2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Status Report on the Integrated and Independent IR Residencies: Origins and Projections for the Future.

The field of interventional radiology (IR) has undergone a historic transformation since 2014, marked by the approval of the IR residency program. This paradigm shift has revolutionized the traditional training pathway, which previously comprised a 1-year vascular and IR fellowship after diagnostic radiology residency. The introduction of integrated and independent IR residencies, including the option for Early Specialization in Interventional Radiology (ESIR), has reshaped the landscape of IR training. The implementation of the IR residency has been exceptionally successful, with the IR residency continuing to be one of the most sought-after residencies for medical students. Additionally, the option for IR training in diagnostic radiology has been retained, accommodating both ESIR and non-ESIR residents. With the continuous growth of accredited programs and rising popularity of IR as a specialty, the future of IR appears limitless.

Balloon-Targeted Extra-Anatomic Sharp Recanalization Technique to Re-establish Supraclavicular Vascular Access.

A balloon-targeted extra-anatomic sharp recanalization (BEST) technique was investigated to re-establish supraclavicular vascular access in patients with central venous occlusion. Query of the authors' institution's database yielded 130 patients who underwent central venous recanalization. Of these, a retrospective review of 5 patients with concurrent thoracic central venous and bilateral internal jugular vein occlusions who underwent sharp recanalization using the BEST technique from May 2018 to August 2022 was performed. Technical success was achieved in all cases without major adverse events. Four (80%) of the 5 patients underwent hemodialysis reliable outflow (HeRO) graft placement using the newly established supraclavicular vascular access.

Prospective Study of Radial Artery Occlusion Following Transradial Arterial Access during IR Procedures.

PURPOSE: To prospectively determine the rate of radial artery occlusion (RAO) in patients undergoing transradial access for intra-arterial interventions. MATERIALS AND METHODS: Seventy-seven patients undergoing transradial access from August 2019 to March 2021 for 120 intra-arterial procedures (yttrium-90 mapping [n = 39] and radioembolization [n = 38], uterine artery embolization [n = 19], transarterial chemoembolization [n = 10], active bleed embolization [n = 8], angiomyolipoma embolization [n = 4], and other [n = 2]) were enrolled. The average patient age was 59 years ± 13.1 (range, 30-90 years), and 43 (55.8%) of the 77 patients were men. The patients underwent radial artery (RA) palpation, ultrasound evaluation, the Barbeau test, and the reverse Barbeau test prior to and following the intervention. Verapamil, nitroglycerin, and heparin were administered in a total of 114 (95%) of the 120 procedures prior to starting the procedure. The incidence of RAO and radial artery spasm (RAS) was calculated, and univariate logistic regression was performed to analyze the predictors of RAS. RESULTS: The preprocedural RA diameter (3.0 mm ± 0.67) was not significantly different from the postprocedural RA diameter (3.0 mm ± 0.65, P = .904). The RAO rate was determined to be 0.8% (1/120), and this artery recanalized within 1 week. Due to the small number of occlusions, statistical analysis of predictors of RAO was not performed. The rate of RAS was 22.7% (27/119). None of the variables tested-including age, sex, RA diameter, initial versus repeat access, operator experience, and artery puncture technique-showed significant prediction for RAS. Patients were seen for follow-up after 111 (92.5%) of the 120 procedures. CONCLUSIONS: Transradial access resulted in a <1% rate of RAO.

Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis.

