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Therapeutic interventions are limited for high-risk burn patients with caval and intracardiac septic thrombi. Percutaneous thrombectomy represents a less invasive alternative to median sternotomy. However, there is limited literature on application of this approach and outcomes in these patients. We report two cases of patients with large total body surface area burns with similar caval and right intracardiac septic thrombi. Both patients were successfully treated using a percutaneous aspiration device.

Purpose: Efficient interventional radiology (IR) procedure room utilization relies on various healthcare professionals performing clinical and nonclinical tasks to minimize room downtime. The coronavirus-19 (COVID) pandemic offers insight into the importance of staff ratios in improving room utilization, by evaluating the effect of a relative increase in support staffing in the setting of reduced physician staffing and reduced overall case volume. Materials and Methods: In March 2020, as a result of a department-wide COVID disaster management plan, a 4-angiosuite IR department in a 900-bed tertiary care center experienced reduced case volume by approximately 1/3, matched by decreased physician staffing (3 to 2 attendings). IR technologist and nurse staffing remained unchanged. Normal staffing resumed June 2020. A prospective database of event times related to room workflow was reviewed for case volume, room turnaround time, and first case delay time before and after volume and staff changes. Turnaround times greater than 2 hours were excluded to correct for gaps in schedule and the prolonged turnaround associated with COVID-positive patient cases. Wilcoxon rank-sum two-sample tests were used to evaluate the differences between time periods. All P values reported are two-sided. Analysis was done in RStudio 1.2.5033 (RStudio Team, Boston, MA). Results: Under standard operation, the median values for room turnaround time, case start delay, weekly case volume, and total case hours were 43.0 minutes, 30.0 minutes, 64 cases, and 44.4 hours, respectively. Under the COVID disaster management plan, a 32.6% (P < 0.001, 95% C.I. 23.3%, 41.9%) estimated increase was observed for room turnaround times, and a 53% (P < 0.001, 95% C.I. 36.7%, 70.0%) estimated increase was observed in case start delay;despite a 29.7% (P < 0.001, 95% C.I. 20.3%, 42.2%) decrease in case number and 29.5% (P = 0.009, 95% C.I. 13.1%, 43.2%) estimated decrease in total case hours. Conclusions: Paradoxically, a relative increase in staffing did not improve measured metrics for room utilization, despite a stable attending physician-to-case ratio. Rather, findings may be allegorical to Parkinson’s law suggesting that work expands so as to fill the time available for its completion.

Pulmonary artery aneurysms (PAAs) and pseudoaneurysms are rare entities in the spectrum of pulmonary arterial diseases. The etiology of these aneurysms is varied and patients present with nonspecific symptoms which make their diagnosis both difficult and less often considered. In this review, we will discuss the clinical manifestations, etiologies, methods of detection, imaging features, and the current role of endovascular treatment in the management of PAAs.

Purpose To evaluate nonprocedural percutaneous nephrostomy (PCN) complications and assess whether the protocol of routine 3-month exchange of PCN is optimal in patients with malignant ureteral obstruction (MUO) and benign ureteral obstruction (BUO). Materials and Methods Retrospective study of 103 patients with a mean age of 48 years (36 men, 67 women) who underwent PCN placement and subsequent PCN exchanges between January 2011 and January 2014 at the institution was conducted. Comparisons of the number of catheter days for those with routine exchange and emergency exchange due to tube obstruction, infection, and mechanical failures were made in patients with MUO and BUO. Results Of the 256 PCN exchange procedures, 139 were performed in the cancer cohort and 117 in the noncancer cohort. Complications requiring emergent exchanges were more common in cancer patients, particularly due to obstruction, which accounted for 57% of exchanges in MUO with a median onset of 50 days. In contrast, the majority of noncancer patients in this study did not require emergent exchange before 3 months. Routine exchanges accounted for 43% and 55% of exchanges in MUO and BUO, respectively. In both the groups, only a small proportion of emergent tube exchanges occurred beyond 105 days. Conclusion A routine 3-month nephrostomy exchange protocol may not be ideal for all patients. The optimal timing for exchange of nephrostomy appears to be earlier for patients with MUO compared with those with BUO. A prospective study is required to define an optimal policy for postprocedural nephrostomy tube care in both the cohorts.

Inferior vena cava (IVC) filters are important devices for patients who are at high risk for developing thrombi and pulmonary embolism but have conditions that preclude the use of pharmacologic anticoagulants. IVC filter retrieval has become an important quality initiative backed by Food and Drug Administration guidelines for prompt removal after the filter is no longer indicated. Filter retrieval is a common procedure that usually has very few complications. However, when the filter is tilted or embedded in the caval wall, advanced techniques of retrieval may be necessary. These techniques have a higher rate of success but also a higher risk of complications such as injury to the IVC. Here, we describe a case of IVC filter retrieval resulting in formation of an arteriovenous fistula between the right renal artery and IVC and subsequent successful repair of this fistula using a vascular plug.

Hepatocellular carcinoma (HCC) is dominantly supplied by arterial blood flow, whereas the normal underlying liver parenchyma is supplied by both the portal vein (75%) and hepatic artery (25%). This distinction in blood supply of tumor tissue relative to liver tissue led to the exploration of targeting the arterial blood supply as a means of therapeutic intervention. This chapter overviews the evolution of transarterial therapies for HCC from the initial attempts of hepatic artery ligation/infusion to the current standard care treatments, including variants of transarterial chemoembolization and radioembolization. Emerging therapeutic approaches, including biologic and biomimetic injection, are discussed as potential future strategies with improved tumor targeting and specificity for the treatment of HCC.

