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This study compared the 30-day infection risk of chest ports accessed on the same day as placement and chest ports with delayed initial access. The aim was to evaluate a larger data set that provided evidence for the development of port access guidelines. A retrospective chart review of 3322 chest port placement procedures performed between October 15, 2003, and June 10, 2015, was conducted at the interventional radiology department of a single institution. Procedure notes and health records were reviewed to determine time of initial port access, evidence of infection within a 30-day window of port placement, and causal organism(s) of infection. The results demonstrated that 64 ports (1.93%) met infection criteria within 30 days of placement, including 30 of the 945 ports immediately accessed and 34 of the 2377 ports not immediately accessed (3.17% vs 1.43%; P < .005). Dual lumen devices had a statistically significant higher rate of infection compared with single lumen devices (P = .006). This study concluded that there is a statistically significant higher rate of infection if a port is accessed immediately versus when access is deferred to later than 24 hours after placement.

Peripherally inserted central catheters and nontunneled central venous catheters are indispensable in current medical practice, with both serving central venous access needs. They are used for infusion therapy, exchange therapy, and hemodynamic monitoring. The central venous system includes the pulmonary arteries, right side of the heart, superior vena cava, inferior vena cava, brachiocephalic veins, subclavian veins, and iliac veins. It should be noted that although these vessels and many other small veins are considered central, they are not necessarily appropriate locations for venous catheter tips. In most cases, the desired position for a central venous catheter tip is in the superior vena cava or right atrium. Present-day venous access devices are available in a wide variety of sizes, forms, and configurations designed to meet specific needs. It is important to be familiar with the range of venous access devices presently available on the market and the features that affect their selection.

Purpose To compare the technical success of the Recovery and G2 filters as retrievable inferior vena cava (IVC) filters. Materials and Methods Recovery ( n = 128) and G2 ( n = 113) filters were placed in the IVCs of 241 patients with the intent of retrieval. The referring physician and/or patient were contacted at 6-month intervals to ensure filter retrieval when indicated. The Recovery and G2 filter groups were compared regarding technical success of filter placement, technical success of attempted retrieval, filter tilt, filter migration, filter fracture, and filter efficacy. Results Filter placement was technically successful in 95% of Recovery filters ( n = 122) and 100% of G2 filters ( n = 113). Recovery filter retrieval was attempted in 55% of patients ( n = 71) at a mean of 228 days (range, 0–838 d) after filter placement. G2 filter retrieval was attempted in 55% of patients ( n = 62) at a mean of 230 days (range, 7–617 d) after filter placement. Technical success rates of filter retrieval were 94% ( n = 67) and 97% ( n = 60) in the Recovery and G2 filter groups, respectively. The G2 filter group had significantly fewer cases of (i) filter tilt at placement, (ii) filter tilt at attempted retrieval, and (iii) filter fracture than the Recovery filter group. In the G2 filter group, there was a significantly higher technical success rate of filter placement and there were more cases of caudal filter migration than in the Recovery filter group. Conclusions Compared with the Recovery filter, the G2 filter is associated with significantly less filter fracture and tilt, greater technical success of filter placement, and more caudal filter migration.

