Comparison of success and cost after retrieval of two inferior vena cava filters.

OBJECTIVE: The objective of this study was to help guide inferior vena cava (IVC) filter choices by better understanding the retrieval characteristics, complications, and total costs between two commonly used IVC filters. METHODS: All patients who underwent retrieval or attempted retrieval of Denali (Bard Peripheral Vascular) or Option (Argon Medical Devices) IVC filters were identified between March 2016 and October 2021 at a single tertiary care center. Those with imaging studies that permitted evaluation of filter placement, presence or degree of tilt, and/or hooking of the filter into the IVC wall were included in the present study. Filter retrieval success, number of attempts, use of advanced techniques, and fluoroscopy and procedural times were recorded and compared between the two filters. RESULTS: A total of 87 patients presented for retrieval of 52 Denali and 35 Option Elite filters during the study period. Denali filters were more likely to be successfully retrieved at the first attempt (94% vs 77%; P = .019). The procedural and fluoroscopy times were shorter for Denali filters (29 minutes vs 63 minutes [P < .001] and 7 minutes vs 25 minutes [P < .001], respectively). Denali filters were less likely to be significantly tilted (≥15○) at retrieval (12% vs 29%; P < .001) or to have the filter hook embedded in the IVC wall (6% vs 40%; P < .001). Tilting of the filter of ≥15○ had no significant effects on the retrieval success rate (no tilt or tilt <15○ vs tilt of ≥15○: 98% vs 100%; P = .58). In contrast, filter hook penetration into the IVC wall significantly reduced successful recovery (41% vs 99%; P < .001). CONCLUSIONS: The findings from this study suggest that although the filter designs are similar, a benefit exists in the ease of retrievability of the Denali over the Option filter. We found that tilting and hooking of the filter in the IVC wall occurred significantly more with the Option filter. These factors likely made retrieval more difficult and contributed to the longer procedure and fluoroscopy times.

Racial and ethnic disparities in inferior vena cava filter placement for deep vein thrombosis in the United States.

OBJECTIVE: We sought to determine whether racial and ethnic disparities existed in inferior vena cava (IVC) filter (IVCF) placement rates among Black and Latino patients for the treatment of acute proximal lower extremity (LE) deep vein thrombosis (DVT) in the United States from 2016 to 2019. METHODS: We performed a retrospective review of National Inpatient Sample data to identify adult patients with a primary discharge diagnosis of acute proximal LE DVT from January 2016 to December 2019, including self-reported patient race and ethnicity. IVCF placement rates were identified using International Classification of Diseases, 10th revision, codes. Weighted multivariable logistic regression was used to compare IVCF use by race and ethnicity. The regression model was adjusted for patient demographics (ie, sex, primary payer, quartile classification of household income), hospital information (ie, region, location, teaching status, bed size), weekend admission, and clinical characteristics (ie, modified Charlson comorbidity index, hypertension, atrial fibrillation, diabetes mellitus type 2, congestive heart failure, dyslipidemia, coronary artery disease, smoking, obesity, alcohol abuse, chronic kidney disease, pulmonary embolism, malignancy, contraindications to anticoagulation, including other major bleeding). RESULTS: Of 134,499 acute proximal LE DVT patients, 18,909 (14.1%) received an IVCF. Of the patients who received an IVCF, 12,733 were White (67.3%), 3563 were Black (18.8%), and 1679 were Latino (8.9%). IVCF placement decreased for all patient groups between 2016 and 2019. After adjusting for the U.S. population distribution, the IVCF placement rates were 11 to 12/100,000 persons for Black patients, 7 to 8/100,000 persons for White patients, and 4 to 5/100,000 persons for Latino patients. The difference in IVCF placement rates was statistically significant between patient groups (Black patients vs White patients, P < .05; Black patients vs Latino patients, P < .05; Latino patients vs White patients, P < .05). CONCLUSIONS: This nationwide study showed that Black patients have higher IVCF placement rates compared with White and Latino patients. Given the known long-term complications and uncertain benefits of IVCFs, coupled with the 2010 U.S. Food and Drug Administration safety warning regarding adverse patient events for these devices, proactive measures should be taken to address this disparity among the Black patient population to promote health equity. Future work should assess whether clinician bias might be perpetuating this disparity.

