Reduced Muscle Mass and Muscle Quality in Patients with Intermittent Claudication due to Peripheral Artery Disease.

BACKGROUND: Peripheral arterial disease (PAD) is associated with reduced muscle mass and quality, but the effects of leg ischemia caused by PAD on muscle quality remain poorly understood. The purpose of this study was to evaluate leg muscle mass and muscle quality in patients with intermittent claudication due to PAD using bioelectrical impedance analysis (BIA). METHODS: One hundred forty-one patients with intermittent claudication due to PAD who visited Tokyo Medical University Hospital from April 2019 to April 2020 were retrospectively analyzed. Leg ischemia was assessed using ankle-brachial pressure index (ABI). The skeletal muscle mass (SMM) assessed leg muscle mass, while the phase angle (PhA) assessed leg muscle quality using BIA. RESULTS: A total of 282 legs in 141 patients were included in the analysis. Leg PhA and SMM showed a decreasing trend according to the severity of leg ischemia (borderline/no ischemia: 2.80 ± 0.50 kg/m2, 4.38 ± 0.94°; mild ischemia: 2.83 ± 0.49 kg/m2, 4.33 ± 1.03°; moderate/severe ischemia: 2.50 ± 0.40 kg/m2, 3.89 ± 0. 88°; P < 0.001 and P = 0.020, respectively). The ABI was moderately correlated with leg SMM (B = 0.347, ß = 0.134, P < 0.001) and leg PhA (B = 0.577, ß = 0.111, P = 0.013) after adjustment for all significant covariates. Leg PhA was moderately correlated with leg SMM (r = 0.318, P < 0.001). CONCLUSIONS: Leg ischemia, especially when moderate or severe, has an adverse effect on both muscle mass and quality in the lower extremities and is associated with skeletal muscle myopathy.

Association of simple renal cysts to aneurysm sac shrinkage in true thoracic aortic aneurysms after thoracic endovascular aortic repair.

BACKGROUND: An increased prevalence of thoracic aortic aneurysms (TAA) has been demonstrated in patients with simple renal cysts (SRC); patients with SRC have a less elastic aortic wall than those without SRC. The purpose of this study was to evaluate aneurysm sac shrinkage after thoracic endovascular aortic repair (TEVAR) for true TAA in patients with and without SRC. METHODS: One hundred three patients with true aneurysms of the thoracic aorta who underwent TEVAR at our university hospital from November 2013 to December 2021 were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography and that on postoperative computed tomography scans at 1 year. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to expansion or shrinkage. RESULTS: The patients were divided into two groups: those with SRC (46 patients [45%]) and those without SRC (57 patients [55%]). At 1 year, there was a significant difference in the proportion of aneurysm sac shrinkage between patients with SRC and those without SRC (23.9% vs 59.6%; P < .001). Patients with SRC showed significantly less aneurysm sac shrinkage than those without SRC (-1.8 ± 5.6 mm vs -5.1 ± 6.6 mm; P = .009). Univariable and multivariable analyses showed that the initial sac diameter (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = .002) and the presence of SRC (odds ratio, 0.15; 95% confidence interval, 0.06-0.40; P < .001) were positively and negatively associated with aneurysm sac shrinkage after TEVAR, respectively. CONCLUSIONS: The presence of a SRC was independently associated with failure of aneurysm sac shrinkage after TEVAR for true TAA. This suggests that the presence of a SRC may be a predictor for the failure of aneurysm sac shrinkage after TEVAR.

Influence of Lower Limb Ischemia on Skeletal Muscle Mass Depletion in Patients with Peripheral Artery Disease.

