Multimodality imaging of a rare intracardiac bronchogenic cyst.

The authors report a case of pathologically proven intracardiac bronchogenic cyst embedded within the interatrial septum of a 30-year-old woman presenting with chest pain and first-degree AV block. Multimodality imaging played an essential role in the discovery, investigation, and diagnosis of this extremely rare entity.

Radioembolization of Secondary Hepatic Malignancies.

Cancer has become the leading cause of mortality in America, and the majority of patients eventually develop hepatic metastasis. As liver metastases are frequently unresectable, the value of liver-directed therapies, such as transarterial radioembolization (TARE), has become increasingly recognized as an integral component of patient management. Outcomes after radioembolization of hepatic malignancies vary not only by location of primary malignancy but also by tumor histopathology. This article reviews the outcomes of TARE for the treatment of metastatic colorectal cancer, metastatic breast cancer, and metastatic neuroendocrine tumors, as well as special considerations when treating metastatic disease with TARE.

"How We Do It" - A Practical Approach to Percutaneous Adrenal Ablation Techniques.

Incidental adrenal masses are common and are found in 4% of the CT scans.1 While clinical history, laboratory results, and imaging characteristics are typically sufficient for diagnosis of an adrenal lesion, a biopsy is sometimes warranted. In some cases, adrenal mass ablation is subsequently indicated. This article serves as a brief but comprehensive review of preprocedural work-up and planning before an adrenal mass ablation, as well as a discussion on ablation techniques, associated challenges and solutions, and management of expected and unexpected outcomes.

Comparison of specialties participating in the BEST-CLI trial to specialists treating peripheral arterial disease nationally.

BACKGROUND: The Best Endovascular vs Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) trial compares open surgery and endovascular therapy for the treatment of critical limb ischemia (CLI). This report describes the types and proportion of investigators participating in BEST-CLI and determines how these compare with those specialists treating peripheral artery disease (PAD) outside of the trial. METHODS: To be credentialed to enroll in BEST-CLI, investigators must be approved by the Surgical and Interventional Management Committee to have sufficient experience and skill in the management of patients with CLI. Investigators must attest to having completed at least 12 below-knee interventions in the last 2 years on CLI patients for endovascular approval and 10 lower extremity below-knee bypass procedures in the last 2 years for open surgical treatment. Investigators who met these criteria but were within their first year of practice were conditionally approved to do procedures under the oversight of a fully approved investigator. The type and proportion of specialists credentialed in BEST-CLI were compared with those treating PAD on a national basis by auditing 10% of Medicare claims for PAD. RESULTS: As of September 2017, a total of 865 physicians were credentialed to enroll in the BEST-CLI trial. Of these, 596 (69%) are vascular surgeons, 128 (15%) are interventional cardiologists, 123 (14%) are interventional radiologists, 7 (1%) are vascular medicine specialists, and 11 (1%) are other. Of the 596 vascular surgeons enrolling in the trial, 113 (19%) are credentialed for open surgery only, 409 (69%) are credentialed for both open surgery and endovascular therapy, and 3 (1%) are credentialed for only endovascular therapy. The remaining 71 participating vascular surgeons were conditionally approved. Of the 136 centers enrolling patients, multispecialty involvement is present in 98 (72%). In 38 (28%), vascular surgery alone is the service enrolling CLI patients. Endovascular treatment by specialty in BEST-CLI vs national Medicare claims is as follows: vascular surgery, 55% vs 51%; interventional cardiology, 17% vs 13%; interventional radiology, 16% vs 25%; and other, 2% vs 10%. CONCLUSIONS: BEST-CLI contains a diverse group of specialists enrolling and treating patients with CLI. Whereas a majority of the participating practitioners are vascular surgeons who do both open and endovascular procedures, a broad variety of specialists are represented in BEST-CLI in a pattern that represents national treatment patterns outside of the BEST-CLI trial. These treatment patterns will help ensure that findings from BEST-CLI are applicable to the real-world practice of treatments for PAD.

A Percutaneous Crossing Algorithm for Femoropopliteal and Tibial Artery Chronic Total Occlusions (PCTO Algorithm).

Peripheral artery chronic total occlusions (PCTOs) are frequently encountered during endovascular treatment of peripheral artery disease. Failure to successfully cross PCTOs accounts for the majority of unsuccessful endovascular procedures and associated complications. This review outlines a contemporary ultrasound-based approach to crossing femoropopliteal (FP) PCTOs based on a review of prospectively collected case report surveys, published evidence, and expert opinion compiled by the writing group members. The authors describe optimal imaging of PCTO lesions as well as key angiographic and ultrasound imaging features for determining the choice of antegrade, retrograde, or hybrid techniques, initial guidewire selection, guidewire escalation, and dissection re-entry approaches. These concepts are illustrated using clearly defined hierarchical steps and case examples. The writing group members recognize that while the algorithm provided may not encompass all clinical situations, it will serve as a foundation for establishing a systematic procedural strategy for crossing PCTOs to maximize crossing efficiency, treatment success, and patient safety.

