Strongly enhanced light-matter coupling of monolayer WS2 from a bound state in the continuum.

Exciton-polaritons derived from the strong light-matter interaction of an optical bound state in the continuum with an excitonic resonance can inherit an ultralong radiative lifetime and significant nonlinearities, but their realization in two-dimensional semiconductors remains challenging at room temperature. Here we show strong light-matter interaction enhancement and large exciton-polariton nonlinearities at room temperature by coupling monolayer tungsten disulfide excitons to a topologically protected bound state in the continuum moulded by a one-dimensional photonic crystal, and optimizing for the electric-field strength at the monolayer position through Bloch surface wave confinement. By a structured optimization approach, the coupling with the active material is maximized here in a fully open architecture, allowing to achieve a 100 meV photonic bandgap with the bound state in the continuum in a local energy minimum and a Rabi splitting of 70 meV, which results in very high cooperativity. Our architecture paves the way to a class of polariton devices based on topologically protected and highly interacting bound states in the continuum.

Two-dimensional perfusion angiography permits direct visualization of redistribution of flow in hepatocellular carcinoma during b-TACE.

OBJECTIVES: To demonstrate in vivo redistribution of the blood flow towards HCC's lesions by utilizing two-dimensional perfusion angiography in b-TACE procedures. MATERIAL AND METHODS: In total, 30 patients with 35 HCC nodules treated in the period between January 2019 and November 2021. For each patient, a post-processing software leading to a two-dimensional perfusion angiography was applied on each angiography performed via balloon microcatheter, before and after inflation. On the colour map obtained, reflecting the evolution of contrast intensity change over time, five regions of interests (ROIs) were assessed: one on the tumour (ROI-t), two in the immediate peritumoural healthy liver parenchyma (ROI-ihl) and two in the peripheral healthy liver parenchyma (ROI-phl). The results have been interpreted with a novel in silico model that simulates the hemodynamics of the hepatic arterial system. RESULTS: Among the ROIs drawn inside the same segment of target lesion, the time-to-peak of the ROI-t and of the ROI-ihl have a significantly higher mean value when the balloon was inflated compared with the ROIs obtained with deflated balloon (10.33 ± 3.66 s vs 8.87 ± 2.60 s (p = 0.015) for ROI-t; 10.50 ± 3.65 s vs 9.23 ± 2.70 s (p = 0.047) for ROI-ihl). The in silico model prediction time-to-peak delays when balloon was inflated, match with those observed in vivo. The numerical flow analysis shows how time-to-peak delays are caused by the obstruction of the balloon-occluded artery and the opening of intra-hepatic collateral. CONCLUSION: The measurements identify predictively the flow redistribution in the hepatic arteries during b-TACE, supporting a proper positioning of the balloon microcatheter.

Cone-Beam CT-Guided Transarterial Tagging of Endophytic Renal Tumors with Indocyanine Green for Robot-Assisted Partial Nephrectomy.

PURPOSE: To evaluate the safety, efficacy, and clinical impact of preoperative cone-beam computed tomography (CT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and ethiodized oil in patients undergoing robot-assisted partial nephrectomy (RAPN) using near-infrared fluorescence imaging (NIR-FI). MATERIALS AND METHODS: Patients with renal endophytic tumors eligible for RAPN and transarterial embolization with ICG and ethiodized oil were prospectively enrolled. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as ethiodized oil accumulation in the nodule, was classified as poor, moderate, good, or optimal on the basis of postembolization cone-beam CT. Surgical visibility of the tumors during RAPN with the use of NIR-FI was classified as follows: (a) not visible, (b) visible with poorly defined margins, and (c) visible with well-defined margins. RESULTS: Forty-one patients underwent preoperative selective embolization. Technical success was 100%. Ethiodized oil accumulation on cone-beam CT was poor in 2 (4.9%), moderate in 6 (14.6%), good in 25 (61.0%), and optimal in 8 (19.5%) of 41 patients. During RAPN with NIR-FI, tumors were visible with well-defined margins in 26 (63.4%), visible with blurred margins in 14 (34.1%), and not visible in 1 (2.4%) of 41 cases. There were no adverse events following endovascular embolization. CONCLUSIONS: Preoperative transarterial superselective embolization of endophytic renal tumors with ICG and ethodized oil in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Role of CT and MR imaging in the assessment of suspected spondylodiscitis and planning of needle biopsy.

