Inflammation and the bone-vascular axis in end-stage renal disease.

UNLABELLED: Bone loss and vascular calcification coincide in patients with end-stage renal disease, similar as to what is observed in the general population. In the present bone biopsy study, we provide further evidence that (micro-)inflammation may represent a common soil for both diseases. INTRODUCTION: Vascular calcification is a common complication of end-stage renal disease (ESRD) and is predictive of subsequent cardiovascular disease and mortality. Mounting evidence linking bone disorders with vascular calcification has contributed to the development of the concept of the bone-vascular axis. Inflammation is involved in the pathogenesis of both disorders. The aim of the present study was to evaluate the relationship between aortic calcification, inflammation, and bone histomorphometry in patients with ESRD. METHODS: Parameters of inflammation and mineral metabolism were assessed in 81 ESRD patients (55 ± 13 year, 68 % male) referred for renal transplantation. Static bone histomorphometry parameters were determined on transiliac bone biopsies performed during the transplant procedure. Aortic calcification was quantified on lateral lumbar X-rays using the Kauppila method. RESULTS: Aortic calcification, low bone turnover, and low bone area were observed in 53, 37, and 21 % of patients respectively. Inflammatory markers were found to be independently associated with aortic calcification (hsIL-6) and low bone area (TNF-α). Low bone area associated with aortic calcification, independent of age, diabetes, and inflammation. CONCLUSIONS: Low bone area and inflammation associates with aortic calcification, independent of each other and traditional risk factors. Our data emphasize the role of (micro-)inflammation in the bone-vascular axis in CKD.

Preoperative arterial embolization facilitates multivisceral transplantation for portomesenteric thrombosis.

Multivisceral transplantation (MvTx) for diffuse venous portomesenteric thrombosis is a surgically and anesthesiologically challenging procedure, partly because of the risk of massive bleeding during visceral exenteration. Preoperative visceral artery embolization might reduce this risk. In three consecutive MvTx, the celiac trunk (CT) and superior mesenteric artery (SMA) were embolized immediately pretransplant. We analyzed demographics, serum D-lactate, pH, base excess, hemoglobin, blood pressure, transfused packed cell (PC) units, intervention time and outcome. Results are reported as median (range). All recipients were male (43, 22, 47 years old). Portomesenteric thrombosis followed antiphospholipid syndrome, neuroendocrine tumor and liver cirrhosis. A peritransplant D-lactate peak of 6.1 (5.1-7.6) mmol/L, lowest pH of 7.24 (7.18-7.36) and lowest base excess level of -9.5 (-7.6 to -11.5) were observed. Values normalized within 3 h posttransplant. Embolization and exenteration times were 80 (70-90) min and 140 (130-165) min, respectively, during which blood pressure remained stable, lowest hemoglobin was 6.1 (6.1-7.6) g/dL and three (2-4) PC were administered. All procedures were uneventful. Follow-up was 7 (4-9) months. The first patient died 4 months post-MvTx after an intracranial bleeding; the other patients are doing well. Our experience suggests that preoperative embolization of CT and SMA facilitates native organ resection in MvTx.

The effect of anastomosis time on outcome in recipients of kidneys donated after brain death: a cohort study.

Whether warm ischemia during the time to complete the vascular anastomoses determines renal allograft function has not been investigated systematically. We investigated the effect of anastomosis time on allograft outcome in 669 first, single kidney transplantations from brain-dead donors. Anastomosis time independently increased the risk of delayed graft function (odds ratio per minute [OR] 1.05, 95% confidence interval [CI] 1.02-1.07, p < 0.001) and independently impaired allograft function after transplantation (p = 0.009, mixed-models repeated-measures analysis). In a subgroup of transplant recipients, protocol-specified biopsies at 3 months (n = 186), 1 year (n = 189), and 2 years (n = 153) were blindly reviewed. Prolonged anastomosis time independently increased the risk of interstitial fibrosis and tubular atrophy on these protocol-specified biopsies posttransplant (p < 0.001, generalized linear models). In conclusion, prolonged anastomosis time is not only detrimental for renal allograft outcome immediately after transplantation, also longer-term allograft function and histology are affected by the duration of this warm ischemia.

TEVAR for Ruptured type B Aortic Dissection in a Patient with Turner Syndrome.

