Ultrasound-guided popliteal sciatic nerve block: an effective alternative technique to control ischaemic severe rest pain during endovascular treatment of critical limb ischaemia.

PURPOSE: There are challenges with pain management related to a severely ischaemic limb. Although opioid-based treatment has been the cornerstone of pain relief, the use of these drugs should be limited because of their side effects in such vulnerable patients. We evaluated the utility and efficiency of sciatic nerve block as an alternative method to relieve severe rest pain during endovascular treatment of critical limb ischaemia. MATERIAL AND METHODS: We retrospectively investigated 10 patients who received ultrasound-guided popliteal sciatic nerve block for the relief of severe rest pain during endovascular treatment of critical limb ischaemia. The degree of pain relief was evaluated by using subjective criteria, from no relief of pain (= 1) to complete relief of pain (= 4). Details of endovascular treatment, time to perform the block, amount of local anaesthetics, duration of the block, need for supplemental analgesia, patient and operator satisfaction, and complications were recorded. RESULTS: All blocks were technically successful, and all of the patients had complete resolution of the pain within five minutes. The degree of pain relief was 3 in two patients and 4 in eight patients. All patients were satisfied with the block anaesthesia, and no patient required additional analgesia during this period. Operator satisfaction was very good in all cases. Complications secondary to block did not occur in any patient. CONCLUSIONS: Ultrasound-guided popliteal sciatic nerve block provides effective pain control, which results in excellent patient and operator satisfaction during endovascular treatment of critical limb ischaemia with severe rest pain.

Management of traumatic bile duct injuries in children.

PURPOSE: Pediatric experience with biliary tract injuries (BTI) is limited and mostly consists of case presentations. The purpose of this study is to evaluate clinical and radiological findings of possible BTI, treatment strategies, and results. METHODS: The records of nine patients with the diagnosis of BTI between July 2009 and November 2017 were reviewed retrospectively. RESULTS: There were seven boys and two girls (mean 8.05 ± 4.39 years). The mechanisms were motor vehicle occupant, fall, crush and gunshot wound. Hepatic laceration routes that extended into the porta hepatis and contracted the gall bladder were demonstrated on computerized tomography (CT). Bile duct injury was diagnosed with bile leakage from the thoracic tube (n = 2), from the abdominal drain (n = 2) and by paracentesis (n = 5). Extrahepatic (n = 8) and intrahepatic (n = 1) bile duct injuries were diagnosed by cholangiography. Endoscopic retrograde cholangiography, sphincterotomy, and stent placement were successfully completed in five patients. Peritoneal drainage stopped after 3-17 days of procedure in four patients. The fifth patient was operated with the diagnosis of cystic duct avulsion. Cholecystectomies, primary repair of laceration, cystic duct ligation, and Roux-en-Y hepatoportoenterostomy were performed in the remaining four patients. All patients presented with clinically normal findings, normal liver functions, and normal ultrasonographic findings in the follow-up period. CONCLUSIONS: The presentation of the parenchymal injury extending to the porta hepatis with contracted gall bladder on CT and diffuse homogenous abdominal fluid should be considered as signs of BTI. We suggest a multi-disciplinary approach for the diagnosis and treatment of BTIs. Surgery may be indicated according to the patient's clinical condition, radiological findings and failure of non-operative treatment.

Rupture of an Aneurysm of a Small Branch of the Superior Mesenteric Artery: A Case Report.

BACKGROUND: Superior mesenteric artery aneurysm (SMAA) is an uncommon vascular disorder. Complications such as rupture have been reported. Once complication has been encountered both surgical and endovascular treatment techniques can be considered. CASE REPORT: We present a case of 68-year old male patient with SMAA rupture treated by endovascular modality. CONCLUSIONS: Endovascular therapy is an effective and less invasive option for rupture of superior mesenteric artery aneurysm.

Ultrasound-guided supraclavicular brachial plexus block for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas.

PURPOSE: To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. MATERIALS AND METHODS: US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0-10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. RESULTS: Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ± 2.6. Pain scores were 0 (no pain) in 26 patients and 1-3 (mild, annoying pain) in 14 patients. The patient's satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator's satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. CONCLUSIONS: US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.

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.

Regression of renal angiomyolipomas with oral rapamycin therapy in a patient with tuberous sclerosis complex disease.

