Risks and benefits of renal artery stenting in fibromuscular dysplasia: Lessons from the ARCADIA-POL study.

INTRODUCTION: Although renal stenting is the standard revascularization method for atherosclerotic renal artery stenosis (RAS) (FMD-RAS), stenting in fibromuscular dysplasia (FMD) RAS is usually limited to periprocedural complications of angioplasty and primary arterial dissection. The main aim of the study was to retrospectively analyze the immediate and long-term results of renal stenting versus angioplasty in patients with FMD. METHODS: Of 343 patients in the ARCADIA-POL registry, 58 patients underwent percutaneous treatment due to FMD-RAS (in 70 arteries). Percutaneous transluminal renal angioplasty (PTRA) was performed as an initial treatment in 61 arteries (PTRA-group), whereas primary stenting was undertaken in nine arteries (stent-group). Stent-related complications were defined as: in-stent restenosis > 50% (ISR); stent fracture; under-expansion; or migration. RESULTS: In the PTRA-group, the initial restenosis rate was 50.8%. A second procedure was then performed in 22 arteries: re-PTRA (12 arteries) or stenting (10 arteries). The incidence of recurrent restenosis after re-PTRA was 41.7%. Complications occurred in seven of 10 (70%) arteries secondarily treated by stenting: two with under-expansion and five with ISR. In the stent-group, stent under-expansion occurred in one case (11.1%) and ISR in three of nine stents (33.3%). In combined analysis of stented arteries, either primarily or secondarily, stent-related complications occurred in 11/19 stenting procedures (57.9%): three due to under-expansion and eight due to ISRs. Finally, despite several revascularization attempts, four of 19 (21%) stented arteries were totally occluded and one was significantly stenosed at follow-up imaging. CONCLUSION: Our study indicates that renal stenting in FMD-RAS may carry a high risk of late complications, including stent occlusion. Further observational data from large-scale registries are required.

Two-Stage Endovascular Treatment of a Traumatic Pseudoaneurysm of Superior Mesenteric Artery Branch in a Soldier After a Military Combat Mission.

Aneurysms and pseudoaneurysms of the visceral arteries are a rare pathology with a prevalence of 0.1-2% in the general population, most common in men. Despite low prevalence, visceral aneurysms pose a significant threat to the patient's health and life; a ruptured superior mesenteric branch aneurysm carries mortality rates of 10-25% and up to 30-90%. This article presents a case of a 50-year-old former active duty soldier and veteran of a military combat mission in Afghanistan, during which he sustained a traumatic injury resulting from a mine explosion under a vehicle. After completing the mission and returning home, the patient developed abdominal pain. The diagnosis made in the general surgery department of the district hospital was upper gastrointestinal obstruction and aneurysmal rupture of the superior mesenteric branch with inflammatory infiltration of the pancreatic-intestinal area. The patient underwent emergency gastrointestinal anastomosis and Braun enteroenterostomy. The aneurysm was not resected. One month later, the patient underwent a follow-up abdominal angiotomography, which revealed an approximately 20-mm aneurysm of a branch of the superior mesenteric artery and celiac artery subocclusion (Dunbar syndrome) with extensive collateral circulation. A diagnosis of pseudoaneurysm/traumatic aneurysm was made, and the patient was referred to a vascular surgery center for endovascular treatment. Following CT angiography, a decision was made to perform a two-stage endovascular repair. The first stage was a bridge therapy aimed to release celiac artery subocclusion with a stent; after 3 weeks, pseudoaneurysm embolization was performed. The decision to use two-stage endovascular treatment was attributable to the risk of gastrointestinal ischemia that might result from intraoperative technical difficulties and complications, coil dislocation, and thrombosis of the superior mesenteric artery or its branch; the coexisting subocclusion of the celiac artery was also considered. The patient was discharged in good condition and returned to normal everyday activities. He also continued follow-up appointments with a vascular surgeon. An angiotomography performed at 1 year of endovascular treatment confirmed good effects of the embolization procedure and coagulation of the aneurysm. Visceral aneurysms are a rare vascular pathology but are associated with significant morbidity and mortality rates. The incidence of ruptured aneurysms is probably underestimated as some patients may be operated on for acute abdominal symptoms, e.g., bowel obstruction.