TEVAR has replaced open surgical repair as preferred treatment for complicated acute type B aortic dissection. But the literature on thoracic endovascular aortic repair (TEVAR) for ruptured type B dissection is scarce. Patients with Turner syndrome are at risk for aortic dissection and rupture at a young age with an immediate mortality rate of 63%. Only a few cases have been described and the best treatment is not yet established. We present a case of a 49 year-old woman with Turner syndrome who suffered from a ruptured aortic dissection Stanford type B. A TEVAR procedure was performed, but the life of the patient could not be saved. In this case report we discuss the lessons we learned as well as some unsolved questions about TEVAR for ruptured type B aortic dissection.

Transjugular intrahepatic portosystemic shunt stent-graft placement: mean optimal portal venous projection view determined by three-dimensional portography.

BACKGROUND: Suboptimal stent-graft placement at the lower anastomosis during transjugular intrahepatic portosystemic shunt (TIPS) may result in early shunt stenosis and occlusion owing to incomplete covering of the parenchymal tract by the covered part of the stent-graft. PURPOSE: To determine the optimal portal venous projection view for stent-graft placement during TIPS and the potential influence of the portal vein anatomy. MATERIAL AND METHODS: On 76 cirrhotic patients (48 men and 28 women) selected for TIPS, rotational, three-dimensional (3D), catheter-directed angiography of the portal vein was performed. The 3D portograms were reviewed by two independent interventional radiologists to determine the optimal angiographic projection views for stent-graft placement. Intra-observer and inter-observer reliabilities were tested and subgroups of patient portal vein anatomy were categorized. RESULTS: Among all patients, the optimal portal venous projection views for stent-graft placement during TIPS centered around 27° (±14°) right oblique and 3° (±7°) craniocaudal. Of these, 56% were within the standard deviations. Intra-observer reliabilities were 0.60 and 0.62 for the two radiologists, respectively. Inter-observer reliability was 0.48. Anatomical variations in the patient population were: normal portal vein (67%), trifurcation at main portal vein (16%), right posterior portal vein as the first branch of main portal vein (3%), no right posterior portal vein (1%), and other variations (13%). Anatomical subgroups did not influence the best angiographic projection view significantly (F4,295 = 0.91, P = 0.457). CONCLUSION: The mean optimal angiographic projection view for TIPS stent-graft placement was 27° right oblique and 3° craniocaudal. Patient anatomic variations do not play a significant role in determining the optimal angiographic view for TIPS stent-graft placement.

Penetration of a fractured Bird's Nest filter strut into the liver parenchyma: report of two cases.

This report deals with two rare but similar cases of asymptomatic fracture of a Bird's Nest inferior vena cava (IVC) filter strut, penetrated into the liver parenchyma. Follow-up over 4 and 6 years, respectively, could not reveal any changes in the position of the fragmented strut in the liver parenchyma or any evidence of clinical symptoms owing to the migrated strut fragment.

p64 flow diverter: Results in 108 patients from a single center.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. RESULTS: Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1-6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. CONCLUSION: The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

Preoperative mapping for haemodialysis access surgery with CO(2) venography of the upper limb.

OBJECTIVE: This study aims to evaluate the impact of CO(2) venography on the planning and outcome of native arteriovenous fistula (AVF) creation. METHODS: Records of patients who underwent CO(2) venography prior to access surgery between January 2000 and December 2008 were reviewed. CO(2) venography was performed selectively in chronic kidney disease (CKD) in stage IV-V patients without suitable veins on clinical examination. Findings at surgery were compared to CO(2) venography images. Patency of AVFs was analysed by the Kaplan-Meier method. Differences in outcome of maturation were compared using a chi(2) test. RESULTS: A total of 209 CO(2) venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO(2) venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO(2) venography (n = 2) or access was attempted with a vein which was thought to be unsuitable on CO(2) venography (n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable (P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively. CONCLUSION: CO(2) venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Outcome of carotid artery stenting at 2 years follow-up: comparison of nitinol open cell versus stainless steel closed cell stent design.

AIM: The aim of this study was to compare the clinical and ultrasound outcome of carotid artery stenting at 2-year follow-up in patients treated with open-cell nitinol stents versus patients treated with closed cell stainless steel stents. METHODS: This was a non-randomized, retrospective study including 123 patients in whom 132 carotid stent-procedures were performed. Nine patients were treated bilaterally. All patients presented with severe asymptomatic (80%) or symptomatic (>70%) carotid artery stenosis and were treated by carotid angioplasty and stent placement with or without filter embolic protection system. Follow-up consisted of physical evaluation at 1, 6, 12 and 24 months and assessment of the stent patency by ultrasound examination at 6, 12 and 24 months after the stent procedure. RESULTS: In 72 procedures a closed cell stainless steel stent was implanted, in the remaining 60 procedures an open cell nitinol stent was placed. In 8 patients with a stainless steel stent (11%) and in 6 patients with a nitinol stent (10%) a stroke occurred during the follow-up period (P=0.79). Ultrasound examination revealed an in-stent restenosis of 50% to 80% in the stainless steel group (N.=9, 15%) and in the nitinol group (N.=10, 17%) (P=0.7). CONCLUSIONS: At 2-year follow-up after carotid artery stenting, there is no difference in clinical outcome or in stent patency among patients treated with open versus closed cell design stents. Subsequently the type of carotid stent design does not seem to impact the overall midterm outcome after carotid artery stenting.

