Charles T. Burke

Transcatheter Thrombolytic Therapy for Acute Mesenteric and Portal Vein Thrombosis

PURPOSE The purpose of this study was to evaluate the utility of transcatheter thrombolytic therapy in 20 patients with acute or subacute (symptoms <40 days) portal and/or mesenteric vein thrombosis with severe symptoms, deteriorating clinical condition, and/or persistent symptoms despite anticoagulation. MATERIALS AND METHODS This retrospective study examined 12 male patients and eight female patients seen over a period of 11 years. The average age was 37.6 years. Four of the patients had previously undergone liver transplantation. An anatomic classification system was established to describe the extent of thrombus at the time of diagnosis. Patients were treated with thrombolytic therapy via the transhepatic route, common femoral vein route, and/or superior mesenteric artery route. Improvement in symptoms, avoidance of bowel resection, complications, and radiographic evidence of clot resolution were the main clinical outcomes. RESULTS Fifteen of the 20 patients exhibited some degree of lysis of the thrombus. Three patients had complete resolution, 12 had partial resolution, and five had no resolution. Eighty-five percent of patients (n = 17) had resolution of symptoms. Sixty percent of patients (n = 12) developed a major complication. No patients required bowel resection after thrombolytic therapy. One patient died with gastrointestinal hemorrhage and septic shock 2 weeks after thrombolytic therapy. Other major complications included bleeding and conditions requiring transfusion. No patients developed new portal or mesenteric thromboses. Two of the patients who received transplants eventually required repeat transplantation. CONCLUSIONS Transcatheter thrombolysis was beneficial in avoiding patient death, resolving thrombus, improving symptoms, and avoiding bowel resection. However, there was a high complication rate, indicating that this therapy should be reserved for patients with severe disease. Further evaluation of these techniques and outcomes should continue to be pursued.

Embedded Inferior Vena Cava Filter Removal: Use of Endobronchial Forceps

PURPOSE Removing a retrievable inferior vena cava (IVC) filter can be extremely difficult with the use of standard techniques if the filter is tilted and embedded in the wall of the IVC. The use of rigid endobronchial forceps has been described in case reports to remove embedded IVC filters, and the present report describes the use of this technique to remove a series of tip-embedded IVC filters in two separate institutions. MATERIALS AND METHODS The medical records were reviewed of 21 consecutive patients at two institutions who underwent attempted IVC filter removal with rigid endobronchial forceps over a 34-month period. The mean age of patients was 32.4 years (range, 14.1-54.1 y). The patients had the following filters: Recovery (n = 6), G2 (n = 10), Günther Tulip (n = 4), and OptEase (n = 1). RESULTS Rotational or biplane venography was used to confirm that the filters were tilted and embedded in the wall of the IVC in all 21 patients. Rigid endobronchial forceps were used successfully to remove 20 embedded IVC filters in 21 patients. There was one case of failure to remove an embedded suprarenal G2 filter. There were no major complications. CONCLUSIONS Rigid endobronchial forceps may be used as a reliable option for removal of embedded IVC filters.

Factors Associated with Failed Retrieval of the Günther Tulip Inferior Vena Cava Filter

PURPOSE To identify potential factors associated with failed retrieval of the Günther Tulip inferior vena cava (IVC) filter. MATERIALS AND METHODS A retrospective review was performed of patients who underwent placement of the Günther Tulip filter with at least one attempt at filter retrieval over a 3-year period. Patient demographics, filter dwell time, filter angulation, and filter leg protrusion were analyzed. RESULTS A total of 188 patients were included in the study. Primary retrieval success was achieved in 166 patients (88.3%), for an overall retrieval success rate of 94.2%. The overall mean dwell time was 63 days, whereas the mean dwell time in cases of retrieval failure was 95.4 days. A total of seven filters were in place for longer than 6 months, four of which were successfully retrieved. The degree of filter tilt was not found to be significantly related to retrieval success (P = .36), even though filter angulation was commonly cited as a reason for retrieval failure. On venography, 90.9% of filters that could not be retrieved showed leg protrusion beyond the lumen of the IVC. Finally, increasing patient age also correlated with retrieval failure (P = .01). CONCLUSIONS Prolonged dwell time and increasing patient age are associated with failed filter retrieval. However, even filters in place for extended periods can be safely removed.

