Endovascular Procedures Research Articles

The Definition, Diagnosis, and Management of Giant Splenic Artery Aneurysms and Pseudoaneurysms: A Systematic Review

Background/Objectives: Giant splenic artery aneurysms (SAAs) and pseudoaneurysms (SAPs) represent rare conditions, characterized by a diameter greater than or equal to 5 cm. The risk of rupture is increased compared to common SAAs and SAPs, necessitating urgent treatments to prevent it. Methods: This systematic review was conducted through a comprehensive search involving the PubMed, Google Scholar, and Scopus databases. A total of 82 patients and 65 articles were included in the analysis. For each patient, we investigated age, sex, symptoms, comorbidities, the presence of a true or a false aneurysm, the dimensional criteria used to define dilations as giant aneurysms or pseudoaneurysms, the dimension of the two greatest diameters, imaging studies, surgical treatment, post-operative length of stay (LOS), and post-operative follow-up. Results: The results revealed a similar incidence in both genders (43 males vs. 39 females) with a median age of 55.79 years. The most frequently described symptom was pain (59.76%). Thirteen cases were false aneurysms and 69 were true aneurysms. The mean greatest diameter was 9.90 cm. The CT scan was the most utilized imaging study (80.49%). Open, endovascular, and hybrid surgery were performed in 47, 26, and 9 patients, respectively, with complication rates of 14.89%, 23.08%, and 22.22% occurring for each treatment. The post-operative LOS was 12.29 days, 2.36 days, and 5 days, respectively. The median follow-up was 17.28 months overall. No recanalization was observed after endovascular procedures during the follow-up period. Conclusions: The dimensional criterion to define SAAs and SAPs as giant was most frequently that at least one diameter was ≥ 5 cm. The CT scan was the most frequently utilized radiological study to diagnose giant SAAs and SAPs. Finally, endovascular procedures, open surgeries, and hybrid treatments presented similar post-operative complication rates. The post-operative LOS was lower for the endovascular group, and the follow-up period did not show aneurysm recanalization in any patients.

Short Term Outcomes of a Prospective Registry in Popliteal and Infrapopliteal Endovascular Interventions for Chronic Limb Threatening Ischaemia

The prevalence of chronic limb threatening ischaemia (CLTI) is increasing worldwide, resulting in the need for more patients undergoing revascularisation, especially for below the knee pathology. Nevertheless, prospective data on below the knee endovascular interventions are lacking. The aim of the study was to provide large scale, real world data on procedural and short term outcomes of popliteal and infrapopliteal endovascular interventions in patients with CLTI. This study is an analysis of the first 1 000 interventions of the Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER). It includes all patients with CLTI undergoing popliteal or infrapopliteal endovascular revascularisation in seven hospitals in the Netherlands. The primary outcomes were limb salvage and amputation free survival (AFS) at three months estimated with the Kaplan-Meier method. Secondary outcomes were procedural complications and primary patency. Between February 2021 and July 2023, 1 000 endovascular procedures were performed in 840 patients (947 limbs), treating 486 popliteal and 1 209 tibial lesions. Wound, Ischemia, and foot Infection (WIfI) stages 1 - 4 were present in 16.8%, 17.2%, 25.4%, and 40.6% of the limbs, respectively. Technical success was hampered by arterial perforation, acute thrombosis, and distal embolisation in 8.7%, 1.0%, and 2.3% of the interventions, respectively. Limb salvage was 100.0%, 96.9%, 94.9%, and 86.1% (p < .001), whereas AFS was 96.9%, 93.2%, 86.6%, and 76.4% for WIfI stages 1 - 4 at three months (p < .001), respectively. Primary patency at the 6 - 8 week visit was 86.4% for popliteal and 74.3% for tibial lesions, respectively. THRILLER presents a large prospective database on outcomes of CLTI endovascular interventions. Popliteal and infrapopliteal endovascular revascularisation for CLTI is safe. Interventions with initial technical success have high rates of limb salvage and survival at three months. The WIfI classification provides a reliable instrument to predict limb salvage and AFS independently at three months.

Incidence of contrast-induced neurotoxicity following endovascular treatment of unruptured intracranial aneurysms: a single-centre cohort study.

