Introduction & objectives Endovenous stenting is the preferred treatment to restore venous outflow in acute deep vein thrombosis (DVT) and chronic venous obstruction (CVO), yet stent patency remains variable and predictors of dysfunction are lacking. The direction of thrombus propagation, descending from iliac to femoral veins or ascending from distal to proximal, may reflect distinct hemodynamic patterns. This study assessed whether thrombus direction independently influences long-term stent patency after iliofemoral venous stenting. Methodology A retrospective single-center study included patients who underwent iliofemoral venous stenting between 2015 and 2023. Thrombus direction was inferred from the chronological sequence of symptoms: ascending when distal pain, swelling, or tightness extended proximally toward the thigh or groin; descending when proximal discomfort (pelvic, lumbar, or inguinal) preceded distal edema. Patients were stratified by thrombus direction and chronicity. The primary endpoint was primary stent patency, defined as uninterrupted flow without reintervention. Kaplan-Meier analysis compared patency between groups. Results Among 141 patients, 59 (42%) had ascending and 82 (58%) descending thrombosis, including acute and chronic cases. Descending thrombosis occurred in younger patients (P=0.023) and more often on the left side (P=0.039). Kaplan–Meier analysis showed higher cumulative primary patency for descending thrombosis, particularly in acute cases (log-rank P=0.036), while in chronic obstruction the trend was non-significant (P=0.067). Survival curves remained separated over time, indicating more durable stent performance in descending thrombosis. Discussion Descending thrombosis likely reflects localised iliac obstruction with preserved distal inflow, providing favorable hemodynamics for stent durability. Conversely, ascending thrombosis often involves valve-bearing femoropopliteal segments, causing reflux, venous hypertension, and inflow reduction — factors promoting restenosis. Thrombus direction thus represents a simple, clinically relevant determinant of stent outcome. Conclusion Thrombus propagation direction significantly influences stent patency. Descending thrombosis is associated with superior long-term results and may inform procedural planning, patient counseling, and post-stenting surveillance.

Chronic venous obstruction affects thousands worldwide and may lead to severe long-term complications such as post-thrombotic syndrome (PTS), marked by pain, swelling, skin changes, and venous ulcers. Endovenous stenting has become a cornerstone in restoring venous outflow, yet surveillance strategies to detect stent dysfunction early remain unstandardized. Doppler ultrasound (DUS), widely available and non-invasive, holds potential as a monitoring tool, but lacks validated markers to guide long-term follow-up. In this retrospective study of 161 patients and over 1,100 DUS assessments, we examined the predictive value of hemodynamic parameters for stent dysfunction and PTS. Stent patency was assessed using DUS or CT venography, and PTS was defined by a Villalta score ≥ 5 at last follow up. Hemodynamic parameters were compared using univariate and multivariable logistic regression models. Significant stent stenosis or occlusion (≥ 50%) was more common in younger patients (mean age 37.7 vs. 48.2 years, p = 0.003), with risk increasing by 4.4% per year decrease in age (OR = 1.044, p = 0.008). Loss of respiratory modulation was strongly associated with stent dysfunction (p < 0.001). Patients who had PTS at last follow up, had lower venous flow (297 vs. 463 mL/min, p = 0.047), reduced peak velocity (p = 0.003), and impaired respiratory modulation (p = 0.017). These findings support using DUS-derived parameters for early, non-invasive detection of stent-related complications to improve long-term patient outcomes.

