NEXUS Arch: A Multicenter Study Evaluating the Initial Experience With a Novel Aortic Arch Stent Graft System.

OBJECTIVE: To assess the initial clinical experience with a novel endograft system (NEXUS Aortic Arch Stent Graft System) designed to treat aortic arch pathologies and address the morphology and hemodynamic challenges of the aortic arch. SUMMARY BACKGROUND DATA: The aortic arch remains the most challenging part of the aorta for both open and endovascular repair. Transcatheter aortic arch repair has the potential to significantly reduce surgical risks. METHODS: Patients underwent transcatheter aortic arch repair with a single branch, 2 stent graft system, implanted over a through-and-through guidewire from the brachiocephalic trunk, to the descending aorta with an ascending aorta stent graft. The ascending aorta stent graft is deployed into a designated docking sleeve to connect the 2 stent grafts and isolate the aortic arch pathology. Proximal landing zone in all cases was in Zone 0. Anatomical inclusion criteria included adequate landing zone in the ascending aorta, brachiocephalic trunk, and descending thoracic aorta. Preparatory debranching procedure was performed in all patients with carotid-carotid crossover bypass and left carotid to left subclavian bypass, or parallel graft from descending aorta to left subclavian artery. Safety and performance were evaluated through 1 year. Survival analysis used the Kaplan-Meier method. RESULTS: Twenty-eight patients, 79% males, with a mean age of 72.2 ± 6.2 years were treated with 100% procedural success. Isolated aortic arch aneurysm was the principle pathology in 17 (60.7%) of patients, while chronic aortic dissection was the principle pathology in 6 (21.4%) of patients. The remaining 5 (17.8%) had combined or other pathologies. At 1 month, the vascular pathology was excluded in 25 of 26 alive patients (96.1%). The 30 days mortality rate was 7.1%, stroke rate was 3.6% (all nondisabling), and combined mortality/stroke rate was 10.7%. One-year mortality was 10.7%, without device or aneurysm-related death. Two patients (7.1%) reported stroke or transient ischemic attack at 1 year that recovered completely. One year combined mortality/stroke rate was 17.8%. There were 3 patients (10.7%) that had device-related unplanned reinterventions through 1 year. CONCLUSIONS: The NEXUS Aortic Arch Stent Graft System, a novel single branch, 2 stent graft system used for endovascular aortic arch repair that requires landing in the ascending aorta, demonstrates a high success rate with excellent 1 year safety and performance.

Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. MATERIALS AND METHODS: MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data. RESULTS: Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013). CONCLUSIONS: Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. CLINICAL IMPACT: Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.

The Use of Vascular Closure Devices for Brachial Artery Access: A Systematic Review and Meta-Analysis.

PURPOSE: To estimate the rates of technical success and adverse events of vascular closure devices (VCDs) in the brachial artery and compare the rates of adverse events with manual compression. MATERIALS AND METHODS: MEDLINE and Embase were searched for observational studies examining VCDs in the brachial artery. Meta-analyses were performed using random effects for the following outcomes: (a) technical success, (b) hematoma at the access site, (c) pseudoaneurysm, (d) local neurological adverse events, and (e) total number of adverse events. A pairwise meta-analysis compared VCD with manual compression for the outcomes of hematoma and the total number of adverse events. RESULTS: Of 1,761 eligible records, 16 studies including 510 access sites were included. Primary procedures performed were peripheral arterial disease interventions, percutaneous coronary intervention, and endovascular thrombectomy for ischemic stroke. The technical success rate was 93% (95% CI, 87%-96%; I2 = 47%). Data on the following adverse events were obtained via meta-analysis: (a) hematoma, 9% (5%-15%; I2 = 54%); (b) stenosis or occlusion at access site, 3% (1%-14%; I2 = 51%); (c) infection, 0% (0%-5%; I2 = 0%); (d) pseudoaneurysm, 4% (1%-13%; I2 = 61%); (e) local neurological adverse events, 5% (2%-13%; I2 = 54%); and (f) total number of adverse events, 15% (10%-22%; I2 = 51%). Angio-Seal success rate was 96% (93%-98%; I2 = 0%), whereas the ExoSeal success rate was 93% (69%-99%; I2 = 61%). When comparing VCD and manual compression, there was no difference in hematoma formation (relative risk, 0.75; 95% CI, 0.35-1.63; I2 = 0%; P = .47) or the total number of adverse events (relative risk, 0.75; 95% CI, 0.35-1.58; I2 = 76%; P = .45). CONCLUSIONS: Despite being off-label, studies suggest that VCDs in the brachial artery have a high technical success rate. There was no significant difference in adverse events between VCDs and manual compression in the brachial artery.

