PURPOSE:Inferior vena cava (IVC) filter retrieval is recommended once mechanical protection against pulmonary embolism is no longer needed, ideally within 3 months of implantation. Building on prior work demonstrating low aggregate retrieval and substantial interfacility variation in the United States, this qualitative study aimed to describe barriers to timely IVC filter retrieval and surveillance processes and implementation strategies associated with exceptionally high (>95th percentile) retrieval rates. METHODS:This qualitative analysis was embedded within a mixed-methods positive deviance study. After risk-adjusted 1-year IVC filter retrieval rates were estimated for US hospitals serving Medicare beneficiaries, we examined four high-performing (retrieval rates 40%-74%) and three intermediate-performing (retrieval rates 7%-40%) hospitals. Semistructured interviews with surveillance personnel were analyzed using team-based rapid qualitative analysis focused on barriers to timely retrieval and high-retrieval surveillance processes. RESULTS:Barriers to timely retrieval were similar across sites and included dependence on individual clinicians to recognize implanted filters, labor-intensive tracking, difficulty obtaining provider input, challenges contacting patients, and competing clinical obligations. High-retrieval hospitals converged on several implementation strategies: an empowered nonphysician champion, protocolized surveillance, presumptive rather than open-ended communication regarding retrieval eligibility with involved clinicians, and reserving additional imaging or clinic evaluation for medically complex patients. Electronic medical record dashboards facilitated workflow but did not differentiate high- from intermediate-retrieval hospitals. CONCLUSIONS:High IVC filter retrieval seemed less dependent on a specific surveillance model than on how programs operationalized follow-up into routine care. Scalable interventions should prioritize accountable nonphysician ownership, risk-stratified escalation, protocolized reassessment, and streamlined clinician decision making, rather than registries or dashboards alone.

To investigate dosimetry-derived tumor-to-perfused normal tissue ratio (T/N) and corresponding clinical outcomes of patients receiving yttrium-90 radioembolization with glass microspheres for tumors identified as hypovascular on arterial-phase cross-sectional imaging. Patients with hypovascular lesions undergoing 90Y-RE at a single institution were included. Inclusion criteria were hypodense or hypoattenuating tumors relative to normal liver on arterial phase CT or MRI, excluding necrotic tumors. Pre-treatment planning mapping angiography 99mTc-MAA SPECT/CT was used for multi-compartment dosimetry for T/N estimation. The final cohort comprised 27 patients (median age 68, range 52-85 years), including 13 with Child-Pugh A cirrhosis, and ECOG status of 0 (n = 15), 1 (n = 11), and 2 (n = 1). Tumor types were hepatocellular carcinoma (n = 11), intrahepatic cholangiocarcinoma (n = 8), and liver metastases (n = 8). Treatment strategies included lobar (19%), lobar plus segmentectomy (22%), single segmentectomy (33%) and multiple segmentectomies (30%). The mean index tumor size was 5.7 ± 3.2 cm. Mean tumor and perfused normal tissue doses were 480 ± 314 Gy and 270 ± 138 Gy, respectively. Median T/N ratio on planning SPECT/CT was 1.56 (range 0.28-4.79). Response assessments using mRECIST criteria for index lesions were complete response (41%), partial response (33%), stable disease (22%), and progressive disease (4%). Nine patients experienced Grade 1 adverse events (ALP, ALT, or AST serum markers) with no other adverse events. Calculated T/N ratios were greater than 1.00 for most patients with hypovascular tumors, indicating that tumor uptake of 90Y may be greater than perceived from arterial-phase cross-sectional imaging. Post-treatment follow-up demonstrated favorable outcomes for this patient population.

