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Purpose To describe interventional oncology therapies combined with immune checkpoint inhibitor (ICI) therapy targeting the programmed death 1 pathway in patients with different neoplasms. Materials and Methods This was a retrospective cohort study of patients who underwent tumor-directed thermal ablation, embolization, or selective internal radiation therapy (SIRT) between January 1, 2011, and May 1, 2019, and received anti–programmed death 1/PD-L1 agents ≤ 90 days before or ≤ 30 days after the interventional procedure. Immune-related adverse events (irAEs) and procedural complications ≤ 90 days after the procedure were graded according to the Common Terminology Criteria for Adverse Events version 5.0. The study included 65 eligible patients (49% female; age 63 years ± 11.1). The most common tumors were metastatic melanoma (n = 28) and non–small cell lung cancer (NSCLC) (n = 12). Patients underwent 78 procedures (12 patients underwent > 1 procedure), most frequently SIRT (35.9%) and cryoablation (28.2%). The most common target organs were liver (46.2%), bone (24.4%), and lung (9.0%). Most patients received ICI monotherapy with pembrolizumab (n = 30), nivolumab (n = 22), and atezolizumab (n = 6); 7 patients received ipilimumab and nivolumab. Results Seven (10.8%) patients experienced an irAE (71.4% grade 1–2), mostly affecting the skin. Median time to irAE was 33 days (interquartile range, 19–38 days). Five irAEs occurred in patients with melanoma, and no irAEs occurred in patients with NSCLC. Management required corticosteroids (n = 3) and immunotherapy discontinuation (n = 1); all irAEs resolved to grade ≤ 1. There were 4 intraprocedural and 32 postprocedural complications (77.8% grade Conclusions No unmanageable or unanticipated toxicities occurred within 90 days after interventional oncology therapies combined with ICIs.

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.

To investigate the relationship between anatomic factors and primary patency of brachiocephalic arteriovenous fistulae (AVFs) after stent graft (SG) placement for cephalic arch stenosis (CAS).This retrospective study reviewed all cephalic arch SGs placed in brachiocephalic AVFs in a tertiary academic medical center between 2014 and 2017. Sixty-three patients were included in the study. The mean patient age at the time of SG placement was 62.6 years ± 19, and the mean patient follow-up was 1,994 days ± 353. A cohort of patients (n = 31) who underwent brachiocephalic fistulograms for CAS but only received percutaneous transluminal angioplasty (PTA) was the control group. Patient demographic characteristics, AVF anatomy, SG type, and clinical outcomes were reviewed. The duration of primary cephalic arch patency after SG placement was compared with that after previous PTA.The median AVF age at the time of data retrieval was 345 days. The primary patency of CAS after SG placement at 6 months, 12 months, and 3 years was 64%, 49.9%, and 23.5%, respectively. Primary cephalic arch patency was significantly associated with the SG diameter (P = .007) but not with cephalic vein-axillary vein junction anatomy, size of feeding artery, or SG length (P.05). The primary patency of CAS in patients treated with PTA only (n = 31) at 6 months, 12 months, and 3 years was 61%, 35%, and 0%, respectively, which was significantly lower than that in patients treated with SG placement (P = .01).This study showed that the primary patency of CAS after SG placement was significantly higher than that of PTA-only treatment. Moreover, primary cephalic arch patency after SG placement was significantly associated with the SG diameter.

Frostbite injuries are becoming more common in the civilian population and are frequently associated with homelessness, mental illness, and alcohol and drug use and abuse. Taking care of these patients requires a multidisciplinary approach, initially by emergency medicine, the burn service, and interventional radiology, and eventually involving case management, social services, and occupational and physical therapy. Timely and rapid rewarming in conjunction with catheter-directed intravascular thrombolysis interventions can restore adequate perfusion to the patient's compromised digits. To improve patient outcomes, it is essential to obtain proper imaging and, if appropriate, immediately initiate an interventional radiology consultation for urgent thrombolysis treatment. This article presents a clinical case study of a patient who suffered frostbite injuries and underwent intravascular thrombolysis interventions that spanned a 24-hour period and required two interventional radiology procedures. Nursing care considerations and thrombolysis management in the emergency department, radiology department, and intensive care unit are reviewed.

