Safety, Effectiveness and Pitfalls of Carbon Dioxide Routine Use as a Contrast Agent for Endovascular Abdominal Aortic Repair.

BACKGROUND: Despite the evidence of good performance, carbon dioxide (CO2) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use. METHODS: We retrospectively collected data of every patient who underwent CO2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment. RESULTS: 49 patients underwent ICM guided EVAR and 52 patients underwent CO2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO2 patients. The radiation exposure was higher in the CO2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups. CONCLUSIONS: EVAR can be safely performed under CO2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations.

Routine postaccess-closure angiography to detect vascular complications following transfemoral TAVR.

BACKGROUND: Vascular complications following transfemoral TAVR are associated with increased morbidity and mortality. Measures that may mitigate this risk are important. AIM: To evaluate the utility of routine, access-vessel angiography post sheath-removal in the detection and management of complications in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: This was a retrospective study of 512 consecutive patients who underwent transfemoral TAVR with routine post access-closure angiography from the radial artery. Rates of mild angiographically evident bleeding, bleeding requiring surgery/interventional-radiology, ischemia, 90-day access-site-related events, and major and minor vascular complications using Valve Academic Research Consortium 3 definitions were recorded. RESULTS: Of 512 patients, digital subtraction angiography (DSA) was undertaken via the radial artery in 467 patients (91%). In the remaining patients (9%) DSA was either not attempted, due to concerns regarding kidney disease and contrast volume, or failed due to anatomical factors (aortic tortuosity/calcification). Significant chronic kidney disease was present at baseline in 72.4% of this cohort (stages III-IV or dialysis). Ninety-four percent of cases underwent TAVR using a balloon-expandable platform. Mild iliofemoral extravasation was observed in 7.7% of the DSA cases. These cases were managed by manual compression with none requiring any vascular intervention subsequently. Valve Academic Research Consortium 3 major and minor access-site-related complications were observed in 0.4% and 12.2%, respectively. Access-site-related bleeding and ischemic events requiring interventional-radiology or vascular-surgery were observed in 0.9% and 1.7% of the DSA cases, respectively. No new renal replacement therapy was needed in any of the DSA cases. Discharge to 90-day access-related complications was 0.8%. CONCLUSIONS: Routine post access-closure angiography is feasible via the radial artery in patients undergoing transfemoral TAVR and appears safe. It facilitates early identification of complications and mitigates risk by enabling prompt action to be taken. Larger studies are needed to confirm these findings.

Percutaneous transluminal stenting for superior vena cava syndrome caused by malignant tumors: a single-center retrospective study.

OBJECTIVES: To evaluate the efficacy of percutaneous stent placement in the treatment of superior vena cava syndrome caused by malignant tumors. METHODS: We retrospectively analyzed the clinical data of 32 patients with superior vena cava syndrome who underwent percutaneous endovascular stent treatment in our department from 2015 to 2019 due to malignant tumors and summarized the patient's sex, age, tumor type, endovascular treatment plan, complications and postoperative follow-up. RESULTS: All patients successfully underwent percutaneous intraluminal stent placement with digital subtraction angiography (DSA). Thirty-seven endovascular stents were implanted in 32 patients, including 21 Eluminexx stents, 12 Wallstent stents and 4 covered stents. The technical success rate was 100%, and there were no serious surgery-related complications. The remission rate of clinical symptoms was 53.1% (17/32) at 24 h and 84.4% (27/32) at 48 h. After 48 h, the symptoms of the remaining patients were slowly relieved, and the symptom relief rate was 100% at 7 days. The follow-up period was 1.5-24 months, with an average follow-up period of 6.5 months. During the follow-up, 3 patients had restenosis and 1 patient had secondary thrombosis in the stent. Their symptoms were relieved after the second treatment. CONCLUSION: For superior vena cava syndrome caused by malignant tumors, percutaneous endoluminal stent therapy can quickly and effectively relieve the clinical symptoms of patients, and the incidence of complications is low.

Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula.

