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Inferior vena cava filters are placed to prevent life-threatening pulmonary embolism in a selected group of patients. Significant complications are known to occur with prolonged dwell times, and rarely during initial placement. In this report, we describe two cases of inadvertent noncaval inferior vena cava filter placements, specifically in the azygous vein and right renal vein, and the complex methods used to retrieve them, which exemplify the critical importance of routine and careful placement techniques. Keywords: IVC filter, Venogram, Filter migration

Objective This study aims to assess the regional variation and overall longitudinal prevalence of approaches to gastrostomy tube placement in patients covered by Medicare or Medicaid. Background Gastrostomy tubes are most commonly inserted endoscopically given the approaches’ demonstrated safety, success, and patient outcomes as compared with laparoscopic approaches. Recently, the growth of interventional radiology services has provided patients with an alternative percutaneous approach. The safety and efficacy of this approach as opposed to endoscopic approaches has yet to be determined. Methods From 2005 to 2014, Medicare Standard Analytic Files derived from Medicare parts A and B, which contain 100% of inpatient and outpatient facility records billed to Medicare, were retrospectively analyzed. Age, sex, year of placement, region, comparative quarterly ratio, regional cost variation, and overall financial cost were compared between both cohorts. Results Our population included a total of 336,021 patients; of those, 30,327 patients underwent fluoroscopic guided procedures, and 305,694 patients underwent endoscopic procedures. Age (p < 0.001), region (p = 0.043), and year of placement (p < 0.001) varied significantly between these populations. Fluoroscopic-guided procedures were found to have a statistically significantly lower average cost of treatment compared with endoscopic gastrostomies ($2,018.62 vs. $2,471.33, respectively, p = 0.03). Conclusion This study demonstrates an increasing prevalence of fluoroscopically placed gastrostomy tubes as compared with those placed endoscopically.

Background The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. Methods All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016–2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan–Meier analysis. Results In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. Conclusion PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

Background/objectives The purpose of this research is to analyze the past and forecast the future prevalence of Hepatitis C Virus (HCV) and Nonalcoholic Steatohepatitis (NASH) and their respective contribution to Hepatocellular Carcinoma (HCC) incidence in the setting of novel anti-viral agents and rising obesity rates in the United States. Methods Existing data of HCV and NASH prevalence in the United States utilizing the National Health and Nutrition Examination Survey (NHANES) and Organ Procurement and Transplantation Network (OPTN) was collected and analyzed to project future prevalence trends. Results Prevalence of NASH and HCV are expected to increase and decline respectively over the next two decades with alcoholic cirrhosis expected to stay relatively unchanged. The estimated prevalence of NASH equaled and overtook the projected prevalence of HCV in 2007 at approximately 3 million persons. Estimates of NASH's contribution to HCC overtook HCV-HCC in 2015 at an approximately 25 million persons. Projection models suggest HCV prevalence declining to 1 million active cases by 2025, while NASH potentially increases to 17–42 million depending on a linear or exponential trendline. Projections of NASH-HCC similarly outpace HCV-HCC by 2025 with 45 million or 106 million (linear, exponential) versus 18 million persons respectively. Conclusions The future prevalence of HCV and NASH are expected to become further divergent with NASH emerging as the major contributor of cirrhosis and HCC in the United States.

To report hepatic arterial-related complications encountered during planning and treatment angiograms for radioembolization and understand any potential-associated risk factors.518 mapping or treatment angiograms for 180 patients with primary or metastatic disease to the liver treated by Yttrium-90 radioembolization between 2/2010 and 12/2015 were retrospectively reviewed. Intra-procedural complications were recorded per SIR guidelines. Patient demographics, indication for treatment, prior exposure to chemotherapeutic agents, operator experience, and disease burden were reviewed. Technical variables including type of radioembolic (glass vs. resin microspheres), indication for angiography (mapping vs. treatment), variant anatomy, and attempts at coil embolization were also assessed.Thirteen (13/518, 2.5%) arterial-related complications occurred in 13 patients. All but two complications resulted during transcatheter coil embolization to prevent non-target embolization. Complications included coil migration (n = 6), arterial dissection (n = 2), focal vessel perforation (n = 2), arterial thrombus (n = 2), and vasospasm prohibiting further arterial sub-selection (n = 1). Transarterial coiling was identified as a significant risk factor of complications on both univariate and multivariate regression analysis (odds ratio 7.8, P = 0.004). Usage of resin microspheres was also a significant risk factor (odds ratio 9.5, P = 0.042). No other technical parameters or pre-procedural variables were significant after adjusting for confounding on multivariate analysis (P 0.05).Intra-procedural hepatic arterial complications encountered during radioembolization were infrequent but occurred mainly during coil embolization to prevent non-target delivery to extra-hepatic arteries.

