Single-procedure 8Fr rheolytic pharmacomechanical thrombectomy for treatment of acute iliofemoral deep venous thrombosis.

PURPOSE: We hypothesize that single-procedure venous-specific rheolytic thrombectomy for treatment of acute iliofemoral deep venous thrombosis (DVT) will result in improved clinical symptoms as measured by the venous clinical severity score (VCSS), as well as durable venous patency, with decreased hemorrhagic risks and costs associated with conventional catheter-directed therapy and prolonged lytic exposure. MATERIALS AND METHODS: Thirty-three consecutive patients with symptomatic, unilateral, iliofemoral DVT who were treated with single-procedure therapy using the 8Fr rheolytic thrombectomy catheter were retrospectively analyzed from 2012-2021. Abstracted data included technical success (> 95% clearance of acute thrombus), adverse events (AEs), and clinical and imaging outcomes at 1-month and 1-year. RESULTS: Technical success was achieved in all 33 patients. Mean pre-procedure VCSS was 7.5 with mean edema and pain sub-scores of 2.6 and 1.8, respectively. Post-procedural total mean VCSS at one month was significantly improved (mean post-procedure VCSS = 0.3, mean reduction of 7.2, P < 0.01). Clinical improvement was sustained at 1-year (mean total VCSS = 0.2, P < 0.01). Primary patency was achieved in all patients at 1-month and 30 (91%) patients at 1-year. Among the 3 patients in which primary patency was not achieved at 1-year, primary-assisted patency was achieved in 2 patients. Secondary patency was achieved in the remaining patient at 1-year. No hemorrhagic AEs occurred in this study. CONCLUSION: This study suggests that single-procedure venous-specific rheolytic thrombectomy for treatment of acute iliofemoral DVT is safe and effective, resulting in durable clinical and radiographic results at one year, while also limiting hemorrhagic risks, mitigating costs of admission, and expediting patient discharge.

Excimer Laser Sheath-Assisted Retrieval of "Closed-Cell" Design Inferior Vena Cava Filters.

Background Numerous reports have shown that inferior vena cava filters are associated with clinically significant adverse events. Complicating factors, such as caval incorporation, may lead to technical challenges at retrieval. The use of advanced techniques including the laser sheath have increased technical success rates; however, the data are limited on which filter types necessitate and benefit from its use. Methods and Results From October 2011 to September 2019, patients with inferior vena cava filter dwell times >6 months or with prior failed retrievals were considered for laser sheath-assisted retrieval. Standard and nonlaser advanced retrieval techniques were attempted first; if the filter could not be safely or successfully detached from the caval wall using these techniques, the laser sheath was used. Technical success, filter type, necessity for laser sheath application based on "open" versus "closed-cell" filter design, dwell times, and adverse events were evaluated. A total of 441 patients (216 men; mean age, 54 years) were encountered. Mean dwell times for all filters was 56.6 months, 54.4 among closed-cell filters and 58.5 among open-cell filters (P=0.63). Technical success of retrieval was 98%, with the laser sheath required in 143 cases (40%). Successful retrieval of closed-cell filters required laser sheath assistance in 60% of cases as compared with 7% of open-cell filters (odds ratio, 20.1; P<0.01). In closed-cell inferior vena cava filters, dwell time was significantly associated with need for laser, requiring it in 64% of retrievals with dwell times >6 months (P=0.01). One major adverse event occurred among laser sheath retrievals when a patient required a 2-day inpatient admission for a femoral access site hemorrhage. Conclusions Closed-cell filters may necessitate the use of the laser sheath for higher rates of successful and safe retrieval.

Single-session inferior vena cava filter removal, recanalization, and endovenous reconstruction for chronic iliocaval thrombosis.

