Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: initial results.

PURPOSE: To report an initial experience of superficial femoral artery (SFA) recanalization performed with a dual femoral-popliteal approach in the supine patient. METHODS: From May 2008 to April 2010, 26 patients (16 men; mean age 68 ± 6.3 years) with intermittent claudication and chronic SFA occlusion (mean length 97.4 ± 3.8 mm, range 35-220) underwent percutaneous recanalization from a retrograde popliteal access. The common femoral artery was punctured with an antegrade (n = 9) or retrograde contralateral (n = 17) approach, then with the patient still supine and the knee gently flexed and medially rotated, the popliteal artery was punctured using an 18-G needle under ultrasound (10, 38.4%) or fluoroscopic (16, 61.5%) guidance with a roadmap technique. Once the SFA was recanalized, the procedure was completed with angioplasty and stenting from the femoral approach. At the end of the procedure, hemostasis at the popliteal access was obtained with manual compression (5-10 minutes). RESULTS: Technical success (puncture of the popliteal artery and SFA recanalization) was achieved in all cases. In the majority of patients (24, 91.6%), endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. Two small hematomas were found in the popliteal region, but no pseudoaneurysm or arteriovenous fistulas were seen on duplex examinations during a mean 12.5-month follow-up (range 6-28). Twenty (76.9%) SFAs were patent; in-stent restenosis occurred in the remaining 6 (23%). Primary patency was 80.7% at 6 months and 76.9% at 1 year. No stent fracture was observed. CONCLUSION: The retrograde popliteal approach with the patient in the supine position can be considered a "first choice" method for safe and effective SFA recanalization, especially in occlusions located at the distal and mid portion SFA.

Transjugular intrahepatic portosystemic shunt with expanded-polytetrafuoroethylene-covered stents in non-cirrhotic patients with portal cavernoma.

AIMS: To evaluate the feasibility and efficacy of Transjugular intrahepatic portosystemic shunt (TIPS) in non-cirrhotic patients with symptomatic portal hypertension secondary to portal cavernoma. METHODS: Our cohort includes 13 consecutive patients. Eleven were considered for Transjugular intrahepatic portosystemic shunt placement for complications not manageable by medical/endoscopic treatment and two because of the need of oral anticoagulation in presence of high-risk varices. Expanded-polytetrafluoroethylene-covered stents were used in all. RESULTS: One of the 13 patients was excluded because of a thrombosis of the superior cava and jugular veins. In 10 patients, Transjugular intrahepatic portosystemic shunt was successfully implanted [83.3%; 95% confidence interval: 52-98%]. One patient had an early shunt dysfunction with recurrence of variceal bleeding which required an emergency surgical shunt. Late shunt dysfunction occurred in two patients, successfully treated with angioplasty and re-stenting. Two patients experienced an episode of encephalopathy. CONCLUSIONS: Transjugular intrahepatic portosystemic shunt is feasible in most of the patients with portal cavernoma and should be considered in those with severe complications uncontrolled by conventional therapy. The use of Transjugular intrahepatic portosystemic shunt to achieve a lifelong anticoagulation therapy in selected patients with high-risk varices may be another possible indication. These patients should be referred to selected Units with large experience in Transjugular intrahepatic portosystemic shunt placement.

Usefulness of coronary flow reserve measured by echocardiography to improve the identification of significant left anterior descending coronary artery stenosis assessed by multidetector computed tomography.

