Time-Driven Cost Analysis of Noncuffed Venous Catheter Placement in Infants: Bedside versus IR Suite

PurposeTo compare the direct bundled costs of interventional radiology (IR) suite versus bedside placement of noncuffed central venous catheters in infants.MethodsA single-center retrospective review was performed of all noncuffed upper extremity (peripherally inserted central venous catheter [PICC]) and tunneled femoral (tunneled femoral central venous catheter [TCVC]) catheters placed in infants between January 1, 2018, and December 31, 2018. Propensity score matching was performed adjusting for age, birth weight, procedure weight, and catheter days. Process maps for each procedure were created based on location and sedation type. Technical success and complications were recorded for each placement. The total direct bundled cost for each catheter placement was calculated by summing the procedure and complication costs.ResultsA total of 142 procedures were performed on 126 matched patients with a technical success of 96% at the bedside and 100% in the IR suite (P = .08). The complication rates did not significantly differ between the 2 groups (P = .51). The total direct bundled costs for catheter placement were $1421.3 ± 2213.2 at the bedside and $2256.8 ± 3264.7 in the IR suite (P = .001).ConclusionsThe bundled cost of bedside femoral catheter placement is significantly less than that of fluoroscopic TCVC and PICC placement performed in the IR suite, mainly related to differences in sedation costs.     

Maturation for Hemodialysis in the Ellipsys Post-Market Registry

PurposeTo prospectively evaluate the maturation of the endovascular arteriovenous fistula system (EndoAVF) for 2-needle cannulation (2NC).Materials and MethodsFrom October 2018 to June 2019, evaluation of 123 patients resulted in 95 arteriovenous fistulae, a rate of 63% (60 of 95) EndoAVF, and 37% (35 of 60) fistulae treated surgically. At 4 weeks, EndoAVF was not suitable for 2NC (defined as a palpable target vein [TV], 500 mL/min flow volume, and 5-mm diameter) underwent maturation procedures.ResultsTechnical success of EndoAVF creation was 96.7% (60 of 62). At 4 weeks, 67% (40 of 60) fistulae underwent maturation procedures: 62% (37 of 60) had balloon dilation, 32% (19 of 60) had brachial vein embolization, and 30% (18 of 60) had cubital vein banding, increasing TV flow volume from 182 ± 123 mL/min to 572 ± 225 mL/min (P < 0.0005). Transposition was required in 33% of patients (20 of 60), reducing the mean TV depth from 10.9 to 3.7 mm (P < .0001). 2NC and fistula success (2NC × 3) was achieved in 87% (47 of 54); 10% of patients (6 of 60) were not on dialysis; 6.8% of patients (4 of 60) died; 5% of fistulas (3 of 60) were abandoned for arm swelling, steal syndrome, and thrombosis. Time to 2NC, fistula success, and tunneled catheter removal were 65.6 ± 45.7 days, 79.1 ± 50.9 days, and 113.4 ± 62 days, respectively. Patients achieving 2NC had brachial artery flow of 944 ± 284 mL/min; and TV flow, diameter, and depth of 674 ± 292 mL/min, 6.1 ± 0.8 mm, and 3.6 ± 1.3 mm, respectively. Major complications were arm swelling, steal syndrome, and thrombosis.ConclusionsMost patients had EndoAVF with maturation procedures at 4 weeks that achieved rapid maturation (Ellipsys Fistula for Hemodialysis Access; NCT03828253).     

