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OBJECTIVE: To develop a large animal model of iliocaval deep venous thrombosis (DVT), which enables development and evaluation of interventional management and existing imaging modalities. METHODS: The experimental protocol consisted of a total endovascular approach. Pigs were percutaneously accessed through the right internal jugular and bilateral femoral veins. Three balloon catheters were inflated to induce venous stasis in the infrarenal inferior vena cava (IVC) and bilateral common iliac veins (CIVs). Hypercoagulability was induced by injecting 10 000 IU of thrombin. After 2.5 hours, the balloon catheters were removed before animal recovery. After seven, 14, 21, 28, or 35 days, animals were euthanised; the IVC and CIV were harvested en bloc, cross sectioned and prepared for histological examination. Multimodal imaging was performed before and after thrombus creation, and before animal euthanasia. RESULTS: Thirteen female domestic pigs with a mean weight of 59.3 kilograms were used. The mean maximum IVC diameter and area were 16.4 mm and 1.2 cm2, respectively. The procedure was successful in 12 animals with occlusive venous thrombosis in the region of interest on immediate post-operative magnetic resonance venography and a mean thrombus volume of 19.8 cm3. Clinical pathology results showed platelet consumption, D dimer increase, and inflammatory response. Histological evaluation demonstrated a red cell, fibrin, and platelet rich thrombus on day 1, with progressive inflammatory cell infiltration from day 7. Collagen deposition appeared in week 2 and neovascularisation in week 3. CONCLUSION: Endovascular occlusion combined with thrombin infusion is a reliable minimally invasive approach to produce acute and subacute DVT in a large animal model.
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Procedimientos Endovasculares , Trombosis de la Vena , Animales , Modelos Animales de Enfermedad , Procedimientos Endovasculares/métodos , Femenino , Humanos , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/cirugía , Stents , Porcinos , Trombina , Resultado del Tratamiento , Grado de Desobstrucción Vascular/fisiología , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugía , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/terapiaRESUMEN
OBJECTIVE: To co-register conventional computed tomography angiography (CTA), with ex vivo micro-computed tomography (microCT) and histology of popliteal atherosclerotic plaques. Improving the non-invasive imaging capabilities may be valuable to advance patient care with peripheral arterial obstructive disease towards lesion and individual based treatment. METHODS: In this prospective observational study, 12 popliteal arteries from 11 symptomatic patients who had undergone transfemoral amputations for chronic limb threatening ischaemia and who had pre-operative CTA, were analysed ex vivo by microCT and histology. A total of 353 histological cross sections were co-registered with microCT and CTA, and classified as: lipid rich (LP, n = 26), fibrous (FP, n = 80), or calcific (CP, n = 247) plaques. CTA and microCT plaque density was calculated in 791 regions of interest as Hounsfield units (HU). RESULTS: CTA and microCT could identify plaque components that were confirmed by histology such as fibrous tissue (FP), lipid pool/core (LP), and calcification (CP). MicroCT densities were 77.8 HU for FP (IQR 52.8, 129.5 HU), -28.4 HU for LP (IQR -87.1, 13.2 HU), and 3826.0 HU for CP (IQR 2989.0, 4501.0 HU). CTA densities of the three components of the plaque were: 78.0 HU for FP (IQR 59.5, 119.8 HU), 32.5 HU for LP (IQR 15.0, 42 HU), and 641.5 HU for CP (IQR 425.8, 1135 HU). The differences were statistically significant between the HU densitometric characteristics among the three groups (p < .0001) for both imaging modalities. Overall, microCT performed better diagnostically than conventional CTA for the three types of plaques: areas under the receiving operator characteristics curve were greater for microCT than CTA for FP (0.97 vs. 0.90), for LP (0.88 vs. 0.67), and for CP (0.97 vs. 0.90). CONCLUSION: CTA and microCT can be used to identify histological atherosclerotic plaque components, with better diagnostic performance for microCT. This study demonstrates the feasibility of using microCT to assess plaque morphology lesions in a manner that approaches histology thus becoming a useful tool for ex vivo assessment of atherosclerosis and towards lesion based treatment.
