bluuebunny/crossref_metadata_2025 huggingface dataset:
Whatever Happened to the Decade of Pain Control and Research?
Authors: Coleman John J.
Published: August 2018

This chapter discusses how the pharmaceutical industry’s actions affected the accomplishments of the Decade of Pain Control and Research, which began on January 1, 2001, following almost two decades of rising concern over the inadequate treatment of chronic pain in the United States. To tell the story of this decade we must describe the accompanying problem of drug diversion and abuse. The development in 1995 of a new opioid product called OxyContin, its aggressive marketing, the morbidity and mortality associated with its misuse, and the eventual felony conviction in 2007 of the drug’s sponsor for fraudulent claims and marketing practices, affected the Decade in unexpected ways. The response by Congress and the regulatory community to what they termed an “epidemic” of prescription drug abuse produced long-lasting policy changes. The chapter also touches on the peculiar and sometimes troubling relationship between the regulators and the regulated.
Evaluation and Treatment of the Chronic Pain Patient
Authors: Peppin John F. , Birthi Pravardhan , McCarberg Bill H. , D’Arcy Yvonne
Published: August 2018

This chapter provides an overview of how, in an ideal world, a pain clinician would evaluate and treat a patient with chronic pain. Pain clinicians will adhere to some or perhaps all of these recommendations, but we are not suggesting that nonadherence yields poor medical practice, illegal practice, or a regulatory issue. This chapter discusses issues related to the evaluation of the chronic pain patient who is being considered for or is currently receiving opioids as a treatment modality. No one treatment, whether pharmacologic, physical, psychological, or interventional, is the answer to the treatment of chronic pain. Chronic pain is a very complex syndrome that requires a coordinated biopsychosocial multidisciplinary approach if there is to be any hope of success. One simple approach, such as opioids or injections, will rarely alleviate chronic pain.
An Overview of the Abuse Potential of Nonopioids
Authors: Herndon Christopher M. , Gable Kelly N.
Published: August 2018

Discussions of the abuse of prescription medications have been overshadowed by the abuse of opioids. However, numerous other medications, in very different classes and for very different reasons, are abused as well. Sedative-hypnotics (e.g., benzodiazepines), barbiturates, antipsychotics, and muscle relaxants are just some of the medications that are abused and misused. It is critical to keep in mind that the opioid crisis is magnified by the abuse of these other medications. This chapter gives a succinct and clear overview of some of these other classes of medications and how they are abused.
Psychiatry and Chronic Pain
Authors: Khouzam Hani Raoul
Published: August 2018

This chapter reviews some of the connections between psychiatry and chronic pain, highlighting the role that psychiatrists can play in diagnosing and treating chronic pain. Identifying and addressing the various psychiatric components of chronic pain can significantly contribute to successful rehabilitation, recovery, and improved overall functioning.

Psychiatric models (gate control, diathesis/stress, biopsychosocial–spiritual approaches, cognitive-behavioral transactional and cognitive-behavioral fear avoidance) are described to provide a theoretical basis for understanding the development and the clinical management of chronic pain.

This chapter also describes how psychiatrists can collaborate with primary care providers in managing chronic pain within the framework of multidisciplinary treatment teams.

It is important for healthcare professionals, regulators, law enforcement personnel, and legislators to identify the connection between psychiatry and chronic pain in the context of its diagnosis, management, and treatment.
Managing Pain in Patients with a History of a Substance Use Disorder
Authors: Cheatle Martin D.
Published: August 2018

Patients with chronic pain tend to be complex and can present with multiple comorbidities, including anxiety, depression, functional disabilities, and substance misuse or abuse. The burgeoning rate of prescription opioid misuse and abuse and opioid-related fatalities has generated a great deal of scholarly activity on understanding the etiology of opioid misuse/abuse and developing risk assessment and mitigation strategies to curb this public health crisis. Balancing effective pain management and reducing the risk of opioid misuse/abuse and diversion can be a daunting endeavor, as is controlling pain in patients with pain and concomitant substance use disorders. This chapter provides an overview of the prevalence of opioid misuse/abuse in patients with chronic pain. It covers pharmacologic and nonpharmacologic therapies for patients with pain and co-occurring opioid use disorder and also discusses the challenges and opportunities to improve pain care and reduce misuse and abuse of opioids.
Opioid Prescribing in Stigmatized and Special Populations
Authors: Dineen Kelly K.
Published: August 2018

There is no question that a lack of careful decision-making around opioid prescribing in the past contributed to the current opioid-related harms. Yet opioids—usually in combination with other treatments—are sometimes the only effective therapies for certain chronic pain patients, in whom the benefits of opioids outweigh the risks of a substance use disorder. This chapter examines special populations such as those with sickle cell disease or those experiencing pain in end-of-life care. Caring for chronic pain patients can be challenging, especially now that the use of opioids for long-term pain control has been called into question. This chapter draws attention to attitudes and biases that may contribute to decision-making errors on the part of providers who are trying to balance the benefits and harms of opioids when treating these particularly vulnerable groups.
The Demise of Interdisciplinary Chronic Pain Management and Its Relationship to the Scourge of Prescription Opioid Diversion and Abuse
Authors: Schatman Michael E.
Published: August 2018

