Data and methods to estimate fetal dose from fluoroscopically guided prophylactic hypogastric artery balloon occlusion.

PURPOSE: To provide data for estimation of fetal radiation dose (DF) from prophylactic hypogastric artery balloon occlusion (HABO) procedures. METHODS: The Monte-Carlo-N-particle (MCNP) transport code and mathematical phantoms representing a pregnant patient at the ninth month of gestation were employed. PA, RAO 20° and LAO 20° fluoroscopy projections of left and right internal iliac arteries were simulated. Projection-specific normalized fetal dose (NFD) data were produced for various beam qualities. The effects of projection angle, x-ray field location relative to the fetus, field size, maternal body size, and fetal size on NFD were investigated. Presented NFD values were compared to corresponding values derived using a physical anthropomorphic phantom simulating pregnancy at the third trimester and thermoluminescence dosimeters. RESULTS: NFD did not considerably vary when projection angle was altered by ±5°, whereas it was found to markedly depend on tube voltage, filtration, x-ray field location and size, and maternal body size. Differences in NFD < 7.5% were observed for naturally expected variations in fetal size. A difference of less than 13.5% was observed between NFD values estimated by MCNP and direct measurements. CONCLUSIONS: Data and methods provided allow for reliable estimation of radiation burden to the fetus from HABO.

Ultrasound Guided Compression Versus Ultrasound Guided Thrombin Injection for the Treatment of Post-Catheterization Femoral Pseudoaneurysms: Systematic Review and Meta-Analysis of Comparative Studies.

OBJECTIVE: To compare results of ultrasound based techniques (ultrasound guided compression-(UGC) versus ultrasound guided thrombin injection (UGTI)) to treat iatrogenic post-catheterization femoral pseudoaneurysms. METHODS: The study design involved a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGray databases were searched up to October 2015. Primary outcome measure was efficacy, while other outcomes examined were safety (complication rate), duration of the procedure, length of hospitalization, and cost of methods. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). RESULTS: Two randomized control trials and 11 observational studies were included in the analysis. Overall, 786 and 318 subjects underwent UGC and UGTI respectively. The latter modality resulted in a significantly higher success rate (97.4% vs. 69.3%, OR 0.06, 95% CI 0.03-0.11) while the complication rate for both techniques was very low (0.69% vs. 0.78%, OR 1.77, 95% CI 0.40-7.88). Data regarding procedural duration and length of hospitalization were very scarce, favoring UGTI (procedural time: MD 35.53 min, 9.11-63.95, length of hospitalization MD 1.99 days, -0.31-4.29). Scarcity of data did not allow proper cost analysis, but two studies suggested that UGTI may offer reduced treatment costs. CONCLUSION: Available evidence suggests that UGTI is superior in terms of efficacy and as safe as UGC and thus should be used as the primary modality for the treatment of post-catheterization femoral pseudoaneurysms.

Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia.

OBJECTIVE: To present our experience with the Ovation Abdominal Stent Graft System (TriVascular Inc., Santa Rosa, CA) during endovascular aneurysm repair (EVAR) and compare results according to the type of anaesthesia. METHODS: We conducted a single-centre retrospective study including patients who underwent EVAR using the Ovation endograft between May 2011 and July 2014. Outcome was evaluated regarding pre-, peri- and immediate postoperative and follow-up measures. Overall results are reported, while additional analysis was performed to compare the outcome between groups of patients undertaking either local or regional/general anaesthesia (LA vs RGA). RESULTS: 66 patients were included. Median follow-up was 13 months (range, 1-39 months). Median age was 72 years and median abdominal aortic aneurysm diameter was 58 mm (range, 54-100 mm). Technical success was 63 (95%), while there were 2 (3%) conversions to open surgery. A total percutaneous approach was used in 50/66 (76%) cases. Overall, 9/66 (14%) subjects suffered from any kind of morbidity. Median hospitalization was 3 days (range, 1-16 days). Immediate and midterm mortality rate was 0%. No endoleak Type I, III, IV or stent migration was observed. There were 8 (13%) Type II endoleaks. Overall, additional endovascular procedures were required in 6 (9%), while surgery was performed in 4 (6%) patients. 44 (67%) patients underwent LA and 22 (23%) RGA. Differences between groups were significant for procedural time (85 vs 107 min; p < 0.001), percutaneous access (91% vs 45%; p < 0.001) and systematic complications (2.3% vs 14%; p = 0.05). CONCLUSION: EVAR with the use of the Ovation endograft shows promising short-term and midterm results regarding safety and effectiveness. Completion of the procedures under LA using a total percutaneous approach seems advantageous and may be used in routine practice. ADVANCES IN KNOWLEDGE: The Ovation Abdominal Stent Graft System is an ultra-low profile stent graft system that allows percutaneous deployment for EVAR and offers excellent overall efficacy and safety. Totally percutaneous EVAR under LA seems advantageous and may be used as a routine with this specific endograft.

