Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism

PurposeTo evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE).Materials and MethodsThis was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%).ResultsPatients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P < .001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (?14.4 mm Hg ± 10.2 vs ?12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7).ConclusionsPatients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.     

Impact of Intrahepatic Venovenous Shunt on Hepatic Venous Pressure Gradient Measurement

PurposeTo quantitatively analyze the impact of intrahepatic venovenous shunt (IHVS) on hepatic venous pressure gradient (HVPG) measurement.Materials and MethodsFrom 2015 to 2019, 222 HVPG measurements performed during transjugular intrahepatic portosystemic shunt creation were eligible for this study. Digital subtraction angiography (DSA) software color-coded each pixel of a two-dimensional DSA series by time-intensity curve to classify IHVS. Different degrees of IHVS were found in 36.5% of patients (81/222). Mild IHVS was found in 10.8% of patients (24/222), moderate IHVS was found in 10.8% of patients (24/222), and severe IVHS was found in 14.9% of patients (33/222).ResultsMean wedged hepatic vein pressure (WHVP) and HVPG were significantly lower in patients with IHVS compared with patients without IHVS (WHVP: 17.78 mm Hg ± 7.00 vs 24.89 mm Hg ± 8.69, P = .001; HVPG: 11.93 mm Hg ± 5.76 vs 18.6 mm Hg ± 6.85, P < .001). Mild IHVS had little effect on WHVP and HVPG. Mean WHVP and HVPG were 11 mm Hg lower in patients with moderate IHVS (WHVP: 20.38 mm Hg ± 8.38 vs 31.5 mm Hg ± 9.39, P = .026; HVPG: 13.88 mm Hg ± 6.33 vs 25.00 mm Hg ± 9.81, P < .001) and 15 mm Hg lower in patients with severe IHVS (WHVP: 13.45 mm Hg ± 5.28 vs 28.64 mm Hg ± 6.38, P = .017; HVPG: 8.27 mm Hg ± 3.85 vs 23.45 mm Hg ± 6.95, P < .001) than mean portal vein pressure and portal vein gradient.ConclusionsFor patients with moderate or severe IHVS, HVPG might greatly underestimate the actual value of portal vein pressure, and the portal vein should be catheterized to measure portal pressure.     

The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis

PurposeTo present final, 2-year results of a randomized trial comparing paclitaxel-coated vs uncoated balloon angioplasty following vessel preparation with ultra–high-pressure percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistulae (AVFs).Materials and MethodsTwenty-three sites enrolled 285 subjects with dysfunctional AVFs located in the arm. Before 1:1 randomization, successful vessel preparation was achieved (full waist effacement, < 30% residual stenosis). Follow-up was clinically driven except for a 6-month office visit.ResultsNinety-six of 141 subjects in the drug-coated balloon (DCB) arm and 111 of 144 in the control arm completed the study. Target lesion primary patency (TLPP) rates for the DCB and control groups were 58% ± 4 vs 46% ± 4 (P = .02) at 9 months, 44% ± 5 vs 36% ± 4 (P = .04) at 12 months, 34% ± 5 vs 28% ± 4 (P = .06) at 18 months, and 27% ± 4 vs 24% ± 4 (P = .09) at 24 months, respectively. Mean time to TLPP event for subjects with an event was longer for DCBs (322 vs 207 d; P < .0001). Fewer interventions were needed to maintain target lesion patency in the DCB group at 9 months (P = .02) but not at 12 (P = .08), 18 (P = .13), or 24 months (P = .19). The noninferiority safety target was met at all intervals (P < .01). Mortality did not differ between groups (P = .27). Post hoc analyses showed equivalent DCB effect in all subgroups.ConclusionsTwo-year results demonstrate long-term safety and variable efficacy of DCB angioplasty in AVFs.     

