Recanalization of Chronic Femoropopliteal Total Occlusions after Failed Anterograde Attempt: Use of an Intravascular Ultrasound-Guided Re-entry Catheter versus the Bidirectional Approach.

PURPOSE: To analyze the feasibility and effectiveness of the use of an intravascular ultrasound (IVUS)-guided re-entry catheter (IGRC) for femoropopliteal chronic total occlusions (FP-CTOs) after a failed anterograde approach compared with the bidirectional approach without the IGRC. MATERIALS AND METHODS: Between June 2019 and December 2022, an IGRC (Pioneer Plus; Philips Volcano, San Diego, California) was used in 52 patients after failure of conventional recanalization techniques (Group A). In the same period, 48 patients who were also eligible for IGRC use were treated without IGRC using the bidirectional approach (Group B). In Groups A and B, 12 (23.1%) and 3 (6.2%) patients experienced claudication, and 40 (76.9%) and 45 (93.7%) patients experienced critical limb-threatening ischemia, respectively. Clinical and procedural records, angiographic imaging findings, and follow-up data were collected, analyzed, and reviewed. RESULTS: Technical success was achieved in 49 (94.2%) patients in Group A and 44 (91.7%) patients in Group B (P = .616). Use of the IGRC was associated with a reduction of procedural time (120 vs 133 minutes; P < .001), radiation exposure (47 vs 59 Gy cm2; P < .001), iodinated contrast medium use (98 vs 138 mL; P = .028), and intraprocedural discomfort (numerical rating scale score, 4 vs 6; P < .001). CONCLUSIONS: Use of the IGRC was equivalently successful for FP-CTO recanalization compared with the use of the bidirectional approach, but it reduced radiation exposure, iodinated contrast medium used, patient discomfort, and procedural time. These advantages suggest that IGRC could be favored as the next-choice option for FP-CTOs after failure of anterograde recanalization.

Subintimal Crossing of Chronic Total Occlusions in Peripheral Arteries With a Dual Guidewire Balloon Catheter: The PRAESTO Study.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of antegrade fenestration re-entry (AFR) using a dual guidewire angioplasty balloon for chronic total occlusion (CTO) in patients with peripheral artery disease (PAD). MATERIAL AND METHODS: This is a retrospective score matching analysis study comparing a study cohort composed of PAD patients with CTO treated with AFR subintimal recanalization using a dual guidewire angioplasty balloon and a matched control group, selected on baseline cardiovascular risk factor and lesions characteristics, treated with a conventional subintimal recanalization. Procedure outcomes include procedural success, successful subintimal re-entry, need for distal puncture, procedural time, fluoroscopy time, and dose area product. Clinical variables, including primary patency, freedom from amputation, freedom from re-interventions, and freedom from death, were used to compare the study groups. RESULTS: Thirty patients in the study group were compared with 60 patients in the matched control group (mean age, male). A significant higher subintimal re-entry success (100% vs 76.7% in control group, p=0.004) and lower need of distal tibial punction (0 vs 14 [23.3%] patients in control group, p=0.004) were observed in the study group. A surgical conversion to bypass was needed in 5 patients in the control group. Shorter procedural and fluoroscopy time were observed in the study group (41.1±10.8 minutes vs 146.6±62. and 16.7±3.5 minutes vs 34.3±14.2 minutes in control group respectively, p<0.001 and p<0.001). Lower DAP were observed in the study group (914.1±309.9 µGym² vs 2026.5±845.7 µGym² in control group p<0.001). No significant difference were observed in terms of primary patency, mortality, amputation, and freedom from re-intervention. CONCLUSION: AFR using the Presto dual guidewire balloon is a step forward for crossing CTO which allows a simplified and quick treatment of BTK and ATK lesions compared with conventional approaches without increase of procedural risk and maintaining good clinical outcomes.

Endovascular treatment of calcific lesions of the common femoral artery using atherectomy device associated with scoring balloon angioplasty in diabetic patients with high "major amputation" risk.

