Migration of Nonfibered Packing Coils Used to Treat Peripheral Pseudoaneurysms: Report of 3 Cases.

Coil migration is a rare complication of vascular embolization. This report describes 3 cases of peripheral pseudoaneurysm embolization with the use of Penumbra packing coils in which coils migrated into the lumens of adjacent viscera: 2 into the duodenum and 1 into the vagina. The coils passed spontaneously in 2 cases and required endoscopic removal in the third. There were no immediate or delayed bleeding or infectious complications following migration. The majority of previously reported coil migration cases have occurred following treatment of pseudoaneurysms adjacent to air-filled structures, and this observation is an important consideration during pretreatment planning.

Endovascular intervention for deep venous thrombosis in patients with inferior vena cava filters.

Patients with inferior vena cava (IVC) filter-associated deep venous thrombosis (DVT) are a challenging subset of patients for endovascular intervention. Given the lack of available data pertaining to this clinical scenario, the purpose of this study was to evaluate the authors' experience with the use of endovascular treatment for DVT in patients with IVC filters. Primary aims included assessing the technical and clinical success, complications, and clinical patency in these patients. This was a retrospective single-center review of adult patients with IVC filters undergoing endovascular treatment of DVT between 1/2005 and 4/2014. Patient electronic medical records were reviewed for demographic data, anticoagulation status, symptoms, symptomatic extremities, extent of thrombosis, therapies received, technical and clinical success, and complications. Query yielded 82 patients (mean 53 years, range 18-96; 66% male), all of whom were included in our analysis. The majority of patients presented with lower extremity pain and swelling, with extensive clot burden despite the use of anticoagulant medication. Treatment elements utilized included pharmacologic lysis in 92%, mechanical thrombectomy in 77%, angioplasty in 63% and stent placement in 50% of patients. Interventions were technically successful in restoring flow in 87% of patients, and clinically successful in improving presenting symptoms in 79% of patients. By SIR criteria, 24% of patients experienced complications (categorized as 10% minor and 14% major). There were two deaths from intracranial hemorrhage. The probability of thrombosis-free survival at 1, 3, 6, 9 and 12 months was 0.85 (CI 0.74-0.93), 0.81 (CI 0.69-0.89), 0.74 (CI 0.62-0.83), 0.70 (CI 0.57-0.8) and 0.70 (CI 0.57-0.8), respectively. Endovascular interventions are usually effective in relieving symptoms in patients with DVT and pre-existing IVC filters. However, these outcomes are achieved with significant complication rates that may exceed those observed when endovascular therapy is provided for other DVT populations.

Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH.

Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.

Management algorithm of acute cholecystitis after percutaneous cholecystostomy catheter placement based on outcomes from 377 patients.

PURPOSE: To report outcomes of percutaneous cholecystostomy (PC) catheter placement in patients with acute cholecystitis (AC) and propose management algorithm of AC after PC catheter placement based on the outcomes. METHOD AND MATERIALS: Retrospective study was performed. 419 patients who underwent PC between July 2010 and September 2016 were included. Patients who underwent PC for indication other than AC were excluded. The primary outcome was definitive treatment of AC following PC, including cholecystectomy or percutaneous cholecystolithotomy. Secondary outcomes include removal of drainage catheter without further management or death with catheter in place. Based on outcomes, we proposed management algorithm of AC after PC catheter placement. RESULTS: 377 of 419 patients underwent PC for treatment of AC (median age, 66 years; range 18-100 years). Technical success rate was 100% with 2.4% major complications rate and 1.6% minor complications rate. Following PC, 118 patients (31%) underwent definitive treatment with cholecystectomy. Sixty-one patients (16%) underwent definitive treatment with percutaneous cholecystolithotomy with removal of catheters. Seventy-four patients (20%) had their catheters removed upon resolution of cholecystitis without undergoing surgery or stone removal. Fifty patients (13%) died with catheters in place due to other comorbidities. Five patients (1%) still had their catheters in place at the end of the study. CONCLUSION: PC remains a viable option for treatment of AC with low complication rate and can be used as bridge to definitive therapy. Our proposed management algorithm can be a guideline for the management of AC after PC catheter placement.

