p64 flow diverter: Results in 108 patients from a single center.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. RESULTS: Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1-6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. CONCLUSION: The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

The p48 flow diverter: First clinical results in 25 aneurysms in three centers.

BACKGROUND: The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75-3mm. We report our first clinical experiences. METHODS: Between March 2018-January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29-73 years). RESULTS: In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9-34.2%) and mortality was 4.5% (1 of 22, 95%CI <0.01-23.5%). Most complications were procedure-related and not device-specific. Of 22 patients with 25 aneurysms treated with p48, 18 patients with 20 aneurysms had angiographic follow-up after 5-18 months. Of 19 aneurysms, 10 were occluded and 7 showed a remnant. Two aneurysms were open after 6 months. Three aneurysms were still not occluded after 12, 14, and 18 months and these 3 were retreated. Retreatment rate was 16% (3 of 19) and the adequate occlusion rate was 90% (17 of 19). CONCLUSIONS: Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately.

Safety and Efficacy of Aneurysm Treatment with the WEB: Results of the WEBCAST 2 Study.

BACKGROUND AND PURPOSE: Flow disruption with the Woven EndoBridge (WEB) device is an innovative technique for the endovascular treatment of wide-neck bifurcation aneurysms. The initial version of the device (WEB Double-Layer) was evaluated in the WEB Clinical Assessment of IntraSaccular Aneurysm Therapy (WEBCAST) study, whereas the French Observatory study evaluated both WEB Double-Layer and Single-Layer versions of the device. WEBCAST 2 was designed to evaluate the WEB Single-Layer with Enhanced Visualization. MATERIALS AND METHODS: Patients with wide-neck bifurcation aneurysms for which WEB treatment was possible were included. Clinical data including adverse events and clinical status at 1 month and 1 year were collected and analyzed. A core laboratory evaluated anatomic results at 1 year following the procedure. RESULTS: Ten European neurointerventional centers included 55 patients (38 women; 27-77 years of age; mean, 54.4 ± 10.0 years) with 55 aneurysms. Aneurysm locations were the middle cerebral artery in 25 aneurysms (45.5%), the anterior communicating artery in 16 (29.1%), the basilar artery in 9 (16.4%), and the internal carotid artery terminus in 5 (9.1%). Procedural morbidity and mortality at 1 month were, respectively, 1.8% (1/55 patients) and 0.0% (0/55 patients). Morbidity and mortality at 1 year were, respectively, 3.9% (2/51 patients) and 2.0% (1/51 patients). At 1 year, complete occlusion was observed in 27/50 aneurysms (54.0%); neck remnant, in 13/50 (26.0%); and aneurysm remnant, in 10/50 (20.0%) (adequate occlusion in 40/50, 80.0%). CONCLUSIONS: WEBCAST 2 confirms the high safety and efficacy of WEB aneurysm treatment demonstrated in the WEBCAST and French Observatory studies.

Vascular targeting of solid tumours: a major 'inverse' volume-response relationship following combretastatin A-4 phosphate treatment of rat rhabdomyosarcomas.

Tumour-specific vascularisation may be therapeutically approached in two different ways: by antiangiogenic treatments specifically directed to dividing and migrating endothelial cells, or by agents that target principally the inadequate and ill-structured tumour vasculature. Combretastatin A-4 phosphate (combreAp), a recently synthesised prodrug (OXiGENE, Lund, Sweden), is a vascular targeting agent of the latter kind. We evaluated the effect of a single intraperitoneal (i.p.) combreAp injection on the growth of rhabdomyosarcomas syngeneic in WAG/Rij rats. Different tumour volume groups, ranging between 0.1 and 27 cm(3), were selected to assess the relationship between the size at treatment time and the response to combreAp. A double combreAp treatment (2x25 mg/kg) was investigated within the same overall aim: the relationship between growth delay and tumour size. Our results show that the systemic administration of combreAp induces a clear-cut differential growth delay in the solid rat rhabdomyosarcomas: with very large tumours (>/= 14 cm(3)), a 17.6-fold stronger effect was measured than with very small tumours (<1 cm(3)). This is the 'inverse' of the volume-response seen with the conventional therapeutic approaches (radiotherapy, chemotherapy or surgery). These combreAp antitumour responses were observed without treatment limiting systemic toxicity in the rats. With clinical digital subtraction angiography, using microsurgical cannulation of a major tumour draining vessel, and with histopathology, we demonstrate that growth delay is related to an early (within 3-6 h) and extensive breakdown of tumour blood vessels. The experiments involving a second injection also indicate a volume-dependent effect of combreAp in reducing the regrowth rate of small or large rhabdomyosarcomas. This significant differential volume-response obtained with 'selective' vascular targeting, stronger in larger tumours than smaller ones, suggests the potential of broadening the therapeutic window.