Step-by-Step Approach to Management of Type II Endoleaks.

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association.

Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.

The Effect of a New Angiographic Imaging Technology on Radiation Dose in Visceral Embolization Procedures.

PURPOSE: To evaluate the impact of a new angiographic imaging technology on radiation dose during visceral embolization procedures involving both fluoroscopy and digital subtraction angiography. MATERIAL AND METHODS: A retrospective analysis from a single-center consecutive series of patients was performed comparing 2 angiographic imaging systems. The AlluraClarity (CIQ; Philips Healthcare, Best, the Netherlands) was used in 100 patients (n = 59 male, mean age: 70.6 years) from July 2013 to April 2014 and compared to the former AlluraXper (AX) technology used in 139 patients (n = 71 male, mean age: 70.1 years) from May 2011 to June 2013. Patients were categorized according to body mass index (BMI [kg/m2])-group 1: BMI <25, group 2: BMI ≥25 and <30, and group 3: BMI ≥30. Fluoroscopy time, the total dose of iodinated contrast administered, and procedural AirKerma (Ka, r [mGy]) were obtained. RESULTS: Mean BMI was 26.4 ± 5.0 kg/m2 in the CIQ and 26.4 ± 7.1 kg/m2 in the AX group ( P = .93). Fluoroscopy time and the amount of contrast media were equally distributed. Ka, r was 1342.9 mGy versus 2214.8 mGy ( P < .001, t test) when comparing CIQ to AX. Comparing CIQ to AX, BMI subgroup analysis revealed a mean Ka, r of 970.1 to 1586.1 mGy ( P = .003, t test), 1484.7 to 2170.1 mGy ( P = .02, t test), and 1848.8 to 3348.9 mGy ( P = .001, t test) in BMI groups 1, 2, and 3, respectively. CONCLUSION: The CIQ technology significantly reduced mean radiation dose by 39.4% for visceral embolization procedures when compared to fluoroscopy time and contrast media dose. This dose relationship was consistent across all BMI groups.

Effect of ß-blocker on aneurysm sac behavior after endovascular abdominal aortic repair.

OBJECTIVE: This study was conducted to determine whether ß-blocker (BB) therapy is associated with abdominal aortic aneurysm (AAA) sac regression after endovascular abdominal aortic repair (EVAR). METHODS: A total of 198 patients (mean age, 76 years) who underwent EVAR were analyzed (104 in the BB group and 94 in the non-BB group). The primary end point was the incidence of AAA sac regression at 1 and 2 years. RESULTS: Hypertension, coronary artery disease, and hyperlipidemia were more common in the BB group. The BB group was also more likely to have been prescribed an aspirin and a statin than the non-BB group. The length of proximal neck was significantly longer in the non-BB group than in the BB group. All study patients were monitored for at least 1 year after EVAR, and 2-year follow-up was available in 104 patients (52.5%). There was no statistically significant difference in the incidence of aneurysm sac regression in either group at 1 year (52.1% in the non-BB group vs 45.2% in the BB group; P = .330) and 2 years (58.5% in the non-BB group vs 64.7% in the BB group; P = .515). The difference of the change of AAA maximum diameter between two groups did not reach statistical significance at 1 year (-6.0 ± 7.0 mm in the non-BB group vs -5.5 ± 8.1 mm in the BB group; P = .644) and 2 years (-9.0 ± 10.5 mm in the non-BB group vs -9.0 ± 10.0 mm in the BB group; P = .977). BB therapy was not associated with increased odds of AAA sac regression. The effect of third-generation BBs on AAA sac regression was not significant. CONCLUSIONS: BB therapy had no effect on AAA sac regression. At the present time, there is insufficient evidence to recommend BB therapy for the purpose of AAA sac regression.

Key Concepts in Critical Limb Ischemia: Selected Proceedings from the 2015 Vascular Interventional Advances Meeting.

Over 500,000 patients each year are diagnosed with critical limb ischemia (CLI), the most severe form of peripheral artery disease. CLI portends a grim prognosis; half the patients die from a cardiovascular cause within 5 years, a rate that is 5 times higher than a matched population without CLI. In 2014, the Centers for Medicare and Medicaid Services paid approximately $3.6 billion for claims submitted by hospitals for inpatient and outpatient care delivered to patients with CLI. Although significant advances in diagnosis, treatment, and follow-up of patients with CLI have been made, many challenges remain. In this article, we summarize selected presentations from the 2015 Vascular Interventional Advances Conference related to the modern demographics, diagnosis, and management of patients with CLI.

