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Although inferior vena cava (IVC) thrombosis is infrequently encountered, it carries a significant risk of post-thrombotic syndrome and pulmonary embolus. Recent studies show no difference in the incidence of post-thrombotic syndrome in patients with iliofemoral deep venous thrombosis (DVT) treated with pharmacothrombolysis vs anticoagulation alone; however, there is an associated increased risk of bleeding. The treatment of IVC thrombosis is less well-studied and the hemodynamic changes may be more significant with pharmacothrombolysis, although the bleeding risk remains. The ClotTriever and FlowTriever systems remove thrombus from veins without the use of thrombolytics. Our study evaluates outcomes of patients undergoing mechanical thrombectomy for the treatment of IVC thrombosis using the ClotTriever and FlowTriever devices.A retrospective chart review was performed to identify consecutive patients who underwent mechanical thrombectomy for the treatment of IVC thrombosis using the ClotTriever and/or FlowTriever systems from November 2018 to January 2020 at four data-sharing institutions. The decision of which device(s) to use was at the discretion of the surgeon. Patient demographics, symptomatology, and imaging characteristics were captured at presentation and follow-up.A total of 15 patients met the inclusion criteria; 10 were male, and the average age was 59 years. The majority of patients were symptomatic at presentation (n = 14), had a prior history of DVT (n = 13), and had a preexisting IVC filter (n = 8). Eleven patients presented with acute onset (1 week) of symptoms, whereas three patients had subacute (1-4 weeks) symptoms. Most patients had an associated iliofemoral DVT (n = 13) and were treated with both ClotTriever and FlowTriever (n = 8); others were treated with either ClotTriever or FlowTriever alone (n = 5 and n = 2, respectively). Technical success was achieved in all but two patients, one who had a nonocclusive thrombus densely adherent to a preexisting IVC filter and another who had a chronic rubbery clot in the IVC that could not be cleared. No patient required concomitant lytic therapy or a postoperative stay in the intensive care unit. Furthermore, there were no postoperative bleeding events, myocardial infarctions, pulmonary emboli, renal impairments, or deaths. The median length of stay was 3 days (range, 1-37 days). Patients underwent postoperative follow-up (n = 7) as well as extended follow-up (6 months; n = 8). All patients who achieved technical success were asymptomatic without evidence of reocclusion of the IVC on follow-up imaging.In our multicenter series of 15 patients, The ClotTriever and FlowTriever showed promise in the treatment of IVC thrombosis without the use of fibrinolytic drugs, with no bleeding events and no requirement for intensive care unit stay.

Superior vena cava (SVC) syndrome comprises a constellation of clinical signs and symptoms caused by obstruction of blood flow through the SVC. The management of patients with life-threatening SVC syndrome is evolving from radiation therapy to endovascular therapy as the first-line treatment. There is a paucity of data and societal guidelines with regard to the management of SVC syndrome. This paper aims to update the practicing interventionalists with the contemporary and the evolving therapeutic approach to SVC syndrome. In addition, the review will focus on endovascular techniques, including catheter-directed thrombolysis, angioplasty, and stenting, and their associated complications.

The right ventricular outflow tract (RVOT) velocity time integral (VTI), an echocardiographic measure of stroke distance, correlates with cardiac index. We sought to determine the prognostic significance of low RVOT VTI on clinical outcomes among patients with acute pulmonary embolism (PE).We conducted a retrospective review of echocardiograms on Pulmonary Embolism Response Team (PERT) activations at our institution. The main outcome was a composite of death, cardiac arrest, or hemodynamic deterioration.Of 188 patients, 30 met the combined outcome (16%) and had significantly lower RVOT VTI measurements (9.0 cm v 13.4 cm, p 0.0001). The AUC for RVOT VTI at a cutoff of 10 cm was 0.78 (95% CI 0.67-0.90) with a sensitivity, specificity, negative predictive value, and positive predictive value of 0.72, 0.81, 0.94, and 0.42, respectively. Fifty-two patients of the cohort were classified as intermediate-high-risk PE and 21% of those met the combined outcome. RVOT VTI was lower among outcome positive patients (7.3 cm v 10.7 cm, p = 0.02).Low RVOT VTI is associated with poor clinical outcomes among patients with acute PE.