PURPOSE: To evaluate safety and retrieval success of retrievable suprarenal inferior vena cava (IVC) filters. MATERIALS AND METHODS: A retrospective chart review of patients who received a retrievable suprarenal IVC filter between January 2008 and December 2017 was conducted. Suprarenal IVC filters were placed in 24 female and 27 male patients. The most common indications for filter placement were IVC thrombus (n = 20; 39.2%) and iliofemoral venous thrombosis with contraindication to anticoagulation (n = 16; 31.3%). The most common indications for suprarenal placement were IVC thrombus (n = 20; 39.2%), anatomic variants (n = 17; 33.3%), and external IVC compression (n = 8; 15.8%). Duplicated IVC was the most common anatomic variant requiring suprarenal placement (n = 7; 13.7%). RESULTS: Günther Tulip (n = 40; 78.4%), Denali (n = 10; 19.6%), and Celect (n = 1; 2.0%) filters were used. Retrieval was attempted in 27 of the 51 filters placed (52.9%). Of the 27 attempted retrievals, the technical success rate was 100% (27/27). The median dwell time was 87.0 days (95% confidence interval, 28-137 d). One complication involving fractured struts during filter retrieval occurred. No significant change in craniocaudal filter position, lateral filter tilt, or renal function between placement and retrieval was observed (P < .05). There were no instances of indwelling filter fracture. CONCLUSIONS: Suprarenal IVC filters, when indicated, can be placed and retrieved with a low complication rate.

Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up.

PURPOSE: To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment. RESULTS: Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088). CONCLUSIONS: BRTO is associated with a lower rate of rebleeding but no change in mortality.

Factors Related to Late False Lumen Enlargement after Thoracic Stent-Graft Placement for Type B Aortic Dissection.

PURPOSE: To evaluate significant factors related to delayed aortic false lumen (FL) enlargement in patients who have undergone thoracic stent-graft placement for type B aortic dissection. MATERIALS AND METHODS: The study included 62 patients (45 male, 17 female) aged 26-80 years (mean age, 58.1 y) who underwent thoracic endovascular aortic repair for type B aortic dissection at a single institution between January 2005 and May 2015. Mean age of aortic dissections was 5.3 months (range, 0.1-73.3 mo). Maximum aortic diameter at presentation was 41.7 mm ± 8.3. The follow-up period ranged from 3 to 104 months (mean, 27.1 mo). Computed tomographic (CT) angiography studies were reviewed to identify FL diameter enlargements > 5 mm at different levels along and distal to the stent graft. Imaging findings and clinical variables were investigated to determine their correlation with FL enlargement. RESULTS: No significant difference was found between the ages of aortic dissections in patients with and without FL enlargement (P = .26). On follow-up CT angiography, 16 patients had 2 or more communication channels between the FL and the systemic circulation, 7 of whom showed FL enlargement > 5 mm (P = .007). Twenty-seven patients showed complete FL thrombosis, none of whom had FL enlargement (P < .001). CONCLUSIONS: Two or more communication channels between the FL and the systemic circulation represent a risk factor for FL enlargement regardless of the age of the dissection. Patients with thrombosis of the FL are less likely to experience FL enlargement.

Midterm Follow-up of Ureteral Embolization Using Vascular Plugs and N-Butyl Cyanoacrylate Glue.

This is a retrospective study of 9 consecutive female patients who underwent ureteral embolization via a "sandwich" technique with two vascular plugs and N-butyl cyanoacrylate glue for ureteral fistulae unresponsive to urinary diversion. Average age was 61 years (range, 39-77 y), average duration of diversion was 48 days (range, 2-120 d), and average follow-up was 11 months (range, 4-23 mo). Seven patients (78%) experienced immediate resolution of urinary leakage, and the other 2 (22%) required unilateral repeat treatment for resolution of leakage. Symptom resolution lasted throughout the follow-up period for all patients. Bilateral internal iliac artery pseudoaneurysms developed in 1 patient and were treated with embolization and stent placement.

Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease.