OBJECTIVES: To investigate the outcomes of patients with calcific lesions in the common femoral artery undergoing endovascular procedures with atherectomy device and scoring balloon angioplasty combined with treatment of steno-occlusive disease of the remaining arterial districts of the lower limb. METHODS: Between January 2015 and December 2018, 11 diabetic patients at high risk for "major amputation", with calcific lesions of the common femoral artery and ischemic ulcers requiring endovascular treatment were retrospectively evaluated. Technical success was defined as revascularization of the common femoral artery with a residual stenosis lower than 30%. Primary endpoints were an immediate increase of perilesional transcutaneous oxygen pressure (TCPO2) > 40 mmHg, ulcerative lesions improvement up to healing or skin flaps re-epithelialization after minor amputation, limb rescue with rejected major amputation, and resolution of rest pain if present. RESULTS: The success rate of the revascularization procedures was 100%. No patient underwent surgical conversion. One case of peri-operative bleeding at the brachial access site was observed. There were no cases of arterial dissection or undesired distal embolization. The average baseline value of perilesional TCPO2 was 21.8 ± 9.2 mmHg. The mean TCPO2 value was 57.4 ± 7.2 mmHg three days after the procedure (P < 0.05), and 51.2 ± 9.8 mmHg 15 days after (P < 0.05). Minor amputations were performed in five patients with advanced ulcerative lesions. No major amputations were performed in the follow-up period. At 14 months follow-up, one patient developed new occlusion of the CFA for extension from the external iliac artery and underwent a new endovascular procedure. We observed an overall primary patency rate of 91% and a primary assisted patency rate of 100% in our 18-month follow-up. CONCLUSIONS: Endovascular approach for severely calcified atherosclerotic lesions of the common femoral artery seems to represent a valid therapeutic option associated with promising results in terms of clinical outcome and low complication rates.

Peripheral arterial disease in patients with renal-diabetic foot ulcers.

OBJECTIVE: To describe the angiographic characteristics of peripheral arterial disease (PAD) in persons with diabetic foot ulcers (DFUs) on dialysis treatment. METHOD: The study is a retrospective analysis of patients with DFUs and PAD who had been referred to our diabetic foot clinic. All patients had been managed by a pre-set limb salvage protocol including revascularisation of the affected limb. Arterial lesions (stenosis between 50-99% and occlusions) were retrospectively evaluated through angiogram analysis. According to the presence or not of dialysis, patients were divided into two patient groups: renal-diabetic foot (RDF) and diabetic foot (DF). Distribution of PAD and immediate revascularisation outcome (technical revascularisation outcome) for RDF and DF were separately reported and compared. RESULTS: The sample included 239 patients: mean age was 71.8 years; 72.4% were male; 87.4% had type 2 diabetes; mean diabetes duration was 21.4 years; and the mean HbA1c was 63±22mmol/mol. The RDF group compared with the DF group reported higher numbers of vessels affected (n=5±1.6 versus 3.9±1.5, respectively, p<0.0001), greater involvement of the superficial femoral artery (90.2% versus 75.8%, respectively, p=0.003), the tibial-peroneal trunk (53.7% versus 25.5%, respectively, p=0.01), the anterior tibial artery (93.9% versus 80.9%, respectively, p=0.03) and below-the-ankle (BTA) arteries (70.7% versus 35.7%, respectively, p=0.0001). The RDF group showed a higher rate of revascularisation failure in comparison to DF patients (43.9% versus 15.3%, respectively, p<0.0001). BTA arterial disease (odds ratio 9.5; 95% Confidence Interval: 3.5-25.4; p=0.0001) resulted as the only independent predictor of revascularisation failure. CONCLUSION: In this study, RDF patients showed a widespread distribution of arterial lesions with a higher involvement of foot arteries in comparison with DF patients. BTA arterial disease was found to be an independent predictor of revascularisation failure.

