Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE?

PURPOSE: To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements. MATERIALS AND METHODS: This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. RESULTS: A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599). CONCLUSIONS: Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.

Outcomes of peripheral artery disease and polyvascular disease in patients with end-stage kidney disease.

OBJECTIVE: Patients with peripheral artery disease (PAD) and end-stage kidney disease are a high-risk population, and concomitant atherosclerosis in coronary arteries (CAD) or cerebral arteries (CVD) is common. The aim of the study was to assess long-term outcomes of PAD and the impact of coexistent CAD and CVD on outcomes. METHODS: The United States Renal Data System was used to identify patients with PAD within 6 months of incident dialysis. Four groups were formed: PAD alone, PAD with CAD, PAD with CVD, and PAD with CAD and CVD. PAD-specific outcomes (chronic limb-threatening ischemia, major amputation, percutaneous/surgical revascularization, and their composite, defined as major adverse limb events [MALE]) as well as all-cause mortality, myocardial infarction, and stroke were studied. RESULTS: The study included 106,567 patients (mean age, 71.2 years; 40.8% female) with a median follow-up of 546 days (interquartile range, 214-1096 days). Most patients had PAD and CAD (49.8%), 25.8% had PAD alone, and 19.2% had all three territories involved. MALE rate in patients with PAD was 22.3% and 35.0% at 1 and 3 years, respectively. In comparison to PAD alone, the coexistence of both CAD and CVD (ie, polyvascular disease) was associated with a higher adjusted rates of all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.24-1.31), myocardial infarction (HR, 1.78; 95% CI, 1.69-1.88), stroke (HR, 1.66; 95% CI, 1.52,1.80), and MALE (HR, 1.07; 95% CI, 1.04-1.11). CONCLUSIONS: Patients with end-stage kidney disease have a high burden of PAD with poor long-term outcomes, which worsen, in an incremental fashion, with the involvement of each additional diseased arterial bed.

Utilizing 3D printing to assist pre-procedure planning of transjugular intrahepatic portosystemic shunt (TIPS) procedures: a pilot study.

BACKGROUND: 3D (three-dimensional) printing has been adopted by the medical community in several ways, procedure planning being one example. This application of technology has been adopted by several subspecialties including interventional radiology, however the planning of transjugular intrahepatic portosystemic shunt (TIPS) placement has not yet been described. The impact of a 3D printed model on procedural measures such as procedure time, radiation exposure, intravascular contrast dosage, fluoroscopy time, and provider confidence has also not been reported. METHODS: This pilot study utilized a quasi-experimental design including patients who underwent TIPS. For the control group, retrospective data was collected on patients who received a TIPS prior to Oct 1, 2020. For the experimental group, patient-specific 3D printed models were integrated in the care of patients that received TIPS between Oct 1, 2020 and April 15, 2021. Data was collected on patient demographics and procedural measures. The interventionalists were surveyed on their confidence level and model usage following each procedure in the experimental group. RESULTS: 3D printed models were created for six TIPS. Procedure time (p = 0.93), fluoroscopy time (p = 0.26), and intravascular contrast dosage (p = 0.75) did not have significant difference between groups. Mean radiation exposure was 808.8 mGy in the group with a model compared to 1731.7 mGy without, however this was also not statistically significant (p = 0.09). Out of 11 survey responses from interventionists, 10 reported "increased" or "significantly increased" confidence after reviewing the 3D printed model and all responded that the models were a valuable tool for trainees. CONCLUSIONS: 3D printed models of patient anatomy can consistently be made using consumer-level, desktop 3D printing technology. This study was not adequately powered to measure the impact that including 3D printed models in the planning of TIPS procedures may have on procedural measures. The majority of interventionists reported that patient-specific models were valuable tools for teaching trainees and that confidence levels increased as a result of model inclusion in procedure planning.

Blueprint for Implementing and Improving Eligible Inferior Vena Cava Filter Retrieval Across Institutions.