Focal aorto-iliac atherosclerosis amenable to endovascular interventions though considered benign carry a significant risk of cardiovascular mortality: clinical investigation.

AIM: Peripheral arterial disease (PAD) manifested as claudication is surprisingly stable regarding limb deterioration but may indicate increased risk for cardiovascular events and death. We examined whether focal atherosclerotic iliac lesions (TransAtlantic InterSociety Consensus for The Management of Peripheral Arterial Disease-TASC II Type A,B) undergoing endovascular procedures indicate a high risk for limb and life and what is the effect of atherosclerotic risk factors in the rate of adverse outcomes. METHODS: We examined patients undergoing iliac endovascular interventions due to TASC II Type A,B lesions causing disabling claudication during a 10-year period. Outcome in terms of limb condition and total mortality during short and long-term follow-up was evaluated. RESULTS: One-hundred thirty-nine patients and one-hundred seventy limbs were examined. Median follow-up was 4.3 years. There were 100 (58.8%) limbs with Type A and 70 (41.2%) with Type B lesions. Primary patency was 81.2% and secondary patency 92.4%. One-hundred fifteen (67.6%) limbs were improved whereas 42 (24.7%) remained stable and 13 (7.7%) deteriorated during long-term follow-up. Major amputation was performed in 2 and minor amputation in 2 limbs resulting in 2.4% total amputation rate. Overall mortality was 22.6% and 64.5% of all deaths represented cardiovascular events. Statistical analysis revealed significant relations of total mortality with hyperlipidemia and diabetes. CONCLUSION: Endovascular treatment of localized iliac lesions offers good long-term results regarding patency, clinical improvement and limb salvage. Nevertheless, even focal atherosclerosis indicates a significant risk of cardiovascular mortality. Modification of atherosclerotic risk factors early in the course of PAD may be beneficial for these patients.

Systemic thrombolysis with the use of tenecteplase for segmental acute renal in-farction potentially associated with multiple thrombophilic gene polymorphisms.

BACKGROUND/AIM: The potential association of acute renal infarction with multiple thrombophilic gene polymorphisms and the experience of treatment with tenecteplase are described for the first time in the international literature. DESCRIPTION OF THE CASE: The case of a 50-year old male with segmental acute renal infarction potentially associated with multiple thrombophilic gene polymorphisms is presented. He was thrombolysed with a single intravenous bolus of tenecteplase in a weight-adjusted dose (0.53mg/Kg bodyweight). Within 30 minutes after drug administration, the patient's symptoms were completely relieved. Patient's clinical course was uneventful with an acceptable renal function outcome eight weeks post-treatment. The following gene polymorphisms were identified: G455A (b-fibrinogen); C677T; A1298C (methylenetetrahydropholate reductase); T196C (platelet glycoprotein IIIa); 4G/5G (plasminogen activator inhibitor-1). CONCLUSION: Tenecteplase is a safe and simple to use thrombolytic, with favourable pharmacokinetic profile, which might be useful if administered early, especially when local thrombolysis is impossible or unavailable and therefore warrants further investigation in clinical trials. Hippokratia 2014; 18 (1): 67-70.

Carotid artery stenting: Influence of experience and cerebrovascular risk factors on outcome.