Even though the efficacy of interdisciplinary pain management programs is supported, their numbers have decreased and the vast majority of Americans with chronic pain do not have access to them. Insurance companies do not want to pay for these services, hospitals believe they are financial losers, and the opioid crisis has placed a pall over the practice of pain medicine. The demise of these programs has left pain medicine in a fragmented state. Few healthcare providers who treat chronic pain patients have the time to coordinate care by multiple professionals The opioid crisis seen in certain areas, such as Appalachia, may be related to the lack of these interdisciplinary programs. There should be concerted efforts to increase access to and funding of these programs. Although they are not a panacea for all types of chronic pain, they can improve patients’ well-being and function and reduce their need for opioid medications.
Pain Management Assessment Beyond the Physician Encounter
Authors: Thakur Anand C.
Published: August 2018

The long-term use of opioids in the treatment of chronic pain patients has increased dramatically over the last two decades. With this increase has come abuse, misuse, diversion, and overdose deaths, resulting in tremendous media attention. Further, there has been an increase in regulatory scrutiny of the prescribing practices of healthcare professionals. Monitoring patient compliance with chronic opioid therapy has become very important. Urine drug monitoring and patient agreements are part of this monitoring effort. However, interpreting test results can be challenging and applying these results to patient care can be complex. Metabolites, interfering substances, and false-positives and false-negative results all need to be considered when interpreting test results. Test results should not be considered sacrosanct and should always be an opportunity for discussion with a patient.
Deployment Finesse of the Cook Zenith Stent Graft
Authors: Angle John Fritz
Published: August 2018

For all abdominal aortic aneurysm endografts, the major challenge is minimizing the risk of a type I endoleak. Percutaneous placement of an abdominal aortic endograft has become a widely-performed procedure. With several devices available on the market, there are many device-specific and experience-based considerations in planning and performing these procedures safely and with good outcomes. Although not always evidence-based, reviewing some case-specific scenarios can introduce techniques or lead to standards of practice that reduce suboptimal outcomes or prevent complications in future procedures. This chapter discusses deployment finesse of the Cook Zenith Flex and Zenith LP stent grafts, but many of the described concepts apply to other abdominal endografts and even thoracic endograft procedures.
Deployment Finesse of the Gore Excluder Stent Graft
Authors: Kahn S. Lowell , Rojas Sergio
Published: August 2018

The Gore Excluder stent graft was approved for use in the United States by the US Food and Drug Administration (FDA) in 2002. The Excluder is a modular, bifurcated endoprosthesis utilized in the treatment of abdominal aortic aneurysms. The Excluder endoprosthesis is constructed from an expanded polytetrafluoroethylene film and an incorporated “weldless” nickel–titanium stent skeleton for support. The device features no sutures, infrarenal fixation, and is made to be inserted through 12–18 Fr introducer sheaths. Since its approval by the FDA, the Excluder has undergone multiple changes, including profile reductions, the addition of an impermeable membrane (due to early graft material design associated with type IV endoleaks), and, most notably, a repositioning mechanism labeled the C3 Excluder. This chapter discusses multiple techniques of deployment of the Gore Excluder stent graft.
The Turret Technique for Contralateral Gate Access
Authors: Kahn S. Lowell
Published: August 2018

Catheterization of the contralateral gate on the main body of aortic stent grafts is an important step of the endovascular aneurysm repair procedure. This step can be readily accomplished with appropriate pre- and intraprocedural planning. In cases in which the catheterization is challenging, several techniques can be utilized to overcome this difficulty. A Glidewire (Terumo Medical) together with a variety of catheters can be employed, most commonly either a hockey stick (e.g., Berenstein (AngioDynamics Inc., Latham, NY) and Kumpe (Cook Medical Inc., Bloomington, IN)) or reverse curve (e.g., Sos 1/2, Cook Medical Inc., Bloomington, IN) configuration. Occasionally, other catheters, such as a Van Schie (Cook Medical Inc., Bloomington, IN), may be useful when the gate is located away from the end of the contralateral sheath. This chapter delineates the Turret technique for rapid gate catheterization.
Tips for Accurate Palmaz Stent Deployment
Authors: Kahn S. Lowell
Published: August 2018

The Palmaz XL stent (Cordis) is a stainless-steel stent designed to be manually mounted on a balloon. Cautious mounting is warranted to avoid potential mal-deployment of the stent. Several mounting techniques are utilized. This chapter delineates the following three mounting techniques to achieve an accurate deployment of the Palmaz stent: use of a second balloon during deployment, use of a long delivery balloon, and use of an asymmetrically mounted stent and long delivery sheath to prevent distal herniation of the Palmaz stent. All three techniques can be used with most Palmaz stent deployments. These techniques are useful for both thoracic and abdominal aortic interventions.
Managing Unilateral or Bilateral Common Iliac Artery Aneurysms with Preservation of the Hypogastric Artery
Authors: Kahn S. Lowell
Published: August 2018

