Aim. To evaluate the effectiveness of catheter-directed thrombolysis (CDT) in patients with critical lower limb ischemia (CLI) due to thromboembolic arterial occlusions and to study the long-term outcomes of the treatment. Materials and methods. Over 2020-2023, 35 patients (13 females, 22 males, aged 53-75) were studied. A total of 57% of patients had femoro-popliteal and below-the-knee (BTK) thromboclusion, 43% had BTK thrombotic occlusion. The study included 35 patients with acute limb ischemia (ALI) classified as Rutherford Category IIA-IIB: 17 patients (48.6%) in Category IIA and 18 patients (51.4%) in Category IIB. All patients underwent catheter-directed thrombolysis (CDT) after diagnostic arteriography and confirmation of acute lower limb arterial thrombosis (ALLAT) with involvement of the outflow arteries. Results. In most patients, significant ischemia regression, pain relief, and absence of critical haemorrhagic complications were observed. In 93.3% of patients, limb preservation was achieved within 2 months after CDT. Limb preservation was achieved in all 11 (100%) patients. CDT combined with percutaneous transluminal angioplasty (PTA) does not affect the frequency of rethrombosis in the revascularized segment, with a p-value of 0.0185 (statistical significance determined by the one-sided Fisher's exact test). The use of CDT led to a high frequency of revascularization and a reduced risk of recurrent thrombosis. One (20%) of the 5 patients who underwent CDT (catheter-directed thrombolysis) developed lower limb arterial rethrombosis, leading to subsequent amputation. Conclusions. CDT is an effective treatment method for patients with lower limb arterial thrombosis and arterial outflow lesions. It provides a high rate of revascularization, significant symptom relief, and a low risk of complications. Regular monitoring and anticoagulant therapy are essential to maintain treatment effectiveness and prevent recurrences. Optimising the CDT protocol in patients and ensuring close monitoring during treatment are critically important for identifying cases that may require alternative interventions. A key component in preventing rethrombosis is long-term angiographic follow-up after CDT to identify causative stenoses or subocclusions involved in ALLAT progression.

BackgroundChronic knee pain after total knee arthroplasty (TKA) is a common complication that is difficult to treat. This report aims to highlight the benefit of combining embolotherapy and neurolysis intervention for symptomatic relief of post-TKA pain in a patient with long-standing pain refractory to conservative management.Case presentationA 77-year-old man who had previously undergone left knee arthroplasty has been grappling with worsening knee effusion and debilitating pain, resulting in limited mobility and progressive musculature deconditioning over a 20-year period. Diagnostic arteriography showed marked diffuse periarticular hyperemia around the medial and lateral joint spaces of the left knee, along with capsular distention. The patient initially underwent microsphere embolization to selectively target multiple branches of the genicular arteries, achieving a 50% reduction in pain at the one-month follow-up. Subsequently, the patient underwent image-guided genicular nerve neurolysis, targeting multiple branches of the genicular nerves, which led to further pain reduction (80% compared to the initial presentation or 60% compared to post-embolization) at the one-month follow-up. This improvement facilitated weight-bearing and enabled participation in physical therapy, with sustained pain relief over the 10-month follow-up period.ConclusionThe combination of genicular artery embolization and genicular nerve block may be a technically safe and effective option for alleviating chronic pain after total knee arthroplasty.

Analysis of Medical Malpractice Claims Involving Interventional Radiologists: A Comprehensive Analysis From Two National Legal Databases

Clinical Outcomes of a Diagnostic and Management Protocol for Popliteal Artery Entrapment Syndrome at a Large Referral Center

As the neurointervention field grows, a new side effect emerges. Delayed leukoencephalopathy (DL) is believed to be an inflammatory or allergic reaction to polymer material that is shed from catheters during endovascular procedures. We present four cases of DL after aneurysm treatment in two patients, endovascular stroke treatment and diagnostic arteriography. We present our diagnostic process, including biopsy results in two patients, our anti-inflammatory treatment and outcomes together with a review of the literature. In our series, prognosis was variable with ongoing seizures in two patients. Our literature review reveals that asymptomatic shedding of polymer material is common, occurring in a third of endovascular stroke procedures, whereas symptomatic DL occurs in <0.5% of therapeutic neuroendovascular procedures. Clinicians should be aware of this rare complication, and oral glucocorticoids seem to be a reasonable first-line treatment strategy.

