Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism.

Background: Early data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration. Objectives: To investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration. Methods: A retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications. Results: A total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.5 ± 2.7 vs. -7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001). Conclusions: CDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT. Condensed unstructured abstract: We report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.2 ± 2.7 vs. -7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).

Labial necrosis after uterine artery embolization for leiomyomata.

BACKGROUND: Uterine artery embolization is increasingly used as an alternative to myomectomy, hysterectomy, and medical treatment for the management of symptomatic leiomyomata. CASE: A woman with an 18-week-size fibroid uterus who underwent uterine artery embolization developed a 3-cm, exquisitely tender, hypopigmented, necrotic-appearing area on the right labium minus. Spontaneous resolution occurred over 4 weeks. CONCLUSION: Labial necrosis is a possible complication of uterine artery embolization and may be successfully managed with conservative therapy.

Ischemic jejunal stricture following endovascular abdominal aortic aneurysm repair -- a case report.

Endograft repair has rapidly become an alternative to conventional open repair of abdominal aortic aneurysms. Various trials continue to show decreased morbidity when compared to open repair. However, as with any new procedure, complications specifically related to this technique are being described. Herein, we report a case of an isolated ischemic jejunal stricture presenting as a small-bowel obstruction secondary to cholesterol emboli following endograft repair of an abdominal aortic aneurysms.

II. Uterine fibroid embolization: technical aspects.

Successful superselective catheterization of the uterine artery requires familiarity with female pelvic arterial anatomy, knowledge of effective catheter and guidewire combinations, and a few tricks. A learning curve can be expected for each of these elements, although it is assumed that the operator will already have experience in basic catheter techniques. Safe transcatheter delivery, understanding of embolization end points, and avoidance of nontarget embolization are essential. Equally important are knowledge of the properties of the embolic agents currently available and their indications for use. Uterine fibroid embolization unavoidably results in radiation exposure to the uterus and ovaries, and adherence to meticulous fluoroscopic technique is crucial to keep the absorbed dose as low as possible.

V. Uterine fibroid embolization: management of complications.

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

IV. Uterine fibroid embolization: follow-up.

Patients generally notice some relief of both menorrhagia and mass-effect symptoms during the first few weeks after uterine fibroid embolization (UFE). Shrinkage of the fibroids continues to take place over several months, peaking somewhere between 3 and 6 months, with measurable shrinkage sometimes noted for up to 1 year. The timing of follow-up visits is intended to coincide with the time course of improvement so that diagnostic imaging and intervention can be performed if symptoms worsen or relief does not appear to be on schedule. The amount of shrinkage of fibroids correlates neither with the intensity of immediate postprocedure symptoms or the degree of symptom relief. Affected fibroids undergo hyaline degeneration, a process in which the hard, cellular tumor is replaced by softer, acellular material. A nationwide registry has been constructed for the accumulation of procedural and follow-up data so that success and complication rates can be accurately determined and long-term issues about the durability of UFE and possible side effects can be addressed.

III. Uterine fibroid embolization: pain management.

Conscious sedation and analgesia are integral components of successful uterine fibroid embolization (UFE), both in providing comfort to the anxious patient undergoing an elective procedure and for providing relief of the severe pelvic pain, cramps, and nausea that may result from acute uterine ischemia and the postembolization syndrome that may follow. The agents used are typically those with which interventional radiologists already have extensive experience in the performance of a variety of invasive procedures. Immediate postprocedure care benefits greatly from the use of narcotic delivered via PCA (patient-controlled analgesia) pump. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also particularly useful for treating the pain and cramping caused by UFE and help reduce the amount of narcotic necessary for pain relief during the recovery period. Detailed instructions for the first week of convalescence are necessary to insure comfort and avoid complications.

VI. Uterine fibroid embolization: developing a clinical service.

Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.

Patient presentation and management of labial ulceration following uterine artery embolization.