OBJECTIVE: The objective of this study was to demonstrate the safety and efficacy of treatment of inferior vena cava filter (IVCF)-related chronic iliocaval thrombosis with single-session IVCF retrieval and iliocaval recanalization, thereby optimizing stent deployment and avoiding adverse events (AEs) related to stent placement across an obstructed filter. METHODS: From January 2015 to April 2018, a cohort of 25 consecutive patients presented for treatment of IVCF-related chronic iliocaval thrombosis with filter retrieval, followed by recanalization with stent placement and adjunctive iliofemoral thrombectomy as needed. Inclusion criteria included computed tomography (CT) imaging and clinical presentations consistent with chronic (>30 days) IVCF-related chronic thrombosis. A retrospective analysis of technical success, clinical success as measured with the Venous Clinical Severity Score, use of advanced filter retrieval techniques, and AEs was performed. Primary patency was evaluated with CT at 1 to 3 months and 1 year. Data analysis was performed using a paired t-test. RESULTS: There were 25 patients (median age, 58.0 years; standard deviation, 15.6 years) with eight types of IVCF encountered; all were treated in a single session. Technical success was achieved in all patients. Mean improvement in the Venous Clinical Severity Score was 1.4 (95% confidence interval, 1.0-1.7; P < .01) in the venous edema subscore and 0.6 (95% confidence interval, 0.2-1.0; P < .01) in the pain subscore. At 1 to 3 months, iliocaval stent patency was maintained in 96% of patients; unilateral iliac vein stent thrombus was seen in one patient. One-year follow-up was available in eight patients, with CT imaging demonstrating maintained patency. Median filter implantation time was 12.3 months (mean, 41.9 months; range, 0.8-245.1 months; standard deviation, 63.3 months). Advanced IVCF retrieval techniques were required for 17 procedures. One major AE and minor AE occurred; no patients died in the study period. CONCLUSIONS: Single-session iliocaval recanalization with IVCF retrieval has high rates of technical and clinical success in patients with IVCF-related chronic iliocaval thrombosis.

Prostate Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Results From a Prospective FDA-Approved Investigational Device Exemption Study.

OBJECTIVE: To evaluate the safety and efficacy of prostate artery embolization (PAE) for lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). METHODS: A prospective, single-center, open-label FDA-approved study was conducted to evaluate the safety and efficacy of PAE for LUTS secondary to BPH. We enrolled men ≥ 45, prostate volume > 40 g, International prostate symptom score (IPSS) > 13, peak flow rate (Qmax) ≤ 12 mL/s, and voided volume ≥ 125 mL. Patients were evaluated with questionnaires (IPSS, quality-of-life [QoL], International index of erectile function, and male sexual health questionnaire for ejaculatory dysfunction) and clinical measures (postvoid residual volume and Qmax at baseline 1, 3, and 12 months) after PAE. Baseline and 6-month total prostate (TV) and central gland (CG) volumes were obtained. RESULTS: 45 patients (mean volume: 99 cc, range: 30-214 g) were treated over the course of the 3-year study. At 1 month, there were improvements in IPSS (23.6 ± 6.1 to 12.0 ± 5.9, P < .0001), QoL (4.8 ± 0.9 to 2.6 ± 1.6, P < .0001), Qmax (5.8 ± 1.0 to 12.4 ± 6.8,P < .0001). At 3 months, there were improvements in IPSS (10.2 ± 6.0, P < .0001), QoL (2.4 ± 1.6, P < .0001) and Qmax (15.3 ± 12.3, P < .0001). At 6 months, there were improvements in IPSS (11.0 ± 7.6, P < .0001) and QoL (2.3 ± 1.7, P < .0001). At 1 year, there were improvements in IPSS (12.4 ± 8.4,P < .0001) and QoL (2.6 ± 1.6, P < .0001). There were reductions in postvoid volume residues: baseline 157 ± 45, 1 month 123 ± 47, P = .057, 3 months 127 ± 114, P = .34, 6 months 112±116, P = .002 and 1 year 109±116 P = .025. Median decreases in TV and CG were 18% (CI: 13-27) (P = 0.0001) and 27% (CI: 20-36)(P = 0.0001), respectively. Self-limited adverse events included dysuria (n = 13), hematuria (n = 6), hematospermia (n = 2), urinary frequency (n = 3) and retention (n = 2). No severe adverse events, nontarget embolization, or adverse effects on erectile function or sexual health. CONCLUSION: This prospective clinical trial demonstrates that PAE is safe and efficacious for BPH, with significant improvement in LUTS and reduction in TV and CG volumes.

Autologous sapheno-saphenous bypass collateral development in the setting of chronic unilateral iliac vein occlusion.

BACKGROUND: Chronic iliac vein occlusion can result in the development of a variety of collateral venous drainage pathways. While several drainage pathways have been well documented, autologous sapheno-saphenous bypass collateral drainage has not been described. This novel collateral drainage pathway is readily visible on cross sectional imaging, may serve as a diagnostic indicator of chronic obstructive venous pathology, and may hint at the underlying etiology. CASE PRESENTATION: This brief report depicts findings and technical considerations in two cases of venous recanalization of sapheno-saphenous collaterals in the setting of chronic unilateral iliac vein occlusion. In both cases at one-month follow-up, the patients' pain had resolved, edema had improved, and computed tomographic venography demonstrated stent patency. CONCLUSIONS: Identification of a sapheno-saphenous collateral can provide an important clue to the underlying venous obstructive pathology, therefore guiding corrective intervention.

