Outcome and technical evolution of type 2 endoleak embolization with ethylene-vinyl-alcohol copolymer.

PURPOSE: This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR). METHODS: A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events. RESULTS: The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded. CONCLUSION: The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

Temporal Analysis of Tachycardia During Catheter Directed Thrombolysis for Acute Pulmonary Embolism.

PURPOSE: To evaluate the effect of catheter directed thrombolysis (CDT) on heart rate (HR) in patients with sinus tachycardia and acute pulmonary embolism (PE). METHODS: A retrospective chart review was performed for patients who underwent CDT with tPA for acute massive or submassive PE between 12/2009 and 2/2020. Included were patients who presented with tachycardia at the time of initiation of CDT. Patients with chronic PE, atrial fibrillation, beta blocker therapy, adjunctive endovascular therapy, systemic thrombolysis, or who expired before conclusion of CDT were excluded. HR was measured approximately every hour during CDT. Graphs were plotted of HR as a function of CDT duration. Two interventional radiologists identified the point of plateau (POP) on the graph where CDT had maximized its benefit in decreasing the patient's HR. Discrepancies were adjudicated by a third interventional radiologist and the median of the 3 measurements was selected. The primary endpoint was the duration of CDT from initiation until the POP. RESULTS: 48 patients were included (52.5 ± 14.7 years, 56.3% female). The POP occurred after 13.1 ± 6.1 hours, by which point HR had been reduced from 110 ± 9.2 bpm to 88 ± 10.6 bpm. Sinus tachycardia was not resolved in 10 patients even though they achieved maximal improvement in HR after 11.3 ± 6.7 hours. CONCLUSION: Patients presenting with sinus tachycardia related to acute PE achieved maximal, sustained reduction in heart rate from CDT, after approximately 13 hours of infusion. Patients who did not resolve their tachycardia by that point in time were unlikely to resolve it by the conclusion of CDT.

The Protégé Nitinol Self-Expanding Stent for the Treatment of Iliofemoral Veno-Occlusive Disease.

PURPOSE: To evaluate the safety and effectiveness of the Protégé nitinol self-expanding stent for the treatment of iliofemoral veno-occlusive disease. MATERIALS AND METHODS: A retrospective review was performed of 376 (284 left, 92 right) Protégé stents in 212 limbs of 183 patients (mean age: 53 ± 17 years, 52% female) treated for iliofemoral veno-occlusive disease between 2011 and 2018. Binary patency was assessed with duplex ultrasound and calculated by Kaplan Meier analysis. Clinical outcomes were evaluated by clinical-etiology-anatomy-pathophysiology (CEAP) classification and Villalta scores. Adverse events were recorded and categorized per Society of Interventional Radiology reporting standards. RESULTS: Of the 212 limbs, 125 presented with acute thrombosis and 28 with chronic thrombosis requiring thrombectomy (n = 44), catheter directed thrombolysis (n = 32), or both (n = 77). Fifty-nine limbs were non-thrombotic. Mean follow-up time was 11.44 ± 11.37 months. Kaplan Meier analysis revealed a primary limb-level patency of 92.3%, 88.6%, 86.9% and 86.9% at 6, 12, 24 and 36 months, respectively. CEAP and Villalta scores improved from a median of C3 (range: 0-6) to C1 (0-5) (p < 0.001) and from a mean of 13.4 ± 7.5 to 5.3 ± 4.9 (p < 0.001), respectively. Nine minor and 2 major adverse events were recorded. CONCLUSIONS: Endovascular treatment of iliofemoral veno-occlusive disease with the Protégé self-expanding stent appears to have good mid-term patency. LEVEL OF EVIDENCE: Level 4, Case Series.

Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism.

PURPOSE: To evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE). MATERIALS AND METHODS: This was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%). RESULTS: Patients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P < .001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (-14.4 mm Hg ± 10.2 vs -12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7). CONCLUSIONS: Patients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.

Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates.

