Mechanical aspiration thrombectomy for the treatment of pulmonary embolism: A systematic review and meta-analysis.

INTRODUCTION: There are no randomized trials studying the outcomes of mechanical aspiration thrombectomy (MAT) for management of pulmonary embolism (PE). METHODS: We performed a systematic review and meta-analysis of existing literature to evaluate the safety and efficacy of MAT in the setting of PE. Inclusion criteria were as follows: studies reporting more than five patients, study involved MAT, and reported clinical outcomes and pulmonary artery pressures. Studies were excluded if they failed to separate thrombectomy data from catheter-directed thrombolysis data. Databases searched include PubMed, EMBASE, Web of Science until April, 2021. RESULTS: Fourteen case series were identified, consisting of 516 total patients (mean age 58.4 ± 13.6 years). Three studies had only high-risk PE, two studies had only intermediate-risk PE, and the remaining nine studies had a combination of both high-risk and intermediate-risk PE. Six studies used the Inari FlowTriever device, five studies used the Indigo Aspiration system, and the remaining three studies used the Rotarex or Aspirex suction thrombectomy system. Four total studies employed thrombolytics in a patient-specific manner, with seven receiving local lysis and 17 receiving systemic lysis, and 40 receiving both. A random-effects meta-analyses of proportions of in-hospital mortality, major bleeding, technical success, and clinical success were calculated, which yielded estimate pooled percentages [95% CI] of 3.6% [0.7%, 7.9%], 0.5% [0.0%, 1.8%], 97.1% [94.8%, 98.4%], and 90.7% [85.5%, 94.3%]. CONCLUSION: There is significant heterogeneity in clinical, physiologic, and angiographic data in the currently available data on MAT. RCTs with consistent parameters and outcomes measures are still needed.

Relationship of Antenna Work and Ablation Cavity Volume Following Percutaneous Microwave Ablation of Hepatic Tumors.

PURPOSE: To formulate a statistical model relating ablation time, power, and work with posttreatment cavity volume following percutaneous microwave ablation of hepatic tumors in vivo. MATERIALS AND METHODS: A retrospective review (October 2015 to October 2018) yielded 122 hepatic tumors treated with microwave ablation. Ablation cavity dimensions were measured at 1-month follow-up examination and calculated using an ellipsoid volume formula. The antenna manufacturer (Neuwave Medical, Madison, Wisconsin) provided the activation time and energy used to calculate the antenna work. Generalized estimating equations with ordinary least-squares regression models were obtained to relate tumor volume with cumulative antenna work. Coefficient of determination (R2) and mean square error were used as statistical measures of model prediction performance. RESULTS: There is a logarithmic relationship between postablation cavity volume (cm3) and cumulative work (kJ), represented by the formula: log10 cm3 = -0.4583 + 0.9887 × cumulative work (log10 kJ) (R2 = 0.41, mean square error, 0.102). Ablation volumes were predicted as a function of antenna work, calculated using an antilog transformation. When a single antenna was used, ablation cavity volume was predicted using a generalized estimating equation ordinary least-squares regression model of power and time: log10cm3= -0.0546 + 0.0485 × total time (min) + 0.0107 × power (W) (R2 = 0.30; mean square error, 0.106). Using this model, a nomogram was developed to predict the postablation cavity volume based on total activation time and target power. CONCLUSION: There is a logarithmic relationship between the ablation work and posttreatment ablation cavity volume, which can be expressed in a nomogram when using a single probe.

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries.

PURPOSE: To evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR). MATERIALS AND METHODS: All patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery. RESULTS: Fifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001). CONCLUSIONS: A potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.

Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis.

PURPOSE: To evaluate safety and retrieval success of retrievable suprarenal inferior vena cava (IVC) filters. MATERIALS AND METHODS: A retrospective chart review of patients who received a retrievable suprarenal IVC filter between January 2008 and December 2017 was conducted. Suprarenal IVC filters were placed in 24 female and 27 male patients. The most common indications for filter placement were IVC thrombus (n = 20; 39.2%) and iliofemoral venous thrombosis with contraindication to anticoagulation (n = 16; 31.3%). The most common indications for suprarenal placement were IVC thrombus (n = 20; 39.2%), anatomic variants (n = 17; 33.3%), and external IVC compression (n = 8; 15.8%). Duplicated IVC was the most common anatomic variant requiring suprarenal placement (n = 7; 13.7%). RESULTS: Günther Tulip (n = 40; 78.4%), Denali (n = 10; 19.6%), and Celect (n = 1; 2.0%) filters were used. Retrieval was attempted in 27 of the 51 filters placed (52.9%). Of the 27 attempted retrievals, the technical success rate was 100% (27/27). The median dwell time was 87.0 days (95% confidence interval, 28-137 d). One complication involving fractured struts during filter retrieval occurred. No significant change in craniocaudal filter position, lateral filter tilt, or renal function between placement and retrieval was observed (P < .05). There were no instances of indwelling filter fracture. CONCLUSIONS: Suprarenal IVC filters, when indicated, can be placed and retrieved with a low complication rate.