In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total of 120 patients, who were diagnosed as hepatic carcinoma with arteriovenous shunting and underwent medical imaging diagnosis and interventional surgery therapy at a designated hospital by this study from December 2014 to December 2018, were chosen as study subjects. Digital subtraction angiography was performed to analyze the imaging features of hepatocellular carcinoma combined with HAVF in each patient; then, according to these imaging diagnosis results, gelatin sponge or coil was used to block the fistula; mitomycin, carboplatin powder, and lipiodol mixed emulsion was combined or separately utilized for hepatic tumor embolization, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis patients at their first intervention, and, after about 1 month, if the sputum disappeared, iodized oil embolization was used again; and hepatic arterial infusion chemotherapy was used only for patients with severe paralysis. The results show that the central type of HAVF is characterized by early angiography of portal vein and large branches and tumor staining after portal vein's angiography; the peripheral type of HAVF is characterized by portal vein branching in hepatic tumor and double rail sign accompanied by the arterial branch; 112 cases of patients completed embolization chemotherapy; 8 cases of patients only received chemotherapy perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of patients iodine oil was well deposited or the tumor was stably reduced; most of the symptoms of refractory ascites, diarrhea, and upper gastrointestinal bleeding were controlled or improved, and there were no complications such as pulmonary embolism and hepatic failure. Therefore, HAVF increases the difficulty of interventional therapy, but, as long as the positive and appropriate treatment measures are taken, it can still achieve better curative effect without serious complications, which can effectively alleviate the clinical symptoms of patients and improve the quality of life of patients. The results of this study provide a reference for the further researches on imaging diagnosis and interventional treatment for hepatocellular carcinoma combined with arteriovenous fistula.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms.

INTRODUCTION: Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI). MATERIALS AND METHODS: Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed. RESULTS: A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI. CONCLUSION: Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial.

OBJECTIVE: Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS: Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS: For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS: In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery.

BACKGROUND: Indocyanine green (ICG) video angiography has been widely used in cerebrovascular surgery. ICG injection is generally safe, with a low incidence of complications. ICG-related anaphylactic reactions during neurosurgery have been rarely reported. We report the cases of 2 patients who had experienced anaphylactic shock in response to intravenous ICG injection (DID Indocyanine Green [Dongindang, Inc., Gyeonggi-do, Republic of Korea]) during intracranial aneurysm (IA) surgery. CASE DESCRIPTION: The first patient, a 69-year-old woman with an unruptured IA, had been undergoing clipping surgery under general anesthesia. Immediately after ICG injection, her blood pressure suddenly decreased from 140/80 mm Hg to 50/30 mm Hg and she developed a skin rash on her abdomen and all extremities. Chest compression was initiated, and her vital signs gradually recovered to their pre-ICG levels within 10 minutes. The second patient was a 58-year-old woman with an unruptured IA who had been undergoing clipping surgery. After ICG injection, her blood pressure had decreased from 130/80 mm Hg to 60/40 mm Hg, and a rash-like skin lesion was observed on her abdomen. After intravenous injection of norepinephrine and dexamethasone, her blood pressure recovered to its pre-ICG level within 30 minutes and remained stable thereafter. The postoperative ICG skin provocation test findings were positive for both patients; however, only 1 patient showed markedly increased serum tryptase levels. CONCLUSION: Despite the rarity of ICG-related anaphylaxis, clinicians should be aware of this unexpected, but potentially life-threatening, drug reaction in patients undergoing cerebrovascular surgery.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. METHODS: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. RESULTS: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO2 was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CONCLUSIONS: CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Transient in-stent stenosis at mid-term angiographic follow-up in patients treated with SILK flow diverter stents: incidence, clinical significance and long-term follow-up.

BACKGROUND: Little is known about in-stent stenosis (ISS) in patients with aneurysms treated with flow diverter (FD) stents. The reported incidence in the literature varies significantly. OBJECTIVE: The aim of this study was to assess the incidence, severity, distribution, clinical significance, and possible predictors for ISS. METHODS: Between July 2012 and June 2016 we retrospectively reviewed all patients treated with SILK FDs in our center. Only cases with short-term (4±2 months) and long-term (>1 year) follow-ups with digital subtraction angiograms were included. ISS was graded as mild (<25%), moderate (25-50%) or severe (>50%). The following predictors for ISS were assessed: gender, age, the presence of subarachnoid hemorrhage, aneurysm size, location, occlusion status, and post-stenting angioplasty. RESULTS: Thirty-six patients met the inclusion criteria. At mid-term follow-up, ISS was observed in 16/36 patients (44%). Eleven patients (69%) had mild ISS, three (19%) moderate, and two (12%) severe ISS. ISS was diffuse in 11 patients (69%) and focal in five patients (31%). All patients were asymptomatic. Thirteen patients were maintained on dual antiplatelet therapy and three on aspirin alone. At long-term follow-up, complete ISS resolution was seen in 11 patients, improvement in three and worsening in two patients. No de novo ISS occurrence was observed. On univariate analysis there was no significant predictor for ISS. CONCLUSIONS: Transient ISS after FD deployment is a common asymptomatic finding on mid-term angiographic follow-up. Complete resolution or improvement at long-term follow-up is seen in most patients who are maintained on dual antiplatelet therapy.

