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Background: Inferior vena cava (IVC) filter tilt is associated with technical difficulties at the time of retrieval. However, the degree of tilt that predisposes patients to undergo complex or failed retrieval has not been defined., Methods: The electronic charts of patients undergoing IVC filter removal between 2010 and 2019 at a single tertiary center were reviewed. Patient and procedural characteristics were recorded. Venograms of placement and retrieval procedures were reviewed, and IVC filter tilt was determined based on its deviation from the IVC axis. IVC diameter and the distance from the lowest renal vein were measured using corresponding filter's length for calibration. All measurements were performed by 3 reviewers and confirmed by 2 reviewers. Patients were divided into 2 groups: those who underwent successful removal procedures requiring standard retrieval methods ("simple retrieval group") and those who required advanced endovascular techniques or had failed completely IVC filter retrievals ("challenging retrieval group"). A regression analysis was performed to determine factors associated with challenging retrieval., Results: There were 365 patients who underwent IVC filter retrieval (n = 294 (80.6%) and n = 71 (19.4%) in the simple and challenging groups, respectively) with no difference in age, sex, comorbidities, or indication between the 2 groups. Failed retrieval occurred in 21 patients (5.8%) and was more common among patients requiring advanced endovascular techniques compared to standard techniques (18.0% vs. 3.2%, P < 0.001). In the overall cohort, the mean filter tilt at the time of retrieval was 4.9° ± 4.4° [0c27°], and 145 patients (39.7%) had a filter tilt ≥5.0°. Compared to the simple retrieval group, patients in the challenging group had significantly longer dwell time, greater tilt of IVC filter during placement and retrieval, as well as higher tilt change between the 2 venograms. There was no correlation between the access site during placement and challenging retrieval. However, patients undergoing filter placement via right jugular vein had lower filter tilt as compared to femoral access. Patients with filter tilt ≥5.0° were more likely to have a challenging filter retrieval compared to patients with ˂5.0° tilt (29.7% vs. 12.7%, P < 0.001). Regression analysis showed that tilt ≥5.0° (odds ratio [OR] = 1.18 [1.11-1.25]), dwell time (OR = 1.04 [1.01-1.07]), and age (OR = 0.97 [0.95-0.99]) were independently associated with challenging retrieval., Conclusions: IVC filter tilt ≥5.0°, dwell time and age are associated with challenging retrieval. Right jugular vein access, multiple imaging projections, and careful filter manipulation during deployment should be considered to maintain tilt at ˂ 5.0° and decrease the likelihood of challenging retrieval., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The effect of changes in bladder volume on the caliber of adjacent veins is underappreciated but essential to recognize to avoid complications such as unnecessary stenting or clot migration causing pulmonary embolism. Here the authors illustrate the importance of this finding in 3 cases using venographic and endovascular sonographic imaging: the first in which BPH-induced chronic bladder outlet obstruction resulted in DVT formation, the second in which the cause was unrecognized and unnecessary stenting performed, and the third in which inappropriate treatment was avoided by decompressing the bladder., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: We present a case in which a 44-year-old female smoker with a complex medical and surgical history presented with acute upper limb ischemia., Methods: The patient was diagnosed with thoracic outlet syndrome causing symptomatic thrombosis of an aberrant right subclavian artery associated with diverticulum of Kommerell. The patient had history of extensive surgeries and radiation in the right chest with fibrotic changes, so surgical dissection in the area was associated with significant risk of nerve injury. Therefore, revascularization of the arm was performed via carotid to brachial artery bypass with reversed saphenous vein and the thoracic outlet was decompressed with segmental clavicular resection., Results: Patient has been symptom free for 3 years with patent bypass., Conclusions: This case demonstrates a unique presentation of distal thrombosis of a symptomatic aberrant right subclavian artery related to thoracic outlet syndrome. The combined claviculectomy-vein bypass is a safe and efficacious surgical approach that provides durable relief.

