Balloon-expandable common iliac artery occluder device for endovascular aneurysm repair.

This study was performed to evaluate the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair of aortoiliac aneurysms. Eighty-four patients (79 men, 5 women; age range 60-95 yr; mean age, 76 yr) with aortoiliac aneurysms underwent endovascular stent-graft repair. The repair consisted of a stent-graft extending from the abdominal aorta to the iliac or common femoral artery, a cross-femoral bypass graft, and an endovascular arterial occluder device within the contralateral common iliac artery. The occluder device consisted of a 5-cm segment of 6-mm diameter polytetrafluoroethylene (PTFE) graft with a purse-string suture occluding the leading end and a Palmaz stent sutured to the trailing end. The occluder device was delivered through a 17F catheter via an arteriotomy. Eighty-three of the 84 patients received aortic endografts. In one case, infrarenal aortic rupture occurred during deployment of the aortic stent requiring conversion to an open surgical repair. Initial technical success for occluder device insertion was achieved in 78 of the remaining 83 patients. Failure to advance the occluder device delivery sheath through a diseased iliac artery occurred in one patient. Common iliac artery rupture occurred during balloon expansion and occluder device deployment in two patients. Two patients required additional coil embolization of the common iliac artery adjacent to the occluder device at the time of stent-graft insertion to correct incomplete iliac occlusion. Delayed occluder device-related complications included one patient with a postoperative iliac endoleak who required percutaneous coil embolization and one patient with a postoperative iliac endoleak in whom a contained aortic aneurysm rupture developed that was treated by surgical ligation of the common iliac artery. Use of the Palmaz stent-based iliac artery occluder device is an effective technique to induce common iliac artery thrombosis to facilitate endoluminal stent-graft aneurysm repair.

Hepatic arterial complications in liver transplant recipients treated with pretransplantation chemoembolization for hepatocellular carcinoma.

PURPOSE: To compare the prevalence of hepatic arterial complications in patients who underwent hepatic arterial chemoembolization for hepatocellular carcinomas before orthotopic liver transplantation with the prevalence of hepatic arterial complications in the total population of liver transplant recipients. MATERIALS AND METHODS: Forty-seven patients underwent selective hepatic arterial chemoinfusion with mitomycin C, doxorubicin hydrochloride, and cisplatin combined with embolization. The prevalence rates for hepatic arterial complications, including pseudoaneurysm, stenosis, anastomotic disruption, and thrombosis, were tabulated and compared with results in 1,154 patients who underwent orthotopic liver transplantation but not chemoembolization. RESULTS: Of the 47 patients who had undergone preoperative hepatic arterial chemotherapy, 13% developed hepatic arterial complications within a mean of 7 days after transplantation; an 8% prevalence of hepatic arterial thrombosis was observed. Of the 1,154 patients who underwent orthotopic liver transplantation but not chemotherapy, 6% developed hepatic arterial complications; a 5% prevalence of hepatic arterial thrombosis was observed. There was no statistically significant difference in the prevalence rates for thrombosis and complications between the patients who underwent chemoembolization before orthotopic liver transplantation and those who did not. The mean interval between chemotherapy and orthotopic liver transplantation was 111 days (range, 3-428 days). CONCLUSION: Patients who undergo hepatic arterial chemotherapy are not at an increased risk of developing hepatic arterial thrombosis or other hepatic arterial complications after orthotopic liver transplantation.

Impact of transrenal aortic endograft placement on endovascular graft repair of abdominal aortic aneurysms.

