Midterm Outcomes of Primary and Secondary Use of an Endoanchor System for Thoracic and Abdominal Aortic Endovascular Aortic Repair.

PURPOSE: To assess the safety, technical success, and midterm outcomes of endoanchor (Heli-FX, Medtronic, Santa Rosa, California) deployment in thoracic endovascular aortic repair (TEVAR) or abdominal endovascular aortic repair (EVAR). MATERIALS AND METHODS: This single-institution, retrospective study of all endoanchor procedures was performed from February 1, 2017 to March 30, 2021. All procedures were performed percutaneously by interventional radiologists. Clinical information and outcome data were retrieved from electronic medical records. Fifty patients (14% females, n = 7; 86% males, n = 43; median age, 79 years [range, 56-93 years]) underwent Endoanchor procedures, with 349 Endoanchors implanted; 33 procedures were primary deployments (at initial stent deployment) and 17 were secondary deployments (previous stent deployment). For the primary group (4 TEVARs and 29 EVARs), indications were prophylactic (n = 30), hostile neck (n = 28), hostile distal landing zone (n = 2), and intraprocedural type 1a endoleaks (n = 3). For the secondary group (4 TEVARs and 13 EVARs), indications were graft migration (n = 8), seal zone expansion without proven endoleak (n = 7) (proximal [n = 4] or distal seal [n = 3]), and proven type 1a endoleak (n = 2). RESULTS: Median number of endoanchors deployed per procedure was 7 (range, 3-10). Median time to deploy endoanchors was 22 minutes (range, 8-46 minutes). The technical success rate of Endoanchor was 99.7% (348/349). The 30-day mortality rate was 0%. The overall adverse event rate was 6% (n = 3). Reinterventions were performed in 12% of patients (n = 6). Median follow-up was 38 months (range, 2-71 months). Overall survival at 1 and 3 years was 95% and 85%, respectively. Overall freedom from type 1a endoleak at 1 and 3 years was 96% and 93%, respectively. CONCLUSIONS: Endoanchor procedures are safe with excellent technical success rate and good midterm clinical outcomes.

Prognostic imaging biomarkers for diabetic kidney disease (iBEAt): study protocol.

BACKGROUND: Diabetic kidney disease (DKD) remains one of the leading causes of premature death in diabetes. DKD is classified on albuminuria and reduced kidney function (estimated glomerular filtration rate (eGFR)) but these have modest value for predicting future renal status. There is an unmet need for biomarkers that can be used in clinical settings which also improve prediction of renal decline on top of routinely available data, particularly in the early stages. The iBEAt study of the BEAt-DKD project aims to determine whether renal imaging biomarkers (magnetic resonance imaging (MRI) and ultrasound (US)) provide insight into the pathogenesis and heterogeneity of DKD (primary aim) and whether they have potential as prognostic biomarkers in DKD (secondary aim). METHODS: iBEAt is a prospective multi-centre observational cohort study recruiting 500 patients with type 2 diabetes (T2D) and eGFR ≥30 ml/min/1.73m2. At baseline, blood and urine will be collected, clinical examinations will be performed, and medical history will be obtained. These assessments will be repeated annually for 3 years. At baseline each participant will also undergo quantitative renal MRI and US with central processing of MRI images. Biological samples will be stored in a central laboratory for biomarker and validation studies, and data in a central data depository. Data analysis will explore the potential associations between imaging biomarkers and renal function, and whether the imaging biomarkers improve the prediction of DKD progression. Ancillary substudies will: (1) validate imaging biomarkers against renal histopathology; (2) validate MRI based renal blood flow measurements against H2O15 positron-emission tomography (PET); (3) validate methods for (semi-)automated processing of renal MRI; (4) examine longitudinal changes in imaging biomarkers; (5) examine whether glycocalyx and microvascular measures are associated with imaging biomarkers and eGFR decline; (6) explore whether the findings in T2D can be extrapolated to type 1 diabetes. DISCUSSION: iBEAt is the largest DKD imaging study to date and will provide valuable insights into the progression and heterogeneity of DKD. The results may contribute to a more personalised approach to DKD management in patients with T2D. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT03716401 ).

