The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization.

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial.

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

Percutaneous Management of Recurrent Head and Neck Cancer: Current Role and Evolving Principles in the Multidisciplinary Setting.

PURPOSE OF REVIEW: In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (H&N) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice. RECENT FINDINGS: Management of recurrent H&N cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent H&N cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.

Microwave ablation of the liver in a live porcine model: the impact of power, time and total energy on ablation zone size and shape.

Objective: To explore various microwave (MW) time/power combinations to achieve maximum single-probe system performance in a live pig liver model.Methods: Fifty-one microwave ablations performed in 12 female pigs using the following time/power combinations: 65 W for 10 min (65W 10MIN), ramped from 20 to 65 W (RAMPED), 95 W pulses with cooling periods (95W PULSED), 40 W for 16 min 15 s (LOW POWER), 1 min 95 W pulse then 8 min 65 W then a second 1 min 95 W pulse (BOOKEND 95W) and 65 W for 15 min (65W 15MIN). Temperatures 1.5 cm from the antenna were measured. Livers were excised, and ablations were measured and compared.Results: At fixed overall energy, LOW POWER produced ablation zones with the smallest volume compared to 65W 10MIN, RAMPED and 95W PULSED. At a fixed time of 10-min, BOOKEND 95W protocol achieved wider and larger ablation zones than 65W 10MIN (p = 0.038, p = 0.008) and 95W PULSED (p = 0.049, p = 0.004). The 65W 15MIN combination had significantly larger diameters (p = 0.026), larger lengths (p = 0.014) and larger volumes (p = 0.005) versus 65W 10MIN. Maximum temperatures were highest with BOOKEND 95W (62.9 °C) and 65 W 15 MIN (63.0 °C) and lowest with LOW POWER (45.9 °C), p = 0.009.Conclusions: Low power ablations, even if controlled for total energy delivery, create small ablation zones. High peak powers are associated with larger ablation zones and high margin temperatures if cooling pauses are avoided. Ramping and pulsing protocols with interleaved cooling appear to be of no benefit versus continuous 65 W for creating large ablation zones.

Intravascular Ultrasound-Guided Revascularization of Chronic Juxtarenal Aortoiliac Occlusion.

Chronic juxtarenal aortoiliac occlusion (JRO) represents the most severe form of aortoiliac occlusive disease, classified under Trans-Atlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. Although endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an intravascular ultrasound-guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected nonhealing forefoot ulcer. A transradial pigtail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pigtail catheter. Intravascular-guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the suprarenal aorta. The intimal fenestration was dilated using a 4-mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing stent grafts were deployed bilaterally, extending from the level of the infrarenal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation 2 days later with successful wound healing and limb salvage at 6 months.

Managing Endovascular Workload during COVID-19 Outbreak-The Singapore Experience.

At the outset and during the throes of the COVID-19 pandemic, as valuable resources are channeled to combat the pandemic, challenges in timely delivery of non-COVID-19-related health care services such as endovascular service arise. As such, this article looks at a tertiary institution's experience in managing its endovascular workload-referenced to the American College of Surgeons' triage of vascular surgery patient acuity-based case classification.

Use of Multilayer Stent and Fenestrated Endograft in a Single Session to Treat Long-Segment Aorta.

A 72-year-old man with suprarenal aneurysm and 2 large penetrating ulcers (PAUs) in the descending aorta was referred for endovascular treatment. To avoid long-segment aortic coverage and the attendant risk of spinal ischemia, combination of 2 different stent technologies was used. A multilayer flow modulator was implanted in the thoracic aorta for the PAU, followed by implantation of a customized 4-vessel fenestrated stent graft for the suprarenal aneurysm. The patient remained well at 2 years with computed tomography evidence of exclusion of the suprarenal aneurysm and involution of the PAU.

Feasibility Study of "Snuffbox" Radial Access for Visceral Interventions.

"Snuffbox" radial access entails sheath insertion into the dorsal branch of the radial artery within the so-called anatomic snuffbox. The purpose of this report is to describe the technique and early experience in 50 visceral interventional procedures performed in 31 patients, which included liver embolotherapy, visceral arterial stent insertion, aneurysm embolization, and emergency embolization. In all cases, the procedures were successfully completed by using the snuffbox access, with a single case of asymptomatic pseudoaneurysm as the only access-related complication. Early experience showed that snuffbox radial access is technically feasible and represents a viable alternative to conventional radial access for visceral intervention procedures.

Diabetic Foot Limb Salvage-A Series of 809 Attempts and Predictors for Endovascular Limb Salvage Failure.

