Publications by authors named "Jacob Cynamon"

29 Publications

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Re: Diagnosis and Treatment of Nonmaturing Fistulae for Hemodialysis Access via Transradial Approach: A Case-Control Study.

Authors:
Jacob Cynamon

J Vasc Interv Radiol 2020 12;31(12):2159-2160

Division of Vascular and Interventional Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E. 210th St., Bronx, NY 10467-2490.

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http://dx.doi.org/10.1016/j.jvir.2020.08.015DOI Listing
December 2020

Association of Addition of Ablative Therapy Following Transarterial Chemoembolization With Survival Rates in Patients With Hepatocellular Carcinoma.

JAMA Netw Open 2020 11 2;3(11):e2023942. Epub 2020 Nov 2.

Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Importance: Hepatocellular carcinoma (HCC) is a heterogeneous disease with many available treatment modalities. Transarterial chemoembolization (TACE) is a valuable treatment modality for HCC lesions. This article seeks to evaluate the utility of additional ablative therapy in the management of patients with HCC who received an initial TACE procedure.

Objective: To compare the overall survival (OS) and freedom from local progression (FFLP) outcomes after TACE alone with TACE that is followed by an ablative treatment regimen using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation for patients with HCC.

Design, Setting, And Participants: This cohort study of 289 adults at a single urban medical center examined survival outcomes for patients with nonmetastatic, unresectable HCC who received ablative therapies following TACE or TACE alone from January 2010 through December 2018. The Lee, Wei, Amato common baseline hazard model was applied for within-patient correlation with robust variance and Cox regression analysis was used to assess the association between treatment group (TACE vs TACE and ablative therapy) and failure time events (FFLP per individual lesion and OS per patient), respectively. In both analyses, the treatment indication was modeled as a time-varying covariate. Landmark analysis was used as a further sensitivity test for bias by treatment indication.

Exposures: TACE alone vs TACE followed by ablative therapy.

Main Outcomes And Measures: Freedom from local progression and overall survival. Hypotheses were generated before data collection.

Results: Of the 289 patients identified, 176 (60.9%) received TACE only and 113 (39.1%) received TACE plus ablative therapy. Ablative therapy included 45 patients receiving stereotactic body radiation therapy, 39 receiving microwave ablation, 20 receiving radiofrequency ablation, and 9 receiving a combination of these following TACE. With a median (interquartile range) follow-up of 17.4 (9.5-29.5) months, 242 of 512 (47.3%) lesions progressed, 211 in the group with TACE alone and 31 in the group with TACE plus ablative therapy (P < .001). Over 3 years, FFLP was 28.1% for TACE alone vs 67.4% for TACE with ablative therapy (P < .001). The 1-year and 3-year OS was 87.5% and 47.1% for patients with lesions treated with TACE alone vs 98.7% and 85.3% for patients where any lesion received TACE plus ablative therapy, respectively (P = .01), and this benefit remained robust on landmark analyses at 6 and 12 months. The addition of ablative therapy was independently associated with OS on multivariable analysis for all patients (hazard ratio, 0.26; 95% CI, 0.13-0.49; P < .001) and for patients with Barcelona clinic liver cancer stage B or C disease (hazard ratio, 0.31; 95% CI, 0.14-0.69; P = .004).

Conclusions And Relevance: Adding ablative therapy following TACE improved FFLP and OS among patients with hepatocellular carcinoma. This study aims to guide the treatment paradigm for HCC patients until results from randomized clinical trials become available.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.23942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645696PMC
November 2020

Transjugular versus Transfemoral Transcaval Liver Biopsy: A Single-Center Experience in 500 Cases.

J Vasc Interv Radiol 2020 09 11;31(9):1394-1400. Epub 2020 Aug 11.

Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210 Street, Bronx, NY 10467.

Purpose: To compare the safety and efficacy of transfemoral transcaval liver biopsies (TFTC) with that of transjugular liver biopsies (TJLB) at a single tertiary-care institution.

Materials And Methods: A retrospective review was performed of 500 consecutive transvenous liver biopsies between December 2010 and December 2018. The cases included 286 TFTC patients at a median age of 54 years old (interquartile range [IQR], 42-63 years of age), 37.4% were female; and 214 TJLB patients at a median age of 55 years old (IQR, 46-61 years of age), 45.4% female. Patient demographic and laboratory data and technical and histopathological success, fluoroscopy times, and complications were recorded. Comparative statistical analyses were performed using a 2-sample test or a Wilcoxon ranked sum test for continuous variables and a chi-square test or Fisher exact test for categorical variables when appropriate.

