To compare post-procedural changes in hemoglobin (HGB) following catheter-directed thrombolysis (CDL) vs. large-bore aspiration thrombectomy (LBAT) of acute pulmonary embolism (PE). Single-center retrospective review of acute high and intermediate-risk PE patients treated with CDL or LBAT between 12/2009 and 9/2023. The LBAT (FlowTriever, Inari Medical, Irvine, CA) group was divided according to usage of an autotransfusion device (ATD) (FlowSaver, Inari Medical). Patients were excluded if they received systemic tPA, had both LBAT and CDL in the same procedure, or had missing HGB data. There were 166 patients in the CDL group (56±15 years). The LBAT group included patients treated without an ATD (LBAT, n=58, 61±16 years) and with ATD (LBATw, n=47, 62±15 years). The age difference was significant (p=.01). The number of patients with intermediate risk PE was 91.6%, 89.6% and 87.3% in the CDL, LBAT and LBATw groups, respectively (p=.2). The remaining patients in each group had high risk PE. LBAT was performed using 16F, 20F and 24F catheters. The mean CDL duration was 25±7 hours, with a mean tPA dose of 27±5 mg. Endpoints included change in HGB between pre- and post-procedural measurements, as well as hemorrhagic adverse events (AE). The mean HGB changes in the CDL, LBAT, and LBATw groups were -1.3±1.3 g/dL, -1.6±0.98 g/dL, and -1.1±0.9 g/dL, respectively (p=.1). The estimated blood loss (EBL) during LBAT was 275.3±109.5 mL without ATD and 93.5±7 mL with ATD (p ≤ .001). The last HGB prior to initial procedure was not significantly different between groups (p=.5), with 13.2±2 g/dL, 13.3±2.4 g/dL, and 12.8±2.2 g/dL in the CDL, LBAT, and LBATw groups, respectively. The first HGB after the final procedure (< 24hrs) was not significant between groups (p=.7). GUSTO minor hemorrhagic AE rate was 3.6% in CDL, 12.1% in LBAT, and 14.9% in LBATw (p=.01). There were 1.2%, 3.4%, and 6.4% moderate hemorrhagic AE in the CDL, LBAT, and LBATw groups, respectively (p=.1). There were 1.2% major hemorrhagic AE in the CDL group and none in either LBAT group (p=.5). Blood transfusions were administered to 1.2%, 3.5% and 6.4% of patients in the CDL, LBAT and LBATw groups, respectively (p=.8). There were no procedure-related deaths in any group. There was no significant difference in post-procedural HGB change between CDL and LBAT regardless of usage of an ATD. There was significantly lower EBL in the LBAT group using ATD. There were more minor hemorrhagic AE in the LBAT groups. Moderate and severe AE rates were not different between the groups.

Effective management of type II endoleaks requires technical proficiency in multiple catheterization techniques depending on the supply and complexity of the endoleak. While the most commonly used access routes remain the transarterial and translumbar approaches, novel approaches such as transcaval access are increasingly being used in cases where the traditional techniques are unsuccessful or inadequate. The perigraft approach is an alternative novel option for endoleak embolization, which involves catheterization of the aneurysm sac between the common iliac artery and endograft. Our study aims to determine safety and effectiveness of the perigraft technique for embolization of type II endoleaks. Single-center retrospective review from 2014 to 2020 of 24 consecutive patients (12.5% female, mean age of 80.1 ± 6.4 years) who underwent 28 type II endoleak embolization procedures via a perigraft approach. Endpoints included technical success of perigraft catheterization, technical success of endoleak embolization, reintervention, freedom from AAA growth at follow-up, and adverse events. Technical success of perigraft catheterization and endoleak embolization were 92.9% and 89.3%, respectively. A combined transarterial and perigraft approach was employed in 30.8% (n = 8/26). Ethylene vinyl alcohol copolymer (Onyx) and coils were used in 92.9% and 46.4% cases, respectively. Freedom from AAA growth occurred in 85% (n = 17/20). Reintervention occurred in 20.8% (n = 5), including 4 repeat perigraft catheterizations. There were 2 SIR minor adverse events including a groin hematoma and dyspnea in a COPD patient. One major adverse event not related to the procedure was recorded involving an admission for atrial fibrillation and urinary retention. During follow up, 1 patient had AAA rupture 20 months after the successful index procedure requiring proximal snorkel extension and endograft relining. The 30-day mortality rate was 0. No type Ib endoleaks developed as a result of perigraft catheterization. The perigraft approach is safe and effective catheterization technique for embolization of type II endoleaks and can replace the translumbar and transcaval approaches in many cases with the advantage of not requiring sac puncture. Like the transcaval approach, it can be performed in a supine patient from a transfemoral approach and can be combined with other approaches if required. The perigraft approach is a useful addition to the armamentarium of catheterization techniques of type II endoleaks.