PURPOSE:To assess whether catheter-directed thrombolysis (CDT) treatment heterogeneity in the multicenter PEERLESS randomized controlled trial is associated with differences in pulmonary embolism (PE) clinical outcomes. MATERIALS AND METHODS:All PEERLESS CDT arm patients were eligible for post hoc analysis, excluding those treated with multiple CDT device types (n = 8), non-tissue plasminogen activator (tPA) thrombolytics (n = 10), or pharmacomechanical CDT (n = 12). Patients were grouped by treatment: ultrasound (US)-assisted thrombolysis or standard CDT (SCDT). Treatment protocols were assessed, and clinical, safety, and quality-of-life outcomes were compared at discharge/7 days, 24 hours, and/or 30 days. RESULTS:A total of 159 patients treated with US-accelerated CDT and 87 treated with SCDT were included. Longer mean treatment duration (12.4 hours vs 20.8 hours, P < .001), higher mean thrombolytic dose (17.2-mg tPA vs 23.4-mg tPA, P < .001), and more intensive care unit stays >24 hours (57.4% vs 80.5%, P < .001) were identified in the SCDT group. However, in-hospital outcomes were not different, including all-cause mortality (0.0% vs 1.1%, P = .35), intracranial hemorrhage (0.6% vs 0.0%, P = 1.00), major bleeding (5.7% vs 10.3%, P = .20), and clinical deterioration and/or bailout (5.0% vs 5.7%, P = .77). Right ventricular/left ventricular ratio reduction (19.9% vs 23.1%, P = .10) and respirations per minute (20.0 vs 19.9, P = .62) were not statistically significantly different at the 24-hour visit. Pulmonary Embolism Quality of Life (18.5 vs 23.0, P = .18) and EuroQol 5-Dimension 5-Level (0.84 vs 0.81, P = .85) were also not different at the 30-day visit. CONCLUSIONS:Treatment duration and tPA dose were significantly lower in patients treated with US-accelerated CDT; however, clinical outcomes did not differ significantly between US-accelerated CDT and SCDT. This suggests that the primary analysis of PEERLESS may be generalizable to tPA-based CDT treatment protocols currently in use.

Pregnancy considerably increases the risk of venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism. The treatment of these disorders poses unique diagnostic and therapeutic challenges, particularly in balancing maternal and fetal safety. Interventional radiology plays a critical role in the management of pregnancy-associated VTE through advanced imaging techniques and minimally invasive procedures such as catheter-directed therapy and inferior vena cava filter placement. This review explores the epidemiology, pathophysiology, and management strategies for VTE in pregnancy with special attention to interventional treatment strategies, emphasizing patient-centered care and multidisciplinary collaboration to optimize outcomes.

Pregnancy considerably increases the risk of venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism. The treatment of these disorders poses unique diagnostic and therapeutic challenges, particularly in balancing maternal and fetal safety. Interventional radiology plays a critical role in the management of pregnancy-associated VTE through advanced imaging techniques and minimally invasive procedures such as catheter-directed therapy and inferior vena cava filter placement. This review explores the epidemiology, pathophysiology, and management strategies for VTE in pregnancy with special attention to interventional treatment strategies, emphasizing patient-centered care and multidisciplinary collaboration to optimize outcomes.

