Endovascular Interventional Treatment Research Articles

Mixing of the Old With the New

A leading cause of severe disability and limb amputation in the developed world is critical limb ischemia (CLI) from severe peripheral artery disease. Current treatments for CLI, such as surgical revascularization, endovascular intervention, and medical treatment, typically result in less than satisfying results. Furthermore, despite early promise, phase II clinical trials of exogenous proangiogenic growth factors for CLI have not demonstrated efficacy, and the prospects for successful gene and cell therapies for CLI are far from certain.1 In this issue of Arteriosclerosis, Thrombosis, and Vascular Biology , Nagahama et al2 demonstrate an innovative nanoparticle-mediated delivery of pioglitazone for enhancing therapeutic neovascularization in a murine model of hindlimb ischemia. See accompanying article on page 2427 Although the thiazolidine (TZD) class of peroxisome proliferator–activated receptor-γ agonists such as pioglitazone has been in clinical use as treatment for type-2 diabetes mellitus, recent …

Endovascular Stent Grafting via the Left Radial Artery for a Spontaneous Isolated Dissecting Rupture of the Superior Mesenteric Artery

A 56-year-old man presented with abrupt onset epigastric and back pain for 4 hours. Computed tomography angiography (CTA) revealed a dissection at the proximal part of the superior mesenteric artery (SMA) without a limitation in distal flow or bowel ischemia (Fig. 1A). However, an 1-week follow-up CTA showed progression of the SMA dissection down to the distal jejunal branch (Fig. 1B). Thus, we decided to perform endovascular interventional treatment. Fig. 1 A 6-Fr introducer sheath was inserted into the left radial artery. A 6-Fr multi-purpose angiographic 1 guiding catheter (Cordis, Miami, FL, USA) was then used to pass a 0.014-inch floppy guidewire into the true lumen of the SMA. A subsequent angiography (Fig. 1C, arrow indicates dissecting inlet) and intravascular ultrasound (IVUS) examination (Fig. 1D, arrow indicates dissecting inlet) showed a huge communicating dissecting rupture at the proximal portion of the SMA. We confirmed blood flow to the false lumen through the dissecting inlet by IVUS Chroma-flow imaging (Fig. 1E, arrow indicates dissecting inlet). Two stent-grafts (Jostent®, Abbott Laboratories, Inc., Abbott Park, IL, USA) (3.5×19 mm followed by 3.5×16 mm) with overlap were deployed consecutively in the proximal SMA to cover the dissection. The follow-up CTA at 9 months (Fig. 1F) showed good patency of the stent-grafts and restoration of the SMA true lumen. The patient remained asymptomatic for 12 months on 100 mg of aspirin daily. There are some reports of isolated SMA dissection, particularly in the Asian population. The causes of an isolated SMA dissection are unknown, and treatment options vary and include surgery, endovascular treatment, or conservative management depending on the extent of dissection and associated complications.1),2) Chromaflow imaging and IVUS were valuable to detect the SMA dissection inlet. The left radial artery is alternative vascular access for treating an SMA lesion, because it offers good alignment and proper backup support by a guiding catheter.

Interventional treatment of carotid cavernous fistula

We reviewed retrospectively the outcomes of interventional endovascular treatment of direct or dural (indirect) carotid cavernous fistulas in 24 consecutive patients requiring endovascular treatment at Royal Prince Alfred Hospital between 1994 and 2009. Data was collected from each patient’s neurological, ophthalmological and radiological reports. Of the 12 patients with direct fistulas all had signs of orbital and ocular venous congestion and ophthalmoplegia; nine also had reduced vision ranging from 6/9 to nil perception of light, two had normal vision and one was unconscious. Nine of the 12 direct fistulas were embolized transarterially, two transvenously, one by a combination of both approaches and all were successfully closed. After treatment, seven of the nine patients with reduced vision had complete or nearly complete restoration of vision, while two who presented with nil perception of light (one in both eyes) had no recovery of vision. In contrast, seven of the 12 patients with dural fistulas had ophthalmoplegia, three had reduced vision, down to 6/24 and one did not have any sign of venous congestion. Vision recovered in all three patients after embolization of the dural fistula. Dural fistulas were embolized transvenously in 11 and transarterially in one patient. Apart from ophthalmoplegia, all other ocular signs and symptoms rapidly resolved after closure of the fistula in each of the 24 patients. The diagnosis was delayed by being missed either during the first admission or at the first specialist consultation in three of the 12 patients with direct fistulas, and in seven of the 12 patients with dural fistulas. One patient with a direct and another with a dural fistula had limited cerebral infarctions during embolization. In this series, endovascular interventional treatment of carotid cavenous fistulas restored visual loss in 10 of 12 patients with visual loss. The two who did not recover had presented with nil perception of light, one after a delay in diagnosis of 6 weeks. Some degree of ophthalmoplegia tended to remain. This emphasizes the need for early diagnosis and treatment before visual loss or ophthalmoplegia becomes severe.

