Percutaneous mechanical thrombectomy in acute and subacute lower-extremity ischemia: impact of adjunctive, solely nonthrombolytic endovascular procedures.

PURPOSE: We aimed to evaluate the role of adjunctive, solely nonthrombolytic endovascular therapy in treatment of acute lower-extremity ischemia by rotational percutaneous mechanical thrombectomy. METHODS: A retrospective, single-center evaluation of 165 patients (167 limbs) that underwent rotational percutaneous mechanical thrombectomy between 2009 and 2016 was performed. RESULTS: Rotational percutaneous mechanical thrombectomy was used as a single therapy in 9.0% (15 limbs), followed by percutaneous aspiration thrombectomy in 6.0% (10 limbs), percutaneous transluminal angioplasty in 19.8% (33 limbs) and stenting in 25.7% (43 limbs). Rotational percutaneous mechanical thrombectomy was followed by any combination of these three interventions in 39.5%. Clinical and technical success was documented in 92.2%, complications in 10.3% (n=17). No significant difference in clinical and technical success was observed using rotational percutaneous mechanical thrombectomy alone or with additional endovascular therapy. On a long-term basis, the re-ischemia-free survival was nearly twice as high as in previous studies that reported more cases treated by rotational percutaneous mechanical thrombectomy alone. CONCLUSION: To assure a long-lasting primary patency after percutaneous mechanical thrombectomy, concomitant treatment of underlying lesions with adjunctive, nonthrombolytic endovascular methods should be considered.

Percutaneous endobiliary forceps biopsy of biliary strictures for histopathologic examination.

PURPOSE: We aimed to investigate the feasibility, accuracy and safety of percutaneous endobiliary cholangio-forceps biopsy of biliary strictures in our institution. METHODS: A total of 13 percutaneous transhepatic endobiliary biopsies (7 men and 6 women, mean age 66.85±16.76 years) were performed between January 2015 and March 2019 using a transluminal forceps biopsy device. Technical success, rate of complications, number of biopsy specimens, procedure and fluoroscopy time, mean radiation exposure were evaluated; sensitivity and accuracy were calculated. RESULTS: Technical success, i.e., acquisition of at least three (median, 3.00; range, 3-5) macroscopic representative samples, could be achieved in all 13 biopsies. Access was gained via the right liver lobe in 12 of 13 cases (92.3%). All patients presented blood work indicative of cholestasis prior the intervention, with mean bilirubin 4.72±3.72 µmol/L, mean γ-glutamyl transferase 574.16 ± 360.92 IU/L, and median alkaline phosphatase 407 IU/L (165-1366 IU/L). In 12 of 13 cases (92.3%), biopsied material was sufficient for the pathologist to make a histopathologic diagnosis. Analysis revealed cases of malignancy in eight of 13 cases (61.5%), all of which turned out to be cases of cholangiocarcinoma. In four benign cases (30.8%), diagnosis was considered to be confirmed by further imaging or clinical follow-ups, which showed no signs of progressive disease. There was one case (7.7%) of a false-negative result with proof of malignancy in subsequent surgical tissue extraction. A calculation of diagnostic performance yielded a sensitivity rate of 88.9% and an accuracy rate of 92.3%. There was one case of minor and one case of major complication in our study collective, leading to an overall complication rate of 15.4%. CONCLUSION: Percutaneous transhepatic biliary drainage (PTBD)-based forceps biopsy via the transhepatic drainage tract in patients with biliary obstruction of unknown origin is a technically feasible and safe technique with good diagnostic value rates. The procedure should be considered in patients not suitable for endoscopic strategies with indication for establishment of PTBD.

Current Treatment Options in Acute Limb Ischemia.

