Treatment of Severe Renal Artery Stenosis with Acute Kidney Injury Requiring Hemodialysis by Percutaneous Transluminal Renal Angioplasty and Stent Implantation.

PURPOSE: To evaluate the outcomes of percutaneous transluminal renal angioplasty with stent implantation (PTRAS) among patients with renal artery stenosis (RAS) who become dialysis-dependent due to acute deterioration of renal function. MATERIALS AND METHODS: This was a single-center retrospective cohort study of all PTRAS procedures performed from 2003 to 2019 in a referral hospital. A total of 109 procedures were performed in 92 patients. Eleven patients (12%) presented with anuric acute kidney injury (AKI) secondary to high-grade RAS (defined as intraluminal stenosis above 70% per angiography) and underwent PTRAS after starting hemodialysis. Data collected included demographic parameters, medical background, creatinine, blood pressure, indication for intervention, procedure characteristics, adverse events, and long-term data including dialysis treatment and mortality. Among the dialysis-dependent AKI group, outcome measures were defined based on the postprocedural improvement in kidney function and discontinuation of dialysis. RESULTS: Following PTRAS, 8 of 11 patients (73%) demonstrated improved kidney function and were able to discontinue dialysis. The median time on dialysis was 18 days (range, 2-35 days) before PTRAS and 4.5 days (range, 1-24 days) to recovery of kidney function after the time of intervention. CONCLUSIONS: Patients with atherosclerotic RAS who develop RAS-related AKI may benefit from PTRAS even after several weeks of anuria and dialysis dependence.

Extra Peritoneal Packing for Exsanguinating Pelvic Hemorrhage: Should We Do It in the Emergency Department?

BACKGROUND: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage. OBJECTIVES: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR). METHODS: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008-2018. RESULTS: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038). CONCLUSIONS: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT.

Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms.

OBJECTIVE: The use of fenestrated and branched endografts for the treatment of complex aortic aneurysms is increasing. Despite the low morbidity and mortality associated with these repairs, reintervention rates in the midterm and long term remain a concern. The purpose of this study was to investigate our experience with reinterventions after fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: We performed a retrospective analysis of all patients treated with F/BEVAR at our institution during the years 2009 to 2019. Among them, we identified those who required reinterventions during the period of follow-up. Data collected included patients' demographics, type of treated aneurysm, indications for reintervention, and methods of repair. RESULTS: During the study period, 47 patients underwent F/BEVAR. A total of 160 branches were placed. Of those, 12 patients (25%) underwent 15 secondary interventions for late-occurring complications. Among those requiring reinterventions, mean age was 70 years (range, 59-80 years), and 10 (83%) were male. The majority of those requiring reinterventions were treated for thoracoabdominal aortic aneurysms. Mean time to reintervention was 14 months (range, 2-32 months). Indications for reinterventions included separation of side branches from fenestrations (nine), separation of side branches (three), type IA endoleak (one), type II endoleak (one), and limb occlusion (one). All endoleaks were detected on routine follow-up imaging. All reinterventions were performed using endovascular techniques. Mean follow-up after reinvention was 22 months (range, 1-53 months). During this period, no patient required open conversion. Follow-up imaging revealed successful obliteration of the endoleak, and none experienced continued growth of the sac. CONCLUSIONS: Reinterventions after F/BEVAR are not uncommon. The majority of reinterventions are performed for endoleaks that are due to failure at the level of the fenestrations or component separation. These endoleaks can be treated successfully with endovascular methods and do not require open conversion. Because of the possibility of development of late endoleaks, continual monitoring of these patients is required after the primary procedure.

Chimney Endovascular Repair of Primary Mycotic Aneurysms Involving the Paravisceral Aorta.