Radiation doses for endovascular aortic repairs performed on mobile and fixed C-arm fluoroscopes and procedure phase-specific radiation distribution.

OBJECTIVE: The objective of this study was to analyze radiation risk to patients during endovascular aneurysm repair (EVAR) using mobile C-arm (MA) or fixed C-arm (FA) fluoroscopes and to describe the dose distribution during the different phases of the procedure. METHODS: Patients treated with EVAR using a single stent graft system between November 2009 and June 2016 were included in this study. The patients were divided into one of two groups (MA or FA) according to the type of C-arm used in the procedure. Data regarding patients' demographics and the total amount of contrast agent (CA) used, dose-area product, and fluoroscopy time for the procedures were prospectively recorded. Based on the dose report from the FA system, five standard and two optional phases of the procedure were identified to determine the dose distribution. RESULTS: Overall, 160 patients were included (mean age, 73.30 ± 8.97 years; 146 men); of these, 107 were treated with an MA system and 53 were treated with an FA system. The mean amounts of CA used were 108.55 ± 42.28 mL in the MA group and 85.37 ± 38.79 mL in the FA group (P = .0014). The mean total dose-area product values were 49.93 ± 38.06 Gy·cm2 in the MA group and 168.34 ± 146.92 Gy·cm2 in the FA group (P < .0001). There was no significant difference in fluoroscopy time between the groups. Per-phase analysis demonstrated that identification of the proximal landing zone and main body deployment required the most radiation, accounting for 24% of the total radiation dose. Overall, 47.6% of the exposure was due to digital subtraction angiography. CONCLUSIONS: Use of an FA system can significantly reduce the amount of CA needed but may also lead to higher radiation doses in EVAR procedures. Dose monitoring remains crucial for the safety of both patients and operators. A detailed analysis of dose distribution is possible with modern systems, which may improve the quality of monitoring in the future.

Midterm Outcomes of Endovascular Aortic Aneurysm Repair with Carbon Dioxide-Guided Angiography.

BACKGROUND: Although iodinated contrast (IC) agents are commonly used in endovascular aneurysm repair (EVAR), perioperative use in patients with renal dysfunction or IC allergies is avoided. Carbon dioxide (CO2)-guided angiography is a promising alternative. We aimed to evaluate short-term and midterm outcomes of EVAR using CO2-guided angiography. METHODS: Three hundred eighty-one patients who underwent EVAR from January 2012 to September 2016 were retrospectively reviewed and divided into an IC-EVAR group (n = 351) and CO2-EVAR group (n = 30). Subjects in the CO2-EVAR group had severe renal dysfunction (n = 27) and IC allergy (n = 4). Intraoperative, postoperative, and follow-up variables were compared. RESULTS: Compared with the IC-EVAR group, preoperative serum creatinine level was significantly higher (2.0 vs. 0.92 mg/dL, P < 0.0001) and mean IC dose was significantly lower (18 vs. 55 mL, P < 0.0001) in the CO2-EVAR group. The fluoroscopy time, operative time, number of stent grafts placed, and technical success rates of the groups were similar; no type I and/or type III endoleaks were detected on completion angiography. There was no acute kidney injury and one case of intestinal necrosis in the CO2-EVAR group, potentially due to cholesterol embolism. Postoperative endoleak, enlargement of aneurysms, survival, freedom from secondary intervention, and renal function change up to 3 months, postoperatively, were similar between the groups. CONCLUSIONS: CO2-EVAR is technically feasible and exhibits prominent renal protection. However, consideration of the aortic lumen status remains an important challenge.

Procedure and step-based analysis of the occupational radiation dose during endovascular aneurysm repair in the hybrid operating room.

