Comparison of outcomes of percutaneous deep venous arterialization in multiple practice settings.

OBJECTIVE: We compared the efficacy of percutaneous deep venous arterialization (pDVA) in patients with no-option chronic limb-threatening ischemia in the hospital vs in office-based laboratory (OBL) settings. METHODS: A retrospective chart review was performed of all patients who underwent pDVA using off-the-shelf devices from January 2018 to March 2023 in a hospital and an OBL. We identified 73 eligible patients, 41 from a hospital setting (59% male; median age, 72 years; interquartile range, 18 years) and 32 from an OBL setting (59% males; 67 years; interquartile range, 16 years). All eligible patients were deemed to have no-option critical limb ischemia, had at least one patent proximal tibial artery available for the creation of an arteriovenous anastomosis, and were classified as having Rutherford classification IV or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford classification III or lower, had active infection, did not have at least one appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival (AFS). Secondary outcomes included technical success, limb salvage, survival, primary patency, reintervention rate, adverse events, and partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank, and two-stage procedure tests. RESULTS: Technical success was achieved in 70 patients (96%) with 1 hospital (2.4%) and 2 OBL (6.3%) patients lost to follow-up. Major AFS estimates at 6 months, 1 year, and 2 years were 51.4%, 40.4%, and 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the OBL group, respectively. Partial wound healing estimates at 6 months, 1 year, and 2 years were 27.5%, 71.7%, and 81.2% in the hospital group and 62.7% at all time points in the OBL group. Complete wound healing estimates at 6 months, 1 year, and 2 years were 6.7%, 33.3%, and 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the OBL group, respectively. There was no significant difference in major AFS (P = .13), limb salvage (P = .07), survival (P = .69), primary patency (P = .53), partial (P = .08), or complete wound healing (P = .79) between groups. Reintervention was performed in 8 hospital (20.5%) and 14 OBL (45.2%) patients. CONCLUSIONS: pDVA is a feasible and safe procedure for no-option critical limb ischemia in the hospital and OBL setting without significant differences in outcomes at ≤2 years.

Percutaneous Deep Venous Arterialization in Patients with No-Option Critical Limb Ischemia Performed in an Office-Based Laboratory Setting.

PURPOSE: To evaluate the feasibility and safety of percutaneous deep venous arterialization (pDVA) performed in an office-based laboratory (OBL) for patients with no-option critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective chart review was performed of all patients who underwent pDVA using commercially available devices from January 2018 to November 2021 in a single OBL. In total, 22 patients (10 males and 12 females; Rutherford 4, 5, and 6: n = 1, 8, and 13, respectively) were identified with a median follow-up of 140 days. Amputation-free survival, wound healing, pDVA patency, and overall survival were evaluated at 30 days, 6 months, and throughout the remaining follow-up period. RESULTS: All patients had undergone failed previous attempts at endovascular arterial reconstruction. At 6 months after procedure, 6.4% of arteriovenous conduits remained patent; 83.3% (10/12) of patients experienced complete or partial wound healing. In addition, 78.6% of patients avoided an above-ankle amputation, and overall survival was 83.6%. Nine patients underwent endovascular reinterventions at 6 months. One mild adverse event and 4 moderate adverse events occurred after procedure, and 1 cardiac death occurred 5 days after procedure. CONCLUSIONS: pDVA is safe and feasible in the OBL for patients with no-option CLI. Many patients avoided an above-ankle amputation during the study period despite low overall pDVA patency.

Cost-Effectiveness of Pharmacomechanical Catheter-Directed Thrombolysis Versus Standard Anticoagulation in Patients With Proximal Deep Vein Thrombosis: Results From the ATTRACT Trial.