PURPOSE: To evaluate the effect of routine administration of post-procedural antibiotics following elective uterine artery embolization (UAE) on infectious complication rates. MATERIALS AND METHODS: The charts of patients who underwent UAE between January 2013 and September 2019 were retrospectively reviewed. Prior to January 15, 2016, all patients received post-procedural antibiotics with 500 mg of ciprofloxacin twice a day orally for 5 days. After January 15, 2016, none of the patients received post-procedural antibiotics. All patients in both groups received pre-procedural intravenous antibiotics. The post-procedural antibiotics group included 217 patients (age, 44.7 ± 6 years); the no-antibiotics group included 158 patients (age, 45.4 ± 5.6 years). Patients in the no-antibiotics group had a significantly higher rate of diabetes mellitus (P = .03) but fewer cases of adenomyosis (P = .048). Otherwise, demographic and fibroid characteristics were similar between the groups. RESULTS: Six infectious complications (6/375, 1.6%) were recorded. No statistically significant difference (P = .66) was observed in the number of infections between the post-procedural antibiotics group (4/217, 1.8%) and the no-antibiotics group (2/158, 1.3%). Three of the 6 infectious complications presented with malodorous vaginal discharge (3/375, 0.8%) and received nominal therapy. The 3 remaining complications (0.8%) were considered major and included 2 patients (0.5%) who underwent hysterectomy and 1 patient (0.3%) who underwent myomectomy. The major infection rate was 0.9% (2/217) in the post-procedural antibiotics group and 0.7% (1/158) in the no-antibiotics group (P = 1). There were no 90-day post-procedural mortalities. CONCLUSIONS: Discontinuation of routine post-procedural antibiotics with ciprofloxacin after elective UAE did not result in increased rates of infectious complications within the first 90 days post procedure.

Tips for pedal access: technical evolution and review.

Pedal access has become an indispensable technique for endovascular therapy of complex lower extremity peripheral vascular disease. From an option as a single access in a patient lacking traditional access approaches to a critical maneuver in combined antegrade-retrograde approaches during the treatment of complex chronic total occlusions, pedal access is an essential tool for any endovascular physician treating peripheral arterial disease. Anticipatory planning is critical in the successful utilization of pedal access. The appropriate tibiopedal vessel should be chosen and combined with the ideal access technique. Knowledge of the current medical devices available for pedal access and post-procedural hemostasis is key and can ease the learning curve. We present the evolution of pedal access with a review of the literature and technical tips to incorporate into everyday practice.

Transcatheter Embolization of Type I Endoleaks Associated With Endovascular Abdominal Aortic Aneurysm Repair Using Ethylene Vinyl Alcohol Copolymer.

PURPOSE: To evaluate the feasibility, safety, and outcome of transcatheter embolization using ethylene vinyl alcohol copolymer (EVOH) of type I endoleaks associated with endovascular abdominal aortic aneurysm repair. PATIENT POPULATION AND METHODS: Retrospective chart review was performed to identify 8 consecutive patients who had undergone EVOH embolization for type I endoleaks between 2012 and 2015. The primary approach used to access the endoleak was the perigraft technique, where the endoleak itself is catheterized at the anastomotic site. RESULTS: Six type Ia and 2 type Ib endoleaks were treated. In 2 patients, a direct transabdominal approach was used to access the endoleak because it was inaccessible via the perigraft approach. Coils were used in addition to EVOH in 5 cases. Residual endoleak was noted in 1 case, whereas 2 patients developed a recurrent type I endoleak during follow-up. No EVOH complications were observed. The 5 remaining patients demonstrated freedom from endoleak and reintervention at a mean follow-up of 6.9 months. CONCLUSION: Type I endoleaks can be safely and effectively treated by embolotherapy with EVOH. Larger endoleaks resulting from grossly undersized endografts appear to be unsuitable for EVOH embolization.

Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution.

