National Diagnostic Reference Levels for Standard Descending Thoracic Endovascular Aortic Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection has highlighted the large number of medical specialties that use fluoroscopy outside diagnostic imaging departments without radiation protection programmes for patients and staff. Vascular surgery is one of these specialties. Thoracic endovascular aortic repair (TEVAR) is a complicated procedure requiring radiation protection guidance and optimisation. The recent EU Basic Safety Standards Directive requires the use and periodic updating of diagnostic reference levels (DRLs) for interventional procedures. The aim of this study was to determine doses for patients undergoing TEVAR with mobile Xray systems and hybrid rooms (fixed Xray systems) to obtain national DRLs and to suggest optimisation actions. METHODS: This was a retrospective cross sectional study. The Spanish Chapter of Endovascular Surgery conducted a national survey in 11 autonomous communities representing around 77.6% of the Spanish population (47.33 million inhabitants). A total of 266 TEVAR procedures from 17 Spanish centres were analysed, of which 53.0% were performed in hybrid operating rooms. National DRLs were obtained and defined as the third quartile of the median values from the different participating centres. RESULTS: The proposed national DRLs are: for kerma area product (KAP), 113.81 Gy·cm2 for mobile Xray systems and 282.59 Gy·cm2 for hybrid rooms; and for cumulative air kerma (CAK) at the patient entry reference point, 228.38 mGy for mobile systems and 910.64 mGy for hybrid rooms. CONCLUSION: Based on the requirement to know radiation doses for standard endovascular procedures, this study of TEVARs demonstrated that there is an increased factor of 2.48 in DRLs for KAP when the procedure is performed in a hybrid room compared with mobile C-arm systems, and an increased factor of 3.98 in DRLs for CAK when the procedure is performed with hybrid equipment. These results will help to optimise strategies to reduce radiation doses during TEVAR procedures.

Optimizing Venous Stenting: Consensus Recommendations for Enhanced Management of Lower Extremity Deep Vein Thrombosis.

INTRODUCTION: Deep vein thrombosis (DVT) poses a complex challenge and often leads to postthrombotic syndrome (PTS), a debilitating complication. The emergence of venous stents offers a potential preventive avenue against this complication. This study aimed to provide consensus recommendations on the use of venous stent for DVT. MATERIALS AND METHODS: From June to July 2023, 20 internal medicine, angiology and vascular surgery, and vascular and interventional radiology experts were involved in the Delphi process. Thirty-one recommendations, categorized into three thematic areas, were rigorously evaluated: indications for stent use, stent selection and placement, and monitoring and prevention of complications. Agreement was evaluated using a Likert scale, with consensus defined as agreement by two-thirds of the participants. RESULTS: Consensus was reached for 23 (74.2%) of 31 recommendations. The agreement was centered on considerations, such as stent placement in specific acute DVT scenarios, emphasizing pivotal stent characteristics. However, there were divergences in the recommended stent length to prevent migration and stent characteristics based on iliocaval bifurcation morphology. Notably, there was no consensus on whether patients with DVT caused by a major transient risk factor need more than 3 months of anticoagulation therapy or whether aspirin should be added to anticoagulant treatment after venous stenting. CONCLUSIONS: These consensus recommendations offer practical insights into optimizing venous stent use to prevent PTS in DVT patients. Addressing the critical aspects of stent selection, placement, and postprocedural care, these recommendations contribute to clinical decision-making. The identified divergences underscore the importance of consensus and thus indicate the need for further investigation.

International Union of Angiology consensus document on vascular compression syndromes.

Vascular compression syndromes (VCS) are rare diseases, but they may cause significant symptoms interfering with the quality of life (QoL) of patients who are often in their younger age. Given their infrequent occurrence, multiform clinical and anatomical presentation, and absence of dedicated guidelines from scientific societies, further knowledge of these conditions is required to investigate and treat them using modern imaging and surgical (open or endovascular) techniques. This consensus document will focus on known VCS, affecting the arterial and venous system. The position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, will show an overview of pathophysiology, diagnostic, and therapeutical approaches for patients with VCS. Furthermore, this document will provide also unresolved issues that require more research that need to be addressed in the future.

Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures.

PURPOSE: Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. TECHNIQUE: The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under "rapid pacing." As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. CONCLUSION: The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. CLINICAL IMPACT: Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures.

Skin and Arterial Wall Deposits of 18F-NaF and Severity of Disease in Patients with Pseudoxanthoma Elasticum.