PURPOSE: To evaluate limb salvage after recanalization of lower extremity arteries using retrograde pedal access in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective review was performed of all patients in whom retrograde pedal arterial access was used for recanalization of infrainguinal occlusive disease between September 2002 and January 2013. Treatment was performed in 99 limbs in 92 patients (64 men and 28 women; median age, 71.6 y; range, 44-91 y) with CLI and no appropriate venous conduit for surgical bypass. Treated limbs were classified as Rutherford class 5 or 6 in 88% and class 4 in 12%. Retrograde and antegrade accesses were combined when occlusions could not be crossed from the antegrade direction. The treated occlusive segments were limited to the femoropopliteal arteries in 22% of procedures, runoff arteries in 32%, or both segments in 46%. Technical success was defined as successful crossing of the lesion and achievement of inline flow to the pedal vessel. Kaplan-Meier analysis was performed to determine limb salvage rate. RESULTS: Technical success was achieved in 88 of 99 (89%) treated limbs. Stents were placed for suboptimal angioplasty results in 41 of 88 (47%) successfully treated limbs. Major complications occurred in 8 of 99 (8%) procedures, 3 of which resulted in periprocedural mortality. Median follow-up was 8 months (mean, 17 mo; range, 1-98 mo). The limb salvage rate for technically successful cases was 74% at 6 months, 64% at 12 months, and 55% at 24 months. CONCLUSIONS: Retrograde pedal access is a viable revascularization technique for achieving limb salvage in patients with CLI.

Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta.

PURPOSE: To report outcomes of coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR). MATERIALS AND METHODS: A retrospective review was performed of 285 patients (160 male) with a mean age of 62 years (range, 13-91 y) who underwent TEVAR at a single institution between March 2005 and May 2013. The LSCA was covered to obtain an adequate proximal landing zone, and a selective LSCA revascularization and embolization strategy was employed. All patient outcomes were recorded including neurologic complications, left arm claudication, endoleak rates, and repeat procedures. RESULTS: The origin of the LSCA was covered in 98/285 (34%) patients. Median follow-up was 533 days (range, 2-2,895 d). Cerebrovascular accident (CVA) rates for covered LSCA and noncovered groups were 11/98 (11%) and 5/188 (3%), respectively (P = .005). LSCA was revascularized at time of initial TEVAR in 44/98 (45%) patients. Of the remaining 54 patients, 10 (19%) required subsequent revascularization for claudication. LSCA embolization was done to prevent or treat endoleak in 41/98 (42%) patients, with 33/98 (34%) patients undergoing LSCA embolization at the time of LSCA coverage and 8 of the remaining 65 (12%) patients requiring subsequent embolization for persistent endoleak. CONCLUSIONS: Coverage of the LSCA during TEVAR is feasible with low complication rates, although it carries an increased risk of CVA. The selective LSCA revascularization and embolization strategy was well tolerated. A more liberal strategy may be required to decrease the rate of delayed revascularization and embolization procedures to treat arm claudication and endoleaks, respectively.

Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration.

PURPOSE: To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). MATERIALS AND METHODS: A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. RESULTS: The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). CONCLUSIONS: BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Combined transmesenteric and transhepatic recanalization of chronic portal and mesenteric vein occlusion to treat bleeding duodenal varices.

Two patients presented with bleeding duodenal varices secondary to mesenteric and portal vein chronic occlusion. After a failed transhepatic recanalization, a combined transmesenteric and transhepatic approach was used to recanalize the chronic portal and mesenteric venous obstruction. The occluded segment was treated with transmesenteric stent placement in one patient and stent placement and coil embolization of varices in the second patient. Follow-up imaging and endoscopy showed decompression of the duodenal varices in both patients and absence of further bleeding episodes.

Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy.

