Gary S. Cohen

A strategy of aggressive regional therapy for acute iliofemoral venous thrombosis with contemporary venous thrombectomy or catheter-directed thrombolysis

PURPOSE Occlusive iliofemoral venous thrombosis is associated with morbid short- and long-term consequences. Having been disappointed with standard anticoagulant therapy and systemic fibrinolysis, we embarked on an aggressive multidisciplinary regional approach to treat these patients, with the goals of therapy being (1) to eliminate iliofemoral venous thrombus, (2) to provide unobstructed venous drainage from the affected limb, and (3) to prevent recurrent thrombosis. METHODS Twelve consecutive patients were treated for extensive iliofemoral venous thrombosis. Each had thrombus from their infrapopliteal veins through their iliofemoral system, and four had vena caval involvement. The conditions of 11 patients failed to improve when the patients were given anticoagulants, and prior systemic fibrinolysis failed in five patients. The treatment strategy includes catheter-directed thrombolysis with intrathrombus infusion of the plasminogen activator or operative thrombectomy or venous bypass with a permanent 4 mm arteriovenous fistula (AVF). RESULTS Nine of 12 patients had a good or excellent clinical outcome (mean follow-up 25 months), which correlated with restored unobstructed venous drainage from the affected limb. Seven patients had catheter-directed lytic therapy attempted. In five patients the catheters were appropriately positioned, and lysis was successful. Five of the eight patients who underwent operations had successful procedures. Two of the three patients with poor operative outcomes had residual thrombus in their iliac veins or vena cava after thrombectomy (without bypass). The third patient, in whom anticoagulation was contraindicated, had an initially successful thrombectomy and AVF; however, vena caval thrombosis developed 2 months after operation. No patient had symptomatic pulmonary emboli, and routine posttreatment ventilation/perfusion lung scanning was not performed. CONCLUSIONS An aggressive multidisciplinary regional approach to patients with obliterative iliofemoral venous thrombosis, designed to remove thrombus and provide unobstructed venous drainage, offers substantially better clinical outcome compared with systemic fibrinolysis and standard anticoagulation. Catheter-directed thrombolysis is successful if the catheter is appropriately positioned within the thrombus. Contemporary venous thrombectomy, which includes thrombus removal, completion phlebography, AVF, and cross-pubic bypass when necessary, is associated with high success rates. Failures can be anticipated and avoided in most patients.

Aortic pseudoaneurysm after penetration by a Simon nitinol inferior vena cava filter.

This report describes an unusual complication related to inferior vena cava (IVC) filter placement. A 50-year-old woman undergoing long-term anticoagulation presented to her primary care physician with abdominal pain after a motor vehicle accident. An IVC filter had been placed 7 years earlier. Computed tomography of the abdomen demonstrated a moderate perisplenic hematoma and a fragmented IVC filter penetrating the aorta. A small infrarenal aortic pseudoaneurysm had developed at the penetration site. Wallgraft placement successfully sealed the aneurysm.

Sheathless Technique of Ash Split-Cath Insertion

A novel technique for insertion of the Ash Split-Cath without a peel-away sheath to decrease the potential for air embolism is described. A retrospective review of 62 attempted Ash Split-Cath insertions at three hospitals was made. Conversion to the usual technique using a sheath was necessary in four cases, mostly because of extensive scarring from previous catheters. There was no air embolus, hematoma, or immediate catheter malfunction. The authors believe that the occurrence of air embolism during placement of Ash Split-Cath may be lessened by eliminating the use of a peel-away sheath.

External Beam Irradiation as an Adjunctive Treatment in Failing Dialysis Shunts

PURPOSE To evaluate the utility of low-dose irradiation as adjunctive treatment for failing dialysis shunts related to stenoses. MATERIALS AND METHODS Thirty-one patients with 41 lesions in their dialysis shunts were successfully enrolled for this study. After imaging of the shunt and calculation of venous stenoses, each patient was randomized into one of two segments of the protocol: (i) angioplasty and/or stent placement alone, and (ii) angioplasty and/or stent placement followed by external beam irradiation. All patients with significant venous stenoses (> or =50%) were treated with appropriately sized PTA (percutaneous transluminal angioplasty) and Wallstents. Patients randomized to the external irradiation segment underwent localized irradiation via a Theratron cobalt unit of 7 Gy 0-24 hours and 24-48 hours after intervention. Those patients randomized to the control group received no additional treatment. Clinical follow-up included resumption of successful dialysis with appropriate hemodynamic parameters. Two follow-up shunt images were obtained, follow-up 1 (fu-1) from 90 to 179 days and follow-up 2 (fu-2) from 180 to 365 days. Percentages of significant recurrent stenoses, defined as greater than 50%, were recorded and re-treated as needed. RESULTS Sixteen of the 31 patients underwent external beam irradiation. There were 21 lesions in the test group that underwent irradiation after intervention, and 20 lesions were treated with intervention alone. There were seven native arteriovenous fistulas and 24 Gore-tex grafts. All stenoses were either venous outflow stenoses (68%) or central stenoses (32%). The authors utilized chi2 analysis to compare restenoses rates between the control and irradiated groups at fu-1 (P<.99) and fu-2 (P<.10). CONCLUSIONS Although the results show that external beam irradiation has minimal effects on the restenoses of dialysis grafts when used in conjunction with PTA and stent placement, further studies with a larger, more homogenous population are needed to assess the trend of improving patency rates after external beam irradiation.