Hepatocellular carcinoma: modern image-guided therapies.

The most common primary malignancy of the liver and the third leading cause of cancer mortality worldwide is hepatocellular carcinoma (HCC), which presents a major global health problem due to its increasing incidence. Most cases of HCC are secondary to either infection (hepatitis B or C) or cirrhosis (alcohol being the most common cause). Clinical presentation is variable and the tumour can be an incidental finding. Treatment options for HCC and prognosis are dependent on many factors but most importantly tumour size and staging. The last two decades have revolutionised the treatment of HCC using image-guided techniques. The concepts of imaging and image-guided techniques are still young and not well described in standard textbooks and hence an up to date review article is essential. The clinical subspecialities may lack familiarity with image-guided techniques but are responsible for management of these patients before and after the treatment by interventional radiologists. This article reviews current image-guided techniques, evidence and outcomes and provides educational highlights and question and answers. The article provides an overview in a simple understandable manner to enable readers from various levels of practice and training to benefit from and apply in their practice.

Acute aortic syndrome-pitfalls on gated and non-gated CT scan.

Acute aortic syndrome (AAS) is a life-threatening condition which includes aortic dissection (AD), penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Multi-detector computed tomography (MDCT) plays a crucial role in the diagnosis of this condition and for further clinical follow-up. It is important for radiologists to be aware of common pitfalls in cardiac-gated and non-gated CT in diagnosing AAS. They should also be wary of common mimics of AAS which may make a significant difference towards management of these patients. In this review, we present from our practice some of the common pitfalls and mimics of AAS on MDCT.

Imaging Real-Time Coronary Anatomy Using a Three-Dimensional Electrophysiology Mapping System.

The aim of this study is to evaluate the feasibility of creating fast three-dimensional maps of coronary arteries and to develop a bipolar coronary guidewire in vitro and determine whether it can be localised accurately within the model.A total of five patients were recruited, and EnSite Precision was utilised to create 3D coronary anatomy. A water bath to accommodate a 3D-printed coronary model was developed to test the performance of the bipolar angioplasty wire.Successful guidewire localisation and 3D reconstruction of coronary anatomy were achieved in all the cases. No complications. The bipolar wire was able to collect point clouds, and localisation of the distal tip was excellent when tested in the water bath.Our study demonstrates the feasibility and safety of utilising EAMS to collect coronary anatomy. Real-time tracking with a bipolar catheter is accurate when tested in vitro.

Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention.

OBJECTIVE: The aim of this pictorial essay is to illustrate the radiologic patterns, sites of bleeding, and vascular interventional techniques used in the management of postpancreatectomy hemorrhage. CONCLUSION: Hemorrhagic complications occur in fewer than 10% of patients after Whipple pancreatoduodenectomy but account for as many as 38% of deaths. Bleeding typically occurs from the stump of the gastroduodenal artery, but other sites of bleeding are increasingly recognized.

Technique-Based Evaluation of Clinical Outcomes and Aortic Remodelling Following TEVAR in Acute and Subacute Type B Aortic Dissection.

INTRODUCTION: To evaluate the clinical outcomes and aortic remodelling rates following thoracic endovascular aortic repair (TEVAR) for acute or subacute type B aortic dissection (TBAD) based on technique. MATERIAL AND METHODS: All TEVARs for acute/subacute TBAD between 01/01/2008 and 01/06/2020 were included. TEVARS were grouped by technique (TEVAR only, PETTICOAT and STABILISE). Aortic remodelling was assessed at three aortic levels on follow-up CT. Thirty-day technical/clinical success rates, re-intervention rates and complications were recorded. RESULTS: A total of 29 patients were included. The median age was 55 years (31-82). The median duration from initial presentation to TEVAR was 7 days (0-84). Intra-procedural complications included one aortic rupture from balloon moulding in a STABILISE case. Thirty-day mortality, stroke, spinal cord ischaemia and visceral ischaemia were 3% (n = 1), 3% (n = 1), 3% (n = 1) and 3% (n = 1), respectively. (All occurred in acute TBAD.) Overall survival was 50.5 months (18-115). Median follow-up was 31 months (1-115). Six patients (21%) required re-intervention, with a median time of 5 months (5-46) from first TEVAR. Overall complete aortic remodelling rates were: 89% at the proximal descending thoracic aorta, 78% at the distal thoracic aorta and 50% at the infra-renal abdominal aorta. At the infra-renal aorta, the STABILISE group (n = 11) had a higher complete aortic remodelling rate (82%) compared to TEVAR alone (n = 12) (20%). CONCLUSION: Endovascular intervention for acute and subacute TBAD is safe with a high rate of technical success. STABILISE results in higher aortic remodelling at the infra-renal aorta (82%) compared to TEVAR alone (20%) but risks aortic rupture from balloon moulding.

