Clinical Efficacy of Percutaneous Vegetectomy in Tricuspid and Right-Heart Indwelling Device Infective Endocarditis.

Several studies have analyzed the efficacy of AngioVac for percutaneous intracardiac vegetectomy, but impact on surgical candidacy or clinical efficacy for infectious endocarditis (IE) is currently unknown. This is a single-arm, retrospective study on IE vegetectomy with impact on surgical risk scores. Analysis included 32 patients who underwent AngioVac vegetectomy for right heart IE at a single institution. The primary endpoint was improvement in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) scores. Secondary endpoints included technical success, improved leukocytosis, procedural safety, 30-day mortality, and 60-day mortality. Findings demonstrate 90.6% (n = 29) technically successful debulking. There was improvement in mean NSQIP scores from 34.6 to 27.9 (P = .007). Zero cases of 30-day all-cause mortality. One patient experienced a major post-procedural complication of pneumothorax, a Class D Adverse Event. 20.5% (n = 5) of valvular vegetation patients went on to have surgical tricuspid valve repair. All indwelling intracardiac devices were removed. Findings suggest that percutaneous vegetectomy improves surgical candidacy, as measured by ACS NSQIP scores, in patients with IE and right heart vegetations and is associated with low complication rates.

Repeat angiography in patients undergoing conventional catheter-directed thrombolysis for submassive pulmonary embolism: a large single-center experience.

PURPOSE: Few studies have examined conventional catheter directed thrombolysis (CDT) for the treatment of submassive pulmonary embolism (PE). Moreover, angiographic resolution of thrombus burden following CDT has infrequently been characterized. This study describes a single-center experience treating submassive PE with CDT while utilizing repeat angiography to determine treatment efficacy. METHODS: A retrospective analysis of 140 consecutive patients who underwent CDT for submassive PE from December 2012 to June 2019 was performed. Angiographic resolution of thrombus burden after CDT was reported as high (>75%), moderate (51-75%), low (26-50%), or insignificant (≤25%). All angiograms were reviewed by two interventional radiologists. Secondary endpoints included reduction in pulmonary artery pressure (PAP) and clinical outcomes. Bleeding events were classified according to the Society of Interventional Radiology (SIR) adverse event criteria. RESULTS: CDT was performed in 140 patients with a mean rtPA dose of 25.3 mg and a mean treatment time of 26.0 hours. Angiographic resolution of thrombus burden was high in 70.0%, moderate in 19.3%, low in 5.7%, and insignificant in 3.6%; in 2 patients (1.4%) repeat angiography was not performed. Systolic PAP was reduced (47 vs. 35 mmHg, p < 0.001), mean PAP was reduced (25 vs 21 mmHg, p < 0.001), and 129 patients (92.1%) improved clinically. Patients with high or moderate resolution of thrombus burden had a clinical improvement rate of 95.2%, while patients with low or insignificant thrombus burden resolution had a clinical improvement rate of 76.9% (p=0.011). Ten patients (7.1%) had hemodynamic or respiratory decompensation requiring mechanical ventilation, systemic thrombolysis, cardiopulmonary resuscitation, or surgical intervention. Seven patients (5.0%) experienced moderate bleeding events and one patient (0.7%) with metastatic disease developed severe gastrointestinal bleeding that resulted in death. Thirty-day mortality was 1.4%. CONCLUSION: In patients with submassive PE undergoing CDT, angiographic resolution of thrombus burden is a safe and directly observable metric that can be used to determine procedural success. In this study, CDT with repeat angiography was associated with a 5.7% bleeding event rate and thirty-day mortality of 1.4%.

Portal Hypertension and Ascites Due to an Arterioportal Fistula: Sequela of a Remote Traumatic Liver Laceration.

Arterioportal fistulas (APFs) are a group of vascular disorders, in which systemic arteries communicate with the portal circulation, presenting as a congenital syndrome or more commonly acquired from iatrogenic instrumentation or abdominal trauma. We report the case of a 58-year-old man who developed ascites without underlying risk factors for portal hypertension, which was attributed to an APF found on imaging, manifesting 43 years after sustaining a liver laceration. After angiographic embolization of the APF, the patient's ascites resolved completely. The prolonged latent period between the patient's abdominal trauma and eventual presentation with ascites highlights the need to consider vascular malformations in the differential diagnosis of unexplained noncirrhotic portal hypertension.

Migration of a distal shunt catheter into the heart and pulmonary artery: report of a case and review of the literature.

INTRODUCTION: A rare complication of ventriculoperitoneal shunt placement is the proximal migration of the distal catheter into the heart and pulmonary artery. There have been 12 reported cases regarding intracardiac migration. In five of the cases, the catheter traveled further into the pulmonary vasculature. CASE REPORT: The authors report another case regarding the latter situation where the catheter tip localized in a right upper lobe pulmonary arterial branch. Removal of the catheter was complicated by redundancy of the catheter and a knot along the catheter. Nevertheless, extraction was successful via endovascular retrieval using interventional radiology and loop snares. Catheter migration likely began where the right internal jugular vein was penetrated during the initial shunt placement. Subsequent venous flow and negative intrathoracic pressure coordinated the proximal migration of the catheter. The authors provide a literature review to provide information regarding management of this rare complication.

