Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020.

Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.

Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents.

OBJECTIVES: To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality. METHODS: Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008-2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors. RESULTS: The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22-0.99; p = .047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13-50.14; p = .024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01-40.52; p = .047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10-10.74; p = .006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786). CONCLUSIONS: Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding. KEY POINTS: • Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.

Impact of Thoracic Endografting on the Hemodynamics of the Native Aorta: Pre- and Postoperative Assessments of Wall Shear Stress and Vorticity Using Computational Fluid Dynamics.

PURPOSE: To quantify the hemodynamic consequences of thoracic endovascular aortic repair (TEVAR) by comparing the preoperative and postoperative wall shear stress (WSS) and vorticity profiles on computational fluid dynamics (CFD) simulations. MATERIALS AND METHODS: The pre- and postoperative computed tomography (CT) scans from 20 consecutive patients (median age 69 years, range 20-87) treated for different thoracic aortic pathologies (11 aneurysms, 5 false aneurysms, 3 penetrating ulcers, and 1 traumatic aortic rupture) were segmented to construct patient-specific CFD models using a meshless code. The simulations were run over the cardiac cycle, and the WSS and vorticity values measured at the proximal and distal landing zones were compared. RESULTS: The CFD runs provided 4-dimensional simulations of blood flow in all patients. WSS and vorticity profiles at the proximal landing zone (located in zones 0-3 in 15 patients) varied in 18 and 20 of the cases, respectively; WSS was increased in 11 cases and the vorticity in 9. Pre- and postoperative WSS median values were 4.19 and 4.90 Pa, respectively. Vorticity median values were 40.38 and 39.17 Hz, respectively. CONCLUSION: TEVAR induces functional alterations in the native thoracic aorta, though the prognostic significance of these changes is still unknown. CFD appears to be a valuable tool to explore aortic hemodynamics, and its application in a larger series would help define a predictive role for these hemodynamic assessments.

Outcomes of Transcatheter Arterial Embolization with a Modified N-Butyl Cyanoacrylate Glue for Spontaneous Iliopsoas and Rectus Sheath Hematomas in Anticoagulated Patients.

PURPOSE: To assess the efficacy and safety of n-butyl cyanoacrylate methacryloxy sulfolane (NBCA-MS) transcatheter arterial embolization for anticoagulation-related soft-tissue bleeding and to evaluate predictive factors of clinical success and 30-day mortality. MATERIALS AND METHODS: A retrospective review of 50 anticoagulated patients (25 male; mean age, 71.7 y ± 14.2; range, 19-87 y) who underwent emergent Glubran 2 NBCA-MS embolization for iliopsoas hematomas (IPHs; n = 38), rectus sheath hematomas (n = 11), or both (n = 1) between 2011 and 2016 was performed. Inclusion criteria were active bleeding on computed tomography (CT) and anticoagulation. The mean number of red blood cell (RBC) units transfused was 4.8 ± 3.2 (range, 0-14), median hemoglobin level before embolization was 9.7 g/dL (range, 6.2-18 g/dL), and median "mean blood pressure" (MBP) was 62.5 mm Hg (range, 58.3-75 mm Hg). Mean International Normalized Ratio before intervention was 2.5 ± 1.5 (range, 1.0-6.9). Angiograms revealed extravasation in 44 of 50 patients (88%). Mean hematoma volume was 1,119.2 cm3 ± 863.5 (range, 134.0-3,589.0 cm3). RESULTS: Technical success was achieved in 100% of patients, and 30-day clinical success was achieved in 66% of patients. Recurrent bleeding and mortality rates within 30 days of embolization were 34% and 44%, respectively. No complications related to the embolization procedure occurred. Lower MBP (P = .003), greater number of RBC units transfused (P = .003), greater volume of hematoma (P = .04), and IPH location (P = .02) were associated with decreased clinical success. Clinical failure (P = .00002), lower MBP (P = .004), greater number of RBC units transfused (P = .002), and IPH location (P = .01) were significantly associated with higher 30-day mortality rates. CONCLUSIONS: Transcatheter arterial embolization with NBCA-MS is safe and effective in treating refractory soft-tissue bleeding in anticoagulated patients despite the high mortality rates associated with this patient population.