Objective: To assess the quality of reporting in diagnostic accuracy studies (DAS) referenced by the Quality Improvement Guidelines for Diagnostic Arteriography and their adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) statement.Materials and Methods: Citations specific to the Society of Interventional Radiology's Quality Improvement Guidelines for Diagnostic Arteriography were collected. Using the 34-item STARD checklist, two authors in a duplicate and blinded fashion documented the number of items reported per diagnostic accuracy study. Authors met, and any discrepancies were resolved in a resolution meeting.Results: Of the 26 diagnostic accuracy studies included, the mean number of STARD items reported was 17.8 (SD ± 3.1). The median adherence was 18 (IQR, 17-19) items. Ten articles were published prior to 2003, the original date of STARD publication, and 16 articles were published after 2003. The mean number of reported items for the articles published prior to STARD 2003, and after STARD 2003 was 17.4 (SD ± 2.4) and 18.1 (SD ± 3.5), respectively. There were 14 STARD items that demonstrated an adherence of < 25%, and 13 an adherence > 75%.Conclusion: The dichotomous distribution of adherence to the STARD statement by DAS investigated demonstrates that areas of deficient reporting may be present and require attention to ensure complete and transparent reporting in the future.

Endoscopic sphincterotomy (ES) and papillectomy (EP) are associated with a non-negligible risk of post-procedural bleeding. Despite first-line endoscopic hemostasis being achieved by several methods, patients may experience bleeding persistence or recurrence. In such cases, fibrin glue (FG) injection may be used as a rescue therapy before more invasive approaches. The aim of this study was to evaluate the efficacy and safety of endoscopic FG injection to treat refractory post-ES and post-EP bleeding. Data were collected retrospectively from patients with refractory immediate or delayed bleeding following ES or EP, between October 2007 and November 2019, at a single institution. Clinical success was defined as bleeding control after FG injection. Overall, 70 patients were included. Clinical success was reached in 64 (91.4%) patients after one session of FG injection. Of six (8.6%) patients in whom the treatment failed, one required subsequent insertion of a fully covered self-expanding metal stent (FC-SEMS) due to immediate massive bleeding, while five experienced bleeding recurrence. Such events were managed with an additional session of FG injection that failed in two cases. Therefore, one patient underwent FC-SEMS plus selective embolization, whereas the other underwent diagnostic arteriography. No severe periprocedural complications occurred. Two cases of intrabiliary glue migration were treated by endoscopic removal with a retrieval basket. Rescue therapy with endoscopic FG injection appears to be effective and safe to treat refractory post-ES and post-EP bleeding. Further studies are required to confirm these preliminary data.

Safety and Efficacy of Transbrachial Access for Endovascular Procedures: A Single-Center Retrospective Analysis

Hypoplastic coronary artery disease is a rare congenital abnormality reported to be associated with myocardial infarction and sudden cardiac death. Provoked positive spasm in the left circumflex coronary artery (LCX) with pharmacological spasm provocation tests was remarkably lower than other coronary arteries. We sometimes encountered patients with rest angina and hypoplastic right coronary artery (H-RCA). Among 5953 patients with diagnostic and follow-up coronary arteriography, we found 93 patients (1.6%) with H-RCA. During the same period, we could perform spasm provocation tests in 564 patients with rest angina including 13 patients with H-RCA and 249 patients with effort angina including 10 patients with H-RCA. Pharmacological spasm provocation tests were performed in 51 of 93 patients including 34 patients with ischemic heart disease (IHD) and 17 patients with non-IHD. Provoked spasm incidence in patients with IHD was higher than in those with non-IHD but not significant (52.9% vs. 29.4%, p = 0.1114). Provoked positive spasm in the LCX in patients with rest angina and H-RCA was significantly higher than that in those without H-RCA (69.2% vs. 23.4%, p < 0.001). Provoked spasm on both left anterior descending artery and LCX in patients with rest angina and H-RCA was also remarkably higher than in those without H-RCA (53.8% vs. 3.1%, p < 0,001). There were no clinical differences between patients with and without H-RCA rest angina. Two-vessel spasm (61.5% vs. 0%, p < 0.01) and LCX-provoked spasm (69.2% vs. o%, p < 0.01) were significantly higher in patients with H-RCA and rest angina than that in those with H-RCA and effort angina. In patients with rest angina and H-RCA, LCX-positive spasm was significantly higher and these patients may have a potential of high disease activity in the clinic as a coronary spastic angina.