AIM: To evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery. PATIENTS AND METHODS: One hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions. RESULTS: Technical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators. CONCLUSIONS: CAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR).

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

Accuracy of multislice CT angiography for the assessment of in-stent restenoses in the iliac arteries at reduced dose: a phantom study.

OBJECTIVE: We investigated the potential of low-dose CT angiography for accurate assessment of in-stent restenoses (ISRs) of the iliac artery. METHOD: A Rando anthropomorphic phantom (Alderson Research Labs, Stanford, CA), custom-made wax simulating hyperplastic tissue and a nitinol stent were used to simulate a patient with clinically relevant iliac artery ISRs. The cylindrical lumen was filled with a solution of iodine contrast medium diluted in saline, representing a patient's blood during CT angiography. The phantom was subjected to standard- and low-dose angiographic exposures using a modern multidetector (MD) CT scanner. The percentage of ISR was determined using the profile along a line normal to the lumen axis on reconstructed images of 2 and 5 mm slice thickness. Percentage ISRs derived using the standard- and low-dose protocols were compared. In a preliminary study, seven patients with stents were subjected to standard- and low-dose MDCT angiography during follow-up. The resulting images were assessed and compared by two experienced radiologists. RESULTS: The accuracy in measuring the percentage ISR was found to be better than 12% for all simulated stenoses. The differences between percentage ISRs measured on images obtained at 120 kVp/160 mAs and 80 kVp/80 mAs were below 6%. Patient image sets acquired using low-exposure factors were judged to be of satisfactory diagnostic quality. The assessment of ISR did not differ significantly between image sets acquired using the standard factors and those acquired using the low-exposure factors, although the mean reduction in patient effective dose was 48%. CONCLUSION: A reduction in exposure factors during MDCT angiography of the iliac artery is possible without affecting the accuracy in the determination of ISRs.

External jugular vein aneurysm: a source of thrombotic complications.

Superficial venous aneurysms are rare and usually are uneventful. We present a case in which a 40-year old female presenting with a thrombosed external jugular vein aneurysm which previously caused an undetected pulmonary embolism. The aneurysm was excised and the external jugular vein was ligated under local anesthesia and anticoagulation was initiated. In conclusion aneurysms of the superficial venous system should be considered as a possible source of pulmonary emboli. These sites can safely be excised and ligated under local anesthesia offering long term protection from its possible complications.

One year clinical outcomes of renal artery stenting: the results of ODORI Registry.

The safety, efficacy and long term clinical benefits of renal artery revascularization by stenting are still a matter of debate. The aim of our study was to define the safety and efficacy of renal artery stenting with the Tsunami peripheral stent (Terumo Corporation, Tokyo, Japan). The ODORI was a prospective, multicentre registry which enrolled 251 consecutive patients, (276 renal arteries) in 36 centres across Europe. The primary endpoint was acute procedural success defined as <30% residual stenosis after stent placement. Secondary endpoints included major adverse events, blood pressure control, serum creatinine level, and target lesion revascularization (TLR) at 6 and 12 months. Patients were 70 +/- 10 years old, 59% were male, 33% had diabetes, and 96% hypertension. The main indications for renal stent implantation were hypertension in 83% and renal salvage in 39%. Direct stent implantation was performed in 76% of the cases. Acute success rate was 100% with residual stenosis of 2.5 +/- 5.4%. Systolic/diastolic blood pressure decreased from a mean of 171/89 at baseline to 142/78 mmHg at 6 months (p < 0.0001 vs. baseline), and 141/80 mmHg at 12 months (p < 0.0001 vs. baseline). Mean serum creatinine concentration did not change significantly in the total population. However, there was significant improvement in the highest tercile (from 283 micromol/l at baseline to 205 and 209 micromol/l at 6 and 12 months respectively). At 12-months, rates of restenosis and TLR were 6.6 and 0.8% respectively. The 12 month cumulative rate of all major clinical adverse events was 6.4% while the rate of device or procedure related events was 2.4%. In hypertensive patients with atherosclerotic renal artery stenosis Tsunami peripheral balloon-expandable stent provides a safe revascularization strategy, with a potential beneficial impact on hypertension control and renal function in the highest risk patients.

