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Technical Feasibility and Clinical Efficacy of Iliac Vein Stent Placement in Adolescents and Young Adults with May-Thurner Syndrome

Bertino, Frederic J; Hawkins, C Matthew; Woods, Gary M; Shah, Jay H; Variyam, Darshan E; Patel, Kavita N; Gill, Anne E
PURPOSE/OBJECTIVE:To report technical feasibility and clinical efficacy of iliac vein stent placement in adolescent patients with May-Thurner Syndrome (MTS). MATERIALS AND METHODS/METHODS:Single-institution retrospective review of the medical record between 2014 and 2021 found 63 symptomatic patients (F = 40/63; mean age 16.1 years, 12-20 years) who underwent left common iliac vein (LCIV) stent placement for treatment of LCIV compression from an overriding right common iliac artery, or equivalent (n = 1, left IVC). 32/63 (50.7%) patients presented with non-thrombotic iliac vein lesions (NIVL). 31/63 (49.2%) patients presented with deep vein thrombosis of the lower extremity and required catheter-directed thrombolysis after stent placement (tMTS). Outcomes include technically successful stent placement with resolution of anatomic compression and symptom improvement. Stent patency was monitored with Kaplan-Meier analysis at 3, 6, 12, 24, and 36 months. Anticoagulation and antiplatelet (AC/AP) regimens were reported. RESULTS:Technical success rate was 98.4%. 74 bare-metal self-expanding stents were placed in 63 patients. Primary patency at 12, and 24-months was 93.5%, and 88.9% for the NIVL group and 84.4% and 84.4% for the tMTS group for the same period. Overall patency for the same time intervals was 100%, and 95.4% for the NIVL group and 96.9%, and 96.9% for the tMTS group. Procedural complication rate was 3.2% (2/63) with no thrombolysis-related bleeding complications. Clinical success was achieved in 30/32 (93.8%) and 29/31 (93.5%) patients with tMTS and NIVL groups, respectively. CONCLUSION/CONCLUSIONS:CIV stent placement in the setting of tMTS and NIVL is technically feasible and clinically efficacious in young patients with excellent patency rates and a favorable safety profile.
PMID: 38097769
ISSN: 1432-086x
CID: 5588912

Pediatric Transplant Interventions

Sharma, Pareena; Shah, Ritu; Zavaletta, Vaz; Bertino, Frederic; Sankhla, Tina; Kim, Jun Man; Leshen, Michael; Shah, Jay
The field of pediatric organ transplantation has grown significantly in recent decades, with interventional radiology (IR) playing an essential role in managing pre and post-transplant complications. Pediatric transplant patients face unique challenges compared to adults, including donor-recipient size mismatch, and complications of a growing child with changing physiology. Interventional radiologists play a major role in pediatric renal and liver transplant. IR interventions begin early in the child's pretransplant journey, with diagnostic procedures such as biopsies, angiograms, and cholangiograms. These procedures are essential for understanding the etiology of organ failure and identifying potential transplant candidates. Minimally invasive therapeutic procedures may serve as bridges to transplant and may include vascular access optimization for hemodialysis, transjugular intrahepatic portosystemic shunts (TIPS) creation, and tumor embolization or ablation. After transplant, image-guided biopsies for the surveillance of graft rejection and treatment of vascular or luminal stenoses, pseudoaneurysms, and anastomotic leaks can maintain the function and longevity of the transplant organ. Careful consideration must be given to patient size and evolving anatomy, radiation exposure, and the need for deeper sedation for pediatric patients. Despite these challenges, the integration of IR in pediatric transplant care has proven beneficial, offering minimally invasive alternatives to surgery, faster recovery times, and improved outcomes.
PMID: 38123288
ISSN: 1557-9808
CID: 5620222

Contemporary management of extracranial vascular malformations

Bertino, Frederic J; Hawkins, C Matthew
Vascular malformations are congenital vascular anomalies that originate because of disorganized angiogenesis, most commonly from spontaneous somatic genetic mutations. The modern management of vascular malformations requires a multidisciplinary team that offers patients the gamut of medical, surgical, and percutaneous treatment options with supportive care. This manuscript discusses the standard and contemporary management strategies surrounding extracranial vascular malformations and overgrowth syndromes.
PMID: 37156889
ISSN: 1432-1998
CID: 5509272

