The chimney graft technique for preserving renal arteries in stent-graft sealing zones.

Patients with juxtarenal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. An alternative procedure that can be used is the "chimney graft" technique. Three cases of abdominal aortic aneurysms were successfully treated in our department with this technique. One type-Ia endoleak occurred which was successfully treated with coiling and biological glue infusion. All of the chimney grafts have remained patent for the period of observation. The "chimney" technique has good results as a bail out procedure in complex EVAR or in well planned difficult cases. Long-term data is necessary to determine the efficacy of this technique.

Association between plaque echogenicity and embolic material captured in filter during protected carotid angioplasty and stenting.

OBJECTIVES/DESIGN: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. MATERIALS/METHODS: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I-V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep(®) liquid-based cytology (LBC) technique. RESULTS: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02-5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28-326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho -0.716; p = 0.02). CONCLUSIONS: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

Current knowledge on E-vita abdominal endograft.

The field of endovascular abdominal aortic repair has changed remarkably compared to what it was prior to 1993, the year of the first commercial endograft deployment in the United States. Over the years of endovascular aneurysm repair experience, various companies have attempted to construct an ideal stent-graft for exclusion of an abdominal aortic aneurysm (AAA). However, it has become evident that not all abdominal aortic anatomies are amenable to endovascular treatment and that the rationale "one device fits all AAAs" can lead to disastrous results. Different endografts have dissimilar properties and characteristics. Type of graft material, configuration and type of stent structural support, modularity, type of transrenal fixation, are potentially influential factors of endograft behavior. The self-expanding E-vita abdominal stent-graft (JOTEC, Hechingen, Germany) is a relatively new infrarenal, modular stent-graft with suprarenal fixation designed for AAA reconstruction. The present paper analyzes the technical characteristics and properties of this device. We also analyze our experience with the endoprosthesis and review the current literature.

Urgent CAS for patients in high neurologic risk.

Patients with residual carotid stenosis discovered following an acute ischemic insult represent a new subset of patients eligible for early carotid intervention that may decrease the risk of recurrent stroke by new emboli and improve cerebral blood flow. Short-term clinical outcomes of patients undergoing urgent CAS appear favorable, indicating that endovascular management may be a reasonable treatment option, particularly when combined with endovascular interventions for intracranial lesions. Data on indication and complication profiles are still limited. This review focuses on current knowledge, advantages and pitfalls of urgent and/or early (up to 2 weeks) carotid stenting in those presenting with an acute neurologic event or recently symptomatic carotid stenosis.

Treatment of Budd-Chiari syndrome by transjugular intrahepatic portosystemic shunt.

Patients with Budd-Chiari syndrome may require therapy with portal decompressive surgery. Transjugular intrahepatic portosystemic shunt has recently emerged as a new treatment alternative to surgical shunting, but reported literature is scarce and its long-term outcome is to be evaluated. The aim of our study was to present two patients with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt. Two female patients with acute and subacute Budd-Chiari syndrome respectively, uncontrolled by medical therapy, were referred for transjugular intrahepatic portosystemic shunting. Both patients had refractory ascites, while one had hepatic insufficiency. Hepatic vein thrombosis was without definitive etiology in one patient and due to essential thrombocytosis in the other. Transjugular intrahepatic portosystemic shunt was successfully created in both patients; in one a transcaval approach was performed. Bare stents were used in one, while in the other a polytetrafluoroethylene-covered stent-graft. Technical success was 100% with no complications. Ascites resolved in both patients and liver function improved. The first patient remains asymptomatic with good shunt patency 6 months after intervention. The second patient is symptom-free two years after the shunt creation, despite stent occlusion. She remains asymptomatic due to hepatic vein collateral development. In patients with acute or subacute Budd-Chiari syndrome uncontrolled by medical therapy, transjugular intrahepatic portosystemic shunt is highly effective with no complications and an associated mid-term clinical success.

Interventional spine procedures.

Minimally invasive techniques for the treatment of some spinal diseases are percutaneous treatments, proposed before classic surgery. By using imaging guidance, one can significantly increase accuracy and decrease complication rates. This review report physiopathology and discusses indications, methods, complications and results of performing these techniques on the spine, including different level (cervical, thoracic, lumbar and sacroiliac) and different kind of treatments (nerve block, disc treatment and bone treatment). Finally the present article also reviews current literature on the controversial issues involved.

Cerebral metastases of malignant melanoma: contemporary treatment modalities and survival outcome.

