Arterial Access Research Articles

Outcomes of Multiple Treatment Strategies for Iatrogenic Trauma From Femoral Artery Access

Outcomes of Multiple Treatment Strategies for Iatrogenic Trauma From Femoral Artery Access

Utilization of Percutaneous Closure Devices for Large Bore Arterial Access in Genetic Aortopathy Patients Does Not Result in Increased Rates of Femoral Cutdown or Access Site Complications

Utilization of Percutaneous Closure Devices for Large Bore Arterial Access in Genetic Aortopathy Patients Does Not Result in Increased Rates of Femoral Cutdown or Access Site Complications

COMPARISON BETWEEN DIFFERENT TRANSRADIAL ARTERY HEMOSTASIS PROTOCOLS IN LIGURIAN CARDIOLOGIES

Abstract Background Transradial artery access (TRA) for coronary angiography and percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access. In our hospital, TRA is widely used and hemostasis is usually achieved using TRBand device. We used to remove the device in about 10 hours according to our protocol. Aims The aim of this study is to describe and compare different TRA hemostasis protocols in order to understand if a shorter protocol could be more effective. Methods This is an observational study performed in all Hospitals of our region (Liguria). All Cardiology Departments were included in this analysis. We requested to all to self–refer: a) which radial hemostasis device was used; b) which deflation protocol (DP) was used. c) If they usually report and analyze adverse events. Adverse events are described as: bleeding, hematoma, ecchymosis, skin damage, local infection, pseudoaneurysm, or artery occlusion. RESULTS In Liguria there are 9 Cardiology Departments with Cath Lab (CL); 8 of them accepted to participate. All the Cath Labs use the TRBAND device but the deflation protocols are very different. 5 Cath Labs follows the DP suggested by the manufacturer. Only 2 CL adopted different DP if and higher dose of heparin was administered. Only one report bleedings or any delete in the DP. None analyze periodically the incidence of adverse events. Conclusions There are different methods to achieve radial hemostasis furthermore with the same device different deflating protocols are used. Further studies are necessary to evaluate the best DP. Regular audits must be strongly suggested in all Cardiology Departments in order to monitorate and improve the adverse events.

Endoluminal Biopsy for Vein of Galen Malformation.

Vein of Galen malformation (VOGM), the result of arteriovenous shunting between choroidal and/or subependymal arteries and the embryologic prosencephalic vein, is among the most severe cerebrovascular disorders of childhood. We hypothesized that in situ analysis of the VOGM lesion using endoluminal tissue sampling (ETS) is feasible and may advance our understanding of VOGM genetics, pathogenesis, and maintenance. We collected germline DNA (cheek swab) from patients and their families for genetic analysis. In situ VOGM "endothelial" cells (ECs), defined as CD31+ and CD45-, were obtained from coils through ETS during routine endovascular treatment. Autologous peripheral femoral ECs were also collected from the access sheath. Single-cell RNA sequencing of both VOGM and peripheral ECs was performed to demonstrate feasibility to define the transcriptional architecture. Comparison was also made with a published normative cerebrovascular transcriptome atlas. A subset of VOGM ECs was reserved for future DNA sequencing to assess for somatic and second-hit mutations. Our cohort contains 6 patients who underwent 10 ETS procedures from arterial and/or venous access during routine VOGM treatment (aged 12 days to ∼6 years). No periprocedural complications attributable to ETS occurred. Six unique coil types were used. ETS captured 98 ± 88 (mean ± SD; range 17-256) experimental ECs (CD31+ and CD45-). There was no discernible correlation between cell yield and coil type or route of access. Single-cell RNA sequencing demonstrated hierarchical clustering and unique cell populations within the VOGM EC compartment compared with peripheral EC controls when annotated using a publicly available cerebrovascular cell atlas. ETS may supplement investigations aimed at development of a molecular-genetic taxonomic classification scheme for VOGM. Moreover, results may eventually inform the selection of personalized pharmacologic or genetic therapies for VOGM and cerebrovascular disorders more broadly.