Prior MDMA (Ecstasy) use is associated with increased basal ganglia-thalamocortical circuit activation during motor task performance in humans: an fMRI study.

MDMA (3,4-methylenedioxymethamphetamine; Ecstasy) is a popular recreational drug that produces long-lasting serotonin (5-HT) neurotoxicity consisting of reductions in markers for 5-HT axons. 5-HT innervates cortical and subcortical brain regions mediating motor function, predicting that MDMA users will have altered motor system neurophysiology. We used functional magnetic resonance imaging (fMRI) to assay motor task performance-associated brain activation changes in MDMA and non-MDMA users. 24 subjects (14 MDMA users and 10 controls) performed an event-related motor tapping task (1, 2 or 4 taps) during fMRI at 3 T. Motor regions of interest were used to measure percent signal change (PSC) and percent activated voxels (PAV) in bilateral motor cortex, sensory cortex, supplementary motor area (SMA), caudate, putamen, pallidum and thalamus. We used SPM5 to measure brain activation via three methods: T-maps, PSC and PAV. There was no statistically significant difference in reaction time between the two groups. For the Tap 4 condition, MDMA users had more activation than controls in the right SMA for T-score (p=0.02), PSC (p=0.04) and PAV (p=0.03). Lifetime episodes of MDMA use were positively correlated with PSC for the Tap 4 condition on the right for putamen and pallidum; with PAV in the right motor and sensory cortex and bilateral thalamus. In conclusion, we found a group difference in the right SMA and positive dose-response association between lifetime exposure to MDMA and signal magnitude and extent in several brain regions. This evidence is consistent with MDMA-induced alterations in basal ganglia-thalamocortical circuit neurophysiology and is potentially secondary to neurotoxic effects on 5-HT signaling. Further studies examining behavioral correlates and the specific neurophysiological basis of the observed findings are warranted.

MDMA (Ecstasy) association with impaired fMRI BOLD thalamic coherence and functional connectivity.

BACKGROUND: MDMA exposure is associated with chronic serotonergic dysfunction in preclinical and clinical studies. A recent functional magnetic resonance imaging (fMRI) comparison of past MDMA users to non-MDMA-using controls revealed increased spatial extent and amplitude of activation in the supplementary motor area during motor tasks (Karageorgiou et al., 2009). Blood oxygenation level dependent (BOLD) data from that study were reanalyzed for intraregional coherence and for inter-regional temporal correlations between time series, as functional connectivity. METHODS: Fourteen MDMA users and ten controls reporting similar non-MDMA abuse performed finger taps during fMRI. Fourteen motor pathway regions plus a pontine raphé region were examined. Coherence was expressed as percent of voxels positively correlated with an intraregional index voxel. Functional connectivity was determined using wavelet correlations. RESULTS: Intraregional thalamic coherence was significantly diminished at low frequencies in MDMA users compared to controls (p=0.009). Inter-regional functional connectivity was significantly weaker for right thalamo - left caudate (p=0.002), right thalamo - left thalamus (p=0.007), right caudate - right postcentral (p=0.007) and right supplementary motor area - right precentral gyrus (p=0.011) region pairs compared to controls. When stratified by lifetime exposure, significant negative associations were observed between cumulative MDMA use and functional connectivity in seven other region-pairs, while only one region-pair showed a positive association. CONCLUSIONS: Reported prior MDMA use was associated with deficits in BOLD intraregional coherence and inter-regional functional connectivity, even among functionally robust pathways involving motor regions. This suggests that MDMA use is associated with long-lasting effects on brain neurophysiology beyond the cognitive domain.