Optimum and stepped care standardised antihypertensive treatment with or without renal denervation for resistant hypertension (DENERHTN): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Conflicting blood pressure-lowering effects of catheter-based renal artery denervation have been reported in patients with resistant hypertension. We compared the ambulatory blood pressure-lowering efficacy and safety of radiofrequency-based renal denervation added to a standardised stepped-care antihypertensive treatment (SSAHT) with the same SSAHT alone in patients with resistant hypertension. METHODS: The Renal Denervation for Hypertension (DENERHTN) trial was a prospective, open-label randomised controlled trial with blinded endpoint evaluation in patients with resistant hypertension, done in 15 French tertiary care centres specialised in hypertension management. Eligible patients aged 18-75 years received indapamide 1·5 mg, ramipril 10 mg (or irbesartan 300 mg), and amlodipine 10 mg daily for 4 weeks to confirm treatment resistance by ambulatory blood pressure monitoring before randomisation. Patients were then randomly assigned (1:1) to receive either renal denervation plus an SSAHT regimen (renal denervation group) or the same SSAHT alone (control group). The randomisation sequence was generated by computer, and stratified by centres. For SSAHT, after randomisation, spironolactone 25 mg per day, bisoprolol 10 mg per day, prazosin 5 mg per day, and rilmenidine 1 mg per day were sequentially added from months two to five in both groups if home blood pressure was more than or equal to 135/85 mm Hg. The primary endpoint was the mean change in daytime systolic blood pressure from baseline to 6 months as assessed by ambulatory blood pressure monitoring. The primary endpoint was analysed blindly. The safety outcomes were the incidence of acute adverse events of the renal denervation procedure and the change in estimated glomerular filtration rate from baseline to 6 months. This trial is registered with ClinicalTrials.gov, number NCT01570777. FINDINGS: Between May 22, 2012, and Oct 14, 2013, 1416 patients were screened for eligibility, 106 of those were randomly assigned to treatment (53 patients in each group, intention-to-treat population) and 101 analysed because of patients with missing endpoints (48 in the renal denervation group, 53 in the control group, modified intention-to-treat population). The mean change in daytime ambulatory systolic blood pressure at 6 months was -15·8 mm Hg (95% CI -19·7 to -11·9) in the renal denervation group and -9·9 mm Hg (-13·6 to -6·2) in the group receiving SSAHT alone, a baseline-adjusted difference of -5·9 mm Hg (-11·3 to -0·5; p=0·0329). The number of antihypertensive drugs and drug-adherence at 6 months were similar between the two groups. Three minor renal denervation-related adverse events were noted (lumbar pain in two patients and mild groin haematoma in one patient). A mild and similar decrease in estimated glomerular filtration rate from baseline to 6 months was observed in both groups. INTERPRETATION: In patients with well defined resistant hypertension, renal denervation plus an SSAHT decreases ambulatory blood pressure more than the same SSAHT alone at 6 months. This additional blood pressure lowering effect may contribute to a reduction in cardiovascular morbidity if maintained in the long term after renal denervation. FUNDING: French Ministry of Health.

3D rotational angiography in the endovascular treatment of visceral aneurysms: preliminary experience in a single centre.

OBJECTIVES: Endovascular embolization is a valid option for the management of visceral artery aneurysms. Imaging is crucial for providing anatomical assessments, but preoperative non-invasive investigations may not be exhaustive. The aim of this work is to present preliminary experience with the use of three-dimensional rotational angiography (3DRA) in this particular theatre. METHODS: Seven patients were treated for eight visceral aneurysms (six splenic and two renal) by endovascular embolization. 3DRA was performed before the treatment using a standard protocol. Different parameters (location of the lesion, the afferent and efferent vessels, aneurysm neck, vascular diameters, working incidence) were analyzed. RESULTS: 3DRA was successfully accomplished in all procedures. Mean aneurysm diameter was 23 mm and mean C-arm working incidence was 29° (R-L) and 9° (C-C). The sandwich technique was used in four lesions and the packing in the remaining four. Technical success was 100 %. The mean radiation dose per procedure was 291 600 mGy.cm(2). The mean procedural time was 2.25 hours. There were no immediate or short-term complications. CONCLUSIONS: 3DRA could be an interesting intraoperative tool to provide anatomical and technical assessments of the visceral arteries necessary for endovascular treatment, especially when information from preoperative imaging is not exhaustive. KEY POINTS: Endovascular embolization is a valid alternative solution for visceral artery aneurysm treatment. Imaging is crucial for anatomical assessments and treatment guidance. 3DRA can contribute to endovascular treatment in lieu of preoperative imaging.