BACKGROUND: The aim of the study was to determine the change in skeletal muscle mass over time by bioelectrical impedance analysis (BIA) in patients with peripheral artery disease (PAD). METHODS: Patients with symptomatic PAD visiting Tokyo Medical University Hospital between January 2018 and October 2020 were retrospectively analyzed. PAD was diagnosed based on ankle brachial pressure index (ABI) < 0.9 with either leg and confirmed by duplex scan and/or computed tomography angiography as needed. Patients undergoing endovascular treatment, surgery, or supervised exercise therapy were excluded before and during the study period. Skeletal muscle mass of the extremities was measured using BIA. The sum of skeletal muscle masses in the arms and legs was calculated as skeletal muscle mass index (SMI). Patients were scheduled to undergo BIA at an interval of 1 year. RESULTS: Of 119 patients, 72 patients were included in the study. All patients were ambulatory and had symptoms of intermittent claudication (Fontaine's stage II). SMI significantly decreased from 6.98 ± 1.30 at baseline to 6.83 ± 1.29 at 1-year follow-up. Individual skeletal muscle mass of the ischemic leg was significantly reduced after 1 year, but not in the nonischemic leg. A decrease in SMI (defined as SMI ≥0.1 kg/m2 per year) was independently associated with low ABI. The optimal cut-off value of ABI for the decrease in SMI was 0.72. CONCLUSIONS: These results suggest that lower limb ischemia due to PAD, especially if ABI is < 0.72 or less, may result in a decrease in skeletal muscle mass that affects health and physical function.

Association of High-Sensitivity C-Reactive Protein With Aneurysm Sac Shrinkage in Patients Undergoing Endovascular Abdominal Aneurysm Repair.

PURPOSE: The factors associated with aneurysm sac shrinkage after endovascular aneurysm repair (EVAR) are not well established. As inflammation is implicated in aneurysm pathophysiology, we hypothesized that high-sensitivity C-reactive protein (hsCRP) was associated with aneurysm sac shrinkage after EVAR and compared the preoperative level of hsCRP between patients with and without postoperative aneurysm sac shrinkage after EVAR. METHODS: From November 2013 to April 2019, 143 patients undergoing EVAR using Gore C3 Excluder (W. L. Gore & Associates, Inc, Flagstaff, Arizona) at our university hospital were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography (CT) and that on postoperative CT scans. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to enlargement or shrinkage. RESULTS: Aneurysm sac size showed a significant decrease from 50.6 ± 9.8 mm to 47.1 ± 10.3 mm at 1 year. At 1 year postoperatively, aneurysm sac shrinkage (≥5 mm) was observed in 48 patients (34%), a stable aneurysm sac was noted in 93 patients (65%), and aneurysm sac enlargement was noted in 2 patients (1.4%). The mean preoperative hsCRP was 0.33 ± 0.54 mg/dL. Univariable analysis showed that preoperative hsCRP (p=0.029) and the presence of a renal cyst (p=0.002) were associated with aneurysm sac shrinkage. Multivariable analysis showed that preoperative hsCRP [>0.19mg/dL] (odds ratio [OR] = 0.22; 95% confidence interval [CI] = 0.05-0.96; p=0.042), and the presence of a renal cyst (OR = 0.31; 95% CI = 0.15-0.67; p=0.002) were independent risk factors for aneurysm sac shrinkage after EVAR. CONCLUSIONS: The level of preoperative hsCRP was independently associated with aneurysm sac shrinkage after EVAR in patients with abdominal aortic aneurysms. These data suggest that the high level of hsCRP can be a negative predictor for aneurysm sac shrinkage after EVAR.

Association of lower limb ischemia with loss of skeletal muscle mass in patients with peripheral artery disease.

PURPOSE: The influence of lower limb ischemia on the loss of skeletal muscle mass, which is a prerequisite for sarcopenia, remains poorly studied in patients with peripheral artery disease (PAD). We determined whether or not lower limb ischemia correlates with a loss of skeletal muscle mass in patients with PAD. METHODS: The data of 101 patients (202 legs) with PAD were retrospectively analyzed. Body composition was measured using a bioelectrical impedance analysis. Based on the Asian Working Group for Sarcopenia, low muscle mass (LMM) was defined as skeletal muscle mass index (SMI) < 7.00 kg/m2 (male) and < 5.70 kg/m2 (female). Both univariable and multivariable analyses of the risk factors for LMM were performed. RESULTS: There were significant differences in age, ankle-brachial pressure index (ABI) per patient, and the geriatric nutritional risk index (GNRI), between patients with and without LMM. Multivariable logistic regression analysis showed age (odds ratio [OR], 1.09; p = 0.009), GNRI (OR, 0.93; p = 0.003), and ABI per patient (OR, 0.02; p = 0.027) as independent risk factors for LMM. CONCLUSION: These data show a detrimental effect of lower limb ischemia on skeletal muscle mass loss, suggesting that PAD may affect the development of secondary sarcopenia.