Coronavirus disease 2019 (COVID-19) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE). Pulmonary Embolism Response Teams (PERT) have previously been associated with improved outcomes. We aimed to investigate whether PERT utilization, recommendations, and outcomes for patients diagnosed with acute PE changed during the COVID-19 pandemic. This is a retrospective cohort study of all adult patients with acute PE who received care at an academic hospital system in New York City between March 1st and April 30th, 2020. These patients were compared against historic controls between March 1st and April 30th, 2019. PE severity, PERT utilization, initial management, PERT recommendations, and outcomes were compared. There were more cases of PE during the pandemic (82 vs. 59), but less PERT activations (26.8% vs. 64.4%, p

Background Pulmonary embolism response teams (PERTs) have become increasingly popular at institutions around the country, although the evidence to support their efficacy is limited. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options. Methods We retrospectively reviewed 201 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes. Results Massive pulmonary embolism accounted for 16 (8.7%) PERT activations. The majority of patients were treated without invasive intervention; 91.4% (95% confidence interval [CI], 87.1%-95.7%) of patients received anticoagulation alone, 4.5% (95% CI, 0%-18.6%) had catheter-directed therapy (CDT), and 3.0% (95% CI, 0%-16.9%) had systemic administration of tissue plasminogen activator (tPA). The average time to intervention was 665 minutes (95% CI, 249-1080 minutes) for CDT and 22 minutes (95% CI, 0-456 minutes) for systemic TPA. The average time to anticoagulation was 2.3 minutes (95% CI, 0-43 minutes). There was a trend toward higher rates of cardiac events (odds ratio [OR], 12.68; 95% CI, 0.62-65.74) and death (OR, 3.19; 95% CI, 0.28-5.18) among patients with massive PE. There was a higher rate of cardiac events (OR, 5.66; 95% CI, 1.34-23.83) among patients who received tPA or an invasive intervention. There was no difference in mortality rates of patients who underwent aggressive management compared with anticoagulation alone. Conclusions A dedicated PERT results in efficient delivery of care and excellent outcomes, in part owing to the rapid (on average, 8 minutes) time to initiation of a multidisciplinary discussion. Patients who ultimately underwent CDT had an interval of >10 hours on average between diagnosis and CDT. This provisional or delayed approach to CDT in selected patients who were not improving with anticoagulation alone (and therefore had potential for higher net benefit from a procedure with its own inherent risks) may have resulted in a lower rate of CDT.

Endovascular management of pulmonary embolism can be divided into therapeutic and prophylactic treatments. Prophylactic treatment includes inferior vena cava filter placement, whereas endovascular therapeutic interventions include an array of catheter-directed therapies. The indications for both modalities have evolved over the last decade as new evidence has become available.

The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate–high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate–high-risk pulmonary embolism.

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high‐risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.

Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000–180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25–65%, 3%, and

Objectives Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. Methods This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of Results During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home ( p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1–3.6, p = 0.03) as opposed to home. Conclusions Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

Background: The Bashir Endovascular Catheter (BEC) is a novel pharmaco-mechanical device designed to enhance thrombolysis by increasing the exposure of thrombus to endogenous and exogenous thrombolytics. The aim of this prospective, multicenter, single-arm study was to evaluate the feasibility and initial safety of the BEC in patients with acute intermediate-risk pulmonary embolism (PE). Methods: Patients with symptomatic PE and right ventricular to left ventricular diameter ratio ≥0.9 as documented by computer tomography angiography were eligible for enrollment. The primary safety end points were device related death or adverse events, and major bleeding within 72 hours after BEC directed therapy. Results: Nine patients were enrolled across 4 US sites. The total dose of r-tPA (recombinant tissue-type plasminogen activator) was 14 mgs in bilateral PE and 12 mgs in unilateral PE over 8 hours delivered via the expanded BEC. At 30-day follow-up, there were no deaths or device-related adverse events. At 48 hours post-BEC therapy, the right ventricular to left ventricular diameter ratio decreased from 1.52±0.26 to 0.97±0.06 ( P =0.0009 [95% CI, 0.33–0.82]; 37.0% reduction). Thrombus burden as measured by the Modified Miller Index decreased from 25.4±5.3 to 16.0±4.0 ( P =0.0005; [95% CI, 5.5–13.4]; 37.1% reduction). Conclusions: In this early feasibility study of the BEC for intermediate-risk PE, there were no deaths or device-related adverse events and a significant reduction in right ventricular to left ventricular diameter ratio and thrombus burden. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03927508.