Peak wall stress does not necessarily predict the location of rupture in abdominal aortic aneurysms.

UNLABELLED: Using finite element analysis, we evaluated if the site of an aortic bleb, known to be prone to rupture, coincides with the location of peak wall stress (PWS) in a patient-specific abdominal aortic aneurysm (AAA) model. REPORT: PWS was not located at the bleb site, even when stress values were estimated for different bleb wall thicknesses (0.5-2.0 mm) while the rest of the AAA wall was considered constant (2 mm). DISCUSSION: The sites of PWS in AAAs should not always be considered as the sites most prone to rupture since other factors, such as wall strength, may play a role in rupture-risk prediction, depicting the need for further investigation of these parameters.

Sustained improvement of vascular endothelial function during anti-TNFalpha treatment in rheumatoid arthritis patients.

OBJECTIVES: Vascular endothelial function and common carotid artery intima-medial thickness (CCA-IMT) are well-established surrogate markers for early atherosclerotic disease, which accounts for 30-40% of excess mortality in rheumatoid arthritis (RA) patients. Our aim was to investigate whether long-term treatment with anti-tumour necrosis factor (TNF)alpha agents can modulate endothelial function and CCA-IMT. METHODS: Twelve patients with RA (mean age 54.8+/-15 years) on anti-TNFalpha treatment (seven adalimumab, five infliximab) due to uncontrolled disease activity, with mean Disease Activity Score (DAS28) 5.7 (range 4.6-6.9) despite disease-modifying anti-rheumatic drugs (DMARDs), were studied prospectively. Patients were assessed at baseline and after 3 and 18 months for endothelial-dependent vasodilatation, assessed by flow-mediated vasodilatation (FMD), endothelial-independent vasodilatation and CCA-IMT. RA disease activity and response to therapy were assessed by the DAS28 index. RESULTS: After 18 months of treatment, 67% of the patients were responders according to European League Against Rheumatism (EULAR) response criteria. Anti-TNFalpha treatment improved FMD (from 7+/-4.3% to 11.1+/-3.8%, p = 0.026) whereas CCA-IMT did not change significantly [from 0.67 (0.4-1) to 0.68 (0.39-1.2) mm; mean change 0.01 (-0.06 to 0.08) mm]. Endothelial-independent vasodilatation remained stable (20.4+/-7.3% to 22.9+/-6.5%, p = 0.4). CONCLUSIONS: In this small cohort of patients with RA and no clinically overt cardiovascular disease (CVD), after 18 months of treatment with anti-TNFalpha agents, endothelial function improved significantly while CCA-IMT remained stable. Longitudinal studies using more patients are needed to determine the clinical significance of these findings in relation to the risk of atherosclerosis.

Treatment of anastomotic stenoses of peripheral bypass grafts with cutting balloon angioplasty.

PURPOSE: The aim of this study was to assess the efficacy of cutting-balloon angioplasty (CBA) in the treatment of anastomotic stenoses of peripheral arterial bypass grafts. MATERIALS AND METHODS: Seventeen patients (12 men and five women; age range 54-79 years, mean age 66.5) with stenosis or occlusion at the proximal or distal anastomoses of peripheral bypass grafts were treated with CBA. The diagnosis of stenosis was based on clinical and colour-Doppler ultrasound findings and confirmed by angiography with measurement of the intraluminal transstenotic pressure gradients. The diameter of the selected cutting balloon was 1-mm smaller than the vessel distal to the anastomosis and, in the event of suboptimal outcome, the procedure was completed with repeat dilatation with a larger standard balloon (+1 mm). RESULTS: Technical success was obtained in 100% of cases. In three patients, CBA was performed after locoregional thrombolysis. No patient required stent placement or emergency surgery due to the presence of residual stenosis, suboptimal outcome or dissection. No complication occurred either during or after the procedure. During a mean follow-up period of 10.4 months (range 5-21 months), two restenoses developed at 9 and 7 months, which were treated with the same technique; in one patient with recurrent bypass occlusion at 5 months, a new bypass was created surgically owing to contraindications for locoregional thrombolysis. Cumulative primary patency at 12 and 18 months was 82.35%, whereas the two cases of restenoses treated with repeat CBA underwent further follow-up at 10 and 7 months, respectively. CONCLUSIONS: Our data confirm the efficacy of CBA in the treatment of anastomotic stenoses of peripheral arterial bypass grafts.

