Hysterosalpingography using a flat panel unit: evaluation and optimization of ovarian radiation dose.

PURPOSE: The aim of the present study was the evaluation and optimization of radiation dose to the ovaries (D) in hysterosalpingography (HSG). METHODS: The study included a phantom study and a clinical one. In the phantom study, we evaluated imaging results for different geometrical setups and irradiation conditions. In the clinical study, 34 women were assigned into three different fluoroscopy modes and D was estimated with direct cervical TLD measurements. RESULTS: In the phantom study, we used a source-to-image-distance (SID) of 110 cm and a field diagonal of 48 cm, and thus decreased air KERMA rate (KR) by 19% and 70%, respectively, for beam filtration: 4 mm Al and 0.9 mm Cu (Low dose). The least radiation exposure was accomplished by using the 3.75 pps fluoroscopy mode in conjunction with beam filtration: Low dose. In the clinical study, D normalized to 50 s of fluoroscopy time with a 3.75 pps fluoroscopy mode reached a value of 0.45 ± 0.04 mGy. Observers' evaluation of diagnostic image quality did not significantly differ for the three different modes of acquisition that were compared. CONCLUSIONS: Digital spot radiographs could be omitted in modern flat panel systems during HSG. Fluoroscopy image acquisitions in a modern flat panel unit at 3.75 pps and a beam filtration of 4 mm Al and 0.9 mm Cu demonstrate acceptable image quality with an average D equal to 0.45 mGy. This value is lower compared to the studied literature. For these reasons, the proposed method may be recommended for routine HSG examination in order to limit radiation exposure to the ovaries.

Paclitaxel-coated balloon angioplasty vs. plain balloon dilation for the treatment of failing dialysis access: 6-month interim results from a prospective randomized controlled trial.

PURPOSE: To report the 6-month results of a prospective randomized trial investigating angioplasty with paclitaxel-coated balloons (PCB) vs. plain balloon angioplasty (BA) for the treatment of failing native arteriovenous fistulae (AVF) or prosthetic arteriovenous grafts (AVG). METHODS: The enrollment criteria for this non-inferiority hypothesis trial included clinical signs of failing dialysis access with angiographic documentation of a significant venous stenotic lesion in patients with AVF or AVG circuits. From March to December 2010, 40 patients (29 men; mean age 64.1 ± 14.3 years) were randomized to undergo either PCB dilation (n = 20) or standard BA (n = 20) of a stenosed venous outflow lesion. Regular angiographic follow-up was scheduled bimonthly. Study outcome measures included device success (<30% residual stenosis without postdilation), procedural success (<30% residual stenosis), and primary patency of the treated lesion (<50% angiographic restenosis and no need for any interim repeat procedures). RESULTS: Baseline and procedural variables were comparably distributed between both groups. Device success was 9/20 (45%) for the PCB device vs. 20/20 (100%) for standard control BA (p<0.001). Procedural success was 100% in both groups after further high-pressure post-dilation as necessary. There were no major or minor complications in either group. At 6 months, cumulative target lesion primary patency was significantly higher after PCB application (70% in PCB group vs. 25% in BA group, p<0.001; HR 0.30, 95% CI 0.12 to 0.71, p<0.006). CONCLUSION: PCB angioplasty improves patency after angioplasty of venous stenoses of failing vascular access used for dialysis.

Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment.

