The Transbrachial Venous Approach for Pelvic Congestion Syndrome Embolization: An Easy Way to Outpatient Procedure.

BACKGROUND: Pelvic congestion syndrome (PCS) is a frequent finding in adult women and transcatheter embolization of dilated and refluxing veins is the treatment of choice. The procedure can be performed through different venous accesses such as the transfemoral, transjugular, and the transbrachial access. The aim of this study was to demonstrate the feasibility and safety of the transbrachial approach for transcatheter embolization in this pathology in 201 women. Advantages and disadvantages of this access were discussed. METHODS: Between January 2007 and October 2020, female patients who underwent transcatheter embolization for PCS were selected. Embolization procedural details such as venous access sites and embolized veins were collected. RESULTS: Two hundred and one patients were selected for pelvic vein embolization due to PCS. The basilic vein was punctured in 103 patients (51.2%), the cephalic vein was chosen in 76 patients (37.8%) and deep brachial veins in 19 (9.6%). Technical success was observed in 198 (98.5%) cases. Only one major adverse effect was registered; one patient presented with hematoma of the arm that could be managed conservatively. CONCLUSION: The transbrachial venous approach for PCS embolization is safe, effective and minimal invasive. It provides a significant patient comfort, has a low complication rate and can be performed on an outpatient basis.

Stabilizing Technique for Bridging Stent Placement in Branched Endovascular Aortic Repair.

PURPOSE: To present a bailout technique for bridging covered stent placement during branched endovascular aortic repair (BEVAR) in complex anatomy. TECHNIQUE: BEVAR is an alternative technique for the treatment of thoracoabdominal aortic aneurysms (TAAAs). Visceral and renal vessels must be preserved by bridging covered stent placement through downward-oriented branches of the main stent graft device. Challenging anatomy such as kinking and elongation of the aorta, or type III aortic arch configuration may impede successful catheterization of these branches due to reduced steerability and pushability of the endovascular material. Different alternative techniques have been described to overcome these anatomic barriers. This technical note adds another endovascular solution to complex cases using the guiding sheath stabilizing technique. It is based on a standard "through-and-through" technique. An attached snare is inserted via femoral approach, providing a stable position for branch catheterization and bridging covered stent deployment. CONCLUSION: The stabilizing technique is safe and easy to perform and provides a stable position of the guiding sheath when antegrade branch catheterization is challenging. This technique is an additional tool for handling challenging cases.

Atypical Renal Artery Preservation with an Iliac Branch Device in an Infrarenal Abdominal Aortic Aneurysm.

Anatomical variations of the renal arteries may complicate endovascular repair of infrarenal abdominal aortic aneurysms (AAA). Occlusion of renal branches may be necessary to seal the aneurysm sac efficiently. Depending on the size of the affected renal arteries and the supplied parenchyma, this can lead to loss of renal function. Iliac branch devices (IBDs) have been created in order to preserve the internal iliac artery in aortoiliac or isolated iliac aneurysms; however, IBDs have the potential to maintain patency of other arteries as well. This case report describes the off-label use of an IBD inside the main body of a bifurcated endoprosthesis in a patient with an AAA and multiple renal arteries in order to preserve the main renal artery that emerges directly out of the aneurysm sac. Special considerations such as limited craniocaudal dimensions for endoprosthesis placement and the reduced vascular space are discussed.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare focal liver lesion - infectious parasitic, fungus.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of parasitic and fungus infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (parasitic and fungus) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Transcollateral approach for percutaneous revascularization of complex superficial femoral artery and tibioperoneal trunk occlusions.

This report describes the use of transcollateral retrograde revascularization in two patients after failed recanalization of the tibioperoneal trunk in one and superficial femoral artery occlusion in the other. Retrograde recanalization was successfully achieved via a distal branch of the profunda femoris artery in the first case and a medial genicular branch in the second. After successful retrograde recanalization, the guide wire was snared in both cases and angioplasty/stent placement was performed in an antegrade fashion.

[All about the Pancreas]. / Alles über das Pankreas.