Percutaneous Retrograde Trans-Gluteal Embolization of Type 2 Endoleak Causing Iliac Aneurysm Enlargement after Endovascular Repair: Case Report and Literature Review.

Late type II endoleaks (T2ELs) arising from the internal iliac artery (IIA) may present during follow-up after endovascular aortic repair (EVAR) of aortoiliac aneurysm and may warrant embolization if enlargement of the aneurysmal sac is demonstrated. When coverage of the IIA ostium has been made due to extensive iliac disease, access options can be challenging. Different treatment options have been reported over recent years, and a careful selection of the best one must be made based on the characteristics of each case. The present study reports a simple and reproducible sheathless percutaneous superior gluteal artery (SGA) access and provides a discussion based on a review of the existing literature on this topic.

Loss and recovery of percutaneous femoral access during transcatheter aortic valve replacement. A case report

Loss and recovery of percutaneous femoral access during transcatheter aortic valve replacement. A case report

Endovascular Salvage of Type Ia and Ib Endoleaks Using a Physician-Modified Fenestrated/Branched Endograft and an Iliac Branch Device Via Unilateral Transfemoral Arterial Access.

This study aims to explore the feasibility and effectiveness of a unilateral transfemoral access endovascular salvage technique for complex abdominal aortic aneurysms with concurrent type Ia and Ib endoleaks following previous endovascular repair. A 69-year-old female with multiple comorbidities presented with an extent IV thoracoabdominal aortic aneurysm complicated by type Ia and Ib endoleaks and chronically occluded left iliac endoprosthesis after prior endovascular repair. Given the patient's medical complexities, open explant repair was deemed high risk. The case was successfully managed using a physician-modified fenestrated/branched endograft (PM-F/BEVAR) and an iliac branch device (IBD) deployed through a single percutaneous transfemoral access. The presented case demonstrates the safety and efficacy of PM-F/BEVAR with concomitant IBD deployment via unilateral transfemoral access. This innovative approach allows endovascular salvage in cases with restricted iliofemoral access and avoids the complexities associated with upper extremity or aortic arch manipulation. While acknowledging the technical challenges, this technique offers a viable alternative for salvaging failed endovascular repairs, emphasizing the importance of real-time modifications in achieving successful outcomes. Further studies and long-term follow-up are warranted to validate the broader applicability and durability of this approach in the management of complex abdominal aortic aneurysms with multiple endoleaks. Although not the conventional approach, unilateral transfemoral access can be utilized to implant either a physician-modified fenestrated aortic endograft or an iliac branch device. Such an approach avoids complicating issues related to upper extremity access. This innovative technique may be necessary when there is a failed prior EVAR in the setting of significant contralateral iliofemoral occlusive disease. Doing both procedures in the same setting to resolve a type Ia and Ib endoleak is feasible as demonstrated in this case report. Expanding the endovascular armamentarium to address EVAR failure will be increasingly useful in the future, especially given the morbidity profile of EVAR explantation.

Current alternatives to traditional radial approach for coronary interventions: A randomized prospective study of the ulnar and distal radial approaches.

The radial artery is the standard access for coronary intervention; however, it is essential to have alternative accesses as it may be used as a conduit during coronary artery bypass grafting or for dialysis fistula. Ulnar and distal radial artery accesses have emerged as alternative accesses for traditional radial artery. To compare distal radial artery access and ulnar artery access as alternatives to traditional radial artery access regarding safety, efficacy, and success rate. Two-hundred patients were included (100 traditional radial [TRA], 50 distal radial [DRA] and 50 ulnar). Access artery follow up ultrasound was performed up to 28 days. Procedural success rate was 97%, 74%, and 92% in the TRA, DRA and ulnar groups, respectively (p < 0.001). Crossover occurred in 3 patients (3%) in TRA, 13 patients (26%) in DRA and 4 cases (8%) in ulnar group (p < 0.001). The most common cause of crossover was failure of artery cannulation. Regarding cannulation time, the mean access time in seconds was 80.19 ± 25.98, 148.4 ± 29.60, 90.5 ± 21.84 in TRA, DRA and ulnar groups, respectively (p < 0.001). Our study concluded that these new approaches proved to be potential alternatives to traditional radial approach; however, ulnar artery access proved to be superior to distal radial artery access as regards success rate and cannulation time.