Assessment of Ki-67 proliferation index in prognosis prediction in patients with nonmetastatic clear cell renal cell carcinoma and tumor thrombus.

PURPOSE: To determine the optimal cut-off value of Ki-67 for predicting the survival of patients with clear cell renal cell carcinoma (ccRCC) and tumor thrombus and to explore the correlation between Ki-67 expression and pathological features. PATIENTS AND METHODS: We retrospectively analyzed Ki-67 immunohistochemical staining of ccRCC and tumor thrombus resected from February 2006 to February 2022. The survival rate was evaluated using the Kaplan-Meier method. The optimal cut-off value of the Ki-67 expression for predicting survival was determined by the minimum P-value method. Clinicopathological data were compared based on Ki-67 status (low versus high expression). Univariate and multivariate Cox regression analysis was used to explore independent predictors. RESULTS: A total of 202 patients (median age, 58 years [IQR, 52-65 years], 147 men) with ccRCC and tumor thrombus were included in the study. The optimal cut-off value of Ki-67 for predicting survival was 30%. 159 (78.7%) and 43 (21.3%) patients were included in the low-expression and high-expression groups. Patients with Ki-67 high expression had significantly worse recurrence-free survival (P < 0.001) and cancer-specific survival (P < 0.001). Ki-67 high expression was associated with adverse pathological features, including tumor necrosis, ISUP nuclear grade, sarcomatoid differentiation, perirenal fat invasion, renal pelvis invasion, and inferior vena cava wall invasion (all P < 0.050). Ki-67 expression ≥ 30% (P = 0.016), tumor side (P = 0.003), diabetes (P = 0.040), blood loss (P = 0.016), inferior vena cava wall invasion (P = 0.016), and sarcomatoid differentiation (P = 0.014) were independent predictors of cancer-specific survival. CONCLUSION: The optimal cut-off level of Ki-67 in predicting the prognosis of ccRCC and tumor thrombus was 30%. The high expression of Ki-67 was associated with the aggressive pathological phenotype and poor prognosis.

Supply Costs in Complex and Routine Inferior Vena Cava Filter Retrieval: 10 Years' Data from a Single Center.

PURPOSE: To characterize the medical supply costs associated with inferior vena cava filter retrieval (IVCFR) using endobronchial forceps (EFs), a snare, or Recovery Cone (RC). MATERIALS AND METHODS: In total, 594 of 845 IVCFRs attempted at a tertiary referral hospital between October 1, 2012, and June 20, 2022 were categorized by intended retrieval strategy informed by, rotational cavography as follows: (a) EF (n = 312) for tilted or tip-embedded/strut-embedded filters and for long-dwelling closed-cell filters and (b) a snare (n = 255) or (c) RC (n = 27) for other well-positioned filters with or mostly without hooks, respectively. List prices of relevant supplies at time of retrieval were obtained or, rarely, estimated using a standard procedure. Contrast use, fluoroscopic time, filter type, dwell time, and patient age and sex were recorded. Mean between-group cost differences were estimated by linear regression, adjusting for date. Additional models evaluated filter type, dwell time, and patient-level effects. RESULTS: Of the 594 IVCFRs, 591 were successful, whereas 2 EF and 1 snare retrievals failed. Moreover, 4 EF retrievals were successful with a snare and 2 with smaller EF, 12 snare retrievals were successful with EF, 1 RC retrieval was successful with a snare and 2 with EF. Principal model indicated a significantly lower mean cost of EF ($564.70, SE ± 9.75) than that of snare ($811.29, SE ± 10.83; P < .0001) and RC ($1,465.48, SE ± 47.12; P < .0001) retrievals. Adjusted models yielded consistent results. Had all retrievals been attempted with EF, estimated undiscounted full-period supplies savings would be $87,201.51. CONCLUSIONS: EFs are affordable for complex IVCFR, and extending their use to routine IVCFR could lead to considerable cost savings.

