Minimally invasive procedure for removal of infected ventriculoatrial shunts.

BACKGROUND: Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. METHODS: We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. RESULTS: We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. CONCLUSION: Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Percutaneous Transanastomotic Stent Graft Deployment to Salvage Dysfunctional Native Forearm Radiocephalic Fistulae: Feasibility and Primary Patency at 12 Months.

PURPOSE: To evaluate feasibility and efficacy of transanastomotic self-expandable polytetrafluoroethylene stent graft placement for salvage of radiocephalic arteriovenous fistulae (RCAVFs). MATERIALS AND METHODS: From 2008 to 2016, 26 patients (21 male; age, 38-80 y) with dysfunctional RCAVFs for juxtaanastomotic lesions that were unresponsive to angioplasty underwent transanastomotic stent graft placement. Stenotic and thrombotic lesions were included. All were deemed unsuitable for surgical revision. Patency rates were calculated per Kaplan-Meier method. A Cox analysis was used to identify influencing factors. RESULTS: Thirty-two stent grafts (6 patients had 2 stents) were deployed. Anatomic and clinical success were achieved in all patients; no major complications occurred. Mechanical and/or pharmacologic thrombolysis was performed in 6 cases before stent graft deployment. During follow-up (median, 34.7 mo; range, 1.9-102.7 mo), 17 repeat interventions were required in 10 patients (43 procedures overall), for an endovascular intervention rate of 0.27 per year. At 3, 6, 12, and 24 months, primary patency (PP) rates were 96% ± 4 (95% CI, 75%-99%), 83% ± 7 (95% CI, 61%-93%), 78% ± 8 (95% CI, 55%-90%), and 69% ± 10 (95% CI, 46%-84%). The corresponding assisted PP rates were 96% ± 4 (95% CI, 76%-99%), 96% ± 4 (95% CI, 76%-99%), 92% ± 5 (95% CI, 71%-98%), and 82% ± 8 (95% CI, 60%-93%). Five AVFs were ultimately abandoned. Per Cox analysis, arterial diameter ≥ 4 mm was associated with better PP (P = .032). CONCLUSIONS: Transanastomotic stent graft placement for RCAVF salvage is feasible and safe, providing patency rates comparable with historical endovascular and surgical data. Its role should be evaluated in larger studies.

Covered stent assisted coil embolization of large Buhler aneurysm in setting of chronic celiac trunk occlusion.

BACKGROUND: The arc of Bühler (AOB) is a residual embryonal anastomosis between the celiac artery (CA) and the superior mesenteric artery (SMA). Although usually asymptomatic, it has clinical relevance when compensatory reverse flow between the SMA and the CA in response to celiac artery obstruction leads to aneurysm formation and bleeding. Endovascular coiling is the mainstay therapy because of the deep AOB retropancreatic location, which hinders open surgery. CASE PRESENTATION: We herein report a case of a 2.8-cm AOB saccular aneurysm and LAM compression of celiac trunk in a 47-year-old man during rehabilitation following motorcycle trauma and vertebral surgery. The patient was considered unsuitable for surgery. Neither conventional coiling nor bare-metal stent and balloon-assisted techniques for coiling were suitable because of the wide necked saccular shape of AOB aneurysm interposed between the SMA and the floor of celiac trunk. To exclude the aneurysm from direct SMA inflow and permit safe and efficient coiling to rule out retrograde sac perfusion, a 9-mm polytetrafluoroethylene stent graft (Viabahn; Gore, Phoenix, AZ, USA) was positioned in the mesenteric artery, followed by antegrade periprosthetic high-density packed coiling of the aneurysm. The AOB remained excluded from mesenteric perfusion. The patient's clinical condition and abdominal contrast-enhanced multislice computed tomographic findings were unremarkable at the 9-year follow-up. CONCLUSION: The 9 year long-term efficacy in our case raises the possibility that perigraft coiling following stent-graft deployment in the SMA may represent a valuable technical option for large Bühler aneurysms that are not amenable to stand-alone coiling.

Endovascular management of KILT syndrome and COVID-19-related extensive deep vein thrombosis in a pregnant patient: A case report.

We report on a 20-year-old pregnant woman who tested positive for SARS-CoV-2 and was diagnosed with KILT syndrome, a rare condition that increases the risk of thrombotic events. The patient showed signs of deep vein thrombosis that extended from the bilateral iliac vein to the inferior vena cava (IVC), which was treated with placement of an IVC filter and endovascular thromboaspiration/thrombolysis. The IVC was successfully recanalized; however, during follow-up, thrombotic restenosis occurred at the filter level, requiring filter removal. This case highlights the potential benefits of endovascular thromboaspiration/thrombolysis and IVC filter placement in patients with KILT syndrome presenting with acute thrombotic events.

