Difficult Vascular Anatomy Research Articles

Endovascular straightening of the internal carotid artery during mechanical thrombectomy: The "tightrope technique".

Mechanical thrombectomy is a standard treatment for acute stroke, but it can be technically challenging in elderly patients with difficult vascular anatomy. To overcome this issue, we propose a new endovascular approach called the "tightrope" technique. This technique uses a stiff guidewire and a standard angiographic catheter to straighten the internal carotid artery (ICA) tortuosity, allowing the guiding catheter to be positioned next to the intracranial level. We retrospectively evaluated all the procedures in which the "tightrope" technique was used. This approach involves advancing a 0.035″ Advantage stiff guidewire and a standard 4 Fr angiographic catheter through the vascular tortuosity. The catheter is twisted over the guide wire in a clockwise direction, gaining tension that gradually straightens the vascular axis, allowing the guiding catheter to pass up to the distal ICA. Between June 2022 and March 2023, we successfully performed consecutive mechanical thrombectomy procedures using the tightrope technique in 11 patients with highly tortuous ICA segments. In all cases, we were able to safely advance the catheter system up to the distal cervical ICA. Although our study included a small cohort of patients, the "tightrope" technique proved to be successful in all patients, allowing for safe advancement of the guiding catheter toward extremely tortuous anatomy. However, further validation in a larger patient population is necessary to determine the technique's effectiveness and safety profile.

Prevalence and predictors of difficult vascular anatomy in forearm artery access for coronary angiography and PCI

Transradial access has established as preferred access for cardiac catheterization. Difficult vascular anatomy (DVA) is a noticeable threat to procedural success. We retrospectively analyzed 1397 consecutive cardiac catheterizations to estimate prevalence and identify predictors of DVA. In the subclavian-innominate-aortic-region (SIAR), DVA was causing failure in 2.4% during right-sided vs. 0.7% in left-sided forearm-artery-access (FAA) attempts (χ2 = 5.1, p = 0.023). Independent predictors were advanced age [odds ratio (OR) 1.44 per 10-year increase, 95% confidence interval (CI) 1.15 to 1.80, p = 0.001] and right FAA (OR 2.52, 95% CI 1.72 to 3.69, p < 0.001). In the radial-ulnar-brachial region (RUBR), DVA was causing failure in 2.5% during right-sided vs. 1.7% in left-sided FAA (χ2 = 0.77, p = 0.38). Independent predictors were age (OR 1.28 per 10-year increase, 95% CI 1.01 to 1.61, p = 0.04), lower height (OR 1.56 per 10-cm decrease, 95% CI 1.13 to 2.15, p = 0.008) and left FAA (OR 2.15, 95% CI 1.45 to 3.18, p < 0.001). Bilateral DVA was causing procedural failure in 0.9% of patients. The prevalence of bilateral DVA was rare. Predictors in SIAR were right FAA and advanced age and in RUBR, left FAA, advanced age and lower height. Gender, arterial hypertension, body mass, STEMI and smoking were not associated with DVA.

Balloon-assisted tracking technique as 'a way forward' for transradial intervention.

In percutaneous coronary interventions, use of the radial artery may be limited by vascular anatomy or vascular complications, such as radial artery spasm, dissection or perforation. The balloon-assisted tracking (BAT) technique is a novel and innovative method to successfully perform transradial procedures in patients with difficult vascular anatomy, severe tortuosity or radial artery spasm. In addition, the BAT technique can serve as a bail-out technique when vascular complications such as artery dissection or perforation occur. We analysed data of all percutaneous coronary intervention patients in whom the BAT technique was undertaken in daily practice and report acute and long-term outcomes. A total of 62 patients were included and, in most patients, the BAT technique was performed for radial spasm. Most patients were administered benzodiazepines or nitrates before the BAT technique was performed. The primary end point, defined as successful passage of the catheter through the artery of the arm using the BAT technique, was 98%. 11% of patients developed a complication within 24 h (haematoma, prolonged pain or visible vascular damage at the end of procedure); all completely recovered at follow-up. No complications occurred during long-term follow-up. BAT is a low-risk and easy-to-use technique that increases the success rate of radial artery access and may prevent vascular complications.

