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Tunneled Central Venous Catheters

Tunneled central venous catheters (CVCs) fill a vital role in patient treatment, especially with new cancer-fighting regimens. The catheters are durable and fit nicely into interventionalists’ armamentarium alongside peripherally inserted central catheter (PICC) lines and chest or arm ports. There are many sizes, lengths, and technologic advancements that allow safe, long-term venous access. These catheters enable the physician to safely administer caustic medications centrally, draw blood…

Peripherally Inserted Central Catheters and Nontunneled Central Venous Catheters

Peripherally inserted central catheters (PICCs) and nontunneled central venous catheters (CVCs) are indispensable in current medical practice, with both serving central venous access needs. They are used for infusion therapy, exchange therapy, and hemodynamic monitoring. The central venous system includes the pulmonary arteries, right side of the heart, superior vena cava (SVC), inferior vena cava (IVC), brachiocephalic veins, subclavian veins, and iliac veins. It should be…

Percutaneous Arterial Venous Fistula Creation

Hemodialysis is a tremendous socioeconomic burden within industrialized countries, with costs exceeding 1.5 billion dollars in Europe and within 2.9 billion dollars in annual costs in the United States. A large and essential component for delivery of dialysis is a stable and usable hemodialysis access. There are primarily three kinds of access: the catheter, a dialysis graft, and a dialysis fistula. The latter, a direct surgical…

Management of Clotted Hemodialysis Access Grafts

Thirty million people in the United States have chronic kidney disease and millions more are at increased risk. In 2015 in the United States alone, 468,000 patients required dialysis (peritoneal dialysis or hemodialysis) for end-stage renal disease. Because many of these patients require hemodialysis, a reliable long-term dialysis access is their lifeline. Although an increase in fistulas is the goal of the National Kidney Foundation Kidney…

Surveillance and Management of Failing Hemodialysis Access

Large numbers of patients depend on hemodialysis for their survival. Worldwide the number of patients receiving renal replacement therapy is expected to rise from 2.6 million to 5.5 million by 2030, with most of the growth expected to occur in Asia. In the United States, approximately 475,000 individuals were receiving hemodialysis for end-stage renal disease (ESRD) through 2016. The increased incidence of diabetes in the US…

Retrograde Balloon Occlusion Variceal Ablation

When compared with esophageal variceal bleeding, bleeding from gastric varices is usually more severe and difficult to control. Gastric varices are classified into two types: gastroesophageal varices and isolated varices. Gastroesophageal varices located at the cardia are considered part of esophageal varices. Gastroesophageal varices always drain into esophageal varices, and they are usually treated endoscopically ( Fig. 79.1 ). In contrast, isolated varices are usually located…

Transjugular Intrahepatic Portosystemic Shunts

Cirrhosis and its complications are common throughout the world. Hepatitis B and C and alcohol abuse account for about 90% of cases. Risk of death comes from variceal bleeding, progressive liver failure, and hepatoma. Key quality-of-life issues include management of ascites and hepatic encephalopathy. Transjugular intrahepatic portosystemic shunt (TIPS) is one of the treatments available to control variceal bleeding and ascites by correction of portal hypertension.…

Parathyroid Venous Sampling

Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by autonomic overproduction of intact parathyroid hormone. It is often asymptomatic and identified through routine biochemical screening demonstrating hypercalcemia with elevated or upper normal levels of circulating intact parathyroid hormone. Osteoporosis may occur, and if PHPT remains untreated there is an increased incidence of cancer of the breast, colon, kidney, or prostate. Benign, usually solitary, parathyroid adenomas account…

Adrenal Venous Sampling

Adrenal venous sampling is almost exclusively used in the setting of excessive aldosterone production to establish and localize unilateral aldosteronism before surgery. Excessive excretion of aldosterone may be primary due to a tumor (Conn syndrome) or hyperactivity of the outer area of the adrenal cortex, or secondary due to nonadrenal conditions that cause a severe imbalance in sodium and potassium. Examples of secondary causes of hyperaldosteronism…

Renal Vein Renin Sampling

Renal vein renin (RVR) sampling can help determine whether renal artery stenosis is a significant contributor to a patient’s hypertension. It can also help determine which patients with renal vascular hypertension (RVH) may benefit from revascularization by percutaneous or surgical methods. Indications To determine which patients with RVH may benefit from revascularization by percutaneous or surgical methods To determine the physiologic significance of an anatomic stenosis…