The aim of our study was to analyze prognostic factors, effect of treatment and survival outcome of a contemporary cohort of melanoma patients with cerebral metastases and eventually propose new recommendations regarding therapy. Sixty four patients with melanoma brain metastases were treated in our department within a 15-year period. We performed a retrospective analysis of their survival with respect to the type of treatment instituted. Four groups were formed according to treatment: Group A patients treated with surgery followed by radiotherapy; group B temozolomide as first-line treatment and radiotherapy after cerebral disease progression; group C radiotherapy alone; group D supportive care only. Patients* characteristics influenced the selection of treatment modality: Group A (7.8%) patients with a single brain metastasis (p=0.001) and controlled extra-cranial disease (p<0.0001), while Group D (21.8%) patients with ulcerated primary lesions (p=0.010) and uncontrolled extra-cranial disease (p<0.0001). Only group B (26.6%) and C (43.7%) patients with similar characteristics including more than one brain lesion. Median overall survival was 3 months. In univariate analysis, median survival for groups A, B, C and D was 12, 5, 3 and 2 months, respectively (p<0.0001). The survival difference between the surgery and non-surgery groups was statistically significant (p=0.0011). Patients treated with supportive care had the worse prognosis (p<0.0001). A survival benefit for patients receiving first-line treatment with temozolomide, as compared to those receiving radiotherapy alone was noted (p=0.0267). In multivariate survival analysis, the number of brain lesions (p=0.0138), the absence of uncontrolled extra-cranial disease (p=0.00221) and the type of treatment for the cerebral disease (p=0.0053) remained significant independent survival predictors. Patients' characteristics remain a critical factor for treatment selection. The number of brain metastases, the extent of disease and the type of treatment represent independent survival predictors. Melanoma patients with a single brain metastasis and controlled extra-cranial disease gain a survival benefit, if surgically treated. Including temozolomide in the first-line treatment of melanoma patients with brain metastases who would have been treated with radiotherapy alone, might present a promising future direction affecting the length of survival.

Iliac artery angioplasty : technique and results.

Percutaneous angioplasty is widely used for the treatment of iliac artery occlusive disease. Access to the ipsi-lateral, or less commonly contralateral, common femoral artery is obtained under local anaesthesia; the lesion is crossed with a guidewire and dilated with an angioplasty balloon catheter. This technique yields excellent immediate results with very few complications. Stent placement is used in lesions not amenable to balloon angioplasty, in complications, and recurrences. Evidence suggests that balloon angioplasty is the procedure of choice for iliac artery occlusive lesions. Stent placement should be reserved for angioplasty failures. However, primary stent placement is indicated in total occlusions. Lesion morphology is an important determinant of immediate success and long-term patency. TASC lesions type A and B are best treated with angioplasty and stenting, while TASC lesions type C and D show better results with surgical treatment. The development of new stent designs may expand the indications of the percutaneous treatment.

Primary stenting of subclavian and innominate artery occlusive disease: a single center's experience.

PURPOSE: To review immediate and midterm results of primary stenting for innominate and subclavian artery occlusive lesions. METHODS: Retrospective data were collected from 48 consecutive symptomatic patients (27 men and 21 women, median age 64 years) having 49 subclavian and innominate artery lesions treated with stenting. Of the patients 52% had concomitant ischemic heart disease, and 30% had carotid and/or vertebral artery disease. Indication for treatment was vertebrobasilar insufficiency (VBI) in 16.6% of the patients; upper limb ischemia (ULI) in 31.3%; VBI and ULI in 12.5%; transient ischemic attack in 16.7%; angina in 12.5% before or after left internal mammary artery-to-coronary artery bypass grafting; and leg claudication in 10.4% before or after axillofemoral bypass grafting. Balloon-expandable stents were used in 44 lesions and self-expandable stents in 5 lesions. In total, 53 stents were placed in 48 patients. RESULTS: Technical success was 96%, and clinical success 94%. We encountered four complications (two puncture site hematomas, one distal hand embolization and one transient cerebral ischemia). Two patients died within 30 days from other causes, and seven patients were lost to follow-up. Mean follow-up time was 16.7 months (range 0.3 to 68.2). Five patients had recurrent lesions treated by surgical (n = 2) or endovascular (n = 3) means. Cumulative primary patency rate was 91.7% and 77% at 12 and 24 months, respectively. Cumulative secondary patency rate was 96.5% and 91.7% at 12 and 24 months, respectively. CONCLUSION: Stenting of subclavian and innominate artery lesions resulted in immediate resolution of patients' symptoms with durable midterm effect and few complications in a larger patient group with serious comorbid conditions.

Malignant melanoma metastatic to the gastrointestinal tract.