Percutaneous Arteriovenous Fistula Creation with the WavelinQ 4-French EndoAVF System: A Single-Center Retrospective Analysis of 30 Patients

PurposeTo retrospectively assess the safety and efficacy of percutaneous arteriovenous fistula (pAVF) creation with the WavelinQ 4-F EndoAVF System.Materials and MethodsFrom February 2018 to June 2020, 30 pAVFs were created in 30 consecutive patients (men; age, 55.3 years ± 13.6). Of the 30 patients, 21 (70%) were already on hemodialysis using a central venous catheter. The primary outcome measures were technical success, complications, and cannulation rate. The secondary outcome measures included the number of secondary procedures needed for cannulation, maintenance time to cannulation, and pAVF survival.ResultsTechnical success was 100%. The adverse event rate was 6.7% (2/30), including a pseudoaneurysm of the brachial artery that developed immediately after sheath removal and an aneurysm of the anastomosis 17 days after the procedure, which was treated with a covered stent placed in the arterial side. The mean follow-up was 547 days ± 315.7 (range, 14–1,071 days). The cannulation rate was 86.7% (26/30). The mean time to cannulation was 61.3 days ± 32.5 (range, 15–135 days). The mean follow-up after cannulation was 566.2 days ± 252.7 (range, 35–1,041 days). Four pAVFs were thrombosed after cannulation, with 2 of them successfully declotted. Sixteen interventions were needed to achieve cannulation after the index procedure in 15 patients (overall, 0.53 procedures/patient). Seven maintenance endovascular interventions (following cannulation) were performed during the follow-up period in 6 patients (overall, 0.27 procedures/patient, 0.17 procedures/patient-years). For the pAVFs that were cannulated, patency was 96% at 1 year, and 82% at 2 and 3 years, according to the Kaplan-Meier survival analysis.ConclusionsThis initial experience suggests that pAVF creation is safe and can be successfully performed with high maturation and long-term patency rates. Larger-scale prospective studies are needed to validate the results.     

Is Routine Preprocedural Bloodwork Needed for Elective Central Venous Access Device Removals in Children without Bleeding Dyscrasias?

PurposeTo assess the utility of routine preprocedural bloodwork during elective removal of central venous access devices (CVADs) with respect to bleeding complications.Materials and MethodsPatients who underwent removal of a CVAD (tunneled central venous catheter [CVC] or port) by the interventional radiology service between January 2009 and December 2013 were retrospectively reviewed. Removals for infection or malfunction, without preprocedural bloodwork, with another concurrent procedure at the time of CVAD removal, or in patients with a bleeding dyscrasia were excluded. Peripherally inserted central catheter removals and temporary CVAD removals were also excluded. Routine preprocedural bloodwork included hemoglobin, platelet count, partial thromboplastin time, and International Normalized Ratio. Postprocedural complications were classified according to the Society of Interventional Radiology clinical practice guidelines.ResultsThere were 802 CVAD removals in 777 patients (351 female, 426 male). Average patient age was 8.6 years (range, 5 wk to 19 y). In total, 246 permanent CVCs and 556 ports were removed. A total of 802 cases had preprocedural bloodwork. Of the 49 patients who had a bleeding complication after the procedure (6.1%; 49 of 802), 44 had normal findings on preprocedural bloodwork and 5 had abnormal findings. There was no statistically significant difference in bleeding complications between those with normal and abnormal bloodwork results (P = .7740).ConclusionsRoutine bloodwork is not necessary before elective CVAD removal in children without a bleeding dyscrasia. Most children have normal findings on preprocedural bloodwork, and the incidence of postprocedural bleeding is low and not determined by bloodwork results.     

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery

PurposeTo assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery.Material and MethodsLymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome.ResultsLG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling.ConclusionsLE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.     

Outcomes of Venoplasty-Assisted,Peripherally Inserted Central Catheter Placement in Patients with Upper-Arm Venous Stenosis: Comparison with Midlines and Contralateral Placement

