By Ripal T. Gandhi, MD, FSIR, and Suvranu Ganguli, MD, FSIR Winter 2019
This column alerts SIR members to abstracts that may have an impact on their practice and how they converse with referring clinicians. If you would like to suggest abstracts you feel should be included, email us at gandhi@baptisthealth.net or sganguli@mgh.harvard.edu.
Residual vein occlusion in relation to immediate compression and postthrombotic syndrome in deep vein thrombosis.
Blood. 2018 Sep 20. pii: blood-2018-03-836783. doi: 10.1182/blood-2018-03-836783. [Epub ahead of print]
Amin EE, Bistervels IM, Meijer K, Tick LW, Middeldorp S, Mostard G, van de Poel M, Serné EH, Otten HM, Klappe EM, Joore MA, Ten Cate H, Ten Wolde M, Ten Cate-Hoek AJ.
Thus far the association between residual vein occlusion and immediate compression therapy and postthrombotic syndrome is undetermined. Therefore, we investigated whether compression therapy immediately after diagnosis of deep vein thrombosis affects the occurrence of residual vein obstruction (RVO) and whether the presence of RVO is associated with postthrombotic syndrome and recurrent venous thromboembolism. In a pre-specified sub study within the IDEAL DVT trial, 592 adult patients from 10 academic and nonacademic centers across the Netherlands, with objectively confirmed proximal deep vein thrombosis of the leg, received no compression or acute compression within 24 hours of diagnosis of deep vein thrombosis with either multilayer bandaging or compression hosiery (pressure 35mmHg). Presence of RVO and recurrent venous thromboembolism was confirmed with compression ultrasonography, incidence of postthrombotic syndrome as a Villalta score of >5 at 6 and 24 months. The average time from diagnosis until assessment of RVO was 5.3 (SD 1.9) months. A significantly lower percentage of patients who did receive compression therapy immediately after deep vein thrombosis had RVO (46.3 percent vs. 66.7 percent; OR 0.46 95 percent CI 0.27–0.80; p=0.005). Postthrombotic syndrome was less prevalent in patients without RVO (46.0 percent vs. 54.0 percent; OR 0.65 95 percent CI 0.46–0.92; p=0.013). Recurrent venous thrombosis showed no significant association with RVO. Immediate compression should therefore be offered to all patients with acute deep venous thrombosis of the leg irrespective of severity of complaints. This study was registered at clinicaltrials.gov (NCT01429714) and the Dutch Trial registry in November 2010 (NTR2597)
A randomized trial of the optimum duration of acoustic pulse thrombolysis procedure in acute intermediate-risk pulmonary embolism: The OPTALYSE PE Trial.
JACC Cardiovasc Interv. 2018 Jul 23;11(14):1401–1410. doi: 10.1016/j.jcin.2018.04.008.
Tapson VF, Sterling K, Jones N, Elder M, Tripathy U, Brower J, Maholic RL, Ross CB, Natarajan K, Fong P, Greenspon L, Tamaddon H, Piracha AR, Engelhardt T, Katopodis J, Marques V, Sharp ASP, Piazza G, Goldhaber SZ.
OBJECTIVES: The aim of this study was to determine the lowest optimal tissue plasminogen activator (tPA) dose and delivery duration using ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk (submassive) pulmonary embolism.
BACKGROUND: Previous trials of USCDT used tPA over 12–24 h at doses of 20–24 mg for acute pulmonary embolism.
METHODS: Hemodynamically stable adults with acute intermediate-risk pulmonary embolism documented by computed tomographic angiography were randomized into this prospective multicenter, parallel-group trial. Patients received treatment with 1 of 4 USCDT regimens. The tPA dose ranged from 4–12 mg per lung and infusion duration from 2–6 h. The primary efficacy endpoint was reduction in right ventricular to left ventricular diameter ratio by computed tomographic angiography. A major secondary endpoint was embolic burden by refined modified Miller score, measured on computed tomographic angiography 48 h after initiation of USCDT.
RESULTS: One hundred one patients were randomized, and improvements in right ventricular to left ventricular diameter ratio were as follows: arm 1 (4 mg/lung/2 h), 0.40 (24 percent; p = 0.0001); arm 2 (4 mg/lung/4 h), 0.35 (22.6 percent; p = 0.0001); arm 3 (6 mg/lung/6 h), 0.42 (26.3 percent; p = 0.0001); and arm 4 (12 mg/lung/6 h), 0.48 (25.5 percent; p = 0.0001). Improvement in refined modified Miller score was also seen in all groups. Four patients experienced major bleeding (4 percent). Of two intracranial hemorrhage events, one was attributed to tPA delivered by USCDT.