Results: TFTC and TJLB data are presented as: technical success rates of 99.3% (283 of 286) and 100% (214 of 214), respectively; histopathologic success rates of 96.5% (275 of 285) and 95.8% (205 of 214), respectively; and major complication rates of 1.4% (4 of 284) and 5.6% (12 of 214), respectively (P = .009). There were no hepatic injuries in the TFTC group, whereas the TJLB group included 6 significant hepatic injuries requiring intervention. Median fluoroscopic times were 5.5 minutes (IQR, 3.9-8.6 minutes) for TFTC and 8.1 minutes (IQR, 5.2-13.1) for TJLB (P < .001).

Conclusions: In this single-institution study, TFTC was associated with a lower major complication rate and lower fluoroscopy times than conventional TJLB with similar technical and histopathologic successes.
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http://dx.doi.org/10.1016/j.jvir.2020.05.024DOI Listing
September 2020

Centers with more therapeutic modalities are associated with improved outcomes for patients with hepatocellular carcinoma.

J Gastrointest Oncol 2019 Jun;10(3):546-553

Departments of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, NY, USA.

Background: Higher facility volume is correlated to better overall survival (OS), but there is little knowledge on the effect of facility treatment modality number on OS in hepatocellular carcinoma (HCC).

Methods: This is a retrospective analysis of data from the National Cancer Database (NCDB) from 2004-2014 on patients with non-metastatic HCC. Treatment modalities assessed were surgical resection, transplantation, ablation, radioembolization, stereotactic body radiation therapy (SBRT), single-agent chemotherapy, and multi-agent chemotherapy. Facilities were dichotomized at the median of the listed treatment modalities.

Results: There were a total of 112,512 patients with non-metastatic HCC. Of a total of 1,230 sites, 830 (67.5%) used four or fewer modalities. Average survival for patients treated at facilities using fewer modalities was 12.0 and 23.5 months for those treated at facilities with more modalities [hazard ratio (HR) =0.52, 95% confidence interval (CI): 0.51-0.53, P<0.001]. After adjusting for facility volume, liver function, tumor and patient characteristics and other prognostic factors in a multivariable Cox model, treatment at a multi-modality facility still provided a survival advantage (HR =0.60, 95% CI: 0.52-0.70, P<0.001). This benefit also persisted after propensity score matching. Sensitivity analysis varying the cut point from 2 to 6 modalities for dichotomization showed that the benefit persisted. Subgroup stratified analyses based on stage showed that the benefit in OS was highest for patients with stage I and II (P≤0.002) but was not significant for stage III or IVa.

Conclusions: Institutions that offered more treatment modalities had improved OS for patients with non-metastatic HCC, especially for those with stage I and II.
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http://dx.doi.org/10.21037/jgo.2019.01.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534702PMC
June 2019

Letter from the Guest Editors.

Semin Nucl Med 2019 May;49(3):168-169

Montefiore Medical Center, Bronx, New York.

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http://dx.doi.org/10.1053/j.semnuclmed.2019.03.002DOI Listing
May 2019

The Role of Non-Contrast Cone Beam CT in Identifying Incomplete Treatment during Uterine Artery Embolization.

J Vasc Interv Radiol 2019 May 14;30(5):679-686. Epub 2019 Mar 14.

Albert Einstein College of Medicine, Bronx, New York; Department of Vascular and Interventional Radiology, Montefiore Medical Center, 111 East 210(th) Street, Bronx, NY 10467. Electronic address:

Purpose: To describe the utility of post-procedure noncontrast cone-beam computed tomography (CT) in identifying cases of incomplete treatment and the need to search for additional vascular supply during uterine artery embolization (UAE).

Materials And Methods: From June 2013 to June 2018, 427 patients (age, 45 ± 5 years) underwent 430 consecutive UAEs with post-embolization noncontrast cone-beam CT. If noncontrast cone-beam CT showed an area of the uterus lacking contrast retention, aortography was performed to search for collateral supply. Procedures were characterized as suspected complete bilateral UAEs or suspected incomplete UAEs, such as in cases of a unilateral uterine artery or diminutive uterine arteries. Rates of inadequate contrast retention on noncontrast cone-beam CT and discovered collateral artery supply were calculated. In 10 consecutive cases in which both noncontrast cone-beam CT and aortography were performed, dose-area product radiation exposure from noncontrast cone-beam CT and aortography was compared using a 2-sided paired-sample t-test.