Embolic Protection During Malignant Inferior Vena Caval Thrombectomy Using the Protrieve Sheath [Letter]

Shin, David S; Abad-Santos, Matthew; Kuyumcu, Gokhan; Monroe, Eric J; Bertino, Frederic J; Jackson, Tyler; Chick, Jeffrey Forris Beecham
PMID: 36703083
ISSN: 1432-086x
CID: 5422272

Percutaneous thrombectomy of upper extremity and thoracic central veins using Inari ClotTriever System: Experience in 14 patients

Sweeney, Ashley M.; Makary, Mina S.; Greenberg, Colvin; Chick, Jeffrey Forris Beecham; Abad-Santos, Matthew; Monroe, Eric J.; Ingraham, Christopher R.; Vaidya, Sandeep; Bertino, Frederic J.; Johnson, Evan; Shin, David S.
Objective: In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA). Methods: Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded. Results: Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms. Conclusions: For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.
ISSN: 2468-4287
CID: 5425982

Virtual interventional radiology education increases confidence in American Board of Radiology Core Exam Preparation

Shin, David S; Greenberg, Colvin H; Woerner, Andrew; Monroe, Eric J; Hage, Anthony N; Bertino, Frederic J; Chick, Jeffrey Forris Beecham
PMID: 36682181
ISSN: 1873-4499
CID: 5422262

Kissing Viabahn VBX Stent-Graft Reconstruction of Thoracic Central Veins for Management of Superior Vena Cava Syndrome

Shin, David S; Jackson, Tyler R; Bertino, Frederic J; Monroe, Eric J; Hage, Anthony N; Lee, Eunjee; Ingraham, Christopher R; Vaidya, Sandeep; Chick, Jeffrey Forris Beecham
PURPOSE/OBJECTIVE:To report technical and clinical outcomes of thoracic central vein reconstruction for superior vena cava (SVC) syndrome using kissing Viabahn VBX stent-grafts. MATERIALS AND METHODS/METHODS:All adult patients with SVC syndrome who underwent attempted bilateral brachiocephalic vein-to-SVC reconstruction using kissing VBX stent-grafts at an academic hospital between August 2019 and February 2021 were reviewed. Technical results, adverse events, imaging follow-up, and clinical outcomes were recorded. Patency over time was assessed with Kaplan-Meier analysis. RESULTS:Twenty-eight patients (16 women, 12 men; mean age, 52.0 years) constituted the study cohort. Seventeen (60.7%) had benign, and 11 (39.3%) had malignant etiologies. Presenting symptoms included neck swelling (n=17; 60.7%), bilateral upper extremity swelling (n=15; 53.6%), dyspnea (n=7; 25%), unilateral upper extremity swelling (n=4; 14.3%), and dysphagia (n=1; 3.6%). SVC reconstruction with VBX stent-grafts in kissing configuration was successfully completed in 27 of 28 patients (96.4%). Four major adverse events were noted in the benign etiology subgroup (23.5%), including intraprocedural hemopericardium (n=3) and delayed pneumothorax (n=1). Twenty-seven (96.4%) patients experienced resolution of the presenting symptoms. Mean clinical follow-up of living patients was 358.8±77.2 days (range, 78-645 days). Mean imaging follow-up of living patients was 272.6±91 days (range, 26-594 days). The primary, primary-assisted, and secondary patency rates at 12-months were 71.8%, 88.8%, and 100%, respectively. CONCLUSION/CONCLUSIONS:For management of SVC syndrome, thoracic central vein reconstruction with kissing VBX stent-grafts is feasible with high rate of symptom resolution and acceptable patency. However, this technique is not recommended in benign SVC syndrome due to a high risk of cardiac tamponade.
PMID: 35843595
ISSN: 2213-3348
CID: 5284562

