Fluoroscopic-guided approaches to radiofrequency vein ablation.

PURPOSE: Ultrasound-guided antegrade access during endovenous lower-extremity vein ablation may be problematic. This study describes fluoroscopic-guided retrograde access to the target veins in cases in which antegrade access proved unfeasible. MATERIALS AND METHODS: The retrograde technique was used to treat a total of 38 legs in 33 patients in whom antegrade access failed. This approach was selected because of small caliber or spasm of the proximal (ie, lower) great saphenous vein (GSV; n = 22), proximal (ie, lower) GSV spasm during access (n = 2), previous incomplete vein ablation (n = 7), skin disease over the proximal GSV (n = 6), and tortuous proximal GSV anatomy (n = 1). Thirty-two legs were treated with an ipsilateral retrograde approach and six were treated with a contralateral retrograde approach. Radiofrequency ablation with or without sclerotherapy was then performed. RESULTS: The technical success rate for retrograde access and subsequent ablation was 100%. No procedural complications occurred. At 1 month, five patients with active ulcers exhibited ulcer healing (100%). CONCLUSIONS: The fluoroscopic retrograde approach can be used to treat GSV reflux when traditional antegrade access is not feasible.

Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage.

PURPOSE: To report initial experience using N-butyl cyanoacrylate (n-BCA) to control lower gastrointestinal hemorrhage (LGIH). MATERIALS AND METHODS: From May 2005 to March 2009, 14 patients with LGIH underwent mesenteric angiography and transcatheter arterial embolization using n-BCA. Candidacy was primarily based on the patient's hemodynamic stability and the risk for future LGIH, determined by the presence of at least one of the following risk factors: more than one arterial feeder supplying the bleeding vessel, underlying coagulopathy, or need to resume anticoagulation after embolization. Outcome measures included technical success (immediate postembolic hemostasis confirmed with completion angiography showing no further extravasation of contrast medium), clinical success (postembolic hemostasis in the absence of complications 30 days after the procedure), and clinical failure (recurrence of LGIH necessitating repeat embolization or surgical treatment). RESULTS: Fourteen patients with active LGIH were treated with n-BCA, with 100% technical success. Two patients had rebleeds resulting in bowel resection. One patient experienced a minor rebleed that spontaneously resolved. One patient died secondary to multiorgan failure in the setting of multiple medical problems. The remaining 10 patients had complete clinical success, experiencing no signs of rebleeding or infarction. CONCLUSIONS: The results suggest that n-BCA can be a useful alternative embolic agent for the treatment of hemodynamically unstable patients with LGIH when standard microcoiling techniques fail or are not feasible and in patients with coagulopathy.

Embolization of an aortic arch pseudoaneurysm with coils and N-butyl-cyanoacrylate.

Endovascular treatment strategies are evolving as viable alternatives for the treatment of aortic pseudoaneurysms. The present report describes an enlarging aortic arch pseudoaneurysm that was successfully treated with a combination of embolization with detachable coils and N-butyl-cyanoacrylate.

Imaging of blunt cerebrovascular injuries.

Arterial dissection, pseudoaneurysm, arteriovenous fistula, arterial laceration and occlusion are uncommon complications of blunt trauma. Angiography has been considered the primary method of evaluation to assess for vascular injuries but, due to the low frequency of these lesions, its screening role has been challenged. Non-invasive imaging, particularly CT angiography (CTA), offers definitive advantages and has emerged as a promising diagnostic screening method. Angiography is shifting to a rather therapeutic role and the endovascular management of these lesions is briefly discussed.

Transvenous sonographically guided percutaneous access for treatment of an indirect carotid cavernous fistula.

When standard transarterial or transvenous interventional techniques failed to provide access to treat an indirect carotid cavernous fistula, we used sonographically guided direct percutaneous access through the facial vein to successfully embolize a lesion.

Combined transvenous and transarterial embolization of a tentorial-incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus. Case report.

Dural arteriovenous malformations (AVMs) involving the tentoria-incisura are associated with an aggressive clinical course characterized by subarachnoid and intracranial hemorrhage (ICH). In these lesions, venous outflow obstruction precipitates leptomeningeal venous drainage, resulting in the arterialization of pial veins and the formation of venous aneurysms, both of which are prone to hemorrhage. Stenotic lesions of the dural sinuses also contribute to the development of retrograde leptomeningeal drainage, which is responsible for the aggressive clinical course of the dural AVM. Endovascular approaches are successful in the treatment of these lesions and of any potential venous outflow obstruction caused by stenosis of a dural sinus. The authors report on a patient with a tentorial-incisural dural AVM and an accompanying stenotic venous sinus. A combined transvenous and transarterial embolization procedure was performed, resulting in complete obliteration of the dural AVM, followed by primary stent placement across a stenotic segment of the straight sinus and normalization of venous outflow. The authors conclude that dural AVMs can be treated safely by using a combined transarterial and transvenous approach and that an extensive search for venous outflow obstruction often reveals stenosis of a draining sinus. Consideration should be given to primary stent placement in the stenotic sinus to protect against ICH.

Direct percutaneous puncture of a cervical internal carotid artery aneurysm for coil placement after previous incomplete stent-assisted endovascular treatment.

Direct percutaneous puncture for coil placement has been described for visceral aneurysms, but the procedure has not been previously reported for aneurysms of the head and neck. We report a case in which stent-assisted endovascular treatment was successfully combined with direct puncture for additional coil placement to treat a symptomatic giant aneurysm of the cervical internal carotid artery.