (CLTI). Cox proportional hazards regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at 1-year for patients with claudication (HR:1.7, 95% CI:1.4-2.0) and CLTI (HR:1.3, 95% CI:1.2-1.5) compared to patients 60 to 80 years of age. CONCLUSIONS: Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age. Vascular providers should emphasize medical therapy prior to LER given the lower rates of medical optimization and worse 1-year MALEs in patients with premature PAD.

The Impact of Clinical Follow-Up After Revascularization on the Outcomes of Patients with Chronic Limb Threatening Ischemia.

BACKGROUND: Guidelines for optimal follow-up for patients undergoing lower extremity revascularization (LER) for peripheral arterial disease recommend multiple visits with imaging during the first year followed by yearly monitoring thereafter. Critical limb-threatening ischemia (CLTI) patients are at a greater risk for mortality and limb amputation than claudicants and thus necessitate closer monitoring. The goal of this article is to study the effects of compliance with follow-up after revascularization for patients with CLTI on major amputation rates and mortality. METHODS: A single-center retrospective chart review of consecutive patients undergoing LER for CLTI was performed. Patients were stratified based on compliance with follow-up to compliant or noncompliant cohorts. Patient characteristics, reinterventions, and perioperative and long-term outcomes were compared between the 2 groups. RESULTS: There were 356 patients undergoing LER and 61% (N = 218) were compliant. There was no significant difference in baseline characteristics between the 2 groups. Noncompliant patients were more likely to undergo endovascular interventions compared to compliant patients (92.8% vs. 79.4%, P = 0.03). There was no difference in perioperative outcomes between the 2 groups with overall 30-day mortality of 0.6%. After mean follow-up of 2.7 years, compliant patients had greater ipsilateral reintervention rates (49.1% vs. 34.1%, P = 0.005) and overall reintervention rates (61% vs. 44.2%, P = 0.002) compared to noncompliant patients. There was no significant difference in mortality or ipsilateral major amputations between the 2 groups. CONCLUSIONS: Patients who were compliant with follow-up after LER for CLTI underwent more reinterventions with no difference in mortality or major limb amputation. Further research regarding the threshold for reintervention and the optimal schedule for follow-up in patients with CLTI is needed.

Outcomes from the ClotTriever Outcomes Registry show symptom duration may underestimate deep vein thrombus chronicity.

OBJECTIVE: The all-comer ClotTriever Outcomes registry assessed indicators of thrombus chronicity in patients with acute, subacute, and chronic lower extremity deep vein thrombosis (DVT). The effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) by chronicity subgroup was also assessed and reported here in this subanalysis. METHODS: All-comer patients with lower extremity DVT were enrolled, with no limitation based on the patients' symptom duration. Chronicity was assessed three times and compared: before the procedure based on symptom duration, during the procedure based on available pre-thrombectomy imaging, and visual inspection of the extracted thrombus morphology after thrombectomy. Patients were grouped into acute, subacute, and chronic subgroups according to their post-thrombectomy thrombus chronicity based on thrombus morphology. Analyses on baseline and procedural characteristics along with thrombus removal were performed across subgroups. The effectiveness of thrombus removal was determined by Marder scores adjudicated by an independent core laboratory, with a prespecified primary effectiveness end point of complete or near-complete (≥75%) thrombus removal. RESULTS: Of the 260 treated limbs from 250 patients, using symptom duration alone, 70.7% were considered acute, 20.9% subacute, and 8.4% chronic. Upon visual inspection, the extracted thrombus chronicity was approximately one-third in each subgroup: 32.7% had acute thrombus, 35.4% subacute thrombus, and 31.9% chronic thrombus. Chronicity assessed using symptom duration alone mismatched the post-thrombectomy chronicity in 55.1% of limbs (P < .0001) with 49.0% being more chronic than suggested by the patients' duration of symptoms. Chronicity assessed using pre-thrombectomy imaging mismatched the post-thrombectomy chronicity in 17.5% of limbs (P < .0001). No patients received thrombolytics and 99.6% were treated in a single session. Complete or near-complete thrombus removal was achieved in a high percentage of limbs regardless of thrombus chronicity: 90.8%, 81.9%, and 83.8% in limbs with acute, subacute, and chronic thrombus, respectively. CONCLUSIONS: This subanalysis from the all-comer ClotTriever Outcomes registry demonstrates that extracted thrombus in DVT may be more chronic than suggested by the patients' duration of symptoms. The addition of imaging is helpful to determine the ability of thrombus to respond to therapy. Irrespective of thrombus chronicity, the ClotTriever system can be effective at removing acute, subacute, and chronic thrombus in a single-session procedure without the need for thrombolytics.