Objective: To investigate the relationship between arteriovenous fistula (AVF) arterial diameter (AD) and AVF aneurysm development and progression. Methods: This study identified all patients who underwent fistulograms which demonstrated AVF aneurysms meeting criteria and requiring surgical intervention between 01/01/2014 and 7/30/2016. Patient demographics were collected and AVF dimensions were measured on fistulograms. A control group with nonaneurysmal AVFs who had undergone serial fistulograms between 2013 and 2016 were identified and identical datasets collected. Statistical analysis was performed with STATA 14.0 using student’s t-test, Chi square tests and linear regression. Results: 45 eligible patients were identified in the AVF aneurysm study group and 24 in the control group, with the mean age of AVF creation being older in the control group (61.8 vs 53 years, p = 0.03). The mean interval between AVF creation and first fistulogram in the study group was 1464 ± 282 days, compared to an interval of 263 ± 101 days in the control group ( p = 0.003). The AD on the first fistulogram in those study group patients with aneurysms evident on first fistulogram was greater than in the control group (6.5±1.8 mm vs 5.0 ± 1.8 mm, p = 0.003). The AD on first fistulogram of the study group predicted maximum aneurysm diameter on last fistulogram ( r = 0.6, p = 0.03) as well as the interval between first fistulogram and surgical revision ( r = −0.33, p = 0.03). Conclusion: AVF aneurysms are a later complication in access natural history and AD may help to predict their progression.

Erector spinae plane block (ESPB) is a fascial plane block that targets the dorsal and ventral branches of the primary dorsal root ganglion. We report a case of a 76-year-old woman who presented for percutaneous posterior interspinous decompression spacer at the L3-L4 level in the setting of neurogenic claudication from severe spinal stenosis. We describe the novel performance of bilateral ESPBs under ultrasound guidance for postprocedural analgesia. Throughout the recovery period, the patient experienced sustained pain relief. ESPB may be a useful adjunct for periprocedural analgesia and recovery in patients undergoing interspinous spacer placements.

The purpose of this study is to investigate the long-term safety and efficacy of a small-diameter expandable transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension.This single-center retrospective study included 28 patients (12 women and 16 men; mean age, 56.9 years) who underwent small-diameter expandable TIPS creation between 2008 and 2010 for refractory ascites (n = 15; mean [± SD] model for end-stage liver disease [MELD] score, 15.5 ± 5.3) or gastrointestinal variceal bleeding (n = 13; mean MELD score, 15.2 ± 8.4). An expandable TIPS was created by deploying a covered stent inside a balloon expandable stent. For patients with recurrent symptoms, TIPS adjustment was made by balloon expandable stent balloon dilation. The TIPS diameter was defined as the diameter of the final angioplasty balloon. TIPS patency and efficacy and the rate of post-TIPS hepatic encephalopathy were evaluated.The median diameter of the initial TIPS was 8 mm in the group with variceal bleeding compared with 6 mm in the group with ascites (p = 0.003). The primary patency rate at 1 and 5 years was 90.8% and 73.3%, respectively. Eighty percent of patients with ascites required no or less-frequent large-volume paracentesis. The clinical success rate for patients with acute variceal bleeding was 92.3%. Six patients with ascites (initial TIPS diameter, 6 mm) and two patients with variceal bleeding (initial diameter, 6 mm and 8 mm) required subsequent TIPS adjustment. Of the 22 patients with no prior history of enecphalophy, seven patients (31.8%) experienced new hepatic encephalopathy within 90 days.A small-diameter expandable TIPS is technically feasible and safe, with efficacy falling within the range of that of conventional TIPS. This technique offers the possibility of individualizing the degree of portal decompression.