All about the Pancreas Abstract. Ultrasound has made tremendous progress with the use of contrast media and elastography, particularly in patients with small, solid pancreatic lesions (SPL) <20mm and cystic tumors (CPL) of any size. In the case of solid and cystic pancreatic lesions, the differential diagnosis must first be evaluated after detection in order to define the indications for radical surgery, strategies for preserving the pancreatic parenchyma or simply for control examinations. Contrast-enhanced transcutaneous (TUS, CEUS) and endoscopic (EUS, CE-EUS) ultrasound and elastography facilitate further characterization of SPL and ZPL. Pancreatic ductal adenocarcinomas (PDAC) show hypoenhancement in contrast-enhanced ultrasound. The majority of the important differential diagnoses, on the other hand, are multi-enhancing. PDAC are almost always harder than healthy pancreatic parenchyma. In contrast, elastographically soft SPL are - with very few exceptions - benign. This review provides an overview of the use of modern ultrasound techniques to detect and characterize solid and cystic pancreatic lesions.

Percutaneous transluminal angioplasty versus turbostatic carbon-coated stents in infrapopliteal arteries: InPeria II trial.

PURPOSE: To determine the clinical outcome and the success of stent application for high-grade lesions of the infrapopliteal arteries compared with treatment with percutaneous transluminal angioplasty (PTA) in critical limb ischemia (CLI). MATERIALS AND METHODS: In this ethics board-approved randomized prospective study, PTA or stent application was performed on 131 lesions in 88 patients with CLI. The primary end points were clinical improvement after endovascular treatment and limb salvage rate. Secondary end points were defined by the minimal lumen diameter (MLD) before and after the revascularization procedure, percentage of residual diameter stenosis (DS), binary restenosis rate (>50% DS and >70% DS), and incidence of target lesion revascularization at 9-month follow-up. RESULTS: At 3 months, the clinical status in the PTA group was less improved than that in the stent group (P = .008). At 9 months, there had been five minor and two major amputations in the PTA group and five major and five minor amputations in the stent group. MLD was significantly larger and the percentage of DS was significantly less in the stent group at completion angiography. At 9 months, the angiographic control showed better trends for the stent group in comparison to the PTA group despite that no significant differences were detected (MLD, 1.19 mm ± 0.92 vs 1.02 mm ± 1.02; DS, 38.68% ± 25.47 vs 43.31% ± 28.37). CONCLUSION: Infrapopliteal stent application is an effective treatment modality in CLI. The PTA and stent groups were essentially equal at 3 and 9 months except for the difference in clinical improvement in the stent group at 3 months.

Bifurcated endograft in aortoiliac type C and D lesions: long-term results.

PURPOSE: To report long-term outcome when using a bifurcated aortic endograft for treatment of aortoiliac occlusive disease (AIOD) in Trans Atlantic Inter Society Consensus (TASC) classification C and D patients. MATERIALS AND METHODS: Between May 2001 and May 2009, 14 patients (11 men, 3 women) with aortoiliac TASC C and D type lesions and a mean age of 59 years ± 10 (range 41-73 years) were treated using a bifurcated aortic endograft. Although these patients were young, all were considered at high surgical risk. Patients were followed up clinically and by computed tomography (CT) every 3 months for 1 year and yearly thereafter. RESULTS: Endoprosthesis placement was performed in all patients with a technical success rate of 100%. There were no amputations or deaths at 30 days after the procedure. The mean follow-up was 62 months (range 11-96 months). One patient was lost during follow-up at 11 months, and another patient died of a nonrelated cause after 49 months. A single limb occlusion of the prosthesis was seen in two patients at 2 months and 7 months; both were successfully treated by intraarterial fibrinolysis. At a mean follow-up of 62 months, primary patency was 85.7%, and secondary patency was 100%. CONCLUSIONS: This series shows promising long-term results following the use of a bifurcated aortic endograft for treatment of AIOD TASC C and D type lesions. Bifurcated aortic endograft is a good minimally invasive alternative to open surgery in high surgical risk patients.

Endovascular treatment of the nutcracker syndrome: report of two cases.

The nutcracker syndrome (NS) is a rare condition characterized by the entrapment of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta. Clinically, it presents with flank pain, hematuria, and symptoms of pelvic venous congestion. Several surgical techniques have been described including left renal vein (LRV) transposition, autotransplantation, LRV bypass, superior mesenteric artery (SMA) transposition, gonadocaval bypass and nephrectomy. More recently, endovascular stenting of the renal vein has been proposed. We present two patients with NS who were successfully managed endovascularly, providing satisfactory mid-term clinical and imaging results.