Isolated common iliac artery aneurysms are uncommon, occurring in 0.03% of the population, and are responsible for less than 2% of clinically significant aneurysm disease. However, the incidence of iliac artery aneurysms is much higher in patients with abdominal aortic aneurysms, with an incidence close to 40% in this population. The presence of bilateral iliac aneurysms in this population is common. This chapter describes two techniques to manage unilateral or bilateral common iliac artery aneurysms with preservation of the hypogastric artery: use of an Endologix AFX stent graft with snorkel placement and use of two bifurcated Gore Excluder stent grafts.
In Vivo Fenestration During Endovascular Aneurysm Repair
Authors: Masrani Abdulrahman , Arslan Bulent
Published: August 2018

Abdominal aortic aneurysms have been managed endovascularly during the past 10–15 years. The main limitations in the ability to treat patients endovascularly are anatomical constraints. The most important factors are aortic neck and iliofemoral access anatomy. This chapter describes a technique to overcome a short neck with a renal artery originating from the aneurysm that does not allow enough proximal landing zone for stent grafting. Several techniques have been developed to overcome this obstacle, including custom-made grafts with fenestrations, back table fenestration, and parallel graft placement. This chapter discusses the in vivo graft fenestration technique to preserve the renal artery lumen during the endovascular repair of an abdominal aortic aneurysm.
Reverse Deployment of the Gore Excluder Contralateral Iliac Limbs for Aortoiliac Interventions
Authors: Kahn S. Lowell
Published: August 2018

Aortoiliac occlusive disease and aneurysmal disease are common pathologies encountered by the interventionalist. There are a multitude of commercially available bifurcated grafts for use in aortoiliac disease, but these devices are costly and require at least a 14 Fr femoral access for deployment. This chapter describes a simple and safe method for reversing deployment of the Excluder contralateral limb. This has great utility not only for aortoiliac interventions but also for central venous stenoses/occlusions. Reversal of the limb allows a proximal diameter of 12–27 mm with a fixed distal diameter of 16 mm. The technique requires use of a 12–15 Fr sheath, most commonly a 12 Fr sheath.
Use of Two Bifurcated Stent Grafts for Creation of an Aorto-Uni-Iliac Endograft
Authors: Kahn S. Lowell
Published: August 2018

Abdominal aortic aneurysms are a common pathology encountered by the interventionalist. Most endovascular repairs are performed with conventional bifurcated devices. However, there are situations in which the use of an aorto-uni-iliac (AUI) device is required because the use of a bifurcated graft is not feasible. Standard indications for use of an AUI include a narrow aortic segment precluding delivery and adequate expansion of a bifurcated graft, unilateral iliac occlusion, tortuosity, severe stenosis, and the presence of iliac aneurysmal disease. Occasionally, an AUI may be used for aortoiliac occlusive disease or as a bailout technique with conventional endografting. This chapter elaborates on the use of two bifurcated stent grafts for creation of an AUI endograft.
Creation of a Flow-Modulating Stent Using Multilayered Wallstents for Aneurysm Exclusion
Authors: Kahn S. Lowell
Published: August 2018

Abdominal aortic aneurysms (AAAs) are a common pathology that is found in 4–9% of patients in the developed world. Risk factors for AAAs include age, male sex, family history, comorbid cardiovascular disease, and smoking. Despite the male predominance of the disease, rupture occurs at a smaller diameter in females, and the outcomes are poorer in this subgroup. Flow-modulating stents are a relatively new development and consist of multilayered bare-metal self-expanding stents. Despite the inherent porosity of the stents, the interconnected stent matrix features flow-diverting properties that preserve luminal and branch vessel flow while simultaneously depressurizing the aneurysm sac, resulting in shrinkage and thrombosis. Flow-modulating stents are unavailable in the United States. This chapter discusses in vivo construction of a flow-modulating stent and its potential applications and complications.
The Endoconduit for Small Iliac Access
Authors: Gandhi Ripal T. , Iglesias Jonathan J. , Peña Constantino S. , Benenati James F.
Published: August 2018

Endoconduits are increasingly being utilized in patients with small iliac access who require introduction of large devices for endovascular aneurysm repair, thoracic endovascular aneurysm repair, and transcatheter aortic valve replacement. Many techniques exist to circumvent the challenges imposed by suboptimal iliac anatomy, the most common of which is placement of an open surgical conduit through a retroperitoneal exposure of the common iliac artery or distal aorta. Endoconduit placement avoids more aggressive surgical approaches and involves the placement of a covered stent across the diseased iliac segment from a femoral approach. Following deployment, the endoconduit is aggressively balloon-angioplastied. This creates a proximal and distal seal while rupturing the diseased iliac segment and allows passage of large-profile sheaths and devices. A stepwise approach to placement of an endoconduit is reviewed, and tips and tricks are presented.
Transcaval Aortic Catheterization for Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair Device Delivery
Authors: Dake Michael D.
Published: August 2018