Defining Prolonged Dwell Time: When Are Advanced Inferior Vena Cava Filter Retrieval Techniques Necessary? An Analysis in 762 Procedures.

BACKGROUND: Despite growth in placement of retrievable inferior vena cava filters, retrieval rates remain low. Filters with extended implantation times present a challenge to retrieval, where standard techniques often fail. The development of advanced retrieval techniques has positively impacted retrieval of retrievable inferior vena cava filters with prolonged dwell times; however, there is no precise definition of the time point when advanced techniques become necessary. We aim to define prolonged retrievable inferior vena cava filters dwell time by determining the inflection point when the risk of standard retrieval technique failure increases significantly, necessitating advanced retrieval techniques to maintain overall technical success of retrieval. METHODS AND RESULTS: From January 2009 to April 2015, 762 retrieval procedures were identified from a prospectively acquired database. We assessed patient age/sex, filter dwell time, procedural technical success, the use of advanced techniques, and procedure-related adverse events. Overall retrieval success rate was 98% (n=745). When standard retrieval techniques failed, advanced techniques were used; this was necessary 18% of the time (n=138). Logistic regression identified that dwell time was the only risk factor for failure of standard retrieval technique (odds ratio, 1.08; 95% confidence interval, 1.05-1.10; P<0.001). Spline function regression analysis demonstrated that if dwell time exceeded 7 months, the risk of standard technique failure was 40.9%. Adverse events occurred at a rate of 2% (n=18; 15 minor and 3 major). CONCLUSIONS: The necessity of advanced techniques to maintain technical success of retrieval increases with dwell time. Patients with retrievable inferior vena cava filters in place beyond 7 months may benefit from referral to centers with expertise in advanced filter retrieval.

A Dedicated Inferior Vena Cava Filter Service Line: How to Optimize Your Practice.

Despite the increased placement of retrievable inferior vena cava filters (rIVCFs), efforts to remove these devices are not commensurate. The majority of rIVCFs are left in place beyond their indicated usage, and often are retained permanently. With a growing understanding of the clinical issues associated with these devices, the United States Food and Drug Administration (FDA) has prompted clinicians to remove rIVCF when they are no longer indicated. However, major obstacles exist to filter retrieval, chief among them being poor clinical follow-up. The establishment of a dedicated IVC filter service line, or clinic, has been shown to improve filter retrieval rates. Usage of particular devices, specifically permanent versus retrievable filters, is enhanced by prospective physician consultation. In this article, the rationale behind a dedicated IVC filter service line is presented as well as described the structure and activities of the authors' IVC filter clinic; supporting data will also be provided when appropriate.

A Comparison of Retrievability: Celect versus Option Filter.

PURPOSE: To compare the retrievability of 2 potentially retrievable inferior vena cava filter devices. MATERIALS AND METHODS: A retrospective, institutional review board-approved study of Celect (Cook, Inc, Bloomington, Indiana) and Option (Rex Medical, Conshohocken, Pennsylvania) filters was conducted over a 33-month period at a single institution. Fluoroscopy time, significant filter tilt, use of adjunctive retrieval technique, and strut perforation in the inferior vena cava were recorded on retrieval. Fisher exact test and Mann-Whitney-Wilcoxon test were used for comparison. RESULTS: There were 99 Celect and 86 Option filters deployed. After an average of 2.09 months (range, 0.3-7.6 mo) and 1.94 months (range, 0.47-9.13 mo), respectively, 59% (n = 58) of patients with Celect filters and 74.7% (n = 65) of patients with Option filters presented for filter retrieval. Retrieval failure rates were 3.4% for Celect filters versus 7.7% for Option filters (P = .45). Median fluoroscopy retrieval times were 4.25 minutes for Celect filters versus 6 minutes for Option filters (P = .006). Adjunctive retrieval techniques were used in 5.4% of Celect filter retrievals versus 18.3% of Option filter retrievals (P = .045). The incidence of significant tilting was 8.9% for Celect filters versus 16.7% for Option filters (P = .27). The incidence of strut perforation was 43% for Celect filters versus 0% for Option filters (P < .0001). CONCLUSIONS: Retrieval rates for the Celect and Option filters were not significantly different. However, retrieval of the Option filter required a significantly increased amount of fluoroscopy time compared with the Celect filter, and there was a significantly greater usage of adjunctive retrieval techniques for the Option filter. The Celect filter had a significantly higher rate of strut perforation.

The Role of Potentially Retrievable Inferior Vena Cava Filters in High-Risk Patients Undergoing Joint Arthroplasty.

