Snuffbox distal transradial access (dTRA) for arteriovenous fistuloplasty in Singapore: Going distal is safe.

AIM: Arteriovenous fistula (AVF) dysfunction resulting from stenosis or occlusion, is a prevalent issue in end-stage renal failure patients reliant on autogenous AVFs for dialysis. Recently, a distal transradial approach (dTRA) has emerged, offering advantages such as diminished access site complications, better patient comfort and reduced risk of radial artery occlusion. Our study seeks to assess the effectiveness, outcomes and complication rates of employing dTRA for arteriovenous fistuloplasty in Singaporean patients. METHODS: A retrospective review of all dTRA fistuloplasties performed on dysfunctional or slow to mature AVFs from 2017 to 2023 in our institution was performed. Patients with a distal radial artery measuring 2 mm or more with no evidence of occlusion or thrombosis were included. Patients who required central venoplasty or cutting balloon angioplasty were excluded. Outcome measures included technical success, mean procedure duration, complications and post-intervention primary patency at 1, 3 and 6 months. Patients were followed up for 12 months post-intervention. RESULTS: A total of 37 patients were included. 97.3% of patients undergoing dTRA fistuloplasty had radiocephalic fistulas while 2.7% had brachiobasilic fistulas. There was 100% technical success (defined as success in radial artery cannulation, sheath insertion and crossing of stenotic lesions) in our study as all patients successfully underwent fistuloplasty via dTRA approach. One-month patency rate was 97.4%, 3-month patency rate was 92.1% and 6-month patency rate was 86.8%. There were no immediate complications (haematoma, infection, bleeding, pseudoaneurysm, occlusion) of the radial artery post-intervention. CONCLUSION: Our paper illustrates the safety and efficacy of utilising dTRA for arteriovenous fistuloplasty. This approach offers distinct benefits in addressing non-mature or dysfunctional distal forearm arteriovenous fistulas and should be taken into account in anatomically suitable cases.

Sequential Irreversible Electroporation for Locally Advanced Pancreatic Cancer.

Pancreatic cancer is a lethal disease, with locally advanced pancreatic cancer (LAPC) having a dismal prognosis. For patients with LAPC, gemcitabine-based regimens, with or without radiation, have long been the standard of care. Irreversible electroporation (IRE), a non-thermal ablative technique, may potentially prolong the survival of patients with LAPC. In this article, the authors present a case of LAPC of the uncinate process (biopsy proven pancreatic neuroendocrine carcinoma) with duodenal invasion. The patient had a combination of chemotherapy and radiation therapy but was found to have stable disease. He then underwent intra-operative IRE with cholecystectomy, Roux-en-Y gastrojejunostomy and hepaticojejunostomy. He subsequently underwent percutaneous IRE 13 months post open IRE. The patient also completed peptide receptor radionuclide therapy and has been started on Lanreotide. Following combination therapy, the pancreatic tumor showed significant reduction in size, with patient survival at 53 months post-diagnosis at the time of writing.

Utility of BeBack crossing catheter in fistula creation during percutaneous deep vein arterialization.

For patients with "no-option" chronic limb-threatening ischemia, a final attempt can be made for limb salvage in the form of percutaneous deep vein arterialization (pDVA). In the present study, we describe five cases of pDVA using a BeBack crossing catheter (Bentley InnoMed GmbH; previously, the GoBack crossing catheter; Upstream Peripheral Technologies). From November 2021 to July 2022, five patients underwent pDVA using the BeBack crossing catheter. The demographic data, procedural details, and patient outcomes were recorded. Successful vascular crossing was achieved in all five cases using the BeBack device. No surgical complications were encountered. The limb salvage rate was 60%, and the wound closure rate was 40%. No mortalities occurred during the follow-up period. The findings from the present study demonstrate that the use of the BeBack crossing catheter for pDVA is safe and feasible.

Comparative Study of Ablation Zone of EMPRINT HP Microwave Device with Contemporary 2.4 GHz Microwave Devices in an Ex Vivo Porcine Liver Model.