BACKGROUND:There are a lack of randomized controlled trial data comparing outcomes of different catheter-based interventions for intermediate-risk pulmonary embolism. METHODS:PEERLESS is a prospective, multicenter, randomized controlled trial that enrolled 550 patients with intermediate-risk pulmonary embolism with right ventricular dilatation and additional clinical risk factors randomized 1:1 to treatment with large-bore mechanical thrombectomy (LBMT) or catheter-directed thrombolysis (CDT). The primary end point was a hierarchal win ratio composite of the following (assessed at the sooner of hospital discharge or 7 days after the procedure): (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) postprocedural intensive care unit admission and length of stay. Assessments at the 24-hour visit included respiratory rate, modified Medical Research Council dyspnea score, New York Heart Association classification, right ventricle/left ventricle ratio reduction, and right ventricular function. End points through 30 days included total hospital stay, all-cause readmission, and all-cause mortality. RESULTS:The primary end point occurred significantly less frequently with LBMT compared with CDT (win ratio, 5.01 [95% CI, 3.68-6.97]; P<0.001). There were significantly fewer episodes of clinical deterioration and/or bailout (1.8% versus 5.4%; P=0.04) with LBMT compared with CDT and less postprocedural intensive care unit use (P<0.001), including admissions (41.6% versus 98.6%) and stays >24 hours (19.3% versus 64.5%). There were no significant differences in mortality, intracranial hemorrhage, or major bleeding between strategies or in a secondary win ratio end point including the first 4 components (win ratio, 1.34 [95% CI, 0.78-2.35]; P=0.30). At the 24-hour visit, respiratory rate was lower for patients treated with LBMT (18.3 +/- 3.3 versus 20.1 +/- 5.1; P<0.001), and fewer had moderate to severe modified Medical Research Council dyspnea scores (13.5% versus 26.4%; P<0.001), New York Heart Association classifications (16.3% versus 27.4%; P=0.002), and right ventricular dysfunction (42.1% versus 57.9%; P=0.004). Right ventricle/left ventricle ratio reduction was similar (0.32 +/- 0.24 versus 0.30 +/- 0.26; P=0.55). Patients treated with LBMT had shorter total hospital stays (4.5 +/- 2.8 overnights versus 5.3 +/- 3.9 overnights; P=0.002) and fewer all-cause readmissions (3.2% versus 7.9%; P=0.03), whereas 30-day mortality was similar (0.4% versus 0.8%; P=0.62). CONCLUSIONS:PEERLESS met its primary end point in favor of LBMT compared with CDT in treatment of intermediate-risk pulmonary embolism. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with CDT, with no difference in mortality or bleeding. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05111613.

Objectives Timely retrieval of inferior vena cava (IVC) filters is recommended to reduce complications and optimize outcomes. This study aims to quantify facility-level variation in risk-adjusted IVC filter retrieval across US hospitals and to identify patient- and hospital-level factors associated with nonretrieval. Methods Medicare beneficiaries undergoing IVC filter implantation were identified in the 100% claims files for years 2016 to 2020. Facility-level variation in device retrieval was quantified using Bayesian hospital profiling. Patient- and hospital-level factors associated with nonretrieval were assessed using logistic regression, adjusting for diagnostic indication, comorbidities, and implantation year. Results IVC filters were implanted in 119,613 Medicare beneficiaries across 2,485 facilities. Retrieval rates were low: median 6.2% within 3 months and 14.8% within 1 year. Excluding deaths within 3 months (30.2%), retrieval ranged from 0% to 100% across facilities. Among high-volume hospitals (top 25th percentile, implanting ≥13 filters per year), 1-year risk-adjusted retrieval ranged from 0% to 74.5%, mean 20% ± 14.2% (positive skew 0.95). Patient factors associated with IVC filter nonretrieval included age > 80 years (odds ratio 2.98, 95% confidence interval [2.73-3.24]), Black race (1.62, [1.51-1.72]), and Hispanic ethnicity (1.45, [1.16-1.80]). Among hospital factors, nonteaching (1.45 [1.37-1.53]), small bed size (1.37 [1.24-1.50]), and safety-net (1.42 [1.34-1.50]) facilities were strongly associated with IVC filter nonretrieval. Discussion High mortality within 3 months of IVC filter implantation suggests opportunity to improve patient selection and, potentially, device type choice. There is large facility-level variance underlying low aggregate IVC filter retrieval nationally; a focus on standardizing device surveillance and identifying best practices from high-performing facilities is warranted.