Direct Access Embolization of Intracranial Vascular Pathology: Preliminary Experience and Technical Notes

Abstract INTRODUCTION Transarterial embolization is widely used for definitive or adjunctive treatment of intracranial vascular pathology and is most commonly performed via the transfemoral approach. However, the ability to treat the lesion successfully depends significantly on the navigation of microcatheters into the distal circulation. Vascular tortuosity oftentimes precludes one's ability to position a microcatheter near the target lesion. In these cases, embolization relies on the ability of the embolysate to travel a fair distance before reaching the target lesion. METHODS We describe our preliminary experience with direct access embolization using a hybrid operating/bi-plane angiography suite. A craniotomy is performed to access and isolate the feeding artery. A microcatheter is inserted into the vessel and navigated to the target lesion. Embolization proceeds using bi-planar angiography. RESULTS Direct access embolization was attempted in 2 patients (45 M, 64 M) during treatment of a dural arteriovenous fistula and an arteriovenous malformation. Three treatments were performed (1 for dAVF, 2 for AVM) using Onyx (Medtronic; Dublin, Ireland) involving 4 vascular pedicles. The dAVF was successfully occluded via this approach. Significant nidal penetration/embolization was achieved in the AVM allowing for complete surgical resection. There were no complications related to this procedure. CONCLUSION Direct access embolization is an innovative technique combining both open and endovascular treatment of intracranial vascular pathology. It can be used in instances where difficult vascular anatomy preclude traditional transarterial routes of navigation. Further investigation is required to better define the safety, efficacy, and best practices of this novel technique.

Introduction of prostate artery embolization (PAE) in Sweden

Background: Transurethral resection of the prostate (TURP) is ‘Gold Standard’ treatment for moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) with bladder-outlet obstruction (BOO). However, TURP is associated with a risk of complications, so minimally invasive methods have been developed. Prostate artery embolization (PAE) is a new minimally invasive procedure. This study reports the outcomes of PAE when introduced in a ‘real life’ clinical setting in a Swedish County hospital.Methods: A prospective, single-center, single-arm study in a consecutive vascular-anatomy ‘all comers’ population, eligible for TURP or adenomaenukleation, but unsuitable for this, treated with PAE from January 2015 to June 2018. Defined improvement of IPSS/QoL scores, or freedom from urinary catheter if previous urinary catheter-dependent, or clean intermittent catheterization (CIC) were considered as clinically successful treatments. PAE was performed until arterial stasis using the Perfected technique. Most patients were treated during a day-care procedure.Results: Of 37 treated men, bilateral PAEs were achieved in 32 patients, unilateral PAEs in four patients, and bilateral failure in one patient due to difficult vascular anatomy. Clinically successful treatment was achieved in 84%, without serious adverse events.Conclusions: PAE was introduced in Sweden, showing PAE as a novel and good minimally invasive alternative in treatment of symptomatic BPH, possible to perform as a day-care procedure.

Wprowadzenie cewnika techniką retrograde i zamknięcie przetrwałego przewodu tętniczego techniką antegrade za pomocą urządzenia Coccoon Duct Occluder u 6-miesięcznego dziecka

Patent ductus arteriosus (PDA) accounts for up to 10% of all congenital heart disease. Transcatheter closure of PDAs has now become treatment of choice replacing surgery. It is simple, consisting of placement of device or vascular occlusion coils either antegrade from femoral vein or retrograde from femoral artery. Here we report a patient of PDA with vascular anatomy too difficult to be antegradely approached and were closed by a retrograde wiring and antegrade snaring using a customised snare. Then device was deployed by usual antegrade approach over snared wire. This retrograde wire-assisted technique and antegrade snaring could be utilized to overcome PDA of difficult vascular anatomy, which could not be easily fulfilled by conventional antegrade venous approach alone.