PURPOSE: Our aim was to assess the role of computed tomography (CT) or magnetic resonance imaging (MRI) in the assessment of spondylodiscitis, identifying the best target structures for biopsy to increase the likelihood of positive cultures. MATERIALS AND METHODS: This study was approved by our Institutional Review Board, and requirement for specific consent form was waived. In this retrospective single Institution study, we evaluated clinical and imaging records of 60 patients who underwent spine biopsy for suspected spondylodiscitis from January 2016 to May 2021. CT and MRI sensitivity and inter-reader agreement were assessed according to the phase of spondylodiscitis, defined as acute, subacute or chronic. Inter-reader agreement for the diagnosis and identification of spondylodiscitis phase was assessed using K statistics. Univariate logistic regression analysis was performed to assess any relationship between MRI/CT findings, spondylodiscitis phase and positive cultures. RESULTS: Sixty patients (48 males) with mean age 59, 2 ± 29 were enrolled in this study. MRI showed higher sensitivity (96% vs 65% of CT) in the diagnosis and good inter-reader agreement (k = 0.8) in the identification of the acute and subacute phase of spondylodiscitis, and moderate inter-reader agreement (k = 0.7) and lower sensitivity (80% vs 95% of CT) for the chronic phase. Univariate analysis showed as MRI-specific findings such as extensive hyperintensity of vertebral body and/or disc on Short Tau Inversion Recovery-T2w images, paravertebral collections, preserved or augmented disc height and presence of a vertebral fractures were mainly found in the acute/subacute phase and was a predictor for positive cultures (p < 0.05). CONCLUSION: MRI and CT are both able to identify the different phases of spondylodiscitis, although MRI is more sensitive in the acute phase. Findings such as extensive hyperintensity of the disc/vertebral body, fractures and paravertebral collections, represent the main targets for biopsy related to a positive culture.

Balloon occluded TACE (B-TACE) vs DEM-TACE for HCC: a single center retrospective case control study.

BACKGROUND: To compare oncological results and safety profile of balloon micro-catheter trans-arterial chemoembolization (b-TACE) and drug-eluting-microsphere (DEM-TACE) in patients with hepatocellular-carcinoma (HCC). METHODS: This is a case-control, retrospective, single-center study. Between January-2015/March-2019, 149 patients (131 males [87.9%]) with 226 HCC were treated, 22 patients (35 HCC; 19 [86.4%] males) with b-TACE and 127 with DEM-TACE (191 HCC, 112 [88.2%] males). Embolization protocol was standardized (sequential 100 ± 25 and 200 ± 25 µm microspheres). Results were evaluated by modified-response-evaluation-criteria-in-solid-tumor [mRECIST] at 1, 3-6 and 9-12 months and time to recurrence after complete response [TTR] at 1 years. Cox's regression weighted with tumor dimensions was performed. Adverse events (AEs) were recorded. RESULTS: mRECIST oncological response at all time points (1, 3-6 and 9-12 months) for both treatments were similar, with the exception of Objective response rate at 9-12 months. Objective response at 1 and 3-6 months between b-TACE vs DEM-TACE [23/35 (65.7%) vs 119/191 (62.3%), 21/29 (72.4%) vs 78/136 (57.4%) (p > 0.05), respectively]. On the contrary, at 9-12 months, it was significantly higher in b-TACE subgroup than DEM-TACE (15/19 [78.9%] vs 48/89 [53.9%], p = 0.05). TTR for complete response at 1 year had a better trend for b-TACE vs DEM-TACE (278.0 days [196.0-342.0] vs 219.0 days [161.0-238.0], OR 0.68 [0.4-1.0], p = 0.10). The use of balloon micro-catheter reduced the relative risk of the event of recurrence by 0.63 [CI95% 0.38-1.04]; p = 0.07). No significant differences were found in AEs rate. CONCLUSION: b-TACE showed a trend of better oncological response over DEM-TACE with and longer TTR with a similar adverse events rate, in patients presenting with larger tumors.

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks.

PURPOSE: To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. MATERIALS AND METHODS: Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4 Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12 months. RESULTS: Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68 min (mean 51.36 min). Mean fluoroscopy time was 16.7 min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6 ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. CONCLUSION: Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Provisional Stenting Using the Zilver PTX Drug-Eluting Stent After Drug-Coated Balloon Angioplasty: Initial Experience From the Double Drug Dose "3D" Study.