We present a case of a 32-year-old female who had been diagnosed tuberous sclerosis complex (TSC) two years ago. In view of serious hemorrhagic complication risk of the selective embolization, we commenced her on oral rapamycin therapy for regression of angiomyolipomas (AMLs). On the 1st year of rapamycin treatment, bilateral renal AMLs were regressed and bilateral selective embolization of the AML was performed after the 1st year of treatment. Rapamycin therapy may regress renal lesions in TSC disease. Therefore, it may increase surgical intervention.

Comparison of Sedoanalgesia Versus Ultrasound-Guided Supraclavicular Brachial Plexus Block for the Prevention of the Pain During Endovascular Treatment of Dysfunctional Hemodialysis Fistulas.

PURPOSE: Although intravenous sedation and analgesia have been widely used as a first choice to relieve pain during treatment of dysfunctional hemodialysis fistulas by interventional radiology, the sedoanalgesic drugs have a considerable risk of respiratory depression, especially in hemodialysis patients. In this study, we compared the utility and efficiency of ultrasound-guided supraclavicular brachial plexus block versus sedoanalgesia for the prevention of pain during endovascular treatment of dysfunctional hemodialysis fistulas MATERIALS AND METHODS: Patients were randomized into two groups: ultrasound-guided supraclavicular brachial plexus block (n = 34) or sedoanalgesia group (n = 34). A visual analogue scale from no pain (= 0) to worst pain possible (= 10) was used to assess the pain intensity. Patient and operator satisfaction were graded from 0 to 2: 0, not satisfied at all; 1, partially satisfied; 2, satisfied (very well or complete satisfaction). Both groups were compared in terms of pain scores, patient and operator satisfaction as well as complications. RESULTS: The median pain score was significantly lower in the block group compared to the sedoanalgesia group, 0 (0-4) versus 6 (2-10), p = 0.0001. Patient satisfaction and operator satisfaction were significantly higher in the block group than in the sedoanalgesia group (p = 0.0001). Severe oxygen desaturation occurred in five (14.7%) patients following the administration of sedoanalgesia. No side effects or complications related to block procedure occurred in any patient. CONCLUSION: Ultrasound-guided supraclavicular brachial plexus block has advantages over the sedoanalgesia during endovascular treatment of dysfunctional hemodialysis fistulas. It can provide safe and efficient analgesia with excellent procedural satisfaction in adult hemodialysis patients. LEVEL OF EVIDENCE: Level 1 (randomized controlled trial).

Endovascular treatment of iliofemoral deep vein thrombosis in pregnancy using US-guided percutaneous aspiration thrombectomy.

PURPOSE: We aimed to describe ultrasonography (US)-guided percutaneous aspiration thrombectomy in pregnant women with iliofemoral deep vein thrombosis. METHODS: This study included nine pregnant women with acute and subacute iliofemoral deep vein thrombosis, who were severe symptomatic cases with massive swelling and pain of the leg. Patients were excluded from the study if they had only femoropopliteal deep vein thrombosis or mild symptoms of deep vein thrombosis. US-guided percutaneous aspiration thrombectomy was applied to achieve thrombus removal and uninterrupted venous flow. The treatment was considered successful if there was adequate venous patency and symptomatic relief. RESULTS: Complete or significant thrombus removal and uninterrupted venous flow from the puncture site up to the iliac veins were achieved in all patients at first intervention. Complete relief of leg pain was achieved immediately in seven patients (77.8%). Two patients (22.2%) had a recurrence of thrombosis in the first week postintervention. One of them underwent a second intervention, where percutaneous aspiration thrombectomy was performed again with successful removal of thrombus and establishment of in line flow. Two patients were lost to follow-up after birth. None of the remaining seven patients had rethrombosis throughout the postpartum period. Symptomatic relief was detected clinically in these patients. CONCLUSION: Endovascular treatment with US-guided percutaneous aspiration thrombectomy can be considered as a safe and effective way to remove thrombus from the deep veins in pregnant women with acute and subacute iliofemoral deep vein thrombosis.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

BACKGROUND AND PURPOSE: Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. MATERIALS AND METHODS: Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. RESULTS: 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3-51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. CONCLUSIONS: Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.