Interim outcomes of mechanical thrombectomy for deep vein thrombosis from the All-Comer CLOUT Registry.

OBJECTIVES: The multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and nonacute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients. METHODS: All-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness end point is complete or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events through 30 days and clinical outcomes include post-thrombotic syndrome severity, symptoms, pain, and quality of life through 6 months. RESULTS: The median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. The median thrombectomy time was 28 minutes. The primary effectiveness end point was achieved in 86% of limbs. Through 30 days, one device-related serious adverse event occurred. At 6 months, 24% of patients had post-thrombotic syndrome. Significant and sustained improvements were observed in all clinical outcomes, including the Revised Venous Clinical Severity Score, the numeric pain rating scale, and the EuroQol Group 5-Dimension Self-Report Questionnaire. CONCLUSIONS: The 6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicities demonstrate favorable effectiveness, safety, and sustained clinical improvements.

Left ventricular myocardial strain and tissue characterization by cardiac magnetic resonance imaging in immune checkpoint inhibitor associated cardiotoxicity.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are highly effective in treating cancer; however, cardiotoxicity can occur, including myocarditis. Cardiac magnetic resonance (CMR) imaging is useful for evaluation of myocarditis, although it has not been well studied in ICI cardiotoxicity. METHODS: We identified patients referred for CMR evaluation of ICI cardiotoxicity from September 2015 through September 2019. We assessed structural and functional parameters, feature tracking (FT) left ventricular and atrial strain, T2- weighted ratios and quantitative late gadolinium enhancement (LGE). We also applied the Updated Lake Louise Criteria for diagnosis of myocarditis. RESULTS: Of the 20 patients referred, the median left ventricular ejection fraction (LVEF) was 52.5% ± 19.1 and 50% had a normal LVEF (≥53%). FT strain analysis revealed an average abnormal global longitudinal strain (GLS) of -9.8%± 4.2%. In patients with a normal LVEF, the average GLS remained depressed at -12.3%± 2.4%. In all patients, GLS demonstrated a significant negative correlation with LVEF (rs = -0.64, p 0.002). Sixteen patients (80%) had presence of LGE (14 non-ischemic pattern and 2 ischemic). Percent LGE did not correlate with any CMR parameters and notably did not correlate with LVEF (rs = -0.29, p = 0.22) or GLS (rs = 0.10, p = 0.67), highlighting the value of tissue characterization beyond functional assessment. Nine patients (45%) met full Updated Lake Louise Criteria and 85% met at least one criterion, suggestive of myocarditis in the correct clinical context. Thirteen patients (65%) were treated for ICI-associated myocarditis and, of these, 54% (n = 7) had recovery of LVEF to normal. There was no correlation between LVEF (p = 0.47), GLS (0.89), or % LGE (0.15) and recovery of LVEF with treatment. CONCLUSION: In patients with suspected ICI cardiotoxicity, CMR is an important diagnostic tool, even in the absence of overt left ventricular dysfunction, as abnormalities in left ventricular strain, T2 signal and LGE can identifying disease.

Outcomes of treatment with paclitaxel-coated devices for peripheral arterial disease.