Purpose: Thermal ablation (TA) and transarterial chemoembolization (TACE) may be used alone or in combination (TACE+TA) for the treatment of hepatocellular carcinoma (HCC). The aim of our study was to compare the time to tumor progression (TTP) and overall survival (OS) for patients who received TA alone or TACE+TA for HCC tumors under 3 cm., Materials and Methods: This HIPAA-compliant IRB-approved retrospective analysis included 85 therapy-naïve patients from 2010 to 2018 (63 males, 22 females, mean age 62.4 ± 8.5 years) who underwent either TA alone (n = 64) or TA in combination with drug-eluting beads (DEB)-TACE (n = 18) or Lipiodol-TACE (n = 3) for locoregional therapy of early stage HCC with maximum tumor diameter under 3 cm. Kaplan-Meier analysis was performed using the log-rank test to assess TTP and OS., Results: All TA and TACE+TA treatments included were technically successful. TTP was 23.0 months in the TA group and 22.0 months in the TACE+TA group. There was no statistically significant difference in TTP (p = 0.64). Median OS was 69.7 months in the TA group and 64.6 months in the TACE+TA group. There was no statistically significant difference in OS (p = 0.14). The treatment cohorts had differences in AFP levels (p = 0.03) and BCLC stage (p = 0.047). Complication rates between patient groups were similar (p = 0.61)., Conclusion: For patients with HCC under 3 cm, TA alone and TACE+TA have similar outcomes in terms of TTP and OS, suggesting that TACE+TA may not be needed for these tumors unless warranted by tumor location or other technical consideration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the prognostic potential of Lipiodol distribution for the pharmacokinetic (PK) profiles of doxorubicin (DOX) and doxorubicinol (DOXOL) after conventional transarterial chemoembolization (cTACE)., Methods: This prospective clinical trial ( ClinicalTrials.gov : NCT02753881) included 30 consecutive participants with liver malignancies treated with cTACE (5/2016-10/2018) using 50 mg DOX/10 mg mitomycin C emulsified 1:2 with ethiodized oil (Lipiodol). Peripheral blood was sampled at 10 timepoints for standard non-compartmental analysis of peak concentrations (C max ) and area under the curve (AUC) with dose normalization (DN). Imaging markers included Lipiodol distribution on post-cTACE CT for patient stratification into 1 segment (n = 10), ≥ 2 segments (n = 10), and lobar cTACE (n = 10), and baseline enhancing tumor volume (ETV). Adverse events (AEs) and tumor response on MRI were recorded 3-4 weeks post-cTACE. Statistics included repeated measurement ANOVA (RM-ANOVA), Mann-Whitney, Kruskal-Wallis, Fisher's exact test, and Pearson correlation., Results: Hepatocellular (n = 26), cholangiocarcinoma (n = 1), and neuroendocrine metastases (n = 3) were included. Stratified according to Lipiodol distribution, DOX-C max increased from 1 segment (DOX-C max , 83.94 ± 75.09 ng/mL; DN-DOX-C max , 2.67 ± 2.02 ng/mL/mg) to ≥ 2 segments (DOX-C max , 139.66 ± 117.73 ng/mL; DN-DOX-C max , 3.68 ± 4.20 ng/mL/mg) to lobar distribution (DOX-C max , 334.35 ± 215.18 ng/mL; DN-DOX-C max , 7.11 ± 4.24 ng/mL/mg; p = 0.036). While differences in DN-DOX-AUC remained insignificant, RM-ANOVA revealed significant separation of time concentration curves for DOX (p = 0.023) and DOXOL (p = 0.041) comparing 1, ≥ 2 segments, and lobar cTACE. Additional indicators of higher DN-DOX-C max were high ETV (p = 0.047) and Child-Pugh B (p = 0.009). High ETV and tumoral Lipiodol coverage also correlated with tumor response. AE occurred less frequently after segmental cTACE., Conclusions: This prospective clinical trial provides updated PK data revealing Lipiodol distribution as an imaging marker predictive of DOX-C max and tumor response after cTACE in liver cancer., Key Points: • Prospective pharmacokinetic analysis after conventional TACE revealed Lipiodol distribution (1 vs. ≥ 2 segments vs. lobar) as an imaging marker predictive of doxorubicin peak concentrations (C max ). • Child-Pugh B class and tumor hypervascularization, measurable as enhancing tumor volume (ETV) at baseline, were identified as additional predictors for higher dose-normalized doxorubicin C max after conventional TACE. • ETV at baseline and tumoral Lipiodol coverage can serve as predictors of volumetric tumor response after conventional TACE according to quantitative European Association for the Study of the Liver (qEASL) criteria.

