Mark F. Given

Gunther Tulip retrievable inferior vena caval filters: indications, efficacy, retrieval, and complications.

PurposeWe evaluated the Gunther Tulip (GT) retrievable inferior vena cava (IVC) filter with regard to indications, filtration efficacy, complications, retrieval window, and use of anticoagulation.MethodA retrospective study was performed of 147 patients (64 men, 83 women; mean age 58.8 years) who underwent retrievable GT filter insertion between 2001 and 2005. The indications for placement included a diagnosis of pulmonary embolism or deep venous thrombosis with a contraindication to anticoagulation (n = 68), pulmonary embolism or deep venous thrombosis while on anticoagulation (n = 49), prophylactic filter placement for high-risk surgical patients with a past history of pulmonary embolism or deep venous thrombosis (n = 20), and a high risk of pulmonary embolism or deep venous thrombosis (n = 10). Forty-nine of the 147 patients did not receive anticoagulation (33.7%) while 96 of 147 patients did, 82 of these receiving warfarin (56.5%), 11 receiving low-molecular weight heparins (7.58%), and 3 receiving antiplatelet agents alone (2.06%).ResultsFilter placement was successful in 147 patients (100%). Two patients had two filters inserted. Of the 147 patients, filter deployment was on a permanent basis in 102 and with an intention to retrieve in 45 patients. There were 36 (80%) successful retrievals and 9 (20%) failed retrievals. The mean time to retrieval was 33.6 days. The reasons for failed retrieval included filter struts tightly adherent to the IVC wall (5/9), extreme filter tilt (2/9), and extensive filter thrombus (2/9). Complications included pneumothorax (n = 4), failure of filter expansion (n = 1), and breakthrough pulmonary embolism (n = 1). No IVC thrombotic episodes were recorded.DiscussionThe Gunther Tulip retrievable filter can be used as a permanent or a retrievable filter. It is safe and efficacious. GT filters can be safely retrieved at a mean time interval of 33.6 days. The newly developed Celect filter may extend the retrieval interval.

Skills transfer after proficiency-based simulation training in superficial femoral artery angioplasty.

Introduction The purpose of this study was to explore whether basic endovascular skills acquired using proficiency-based simulation training in superficial femoral artery (SFA) angioplasty translate to real-world performance. Methods Five international experts were invited to evaluate a preliminary 28-item rating scale for SFA angioplasty using a modified Delphi study. To test the procedural scale, 4 experts and 11 final-year medical students then performed 2 SFA angioplasties each on the vascular intervention simulation trainer simulator. Thereafter, 10 general surgical residents (novices) received didactic training in SFA angioplasty. Trainees were then randomized with 5 trainees receiving further training on the vascular intervention simulation trainer simulator up to proficiency level. All 10 trainees then performed 1 SFA angioplasty on a patient within 5 days of training. The trainees’ performance was assessed by 1 attending consultant blinded to the trainees’ training status, using the developed procedural scale and a global rating scale. Results Four items were eliminated from the procedural scale after the Delphi study. There were significant differences in the procedural scale scores between the experts and the students in the first trial [mean (SD), 94.25 (2.22) vs. 74.90 (8.79), P = 0.001] and the second trial [95.25 (0.50) vs. 76.82 (9.44), P < 0.001]. Simulation-trained trainees scored higher than the controls on the procedural scale [86.8 (5.4) vs. 67.6 (6), P = 0.001] and the global rating scale [37.2 (4.1) vs. 24.4 (5.3), P = 0.003]. Conclusions Basic endovascular skills acquired using proficiency-based simulation training in SFA angioplasty do translate to real-world performance.

Subintimal Angioplasty: Predictors of Long-term Success

PURPOSE To determine the clinical outcomes and success rates after percutaneous subintimal angioplasty (SIA) in patients with lower-limb occlusive lesions causing intermittent claudication (IC) or critical limb ischemia (CLI) at midterm to long-term follow-up. The secondary aim was to elicit factors predictive of a successful outcome. MATERIALS AND METHODS Between January 1999 and June 2006, 75 consecutive patients (45 men; age range, 46-91 years; CLI in 79%) underwent SIA of iliac and infrainguinal (84%) occlusions. Outcomes were determined on an intent-to-treat basis. The composite endpoint of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up, which was defined as the development of IC, CLI, or need for subsequent endovascular or surgical revascularization. Actuarial freedom from MACO was assessed via Kaplan-Meier curves and multivariable Cox proportional-hazards regression. RESULTS SIA was performed on 75 lesions, with an initial procedure success rate of 83% (n = 62). Procedure failure was caused by heavily calcified lesions (n = 5) and failure of reentry (n = 8). A total of 56.3% of patients with claudication were free from ipsilateral claudication at follow-up (mean, 32 months; range, 1-64 months), and those with CLI had a 79.7% limb salvage rate at a mean follow-up of 30.7 months (range, 0.5-91 months). On Cox regression analysis, the following variables were identified as independent predictors of MACO within the limb treated with SIA: ABI after SIA (hazard ratio, 0.21; 95% CI, 0.05-0.89; P = .035) and number of patent runoff vessels (ie, </=1 vs >/=2; hazard ratio, 0.29; 95% CI, 0.15-0.59; P = .001). CONCLUSIONS SIA is a feasible therapeutic option for occlusive atherosclerotic lesions in IC and CLI and is the evolving preferred strategy in CLI and perhaps IC with long-segment occlusions.