Contrast-induced neurotoxicity (CIN) is a recognised complication of endovascular procedures and has been increasingly observed in recent years. Amongst other clinical gaps, the precise incidence of CIN is unclear, particularly following intracranial interventional procedures. A retrospective study of consecutive patients undergoing elective endovascular treatment of unruptured intracranial aneurysms (UIAs) was performed. Patients with previously ruptured aneurysms were excluded. The primary aim of this study was to determine the incidence of CIN following endovascular UIA treatment. Our secondary aim was to isolate potential predictive factors for developing CIN. From 2017 to 2023, a total of 158 patients underwent endovascular UIA treatment, with a median age of 64 years (IQR: 54-72), and 70.3% of female sex. Over the study period, the crude incidence of CIN was 2.5% (95% CI: 0.7 - 6.4%). The most common clinical manifestation of CIN was confusion (75%) and seizures (50%). Statistical analysis was conducted, and prolonged procedural duration was found be significantly associated with developing CIN (OR 12.55; p = 0.030). Clinicians should be aware of the risk of CIN following endovascular neurointervention, particularly following technically challenging cases resulting in prolonged procedural time.

A Needle's Misdirection: Unravelling Vascular Injuries in Malpositioned Central Venous Catheters and Safe Removal Approaches

Central venous catheters (CVC) are commonly inserted to obtain vascular access. Complications such as vascular injuries arising from malpositioned CVC may occur, and safe surgical removal is required to prevent further complications. We retrospectively reviewed all patients treated in the cardiothoracic surgery department at our institution in the past 10 years for intrathoracic vascular injuries in malpositioned CVC without the need for concurrent cardiac or thoracic surgical procedures. Among the 21 patients in our series, 2 patients (10%) had a single arterial injury, 16 patients (76%) had venous injuries only, and 3 patients (14%) had both arterial and venous injuries. 16 patients (76%) underwent surgery to remove the malpositioned CVC; majority of them underwent sternotomy (n=12, 57%) and 7 of them had repair of blood vessels, and 4 patients (19%) underwent video assisted thoracoscopic surgery (VATS). 2 out of the 5 patients who had their CVC directly removed followed by external compression required emergency sternotomy due to pericardial effusion. In patients with artery or mediastinal vessel injuries, a sternotomy approach was preferred, whereas VATS was chosen when subclavian vessels or brachiocephalic vein injuries were noted. Endovascular procedures are alternatives for high surgical risk patients, but these advanced procedures are currency limited due to high expertise and facilities requirements.

A National Survey of Interventional Radiology Trainees on Peripheral and Aortic Endovascular Training.

The development of technical skills in peripheral and aortic endovascular intervention is an essential part of interventional radiology (IR) training. Access to endovascular training remains contentious, with IR and vascular surgery (VS) trainees competing for opportunities. The Collaborative Peripheral and Aortic Endovascular Training Survey (CPAETS) aimed to evaluate IR trainees' experiences, expectations, and barriers to endovascular training. CPAETS was a joint survey between the British Society of Interventional Radiology and the Rouleaux Club (UK Vascular Trainees' Association), open for 12 weeks and distributed to UK-based IR and VS trainees. This article focuses on IR trainee responses. Thirty-two responses were received from IR trainees across England, Scotland and Wales. Overall, 59% of respondents were satisfied with their endovascular training. IR trainees reported less regular hands-on experience of aortic endovascular procedures (50%) compared to peripheral endovascular procedures (93%). Consequently fewer trainees (65%) felt confident in achieving the necessary aortic endovascular competencies by the end of their training, compared to peripheral procedures (89%). Limited exposure to aortic endovascular procedures resulted in reduced confidence levels in performing aortic intervention as compared to peripheral procedures. Potential solutions to bridge some of these IR training gaps include greater pre-operative and post-operative presence, the use of simulators and IR fellowships to ensure adequate training opportunities. This article provides a snapshot of the current gaps in IR endovascular training in the UK, with insight into solutions that can enable trainees to develop clinical and technical competencies required for IR consultant practice.

Can wound blush be used as an indicator for termination of endovascular procedures in chronic limb-threatening ischemia patients?