Transoral percutaneous radiofrequency ablation with a steerable needle and cementoplasty under CBCT and infrared augmented reality navigation system guidance for the treatment of a C1 solitary plasmacytoma: A case report.

We report a case of a 40-year-old female with a solitary plasmacytoma of the right transverse apophysis of C1 who underwent combined transoral ablation using a curved steerable needle and cementoplasty under CBCT and infra-red augmented reality navigation system. An imaging work-up revealed an osteolytic lesion determining partial collapse of the right lateral mass of C1 and involving the vertebral foramen. After a biopsy, that revealed a solid tissue consistent with plasmacytoma, it was decided to proceed with radiation therapy. Subsequent PET-CT restaging scans showed residual tumors treated with a transoral percutaneous approach, combining ablation and cementoplasty. This report evaluates the benefits of this combined procedure and the transoral approach, focusing on the advantages of steerable devices and navigation systems.

Genicular Artery Embolization: A New Tool for the Management of Refractory Osteoarthritis-Related Knee Pain.

Osteoarthritis (OA) of the knee is a prevalent cause of chronic pain and disability, particularly affecting women. While traditionally attributed to chronic wear and tear, recent evidence highlights multifactorial pathogenesis involving low-grade inflammation and neoangiogenesis. Current therapeutic options include physical therapy, pharmacotherapy, and total knee arthroplasty (TKA). However, a subset of patients remain symptomatic despite conservative measures, necessitating the development of minimally invasive interventions. Genicular artery embolization (GAE) emerges as a promising option, targeting neovascularization and inflammatory processes in OA. This paper reviews the pathophysiological basis, patient selection criteria, procedural details, and outcomes of GAE. Notably, GAE demonstrates efficacy in relieving knee pain and improving function in patients refractory to conventional therapy. While further research is warranted to elucidate its long-term outcomes and compare it with existing modalities, GAE represents a novel approach in the management of symptomatic knee OA, potentially delaying or obviating the need for surgical intervention. Here, we synthesize the relevant literature, technical details of the procedure, and future perspectives. Moreover, the success of GAE prompts the exploration of transarterial embolization in other musculoskeletal conditions, underscoring the evolving role of interventional radiology in personalized pain management strategies.

Spontaneous Soft Tissue Hematomas in Patients with Coagulation Impairment: Safety and Efficacy of Transarterial Embolization.

The aim of this study is to report the authors' experience of percutaneous transarterial embolization (TAE) in patients with spontaneous soft tissue hematomas (SSTH) and active bleeding with anticoagulation impairment. The study retrospectively identified 78 patients who received a diagnosis of SSTH by CT scan and underwent TAE between 2010 and 2019 in a single trauma center. The patients were stratified using Popov classification into categories: 2A, 2B, 2C, and 3. The patient's 30-day survival after TAE was considered the primary outcome; immediate technical success, the need for additional TAE, and TAE-related complications were considered secondary outcomes. Immediate technical success, complication rate, and risk factors for death were analyzed. Follow-up stopped on day 30 from TAE. 27 patients (35%) fell into category 2A, 8 (10%) into category 2B, 4 (5%) into category 2C, and 39 (50%) into category 3. Immediate technical success was achieved in 77 patients (98.7%). Complications included damage at the arterial puncture site (2 patients, 2.5%) and acute kidney injury (24 patients, 31%). Only 2 patients (2.5%) had been discharged with a new diagnosis of chronic kidney disease. The 30-day overall mortality rate was 19% (15 patients). The mortality rate was higher in hemodynamically unstable patients, in Popov categories 2B, 2C, and 3, and in patients with an initial eGFR < 30 mL/min × 1.73 m2. The study demonstrated a higher mortality risk for categories 2B, 2C, and 3 compared to category 2A. Nonetheless, TAE has proven effective and safe in type 2A patients. Even though it is unclear whether type 2A patients could benefit from conservative treatment rather than TAE, in the authors' opinion, a TAE endovascular approach should be promptly considered for all patients in ACT with active bleeding demonstrated on CT scans.

Case of IV Stage Juvenile Nasopharyngeal Angiofibroma Presurgically Treated with a Single ECA Stop-Flow Embolization Technique Using Onyx 18.