PURPOSE: Ureteral patency in malignant ureteral obstruction cases is a therapeutic challenge. We report our long-term experience with palliative treatment for extrinsic malignant ureteral obstruction with percutaneous placement of metal mesh stents. MATERIALS AND METHODS: From January 1996 to December 2005, 90 patients with a mean age of 59 years (range 35 to 80) with ureteral obstruction due to extrinsic ureteral compression and/or encasement by primary or metastatic tumors, or retroperitoneal lymphadenopathy underwent implantation of self-expandable metal mesh stents. A total of 119 ureters were managed. Followup included urinalysis, blood biochemistry tests and transabdominal ultrasound or intravenous urography. RESULTS: The technical success rate of percutaneous antegrade insertion of ureteral self-expandable metal mesh stents was 100%. Renal biochemistry normalized and hydronephrosis gradually resolved 1 to 2 weeks after stent insertion. Median followup was 15 months (range 8 to 38). Hyperplastic reaction and/or encrustation, or tumor ingrowth developed in 45 stents. Secondary intervention, such as repeat balloon dilation and coaxial stenting, was done to improve patency. Migration was observed in 13 metal stents. The primary and secondary patency rates during followup were 51.2% and 62.1%, respectively. A double pigtail or external-internal stent was inserted in 45 cases in which secondary interventions did not ensure patency. CONCLUSIONS: Internal drainage of extrinsic malignant ureteral obstruction with metal mesh stents provides long-term decompression of the upper urinary tract in select cases. Certain problems limit the application of metal mesh stents in the ureter. Further studies are warranted to identify independent predictors of ureteral patency after the application of metal stents for malignant obstruction.

Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm: Successful treatment with transcatheter arterial embolization. A case study and review of the literature.

Splenic arteriovenous fistula (SAVF) accounts for an unusual but well-documented treatable cause of portal hypertension([1-4]). A case of a 50-year-old multiparous female who developed suddenly portal hypertension due to SAVF formation is presented. The patient suffered from repeated episodes of haematemesis and melaena during the past twelve days and thus was emergently admitted to hospital for management. Clinical and laboratory investigations established the diagnosis of portal hypertension in the absence of liver parenchymal disease. Endoscopy revealed multiple esophageal bleeding varices. Abdominal computed tomography (CT) and transfemoral celiac arteriography documented the presence of a tortuous and aneurysmatic splenic artery and premature filling of an enlarged splenic vein, findings highly suggestive of an SAVF. The aforementioned vascular abnormality was successfully treated with percutaneous transcatheter embolization. Neither recurrence nor other complications were observed.

Starclose SE® hemostasis after 6F direct antegrade superficial femoral artery access distal to the femoral head for peripheral endovascular procedures in obese patients.

PURPOSE: Direct superficial femoral artery (SFA) antegrade puncture is a valid alternative to common femoral artery (CFA) access for peripheral vascular interventions. Data investigating vascular closure device (VCD) hemostasis of distant SFA 6F access are limited. We aimed to investigate the safety and effectiveness of the Starclose SE® VCD for hemostasis, following direct 6F antegrade SFA access distal to the femoral head. METHODS: This prospective, single-center study included patients who were not suitable for CFA puncture and were scheduled to undergo peripheral endovascular interventions using direct antegrade SFA 6F access, at least 2 cm below the inferior edge of femoral head. Hemostasis was obtained with the Starclose SE® VCD (Abbott Laboratories). Primary endpoints were successful hemostasis rate and periprocedural (30-day) major complication rate. Secondary endpoint was the rate of minor complications. Clinical and Doppler ultrasound follow-up was performed at discharge and at one month. RESULTS: Between September 2014 and August 2015, a total of 30 patients (21 male; 70.0%) with a mean body mass index of 41.2 kg/m2 were enrolled. Mean age was 72±9 years (range, 67-88 years). Most patients suffered from critical limb ischemia (87.1%) and diabetes (61.3%). Calcifications were present in eight cases (26.6%). Reason for direct SFA puncture was obesity (100%). Successful hemostasis was achieved in 100% of the cases. No major complications were noted after one-month follow-up. Minor complications included two <5 cm hematomas (6.6%) not necessitating treatment. CONCLUSION: In this prospective study, Starclose SE® VCD was safe and effective for hemostasis of antegrade direct SFA puncture. Uncomplicated hemostasis was achieved even in cases of puncturing 2 to 7 cm below the inferior edge of the femoral head.

Hemobilia secondary to hepatic artery pseudoaneurysm: an unusual complication of bile leakage in a patient with a history of a resected IIIb Klatskin tumor.