During the past decade, development of catheter-based techniques for treatment of thoracic aortic and aortic valve pathologies has required that interventionalists focus on the anatomic suitability of vascular access to allow safe introduction of large size devices. Both thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures require 20 French and larger sheaths and most of major complications during these procedures have been access related. This chapter reviews transcaval aortic access techniques for delivering large devices during TEVAR and TAVI. Alternative arterial access or adjunctive femoral access techniques that increase the safety of access and reduce the overall procedural risk for patients with challenging access are critically important for the success of TEVAR or TAVI. The procedure involves transcatheter puncture of the abdominal aorta from the inferior vena cava, with delivery of a large vascular sheath and tract closure post device delivery using a nitinol occlusion device.
Subintimal Arterial Recanalization Using the Bull’s-Eye Technique
Authors: Kahn S. Lowell
Published: August 2018

Antegrade retrograde revascularization is invaluable to the interventionalist, but is commonly complicated by the two catheters/wires lying in different planes and/or lumens relative to one another. This chapter describes the “bull’s-eye” technique with use of the Outback® LTD® Re-Entry Catheter (Cordis Corp., Milpitas, CA) steered toward a specific target, most commonly a snare to connect the two accesses. Although a snare the most commonly used target, this technique has been employed using a balloon or catheter as the target for the Outback®. This technique is widely applicable for large (aortic) to small (tibial) vessel revascularizations. It has also been employed successfully with challenging chronic central and peripheral venous occlusions.
Balloon Occlusion of Subintimal Tract to Assist Distal Luminal Re-entry During Subintimal Recanalization of Chronic Total Occlusions
Authors: Jaffan Abdel Aziz A.
Published: August 2018

The balloon occlusion of subintimal tract (BOST) technique may be used to assist in regaining luminal re-entry in difficult cases during subintimal recanalization of chronic total occlusions in the femoropopliteal artery. Subintimal recanalization or percutaneous intentional extraluminal recanalization (PIER) is an established technique used in endovascular recanalization of chronically occluded arteries of the peripheral circulation. The primary limitation of PIER is the high technical failure rate. Failure is mainly due to the inability to re-enter the patent true lumen distal to the site of the occlusion. The BOST technique can help overcome this limitation. This chapter provides a description of the technique.
Extravascular Recanalization of Chronic Total Occlusions
Authors: Kahn S. Lowell
Published: August 2018

Subintimal revascularization is a mainstay of therapy for lower extremity interventions. This stems from the realization that true lumen traversal is not always possible, subintimal revascularization has a high technical success rate, and the subintimal space may confer advantages over a heavily calcified true lumen. Most commonly in the tibial vasculature, there are times when subintimal recanalization is not possible because the wire and catheter may leave the subintimal plane and enter the periadventitial tissue. Although this is not intentional, exit from the vessel historically results in a technical failure because future passes of the wire and catheter are likely to follow suit, as evidenced by extravasation on contrast injection. This chapter describes two techniques to salvage this scenario and accept an extravascular tract for revascularization: the Outback® extravascular revascularization technique and the percutaneous gun-sight extravascular revascularization technique.
Retrograde Femoral Access for Difficult Superficial Femoral Artery Occlusions
Authors: Sewall Luke E.
Published: August 2018

Obtaining retrograde femoral access is a novel approach to treat difficult chronic total occlusions of the femoral arteries. The technique involves direct ultrasound-guided puncture of the mid to proximal superficial femoral artery. Using this access, a guidewire is advanced in a retrograde manner into the patent femoral or iliac artery above. This wire is then snared and brought out the contralateral sheath to allow safe access into the occluded vessel. The recanalization procedure can then be completed in a standard fashion. This technique is extremely useful in flush occlusions of the superficial femoral artery origin or in occluded stents, both of which often have very difficult proximal caps. This chapter outlines the details of this unusual technique.
The “Poor Man’s” Scoring Balloon
Authors: Kahn S. Lowell
Published: August 2018

This chapter describes the bench creation of a “poor man’s scoring balloon” as an alternative to commercially available scoring balloons. This is a simple procedure whereby two wires are placed side by side through the stenosis or occlusion to be treated. A standard angioplasty balloon is advanced over the working wire adjacent to the buddy wire. A minimal twisting is performed while advancing the balloon to wrap the buddy wire modestly around the balloon. The balloon is then inflated, and the spiral buddy wire acts as a scoring element to produce a more effective angioplasty. Given that two or more wires are often utilized in a peripheral revascularization, this technique can be performed with little or no additional cost. This procedure is simple to perform and works well in calcified or fibrotic lesions.
Balloon-Assisted Thrombin Injection for Pseudoaneurysms with Wide or Short Neck Morphology
Authors: Kahn S. Lowell
Published: August 2018

Pseudoaneurysms after cardiac catheterizations are not uncommon. Although most commonly they occur superficial to the common femoral artery, they are reported to occur at any location intentionally or unintentionally accessed. Ultrasound-assisted thrombin injection is a mainstay of therapy in appropriate patients. Although variations exist regarding the optimal location and amount of thrombin injection, the superior outcomes, low complication rate, and low cost associated with this method render great appeal to its utilization. This chapter describes an adjunctive technique (as well as a simple modification) to prevent the entrance of thrombin to the vasculature using a balloon to isolate the pseudoaneurysm. Although typically not necessary, this technique is valuable in the treatment of high-risk pseudoaneurysms and is well described in the literature.
Distal Occlusion Thrombectomy Technique
Authors: Kahn S. Lowell
Published: August 2018