OBJECTIVE: The treatment of femoropopliteal peripheral artery disease (PAD) using paclitaxel-coated devices (PCDs) has been shown to improve patency in several randomized trials. However, a recent meta-analysis of trial data suggested an increased risk of mortality with PCD usage. Although subsequent studies have found no association with mortality, the subject has remained controversial. Thus, the aim of the present study was to further investigate the outcomes and causes of mortality for patients treated with PCDs. METHODS: Patients who had undergone endovascular interventions for PAD from 2013 to 2016 at a single institution were reviewed. The patients were stratified by the use of PCDs, which included drug-coated balloons and drug-eluting stents. The cumulative dose of paclitaxel was calculated for the patients who had received multiple interventions. The causes of mortality were identified and compared between the two groups. RESULTS: Of the 366 included patients, 138 (38%) had received a PCD and 228 (62%) had received a non-drug-coated (NDC) device. Patients treated with PCDs were less likely to have undergone open surgery compared with patients treated with NDC devices. No differences were found in the indications or 30-day outcomes between the two groups. After a mean follow-up of 3.1 ± 1.8 years, no differences were found in the primary patency, reintervention rate, mean number of reinterventions, major amputation (5% vs 4%; P = .465), or mortality (16% vs 20%; P = .363) between the PCD and NDC groups. Also, no overall difference was found in the cause of mortality with and without PCD use or in the Kaplan-Meier survival curves. Furthermore, PCD use was not associated with an increased risk of mortality in Cox regression analysis. The cumulative dose of paclitaxel in patients treated with PCDs ranged from 383 to 49,259 µg (median, 7561 µg). A comparison of the patients treated with a cumulative dose of paclitaxel in the upper 50th percentile compared with the lower 50th percentile showed no significant differences in mortality (13% vs 19%; P = .333). CONCLUSIONS: PCD use was shown to be safe and not associated with an increased risk of long-term mortality in the present study. Continued monitoring of PCD use is warranted to ensure the safety of this technology.

Cine-Computed Tomography for the Evaluation of Prosthetic Heart Valve Function.

BACKGROUND: After aortic valve replacement (AVR), suspected prosthetic valve dysfunction (mechanical or biological) may arise based on echocardiographic transvalvular velocities and gradients, leading to reoperative surgical intervention being considered. Our experience has found that 4-dimensional (space and time) image reconstruction of ECG-gated computed tomography, termed cine-CT, may be helpful in such cases. We review and illustrate our experience. METHODS: Twenty-seven AVR patients operated previously by a single surgeon (who performs >100 AVRs/year) were referred for repeat evaluation of suspected aortic stenosis (AS) based on elevated transvalvular velocities and gradients. The patients were fully evaluated by cine-CT. RESULTS: In all but 2 cases, the cine-CT strikingly and visually confirmed normal leaflet function and excursion, with no valve thrombosis, restriction by pannus, or obstruction by clot. In only 2 cases did cine-CT reveal decreased mechanical valve leaflet excursion. Repeat surgery was required in only 1 case while all other patients continued clinically without cardiac events. CONCLUSIONS: Echocardiography is an extraordinarily useful tool for the evaluation of prosthetic valve function. Increased pressure recovery beyond the valve and other factors may occasionally lead to exaggerated gradients. Cine-CT is emerging as an extremely valuable tool for further evaluation of suspected prosthetic valve AS. Our experience has been extremely helpful, as is shown in the dramatically reassuring images.

Simultaneous proximal embolic protection and inferior vena cava mechanical thrombectomy using the FlowTriever system.