Diagnostic Performance of CT-Guided Bone Biopsies in Patients with Suspected Osteomyelitis of the Appendicular and Axial Skeleton with a Focus on Clinical and Technical Factors Associated with Positive Microbiology Culture Results

PurposeTo assess diagnostic performance of CT-guided percutaneous needle bone biopsy (CTNBB) in patients with suspected osteomyelitis and analyze whether certain clinical or technical factors were associated with positive microbiology results.Materials and MethodsAll CTNBBs performed in a single center for suspected osteomyelitis of the appendicular and axial skeleton during 2003–2018 were retrospectively reviewed. Specific inclusion criteria were clinical and radiologic suspicion of osteomyelitis. Standard of reference was defined using outcome of surgical histopathology and microbiology culture and clinical and imaging follow-up. Technical and clinical data (needle size, comorbidities, clinical factors, laboratory values, blood cultures) were collected. Logistic regression was performed to assess associations between technical and clinical data and microbiology biopsy outcome.ResultsA total of 142 CTNBBs were included (46.5% female patients; age ± SD 46.10 y ± 22.8), 72 (50.7%) from the appendicular skeleton and 70 (49.3%) from the axial skeleton. CTNBB showed a sensitivity of 42.5% (95% confidence interval [CI], 32.0%–53.6%) in isolating the causative pathogen. A higher rate of positive microbiology results was found in patients with intravenous drug use (odds ratio [OR] = 5.15; 95% CI, 1.2–21.0; P = .022) and elevated white blood cell count ≥ 10 × 10⁹/L (OR = 3.9; 95% CI, 1.62–9.53; P = .002). Fever (≥ 38°C) was another clinical factor associated with positive microbiology results (OR = 3.6; 95% CI, 1.3–9.6; P = .011).ConclusionsCTNBB had a low sensitivity of 42.5% for isolating the causative pathogen. Rate of positive microbiology samples was significantly higher in patients with IV drug use, elevated white blood cell count, and fever.     

Single-Use versus Reusable Endoscopes for Percutaneous Biliary Endoscopy with Lithotripsy: Technical Metrics,Clinical Outcomes,and Cost Comparison

PurposeTo compare procedure and fluoroscopy time, technical and clinical success, and costs between single-use and reusable endoscopes in patients undergoing percutaneous biliary endoscopy (PBE) with lithotripsy.Material and MethodsThirty-four patients (67 procedures) were retrospectively included in the study. The patients were treated with PBE for gallstone removal from October 24, 2014, to February 12, 2020, using reusable (28 procedures) or single-use (39 procedures) endoscopes. The procedure time, fluoroscopy time, technical success rate (accessing the biliary system and locating the gallstone), clinical success rate (at least partial gallstone removal), complication rate, and cost of use were compared between the procedures.ResultsThe mean (± standard deviation) procedure time was not significantly different between single-use (136 minutes ± 45) and reusable endoscopes (136 minutes ± 51) (P = .47). The mean fluoroscopy time was significantly shorter for single-use endoscopes (11 minutes ± 8.4) than for reusable endoscopes (18 minutes ± 12) (P = .01). When comparing single-use versus reusable endoscopes, the technical success (95% [n = 37] vs 93% [n = 26]) and the clinical success (90% [n = 35] vs 75% [n = 21]) rates were not significantly different (both, P > .05). Only 1 complication was noted in the reusable endoscope group (P = .42). The cost per case was lower for single-use ($1,500) than for reusable ($3,987) endoscope procedures, primarily due to differences in capital costs and repair costs.ConclusionsSingle-use endoscopes offer the potential for lower patient radiation exposure and lower cost per case, which may reduce the financial barriers to offering PBE in interventional radiology practices. The clinical and technical success rates did not differ by endoscope type.     

Prostatic Artery Embolization Using 100–300-μm Trisacryl Gelatin Microspheres to Treat Lower Urinary Tract Symptoms Attributable to Benign Prostatic Hyperplasia: A Single-Center Outcomes Analysis with Medium-Term Follow-up