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Angiografía por Tomografía Computarizada , Isquemia/diagnóstico por imagen , Enfermedad Arterial Periférica/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Microtomografía por Rayos X , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Angiografía por Tomografía Computarizada/métodos , Femenino , Humanos , Isquemia/patología , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/patología , Placa Aterosclerótica/patología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/patología , Estudios Prospectivos , Microtomografía por Rayos X/métodosRESUMEN
BACKGROUND: Central venous occlusive disease (CVOD) is a prevalent problem in patients with end-stage renal disease (ESRD) and can lead to access malfunction or ligation for symptomatic relief. The purpose of this study is to evaluate the efficacy of the TriForce® Peripheral Crossing Set (Cook Medical), a novel reinforced telescoping catheter set designed to provide additional support for crossing difficult central venous occlusions. METHODS: This is a single-center retrospective study from a quaternary referral center. We identified 37 patients over a 17-month period who underwent 56 attempts at endovascular recanalization for the treatment of central venous occlusion. Technical success rates, procedural data, and outcomes were compared between those undergoing recanalization using traditional wire/catheter sets versus the TriForce catheter set. RESULTS: Average age was 48 ± 2 years. Comorbidities were similar between the two cohorts and included ESRD (61%), deep venous thrombosis (30%), and May-Thurner syndrome (7%). Forty attempts were made with traditional wire/catheter sets and 16 attempts with the TriForce catheter set to treat 2.1 ± 0.2 and 1.9 ± 0.3 occluded venous segments, respectively (P = 0.74). Technical success rates were significantly higher for the group undergoing recanalization using the TriForce catheter (69% versus 38%, P = 0.04) and 4 patients were successfully recanalized using the TriForce catheter set after a failed attempt with traditional wire/catheter sets. Mean fluoroscopy time and radiation dose were 13 ± 3 min and 14,623 ± 2,775 µGy∗m2 for traditional techniques versus 30 ± 6 min and 30,408 ± 10,433 µGy∗m2 for the novel telescoping catheter set (P = 0.01 and 0.09, respectively). Freedom from reintervention at 1 year was 60% for the TriForce cohort versus 44% for the traditional wire/catheter cohort (P = 0.25). CONCLUSIONS: The novel TriForce reinforced telescoping catheter set is a useful adjunct that may improve recanalization rates of CVOD compared with traditional wire/catheter sets.
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Procedimientos Endovasculares/instrumentación , Dispositivos de Acceso Vascular , Enfermedades Vasculares/terapia , Venas , Obstrucción del Catéter , Cateterismo Venoso Central/efectos adversos , Constricción Patológica , Procedimientos Endovasculares/efectos adversos , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico por imagen , Enfermedades Vasculares/etiología , Enfermedades Vasculares/fisiopatología , Grado de Desobstrucción Vascular , Venas/diagnóstico por imagen , Venas/fisiopatologíaRESUMEN
OBJECTIVE: To review the existing literature on large animal models of central venous thrombosis (CVT) and to evaluate its relevance in regard to the development and testing of dedicated therapeutics applicable to humans. METHODS: A systematic literature search was conducted in PubMed and Embase. Articles describing an in vivo experimental protocol of CVT in large animals, involving the iliac vein and/or the vena cava and/or the brachiocephalic vein, were included. The primary aim of the study, animal characteristics, experimental protocol, and thrombus evaluation were recorded. RESULTS: Thirty-eight papers describing more than 30 different protocols were included. Animals used were pigs (53%), dogs (21%), monkeys (24%), and cattle (3%). The median number of animals per study was 12. Animal sex, strain, and weight were missing in 18 studies (47%), seven studies (18%), and eight studies (21%), respectively. CVT was always induced by venous stasis: solely (55%), or in addition to hypercoagulability (37%) or endothelial damage (10%). The size of the vessel used for thrombus creation was measured in four studies (10%). Unexpected animal death occurred in nine studies (24%), ranging from 3% to 37% of the animals. Twenty-two studies (58%) in the acute phase and 31 studies in the chronic phase (82%) evaluated the presence or absence of the thrombus created, and its occlusive characteristic was reported, respectively, in five and 17 studies. Histological examination was performed in 24 studies (63%) with comparison to human thrombus in one study. CONCLUSION: This review showed advantages and weaknesses of the existing large animal models of CVT. Future models should insist on more rigour and consistency in reporting animal characteristics, as well as evaluating and comparing the thrombus created to human thrombus.
