Careful Preprocedural Planning Research Articles

Computed tomography to guide transcatheter aortic valve implantation.

Since its introduction in 2022, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment and prognosis of patients with aortic stenosis. Robust clinical trial data and awealth of scientific evidence support its efficacy and safety. One of the key factors for success of the TAVI procedure is careful preprocedural planning using imaging. Computed tomography (CT) has developed into the standard imaging method for comprehensive patient assessment in this context. Suitability of the femoral and iliac arteries for transfemoral access, exact measurement of aortic annulus size and geometry as the basis for prosthesis selection, quantification of the spatial relationship of the coronary ostia to the aortic annular plane, and identification of optimal fluoroscopic projection angles for the implantation procedure are among the most important information that can be gained from preprocedural CT. Further research is aimed at improving risk stratification, for example, with respect to annular perforation, periprosthetic aortic regurgitation, and need for postprocedural implantation of apermanent pacemaker.

Iliofemoral artery predilation prior to transfemoral transcatheter aortic valve implantation in patients with aortic valve stenosis and advanced peripheral artery disease

To investigate the feasibility and safety of percutaneous transluminal angioplasty (PTA) of the iliofemoral arteries (IFA) before transfemoral transcatheter aortic valve implantation (Tf-TAVI) in patients with advanced peripheral artery disease (PAD). Although Tf-TAVI represents the access of choice, alternative vascular access routes are preferred for patients displaying advanced PAD. PTA of the IFA represents a less invasive option, broadening the spectrum of patients eligible for Tf-TAVI. All patients requiring PTA of the IFA before Tf-TAVI, between 2012 and 2021, were included. Primary efficacy endpoint was the rate of successful transcatheter heart valve (THV) delivery and implantation. Primary safety endpoint was the rate of PTA and access-site-related vascular complications, procedural- and in-hospital complications. Among 2726 Tf-TAVI procedures, 59 patients required IFA predilation. Successful THV delivery and implantation was achieved in 57 (96.6%) patients, respectively. Sheath placement was achieved in 59 (100%) patients with only one minor dissection and no major vascular complications following iliofemoral PTA. Regarding access site complications, two (3.4%) vessel perforations and one (1.7%) vessel rupture were observed, with eight (13.5%) patients requiring unplanned endovascular interventions. There was one intraprocedural death due to THV-induced vessel laceration, while in-hospital all-cause mortality was 8.5% in the present high-risk patient cohort. Predilation of IFA is safe and effective in patients with advanced PAD. Careful preprocedural planning is paramount in improving procedural safety and efficacy. This strategy has the potential to broaden the spectrum of patients eligible for Tf-TAVI.

Percutaneous transhepatic biliary stone removal: A single-center retrospective study

Objectives: To report, the authors’ experience with percutaneous transhepatic biliary stone removal, focusing on the technical aspects and overall performance, as well as reviewing few challenging cases. Material and Methods: All cases of percutaneous transhepatic biliary stone removal from 2015 to 2022 were retrieved, including intrahepatic locations. Cases with negative initial cholangiogram suggestive of stone passage were excluded from the study. The demographic data, procedural indications and details, stone characteristics, fluoroscopic images, success rate, and complications were retrospectively evaluated by two experienced observers. Results: The final study included 67 patients (mean age = 76.8). Majority of indications were altered gastric anatomy and failed endoscopic retrograde cholangiopancreatography. The mean largest stone size was 9 mm and most cases had multiple stones. Balloon sphincteroplasty was performed in all cases and mechanical lithotripsy in 24%. Fourteen cases required repeated trials, and they were mostly staged, depending on technical factors and patient condition. Recurrent pyogenic cholangitis (RPC) usually required repeated trials, and two separate sites of catheterization were made in the same lobe for one challenging case. Complete stone retrieval was not achieved in 9% (six out of 67) of cases: failure of mechanical lithotripsy (n = 2); failure of balloon occlusion technique (n = 1); refluxed stone (n = 1); and multiplicity of intrahepatic stones (n = 2). Three minor complications were encountered, including sepsis and self-controlled hemobilia. No major complications. Conclusion: Percutaneous extrahepatic biliary stone removal is a safe and technically feasible procedure after a failed endoscopic approach or altered biliary tract anatomy. Cases of RPC or previous Whipple’s operation could be technically challenging. Careful pre-procedural planning and anatomical review are crucial.

Akutna ishemija lijeve ruke nakon TEVAR-a zbog anatomske varijante vertebralne arterije

Aim: In this case we report acute left arm ischemia after thoracic endovascular aortic repair of the saccular thoracic aortic aneurysm due to a rare anatomical variation of the left vertebral artery. Case report: Thoracic aortic stent-graft was deployed to cover the aneurysm, but six hours later acute left arm ischemia occurred due to a rare form of vertebral artery origin from the aortic arch instead of from the left subclavian artery. This hostile anatomy led to an iatrogenic acute ischemia which was the indication for an emergency left-common-carotid-to-subclavian-artery bypass grafting. Conclusion: Multidisciplinary approach and careful pre-procedural planning should always be the standard procedure in complex cases to avoid this complication.

