Postembolization Persistence of Pulmonary Arteriovenous Malformations: A Retrospective Comparison of Coils and Amplatzer and Micro Vascular Plugs Using Propensity Score Weighting.

BACKGROUND. Endovascular embolization of pulmonary arteriovenous malformations (PAVMs) was historically performed with embolic coils. The Amplatzer Vascular Plug device (AVP) was introduced for this purpose in 2007 and the Micro Vascular Plug device (MVP) in 2013. OBJECTIVE. The purpose of this study was to compare coils, AVPs, and MVPs in terms of risk of persistence after PAVM embolization by use of propensity score weighting to account for biases in device selection. METHODS. This retrospective study included 112 patients (78 women and girls, 34 men and boys; mean age, 45 years) who underwent embolization of 393 PAVMs with a single device type (coil, MVP, or AVP) from January 2003 to January 2020. Persistence was defined as less than 70% reduction in PAVM sac size or contrast enhancement of the sac on follow-up pulmonary CTA. A Cox proportional hazards regression model was used to assess associations between embolic device selection and PAVM persistence. Inverse propensity score weighting was used to account for differences in embolic device selection based on patient and PAVM characteristics. RESULTS. The median postembolization follow-up period was 1.5 years (IQR, 0.3-5.6 years). Persistence was found in 10% (41/393) of PAVMs, including 16% (34/207) of those treated with coils, 8% (7/88) of those treated with AVPs, and 0% (0/98) of those treated with MVPs. Variables associated with embolization device (p < .25) were age, sex, pediatric versus adult status, smoking status, PAVM complexity, PAVM laterality, number of feeding arteries, and feeding artery diameter. The Cox regression model incorporated inverse propensity score weighting to account for the differences between treatment groups in these variables and incorporated feeding artery diameter because of imbalance remaining after weighting. With coils as the referent, MVPs had a hazard ratio for persistence of less than 0.01 (95% CI, < 0.01 to < 0.01; p < .001), and AVPs had a hazard ratio of 0.37 (95% CI, 0.16-0.90; p = .03). CONCLUSION. The risk of persistence after PAVM embolization was significantly lower for MVPs alone than for coils or AVPs alone. In addition, the risk of persistence was lower for AVPs than for coils. CLINICAL IMPACT. The findings support the clinical use of MVPs as the preferred device for PAVM embolization over coils and polytetrafluoroethylene-covered plugs.

Characteristics and Outcomes of Percutaneous Biliary Interventions in the United States.

OBJECTIVE: To explore baseline characteristics, comorbidities, and clinical diagnoses in the prediction of outcomes for inpatient percutaneous biliary interventions in the United States. METHODS: Hospitalizations for percutaneous transhepatic cholangiography and percutaneous biliary drainage were studied using the National Inpatient Sample 2012 to 2015. Associations between baseline characteristics, comorbidities, clinical diagnoses, and outcomes were analyzed using multivariable regression modeling. Regional variations were studied in an exploratory analysis. RESULTS: Hospitalizations for percutaneous biliary interventions had average inpatient mortality of 3.8% ± 0.8% and length of stay of 7.6 ± 0.3 days. Hypertension was the most common comorbidity (50.5% ± 0.8%), and paralysis was associated with the highest inpatient mortality (19.1% ± 5.7%) and length of stay (11.4 ± 1.3 days). Compared with nonmalignant biliary-pancreatic disorders, sepsis was associated with the highest inpatient mortality (6.5% ± 1.1%; adjusted odds ratio [aOR]: 5.2 [3.9-7.0]) and length of stay (9.0 ± 3.0 days; aOR: 2.2 [1.9-2.5]), followed by underlying malignancy (mortality of 5.5% ± 0.6%; aOR: 2.3 [1.7-3.0]; length of stay of 8.3 ± 0.2 days; aOR: 1.6 [1.4-1.8]). The observed associations were independent of baseline characteristics and comorbidities. With regard to regional variations, the Middle Atlantic states had the lengthiest hospital stays (38.8% ± 2.0% >8 days) and the East South Central states had the highest inpatient mortality (6.6% ± 1.6%) while having the highest frequency of malignancy (37.9% ± 3.7%) and the lowest frequency of postoperative cases (15.2% ± 2.4%). CONCLUSION: In addition to baseline characteristics and comorbidities, sepsis and malignancy were determinants of higher mortality and increased length of stay in hospitalizations for percutaneous biliary interventions. We observed significant regional variations in clinical diagnoses and outcomes across the United States.

Transplant uretero-inguinal hernia resulting in urosepsis.

Uretero-inguinal hernias are rare and can be difficult to diagnose. We present a case of a rare transplant kidney uretero-inguinal hernia. An 81-year-old male presented with urosepsis and was found to have an obstructed transplanted kidney secondary to herniation of the ureter into an inguinal hernia. The patient required interventional radiology decompression of the urinary system with a percutaneous nephrostomy tube. In this case, the patient's uretero-inguinal hernia was the extraperitoneal subtype allowing the diagnosis to be made easily on computed tomography imaging of the abdomen and pelvis which facilitated rapid treatment.

MVP™ Micro Vascular Plug Systems for the Treatment of Pulmonary Arteriovenous Malformations.

PURPOSE: To describe our institutional experience with MVP™ micro vascular plug systems for the treatment of pulmonary arteriovenous malformations (PAVMs). MATERIALS AND METHODS: We performed a retrospective medical record review of 52 patients with 119 PAVMs treated exclusively with MVP™ systems (69 procedures/153 MVP™ systems) between July 2014 and July 2018. All patients had PAVMs with feeding artery diameters ≥ 2 mm. MVP™ systems were deployed according to physician preference. We collected patient demographic information; procedural data (including size of feeding artery, size and number of embolics used per PAVM, fluoroscopy time, contrast administration), technical success rates, complications, and persistence. Persistence was assessed using computed tomography angiography (CTA) performed 1-3 months and 3-5 years after embolization per clinical protocol. RESULTS: All procedures were technically successful without major complications. Mean feeding artery diameter was 3.3 ± 1.2 mm. Mean fluoroscopy time per procedure and contrast volume administered per procedure were 35 ± 16 min and 217 ± 101 mL, respectively. A mean of 1.3 ± 0.8 MVP™ systems was used per PAVM. There were no instances of persistence during a mean follow-up time of 328 ± 258 days (range 26 to 914 days). CONCLUSIONS: For PAVMs with feeding artery diameters of 2 to 7.9 mm (mean 3.3 ± 1.2 mm), MVP™ systems are safe and effective given their high technical success rates and lack of persistence. Further prospective work will be required to elucidate the advantages and disadvantages of these MVP™ systems for PAVM embolization. LEVEL OF EVIDENCE: Level III.