BACKGROUND: Primary mycotic aneurysm of the aorta (MAA) is a rare and potentially life-threatening disease. Endovascular aneurysm repair (EVAR) of MAAs involving the paravisceral aorta has been rarely reported. The purpose of this study is to report our experience with chimney EVAR (CHEVAR) in patients with MAAs involving the paravisceral aorta. METHODS: We performed a retrospective review of all patients treated with EVAR at our institution during the years 2009-2019. Of those, we identified the patients who were treated with CHEVAR for MAAs. Diagnosis of MAAs was based on clinical presentation, abnormal laboratory results, and a computed tomography scan suggestive of a MAA. The data collected included patient demographics, clinical presentation, the antibiotic regimen before and after the surgery, preoperative imaging, surgical details, and perioperative and long-term morbidity and mortality. RESULTS: During the study period, we performed 54 cases of CHEVARs for aortic aneurysms. Of those, 8 (15%) were performed for mycotic aneurysms involving the visceral segment. Six (75%) were men, and the mean age was 68 years (range: 59-76). All patients were symptomatic at the time of diagnosis, presenting with either back or abdominal pain. A total of 16 visceral vessels (celiac trunk, 2; superior mesenteric artery, 7; right renal artery, 4; and left renal artery, 3) were revascularized with parallel grafts (PGs). Six patients required 2 PGs, 1 patient required 3 PGs, and 1 patient had a single PG inserted. Fifteen (94%) PGs were upward-pointing chimney stent grafts, and 1 was placed in a downward-pointing "periscope" configuration. Eight visceral arteries in 6 patients were sacrificed, either by preoperative occlusion or intentional coverage with the endograft during the procedure. The vessels sacrificed included 4 celiac trunks and 4 renal arteries (3 main branches and 1 accessory renal artery). Technical success was achieved in all patients. One patient expired in the perioperative period. One patient developed an infection-related complication. One patient experienced worsening of his renal function and eventually required dialysis. Of the 4 patients who underwent intentional sacrifice of a kidney, all experienced a moderate decrease in renal function from the baseline ( mean preoperative and postoperative serum creatinine 0.76 mg/dL and 1.2 mg/dL, respectively, increase of 43%). The mean follow-up was 8 months (range: 3-28 months). During this period, 2 patients expired, 1 from an aneurysm-related cause. No stent occlusion of the PGs occurred and no reintervention due to endoleaks was required. No patient required explanation of the stent grafts or conversion to an open repair. CONCLUSIONS: CHEVAR is a feasible and safe treatment modality for MAAs involving the visceral segment. Occasionally, intentional occlusion of the selected visceral arteries may be required to minimize the risk of gutter endoleaks in this urgent setting. Further follow-up is needed to accurately assess the durability of this repair.

Morbidity and Mortality Following Endovascular Repair of Abdominal Aortic Aneurysms in the Elderly.

BACKGROUND: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is associated with decreased perioperative morbidity and mortality. OBJECTIVES: To report the outcomes of EVAR among patients older than 80 years of age. METHODS: In this retrospective study, we reviewed patients older than 80 years of age who underwent elective EVAR at our institution between 2007 and 2017. The demographics, perioperative morbidity and mortality, and long-term results are reported. RESULTS: During the study period, 444 patients underwent elective EVAR for AAAs. Among them 128 patients (29%) were > 80 years of age. Mean age was 84 ± 3.4 (range 80-96) years, and 110 patients (86%) were male. The EVAR was technically successful in 127 patients (99%) and there were intraoperative mortalities. Within 30 days of the surgery, nine patients (7%) died. Major and minor adverse events occurred in 26 (20%) and 59 (46%) patients, respectively. Factors associated with increased risk of perioperative morbidity and mortality included chronic kidney disease, peripheral artery disease, and the existence of three or more co-morbidities. CONCLUSIONS: EVAR in the elderly can be performed with a high rate of success; however, it is associated with a substantial rate of morbidity and mortality, particularly when patients present with multiple co-morbidities. When performing EVAR in this population group, the risk of rupture must be considered opposed to the life expectancy of these patients and the risk of perioperative morbidity and mortality.

Primary Retrograde Dorsalis Pedis Artery Single Access for Revascularization of Chronic Total Occlusion in Patients with Critical Limb Ischemia.

