Analysis of predictive and preventive factors for access complications associated with vascular closure devices in complicated endovascular procedures.

PURPOSE: The main goal is to evaluate the effectiveness of angioseal and starclose vascular closure devices (VCDs) in high-risk patients under intensive anticoagulation who require therapeutic angiographic procedures and to discuss which factors are important in complications associated with VCDs. MATERIALS AND METHODS: Medical records of the patients who underwent therapeutic complex interventional vascular procedures were reviewed retrospectively. One hundred sixty-six patients were divided into two groups regarding VCDs used for access-site closure after the procedure: group 1, (angioseal); group 2, (starclose). Data including patients' demographics and comorbidity information, procedural characteristics, and complications were analyzed. RESULTS: The device deployment success rate was 100%. For the procedural characteristics, there was no significant difference between the groups except access site (P = 0.016) and sheath size > 6F (P = 0.0001). No major complications had occurred in none of the patients. Minor complications including hematoma, access-site pain, and access-site infection, except prolonged hemostasis did not differ significantly between groups. The patients' demographic and periprocedural factors were not significantly correlated with the development of complications. CONCLUSION: Contrary to published reports, our study showed that demographic and periprocedural factors may not be responsible for the vascular access-site complications associated with VCDs.

Right- Versus Left-Sided Approach for Transhepatic Tunneled Catheter Placement: Is There a Difference?

OBJECTIVE: We aimed to compare the technical difficulties, complications, long-term efficacy, and risks between right- and left-sided approach transhepatic tunneled catheterization. METHODS: We retrospectively evaluated transhepatic tunneled catheter placement cases in our institution between May 2012 and November 2019. Demographic and procedural parameters were recorded. Statistical tests were used to compare the complication rates of right- and left-sided approach. Furthermore, Cox regression analyses were used to investigate the relationship between functional catheter days and included parameters. RESULTS: A total of 83 procedures were performed in 46 patients, with a female to male ratio of 1.88 and a mean age of 55.5 ± 18.2 years. Indication for catheter placement was chronic renal insufficiency and loss of central venous access through traditional routes in all cases. Median functional catheter durations were 28 days (1-382) and 55.5 days (1-780) for right-sided and left-sided access, respectively. Complication rates were similar for both sides. There was no difference between primary and revision procedures in terms of safety and efficacy outcomes. In univariate Cox regression analysis, gender was the only variable which was found to be statistically significant (HR = 2.014 (1.004-4.038)) for functional catheter days. In multivariate Cox regression model, gender and access side were included which failed to reach statistical significance. CONCLUSIONS: In our study, both right- and left-sided approaches provided similar safety and efficacy outcomes, suggesting that both techniques can be employed based on physician's preference.

Tunneled Peritoneal Catheter Placement in Palliation of Malignant Ascites: A Study with Two Different Types of Catheters.

OBJECTIVES: Malignant ascites (MA) is abnormal accumulation of fluid in the peritoneal cavity and has negative effects on the quality of life. The purpose of this retrospective study is to explore feasibility, safety and efficacy of tunneled peritoneal catheter placement using both peritoneal dialysis and hemodialysis catheters in the palliation of MA. METHODS: Between October 2013-June 2016, thirty patients with resistent MA underwent tunneled peritoneal catheterisation in our interventional radiology department. Tunneled peritoneal catheter (TPC) was placed in 22 (n=22/30; %73) patients, tunneled hemodialysis catheter (THC) was placed in 8 patients (n=8/30; %27). Routine visits were scheduled for months 1, 3, 6, 9, and 12 of the catheterization, and the records were evaluated retrospectively. RESULTS: The overall duration of catheterization varied from 2 to 334 days (mean 66.4 ± 68.5, median: 57 days). Catheters remained intact in 29 patients (96.7%) until the endpoint. There was one (3.3%) malfunctioning catheter among both groups. Overall, four patients developed infection, which were classified into major (n=2/30, %6.7) and minor (n=2/30, %6.7) complications according to SIR criteria. CONCLUSION: Tunneled peritoneal catheterization using both TPCs and THCs provided a safe method with relatively high patency, and low infection and systemic complication rates in the palliation of MA.

Endovascular Treatment in Traumatic and Spontaneous Carotid Cavernous Fistulas: with Different Embolization Agents and via Various Vascular Routes.

