Current Evidence for Endovascular Therapies in the Management of Acute Deep Vein Thrombosis.

Acute lower extremity deep vein thrombosis (DVT), specifically proximal iliofemoral DVT, is a relatively common disorder that can result in a chronic debilitating post-thrombotic syndrome (PTS), with a significant effect on a patient's quality of life. Anticoagulation is first-line therapy; however, percutaneous interventions have emerged as treatment options for patients where there is concern that anticoagulation alone will not resolve the DVT as well as prevent PTS. This paper will discuss the existing data on these interventions and review current endovascular techniques, including catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy in the management of DVT.

Null mutants of a tomato Rho of plants exhibit enhanced water use efficiency without a penalty to yield.

Improving water use efficiency in crops is a significant challenge as it involves balancing water transpiration and CO2 uptake through stomatal pores. This study investigates the role of SlROP9, a tomato Rho of Plants protein, in guard cells and its impact on plant transpiration. The results reveal that SlROP9 null mutants exhibit reduced stomatal conductance while photosynthetic CO2 assimilation remains largely unaffected. Notably, there is a notable decrease in whole-plant transpiration in the rop9 mutants compared to the wild type, especially during noon hours when the water pressure deficit is high. The elevated stomatal closure observed in rop9 mutants is linked to an increase in reactive oxygen species formation. This is very likely dependent on the respiratory burst oxidase homolog (RBOH) NADPH oxidase and is not influenced by abscisic acid (ABA). Consistently, activated ROP9 can interact with RBOHB in both yeast and plants. In diverse tomato accessions, drought stress represses ROP9 expression, and in Arabidopsis stomatal guard cells, ABA suppresses ROP signaling. Therefore, the phenotype of the rop9 mutants may arise from a disruption in ROP9-regulated RBOH activity. Remarkably, large-scale field experiments demonstrate that the rop9 mutants display improved water use efficiency without compromising fruit yield. These findings provide insights into the role of ROPs in guard cells and their potential as targets for enhancing water use efficiency in crops.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates.

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

Clinical Impact and Safety of Non-Target Punctures (NTP) during Portal Vein Access in TIPS Procedure.

BACKGROUND: Although non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures. METHODS: A retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts. RESULTS: A total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP. CONCLUSIONS: NTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.

Transarterial Embolization of Bone Metastases.

Embolization of bone metastases is most commonly performed for hypervascular tumors prior to surgical resection. When employed in this fashion embolization can significantly decrease perioperative hemorrhage and improve surgical outcomes. In addition, embolization of bone metastases may lead to local tumor control and decreased tumoral associate bone pain. Careful techniques and choice of embolic material are required when performing embolization of bone lesions to ensure low procedural complications and high rates of clinical success.4 The indications, technical considerations, and complications associated with embolization of metastatic hypervascular bone lesions will be discussed in this review with subsequent case examples.

Survival Advantage of Yttrium-90 Radioembolization to Systemic Therapy in Patients with Hepatic Metastases from Colorectal Cancer in the Salvage Setting: Results of a Matched Pair Study.

RATIONALE AND OBJECTIVES: Patients with hepatic metastases from colorectal cancer have a poor prognosis in the salvage setting. This study assessed the survival benefit of adding transarterial 90Y radioembolization in the salvage setting to systemic therapy. MATERIALS AND METHODS: In this retrospective, matched-pair study, 21 patients who underwent radioembolization plus systemic therapy were matched with a cohort of 173 patients who received systemic chemotherapy alone in the salvage setting, defined as progression on at least two different regimens of systemic chemotherapy. Patients were matched one-to-one on Eastern Cooperative Oncology Group Performance Status, presence of extrahepatic disease, and presence of tumor KRAS mutation. Radioembolization patients underwent treatment using standard dosimetry to either a hepatic lobe or the whole liver. Survival data was analyzed using Kaplan-Meier analysis. RESULTS: Patients who underwent radioembolization plus systemic therapy vs. those who had systemic therapy alone had similar demographics and exposure to prior systemic chemotherapies. Median survival from the date of primary diagnosis was 38 (95% CI 26 to 50) v 25 (95% CI 15 to 35) months in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.17). Median survival from the date of hepatic metastases was 31 (95% CI 23.8 to 38.2) v 20 months (95% CI 10.2 to 29.8) in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.03). CONCLUSION: The addition of radioembolization to systemic therapy in patients with metastatic colorectal cancer to the liver may improve survival in the salvage setting.

Predictors of Active Extravasation and Complications after Conventional Angiography for Acute Intraabdominal Bleeding.