The distal occlusion balloon thrombectomy technique involves placement of an occlusion balloon immediately distal to the thrombus or embolus. The balloon overlaps the antegrade wire. With the balloon inflated, the thrombotic/embolic material is removed over the antegrade wire using the desired thrombectomy catheter or device. The inflated balloon prevents distal migration of the embolic material during removal. Intermittent digital subtraction angiography is performed to assess for residual debris. When sufficiently extracted, the balloon is deflated and removed. Most commonly, this is performed with the balloon inserted in a retrograde manner. However, if distal access is not feasible, the antegrade sheath can be upsized.
Flip Techniques: Obtaining Antegrade and Retrograde Femoral Access Through a Single Access Site
Authors: Kahn S. Lowell
Published: August 2018

Retrograde access of the common femoral artery for ipsilateral iliac and up-and-over contralateral iliac-to-tibial interventions has been the standard of care for lower extremity procedures. However, ipsilateral antegrade access has gained popularity for infrainguinal occlusive disease. Proximity of the access site to the point of occlusion confers a higher technical success rate. Interestingly, there are times where conversion of a single femoral access from retrograde to antegrade or antegrade to retrograde may be desired. Three techniques are reviewed in this chapter: the first technique involves using a reverse curve catheter in conjunction with a Glidewire. The second technique is a “rebound” method whereby a Fogarty catheter is inflated just beyond the tip of a retrograde sheath to deflect a side-by-side Glidewire in the opposite direction. The third technique describes converting an antegrade sheath back to retrograde using a “buddy wire.”
Technical Pearls for Managing the Scarred Groin
Authors: Kahn S. Lowell
Published: August 2018

The femoral artery is considered one of the most common access sites for endovascular interventions. Its accessibility, size, and ease of compression over the femoral head post intervention make it favorable for vascular access during endovascular interventions. Combined with the frequency with which the femoral artery is utilized in a variety of bypass and aortoiliac surgical interventions, scarred groins are frequently encountered. Further complicating femoral access are the rising rates of obesity that have doubled during the past 35 years, with more than two-thirds (68.6%) of American adults reported as overweight or obese as of 2012. Despite its frequency, a scarred groin presents a unique challenge to the interventionalist, particularly in obese patients. This chapter discusses considerations for managing the scarred groin.
Use of a Fogarty Occlusion Balloon During Splenic Artery Embolization to Prevent Distal Coil Migration
Authors: Kahn S. Lowell
Published: August 2018

Splenic embolization has become a mainstay of therapy in the setting of splenic trauma for patients not requiring urgent surgery. This chapter describes a simple balloon occlusion technique to facilitate proximal embolization of the target splenic artery. Although the example presented is for a splenic artery, the technique may be extrapolated for other embolization procedures. Briefly, an occlusion balloon is delivered and supported proximally in the splenic artery, ideally distal to the dorsal pancreatic artery. After inflation of the occlusion balloon, the guidewire is removed and embolization is performed with standard 0.035-in. coils. This method allows for a dense packing of the coils and the use of fewer coils to obtain vascular stasis.
Combined Endovascular and Surgical Retrograde Superior Mesenteric Artery Recanalization
Authors: Peeran Syed M.
Published: August 2018

Acute mesenteric ischemia is a life-threatening vascular emergency associated with a very high mortality rate. In the setting of necrotic bowel, the current standard of care requires a laparotomy with bowel resection and surgical or endovascular revascularization of the superior mesenteric artery. Unfortunately, mesenteric bypass confers high perioperative mortality, in some reports up to 45%. A hybrid technique that employs an exploratory laparotomy, catheterization of the distal superior mesenteric artery, and stent deployment across the atherosclerotic lesion was first described in 2004 for the treatment of acute-on-chronic mesenteric ischemia. This chapter describes the appropriate clinical indications, the technical aspects of performing this hybrid procedure, as well as the challenges and common pitfalls encountered.
Techniques for Treating Visceral Aneurysms and High-Flow Arteriovenous Malformations of the Renal and Visceral Vasculature
Authors: Mehta Nikhil , Arslan Bulent
Published: August 2018

Techniques for treating visceral aneurysms are based on location and anatomic region and also on whether an aneurysm is a true aneurysm or a pseudoaneurysm. Visceral artery aneurysms typically require treatment if they are greater than 2 cm. Aneurysms that are favorable for endovascular therapy include saccular aneurysms preferably with a narrow neck and/or aneurysms that have good collateral blood flow to the target organ. Endovascular techniques for treating arteriovenous malformations (AVMs) are multifaceted and require appropriate identification of the AVM using multiple imaging modalities in addition to angiography. AVMs can be defined as slow flow, intermediate flow, and high flow.
Branched Stent Graft Placement in the Vena Cava Using the Endologix AFX
Authors: Kahn S. Lowell
Published: August 2018