PurposeTo report medium-term outcomes of prostatic artery embolization (PAE) using 100–300-μm trisacryl gelatin microspheres to treat lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH) and to evaluate how cone-beam computed tomography-measured prostate gland volume (PGV), median lobe enlargement (MLE), age, and Charlson Comorbidity Index (CCI) affect these results.Materials and MethodsSeventy-four consecutive patients who underwent PAE from April 2014 through August 2018 were retrospectively reviewed. Patients had International Prostate Symptom Score (IPSS) >12, Quality of Life (QoL) score >2, prostate gland volume (PGV) >40 mL, age older than 45 years, and medical therapy failure. Twelve patients were excluded for bladder pathology or prostate cancer. Patients (n = 62, age = 71.8 ± 9.3 years, CCI = 3.5 ± 1.7, PGV = 174 ± 110 mL) had pre-procedure IPSS = 22.4 ± 5.6, QoL score = 4.4 ± 0.9, and post-void residual (PVR) = 172 ± 144 mL. Post-procedure values were compared to baseline at 1, 3, 6, 12, and 24 months. Associations between outcomes and PGV, MLE, age, and CCI were evaluated. Adverse event recording used Clavien-Dindo classification.ResultsOne month after PAE (n = 37), IPSS improved to 7.6 ± 5.2 (P < .0001) and QoL score improved to 1.7 ± 1.4 (P < .0001). At 3 months (n = 32), improvements continued, with IPSS = 6.4 ± 5.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 53 ± 41 mL (P < .001), and PGV = 73 ± 38 mL (P < .0001). Results were sustained at 6 months (n = 35): IPSS = 6.4 ± 4.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 68 ± 80 mL (P < .0001), PGV = 60 ± 19 mL (P < .001). At 12 months, patients (n = 26) had IPSS = 7.3 ± 5.5 (P < .0001), QoL score = 1.2 ± 0.8 (P <.0001), PVR = 89 ± 117 mL (P < .0001), PGV = 60 ± 48 mL (P < .01). At 24 months, patients (n = 8) had IPSS = 8.0 ± 5.4 (P < .0001), QoL score = 0.7 ± 0.5 (P < .0001), PVR = 91 ± 99mL (P = 0.17), and PGV = 30 ± 5mL (P = .11). Improvements were independent of PGV, MLE, age, and CCI. Two grade II urinary infections occurred.ConclusionsPAE with 100–300-μm microspheres produced sustained substantial improvements in LUTS, PGV, and PVR, which were independent of baseline PGV, MLE, age, or CCI.     

Sex-Related Differences in the Long-Term Outcomes of Patients with Femoropopliteal Arterial Disease Treated with the IN.PACT Drug-Coated Balloon in the IN.PACT SFA Randomized Controlled Trial: A Post Hoc Analysis

PurposeTo evaluate sex-related disparities in long-term outcomes of patients with peripheral artery disease (PAD) treated with IN.PACT drug-coated balloon (DCB) or percutaneous transluminal angioplasty (PTA).Materials and MethodsA post hoc analysis of the IN.PACT SFA trial was performed. Participants with Rutherford Clinical Classification 2–4 PAD and femoropopliteal artery lesions up to 18 cm long were randomly assigned to treatment with DCB (n = 220) or PTA (n = 111). Effectiveness outcomes were evaluated, including 36-month primary patency (freedom from binary restenosis and freedom from clinically driven [CD] target lesion revascularization [TLR]).ResultsIn the DCB group, women were significantly older (69.4 y ± 9.9) than men (66.4 y ± 9.1; P = .025). Mean reference vessel diameter (RVD) was significantly smaller in women (4.4 mm ± 0.68) compared with men (4.8 mm ± 0.89, P < .001). Primary patency was 65.4% in women and 71.8% in men (P = .302). Freedom from CD-TLR was 81.1% in women and 86.4% in men (P = .285). Women treated with PTA were older (70.4 y ± 8.3) than men (66.9 y ± 9.5; P = .063). Mean RVD was significantly smaller in women (4.2 mm ± 0.77) compared with men (4.9 mm ± 0.77, P < .001). Primary patency was 42.3% in women and 46.7% in men (P = .551). Freedom from CD-TLR was 59.4% in women and 75.5% in men (P = .109). No significant differences were noted in safety and mortality outcomes.ConclusionsIn both groups, women were older and had smaller vessels. Particularly in the PTA group, women had worse clinical outcomes, though not reaching statistical significance. Further evaluation is necessary to understand the disparate nature of disease progression and outcomes following endovascular treatment in women compared with men.     

