Comparing Mobile C-Arm with a Hybrid Operating Room for Imaging in Fenestrated Stent-Graft Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: To evaluate the advantages of a hybrid operating room (OR) (group 2) compared with a fluoroscopic mobile C-arm (group 1) during fenestrated stent-graft endovascular aneurysm repair (f-EVAR). METHODS: This single-center study retrospectively analyzed prospectively collected data of consecutive patients treated with f-EVAR for short-necked, juxtarenal, and suprarenal aortic aneurysms between January 2006 and July 2016. Primary end points were technical success and perioperative complications. Secondary end points included 30-day and 1-year mortality as well as target vessel patency. RESULTS: About 96 patients were treated (85 men; 74.1 ± 6.3 years); 46 patients (48%) belonging to group 1 and 50 (52%) patients belonging to group 2. Technical success was achieved in 92.7% of the procedures (group 1 91.3% vs. group 2 94%, P = 0.72). Significantly more complex interventions were performed in group 2 (n = 38 of 50) compared with group 1 (n = 14 of 46; P < 0.001), in which primarily renal f-EVAR interventions were performed. In group 2, significantly less contrast was used (median 150 mL vs. 100 mL; P < 0.001). The 30-day mortality in group 1 was 9% and 2% in group 2 (P = 0.14), and 1-year survival was also not significantly different between both groups. Target visceral vessel primary patency was significantly higher in group 1 (87.6% vs. 85.5% [P = 0.006] and 83.8% vs. 78.3% [P = 0.03]) at 6 and 12 months, respectively). There was no significant difference in renal artery primary patency at 6 and 12 months. CONCLUSIONS: Immediate and 1-year outcomes after f-EVAR for abdominal aortic aneurysm were comparable using a hybrid OR compared with a mobile C-arm, despite the use of significantly more complex stent grafts in the patients treated in the hybrid OR. The use of a hybrid OR may assist in achieving satisfying results in complex f-EVAR.

A Stopped Pilot Study of the ProGlide Closure Device After Transbrachial Endovascular Interventions.

Purpose: To evaluate the feasibility and safety of the suture-mediated ProGlide device in closure of the brachial artery after endovascular interventions. Materials and Methods: From 2016 to 2017, a pilot study was performed using the ProGlide to achieve hemostasis after percutaneous access of distal brachial arteries >4 mm in diameter. In an interim analysis, the results were compared to a matched control group taken from a 60-patient historical cohort who underwent brachial artery access and manual compression to achieve hemostasis between 2014 and 2017. The primary outcome was access-related reintervention and the secondary outcome was the incidence of access-site complications. Results: Seven patients (mean age 67.9 years; 6 men) were enrolled in the study before it was stopped in 2017. Four patients experienced 6 access-site complications (neuropathy, hematoma, occlusion, and pseudoaneurysm). These resulted in 3 access-related reinterventions: surgical evacuation of a hematoma, thrombectomy of the occluded brachial artery, and surgical repair of the pseudoaneurysm. In the interim comparison to the 19 matched patients (mean age 61.9 years; 6 men), the ProGlide group had proportionally more patients experiencing access-related complications (57% vs 16% for manual compression, p=0.035) and resultant reinterventions (43% vs 11%, p=0.064). Based on this data the trial was stopped. Conclusion: Considering this experience, it is not advisable to use the ProGlide in transbrachial endovascular interventions due to the high incidence of complications and access-related reinterventions.

A Systematic Review and Meta-Analysis on Outcomes and Complications of Percutaneous Endoscopic Versus Radiologic Gastrostomy for Enteral Feeding.

