Best practices for vascular arterial access and closure: a contemporary guide for the cardiac catheterization laboratory.

More than 1 million transcatheter-based cardiovascular procedures across the spectrum of interventional cardiology are performed annually in the United States. With the expanded indications for and increased complexities associated with these procedures, interventional cardiologists are expected to possess the requisite expertise to complete these interventions safely and effectively. While the art of vascular access and closure remains a prerequisite and critical skillset in contemporary practice, there remain significant variations in the techniques employed, resulting in the bleeding and vascular complications encountered in clinical practice. With an increasing recognition of the potential merits to standardized approaches to vascular access and closure, cardiovascular societies have put forth recommendations around best practices for performing these procedures in the cardiac catheterization laboratories. In this review, we aim to: (1) Examine the evolving definitions of bleeding and vascular complications; (2) Review best practices for transradial and transfemoral access and closure, including for large bore procedures; and (3) Highlight knowledge gaps and proposed areas of clinical research pertaining to vascular access which may inform clinical practice and potentially optimize the outcomes of patients undergoing transcatheter-based cardiac and vascular interventions.

Mid-Term Results of Treating Kommerell's Diverticulum and Aberrant Subclavian Artery Anomalies Using a Patient-Centered Team Approach.

INTRODUCTION: The management of Kommerell's Diverticulum (KD) has evolved from open surgical resection and graft replacement of the aorta, to endovascular repair in asymptomatic patients due to its recognized possible sequelae - aortic rupture and dissection. Despite these technical advances, standard indications for intervention and treatment algorithms remain unclear. We will present our single-center experience in the treatment of KD, supporting a multidisciplinary endovascular-first approach. METHODS: All patients who underwent thoracic endovascular aortic repair (TEVAR) for KD between 2017 and 2020 were retrospectively identified from a prospectively maintained institutional surgery database. Chart review was used to characterize presenting symptoms, interventions, technical results, and complications. Revascularization was performed using carotid-axillary bypass. Routine endovascular subclavian artery occlusion was employed to eliminate retrograde diverticulum perfusion and avoid open ligation. RESULTS: 8 patients were identified, including 6 females and 2 males between the ages of 44-76. Patients presented with dysphagia (n = 3), acute embolic stroke (n = 1), transient ischemic attack (TIA) (n = 1), upper extremity embolization (n = 1), and acute type B aortic dissection (n = 1). One patient had a prior incomplete open repair that was successfully treated endovascularly. Another patient had a mediastinal neoplasm infiltrating an incidental aberrant subclavian artery and KD. All cases had symptomatic improvement and successful endovascular repair as demonstrated on post-operative imaging. Perioperative complications included percutaneous access site pseudoaneurysm (n = 2), stroke (n = 1), and subclavian artery rupture immediately recognized and treated (n = 1). There was no perioperative mortality. CONCLUSION: Endovascular techniques have resulted in technical success and symptomatic improvement for KD without open thoracotomy or sternotomy. Significant rates of endovascular complications and paucity of long-term durability data should be considered. Until formal criteria for repair are established, early application of TEVAR using a consistent multi-specialty approach may mitigate the risk of unpredictable aortic complications in these patients while avoiding the accepted morbidity and mortality of open surgery.

Endovascular Repair of an Iatrogenic Pulmonary Artery Pseudoaneurysm.

Pulmonary pseudoaneurysms have various causes and typically arise from the main pulmonary artery. Surgical and endovascular options may be considered for treatment. We report the case of a man with a pseudoaneurysm arising from the right pulmonary artery, treated with a septal occlusion device and percutaneous thrombin injection. (Level of Difficulty: Advanced.).

Retrograde Carotid Stenting Using Newly Released Venous Stent for Cerebral Malperfusion in Type A Aortic Dissection.

Stanford Type A aortic dissections (TAAD) should be considered for repair, given the involvement of branch vessels which can result in malperfusion, specifically cerebral malperfusion secondary to dissection of the innominate and carotid arteries. This is a case report with a focus on four patients presenting with both acute and chronic symptomatic TAAD, with extension into the innominate and common carotid arteries. In all four cases, the decision to intervene utilizing a hybrid endovascular approach was made to increase perfusion to the brain and alleviate symptoms. Through the use of retrograde carotid stenting utilizing both the VICI venous stent (Boston Scientific, Marlborough, MA) and Abre self-expanding Nitinol stent (Medtronic, Minneapolis, MN) we obtained good results, specifically absence of symptoms and return to normal function of the patients.

Contrast-enhanced magnetic resonance angiography following subintimal recanalization.