Impact of Internal Carotid Stenosis Treatment on Cerebral Blood Flow Volume: A Comparative Study between Preoperative and Postoperative Values.

BACKGROUND Among patients with ICA stenosis, there are some cases with elevated, undisrupted, and diminished cerebral blood flow (CBF). The aim of this study was to assess the influence of ICA stenosis treatment on postoperative CBF changes in relation to preoperative CBF values. MATERIAL AND METHODS We qualified 58 patients ≥65 years old (28 males, 30 females, mean age 71.02±6.34 years) for surgical intervention due to symptomatic ≥70% ICA stenosis. In all patients, a flow volume in all extracranial arteries (internal carotid [ICA], external carotid [ECA], and vertebral arteries [VA]) was measured preoperatively and 2-3 days following the surgery. The CBF values were compared with the ones established for a healthy population of the same age. RESULTS Preoperatively, there were 3 subgroups of patients, comparing to healthy population: with elevated CBF - "significant compensation," with undisrupted CBF - "mild compensation," and with diminished CBF - "no compensation." Postoperatively, a significant CBF increase was observed in patients with preoperative "no" and "mild compensation" - 277.18±154.26 ml/min (P=0.0000001) and 221.56±98.8 ml/min (P=0.0000001). In a "significant compensation" group, there was no flow increase observed (CBF change of 2.57±58.5 ml/min, P=0.954) - a redistribution of flow was observed. CONCLUSIONS In patients with lower preoperative CBF values, surgical treatment caused a significant increase in global cerebral inflow, which was more prominent in patients with the lowest preoperative CBF. In patients with high preoperative CBF, surgical treatment resulted in a flow redistribution, but did not cause a CBF increase. Volumetric flow assessment in DUS can predict hemodynamic benefit from surgery in terms of CBF increase.

Rapid Formation and Hybrid Treatment of a Large Superior Mesenteric Artery Aneurysm.

BACKGROUND Superior mesenteric artery (SMA) aneurysms account for about 5.5% of all visceral aneurysms, and are most commonly secondary to infectious causes or dissection. They tend to expand and rupture. Here, we present our successful diagnosis and treatment of a 41-year-old man with asymptomatic coeliac trunk stenosis, in whom the large aneurysm of the branch of the SMA developed in a very short time after conservative treatment of plastron appendicitis. CASE REPORT A 41-year-old man was diagnosed with plastron appendicitis during abdomen ultrasound (US) examination. Following 2 weeks of conservative treatment with intravenous antibiotic therapy, complete resolution of symptoms was obtained and confirmed in the computed tomography (CT) scan, and no other pathologies were diagnosed. Three weeks later, during the US examination, a 33-mm aneurysm of the branch of the SMA was diagnosed. The patient was admitted to the Vascular Surgery Department, where a critical stenosis of the coeliac trunk secondary to the compression by median arcuate ligament and a 33-mm true visceral aneurysm of one of the branches of the SMA were diagnosed. Successful treatment of the aneurysm was performed. Surgical decompression of the coeliac trunk and subsequent elective endovascular embolization of the SMA aneurysm with angioplasty of the coeliac trunk were performed. The postoperative period was uneventful and the patient was released from the hospital and remains asymptomatic. CONCLUSIONS Visceral artery aneurysm can form very quickly. In some of the aneurysms, a combination of open surgical and endovascular methods should be performed.

Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography.