OBJECTIVE: Computed tomographic angiography (CTA) by 16-channel multidetector scanner is increasingly replacing conventional digital subtraction angiography (DSA) for diagnosing or excluding blunt carotid/vertebral injuries (BCVI). To date there has been only 1 study in which all patients received both examinations. That study reported a high accuracy for 16-detector CTA. The current prospective parallel comparative study aims at validating this high accuracy and examining the rates of evaluability of CTA performed with a 16-detector scanner with image reconstruction by modern imaging software. METHODS: Patients at risk for BCVI (facial/cervical-spinal fractures; unexplained neurologic deficit; anisocoria; lateral neck soft tissue injury; clinical suspicion) underwent both CTA (16-channel multidetector scanner) and DSA. Results of the 2 studies and the clinical course were prospectively recorded. RESULTS: During the 40-month study period ending March 2007, approximately 7000 blunt trauma patients were evaluated and of these 119 (1.7%) consecutive patients meeting inclusion criteria were screened by CTA. Ninety-two patients underwent confirmatory DSA. Twenty-three (22%) DSA identified 26 BCVI (vertebral, 13; carotid, 13). Among these 23 CTAs, 17 identified 19 BCVIs (vertebral, 10; carotid, 9) (true positives), and 6 failed to identify 7 BCVIs (vertebral, 3; carotid, 4) (false negatives). Sixty-nine of the 92 DSA were normal. Of these 69 CTAs, 10 were falsely suspicious for 11 BCVIs (vertebral, 7; carotid, 4) (false positives), and 56 were normal (true negatives). The remaining 3 CTAs were nonevaluable (mistimed contrast, 1; streak artifact, 2). Sixteen of 89 (18%) evaluable CTAs, were suboptimal (mistimed contrast, 9; streak artifacts, 4; motion artifact, 2; body habitus, 1). Excluding the 3 nonevaluable CTAs, the sensitivity, specificity, positive and negative predictive values of CTA for diagnosing or excluding BCVI were 74%, 86%, 65%, and 90% respectively. One patient with grade II carotid artery injuries (by CTA and DSA) on antiplatelet agent developed stroke related to carotid artery injuries. CONCLUSIONS: Current CTA technology cannot reliably diagnose or exclude BCVI. Twenty percent of CTAs are either nonevaluable or suboptimal. Until more data are available and the technique is standardized, the current trend towards using CTA to screen for and/or diagnose these rare but potentially devastating injuries is dangerous.

CTA and MRA in mesenteric ischemia: part 2, Normal findings and complications after surgical and endovascular treatment.

OBJECTIVE: A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting. CONCLUSION: We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.

Percutaneous extraction of bilateral renal mycetomas in premature infant using mechanical thrombectomy device.

Although mycotic infections of the urinary system occur not infrequently, obstruction of the upper urinary tract because of mycetomas or fungus balls is exceedingly rare. Treatment consists of antifungal treatment and appropriate urinary drainage. In cases resistant to treatment with external drainage and chemotherapy, open surgery is typically performed to remove the mycetoma. However, this can also be achieved percutaneously using mechanical thrombectomy devices, as shown in this case of a 4-month-old infant presenting with renal failure due to bilateral obstructing mycetomas.

Percutaneous intentional extraluminal recanalization in patients with chronic critical limb ischemia.

PURPOSE: To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI). MATERIALS AND METHODS: Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival. RESULTS: Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%). CONCLUSION: PIER is a useful percutaneous technique for limb salvage in patients with CCLI.

Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up.