PurposeTo compare the effectiveness and safety of percutaneous transluminal angioplasty and peripherally inserted central catheter (PTA + PICC), contralateral PICC, and midline catheterization (MC) in patients with venous stenosis.Materials and MethodsA total of 7,327 PICC procedures were performed in 5,421 patients at a single institution between 2013 and 2019. Among them, 87 patients had upper-arm venous stenoses and were managed with PTA + PICC, contralateral PICC, or MC. Data on catheter-dwell time, clinical success rate, and adverse events were recorded. The procedure was considered to have clinically succeeded when a PICC was removed from the patient just before discharge or after the completion of therapy. Catheter survival time and the chance of adverse events were compared among the groups using the Kaplan-Meier method and log-rank test.ResultsPTA + PICC, contralateral PICC, and MC procedures were performed for 57 (65.5%, 57/87), 10 (11.5%, 10/87), and 20 (23.0%, 23/87) patients, respectively. The mean catheter-dwell time in the PTA + PICC, contralateral PICC, and MC groups was 49.7, 28.7, and 15.1 days, respectively, and the clinical success rate of each group was 86.0% (49/57), 80.0% (8/10), and 50.0% (10/20). The PTA + PICC group had a significantly longer catheter survival time than the MC group (P < .001). The chance of a catheter-related infection (P = .008) was significantly lower in the PTA + PICC group than in the MC group.ConclusionsPTA + PICC or contralateral PICC should be considered prior to ipsilateral MC when venous stenosis is encountered during PICC procedures.     

Intravascular Ultrasound-Guided Transvenous Biopsy of Retroperitoneal Lymph Nodes: Diagnostic Accuracy and Safety Compared with CT-Guided Percutaneous Biopsy

PurposeTo compare the diagnostic accuracy and adverse event rates of intravascular ultrasound (US)-guided transvenous biopsy (TVB) versus those of computed tomography (CT)-guided percutaneous needle biopsy (PNB) for retroperitoneal (RP) lymph nodes.Materials and MethodsIn this single-institution, retrospective study, 32 intravascular US-guided TVB procedures and a sample of 34 CT-guided PNB procedures for RP lymph nodes where targets were deemed amenable to intravascular US-guided TVB were analyzed. Procedural metrics, including diagnostic accuracy, defined as diagnostic of malignancy or a clinically verifiable benign result, and adverse event rates were compared.ResultsThe targets of intravascular US-guided TVB were primarily aortocaval (47%, 15/32) or precaval (34%, 11/32), whereas those of CT-guided PNB were primarily right pericaval (44%, 15/34) or retrocaval (44%, 15/34) (P < .001). The targets of intravascular US-guided TVB averaged 2.4 cm in the long axis (range, 1.3–3.7 cm) compared with 2.9 cm (range, 1.4–5.7 cm) for those of CT-guided PNB (P = .02). There was no difference in the average number of needle passes (3.8 for intravascular US-guided TVB vs 3.9 for CT-guided PNB; P = .68). The diagnostic accuracy was 94% (30/32) and the adverse event rate was 3.1% (1/32) for intravascular US-guided TVB, similar to those of CT-guided PNB (accuracy, 91% [31/34]; adverse event rate, 2.9% [1/34]).ConclusionsIntravascular US-guided TVB had a diagnostic accuracy and adverse event rate similar to CT-guided PNB for RP lymph nodes, indicating that intravascular US-guided TVB may be as safe and effective as conventional biopsy approaches for appropriately selected targets.     

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement

PurposeTo evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE).Materials and MethodsData were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis).ResultsIn total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2–2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year).ConclusionsTDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.     

Impact of Renal Function Trajectory on Renal Replacement Therapy and Mortality Risk after Renal Artery Revascularization

PurposeTo determine the impact of renal function trajectory, defined as the change in renal function over time before and after renal artery stent placement, on long-term risk for renal replacement therapy (RRT) and mortality.Materials and MethodsEstimated glomerular filtration rates (eGFRs) 6–12 months before renal artery stent placement, at the time of intervention, and 6–12 months after intervention were determined in 398 patients. The effect of eGFR change before and after renal artery stent placement was calculated. Cox proportional-hazards ratio was used to determine the risks for RRT and all-cause mortality.ResultsThe risk for RRT was significantly influenced by eGFR change from the time of intervention to follow-up at 6–12 month after treatment (P = .02). In addition, among patients with a postintervention eGFR ≤ 40 mL/min/1.73 m², for every 1 unit of eGFR increase, there was a significant decrease in RRT and all-cause mortality (P < .001 and P < .001, respectively). Secondary parameters that increased RRT risk included diabetes at the time of intervention (P = .03), increased baseline proteinuria (P < .001), and stage 4 or 5 chronic kidney disease (CKD; P = .01 and P = .003, respectively). Multivariate analysis demonstrated higher all-cause mortality rates among patients with diabetes at the time of intervention (P = .009).ConclusionsPostintervention eGFR trajectory improvement approaching 40 mL/min/1.73 m² was associated with decreased RRT and mortality risk. These findings suggest that patients with advanced CKD and renal artery stenosis may benefit from revascularization regardless of their preinterventional renal function measurement.     