COVID-19 and Stroke: Casual or Causal Role?

BACKGROUND: The COVID-19 outbreak is currently the major public health concern worldwide. This infection, caused by the novel coronavirus Sars Cov2, primarily affects respiratory system, but there is increasing evidence of neurologic involvement and cerebrovascular accidents. CASE REPORT: We present a case of stroke in a 62-year-old COVID-19-positive patient, with multiple vascular risk factors. The patient arrived 1 h after onset of symptoms, was treated with recombinant tissue plasminogen activator (rtPA) with improvement of neurologic deficits, and later developed right foot arterial ischemia (recanalized by balloon catheter angioplasty) and left arm superficial venous thrombosis. A control computed tomography (CT) scan 7 days after onset showed hemorrhagic transformation of ischemic lesion without mass effect. However, respiratory and neurologic conditions improved so that the patient was discharged to rehabilitation. DISCUSSION: Until now, few cases of stroke in COVID-19 have been described, mainly in severe forms. This patient had ischemic injuries in different sites as well as venous thrombosis; hence, we speculate that Sars Cov2 could have a direct role in promoting vascular accidents since its receptor ACE2 is a surface protein also expressed by endothelial cells. This case suggests that COVID-19 can favor strokes and in general vascular complications, even in milder cases, and the presence of preexisting risk factors could play a determinant role.

Multicentric Experience with an Intermediate Aspiration Catheter for Distal M2 Ischemic Stroke.

BACKGROUND: To assess technical and clinical outcomes of an intermediate bore aspiration catheter (AXS Catalyst 5; Stryker) as front-line therapy for M2-M3 acute occlusions. METHODS: A multicentric, retrospective data collection of patients with symptomatic M2-M3 ischemic stroke, treated with direct aspiration first-pass technique was obtained. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. RESULTS: A total of 44 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 68,4 years). Median NIHSS at baseline was 10. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 90,9% of patients with mean time to recanalization of 49,7 minutes and a mean of 1.6 attempts. First-attempt recanalization with CAT 5 was obtained in 52,3% of patients with a mean time to recanalization of 29.2 min. A stent retriever with proximal aspiration was incorporated as a rescue device in 3 cases. No major complications was detected. The median National Institutes of Health Stroke Scale score at discharge was 4. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 70,5% of patients. CONCLUSIONS: ADAPT technique with the intermediate aspiration catheter CAT 5 system achieves successful revascularization and functional independence for patients with acute ischemic stroke secondary to distal M2 occlusions.

Six-Month Angiographic and Clinical Outcomes of Therapeutic Ultrasound Pretreatment Associated With Plain Balloon Angioplasty for Below-the-Knee Lesions in Patients With Critical Limb Ischemia: A Prospective, Single-Center Pilot Study.

PURPOSE: To evaluate the safety and efficacy of low-frequency, high-intensity ultrasound energy delivered via a new dedicated ultrasound catheter followed by conventional balloon angioplasty to treat calcified infrapopliteal lesions. MATERIALS AND METHODS: A prospective, nonrandomized, single-center pilot study enrolled 12 patients (mean age 72.2±5.3 years; 8 men) with critical limb ischemia (9 Rutherford category 5 and 3 category 6) between January and November 2017. Of the 19 target lesions, 11 had severe calcification. Patients were treated with the Kapani ultrasound system before conventional balloon dilation. Primary safety endpoints included 30-day death, major target limb amputation, and target vessel acute occlusion. The main efficacy outcome was primary patency at 6 months, defined as freedom from both clinically-driven target lesion revascularization (TLR) and angiographically-defined restenosis (>50% lumen reduction). RESULTS: Technical success (<30% residual stenosis) was achieved in all lesions without complications or stent implantation. Ultrasound energy was delivered over a mean 185.2±67.3 seconds followed by low-pressure dilation (mean 6.1±1.9 atm). Angiography confirmed primary patency at 6 months in 18 (95%) of 19 lesions. No death, TLR, or amputation was reported in follow-up. Complete ulcer healing was observed in all 12 patients at 6 months. CONCLUSION: This pilot trial with a small number of patients suggests that low-frequency, high-intensity ultrasound energy delivery followed by plain balloon angioplasty is a safe approach to treat infrapopliteal atherosclerotic lesions. Angiographically-documented results at 6 months indicate a potential for this combined therapy in the treatment of CLI patients with calcified BTK lesions. Further studies on a larger randomized cohort are needed to confirm these positive clinical outcomes.