Three-Year Efficacy and Safety of the Misago Peripheral Stent for Superficial Femoral Artery Disease: Final Results from the OSPREY Trial.

PURPOSE: This study evaluated the long-term outcomes of the Misago peripheral stent trial (Terumo) for atherosclerotic lesions in the superficial femoral artery (SFA) in patients with claudication. MATERIALS AND METHODS: This was a prospective multicenter, single-arm, clinical trial of primary stent placement for de novo cases of SFA disease conducted in the United States and Asia. The primary endpoint was freedom from clinically driven target lesion revascularization (CD-TLR) at 36 months. Secondary outcomes were ankle-brachial index (ABI), Rutherford score, Walking Impairment Questionnaire (WIQ), a quality of life survey, and rate of device fracture. RESULTS: A total of 276 patients (64.4% male; mean age, 69.3 ± 10.1 years) were enrolled. Freedom from CD-TLR was 78.5% (95% confidence interval [CI], 73.0%-83.0%) at 24 months and 75.4% (95% CI, 69.6%-80.2%) at 36 months. Baseline ABI was 0.7 ± 0.1 and 0.98 ± 0.20 (P < .001) at 30 days after the procedure. Baseline Rutherford score was 3.6 ± 0.6 and 1.6 ± 1.0 30 at 30 days after the procedure (P < .001). Mean (and changed) ABI and Rutherford score at 36 months compared to day 30 after the procedure were, respectively, 0.91 (-0.1 ± 0.2) and 1.5 (-0.2 ± 1.1). WIQ score at baseline was 21.49 ± 26.30 and 50.51 ± 38.49 at 30 days after the procedure ( P < .001). The mean WIQ score at 2 years was 46.65 ± 37.31 (P = .12). Stent fracture rate at 36 months was 2.0% (4 of 202 patients). CONCLUSIONS: OSPREY (Occlusive-Stenotic Peripheral Artery Revascularization Study) 36-month data demonstrated persistent freedom from CD-TLR and sustained improvement in ABI and Rutherford score with primary stent placement for SFA lesions.

Meta-analysis of Individual Patient Data After Kissing Stent Treatment for Aortoiliac Occlusive Disease.

PURPOSE: To evaluate short- and long-term technical and clinical outcomes after kissing stent treatment of aortoiliac occlusive disease (AIOD) based on an individual participant data (IPD) meta-analysis. MATERIALS AND METHODS: A search of the Scopus database identified 156 articles on KS treatment of AIOD; of these 22 met the inclusion criteria. Authors of 19 articles with contact information were approached to join an IPD consortium. Eight author groups responded and 5 provided anonymized data for merging into an IPD database. The number of included procedures was equal before and after 2005. The primary study outcome was the cumulative patency at 24 months. Secondary outcomes were patency at up to 60 months, complications, and changes in Rutherford category and ankle-brachial index. The predictive value of stent protrusion length, pre-/postdilation, stent type, and patient demographics on primary patency were examined with Cox proportional hazard modeling; outcomes are reported as the hazard ratio (HR). The Kaplan-Meier method was employed to estimate patency rates. RESULTS: In total, 605 (40.9%) of 1480 patients presented in the literature were included in the IPD analysis. The indication for intervention was intermittent claudication in 84.2% and critical limb ischemia in 15.8%. Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A or B in 52.8% and TASC C and D in 47.2%. The overall primary patency estimate was 81% at 24 months. Primary patency significantly increased after 2005 (p=0.005). Cox regression analysis revealed only age as a significant predictor of sustained primary patency (HR 0.60, p<0.005). Any previous endovascular intervention (HR 2.52, p=0.02) was the main predictor for loss of secondary patency; history of cardiovascular disease (HR 0.27, p=0.04) was the main predictor of sustained secondary patency. CONCLUSION: The kissing stent technique has a good safety profile and acceptable patency rates up to 2 years, even in TASC C and D lesions, supporting an endovascular-first approach for AIOD.

