Prognostic Value of Coronary Artery Calcification Identified by the Semi-quantitative Weston Method in the Emergency Room or Other Hospitalized Patients.

Background: Coronary artery calcification (CAC) may provide insight to the patients' coronary artery disease (CAD) risks and influence early intervention. With increasing use of non-gated CT scans in clinical practice, the visual coronary artery scoring system (Weston Method) could quickly provide clinicians with important information of CAC for patient triage and management. Methods: We retrospectively studied the available CT imaging data and estimated CAC burden using the Weston method in 493 emergency room or other hospitalized patients. The Weston scores were calculated by the sum of the score for each vessel including the left main, left anterior descending, left circumflex artery and right coronary artery (range 0-12). The primary endpoint was a composite of the major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and coronary revascularization. Results: During a median follow-up of 85 months, a total of 25 (5.1%) MACE were recorded and 57 (11.2%) patients died from any causes. Detectable CAC was most common (96%) in the left anterior descending coronary arteries. Multivariable analysis showed that CAC total scores were independent predictors for MACE and all-cause mortality. Receiver operating characteristic analysis showed that CAC total score ≥5 was the optimal cutoff value for predicting MACEs. Conclusions: In the emergency room and hospitalized patients, the semi-quantitation of CAC burden using the Weston score system was related to the long-term cardiovascular outcomes including mortality. Clinicians and radiologists should maximize the value of non-contrast chest CT images by reporting CAC details.

Clinical Response to Celiac Plexus Block Confirms the Neurogenic Etiology of Median Arcuate Ligament Syndrome.

PURPOSE: To evaluate the response of median arcuate ligament syndrome (MALS) symptoms, including postprandial pain, nausea, and vomiting, to celiac plexus block (CPB) and correlate the response with arterial anatomy. MATERIALS AND METHODS: In a single-institution, retrospective cohort of clinically diagnosed MALS patients, 96 patients (female, 75; male, 21; mean age, 27 years) underwent 103 computed tomography‒guided percutaneous CPB procedures. Imaging, procedural, and clinical reports were reviewed. Primary outcomes evaluated were technical success, change in self-reported pain score, and change in nausea and vomiting. RESULTS: Computed tomography imaging before the procedure was available for 81 of 96 patients and demonstrated findings of celiac artery compression in 22 of 81 (27%) patients. Technical success was achieved in 102 of 103 cases. No major adverse events and 1 moderate adverse event were reported. The postprandial pain score decreased in 86 (84%) patients, and the mean score decreased from 6.3 to 0.9 points (P < .001). The prevalence of postprandial nausea decreased from 37.9% to 11.6% (P < .001) and that of vomiting decreased from 15.5% to 4.9% (P = .019). No differences were noted in pain relief after CPB between patients with and without celiac artery compression (P = .745). CONCLUSIONS: In patients with a clinical diagnosis of MALS, a large majority reported pain relief and decreased gastrointestinal symptoms after CPB. Pain relief did not correlate with the presence of celiac arterial abnormalities. This supports neuropathy as the primary etiology of MALS and suggests that the absence of celiac stenosis should not be used as an exclusion criterion.

Phase I Hepatic Immunotherapy for Metastases Study of Intra-Arterial Chimeric Antigen Receptor-Modified T-cell Therapy for CEA+ Liver Metastases.

PURPOSE: Chimeric antigen receptor-modified T cells (CAR-T) have demonstrated encouraging results in early-phase clinical trials. Successful adaptation of CAR-T technology for CEA-expressing adenocarcinoma liver metastases, a major cause of death in patients with gastrointestinal cancers, has yet to be achieved. We sought to test intrahepatic delivery of anti-CEA CAR-T through percutaneous hepatic artery infusions (HAIs). EXPERIMENTAL DESIGN: We conducted a phase I trial to test HAI of CAR-T in patients with CEA(+) liver metastases. Six patients completed the protocol, and 3 received anti-CEA CAR-T HAIs alone in dose-escalation fashion (10(8), 10(9), and 10(10) cells). We treated an additional 3 patients with the maximum planned CAR-T HAI dose (10(10) cells × 3) along with systemic IL2 support. RESULTS: Four patients had more than 10 liver metastases, and patients received a mean of 2.5 lines of conventional systemic therapy before enrollment. No patient suffered a grade 3 or 4 adverse event related to the CAR-T HAIs. One patient remains alive with stable disease at 23 months following CAR-T HAI, and 5 patients died of progressive disease. Among the patients in the cohort that received systemic IL2 support, CEA levels decreased 37% (range, 19%-48%) from baseline. Biopsies demonstrated an increase in liver metastasis necrosis or fibrosis in 4 of 6 patients. Elevated serum IFNγ levels correlated with IL2 administration and CEA decreases. CONCLUSIONS: We have demonstrated the safety of anti-CEA CAR-T HAIs with encouraging signals of clinical activity in a heavily pretreated population with large tumor burdens. Further clinical testing of CAR-T HAIs for liver metastases is warranted.