Occlusive portal vein thrombosis as a new marker of decompensated cirrhosis

Natural history of liver cirrhosis is divided into compensated and decompensated stage. Traditionally, the markers of decompensated cirrhosis include ascites, variceal hemorrhage, hepatic encephalopathy and jaundice. The clinical importance of portal vein thrombosis (PVT) is increasingly recognized in patients with liver cirrhosis. The presence of PVT is not only an independent predictor of failure to control active variceal bleeding and prevent variceal rebleeding, but also significantly associated with increased mortality in patients with liver cirrhosis. Besides, it greatly influences the technical success and outcome of endovascular interventional treatment and liver transplantation for liver cirrhosis and its secondary portal hypertension. Thus, we hypothesize that PVT should be regarded as a critical marker of decompensated cirrhosis, whether clinical events such as the development of ascites, encephalopathy, and variceal bleeding occur or not. Our hypothesis adds PVT into the definition of decompensated cirrhosis and reminds clinicians and investigators that PVT plays a vital role in natural history of liver cirrhosis. Further, it is essential to construct a new system of preventing and treating liver cirrhosis in the presence of PVT.

Endovascular management of vertebral artery dissecting aneurysms: review of 25 patients.

Management of Vertebral Artery (VA) dissections remains controversial. The clinical and angiographic variables of VA dissections were evaluated to demonstrate the safety and efficacy of endovascular intervention in treatment of VA dissecting aneurysms. 25 patients with 27 VAdissecting aneurysms were treated with endovascular intervention during the last 10 years.17 patients were admitted with subarachnoid hemorrhage. 23 aneurysms treated using destructive endovascular trapping, while reconstructive techniques were used in 3 aneurysms treated with stent-assisted coiling and one aneurysm treated with false lumen embolization. The right VA was involved in 14 patients, the left VA in 9 patients, while 2 patients had bilateral VA dissection. The pearl and string sign was the commonest angiographic sign in 12 aneurysms. Perioperative complications included; rebleeding in one patient, symptomatic brain stem infarction in two patients and silent cerebellar ischemic lesion in one patient. Afavorable outcome was evident more in patients with unruptured VA dissection (100%) versus (76.5%) in patients presented with SAH. The endovascular technique should be individualized according to the clinical status of the patient, angiographic variables, condition of the posterior circulation and the available supplies.

High-resolution 3D contrast-enhanced MRA with parallel imaging techniques before endovascular interventional treatment of arterial stenosis

This study aimed to evaluate the efficacy of high-resolution 3D contrast-enhanced magnetic resonance angiography (3D CE MRA) with parallel imaging techniques for the diagnosis of various arterial stenoses and its value for planning endovascular interventional treatment. Thirty-five patients underwent 3D CE MRA before endovascular interventional treatment. Numbers of patients were as follows: clinically documented renal artery stenosis (n = 10), renal transplant artery stenosis (n = 1), carotid artery stenosis (n = 12), iliac artery stenosis (n = 11) and femoro-popliteal artery stenosis (n = 1). A total of 39 arterial segments were treated. The depiction of various arterial stenoses was evaluated. The degree and length of the stenoses were compared and analyzed between 3D CE MRA and digital subtraction angiography (DSA). The accuracy of MRA in depicting lesion characteristics (ulceration, eccentricity, post-stenotic dilatation) was reviewed. The overall value of 3D CE MRA in planning interventional treatment was determined. The quality of 3D CE MRA in the demonstration of various arterial stenoses was judged excellent or good. A strong correlation was noted between 3D CE MRA and DSA regarding severity and length of stenosis. The accuracy of 3D CE MRA in depicting lesion characteristics was good. 3D CE MRA overestimated three severe iliac artery stenoses. Except in these three segments, the value of 3D CE MRA analysis was judged high. 3D CE MRA was found to be better than DSA in revealing the distal reconstitution and occluded segment in cases of iliac artery stenosis. 3D CE MRA is accurate in demonstrating the relevant anatomy necessary to plan endovascular interventional treatment for patients with arterial stenosis.

