Shawn Sarin

Prophylactic inferior vena cava filters in high-risk bariatric surgery.

BackgroundBariatric patients are at significant risk for venous thromboembolism (VTE) and a subset may benefit from retrievable inferior vena cava filters (rIVCFs). Optimal VTE prophylaxis and a consensus on factors which make bariatric patients high risk have not been established. This study describes our experience with the use of rIVCFs in combination with chemoprophylaxis for high-risk bariatric surgery patients.MethodsA retrospective review was performed of high-risk patients bariatric surgery patients. Patients with a hypercoaguable condition, prior history of VTE, body mass index (BMI)u2009>u200955xa0kg/m2, and severe immobility were considered high risk. Patients underwent rIVCF placement and standard chemoprophylaxis. A venogram was performed at retrieval.ResultsForty-four patients, age of 48u2009±u200912xa0years and BMI of 58.4u2009±u20099.4xa0kg/m2 underwent gastric bypass with rIVCF placement. Follow-up was 204xa0days. One patient had a preoperative deep venous thrombosis (DVT). All patients received chemoprophylaxis and rIVCF placement. Indications for rIVCF were BMI (68%), prior VTE (30%), and immobility (2%). The operation was performed laparoscopically in all patients, and the mean operative time was 106.1u2009±u200921.6xa0min and length of stay was 3.1u2009±u20091.2xa0days. Postoperative venous duplex revealed two DVTs (5%). Retrieval was successful in 28 patients. No significant thrombus was found on venogram. Two minor complications of filter placement occurred. One mortality occurred due to MI, and no pulmonary emboli were clinically evident.ConclusionsrIVCFs in our cohort of high-risk bariatric surgery patients was associated with an acceptably low incidence of DVT (5%) and no clinically evident PE. Despite safe removal after long dwell times, previous data suggest that rIVCFs are associated with a higher incidence of VTE. Thus, filters, if placed, should be removed once the risk of VTE has passed. Larger multicenter studies are needed to truly identify long-term safety and efficacy of rIVCFs.

Vascular Closure Devices: Technical Tips, Complications, and Management

Vascular closure devices (VCDs) are used to obtain hemostasis at the vascular access site while limiting the need for manual compression. They have gained significant popularity since their introduction in the mid-1990s. In the past 20 years, there has been a multitude of different devices introduced with various mechanisms of action. Manual compression remains the gold standard but can be very time consuming and painful for the patient. VCDs are advantageous in that they can reduce time to hemostasis and patient recovery and improve patient comfort. However, a large number of catheter-based procedures are performed without these closure devices owing to lack of operator familiarity, risk of complications, and cost. Most VCDs are approved for arteriotomies between 5 and 8F, with 1 device approved for up to 21F. Major complications include infection and limb ischemia. This article provides an update on currently approved VCDs, a brief overview of the literature, and our institutional experience with these devices.

Radiologic Techniques and Effectiveness of Angiography to Diagnose and Treat Acute Upper Gastrointestinal Bleeding

The use of catheter-based techniques to treat upper gastrointestinal hemorrhage has evolved considerably over the past few decades. At present, the state-of-the-art interventional suites provide optimal imaging. Coupled with advanced catheter technology, the two may be used to manage and treat the patient with acute upper gastrointestinal hemorrhage. This article summarizes these techniques and, when possible, compares them with other methods such as surgery and endoscopy. The specific role of transcatheter embolotherapy is highlighted, alongside an additional discussion on pharmacologic infusion of vasopressin.

Endometrial Stromal Sarcoma Metastatic from the Uterus to the Inferior Vena Cava and Right Atrium.

Endometrial stromal sarcoma metastases usually occur within the pelvis and rarely involve the great vessels or the heart. We present the case of a 55-year-old woman who was referred for endovascular therapy to treat presumed thrombosis of the inferior vena cava. The suspected thrombus was recalcitrant to endovascular removal with use of an AngioVac venous drainage device. Results of an intraprocedural transvenous biopsy revealed the mass to be the intravascular extension of an endometrial stromal sarcoma. The patient underwent surgical excision of the tumor, and, shortly thereafter, a hysterectomy and salpingo-oophorectomy. This complex case highlights both the rarity of malignancy masquerading as caval thrombus and the importance of multispecialty collaboration.

Emergency endovascular stenting of the right iliac artery in a patient with secondary haemorrhage following transplant nephrectomy.

A patient presented with abdominal pain, hypotension and a retroperitoneal haematoma 5u2005days after transplant nephrectomy. Vascular injury sustained from transplant nephrectomy was repaired using endovascular techniques. Several known advantages to endovascular repair include: (1) intervention by a less invasive approach, (2) performance under local anaesthesia, (3) association with a shorter hospital stay and (4) reduction in morbidity and mortality. There were no infectious complications to the stent or the patient despite positive blood cultures obtained upon admission to the hospital. It was concluded that endovascular repair of an iliac artery used for kidney transplantation had favourable outcomes with respect to infection control and use of the vessel for future anastomosis.

Uterine Artery Embolization

Uterine artery embolization has become a significant interventional procedure that is xadperformed electively to treat symptoms related to symptomatic uterine leiomyoma. This chapter will deal with elective workup and management of uterine leiomyoma.

Venous thromboembolic disease: the use of "optional" inferior vena cava filters.

Approximately 140,000 to 200,000 patients die as a result of pulmonary embolism in the United States each year. If the diagnosis is made and therapy initiated, the mortality rate drops to 8%. Vena cava filters play a role in the management of patients with thromboembolic disease. Deployment of optional filters is changing practice paradigms.

Radiofrequency wire ‘power wire’ recanalization of calcified chronically occluded inferior vena cava

BackgroundRadiofrequency (RF) wire recanalization of short segments of central venous obstruction has been considered safe; however its use for recanalization of long segments of inferior vena cava (IVC) has not been reported.Case presentationA 55-year-old female with recurrent massive hematemesis was found to have systemic venous upper esophageal varices on endoscopy and an extensive chronic IVC occlusion on CT. Using both a percutaneous transhepatic and transfemoral approach IVC recanalization was performed. A snare was advanced to the cavo-atrial junction via transhepatic venous access. From the groin utilizing RF wire steerable guide sheaths, endovascular reconstruction of the IVC was performed. Post recanalization venography demonstrated patent stented IVC and marked decrease in the intraabdominal-pelvic collaterals. No recurrence of hematemesis was noted. After 6 months, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft.ConclusionsUsing appropriate techniques, Power wire recanalization of long occlusive segments of IVC can be safe and effective.