PURPOSE: Successful endovascular repair of an abdominal aortic aneurysm (AAA) requires the creation of a hemostatic seal between the endograft and the underlying aortic wall. A short infrarenal aortic neck may be responsible for incomplete aneurysm exclusion and procedural failure. Sixteen patients who had an endograft positioned completely below the lowest renal artery and 37 patients in whom a porous portion of an endograft attachment system was deliberately placed across the renal arteries were studied to identify if endograft positioning could impact on the occurrence of incomplete aneurysm exclusion. METHODS: Fifty-three patients underwent aortic grafting constructed from a Palmaz balloon expandable stent and an expandable polytetrafluoroethylene (ePTFE) graft implanted in an aorto-ilio-femoral, femoral-femoral configuration. Arteriography, duplex ultrasonography and spiral CT scans were performed in each patient before and after endografting to evaluate for technical success, the presence of endoleaks, and renal artery perfusion. RESULTS: There was no statistically significant difference in patient demography, AAA size, or aortic neck length or diameter between patients who had their endografts placed below or across the renal arteries. However, significantly more proximal aortic endoleaks occurred in those patients with infrarenal endografts (P < or = .05). Median serum creatinine level before and after endografting was not significantly different between the 2 patient subgroups, with the exception of 2 patients who had inadvertent coverage of a single renal orifice by the endograft. Median blood pressure and the requirement for antihypertensive therapy remained the same after transrenal aortic stent grafting. Significant renal artery compromise did not occur after appropriately positioned transrenal stents as shown by means of angiography, CT scanning, and duplex ultrasound scan. Mean follow-up time was 10.3 months (range, 3 to 18 months). Patients who had significant renal artery stenosis (> or =50%) before aortic endografting did not show progression of renal artery stenosis after trans-renal endografting. Two patients with transrenal aortic stent grafts had inadvertent coverage of 1 renal artery by the endograft because of device malpositioning, which resulted in nondialysis dependent renal insufficiency. In addition, evidence of segmental renal artery infarction (<20% of the kidney), which did not result in an apparent change in renal function, was shown by means of follow-up CT scans in 2 patients with transrenal endografts. CONCLUSION: Transrenal aortic endograft fixation using a balloon expandable device in patients with AAAs can result in a significant reduction in the risk of proximal endoleaks. Absolute attention to precise device positioning, coupled with the use of detailed imaging techniques, should reduce the risk of inadvertent renal artery occlusion from malpositioning. Long-term follow-up is essential to determine if there will be late sequelae of transrenal fixation of endografts, which could adversely effect renal perfusion.

Aortoiliac aneurysms: endoluminal repair--clinical evidence for a fully supported stent-graft.

PURPOSE: To evaluate aortoiliac aneurysms repaired with endovascular stent-grafts complicated by hemodynamically significant graft stenosis. MATERIALS AND METHODS: Fifty-four patients (52 men, two women; age range, 41-90 years; mean age, 75 years) with aneurysms of the infrarenal aorta (n = 36) or iliac artery (n = 18) underwent repair by means of placement of an endovascular stent-graft. Technical success was evaluated angiographically during and after placement. At follow-up (range, 12-44 months), all patients underwent sequential duplex ultrasonography, helical computed tomography, and physical examination. RESULTS: Stent-grafts were placed successfully in all cases. Stenosis at the internal iliac arterial origin was identified at angiography in 17 patients (31%). Supplemental intragraft stents were placed in 11 patients, and stent-graft angioplasty alone was performed in one patient. Intragraft stents were placed percutaneously in five patients when stenosis was discovered during follow-up. CONCLUSION: Supplemental intragraft stents were required in 31% of aortoiliac endovascular stent-grafts to correct stent-graft stenosis and preserve long-term function. Placement of a fully supported stent-graft is necessary to repair an aortoiliac aneurysm.

Central venous access: low internal jugular vein approach using imaging guidance.

OBJECTIVE: The use and safety of a low internal jugular vein cannulation technique for central venous access was prospectively evaluated. CONCLUSION: The inferior internal jugular vein provides a safe and direct route to the superior vena cava and right atrium for central venous access. Use of an internal jugular vein cannulation site at the base of the neck avoids kinking of tunneled and untunneled catheters.

Percutaneous renal biopsy complicated by renal capsular artery pseudoaneurysm.

We report a case of renal capsular artery pseudoaneurysm caused by percutaneous renal biopsy. The injury was diagnosed and treated with arteriography and transarterial embolization. Because the arterial injury was extraparenchymal, the clinical manifestations of blood loss were flank pain and decreasing hematocrit without hematuria. Injury to renal capsular arteries during percutaneous renal biopsy is a rare possibility because of their small size.

Obstetric embolotherapy: effect on menses and pregnancy.