Results: Of the 411 suspected complete bilateral UAEs, noncontrast cone-beam CT showed an area of the uterus lacking contrast retention in 38 (9.2%) cases. Of the 19 suspected incomplete UAEs, noncontrast cone-beam CT demonstrated incomplete treatment in 6 (31.6%) patients. Aortography was performed in 40 of the 44 cases of incomplete treatment on noncontrast cone-beam CT, and collateral supply was found in 28 (70.0%) cases. In 22 of these cases (5.2% of the 427 patients studied), noncontrast cone-beam CT led to the discovery of significant collateral supply requiring further embolization. Dose-area product radiation exposure from noncontrast cone-beam CT was less than from aortography (P = .007).

Conclusions: Post-UAE noncontrast cone-beam CT can be used to select a subset of patients with a higher likelihood of collateral supply who may benefit from post-embolization aortography.
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http://dx.doi.org/10.1016/j.jvir.2018.11.036DOI Listing
May 2019

Catheter directed interventions for inferior vena cava thrombosis.

Cardiovasc Diagn Ther 2016 Dec;6(6):612-622

Albert Einstein College of Medicine, Bronx, NY, USA;; Division of Vascular and Interventional Radiology, Department of Radiology, Montefiore Medical Center, Bronx, NY, USA.

Inferior vena cava (IVC) thrombosis, although similar in many aspects to deep venous thrombosis (DVT), has distinct clinical implications, treatments and roles for endovascular management. Etiologies of IVC thrombosis vary from congenital malformations of the IVC to acquired, where indwelling IVC filters have been implicated as a leading cause. With an increasing incidence of IVC thrombosis throughout the United States, clinicians need to be educated on the clinical signs and diagnostic tools available to aid in the diagnosis as well as available treatment options. Untreated IVC thrombus can result in serious morbidity and mortality, both in the acute phase with symptoms related to venous outflow occlusion and embolism, and in the long-term, sequelae of post-thrombotic syndrome (PTS) related to chronic venous occlusion. This manuscript will discuss the clinical presentation of IVC thrombosis, diagnostic and treatment options, as well as the role of endovascular management.
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http://dx.doi.org/10.21037/cdt.2016.11.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5220197PMC
December 2016

Gastric Ischemia as a Result of an Iatrogenic Arterioportal Fistula: A Perfect Storm.

J Vasc Interv Radiol 2016 Mar;27(3):446-8

Department of Clinical Radiology, Montefiore Medical Center, Bronx, New York; Department of Vascular and Interventional Radiology, Montefiore Medical Center, Bronx, New York.

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http://dx.doi.org/10.1016/j.jvir.2015.11.029DOI Listing
March 2016

Transfemoral Transcaval Core-Needle Liver Biopsy: An Alternative to Transjugular Liver Biopsy.

J Vasc Interv Radiol 2016 Mar 23;27(3):370-5. Epub 2015 Dec 23.

Department of Radiology, Division of Vascular and Interventional Radiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467.

Purpose: To describe the technique and outcome of transfemoral transcaval (TFTC) core-needle liver biopsies.

Materials And Methods: Retrospective chart review was performed on 121 patients who underwent transvenous liver biopsies at a single institution between February 2014 and July 2015, yielding 66 total TFTC liver biopsies for review (65.2% male; mean age, 53.2 y ± 15.0). From August 2014 through July 2015, TFTC biopsies accounted for 64 of 77 (83%) transvenous biopsies. Hepatic tissue was obtained directly through the intrahepatic inferior vena cava from a femoral venous approach. Procedural complications were classified according to Society of Interventional Radiology guidelines.

Results: Of the 66 biopsies, technical success was achieved in 64 cases (97.0%). Histopathologic diagnoses were made in 63 cases (95.5%). Fragmented or limited specimens in which a pathologic diagnosis was still made occurred in four cases (6.1%). Complications occurred in two cases (3.0%). Venous pressure measurements were requested in 60 cases, and all were successfully obtained.

Conclusions: TFTC core-needle liver biopsies are feasible and safe as demonstrated in this series of patients.
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http://dx.doi.org/10.1016/j.jvir.2015.11.030DOI Listing
March 2016

A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study.

JACC Cardiovasc Interv 2015 Aug;8(10):1382-1392

Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Objectives: This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington).

Background: Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%.

Methods: Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation.

Results: Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8; p < 0.0001) also decreased post-procedure. One GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries)-defined severe bleed (groin hematoma with transient hypotension) and 16 GUSTO-defined moderate bleeding events occurred in 15 patients (10%). No patient experienced intracranial hemorrhage.

Conclusions: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis decreased RV dilation, reduced pulmonary hypertension, decreased anatomic thrombus burden, and minimized intracranial hemorrhage in patients with acute massive and submassive PE. (A Prospective, Single-arm, Multi-center Trial of EkoSonic® Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE) [SEATTLE II]; NCT01513759).
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http://dx.doi.org/10.1016/j.jcin.2015.04.020DOI Listing
August 2015

Image-guided percutaneous ablation of lung malignancies: A minimally invasive alternative for nonsurgical patients or unresectable tumors.