Time Course of Leg Edema after Endovenous Radiofrequency Ablation for Saphenous Varicose Veins.

BACKGROUND: The objectives of the study were to quantitatively evaluate leg edema in patients undergoing endovenous radiofrequency ablation (RFA) for saphenous varicose veins using bioelectrical impedance analysis (BIA) and to elucidate the time course of leg edema after RFA. METHODS: The data of 87 patients with 128 limbs undergoing RFA for saphenous varicose veins in Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Saphenous vein reflux was evaluated by duplex scan. Extracellular water/total body water ratio (ECW/TBW) of the leg was measured by BIA. Moderate to severe leg edema (ECW/TBW ≥ 0.400) was defined as significant leg edema. Venous reflux was evaluated as a venous filling index (VFI) using air plethysmography. RESULTS: BIA revealed that 26 legs (20.3%) had significant edema and 102 legs (79.7%) did not before RFA. The proportion of patients with significant leg edema increased significantly from preoperative to 1 week after RFA (P < 0.05) and decreased 1 month after RFA (P < 0.01). The ECW/TBW increased significantly from preoperative (0.393 ± 0.008) to 1 week after RFA (0.394 ± 0.008, P < 0.05), whereas it decreased significantly before or 1 week to 1 month after RFA (0.391 ± 0.008, P < 0.05). There was a significant, moderate correlation between the decrease of the VFI and that of ECW/TBW (r = 0.34, P < 0.001). CONCLUSIONS: This is the first study to quantitatively elucidate the time course of leg edema after RFA. Leg edema worsens one week after RFA, but it is improved one month after RFA, compared with that preoperatively.

Simple renal cyst and its association with sac shrinkage after endovascular aneurysm repair for abdominal aortic aneurysms.

OBJECTIVE: Patients with abdominal aortic aneurysm (AAA) frequently have simple renal cyst (SRC), a common manifestation of connective tissue degeneration. This study aimed to determine whether SRC is a risk factor for failure of sac shrinkage after endovascular aneurysm repair (EVAR). METHODS: Between October 2013 and May 2017, there were 155 consecutive patients with an infrarenal AAA or a common iliac artery aneurysm who underwent EVAR with the GORE C3 Excluder (W. L. Gore & Associates, Flagstaff, Ariz) at Tokyo Medical University Hospital. All these patients were registered in a prospectively maintained database. Any kidney lesion >5 mm in diameter, with no evidence of contrast enhancement or septation and with low attenuation, was defined as SRC. A change in sac size of >5 mm from baseline was considered significant. The patients were divided into those with SRC and those without SRC, and sac shrinkage at 1 year and 2 years was compared. The presence of SRC was assessed with respect to being a risk factor for failure of sac shrinkage at 1 year using univariate and multivariable logistic regression analysis. RESULTS: The patients were divided into two groups: those with SRC (92 patients [59.0%]) and those without SRC (63 patients [41.0%]). At 1 year and 2 years, significant differences were observed in the proportion of sac shrinkage between patients with SRC and those without SRC (19.2% vs 42.4% [P = .003] and 19.6% vs 53.3% [P = .001], respectively). Patients with SRC showed significantly less sac shrinkage than those without SRC at 1 year and 2 years (-2.0 ± 5.5 mm vs -4.4 ± 6.2 mm [P = .002] and -1.8 ± 6.3 mm vs -6.4 ± 8.6 mm [P = .005], respectively). Multivariable analysis demonstrated that SRC (odds ratio, 0.28; 95% confidence interval, 0.12-0.63; P = .002) and initial sac size (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = .027) were positive and negative risk factors for sac shrinkage, respectively. CONCLUSIONS: The presence of SRC is a risk factor for failure of sac shrinkage after EVAR. This suggests that AAA in patients with SRC has a more degenerated wall than in those without SRC. The property of the aneurysm wall may be associated with sac shrinkage after EVAR.

