The management of type II endoleaks that develop after endovascular repair of aortic aneurysms now includes the transcaval approach. We reviewed the safety and efficacy of this technique in 10 consecutive patients (82 ± 7 years old; 80% male) who presented with a mean sac enlargement of 1.2 ± 0.7 cm and documented flow within the aortic sac. Patients presented a mean of 5.5 ± 3.1 years after endovascular aneurysm repair, and five (50%) patients had prior attempts at endovascular repair of the documented endoleak. Patients underwent a percutaneous transcaval approach to the aorta with use of the Rösch-Uchida Transjugular Liver Access Kit (Cook Medical, Bloomington, Ind) through an 8F sheath in a biplane angiography room. Coil embolization of the sac and lumbar arteries and occasional use of gelatin granules and human thrombin slurry allowed obliteration of the endoleak. No complications developed. Nine patients (90%) were noted to have a decreased sac diameter on the postprocedure study, and only one (10%) had persistent (but markedly diminished) flow noted on the follow-up ultrasound examination. Follow-up is early and extends to 6 months without recurrence of the endoleaks. The ability to safely access the aortic sac through the vena cava is a potentially efficient, safe, and useful technique to treat aortic endoleaks.

Objective: We sought to assess the early success and safety of catheter-directed, ultrasound-assisted (CDUA) thrombolysis for acute pulmonary embolism (PE) in patients deemed to be "high risk" for thrombolytic therapy.Methods: A retrospective evaluation of patients who underwent CDUA pulmonary thrombolysis in our practice during 39 months is reported. There were 91 patients considered, all of whom presented with acute PE as diagnosed by computed tomography angiography. The ratio of the right ventricle to left ventricle diameter (RVaxial:V-axial) was noted, as were preprocedure pulmonary artery pressures (PAPs). Demographic data, significant medical history, and procedure details were recorded. Standard thrombolysis protocol was followed (1 mg of tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). Minitab 17 (Minitab Inc, State College, PA) was used for data analysis.Results: There were 91 patients who had a computed tomography diagnosis of acute PE and pulmonary hypertension (PAP >25 mm Hg). Seventeen patients (19%) were deemed to be at high risk for bleeding, predicted by recent hemorrhage, major surgery within 3 weeks, acute myocardial infarction, and cardiac arrest with cardiopulmonary resuscitation within 1 week. The high-risk patients in our study were noted to have higher RV:LV ratios and lower oxygen saturations on admission (P < .05). On computed tomography angiography, the mean pretherapy RVaxial:V-axial ratio was 1.5 +/- 0.4. The mean pretherapy PAP was 56.2 +/- 15.2 mm Hg. After 18.5 +/- 3.5 hours of thrombolysis, the mean post-therapy PAP was 34.3 +/- 10.4 mm Hg, with a pressure drop of 21.9 +/- 4.8 mm Hg (39% decrease; P < .001). In total, seven patients (8%) suffered bleeding complications that required intervention four gastrointestinal bleeds, a rectus sheath hematoma, and one gross hematuria. Three of the seven complications occurred in the high-risk group (3/17) and the other four in the general population of patients (4/74; P = .118). Minor bleeding complications (n = 14 [15%]) did not require intervention and included puncture site hematomas, ecchymosis, and mild traumatic hematuria. Considering all bleeding complications, increasing RVaxial:V-axial ratio was a predictor of any bleeding complication, independent of all risk factors (P = .005).Conclusions: CDUA thrombolysis for acute PE effectively reduced mean PAPs. Given the low incidence of major bleeding complications, even in those deemed to be clinically at high risk for bleeding, we additionally conclude that this procedure can be performed safely. Although larger studies with longer follow-up are necessary, CDUA pulmonary thrombolysis for the management of acute submassive PE appears to be effective in decreasing right sided heart strain and can be performed with an acceptable risk profile.

We report our experience with catheter-directed, ultrasound-assisted thrombolysis for acute pulmonary embolism (PE). We were particularly interested in the metrics to assess early success and the safety of this procedure in patients deemed to be at high risk for thrombolytic therapy. A retrospective evaluation of patients who underwent catheter-directed pulmonary thrombolysis in our practice during 29 months is reported. There were 62 patients considered, all of whom presented with acute PE as diagnosed by computed tomography (CT) angiography. The ratio of the right ventricle to left ventricle diameter (RV:LV) was noted, as were preprocedure pulmonary artery pressures (PAPs). Demographic data, significant medical history, and procedure details were recorded. CT scans were reviewed, and confirmatory RV:LV ratios were obtained. Standard thrombolysis protocol was followed (1 mg tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). Minitab v17 (Minitab, State College, Pa) was used for data analysis. Sixty-two patients had a CT diagnosis of acute PE and pulmonary hypertension (PAP >25 mm Hg). Twelve patients (19%) were deemed to have a high risk for bleeding. On CT angiography, the mean pretherapy RVaxial:LVaxial ratio was 1.5 ± 0.4. The mean pretherapy PAP was 55.0 ± 13.1 mm Hg. After 19.4 ± 3.4 hours of thrombolysis, the mean post-therapy PAP was 35.0 ± 10.7 mm Hg, with a pressure drop of 21.3 ± 11.8 mm Hg (39% decrease). Three patients (5%) suffered bleeding complications, two gastrointestinal bleeds and one rectus sheath hematoma. One of the three complications occurred in the high-risk group (1/12) and the other two in the general population of patients (2/50; Fisher exact test, P = .488). Minor bleeding complications (n = 11; 18%) included puncture site hematomas, ecchymosis, and traumatic hematuria. Considering all bleeding complications, increasing RVaxial:LVaxial ratio was a predictor of a bleeding complication, independent of all risk factors (likelihood ratio test, P = .005). Catheter-directed thrombolysis for acute PE effectively reduced mean PAP in patients with a dilated RV. As only three patients had notable bleeding complications, only one of whom was at high risk, we additionally conclude that this is a safe procedure. We encourage the use of catheter-directed, ultrasound-assisted pulmonary thrombolysis for the management of severe, acute pulmonary embolization with a dilated RV.

Objective: The natural history of balloon angioplasty is that of recurrent stenosis and, ultimately, thrombosis of the vessel. Hemodialysis (HD) accesses tend to have a more rapid progression to failure than other native vessels subjected to balloon dilatation. We reviewed our patient data to determine the validity of a routine follow-up for a failing HD access. Method: All patients scheduled for a routine follow-up after an initial endovascular intervention on their HD access were included in this report. None of the patients had symptoms of a failing HD access by physical examination or dialysis unit measurements. Findings on diagnostic angiography and the specific interventions were recorded. Results: A total of 121 patients underwent routine diagnostic angiography between January and September 2010. The follow-up study for all patients was scheduled at the time of their initial endovascular intervention (mean = 88.7 days.) Seventy-six percent (86 of 121) of these asymptomatic patients required an intervention at the time of their diagnostic angiogram. Sixty-eight percent (59 of 87) of patients with arteriovenous fistulae and 79% (27 of 34) with an arteriovenous graft required an intervention for an unsuspected stenotic lesion (χ2 = 1.09; P = .297; NS). Conclusion: The need for routine follow-up is warranted based on the results presented. Seventy percent of patients undergoing an endovascular intervention had a documented stenotic lesion associated with their access that was not evident on clinical evaluation. Therefore, these results justify a standardized approach to the follow-up of patients undergoing an endovascular intervention of their HD access.