J Bronchology Interv Pulmonol 2014 Jan;21(1):68-81

*Department of Radiology, Bridgeport Hospital, Yale New Haven Health System †Department of Radiology, St Vincent's Medical Center, Bridgeport, CT ‡Department of Radiology, Montefiore Medical Center, Bronx, NY.

Lung cancer remains the malignancy with the highest mortality and second highest incidence in both men and women within the United States. Image-guided ablative therapies are safe and effective for localized control of unresectable liver, renal, bone, and lung tumors. Local ablative therapies have been shown to slow disease progression and prolong disease-free survival in patients who are not surgical candidates, either due to local extent of disease or medical comorbidities. Commonly encountered complications of percutaneous ablation of lung tumors include pneumothorax, pleural inflammation, pleural effusions, and pneumonia, which are usually easily managed. This review will discuss the merits of image-guided ablation in the treatment of lung tumors and the underlying mechanism, procedural techniques, clinical utility, toxicity, imaging of tumor response, and future developments, with a focus on radiofrequency ablation.
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http://dx.doi.org/10.1097/LBR.0000000000000008DOI Listing
January 2014

Early endovascular grafts at Montefiore Hospital and their effect on vascular surgery.

J Vasc Surg 2014 Feb 19;59(2):547-50. Epub 2013 Dec 19.

Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina.

Vascular surgery is very fortunate. It recognized the transition from open surgery to endovascular procedures as treatments for vascular disease early enough to adapt as a specialty. As a result, most vascular surgeons in North America became competent with endovascular techniques, and the survival of the specialty was assured. The endovascular graft program at Montefiore Hospital played a major role in vascular surgery's early recognition of the importance of the endovascular revolution. This article will review the history of this early endovascular graft program and how it influenced the specialty.
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http://dx.doi.org/10.1016/j.jvs.2013.09.051DOI Listing
February 2014

Retained fibrin sheaths: chest computed tomography findings and clinical associations.

J Thorac Imaging 2014 Mar;29(2):118-24

Departments of *Radiology §Medicine ∥Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx †Department of Radiology, Staten Island University Hospital, Staten Island, NY ‡Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Purpose: Fibrin sheaths may develop around long-term indwelling central venous catheters (CVCs) and remain in place after the catheters are removed. We evaluated the prevalence, computed tomographic (CT) appearance, and clinical associations of retained fibrin sheaths after CVC removal.

Materials And Methods: We retrospectively identified 147 adults (77 men and 70 women; mean age 58 y) who underwent CT after CVC removal. The prevalence of fibrin sheath remnants was calculated. Bivariate and multivariate analyses were performed to assess for associations between sheath remnants and underlying diagnoses leading to CVC placement; patients' age and sex; venous stenosis, occlusion, and collaterals; CVC infection; and pulmonary embolism.

Results: Retained fibrin sheaths were present in 13.6% (20/147) of cases, of which 45% (9/20) were calcified. Bivariate analysis revealed sheath remnants to be more common in women than in men [23% (16/70) vs. 5% (4/77), P=0.0018] and to be more commonly associated with venous occlusion and collaterals [30% (6/20) vs. 5% (6/127), P=0.0001 and 30% (6/20) vs. 6% (7/127), P=0.0003, respectively]. Other variables were not associated. Multivariate analysis confirmed the relationship between fibrin sheaths and both female sex (P=0.005) and venous occlusion (P=0.01).

Conclusions: Retained fibrin sheaths were seen on CT in a substantial minority of patients after CVC removal; nearly half of them were calcified. They were more common in women and associated with venous occlusion.
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http://dx.doi.org/10.1097/RTI.0b013e318299ff22DOI Listing
March 2014

Value of noncontrast CT immediately after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads.

J Vasc Interv Radiol 2012 Aug 26;23(8):1031-5. Epub 2012 Jun 26.

Department of Radiology and Division of Vascular and Interventional Radiology, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467, USA.

Purpose: To retrospectively evaluate the presence and distribution patterns of contrast agent retention in the liver on noncontrast computed tomography (CT) immediately following chemoembolization with drug-eluting beads (DEBs).

Materials And Methods: From 2008 to 2010, 95 patients with 224 liver lesions had chemoembolization performed with DEBs and a noncontrast CT examination of the liver performed immediately after embolization. Of these, 85 patients with 193 lesions were included. The postembolization CT scan was reviewed by a diagnostic radiologist, and the presence of contrast agent retention within the lesion was assessed. Varying patterns of contrast agent retention were defined.