Use of POCUS for the assessment of dehydration in pediatric patients-a narrative review.

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions.   Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient's physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project.

INTRODUCTION: Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM. METHODS: Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ). RESULTS: 44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083). CONCLUSIONS: None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.

Ultrasonographic assessment of pulmonary and Central venous congestion in experimental heart failure.

Pulmonary and systemic congestion as a consequence of heart failure are clinically recognized as alarm signals for clinical outcome and mortality. Although signs and symptoms of congestion are well detectable in patients, monitoring of congestion in small animals with heart failure lacks adequate noninvasive methodology yet. Here, we developed a novel ultrasonography-based scoring system to assess pulmonary and systemic congestion in experimental heart failure, by using lung ultrasound (LUS) and imaging of the inferior vena cava (Cava), termed CavaLUS. CavaLUS was established and tested in a rat model of supracoronary aortic banding and a mouse model of myocardial infarction, providing high sensitivity and specificity while correlating to numerous parameters of cardiac performance and disease severity. CavaLUS, therefore, provides a novel comprehensive tool for experimental heart failure in small animals to noninvasively assess congestion.NEW & NOTEWORTHY As thorough, noninvasive assessment of congestion is not available in small animals, we developed and validated an ultrasonography-based research tool to evaluate pulmonary and central venous congestion in experimental heart failure models.

A clinical assessment of portable point-of-care testing for quick cortisol assay during adrenal vein sampling.

This study assessed the clinical performance of point-of-care testing (POCT) for quick cortisol assay (QCA) during adrenal vein sampling (AVS) using a newly invented portable quantitative assay instrument. An observational study was conducted prospectively at two centres in Japan. Forty-eight patients with primary aldosteronism considered for adrenalectomy were enrolled in this study and underwent AVS. Three basal adrenal vein samples from each adrenal vein and two from the inferior vena cava were collected sequentially. The cortisol concentration of adrenal vein samples was measured by routine method and QCA. A total of 338 adrenal vein samples were analysed from 250 sites to determine AVS success or failure. The distribution of turnaround time of the QCA for AVS success or failure followed a normal distribution with an average of 20.5 min. A positive correlation between the routine method and QCA was observed regarding cortisol concentration or selectivity index. No significant difference between the two methods was observed regarding the success rate of AVS. Using the routine method as a reference, the sensitivity and specificity of AVS success or failure were 99.1% (210/212) and 81.6% (31/38), respectively. Easy, quick, portable, and precise POCT-QCA demonstrated its compatibility with routine methods regarding clinical performance.

[The assessment of volume status]. / Het beoordelen van de vullingsstatus.

Accurately assessing volume status is crucial, as an incorrect evaluation can lead to inappropriate therapy. Evaluating volume status using medical history and physical examination can be challenging. Medical history and physical examination are readily available, cost-effective, and non-invasive, remaining the initial steps in assessing fluid status. Point-of-care ultrasound (POCUS) is a valuable adjunct to physical examination. The collapse point of the internal jugular vein, the diameter of the inferior vena cava, and the presence of pulmonary B-lines can be easily and rapidly assessed using POCUS. Combining medical history, physical examination, and POCUS enhances diagnostic certainty in evaluating volume status.

SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension?

BACKGROUND: Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients. METHODS: This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status. RESULTS: One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status. CONCLUSION: IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure.

