Percutaneous Transesophageal Gastrostomy: Procedural Technique and Outcomes.

PURPOSE: To demonstrate the safety and effectiveness of percutaneous transesophageal gastrostomy (PTEG) as a palliative option in patients with malignant bowel obstructions (MBOs), and provide a comprehensive review of PTEG indications, placement technique, and short- and long-term outcomes. MATERIALS AND METHODS: Thirty-eight consecutive patients who underwent a PTEG procedure attempt from 2014 to 2022 were included in this analysis. Clinical indications, method of placement, technical and clinical success, adverse events, including procedure-related mortality, and effectiveness were assessed. Technical success was defined as placement of a PTEG. Clinical success was defined as improvement in clinical symptoms following PTEG placement. RESULTS: Of the 38 patients who underwent PTEG, 19 (50%) were men and 19 (50%) were women (median age, 58 years; range, 21-75 years). Three (8%) PTEG placements were performed with the patients under moderate sedation, whereas the remainder (92%) were performed with the patients under general anesthesia. Technical success was achieved in 35 of the 38 (92%) patients. The mean catheter duration was 61 days (median, 29 days; range, 1-562 days), with 5 of the 35 patients requiring tube exchanges after initial placement. Moreover, 7 of the 35 patients with successful PTEG placement experienced an adverse event, including 1 case of non-procedure-related mortality. All patients with successful PTEG placement experienced improvement in clinical symptoms. CONCLUSIONS: PTEG is an effective and safe option for patients with contraindications to traditional percutaneous gastrostomy tube placement in the setting of MBO. PTEG is an effective means of providing palliation and improving the quality of life.

Interventional Radiology Management of Adult Liver Transplant Complications.

Liver transplant remains the definitive therapy for patients with end-stage liver disease. Outcomes have continued to improve, in part owing to interventions used to treat posttransplant complications involving the hepatic arteries, portal vein, hepatic veins or inferior vena cava (IVC), and biliary system. Significant hepatic artery stenosis can be treated with angioplasty or stent placement to prevent thrombosis and biliary ischemic complications. Hepatic arterioportal fistula and hepatic artery pseudoaneurysm are rare complications that can often be treated with endovascular means. Treatment of hepatic artery thrombosis can have mixed results. Portal vein stenosis can be treated with venoplasty or more commonly stent placement. The rarer portal vein thrombosis can also be treated with endovascular techniques. Hepatic venous outflow stenosis of the hepatic veins or IVC is amenable to venoplasty or stent placement. Complications of the bile ducts are the most encountered complication after liver transplant. When not amenable to endoscopic intervention, biliary stricture, bile leak, and ischemic cholangiopathy can be treated with percutaneous transhepatic cholangiography with biliary drainage and other interventions. New techniques have further improved care for these patients. Transsplenic portal vein recanalization has improved transplant candidacy for patients with chronic portal vein thrombosis. Spontaneous splenorenal shunt and splenic artery steal syndrome (nonocclusive hepatic artery hypoperfusion syndrome) remain complicated topics, and the role of endovascular embolization is developing. When patients have recurrence of cirrhosis after transplant, most commonly due to viral hepatitis, transjugular intrahepatic portosystemic shunt (TIPS) may be required to treat symptoms of portal hypertension. Online supplemental material is available for this article. ©RSNA, 2022.

Ergonomics in IR.

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

The use of collimator angle optimization and jaw tracking for VMAT-based single-isocenter multiple-target stereotactic radiosurgery for up to six targets in the Varian Eclipse treatment planning system.

