BACKGROUND The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter “pharmacomechanical thrombolysis”) rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. METHODS We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. RESULTS Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P = 0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P = 0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P = 0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P = 0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. CONCLUSIONS Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335.)

Colonoscopy is the primary screening procedure for colorectal cancer and car− ries very low risk of complications (be− tween 0.3 % and 0.35 %) [1]. It is estimated that 1.69 million colonoscopies are per− formed each year in the USA alone [2]. The most common complications are in− traluminal gastrointestinal bleeding and colonic perforation [1]. Infrequently, he− moperitoneum occurs, mostly involving damage to the spleen. We present a case of hemoperitoneum following colonosco− py without splenic injury. A 59−year−old female presented to our emergency department following a syn− copal episode 12 hours after an unre− markable screening colonoscopy. Despite minor abdominal discomfort noted after the procedure, she resumed her normal activities. Pertinent history included a prior appendectomy. Besides pallor and minimal abdominal tenderness to palpa− tion, physical exam was within normal limits. Laboratory tests showed a hemo− globin concentration of 10.4 g/dL and a hematocrit of 28.8 %. Leukocyte count, electrolytes, blood urea nitrogen, and creatinine were normal. Stool was guaiac negative. An abdominal radiograph ex− cluded pneumoperitoneum (l " Fig. 1). Computed tomography (CT) scans of the abdomen and pelvis showed moderate amounts of free fluid demonstrating a density level suggestive of blood. The spleen appeared normal and there was no free air or extravasation of contrast from the bowel (l " Fig. 2 a, b). She was monitored for further bleeding and was subsequently discharged after 6 days. Intra−abdominal hemorrhage, a rare com− plication of colonoscopy, is most com− monly reported in conjunction with splenic injury. Other documented causes of hemoperitoneum after colonoscopies include a torn mesenteric vessel, a rup− tured epiploic appendix, and a necrosed intestinal leiomyosarcoma [3 ± 5]. Due to the lack of other findings, it was speculat− ed that the etiology in this case was a torn mesenteric vein. Intra−abdominal adhe− sions from her appendectomy could have contributed. Endoscopy_UCTN_Code_CPL_1AJ_2ABHemoperitoneum after colonoscopy Fig. 1 Abdominal radiograph centered at the diaphragm ex− cludes the presence of pneumoperitoneum.

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<b><i>Background:</i></b> Innovations in artificial intelligence (AI) have proven to be effective contributors to high-quality health care. We examined the beneficial role AI can play in noninvasively grading vascular access aneurysms to reduce high-morbidity events, such as rupture, in ESRD patients on hemodialysis. <b><i>Methods:</i></b> Our AI instrument noninvasively examines and grades aneurysms in both arteriovenous fistulas and arteriovenous grafts. Aneurysm stages were adjudicated by 3 vascular specialists, based on a grading system that focuses on actions that need to be taken. Our automatic classification of aneurysms builds on 2 components: (a) the use of smartphone technology to capture aneurysm appearance and (b) the analysis of these images using a cloud-based convolutional neural network (CNN). <b><i>Results:</i></b> There was a high degree of correlation between our noninvasive AI instrument and the results of the adjudication by the vascular experts. Our results indicate that CNN can automatically classify aneurysms. We achieved a &#x3e;90% classification accuracy in the validation images. <b><i>Conclusion:</i></b> This is the first quality improvement project to show that an AI instrument can reliably grade vascular access aneurysms in a noninvasive way, allowing rapid assessments to be made on patients who would otherwise be at risk for highly morbid events. Moreover, these AI-assisted assessments can be made without having to schedule separate appointments and potentially even via telehealth.

Background Postthrombotic syndrome is a common complication of deep vein thrombosis, with limited treatment options. Methods and Results ACCESS PTS (Accelerated Thrombolysis for Post‐Thrombotic Syndrome Using the Acoustic Pulse Thrombolysis Ekosonic Endovascular System) is a multicenter, single‐arm, prospective study evaluating patients with chronic deep vein thrombosis and postthrombotic syndrome (Villalta score ≥8) who received minimum 3 months of anticoagulation. Patients underwent percutaneous transluminal venoplasty and ultrasound‐accelerated thrombolysis, with data collected on clinical characteristics, postthrombotic syndrome, imaging, and quality of life to 1 year. The primary efficacy outcome was a reduction of ≥4 points in the Villalta score 30 days after procedure. The primary safety outcomes were major bleeding episodes within 72 hours and symptomatic pulmonary embolism during the index hospitalization. A total of 82 limbs (78 patients) were treated (age, 54.6±12.7 years; 32.1% women; mean Villalta score, 15.5±5.2). The primary end point was met in 64.6% (51/79). At 1 year, 77.3% (51/66) of limbs continued with a Villalta reduction ≥4. At 365 days, >90% of segments had patency with ultrasound flow present. Baseline to 1‐year Physical Component Summary mean score of the Short Form‐36 increased from 38.9±9.5 to 45.2±9.8 ( P ≤0.0001), and mean VEINES ‐ QOL (Venous Insufficiency Epidemiological and Economic Study–Quality of Life) increased from 61.9±19.7 to 82.6±20.8 at 1 year ( P <0.0001). Iliofemoral venous stenting was performed in 42 patients, with similar improvements seen in all outcomes, regardless of stenting status. One patient developed severe bleeding within 72 hours of the intervention and died at 32 days after procedure (1.3% mortality rate). Conclusions Percutaneous transluminal venoplasty and ultrasound‐accelerated thrombolysis resulted in successful recanalization of chronic venous obstruction with improved postthrombotic syndrome severity and quality of life. Results were sustained at 1‐year after procedure. Clinical Trial Registration URL : https://www.clinicaltrials.gov/ . Unique identifier: NCT 02159521.