A case of concomitant aortic stenosis and aortic arch aneurysm: a combined endovascular approach

Aortic valve stenosis and aortic aneurysmal disease are increasingly prevalent with advancing age. When associated, their treatment is very challenging. A female patient with previous Tirone-David procedure presented to our hospital with acute heart failure. She was diagnosed with severe aortic stenosis, aneurysm of the aortic arch and the descending thoracic aorta. She underwent successful concomitant aortic arch TEVAR and transcatheter aortic valve repair, with optimal acute and mid-term result. Our case demonstrates that a careful pre-procedural planning, along with a good cooperation between interventional cardiologists, cardiac surgeons, radiologists and clinical cardiologists, are essential in order to guarantee an excellent outcome for the patient.

Transcatheter Aortic Valve Replacement During Pregnancy

Transcatheter aortic valve replacement (TAVR) is an approved and widely accepted standard treatment for severe symptomatic aortic stenosis (AS) in high-risk surgical candidates.1 Severe symptomatic AS during pregnancy presents a difficult clinical challenge.2 A 22-year-old female patient presented to our service at 15 weeks’ gestation with congenital symptomatic AS. After a thoughtful heart team evaluation, TAVR was recommended to the patient and performed at 22 weeks’ gestation. The authors further explore and discuss the preprocedure planning and treatment decisions of this case. The heart team focused on the timing and special considerations needed to ensure the health and safety of the patient and fetus. With careful preprocedural planning, TAVR can be a low-risk treatment option during pregnancy and provide a reliable bridge to a healthy, term delivery. A 22-year-old pregnant female patient presented with severe symptomatic AS at 15 weeks’ gestation. The patient was 165 cm tall, weighed 74 kg with a body mass index of 27 kg/m2 and body surface area of 1.84 m2 at the time of presentation. The patient’s clinical history includes congenital bicuspid aortic valve disease, which required balloon aortic valvuloplasty (BAV) at the age of 9 years. Throughout young adulthood, she had been asymptomatic with high levels of activity. Her chief complaints on presentation were increased dizziness, dyspnea on exertion, and chest discomfort. Echocardiography demonstrated a normal ejection fraction, an aortic peak flow velocity of 4.04 m/s, an aortic valve mean gradient of 38.22 mm Hg, an aortic valve area of 1.0 cm2, and mild-to-moderate aortic insufficiency (AI). The ascending aorta was mildly enlarged (3.9 cm). There was mild narrowing of periductal isthmus with no Doppler gradient (Figure 1; Table 1). Stress echocardiography testing showed moderate AI and below-average exercise capacity. The patient completed 8 to 9 metabolic equivalents …

Diagnostic and Interventional Radiology for Liver Diseases

Diagnostic and Interventional Radiology for Liver Diseases

Percutaneous radiofrequency ablation of hepatocellular carcinoma: analysis of 80 patients treated with two consecutive sessions

This study investigated the reasons for some patients requiring two consecutive sessions of percutaneous radiofrequency (RF) ablation of hepatocellular carcinoma (HCC). We reviewed our database of 1,179 patients (1,624 treatments) with HCCs treated by percutaneous ultrasound (US)-guided RF ablation over 6 years. We retrospectively evaluated 80 patients who required a second session after the first session. The medical records and follow-up CTs were studied. We assessed the reasons for the second session and the patient outcomes. A second session was required in 80 (4.8%) out of 1,642 treatments of percutaneous RF ablation for HCC. The reason for the second session included technical failure related to the patient or the procedure (n=26), technical failure due to residual (n=40), newly detected (n=11) or missed (n=3) tumors found at the immediate follow-up CT. All patients were retreated with a second RFA session the next day. Seventy-five (93%) of 80 patients achieved complete ablation after the second session. The remaining five patients were treated by TACE (n=1), additional RFA (as second treatment at next admission) (n=3), or were lost to follow-up (n=1). After 1 month follow-up, 72 patients (96%) showed complete ablation after the second session. The interventional oncologist should understand the technical reasons for a patient requiring a second session of RF ablation when providing treatment for HCCs and perform careful pre-procedural planning to minimize the need for multi-session procedures.

Percutaneous management of pancreatic fluid collections

Percutaneous catheter drainage of both infected and non-infected pancreatic fluid collections is a safe, efficacious procedure. The results of this procedure depend upon proper selection of patients based upon their clinical status as well as the morphological findings depicted by computed tomography and endoscopic retrograde cholangiopancreatography, careful preprocedural planning and execution of the drainage procedure, good catheter care with follow-up imaging and contrast studies, and attention to the criteria of catheter removal. An average success rate of 80% should be expected with a complication rate of about 15%.