Effectiveness and Safety of Large-Bore Aspiration Thrombectomy for Intermediate- or High-Risk Pulmonary Embolism.

PURPOSE: To evaluate effectiveness and safety of large-bore mechanical thrombectomy of intermediate- or high-risk pulmonary embolism (PE) and factors associated with effectiveness. MATERIALS AND METHODS: A retrospective review of 257 patients with intermediate- or high-risk PE who underwent mechanical thrombectomy using the Flowtriever system (Inari Medical, Irvine, California) between July 2019 and November 2021 was conducted. Data were analyzed using the linear regression and Kaplan-Meier methods with a Type 1 error set at 0.05. RESULTS: Patients' mean age was 62 years, and 51% were male. PE risk was classified as high, intermediate-high, and intermediate-low in 37 (14%), 201 (78%), and 18 (7%) of the patients, respectively. Procedural technical success was 100%. The mean pulmonary artery pressure (MPAP) decreased from a mean of 32 mmHg (SD ± 9) before to 24 mmHg (SD ± 9) after thrombectomy (mean decrease, 8 mmHg [SD ± 6]; P < .0001). Immediate complications occurred in 2% of the patients. Postprocedural 30-day and all-time PE-attributable mortality in a mean of 1.3-year follow-up was 2% and 6%, respectively. In multivariate analysis, the presence of lower extremity DVT at presentation (ß ± SE, -7.60 ± 3.22; P = .019) and a higher prethrombectomy MPAP (ß ± SE, -0.19 ± 0.04; P < .001) were associated with lower degrees of decrease in MPAP in the intermediate-high-risk PE group. Among 14 patients with postthrombectomy PE-attributable mortality, 13 had postthrombectomy MPAPs of >20 mmHg. CONCLUSIONS: Large-bore aspiration thrombectomy is a safe and effective treatment for reducing PAP in patients with intermediate- or high-risk PE. Postthrombectomy MPAPs of >20 mmHg might indicate postthrombectomy PE-attributable mortality in high-risk patients.

Interventional Radiology: A Potential Antidote to Physician Burnout.

Physician burnout affects more than half of U.S. physicians, is multifactorial in origin, and should be addressed at organizational, group, and individual levels. By examining the career of one private practice interventional radiologist, insight into lessons learned and strategies for promotion of a fulfilling career might apply to others. Priorities may vary depending on stage of career, but some common themes of meaning and purpose that most interventional radiology (IR) physicians embrace throughout their careers emerge. Recognizing and cultivating these might provide keys to mitigating professional burnout and promoting a fulfilling IR career.

Preservation of Cardiopulmonary Function in Patients Treated with Ultrasound-Accelerated Thrombolysis in the Setting of Submassive Pulmonary Embolism.

PURPOSE: To evaluate the clinical effectiveness of ultrasound-assisted thrombolysis (USAT) in resolution of right ventricular dysfunction (RVD), preservation of cardiopulmonary function, and quality of life (QoL) in patients with acute submassive pulmonary embolism (PE). MATERIALS AND METHODS: A single-center prospective study of patients presenting with acute PE and signs of RVD, as determined by right ventricle-to-left ventricle diameter ratio (RV:LV) > 0.9 on computed tomographic angiography of the thorax, was performed. Patients underwent USAT with recombinant tissue plasminogen activator. Primary endpoints measured were RV:LV by echocardiogram at baseline presentation and at 72 hours and 90 days after treatment. Secondary endpoints were QoL scores assessed by SF-36 Health Surveys at baseline and at 90 days, cardiopulmonary exercise test (CPET) parameters at 90 days, and procedural outcomes, including response of pulmonary artery pressure (PAP) and procedural complications. RESULTS: Twenty-five patients were treated between June 17, 2013, and September 15, 2014, with mean reduction of RV:LV by echocardiogram from 1.38 ± 0.28 at presentation to 0.92 ± 0.14 (P < .0001) at 72 hours and 0.84 ± 0.25 (P < .0001) at 90 days. SF-36 Health Survey scores demonstrated no long-term self-perceived adverse physical or mental effects as a result of PE. CPET parameters, including VO2max, weight-adjusted VO2, VE/VCO2, and VD/VT demonstrated no pulmonary vascular impairment at 90 days. PAP significantly improved after USAT, with mean initial systolic pressure of 50.46 ± 13.98 mmHg reduced to 39.64 ± 8.66 mmHg (P = .0001). There were no deaths, recurrent venous thromboembolism, hemodynamic decompensation, or hemorrhage. CONCLUSIONS: USAT resulted in significant reduction of RV:LV at 72 hours, which was preserved at 90 days. QoL and objective measures of cardiopulmonary function are preserved at 90 days in this population. Further studies with long-term follow-up are needed to determine the potential value of USAT for the prevention of post-PE syndrome in patients with submassive PE.