OBJECTIVE:To compare the comparative effects of treatment with contemporary mechanical thrombectomy (MT) or anticoagulation (AC) on Villalta scores and post-thrombotic syndrome (PTS) incidence through 12 months in iliofemoral deep vein thrombosis (DVT). METHODS:Patients with DVT in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) randomized trial and the ClotTriever Outcomes (CLOUT) registry were included in this analysis. Both studies evaluated the effects of thrombus removal on the incidence of PTS. Patients with bilateral DVT, isolated femoral-popliteal DVT, symptom duration of >4 weeks, or incomplete case data for matching covariates were excluded. Propensity scores were used to match patients 1:1 who received AC (from ATTRACT) with those treated with mechanical thrombectomy (from CLOUT) using nearest neighbor matching on nine baseline covariates, including age, body mass index, leg treated, provoked DVT, prior venous thromboembolism, race, sex, Villalta score, and symptom duration. Clinical outcomes, including Villalta score and PTS, were assessed. Logistic regression was used to estimate the likelihood of developing PTS at 12 months. RESULTS:A total of 164 pairs were matched, with no significant differences in baseline characteristics after matching. There were fewer patients with any PTS at 6 months (19% vs 46%; P < .001) and 12 months (17% vs 38%; P < .001) in the MT treatment group. Modeling revealed that, after adjusting for baseline Villalta scores, patients treated with AC had significantly higher odds of developing any PTS (odds ratio, 3.1; 95% confidence interval, 1.5-6.2; P = .002) or moderate to severe PTS (odds ratio, 3.1; 95% confidence interval, 1.1-8.4; P = .027) at 12 months compared with those treated with MT. Mean Villalta scores were lower through 12 months among those receiving MT vs AC (3.3 vs 6.3 at 30 days, 2.5 vs 5.5 at 6 months, and 2.6 vs 4.9 at 12 months; P < .001 for all). CONCLUSIONS:MT treatment of iliofemoral DVT was associated with significantly lower Villalta scores and a lower incidence of PTS through 12 months compared with treatment using AC. Results from currently enrolling clinical trials will further clarify the role of these therapies in the prevention of PTS after an acute DVT event.

This review explores the clinical presentation of lower extremity DVT and pulmonary embolism (PE), treatment strategies, and outcomes for venous thromboembolism (VTE) in the pediatric population. Traditional therapy for pediatric VTE was anticoagulation alone with thrombolysis and surgery reserved only in life or limb-threatening cases. Catheter-directed thrombolysis (CDT), pharmacomechanical thrombectomy (PMT) and mechanical thrombectomy (MT) have emerged as effective and safe treatment options for VTE management. Although most data are from adult studies, early pediatric studies suggest that these interventional procedures can be effective in children. The significant clinical impact of post-thrombotic syndrome (PTS) is also discussed, as PTS can lead to lifelong physical symptoms and psychosocial damage.

Abstract Background The management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation. Methods At a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation. Results Six hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS. (-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011). These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras. Conclusions We observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.

Hemorrhoid disease is very common, affecting greater than one-third of adults. Conservative management and several office-based procedures are useful in the treatment of internal hemorrhoids. Patients with refractory hemorrhoid disease have traditionally been treated with surgical hemorrhoidectomy. Rectal artery embolization has emerged as an alternative to surgical hemorrhoidectomy and has been shown to be safe and effective in case series and clinical trials completed over the past decade. Embolization has significantly less postprocedure pain when compared with surgical hemorrhoidectomy with similar outcomes. Pre- and postprocedure imaging are not routinely performed. Intraprocedural imaging consists of selective catheterization of the superior rectal arteries from the inferior mesenteric artery, and the middle rectal arteries from the internal iliac artery. The inferior rectal artery is seldom embolized due to the supply of the levator ani muscle and skin. To date, intermediate and large particles and fibered and nonfibered coils have been used successfully.

