Endovascular Treatment of TASC C and D Femoropopliteal Arterial Disease With Heparin-Bonded Covered Stents: The Impact of Distal Run-Off Vessels.

INTRODUCTION: In the last 2 decades, several studies in the literature evaluated the possible role of covered stents in the treatment of TransAtlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions but, despite the encouraging results, the employment of these devices was never included in clinical guidelines. The aim of this study is to evaluate the role of the technical aspects in patients with TASC C or D lesions that were treated with the GORE VIABAHN endoprosthesis and to elaborate a computerized method to objectively estimate the post-stent run-off and predict stent-graft failure. MATERIALS AND METHODS: In this monocentric retrospective study, we collected the patients who were treated in our department from December 2014 to May 2021. Inclusion criteria comprised: (1) patients who underwent endovascular treatment of a TASC C or D femoropopliteal lesions using one or more heparin-bonded covered stent(s) and (2) clinical follow-up >2 years. Exclusion criteria were clinical follow-up <2 years or missing. An in-house computerized analysis to estimate the post-stent run-off, CEVERO (Computerized Estimation of VEssel Run-Off), was elaborated. RESULTS: Sixty-six patients were enrolled in the study. Eleven patients had a TASC type C lesion, and 55 patients presented a type D lesion. The median follow-up time was 2.6 years. Twenty-nine patients (43.9%) experienced a major adverse limb event. Primary patency after 6, 12 and 24 months was 74.2%, 60.6%, and 57.6%; primary-assisted patency was 78.8%, 65.2%, and 59.1%. The presence of <2 run-off vessels (p<0.001) was correlated with stent-graft failure. The CEVERO analysis demonstrated an accuracy of 90.0% in predicting stent-graft failure. CONCLUSIONS: The treatment of TASC C and D femoropopliteal lesions remains technically challenging. Our study supported the hypothesis that run-off is the most critical factor in determining the outcome of the procedure and that concomitant angioplasty of the tibial vessels might improve the patency of the covered stent. The CEVERO analysis could permit a real-time, objective estimation of the distal run-off using conventional angiographic images, and it might be employed as a tool in the intraprocedural decision-making process, but its clinical applicability should be evaluated on external validation cohorts. CLINICAL IMPACT: The endovascular treatment of TASC C and D femoropopliteal lesions is technically challenging and run-off seems to be the most critical factor in determining the outcome. Concurrent angioplasty of the tibial vessels can create adequate run-off to avoid stent failure. The CEVERO analysis is a computerized estimation of run-off that might be a useful tool in the decision-making process.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay.

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Endovascular Management of Iatrogenic Arterial Injuries after Orthopedic Surgery of the Lower Limb.

PURPOSE: To evaluate the safety and effectiveness of embolization, and to identify the contributory factors of failures in patients treated for iatrogenic arterial injuries after orthopedic surgery of the lower limb. MATERIALS AND METHODS: In this retrospective study, data from patients treated from December 2008 to March 2022 for an arterial injury due to orthopedic surgery of the lower limb were analyzed from a single center. Demographic, clinical, and procedure-related data were collected. Perioperative and 30-day mortalities were estimated. Odds ratios and hazard ratios were calculated for several potential risk factors: age of >75 years, atherosclerosis, preexisting infection, urgency of surgery (trauma vs elective), previous surgery, multiple distant injuries, and multiple vascular supplies to the same injury. RESULTS: Eighty-six procedures performed on 78 patients were included in the study. The rates of technical and clinical success were 100% and 92.3%, respectively. Six (7.7%) patients were retreated because of persistent bleeding. The perioperative mortality was 1.3%, and the 30-day mortality rate was 7.7%. The presence of multiple arterial supplies, multiple injuries, previous surgery, presence of atherosclerosis, or a preexisting musculoskeletal infection resulted in a higher risk of retreatment. CONCLUSIONS: Embolization is safe and effective in the management of iatrogenic arterial injuries after orthopedic surgery. The number of involved vascular territories was the most critical factor in determining technical failure.

Contrast-enhanced CT and liver surface nodularity for the diagnosis of porto-sinusoidal vascular disorder: A case-control study.

BACKGROUND AND AIMS: Porto-sinusoidal vascular disorder (PSVD) is a rare and commonly overlooked cause of portal hypertension. The interest of CT analysis, including quantification of liver surface nodularity (LSN) for PSVD diagnosis has not been established. This study aimed at assessing the performance of LSN and CT features for a PSVD diagnosis in patients with signs of portal hypertension. APPROACH AND RESULTS: This retrospective case-control study included a learning cohort consisting of 50 patients with histologically proven PSVD, according to VALDIG criteria, and 100 control patients with histologically proven cirrhosis, matched on ascites. All patients and controls had at least one sign of portal hypertension and CT available within 1 year of liver biopsy. Principal component analysis of CT features separated patients with PSVD from patients with cirrhosis. Patients with PSVD had lower median LSN than those with cirrhosis (2.4 vs. 3.1, p < 0.001). Multivariate analysis identified LSN < 2.5 and normal-sized or enlarged segment IV as independently associated with PSVD. Combination of these two features had a specificity of 90% for PSVD and a diagnostic accuracy of 84%. Even better results were obtained in an independent multicenter validation cohort including 53 patients with PSVD and 106 control patients with cirrhosis (specificity 94%, diagnostic accuracy 87%). CONCLUSIONS: This study that included a total of 103 patients with PSVD and 206 patients with cirrhosis demonstrates that LSN < 2.5 combined with normal-sized or enlarged segment IV strongly suggests PSVD in patients with signs of portal hypertension.

CT-based liver surface nodularity for the detection of clinically significant portal hypertension: defining measurement quality criteria.

PURPOSE: To establish measurement quality criteria for the noninvasive assessment of clinically significant portal hypertension (CSPH) in patients with cirrhosis using CT-based liver surface nodularity (LSN) measurements. METHODS: Seventy-four consecutive patients with cirrhosis (mean 62 ± 13 years), including 30 with CSPH (41%), underwent CT and hepatic venous pressure gradient measurements. Three independent readers performed 15 LSN measurements/patient using dedicated software. LSN was computed based on the median and means of one to 15 measurements. Accuracy for diagnosing CSPH was assessed using receiver operating characteristic (ROC) curve analysis. Variability was assessed by the intra-class correlation coefficient (ICC) and the Bland-Altman plot (BA). Quality criteria were identified to maximize the accuracy of LSN and minimize variability. RESULTS: The area under the (AU) ROCs of mean and median LSN measurements based on one to 15 measurements ranged from 0.79 ± 0.05 to 0.91 ± 0.04 and 0.86 ± 0.04 to 0.91 ± 0.03, respectively, with no difference on pair-wise comparisons (all p > 0.05). AUROCs of LSN increased from one to eight and leveled off between eight and 15 measurements. Inter- and intra-reader variability decreased from one to 15 measurements, with only slight improvement after more than eight measurements. Intra- and inter-observer agreements were excellent with eight measurements (ICC = 0.90 [95%CI 0.84-0.94], and ICC = 0.93 [95%CI 0.89-0.95], respectively), and variability for intra-observer and inter-observer agreement was low (BA bias 4.2% (95% limits of agreement [LoA] [- 15.3; + 23.7%]) and 4.8% LoA [ - 17.5; + 27.1%], respectively). CONCLUSIONS: CT-based LSN measurement is highly reproducible and accurate. We suggest using at least 8 valid measurements to determine the mean LSN value for the detection of CSPH.