Retrieval of TRAPEASE and OPTEASE Inferior Vena Cava Filters with Extended Dwell Times.

PURPOSE: To demonstrate that OPTEASE and TRAPEASE filters can be removed after dwell times greater than 60 days. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent an attempted removal of a TRAPEASE or OPTEASE filter with a greater than 60-day dwell time between 2009 and 2015 at a single institution. Eleven patients within that time span were identified, and 10 were included in the review. One patient was excluded from the study because the date of filter placement was unknown. RESULTS: All filters were successfully retrieved. The average dwell time for removed TRAPEASE filters was 1,273 days (range, 129-3,582 d), with a median of 492 days (n = 5). The average dwell time for OPTEASE filters was 977 days (range, 123-2,584 d), with a median of 661 days (n = 5). The average dwell time of all filters was 1,125 days (range, 123-3,582 d), with a median of 577 days (n = 10). All patients exhibited inferior vena cava (IVC) stenosis after filter retrieval. An IVC pseudoaneurysm was present following retrieval in one case and resolved. In one case, a fractured filter strut was left completely embedded in the caval wall. Two patients reported unilateral leg swelling on clinical follow-up, and the remainder reported no leg swelling or tightness. CONCLUSIONS: Initial experience suggests that TRAPEASE and OPTEASE filters can be removed after extended dwell times.

Computed Tomography (CT)-Guided Needle Biopsy of Lung Lesions: A Single Center Experience.

(1) Objective: Lung cancer is one of the leading causes of cancer death among men and women across the globe. The accurate and timely diagnosis of lung lesions is of paramount importance for prognosis. This single-center study is the first to assess the diagnostic yield and complication rate of a computed tomography (CT)-guided needle biopsy of pulmonary parenchymal and pleural nodules in an academic training center in the United States. (2) Methods: This is a retrospective study approved by IRB. Patients who underwent CT-guided needle biopsy between 2016 and 2020 were reviewed. A CT-guided needle biopsy involving mediastinal lesions was excluded, focusing only on lung parenchymal and pleural lesions. A CT-guided needle biopsy aborted at any point during the procedure was also excluded from this study. (3) Results: 1063 patients were included in this study; 532 were males, and 531 were females. Lesion size ranged from 0.26 cm to 9.2 cm. 1040 patients received diagnoses, among which 772 had a specific diagnosis, and 268 had nonspecific inflammatory or non-malignant diagnoses. Twenty-three cases were non-diagnostic. Among the patients with specific diagnoses, 691 were malignant, 5 were hamartomas, 30 were fungal infections, 6 were acid-fast-positive organisms, and 40 were unspecified atypical cells. Of the patients that had a malignant diagnosis, 317 were adenocarcinoma, 197 were squamous cell carcinoma, 26 were a neuroendocrine tumor, 45 were non-small cell carcinoma (undifferentiated), 17 were small cell carcinoma, and 89 were other metastatic malignancies to the lung. Various common complications, including pneumothorax (337), hemorrhage (128), and hemoptysis (17), were observed, and 42 of the cases required chest tube intervention; others were treated with observation. Other rare complications observed included hemothorax (4) and oxygen desaturation (2), and there was no death in this series. (4) Conclusions: CT-guided needle biopsy is a reliable diagnostic modality for patients with lung parenchymal and pleural nodules, and it can effectively distinguish between benign and cancerous lesions before invasive procedures such as video-assisted thoracoscopy (VATs) or thoracotomy are planned. Our study showed a higher rate of pneumothorax and pulmonary hemorrhage compared to the rates established in guidelines, attributable to the varying experience level in a busy training academic center.

Percutaneous microwave ablation for early-stage intrahepatic cholangiocarcinoma: A single-institutional cohort.