PURPOSE:This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR).METHODS:A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events.RESULTS:The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded.CONCLUSION:The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

To compare the effectiveness and safety percutaneous Cryoablation (Cryo) and of microwave ablation (MWA) for the treatment of renal masses. A retrospective review was performed of renal mass ablation procedures between 2008 and 2020, which found 245 Cryo procedures and 94 MWA procedures (Age: 67.4 ± 12.9 vs. 67.8 ± 11.3 years, P = .8, Female: 37.6% vs. 34%, P = .6, respectively). Among these, there were 76 cryo procedures and 45 MWA procedures that were performed for biopsy proven renal cell carcinoma (RCC) (Age: 69.4 ± 10.7 vs. 66.5 ± 11.3 years, P = .2, Female: 26.3% vs. 28.9%, P = .8, respectively). The mRENAL and MC2 scores were similar between both groups, including between the proven RCC subgroups. Technical success was defined as the ablation zone encompassing mass and >5-mm margin, and along with adverse events, was reported for the entire cohort. Primary technical success (defined as no residual enhancement on first follow-up imaging) and time local progression were calculated for the RCC cohort. The technical success rate was similar (94.3% vs. 97.9%, P = .3) when comparing the entire cohort for Cryo and MWA, respectively, and in the RCC subgroups (93.4% vs. 97.8%, P = .4). Mean follow-up duration was 28.4 ± 24.6 months for Cryo and 33.5 ± 19.2 months for MWA (P = .2). Primary technical success was significantly higher (P = .049) with MWA (97.7%) than for Cryo (85.5%). The time to local progression was 74.8 months for a single patient in the Cryo RCC group. Reintervention rate for residual tumor or recurrence was higher in the Cryo RCC group than the MWA RCC group (12.5% vs. 2.3%, P = .09). The Cryo group had significantly more hemorrhagic complications (within 30 days of procedure) than the MWA group (25/239 (10.5%) vs. 3/94 (3.2%), P = .03). Injury to the collecting system occurred more commonly in the MWA group (6.4% vs. 2.1%, P = .08). Procedure related readmission rate was similar in the Cryo and MWA groups (4.1% vs. 4.3% respectively, P = .7). Percutaneous microwave ablation appears to have higher primary technical success, possibly resulting in less reinterventions for residual or recurrent RCC lesions. MW ablation resulted in more collecting system injuries but less hemorrhagic complications.

Purpose: To establish transhepatic percutaneous cryoablation of renal masses as a safe and effective approach.Materials and Methods: A retrospective review of records from 3 separate medical centers was performed identifying 23 patients (median age, 63 years [range 41-84 years]; 12 female [52.2%]) who underwent percutaneous transhepatic cryoablation for right-sided renal masses (median diameter, 2.4 cm [1.5-4.6 cm]) between 2008 and 2021. The median radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines (RENAL) nephrometry score was 5 (4-10). Adverse events (AEs) were classified according to the Society of Interventional Radiology (SIR) and Clavien-Dindo (CD) classifications. Primary and secondary technical success of each procedure were recorded.Results: Renal cell carcinoma (of any subtype) was found in 10 (71.5%) of the 14 masses that were biopsied. Tract cautery was used for transhepatic probes in 14 (63.6%) of 22 procedures. Three (13%) of 23 patients had postprocedural AEs. Two cases (8.6%) were hemorrhages related to transhepatic access (SIR moderate-2, CD 2; SIR severe-3, CD 1), and 1 case (4.4%) was related to bowel injury (SIR severe-3, CD 3a). There were no instances of pneumothorax. Tract cautery was used in the procedures that resulted in an AE. Primary technical success was achieved in 84.2% (16/19) of procedures, whereas secondary technical success was achieved in 2 additional patients. The secondary technical success rate was 94.7% (18/ 19). Four patients did not have imaging follow-up.Conclusions: The transhepatic approach to cryoablation of renal masses appears to have an acceptable safety profile and technical success rate. Larger studies, preferably comparative to nontranshepatic approach, are recommended.