Superior vena cava syndrome (SVCS) comprises a constellation of symptoms resulting from stenosis, occlusion, or thrombosis of the SVC of benign and malignant etiologies. The diagnosis is most commonly seen with thoracic malignancies, with primary lung cancer accounting for up to 70% of cases. Up to 4% of lung cancer patients present with SVCS at the time of diagnosis, and many more develop it at a later time. In younger patients with SVCS, lymphoma is commonly responsible. Recently, there has been a rise in benign SVCS secondary to the increased use of central venous catheters and pacemakers. Endovascular stenting of the SVC for SVCS has been described for more than 25 years and is now the first-line treatment of choice for benign and malignant SVCS. This chapter describes the use of the Endologix AFX AAA system for the treatment of SVCS.
Needle Recanalization of Chronic Venous Total Occlusions
Authors: Plotnik Adam N. , Kee Stephen
Published: August 2018

Recanalization of chronic venous occlusions is often difficult. Sharp recanalization of occluded central veins was first described in 1996, with subsequent further variations reported in the literature. The needle recanalization of chronic venous total occlusions (NRCVTO) technique may be employed where standard initial techniques have failed. Initial efforts to cross the occlusion should always begin with an angled or straight 0.035-in. glidewire together with a 4 Fr diagnostic catheter. The NRCVTO technique employs the use of a trans-septal needle together with a 0.014-in. guidewire. A target is then provided in the vessel distal to the occlusion in the form of a 4 Fr 10-mm snare, which is usually placed via a transfemoral or, less commonly, transhepatic approach.
Recanalization of Chronic Central Venous Occlusions: Techniques to Cross Difficult Venous Occlusions
Authors: Madassery Sreekumar , Arslan Bulent
Published: August 2018

With approximately 400,000 patients on hemodialysis in the United States alone, there are increasingly more patients who eventually develop central venous occlusions, mostly because of numerous central venous catheterizations and the placement of arteriovenous fistulas and grafts. With improving technical abilities to obtain central venous access for catheters and maintain fistula/graft patency, increasingly more patients present with signs of central venous stenosis/occlusion. For many, the underlying occlusion is chronic, with well-formed collateral vessels that have developed over time, thus allowing continued dialysis or asymptomatic function. However, for many patients there is a gradual progression of symptoms. This chapter discusses several techniques to cross chronic central venous occlusions.
Managing Chronic Iliac Venous Occlusions That Extend Below the Inguinal Ligament
Authors: Parikh Roshni A. , Williams David M.
Published: August 2018

This chapter describes the management, applications, challenges, and potential complications when venous occlusions extend below the inguinal ligament. Recanalization of a chronic iliocaval occlusion in combination with anticoagulation can significantly improve a patient’s quality of life. The success of treating iliocaval venous obstruction, however, depends on good venous inflow. Without adequate venous inflow, the outflow stents will fail. Evaluation of the saphenofemoral junction, femoral vein confluence, and/or saphenous vein, recanalization of the occluded segments, and extension of the stents will improve the venous inflow. This chapter describes the steps involved in the evaluation of both venous outflow and venous inflow and the establishment of flow throughout.
Management of Acute Iliocaval Thrombosis
Authors: Tasse Jordan C. , Arslan Bulent
Published: August 2018

Acute deep vein thrombosis (DVT) occurs in approximately 300,000 people per year in the United States. Iliocaval thrombosis is most commonly related to the progression of lower extremity DVT. Inferior vena cava (IVC) thrombosis occurs in approximately 4–15% of patients with acute DVT. Vena cava thrombosis is frequently associated with neoplastic disease. Foreign body placement such as an IVC filter or a venous catheter is a frequently reported cause of iliocaval thrombosis. External compression due to right common iliac artery mass effect (May–Thurner syndrome), tumor, lymphadenopathy, or aortic aneurysm are also commonly seen. This chapter discusses the interventional measures to manage acute iliocaval thrombosis.
Management of Chronic Iliocaval Thrombosis
Authors: Ahmed Osmanuddin
Published: August 2018

Chronic deep venous thrombosis (DVT) is defined by thrombus persisting beyond 28 days of initial onset and represents a condition that leads to long-standing venous hypertension, valvular incompetence, and ultimately chronic venous insufficiency and occlusion. As chronic thrombus organizes, it contracts and becomes adherent to the vein wall, causing scarring and consequent atresia of the lumen. The sequelae of such disease are manifested by limb edema, pain, discoloration, exercise intolerance, and ulceration—all encompassed within a clinical spectrum known as post-thrombotic syndrome. Attempts at recanalization with venoplasty and stenting of chronic inferior vena cava (IVC) and iliac occlusions are performed to restore the main venous outflow of the extremities to reverse or arrest the morbidity associated with this disease. This chapter discusses the interventional management of chronic iliocaval thrombosis.
Directional AngioJet Thrombectomy with Guide Catheter Helical Spin Technique
Authors: Kahn S. Lowell
Published: August 2018