Effect of vertebral compression fractures on aortic neck angulation after endovascular aneurysm repair.

OBJECTIVE: Aortic neck angulation (ANA) prior to endovascular aneurysm repair (EVAR) and its changes after EVAR are considered important predictors of postoperative complications. We sought to assess the effects of vertebral body height loss on ANA in patients post-EVAR. METHODS: All patients who had undergone EVAR for infrarenal aortic aneurysms in our institution between August 2010 and December 2018 were assessed. Anterior and posterior vertebral body heights were measured in all patients on preoperative, early postoperative, and follow-up computed tomography scans (T12-L5 vertebral bodies). Patients who had significant height loss in their follow-up period were designated as the Study group. These were matched to a Control group of the same size using propensity-score matching based on age, gender, and duration between follow-up scans. Aortic neck morphology indices including ANA and its changes were measured, and information related to postoperative endoleaks and aneurysm sac size were extracted in the Study and Control groups. RESULTS: During the follow-up period, 10 of 185 patients had a radiologically significant vertebral body compression fracture. There was no significant difference between the Study (n = 10) and Control groups in age (77.6 ± 6.9 vs 77.2 ± 7.5 years; P = .64), gender (seven males and three females in each group; P = 1.0), duration between postoperative scans (1830 ± 665 vs 1800 ± 670 days; P = .25), preoperative ANA (36.0° ± 15.6° vs 42.4° ± 18.6°; P = .41), and early postoperative ANA (21.9° ± 11.7° vs 20.9° ± 16.3°; P = .72). Changes in ANA in the postoperative period (7.2° ± 11.1° vs -4.7° ± 6.7°; P = .009; power = .838) were significantly higher in the Study group. CONCLUSIONS: Post-EVAR vertebral body compression fractures exacerbate ANA. Awareness of this can guide both preoperative assessment and postoperative management and follow-up.

Arteries of the Lower Limb-Embryology, Variations, and Clinical Significance.

OBJECTIVES: The purpose of this article is to review the embryology of the lower limb arterial anatomy along with common variants and their clinical relevance. DESIGN: Embryologic variations of the lower limb arterial system may be explained by i.) persistence of primordial arterial segments, ii.) abnormal fusion, iii.) segmental hypoplasia/absence, or a combination of both. Persistent sciatic artery, corona mortis, and popliteal entrapment syndrome will also be discussed with associated symptoms, and potential complications. CONCLUSION: Knowledge of these variations is essential for surgical and endovascular management as failure to recognize them can result in complications.

Toronto PowerWire fenestration technique to access false lumen branches in fenestrated endovascular aneurysm repair for chronic type B dissection.

Chronic type B aortic dissection with aneurysmal degeneration requiring intervention presents significant therapeutic challenges. Thoracic endovascular aortic repair with a fenestrated endograft is a feasible option, but false lumen branches without an adjacent re-entry or perforation in the septum can pose a significant challenge. We present two cases of fenestrated endovascular aneurysm repair for chronic type B aortic dissection in which a renal artery from the false lumen was cannulated by creating a "neofenestration" through the dissection flap using a radiofrequency PowerWire (Baylis Medical Inc, Montreal, Quebec, Canada) technique (Toronto PowerWire fenestration technique).

Outcomes at a single center after subintimal arterial flossing with antegrade-retrograde intervention for critical limb ischemia.