Introduction We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed. Methods Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use. Results A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58–1.0), and 1.0 (95%CI 0.83–1.0) between independent raters of the recorded interview of 16 focus groups members. Conclusion We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.

Purpose To assess trends in inferior vena cava (IVC) filter placement and retrieval procedures in Medicare beneficiaries over the last two decades. Methods Using Physician/Supplier Procedure Summary Master Files from 1994 through 2015, we calculated utilization rates for IVC filter placement and retrieval procedures in Medicare fee-for-service beneficiaries. Services were stratified by provider specialty group and site of service. Results IVC filter placement rates increased from 1994 to 2008 (from 65.0 to 202.1 per 100,000 beneficiaries, compound annual growth rate [CAGR] +8.4%) and then decreased to 128.9 by 2015 (CAGR −6.2%). This decrease was observed across all specialty groups and sites of service. From 1994 to 2015, placement procedure market share increased for radiologists (from 45.1% to 62.7%) and cardiologists (from 2.5% to 6.7%) but decreased for surgeons (from 46.6% to 27.9%). Overall, procedures shifted slightly from the inpatient (from 94.5% to 86.5% of all procedures) to outpatient hospital (from 4.9% to 14.9%) settings. Between 2012 and 2015, retrieval rates increased from 12.0 to 17.7 (CAGR +13.9%). Retrievals as a percentage of placement procedures were similar across specialties in 2015 (range 13.0%-13.8%). Conclusion Despite prior dramatic growth, the utilization of IVC filters in Medicare beneficiaries markedly declined over the last decade, likely relating to evolving views regarding efficacy and long-term safety. This decline was accompanied by several filter-related market shifts, including increasing placement by radiologists and cardiologists, increasing outpatient placement procedures, and increasing retrieval rates.

Anesthesiologists are familiar with pulmonary emboli prophylaxis paradigms and many have witnessed acute intraoperative embolization. Clinicians must balance conservative anticoagulation and aggressive intervention in perioperative submassive pulmonary emboli, yet the bulk of the literature excludes surgery as a relative contraindication. This review will summarize the current treatment options for acute pulmonary emboli, drawing attention to special considerations in perioperative submassive pulmonary emboli, and discuss right ventricular monitoring to improve assessment of intervention efficacy.Recent reviews have identified the elevated risk and inadequacy of treatment of pulmonary embolism in intra and postoperative patients, in part because of the risks of systemic anticoagulation. Early studies of catheter-directed therapies have shown promising efficacy with a reduction in bleeding risk, which is especially important for perioperative patients. Success relies on defining endpoints, yet the practice of measuring mean pulmonary artery pressure alone to assess intervention efficacy is flawed.Identifying submassive pulmonary emboli that requires treatment and optimizing therapy remains difficult. Researchers must consider avoiding systemic anticoagulation and focus on designing trials that evaluate intervention efficacy in surgical patients. The success of catheter-directed therapy in early trials warrants further investigation into using these therapies in the treatment of perioperative submassive pulmonary emboli.

Pulmonary Embolism Response Teams (PERTs) have emerged to provide rapid multidisciplinary assessment and treatment of PE patients. However, descriptive institutional experience and preliminary outcomes data from such teams are sparse. PERT activations were identified through a retrospective review. Only confirmed submassive or massive PEs were included in the data analysis. In addition to baseline variables, the therapeutic intervention, length of stay (LOS), in-hospital mortality, and bleeding rate/severity were recorded. A total of 124 PERT activations occurred over 20 months: 43 in the first 10 months and 81 in the next 10. A total of 87 submassive (90.8%) and massive (9.2%) PE patients were included. The median age was 65 (51–75 IQR) years. Catheter-directed thrombolysis (CDT) was administered to 25 patients, systemic thrombolysis (ST) to six, and anticoagulation alone (AC) to 54. The median ICU stay and overall LOS were 6 (3–10 IQR) and 7 (4–14 IQR) days, respectively, with no association with any variables except a brain natriuretic peptide (BNP) >100 pg/mL ( p=0.008 ICU LOS; p=0.047 overall LOS). Twelve patients (13.7%) died in the hospital, nine of whom had metastatic or brain cancer, with a median overall LOS of 13 (11–17 IQR) days. There were five major bleeds: one in the CDT group, one in the ST group, and three in the AC group. Overall, (1) PERT activations increased after the first 10 months; (2) BNP >100 pg/mL was associated with a longer LOS; (3) rates of mortality and bleeding did not correlate with treatment; and (4) the majority of in-hospital deaths occurred in patients with advanced cancer.