The presence of thrombus in the central veins is associated with a higher risk of development post-thrombotic syndrome. The AngioJet Solent Proxi (90 cm) and Omni (120 cm) catheters are commonly used peripheral thrombectomy devices indicated for acute arterial and venous thrombus removal. Both catheters are 6 Fr sheath/8 Fr guide catheter compatible, and both offer the Power Pulse feature, allowing the direct infusion of tissue plasminogen activator into the thrombus. The catheters are indicated for use in vessels greater than 3 mm, with an optimal vessel range between 6 and 20 mm. Their use in the removal of iliac vein and inferior vena cava thrombus is frequent. Although the system is purported to provide effective thrombectomy capabilities in larger vessels, incomplete thrombus removal is common with larger vessels. This chapter proposes a simple modification in the standard use of the AngioJet Solent Proxi and Omni catheters.
Dual and Balloon-Assisted AngioJet Thrombectomy for Iliofemoral Deep Venous Thrombosis
Authors: Irani Zubin , Zhao Sara
Published: August 2018

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.
Tips and Tricks of the AngioVac Device
Authors: Stevens David C. , Butty Sabah
Published: August 2018

The AngioVac system, which consists of a coil-reinforced large-bore cannula, bypass circuit, bubble trap/filter, and reinfusion cannula, allows percutaneous removal of unwanted vascular debris, such as venous thrombus or cardiac vegetations, during veno-veno bypass. External suction is applied via a centrifugal bypass pump and debris is funneled into the cannula and trapped in the bubble trap/filter. The blood is then returned through an 18 Fr venous reinfusion cannula. The use of the device in the iliocaval venous segments and right heart is effective and safe. Due to the challenging anatomy, pulmonary artery thrombectomy carries an increased risk of complication and should be undertaken with great care. The AngioVac system is a versatile tool for removing thrombus and other unwanted debris from the central venous system and the right heart.
Optimal Technique for Catheterizing the Pulmonary Arteries Without Dedicated Pulmonary Catheters
Authors: Carberry George , Brunner Michael
Published: August 2018

With the emergence of high-resolution computed tomography angiography, the number of transcatheter pulmonary arteriograms being performed has steeply declined. For this reason, many interventional departments no longer stock dedicated pulmonary artery catheters such as the pre-shaped 7 Fr Grollman catheter for a femoral vein approach. Interventionalists are therefore required to improvise with catheters that are available on hand. Transcatheter pulmonary arteriography may be indicated when dedicated pulmonary artery catheters are not available for use. In this chapter, a step-by-step approach is described and accompanied by illustrations demonstrating how a common diagnostic catheter, the 5 Fr Omniflush catheter, can be used to perform pulmonary arteriography.
Minimally Invasive Repair of Azygos Catheter Migration
Authors: Patel Mikin V. , Zangan Steven
Published: August 2018

Central venous catheters are frequently placed to facilitate the care of patients with multiple conditions, often via jugular approach. Occasionally, the catheter tip can migrate after placement and become positioned within the azygos arch. This abnormal catheter positioning can lead to an increased number of complications, including catheter malfunction, thrombosis, or even rupture of the azygos vein requiring surgical intervention. Although invasive repositioning of the catheter is always an option, minimally invasive options can be attempted to repair azygos catheter malposition. Fortunately, noninvasive maneuvers, including manipulation of the port on the skin and patient breathing instructions, can sometimes repair the malpositioned catheter.
Placing a Jugular Port Without Direct Percutaneous Jugular Vein Access
Authors: Rush Michael , Ferguson Cynthia Toot , Kahn S. Lowell
Published: August 2018

A traditional subcutaneous port requires creation of a subcutaneous reservoir for the port and a separate small incision at the point of venous access, most commonly the internal jugular vein. The catheter of the port is tunneled from the port reservoir to the venous access incision and placed centrally through a peel-away sheath. Placing a subcutaneous jugular port without direct percutaneous jugular vein access is a skill that can be employed by the interventional radiologist and is described in this chapter. Considerations for site selection, accessing venous circulation, and appropriate placement of the port reservoir are described. This method of implanting a subcutaneous chest port has a high rate of technical success and low rate of complications.
Transhepatic Snare Placement for Translumbar Inferior Vena Cava Access
Authors: Patel Mikin V. , Zangan Steven
Published: August 2018

In patients requiring long-term chemotherapy, antibiotics, hemodialysis, or parenteral nutrition, central venous access is usually possible via catheter placement in the jugular, subclavian, or femoral veins. As these routes become complicated by thrombosis, stenosis, infection, or surgical intervention, the options for central venous catheter placement become limited, and direct puncture of the inferior vena cava (IVC) may be required. This chapter reviews the technique for placement of a catheter in the IVC via translumbar approach. Because direct access using anatomic landmarks can be challenging, initial puncture of the hepatic veins can be used to guide placement of an IVC catheter.
Fibrin Sheath Removal Techniques
Authors: Kahn S. Lowell
Published: August 2018

Although autogenous arteriovenous fistula creation is the gold-standard dialysis access, catheters represent between 40% and 60% of dialysis access in the United States. Catheters are placed for a variety of reasons, commonly as temporary access for acute renal failure or as a bridge to a more permanent access in patients with end-stage renal disease. Fibrin sheaths represent a heterogeneous matrix of cells and debris that form around catheters and are a known common cause of catheter failure and central venous stenosis. Their formation is ubiquitous in the dialysis population, occurring with 80–100% of catheters within 1 week of implantation. This chapter presents several techniques for the management of the fibrin sheath—the traditional catheter stripping technique, the internal catheter stripping technique, and the fibrin sheath angioplasty technique.
Obtaining Hemostasis at Puncture Sites
Authors: Madassery Sreekumar
Published: August 2018