Introduction et objectifs Le stenting endoveineux est un traitement permettant de prendre en charge les obstructions veineuses proximales chroniques et aigus avec pour objectif de limiter le syndrome post-thrombotique (SPT). Actuellement, l’absence de recommandations de protocoles standardisés pour le suivi échographique justifie une étude approfondie sur les indicateurs associés à la perméabilité des stents pour détecter précocement les complications. Méthodologie Une étude rétrospective a été menée incluant des patients avec un stenting veineux proximal post-thrombose veineuse profonde. Les paramètres Doppler mesurés incluaient la vélocité de pic, le débit veineux fémoral commun, le ratio de débit entre les veines stentées et non stentées controlatérales, ainsi que la modulation respiratoire des flux veineux. Les facteurs associés aux occlusions et/ou sténose≥50 % de stent et la présence d’un SPT ont été évalués. Résultats Cent soixante-deux patients ont été inclus dans l’étude, avec plus de 1100 écho-Dopplers évalués. Parmi eux, 30 patients ont présenté une sténose sévère du stent (≥50 %), avec une incidence significativement plus élevée chez les patients plus jeunes (p=0,002). La sténose sévère était corrélée à un risque accru d’embolie pulmonaire (p<0,001) et de complications majeures. En comparaison, 29 patients plus âgés ont développé un SPT, indiquant une progression du risque avec l’âge (p=0,02). La modulation respiratoire et le ratio de débit se sont révélé être des marqueurs associés à la perméabilité des stents, un ratio de débit réduit traduisant des asymétries de flux entre les veines stentées et non stentées, était associé à un risque important de sténoses. Discussion Ces résultats soulignent l’importance de la modulation respiratoire et du ratio de débit comme indicateurs spécifiques de surveillance pour les stents veineux. Un suivi rigoureux de ces paramètres s’avère particulièrement crucial pour les patients jeunes à risque de sténose sévère et pour les patients plus âgés, plus susceptibles de développer un SPT. Conclusion L’échographie Doppler, via l’analyse de la modulation respiratoire et du ratio de débit, pourrait optimiser la surveillance post-stenting, permettant une détection précoce des complications et améliorant les résultats cliniques des patients.

A standardized grading system for venous post-thrombotic syndrome (PTS) in cross-sectional imaging is lacking. This study aimed to develop and validate GRAVITS (GRavity of Venous Insufficiency in post-Thrombotic Syndrome scoring), a novel MRI-Venography/CT-Venography-based scoring system for venous obstruction, using a Delphi consensus. The Delphi consensus involved a survey distributed to 22 experts from the French Society of Cardiovascular Imaging. Data was reviewed and discussed in a consensus meeting, where a structured voting process established the GRAVITS system. A retrospective cohort of 40 PTS patients from three centers was analyzed. Twelve venous imaging specialists evaluated venous sequelae in axial MRV/CTV slices using GRAVITS. Inter-observer reproducibility was measured using Krippendorff’s alpha (α) and tested across vein types, imaging types, and vein pathological reference status. Intra-observer reproducibility was measured using weighted Kappa (κw). Correlations between GRAVITS scores and clinical scores (Villalta, CIVIQ-20) were assessed using Spearman tests. GRAVITS, defined as an ordinal score with four levels (“A: normal vein” to “D: totally occluded vein”), was evaluated in 851 venous segments (40 patients, median age 43.4, 55

PURPOSE:Pelvic congestion syndrome (PCS) is a major cause of chronic pelvic pain in women of reproductive age. It is often associated with pelvic venous insufficiency and venous dilatation of the ovarian and uterine veins, resulting in a variety of symptoms exacerbated by venous hypertension. Despite its prevalence, PCS lacks standardized diagnostic and management protocols, making effective treatment challenging. The purpose of this expert consensus statement was to summarize the opinions of French radiologists and gynecologists regarding the diagnosis, imaging, treatment, and management of PCS. MATERIALS AND METHODS:A working group of 14 expert radiologists and gynecologists from various French medical centers used a Delphi panel approach with several rounds of remote and face-to-face meetings to formulate and refine expert opinions based on the current literature and clinical expertise. These opinions were categorized according to diagnostic criteria, imaging techniques, therapeutic options, and follow-up protocols. RESULTS:The group formulated 72 initial opinions, and 65 were retained after rigorous evaluation for consensus. Key diagnostic tools include Doppler ultrasound for detection of venous reflux and magnetic resonance imaging for detailed assessment of venous anatomy. Endovascular embolization was highlighted as the primary treatment approach and recommended after thorough imaging evaluation. Noninvasive treatments and multidisciplinary care were also emphasized for comprehensive management. The expert opinion also included post-treatment follow-up to assess quality of life and symptom resolution. CONCLUSION:This structured consensus approach helped develop standardized expert opinions on management of, providing clear guidelines for diagnosis, treatment, and follow-up. These guidelines should improve clinical practice and patient care in the management of PCS.