OBJECTIVE: The subintimal arterial flossing with antegrade-retrograde intervention technique has been used to overcome antegrade recanalization failures for peripheral lower limb arterial occlusive disease. There are few outcomes published for this technique and we sought to evaluate outcomes at our institution over a 7-year period. METHODS: A retrospective review was performed of all subintimal arterial flossing with antegrade-retrograde intervention procedures of infrainguinal occlusive disease from 2009 to 2016. Retrograde and antegrade accesses were combined when occlusions could not be crossed from the antegrade direction. Baseline patient characteristics, procedures, procedure time, fluoroscopy time, contrast used, and radiation dose were collected. Posterior tibial waveforms, ankle-brachial index, limb salvage, vessel patency, and the presence of symptoms were assessed at follow-up. RESULTS: Treatment was performed in 52 limbs in 52 patients (35 men and 17 women; mean age, 77.62 ± 11.61 years) with critical limb ischemia and no appropriate venous conduit for surgical bypass. Among the cohort, 63.5% were diabetics, 98% had hypertension, 53.8% had a prior myocardial infarction, and 36.5% end-stage renal disease. The average Rutherford Category before the intervention was 5.08 ± 1.01. Retrograde pedal access was most commonly obtained in the anterior tibial artery/dorsalis pedis (55.7%), followed by the posterior tibial artery (40.3%). The technical success rate was 63.5% (33/52); adjunctive stenting was needed in 19 (36.5%) to optimize results. Preprocedural ankle-brachial index score was 0.54 ± 0.25, which improved after the procedure to an ankle-brachial index score of 0.77 ± 0.25. The primary patency rates at 3 and 6 months were 65% and 60%, respectively. The limb salvage rate at a mean follow-up of 5.4 months was 78.8%. There were 5 complications; 4 were hematomas managed conservatively and 1 was a major retroperitoneal bleed resulting in patient death. CONCLUSIONS: Retrograde pedal access is a viable revascularization technique for achieving limb salvage in patients with critical limb ischemia with acceptable patency for limb-threatening ischemia. This technique expands revascularization options after failed conventional endovascular antegrade approaches.

Intraarterial Lidocaine for Pain Control in Uterine Artery Embolization: A Prospective, Randomized Study.

PURPOSE: To assess efficacy of two different techniques of lidocaine injection in the uterine arteries to reduce pain following uterine artery embolization (UAE) for leiomyomas. MATERIALS AND METHODS: This prospective randomized single-blinded study was performed with 60 patients enrolled between November 2014 and December 2015 equally randomized to 3 arms. Group A received 10 mL lidocaine 1% (100 mg) mixed with polyvinyl alcohol particles (355-500 µm). Group B received the same dose of lidocaine injected after embolization. Group C was a control group. Pain was assessed on a 100-point visual analog scale at 4, 7, and 24 hours after the procedure. Narcotic agent dose to 24 hours was recorded. Outcomes were examined by analysis of variance and pairwise comparison. Leiomyoma infarction was assessed with magnetic resonance imaging 3 months after the procedure. RESULTS: Technical success rate of UAE was 100%. Mean pain score at 4 hours was significantly lower in the lidocaine groups (group A, 28.6; group B, 35.8) compared with the control group (59.4; P = .001). Pain scores at 7 and 24 hours were not statistically different among the 3 arms. The mean in-hospital narcotic agent dose was significantly lower in both lidocaine groups than in the control group (group A, 8.5 mg [P = .002]; group B, 11.1 mg [P = .03]; group C, 17.4 mg). There were no adverse events related to the use of lidocaine. The number of patients with complete infarction of leiomyomas at 3 months was significantly lower in group A at 38.9% (group B, 77.8%; group C, 75%; P = .0451). CONCLUSIONS: Lidocaine injected in the uterine arteries reduced postprocedural pain and narcotic agent dose after UAE. There were more cases of incomplete necrosis when lidocaine was mixed with the particles.

Combined Coil Embolization and Foam Sclerotherapy for the Management of Varicose Veins.

BACKGROUND: We propose a novel technique for endovenous treatment of varicose veins (VVs) using combined coil embolization and foam sclerotherapy of the great saphenous vein (GSV). METHODS: A retrospective case-series analysis on patients undergoing fluoroscopically guided coil embolization of the GSV and foam sclerotherapy of the GSV and below-knee varices at a single Canadian center. RESULTS: Twenty-two patients underwent the procedure on 23 legs. Most patients (78.3%) presented for follow-up 57.2 ± 21.9 days postoperatively. Doppler studies demonstrated complete GSV occlusion in all patients. While 3 patients (13.6%) noted skin discoloration overlying the treated VVs, none complained of pain on follow-up or developed leg numbness, deep vein thrombosis, or pulmonary emboli. CONCLUSIONS: Coil embolization and foam sclerotherapy are a novel and effective treatment for VVs that uses existing and readily available angiographic equipment.

