Mean Primary Patency Research Articles

Predictors of long-term outcomes after polytetrafluoroethylene-covered stent-graft repair of peripheral arterial aneurysms, pseudo-aneurysms, and arterio-venous fistulas.

To evaluate the primary patency rate at three years for the infra-aortic peripheral arterial pathologies treated with polytetrafluoroethylene-covered stent-grafts. Patients treated with self-expandable polytetrafluoroethylene-covered stent-grafts for infra-aortic peripheral arterial aneurysms, pseudo-aneurysms, and arterio-venous fistulas were evaluated retrospectively. A total of 48 patients (35 male, 13 female; mean age: 53.8 ± 13.5) were included with 29.0 ± 16.5 months (median 27, range 4-70) mean follow-up period. The primary objective was to determine the primary patency rate at three years. The secondary objectives were to compare type and localization of pathology, and length and diameter of the stent-grafts with primary patency rate. Kaplan-Meier test was used as the main statistical method. Overall mean primary patency rate at three years was 77.10%. Polytetrafluoroethylene-covered stent-graft implantation in aneurysms had worse primary patency rate than pseudo-aneurysms and arterio-venous fistulas (66.6%, P = 0.03; 76.9%, P = 0.03; 88.2%, P = 0.01, respectively). Stent-graft location, length, and diameter are not associated with primary patency rate (P > 0.05) but stent diameter is associated with better primary assisted and secondary patency rates (P < 0.05). Pathology of the lesion is associated with the long-term primary patency rate of polytetrafluoroethylene-covered stent-grafts but not the stent-graft location, length, or diameter. Stent diameter is associated with primary assisted and secondary patency rates.

Surgical management of central venous occlusive disease in hemodialysis patients

Background Central venous disease is a common and complex problem that compromises functioning access in patients undergoing hemodialysis which may result in loss of the access. Prior ipsilateral insertion of central venous catheters is a common risk factor. Percutaneous angioplasty with or without stenting is considered the primary method to treat central venous stenosis. However, it carries poor long-term patency rates and require multiple and repetitive interventions. Surgical options could be the choice if endovascular approaches are refractory or impossible. Aim The purpose of this retrospective, observational study is to report our experience in the surgical management to maintain hemodialysis access compromised by venous hypertension (VHTN) due to central venous occlusive disease. Patients and methods This is a retrospective analysis of 14 patients with existing upper extremity hemodialysis access who underwent extra-anatomic surgical bypass to treat symptomatic VHTN due to central vein occlusive disease after failure of endovascular management. Results Technical success was achieved in the 14 (100%) cases while clinical success occurred in 13 (92.6%) cases; 12 (85.7%) patients had performed their hemodialysis sessions via their preexisting access within 24 h postprocedurally. Maximum postoperative hospital stay was 3 days. No in-hospital morbidity or death was recorded. The mean primary and secondary patency were 18.3 and 22.7 months, respectively. Primary patency rates at 6, 12, 18, and 24 months were 85, 78, 64, and 57%, respectively. Secondary patency rates at 6, 12, 18, and 24 months were 92, 85, 71, and 64%, respectively. Conclusion Extra-anatomic surgical bypass of central venous obstruction is an effective and safe method to provide symptomatic relief of VHTN and salvage of existing access in hemodialysis patients when endovascular solutions are unfeasible.

Endovascular management in immature arteriovenous fistula for hemodialysis

To evaluate the outcomes and prognostic factors of endovascular management in immature arteriovenous fistula (AVF) for hemodialysis.From April 2007 to September 2017, 54 patients (male:female = 31:23, mean age 65.63 years, range 33–90 years) who underwent endovascular management for the salvage of immature AVF were retrospectively reviewed. Clinical data, procedural details, and results were evaluated. Primary and secondary patency rates and factors influencing the patency were also analyzed.Technical and clinical success rates were 88.9% (48/54) and 85.2% (46/54), respectively. Mean primary and secondary patency was 42.10 (±8.85) and 91.5 (±14.77) months, respectively. Primary and secondary patency rates were 66% and 89% in 1 year, 66% and 78% in 2 years, and 51% and 78% in 3 years. In multivariate analysis, only brachiocephalic AVF and antegrade access procedures showed significantly shorter primary patency (HR 5.196; 95% CI (1.04–25.77); P = .044, HR 8.096; 95% CI (1.36–48.00); P = .021). There was no statistically significant factor associated with secondary patency in the multivariate study.Endovascular management in immature AVF is safe and effective to make the AVF available. Brachiocephalic AVF and antegrade access procedures are the factors influencing the patency in multivariate analysis.

