Geniculate Artery Embolization in Patients With Recurrent Hemarthrosis After Knee Arthroplasty: A Retrospective Study.

BACKGROUND: Recurrent hemarthrosis after knee arthroplasty is an uncommon and disabling complication of this frequently performed procedure. Selective endovascular embolization of the geniculate arteries is one of the therapeutic options to manage this complication. The purpose of this study is to analyze the effectiveness of this treatment in patients suffering from recurrent hemarthrosis after knee arthroplasty. METHODS: We performed a retrospective study of 31 patients (39 embolization procedures) with recurrent hemarthrosis after knee arthroplasty. There were 17 men and 14 women with a median age of 67 years (range 48-90). All patients were referred for geniculate artery embolization between January 2007 and November 2016. RESULTS: Twenty-seven procedures were executed on the right side and 12 on the left side. Total knee arthroplasty was performed on 29 patients, only 2 patients underwent unicompartmental knee arthroplasty. Embolization of the superior geniculate arteries was achieved in all patients. In 12 of 39 procedures (31%), at least 1 of the inferior geniculate arteries could not be catheterized, therefore embolization was achieved through collaterals. Symptomatic improvement was observed in 26 of 31 patients (84%). Discomfort or mild postprocedural pain was observed in most patients, needing only minor pain medication, mostly resolving within 24 hours. Two patients presented with a severe complication: a 48-year-old male patient developed septic arthritis and an 85-year-old hypertensive female patient treated with anticoagulants showed aseptic necrosis of the femoral condyles. CONCLUSION: Embolization of geniculate arteries is a safe and effective treatment in recurrent hemarthrosis post knee arthroplasty. Clinical improvement was seen in most patients.

4-French-compatible endovascular material is safe and effective in the treatment of femoropopliteal occlusive disease: results of the 4-EVER trial.

PURPOSE: To report the 1-year results of a prospective multicenter trial to evaluate the safety and efficacy of treating symptomatic femoropopliteal occlusive disease using 4-F-compatible materials and no closure device. METHODS: The non-randomized 4-EVER trial (4-F endovascular treatment approach to infrainguinal disease) was conducted at 5 European hospitals (ClinicalTrials.gov identifier NCT01413139). The protocol mandated the use of only 4-F sheaths, self-expanding nitinol stents (Astron Pulsar or Pulsar-18 stent), and balloons from a single manufacturer. Between June 2010 and June 2011, 120 symptomatic patients (82 men; mean age 71±9.7 years, range 47-90), primarily claudicants, treated for 120 femoropopliteal lesions (>90% TASC A/B) were enrolled. The mean lesion length was 71.0±45.9 mm. Follow-up evaluations were scheduled on day 1 and at 1, 6, 12, and 24 months. A duplex ultrasound was performed on all follow-up visits to determine vessel patency (primary outcome measure at 1 year), and biplanar radiography was performed at 12 and 24 months to assess stent fracture. RESULTS: Stents were successfully implanted in all patients: an Astron Pulsar stent in 70 (58.3%) lesions and a Pulsar-18 stent in 46 (38.3%); 4 (3.3%) patients had both stents implanted for flow-limiting dissection after predilation. No closure devices were used; the mean manual compression time was 8.1 minutes (2-15). Four (3.3%) patients developed significant hematoma at the puncture site, but none required surgical repair. The overall 12-month primary patency rate was 81.4%: 85.2% for the Astron Pulsar and 73.4% for the Pulsar-18 (p=0.236). Freedom from target lesion revascularization at 12 months for the entire cohort was 89.3%. CONCLUSION: Compared to published historical data for superficial femoral artery type A/B lesion stenting using 6-F devices, the 4-F devices applied in this trial showed similar patency at 12 months, fewer access site complications, and shorter manual compression times, supporting the supposition that 4-F endovascular treatment is safe and effective.

Renal Pseudoaneurysm with Associated Arteriovenous Fistula as a Cause of Delayed Bleeding after Percutaneous Nephrolithotomy: A Case Report and Current Literature Review.