Endovascular treatment for a thoracic-abdominal aortic aneurysm without fenestrations or branches.

We describe a case of a patient with a thoraco-abdominal aortic aneurysm, affecting the origin of the celiac trunk, with the particularity of the normal aortic diameter in the segment between superior mesenteric artery and both renal arteries. Endovascular treatment was performed with no fenestrated or branch endoprosthesis. The procedure was divided into two steps. In the first attempt, an aortic prosthesis was deployed at the infrarenal aorta. Then, a thoracic endoprosthesis was deployed in a second procedure. In this case, the celiac trunk was intentionally occluded in order to increase the distal landing zone. At the end, the segment between the superior mesenteric artery above and below the renal arteries was covered by the uncovered struts of both endoprosthesis, with no effects in visceral artery flow. Multislice computed tomographic angiography after six months revealed complete patency of the superior mesenteric artery, both renal arteries and good back-filling of the branches of the celiac axis, with no evidence of aortic endoleak.

Bridging Stent Placement in Vena Cava Syndrome With Tumor Thrombotic Extension in the Right Atrium.

Venous stent placement of symptomatic occlusion of the superior and inferior vena cava is considered the treatment of choice in malignant disease because this technique can restore patency and achieve a relief of symptoms. However, tumor thrombus extension into the right atrium harbors the potential risk of stent migration and perforation. One strategy to avoid this potential life-threatening complication could be the placement of a bridging stent from the superior vena cava-to-inferior vena cava. This case reports describes the superior vena cava-to-inferior vena cava bridging stent technique in 2 patients with malignant occlusion of the superior and inferior vena cava. Special considerations such as technical details of the devices and potential complications are discussed.

Common Femoral Artery Stenting: Computed Tomography Angiography Based Long-Term Patency.

BACKGROUND: Despite considerable morbid-mortality rates, common femoral endarterectomy is still considered the gold standard for atherosclerotic common femoral artery (CFA) disease. The aim of this study was to demonstrate computed tomography angiography based long-term patency after CFA stent placement and to analyze associated risk factors for restenosis. METHODS: A retrospective and observational study was carried out in consecutive patients treated with endovascular stent placement in CFA lesions. A clinical follow-up and imaging study was performed using MD-CTA to assess different degrees of in stent restenosis (ISR) and primary, assisted, and secondary patency rates. RESULTS: In a 5-year period, 35 extremities were treated in 33 patients with self-expandable nitinol stents. The technical success was 100% without complications related to the procedure. The mean follow-up (FU) was 32.2 months, and 8 limbs were lost. The degree of CFA stenosis was reduced from 79.69 ± 26.47% to 11.23 ± 24.53%. ISR < 20%, 20-70%, and ≥ 70% was evident in 15 (55.6%), 9 (33.3%), and 3 (11.1%) limbs, respectively. Estimated primary, assisted, and secondary patency was 79.5, 96.3, and 96.3%, respectively, after 24 months and 79.5, 96.3, and 96.3%, respectively after 60 months, with a freedom of clinical driven target lesion revascularisation rate of 87.8%. CONCLUSION: Endovascular treatment with self-expandable nitinol stents in CFA lesions had a high technical success rate and was related to few complications. A mild form of intimal hyperplasia was observed in a considerable number of cases. However, long-term patency was high; therefore, CFA stent placement might be a suitable therapeutic alternative in selected patients.

Infrainguinal revascularization using the Crosser vibrational system.

Revascularization of infrainguinal vessels is still a challenge. Complications such as flow-limiting dissections or perforation are responsible for a limited success rate. Failed revascularization attempt leads to amputation in a significant number of patients and increases mortality. We report the use of a novel percutaneous device using the CROSSER catheter system in two patients with peripheral vascular disease. In case # 1 anterior tibial artery patency was restored in a diabetic foot and in case # 2 a chronic traumatic occlusion of the superficial femoral artery was revascularized. In both cases the lesion was recanalized in a short time without any procedure-related complications. The CROSSER catheter system can overcome technical problems and make reentry devices and retrograde distal accesses less relevant. It opens new horizons for the treatment of complex below-the-knee lesions.

Non-protected carotid artery stent without angioplasty in high-risk patients with carotid and coronary artery disease undergoing cardiac surgery.