OBJECTIVE: This study measured the cumulative occupational X-ray radiation dose received by support staff during endovascular aortic procedures and during additional intraoperative steps in the hybrid operating room. METHODS: Radiation dose measurements were performed during interventions on 65 patients receiving 90 stent grafts during endovascular aneurysm repair (EVAR), bifurcated EVAR, thoracic EVAR, iliac branched device deployment, aortouni-iliac stenting, and fenestrated/branched EVAR (F/BrEVAR). X-ray imaging was acquired using the Philips Allura FD20 Clarity System (Philips Medical Systems, Best, The Netherlands). The occupational radiation dose (also referred to as the estimated effective dose, E, measured in millisieverts) was measured with the DoseAware Xtend system (Philips Medical Systems) personal dosimeters. E was reported per staff member (ESTAFF), where "staff" was a generic term for each staff member included in the study: the first operator (FO), the second operator (ESO), a virtual maximum operator (MO), and all additional supporting staff, including the sterile nurse, nonsterile nurse, anaesthesiologist, and radiation technician. The primary outcome was the median cumulative ESTAFF (or EFO, EMO, and so on), which was presented as the median cumulative dose per intervention and stratified for several within-interventional EVAR and F/BrEVAR steps or stents. The second outcome was the percentage of the absorbed E by a supporting staff member in relation to the E measured by the reference badge attached on the C-arm (ESTAFF% or EFO%, EMO%, and so on). All outcomes are presented as median with interquartile range, unless stated differently. RESULTS: The occupational effective dose in millisieverts of the MO (EMO) was 0.055 (0.029-0.082) for aortouni-iliac stenting (n = 6), 0.084 (0.054-0.141) during thoracic EVAR (n = 14), 0.036 (0.026-0.068) during bifurcated EVAR (n = 38), 0.054 (0.035-0.126) during iliac branched device deployment (n = 8), and 0.345 (0.235-0.757) during F/BrEVAR (n = 24). The median EMO in millisieverts was 0.025 (0.012-0.062) per renal target vessel (TV) and 0.146 (0.07-0.315) for a nonrenal visceral TV. During all noncomplex interventions, the EMO% was 4.4% (2.7%-7.3%), with the lowest median rate at 3.5% (2.5%-5%) for EVAR. The highest median rate EMO% was found for F/BrEVAR procedures: 8.2% (5.0%-14.4%). CONCLUSIONS: With maximum operator shielding during femoral access, relative occupational radiation risk can be minimized. However, digital subtraction angiography image acquisition, recanalization of TVs, recanalization of superior mesenteric artery or celiac artery, and recanalization of branched TVs are predictors for increased occupational radiation dose risks caused by increased radiation doses to the patient and reduced options for shielding of the operator.

The Incidence, Risk Factors, and Outcomes of Contrast-Induced Nephropathy In Patients With Critical Limb Ischemia Following Lower Limb Angiography.

Intra-arterial digital subtraction angiography (DSA) is commonly used for the diagnosis and treatment of patients with critical limb ischemia (CLI). The aim of this study was to analyze the incidence of contrast-induced nephropathy (CIN) in patients with CLI and to assess their outcomes. Between May 2013 and May 2014, a prospective and observational study was conducted with 107 patients admitted exclusively for CLI treatment. The main outcomes included hemodialysis independence (HI) and overall survival (OS), as assessed by Kaplan-Meier curves. Overall, there was a predominance of males (57%), with a mean age of 70.5 (10.7) years. The incidence of CIN was 35.5%, and chronic kidney failure was the only factor associated with elevated risk of this condition (relative risk [RR] = 1.9; 95% confidence interval = 1.17-3.09; P = .017). The median follow-up was 645 days, and in 720-day analyses, patients who experienced CIN had worse HI (81.2% vs 96.3%; P = .0107) and OS (49.5% vs 66.3%; P = .0463). The current study found a high incidence of CIN in patients with CLI after DSA. This renal impairment was associated with a worse prognosis in terms of survival.

Repeated Endovascular Treatments in Patients with Recurrent Cerebral Vasospasms After Subarachnoid Hemorrhage: A Worthwhile Strategy?

