Percutaneous Treatment of Giant Cystic Echinococcosis in Liver: Catheterization Technique in Patients with CE1 and CE3a.

PURPOSE: This study aimed to evaluate the efficacy, safety, and follow-up results of the percutaneous treatment of cystic echinococcosis (CE) patients with giant hepatic cysts (at least one diameter > 10 cm). METHODS: Between January 2013 and 2018, 31 CE patients with 34 giant cysts classified as CE1 or CE3a (Gharbi type 1 or 2) according to the World Health Organization criteria and treated with the catheterization technique were analyzed retrospectively. RESULTS: Thirty-four giant hepatic cysts were treated using the catheterization technique. Technical success was 100%. One procedure was sufficient for 27 of these cysts, while six patients underwent a second procedure due to recurrence, recollection or complications; one did not accept a repeat procedure and decided to refer to surgery due to pain. Ten (29%) major complications developed. The overall clinical success was 97%. The mean follow-up period was 20 months (5-61 months), and the total reduction in the cyst volume was 92%. CONCLUSION: The catheterization technique is effective in treating giant CE with acceptable complication rates. LEVEL OF EVIDENCE: Level 4, Clinical Investigation.

Implementation of the EXOSEAL Vascular Closure Device in the Transpopliteal Arterial Approach.

PURPOSE: To investigate the feasibility and safety of the EXOSEAL vascular closure device (VCD) in achieving hemostasis in transpopliteal arterial interventions. MATERIALS AND METHODS: Between May 2014 and May 2016, 46 procedures involving transpopliteal arterial access in 28 patients (18 bilateral and 10 unilateral) were analyzed retrospectively. Popliteal arterial puncture was performed under ultrasonographic (US) and fluoroscopic guidance by using a micropuncture access set with a 21-gauge needle. Six-French sheaths were used in 45 procedures, and a 7-F sheath was used in 1 procedure. Hemostasis was achieved with the EXOSEAL VCD. All patients were examined for any access-related complications with US at 6 and 24 hours after the procedure. One week later, all patients were followed up in the outpatient clinic. RESULTS: In 44 of the 46 procedures, the EXOSEAL VCD was applied successfully. The technical failure rate was 4.4%. An excessively steep angle of the introducer sheath and improper placement of the EXOSEAL plug in the setting of high blood pressure (220/120 mm Hg) were the reasons for the 2 failures. Among the 44 successful procedures, 1 (2.3%) minor 3-cm hematoma was found to be associated with the VCD. In 1 of the 46 procedures, an arteriovenous fistula (2.2%) was observed as a puncture-related complication and treated with a stent graft. CONCLUSIONS: The EXOSEAL VCD can be safely used for hemostasis in interventions that use transpopliteal arterial approaches, with a high technical success rate and a low rate of entry-site complications.

Comparison of ultrasound guidance with the traditional palpation and fluoroscopy method for the common femoral artery puncture.

OBJECTIVES: To compare the success and complication rates of ultrasound-guided or palpation-guided punctures of the common femoral artery in a prospective randomized study. BACKGROUND: Percutaneous femoral arterial access is sometimes difficult to perform and is the source of complications. It has not been established whether ultrasound-guided puncture of the common femoral artery is the standard practice for angiography. MATERIALS AND METHODS: Two hundred and eight patients were randomized into two groups. One had ultrasound-guided puncture and the other had palpation-guided puncture of the common femoral artery. The technical success, first pass success rate, total number of attempts required for access, time to sheath insertion, pain during puncture, and access-related complication were compared. RESULTS: Technical success tended to be higher and the complication rates tended to be lower in the ultrasound-guided group but the difference did not reach statistical significance (P = 0.052 and P = 0.052). The first pass success rate was higher, total number of attempts required for access and time to sheath insertion were lower in the ultrasound-guided group. Atheromatous plaques on the common femoral artery, iliac artery obstructive lesion, previous ipsilateral puncture of the common femoral artery, obesity, and blood pressure during puncture did not change the outcome. CONCLUSIONS: Ultrasound guidance improves secondary outcomes of the common femoral artery puncture when compared to palpation-guided puncture. Technical success and complication rates seem lower in the presence of ultrasound guidance but larger study populations are needed to verify the result.