Relationship between fluorodeoxyglucose uptake in the large vessels and late aortic diameter in giant cell arteritis.

OBJECTIVE: GCA carries an increased risk of developing thoracic aortic aneurysms. Previous work with fluorodeoxyglucose (FDG)-PET has shown that the aorta is frequently involved in this type of vasculitis. We wanted to investigate whether there is a correlation between the extent of vascular FDG uptake during the acute phase of GCA and the aortic diameter at late follow-up. METHODS: All patients with biopsy-proven GCA who ever underwent an FDG-PET scan in our centre were asked to undergo a CT scan of the aorta. The diameter of the aorta was measured at six different levels (ascending aorta, aortic arch, descending aorta, abdominal suprarenal, juxtarenal and infrarenal aorta) and the volumes of the thoracic and of the abdominal aorta were calculated. RESULTS: Forty-six patients agreed to participate (32 females, 14 males). A mean of 46.7 +/- 29.9 months elapsed between diagnosis and CT scan. All aortic dimensions were significantly smaller in women than in men, except for the diameter of the ascending aorta. Patients who had an increased FDG uptake in the aorta at diagnosis of GCA, had a significantly larger diameter of the ascending aorta (P = 0.025) and descending aorta (P = 0.044) and a significantly larger volume of the thoracic aorta (P = 0.029). In multivariate analysis, FDG uptake at the thoracic aorta was associated with late volume of the thoracic aorta (P = 0.039). CONCLUSION: GCA-patients with increased FDG uptake in the aorta may be more prone to develop thoracic aortic dilatation than GCA patients without this sign of aortic involvement.

Symptomatic stenosis of the cavernous portion of the internal carotid artery due to an irresectable medial sphenoid wing meningioma: treatment by endovascular stent placement.

A 48-year-old woman, with right-sided proptosis and decreased visual acuity, presented with acute left sensorimotor deficit. Recent ischemia in the right posterior watershed area was found on CT and MR imaging, as well as a right-sided medial sphenoid wing meningioma causing high-grade stenotic encasement of the cavernous portion of the right internal carotid artery. Because the patient was symptomatic and complete resection of the meningioma was impossible, the stenosis was successfully treated with a balloon-expanding stent.

Cerebral ischemia after filter-protected carotid artery stenting is common and cannot be predicted by the presence of substantial amount of debris captured by the filter device.

PURPOSE: Protected carotid artery stent placement is currently under clinical evaluation as a potential alternative to carotid endarterectomy. The current study was undertaken to determine the incidence of new ischemic lesions found on diffusion-weighted MR imaging (DWI) in nonselected patients after protected carotid artery stent placement using a filter device and to determine the potential relationship between these new ischemic lesions and the presence or absence of a clear amount of debris captured by the neuroprotection filter device. MATERIALS AND METHODS: A nonrandomized cohort of 52 patients (40 men, 12 women) presenting with carotid occlusive disease underwent protected carotid artery stent placement using a filter device. DWI obtained 1 day before stent placement was compared with that obtained 1 day after stent placement. In addition, the macroscopic and microscopic analysis of debris captured by the filter device during the carotid stent placement procedure was assessed. RESULTS: Neuroprotected carotid stent placement was technically successful in all 53 procedures but was complicated by a transient ischemic attack in 3 patients (5.6%). In 22 patients (41.5%), new ischemic lesions were found on DWI, and in 21 filter devices (39.6%), a substantial amount of atheromatous plaque and/or fibrin was found. No clear relationship between the presence of debris captured by the filter device and new lesions detected by DWI was found (P = .087; odds ratio 3.067). CONCLUSION: Neuroprotected carotid artery stent placement will not avoid silent cerebral ischemia. Systematic microscopic analysis of debris captured by the filter device has no predictive value for potential cerebral ischemia after carotid artery stent placement.

Preoperative internal iliac artery coil embolization for aneurysms involving the iliac bifurcation.