Impact of Venous Collaterals on Clinical Outcomes in Paget-Schroetter Syndrome.

PURPOSE: To characterize the degree of venous collateralization before and after endovascular therapy and determine the effect of collateralization on success of thrombolysis and rate of repeat intervention in patients with Paget-Schroetter syndrome. MATERIALS AND METHODS: A single-center retrospective study of 37 extremities in 36 patients (mean age, 32.64 y; range, 15-72 y; 24 men) with PSS treated with endovascular therapy from 2007 through 2017 was conducted. Venograms at presentation, after lysis, postoperatively, and at each repeat intervention were graded for venous stenosis, thrombus burden, and collateralization on a 5-point scale. Collateralization was classified as high-grade (9 extremities) or low-grade (28 extremities) based on grading of the venograms at presentation. RESULTS: Primary technical success rate for endovascular treatment was 100%. Eighty-six percent of patients (32 of 37) underwent thrombolysis, 91% (34 of 37) underwent mechanical thrombectomy, and 83% (30 of 37) underwent balloon angioplasty. Overall primary patency rate was 50% at 12 months. The repeat intervention rate within 12 months was significantly higher for extremities with high- vs low-grade collateralization (89% vs 43%; P = .016). There was a significant decrease in the median grade of collateral severity after initial intervention (2 vs 1; P = .044) and 1 day postoperatively (2 vs 1; P = .040) vs the venogram at presentation. CONCLUSIONS: Severity of venous collateralization on the venogram at presentation of patients with PSS does not appear to affect success of endovascular therapy but may predict long-term patency of affected extremities. Patients in this cohort with severe collateralization on presentation were more likely to need repeat intervention.

Predictors of All-Cause Mortality after Endovascular Aneurysm Repair: Assessing the Role of Psoas Muscle Cross-Sectional Area.

PURPOSE: To evaluate psoas muscle area (PMA) as a predictor of all-cause mortality after endovascular aneurysm repair (EVAR) and compare it with other predictor variables. MATERIAL AND METHODS: Retrospective review of 407 patients who underwent EVAR over a 7-year period was performed. Demographics, comorbidity variables, and outcomes were collected. Preprocedure computed tomography scans were used to measure the PMA. Descriptive statistics summarized the demographic information and predictor variables. Kaplan-Meier analysis and univariate and multivariate Cox proportional regression analyses were performed. The main outcome measure was survival time. RESULTS: Median survival time for patients with PMA in the lowest quartile of the distribution (≤1442 mm2) was 65.5 months (95% confidence interval [95% CI] 37.7-78.9) vs 91.2 months (95% CI 77.9-110.0 when PMA >1442 mm2). Multivariate analysis revealed lower PMA was associated with decreased survival (adjusted hazard ratio [AHR] 1.68; 95% CI 1.15-2.40, P = .006). Similarly, the presence of coronary artery disease (AHR 1.54, 95% CI 1.01-2.35, P = .045) and statin use after EVAR were associated with decreased survival (AHR 2.36, 95% CI 1.24-4.49, P = .009). Hyperlipidemia was associated with increased survival after EVAR (AHR 0.51, 95% CI 0.33-0.81, P = .004). Compared with patients with low body mass index (BMI) (<18.5), a normal BMI was associated with increased survival (AHR 0.21, 95% CI 0.08-0.53, P = .001). CONCLUSIONS: Although PMA is a risk factor for decreased survival time, other factors such as patient hyperlipidemia, presence of coronary artery disease, post-EVAR statin use, and BMI are also predictive of postoperative mortality.

Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: Results from the ATTRACT Multicenter Randomized Trial.