BACKGROUND: To review patient characteristics and outcomes of in-patient diabetic foot limb salvage and identify risk factors predicting for endovascular limb salvage failure. METHODS: Retrospective study of limb salvage attempts in 809 patients between August 2013 and July 2015. RESULTS: Sixty-eight percent of our study population were male with mean age at 65 years and 73% presented with Rutherford grade 6 critical limb ischemia, with the remaining 27% Rutherford grade 5. Eighty-one percent had toe pressures of less than 50 mm Hg, 64% had infrainguinal trans-Atlantic inter-society consensus (TASC II) C or D lesions while 78% had infrapopliteal TASC II C or D lesions. Seven hundred seventy-seven patients (96%) underwent endovascular-first approach limb salvage, with 95% requiring infrapopliteal angioplasty, with 84% of them requiring 2-vessel or 3-vessel revascularization. Thirty-two patients (4%) underwent surgical bypass limb salvage, with 63% performed as salvage procedures for failed angioplasties. The mean in-patient stay was 12.3 days within the endovascular group and 31.1 days within the bypass group (P < 0.01). One-year limb salvage was successful in 88% of endovascular group, as compared with 72% in bypass group (P = 0.01). Overall 1-year survival was 93% within the endovascular group and 88% within the bypass group (P = 0.27). The mean in-patient cost was SGD$5,518 within the endovascular group and SGD$15,141 within the bypass group (P < 0.01). Multivariate analysis showed that independent predictors for failure of endovascular limb salvage include end-stage renal failure (ESRF) (odds ratio [OR] 2.04, P = 0.01), toe pressures <50 mm Hg (OR 2.15, P = 0.01), infrainguinal TASC II patterns C or D (OR 1.99, P = 0.03), and indirect angiosome revascularization (OR 2.03, P = 0.02). CONCLUSIONS: Within our study population of Asian ethnicity, most in-patient diabetic foot peripheral arterial disease presented with Rutherford grade 6 disease, with mostly TASC II C or D lesions and required infrapopliteal revascularization. As most patients had multiple comorbidities and were poor surgical candidates, the majority underwent endovascular-first approach revascularization. Independent predictors of endovascular limb salvage failure include ESRF, toe pressures <50 mm Hg, infrainguinal TASC II patterns C or D, and indirect angiosome revascularization.

Accentuation of Insufficient Landing Zone Using High-volume Three-dimensional Coils during Iliac Aneurysm Stent Grafting for Hypogastric Artery Preservation.

We describe the technique using high-volume three-dimensional coils to "augment" an insufficient stent-graft landing zone. This was performed to preserve hypogastric artery perfusion in the case of common iliac artery aneurysm which resides next to the internal iliac artery.

Local Treatment of Desmoid Tumors: An Update.

Desmoid tumors (DTs) are rare fibroblastic proliferations, characterized by infiltrative growth and a propensity for local recurrence. Traditional strategies such as surgery, radiotherapy, and chemotherapy are the mainstays of treatment, each with its limitations and associated risks. The trend in DT management leans toward a "wait-and-see" strategy, emphasizing active surveillance supported by continuous MRI monitoring. This approach acknowledges the unpredictable nature of the disease, and a multidisciplinary management of DT requires a nuanced approach, integrating traditional therapies with emerging interventional techniques. This review highlights the emerging role of minimally invasive interventional radiological technologies and discusses interventional radiology techniques, including chemical, radiofrequency, microwave, cryoablation, and high-intensity focused ultrasound ablations as well as transarterial embolization.

Use of Wallstent device as an embolic protection device during stenting of aortic thrombus.

Blue toe syndrome can occur due to distal embolization from proximal lesions such as an aortic thrombus. We describe the case of a patient who presented with chronic limb threatening ischemia due to a flow-limiting infrarenal aortic thrombus, with gangrene from distal embolization to the left fifth toe, and was successfully treated with endovascular aortic stent graft insertion. Distal embolization during instrumentation was successfully prevented by using a partially deployed Wallstent (Boston Scientific) as an embolic protection device. The reconstrainable Wallstent device can be considered for distal thromboembolic protection during aortic stenting, in particular, when distal embolization is a concern and commercial devices are not readily available.

Single-centre experience with endovascular rotational thrombectomy for single session salvage of thrombosed arteriovenous fistulas and grafts.

OBJECTIVES: This paper documents our experience and outcomes of using a relatively new endovascular rotational thrombectomy device for salvage of thrombosed vascular access. METHODOLOGY: A retrospective study reviewing patients with thrombosed native AVF or AVG who underwent endovascular declotting using a rotational thrombectomy device between November 2018 and May 2020 at a tertiary university hospital in Southeast Asia. We evaluated demographics, procedural data, technical and procedural success, patency rates and complications. RESULTS: A total of 40 patients underwent single session endovascular declotting of thrombosed vascular access. The mean follow-up period was 21.6 months (range 13.4-31 months). The technical success was 92.5% and clinical success was 80%. About 50% of patients had concomitant thrombolysis for pharmacomechanical thrombectomy. One patient had a myocardial infarction during the post-operative period. There were no other major complications within 30 days. The primary patency was 45.5% at 6 months and 22.7% at 12 months. Assisted primary patency was 68.1% at 6 months and 61.6% at 12 months, which was maintained up to 2 years. The secondary patency was 84.1% at 6 and 12 months. CONCLUSION: Our study shows that rotational thrombectomy device for single session thrombectomy of thrombosed arteriovenous fistulas and grafts is safe and effective. A high technical and clinical success rate was achieved, with low complication rates and specific advantages compared to other techniques, including reduced length of hospital stay. Our reported mid-term outcomes are reasonable with an assisted primary patency of 62% at 12 and 24 months. The use of newer techniques and novel dedicated thrombectomy devices show promise.