Endovascular repair of abdominal aortic aneurysms involving the iliac artery, which is seen in about 20% of patients, requires extension of the stent-graft limb into the external iliac artery. Occlusion of the IIA is used to prevent a potential type II endoleak via retrograde flow in the IIA after covering the IIA origin with a stent-graft limb. In this article, the major indications for coil-embolization of the internal iliac artery in aneurysmal disease are reviewed and discussed, as well as the technique and the outcome regarding endoleak incidence and complications.

Budd-Chiari syndrome: reassessment of a step-wise treatment strategy.

BACKGROUND AND STUDY AIMS: The Budd-Chiari syndrome is a rare disorder characterized by hepatic venous outflow obstruction. A step-wise management was recently proposed. The aim of this study is to reassess our treatment approach and long-term outcome. PATIENTS AND METHODS: The data of 37 Budd-Chiari patients, seen in our unit, were critically analyzed and compared with the ENVIE (European Network For Vascular Disorders of the Liver) data. RESULTS: Most patients had multiple prothrombotic conditions (41%), of which an underlying myeloproliferative neoplasm was the most frequent (59%). The JAK2V617F mutation was associated with more complete occlusion of all hepatic veins (JAK2 mutation +: 70% vs JAK2 mutation -: 23% and a higher severity score. The step-wise treatment algorithm used in our unit, in function of the severity of the liver impairment and the number and the extension of hepatic veins occluded, resulted in the following treatments: only anticoagulation (n = 7.21%), recanalization procedure (n = 4.21%), portosystemic shunts (n = 9.26%) and liver transplantation (n = 14.44%). This resulted in a 10 year survival rate of 90%. Treatment of the underlying hemostatic disorder offered a low recurrence rate. None of the 21 patients with a myeloproliferative neoplasm died in relation to the hematologic disorder. CONCLUSIONS: An individualized treatment regimen consisting of anticoagulation and interventional radiology and/or transplantation when necessary and strict follow-up of the underlying hematologic disorder, provided an excellent long-term survival, which confirm the data of the ENVIE study.

Spontaneous life-threatening hemobilia during acute liver failure successfully treated with transarterial embolization.

A 28-year-old patient admitted with jaundice, vomiting and deteriorating coagulopathy was diagnosed with acute liver failure. After listing for urgent transplantation, he developed Boerhaave's syndrome and massive hemobilia, two life-threatening complications. Massive hemobilia secondary to a fistula between the right hepatic artery and the right bile duct occurred several days after transjugular biopsy and was controlled with fluid resuscitation, transfusion and arterial embolization. Two days later he was transplanted successfully, and is currently doing well after more than 72 months. Aggressive treatment of potentially reversible complications during acute liver failure whilst awaiting transplantation is mandatory to allow survival of these patients.

Diagnosis and treatment of endoleaks after endovascular repair of thoracic and abdominal aortic aneurysms.

A common complication of endovascular repair of a thoracic or abdominal aortic aneurysm (TEVAR - EVAR) is an endoleak occurring in up to 30% of cases. Endoleak is defined as the persistence of blood flow outside the lumen of the endoprosthesis, but within the aneurysm sac and can be classified into 5 categories, depending on the blood flow into the aneurysm sac. Typical features of the different types of endoleaks are discussed as well as the imaging modalities to detect and classify an endoleak and the diverse (endovascular) treatment options.

Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience.

PURPOSE: The management of hemodynamically unstable patients with severe pelvic fractures remains a challenge. Various treatment strategies have been advocated. This study analyzed the value of transcatheter angiographic embolization (TAE) for persistent haemodynamic instability after initial fracture stabilization. MATERIALS AND METHODS: From January 2002 to July 2011, 803 patients were identified with pelvic fractures, 295 of them (37%) were presenting with unstable pelvic fractures. Fifteen patients, all with unstable fractures (2%), remained hypotensive (systolic blood pressure<90 mmHg) despite adequate fluid resuscitation and emergent surgical fracture stabilization, subsequently underwent TAE. RESULTS: The median age in the TAE-group was 57.9 years±20.12 (min 22; max 82) and the median ISS (injury severity score) was 35.8±11.7 (min 22; max 66). 13 out of 15 patients (87%) received initial external fixation and 2 patients (13%) where treated with a C-Clamp before TAE. Radiological success, defined as absence of contrast extravasation on completion angiography, was observed in all 15 patients. In total 3 (20%) patients died during the period of hospitalization, none of them owing to persistent or recurrent pelvic haemorrhage. In the remaining 12 patients, no early or late complications of TAE were identified. Preperitoneal pelvic packing was performed in two patients, both had open pelvic fractures. CONCLUSION: TAE is a safe and very efficient procedure to treat persistent haemorrhage in patients with unstable pelvic fractures initially treated by surgical fracture stabilization procedures. On the long term, no early or late bleeding recurrence could be demonstrated with an overall survival rate of 80%. Preperitoneal pelvic packing can be reserved for patients with open fractures and active bleeding.