Purpose: To explore the provisional use of a drug-eluting stent (DES) after suboptimal drug-coated balloon (DCB) angioplasty in complex, calcified femoropopliteal lesions. Materials and Methods: A prospective, single-center, investigator-initiated pilot study enrolled 15 patients (mean age 71.3 years; 9 men) with symptomatic stenosis (n=6) or occlusion (n=9) of the native superficial femoral and/or proximal popliteal arteries who experienced suboptimal DCB dilation despite postdilation. Lesion characteristics were evaluated with computed tomography angiography and duplex ultrasound confirmed by intravascular ultrasound. Follow-up included clinical and imaging evaluations as well as blood tests to monitor inflammatory markers. Endpoints included systemic inflammation, acute/chronic thrombosis, aneurysm formation, and mortality. Results: Provisional stenting was required for residual stenosis >50% in 4 cases and flow-limiting dissection in 11. Provisional spot stenting was done using the Zilver PTX DES. Clinical improvement was observed in all cases. After 24-month follow-up all patients were alive and in good clinical condition. One- and 2-year primary patency rates were 93.3% and 92.9%, respectively; secondary patency was 100%. Restenosis required reintervention in 2 cases. No local or systemic complications or toxicity were observed due to the use of a double dose of paclitaxel. No significant increase in any inflammation marker was observed in the perioperative period, and no aneurysm formation was seen over 24 months of follow-up. Conclusion: Combined DCB plus DES therapy seems to be safe and correlated with high primary patency following suboptimal angioplasty. Larger studies are required to confirm the safety and efficacy of this approach.

Updated Clinical and Radiological Classification of Lower Limb Atherosclerotic Disease.

Lower limb atherosclerotic disease has classically been classified as acute or chronic; however, this is an evolving process that has a wide spectrum of clinical and imaging aspects. Owing to the evolvement of endovascular and imaging techniques, we have now garnered new information regarding the pathophysiology and behavior of atherosclerotic disease, also in response to endovascular and surgical techniques. Clinical presentation can actually be classified according to the time of presentation, ranging from acute (<2 weeks) and subacute (from 2 weeks to 3 months) to chronic (over 3 months) and acute/subacute on underlying chronic disease. Imaging characteristics such as the presence of thrombus, number of collaterals, and target vessel wall features may help in defining the correct type of atherosclerotic lesion, triggering the appropriate treatment strategy. Clinical and imaging characteristics of those different stages are complex and not systematically addressed by current guidelines, that do not show any specific recommendations for imaging pathways/characteristics or treatment. This review illustrates the clinical and imaging characteristics of the different stages of lower limb atherosclerotic disease and related treatment options.

Under-dilated TIPS Associate With Efficacy and Reduced Encephalopathy in a Prospective, Non-randomized Study of Patients With Cirrhosis.

BACKGROUND & AIMS: Portosystemic encephalopathy (PSE) is a major complication of trans-jugular intrahepatic porto-systemic shunt (TIPS) placement. Most devices are self-expandable polytetrafluoroethylene-covered stent grafts (PTFE-SGs) that are dilated to their nominal diameter (8 or 10 mm). We investigated whether PTFE-SGs dilated to a smaller caliber (under-dilated TIPS) reduce PSE yet maintain clinical and hemodynamic efficacy. We also studied whether under-dilated TIPS self-expand to nominal diameter over time. METHODS: We performed a prospective, non-randomized study of 42 unselected patients with cirrhosis who received under-dilated TIPS (7 and 6 mm) and 53 patients who received PTFE-SGs of 8 mm or more (controls) at referral centers in Italy. After completion of this study, dilation to 6 mm became the standard and 47 patients were included in a validation study. All patients were followed for 6 months; Doppler ultrasonography was performed 2 weeks and 3 months after TIPS placement and every 6 months thereafter. Stability of PTFE-SG diameter was evaluated by computed tomography analysis of 226 patients with cirrhosis whose stent grafts increased to 6, 7, 8, 9, or 10 mm. The primary outcomes were incidence of at least 1 episode of PSE grade 2 or higher during follow up, incidence of recurrent variceal hemorrhage or ascites, incidence of shunt dysfunction requiring TIPS recanalization, and reduction in porto-caval pressure gradient. RESULTS: PSE developed in a significantly lower proportion of patients with under-dilated TIPS (27%) than controls (54%) during the first year after the procedure (P = .015), but the proportions of patients with recurrent variceal hemorrhage or ascites did not differ significantly between groups. No TIPS occlusions were observed. These results were confirmed in the validation cohort. In an analysis of self-expansion of stent grafts, during a mean follow-up period of 252 days after placement, none of the PTFE-SGs self-expanded to the nominal diameter in hemodynamically relevant sites (such as portal and hepatic vein vascular walls). CONCLUSIONS: In prospective, non-randomized study of patients with cirrhosis, we found under-dilation of PTFE-SGs during TIPS placement to be feasible, associated with lower rates of PSE, and effective.