Results: Of the 193 lesions included, 146 (76%) retained contrast medium. Aside from some contrast medium in vessels, very little if any contrast medium was seen in the surrounding liver. Various patterns of contrast agent retention were noted within lesions. In a single case, repeat imaging was obtained 6 hours later, which demonstrated washout of contrast agent in a lesion that had retained contrast agent on the postprocedure CT scan. Of significance, 13 additional foci of contrast agent retention were identified on postchemoembolization CT scans that, on retrospective review of preprocedure imaging, represented enhancing lesions not previously identified.

Conclusions: Noncontrast CT after chemoembolization with DEBs demonstrates contrast agent retention in 76% of cases, without significant contrast medium seen in the adjacent liver parenchyma. The presence or absence of contrast agent retention may prove to be useful in evaluating accurate targeting of a lesion.
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http://dx.doi.org/10.1016/j.jvir.2012.04.020DOI Listing
August 2012

Renal artery pseudoaneurysm following laparoscopic partial nephrectomy.

Urology 2009 Oct 3;74(4):819-23. Epub 2009 Aug 3.

Department of Urology, Montefiore Medical Center, Bainbridge, Bronx, New York, USA.

Objectives: To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN).

Methods: Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine.

Results: We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence.

Conclusions: Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding.
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http://dx.doi.org/10.1016/j.urology.2009.03.056DOI Listing
October 2009

Mechanical and enzymatic thrombolysis of acute pulmonary embolus: review of the literature and cases from our institution.

Vascular 2008 Jul-Aug;16(4):213-8

Department of Interventional Radiology, Montefiore Medical Center, Bronx, NY 10467, USA.

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Patients with massive PE have a high mortality rate, with two of every three deaths occurring in the first hour. The mainstay of treatment for PE is anticoagulation. However, when the patient is in extremis, intravenous lysis of the clot is indicated. Recently, mechanical fragmentation with or without pharmacologic thrombolysis has been shown to have a role in therapy for patients with massive PE, as well as in those patients who have a contraindication to anticoagulation. We discuss our experience with mechanical fragmentation in the treatment of PE and review the literature.
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http://dx.doi.org/10.2310/6670.2008.00031DOI Listing
December 2008

Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery.

J Vasc Interv Radiol 2007 Jul;18(7):914-9

Department of Radiology, Division of Vascular Radiology, Montefiore Medical Center, University Hospital for the Albert Einstein College of Medicine, Bronx, NY 10467-2490, USA.

A new technique for percutaneous gastrostomy of a decompressed excluded gastric segment after Roux-en-Y gastric bypass (RYGBP) surgery is described and the results in a single institution are reviewed. Computed tomography guidance was used to place a 21- or 22-gauge needle into the lumen of the stomach and distend it to allow placement of a feeding catheter. Ten women underwent the procedure, and despite only three patients having clear access windows, gastrostomy placement was ultimately successful in all 10 patients. Percutaneous gastrostomy of the decompressed excluded gastric segment after RYGBP surgery can be challenging, but a high rate of success can be achieved.
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http://dx.doi.org/10.1016/j.jvir.2007.03.001DOI Listing
July 2007

Type II endoleak after endoaortic graft implantation: diagnosis with helical CT arteriography.

Radiology 2006 Sep 25;240(3):885-93. Epub 2006 Jul 25.

Departments of Radiology and Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467, USA.

Purpose: To retrospectively assess endoleak shapes and locations within aneurysms to differentiate type II from type I and type III endoleaks.

Materials And Methods: The institutional review board granted an exemption for this HIPAA-compliant study; patient informed consent was not required. A retrospective review of arterial phase helical computed tomographic (CT) studies and medical records was performed for 39 patients (29 men, 10 women; age range, 60-89 years; mean, 78.5 years) who had an endoleak after endoaortic graft implantation for treatment of abdominal aortic aneurysm and who subsequently underwent angiography (n = 25), surgery (n = 8), or long-term follow-up (n = 6) to classify their endoleak into a specific type. At CT, endoleak shape (tubular or nontubular) and location (central or peripheral) were recorded. An endoleak was classified as type II if it contained a peripheral tubular component (PTC) near the aortic wall, with or without an identifiable feeding vessel. Endoleaks without these features were classified as type I or III. The Fisher exact test was used to assess associations between CT findings and endoleak type.