BACKGROUND: Acute limb ischemia represents a clinical emergency with eventual limb loss and life-threatening consequences. It is characterized by a sudden decrease in limb perfusion. Acute ischemia is defined as a duration of symptoms for less than 14 days. Aging of the population increases the prevalence of acute limb ischemia. The two principal etiologies are arterial embolism and in situ thrombosis of an atherosclerotic artery. Immediate diagnosis, accurate assessment and urgent intervention when needed are crucial to save the limb and to prevent a major amputation. Delay in diagnosis and therapy may lead to irreversible ischemic damage. METHOD: To assess the current treatment options in acute limb ischemia, this review is based on a selective literature search in PubMed representing the current state of research. RESULTS AND CONCLUSION: Patients with acute limb ischemia should receive immediate anticoagulation. Treatment depends on the classification based on the degree of ischemia and limb viability. Especially acute (< 14 days symptom duration) Rutherford Categories IIa and IIb with marginally and immediately threatened limbs require definitive therapeutic intervention and are salvageable, if promptly revascularized. The current literature suggests that open surgical revascularization is more time effective then catheter-directed thrombolysis. However, with the advent of thrombolytic delivery systems and mechanical thrombectomy devices, treatment time can be minimized and successful utilization in patients with Category IIb (Rutherford Classification for Acute Limb Ischemia) has been reported with promising limb-salvage and survival rates. Large randomized studies are still missing, and guidelines suggest choosing the method of revascularization depending on anatomic location, etiology, and local practice patterns, with the time to restore the blood flow being an important factor to consider. KEY POINTS: · Acute limb ischemia is an interdisciplinary emergency. It can lead to limb loss with life-threatening consequences.. · Immediate diagnosis and treatment are crucial to prevent irreversible damage.. · An endovascular approach should be considered in acute limb ischemia Category IIa and IIb of the Rutherford Classification for Acute Limb Ischemia (< 14 days), on a case-based decision and local capabilities. Especially elderly, multimorbid patients with high perioperative risk (may probably) benefit from these minimally invasive procedures.. CITATION FORMAT: · Fluck F, Augustin A, Bley T et al. Current Treatment Options in Acute Limb Ischemia. Fortschr Röntgenstr 2020; 192: 319 - 326.

Endovascular Therapy of Gastrointestinal Bleeding. / Die endovaskuläre Therapie gastrointestinaler Blutungen.

BACKGROUND: Gastrointestinal (GI) bleeding is a frequently occurring disease pattern, with a broad variety of possible causes. The most acute bleeding responds well to conservative, medicinal and endoscopic therapies. Nevertheless, a certain amount of endoscopically not-identifiable or controllable non-varicose GI-bleeding requires alternative, sometimes surgical, therapy concepts. The updated S2k guideline "gastrointestinal bleeding" makes the case for interventional radiology with its minimally invasive endovascular techniques. METHODS: This review article discusses the role of interventional radiology in the therapy of non-variceal upper and lower gastrointestinal bleeding according to the current literature and updated guideline. In this regard it covers the indications, techniques, results and complications of endovascular therapy. RESULTS AND CONCLUSION: Considering interdisciplinary therapy options, the guideline-oriented endovascular treatment of gastrointestinal bleeding, using embolization and implantion of covered stents, shows to be a reasonable option with good technical and clinical success rates and a low rate of complications. In this context solid knowledge of vascular anatomy is essential to acquire adequate hemostasis. KEY POINTS: · Interventional radiology contributes significantly to the diagnosis and treatment of non-variceal bleedings of various etiologies.. · In this context the S2K guideline "gastrointestinal bleeding" is the foundation for the decision-making process for hemostatic therapy.. · Embolization is the first choice when it comes to endovascular treatment of gastrointestinal bleeding.. · Adequate periinterventional management increases the success rate of endovascular therapy.. CITATION FORMAT: · Augustin AM, Fluck F, Bley T et al. Endovascular therapy of gastroinestinal bleeding. Fortschr Röntgenstr 2019; 191: 1073 - 1082.

[Aortic Intramural Hematoma: a Challenging Diagnosis]. / Intramurales Hämatom der Aorta: eine diagnostische Herausforderung.

HISTORY AND CLINICAL FINDINGS: A 75-year-old woman was admitted to our institution for acute abdominal pain. She had a history of atrial fibrillation, pacemaker implantation and diastolic heart failure. At time of admission, she was under oral anticoagulation therapy with apixaban. EXAMINATIONS AND DIAGNOSIS: The X-ray of the chest showed a reduction in transparency surrounding the calcification of the aortic arch. CT angiography revealed evidence of an intramural hematoma of the aorta ranging from the left subclavian artery to the inferior mesenteric artery with presence of localized ulcer-like projections. THERAPY AND COURSE: Since the IMH was limited to the descending aorta, we first chose a conservative strategy with tight blood pressure control. Unfortunately, the patients' clinical symptoms did not improve. Her pain persisted despite medical treatment. After joint discussion with surgery and radiology, an endovascular aortic repair was successfully performed. The patient recovered well and could be discharged from the hospital. CONCLUSIONS: Acute aortic syndrome describes a life-threatening condition, including acute aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Rapid and correct diagnosis is imperative for adequate management. Once the definitive diagnosis of an aortic syndrome is made, prompt and appropriate therapeutic interventions should be undertaken. Urgent surgery for acute aortic syndromes involving the ascending aorta (Stanford Type A) and medical therapy alone for uncomplicated cases involving the descending aorta (Stanford Type B) are typically recommended. In complicated Stanford Type B situations, endovascular aortic repair (TEVAR) should be considered.