Direct sac puncture versus transarterial embolization of type II endoleaks: An evaluation and comparison of outcomes.

Purpose To determine the outcomes of type II endoleak embolization with aneurysm sac obliteration and whether the approach - direct sac puncture or transarterial - affects outcome. Methods A retrospective review of patients who underwent endovascular aneurysm repairs and subsequent type II endoleak embolization over 10 years was performed. Twenty-three patients (median age: 73 years, range: 40-88 years) underwent 35 embolizations. Embolization was performed with the goal of obliterating both the endoleak sac and feeding vessels. Embolization agents used include cyanoacrylate glue only (48%), glue and coils (36%), coils only (13%), and other (3%). Results Mean follow-up was 21.8 months. Patients underwent an average of 1.5 embolizations, with 35% requiring more than one. Technical success rate was 89%. Freedom from aneurysm sac expansion was achieved in 91%. Freedom from type II endoleak was accomplished in 70%. There were no ruptured aneurysms during the follow-up period. Direct sac puncture and transarterial approaches had similar incidences of aneurysm sac growth ( p = 0.74), persistent type II endoleak ( p = 0.32), and complications ( p = 0.64). However, direct sac puncture had significantly shorter fluoroscopy ( p < 0.001) and total procedure times ( p < 0.001) than transarterial embolizations. Conclusion Direct sac puncture and transarterial embolization of type II endoleak with aneurysm sac obliteration are similarly effective for the prevention of aneurysm sac growth. However, direct sac puncture is our preferred approach given its significantly shorter fluoroscopic and procedural times.

The in-hospital costs of treating high-risk patients with fenestrated and branched endografts.

OBJECTIVE: This study determined the 30-day morbidity and mortality and in-hospital costs of elective fenestrated (fEVAR) and branched (bEVAR) endovascular aneurysm repairs at a single academic institution and determined factors that influence them. METHODS: All elective fEVAR or bEVAR patients treated between November 2007 and March 2014 in a Canadian academic hospital were included. Procedural details, 30-day morbidity and mortality rates, and cost of hospitalization were analyzed. Nonparametric bootstrap analysis was used to compare means between groups and calculate confidence intervals (CIs). RESULTS: There were 84 consecutive fEVAR (n = 61) and bEVAR (n = 23) procedures. The 30-day mortality was 3.3% for fEVAR and 4.3% for bEVAR. Mean hospital stay was 7.2 ± 0.8 days for fEVAR and 12.6 ± 2.2 days for bEVAR. The mean cost of the index hospitalization was $57,000 for fEVAR and $91,000 for bEVAR. Device-related costs accounted for 55% of the total costs. The occurrence of intraoperative or postoperative events were used to further divide each of the fEVAR and bEVAR groups into "complicated hospitalization" (fEVAR, n = 10; bEVAR, n = 13) and "uncomplicated hospitalization" (fEVAR, n = 51; bEVAR, n = 10) groups. Device-related costs were not significantly different between the complicated and uncomplicated hospitalization groups (mean difference [95% CI] fEVAR: $3383 [-$3405 to $9809], P = .3; and bEVAR: $1930 [-$7892 to $11,288], P = .68). However, there were significant differences between the complicated and uncomplicated hospitalization groups in hospital length of stay (mean difference [95% CI] fEVAR: 8.1 [3.0-13.2] days, P = .001; and bEVAR: 10.8 [5.9-19.9] days, P = .002) and nondevice-related costs (mean difference [95% CI,] fEVAR: $25,843 [$11,689-$43,247], P = .001; and bEVAR; $20,326 [$9362-$36,615], P = .002). CONCLUSIONS: bEVAR and fEVAR are expensive interventions. Intraoperative adverse events and postoperative systemic complications dramatically increase costs and length of stay. Measures to minimize complications will reduce hospitalization costs and improve patient outcomes.

Effects of Pulsatile Fatigue on In Situ Antegrade Fenestrated Polyester Stent Grafts Deployed in a Patient-Specific Phantom Model of Juxtarenal Aortic Aneurysm.