Background: Pseudoaneurysm (PA) with associated arteriovenous fistula (AVF) is a rare delayed bleeding complication, occurring in less than 1% of patients after percutaneous nephrolithotomy (PNL). Case presentation. A 54-year-old man underwent PNL on February 28, 2023, for a large renal calculus in the right kidney lower pole, with postoperative delayed bleeding: macroscopic hematuria and bladder clot retention after 3 weeks. An iatrogenic PA and AVF were diagnosed after the failure of conservative measures. The patient was successfully treated with superselective angioembolization (SAE) under local anesthesia. Conclusion: Late hemorrhagic complications after PNL can be severe. Rapid identification of a renal PA and AVF with SAE has a high success rate and low complication rate, avoiding prolonged hospitalization time and major renal surgery for this patient.

Can angiographic Flat Detector Computed Tomography blood volume measurement be used to predict final infarct size in acute ischemic stroke?

INTRODUCTION AND PURPOSE: Flat detector computed tomography (FD-CT) technology is becoming more widely available in the angiography suites of comprehensive stroke centers. In patients with acute ischemic stroke (AIS), who are referred for endovascular therapy (EVT), FD-CT generates cerebral pooled blood volume (PBV) maps, which might help in predicting the final infarct area. We retrospectively analyzed pre- and post-recanalization therapy quantitative PBV measurements in both the infarcted and hypoperfused brain areas of AIS patients referred for EVT. MATERIALS AND METHODS: We included AIS patients with large vessel occlusion in the anterior circulation referred for EVT from primary stroke centers to our comprehensive stroke center. The pre- and post-recanalization FD-CT regional relative PBV (rPBV) values were measured between ipsilateral lesional and contralateral non-lesional areas based on final infarct area on post EVT follow-up cross-sectional imaging. Statistical analysis was performed to identify differences in PBV values between infarcted and non-infarcted, recanalized brain areas. RESULTS: We included 20 AIS patients. Mean age was 63 years (ranging from 36 to 86 years). The mean pre- EVT rPBV value was 0.57 (±0.40) for infarcted areas and 0.75 (±0.43) for hypoperfusion areas. The mean differences (Δ) between pre- and post-EVT rPBV values for infarcted and hypoperfused areas were respectively 0.69 (±0.59) and 0.69 (±0.90). We found no significant differences (p > 0.05) between pre-EVT rPBV and ΔrPBV values of infarct areas and hypoperfusion areas. CONCLUSION: Angiographic PBV mapping is useful for the detection of cerebral perfusion deficits, especially in combination with the fill run images. However, we were not able to distinguish irreversibly infarcted tissue from potentially salvageable, hypoperfused brain tissue based on quantitative PBV measurement in AIS patients.

Transarterial Chemoembolization With Drug-Eluting Beads Versus Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Outcomes From a Multicenter, Randomized, Phase 2 Trial (the TRENDY Trial).

PURPOSE: To compare transarterial chemoembolization delivered with drug eluting beads (TACE-DEB) with stereotactioc body radiation therapy (SBRT) in patients with hepatocellular carcinoma (HCC) in a multicenter randomized trial. METHODS AND MATERIALS: Patients were included if they were eligible for TACE. They could also be recruited if they required treatment prior to liver transplantation. A maximum of four TACE-DEB procedures and ablation after incomplete TACE-DEB were both allowed. SBRT was delivered in six fractions of 8-9Gy. Primary end point was time to progression (TTP). Secondary endpoints were local control (LC), overall survival (OS), response rate (RR), toxicity, and quality of life (QoL). The calculated sample size was 100 patients. RESULTS: Between May 2015 and April 2020, 30 patients were randomized to the study. Due to slow accrual the trial was closed prematurely. Two patients in the SBRT arm were considered ineligible leaving 16 patients in the TACE-DEB arm and 12 in the SBRT arm. Median follow-up was 28.1 months. Median TTP was 12 months for TACEDEB and 19 months for SBRT (p=0.15). Median LC was 12 months for TACE-DEB and >40 months (not reached) for SBRT (p=0.075). Median OS was 36.8 months for TACEDEB and 44.1 months for SBRT (p=0.36). A post-hoc analysis showed 100% for SBRT 1- and 2-year LC, and 54.4% and 43.6% for TACE-DEB (p=0.019). Both treatments resulted in RR>80%. Three episodes of possibly related toxicity grade ≥3 were observed after TACE-DEB. No episodes were observed after SBRT. QoL remained stable after both treatment arms. CONCLUSIONS: In this trial, TTP after TACE-DEB was not significantly improved by SBRT, while SBRT showed higher local antitumoral activity than TACE-DEB, without detrimental effects on OS, toxicity and QoL. To overcome poor accrual in randomized trials that include SBRT, and to generate evidence for including SBRT in treatment guidelines, international cooperation is needed.