Few studies have documented relationships between endovascular therapy, duplex ultrasonography (DUS), post-thrombotic syndrome (PTS), and quality of life (QOL). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial randomized 692 patients with acute proximal deep vein thrombosis (DVT) to receive anticoagulation or anticoagulation plus pharmacomechanical catheter-directed thrombolysis (PCDT). Compression DUS was obtained at baseline, 1 month and 12 months. Reflux DUS was obtained at 12 months in a subset of 126 patients. Clinical outcomes were collected over 24 months. At 1 month, patients who received PCDT had less residual thrombus compared to Control patients, evidenced by non-compressible common femoral vein (CFV) (21% vs 35%, p < 0.0001), femoral vein (51% vs 70%, p < 0.0001), and popliteal vein (61% vs 74%, p < 0.0001). At 12 months, in the ultrasound substudy, valvular reflux prevalence was similar between groups (85% vs 91%, p = 0.35). CFV non-compressibility at 1 month was associated with higher rates of any PTS (61% vs 46%, p < 0.001), a higher incidence of moderate-or-severe PTS (30% vs 19%, p = 0.003), and worse QOL (difference 8.2 VEINES-QOL (VEnous INsufficiency Epidemiological and Economic Study on Quality of Life) points; p = 0.004) at 24 months. Valvular reflux at 12 months was associated with moderate-or-severe PTS at 24 months (30% vs 0%, p = 0.01). In summary, PCDT results in less residual thrombus but does not reduce venous valvular reflux. CFV non-compressibility at 1 month is associated with more PTS, more severe PTS, and worse QOL at 24 months. Valvular reflux may predispose to moderate-or-severe PTS. ClinicalTrials.gov Identifier NCT00790335.

Midterm Follow-up of Ureteral Embolization Using Vascular Plugs and N-Butyl Cyanoacrylate Glue.

This is a retrospective study of 9 consecutive female patients who underwent ureteral embolization via a "sandwich" technique with two vascular plugs and N-butyl cyanoacrylate glue for ureteral fistulae unresponsive to urinary diversion. Average age was 61 years (range, 39-77 y), average duration of diversion was 48 days (range, 2-120 d), and average follow-up was 11 months (range, 4-23 mo). Seven patients (78%) experienced immediate resolution of urinary leakage, and the other 2 (22%) required unilateral repeat treatment for resolution of leakage. Symptom resolution lasted throughout the follow-up period for all patients. Bilateral internal iliac artery pseudoaneurysms developed in 1 patient and were treated with embolization and stent placement.

One-year outcomes of the U.S. and Japanese regulatory trial of the Misago stent for treatment of superficial femoral artery disease (OSPREY study).

OBJECTIVE: The purpose of this study was to assess the safety and efficacy of the Misago stent (Terumo Corp, Tokyo, Japan) in occlusive and stenotic superficial femoral artery (SFA) disease. METHODS: The safety and efficacy of the Misago SFA stent were evaluated prospectively in this initial collaboration trial between Japan and the United States. Because this trial enrolled patients mainly from Japan and the United States and because there is a question as to whether a race difference exists in SFA stent performance, the race difference on outcome was also analyzed. In addition, results were compared with a prior SFA stent trial. RESULTS: The Misago stent was implanted in 261 subjects with TransAtlantic Inter-Society Consensus (TASC) type A and type B SFA lesions (201 subjects in the United States, 50 in Japan, 9 in Taiwan, 1 in South Korea). The mean age of the patients was 69.3 ± 10.0 years, and the mean lesion length was 83.8 ± 41.3 mm. The overall 12-month primary patency rate and clinically driven target lesion revascularization were 82.9% and 13.0%, respectively. Regional differences within the Occlusive/Stenotic Peripheral Artery Revascularization Study (OSPREY) and outcomes between U.S. and Asian patients were similar, including primary patency (82.9% vs 83.0%; P = .889), clinically driven target lesion revascularization (13.4% vs 11.7%; P = .829), stent fracture rate (1.3% vs 0.0%; P = 1.000), and stent thrombosis rate (0.5% vs 0.0%; P = 1.000). CONCLUSIONS: OSPREY 12-month data showed satisfactory outcome of the Misago stent for the treatment of TASC type A and type B SFA lesions and appears to be comparable to recent stent trials. In addition, the lack of difference in outcome among races supports the value of international trials.

Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease.