Clinical and Morphological Outcomes in Endovascular Aortic Repair of Abdominal Aortic Aneurysm Using GORE C3 EXCLUDER: Comparison between Patients Treated within and Outside Instructions for Use.

BACKGROUND: The goals of this study were to evaluate mid-term outcome in endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) using a GORE C3 EXCLUDER and compare results between patients treated within and outside the instructions for use (IFU). METHODS: Over a 3-year period spanning October 2013 to September 2016, consecutive patients undergoing EVAR for AAA using the C3 EXCLUDER at Tokyo Medical University Hospital were registered on a prospectively maintained database. The data thus obtained were retrospectively analyzed. RESULTS: A total of 109 AAA patients underwent EVAR using the C3 EXCLUDER. The median follow-up duration was 729 days (interquartile range, 542-1,069 days). Technical success was achieved in 98.2% of cases. Adjunctive, unplanned proximal cuff-extender implantation was required in 8 patients (9.2%). Of the total number, 29 (24.8%) were categorized as being treated outside the IFU. No significant difference was observed in freedom from overall mortality or aneurysm-related mortality between patients treated within and outside the IFU. Freedom from reintervention tended to be lower in patients treated outside the IFU. There was aneurysm sac shrinkage (≥5 mm) in 30.3% and 39.1%; stable aneurysm sac in 69.7% and 56.3%; and aneurysm sac expansion (≥5 mm) in 0% and 4.7% of cases at 1 and 2 years, respectively. No significant difference was observed in aneurysm sac shrinkage between patients treated within and outside the IFU. CONCLUSIONS: The C3 EXCLUDER showed good clinical performance and aneurysm sac shrinkage, regardless of whether the patient was treated within or outside the IFU. The results suggest, however, that in those treated outside the IFU, precise planning, careful operative procedure, and subsequent follow-up are required to obtain short-term and mid- to long-term success in EVAR for AAA using the C3 EXCLUDER.

Management of Failed Crossover Stenting across the Ostium of the Deep Femoral Artery: Report of 2 Cases.

Little is known regarding the consequences of bifurcation patency loss after failed crossover superficial femoral artery (SFA) stenting. We report on 2 cases concerning patients presenting with acute and chronic symptoms of critical limb ischemia after failed crossover SFA stenting and undergoing open surgical repair. We discuss the risk and management of failed crossover SFA stenting.

The Role of Common Femoral Artery Endarterectomy in the Endovascular Era.

BACKGROUND: The purpose of this study was to review our experiences treating peripheral artery disease (PAD) by common femoral artery endarterectomy (CFE) with and without endovascular therapy (EVT), and to describe the role of CFE in the endovascular era. METHODS: We retrospectively reviewed a contemporary series of 38 limbs from January 2010 to September 2014. Clinical outcomes of primary patency, assisted primary patency, limb salvage, and survival were analyzed with the Kaplan-Meier method. Multivariable perioperative predictors of primary patency were identified using the stepwise Cox proportional hazards regression model. RESULTS: Hemodynamic success was achieved in 36 of the 38 limbs (95%). The mean ankle brachial pressure index improved significantly, rising from 0.56 ± 0.04 preoperatively to 0.89 ± 0.04 postoperatively (P = 0.0001). Overall primary and assisted primary patency rates, respectively, were 90% and 100% at 12 months and 85% and 94% at 24 months. There was no significant difference in primary patency rate between isolated CFE and hybrid CFE plus EVT. Both limb salvage and survival rates were 97% at 12 months and 97% at 24 months. Multivariate Cox regression analysis revealed that no clinical or perioperative risk factors were predictive of decreased primary patency. CONCLUSIONS: CFE is a safe, effective, and durable procedure for common femoral artery disease, and hybrid CFE plus EVT can be a valid alternative to open surgical bypass for multilevel occlusive artery disease. These observations stress that CFE plays a vital role in the management of PAD even in the endovascular era.