Objectives: Cholangiocarcinoma (CCA) is the second-most common primary hepatic malignancy with an increasing incidence over the past two decades. CCA arises from the epithelial cells lining the bile ducts and can be classified as intrahepatic, perihilar, or distal based on the site of origin in the biliary tree. Surgical resection is the definitive curative therapy for early-stage intrahepatic CCA; however, only a minority of patients may be ideal surgical candidates. Percutaneous microwave ablation (MWA) is a minimally invasive procedure widely used for hepatocellular carcinoma and colorectal cancer metastases to the liver. Growing evidence suggests MWA can play a role in the management of patients with early-stage intrahepatic CCA. In this study, we aim to describe the safety and efficacy of MWA for the management of intrahepatic CCA. Material and Methods: A retrospective review of patients with intrahepatic CCA treated with MWA at our tertiary referral medical center was performed. Eight patients were treated between 2014 and 2019. Diagnosis of CCA was made based on histopathological studies of samples obtained by surgical resection or percutaneous liver biopsy. All procedures were performed under computed tomography (CT) guidance using a high-power single antenna MWA system. General anesthesia was used for all procedures. Patient medical history, procedural technical information, outcomes, and follow-up data were reviewed. Progression-free survival was estimated with a Kaplan-Meier curve. Results: A total of 25 tumors with an average size of 2.2 ± 1.7 cm (range 0.5-7.8) were treated with MWA. Our cohort consisted of eight patients (4 males and 4 females) with an average age of 69.3 ± 5.7 years (range 61-79). Three out of eight (3/8, 37.5%) patients were treated initially with surgical resection. NASH-related cirrhosis was documented in 3/8 (37.5%) patients, while 1/8 (12.5%) had alcoholic cirrhosis; the remaining 4 patients (4/8, 50%) did not have cirrhosis. All patients were discharged within 24 h after ablation. Average total follow-up time was 10.6 ± 11.8 months (range 0-41). The incomplete ablation rate and local recurrence rate were 4% (1/25 lesions) and 12% (3/25 lesions), respectively. Conclusion: In patients who do not qualify for surgical resection, MWA is a safe alternative therapy for the treatment of intrahepatic CCA.

Recurrent hepatic artery pseudoaneurysm repair with overlapping tapered stent-graft technique.

Hepatic artery pseudoaneurysms (HAPs) are rare but life-threatening complications associated with hepatic artery infusion pump (HAIP) therapy for unresectable liver metastases. Traditional management options include open surgery or stent placement, but these approaches have drawbacks. We present a unique case of a dislodged stent embedded in a HAP, resulting in delayed type-I endoleak. To address this, we employed a novel technique using multiple overlapping tapered stents to reconstruct the hepatic artery. This approach successfully excluded the pseudoaneurysm without endoleak. Stent-graft placement emerges as a safer and more effective option for managing HAP, preserving hepatic arterial flow, and reducing morbidity compared to other methods. However, further research is needed to evaluate this technique's long-term outcomes and potential complications.

Pulmonary artery-bronchus fistula treated with coil embolization.

Bronchopulmonary arterial fistula consists of an abnormal connection between the bronchus and the vascular tree and is a rare but serious complication associated with a variety of lung interventions. We present a case of a 61-year-old female with a history of metastatic breast cancer treated with lumpectomy and radiation 20 years prior, who was found to have a fistula between the right pulmonary artery and the right mainstem bronchus. Our patient was treated endovascularly with coil embolization in the setting of massive hemoptysis flooding the trachea, which was successful in controlling the acute bleed, although care was withdrawn in the following days following a discussion with the family given the presence of advanced metastatic disease. This case illustrates the use of endovascular techniques to treat an actively bleeding bronchopulmonary arterial fistulae, including a review of the existing literature regarding the optimal endovascular management strategy. Although our patient did not achieve the best outcome, endovascular intervention with stent-placement or embolization can serve to temporarily halt blood flow through the fistula, stabilizing the patient and allowing for more radical therapy after improvement.

Seurat Spleen: A Pathognomonic Sign in Angiography.