Managing hepatocellular carcinoma (HCC) in patients with a transjugular intrahepatic portosystemic shunt (TIPS) is becoming increasingly common. This study aimed to evaluate the safety and efficacy of percutaneous thermal ablation for treating HCC in patients with TIPS. This retrospective longitudinal study was conducted at Nantes University Hospital. The main inclusion criteria were patients undergoing percutaneous thermal ablation for HCC. Patients with a pre-existing TIPS were included in the ‘TIPS group’. A 1:1 control group without TIPS, the ‘n-TIPS group’, was created for this case-control study. The primary endpoints were overall survival and progression-free survival over 12 months. Safety was assessed by comparing complications between the groups. Between 2008 and 2020, 371 patients underwent percutaneous thermal ablation for HCC. The ‘TIPS group’ included 34 patients (66 nodules), while 34 patients (84 nodules) were randomly assigned to the ‘n-TIPS group.’ Overall survival rates at 1 year were 97

We investigated the efficacy of iliofemoral venous stenting in women of childbearing age treated for post-thrombotic syndrome (PTS) and assessed the influence of pregnancy on stent occlusion. A retrospective analysis was conducted on women of childbearing age who underwent endovascular stenting for PTS due to chronic iliocava occlusion across 15 centers from 2009 to 2020. The study assessed pregnancy rates, primary patency rates, secondary patency rates, and clinical efficacy using the Villalta score for PTS severity and the Chronic Venous Disease Quality of Life Questionnaire – version 20 (CIVIQ-20), 6–12 months after the procedure. The impact of pregnancy on stent occlusion was analyzed using classical and multi-state survival analyses. Prophylactic low-molecular-weight heparin or fondaparinux was administered to patients during pregnancy until 6 weeks post-partum. In total, 211 women with PTS underwent endovascular stenting, with a median age of 31 years (range: 16–42). Following recanalization, significant improvements were observed in the Villalta score (p < 0.0001) and the CIVIQ-20 score (p < 0.0001). Thirty-seven (17.6 • The severity of post-thrombotic syndrome and the quality of life, as measured using the Villalta score and Chronic Venous Disease Quality of Life Questionnaire – version 20, respectively, showed significant improvements 6–12 months after iliofemoral venous stenting. • The occurrence of pregnancy after recanalization in women of childbearing age did not lead to a significant increase in the risk for stent occlusion.

Alors que l’importance des troubles veineux pelviens (PeVD) est de plus en plus reconnue, les progrès dans ce domaine ont été limités par l’absence de critères diagnostiques validés, d’un instrument de classification fiable. Les symptômes pelviens d’étiologie vasculaire exigent une approche holistique pour un diagnostic approprié. Les PeVD peuvent causer des douleurs pelviennes chroniques et des varices atypiques. Le diagnostic repose sur des études d’imagerie et leur corrélation avec la présentation clinique. La présentation suivante décrit la classification symptômes–varices–pathophysiologie (« SVP ») qui comprend trois domaines : symptômes (S), varices (V) et physiopathologie (P), le domaine physiopathologique englobant les domaines anatomique (A), hémodynamique (H) et étiologique (E) caractéristiques de la maladie du patient. L’instrument SVP définit avec précision les diverses populations atteintes de PeVD, une étape importante dans l’amélioration de la prise de décision clinique, le développement de mesures de résultats spécifiques à la maladie et identifier des populations de patients homogènes pour les essais cliniques. Nous détaillerons les implications thérapeutiques endovasculaires orientées par ces éléments cliniques, physiopathologiques et anatomiques.

Objective: This study assessed primary stent patency predictive factors in three groups of patients with history of lower limb (LL) vein thrombosis: non-thrombotic iliac vein lesion (NIVL), acute deep vein thrombosis (aDVT), and post-thrombotic syndrome (PTS). Methods: Consecutive patients from January 2014 to December 2020 with history of LL vein stenting from seven hospitals were included. All patients received an iliac or common femoral venous stent and had at least a six month follow up available with stent imaging. Anticoagulant and antiplatelet therapy strategies employed after venous stenting are reported and compared between groups. Results: This study included 377 patients: 134 NIVL, 55 aDVT, and 188 PTS. Primary patency was statistically significantly higher in the NIVL group (99.3%) compared with the PTS group (68.6%) (p < .001) and the aDVT group (83.6%) (p 1/4 .002). PTS patients received a statistically significantly greater number of stents (p < .001) and had more stents below the inguinal ligament (p < .001). Median follow up was 28.8 months (IQR 16, 47). Discontinuation of antiplatelet therapy at the last assessment was 83.6% for NIVL, 100% for aDVT, and 95.7% for the PTS group (p < .001). Discontinuation of anticoagulation therapy at the last assessment was 93.2% for NIVL, 25.0% for aDVT, and 70.3% for the PTS group (p < .001). The only predictor of worse primary patency in the aDVT group was long term anticoagulation before stenting. Conclusion: Patients with NIVL have better primary patency after venous stenting than patients with venous thrombotic disorders. Long term anticoagulation before stenting was the only factor associated with poorer primary patency in patients with aDVT.