Intrasinus administering rt-PA combined with mechanical thrombectomy for serious cerebral venous sinus thrombosis

Objective To investigate the effect of endovaseular interventional therapy, intrasinus administered recombinant tissue plasminogen activator(rt-PA) combined with mechanical thrombeetomy for serious cerebral venous sinus thrombosis(CVST). Method Eleven patients with serious CVST were accepted endovascular interventional therapy under general anaesthesia and systemic heparinization. Fifteen procedures were performed: rhcolytic thrombectomy with AngioJet catheter combined with intrasinus rt-PA thrombolysis in eight procedures, AngioJet catheter thrombectomy without intrasinus rt-PA thrombelysis in one procedure, and clot disruption with micro-balloon or micro-guidwire combined with intrasinus rt-PA thrombelysis in six procedures. Four of eleven patients were required a second endovascular interventional treatment for partial rethrombosis after the first procedure. Total rt-PA dose per procedure was ranged from 0 to 15 mg,mean (9. 4 ±4. 5)mg. All of the procedures were technically successful, no complications occurred. Results Eight patients were stupor or coma when they accepted therapy in our study, and two patients had transtentorial herniation. Eight of eleven patients experienced excellent or good clinical outcomes, and three patients died. The duration of follow-up ranged from 10 to 32 months(mean 21 months) ,MRI/MRV showed the affectedsinuses smoothly in six patients, partially smoothly in 2 patients. No patient has a rethrombesis. Conclusions The patient with serious CVST can be rapidly fatal only by routine therapy. Rhcolytic thrombectomy with AngioJet catheter or micro-balloon combined with intrsinus rt-PA thrombolysis can rapidly recanalize the affected dural sinuses in patients with CVST. It is a safe and effective endovascular method for high-risk patient with CVST. Key words: Venous thrombosis; Thrombolytic therapy; AngioJet catheter; rt-PA

Endovascular interventional treatment for symptomatic stenosis of middle cerebral artery

To study the feasibility, security and validity of percutaneous angioplasty (PTA) or percutaneous angioplasty and stenting (PTAS) for symptomatic stenosis of middle cerebral artery. The results of treatment and follow-up of 39 cases with symptomatic stenosis of middle cerebral artery who had either recurrent transient ischemic attacks (TIAs) or resistant to medical therapy and were performed PTA or PTAS were studied retrospectively. Among the 39 cases with stenosis of middle cerebral artery (23 in left, 13 in right, 3 in bilateral side and 5 cases combining with stenosis of carotid artery) PTA were successfully performed in 9 cases and PTAS in 30 (whose post-operative residual stenosis were less than 10%). After operation the patients were administrated with antiplatelet drugs. The clinic symptom and sign of ischemia were improved obviously after operation. During the procedure the contrast could be seen outside the vessel in 2 cases, the patients had no obvious symptom of hemorrhage and got well rapidly. But in another case her consciousness changed 1 h after PTAS and the limbs could not move in right side. Emergency CT scan showed cerebral hemorrhage in left basic node area. The patient suffered language barrier and incomplete hemiplegy in right side. No complication was occurred in the others. During 5 to 60 months follow-up, the symptom of weakness in right arm reoccurred but lighter than before in only one case. TCD rechecked in 26 cases and demonstrated the blood beam speed was faster than normal in two case. DSA rechecked in 14 cases showed restenosis in-stent in the 2 cases and they were treated by medicine. PTA and PTAS is a feasible, safe and effective therapeutic method for the patients with symptomatic stenosis of middle cerebral artery. Further study in large number of patients is needed for long-term outcome.

Review: Interventional radiology in peripheral vascular disease

Peripheral vascular diseases (PVD) are referred to as diseases affecting the blood vessels other than the heart and the brain. Interventional endovascular treatment whenever feasible has become the first line of management in the treatment of PVD. Interventions may be aimed at either revascularization or deliberate occlusion of a diseased vessel(s). This article reviews the various peripheral vascular diseases with their appropriate endovascular management.