Results: There were 22 type II and 17 type I or III endoleaks. CT enabled correct identification of 22 (100%) of 22 type II endoleaks, all of which contained a PTC. Of 17 type I or III endoleaks, only two (12%) contained a PTC and were misclassified as type II endoleaks; the remaining 15 (88%) were correctly classified. Overall, CT enabled correct identification of endoleaks as type II or type I or III in 37 (95%) of 39 patients. PTCs were significantly more common (P < .001) in type II than in type I or III endoleaks, with a sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 100%, 88.2%, 94.9%, 100%, and 91.7%, respectively.

Conclusion: A PTC is a statistically significant predictor of type II endoleak in most patients.
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http://dx.doi.org/10.1148/radiol.2403051013DOI Listing
September 2006

A new method for aggressive management of deep vein thrombosis: retrospective study of the power pulse technique.

J Vasc Interv Radiol 2006 Jun;17(6):1043-9

Department of Radiology, Division of Vascular Radiology, Montefiore Medical Center, University Hospital for the Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York 10467-2490, USA.

Failure to treat deep vein thrombosis (DVT) is associated with significant morbidity and mortality. Anticoagulation, although effective at preventing clot progression, is not able to prevent postthrombotic syndrome. Catheter-directed thrombolysis is a more aggressive alternative, with some small studies suggesting a better long-term outcome, but the associated risks are significant, and the treatment can require 2-3 days in a monitored setting. This report describes the power pulse technique, in which mechanical thrombectomy is combined with thrombolytic agents to maximize the effectiveness of the treatment and reduce the need for prolonged infusion and its associated risks. A 24-patient retrospective study showed complete thrombus removal (>90%) in 12 patients, substantial thrombus removal (50%-90%) in seven patients, and partial thrombus removal (<50%) in five patients. All 24 patients had resolution of presenting symptoms. Only two patients required blood transfusion, and one patient experienced temporary nephropathy.
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http://dx.doi.org/10.1097/01.RVI.0000221085.25333.40DOI Listing
June 2006

Massive upper GI bleeding in a long-term hemodialysis patient.

Chest 2005 Sep;128(3):1868-9, 1870-73

Department of Medicine, Montefiore Medical Center, Goldzone Main Floor, 111 E 210th St, Bronx, NY 10467, USA.

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http://dx.doi.org/10.1378/chest.128.3.1868DOI Listing
September 2005

A phase I trial of alfimeprase for peripheral arterial thrombolysis.

J Vasc Interv Radiol 2005 Aug;16(8):1075-83

Department of Vascular Surgery, Desk S40, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Purpose: To evaluate the safety profile, pharmacokinetics, and thrombolytic activity of alfimeprase, a novel direct-acting thrombolytic agent, in patients with chronic peripheral arterial occlusion (PAO).

Materials And Methods: In this multicenter, open-label, single-dose, dose-escalation study, 20 patients with worsening symptoms of lower extremity ischemia within 6 months of enrollment were treated with alfimeprase in five escalating dose cohorts (0.025 mg/kg, 0.05 mg/kg, 0.1 mg/kg, 0.3 mg/kg, and 0.5 mg/kg) by means of intraarterial and sometimes intrathrombic pulsed infusion. The primary endpoint was safety assessed by adverse event rates. Additional safety assessments included vital sign monitoring, serum chemistry testing, hematologic testing, and coagulation testing for 28 days after the procedure, as well as alpha2-macroglobulin and antialfimeprase antibody testing for as long as 3 months after treatment. Pharmacokinetic parameters were evaluated with use of an assay that measures free and alpha2-macroglobulin-bound (ie, total) alfimeprase.

Results: No patient experienced a hemorrhagic adverse event. Mean plasminogen and fibrinogen concentrations were not substantially altered by treatment. Three transient treatment-related adverse events were reported in the same patient: one incidence each of increased blood fibrinogen level, skin rash, and headache. All three adverse events were graded as mild. The pharmacokinetic profile of alfimeprase suggested that the half-life for total alfimeprase ranges from 11 to 54 minutes (median, 25 min) in patients with PAO. The serum alpha2-macroglobulin concentrations decreased transiently in a dose response-like manner between 12 and 24 hours and returned to within normal limits approximately 14 days after alfimeprase exposure.

Conclusions: Alfimeprase in doses as high as 0.5 mg/kg was generally well-tolerated in patients with chronic PAO. No bleeding complications were noted. The stable fibrinogen concentrations suggest that the activity of alfimeprase may be limited to the target thrombus. Alfimeprase holds the potential to achieve dissolution of thrombus with a diminished risk of hemorrhage.
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http://dx.doi.org/10.1097/01.RVI.0000167863.10122.2ADOI Listing
August 2005

1992: Parodi, Montefiore, and the first abdominal aortic aneurysm stent graft in the United States.