RéSUMé: CONTEXTE: La détermination précise de l'état du liquide d'un patient pendant la réanimation au service des urgences (SU) aide à guider l'administration appropriée du liquide dans le cadre d'une hypotension indifférenciée. Notre objectif était de déterminer l'utilité diagnostique de l'échographie au point de soins (PoCUS) pour la taille de la veine cave inférieure (IVC) et l'collapsibilité dans la prédiction d'un état de liquide de surcharge volumique chez les patients souffrant d'une hypotension respiratoire spontanée. MéTHODES: Il s'agissait d'une analyse secondaire post-hoc des données SHOC-ED, un essai contrôlé randomisé prospectif examinant PoCUS chez des patients atteints d'hypotension indifférenciée. Nous avons collecté prospectivement des données sur la taille et la collapsibilité des IVC pour 138 patients du groupe PoCUS à l'aide d'un formulaire de collecte de données standard, et attribué indépendamment un état de fluide (volume surchargé, normal, épuisement du volume) à partir d'une revue de dossier clinique composite mise en aveugle aux résultats PoCUS. Le résultat principal était la performance diagnostique des caractéristiques IVC sur PoCUS dans la détection d'un état de fluide surchargé en volume. RéSULTATS: 129 patients avaient terminé l'évaluation IVC des déterminants par PoCUS, dont 125 ont reçu une détermination finale du statut hydrique, dont 107 ont été classés comme étant une diminution du volume, 13 normaux et 7 surchargés. Une courbe des caractéristiques de fonctionnement du récepteur (ROC) a été tracée en utilisant plusieurs catégories de taille et d'affaissement IVC. La meilleure performance globale a utilisé les paramètres combinés d'une IVC dilatée (> 2,5 cm) avec une collapsibilité minimale (moins de 50%) qui avait une sensibilité de 85,7% et une spécificité de 86,4% avec une zone sous la courbe (AOC) de 0,92 pour prédire un état de fluide surchargé en volume. CONCLUSION: IVC PoCUS est faisable chez les patients adultes souffrant d'une hypotension respiratoire spontanée et démontre une valeur potentielle en tant que prédicteur d'un état de liquide surchargé en volume chez les patients atteints d'hypotension indifférenciée. La taille IVC peut être la mesure préférée.

Image Acquisition Method for the Sonographic Assessment of the Inferior Vena Cava.

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical decision-making. Among the applications of POCUS, imaging the inferior vena cava (IVC) is practiced by a wide variety of specialties, such as nephrology, emergency medicine, internal medicine, critical care, anesthesiology, pulmonology, and cardiology. Although each specialty uses IVC data in slightly different ways, most medical specialties, at minimum, attempt to use IVC data to make predictions about intravascular volume status. While the relationship between IVC sonographic data and intravascular volume status is complex and highly context-dependent, all clinicians should collect the sonographic data in standardized ways to ensure repeatability. This paper describes standardized IVC image acquisition including patient positioning, transducer selection, probe placement, image optimization, and the pitfalls and limitations of IVC sonographic imaging. This paper also describes the commonly performed anterior IVC long-axis view and three other views of the IVC that can each provide helpful diagnostic information when the anterior long-axis view is difficult to obtain or interpret.

Preanesthetic ultrasonography assessment of inferior vena cava diameter in the supine position, left lateral tilt position, and with the left uterine displacement maneuver in full-term pregnant women: A randomized cross-over design study.

Preanesthetic ultrasonography assessment of inferior vena cava diameter (IVCD) in the supine position (SP), left lateral tilt position (LLT), and with the left uterine displacement maneuver (LUD) in full-term pregnant women: a randomized cross-over design study. AIM: We pre-anesthetically measured IVCD using ultrasonography in the SP, LLT, and the LUD in full-term pregnant women, using a cross-over design, to evaluate the effectiveness of LLT and LUD on increasing IVCD, and the presence of inter-individual differences among patients in the effect of posture on IVCD. METHODS: Twenty-two parturients scheduled for elective cesarean section under spinal anesthesia were recruited. All patients were sequentially placed in the SP, LLT, and with LUD before spinal anesthesia induction. Indices of IVCD, measured by subxiphoid ultrasonography, including maximum IVCD (IVCDmax), minimum IVCD (IVCDmin), and collapsibility index (CI) were recorded in each of the postures. Mean or median values of all measurements were compared among the postures. RESULTS: The mean values of IVCDmax observed with both LLT and LUD were significantly larger than those in the SP, respectively (SP vs. LLT: p < 0.05, SP vs. LUD: p < 0.01), although there were no significant differences between IVCDmax with LLT and LUD. There were no significant differences in IVCDmin and CI between any of the postures. IVCDmax was highest with LUD in 11 patients (55%), in the LLT in seven patients (35%) and in the SP in two patients (10%). CONCLUSIONS: LLT and LUD might be equally effective in enlarging the narrowed IVCD as compared to SP. However, both LLT and LUD might not necessarily be appropriate treatments to relieve IVC compression in some cases.