Use of yttrium-90 microspheres in patients with advanced hepatocellular carcinoma and portal vein thrombosis.

PURPOSE Patients with portal vein thrombosis (PVT) and hepatocellular carcinoma (HCC) have limited treatment options because of increased disease burden and diminished hepatic perfusion. Yttrium-90 ((90)Y) microspheres may be better tolerated than chemoembolization in these patients. The present study reviews the safety and efficacy of (90)Y microspheres in HCC with major PVT. MATERIALS AND METHODS A retrospective review of HCC with main (n = 10) or first-branch (n = 12) PVT treated with (90)Y microspheres (N = 22) was conducted. Cancer of the Liver Italian Program (CLIP) scores ranged from 2 to 5, with 18% of patients having a score of 4 or greater. Imaging response at 8-12 was based on Response Evaluation Criteria In Solid Tumors. Overall survival (OS) was estimated by the Kaplan-Meier method. RESULTS A total of 32 microsphere treatments (26 glass, six resin) were administered to 22 patients. Common grade 1/2 toxicities included abdominal pain (38%), nausea (28%), and fatigue (22%). Four posttreatment hospitalizations occurred, all less than 48 hours in duration. One death occurred 10 days after therapy. The partial response rate was 8% and progressive disease was seen in 42% of patients. Stable disease was achieved in 50% of treatments. Median OS was 7 months from initial treatment. Patients with Child-Pugh class A disease had a median OS of 7.7 months; those with class B/C disease had an OS of 2.7 months (P = .01). Median OS for patients with CLIP scores of 2/3 was 7 months, versus 1.3 months for those with scores of 4/5 (P = .04). CONCLUSIONS Yttrium-90 microspheres are tolerated in patients with HCC and major PVT. Compared with chemoembolization, rates of severe adverse events appear low. Radiographic response rates are low. The median OS of 7 months is promising and warrants further study versus systemic therapy.

Risk-group targeted inferior vena cava filter placement in gastric bypass patients.

BackgroundDespite a growing body of evidence guiding appropriate perioperative thromboprophylaxis in the general population, few data direct strategies to reduce deep venous thrombosis (DVT) and pulmonary embolism (PE) in the morbidly obese. We have implemented a novel protocol for venous thromboembolism (VTE) risk stratification in Roux-en-Y gastric bypass (RYGB) candidates at our institution, which augments clinical assessment with screening for thrombophilias, to guide retrievable inferior vena cava (IVC) filter utilization.MethodsA retrospective review of prospectively collected data from patients who underwent primary RYGB between 2001 and 2008 at the University of North Carolina at Chapel Hill was completed. During that time, clinical assessment of VTE risk was amplified by focused plasma screening for common thrombophilias (factors VIII, IX, and XI, d-dimer, fibrinogen). Preoperative prophylactic IVC filters were offered to high-risk patients. The database was reviewed for perioperative DVTs, PEs, and filter-related complications.ResultsOf 330 patients, in 162 attempts, 160 had prophylactic IVC filters placed with four complications overall (2.47%). No patient had symptoms of PE during the planned 6-week filter period, though one had a PE occur immediately after filter removal (0.63%); in contrast, five of 170 patients (2.94%) without prophylactic IVC filters presented with symptomatic PE (p = 0.216). In total, 147 (91.88%) prophylactic filters were removed.ConclusionsRisk-group targeted prophylactic inferior vena cava filter placement prior to RYGB is safe with a trend towards reduced occurrence of PE.

SIR 2003 Film Panel Case 8: Aortocaval Fistula Supplied by a Type II Endoleak

The patient is a 66-year-old man who presented to the emergency room with complaints of nausea, diaphoresis, syncope, and chest tightness. He also had a history of intermittent back pain for several days before admission. Physical examination in the emergency room revealed hypotension and a large palpable abdominal mass. Before being taken directly to the operating room, the patient ruled in for a myocardial infarction. In the operating room, an 8-cm aneurysm with an aortocaval fistula was discovered by angiography, and subsequently excluded with an AneuRx endovascular stent-graft placed with only local anesthesia (Fig 8.1). The patient did well postoperatively on -blockade. Cardiology consult recommended continued -blockade and aspirin. On postoperative day 3, the patient was ambulating and was transferred to the floor. A plain film series of the abdomen (Fig 8.2) and computed tomography (CT) of the abdomen were performed on postoperative day 4 (Fig 8.3).

Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors.

Tumor ablation is a minimally invasive technique used to deliver chemical, thermal, electrical, or ultrasonic damage to a specific focal tumor in an attempt to achieve substantial tumor destruction or complete eradication. As the technology continues to advance, several image-guided tumor ablations have emerged to effectively manage primary and secondary malignancies in the liver. Percutaneous chemical ablation is one of the oldest and most established techniques for treating small hepatocellular carcinomas. However, this technique has been largely replaced by newer modalities including radiofrequency ablation, microwave ablation, laser-induced interstitial thermotherapy, cryoablation, high-intensity-focused ultrasound ablation, and irreversible electroporation. Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.

Bronchial Artery Embolization

Massive hemoptysis is a frightening and potentially life-threatening clinical event. Patients with chronic inflammatory lung diseases such as bronchiectasis, sarcoidosis, tuberculosis, and cystic fibrosis develop markedly hypertrophied and fragile bronchial arteries that may lead to clinically significant hemoptysis. Surgical intervention is hazardous and often impossible in these patients with diffuse parenchymal lung disease. Superselective catheterization of the bronchial arteries feeding the affected areas followed by particulate embolization has proven to be an effective treatment for the control of bleeding. With modern microcatheters and guidewires, bronchial artery embolization is safe and well tolerated by patients. Because this treatment does not directly influence the primary underlying disease, recurrent episodes of bleeding are likely, which will require additional embolization procedures. In patients who have undergone prior bronchial artery embolization, the dominant feeding arterial supply often originates from nonbronchial systemic collateral vessels.

Endovascular Management of Chronic Upper Extremity Deep Vein Thrombosis and Superior Vena Cava Syndrome

Chronic upper extremity deep vein thrombosis (UEDVT) and superior vena cava syndrome (SVCS) are important and underdiagnosed entities that are associated with significant morbidity, and both are becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Currently, as many as 25% of patients with an indwelling catheter are diagnosed with chronic UEDVT or venous stenosis. SVCS is most commonly seen in the setting of malignancy, especially lung cancer and lymphoma. Endovascular management of chronic UEDVT and SVCS is accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. In this article, the indications for treatment, complications, and success rates of the endovascular management of UEDVT and SVCS are reviewed. Relevant findings on presentation and physical exam as well as various imaging modalities and imaging findings are evaluated. Details of preprocedure evaluation, relevant anatomy, and avoidance of potential complications are discussed.

Direct Puncture of the Recanalized Paraumbilical Vein for Portal Vein Targeting During Transjugular Intrahepatic Portosystemic Shunt Procedures: Assessment of Technical Success and Safety

PURPOSE To assess the success of direct percutaneous puncture of the recanalized paraumbilical vein (RPUV) for access and visualization of the portal vein (PV) to guide transhepatic puncture during transjugular intrahepatic portosystemic shunt (TIPS) creation. The predictive value of successful catheterization based on preprocedural vein diameter was analyzed. MATERIALS AND METHODS A retrospective review of all TIPS procedures from 2002 to 2008 performed at a single institution was conducted, and a subset of procedures in which portal venography was attempted via the paraumbilical vein were identified. In this subset, TIPS outcomes and diameters of the RPUV near the skin puncture site and left PV junction were measured and analyzed with a two-tailed Student t test. RESULTS During the study period, 114 TIPSs were created. RPUV punctures were found in 22 patients (19.3%) and portal venography was successful in 14 of the 22 patients (64%), all without complications. In the remainder (n = 8), access via the RPUV failed secondary to a small vein diameter (< 0.3 cm; n = 3), moderate to severe vessel tortuosity (n = 4), and distal thrombosis (n = 1). Puncture, catheterization, and portal venography was successful when the paraumbilical vein measured a mean of 0.75 cm at the skin and a mean of 0.84 cm at the junction with the left PV when analyzed against the failed attempts. CONCLUSIONS Portal venography via the RPUV is a feasible and probably safe alternative to other methods of PV opacification during TIPS procedures.