Conventional angiography is used to evaluate and treat possible sources of intraabdominal bleeding, though it may cause complications such as contrast-induced nephropathy (CIN). The study's purpose was to identify factors predicting active extravasation and complications during angiography for acute intraabdominal bleeding. All conventional angiograms for acute bleeding (January 2013-June 2015) were reviewed retrospectively, including 75 angiograms for intraabdominal bleeding in 70 patients. Demographics, comorbidities, vital signs, complications within one month, and change in hematocrit (ΔHct) and fluids and blood products administered over the 24 h prior to angiography were recorded. Of 75 exams, 20 (27%) demonstrated extravasation. ΔHct was the only independent predictor of extravasation (p = 0.017), with larger ΔHct (-17%) in patients with versus those without extravasation (-1%) (p = 0.01). CIN was the most common complication, occurring in 10 of 66 angiograms (15%). Glomerular filtration rate (GFR) was the only independent predictor (p = 0.03); 67% of patients with GFR < 30, 29% of patients with GFR 30-60, and 8% of patients with GFR > 60 developed CIN. For patients with intraabdominal bleeding, greater ΔHct decrease over 24 h before angiography predicts active extravasation. Pre-existing renal impairment predicts CIN. Patients with large hematocrit declines should be triaged for rapid angiography, though benefits can be weighed with the risk of renal impairment.

Percutaneous radiologically guided gastrostomy tube placement: comparison of antegrade transoral and retrograde transabdominal approaches.

PURPOSE: We aimed to compare the antegrade transoral and the retrograde transabdominal approaches for fluoroscopy-guided percutaneous gastrostomy tube (G-tube) placement. METHODS: Following institutional review board approval, all G-tubes at two academic hospitals (January 2014 to May 2015) were reviewed retrospectively. Retrograde approach was used at Hospital 1 and both antegrade and retrograde approaches were used at Hospital 2. Chart review determined type of anesthesia used during placement, dose of radiation used, fluoroscopy time, procedure time, medical history, and complications. RESULTS: A total of 149 patients (64 women, 85 men; mean age, 64.4±1.3 years) underwent G-tube placement, including 93 (62%) placed via the retrograde transabdominal approach and 56 (38%) placed via the antegrade transoral approach. Retrograde placement entailed fewer anesthesiology consultations (P < 0.001), less overall procedure time (P = 0.023), and less fluoroscopy time (P < 0.001). A comparison of approaches for placement within the same hospital demonstrated that the retrograde approach led to significantly reduced radiation dose (P = 0.022). There were no differences in minor complication rates (13%-19%; P = 0.430), or major complication rates (6%-7%; P = 0.871) between the two techniques. CONCLUSION: G-tube placement using the retrograde transabdominal approach is associated with less fluoroscopy time, procedure time, radiation exposure, and need for anesthesiology consultation with similar safety profile compared with the antegrade transoral approach. Additionally, it is hypothesized that decreased procedure time and anesthesiology consultation using the transoral approach are likely associated with reduced cost.

Effects of lidocaine-induced inactivation of the bed nucleus of the stria terminalis, the central or the basolateral nucleus of the amygdala on the opponent-process actions of self-administered cocaine in rats.

RATIONALE: In addition to its rewarding actions, cocaine has profound negative effects that are unmasked as the rewarding impact of the drug fades. While much is known about the neurobiology of cocaine reward, the mechanisms underlying the negative actions of the drug remain unclear. OBJECTIVES: The current study investigates the role of three brain regions each implicated in the modulation of negative affective states-the bed nucleus of the stria terminalis (BNST), the central (CeA), and the basolateral (BLA) nucleus of the amygdala. METHODS: The dual actions of cocaine were assessed using a runway self-administration procedure in which rats exhibit both approach to and avoidance of a goal box associated with cocaine administration (retreat behaviors). Here, rats ran a straight alley once/day for i.v. cocaine (1.0 mg/kg/injection) over 14 days during which the BNST, CeA, or BLA was inactivated via bilateral intracranial infusions of lidocaine (0 or 20 µg/0.5 µl/side) administered 15 min prior to testing. The impact of lidocaine on spontaneous locomotor activity was also assessed to rule out nonspecific actions of the treatments. RESULTS: Control animals running for cocaine developed the expected pattern of approach-avoidance retreat behavior. Inactivation of the BNST attenuated such behavior, BLA inactivation had no appreciable effects, and CeA inactivation produced intermediate and more variable results. Locomotor activity was unaffected by any of the treatments. CONCLUSIONS: These data suggest that the BNST and to a lesser extent the CeA, but not the BLA, play a role in mediating the opponent-process actions of self-administered cocaine.