PURPOSE:To evaluate the effect of catheter directed thrombolysis (CDT) on heart rate (HR) in patients with sinus tachycardia and acute pulmonary embolism (PE).METHODS:A retrospective chart review was performed for patients who underwent CDT with tPA for acute massive or submassive PE between 12/2009 and 2/2020. Included were patients who presented with tachycardia at the time of initiation of CDT. Patients with chronic PE, atrial fibrillation, beta blocker therapy, adjunctive endovascular therapy, systemic thrombolysis, or who expired before conclusion of CDT were excluded. HR was measured approximately every hour during CDT. Graphs were plotted of HR as a function of CDT duration. Two interventional radiologists identified the point of plateau (POP) on the graph where CDT had maximized its benefit in decreasing the patient's HR. Discrepancies were adjudicated by a third interventional radiologist and the median of the 3 measurements was selected. The primary endpoint was the duration of CDT from initiation until the POP.RESULTS:48 patients were included (52.5 ± 14.7 years, 56.3% female). The POP occurred after 13.1 ± 6.1 hours, by which point HR had been reduced from 110 ± 9.2 bpm to 88 ± 10.6 bpm. Sinus tachycardia was not resolved in 10 patients even though they achieved maximal improvement in HR after 11.3 ± 6.7 hours.CONCLUSION:Patients presenting with sinus tachycardia related to acute PE achieved maximal, sustained reduction in heart rate from CDT, after approximately 13 hours of infusion. Patients who did not resolve their tachycardia by that point in time were unlikely to resolve it by the conclusion of CDT.

To evaluate the safety and effectiveness of the Protégé nitinol self-expanding stent for the treatment of iliofemoral veno-occlusive disease. A retrospective review was performed of 376 (284 left, 92 right) Protégé stents in 212 limbs of 183 patients (mean age: 53 ± 17 years, 52% female) treated for iliofemoral veno-occlusive disease between 2011 and 2018. Binary patency was assessed with duplex ultrasound and calculated by Kaplan Meier analysis. Clinical outcomes were evaluated by clinical-etiology-anatomy-pathophysiology (CEAP) classification and Villalta scores. Adverse events were recorded and categorized per Society of Interventional Radiology reporting standards. Of the 212 limbs, 125 presented with acute thrombosis and 28 with chronic thrombosis requiring thrombectomy (n = 44), catheter directed thrombolysis (n = 32), or both (n = 77). Fifty-nine limbs were non-thrombotic. Mean follow-up time was 11.44 ± 11.37 months. Kaplan Meier analysis revealed a primary limb-level patency of 92.3%, 88.6%, 86.9% and 86.9% at 6, 12, 24 and 36 months, respectively. CEAP and Villalta scores improved from a median of C3 (range: 0–6) to C1 (0–5) (p < 0.001) and from a mean of 13.4 ± 7.5 to 5.3 ± 4.9 (p < 0.001), respectively. Nine minor and 2 major adverse events were recorded. Endovascular treatment of iliofemoral veno-occlusive disease with the Protégé self-expanding stent appears to have good mid-term patency. Level 4, Case Series

Purpose: To evaluate whether extended catheter-directed thromholysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE). Materials and Methods: This was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y +/- 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%). Results: Patients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg +/- 14.3 vs 22.6 mg +/- 9.9, P < .001) to achieve a similar final Miller score (6.4 +/- 3.8 vs 7.6 +/- 3.9, P = .1) and a similar reduction in systolic PAP (-14.4 mm Hg +/- 10.2 vs -12.6 mm Hg +/- 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 +/- 5.8 vs 19 +/- 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours +/- 5.5 vs 20 hours +/- 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 +/- 5 vs 7.6 +/- 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 min Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7). Conclusions: Patients presenting with higher art rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.