Flat Detector CT with Cerebral Pooled Blood Volume Perfusion in the Angiography Suite: From Diagnostics to Treatment Monitoring.

C-arm flat-panel detector computed tomographic (CT) imaging in the angiography suite increasingly plays an important part during interventional neuroradiological procedures. In addition to conventional angiographic imaging of blood vessels, flat detector CT (FD CT) imaging allows simultaneous 3D visualization of parenchymal and vascular structures of the brain. Next to imaging of anatomical structures, it is also possible to perform FD CT perfusion imaging of the brain by means of cerebral blood volume (CBV) or pooled blood volume (PBV) mapping during steady state contrast administration. This enables more adequate decision making during interventional neuroradiological procedures, based on real-time insights into brain perfusion on the spot, obviating time consuming and often difficult transportation of the (anesthetized) patient to conventional cross-sectional imaging modalities. In this paper we review the literature about the nature of FD CT PBV mapping in patients and demonstrate its current use for diagnosis and treatment monitoring in interventional neuroradiology.

Visceral artery pseudoaneurysms: two case reports and a review of the literature.

BACKGROUND: Visceral artery pseudoaneurysms are relatively rare but have a high mortality rate in case of rupture. Their detection in the last decades is rising due to an increased use of computed tomography and angiography. However, due to the nonspecific nature of the clinical symptoms and signs, diagnosis is often delayed or missed. We describe two cases of patients presenting with nonspecific abdominal complaints and anemia leading to a diagnosis of visceral pseudoaneurysm. Both cases are successfully treated with a different endovascular intervention. CASE PRESENTATION: The first case is a 67-year-old Caucasian man presenting with diffuse abdominal pain, vomiting, diarrhea, and weight loss. Digital angiography showed a complex pseudoaneurysm of the superior mesenteric artery. The patient was treated with stent placement and selective embolization of the afferent branches. The second patient is a 78-year-old Caucasian man with a history of chronic pancreatitis admitted with epigastric pain, rectal bleeding and melena. Angiography showed a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated with coil embolization. CONCLUSIONS: We report two cases of visceral pseudoaneurysms and review the literature concerning etiology, presentation, diagnosis, and treatment. Visceral artery pseudoaneurysms should be considered in the differential diagnosis of a patient with nonspecific abdominal symptoms. Diagnosis is often made with computed tomography or computed tomography angiography but digital angiography remains the gold standard. Treatment options include surgical, endovascular or percutaneous interventions. The choice of treatment is case specific.

Severe hemoptysis 6 years after coronary artery bypass grafting.

A patient with a history of coronary artery bypass grafting was admitted with severe hemoptysis. Bronchoscopy showed recent bleeding with clot formation in the lingular bronchus, but no tumor was visualized. Several biopsies of the underlying mucosa were negative. Coronary angiography showed patent venous and arterial bypass grafts. Selective angiography of the left internal mammary artery revealed one large and two smaller aberrant bronchial side branches, which probably caused the lingular hemorrhage. We performed embolization of the largest aberrant branch. After a follow-up of 3 months, hemoptysis had not recurred.

Basilar artery thrombosis in a trauma patient. Case report and review of the literature.

Thrombotic disease of the vertebrobasilar circulation is associated with a poor prognosis. It may occur in trauma patients, especially those with neck injuries and even several months after the initial insult. We report on the case of a young polytrauma patient, victim of a traffic accident, with associated cervical and thoracic spinal injuries resulting in paraplegia. Consciousness was not impaired initially, but during transfer to our hospital he became suddenly unconscious. An occluded basilar artery was found on angiography, but unfortunately we were unable to reopen the vessel with thrombolytic therapy. This case again proves that lesions of the vertebro-basilar system must always be suspected in neck injuries. Even after minor whiplash injuries, fatal basilar thrombosis may occur. A review of all reported cases of traumatic basilar artery thrombosis is given and the use of thrombolytic therapy is discussed.

Spontaneous dissection of the celiac trunk: a rare cause of abdominal pain--case report and review of the literature.