Effectiveness and Safety of Atherectomy versus Plain Balloon Angioplasty for Limb Salvage in Tibioperoneal Arterial Disease

PurposeTo evaluate the effectiveness and safety of atherectomy versus plain balloon angioplasty (POBA) for treatment of critical limb ischemia (CLI) due to tibioperoneal arterial disease (TPAD).Materials and MethodsPatients enrolled in the Vascular Quality Initiative registry who had CLI (Rutherford Class 4–6) and underwent atherectomy versus POBA alone for isolated TPAD were retrospectively identified. Of eligible patients, a cohort of 2,908 patients was propensity matched 1:1 by clinical and angiographic characteristics. The atherectomy group comprised 1,454 patients with 2,183 arteries treated, and the POBA group comprised 1,454 patients with 2,141 arteries treated. The primary study endpoint was major ipsilateral limb amputation. Secondary endpoints were minor ipsilateral amputations, any ipsilateral amputation, primary patency, target vessel reintervention (TVR), and wound healing at 12 months.ResultsThe median follow-up period was 507 days, the mean patient age was 69 years ± 11.7, and the mean occluded length was 6.9 cm ± 6.5. There was a trend toward higher technical success rates with atherectomy than with POBA (92.9% vs 91.0%, respectively; P = .06). The rates of major adverse events during the procedure were not significantly different. The 12-month major amputation rate was similar in the atherectomy and POBA groups (4.5% vs 4.6%, respectively; P = .92; odds ratio, 0.97; 95% CI, 0.68–1.37). There was no difference in 12-month TVR (17.9% vs 17.8%; P = .97) or primary patency (56.4% vs 54.5%; P = .64) between the atherectomy and POBA groups.ConclusionsIn a large national registry, treatment of CLI from TPAD using atherectomy versus POBA showed no significant differences in procedural adverse events, major amputations, TVR, or vessel patency at 12 months.     

Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access: A randomized trial Comparing with Angioplasty Alone

PurposeTo assess whether angioplasty of hemodialysis access (HA) stenosis with a drug-coated balloon (DCB) would prevent restenosis in comparison with plain-balloon percutaneous transluminal angioplasty (PTA).Materials and MethodsThis prospective randomized clinical trial enrolled 120 patients with dysfunctional arteriovenous fistulae (n = 109) and grafts (n = 11), due to a ≥50% stenosis between March 2014 and April 2018. All patients underwent high-pressure balloon angioplasty and were then randomized to either DCB (n = 60) or PTA (n = 60). Patients were followed-up for 1 year, and angiography was performed 6 months after angioplasty. The primary endpoint was the late lumen loss (LLL) at 6 months. Secondary endpoints included other angiographic parameters at 6 months and HA failures, adverse event, and mortality at 12 months. Continuous variables were compared with a Student t-test, and Kaplan-Meier curves were used for freedom from HA failure and for mortality.ResultsLLL in the DCB and in the PTA group were 0.64 mm ± 1.20 and 1.13 mm ± 1.51, respectively (P = .082, adjusted P = .0498). DCB was associated with lower percentage stenosis (54.2% ± 19.3 vs 61.7% ± 18.2; P = .047) and binary restenosis ≥50% (56.5% vs 81.1%; P = .009) than PTA. The number of HA failures after 12 months was lower for DCB than for PTA (45% vs 66.7%; P = .017). Mortality at 12 months was 10% and 8.3% in the DCB and PTA groups, respectively (P = .75).ConclusionsDespite LLL improvement that failed to reach statistical significance, this study demonstrated decreased incidence and severity of restenosis with DCB compared with PTA to treat dysfunctional HA.     

Efficacy and Safety of Ultrasound-Guided Supraclavicular Brachial Plexus Block during Angioplasty of Dysfunctional Arteriovenous Access: A Prospective,Randomized Single-Center Clinical Trial

PurposeTo evaluate the efficacy and safety of the ultrasound-guided supraclavicular brachial plexus block (BPB) during angioplasty of dysfunctional arteriovenous access.Materials and MethodsEighty study participants with dysfunctional arteriovenous access were enrolled in this prospective, randomized clinical trial between November 2016 and February 2018. Eighty patients were randomized to either the ultrasound-guided supraclavicular BPB group (mean age ± standard deviation [SD], 65.1 ± 12.4; male:female = 17:23) or the no regional anesthesia group (mean age ± SD, 64.0 ± 11.7; male:female = 25:15). Pain was assessed on the 10-point Visual Analogue Scale. Participant satisfaction was examined. Six-month clinical follow-up was done to evaluate arteriovenous access patency and long-term complications.ResultsThe BPB group showed a lower average pain score than the control group (mean ± SD, 0.9 ± 1.9 vs 6.4 ± 2.5; P < .001). Participant satisfaction (mean ± SD, 2.8 ± 0.5 vs 2.1±0.8; P < .001) was also higher in the BPB group. Six-month patency was 65% (26/40) in the BPB group and 59% (23/39) in the control group, with no significant difference between the 2 groups (P = .59). No major immediate or delayed complications were observed.ConclusionsUltrasound-guided BPB is highly effective in reducing pain during angioplasty of dysfunctional arteriovenous access with an acceptable safety profile.     