OBJECTIVE: Endovascular interventions in patients with subarachnoid hemorrhage (SAH) and symptomatic cerebral vasospasm (sCVS) are commonly performed, but the potential benefits of repeated interventions have not been proven. The aim of this study was to show the potential burden and opportunities of repeated endovascular interventions in cases of recurrent sCVS. METHODS: We reviewed 15 patients with SAH who underwent more than 2 endovascular treatments of recurrent sCVS (CVS group) regarding the radiation doses, their clinical course, and their functional outcome. A case-control group of SAH patients without sCVS individually matched for age, World Federation of Neurosurgical Societies score, Fisher grade, and treatment modality was used as control group (non-CVS group). RESULTS: A total of 70 endovascular treatments were performed in the CVS group. CVS group patients received longer mechanical ventilation (585 days vs. 439 days) and showed a higher rate of tracheostomy (12/15 vs. 7/15) and shunt-dependent hydrocephalus (6/15 vs. 2/15) than did the non-CVS patients. Moreover, patients from the CVS group underwent significantly (P < 0.001) more angiographies (median, 5 vs. 2) and CTP/CTA scans (median, 4 vs. 1) and consequently received significantly (P < 0.001) higher radiation doses. The rate of unfavorable outcomes (mRS 3-6) after 3 months was nonsignificantly higher in the CVS group (6/15 vs. 2/15), but after 6 months at least 5/14 patients from the CVS group showed a favorable outcome. CONCLUSION: Repeated endovascular treatments of SAH patients with recurrent CVS are complex and expose the patients to high radiation doses. Nevertheless, favorable results could be achieved in patients in otherwise poor condition.

Endovascular aortic sealing with Nellix reduces intraoperative radiation dose when compared to endovascular aortic repair.

OBJECTIVE: To analyze radiation exposure during endovascular aortic sealing (EVAS) in comparison with standard endovascular aortic repair (EVAR) in clinical practice. METHODS: From December 2013 to October 2016 (35 months), 60 patients were analyzed for intraoperative radiation exposure during EVAR: 30 consecutive patients (mean age, 73.10 years; 28 male) received EVAS (Nellix Endologix); within the same time frame, 30 patients were treated with standard EVAR (mean age, 71.87 years; 30 male). An indirect dose analysis was performed for both groups of patients, including effective dose and cumulative air kerma. Furthermore, fluoroscopy time (FT), dose area product, and time of procedure were included in the study. RESULTS: The effective dose was significantly reduced in the EVAS group (3.72 mSv) compared with the group treated with standard EVAR (6.8 mSv; P ≤ .001). The cumulative air kerma was also lowered in EVAS (67.65 mGy vs 139 mGy in EVAR; P ≤ .001). FT for the entire group was 13 minutes and was shorter (P < .001) for EVAS (9 minutes) in comparison with EVAR (19 minutes). The dose area product for the entire cohort was 16.95 Gy.cm2 and was lower during EVAS (12.4 Gy.cm2) than during EVAR (22.6 Gy.cm2; P < .001). The median operating time for the entire group was 123.5 minutes and was significantly shorter (P < .01) for EVAS (119 minutes vs EVAR at 132 minutes). The FT shows a significant correlation with the patient's weight (P = .022), body mass index (P = .004), and time of procedure (P = .005). CONCLUSIONS: EVAS is associated with a relevant decrease in indirect measured radiation dose and time of procedure compared with standard EVAR. A relevant reduction in dose during EVAS is highly likely to result in lower exposure to radiation for physicians and staff. Such a result would be highly advantageous and calls for further analysis.

Carbon dioxide (CO2) angiography as an option for endovascular abdominal aortic aneurysm repair (EVAR) in patients with chronic kidney disease (CKD).

To assess feasibility, efficacy and safety of carbon dioxide (CO2) digital subtraction angiography (DSA) to guide endovascular aneurysm repair (EVAR) in a cohort of patients with chronic kidney disease (CKD). After Ethical Committee approval, the records of 13 patients (all male, mean age 74.6 ± 8.0 years) with CKD, who underwent EVAR to exclude an abdominal aortic aneurysm (AAA) under CO2 angiography guidance, were reviewed. The AAA to be excluded had a mean diameter of 52.0 ± 8.0 mm. CO2 angiography was performed by automatic (n = 7) or hand (n = 6) injection. The endograft was correctly placed and the AAA was excluded in all cases, without any surgical conversions. Two patients (15.4%) had an endoleak: one type-Ia, detected by CO2-DSA and effectively treated with prosthesis dilatation; one type-III, detected by CO2-DSA, confirmed using 10 ml of ICM, and conservatively managed. In one patient, CO2 angiograms were considered of too low quality for guiding the procedure and 200 ml of ICM were administered. Overall, 11 patients (84.6%) underwent a successful EVAR under the guidance of the sole CO2 angiography. No patients suffered from major complications, including those typically CO2-related. Two patients suffered from abdominal pain during the procedure secondary to a transient splanchnic perfusion's reduction due to CO2, and one patient had a worsening of renal function probably caused by a cholesterol embolization during the procedure. In patients with CKD, EVAR under CO2 angiography guidance is feasible, effective, and safe.