Background/aimsThe MELD score was developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS) placement. Given changes in practice patterns and development of new prognostic tools in cirrhosis, we aimed to evaluate common models to predict mortality after TIPS placement.MethodsAnalysis of consecutive patients who underwent TIPS placement for ascites or bleeding. Performance to predict 90-day mortality was assessed by C statistic for six models (MELD, MELD-Na, CLIF-C ACLF, Child-Pugh, Platelet-Albumin-Bilirubin, and Emory score). Added predictive value to MELD score was assessed for univariate predictors of 90-day mortality. Stratified analysis by TIPS indication, emergent placement status, and TIPS stent type was performed.Results413 patients were analyzed (248 with variceal bleeding, 165 with refractory ascites). 90-day mortality was 27% (113/413). Mean MELD score was 15 ± 7.9. MELD score best predicted mortality for all patients (c = 0.779), for variceal bleeding (c = 0.844), and for emergent TIPS (c = 0.817). CLIF-C ACLF score best predicted mortality for refractory ascites (c = 0.707). Addition of sodium to the MELD score did not improve predictive value across multiple strata. Addition of hemoglobin improved MELD score's predictive value in variceal bleeding. Addition of age improved MELD score's predictive value in refractory ascites.ConclusionsMELD score best predicted 90-day mortality. Addition of sodium to the MELD score did not improve its performance, though mortality prediction was improved using Age-MELD for ascites and Hemoglobin-MELD for bleeding. An individualized risk stratification approach may be best when considering candidates for TIPS placement.

Radiofrequency (RF) ablation of the lateral sacral plexus has been used for the treatment of sacroiliac joint pain including as an adjunct to other palliative therapies for the treatment of painful osseous metastasis. The treatment goal is targeted ablation of the dorsal lateral branches of S1-S4. Though several techniques have been described, the Simplicity III (Neurotherm, Middleton, MA) system allows for ablation to be achieved with a single RF probe by utilizing a multi-electrode curved RF probe to create a continuous ablation line across all sacral nerves. In the standard approach, there is sequential introduction of a spinal needle along the desired ablation tract for local anesthesia followed by separate placement of the ablation probe. Though fluoroscopic guidance is utilized, multiple needle passes increase the risk of complication such as bowel perforation or probe insertion through a neural foramen. It may also extend procedure time and increase radiation dose. We illustrate a technique for Simplicity III RF ablation of the dorsal sacral plexus using a modified Seldinger approach for treatment of a patient with sacroiliac joint pain due to osseous renal cell carcinoma metastasis. The desired ablation tract is initially anesthetized via a hollow micropuncture needle. The needle is then exchanged for a peelaway sheath. The RF probe is inserted through the peelaway sheath thus ensuring the probe is placed precisely along the previously anesthetized tract allowing the procedure to be completed using a single percutaneous puncture. We believe that this approach decreases the risks of bowel perforation, patient discomfort as a result of multiple percutaneous punctures, and procedure time. Key words: Simplicity 3, sacral plexus ablation, image-guided approach, modified Seldinger, chronic sacral pain, thin wall introducer needle

Kidney Disease Outcomes Quality Initiative guidelines recommend arteriovenous fistulas as the preferred access for hemodialysis patients. However, this may not hold across all populations of patients, especially the elderly, given their comorbidities and relatively reduced life expectancy. Therefore, we investigated whether fistulas held benefit over arteriovenous grafts as hemodialysis access in elderly patients.We retrospectively searched a vascular access database to compare the outcomes for 138 fistulas and 44 grafts that were placed in elderly patients (≥75 years old) during a 4-year period at a tertiary medical center.The primary failure rate was higher for the fistulas compared with the grafts (odds ratio, 2.89; P = .008), and more fistulas required one or more interventions before their successful use compared with grafts (31% vs 10%, respectively; P = .03). In addition, the time to catheter-free dialysis was longer for fistulas than for grafts (P .001). However, the primary and secondary patency rates were comparable between the fistulas and grafts and between the different access locations. The all-cause mortality rates were also comparable between the fistula and graft groups.Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.

Transjugular intrahepatic portosystemic shunt (TIPS) was first described by Rosch et al. in 1969, and in 1982, Colopinto et al. described its first clinical application in a patient with cirrhosis and variceal hemorrhage. It was not until 1988 that the first metal-lined shunt was created, and in 1997 the first polytetrafluoroethylene (PTFE)-lined stent was used in humans for shunt revision after stenosis, created by pinning the Gore PTFE graft material between two metal stents. Introduced in 2000, the Viatorr stent graft is now the most commonly used device for TIPS. One of the major side effects of TIPS creation is hepatic encephalopathy (HE). This chapter discusses the adjustable small-diameter transjugular intrahepatic portosystemic shunt.