(1) Background: Percutaneous microwave ablation (MWA) is an accepted treatment of non-operative liver cancer. This study compares the ablation zones of four commercially available 2.45 GHz MWA systems (Emprint, Eco, Neuwave, and Solero) in an ex vivo porcine liver model. (2) Methods: Ex vivo porcine livers (n = 85) were obtained. Two ablation time setting protocols were evaluated, the manufacturer's recommended maximum time and a 3 min time, performed at the manufacturer-recommended maximum power setting. A total of 236 ablation samples were created with 32 (13.6%) samples rejected. A total of 204 samples were included in the statistical analysis. (3) Results: For single-probe protocols, Emprint achieved ablation zones with the largest SAD. Significant differences were found in all comparisons for the 3 min time setting and for all comparisons at the 10 min time setting except versus Neuwave LK15 and Eco. Emprint produced ablation zones that were also significantly more spherical (highest SI) than the single-probe ablations from all other manufacturers. No statistical differences were found for ablation shape or SAD between the single-probe protocols for Emprint and the three-probe protocols for Neuwave. (4) Conclusions: The new Emprint HP system achieved large and spherical ablation zones relative to other 2.45 GHz MWA systems.

The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization.

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Getting a Foothold on Diabetic Foot Disease-Outcomes of a Multidisciplinary Clinical Pathway for Inpatient Diabetic Foot Care: A 17-Year Institutional Review.

INTRODUCTION: Diabetes foot disease (DFD) contributes to poor quality of life, clinical and economic burden. Multidisciplinary diabetes foot teams provide prompt access to specialist teams thereby improving limb salvage. We present a 17-year review of an inpatient multidisciplinary clinical care path (MCCP) for DFD in Singapore. METHODS: This was a retrospective cohort study of patients admitted for DFD and enrolled in our MCCP to a 1700-bed university hospital from 2005 to 2021. RESULTS: There were 9279 patients admitted with DFD with a mean of 545 (±119) admissions per year. The mean age was 64 (±13.3) years, 61% were Chinese, 18% Malay and 17% Indian. There was a higher proportion of Malay (18%) and Indian (17%) patients compared to the country's ethnic composition. A third of the patients had end stage renal disease and prior contralateral minor amputation. There was a reduction in inpatient major lower extremity amputation (LEA) from 18.2% in 2005 to 5.4% in 2021 (odds ratio 0.26, 95% confidence interval 0.16-0.40, P < .001) which was the lowest since pathway inception. Mean time from admission to first surgical intervention was 2.8 days and mean time from decision for revascularization to procedure was 4.8 days. The major-to-minor amputation rate reduced from 1.09 in 2005 to 0.18 in 2021, reflecting diabetic limb salvage efforts. Mean and median length of stay (LOS) for patients in the pathway was 8.2 (±14.9) and 5 (IQR = 3) days, respectively. There was a gradual trend of increase in the mean LOS from 2005 to 2021. Inpatient mortality and readmission rate was stable at 1% and 11%. CONCLUSION: Since the institution of a MCCP, there was a significant improvement in major LEA rate. An inpatient multidisciplinary diabetic foot care path helped to improve care for patients with DFD.

Irreversible electroporation of the pancreas - A decade on.

Irreversible electroporation (IRE) employs the use of an electric field to cause irreversible permeability of the cell membrane, inducing apoptosis. The use of IRE for locally advanced pancreatic cancer (LAPC) was first described in 2012. The crucial advantage of IRE compared with other devices employing thermal ablation is the safety around vital structures such as vessels and ducts. This makes it an attractive option for use in the pancreas due to the close proximity of multiple major vascular structures, biliary ducts, and adjacent gastrointestinal organs. Over the past decade, IRE has established itself as a useful treatment adjunct and may soon become the standard of care, particularly for LAPC. This article will explore the current evidence and provide a concise summary of pertinent issues, including patient selection, preoperative management, clinical outcomes, radiological response and future prospects of IRE in pancreatic cancer.

Emerging Indications for Interventional Oncology: Expert Discussion on New Locoregional Treatments.