While pulmonary embolism (PE) causes approximately 100 000-180 000 deaths per year in the United States, mortality is restricted to patients who have massive or submassive PEs. This state of the art review familiarizes the reader with these categories of PE. The review discusses the following topics: pathophysiology, clinical presentation, rationale for stratification, imaging, massive PE management and outcomes, submassive PE management and outcomes, and future directions. It summarizes the most up-to-date literature on imaging, systemic thrombolysis, surgical embolectomy, and catheter-directed therapy for submassive and massive PE and gives representative examples that reflect modern practice.

In the event traditional therapies like anticoagulation and systemic thrombolysis are contraindicated or deemed insufficient in the treatment of a patient with acute pulmonary embolism (PE), escalation of care may call for the use of minimally invasive, image-guided endovascular therapies. The endovascular techniques used to remove, macerate, and dissolve acute pulmonary emboli (PE) are known collectively as catheter-directed therapy (CDT). CDT includes mechanical techniques such as clot fragmentation and aspiration thrombectomy, as well as pharmacological techniques like the targeted infusion of a thrombolytic agent via a multi-sidehole catheter. The goal of CDT in the treatment of acute PE is to debulk the thromboembolic load in the pulmonary vasculature, relieve life-threatening right heart strain, and improve pulmonary perfusion. This approach may improve short-term outcomes in patients with acute PE, though its effects on mortality, clinical deterioration, and the long-term sequelae of PE are unknown. This chapter will focus on the rationale for CDT in acute PE, the literature examining its use, and periprocedural management.

After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

Purpose To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. Materials and Methods This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. Results Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. Conclusions In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

Background The AngioVac (AngioDynamics, Latham, NY) device utilizes a venovenous bypass circuit for percutaneous venous thrombectomy and has been applied in the setting of iliocaval thrombosis as well as right heart thrombus and pulmonary emboli. We describe our experience with the AngioVac device in 12 patients with a variety of indications with the goal of identifying factors correlating with successful thrombectomy. Methods From August 2013 to June 2015, 12 patients underwent AngioVac percutaneous thrombectomy at our institution. Preoperative, intraoperative, and postoperative data were retrospectively analyzed. Results Indications for thrombectomy included iliocaval thrombosis in 33% (4), right heart thrombus in 42% (5), and pulmonary embolus in 25% (3). We experienced a 58% complete success rate. Partial success was achieved in 17%, and no thrombus was extracted in 25%. Iliocaval and right heart thrombi were the most amenable to AngioVac thrombectomy with 100% (4/4) and 60% (3/5) complete success rates, respectively. Pulmonary embolus was the least amenable to thrombectomy with a 33% partial success rate (1/3) and 67% failure rate (2/3). Conclusion The AngioVac devices allow for percutaneous thrombectomy in the setting of iliocaval and right heart thrombus in patients for whom medical therapy fails or for those in whom surgical intervention is considered high risk. Pulmonary emboli are less amenable, likely due to limited steeribility of the device. Larger studies are needed to make more definitive conclusions, and newer iterations of the device will likely allow for improved outcomes.

Long-term right ventricular (RV) function, functional capacity, exercise capacity, and quality of life following pulmonary embolism (PE), and the impact of thrombolysis, are unclear. A systematic review of studies that evaluated these outcomes with ⩾ 3-month mean follow-up after PE diagnosis was performed. For each outcome, random effects meta-analyses were performed. Twenty-six studies (3671 patients) with 18-month median follow-up were included. The pooled prevalence of RV dysfunction was 18.1%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of RV dysfunction versus those treated with anticoagulation (odds ratio: 0.51, 95% CI: 0.24 to 1.13, p=0.10). Pooled prevalence of at least mild functional impairment (NYHA II–IV) was 33.2%, and at least moderate functional impairment (NYHA III–IV) was 11.3%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of at least moderate functional impairment versus those treated with anticoagulation (odds ratio: 0.48, 95% CI: 0.15 to 1.49, p=0.20). Pooled 6-minute walk distance was 415 m (95% CI: 372 to 458 m), SF-36 Physical Component Score was 44.8 (95% CI: 43 to 46), and Pulmonary Embolism Quality of Life (QoL) Questionnaire total score was 9.1. Main limitations included heterogeneity among studies for many outcomes, variation in the completeness of data reported, and inclusion of data from non-randomized, non-controlled, and retrospective studies. Persistent RV dysfunction, impaired functional status, diminished exercise capacity, and reduced QoL are common in PE survivors. The effect of thrombolysis on RV function and functional status remains unclear.