Abstract No. 442 Femoral flip: reversible femoral access

Medical Malpractice in Image-Guided Procedures: An Analysis of 184 Cases

BackgroundChoriocarcinoma is a highly malignant tumor but with a good prognosis due to the valid response to systemic chemotherapy. We present a case of a young woman affected by a giant pelvic arterio-venous fistula following a metastatic gestational choriocarcinoma, conditioning metrorrhagia and pulmonary embolism, successfully treated by multimodal transcatheter embolization, using a simultaneous transarterial and transvenous approach.Case presentationIn a young patient affected by choriocarcinoma and metrorrhagia, a computed tomography showed a giant arterio-venous fistula, pulmonary metastases and embolism. A transfemoral diagnostic arteriography showed a giant arterio-venous fistula sustained by right and left hypogastric arteries with early opacification of the right gonadal vein and of the inferior vena cava. A transarterial embolization of the distal branches of hypogastric arteries with poly-vinyl-alcohol particles, coils and Squid was performed. A transfemoral phlebography of the right gonadal vein showed multiple thrombi, responsible of the pulmonary embolism. An Amplatzer plug via trans-jugular was finally placed at the confluence of the gonadal vein in the vena cava, to reduce arterio-venous fistula out-flow and to occlude the vein, preventing further episodes of pulmonary embolism. Metrorrhagia progressively disappeared. A second transarterial embolization combined with a complete response to systemic chemotherapy determined arterio-venous fistula resolution.ConclusionsThis was a very rare case of a giant pelvic arterio-venous fistula following choriocarcinoma in a patient symptomatic for metrorrhagia with an accidental finding of pulmonary embolism at computed tomography. A transcatheter embolization was successfully performed with different embolic materials, using a simultaneous transarterial and transvenous approach: the goal was not only to obtain metrorrhagia resolution but also to avoid a massive pulmonary embolism, a potential life threatening condition, in a young woman affected by a highly malignant tumor but with a good prognosis.

Aim. To consider an opportunity for application of different combinations of biochemical and bioimaging parameters to create different multimarker diagnostic panels designed for assessment of risk of coronary atherosclerosis and its complications.Material and methods. To the analysis, data included, obtained from patients 18 y.o. and older (n=502), investigated at NMRCPR of the Ministry of Health in 2011-2013, who had undergone diagnostic coronary arteriography and duplex carotid scanning. Atherosclerosis burden was measured according the Gensini score. Subfractional spectrum of apoB-lipoproteides was assessed with the Quantimetrix Lipoprint LDL System (USA), biochemistry was done with standard lab. methods. Statistics was done with software Statistica v.10, IBM SPSS Statistics v.20, SAS v.9.4.Results. Several multimarker combinations (panels) for non-invasive estimation of risk of coronary atherosclerosis detection and its severity were proposed. These are 1) an index K, calculated as ratio of the sum of potentially atherogenic subfractions to the large physiologically active LDL1 particles; index K &gt;1,7 indicates an increased atherogenic potential of apo B-containing particles even with normal lipid profile, and can be used for non-invasive prediction of coronary atherosclerosis; 2) duplex complexes as adiponectin to endothelin ratio which &lt;7,0 is associated with coronary atherosclerosis risk only in men, and as leptin to insulin ratio which &lt;3,5 is associated with elevated atherosclerosis risk only in women; 3) integrated biomarker BIO represented the combination of individual visual and biochemical variables and permitted to discriminate patients from those with no coronary atherosclerosis or having subclinical or severe atherosclerotic lesions.Conclusion. Proposed multimarker diagnostic panel could be regarded as novel potential biomarkers of coronary atherosclerosis risk and severity, however validation of these markers is necessary. The problem of cardiovascular risk stratification and further prevention activities should be solved with the search for novel markers and combinations of markers.

Aim. The search for genetic markers of ADIPOQ, associated with the level of adiponectin and development of coronary atherosclerosis.Material and methods. To the study, patients included, who had undergone diagnostic coronary arteriography in 2011-2012 in the NMRCPM with assessment of the severity of coronary atherosclerosis. The level of adiponectin was measured in plasma with the test-system based on the immune enzyme analysis. Genetic variants rs17300539, rs182052 and rs266729 gene ADIPOQ were measured realtime (Applied Biosystems, 7500 Real Time PCR System). Alleles of the studied variants were summarized by a unified score of genetic risk (SGR).Results. To the study, 447 patients included, of those 319 males (70,7%). Median of age was 61 [55-69] y.o. All patients were selected to 2 groups by SGR (≤2 and &gt;2, respectively). Groups differed by the level of adiponectin 7,64 vs 8,29 mcg/mL (р=0,01), total cholesterol 4,60 vs 5,00 mM/L (p=0,03), cholesterol of low density lipoproteides 2,8 vs 3,09 mM/L (p=0,03), and the rate of unstable angina development 2,15% vs 6,8% (р=0,02) and type 2 diabetes 11,8% vs 21,1% (р=0,01), respectively. There was no difference in the groups by Syntax and Gensini score.Conclusion. Genetic score based on the three variants of ADIPOQ does determine the plasmatic level of adiponectin and risk of unstable angina and diabetes, but not the grade of coronary atherosclerosis.