OBJECTIVE: Drug eluting stents have recently been associated with the increased risk of adverse thrombogenic events and/or late luminal loss, which is highly associated with incomplete re-endothelialization. The increased risks behoove the design of alternative delivery modalities and/or drugs that do not compromise the re-endotheliaization process. The objective of the present study is to elucidate the biological mechanism(s) by which non-stent-based delivery modalities for the anti-proliferative lipid metabolite, C(6)-ceramide, could lead to a reduction in arterial injury after angioplasty. RESULTS: Immunohistochemical studies in rabbit and porcine models suggest that C(6)-ceramide-coated balloon catheters limit arterial stenosis without inhibiting endothelial wound healing responses. Specifically, C(6)-ceramide-coated balloon catheters reduce internal elastica injury with a corresponding reduction in medial fracture length in a 28-day porcine coronary artery stretch model. In addition, C(6)-ceramide decreases the formation of the fibrin matrix to possibly augment the subsequent wound healing response. We hypothesized that differential metabolism of exogenous ceramide by coronary endothelial and smooth muscle cells could explain the apparent discrepancy between the anti-proliferative actions of ceramide and the pro-wound healing responses of ceramide. Human coronary artery endothelial cells (HCAEC), in contrast to human coronary artery smooth muscle cells (HCASMC), preferentially express ceramide kinase and form ceramide-1-phosphate, which promotes endothelial cell survival. CONCLUSION: Differential metabolism of ceramide between HCASMC and HCAEC offers a mechanism by which ceramide preferentially limits smooth muscle cell growth, in the presence of active wound healing. The combinatorial ability of ceramide to limit vascular smooth muscle proliferation and promote re-endothelialization, offers the potential for C(6)-ceramide-coated catheters to serve as adjuncts to stent-based modalities or as a stand-alone treatment.

PURPOSE A number of percutaneous thrombectomy devices are undergoing investigation for treatment of patients with venous thromboembolism. Use of radiopaque thrombus to monitor thrombus delivery and assess thrombectomy has been previously reported. The purpose of this project was to quantitatively test the effect of mixing different ratios of blood and contrast material to facilitate maximum thrombus formation and radiopacity. MATERIALS AND METHODS The following ratios of blood and contrast material were mixed: 2 mL blood to 8 mL contrast material (ratio = 0.25), 4 mL blood to 6 mL contrast material (ratio = 0.67), 6 mL blood to 4 mL contrast material (ratio = 1.5), and 8 mL blood to 2 mL contrast material (ratio = 4). Contrast material was added at day 0, 3, or 6. Each sample received one of two ionic contrast agents to opacify the clots. At day 14, thrombus mass and opacity were determined. RESULTS Three combinations of blood and contrast material produced maximum thrombus and radiopacity. These were sodium iothalamate 30% with a ratio of 4 with contrast material added on day 0 and sodium iothalamate 60% with a ratio of 1.5 with contrast material added on day 3 or 6. CONCLUSIONS When forming radiopaque thrombi, significant differences can result from the ratio of blood to contrast material used. Contrast material type can also affect radiopacity and mass formed. The use of optimal ratios of blood to contrast material should maximize device evaluation with minimal wasting of valuable resources such as test subjects, physician time, and equipment.

Purpose To determine whether definable differences exist between arterial and venous smooth muscle cells (SMCs), as measured by proliferative response to co-culture with arterial or venous endothelial cells (ECs). Materials and Methods Human aortic ECs (A-ECs) and saphenous vein ECs (V-ECs) were cultured opposite either aortic SMCs (A-SMCs) or saphenous vein SMCs (V-SMCs). At selected time intervals, SMCs were counted by fluorescence microscopy. Results In the presence of an intact EC monolayer, A-ECs induced a 9%–31% increase in A-SMC ( P ≤ .001) and a 15%–37% increase in V-SMC ( P ≤ .001) proliferation. Saphenous vein ECs induced a 50%–71% increase in A-SMC ( P ≤ .001) and a 40%–62% increase in V-SMC ( P ≤ .001) proliferation. The small proliferative difference between A-SMCs and V-SMCs was significant for co-culture with A-ECs ( P ≤ .001) and V-ECs ( P ≤ .001). Of note, compared to A-ECs, V-ECs induced a significantly greater A-SMC ( P ≤ .001) and V-SMC ( P ≤ .001) proliferative response. Conclusion A small, but definable, difference exists between A-SMCs and V-SMCs, as measured by proliferative response in co-culture with A-ECs and V-ECs.