PURPOSE: To evaluate the dorsalis pedis artery (DPA) approach as a single access site for revascularization in patients with critical limb ischemia (CLI) when the femoral approach is hostile or unavailable. MATERIALS AND METHODS: A retrospective review of patients who underwent iliac and femoropopliteal ipsilateral revascularization via a single access site from the DPA between January 2017 and February 2018 was performed. Fifteen limbs in 15 patients (10 men and 5 women; average age 72 y; range, 49-96 y) with CLI and unavailable femoral access were included. Patients were unsuitable candidates for a surgical bypass graft. Treated limbs were classified as Rutherford category 5 and 6 in 12 patients and category 4 in 3 patients. Treated occluded segments involved 2 iliac arteries, 12 femoropopliteal arteries, 1 bypass graft, and 2 posterior tibial arteries. Technical success was defined as recanalization of the occluded artery with residual stenosis < 30% and improvement in ankle-brachial index after 24 hours. Patients were followed for up to 13 months. Endpoints were freedom from reintervention and limb salvage for 1 year. RESULTS: Technical success was achieved in 14 of 15 patients (93%). Stents were placed in 13 of 15 patients (86%). No complications were encountered immediately after the procedure. Median follow-up was 7.1 months (range, 1.4-13.5 mo). One patient was lost to follow-up. Reintervention was needed in 5 limbs after an average of 4.2 months. Limb salvage rate at 1 year was 83%. CONCLUSIONS: Using the DPA as a single access could be a valuable approach when traditional access sites are unavailable for treating patients with CLI.

Somatic NRAS mutation in patient with generalized lymphatic anomaly.

Generalized lymphatic anomaly (GLA or lymphangiomatosis) is a rare disease characterized by a diffuse proliferation of lymphatic vessels in skin and internal organs. It often leads to progressive respiratory failure and death, but its etiology is unknown. Here, we isolated lymphangiomatosis endothelial cells from GLA tissue. These cells were characterized by high proliferation and survival rates, but displayed impaired capacities for migration and tube formation. We employed whole exome sequencing to search for disease-causing genes and identified a somatic mutation in NRAS. We used mouse and zebrafish model systems to initially evaluate the role of this mutation in the development of the lymphatic system, and we studied the effect of drugs blocking the downstream effectors, mTOR and ERK, on this disease.

Parallel stent grafts for the treatment of complex aortic aneurysms: A single center study.

Background "Chimney" techniques with parallel grafts used in order to extend the landing zones in endovascular aneurysm repair (ch-EVAR) are increasingly being reported. Conflicting data has been reported regarding the success and durability of the repair. We report a single center experience using ch-EVAR in treating complex aortic pathologies. Methods We performed a retrospective review of all patients treated with ch-EVAR in our institution between 2013 and 2017. Data collected included patients demographics, indications for surgery, configuration of parallel grafts, technical success, and perioperative morbidity and mortality. Follow-up data included aortic sac size, reintervention rate, and overall mortality. Results Thirty-five patients underwent treatment of their aneurysms with parallel grafts. Sixty parallel grafts were placed. Mean age was 75 years (range 59-93) and 30 (85%) were male. Technical success was achieved in 32 (91%) patients. Mean follow up was 12 months. Sac size decreased in diameter or remained unchanged in 26 of the 30 (86.6%) patients. Four patients were found to have enlarging aneurysms due to gutter endoleaks. All were treated successfully with endovascular methods. The estimated primary patency was 95% at 12 months. Probability of freedom from intervention was 75% at 12 months. No late aneurysm related mortality occurred. Conclusion The use of ch-EVAR in treating complex aortic aneurysms is technically feasible and safe. Gutter endoleaks are encountered only in a minority of the cases, and can be treated with minimally invasive techniques. Longer term follow up is required to evaluate the patency of these parallel grafts and the durability of the aneurysm exclusion.

Acute renal artery occlusion: Presentation, treatment, and outcome.