Predicting the outcomes of endovascular revascularization of chronic limb-threatening ischemia (CLTI) patients with foot wounds can be challenging. Angiographic wound blush (WB) assessment has been found to be a helpful tool to assess wound perfusion. The aim of this study is to evaluate WB during endovascular revascularization of CLTI patients and its effects on treatment outcomes. This prospective study included all CLTI patients with foot wounds who underwent successful endovascular revascularization of infrainguinal arterial disease between 2019 and 2021. Patients were grouped according to the WB status into positive WB (group A) and negative WB (group B). Both groups were compared for demographics, comorbidities, clinical picture, and 12-month limb-based patency (LBP) and amputation-free survival (AFS) rates. The study included 69 patients of Rutherford classes 5 (46.4%) and 6 (53.6%), with the main arterial lesion located at the femoropopliteal (58%) or infrapopliteal (42%) segments. Completion angiography showed positive WB in 38 (55.1%) patients and negative WB in 31 (44.9%) patients. Both groups were comparable regarding patient presentation, site of the main arterial lesion, and distribution of foot lesions in relation to the feeding artery. The overall 12-month LBP and AFS rates were 21.7% and 39.1%, respectively, with significantly better rates in group A than in group B (LBP, 31.6% vs 9.7%, p = 0.001 and AFS, 54.1% vs 22.2%, p = 0.006, respectively). Successful angiosome-based direct flow to the foot was achieved in 38 patients (55.1%), resulting in significantly better 12-month AFS rates than those with indirect revascularization (54.8% vs 26.3%, p = 0.036, respectively), despite the comparable 12-LBP rates between the direct and indirect revascularization groups (29% vs 15.8%, p = 0.133, respectively). Multivariate logistic regression analysis identified smoking as a significant predictor of a major amputation, whereas positive WB and successful direct revascularization were significant predictors of limb salvage. WB can serve as a predictor for AFS and LBP during endovascular revascularization of CLTI patients with foot wounds. A positive WB may guide the decision to conclude an endovascular procedure, potentially avoiding unnecessary complicated maneuvers to recanalize more vessels. Conversely, a negative WB may suggest the need for further revascularization attempts to augment wound perfusion and healing.

High- Versus Low-Dose Paclitaxel-Coated Balloons for Femoropopliteal Disease: A systematic review and meta-analysis.

To evaluate the comparative effectiveness of high- and low doses of paclitaxel in endovascular revascularization procedures for patients with femoropopliteal disease. The databases (Embase, PubMed, Scopus, and Web of Science) were searched for studies that had compared outcomes of high-dose and low-dose paclitaxel-coated balloons (PCBs) in the treatment of patients with femoropopliteal disease. Randomized controlled trials and nonrandomized comparative studies (eg, cohort studies and case-control studies) were eligible for inclusion. The primary outcomes of interest were patency rates, risk of restenosis, and clinically-driven target lesion revascularization (CD-TLR). Pooled effect sizes were reported as relative risk (RR) with 95% confidence intervals (CI). The analysis included 7 studies. High-dose PCB use was associated with higher patency (RR, 1.10; 95% CI, 1.00-1.21), reduced risk of restenosis (RR, 0.60; 95% CI, 0.46-0.79), and reduced need for CT-TLR (RR, 0.57; 95% CI, 0.41-0.79) compared to low-dose PCB. Rates of limb salvage (RR, 1.01; 95% CI, 0.99-1.04), freedom from major adverse limb events (RR, 1.39; 95% CI, 0.79-2.42), and overall survival (RR, 1.02; 95% CI, 0.99-1.05) were comparable in the 2 groups. There was no evidence of publication bias. High-dose PCB correlates with superior outcomes in patients with femoropopliteal disease, particularly in terms of better vascular patency, reduced restenosis risk, and lower need for target lesion revascularization, compared to low-dose PCB.

Real world experience with the TREO device in standard EVAR: Mid-term results of 150 cases from a German Multicenter study.