Pictorial review on the endovascular management of paediatric aortic injuries.

Paediatric aortic trauma is a rare injury which can be fatal if not identified and managed appropriately. Surgical repair remains the gold-standard in moderate to severe aortic injuries. In the last decade however, endovascular treatment has gained popularity in children who have suitable vascular anatomy for intervention and are either not fit for surgery or in whom, endovascular intervention is the only alternative that will make a difference in the clinical outcome. Children pose a unique set of challenges to endovascular therapy. In this article, we aim to illustrate the different endovascular options that are available for the treatment of acute traumatic aortic injury and visceral thromboembolisation through pictorial representation. We will also demonstrate the feasibility and the limitation of this technique.

Computational tools for clinical support: a multi-scale compliant model for haemodynamic simulations in an aortic dissection based on multi-modal imaging data.

Aortic dissection (AD) is a vascular condition with high morbidity and mortality rates. Computational fluid dynamics (CFD) can provide insight into the progression of AD and aid clinical decisions; however, oversimplified modelling assumptions and high computational cost compromise the accuracy of the information and impede clinical translation. To overcome these limitations, a patient-specific CFD multi-scale approach coupled to Windkessel boundary conditions and accounting for wall compliance was developed and used to study a patient with AD. A new moving boundary algorithm was implemented to capture wall displacement and a rich in vivo clinical dataset was used to tune model parameters and for validation. Comparisons between in silico and in vivo data showed that this approach successfully captures flow and pressure waves for the patient-specific AD and is able to predict the pressure in the false lumen (FL), a critical variable for the clinical management of the condition. Results showed regions of low and oscillatory wall shear stress which, together with higher diastolic pressures predicted in the FL, may indicate risk of expansion. This study, at the interface of engineering and medicine, demonstrates a relatively simple and computationally efficient approach to account for arterial deformation and wave propagation phenomena in a three-dimensional model of AD, representing a step forward in the use of CFD as a potential tool for AD management and clinical support.

Endovascular stent graft repair of suture-line pseudoaneurysm following ascending aorta replacement.

Ascending aorta pseudoaneurysm (AAPA) is an uncommon complication following replacement of the ascending aorta with a prosthetic graft, carry a high risk of rupture, and warrant urgent intervention. The open surgical procedure "gold standard" of care is not always favorable, as the reoperations are technically more difficult or patient's general condition doesn't allow proceeding. Case discussed is an 80-year-old male patient who presented with worsening cough and hemoptysis. He underwent ascending aorta replacement 10 years ago. Computed tomography (CT) scan revealed a contrast-filled mediastinal mass communicating with the ascending aorta and extended into the right lung. Due to the patient's advanced age, friability and clinical condition, combined with the position of the AAPA behind the sternum, surgery was deemed to be high risk. However, favorable anatomical conditions provided a safe landing zone for an endovascular stent. The patient underwent closed procedure. Postprocedure CT showed complete obliteration of the AAPA.

Endovascular management of extra-cranial supra-aortic vascular injuries.