Spontaneous dissection of the celiac trunk is uncommon and rarely considered in patients presenting with acute onset of epigastric pain. We report the case of a 48-year old male, diagnosed with a spontaneous dissection of the celiac trunk extending towards the common hepatic artery. He was treated conservatively and remained asymptomatic after two years of follow-up. Conservative treatment seems justified in the absence of bowel ischemia or signs of hemorrhage. Initial Computed Tomography angiography revealed the presence of a dissection with a pseudoaneurysm that remained stable and regressed towards a normal Computed Tomography angiography after 7 months of follow-up. Radiologic follow-up is warranted as progression of the dissection and/or total occlusion with or without symptoms can occur. The risk factors, the natural course and optimal treatment remain unclear due to the rarity of the disorder. Our patient had no predisposing cardiovascular risk factors. Nevertheless, we observed a hypertrophic ligamentum arcuatum on Computed Tomography, possibly facilitating the evolution towards a dissection. Next to the case report, we provide a review of the available literature.

The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: : To present our results and demonstrate advantages of rapid endovascular balloon occlusion (REBO) of the juxtarenal aorta in unstable patients with ruptured abdominal aortic aneurysm (rAAA). METHODS: : Since 2006, all unstable patients with rAAA are immediately transferred to the operating room (OR). No computed tomography scan is performed once diagnosis is made on ultrasound examination. Instability is defined as systolic blood pressure less than 60 mm Hg, unconsciousness, cardiac ischemia, or intubation. Once arrived in the OR, a Reliant aortic balloon is introduced and inflated at the level of the renal arteries. Subsequently, an angiogram is made through the contralateral femoral artery in order to decide between open or endovascular repair (EVAR). RESULTS: : Twelve patients with rAAA were defined as unstable. REBO was installed within 10 minutes after arrival in the OR. Aortic occlusion resulted in immediate hemodynamic stability. Five patients were suitable for EVAR. Seven patients had open repair. For these abdominal dissection was more careful since no instability was encountered. All patients survived the procedure except one. Mean stay on intensive care unit was 19.7 days for open group and 8.4 for EVAR. CONCLUSIONS: : REBO of the juxtarenal abdominal aorta by pc technique in unstable patients with rAAA resulted in a 17% 30-day mortality and a 100% 1-year event-free follow-up for survivors. With this technique, EVAR exclusion is still a valuable treatment. Exposure and decision making for the open group is easier to perform with less risk for additional damaging to neighboring structures during dissection since urgent cross-clamping is not necessary.

AMS INSIGHT--absorbable metal stent implantation for treatment of below-the-knee critical limb ischemia: 6-month analysis.

Endoluminal treatment of infrapopliteal artery lesions is a matter of controversy. Bioabsorbable stents are discussed as a means to combine mechanical prevention of vessel recoil with the advantages of long-term perspectives. The possibility of not having a permanent metallic implant could permit the occurrence of positive remodeling with lumen enlargement to compensate for the development of new lesions. The present study was designed to investigate the safety of absorbable metal stents (AMSs) in the infrapopliteal arteries based on 1- and 6-month clinical follow-up and efficacy based on 6-month angiographic patency. One hundred seventeen patients with 149 lesions with chronic limb ischemia (CLI) were randomized to implantation of an AMS (60 patients, 74 lesions) or stand-alone percutaneous transluminal angioplasty (PTA; 57 patients, 75 lesions). Seven PTA-group patients "crossed over" to AMS stenting. The study population consisted of patients with symptomatic CLI (Rutherford categories 4 and 5) and de novo stenotic (>50%) or occlusive atherosclerotic disease of the infrapopliteal arteries who presented with a reference diameter of between 3.0 and 3.5 mm and a lesion length of <15 mm. The primary safety endpoint was defined as absence of major amputation and/or death within 30 days after index intervention and the primary efficacy endpoint was the 6-month angiographic patency rate as confirmed by core-lab quantitative vessel analysis. The 30-day complication rate was 5.3% (3/57) and 5.0% (3/60) in patients randomized for PTA alone and PTA followed by AMS implantation, respectively. On an intention-to-treat basis, the 6-month angiographic patency rate for lesions treated with AMS (31.8%) was significantly lower (p = 0.013) than the rate for those treated with PTA (58.0%). Although the present study indicates that the AMS technology can be safely applied, it did not demonstrate efficacy in long-term patency over standard PTA in the infrapopliteal vessels.