Feasibility study of catheter-directed thrombolysis with recombinant staphylokinase in deep venous thrombosis.

The feasibility of catheter-directed thrombolysis with recombinant staphylokinase was evaluated in six selected patients with deep vein thrombosis. The patients underwent intrathrombus infusion of recombinant staphylokinase (2 mg bolus followed by a continuous infusion of 1 mg/h). Heparin was given via the catheter as a bolus (5000 U) and as a continuous infusion (1000 U/h). Complete lysis was obtained in five patients and partial lysis in one patient. Complications consisted of minor bleeding in four subjects. Symptomatic reocclusion occurred in one. Debulking of the thrombus mass by a high speed rotating impeller (n = 1) and stenting (n = 3) were used as additional interventions. An underlying anatomical abnormality was present in two patients. Long term follow up revealed normal patency in all patients and normal valve function in four patients. Symptomatic venous insufficiency with valve dysfunction was present in the two with a second thrombotic episode. Thus catheter-directed infusion of recombinant staphylokinase in patients with deep vein thrombosis appears feasible and may be associated with a high frequency of thrombolysis. Larger studies to define the clinical benefit of this treatment appear to be warranted.

Outcome and one year follow-up of intra-arterial staphylokinase in 191 patients with peripheral arterial occlusion.

Wild-type or equipotent variants of recombinant staphylokinase (rSak) were given intra-arterially (as a 2 mg bolus injection followed by an infusion of 1 mg/h or 0.5 mg/h overnight, with concomitant heparin [1000 IU/h]) to 191 patients of less than 80 years (62 +/- 1 years, mean +/- SEM), with a peripheral arterial occlusion (PAO) of less than 120 days (mean 14 +/- 1 days, median 11 days, 5 to 95 percentiles 3 to 30 days). Ninety nine patients presented with acute or subacute ischemia, 57 with severe claudication, 33 with chronic rest pain and 2 with gangrene. Occlusion occurred in 122 native arteries and in 69 grafts. Revascularization was complete in 83 percent (158/191), partial in 13 percent (24/191) and absent in 4 percent (7/191) after administration of 12 +/- 0.5 mg rSak over 14 +/- 0.7 h. Complete revascularization of acute occlusions of popliteal or more distal arteries was less frequent (60 percent, 15/25) than of acute occlusions of more proximal native arteries (95 percent, 37/39, p <0.001) or grafts (89 percent, 50/56, p = 0.005). Additional endovascular procedures were performed in 47 percent and subsequent elective bypass surgery in 23 percent of patients. Major bleeding occurred in 12 percent (23/191), one month mortality was 3.1 percent (6/191) and one year mortality was 6.9 percent (12/174). However, four patients (2.1 percent) had an intracranial bleeding following therapy: a 85 year old woman with severe diabetic arteriopathy, who was included in violation of the protocol, a 79 and a 74-year-old woman and a 74-year-old man, all with severe hypertension and limb threatening ischemia; these four patients died within two months after treatment. Amputations were performed within the first year in 16 of 162 surviving patients (9.8 percent): in 7 percent (7/96) with an occluded native artery and 14 percent (9/66) with an occluded graft (p = 0.19). No significant difference in lysis rate, one month mortality or one year amputation-free survival was observed in occlusions of recent onset (< or =14 days, n = 126) as compared to occlusions of longer duration (>14 days, n = 65). Treatment was interrupted prematurely in 4 patients because of a suspected allergic reaction. Fibrinogen levels remained unaffected during treatment (3.3 +/- 0.1 g/l before vs. 3.3 +/- 0.1 g/l after infusion, n = 167). In conclusion, rSak appears to be a highly effective thrombolytic agent in patients with PAO, resulting in a low one month mortality (3.1 percent) and a high one year amputation free survival (84 percent), with an acceptable incidence of major bleedings, but with occasional fatal intracranial hemorrhages.