Supra-aortic vessel injuries are uncommon but can be life-threatening and surgically challenging. Trauma to these vessels may be blunt or penetrating, including iatrogenic trauma following the insertion of central venous lines, which may be preventable. Recent advances in technology have resulted in endovascular therapy becoming a common first-line treatment, and interventional radiologists now play a major role in the management of these vascular injuries. We review the literature on the endovascular management of these types of injuries and describe a spectrum of case-based extra-cranial supra-aortic vascular injuries managed at our institution and the range of imaging appearances, including active contrast extravasation, traumatic vessel occlusion, true aneurysms, pseudoaneurysms, and arteriovenous fistulae.

Iliac artery occlusion with "oxbow lake" formation following stent deployment in a tortuous external iliac artery during EVAR: a case report.

In this case report, we describe a complication that we term the "oxbow lake" deformity. This phenomenon occurs when a tortuous elongated external iliac artery segment is artificially straightened by an iliac stent resulting in kinking and compression of a redundant loop with lumen compromise. We describe the anatomy, corrective treatment, and outcome. This occurrence is potentially foreseeable with tortuous vascular anatomy and recognition can allow appropriate management planning avoiding complications for the patient.

Lower respiratory tract infection and rapid expansion of an abdominal aortic aneurysm: a case report.

INTRODUCTION: The rate of abdominal aortic aneurysm expansion is related to multiple factors. There is some evidence that inflammation can accelerate aneurysm expansion. However, the association between pulmonary sepsis and rapid abdominal aortic aneurysm expansion is rarely reported. CASE PRESENTATION: Here we present a case of a rapidly expanding abdominal aortic aneurysm in a 68-year-old Caucasian man with a concomitant lower respiratory tract infection and systemic sepsis requiring intensive monitoring and urgent endovascular intervention. Our patient had an uncomplicated post-operative recovery and a follow-up computed tomography scan at one month demonstrated no evidence of an endoleak. CONCLUSION: This case highlights the potential association between pulmonary sepsis and rapid abdominal aortic aneurysm expansion. In such cases, a policy of frequent monitoring should be adopted to identify those patients requiring definitive management.

Preoperative imaging of left portal vein at the Rex recess for Rex shunt formation using wedged hepatic vein carbon dioxide portography.

BACKGROUND: In children with extrahepatic portal vein obstruction (EHPVO), formation of a mesentericoportal bypass (Rex shunt) restores hepatopetal flow, relieves portal hypertension, and reduces variceal bleeding and hypersplenism. The Rex shunt is created by inserting a vein graft between the superior mesenteric vein and the umbilical segment (Rex) of the left portal vein within the Rex recess of the liver. The preoperative evaluation of a patient with EHPVO includes an accurate assessment of the venous inflow and outflow. The inflow portal vein is readily assessed by ultrasound and magnetic resonance imaging. The outflow intrahepatic portal vein is harder to assess. We report our experience of patients evaluated with wedged hepatic vein carbon dioxide portography (WHVCP). METHOD: All children referred for venography from October 2001 to October 2007 were prospectively identified, and clinical and radiologic data were reviewed retrospectively. The imaging findings were correlated to findings at surgery. RESULTS: Eleven children (range, 3-14 years, median, 6 years) were referred for preoperative wedged hepatic venography. The left portal vein at the Rex recess was clearly identified in 9 patients (82%). In the other 2 patients (18%), the Rex segment was not identified despite opacification of left and right intrahepatic portal veins; this was taken to indicate an occluded segment. Wedged venography was performed with carbon dioxide in 10 patients (91%). Carbon dioxide was contraindicated in the final patient because of the presence of a ventricular septal defect. CONCLUSION: Our series demonstrates the use of WHVCP as a diagnostic tool in preoperative assessment of the Rex segment of left portal vein in children with extrahepatic portal vein obstruction.

Complete left pericardial defect: evaluation with supine and decubitus dual source CT.

We present a case of complete left pericardial defect which was evaluated with retrospectively gated dual source CT. Imaging findings included right heart chamber dilatation, extreme levoposition and excessive cardiac mobility which was demonstrated by repeat imaging in the left lateral decubitus position. Cardiac CT is an excellent means of evaluating pericardial disease owing to its high spatial resolution. Decubitus imaging helps confidently distinguish partial from complete forms of pericardial defect.