PURPOSE: We evaluated carotid cavernous fistula (CCF) cases which were treated with various vascular routes and different embolization agents. Our aim was to present endovascular treatment procedures, clinical and radiological findings, and to discuss the safety and clinical efficacy of the treatment. MATERIALS AND METHODS: The demographic information, presenting symptoms and clinical findings of 25 CCF cases in 23 patients treated with endovascular route were reviewed. The type of fistula, the feeding arteries, the draining veins, and the details of the treatment were documented on the basis of digital subtraction angiography (DSA) images. The efficacy of the treatment was evaluated according to current and follow-up DSA findings with clinical symptoms. RESULTS: All of which 25 CCF were closed to the fullest extent, one of them closed spontaneously, 20 were closed in one session and 4 in two sessions (100%). 18 of the cases (75%; 18/24) were treated with a venous approach, 5 cases (21%; 5/24) with an arterial approach, and 1 case (4%; 1/24) with a combined arterial-venous approach. Coils were used in 18 cases (75%; 18/24), a covered stent was used in 1 case (4%; 1/24), a detachable balloon was used in 1 case (4%; 1/24), n-Butyl Cyanoacrylate was used in 1 case (4%; 1/24), and combined (2 stent-coil, 1 coil-ethylene vinyl alcohol copolymer) embolization agents were used. CONCLUSION: The endovascular treatment of CCF has high success and low complication rates. The significant point of the treatment is achieving complete fistula obliteration in the least possible number of sessions with appropriate embolization agents.

Percutaneous Coil Embolization for the Treatment of a Giant Brachial Artery Pseudoaneurym in a Child.

Brachial artery pseudoaneurysm is a rare phenomenon. When a diagnosis of brachial artery pseudoaneurysm is established, early and appropriate treatment should be performed as soon as possible to prevent possible complications, such as hemorrhage, rupture, and upper limb and finger losses. Open surgical repair is usually the cornerstone of treatment; however, we here report a case of giant brachial pseudoaneurysm in a 2-year-old girl, which was successfully treated with percutaneous coil embolization.

Choosing the appropriate side for subcutaneous port catheter placement in patients with mastectomy: ipsilateral or contralateral?

PURPOSE: To evaluate long-term clinical follow-up results of implanting subcutaneous port catheters (SPCs) on ipsilateral or contralateral with mastectomy side in patients with axillary lymph node dissection. METHODS: A total of 73 patients composed of ipsilateral (34 catheters) and contralateral (39 catheters) groups, with SPCs were included. All patients had lumpectomy or modified radical mastectomy for breast cancer. Ipsilateral and contralateral groups had similar patient characteristics. RESULTS: Five late complications were seen in the ipsilateral group and 2 late complications in the contralateral group. No statistical significant difference was seen between two groups in regard to late complications. Four complications of the ipsilateral group were classified as major group C and 1 as major group D, while 1 complication of the contralateral group was classified as minor group B and 1 as major group C according to Society of Interventional Radiology (SIR) classification. No statistical significant difference was seen between complication rates of two groups in regard to SIR classification. CONCLUSIONS: SPC related complications do not differ in regard to ipsilateral or contralateral side selection on mastectomized patients with breast cancer and lymph node dissection. SPCs can be implanted on ipsilateral or contralateral sides of the operation in these patients.

Safety and functionality of transhepatic hemodialysis catheters in chronic hemodialysis patients.

PURPOSE: We aimed to investigate the safety and functionality of tunneled transhepatic hemodialysis catheters in chronic hemodialysis patients. METHODS: Thirty-eight patients (20 women aged 56±10 years and 18 men aged 61±11 years) with transhepatic tunneled hemodialysis catheters were evaluated. The date of the first transhepatic catheterization, indications, procedure details, functional time periods of catheters, reasons for the removal or revision of catheters, catheter-related complications, and current conditions of patients were retrospectively analyzed. RESULTS: A total of 69 catheters were properly placed in all patients (100% technical success) under imaging guidance during the 91-month follow-up period. The functionality of 35 catheters could not be evaluated: five catheters were removed because of noncomplication related reasons (surgical fistulas were opened in two cases [2/35, 5.7%], transplantation was performed in three cases [3/35, 8.6%]), 18 patients died while their catheters were functional (18/35, 51.4%), and 12 catheters were still functional at the time of the study (12/35, 34.3%). The functionality of catheters was evaluated the remaining 34 catheters that necessitated revision because of complications. Furthermore, only half of the catheters were functional on day 136 when evaluated using Kaplan-Meier analysis. The four main complications were thrombosis (16/34, 47%; complication rate of 0.37 days in 100 catheters), infection (8/34, 23.5%; 0.18 days in 100 catheters), migration (8/34, 23.5%; 0.18 days in 100 catheters), and kinking (2/34, 6%; 0.04 days in 100 catheters). CONCLUSION: Transhepatic venous catheterization is a safe and functional alternative route in chronic hemodialysis patients without an accessible central venou route. The procedure can be performed with high technical success and low complication rates under imaging guidance.

Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis.