PURPOSE: Island blocking occurs in single-isocenter multiple-target (SIMT) stereotactic radiotherapy (SRS) whenever targets share multi-leaf collimator (MLC) leaf pairs. This study investigated the effect on plan quality and delivery, of reducing island blocking through collimator angle optimization (CAO). In addition, the effect of jaw tracking in this context was also investigated. METHODS: For CAO, an algorithm was created that selects the collimator angle resulting in the lowest level of island blocking, for each beam in any given plan. Then, four volume-modulated arc therapy (VMAT) SIMT SRS plans each were generated for 10 retrospective patients: two CAO plans, with and without jaw tracking, and two plans with manually selected collimator angles, with and without jaw tracking. Plans were then assessed and compared using typical quality assurance procedures. RESULTS: There were no substantial differences between plans with and without CAO. Jaw tracking produced statistically significant reduction in low-dose level parameters; healthy brain V10% and mean dose were reduced by 9.66% and 15.58%, respectively. However, quantitative values (108 cc for V10% and 0.35 Gy for mean dose) were relatively small in relation to clinical relevance. Though there were no statistically significant changes in plan deliverability, there was a notable trend of plans with jaw tracking having lower gamma analysis pass rates. CONCLUSION: These findings suggest that CAO has limited benefit in VMAT SIMT SRS of 2-6 targets when using a low-dose penalty to the healthy brain during plan optimization in Eclipse. As clinical benefits of jaw tracking were found to be minimal and plan deliverability was potentially reduced, a cautious approach would be to exclude jaw tracking in SIMT SRS plans.

Computed tomography angiography evaluation of acute limb ischemia.

Acute limb ischemia (ALI), a subclass of critical limb ischemia, is a medical emergency. The cause of ALI is usually thrombotic or embolic in nature, and the specific etiology often dictates the appropriate therapy. While the diagnosis is a clinical with common presenting symptoms, advances in ultrasound, computed tomography, and magnetic resonance technology have impacted the diagnosis and subsequent therapy. In ALI, the time to revascularization is critical and computed tomography angiography (CTA) provides a highly sensitive and specific technique for rapidly identifying occlusions and precisely defining vascular anatomy prior to interventions. In patients with significant renal disease, magnetic resonance angiography with or without contrast provides effective alternatives at the expense of imaging time. Treatment can include a variety of endovascular or surgical interventions, including thromboembolectomy, angioplasty, or bypass. Proper evaluation of the etiology of the ischemia, affected vasculature, and medical history is critical to select appropriate treatment and improve patient outcomes. Here, we examine the presentation, evaluation, and treatment of ALI and the role of CTA in diagnosis and therapy.

Pulse energy measurement at the SXR instrument.

A gas monitor detector was implemented and characterized at the Soft X-ray Research (SXR) instrument to measure the average, absolute and pulse-resolved photon flux of the LCLS beam in the energy range between 280 and 2000 eV. The detector is placed after the monochromator and addresses the need to provide reliable absolute pulse energy as well as pulse-resolved measurements for the various experiments at this instrument. This detector provides a reliable non-invasive measurement for determining flux levels on the samples in the downstream experimental chamber and for optimizing signal levels of secondary detectors and for the essential need of data normalization. The design, integration into the instrument and operation are described, and examples of its performance are given.

The Matter in Extreme Conditions instrument at the Linac Coherent Light Source.

The LCLS beam provides revolutionary capabilities for studying the transient behavior of matter in extreme conditions. The particular strength of the Matter in Extreme Conditions instrument is that it combines the unique LCLS beam with high-power optical laser beams, and a suite of dedicated diagnostics tailored for this field of science. In this paper an overview of the beamline, the capabilities of the instrumentation, and selected highlights of experiments and commissioning results are presented.

Safety and effectiveness of transsplenic access for portal venous interventions: a single-center retrospective study.

PURPOSE: To assess the safety and effectiveness of percutaneous transsplenic access (PTSA) for portal vein (PV) interventions among patients with PV disease. MATERIALS AND METHODS: Adult patients with PV disease were enrolled if they required percutaneous catheterization for PV angioplasty, embolization, thrombectomy, variceal embolization, or transjugular intrahepatic portosystemic shunt (TIPS) placement for a difficult TIPS or recanalization of a chronically occluded PV. The procedures were performed between January 2018 and January 2023. Patients were excluded if they had an active infection, had a chronically occluded splenic vein malignant infiltration of the needle tract, had undergone splenectomy, or were under age 18 years. RESULTS: Thirty patients (15 women, 15 men) were enrolled. Catheterization of the PV through PTSA succeeded for 29 of 30 patients (96.7%). The main adverse effect recorded was flank pain in 5 of 30 cases (16.7%). No bleeding events from the spleen, splenic vein, or percutaneous access point were recorded. Two cases (6.7%) each of hepatic bleeding and rethrombosis of the PV were reported, and a change in hemoglobin levels (mean [SD], - 0.5 [1.4] g/dL) was documented in 14 cases (46.7%). CONCLUSION: PTSA as an approach to accessing the PV is secure and achievable, with minimal risk of complications. Minimal to no bleeding is possible by using tract closure methods.