ABSTRACT Introduction Malignant bowel obstruction is a common complication in patients with end-stage cancer. Gastric decompression can reduce symptoms; however, percutaneous gastrostomy tube placement may not always be feasible. A percutaneous transesophageal gastrostomy (PTEG) is an alternative for nasogastric decompression. This study describes a technical modification of PTEG tube placement for patient comfort. Methods: A single-center retrospective review was performed to compare outcomes from tunneled versus nontunneled PTEGs. Similar to previous descriptions, an esophageal balloon was percutaneously punctured with a needle for placement of a tube entering the neck and tracked through the esophagus into the stomach. Rather than suturing to the neck, the tube was navigated through a subcutaneous tunnel to create a tunneled transesophageal gastrostomy. Results: Between Dec 2017 and Oct 2023, 27 patients underwent attempted PTEG tube placement, 10 of which were tunneled. Median time to death was 24 days after the procedure. Adverse events occurred in 10 of 27 patients (37.0%) and included cellulitis, tube retraction requiring tube repositioning and replacement, tube clogging, failed placement, postprocedure extended intubation, postprocedure hypotension, and aspiration. More infections were noted in the tunneled PTEGs than in the nontunneled PTEGs. Twenty-four patients reported partial or complete symptom relief. Seventeen patients were able to tolerate a liquid, low-fiber, or soft regular diet with a PTEG. Conclusion: Using established techniques of tunneling central venous catheters and the process of placing PTEG tubes, a simple modification to the procedure can have the gastrostomy exit along the chest wall rather than the neck. However, this may cause increased infectious complications.

IMPORTANCE Inferior vena cava filters are commonly implanted and infrequently retrieved. Nonretrieval contributes to significant morbidity, motivating US Food and Drug Administration and multisociety communications emphasizing the need for improved device surveillance. Current guidelines suggest that implanting physicians and referring physicians should be responsible for device follow-up, but it is not known whether shared responsibility contributes to lower retrieval. OBJECTIVE To determine if primary responsibility for follow-up care assumed by the implanting physician team is associated with increased device retrieval. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined a prospectively collected registry of patients with inferior vena cava filters implanted from June 2011 to September 2019. Medical record review and data analysis was completed in 2021. The study included 699 patients who underwent implantation of retrievable inferior vena cava filters at an academic quaternary care center. EXPOSURES Prior to 2016, implanting physicians had a passive surveillance strategy whereby letters highlighting indications for and the need for timely retrieval were mailed to patients and ordering clinicians. Starting in 2016, implanting physicians assumed active responsibility for surveillance, whereby candidacy for device retrieval was assessed periodically via phone calls and retrieval scheduled when appropriate. MAIN OUTCOMES AND MEASURES The main outcome was the odds of inferior vena cava filter nonretrieval. Within regression modeling of the association between the surveillance method and nonretrieval, additional covariates of patient demographics, concomitant malignant neoplasm, and presence of thromboembolic disease were included. RESULTS Of the 699 patients who received retrievable filter implants, 386 (55.2%) were followed up with passive surveillance, 313 (44.8%) with active surveillance, 346 (49.5%) were female, 100 (14.3%) were Black individuals, and 502 (71.8%) were White individuals. The mean (SD) age at filter implantation was 57.1 (16.0) years. Mean (SD) yearly filter retrieval increased following the adoption of active surveillance, from 190 of 386 (48.7%) to 192 of 313 (61.3%) (P <.001). Fewer filters were deemed permanent in the active group vs passive group (5 of 313 [1.6%] vs 47 of 386 [12.2%]; P <.001). Age at the time of implantation (OR, 1.02; 95% CI, 1.01-1.03), concomitant malignant neoplasm (OR, 2.18; 95% CI, 1.47-3.24), and passive contactmethod (OR, 1.70; 95% CI, 1.18-2.47) were associated with increased odds of filter nonretrieval. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that active surveillance by implanting physicians is associated with improved inferior vena cava filter retrieval. These findings support encouraging physicians who implant the filter to take primary responsibility for tracking and retrieval.