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Venas Braquiocefálicas , Vena Ilíaca , Venas Cavas , Trombosis de la Vena , Animales , Coagulación Sanguínea , Venas Braquiocefálicas/patología , Modelos Animales de Enfermedad , Perros , Haplorrinos , Humanos , Vena Ilíaca/patología , Especificidad de la Especie , Sus scrofa , Venas Cavas/patología , Trombosis de la Vena/sangre , Trombosis de la Vena/etiología , Trombosis de la Vena/patología , Trombosis de la Vena/terapiaRESUMEN
BACKGROUND: Understanding morphological changes of ascending aorta, aortic arch and descending aorta with cardiac and respiratory motion is critical for planning of endovascular repair of thoracic aorta. The aim of this study was to determine the impact of the cardiac cycle on thoracic aortic geometry. METHODS: In this retrospective study, electrocardiogram-gated cardiac computed tomography from 116 patients who were evaluated for transcatheter aortic valve replacement were reviewed. A protocol for measurements of maximal diameters and lengths of the thoracic aorta and supra-aortic vessels was established. Measurements were made in multiplanar views perpendicular to the semiautomatically created centerline on both systolic and diastolic phases. RESULTS: Mean age was 77 ± 11 years of our study cohort. Mean systolic and diastolic diameter were 31.6 ± 0.42 and 30.1 ± 4.4 mm at the sinotubular junction (STJ), 35.6 ± 4.8 and 34.8 ± 4.7 mm in the ascending aorta, 29.1 ± 3.3 and 28.5 ± 3.3 mm in the aortic arch (distal left common carotid artery), and 26.7 ± 5.4 and 25.8 ± 5.4 mm in the descending aorta. Mean diameter change was 1.5 ± 0.9 mm at the STJ, 0.8 ± 0.9 mm in the ascending aorta, 0.6 ± 0.8 mm in the aortic arch, and 0.9 ± 1.2 mm in the descending aorta. Mean arterial strain was 5.0 ± 3.2% at the level of the STJ, 2.4 ± 2.7% in the ascending aorta, 2.0 ± 2.9% in the aortic arch, and 3.9 ± 5.7% in the descending aorta. CONCLUSIONS: Our results demonstrated that small but significant circumferential and longitudinal strain was present at every aortic level. These findings may have implications for endovascular thoracic aortic repair and may provide reference values for future comparison.
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Aorta Torácica/diagnóstico por imagen , Aortografía , Técnicas de Imagen Sincronizada Cardíacas , Angiografía por Tomografía Computarizada , Electrocardiografía , Hemodinámica , Anciano , Anciano de 80 o más Años , Aorta Torácica/fisiopatología , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios RetrospectivosRESUMEN
OBJECTIVE: Type B acute aortic syndrome (AAS) encompasses aortic dissection (AD) and intramural haematoma (IMH), the diagnosis, evolution, and treatment of which are subject to controversies. The aim of this pilot investigation was to assess the ability of specific magnetic resonance imaging (MRI) criteria to differentiate AD from IMH and predict optimal aortic remodeling following AAS. METHODS: In this retrospective study, all patients presenting between 2008 and 2015 with type B AAS, who had diagnostic MRI following admission, were included. Three MRI criteria were proposed to identify IMH: (i) no visualised entry tear; (ii) no contrast uptake in the aortic lesion on the first pass angiographic run; (iii) no contrast uptake in the aortic lesion on the equilibrium phase T1 sequence. On each patient's diagnostic and follow up imaging studies, the volume of (i) false lumen/IMH, (ii) total aorta, and (iii) true lumen were calculated. Using the Wilcoxon signed rank test, the evolution of these volumes according to the presence or absence of the aforementioned criteria were compared. RESULTS: Of 39 patients, in seven all MRI criteria were positive (group IMH) and 32 had one or more negative criteria (group AD). Patients with IMH and AD were similar with respect to sex, age, and delay between onset of symptoms and diagnostic and follow up imaging studies. Eighteen patients had a follow up imaging study after a mean period of 11.2 months: six in the IMH group and 12 in the AD group. Lesion volume decrease and relative true lumen volume increase were statistically significant in group IMH (p = .046 and p = .046, respectively), whereas there was a statistically significant increase of lesion volume (p = .008) in the AD group. CONCLUSION: This pilot study proposed three simple MRI criteria to differentiate between AD and IMH. Once prospectively and clinically validated, this could have substantial therapeutic benefits as IMH are likely to heal spontaneously.