We report a case of a 74-year-old woman with a 16-year history of a double bilo-enteric anastomosis due to resected hilar cholangiocarcinoma (Type IIIb Klatskin tumor). The patient presented with cholangitis secondary to benign anastomotic stenosis which resulted in a large intrahepatic biloma. In order to restore the patency of the anastomosis and overcome cholangitis, several attempts took place, including endobiliary stenting, balloon-assisted biloplasty and transhepatic billiary drainage. Anastomotic patency was achieved, complicated, however, by persistent upper gastro-intestinal bleeding, presented as hemobilia. A biloma-induced pseudoaneurysm of the left hepatic artery was diagnosed. This had ruptured into the biliary tract, and presented the actual cause of the hemobilia. Selective embolism of the pseudoaneurysm resulted in control of the hemorrhage, and was successfully combined with transhepatic dilatation of the anastomosis and percutaneous drainage of the biloma. The patient was ultimately cured and seems to be in excellent condition, 5 mo after treatment.

Randomized controlled trial comparing primary and staged basilic vein transposition.

OBJECTIVE: It is unclear if brachio-basilic vein fistula should be performed as a primary or staged procedure, particularly for smaller basilic veins. Our aim was to report on a randomized controlled trial comparing these two techniques. METHODS: Sixteen patients with a basilic vein ≥2.5 mm were randomized into primary transposed brachio-basilic vein (TBBV) fistula (n = 9) and staged TBBV fistula (n = 7). Patients with basilic veins enlarged by previous arteriovenous fistulas were excluded. Baseline characteristics of the two study groups, including vein size, were comparable (median basilic vein diameter 3.5 mm, range 2.8-4.1 mm). The staged group had a brachio-basilic vein fistula performed first followed by the transposition procedure performed at least 6 weeks later to allow the basilic vein to enlarge. TBBV fistula maturation at 10 weeks, primary, assisted-primary, and secondary patency were the primary outcome measures. Early failures were included in the calculation of patency rates. RESULTS: Transposed brachio-basilic vein fistula maturation rate after primary procedures (3/9, 33%) was lower compared to maturation rate after staged procedures (7/7, 100%, P = 0.011, Fisher's exact test), which led to premature termination of the trial. Time to hemodialysis [median (interquartile range)] of primary and staged procedures was 54 (51.5-113.5) days and 97 (93-126) days, respectively (P = 0.16). One-year primary and assisted-primary patency rates of primary and staged procedures were equivalent (44 vs 57%, P = 0.76 and 44 vs 71%, P = 0.29, respectively); however, there was a trend toward a better 1-year secondary patency after staged procedures (86 vs 44% for primary procedures, P = 0.09). CONCLUSIONS: Among candidates for TBBV fistula with a small basilic vein, staged transposition achieves higher maturation rates compared to primary procedures, a difference reflected in long-term secondary patency. TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT01274117.

Prevalence of nonresponsiveness to aspirin in patients with symptomatic peripheral arterial disease using true point of care testing.

PURPOSE: This study was designed to determine the prevalence of platelet nonresponsiveness to aspirin using point of care testing in a population with symptomatic peripheral arterial disease (PAD). METHODS: This was an observational, single-centre study including all patients with symptomatic PAD receiving aspirin. In patients receiving dual antiplatelet therapy with additional clopidogrel, platelet responsiveness to clopidogrel also was tested. Platelet responsiveness was assessed with the VerifyNow P2Y12 assay. Patients with residual aspirin reaction units ≥550 and platelet reactivity units ≥234 were considered nonresponders. The study's primary endpoint was to determine the prevalence of nonresponsiveness to aspirin; secondary endpoints included the prevalence of dual nonresponsiveness. RESULTS: In total, 145 consecutive patients (mean age 67 ± 9 years) receiving aspirin 100 mg were tested, whereas 128 of 145 (88.3 %) were under dual antiplatelet therapy with additional clopidogrel 75 mg. The prevalence of nonresponsiveness to aspirin was 20.7 % (30/145). Among the 128 patients receiving dual antiplatelet therapy, 65 (50.8 %) demonstrated nonresponsiveness to clopidogrel and 16 (11.7 %) dual nonresponsiveness to both aspirin and clopidogrel. Aspirin nonresponsiveness was not significantly different in patients suffering from diabetes, renal disease, critical limb ischemia (CLI) or those receiving statin, antihypertensive or proton-pump inhibitors therapy. Clopidogrel nonresponsiveness was significantly higher in older patients (p = 0.01) and those suffering from CLI (p = 0.03) and renal disease (p = 0.001) and significantly lower in smokers (p = 0.01). CONCLUSIONS: The prevalence of platelet nonresponsiveness to aspirin detected using the VerifyNow point of care testing in symptomatic PAD patients was 20.7 % and the clinical impact of the phenomenon merits further investigation.