OBJECTIVE: Acute renal artery occlusion is an uncommon disease requiring rapid diagnosis for prevention of kidney loss or permanent kidney damage. The purpose of this study was to identify patients with acute kidney infarction; to characterize their presentation, imaging, and treatment; and to compare the subgroup of patients who underwent catheter-directed thrombolysis (CDT) with those who were treated without intervention. METHODS: Hospital records between 2005 and 2015 were queried for keywords suggestive of kidney infarction. Patients were divided into two groups: the CDT group and the noninterventional group. Data collected included demographics, comorbidities, methods of diagnosis, and time from presentation to diagnosis. For patients treated with CDT, additional data collected included details of thrombolytic therapy and follow-up studies. The two groups were compared regarding their clinical characteristics and outcome. RESULTS: Forty-two patients were diagnosed with acute kidney infarction; 13 (31%) were treated with CDT and 29 (69%) were treated conservatively. Median time from presentation to diagnosis was 42 hours in the CDT group and 32 hours in the untreated group. Among the CDT group, complete or partial resolution of the thrombus was seen in all patients. Two required permanent dialysis, both renal transplant patients. Median follow-up was 30 months (interquartile range, 2.7-46.2) in the CDT group and 13 months (interquartile range, 0.11-16) in the noninterventional group. Mean creatinine clearance at diagnosis and at last follow-up was 74.3 and 54.6 mL/min, respectively, in the CDT group (a decrease of 27%; P = .032) and 66.1 and 60 mL/min in the conservatively treated group (a decrease of 9%; P = .04). Follow-up imaging was available in nine patients treated with CDT. Mean interval from treatment to follow-up imaging was 13 months (range, 1-35 months) and consistently showed a functional but smaller treated kidney. (Mean pole-to-pole kidney length at baseline and late follow-up: 10.4 cm and 8.5 cm, respectively). CONCLUSIONS: Most patients presenting with acute kidney infarction are managed conservatively. A subset of patients with complete occlusion of the renal artery undergo CDT with good angiographic results. The treated kidney is expected to decrease in size over time, and overall kidney function is expected to decrease compared with baseline. Deterioration in renal function appears to stabilize and does not continue over time. CDT for acute renal artery occlusion is a safe modality of therapy and should be attempted for the purpose of kidney salvage, even in the setting of prolonged ischemia.

Treatment of renal angiomyolipoma: pooled analysis of individual patient data.

BACKGROUND: This study was performed to evaluate the impact of baseline characteristics and treatment methods on the outcome of sporadic renal angiomyolipoma (AML). METHODS: This was a pooled analysis of individual data of 441 patients with AML retrieved from 58 studies and 3 institutional series. RESULTS: Ninety-three patients underwent nephrectomy, 163 partial nephrectomy/enucleation, 128 embolisation, 19 cryoablation, 6 radiofrequency ablation, and 32 conservative treatment. Their mean follow-up period was 44.5 months. Patients who experienced major bleeding at presentation had significantly larger tumours than did those without bleeding (mean diameter, 10.1 vs. 5.9 cm, respectively; p < 0.0001). A total of 9.4 % and 26.4 % of bleeding tumours had a diameter of <4 and <6 cm, respectively. A tumour diameter of ≥8.0 cm (hazard ratio, 2.07; 95 % confidence interval, 1.20-4.77) and the treatment method (p = 0.001) were independent predictors of re-intervention. The risk of re-intervention was significantly higher after embolisation, particularly for large tumours (5-year rate of freedom from re-intervention: diameter of ≥8.0 cm, 49.2 %; diameter of <8.0 cm, 74.8 %; p = 0.018). Conservatively treated AMLs had a mean baseline diameter of 3.2 ± 2.7 cm; after 41 months, their mean diameter was 3.7 ± 3.1 cm (p = 0.109). CONCLUSIONS: The prevalence of major bleeding is high in sporadic AMLs with a diameter of >6 cm. These results suggest that conservative treatment can be considered in AMLs of <6 cm in diameter. Among current treatment methods, embolisation was associated with a significantly higher risk of re-intervention. Further studies are needed to define risk factors for bleeding and assess the relative benefits of different treatment modalities.

Secondary sclerosing cholangitis following major burn.