Updated Management of Malignant Biliary Tract Tumors: An Illustrative Review.

The management of malignant biliary tumors (MBTs) is complex and requires a multidisciplinary approach. Guidelines and methods of staging for biliary tumors have recently been released by main international societies, altering the clinical and radiologic approach to this pathologic condition. The aim of the present review is to detail the updated role of imaging in preoperative staging and follow-up and to illustrate clinical/therapeutic pathways. In addition, future perspectives on imaging and targeted/embolization therapies are outlined.

Use of ultrasound in the insertion of a vascular closure device: a comparative retrospective study with the standard blind technique.

PURPOSE: To evaluate whether ultrasound (US) assistance can decrease the rate of complications related to the use of vascular closure devices (VCDs). MATERIALS AND METHODS: A retrospective comparative study was done on 150 consecutive patients who had a VCD inserted under US guidance after retrograde common-femoral-artery (CFA) puncture. This group was compared to a historical control group of 150 consecutive patients who had the same VCDs inserted with the standard blind technique. After the procedures, patients were placed at bedrest for at least 6 h. Technical success, defined as correct deployment without adjunctive manual compression, blood count and US evaluation of the arterial puncture site was done at 24 h and at 3 months. Differences in terms of efficacy and safety were statistically evaluated using US guidance as a predictor for a lower complication rate. RESULTS: Technical success was achieved in 147/150 patients (98 %) in the study group vs. 141/150 cases (94 %) of the control group (p = 0.038). In three cases (2 %) adjunctive manual compression (≤5 min) was required. One pseudoaneurysm (0.65 %) occurred after 24 h, solved with manual compression. Six minor complications (4 %)--haematoma (n = 5; 3.35 %), recurrent wound bleeding (n = 1; 0.65 %)--were reported. In the control group four (2.65 %) major complications occurred: CFA occlusion managed with surgical bypass, CFA dissection solved by surgical bypass, two pseudoaneurysms solved with manual compression. Thirteen (8.65 %) minor complications were observed with haematoma (n = 10; 6.65 %), and recurrent wound bleeding (n = 3; 2.0 %). The comparative analysis of the total complication rate and major complication rate between the study group and the control group was statistically significant (p = 0.016 and p = 0.049, respectively). A 24-h evaluation showed a triphasic flow within the CFA in 150/150 patients (100 %) of the study group and in 146/150 cases (97.35 %) of the control group. CONCLUSION: VCD inserted under US guidance increases the success rate reducing the number of complications.

Room temperature Bloch surface wave polaritons.

Polaritons are hybrid light-matter quasi-particles that have gathered a significant attention for their capability of showing room temperature and out-of-equilibrium Bose-Einstein condensation. More recently, a novel class of ultrafast optical devices have been realized by using flows of polariton fluids, such as switches, interferometers, and logical gates. However, polariton lifetimes and propagation distances are strongly limited by photon losses and accessible in-plane momenta in normal microcavity samples. In this work, we show experimental evidence of the formation of room temperature propagating polariton states arising from the strong coupling between organic excitons and a Bloch surface wave. This result, which was only recently predicted, paves the way for the realization of polariton devices that could allow lossless propagation up to macroscopic distances.

Endovascular treatment of infrapopliteal arteries: angioplasty vs stent in the drug-eluting era.

UNLABELLED: To analyse data comparing drug-eluting devices versus non-coated devices in the treatment of vascular disease in the infrapopliteal region. All data available in the literature (16 studies were included) comparing drug-eluting stents (DESs) and drug-eluting balloons (DEBs) versus bare-metal stents (BMSs) and conventional balloons were analysed. For each single study, primary and secondary endpoints were reported. As comparative studies between DEBs and DESs were not available, a technical evaluation of the advantages and disadvantages of both were also included. Besides the limitations of the published studies, all of them were reporting interesting results for the new generation devices (DEB and DES). DES: primary patency at 1 year comprised between 75.0 % and 86 %; target lesion revascularisation between 8.7 % and 13.8 %. DEB: primary patency comprised between 71 % and 84.6 % at 12 months; target lesion revascularisation between 15.3 % and 17.6 %. However, limb salvage rates were not always higher using a DEB rather than a standard percutaneous transluminal angioplasty (PTA); a clinical improvement for patients treated with DEB was demonstrated only in the Leipzig registry. On the basis of the results available, the drug-eluting devices produced better results. DEB can be considered the leading approach in below-the-knee disease. A comparative evaluation with DES is mandatory in the future. KEY POINTS: •We present data about advanced endovascular treatment of peripheral artery disease. •This provides an update on drug-eluting devices in infrapopliteal vascular disease. •Drug-eluting devices (DEB/DES) show promising results compared with traditional ones.