Percutaneous transhepatic cholangioscopy for diagnosis and therapy of biliary diseases in older patients.

OBJECTIVE: To describe the use of percutaneous cholangioscopy in older patients with complex diagnostic and therapeutic bile duct disorders. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Fourteen patients with a mean age of 74 (SD +/- 9) years (range, 60-91 years) underwent percutaneous cholangioscopy. Eleven of these patients presented with endoscopically irretrievable bile duct stones. These 11 patients represent 4.1% of a group of 342 patients (age > or = 60 years) with a mean age of 76 (SD +/- 9) years who were treated endoscopically because of common bile duct stones between January 1993 and January 1996. Three patients presented with obstructive jaundice resulting from a bile duct stricture. In these three patients, brushing cytology of the strictures had proved to be negative. INTERVENTION: After creation and dilatation of a percutaneous transhepatic tract, cholangioscopy was carried out with a flexible cholangioscope. All procedures were performed under mild sedation and analgesia. Stone disintegration was obtained by electrohydraulic lithotripsy, applied through the working channel of the cholangioscope. RESULTS: Complete stone disintegration and removal was obtained after one to three cholangioscopic sessions in all 11 patients with stones. A histological diagnosis of malignancy was obtained in the three patients with biliary strictures. CONCLUSIONS: Percutaneous cholangioscopy is a well tolerated and promising technique in our diagnostic and therapeutic strategy in older patients with complex biliary disorders not responsive to peroral endoscopic diagnosis or treatment.

Post-traumatic high-flow priapism in a 6-year-old boy: management by percutaneous placement of bilateral vascular coils.

Post-traumatic high-flow priapism in children is a very rare disorder. Treatment of high-flow priapism by catheterization and embolization in children has been described only four times in published reports. To our knowledge, our case report is the first in which embolization was superselective and thus could be performed bilaterally.

Self expandable stents for relief of venous baffle obstruction after the Mustard operation.

OBJECTIVE: Obstruction of the venous pathways after Mustard repair for transposition of the great arteries is associated with an increased risk of arrhythmia and sudden death. The purpose of this study was to assess the effectiveness of the largest (tracheal 22 x 40 mm) Wallstents in treating baffle obstructions. DESIGN: Retrospective analysis of patients with stented venous pathways. SUBJECTS: Eleven patients with baffle obstruction after Mustard repair for transposition of the great arteries. INTERVENTIONS: Stenoses were dilated with an 18 or 20 mm balloon. However, recoil was noticed in 11 patients: immediately (n = 7) or on repeat angiography (n = 4). Eighteen stents were implanted (mean (SD)) 18 (3.3) years postoperatively. After dilatation a tracheal Wallstent (11.5 F) was deployed. MAIN OUTCOME MEASURES: Relief of obstruction, haemodynamic improvement. RESULTS: In the inferior vena cava, 10 stents were deployed in seven baffle obstructions with an increase in diameter from 9.8 (2.4) mm to 16.5 (1.4) mm (p < 0.01) and a mean (SD) pressure gradient decrease from 5.1 (3.6) mm Hg to 1.4 (2.0) mm Hg; in the superior vena cava, eight stents were implanted increasing the diameter from 9.1 (3.7) mm to 15.6 (3.8) mm (p < 0.001) with a decrease in mean pressure gradient from 5.1 (2.7) mm Hg to 1.9 (1.5) mm Hg. No complications were experienced during implantation. No anticoagulation was prescribed. During follow up (1.7 (0.6) years; range, 0.9-2.6) no problems were noted; five patients were re-catheterised without change in measurements. There was no evidence of peal formation in any of the stents. CONCLUSION: It is concluded that Wallstents are safe, easy to use, and effective in relieving baffle obstruction. Anticoagulation does not seem necessary.