Background: Juvenile nasopharyngeal angiofibroma (JNA) is a rare tumor that mainly affects young boys. Its intervention may be complex due to its high vascularity, location, and extension. Preoperative embolization is used to prevent intrasurgical and postsurgical bleeding. Two main kinds of embolization are described in literature: intratumoral and transarterial, and numerous embolic materials are used. Case Presentation. We want to present a case of presurgical embolization of a stage IV JNA, performed using a single stop-flow balloon assisted technique with the balloon cuffed exclusively in the external carotid artery and using Onyx 18 as an embolic agent. Conclusions: The embolization with an exclusive external carotid artery single stop-flow technique using Onyx 18 is a safe, effective, and a definitive approach.

Pulmonary Artery Pseudoaneurysms Embolization: Bicentric Experience and Review of the Literature.

The purpose of this bicentric case series was to report the safety, efficacy, and clinical outcome of transcatheter embolization in pulmonary artery pseudoaneurysms (PAPAs). Between January 2016 and June 2021, eight patients with PAPA were subjected to transcatheter embolization. The total number of patients was eight, of which five were female, with a mean age of 62 ± 14 years (average ± standard deviation). Etiology was traumatic in 2/8 cases and iatrogenic in 6/8 cases (after positioning a Swan-Ganz catheter in 5/6 cases and a temporary pacemaker in the latter case). In a single case, the PAPA was incidentally discovered during a routine X-ray, in the remaining 7 cases, the procedure was performed in emergency settings. PAPA embolization was performed using detachable coils alone in 3 cases; coils and glue in 1 case; coils, glue, and vascular plug in 1 case; coils and non-adhesive liquid embolic agents (Onyx and Squid respectively) in 2 cases; and non-adhesive liquid embolic agent alone (Onyx) in 1 case. No peri-procedural or post-procedural complications were recorded. Both the technical and clinical success rates were 100.0%. In conclusion, endovascular embolization is a technically feasible and safe therapeutic option for patients with PAPAs.

Safety and Feasibility of Steerable Radiofrequency Ablation in Combination with Cementoplasty for the Treatment of Large Extraspinal Bone Metastases.

Background: Radiofrequency ablation (RFA) and cementoplasty, individually and in concert, has been adopted as palliative interventional strategies to reduce pain caused by bone metastases and prevent skeletal related events. We aim to evaluate the feasibility and safety of a steerable RFA device with an articulating bipolar extensible electrode for the treatment of extraspinal bone metastases. Methods: All data were retrospectively reviewed. All the ablation procedures were performed using a steerable RFA device (STAR, Merit Medical Systems, Inc., South Jordan, UT, USA). The pain was assessed with a VAS score before treatment and at 1-week and 3-, 6-, and 12-month follow-up. The Functional Mobility Scale (FMS) was recorded preoperatively and 1 month after the treatment through a four-point scale (4, bedridden; 3, use of wheelchair; 2, limited painful ambulation; 1, normal ambulation). Technical success was defined as successful intraoperative ablation and cementoplasty without major complications. Results: A statistically significant reduction of the median VAS score before treatment and 1 week after RFA and cementoplasty was observed (p < 0.001). A total of 6/7 patients who used a wheelchair reported normal ambulation 1 month after treatment. All patients with limited painful ambulation reported normal ambulation after the RFA and cementoplasty (p = 0.003). Technical success was achieved in all the combined procedures. Two cement leakages were reported. No local recurrences were observed after 1 year. Conclusions: The combined treatment of RFA with a steerable device and cementoplasty is a safe, feasible, and promising clinical option for the management of painful bone metastases, challenging for morphology and location, resulting in an improvement of the quality of life of patients.

Quantib Prostate Compared to an Expert Radiologist for the Diagnosis of Prostate Cancer on mpMRI: A Single-Center Preliminary Study.