Background: The objective of the study was to analyze mid-term results of unselected patients treated with the TREO (Terumo Aortic, Florida, USA) device at six German hospital sites. Methods: A multicenter, retrospective analysis of patients treated within and outside instructions for use (IFU) from January 2017 to November 2020 was performed. Primary outcomes were technical success, mortality and endograft related complications according to IFU status. Secondary outcomes were aneurysm/procedure related re-interventions. Results: 150 patients (92% male, mean age 73 ±8 years) were treated (within IFU 84% vs. outside IFU 16%) with the TREO device for abdominal aortic aneurysms (n=127 intact, n=17 symptomatic and n=6 ruptured; p=0.30). Technical success was achieved in 147/150 (within IFU 99% vs. outside IFU 92%, p=0.08). 30-day mortality was 2%, one year and overall mortality was 3% and 5%. During a mean follow-up of 28.4 months (range: 1-67.4 months), 35 (25%; within IFU 23% vs. outside IFU 35%, p=0.23) patients suffered from endoleaks. The majority were endoleaks type II (n=33), the remaining type Ia (n=5) and type Ib (n=3). No endoleaks type III-V, migrations or aneurysm ruptures occurred. Overall, 19 patients (13%; within IFU 13% vs. 15% outside IFU, p=0.70) received a secondary intervention: nine endoleak related endovascular procedures, three open conversions, two endograft limb related interventions, four surgical revisions of the femoral access sites and two bowl ischemia related procedures, respectively. Conclusions: This non industry-sponsored, multicenter trial indicates that using the TREO device in a real-world setting (both within and outside IFU) seems feasible in the treatment of patients suffering from AAA. While the rate of complications and secondary interventions is in line with previously published data, the findings highlight the fact that standard EVAR is associated with serious adverse events.

A large vertebral artery fenestration involving the distal segments associated with bilateral duplication of the superior cerebellar artery: a case report.

The aim of our study is to report a case of a large fenestrated vertebral artery (FVA) and bilateral duplication of the superior cerebellar artery (SCA) incidentally diagnosed using Computed Tomography Angiography (CTA) and Digital Subtraction Angiography (DSA). A 63-year-old female patient presenting to the neurology clinic with complaints of dizziness and balance disorder. CTA and DSA revealed a large FVA involving the V3 and V4 segments. Additionally, we observed bilateral duplicated SCAs originating from the distal basilar artery. FVA is a rare anomaly resulting from fusion failure during the embryological period, with a reported incidence of 0.1%. FVA is often (70%) detected in the extracranial region, but it can also occur intracranially at a frequency of approximately 30%. Although various nomenclatures are used in the literature, we identified only two reports of a single fenestration encompassing the V3 and V4 segments, i.e., involving both the extracranial and intracranial regions. While duplication of the SCA is relatively common, bilateral duplication of SCA occurs at a rate of 0.9-5%. This case report describes an unusual case of VA fenestration involving both extracranial and intracranial segments, along with bilateral duplication of the SCAs. While rare, these findings highlight the importance of recognizing such vascular anomalies, which could be relevant for planning surgical or endovascular procedures in the posterior circulation.

ESR Essentials: arterial vascular access and closure devices-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe.

Vascular access is the initial, very important, step of endovascular procedures. Various access sites include the common femoral artery, brachial artery, radial artery, popliteal artery, and distal tibial vessels (pedal arteries). Successful arterial access requires advanced knowledge of anatomy, as well as proper training and experience. Today, vascular access should be obtained using real-time, ultrasound guidance to reduce access time, patient discomfort, and puncture-related complications including dissection, arteriovenous communication, and bleeding. Nevertheless, high-level evidence to support this recommendation in peripheral procedures is limited and level A data are mainly derived from randomized cardiac trials investigating only radial and femoral access. Vascular closure devices (VCDs) for femoral access can be broadly categorized as active closure devices, compression assist devices, and external/topical hemostasis devices. There is high-level evidence demonstrating that their use is related to less time for ambulation and increased patient satisfaction. However, available data failed to clearly demonstrate a benefit in complications compared to standard manual compression in peripheral endovascular arterial procedures, and thrombotic and infectious complications reported following VCD use remain an issue. Heterogeneity noted in the literature, caused by the vast variety of devices, access sites, sheath sizes, clinical scenarios, and procedures, poses difficulties in data analysis and future study design. As a result, an individualized VCD use is currently suggested for ≥ 5 Fr femoral artery access not only to reduce time to hemostasis and ambulation and to improve patient comfort, but also to reduce bleeding complications in cases of femoral access with increased bleeding risk, deranged coagulation, and large-bore access, though a high level of evidence to support this later recommendation is limited. KEY POINTS: US guidance is strongly recommended for femoral access and is mandatory to obtain more challenging access. The use of VCDs for femoral hemostasis is generally safe, effective, and currently supported by level I evidence. Proper training and correct VCD choice, based on the patient's individual characteristics, are imperative to optimize outcomes.

Endovascular surgical neuro-oncology: advancing a new subspecialty.