PURPOSE: To evaluate the effects of in situ fenestration on the fabric of stent grafts deployed in a patient-specific phantom of a juxtarenal abdominal aortic aneurysm. MATERIALS AND METHODS: Four patient-specific juxtarenal abdominal aortic aneurysm polyurethane models were created, and bifurcated Zenith (Cook, Inc, Bloomington, Indiana) and Endurant (Medtronic, Minneapolis, Minneapolis) endografts were deployed into the models, covering the renal arteries. Antegrade in situ fenestration was carried out with radiofrequency puncture followed by balloon dilation with either conventional or cutting balloons. Renal covered stents were deployed and flared. Specimens were mounted onto an accelerated fatigue tester for 40M cycles (1 patient life-year), and evaluated with microscopy, caliper measurements, and fabric counts. RESULTS: Cutting balloons resulted in more fabric fraying. None of the fenestrations grew beyond the targeted 6-mm diameter despite accelerated fatigue. Fluoroscopic images demonstrated a very prominent waist of the renal fenestration in the Cook device when a conventional balloon was used compared with a cutting balloon. The average fenestration diameter for the Cook device was only 3.1 mm with the conventional balloon compared with 4.8 mm with the cutting balloon. The average fenestration diameter for the Medtronic device was 3.8 mm with the conventional balloon compared with 5.1 mm with the cutting balloon. The fabric counts suggested crowding of yarns around the fenestrations with conventional balloons but less with cutting balloons. CONCLUSIONS: This experimental work suggests that the size of in situ renal fenestrations does not expand beyond the target diameter despite cyclic fatigue. Although the small number of devices tested and selected aortorenal anatomy in this study may limit conclusions, textile analysis suggests that cutting balloons should be used for the Cook Zenith device, whereas conventional balloons should be used for the Medtronic Endurant device when performing in situ fenestration.

Coil embolization of the false lumen in complicated type B aortic dissection.

A patent false lumen with persistent flow after endovascular repair of type B aortic dissection (TBAD) is associated with an ongoing risk of aortic dilation and rupture. We describe the case of a 64-year-old man who initially underwent thoracic endovascular aortic repair for acute complicated TBAD, but continued to have symptomatic retrograde aneurysm filling and dilatation because of a patent false lumen. Coil embolization of the patent false lumen successfully excluded the aneurysmal thoracic aorta from further perfusion, and led to a decease in aneurysm size on follow-up. Our case report is followed by a discussion on this management strategy and a review of literature.

Efficacy of Ovarian Artery Embolization for Uterine Fibroids: Clinical and Magnetic Resonance Imaging Evaluations.

PURPOSE: The objective of the study was to assess the efficacy of ovarian artery embolization (OAE) treatment for symptomatic uterine leiomyomas. METHODS: A retrospective review of 17 patients who underwent OAE in conjunction with uterine artery embolization in a 6-year period (2006-2012) was performed. Ten patients had previous failed embolization, while 7 had not received any embolization therapy before. Percent uterine volume change, percent dominant fibroid volume change, and percent dominant fibroid infarction were assessed with magnetic resonance (MR) imaging. Resolution of menorrhagia, dysmenorrhea/pain, and bulk and/or pressure symptoms including urinary frequency were evaluated clinically. Change in menopausal state was also an outcome of interest. RESULTS: Mean MR imaging follow-up was performed 3 months post-OAE. MR images showed complete infarction in the majority of cases (64.7%; n = 11), with infarction rates of 90%-100% in 3 cases, 1 case with 30%-50% infarction, and 2 cases with 0%-10% infarction. Average uterine size reduction on MR was 32.3% (95% confidence interval [CI]: 22.5%-42.2%; P < .001). The average size reduction for the dominant fibroid was 42.4% (95% CI: 27.7%-57.0%; P = .01). The mean time to final follow-up visit was 11 months. At this point complete symptom resolution (menorrhagia, dysmenorrhea and bulk-related) was achieved in 82.4% (n = 14) of cases. At the final follow-up 11.8% (n = 2) of cases reported menopause. CONCLUSIONS: We observed OAE to be an effective and safe adjunct to uterine artery embolization when hypertrophic ovarian artery(ies) require intervention. However, incomplete fibroid infarction of 23% remains a concern with a potential for long-term treatment failure. In addition, long-term effect on ovarian function is uncertain.

Prevalence and significance of extravascular incidental findings on computed tomographic angiography and magnetic resonance angiography.

Computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) are routinely used to evaluate patients with vascular disease. They have the ability to detect unexpected non-vascular pathology. The purpose of this study was to determine the prevalence and significance of extravascular incidental findings in patients undergoing CTA or MRA. A retrospective review of 737 patients who underwent CTA and 184 patients who underwent MRA during a five-year period was performed. Incidental findings were classified as low, moderate or high significance findings. For patients with high significance extravascular findings, assessment of the rates of appropriate follow-up was conducted. Among the CTA patients, 539 (73.1%) had incidental findings. Low, moderate and high significance findings were discovered in 514 (69.7%), 95 (12.9%) and 41 (5.6%) patients, respectively. Twenty (48.8%) patients with high significance findings received appropriate follow-up investigations. Among the MRA patients, 95 (51.6%) had extravascular findings. Low, moderate and high significance findings were present in 80 (43.5%), 27 (14.7%), and 3 (1.6%) patients, respectively. Two (66.7%) patients with high significance findings were properly followed up. In conclusion, incidental findings on CTA and MRA are very common. A small percentage of these findings could be serious and were not all adequately followed-up in our study population. Referring physicians should be aware of the potential for serious incidental findings and manage them appropriately.

Central venous stenosis associated with pacemaker leads: short-term results of endovascular interventions.

PURPOSE: To determine the safety and outcomes of performing endovascular interventions across pacemaker (PM) lead-related central vein stenosis/occlusion. MATERIALS AND METHODS: Clinical and imaging records from April 2002 to August 2010 were reviewed for patients presenting with clinically significant central venous stenosis or central venous obstruction with indwelling PM leads and were evaluated to determine if any lead dysfunction or complications occurred following intervention. Thirteen patients were identified who underwent 14 interventions. Outcomes were assessed based on recurrent clinical symptoms and repeat venograms, and patency was determined with Kaplan-Meier analysis. RESULTS: All procedures were technically successful (100%) with no procedural complications. All patients underwent balloon angioplasty; two patients also underwent stent placement for persistent flow-limiting stenosis within the superior vena cava. No incidence of PM or lead dysfunction, infection, or need for PM intervention was identified in any patient at the time of the index procedure and at 30 or 90 days. In the two patients who received stents across PM leads, no manifestations of PM or lead dysfunction or infection, or need for intervention, were identified at 1 year after stent placement in one patient and at 3 years in the other patient. For eight patients, sufficient follow-up studies were available, with 30-, 60-, and 120-day primary patency rates of 87.5%, 75%, and 50%, respectively. CONCLUSIONS: Endovascular interventions across PM leads resulted in no adverse clinical cardiac or PM sequelae, but with limited primary patency compared with historical outcomes for central venous interventions in the absence of PM leads.

Bridging stent-graft pullout force analysis.

PURPOSE: To assess the pullout force (POF) of bridging stent-grafts used in thoracoabdominal stent-grafts and iliac bifurcated grafts. METHODS: In an experimental setup, the POFs of Viabahn or Fluency with or without a Zilver stent were measured when deployed into the renal and celiac branches of a Zenith thoracoabdominal cuff-bearing branched stent-graft. The POFs of the Atrium i-Cast, Viabahn, Fluency, and Fluency+Zilver were measured when deployed into an iliac bifurcated graft with a short side-branch for the internal iliac artery. At least 10 trials were performed for each stent in air at room temperature. RESULTS: The median POF (IQR; absolute range) required to dislodge each bridging stent-graft from the 6-mm renal branch was 1.89 N (0.47 N; 1.65-2.5) for the 7-mm Viabahn, 1.17 N (0.39 N; 0.68-1.57 N) for the 7-mm Fluency, and 2.08 N (0.49 N; 1.59-2.62 N) for the 7-mm Fluency with a supporting 8-mm Zilver stent (p<0.001). For the 8-mm celiac branch, the POFs were 2.79 N (0.82 N; 2.31-4.16 N), 1.74 N (0.18 N; 1.51-1.91 N), and 2.73 N (0.94 N; 1.9-3.61 N) for the 9-mm Viabahn, 9-mm Fluency, and 9-mm Fluency with a 10-mm Zilver stent, respectively (p<0.001). For the 8-mm internal iliac branch, the POFs were 3.53 N (0.85 N; 2.55-4.72 N) for the 9-mm i-Cast, 3.82 N (0.41 N; 3.29-4.45 N) for the 9-mm Viabahn, 2.32 N (0.23 N; 1.63-2.64 N) for the 9-mm Fluency, and 2.61 N (0.71 N; 1.65-3.63 N) for the 9-mm Fluency with a 10-mm Zilver stent (p<0.001). CONCLUSION: There is a small but significant difference in pullout forces among various bridging stent-grafts. As pullout forces may be one factor contributing to type III endoleaks in complex endovascular repairs involving fenestrated and branched stent-grafts, further study is warranted to compare these grafts clinically to determine if they perform differently. According to this study, the theoretical advantages associated with the Viabahn stent-graft make it a strong choice for minimizing branch dislocations.