BACKGROUND: The optimal technique for long-term enteral feeding has not yet been established. Both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are widely used. Aim was to extensively review outcomes of PEG and PRG. MATERIALS AND METHODS: A systematic review using Medline, Embase, and Cochrane was performed, using standardized tools for assessing bias. Main outcomes were infectious and tube-related complications, procedure related and 30-day mortality. Pooled risk differences (RDs) with corresponding 95% confidence intervals (95% CIs) were calculated using random effects. Arcsine transformations were applied. RESULTS: In total, 344 studies were identified, of which 16 were included, reporting on 934 PEGs and 1093 PRGs. No differences were found for infectious complications [RD, 0.03 (-0.05 to 0.11)], procedure-related mortality [RD, 0.01 (-0.04 to 0.06)], or 30-day mortality [RD, 0.06 (-0.01 to 0.13)]. Tube-related complications were higher in PRG [RD, 0.16 (0.06-0.26)]. Subgroup analysis was performed for head and neck cancer (HNC) and motor neuron disease. In HNC, this revealed significantly lower tube-related complications and procedure-related mortality after PEG. In motor neuron disease, no differences were seen. The level of evidence appears sufficient considering the low degree of heterogeneity. CONCLUSIONS: No differences were found with regard to mortality or infectious complications. PEG showed lower risk of tube-related complications. Subgroup analysis revealed PEG to be favorable in HNC based on lower rates of procedure-related mortality and tube-related complications. Local experience and availability should be taken into account in the decision process.

Implementation of Size-Dependent Local Diagnostic Reference Levels for CT Angiography.

OBJECTIVE: Diagnostic reference levels (DRLs) are established for standard-sized patients; however, patient dose in CT depends on patient size. The purpose of this study was to introduce a method for setting size-dependent local diagnostic reference levels (LDRLs) and to evaluate these LDRLs in comparison with size-independent LDRLs and with respect to image quality. MATERIALS AND METHODS: One hundred eighty-four aortic CT angiography (CTA) examinations performed on either a second-generation or third-generation dual-source CT scanner were included; we refer to the second-generation dual-source CT scanner as "CT1" and the third-generation dual-source CT scanner as "CT2." The volume CT dose index (CTDIvol) and patient diameter (i.e., the water-equivalent diameter) were retrieved by dose-monitoring software. Size-dependent DRLs based on a linear regression of the CTDIvol versus patient size were set by scanner type. Size-independent DRLs were set by the 5th and 95th percentiles of the CTDIvol values. Objective image quality was assessed using the signal-to-noise ratio (SNR), and subjective image quality was assessed using a 4-point Likert scale. RESULTS: The CTDIvol depended on patient size and scanner type (R2 = 0.72 and 0.78, respectively; slope = 0.05 and 0.02 mGy/mm; p < 0.001). Of the outliers identified by size-independent DRLs, 30% (CT1) and 67% (CT2) were adequately dosed when considering patient size. Alternatively, 30% (CT1) and 70% (CT2) of the outliers found with size-dependent DRLs were not identified using size-independent DRLs. A negative correlation was found between SNR and CTDIvol (R2 = 0.36 for CT1 and 0.45 for CT2). However, all outliers had a subjective image quality score of sufficient or better. CONCLUSION: We introduce a method for setting size-dependent LDRLs in CTA. Size-dependent LDRLs are relevant for assessing the appropriateness of the radiation dose for an individual patient on a specific CT scanner.

Endovascular treatment of complex aortic aneurysms: prevalence of acute kidney injury and effect on long-term renal function.