Excellent outcomes of angioplasty/stenting for the post-thrombotic syndrome (PTS) have been reported, notably regarding objective criteria in the vast French SFICV cohort. Differences may exist between patient-reported and objective outcomes. We investigated this possibility by using validated scales because significative correlations are discordant in the literature between patency and patient-reported characteristics. Patient-reported outcomes seem to be a more consistent tool than radiologic patency for the diagnosis and follow-up of patients displaying PTS. We retrospectively reviewed the Villalta scale and 20-item ChronIc Venous dIsease quality-of-life Questionnaire (CIVIQ-20) scores recorded after endovascular stenting for PTS at 14 centres in France in 2009–2019. We also collected patency rates, pre-operative post-thrombotic lesion severity, and the extent of stenting. We performed multivariate analyses to identify factors independently associated with improvements in each of the two scores. The 539 patients, including 324 women and 235 men, had a mean age of 44.7 years. The mean Villalta scale improvement was 7.0 ± 4.7 (p < 0.0001) and correlated with the thrombosis sequelae grade and time from thrombosis to stenting. The CIVIQ-20 score was available for 298 patients; the mean improvement was 19.2 ± 14.8 (p < 0.0001) and correlated with bilateral stenting, single thrombosis recurrence, and single stented segment. The objective gains demonstrated in earlier work after stenting were accompanied by patient-reported improvements. The factors associated with these improvements differed between the Villalta scale and the CIVIQ-20 score. These results proved that clinical follow-up with validated scores is gainful in patients treated for PTS thanks to a mini-invasive procedure.

To report the effectiveness of pharmacomechanical catheter-directed thrombolysis (PCDT) in the management of acute iliofemoral deep venous thrombosis (DVT) via the jugular vein using a slow rotation and large-tip device (SRD) in a large cohort of patients. From 2011 to 2021, 277 patients (mean age 45 years, 59.2

(1) Background: Bronchial artery embolization has been shown to be effective in the management of neoplastic hemoptysis. However, knowledge of pulmonary artery embolization is lacking. The aim of this study was to evaluate the safety and efficacy of pulmonary artery embolization in patients presenting with hemoptysis related to lung tumors. (2) Methods: This retrospective study reviewed all consecutive patients with cancer and at least one episode of hemoptysis that required pulmonary artery embolization from December 2008 to December 2020. The endpoints of the study were technical success, clinical success, recurrence of hemoptysis and complications. (3) Results: A total of 92 patients were treated with pulmonary artery embolization (63.1 years ± 9.9; 70 men). Most patients had stage III or IV advanced disease. Pulmonary artery embolization was technically successful in 82 (89%) patients and clinically successful in 77 (84%) patients. Recurrence occurred in 49% of patients. Infectious complications occurred in 15 patients (16%). The 30-day mortality rate was 31%. At 3 years, the survival rate was 3.6%. Tumor size, tumor cavitation and necrosis and pulmonary artery pseudoaneurysm were significantly associated with recurrence and higher mortality. (4) Conclusions: Pulmonary artery embolization is an effective treatment to initially control hemoptysis in patients with lung carcinoma, but the recurrence rate remains high and overall survival remains poor.