To evaluate the effect of adjunctive endovascular therapy on oxygen requirements at time of discharge for patients with acute pulmonary embolism (PE) Retrospective review of consecutive patients who presented with acute massive or submassive PE between January 2017 and August 2018 was performed. Oxygen requirements at discharge were compared with oxygen requirements at admission. Patients who did not survive the index admission were excluded. The control group included patients who were treated with anticoagulation (AC), while the study group included patients who underwent adjunctive EVT, including catheter-directed thrombolysis and/or aspiration thrombectomy. The primary endpoint was discharge with new or increased oxygen demand when compared with their preadmission status. A total of 195 patients were included in the cohort of which 147 (75.4%) were in the AC group and 48 (24.6%) in the CDT group. Aside from a higher rate of malignancies in the AC group (19% vs 6.3%, P = .04), demographics were similar between the groups. Initial PESI score and rate of administration of systemic tPA were slightly higher in the AC group (92.7 ± 36.1 vs 87.9 ± 31, P = .6 and 8.2% vs 2.1%, P = .19, respectively), but these did not reach statistical significance. A total of 31 patients (15.9%) were discharged with new or increased oxygen requirements, including 19.7% (29 of 147) in the AC group and 4.2% (2 of 48) in the EVT group, which was a statistically significant difference (P = .01). Adjunctive endovascular therapy appears to significantly decrease oxygen requirements at time of discharge when compared to anticoagulation alone in patients presenting with acute pulmonary embolism.

The article by Graif et al ( 1 Graif A. Patel K.D. Wimmer N.J. et al. Large bore aspiration thrombectomy versus catheter directed thrombolysis for acute pulmonary embolism: a propensity score-matched comparison. J Vasc Interv Radiol. 2020; 32 (•••–•••) PubMed Google Scholar ) summarizing a single-center retrospective comparative study of patients treated with catheter-directed thrombolysis (CDT) versus large-bore aspiration thrombectomy (LBAT) using the FlowTriever device (Inari Medical, Irvine, California) for acute massive/submassive pulmonary embolism (PE) is of substantial interest to physicians who manage PE. On one hand, this article is well written, includes detailed data on patients treated with 2 different endovascular methods, and highlights the potential opportunity to improve PE care using multimodality therapy. On the other hand, comparing treatments in an unbiased way presents a difficult challenge for any retrospective study. This study’s methodologic limitations leave substantial uncertainty as to the validity of the authors’ conclusions and shine additional light into the yawning gap between current endovascular clinical practice and evidence-based medicine that puts patient safety first. Response to “Pulmonary Embolism: Putting the Horse Back in Front of the Cart”Journal of Vascular and Interventional RadiologyVol. 32Issue 3PreviewWe would like to thank Dr. Vedantham for commenting (1) on our manuscript: “Large-Bore Aspiration Thrombectomy (LBAT) versus Catheter-Directed Thrombolysis (CDT) for Acute Pulmonary Embolism (PE): A Propensity Score–Matched Comparison” (2), published in the December issue of JVIR. Such feedback is what propels science forward, as it hones our research techniques and improves the level of evidence upon which we base the care we offer to our patients. Full-Text PDF