Venous Malformations

Patel, Nihal D; Chong, Anthony T; Kolla, Avani M; Mabud, Tarub S; Kulkarni, Kopal; Masrouha, Karim; Taslakian, Bedros; Bertino, Frederic J
Venous malformations, the most common type of vascular malformation, are slow-flow lesions resulting from disorganized angiogenesis. The International Society for the Study of Vascular Anomalies (ISSVA) classification offers a categorization scheme for venous malformations based on their genetic landscapes and association with congenital overgrowth syndromes. Venous malformations present as congenital lesions and can have broad physiologic and psychosocial sequelae depending on their size, location, growth trajectory, and tissue involvement. Diagnostic evaluation is centered around clinical examination, imaging evaluation with ultrasound and time-resolved magnetic resonance imaging, and genetic testing for more complex malformations. Interventional radiology has emerged as first-line management of venous malformations through endovascular treatment with embolization, while surgery and targeted molecular therapies offer additional therapeutic options. In this review, an updated overview of the genetics and clinical presentation of venous malformations in conjunction with key aspects of diagnostic imaging and treatment are discussed.
PMID: 36561936
ISSN: 0739-9529
CID: 5422252

Combined ultrasound and fluoroscopy guided tunneled external lumbar drain placement in children

Bertino, Frederic; Shin, David S; Weaver, John J; Jeyakumar, Arthie; Chick, Jeffrey Forris Beecham; Woods, Michael A; Monroe, Eric J
External lumbar drain placement has been shown to be an efficacious and safe approach to managing various forms of intracranial hypertension in adult patients and children. The use of ultrasound guidance for lumbar punctures in young patients has been described however, but the modality is not routinely used for the placement of tunneled lumbar drains. In this report, two cases are presented that detail experience using ultrasound guidance for tunneled lumbar drains in children.
PMID: 34939680
ISSN: 1097-0096
CID: 5210482

Portomesenteric and portosystemic venous reconstructions in children using balloon-expandable endoprostheses

Parra, Jorge R; Bertino, Frederic J; Shin, David S; Chick, Jeffrey Forris Beecham; Koo, Kevin S H; Monroe, Eric J
BACKGROUND:Portomesenteric and portosystemic venous occlusive disease may lead to portomesenteric hypertension, variceal bleeding, ascites and hypersplenism. Data regarding endovascular reconstructive strategies in children, however, are limited. OBJECTIVE:To report technical success, outcome and patency of portomesenteric and portosystemic venous reconstruction using VIABAHN VBX balloon-expandable endoprostheses in pediatric patients. MATERIALS AND METHODS/METHODS:Five pediatric patients (median age: 15 years, range: 4-18 years), including 3 (60%) boys and 2 (40%) girls, with portomesenteric or portosystemic venous occlusion or recurrent stenosis, underwent balloon-expandable stent graft reconstruction. Presenting symptoms included acute variceal bleeding, without (n = 2, 40%) or with (n = 1, 20%) splenomegaly, and transfusion-dependent chronic melena (n = 1, 20%). One patient was asymptomatic (n = 1, 20%). Preprocedural imaging included Doppler ultrasound and contrast-enhanced computed tomography (CT) in all patients. Initial imaging showed 4 (80%) occlusions and 1 (20%) recurrent stenosis greater than 50%. Technical aspects of the reconstructions, technical successes, clinical outcomes and adverse events were recorded. Technical success was defined as completion of stent graft reconstruction. Adverse events were categorized according to Society of Interventional Radiology criteria. Clinical success was defined as resolution of the presenting symptoms and/or prevention of portal hypertensive sequela. RESULTS:Venous reconstruction was technically successful in all five patients. Stent graft locations included the main portal vein in 2 (40%), the superior mesenteric vein in 1 (20%), autologous Meso-Rex shunt in 1 (20%) and splenocaval shunt in 1 (20%). Six stent grafts were placed (two stent grafts placed in a single patient). Stent grafts had a median diameter of 7 mm (range: 6-10 mm) and a median length of 59 mm (range: 19-79 mm). Median fluoroscopy time was 36.6 min (range: 13.4-95.8 min) and median air kerma was 301.0 mGy (range: 218.0-1,148.2 mGy). No adverse events occurred. Median clinical follow-up was 18 months (range: 6-29 months). Median imaging follow-up was 17 months (range: 2-29 months). Clinical success was achieved in all patients and maintained during the follow-up period. One patient required follow-up intervention with superior mesenteric vein side extension with a self-expanding bare metal stent due to perigraft stenosis detected on CT 3 months after stent placement. There were no stent graft occlusions. CONCLUSION/CONCLUSIONS:Portomesenteric and portosystemic venous reconstruction using balloon-expandable stent grafts in pediatric patients was feasible and clinically successful in this preliminary experience. Additional studies are warranted.
PMID: 34751814
ISSN: 1432-1998
CID: 5210462