Balloon Pulmonary Angioplasty for the Treatment of Nonoperable Chronic Thromboembolic Pulmonary Hypertension: Single-Center Experience with Low Initial Complication Rate

PurposeTo evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) for nonoperable chronic thromboembolic pulmonary hypertension (CTEPH) patients during the initial experience of a single center.MethodsA total of 18 CTEPH patients (5 with residual pulmonary hypertension after pulmonary endarterectomy) were treated with BPA during the period 2014–2018 and were retrospectively reviewed. Mean age was 61 ± 19 years; 55% were female; mean pulmonary artery pressure was 44 ± 12 mmHg; cardiac output was 4.3 ± 1.0 l/min; and pulmonary vascular resistance was 8.4 ± 3.6 WU. Patients were evaluated by New York Heart Association functional class, 6-minute walk distance, N-terminal pro b-type natriuretic peptide, echocardiography, right heart catheterization, and before and after completions of BPA.ResultsA total of 91 procedures were performed, with a median number of 4 BPA sessions per patient (range, 2–8). There were no deaths or major complications requiring extracorporeal support or (non)invasive ventilation. The most common complication was self-limiting hemoptysis (3%). According to Society of Interventional Radiology classification, 4 mild, 4 moderate, and 1 severe adverse events were noted. Invasive hemodynamics significantly improved, with a cardiac index increase of 15% (P = .0333), decrease of mean pulmonary artery pressure of 30% (P = .0013), and decrease of pulmonary vascular resistance of 45% (P = .0048). Stroke volume index (P = .0171) and pulmonary arterial compliance (P = .0004) were also significantly enhanced.ConclusionsBPA significantly improves cardiopulmonary hemodynamics with an acceptable safety profile. Further studies assessing the long-term efficacy of BPA are required.     

Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone

PurposeTo investigate the outcomes of stent thrombectomy combined with aspiration versus aspiration alone in acute mesenteric ischemia (AMI).Materials and MethodsThis was a single-center, retrospective cohort study. Between May 1, 2012, and January 1, 2021, 41 patients (mean age, 73.8 years ± 7.9) with AMI who underwent stent thrombectomy plus aspiration (Group 1, n = 14) or aspiration alone (Group 2, n = 27) were included. The treatment regimens and clinical and follow-up outcomes of the patients were reviewed and analyzed. Group differences were compared using a χ² test, Fisher exact test, independent t test, or Mann-Whitney U test. The cumulative survival rate was calculated using a Kaplan-Meier curve.ResultsThe overall clinical success rate was 78.0% (32/41), and no significant differences were found between Group 1 and Group 2 (78.6% vs 77.8%, P = 1.00). Compared with Group 2, Group 1 was associated with a higher complete clearance rate (44.4% vs 78.6%, P = .04), less adjunctive local thrombolysis (48.1% vs 14.3%, P = .03), and a shorter length of hospital stay (10.7 days ± 9.0 vs 5.7 days ± 4.7, P = .03). The estimated survival rates at 1 month, 3 months, 6 months, 1 year, and 2 years were 73.2%, 72.5%, 71.4%, 65.3%, and 59.8%, respectively. No significant difference was found in the survival rate between the groups (log-rank test, P = .96). The recurrence rates for Group 1 and Group 2 were 8.3% (1/12) and 4.0% (1/25), respectively.ConclusionsCompared with aspiration alone, aspiration combined with stent thrombectomy showed a higher complete clearance rate, reduced adjunctive thrombolysis, and a shorter length of hospital stay.     

