Jeffrey A. Leef

Use of Retrievable Compared to Permanent Inferior Vena Cava Filters: A Single-Institution Experience

The purpose of this study was to review the use, safety, and efficacy of retrievable inferior vena cava (IVC) filters in their first 5 years of availability at our institution. Comparison was made with permanent filters placed in the same period. A retrospective review of IVC filter implantations was performed from September, 1999, to September, 2004, in our department. These included both retrievable and permanent filters. The Recovery nitinol and Günther tulip filters were used as retrievable filters. The frequency of retrievable filter used was calculated. Clinical data and technical data related to filter placement were reviewed. Outcomes, including pulmonary embolism, complications associated with placement, retrieval, or indwelling, were calculated. During the study period, 604 IVC filters were placed. Of these, 97 retrievable filters (16%) were placed in 96 patients. There were 53 Recovery filter and 44 Tulip filter insertions. Subjects were 59 women and 37 men; the mean age was 52 years, with a range of from 18 to 97 years. The placement of retrievable filters increased from 2% in year 1 to 32% in year 5 of the study period. The total implantation time for the permanent group was 145,450 days, with an average of 288 days (range, 33–1811 days). For the retrievable group, the total implantation time was 21,671 days, with an average of 226 days (range, 2–1217 days). Of 29 patients who returned for filter retrieval, the filter was successfully removed in 28. There were 14 of 14 successful Tulip filter retrievals and 14 of 15 successful Recovery filter retrievals. In one patient, after an indwelling period of 39 days, a Recovery nitinol filter could not be removed secondary to a large clot burden within the filter. For the filters that were removed, the mean dwell time was 50 days for the Tulip type and 20 days for the Recovery type. Over the follow-up period there was an overall PE incidence of 1.4% for the permanent group and 1% for the retrieval group. In conclusion, there was an increase in the use of retrievable filters over the study period and an overall increase in the total number of filters implanted. The increased use of these filters appeared to be due to expanded indications predicated by their retrievability. Placement and retrieval of these filters have a low risk of complications, and retrievable filters appeared effective, as there was low rate of clinically significant pulmonary embolism associated with these filters during their indwelling time.

Angiographic access site complications in the era of arterial closure devices.

Coronary and peripheral angiography is associated with a low but significant risk of access site complications. While percutaneous devices have been shown to permit more rapid puncture site closure, previous reports have suggested the incidence and severity of complications associated with these devices are greater than with manual compression. This study compares access site complications with and without closure devices in the current era. The authors conducted a retrospective review of patients with access site complications after coronary or peripheral angiography between 1998 and 2000. Forty-five complications requiring vascular surgical consultation were identified in the 4,800 procedures performed during this time period. Fourteen complications occurred in 1,536 procedures (0.9%) using suture-mediated or collagen devices and 31 occurred in 3,264 procedures without devices (0.9%). The types of procedures and catheter sizes (mean 7 Fr) used were not different in the 2 groups. Other than complications involving a retained device, there was no difference between device and manual compression with respect to incidence or types of complication, requirement for operation, type of operation, or outcome. Access site complications identified included pseudoaneurysm (n = 22; 49%), bleeding or hematoma (n = 8; 18%), arteriovenous fistula (n =5; 11%), arterial thrombosis (n = 4; 9%), infection (n = 4; 9%), and retained device (n = 2; 4%). Twenty-four patients (71% vs 45%; p=NS) required operative intervention including pseudoaneurysm repair, hematoma drainage, and thrombectomy. Eleven patients (26%) underwent successful ultrasound-guided pseudoaneurysm compression and 9 patients (21%) required no intervention. These data demonstrate that closure devices facilitate arterial puncture site repair without an increase in access site complications. These devices can be safely utilized when rapid hemostasis is desired after coronary or peripheral angiography.

Intravascular Stents in the Management of Acute Superior Vena Cava Obstruction of Benign Etiology

The purpose of our study was to report our experience with percutaneous placement of intravascular stents to relieve venous occlusion in patients with acute superior vena cava syndrome resulting from benign etiologies. Six patients ranging in age from 39 to 66 years received thrombolysis followed by placement of stents within the superior vena cava or received stent placement alone as emergency treatment for symptoms of acute superior vena cava obstruction. Treatment was successful in all patients, with establishment of a patent lumen angiographically, and patients experienced prompt symptomatic relief. Follow-up examination at intervals of 5 months to 2 years has demonstrated no evidence of reocclusion. Three patients have subsequently had central lines placed across the stented vena cava for vascular access. Percutaneous placement of intravascular stents to treat acute occlusion offered a safe and effective method of treatment in patients with superior vena cava syndrome resulting from benign causes.

