Aspiration Thrombectomy-Assisted Endovascular Retrieval of an Embolized Angio-Seal Device Causing Claudication.

The Angio-Seal vascular closure device is used to reduce time to hemostasis after femoral artery puncture. Although rare, complications associated with Angio-Seal are significant, including infection, pseudoaneurysm formation, symptomatic femoral artery stenosis, and separation and embolization, leading to limb-threatening ischemia. This report describes Angio-Seal polymer anchor embolization to the tibioperoneal trunk successfully retrieved using the 8-French Indigo Aspiration System.

Total endovenous recanalization and stent reconstruction for naïve non-inferior vena cava filter-associated chronic iliocaval occlusive disease: Placement of 352 venous stents in 69 debilitated patients.

The aim of this study was to report the technical success, adverse events, clinical outcomes, and long-term stent patency of iliocaval stent reconstruction for naïve, non-inferior vena cava (IVC) filter-related, chronic iliocaval thrombosis. A total of 69 patients, including 47 (68%) men, with a mean age of 36 years (range: 8-71 years), underwent first-time iliocaval stent reconstruction for non-IVC filter-associated iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.2 (range: 0-5), including 30 (43%) patients with IVC atresia. Upon initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification was C3 in 55 (80%) patients, C4 in four (5.8%) patients, C5 in one (1.4%) patient, and C6 in seven (10%) patients. Technical aspects of stent reconstruction, technical success, adverse events, 2-week and 6, 12, and 24-month clinical response, and 6, 12, and 24-month primary, primary-assisted, and secondary stent patency rates were recorded. Technical success was defined as recanalization and stent deployment. Adverse events were reported according to the Society of Interventional Radiology classification system. Clinical success was defined as a 1-point decrease in CEAP classification and stent patency was defined by the Cardiovascular and Interventional Radiological Society guidelines. The technical success rate was 100%. There were 352 venous stents deployed during stent reconstructions. One (1.4%) severe, four (5.8%) moderate, and four (5.8%) minor adverse events occurred and median post-procedure hospitalization was 1 day (range: 1-45 days). Clinical success at 2 weeks and 6, 12, and 24 months was 76%, 85%, 87%, and 100%, respectively. The estimated 6, 12, and 24-month primary patency rates were 91%, 88%, and 62%, respectively. The estimated 6, 12, and 24-month primary-assisted patency rates were 98%, 95%, and 81%, respectively. The estimated 6, 12, and 24-month secondary-assisted patency rates were all 100%. In conclusion, iliocaval stent reconstruction is an effective treatment for non-IVC filter-associated chronic iliocaval thrombosis with high rates of technical success, clinical responses, and stent patency.

Interventional Radiology-Operated Endoscopy as an Adjunct to Image-Guided Interventions.

PURPOSE: Interventional radiology-operated endoscopy is an underused technique, which may have a significant impact on the ability to treat patients with a variety of conditions. The purpose of this article is to discuss the setup, equipment, and potential clinical uses of interventional radiology-operated endoscopy. METHODS: A number of new and innovative interventions may be performed in the biliary, genitourinary, and gastrointestinal systems through percutaneous access that interventional radiologists already create. When used in combination, endoscopy adds an entirely new dimension to the fluoroscopic-guided procedures of which interventional radiologists are accustomed. RESULTS: Interventional radiologists are in a unique position to implement endoscopy into routine practice given the manual dexterity and hand-eye coordination already required to perform other image-guided interventions. CONCLUSION: Although other specialists traditionally have performed endoscopic interventions and local politics often dictate referral patterns, a collaborative relationship among these specialists and interventional radiology will allow for improved patient care. A concerted effort is needed by interventional radiologists to learn the techniques and equipment required to successfully incorporate endoscopy into practice.

Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) placement has been extensively studied in adults. The experience with TIPS placement in pediatric patients, however, is limited. OBJECTIVE: The purpose of this study was to report technical success and clinical outcomes in pediatric patients undergoing TIPS placement. MATERIALS AND METHODS: Twenty-one children - 12 (57%) boys and 9 (43%) girls, mean age 12.1 years (range, 2-17 years) - underwent TIPS placement from January 1997 to January 2017. Etiologies of hepatic dysfunction included biliary atresia (n=5; 24%), cryptogenic cirrhosis (n=4; 19%), portal or hepatic vein thrombosis (n=4, 14%), autosomal-recessive polycystic kidney disease (n=3; 14%), primary sclerosing cholangitis (n=2; 10%) and others (n=3, 14%). Indications for TIPS placement included variceal hemorrhage (n=20; 95%) and refractory ascites (n=1; 5%). Technical success, manometry findings, stent type, hemodynamic success, complications, liver enzymes, and clinical outcomes were recorded. RESULTS: TIPS placement was technically successful in 20 of 21 (95%) children, with no immediate complications. Mean pre- and post-TIPS portosystemic gradient was 18.5±10.7 mmHg and 7.1±3.9 mmHg, respectively. Twenty-two total stents were successfully placed in 20 children. Stents used included: Viatorr (n=9; 41%), Wallstent (n=7; 32%), Express (n=5; 23%), and iCAST (n=1; 5%). All children had resolution of variceal bleeding or ascites. TIPS revision was required in 9 (45%) children, with a mean of 2.2 revisions. Hepatic encephalopathy developed in 10 children (48%), at a mean of 223.7 days following TIPS placement. During the study, 6 (29%) children underwent liver transplantation. CONCLUSION: TIPS placement in pediatric patients has high technical success with excellent resolution of variceal hemorrhage and ascites. TIPS revision was required in nearly half of the cohort, with hepatic encephalopathy common after shunt placement.

Trends in Interventional Radiology Through the Eye of the Journal of Vascular and Interventional Radiology: A 27-Year History.

PURPOSE: To report the quantity, manuscript types, geographic distribution of publications, and published content trends in a major interventional radiology journal over 27 years. MATERIALS AND METHODS: Available publication data from the Journal of Vascular and Interventional Radiology was collected via Scopus from November 1990 to November 2017. Quantity, manuscript type, geographic distribution, number of citations, and publication content were analyzed. RESULTS: 6925 papers were published in JVIR during the study period. The number of publications increased by 234% from an average of 103 publications/year in the first 5 years to 344 publications/year in the last 5 years. Manuscript types included 4891 original articles (70.6%), 987 letters (14.3%), 360 review articles (5.2%), 324 notes (4.7%), 167 conference papers (2.4%), 102 editorials (1.5%), 61 errata (0.9%), 23 articles in press (0.3%), and 10 short surveys (0.1%). The majority of publications originated in the United States with 3945 articles (57.0%), followed by Canada with 366 articles (5.3%), and Japan and South Korea with 360 (5.2%) and 340 articles (4.9%), respectively. As for article content, arterial disease and interventions were discussed in 2256 publications (32.6%), followed by venous (1237; 17.9%), miscellaneous (1072; 15.5%), oncology (1006; 14.5%), genitourinary (758; 10.9%), portal (337; 4.9%), neurovascular (253; 3.7%), gastrointestinal (232; 3.4%), biliary (210; 3.0%), pediatric (130; 1.9%), clinical trials (119; 1.7%), and guideline development (119; 1.7%). CONCLUSION: There has been a marked increase in the number of publications in JVIR over 27 years. JVIR has shown continued growth since its inception and has strengthened its international reputation with more global research than ever before.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study.

PURPOSE: Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation. MATERIALS AND METHODS: 406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ±â€¯15 years (range: 18-88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success. RESULTS: Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9-1353 days). CONCLUSION: Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Approach, Technical Success, Complications, and Stent Patency of Sharp Recanalization for the Treatment of Chronic Venous Occlusive Disease: Experience in 123 Patients.

PURPOSE: To report the technical success and complications following sharp recanalization of chronic venous occlusions. MATERIALS AND METHODS: A total of 123 patients, including 75 (61.0%) men and 48 (39.0%) women, with mean age of 50.5 ± 17.5 years (range 19-90 years), underwent sharp recanalization of chronic venous occlusions. The etiologies of occlusion were chronic deep venous thrombosis (n = 43; 35.0%), prior central venous access (n = 39; 31.7%), indwelling cardiac leads (n = 21; 17.1%), and occluded venous stents (n = 20; 16.3%). The sites of venous occlusion included 59/123 (48.0%) thoracic central veins, 37 (30.1%) non-thoracic central veins, and 27 (22.0%) peripheral veins. Median length of occlusion was 3.2 ± 1.4 cm (range 1.3-10.9 cm). RESULTS: Sharp recanalization was most commonly attempted with transseptal needles in 108/123 (87.8%), with a mean number of 1.2 ± 0.4 crossing devices per patient (range 1-4 devices). Targeting devices included a loop snare (n = 92; 74.8%), partially deployed Wallstent (n = 21; 17.1%), partially deployed Amplatzer vascular plug (n = 8; 6.5%), and an angioplasty balloon (n = 3; 2.4%). Technical success was achieved in 111 (90.2%) patients. There were 3 (2.4%) severe, 1 (0.8%) moderate, and 7 (5.7%) minor adverse events. Severe adverse events included 1 case each of pericardial tamponade, hemothorax, and inferior vena cava filter occlusion. 88 (71.5%) patients had venous stents placed; at the last follow-up examination, 68/86 (79.0%) stents were patent. CONCLUSION: Sharp recanalization has a high technical success and low rate of adverse events in the recanalization of chronic venous occlusions.

Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training.

PURPOSE: To create a three-dimensional endoscopic model of the biliary tract from magnetic-resonance cholangiopancreatography imaging and to evaluate its effectiveness as a tool for training in endoscopic biliary interventions. MATERIALS AND METHODS: A magnetic-resonance cholangiopancreatography study was performed on a patient with biliary obstruction secondary to a distal bile duct cholangiocarcinoma. Using Vitrea, a three-dimensional volume-rendered image was created, and exported as a standard tessellated language file. The standard tessellated language model was then edited with MeshMixer. Three cylindrical entry ports were created. The ports were aligned and overlapped with the dominant ducts in three separate areas of the model and fused to the model. A 0.2 cm shell was created around the model and the model was hollowed. The ends of the ports were cut off, allowing access to the hollowed-out model. The model was printed at 125% scale to allow easy access with a 9.5-French (≤3.23 mm) endoscope. The model was printed using a Stratasys Dimension Elite Plus printer. After printing, the model was post-processed to remove support materials. A 10-question survey was administered to all trainees before and after use of the printed phantom to practice endoscopy skills. RESULTS: 11 trainees participated in the three-dimensional endoscopy simulation with most of the trainees (73%) having no prior formal endoscopy training. Using a 10-point Likert scale, the mean comfort-level of the trainees to use endoscopy alone for cholecystostomy, percutaneous biliary drainage, percutaneous nephrostomy, and percutaneous gastrostomy increased by 38.9%, 32.8%, 32.8%, and 34.3%, respectively, following the training experience. CONCLUSION: The use of a three-dimensionally printed endoscopic model as a simulation tool has the potential to improve trainee comfort using endoscopy during interventional radiology procedures.

Vascular and lymphatic complications after thoracic duct cannulation.

OBJECTIVE: The objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation. METHODS: There were 58 patients who underwent attempted thoracic duct cannulation. Patients presented with chyle leak in the chest (n = 40), abdomen (n = 9), neck (n = 8), and pelvis (n = 1). Vertebral body level and geographic access, needle gauge, additional access for treatment, technical success, intervention performed, immediate and delayed complications, and follow-up duration were recorded. Imaging and electronic medical records were reviewed at follow-up for complications and treatment success. RESULTS: Access into the lymphatic system was obtained at L1 (n = 21), T12 (n = 17), L2 (n = 14), L3 (n = 3), T11 (n = 1), L4 (n = 1), and L5 (n = 1). Lymphatic access was achieved in the center (n = 28), on the right (n = 16), or on the left (n = 14) of the vertebral body; 21-, 22-, and 25-gauge needles were used in 45 patients, 12 patients, and 1 patient, respectively. Arm venous and percutaneous supraclavicular access was successful in 15 patients and eight patients, respectively. Cannulation of the thoracic duct was achieved in 52 (89.7%) patients. Embolization, disruption, and stenting were performed in 41 (70.7%), 12 (20.7%), and 2 (3.4%) patients; 3 (5.2%) patients had normal thoracic ducts after successful cannulation. Immediate complications consisted of shearing of the access wire in two (3.4%) patients. Retrospective analysis of initial follow-up imaging in 49 (84.5%) patients revealed the following late complications: inferior vena cava and right renal vein thrombosis and one perinephric lymphatic collection. CONCLUSIONS: Of 58 patients who had attempted thoracic duct cannulation, successful access was achieved in 90% of patients. Early and delayed complications occurred in 3.4% and 4% of patients, respectively. Thoracic duct cannulation represents a highly successful technique that aids in the treatment of chyle leaks in medically complex patients.

Prone transradial catheterization for combined single-session endovascular and percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients.

