[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]. / Le cas clinique du mois. Les endofuites, une complication spécifique du traitement endovasculaire des pathologies aortiques.

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

Thrombolysis of occluded infra-inguinal bypass grafts: is it worthwhile?

BACKGROUND: Thrombosis of an infra-inguinal bypass graft often results in a limb-threatening ischemia. There is no consensus on the optimal management strategy. AIM OF THE STUDY: To analyse safety and efficacy of catheter-guided intra-arterial thrombolysis to re-open thrombosed infra-inguinal bypass grafts and to identify factors that influence graft patency and limb salvage rate after thrombolytic procedures. METHODS: A continuous cohort-study of 106 thrombolytic procedures between 1993 to 2008. RESULTS: Despite a high initial success rate (76%), the mid-term results are less convincing, with a 58% re-occlusion rate at 45 months follow-up. Thrombosed vein grafts, old (2 weeks or more) occlusions, poor run-off and failure to identify or rectify an underlying causative stenosis are determinant for a poor long-term outcome of thrombolytic procedures. COMMENTS: The outcome results of author's experience are consistent with literature reports. Thrombolysis of occluded infra-inguinal bypass grafts should be limited to selective cases (recent occlusion, prosthetic or vein graft in place since 1 year or more, critical limb ischemia). Despite its obvious advantages, the long-term outcome of thrombolytic procedures is deceiving. The inherent risk of hemorrhagic complications should also be taken in account at the decision making of treatment strategy. The question whether, in general, catheter-guided selective intra-arterial thrombolysis offers a significant advantage over operative revascularisation (thrombectomy or new bypass) remains unanswered. A more selective approach seems to favour thrombolysis as most appropriate strategy in the management of recent (< 2 weeks) thromboses of grafts in place since at least 1 year.

[Clinical case of the month. Cerebrovascular accident related to arterial brachiocephalic trunk stenosis]. / Le cas clinique du mois. Accident ischémique cérébral sur sténose du tronc artériel brachiocéphalique.

The authors report the case of a 47-year old man, admitted for syncope and left-sided motor deficit. Diagnostic investigations revealed a right middle cerebral artery embolic stroke, secondary to a critical stenosis of the arterial brachiocephalic trunk, harboring a floating thrombus. The treatment options for occlusive lesions of the brachiocephalic trunk are discussed, as well as the optimal delay between stroke and brain revascularization.

Intra-arterial thrombolysis of thrombosed popliteal artery aneurysm. A series of six cases.

AIM OF THE STUDY: To evaluate the role of perioperative, catheter-guided fibrinolysis in the management of thrombosed popliteal artery aneurysms. MATERIAL: From 1990 to 2005, six patients suffering subacute limb ischemia, secondary to thrombosis of a popliteal artery aneurysm, benefited selective intra-arterial fibrinolysis, followed by subsequent aneurysm exclusion and bypass grafting. This represents ten percent of all popliteal aneurysms operated on in that time period and 28% of all thrombosed popliteal artery aneurysms. RESULTS: The lytic procedure was successful in all cases, restituting patency in two (n = 3), one (n = 2) or all (n = 1) crural arteries. The venous bypass graft remained patent in all but one patient. In one patient, the graft occluded at 10 months without limb loss. This outcome compares more favorable than the result obtained with emergent surgery alone for thrombosed popliteal artery aneurysms with profound limb ischemia (eight patients, of whom one required amputation at day 5 and one lost his limb at nine months following graft thrombosis). CONCLUSION: Preoperative intra-arterial lytic therapy, in the setting of subacute limb ischemia caused by thrombosis of a popliteal artery aneurysm, can be considered as safe and effective.

Traumatic injuries: radiological hemostatic intervention at admission.

Blunt trauma victims and selected patients with penetrating trauma are systematically investigated after resuscitation and hemodynamic stabilization with cross-sectional imaging. Computed tomography is a good predictor of the need for hemostatic arteriographic embolization, based on contrast medium extravasation observed on CT. In centers admitting polytrauma patients, the CT and angiography units should be installed together within the emergency environment. Trauma-dedicated interventional radiologists should be on call for optimal patient management. Posttraumatic retroperitoneal and pelvic bleeding is a primary indication for angiographic hemostasis, together with orthopedic fixation of pelvic bone fractures. Angiography should be carried out rapidly, before the patient decompensates for considerable blood loss. In patients with visceral bleeding, arterial embolization can obviate primary surgery or potentializes surgical intervention and contributes to changing hierarchy of injuries to be treated surgically. Failure to achieve primary hemostasis may occur according to the type of specific organ injury and coagulation and metabolic parameters of the patient. Postembolization complications are few and are usually non-life-threatening and rarely carry definitive sequelae.

Sedation, analgesia and anesthesia for interventional radiological procedures in adults. Part I. Survey of interventional radiological practice in Belgium.