CONCLUSIONS: Treatment with USCDT using a shorter delivery duration and lower-dose tPA was associated with improved right ventricular function and reduced clot burden compared with baseline. The major bleeding rate was low, but one intracranial hemorrhage event due to tPA delivered by USCDT did occur.
Is routine renal tumor biopsy associated with lower rates of benign histology following nephrectomy for small renal masses?
J Urol. 2018 Oct;200(4):731–736. doi: 10.1016/j.juro.2018.04.015. Epub 2018 Apr 11.
Richard PO, Lavallée LT, Pouliot F, Komisarenko M, Martin L, Lattouf JB, Finelli A.
PURPOSE: Renal tumor biopsies have been proposed as a management alternative to avoid treatment of benign or low-risk small renal masses. However, many urologists are reluctant to recommend renal tumor biopsy because they feel its result frequently will not impact management. Our primary objective was to evaluate if centers that routinely favor renal tumor biopsy have lower rates of benign histology after surgery than centers where a selective renal tumor biopsy approach is used.
MATERIALS AND METHODS: This was a retrospective multicenter study of patients who underwent partial or radical nephrectomy for a lesion suspicious for localized renal cell carcinoma which measured 4 cm or less (cT1a and pT1a or pT3a) between 2013 and 2015. A logistic regression model was used to examine whether the odds of obtaining a benign tumor following surgery differed between centers that routinely favor renal tumor biopsy and centers where a selective renal tumor biopsy approach is used.
RESULTS: A total of 542 small renal masses in 516 patients were included in study. The rate of histologically benign tumors after surgery was 11 percent. This rate was significantly lower at centers that routinely favor renal tumor biopsy than at centers where a selective renal tumor biopsy approach is used (5 percent vs. 16 percent, p<0.001). On multivariable analysis older age, smaller tumors and centers where a selective renal tumor biopsy approach is used were significantly associated with greater odds of finding a histologically benign tumor postoperatively. Compared to centers that routinely favor renal tumor biopsy, the odds of finding a benign tumor at surgery was 4 times more likely at centers where a selective renal tumor biopsy approach is used (OR 4.1, 95 percent CI 1.9-8.3).
CONCLUSIONS: Routine renal tumor biopsy reduces surgery for benign tumors and the potential for short-term and long-term morbidity associated with these procedures. This study suggests that routine renal tumor biopsy may be a valuable tool to decrease overtreatment of small renal masses.
Influence of postoperative hepatic angiography on mortality after laparotomy in Grade IV/V hepatic injuries.
J Trauma Acute Care Surg. 2018 Aug;85(2):290–297. doi: 10.1097/TA.0000000000001906.
Matsumoto S, Cantrell E, Jung K, Smith A, Coimbra R.
BACKGROUND: Mortality rate for severe liver injuries remains high. As an adjunct to surgery, postoperative hepatic angiography (PHA) may have a positive impact on outcomes. This study sought to compare outcomes following surgical management of severe liver injuries with and without PHA using propensity score matching analysis.
METHODS: Data from the National Trauma Data Bank from 2007 to 2014 were analyzed. The study population consisted of patients older than 18 years, sustaining severe liver injuries (i.e., American Association for the Surgery of Trauma Organ Injury Scale [AAST-OIS] Grade IV or V) who underwent surgery. Patients were divided into two groups. The PHA group consisted of those undergoing surgery followed by PHA. In the surgery-only group, no angiography was performed. To determine the impact of PHA on outcomes, propensity score matching analysis (1:3) was used.
RESULTS: A total of 3,871 patients met inclusion criteria. Of those, 205 (5.3 percent) patients underwent PHA. Prior to matching, patients in the PHA group had higher severity, but overall in-hospital mortality was found to be similar between the two groups. After 1:3 propensity-score matching, 196 patients in the PHA group were matched with 588 in the surgery-only group with well-balanced baseline characteristics. The in-hospital mortality was significantly lower in the PHA group compared with the surgery-only group (24.5 percent vs. 35.9 percent; odds ratio, 0.58; 95 percent confidence interval, 0.40–0.84). However, hospital length of stay was longer (16.0 [7.0–29.8] vs. 11 [1.0–25.0] days, p = 0.001), and the incidence of deep and organ/space surgical site infection (3.6 percent vs. 1.2 percent, 8.2 percent vs. 3.5 percent, respectively) was higher in the PHA group.
CONCLUSION: The use of PHA was associated with decreased mortality rates. A multimodality approach using both surgical intervention followed by PHA appears to identify patients that may benefit from arterial embolization, leading to decreased mortality of severe liver injuries.