Determining End Points for Critical Limb Ischemia Interventions.

Critical limb ischemia is a condition that has increased in prevalence and carries a high degree of morbidity. Although endovascular therapy for treatment of patients with critical limb ischemia has undergone significant advances with improved outcomes over the past decade, these patients often have multilevel disease, and it may take weeks or months for ulceration healing. For this reason, the acceptable therapeutic end points during and immediately following revascularization remain somewhat obscure. There are multiple tools available to guide the treating vascular specialist in this regard. Establishment of in-line flow to the foot and the angiosome containing the ulceration, appearance of a "wound blush," restoration of pulses, and bleeding at the ulcer site are basic tenets intraprocedurally. Postprocedural noninvasive testing including the ankle-brachial and toe-brachial indices, segmental pressure measurements, pulse volume recordings, transcutaneous oxygen tension, skin perfusion pressures (SPPs), and toe pressures all play a role in determining the likelihood of clinical improvement. Newer technologies such as two-dimensional (2D) perfusion angiography, fluorescence angiography, and tissue oxygen saturation mapping may allow better real-time assessment of flow restoration. In combination with close clinical follow-up and wound care, these tools provide treating physicians with a better grasp of the necessary end points to optimize patients for clinical improvement.

Robotic system-assisted endovascular treatment of a dissection-related pseudoaneurysm of the celiac axis secondary to fibromuscular dysplasia.

Spontaneous celiac artery dissection caused by fibromuscular dysplasia is rare. Subsequent thrombosis and occlusion of the celiac trunk can result in intestinal ischemia and hepatic failure. We describe a case of spontaneous celiac artery dissection with an associated pseudoaneurysm caused by fibromuscular dysplasia, extending into the common hepatic artery. An endovascular intervention featuring robotic-assisted celiac artery cannulation with stent-assisted coil embolization resulted in successful treatment.

The Effect of Realtime Monitoring on Dose Exposure to Staff Within an Interventional Radiology Setting.

PURPOSE: The purpose of this study is to evaluate a new device providing real-time monitoring on radiation exposure during fluoroscopy procedures intending to reduce radiation in an interventional radiology setting. MATERIALS AND METHODS: In one interventional suite, a new system providing a real-time radiation dose display and five individual wireless dosimeters were installed. The five dosimeters were worn by the attending, fellow, nurse, technician, and anesthesiologist for every procedure taking place in that suite. During the first 6-week interval the dose display was off (closed phase) and activated thereafter, for a 6-week learning phase (learning phase) and a 10-week open phase (open phase). During these phases, the staff dose and the individual dose for each procedure were recorded from the wireless dosimeter and correlated with the fluoroscopy time. Further subanalysis for dose exposure included diagnostic versus interventional as well as short (<10 min) versus long (>10 min) procedures. RESULTS: A total of 252 procedures were performed (n = 88 closed phase, n = 50 learning phase, n = 114 open phase). The overall mean staff dose per fluoroscopic minute was 42.79 versus 19.81 µSv/min (p < 0.05) comparing the closed and open phase. Thereby, anesthesiologists were the only individuals attaining a significant dose reduction during open phase 16.9 versus 8.86 µSv/min (p < 0.05). Furthermore, a significant reduction of total staff dose was observed for short 51 % and interventional procedures 45 % (p < 0.05, for both). CONCLUSION: A real-time qualitative display of radiation exposure may reduce team radiation dose. The process may take a few weeks during the learning phase but appears sustained, thereafter.

Computed tomography angiography and magnetic resonance angiography imaging in critical limb ischemia: an overview.

Critical limb ischemia (CLI) is exhibited in patients with symptoms of severe claudication (rest pain) and ischemic tissue loss and gangrene. Magnetic resonance angiography and computed tomography angiography have risen to the forefront of vascular imaging over the last 2 decades. Both modalities have been shown to compare favorably with digital subtraction angiography in guiding the clinical management of patients with CLI. Understanding the advantages and limitations of both modalities allows for the proper selection of the best examination for a particular patient with CLI. Ultimately, the enhanced understanding of the vascular anatomy by obtaining noninvasive imaging should make subsequent revascularization safer and more effective.

Critical limb ischemia and the diseased popliteal artery.

The unique anatomical location and particular biomechanical factors affecting the popliteal artery provide a challenge to determine the proper endovascular, surgical, or combined intervention for patients with critical limb ischemia who often require prompt management in the presence of severe lifestyle-limiting symptoms or of the risk of limb loss or both. Herein, we provide an overview and practical guide for endovascular management of popliteal artery disease in the setting of critical limb ischemia.