Purpose Significant inferior vena cava (P/C) filter migration has been associated with deployment of some filter types in P/Cs measuring more than 28 mm in diameter at inferior vena cavography. The purposes of this study were to (a) determine if significant differences exist between TVC measurements obtained using a gold standard technique and two other widely accepted methods, and (b) if differences exist, how often do these differences cause incorrect TVC sizing around a diameter of 28 mm, with its associated filter migration issues. Materials and Methods One hundred thirteen consecutive inferior vena cavograms were retrospectively reviewed. The transverse diameter of the infrarenal IVC was determined by using a calibrated intravascular catheter (the gold standard), subtraction of 20% from the measured transverse TVC diameter on a cut-film radiograph, and a radiopaque ruler placed immediately posterior to the patient. Results The concordance correlation of the 20% magnification method versus internal calibration was 0.94. Kappa analysis to determine agreement at a diameter of 28 mm yielded a Kappa coefficient of 0.490. The concordance correlation of an external ruler versus internal calibration was 0.43, with a Kappa coefficient of 0. Conclusion The poor Kappa correlations for both methods demonstrate that they are unreliable in identifying megacava. Inferior vena cavography prior to TVC filter placement should be performed with a calibrated intravascular catheter.

Purpose This study reports the authors' experience with long-term follow-up of 100 consecutive peripherally inserted, subcutaneous arm ports for central venous access. Materials and Methods One hundred patients with subcutaneous arm ports inserted by interventional radiologists were retrospectively studied. Data were collected from the patients' medical records and from telephone canvassing. Using each insertion period as an observation, the complication rates per 100 catheter days were determined with 95% confidence intervals (CIs). Results One hundred subcutaneously implanted ports were placed in 98 patients; three devices (three patients) were lost to follow-up, leaving 97 devices in 95 patients. Total exposure time was 23,842 days (mean, 246 days; range, 2–865 days). Seven infectious and two noninfectious complications occurred with seven (7.2%) devices in six patients (6.3%), yielding 0.038 complications per 100 catheter days at risk (95% CI; 0.011–0.069) and 0.029 infections per 100 catheter days at risk (95% CI; 0.008–0.058). A successful clinical outcome was defined as a functional port at removal, time of death, or at study closure (minimum of 6 months of follow-up), which was not removed because of a complication. This successful outcome was achieved in 91 ports (93.8%). Procedural-related complications, defined as those occurring up to 30 days after insertion, occurred in only one port (thrombophlebitis and catheter tip infection — day 9). All other patients received several months of service from their port. Fifteen devices were placed in 13 patients with HIV for 3,486 days, with a total complication rate of 0.11 per 100 catheter days (95% CI; 0.0– 0.28), all of which were infections. Devices in HIV-positive patients were associated with higher total complication (20% vs 4.9%) and infection rates (20% vs 3.7%) than devices in patients without HIV infection. This gives a relative risk 8.17 × ( P =.04) greater for infectious complications for devices placed in HIV-infected individuals. Conclusions Subcutaneous arm ports placed by interventional radiologists are effective for central venous access with excellent functionality (93.8% achieved a successful long-term outcome) and a very low procedural complication rate. Although infections were more frequent in HIV-infected individuals, these devices are associated with a very low incidence of both immediate and long-term complications, including infection, for all patients.