Percutaneous Treatment of Venous Outflow Obstruction in Pediatric Liver Transplants

PURPOSE To evaluate the efficacy and safety of percutaneous dilation in the treatment of impaired venous outflow in pediatric patients with liver transplants. MATERIALS AND METHODS Review was undertaken of the records of 35 procedures to dilate impaired venous outflow in 16 consecutive children (aged 11 days to 17.8 years; mean, 7.2 +/- 5.8 y) after liver transplantation over a period of 8 years. Patients presented clinically with signs or symptoms of obstruction of the hepatic venous or inferior vena cava anastomosis and/or abnormal noninvasive imaging findings and were referred primarily to the interventional radiology department for treatment. None were excluded. Technical and clinical success rates were calculated. After venoplasty, patients with incomplete venographic resolution or pressure gradients exceeding 5 mm Hg were treated with stents. Seven died or required repeat transplantation during the study period for reasons unrelated to venous outflow obstruction. Patency rates were calculated for all other patients with sufficient follow-up in the pediatric hepatology clinic. RESULTS The combined technical success rate for venoplasty (12 of 16) and stent placement (three of 16) was 94% (15 of 16), and the clinical success rate was 81% (13 of 16). One minor complication occurred: a transient hypoxic episode. Primary patency rates were 72.7% (eight of 11) at 3 months, 60% (six of 10) at 6 months, 55.6% (five of nine) at 12 months, 50% (four of eight) at 18 months, and 50% (three of six) at 36 months. Primary assisted and secondary patency rates were 90.9% (10 of 11) at 3 months, 90% (nine of 10) at 6 months, 88.9% (eight of nine) at 12 months, 87.5% (seven of eight) at 18 months, and 83.3% (five of six) at 36 months. CONCLUSIONS Excellent technical and clinical success rates can be achieved with percutaneous dilation of impaired venous outflow after pediatric liver transplantation. Long-term patency may require repeated interventions.

Evaluation and Treatment of Suspected Type II Endoleaks in Patients with Enlarging Abdominal Aortic Aneurysms

PURPOSE To evaluate angiographic diagnosis and embolotherapy of patients with enlarging abdominal aortic aneurysms and computed tomographic (CT) diagnosis of type II endoleak. MATERIALS AND METHODS A retrospective review was performed of all patients referred to a single vascular and interventional radiology section from January 1, 2003, to June 1, 2011, with a diagnosis of enlarging aneurysm and type II endoleak. Twenty-five patients underwent 40 procedures between 12 and 82 months after endograft insertion (mean, 48 mo) for diagnosis and/or treatment of endoleaks. RESULTS Type II endoleaks were treated with cyanoacrylate, coils, and ethylene vinyl alcohol copolymer in 16 patients. Technical success rate was 88% (14 of 16 patients) and clinical success rate was 100% (16 of 16 patients). Aneurysm growth was arrested in all cases over a mean follow-up of 27.5 months (range, 6-88 mo). Endoleaks in nine patients were misclassified on CT; two had type I endoleaks and seven had type III endoleaks. Four of the nine patients (two type I endoleaks and two type III endoleaks) were correctly classified after initial angiography. The other five type III endoleaks were correctly classified on CT after coil embolization of the inferior mesenteric artery. Direct embolization was performed via sac puncture with ethylene vinyl alcohol copolymer in two of the latter five patients and eliminated endoleaks in both. CONCLUSIONS Aneurysm growth caused by type II endoleaks was arrested by embolization. CT misclassification occurred relatively commonly; type III endoleaks purported to be type II endoleaks were found in 28% of patients (seven of 25).

PERCUTANEOUS TRANSLUMINAL MESENTERIC ANGIOPLASTY

The endovascular treatment of chronic mesenteric ischemia remains in its infancy. This state is most certainly related to the small patient population affected by this devastating condition and the surgeons limited desire to pursue percutaneous options for this group. Surgical trepidation is not unwarranted because in many facets mesenteric angioplasty is similar to percutaneous carotid intervention. Interventions in these vessels represent manipulation of terminal and unduplicated arterial systems. Complications compromising flow to either vascular bed can yield rapid grave outcomes. Despite this risk, early experience with mesenteric angioplasty for chronic ischemia suggests that it is a viable treatment alternative and that it can be performed with relative safety. A randomized prospective trial of mesenteric angioplasty with operative bypass grafting appears to be the next logical step.

Comparison of iodixanol and ioxaglate for adult aortography and renal/visceral angiography: A phase III clinical trial

RATIONALE AND OBJECTIVES We investigated whether iodixanol offers improved safety or tolerance compared with ioxaglate and evaluated whether iodixanol-enhanced radiographs are diagnostically comparable or superior to those produced with ioxaglate. Iodixanol is a new isosmotic hexa-iodinated nonionic contrast agent being evaluated for intravascular use. METHODS Fifty-four adult patients undergoing renal or visceral angiography, aortography, or both were enrolled in a prospective, randomized, double-blind, two-center study in which iodixanol and ioxaglate were compared. Subjects were monitored for adverse events, injection-associated discomfort, and changes in laboratory parameters and vital signs. Efficacy was measured by the overall quality of angiographic enhancement. RESULTS No serious adverse events occurred during this trial. Mild-to-moderate adverse events were more common in patients receiving ioxaglate (p = .041). Injection-associated pain was reported by three patients receiving ioxaglate and none receiving iodixanol (p = .093). Clinical laboratory and vital-sign data showed no differences between groups, and there was no difference in the overall quality of angiographic visualization (p = .711). CONCLUSION Iodixanol resulted in improved safety and patient tolerability while providing images of equivalent diagnostic efficacy compared with ioxaglate.