Background Chronic venous occlusions can result in debilitating symptoms and can be refractory to standard methods of venous recanalization because of the formation of dense fibrous tissue. A transjugular liver access cannula can be incorporated into recanalization efforts to treat such refractory cases. This report describes our experience using the transjugular liver access cannula technique in nine patients. Methods A review of patients requiring venous recanalization between May 2012 and October 2014 identified nine cases that required the use of a transjugular liver access cannula as a guiding instrument. Lesion characteristics, technical success, and clinical outcomes were evaluated. Results The transjugular liver access cannula was used to traverse a total of nine chronic occlusions in both the upper and lower central venous systems in nine patients. The technical success rate was 100%. There were no clinically significant complications. One patient was lost to follow-up. Of the remaining eight patients, seven experienced symptomatic relief within 1 month of recanalization. Conclusions The transjugular liver access cannula may serve as a useful adjunctive tool during difficult venous recanalizations, especially when traditional guidewire and catheter techniques fail.

This article will focus on 3 avenues for future research: (1) addressing the lack of short- and long-term clinical outcome research on catheter-directed therapy; (2) determining the safety and efficacy of novel thrombus removal devices; and (3) translating our knowledge of the pathobiology and pathophysiology of pulmonary embolism into novel diagnostic and therapeutic strategies.

Venous thromboembolism including pulmonary embolism and deep vein thrombosis leads to short- and long-term morbidity and in some cases mortality. Although treatment approaches vary among institutions based on local expertise, the employment of interventional techniques is of great interest. Several studies have shown clinical and physiological benefits from catheter-based techniques. However, these therapies are not without risk, especially with the use of powerful thrombolytic agents that increase the rate of bleeding. This chapter reviews the catheter-based techniques for the management of deep vein thrombosis and pulmonary embolism as well as the indications and complications of inferior vena cava filters.

Limited evidence is available to guide periprocedural management of oral anticoagulants in the setting of interventional radiology (IR) procedures. For direct oral anticoagulants, therapy interruption (TI) is based on medication half-life and procedural bleeding risk. Periprocedural management of warfarin includes INR monitoring, and possible bridging with parenteral anticoagulants. It is unknown if these recommendations apply to IR procedures. To evaluate bleeding complications and thromboembolic events following periprocedural management of the factor Xa (FXa) inhibitors or warfarin in patients undergoing IR procedures. We performed a retrospective, observational study at NYU Langone Health (NYULH) of all adult patients who underwent an IR procedure from January 2015 to July 2017 and were receiving apixaban, rivaroxaban, or warfarin. Patients who were pregnant or who had a mechanical heart valve were excluded. At NYULH, TI is not required for FXa inhibitors, and an INR

Patients suffering from acute lower extremity deep vein thrombosis (DVT) are at risk for developing chronic limb pain, heaviness, and fatigue, known as the post-thrombotic syndrome (PTS). Although several studies have shown that catheter-directed therapy reduces clot burden and may improve clinical outcomes, the multicenter randomized controlled ATTRACT trial showed no difference in PTS or quality of life at 2 years between patients treated with pharmacomechanical catheter-directed thrombolysis (PCDT) and those treated with anticoagulation alone, and a higher major bleeding rate in the PCDT group. PCDT is not indicated for most patients diagnosed with lower extremity DVT. Since PCDT may benefit patients with iliofemoral DVT, intervention can be considered in this subset of patients if they are at low risk of bleeding.