Pleural Effusion after Hepatic Radiofrequency Ablation with Artificial Ascites: Clinical Spectrum and Significance

PurposeTo retrospectively investigate incidence, clinical outcome, and risk factors of iatrogenic pleural effusion in patients with hepatic tumors undergoing radiofrequency (RF) ablation using artificial ascites (AA).Materials and MethodsPatients (N = 163) who underwent RF ablation using AA were classified into pleural effusion and non–pleural effusion groups according to the presence of pleural effusion on immediate follow-up CT and chest radiograph after RF ablation. The pleural effusion group included asymptomatic and symptomatic subgroups. The incidence and subsequent clinical outcomes of patients developing pleural effusion after RF ablation were evaluated.ResultsOverall, 96 patients (58.9%) developed pleural effusion, which resolved in 4.4 d ± 3.1. Hospital length of stay in the pleural effusion group was longer than the non-pleural effusion group (6.5 d ± 2.6 vs 5.7 d ± 2.8, P < .01). The pleural effusion group had longer AA infusion time (P = .01), larger infused AA volume (P < .01), and longer ablation time (P < .01) than the non-pleural effusion group. Eighteen patients (18.8%) developed symptomatic pleural effusion and had a larger infused AA volume than asymptomatic patients with pleural effusion (P < .01). Pleural effusion duration and hospital length stay were also longer in the symptomatic pleural effusion subgroup than in the asymptomatic subgroup (P < .01). Infused AA volume was the only independent prognostic factor of pleural effusion duration in multivariate analysis (P = .038).ConclusionsPleural effusion frequently occurs after RF ablation using AA. Although generally considered negligible, pleural effusion could be a clinical problem and prolong hospitalization. Therefore, operators should be careful not to infuse too much AA when performing RF ablation.     

Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery

PurposeTo evaluate efficacy and safety of transcatheter arterial embolization (TAE) in managing postpartum hemorrhage (PPH) due to genital tract injury after vaginal delivery and to investigate factors associated with outcome of TAE.Materials and MethodsA retrospective review of 43 women (mean age, 32.6 years) who underwent TAE to manage PPH secondary to genital tract injury after vaginal delivery was performed at a single institution between January 2007 and December 2018. Clinical data and outcomes were obtained. Patients were classified into clinical success (n = 39) and failure (n = 4) groups, and comparisons between the groups were performed.ResultsThe clinical success rate of TAE for PPH due to genital tract injury was 90.7%. In the clinical failure group, transfusion volumes were higher (failure vs success: packed red blood cells, 14 pt ± 3.37 vs 6.26 pt ± 4.52, P = .003; platelets, 10.33 pt ± 4.04 vs 2.92 pt ± 6.15, P = .036); hemoglobin levels before the procedure were lower (failure vs success: 7.3 g/dL vs 10.7, P = .016). Periprocedural complications included pulmonary edema (25.6%), fever (23.3%), and pain (9.3%). Twenty-four patients were either followed for > 6 months or answered a telephone survey; 23 (95.8%) recovered regular menstruation, and pregnancy was confirmed in 11 (45.8%). Regarding fertility desires, 7 women attempted to conceive, 6 of whom (85.7%) became pregnant.ConclusionsTAE is an effective and safe method for managing PPH due to genital tract injury after vaginal delivery. Lower hemoglobin levels before the procedure and higher transfusion volumes were associated with clinical failure of TAE.     

Portal Vein Recanalization for Noncirrhotic Portal Vein Cavernous Transformation: Transjugular Intrahepatic Portosystemic Shunt Creation versus Portal Vein Stent Placement

PurposeTo compare the clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation versus portal vein stent placement (PVS) in patients with noncirrhotic cavernous transformation of the portal vein (CTPV).Materials and MethodsIn this retrospective study, clinical data from patients with noncirrhotic CTPV who underwent TIPS creation or PVS were compared. A total of 54 patients (mean age, 43.8 years ± 15.8; 31 men and 23 women) were included from January 2013 to January 2021; 29 patients underwent TIPS creation, and 25 patients underwent PVS. Stent occlusion, variceal rebleeding, survival, and postprocedural complications were compared between the 2 groups.ResultsThe mean follow-up time was 40.2 months ± 26.2 in the TIPS group and 35.3 months ± 21.1 in the PVS group. The stent occlusion rate in the PVS group (16%, 4 of 25) was significantly lower than that in the TIPS group (41.4%, 12 of 29) during the follow-up (P = .042). The cumulative variceal rebleeding rates in the TIPS group were significantly higher than those in the PVS group (28% vs 4%; P = .027). The procedural success rate was 69% in the TIPS group and 86% in the PVS group (P = .156). There was a higher number of severe adverse events after TIPS than after PVS (0% vs 24%; P = .012).ConclusionsPortal vein recanalization with PVS may be a preferable alternative to TIPS creation in the treatment of noncirrhotic CTPV because of higher stent patency rates, lower risk of variceal rebleeding, and fewer adverse events.     