We aimed to report approach, safety, technical success, and clinical outcomes of prone trans- radial access (PTRA) and demonstrate feasibility for procedures requiring simultaneous arterial intervention and prone percutaneous access. Fifteen patients underwent PTRA, seven females (47%) and eight males (53%), mean age of 55 years (range, 19-78 years). All patients underwent PTRA for combined transarterial and posterior-approach percutaneous interventions. Variables included sheath size (French, F), type of anesthesia, arterial intervention technical success, posterior-approach percutaneous intervention technical success, estimated blood loss (mL), fluoroscopy and procedure time, complications, and follow-up. Mean sheath size was 4 F (range, 4-6 F; SD = 0.5). Arterial interventions included transarterial embolization of renal (n=6), hepatic (n=2), and pelvic vessels (n=2), diagnostic arteriography (n=4), and embolization of an arteriovenous malformation (n=1). Posterior-approach intervention technical success was 100% (15/15). PTRA technical success was 100% (15/15). Posterior-approach percutaneous interventions included retroperitoneal (n=5) and pelvic (n=1) mass biopsies, nephrostomy tube placement (n=2), cryoablation of pelvic (n=2) and renal (n=1) masses, sclerotherapy of arteriovenous malformations (n=2), foreign body removal from the renal collecting system (n=2), ablation of a renal tumor (n=1), intracavitary injection of pulmonary mycetoma (n=1), and ablation and cementoplasty of a vertebral body tumor (n=1). The biopsies were diagnostic (6/6). There were no minor or major access-site complications. PTRA is a safe and feasible method for performing combined arterial and posterior approach percutaneous interventions without the need for repositioning.

Lesiones vasculares asociadas con accidentes de motocicleta. Serie de casos

Introduction Although rare, arteriovenous fistula (AVF) is the most common vascular malformation of the spine, and it is mainly located in the thoracic region. The fistula is identified by arteriography, which enables the treatment by embolization or guides the microsurgical therapy. Clinical Presentation We describe the case of a 61-year-old woman with neurogenic claudication evolving to paraparesis. A dorsal intradural AVF was identified by magnetic resonance imaging (MRI) and arteriography, and it was submitted to an embolization, but the procedure was unsuccessful. The patient was then referred for neurosurgery, and the AVF was obliterated using a microsurgical technique guided by multimodal intraoperative monitoring. We identified the AVF in the intraoperative moment and we then cut and coagulated the extradural portion of the nerve root. Discussion Arteriovenous fistulas occur in the dura mater of the nerve roots with the arterialization of the venous plexus. The treatment prevents the progression of the deficits. While performing diagnostic arteriography, attempts of embolization are possible. Conclusion Although the initial attempt of embolization at the moment of the diagnostic arteriography is achievable, it has failure rates of 50%, unlike the surgical treatment, which is definitive in all cases, as reported in this article.

In recent years there has been an increase in the number of endovascular examinations in the study of both cardiovascular and cerebrovascular diseases. One very infrequent complication is neurotoxicity due to contrast, and it must be suspected within the context of a neurological deficit following such examinations in order to be able to diagnose it.A 61-year-old male who presented an epileptic attack and later deficit in the left hemisphere following diagnostic arteriography. After ruling out the possibility of an urgent vascular pathology, he was submitted to a magnetic resonance brain scan with the suspicion of this condition. The clinical signs and symptoms were limited to 72 hours with cortisone therapy.Contrast-induced encephalopathy covers a wide range of clinical features which, in the vast majority of cases, are self-limiting to 24-72 hours, and within the context of neuronal damage following contrast infusion. Its prognosis is excellent, and diagnostic suspicion is crucial in its treatment.Encefalopatia por contraste iodado: una patologia que se debe tener en cuenta en el desarrollo de las exploraciones endovasculares.Introduccion. En los ultimos años ha aumentado el numero de exploraciones endovasculares en el estudio de la patologia tanto cardiovascular como cerebrovascular. Una de las complicaciones poco frecuentes es la neurotoxicidad por contraste y su sospecha resulta imprescindible en el contexto de un deficit neurologico tras dichas exploraciones para llegar a su diagnostico. Caso clinico. Varon de 61 años que tras una arteriografia diagnostica en el estudio de una hemorragia subaracnoidea presento una crisis epileptica y posteriormente deficit hemisferico izquierdo. Tras descartar una patologia vascular urgente, se realizo una resonancia magnetica cerebral con sospecha de encefalopatia poscontraste. La clinica se limito en 72 horas con corticoterapia. Conclusiones. La encefalopatia por contraste abarca un amplio espectro clinico, en la inmensa mayoria de los casos autolimitado en 24-72 horas, y en el contexto del daño neuronal tras la infusion de contraste. Su pronostico es excelente y la sospecha diagnostica es vital en el tratamiento.

The first assessment of operative logs for traditional vascular fellowship track versus integrated vascular training programs

Impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation with hepatic venous sampling for preoperative localization of occult insulinoma