Purpose Mechanical thrombectomy for the treatment of deep vein thrombosis (DVT) is being increasingly utilized to reduce symptoms and prevent postthrombotic syndrome (PTS), but more data on clinical outcomes are needed. Mechanical thrombectomy was studied in the ClotTriever Outcomes (CLOUT) registry with 6-month full analysis outcomes reported herein. Materials and Methods The CLOUT registry is a prospective, all-comer study that enrolled 500 lower extremity DVT patients across 43 US sites treated with mechanical thrombectomy using the ClotTriever System. Core-lab assessed Marder scores and physician-assessed venous patency by duplex ultrasound, PTS assessment using Villalta score, venous symptom severity, pain, and quality of life scores through 6 months were analyzed. Adverse events were identified and independently adjudicated. Results All-cause mortality at 30 days was 0.9%, and 8.6% of subjects experienced a serious adverse event (SAE) within the first 30 days, 1 of which (0.2%) was device related. SAE rethrombosis/residual thrombus incidence was 4.8% at 30 days and 8.0% at 6 months. Between baseline and 6 months, venous flow increased from 27.2% to 92.5% of limbs ( P < 0.0001), and venous compressibility improved from 28.0% to 91.8% ( P < 0.0001), while median Villalta scores improved from 9.0 at baseline to 1.0 at 6 months ( P < 0.0001). Significant improvements in venous symptom severity, pain, and quality of life were also demonstrated. Outcomes from iliofemoral and isolated femoral-popliteal segments showed similar improvements. Conclusion Outcomes from the CLOUT study, a large prospective registry for DVT, indicate that mechanical thrombectomy is safe and demonstrates significant improvement in symptoms and health status through 6 months. Level of Evidence 3: Non-randomized controlled cohort/follow-up study.

PURPOSE:To describe national trends in the utilization of endovascular approaches (including balloon angioplasty, atherectomy, and stent placement) for the management of femoropopliteal peripheral arterial disease (PAD).MATERIALS AND METHODS:The Medicare Physician/Supplier Procedure Summary dataset containing 100% of Part B claims was interrogated for years 2011-2019. The Current Procedural Terminology codes specific for femoropopliteal angioplasty, stent placement, and atherectomy were used to create summary statistics for utilization by year, place of service (hospital inpatient, hospital outpatient, and office-based laboratory), and provider specialty (cardiology, radiology, and surgery).RESULTS:The use of atherectomy increased from 34,732 (33%) procedures in 2011 to 75,435 (53%) procedures in 2019, and atherectomy became the dominant treatment strategy for femoropopliteal PAD. The relative utilization of stent placement (36,793 [35%] to 28,899 [20%]) and angioplasty only (34,398 [32%] to 38,228 [27%]) decreased concomitantly from 2011 to 2019. By 2019, the use of atherectomy was twofold higher in office-based laboratories than in the outpatient hospital setting (44,767 and 20,901, respectively). Treatment strategy varied by provider specialty in 2011 when cardiologists used atherectomy most frequently (17,925 [43%]), whereas radiologists used angioplasty alone (5,928 [6%]) and surgeons stented (18,009 [37%]) most frequently. By 2019, all specialties utilized atherectomy most frequently (29,564 [59%] for cardiology, 10,912 [58%] radiology, and 33,649 [47%] surgery).CONCLUSIONS:The national approach to endovascular management of femoropopliteal PAD has changed since 2011 toward an implant-free strategy, including a multifold increase in the use of atherectomy. Discordant rates of atherectomy use between the ambulatory hospital and office-based settings highlight the need for comparative effectiveness studies to guide management.

