SUPERA Stenting in the Common Femoral Artery: Early Experience and Practical Considerations.

PURPOSE: Endovascular therapy in the management of de novo common femoral disease remains controversial. Considerable interest has been generated in recent years due to recent technological advancement in the design of vascular stents. In particular, SUPERA (Abbot Vascular Inc, Santa Clara USA) stents are designed to offer increased flexibility and less adverse interactions with the arterial wall, thus making it potentially better suited for common femoral lesions. However, despite such theoretical advantages, there is lack of data in its use in clinical practice. This study provides illustrative examples of SUPERA stents in different clinical settings and contributes to important clinical data for the overall efficacy and safety profile of endovascular interventions in common femoral artery (CFA) disease. MATERIALS AND METHODS: Retrospective analysis of all endovascular CFA procedures between January 1, 2011, and December 31, 2019, was conducted. Data collected included demographics, clinical symptoms, medical comorbidities, procedural characteristics, and immediate and short-term complications. Detailed analysis was performed on the stenting cohort. RESULTS: During our study period, a total of 69 patients underwent endovascular interventions involving the CFA at our institution, of which 16 patients had stenting procedures for a total of 18 stent deployments. Technical success was achieved in all stenting procedures. A total of 15 SUPERA stents were placed in 13 patients. No stent fractures were observed. Overall primary patency rate of SUPERA stents at the time of 12-month follow-up was 100% in patients who had a follow-up assessment (n = 12 stents). CONCLUSION: Endovascular intervention of the CFA is an evolving topic in the interventional radiology and vascular surgery community. Recent development of newer generation of devices such as SUPERA peripheral stents offers significant potential benefits given their inherent design. Despite the theoretically promising design of the SUPERA, there is a lack of data to support its use. This study contributes important patient-level data for SUPERA stent deployments.

The Renal Vasculature: What the Radiologist Needs to Know.

The physiologic role of the kidneys is dependent on the normal structure and functioning of the renal vasculature. Knowledge and understanding of the embryologic basis of the renal vasculature are necessary for the radiologist. Common anatomic variants involving the renal artery (supernumerary arteries and prehilar branching) and renal vein (supernumerary veins, delayed venous confluence, retroaortic or circumaortic vein) may affect procedures like renal transplantation, percutaneous biopsy, and aortic aneurysm repair. Venous compression syndromes (anterior and posterior nutcracker syndrome) can be symptomatic and can be diagnosed with a combination of radiologic features. Renal artery stenosis is commonly atherosclerotic and is diagnosed with Doppler US, CT angiography, or MR angiography. Fibromuscular dysplasia, the second most common cause of renal artery narrowing, has a characteristic string-of-beads appearance resulting from multifocal stenoses and dilatations. Manifestations of renal vasculitis differ depending on whether the affected vessels are large, medium, or small. Renal vascular injury is graded according to the American Association for the Surgery of Trauma (AAST) renal injury scale, which defines vascular injury and active bleeding in renal injuries. Both renal arteries and veins are affected by primary neoplasms or secondarily by neoplasms from adjacent structures. Differentiation between bland thrombus and tumor thrombus and the extent of involvement dictate management in malignancies, especially renal cell carcinoma. Aneurysms, pseudoaneurysms, arteriovenous malformations, and arteriovenous fistulas can affect renal vessels and can be diagnosed with specific imaging features. The radiologist has a critical role in identification of specific imaging characteristics and establishing the diagnosis in the varied pathologic conditions affecting the renal vasculature, which is critical for directing management. Thus, the renal vasculature should be an integral part of radiologists' checklist. ©RSNA, 2021.

Diagnostic Imaging Modalities to Assess Treatment Response of Bone Metastasis in Patients Receiving Palliative Radiotherapy: A Scoping Review of the Literature.

PURPOSE: Several studies have used objective radiologic data to assess the effect of palliative radiotherapy on tumor burden. The purpose of this literature review was to survey the various metrics that have been used to quantify bone tumor response to palliative radiotherapy by radiographical means and to determine whether any of these metrics were associated with clinical palliative outcomes. METHODS: In accordance with PRISMA extension for Scoping Reviews guidelines, a literature search Ovid Medline and OldMedline from 1946 to February 6, 2019, Embase Classic/Embase from 1947 to 2019 week 5, and Cochrane Central Register of Controlled Trials February 2019 to extract articles related to quantified radiologic evaluation of bone metastases following palliative radiotherapy. Imaging modality, quantification metric, and association between imaging modality and clinical response were recorded. RESULTS: Fourteen articles selected for full-text review utilized computed tomography (10 studies), fluorodeoxyglucose-positron emission tomography (3 studies), magnetic resonance imaging (1 study), diffusion-weighted magnetic resonance imaging (3 studies), and X-ray (1 study) imaging modalities. Variables assessed included tumor volume regression, bone density, metabolic activity, and signal intensity. Studies differed both in the type of imaging modality used and metric derived to quantify the radiologic findings. Fifty percent of the included studies aimed to identify a relationship between a quantified radiologic metric and clinical palliative response. Of these studies, 86% reported a correlation. CONCLUSION: Quantified radiologic metrics can provide an objective measure of response to palliative radiotherapy and may be useful in predicting clinical palliative response. More studies are needed to validate these metrics and develop a standardized protocol for radiologic evaluation that can be implemented into a clinical workflow.