Interventional radiologists have the unique ability to apply their imaging knowledge, wide scope of technical skills, and use of innovative technologies to comprehensively address the percutaneous management of the thromboembolic disease processes. This report illustrates successful management of a thrombosed IVC, while protecting against possible pulmonary embolism. Here, we present a 49-year-old female with stage IIIB ovarian cancer who presented with severe bilateral lower extremity edema and anasarca in setting of occlusive thrombus of IVC. The thrombus was the result of compressionfrom a large hepatic hematoma which gradually developed after radical hysterectomy. A new mechanical thrombectomy device approved for use in pulmonary embolism, Inari FlowTriever catheter, was used off-label to remove the clot. The self-expanding mesh discs in the Inari FlowTriever catheter were utilized to protect against pulmonary embolism while percutaneously draining the hepatic hematoma and alleviating the IVC compression. The IVC was largely patent at the end of the procedure, and the patient experienced complete resolution of her symptoms. This case report demonstrates the successful and safe off-label use of a new mechanical thrombectomy device approved for pulmonary embolism thrombectomy in the IVC and illustrates a novel application of the nitinol mesh discs in the device as proximal embolic protection.

Natural history and management of Kommerell's diverticulum in a single tertiary referral center.

OBJECTIVE: The Kommerell diverticulum (KD) is an extremely rare developmental abnormality of the aorta related to an aberrant subclavian artery (ASCA). The objective of our study was to review the natural history of KD and ASCA using our single-center experience in diagnosing and managing KD and ASCA. METHODS: A retrospective review of the Yale radiological database from January 1999 to December 2016 was performed. Only patients with KD/ASCA and a computed tomography (CT) scan of the chest were selected for review. The primary goal was to examine the natural history of KD and ASCA and the secondary goals were to review the management and outcomes of those patients treated for KD and ASCA. RESULTS: There were 75 patients with KD/ASCA identified, with a mean age of 63 ± 19 years; 49 were female (65%). On CT scans, left- and right-sided aortas were present in 47 (63%) and 28 (37%) patients. A right ASCA or a left ASCA were present in 47 (63%) and 28 (37%) patients. Six patients were symptomatic on presentation. Symptoms included dysphagia, chest or back pain, and emboli to the fingers. The mean KD diameter was 21.8 ± 6.0 mm and the distance to the opposite aortic wall (DAW) was 48.3 ± 10.8 mm. Sixty-six patients were followed for a mean of 31.7 ± 32.5 months. One patient ruptured without repair. Nine patients underwent operative intervention, including eight open and one endovascular repair. Complications from operative intervention included ischemic stroke with hemorrhagic transformation, deep vein thrombosis and pneumonia. The mean growth rate for KD and DAW was 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year, respectively. On multivariable regression analysis, hypertension was a predictor of growth of DAW (P = .03). CONCLUSIONS: KD is uncommon and shows a female predominance. The diverticulum grows, albeit slowly (KD and DAW growth rates of 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year). Most patients are asymptomatic, but dysphagia, chest/back pain, and distal emboli may occur. Rupture is rare. Symptomatic patients should be operated. Asymptomatic patients can be followed with serial CT scans.

Routine anterior spinal artery visualization prior to descending and thoracoabdominal aneurysm repair: High detection success.

BACKGROUND: Paraplegia is adevastating complication of open descending (DTAA) and thoracoabdominal aortic aneurysm (TAAA) repair. Despite major advances in imaging and surgical techniques, paraplegia continues to be problematic. We present our experience with routine application of enhanced imaging techniques to detect the anterior spinal artery (ASA) before DTAA and TAAA repair. METHODS: We retrospectively reviewed 177 patients with DTAA and TAAA who underwent imaging to detect the ASA before open surgical repair. High definition CT angiography (CTA) and dual energy CT scanning (DECT) were our modalities of choice with angiography used earlier and magnetic resonance angiography (MRA) used when CT was contraindicated. Descriptive statistics and χ2 analyses were conducted. RESULTS: The imaging protocol successfully detected the level of the ASA in 132 (74.5%) patients, utilizing CTA in 67, DECT in 28, spinal angiography in 31, and MRA in 6. Cross sectional modalities with advanced visualization technique (CT, DECT, and MRA) were more successful at detecting the ASA than angiography (80.72%, 82.35%, 75% vs 59.62%, respectively, P = .04). Concerted efforts were made not to leave the operating room without continuity of the ASA with the circulation (via limited resection, beveled anastomosis, or reimplantation). Transient lower extremity weakness was observed in 11 (6.2%) patients, and permanent paraplegia in 2 (1.12%) patients. CONCLUSION: Modern imaging technology provides multiple methodologies highly successful at detecting the ASA. The ASA can then be preserved intraoperatively, contributing to low paraplegia rates. We strongly recommend routine application of this technology to arm the surgeon with precise information about the specific patient's spinal cord blood supply.