The treatment options for high risk acute pulmonary embolism (PE) patients with failed systemic thrombolytic treatment (STT) is limited. The clinical use of catheter directed thrombolysis with the EkoSonic Endovascular System (EKOS) in this population has not been evaluated before. Catheter directed thrombolysis is an effective treatment modality for high risk PE patients with failed STT. Thirteen consecutive patients with failed STT were included in the study. EKOS catheters were placed and tissue plasminogen activator (t-PA) in combination with unfractionated heparin were given. Clinical and echocardiographic properties of the patients were collected before EKOS, at the end of EKOS and during the follow-up visit 6 months after discharge. The duration of EKOS treatment was 21.8 ± 3.8 h and the total dose of tPA was 31.2 ± 15.3 mg. One patient who presented with cardiac arrest died and the clinical status of the remaining subjects improved significantly. Any hemorrhagic complication was not observed. EKOS resulted in significant improvement of right ventricular functions and decrease of systolic pulmonary artery pressure. During a follow-up period of 6 months none of the patients died or suffered recurrent PE. In addition, echocardiographic parameters or right ventricular function significantly got better compared to in-hospital measurements. EKOS is an effective treatment modality for high risk PE patients with failed STT and can be applied with very low hemorrhagic complications.

Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery.

BACKGROUND Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. MATERIAL AND METHODS Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. RESULTS The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 ± 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. CONCLUSIONS CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

Retrievable Stent-Assisted Coiling Technique Using a Solitaire Stent: Treatment of Pancreaticoduodenal Artery Aneurysm Associated With Celiac Artery Occlusion.

True aneurysm of pancreaticoduodenal arcade (PDA) is usually accompanied by stenosis or occlusion of celiac trunk (CeT). The up-to-date and first choice treatment modality of PDA aneurysm is the endovascular approach in nearly all cases except few selected ones necessitating surgery. The main approach in endovascular treatment is embolization of the aneurysm by preserving the parent artery. A case with concomitant CeT occlusion and PDA aneurysm was treated with coil embolization by preserving inferior pancreaticoduodenal artery with retrievable Solitaire(®) stent. In our knowledge, this is the first case with PDA aneurysm treated with this technique.

Dissection of a non-bifurcating cervical carotid artery.

A non-bifurcating cervical carotid artery is a rare anomaly in the population. Radiologic diagnosis of pathologies seen together with this anomaly can be challenging. Despite not being diagnostic all the time, digital subtraction angiography is accepted as the gold standard method for the diagnosis of dissection. We present a case of a non-bifurcating cervical carotid artery and concomitant dissection, which presented to the hospital with trauma and ischemic findings.

Effectiveness of percutaneous vertebroplasty in patients with multiple myeloma having vertebral pain.

PURPOSE: We aimed to assess the effectiveness, benefits, and reliability of percutaneous vertebroplasty (PV) in patients with vertebral involvement of multiple myeloma. METHODS: PV procedures performed on 166 vertebrae of 41 patients with multiple myeloma were retrospectively evaluated. Most of our patients were using level 3 (moderate to severe pain) analgesics. Magnetic resonance imaging was performed before the procedure to assess vertebral involvement of multiple myeloma. The following variables were evaluated: affected vertebral levels, loss of vertebral body height, polymethylmethacrylate (PMMA) cement amount applied to the vertebral body during PV, PMMA cement leakages, and pain before and after PV as assessed by a visual analogue scale (VAS). RESULTS: Median VAS scores of patients decreased from 9 one day before PV, to 6 one day after the procedure, to 3 one week after the procedure, and eventually to 1 three months after the procedure (P < 0.001). During the PV procedure, cement leakage was observed at 68 vertebral levels (41%). The median value of PMMA applied to the vertebral body was 6 mL. CONCLUSION: Being a minimally invasive and easily performed procedure with low complication rates, PV should be preferred for serious back pain of multiple myeloma patients.

The gently pull-back technique for neck bypass in treatment of wide-necked internal carotid artery aneurysms: A report of three cases and review of the literature.

Neck bypass failure in endovascular treatment of wide-necked internal carotid artery (ICA) aneurysms may adversely affect the technical success of the procedure. We used the gently pull-back technique to bypass the aneurysm neck and access the distal parent artery during endovascular treatment in patients with wide-necked ICA aneurysms. In this technique, a loop was made in the aneurysm and the distal parent artery was reached by using a small diameter microguidewire and a microcatheter. After providing reliable distal access, the microguidewire was removed and the whole system which consists of the microcatheter was gently pulled back. Finally the microcatheter was straightened and the aneurysm neck was passed. After crossing the aneurysm neck, a flow-diverting stent treatment and stent-assisted coiling were performed in three cases with wide-necked ICA aneurysm. The gently pull-back technique is a simple and effective method which requires no extra intravascular device and helps to bypass the aneurysm neck through a small diameter microguidewire and a microcatheter. This technique may be useful for neck aneurysm bypass in endovascular treatment of wide-necked ICA aneurysms.