Endovascular surgical neuro-oncology is a relatively new subspecialty which uses endovascular neuro-interventional techniques for the management of nervous system tumors and tumor-related vascular conditions. Although there are several endovascular procedures that are widely available as standard-of-care diagnostic and treatment adjuncts, there has been a renewed interest to explore endovascular approaches as a means for selective intra-arterial delivery of therapeutic agents to nervous system tumors, including methods for opening the blood brain and blood tumor barriers. In this review, we discuss the historical development of various forms of endovascular intra-arterial treatment for tumors over the past 40 years, summarize endovascular approaches that are currently being employed, and highlight current clinical trials.

Endovascular (stent-graft)-assisted open vascular anastomosis.

Endovascular and open surgical approaches are an integral part of treating patients with complex vascular disease and are often considered separately. In some situations, traditional open surgical techniques can be used to facilitate an endovascular approach, as example: iliac conduit use for EVAR/TEVAR, subclavian or axillary conduits for complex endovascular aortic repairs (chimney, B-FEVAR), and bypass to great vessels or visceral artery (celiac, superior mesenteric and renal arteries) debranching. As devices and techniques evolve, the open and endovascular approaches can be utilized in more complimentary fashion. This paper describes the use of endovascular procedures to assist difficult open surgical situations such as iliofemoral bypass, aortic arch debranching involving the left subclavian artery, and distal right iliac artery management during open thoracoabdominal aortic aneurysm (TAAA) repair.

Microsurgery for Vertebral and Posterior Inferior Cerebellar Artery Aneurysms via Lateral Suboccipital Craniotomy

Among ruptured intracranial aneurysms, aneurysms of the vertebral artery(VA) and posterior inferior cerebellar artery(PICA) are relatively rare, and they exhibit distinct characteristics. These include: 1) a high frequency of diverse aneurysmal morphologies, such as fusiform or dissecting aneurysms; 2) proximity to the lower cranial nerves; 3) the presence of perforators to the medulla oblongata; and, 4) obstruction to the surgical approach by specific bony structures, such as the occipital condyle and jugular tubercle. Consequently, these aneurysms often require interventions that are more complex than simple clipping or coiling, which is typical for anterior circulation aneurysms. Interventions include skull base techniques such as the far-lateral approach and revascularization procedures such as occipital artery(OA)-PICA bypass. Despite these complexities, the rarity of these aneurysms and the recent advancements in endovascular procedures pose challenges for young neurosurgeons in acquiring adequate microsurgical experience. This narrative review addresses the clinical features of VA and PICA aneurysms, the history and variations in the lateral suboccipital approach for these aneurysms, and several bypass techniques for reconstructing the PICA. Lastly, we illustrate our current microsurgical practices through a case presentation accompanied by a surgical video showcasing both the far-lateral approach and the OA-PICA bypass.

Clip versus coil shift for aneurysm treatment in Brazil: an exploratory analysis of trends in a 10-year time-series.

Regarding intracranial aneurysm treatment, the clip versus coil debate remains inconclusive and lacking studies in Brazil. To examine trends in the management of intracranial aneurysms in Brazil over time, both ruptured and unruptured. A descriptive and exploratory study was conducted based on data of neurovascular procedures for aneurysm treatment using the Brazilian Public Health System database (DATASUS). The variables analyzed were the number of procedures, mortality rates, length of hospital stays, and global costs of hospitalization, from 2010 to 2019. Temporal trend analysis and statistical comparisons were conducted to assess changes over time and differences between the treatment options. The mean annual number of aneurysm treatments with endovascular embolization was 2206.30 (± 309.5), with a non-significant increasing trend (B = 55.66; p = 0.104). Conversely, microsurgical clipping exhibited a significant decreasing trend (B = -69.97; p < 0.001) with a mean of 1133.1 (± 223.12) procedures. The mortality rate associated with clipping procedure was higher in the period, with a mean difference of 5.23 (± 0.39); ([CI95%: 4.36; 6.10]; p < 0.001) and showed an increase trend, while embolization showed a stable trend. The length of in-hospital stay remained stable for clipping but increased for embolization. Costs associated with clipping increased over time, whereas costs for embolization decreased. This study highlights a significant shift in the treatment of aneurysm towards Endovascular Embolization. Despite higher costs, endovascular procedures were associated with lower mortality rates and shorter hospital stays. These findings provide valuable insights into aneurysm treatment patterns and indicators in a middle-income country's Public Health System.

Axillary compared to brachial access for endovascular procedures.