A Prospective Clinical Study of a Percutaneous Vascular Access System for Hemodialysis Catheters.

Dysfunctional or infected hemodialysis polyester-cuffed catheters often require removal and are dissected out. The DermaPort™, percutaneous vascular access system (PVAS) permanently integrates a titanium mesh with the skin forming a stable, sterile barrier that allows for catheter placement, adjustment, or catheter exchange. This study aimed to describe the use and clinical outcomes of the DermaPort PVAS. Thirty-eight patients who were receiving hemodialysis via a tunneled catheter were enrolled in this prospective open-label study. Assessments were performed biweekly for the first month and monthly thereafter, which included physical examination of the site of implantation for infection, catheter blood flow, and need for interventions to maintain catheter patency. Patient satisfaction was assessed with a visual analog score. Implantation of technical success was 100% with the implantation site demonstrating early tissue incorporation after 2weeks and full incorporation within 4weeks. The DermaPort™ successfully enabled 31 catheter exchanges and 10 repositions thru the port without dissection in 18 patients with nine repositions (90%) performed at bedside. The mean primary patency of the DermaPort™ was 172 ± 150days, and mean secondary patency was 430 ± 203days. There were no reportable serious adverse events in 12,100 catheter days of use and zero explantations of the device attributed to infection. The observed catheter infection rate was 0.33/1000days. The DermaPort™ system can be effectively implanted and facilitates catheter interventions in hemodialysis patients requiring long-term catheter use and has a lower infection rate than historical catheter infection rates. Clinical Trial Protocol Number DermaPort-001 (no clinicaltrials.gov number as study was performed 9years ago). Health Canada Reference Application Number: 118393.

Endovascular Management for Salvage of Failing Arteriovenous Fistula

Background: Failure of arteriovenous access for hemodialysis is a challenging problem. Maintaining the patency of this access is one of the most important corner stones in the care of patients with chronic renal failure. Recently, percutaneous transluminal balloon angioplasty (PTA) is considered the first line of treatment for dealing with this issue. Aim: The purpose of this retrospective observational study was to evaluate the primary and secondary patency rates after initial endovascular intervention to restore and preserve the patency of failing autogenous arteriovenous fistulae and to identify the potential factors that affect the durability of the procedure. Methods:The results of 56 patients with failing autogenous arteriovenous fistulae were retrospectively analyzed after being treated with percutaneous transluminal balloon angioplasty from November 2014 to December 2018. Technical & clinical success rates were reported. The variables, including patients’ demographics, co-morbidities, medications, fistula age, fistula type, site, number of lesions and degree of stenosis were analyzed and correlated with primary and secondary patency rates. Results: The mean age of the fistulae included in the study since their creation was 17.4 ± 9.6 months, most of which were radiocephalic fistulas (64.3%). The most common cause of autogenous access dysfunction was 90-99% stenosis while the most common site of stenosis was juxta-anastomotic. Technical and clinical success rates of the study population were 92.9% and 89.3%, respectively. The mean primary and secondary patency were 12.3 and 19.9 months, respectively. Primary patency rates at 6,12,18 and 24 months were 79%, 64%, 57% and 44% respectively. Secondary patency rates at 6,12,18 and 24 months were 85%, 76%, 68% and 52% respectively. Patient age ≥ 60 years old was associated with reduced post-PTA primary patency (P < 0.001) and secondary patency (P = 0.018). Dyslipidemia showed marked decrease in both primary and secondary patency rates (P < 0.001). Insulin intake (P < 0.001) was a predictor of primary patency decrease while use of antiplatlets was to a less extent predictor of secondary patency loss (P = 0.004). Radiocephalic fistulae had short primary patency (P = 0.016), while stenotic lesions > 90% showed a significant decrease (P < 0.001) in primary patency more obvious than with secondary patency (P = 0.006). Lesions at arteriovenous anastomosis were significantly associated with decrease in primary patency (P < 0.001). Statins were the only medications associated with longer primary patency (P < 0.001). Age of fistula and number of lesions were independent factors. Conclusion: Endovascular treatment is both safe and effective in managing failing autogenous arteriovenous fistulas. Although its technical and success rates are high, primary and secondary patency rates are still questionable. Dyslipidemia, insulin, statin and antiplatelet intake together with age of patient, degree and site of stenosis are potential risk factors that affect these rates.