Anticipatory and compensatory postural adjustments in people with low back pain: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Despite altered anticipatory (APAs) and compensatory postural adjustments (CPAs) being hypothesized to contribute to the onset and persistence of low back pain (LBP), results from studies comparing people with and without LBP are conflicting. PURPOSE: This systematic review aimed to determine whether APAs or CPAs are altered in the presence of acute and chronic LBP. STUDY DESIGN: A systematic review of studies was carried out. PATIENT SAMPLE: No patient sample was required. OUTCOME MEASURES: Between group standardized mean differences and 95% confidence intervals for APAs ad CPAs METHODS: A comprehensive search was conducted for articles comparing people with LBP (acute or chronic) to healthy controls for the onset or amplitude of muscle activity, center of pressure (COP), or kinematic responses to expected or unexpected perturbations. Two independent reviewers extracted data and assessed the methodological quality of relevant studies. Differences between people with and without LBP were calculated as standardized mean differences, and included in a meta-analysis if outcomes were homogeneous. Otherwise, a narrative synthesis was conducted. RESULTS: Twenty-seven studies were included, of which the majority examined muscle onsets in response to expected and unexpected perturbations. Only two studies compared people with and without acute LBP, and results for these studies were conflicting. The results show delayed muscle onsets in response to expected and unexpected perturbations for people with chronic LBP when compared with healthy controls. No conclusive evidence for differences between people with and without chronic LBP for COP or kinematic responses. CONCLUSIONS: There is currently no convincing evidence of differences between people with and without acute LBP for APAs or CPAs. Conversely, delayed muscle onsets in people with chronic LBP suggest APAs and CPAs are altered in this population. However, the functional relevance of these delayed muscle onsets (eg, COP and kinematics) is unknown.

Improved compensatory postural adjustments of the deep abdominals following exercise in people with chronic low back pain.

The purpose of this study was to determine if 8 weeks of exercise affects motor control in people with chronic low back pain (CLBP), measured by anticipatory (APAs) and compensatory postural adjustments (CPAs). APAs and CPAs were measured prior to and following 8 weeks in two groups of people with CLBP: an exercise group (n=12) who attended three exercise sessions per week for 8 weeks; and a non-exercise control group (n=12) who were advised to continue their usual activities for the duration of the study. APAs and CPAs were recorded during unilateral arm flexion, bilaterally from rectus abdominis (RA), transverse abdominis/internal oblique (TA/IO), and erector spinae (ES) via surface electromyography. Analysis of muscle onsets and APA amplitudes suggests APAs did not change for either group. Ipsi-lateral TA/IO CPAs increased for the exercise group and ipsi-lateral TA/IO CPAs decreased for the control group. Only exercise promoted a pattern of TA/IO activity during CPAs similar to healthy individuals, suggesting improved control of rotational torques. These results show motor control improvement following exercise in people with CLBP, highlighted by improved side specific control of TA/IO.

Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain.

BACKGROUND: Chronic low back pain is a worldwide burden that is not being abated with our current knowledge and treatment of the condition. The fear-avoidance model is used to explain the relationship between pain and disability in patients with chronic low back pain. However there are gaps in empirical support for pathways proposed within this model, and no evidence exists as to whether physical activity moderates these pathways. METHODS: This was a cross-sectional study of 218 people with chronic low back pain. Multiple mediation analyses were conducted to determine the role of fear, catastrophizing, depression, and anxiety in the relationship between pain and disability. Separate analyses were performed with physical activity as the moderator. Individuals were classified as performing regular structured physical activity if they described on average once per week for > 30-minutes an activity classified at least moderate intensity (≥ 4-6 METs), activity prescribed by an allied health professional for their back pain, leisure time sport or recreation, or self-directed physical activity such as resistance exercise. RESULTS: Fear, catastrophizing, and depression significantly mediated the relationship between pain and disability (p<0.001). However the mediating effect of catastrophizing was conditional upon weekly physical activity. That is, the indirect effect for catastrophizing mediating the relationship between pain and disability was only significant for individuals reporting weekly physical activity (B = 1.31, 95% CI 0.44 to 2.23), compared to individuals reporting no weekly physical activity (B = 0.21, 95% CI -0.50 to 0.97). Catastrophizing also mediated the relationship between pain and fear (B = 0.37, 95% CI 0.15 to 0.62), with higher scores explaining 53% of the total effect of pain on fear. CONCLUSIONS: These results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability. We have also extended understanding for the mediating effect of catastrophizing on back pain related disability. Back pain patients engaged with regular physical activity may require counselling with regards to negative pain perceptions.