Prognostic Significance of the Renal Resistive Index After Renal Artery Revascularization in the Context of Flash Pulmonary Edema.

PURPOSE: To evaluate the prognostic value of the renal resistive index (Ri) after renal artery revascularization in the context of flash pulmonary edema. METHODS: Between 2000 and 2008, 43 patients (mean age 72.1±10.9 years; 23 women) underwent renal artery angioplasty/stenting in the context of flash pulmonary edema. Intrarenal Ri was assessed using duplex ultrasound. The majority (97.7%) of patients had hypertension, and nearly half (46.5%) had diabetes mellitus. For this retrospective analysis, the patients were divided into 2 groups according to the median Ri (<0.8 and ≥0.8) of the population. A Cox proportional hazards model was used to identify predictors of all-cause mortality (primary endpoint) and rehospitalization for heart failure; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). The mean follow-up was 49.8±30.6 months. RESULTS: There was no difference between the groups regarding clinical characteristics. A high Ri was associated with the risk of all-cause death (HR 2.54, 95% CI 1.15 to 5.60, p=0.021). This relationship was still statistically significant after adjustment for age, gender, diabetes, glomerular filtration rate, and treatment with a renin-angiotensin system inhibitor (HR 1.74, 95%CI 1.08 to 2.81, p=0.032). A high Ri was also associated with cardiovascular death in unadjusted and adjusted analyses. In contrast, a high Ri was not associated with the risk of rehospitalization for heart failure. CONCLUSION: After renal artery revascularization for flash pulmonary edema, a high intrarenal Ri is independently associated with all-cause mortality. Determination of the intrarenal Ri after this procedure may be useful for identifying at-risk patients.

Evaluation of visceral artery displacement by endograft delivery system insertion.

PURPOSE: To assess the displacement of the aorta and its visceral branch ostia after insertion of a rigid system including a stiff guidewire and endograft delivery system during endovascular aneurysm repair (EVAR). METHODS: Between January and May 2013, 20 consecutive patients (19 men; mean age 67.2 years, range 61-83) undergoing EVAR (n=13) or fenestrated EVAR (FEVAR, n=7) were prospectively enrolled. Each patient underwent an intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) acquisition after the insertion of the endograft delivery system. Each ceCBCT was loaded on a workstation and manually registered with the preoperative computed tomographic angiogram (CTA) in a way that optimized superposition of the spine from both images. The locations of the superior mesenteric artery (SMA) and of both renal artery ostia were depicted in 3D multiplanar reconstructions by 3 independent operators on the CTA and on the ceCBCT. Motion of the aortic segment at the level of the visceral arteries was estimated by the barycenter of the origin of the SMA and both renal arteries. RESULTS: The ostium displacement between the CTA and ceCBCT images was 6.7 mm (range 2.2-13.5) for the SMA; 6.2 mm (2.5-13.5) and 6.4 mm (1.9-14.5) for the right and the left renal arteries, respectively; and 5.5 mm (2.3-11.4) for the aortic segment. The displacement was mostly posterosuperior and to the left (65%). The radiation dose and contrast volume required to perform the ceCBCT were 30% and 41%, respectively, of the amounts used in the EVAR procedures. CONCLUSION: This study demonstrates a significant displacement of the main aortic branches after rigid material insertion. Image fusion applications aimed at providing intraoperative guidance must allow an easy and rapid repositioning of the overlay during the procedure to match the deformation of the aortic anatomy during the procedure.

Thrombocytopenia: an early marker of late mortality in type B aortic dissection.