Deep learning-based model for difficult transfemoral access prediction compared with human assessment in stroke thrombectomy

BackgroundIn mechanical thrombectomy (MT), extracranial vascular tortuosity is among the main determinants of procedure duration and success. Currently, no rapid and reliable method exists to identify the anatomical features precluding...

IMPACT OF ACCESSORY RENAL ARTERIES ON HYPERTENSION IN YOUNG PATIENTS

Objective: To determine whether there is a correlation between hypertension, accessory renal arteries, and levels of renin and aldosterone. Design and method: From March 2023 to December 2023, 11 young patients (9 males and 2 females) between 22-41 years were hospitalized with suspected secondary arterial hypertension (AH). Prior to hospitalization, all underwent standard pre-analytical medication preparation with cessation of hormone affecting medications and transferred to alternative treatment. For all patients, a computer tomography was conducted following a renal angiography protocol for the presence of adrenal glands formations and the presence of accessory renal arteries. In parallel with the imaging study, laboratory analyses for renin/aldosterone, metanephrine, and normetanephrine were done. ECG, echocardiography and 24-hour monitoring of arterial blood pressure were performed. Results: In 10 (91%) of the examined patients, accessory renal arteries were identified - 2 (20%) on the right with two accessory renal arteries; 4 (40%) on the left, and the remaining 4 (40%) had bilateral accessory renal arteries. One patient exhibited an accessory artery in conjunction with Nutcracker Syndrome, and another patient with a combination of a hormonally inactive adenoma of the right adrenal gland. The average blood pressure during 24-hour monitoring was 165/96±12/8 mmHg. Echocardiography revealed initial left ventricular hypertrophy in 50% of the examined patients, with a trend towards reduced relaxation. Overall, 8 patients had abnormal renin/aldosterone abnormalities - 7 (64%) in the group with accessory renal arteries (ARA), and 1 (9%) in the group without ARA where primary hyperaldosteronism was diagnosed. In the ARA, 6 had elevated levels of both renin and aldosterone. In 1 case in ARA group, only renin was elevated. Metanephrine and normetanephrine levels were within normal limits in all cases. Conclusions: We find relatively high rate of the presence of ARA, which may be regarded as an etiological entity. Elevated levels of renin and aldosterone were detected in a significant subset of the patients. Hypertensive patients with ARA may develop early severe damage of target organs.

Transpalpebral transorbital endoscopic lateral approach to the middle cranial fossa: anatomical study in cadaver

Transorbital expanded endoscopic approaches allow different areas of the skull base to be approached. The aim of our study is to analyse the main anatomical bone and neurovascular structures of the middle cranial fossa by means of a transpalpebral transorbital lateral endoscopic approach (TTLEA). An anatomical study was performed on 12 orbital cavities corresponding to 6 cadaver heads. All specimens were previously injected with colored latex through both carotid systems. The mean distance from the orbital rim to the zygomatic-facial foramen and to the zygomatic-temporal foramen was 11 mm and 16 mm respectively. In all cases the meningo-orbital foramen was found at a mean distance from the orbital rim of 34 mm. The superior orbital fissure (SOF) was located posterior to the meningo-orbital foramen at 39 mm. The foramen rotundum and foramen ovale were located separated from each other by 10 mm on average. Anterior to the foramen ovale a bony prominence was observed in all cases. In 11 cases (92%) the entrance of the accessory meningeal artery into the foramen ovale was evident and in one case an accessory foramen was observed. The middle meningeal artery was located in all dissections within the foramen spinosum. The TTLEA offers a wide and direct exposure of the middle cranial fossa. It should be considered as an alternative to transcranial approaches in certain lesions invading the lateral region of the middle cranial fossa, the lateral wall of the cavernous sinus or the infratemporal fossa.

