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Alzubaidi S, Wallace A, Naidu S, Knuttinen MG, Kriegshauser SJ, Oklu R, Al-Ogaili M, Patel I. Single-arm prospective study comparing ablation zone volume between time zero and 24 h after microwave ablation of liver tumors. Abdom Radiol (NY) 2024:10.1007/s00261-024-04185-z. [PMID: 38400983 DOI: 10.1007/s00261-024-04185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Percutaneous thermal ablation is an effective treatment for primary and metastatic liver tumors and is a recommended local therapy for early-stage hepatocellular carcinoma (HCC). Reported evidence shows an increase in the ablation zone volume over the first 24-h post-liver ablation. This report compares ablation zone volumes immediately at the completion (T = 0) of 26 microwave ablations of liver tumors to 24-h post-procedure (T = 24) volumes. MATERIALS AND METHODS 20 patients, 13 (65%) males, underwent a total of 26 hepatic microwave ablations (MWA) under ultrasound guidance. Contrast-enhanced CT (CECT) or MRI was performed immediately and another CECT 24 h post operatively. Evaluation of the ablation zone and comparison of the two post-operative scans were done using BioTrace software. The expansion of ablation zones on post-op CECTs was matched point by point per direction. The distance between each 2 points was measured and grouped by distance. The incidence of each specific distance was then converted into a percentage, first for each case separately, then for all cases altogether. Data were tested by a matched paired one-sided t test. RESULTS The median lesion diameter was 1.5 cm (range 0.5-3.3) with 16 (62%) HCC cases and 9 hepatic metastases (4 neuroendocrine carcinoma, 4 colorectal carcinomas, 1 breast carcinoma, 1 pancreatic cancer). The data show a consistent volume expansion greater than 30% (p = 7.7e-5) 24-h post-ablation, where the median expansion is 57%. Distances between T = 0 and T = 24 equal to 3-7 mm occur in over 35% of the cases. CONCLUSION The ablation zone expansion at 24-h post-op was not uniform. The final ablation zone is difficult to predict at the time of the procedure. The awareness of the ablation zone expansion is important when treating near-critical structures, managing the heat sink effect, and preserving liver parenchyma.
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Affiliation(s)
- Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Alex Wallace
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Martha-Garcia Knuttinen
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Scott J Kriegshauser
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mustafa Al-Ogaili
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA.
| | - Indravadan Patel
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ, 85054, USA
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Rotellini-Coltvet L, Wallace A, Saini G, Naidu S, Kriegshauser JS, Patel I, Knuttinen G, Alzubaidi S, Oklu R. Percutaneous Transesophageal Gastrostomy: Procedural Technique and Outcomes. J Vasc Interv Radiol 2023; 34:1901-1907. [PMID: 37419279 DOI: 10.1016/j.jvir.2023.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023] Open
Abstract
PURPOSE To demonstrate the safety and effectiveness of percutaneous transesophageal gastrostomy (PTEG) as a palliative option in patients with malignant bowel obstructions (MBOs), and provide a comprehensive review of PTEG indications, placement technique, and short- and long-term outcomes. MATERIALS AND METHODS Thirty-eight consecutive patients who underwent a PTEG procedure attempt from 2014 to 2022 were included in this analysis. Clinical indications, method of placement, technical and clinical success, adverse events, including procedure-related mortality, and effectiveness were assessed. Technical success was defined as placement of a PTEG. Clinical success was defined as improvement in clinical symptoms following PTEG placement. RESULTS Of the 38 patients who underwent PTEG, 19 (50%) were men and 19 (50%) were women (median age, 58 years; range, 21-75 years). Three (8%) PTEG placements were performed with the patients under moderate sedation, whereas the remainder (92%) were performed with the patients under general anesthesia. Technical success was achieved in 35 of the 38 (92%) patients. The mean catheter duration was 61 days (median, 29 days; range, 1-562 days), with 5 of the 35 patients requiring tube exchanges after initial placement. Moreover, 7 of the 35 patients with successful PTEG placement experienced an adverse event, including 1 case of non-procedure-related mortality. All patients with successful PTEG placement experienced improvement in clinical symptoms. CONCLUSIONS PTEG is an effective and safe option for patients with contraindications to traditional percutaneous gastrostomy tube placement in the setting of MBO. PTEG is an effective means of providing palliation and improving the quality of life.
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Affiliation(s)
- Lisa Rotellini-Coltvet
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona.
| | - Alex Wallace
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | - Gia Saini
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | | | - Indravadan Patel
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | - Grace Knuttinen
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | - Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Mayo Clinic Hospital Arizona, Phoenix, Arizona
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Naidu S, Madabatula N, Khattar H, Nandini R, Jayaswathy B. Radiation Induced Lumbar Plexopathy (RILP) in Patients of Cancer Cervix Treated by IMRT Technique: A Study of Dosimetry and Clinical Correlation. Int J Radiat Oncol Biol Phys 2023; 117:e535. [PMID: 37785657 DOI: 10.1016/j.ijrobp.2023.06.1822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To assess the Dosimetric parameters of lumbo sacral plexus in carcinoma cervix patients treated with concurrent chemo-radiation by Intensity modulated radiotherapy (IMRT) technique & to clinically correlate these Dosimetric parameters with the lumbo sacral plexus toxicity. MATERIALS/METHODS Total twenty-four patients were included in this study between December 2020 to December 2021. They were all treated by Intensity modulated radiotherapy (IMRT) technique. Radiotherapy dose delivered was 50Gy in 25 fractions at 2Gy/#, it was followed by 3 applications of intracavitary brachytherapy of 7Gy/ fraction each. The lumbo-sacral plexus was delineated according to guidelines given by Sun and Xi et al. No dose constraint was prescribed to the lumbo-sacral plexus prior to the treatment. Magnetic resonance imaging (MRI) of bilateral lumbo-sacral plexus test was done prior to the treatment and 12 months' post treatment. Dose received by the lumbo-sacral plexus was calculated DVH parameters was evaluated. The lumbo-sacral plexus toxicity was assessed by the 10-point questionnaire pre-treatment & post treatment and was compared. Assessment of toxicity was done by RTOG (Radiation Therapy Oncology Group) scoring criteria. RESULTS Out of the 24 patients treated, 7 patients had gross nodes which were treated with a boost dose of 60 Gy. Out of these patients 9 patients (37.5%) developed signs and symptoms of radiation induced lumbar plexopathy (RILP). Among these patients, the most common symptom was weakness in the lower limbs followed by impaired leg movement and activities interfering daily activities such as walking, squatting and getting up from the chair. Other positive findings included stiffness, lower limb pain, lower back ache radiating the lateral aspect of the thigh and numbness of the lower limbs. Total prescribed dose to 95% of the planned target volume ranged from 49.2Gy - 61.9 Gy (median - 57 Gy). The mean volume of the LS plexus was 128 cc (range, 92- 143 cc). The mean of the D-max of LS plexus was 56.2 Gy (range, 43.2 Gy- 61.9 Gy). The V30 Gy was received by 84 % of LS plexus, whereas V40, V50, V60 was received by 64 %, 13 % and 4%. The most common significant findings on MRI post treatment were unilateral thickening of the nerve roots followed by hyperintensity in T2 weighted image and STIR sequencing. Mild contrast uptake and edema were present in the nerve roots. CONCLUSION Radiation induced lumbar plexopathy (RILP) is one of the late complications after chemoradiotherapy in patients of carcinoma cervix, which is often misdiagnosed or missed on follow up. Therefore, lumbar plexus must be contoured in all pelvic malignancies which are treated by chemoradiotherapy with IMRT technique as it prevents dose dumping in that region. Further studies with longer follow up are needed.