The authors report their experience with percutaneous transluminal angioplasty (PTA) and stenting of the left subclavian artery (LSA) in patients with recurrent angina and a left internal mammary (LIMA)-coronary bypass graft or in patients who will be undergoing LIMA-coronary artery bypass grafting. From November 1990 to February 2001, 21 patients (11 men and 10 women) with significant left subclavian artery stenosis were treated; 18 patients had a prior LIMA bypass graft, and 3 patients were treated before coronary artery bypass surgery. Angiographic follow-up was performed in 12 patients and clinical follow-up was obtained in all patients. All lesions were atherosclerotic in etiology and located in the proximal left subclavian artery. The mean stenosis was 81% (range 50-100%). All patients initially underwent PTA. Stents were placed in 7 patients for suboptimal PTA results. Technical success was achieved in all patients. Pressure gradient measurements were available in 6 patients. Mean pretreatment gradient was 29 mm Hg (range, 10-50 mm Hg) and fell to 3 mm Hg (0-8 mm Hg) posttreatment. There were 2 minor and 2 major complications. The 30-day mortality rate was 9.5% (2 patients). The remaining 19 patients had clinical or angiographic follow-up of 4-68 months (mean, 27 months). Three patients were found to have recurrent stenoses by angiography 8-43 months after PTA and 3 more had clinical signs of recurrent stenosis. Therefore, the long-term clinical patency rate of LSA PTA and stent was 15 of 19 (79%). One was managed with bypass surgery, 1 with repeat PTA and stent placement, and 1 was managed conservatively. Therefore, the assisted patency was 15 of 19 (79%). Eleven of 19 (58%) of the patients in long-term follow-up had cardiac symptoms, but repeat angiography excluded recurrent LSA stenosis as the cause of their symptoms in 7 cases. Only 4/19 (21%) had cardiac symptoms potentially attributable to LSA restenosis. Four patients expired during follow-up, but 3 had no evidence of subclavian stenosis. PTA and stenting is an effective treatment of proximal left subclavian artery stenosis in patients who develop angina after a LIMA-coronary artery bypass, or in patients before a LIMA-CABG. Cardiac symptoms after LSA PTA and stent are most often due to progressive coronary artery disease rather than to recurrent LSA stenosis.

MR angiography of the mesenteric vasculature.

MRA has evolved from a research tool to a robust clinical diagnostic modality. In many centers worldwide, it is the technique of choice for evaluating patients with suspected CMI, assessing operability of patients with pancreatic cancer, and investigating the portal system. Evolving indications include the assessment of liver transplant patients before and after transplant and of living related liver transplant donors. The search for the bleeding source in patients with gastrointestinal hemorrhage may be an indication in the future, once intravascular contrast agents become available.

Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and longterm followup.

BACKGROUND: The purpose of this study was to review the results of percutaneous transluminal angioplasty (PTA), stenting, or both in the treatment of patients who present with symptoms and angiographic findings most consistent with chronic mesenteric ischemia. STUDY DESIGN: A retrospective analysis of 33 consecutive patients from a single institution who underwent PTA, stenting, or both for treatment of symptoms most characteristic of chronic mesenteric ischemia was performed. RESULTS: There were 12 men and 21 women with a mean age of 63 years (range 40 to 89 years). Median weight loss was 28 lb (range 6 to 80 lb). Postprandial pain was present in 88% of the patients (29 of 33). All lesions treated were stenoses. PTA alone was performed in 21 patients (32 vessels), and PTA and stenting were performed in 12 patients (15 vessels). PTA was technically successful in 26 of 32 vessels (81.3%); PTA plus stenting was technically successful in 15 of 15 vessels (100%) (p = 0.073). Complete alleviation of symptoms occurred immediately in 27 of the patients (82%), and 2 patients (6%) had significant improvement in symptoms. There were four immediate clinical failures (12%): two patients were found to have occult malignancy and one had immediate relief of symptoms after surgical release of the median arcuate ligament. Followup data were obtained in all patients with clinically successful procedures (mean 38 months, median 25 months, range 1 to 123 months). Angiographic followup was available in 52% of the patients (15 of 29), at a mean of 20 months. The primary longterm clinical success rate was 83.3% (24 of 29). Four of the five patients with recurrent symptoms were successfully retreated with endovascular therapy. The primary assisted longterm clinical success rate was 96.6% (28 of 29). The 5-year survival rate was 76.1%. Major complications occurred in 13% of the procedures, with a 30-day mortality rate of 0%. CONCLUSION: Endovascular therapy for treatment of mesenteric arterial stenoses is effective in the treatment of patients with symptoms and angiographic findings characteristic of chronic mesenteric ischemia.