The Preoperative Lymphocyte-To-Monocyte Ratio Predicts Mortality Among Patients Undergoing Endovascular Aortic Repair for Abdominal Aortic Aneurysm.

PURPOSE: The purpose of this study was to investigate the preoperative lymphocyte-to-monocyte ratio (LMR) as a potential surrogate biomarker predictive of overall mortality in patients undergoing endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA). METHODS: Data on patients with AAA treated by EVAR between March 2012 and December 2016 were obtained from a prospectively maintained EVAR database at Tokyo Medical University Hospital, Tokyo, Japan. The LMR was calculated by dividing the absolute lymphocyte count by the absolute monocyte count. RESULTS: One hundred seventy-six patients were included in this study after selection based on the exclusion criteria. The subjects consisted of 148 males and 28 females with a mean age of 78.5 years (range, 51-89 years). The median follow-up period was 4.98 years (range, .03-9.28). A receiver operating characteristic curve analysis determined the optimal cut-off value of the preoperative LMR for predicting overall mortality with 3.21 (area under the curve, .71; 95% confidence interval [CI], .62-.79; sensitivity, 57.4%; specificity, 77.0%; P < .001). On univariable and multivariable analyses, octogenarian (hazard ratio [HR], 1.89; 95%CI, 1.10-3.22; P = .020), poor nutritional status (HR, 2.95; 95%CI, 1.73-5.03; P < .001), chronic obstructive pulmonary disease (HR, 1.79; 95%CI, 1.06-3.03; P = .031), active cancer (HR, 2.60; 95%CI, 1.53-4.41; P < .001), and low preoperative LMR (HR, 2.56; 95%CI, 1.53-4.30; P < .001) were identified as independent predictors for overall mortality. CONCLUSION: This study showed that a low preoperative LMR (<3.21) is an independent predictor of overall mortality after EVAR for AAA. The LMR may help in decision-making regarding the prediction of poor prognosis after EVAR.

Serious Adverse Events with Cyanoacrylate Closure of Varicose Veins: An Initial Report from a Large-Scale National Survey in Japan.

Objective: Cyanoacrylate closure (CAC) is a minimally invasive technique for the treatment of varicose veins. A recent paper reported serious adverse events (AEs) associated with this use. This triggered an urgent survey to determine the incidence of AEs in Japan. Methods: The CAC-AE survey was sent to all 1,030 institutions authorized for CAC treatments. Cases performed between January 2020 and October 2023 were surveyed. Data on serious AEs and mortality were collected. Results: There were 623 surveys returned. There were 16 cases of proximal deep vein thrombosis, 3 cases of pulmonary embolism (PE), and 0 cases of stroke. Deep vein occlusion due to cyanoacrylate extension was observed in 1 case. Vein resection due to infection was observed in 4 cases. There were 299 cases of localized phlebitis and/or allergic reactions requiring steroid administration. Systemic allergic reactions requiring steroid administration were observed in 66 cases. There was no anaphylaxis associated with cyanoacrylate. There was one postoperative death from PE. Conclusion: This report's intent is to provide real world data on serious AEs following CAC from Japan given current concern over these events. An extensive report investigation of individual complications with analysis including causality will be provided following a full investigation separately.

Prognostic Value of Nutritional Markers for Long-Term Mortality in Patients Undergoing Endovascular Aortic Repair.

Objective: The relationship between nutritional status and morbidity and death in a number of diseases and disorders has garnered considerable attension. In patients having endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA), we assessed the prognostic value of nutritional markers of albumin (ALB), body mass index (BMI), and geriatric nutritional risk index (GNRI) for long-term mortality. Materials and Methods: Retrospective data analysis was done on patients who had undergone elective EVAR for AAA more than 5 years earlier. Results: A total of 176 patients underwent EVAR for AAA between March 2012 and April 2016. The optimal cutoff value of ALB, BMI, and GNRI for predicting long-term mortality was calculated as 3.75 g/dL (area under the curve [AUC] 0.64), 21.4 kg/m2 (AUC 0.65), and 101.4 (AUC 0.70), respectively. Low ALB, low BMI, and low GNRI as well as age ≥75 years, chronic obstructive pulmonary disease, chronic kidney disease, and active cancer were independent risk factors for long-term mortality. Conclusion: Malnutrition, which is measured by ALB, BMI, and GNRI, is an independent risk factor for long-term mortality in patients receiving EVAR for AAA. Of the nutritional markers, the GNRI can be the most reliable nutritional indicator to identify a potentially high-risk group of mortality after EVAR.