A questionnaire was mailed to 217 interventional radiologists to evaluate current practice in analgesia and sedation in adults. Response rate was 15% (33/217). Diagnostic angiography was performed with local anesthesia in 94% to 99%; for PTA, local thrombolysis or stent placement, light sedation was added in 0.1%. Premedication was given in 43% of diagnostic angiographies and in 68% of therapeutic procedures. Radiologists consulted an anesthesiologist before administration of intravenous sedation, always in 54% of cases, occasionally in 19% and never in 27%. General anesthesia with artificial ventilation was applied in 56% of TIPS, in 70% of aortic stent grafting and in 82% of neuroradiological interventions. Intravenous sedation was applied given in 53% of percutaneous biliary drainage, in 42% of bile duct dilatation or stenting, in 40% of percutaneous nephrostomy and in 72% of ureteral balloon dilatation. Patient monitoring during an interventional procedure was always carried out by an anesthesiologist in 52% of cases. 21% of radiologists never visited the patient before a therapeutic procedure, and 36% never did so after completion of a procedure. This survey showed that high standard practice of sedation and analgesia, with the assistance of anesthesiologists, is underused by interventional radiologists in Belgium.

Use of a balloon occlusion catheter to facilitate transarterial coil embolisation of a patent ductus arteriosus in two dogs.

Two dogs with a history of coughing and exercise intolerance were suspected to have a patent ductus arteriosus (PDA), and the presence of a type III PDA was confirmed by radiography, electrocardiography, ultrasonography and angiography. Transarterial coil embolisation was carried out by using a modified technique. An occlusion balloon catheter was inserted through a femoral vein and placed at the pulmonary side of the ductus before the embolisation coils were put in place. Both dogs remained healthy during a follow-up period of nine months.

Radiologic damage control: evaluation of a combined CT and angiography suite with a pivoting table.

PURPOSE: To evaluate retrospectively the integrated diagnostic and therapeutic management of severely polytraumatized patients using a combined computed tomography (CT) and angiography suite with a single pivoting table. METHODS: Eleven patients, aged 16-74 years (median 30 years), were managed with spiral CT and angiography without patient transfer. Four patients were unstable, seven had received blood transfusions (2-18 units) and six were intubated. In 10 patients in whom active bleeding was demonstrated (splenic 5, hepatic 2, renal 2, left inferior epigastric artery 1), hemostatic embolization was obtained. RESULTS: Total procedure time did not exceed 80 min. Immediate hemostasis was achieved in all patients. Recurrent bleeding from the liver required additional embolization in one patient. Median length of stay in the intensive care unit was 4 days and median hospital stay was 27 days. All patients survived without significant sequelae. CONCLUSION: The use of a combined CT-angiography suite enables rapid diagnostic investigation and hemostatic embolization in actively bleeding trauma patients.

Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization.

We report a case of life-threatening esophageal hemorrhage after metal stent implantation successfully treated by arterial embolization. An 85-year-old woman was admitted in shock secondary to massive hematemesis and melena. Recent medical history revealed esophageal cancer treated 8 weeks previously by endoesophageal radiotherapy (40 Gy) and endoscopic placement of a covered Wall-stent prosthesis. Selective arteriography of the fifth posterior right intercostal artery showed massive contrast extravasation in the esophagus. Embolization was performed with 150-250-micron polyvinyl alcohol particles. Follow-up at 5 months was uneventful. Arteriography and embolization are advised when severe hemorrhage occurs after esophageal implantation of metal stents.

Arterial embolization of bone metastases: is it worthwhile?

Arterial embolization was performed in ten skeletal metastases occurring in nine patients: eight patients presented with renal cell carcinoma and one with bronchogenic carcinoma. Five metastatic lesions were located in the spine, one in the pelvis, three in the proximal humerus and one in the proximal femur. Selective arterial embolization was performed preoperatively in seven cases and as a palliative treatment in three cases. The embolic material used was polyvinyl alcohol particles, gelatin sponge and coils or a combination of these. Arterial embolization was technically successful in all patients achieving subtotal (> 90%) tumour devascularization in five metastases and a 75% devascularization in the remaining five lesions. In operative patients, median intra-operative volume of blood transfusion was 510 mL. Palliative embolization was followed by major pain relief in two cases and moderate relief in one case lasting from 7 to 26 months. Arterial embolization is an effective and safe adjunctive treatment of hypervascular bone metastases.

Thrombolysis of occluded infrainguinal bypass grafts.