PURPOSE:To compare effectiveness and safety of large-bore aspiration thrombectomy (LBAT) with catheter-directed thrombolysis (CDT) for treatment of acute massive and submassive pulmonary embolism (PE). MATERIALS AND METHODS:This retrospective review included patients with acute PE treated with LBAT or CDT using tissue plasminogen activator (tPA) between December 2009 and May 2020. A propensity score based on Pulmonary Embolism Severity Index class and PE severity (massive vs submassive) was calculated, and 26 LBAT cases (age 60.2 y ± 17.1, 14/26 women) were matched with 26 CDT cases (age 59.7 y ± 14.2, 14/26 women). RESULTS:The CDT group had 22.1 mg ± 8.1 tPA infused over 21.2 h ± 6.6. Both groups demonstrated similar initial and final systolic pulmonary artery pressure (PAP) (LBAT: 54.5 mm Hg ± 12.9 vs CDT: 54.5 mm Hg ± 16.3, P = .8, and LBAT: 42.5 mm Hg ± 14.1 vs CDT: 42.6 mm Hg ± 12.1, P = .8, respectively) and similar reductions in heart rate (LBAT: -5.4 beats/min ± 19.2 vs CDT: -9.6 beats/min ± 15.8, P = .4). CDT demonstrated a higher reduction in Miller score (-10.1 ± 3.9 vs -7.5 ± 3.8, P = .02). LBAT resulted in 1 minor hemorrhagic complication and 2 procedure-related mortalities, and CDT resulted in 1 minor and 1 major hemorrhagic complication. CONCLUSIONS:LBAT and CDT resulted in similar reductions of PAP and heart rate when used to treat acute PE. CDT reduced thrombus burden to a greater degree. Although hemorrhagic complications rates were not significantly different, the LBAT group demonstrated a higher rate of procedure-related mortality. Larger studies are needed to compare the safety of these techniques.

Purpose The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. Methods This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. Results Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses ( p < 0.001 for both). Conclusion The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Comparing the outcome measures and safety of endovascular therapy (EVT) with anticoagulation (AC) in the treatment of acute pulmonary embolism (PE) utilizing a Pulmonary Embolism Response Team (PERT). Retrospective review of medical records between January 2017 and August 2018 was performed to identify patients with acute massive or submassive PE who were evaluated by the PERT. Included were patients who received AC with or without EVT. Excluded were patients who were treated with IVC filter only. Analysis was performed comparing patients who received AC alone and those who received AC and EVT. A subgroup analysis was performed for patients who were initially admitted to the ICU comparing AC with or without EVT. A total of 207 patients were identified, 4 were excluded as they did not receive AC and were treated only with IVC filters. There were 153 patients in the AC group and 50 in the EVT group. The AC group was significantly older (64.7 ± 16.4 vs. 58.2 ± 16.2 years, P = 0.02) and had a shorter ICU stay (0.97 ± 2.6 vs. 1.4 ± 1.5 days, P <0.001), although only 35.9% (n = 55) of the AC group were admitted to the ICU (compared to 70% (n = 35) in the EVT group, P <0.001). The rate for initial admission to a stepdown unit was 45.8% for the AC group and 16% for the EVT group (P <0.001). There was a 7.2% major hemorrhagic complication rate in the AC group and 6% in the EVT group (P = 1). The minor hemorrhagic complication rate was 1.3% for the AC group and 0% for the EVT (P = 1). When comparing patients who were initially admitted to the ICU, age (61.7 ± 16.7 vs. 57.7 ± 16.9 years, P = 0.2) and ICU stay (2 ± 2.2 vs. 1.9 ± 1.5 days, P = 0.15) were not significantly different between the AC and EVT groups, respectively. The total hospital stay for the AC group in the subgroup analysis was 7.7 ± 10.2 days while the EVT group stay was 6.3 ± 7.4 (P = 0.2). For patients evaluated by the PERT, major hemorrhagic complication rates were not significantly different between AC and EVT, and for patients initially admitted to the ICU, the ICU length of stay was not significantly different.

Purpose: To evaluate the effect of catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) on plasma fibrinogen levels (PFLs) in the setting of acute pulmonary embolism (PE) and the relationship between PFL and hemorrhagic complications. Materials and Methods: A retrospective review of CDT procedures between 2009 and 2019 identified 147 CDT procedures for massive or submassive PE (55.8% males; age, 56.5 +/- 14.8 years; 90.5% submassive). All patients received therapeutic anticoagulation during CDT with unfractionated heparin (UFH) (69.4%) or low-molecular-weight heparin (LMWH. 30.6%) infusion. CDT was performed with ultrasound-accelerated thrombolysis (USAT) catheters (n = 98), conventional catheter-directed thromholysis (C('DT) catheters (n = 34), or a combination of both (n = 15). Results: There was a decrease (P = .007) of 15.1 +/- 69.4 mg/dl from the initial PFL (376.1 +/- 122.7 mg/dl) to the final PFL (361 +/- 118.7 mg/dl), which was measured after a mean of 24.1 +/- 11.7 hours with a mean tPA dose of 28.3 +/- 14.2 mg. The fibrinogen nadir was 327.6 +/- 107.1 mg/dl measured 13.4 +/- 10.3 hours after initiation of thrombolysis. Of patients with hemorrhagic complications (n = 6), initial, final, and nadir PFL were not significantly lower (P = .053, P = .081, and P = .086, respectively) than the remainder of the cohort. No significant difference was noted in initial and final PFL between the LMWH and UFH groups (P = .2 and P = .1, respe .lively) or between the CCDT and USAT groups (P = .5 and P = .9, respectively). The UFH group had a lower nadir PFL than the LMWH group (P = .03). Conclusions: Despite a significant drop in PFL during CDT for acute PE, this was not associated with hemorrhagic complications. These findings were not affected by the choice of anticoagulant or catheter delivery system.