Single-arm prospective study comparing ablation zone volume between time zero and 24 h after microwave ablation of liver tumors.

PURPOSE: Percutaneous thermal ablation is an effective treatment for primary and metastatic liver tumors and is a recommended local therapy for early-stage hepatocellular carcinoma (HCC). Reported evidence shows an increase in the ablation zone volume over the first 24-h post-liver ablation. This report compares ablation zone volumes immediately at the completion (T = 0) of 26 microwave ablations of liver tumors to 24-h post-procedure (T = 24) volumes. MATERIALS AND METHODS: 20 patients, 13 (65%) males, underwent a total of 26 hepatic microwave ablations (MWA) under ultrasound guidance. Contrast-enhanced CT (CECT) or MRI was performed immediately and another CECT 24 h post operatively. Evaluation of the ablation zone and comparison of the two post-operative scans were done using BioTrace software. The expansion of ablation zones on post-op CECTs was matched point by point per direction. The distance between each 2 points was measured and grouped by distance. The incidence of each specific distance was then converted into a percentage, first for each case separately, then for all cases altogether. Data were tested by a matched paired one-sided t test. RESULTS: The median lesion diameter was 1.5 cm (range 0.5-3.3) with 16 (62%) HCC cases and 9 hepatic metastases (4 neuroendocrine carcinoma, 4 colorectal carcinomas, 1 breast carcinoma, 1 pancreatic cancer). The data show a consistent volume expansion greater than 30% (p = 7.7e-5) 24-h post-ablation, where the median expansion is 57%. Distances between T = 0 and T = 24 equal to 3-7 mm occur in over 35% of the cases. CONCLUSION: The ablation zone expansion at 24-h post-op was not uniform. The final ablation zone is difficult to predict at the time of the procedure. The awareness of the ablation zone expansion is important when treating near-critical structures, managing the heat sink effect, and preserving liver parenchyma.

Substance use patterns in 9-10 year olds: Baseline findings from the adolescent brain cognitive development (ABCD) study.

BACKGROUND: The Adolescent Brain Cognitive Development ™ Study (ABCD Study®) is an open-science, multi-site, prospective, longitudinal study following over 11,800 9- and 10-year-old youth into early adulthood. The ABCD Study aims to prospectively examine the impact of substance use (SU) on neurocognitive and health outcomes. Although SU initiation typically occurs during teen years, relatively little is known about patterns of SU in children younger than 12. METHODS: This study aims to report the detailed ABCD Study® SU patterns at baseline (n = 11,875) in order to inform the greater scientific community about cohort's early SU. Along with a detailed description of SU, we ran mixed effects regression models to examine the association between early caffeine and alcohol sipping with demographic factors, externalizing symptoms and parental history of alcohol and substance use disorders (AUD/SUD). PRIMARY RESULTS: At baseline, the majority of youth had used caffeine (67.6 %) and 22.5 % reported sipping alcohol (22.5 %). There was little to no reported use of other drug categories (0.2 % full alcohol drink, 0.7 % used nicotine, <0.1 % used any other drug of abuse). Analyses revealed that total caffeine use and early alcohol sipping were associated with demographic variables (p's<.05), externalizing symptoms (caffeine p = 0002; sipping p = .0003), and parental history of AUD (sipping p = .03). CONCLUSIONS: ABCD Study participants aged 9-10 years old reported caffeine use and alcohol sipping experimentation, but very rare other SU. Variables linked with early childhood alcohol sipping and caffeine use should be examined as contributing factors in future longitudinal analyses examining escalating trajectories of SU in the ABCD Study cohort.

The context of illicit drug overdose deaths in British Columbia, 2006.