Purpose The critical role of endothelial cells (ECs) in arterial disease is well established, but little is known of their role in venous disease. Previous studies suggest inherent differences between arteries and veins: arterial stenoses demonstrate a large lipid component, whereas hemodialysis-related venous stenoses are characterized by marked smooth muscle cell (SMC) proliferation. This study compares effects of venous versus arterial ECs on SMC proliferation in co-culture. Materials and Methods Human saphenous vein ECs (HSV-ECs) or human aortic ECs (HA-ECs) were cultured on the underside of 10-μm, porous polycarbonate membranes and allowed to grow to confluence for 48 hours. After EC confluence, human aortic SMCs (HA-SMCs) were cultured on the membranes opposite the EC (day 0). On days 0, 1, 2, 4, 6, and 8, membranes were harvested ( n = 3 per day), stained with Hoechst dye, and HA-SMCs were counted by fluorescence microscopy. Controls were HA-SMCs cultured alone. Comparisons were made by two-way multivariate analysis of variance. Results During the entire 8-day period, there was significant induction of HA-SMC proliferation by both HSV-ECs ( P = .0003) and HA-ECs ( P = .0012). Maximal inductions were 88% ± 11% for HSV-ECs ( P = .0015) and 24% ± 6% for HA-ECs ( P = .0015). HSV-ECs exhibited a three-to ninefold greater induction than HA-ECs ( P = .0003). Conclusion HSV-ECs induce adjacent HA-SMC proliferation, possibly in a paracrine manner to a significantly greater extent than HA-ECs.

Investigation of a technique for nonsurgical female sterilization.A custom designed platinum microcoil with Dacron fibers was placed unilaterally into a fallopian tube and uterine horn of 10 rabbits after transcervical selective tubal catheterization with use of fluoroscopic guidance. The contralateral uterus and fallopian tube served as controls. After the rabbits were bred, pregnancy was determined by palpation and confirmed at autopsy. Postmortem histopathologic evaluation of uteri and fallopian tubes was performed.Nine of the 10 rabbits became pregnant. None of the animals had embryos on the microcoil side. Nine rabbits had a total of 45 embryos on the control side. One animal failed to become pregnant on either side. The microcoil remained in good position in all 10 rabbits. There was a microcoil-associated, mild inflammatory tissue response in the uteri and fallopian tubes.A platinum occlusion microcoil placed in a utero-tubal location has potential as a means for nonsurgical female sterilization.At Milton S. Hershey Medical Center in Hershey, Pennsylvania, researchers used fluoroscopy to guide transcervical selective tubal catheterization in order to correctly insert a custom-designed platinum microcoil with Dacron fibers 1.5-6 cm into a fallopian tube and 1.5-5.5 cm into a uterine horn of 10 rabbits. The fallopian tube and uterine horn on the opposite side were the controls. The researchers sacrificed the rabbits to conduct histopathologic examination of the uteri and fallopian tubes in order to determine the presence or absence of embryos. One rabbit had no embryos on either side, even after 4 breeding attempts. Among the remaining 9 rabbits, there were no embryos on the microcoil side and 45 embryos on the control side. The position of the microcoil did not change in any rabbit. The microcoil caused a mild inflammatory tissue response in the uteri and fallopian tubes. Longer-term studies in more animals are necessary to confirm the efficacy and safety of this sterilization method as well as to determine the potential for retrievability of the microcoil and reversibility of the sterilization effect. In conclusion, a uterotubal coil may someday be a safe, effective, minimally invasive means of female sterilization.

Purpose To review utility, safety, and efficacy of optional inferior vena cava (IVC) filters in patients 65 years or older at a single institution over a 6-year period. Materials and Methods Retrospective review of permanent and optional IVC filters placed in elderly patients was performed. Older and younger groups were compared based on technical success of filter placement and clinical success measured by recurrent pulmonary embolism (PE) or thrombotic complications. The rate of successful filter removal was compared with that in the cohort of patients of all ages who received optional filters. Results Fifty-three patients received an optional filter and 445 received a permanent filter. Technical success rates for filter placement in the permanent and optional filter groups were 99.8% (447 of 448) and 98.1% (53 of 54), respectively ( P = .51). Rates of PE after filter placement were 0% and 1.4% (five of 359) in the optional and permanent filter groups, respectively ( P = .87). Incidences of deep vein thrombosis were 12% (six of 50) and 4.5% (16 of 359) in optional and permanent filter recipients, respectively ( P = .06). Filter retrieval was attempted in 55.6% of optional filter recipients (30 of 54), similar to that seen in patients of any age with optional filters. Retrieval was unsuccessful in one patient in whom a suprarenal IVC filter was placed. Conclusions Optional filters are safe and effective in patients aged 65 years or older. Age alone is a poor predictor of a clinical opportunity to remove a filter. With appropriate patient selection and aggressive follow-up, retrieval rates comparable with those in younger populations can be achieved.