Safety and efficacy of the AngioJet device in the treatment of thrombosed arteriovenous fistula and grafts: A systematic review.

The AngioJet Hemolytic Thrombectomy Device "AngioJet" (Boston Scientific, Malborough, MA, USA) is a rheolytic thrombectomy device that can be used in the treatment of hemodialysis arteriovenous fistula and graft thrombosis. We aim to appraise the current evidence on AngioJet thrombectomy in hemodialysis vascular access thrombosis, and to determine its safety, including complications and efficacy. An electronic literature search was performed on the MEDLINE and Embase databases. References of retrieved articles were also reviewed. Articles using AngioJet for the treatment of arteriovenous fistula or graft were included. Patients less than 18 years old, non-English articles, single case reports, small case series (<5 cases), conference publications, and nonhuman models were excluded. A total of 688 articles were initially evaluated and 10 articles fulfilled the inclusion criteria, which included 836 patients with 431 grafts and 234 fistulas. Results were heterogeneously reported. The adjusted mean primary patency rates for 1, 3, 6, and 12 months were 64.6%, 43.8%, 42.5%, and 30.5%, respectively; adjusted mean secondary patency rates for 3, 6, and 12 months were 76.5%, 75.1%, and 74.5%, and assisted primary patency rates were 61.9%, 47.3%, and 35.3%, respectively. There were 126 complications, most were minor. There were seven deaths, but were unable to be attributable to the AngioJet. The AngioJet is an effective and safe treatment option for thrombosed fistulas and grafts. However, the quality of the current evidence is poor. Further research with prospective randomized controlled trials using standardized data reporting methods is needed to prove its safety and efficacy.

IF11. Stent Graft vs Balloon Angioplasty for Treatment of Hemodialysis Prosthetic Graft Outlet Stenosis: A Prospective Randomized Study

Hemodialysis graft outlet stenosis is the most common problem for hemodialysis patients using prosthetic grafts as their vascular access. Currently, balloon angioplasty remains the first-line endovascular treatment for those lesions. However, covered graft implantation seems to be an effective and promising solution. A prospective and randomized study was conducted in a section of vascular surgery of a tertiary medical center in which 98 patients with dialysis grafts with symptomatic outlet stenosis were randomized into two groups: 49 stent graft group patients and 49 balloon angioplasty group patients. After intervention, 3 months, and 6 months, a survey with angiography was done for those patent grafts to compare the rate of angiographic restenosis of the two groups. In addition, the primary patency of two groups was carefully followed, calculated, and analyzed. The postintervention restenosis rate of the stent graft group was obviously better than the balloon group, at 9% vs 69% at 3 months and 29% vs 72% at 6 months. The primary patency rates of stent graft vs balloon groups at 3 months, 6 months, and 12 months were 91.7%, 83.2%, and 46.9% vs 65.3%, 27.8%, and 7.8%. The mean primary patency after treatment was 380.22 ± 28.54 days for the stent graft group and 151.08 ± 16.79 days for balloon group. Stent graft provides a better solution over plain balloon angioplasty on hemodialysis graft outlet stenosis treatment, with a lower postintervention restenosis rate and longer primary patency.