Thoracic venous injuries are predominantly attributed to traumatic and iatrogenic causes. Gunshot wounds and knife stabbings make up the vast majority of penetrating trauma whereas motor vehicle collisions are the leading cause of blunt trauma to the chest. Iatrogenic injuries, mostly from central venous catheter complications are being described in growing detail. Although these injuries are rare, they pose a diagnostic challenge as their clinical presentation does not substantially differ from that of arterial injury. Furthermore, the highly lethal nature of some of these injuries provides limited literature for review and probably underestimates their true incidence. The widespread use of multi-detector computed tomography (MDCT) has increased the detection rate of these lesions in hemodynamically stable patients that survive the initial traumatic event. In this article, we will discuss and illustrate various causes of injury to each vein and their supporting CT findings while briefly discussing management. The available literature will be reviewed for penetrating, blunt, and iatrogenic injuries to the vena cava, innominate, subclavian, axillary, azygos, and pulmonary veins.

"Blush," defined as a focal area of contrast pooling within a hematoma, is frequently encountered in patients with severe blunt torso trauma. Contemporary clinical practice guidelines recommend the use of angiography with embolization in all hemodynamically stable patients with evidence of active extravasation. Patients presenting with blush visualized on computed tomography (CT), but not demonstrated on subsequent angiography, present a challenging clinical dilemma. The purpose of this study was to study the natural course of patients with this blush disparity between CT and angiography.The study was conducted as a retrospective analysis of patients who underwent angiography after initial CT scans revealed blush after blunt abdominal trauma at a level I trauma center (January 2005 to December 2014).A total of 143 patients with blunt splenic injuries were found to have CT blush and underwent catheter angiography. Of the 143 patients with blush on CT, 24 (17%) showed no evidence of blush on angiography. Patients with CT-angiographic discrepancy were more than twice as likely to rebleed compared with those with angiographic evidence of blush (25% vs 10%, P.05). This is due to the fact that although all patients with blush on angiography underwent embolization, only 7/22 of those with no evidence of blush were embolized. Sixty-eight patients with blunt liver injuries demonstrated blush on CT and underwent catheter angiography. Of the 68 patients with blush on CT, 22 patients (33%) showed no evidence of blush on angiography. None of these 22 patients underwent angioembolization. The rebleeding rate in this cohort was 32% (7/22). Again, this was more than twice the rate observed in patients who did have angiographic evidence of blush and were embolized (11%, 5/46).CT imaging has enhanced our ability to detect contrast extravasation after injury, and evidence of blush on CT suggests the presence of active hemorrhage. This analysis suggests that in clinical situations in which CT blush is noted secondary to blunt trauma to the spleen or liver, a negative angiogram still carries a significant risk of recurrent hemorrhage; consideration for empiric embolization at the time of the initial procedure even in the absence of blush on angiographic evaluation is thus warranted. Prospective studies are needed to validate these findings and to assess the utility of this clinical paradigm.

Pulmonary arteriovenous malformations (PAVM) are abnormal direct communications between the branches of pulmonary arteries and veins, and are often seen in patients with hereditary hemorrhagic telangiectasia (HHT). If untreated, the right to left shunt can result in symptoms of hypoxemia, paradoxical emboli to the left side circulation, stroke and intracranial abscess. Endovascular therapy is a minimally invasive outpatient based treatment wherein the feeding artery to the PAVM is occluded with coils or plugs or a combination of both and is associated with minimal morbidity and no mortality. In this manuscript, we will review the indications and contraindications for endovascular therapy, pre-procedural work up, procedure technique and variations, complications, and outcomes.

The uncommon presentation of an arterioportal fistula (APF) involving the superior mesenteric artery (SMA) associated with a pseudoaneurysm represents a therapeutic challenge. We present the case of a 24-year-old female admitted to the hospital after multiple gunshot wounds to the abdomen; the patient underwent multiple surgeries and, in the process, developed a SMA pseudoaneurysm and fistula. The vascular interventional radiology team was consulted for treatment of the pseudoaneurysm and fistula. A covered stent was inserted percutaneously to exclude the APF and the pseudoaneurysm in a single procedure. The patient returned to our service after 21 months for a follow-up CT scan, which demonstrated the stent and the distal vasculature to be patent.

Purpose To estimate the least costly routine exchange frequency for percutaneous nephrostomies (PCNs) placed for malignant urinary obstruction, as measured by annual hospital charges, and to estimate the financial impact of patient compliance. Materials and Methods Patients with PCNs placed for malignant urinary obstruction were studied from 2011 to 2013. Exchanges were classified as routine or due to 1 of 3 complication types: mechanical (tube dislodgment), obstruction, or infection. Representative cases were identified, and median representative charges were used as inputs for the model. Accelerated failure time and Markov chain Monte Carlo models were used to estimate distribution of exchange types and annual hospital charges under different routine exchange frequency and compliance scenarios. Results Long-term PCN management was required in 57 patients, with 87 total exchange encounters. Median representative hospital charges for pyelonephritis and obstruction were 11.8 and 9.3 times greater, respectively, than a routine exchange. The projected proportion of routine exchanges increased and the projected proportion of infection-related exchanges decreased when moving from a 90-day exchange with 50% compliance to a 60-day exchange with 75% compliance, and this was associated with a projected reduction in annual charges. Projected cost reductions resulting from increased compliance were generally greater than reductions resulting from changes in exchange frequency. Conclusions This simulation model suggests that the optimal routine exchange interval for PCN exchange in patients with malignant urinary obstruction is approximately 60 days and that the degree of reduction in charges likely depends more on patient compliance than exact exchange interval.