Percutaneous Transanastomotic Stent Graft Deployment to Salvage Dysfunctional Native Forearm Radiocephalic Fistulae: Feasibility and Primary Patency at 12 Months.

PURPOSE: To evaluate feasibility and efficacy of transanastomotic self-expandable polytetrafluoroethylene stent graft placement for salvage of radiocephalic arteriovenous fistulae (RCAVFs). MATERIALS AND METHODS: From 2008 to 2016, 26 patients (21 male; age, 38-80 y) with dysfunctional RCAVFs for juxtaanastomotic lesions that were unresponsive to angioplasty underwent transanastomotic stent graft placement. Stenotic and thrombotic lesions were included. All were deemed unsuitable for surgical revision. Patency rates were calculated per Kaplan-Meier method. A Cox analysis was used to identify influencing factors. RESULTS: Thirty-two stent grafts (6 patients had 2 stents) were deployed. Anatomic and clinical success were achieved in all patients; no major complications occurred. Mechanical and/or pharmacologic thrombolysis was performed in 6 cases before stent graft deployment. During follow-up (median, 34.7 mo; range, 1.9-102.7 mo), 17 repeat interventions were required in 10 patients (43 procedures overall), for an endovascular intervention rate of 0.27 per year. At 3, 6, 12, and 24 months, primary patency (PP) rates were 96% ± 4 (95% CI, 75%-99%), 83% ± 7 (95% CI, 61%-93%), 78% ± 8 (95% CI, 55%-90%), and 69% ± 10 (95% CI, 46%-84%). The corresponding assisted PP rates were 96% ± 4 (95% CI, 76%-99%), 96% ± 4 (95% CI, 76%-99%), 92% ± 5 (95% CI, 71%-98%), and 82% ± 8 (95% CI, 60%-93%). Five AVFs were ultimately abandoned. Per Cox analysis, arterial diameter ≥ 4 mm was associated with better PP (P = .032). CONCLUSIONS: Transanastomotic stent graft placement for RCAVF salvage is feasible and safe, providing patency rates comparable with historical endovascular and surgical data. Its role should be evaluated in larger studies.

Covered stent assisted coil embolization of large Buhler aneurysm in setting of chronic celiac trunk occlusion.

BACKGROUND: The arc of Bühler (AOB) is a residual embryonal anastomosis between the celiac artery (CA) and the superior mesenteric artery (SMA). Although usually asymptomatic, it has clinical relevance when compensatory reverse flow between the SMA and the CA in response to celiac artery obstruction leads to aneurysm formation and bleeding. Endovascular coiling is the mainstay therapy because of the deep AOB retropancreatic location, which hinders open surgery. CASE PRESENTATION: We herein report a case of a 2.8-cm AOB saccular aneurysm and LAM compression of celiac trunk in a 47-year-old man during rehabilitation following motorcycle trauma and vertebral surgery. The patient was considered unsuitable for surgery. Neither conventional coiling nor bare-metal stent and balloon-assisted techniques for coiling were suitable because of the wide necked saccular shape of AOB aneurysm interposed between the SMA and the floor of celiac trunk. To exclude the aneurysm from direct SMA inflow and permit safe and efficient coiling to rule out retrograde sac perfusion, a 9-mm polytetrafluoroethylene stent graft (Viabahn; Gore, Phoenix, AZ, USA) was positioned in the mesenteric artery, followed by antegrade periprosthetic high-density packed coiling of the aneurysm. The AOB remained excluded from mesenteric perfusion. The patient's clinical condition and abdominal contrast-enhanced multislice computed tomographic findings were unremarkable at the 9-year follow-up. CONCLUSION: The 9 year long-term efficacy in our case raises the possibility that perigraft coiling following stent-graft deployment in the SMA may represent a valuable technical option for large Bühler aneurysms that are not amenable to stand-alone coiling.

U-bent Viabahn stent graft in the main left pulmonary artery in a hemodialysis patient after asymptomatic migration: Percutaneous removal and technical considerations.