Multidetector computed tomography (MDCT) detects coronary artery disease. However, an overestimation of coronary artery stenosis and artifacts can prevent accurate identification of significant coronary narrowing. The combination of MDCT with coronary flow reserve (CFR), the hyperemic/baseline peak flow velocity ratio, measured by transthoracic Doppler echocardiography might be helpful. We studied 144 consecutive patients with CFR and quantitative coronary angiography, obtained using both MDCT and invasive coronary angiography (reference method). It was hypothesized that the CFR might provide an incremental value to MDCT in detecting significant (> or =70%) left anterior descending (LAD) coronary artery stenosis. A CFR cutoff of <2 was used to discriminate significant stenosis. CFR was feasible in 141 (98%) of 144 patients, and MDCT was feasible in 131 (91%) of 144 patients (p <0.02). In a univariate model, the prediction of significant LAD stenosis was slightly, but significantly (p <0.0001), better with CFR (sensitivity 90%, specificity 96%, positive predictive value 84%, negative predictive value 97%, and diagnostic accuracy 94%, chi-square = 97.5) than with MDCT (sensitivity 80%, specificity 93%, positive predictive value 71%, negative predictive value 95%, diagnostic accuracy 90%, chi-square = 63.2). When the findings from transthoracic Doppler echocardiography and MDCT agreed, the diagnostic accuracy increased (96%; chi-square = 86.1, p <0.0001). In a multivariate prediction of significant LAD stenosis using a logistic neural network, CFR overshadowed MDCT, and the area under the receiver operating curve was 0.99. Of the 13 patients missed by MDCT, the diagnostic accuracy of transthoracic Doppler echocardiography to predict significant LAD stenosis was 100%. Thus, CFR could improve the diagnostic accuracy of MDCT to detect significant LAD stenosis.

Management strategies for thoracic stent-graft repair of distal aortic arch lesions: is intentional subclavian artery occlusion a safe procedure?

The aim of this retrospective analysis was to assess the clinical consequences after intentional left subclavian artery (LSA) occlusion. Thirty-seven patients, 27 type B dissection and 10 thoracic aneurysm, with short proximal neck (less than 2 cm) underwent endovascular treatment with intentional exclusion of LSA origin. No immediate complications occurred. Mean arterial pressure gradient, between right and left arms, ranged from 15 to 45 mmHg. After a mean follow-up of 43.70 + or - 24.01 months, mild left arm symptoms secondary to flow reduction occurred in eight cases (21.6%) but only one required LSA transposition, after 8 months, for visual impairment. Type II endoleaks from excluded LSA occurred in 10 cases (27.0%): in seven patients, leaks were treated with coils and/or glue embolization; in one case, leak sealed spontaneously; one patient died before leak embolization could occur; one patient refused any further treatment. Intentional exclusion of the LSA may be justified when a longer proximal landing zone in the aortic arch is required.

Management of malignant biliary obstruction: technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience.

To evaluate the efficacy and safety of an expanded polytetrafluoroethylene-fluorinated ethylene-propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction. Eighty consecutive patients with malignant common bile duct strictures were treated by placement of 83 covered metallic stents. The stent-graft consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Clinical evaluation, assessment of serum bilirubin and liver enzyme levels were analyzed before biliary drainage, before stent-graft placement and during the follow-up period at 1, 3, 6, 9 and 12 months. Technical success was obtained in all cases. After a mean follow-up of 6.9+/-4.63 months, the 30-day mortality rate was 14.2%. Survival rates were 40% and 20.2% at 6 and 12 months, respectively. Stent-graft patency rates were 95.5%, 92.6% and 85.7% at 3, 6 and 12 months, respectively. Complications occurred in five patients (6.4%); among these, acute cholecystitis was observed in three patients (3.8%). A stent-graft occlusion rate of 9% was observed. The percentage of patients undergoing lifetime palliation (91%) and the midterm patency rate suggest that placement of this ePTFE/FEP-covered stent-graft is safe and highly effective in achieving biliary drainage in patients with malignant strictures of the common bile duct.

Hepatocellular carcinoma: role of unenhanced and delayed phase multi-detector row helical CT in patients with cirrhosis.