BACKGROUND: Illicit drug overdose deaths (IDD) relate to individual drug dose and context of use, including use with other drugs and alcohol. IDD peaked in British Columbia (BC) in 1998 with 417 deaths, and continues to be a public health problem. The objective of this study was to examine IDD in 2006 in BC by place of residence, injury and death, decedents' age and sex and substances identified. METHODS: IDD data was obtained through the BC Coroners Office and entered into SPSS (version 14). Fisher's exact and Pearson's chi2 were used for categorical data; Mann-Whitney U-test for continuous variables. Rates were calculated using 2006 population estimates. RESULTS: We identified 223 IDD in BC; 54 (24%) occurred in Vancouver. Vancouver decedents (compared to those occurring outside Vancouver) were older (mean age 43.9 vs. 39.2 years; p < 0.01) and more likely to be male (90.7% vs. 77.5%; p = 0.03). Provincially Aboriginal ethnicity was reported for 19 deaths; 13 (30.2%) of 43 females and 6 (3.3%) of 180 males (p = < 0.001).Cocaine was identified in 80.3%, opiates 59.6%, methadone 13.9%, methamphetamine/amphetamine 6.3%, and alcohol in 22.9% of deaths. Poly-substance use was common, 2 substances were identified in 43.8% and 3 or more in 34.5% of deaths. Opiates were more frequently identified in Vancouver compared to outside Vancouver (74.1% vs. 55.0%) p = 0.015. CONCLUSION: Collaboration with the Coroner's office allowed us to analyze IDD in detail including place of death; cocaine, opiates and poly-substance use were commonly identified. Poly-substance use should be explored further to inform public health interventions.

History and Evolution of Yttrium-90 Radioembolization for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer and affects millions worldwide. Due to the lack of effective systemic therapies for HCC, researchers have been investigating the use of locoregional tumor control with Yttrium-90 (Y90) radioembolization since the 1960s. Following the development of glass and resin Y90 microspheres in the early 1990s, Y90 radioembolization has been shown to be a safe and efficacious treatment for patients with HCC across Barcelona Clinic Liver Cancer (BCLC) stages. By demonstrating durable local control, good long term outcomes, and equivalent if not superior tumor responses and tolerability when compared to alternative therapies including transarterial chemoembolization (TACE) and sorafenib, Y90 radioembolization is being increasingly used in HCC treatment. More recently, investigations into variations in Y90 radioembolization technique including radiation segmentectomy and radiation lobectomy have further expanded its clinical utility. Here, we discuss the history and evolution of Y90 use in HCC. We outline key clinical trials that have established the safety and efficacy of Y90 radioembolization, and also summarize trials comparing its efficacy to existing HCC treatments. We conclude by reviewing the techniques of radiation segmentectomy and lobectomy, and by discussing dosimetry.

Multicentre, randomised trial to investigate early nasal high-flow therapy in paediatric acute hypoxaemic respiratory failure: a protocol for a randomised controlled trial-a Paediatric Acute respiratory Intervention Study (PARIS 2).

INTRODUCTION: Acute hypoxaemic respiratory failure (AHRF) in children is the most frequent reason for non-elective hospital admission. During the initial phase, AHRF is a clinical syndrome defined for the purpose of this study by an oxygen requirement and caused by pneumonia, lower respiratory tract infections, asthma or bronchiolitis. Up to 20% of these children with AHRF can rapidly deteriorate requiring non-invasive or invasive ventilation. Nasal high-flow (NHF) therapy has been used by clinicians for oxygen therapy outside intensive care settings to prevent escalation of care. A recent randomised trial in infants with bronchiolitis has shown that NHF therapy reduces the need to escalate therapy. No similar data is available in the older children presenting with AHRF. In this study we aim to investigate in children aged 1 to 4 years presenting with AHRF if early NHF therapy compared with standard-oxygen therapy reduces hospital length of stay and if this is cost-effective compared with standard treatment. METHODS AND ANALYSIS: The study design is an open-labelled randomised multicentre trial comparing early NHF and standard-oxygen therapy and will be stratified by sites and into obstructive and non-obstructive groups. Children aged 1 to 4 years (n=1512) presenting with AHRF to one of the participating emergency departments will be randomly allocated to NHF or standard-oxygen therapy once the eligibility criteria have been met (oxygen requirement with transcutaneous saturation <92%/90% (dependant on hospital standard threshold), diagnosis of AHRF, admission to hospital and tachypnoea ≥35 breaths/min). Children in the standard-oxygen group can receive rescue NHF therapy if escalation is required. The primary outcome is hospital length of stay. Secondary outcomes will include length of oxygen therapy, proportion of intensive care admissions, healthcare resource utilisation and associated costs. Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: Ethics approval has been obtained in Australia (HREC/15/QRCH/159) and New Zealand (HDEC 17/NTA/135). The trial commenced recruitment in December 2017. The study findings will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. Authorship of all publications will be decided by mutual consensus of the research team. TRIAL REGISTRATION NUMBER: ACTRN12618000210279.