Coil embolization of bilateral internal mammary artery aneurysms in the setting of a heterozygous missense variant of unknown significance in COL5A1 and fibromuscular dysplasia.

Internal mammary artery aneurysms are rare but serious clinical entities. Rupture results in hemothorax and can be life threatening. Most reported cases are pseudoaneurysms secondary to iatrogenic or traumatic causes. Noniatrogenic, nontraumatic, true internal mammary artery aneurysms have most commonly been associated with vasculitides or connective tissue disorders; rare cases have been deemed idiopathic. We describe a rare case of bilateral internal mammary artery aneurysms-successfully treated with coil embolization-in the setting of heterozygosity for a missense variant of unknown significance in the COL5A1 gene and multifocal fibrodysplastic changes on angiography.

Costs and complications of endovascular inferior vena cava filter retrieval.

OBJECTIVE: Advanced endovascular techniques are frequently used for challenging inferior vena cava (IVC) filter retrieval. However, the costs of IVC filter retrieval have not been studied. This study compares IVC filter retrieval techniques and estimates procedural costs. METHODS: Consecutive IVC filter retrievals performed at a tertiary center between 2009 and 2014 were retrospectively reviewed. Procedures were classified as standard retrieval (SR) if they required only a vascular sheath and a snare device and as advanced endovascular retrieval (AER) if additional endovascular techniques were used for retrieval. Cost data were based on hospital bills for the procedures. Patients' characteristics, filter dwell time, retrieval procedure details, complications, and costs were compared between the groups. All statistical comparisons were performed using SAS 9.3 software. RESULTS: There were 191 IVC filter retrievals (SR, 157; AER, 34) in 183 patients (mean age, 55 years; 51% male). Fifteen filters (7.9%) were placed at an outside hospital. The indications for placement were mostly therapeutic (76% vs 24% for prophylaxis). All IVC filters were retrievable, with Bard Eclipse (Bard Peripheral Vascular, Tempe, Ariz; 34%) and Cook Günther Tulip (Cook Medical, Bloomington, Ind; 24%) the most common. Venous ultrasound examination of the lower extremities of 133 patients (70%) was performed before retrieval, whereas only 5 patients (2.6%) received a computed tomography scan of the abdomen. There was no difference in the mean filter dwell time in the two groups (SR, 147.9 ± 146.1 days; AER, 161.4 ± 91.3 days; P = .49). AERs were more likely to have had prior attempts at retrieval (23.5%) compared with SRs (1.9%; P < .001). The most common AER techniques used were the wire loop and snare sling (47.1%) and the stiff wire displacement (44.1%). Bronchoscopy forceps was used in four cases (11.8%); this was the only off-label device used. AERs were more likely to require more than one venous access site for the retrieval procedure (23.5% vs 0%; P < .001). AERs were significantly more likely to have longer fluoroscopy time (34.4 ± 18.3 vs 8.1 ± 7.9 minutes; P < .001) and longer total procedural time (102.8 ± 59.9 vs 41.1 ± 25.0 minutes; P < .001) compared with SRs. The complication rate was higher with AER (20.6%) than with SR (5.2%; P = .006). Most complications were abnormal radiologic findings that did not require additional intervention. The procedural cost of AER was significantly higher (AER, $14,565 ± $6354; SR, $7644 ± $2810; P < .001) than that of SR. This translated to an average increase in cost of $6921 ± $3544 per retrieval procedure for AER. CONCLUSIONS: Advanced endovascular techniques provide a feasible alternative when standard IVC filter retrieval techniques do not succeed. However, these procedures come with a higher cost and higher rate of complications.