Uterine artery embolization is a safe and effective procedure for the treatment of symptomatic uterine fibroids. Nontarget embolization of adjacent internal iliac artery branches is a reported complication of uterine artery embolization. The following report describes the presentation and management of ulcerations of the labium minora due to nontarget embolization of the internal pudendal artery.

Percutaneous retrieval of a Greenfield filter after migration to the left pulmonary artery.

A Titanium Greenfield filter migrated to the left pulmonary artery during its deployment in a 67-year-old woman. The filter was successfully removed percutaneously without complications with use of an Amplatz Goose Neck snare and the 12-F sheath from the Greenfield filter kit.

Turf wars in radiology: the battle for peripheral vascular interventions.

Interventional radiologists in many hospitals are involved in confrontations with cardiologists and vascular surgeons over who should be allowed to perform percutaneous noncardiac peripheral vascular interventions. There are valid reasons why radiologists should be the ones doing these procedures: first, because in any given hospital, radiologists are generally the physicians with the best training and most experience, and second, because they are generally not in a position to self-refer and will therefore be able to help keep utilization under control. If cardiologists or vascular surgeons request vascular interventional privileges at your hospital, there are steps you can take to see if they are properly qualified. If they are granted privileges, there are other steps you can take to ensure that high standards of patient care are maintained. The authors also present some discussion of how interventional radiologists can position themselves to either compete with or collaborate with the other clinical services. Throughout any confrontations that might occur, radiologists should stress that patients undergoing these procedures deserve the best possible care, which means that they should be performed by those physicians on the hospital staff who are the most knowledgeable and the least likely to commit medical errors.

Endovascular repair of carotid artery aneurysms following carotid endarterectomy.

Aneurysm of the carotid artery following endarterectomy is a rare entity that historically has required reoperation. Endovascular deployment of a covered stent can theoretically exclude an aneurysm while minimizing the risks seen with reoperation. Herein, we review the scientific literature on this evolving technique and report an additional case involving successful treatment of an aneurysm that developed following remote endarterectomy.

The changing roles of radiologists, cardiologists, and vascular surgeons in percutaneous peripheral arterial interventions during a recent five-year interval.

PURPOSE: This study aimed to determine the relative roles of radiologists, cardiologists, vascular surgeons, and other physicians in performing percutaneous peripheral arterial interventions and how these roles have changed over a recent 5-year period. METHODS AND MATERIALS: The authors reviewed the Medicare Part B fee-for-service databases between 1997 and 2002 for the Current Procedural Terminology (4th ed.) (CPT-4) surgical procedure codes for percutaneous transluminal angioplasty (PTA) of noncardiac peripheral arteries (six codes), the transcatheter placement of noncardiac intravascular stents (two codes), and endovascular aortic stent graft placement (six codes). Using the Medicare physician specialty codes, procedure volume in each CPT-4 code was determined for radiologists, cardiologists, vascular surgeons, and other physicians. Percentage changes from 1997 to 2002 were calculated for PTA and intravascular stent placement procedures. RESULTS: Between 1997 and 2002, the total Medicare procedure volume in the eight procedure codes relating to PTA and stent placement increased by 95%. In 2002, radiologists performed 72,657 of these procedures, cardiologists 62,901, vascular surgeons 17,895, and other physicians 19,666. Over the 5-year interval, procedure volume among radiologists increased 29%, among cardiologists by 181%, among vascular surgeons by 398%, and among other physicians by 195%. Radiologists' share in the total pool of procedures in 2002 was 42.0% (down from 63.3% in 1997), cardiologists' 36.3% (up from 25.2% in 1997), vascular surgeons' 10.3% (up from 4.0% in 1997), and other physicians' 11.4% (up from 7.5% in 1997). Trend data were not available for endovascular aortic stent graft procedures. CONCLUSION: Between 1997 and 2002, procedure volume in percutaneous peripheral arterial interventions grew at faster rates among cardiologists, vascular surgeons, and other physicians than it did among radiologists. As a result, radiologists' share of this market declined during the interval. However, procedure volume among radiologists continued to grow over the 5 years, and in 2002, they still had the largest share among the four physician specialty groups. Thus, despite the erosion, interventional radiologists still maintain a strong position in this rapidly growing field.

Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement.

The purpose of this study was to determine the incidence of central vein stenosis and occlusion following upper extremity placement of peripherally inserted central venous catheters (PICCs) and venous ports. One hundred fifty-four patients who underwent venography of the ipsilateral central veins prior to initial and subsequent venous access device insertion were retrospectively identified. All follow-up venograms were interpreted at the time of catheter placement by one interventional radiologist over a 5-year period and compared to the findings on initial venography. For patients with central vein abnormalities, hospital and home infusion service records and radiology reports were reviewed to determine catheter dwell time and potential alternative etiologies of central vein stenosis or occlusion. The effect of catheter caliber and dwell time on development of central vein abnormalities was evaluated. Venography performed prior to initial catheter placement showed that 150 patients had normal central veins. Three patients had central vein stenosis, and one had central vein occlusion. Subsequent venograms (n = 154) at the time of additional venous access device placement demonstrated 8 patients with occlusions and 10 with stenoses. Three of the 18 patients with abnormal follow-up venograms were found to have potential alternative causes of central vein abnormalities. Excluding these 3 patients and the 4 patients with abnormal initial venograms, a 7% incidence of central vein stenosis or occlusion was found in patients with prior indwelling catheters and normal initial venograms. Catheter caliber showed no effect on the subsequent development of central vein abnormalities. Patients who developed new or worsened central vein stenosis or occlusion had significantly (p = 0.03) longer catheter dwell times than patients without central vein abnormalities. New central vein stenosis or occlusion occurred in 7% of patients following upper arm placement of venous access devices. Patients with longer catheter dwell time were more likely to develop central vein abnormalities. In order to preserve vascular access for dialysis fistulae and grafts and adhere to Dialysis Outcomes Quality Initiative guidelines, alternative venous access sites should be considered for patients with chronic renal insufficiency and end-stage renal disease.

Infectious complications of implantable venous access devices in patients with sickle cell disease.

PURPOSE: To evaluate the incidence of implantable venous access device infection in patients with sickle cell disease. MATERIALS AND METHODS: The authors performed a retrospective search of their hospital's information system from January 1, 1996 to December 31, 2001 to identify hospital admissions with ICD-9 codes related to sickle cell anemia. This search yielded 2703 admissions in 293 patients. A search of the radiology information system identified 23 of these patients who had placement of an implantable venous access device. Excluding two patients who were lost to follow-up, the population of this study included eight men and 13 women aged 23 to 62 years old (mean, 37 years). A total of 30 implantable venous access devices (25 venous ports, five tunneled catheters) were placed by interventional radiologists. Cases of device infection were identified based on clinical data, microbiology, reports of device removal, and clinical follow-up. Infections were defined according to the Centers for Disease Control criteria for catheter-related bloodstream infection. The incidence of infection, organism, and time from device placement to infection was determined. RESULTS: In 21 patients with 30 devices, 18 device infections (60%) occurred in 12 patients (57%) involving 15 venous ports and three tunneled catheters. There were a total of 12389 days of catheter use and a rate of 1.5 infections per 1000 catheter days. Infections occurred from 16 to 1542 days (mean, 349 days) after device placement. Blood, wound, and catheter tip cultures yielded solitary organisms in 13 cases and mixed organisms in four cases. Staphylococcus aureus was the most common pathogen (59%). One patient was considered infected based on clinical signs and purulent discharge from the port site, despite negative cultures after partial antibiotic treatment. One patient died of sepsis resulting from an infected port. CONCLUSION: This study shows a high incidence of infection associated with placement of implantable venous access devices in patients with sickle cell disease. Therefore, the authors avoid placing these devices in this patient population.