Endovascular treatment for Angio-Seal-related complications: long-term outcome

•Endovascular techniques can be used to treat Angio-Seal vascular closure device related stenotic, occlusive and embolic complications.•A range of techniques can be employed including thrombolysis, angioplasty and stent placement.•This can avoid surgery, particularly in medically unfit patients.

Impact of an Assistant on the Technical Skills of the Primary Operator in Superficial Femoral Artery Angioplasty

Objective: To assess the impact of an assistant on the technical skills of the operator performing superficial femoral artery (SFA) angioplasty on the vascular intervention simulation trainer (VIST) simulator. Methods: Eight experts performed 2 SFA angioplasties each on the VIST. Four experts had an assistant available. Experts’ video recordings were blindly evaluated using global and procedural rating scales. Results: Experts with assistants scored higher than the controls in the first: global rating scale (47.8 ± 0.5 vs 33.5 ± 5.1, P = .01); procedural rating scale (94.3 ± 2.2 vs 89 ± 2.5, P = .02) and the second procedure: global rating scale (47.8 ± 0.5 vs 38 ± 7, P = .03); procedural rating scale (95.3 ± 0.5 vs 89.5 ± 2.4, P = .02). Conclusions: The presence of an assistant had a positive influence on the technical skills of the operator performing SFA angioplasty on the VIST simulator.

IVC filter limb penetration of the caval wall during retroperitoneal surgery/lymph node dissection

Optional inferior vena cava (IVC) filters are being increasingly used for protection against pulmonary embolism in patients with deep vein thrombosis where anticoagulation is contraindicated. We describe two cases during retroperitoneal surgery where the IVC filters were found to have perforated the cava wall and were subsequently removed intra‐operatively. Cava wall penetration by filter limbs poses a significant danger during retroperitoneal lymph node dissection and filters should be removed preoperatively.

Vascular Malformations and Treatment

These are endothelial malformations which may be arterial, venous, capillary, lymphatic or mixed (e.g. arteriovenous). They are uncommonly encountered and treatment is complex. Patients with vascular malformations are best managed in an expert centre via a multidisciplinary approach by experienced clinicians incorporating input from different specialties including IR, Dermatology and Plastic surgery. They are divided into low and high-flow lesions. Low-flow lesions include venous, capillary, lymphatic or mixed malformations without arterial supply. High-flow malformations involve an arterial component. Pre-treatment characterisation with diagnostic imaging is mandatory as low and high-flow lesions are managed differently. MRI and ultrasound are the most commonly employed diagnostic modalities.

Acute Embolisation Procedures

Embolisation is a minimally invasive technique used to occlude vascular supply to organs, tumours or vascular malformations. This often involves the precise delivery of embolic materials under imaging guidance with fluoroscopy, ultrasound or CT. The interventionalist has a choice of embolic materials to choose from depending on the clinical scenario and desired therapeutic outcome. These include specially designed devices such as metallic coils and vascular plugs, microparticles, gelatine sponges and liquid agents such as glue, thrombin or non-adhesive liquid embolics (ethylene vinyl alcohol copolymer). Acute embolisation procedures are performed in emergency situations such as in the trauma patient to control haemorrhage. This is often performed as an alternative or adjunct to more invasive surgical treatment. These procedures require close teamwork between interventional radiologists and many individuals of the trauma team including referring clinicians, trauma surgeons, anaesthetists, nurses and radiographers to deliver a safe and efficient service to the critically ill patient (Fig. 5.1).

Elective Embolisation Procedures

Elective embolisation procedures encompass the minimally-invasive treatment of a diverse range of oncologic and non-oncologic conditions. This chapter will focus on the treatment of non-oncologic conditions including uterine fibroids, benign prostatic hyperplasia and gonadal vein embolisation (varicocoele and pelvic varicosities seen in pelvic congestion syndrome). Embolisation of tumours and vascular malformations will be covered in subsequent chapters. The embolic materials available to the Interventional Radiologist include specially designed devices such as metallic coils and vascular plugs, microparticles, gelatine sponges and liquid agents such as glue, thrombin or non-adhesive liquid embolics (ethylene vinyl alcohol copolymer).

A prospective comparison of the performance and survival of two different tunnelled haemodialysis catheters: SplitCath® versus DuraMax®

Background Despite their well-recognised shortcomings, haemodialysis catheters (HDCs) remain an important form of haemodialysis access for many patients. There are several HDCs commercially available, each differing considerably in design, which is known to significantly influence performance and survival. We sought to determine which of two tunnelled HDCs, DuraMax® (Angiodynamics, NY, USA) or SplitCath® (MedComp, PA, USA) delivers the best performance, safety and reliability for dialysis patients. Methods Eighty-six patients were prospectively randomised to receive either DuraMax® (DM) or SplitCath® (SC). Outcomes included: (i) mean flow rates (mL/min) averaged over the first 10 weeks of dialysis, and urea reduction ratio (URR); and (ii) long-term catheter survival with appraisal of any events leading to catheter dysfunction and early removal. Results Median flow rates (interquartile range) in the DM and SC groups were 321 (309-343) and 309 (294-322) mL/min, respectively (p = 0.002). URR values for the DM and SC groups were 71 (65-76) and 74 (70-78), respectively, (p = 0.094). There was no significant difference in long-term survival or frequency of incidents that required early HDC removal (9/43 in the DM group, 5/43 patients SC). A slightly higher incidence of HDC dislodgement was noted in the DM group, although this study was not statistically powered to determine its significance. Conclusions We conclude that DM yields slightly higher flow rates in the first 10 weeks of dialysis, and a similar low incidence of complications and long-term survival for both DM and SC HDCs.