BACKGROUND AND AIMS: Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a relatively new previously unrecognized entity which may lead to severe biliary disease with rapid progression to cirrhosis. We present for the first time a case series of patients with rapidly progressive SSC-CIP requiring aggressive intensive care treatment following major burn injury. RESULTS: SSC-CIP was diagnosed in 4 consecutive patients hospitalized due to major burn injuries at our Intensive Care Unit (ICU). SSC-CIP was diagnosed when ERCP (n = 1) or MRCP (n = 3) demonstrated irregular intrahepatic bile ducts with multiple strictures and dilatations and, when a liver biopsy (n = 3) demonstrated severe cholestasis and bile duct damage. All patients were males; none of whom had pre-existing liver disease. Ages: 18-56 y. All patients suffered from severe (grade 2-3) burn injuries with total burn surface area ranging from 35 to 95%. Mean length of ICU hospitalization was 129.2 ± 53.0 days. All patients required mechanical ventilation (with a mean PEEP of 8.4 ± 2.1 cm H2O) and the administration of catecholamines for hemodynamic stabilization. All patients demonstrated severe cholestasis. Blood cultures and cultures from drained liver abscesses grew hospital acquired multiple resistant bacteria. Liver cirrhosis developed within 12 months. One patient underwent orthotopic liver transplantation. Two patients (50%) died. In conclusion, SSC-CIP following major burn injury is a rapidly progressive disease with a poor outcome. Liver cirrhosis developed rapidly. Awareness of this grave complication is needed for prompt diagnosis and considerations of a liver transplantation.

Non-surgical treatment of latrogenic postoperatively diagnosed ureteral injuries.

BACKGROUND: latrogenic ureteral injury may be seen following abdominopelvic surgeries. While ureteral injuries identified during surgery should be immediately and surgically repaired, those that are postoperatively diagnosed may be treated non-surgically by draining the ipsilateral kidney. Data regarding the outcome of this approach are still missing. OBJECTIVES: To evaluate the success rates of non-surgical management of ureteral injuries diagnosed following abdominopelvic surgeries. METHODS: We retrospectively reviewed the files of all patients treated for iatrogenic ureteral injuries diagnosed following abdominopelvic surgeries. Patients' ipsilateral kidney was percutaneously drained following diagnosis of injury by either nephrostomy tube (NT)/nephro-ureteral stent (NUS) or double-J stent (DJS) inserted retrogradely. The tube was left in place until a pyelogram confirmed healing or a conservative approach was abandoned due to failure. RESULTS: Twenty-nine patients were identified as having ureteral injury following abdominopelvic surgery. Median time from injury to renal drainage was 9 days, interquartile range (IQR) 4-17 days. Seven cases (24%) had surgical repair. Among the other 22 patients, in 2 oncology patients the conservative approach was maintained although renal drainage failed to resolve the injury. In the remaining 20, median drainage length was 60 days (IQR 43.5-85). Calculated overall success rates following renal drainage was 69% (18/29), and with NUS approached 78.5%. CONCLUSIONS: Ureteral injuries diagnosed following abdominopelvic surgeries can be treated conservatively. Ipsilateral renal drainage should be the first line of treatment before surgical repair, and NUS may be the preferred drainage to obtain spontaneous ureteral healing.

Magnetic resonance imaging of pelvic entheses--a systematic comparison between short tau inversion recovery (STIR) and T1-weighted, contrast-enhanced, fat-saturated sequences.

OBJECTIVE: To assess the contribution of contrast material in detecting and evaluating enthesitis of pelvic entheses by MRI. MATERIALS AND METHODS: Sixty-seven hip or pelvic 1.5-T MRIs (30:37 male:female, mean age: 53 years) were retrospectively evaluated for the presence of hamstring and gluteus medius (GM) enthesitis by two readers (a resident and an experienced radiologist). Short tau inversion recovery (STIR) and T1-weighted pre- and post-contrast (T1+Gd) images were evaluated by each reader at two sessions. A consensus reading of two senior radiologists was regarded as the gold standard. Clinical data was retrieved from patients' referral form and medical files. Cohen's kappa was used for intra- and inter-observer agreement calculation. Diagnostic properties were calculated against the gold standard reading. RESULTS: A total of 228 entheses were evaluated. Gold standard analysis diagnosed 83 (36%) enthesitis lesions. Intra-reader reliability for the experienced reader was significantly (p = 0.0001) higher in the T1+Gd images compared to the STIR images (hamstring: k = 0.84/0.45, GM: k = 0.84/0.47). Sensitivity and specificity increased from 0.74/0.8 to 0.87/0.9 in the STIR images and T1+Gd sequences. Intra-reader reliability for the inexperienced reader was lower (p > 0.05). CONCLUSIONS: Evidence showing that contrast material improves the reliability, sensitivity, and specificity of detecting enthesitis supports its use in this setting.