Heparin during endovascular stroke treatment seems safe.

BACKGROUND AND PURPOSE: the effect of intravenous heparin during mechanical thrombectomy for acute ischemic stroke is not clear. We aimed to study efficacy and safety of heparin use during endovascular stroke treatment in a real-world setting. MATERIALS AND METHODS: patients with anterior circulation stroke were divided, based on the use of intraprocedural heparin, in those treated and those untreated. Main outcomes were successful reperfusion defined as a TICI Score ≥ 2b, 3-month functional independence defined as a modified Rankin Scale ≤ 2, symptomatic intracranial hemorrhage (sICH) and mortality. RESULTS: 361 patients were eligible for analysis; 200 were (H+) and 161 (H-). The (H-) group showed higher age and ASPECTS (74 ± 14 vs. 68.9 ± 12.2; P = 0.001; 8 ± 1.6 vs. 7.4 ± 2.1; P = 0.009) without differences in vascular risk factors. Heparin untreated patients showed a shorter onset-to-reperfusion time (271 ± 57.6 min vs. 309 ± 102.2 min; P < 0.001). No differences were found in 3-month functional independence, sICH and mortality whereas the rate of successful reperfusion was higher in the (H-) group. After logistic regression analysis successful reperfusion was independently associated with CT ASPECTS (OR: 1.16; 95%CI 1.01-1.35; P = 0.040) but inversely associated with the use of heparin (OR: 0.48; 95% CI 0.24-0.98; P = 0.045). CONCLUSIONS: Heparin use during mechanical thrombectomy for anterior circulation acute ischemic stroke in a real world setting is safe.

Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset.

PURPOSE: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). TECHNIQUE: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow "U-shaped" loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. CONCLUSION: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke-Early and 12-Month Outcomes in a Comprehensive Stroke Center.

PURPOSE: To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center. MATERIALS AND METHODS: Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed. RESULTS: Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P = .08). Complication rates were similar between groups. mRS scores showed a significant improvement over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A subanalysis in patients with NIHSS scores ≥ 4 showed no differences in complication rate and outcome. CONCLUSIONS: CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced centers, even after major atherosclerotic stroke.

Risk of contrast induced nephropathy in diabetic patients affected by critical limb ischemia and diabetic foot ulcers treated by percutaneous transluminal angioplasty of lower limbs.

BACKGROUND: The aim of this study is to evaluate the risk of contrast induced nephropathy (CIN) in diabetic patients with critical limb ischemia (CLI) and foot ulcers (FUs) treated by percutaneous transluminal angioplasty of lower limbs. METHODS: The study group was composed of 145 diabetic patients who underwent a limb salvage protocol because of CLI and FUs between 2012 and 2015. All patients received a prophylactic strategy against the administration of contrast medium. Serum creatinine (SCr) levels were evaluated the day of procedure and for 3 days after. CIN was considered in case of increase of 25% of SCr in comparison to baseline value or an absolute increase of at least 0.5 mg/dl without other interfering factors. RESULTS: CIN occurred in 9% (14/145) of the cases. In the 1-year follow-up SCr returned to baseline values in 10 patients (71 %), 3 patients died (21%), and 1 patient had a major cardiovascular event (7%). No patients required dialysis. The risk was independent of chronic kidney disease stage. The rate of contrast nephropathy in each stage (X = 0.27) was as follows: 3/20 (15%) in stage 2; 3/66 (4.6%) in stage 3, 7/51 (13.7%) in stage 4; and 1/8 (12.5%) in stage 5. At the univariate analysis factors predicting this risk were anemia (HR 95% 2.5 [CI 1.8-4.2] P = .039) and heart failure (HR 95% 2.6 [CI 2.1-4.6] P = .038), while any significant variable was found at multivariate analysis. CONCLUSIONS: Peripheral percutaneous transluminal angioplasty in diabetic patients with CLI and FUs can be performed with a good safety factor and a low risk of contrast medium toxicity.