Arteriovenous Hybrid Graft with Outflow in the Proximal Axillary Vein

The patency of long-term hemodialysis access in end-stage renal disease patients remains a significant challenge. Often these patients are affected with limited venous outflow options, requiring limb abandonment, and creation of new access in the contralateral arm. Vascular surgeons are familiar with the exposure of the proximal axillary artery via an infraclavicular incision. The axillary vein is easily exposed through this technique. The use of the hybrid Gore graft can make the venous anastomosis easier. A hybrid graft with its venous outflow placed in the proximal axillary vein can extend the options of upper extremity access procedures. We reviewed our early experience with this technique. A review of dialysis procedures at the Loma Linda VA was performed. All patients undergoing placement of arteriovenous grafts utilizing the Gore hybrid placed into the proximal axillary vein for outflow were identified. Outcomes in terms of primary and secondary patency rates were determined. Eight patients had placement of an arteriovenous hybrid graft in the proximal axillary vein via an infraclavicular incision. All patients had exhausted other options for hemodialysis access in the ipsilateral upper extremity. All grafts were used successfully for dialysis. The mean primary and secondary patency rates at 6months were 37.5% and 62.5%, respectively. One patient developed steal syndrome, requiring proximalization of the graft. Seven out of the 8 patients required secondary procedures including thrombectomy (n=16) and angioplasty (n=17). Placement of a hybrid graft in the proximal axillary vein is an effective and suitable option for patients who have exhausted arteriovenous access sites in the arm. This procedure can easily be performed in an outpatient setting with a low complication rate and allowing for preservation of the contralateral upper extremity for future use.

Arteriovenous access does not perform as well for plasmapheresis.

Access surgeons are occasionally asked to create arteriovenous access for non-dialysis functions. Subjectively noting overall poor results, we seek to present our experience with arteriovenous access creation for apheresis. Billing records were reviewed using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) codes to identify patients undergoing arteriovenous access creation for diseases other than renal failure from January 2007 to August 2014. Inpatient and outpatient records were reviewed to identify patient demographics, disease-specific medications/treatments, access-specific characteristics, patency data, and reinterventions required. A total of 16 access creation procedures were performed for 8 patients, accounting for just 1.6% of total access creations during the period. Treatment was for myasthenia gravis (n = 6), chronic inflammatory degenerative polyneuropathy (n = 9), and stiff man syndrome (n = 1). Access failure was by thrombosis (n = 7), non-maturation (n = 4), and infection/steal syndrome (n = 1), with four accesses still functional at conclusion of review. There was 50% autogenous access creation and overall maturation rate of 37.5%. Mean primary patency was 236 days (range 10-878), with secondary patency achieved in three patients adding a mean of 174 days (range 2-517). Cumulative 3-month and 1-year patency rates were 36.5% and 25%, respectively. Arteriovenous access creation for plasmapheresis represents a minority of access procedures. Though it remains unclear why, patency and maturation rates are significantly lower than expected when compared to access for hemodialysis access. These high failure rates must be taken into account when considering replacement of temporary catheters with surgical access for non-hemodialysis needs.

Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt.

AIMTo evaluate the effect of initial stent position on transjugular intrahepatic portosystemic shunt (TIPS).METHODSWe studied 425 patients from January 2004 to January 2015 with refractory ascites or variceal bleeding who required TIPS placement. Patients were randomly divided into group A (stent in hepatic vein, n = 57), group B (stent extended to junction of hepatic vein and inferior vena cava, n = 136), group C (stent in left branch of portal vein, n = 83) and group D (stent in main portal vein, n = 149). Primary unassisted patency was compared using Kaplan-Meier analysis, and incidence of recurrence of bleeding, ascites and hepatic encephalopathy (HE) were analyzed.RESULTSThe mean primary unassisted patency rate in group B tended to be higher than in group A at 3, 6 and 12 mo (P = 0.001, 0.000 and 0.005), and in group D it tended to be lower than in group C at 3, 6 and 12 mo (P = 0.012, 0.000 and 0.028). The median shunt primary patency time for group A was shorter than for group B (5.2 mo vs 9.1 mo, 95%CI: 4.3-5.6, P = 0.013, log-rank test), while for group C it was longer than for group D (8.3 mo vs 6.9 mo, 95%CI: 6.3-7.6, P = 0.025, log-rank test). Recurrence of bleeding and ascites in group A was higher than in group B at 3 mo (P = 0.014 and 0.020), 6 mo (P = 0.014 and 0.019) and 12 mo (P = 0.024 and 0.034. Recurrence in group D was higher than in group C at 3 mo (P = 0.035 and 0.035), 6 mo (P = 0.038 and 0.022) and 12 mo (P = 0.017 and 0.009). The incidence of HE was not significantly different among any of the groups (P = 0.965).CONCLUSIONThe initial stent position can markedly affect stent patency, which potentially influences the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Transjugular Access for Endovascular Treatment of Immature Autogenous Arteriovenous Fistulae