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Aneurisma de la Aorta/diagnóstico por imagen , Hematoma/diagnóstico por imagen , Angiografía por Resonancia Magnética , Cicatrización de Heridas , Anciano , Aneurisma de la Aorta/fisiopatología , Aneurisma de la Aorta/terapia , Diagnóstico Diferencial , Femenino , Hematoma/fisiopatología , Hematoma/terapia , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Síndrome , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) is an evolving technique to treat juxtarenal abdominal aortic aneurysms (AAAs). Catheterization of visceral and renal vessels after the deployment of the fenestrated main body device is often challenging, usually requiring additional fluoroscopy and multiple digital subtraction angiograms. The aim of this study was to assess the clinical utility and accuracy of a computed tomography angiography (CTA)-fluoroscopy image fusion technique in guiding visceral vessel cannulation during FEVAR. METHODS: Between August 2014 and September 2016, all consecutive patients who underwent FEVAR at our institution using image fusion guidance were included. Preoperative CTA images were fused with intraoperative fluoroscopy after coregistering with non-contrast-enhanced cone beam computed tomography (syngo 3D3D image fusion; Siemens Healthcare, Forchheim, Germany). The ostia of the visceral vessels were electronically marked on CTA images (syngo iGuide Toolbox) and overlaid on live fluoroscopy to guide vessel cannulation after fenestrated device deployment. Clinical utility of image fusion was evaluated by assessing the number of dedicated angiograms required for each visceral or renal vessel cannulation and the use of optimized C-arm angulation. Accuracy of image fusion was evaluated from video recordings by three raters using a binary qualitative assessment scale. RESULTS: A total of 26 patients (17 men; mean age, 73.8 years) underwent FEVAR during the study period for juxtarenal AAA (17), pararenal AAA (6), and thoracoabdominal aortic aneurysm (3). Video recordings of fluoroscopy from 19 cases were available for review and assessment. A total of 46 vessels were cannulated; 38 of 46 (83%) of these vessels were cannulated without angiography but based only on image fusion guidance: 9 of 11 superior mesenteric artery cannulations and 29 of 35 renal artery cannulations. Binary qualitative assessment showed that 90% (36/40) of the virtual ostia overlaid on live fluoroscopy were accurate. Optimized C-arm angulations were achieved in 35% of vessel cannulations (0/9 for superior mesenteric artery cannulation, 12/25 for renal arteries). CONCLUSIONS: Preoperative CTA-fluoroscopy image fusion guidance during FEVAR is a valuable and accurate tool that allows visceral and renal vessel cannulation without the need of dedicated angiograms, thus avoiding additional injection of contrast material and radiation exposure. Further refinements, such as accounting for device-induced aortic deformation and automating the image fusion workflow, will bolster this technology toward optimal routine clinical use.