Splenic artery aneurysm (SAAs) rupture is associated with a high mortality rate. Regular surveillance with imaging before and after intervention is crucial to guide best evidence treatment. The following study aimed to determine the efficacy of color Doppler ultrasound imaging (DUS) compared to digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) as a follow-up modality after selective coil embolization of true SAAs. We analyzed data from 20 patients, 15 females (48.1 ± 16.1 years) undergoing selective SAA coil embolization using detachable fibered embolization coils. Imaging using DUS, MRA, and DSA was performed 3 months after the initial embolization or the consequent re-embolization procedure. Primary clinical success, defined as Class I aneurysm occlusion, on 3-month follow-up was seen in 16 (80.0%) patients. DUS had a sensitivity of 94.4% and a specificity of 42.9% when compared to DSA and 92.3% and 30%, respectively, when compared to MRA in identifying Class I aneurysm occlusion. The positive predictive value (PPV) of DUS in identifying the need for re-embolization was 75.0%, while the NPV of DUS in these terms was 90.5%. DUS showed a high sensitivity in detecting aneurysm occlusion and clinical success, simultaneously exhibiting poor specificity. Still, with caution, this follow-up modality could be used for monitoring select low-risk patients after selective embolization of SAAs. DUS could provide a higher cost-to-benefit ratio, enabling more systematic post-procedural follow-up, as it is far more commonly used compared to MRA and non-invasive compared to DSA.

Transplant Renal Artery Stenosis: Underrecognized, Not So Rare, but Curable Complication.

Transplant renal artery stenosis (TRAS) constitutes 75% of all vascular complications in kidney transplant recipients, being a significant source of graft dysfunction and loss. TRAS is a heterogeneous disease with different risk factors and causes. The incidence differs greatly, and it is likely it will increase because of the aging population of potential recipients and donors of renal grafts and the expanding use of extended-criteria donors. Prompt diagnosis and treatment of TRAS can prevent irreversible allograft dysfunction and loss. Current evidence of risk factors, diagnostic challenges, and therapeutic options are presented in this short review.

Loneliness and mental well-being in the Polish population during the COVID-19 pandemic: a cross-sectional study.

OBJECTIVE: There is a growing concern that the restrictions imposed due to the COVID-19 pandemic could lead to increased loneliness and mental disorders, which are considered a major public health problem. The aim of the study was to assess loneliness, anxiety, depression and irritability in the Polish population during the COVID-19 pandemic. DESIGN: A cross-sectional study. The study participants completed an online questionnaire using the computer-assisted web interview technique. Data were collected using Revised UCLA Loneliness Scale and Hospital Anxiety and Depression Scale. SETTING: Poland. PARTICIPANTS: This study was conducted between 6 October and 12 October 2020, in a representative sample of 890 Polish residents. PRIMARY OUTCOME MEASURES: Self-reported loneliness; sociodemographic and COVID-19 pandemic factors associated with loneliness, anxiety, depression and irritability. RESULTS: The analyses showed a moderately high degree of loneliness in 22%, symptoms of anxiety in 27%, depression in 14% and irritability in 33% of the respondents. The increasing severity of anxiety, depression and irritation in the study group was accompanied by higher loneliness. Generally, younger people, both tested positive for SARS-CoV-2 and those who experienced home quarantine, scored higher in both scales. CONCLUSIONS: It is necessary to identify those most vulnerable to loneliness, anxiety and depression during a crisis to assess health needs and proactively allocate resources during and after the pandemic. Loneliness, anxiety, depression and irritability are important factors to consider in a population of younger, disadvantaged people, who tested positive for SARS-CoV-2, people who were quarantined at home, and people who believe that their physical and mental health is worse than in the pre-pandemic period. It is important to cater for the mental health of individuals during the COVID-19 pandemic and to promote psychological interventions to improve mental well-being in potentially vulnerable social groups.

Coil Embolization of Post-Traumatic Pseudoaneurysm of the Ascending Aorta.

