[Occlusion of hemodialysis vascular accesses by means of endovascular procedures]. / Chiusura degli accessi vascolari per emodialisi con procedure endovascolari.

Correct management of complications is crucial to the long-term survival of vascular access for hemodialysis. The present work report our experience with endovascular procedures in the occlusion of complicated arteriovenous fistulas (AVFs) and grafts in patients with a high surgical risk. Among the endovascular procedures carried out between January 2003 and December 2006, all those regarding the occlusion of vascular accesses by means of embolization or exclusion were selected retrospectively. Embolization means the release into the circulation of material to occlude the vascular lumen; exclusion is obtained by means of covered stents, which, when placed in a blood vessel, exclude its ramifications. Seven procedures of endovascular occlusion of vascular accesses were performed in the study period. All patients were considered as having a high surgical risk or presented technical difficulties related to surgical intervention. Venous hypertension was the indication in 5 cases and grade III or IV steal syndrome was the indication in 2 cases. Six AVFs were treated: 2 distal radiocephalic, 1 brachiocephalic, 2 brachiobasilic, and 1 Gracz AVF; an antebrachial graft was also treated. Occlusion was obtained in 4 cases by means of embolization and in 3 cases by means of exclusion. The technical success was 100% with virtually no complications. Endovascular occlusion of vascular access represents an effective and safe procedure in selected cases, also when compared with the surgical approach. Furthermore, the different technical solutions available allow to adequately solve the problems linked to anatomical variability and to the sites of the vascular accesses.

Endovenous laser therapy of the incompetent great saphenous vein.

PURPOSE: The aim of this study was the development of a new, even less invasive technique, for the treatment of varicose veins of the lower limbs than traditional surgery (ligation with stripping of the saphenous vein). MATERIALS AND METHODS: The new interventional radiological procedure uses the 810- to 980-nm endovascular laser fibre proposed by Min et al. Our technique involves the superselective catheterisation of the great saphenous vein under fluoroscopy with contralateral venous access achieved by performing iliac crossover. Retrograde and anterograde phlebographies are performed with a needle cannula positioned in the dorsum of the foot. This enables accurate venous mapping during the procedure of laser photothermolysis. We treated 52 patients between June 2003 and June 2004, with a percentage of recanalisation of 7.5% at 1 year. RESULTS AND CONCLUSIONS: The contralateral approach allows greater control over the entire procedure, with a reduction in potential risks in relation to the saphenofemoral junction given that, unlike in the technique proposed by Min et al. the tip of the laser is directed at all times towards the saphenous vein and never towards the femoral vein. This more radical procedure offers a significant reduction in the possibility of relapse of varicose disease of the saphenofemoral junction.

[Percutaneous mechanical revascularization of chronic iliac artery occlusion with "first intention" stent placement]. / Rivascolarizzazione meccanica percutanea delle occlusioni croniche dell'arteria iliaca mediante posizionamento "di prima intenzione" di stent.

INTRODUCTION: Percutaneous treatment of chronic iliac artery occlusion has not yet gained complete acceptance as the method of choice. The reason of this widespread skepticism are the poor results achieved with angioplasty and/or lysis therapy. The introduction of stents seems to open new perspectives to percutaneous treatment and the latest follow-up studies report encouraging results. MATERIAL AND METHODS: We report our personal experience in percutaneous mechanical revascularization of chronic iliac occlusion with primary stent placement in 29 patients with 2 years' maximum follow-up. Clinically the patients had at least 3 months' claudication and were in Fontaine stages II to IV. The occlusion was passed mechanically using a hydrophilic guide wire, through the contralateral access in 19 cases and ipsilaterally in 10. The stents were primarily implanted in the last 12 patients; in the first 15 patients, after dilatation with undersized balloons, 25 Wallstent and 12 Palmaz stents were implanted. Each patient underwent color Doppler follow-up for 3-24 months. Nine patients underwent angiography too, after one year. RESULTS: The mechanical passage of the guide-wire through the occluded segment was successful in 27 of 29 (93.1%) patients referred for percutaneous revascularization of a chronic occlusion of the iliac artery. The stent was placed and immediate patency was achieved in 100% of these 27 patients. Clinical improvement was of two stages in 24 patients and of one stage in 3 patients. The follow-up showed neither reocclusions nor critical stenoses of the restored iliac segment. Five embolic complications (5%) occurred after angioplasty, all of them treated percutaneously; surgery was never necessary. DISCUSSION AND CONCLUSIONS: The follow-up studies published in the literature in the last few years and our personal experience encourage the percutaneous treatment of chronic iliac artery occlusions. Percutaneous mechanical revascularization with primary stent positioning can be proposed because it is a reliable and efficacious tool, particularly in young patients in whom a surgical aortoiliac or aortofemoral bypass might injure the pudendal plexis and cause sexual disturbances.

[Intra-arterial digital angiography using a trans-humeral approach in the assessment of ambulatory patients]. / Angiografia digitalizzata per via arteriosa con approccio transomerale nello studio dei pazienti ambulatoriali.

The authors report their experience with intraarterial digital subtraction angiography (DSA) performed on outpatients via brachial artery catheterization. A total of 120 outpatients were studied for cerebral and lower limbs vascular diseases. Transbrachial catheterization was performed with 5F or, preferably, with 4F angiographic catheters. Success rate was high and the transbrachial approach was always easy. In the course of cerebral examination (18/120 cases) the catheter was always easily positioned in the ascending thoracic aorta, through right transbrachial approach. In the course of abdominal aorta and lower extremities examination (102/120 cases), the ideal catheter positioning--in the descending aorta--was performed in 95/102 cases, by left transbrachial approach, while in 7/102 patients the catheter was placed in the ascending aorta. The complication rate was low: 7/120 ecchymosis, 4/120 small hematomas spontaneously resorbed, and 2/120 transient spasms of brachial artery. The authors suggest trasbrachial intraarterial DSA as an alternative to intravenous DSA in outpatients.

[ERCP in the diagnosis of bilio-pancreatic pathology. Comparison with echography and CT]. / L'ERCP nella diagnostica della patologia bilio-pancreatica. Raffronto con ecografia e TC.

The authors have evaluated both sensitivity and specificity of ERCP in comparison with other imaging methods, such as US and CT, on the basis of a study of 63 patients with suspected pancreatobiliary pathologies. Our results show ERCP of chronic pancreatitis to have 83% sensitivity and 66% specificity. As for biliary pathologies, sensitivity was 94% and specificity 88%. In pancreatic pathologies, CT sensitivity was 99% and its specificity was 70%. The combined use of ERCP and CT determines a considerable rise in the percentages, and allows the evaluation of both the excretory tree and the parenchyma. As for biliary pathologies, the role of ERCP is fundamental, since its combination with the other methods (CT: sensitivity 72%, specificity 3.5%; US: sensitivity 70%, specificity 3.5%) has not determined but a slight increase in sensitivity, and no significant increase in specificity.