Fluid responsiveness assessment using inferior vena cava collapsibility among spontaneously breathing patients: Systematic review and meta-analysis.

OBJECTIVE: To synthesize the evidence about diagnostic accuracy of inferior vena cava collapsibility (IVCc) in prediction of fluid responsiveness among spontaneously breathing patients. DESIGN: Systematic review of diagnostic accuracy studies. SETTING: Intensive care units or emergency departments. PATIENTS AND PARTICIPANTS: spontaneously breathing patients with indication for fluid bolus administration. INTERVENTIONS: A search was conducted in MEDLINE and EMBASE. We included studies assessing IVCc accuracy for fluid responsiveness assessment with a standard method for cardiac output measure as index test. MAIN VARIABLES OF INTEREST: General information (year, setting, cutoffs, standard method), sensitivity, specificity, and area under the receiving operator characteristics curve (AUROC). Risk of bias was assessed with QUADAS 2 tool. We obtained the pooled sensitivity, specificity and summary ROC curve, with estimated confidence intervals from a bivariate model. We also calculated positive and negative likelihood ratios and developed a Fagon nomogram. RESULTS: Eight studies were included with 497 patients. Overall, the studies presented a high risk of bias. IVCc sensitivity was 63% (95% CI - 46-78%) and specificity 83% (95% CI - 76-87%). Despite moderate accuracy of IVCc (SROC 0.83, 95% CI - 0.80-0.86), post-test probability of being fluid responsive based on a 50% pre-test probability led to considerable misclassification. CONCLUSIONS: IVCc had moderate accuracy for fluid responsiveness assessment in spontaneously breathing patients and should not be used in isolation for this purpose.

Assessment of flow mechanics in the lower extremity venous system.

BACKGROUND: The Reynolds number (Re) is a dimensionless parameter that describes fluid flow mechanics. Veins are compliant and collapsible vascular conduits that can accommodate large volume changes in response to small pressure changes. However, only sparse information is available about flow parameters such as the Re in the venous system. METHODS: Bilateral duplex ultrasound examination of 15 healthy volunteers (30 limbs) was performed before and after exercise (four flights of stairs) of the veins of the lower extremity (left and right sides) and inferior vena cava. These volunteers had been confirmed to not have any signs or symptoms of lower extremity venous disease via focused history and physical examination findings. RESULTS: Most of the volunteers were women (73%). Their mean age was 37 ± 12.8 years. The Re was highest in the inferior vena cava among all the veins examined (470 ± 144 before exercise and 589 ± 205 after exercise; P = .04). The association between the change in Re before and after exercise and the specific vein examined was also significant for the right and left external iliac veins, right and left common femoral veins, right and left profunda femoris veins, right and left femoral veins, and right common iliac vein. Resistance and velocity maps for the lower extremity venous system were also created. The velocity increased and the resistance decreased as one moved up the venous tree toward the right atrium. CONCLUSIONS: The Re increased for most of the lower extremity veins after exercise in our healthy volunteers. However, the critical value for turbulent flow was not reached despite the exercise.

Cost Burden and Cost Influencers of Inferior Vena Cava Filter Placement and Retrieval among Medicare Beneficiaries with Acute Venous Thromboembolism.