Introduction: Placement of removable inferior vena cava filters (rIVCFs) has increased, but this has not been accompanied by timely removal, with retrieval rates as low as 8.5% at some institutions. Failure to remove rIVCFs that were not medically necessary resulted in increased complications. This study discussed the development of an inferior vena cava (IVC) filter follow-up protocol. Methods: A method to monitor IVC filter placement and retrieval was developed. A weekly report was generated detailing placement and removal of rIVCFs. A standardized retrieval calculator was utilized to determine efficacy of removal. An IVC filter Retrieval Assessment Form was developed. Managing physicians and patients with medically unnecessary filters were sent letters with a retrieval checklist and order form. If not removed within one year, additional letters were sent. Standardized IVC filter reporting templates were created and utilized after insertion of all filters with retrieval status. Letters eventually were built into the electronic medical record for direct routing. Results: From 2015 to 2020, IVC filters were placed in 719 patients. Of those, 58% were eligible for retrieval. Initial rates of rIVCF removal in eligible patients were as low as 30-33% in 2015. The retrieval rate of eligible filters rose to 44% in September 2018. The rate of retrieval rose to 61% in January 2021. Conclusions: Employing a systemic protocol to aid in follow-up of patients following rIVCF placement may improve rates of retrieval. Regular evaluation and revision of the process demonstrated a significant role in achieving an increase in retrieval rates.

3D printed model to assist endovascular prostate artery embolization for benign prostatic hyperplasia.

With the growth and ease of 3D printing accessibility, the medical community has begun to adopt it in various ways. Modeling of prostatic arteries for embolization is an application that has yet to be fully explored. We present a case where a patient specific 3D-printed model was used as a reference during prostate artery embolization for a 70-year-old male with obstructive benign prostatic hyperplasia refractory to medical treatment. The prostate arteries were segmented from preoperative contrast enhanced computed tomography using 3D Slicer software and printed on a FormLabs Form2 resin printer. The models were then used for operative planning for the embolization of both right and left prostate arteries. The procedure was a success without complications and the patient returned 1 month later with significantly improved symptoms. Additionally, interventionists found the model to be helpful in selecting approach for arterial embolization.

Chronic Portal Vein Thrombosis with Percutaneous Main Portal Vein Reconstruction and Coil Embolization of a Massive Coronary Vein: A Case Report.

BACKGROUND Portal vein thrombosis (PVT) is a well-recognized complication in patients with cirrhosis and frequently requires a nuanced approach to treatment. There is a paucity of existing literature and evidence-based recommendations regarding the optimal treatment approach to chronically occluded portal veins. Management options range from observation to anticoagulation and interventional therapies such as transjugular intrahepatic portosystemic shunts (TIPS), thrombolysis, or surgical thrombectomy. For select patients with little success from traditional medical therapies and previously failed TIPS procedures, a direct transhepatic approach to restoring blood flow and resolving variceal bleeding may be appropriate. CASE REPORT A 31-year-old man with a past medical history of portal hypertension, refractory ascites, gastroesophageal varices, and decompensated cirrhosis secondary to alcohol abuse had previously undergone an unsuccessful TIPS placement. Preprocedural imaging demonstrated a cirrhotic liver, splenomegaly, and gastroesophageal varices compatible with portal hypertension. Also noted were focal calcifications in the region of the diminutive main portal vein, medial splenic vein, and superior mesenteric vein, compatible with sequalae of chronic thrombosis. Restoration of flow through the occluded segment of the main portal vein and cessation of variceal bleeding was successfully resolved through the combination of portal vein reconstruction and massive volume embolization of the large coronary vein using a direct, percutaneous approach. CONCLUSIONS A direct, percutaneous approach to main portal vein reconstruction and massive volume embolization after a previously failed TIPS may be a potential alternative approach for select patients.

A case of two shunts in the endovascular treatment of type II Abernethy syndrome.