OBJECTIVES: To analyse predictors for short- and long-term renal function changes after fenestrated and branched endovascular aortic repair (EVAR). METHODS: A total of 157 patients underwent fenestrated and branched EVAR. Procedural intra-arterial iodinated contrast volume was documented. Serum creatinine and estimated glomerular filtration rate (eGFR) at baseline, during 48 h following EVAR, at discharge and latest moment of follow-up were recorded. Development of post-EVAR acute kidney injury (AKI; according to AKIN criteria), and potential risk factors for renal failure were recorded. Multivariate regression analyses were used to identify independent risk factors for AKI and eGFR decrease during follow-up. RESULTS: Forty-three patients (28 %) developed post-EVAR AKI. Long procedure time and occlusion of accessory renal arteries were independent risk factors for development of AKI. (odds ratio (OR) 1.005 per minute, 95 % CI 1.001-1.01; p = 0.025 and OR 3.02, 95 % CI 1.19-8.16; p = 0.029). Post-EVAR AKI was associated with a significantly increased risk for eGFR decrease at discharge and latest follow-up (hazard ratio (HR) 3.47, 95 % CI 1.63-7.36, p = 0.001 and HR 3.01, 95 % CI 1.56-5.80; p = 0.001). Iodinated contrast volume was not an independent risk factor for AKI or eGFR decrease during follow-up. CONCLUSION: Development of post-EVAR AKI is an independent risk factor for long-term renal function decrease. KEY POINTS: • Longer procedure time is associated with an increased risk for AKI. • Renal perfusion defects on angiography are associated with increased risk for AKI. • Post-EVAR AKI is associated with higher probability for long-term eGFR decrease. • Iodinated contrast volume is not an independent risk factor for AKI. • Iodinated contrast volume is not an independent risk factor for long-term eGFR decrease.

Quantification of Respiratory Movement of the Aorta and Side Branches.

PURPOSE: To assess and quantify the magnitude and direction of respiratory movement of the aorta and origins of its side branches. METHODS: A quantitative 3-dimensional (3D) subtraction analysis of computed tomography (CT) scans during inspiration and expiration was performed to determine the respiratory geometric movements of the aorta and side branches in 60 patients. During breath-hold expiration and inspiration, 1-mm-thick CT slices of the aorta were acquired in unenhanced and contrast-enhanced scans. The datasets were compared using dedicated multiplanar reformation image subtraction software to determine the change in position of relevant anatomic sections, including the ascending thoracic aorta (AA), the origins of the brachiocephalic artery (BA) and left subclavian artery (LSA), the descending thoracic aorta (DTA) at the level of the tenth thoracic vertebra, as well as the origins of the celiac trunk, superior mesenteric artery, and the renal arteries. RESULTS: Complex movement was visible during inspiration; the regions of interest in the thoracic aorta and side branches moved in the anterior, medial, and caudal directions compared with the expiration state. Mean 3D movement vectors (± standard deviation) were 8.9±3.6 mm (AA), 12.0±4.1 mm (BA), 11.1±3.9 mm (LSA), and 4.9±2.5 mm (DTA). Abdominal side branches moved in the caudal direction 1.3±1.1 mm. There was significantly less movement in the DTA compared to AA (p<0.001). The correlation coefficient between the extent of LSA movement and thoracic excursion was 0.78. CONCLUSION: The aorta and side branches undergo considerable respiratory movement. The results from this study provide an important contribution to understanding aortic dynamics.

FLOW: Flow dysfunction of hemodialysis vascular access: A randomized controlled trial on the effectiveness of surveillance of arteriovenous fistulas and grafts.

INTRODUCTION: It is assumed that identification and correction of asymptomatic stenoses in the vascular access circuit will prevent thrombosis that would require urgent intervention to continue hemodialysis treatment. However, the evidence base for this assumption is limited. Recent international clinical practice guidelines reach different conclusions on the use of surveillance for vascular access flow dysfunction and recommend further research to inform clinical practice. METHODS: The FLOW trial is a double-blind, multicenter, randomized controlled trial with a 1:1 individual participant treatment allocation ratio over two study arms. In the intervention group, only symptomatic vascular access stenoses detected by clinical monitoring are treated, whereas in the comparison group asymptomatic stenoses detected by surveillance using monthly dilution flow measurements are treated as well. Hemodialysis patients with a functional arteriovenous vascular access are enrolled. The primary outcome is the access-related intervention rate that will be analyzed using a general linear model with Poisson distribution. Secondary outcomes include patient satisfaction, access-related serious adverse events, and quality of the surveillance process. A cost effectiveness analysis and budget impact analysis will also be conducted. The study requires 828 patient-years of follow-up in 417 participants to detect a difference of 0.25 access-related interventions per year between study groups. DISCUSSION: As one of the largest randomized controlled trials assessing the clinical impact of vascular access surveillance using a strong double-blinded study design, we believe the FLOW trial will provide much-needed evidence to improve vascular access care for hemodialysis patients.

Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms.

BACKGROUND: The impact of stent-graft complexity on clinical outcome after fenestrated endovascular aortic aneurysm repair (FEVAR) has been conflicting in the literature. The objective of this study was to compare mid-term results of stent-grafts with renal fenestrations alone with more complex stent-grafts including mesenteric fenestrations. METHODS: A single center retrospective study was conducted on 154 patients, who underwent FEVAR from 2006 to 2020 at our institution. RESULTS: There were 54 (35.1%) patients in the renal FEVAR group and 100 (64.9%) patients in the complex FEVAR group. Median follow-up of the total group was 25 months (IQR 7-45). There were no significant differences in technical success and perioperative mortality. Intraoperative complications (4% vs. 18%, P=0.001), operative time (145 min vs. 191 min, P=0.001), radiation dose (119372 mGy*cm2 vs. 159573 mGy*cm2, P=0.004) and fluoroscopy time (39 min vs. 54 min, P=0.007) were significantly lower in the renal FEVAR group. During follow-up target vessel instability, endoleaks and reinterventions were not significantly different between the two groups. CONCLUSIONS: In this single center retrospective study, renal FEVAR was a safe and effective treatment for patients with juxtarenal AAA demonstrating fewer intraoperative complications and similar mid-term outcomes as complex FEVAR. If the anatomy is compatible for renal FEVAR, it might be unnecessary to expose patients to potentially more complications by choosing a complex FEVAR strategy.

12Fr-Pigtail Versus 14Fr-Balloon Percutaneous Radiologic Gastrostomy (PRG), Retrospective Evaluation of Outcomes and Complications; A Maastricht University Medical Centre Study.

PURPOSE: To retrospectively compare tube and placement related results of a 12Fr-pigtail and a 14Fr-balloon gastrostomy tube. MATERIALS AND METHODS: All consecutive patients who underwent percutaneous radiologic gastrostomy (PRG) between January 2016 and June 2020 were enrolled in this retrospective single-center analysis. Follow-up for all patients was 180 days. Mortality after 30 days, technical success, days to first complication within 180 days, reason of unexpected visit (tube, anchor or pain related), and tube specific complications (obstruction, pain, luxation, leakage) were taken as outcome measures. Data were obtained from both PACS software and electronic health records. RESULTS: A total of 247 patients were enrolled (12Fr-pigtail: n = 139 patients and 14Fr-balloon: n = 108 patients). 30-day mortality was very low in both groups and never procedure related. Technical success was 99% in both groups. The average number of complications within 180 days after initial PRG placement was significantly higher in the 12Fr-pigtail group (12Fr-pigtail: 0.93 vs. 14Fr-balloon: 0.64, p = 0.028). Time to first complication within 180 days was significantly longer in the 14Fr-balloon group (12Fr-pigtail: 29 days vs. 14Fr-balloon: 53 days, p = 0.005). In the 14Fr-balloon group, the rate of tube-related complications (luxation and obstruction) was significantly lower compared to 12Fr-pigtail (29% vs. 45%, p = 0.011). CONCLUSION: 14Fr-balloon gastrostomy tubes have significantly lower (tube-related) complications rates and longer time to first complication compared to 12Fr-pigtail tubes. No procedure-related mortality was observed in either group. Technical success was very high in both groups. Level of Evidence Level 3, non-controlled retrospective cohort study.

Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients. METHODS AND ANALYSIS: OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year. ETHICS AND DISSEMINATION: Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines. TRIAL REGISTRATION NUMBER: NL7933. PROTOCOL VERSION AND DATE: V.5, 25 February 2021.