Splenic injury commonly occurs following abdominal trauma and can result in severe complications and death if it goes unrecognized. The Seurat spleen is a term used to describe the angiographic appearance of splenic injury following blunt trauma, given its resemblance to the pointillistic artwork of French neo-impressionist Georges Seurat. We present a case of a 43-year-old man who presented following a motor vehicle collision and was found to have multiple punctate foci of contrast extravasation in the spleen consistent with the Seurat spleen angiographic sign. This angiographic pattern can be used as a pathognomonic sign to identify splenic injury, with early identification crucial to preventing further complications of the injury.

Impending fibroid expulsion on MRI after uterine fibroid embolization.

Uterine fibroids are common benign tumors seen in women and can be managed with a variety of treatment options, including hysterectomy, myomectomy, and uterine fibroid embolization (UFE). UFE is an acceptable alternative to surgical treatment in well-selected cases and offers the added benefit of decreased hospital stay and avoidance of general anesthesia risk. Like any other procedure, UFE carries risks and complications. Post-UFE fibroid expulsion is one of them. We present a case of impending fibroid expulsion pre-emptively identified on magnetic resonance imaging at 6-month follow-up after UFE. While the majority of fibroid expulsions occur spontaneously by 3 months post-UFE, delayed expulsions have been reported as late as 4 years following the procedure. Therefore, a high degree of clinical suspicion is paramount for early diagnosis of this complication in UFE patients.

Manual on-the-fly physician postprocessing of computed tomographic angiography data guides embolotherapy of atypical bleeding following paracentesis; a case report.

Major bleeding, typically due to laceration of abdominal wall arteries or venous varices, is a rare but serious complication of paracentesis. We report a case of major bleeding post paracentesis to evidence that a sequence of 1) customized post processing of computed tomographic angiography data for periprocedural guidance, followed by 2) transcatheter cyanoacrylate glue embolotherapy, is the optimal treatment of this complication.

Uterine-sparing management of pyomyoma after uterine fibroid embolization.

Uterine fibroid embolization (UFE) is an increasingly popular treatment for uterine fibroids. One extremely rare complication after fibroid embolization is pyomyoma, which is the localized infection of the leiomyoma after embolization. Only 10 cases of pyomyoma after UFE have been reported in the literature. We present a case of delayed submucosal pyomyoma identified on computed tomography after 42 days post-UFE. While the majority of previously reported cases were managed by hysterectomy, our patient was treated with a uterine-sparing hysteroscopic transcervical approach. A high level of clinical suspicion is necessary to diagnose this complication after UFE to avoid major morbidity. Submucosal pyomyomas offer a favorable anatomical location easily accessible by hysteroscopy and a conservative approach may be sufficient to manage this complication.

Gastrointestinal bleeding from supraduodenal artery with aberrant origin.

Angiography and endovascular embolization play an important role in controlling acute arterial upper gastrointestinal hemorrhage, particularly when endoscopic intervention fails to do so. In our case, the patient presented with recurrent life-threatening bleed in spite of multiple prior endoscopic interventions and gastroduodenal artery embolization. Our teaching points focus on the role of angiography in acute upper gastrointestinal bleed and when to conduct empiric embolization, while reviewing the supraduodenal artery as an atypical but important potential culprit for refractory upper gastrointestinal bleed.

Vascular Closure Devices: Technical Tips, Complications, and Management.

Vascular closure devices (VCDs) are used to obtain hemostasis at the vascular access site while limiting the need for manual compression. They have gained significant popularity since their introduction in the mid-1990s. In the past 20 years, there has been a multitude of different devices introduced with various mechanisms of action. Manual compression remains the gold standard but can be very time consuming and painful for the patient. VCDs are advantageous in that they can reduce time to hemostasis and patient recovery and improve patient comfort. However, a large number of catheter-based procedures are performed without these closure devices owing to lack of operator familiarity, risk of complications, and cost. Most VCDs are approved for arteriotomies between 5 and 8F, with 1 device approved for up to 21F. Major complications include infection and limb ischemia. This article provides an update on currently approved VCDs, a brief overview of the literature, and our institutional experience with these devices.

Placenta previa-accreta: risk factors and complications.

OBJECTIVE: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). STUDY DESIGN: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. RESULTS: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. CONCLUSION: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.