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Affiliation(s)
- S Naidu
- BIBI Cancer Hospital, Hyderabad, India
| | | | - H Khattar
- SHRI Ram Murti Smarak Institute of Medical Sciences, Bareilly, India
| | - R Nandini
- BIBI Cancer Hospital, Hyderabad, India
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Umbarkar P, Kannan V, Anand VJ, Deshpande S, Hinduja R, Babu V, Naidu S, Jadhav O, Jejurkar A. A comparative study of rectal volume variation in patients with prostate cancer: A tertiary care center study. Radiography (Lond) 2023; 29:845-850. [PMID: 37399732 DOI: 10.1016/j.radi.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Every day variations in rectal filling in prostate cancer radiotherapy can significantly alter the delivered dose distribution from what was intended. The goal of this study was to see if the time of treatment delivery affected the rectal filling. METHODS This is a retrospective study which included 50 patients with localized prostate cancer treated with volumetric modulated arc therapy (VMAT) to the primary and regional lymph nodes. Cone Beam Computed Tomography (CBCT) image-sets were done for all patient's daily setup verification. The radiation therapist contoured the rectum on all CBCT image sets. The rectal volumes delineated on CBCT and the planning CT image sets were compared. The change in rectal volumes between morning and afternoon treatments were calculated and compared. RESULTS A total of 1000 CBCT image sets were obtained on 50 patients in the morning and afternoon. The percentage variation of the CBCT rectal volumes over the planning CT scan was 16.57% in the AM group and 24.35% in the PM group. CONCLUSION The percentage change in rectal volume was significantly lesser in AM group compared to PM group and therefore morning treatments may result in dose distribution that is close to the intended dose distribution. IMPLICATIONS FOR PRACTICE In prostate cancer radiotherapy our study suggests that a simple technique of changing the time of treatment from afternoon to morning can help to reduce the rectal volume.
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Affiliation(s)
- P Umbarkar
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - V Kannan
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - V J Anand
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - S Deshpande
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - R Hinduja
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - V Babu
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - S Naidu
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - O Jadhav
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
| | - A Jejurkar
- Radiotherapy Section, Dept. of Medicine., PD Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, India.
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Sriramoju A, Suppah M, Chao CJ, Sorajja D, Sweeney J, Naidu S, Lee R. Sinus Node Dysfunction After Percutaneous Transcatheter Closure of Right Coronary Artery-Superior Vena Cava Fistula. JACC Case Rep 2023; 16:101890. [PMID: 37396315 PMCID: PMC10313493 DOI: 10.1016/j.jaccas.2023.101890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 07/04/2023]
Abstract
Congenital right coronary artery-superior vena cava (RCA-SVC) fistula is rare and typically does not manifest any symptoms until the fifth decade of life. The present case demonstrates a 48-year-old woman who developed Sinus node dysfunction of unknown cause after Percutaneous coil embolization of the RCA-SVC fistula requiring permanent pacemaker. (Level of Difficulty: Intermediate.).
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Affiliation(s)
| | | | | | | | | | | | - Richard Lee
- Address for correspondence: Dr Richard Lee, Division of Cardiovascular Diseases, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA.
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Delanne J, Lecat M, Blackburn P, Klee E, Stumpel C, Stegmann S, Stevens S, Nava C, Heron D, Keren B, Mahida S, Naidu S, Babovic-Vuksanovic D, Herkert J, Torring P, Kibæk M, De Bie I, Pfundt R, Hendriks Y, Ousager L, Bend R, Warren H, Skinner S, Lyons M, Poe C, Chevarin M, Jouan T, Garde A, Thomas Q, Kuentz P, Tisserant E, Duffourd Y, Philippe C, Faivre L, Thauvin-Robinet C. Further clinical and molecular characterization of an XLID syndrome associated with BRWD3 variants, a gene implicate in leukemia-related JAK-STAT pathway. Eur J Med Genet 2022; 66:104670. [DOI: 10.1016/j.ejmg.2022.104670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/13/2022] [Accepted: 11/11/2022] [Indexed: 11/21/2022]
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Alzubaidi SJ, Khurana A, Sill A, Knuttinen JMG, Kriegshauser S, Naidu S, Patel I, Oklu R. Establishing a telemedicine program for interventional radiology: a study of patient opinion and experience. Diagn Interv Radiol 2022; 28:603-608. [PMID: 36550761 PMCID: PMC9885727 DOI: 10.5152/dir.2022.21837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The COVID-19 pandemic forced healthcare officials to implement new policies, such as the use of virtual consultations over office-based medical appointments, to reduce the transmission of the virus. The purpose of this study is to quantitatively compare patients' experiences with virtual outpatient telemedicine encounters at a single academic institution in Interventional Radiology (IR) and in-person visits during the course of the COVID-19 pandemic. METHODS The TeleENT Satisfaction Questionnaire and the Medical Communication Competence Scale (MCCS) were used to survey patients' satisfaction with both in-person and virtual office visits. RESULTS Ninety respondents (38 in-person, 52 virtual) acknowledged numerous benefits of virtual visits versus in-person office visits including reductions in time, cost, and potential viral transmission risk during the COVID-19 pandemic. No statistically significant difference was noted, based on a Likert scale from 1 to 7, between in-person and virtual visits (all p > 0.05) for scheduling related factors. No statistically significant difference was noted in any of the MCCS subscales between the two cohorts in regards to medical information communication (all p > 0.05). A majority of patients with virtual encounters (82.7%) stated that it was easy to obtain an electronic device for use during the telemedicine visit, and 73.1% of patients felt that setting up the telemedicine encounter was easy. CONCLUSION This study demonstrates that telemedicine is an acceptable alternative to in-office appointments and could increase access to IR care outside of the traditional physician-patient interaction. With telemedicine visits, patients can communicate their concerns and obtain information from the doctor with noninferior communication compared to in-person visits.
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Affiliation(s)
- Sadeer J Alzubaidi
- Division of Vascular and Interventional Radiology, Mayo Clinic, Arizona, US
| | | | - Andrew Sill
- Department of Radiology, Mayo Clinic, Arizona, US
| | | | - Scott Kriegshauser
- Division of Vascular and Interventional Radiology, Mayo Clinic, Arizona, US
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Mayo Clinic, Arizona, US
| | - Indravadan Patel
- Division of Vascular and Interventional Radiology, Mayo Clinic, Arizona, US
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Mayo Clinic, Arizona, US
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Bandyopadhyay D, Malik A, Goel A, Biswas S, Hajra A, Gupta R, Lanier G, Naidu S. Meta-analysis comparing the efficacy of dobutamine versus milrinone in acute decompensated heart failure and cardiogenic shock. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
This study aims to evaluate the difference between dobutamine and milrinone in patients presenting with acute decompensated heart failure (AHF).