Use of the reversed Zenith iliac limb extension in the treatment of iliac artery aneurysms and various aortoiliac pathologies: outcome in midterm follow-up.

PURPOSE: To report the midterm follow-up after treatment of various aortoiliac pathologies in an acute setting using reversed Zenith iliac limb extensions when appropriately sized stent-grafts were not available. METHODS: From 2005 to 2007, 12 patients (10 men; mean age 71.5 ± 7.3 years) were treated with reversed Zenith iliac limb extensions for solitary iliac artery aneurysms (n = 8), an abdominal aortic aneurysm (AAA) in a small caliber aorta (n = 1), an anastomotic pseudoaneurysm in an aortobi-iliac graft (n = 1), a hypogastric artery aneurysm (n = 1), and a ruptured AAA secondary to a late type Ib endoleak after Talent stent-graft implantation (n = 1). The Zenith iliac limb extensions were deployed on the back table and reloaded in a reversed manner to treat aneurysms and other lesions with a broad range of different diameter necks and landing zones. RESULTS: The technical success rate was 100%, and no endoleaks were present at the end of the procedures. The endoleak patient with the ruptured AAA died owing to respiratory insufficiency. The other 11 patients have a mean follow-up of 29±9 months. In this period, 2 patients received a femorofemoral crossover bypass because of an occluded iliac limb extension. One patient had a type II endoleak without growth of the iliac aneurysm. Two patients died of a ruptured 4.4-cm AAA at 16 months and of respiratory insufficiency due to metastases at 47 months, respectively. CONCLUSION: When necessary, it is feasible to use a revered Zenith limb extension to treat solitary iliac aneurysms and other aortoiliac pathologies, achieving satisfactory midterm outcomes.

CIRSE Clinical Practice Manual.

BACKGROUND: Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care. PURPOSE: To provide principles for delivering high quality of care in IR. METHODS: Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services. RESULTS: There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient's condition with the interventional radiologists taking ultimate responsibility for the patient's outcomes. CONCLUSIONS: The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial.

BACKGROUND: Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function. OBJECTIVE: To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function. DESIGN: Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment. SETTING: 10 European medical centers. PARTICIPANTS: 140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater. INTERVENTION: Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin. MEASUREMENTS: The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality. RESULTS: Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points. LIMITATION: Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting. CONCLUSION: Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Percutaneous transhepatic portal vein stenting as rescue treatment for recurrent oesophageal variceal bleeding in a 31-year-old woman with haepatocellular carcinoma in a non-cirrhotic liver.

A 31-year-old woman with hepatocellular carcinoma suffered from recurrent oesophageal variceal bleeding due to portal hypertension, which was caused by severe compression of the portal vein by metastatic lymph nodes. Endoscopic band ligation and pharmacological treatment did not suffice to prevent recurrence of variceal bleeding. Eventually, after the fifth variceal bleeding within 6 months, the patient was admitted to the intensive care unit in a haemodynamic shock. A Sengstaken-Blakemore tube was inserted and all treatment options were discussed, but only percutaneous transhepatic recanalisation of the portal vein with stent placement to reduce portal vein pressure was thought to be feasible with any chance to relieve portal vein pressure. After successful portal vein stenting, our patient did not have any recurrent bleeding in the remaining year of her life. We suggest that percutaneous transhepatic portal vein stenting may be a feasible and adequate last line treatment for complications of portal hypertension.

Stabilization of a steerable sheath during retrograde access to antegrade-oriented branches in complex endovascular aortic aneurysm repair.

During branched endovascular aneurysm repair, cannulation of the visceral target vessels through antegrade branches and insertion of bridging stents are frequently done from an upper extremity access. A retrograde femoral approach is a challenging alternative when an antegrade approach is not preferred. Herein, we describe a technique to increase stability of a steerable sheath, using a single suture, for bridging antegrade-facing branches from a retrograde access. This technique secures the sheath's deflected tip and provides more pushability to the steerable sheath.