Endovascular treatment of a ruptured paraclinoid aneurysm of the carotid syphon achieved using endovascular stent and endosaccular coil placement.

We herein report a case of a ruptured superior hypophyseal aneurysm of the left supraclinoid carotid artery that could not be treated with a Guglielmi detachable coil (GDC), even in combination with a supporting nondetachable balloon. After an unsuccessful attempt at surgical clipping, treatment consisted of the placement of a stent over the neck of the aneurysm, advancement of a microcatheter through the stent mesh, and endosaccular embolization with a GDC. The late clinical outcome was excellent.

Gastroepiploic artery coronary bypass graft: non-invasive patency evaluation using color and duplex Doppler ultrasonography.

OBJECTIVE: Color and duplex Doppler ultrasound and digital subtraction angiography were compared for the evaluation of graft patency of the gastroepiploic artery (GEA). METHODS: In 77 observations, ultrasound and digital subtraction angiography were compared. The coronary resistance index (cRI) was defined as the maximal systolic flow velocity minus the maximal diastolic flow velocity, divided by the maximal systolic flow velocity. On digital subtraction angiography, the graft was considered patent, occluded, or patent but non-functional. Grafts were defined as non-functional when they had a diameter of less than 5F with the absence of opacification of the native coronary artery. RESULTS: Of the 77 observations, 64 GEAs were patent angiographically, three were occluded and ten grafts were considered as patent but non-functional. Using color and duplex ultrasound, the GEA was identified in 65 out of 77 observations. There were no cases of false positive visualization of the GEA. All sonographically detected non-functional grafts (n = 7) had a cRI of greater than 0.60. When the non-visualized grafts are considered either non-functional or occluded, a cut-off value for a cRI of 0.60 results in a sensitivity and specificity of 100 and 75%, respectively. CONCLUSION: We propose ultrasound as a primary screening tool for evaluating graft patency. While color Doppler is a suitable technique for graft visualization, spectral analysis with the calculation of a cRI is required for functional evaluation.

Carcinoma of the kidney, testis, and rare urologic malignancies.

The purpose of this symposium was to provide a forum for discussion on current information on the etiology and diagnosis of, and therapy for, tumors of the kidney, testis, and several uncommon malignancies of the genitourinary tract. The most recent contributions in epidemiology and molecular genetics were discussed with specific reference to their importance for clinical practice. Contemporary treatment approaches with the emphasis on multidisciplinary patient management of tumors commonly seen in the clinic as well as those that are only rarely diagnosed by urooncologists were presented. Major stress was given to the management optimization as it pertains to short- and long-term quality of life issues of patients treated for these tumors. Methods to reduce treatment toxicity including carcinogenic potential of chemotherapy, radiotherapy, or their combination were found to be of nearly equal importance to patient survival. Symposium participants reached consensus on a number of important points: 1) The management of patients with several malignancies discussed requires the presence of a multidisciplinary team of specialist who are interested in diagnosis and treatment of genitourinary tumors; 2) Patients managed in such an environment are expected to have optimal survival and the best possible quality of life; 3) Real advances in the management of patients can be best obtained through well-designed prospective clinical trials; and 4) There is a need for timely introduction of relevant advances in epidemiology and molecular genetics to clinics.

Stent-grafts in the superficial femoral artery.