Lower extremity deep venous thrombosis (DVT) may be complicated by pulmonary embolism, post-thrombotic syndrome, and phlegmasia cerulea dolens. Due to these complications, the American Venous Forum now recommends thrombus removal for large or symptomatic thrombus burden. The AngioJet Solent Proxy and Omni thrombectomy sets are indicated for use in iliofemoral and lower extremity veins with a diameter ≥3 mm. The device has quickly become a preferred device among the available mechanical thrombectomy options. The AngioJet system has been demonstrated as both efficacious and safe as a method of thrombectomy in lower extremity DVT. This chapter discusses two techniques to utilize the AngioJet device in iliofemoral DVT.

Purpose To evaluate the safety and effectiveness of combined scoring balloon (SB) and paclitaxel-coated balloon (PCB) angioplasty for stenosis in the dysfunctional hemodialysis access circuit. Material and methods Patients were referred from outpatient dialysis centers by their nephrologists because of dysfunctional dialysis access circuit. Fistulogram/graftogram was performed by experienced interventional radiologists. Those with in-stent stenosis, stent edge stenosis or vessel diameter at the culprit segment larger than 6 mm were excluded. Angioplasty of the stenotic segment was performed with SB and followed by PCB. All study outcomes were defined according to the Society of Interventional Radiology technology assessment committee reporting standards for percutaneous interventional procedures in dialysis access circuit. Results A total of 23 patients received combined SB/PCB angioplasty for stenosis of hemodialysis access circuit which included 15 fistulas and 8 grafts. There were 10 men and 13 women with a mean age of 63.3 ± 2.7 (SD) years (range: 37–85 years). The technical success and clinical success rates were both 100%. There were no complications during or after the procedures. The target lesion primary patency rates at 3, 6 and 12 months were 91.3%, 69.6%, and 45.2%, respectively and the estimated median target lesion restenosis (TLR) free duration was 11.0 months (95% confidence interval [CI]: 5.1–16.9 months). In patients with a recurrent stenosis, the median TLR-free duration of combined angioplasty was significantly higher than that of prior angioplasty with plain balloon (10.2 months [95% CI: 6.4–14.0 months] vs. 4.2 months [95%CI: 2.1–6.4 months]) (P = 0.047). The mean TLR-free duration was significantly higher in patients with a juxta-anastomotic stenosis than those with non-juxta-anastomotic lesion (21.3 months [95% CI: 14.7–28.0 months] vs. 8.2 months [95% CI: 5.1–11.4 months]) (P = 0.004). Conclusion Combined SB/PCB angioplasty is safe and effective for the hemodialysis access stenosis.

Purpose To evaluate the safety and efficacy of yttrium-90 (90Y) transarterial radioembolization (TARE) around immunotherapy in patients with unresectable hepatic metastases from uveal melanoma (UM). Materials and Methods From March 2013 to December 2017, 11 patients with unresectable hepatic metastases from UM were treated with TARE around immunotherapy. Two patients received TARE as a first-line treatment followed by immunotherapy. Nine patients received immunotherapy before TARE, and 6 of these patients received additional immunotherapy after TARE. Retrospective review of the clinical data was performed to assess hepatic progression-free survival (hPFS), overall survival (OS), treatment response, and toxicities. The median follow-up period from TARE was 10.5 months (range 1–35.5 months). Results The median OS from diagnosis of hepatic metastases was 35.5 months (95% confidence interval [CI] 10.0–55.0 months). The median hPFS and OS from the start of TARE were 15.0 months (95% CI 5.9–24.1 months) and 17.0 months (95% CI 1.8–32.2 months), respectively. Complete response was observed in 1 patient (9.1%), partial response in 2 (18.2%), stable disease in 4 (36.4%), and progressive disease in 4 (36.4%). Ten patients had grade 1 or 2 clinical toxicities, and 1 had grade 3 with a peptic ulcer. Six patients had grade 1 or 2 biochemical toxicities and 1 had grade 3, which was related to tumor progression. Conclusions The present results suggest that TARE around immunotherapy is safe and effective. The combined treatment may improve hPFS and OS in patients with hepatic metastases from UM.