Hemodynamic depression (HD) is a frequent complication related to carotid endartherectomy or carotid artery stenting (CAS), often not well tolerated in patients with coronary artery disease. The purpose of this study is to assess whether CAS without angioplasty is beneficial in patients with severe carotid artery disease before coronary revascularization surgery (CABG) regarding the occurrence of HD. Between October 2002 and August 2006, 39 CAS were performed in 35 patients before cardiac surgery. Outcome measures, including periprocedural and 30-day post stenting and cardiac surgery complications, were assessed. Twenty-seven patients underwent CABG and eight combined CABG and valve replacement. During or immediately after CAS there was no episode of bradycardia or hypotension necessitating medical treatment. In the period between CAS-CABG, there was no case of HD. We also found no myocardial infarction. There were five neurological complications, two of them in the period between CAS-CABG (one transitory ischemic attack (TIA) and one minor stroke) and three after CABG (one TIA and two strokes). Three of them were discharged symptom-free. CAS without angioplasty can be a safe alternative to treat patients with coexistence of carotid and cardiac disease, since does not produce hemodynamic depression, therefore diminishing the cardiac complications.

Clinical follow-up in endovascular treatment for TASC C-D lesions in femoro-popliteal segment.

OBJECTIVE: To demonstrate the technical success and clinical follow-up after endovascular treatment of femoropopliteal segment TASC II C and D lesions. METHODS: From July 2002 to February 2007, 234 limbs in 190 patients with femoropopliteal segment TASC II C (n = 112) and D (n = 122) lesions were treated. Endovascular treatment consisted of PTA, fibrinolysis and PTA, subintimal recanalization and PTA, and finally stent graft. Patients were clinically evaluated at 30 days, 3, 6 month, and at 1 year in the outpatient setting with clinical examination and ankle-brachial indices (ABI). In the case of stent placement, additional ultrasound evaluation was performed at 12, 24, and 48 month. RESULTS: 49.5% of procedures were performed on patients with lifestyle-limiting claudication (IC) and 50.5% were performed for critical limb ischemia (CLI). Technical success, defined as successful recanalization and treatment of the occluded vessel, was achieved in 97% of cases. Periprocedural mortality was 3.15% and all deaths occurred in the CLI group. A follow-up 13 +/- 6 months and was achieved in 76%. During the follow-up, clinical outcome for IC group and clinical CLI group was asymptomatic 72% vs. 29.8%, symptomatic with clinical improvement 22% vs. 33.7%, and major amputation 3% vs. 23.3%. CONCLUSION: The majority of claudicating patients with femoropopliteal TASC II C and D lesions will benefit from the endovascular treatment. Patient presenting CLI have a worse outcome, nevertheless the endovascular treatment can delay amputation, preserving the native vessel and does not impede surgical bypass if needed. For this reason, we consider that endovascular treatment may be the first choice treatment even in femoropopliteal TASC II C and D lesions.

Endovascular management of a spontaneous dissecting aneurysm of the superior mesenteric artery: case report and discussion of treatment options.

Spontaneous dissection of the superior mesenteric artery represents a rare cause of abdominal angina. Conservative or more aggressive treatments such as surgery or endovascular therapy depend on the symptoms. We present a case report of acute mesenteric ischemia due to spontaneous dissection of the superior mesenteric artery successfully treated by endovascular stent placement. In the discussion we review the different alternatives of treatment presented in the literature.

[Occlusion of a pulmonary arteriovenous fistula with an amplatzer vascular plug]. / Oclusión de una fístula arteriovenosa pulmonar con el tapón vascular Amplatzer.

Pulmonary arteriovenous malformations are rare anomalies that carry a considerable risk of serious complications such as cerebral thromboembolism or abscess and pulmonary hemorrhage. The first-line treatment of such malformations is detachable coil or balloon embolotherapy. However, coils and balloons may migrate and cause paradoxical embolism especially in malformations with large arteriovenous shunts. We report a case in which we used a new vascular occlusion device (amplatzer vascular plug), to occlude a pulmonary arteriovenous fistula in a patient with Rendu-Osler-Weber syndrome.

[Primary mechanical thrombectomy for acute occlusions of cerebral arteries]. / Trombectomía mecánica primaria como tratamiento de la oclusión aguda de arterias intracerebrales.