Background
Inotropes are indicated for treating AHF, especially in patients with concomitant hypoperfusion indicative of cardiogenic shock. However, previous studies have not identified the optimal inotrope. We sought to compare outcomes associated with milrinone versus dobutamine in patients with AHF.
Methods
A systematic literature search was performed to identify relevant trials from inception to August 2021. Our primary outcome of interest was mortality. Analysis was sub-categorized according to subpopulation, including AHF, AHF with cardiogenic shock (AHF-shock), AHF with a bridge to transplantation (AHF-BTT), and AHF with destination therapy (AHF-DT). Summary effects were calculated using a fixed-effects model as risk ratio or mean difference with 95% confidence intervals for all the clinical endpoints.
Results
Ten studies, including one randomized controlled trial with 21,106 patients, were included in the analysis (4918 patients were in the Milrinone group, while 15188 were in the Dobutamine group). Milrinone was associated with a lower risk of mortality in patients with AHF [relative risk (RR) 0.87; confidence interval (CI):0.79–0.97; p<0.05, heterogeneity I2=0%] with event rates of 9.4% vs. 9.8% [number needed to treat (NNT) of 250]. Milrinone was also associated with improved mortality with RR 0.76 (0.79–0.95; p<0.05) in patients with AHF-DT. There was a non-significant trend towards improved mortality in AHF-shock patients. However, AHF-BTT patients had a non-significant trend towards improved mortality with dobutamine. There was no difference between the two strategies for the outcomes of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay (LOS) in the overall population. Intensive care unit (ICU) LOS was lower in AHF-shock patients in the milrinone group, whereas dobutamine was associated with a lower length of ICU stay in AHF patients.
Conclusion
The cumulative data comparing milrinone with dobutamine indicate an overall marginal benefit of milrinone compared to dobutamine in the totality of patients with AFH with or without cardiogenic shock, and whether or not they are bridged to transplantation or destination assist device. More appropriately powered prospective studies are needed to identify a conclusive benefit of one inotrope over another.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Bandyopadhyay
- New York Medical College , New York , United States of America
| | - A Malik
- New York Medical College , New York , United States of America
| | - A Goel
- New York Medical College , New York , United States of America
| | - S Biswas
- Rochester Regional Health , Rochester , United States of America
| | - A Hajra
- Albert Einstein College of Medicine , Bronx , United States of America
| | - R Gupta
- Lehigh Valley Hospital , Allentown , United States of America
| | - G Lanier
- New York Medical College , New York , United States of America
| | - S Naidu
- New York Medical College , New York , United States of America
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Alzubaidi S, Naidu S, Kriegshauser J, Oklu R, Knuttinen G, Patel I. Abstract No. 169 A novel ultrasound-based technology for monitoring of thermal tissue damage in liver ablation procedures. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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10
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Cheema KP, Sorajja D, Naidu S. PC-578-04 TRANSHEPATIC PERMANENT PACEMAKER LEAD PLACEMENT. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jamal L, Saini A, Quencer K, Altun I, Albadawi H, Khurana A, Naidu S, Patel I, Alzubaidi S, Oklu R. Emerging approaches to pre-hospital hemorrhage control: a narrative review. Ann Transl Med 2021; 9:1192. [PMID: 34430633 PMCID: PMC8350651 DOI: 10.21037/atm-20-5452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
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Affiliation(s)
- Leila Jamal
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aman Saini
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keith Quencer
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aditya Khurana
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
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Khurana A, Quencer K, Saini A, Sill A, Albadawi H, Jamal L, Naidu S, Patel I, Alzubaidi S, Oklu R. Endovascular interventions in the management of acute extremity trauma: a narrative review. Ann Transl Med 2021; 9:1197. [PMID: 34430638 PMCID: PMC8350664 DOI: 10.21037/atm-20-5428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
Minimally invasive endovascular interventions including stenting and embolization have been widely adopted for the treatment of emergent and traumatic thoracoabdominal injuries. In recent years, these techniques have been utilized in the setting of extremity vascular trauma with promising outcomes. By allowing for the rapid diagnosis and subsequent treatment of penetrating or blunt vascular extremity trauma, these techniques can help to minimize blood loss, reduce operative complications, and potentially prevent limb amputation. Here, we present a narrative review of the ever-increasing role of minimally invasive interventions in the management of extremity trauma and compare its use and outcomes to open surgical repair. A special focus is placed on diagnostic imaging modalities in trauma and the role of interventional radiologists in the work-up and treatment of extremity trauma. We discuss diagnostic imaging modalities that aid in the triaging of extremity trauma, such as Doppler sonography, CT angiography, and catheter-based angiography. We present an overview on the literature related to endovascular interventions such as embolotherapy and stent grafting as well as the technical challenges associated with each technique. Finally, we present our own cases on the workup and endovascular treatment of extremity trauma, including CT angiography, particulate and coil embolization, and stent graft placement.
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Affiliation(s)
- Aditya Khurana
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Keith Quencer
- University of Utah, Interventional Radiology, Salt Lake City, Utah, USA
| | - Aman Saini
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Andrew Sill
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Hassan Albadawi
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Leila Jamal
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Indravadan Patel
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Scottsdale, AZ, USA
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Naidu S, Alzubaidi S, Knuttinen G, Patel I, Fleck A, Sweeney J, Aqel B, Larsen B, Buras M, Golafshar M, Oklu R. Treatment of Hepatic Artery Stenosis in Liver Transplant Patients Using Drug-Eluting versus Bare-Metal Stents. J Clin Med 2021; 10:jcm10030380. [PMID: 33498286 PMCID: PMC7863956 DOI: 10.3390/jcm10030380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/10/2021] [Accepted: 01/14/2021] [Indexed: 01/10/2023] Open
Abstract
Hepatic artery stenosis after liver transplant is often treated with endovascular stent placement. Our institution has adopted use of drug-eluting stents, particularly in small-caliber arteries. We aimed to compare patency rates of drug-eluting stents vs. traditional bare-metal stents. This was a single-institution, retrospective study of liver transplant hepatic artery stenosis treated with stents. Primary patency was defined as time from stent placement to resistive index on Doppler ultrasonography (<0.5), hepatic artery thrombosis, or any intervention including surgery. Fifty-two patients were treated with stents (31 men; mean age, 57 years): 15, drug-eluting stents; 37, bare-metal stents. Mean arterial diameters were 4.1 mm and 5.1 mm, respectively. Technical success was 100% (52/52). At 6 months, 1, 2, and 3 years, primary patency for drug-eluting stents was 80%, 71%, 71%, and 71%; bare-metal stents: 76%, 65%, 53%, and 46% (p = 0.41). Primary patency for small-caliber arteries (3.5–4.5 mm) with drug-eluting stents was 93%, 75%, 75%, and 75%; bare-metal stents: 60%, 60%, 50%, and 38% (p = 0.19). Overall survival was 100%, 100%, 94%, and 91%. Graft survival was 100%, 98%, 96%, and 90%. Stenting for hepatic artery stenosis was safe and effective. While not statistically significant, patency improved with drug-eluting stents compared with bare-metal stents, especially in arteries < 4.5 mm in diameter. Drug-eluting stents can be considered for liver transplant hepatic artery stenosis, particularly in small-caliber arteries.