Pseudoxanthoma elasticum (PXE) is a genetic disease characterized by the calcification of elastin fibers. Our aim was to quantify vascular calcification in the arteries and the deposition of 18F-sodium-fluoride (18F-NaF) in the skin and vessel walls with positron emission tomography/computed tomography. This was an observational study including 18 patients with PXE. Vascular calcification was measured in Agatston units, and deposition in the skin and vessel walls was shown using target-to-background ratio (TBR). Severity of the disease was scored by Phenodex. We found higher vascular calcification in the popliteal, femoral, and aortic arch vessels compared to other vascular regions; however, the uptake of radiotracer was the highest in the aorta and femoral arteries. In the skin, the highest uptake was observed in the neck and the axillae. There was no significant association between 18F-NaF deposition in the arteries or skin and the global Phenodex score. In contrast, the Phenodex score was significantly associated in univariate analyses with the averaged vascular calcium score (p < 0.01). In the neck, patients with higher skin Phenodex scores exhibited higher radiotracer uptake. As a conclusion, because vascular calcification is physiological, our data suggested that the detection of cutaneous (neck) 18F-NaF deposits might serve to monitor the calcification process in the short-term for patients with PXE.

A Rare Case of Ischemia-Reperfusion Injury After Mesenteric Revascularization.

Endovascular treatment of chronic mesenteric ischemia is currently the treatment of choice, regardless of the number of involved vessels. Unlike other anatomic areas, the hyperperfusion produced by revascularization and the consecutive reperfusion syndrome is only described in cases of acute bowel ischemia, which is usually resolved with traditional surgery. We present a case of severe hyperperfusion syndrome secondary to endovascular correction with stents of a critical ischemia affecting the celiac trunk and superior mesenteric artery.

Endovascular treatment of posterior nutcracker syndrome with a new autoexpandable stent.

The endovascular treatment of nutcracker syndrome is currently considered by some to be the preferred treatment option in this pathologic process despite its risks. However, currently, there are few data about the pure endovascular approach in the posterior nutcracker syndrome related to evolution in the midterm. We present two successful cases of a complete endovascular approach in this disease, with follow-up of 9 months and 17 months without complications.

Endovascular Treatment of Complex Carotid-Jugular Fistula.

Inadvertent complications of jugular vein catheterization are not uncommon, however, a persistent symptomatic carotid-jugular fistula has been rarely reported. A 72-year-old male with infected surgical wound after coxofemoral disarticulation for sarcoma presented with symptoms of acute right heart failure. A fistula between the right common carotid artery (CCA) and the internal jugular vein was demonstrated on Doppler ultrasound and confirmed on computed tomography angiogram. Catheterization of the right CCA seemed not possible using a conventional femoral approach due to the tortuosity and elongation of the brachiocephalic artery. A small incision in the right temporal area was used to access the superficial temporal artery and a wire was advanced retrograde into the aorta where it was snared from below, allowing for successful treatment of the fistula with a covered stent. This alternative technique may facilitate safe and stable carotid artery stenting even in patients with a severely tortuous access route due to atherosclerotic disease.

Cell viability evaluation of transdifferentiated endothelial-like cells by quantitative electron-probe X-ray microanalysis for tissue engineering.

Development of an efficient vascular substitute by tissue engineering is strongly dependent on endothelial cell viability. The aim of this study was to evaluate cell viability of transdifferentiated endothelial-like cells (Tr-ELC) by using for the first time electron probe X-ray microanalysis (EPXMA), not only to accurately analyze cell viability by quantifying the intracellular ionic concentrations, but also to establish their possible use in vascular tissue engineering protocols. Human umbilical cord Wharton's jelly stem cells (HWJSC) and endothelial cells from the human umbilical vein (HUVEC) were isolated and cultured. Transdifferentiation from HWJSC to the endothelial phenotype was induced. EPXMA was carried out to analyze HUVEC, HWJSC and Tr-ELC cells by using a scanning electron microscope equipped with an EDAX DX-4 microanalytical system and a solid-state backscattered electron detector. To determine total ion content, the peak-to-local-background (P/B) ratio method was used with reference to standards composed of dextran containing known amounts of inorganic salts. Our results revealed a high K/Na ratio in Tr-ELC (9.41), in association with the maintenance of the intracellular levels of chlorine, phosphorous and magnesium and an increase of calcium (p=0.031) and sulfur (p=0.022) as compared to HWJSC. Calcium levels were similar for HUVEC and Tr-ELC. These results ensure that transdifferentiated cells are highly viable and resemble the phenotypic and microanalytical profile of endothelial cells. Tr-ELC induced from HWJSC may fulfill the requirements for use in tissue engineering protocols applied to the vascular system at the viability and microanalytical levels.