Indwelling central venous catheters have been reported to increase the risk of superior venous cava (SVC) syndrome. This case report describes the development of acute SVC syndrome in a 28-year-old woman with end-stage renal disease implanted with a left-side hemodialysis reliable outflow graft and a right-side double lumen hemodialysis catheter via internal jugular veins. Her symptoms were not alleviated after catheter removal and systemic anticoagulation therapy. She was eventually treated with catheter-directed thrombolysis and a predischarge computer tomographic venogram on postthrombolytic procedure day 7 showed patent central veins and patient remained asymptomatic. This case demonstrates that catheter-directed thrombolysis can be safely employed to treat refractory catheter-induced acute SVC syndrome in end-stage renal disease patients.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

Autogenous arteriovenous fistulae are the best method for prolonged, successful dialysis access. However, a substantial limitation of dialysis fistulae is their high primary failure rate, estimated to be as high as 70% for radiocephalic fistulae. Fistula maturation is influenced by demographic risk factors as well as anatomical barriers, the latter of which can be readily identified by noninvasive ultrasound imaging and physical examination. These barriers can be categorized as inflow problems (native arterial disease, arteriovenous anastomotic stenosis, and juxta-anastomotic stenosis) or outflow problems (proximal venous stenosis or collateral veins). Venous stenoses represent the most commonly observed barrier to fistula maturation. By treating these barriers with a systematic approach, interventionalists can significantly improve the likelihood of a fistula's usability for dialysis.

Creating a vascular access in the presence of a cardiovascular implantable electronic device (CIED) in a patient with or approaching end-stage renal disease can be challenging. In this study, we aimed to evaluate the impact of a CIED on the outcomes of vascular access creation in hemodialysis patients and determine their effects on vascular access patency. This is a single-center retrospective review of hemodialysis patients who underwent vascular access creation after CIED placement. Outcomes of vascular access creation and need for endovascular interventions were compared between patients with vascular access created ipsilateral and contralateral to the site of CIED. Comparing patients with arteriovenous (AV) access created ipsilateral to CIED placement (n=19) versus the contralateral side (n=17), the primary failure rate was 78.9% versus 35.3% (p=0.02). For AV accesses that were matured, the median primary patency durations for AV accesses created ipsilateral to the CIED was 11.2 months compared to 7.8 months for AV accesses created contralateral to the CIED (p=1.00). AV accesses created ipsilateral to a CIED have a higher primary failure rate compared with the contralateral arm and should be avoided as much as possible.

Purpose Balloon angioplasty is the standard treatment for dysfunctional hemodialysis fistulas, but angioplasty response of stenotic lesions located in different segments of the dialysis circuit has not been explicitly evaluated. The purpose of this study is to describe the distribution of stenotic lesions in the most common types of arteriovenous fistulas and to investigate the response to balloon angioplasty of stenotic lesions located in various segments of the fistula circuit. Materials and Methods This single-center, retrospective study was approved by the Institutional Review Board. A total of 263 fistulograms performed between January, 2014 and June, 2015 were reviewed. Stenotic lesion response to angioplasty was analyzed based on lesion location using a Kaplan-Meier analysis. Results Juxta-anastomotic stenoses (48%) were the most common lesions in radiocephalic fistulas, while the cephalic arch (30%) and venous outflow tract (24%) were the most common locations of stenotic lesions in brachiocephalic fistulas and basilic vein transposition fistulas, respectively. Primary patency after balloon angioplasty was significantly higher in lesions located in the venous segments manipulated during surgeries compared to the lesions located in the surgically naive zone (p = 0.001). The 6-month and 12-month primary patency of lesions post-angioplasty in the surgical zone were 76% and 71% compared to 58% and 43% in the surgically naive segments. Conclusions The distribution of stenotic lesions differs among each type of fistula. The primary patency of balloon angioplasty of stenotic lesions located in the surgically manipulated venous segment was significantly better than lesions located in the rest of the fistula circuit.