The placement of peripherally inserted central catheters has grown into one of the most common forms of intravenous access. Although complications associated with peripherally inserted central catheters are low, most healthcare providers will encounter them on a frequent basis. Awareness of these complications will help the clinician manage these issues appropriately.

This report details the percutaneous removal of a metallic foreign body from the wall of the thoracic aorta. The foreign body was presumably swallowed and migrated from the esophagus into the aortic lumen progressively during a period of 10 months. The patient had no adverse consequences from the procedure immediately or in the subsequent 18 months of follow-up.

The Holy Grail of cardiovascular pharmacology has been the search for an effective therapy targeting restenosis after angioplasty and/or intra-arterial stenting. The failure of promising therapeutics in clinical trials underscores the complexity and redundancy of the signaling cascades regulating mitogenesis and fibrogenesis. Novel therapeutic modalities have potential to target dysfunctional signaling elements directly in vascular smooth muscle cells. Significant progress in the treatment against restenosis will require the exploitation and cross-fertilization of developments in the fields of pharmacology, bioengineering, genetics, and molecular biology. Collaboration among researchers in these fields will be essential.

NEARLY 70 years ago, Osborne et al (1) first reported the imaging of the urinary tract using iodinated contrast material. In the last 30 years, there has been a marked increase in diagnostic and interventional procedures in which iodinated contrast is used. The structure of radiocontrast agents has been modified over the last several decades, yielding compounds with significantly less chemotoxicity. Unfortunately, the administration of even the newest radiocontrast agents may cause nephrotoxicity. Contrast media-induced nephropathy (contrast nephropathy; CN) has been reported to be the third-leading cause of acute renal failure in hospitalized patients (2–5), occurring at a rate of 1%–6% in unselected patient populations (4,5), and up to 40%–50% in high-risk patient populations (6–8). Unfortunately, it is frequently this higher-risk group, particularly those with preexisting renal insufficiency and diabetes mellitus, which is encountered by the cardiovascular and interventional radiologist. Based on multiple laboratory and clinical investigations performed over the last decade, the current discussion will focus on the pathogenesis and clinical presentation of CN, identification of patients at higher risk of developing CN, and interventions that may diminish the risk of CN.

PURPOSE Peripherally inserted central catheters (PICCs) have become an essential component of the management of an increasing number of patients, including patients who may require hemodialysis. Reported symptomatic venous thrombosis rates associated with PICC lines are based on clinical signs and symptoms and range from 1% to 4%. The purpose of this study is to evaluate the true rate of thrombosis of upper extremity veins after the placement of PICCs and the potential impact on future access in hemodialysis patients. MATERIALS AND METHODS A retrospective analysis was performed. Patients who had (i) normal findings during initial venography, (ii) PICC placement, and (iii) who underwent subsequent repeated venography were included. Age, sex, vein cannulated, catheter size, location, and incidence of thrombosis were analyzed. RESULTS Three hundred fifty-four PICCs were placed in 119 patients. Of the 144 extremities, 137 had normal findings during initial venography. Of the 137 extremities, 32 developed thrombosis of the cannulated vein (or central veins) after initial PICC placement (23.3%). When all extremities with multiple PICC lines placed were considered, 52 developed thrombosis, for an overall thrombosis rate of 38%. The incidence of thrombosis by site was cephalic 57%, basilic 14%, and brachial 10%. No significant differences were noted in the rates of thrombosis by age, sex, or catheter size. CONCLUSIONS There is a relatively high rate of venous thrombosis associated with PICCs, particularly cephalic thrombus. Because of the high rate of thrombosis associated with these catheters, an alternative mode of access should be considered in current or potential hemodialysis patients. All patients with a history of PICC line placement requiring dialysis access should undergo upper extremity venography prior to the placement of permanent access.