Assessment of protective effects of pheniramine maleate on reperfusion injury in lung after distant organ ischemia: a rat model.

OBJECTIVE: The aim of this study is to investigate the protective effects of methylprednisolone (MP) and pheniramine maleate (PM) on reperfusion injury of lungs developing after ischemia of the left lower extremity of rats. MATERIALS AND METHODS: A total of 28 randomly selected male rats were divided into 4 groups, each consisting of 7 rats. Group 1 was the control group. Group 2 was the sham group (ischemia/reperfusion [I/R]). Rats in group 3 were subjected to I/R and given PM (Ph group) and rats in group 4 were subjected to I/R and given MP (Pn group). RESULTS: Malondialdehyde levels were significantly lower in Ph group than in I/R group (P < .05). Superoxide dismutase and glutathione peroxidase enzyme activities were found to be significantly higher in Ph group than in the I/R group (P < .05). Histological examination demonstrated that PM had protective effects against I/R injury. CONCLUSIONS: The PM has a protective effect against I/R injury in rat lung.

Endovascular treatment of surgically implanted arterial graft thrombosis by using manual aspiration thrombectomy.

The purpose of this study was to present our experience with guiding catheters in manual aspiration thrombectomy of occluded infra-aortic bypass grafts. This material was designed as a guiding catheter but was also used for thrombus aspiration. Six consecutive patients (all male; mean age, 61.0±5.7 years; range, 54-68 years) who underwent manual aspiration thrombectomy at the discretion of the operator for infra-aortic bypass graft thrombosis between 2002 and 2010 were retrospectively reviewed. The angiographic success described as either stenosis or residual thrombus less than 30% was 67%. Primary patency was 50%, and secondary patency was 66.7%. Additional stents were needed in four lesions of three patients. Manual aspiration thrombectomy is intended to remove both soft acute blood clots and hard organized embolic and thrombotic obstructions. Manual aspiration thrombectomy appears to be a safe and effective method for treating delayed graft thrombosis. This method provides an alternative to surgical thrombectomy, especially for patients who are not good candidates for the surgery.

Assessment of the coronary venous system by using cardiac CT.

PURPOSE: We aimed to investigate the coronary venous system and its variations by using dual source computed tomography (CT). MATERIALS AND METHODS: Retrospective assessment was carried out on 339 patients who underwent coronary CT angiography using 128-slice dual source CT for suspected coronary artery disease. The examinations were performed according to routine imaging protocols used to evaluate coronary arteries. The coronary venous system was evaluated in each case using maximum intensity projection and volume rendering technique multiplanar reformation reconstructions. In each patient, the presence and calibration of normal anatomy, as well as the variations of the coronary sinus, middle cardiac vein, small cardiac vein, posterior cardiac vein, great cardiac vein, anterior interventricular vein, posterolateral vein, left marginal vein, and anterolateral vein were recorded. RESULTS: The coronary sinus, middle cardiac vein, great cardiac vein, and anterior interventricular vein were visualized in all of the patients. In all cases, one of the lateral or posterolateral veins of appropriate localization and diameter for cardiac resynchronization therapy was detected. The posterior cardiac vein was visualized in 87% of the cases, the left marginal vein in 87.9%, and the small cardiac vein in 20%. There was no significant difference in the diameters or visibilities of the coronary veins in terms of age. CONCLUSION: The coronary venous system and its tributaries may be examined in detail using CT angiography examination performed according to the routine coronary CT angiography protocol used for dual source CT. Dual source CT may be a valuable tool for evaluation of the coronary veins prior to invasive procedures that are directed at the coronary venous system.

Impotence due to external iliac steal syndrome: treatment with percutaneous transluminal angioplasty and stent placement.

We report a case of erectile dysfunction caused by external iliac artery occlusion, associated with pelvic steal syndrome; bilateral internal iliac arteries were patent. The patient stated that he had experienced erectile dysfunction at similar times along with claudication, but he did not mention it before angiography. He expressed that the erectile dysfunction did not last long and that he felt completely okay after the interventional procedure, in addition to his claudication. Successful treatment of the occlusion, by percutaneous transluminal angioplasty and stent implantation, helped resolve erectile dysfunction completely and treat the steal syndrome.

