ABSTRACT
Purpose: To examine the outcomes of patients with venous thromboembolism (VTE) who underwent placement of a bioabsorbable inferior vena cava filter (IVCF) for temporary pulmonary embolism (PE) protection Materials and Methods: From 10/1/2020 to 11/31/2021, 17 patients (mean age 71, range 45-92, 58% female) underwent placement of a bioabsorbable IVCF (Sentry, Boston Scientific) at a single academic center. Thirteen of the 17 filters (76.4%) were placed in the inpatient setting, and the remainder were placed outpatient. VTE risk factors included malignancy (70.6%), immobility (5.9%), COVID-19 (5.9%), and unprovoked (7.6%). Prior to IVCF, 11 patients presented with deep venous thrombosis (DVT) alone, two had PE alone, and four were diagnosed both DVT and PE. The contraindication to anticoagulation (AC) was active bleeding in 47.1% of the cohort, upcoming surgery in 41.2%, worsening of DVT on AC in 5.9%. and brain tumor in 5.9%. The pre-implantation infrarenal IVC diameter ranged from 1.6 to 2.6 cm. Technical success (TS), adverse events (AEs), and follow-up IVCF characteristics were recorded. Results: TS was 100%. No AEs occurred during placement. Mean follow-up period was 4.9 months (range 0-12.9). No new PEs were diagnosed after IVCF placement, and no patients required replacement of IVCF. Nine of the 17 patients had follow-up CTs after filter placement, two had follow up radiographs in which the filter state could be assessed, and the remaining six had no imaging evaluating the filter after placement. Asymptomatic IVCF associated non-occlusive thrombosis was seen in 3 patients. The longest amount of time after placement that a Sentry filter was observed to still be in the filter state was 3.9 months, and the shortest time in which imaging showed a filter bio-converted to the open state was 3.1 months. Three patients underwent serial imaging which incidentally demonstrated the timeframe in which the IVCF converted from a filter-state to an open-state. In one patient this conversion occurred between 2.1 and 3.1 months, in another between 1.7 and 3.3 months, and in the last patient between 3.9 and 4.4 months. Conclusion: In VTE patients with either a temporary contraindication to anticoagulation or a transitory high-PE-risk period, bioconvertible IVC filters are a safe and effective option for short-term protection against pulmonary embolism.
ABSTRACT
Background May-Thurner syndrome and pregnancy are independent risk factors for the development of deep vein thrombosis (DVT). Emerging data suggests an association for venous thromboembolism (VTE) development in COVID-19 patients. Treatments for DVT vary and include thrombolysis, mechanical thrombectomy and long-term anticoagulation. We describe a unique case of this in a postpartum female. Case A 31 year old female G3P0121 and recent cesarean section 1 month ago presented with left lower extremity swelling, severely limited ambulation and 3+ edema of the left leg extending to the hip without any right leg edema. She was COVID-19 antibody positive. Occlusive DVTs were confirmed via venous duplex ultrasound and computed tomographic venography of the abdomen and pelvis, extending from distal inferior vena cava to the left popliteal vein. Decision-making Invasive venography confirmed the non-invasive imaging findings. After administering 12-14 mg of tissue plasminogen activator (tPA), multiple aspirations were performed using a rheolytic thrombectomy catheter. However persistent dense thrombus in the iliac and femoral veins remained, thus subsequent balloon angioplasty was performed but unsuccessful. Intravascular ultrasound confirmed the presence of May-Thurner syndrome at the junction of the left common iliac vein and the inferior vena cava. Finally an infusion catheter was placed for tPA. Within 48 hours, patient developed oliguric renal failure likely due to a combination of contrast-induced and pigment nephropathy requiring intermittent hemodialysis. Repeat ultrasound showed resolution of DVT along with improving edema and renal function. Warfarin was chosen for long-term anticoagulation due to renal failure and breast-feeding. Conclusion Pregnancy is a pro thrombotic state that may lead to VTE even in the postpartum period. Decision-making and treatment in these patients may be complex and require a multidisciplinary approach.
ABSTRACT
Purpose: To assess the impact of COVID-19 on the overall volume of IR outpatient-based evaluation and management encounters (E&M) and to demonstrate the role of telehealth in offsetting the loss of volume caused by COVID-19 Materials and Methods: A retrospective review of IR E&M in a large academic health system between January 6, 2020 and August 23, 2020, was conducted using the same time period in 2019 as a historical control. IR encounters were collected by gathering the weekly volume of submitted E&M current procedural technology (CPT) codes from the IR division. IR encounters were classified as outpatient or telehealth E&M. The E&M volume in 2019 was used as a historical control. Data were divided into three periods: pre-surge (January 6–March 15, 2020), surge (March 16–June 7, 2020), and recovery (June 8–August 23, 2020). The mean encounters per week during the surge and recovery periods were compared to the pre-surge baseline using a Welch t test for 2020 data, and the same comparison was made for 2019 data for a historical control. Results: During the surge period, outpatient E&M volume, inclusive of telemedicine, fell by 55.8% relative to the pre-surge 2020 baseline. The volume grew steadily during the recovery period but remained 19.8% below pre-surge 2020 levels. The surge and recovery mean weekly E&M volume was significantly different from the equivalent periods in 2019 (P < 0.001 and P = 0.02, respectively). During the surge, telemedicine comprised 44.6% of the total outpatient E&M. The contribution of telemedicine gradually fell over the recovery period, comprising just 11.5% in the final week of the study, and 16.7% during the recovery. Outpatient E&M reached a nadir during the week of April 13th, reflecting a 70.6% decline relative to the same period in 2019. The recovery period demonstrated a gradual increase in outpatient E&M with a decline in telehealth encounters balanced by a growth of in-person visits. During the last week of the recovery period (week of 8/17), outpatient in-person E&M had recovered to 2019 levels, and with the inclusion of telehealth exceeded E&M in 2019 for the same period by 93.3%. Conclusions: Telemedicine becomes an important way to maintain outpatient E&M volume in the event of a pandemic when social distancing and stay-at-home orders preclude face-to-face visits. Revenue from outpatient E&M may help bridge the gap until resumption of elective procedures and recovery of procedural case volume.
ABSTRACT
Purpose: The COVID-19 pandemic led to unprecedented radiology volume loss and substantial changes in case mix. This study seeks to identify the specific sources of procedural volume loss and recovery in a large academic system at the epicenter of the pandemic. Materials and Methods: All procedures performed during the first 33 weeks of 2020 in the Department of Radiology of a large academic health system were reviewed retrospectively. Data included modality, billed current procedural terminology (CPT) codes, and patient service location. Each procedure was assigned to 1 of 8 categories: biopsy, drainage, enteric access, venous access, neuro (both spinal and cerebral), oncology, vascular (both arterial and venous), and other. For analysis of the effects of COVID-19, volumes were aggregated weekly and a “surge” period was defined beginning with the first local COVID-19 positive patient and ending when new daily cases crossed below 25% of the peak. Results: There were significant decreases in all categories during the surge period. The largest declines were seen in vascular (-52%), biopsy (-44%), and oncology (-43%) procedures and the smallest in venous (-14%) and enteric (-12%) access. When stratified by site of service, there were relative increases over baseline in inpatient oncology (+44%), biopsy (+18%), and enteric access (+10%) procedures following the surge. Conclusions: During the local COVID-19 outbreak, procedural volume loss was offset by increasing the department’s role in providing venous and enteric access. The relative increase in inpatient interventional oncology and biopsies during the recovery is likely multifactorial but may support prior assertions that delayed diagnosis and treatment due to the pandemic has resulted in more severe disease at presentation. [Formula presented]