Background: To evaluate the clinical utility of an Artificial Intelligence (AI) radiology solution, Quantib Prostate, for prostate cancer (PCa) lesions detection on multiparametric Magnetic Resonance Images (mpMRI). Methods: Prostate mpMRI exams of 108 patients were retrospectively studied. The diagnostic performance of an expert radiologist (>8 years of experience) and of an inexperienced radiologist aided by Quantib software were compared. Three groups of patients were assessed: patients with positive mpMRI, positive target biopsy, and/or at least one positive random biopsy (group A, 73 patients); patients with positive mpMRI and a negative biopsy (group B, 14 patients), and patients with negative mpMRI who did not undergo biopsy (group-C, 21 patients). Results: In group A, the AI-assisted radiologist found new lesions with positive biopsy correlation, increasing the diagnostic PCa performance when compared with the expert radiologist, reaching an SE of 92.3% and a PPV of 90.1% (vs. 71.7% and 84.4%). In group A, the expert radiologist found 96 lesions on 73 mpMRI exams (17.7% PIRADS3, 56.3% PIRADS4, and 26% PIRADS5). The AI-assisted radiologist found 121 lesions (0.8% PIRADS3, 53.7% PIRADS4, and 45.5% PIRADS5). At biopsy, 33.9% of the lesions were ISUP1, 31.4% were ISUP2, 22% were ISUP3, 10.2% were ISUP4, and 2.5% were ISUP5. In group B, where biopsies were negative, the AI-assisted radiologist excluded three lesions but confirmed all the others. In group-C, the AI-assisted radiologist found 37 new lesions, most of them PIRADS 3, with 32.4% localized in the peripherical zone and 67.6% in the transition zone. Conclusions: Quantib software is a very sensitive tool to use specifically in high-risk patients (high PIRADS and high Gleason score).

Green Tattoo Pre-Operative Renal Embolization for Robotic-Assisted and Laparoscopic Partial Nephrectomy: A Practical Proof of a New Technique.

(1) Background: Our aim is to describe a new mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) pre-operative renal embolization technique for assisted-robotic and laparoscopic partial nephrectomy with near-infra-red fluorescence imaging. (2) Methods: Thirteen patients with biopsy-proven renal tumors underwent pre-operative mixed indocyanine-ethylene vinyl alcohol (EVOH) embolization (Green-embo) between June 2021 and August 2022. All pre-operative embolizations were performed with a super selective stop-flow technique using a balloon microcatheter to deliver an indocyanine-EVOH mixture into tertiary order arterial branch feeders and the intra-lesional vascular supply. Efficacy (evaluated as complete embolization, correct tumor mapping on infra-red fluorescence imaging and clamp-off surgery) and safety (evaluated as complication rate and functional outcomes) were primary goals. Clinical and pathological data were also collected. (3) Results: Two male and eleven female patients (mean age 72 years) received pre-operative Green-embo. The median tumor size was 29 mm (range 15-50 mm). Histopathology identified renal cell carcinoma (RCC) in 9 of the 13 (69%) patients, oncocytoma in 3 of the 13 (23%) patients and sarcomatoid RCC in 1 of the 13 (8%) patients. Lesions were equally distributed between polar, meso-renal, endo- and exophytic locations. Complete embolization was achieved in all the procedures. A correct green mapping was identified during all infra-red fluorescence imaging. All patients were discharged on the second day after the surgery. The median blood loss was 145 cc (10-300 cc). No significant differences were observed in serum creatinine levels before and after the embolization procedures. (4) Conclusions: The Green-tattoo technique based on a mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) is a safe and effective pre-operative embolization technique. The main advantages are the excellent lesion mapping for fluorescence imaging, reduction in surgical time, and definitive, complete and immediate tumor devascularization based on the deep Onyx-18 penetration, leading to a very low intra-operative blood loss.

Combined Trans-Arterial Embolization and Ablation for the Treatment of Large (>3 cm) Liver Metastases: Review of the Literature

(1) Background: The aim of this review was to determine the state of clinical practice in the role of the combined approach of embolization and ablation in patients with secondary liver lesions greater than 3 cm who are not candidates for surgery, and to study its safety and efficacy. (2) Methods: Two reviewers conducted the literature search independently. Eight articles on the combined approach of embolization and ablation in secondary liver lesions were selected. (3) Results: The studies were published between 2009 and 2020. Two studies were prospective in design. The sample size was < 100 patients for all studies. All studies demonstrated the safety of the combined approach based on the low complication rate. Some studies lamented non-uniform systemic chemotherapy regimens and the variability in the sequence of embolization and ablation. (4) Conclusions: This review presents the combined approach of ablation and embolization in liver lesions greater than 3 cm as a safe therapeutic procedure with positive effects on patient survival. Prospective and multicentric studies are needed to further evaluate its efficacy.

Testicular artery originating from the inferior mesenteric artery: an alert for interventionalists - A case report.