PURPOSE: To describe the appearance of lower extremity runoff vessels following subintimal recanalization (SIR) on contrast-enhanced magnetic resonance angiography (ceMRA) and compare 2 different ceMRA techniques. METHODS: A total of 6 patients underwent stepping table 3-dimensional (3D) ceMRA and time-resolved 2-dimensional (2D) MRA within 1 to 3 days (mean 1.83 days) following SIR. The 2 techniques were compared with intra-arterial digital subtraction angiography (DSA). RESULTS: A total of 15 arteries were recanalized in 6 patients. Three-dimensional ceMRA allowed evaluation of patency in all segments above the knee. Postprocedural hyperemia impaired the assessment of the trifurcation vessels on 3D ceMRA. Due to its higher temporal resolution 2D MRA was not affected by venous contamination and allowed reliable confirmation of patency of the recanalized vessels. CONCLUSIONS: Diagnostic MRA studies of the lower extremity runoff vessels following SIR is possible, but a hybrid technique using a stepping table MR DSA and a time-resolved sequence like 2D MRA of the calf station is necessary for runoff assessment.

Evaluation of vascular complications of pancreas transplantation with high-spatial-resolution contrast-enhanced MR angiography.

PURPOSE: To retrospectively evaluate high-spatial-resolution contrast material-enhanced three-dimensional (3D) magnetic resonance (MR) angiography for assessment of vascular complications of pancreas allografts. MATERIALS AND METHODS: The institutional review board approved the study and waived the requirement for informed patient consent owing to the retrospective nature of the study with use of an anonymous-subject database. The study was HIPAA compliant. The clinical and MR angiography findings in 11 patients (eight men, three women; mean age, 43 years; age range, 30-54 years) who had a history of pancreatic transplant dysfunction and underwent a total of 13 contrast-enhanced 3D MR angiography examinations were retrospectively reviewed. Comparison with conventional angiography findings was possible for four MR angiography examinations, comparison with surgical findings was possible for two examinations, and clinical follow-up was possible for all examinations. Two observers in consensus and blinded to the clinical results performed image analysis of the arterial and venous segments. Classification agreement was assessed with quadratic weighted kappa statistics. RESULTS: Ten MR angiography examinations revealed vascular complications or signs suggestive of rejection. Only three examinations were considered to have completely normal results. All major complications were detected and included complete or partial arterial graft occlusion, stenosis of the arterial Y-graft caused by a kink, complete venous thrombosis, and arteriovenous fistula with pseudoaneurysm formation. For 46 arterial segments and 15 venous segments with angiographic and/or surgical comparison, overall agreement with MR angiography findings was nearly perfect (mean kappa, 0.983; standard error of the mean, 0.128). CONCLUSION: High-spatial-resolution MR angiography of pancreas allografts enables assessment of the arterial and venous vascular anatomy and can be used to reliably identify clinically relevant vascular complications.

Magnetic resonance urography for the assessment of potential renal donors: comparison of the RARE technique with a low-dose gadolinium-enhanced magnetic resonance urography technique in the absence of pharmacological and mechanical intervention.

The aim of this study was to determine whether magnetic resonance urography without pharmacological (diuretic) stimulation and mechanical compression allows conclusive evaluation of the urinary system in potential renal donors. In 28 consecutive patients magnetic resonance urography (MRU) was performed on a 1.5-T system. Two techniques, rapid acquisition with relaxation enhancement (RARE) and a gadolinium (Gd)-enhanced 3D fast low angle shot (FLASH) sequence were compared in the absence of adjunctive measures. Two reviewers assessed image quality, presence of artifacts and completeness of visualization of the collecting systems and ureters. Among the 53 MR urograms, there was no difference in image quality and presence of artifacts between RARE and Gd-MRU. Despite high image quality, visualization of the urinary collecting system was insufficient. Continuous visualization from the collecting system to the distal ureter was demonstrated bilaterally in only 14% of the RARE and 26% of Gd-enhanced MR urograms, respectively. Overall, Gd-enhanced MRU was superior to the RARE technique in displaying the segments of the urinary collecting system, but this difference was not found to be statistically significant. Neither the RARE technique nor the gadolinium-enhanced MRU technique is accurate enough to allow the evaluation of the collecting system and ureters in potential renal donors in the absence of pharmacological intervention and compression.

Evaluation of an absorbable cyanoacrylate adhesive as a suture line sealant.

BACKGROUND: Previous formulations of cyanoacrylate, though very effective, proved to have too high a tissue reactivity to be used internally. A novel cyanoacrylate compound with less tissue reactivity was recently developed. The objective of this study was to assess this novel cyanoacrylate compound for the use as vascular suture line sealant. MATERIALS AND METHODS: Twelve adult female sheep received a 6 mm PTFE interposition graft in each iliac artery, for a total of 24 grafts. Using oxidized cellulose (Surgicel) as a control, two formulations of a new cyanoacrylate compound (named "compound A" and "compound B") were assessed during this trial. Hemostatic efficiency was measured at the time of operation by the assessment of bleeding time and amount of blood loss. Long-term graft patency was assessed angiographically at 4, 6, and 18 months. Tissue reaction at 2 weeks, 1, 6, and 18 months was assessed grossly by vascular surgeons and microscopically by a blinded pathologist. RESULTS: Average time to hemostasis was 37.6, 50.6, and 219 s in group A, group B, and oxidized cellulose control groups, respectively (P

Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia.

