Endovascular gamma irradiation for the prevention restenosis after angioplasty of femoropopliteal de novo stenoses.

The purpose of this study was to investigate the effectiveness and detect side effects of centered, overlapped endovascular gamma irradiation after angioplasty of de novo femoropopliteal stenoses. Thirty patients (age 65.3+/-9.2 years) with arterial occlusive disease were prospectively enrolled to receive endovascular gamma irradiation (192-iridium, 14 Gy centered at 2 mm vessel wall) immediately after percutaneous transluminal angioplasty (PTA) of femoropopliteal stenoses. Irradiation overlapped dilatation by 1-2 cm at each end. Follow-up involved angiography after 12 months; duplex sonography; and interviews before and after PTA and at 1, 6, and 12 months follow-up. PTA and centered endovascular irradiation were performed successfully in all patients. Three thromboembolic complications occurred during irradiation. Angiographic and clinical follow-up was possible in 28 patients. The angiographic degree of stenosis was 73.8%+/-16.3% before and 3.6%+/-23.5% after PTA and was 3.5%+/-43.7% at the 1-year follow-up. Restenosis (>50%) of the target lesion developed in three patients (10.7%) and edge stenoses (>30%) in nine patients (32.1%). An aneurysm of the irradiated segment in one patient was treated by stenting. The rate of retreatment was 17.9%. The vessel diameter after endovascular gamma irradiation and PTA of femoropopliteal stenoses remained stable. Restenosis, induction of edge stenoses, and aneurysm were reasons for reinterventions.

Percutaneous treatment of a splenic artery pseudoaneurysm by thrombin injection.

Pseudoaneurysms in the visceral arteries are rare complications of pancreatitis. In the reported case, a 42-year-old man with a splenic pseudoaneurysm was successfully treated by computed tomography (CT)-guided direct thrombin injection into the pseudoaneurysm lumen. Selective catheterization of the splenic artery had proven technically impossible. During the procedure, contrast medium was injected via a pigtail catheter into the aorta for planning, correct positioning of the needle tip, and control imaging after injection. CT examinations 1 day, 3 weeks, and 6 months after treatment demonstrated complete occlusion shrinkage of the pseudoaneurysm, and the patient was symptom-free.

Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients.

PURPOSE: To prospectively evaluate ultrasonographically (US) guided percutaneous thrombin injection for treatment of femoral artery and brachial artery pseudoaneurysms. MATERIALS AND METHODS: The university institutional review board approved the study. Informed consent was obtained from all patients. Two hundred forty patients with postcatheterization femoral artery (n = 132) or brachial artery (n = 8) pseudoaneurysms were treated with US-guided bovine thrombin (1.000 IU/mL) injection. At diagnosis, 107 (44.6%) patients received anticoagulation therapy; 159 (66.2%), antiplatelet therapy; and 76 (31.7%), both therapies. Pseudoaneurysm size, length and width of pseudoaneurysm neck, thrombin dose, therapy outcome, and complications were documented. The peak blood flow in peripheral arteries was determined before and after thrombin injection. Follow-up duplex US was performed 12-24 hours, 5-7 days, and 21-25 days after treatment. A nonpaired t test was used to compare differences in age between the male and female patients. Two-way analysis of covariance was performed to analyze the influences of factors that may have been related to the amount of thrombin used. RESULTS: Mean pseudoaneurysm volume was 4.69 cm3 +/- 5.49 (standard deviation). Simple and complex pseudoaneurysms were treated in 165 and 75 patients, respectively. A total of 260 thrombin injections were performed: 1.04 injections per patient with a simple pseudoaneurysm and 1.17 injections per patient with a complex pseudoaneurysm. The mean injected thrombin dose was 425.31 IU +/- 341.75 for all pseudoaneurysms, 382.12 IU +/- 281.00 for simple pseudoaneurysms only, and 520.33 IU +/- 434.64 for complex pseudoaneurysms only. There was only a computational correlation between pseudoaneurysm size and thrombin dose (r2 = 0.07). The primary success rate was 93.8% overall, 95.8% for simple pseudoaneurysms, and 89% for complex pseudoaneurysms. The secondary success rate was 99.6% overall, 100% for simple pseudoaneurysms, and 99% for complex pseudoaneurysms. Early (at < or =24 hours) reperfusion occurred in one simple and five complex pseudoaneurysms. Four late reperfusions-two in simple and two in complex pseudoaneurysms-were detected at 1-week follow-up; no late reperfusions were detected at 3 weeks. Thromboembolic complications occurred in two patients and resolved spontaneously. One mild allergic reaction and no infections occurred. CONCLUSION: US-guided percutaneous thrombin injection enables successful, safe management of postcatheterization pseudoaneurysms.

Open versus endovascular repair of para-anastomotic aneurysms in patients who were morphological candidates for endovascular treatment.