Interventional oncology (IO) employs image-guided techniques to perform minimally invasive procedures, providing lower-risk alternatives to many traditional medical and surgical therapies for cancer patients. Since its advent, due to rapidly evolving research development, its role has expanded to encompass the diagnosis and treatment of diseases across multiple body systems. In detail, interventional oncology is expanding its role across a wide spectrum of disease sites, offering a potential cure, control, or palliative care for many types of cancer patients. Due to its widespread use, a comprehensive review of the new indications for locoregional procedures is mandatory. This article summarizes the expert discussion and report from the "MIOLive Meet SIO" (Society of Interventional Oncology) session during the last MIOLive 2022 (Mediterranean Interventional Oncology Live) congress held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions. The aim of this paper is to provide an updated review of the new techniques and devices available for innovative indications not only to residents and fellows but also to colleagues approaching locoregional treatments.

Single-centre experience with endovascular rotational thrombectomy for single session salvage of thrombosed arteriovenous fistulas and grafts.

OBJECTIVES: This paper documents our experience and outcomes of using a relatively new endovascular rotational thrombectomy device for salvage of thrombosed vascular access. METHODOLOGY: A retrospective study reviewing patients with thrombosed native AVF or AVG who underwent endovascular declotting using a rotational thrombectomy device between November 2018 and May 2020 at a tertiary university hospital in Southeast Asia. We evaluated demographics, procedural data, technical and procedural success, patency rates and complications. RESULTS: A total of 40 patients underwent single session endovascular declotting of thrombosed vascular access. The mean follow-up period was 21.6 months (range 13.4-31 months). The technical success was 92.5% and clinical success was 80%. About 50% of patients had concomitant thrombolysis for pharmacomechanical thrombectomy. One patient had a myocardial infarction during the post-operative period. There were no other major complications within 30 days. The primary patency was 45.5% at 6 months and 22.7% at 12 months. Assisted primary patency was 68.1% at 6 months and 61.6% at 12 months, which was maintained up to 2 years. The secondary patency was 84.1% at 6 and 12 months. CONCLUSION: Our study shows that rotational thrombectomy device for single session thrombectomy of thrombosed arteriovenous fistulas and grafts is safe and effective. A high technical and clinical success rate was achieved, with low complication rates and specific advantages compared to other techniques, including reduced length of hospital stay. Our reported mid-term outcomes are reasonable with an assisted primary patency of 62% at 12 and 24 months. The use of newer techniques and novel dedicated thrombectomy devices show promise.

Utility of paclitaxel-coated balloons for the treatment of infrainguinal disease in the Asian population - 24-month outcome data from the BIOLUX P-III Global Registry 24-month Asian outcomes of BIOLUX P-III.

BACKGROUND: Results from the BIOLUX P-III registry have demonstrated favourable outcomes of Passeo-18 Lux™ (Biotronik®, Buelach, Switzerland) drug-coated balloon in treating obstructive infrainguinal peripheral artery disease, but it has not been established if Asians would benefit to the same extent as non-Asians. METHODS: A subgroup analysis was performed on the 24-month data comparing the Asian cohort (AC) to non-Asian cohort (NAC). RESULTS: AC included 49 patients with 77 lesions. AC was significantly younger (65.6 vs 70.3 years, p < 0.05), had more diabetes (87.8% vs 45.3%, p < 0.05), and was more likely to present with CLTI (73.5% vs 35.3%, p < 0.001) compared to NAC. They had significantly longer mean target lesions (115 vs 86.9 mm, p = 0.006), and received significantly higher paclitaxel doses (10.7 vs 7.2 mg, p = 0.0005). Device, technical and procedural successes were 125/125(100%), 95/97(97.5%) and 45/49(91.8%), respectively. There was no significant difference in target lesion revascularization rates between groups (10.5% vs 12%, p = 0.91). However, the AC had more major adverse events (30.2% vs 16.1%, p = 0.001), amputations (26.3% vs 6.2%, p < 0.05) and mortality (37.9% vs 10.6%, p < 0.05) at 24 months. CONCLUSION: Passeo-18 Lux™ use was efficacious in Asians, but was associated with higher adverse events, amputations and mortality rates, likely attributable to poorer patient comorbidities and more extensive PAD.

Impact and the delivery of loco-regional treatment for hepatocellular carcinoma during the COVID-19 pandemic.