The Ascending Pharyngeal Artery, Accessory Meningeal Artery, Lingual Artery, Vasa Nervorum, and Potential Anastomotic Channels

The ascending pharyngeal, accessory meningeal, and lingual arteries branch from the proximal segment of the external carotid artery. These branches give rise to smaller branches that contribute blood supply to the pharyngeal mucosa, parapharyngeal tissue, middle ear, submandibular tissues, tongue, and dura mater of the middle and posterior fossa. These arteries may also supply the cranial nerves and have potential anastomotic channels that function with the internal carotid and vertebral arteries. M igration of embolic material into the vasa nervorum and potential anastomoses may cause complications. Therefore, knowledge of these functional anatomies is crucial for neuro-interventionalists.

FIBROMUSCULAR DYSPLASIA IN CHILDREN – A SINGLE-CENTER EXPERIENCE

Objective: Fibromuscular dysplasia (FMD) is a stenotic disease of the arteries - most often renal, carotid, and cerebral. The disease can occur at any age and is the most common cause of renovascular hypertension in children. The study aimed to present the clinical course of FMD in patients of our Department. Design and method: In 2016-2023, the Department took care of 8 patients with FMD (4 boys, 4 girls). In all patients, we analyzed: age, sex, clinical symptoms, biochemical parameters, renin and aldosterone concentrations, imaging studies (ultrasonography, computed tomography), pharmacological and invasive treatment, and outcome. Results: Age at diagnosis ranged from 10/12 to 15 9/12 years. All patients were referred due to arterial hypertension (7/8 of 2nd degree). Patients presented various symptoms: hypertensive crisis with heart failure (patient 10/12 months), headache (2 patients), vomiting (1 patient), hyperactivity (1 patient), polydipsia and polyuria (1 patient). All patients had normal renal function, 5/8 hypokalemia, 1/8 hyponatremia, and 5/8 metabolic alkalosis; all had hyperreninemia with hyperaldosteronism. Imaging examinations showed critical stenosis of the renal artery trunk in 3 patients, slight stenosis in 1 patient, and stenosis of accessory arteries or branches of main arteries in the remaining patients. Stenosis in other vessels was found in 2 patients (left middle cerebral artery in one patient and abdominal aorta, celiac trunk, superior mesenteric artery, and inferior mesenteric artery in another one). Invasive treatment was performed in 6/8 patients - in 2 patients nephrectomy was necessary; in 2 – embolization of the vessel; in 2 – angioplasty, one patient is waiting for the procedure. Before the procedure, the patients required 3 (max. 5) antihypertensive drugs. After the procedure, antihypertensive treatment was discontinued in 3 patients, and the number and dose of drugs were reduced in the remaining patients. Conclusions: 1. Renal artery stenosis should be excluded in all pediatric hypertensive patients, regardless of age and symptoms. 2.Patients with FMD require an individually selected therapeutic plan. 3.Vessel embolization is an effective method of treating stenoses of the peripheral branches of the renal arteries in the course of FMD in children.

LB-1 | Temporal Trends and Clinical Outcomes with Radial Versus Femoral Arterial Access for Percutaneous Coronary Intervention in the United States

LB-1 | Temporal Trends and Clinical Outcomes with Radial Versus Femoral Arterial Access for Percutaneous Coronary Intervention in the United States