Anticipatory and compensatory postural adjustments in people with low back pain: a protocol for a systematic review and meta-analysis.

BACKGROUND: Anticipatory (APAs) and compensatory (CPAs) postural adjustments are organised by the central nervous system (CNS) and serve to control postural perturbations. Ineffective APAs and CPAs have been hypothesised to contribute to the persistence of symptoms and disability in people with low back pain (LBP). Despite two decades of research, there is no systematic review investigating APAs and CPAs in people with LBP. Thus, the aim of the current review is to determine if APA and CPA onset or amplitude, as measured by electromyography (EMG), centre of pressure (COP), and kinematics, are altered in people with LBP. METHODS/DESIGN: A systematic review and meta-analysis will be conducted. Searches will be conducted in electronic databases for full-text articles published before January 2016 using pre-defined search strategies that utilise combinations of keywords and medical subject heading terms. Two independent reviewers will screen potentially relevant articles for inclusion, extract data, and assess risk of bias for individual studies. Any disagreements will be resolved by a third reviewer. Studies comparing APA onset and amplitude and CPA onset and amplitude measured by EMG, COP, or kinematics between people with LBP and healthy individuals will be included if all aspects of the eligibility criteria are met. Data will be synthesised if studies are homogeneous; otherwise, results will be reviewed narratively. DISCUSSION: To our knowledge, this is the first systematic review to examine APAs and CPAs, as measured by EMG, COP, and kinematics in people with LBP. The findings of this review may aid in the identification of factors that play a role in the persistence of symptoms and disability and aid in the development of interventions to treat symptoms. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016032815.

Hamstring Fatigue and Muscle Activation Changes During Six Sets of Nordic Hamstring Exercise in Amateur Soccer Players.

The Nordic hamstring exercise (NHE) is a bodyweight movement commonly prescribed to increase eccentric hamstring strength and reduce the incidence of strain injury in sport. This study examined hamstring fatigue and muscle activation responses throughout 6 sets of 5 repetitions of the NHE. Ten amateur-level soccer players performed a single session of 6 sets of 5 repetitions of NHE. Maximal eccentric and concentric torque output (in newton meters) was measured after every set. Hamstrings electromyograms (EMG) were measured during all maximal contractions and exercise repetitions. Hamstring maximal eccentric torque was reduced throughout the range of motion after only a single set of NHE between 7.9 and 17.1% (p ≤ 0.05), with further reductions in subsequent sets. Similarly, maximal concentric torque reductions between 7.8 and 17.2% were observed throughout the range of motion after 1 set of NHE (p ≤ 0.05). During the descent phase of the NHE repetitions, hamstring muscle activity progressively increased as the number of sets performed increased. These increases were observed in the first half of the range of motion. During the ascent phase, biceps femoris muscle activity but not medial hamstrings was reduced from the start of exercise during latter sets of repetitions. These data provide unique insight into the extent of fatigue induced from a bodyweight only exercise after a single set of 5 repetitions. Strength and conditioning coaches need to be aware of the speed and extent of fatigue induced from NHE, particularly in practical settings in which this exercise is now prescribed before sport-specific training sessions (i.e., the FIFA-11 before soccer training).

Muscle activation does not increase after a fatigue plateau is reached during 8 sets of resistance exercise in trained individuals.

The premise of eliciting the greatest acute fatigue is accepted and used for designing programs that include excessive, potentially dangerous volumes of high-intensity resistance exercise. There is no evidence examining acute fatigue and neuromuscular responses throughout multiple sets of moderate-to-high intensity resistance exercise. Fifteen resistance-trained male subjects performed a single exercise session using 8 sets of Bulgarian split squats performed at 75% maximal force output. Maximal force output (N) was measured after every set of repetitions. Electromyographic (EMG) activity of vastus lateralis was monitored during all force trials and exercise repetitions. Repetitions per set decreased from the first to the third set (p < 0.001). Maximal force output decreased from preexercise to set 4 (p < 0.001). Electromyographic amplitudes during exercise did not change. Secondary subgroup analysis was performed based on the presence, or not, of a fatigue plateau (<5% reductions in maximal force output in subsequent sets). Nine participants exhibited a fatigue plateau, and 6 did not. Participants who plateaued performed less first-set repetitions, accrued less total volume, and did not exhibit increases in EMG amplitudes during exercise. Initial strength levels and neuromuscular demand of the exercise was the same between the subgroups. These data suggest that there are individual differences in the training session responses when prescribing based off a percentage of maximal strength. When plateaus in fatigue and repetitions per set are reached, subsequent sets are not likely to induce greater fatigue and muscle activation. High-volume resistance exercise should be carefully prescribed on an individual basis, with intrasession technique and training responsiveness continually monitored.