INTRODUCTION: Some patients undergoing total joint arthroplasty are at increased risk for venous thromboembolism (VTE). The aim of the present study was to evaluate the safety and efficacy of prIVCF in preventing PE in patients undergoing joint replacement surgery who are at high-risk for VTE. MATERIALS AND METHODS: In this prospective, IRB-approved study, prIVCF were placed in consecutive patients who met specific high-risk criteria (history of VTE or hypercoaguable state) prior to total joint arthroplasty. Patients were followed until the IVC filter was removed. Outcomes and complications were recorded per Society of Interventional Radiology guidelines. RESULTS: One hundred and nine potentially retrievable IVC filters were placed in 105 patients, who all subsequently underwent joint arthroplasty. One hundred eight IVC filters (98.9%) were retrieved successfully in a mean time of 44.1 days (range 13-183 days). There was 1 failed IVC filter retrieval attempt (0.9%) at 46 days post implantation. Two patients (1.9%) presented with recurrent PE and were successfully treated with anticoagulation prior to IVC filter retrieval. There were no fatalities from perioperative PE. In 1 patient (0.9%), a fractured filter leg had embolized during retrieval. CONCLUSION: Potentially retrievable IVC filters are safe and effective for prophylaxis against PE in patients at high-risk for VTE undergoing joint arthroplasty.

Prospective randomized pilot study of Y90+/-sorafenib as bridge to transplantation in hepatocellular carcinoma.

BACKGROUND & AIMS: To investigate the safety and adverse event profile of sorafenib plus radioembolization (Y90) compared to Y90 alone in patients awaiting liver transplantation. METHODS: 20 patients with HCC were randomized to Y90 alone (Group A) or Y90+sorafenib (Group B). Adverse events, dose reductions, and peri-transplant complications were assessed. RESULTS: All patients in the sorafenib group necessitated dose reductions. Seventeen of 20 patients underwent liver transplantation; median time-to-transplant was 7.8 months (range: 4.2-20.3) and similar between groups (p = 0.35). In the sorafenib group, there were 4/8 peri-transplant (<30 days) biliary complications (p = 0.029) and 3/8 acute rejections (p = 0.082); there were none in the Y90-only group. Survival rates were 70% (Group A) and 72% (Group B) at 3 years (p = 0.57). CONCLUSIONS: The addition of sorafenib to Y90 necessitated dose reductions in all patients awaiting transplantation. Preliminary data suggest that the combination was associated with more peri-transplant biliary complications and potentially trended towards more acute rejections. Caution should be exercised when considering sorafenib in the transplant setting. Further investigation is warranted.

The role of DNA-stained currency in gang robberies within the United Kingdom.

Cash-and-valuables-in-transit (CViT) robberies have become a substantial problem-especially in the current global economy. Over £19.4 million were stolen in 2008 and £17.1 million in 2009 in the United Kingdom alone. The transportation of cash and valuable items between financial institutions has long been a target of robberies in the U.K. After a robbery has occurred, police collect evidence in the form of ink-stained currency. These stained notes are submitted for analysis. Samples are subjected to polymerase chain reaction in order to amplify any possible botanically derived DNA markers present on the notes. After amplification, capillary electrophoresis allows for the deciphering of the "DNA profile." The DNA profile is then linked to a particular cash box, and this information is compared with records of whether or not that box had been stolen. The cases below are three such instances where botanically marked currency was used to help solve robberies.

Optional or permanent: clinical factors that optimize inferior vena cava filter utilization.

PURPOSE: To test the hypothesis that patient parameters identifiable at the time of inferior vena cava (IVC) filter placement can be used to predict the need for a permanent versus optional filter. MATERIALS AND METHODS: A comprehensive institutional database of details and patient parameters for all optional IVC filters placed at a single institution between December 2008 and July 2011 was reviewed. IVC filters were categorized as removed if removal was attempted or as kept permanent if not. Patient parameters (age, sex, history of venous thromboembolism [VTE], presence of neurologic disease or malignancy, indication for filter placement) were compared between groups by multiple logistic regression analysis, and a prediction model based on these parameters was constructed. RESULTS: A total of 265 optional IVC filters were placed and analyzed; 167 were removed and 98 were kept permanent. In the multivariable model predicting filter disposition, significant factors associated with permanence were age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), male sex (OR, 3.01; 95% CI, 1.64-5.54), underlying malignancy (OR, 3.27; 95% CI, 1.77-6.03), and an indication of anticoagulation failure (OR, 8.12; 95% CI, 1.83-36.0). Significant factors associated with removal were history of VTE (OR, 0.39; 95% CI, 0.21-0.74), prophylactic filter placement indication (OR, 0.14; 95% CI, 0.04-0.43), and high-risk VTE (OR, 0.37; 95% CI, 0.15-0.94). The c-statistic for the prediction model based on these parameters was 0.80. CONCLUSIONS: Patient parameters can be used to quantitatively predict an optional IVC filter being kept permanent. These findings can aid in optimization of prospective decision-making in IVC filter placement.