Outcomes of Postprocedural Closeout Checklist Implementation to Prevent Adverse Events during Interventional Radiology Procedures: An Initiative to Improve Outcomes

PurposeTo assess whether adherence to a postprocedural closeout (PPC) checklist decreases adverse events during image-guided procedures.Materials and MethodsBased on the analysis of prior adverse events related to image-guided procedures, the Radiology Quality Committee developed a PPC checklist. The rates of serious reportable events related to image-guided procedures performed in the radiology department were recorded annually from 2015 to 2021. The rate of adverse events was normalized to the procedure volume in the corresponding periods. The number of patients requiring repeat procedures was recorded. The severity of impact was classified according to the Society of Interventional Radiology Adverse Event Classification System. The annual rates before (2015 and 2016) and after (2017–2021) the implementation of PPC were compared.ResultsSeventy-seven safety reports were identified in image-guided procedures over the study period, of which 43 cases were not related to the PPC, leaving 34 cases for the analysis. Radiology adverse events decreased from 0.069% (14/20,218, 7/y) before PPC implementation to 0.034% (20/58,793, 4/y) after implementation (P = .05, 43% decrease). Radiology repeat procedures decreased from 0.040% (8/20,218, 4/y) before PPC implementation to 0.007% (4/58,793, 0.8/y) after implementation (P = .0033, 80% decrease). Moreover, severity of adverse events decreased (P = .009).ConclusionsImplementation of a PPC checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the end of image-guided procedures by 43%, need for repeat procedures by 80%, and severity of impact of errors.     

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology

PurposeTo assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice.Materials and MethodsBilling and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures—(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement—were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals).ResultsDepartmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%.ConclusionsDepartmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.     

Infectious Recidivism in Tunneled Dialysis Catheters Removed for Bloodstream Infection in the Intensive Care Unit

PurposeTo determine the rate of recurrent infection of ICU patients who underwent tunneled dialysis catheter (TDC) exchange or removal for bloodstream infection.Materials and MethodsForty seven patients, with a total of 61 TDCs removed for bloodstream infection while admitted in an ICU from 2017–2020, were identified. TDCs were exchanged over a wire or removed and replaced. Thirteen patients (21%) were managed with non-tunneled dialysis catheters (NTDCs) until delayed TDC replacement at ICU departure. Forty seven TDCs were removed for bacteremia (77%), 13 for fungemia (21%), and 1 for both (2%). Thirty TDCs (49%) were exchanged over-the-wire (ICU-exchanged TDCs), and 31 (51%) were removed. Of the patients who underwent TDC removal, 9 had a new TDC placed while still admitted in the ICU (ICU-replaced TDCs), and 7 underwent delayed TDC replacement at ICU departure. Data regarding infection, removal technique, catheter replacement, and patient outcomes were analyzed.ResultsThere were 10 instances of recurrent bloodstream infection (infectious recidivism), occurring in 7 ICU-exchanged TDCs (7/30, 23%) and 3 ICU-replaced TDCs (3/9, 33%). Bloodstream infection complicated 22% of NTDCs used in patients undergoing delayed TDC replacement. No cases of TDC infectious recidivism were observed in patients who underwent delayed TDC replacement (0/7, 0%) after ICU departure.ConclusionsHigh rates of infectious recidivism exist in the ICU, meriting further investigation into how to optimally manage these patients. In those in whom TDCs are removed, withholding TDC replacement until ICU departure may help to minimize the rate of recurrent infection.     