PURPOSE: To describe the technique of subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to improve technical success for the performance of subintimal recanalization when there is failure to reenter the distal true lumen or when there is a limited segment of patent distal target artery available for reentry. MATERIALS AND METHODS: Subintimal recanalization was attempted in an antegrade direction in all patients. If reentry into the distal true lumen was unsuccessful or a short segment of target artery was present, retrograde access was obtained in the distal target artery (popliteal, anterior tibial/dorsalis pedis, or posterior tibial) and a retrograde subintimal channel was created. A guide wire was used to connect the retrograde and antegrade subintimal channels simultaneously to create a "flossing" guide wire. The subintimal tract was dilated with balloon angioplasty with or without stent implantation. Limb salvage, amputation-free survival, and survival rates over time were determined. RESULTS: The SAFARI technique resulted in successful subintimal recanalization creating straight-line flow to the foot in all 21 limbs in 20 patients in which the technique was attempted. Antegrade-retrograde access was performed with the femoral artery and the following vessels: popliteal, n = 11; anterior tibial/dorsalis pedis, n = 10; and posterior tibial, n = 2 (two limbs involved multiple accesses). All procedures were successful. The limb salvage rate with SAFARI was 90% (95% CI, 74%-100%) at 6 months. CONCLUSIONS: The SAFARI technique can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry. The SAFARI technique improves technical success in the performance of subintimal recanalization. Limb salvage rates are comparable to those with antegrade subintimal recanalization.

Contrast-enhanced MR angiography at 1.5 T after implantation of platinum stents: in vitro and in vivo comparison with conventional stent designs.

OBJECTIVE: The objective of our study was to evaluate the in vitro and in vivo 3D contrast-enhanced MR angiography characteristics of a new platinum-based balloon-expandable stent system and compare this system with a variety of competing metallic stents. MATERIALS AND METHODS: All experiments were performed on 1.5-T scanners. In vitro experiments were performed using 10 stents implanted into a custom-built phantom. Different orientations of the stents along the magnetic field and multiple flip angles were examined. In addition, 19 patients underwent contrast-enhanced MR angiography after the implantation of 36 stents, including four patients with six platinum stents. Angiographic correlation was available for all 19 patients, and luminal patency and stent-induced artifacts were assessed quantitatively. RESULTS: Of the tested balloon-expandable stents, only the platinum-based stents created artifact causing luminal narrowing of 30% or less. All other balloon-expandable stents induced larger artifacts that resulted in higher degrees of narrowing. Thus, if patent, the platinum-based stents allow significant in-stent stenosis to be ruled out reliably. Selected nitinol- or tantalum-based self-expandable stents also are suitable in this regard. CONCLUSION: Of the tested devices, platinum-based stents are the only type of currently available balloon-expandable stent that creates 30% or less artifact-induced apparent stenosis and thus are suitable for MR angiography.

Percutaneous intentional extraluminal recanalization in patients with chronic critical limb ischemia.

PURPOSE: To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI). MATERIALS AND METHODS: Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival. RESULTS: Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%). CONCLUSION: PIER is a useful percutaneous technique for limb salvage in patients with CCLI.

Subintimal recanalization is safe and effective in treating chronic critical limb ischemia in selected patients.

Subintimal recanalization is a percutaneous technique that allows revascularization in patients with limb-threatening ischemia. It was first described by Bolia (Cardiovasc Intervent Radiol 13;357-63:1990) but has not gained widespread use in the United States. Twenty-five patients with 32 threatened limbs were referred from a single surgeon's practice over a 23-month period. All patients were either high-risk surgical patients, due to severe medical comorbidities, or not surgical candidates due to poor target vessels, lack of appropriate conduit, or failed previous surgical revascularizations. The average age of patients was 69. There were 15 men and 10 women treated. Subintimal recanalization was immediately successful in 30 limbs. One peri-procedural death occurred, although this patient underwent a surgical bypass graft procedure in the same hospitalization. Three significant complications occurred (myocardial infarction, ventricular arrhythmia, and gastrointestinal hemorrhage). Primary patency is 83 per cent. Secondary patency is 90 per cent. Limb salvage rate is 88 per cent. Mean follow-up period is 10 months. Eight patients died in the follow-up period due to unrelated causes.

Pancreatic pseudoaneurysm in a child with hereditary pancreatitis: diagnosis with multidetector CT angiography.

Pseudoaneurysm formation is a serious vascular complication of pancreatitis. It most commonly affects splenic and gastroduodenal arteries. We report a rare case of superior mesenteric artery pseudoaneurysm in a child with hereditary pancreatitis. Multidetector CT angiography allowed the comprehensive assessment of the aneurysm and allowed accurate surgical planning obviating the need for catheter angiography.

Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion.

Subintimal recanalization can be a useful procedure in selected patients with severe peripheral vascular disease with tissue loss or rest pain and limited surgical bypass options. Technical failure occurs in approximately 20% of patient who undergo percutaneous intentional extraluminal recanalization due to inability to reenter the distal true lumen. A technique to improve technical success when performing subintimal recanalization when there is failure to reenter the distal true lumen or possibly when there is a limited segment of patent distal target vessel for reentry is proposed. Further evaluation of this technique is necessary to confirm its safety and determine its technical and clinical success.