Hepatocellular carcinoma (HCC) is the second most lethal tumour, with therapies broadly divided into curative and palliative intent. Unfortunately, the majority of HCCs were found to be unresectable at diagnosis. Advances in novel loco-regional therapies have given patients with unresectable HCC a vital chance for disease control and survival. However, the COVID-19 pandemic has greatly shaped and impacted treatment protocols and delivery for HCC patients. This review article aims to describe the impact of the COVID-19 pandemic on the delivery of loco-regional treatment modalities for HCC and compare treatment trends between the pre -pandemic and pandemic eras. Treatment of HCC involves complex collaboration between clinical professionals within their local and global healthcare institutions. The COVID-19 pandemic has had a profound impact on the treatment of HCC. The delivery of loco-regional treatment for HCC will need to adapt to each healthcare system's unique structure.

Clinical practice guidelines on image-guided thermal ablation of primary and metastatic lung tumors (2022 edition).

The main contents of the Clinical Practice Guidelines on Image-Guided Thermal Ablation (IGTA) of Primary and Metastatic Lung Tumors (2022 Edition) include the following: epidemiology of primary and metastatic lung tumors; the concepts of the IGTA and common technical features; procedures, indications, contraindications, outcomes evaluation, and related complications of IGTA on primary and metastatic lung tumors; and limitations and future development.

Technical Aspects of Percutaneous Deep Venous Arterialization Using Off-the-Shelf Devices.

PURPOSE: Chronic limb-threatening ischemia (CLTI) represents the clinical end stage of lower extremity peripheral arterial disease (PAD). Although conventional open and endovascular revascularization options are available, some CLTI patients do not respond to these treatments, generally due to small vessel occlusive disease, with only limited or no clinical improvement achieved. This article aims to provide insights related to pertinent venous anatomy of the leg and below the ankle and a technical review of percutaneous deep venous arterialization (pDVA) creation using commonly-available devices. TECHNIQUE: For patients with "no-option" CLTI, the risk of major amputation and mortality remains high. Although arterial revascularization remains the optimal treatment of CLTI, some patients with severely-diseased or gracile distal arteries have poor outcome. Deep venous arterialization (DVA), in a subset of patients with tibial anatomy amenable to DVA creation, represents the last-ditch attempt before these patients are deemed to have "no-hope" at limb salvage, and major amputation becomes necessary. Refinement in technique and advancement in device development have been shown to allow pDVA to be created with respectable outcomes for the "no-option" CLTI patient population. CONCLUSION: The pDVA has garnered increasing interest among endovascular specialists to further understand the anatomical and technical key points of this procedure, and it may yet prove to be a useful addition in the armamentarium in our battle against CLTI. CLINICAL IMPACT: Percutaneous deep venous arterialisation provides another option in the treatment of challenging "no-option" CLTI patients, and off-the-shelf devices will allow this procedure to be performed in centers where dedicated devices are not available.

Endovascular repair of mycotic aortic aneurysms confers good medium-term outcomes and aneurysmal sac resolution.

INTRODUCTION: Mycotic aortic aneurysm (MAA) is a life-threatening condition. Endovascular repair (EVAR) of aortic aneurysms has been found to be a safe and effective alternative to open repair. We aimed to present the short- to medium-term outcomes for EVAR of MAA in our cohort. METHODS: We conducted a retrospective study of 23 consecutive patients with MAA who underwent EVAR in our hospital from January 2008 to July 2017. RESULTS: The mean age of our study population was 62 years. The mean aneurysmal size was 3.2 cm. Abdominal MAAs (n = 16, 70%) were the most common, followed by thoracic MAAs (n = 4, 17%). There was no 30-day mortality in our cohort. Endoleak (Types 1, 3, 4) was detected in 3 (13%) cases. At the one-month surveillance computed tomography aortogram, all patients had a reduction in aneurysmal size and 5 (22%) had complete aneurysmal sac resolution. 7 (30%) patients had sac resolution at six months and 8 (35%) patients, at 12 months. The overall survival was 91%, 80% and 61% at one, 12 and 60 months, respectively. CONCLUSION: EVAR is a feasible and durable method for the repair of MAA, with a five-year overall survival of 61%. All patients in our study had a reduction in aneurysmal size at one month, with 65% having complete aneurysmal sac resolution by 12 months.

