Safety of percutaneous axillary artery access with a suture-mediated closing device for parallel endograft aortic procedures - a retrospective pilot study.

BACKGROUND: The aim of this study was to evaluate the technical success of percutaneous ultrasound-guided access to the infraclavicular axillary artery with a suture-mediated closing device for patients requiring large-sized upper extremity access. PATIENTS AND METHODS: In 18 consecutive patients (17 male, one female, mean age 73.5 ± 9.6 years, range 52-88 years), artery accesses with the preclosing modification for chimney endografts was gained with 20 ultrasound-guided infraclavicular axillary. Retrospectively, the following endpoints were analysed: technical success of percutaneous ultrasound-guided puncture of the infraclavicular axillary artery as well as introduction and deployment, primary successful haemostasis by preclosing, bailout procedures, overall complication rate including local vascular, cerebrovascular, and peripheral neurological complications. RESULTS: Ultrasound-guided puncture and preclosing procedure was successful in all patients. Mean sheath size was 9.4 ± 1.6 French. Ultrasound-guided puncture as well as introduction and deployment were successful in all patients (100 %). Primary successful haemostasis by preclosing was 70 % (14/20). Postclosing with one or two devices enabled successful haemostasis in another 15 %. Bailout stent graft implantation was necessary in three accesses (15 %), either by transfemoral (n = 2) or transbrachial (n = 1) route. Overall complication rate was 16.5 %, all of them were minor haematomas. CONCLUSIONS: Percutaneous ultrasound-guided infraclavicular axillary artery access with preclosing modification seems feasible and safe. The access related complication rate is low and complications can potentially be managed by endovascular means.

Outcome of endovascular revascularisation in patients with acute obstructive mesenteric ischaemia - a single-centre experience.

BACKGROUND: Acute embolic or thrombotic mesenteric ischaemia (AMI) is a rare but life-threatening clinical condition. Despite diagnostic and therapeutic advances, the mortality rate remains high, between 60 % and 90 %. Over the last years revascularisation was increasingly performed by endovascular techniques. The aim of this study was to retrospectively analyse the clinical outcome of catheter-directed thrombolysis (CDT) and aspiration thrombectomy (AT) in patients with AMI with regard to technical success, intervention-related complication rate, need for secondary abdominal surgery, clinical course and 30-day mortality rate. PATIENTS AND METHODS: Thirteen patients (4 men, 9 women; mean age 74.5 ± 17 years) with 12 embolic and one thrombotic occlusion of the superior mesenteric artery (SMA) underwent emergent endovascular revascularisation of SMA. Clinical data including all imaging reports, laboratory analysis and follow-up data were derived from the electronic patient file and images were reviewed on a Picture Archiving and Communication System. RESULTS: Eleven patients (n = 11; 84.6 %) underwent CDT and AT, and two patients (n = 2; 15.4 %) had AT alone. Technical success with complete restoration of SMA perfusion was achieved in 38.5 % (n = 5). Adjunctive angioplasty ± stenting was mandatory in 2 patients. Overall, the intervention-related complication rate was 38.5 %. In total, 46.2 % (n = 6) clinically improved following the intervention, while 38.5 % required explorative laparotomy after the intervention, with 2 colectomies and 2 small bowel resections. Overall, the 30-day mortality rate was 30.8 %. CONCLUSIONS: Endovascular revascularisation with CDT in combination with AT is feasible, with a technical success rate of 38.5 % (n = 5). Endovascular revascularisation was beneficial for 46.2 % (n = 6) of the patients, who clinically improved following the intervention. The need for secondary explorative laparotomy was rather low, with 38.5 % (n = 5) of the patients. The 30-day-mortality remains high with 30.8 %.

Comparing percutaneous primary and secondary biliary stenting for malignant biliary obstruction: A retrospective clinical analysis.