Efficacy and safety results with the LifeSite hemodialysis access system versus the Tesio-Cath hemodialysis catheter at 12 months.

PURPOSE: To compare the performance and safety of a fully subcutaneous vascular access device, the LifeSite hemodialysis access system, versus a tunneled hemodialysis catheter, the Tesio-Cath, at 1 year after implantation. MATERIALS AND METHODS: Sixty-eight patients who required hemodialysis received implantation of the LifeSite device or a Tesio-Cath device as a part of this multicenter study. Thirty-four patients were treated in each group. The endpoints observed included blood flow rates and associated venous pressures, overall and device-related adverse events, the need for thrombolytic infusions, device-related infections (DRIs) and associated hospitalizations, and technical device survival. RESULTS: During the 12-month observation period, significantly higher venous pressures were required in patients with the Tesio-Cath to achieve blood flow rates comparable with those achieved with the LifeSite device. Patients in the LifeSite group experienced a significantly lower rate of non-device-related adverse events (P < .001), device-related adverse events (P < .016), need for thrombolytic infusions (P < .002), and DRIs (P < .013) compared with patients in the Tesio-Cath group. There was a trend toward a lower number of hospital days per month for DRIs in the LifeSite group, with the rate for the Tesio-Cath group being twice that in the LifeSite group. The use of the LifeSite device was also associated with a significantly higher probability of device survival for 12 months after censoring for planned removals (P < .031). CONCLUSIONS: The results of the present study demonstrate superior device performance and technical device survival, reduced complications, and the need for fewer interventions with the LifeSite hemodialysis access system compared with a standard hemodialysis catheter during a 1-year time period after implantation.

Endovascular technique for revision of excess catheter length in subcutaneous implanted venous access devices.

To describe the implementation of a technique to trim the excess length of a central venous catheter via a process of endovascular snaring without exposing or changing the device. We report on the outcome of this technique in 3 patients. The technique was successful in two cases and successful with a modification in the remaining case. The technique is useful to salvage an implanted venous access device. It appears to be less invasive with reduced procedure time and less patient discomfort than other techniques.

The use of tissue plasminogen activator infusion to re-establish function of tunneled hemodialysis catheters.

PURPOSE: To evaluate the safety and efficacy of the recombinant tissue plasminogen activator alteplase in the clearance of poorly functioning tunneled hemodialysis catheters. METHODS: We retrospectively reviewed the outcomes of 25 patients who presented with poorly functioning hemodialysis catheters and were treated with alteplase. After confirming fluoroscopically the need for thrombolytic therapy, alteplase was administered over 2 hours as a 2.5-mg/hour/catheter lumen infusion (total 10 mg). Treatment was considered a clinical success if a flow rate of 250 mL or more per minute was established. RESULTS: Clinical success was achieved in each of 25 patients (100%). There were no thrombolytic-related complications. Catheter survival was extended 30 days in 54% of patients and 45 days in 33% of patients. CONCLUSION: Alteplase is a safe and effective means of producing clearance of blocked tunneled catheters.

Safety of limited supplemental iodinated contrast administration in azotemic patients undergoing CO2 angiography.

PURPOSE: To determine if limited doses of iodinated contrast significantly worsen the underlying renal insufficiency that had warranted the use of CO(2) for diagnostic angiography. METHODS: The records of 122 consecutive patients who had undergone CO(2) angiography for peripheral vascular disease at our institution over a 5-year period were reviewed. The volume and type of iodinated contrast and the volume of CO(2) administered were recorded. Serum creatinine measurements obtained before angiography and from 2 to 3 days after angiography were recorded. RESULTS: One hundred patients had pre-angiography and post-angiography creatinine levels available for analysis (51 CO(2) only, 49 CO(2) with iodinated contrast). The average pretreatment creatinine level was 2.8+/-1.5 mg/dL (range 1.8-6.6) for the CO(2) only group and 3.0+/-1.4 mg/dL (range 1.8-8.2) for the CO(2) plus iodinated contrast group (p=0.46). After angiography, the mean change in creatinine was +0.17+/-0.87 mg/dL for the CO(2) only group and +0.03+/-0.98 mg/dL in the CO(2) plus contrast group (p=0.27). Complications included 1 patient with a failing renal transplant who received iodinated contrast and ultimately required return to hemodialysis. A second patient had a transient 1-mg/dL rise of creatinine but did not require dialysis. CONCLUSIONS: This study supports the relative safety of CO(2) angiography with the limited used of iodinated contrast supplementation for diagnostic studies or interventions in azotemic patients with peripheral vascular disease.

Early ambulation after diagnostic angiography using 4-f catheters and sheaths: a feasibility study.