EN: Cerebral ischemia due to occlusion of the principal intracranial arteries is a significant cause of morbidity and mortality. New devices for mechanical thrombectomy can facilitate rapid extraction of the thrombus. This paper describes the results of primary mechanical thrombectomy with the Solitaire revascularization device without intravenous fibrinolysis. From January 2010 to April 2013, 24 patients with occlusions of the main intracerebral arteries were treated by primary thrombectomy. The mean (SD) time elapsed from onset of symptoms until revascularization was 268 (11.3) minutes (range, 143-486 minutes). Revascularization was achieved in 19 patients (79.2%) within a punctureto- revascularization time of 63.9 (35.5) minutes. The mean score on the National Institute of Health Stroke Scale on admission was 21 (7.5) (range, 7-38). A score on the modified Rankin scale of 2 or lower was recorded for 15 patients (62.5%) on discharge and for 13 patients at 3 months. Three patients (12.5%) died from cerebral hemorrhage or infarct. It can be concluded that after ischemic stroke from occlusions of the main cerebral arteries, about 2 out of 3 of our patients benefited from primary mechanical extraction without intravenous fibrinolysis and had no or minimal disability on discharge.

ES: La isquemia cerebral por oclusión de las arterias principales intracraneales causa una importante morbimortalidad. Nuevos dispositivos para la trombectomía mecánica permiten la extracción del trombo en un tiempo reducido. Se muestran los resultados de la trombectomía mecánica primaria sin el uso de fibrinolisis intravenosa utilizando el dispositivo Solitaire. Desde enero de 2010 hasta abril de 2013, 24 pacientes presentaron una oclusión de vasos intracerebrales principales y fueron tratados mediante trombectomía primaria. El tiempo de inicio de síntomas hasta la recanalización fue de 268 (11,3) min (rango: 143-486 min). La recanalización se consiguió en 19 pacientes (79,2%), con un tiempo punción-revascularización de 63,9 (35,5) min. El NIHSS (National Institute of Health Stroke Scale) al ingreso fue de 21 (7,5) (7-38). Un mRS (modified Rankin scale) inferior o igual a 2 al alta se observó en 15 pacientes (62,5%) y en 13 a los 3 meses. Tres pacientes (12,5%) fallecieron por hemorragia cerebral o infarto. Se concluye que aproximadamente dos de cada tres pacientes se beneficiaron de la extracción mecánica primaria con ninguna o mínima discapacidad al alta, después de un ictus isquémico de vasos principales y sin utilizar la fibrinolisis intravenosa.

Mechanical thrombectomy in patients with tumour-related ischaemic stroke.

Ischaemic stroke is a common cause of death and incapacity and is related in most cases to vascular disease. Intracranial vessel occlusion due to tumour emboli is a rare entity and adequate treatment for this condition is not defined. The use of mechanical thrombectomy devices is considered the treatment of choice for major intracranial vessel occlusion; however, no recommendation can be made in the case of tumour thrombembolia. This report describes two cases who presented with a middle cerebral artery occlusion due to tumour emboli and that were treated using the Solitaire thrombectomy device.

Endoluminal occlusion devices: technology update.

Endoluminal occlusion has been performed since the early beginning of interventional radiology. Over recent decades, major technological advances have improved the techniques used and different devices have been developed for changing conditions. Most of these occlusion devices have been implemented in the vascular territory. Early embolization materials included glass particles, hot contrast, paraffin, fibrin, and tissue fragments such as muscle fibers and blood clots; today, occlusion materials include metallic devices, particles, and liquid materials, which can be indicated for proximal or distal occlusion, high-flow and low-flow situations, and in large-caliber and small-caliber vessels, based on need. Technological progress has led to a decreased size of delivery catheters, and an increase in safety due to release systems that permit the withdrawing and replacement of embolization material. Furthermore, bioactive embolization materials have been developed to increase the efficacy of embolization or the biological effect of medication. Finally, materials have been modified for changing indications. Intravascular stents were initially developed to keep an artery open; however, by adding a covering membrane, these stents can be used to occlude the wall of a vessel or other endoluminal structures. This article gives an overview of the devices most utilized for occlusion of endoluminal structures, as well as their major purpose in the endovascular territory.