Stent-grafts versus angioplasty and/or bare metal stents for failing arteriovenous grafts: a cross-over longitudinal study.

BACKGROUND: A well-established method to preserve failing synthetic arteriovenous grafts (AVGs) dialysis accesses is percutaneous transluminal angioplasty (PTA). Nevertheless, the one-year primary patency rate following PTA is approximately 25%. This study was designed to compare the angiographic and clinical outcomes following stent-graft insertion versus angioplasty and/or bare metal stenting (BMS) of recurrently failing AVGs, because of anastomotic and/or venous outflow stenoses. METHODS: Self-expanding stent-grafts were deployed for the treatment of failing AVGs in case of recurrent stenosis after treatment with conventional angioplasty or bail-out BMS. Regular angiographic follow-up was scheduled every two months the first six months and every three months thereafter. Data from previous procedures on the same treatment site were retrieved from our database. Primary patency was defined as a functioning graft with a patent treatment site without angiographic restenosis >50% and without any subsequent repeat procedures. Outcome data were analyzed by Kaplan-Meier analysis. RESULTS: In total, 35 patients previously treated with angioplasty and/or BMS for the treatment of recurrent significant AVG stenosis (group PTA), underwent stent-graft placement of the same treatment site (group SG). Of those, 20 patients had undergone angioplasty and 15 bail-out BMS. Mean lesion length was 4.8±1.7cm. Primary patency was significantly improved in the SG group (Hazard Ratio [HR] = 0.2 [95% CI= 0.11-0.36], P=.0001) by log-rank test. The estimated six and 12-month patency rates were 76.9% vs. 25.7%, and 61.4% vs. 8.6% for groups SG and PTA respectively, (P<.0001). CONCLUSIONS: Stent-graft placement significantly improves primary patency of anastomotic and venous outflow stenoses in recurrently failing prosthetic arteriovenous grafts.

Cryoplasty versus conventional balloon angioplasty of the femoropopliteal artery in diabetic patients: long-term results from a prospective randomized single-center controlled trial.

The purpose of this study was to investigate the immediate and long-term results of cryoplasty versus conventional balloon angioplasty in the femoropopliteal artery of diabetic patients. Fifty diabetic patients (41 men, mean age 68 years) were randomized to cryoplasty (group CRYO; 24 patients with 31 lesions) or conventional balloon angioplasty (group COBA; 26 patients with 34 lesions) of the femoropopliteal artery. Technical success was defined as <30% residual stenosis without any adjunctive stenting. Primary end points included technical success, primary patency, binary in-lesion restenosis (>50%), and freedom from target lesion recanalization. Cox proportional hazards regression analysis was performed to adjust for confounding factors of heterogeneity. In total, 61.3% (19 of 31) in group CRYO and 52.9% (18 of 34) in group COBA were de novo lesions. More than 70% of the lesions were Transatlantic Inter-Society Consensus (TASC) B and C in both groups, and 41.4% of the patients in group CRYO and 38.7% in group COBA suffered from critical limb ischemia. Immediate technical success rate was 58.0% in group CRYO versus 64.0% in group COBA (p = 0.29). According to 3-year Kaplan-Meier estimates, there were no significant differences with regard to patient survival (86.8% in group CRYO vs. 87.0% in group COBA, p = 0.54) and limb salvage (95.8 vs. 92.1% in groups CRYO and COBA, respectively, p = 0.60). There was a nonsignificant trend of increased binary restenosis in group CRYO (hazard ratio [HR] 1.3; 95% CI 0.6-2.6, p = 0.45). Primary patency was significantly lower in group CRYO compared with group COBA (HR 2.2; 95% CI 1.1-4.3, p = 0.02). Significantly more repeat intervention events because of recurrent symptoms were required in group CRYO (HR 2.5; 95% CI 1.2-5.3, p = 0.01). Cryoplasty was associated with lower primary patency and more clinically driven repeat procedures after long-term follow-up compared with conventional balloon angioplasty.