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Affiliation(s)
- Sailendra Naidu
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
- Correspondence:
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
| | - Grace Knuttinen
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
| | - Andrew Fleck
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
| | - John Sweeney
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
| | - Bashar Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
| | - Brandon Larsen
- Division of Anatomic Pathology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
| | - Matthew Buras
- Division of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (M.B.); (M.G.)
| | - Michael Golafshar
- Division of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (M.B.); (M.G.)
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA; (S.A.); (G.K.); (I.P.); (A.F.); (R.O.)
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Hinduja RH, Kannan V, Anand V, Bajpai R, Deshpande S, Naidu S, Chauhan K, Umbarkar P, Kabre R, Alurkar P. PO-0971: Factors predicting magnitude of heart dose reduction with DIBH-RT in left breast cancers. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Deshpande S, Naidu S, Chavan K, Kannan V. PO-1396: Dosimetric comparison of AAA and Acuros XB algorithm for breast DIBH VMAT treatment. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Henkin S, Wysokinski WE, Tweet M, Shamoun F, Naidu S, Sutkowska K, Bator K, Shields R, Greene E, Keller S, Hodge D, McBane R. Spontaneous visceral artery dissections in otherwise normal arteries: Clinical features, management, and outcomes compared with fibromuscular dysplasia. J Vasc Surg 2020; 73:516-523.e2. [PMID: 32623103 DOI: 10.1016/j.jvs.2020.05.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/22/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Visceral artery dissection with otherwise normal-appearing arteries (VADNA), diagnosed on imaging and suggestive of segmental arterial mediolysis, is a poorly understood disease entity. Study objectives were to define the clinical features, management, and outcomes of patients with VADNA compared with patients with fibromuscular dysplasia (FMD). METHODS In this single-center retrospective cohort study, consecutive patients with a diagnosis of VADNA or FMD evaluated in the Mayo Clinic Gonda Vascular Center (January 1, 2000-April 1, 2017) were identified. Patient demographics, symptom presentation, management, composite adverse arterial events (recurrent arterial dissection, stroke or transient ischemic attack, myocardial infarction, mesenteric or renal infarction, or need for revascularization), and overall survival were compared between VADNA and FMD patients. RESULTS There were 103 VADNA patients (age [mean ± standard deviation], 51.7 ± 11.0 years; 27.9% female) and 248 FMD controls (49.8 ± 8.9 years; 81.8% female) identified. The most common symptom for VADNA patients was abdominal or flank pain (80.6%). For FMD, chest pain, headache, and dizziness were more frequent presenting complaints. The median follow-up was longer for VADNA patients (42 months; interquartile range, 9-76 months) compared with FMD patients (19 months; interquartile range, 0.6-52 months; P < .001). During this time interval, there were twofold more composite arterial events in the VADNA group compared with the FMD group (17% vs 8.1%; P = .01). This difference was primarily driven by recurrent dissections. All-cause mortality was low and similar for both groups (3.8% vs 0.4%; P = .10). CONCLUSIONS VADNA patients carry a higher risk of recurrent arterial events compared with those with FMD. This difference was primarily driven by recurrent dissections.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Marysia Tweet
- Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Fadi Shamoun
- Cardiovascular Department, Mayo Clinic, Scottsdale, Ariz
| | | | | | - Kaja Bator
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Raymond Shields
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Eddie Greene
- Nephrology and Hypertension Division, Mayo Clinic, Rochester, Minn
| | - Shelly Keller
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Robert McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn.
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Alzubaidi S, Patel I, Saini A, Knuttinen G, Naidu S, Kriegshuaser S, Albadawi H, Oklu R. Current concepts in portal vein thrombosis: etiology, clinical presentation and management. Abdom Radiol (NY) 2019; 44:3453-3462. [PMID: 31407054 DOI: 10.1007/s00261-019-02174-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT. RESULTS PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options. CONCLUSION Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.
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18
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Sahota A, Naidu S, Jacobi A, Giannarelli C, Fayad Z, Mani V. Vaping Safer Than Smoking But Not Without Cardiovascular Risk: A Pet/Mri Study. Atherosclerosis 2019. [DOI: 10.1016/j.atherosclerosis.2019.06.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Kamath NP, Tandon S, Nayak R, Naidu S, Anand PS, Kamath YS. The effect of aloe vera and tea tree oil mouthwashes on the oral health of school children. Eur Arch Paediatr Dent 2019; 21:61-66. [DOI: 10.1007/s40368-019-00445-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
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20
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Dwivedi P, Kumar RR, Dhooria A, Adarsh MB, Malhotra S, Kakkar N, Naidu S, Sharma SK, Sharma A, Jain S, Dhir V. Corticosteroid-associated lupus pancreatitis: a case series and systematic review of the literature. Lupus 2019; 28:731-739. [PMID: 31023131 DOI: 10.1177/0961203319844004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute pancreatitis is an uncommon complication that occurs in 0.85% to 4% of patients with systemic lupus erythematosus (SLE). In some patients, it occurs within days to weeks of starting medium-to-high dose corticosteroids. The authors have used the term 'corticosteroid-associated lupus pancreatitis' for these patients, and they report a case series and perform a systematic review of previously published reports. METHODS For the purpose of this study, corticosteroid-associated lupus pancreatitis was defined as occurrence of acute pancreatitis in patients with SLE (fulfilling the 1997 ACR), within 3 weeks of starting therapy with medium-to-high dose corticosteroids - either newly initiated or escalated from a lower dose. All patients with SLE admitted in the last 2.5 years in a North Indian university hospital were reviewed, and those with pancreatitis who fulfilled the above criteria were included in the case series. For the systematic review, a PUBMED search using the keywords 'lupus' and 'pancreatitis' was performed, and reports in English were reviewed for an association with corticosteroids. RESULTS Among 420 admissions of SLE patients, six patients (1.4%) fulfilled criteria for corticosteroid-associated lupus pancreatitis. All were female, with mean age and disease duration of 19.7 ± 3.3 and 3.8 ± 2.5 years respectively. All had active disease and developed acute pancreatitis within 48-72 hours of newly initiating medium-to-high dose corticosteroids (in three patients) or escalating them to medium-high dose (in three patients). After the development of pancreatitis, corticosteroids were continued in all except one patient. In addition, two patients received pulse methylprednisolone, two received pulse cyclophosphamide and one was started on azathioprine. Three patients died during hospitalization, all with severe pancreatitis. On systematic review, among 451 cases of lupus pancreatitis reported, 23 (5%) fulfilled criteria for 'corticosteroid-associated lupus pancreatitis'. A majority of them had pancreatitis within 3 days of starting treatment with medium-to-high dose corticosteroids. The mortality in these patients was 37.5%. CONCLUSION In a small but substantial proportion of patients with lupus who develop pancreatitis, it occurs within days to weeks of starting medium-to-high dose corticosteroids. Many of these patients continue to receive corticosteroids, and some receive more aggressive immunosuppression. However, they have significant mortality, and further studies are required to identify appropriate treatment in this subgroup of patients.