A retrospective study of 385 melanoma patients was performed, with the goal of evaluating the clinical characteristics, the role of imaging and the impact of treatment on patients with gastrointestinal (GI) metastases. Eighteen patients (4.7%) had GI tract metastases. In 50% the primary lesion was on the lower extremities (P< 0.01), while 61.1% had nodular melanomas (P < 0.01). Imaging and/or endoscopy were undertaken in 72.2% of the patients, yielding positive results in all. Eight patients underwent curative surgery, two received no treatment, while the remaining eight patients had chemotherapy or immunochemotherapy. Long-term palliation was offered to 87.5% of the surgical patients compared with 50% of the patients treated medically. Median survival in the patients treated with surgery was 47.5 months compared with 5.8 months in the medical group (P < 0.01). GI tract metastases were more common in patients with nodular melanoma of the lower extremities. To our knowledge, this is the first study correlating the primary lesion's characteristics with the development of GI tract metastases. Imaging is effective in the diagnosis of GI tract involvement. Melanoma patients with GI tract metastases can benefit from palliation by surgical resection. Survival is improved when such patients are treated with curative surgery.

Malignant fibrous histiocytoma of the trunk metastatic to the liver: treatment with transcatheter intrahepatic chemoembolization.

We report a patient with symptomatic liver metastases as the sole site of recurrence of a previously resected malignant fibrous histiocytoma of the trunk. We treated the patient with two sessions of transcatheter chemoembolization. Tumor regression was achieved, and the patient remained free of symptoms 23 months after the diagnosis of liver involvement, when he died of acute myocardial infarction. To our knowledge, this is the only case of transcatheter chemoembolization of liver metastases from soft-tissue sarcoma reported in the literature. Although it is a single case, it shows that this method may be a promising therapy for this grave disease.

Emergency endovascular treatment of a superior mesenteric artery occlusion.

Endovascular treatment of acute mesenteric ischemia is rarely reported. We report a patient with a 1-year history of chronic mesenteric ischemia who presented with acute worsening of his symptoms and peritoneal signs. Aortography depicted an occlusion of the superior mesenteric artery, which was successfully managed with immediate percutaneous angioplasty (PTA) and stent placement. The patient's clinical condition improved markedly and an exploratory laparotomy performed the following day confirmed the viability of the intestine. He remains symptom-free 12 months after the procedure, and color Doppler follow-up showed that the stent is patent.

Ruptured adrenal artery aneurysm: a case report.

A case of ruptured adrenal artery aneurysm is presented. The ultrasound, computed tomography and selective renal angiography findings are described in detail. Aneurysms of adrenal arteries are particularly rare. Early diagnosis is important because of their tendency towards rupture and subsequent high mortality rate.

Malignant biliary obstruction: management with percutaneous metallic stent placement.

BACKGROUND/AIMS: To report our experience on palliative management of malignant biliary obstruction with percutaneous placement of metallic stents. METHODOLOGY: During a 3-year period 20 patients with malignant biliary obstruction were treated with percutaneous insertion of metallic biliary endoprostheses. RESULTS: Stent placement was successful in 19 patients, with significant improvement of jaundice in 18 patients. 17 patients have died up to date. In this group survival was 4-324 days (mean: 107 days) and mean stent primary and secondary patency 94.3 and 97.4 days, respectively. Three patients are alive with a follow-up from 20-195 days. Mean secondary patency is 65.3 days (20-134 days). We encountered serious complications in 4 patients (20%). Thirty-day mortality was 15%, while procedural mortality was 10%. Four patients presented 13-120 days (mean: 71.5 days) after the procedure with stent reocclusion (reocclusion rate: 20%). CONCLUSIONS: The procedure is relatively easy and safe to perform, yields excellent palliation of the patient's symptomatology and, therefore, contributes substantially to the maintenance of good quality of life of the patient with malignant biliary obstruction.

Splenic aneurysm with arteriovenous fistula. A case report.

BACKGROUND/AIM: Fistulous communication between the splenic artery and the vein is rare. We present one such case. PATIENT AND METHODS: A 50 year old woman was admitted to the hospital complaining of abdominal pain and diarrhea, both unrelated to the meals. Physical examination, laboratory testing, computed tomography, and aortogram were performed. RESULTS: The patient was treated by surgical resection of splenic artery and vein, as well as with splenectomy. Pathological examination showed a 5x5 cm aneurysm of the splenic artery that was connected to the splenic vein through a fistulous tract.

A bleeding renal artery pseudo-aneurysm complicating renal biopsy. Treatment with transcatheter embolization.

We report the treatment of a bleeding renal artery pseudoaneurysm by transcatheter embolization. The patient, a 30 years old woman, developed macroscopic hematuria following renal biopsy. The presence of a leaking pseudoaneurysm of the lower pole segmental artery was confirmed by left selective renal angiogram; subsequently successful transcatheter embolization was performed using a 5.0 french Cobra catheter and 3 mm steel coils.