US-guided retrograde tibial artery puncture for recanalization of complex infrainguinal arterial occlusions.

PURPOSE: We aimed to describe the technical aspects and outcomes of the retrograde tibial approach and balloon predilation for recanalization of complex infrainguinal arterial occlusions and determine the efficacy of this approach in minimizing failure rates. MATERIALS AND METHODS: Between September 2006 and April 2011, antegrade revascularization failed in 22 limbs with complex total occlusions within the infrainguinal arterial territory. For each of these antegrade failure cases in 22 patients, a retrograde tibial puncture had been attempted. Percutaneous recanalization and predilation were initially performed through tibial access, and final balloon dilatation or stent placement was performed from antegrade femoral access. The patients were followed up for functionality and wound healing. RESULTS: Access from the tibial artery was successfully obtained for all patients (100%). Successful recanalization was obtained in 18 patients (82%). Retrograde access was performed from the anterior tibial/dorsalis pedis artery in 12 patients and posterior tibial artery in 10 patients. One major and one minor complications were documented. CONCLUSION: Retrograde tibial recanalization technique in the infrainguinal complex arterial occlusion safely increases the success rates of percutaneous recanalization in the failed traditional approach and is a feasible endovascular option to avoid more invasive, time-consuming, and high-risk procedures.

Endovascular treatment of infrarenal abdominal aortic lesions with or without common iliac artery involvement.

PURPOSE: To evaluate the results of stent placement for obstructive atherosclerotic aortic disease with or without involvement of the common iliac artery. MATERIALS AND METHODS: Forty patients had self-expanding stents primarily or after balloon dilatation in the abdominal aorta between January 2005 and May 2011. All patients had trouble walking. Follow-up examinations were performed with clinical visits; these included color Doppler ultrasonography and computed tomographic angiography. RESULTS: Technical, clinical, and hemodynamic success was achieved in all patients. None of the patients underwent reintervention during the follow-up period, which ranged from 3 months to 6 years (median 24 months). Nine complications occurred in six patients. Of the nine complications, four were distal thromboembolisms, which were successfully treated with catheter-directed thrombolysis or anticoagulation therapy. CONCLUSION: Endovascular treatment of the obstructive aortic disease using self-expanding stents was safe and effective, with high technical success and long-term patency. Thromboembolic complications were high even though direct stenting was considered protective for thromboembolism formation. Particularly for infrarenal aortic stenosis, it can be recommended as the first-line treatment option for patients with obstructive atherosclerotic aortic disease.

The effect of endovascular revascularization of common iliac artery occlusions on erectile function.

PURPOSE: To determine the incidence of erectile dysfunction in patients with common iliac artery (CIA) occlusive disease and the effect of revascularization on erectile function using the sexual health inventory for males (SHIM) questionnaire. METHODS: All patients (35 men; mean age 57 ± 5 years; range 42-67 years) were asked to recall their sexual function before and 1 month after iliac recanalization. Univariate and multivariate analyses were performed to determine variables effecting improvement of impotence. RESULTS: The incidence of impotence in patients with CIA occlusion was 74% (26 of 35) preoperatively. Overall 16 (46%) of 35 patients reported improved erectile function after iliac recanalization. The rate of improvement of impotence was 61.5% (16 of 26 impotent patients). Sixteen patients (46%), including seven with normal erectile function before the procedure, had no change. Three patients (8%) reported deterioration of their sexual function, two of whom (6%) had normal erectile function before the procedure. The median SHIM score increased from 14 (range 4-25) before the procedure to 20 (range 1-25) after the procedure (P = 0.005). The type of recanalization, the age of the patients, and the length of occlusion were related to erectile function improvement in univariate analysis. However, these factors were not independent factors for improvement of erectile dysfunction in multivariate analysis (P > 0.05). CONCLUSION: Endovascular recanalization of CIA occlusions clearly improves sexual function. More than half of the patients with erectile dysfunction who underwent endovascular recanalization of the CIA experienced improvement.

Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy: long-term results of 139 patients in a single center.