Endovascular treatment of a symptomatic vertebral artery pseudoaneurysm.

A 35-year-old patient was brought to the emergency department referring dysarthria, left ear tinnitus for 5 min, and short-lasting blindness, with headache in the 45 min before the clinical presentation. In the magnetic resonance imaging, an acute-subacute lesion in the cerebellum right-anterior lobe (in the territory of the cerebellum anterior artery) and a dilatation near the ostium of the right vertebral artery were seen. For a better assessment, an Angio-CT was done, showing a 9-mm saccular pseudoaneurysm of the right vertebral artery close to the origin of the vessel, without being able to determine if it had been caused because of a dissection. The rest of the study (cerebral vessels and supra-aortic vessels) showed no disorders. He was operated under local anesthesia and sedation a week after the onset of the symptoms. Through a 0.014 wire, a Biotronik PK Papyrus balloon-expandable covered cobalt-chromium stent was deployed covering the hole in the artery. Antiplatelet drugs were prescribed, and the patient was discharged 24 hr after surgery. He has remained symptom free since then.

[Preliminary analysis of the relationship between peripheral arterial disease and other atherosclerosis markers and diabetic nephropathy]. / Análisis preliminar de la relación de la enfermedad arterial periférica y otros marcadores de la arteriosclerosis con la nefropatía diabética.

OBJECTIVES: To determine lipid serum levels, lipoproteins and other markers related to nephropathy and peripheral arterial disease (PAD) in a type 2 diabetes population stratified according to their level of renal dysfunction. METHODS: A cross-sectional study was conducted on 72 type 2 diabetic patients followed-up in outpatient clinics. Patients were divided into 4 groups according to their estimated glomerular filtration rate (eGFR, mL/min) and albumin/creatinine ratio (ACR, mg/g) (eGFR > 60 and ACR < 30 [n = 23], eGFR > 60 and ACR > 30 [n = 12], eGFR30-60 [n = 23] and eGFR < 30 [n = 14]). Clinical and anthropometric characteristic of all patients were recorded. Fasting lipids and apolipoproteins, as well as renal and hematology parameters were measured. Finally, a multivariate Wald stepwise logistic regression statistic analysis was performed to determine variables independently associated with the presence of renal dysfunction. RESULTS: The univariate statistical analysis showed that the higher renal dysfunction, the higher the prevalence of hypertension, smoking habit and triglycerides levels, and the lower hemoglobin levels (P < .05). The multivariate statistical analysis showed that only triglycerides levels (OR: 1.019, 95% CI: 1.004-1.034) and hemoglobin levels (OR: 0.516 95% CI: 0.292-0.914) were independently associated to the presence of renal dysfunction (eGFR < 60 mL/min.). The further inclusion of the presence of PAD in the statistical model did not modify those associations. CONCLUSION: The results confirm the relationship between triglycerides levels and diabetic nephropathy, independently of the presence of PAD.

Femoro-saphenous arteriovenous access-related lower limb ischemia treated by distal arteries percutaneous angioplasty.

This is the first reported case of transposed femoro-saphenous angio-access complicated after four years by distal ischemia, which was successfully treated by percutaneous transluminal angioplasty (PTA) of the distal femoral and popliteal artery. Endovascular recanalization and angioplasty of the distal vessels offers a minimally invasive approach with preservation of the angio-access in these patients with high comorbidities.

Atypical Vascular Involvement in a Case of Behçet's Disease.

Introduction. Behçet's disease (BD) is a form of vasculitis of unknown etiology which is rare in our environment. It is characterized by a variety of clinical manifestations and usually affects young adults. Recurrent oral and genital ulcers are a characteristic and extremely frequent symptom, but mortality is linked with more significant symptoms such as aortic pseudoaneurysm, pulmonary pseudoaneurysm, and cerebral venous thrombosis. Patient and Method. We present a case of a young male with atypical BD and severe polyvascular involvement (previous cerebral venous thrombosis and current peripheral venous thrombosis, acute ischemia, and peripheral arterial pseudoaneurysm) who required urgent surgical intervention due to a symptomatic external iliac pseudoaneurysm. Result. The pseudoaneurysm was successfully treated, we performed an iliofemoral bypass, and we treated it with steroids and immunosuppressive therapy. Conclusions. These rare clinical manifestations highlight the importance of considering BD in young patients, even in usual cases of vascular intervention, whether arterial or venous in nature.