Complications of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure: a case-controlled study.

PURPOSE: To evaluate the incidence and types of complications encountered with use of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure in a retrospective case-controlled study. MATERIALS AND METHODS: The authors identified 100 consecutive patients, 15 men and 85 women 21-85 years of age (mean, 50 years), between December 2000 and July 2001 in whom the Closer percutaneous suture-mediated closure device was used during 65 uterine artery embolization (UAE) procedures, 11 hepatic chemoembolization procedures, nine diagnostic angiography procedures, seven peripheral vascular interventions, six visceral arterial interventions, and two thrombolysis procedures. An age-, sex-, and procedure-matched control population was identified in which manual compression was performed. Procedure reports and clinical charts were reviewed for the presence of puncture-site complications, as categorized according to Society of Interventional Radiology reporting standards, and for risk factors and comorbid conditions (hypertension, diabetes, stroke, smoking, and coronary artery disease). Follow-up visits and imaging studies were reviewed for patients with complications. RESULTS: In the Closer group, there were seven device failures, four minor complications, and three major complications. Minor complications included two groin hematomas and two cases of persistent pain at the arteriotomy site. Three major complications consisted of two cases of external iliac artery dissection, one with distal embolization, and one case of common femoral artery (CFA) occlusion and distal embolization. All major complications occurred in women undergoing UAE. One patient required thromboendarterectomy and patch angioplasty to repair the CFA occlusion, as well as amputation of a gangrenous toe. In the manual-compression group, there was one minor complication (a groin hematoma) and no major complications. There were significantly more complications in the Closer group than in the manual compression group (P =.02). CONCLUSIONS: Significantly more complications were associated with use of a percutaneous suture-mediated closure device than with manual compression for arteriotomy-site hemostasis. Major complications and associated morbidity may be seen with use of percutaneous suture-mediated closure devices. In particular, an unexpectedly high frequency of device-related complications was demonstrated in young women undergoing UAE.

Application of duplex US for characterization of endoleaks in abdominal aortic stent-grafts: report of five cases.

Endoleaks were detected with helical computed tomographic (CT) angiography in five patients after placement of an aortobiliac stent-graft. The leaks were subsequently evaluated with duplex ultrasonography (US) and, in four patients, with conventional aortography as well. CT angiography revealed a total of seven endoleaks, all of which were prospectively classified as reconstitution (type II) leaks. Duplex US demonstrated six of the seven endoleaks. At duplex US, two of the leaks were characterized as attachment-site (type I) leaks; these two diagnoses were confirmed during subsequent angiography and profoundly altered clinical care. As an adjunct to CT angiography in evaluating endoleaks, duplex US provides hemodynamic information that enables further characterization of the type of endoleak and facilitates appropriate clinical care.

Angiographic assessment of initial balloon angioplasty results.

PURPOSE: To determine the influence of three factors involved in the angiographic assessment of balloon angioplasty-interobserver variability, operator bias, and the definition used to determine success-on the primary (technical) results of angioplasty in the peripheral arteries. MATERIALS AND METHODS: Percent stenosis in 107 lesions in lower-extremity arteries was graded by three independent, experienced vascular radiologists ("observers") before and after balloon angioplasty and their estimates were compared with the initial interpretations reported by the physician performing the procedure ("operator") and an automated quantitative computer analysis. Observer variability was measured with use of intraclass correlation coefficients and SD. Differences among the operator, observers, and the computer were analyzed with use of the Wilcoxon signed-rank test and analysis of variance. For each evaluator, the results in this series of lesions were interpreted with three different definitions of success. RESULTS: Estimation of residual stenosis varied by an average range of 22.76% with an average SD of 8.99. The intraclass correlation coefficients averaged 0.59 for residual stenosis after angioplasty for the three observers but decreased to 0.36 when the operator was included as the fourth evaluator. There was good to very good agreement among the three independent observers and the computer, but poor correlation with the operator (P