Background Patients with cirrhosis and refractory ascites have physiologic and hormonal dysregulation that contributes to decreased kidney function. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) can reverse these changes and potentially improve kidney function. We sought to evaluate change in estimated glomerular filtration rate (eGFR) following TIPS placement. Study Design Retrospective, matched cohort analysis. Settings & Participants Patients who underwent first-time TIPS placement for refractory ascites in 1995 to 2014. Frequency matching was used to generate a comparator group of patients with cirrhosis and ascites treated with serial large-volume paracentesis (LVP) in a 1:1 fashion. Predictor TIPS placement compared to serial LVP. Outcome Change in eGFR over 90 days' follow-up. Measurements Multivariable regression stratified by baseline eGFR 2 ; analysis of effect modification between TIPS placement and baseline eGFR. Results 276 participants (TIPS, n=138; serial LVP, n=138) were analyzed. After 90 days, eGFRs increased significantly after TIPS placement in participants with baseline eGFRs 2 compared to treatment with serial LVP (21 [95% CI, 13-29] mL/min/1.73m 2 ; P 2 (1 [95% CI, −9 to 12] mL/min/1.73m 2 ; P =0.8). There was significant effect modification between TIPS status and baseline eGFR ( P =0.001) in a model that included all participants. Limitations Outcomes restricted by clinically recorded data; clinically important differences may still exist between the TIPS and LVP cohorts despite good statistical matching. Conclusions TIPS placement was associated with significant improvement in kidney function. This was most prominent in participants with baseline eGFRs 2 . Prospective studies of TIPS use in populations with eGFRs 2 are needed to evaluate these findings.

Purpose To evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury. Materials and Methods A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8–62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9–83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5–96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7–95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12–96 h) was assessed. Complications were recorded. Results Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12–48 mg) over a mean period of 34 hours (range, 12–72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation ( P = .007). There was no significant correlation between amputation rates and duration of cold exposure ( P = .9), time to rewarming therapy ( P = .88), and time to thrombolysis ( P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma. Conclusions Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

Purpose: To evaluate the safety of inferior vena cava (IVC) filter retrieval in therapeutically anticoagulated patients in comparison to prophylactically or not therapeutically anticoagulated patients with respect to retrieval-related hemorrhagic complications. Materials and methods: This was a retrospective study of 115 consecutive attempted IVC filter retrievals in 110 patients. Filter retrievals were stratified as performed in patients who were therapeutically anticoagulated (group 1), prophylactically anticoagulated (group 2), or not therapeutically anticoagulated (group 3). The collected data included anticoagulant and antiplatelet medications (type, form and duration of administration, dosage) at the time of retrieval. Phone interviews and chart review was performed for the international normalized ratio (INR), activated partial thromboplastin time, platelet count, infusion of blood products, and retrievalrelated hemorrhagic complications. Results: Group 1 included 65 attempted filter retrievals in 61 therapeutically anticoagulated patients by measured INR or dosing when receiving low-molecular-weight heparin (LMWH). Four retrievals were not successful. In patients receiving oral anticoagulation, the median INR was 2.35 (range, 2 to 8). Group 2 comprised 23 successful filter retrievals in 22 patients receiving a prophylactic dose of LMWH. Group 3 included 27 attempted filter retrievals in 27 patients not receiving therapeutic anticoagulation. Six retrievals were not successful. Five patients were receiving oral anticoagulation with a subtherapeutic INR (median, 1.49; range, 1.16 to 1.69). No anticoagulation medication was administered in 22 patients. In none of the groups were hemorrhagic complications related to the retrieval procedures identified. Conclusions: These results suggest that retrieval of vena cava filters in anticoagulated patients is safe. Interruption or reversal of anticoagulation for the retrieval of vena cava filters is not indicated. (CHEST 2007; 132:31–36)

The presence of collateral veins is one of the most common causes of fistula failure to mature. The traditional approach to eliminate collateral vessel flow is coil embolization under fluoroscopy or surgical cut down and branch vessel ligation. However, both approaches are expensive and time consuming. Here, we described an image-guided nonsurgical method to ligate collateral veins. The collateral veins were ligated using Hawkins-Akins needle under ultrasound guidance. The average time for one ligation procedure was 17 minutes. There was a significant increase of blood flow in the venous outflow postligation procedure. Four weeks postprocedure ultrasound demonstrated occlusion of the target vessels. This procedure was well tolerated without major complications. In summary, the novel procedure described here offers an image-guided nonsurgical approach for collateral vein occlusion.

Inferior vena cava (IVC) filter placement has seen a rising trend over the past decade. Although effective in the prevention of future pulmonary emboli, filters are associated with several long-term complications including deep venous thrombosis, filter migration, filter fracture, and caval thrombosis. The IVC filters have evolved over the years to minimize these unwarranted sequelae. We describe a technique to remove a permanent IVC filter in a patient who no longer required mechanical protection.