BACKGROUND: In patients with acute deep vein thrombosis (DVT), pharmacomechanical catheter-directed thrombolysis (PCDT) in conjunction with anticoagulation therapy is increasingly used with the goal of preventing postthrombotic syndrome. Long-term costs and cost-effectiveness of these 2 treatment strategies from the perspective of the US healthcare system have not been compared. METHODS AND RESULTS: Between 2009 and 2014, the ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) randomized 692 patients with acute proximal DVT to PCDT plus anticoagulation (n=337) or standard treatment with anticoagulation alone (n=355). Costs (2017 US dollars) were assessed over a 24-month follow-up period using a combination of resource-based costing, hospital bills, Medicare reimbursement rates, and the Drug Topics Red Book. Health state utilities were obtained from the Short Form-36. In-trial results and US life tables were used to develop a Markov cohort model to evaluate lifetime cost-effectiveness. For the PCDT group, mean costs of the initial procedure were $13 600; per-patient costs associated with the index hospitalization were $21 509 for PCDT and $3877 for standard care (difference=$17 632; 95% CI, $16 117-$19 243). The 24-month difference in costs was $20 045 (95% CI, $16 093-$24 120). Utility scores increased significantly between baseline and 6 months for both groups, with no significant differences between groups at any follow-up time point. Projected differences in lifetime costs of $16 740 and quality-adjusted life years (QALYs) of 0.08, yield an incremental cost-effectiveness ratio for PCDT of $222 041/QALY gained. In probabilistic sensitivity analysis, the probability that PCDT would achieve a lifetime incremental cost-effectiveness ratio <$50 000/QALY or <$150 000/QALY was 1% and 25%, respectively. For iliofemoral DVT, QALY gains with PCDT were greater, yielding an incremental cost-effectiveness ratio of $137 526/QALY; for femoral-popliteal DVT, standard therapy was an economically dominant strategy. CONCLUSIONS: With an incremental cost-effectiveness ratio >$200 000/QALY gained, PCDT is not an economically attractive treatment for proximal DVT. PCDT may be of intermediate value in patients with iliofemoral DVT. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00790335.

Synthesis and structure-activity relationships of 2- and/or 4-halogenated 13ß- and 13α-estrone derivatives as enzyme inhibitors of estrogen biosynthesis.

Ring A halogenated 13α-, 13ß-, and 17-deoxy-13α-estrone derivatives were synthesised with N-halosuccinimides as electrophile triggers. Substitutions occurred at positions C-2 and/or C-4. The potential inhibitory action of the halogenated estrones on human aromatase, steroid sulfatase, or 17ß-hydroxysteroid dehydrogenase 1 activity was investigated via in vitro radiosubstrate incubation. Potent submicromolar or low micromolar inhibitors were identified with occasional dual or multiple inhibitory properties. Valuable structure-activity relationships were established from the comparison of the inhibitory data obtained. Kinetic experiments performed with selected compounds revealed competitive reversible inhibition mechanisms against 17ß-hydroxysteroid dehydrogenase 1 and competitive irreversible manner in the inhibition of the steroid sulfatase enzyme.

Enhancement of abdominal structures on MRI at 1.5 and 3 T: a retrospective intraindividual crossover comparison.

OBJECTIVE: To quantitatively compare the extent of enhancement of abdominal structures on MRI in an intraindividual fashion at 1.5 and 3 T. METHODS: HIPAA-compliant, retrospective, longitudinal, intraindividual, crossover study, with waived informed consent, of consecutive individuals scanned at both 1.5 and 3 T closed-bore magnets using gadobenate dimeglumine during different phases of enhancement at tightly controlled arterial phase timing. Quantitative ROI measurements and qualitative sub-phase arterial phase assignments were independently performed by two radiologists. Qualitative discrepancies were resolved by a senior radiologist. RESULTS: Final population included 60 patients [41 female and 19 male; age, 49.35 ± 18.31 years (range 16-81); weight, 78.88 ± 20.3 kg (range 44.5-136)]. Similar enhancement peak patterns were noted at both field strengths. Interobserver agreement of quantitative evaluations was substantial. Significantly higher amplitudes of enhancement peaks were noted for all abdominal solid organs during all phases at 3 T, except for the pancreas (p = 0.17-0.30). Significantly higher amplitudes of enhancement peaks of the abdominal aorta at 1.5 T were noted. CONCLUSION: Similar peak patterns of enhancement for abdominal structures were observed at 1.5 and 3 T, with solid abdominal organs showing a higher percentage enhancement at 3 T, while unexpectedly higher aortic higher percentage enhancement was observed at 1.5 T. KEY POINTS: • Similar enhancement peak patterns at both field strengths for studied abdominal structures. • Significantly higher percentage enhancement of most abdominal organs at 3 T. • Non-statistically significant trend of higher pancreatic percentage enhancement at 3 T. • Significantly lower abdominal aortic percentage enhancement at 3 T.

Superficial Femoral Artery Intervention: Creating an Algorithmic Approach for the Use of Old and Novel (Endovascular) Technologies.