BACKGROUND: Abernethy malformation is a rare condition defined by a congenital extrahepatic portosystemic shunt, often leading to absence or hypoplasia of the intrahepatic portal venous system. Although there are no consensus treatment guidelines, interventional techniques now offer minimally invasive treatment options for Abernethy malformations. This case report describes a case of Abernethy Syndrome Type II where the patient had two separate extrahepatic portosystemic shunts treated with endovascular occlusion with two Amplatzer plugs and demonstrates the feasibility of this treatment for this rare condition. This case was in a young adult, adding to the scarce literature of treatment for Abernethy syndrome in the adult population. CASE PRESENTATION: We report a case of a 20-year-old female patient with neurocognitive behavioral difficulty, voracious appetite, and chronic encephalopathy secondary to type II Abernethy malformation with not one, but two extrahepatic portosystemic shunts. The patient had failed medical management and was not a liver transplant candidate. Therefore, she presented to us for an endovascular treatment option. The two shunts were treated with endovascular occlusion using Amplatzer vascular plugs. Following embolization, flow into the hypoplastic portal vein improved with near complete occlusion of flow into the portosystemic shunts, thus restoring blood flow into the native portal system. At 3 month follow up, a CT demonstrated complete occlusion of the two portosystemic shunts, and a portal vein diminutive in caliber. The portal vein measured 7 mm in diameter on both pre and post-procedure CT scans. The total volume of the liver was found to be 843 cm3 on pre-procedure CT & 1191 cm3 on post-procedure CT. CONCLUSIONS: This report demonstrates the feasibility of using endovascular embolization to treat Abernethy II malformations. The management strategy of Type II Abernethy Syndrome should be to redirect blood flow into the hypoplastic native portal system, allowing for physiologic hepatic metabolism of splanchnic blood, hypertrophy of the portal system, and growth of the liver from the increased trophic flow.

Nationwide study of six-month readmissions in critical limb ischemia: Predictors and impact of revascularization strategies.

OBJECTIVE: There is a paucity of data regarding six-month readmissions in critical limb ischemia patients and the influence of management strategy during index-admission [endovascular, surgical, hybrid procedure, medical therapy, and amputation]. We aimed to investigate the incidence, predictors, and impact of management strategies on six-month readmission in patients with critical limb ischemia. METHODS: A secondary analysis of the Nationwide Readmissions Database (2016-2017) was conducted. Propensity score matching was performed for subgroup analysis. RESULTS: We identified 50,058 patients with primary diagnosis of critical limb ischemia. Six-month all-cause and critical limb ischemia-related readmission rate was 52.36% and 10.86%, respectively. The risk of all-cause readmission was lower with amputation but was similar among other subgroups. Patients receiving surgical [HR 0.62, CI(0.48-0.79), p < 0.001] and hybrid procedure [HR 0.65 (0.46-0.93), p = 0.02] had lower risk of unplanned critical limb ischemia-related readmission compared to endovascular, though the risk of unplanned revascularization/amputation during readmission was similar between the three strategies. The risk of non-critical limb ischemia-related readmission was higher with surgical [HR 1.13, CI(1.04-1.23), p = 0.003] and hybrid procedure [HR 1.17, CI(1.08-1.28), p < 0.001], driven by increased procedure-related/wound complications. Eventhough endovascular patients were older with more severe critical limb ischemia presentation, a lower proportion received home-health or placement upon discharge from index-admission. This could account for higher readmission without higher repeat revascularization in endovascular group. CONCLUSION: The risk of critical limb ischemia and non-critical limb ischemia-related readmission differ according to the management strategy. Significant differences in discharge disposition exist depending on revascularization strategy. Study findings identify opportunities for reducing readmissions by focusing on nonprocedural aspects like wound-care, discharge planning and placement.

Lidocaine Versus Bupivacaine in the Treatment of Headache with Intranasal Sphenopalatine Nerve Block.