Percutaneous closure of aortopulmonary window in a preterm infant

ABSTRACT Aorto-pulmonary window (APW) is a rare congenital heart disease. The non-restrictive types of APWs present at an early age and require early surgical correction. The transcatheter device closure in young infants pose significant challenges that include hemodynamic instability during arteriovenous loop formation and due to potential encroachment of the occlusive device on vital adjacent structures, and sizing of introducer sheaths and delivery systems. We report a successful transcatheter closure of an AP window in a 1.35 Kg preterm infant with heart failure requiring mechanical ventilation. To the best of our knowledge this is the smallest and youngest baby , wherein transcatheter device closure has been attempted for a non-restrictive aorto-pulmonary window. The procedure was done through a 4 French right femoral venous access, thus avoiding an arterial access. A 0.025 Terumo wire was maneuvered through the pulmonary artery across the APW without formation of an arteriovenous loop. The APW was successfully occluded with a Konar multi-functional device delivered via a 4-French delivery system. The baby could be successfully weaned off the ventilator and could be discharge. On 1 month follow up, baby was in good health and gaining adequate weight. Thus we conclude that careful selection of patients allows successful closure of APW, even in the smallest baby.

Abstract 1153: Adipose-derived Mesenchymal Stem-cell Therapy Improves Arteriogenesis, Hemodynamics, And Walking Performance In A Porcine Model Of Peripheral Artery Disease

Background: There are few effective alternatives to revascularization for peripheral artery disease (PAD). We used our porcine model of PAD to test the hypothesis that adipose derived mesenchymal stem cells (ADMSC) injected around the aortic trifurcation in the pelvis improve ischemic limb hemodynamics and walking performance (WP). Methods: In Ossabaw miniswine (N=13, Age=6 mo) with metabolic syndrome, right (R) hindlimb ischemia was induced with R External Iliac and Superficial Femoral artery coil occlusion (T0) via carotid artery access. All swine had weekly testing of WP on a treadmill. At weeks 0 (T0), 4 (T4), and 8 (T8), ankle brachial indices (ABI) and muscle tissue oximetry (STO 2 ) were measured. At T4 and T8 all swine underwent angiography. At T4, in treatment (Tx) swine (N=4) ADMSC were isolated using stromal vascular fractionation of autologous abdominal wall fat. Using jugular vein access, a catheter with a retractable side-deploying needle was inserted in the R iliac vein and stabilized by a juxtaposed angioplasty balloon. The needle was deployed to access the retroperitoneum and ADMSC were infused around the aortic trifurcation. Results: Ischemic controls (IC) had no differences between T4 and T8 in ABIs, and mean STO 2 differences between R and L in calves and thighs. Tx improved both ABI and mean STO 2 measurements (table 1). IC had no changes in WP between T4 and T8, while Tx showed improvements (table1). On angiography, IC had growth of R Internal iliac artery (RIIA, the main inflow to the ischemic R hindlimb) and shorter appearance time (AT) of RIIA compared to L with no difference between T4 and T8. Tx showed increased growth of RIIA and shorter AT at T8 compared to T4 (table 1). Conclusion: In a clinically-relevant (similar to humans in size, anatomy, physiology and comorbidities) porcine model of PAD we found that ADMSC injection around the aortic trifurcation in the pelvis induces arteriogenesis and improves ischemic limb hemodynamics and walking performance.

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction.

Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies. An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion. This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.

Feasibility of Reduced Iodine Loads for Vascular Assessment Prior to Transcatheter Aortic Valve Implantation (TAVI) Using Spectral Detector CT.