PURPOSE: To assess the feasibility and safety of early ambulation in patients undergoing transfemoral diagnostic angiography using 4-F catheters or sheaths. METHODS: In this prospective study approved by the institutional review board, patients undergoing diagnostic angiography were randomized to ambulate 3 or 6 hours after catheter or sheath removal. All patients were assessed for hematoma formation, pseudoaneurysm development, and other groin complications during the in-hospital recovery period and after 30 days. Patient satisfaction and comfort level were also assessed by survey. RESULTS: Of 110 patients (66 men; mean age 64.9 +/- 12.8 years) who participated in this study, 47 were randomized to the 6-hour (6-H) group and 63 to the 3-hour (3-H) group. In the 3-H and 6-H groups, respectively, a 4-F catheter was used in 45 (71%) and 35 (74%) patients and a 4-F sheath in 18 (29%) and 12 (26%). No clinically significant groin complications were encountered in either group. Moderate to severe discomfort was reported in 9 (16%) of the 56 patients responding to the discomfort survey in the 3-H group compared to 10 (26%) of the 38 in the 6-H survey respondents. CONCLUSIONS: It is feasible and safe to ambulate patients 3 hours after diagnostic angiography performed with a 4-F catheter with or without a 4-F sheath. Early ambulation of patients after angiography has the additional benefits of increasing patient satisfaction and resource utilization.

Percutaneous transrenal hemodialysis catheter insertion.

During the course of providing adequate access for hemodialysis, the majority of patients with end-stage renal disease will encounter episodes of catheter dependency. Although catheter-based dialysis is inferior to that obtained through native or synthetic arteriovenous conduits, it is often the only way to provide durable venous access into the central venous circulation system for large volume exchanges. Traditional sites for venous access such as internal/external, subclavian, and common femoral veins will eventually occlude. When alternative percutaneous access sites such as translumbar, transhepatic, and transazygous fail or become less desirable, other approaches become necessary. The authors report a successful case of transrenal access into the renal vein with consequent insertion of a tunneled catheter for hemodialysis in a patient with limited options.

Multicenter clinical trial results with the LifeSite hemodialysis access system.

BACKGROUND: The LifeSite Hemodialysis Access System is a subcutaneous access device designed to maximize blood flow while minimizing access-related complications. The purpose of this study was to compare the efficacy and safety of the LifeSite System to a similar but transcutaneous access device, the Tesio-Cath Hemodialysis Catheter. METHODS: The study was conducted in two phases. A multi-center randomized prospective design was utilized for the first phase (Phase 1) where thirty-four patients were enrolled in the Tesio-Cath group and 36 patients into the LifeSite group where 0.2% sodium oxychlorosene was used as an antimicrobial solution for the LifeSite. A nonrandomized, but otherwise identical, second phase of the study followed where a 70% isopropyl alcohol solution was utilized as the antimicrobial solution for 34 additional LifeSite patients (Phase 2). RESULTS: Device function was evaluated in Phase 1 of the trial. Actual blood flow (determined by ultrasound dilution) was greater in the LifeSite versus the Tesio-Cath group (358.7 vs. 331.8 mL/min, P < 0.001 for machine-indicated blood flow of 400 mL/min). Infection comparisons were performed for all three groups encompassing Phase 1 and 2 of the trial; Tesio-Catheter, LifeSite System with oxychlorosene, and LifeSite System with 70% isopropyl alcohol. Device-related infections were defined as systemic bacteremia without another obvious site of origin and exit site infections requiring systemic antibiotics or device removal. This revealed infection rates per 1000 device use days of 1.3 for the LifeSite alcohol group, 3.3 for the Tesio-Cath group, and 3.4 per for the LifeSite oxychlorosene group. There was no statistically significant difference in device related infection rates between the Tesio-Cath and the LifeSite oxychlorosene groups. There were significant differences in infection rate between LifeSite alcohol group and the other two groups (P < 0.05). Device thrombosis was defined by the need for instillation of thrombolytic agents to maintain blood flow>300 mL/min. There was no difference in the need for thrombolytic infusions between the LifeSite oxychlorosene group and the Tesio-Cath group (P = 0.1496); however, the LifeSite alcohol group required significantly fewer thrombolytic infusions than the Tesio-Cath group (P = 0.0295) to maintain adequate blood flow. Device survival at 6 months after stratification by diabetic status and adjusting for age was significantly better in the LifeSite alcohol group (89.9%) than in the LifeSite oxychlorosene group (64.8%, P = 0.0286) and in the Tesio-Cath (69.1%, P = 0.0292) group. CONCLUSIONS: The LifeSite Hemodialysis Access System, when used with 70% isopropyl alcohol as an antimicrobial solution, provides superior performance with a lower infection rate and better device survival than a standard cuffed tunneled hemodialysis catheter.