This chapter pertains to femoral artery access. Attaining an “ideal” access is essential for maximizing the chances of maintaining effective hemostasis. Deciding whether to perform arterial access closure using the gold standard of manual compression versus a vascular closure device (VCD) requires the operator to evaluate many characteristics of the patient. The location of the arteriotomy, vessel size, degree of calcification, use of anticoagulants, and sheath size during the procedure are the primary factors that need to be considered. The ISAR-CLOSURE study reported that use of VCDs was not inferior to manual compression. This chapter discusses applications and potential complications of VCDs.
Elimination of Post-Procedural Bleeding After Placement of Tunneled Dialysis Catheters
Authors: Syed Almas , Heithaus Robert Evans , Rees Chet R.
Published: August 2018

This chapter discusses how to prevent postoperative bleeding with the placement of tunneled dialysis catheters. Tunneled intravenous chest catheters, particularly dialysis catheters, sometimes result in oozing or frank bleeding from the incisions during the first 24 hours after placement. This problem is exacerbated by the large diameter and stiffness of these catheters. Moreover, patients requiring these catheters frequently suffer from abnormal hemostasis profiles—an elevated international normalized ratio, thrombocytopenia, or abnormal platelet function due to uremia is commonly seen. The technique discussed in this chapter ensures that the potential bleeding sites throughout the operative site and tract are coated and permeated by a hemostatic agent.
Balloon-Assisted Removal of the Trapped Catheter
Authors: Kahn S. Lowell
Published: August 2018

Although uncommon, a trapped central venous catheter (CVC) can present a significant problem for the interventionalist and pose considerable risk to the patient. The use of chronic long-term CVCs is on the rise, with an average catheter dwell time of 10 months. Although all CVCs are prone to complications, chronic catheters exhibit a higher rate of complications. Chronic catheters are also at risk of becoming trapped, whereby they cannot be removed by standard technique. A simple, elegant technique to remove a trapped CVC via inserting an angioplasty balloon into the lumen of a stuck catheter has been described, as has a modified technique with inclusion of a hemostatic sheath and a stiff guidewire inserted into the cut catheter to ensure hemostasis, prevent air embolism or endoluminal thrombosis, and avoid injury to the central veins and heart. Examples of both applications are provided in this chapter.
The Rapid Fistula Declot
Authors: Preddie Dean C. , Miller Gregg A.
Published: August 2018

The rapid fistula declot is an endovascular approach to efficiently salvage the acutely thrombosed dialysis arteriovenous fistula (AVF). Thrombectomy of the AVF has historically been performed in the inpatient setting, but the advent of the outpatient vascular access center has vastly improved the efficiency and cost-effectiveness of dialysis access management. Fistula surveillance has generally been accepted to improve the life span of the AVF; however, due to the contribution of multiple factors, including uremia-induced vascular dysfunction, acute access thrombosis remains an issue. The rapid fistula declot is encapsulated in a simple algorithm of (1) clot removal, (2) repair of culprit stenoses, and (3) flow restoration. The preferred approach to each step is discretionary as long as near-complete evacuation of the fistula and venous outflow pathways of thrombus precedes flow restoration.
Endovascular Options for Nonmaturing Fistulas due to Collateral Flow
Authors: Soni Jayesh M.
Published: August 2018

The “failing to mature” arteriovenous fistula (AVF) is a surgically created AVF that fails to properly dilate to become usable for hemodialysis within 8–12 weeks after its creation. Difficult cannulation and inadequate AVF flow are the clinical manifestations of the “failing to mature” fistula. Early thrombosis of a newly created fistula is a possible cause of a “failing to mature” AVF. Early AVF thrombosis has similar underlying derangements as the immature fistula and both can be salvaged using endovascular techniques, including embolization of collateral veins via coils or endovascular plugs. Complications of collateral vein embolization include local hematoma formation, inadvertent coiling of the outflow vein, pain, erythema at the site of collateral vein embolization, migration of the coils, and, rarely, skin erosion at the site of the embolized superficial collateral vein. Patients need to be followed up with a fistulagram within 1 month of embolization.
Percutaneous Creation of Jump Bypass in a Native Arteriovenous Hemodialysis Fistula
Authors: Miller Peter , Butty Sabah , Casciani Thomas
Published: August 2018

This chapter describes the experience with percutaneous creation of jump bypass grafts in nonmature and failed arteriovenous hemodialysis fistulas based on a case series of 10 patients. Percutaneous intervention has been used to salvage nonmature fistulas, dysfunctional fistulas, and grafts. Frequently, venous outflow stenosis is the major cause of arteriovenous fistula and graft failure. Long-segment stenoses and chronically occluded venous outflow stenoses are more difficult to treat percutaneously and may require surgical revision. This chapter describes an endovascular technique creating a percutaneous jump bypass from the cephalic vein to the basilic vein using stent grafts in all patients with excellent immediate results. Limited available follow-up is also reported, including patency of two stent grafts for more than 2 years.