Retrograde trans-anterior communicating artery rescue of unopened Pipeline Embolization Device with balloon dilation: complication management

As the use of the Pipeline Embolization Device (PED) for the treatment of complex intracranial aneurysms rises, knowledge about complications continues to accumulate amidt a paucity of reports on techniques...

First clinical experience with the GARDEX EPD: a novel embolic protection device for carotid artery stenting

Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy in the treatment of carotid artery disease. The use of an embolic protection device (EPD) can reduce the frequency of embolic events during CAS. Difficult vascular anatomy may complicate current generation EPD placement. This problem is addressed by a new EPD, the GARDEX System. The aim of this study was to assess the safety and performance of the GARDEX EPD during CAS. Thirty-eight patients underwent CAS with the GARDEX EPD in two medical centres. All patients were prospectively followed up for 30 days. Device performance and procedural details were collected and analysed prospectively. Vessel anatomy and lesion morphology were evaluated and stratified into a scoring system for anatomic difficulty. More than a third of the patients were considered to have difficult vascular anatomy for CAS. All enrolled patients were successfully treated. There was one (2.6%) minor periprocedural stroke and there were two (5.3%) periprocedural TIAs which resolved within 24 hours. No additional complications were noted during the 30-day follow-up period. In this first experience, CAS under cerebral protection with the GARDEX EPD was safe and feasible. Our data suggest that the use of the GARDEX EPD is simple and shows high success rates even in challenging anatomies. The role of this new device in CAS needs to be further confirmed in a larger patient population.

Abstract No. 188: Impact of C-Arm CT in Patients with Hepatocellular Carcinoma Undergoing Transhepatic Arterial Chemoembolization

To evaluate the impact of C-arm CT on treatment algorithms in patients undergoing transhepatic arterial chemoembolization for hepatocellular carcinoma (HCC). From March 2008 to July 2008, 87 patients with HCC underwent 100 consecutive hepatic transhepatic arterial chemoembolizations. Non-contrast and selective/subselective contrast enhanced C-arm CT acquisitions (8 second rotational C-arm CT scan of ∼200 degrees) with 3D reconstruction were obtained in addition to conventional digital subtraction angiograms (DSA) in all patients. Impact on diagnosis and treatment was determined by the operating physician as follows: a) change in number or characterization of lesion(s) from that documented by prior diagnostic cross-sectional imaging study and its influence on eligibility for liver transplantation b) utility in evaluating extra-hepatic supply to the tumor c) utility of 3D angiography for selective catheterization of difficult vascular anatomy d) evaluating target and non-target embolization. The mean number of C-arm CT acquisitions per study was 3.3 (range, 2 -8). There was one technical failure. In twenty one of the 100 procedures (21%), C-arm CT significantly changed the number and characterization of the lesions that resulted in a change in the patient's eligibility for transplantation or their need for additional therapy. In 19 procedures (19%), C-arm CT was crucial in delineating the segmental arterial vessel(s) supplying the tumor and providing 3D angiography for easier catheterization. Non-contrast, C-arm CT obtained during or after administration of the chemotherapy increased the confidence level of adequate target embolization (dense ethiodol uptake in treated lesions) in 95% of the chemoembolizations. In 5% of the cases, C-arm CT provided no added value either due to technical failure (n=1) or significant breathing artifact (n=4). C-arm CT is a useful tool in patients undergoing transhepatic arterial chemoembolization and results in a significant change in the treatment plan in over one fifth of the patients.

A Consecutive Series of 70 Laparoscopic Donor Nephrectomies Demonstrates the Safety of This New Operation

Laparoscopic donor nephrectomy (LDN) has the potential to overcome some of the disincentives to living kidney donation. This study presents the results of a consecutive series of 70 LDN from a single center with an emphasis on postoperative complication rates and donor recovery times. There was no selection bias based on donor body mass index or because of difficult vascular anatomy. All donors received postoperative analgesia using a patient-controlled system and returned to activities and employment at their discretion. There was no donor mortality and no episode of thromboembolic disease. One operation was converted from open to LDN because of renal artery bleeding. Postoperative complications encompassed chest infection (6%), unilateral pulmonary edema (3%), ileus (3%), wound infection (3%), paraesthesia of L1 (4%), testicular pain (3%), persistent wound pain (1.4%), and reoperation for division of adhesions (3%). In conclusion, LDN is a safe procedure with low postoperative morbidity. There were some unexpected complications, but recovery time was short.