Endovascular repair of complex aortic aneurysms.

BACKGROUND: Surgery for complex aortic aneurysms (thoracoabdominal, juxtarenal and pseudoaneurysms) is associated with a high morbidity and mortality rate. Branched and fenestrated stent grafts constitute a new technology intended as an alternative treatment for this disease. OBJECTIVES: To describe a single-center experience with fenestrated and branched endografts for the treatment of complex aortic aneurysms. METHODS: We reviewed all cases of complex aortic aneurysms treated with branched or fenestrated devices in our center. Data collected included device specifics, perioperative morbidity and mortality, re-intervention rates and mid-term results. RESULTS: Between 2007 and 2012 nine patients were treated with branched and fenestrated stent grafts. Mean age was 73 years. Mean aneurysm size was 63 mm. Perioperative mortality was 22% (2/9). During the follow-up, re-interventions were required in 3 patients (33%). Of 34 visceral artery branches 33 remained patent, resulting in a patency rate of 97%. Sac expansion was seen in a single patient due to a large endoleak. No late aneurysm-related deaths occurred. CONCLUSIONS: Branched and fenestrated stent grafts are feasible and relatively safe alternatives for the treatment of complex aortic aneurysms involving the visceral segment. Further research is needed to determine the long-term durability of this new technology.

Endovascular treatment of lower extremity ischemia in chronic renal failure patients on dialysis: early and intermediate term results.

BACKGROUND: Peripheral arterial occlusive disease is common in patients with chronic renal failure requiring dialysis. Despite the increasing use of endovascular revascularization for lower extremity ischemia, the success rates of treating lower extremity ischemia in this challenging population remain obscure. OBJECTIVES: To assess the results of endovascular revascularization for lower extremity ischemia in dialysis patients. METHODS: We conducted a retrospective review of all dialysis patients who underwent endovascular treatment for critical limb ischemia (CLI) in our institution between 2007 and 2011. Data collected included comorbidities, clinical presentation, anatomic distribution of vascular lesions, amputation and survival rates. RESULTS: We identified 50 limbs (41 patients). Indications included gangrene in 22%, non-healing wounds in 45%, rest pain in 31%, and debilitating claudication in 4%. Mean follow-up was 12 months (1-51 months). Nineteen patients required amputations. Freedom from amputation at 5 years was 40%. Factors associated with amputation included non-healing wounds or gangrene (68% and 36% respectively) and diabetes (P < 0.05). The survival rate was 80% after 5 years. CONCLUSIONS: Despite improvement in endovascular techniques for lower extremity revascularization, the incidence of limb salvage among dialysis patients remains poor, resulting in a high rate of major amputations.

[Chronic thromboembolic pulmonary hypertension: can successful thrombendarterectomy normalize exercise capacity and gas exchange?].

INTRODUCTION: Chronic thromboembolic pulmonary hypertension, a rare complication of pulmonary embolism is amenable to thrombendarterectomy (TEA) and when successful, improves exercise capacity and normalizes resting pulmonary arterial pressure. GOAL: To test if exercise capacity and exercise gas exchange are also normalized after successful TEA. METHODS: Over a period of 4 years, 5 patients underwent TEA at Sheba Medical Center. All experienced marked clinical improvement; their functional capacity (NYHA class) improved by 1-3 stages and resting pulmonary blood pressure normalized. One to 3 years after surgery each underwent a 6 minute walking test and incremental exercise to measure maximal oxygen uptake. RESULTS: It was found that following TEA, the 6 minute walking distance improved by 100-215 meters and more. Maximal oxygen uptake remained below normal in 4/5 cases and ranged 42-87% of predicted values. Hemoglobin oxygen saturation that was normal after TEA at rest, fell in all with exercise to 91-96%. Exercise gas exchange remained abnormal, consistent with residual pulmonary vascuLar disease. CONCLUSIONS: Thrombendarterectomy in chronic thromboembolic pulmonary hypertension caused marked clinical improvement and normalized resting pulmonary arterial pressures. Exercise capacity also improved but peak oxygen uptake remained below normal and exercise gas exchange remained abnormal. SUMMARY: Chronic thromboembolic pulmonary hypertension can be effectively treated. However, despite remarkable improvement, residual pulmonary vascular disease persists and is not relieved following successful operation.