OPINION STATEMENT: Femoropopliteal (FP) disease is a common presentation of peripheral arterial disease (PAD), and a challenging anatomic region for durable treatment. Surgical bypass has historically been the primary therapeutic modality, but has been supplanted in the last decade by endovascular therapy, even with the most complex presentation of disease. Endovascular therapy has the advantage of a more favorable and rapid recovery, while preserving future treatment options. Endovascular management of FP disease, initially with "Plain Old" balloon angioplasty (POBA) has yielded over the years to bare metal stents (BMS), and more recently, to technologies seeking to limit BMS use due to difficult-to-treat patterns of in-stent restenosis (ISR). Despite a myriad number of endovascular devices and strategies, the approach to FP intervention lends itself to an algorithmic schema largely predicated on lesion length, severity of calcification, recanalization method, and clinical goals based upon individual patient status. In addition, treatment costs are a growing consideration in device selection. These criteria can be summarized into what we have termed as a "CADENCE" approach to treatment, an acronym representing the following factors: Clinical scenario, Anatomy, Device performance specifications, Experience/Ease, Novelty, Cost, and Evidence-base (Fig. 1). While the individual components of the CADENCE strategy are not always hierarchical, they combine to give a framework for reasonable interventional strategies for a given patient presentation and lesion appearance. Since there is a notable lack of prospective data for FP interventions, most notably with regard to direct device comparisons, actual practice is often experiential, and further data to guide optimal patient care are needed.

Above and below knee femoropopliteal VIABAHN®.

OBJECTIVES: To assess the clinical outcomes of VIABAHN® stent grafts deployed across the knee to those deployed above the knee. BACKGROUND: The placement of stent-grafts across the knee joint and extending into the distal popliteal artery has been avoided due to a perceived higher risk of stent fractures, restenosis, and thrombosis due to the unique hemodynamic forces in this region. METHODS: A retrospective evaluation was conducted of 114 patients in 127 limbs. Patients were divided into two groups based on the location of the distal end of the deployed VIABAHN® stent: above knee (AK) (n=89) in which the VIABAHN® implant ended at or above the femoral condyles and below the knee (BK) (n=38) with extension of the graft into the below knee popliteal segment. Study end points were loss of primary, assisted, and secondary patency. RESULTS: One year primary, assisted, and secondary patency rates in the AK versus BK group were 67.7% vs. 47.2% (P=0.0092), 77.1% vs. 53.7% (P=0.0022), and 86.3% vs. 59.8% (P=0.0035), respectively. Univariate analysis demonstrated an increased relative risk of a primary [RR=2.07 (P=0.001)], assisted [RR=2.34 (P=0.002)], or secondary events [RR=2.98 (P=0.002)] in patients when the stent was placed below the femoral condyles. Major amputations occurred in 10% of AK and 34% of BK patients (P=0.002). CONCLUSIONS: VIABAHN® stent grafts have a significantly lower clinical patency and higher rates of amputation when they extend across the knee joint.

Optimal use of atherectomy in critical limb ischemia.

Critical limb ischemia (CLI) is the most severe and debilitating form of peripheral arterial disease and is associated with high rates of limb loss and cardiovascular mortality. The unique physical environment of tibial occlusive disease underlying most CLI cases limits treatment options and long-term durability, with resulting frequent rates of persistent obstruction, restenosis, and reintervention. Atherectomy represents a potential strategy to improve acute and late results when treating patients with CLI. Available atherectomy devices each have specific performance characteristics, evidentiary rationale, and limitations that mandate a clear understanding of the optimal albeit evolving use of this category of interventional tools.

Percutaneous Stent-Graft Repair of Anastomotic Pseudoaneurysms following Vascular Bypass Procedures: A Report of Two Cases.

Anastomotic pseudoaneurysms are common entities following vascular bypass procedures and, if left untreated, serious complications such as thromboses, infection, and rupture can frequently occur. Therefore, attempts to employ various methods of repair have been utilized in treating anastomotic pseudoaneurysms to maximize operational success and future risk reduction. Herein, the authors report two cases of anastomotic pseudoaneurysms which were repaired percutaneously utilizing a combination of strategies such as careful preoperational image planning, multiple commercially available devices, and secondary embolization techniques.

Sternal erosion detected by computed tomographic angiography before repeat sternotomy in an adolescent with congenital heart disease.

The case of a 17-year-old male with congenital heart disease who was found to have erosion of a pseudoaneurysm into his posterior sternum is presented. The pseudoaneurysm originated from a right ventricle-to-pulmonary artery homograft, which had been placed 11 years before. It had not been appreciated by echocardiography. The pseudoaneurysm and erosion were visualized with computed tomographic angiography before scheduled surgical replacement of the homograft. This unexpected finding was critical for operative planning and was confirmed on direct visualization in the operating room.