PURPOSE: To determine, by using multi-detector row helical computed tomography (CT), the added value of obtaining unenhanced and delayed phase scans in addition to biphasic (hepatic arterial and portal venous phases) scans in the detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. MATERIALS AND METHODS: Local ethical committee approval and patient consent were obtained. One hundred ninety-five patients (129 men, 66 women; mean age, 61 years; age range, 39-78 years) with 250 HCCs underwent multi-detector row helical CT of the liver. A quadruple-phase protocol that included unenhanced, hepatic arterial, portal venous, and delayed phases was performed. Analysis of images from hepatic arterial and portal venous phases combined, hepatic arterial and portal venous phases with the unenhanced phase, hepatic arterial and portal venous phases with the delayed phase, and all phases combined was performed separately by three independent radiologists. Relative sensitivity, positive predictive value, and area under the receiver operating characteristic curve (A(z)) were calculated for each reading session. RESULTS: Mean sensitivity and positive predictive values, respectively, for HCC detection were 88.8% (666 of 750 readings) and 97.8% (666 of 681 readings) for the combined hepatic arterial and portal venous phases, 89.2% (669 of 750 readings) and 97.8% (669 of 684 readings) for hepatic arterial and portal venous phases with the unenhanced phase, 92.8% (696 of 750 readings) and 97.3% (696 of 715 readings) for hepatic arterial and portal venous phases with the delayed phase, and 92.8% (696 of 750 readings) and 97.3% (696 of 715 readings) for all four phases combined. The reading sessions in which delayed phase images were available for interpretation showed significantly (P < .05) superior sensitivity and A(z) values. CONCLUSION: Unenhanced phase images are not effective for HCC detection. Because of the significant increase in HCC detection, a delayed phase can be a useful adjunct to biphasic CT in patients at risk for developing HCC.

Stent repair of bilateral post-traumatic dissections of the internal carotid artery.

PURPOSE: To report endovascular repair of bilateral internal carotid arteries (ICAs) in a youth following an accident. CASE REPORT: A 17-year-old boy presented with dissection of both ICAs after a motorcycle accident. The lesions started 2 cm above the bifurcation and continued upward to the siphon, with normal flow into the circle of Willis. Surgical repair was excluded due to the critical clinical condition of the patient and owing to the anatomical extent of the dissection. Carotid Wallstent endoprostheses were deployed bilaterally to repair the dissected segments of the ICAs. After 13 months, the patient is in good health, with complete patency of both arteries. CONCLUSIONS: The good result we experienced in this case indicates that stents may be a safe and effective treatment for traumatic bilateral carotid dissections. However, the long-term durability of these devices in a young patient remains to be determined.

Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience.

PURPOSE: To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients). RESULTS: A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation. CONCLUSION: The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.

Focal liver lesions in the cirrhotic patient: multislice spiral CT evaluation.

Imaging of the cirrhotic patient is a very difficult task due to the several morphologic and structural alterations that occur in the hepatic parenchyma. The presence of areas of fibrosis and regenerative nodules, often associated with haemodynamic alterations due to the portal hypertension, can make the identification of hepatocellular carcinoma very difficult or, in many cases, simulate the presence of tumour. Despite the use of state-of-the-art equipment and optimised study protocols, computed tomography (CT) has poor sensitivity for the detection of hepatocellular carcinoma. The present article illustrates the spiral CT findings that most often can be found in the evaluation of cirrhotic patients. In particular, the authors illustrate the CT patterns of regenerative nodules, dysplastic nodules, hepatocellular carcinomas and of all lesions that may mimic hepatocellular carcinoma.

Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results.

OBJECTIVES: Polytetrafluoroethylene (PTFE)-covered stent grafts appear to have the potential to improve TIPS patency, but data available are few and controversial. The aim of this prospective nonrandomized trial was to assess TIPS safety and 1-yr patency with a new commercially available PTFE-covered stent graft in comparison with a group of historical controls treated with conventional stents. METHODS: Between July 1992 and December 1999, 87 consecutive cirrhotics underwent TIPS with conventional stents, while from January 2000 to November 2001, 32 consecutive cirrhotics were treated with PTFE-covered stent grafts. All patients were followed by the same medical team according to a prospective protocol for a diagnostic work-up and a surveillance strategy. RESULTS: The two groups were comparable for age, sex, etiology, and severity of cirrhosis. The 1-yr probability of remaining free of shunt dysfunction tended to be higher in the covered stent group: 76.3% (95% CI = 58.7-93.9%) versus 57.5% (95% CI = 46.6-68.4%); log rank test: p = 0.055. However, stenoses inside the stent were significantly higher in patients with bare stents (88% vs 17%), while stenoses at the hepatic or portal vein were more frequent in PTFE-covered stent-graft group (50% vs 9% and 33% vs 3%, respectively), (chi2 = 15.42; df = 2.0; p = 0.0004). Stenoses inside the covered portion of the stent did not occur. One-year cumulative rebleeding, encephalopathy, and survival were similar. CONCLUSIONS: PTFE-covered stents are able to solve pseudointimal hyperplasia within the stent tract, but have a high incidence of hepatic or portal vein stenosis. Improvements in stent design and insertion techniques are necessary to fully achieve the potential benefit of this new device.