Testicular arteries usually arise from the abdominal aorta. During an elective embolization of superior rectal arteries for hemorrhoidal disease performed in a 52-year-old male patient, a previously unreported vascular variant was identified. On selective angiography, the inferior mesenteric artery split into left colic artery and left testicular artery, without any evidence of vascular supply to the hemorrhoidal cushions. Superior rectal arteries were embolized after catheterization of the median sacral artery. A thorough knowledge of vascular variations is essential for interventional radiologists in order to recognize them and avoid potential complications.

Multivessel endovascular therapy for undiagnosed vascular type Ehlers-Danlos syndrome. Successful percutaneous transcatheter coil embolization of hepatic artery pseudoaneurysm with stenting of right renal and iliac arteries in emergency setting.

Among Ehlers-Danlos syndromes, the vascular type is the most severe because of its vascular complications. Transcatheter embolization of medium-sized arteries has become the first-line therapy for life-threatening hemorrhage. Ongoing multiple lesions causing hemorrhagic or ischemic complications in the acute phase can challenge patient management. Multivessel endovascular treatment has never been reported. In this study, we report successful single-session treatment by coiling of a ruptured pseudoaneurysm of the hepatic artery with stenting of dissected right renal and iliac arteries in a 46-year-old female. Percutaneous transfemoral approach was gained and sealed with a plug-based closure device. Genetic disease was subsequently confirmed by molecular analysis.

One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics.

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients.

New therapeutic options provided by off-label deployment of stent graft for tailored arteriovenous access salvage: Two cases.

A tailored therapy to patient requirements by combining endovascular and surgical steps can be necessary to prolong the life of a vascular access. Stent grafts play a growing role for the therapy of dialytic access complications. Randomized multi-center trials, however, support the on-label use of stent grafts in the treatment of graft venous outflow and in-stent restenosis. The main contraindication to their use is an ongoing infection. We report two cases of new off-label application of Viabahn (Gore, flagstaff, USA) stent graft. In the first case, the failure of a radiocephalic early cannulation graft was treated by stent graft placement on the arterial inflow anastomosis, when emergent angiographic examination revealed the previously unknown high takeoff of the radial artery from the axillary artery. At 13-month follow-up, the target lesion remained untreated. In the second case, elbow stent graft occlusion with extended thrombosis occurred in a right radiocephalic fistula after 3 years of unassisted patency. Being the last option for vascular access, successful endovascular recanalization was carried out. After 3 months, however, the clinical setting relapsed. A two-stage hybrid strategy with vascular surgeon was arranged due to ongoing signs of local infection. Flow was restored by emergent thromboaspiration associated with a new stent graft placement as a endovascular bridge to subsequent surgical treatment. After 2 days, the overlapped stent grafts were excised as planned. Surgical rerouting was completed by polytetrafluoroethylene prosthetic bridge implantation across the elbow. At 4 months, the follow-up remained uneventful. In selected instances, the off-label use of stent grafts may expand the therapeutic options of the vascular access team.

Disabling portosystemic encephalopathy in a non-cirrhotic patient: Successful endovascular treatment of a giant inferior mesenteric-caval shunt via the left internal iliac vein.

Hepatic encephalopathy is suspected in non-cirrhotic cases of encephalopathy because the symptoms are accompanied by hyperammonaemia. Some cases have been misdiagnosed as psychiatric diseases and consequently patients hospitalized in psychiatric institutions or geriatric facilities. Therefore, the importance of accurate diagnosis of this disease should be strongly emphasized. A 68-year-old female patient presented to the Emergency Room with confusion, lethargy, nausea and vomiting. Examination disclosed normal vital signs. Neurological examination revealed a minimally responsive woman without apparent focal deficits and normal reflexes. She had no history of hematologic disorders or alcohol abuse. Her brain TC did not demonstrate any intracranial abnormalities and electroencephalography did not reveal any subclinical epileptiform discharges. Her ammonia level was > 400 mg/dL (reference range < 75 mg/dL) while hepatitis viral markers were negative. The patient was started on lactulose, rifaximin and low-protein diet. On the basis of the doppler ultrasound and abdomen computed tomography angiography findings, the decision was made to attempt portal venography which confirmed the presence of a giant portal-systemic venous shunt. Therefore, mechanic obliteration of shunt by interventional radiology was performed. As a consequence, mesenteric venous blood returned to hepatopetally flow into the liver, metabolic detoxification of ammonia increased and hepatic encephalopathy subsided. It is crucial that physicians immediately recognize the presence of non-cirrhotic encephalopathy, in view of the potential therapeutic resolution after accurate diagnosis and appropriate treatments.