Percutaneous vertebroplasty with the rotational fluoroscopy imaging technique.

OBJECTIVE: To evaluate the feasibility of the rotational angiography unit (RAU) as a single technique to guide percutaneous vertebroplasty (PVP). MATERIALS AND METHODS: Twenty-five consecutive patients (35 vertebral bodies, 20 lumbar and 15 thoracic) were treated using RA fluoroscopy. Using a state-of-the-art flat-panel angiographer (Artis zee, Siemens, Erlangen, Germany), rotational acquisitions were obtained in all patients for immediate post-procedure 2D/3D reconstructions. Pre- and postoperative back pain was assessed with the visual analog scale (VAS). Fluoroscopy time, patient radiation dose exposure, technical success, mean procedure time, mean number of rotational acquisitions and procedural complications were recorded. All features were compared with a historical cohort of patients (N = 25) who underwent PVP under CT and mobile C-arm fluoroscopy guidance. RESULTS: In all cases, safe and accurate control of the needle insertion and bone-cement injection was successfully obtained with high-quality fluoroscopy images. One cement leakage was detected in the RAU group, and two leakages were detected in the CT and C-arm fluoroscopy group. Technical features were significantly different between the two groups (RAU vs. CT): mean procedure time: 38.2 min vs. 60.2 min (p = 0.02); median fluoroscopy time: 14.58 and 4.58 min (p = 0.02); median number of rotational acquisitions: 5 vs. 10 (p = 0.02); mean patient dose: 6 ± 1.3 mSv vs. 23 ± 1.3 mSv (p = 0.02). There were minor complications (pain, small hematoma) in two patients (8%) in the study group and three cases (12%) in the control group. CONCLUSION: RAU guidance is an effective and safe technique for performing PVP because it reduces the procedural time and radiation exposure.

CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair.

BACKGROUND: Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE: This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS: The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS: Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.

Minimally invasive treatment of gastric leak after sleeve gastrectomy.

PURPOSE: Obesity is a leading problem in Western countries, and laparoscopic sleeve gastrectomy (SG) is the most commonly used procedure for the surgical management of morbid obesity. SG is recognised as one of the safest and most effective bariatric procedures but it is limited by a rate of gastric leaks (GL) ranging from 1.4% to 20%. No international consensus exists about the treatment of GL. This paper reports our experience with the noninvasive management of GL. MATERIALS AND METHODS: From July 2004 to December 2010, 16 patients with GL after SG were referred to our unit. All patients underwent contrast radiography (Gastrografin) and computed tomography (CT) examination. On the basis of the radiographic findings, patients were divided into those eligible for drainage and those not eligible. RESULTS: Twelve patients (75%) were eligible for percutaneous drainage. Of these, seven patients (44%) were successfully treated with percutaneous drainage alone, whereas five patients (31%) required placement of a covered stent due to incomplete resolution of the collection. After 1009.8±456.7 days of follow-up, one patient died from a cardiovascular event and two patients required a bilio-pancreatic-digestive bypass (BPD-BP). Twelve patients (75%) were in an excellent state of health with significant reduction of their body mass index (BMI). CONCLUSIONS: Our experience confirms the value of an algorithm based on patient eligibility for percutaneous drainage in the treatment of GL. The patient's general condition and in particular the presence of sepsis supports the value of this approach in preference to the conventional surgical approach.

Risk management in radiology.

Recent US nationwide research on malpractice lawsuits shows that the most common cause of medical malpractice suits against radiologists was error in diagnosis (mainly failure to diagnose instead of delay); the category next in frequency was procedural complications, followed by inadequate communication with either patient or referring physician. Risk management is a fundamental instrument to prevent and limit errors and adverse events. This article analyzes risk management in radiology addressing the most common ethical-legal issues on appropriateness of prescriptions, informed consent, and management of adverse events. Effective remedial actions are proposed to avoid malpractice claims that would help physicians in preventing malpractice stress syndrome, leading to defensive medicine.

Carotid artery stenting: analysis of a 12-year single-center experience.