PURPOSE: To examine the frequency, costs, and cost influencers of inferior vena cava filters (IVCFs) placements and retrievals among a national sample of patients using Medicare data. MATERIALS AND METHODS: This retrospective cohort study used the U.S. Medicare 100% database, a nationally representative sample of all U.S. patients aged ≥65 years, from 2014 through 2020. Procedures and clinical characteristics were identified from the diagnosis and procedure codes on Medicare claims. Beneficiaries aged ≥65 years with newly diagnosed venous thromboembolism (VTE) were identified and followed to obtain data on IVCF placements and retrievals. Data on the costs of the index IVCF procedures and any subsequent IVCF placements and retrievals were obtained. Multivariate models were used to estimate the impact of patient and clinical characteristics on costs. RESULTS: Among 501,216 patients with newly diagnosed VTE, 4,995 (1%) received an IVCF placement; of these, 1,215 (24.3%) had a retrieval procedure. Beneficiaries with IVCF placements and retrievals differed from a demographic and clinical perspective than from those without. Costs varied by the site of service, VTE acuity, and VTE type. Cost influencers included age, race, census region, service location, and VTE type. CONCLUSIONS: IVCF placement costs were driven by baseline patient characteristics (age, race, geographic residence, acute VTE diagnosis, and inpatient site of service), whereas retrieval costs were driven by age and deep vein thrombosis diagnosis. Strategies to mitigate the retrieval costs or the need to retrieve IVCFs may reduce the overall cost burden of IVCFs.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension.

BACKGROUND: Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. METHODS: One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. RESULTS: Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). CONCLUSIONS: Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Assessment of Intravascular Volume Status in Children with Nephrotic Edema Using Serum and Urinary Indices and Its Correlation with Inferior Vena Cava Collapsibility Index.

Identification of volume status in nephrotic syndrome (NS) is important but clinically challenging. Urinary and serum indices can be helpful in assessing the volume status and so can be inferior vena cava collapsibility index (IVCCI). This study was done to assess the serum and urinary indices in children with nephrotic edema and to correlate them with IVCCI for intravascular volume assessment. Fifty children with nephrotic edema and 47 children in remission were analyzed for blood and urine indices. Volume status was defined as overfilling or underfilling based on the biochemical indices and also by IVCCI. Eighty-four percent individuals among cases and 23% among controls had sodium retention (FENa < 0.5%). Among cases, 54% had primary sodium retention compared to 17% among controls (p = 0.0002). Hypovolemia was observed among 36% cases based on biochemical indices and in 20% cases as per IVCCI. Hypovolemia was significantly associated with low urinary sodium and low serum albumin.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension

Abstract Background Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. Methods One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. Results Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p= 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p= 0.615). Conclusions Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Utility of ultrasonography in preoperative assessment of tumor thrombi in kidney cancer.

INTRODUCTION: This study examined the clinical accuracy of ultrasonography compared to magnetic resonance imaging (MRI) and intraoperative findings for evaluation of tumor thrombi level in patients with renal cell carcinoma. MATERIALS AND METHODS: We retrospectively identified 38 patients at our institution who underwent both ultrasonography and MRI before undergoing open radical nephrectomy with tumor thrombectomy between 2010 and 2019. We compared tumor thrombus level findings of both ultrasonography and MRI, as well as the diagnostic accuracy of each to intraoperative findings. Agreement between ultrasonography, MRI, and surgery was tested with kappa. Logistic regression models identified factors that predict a mismatched thrombus level between an imaging modality and surgical findings. RESULTS AND CONCLUSIONS: Tumor thrombus levels determined by ultrasonography matched with MRI in 26 (68.4%) cases. Compared to operative findings, ultrasonography accurately identified the cephalad extent of thrombi in 30 (79.0%) cases, under-staged five (13.2%) cases, and over-staged three (7.9%). Magnetic resonance imaging agreed with operative findings in 30 (79.0%) cases, under-staged five (13.2%) and over-staged three (7.9%) cases. On univariable regression assessment, M1 stage was predictive of a mismatched result between MRI and surgery (OR: 6.0, 95% CI: 1.02-35.3, p = 0.047), but this association did not hold-up in a multivariable model. Ultrasonography and magnetic resonance imaging identified the preoperative tumor thrombus level at a rate of 79%. Ultrasonography is an effective preoperative imaging modality for evaluating tumor thrombi associated with kidney cancer, notably as an adjunct to magnetic resonance imaging.