Autologous angiogenic therapy with cultured mesenchymal stromal cells in platelet-rich plasma for critical limb ischemia.

Introduction: The prevalence of diabetes mellitus is increasing globally, including in Japan. Patients with diabetes often experience microangiopathy and macroangiopathy, which lead to difficult-to-treat foot ulcers and diabetic gangrene. Conventional cellular therapies have limited safety and are invasive. In this study, we investigated the use of cultured autologous mesenchymal stromal cells derived from the bone marrow and grown in platelet-rich plasma as a potential treatment for diabetic complications. Methods: A prospective clinical trial was conducted to assess safety as the primary endpoint and efficacy as the secondary endpoint of the aforementioned therapy in five patients with critical limb ischemia, with or without hemodialysis. Results: Five patients with critical limb ischemia were enrolled between 2016 and 2019, three of whom underwent hemodialysis. Platelet-rich plasma was obtained from 288 ± 39.6 mL of blood/patient, yielding 31.6 ± 1.67 mL of platelet-rich plasma. Bone marrow aspiration yielded 18.4 ± 4.77 mL/patient, and 4.64 ± 1.51 × 107 cells were incubated for 16 ± 2.8 days to obtain 3.26 ± 0.33 × 107 mesenchymal stromal cells. Although several adverse events were observed, none were directly attributed to cell therapy. Clinical severity, as assessed by both the Fontaine stage and Rutherford category, improved significantly following therapy. This improvement was accompanied by enhancements in the 6-min walking distance, dorsal skin perfusion pressure, ankle transcutaneous partial oxygen pressure, and ankle brachial pressure index. Conclusion: Autologous angiogenic therapy with cultured mesenchymal stromal cells derived from the bone marrow and grown in platelet-rich plasma is a safe and feasible, and was expected as a potential treatment for critical limb ischemia.

Complete Resection of a Cavoatrial Metastatic Liposarcoma under Hypothermic Circulatory Arrest.

A patient underwent surgical resection twice for primary and metastatic dedifferentiated liposarcomas. Computed tomography revealed a tumor mass at the cavoatrial junction. Prompt surgical resection of the tumor with thrombectomy was successfully performed using cardiopulmonary bypass with hypothermic circulatory arrest. Despite the poor prognosis of metastatic or recurrent liposarcoma, the patient has survived for 8 years since the first tumor resection.

Significance of perioperative intrasac pressure in sac shrinkage after endovascular abdominal aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) results in a marked reduction of intrasac pressure, which is the likely cause of aneurysm sac shrinkage. We evaluated the change of intrasac pressure during operation and its association with aneurysm sac shrinkage one year after EVAR. METHODS: This study included 113 patients undergoing EVAR using the Gore C3 Excluder at our university hospital between March 2016 and December 2020. A direct intrasac pressure was measured before and after stent deployment. The Pressure Index (PI) was defined as the ratio of intrasac pressure to systemic blood pressure. RESULTS: Patients were divided into two groups: patients with aneurysm sac shrinkage (N.=33, 29%) and those without (N.=80, 71%). Systolic and diastolic PI after stent graft deployment were significantly higher in patients with aneurysm sac shrinkage than those without, respectively (systolic PI, 64.6±13.9% vs. 58.1±12.0%, P=0.014; diastolic PI, 103.8±24.7% vs. 96.4±12.9%, P=0.039). Multivariable analysis revealed post-deployment systolic PI as an independent risk factor predictive of aneurysm sac shrinkage (odds ratio 1.04; 95% CI 1.01-1.08; P=0.016). CONCLUSIONS: Although systolic intrasac pressure, described as systolic PI, was an independent risk factor for aneurysm sac shrinkage, contrary to our expectation, it was significantly higher in patients with aneurysm sac shrinkage than those without. This seemingly contradictory result may be explained by the properties of an aneurysm sac, which influence the change of intrasac pressure.