Superficial femoral artery disease is still cumbersome to treat. While percutaneous transluminal angioplasty (PTA) and stent replacement are well established treatment modalities for occlusive iliac or renal artery diseases, less favorable results are obtained with these techniques in the superficial femoral artery. Bypass surgery with the use of an autologous vein still gives the best results. A less invasive alternative is therefore desirable. The use of stent-grafts seems promising as it combines the technology of a less invasive endovascular treatment with the advantages of creating an anatomical endoprosthetic smooth conduit. This article gives an overview of the different types of stent-grafts and their clinical applications.

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management.

OBJECTIVE: To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding. STUDY DESIGN: In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored. RESULTS: In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation. CONCLUSION: Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.

Local thrombolysis for occluded arterial grafts: is the yield worth the effort?

This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.

Nonsurgical extraction of intracardiac double-knotted pulmonary artery catheter.

A 75-year-old patient was admitted to the operating room for an emergency laparotomy for leaking abdominal aortic aneurysm. A pulmonary artery catheter (PAC) was inserted through the right internal jugular vein but it was impossible to advance the catheter lip into the pulmonary artery. We tried to withdraw the catheter but this was also impossible. A postoperative chest radiograph revealed a catheter knot in the right atrium. We succeeded in removing the PAC through a 14-French sheath introducer placed in the femoral vein via fluoroscopy.

[Transjugular intrahepatic portosystemic shunt in the treatment of refractory ascites in 21 patients]. / Plaatsing van een transjugulaire intrahepatische portosystemische shunt als behandeling van refractaire ascites bij 21 patiënten.

OBJECTIVE: To determine the value of the transjugular intrahepatic portosystemic stent shunt (TIPS) in the treatment of patients with cirrhosis and refractory ascites. DESIGN: Descriptive follow-up study. SETTING: University Hospital Gasthuisberg, Leuven, Belgium. METHODS: In a period of three years, 21 consecutive patients with cirrhosis and refractory ascites were treated with TIPS. Refractory ascites was defined as ascites resistant to maximum diuretic therapy and repeated paracentesis. The mean follow-up was 9 months (range 3-26). RESULTS: Creation of the stent shunt was technically successful in 20 patients and resulted in a decrease of the pressure gradient between the portal vein and the inferior vena cava by approximately 47%. The procedure was immediately lethal in two patients. Complications occurred later on in four patients: thrombosis of the stent in 3 patients and disabling encephalopathy in one. Five other patients died from liver failure, four of them possibly related to the increase of the portosystemic shunting. The stent shunt had no ill effects on kidney function. Thirteen patients were still alive at the end of follow-up. Five patients (24%) had a total and sustained remission of the ascites. Seven patients (33%) still had ascites but needed no paracentesis. One patient did not respond to the treatment. The best results were observed in 14 alcoholics: 9 (64%) responded favourably (43% in non-alcoholics), in 4 of these the ascites had disappeared. CONCLUSIONS: TIPS placement needs substantial experience to avoid technical complications. In case of refractory ascites, only patients for whom later liver transplantation is considered should be submitted to the procedure, because TIPS placement can lead to deterioration of liver function.

Optimization of distal artery opacification in peripheral arteriography: comparison between nitroglycerin, tolazoline and buflomedyl.

A prospective double blind randomized comparative study was performed in patients with insufficient distal artery opacification during peripheral arteriography, in order to compare the vasodilating capabilities of intraarterially injected nitroglycerin, tolazoline and buflomedyl versus placebo. All three vasodilating agents showed statistically significant improvement of distal artery opacification as compared to the placebo (p < 0.0001). Overall results were better for buflomedyl (p = 0.231) then for tolazoline (p = 0.142) and nitroglycerin, but these differences were statistically not significant. It is concluded that buflomedyl is an excellent vasodilating agent in peripheral arteriography.

Arterial bleeding after biliary drainage catheter placement: diagnosis and treatment.

A case of hepatic arterial haemorrhage after percutaneous biliary drainage catheter placement is presented. Temporary control of the haemorrhage was obtained by placement of a larger drainage catheter which tamponaded the bleeding artery. Hepatic angiography followed by transcatheter embolotherapy provided a definitive control of bleeding.