BACKGROUND Traumatic rupture of the ascending aorta is a life-threatening injury, with a survival rate of around 15% to 20%. Treatment with open surgical repair is the criterion standard. However, open surgical repair is associated with high mortality and morbidity in patients with multiple traumas. There are no systematic data on traumatic thoracic rupture and aorta rupture in a cohort of patients who had undergone partial or total replacement of the thoracic aorta. We can only speculate about the mechanisms and consequences of such an injury. Therefore, even unorthodox endovascular techniques are a welcome advancement in this field and should be considered, providing they do not compromise patient safety. CASE REPORT A 61-year-old man presented with polytrauma after a fall from height. Since the patient had a history of a Bentall procedure, hypertension, coronary disease, and nicotinism, we quickly excluded open surgery as a treatment option. However, the patient's condition, additional injuries, and anatomical features prompted us to perform coil pseudoaneurysm, reducing his operative trauma and allowing for his faster recovery and early rehabilitation. The patient has remained under careful clinical supervision. The result of the patient's 1-year follow-up was satisfactory. CONCLUSIONS In this case, the endovascular approach was an effective, if temporary, option to open or hybrid surgery. This demonstrates that minimally invasive surgery can be helpful in some patients and can also be helpful as a bridge therapy. A good rapport between the surgeon and the patient is crucial to understanding the advantages and disadvantages of such treatment.

Multiple occlusions in extracranial arteries in patients with aortic arch syndrome: is minimally invasive treatment still possible? Technical aspects of the treatment based on our own experience and a review of the literature.

Takayasu arteritis is a large vessel vasculitis of granulomatous nature and unknown aetiology affecting predominantly the aorta and its major branches, which may lead to ischaemic symptoms of many organs including the central nervous system. To decrease the risk of neurological complications and improve the quality of life, an arterial revascularisation may be necessary. The treatment options include pharmacotherapy as well as both open surgical and endovascular procedures, which has to be carefully chosen to obtain clinical success. There is an ongoing debate on the advantages, possibilities, and indications for implementing endovascular and open surgical methods, especially in high-risk patients. In this article we present our own experience in the treatment of an unusually complex and high-risk patient with multiple occlusion of supra-aortic branches, focusing on the technical aspects of the procedures and the decision-making process, as well as to confront with contemporary medical knowledge.

Volumetric Flow Changes in Extracranial Arteries in a Symptomatic Patient with Significant Bilateral Carotid Artery Stenosis: A Case Study and Literature Review.

BACKGROUND Hemodynamically significant carotid artery stenoses are rarely diagnosed in people under 60 years of age, being mainly secondary to other concomitant diseases. Cerebral blood flow volume, which correlates with cerebrovascular reserve and susceptibility of ischemic symptoms occurrence, may aid in the diagnosis and monitoring of patients with carotid artery disease. In this report we present the case of a patient with significant bilateral carotid stenosis, focusing on the ultrasonographically measured changes in blood flow volume in extracranial arteries following surgeries. CASE REPORT A 41-year-old man with a positive history of transient ischemic attack (TIA)  was referred to our department after being diagnosed with significant 80% to 85% right internal carotid artery (ICA) and 60% left ICA stenosis. After successful carotid endarterectomy, the flow volume in extracranial arteries significantly increased (from 755 mL/min to 1053 mL/min) due to an increase of flow volume in the right ICA. With the progression of left ICA stenosis, cerebral blood flow decreased, and the patient presented with a second TIA. Following the successful treatment of the left ICA stenosis (consisting of carotid endarterectomy and stent implantation because neointimal hyperplasia resulted in significant, recurrent 80% left ICA stenosis), an increase in flow volume was observed. CONCLUSIONS Assessment of the blood flow volume in extracranial arteries may be an effective tool in monitoring patients with carotid stenoses. Due to the lack of literature on this topic, further research on cerebral blood flow volume in surgical and non-surgical patients is needed to understand this phenomenon.

Combined Treatment of Multiple Splanchnic Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome: A Case Study and Review of the Literature.