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Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/métodos , Cateterismo Periférico/métodos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/métodos , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Vísceras/irrigación sanguínea , Anciano , Puntos Anatómicos de Referencia , Implantación de Prótesis Vascular/efectos adversos , Cateterismo Periférico/efectos adversos , Tomografía Computarizada de Haz Cónico , Procedimientos Endovasculares/efectos adversos , Femenino , Fluoroscopía , Humanos , Masculino , Imagen Multimodal , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Punciones , Reproducibilidad de los Resultados , Estudios Retrospectivos , Texas , Resultado del Tratamiento , Grabación en VideoRESUMEN
OBJECTIVE: Combining three-dimensional (3D) catheter control with electromagnetic (EM) tracking-based navigation significantly reduced fluoroscopy time and improved robotic catheter movement quality in a previous in vitro pilot study. The aim of this study was to expound on previous results and to expand the value of EM tracking with a novel feature, assistednavigation, allowing automatic catheter orientation and semiautomatic vessel cannulation. METHODS: Eighteen users navigated a robotic catheter in an aortic aneurysm phantom using an EM guidewire and a modified 9F robotic catheter with EM sensors at the tip of both leader and sheath. All users cannulated two targets, the left renal artery and posterior gate, using four visualization modes: (1) Standard fluoroscopy (control). (2) 2D biplane fluoroscopy showing real-time virtual catheter localization and orientation from EM tracking. (3) 2D biplane fluoroscopy with novel EM assisted navigation allowing the user to define the target vessel. The robotic catheter orients itself automatically toward the target; the user then only needs to advance the guidewire following this predefined optimized path to catheterize the vessel. Then, while advancing the catheter over the wire, the assisted navigation automatically modifies catheter bending and rotation in order to ensure smooth progression, avoiding loss of wire access. (4) Virtual 3D representation of the phantom showing real-time virtual catheter localization and orientation. Standard fluoroscopy was always available; cannulation and fluoroscopy times were noted for every mode and target cannulation. Quality of catheter movement was assessed by measuring the number of submovements of the catheter using the 3D coordinates of the EM sensors. A t-test was used to compare the standard fluoroscopy mode against EM tracking modes. RESULTS: EM tracking significantly reduced the mean fluoroscopy time (P < .001) and the number of submovements (P < .02) for both cannulation tasks. For the posterior gate, mean cannulation time was also significantly reduced when using EM tracking (P < .001). The use of novel EM assisted navigation feature (mode 3) showed further reduced cannulation time for the posterior gate (P = .002) and improved quality of catheter movement for the left renal artery cannulation (P = .021). CONCLUSIONS: These results confirmed the findings of a prior study that highlighted the value of combining 3D robotic catheter control and 3D navigation to improve safety and efficiency of endovascular procedures. The novel EM assisted navigation feature augments the robotic master/slave concept with automated catheter orientation toward the target and shows promising results in reducing procedure time and improving catheter motion quality.
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Aneurisma de la Aorta/cirugía , Cateterismo Periférico/instrumentación , Fenómenos Electromagnéticos , Procedimientos Endovasculares/instrumentación , Radiografía Intervencional/instrumentación , Procedimientos Quirúrgicos Robotizados/instrumentación , Dispositivos de Acceso Vascular , Aneurisma de la Aorta/diagnóstico por imagen , Automatización , Diseño de Equipo , Fluoroscopía , Humanos , Modelos Anatómicos , Tempo Operativo , Fantasmas de ImagenRESUMEN
OBJECTIVE: One limitation of the use of robotic catheters is the lack of real-time three-dimensional (3D) localization and position updating: they are still navigated based on two-dimensional (2D) X-ray fluoroscopic projection images. Our goal was to evaluate whether incorporating an electromagnetic (EM) sensor on a robotic catheter tip could improve endovascular navigation. METHODS: Six users were tasked to navigate using a robotic catheter with incorporated EM sensors in an aortic aneurysm phantom. All users cannulated two anatomic targets (left renal artery and posterior "gate") using four visualization modes: (1) standard fluoroscopy mode (control), (2) 2D fluoroscopy mode showing real-time virtual catheter orientation from EM tracking, (3) 3D model of the phantom with anteroposterior and endoluminal view, and (4) 3D model with anteroposterior and lateral view. Standard X-ray fluoroscopy was always available. Cannulation and fluoroscopy times were noted for every mode. 3D positions of the EM tip sensor were recorded at 4 Hz to establish kinematic metrics. RESULTS: The EM sensor-incorporated catheter navigated as expected according to all users. The success rate for cannulation was 100%. For the posterior gate target, mean cannulation times in minutes:seconds were 8:12, 4:19, 4:29, and 3:09, respectively, for modes 1, 2, 3 and 4 (P = .013), and mean fluoroscopy times were 274, 20, 29, and 2 seconds, respectively (P = .001). 3D path lengths, spectral arc length, root mean dimensionless jerk, and number of submovements were significantly improved when EM tracking was used (P < .05), showing higher quality of catheter movement with EM navigation. CONCLUSIONS: The EM tracked robotic catheter allowed better real-time 3D orientation, facilitating navigation, with a reduction in cannulation and fluoroscopy times and improvement of motion consistency and efficiency.