Efficacy of endovascular treatment and feasibility of stent-assisted coiling in the presence of severe and symptomatic vasospasm.

BACKGROUND AND PURPOSE: In patients with aneurysmal subarachnoid hemorrhage, deciding the optimal treatment strategy is challenging in the presence of severe and symptomatic vasospasm and the existing literature is limited. The purpose of this study was to evaluate the safety and effectiveness of endovascular treatment of intracranial aneurysms and the feasibility of stent-assisted coiling during severe and symptomatic vasospasm. MATERIALS AND METHODS: Fifteen consecutive patients with 18 aneurysms who underwent endovascular treatment during severe and symptomatic vasospasm were included in the study. Patient and aneurysm characteristics, treatment technique, and clinical and angiographic outcomes were retrospectively evaluated. RESULTS: Aneurysms were treated by the following techniques: single catheter coiling in 9, stent-assisted coiling in 8 (3 aneurysms with Y-configuration double stents), and balloon-assisted coiling in 1. All patients showed angiographic improvement of vasospasm after treatment including a noticeable dilation of the spastic parent arteries following deployment of the stents. According to the immediate post-treatment angiography results, 14 aneurysms (77.8%) had class I occlusion and 4 (22.2%) had class II occlusion. Three patients died during the course of subarachnoid hemorrhage. Mortality was related to the poor grade (Hunt and Hess grade V) and cardiovascular complications in two and refractory vasospasm one patient. The remaining patients had favorable clinical outcomes at follow-up (modified Rankin Scale 0-2). CONCLUSIONS: Endovascular treatment of intracranial aneurysms during severe and symptomatic vasospasm is safe and effective. Stent-assisted coiling in the presence of severe vasospasm is also feasible in wide-necked aneurysms with the additional benefits of mechanical vasodilation.

Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini.

PURPOSE: To retrospectively evaluate the feasibility and effectiveness of endovenous laser ablation or ultrasound-guided foam sclerotherapy for Giacomini vein insufficiency. This is the largest cohort of patients treated for Giacomini vein insufficiency with endovenous laser ablation or ultrasound-guided foam sclerotherapy. MATERIAL AND METHODS: Over a three-year period, 23 females and nine males (age range, 19-67 years) treated for Giacomini vein insufficiency with or without saphenous vein insufficiency were retrospectively reviewed. Diagnosis of venous insufficiency was made by color Doppler ultrasonography. Symptomatic insufficiency of the Giacomini vein or the saphenous veins was treated with endovenous laser ablation. Ultrasound-guided foam sclerotherapy was used for tortuous incompetent Giacomini veins. The venous disease was categorized according to the clinical, etiological, anatomical, and pathological classification, and clinical severity was graded with the venous clinical severity score. Follow-up included clinical examination and color Doppler ultrasonography. RESULTS: Thirty-nine limbs in 32 patients were treated (25 endovenous laser ablation and seven ultrasound-guided foam sclerotherapy). All procedures were technically successful. One patient in the ultrasound-guided foam sclerotherapy group had a recurrence with successful repeated treatment. Recurrence was not seen in the endovenous laser ablation group. No complications were observed. All patients had resolution and improvement in 100% of their symptoms at 12 months of follow-up. CONCLUSION: Giacomini vein insufficiency is mostly seen with insufficiency of the great saphenous vein and can be effectively treated with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

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.

The role of contrast-enhanced MR angiography in the assessment of recently ruptured intracranial aneurysms: a comparative study.

We evaluated contrast-enhanced MR angiography (MRA) for the identification of recently ruptured cerebral aneurysms. We studied 23 aneurysms in 18 patients (age range 34-72 years) with aneurysms of the anterior (n = 17) and posterior (n = 6) circulation by comparing 3D time-of-flight (TOF), contrast-enhanced MRA and digital subtraction angiography (DSA). In four of 23 aneurysms, 3D-TOF did not show the lesion. Contrast-enhanced MRA successfully depicted all aneurysms except one. T1 contamination artefacts from subarachnoid or intraparenchymal haemorrhages were evident on the 3D-TOF images in six cases. The artefacts were completely eliminated on the contrast-enhanced MRA images by subtraction of the pre-contrast images. The diagnostic information in patients with subarachnoid haemorrhages (SAHs) provided by contrast-enhanced MRA was comparable to that provided by DSA.