To evaluate the point in time, during catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE), when thrombolytic therapy has maximized its yield in the improvement of tachycardia. A retrospective chart review was performed for patients who underwent CDT with tPA for acute PE between December 2009 and August 2019. Included were patients with acute massive and submassive PE who presented with tachycardia (heart rate [HR] ≥100) at the time of initiation of CDT. Patients with chronic PE, atrial fibrillation, concomitant beta blocker therapy, or who expired before conclusion of CDT were excluded. HR was measured every hour or less during CDT. Graphs were plotted of HR as a function of CDT duration. Two interventional radiologists (IR) independently identified the inflection point on the graph where CDT had maximized its benefit in decreasing the patient’s HR. Discrepancies were adjudicated by a 3rd IR and the median of the 3 measurements was selected. The primary endpoint was the duration of CDT from initiation until the inflection point. Chart review identified 175 consecutive cases of CDT of which 109 were excluded, yielding a final cohort of 66 cases (age: 52.6 ± 14.8 years, 53% males). Initial HR was 110.2 ± 9.8 b/min and final HR was 86.8 ± 10.2 b/min (P <0.001) after 29.1 ± 13.7 hours of CDT at a mean infusion rate of 0.6 ± 0.2 mg/hr per catheter for a total dose 30.1 ± 14.4 mg. The primary endpoint was achieved after 13.8 ± 8.2 hours at a mean HR of 86.5 ± 9.4. There was no significant difference between the HR at the inflection point and the final HR (P = 0.64). A subgroup analysis was performed to compare patients whose tachycardia had resolved at the end of CDT (n = 59) with those for whom tachycardia did not resolve (n = 7). Although the HR at the inflection point in the latter group remained ≥100 (100.3 ± 7.1 b/min vs. 84.9 ± 8.2 b/min, P <0.001), the time to the inflection point was similar (P = 0.435). Maximum improvement of acute PE related tachycardia was achieved after approximately 14 hours of infusion without further improvement in HR despite continued CDT. This temporal relationship was sustained in the subgroup of patients whose tachycardia did not resolve.

The axillary artery is a useful alternative to other antegrade access options, such as brachial or radial, as it is closer to the peripheral vasculature, tends to be relatively spared of severe atherosclerotic disease, and can accommodate larger sheath sizes. This study looks to evaluate the feasibility and safety of percutaneous axillary artery access for endovascular interventions in patients with peripheral arterial disease (PAD). A retrospective electronic record review was performed of all patients who underwent percutaneous axillary access for endovascular PAD interventions from April 2018 to August 2019. Patient demographics and medical comorbidities were collected. Each procedure was reviewed for access indication, technical success, complications, as well as sheath size and closure devices used. Twenty percutaneous axillary access procedures were performed on 18 patients with a mean age of 68 (44.4% male). All axillary artery punctures were performed under ultrasound guidance. Procedural indications included chronic limb ischemia (n = 8), acute limb ischemia (n = 6), visceral intervention (n = 1) and aortic intervention with snorkel (n = 3). Reasons for axillary access included need for antegrade approach in 15 cases, hostile groin in 2, and occluded or heavily calcified common femoral arteries in 3. Sheath sizes ranged from 5 to 8 French. Hemostasis was achieved with closure devices in all patients including Angio-Seal (Terumo, Tokyo, Japan) in 19 accesses and Mynx Grip (Cardinal Health, Dublin OH) in 1. There were no perioperative access-related complications including stroke, arterial occlusion or hematoma. Axillary artery access is a viable access strategy in complex endovascular interventions requiring an antegrade approach with larger sheath sizes. This technique appears to be a feasible, effective, and safe based on this limited cohort.

