Optimal Medical Therapy Following Deep Venous Interventions: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel.

The optimal medical management of patients following endovascular deep venous interventions remains ill-defined. As such, the Society of Interventional Radiology Foundation (SIRF) convened a multidisciplinary group of experts in a virtual Research Consensus Panel (RCP) to develop a prioritized research agenda regarding antithrombotic therapy following deep venous interventions. The panelists presented the gaps in knowledge followed by discussion and ranking of research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were identified as high priority: 1) characterization of biological processes leading to in-stent stenosis/rethrombosis; 2) identification and validation of methods to assess venous flow dynamics and their effect on stent failure; 3) elucidation of the role of inflammation and anti-inflammatory therapies; and 4) clinical studies to compare antithrombotic strategies and improve venous outcome assessment. Collaborative, multicenter research is necessary to answer these questions and thereby enhance the care of patients with venous disease.

An international, multicenter study of intravenous bevacizumab for bleeding in hereditary hemorrhagic telangiectasia: the InHIBIT-Bleed study.

Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease) is a rare multisystem vascular disorder causing chronic gastrointestinal bleeding, epistaxis, and severe anemia. Bevacizumab, an anti-vascular endothelial growth factor antibody, may be effective to treat bleeding in HHT. This international, multicenter, retrospective study evaluated the use of systemic bevacizumab to treat HHT-associated bleeding and anemia at 12 HHT treatment centers. Hemoglobin, epistaxis severity score, red cell units transfused, and intravenous iron infusions before and after treatment were evaluated using paired means testing and mixed-effects linear models. 238 HHT patients received bevacizumab for a median of 12 (range, 1-96) months. Compared with pretreatment, bevacizumab increased mean hemoglobin by 3.2 g/dL (95% CI, 2.9-3.5 g/dL) [mean hemoglobin 8.6 (8.5, 8.8) g/dL versus 11.8 (11.5, 12.1) g/dL, p<0.0001)] and decreased the epistaxis severity score (ESS) by 3.4 (3.2-3.7) points [mean ESS 6.8 (6.6-7.1) versus 3.4 (3.2-3.7), P<0.0001] during the first year of treatment. Compared with 6 months pretreatment, RBC units transfused decreased by 82% [median of 6.0 (IQR 0.0-13.0) units versus 0 (IQR, 0.0-1.0) units, P<0.0001] and iron infusions decreased by 70% [median of 6.0 (1.0-18.0) infusions versus 1.0 (0.0-4.0) infusions, P<0.0001] during the first 6 months of bevacizumab treatment. Outcomes were similar regardless of underlying pathogenic mutation. Following initial induction infusions, continuous/scheduled bevacizumab maintenance achieved higher hemoglobin and lower ESS than intermittent/as needed maintenance but with more drug exposure. Bevacizumab was well tolerated: hypertension, fatigue, and proteinuria were the most common adverse events. Venous thromboembolism occurred in 2% of patients. In conclusion, systemic bevacizumab was safe and effective to manage chronic bleeding and anemia in HHT.

Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia.

DESCRIPTION: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications. METHODS: The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved. RECOMMENDATIONS: The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.

Lightly Embalmed Cadavers as a Training Tool for Ultrasound-Guided Procedures Commonly Used in Interventional Radiology.

RATIONALE AND OBJECTIVES: Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care. MATERIALS AND METHODS: Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access. RESULTS: The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient. CONCLUSION: Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Use of a mechanical thrombectomy device to treat early hepatic artery thrombosis after orthotopic liver transplant.

Hepatic artery thrombosis (HAT) is a major cause of morbidity and mortality after orthotopic liver transplantation, occurring in 5% of cases (Piardi et al, 2016). HAT is the second main cause of graft loss after primary nonfunction, the leading cause of graft failure in the immediate postoperative period (<1 month), and is associated with a mortality rate of up to 60% without intervention (Piardi et al, 2016; Pareja et al., 2010; Crossin et al., 2003). Although retransplantation is the preferred therapy, the limited availability of donor organs can necessitate urgent, alternative treatment. These patients present physicians with an often-severe clinical picture, which requires consideration of endovascular approaches as opposed to the more traditional, invasive surgical interventions. The following case study presents a novel mechanical therapy that uses an endovascular approach for revascularization-a stent retriever device.

Executive summary of the 11th HHT international scientific conference.

Hereditary hemorrhagic telangiectasia (HHT) is a hereditary condition that results in vascular malformations throughout the body, which have a proclivity to rupture and bleed. HHT has a worldwide incidence of about 1:5000 and approximately 80 % of cases are due to mutations in ENG, ALK1 (aka activin receptor-like kinase 1 or ACVRL1) and SMAD4. Over 200 international clinicians and scientists met at Captiva Island, Florida from June 11-June 14, 2015 to present and discuss the latest research on HHT. 156 abstracts were accepted to the meeting and 60 were selected for oral presentations. The first two sections of this article present summaries of the basic science and clinical talks. Here we have summarized talks covering key themes, focusing on areas of agreement, disagreement, and unanswered questions. The final four sections summarize discussions in the Workshops, which were theme-based topical discussions led by two moderators. We hope this overview will educate as well as inspire those within the field and from outside, who have an interest in the science and treatment of HHT.

The interventional radiology business plan.

Strategic planning and business planning are processes commonly employed by organizations that exist in competitive environments. Although it is difficult to prove a causal relationship between formal strategic/business planning and positive organizational performance, there is broad agreement that formal strategic and business plans are components of successful organizations. The various elements of strategic plans and business plans are not common in the vernacular of practicing physicians. As health care becomes more competitive, familiarity with these tools may grow in importance. Herein we provide an overview of formal strategic and business planning, and offer a roadmap for an interventional radiology-specific plan that may be useful for organizations confronting competitive and financial threats.

Diagnosis and treatment of central venous access-associated infections.

This paper provides readers with a basic understanding of the types of central venous access-associated infections as well as appropriate diagnostic techniques. Preventive measures are the most effective way to reduce rates of catheter-associated infection and are discussed in detail. Diagnosis and treatment of each type of infection are reviewed for nontunneled central venous catheters, tunneled dialysis catheters, and venous access ports. Readers should be able to employ the methods described in this paper to reduce the rate of central venous access-associated infections at their hospitals.

Management of pulmonary arteriovenous malformations.

Pulmonary arteriovenous malformations are rare lesions with significant clinical complications. These lesions are commonly seen in patients with hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome). Interventional radiologists are a key part of the treatment team in this complex disease, and a thorough understanding of the disease process is critical to providing good patient care. In this article, the authors review the disease course and its association with hereditary hemorrhagic telangiectasia, discusses the clinical evaluation and treatment of these complex patients, and outlines complications and follow-up.