Transhepatic Dialysis Catheter Tract Embolization to Close a Venous-Biliary-Peritoneal Fistula

O SCVIR, 1998 THE use of transhepatic venous catheters in patients with extremely limited venous access has been described (1-4). Transhepatic placement of large-bore hemodialysis catheters also has been reported (5,6). These limited studies describe techniques for insertion and maintenance of these catheters; however, none describe techniques to limit complications secondary to removal of these catheters. Potential complications include hemorrhage, biliary fistulas, and peritonitis. At our institution, we had a case of near fatal intraperitoneal hemorrhage that developed after inadvertent removal of a transhepatic hemodialysis catheter. Several investigators have described techniques to limit hemorrhage after percutaneous liver biopsy (7-9) and biliary or gallbladder drainage (10-12). Applying similar techniques to those previously described, we present a case of catheter tract embolization after transhepatic hemodialysis catheter removal to isolate a catheter tract-biliary fistula and to prevent potential intraperitoneal hemorrhage.

Selective Arterial Embolization of Idiopathic Priapism

We report a case of idiopathic priapism that was only identified as high-flow or arterial priapism after drainage of the corpora cavernosa. Following failure of conservative and surgical treatment attempts, two consecutive embolizations of a unilateral penile artery were performed with gelgoam particles.

Multidisciplinary management of hepatocellular carcinoma: a model for therapy

A multidisciplinary model is a useful approach in the management of hepatocellular carcinoma (HCC) to coordinate, individualize, and optimize care. The HCC Multidisciplinary Team (MDT) at Temple University Hospital was established in 2008 and comprises hepatologists, interventional radiologists, transplant surgeons, oncologists, residents, midlevel providers, and support staff. Patients may be enrolled by referral from (1) oncologists at Temple, (2) the hepatitis screening clinic recently established at Temple and staffed by hepatology residents, or (3) community practices. MDT conferences are held weekly, during which cases are discussed (based on medical history, interpretation of images, and laboratory analyses) and treatment plans are formulated. The Temple treatment algorithm follows current standards of care, guided by tumor volume and morphology, but the novel multidisciplinary interaction challenges members to tailor therapy to achieve the best possible outcomes. Patients with a solitary lesion ≤ 2 cm may receive no treatment until eligible for transplantation or locoregional therapy or resection, with imaging every 3 to 6 months to monitor tumor progression. In patients with tumors > 2 cm and ≤ 5 cm, microwave ablation therapy is used if lesions are discrete and accessible. Conventional transarterial chemoembolization (TACE) or drug-eluting bead TACE (DEB-TACE) or yttrium-90 microspheres are utilized in multifocal disease. Patients with lesions > 5 cm are candidates for TACE for downstaging the tumor. Sorafenib is typically reserved for unresectable lesions between 2 cm and 5 cm. Frequently, we administer sorafenib continuously and in combination with DEB-TACE. In our experience, sorafenib does not produce effects on the tumor vasculature or blood flow that would impair the efficacy of DEB-TACE. The literature documents improved outcomes in HCC and other cancers associated with the introduction of multidisciplinary care. The role and organization of the MDT is influenced by team culture, expertise, and process, as well as institutional and larger environmental contexts.

Effort thrombosis: effective treatment with vascular stent after unrelieved venous stenosis following a surgical release procedure.

Acute symptomatic effort thrombosis in a 33-year-old male necessitated an aggressive approach consisting of thrombolysis, angioplasty, and surgical thoracic outlet release. The patient required postoperative placement of a Wallstent and was placed on anticoagulation. He has remained symptom free for the past 10 months, both clinically and sonographically.

Urinoma secondary to surgical spinal fusion: Radiologic diagnosis and treatment

SummaryWe have presented a case of urinoma secondary to ureteral injury during spinal fusion via retroperitoneal approach demonstrated by CT. The presumed diagnosis of urinoma was confirmed and treated by interventional radiologie techniques.

Expanding Radiology’s Role in a Value-Based Health Economy

INTRODUCTION As the transition from fee-for-service to value-based reimbursement continues, there is an increasing financial incentive for hospitals and health care systems to provide high-quality and efficient health care. Hospitals and health care systems are now faced with reimbursements tied to quality metrics and fixed bundle payments for health services provided and are at risk for the cost and quality of care. This is a significant change from the fee-for-service model, in which radiology departments were incentivized to maximize volume without regard for appropriateness or quality. Michael Porter [1] defined value as health outcomes achieved per dollar spent. Implicit in this definition is the collective nature of value delivery. The health outcomes achieved are the result of the combined efforts of many people, processes, and systems. The challenge of defining what it means to add value in radiology is rooted in this complexity. The cost of an imaging test (both to the patient or insurer and the cost to deliver the test) is easily measured but is often a small percentage of the overall cost of care for a patient and only one of many factors and steps in the outcome for an individual patient. The attractiveness of holding organizations accountable for