A CONSECUTIVE SERIES OF 70 LAPAROSCOPIC LIVE DONOR NEPHRECTOMIES DEMONSTRATING THE SAFETY OF THIS NEW OPERATION

P147 Aims: Laparoscopic live donor nephrectomy (LDN) has the potential to overcome some of the disincentives to live kidney donation but has yet to be widely adopted in the UK. This study presents the results of a consecutive series of 70 LDN from a single centre with an emphasis postoperative complication rates and donor recovery times. Methods: 70 live donors (39 women and 31 men; mean age 46 yrs) underwent transperitoneal LDN. Two consultant surgeons working together performed all operations. There was no selection on the basis of donor body mass index (range 18-45 kg/m2) or because of difficult vascular anatomy. All patients received postoperative analgesia using a patient controlled analgesia system. Donors were allowed to resume normal activities and return to work at their own discretion. Results: There was no donor mortality and no episodes of thromboembolic disease. One operation was converted to an open procedure because of bleeding from the renal artery. The following postoperative complications were recorded: chest infection 4(6%); paraesthesiae of L1 dermatome 3 (4%) wound infection 2 (3%); unilateral pulmonary oedema 2 (3%); ileus 2 (3%); testicular pain 2 (3%); persistent wound pain 1 (1.4%). Two (3%) patients were re-laparoscoped for division of adhesions. Donor recovery rates (mean ±) are shown in the table. Recipient transplantation was complicated by ureteric stenosis in 2 cases (3%) but there were no vascular thromboses.FigureConclusions: LDN is a safe procedure with low postoperative morbidity and no compromise to the procured graft. Nonetheless, some unexpected complications such as L1 paraesthesia, testicular pain and pulmonary oedema were recorded. LDN is associated with short recovery times.

Esophageal substitution with colon — the Waterston operation

Twenty-three interpleural (Waterston) colon replacements of the esophagus are reported, 21 for esophageal atresia and 2 for corrosive strictures. Twenty patients are alive with an intact replacement; 17 are swallowing well and 3 have some dysphagia. Two grafts were converted to reverse gastric tubes, 1 for venous infarction and the other because of difficult vascular anatomy. One child died from disseminated intravascular coagulation following gastroenteritis shortly after successful completion of the interposition. Technical details of the operation are described. The need for replacement has been much less in recent years because of improved surgical techniques for esophageal atresia, particularly elective ventilation and the upper pouch flap operation. Recognition that corrosive and reflux strictures, if a dilatable channel can be maintained, will improve if dilatation is persevered with for 2 years may avoid the need for replacement.

Percutaneous transluminal coronary angioplasty as palliation for patients considered poor surgical candidates

Thirty-one patients with angina inadequately controlled by medical therapy, but who were poor surgical candidates because of advanced age and poor general condition, or because of depressed left ventricular function, had percutaneous transluminal coronary angioplasty (PTCA). These high-risk patients were identified prospectively, and coronary artery bypass surgery (CABS) was planned only in the event of arterial occlusion and chest pain. PTCA was successful in 11 of 17 (65%) high-risk geriatric patients, in 11 of 12 (92%) patients with left ventricular ejection fraction less than 40%, and in two additional patients having PTCA without surgical stand-by because of technically difficult vascular anatomy for CABS. There were no PTCA-related deaths; three of the 31 high-risk patients had emergency surgery because of arterial occlusion, and the remaining four patients with PTCA failure remain on medical therapy for angina. The clinical course of the 31 high-risk patients was similar to that of 155 patients having PTCA during the study period who were considered good candidates for either PTCA or CABS. PTCA may thus be considered an intermediate, palliative procedure for patients with inadequate control of ischemic symptoms who are poor surgical candidates.