BACKGROUND Median arcuate ligament syndrome (MALS) is a rare and often misdiagnosed condition affecting about 0.4% of the population, typically ages 20-50 years old, and more frequently females. Caused by the compression of the celiac artery and adjacent nervous structures by the median arcuate ligament, it is typically manifested by postprandial abdominal pain, nausea or vomiting, and loss of weight. This condition also results in compensatory increased blood flow in peripancreatic arcades, facilitating formation of true aneurysms of the visceral vessels. CASE REPORT A 45-year-old woman with hypertension and left inferior renal pole cysts was referred to our department due to chronic, recurrent postprandial abdominal pains, nausea, and weight loss of approximately 15 kg in 1 year. A computed tomography (CT) scan demonstrated complete occlusion of the celiac trunk, significant stenosis of the superior mesenteric artery, and multiple aneurysms up to 17 mm in collateral circulatory vessels. Surgical decompression of the median arcuate ligament was performed and venous bypass was implanted between the aorta and the common hepatic artery, resulting in restoration of proper blood in the visceral circulation. Subsequently, 2 endovascular embolizations of visceral aneurysms were successfully performed. In the 48-month follow-up period, there was resolution of symptoms and no aneurysm formation was observed. CONCLUSIONS Endovascular methods should be the treatment of choice in patients with splanchnic artery aneurysms. However, in patients with multiple aneurysms secondary to MALS, arterial reconstruction may be considered prior to performing an endovascular procedure to restore physiological blood flow in the visceral circulation.

Selective occlusion of splenic artery aneurysms with the coil packing technique: the impact of packing density on aneurysm reperfusion correlated between contrast-enhanced MR angiography and digital subtraction angiography.

PURPOSE: The aim was to evaluate the relationship between coil packing densities after splenic artery aneurysm (SAA) treatment using detachable microcoils and rates of SAA reperfusion and to suggest a post-treatment surveillance protocol using contrast-enhanced MRA. MATERIALS AND METHODS: Evaluated were 16 patients (4 men; mean age 46.7), who underwent true SAA embolization using detachable microcoils (Concerto, Medtronic). SAAs were treated by selective coil packing (CP) or stent-assisted coil exclusion (SAC). Contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) were performed at 3 months post-procedure and correlated. RESULTS: Primary CP was used in 13 patients, while SAC was used in three patients. On follow-up, complete aneurysm occlusion was seen in seven patients (43.8%). Sac reperfusion occurred in nine patients (56.2%) and was demonstrated in all CE-MRA and six DSA studies. Mean aneurysm packing density was 20.10 ± 8.05% for the CP group and 32.90 ± 11.95% for the SAC group (p = 0.038). There was a significant difference in the incidence of aneurysm sac reperfusion on CE-MRA study between CP and SAC (9 vs. 0). No sac reperfusion was seen in aneurysms with packing densities ≥ 29%, irrespective of either embolization method. CONCLUSION: Favorable midterm results for coil packing of SAAs seem to depend on the coil packing density with a coil volume approximately a quarter of the aneurysm volume being most effective. Follow-up should involve the use of CE-MRA as this modality has been shown to be superior over DSA in detecting aneurysm reperfusion and coil compaction. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Treatment Algorithm of Peripancreatic Arteries Aneurysm Coexisting with Coeliac Artery Lesion: Single Institution Experience.

INTRODUCTION: True aneurysms of peripancreatic arterial arcades (PAAAs) coexisting with celiac axis lesion are often asymptomatic. However, they may rupture regardless of their size and cause life-threatening hypovolemia. No treatment guidelines exist to date. We present a series of 21 patients and our management algorithm. MATERIAL AND METHODS: For ruptured aneurysms we preformed endovascular embolization. Further treatment was dependent on patient's condition and control studies. In case of unruptured aneurysms, we assessed collateral circulation between superior mesenteric artery and celiac axis in angio-CT. If there was a pathway free from aneurysms, endovascular approach was chosen. Otherwise, surgical or combined treatment was favored. RESULTS: Endovascular treatment was performed in 14 patients with no complications. Follow-up studies revealed incomplete occlusion of the aneurysms in two cases. Surgical or combined treatment was performed in 7 patients with three serious perioperative complications. They were managed conservatively in two cases and surgically in one. Follow-up studies showed aneurismal dilatation and stenosis of a renohepatic by-pass in one case. CONCLUSION: We present our management algorithm of PAAAs. Our results support the leading role of endovascular treatment. We present its limitations favoring surgical or combined treatment. All patients should be carefully followed.