Percutaneous Treatment of Benign Biliary Anastomotic Strictures: Retrievable Covered Self-Expandable Metal Stent with Fixation String Versus Large-Bore Catheters

PurposeTo retrospectively compare the safety and efficacy of a covered self-expandable metal stent (CSEMS) with a transhepatic fixation string and a large-bore catheter for benign biliary anastomotic stricture after hepatobiliary surgery.Materials and MethodsFrom March 2012 to June 2017, 49 patients with benign biliary anastomotic strictures, untreatable with endoscopy, were included. Twenty-three patients (catheter group) were treated with a large-bore catheter (with progressive catheter upsizing to 16–18 Fr), whereas 26 patients (stent group) were treated by CSEMS (10-mm stent) placement. Technical success, clinical success, primary patency, recurrent strictures, complication rate, and catheter or stent indwelling time were compared between the groups.ResultsTechnical success and clinical success were achieved in all patients. In the stent group, stent retrieval was successful in all patients. The overall complication rate was 24.5% (catheter group vs. stent group, 30.4% vs. 19.2%; P = .363). Stent migration occurred in 1 patient during follow-up (1/26, 3.8%). The mean indwelling time was 10.3 ± 3.0 months (range, 8–16 months; median, 10 months) in the catheter group and 4.0 ± 1.2 months (range, 3–7 months; median, 4 months) in the stent group (P < .001). Recurrent strictures occurred in 10 (43.5%) patients in the catheter group and 4 (15.4%) patients in the stent group (P = .030). The 1- and 3-year primary patency rates were 82.6% and 69.3% in the catheter group and 92.3% and 84.4% in the stent group (P = .042).ConclusionsPercutaneous placement of a retrievable CSEMS showed superior intermediate-term outcomes over a large-bore catheter in patients with benign biliary anastomotic strictures.     

Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography,Endoscopy, and Biliary Interventions

PurposeThe purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology.Materials and MethodsA total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated.ResultsThere were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention.ConclusionsThe modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.     

Multicenter Experience with the Surfacer Inside-Out Access Catheter System in Patients with Thoracic Venous Obstruction: Results from the SAVE Registry

PurposeTo report the device performance and safety for the Surfacer Inside-Out access catheter system in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA).Materials and MethodsFive sites prospectively enrolled 30 patients requiring a tunneled dialysis catheter between February 2017 and September 2018 in the SAVE (Surfacer System to Facilitate Access in Venous Obstructions) registry. Patient demographics, medical history, and type of TCVO were documented at enrollment. Device performance and adverse events were collected during the procedure and upon hospital discharge. Twenty-nine of the 30 patients enrolled required CVA for hemodialysis. Retrospective classification of TCVOs according to SIR reporting standards showed 9 patients (30%) had Type 4 obstructions, 8 (26.7%) had Type 3, 5 (16.7%) had Type 2, and 8 (26.7%) had Type 1 obstruction.ResultsCentral venous catheters (CVCs) were successfully placed in 29 of 30 patients (96.7%). The procedure was discontinued in 1 patient due to vascular anatomical tortuosity. All 29 patients with successful CVC placement achieved adequate catheter patency and tip positioning. There were no device-related adverse events, catheter malposition, or intra- or postprocedural complications. Mean time from device insertion to removal for the 29 patients who successfully completed the procedure was 24 ± 14.9 (range, 6–70) minutes. Mean fluoroscopy time was 6.8 ± 4.5 (range, 2.2–25.5) minutes.ConclusionsThe Surfacer Inside-Out procedure provided an alternative option to restore right-sided CVA in patients with TCVO.     