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Aneurisma de la Aorta/cirugía , Fenómenos Electromagnéticos , Procedimientos Endovasculares/instrumentación , Imanes , Procedimientos Quirúrgicos Robotizados/instrumentación , Transductores , Dispositivos de Acceso Vascular , Aneurisma de la Aorta/diagnóstico por imagen , Aortografía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Diseño de Equipo , Estudios de Factibilidad , Fluoroscopía , Humanos , Imagenología Tridimensional , Ensayo de Materiales , Modelos Anatómicos , Destreza Motora , Tempo Operativo , Estudios Prospectivos , Dosis de Radiación , Exposición a la Radiación , Interpretación de Imagen Radiográfica Asistida por Computador , Arteria Renal/diagnóstico por imagen , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Análisis y Desempeño de Tareas , Factores de TiempoRESUMEN
OBJECTIVE: Three-dimensional image fusion of preoperative computed tomography (CT) angiography with fluoroscopy using intraoperative noncontrast cone-beam CT (CBCT) has been shown to improve endovascular procedures by reducing procedure length, radiation dose, and contrast media volume. However, patients with a contraindication to CT angiography (renal insufficiency, iodinated contrast allergy) may not benefit from this image fusion technique. The primary objective of this study was to evaluate the feasibility of magnetic resonance angiography (MRA) and fluoroscopy image fusion using noncontrast CBCT as a guidance tool during complex endovascular aortic procedures, especially in patients with renal insufficiency. METHODS: All endovascular aortic procedures done under MRA image fusion guidance at a single-center were retrospectively reviewed. The patients had moderate to severe renal insufficiency and underwent diagnostic contrast-enhanced magnetic resonance imaging after gadolinium or ferumoxytol injection. Relevant vascular landmarks electronically marked in MRA images were overlaid on real-time two-dimensional fluoroscopy for image guidance, after image fusion with noncontrast intraoperative CBCT. Technical success, time for image registration, procedure time, fluoroscopy time, number of digital subtraction angiography (DSA) acquisitions before stent deployment or vessel catheterization, and renal function before and after the procedure were recorded. The image fusion accuracy was qualitatively evaluated on a binary scale by three physicians after review of image data showing virtual landmarks from MRA on fluoroscopy. RESULTS: Between November 2012 and March 2016, 10 patients underwent endovascular procedures for aortoiliac aneurysmal disease or aortic dissection using MRA image fusion guidance. All procedures were technically successful. A paired t-test analysis showed no difference between preimaging and postoperative renal function (P = .6). The mean time required for MRA-CBCT image fusion was 4:09 ± 01:31 min:sec. Total fluoroscopy time was 20.1 ± 6.9 minutes. Five of 10 patients (50%) underwent stent graft deployment without any predeployment DSA acquisition. Three of six vessels (50%) were cannulated under image fusion guidance without any precannulation DSA runs, and the remaining vessels were cannulated after one planning DSA acquisition. Qualitative evaluation showed 14 of 22 virtual landmarks (63.6%) from MRA overlaid on fluoroscopy were completely accurate, without the need for adjustment. Five of eight incorrect virtual landmarks (iliac and visceral arteries) resulted from vessel deformation caused by endovascular devices. CONCLUSIONS: Ferumoxytol or gadolinium-enhanced MRA imaging and image fusion with fluoroscopy using noncontrast CBCT is feasible and allows patients with renal insufficiency to benefit from optimal guidance during complex endovascular aortic procedures, while preserving their residual renal function.