Purpose: The purpose of this study was to evaluate whether concomitant left gastric vein embolization (LGVE) during transjugular intrahepatic portosystemic shunt (TIPS) for acute variceal hemorrhage could reduce the risk of bleeding recurrence. Material and method: A national multicenter observational study was conducted in 14 centers between January 2019 and December 2020. All cirrhotic patients who underwent TIPS placement for acute variceal bleeding were included. During TIPS procedure, size of left gastric vein (LGV), performance of LGVE, material used for LGVE and portosystemic pressure gradient (PPG) before and after TIPS placement were collected. A propensity score for the occurrence of LGVE was calculated to assess effect of LGVE on rebleeding recurrence at six weeks and one year. Results: A total of 356 patients were included (mean age 57.3 +/- 10.8 [standard deviation] years; 283/356 [79%] men). Median follow-up was 11.2 months [interquartile range: 1.2, 13.3]. The main indication for TIPS was pre-emptive TIPS (162/356; 46%), rebleeding despite secondary prophylaxis (105/356; 29%), and salvage TIPS (89/356; 25%). Overall, 128/356 (36%) patients underwent LGVE during TIPS procedure. At six weeks and one year, rebleeding-free survival did not differ significantly between patients who underwent LGVE and those who did not (6/128 [5%] vs. 15/228 [7%] at six weeks, and 11/128 [5%] vs. 22/228 [7%] at one year, P = 0.622 and P = 0.889 respectively). A total of 55 pairs of patients were retained after propensity score matching. In patients without LGVE, the rebleeding rate was not different from those with LGVE (3/55 [5%] vs. 4/55 [7%], P > 0.99, and 5/55 [9%] vs. 6/55[11%], P > 0.99, at six weeks and one year respectively). Multivariable analysis identified PPG after TIPS placement as the only predictor of bleeding recurrence (haz-ard ratio = 1.09; 95% confidence interval: 1.02-1.18; P = 0.012). Conclusion: In this multicenter national real-life study, we did not observe any benefit of concomitant LGVE during TIPS placement for acute variceal bleeding on bleeding recurrence rate. (c) 2023 Societe francaise de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Rationale and ObjectivePercutaneous thermal ablative technique is a common radiological procedure for malignant lesions treatment. Controlled assisted ventilation during general anesthesia is the usual mode of ventilation, but high-frequency jet ventilation (HFJV) can be a helpful alternative for the operator. The objective was to evaluate the safety of HFJV during thermal ablation procedures.Materials and MethodsThis monocentric prospective analysis included adult patients undergoing percutaneous thermal ablation procedures for abdominal tumor performed under HFJV. Procedures with a transpulmonary path were excluded. The primary outcome was the incidence of respiratory complications. Secondary outcomes included gas exchange modifications (hypercapnia, hypoxemia, pulmonary atelectasis) and the incidence of barotrauma.ResultsSixty patients were included during the study period. The mean duration time was 88 min. All procedures went according to the protocol and there was no respiratory complication. There was no barotrauma event. Three patients had an exhaled capnia above 45 mmHg at the end of the procedure which normalized within 10 min of conventional ventilation.ConclusionHFJV during thermal ablation procedures is safe regarding gas exchange and barotrauma. This technique could be an interesting alternative to conventional ventilation during image-guided thermal ablation procedures.Clinical Trials databaseThis study was registered in Clinical Trials database (NCT04209608).

L’ensemble des techniques d’imagerie permet d’objectiver la présence de varices pelviennes sous réserve que l’opérateur en connaisse le caractère possiblement symptomatique et sache les décrire. L’échographie reste le premier examen à considérer pour tout bilan pelvien. Elle permet le diagnostic des lésions organiques comme la visualisation des varices et leur évaluation dynamique. L’échographie périnéale complémentaire de l’exploration des membres inférieurs permet de décrire précisément la disposition des émergences pelviennes. Le scanner est un bon outil d’évaluation vasculaire global mais reste un examen irradiant, et mal contrasté à cet étage, il ne permet pas une bonne évaluation des lésions utérines et gonadiques notamment. L’IRM est un excellent outil d’évaluation pelvienne et vasculaire, complémentaire de l’échographie. Elle permet un bilan complet de l’anatomie veineuse de l’étage rénal aux émergences périnéales. À l’étage pelvien quelques séquences dédiées permettent la détection des diagnostics différentiels dans le cadre de douleurs chroniques. Pour chaque technique, la performance diagnostique est étroitement liée aux connaissances qu’a l’opérateur des pathologies à rechercher selon les symptômes, permettant une technique d’exploration adaptée à chaque situation. L’interprétation des images sera dans chaque cas intimement corrélée à la clinique.