BACKGROUND: Stent grafts (SG) have gained the highest level of evidence for superior management over angioplasty of arteriovenous graft (AVG) venous outflow stenosis, which increases their use in hemodialysis patients. Migration to the heart and lungs is the most feared complication of SG of the venous system. METHOD: We present a previously unreported case of asymptomatic migration of a 10-cm-long Viabahn lodged in a U-shaped configuration in the main left pulmonary artery after AVG intervention in a 50 year old male hemodialysis patient. RESULTS: Through a single femoral access percutaneous retrieval of migrated SG was accomplished. Technique of coaxial buddy snaring technique is described. CONCLUSION: Our technique may expand the endovascular likelihood of successful stent removal.

Genomic Evaluation of Coffea arabica and Its Wild Relative Coffea racemosa in Mozambique: Settling Resilience Keys for the Coffee Crop in the Context of Climate Change.

Climate change is negatively affecting the coffee value chain, with a direct effect on approximately 100 million people from 80 countries. This has been attributed to the high vulnerability of the two-mainstream species, Coffea arabica and Coffea canephora, to extreme weather events, with notable uneven increases in market prices. Taking into account the narrow genetic plasticity of the commercial coffee cultivars, wild-relatives and underutilized Coffea species are valuable genetic resources. In this work, we have assessed the occurrence of Coffea species in to understand the degree of genetic relationships between Coffea species in the country, as well as the patterns of genetic diversity, differentiation, and genetic structure. Only one wild species was found, C. racemosa, which showed a high level of genetic separation with C. arabica, based on plastid, as well as SSR and SNP analysis. C. arabica presented low levels of diversity likely related to their autogamous nature, while the allogamous C. racemosa presented higher levels of diversity and heterozygosity. The analysis of the functional pathways based on SNPs suggests that the stress signaling pathways are more robust in this species. This novel approach shows that it is vital to introduce more resilient species and increase genomic diversity in climate-smart practices.

Green Tattoo Pre-Operative Renal Embolization for Robotic-Assisted and Laparoscopic Partial Nephrectomy: A Practical Proof of a New Technique.

(1) Background: Our aim is to describe a new mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) pre-operative renal embolization technique for assisted-robotic and laparoscopic partial nephrectomy with near-infra-red fluorescence imaging. (2) Methods: Thirteen patients with biopsy-proven renal tumors underwent pre-operative mixed indocyanine-ethylene vinyl alcohol (EVOH) embolization (Green-embo) between June 2021 and August 2022. All pre-operative embolizations were performed with a super selective stop-flow technique using a balloon microcatheter to deliver an indocyanine-EVOH mixture into tertiary order arterial branch feeders and the intra-lesional vascular supply. Efficacy (evaluated as complete embolization, correct tumor mapping on infra-red fluorescence imaging and clamp-off surgery) and safety (evaluated as complication rate and functional outcomes) were primary goals. Clinical and pathological data were also collected. (3) Results: Two male and eleven female patients (mean age 72 years) received pre-operative Green-embo. The median tumor size was 29 mm (range 15-50 mm). Histopathology identified renal cell carcinoma (RCC) in 9 of the 13 (69%) patients, oncocytoma in 3 of the 13 (23%) patients and sarcomatoid RCC in 1 of the 13 (8%) patients. Lesions were equally distributed between polar, meso-renal, endo- and exophytic locations. Complete embolization was achieved in all the procedures. A correct green mapping was identified during all infra-red fluorescence imaging. All patients were discharged on the second day after the surgery. The median blood loss was 145 cc (10-300 cc). No significant differences were observed in serum creatinine levels before and after the embolization procedures. (4) Conclusions: The Green-tattoo technique based on a mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) is a safe and effective pre-operative embolization technique. The main advantages are the excellent lesion mapping for fluorescence imaging, reduction in surgical time, and definitive, complete and immediate tumor devascularization based on the deep Onyx-18 penetration, leading to a very low intra-operative blood loss.