Limited knowledge exists regarding access site complication rates between trans-axillary and trans-brachial approaches with sheath sizes ≥6Fr. We retrospectively reviewed our institution experience with access site complications for percutaneous trans-axillary and trans-brachial arterial interventions using sheath sizes ranging from 6Fr to 10Fr. We examined 67 endovascular interventions performed over 18 months, restricted to sheath sizes of 6Fr to 10Fr. Procedures utilizing trans-brachial (41 cases) and trans-axillary (26 cases) approaches under sonographic guidance were included. Cases involving hemodialysis accesses and those requiring surgical cut-down were excluded. The primary outcome measure was the occurrence of major access site complications (SIR grade-II/III) within 30 days, with data collected on hemostasis method, sheath size, and complications. Statistical analysis involved ANCOVA and Fisher's exact tests, with significance set at p < .05. Successful percutaneous arterial access was achieved in all cases using either approach (trans-axillary or trans-brachial). Closure devices were employed in all axillary punctures and in 71% of brachial punctures. Major access site complications occurred in 7 out of 41 cases (17%) in the trans-brachial group and in 4 out of 26 cases (15%) in the trans-axillary group. However, there was no statistically significant difference in complication rates between the two groups, regardless of access site or sheath size. Trans-axillary access serves as a safe and effective upper limb access method for percutaneous endovascular procedures requiring sheath size of 7Fr or larger when compared to trans-brachial approach.

Computed tomography angiography-guided analysis of morphologic properties of the thoracic aorta and arch branches among the adult population: A cross-sectional study.

Before performing any surgical or endovascular procedure, the anatomical classification of the patient is essential for treatment planning. Computed Tomographic Angiography (CTA) is a standard method to evaluate thoracic aortic anatomy and associated variations. This cross-sectional, descriptive study was performed among adult participants without any peripheral vascular diseases undergoing thoracic CTA. Demographic data were collected along with factors retrieved from the patients CTA, such as the type of aortic arch, length, and diameter of ascending and descending aorta, the diameter of the main branches and the distance between branches, the angles by which the main arteries rise from their origins, and left anterior oblique angle of the aortic arch. 164 patients, with a mean age of 57 ± 19.3 years, entered the study. 53 (33.8%) had a bovine arch, which was mostly observed among males. A decrease in the frequency of type I arch and also an increase in the frequency of type 2 and 3 arches was observed with the increase in age (p < 0.001). The BCT diameter had a direct association with both left common carotid artery diameter (r = 0.478, p < 0.001) and left subclavian artery diameter (r = 0.470, p < 0.001). The length of the descending aorta had a direct correlation (r = 0.294, p < 0.001) with the length of the ascending aorta. Complex endovascular interventions are vital method in treating aorta, head, and neck pathologies. Accurate knowledge of thoracic aortic anatomy is becoming crucial for diagnosis and intervention planning.

Aspects of renal function and renal artery anatomy as indications for renal denervation.

Renal denervation (RDN) is a minimally invasive, endovascular catheter-based procedure using radiofrequency, ultrasound, or alcohol-mediated ablation to treat resistant hypertension. As more attention is focused on the renal sympathetic nerve as a cause and treatment target of hypertension, understanding the anatomy of the renal artery may have important implications for determining endovascular treatment strategies as well as for future selection of devices and appropriate candidates for RDN treatment. However, the anatomical structure of the renal artery (RA) is complex, and standardized morphological evaluations of the RA structure are lacking. Computed tomography angiography or magnetic resonance angiography imaging is useful for assessing RA anatomy before conducting RDN. RA echocardiography is an established noninvasive screening method for significant stenosis. Major randomized controlled trials have limited enrollment to patients with preserved renal function, usually defined as an estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73 m2. Therefore, the level of renal function at which RDN is indicated has not yet been determined. This mini-review summarizes the characteristics of renal artery anatomy and renal function that constitute indications for renal denervation. (Role of Clinical Trials: K. Kario is an Executive Committee Principal Investigator for the Spyral OFF MED, the Spyral ON MED, the DUO and the REQUIRE; a Coordinating investigator for the TCD-16164 study; a Site Principal Investigator for the HTN-J, the Spyral OFF MED, the Spyral ON MED, the DUO, the REQUIRE and the TCD-16164 study). Evaluation of renal arteries for radiofrequency renal denervation. A Simultaneous quadrantal ablations at four sites in the main renal artery or the equivalent renal artery to the main renal artery. B If there is a renal artery branch with a diameter >3 mm in the middle of the main renal artery, this branch is the distal end of the main renal artery. In this case, four simultaneous and quadrantal ablations can be performed on the equivalent renal arteries. C Four simultaneous and quadrantal ablations can be performed in the branch renal artery. D Sonication should be spaced at least 5 mm (one transducer*) apart. Perform 2 to 3 mm proximal to the arterial bifurcation. Perform 2 to 3 mm distal to the abdominal aortic inlet.