Phase II trial of capecitabine and oxaliplatin (CAPOX) plus cetuximab in patients with metastatic colorectal cancer who progressed after oxaliplatin-based chemotherapy.

BACKGROUND: Cetuximab is an IgG1 monoclonal antibody targeting the epidermal growth factor receptor and is able to reverse the resistance to irinotecan in patients with metastatic colorectal cancer (mCRC). This phase II trial evaluates the safety and efficacy of cetuximab combined with capecitabine and oxaliplatin (CAPOX) in the treatment of patients with mCRC progressing under oxaliplatin-based chemotherapy. PATIENTS AND TREATMENT: Forty patients with mCRC were treated with cetuximab (loading dose 400 mg/m(2) and then 250 mg/m(2) i.v. weekly) in combination with CAPOX (d(1): L-OHP 85 mg/m(2) and d(1-7) capecitabine 2000 mg/m(2) every 2 weeks). Thirty-one (77.5%) and nine (22.5%) patients had oxaliplatin-refractory and -resistant disease, respectively; in addition, 32 (80%) patients had also progressed on prior irinotecan-based chemotherapy. RESULTS: One hundred and thirty-four cycles were administered (median of four cycles per patient). Main toxic effects included grade 3-4 neutropenia (12.5%), grade 3/4 diarrhea (7.5%), grade 3 fatigue (2.5%), and grade 2-3 neurotoxicity (22.5%). One (2.5%) complete and seven (17.5%) partial responses were achieved [overall objective response rate (ORR): 20%; 95% confidence interval (CI): 9% to 32%)], whereas 11 (27.5%) patients had stable disease [disease control rate (DCR): 47.5%; 95% CI: 30.2% to 64.5%]. The ORR and DCR were 18.7% and 46.8%, respectively, in patients with oxaliplatin-refractory disease. The median time to tumor progression was 3 months, the median survival 10.7 months and the probability of 1-year survival rate 53.4%. CONCLUSIONS: The combination of cetuximab plus CAPOX is safe and has a promising activity in patients with mCRC refractory or resistant to oxaliplatin.

Deep venous thrombosis in a child associated with an abnormal inferior vena cava.

Congenital anomalies of the inferior vena cava (IVC), such as absence or atresia, although well documented, are uncommon and result from aberrant development during embryogenesis. Absence or atresia of the IVC is usually discovered accidentally. Patients are typically asymptomatic of the condition itself. Many concurrent cardiovascular-associated abnormalities have been described. We report a 10-y-old boy admitted to the emergency room with painful swelling of his right lower limb without previous trauma or surgery. After 3 d, swelling also involved the left lower limb. A Doppler ultrasound of the lower limbs revealed bilateral thrombosis of the vena iliaca communis, vena iliaca externa, femoral vein communis and superficial extending to the IVC. Magnetic resonance imaging (MRI) of the abdomen was performed. On MRI, we demonstrated a hypoplastic IVC. The results of blood coagulation studies, including levels of antiphospholipid antibodies, proteins C and S, and antithrombin III, were normal. The patient was treated with intravenous heparin for 8 d and discharged with oral warfarin therapy, which has been recommended for life. Therapy against deep venous thrombosis must be focused on its prevention in the future. An abnormal inferior vena cava should be considered in young patients with deep venous thrombosis without apparent cause.

Treatment of advanced malignant eccrine poroma with locoregional chemotherapy.

Malignant eccrine poroma is a rare disease with approximately 200 cases reported in the literature. Regional cutaneous and systemic metastases are rarely observed and their management has been generally unsuccessful. We report on a case in which topical 5-fluorouracil application and intra-arterial chemotherapy with docetaxel resulted in a histologically confirmed complete response of multiple regional skin metastases for more than 2 years. Despite intravenous administration of docetaxel, slow progression of systemic disease was observed.