Mid-term and long-term mortality after aortic dissection remain high and due to unknown factors. To determine predicting factors at the acute phase associated with mid- and long-term all-cause mortality, patients with type B aortic dissection including intramural hematoma, treated in one referral university center in an area with a population of 4 million, were analyzed over a period of 12 years (from 1996 to 2008). Based on the total population, 77 patients discharged after type B aortic dissection (including 11 intramural hematoma) were recorded as treated with either medical treatment alone (n = 41) or with additional endovascular therapy (n = 36). The mean follow-up period was 50.8 months, with a survival rate of 78 % (17 deaths). Patient history, symptoms, medical treatment, biological parameters, imaging, and intervention during acute phase (more than 150 parameters) were analyzed to identify any relationship with complications and death. Kaplan-Meier survival curve and Cox proportional hazards analyses identified independent predictors of follow-up mortality from any cause. Factors influencing mortality (P < 0.05) were a low systolic blood pressure (SBP) at admission, a thrombocytopenia in the acute period, chronic bronchitis, diameter of ascending aorta, and renin-angiotensin system inhibitor intake. Independent predictors of mortality were chronic bronchitis (P = 0.0022, hazard ratio (HR) 17.5), early thrombocytopenia (P = 0.042, HR 3.5), and admission SBP <120 mmHg (P = 0.0048, HR 7.928). Treated (medical ± endovascular) type B aortic dissection held a worse long-term prognosis, which can be correlated with predicting factors, especially in-hospital thrombocytopenia, and should require closer follow-up.

Off-the-shelf branched endograft for emergent aneurysm repair.

A 65-year-old man with a tender, 98-mm-diameter, pararenal aortic aneurysm was referred to our center. This patient was unfit for open repair and could not wait 8 weeks for a custom-made endograft to be manufactured. We describe the endovascular treatment of his aneurysm with a 4-branch endograft that had been constructed for another patient. He had an uneventful recovery. Postoperative CT scan confirmed patency of all visceral branches and exclusion of the aneurysm. Various branched and fenestrated endografts are or will soon be available "off-the-shelf" to treat ruptured or symptomatic pararenal and thoracoabdominal aneurysms. We assess the pros and cons of this new generation of endografts designed to adapt to most aortic anatomies.

Amplatzer™ Vascular Plugs for Embolisation: A 10-Year Single-Centre Retrospective Study.

Our objective was to investigate the indications, effectiveness, and safety of Amplatzer™ Vascular Plugs (AVPs) in clinical practice. To retrospectively identify patients managed with AVPs at the Dijon University Hospital between January 2011 and April 2021, we searched materials vigilance registries and procedure reports. The 110 identified patients underwent 111 procedures with delivery of 202 AVPs into 118 vessels; 84% of the procedures were performed by radiologists with over 10 years' experience and 67% were scheduled. Varicocele, haemostasis, pelvic varicose veins, and arterio-venous dialysis fistulas accounted for 69% of procedures. The technical and clinical success rates were 99% and 97%, respectively. The single major complication was AVP migration in a high-flow internal iliac vein, with no residual abnormalities after successful device retrieval. Several AVPs and/or concomitant injection of coils or liquid agents were used in 80% of cases. The use of AVPs alone occurred chiefly for splenic artery embolisation in trauma patients and for collateral vein occlusion in dysfunctional arterio-venous dialysis fistulas. No cases of recanalisation occurred during the 19 ± 29 month follow-ups. Based on their good safety and effectiveness profile, AVPs deserve to be part of the therapeutic armamentarium of every interventional radiologist.

Predictive Factors of Local Recurrence after Colorectal Cancer Liver Metastases Thermal Ablation.

BACKGROUND: Identify risk factors for local recurrence (LR) after radiofrequency (RFA) and microwave (MWA) thermoablations (TA) of colorectal cancer liver metastases (CCLM). METHODS: Uni- (Pearson's Chi2 test, Fisher's exact test, Wilcoxon test) and multivariate analyses (LASSO logistic regressions) of every patient treated with MWA or RFA (percutaneously and surgically) from January 2015 to April 2021 in Centre Georges François Leclerc in Dijon, France. RESULTS: Fifty-four patients were treated with TA for 177 CCLM (159 surgically, 18 percutaneously). LR rate was 17.5% of treated lesions. Univariate analyses by lesion showed factors associated with LR: sizes of the lesion (OR = 1.14), size of nearby vessel (OR = 1.27), treatment of a previous TA site LR (OR = 5.03), and non-ovoid TA site shape (OR = 4.25). Multivariate analyses showed that the size of the nearby vessel (OR = 1.17) and the lesion (OR = 1.09) remained significant risk factors of LR. CONCLUSIONS: The size of lesions to treat and vessel proximity are LR risk factors that need to be considered when making the decision of thermoablative treatments. TA of an LR on a previous TA site should be reserved to specific situations, as there is an important risk of another LR. An additional TA procedure can be discussed when TA site shape is non-ovoid on control imaging, given the risk of LR.