Endovascular Stroke Treatment of Acute Tandem Occlusion: A Single-Center Experience.

PURPOSE: To evaluate outcomes and prognostic factors in patients with acute ischemic stroke caused by tandem internal carotid artery/middle cerebral artery occlusion undergoing endovascular treatment. MATERIALS AND METHODS: Characteristics of consecutive patients with tandem occlusion (TO) were extracted from a prospective registry. Collateral vessel quality on pretreatment computed tomographic (CT) angiography was evaluated on a 4-point grading scale, and patients were dichotomized as having poor or good collateral flow. Outcome measures included successful reperfusion according to Thrombolysis In Cerebral Infarction score, good outcome at 3 months defined as a modified Rankin scale score ≤ 2, symptomatic intracranial hemorrhage (ICH; sICH), and mortality. RESULTS: A total of 72 patients with TO (mean age, 65.6 y ± 12.8) were treated. Intravenous thrombolysis was performed in 54.1% of patients, and a carotid stent was inserted in 48.6%. Successful reperfusion was achieved in 64% of patients, and a good outcome was achieved in 32%. sICH occurred in 12.5% of patients, and the overall mortality rate was 32%. Univariate analysis demonstrated that good outcome was associated with good collateral flow (P = .0001), successful reperfusion (P = .001), and lower rate of any ICH (P = .02) and sICH (P = .04). On multivariate analysis, good collateral flow (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.75; P = .01) and age (OR, 1.08; 95% CI, 1.01-1.15; P = .01) were the only predictors of good outcome. The use of more than one device for thrombectomy was the only predictor of sICH (OR, 10.74; 95% CI, 1.37-84.13; P = .02). CONCLUSIONS: Endovascular treatment for TO resulted in good outcomes. Collateral flow and age were independent predictors of good clinical outcomes at 3 months.

Proposal for a Vascular Computed Tomography-Based Grading System in Posterior Circulation Stroke: A Single-Center Experience.

OBJECTIVE: The aim of this study is to investigate the role of a computed tomography angiography (CTA)-based approach in patients undergoing mechanical thrombectomy for vertebrobasilar stroke treatment. METHODS: A CTA and digital subtraction angiography (DSA) retrospective analysis of patients with acute vertebrobasilar stroke treated with thrombectomy was performed. A modified Rankin Scale score of 3 or lower at 3 months was considered as favorable outcome. The posterior circulation ASPECTS (pc-ASPECTS) was evaluated on CTA and vertebrobasilar segments involved in the occlusion were assessed using a 6-point posterior circulation computed tomography angiography (pc-CTA) vascular score aimed at evaluating the posterior circulation vascular pattern including collaterals. The primary end point was the correlation between pc-CTA and outcome; secondary end points included the concordance between CTA-DSA images and the correlation between pc-ASPECTS and outcome. RESULTS: Fifteen patients with vertebrobasilar stroke were retrospectively analyzed. All patients in coma showed a bad outcome (P = .01) and all patients with an alert state showed a good outcome (P = .004). An excellent interobserver agreement for pc-CTA (P = .001) was observed with poor interobserver agreement for pc-ASPECTS (P = .21). No significant correlations between pc-ASPECTS and clinical outcome were observed. Patients with good outcome had a lower pc-CTA (P = .02). The patency of the distal third of the basilar artery and both posterior cerebral arteries was related with good outcome. CONCLUSION: The pc-CTA seems to have prognostic value in patients with vertebrobasilar stroke undergoing mechanical thrombectomy. It may be used as an additional prognostic triage technique in this subgroup of stroke patients.