MRI-guided biopsy to correlate tissue specimens with MR elastography stiffness readings in liver transplants.

RATIONALE AND OBJECTIVES: Magnetic resonance elastography (MRE) can noninvasively measure the stiffness of liver tissue and display this information in anatomic maps. Magnetic resonance imaging (MRI) guidance has not previously been used to biopsy segments of heterogeneous stiffness identified on MRE. Dedicated study of MRE in post-liver transplant patients is also limited. In this study, the ability of real-time MRI to guide biopsies of segments of the liver with different MRE stiffness values in the same post-transplant patient was assessed. MATERIALS AND METHODS: MRE was performed in 9 consecutive posttransplant patients with history of hepatitis C. Segments of highest and lower stiffness on MRE served as targets for subsequent real-time MRI-guided biopsy using T2-weighted imaging. The ability of MRI-guided biopsy to successfully obtain tissue specimens was assessed. The Wilcoxon signed-rank test was used to compare mean stiffness differences for highest and lower MRE stiffness segments, with α = 0.05. RESULTS: MRI guidance allowed successful sampling of liver tissue for all (18/18) biopsies. There was a statistically significant difference in mean MRE stiffness values between highest (4.61 ± 1.99 kPa) and lower stiffness (3.03 ± 1.75 kPa) (P = .0039) segments biopsied in the 9 posttransplant patients. CONCLUSION: Real-time MRI can guide biopsy in patients after liver transplantation based on MRE stiffness values. This study supports the use of MRI guidance to sample tissue based on functional information.

Improving inferior vena cava filter retrieval rates: impact of a dedicated inferior vena cava filter clinic.

PURPOSE: To test the hypothesis that an inferior vena cava (IVC) filter clinic increases the retrieval rate of optional IVC filters. MATERIALS AND METHODS: Patients who had optional IVC filters placed at the authors' institution between January 2000 and December 2008 were identified and retrospectively studied. A dedicated IVC filter clinic was established at this institution in January 2009, and there is a comprehensive database of prospectively acquired data for patients seen in the IVC filter clinic. Patients were chronologically classified into preclinic and postclinic groups. The number of optional filters retrieved and failed retrieval attempts were recorded. RESULTS: In the preclinic and postclinic periods, 369 and 100 optional IVC filters were placed. Median (interquartile range) number of optional filters placed per month for preclinic and postclinic periods was 3 (range 2-5) and 10 (range 6.5-10.5) (P < .001). Retrieval rates in preclinic and postclinic periods were 108 of 369 (29%) and 60 of 100 (60%) (P < .001). The median time to filter retrieval in the postclinic group was 1.5 months (95% confidence interval 1.2-1.8). The number of failed retrieval attempts in preclinic and postclinic periods was 23 of 369 (6%) and 5 of 100 (5%) (P = .823). CONCLUSIONS: The retrieval rate of optional IVC filters at this institution was significantly increased by the establishment of a dedicated IVC filter clinic. This retrieval increase is not related to a decrease in technical failures but more likely relates to more meticulous patient management and clinical follow-up.

The intergenerational transfer of psychosocial risk: mediators of vulnerability and resilience.

The recurrence of social, behavioral, and health problems in successive generations of families is a prevalent theme in both the scientific and popular literatures. This review discusses recent conceptual models and findings from longitudinal studies concerning the intergenerational transfer of psychosocial risk, including intergenerational continuity, and the processes whereby a generation of parents may place their offspring at elevated risk for social, behavioral, and health problems. Key findings include the mediational effects of parenting and environmental factors in the transfer of risk. In both girls and boys, childhood aggression and antisocial behavior appear to predict long-term trajectories that place offspring at risk. Sequelae of childhood aggression that may threaten the well-being of offspring include school failure, adolescent risk-taking behavior, early and single parenthood, and family poverty. These childhood and adolescent behavioral styles also predict harsh, aggressive, neglectful, and unstimulating parenting behavior toward offspring. Buffering factors within at-risk families include maternal educational attainment and constructive parenting practices (e.g., emotional warmth, consistent disciplinary practices, and cognitive scaffolding). These findings highlight the potential application and relevance of intergenerational studies for social, educational, and health policy.