Incremental value of the combined brain-cardiac CT protocol on prediction of atrial fibrillation after stroke.

Introduction: Atrial fibrillation (AF) is one of the most common causes of ischemic stroke. It is essential to target patients at highest risk of AF detected after stroke (AFDAS), who should benefit from a prolonged rhythm screening strategy. Cardiac-CT angiography (CCTA) was added to the stroke protocol used in our institution in 2018. We sought to assess, for AFDAS, the predictive value of atrial cardiopathy markers by a CCTA performed on admission for acute ischemic stroke. Patients and Methods: From November 2018 to October 2019, consecutive stroke patients with no history of AF were included. Let atrial volume (LAV), epicardial adipose tissue (EAT) attenuation and volume, and LAA characteristics were measured on CCTA. The primary endpoint was the presence of AFDAS at follow-up, diagnosed by continuous electrocardiographic monitoring, long-term external Holter monitoring during hospital stay, or implantable cardiac monitor (ICM). Results: Sixty of the 247 included patients developed AFDAS. Multivariable analysis shows independent predictors of AFDAS: age >80 years (HR 2.46; 95%CI (1.23-4.92), p = 0.011), indexed LAV >45 mL/m2 (HR 2.58; 95%CI (1.19-5.62), p = 0.017), EAT attenuation > -85HU (HR 2.16; 95%CI (1.13-4.15), p = 0.021) and LAA thrombus (HR 2.50; 95%CI (1.06-5.93), p = 0.037). Added consecutively to AFDAS prediction AS5F score (combining age and NIHSS >5), these markers had an incrementally better predictive value compared with the global Chi2 of the initial model (p = 0.001, 0.035, and 0.015 respectively). Discussion and conclusion: Adding CCTA to the acute stroke protocol to assess markers of atrial cardiopathy associated with AFDAS may help to better stratify the AF screening strategy, including the use of an ICM.

Haemodynamic imaging of thoracic stent-grafts by computational fluid dynamics (CFD): presentation of a patient-specific method combining magnetic resonance imaging and numerical simulations.

OBJECTIVES: In the last decade, there was been increasing interest in finding imaging techniques able to provide a functional vascular imaging of the thoracic aorta. The purpose of this paper is to present an imaging method combining magnetic resonance imaging (MRI) and computational fluid dynamics (CFD) to obtain a patient-specific haemodynamic analysis of patients treated by thoracic endovascular aortic repair (TEVAR). METHODS: MRI was used to obtain boundary conditions. MR angiography (MRA) was followed by cardiac-gated cine sequences which covered the whole thoracic aorta. Phase contrast imaging provided the inlet and outlet profiles. A CFD mesh generator was used to model the arterial morphology, and wall movements were imposed according to the cine imaging. CFD runs were processed using the finite volume (FV) method assuming blood as a homogeneous Newtonian fluid. RESULTS: Twenty patients (14 men; mean age 62.2 years) with different aortic lesions were evaluated. Four-dimensional mapping of velocity and wall shear stress were obtained, depicting different patterns of flow (laminar, turbulent, stenosis-like) and local alterations of parietal stress in-stent and along the native aorta. CONCLUSIONS: A computational method using a combined approach with MRI appears feasible and seems promising to provide detailed functional analysis of thoracic aorta after stent-graft implantation. KEY POINTS : • Functional vascular imaging of the thoracic aorta offers new diagnostic opportunities • CFD can model vascular haemodynamics for clinical aortic problems • Combining CFD with MRI offers patient specific method of aortic analysis • Haemodynamic analysis of stent-grafts could improve clinical management and follow-up.

Contrast-enhanced ultrasound vs. CT angiography in fenestrated EVAR surveillance: a single-center comparison.