Evaluation of Fibrinogen Levels during Catheter-Directed Thrombolysis for Acute Pulmonary Embolism

PurposeTo evaluate the effect of catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) on plasma fibrinogen levels (PFLs) in the setting of acute pulmonary embolism (PE) and the relationship between PFL and hemorrhagic complications.Materials and MethodsA retrospective review of CDT procedures between 2009 and 2019 identified 147 CDT procedures for massive or submassive PE (55.8% males; age, 56.5 ± 14.8 years; 90.5% submassive). All patients received therapeutic anticoagulation during CDT with unfractionated heparin (UFH) (69.4%) or low-molecular-weight heparin (LMWH, 30.6%) infusion. CDT was performed with ultrasound-accelerated thrombolysis (USAT) catheters (n = 98), conventional catheter-directed thrombolysis (CCDT) catheters (n = 34), or a combination of both (n = 15).ResultsThere was a decrease (P = .007) of 15.1 ± 69.4 mg/dl from the initial PFL (376.1 ± 122.7 mg/dl) to the final PFL (361 ± 118.7 mg/dl), which was measured after a mean of 24.1 ± 11.7 hours with a mean tPA dose of 28.3 ± 14.2 mg. The fibrinogen nadir was 327.6 ± 107.1 mg/dl measured 13.4 ± 10.3 hours after initiation of thrombolysis. Of patients with hemorrhagic complications (n = 6), initial, final, and nadir PFL were not significantly lower (P = .053, P = .081, and P = .086, respectively) than the remainder of the cohort. No significant difference was noted in initial and final PFL between the LMWH and UFH groups (P = .2 and P = .1, respectively) or between the CCDT and USAT groups (P = .5 and P = .9, respectively). The UFH group had a lower nadir PFL than the LMWH group (P = .03).ConclusionsDespite a significant drop in PFL during CDT for acute PE, this was not associated with hemorrhagic complications. These findings were not affected by the choice of anticoagulant or catheter delivery system.     

Evaluation of Technical Success,Efficacy, and Safety of Portomesenteric Venous Intervention following Nontransplant Hepatobiliary or Pancreatic Surgery

PurposeTo evaluate technical success, efficacy and safety of portomesenteric venous (PMV) intervention for PMV stenosis or occlusion following nontransplant hepatobiliary or pancreatic (HPB) surgery.Materials and MethodsA retrospective review identified 42 patients (mean age 60 y) with PMV stenosis (n = 33; 79%) or occlusion (n = 9; 21%) who underwent attempted PMV intervention following HPB surgery between June 1, 2011, and April 1, 2018. Main outcomes were technical success, primary patency rates, and complications. Technical success was compared by venous pathology and primary PMV patency based on anticoagulation status after the procedure using Fisher exact test. Rates of primary patency by stent group were estimated using Kaplan-Meier method.ResultsTechnical success was 91% (n = 38/42) and significantly higher in patients with stenosis (n = 33/33; 100%) vs occlusion (n = 5/9; 56%) (P = .001). Primary presenting symptom resolved in 28 (87%) patients, including 6 (100%) patients with gastrointestinal bleeding. At mean imaging follow-up of 8.6 months ± 8.8, primary stent patency was 76%. There was no significant difference in primary stent patency based on anticoagulation status after the procedure (P = .48). There were 2 (4.8%) periprocedural complications.ConclusionsPortomesenteric venoplasty and stent placement following nontransplant HPB surgery is safe with a high rate of technical success if performed before chronic occlusion.     

Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding

PurposeTo assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for the treatment of acute lower gastrointestinal bleeding (LGIB).Materials and MethodsThe single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 men; mean age, 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as the absence of recurrent bleeding within 30 days of embolization.ResultsTechnical success for embolization of LGIB was achieved in 87% of the cases (134/154); clinical success rate was 76.1% (102/134) among the technically successful cases. Clinical success was 82.2% (60/73) for coils alone and 68.9% (42/61) for particles with or without coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 (5.3%) patients who underwent particle embolization with or without coils versus zero of 66 patients when coils alone were used (P = .09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the procedure were found in 3 of the 15 who underwent embolization with coils alone versus 8 of 18 who underwent embolization with particles with or without coils (P = .27).ConclusionsParticle embolization for the treatment of LGIB as second-line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.     