PURPOSE: Percutaneous transhepatic primary biliary stenting (PS) is an alternative to the widely used staged procedure (secondary biliary stenting, SS) for treating obstructive jaundice in cancer patients. To evaluate the efficacy and safety of PS and SS, a retrospective analysis was carried out. MATERIALS AND METHODS: The percutaneous biliary stenting procedures performed between January 2000 and December 2007 at one hepatobiliary center were retrospectively analyzed, comparing the technical success rates, complications, and length of hospitalization of the two procedures. Of 61 patients (mean age 65.5 ± 13.1 years; range 31.1-92.7 years) suffering from obstructive jaundice caused by primary or metastatic tumors, 30 received PS and 31 received SS. The groups were comparable in the anatomical level of the obstruction, stent configuration, or the concurrent presence of cholangitis. Placement of metallic stents required one session for patients in the PS group and an average of 2.6 ± 1.1 sessions for patients in the SS group. RESULTS: The overall technical success rate was 98.4% with 1 (1/61) failed approach to transcend the occlusion in the SS group. The rate of minor complications was 10% in the PS group and 6.5% in the SS group. The corresponding rates of major complications were 23.3% and 54.8%, respectively. SS patients had a higher rate of complications in general (P < 0.05), as well as a higher rate of severe complications in particular (P < 0.05). Procedural mortality was 0% for both the groups. The mean overall length of hospitalization was 7.7 ± 9.6 days for PS and 20.6 ± 19.6 days for SS (P < 0.001). CONCLUSION: Primary percutaneous biliary stenting of malignant biliary obstructions is as efficacious and safer than a staged procedure with secondary stenting. By virtue of requiring shorter hospital stays, primary stenting is likely to be more cost-effective.

Sclerotherapy of lymphatic cysts of the leg with OK-432.

Lymphatic cysts can either represent lymphatic malformations (LMs) or may occur after trauma or operation. Independent of their etiology lymphatic cysts can cause functional impairment and recurrent skin infections. We report the successful use of OK-432 injected transcutanously to treat lymphatic macrocysts. Treatment of LMs with OK-432 has been reported to be a safe and minimally invasive procedure. The underlying mechanism is still unclear but injection leads to an inflammation of the wall resulting in occlusion or shrinkage of the cyst.

CT-guided navigation of percutaneous hepatic and renal radiofrequency ablation under high-frequency jet ventilation: feasibility study.

PURPOSE: Computed tomography (CT)-guided navigation during percutaneous radiofrequency (RF) ablations of liver and kidney lesions is hampered by respiratory motion and time-dependent lesion conspicuity after contrast agent injection. Therefore, target immobilization by general anesthesia with high-frequency jet ventilation (HFJV) instead of conventional ventilation (CV) with repeated breath-holds may facilitate and speed up navigation of RF ablation probes. MATERIALS AND METHODS: Nineteen consecutive patients who underwent percutaneous RF ablation of liver (n = 9) or renal tumors (n = 10) with CT guidance under HFJV (n = 9) or CV (n = 10) were included. The choice of the anesthesiologic technique was left to the discretion of the interventionalist. Complexity of the intervention (ie, number of lesions ablated per session, conspicuity of the lesion on nonenhanced CT, and access pathway), volume of the ablated tissue, radiation exposure, and complications were compared between the HFJV and CV groups. RESULTS: In this feasibility study, a statistically significant radiation dose reduction (P < .05) was noted in the HFJV group compared with the CV group for liver and renal RF ablation. No complications were observed in the HFJV group, whereas renal subcapsular hematoma (n = 2) and pulmonary embolism (n = 1) occurred in the CV group. CONCLUSIONS: Percutaneous CT-guided navigation of RF ablation probes under HFJV is feasible and safe. It might be advantageous for the treatment of complex kidney and liver tumors, allowing less irradiation exposure to the patient and the interventional radiologist.

Midterm outcome of endovascular repair of ruptured isolated iliac artery aneurysms.

PURPOSE: This study analyzed the clinical and morphologic outcomes of endovascular treatment of ruptured isolated iliac artery aneurysms (RIIAA) at midterm follow-up. METHODS: Eleven patients with RIIAA (1 woman, 10 men; mean age, 73 years; mean IIAA diameter, 69.1 mm) were identified in a single-center database of patients who underwent endovascular aortoiliac aneurysm repair between April 2001 and December 2009. Devices inserted included 9 leg endografts in 7 patients (Excluder, n=7; Zenith, n=2), 3 bifurcated stent grafts in 3 patients (Excluder), and 1 aortouniiliac stent graft in 1 patient (Zenith). Endovascular occlusion of the internal iliac artery or its branches was performed in all cases by coils (n=10) or Amplatzer occluder plug (n=1). Immediately after endovascular aneurysm exclusion, a computed tomography (CT) angiography was obtained in nine patients. Except for this adjunct postimplantation CT scanning, the imaging follow-up was the same as for nonruptured aortoiliac aneurysms at 3, 6, and 12 months and annually thereafter. RESULTS: Mean delay from hospital admission to intervention was 78.5 minutes. Mean intervention time was 150 minutes. The assisted primary technical success rate was 100%. Median lengths of stay were 2 days in the intensive care unit and 13 days in the hospital. Abdominal compartment syndrome developed in three patients who received open abdomen treatment. The 30-day mortality was 18%. The mean follow-up was 23 months (range, 0-69 months). There were no late deaths during the follow-up. There was no need for late surgical conversion. Aneurysm sac shrinkage (defined as >5 mm) was recorded in five patients, whereas the sac diameter remained stable in four. There was no patient with aneurysm sac growth. Additional stent graft insertion as the only secondary intervention for a type Ib leak was performed. Type II endoleaks (primary and secondary) were found in 36% and secondary Ib in 9% of the patients. CONCLUSION: Emergency stent grafting of RIIAA is feasible and safe with good midterm outcome.

