[Arterial closure devices. What device for which clinical situation?]. / Arterielle Verschlusssysteme. Welches wofür?

CLINICAL/METHODICAL ISSUE: Access site complications after endovascular catheterization sometimes require open surgery and negatively impair safety, patient comfort and reimbursement. Increasing numbers of procedures and patients with multiple anticoagulants as well as cost pressure explain the demand for an immediate and stable access site closure. STANDARD RADIOLOGICAL METHODS: Manual compression followed by compression bandage and bed rest for 4-24 h is still the gold standard but is unable to prevent access site complications in all cases. METHODICAL INNOVATIONS: Arterial vascular closure devices allow immediate and stable closure of the puncture channel either by suture or by implantation of occluding foreign bodies or gluing fluids. PERFORMANCE: The safety has been proven in several clinical trials. The main advantage lies in closing large lumen access sites without surgery and in patients treated with multiple anticoagulants as well as in outpatient procedures. ACHIEVEMENTS: They have become a valuable supplement to the interventional arsenal. PRACTICAL RECOMMENDATIONS: The physician, however, has to decide between different systems and mechanisms with respect to patient constitution, selected access vessel and level of calcification and diameter. Furthermore, all systems require a defined training prior the first use.

CTA for screening of complicated atherosclerotic carotid plaque--American Heart Association type VI lesions as defined by MRI.

BACKGROUND AND PURPOSE: High-resolution carotid MR imaging can accurately identify complicated American Heart Association lesion type VI plaques, which are characterized by thrombus, hemorrhage, or a ruptured fibrous cap. The purpose of this study is to evaluate whether CTA can be used as screening tool to predict the presence or absence of American Heart Association lesion type VI plaques as defined by high-resolution MR imaging. METHODS: Fifty-one patients with suspected ischemic stroke or TIA with carotid CTA and carotid MR imaging performed within 14 days of the event/admission from April 2008 to December 2010 were reviewed. Vessels with stents or occlusion were excluded (n = 2). Each carotid artery was assigned an American Heart Association lesion type classification by MR imaging. The maximum wall thickness, maximum soft plaque component thickness, maximum calcified component thickness, and its attenuation (if the soft plaque component thickness was >2 mm) were obtained from the CTA. RESULTS: The maximum soft plaque component thickness proved the best discriminating factor to predict a complicated plaque by MR imaging, with a receiver operating characteristic area under the curve of 0.89. The optimal sensitivity and specificity for detection of complicated plaque by MR imaging was achieved with a soft plaque component thickness threshold of 4.4 mm (sensitivity, 0.65; specificity, 0.94; positive predictive value, 0.75; and negative predictive value, 0.9). No complicated plaque had a soft tissue plaque thickness <2.2 mm (negative predictive value, 1) and no simple (noncomplicated) plaque had a thickness >5.6 mm (positive predictive value, 1). CONCLUSIONS: Maximum soft plaque component thickness as measured by carotid CTA is a reliable indicator of a complicated plaque, with a threshold of 2.2 mm representing little to no probability of a complicated American Heart Association lesion type VI plaque.