Foreign Body Retrieval

Whether present in the vasculature or in the soft tissues, foreign bodies left unchecked can erode into adjacent vital organs or migrate into remote locations. There are extreme reports of a lumboperitoneal shunts, ingested toothpicks, septal occluders, vertebroplasty cement, Onyx subdermal contraceptive implants, and embedded knitting needles traveling to locations far distant from their original location and causing tissue injury. Although many foreign bodies require surgical…

Percutaneous Management of Varicose Veins

Epidemiology Chronic venous disease (CVD), which includes varicose and spider veins, is extraordinarily common: approximately 22%–29% of the adult Western population has varicose veins and 5% has more advanced CVD findings. Many patients with CVD have symptoms that may interfere with daily living such as heaviness, aching, swelling, throbbing, and itching (often referred to as HASTI symptoms). More advanced venous disease is associated with skin damage…

Caval Filtration

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality. The most feared condition is pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) dislodging from the lower extremity or pelvis, or, less commonly from the upper extremity, embolizing to the lungs. Nonfatal PE is diagnosed in approximately 400,000 to 630,000 patients per year in the United States with an additional 50,000 to 200,000 fatalities…

Portal-Mesenteric Venous Thrombosis

The importance of portal vein thrombosis (PVT) lies mainly in the complications of prehepatic portal hypertension, which in the chronic state causes bleeding through varices. Acute PVT is the main cause of prehepatic portal hypertension in the Western world and the primary cause of portal hypertension of any type in noncirrhotic patients in developed countries. PVT accounts for some 8% to 10% of all cases of…

Acute Extremity Venous Occlusive Disease

Acute Lower Extremity Deep Venous Thrombosis The annual incidence of venous thromboembolism, including both deep vein thrombosis (DVT) and pulmonary embolism, is estimated at 300,000 to 600,000 per year. Postthrombotic syndrome (PTS) is a common late complication of lower extremity DVT. The incidence of PTS is approximately 40% in adult patients with a symptomatic first episode deep venous thrombosis (DVT) within 2 years. Early clot lysis…

Chronic Lower Extremity Venous Occlusive Disease

Venous thromboembolism—comprising pulmonary embolism and deep venous thrombosis (DVT)—is a common disease with a high recurrence rate. The incidence rates of venous thromboembolism in Western countries range from 8 to 27 per 10,000 person-years. The reported incidence of clinically diagnosed DVT is approximately twice that of pulmonary embolism. One of the most common complications of DVT is postthrombotic syndrome (PTS). PTS develops in 20% to 30%…

Superior Vena Cava Occlusive Disease

Superior vena cava (SVC) syndrome is a clinical entity with varied presentation and severity caused by obstruction of the central veins and superior vena cava. The condition can result from either malignant or benign etiologies. Benign etiologies include catheters or pacemakers, mediastinal fibrosis, hypercoagulability, and postsurgical or postradiation changes. Although historically malignant SVC obstruction has been much more common, there has been an increase in prevalence…

Cervical Artery Dissection

Cervical artery dissection involving the extracranial carotid and vertebral arteries is an infrequent cause of stroke but accounts for a significant percentage of ischemic strokes in young adults: 20% to 25% of strokes in those younger than 45 years of age can be attributed to cervical artery dissections, whereas only 2% of all strokes overall are believed to be due to dissections. The incidence is equal…

Management of Head and Neck Injuries

Traumatic head and neck vascular injuries such as dissections, transections, pseudoaneurysms, arteriovenous fistulae, and large artery occlusions are relatively uncommon but can result in potentially devastating stroke, severe blood loss, and even exsanguination and death. Rapid, early diagnostic imaging followed by effective management of neurovascular injuries can help improve patient outcome by focusing attention on prompt treatment of these lesions. Advances in multidetector computed tomography (CT)…

Subarachnoid Hemorrhage

Patients who present to an emergency department with thunderclap headache often described as “the worst headache of my life” should always prompt treating physicians into assessing for an acute subarachnoid hemorrhage (SAH). In up to 80% of patients with SAH without a preceding trauma, the underlying cause is deemed to be an underlying aneurysm of the intracerebral arteries. Intracranial aneurysms are present in 1%–2% of the…