PURPOSE: To compare the outcomes of open versus endovascular repair of para-anastomotic aneurysms (PAA) in the aortic and iliac arteries in a cohort of patients who fulfilled morphological criteria for endovascular repair. METHODS: A retrospective review of 31 consecutive patients with PAA treated between 1985 and 2002 identified 26 (84%) patients who would have been candidates for endovascular repair based on preoperative computed tomography and angiography. Of these 26 patients, 10 (9 men; median age 65 years, range 60-75) underwent endovascular repair; the remaining 16 patients (14 men; median age 61.5 years, range 49-78) had open repair. The baseline data and outcome measures were compared between the treatment groups. RESULTS: The patient groups were well matched for age, sex, weight, risk factors, comorbidities, aneurysm length, and elapsed time from initial graft placement. Both groups had technically successful PAA repairs; however, median blood loss (300 versus 1000 mL; p=0.05) and procedural time (100 versus 215 minutes; p<0.001) were significantly reduced in the endovascular group. Median transfusion volume was significantly greater (1000 versus 0 mL; p=0.01) in the surgically treated patients. The median stay in ICU was similar (18 versus 24 hours in the surgical cohort). Length of stay was significantly shorter in the endovascular group: 7.5 versus 17.0 days (p=0.001) after the repair and 11 versus 22 days (p=0.01) for overall hospitalization. One (10%) patient in the endovascular group died from a myocardial infarction on the third postoperative day. In the open group, there were 3 (19%) procedure-related deaths. CONCLUSIONS: Patients with PAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. If long-term follow-up demonstrates durable results, stent-graft repair may become the therapy of choice in PAAs.

Comparison of magnetic resonance imaging and computed tomography of 8 aortic stent-graft models.

PURPOSE: To report the systematic comparison of magnetic resonance imaging (MRI) with contrast-enhanced computed tomography (CT) for evaluating 8 different aortic stent-graft models. METHODS: MR angiography (MRA) was performed using a 1.5-T whole body system within 2 days of a CT examination (4 detector row scanner) on 8 patients with one of these stent-graft models: AneuRx, Endofit, PowerLink, Excluder, LifePath, Talent, Vanguard, or Zenith. Using a 4-point scale (maximum score 112 points), 4 independent readers (1 vascular surgeon and 3 radiologists) rated the impact of stent-related artifacts on the diagnostic quality of each imaging method for 28 parameters: length, diameter, collateral aortic side branches, stent-graft prostheses, and contrast. Each examiner also scored his personal diagnostic confidence with each stent-graft model. RESULTS: The scores for diagnostic confidence in the CT imaging were 4 points for each stent-graft, with the exception of the LifePath (3 points). The diagnostic confidence in the MR images was mainly poor, with a median score of only 1; however, 3 stent-grafts (AneuRx, Excluder, and Vanguard) received > or =3 points. The total scores for comparative assessment were significantly different (p<0.05) between CT imaging (111.5) and MR (58.5). CT studies of all stent-grafts received >101 points, while only 3 devices acquired >80 points (AneuRx, Excluder, and Vanguard). Bland-Altman analysis showed that the reliability of the 4 readers was higher using the CT method. The total assessment scores of the stent-graft systems were related only on the different imaging methods (p<0.0001) and not to the different readers (p=0.983). CONCLUSIONS: CT and MRI are fast, reliable means of providing all relevant information for stent-graft surveillance. Of 8 different stent-graft models, only 3 could be adequately assessed by MRA. Therefore, the potential advantages of the MR technique (e.g., use of minimally nephrotoxic contrast media, lack of ionizing radiation) are available only to a small proportion of patients.

Centered endovascular irradiation to prevent postangioplasty restenosis of arteriovenous fistula in hemodialysis patients; Results of a feasibility study.

PURPOSE: To report follow-up results of a prospective trial on centered endovascular gamma-irradiation (CEGI) after percutaneous transluminal angioplasty (PTA) for stenosis of arteriovenous fistula in hemodialysis patients. METHODS AND MATERIALS: Eight patients receiving PTA for recurrent (n = 4) or de novo arteriovenous fistula stenoses were treated with CEGI with iridium-192 (14 Gy). Angiography was performed after 6 and 12 months or if problems reoccurred during hemodialysis. Parameters of hemodialysis and duplex sonography were determined the day before and after PTA and after 1, 3, 6, 9, and 12 months. RESULTS: CEGI was performed successfully and without complications in seven patients. In six patients, restenosis occurred 6-52 weeks (mean 20.8 +/- 17.9 weeks) after PTA and required PTA. Parameters of hemodialysis and duplex sonography deteriorated during follow-up. CONCLUSIONS: Centered endovascular gamma-irradiation with iridium 192 immediately after PTA of fistula stenoses was a safe and feasible method but did not prevent restenosis.

Aneurysmal re-rupture during selective cerebral angiography.