Transcatheter CT Hepatic Arteriography Compared with Conventional CT Fluoroscopy Guidance in Percutaneous Thermal Ablation to Treat Colorectal Liver Metastases: A Single-Center Comparative Analysis of 2 Historical Cohorts

PurposeTo evaluate safety and efficacy of CT hepatic arteriography compared with conventional CT fluoroscopy guidance in percutaneous radiofrequency (RF) and microwave (MW) ablation to treat colorectal liver metastases (CRLM).Materials and MethodsThis single-center comparative, retrospective study analyzed data of 108 patients treated with 156 percutaneous ablation procedures (42 CT fluoroscopy guidance [25 RF ablation, 17 MW ablation]; 114 CT hepatic arteriography guidance [18 RF ablation, 96 MW ablation]) for 260 CRLM between January 2009 and May 2019. Local tumor progression-free survival (LTPFS) was assessed using univariate and multivariate Cox proportional hazard regression analyses. LTPFS and overall survival (OS) were estimated using the Kaplan-Meier method.ResultsThere were no complications related to the transarterial catheter procedure. CT hepatic arteriography proved superior to CT fluoroscopy regarding 2-year LTPFS (18/202 [8.9%] vs 19/58 [32.8%]; P < .001, respectively). CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.28; 95% confidence interval, 0.15–0.54; P < .001) and MW ablation versus RF ablation (hazard ratio = 0.52; 95% confidence interval, 0.24–1.12; P = .094) were positive predictors for longer LTPFS. Multivariate analysis revealed that CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.41; 95% confidence interval, 0.19–0.90; P = .025) was associated with a significantly superior LTPFS. OS was similar between the 2 cohorts (P = .3).ConclusionsWhile adding procedure time and marginal patient burden, transcatheter CT hepatic arteriography–guided ablation was associated with increased local disease control and superior LTPFS compared with conventional CT fluoroscopy. CT hepatic arteriography represents a safe and valid alternative to CT fluoroscopy, as it reduces the number of repeat ablations required without adding risk or detrimental effect on survival.     

Management of Port Occlusions in Adults: Different-Site Replacement versus Same-Site Salvage

PurposeTo compare the safety and effectiveness of different-site port placement versus same-site port salvage in adult patients with occluded ports.Materials and MethodsNinety-five occluded subcutaneous infusion ports (ports) in 95 patients presenting between July 1, 2002, and June 30, 2017, were retrospectively reviewed: 48 (51%) different-site placements (replacements; same-day indwelling port removal and different-site new port placement) and 47 (49%) same-site salvages (salvages; 35 fibrin sheath strippings, 12 over-the-wire exchanges). Demographic information, indication for initial placement and replacement or salvage, procedural details, post-intervention primary catheter patency, and post-intervention port sequelae were recorded. Post-intervention primary catheter patency, and malfunction and infection rates were compared with Kaplan-Meier estimation and the log-rank test, and Fisher exact test, respectively. The association of patient risk factors and port patency was assessed with Cox regression.ResultsMedian primary catheter patency after replacement was 254 days (interquartile range [IQR], 297) and after salvage was 391 days (IQR, 906) (P = .25). Within the salvage group, median primary catheter patency after stripping was 391 days (IQR, 658) and after exchange was 666 days (IQR, 1412) (P = .08). There was no statistical difference in malfunction (P = .12) and infection (P = .74) rates between the replaced and salvaged groups or in malfunction (P = .09) and infection (P = .1) rates between the exchanged and stripped subgroups. None of the patient or catheter characteristics assessed were significantly associated with primary catheter patency.ConclusionsThere was no statistical difference between patency, malfunctions, or infections after replacement and salvage, or after stripping and exchange, so technique selection should be based on the patient’s estimated lifetime venous access requirements, cost, and physician preference.