Quiescent-Interval Single-Shot Magnetic Resonance Angiography.

Lower extremity peripheral arterial disease (PAD) is a chronic, debilitating disease with a significant global burden. A number of diagnostic imaging techniques exist, including computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CEMRA), to aid in PAD diagnosis and subsequent treatment planning. Due to concerns of renal toxicity or nephrogenic systemic fibrosis (NSF) for iodinated and gadolinium-based contrasts, respectively, a number of non-enhanced MRA (NEMRA) protocols are being increasingly used in PAD diagnosis. These techniques, including time of flight and phase contrast MRA, have previously demonstrated poor image quality, long acquisition times, and/or susceptibility to artifacts when compared to existing contrast-enhanced techniques. In recent years, Quiescent-Interval Single-Shot (QISS) MRA has been developed to overcome these limitations in NEMRA methods, with promising results. Here, we review the various screening and diagnostic tests currently used for PAD. The various NEMRA protocols are discussed, followed by a comprehensive review of the literature on QISS MRA to date. A particular emphasis is placed on QISS MRA feasibility studies and studies comparing the diagnostic accuracy and image quality of QISS MRA versus other diagnostic imaging techniques in PAD.

Below-knee deep vein thrombosis (DVT): diagnostic and treatment patterns.

BACKGROUND: Guidelines are lacking for isolated below-knee deep vein thrombosis (BKDVT). The American College of Chest Physicians (ACCP) suggests anticoagulation only if symptoms are severe, otherwise surveillance with follow-up ultrasound in 2 weeks is recommended. Yet clinical practice remains highly variable. Little is known about the natural history of BKDVT and how to best manage these patients. METHODS: A retrospective analysis was conducted of medical records from 2014-2016. Risk factors were assessed such as age, gender, malignancy, recent surgery, and history of DVT. Treatment decisions and outcomes were identified. Radiology reports were graded for clarity. Chi-square and logistic regression were used to correlate risk factors with outcomes and determine odds of treatment. RESULTS: New isolated BKDVT was identified in 102 patients. Patients were symptomatic or had previous pulmonary embolism (PE) or DVT in all cases. Eighteen were positive for PE at diagnosis (17.6% of all patients or 62.1% with chest CT). Malignancy was independently associated with PE (P=0.015); no other risk factors were significant. Treatment was not associated with clinical risk factors. The language used for radiology reports was highly variable and was associated with the decision to treat with anticoagulation. One hundred percent were treated (n=24) when the report stated "positive DVT" and 89.2% (n=58) were treated after an objective description without the word "DVT" (P=0.01). Treatment was much less likely if the report described BKDVT anatomically but was said to be "negative for DVT" (P<0.001). A total of 86.3% (n=88) of all patients were treated, compared to 46.2% (n=6) of patients in this group (n=13). IVC filters were placed in 3 patients. Of the 14 untreated patients, 5 received surveillance, 3 developed new proximal DVT, and none developed PE. CONCLUSIONS: About 90% of patients diagnosed with BKDVT received anticoagulation after the initial diagnosis. Surveillance was not commonly recommended and is likely underutilized. Radiology reporting was highly variable and correlated with clinical treatment decisions, whereas other clinical risk factors did not. Describing BKDVT findings only in terms of being "positive" or "negative" for DVT may be inadequate.

Animal models of venous thrombosis.

Venous thrombosis (VT) is a prevalent clinical condition with significant adverse sequela or mortality. Anticoagulation and pharmacologic or pharmacomechanical thrombolytic therapies are the mainstays of VT treatment. An understanding of thrombosis biology will allow for more effective VT-tailored diagnosis and therapy. In vivo models of thrombosis provide indispensable tools to study the pathogenesis of thrombus formation and to evaluate novel therapeutic or preventive adjuncts for VT management or prevention. In this article, we review the most prominent in vivo models of VT created in rodents and swine species and outline how each model can serve as a useful tool to promote our understanding of VT pathogenesis and to examine novel therapies.