Inexplicable late type Ia endoleak associated with the low-profile Ovation endograft in a patient with favorable neck anatomy: treatment with transcaval coil embolization.

PURPOSE: To report an unusual late type Ia endoleak after endovascular aneurysm repair with a low-profile sealing ring endograft and its treatment with transcaval sac embolization. CASE REPORT: An 82-year-old man was treated for a 47-mm abdominal aortic aneurysm associated with a 35-mm left common iliac artery aneurysm using an Ovation Abdominal Stent Graft System. Correct endograft placement was documented at 3-month follow-up. Seven months after the repair, the patient was admitted to the emergency department with acute left inguinal pain. Computed tomography showed aneurysm sac enlargement (57 mm) and a contained rupture of the left common iliac artery due to a late type Ia endoleak. The endoleak was embolized with coils and thrombin via a transcaval approach. Sac shrinkage without signs of endoleak was observed at 12-month follow-up. CONCLUSION: In this case, late endograft failure with sealing ring collapse created an inflow channel into the aneurysm sac, with massive type Ia endoleak.

Foot Embolization During Limb Salvage Procedures in Critical Limb Ischemia Patients Successfully Managed With Mechanical Thromboaspiration: A Technical Note.

PURPOSE: To illustrate the use of a mechanical thromboaspiration device originally designed for clot retrieval in acute stroke in the treatment of acute distal embolism occurring during percutaneous revascularization of the femoropopliteal and below-the-knee arterial segments. TECHNIQUE: The Penumbra system was adapted for aspiration of thrombus in the distal foot arteries as a standalone device. The 2 over-the-wire, tapered lumen catheters have long working lengths (139 cm for the 4MAX to 153 cm for the 3MAX) that allow advancement below the ankle even with a retrograde contralateral approach. Once the occluded arterial segment is reached, the catheters are connected to the dedicated pump for continuous vacuum aspiration. The use of the device is illustrated in 3 diabetic patients (1 woman and 2 men; ages 88, 70, and 73 years, respectively) undergoing limb salvage procedures who experienced distal embolization that would have seriously jeopardized the foot circulation. The lumens of the occluded arteries were restored without complication. CONCLUSION: While further evaluation in a larger cohort of patients is needed, this initial experience using the Penumbra system in the peripheral vasculature suggests that this is a rapid, effective approach to address intraprocedural foot embolization and avoid possible grave clinical sequelae.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Patient skin dose measurements using a cable free system MOSFETs based in fluoroscopically guided percutaneous vertebroplasty, percutaneous disc decompression, radiofrequency medial branch neurolysis, and endovascular critical limb ischemia.

The purpose of this work has been to dosimetrically investigate four fluoroscopically guided interventions: the percutaneous vertebroplasty (PVP), the percutaneous disc decompression (PDD), the radiofrequency medial branch neurolysis (RF) (hereafter named spine procedures), and the endovascular treatment for the critical limb ischemia (CLI). The X-ray equipment used was a Philips Integris Allura Xper FD20 imaging system provided with a dose-area product (DAP) meter. The parameters investigated were: maximum skin dose (MSD), air kerma (Ka,r), DAP, and fluoroscopy time (FT). In order to measure the maximum skin dose, we employed a system based on MOSFET detectors. Before using the system on patients, a calibration factor Fc and correction factors for energy (CkV) and field size (CFD) dependence were determined. Ka,r, DAP, and FT were extrapolated from the X-ray equipment. The analysis was carried out on 40 patients, 10 for each procedure. The average fluoroscopy time and DAP values were compared with the reference levels (RLs) proposed in literature. Finally, the correlations between MSD, FT, Ka,r, and DAP values, as well as between DAP and FT values, were studied in terms of Pearson's product-moment coefficients for spine procedures only. An Fc value of 0.20 and a very low dependence of CFD on field size were found. A third-order polynomial function was chosen for CkV. The mean values of MSD ranged from 2.3 to 10.8cGy for CLI and PVP, respectively. For these procedures, the DAP and FT values were within the proposed RL values. The statistical analysis showed little correlation between the investigated parameters. The interventional procedures investigated were found to be both safe with regard to deterministic effects and optimized for stochastic ones. In the spine procedures, the observed correlations indicated that the estimation of MSD from Ka,r or DAP was not accurate and a direct measure of MSD is therefore recommended.

Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.

PURPOSE: To assess the technical and midterm results in the treatment of type II endoleaks comparing nonselective (nTCE) vs. selective (sTCE) transcaval embolization. METHODS: During a 4-year period, 26 patients (18 men; median age 73 years, range 68-78) underwent direct transcaval aneurysm puncture followed by embolization of the sac (nTCE, n=9) or of the feeding vessels (sTCE, n=17). Intrasac pressure was recorded immediately after aneurysm sac puncture and at the end of the procedure. Technical success was defined as successful deployment of embolization material in the sac or in the feeding vessel. Clinical success was defined as absence of endoleak with stabilization of the sac on follow-up CTA. RESULTS: Technical success was 100% in the 9 patients treated with nTCE. Mean intrasac pressures before and after nTCE were 58.6±18.4 (range 51-105) and 6.5±1.2 mmHg (range 4-9), respectively. Over a mean 25.9±11.0 months of follow-up, 4 patients developed recurrent endoleak at a mean 9.7±3.9 months. Three patients were subsequently treated with sTCE, while the last patient underwent emergency surgery for aneurysm rupture due to an enlarging sac 5 months after nTCE. The 20 patients in the sTCE group had a successful procedure with no recurrence in a follow-up of 24.1±7.2 months. Mean intrasac pressure was reduced after sTCE from 63.6±15.2 mmHg (range 43-120) to 7.8±2.3 mmHg (range 5-12). CONCLUSION: The selective TCE approach appears to be a feasible and effective primary therapeutic option for treating type II endoleak.

Long-term results of drug-eluting balloon angioplasty for treatment of refractory recurrent carotid in-stent restenosis.

PURPOSE: To evaluate the potential role, safety, and efficacy of paclitaxel-eluting balloon angioplasty for treatment of recurrent carotid in-stent restenosis (ISR). METHODS: Among 856 consecutive patients who underwent carotid artery stenting from May 2002 to January 2008, 41 patients had a significant ISR (>80% stenosis). Of these, 9 patients (7 women; mean age 78.1±5.6 years) had recurrent ISR despite multiple endovascular treatments (3.4±0.9 interventions) within a short period of time (2-5 months). These patients were treated with drug-eluting balloon (DEB) angioplasty for neointimal hyperplasia. Imaging (ultrasound or computed tomographic angiography) was performed at 1, 3, and 6 months and yearly thereafter. RESULTS: Technical success was obtained in 100% of cases, with angiographic stenosis decreasing from 87%±4% to 6%±4% post treatment. Peak systolic velocity decreased significantly from 4.7±1.5 m/s to 0.6.±0.3 m/s after the procedure. Over a mean follow-up of 36.6±2.7 months, ultrasound imaging indicated recurrent ISR in only 3 patients at 18, 25, and 32 months after DEB angioplasty, respectively. The target vessel revascularization rate was 33.3% at 36 months. No neurological or myocardial events were recorded during follow-up. One patient died at 3 months. CONCLUSION: DEB may have a potential role improving outcomes of those patients treated for early recurrent carotid ISR.

CIRSE Standards of Practice on Carotid Artery Stenting.

BACKGROUND: Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis. PURPOSE: This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure. METHODS: The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022. RESULTS: Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.