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Affiliation(s)
- P Dwivedi
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R R Kumar
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Dhooria
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - M B Adarsh
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Malhotra
- 2 Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - N Kakkar
- 2 Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Naidu
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S K Sharma
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Sharma
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Jain
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - V Dhir
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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21
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Saini A, Wallace A, Alzubaidi S, Knuttinen MG, Naidu S, Sheth R, Albadawi H, Oklu R. History and Evolution of Yttrium-90 Radioembolization for Hepatocellular Carcinoma. J Clin Med 2019; 8:jcm8010055. [PMID: 30621040 PMCID: PMC6352151 DOI: 10.3390/jcm8010055] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 12/18/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer and affects millions worldwide. Due to the lack of effective systemic therapies for HCC, researchers have been investigating the use of locoregional tumor control with Yttrium-90 (Y90) radioembolization since the 1960s. Following the development of glass and resin Y90 microspheres in the early 1990s, Y90 radioembolization has been shown to be a safe and efficacious treatment for patients with HCC across Barcelona Clinic Liver Cancer (BCLC) stages. By demonstrating durable local control, good long term outcomes, and equivalent if not superior tumor responses and tolerability when compared to alternative therapies including transarterial chemoembolization (TACE) and sorafenib, Y90 radioembolization is being increasingly used in HCC treatment. More recently, investigations into variations in Y90 radioembolization technique including radiation segmentectomy and radiation lobectomy have further expanded its clinical utility. Here, we discuss the history and evolution of Y90 use in HCC. We outline key clinical trials that have established the safety and efficacy of Y90 radioembolization, and also summarize trials comparing its efficacy to existing HCC treatments. We conclude by reviewing the techniques of radiation segmentectomy and lobectomy, and by discussing dosimetry.
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Affiliation(s)
- Aman Saini
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Alex Wallace
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - M Grace Knuttinen
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Rahul Sheth
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, TX 77054, USA.
| | - Hassan Albadawi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
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22
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Saini A, Wallace A, Albadawi H, Naidu S, Alzubaidi S, Knuttinen MG, Panda A, Oklu R. Quiescent-Interval Single-Shot Magnetic Resonance Angiography. Diagnostics (Basel) 2018; 8:diagnostics8040084. [PMID: 30567304 PMCID: PMC6315503 DOI: 10.3390/diagnostics8040084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/15/2018] [Accepted: 12/15/2018] [Indexed: 01/22/2023] Open
Abstract
Lower extremity peripheral arterial disease (PAD) is a chronic, debilitating disease with a significant global burden. A number of diagnostic imaging techniques exist, including computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CEMRA), to aid in PAD diagnosis and subsequent treatment planning. Due to concerns of renal toxicity or nephrogenic systemic fibrosis (NSF) for iodinated and gadolinium-based contrasts, respectively, a number of non-enhanced MRA (NEMRA) protocols are being increasingly used in PAD diagnosis. These techniques, including time of flight and phase contrast MRA, have previously demonstrated poor image quality, long acquisition times, and/or susceptibility to artifacts when compared to existing contrast-enhanced techniques. In recent years, Quiescent-Interval Single-Shot (QISS) MRA has been developed to overcome these limitations in NEMRA methods, with promising results. Here, we review the various screening and diagnostic tests currently used for PAD. The various NEMRA protocols are discussed, followed by a comprehensive review of the literature on QISS MRA to date. A particular emphasis is placed on QISS MRA feasibility studies and studies comparing the diagnostic accuracy and image quality of QISS MRA versus other diagnostic imaging techniques in PAD.
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Affiliation(s)
- Aman Saini
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Alex Wallace
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Hassan Albadawi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - M Grace Knuttinen
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Anshuman Panda
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, Arizona 85054, USA.
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Venkatesan K, Deshpande S, Anand V, Bajpai R, Naidu S, Babu V, Nagshet S, Mittal V, Deshmane V. Comparison of Heart and Lung Doses in Deep Inspiration Breath Hold Radiation Therapy and Prone Position Radiation Therapy for Whole Breast Radiation Therapy. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Acute limb ischemia (ALI), a subclass of critical limb ischemia, is a medical emergency. The cause of ALI is usually thrombotic or embolic in nature, and the specific etiology often dictates the appropriate therapy. While the diagnosis is a clinical with common presenting symptoms, advances in ultrasound, computed tomography, and magnetic resonance technology have impacted the diagnosis and subsequent therapy. In ALI, the time to revascularization is critical and computed tomography angiography (CTA) provides a highly sensitive and specific technique for rapidly identifying occlusions and precisely defining vascular anatomy prior to interventions. In patients with significant renal disease, magnetic resonance angiography with or without contrast provides effective alternatives at the expense of imaging time. Treatment can include a variety of endovascular or surgical interventions, including thromboembolectomy, angioplasty, or bypass. Proper evaluation of the etiology of the ischemia, affected vasculature, and medical history is critical to select appropriate treatment and improve patient outcomes. Here, we examine the presentation, evaluation, and treatment of ALI and the role of CTA in diagnosis and therapy.
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Saini A, Pershad Y, Albadawi H, Kuo M, Alzubaidi S, Naidu S, Knuttinen MG, Oklu R. Liquid Biopsy in Gastrointestinal Cancers. Diagnostics (Basel) 2018; 8:diagnostics8040075. [PMID: 30380690 PMCID: PMC6316210 DOI: 10.3390/diagnostics8040075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 12/18/2022] Open
Abstract
Liquid biopsy is the sampling of any biological fluid in an effort to enrich and analyze a tumor's genetic material. Peripheral blood remains the most studied liquid biopsy material, with circulating tumor cells (CTC's) and circulating tumor DNA (ctDNA) allowing the examination and longitudinal monitoring of a tumors genetic landscape. With applications in cancer screening, prognostic stratification, therapy selection and disease surveillance, liquid biopsy represents an exciting new paradigm in the field of cancer diagnostics and offers a less invasive and more comprehensive alternative to conventional tissue biopsy. Here, we examine liquid biopsies in gastrointestinal cancers, specifically colorectal, gastric, and pancreatic cancers, with an emphasis on applications in diagnostics, prognostics and therapeutics.
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Affiliation(s)
- Aman Saini
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Yash Pershad
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Hassan Albadawi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Malia Kuo
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sadeer Alzubaidi
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - M-Grace Knuttinen
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Laboratory for Minimally Invasive Therapeutics, Mayo Clinic, Phoenix, AZ 85054, USA.
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Knuttinen MG, Yi J, Magtibay P, Miller CT, Alzubaidi S, Naidu S, Oklu R, Kriegshauser JS, Mar WA. Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities. J Clin Med 2018; 7:jcm7040087. [PMID: 29690541 PMCID: PMC5920461 DOI: 10.3390/jcm7040087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 11/16/2022] Open
Abstract
Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.
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Affiliation(s)
| | - Johnny Yi
- Mayo Clinic Arizona; Phoenix, AZ 85054 USA.
| | | | | | | | | | - Rahmi Oklu
- Mayo Clinic Arizona; Phoenix, AZ 85054 USA.