PURPOSE: To report the outcomes following catheter angiography with or without embolization in patients with acute upper gastrointestinal nonvariceal hemorrhage (UGINH). MATERIALS AND METHODS: A review of electronic medical records was performed to identify all potential patients for this study between 2001 and 2011. Patients with first-time UGINH who required angiographic localization and endovascular treatment were included. Patients with variceal bleeding and prior surgical or endovascular intervention for the gastrointestinal system were excluded. Society of Interventional Radiology guidelines and American College of Radiology "appropriateness criteria" reporting standards were followed. RESULTS: We identified 74 patients (men/women=46/28) with a mean age of 60 years. Thirty-four patients were found to have active bleeding on angiography. One patient from this group did not undergo embolization because of an angiographic diagnosis of aortoenteric fistula. Technical failure was encountered in 2/34 patients; therefore, the technical success of embolization was 94%. Forty of 74 patients showed no angiographic evidence of active bleeding; 18 patients underwent prophylactic embolization using endoscopically placed clips as targets; and 22 patients had no embolotherapy. Thus, we grouped the patients into 3 groups: (1) therapeutic embolization; (2) prophylactic/empiric embolization; and (3) no embolotherapy groups. The clinical success of embolization was 67% to 68% in the therapeutic embolization group and 67% in the prophylactic embolization group. Early rebleeding rates were 33.8%, 51.6%, 33.3%, and 12% among all the patients, the therapeutic embolization group, the prophylactic embolization group, and the no endovascular treatment group, respectively. Mortality was significantly high in patients with advanced age (P=0.001), cerebrovascular disorders (P=0.037), and positive angiography (P=0.026), even when clinical success was achieved. CONCLUSIONS: Acute UGINH remains a clinical challenge with increased mortality rates, even with high technical success rates. Patients with negative findings on angiography have lower early rebleeding rates than patients with active bleeding during angiography or endoscopy-guided prophylactic/empiric embolization.

Is fibromuscular dysplasia underdiagnosed? A comparison of the prevalence of FMD seen in CORAL trial participants versus a single institution population of renal donor candidates.

Renal artery fibromuscular dysplasia (FMD) may be underdiagnosed. We evaluated the prevalence of FMD in CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) renal artery stent trial participants, in which FMD was an exclusion criterion for inclusion. We also evaluated the prevalence of FMD in a relatively healthy population of patients undergoing computed tomographic angiographic (CTA) screening for renal donor evaluation. All renal donor CTAs performed at our institution from January 2003 through November 2011 were retrospectively reviewed for the presence of FMD along with patient sex and age. These results were compared to angiographic core lab (ACL) findings for the CORAL trial. The CORAL ACL database contained 997 patients (mean age 69.3 years; 50% female). Fifty-eight (5.8%) CORAL trial patients (mean age 71.8 years; 75.9% female) demonstrated incidental FMD. The renal donor cohort included 220 patients (mean age 40.5 years; 64.5% female). Five (2.3%) demonstrated FMD (mean age 48.6 years; all female). The odds of FMD in the CORAL cohort were 2.65 times that seen in the renal donor cohort (95% CI: 1.12, 7.57). In C: onclusion, the 5.8% prevalence of renal artery FMD in the CORAL trial population, the presence of which was biased against, suggests underdiagnosis.

Intra-arterial locoregional therapies for intrahepatic cholangiocarcinoma.

INTRODUCTION: Intrahepatic cholangiocarcinoma (ICC) is the 2nd most common primary liver malignancy. For nonsurgical candidates, the primary treatment option is systemic chemotherapy, which can be combined with locoregional therapies to enhance local control. Common intra-arterial locoregional therapies include transarterial hepatic embolization, conventional transarterial chemoembolization, drug-eluting bead transarterial chemoembolization, transarterial radioembolization with Yttrium-90 microspheres, and hepatic artery infusion. This article aims to review the latest literature on intra-arterial locoregional therapies for treating ICC. AREAS COVERED: A literature search was conducted on PubMed using keywords: intrahepatic cholangiocarcinoma, intra-arterial locoregional therapy, embolization, chemoembolization, radioembolization, hepatic artery infusion, and immunotherapy. Articles from 2008 to 2024 were reviewed. Survival data from retrospective and prospective studies, meta-analyses, and clinical trials were evaluated. EXPERT OPINION: Although no level I evidence supports the superiority of any specific intra-arterial therapy, there has been a shift toward favoring radioembolization. In our expert opinion, radioembolization may offer superior outcomes when performed by skilled operators with meticulous planning and personalized dosimetry, particularly for radiation segmentectomy or treating lobar/bilobar disease in appropriate candidates.