Safety of Therapeutic Anticoagulation with Low-Molecular-Weight Heparin or Unfractionated Heparin Infusion during Catheter-Directed Thrombolysis for Acute Pulmonary Embolism

PurposeTo examine the safety of therapeutic-dose anticoagulation during catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE).Materials and MethodsA retrospective review of 156 consecutive cases (age, 56.6 ± 15.4 years; 85 males) of CDT with alteplase for acute PE (symptoms, <14 days) between 2009 and 2019 was performed. All patients received full-dose anticoagulation before, during, and after thrombolysis with low-molecular-weight heparin (LMWH) (n = 45) or unfractionated heparin (n = 111) infusion. Massive PE was diagnosed in 21 of 156 patients at presentation; submassive PE was diagnosed in 135 of 156 patients at presentation. The Simplified Pulmonary Embolism Severity Index was ≥1 in 69 of 156 patients.ResultsThere were 4 mild (2.6%), 3 moderate (1.9%), and 3 severe (1.9%) hemorrhagic complications (Global Use of Strategies to Open Occluded Arteries), 1 of which (0.6%) was intracranial. No significant differences in hemorrhagic complication rates (P = .3, P = 1.0, and P = .6, respectively) or general complication rates (Society of Interventional Radiology [SIR] minor, P = .2; SIR major, P = .7) were noted between the LMWH and heparin groups. Mean pulmonary arterial pressure for the entire cohort improved from 28.9 ± 7.6 mmHg to 20.4 ± 6.5 mmHg (P < .001), whereas the Miller score improved from 19.3 ± 4.6 to 7.3 ± 3.9 (P < .001). The average infusion duration was 26 ± 11.9 hours over 2.3 ± 0.6 total visits to the angiography lab, during which a mean of 27.85 ± 14.2 mg of tissue plasminogen activator were infused.ConclusionsTherapeutic anticoagulation during CDT for PE appears to be safe. The current study did not find a significant difference between LMWH and heparin infusion with respect to hemorrhagic and general complication rates.     

Clinical Outcomes of Percutaneous Biliary Endoscopy: A 7-Year Single-Institution Experience

PurposeTo evaluate safety and effectiveness of percutaneous biliary endoscopy (PBE) performed on patients ineligible for surgery or endoscopic retrograde cholangiopancreatography.Materials and MethodsRetrospective review was conducted for all patients who underwent PBE at a single academic institution between June 2013 and February 2020; 39 patients underwent 58 choledochoscopy sessions, and 21 patients underwent 48 cholecystoscopy sessions. Choledochoscopy indications included stone removal (23 of 39 patients) or biliary stenosis evaluation (19 of 39 patients). Cholecystoscopy indications included calculous cholecystitis (18 of 21 patients) and symptomatic cholelithiasis (3 of 21 patients). Technical success, procedural and fluoroscopy times, and tube-free survival were assessed.ResultsFor all PBEs performed for stone clearance, using disposable endoscopes led to shorter mean ± SD procedural (128.7 minutes ± 56.2 vs 240.2 minutes ± 184.6; P < .01) and fluoroscopy times (10.7 minutes ± 7.9 vs 16.5 minutes ± 12.0; P = .01) than using reusable endoscopes. Increasing institutional experience was associated with reduced procedural time (β = −56.73; P < .001). Choledochoscopy technical success was 94.8% with 1 adverse event of bile duct perforation with bile leak requiring drainage. For patients with choledocholithiasis, biliary drains were removed in 14 (60.9%) patients, with a mean tube-free survival of 22.1 months ± 23.8. For cholecystoscopy, technical success was 93.8% with no adverse events. Cholecystostomy tubes were removed in 15 (71.4%) patients, with a mean tube-free survival of 7.5 months ± 8.8.ConclusionsThis study supports PBE as a safe and feasible option for nonsurgical patients or those with altered anatomy precluding endoscopic retrograde cholangiopancreatography. Moreover, PBE may result in tube-free survival.     