The iliac and femoral arteries: Dimensions and tortuosity in a South African radiological sample

BackgroundArterial morphology varies and changes with increasing age. This may challenge the success of endovascular procedures and influence candidate selection. The study aimed to determine the mean dimensions, tortuosity severity, and tortuosity phenotype of the iliofemoral pathway of adult males and females from a South African sample. Furthermore, the relationship between increased age and changes in vessel morphology was investigated. DesignA retrospective cross-sectional study was conducted using a sample of 224 (117 males and 107 females) computed tomography angiograms of patients hospitalized due to traumatic injuries (aged 18–80 years), accessed from Tygerberg Hospital, Cape Town, South Africa. MethodsThe arterial lengths and lumen diameters of the common iliac (CIA), external iliac (EIA), and femoral arteries (FA) were measured. Tortuosity severity was described by visual estimation and quantified using the tortuosity index (TI) and inflection count metric (ICM). The data were compared between right and left sides of the body, the sexes, and age categories. ResultsOn average, the common iliac artery was the widest (9.50 ± 1.53 mm), while the external iliac artery was the longest (110.89 ± 16.04 mm). Bilateral asymmetries were observed. Arterial diameters were larger in males. Regression analysis revealed a strong positive relationship between arterial tortuosity and increasing age, particularly in females. Tortuosity was most frequently observed in the external iliac artery. However, the c-shaped curving tortuosity phenotype was observed in all three arteries investigated. ConclusionThe morphology of the iliofemoral arterial pathway varied bilaterally, between the sexes, and with increased age. These findings align with previous studies, noting the variable morphology of the iliofemoral pathway, in countries outside of Sub-Saharan Africa. Sex- and age-specific descriptions of arterial anatomy may enhance the safety of endovascular procedures and interventions. These descriptions contribute towards the development of a reference database of typical arterial anatomy in South Africa, ultimately assisting with patient selection and the identification of vascular pathologies.

Cerebral Venous Thrombosis in Children: About 3 Cases

The cerebral venous system is an unusual site for thrombosis. It is a rare pathology in children, with a considerable risk of morbidity and mortality in the absence of specific treatment. The incidence has increased over the last few decades due to improvements in neuroradiological techniques. Clinical features range from seizures, headache and respiratory distress to threatening focal neurological deficits and comatose state. The risk factors are age-dependent, frequently multiple and different from those reported in adults. Infections are the most common predisposing factor both in neonates and older children, followed by hypercoagulable/hematological states, dehydration and various other conditions. In majority of cases, it results from combination of prothombotic risk factors with or without underlying clinical condition. The prognosis is favorable in most cases if the diagnosis is made quickly and treatment is initiated promptly, although acute complications or chronic disability still occur in a quarter of patients. The mainstay of treatment is anticoagulation, which is needed to stop the clot spreading and recanalize it. Endovascular procedures are reserved for patients with a particularly severe presentation or rapidly developing neurological symptoms despite appropriate anticoagulation, although data from clinical trials is lacking. The aim of this work is to study the clinical, etiological, therapeutic and evolutionary characteristics of cerebral venous thrombosis (CVT) in the pediatric population.

Endovascular Conversion of a Failed Nellix AAA-Repair by a Custom-Made Branched Device.

This technical note presents a case of a patient with a failed Nellix device (Endologix, Irvine, Calif) who was not deemed fit for open conversion. Our planned approach for repair involved an endovascular procedure utilizing a custom-made branched device. An endovascular repair was performed via a custom-made four outer branched device in conjunction with a custom-made bifurcated graft featuring inverted limbs (Cook Inc., Bloomington, Ind). All branches were connected to the target vessel with Gore Viabahn VBX balloon-expandable covered stents (Gore & Associates Inc.). Endovascular conversion with branched endovascular repair in a patient not deemed fit for open surgery was successfully performed, thereby reducing the risk of a high morbid and mortal procedure. Novel useful treatment solution of failed EVAR with Nellix device.