From January 1993 to December 1995, intraarterial catheter guided urokinase infusion was used as an initial approach in the management of 29 episodes of infrainguinal graft thrombosis (12 venous and 17 prosthetic grafts) in 27 patients. The infusion catheter was embedded inside the occluding clot which was infiltrated by 225.000 U urokinase from distal to proximal. Local low-dose urokinase (1.000 U/kg/hr) was continued for a mean of 39 hours. By this regimen, prompt relief of ischaemia was achieved in 69% (20/29) of cases. Complete recanalization was obtained in 79% of cases. In six cases, the graft remained totally (n = 3) or partially (n = 3) occluded. Two of these patients benefited from secondary surgery, two improved clinically by conservative treatment, and two required amputation. In the 23 successful cases, thrombolysis unmasked an underlying flow-limiting stenosis in 83% (19/23), that was subsequently corrected by percutaneous balloon angioplasty (n = 15), by surgery (n = 3), or by a combination of both (n = 4). One early rethrombosis resulted in an amputation. The immediate limb-salvage rate was 89% (26/29). Surgical intervention was avoided in 17 cases (58%). The main hospital stay was 13 days. The short-term follow-up (mean of 17 months) reveals a high early rethrombosis rate (8/23 or 35%) within one year. Four of these repeated graft failures evolved to amputation. At one year, the overall limb salvage rate dropped to 79%. Thrombolytic management of infrainguinal occluded bypass grafts gives excellent initial technical results (79%), minimizing the need for major surgical revision. It is however characterized by a high procedure-related morbidity (21%). These immediate favourable results are not longstanding. Diffuse graft disease, limited outflow and high recurrence rate of anastomotic stenoses after balloon angioplasty explain poor long-term results after thrombolysis of failed grafts.

Treatment of symptomatic pelvic varices by ovarian vein embolization.

PURPOSE: Pelvic congestion syndrome is a common cause of chronic pelvic pain in women and its association with venous congestion has been described in the literature. We evaluated the potential benefits of lumbo-ovarian vein embolization in the treatment of lower abdominal pain in patients presenting with pelvic varicosities. METHODS: Nineteen patients were treated. There were 13 unilateral embolizations, 6 initial bilateral treatments and 5 treated recurrences (a total of 30 procedures). All embolizations were performed with either enbucrilate and/or macrocoils, and there was an average clinical and Doppler duplex follow-up of 15.4 months. RESULTS: The initial technical success rate was 96.7%. There were no immediate or long-term complications. Variable symptomatic relief was observed in 73.7% of cases with complete responses in 57.9%. All 8 patients who had partial or no pain relief complained of dyspareunia. The direct relationship between varices and chronic pelvic pain was difficult to ascertain in a significant number of clinical failures. CONCLUSION: Transcatheter embolization of lumbo-ovarian varices is a safe technique offering symptomatic relief of pelvic pain in the majority of cases. The presence of dyspareunia seemed to be a poor prognostic factor, indicating that other causes of pelvic pain may coexist with pelvic varicosities.

Multiple pulmonary artery pseudoaneurysms: intrasaccular embolization.

We report the case of a 32-year-old female presenting with two pulmonary artery false aneurysms of mycotic origin. Considering the natural history and potential complications, we treated the patient by intrasaccular embolization with steel coils. No complication occurred.

A combined CT and angiography suite with a pivoting table.

In a suite with fully interactive computed tomography (CT) and C-arm fluoroscopy units, emergency and elective interventional procedures were performed successfully in 41 patients (overall time range, 40-180 minutes [mean, 80 minutes]). The table can be manually pivoted from the fixed CT position to the free-floating angiography position, in an overall working space of about 40 m(2), with room for anesthesiology and monitoring equipment and personnel.

Evaluation of colour images printed by a thermal dye diffusion process.

Dry printing of medical images, without photochemicals, may be based on the principle of thermal dye diffusion. The Drystar (Agfa Gevaert, Mortsel, Belgium) system was evaluated in colour-coded Doppler examinations of the carotid arteries. A total of 25 consecutive patients were examined for the colour test and 37 patients for the black-and-white test. Colour and black-and-white data were available on the same view. The performances of the Drystar were tested against against laser films, matrix films and two types of glossy paper using the following criteria: grey scale, colour scale, quality of reproduction of vascular colouring, registration, endothelial layer, intraluminal echogenicity, spectral resolution, and artefacts. The overall handiness of the document was graded. A significant difference (p = 0.00005) was noted in favour of the Drystar concerning registration, grey scale, spectral resolution and vascular colouring. The global score for handiness of the colour film was 96%. Radiologists preferred the colour hard copy as compared with glossy paper prints. As in the black-and-white test, blue-base and clear-base films obtained with the Drystar were rated inferior to laser films, a double line print mode was included in the printer, giving a density of 2.3 OD.

Treatment of Budd-Chiari syndrome by metallic stent as a bridge to liver transplantation.

A 49-year-old male with Budd-Chiari syndrome complicated by liver cirrhosis and intractable ascites is reported. The left hepatic vein was stenosed by a short subocclusive ostial web; the right and medial hepatic veins were thrombosed. A spontaneous intrahepatic portosystemic shunt had developed between the left portal and left hepatic veins. After ineffective balloon angioplasty, the left hepatic venous outflow was restored by placement of a 10-mm-diameter Wallstent across the web via a femoral approach. The hepatic venous pressure dropped from 29 to 12 mmHg. Rapid clinical improvement followed. The patient underwent liver transplantation 3 months later in stable condition.