Radiation Exposure of Patients and Interventional Radiologists during Prostatic Artery Embolization: A Prospective Single-Operator Study.

PURPOSE: To prospectively analyze the radiation exposure of patients and interventional radiologists during prostatic artery embolization (PAE). MATERIALS AND METHODS: Twenty-five consecutive PAE procedures performed with an Artis zee system in a single center by an interventional radiologist were prospectively monitored. The mean age, weight, and prostate volume of the patients were 65.7 year (range, 43-85 y), 71.4 kg (range, 54-88 kg), and 79 cm3 (range, 36-157 cm3), respectively. In addition to Digital Imaging and Communications in Medicine radiation data, direct measures were also obtained. Radiochromic film was used to evaluate peak skin dose (PSD). The radiologist wore a protective apron and a thyroid collar, and a ceiling-suspended screen and a table curtain were used. To estimate the absorbed doses, nine pairs of dosimeters were attached to the operator's body. RESULTS: The average fluoroscopy time was 30.9 minutes (range, 15.5-48.3 min). The mean total dose-area product (DAP) was 450.7 Gy·cm2 (range, 248.3-791.73 Gy·cm2) per procedure. Digital subtraction angiography was responsible for 71.5% of the total DAP, followed by fluoroscopy and cone-beam computed tomography. The mean PSD was 2,420.3 mGy (range, 1,390-3,616 mGy). The average effective dose for the interventional radiologist was 17 µSv (range, 4-47 µSv); values for the eyes, hands, and feet were obtained, and were all greater on the left side. CONCLUSIONS: PAE may lead to high x-ray exposures to patients and interventional radiologists.

A Novel Technique to Reduce Contrast Exposure During Subclavian Interventions.

We describe a novel technique to minimize total body contrast exposure during endovascular angiography. A patient with severe renal impairment and history of contrast-induced nephropathy was referred for subclavian artery intervention. Angiography and intervention was performed via transfemoral access, while a transradial sheathless-guiding catheter was used to aspirate injected contrast/blood mix from the downstream axillary artery. Semiquantitative analysis indicated approximately 50% of the injected contrast was retrieved. Adaptation of this simple strategy could be considered for selected coronary, lower extremity, and carotid procedures, using contrast removal techniques from the coronary sinus, femoral, and jugular veins.

A Multicenter Analysis of Computed Tomography Angiography Alone Versus Digital Subtraction Angiography for the Surgical Treatment of Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA). METHODS: We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders. RESULTS: Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups. CONCLUSIONS: Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms.

Endovascular Aneurysm Sealing Is Associated With Reduced Radiation Exposure and Procedure Time Compared With Standard Endovascular Aneurysm Repair.

PURPOSE: To compare indirect measures of radiation exposure and operating time between endovascular aneurysm sealing (EVAS) and endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA). METHODS: The study compared 32 consecutive patients (mean age 78 years; 21 men) with AAA who underwent standard EVAS with 32 consecutive patients (mean age 78 years; 25 men) treated with EVAR between November 2013 and May 2015. Electronic medical records and image archiving databases were interrogated to retrieve relevant information and scans. Screening time and dose area product (DAP) were the primary outcome measures. Data are presented as median and interquartile range (IQR). Correlations were tested with the Spearman rank coefficient (ρ). RESULTS: The screening time was shorter in EVAS than in EVAR [16 (IQR 14, 20) vs 32 (IQR 26, 38) minutes; p<0.001]. DAP was lower in EVAS than in EVAR [54 (IQR 42, 77) vs 111 (IQR 75, 157) Gy∙cm(2); p<0.001]. Digital subtraction angiography delivered 20% (IQR 15%, 28%) of the DAP in EVAS compared with 14% (IQR 11%, 19%) in EVAR (p<0.001), but the absolute time used on digital subtraction was marginally lower in EVAS than in EVAR [1.07 (IQR 0.52, 1.23) vs 1.19 (IQR 0.70, 1.39) minutes; p=0.037]. The operating time was shorter for EVAS [121 (IQR 105, 146) vs 162 (IQR 145,186) minutes; p<0.001]. There was a moderate correlation between DAP and screening time (ρ=0.597, p<0.001), fluoroscopy time (ρ=0.595, p<0.001), digital subtraction time (ρ=0.301, p=0.015), and operating time (ρ=0.512, p<0.001). CONCLUSION: EVAS is associated with reduced radiation exposure and operating room usage compared with EVAR, which may have safety and financial implications.