PURPOSE: To evaluate limb salvage after recanalization of lower extremity arteries using retrograde pedal access in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective review was performed of all patients in whom retrograde pedal arterial access was used for recanalization of infrainguinal occlusive disease between September 2002 and January 2013. Treatment was performed in 99 limbs in 92 patients (64 men and 28 women; median age, 71.6 y; range, 44-91 y) with CLI and no appropriate venous conduit for surgical bypass. Treated limbs were classified as Rutherford class 5 or 6 in 88% and class 4 in 12%. Retrograde and antegrade accesses were combined when occlusions could not be crossed from the antegrade direction. The treated occlusive segments were limited to the femoropopliteal arteries in 22% of procedures, runoff arteries in 32%, or both segments in 46%. Technical success was defined as successful crossing of the lesion and achievement of inline flow to the pedal vessel. Kaplan-Meier analysis was performed to determine limb salvage rate. RESULTS: Technical success was achieved in 88 of 99 (89%) treated limbs. Stents were placed for suboptimal angioplasty results in 41 of 88 (47%) successfully treated limbs. Major complications occurred in 8 of 99 (8%) procedures, 3 of which resulted in periprocedural mortality. Median follow-up was 8 months (mean, 17 mo; range, 1-98 mo). The limb salvage rate for technically successful cases was 74% at 6 months, 64% at 12 months, and 55% at 24 months. CONCLUSIONS: Retrograde pedal access is a viable revascularization technique for achieving limb salvage in patients with CLI.

Transcaval Aortic Access for Percutaneous Thoracic Aortic Aneurysm Repair: Initial Human Experience.

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. The present report describes its use for thoracic endovascular aortic repair (TEVAR) in a 61-year-old man with a descending thoracic aneurysm. Transcaval access was performed in lieu of a surgical iliac conduit in view of small atherosclerotic pelvic arteries. TEVAR was successfully performed, followed by intervascular tract occlusion with the use of a ventricular septal occluder. Computed tomography 2 d later demonstrated no extravasation. At 1 mo, the aneurysm was free of endoleaks, the aortocaval tract had healed, and the patient had returned to baseline functional status.

Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta.

PURPOSE: To report outcomes of coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR). MATERIALS AND METHODS: A retrospective review was performed of 285 patients (160 male) with a mean age of 62 years (range, 13-91 y) who underwent TEVAR at a single institution between March 2005 and May 2013. The LSCA was covered to obtain an adequate proximal landing zone, and a selective LSCA revascularization and embolization strategy was employed. All patient outcomes were recorded including neurologic complications, left arm claudication, endoleak rates, and repeat procedures. RESULTS: The origin of the LSCA was covered in 98/285 (34%) patients. Median follow-up was 533 days (range, 2-2,895 d). Cerebrovascular accident (CVA) rates for covered LSCA and noncovered groups were 11/98 (11%) and 5/188 (3%), respectively (P = .005). LSCA was revascularized at time of initial TEVAR in 44/98 (45%) patients. Of the remaining 54 patients, 10 (19%) required subsequent revascularization for claudication. LSCA embolization was done to prevent or treat endoleak in 41/98 (42%) patients, with 33/98 (34%) patients undergoing LSCA embolization at the time of LSCA coverage and 8 of the remaining 65 (12%) patients requiring subsequent embolization for persistent endoleak. CONCLUSIONS: Coverage of the LSCA during TEVAR is feasible with low complication rates, although it carries an increased risk of CVA. The selective LSCA revascularization and embolization strategy was well tolerated. A more liberal strategy may be required to decrease the rate of delayed revascularization and embolization procedures to treat arm claudication and endoleaks, respectively.

Secondary procedures following thoracic aortic stent grafting in the first 3 years of the VALOR test and VALOR II trials.

PURPOSE: To compare the durability of thoracic endovascular aortic repair (TEVAR) in two similar clinical trials that used early- and later-generation stent grafts. MATERIALS AND METHODS: Secondary procedures from the prospective, nonrandomized, multicenter, clinical trial databases of the test arm of the VALOR and VALOR II trials were analyzed at 3 years. Descriptive and statistical analyses were employed to compare the rate of and potential predictors for secondary procedures. RESULTS: A total of 127 and 96 patients were available for a minimum of 3 years of follow-up in the test arm of VALOR and VALOR II, respectively. By the first year after the index procedure, VALOR II patients were significantly less likely to have undergone a secondary procedure versus patients in the test arm of VALOR (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01-0.63; P = .02), with most procedures performed for type I endoleak. Multivariate predictors at 3 years for the need for a secondary procedure in the VALOR test arm were maximum aneurysm diameter (P = .002) and aneurysm length (P = .01), both of which remained significant at the end of the study period. The estimated freedoms from secondary procedures in the VALOR test arm and VALOR II at 3 years were 85.1% (95% CI, 78.5%-89.8%) and 94.9% (95% CI, 88.8%-97.7%), respectively (P < .001). CONCLUSIONS: The rate of secondary procedures after TEVAR differed between the two cohorts, being substantially lower in the VALOR II trial at 1 year of follow-up. This finding suggests significant benefit from advances in some combination of operator experience, imaging systems, treatment planning, and device design.

Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration.

PURPOSE: To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). MATERIALS AND METHODS: A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. RESULTS: The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). CONCLUSIONS: BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Combined transmesenteric and transhepatic recanalization of chronic portal and mesenteric vein occlusion to treat bleeding duodenal varices.

Two patients presented with bleeding duodenal varices secondary to mesenteric and portal vein chronic occlusion. After a failed transhepatic recanalization, a combined transmesenteric and transhepatic approach was used to recanalize the chronic portal and mesenteric venous obstruction. The occluded segment was treated with transmesenteric stent placement in one patient and stent placement and coil embolization of varices in the second patient. Follow-up imaging and endoscopy showed decompression of the duodenal varices in both patients and absence of further bleeding episodes.

Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy.

PURPOSE: To report the outcomes following catheter angiography with or without embolization in patients with acute upper gastrointestinal nonvariceal hemorrhage (UGINH). MATERIALS AND METHODS: A review of electronic medical records was performed to identify all potential patients for this study between 2001 and 2011. Patients with first-time UGINH who required angiographic localization and endovascular treatment were included. Patients with variceal bleeding and prior surgical or endovascular intervention for the gastrointestinal system were excluded. Society of Interventional Radiology guidelines and American College of Radiology "appropriateness criteria" reporting standards were followed. RESULTS: We identified 74 patients (men/women=46/28) with a mean age of 60 years. Thirty-four patients were found to have active bleeding on angiography. One patient from this group did not undergo embolization because of an angiographic diagnosis of aortoenteric fistula. Technical failure was encountered in 2/34 patients; therefore, the technical success of embolization was 94%. Forty of 74 patients showed no angiographic evidence of active bleeding; 18 patients underwent prophylactic embolization using endoscopically placed clips as targets; and 22 patients had no embolotherapy. Thus, we grouped the patients into 3 groups: (1) therapeutic embolization; (2) prophylactic/empiric embolization; and (3) no embolotherapy groups. The clinical success of embolization was 67% to 68% in the therapeutic embolization group and 67% in the prophylactic embolization group. Early rebleeding rates were 33.8%, 51.6%, 33.3%, and 12% among all the patients, the therapeutic embolization group, the prophylactic embolization group, and the no endovascular treatment group, respectively. Mortality was significantly high in patients with advanced age (P=0.001), cerebrovascular disorders (P=0.037), and positive angiography (P=0.026), even when clinical success was achieved. CONCLUSIONS: Acute UGINH remains a clinical challenge with increased mortality rates, even with high technical success rates. Patients with negative findings on angiography have lower early rebleeding rates than patients with active bleeding during angiography or endoscopy-guided prophylactic/empiric embolization.

Is fibromuscular dysplasia underdiagnosed? A comparison of the prevalence of FMD seen in CORAL trial participants versus a single institution population of renal donor candidates.

Renal artery fibromuscular dysplasia (FMD) may be underdiagnosed. We evaluated the prevalence of FMD in CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) renal artery stent trial participants, in which FMD was an exclusion criterion for inclusion. We also evaluated the prevalence of FMD in a relatively healthy population of patients undergoing computed tomographic angiographic (CTA) screening for renal donor evaluation. All renal donor CTAs performed at our institution from January 2003 through November 2011 were retrospectively reviewed for the presence of FMD along with patient sex and age. These results were compared to angiographic core lab (ACL) findings for the CORAL trial. The CORAL ACL database contained 997 patients (mean age 69.3 years; 50% female). Fifty-eight (5.8%) CORAL trial patients (mean age 71.8 years; 75.9% female) demonstrated incidental FMD. The renal donor cohort included 220 patients (mean age 40.5 years; 64.5% female). Five (2.3%) demonstrated FMD (mean age 48.6 years; all female). The odds of FMD in the CORAL cohort were 2.65 times that seen in the renal donor cohort (95% CI: 1.12, 7.57). In C: onclusion, the 5.8% prevalence of renal artery FMD in the CORAL trial population, the presence of which was biased against, suggests underdiagnosis.