Single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm.

PURPOSE: We aimed to evaluate the safety and effectiveness of single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm. METHODS: Hospital database was screened for patients who underwent single-stage endovascular treatment between February 2008 and June 2013 and seven patients were identified. The procedures included unilateral carotid artery stenting (CAS) (n=4), bilateral CAS (n=2), and proximal left subclavian artery stenting (n=1) along with ipsilateral intracranial aneurysm treatment (n=7). The mean internal carotid artery stenosis was 81.6% (range, 70%-95%), and the subclavian artery stenosis was 90%. All aneurysms were unruptured. The mean aneurysm diameter was 7.7 mm (range, 5-13 mm). The aneurysms were ipsilateral to the internal carotid artery stenosis (internal carotid artery aneurysm) in five patients, and in the anterior communicating artery in one patient. The patient with subclavian artery stenosis had a fenestration aneurysm in the proximal basilar artery. Stenting of the extracranial large vessel stenosis was performed before aneurysm treatment in all patients. In two patients who underwent bilateral CAS, the contralateral carotid artery stenosis, which had no aneurysm distally, was treated initially. RESULTS: There were no procedure-related complications or technical failure. The mean clinical follow-up period was 18 months (range, 9-34 months). One patient who underwent unilateral CAS experienced contralateral transient ischemic attack during the clinical follow-up. There was no restenosis on six-month follow-up angiograms, and all aneurysms were adequately occluded. CONCLUSION: A single-stage procedure appears to be feasible for treatment of patients with severe extracranial large vessel stenosis and concomitant ipsilateral intracranial aneurysm.

Modified Y-configured stents with the waffle-cone technique by use of Solitaire® stent for patients with wide-necked bifurcation aneurysms.

Endovascular treatment of wide-necked bifurcation aneurysms can be challenging, despite improvements in endovascular techniques. Y stent-assisted coiling is one such technique, but this may not be technically feasible, especially in cases of acute angulation between the proximal and distal parent arteries, and may require use of "modified Y-configured stents with the waffle-cone technique". We report three cases of wide-necked bifurcation aneurysms that were successfully treated by use of the Solitaire® stent.

Rare use of twin Solitaire® stents in the double waffle-cone technique for endovascular treatment of a wide-necked bifurcation aneurysm.

Endovascular treatment of wide-necked bifurcation aneurysms may be challenging. The waffle-cone technique can be used in these aneurysms in case of acute angulation between parent artery and distal artery of the aneurysm. Solitaire® stent (Ev3, Irvine, CA, USA) has the significant advantage of mitigating the potential complication risks. This study reports the second case in the literature in which endovascular treatment of a wide-necked bifurcation aneurysm with the double waffle-cone technique by using twin Solitaire® stents proved to be successful.

Treatment of complex intracranial aneurysms using flow-diverting silk® stents. An analysis of 32 consecutive patients.

This study describes the peri-procedural and late complications and angiographic follow-up results of 32 patients with 34 complex aneurysms treated with flow diverter Silk stents in a single centre. In this retrospective study, 40 Silk stents (SS) were implanted in 34 complex intracranial aneurysms in 32 patients. In our series, 20 (58.8%) carotid-ophthalmic internal carotid artery (ICA), six (17.6%) cavernous ICA, two (5.9%) supraclinoid ICA, two (5.9%) petrosal ICA (the same patient- bilateral) and four (11.8%) posterior circulation aneurysms were treated. One of the posterior circulation lesions was a fenestrated-type aneurysm. Twenty wide-necked, saccular; eight neck remnant; four fusiform and two blister-like aneurysms were included in our series. SS were successfully implanted in all patients (100%). Misdeployment occurred in 17.6% of patients. In two of these patients adequate stent openness was achieved via Hyperglide balloon dilatation. Coil embolization in addition to SS placement was utilized in four aneurysms. One patient (3%) experienced transient morbidity due to a thromboembolic event and there was one mortality (3%) due to remote intraparenchymal haemorrhage. Complete occlusion of 27/33 (81.8 %) and 29/33 (87.9 %) aneurysms was achieved six and 12 months after the procedure, respectively. In-stent intimal hyperplasia was detected in 6.1 % patients. Flow-diverter Silk stent implantation is an effective method of treating complex aneurysms with acceptable mortality and morbidity rates. Complete occlusion is achieved in most of the complex aneurysms.