Ann Vasc Surg 2005 Sep;19(5):749-51

Division of Vascular Surgery, Department of Surgery, Montefiore Medical Center-Albert Einstein College of Medicine, New York, NY, 10467, USA.

In 1990 Juan C. Parodi performed the first endovascular abdominal aortic aneurysm (AAA) repair in Buenos Aires. Two years later, in 1992, Parodi and Claudio Schonholz visited Montefiore Medical Center in New York to perform with us the first endovascular AAA repair to be done in the United States. Since then the Montefiore/Einstein vascular group has performed 1522 endovascular grafts in 674 patients for many types of vascular lesions using a variety of both surgeon-made and industry-made devices. The purpose of the present article is to describe the events that surrounded the performance of the first seminal endovascular AAA repair at our institution on November 23, 1992.
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http://dx.doi.org/10.1007/s10016-005-6858-9DOI Listing
September 2005

Subintimal angioplasty for chronic arterial occlusions.

Tech Vasc Interv Radiol 2004 Mar;7(1):16-22

Department of Radiology, Montefiore Medical Center, Bronx, NY, USA.

Percutaneous treatment of peripheral arterial disease has evolved greatly. The prevalence of superficial femoral artery occlusions has necessitated new devices and techniques to treat these patients percutaneously. Presently several therapies are available or under investigation. These range from stents, drug eluting stents, covered stents, cryoangioplasty, laser recanilization, blunt micro dissection, and subintimal angioplasty. This paper will discuss the indications, technique, and results of subintimal angioplasty.
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http://dx.doi.org/10.1053/j.tvir.2004.01.008DOI Listing
March 2004

Spontaneous retroperitoneal hemorrhage localized by blood pool scintigraphy.

Clin Nucl Med 2004 Feb;29(2):96-8

Department of Nuclear Medicine and Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, USA.

A healthy 17-year-old girl presented to the emergency department with a 1-day history of left upper quadrant abdominal pain associated with nausea and vomiting. Her hematocrit was 22. On physical examination, she had left upper quadrant fullness and tenderness. Initial computed tomography revealed a large, loculated, left-sided retroperitoneal hematoma. Blood pool scintigraphy with labeled red cells revealed a very large photon-deficient area with 3 areas of active bleeding in the upper margin of the cold area. An angiogram showed active extravasation from the left inferior phrenic artery. The patient was felt to have had spontaneous adrenal hemorrhage, likely within a preexisting, large adrenal cyst. Spontaneous hemorrhage into an adrenal cyst is a rare entity that can be life-threatening if not treated early in its course.
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http://dx.doi.org/10.1097/01.rlu.0000110475.09814.83DOI Listing
February 2004

Endovascular grafts and other catheter-directed techniques in the management of ruptured abdominal aortic aneurysms.

Semin Vasc Surg 2003 Dec;16(4):326-31

Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY 10467, USA.

Abdominal aortoiliac aneurysms that are ruptured and treated with open surgical repair have high morbidity and mortality rates. We have employed endovascular approaches to treat this entity since 1994. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guidewire into the supraceliac aorta and arteriography. If aortoiliac anatomy was suitable, an endovascular graft repair was performed. If the anatomy was unfavorable, the aneurysm was repaired in a standard open fashion. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 36 patients so managed, 30 underwent endovascular graft repair and six required open repair. Four patients died within 30 days (operative mortality = 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques, including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. These techniques should become widely used for the treatment of ruptured aneurysms.
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http://dx.doi.org/10.1053/j.semvascsurg.2003.08.011DOI Listing
December 2003

Treatment of ruptured abdominal aneurysms with stent grafts: a new gold standard?

Semin Vasc Surg 2003 Jun;16(2):171-5

Montefiore Medical Center, Albert Einstein College of Medicine, 11 East 210th Street, New York, NY 10467, USA.

Ruptured abdominal aortoiliac aneurysms, when treated with open surgical repair, have high morbidity and mortality rates. Since 1994, the authors have used endovascular approaches to treat this entity. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guide wire into the supraceliac aorta, and arteriography. If aortoiliac anatomy was suitable, an endovascular graft (stent-graft) repair was performed. If the anatomy was unfavorable, standard open repair was performed. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 35 patients treated in this manner, 29 underwent endovascular graft repair, and 6 required open repair. Four patients died within 30 days (operative mortality rate, 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. The authors believe these techniques will become widely used for the treatment of ruptured aneurysms.
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http://dx.doi.org/10.1016/s0895-7967(03)00003-6DOI Listing
June 2003

Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding.