Iodixanol and ioxaglate in adult aortography and peripheral arteriography: A phase III clinical trial

RATIONALE AND OBJECTIVES This study compared the safety and efficacy of iodixanol with those of ioxaglate in adult patients undergoing aortography or peripheral arteriography. METHODS Forty-six patients were enrolled in this controlled, randomized, double-blind, two-center study. The patients were monitored for adverse events, injection-related discomfort, and trends in laboratory data or vital signs. Diagnostic efficacy was assessed by the quality of contrast enhancement. RESULTS All procedures were diagnostic, with no significant difference in quality of visualization (p = .205). No significant difference was seen in the number of patients experiencing mild or moderate adverse effects (p = .106). Patients receiving ioxaglate reported a significantly greater incidence of injection-related pain (p = .025). CONCLUSION The results of this study support the conclusion that iodixanol at 320 mg I/kg is safe and effective for adult aortography and peripheral arteriography and causes significantly less injection-related pain than ioxaglate.

Sonographic Needle Guidance in Cholangiography in Children

PURPOSE To evaluate feasibility and benefits of sonographic guidance of percutaneous transhepatic cholangiography (PTC) in children with liver transplants. MATERIALS AND METHODS The authors prospectively followed 24 PTC procedures in 19 pediatric patients (11 females, 8 males; age 3 months to 17 years) randomized to fluoroscopic or sonographic guidance. The number of needle passes, the contrast material dose, fluoroscopy time, and procedure time for each procedure were recorded. All patients were transplant recipients-six whole and 13 reduced-size grafts. Cases were randomly assigned to two groups: group I, fluoroscopically guided PTC (12 procedures); group II, sonographically guided PTC (12 procedures). RESULTS The technical success rate was 92% (11 of 12) for each group. In group I, there were two procedure-related complications: postprocedural fever caused by biliary to portal vein fistula, and peritoneal bleeding requiring surgery. In group II, there were no procedure-related complications. A mean of 8.2 +/- 3.7 needle passes were required in group I compared to only 2.0 +/- 1.3 in group II (P < .0001). A mean contrast material dose of 19.5 mL +/- 13.4 was required in group I compared to only 2.5 mL +/- 1.9 in group II (P < .001). A mean procedure time of 15.7 minutes +/- 7.4 was required in group I compared to only 6.1 minutes +/- 4.5 in group II (P < .001). A mean fluoroscopy time of 10.4 minutes +/- 5.0 was required in group I compared to only 1.0 minutes +/- 0.7 in group II (P < .0001). CONCLUSION In pediatric patients who have undergone liver transplantation, sonographic guidance significantly decreases the number of needle passes, contrast material dose, and fluoroscopy time required for PTC.

Indwelling and Retrieval Complications of Denali and Celect Infrarenal Vena Cava Filters

PURPOSE To compare indwelling and retrieval complications of Denali and Celect filters placed in the infrarenal inferior vena cava (IVC). MATERIALS AND METHODS A retrospective study was conducted over 2 years at a single institution in which 171 Denali and 162 Celect filters were placed in 333 patients with a mean age of 62.3 years ± 15.7 (161 men; 48.3%). Filter indications included venous thromboembolic disease (n = 320; 96.1%) and surgical prophylaxis (n = 13; 3.9%). A jugular approach was used to place 303 filters (91.0%). Computed tomography (CT) follow-up, complications, and retrieval data were obtained. RESULTS Follow-up CT imaging was performed on 58 filters from each group with lower incidences of caval strut penetration (one vs 12) and filter tilt (one vs 15) in the Denali filter group (P = .002 and P < .001, respectively). There was no difference in incidences of breakthrough pulmonary embolism (P = .68). Retrieval attempts were performed on 43 Denali and 53 Celect filters with mean indwelling times at retrieval of 128.2 and 144.1 days, respectively (P = .40). Mean fluoroscopy time at retrieval was lower in the Denali group (3.1 min vs 6.0 min; P = .01). There were fewer cases of complex retrieval in the Denali group (n = 2 vs 10; P = .06). Tilt, fluoroscopy time, and air kerma were associated with complex retrieval (P = .04, P < .001, and P < .001, respectively). There was one Denali filter deployment complication that led to retrieval failure. CONCLUSIONS This study suggests that Denali filters are associated with lower incidences of strut penetration and filter tilt as well as shorter fluoroscopy time at retrieval compared with Celect filters when placed in the infrarenal IVC.