Aortic angiosarcoma with cutaneous metastases.

Primary aortic tumors are rare and include a variety of histologic types, including aortic angiosarcomas, with less than 100 cases being reported since the first description of these tumors in 1873. The diagnosis of aortic angiosarcoma is usually confirmed by postoperative histopathologic examination or postmortem study. We present a case of primary aortic angiosarcoma presenting with intermittent claudication and radiologic findings of aortoiliac atherosclerotic disease treated initially with stenting; lower extremity embolic skin metastases developed during follow-up that prompted resection of the aortic bifurcation and restoration of the arterial continuity with a bypass. Despite postresection recurrence, a 3-year survival was achieved with aggressive multidisciplinary management.

Infrapopliteal application of paclitaxel-eluting stents for critical limb ischemia: midterm angiographic and clinical results.

PURPOSE: To report the midterm (30%, or flow-limiting dissection). Patients were followed up with regular clinical evaluation, and digital subtraction angiography was scheduled at 6 months and 1 year. Life-table analysis and Kaplan-Meier plotting of angiographic and clinical variables were performed. Cox proportional-hazards regression analysis was employed to adjust for various covariates and search for independent adverse predictors of angiographic and clinical outcome. RESULTS: Infrapopliteal procedures were performed in 29 patients with 32 limbs with CLI; 79.3% of the patients had diabetes and 34.5% had renal disease. A total of 62 coronary PES were deployed in 50 below-knee lesions (mean stent-implanted length, 25.51 mm+/-12.16). Technical success rate was 100%. The 1-year mortality rate was 16.9%, and the limb salvage rate was 88.5%. The 1-year angiographic in-stent primary patency rate was 30.0%, whereas the incidence of in-stent binary (>50%) restenosis was 77.4%. The 1-year incidence of clinically driven repeat interventions was 30.5%. The Cox model calculated renal disease as the only independent predictor of decreased primary patency and increased repeat intervention events. Initial occlusions also adversely affected primary patency. CONCLUSIONS: Infrapopliteal PES achieved acceptable clinical results in CLI, even though they failed to inhibit vascular restenosis and decrease the need for repeat interventions. Renal disease and initial occlusions are adverse prognostic factors for infrapopliteal endovascular procedures.

Application of paclitaxel-eluting metal mesh stents within the pig ureter: an experimental study.

OBJECTIVE: The purpose of the present study is to compare the standard bare metal stents (BMS) with the Paclitaxel-Drug Eluting Stent (DES) in the ureter of a pig model. MATERIALS AND METHODS: We report on an experimental study with ten female pigs weighing between 25 and 30 kg. The stents were randomly placed in either the right or left ureter in each of 10 study animals, for a total of 20 stented ureters. Ten ureters were stented with an R-Stent (Orbus Medical Technologies, Hoevelaken Netherlands), and ten with a Paclitaxel-Eluting Coronary Stent (Boston Scientific, Natick, MA, USA). Patency was measured by radiograph of the nephrostomy tract, intravenous urography and virtual endoscopy at 24 hours and 21 days after the initial procedure, respectively. RESULTS: Free flow of urine through the stents into the bladder was documented in all stented ureters 24 hours after stent insertion by radiograph of the nephrostomy tract. At the 21 day follow-up examination, 5 R-Stents were found to be completely occluded and two partially stenosed, whereas no occluded stent was detected in the Paclitaxel-DES group. Pathology examination of the stents at 21 days follow-up showed that the obstructed R-Stents generated severe inflammation with metaplasia of the urothelium. The Paclitaxel-Eluting MS generated a mild inflammatory response within the ureteral lumen at the site of the stent, without hindering ureteral patency. R-stents proved to develop more hyperplasia compared to the Paclitaxel-Eluting MS. CONCLUSIONS: Paclitaxel-DES, when compared with the standard R- Stent BMS, generated less inflammation and/or hyperplasia of the surrounding tissues, thus maintaining ureteral patency. Long-term animal trials are required to further validate our results.