Acute deep vein thrombosis (DVT) occurs in approximately 300,000 people per year in the United States. Iliocaval thrombosis is most commonly related to the progression of lower extremity DVT. Inferior vena cava (IVC) thrombosis occurs in approximately 4–15% of patients with acute DVT. Vena cava thrombosis is frequently associated with neoplastic disease. Foreign body placement such as an IVC filter or a venous catheter is a frequently reported cause of iliocaval thrombosis. External compression due to right common iliac artery mass effect (May–Thurner syndrome), tumor, lymphadenopathy, or aortic aneurysm are also commonly seen. This chapter discusses the interventional measures to manage acute iliocaval thrombosis.

Eight patients with primary (n = 6) and metastatic (n = 2) disease of the liver underwent yttrium-90 radioembolization with glass microspheres using a combination of segmental and ipsilateral lobar approach to treat multifocal tumors containing a single dominant tumor. The superselective dose was administered to the dominant tumor, whereas lobar infusion was used for smaller tumors. Assuming uniform distribution, median dose to the segment with dominant tumor was 412.3 Gy and to the remaining lobe was 117.5 Gy. No instances of radiation-induced liver disease occurred. Combined segmental and ipsilateral lobar radioembolization is a well-tolerated procedure to treat unilateral multifocal hepatic tumors including a single dominant tumor.

Lymphatic leak is a well-documented complication following neck dissection surgeries. When conservative methods fail to control the leak, thoracic duct embolization becomes an option. Transabdominal access is the standard for this procedure; however, it is not always feasible. We discuss a technique of selective lymphatic vessel embolization utilizing retrograde transvenous access.

OBJECTIVE: To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS: All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child–Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS: All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION: Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. ADVANCES IN KNOWLEDGE: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.

Purpose: To compare our experience using paclitaxel-coated balloon angioplasty (PCBA) of femoropopliteal lesions in patients undergoing revascularization in the setting of CLI compared with current data in the literature. Materials: Angiography, diagnostic imaging, demographics, risk factors, and clinical notes of patients who underwent PCBA from October 2014 to September 2015 for treatment of CLI were reviewed. Study outcome measures include latest follow up study demonstrating luminal patency, amputation and death attributable to CLI. Patients were excluded if PCBA was used within a stent, the target lesion was stented in the same case, treatment was performed with a planned subsequent amputation, or there is lack of any follow up (defined as subsequent ankle-brachial index (ABI), arterial duplex ultrasound, angiography, or clinical exam). Results: A total of 58 stenoses in 41 patients (24 men; mean age 64.8) underwent PCBA during lower extremity revascularization in this interval. Of these, 19 patients (Rutherford class 4, 5, or 6) with 21 lesions met inclusion criteria. These lesions were pretreated with plain-old balloon angioplasty for predilation or atherectomy followed by PCBA. 5 patients were chronically occluded (26%), and 11 (58%) patients also underwent infrapopliteal disease treatment. Average target lesion length was 4.8 cm and luminal narrowing was 79.6%. Mean follow up was 131.7 days (range 8-339 days, median 108 days) and reintervention was performed only in 2 of 21 lesions (92%). Two patients died of other causes with last documented patency at 56 and 83 days follow up. In patients that have available pre and post PCBA ABIs, the average ratio was 0.61 compared to 0.80 following revascularization. Conclusions: Early follow up demonstrates promising patency rates of femoro-popliteal PCBA in the setting of CLI, as well as high rate of concurrent additional infrapopliteal intervention. Current PCBA data in the literature is comprised of significantly lower Rutherford class patients and minimal concurrent infra-popliteal interventions.