J Vasc Interv Radiol 2003 Feb;14(2 Pt 1):211-6

Department of Radiology, Division of Vascular Radiology, Montefiore Medical Center, University Hospital for the Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York 10467-2490, USA.

Purpose: To demonstrate results in managing lower gastrointestinal (GI) bleeding with the use of superselective catheterization and intentional induction of vasospasm of the bleeding vessel without the use of embolic agents or vasospasm-inducing medications.

Materials And Methods: A retrospective review of 15 episodes of lower GI bleeding treated in the past 6 years by intentional catheter-induced vasospasm (CIV) to achieve thrombosis of a bleeding source was conducted. Nine patients had angiographically proven inferior mesenteric artery bleeding and six had angiographically proven superior mesenteric artery bleeding.

Results: Bleeding was stopped initially in all patients after effective treatment of the feeding artery. Only one patient experienced a repeat episode of bleeding 2 days later, which required hemicolectomy. Two other patients who underwent adequate embolization underwent surgery at the discretion of the surgeon involved. The remainder were clinically observed and discharged after return of stable vital signs and hematocrit levels. None of the patients treated had clinically evident intestinal ischemia or infarction. There was one significant repeat incidence of bleeding 2 months after CIV that may have represented recurrent bleeding from the original site.

Conclusion: CIV may be a safe and effective first-line method of embolizing known lower GI bleeding. Whether CIV is used as primary therapy or as the result of spasm incurred during superselective catheterization, the patient may be regarded as successfully treated and followed accordingly, thereby possibly avoiding acute surgical therapy.
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http://dx.doi.org/10.1097/01.rvi.0000058323.82956.e4DOI Listing
February 2003

Does subintimal angioplasty have a role in the treatment of severe lower extremity ischemia?

J Vasc Surg 2003 Feb;37(2):386-91

Division of Vascular Surgery, Department of Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, NY 10467, USA.

Objective: Subintimal angioplasty (SIA) has been advocated to treat long segment lower extremity arterial occlusions, but many question its value. We evaluated the role of SIA in a group of patients with severe lower extremity arterial occlusive disease.

Methods: During a 2.5-year period, 39 patients with arterial occlusions (median length, 8 cm; range, 2 to 31 cm) were treated on an intention-to-treat basis with SIA. Twenty-five patients had gangrene, five had rest pain, and nine had disabling (
Results: SIA was technically successful in 34 of 39 patients (87%). All five failures were from an inability to reenter the patent lumen distally. These five patients underwent successful bypasses that in no case were more distal than would have been required before SIA. In the 34 technically successful SIAs, pain completely resolved (14/14) and areas of gangrene (21/25) healed. The cumulative patency rate in patients who underwent successful SIA was 74% +/- 10% at 12 months. The mean increase in ankle-brachial index after SIA was 0.34 (range, 0.1 to 0.69). There were two distal embolic events, successfully treated surgically (n = 1) or with catheter-directed techniques (n = 1). Three patients underwent subsequent bypass, and the remaining five patients remain asymptomatic.

Conclusion: SIA is feasible and can be effective in some patients with lower extremity arterial occlusions and threatened limbs. These results, plus SIA's many advantages, support an increasing role for it in the treatment of lower extremity arterial occlusive disease.
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http://dx.doi.org/10.1067/mva.2003.20DOI Listing
February 2003

Thrombolysis for the treatment of thrombosed hemodialysis access grafts.

Rev Cardiovasc Med 2002 ;3 Suppl 2:S84-91

Division of Vascular and Interventional Radiology, Montefiore Medical Center, Bronx, NY, USA.

Maintaining the patency of hemodialysis access grafts remains problematic. It is best to recognize the failing graft prior to its thrombosis by noting an increase in recirculation, decreased flow (as measured by a Transonics device), changes in Doppler ultrasound findings, elevation of venous pressures, or swelling of the arm. If a failing graft is suspected, an angiogram should be performed to evaluate the graft. If a problem is identified it should be corrected. If it is a graft thrombosis, it can be opened using percutaneous techniques. Percutaneous declotting has been evolving since its introduction in the early 1980s. At first, a low-dose thrombolytic infusion through a single catheter was used. Crossing catheters with a higher-dose infusion was then introduced. Finally, pharmacomechanical thrombolysis, which used crossing catheters and a pulse-spray technique, became popular. Several mechanical devices have proven to be efficacious as well. In 1997, we described the "lyse-and-wait" technique. We believe "lyse and wait" to be a simpler and quicker technique, and its initial success has been similar to that for the previously described techniques. After the graft is successfully declotted, the arterial plug must be mobilized and the stenotic lesion must be addressed either by angioplasty, stent placement, surgery, or any combination of these interventions.
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April 2003