IVC filter removal after extended implantation periods.

OBJECTIVE: Life-threatening complications have been reported in patients with chronic retrievable IVC filters. National health agencies have urged hospitals to assess all patients with retrievable IVC filters for filter removal. The aim of the current study was to identify those patients with unretrieved chronic IVC filters, document complications and removal techniques. METHODS: We identified a cohort with unretrieved IVC filters inserted between January 2001 and December 2013. These patients were invited back to clinic for review with CT imaging to determine complications, if any, and offer removal. Data collected included demographics, complications and retrieval characteristics. RESULTS: 289 patients were discovered to still have a filter in situ. Of these, 193 patients were verified as deceased. Eighty-nine patients were notified, with no current contact information available on the remaining seven. Thirty-six attended for review, 20 females, 16 males, with an average age of 63.5 years. Complications identified at CT were 2 occluded IVCs (5.8%), 4 fractured filters (11.7%) and filter penetration in all cases (37.5% grade 2, 56.25% grade 3). Sixteen patients agreed to proceed with filter removal, 10 declined the opportunity and 6 were unfit or had ongoing indication for the filter. Two are awaiting removal and two had IVC occlusion. Subsequent retrieval was successful in 93% of cases (14/15). The mean time to removal from implant was 3846.9 days (SD 980.3). Advanced techniques were utilized in 10 cases and there were no mortalities or morbidities. CONCLUSION: Retrievable inferior vena cava filters are not benign and practitioners need to be aware of regulatory guidelines. Unretrieved filters can be successfully retrieved using standard and advanced methods with low morbidity and mortality.

Symptomatic palliation with radiotherapy in extensive heterotopic ossifications.

Heterotopic ossification (HTO) is the dystrophic formation of mature lamellar bone outside the confines of normal osseous tissues. It is frequently a complication which occurs following traumatic insult, both iatrogenic and non-iatrogenic, and neurological compromise. While mild degree of disease is often asymptomatic, significant pain and mobility limitations may result in reduced quality of life in advanced cases. Currently, the commonly accepted management for patients experiencing significant symptomatic HTOs is a combination therapy of surgical excision with prophylactic radiotherapy in the immediate perioperative period. In this article, we present a patient who achieved satisfactory pain relief and improvements in overall quality of life with the sole use of external beam radiation to illustrate the possibility of using radiotherapy alone for symptomatic management of HTO.

Temporary inferior vena cava filter indications, retrieval rates, and follow-up management at a multicenter tertiary care institution.

OBJECTIVE: The aim of this study was to investigate the practice pattern of inferior vena cava (IVC) filters and to determine factors predictive of filter retrievals at a multicenter, tertiary care institution. METHODS: A retrospective review of all IVC filter procedures performed between January 2001 and July 2013 was conducted. Data collected included demographics, venous thromboembolism risk factors, medical comorbidities, insertional and retrieval characteristics, referring services, complications, discharge, and follow-up management. RESULTS: During the study period, 1123 IVC filter procedures were performed; 69% (n = 810) were insertions and 31% (n = 313) were retrievals. Of the patients receiving filters, the average age was 61.4 years, and 53.3% were male. Overall, 408 filters (51.5%) were placed with absolute indications, 214 (27.0%) for relative indications, 138 (17.4%) prophylactically, and 32 (4.0%) for reasons outside the established guidelines. Of the 663 retrievable filters, successful removal rate was 41.6% (n = 276); the mean time to first retrieval attempt was 76.4 days (standard deviation = 110.5). Documentation of the filter was present in 342 (43.1%) discharge summaries, and outlined instructions for filter management were seen in 129 (16.3%) cases. Significant predictors of filter removal were thrombosis follow-up (odds ratio [OR], 6.7; P < .01) and the ordering service as filters ordered by medical specialties were less likely to be retrieved than filters ordered by surgical specialties (OR, 0.53; P = .04). Compared with discharge summaries without filter management instructions, those with plans had higher filter retrieval rates (OR, 3.74; P < .00). Filter-related complications was observed in 57 patients. CONCLUSIONS: Given the established complications relating to long indwelling times and recent Food and Drug Administration guidelines, a multidisciplinary and systematic follow-up protocol needs to be implemented to optimize filter retrieval rates and to ensure exemplary quality of care.

First bite syndrome: a complication of carotid endarterectomy.

First bite syndrome (FBS) is an uncommon pain syndrome characterised by severe cramping or spasm in the parotid region with the first bite of each meal. The proposed pathogenesis is sympathetic denervation of the parotid gland secondary to iatrogenic injury with resultant cross-stimulatory parasympathetic hypersensitivity response. FBS is a potential sequela of surgeries involving the infratemporal fossa, parapharyngeal space and/or deep lobe of the parotid gland, however, only four cases of FBS secondary to carotid endarterectomy have been documented to date. We present a case and management of a 77-year-old man who developed FBS after an ipsilateral carotid endarterectomy, to raise awareness of this complication among surgeons who operate in the neck region.