Statins as a preventative therapy for venous thromboembolism.

The anti-inflammatory effects of statins have likely not been used to their fullest extent, particularly in reducing venous thromboembolic events. Current therapy for thrombotic events hinges on anticoagulation via heparin, warfarin or new oral anticoagulants. Interventional procedures with thrombectomy may also play a critical role. Unfortunately, thrombotic events can occur and recur despite meticulous anticoagulation therapy. Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE), two complicated and prevalent diseases that can cause chronic disease states such as post-thrombotic syndrome (PTS). In 2009 the JUPITER trial demonstrated that rosuvastatin may be effective when dealing with vascular inflammation by providing an anti-inflammatory effect. Multiple subsequent studies have looked at this association with some promising findings. The mechanism of action for statins is not entirely understood but there has been a variety of proposals and subsequent testing of inflammatory biomarkers. Additional prospective trials are needed to confirm the possible benefit of VTE reduction through an anti-inflammatory effect, but if this can be shown then statins may become a safe adjunctive therapy for VTE prevention.

Anti-fouling strategies for central venous catheters.

Central venous catheters (CVCs) are ubiquitous in the healthcare industry and carry two common complications, catheter related infections and occlusion, particularly by thrombus. Catheter-related bloodstream infections (CRBSI) are an important cause of nosocomial infections that increase patient morbidity, mortality, and hospital cost. Innovative design strategies for intravenous catheters can help reduce these preventable infections. Antimicrobial coatings can play a major role in preventing disease. These coatings can be divided into two major categories: drug eluting and non-drug eluting. Much of these catheter designs are targeted at preventing the formation of microbial biofilms that make treatment of CRBSI nearly impossible without removal of the intravenous device. Exciting developments in catheter impregnation with antibiotics as well as nanoscale surface design promise innovative changes in the way that physicians manage intravenous catheters. Occlusion of a catheter renders the catheter unusable and is often treated by tissue plasminogen activator administration or replacement of the line. Prevention of this complication requires a thorough understanding of the mechanisms of platelet aggregation, signaling and cross-linking. This article will look at the advances in biomaterial design specifically drug eluting, non-drug eluting, lubricious coatings and micropatterning as well as some of the characteristics of each as they relate to CVCs.

Deep vein thrombosis: pathogenesis, diagnosis, and medical management.

Deep vein thrombosis (DVT) is a major preventable cause of morbidity and mortality worldwide. Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), affects an estimated 1 per 1,000 people and contributes to 60,000-100,000 deaths annually. Normal blood physiology hinges on a delicate balance between pro- and anti-coagulant factors. Virchow's Triad distills the multitude of risk factors for DVT into three basic elements favoring thrombus formation: venous stasis, vascular injury, and hypercoagulability. Clinical, biochemical, and radiological tests are used to increase the sensitivity and specificity for diagnosing DVT. Anticoagulation therapy is essential for the treatment of DVT. With few exceptions, the standard therapy for DVT has been vitamin K-antagonists (VKAs) such as warfarin with heparin or fractionated heparin bridging. More recently, a number of large-scale clinical trials have validated the use of direct oral anticoagulants (DOACs) in place of warfarin in select cases. In this review, we summarize the pathogenesis, diagnosis, and medical management of DVT, with particular emphasis on anticoagulation therapy and the role of DOACs in the current treatment algorithm.

Pathogenesis of Thromboembolism and Endovascular Management.

Venous thromboembolism (VTE), a disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with high mortality, morbidity, and costs. It can result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. VTE affects 1/1000 patients, costs $13.5 billion annually to treat, and claims 100,000 lives annually in the US. The current standard of care for VTE is anticoagulation, though thrombolysis may be performed in patients with PE and threatened limb. This review discusses pathogenesis and medical treatment of VTE and then focuses on endovascular treatment modalities. Mechanical- and catheter-directed thrombolysis (CDT) is discussed, as well as patient selection criteria, and complications. The first prospective study (CaVenT) comparing CDT with anticoagulation alone in acute DVT, despite study shortcomings, corroborates the existing literature indicating improved outcomes with CDT. The potential of the ongoing prospective, multicenter, randomized ATTRACT trial is also highlighted.