Computed Tomography (CT) Angiography in Pre-Embolization Assessment of Location of Gastrointestinal Bleeding in Paediatric Patient with Granulomatosis with Polyangiitis (Wegener's Granulomatosis) - Case Report.

BACKGROUND: Acute gastrointestinal bleeding is an emergency with a high morbidity and mortality. Early diagnosis and appropriate intervention can be lifesaving and can prevent long-term complications. CASE REPORT: In this case report, we discuss and illustrate the role of CT angiography in the evaluation of acute, active gastrointestinal haemorrhage and show its usefulness prior to embolization. We describe a 15-year-old girl with granulomatosis with polyangiitis, formerly known as Wegener's granulomatosis. CONCLUSIONS: An accurate pre-embolization assessment of bleeding with CT angiography shortens the total diagnostic time, which results in prompt and more effective endovascular treatment.We describe the clinical presentation of our patient and present diagnostic and interventional radiologic findings.

Promoting False-Lumen Thrombosis after Thoracic Endovascular Aneurysm Repair in Type B Aortic Dissection by Selectively Excluding False-Lumen Distal Entry Tears.

PURPOSE: To evaluate the efficacy and clinical outcomes of ancillary endovascular procedures in promoting false-lumen (FL) thrombosis (FLT) and preventing aortic expansion in patients after thoracic endografting for type B dissections. MATERIALS AND METHODS: This retrospective review included 15 patients (12 men and 3 women; mean age, 59.6 y). Mean aortic diameter at the time of ancillary treatment was 47.4 mm. Different techniques were used as single procedures or sequentially: covered stent occlusion of detached visceral artery entry tears, occlusion of single entry tears with vascular plugs, or aortic endograft occlusion of multiple FL entry tears. FL embolization with ethylene vinyl alcohol copolymer was performed when selective occlusion was considered insufficient to close distal entry tears. Apart from endovascular aneurysm repair, all procedures were performed percutaneously under local anesthesia. If FL diameter increase persisted after 6-month follow-up computed tomographic (CT) angiography, another intervention was planned; otherwise, yearly follow-up was performed. RESULTS: Mean clinical follow-up duration was 43.8 months (range, 8 d to 86.8 mo), with no in-hospital mortality. Estimated overall survival rates were 93.3%, 86.6%, and 77% at 12, 24, and 48 months, respectively. Three late deaths occurred, one of which was dissection-related at 40 months. Eight surviving patients (53%) had total FLT and 3 had partial FLT with stable aortic diameter on follow-up CT angiography. FL diameter increased in one patient, requiring further intervention. CONCLUSIONS: Selective exclusion of new distal entry tears remaining after thoracic endovascular aneurysm repair can stabilize abdominal aortic expansion and promote FLT.

Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.

INTRODUCTION: Type 2 endoleaks (T2E) occur in 10 to 20% of patients after endovascular abdominal aortic aneurysm repair (EVAR) and remain a significant clinical issue. AIM: To evaluate the efficacy and clinical outcomes of transarterial treatment of persistent type II endoleaks after EVAR using the liquid embolic Onyx. MATERIAL AND METHODS: From February 2012 to August 2015 transarterial T2E embolization was attempted in 22 patients (21 men, median age: 73, range: 62-88 years). Indications for treatment included an increase in the diameter of the aneurysm sac above 5 mm and a persistent endoleak observed for more than 6 months. Mean time from EVAR to endoleak treatment was 43 months (range: 2-125 months). RESULTS: Primary technical success was achieved in 17 (77.3%) patients and secondary technical success in 81.8%, with 0% in-hospital mortality. The mean procedure time was 95 ±48 min, with an average fluoroscopy time of 54 ±25 min. The mean amount of Onyx used was 7.5 ±6.6 ml. Clinical success was seen in 17/21 patients with follow-up imaging (80.9%). Mean follow-up time was 17 months (range: 3-38 months). CONCLUSIONS: Onyx has been shown to effectively stabilize previous aneurysm growth as a result of the T2E in the majority of our patients. Transarterial embolization of T2E can be significantly improved as compared to previously reported results by using liquid embolic polymers such as Onyx.