PURPOSE: We aimed to report approach, safety, technical success, and clinical outcomes of prone trans- radial access (PTRA) and demonstrate feasibility for procedures requiring simultaneous arterial intervention and prone percutaneous access. METHODS: Fifteen patients underwent PTRA, seven females (47%) and eight males (53%), mean age of 55 years (range, 19-78 years). All patients underwent PTRA for combined transarterial and posterior-approach percutaneous interventions. Variables included sheath size (French, F), type of anesthesia, arterial intervention technical success, posterior-approach percutaneous intervention technical success, estimated blood loss (mL), fluoroscopy and procedure time, complications, and follow-up. RESULTS: Mean sheath size was 4 F (range, 4-6 F; SD = 0.5). Arterial interventions included transarterial embolization of renal (n=6), hepatic (n=2), and pelvic vessels (n=2), diagnostic arteriography (n=4), and embolization of an arteriovenous malformation (n=1). Posterior-approach intervention technical success was 100% (15/15). PTRA technical success was 100% (15/15). Posterior-approach percutaneous interventions included retroperitoneal (n=5) and pelvic (n=1) mass biopsies, nephrostomy tube placement (n=2), cryoablation of pelvic (n=2) and renal (n=1) masses, sclerotherapy of arteriovenous malformations (n=2), foreign body removal from the renal collecting system (n=2), ablation of a renal tumor (n=1), intracavitary injection of pulmonary mycetoma (n=1), and ablation and cementoplasty of a vertebral body tumor (n=1). The biopsies were diagnostic (6/6). There were no minor or major access-site complications. CONCLUSION: PTRA is a safe and feasible method for performing combined arterial and posterior approach percutaneous interventions without the need for repositioning.

Bleeding diverticulum of the colon treated with CT-guided percutaneous injection of epinephrine and cyanoacrylate.

Hematochezia may be a result of anatomic, vascular, inflammatory, infectious, or neoplastic diseases. Colonoscopic evaluation and therapy may be limited because of intermittent bleeding in the setting of numerous diverticula. This report describes a patient with diverticulosis who presented with hematochezia and hemodynamic instability with failed colonoscopic and arteriographic evaluations, and was treated with percutaneous transcolonic diverticular cyanoacrylate and epinephrine injection.

Selective Penile Arterial Embolization Preserves Long-Term Erectile Function in Patients with Nonischemic Priapism: An 18-Year Experience.

OBJECTIVE: To report long term outcomes of selective arterial embolization for nonischemic priapism on erectile function utilizing validated outcome questionnaires after selective arterial embolization. MATERIALS AND METHODS: Twenty men, mean age of 36 years (range: 8-58 years), underwent selective penile embolization for nonischemic priapism between December 1997 and February 2016 (218 months). Each identified case of nonischemic priapism was embolized using gelatin sponge, autologous blood clot, platinum microcoils, polyvinyl alcohol particles, or a combination of these. A variety of procedural details, immediate complications, recurrence of nonischemic priapism, post-procedure performance on Sexual Health Inventory for Men and International Index of Erectile Function Questionnaires, and follow-up duration were recorded. RESULTS: Mean time from development of symptoms until treatment was 117 days (range: 1-1,042 days). After selective arterial embolization, nonischemic priapism resolved in 18 (90%) patients. No patients with successful treatment of their nonischemic priapism developed a recurrence of nonischemic priapism during the study period following the initial treatment. Eight (40%) patients experienced ischemic priapism following embolization with 4 (50%) resolving after treatment. Mean post-procedure Sexual Health Inventory for Men score was 22.1 (range: 16-25). Mean post-embolization erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction domains on the International Index of Erectile Function were 25.8 (range: 16-30), 7.8 (range: 6-10), 7.4 (range: 5-10), 10.9 (range: 6-14), and 7.9 (range: 6-10), respectively. Mean follow-up was 4,601 days (range: 970-6,711 days). CONCLUSION: Resolution of nonischemic priapism following selective arterial embolization occurred in 90% of the patients. Two validated questionnaires showed no erectile dysfunction following treatment. Mild orgasmic dysfunction, sexual desire dysfunction, intercourse dissatisfaction, and overall satisfaction dysfunction were noted following treatment.

Balloon tract dilatation facilitates fluoroscopically guided removal of deeply penetrating foreign bodies.

Previous reports describe removal of foreign bodies using image guidance with serial tract dilation or blunt and sharp dissection techniques. This report describes a novel technique utilizing balloon tract dilatation to facilitate the removal of retained radiopaque soft tissue foreign bodies under fluoroscopic guidance. This technique offers a minimally invasive approach for rapid retrieval of deeply penetrating foreign bodies, obviating the need for a large incision or surgical cut down.

#VascularSurgery.