Sonographic evaluation of transjugular intrahepatic portosystemic shunt.

The purpose of this article is to review the role of sonography before, during and after transjugular intrahepatic portosystemic shunt placement. A sonographic assessment of the liver and abdomen is recommended before the procedure. We illustrate several important sonographic findings for the echographist, which may alter the procedure approach or even preclude transjugular intrahepatic portosystemic shunt placement. The most challenging step during the procedure is the puncture of the right portal vein. Sonography can be a helpful tool in reducing the number of needle passes, thereby reducing the risk of hemorrhagic complications. Because of its non-invasive and cost-benefit nature, sonography is useful for transjugular intrahepatic portosystemic shunt follow-up. A baseline study at 24 to 48 hours is recommended to discover procedure-related complications. Long-term follow-up is important to detect malfunction of the shunt. Doppler ultrasound is very accurate in detecting shunt thrombosis. However, no consensus exists on the optimal sonographic screening protocol for detecting stenosis. We describe three sonographic parameters to detect transjugular intrahepatic portosystemic shunt stenosis with high sensitivity. Finally, additional sonographic parameters and potential pitfalls are provided in order to improve sensitivity.

Embolization of an internal iliac artery aneurysm after image-guided direct puncture.

OBJECTIVE: To evaluate the feasibility, safety, and efficacy of embolization of internal iliac artery aneurysm (IIAA) after percutaneous direct puncture under (cone-beam) computed tomography (CT) guidance. METHODS: A retrospective case series of three patients, in whom IIAA not accessible by way of the transarterial route, was reviewed. CT-guided puncture of the IIAA sac was performed in one patient. Two patients underwent puncture of the IIAA under cone-beam CT guidance. RESULTS: Access to the IIAA sac was successful in all three patients. In two of the three patients, the posterior and/or anterior division was first embolized using platinum microcoils. The aneurysm sac was embolized with thrombin in one patient and with a mixture of glue and Lipiodol in two patients. No complications were seen. On follow-up CT, no opacification of the aneurysm sac was seen. The volume of one IIAA remained stable at follow-up, and the remaining two IIAAs decreased in size. CONCLUSION: Embolization of IIAA after direct percutaneous puncture under cone-beam CT/CT-guidance is feasible and safe and results in good short-term outcome.

Ten years of experience with the GORE EXCLUDER® stent-graft for the treatment of aortic and iliac aneurysms: outcomes from a single center study.

PURPOSE: This study was designed to assess the long-term outcome of selected patients with aortic, aortoiliac, and isolated common iliac aneurysms treated with the GORE EXCLUDER® stent-graft. METHODS: Between December 1998 and June 2010, 121 nonconsecutive patients underwent insertion of a GORE EXCLUDER® stent-graft to treat an aortic (n=80; 66%), aortoiliac (n=25; 21%), or isolated common iliac (n=16; 13%) aneurysm. Procedural and follow-up data were collected prospectively. Primary endpoints are overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary endpoints are device- and procedure-related complications, including all types of endoleaks or endotension, and reintervention. RESULTS: The mean follow-up is 4.98 years (standard deviation, 3.18; median follow-up, 4.05 years). The estimated percentage overall survival (with 95% confidence interval) after respectively 5 and 10 years of follow-up is 74.5% (65.8; 81.3) and 57.8% (47.7; 66.7). The estimated intervention-free survival after respectively 5 and 10 years is 90% (84.3; 96.1) and 77.7% (67; 88.4). There was no aneurysm rupture during follow-up. Early postoperative complications occurred in 16 patients (13%); none were fatal. Late reinterventions were performed in 18 patients (15%). Finally, throughout the follow-up period, endoleaks were identified: type I (n=4; 3%); type II (n=39; 32%); type III (n=0; 0%); endotension was seen in 11 patients (9%). CONCLUSIONS: Aneurysm exclusion with use of the GORE EXCLUDER® stent-graft is durable through a mean follow-up of nearly 5 years. There was no postprocedural aneurysm rupture. Complications occurred throughout the follow-up period, requiring continued clinical and radiological surveillance.