PURPOSE: To determine the long-term effects of uterine embolotherapy with gelatin sponge pledgets on menses and fertility. MATERIALS AND METHODS: Between June 1990 and December 1995, 17 women (aged 20-44 years) with obstetric hemorrhage underwent selective gelatin sponge pledget embolization of uterine vessels. Gynecologic information in the 12 women who did not undergo hysterectomy was obtained by means of direct communication or from the patients' physicians. RESULTS: In 11 (92%) of the 12 women, normal menses resumed within 2-5 months of the procedure. There were no complications related to embolotherapy. The follow-up period was 1-6 years. All three patients who desired to conceive had full-term, healthy newborns. The only patient who is amenorrheic is currently receiving medroxyprogesterone acetate; her ultimate menstrual and fertility status cannot yet be determined. CONCLUSION: Selective embolization of the uterine vessels with gelatin sponge pledgets is a safe and effective method of managing pregnancy-related hemorrhage. Our results suggest that women who undergo this procedure can expect to have a return of normal menses with no adverse effect on fertility.

MR imaging in male infertility.

In patients with male infertility, endorectal magnetic resonance (MR) imaging provides high-resolution images of the prostate gland and ejaculatory apparatus. The multiplanar capability of MR imaging allows production of a detailed map of the reproductive tract for guiding treatment. Causes of male infertility can be classified as congenital, acquired, infectious, or hormonal. Wolffian duct abnormalities include agenesis of the kidney, vas deferens, or seminal vesicle and cysts of the vas deferens, seminal vesicle, or urogenital sinus-ejaculatory duct. Müllerian duct abnormalities are less common and consist of müllerian duct cysts and utricle cysts. Cowper duct cysts and peripheral-zone prostatic cysts are acquired causes of male infertility. Prostatitis, an infectious cause of male infertility, may mimic carcinoma on long repetition time/echo time images. A low testosterone levels is one of the hormonal causes of male infertility. Pitfalls in the interpretation of MR images can be avoided by familiarity with normal and abnormal findings in patients with male infertility.

Venous architecture of cerebral hemispheric white matter and comments on pathogenesis of medullary venous and other cerebral vascular malformations.

The parenchymal veins, especially the deep medullary veins, of the cerebral hemispheres were studied in detail by analyzing the stereoroentgenograms of multiple brain slices of postmortem injected brain specimens (injected into the internal carotid arteries in 17 cases and into the jugular veins in 12 cases). The presence of four zones--the first (or outer), the second (or candelabra), the third (or palmate) and the fourth (or subependymal) zone--of venous convergence was confirmed within the centrum semiovale, particularly in the frontoparietal area. Other venous convergences such as those related to the optic radiation in the para-atrial area were also found. Arterial branching zones were also observed in the areas similar to those of the medullary veins. It appears that these converging zones are created by rapidly growing crossing nerve fiber tracts, i.e., projection, commissural, and association fibers which grow rapidly during intrauterine and postnatal life. Pathogenesis of medullary venous malformation is also discussed from anatomical viewpoint, venoarchitecture of the pial, parenchymal, and subependymal veins and of the dural venous sinuses. The possibility of a similar mechanism (partial, mild, repetitive venoocclusive disease developing over a long period with fluctuating venous pressure) leading to formation of most (if not all) cases of medullary venous malformation and in some, if not many, cases of cerebral vascular malformations [aside from gene abnormality (chromosome 7) in familial cavernous angiomatosis, particularly in Hispanic American or other familial hereditary conditions] has been postulated.

Atypical angiographic appearance of a superficial femoral artery mycotic aneurysm.

An unusual presentation of mycotic aneurysm is described. In this case, a large thrombosed mycotic aneurysm of the superficial femoral artery was associated with segmental occlusion of the adjacent artery. Small vessels were delineated in the periphery of the aneurysm on angiography.

Venographic appearance of portosystemic collateral pathways.

Many imaging modalities can be used to evaluate various portosystemic collateral pathways seen in patients with portal hypertension. A knowledge of various typical and atypical pathways is essential for a proper understanding of the disease process. Transjugular transhepatic portographic appearance of such pathways are discussed in detail.

Renovascular hypertension.

In current clinical practice, angiographic evaluation of patients with suspected renovascular hypertension usually follows clinical suspicion and positive captopril scintigraphy. Early digital angiography and percutaneous renal artery angioplasty have evolved as the accepted treatment pattern. Doppler sonography and MR angiography continue to be evaluated as potential methods of noninvasive screening.