BACKGROUND: To characterize the vascular surgery Twitter network. METHODS: A total of 20,841 consecutive tweets by 8,282 unique Twitter accounts regarding vascular surgery from October 23, 2014 to January 15, 2018 were analyzed. Twitter analytics, including activity metrics, content analysis, user characteristics, engagement, and network analysis were performed using Symplur Signals, a health care social media analytics platform. RESULTS: Vascular surgery tweets, the number of users tweeting about vascular surgery, and vascular surgery tweet impressions have increased by an annual average of 77.8%, 55.3%, and 209.1% from 2015 to 2017, respectively. Twitter activity trend analysis showed consistent growth over the study period with an average of 25.7 ± 2.6 additional tweets per month (P < 0.001). As for tweet content, 2,220 tweets (10.7%) were pertaining to patients, and 2,198 tweets (10.5%) were regarding new or innovative topics. 15,422 tweets (74.0%) included links to journals or websites and 6,826 tweets (32.8%) contained at least 1 image. Deep venous thrombosis, pulmonary embolism, diabetes, endovascular interventions, trauma, and practice guidelines were among the most commonly discussed health topics. Physicians composed 5,618 tweets (27%), while patients submitted 2,447 tweets (11.7%). As for engagement, 8,886 tweets (42.6%) were retweets, 11,816 tweets (56.7%) mentioned at least 1 other user, and 786 tweets (3.8%) were replies. Network analysis revealed central hubs to be vascular surgery societies, academic institutions, academic journals, and physicians. CONCLUSIONS: The use of Twitter to discuss vascular surgery is growing rapidly with increasing use by vascular surgeons and vascular medicine physicians. An effort to involve more patients in the vascular surgery Twitter social network may allow for more opportunities to educate, and garner interest and support for vascular surgery.

Erratum: Pediatric Portal Interventions.

[This corrects the article DOI: 10.1055/s-0038-1642043.].

Contemporary Interventional Radiology Dosimetry: Analysis of 4,784 Discrete Procedures at a Single Institution.

PURPOSE: To report dosimetry of commonly performed interventional radiology procedures and compare dose analogues to known reference levels. MATERIALS AND METHODS: Demographic and dosimetry data were collected for gastrostomy, nephrostomy, peripherally inserted central catheter placement, visceral arteriography, hepatic chemoembolization, tunneled catheter placement, inferior vena cava filter placement, vascular embolization, transjugular liver biopsy, adrenal vein sampling, transjugular intrahepatic portosystemic shunt (TIPS) creation, and biliary drainage between June 12, 2014, and April 26, 2018, using integrated dosimetry software. In all, 4,784 procedures were analyzed. The study included 2,691 (56.2%) male subjects and 2,093 (43.8%) female subjects with mean age 55 ± 21 years (range: 0-104 years) and with mean weight of 76.9 ± 29.4 kg (range: 0.9-268.1 kg). Fluoroscopy time, dose area product (DAP), and reference dose were evaluated. RESULTS: TIPS had the highest mean fluoroscopy time (49.1 ± 16.0 min) followed by vascular embolization (25.2 ± 11.4 min), hepatic chemoembolization (18.8 ± 12.5 min), and visceral arteriography (17.7 ± 3.2 min). TIPS had the highest mean DAP (429.2 ± 244.8 grays per square centimeter [Gy·· cm2]) followed by hepatic chemoembolization (354.6 ± 78.6 Gy·· cm2), visceral arteriography (309.5 ± 39.0 Gy·· cm2), and vascular embolization (298.5 ± 29 Gy·· cm2). TIPS was associated with the highest mean reference dose (2.002 ± 1.420 Gy) followed by hepatic chemoembolization (1.746 ± 0.435 Gy), vascular embolization (1.615 ± 0.381 Gy), and visceral arteriography (1.558 ± 1.720 Gy). Of the six procedures available for comparison with the reference levels, the mean fluoroscopy time, DAP, and reference dose for each procedure were below the proposed reference levels. CONCLUSION: Advances in image acquisition technology and radiation safety protocols have significantly reduced the radiation exposure for a variety of interventional radiology procedures.

Transpsoas cystolitholapaxy in a pediatric patient with myelomeningocele, augmented neobladder, and Mitrofanoff appendicovesicostomy.

Recurrent urolithiasis is a common and potentially morbid complication of spina bifida. Although the size, the location, and the composition of these stones often necessitates percutaneous intervention, access is often complicated by body habitus and spinal deformity. There is little consensus regarding the approach to percutaneous lithotripsy when a clear path to the collecting system is unavailable, particularly in the setting of surgically augmented urological anatomy. Here we present the first known case in which a pediatric patient with spina bifida underwent percutaneous lithotripsy of bladder stones via a transpsoas approach.