Purpose: A large multicenter study has recently questioned the overall clinical efficacy of vena caval filters, especially when inserted prophylactically, because of the subsequent development of deep venous thrombosis (DVT) at the insertion site. We examined the incidence of this complication with newer, smaller diameter percutaneous devices. Methods: We reviewed our vascular surgery and interventional radiology clinical registries to identify patients in whom a femoral percutaneous vena caval filter had been placed from 1993 to 1998. This list was cross referenced with patients who had undergone lower extremity venous ultrasound scan examinations for the diagnosis of DVT in the vascular laboratory within a 60-day period before and after the insertion of the filter device. Results: A total of 35 patients during this 5-year period had timely follow-up venous duplex scan studies performed. The indications for filter placement were DVT in 16 patients (46%), pulmonary embolus in 13 patients (37%), DVT and pulmonary embolus in three patients (9%), and prophylactically in three patients (9%) at high risk for thromboembolization. Of the patients with documented thromboembolic events, 91% (29 of 32) had contraindications to anticoagulation therapy, and the remaining 9% (3 of 32) represented failure of anticoagulation therapy. A Greenfield filter was used in 13 patients (37%), a Simon Nitinol filter was used in 11 patients (31%), and a VenaTech filter was used in nine patients (26%). The other two patients (6%) had a Bird’s Nest filter inserted. At a mean follow-up period of 12 ± 2 days (median, 6 days), there was a 40% (14 of 35) incidence of proximal DVT in venous segments without evidence of thrombus before filter insertion. The majority (71%; 10 of 14) occurred in the common femoral vein, with three located in the superficial femoral vein and one in the external iliac vein. The lowest incidence of DVT was seen with the Greenfield and Bird’s Nest filters as compared with the smaller Simon Nitinol and VenaTech filters (20% vs 55%; P < .05). The highest incidence of thrombosis occurred in patients with pre-insertion pulmonary emboli (50%; 8 of 16) as compared with those patients with DVT (38%; 6 of 16) and prophylactic insertion (0%; 0 of 3). However, the subgroups were too small to attain statistical significance. Conclusion: There is a continuing and significant incidence of new DVT development ipsilateral to the percutaneous femoral insertion site of vena caval filters. The smaller diameter filters are not associated with a lower incidence of femoral thrombosis. (J Vasc Surg 1999;30:821-9.)

Purpose Massive pulmonary embolus (PE) is often rapidly fatal. Surgical thrombectomy has a mortality rate as high as 74%. Multiple percutaneous methods have been tested with limited success. The purpose of this study was to evaluate the Arrow-Trerotola percutaneous thrombolytic device (PTD) for (i) the ability to clear pulmonary embolus and (ii) the effect on normal pulmonary vasculature. These were tested in a canine model. Materials and Methods Iatrogenic unilateral massive PEs were created in nine canines. These PEs were then treated with the PTD. The device was also activated in the normal pulmonary artery. Immediately after treatment, six animals were killed. Three animals were allowed to recover and underwent pulmonary arteriography 1 month later to evaluate pulmonary hypertension, stenosis, or occlusion; they were then killed. Autopsy specimens were evaluated for histologic evidence of acute or chronic vascular injury. Results Acutely, the PTD effectively thrombolysed the PE in all animals. Histologically, there was moderate intimal injury, but no evidence of pulmonary artery disruption. There was one device failure. One month after treatment, there was no radiographic evidence of pulmonary stenosis at device activation sites, no pulmonary hypertension, and only mild histologic evidence of scar formation. Conclusion In preliminary animal testing, the PTD is safe and effective for treating large central pulmonary emboli. Human clinical trials are warranted.