One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics.

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients.

New therapeutic options provided by off-label deployment of stent graft for tailored arteriovenous access salvage: Two cases.

A tailored therapy to patient requirements by combining endovascular and surgical steps can be necessary to prolong the life of a vascular access. Stent grafts play a growing role for the therapy of dialytic access complications. Randomized multi-center trials, however, support the on-label use of stent grafts in the treatment of graft venous outflow and in-stent restenosis. The main contraindication to their use is an ongoing infection. We report two cases of new off-label application of Viabahn (Gore, flagstaff, USA) stent graft. In the first case, the failure of a radiocephalic early cannulation graft was treated by stent graft placement on the arterial inflow anastomosis, when emergent angiographic examination revealed the previously unknown high takeoff of the radial artery from the axillary artery. At 13-month follow-up, the target lesion remained untreated. In the second case, elbow stent graft occlusion with extended thrombosis occurred in a right radiocephalic fistula after 3 years of unassisted patency. Being the last option for vascular access, successful endovascular recanalization was carried out. After 3 months, however, the clinical setting relapsed. A two-stage hybrid strategy with vascular surgeon was arranged due to ongoing signs of local infection. Flow was restored by emergent thromboaspiration associated with a new stent graft placement as a endovascular bridge to subsequent surgical treatment. After 2 days, the overlapped stent grafts were excised as planned. Surgical rerouting was completed by polytetrafluoroethylene prosthetic bridge implantation across the elbow. At 4 months, the follow-up remained uneventful. In selected instances, the off-label use of stent grafts may expand the therapeutic options of the vascular access team.

Disabling portosystemic encephalopathy in a non-cirrhotic patient: Successful endovascular treatment of a giant inferior mesenteric-caval shunt via the left internal iliac vein.

Hepatic encephalopathy is suspected in non-cirrhotic cases of encephalopathy because the symptoms are accompanied by hyperammonaemia. Some cases have been misdiagnosed as psychiatric diseases and consequently patients hospitalized in psychiatric institutions or geriatric facilities. Therefore, the importance of accurate diagnosis of this disease should be strongly emphasized. A 68-year-old female patient presented to the Emergency Room with confusion, lethargy, nausea and vomiting. Examination disclosed normal vital signs. Neurological examination revealed a minimally responsive woman without apparent focal deficits and normal reflexes. She had no history of hematologic disorders or alcohol abuse. Her brain TC did not demonstrate any intracranial abnormalities and electroencephalography did not reveal any subclinical epileptiform discharges. Her ammonia level was > 400 mg/dL (reference range < 75 mg/dL) while hepatitis viral markers were negative. The patient was started on lactulose, rifaximin and low-protein diet. On the basis of the doppler ultrasound and abdomen computed tomography angiography findings, the decision was made to attempt portal venography which confirmed the presence of a giant portal-systemic venous shunt. Therefore, mechanic obliteration of shunt by interventional radiology was performed. As a consequence, mesenteric venous blood returned to hepatopetally flow into the liver, metabolic detoxification of ammonia increased and hepatic encephalopathy subsided. It is crucial that physicians immediately recognize the presence of non-cirrhotic encephalopathy, in view of the potential therapeutic resolution after accurate diagnosis and appropriate treatments.

Stent Grafts Provided Superior Primary Patency for Central Venous Stenosis Treatment in Comparison with Angioplasty and Bare Metal Stent: A Retrospective Single Center Study on 70 Hemodialysis Patients.