Defining the optimal degree of heparin anticoagulation for peripheral vascular interventions: insight from a large, regional, multicenter registry.

BACKGROUND: The optimal degree of heparin anticoagulation for peripheral vascular interventions (PVIs) has not been defined. We sought to correlate total heparin dose and peak procedural activated clotting time (ACT) with postprocedural outcomes in patients undergoing PVI. METHODS AND RESULTS: We studied 4743 patients who received heparin during PVIs in a regional, multicenter registry. From those, 1246 had recorded peak procedural ACT with the same point-of-care device. Periprocedural and in-hospital outcomes were compared between patients who received a total heparin dose <60 U/kg (n=2161) and ≥60 U/kg (n=2582). Similarly, outcomes were evaluated between groups with a peak procedural ACT <250 seconds (n=855) and ≥250 seconds (n=391). Technical and procedural success as well as intraprocedural thrombotic events did not differ between groups. Patients with heparin dose ≥60 U/kg had a higher rate of postprocedural hemoglobin drop ≥3 g/dL (7.09% versus 5.09%, respectively, P=0.004) and a higher transfusion rate compared with those with heparin dose <60 U/kg (4.92% versus 3.15%, respectively, P=0.002). In multivariate analysis, independent predictors of bleeding requiring transfusion were total heparin dose ≥60 U/kg, ACT ≥250 seconds, female sex, age ≥70 years, prior anemia, prior heart failure, low creatinine clearance, hybrid vascular surgery, rest pain, and below-knee intervention. In propensity-matched, risk-adjusted models and after hierarchical modeling, total heparin dose ≥60 U/kg and ACT ≥250 seconds remained strong predictors of post-PVI drop in hemoglobin ≥3 g/dL or transfusion. CONCLUSIONS: During PVI, higher total heparin dose (≥60 U/kg) and peak ACT ≥250 seconds were predictors of postprocedural transfusion. The high technical and procedural success in all groups suggests that use of weight-based heparin dosing with a target ACT <250 seconds in PVI may minimize the bleeding risk without compromising procedural success or increasing thromboembolic complications.

Long-term retrieval success rate profile for the Günther Tulip vena cava filter.

PURPOSE: To evaluate the likelihood of successful retrieval of the Günther Tulip vena cava filter after various implant durations (up to 494 days). MATERIALS AND METHODS: Retrievable Günther Tulip filters were placed in 554 patients. All patients satisfied requirements for filter placement; the primary indication for placement was specified for 394 patients (71%), as follows: unspecified trauma (n = 164), bariatric procedures (n = 128), orthopedic procedures (n = 36), and other (n = 66). Filter tilt and vena cava injury were assessed at implantation. Filters were not repositioned after placement. At retrieval, filter orientation, vena cava injury, other device-related incidents, and the degree of difficulty associated with retrieval were reported. RESULTS: Filter retrieval was attempted in 275 patients and successful in 248 (90.2%). The mean filter indwell time was 58.9 days (range, 3-494 days). Unsuccessful retrievals (n = 27) were attributed primarily to improper hook orientation (n = 10) or excessive tissue in-growth at the filter legs (n = 16). Of the remaining 279 patients, 223 withdrew from the study, 41 were associated with a decision to keep the filter as a permanent device, 13 died for reasons unrelated to the study, and two had no reported endpoint data. A Kaplan-Meier product-limit survival estimate revealed that the probability of successful device retrieval remained greater than 94% at 12 weeks and greater than 67% at 26 weeks. CONCLUSIONS: This study contributes to the body of clinical data related to retrievable filters, demonstrating reliable retrieval rates at 12 weeks, with successful retrievals up to 17 months after implantation.

Endovascular repair of spontaneous or traumatic iliac vein rupture.

Spontaneous rupture of the iliac vein and rupture resulting from blunt trauma are both very unusual. Herein one case of each are reported and were managed by emergent endovascular repair with use of covered stents. Favorable outcomes were achieved in both cases.