Background Chronic venous occlusion is common particularly in cancer patient due to hypercoagulate state associated with venous compression. Treatment options include endovascular management with venoplasty and stenting. Recanalization can be challenging in patients with complete venous occlusion secondary to significant external compression by a mass. Case presentation We report a case of a 73-year-old man with a history of bladder and prostate cancer who presented with worsening right leg edema and pain due to deep venous thrombosis secondary to a retroperitoneal mass. Management was sharp recanalization, venoplasty and stenting. Conclusion Endovascular intervention of chronic venous occlusion is technically challenging and time consuming. Sharp venous recanalization is feasible and safe in patients who failed standard recanalization procedures. We present a case of cancer-related obstruction of the right iliac veins and acute thrombosis of the femoral vein with symptomatic lower limb swelling relieved by sharp recanalization through the tumor mass.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Acute pulmonary embolism (PE) is a major public health problem. It is the third most common cause of death in hospitalized patients. In the United States, there are up to 600,000 cases diagnosed per year with 100,000-180,000 acute PE-related deaths. Common risk factors include underlying genetic conditions, acquired conditions, and acquired hypercoagulable states. Acute PE increases the pulmonary vascular resistance and the load on the right ventricle (RV). Increased RV loading causes compensatory RV dilation, impaired contractility, tachycardia, and sympathetic activation. RV dilation and increased intramural pressure decrease diastolic coronary blood flow, leading to RV ischemia and myocardial necrosis. Ultimately, insufficient cardiac output from the RV causes left ventricular under-filling which results in systemic hypotension and cardiovascular collapse. Current prognostic stratification strategy separates acute PE into massive, submassive, and low-risk by presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive, and low-risk acute PE have mortality rates of 25%-65%, 3%, and

The post-Pulmonary Embolism (post-PE) syndrome is being increasingly recognized as a long-term consequence of PE. Its most severe manifestation, chronic thromboembolic pulmonary hypertension (CTEPH), affects a small proportion of PE survivors. However, many more with less severe post-PE syndrome have reduced quality of life and functional capacity. The pathophysiology is incompletely understood, but involves unresolved pulmonary artery thrombi, right ventricular damage, and abnormal gas exchange. Treatment has only been established for CTEPH, and further studies are required to determine how less severe forms of the post-PE syndrome should be treated and if preventive strategies can reduce its incidence.

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.

Patients with venous thromboembolism (VTE) are prone to the development of both short-term and long-term complications that can substantially affect their functional capacity and quality of life. Patients with deep vein thrombosis (DVT) often develop recurrent VTE or the post-thrombotic syndrome, whereas patients with pulmonary embolism (PE) can develop long-term symptoms and functional limitations along a broad spectrum extending to full-blown chronic thromboembolic pulmonary hypertension. Clinicians who care for patients showing severe clinical manifestations of DVT and PE are often faced with challenging decisions concerning whether and how to escalate to more aggressive treatments such as those involving the use of thrombolytic drugs. The purpose of this chapter is to provide guidance on how best to individualize care to these patients.

BACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20% risk of major bleeding, including a 2% to 5% risk of hemorrhagic stroke. We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PE. METHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry. Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy and/or catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase. Clinical success was defined as meeting all the following criteria: stabilization of hemodynamics; improvement in pulmonary hypertension, right-sided heart strain, or both; and survival to hospital discharge. Primary safety outcomes were major procedure-related complications and major bleeding events. RESULTS Fifty-three men and 48 women (average age, 60 years [range, 22-86 years]; mean BMI, 31.03 ± 7.20 kg/m2) were included in the study. The average thrombolytic doses were 28.0 ± 11 mg tPA (n = 76) and 2,697,101 ± 936,287 International Units for urokinase (n = 23). Clinical success was achieved in 24 of 28 patients with massive PE (85.7%; 95% CI, 67.3%-96.0%) and 71 of 73 patients with submassive PE (97.3%; 95% CI, 90.5%-99.7%). The mean pulmonary artery pressure improved from 51.17 ± 14.06 to 37.23 ± 15.81 mm Hg (n = 92) (P ≤ .0001). Among patients monitored with follow-up echocardiography, 57 of 64 (89.1%; 95% CI, 78.8%-95.5%; P≤.0001) showed improvement in right-sided heart strain. There were no major procedure-related complications, major hemorrhages, or hemorrhagic strokes. CONCLUSIONS CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding. At experienced centers, CDT is a safe and effective treatment of both acute massive and submassive PE. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01097928; URL: www.clinicaltrials.gov

Venous thromboembolism (VTE) is the third most life-threatening cardiovascular disease in the USA, affecting a significant number of people each year. The treatment of VTE, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), includes both medical and interventional therapies. The severity of the disease varies, with some patients requiring only outpatient medical management, while others may experience significant lifelong morbidity, limb loss, or death. This chapter discusses the pathophysiology of VTE and its historical origins and treatments. Clinical manifestations, diagnostic and treatment methods, and procedural techniques are reviewed.