Type A aortic dissection developing during endovascular repair of an acute type B dissection.

PURPOSE: To describe an extension of type B dissection into type A during endoluminal treatment of acute type B dissection. CASE REPORT: A 57-year-old man with acute type B dissection underwent endovascular repair using 2 Excluder stent-grafts. Before releasing the second stent-graft, the patient complained of mild central chest pain, headache, and visual flashes, but no hemodynamic changes were noticed. An angiogram, performed soon afterwards, showed a retrograde extension of the dissection through the aortic arch involving both the left carotid artery and the ascending aorta. The procedure was completed, and the patient was transported to the operating room where the proximal ascending aorta was replaced. Spiral computed tomographic angiography performed 2 weeks after the procedure showed complete exclusion of the primary entry tear. At 6-month follow-up, the patient was asymptomatic; the left carotid artery dissection had disappeared. CONCLUSIONS: Endovascular repair of acute type B dissection is technically feasible, but longer experience will help prevent technical complications.

Intrahepatic aneurysmal portohepatic venous shunt: embolization with a tissue adhesive solution.

PURPOSE: To report the endovascular treatment of an intrahepatic portosystemic venous shunt (IPSVS) using a tissue adhesive solution. CASE REPORT: A 40-year-old woman without diagnosed liver disease presented for evaluation of vague abdominal pains. A latent portosystemic encephalopathy was diagnosed only during hospitalization, when ultrasound examination disclosed a venous-venous right hepatic communication. The patient was treated with selective percutaneous embolization using a tissue adhesive after blocking the lesion's venous inflow and outflow tracts. The result was excellent, and the patient recovered completely in a few days. After 5 months, the patient is asymptomatic and event-free. CONCLUSIONS: Large IPSVS may be successfully treated percutaneously using a tissue adhesive solution, avoiding a more invasive procedure.

Hepatocellular carcinoma: detection with triple-phase multi-detector row helical CT in patients with chronic hepatitis.

PURPOSE: To evaluate whether the use of two arterial phase image acquisition series, when combined with portal venous phase imaging at multi-detector row helical computed tomography (CT), would be superior enough to use of a single arterial phase image acquisition series to warrant the increased radiation dose. MATERIALS AND METHODS: Multi-detector row CT was performed in 77 patients with 140 foci of hepatocellular carcinoma (HCC). A triple-phase protocol that included an early arterial phase, a late arterial phase, and a portal venous phase was performed. Images were analyzed separately by three radiologists to document the presence and number of HCC nodules. Separate reading sessions were performed for images from the early arterial phase, images from the late arterial phase, images from both arterial phases combined, and images from all three phases. Sensitivity and positive predictive values were calculated for each reading session. RESULTS: The average sensitivity and positive predictive values, respectively, for the detection of HCC were 48.5% and 96.4% for early arterial phase images, 87.1% and 94.0% for late arterial phase images, 87.1% and 94.0% for images from both arterial phases, and 88.5% and 93.4% for images from all three phases. Analysis of images from both arterial phases together yielded no improvement in either sensitivity or positive predictive value compared with analysis of late arterial phase images alone. Analysis of the combination of late arterial and portal venous phase images resulted in the highest sensitivity value. CONCLUSION: The acquisition of images during two arterial contrast phases does not provide additional benefit over timed conventional biphasic CT technique.

Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial.