Life-threatening post-thrombectomy hypotension due to residual complications from a translumbar catheter.

Translumbar catheters offer an alternative life-saving option in patients without conventional dialysis access, though their use and complication rates are poorly understood. We report the first case in the medical literature of a translumbar catheter inducing a central venous stenosis. This occult sequela converted what is usually a subclinical complication from an arteriovenous graft thrombectomy into a life-threatening one. This unusual clinical presentation highlights the need for clinicians to recognize the potential serious implications of translumbar catheter-induced occult central venous stenosis.

Time to hemostasis after traction removal of tunneled cuffed central venous catheters.

PURPOSE: Many patients undergo placement of tunneled cuffed central venous catheters (TCCVCs) for indications including administration of medical therapy and hemodialysis. They are removed when no longer needed or if there is a device complication. There is no consensus regarding the necessity of routine preremoval coagulation studies or platelet count, so this study was performed to determine if abnormal coagulation status affects the time to hemostasis (TH) after traction removal of TCCVCs. MATERIALS AND METHODS: Adult patients referred to our group for removal of a TCCVC placed via a jugular or subclavian route were considered candidates for inclusion. Blood was submitted for evaluation of prothrombin time (PT) and International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), and platelet count. Catheters were removed with the traction technique, and presence of hemostasis was assessed at 5-minute intervals of manual compression. RESULTS: Between November 19, 2001, and April 20, 2004, 179 subjects were enrolled and completed the study. There were 165 subjects in whom TH was within the first 5-minute interval and 14 in whom more than 5 minutes was required. Statistically significant factors associated with prolonged TH were primary diagnosis of end-stage renal disease (P = .005), use of antiplatelet agents (P = .03), and procedure performed by a "low-volume" operator (P = .002). CONCLUSIONS: Routine preremoval evaluation of coagulation parameters is not necessary. Patients who are likely to have abnormal platelet function but not abnormal platelet number appear to be at risk for prolonged TH, but even in those cases, the THs are rarely more than 15 minutes.

Magnetic resonance urography for the assessment of potential renal donors: comparison of the RARE technique with a low-dose gadolinium-enhanced magnetic resonance urography technique in the absence of pharmacological and mechanical intervention.

The aim of this study was to determine whether magnetic resonance urography without pharmacological (diuretic) stimulation and mechanical compression allows conclusive evaluation of the urinary system in potential renal donors. In 28 consecutive patients magnetic resonance urography (MRU) was performed on a 1.5-T system. Two techniques, rapid acquisition with relaxation enhancement (RARE) and a gadolinium (Gd)-enhanced 3D fast low angle shot (FLASH) sequence were compared in the absence of adjunctive measures. Two reviewers assessed image quality, presence of artifacts and completeness of visualization of the collecting systems and ureters. Among the 53 MR urograms, there was no difference in image quality and presence of artifacts between RARE and Gd-MRU. Despite high image quality, visualization of the urinary collecting system was insufficient. Continuous visualization from the collecting system to the distal ureter was demonstrated bilaterally in only 14% of the RARE and 26% of Gd-enhanced MR urograms, respectively. Overall, Gd-enhanced MRU was superior to the RARE technique in displaying the segments of the urinary collecting system, but this difference was not found to be statistically significant. Neither the RARE technique nor the gadolinium-enhanced MRU technique is accurate enough to allow the evaluation of the collecting system and ureters in potential renal donors in the absence of pharmacological intervention and compression.

MR angiography of the renal arteries.

During, the past decade. MRA has evolved from an cxperimental technique into the modality of choice for the noninvasive evaluation of renovascular disease. The recent widespread application of MRA for these indications has been driven primarily by the advent of 3D contrast-enhanced MRA. which provides a fast, reliable technique for imaging large vascular territories and generates images, after postprocessing, similar in appearance to digital subtraction angiography. The cross-sectional volumetric nature of contrast-enhanced MRA affords some advantages over conventional catheter angiography. Although 3D contrast-enhanced MRA forms the backbone of vascular MR studies, several adjunctive sequences are employed to maximize the diagnostic yield of the examination. For example. flow-dependant imaging is used to complement the morphologic images of contrast-enhanced MRA by providing hemodynamic information. As such, MRA is unique among noninvasive imaging modalities in that it offers a comprehensive evaluation of anatomy and function. The availability and reliability of MRA extend renal artery screening to a wider spectrum of patients. Current applications of renal MRA range from detection of renal artery stenosis to evaluation for renal transplant donors.

MR angiography of the mesenteric vasculature.

MRA has evolved from a research tool to a robust clinical diagnostic modality. In many centers worldwide, it is the technique of choice for evaluating patients with suspected CMI, assessing operability of patients with pancreatic cancer, and investigating the portal system. Evolving indications include the assessment of liver transplant patients before and after transplant and of living related liver transplant donors. The search for the bleeding source in patients with gastrointestinal hemorrhage may be an indication in the future, once intravascular contrast agents become available.

Body MR venography.

MRV offers unique diagnostic possibilities for detection and characterization of venous disease. It allows evaluation of perivascular and vascular anatomy, evolution of thromboembolic events, and assessment of vascular flow. MRI is a diagnostic tool that can be tailored for a variety of clinical dilemmas, not only DVTs. Continued improvements in hardware and software will expand the role of MRV.