PURPOSE: To analyze a 12-year experience performing carotid artery stenting (CAS) with cerebral protection. METHODS: In accord with NASCET criteria, 672 patients underwent CAS at our hospital between November 1999 and September 2011 for de novo or postsurgical restenosis; among these, 636 patients (474 men; mean age 68 ± 6.8 years, range 63-85) had a minimum 6-month follow-up, which qualified them for this analysis. The majority of patients (381, 59.9%) were symptomatic; 47 patients had staged bilateral CAS procedures (total of 683 procedures). A cerebral protection device was used in 94.7%. Patients underwent duplex ultrasound and clinical evaluation during follow-up. Neurological adverse events were correlated with plaque morphology, patient age >80 years, learning curve, and spasm. RESULTS: Technical success was achieved in all cases. Neurological events [3 (0.4%) major strokes, 8 (1.2%) minor strokes, and 11 (1.6%) transient ischemia attacks] occurred in 22 (3.2%) of the 683 cases within 30 days of the procedure (no events in follow-up). These involved 5 (2.0%) of the 255 asymptomatic patients and 17 (4.5%) of the 381 symptomatic patients (p=0.001). Neurological events proved to be higher in patients >80 years (6.4% vs. 2.7% of patients <80 years, p<0.05) and in those with complex plaque morphology (6.1% vs. 1.0% in stable plaques, p<0.001). After a mean follow-up of 76 ± 32.4 months, 478 (70%) patients were alive, with a 30-day mortality of 1.9% (none due to stroke). In-stent stenosis occurred in 9 (1.3%) stents and was resolved with angioplasty or re-stenting. The primary patency rate was 98.7%. CONCLUSION: CAS is a valid technique for the treatment of carotid occlusive disease, with a very low rate of in-stent stenosis. Neurological complications were correlated with complex plaque morphology, which makes accurate pretreatment evaluation of the lesion mandatory if good CAS outcomes are to be achieved.

Lower limb multilevel treatment with drug-eluting balloons: 6-month results from the DEBELLUM randomized trial.

PURPOSE: To report 6-month results of the DEBELLUM (Drug-Eluting Balloon Evaluation for Lower Limb MUltilevel TreatMent) randomized trial to evaluate the efficacy of a drug-eluting balloon (DEB) to reduce restenosis after treatment of multilevel lower limb occlusive disease vs. a conventional angioplasty balloon (AB). METHODS: Between September 2010 and March 2011, 50 consecutive patients (37 men; mean age 66±4 years) with 122 lesions (96 stenoses and 26 occlusions) of the femoropopliteal (92, 75.4%) or below-the-knee (BTK) arteries (30, 24.6%) were enrolled and randomly assigned to the DEB (25 patients with 57 lesions) or AB (25 patients with 65 lesions) group. Twenty patients presented multilevel lesions. Mean lesion length was 7.5±3.5 cm. Thirty-one (62%) of the patients were Fontaine stage IIb, while 19 (38%) were stage III or IV. DEBs or ABs were used for dilation of de novo lesions or for postdilation after primary stenting (superficial femoral artery only). Patients requiring provisional stenting after angioplasty secondary to flow-limiting dissection or residual stenosis >50% were ineligible. Primary endpoint was late lumen loss at 6 months. Secondary endpoints were target lesion revascularization (TLR), amputation, and thrombosis. RESULTS: Late lumen loss was lower in the DEB group (0.5±1.4 vs. 1.6±1.7 mm, p<0.01). TLR was necessary in 6.1% of the DEB group vs. 23.6% of the AB group (p=0.02). Comparing the DEB to AB groups, the thrombosis rates were 3.0% vs. 5.2% (p=0.6), and the amputation rates were 3.0% vs. 7.9% (p=0.36). The binary restenosis rates were 9.1% (3/33 limbs) in the DEB group vs. 28.9% (11/38 limbs) in the control group (p=0.03). The ankle-brachial index improved to a greater degree in the DEB group: 0.87±0.22 vs. 0.70±0.13 (p<0.05). The Fontaine stage improved in both groups but more so in patients treated with DEBs (p=0.04). CONCLUSION: The DEBELLUM trial confirmed the ability of paclitaxel-eluting balloons to reduce restenosis vs. conventional balloons at 6 months after treatment of multilevel (femoropopliteal and BTK) arterial disease in patients affected by claudication and CLI. A lower TLR rate and better clinical outcomes appear to be associated with the use of DEBs regardless of stent placement.