Lymphoceles are lymphatic fluid collections resulting from lymphatic vessel disruption after surgery or trauma. They are most often described following retroperitoneal surgeries such as cystectomies, prostatectomies, renal transplants, and gynecologic surgeries. Most lymphoceles are asymptomatic and resolve spontaneously without treatment. If persistent, they can become infected or exert mass effect on adjacent structures causing pain, urinary, or lower limb edema particularly for lymphoceles in the pelvis Symptomatic lymphoceles should be treated to relieve symptoms and prevent functional compromise of vital adjacent structures. Although surgery has been traditionally accepted as the gold standard treatment, advances in imaging and interventional technology allow for less invasive, percutaneous treatment. Available minimally invasive treatment options include percutaneous aspiration, catheter drainage, sclerotherapy, and lymphangiography with lymphatic embolization. A review of these treatment options and a suggested algorithm for managing lymphoceles is presented., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright by International Society of Lymphology.)

Objective: To present outcomes for prostatic artery embolization (PAE) to treat urinary retention and gross prostatic hematuria in nonindex benign prostatic hyperplasia patients., Materials and Methods: Seventy-five patients undergoing PAE from December 2013 to August 2018 (age = 77.5 ± 8.6, age-adjusted Charlson comorbidity index = 4.6 ± 2.0, prostate volume = 224 mL ± 135 mL) for retention (n = 46) and/or gross prostatic hematuria (n = 55) were retrospectively reviewed. Twenty-six patients had both problems. Urinary retention patients (UR, n = 46, catheterization = 162.4 ± 148.1 days) underwent voiding trials 1-2 months post-PAE, with International Prostate Symptom Score (IPSS), Quality of Life (QoL), and postvoid residual (PVR) recorded at 3, 6, 12, 24, and 36 months. Pre- and post-PAE hematuria-related visits were compared for gross hematuria patients (GH, n = 39), as were transfusion rates for severe hematuria patients requiring bladder irrigation (SH, n = 16). Ninety-day adverse event tabulation used Clavien-Dindo classification., Results: Three months post-PAE, 33/38(87%) UR patients were catheter-free (IPSS = 8.9 ± 5.3, QoL = 1.6 ± 1.7, PVR = 158 mL ± 207 mL). Results were similar at 6 months (catheter-free = 26/28(93%), IPSS = 6.5 ± 4.4, QoL = 1.1 ± 0.9, PVR = 149 mL ± 139 mL), 12 months (catheter-free = 19/20(95%), IPSS = 4.7 ± 4.8, QoL = 0.6 ± 0.9, PVR = 125 mL ± 176 mL), 24 months (catheter-free = 11/12(92%), IPSS = 4.4 ± 3.0, QoL = 0.9 ± 0.8, PVR = 66 mL ± 68 mL), and 36 months (catheter-free = 5/6(83%), IPSS = 5.8 ± 3.8, QoL = 0.8 ± 1.0, PVR =99 mL ± 71 mL). Out of 37, 34(92%) GH patients remained hematuria-free at 483 ± 137 days, with 22 hematuria-related visits pre-PAE vs none post-PAE. Hematuria resolved <48 hours post-PAE in 14/16(87.5%) SH patients, with 36 blood units transfused pre-PAE, 4 units transfused <48 hours post-PAE, and none thereafter. Subsequently, 13/16(81%) remained hematuria-free at 500 ± 501 days; 2/16(13%) required fulguration; 1/16(6%) developed bladder tumor. There were 2 deaths <30 days post-PAE, and 8(11%) Grade-II urinary infections., Conclusion: PAE provided safe, effective, and durable treatment for retention and gross hematuria in nonindex benign prostatic hyperplasia patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We present a case of a 56-year-old white male with a medical history of hypertension,who initially presented with chest pain, diaphoresis, and electrocardiogram (ECG) changes suggesting myocardial infarction. Initial frontal radiograph showed marked displacement of the cardiac silhouette into the left hemithorax. Cardiac catheterization was performed per hospital protocol showing no evidence of cardiac or coronary disease, but demonstrated marked rotation of the heart and abnormal displacement of the heart into the left hemithorax. As both of these findings could not explain the patient's symptoms, computerized tomography angiography (CTA) of the chest was performed demonstrating congenital absence of the pericardium, a rare entity estimated to occur in one in 10,000 to 14,000 people.