The Manuscripts We Deserve.

“He's the hero Gotham deserves, but not the one it needs right now. So we'll hunt him. Because he can take it. Because he's not our hero. He's a silent guardian, a watchful protector. A dark knight.”

- Jim Gordon

Too often I have read a paper or watched a lecture and thought, “That is compelling evidence, I should definitely start doing that.” However, I always fall back on tried and true methods because, “that’s the way I’ve always done it” or “it’s always worked for me.” Take a look at the papers presented below. These manuscripts have data that can help define your daily practice. Will they define it in a profound manner and be a milestone by which you judge your career? Maybe not. However, these are the papers that we as a specialty should be taking note of. Real data with definable action items that you can implement into your daily grind. We need papers that question if that annoying CVC-tip thrombus is really clinically significant or evaluate if the indirect portal venogram (aka arterial portography) is really necessary in the 21st century. While our specialty can change and adapt at acute angles, we will more likely adjust our course through small, definable change. The authors that presented these manuscripts should be applauded. They are the offensive linemen of our specialty. Slogging through it not for some flash in the pan new way to treat HCC, but for changing our daily flow. We need the dreamers but we also need people putting in the gritty work to answer those annoying questions that everyone else doesn’t have the patience for.

What to do with the annoying catheter-tip associated thrombus detected on echo?

Chick JF, Reddy SN, Bhatt RD, Shin BJ, Kirkpatrick JN, Trerotola SO. Significance of echocardiographically detected central venous catheter tip-associated thrombi. J Vasc Interv Radiol. 2016. doi: 10.1016/j.jvir.2016.07.013

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The authors evaluated 170 echocardiograms and found 49 patients with CVC tip-associated thrombi. Ejection fraction, presence of a PFO, other intracardiac shunt, and mean thrombus size were all evaluated. A variety of outcome measures were collected including management decision, thrombus, extension, PE, paradoxical emboli, and stroke within 3 months. Of the 49 patients with CVC tip–associated thrombi, those without PFO or other intracardiac shunts had no embolic or other complications detected, regardless of anticoagulation status. The authors conclude that, “This suggests a benign course for such thrombi and that anticoagulation, catheter removal, thrombectomy, and thrombolysis may be unnecessary when catheter tip–associated thrombi are incidentally detected on echocardiography.”

Do we really need the post-retrieval IVC-gram?

Mintz JD, Stavropoulos SW, Trerotola SO. Is a venacavogram necessary after inferior vena cava filter retrieval? J Vasc Interv Radiol. 2016. doi: 10.1016/j.jvir.2015.08.016

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Authors looked at the utility of IVC-gram after 224 IVC filter retrievals using routine and complex techniques. Complex retrievals included forceps or other adjuncts. The IVC-gram from the retrievals was evaluated for stenosis, filling defect, dissection, and extravasation. Abnormalities requiring additional treatment were considered major and those that required no additional treatment were considered minor. Minor abnormalities were seen in 52% of routine retrievals and 79% of complex retrievals. The results were significant with a P<0.01. Major abnormalities were seen in 3% of complex retrievals and 0% or routine retrievals. The authors conclude that the lack of major abnormalities on venacavography after routine IVC filter retrieval “may justify omitting venacavography after retrieval regardless of dwell time.” However, extravasation can be infrequently seen after complex retrieval and will require additional treatment. Therefore, “venacavography remains warranted in this setting.”

Do we still need to do an indirect portal venogram prior to TACE?

Hui TC, Pua U. Arterial portography during transarterial chemoembolization: still a necessity in the age of contrast-enhanced cross-sectional imaging? J Vasc Interv Radiol. 2014. 25:41-46.

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This manuscript evaluates the necessity of arterial portography (AP) if a patent PV is seen on cross-sectional imaging prior to TACE. This study included 243 total procedures with 93 of those undergoing an AP. The mean time between imaging and TACE was 46.5 days. No new cases of portal vein thrombosis were detected on AP when pre-procedure imaging demonstrated a patent portal vein. However in the group that omitted AP, post-prcoedure imaging showed one case of main PVT, 2 right PVT, and 2 left PVT. No significant difference in morbidity or mortality were detected between the two groups. The authors conclude that “AP is unnecessary if TACE is performed in a reasonable time frame” following CT or MRI demonstrating a patent PV.

Post author:
Luke R. Wilkins, MD
University of Virginia
@lukewilkins_UVA