IMPORTANCE Despite historically high rates of use, most inferior vena cava (IVC) filters are not retrieved. The US Food and Drug Administration safety communications recommended retrieval when the IVC filter is no longer indicated out of concern for filter-related complications. However, failure rates are high when using standard techniques for retrieval of long-dwelling filters, and until recently, there have been no devices approved for retrieval of embedded IVC filters. OBJECTIVE To evaluate the safety and success of excimer laser sheath-assisted retrieval of embedded IVC filters. DESIGN, SETTING, AND PARTICIPANTS A retrospective, multicenter, clinical cohort study of excimer laser sheath-assisted IVC filter retrievals from 7 US sites was conducted between March 1, 2012, and February 28, 2021, among 265 patients who underwent IVC filter retrieval using the laser. Patients were substratified between a high-volume single center and a multicenter data set. A blinded physician committee adjudicated reported complications and their association with use of the laser. EXPOSURES Retrieval of IVC filters using excimer laser sheath. MAIN OUTCOMES AND MEASURES The primary safety end point was device-related major complication rate (Society of Interventional Radiology categories C to F, which included any adverse event associated with morbidity or disability that increases the level of care, results in hospital admission, or substantially lengthens the hospital stay). The primary success end point was technical success of IVC filter retrieval. The primary end points were compared with literature-derived, meta-analysis-suggested target performance goals. RESULTS The single-center experience included 139 participants (mean [SD] age, 52 [16] years; 78 female participants [56.1%]), and the multicenter experience included 126 participants (mean [SD] age, 52 [16] years; 75 female participants [59.5%]). The device-related major complication rate was 2.9% (4 of 139; 95% CI, 0.8%-7.2%; P =.001) for the single-center experience and 4.0% (5 of 126; 95% CI, 1.3%-9.0%; P =.01) for the multicenter experience, both of which were significantly lower than the primary safety performance goal (10%). No major complications were considered to be definitively associated with use of the laser. The technical success rate was 95.7%(133 of 139; 95% CI, 90.8%-98.4%; P =.007) for the single-center experience and 95.2%(120 of 126; 95% CI, 89.9%98.2%; P =.02) for the multicenter experience, both of which were significantly higher than the primary performance goal (89.4%). CONCLUSIONS AND RELEVANCE This cohort study demonstrated high technical success and low complication rates of excimer laser sheath-assisted retrieval of embedded IVC filters in centers with variable case volume and experience, which suggests a wide applicability of the technique with proper training. The excimer laser sheath offers physicians a valuable tool for retrieval of challenging embedded IVC filters.

1University of Colorado Anschutz Medical Campus, Aurora, CO 2University of Colorado School of Medicine, Aurora, CO

Purpose: Retrievable inferior vena cava filters (IVCF) have been increasingly used for mechanical pulmonary embolism prophylaxis since their development. The Captus Vascular Retrieval System (Avantec Vascular, Sunnyvale, California) is a new device developed for retrieval of IVCF. This study compared the safety and efficacy of the new Captus device against the existing EnSnare Endovascular Snare System (Merit Medical, South Jordan, Utah) for IVCF retrieval. Methods: Patients undergoing IVCF retrieval at a single institution between July 2015 and July 2020 were retrospectively identified. All adult patients (>18 years) undergoing filter retrieval with either Captus or Ensnare were included. Technical success and complications were compared by device. A complexity score was assigned to each case to adjust for selection bias. Logistic regression was used to model the association between device type and primary technical success. Results: 99 IVCF retrievals met inclusion criteria, 59 with Captus and 40 with Ensnare. The majority of the cohort consisted of low complexity cases (n = 51, 86% Captus versus n = 31, 78% Ensnare; p = 0.28). Technical success for low and medium complexity retrievals was 88% and 62% with Captus and 96% and 33% with Ensnare. There was no significant association between device type and technical success, adjusting for case complexity (Captus OR 0.55, 95% CI 0.08-2.72, p = 0.49). There were no device-related complications. Conclusion: No statistically significant difference in device technical success or complications between the Ensnare and Captus devices for uncomplicated IVCF retrieval. Precis: The Captus Vascular Retrieval System is a new device for IVC filter retrieval which has similar technical success to the existing EnSnare.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective intervention to address complications of decompensated portal hypertension, most commonly variceal hemorrhage and refractory ascites. While TIPS is con-sidered challenging, reported technical success rate is high at 95%. 1,2 Variant anatomy and relative contraindications such as portal vein thrombosis pose additional challenges and can reduce likelihood of success. 3,4 Most operators consider puncture of the portal vein to be the technically dif fi cult part of TIPS creation, which frequently requires multiple needle passes. Existing methods for the guidance of a needle pass into the portal vein do not provide real-time feedback and multiple needle passes are not without risk. Indirect portal venogram via injection of contrast or CO 2 increases risk of hepatic laceration and air embolus, respectively. Direct venogram via percutaneous needle puncture of the portal system carries a heightened risk of hemorrhage. 3,5,6 Needle passes without real-time imaging guidance can lead to complications such as extrahepatic portal vein puncture, extracapsular puncture, hemoperitoneum, and hemobilia. Intracardiac