PURPOSE: To evaluate the immediate and long-term outcomes of percutaneous manual aspiration thrombectomy with provisional stent placement in treating acute and subacute iliofemoral deep venous thrombosis (DVT). MATERIALS AND METHODS: One hundred and thirty-nine consecutive patients (75 women; mean age, 51 years) with acute (n=110) or subacute (n=29) iliofemoral DVT underwent endovascular treatment (total of 148 limbs). All patients were treated with percutaneous manual aspiration thrombectomy by using large-bore guiding catheters with adjunctive catheter-directed thrombolysis and stent placement, if needed. Venography was used to grade thrombus removal. RESULTS: Thrombus removal was less than 50% in five limbs (3.4%), between 50% and 95% in 45 limbs (30.4%), and more than 95% in 98 limbs (66.2%). At least one stent was placed in 99 limbs. Recurrent thrombosis occurred in 27 patients, mostly during the first few months after the procedure. Rethromboses were more frequent among postpartum patients. One patient had a major pulmonary embolism. No major hemorrhage or procedure-related deaths occurred. CONCLUSION: Manual aspiration thrombectomy is a safe, rapid, and effective treatment option for acute and subacute iliofemoral DVT. Hence, catheter-directed thrombolysis may not be required in a majority of patients.

Diffuse unilateral pediatric arteriopathy: successful treatment with repeated angioplasty.

We report a three-year-old girl exhibiting severe long-segment stenoses and occlusions with diffuse arterial involvement of the upper and lower extremities on the right side. The obstructive lesions, which caused atrophy of the right limb and chronic ulceration of the foot, were treated successfully with repeated percutaneous transluminal angioplasty. Obstructive peripheral arterial disease can cause growth retardation of the involved extremity, which can be salvaged by repeated endovascular therapy even in a small growing child.

Endovascular treatment of veno-occlusive Behcet's disease.

PURPOSE: To retrospectively evaluate the outcome of endovascular treatments for patients with chronic veno-occlusive disease in different vascular beds secondary to Behcet's disease (BD). There are few case reports on the subject, and this is the largest study to date. MATERIALS AND METHODS: From January 2001 through October 2009, chronic venous occlusions were treated in 10 patients (all male [age range 18-76 years]) with BD using percutaneous transluminal angioplasty and/or stent placement. All patients were symptomatic and had chronic iliofemoral deep venous thrombosis (DVT; n = 5), central venous occlusion (n = 3), or Budd-Chiari syndrome (BCS; n = 2). All patients met criteria of the International Study Group on Behcet's Disease. RESULTS: Two of five patients with DVT had unsuccessful recanalization attempts. Three patients had successful recanalization with stent placement. All three veins were occluded within 1 month with unsuccessful reinterventions. Three patients with chronic central venous occlusion had successful recanalization with percutaneous transluminal angioplasty (n = 1) and stent placement (n = 2). Two patients had reocclusion with successful reintervention. Two BCS patients had successful treatment with stent placements. Overall technical success was 69%, and no procedural complications were encountered. None of the patients with chronic DVT had patent veins; however, all patients with central venous occlusion or BCS had patent veins on color Doppler ultrasonography at follow-up ranging from 3 to 48 months after intervention. CONCLUSION: Endovenous treatment for chronic iliofemoral DVT due to BD had a poor outcome. However, long-term outcome after endovenous treatment for upper-extremity central venous occlusion and BCS syndrome was good.

Successful treatment of delayed aortobifemoral graft thrombosis with manual aspiration thrombectomy.

We present a 67-year-old man who had undergone aortobifemoral synthetic graft surgery one year earlier. The patient experienced thrombosis of the graft nine months after the operation, and thrombectomy of the graft was planned. However, the patient refused to undergo repeat surgery for thrombus removal and was referred to our center for possible endovascular treatment. We treated the patient with percutaneous aspiration thrombectomy. The thrombi were chronic in nature but could be removed with minimal residue in any part of the graft by using repeated aspiration thrombectomy with 7 F guiding catheters. Underlying stenosis of both distal graft anastomoses was treated with percutaneous balloon angioplasty, and a self-expanding stent was deployed on the right distal anastomosis. A small fragment of thrombus embolized to the right popliteal artery and was removed with aspiration thrombectomy through a second antegrade puncture on the right side. We believe this is the first report of aspiration thrombectomy for an aortobifemoral graft thrombosis. The method was successful despite the chronic nature of the thrombi. Manual aspiration thrombectomy with largebore guiding catheters can be used as an effective recanalization method for delayed aortobifemoral graft occlusion and could be regarded as a good alternative technique to surgical thrombectomy in selected patients.