PURPOSE: To evaluate contrast-enhanced ultrasound (CEUS) as an effective alternative to computed tomographic angiography (CTA) during follow-up after fenestrated endovascular aneurysm repair (EVAR) of juxtarenal aortic aneurysms. METHODS: Between January 2008 and April 2011, 62 patients (all men; mean age 72 years) underwent fenestrated EVAR follow-up with both CTA and CEUS. In a retrospective analysis, the first CTA and CEUS postoperative examinations after EVAR were compared for endoleak detection, aneurysm sac diameter, and target vessel patency. The examinations were performed within 30 days of the procedure and the interval between the 2 scans was <7 days. Only fenestrated endografts with up to 3 fenestrations (with or without a scallop) were eligible so that the entire implant could be visualized with standard abdominal ultrasound. RESULTS: The mean diameters of the aneurysm sac were 56.58±8.56 mm with CEUS and 57.70±8.59 mm with CTA. The mean difference in aneurysm sac diameter was -1.13±3.19 mm (95% CI -0.34 to -1.92), with CTA measurements tending to be slightly larger. Bland-Altman plots showed good agreement between the imaging modalities with respect to aneurysm sac diameter (Spearman correlation coefficient r(s)=0.921, p<0.01). Endoleaks were detected by CTA in 7 (11.3%) of 62 patients and by CEUS in 6 (9.7%). In 59 (95.16%) cases, the tests agreed, and their equivalence was confirmed by binomial distribution testing. There was complete agreement between CEUS and CTA in the assessment of target vessels (144/146 patent target arteries; 1 had a significant stenosis and another was thrombosed). CONCLUSION: CEUS is as accurate as CTA in endoleak detection, abdominal aortic aneurysm diameter measurement, and the evaluation of target vessels during surveillance of fenestrated stent-grafts. Although it cannot yet be proposed as the only imaging modality during follow-up, CEUS could be usefully employed with the self-evident advantage of reducing lifetime exposure to ionizing radiation.

Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms.

PURPOSE: To evaluate the suitability of a standardized fenestrated endograft in patients with juxtarenal abdominal aortic aneurysms. METHODS: High resolution computed tomographic angiograms from 100 consecutive patients (96 men; mean age 72 years) with juxta- (n = 78) and pararenal (n = 22) aneurysms treated electively between 2005 and 2010 with custom-made fenestrated endografts were reviewed. A centerline of flow reconstruction was carried out in a 3D imaging workstation to precisely define the aortic morphology, including aortic diameters and distances between visceral and renal arteries. The applicability of 2 different "off-the-shelf" standardized fenestrated endografts designed by the manufacturer was evaluated in this cohort. Both designs included 2 fenestrations for the renal arteries, 1 for the superior mesenteric artery (SMA), and a scallop for the celiac trunk. The designs differed in the lengths of the SMA to renal fenestration and renal to renal fenestration. RESULTS: Endovascular treatment with one or both "off-the-shelf" endografts was deemed possible in 72 patients (56 with design 1, 52 with design 2, and 36 with both endografts). Of the 28 patients who were not candidates for a standardized fenestrated stent-graft of either design, the primary cause was a right renal artery that did not match the position of its corresponding fenestration. CONCLUSION: Standardized fenestrated designs suitable for endovascular treatment of >70% of patients with juxta- and pararenal aneurysms currently treated with custom-made fenestrated endografts will soon be available. This new generation of endografts will permit rapid treatment of a large majority of patients requiring fenestrated endograft repair.

Portal vein embolization with ethylene-vinyl alcohol copolymer for contralateral lobe hypertrophy before liver resection: safety, feasibility and initial experience.

BACKGROUND: To report our preliminary experience with preoperative portal vein embolization (PVE) using liquid ethylene vinyl alcohol (EVOH) copolymer. METHODS: Retrospectively review of patients with primary or secondary liver malignancies scheduled for extensive hepatectomy after the induction of future liver remnant (FLR) hypertrophy by right or left PVE with EVOH as the only embolic agent between 2014 and 2018 at two academic centers. Cross-sectional imaging liver volumetry data obtained before and 3-6 weeks after PVE were used to assess the FLR volume (FLRV) increase, degree of FLR hypertrophy and the FLR kinetic growth rate (KGR). RESULTS: Twenty-six patients (17 males; mean age, 58.7±11 years; range, 32-79 years) were included. The technical and clinical success rate was 100%. PVE produced adequate FLR hypertrophy in all patients. Embolization occurred in all targeted portal branches and in no non-target vessels. The %FLRV increased by 52.9%±32.5% and the degree of FLR hypertrophy was 16.7%±6.8%. The KGR was 4.4%±2.0% per week. Four patients experience minor complications after PVE which resolved with symptomatic treatment. The resection rate was 84.5%. One patient died during surgery for reasons unrelated to PVE. CONCLUSIONS: Preoperative PVE with EVOH copolymer is feasible, safe, and effective in inducing FLR hypertrophy.