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Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular , Angiografía por Tomografía Computarizada , Tomografía Computarizada de Haz Cónico , Procedimientos Endovasculares , Interpretación de Imagen Asistida por Computador , Imagenología Tridimensional , Angiografía por Resonancia Magnética , Imagen Multimodal/métodos , Insuficiencia Renal/complicaciones , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Aortografía/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Tomografía Computarizada de Haz Cónico/efectos adversos , Medios de Contraste/administración & dosificación , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Estudios de Factibilidad , Femenino , Óxido Ferrosoférrico/administración & dosificación , Fluoroscopía , Gadolinio DTPA/administración & dosificación , Humanos , Angiografía por Resonancia Magnética/efectos adversos , Masculino , Imagen Multimodal/efectos adversos , Tempo Operativo , Valor Predictivo de las Pruebas , Insuficiencia Renal/diagnóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Texas , Resultado del TratamientoRESUMEN
Retrograde perigraft access to the aneurysmal sac for type 2 endoleak embolization is a relevant alternative to standard transarterial and translumbar approaches. Entering the space between the graft and the iliac artery requires support and pushability, and might be challenging with standard endovascular catheters. We describe the case of a 78-year-old woman with an enlarging aneurysm due to type 2 endoleak, 3 years after EVAR. Despite multiple attempts at manual catheterization, we were unable to engage the space between the iliac wall and the stent graft. The assistance of a robotic catheter allowed for precise positioning of the wire and catheter, maximizing pushability. This permitted fast wire access to the perigraft space and facilitated catheter progress to the sac expeditiously. Endovascular robotic catheter assistance allows optimal support for such retrograde perigraft navigation for type 2 endoleak embolization.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Cateterismo , Embolización Terapéutica/métodos , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Arteria Ilíaca/cirugía , Robótica , Anciano , Angioplastia de Balón , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Endofuga/diagnóstico por imagen , Endofuga/etiología , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: The aim was to report the midterm outcome for nonagenarians with critical limb ischemia (CLI) and to identify factors affecting survival or limb salvage rates. METHODS: Nonagenarians who underwent endovascular surgery (ES), open surgery (OS), or primary amputation (PA) for CLI between 2005 and 2014 were included. Cox regression model identified factors affecting survival and limb salvage. RESULTS: ES was performed in 116 patients (119 limbs), OS in 73 patients (73 limbs), and PA in 54 patients (57 limbs). Mean follow-up was 10.38 months. There was no difference in survival between ES, OS, and PA groups: survival rate was 51.2% at 1 year and 38.9% at 2 years after ES, 48.3% at 1 year and 39.6% at 2 years after OS, and 50.6% at 1 years and 40.8% at 2 years after PA (P = 0.58). There was no difference in limb salvage between ES and OS groups: limb salvage rate was 88.2% and 77.8% at 1 and 2 years after ES and 87.3% and 77.6% at 1 and 2 years after OS. Coronary artery disease (hazard ratio [HR] 1.54; confidence interval [CI] 1.04-1.08; P = 0.01) was risk factor for death. Fully dependent state was risk factor for death (HR 4.2; CI 3.55-4.87; P < 0.001) and major amputation (HR 5.3; CI 1.32-1.67; P < 0.001). In fully dependent patients, 1-year and 2-year survival rate was 28.9% and 20.6%, respectively, and 1-year and 2-year limb salvage rate was 61.2% and 44.5%, respectively. CONCLUSIONS: With acceptable early and late mortality, limb salvage and maintenance of functional status and level of independent living, revascularization in nonagenarians is effective as long as the patient is not fully dependent.