US-guided percutaneous thrombin injection of postcatheterization pseudoaneurysms.

PURPOSE: This study retrospectively evaluated ultrasonography-guided (US-guided) percutaneous thrombin injection for the treatment of postcatheterization femoral and brachial artery pseudoaneurysms. MATERIALS AND METHODS: Fifty-five patients with postcatheterization femoral artery (n = 53) or brachial artery (n = 2) pseudoaneurysms were treated using US-guided human thrombin (500 IU/mL) injection. Pseudoaneurysm size, thrombin dose, therapy outcome, and complications were documented. Follow-up color Doppler US was performed 7 and 30 days after treatment. Short-duration supplemental compression was applied to six patients at the first week follow-up examination after a reinjection of thrombin had failed. RESULTS: Mean pseudoaneurysm volume was 20.3 ± 18.7 cm(3). The mean injected thrombin dose was 478 ± 238 IU. Thirty-eight (69.1%) of the 55 pseudoaneurysms were thrombosed with a single injection, and 11 of 17 pseudoaneurysms were thrombosed after a second injection. All (100%) of the 41 pseudoaneurysms that were diagnosed within the first two weeks of postcatheterization were successfully treated. The overall primary success rate was 89.1% (49 of 55 pseudoaneurysms). Supplemental compression promoted thrombosis in four of the six patients who had treatment failure with thrombin injection. The secondary success rate was 96.4% (53 of 55 pseudoaneurysms). There were no complications. CONCLUSION: US-guided thrombin injection was most successful within the first two weeks, and the supplemental compression might aid in the closure of partially thrombosed pseudoaneurysms.

Ultrasound-guided puncture of the femoral artery for total percutaneous aortic aneurysm repair.

PURPOSE: The purpose of this study was to evaluate the outcomes of ultrasound-guided femoral artery access for total percutaneous endovascular repair of abdominal and thoracic aortic aneurysms. MATERIALS AND METHODS: Total percutaneous aneurysm repair of the abdominal and thoracic aorta was performed in 52 consecutive patients (46 males, 6 females; mean age, 64.6±16 years; age range, 24-93 years) in a total of 85 access arteries. Of the aortic aneurysms repaired, 33 were abdominal, and 19 were thoracic. Ultrasound- guided puncture of the access artery was performed in all patients. The access artery was closed with a Prostar XL device at the end of the procedure. RESULTS: The outer diameter of the vascular sheaths or the stent graft system ranged from 14 F to 27 F. All but one patient achieved successful closure of the arterial puncture with the closure device. One patient required surgical cutdown because of device failure. Two patients required long-duration manual compression. Technical success was achieved in 49 patients (94%). Forty-five patients (87%) were discharged on the first postoperative day. There were no complications of the access arteries one day or one month postoperatively, as determined by ultrasonography and computed tomography examinations, respectively. The mean diameters of the access arteries prior to and one month after the procedure were unchanged, as demonstrated by computed tomography. CONCLUSION: Ultrasound-guided puncture of the common femoral artery for percutaneous closure of the access site has a high technical success rate and a very low complication rate. The addition of ultrasound guidance decreases the difficulty of the procedure and helps to avoid some of its complications.

Is unilateral breast enlargement always a sign of cancer?

Breast swelling is caused by many etiological factors, but should alert central vein occlusion in hemodialysis patients when the permanent vascular access is in the same arm. The swelling of the breast is caused by venous hypertension in the venous plexus draining the breast. Endovascular treatment relieves venous hypertension and related clinical signs. Additional diagnostic workup or invasive interventions such as a biopsy should be avoided in such patients, as diagnosis is straightforward with the presence of a functioning arteriovenous fistula in the same arm.