Reduced iodine loads for computed tomography (CT)-based vascular assessment prior to transcatheter aortic valve implantation (TAVI) may be feasible in conjunction with a spectral detector CT scanner. This prospective single-center study considered 100 consecutive patients clinically referred for pre-TAVI CT. They were examined on a dual-layer detector CT scanner to obtain an ECG-gated cardiac scan and a non-ECG-gated aortoiliofemoral scan. Either a standard contrast media (SCM) protocol using 80 mL Iohexol 350 mgI/mL (iodine load: 28 gI) or a body-mass-index adjusted reduced contrast media (RCM) protocol using 40-70 mL Iohexol 350 mgI/mL (iodine load: 14-24.5 gI) were employed. Conventional images and virtual monoenergetic images at 40-80 keV were reconstructed. A threshold of 250 HU was set for sufficient attenuation along the arterial access pathway. A qualitative assessment used a five-point Likert scale. Sufficient attenuation in the thoracic aorta was observed for all patients in both groups using conventional images. In the abdominal, iliac, and femoral segments, sufficient attenuation was observed for the majority of patients when using virtual monoenergetic images (SCM: 96-100% of patients, RCM: 88-94%) without statistical difference between both groups. Segments with attenuation measurements below the threshold remained qualitatively assessable as well. Likert scores were 'excellent' for virtual monoenergetic images 50 keV and 55 keV in both groups (RCM: 1.2-1.4, SCM: 1.2-1.3). With diagnostic image quality maintained, it can be concluded that reduced iodine loads of 14-24.5 gI are feasible for pre-TAVI vascular assessment on a spectral detector CT scanner.

Clinical Anatomy of the Superficial Preprostatic Vein and Accessory Pudendal Artery in Robot-Assisted Radical Prostatectomy.

Purpose: We herein describe the superficial preprostatic vein (SPV) anatomy and determine its relationship with the accessory pudendal artery (APA). Materials and Methods: We reviewed 500 patients with localized prostate cancer who underwent conventional robot-assisted radical prostatectomy between April 2019 and March 2023 at our institution. SPV was defined as "any vein coming from the space between the puboprostatic ligaments and running within the retropubic adipose tissue anterior to the prostate toward the vesical venous plexus or pelvic side wall." While APA was defined as "any artery located in the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum." The intraoperative anatomy of each SPV and APA was described. Results: SPVs had a prevalence rate of 88%. They were preserved in 252 men (58%) and classified as I-, reversed-Y (rY)-, Y-, or H-shaped (64%, 22%, 12%, and 2%, respectively) based on their intraoperative appearance. Overall, 214 APAs were found in 142 of the 252 men with preserved SPV (56%; 165 lateral and 50 apical APAs in 111 and 41 men, respectively). SPVs were pulsatile in 39% men perhaps due to an accompanying tiny artery functioning as a median APA. Pulsations seemed to be initially absent in most SPVs but become apparent late during surgery possibly due to increased arterial and venous blood flow after prostate removal. Pulsations were common in men with ≥1 APA. Conclusions: This study, which described the anatomical variations in arteries and veins around the prostrate and their preservation techniques, revealed that preserving this vasculature may help preserve postprostatectomy erection. ClinicalTrials: The Clinical Research Registration Number is 230523D.

Feasibility of an animal model for long-term mechanical circulatory support with Impella 5.5 implanted through carotid artery access in sheep.

Impella is a mechanical circulatory support device of a catheter-based intravascular microaxial pump for left ventricular support and unloading. However, nonclinical studies assessing the effects of the extended duration of left ventricular unloading on cardiac recovery are lacking. An animal model using Impella implanted with a less invasive procedure to enable long-term support is required. This study aimed to evaluate the feasibility of an animal model for long-term support with Impella 5.5 implanted through carotid artery access in sheep.Impella 5.5 was implanted in four sheep through the proximal region of the left carotid artery without a thoracotomy, and myocardial injuries were induced by coronary microembolization. Support by Impella 5.5 was maintained for 4 weeks, and the animals were observed. The position of Impella 5.5 and cardiac function was evaluated using cardiac computer tomography at 2 and 4 weeks after implantation.All four animals completed the 4-week study without major complications. The discrepancy in the Impella 5.5 flow rate between the conscious and anesthetized states was observed depending on the device's position. Animals in whom the inflow was above the left ventricular papillary muscle had a relatively high flow rate under the maximum performance level without a suction alarm during the conscious state. Pathological changes in the aortic valve were observed. Cardiac function under the minimum performance level was observed with no remarkable deterioration.The animal model with myocardial injuries supported for 4 weeks by Impella 5.5 implanted through carotid artery access in sheep was feasible.