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Pershad Y, Albadawi H, Naidu S, Knuttinen M, Kriegshauser J, Oklu R. Abstract No. 599 Time-driven activity-based costing in interventional radiology: a pilot study. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Sheth RA, Niekamp A, Quencer KB, Shamoun F, Knuttinen MG, Naidu S, Oklu R. Thrombosis in cancer patients: etiology, incidence, and management. Cardiovasc Diagn Ther 2017; 7:S178-S185. [PMID: 29399521 DOI: 10.21037/cdt.2017.11.02] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Venous thromboembolism (VTE) is the second most common cause of mortality in cancer patients. The mechanisms of cancer-associated thrombosis (CAT), much like cancer itself, are multi-factorial and incompletely understood. Cancer type, stage, tumor-derived factors and genetics all affect CAT risk. Furthermore, cancer therapies as well as the indwelling vascular devices through which these therapies are delivered can increase the risk for CAT. In this review, we summarize mechanisms of hypercoagulability in cancer patients, patterns of thrombosis associated with cancer, current guidelines for the diagnosis and management of CAT, and important considerations regarding the placement of implantable vascular devices in the care of cancer patients with VTE.
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Affiliation(s)
- Rahul A Sheth
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Niekamp
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith B Quencer
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Fadi Shamoun
- Division of Vascular Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
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Knuttinen MG, Naidu S, Oklu R, Kriegshauser S, Eversman W, Rotellini L, Thorpe PE. May-Thurner: diagnosis and endovascular management. Cardiovasc Diagn Ther 2017; 7:S159-S164. [PMID: 29399519 DOI: 10.21037/cdt.2017.10.14] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Common left iliac vein compression, otherwise known as May-Thurner (MT), is an anatomical risk factor for lower extremity deep vein thrombosis (DVT). MT refers to chronic compression of the left iliac vein against the lumbar spine by the overlying right common iliac artery. The compression may be asymptomatic. The syndrome is a clinical spectrum of physical findings and history plus the lesion. It is characterized by the varying degrees of venous hypertension. This can be non-thrombotic, combined with acute DVT or post-thrombotic. Traditionally, acute DVT was treated with standard anticoagulation and sometimes, thrombectomy. However these measures do not address the underlying culprit lesion of mechanical compression. Furthermore, if managed only with anticoagulation, patients with residual thrombus are at risk for developing recurrent DVT or post-thrombotic syndrome (PTS). Both retrospective and prospective studies have shown that endovascular management should be the preferred approach to dissolve proximal thrombus and to also treat the underlying compression with endovascular stent placement.
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Affiliation(s)
- M-Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - William Eversman
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Lisa Rotellini
- Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
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Wallace A, Albadawi H, Hoang P, Fleck A, Naidu S, Knuttinen G, Oklu R. Statins as a preventative therapy for venous thromboembolism. Cardiovasc Diagn Ther 2017; 7:S207-S218. [PMID: 29399524 DOI: 10.21037/cdt.2017.09.12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The anti-inflammatory effects of statins have likely not been used to their fullest extent, particularly in reducing venous thromboembolic events. Current therapy for thrombotic events hinges on anticoagulation via heparin, warfarin or new oral anticoagulants. Interventional procedures with thrombectomy may also play a critical role. Unfortunately, thrombotic events can occur and recur despite meticulous anticoagulation therapy. Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE), two complicated and prevalent diseases that can cause chronic disease states such as post-thrombotic syndrome (PTS). In 2009 the JUPITER trial demonstrated that rosuvastatin may be effective when dealing with vascular inflammation by providing an anti-inflammatory effect. Multiple subsequent studies have looked at this association with some promising findings. The mechanism of action for statins is not entirely understood but there has been a variety of proposals and subsequent testing of inflammatory biomarkers. Additional prospective trials are needed to confirm the possible benefit of VTE reduction through an anti-inflammatory effect, but if this can be shown then statins may become a safe adjunctive therapy for VTE prevention.
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Affiliation(s)
- Alex Wallace
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Peter Hoang
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Andrew Fleck
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Wallace A, Albadawi H, Patel N, Khademhosseini A, Zhang YS, Naidu S, Knuttinen G, Oklu R. Anti-fouling strategies for central venous catheters. Cardiovasc Diagn Ther 2017; 7:S246-S257. [PMID: 29399528 DOI: 10.21037/cdt.2017.09.18] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Central venous catheters (CVCs) are ubiquitous in the healthcare industry and carry two common complications, catheter related infections and occlusion, particularly by thrombus. Catheter-related bloodstream infections (CRBSI) are an important cause of nosocomial infections that increase patient morbidity, mortality, and hospital cost. Innovative design strategies for intravenous catheters can help reduce these preventable infections. Antimicrobial coatings can play a major role in preventing disease. These coatings can be divided into two major categories: drug eluting and non-drug eluting. Much of these catheter designs are targeted at preventing the formation of microbial biofilms that make treatment of CRBSI nearly impossible without removal of the intravenous device. Exciting developments in catheter impregnation with antibiotics as well as nanoscale surface design promise innovative changes in the way that physicians manage intravenous catheters. Occlusion of a catheter renders the catheter unusable and is often treated by tissue plasminogen activator administration or replacement of the line. Prevention of this complication requires a thorough understanding of the mechanisms of platelet aggregation, signaling and cross-linking. This article will look at the advances in biomaterial design specifically drug eluting, non-drug eluting, lubricious coatings and micropatterning as well as some of the characteristics of each as they relate to CVCs.
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Affiliation(s)
- Alex Wallace
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Nikasha Patel
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Ali Khademhosseini
- Department of Bioengineering, Department of Chemical and Biomolecular Engineering, Henry Samueli School of Engineering and Applied Sciences, University of California-Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Radiology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.,Center for Minimally Invasive Therapeutics (C-MIT), University of California-Los Angeles, Los Angeles, CA, USA.,California NanoSystems Institute (CNSI), University of California-Los Angeles (UCLA), Los Angeles, CA, USA
| | - Yu Shrike Zhang
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Hoang P, Wallace A, Sugi M, Fleck A, Pershad Y, Dahiya N, Albadawi H, Knuttinen G, Naidu S, Oklu R. Elastography techniques in the evaluation of deep vein thrombosis. Cardiovasc Diagn Ther 2017; 7:S238-S245. [PMID: 29399527 DOI: 10.21037/cdt.2017.10.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Deep venous thrombosis (DVT) is a significant medical problem with an incidence of 1 in 1,000 adults and greatly reduces quality of life through post-thrombotic syndrome. Treatment choice for DVT can be influenced by the age of the clot. While new endovascular catheter techniques treat venous clots to potentially prevent post-thrombotic syndrome, they require improved imaging techniques to accurately determine clot age. This review investigates experimental and clinical evidence of elastography techniques for aging DVT. Strain elastography and shear wave elastography are the most common techniques to age thrombus. These elastography techniques can distinguish between acute and chronic clots by characterizing tissue stiffness. When clot age cannot be determined with ultrasound duplex analysis, elastography may offer a helpful adjunct. However, further investigation is required to validate accuracy and reproducibility for clinical implementation of this novel technique.