Intraoperative effect of ICP, cerebral oxygen and glucose metabolism in interventional endovascular treatment of intracranial aneurysms with Guglielmi detachable coil

目的 对比观察血管内栓塞和开颅夹闭治疗颅内动脉瘤对病人术中颅内压、脑氧和脑糖代谢的影响.方法 选择Hunt分级为Ⅰ～Ⅲ级的脑动脉瘤择期手术44例,按治疗方法分为电解可脱弹簧圈(GDC)栓塞(Ⅰ组)和开颅脑动脉瘤夹闭(Ⅱ组),各22例.分别观察麻醉后手术前(T0)、脑动脉瘤夹闭前(GDC栓塞前,T1)和夹闭后10 min(GDC栓塞后,T2)等时相脑脊液压(CSFP)、动脉瘤跨壁压(TMP)和脑氧、脑糖代谢等指标及术毕麻醉恢复情况.结果 Ⅰ组:与T0比较,T1和T2的颈内静脉球部血氧饱和度(SjvO2)明显增加,脑氧摄取率(ERO2)减少,差异具有显著性(P 0.05).Ⅱ组:与T0比较,T1和T2的D(a-jv)BL和D(a-jv)BG增加,D(a-jv)O2减少,差异具有显著性意义(P 0.05).Ⅰ组:与T0比较,T1和T2的CSFP和TMP无明显变化(P>0.05).Ⅱ组:与T0比较,T1和T2的CSFP降低,TMP增加,差异具有显著性(P<0.05).与Ⅰ组比较,Ⅱ组T1和T2相应时相的CSFP降低,TMP增加,差异具有显著性意义(P<0.05).与Ⅱ组比较,Ⅰ组术毕自主呼吸恢复时间和拔除气管导管时间明显缩短(P<0.05).结论 与开颅夹闭治疗脑动脉瘤比较,GDC栓塞颅内动脉瘤围术期颅内压、动脉瘤跨壁压、脑氧和脑糖代谢等指标更稳定,而且术后麻醉恢复更快。

Whole-brain functional magnetic resonance imaging of cerebral arteriovenous malformations involving the motor pathways.

To investigate cortical, basal ganglia and cerebellar activation in patients with arteriovenous malformations (AVMs) involving the motor pathways, we studied ten patients (six male, four female, mean age 30.3 years, range 7.4-44.1) by whole-brain functional magnetic resonance imaging (fMRI) in a 1.5-T scanner with the EPI-BOLD-technique. In seven cases multiple fMRI studies were available, acquired in the course of the multi-session endovascular interventional treatment. Self-paced right- and left-handed finger-tapping tasks were used to invoke activation. In six patients a super-selective amytal test (Wada test) was performed during diagnostic pre-interventional angiography studies. Abnormal cortical activation patterns, with activation of the primary sensorimotor area, the supplementary motor area and/or the cerebellum shifted to unphysiological locations, were found in four patients. In all cases, localization of the AVM could account for the changes from the normal. After endovascular procedures, fMRI demonstrated shifts in the activation pattern in three patients. In the six patients that had undergone fMRI studies and the Wada test, both methods yielded comparable results. The fact that AVMs are structural anomalies for which the brain can partly compensate ('plasticity') was underlined by these results. fMRI is a valuable tool in the pre-therapeutic evaluation and post-interventional follow-up of patients with cerebral AVMs in whom an operation or an endovascular procedure is planned.

Interventional endovascular therapy: SPECT cerebral blood flow imaging compared with transcranial doppler monitoring of ballon angioplasty and intraarterial papaverine for cerebral vasospasm

The effects of interventional endovascular treatment of cerebral vasospasm with balloon angioplasty or papaverine infusion were evaluated by single-photon emission computed tomography (SPECT) and transcranial Doppler (TCD) in 44 patients whose cerebral vasospasm was refractory to medical management. SPECT revealed blood flow improvements in 42% of patients with papaverine treated vessels and 70% of patients with balloon angioplasty (P=.037). TCD correlated with SPECT in 71% of patients in the papaverine group and 73% of patients in the balloon angioplasty group. TCD showed 93% of segments improved by angioplasty, whereas 43% of segments were improved with papaverine (P<.001). Disagreements were largely represented by patients with TCD velocity improvements in which SPECT blood flow imaging was, unchanged or worsened. Balloon angioplasty seems superior to papaverine infusion for treatment of vasospasm. SPECT and TCD are complementary tests in the evaluation of vasospasm and effect of interventional therapy.

Classification of the Venous Route of Carotid Cavernous Sinus Fistula

It is important to investigate the venous routes in and around the carotid cavernous sinus before endovascular interventional treatment to avoid complications such as glaucoma and central retinal vein thrombosis. This paper classifies the anatomical features of the cavernous sinus and its venous routes and discusses four successfully treated cases.

The development of the E. Stanley Crawford Critical Issues Forum

The development of the E. Stanley Crawford Critical Issues Forum