Technical Success of the GoBack™ Crossing Catheter in Chronic Total Occlusion in Patients with Chronic Limb Threatening Ischemia.

PURPOSE: To assess the technical success of GoBack™ crossing catheter in chronic total occlusion. MATERIALS AND METHODS: A retrospective review of chronic limb threatening ischemia (CLTI) patients treated for chronic total occlusions (CTO) with the application of the GoBack™ crossing catheter (Upstream Peripheral Technologies, Haifa, Israel) between May 2020 and January 2021 was performed. Sixteen GoBack catheters were applied in twelve limbs in 12 patients (ten men, average age 75.7 years). Treated limbs were classified as Rutherford Category 5 and 6 in ten patients and four in two patients. Average occlusion length was 287 mm (62-466). All occluded arteries were heavily calcified. Technical success was defined as successful application of the GoBack catheter for lesion crossing or luminal reentry. RESULTS: Successful application of the four French catheter was achieved in 11 of the 12 cases (92%) for reentry in external iliac (1), superficial femoral (2), popliteal (2) and posterior tibial (1) arteries in six out of six cases (100%) and lesion crossing in popliteal (4), peroneal (1) and posterior tibial arteries in five out of six cases (83%). The 2.9 Fr catheter was successfully applied once out of four (25%) in lesion crossing in the posterior tibial artery. CONCLUSION: The GoBack™ 4 Fr crossing catheter in revascularization of CLI patients with CTO could be valuable when manual crossing or reentry is unsuccessful and is applicable from any access site.

Time-resolved MR angiography of the calf arteries using a phased array cardiac coil: comparison of visibility with standard three-step bolus chase MR angiography.

BACKGROUND: Standard bolus chase MR angiography (MRA) is increasingly replacing digital subtraction angiography (DSA) in the diagnostic evaluation of peripheral vascular disease. However, a major limitation of bolus chase MRA is the relatively poor visibility of the calf arteries. PURPOSE: To evaluate the feasibility of visualizing the calf arteries and the visibility quality of an 8-channel cardiac phased array coil using time-resolved imaging of contrast kinetics (TRICKS) MRA compared with standard bolus chase MRA on a 1.5 Tesla MRI scanner. MATERIAL AND METHODS: MRA findings of 59 sequential patients (mean age 57.8 years, range 14-83 years; 41 men) were retrospectively evaluated. All examinations included preliminary TRICKS for the lower leg using a surface 8-channel cardiac coil, followed by a 3-step MRA of the abdominal aorta, thigh, and lower leg using a body coil. Images yielded by both methods were separately evaluated by consensus of two radiologists unaware of the patients' clinical data. Visibility of the calf arteries (popliteal, tibialis anterior, tibialis posterior, tibioperoneal trunk, and peroneal) for both sides was subjectively classified as 'diagnostic' or 'non-diagnostic'. Descriptive statistics for image diagnostic quality were assessed. RESULTS: A total of 575 calf arterial segments were evaluated. Visibility of all calf arteries was significantly better with TRICKS than with the standard bolus chase MRA (P < 0.001). The improvement of calf artery visibility with TRICKS was more pronounced in patients with peripheral vascular disease compared to those with arteritis, vascular malformation and popliteal entrapment syndrome. CONCLUSION: Using a cardiac coil for MRA of the lower extremities resulted in visibility comparable to that of a dedicated leg coil, with diagnostic superiority for the TRICKS method compared to the standard bolus chase method.