Lightweight bilayer barium sulfate-bismuth oxide composite thyroid collars for superior radiation protection in fluoroscopy-guided interventions: a prospective randomized controlled trial.

PURPOSE: To test whether newer bilayer barium sulfate-bismuth oxide composite (XPF) thyroid collars (TCs) provide superior radiation protection and comfort during fluoroscopy-guided interventions compared with standard 0.5-mm lead-equivalent TCs. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study, and 144 fluoroscopy-guided vascular interventions were included at one center between October 2011 and July 2012, with up to two operators randomly assigned to wear XPF (n = 135) or standard 0.5-mm lead-equivalent (n = 121) TCs. Radiation doses were measured by using dosimeters placed outside and underneath the TCs. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100, with 100 indicating optimal comfort). Adjusted differences in comfort and radiation dose reductions were calculated by using a mixed logistic regression model and the common method of inverse variance weighting, respectively. RESULTS: Patient (height, weight, and body mass index) and procedure (type and duration of intervention, operator, fluoroscopy time, dose-area product, and air kerma) data did not differ between the XPF and standard groups. Comfort was assessed in all 256 measurements. On average, the XPF TCs were 47.6% lighter than the standard TCs (mean weight ± standard deviation, 133 g ± 14 vs 254 g ± 44; P < .001) and had a significantly higher likelihood of a high level of comfort (visual analog scale >90; odds ratio, 7.6; 95% confidence interval: 3.0, 19.2; P < .001). Radiation dose reduction provided by the TCs was analyzed in 117 data sets (60 in the XPF group, 57 in the standard group). The mean radiation dose reductions (ie, radiation protection) provided by XPF and standard TCs were 90.7% and 72.4%, with an adjusted mean difference of 17.9% (95% confidence interval: 7.7%, 28.1%; P < .001) favoring XPF. CONCLUSION: XPF TCs are a lightweight alternative to standard 0.5-mm lead-equivalent TCs and provide superior radiation protection during fluoroscopy-guided interventions.

Buerger disease (thromboangiitis obliterans).

Buerger disease is a nonatherosclerotic vasculitis that is triggered by substantial exposure to tobacco. This disease usually affects small- and medium-sized arteries in the upper and lower extremities. All clinicians who take care of patients with peripheral arterial disease should know the clinical features and diagnostic evaluation of Buerger disease. In this article, we review the clinical presentation and diagnostic criteria for Buerger disease. We describe the diagnostic work-up of patients suspected of having Buerger disease and discuss the typical findings on noninvasive arterial studies and angiography. Lastly, we review the management of these patients, including medical therapy, with an emphasis on smoking cessation, as well as the potential role of revascularization, both surgical and endovascular.

Evaluation of novel disposable, light-weight radiation protection devices in an interventional radiology setting: a randomized controlled trial.

OBJECTIVE: Radiation exposure to interventionalists is increasing. The currently available standard radiation protection devices are heavy and do not protect the head of the operator. The aim of this study was to evaluate the effectiveness and comfort of caps and thyroid collars made of a disposable, light-weight, lead-free material (XPF) for occupational radiation protection in a clinical setting. SUBJECTS AND METHODS: Up to two interventional operators were randomized to wear a XPF or standard 0.5-mm lead-equivalent thyroid collars in 60 consecutive endovascular procedures requiring fluoroscopy. Simultaneously a XPF cap was worn by all operators. Radiation doses were measured using dosimeters placed outside and underneath the caps and thyroid collars. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100 [100 = optimal]). RESULTS: Patient and procedure data did not differ between the XPF and standard protection groups. The cumulative radiation dose measured outside the cap was 15,700 µSv and outside the thyroid collars 21,240 µSv. Measured radiation attenuation provided by the XPF caps (n = 70), XPF thyroid collars (n = 40), and standard thyroid collars (n = 38) was 85.4% ± 25.6%, 79.7% ± 25.8% and 71.9% ± 34.2%, respectively (mean difference XPF vs standard thyroid collars, 7.8% [95% CI, -5.9% to 21.6%]; p = 0.258). The median XPF cap weight was 144 g (interquartile range, 128-170 g), and the XPF thyroid collars were 27% lighter than the standard thyroid collars (p < 0.0001). Operators rated the comfort of all devices as high (mean scores for XPF caps and XPF thyroid collars 83.4 ± 12.7 (SD) and 88.5 ± 14.6, respectively; mean scores for standard thyroid collars 89.6 ± 9.9) (p = 0.648). CONCLUSION: Light-weight disposable caps and thyroid collars made of XPF were assessed as being comfortable to wear, and they provide radiation protection similar to that of standard 0.5-mm lead-equivalent thyroid collars.