Carbon dioxide (CO2) vs iodinated contrast digital subtraction angiography during balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerosant for gastric varices.

PURPOSE: To compare the visualization of the target gastric varices (GV) on balloon-occluded retrograde transvenous venography (BRTV) using iodinated contrast material vs carbon dioxide (CO(2)) in preparation for subsequent balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerotherapy. MATERIALS AND METHODS: In 16 consecutive patients with nonruptured GV, BRTV was performed first using iodinated contrast material and then with CO(2). BRTV was repeated whenever there were changes in the catheter or patient position or when coil embolization of collaterals was needed. Each visualization grade of GV (grade 1 = GV only; grade 2 = GV > collaterals; 3 = GV < collaterals; grades 4-5 = collaterals only) was determined by two observers in consensus. During foam BRTO, the GV visualization grade was recorded again and confirmed by C-arm computed tomography (CT). RESULTS: In 38 pairs of BRTV, GV grades were significantly (P < .0001) lower (ie, favoring BRTO) on CO(2) BRTV (mean ± standard deviation, 1.8 ± 0.8) than on iodine BRTV (3.4 ± 0.8). GV grades on foam BRTO (1.4 ± 0.7) were similar to the grades obtained on the most recent CO(2) BRTV (1.3 ± 0.5) but were significantly smaller (P < .0001) than on iodinated BRTV (3.1 ± 0.9). GV were opacified by foam on initial C-arm CT in 14 patients (87.5%), and complete thrombosis of GV was obtained without any complication in all 16 patients (100%). CO(2) reached the GV even when iodinated contrast material could not (grade 4) in seven of our 16 patients (43.8%), leading to successful BRTO. CONCLUSIONS: CO(2) BRTV visualized GV better than did iodine BRTV and changed the management of more than 40% of patients by enabling successful foam BRTO in patients in which conventional liquid BRTO could not be performed.

Balloon-occluded retrograde transvenous obliteration of gastric varices: use of CT-guided foam sclerotherapy to optimize technique.

OBJECTIVE: Balloon-occluded retrograde transvenous obliteration has been traditionally based on liquid sclerotherapy. However, overdose and systemic spillage of liquid sclerosant can cause severe complications, such as hemolysis, which lead to hemoglobinuria, allergy, acute respiratory distress syndrome, and other disorders. The purpose of this study was to evaluate the performance of foam sclerotherapy with C-arm CT guidance to reduce the amount of sclerosant and to optimize the safety of balloon-occluded retrograde transvenous obliteration while preserving its efficacy. MATERIALS AND METHODS: Twenty consecutively registered patients with gastric varices underwent balloon-occluded retrograde transvenous obliteration with polidocanol foam. C-arm CT guidance was used to confirm gas filling of the target vessels. In this retrospective analysis of a prospectively encoded database, total net doses of polidocanol used for transvenous obliteration and of contrast medium used for venography before transvenous obliteration were compared, and subsequent complications, including hemoglobinuria, were documented. RESULTS: In all patients, foam was observed in the target vessels at C-arm CT. The mean dose of polidocanol used for balloon-occluded retrograde transvenous obliteration (3.9 ± 1.5 mL) was significantly smaller (p < 0.001) than the dose of contrast medium used for venography (16.4 ± 7.9 mL). Hemoglobinuria was found in only one patient. Except in one instance of recanalization, full variceal thrombosis was confirmed at contrast-enhanced CT 1 week after transvenous obliteration (success rate, 95%). In one patient, air migrated into the liver during transvenous obliteration but was spontaneously absorbed. No serious complication occurred. CONCLUSION: Balloon-occluded retrograde transvenous obliteration with polidocanol foam under C-arm CT guidance allowed significant reduction of sclerosant dose and resulted in a low complication rate while a high technical success rate and efficacy were maintained.