Asunto(s)
Amputación Quirúrgica , Procedimientos Endovasculares , Isquemia/cirugía , Procedimientos Quirúrgicos Vasculares , Actividades Cotidianas , Factores de Edad , Anciano de 80 o más Años , Amputación Quirúrgica/efectos adversos , Amputación Quirúrgica/mortalidad , Distribución de Chi-Cuadrado , Enfermedad Crítica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Vida Independiente , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: Use of the forearm basilic vein for the creation of an arteriovenous fistula has been codified as second-choice vascular access for hemodialysis in the last clinical guidelines of the Society for Vascular Surgery in 2008. Poor literature data on this technical option and on its evaluation and outcomes led us to initiate a retrospective single-center study. METHODS: We analyzed the outcomes of every arteriovenous fistula using the forearm basilic vein created in our department. It is a retrospective study in which we collected data prospectively by contacting dialysis centers, nephrologists, and patients. Primary end point was primary patency rate at 1 year. Secondary end points were secondary patency rate at 1 year, time of maturation, and Doppler flow measurement before the first puncture. RESULTS: From February 2004 to June 2014, 49 forearm basilic arteriovenous fistulas were created: 33 ulnar-basilic and 16 radial basilic arteriovenous fistulas. Initial technical success rate was 98%. Functional success rate was 60%. Primary and secondary patency rates at 1 year were respectively 21% and 48%. Median time of maturation was 81 days, and mean Doppler flow measurement was 678 mL/min. Ulnar-basilic fistulas had a statistically significant shorter time of maturation than radial basilic fistulas (P ≤ 0.05). CONCLUSIONS: Despite poor primary patency rate and a long time of maturation, forearm basilic arteriovenous fistula has satisfactory secondary patency rate and keeps all the advantages of a distal-located vascular access concerning complications. It is worth its second-choice place in the current algorithm of creation of vascular access for hemodialysis.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/métodos , Arteria Braquial/cirugía , Antebrazo/irrigación sanguínea , Arteria Radial/cirugía , Diálisis Renal , Insuficiencia Renal Crónica/terapia , Venas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Derivación Arteriovenosa Quirúrgica/efectos adversos , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/fisiopatología , Femenino , Francia , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Arteria Radial/diagnóstico por imagen , Arteria Radial/fisiopatología , Flujo Sanguíneo Regional , Insuficiencia Renal Crónica/diagnóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler , Grado de Desobstrucción Vascular , Venas/diagnóstico por imagen , Venas/fisiopatología , Adulto JovenRESUMEN
Aneurysmal evolution of an aberrant right subclavian artery (ARSA) is an operative indication. Endovascular treatment is a minimally invasive procedure, which offers good short-term and midterm results. We describe a case of a 9-cm diameter ARSA aneurysm in a symptomatic man, treated with the triple-barrel technique using a thoracic aortic stent graft combined with surgical and endovascular revascularization of the supra-aortic trunks. Postoperatively, the patient developed a type III endoleak which was covered. The triple-barrel technique has been a proposed treatment approach for complex aortic arch pathologies and remains a less invasive option when compared with open surgery.
Asunto(s)
Aneurisma/cirugía , Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Anomalías Cardiovasculares/cirugía , Trastornos de Deglución/cirugía , Procedimientos Endovasculares/instrumentación , Stents , Arteria Subclavia/anomalías , Anciano , Aneurisma/diagnóstico , Aorta Torácica/anomalías , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Anomalías Cardiovasculares/diagnóstico , Trastornos de Deglución/diagnóstico , Endofuga/diagnóstico , Endofuga/etiología , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Humanos , Masculino , Diseño de Prótesis , Reoperación , Arteria Subclavia/cirugía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Patients with Crohn disease (CD) or ulcerative colitis are known to be at increased risk of arterial thromboembolic complications. We report the case of a 33-year-old woman suffering from CD for 19 years who presented lower limb claudication. Computed tomography scan revealed an aortoiliac occlusion extending from the level of the inferior mesenteric artery to both iliac bifurcations. Endovascular recanalization was attempted as a first option but failed. We then performed an aortobi-femoral bypass through a left retroperitoneal approach that allowed a total relief of the symptoms. Histologic study of the aorta demonstrated a nonspecific aortitis with lymphohistiocytic cell infiltration in the media and adventitia tunica. There was no signs of associated vasculitis. At the light of a literature review, we discussed our surgical strategy and the inflammation of the aortic wall as local factor of thrombosis that has never been previously described.