A Comparative Study of Cavitary and Noncavitary Non–small Cell Lung Cancer Patients Treated with CT-Guided Microwave Ablation

PurposeTo explore the outcomes of computed tomography‒guided microwave (MW) ablation in patients with cavitary non–small cell lung cancer (NSCLC) and to compare the outcomes of cavitary and noncavitary NSCLC treated with MW ablation.Materials and MethodsA total of 317 patients with NSCLC (194 men and 123 women) treated with MW ablation were include: 19 patients with cavitary NSCLC and 298 patients with noncavitary NSCLC. Complications, progression-free survival (PFS), and overall survival (OS) were evaluated and compared between the 2 groups. The Kaplan-Meier method was used to investigate the correlation of cavity and OS in patients with NSCLC.ResultsA total of 364 MW ablation procedures were performed. Adenocarcinoma was the predominant histopathological subtype in patients with cavitary NSCLC (73.7%). Cavitary NSCLC had an incidence rate of 57.9% in overall complications, which was significantly higher than that of 34.6% for noncavitary NSCLC (P = .040). In a mean follow-up of 27.2 months ± 11.9, the median PFS and OS for cavitary NSCLC were 9.0 months ± 8.5 and 14.0 months ± 10.8, respectively, and those for noncavitary NSCLC were 13.0 months ± 10.7 and 17.0 months ± 10.9, respectively. There was no significant difference in PFS (P = .180) or OS (P = .133) between cavitary and noncavitary NSCLC. In addition, the local recurrence rates for cavitary and noncavitary NSCLC were 15.8% and 21.5%, respectively, and no significant difference was found (P = .765). The Kaplan-Meier method revealed no association between the cavity and OS in patients with NSCLC treated with MW ablation.ConclusionsMW ablation was an effective and safe approach for cavitary NSCLC treatment. Compared with noncavitary NSCLC, cavitary NSCLC manifested with more complications but a comparable outcome after MW ablation.     

Three-Year Efficacy and Safety of the Misago Peripheral Stent for Superficial Femoral Artery Disease: Final Results from the OSPREY Trial

PurposeThis study evaluated the long-term outcomes of the Misago peripheral stent trial (Terumo) for atherosclerotic lesions in the superficial femoral artery (SFA) in patients with claudication.Materials and MethodsThis was a prospective multicenter, single-arm, clinical trial of primary stent placement for de novo cases of SFA disease conducted in the United States and Asia. The primary endpoint was freedom from clinically driven target lesion revascularization (CD-TLR) at 36 months. Secondary outcomes were ankle-brachial index (ABI), Rutherford score, Walking Impairment Questionnaire (WIQ), a quality of life survey, and rate of device fracture.ResultsA total of 276 patients (64.4% male; mean age, 69.3 ± 10.1 years) were enrolled. Freedom from CD-TLR was 78.5% (95% confidence interval [CI], 73.0%–83.0%) at 24 months and 75.4% (95% CI, 69.6%–80.2%) at 36 months. Baseline ABI was 0.7 ± 0.1 and 0.98 ± 0.20 (P < .001) at 30 days after the procedure. Baseline Rutherford score was 3.6 ± 0.6 and 1.6 ± 1.0 30 at 30 days after the procedure (P < .001). Mean (and changed) ABI and Rutherford score at 36 months compared to day 30 after the procedure were, respectively, 0.91 (−0.1 ± 0.2) and 1.5 (−0.2 ± 1.1). WIQ score at baseline was 21.49 ± 26.30 and 50.51 ± 38.49 at 30 days after the procedure ( P < .001). The mean WIQ score at 2 years was 46.65 ± 37.31 (P = .12). Stent fracture rate at 36 months was 2.0% (4 of 202 patients).ConclusionsOSPREY (Occlusive-Stenotic Peripheral Artery Revascularization Study) 36-month data demonstrated persistent freedom from CD-TLR and sustained improvement in ABI and Rutherford score with primary stent placement for SFA lesions.     

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women

PurposeTo evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women.Materials and MethodsEighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined.ResultsA total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19–85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001).ConclusionsImaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.