BACKGROUND: Intranasal sphenopalatine ganglion (SPG) block has been shown to be an effective treatment for headaches. Multiple therapeutic agents have been studied, although the wide availability and low cost of lidocaine and bupivacaine have made them attractive treatment options. To the authors knowledge, no study has yet demonstrated superiority of one anesthetic over the other. OBJECTIVE: To determine the efficacy of lidocaine versus bupivacaine when performing intranasal sphenopalatine ganglion (SPG) block for the treatment of headaches. STUDY DESIGN: Retrospective cohort study. SETTING: A single tertiary care academic institutionMETHODS: This retrospective study identified patients who underwent SPG block at a single institution from January 1, 2014 to December 20, 2017. Patients were included if they were treated with either lidocaine or bupivacaine and had both pre- and post-procedure pain scores recorded on a 0-10 scale. Patients were excluded if they were less than 18 years of age. RESULTS: 386 total procedures were performed. 303 (78.5%) were lidocaine delivered via the SphenoCath device, and 83 (21.5%) were bupivacaine delivered via the Tx360 device. 90.2% of treatments (n = 348) decreased the patient's pain level. Of the treatments performed with lidocaine, 89.1% (n = 270) resulted in improvement of the patient's pain level with a mean decrease in pain level of 3.1 (SD ± 2.3). Of the treatments performed with bupivacaine, 94.0% (n = 78) resulted in improvement of the patient's pain level, with a mean decrease in pain level of 3.0 (SD ± 1.9). No statistically significant difference was found between the 2 anesthetics. LIMITATIONS: The retrospective study design may introduce selection bias. Both lidocaine and bupivacaine were administered by different devices (Sphenocath and Tx360 respectively) which may account for differences in initial treatment success. There were differences in the size of the two groups, which may also introduce error. CONCLUSIONS: This study demonstrates similar efficacy of SPG block performed with lidocaine or bupivacaine. While no difference was found, the particular advantages and disadvantages of the intranasal delivery device may influence physician choice. KEY WORDS: Sphenopalatine ganglion nerve block, lidocaine, bupivacaine, sphenocath, Tx360, pain intervetnio, headache, miimally invasive therapy.

Successful Percutaneous Treatment of an Arteriovenous Malformation of the Toe.

Arteriovenous malformations (AVMs) of the toe are a rare entity. To the author's knowledge, there are only 2 published case reports, and both patients underwent amputation of the affected digits. Little is known about the optimal treatment of AVMs involving the toe. The authors present the case of a 20-year-old male with a large AVM of the second toe, which was successfully treated with intra-arterial sodium tetradecyl sulfate. Percutaneous treatment of these lesions is possible and should be considered before amputation.

Congenital Renal Arteriovenous Malformation: A Rare but Treatable Cause of Hypertension.

BACKGROUND Congenital renal vascular anomalies have been classified into 3 categories: cirsoid, angiomatous, and aneurysmal. These classifications are based on the size, location, and number of vessels involved. Aneurysmal malformations, such as the one reported here, have a single (and dilated) feeding and draining vessel. The prevalence of renal AVMs is estimated at less than 0.04%, making them rare causes of secondary hypertension. CASE REPORT A 29-year-old white woman was seen in the hypertension clinic as a referral from high-risk obstetric clinic for management of hypertension (HTN). A secondary hypertension workup with Doppler waveforms of the renal arteries revealed prominent diastolic flow in the left compared to the right. For confirmation, an MRA was done, which showed a large left renal upper-pole arteriovenous malformation (AVM) with associated vascular shunting and early opacification of the left renal vein. This congenital AVM was identified as the cause of her hypertension. Angiography and coil embolization were performed. The patient's BP normalized within a few days and she was taken off her antihypertensive medications. CONCLUSIONS This case illustrates that a careful review of duplex waveforms beyond just peak velocity and ratios is important to identify uncommon pathologies. This is important, as renal AVMs respond well to embolization, with resolution of hypertension in 59% of patients treated.

Imaging characteristics of occipital bone osteoblastoma.

Osteoblastoma is a rare benign tumor of the calvarium. We present the case of a 20-year-old female with occipital osteoblastoma and discussion of imaging modalities of calvarial osteoblastoma. To our knowledge, this is the ninth reported case of occipital osteoblastoma. Imaging characterization of osteoblastoma may vary. Plain radiograph, CT, MRI, and CT angiography establish osteoblastoma characterization and vascular supply prior to surgical resection.

Inferior Vena Cava Torsion and Stenosis Complicated by Compressive Pericaval Regional Ascites following Orthotopic Liver Transplantation.

Inferior vena cava (IVC) stenosis and torsion are well-described rare complications following orthotopic liver transplantation (OLT). We present a case of inferior vena cava intermittent torsion and stenosis complicated by compressive regional ascites. To the best of our knowledge, this is the second case of post-OLT regional ascites related compressive IVC stenosis reported and the first reported case of torsion complicated by regional ascites compression.