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Affiliation(s)
- Peter Hoang
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Alex Wallace
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Mark Sugi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Andrew Fleck
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Yash Pershad
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Nirvikar Dahiya
- Division of Diagnostic Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Fleck D, Albadawi H, Wallace A, Knuttinen G, Naidu S, Oklu R. Below-knee deep vein thrombosis (DVT): diagnostic and treatment patterns. Cardiovasc Diagn Ther 2017; 7:S134-S139. [PMID: 29399516 DOI: 10.21037/cdt.2017.11.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Guidelines are lacking for isolated below-knee deep vein thrombosis (BKDVT). The American College of Chest Physicians (ACCP) suggests anticoagulation only if symptoms are severe, otherwise surveillance with follow-up ultrasound in 2 weeks is recommended. Yet clinical practice remains highly variable. Little is known about the natural history of BKDVT and how to best manage these patients. Methods A retrospective analysis was conducted of medical records from 2014-2016. Risk factors were assessed such as age, gender, malignancy, recent surgery, and history of DVT. Treatment decisions and outcomes were identified. Radiology reports were graded for clarity. Chi-square and logistic regression were used to correlate risk factors with outcomes and determine odds of treatment. Results New isolated BKDVT was identified in 102 patients. Patients were symptomatic or had previous pulmonary embolism (PE) or DVT in all cases. Eighteen were positive for PE at diagnosis (17.6% of all patients or 62.1% with chest CT). Malignancy was independently associated with PE (P=0.015); no other risk factors were significant. Treatment was not associated with clinical risk factors. The language used for radiology reports was highly variable and was associated with the decision to treat with anticoagulation. One hundred percent were treated (n=24) when the report stated "positive DVT" and 89.2% (n=58) were treated after an objective description without the word "DVT" (P=0.01). Treatment was much less likely if the report described BKDVT anatomically but was said to be "negative for DVT" (P<0.001). A total of 86.3% (n=88) of all patients were treated, compared to 46.2% (n=6) of patients in this group (n=13). IVC filters were placed in 3 patients. Of the 14 untreated patients, 5 received surveillance, 3 developed new proximal DVT, and none developed PE. Conclusions About 90% of patients diagnosed with BKDVT received anticoagulation after the initial diagnosis. Surveillance was not commonly recommended and is likely underutilized. Radiology reporting was highly variable and correlated with clinical treatment decisions, whereas other clinical risk factors did not. Describing BKDVT findings only in terms of being "positive" or "negative" for DVT may be inadequate.
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Affiliation(s)
- Drew Fleck
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Alex Wallace
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Fleck D, Albadawi H, Shamoun F, Knuttinen G, Naidu S, Oklu R. Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. Cardiovasc Diagn Ther 2017; 7:S228-S237. [PMID: 29399526 DOI: 10.21037/cdt.2017.09.15] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Deep vein thrombosis (DVT) is a major health problem worldwide. The risk of pulmonary embolism following DVT is well established, but the long-term vascular sequelae of DVT are often underappreciated, costly to manage, and can have extremely detrimental effects on quality of life. Treatment of DVT classically involves oral anticoagulation, which reduces the risk of pulmonary embolism but does not remove the clot. Anticoagulation therefore does little to prevent the venous damage and scarring that occurs following DVT, leaving the patient at risk for permanent venous insufficiency and development of post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) is a minimally invasive endovascular treatment that is used as an adjunct to anticoagulation. CDT lowers the risk of PTS by reducing clot burden and protecting against valvular damage. A catheter is advanced directly to the site of thrombosis under fluoroscopy followed by a slow, prolonged infusion of a relatively low dose of thrombolytic agent. CDT restores venous patency faster than anticoagulation, which hastens the relief of acute symptoms. Adjunctive CDT modalities have become increasingly popular among interventional radiologists, allowing for additional mechanical thrombectomy or ultrasound-enhanced thrombolysis at the time of catheter placement. These pharmacomechanical CDT (PCDT) techniques have the potential to reduce treatment time and associated healthcare costs. Numerous observational and retrospective studies have consistently shown a benefit of CDT plus anticoagulation over anticoagulation alone for prevention of PTS. Patients with long life expectancy and acute thrombosis involving the iliac and proximal femoral veins (iliofemoral DVT) have the greatest benefit from CDT, which may decrease the risk of PTS and/or decrease the severity of PTS symptoms if they do occur. Randomized controlled trials remain limited but generally support the observational data. CDT also plays an important role in those with acute limb-threatening venous occlusion or severe symptoms from DVT. Although adverse outcomes are rare, a potential devastating outcome is intracranial bleeding. While the available literature suggests the risk of serious morbidity from bleeding is quite rare, the absolute risk of bleeding is not clear and will require outcomes data from randomized trials. Future studies should also examine the cost-effectiveness of CDT for PTS prevention, particularly with respect to quality-adjusted life years, and compare the effectiveness of available PCDT devices.
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Affiliation(s)
- Drew Fleck
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Fadi Shamoun
- Division of Vascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Stone J, Hangge P, Albadawi H, Wallace A, Shamoun F, Knuttien MG, Naidu S, Oklu R. Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovasc Diagn Ther 2017; 7:S276-S284. [PMID: 29399531 DOI: 10.21037/cdt.2017.09.01] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Deep vein thrombosis (DVT) is a major preventable cause of morbidity and mortality worldwide. Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), affects an estimated 1 per 1,000 people and contributes to 60,000-100,000 deaths annually. Normal blood physiology hinges on a delicate balance between pro- and anti-coagulant factors. Virchow's Triad distills the multitude of risk factors for DVT into three basic elements favoring thrombus formation: venous stasis, vascular injury, and hypercoagulability. Clinical, biochemical, and radiological tests are used to increase the sensitivity and specificity for diagnosing DVT. Anticoagulation therapy is essential for the treatment of DVT. With few exceptions, the standard therapy for DVT has been vitamin K-antagonists (VKAs) such as warfarin with heparin or fractionated heparin bridging. More recently, a number of large-scale clinical trials have validated the use of direct oral anticoagulants (DOACs) in place of warfarin in select cases. In this review, we summarize the pathogenesis, diagnosis, and medical management of DVT, with particular emphasis on anticoagulation therapy and the role of DOACs in the current treatment algorithm.
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Affiliation(s)
- Jonathan Stone
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Patrick Hangge
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Alex Wallace
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Fadi Shamoun
- Division of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - M Grace Knuttien
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Courtice S, Mohanlal A, Ward L, Naidu S, Finucane J, Wright O. MON-LB341: ‘Feed not Fast’: A Multidisciplinary Systems Approach to Malnutrition in an Acute Hospital. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)31085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Purpose To determine the prevalence of and risk factors for needlesticks in interventional radiology physicians, as well as the attitudes, behaviors, and conditions that promote or interfere with reporting of these injuries. Materials and Methods A total of 3889 interventional radiologists from academic and private practice in the United States were surveyed by emailing all interventional radiologist members of the Society of Interventional Radiology, including attending-level physicians and trainees (April-August 2016). The institutional review board waived the need for consent. Questions inquired about the nature, frequency, and type of needlestick and sharps injuries and whether and to whom these incidents were reported. Stepwise regression was used to determine variables predicting whether injuries were reported. Results In total, 908 (23%) interventional radiologists completed at least a portion of the survey. Eight hundred fourteen (91%) of 895 respondents reported a prior needlestick injury, 583 (35%) of 895 reported at least one injury while treating an HIV-positive patient, and 626 (71%) of 884 reported prior training regarding needlestick injury. There was, on average, one needlestick for every 5 years of practice. Most needlestick or sharps injuries were self inflicted (711 [87%] of 817) and involved a hollow-bore device (464 [56%] of 824). Only 566 (66%) of 850 injuries were reported. The most common reasons for not reporting included perceived lack of utility of reporting (79 [28%] of 282), perceived low risk for injury (56 [20%] of 282), noncontaminated needle (53 [19%] of 282), too-lengthy reporting process (37 [13%] of 282), and associated stigma (23 [8%] of 282). Only 156 (25%) of 624 respondents informed their significant other. Stepwise regression assessing variables affecting the likelihood of reporting showed that male sex (P = .009), low-risk patient (P < .0001), self injury (P = .010), trainee status (P < .0001), and the total number of prior injuries (P = .019) were independent predictors of not reporting. Conclusion Needlestick injuries are ubiquitous among interventional radiologists and are often not reported. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Amy R Deipolyi
- From the Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (A.R.D.); Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (A.M.P.); and Division of Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (S.N., R.O.)