Les compressions des racines/nerfs ne génèrent pas forcément de douleurs, comme le démontrent l’indolence de nombreuses sténoses lombaires et certains conflits disco-radiculaires. Les radiculalgies et douleurs des syndromes canalaires pourraient, donc, surtout résulter d’œdèmes induits par des stases veineuses autour des ganglions spinaux, racines et nerfs, peu ou non visibles sur l’imagerie. Cette revue recense les arguments en faveur de cette congestion des vasa-nervorum dans la pathogénie des radiculalgies, tant dans le contexte des sténoses lombaires et hernies discales obstruant les veines radiculaires, mais aussi du fait d’autres sources de stase dans les plexus veineux intra- et péri-rachidiens (grossesse, atrésie ou thrombose de la veine cave, hypertension portale, varices épidurales, fistules artérioveineuses, hémangiomes vertébraux). Sont également évoquées les stases veineuses autour du tronc du sciatique (syndromes nutcracker et de May–Thurner, veines glutéales supérieures et inférieures). La prise de conscience que des stases veineuses peuvent suffire à induire des radiculalgies/plexopathies/névralgies : i) remet en question la notion que les compressions sont indispensables à leur induction, une simple traction durable par adhérences du nerf dans deux sites s’écartant trop pouvant aussi suffire à oblitérer les vasa-nervorum ; ii) incite à optimiser des techniques d’IRM permettant de visualiser aussi bien ces vaisseaux que le faisaient les phlébographies lombaires ; iii) pourrait inciter à prévenir les adhérences/arachnoïdites secondaires à la fuite de fibrine survenant lors des stases veineuses aiguës ; iv) fait espérer que des traitements comme des injections hyper-sélectives d’activateur du plasminogène puissent à l’avenir prévenir ou faire régresser les microthromboses survenant dans les veines épidurales/intradurales.

Compression of roots/nerves can disrupt some of their functions, but does not necessarily cause pain. This is illustrated by the frequency of nearly asymptomatic spinal stenosis or disc herniations. In fact, pain of radiculopathies (and nerve entrapments) may mostly be the consequence of intraneural oedema induced by microscopical venous stasis around roots/spinal ganglia (or nerves) not or poorly shown by imaging. This narrative review first lists arguments for a role of congestion of vasa-nervorum in the pathophysiology of radiculopathies, including those induced by disc herniation and spinal stenosis, but also other sources of overpressures in spinal venous plexuses (pregnancy, vena cava atresia and thrombosis, portal hypertension, epidural varices, arterio-venous fistula, vertebral hemangioma or hemangioblastoma). It also details sources of venous congestion around nerves outside the spine, from pelvis (May-Thurner syndrome, Nut-cracker syndrome) to buttocks (superior and inferior gluteal veins), and even thighs and legs. A better recognition of a preeminent role of venous congestion in radiculopathies, plexopathies, and nerve entrapments, should have major consequences: (i) discard the dogma that compression is mandatory to induce root/nerve suffering, since root/nerve adherences in two locations can impair blood flow in vasa-nervorum through root/nerve stretching; (ii) implementation of sensitive techniques to visualise impingement of blood flow around or within roots and nerves; (iii) better prevention of roots/nerves adherence, or arachnoiditis induced by extravascular fibrin deposition secondary to venous stasis.; (iv) optimizing treatments dampening clot formation and/or extravascular fibrin leakage in the intradural/peridural spaces, or around roots/nerves, like guided injection of tissue plasminogen activator.

Abstract Background Recent guidelines advocate a step-up approach for managing suspected infected pancreatic necrosis (IPN) during acute pancreatitis. Nearly half the patients require secondary necrosectomy after catheter drainage. Our primary objective was to assess the external validity of a previously reported nomogram for catheter drainage, based on four predictors of failure. Our secondary objectives were to identify other potential predictors of catheter-drainage failure. We retrospectively studied consecutive patients admitted to the intensive care units (ICUs) of three university hospitals in France between 2012 and 2016, for severe acute pancreatitis with suspected IPN requiring catheter drainage. We assessed drainage success and failure rates in 72 patients, with success defined as survival without subsequent necrosectomy and failure as death and/or subsequent necrosectomy required by inadequate improvement. We plotted the receiver operating characteristics (ROC) curve for the nomogram and computed the area under the curve (AUROC). Results Catheter drainage alone was successful in 32 (44.4%) patients. The nomogram predicted catheter-drainage failure with an AUROC of 0.71. By multivariate analysis, catheter-drainage failure was independently associated with a higher body mass index [odds ratio (OR), 1.12; 95% confidence interval (95% CI), 1.00–1.24; P = 0.048], heterogeneous collection (OR, 16.7; 95% CI, 1.83–152.46; P = 0.01), and respiratory failure onset within 24 h before catheter drainage (OR, 18.34; 95% CI, 2.18–154.3; P = 0.007). Conclusion Over half the patients required necrosectomy after failed catheter drainage. Newly identified predictors of catheter-drainage failure were heterogeneous collection and respiratory failure. Adding these predictors to the nomogram might help to identify patients at high risk of catheter-drainage failure. ClinicalTrials.gov number: NCT03234166.