PURPOSE: To determine and present the initial technical and clinical results of using an expanded polytetrafluoroethylene-fluorinated ethylene propylene (ePTFE-FEP)-covered biliary endoprosthesis to treat malignant biliary obstruction. MATERIALS AND METHODS: This prospective nonrandomized study included 42 patients with malignant obstruction of the common bile duct, common hepatic duct, and hilar confluence. Unilateral (n = 38) or bilateral (n = 4) bile duct drainage was performed by using fully covered endoprostheses with anchoring fins. To avoid branch duct blockage, endoprostheses with drainage holes at the proximal end were available. Procedure- and device-related complications were recorded. Patient survival and stent patency rates were calculated with Kaplan-Meier survival analysis. Mean follow-up bilirubin and alkaline phosphatase levels were calculated, and differences in means were evaluated with a paired t test. RESULTS: Successful deployment, correct positioning, and patency of the device were achieved in all patients. Procedure-related complications occurred in two (5%) patients. Thirty-day mortality rate was 20% (eight of 41 patients), and median survival time was 146 days. Laboratory values decreased significantly after the procedure (P <.001). Recurrent obstructive jaundice occurred in six (15%) patients. Primary patency rates at 3, 6, and 12 months were 90%, 76%, and 76%, respectively. Calculation of the composite end point of death or obstruction revealed a median patency duration of 138 days. No endoprosthesis migration was observed. Branch duct obstruction was observed in four (10%) patients. Postmortem examination of one stent revealed a widely patent endoprosthesis with intact covering. CONCLUSION: Initial results of percutaneous treatment of malignant biliary obstructions with fully covered ePTFE-FEP endoprostheses suggest that they are safe and potentially clinically effective.

New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction.

PURPOSE: To determine the technical efficacy and safety of an expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction and to evaluate its clinical efficacy by estimating stent patency and patient survival rates. MATERIALS AND METHODS: Twenty-six patients with common bile duct stricture caused by malignant disease were treated by placement of 29 stents. The stent consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Multiple wire sections elevated from the external surface provide anchoring. Stents are available in two versions, with or without holes in the proximal stent lining. Holes should provide drainage of the cystic duct or biliary side branches when covered by the proximal stent end. Clinical evaluation and assessment of serum bilirubin and liver enzyme levels were done before stent placement and at 1, 3, 6, and 9 months. Average follow-up duration was 5.4 months (range, 5 d to 12.5 mo). RESULTS: Placement was successful in all cases. The 30-day mortality rate was 11.5%. The survival rates were 40% and 15% at 6 and 12 months, respectively. Eighty-four percent of patients had adequate palliative drainage during their lifetime. The stent patency rates were 91%, 77%, and 77% at 3, 6, and 12 months, respectively. Four patients (16%) presented with stent occlusion and needed repeat intervention. No migration occurred. Complications other than stent occlusion occurred in five patients (19%); among these, acute cholecystitis was observed in three patients (12%). CONCLUSION: Preliminary results suggest that placement of this ePTFE/FEP-covered stent is feasible and effective in achieving biliary drainage. The percentage of patients undergoing lifetime palliation and the midterm patency are promising. However, the incidence of acute cholecystitis is high. Treatment of a larger group of patients is mandatory to validate these long-term results.

MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt.

BACKGROUND/AIMS: Patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) are at risk of early death due to end-stage liver failure. The aim of this study was to compare model of end-stage liver disease (MELD) and Child-Pugh scores as predictors of survival after TIPS. METHODS: We studied 140 cirrhotic patients treated with elective TIPS. Concordance (c)-statistic was used to assess the ability of MELD or Child-Pugh scores to predict 3-month survival. The prediction of overall survivals was estimated by comparing actuarial curves of subgroups of patients stratified according to either Child-Pugh scores or MELD risk scores. RESULTS: During a median follow-up of 23.7 months, 55 patients died, 14 underwent liver transplantation and seven were lost to follow-up. For 3-month survival, the discrimination power of MELD score was superior to Child-Pugh score (0.84 vs. 0.70, z=2.07; P=0.038). Unlike Pugh score, MELD score identified two subgroups of Child C patients with different overall survivals (P=0.027). The comparison between observed and predicted survivals showed that MELD score overrates death risk. CONCLUSIONS: MELD score is superior to Child-Pugh score as predictor of short-term outcome after TIPS. Its accuracy, however, decreases for long-term predictions.