| | - Anand M Prabhakar
- From the Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (A.R.D.); Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (A.M.P.); and Division of Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (S.N., R.O.)
| | - Sailendra Naidu
- From the Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (A.R.D.); Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (A.M.P.); and Division of Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (S.N., R.O.)
| | - Rahmi Oklu
- From the Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (A.R.D.); Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (A.M.P.); and Division of Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (S.N., R.O.)
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McAdams S, Abdul-Muhsin H, Davila V, Naidu S, Money S, Castle E. V3-02 TRANSPERITONEAL ROBOT ASSISTED INFERIOR VENA CAVA FILTER EXTRACTION: YOU ALREADY KNOW HOW TO DO THIS! J Urol 2017. [DOI: 10.1016/j.juro.2017.02.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Deipolyi AR, Zhang YS, Khademhosseini A, Naidu S, Borad M, Sahin B, Mathur AK, Oklu R. Portal Vein Embolization: Impact of Chemotherapy and Genetic Mutations. J Clin Med 2017; 6:jcm6030026. [PMID: 28257031 PMCID: PMC5372995 DOI: 10.3390/jcm6030026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/12/2017] [Accepted: 02/21/2017] [Indexed: 12/12/2022] Open
Abstract
We characterized the effect of systemic therapy given after portal vein embolization (PVE) and before hepatectomy on hepatic tumor and functional liver remnant (FLR) volumes. All 76 patients who underwent right PVE from 2002–2016 were retrospectively studied. Etiologies included colorectal cancer (n = 44), hepatocellular carcinoma (n = 17), cholangiocarcinoma (n = 10), and other metastases (n = 5). Imaging before and after PVE was assessed. Chart review revealed systemic therapy administration, SNaPshot genetic profiling, and comorbidities. Nine patients received systemic therapy; 67 did not. Tumor volume increased 28% in patients who did not receive and decreased −24% in patients who did receive systemic therapy (p = 0.026), with no difference in FLR growth (28% vs. 34%; p = 0.645). Among 30 patients with genetic profiling, 15 were wild type and 15 had mutations. Mutations were an independent predictor of tumor growth (p = 0.049), but did not impact FLR growth (32% vs. 28%; p = 0.93). Neither cirrhosis, hepatic steatosis, nor diabetes impacted changes in tumor or FLR volume (p > 0.20). Systemic therapy administered after PVE before hepatic lobectomy had no effect on FLR growth; however, it was associated with decreasing tumor volumes. Continuing systemic therapy until hepatectomy may be warranted, particularly in patients with genetic mutations.
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Affiliation(s)
- Amy R Deipolyi
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Yu Shrike Zhang
- Biomaterials Innovation Research Center, Division of Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA 02139, USA.
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA.
| | - Ali Khademhosseini
- Biomaterials Innovation Research Center, Division of Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA 02139, USA.
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA.
| | - Sailendra Naidu
- Division of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Mitesh Borad
- Division of Oncology, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Burcu Sahin
- Department of Radiology, Ankara Oncology Training and Research Hospital, Ankara, Turkey.
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Rahmi Oklu
- Biomaterials Innovation Research Center, Division of Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Division of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA.
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Naidu S, Menias C, Oklu R, Hines R, Alhalabi K, Shamoun F, Mcbane R. Segmental arterial mediolysis: imaging characteristics and disease course in 115 patients. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.1023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Deipolyi A, Prabhakar A, Nanda A, Naidu S, Knuttinen M, Huettl E, Oklu R. Needlestick injuries in interventional radiology. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hoang P, Fleck D, Wallace A, Behravesh S, Kriegshauser J, Naidu S, Huettl E, Deipolyi A, Knuttinen M, Oklu R. Percutaneous biopsies in the era of precision medicine: causes of inadequate sampling. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Behravesh S, Gupta N, Deipolyi A, Hoang P, Wallace A, Fleck D, Naidu S, Huettl E, Knuttinen M, Oklu R. Nutcracker syndrome: is compression of the left renal vein sufficient for diagnosis? J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fleck D, Hoang P, Behravesh S, Wallace A, Naidu S, Huettl E, Prabhakar A, Knuttinen M, Oklu R. Outcomes and clinical management of isolated below-knee DVT. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Abstract
Venous malformation (VM) is the most common type of congenital vascular malformation (CVM). They are present at birth and are often symptomatic, causing morbidity and pain. VMs can be challenging to diagnose and are often confused with hemangioma in terminology as well as with imaging. An accurate clinical history and cross-sectional imaging are critical for diagnosis and for devising management. This manuscript will review imaging approaches to diagnosing VMs and current treatment strategies.
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Affiliation(s)
- Sasan Behravesh
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Wayne Yakes
- Vascular Malformation Center, Englewood, CO 80113, USA
| | - Nikhil Gupta
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Brian W Chong
- Department of Radiology and Neurological Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Ali Khademhosseini
- Biomaterials Innovation Research Center, Division of Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02139, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;; Biomaterials Innovation Research Center, Division of Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02139, USA
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Deshpande S, Dhote D, Naidu S, Sutar A, Kannan V. SU-F-J-48: Effect of Scan Length On Magnitude of Imaging Dose in KV CBCT. Med Phys 2016. [DOI: 10.1118/1.4955956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Deshpande S, Dhote D, Thakur K, Kumar M, Kumar R, Pawar A, Sutar A, Naidu S, Kannan V. EP-1612: Optimizing breast imaging dose in CBCT using patient specific acquisition parameter. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32863-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Naidu S, Gopalan PD. The informed consent process for anaesthesia: perspectives of elective surgical patients at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Southern African Journal of Anaesthesia and Analgesia 2016. [DOI: 10.1080/22201181.2016.1157963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tung K, Naidu S, Knuttinen M, Kriegshauser J. Interventional management of anterior abdominal wall hematomas: single center experience. J Vasc Interv Radiol 2016. [DOI: 10.1016/j.jvir.2015.12.387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Naidu S, Saini U, ElNaggar A, Rath K, Hemant B, Lata P, Wanner R, Sudhakar M, Suarez A, Hays J, Goodfellow P, Cohn D, Karuppaiyah S. Suppression of ovarian cancer growth and metastasis with HO-3867, a STAT3 inhibitor, in human tissue culture and in an orthotopic mouse model. Gynecol Oncol 2015. [DOI: 10.1016/j.ygyno.2015.01.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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