To evaluate the need for routine prophylactic postprocedural antibiotics (ABX) following uterine fibroid embolization (UFE) in the prevention of procedure-related endometritis. Patients undergoing UFE at a single center between January 2013 and September 2019 were enrolled in a retrospective cohort study and divided into two groups. The control group consisted of patients treated before January 2016, who were prescribed postprocedural oral Ciprofloxacin 500 mg BID for 7 days. The study group consisted of patients treated after January 2016, who were not routinely prescribed postprocedural ABX. Patient demographics, procedural details and 90-day follow-up data were collected. The primary endpoint was the rate of endometritis within 90 days post procedure. A total of 434 patients were identified, consisting of 241 in the control group and 193 in the study group. Patient demographics and procedural details were similar in both groups including the diameter of the dominant fibroid, total number of fibroids and total number of vials of embolic material administered (P = 0.12, P = 0.052, P = 0.13, respectively). 29/192 (15.1%) patients in the study group underwent UFE with Embozene particles (Boston Scientific, Marlborough, MA). All other patients underwent UFE utilizing Embosphere particles (Merit Medical Systems, South Jordan, UT). Four (1.7%) and 2 (1%) patients developed endometritis in the control and experimental groups, respectively. Of the cases of suspected endometritis, two patients went on to undergo emergent total abdominal hysterectomy, both of whom were in the control group. One patient in the study group underwent myomectomy of a prolapsing fibroid. All other cases of endometritis were treated with antibiotics alone. The difference in infection rates between the groups was not statistically significant (P = 0.69). Foregoing routine postprocedural ABX did not result in a significantly increased rate of procedure-related endometritis in this cohort. However, the cohort is under-powered to demonstrate non-inferiority of the study group, as the reported post-UFE infection rate is exceedingly low.

Report outcomes of below-the-ankle (BTA) revascularization in critical limb ischemia (CLI) and investigate the association of pedal arch patency with limb salvage. A single-center review was conducted of CLI patients undergoing BTA revascularization (2009-2018). Records were reviewed for demographics, comorbidities, technical details and wound healing. Postintervention arteriograms were classified as demonstrating a complete (CPA), incomplete (IPA) or absent (APA) pedal arch. Clinical endpoints included overall survival (OS), minor (ankle preserving) amputation-free survival (AFS) and major (above-the-ankle) AFS at 6- and 12-months following initial BTA intervention. Sixty consecutive Rutherford Class 5 and 6 patients underwent BTA revascularization with concurrent tibial (100%) and femoropopliteal (55%) endovascular therapy. The mean age was 69 years with 58% male, 82% diabetic, 56% CKD and 48% smoker. Angioplasty of 81 BTA lesions (53 dorsalis pedis, 16 pedal arch, 12 lateral plantar) was performed including adjunctive orbital atherectomy in 3 cases. The pedal loop technique was used in 6 cases and retrograde pedal access technique in 18 cases. The 6- and 12-month OS was 95% and 95% with 3 mortalities attributed to cardiac arrest on postop day 32, 44 and 59. The 6- and 12-month minor AFS rate was 63% and 63%, respectively, with average amputation at 0.9 months. The 6- and 12-month major AFS rate was 65% and 58%, respectively, with average amputation at 2.5 months. Mean follow-up was 18.3 months with 43% achieving complete wound healing on average at 7.4 months and 42% censored due to major amputation or death. Postintervention, there were 25 (42%) complete pedal arches (CPA) and 35 (58%) incomplete pedal arches. Subgroup analyses showed no significant difference (P > 0.05) between pedal arch status and demographics, comorbidities, OS, major AFS or wound healing rates. However, the association between CPA and minor AFS was significant (P < 0.001). This study establishes a CPA as predictive of avoiding minor amputation in patients with CLI. Further study to stratify angiographic endpoints and patient selection for BTA intervention is needed.