Complete endovascular renal and visceral artery revascularization and exclusion of a ruptured type IV thoracoabdominal aortic aneurysm.

PURPOSE: To present a technique for renal and visceral revascularization allowing complete endovascular treatment of a ruptured type IV thoracoabdominal aneurysm using devices already stocked in most centers performing endovascular aneurysm repair. TECHNIQUE: Open arterial access is obtained to both common femoral arteries and the left subclavian artery (LSA). Access to the visceral and renal arteries is obtained through separate 8-F sheaths for each visceral and renal branch. Both visceral arteries (celiac trunk and superior mesenteric artery) are accessed through 2 separate sheaths placed into the LSA, and both renal arteries are accessed through 2 separate sheaths placed into the left common femoral artery. Corresponding covered stents are introduced and positioned in the celiac trunk, superior mesenteric artery, and both renal arteries but not deployed. The aortic stent-graft is then introduced and deployed through the right common femoral artery. Once the aneurysm exclusion is completed, the stent-grafts to the branches are deployed so that they are positioned between the aortic wall and the aortic stent-graft. Finally, the branch stent-grafts as well as the aortic stent-graft are fully expanded with balloon catheters inflated simultaneously as in the kissing balloon technique. CONCLUSION: To our knowledge, no one has reported using this technique to successfully treat a ruptured thoracoabdominal aneurysm and revascularize all 4 major renovisceral arteries. A main advantage of this technique over use of branched stent-grafts is that it can be performed even in the emergency setting with devices that are in stock in most institutions performing endovascular aneurysm exclusion.

A "Buddy Wire" technique for successful OptEase filter retrieval.

The present report describes a transfemoral, single-access OptEase filter retrieval technique that takes advantage of its particular two-level mirrored umbrella design. By threading a stiff "buddy" guide wire through the device, the filter is aligned to the long vena cava axis. This technique separates the retrieval hooklet from the adjacent venous wall, thereby facilitating its snaring. This simple technique has been successful in 10 patients after a failed standard retrieval attempt. In this series of 118 consecutively placed OptEase filters, the overall filter retrieval rate increased from 72% to 80% with this maneuver, and the rate of successful intended retrieval increased from 83% to 93%.

Clinical comparison of two optional vena cava filters.

PURPOSE: To compare the clinical safety and efficiency of two optional inferior vena cava (IVC) filters. MATERIAL AND METHODS: Ninety-three consecutive Günther Tulip filters (92 patients) were compared with 83 consecutive OptEase filters (80 patients). Filters were placed at the same institution in patients with high-risk multiple trauma or those undergoing neurosurgery with contraindications to primary prophylaxis (70 patients in the Günther Tulip group and 44 in the OptEase group) and in patients with venous thromboembolism and contraindications to anticoagulation (22 patients in the Günther Tulip group and 36 in the OptEase group). The filters were placed in an angiography suite. Catheter vena cavography was performed before filter placement and intended retrieval. Permanent filters were followed-up with duplex ultrasonography and conventional radiography. RESULTS: All filters were inserted infrarenally without any complications. Fluoroscopy times for placement and retrieval were longer for the Günther Tulip group than the OptEase group. The mean dwelling time was 11 days (range, 3-27 days) for the Günther Tulip filters and 13.8 days (range, 1-34 days) for the OptEase filters. No symptomatic pulmonary emboli (PE) occurred in patients with intended temporary filtration while the devices were in place. Forty-six of the 93 Günther Tulip filters (49%) and 58 of the 83 OptEase filters (70%) were removed. Two Günther Tulip filters could not be retrieved for technical reasons. The mean follow-up for the permanent Günther Tulip (n = 19) and OptEase (n = 8) filters was 41 and 7 months, respectively. One patient from each group had late caval thrombosis. There were no cases of filter migration or disintegration. CONCLUSION: Both optional IVC filters are safe and seem to prevent symptomatic PE. On the basis of the fluoroscopy times, the OptEase filters appear to be more operator-friendly. Late filter-associated complications are rare with these filter designs.