Percutaneous sodium tetradecyl sulfate sclerotherapy for peripheral venous vascular malformations: a single-center experience.

PURPOSE: To evaluate the efficacy, safety, and long-term outcomes of percutaneous sodium tetradecyl sulfate (STS)sclerotherapy for peripheral venous vascular malformations (VVMs). MATERIALS AND METHODS: A retrospective review of a prospectively compiled database was performed to identify patients with a VVM who were referred from 1997 to 2004. Of the 132 patients identified, 78 underwent sclerotherapy. Six of the 78 patients were lost to follow-up. Of the remaining 72 patients (24 male and 48 female patients; mean age, 31.7 years; age range, 14-62 years), 42 (58%) had lower limb VVMs, 19 (26%) had upper limbVVMs, and nine (12%) had truncal and/or central VVMs. Two patients (2.8%) had multifocal lesions. Seven of the 72 patients (9.7%) had Klippel-Trénauney syndrome. Treatment response was assessed clinically and by means of lesion size measurement with magnetic resonance (MR) imaging. RESULTS: A total of 226 treatment sessions were performed (mean, 3.1 sessions per patient; range, 1-13 sessions). The mean follow-up was 41 months (range, 21-84 months). After treatment, 11 patients (15%) became asymptomatic, 20(28%) rated the response to therapy as good, 17 (24%) improved, 20 (28%) were unchanged, and four (5.6%) worsened.Thirty-five patients underwent MR imaging before and after treatment. The size of the VVM was seen to decrease in19 patients (54%), be unchanged in 11 (31%), and increase in five (14%). A reduction in lesion size at MR imaging did not necessarily correlate with a positive clinical response. Overall, patients with infiltrative lesions had a poorer outcome than did those with localized lesions. There were no major complications and seven minor complications(3.1% per session, 9.7% per patient). CONCLUSIONS: An improvement in symptoms was observed in 70% of the patients with VVMs treated with percutaneous STS. Although the treatment is safe, complete cure is unusual and multiple treatment sessions are almost always required.

Patency of endovascular treatment for central venous stenosis: is there a difference between dialysis fistulas and grafts?

PURPOSE: To determine if there is a difference in intervention patency for central venous stenosis (CVS) and occlusion between patients with autogenous hemodialysis fistulas and those with grafts. MATERIAL AND METHODS: A retrospective study was performed from March 1998 to September 2005 identifying all patients with autogenous fistulas and synthetic grafts who underwent percutaneous angioplasty and/or stent placement for CVS. This study cohort consisted of 38 patients (22 with fistulas and 16 with grafts). Age, sex, type of access, location and side of the access, location and side of the CVS, presence of diabetes, previous hemodialysis catheter placement, date and type of interventions, and outcomes were recorded. The patency of each intervention was estimated by using the Kaplan-Meier survival curves. Univariate and multivariate analysis of the variables were performed. RESULTS: Eighty-nine interventions were performed; 83 were angioplasties and six were stent placements. Previous catheter placement on the side of the CVS occurred in 29 of the 38 patients (76%). Technical and clinical success of the interventions were 93.3% and 94.4% respectively. The intervention or primary patency rates +/- standard errors at 3, 6, and 9 months in the fistula group were 88.5% +/- 4.8, 59.4% +/- 7.6, and 46% +/- 7.9, respectively. In the graft group, the rates were 78.1% +/- 7.3, 40.7% +/- 9, and 16% +/- 7.3, respectively. With multivariate analysis, intervention patency remained significantly longer for fistulas (P .014) and in patients who did not have a previous catheter (P .001). CONCLUSION: Longer intervention-free survival for CVS was observed in patients with autogenous fistulas compared with grafts and in patients who did not previously undergo hemodialysis catheter insertion.