PURPOSE: To compare patency in dialysis patients following different endovascular treatment of symptomatic central venous stenosis. MATERIALS AND METHODS: A 10-year retrospective evaluation in 70 patients (32 men) dialyzing through vascular access (33, 47%) and tunneled catheters (37, 53%) was made. Three cohorts were compared: angioplasty alone (22), bare metal stent (28), and stent graft (20). Patencies were described with Kaplan-Meier method, and Cox uni- and multivariate models were analyzed to find factors associated. RESULTS: All patients had a favorable anatomical and clinical outcome. Restenosis occurred in 22 (31%) of 70 patients requiring 41 additional interventions; 34 of 70 patients died (median follow-up 19.4 months). Primary patency at 3, 6, 12, and 24 months was 100%, 100%, 100%, and 84% for stent graft versus 90%, 79%, 58%, and 43% for angioplasty (P = .014) versus 84%, 80%, 75%, and 46% for bare-metal stent (P = .062). The overall comparison was more favorable for stent graft (P = .020) when the sites of lesions were matched. Patencies for angioplasty and bare-metal stents were equivalent (P = .141). A lower risk of restenosis (hazard rate [HR] 0.20, confidence interval [CI] 0.06-0.7) and fewer reinterventions (P < .01) were associated with stent graft, whereas age (HR 1.04, CI 1.001-1.08) and cardiovascular disease (HR 2.26, CI 1.06-4.84) influenced the overall survival. No difference in assisted primary patency was found. CONCLUSION: Stent graft seems to improve primary patency for central venous stenosis and requires fewer reinterventions in a dialysis population with a high prevalence of long-term catheters.

Knee bursitis: a sonographic evaluation.

OBJECTIVE: To evaluate the use of ultrasound for the diagnosis of knee bursitis. MATERIALS AND METHODS: One-hundred and fifty-eight patients who, from May 2013 to May 2014, had an ultrasound examination of the knee and magnetic resonance imaging (MRI) of the knee during the following month were eligible for the study. The exams were reviewed by two musculoskeletal radiologists with 20 years of experience. RESULTS: Of these patients, 15 (7 men, 8 women) had bursitis, while 143 (76 men, 67 women) had no bursitis. In evaluating knee bursitis, US, when compared to MRI, correctly identified 13 out of 15 cases of bursitis, showing a sensitivity of 86.67 %, specificity 100 %, and K index of 0.92. Particularly in the suprapatellar bursa, ultrasound showed bursitis in 5 cases versus 7 by MRI (sensitivity of 71.4 %, specificity of 100 %, and K index of 0.82). CONCLUSION: Ultrasound can be used as a valuable tool for the evaluation of bursitis of the superficial bursae in patients who cannot undergo MRI.

Joint effusion of the knee: potentialities and limitations of ultrasonography.

PURPOSE: This study aimed at comparing the diagnostic accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for the detection of joint effusion of the knee. METHODS: For this retrospective study, approbation by the institutional review board was not required, and written informed consent from the patients was waived. One hundred and fifty-eight patients (83 men and 75 women; median age 41.2 years; age range 13-81 years) who underwent US and MRI of the knee were included in the study. The sensitivity and specificity of US with respect to MRI in the evaluation of the effusion of the knee and in each recess were compared. RESULTS: In evaluating joint effusion of the knee, compared with MRI, US correctly identified 78 of 96 patients with joint effusion, showing a sensitivity of 81.3 % and a specificity of 100 %, with a positive predictive value (PPV) of 100 % and a negative predictive value (NPV) of 77.5 % (p value = 0.001). Various results were obtained comparing ultrasound with MRI, regarding the various recesses. CONCLUSION: US showed high specificity and sensitivity in diagnosing knee joint effusion and could be used in patients who cannot undergo MRI.

Dialysis catheter-related superior vena cava syndrome with patent vena cava: long term efficacy of unilateral Viatorr stent-graft avoiding catheter manipulation.

Central venous catheters are the most frequent causes of benign central vein stenosis. We report the case of a 79-year-old woman on hemodialysis through a twin catheter in the right internal jugular vein, presenting with superior vena cava (SVC) syndrome with patent SVC. The clinically driven endovascular therapy was conducted to treat the venous syndrome with a unilateral left brachiocephalic stent-graft without manipulation of the well-functioning catheter. The follow-up was uneventful until death 94 months later.