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck.

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

Intravascular ultrasound correlation of unenhanced magnetic resonance venography in the context of pelvic deep venous disease.

OBJECTIVE: In the present retrospective, assessor-blinded cross-sectional study, we compared the diagnostic efficacy of the relaxation-enhanced angiography without contrast and triggering (REACT) protocol for magnetic resonance venography (MRV) and intravascular ultrasound (IVUS). METHODS: All patients without prior lower limb vascular stenting who had undergone MRV with the REACT protocol and IVUS at our institution from January 2018 to May 2020 were included. The REACT protocol for MRV comprises three main phases: the adiabatic-based T2-preparation module, the non-volume-selective short tau inversion recovery pulse sequence, and the three-dimensional, modified two-point chemical-shift water-fat separated turbo-field echo pulse sequence. The IVUS findings served as the reference standard for stenosis and were used in the diagnostic efficacy analysis of the REACT protocol for MRV. The REACT protocol MRV images were reviewed by three board-certified interventional radiologists, and an interrater analysis was performed. RESULTS: A total of 33 patients (110 segments with IVUS correlation; 18 men [54.5%] and 15 women [45.5%]) were included. Most patients were Chinese (63.6%), and 24 had had bilateral deep venous disease (72.7%). The mean patient age was 59.0 years (range, 26.0-79.5 years). Moderate agreement was found between the three radiologists' diagnoses of iliac vein pathology using the REACT protocol for MRV (κ = 0.524; 95% confidence interval [CI], 0.426-0.623; P < .001). Compared with IVUS, REACT protocol MRV achieved a sensitivity of 96.10% (95% CI, 89.03%-99.19%), specificity of 78.79% (95% CI, 61.09%-91.02%), positive predictive value of 91.36% (95% CI, 84.54%-95.33%), and negative predictive value of 89.66% (95% CI, 73.81%-96.38%). Overall, 78.5% agreement was noted between the REACT protocol MRV and IVUS findings. Good agreement between the index test and reference standard was noted (κ = 0.779; 95% CI, 0.645-0.907; P ≤ .05). CONCLUSIONS: REACT protocol MRV has the potential to be a highly sensitive and specific screening tool to diagnose deep venous disease.

Percutaneous Ablation of Metastatic Lymph Nodes: An Insight from the Comparison of Efficacy and Safety Between Cryoablation and Radiofrequency Ablation.

PURPOSE: To retrospectively compare efficacy and safety of computed tomography (CT)-guided percutaneous ablation of metastatic lymph nodes (LN) between cryoablation (CA) and radiofrequency ablation (RFA). MATERIALS AND METHODS: A bi-central institutional database research identified 28 patients (42 metastatic LNs) who underwent percutaneous CT-guided ablation. RFA group included 18 patients/26 tumors; CA group included 10 patients/16 tumors. Contrast-enhanced CT or MRI was used for post-ablation follow-up. Patient and tumor characteristics, technical and clinical success on a per tumor and a per patient basis and complication rates were recorded, evaluated and compared between the 2 groups. RESULTS: Both RFA and CA groups had the same median tumor size (2.00 vs. 2.20 cm, p = 0.257), the same median follow-up time (20.50 vs. 20.00 months, p = 0.923) and the same median length of hospital stay (1.00 vs. 1.00 days, p = 0.283). CA group had a higher median procedure time (110.50 vs. 52.00 min, p = 0.001). On a per lesion basis, the overall complete response post-ablation was 88.46% (23/26 lesions) in the RFA and 93.75% (15/16 lesions) in the CA group; no association was revealed between local tumor control and ablation technique (p = 0.709). No complications were recorded in both Groups. On a per patient basis, CA had a longer disease-free interval (24.00 vs. 14.50, p = 0.012) which, however, did not affect the overall survival between the two techniques (26.0 vs. 22.0, p = 0.099 for CA and RFA respectively). CONCLUSION: Our limited data suggest that CT-guided RFA and CA are equally effective on terms of efficacy and safety for the treatment of metastatic lymph nodes.