Novel diagnostic and imaging techniques in endovascular iliac artery procedures.

INTRODUCTION: Endovascular revascularization has become the preferred treatment for most patients with iliac artery obstructions, with a high rate of clinical and technical success. AREAS COVERED: This review will describe novel developments in the diagnosis and treatment of iliac artery obstructions including the augmentation of preprocedural imaging with advanced flow models, image fusion techniques, and state-of-the-art device-tracking capabilities. EXPERT OPINION: The combination of these developments will change the endovascular field within the next 5 years, allowing targeted iliac treatment without the need for radiographic imaging or iodinated contrast media.

Surgical or endovascular repair of thrombosed dialysis vascular access: is there any evidence?

INTRODUCTION: Endovascular and surgical strategies have been used to manage patients with thrombosed vascular access for hemodialysis. We analyzed the evidence to see whether endovascular or surgical treatment has the best outcome in terms of primary success rate and long-term patency. METHODS: We performed a systematic literature search of endovascular and surgical repair of thrombosed hemodialysis vascular access. The analysis included meta-analysis, randomized, and population-based studies of thrombosed arteriovenous fistulae and grafts. RESULTS: One meta-analysis and eight randomized studies on the treatment of arteriovenous graft thrombosis were identified. Studies conducted before 2002 demonstrated a significantly better primary success rate and primary and secondary patencies of surgical thrombectomy vs endovascular intervention. After 2002, similar results of both techniques have been reported. Only population-based studies on the treatment of thrombosed autogenous arteriovenous fistulae have been published, showing similar outcome of surgical and endovascular intervention in terms of primary success. The long-term primary and secondary patencies are slightly better for surgical treatment, but this concerns only forearm fistulae. CONCLUSIONS: The outcome of endovascular and surgical intervention for thrombosed vascular access is comparable, in particular for thrombosed prosthetic grafts. Surgical treatment of autogenous arteriovenous fistulae is likely to have benefit compared with endovascular means. Definitive randomized trials are needed to provide the level 1 evidence to resolve this latter issue.

Retrograde catheterization of haemodialysis fistulae and grafts: angiographic depiction of the entire vascular access tree and stenosis treatment.

BACKGROUND: The European Best Practice Guidelines on Vascular Access propose magnetic resonance angiography (MRA) of dysfunctional dialysis fistulae and grafts if visualization of the complete arterial inflow and outflow vessels is needed. In a prospective multi-centre study we determined the technical success rate of complete vascular access tree depiction by digital subtraction angiography (DSA) as an alternative to MRA. Instead of a more invasive brachial artery of femoral artery approach, we performed a retrograde catheterization of the venous outflow or graft, and stenoses were treated in connection with DSA. METHODS: A catheter was advanced into the central arterial inflow after retrograde puncture of the venous outflow or graft for depiction of the complete inflow, access region and complete outflow. Access DSA through femoral artery puncture was done if the retrograde approach failed to depict the complete vascular access tree. Stenoses with a luminal diameter reduction >or=50% were treated, if possible, in connection with DSA. RESULTS: A total of 116 dysfunctional haemodialysis fistulae and 50 grafts were included. Retrograde DSA depicted the complete vascular tree in 162 patients (97.6%). The arteriovenous anastomosis of four fistulae could not be negotiated by a catheter. DSA demonstrated 247 significant stenoses: 30, 128 and 89 were located in the arterial inflow (12.1%), AV anastomosis and graft region (51.8%) and venous outflow (36.0%), respectively. Ten patients (6.0%) had no stenosis. Eight (4.8%), 55 (33.1%) and 33 (19.9%) patients demonstrated stenoses in only inflow, access region or outflow, respectively. Stenoses in two or three vascular territories were present in 53 (31.9%) and 7 (4.2%) patients, respectively. A technically successful endovascular intervention was obtained in 135 of the 139 patients (97.1%) who underwent angioplasty and/or stent placement. Additional sheath insertion by antegrade outflow puncture was needed in 46 patients (33.1%) for the treatment of coexisting venous outflow stenoses, located downstream from the retrograde positioned sheath. Two minor complications were observed at DSA/angioplasty. CONCLUSION: As an alternative to MRA, full retrograde DSA is safe and effective for stenosis detection and stenosis treatment. However, access evaluation by a non-invasive imaging modality such as colour duplex ultrasound will be sufficient in most cases as proximal inflow stenoses are encountered in a minority of patients. Full retrograde DSA, including complete arterial inflow depiction, may then be reserved for cases with an unsuccessful outcome following endovascular intervention of stenoses depicted at ultrasound.

Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding: a retrospective analysis on outcomes and complications.

Background and study aims Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are techniques used for long-term enteral feeding. Our primary aim was to analyze procedure-related and 30-day mortality and complications between PEG and PRG in relation to indications. Patients and methods A single-center retrospective analysis was performed thath included all adult patients receiving initial PEG (January 2008 until April 2016) and PRG (January 2010 until April 2016). Outcomes were mortality (procedure-related, 30-day), complications (early (≤ 30 days) and late) and success rates. Results A total of 760 procedures (469 PRG and 291 PEG) were analyzed. Most common indications were head and neck cancer (HNC), cerebrovascular accident (CVA) and amyotrophic lateral sclerosis (ALS). Success rates for placement were 91.2 % for PEG and 97.1 % for PRG ( P  = 0.001). Procedure-related mortality was 1.7 % in PEG and 0.4 % in PRG ( P  = 0.113). The 30-day mortality was 10.7 % in PEG and 5.1 % in PRG ( P  = 0.481 after multivariate logistic regression) CVA was associated with higher 30-day mortality, whereas ALS, higher body weight, and prophylactic placements in HNC were associated with lower rates. Tube-related complications were less frequent in PEG, both early (2.7 % vs. 26.4 %, P  ≤ 0.001) and late (8.6 % vs. 31.5 %, P  ≤ 0.001). The percentage of major complications and infections did not differ. Conclusions With respect to procedure-related and 30-day mortality, PEG and PRG compare equally. PRG had a higher procedural success rate. Tube-related complications and pain are less frequent after PEG compared to PRG. The choice for either PEG or PRG therefore should primarily be based on local facilities and expertise.

A Technical Report on the Performance of a New Large Bore Cerebral Aspiration Catheter, the First Results.

AIMS AND BACKGROUND: We describe the initial results of the Syphontrack Super Distal Access (SDA) catheter (InNeuroco Inc., Sunrise, Fl, USA) used for endovascular treatment of patients with acute ischemic stroke of the anterior circulation. METHODS: A retrospective review of prospectively collected data from June 2017 to May 2018 in Maastricht University Medical Center plus (MUMC +) with direct distal aspiration or a combination of distal aspiration with stent retriever thrombectomy was performed. Primary outcome measurements were accessibility and reperfusion grade (eTICI). Secondary outcome measurements were early neurologic recovery (a decrease of four or more points on the NIHSS), symptomatic intracranial hemorrhage (sICH) within 24 h and mRS score at 3 months. RESULTS: The first 50 patients in whom the SDA catheter was used are included. Direct distal aspiration was performed in 33/50 (66%). In 29/33 (88%), distal position in contact with the clot was achieved of which 15 (52%) were successful (eTICI 2b or higher) after first attempt. Total successful reperfusion rate was 23/50 (46%) after first pass. Final successful reperfusion, after multiple attempts, was reached in 48/50 (96%). Early neurologic recovery was seen in 21/50 (42%), and functional independence (mRS score of 0-2) at 3 months was achieved in 17/50 (35%). sICH occurred in 4/50 (8%) within 24 h post-procedural. CONCLUSION: In our clinical practice, endovascular treatment of ischemic stroke with the SDA catheter had similar technical and clinical results as reported in the literature.