Two cases of aneurysmal re-rupture during intracranial angiography are presented. This event is accompanied by disastrous consequences with regard to the clinical condition of the patient, as is evident from the cases presented as well as from the literature. Acute alterations of intraluminal pressure as well as a time interval of less than 6 h seems to increase the risk of re-bleeding during angiography. The introduction of and the growing experience with CT and MR angiography may in the near future provide sufficient diagnostic information for surgical planning and thus help to overcome the risk of aneurysmal re-rupture during intra-arterial angiography.

Endovascular gamma-irradiation to prevent recurrent femoral in-stent restenosis. A case report.

We report about a patient with twice recurrence of femoral in-stent restenoses. Centered endoluminal gamma-irradiation with 192 iridium was performed immediately after the second stent recanalization. The irradiation dose was 14 Gy calculated at 2-mm depth of vessel wall. One-year follow-up demonstrates neither clinical nor angiographic evidence of restenosis.

De novo femoropopliteal stenoses: endovascular gamma irradiation following angioplasty--angiographic and clinical follow-up in a prospective randomized controlled trial.

PURPOSE: To assess and report the follow-up results of a randomized controlled trial on centered endovascular gamma irradiation performed after percutaneous transluminal angioplasty (PTA) for de novo femoropopliteal stenoses. MATERIALS AND METHODS: Thirty patients who underwent PTA for de novo femoropopliteal stenoses were randomly assigned to undergo 14-Gy centered endovascular irradiation (irradiation group, n = 15) or no irradiation (control group, n = 15). Intraarterial angiography was performed 6, 12, and 24 months after treatment; duplex ultrasonography (US), the day before and after PTA and 1, 3, 6, 9, 12, 18, and 24 months later. Treadmill tests and interviews were performed the day before PTA and 1, 3, 6, 9, 12, 18, and 24 months later. Results of angiography, duplex US, treadmill tests, and interviews were evaluated with the nonpaired t or the Fisher exact test. RESULTS: Baseline characteristics did not differ significantly between the two groups. Mean absolute individual changes in degree of stenosis, compared with the degrees of stenosis shortly after PTA, in the irradiation group versus in the control group were -10.6% +/- 22.3 versus 39.6% +/- 24.6 (P <.001) at 6 months, -2.0% +/- 34.2 versus 40.6% +/- 32.6 (P =.002) at 12 months, and 7.4% +/- 43.2 versus 37.7% +/- 34.5 (P =.043) at 24 months. The rates of target lesion restenosis at 6 (P =.006) and 12 (P =.042) months were significantly lower in the irradiation group. The numbers of target lesion re-treatments were similar between the groups, but target vessel re-treatments were more frequent in the irradiation group. There were no significant differences in interview or treadmill test results between the two groups at t test analysis. CONCLUSION: The degree of stenosis was significantly reduced 6, 12, and 24 months after angioplasty of de novo femoropopliteal stenoses in the patients who underwent endovascular irradiation.

Endovascular gamma irradiation of femoropopliteal de novo stenoses immediately after PTA: interim results of prospective randomized controlled trial.

PURPOSE: To report an interim analysis of whether centered endovascular irradiation with the iridium 192 ((192)Ir) source immediately after percutaneous transluminal angioplasty (PTA) of de novo femoropopliteal stenoses lowers the restenosis rate. MATERIALS AND METHODS: Thirty patients undergoing PTA to treat femoropopliteal stenoses were randomized for prophylaxis against restenosis with centered endovascular irradiation with a (192)Ir source (a dose of 14 Gy 2 mm deep to the vessel wall, irradiation group) or no irradiation (control group). Angiographic follow-up was available for 22 patients at 6 months (irradiation group, n = 10) and 12 patients at 12 months (irradiation group, n = 6). Duplex sonography, treadmill testing, and interviews were performed the day before and the day after PTA and after 1, 3, 6, 9, and 12 months. Results of angiography, duplex sonography, treadmill testing, and interviews were evaluated with a t test and multivariate analysis of variance (clinical characteristics, chi(2) test). RESULTS: Baseline characteristics were comparable in the two groups. Interim analysis of the 6-month follow-up data revealed a trend toward a significantly lower restenosis rate in the irradiation group. The change in the degree of stenosis compared with that after PTA was -14.7% +/- 20.8 (mean +/- SD) in the irradiation group versus 37.7% +/- 27.3 in the control group (P =.001) and became even more marked at 12 months (-9.5% +/- 34.5 vs 45.5% +/- 40.7 [P =.03], respectively). The follow-up results of treadmill testing and interviews showed a nonsignificant benefit for the irradiation group. One thromboembolic complication occurred during irradiation. No side effects were observed during follow-up. CONCLUSION: Endovascular irradiation with a centered (192)Ir source immediately after PTA of de novo femoropopliteal stenoses reduces the restenosis rate.