PurposeTo assess the feasibility and outcome of transjugular access for endovascular treatment of immature arteriovenous fistulae (AVFs). Materials and MethodsBetween August 2013 and January 2016, 90 patients (mean age, 64.5 y ± 12.8) underwent endovascular treatment of immature AVFs via transjugular access. The mean age of fistulae was 3.3 months ± 1.8. Total procedure time and technical and clinical success rates of endovascular procedures were assessed. Primary and secondary patency rates were calculated according to the Kaplan–Meier method, and complications were assessed. ResultsAll patients had inflow lesions, among which 19 (21.1%) had occlusions. The juxtaanastomotic segment was the most common site (44.3%). Transjugular access was successful in 83 patients (92.2%), and 7 required additional standard or transarterial access. The mean procedure time was 36.5 minutes. Technical and clinical success rates were 98.9% and 90.5%, respectively. Mean primary and secondary patency durations were 14.3 months ± 1.7 and 31.0 months ± 0.7, respectively. Primary patency rates at 3, 6, and 12 months were 84.4%, 67.3%, and 48.8%, respectively. Secondary patency rates at 6 and 18 months were 98.6% and 95.5%, respectively. Venous rupture occurred as a result of balloon inflation in 9 patients (10%), and was managed by balloon tamponade. There were no complications related to transjugular access during a mean follow-up period of 12.6 months. ConclusionsTransjugular access for angioplasty of immature AVFs is feasible and safe. Potential problems associated with access in the outflow vein could be avoided by transjugular access.

Current status and future perspectives of bioresorbable stents in peripheral arterial disease

Endovascular treatment of peripheral arterial disease (PAD) still yields unsatisfactory patency rates. Recent new developments include the use of bioresorbable stents. The objective of this study was to provide an overview of currently available data on the use of bioresorbable stents in lower limb PAD and to summarize the needs for future research focus. A systematic search in the databases of MEDLINE, Embase, and the Cochrane Library was performed. Studies using predefined inclusion and exclusion criteria were included and critically appraised by two independent reviewers. Inclusion criteria were (1) original data on (2) bioresorbable stents in (3) lower limb arteries including the iliac tract. Primary end points were safety and feasibility of bioresorbable stents, including 30-day adverse events. Secondary end points included radial force, bioresorption process, long-term primary and secondary patency, and clinical outcomes, such as amputation rate, Rutherford category, and ankle-brachial index improvement. Seven published studies with a total of 316 patients were included, and five conference abstracts including 272patients were assessed. Median follow-up time was 12months. Overall technical success rate was 99% (range, 95.0%-100%). The 30-day adverse event rates were reported in 5.0% of patients (range, 0%-13.3%); these included one death, two major amputations, and seven reinterventions. Mean primary patency rate was 61.6% in the femoral arteries (range, 32.1%-80.0%) after 6 to 12months compared with 50.3% in below-the-knee lesions (range, 31.8%-92.9%). Secondary patency rates were 91.5% (range, 84%-97.1%) and 72.1% (range, 62.9%-100%), respectively. The 1-year amputation rate was 3.0% in the whole group (range, 0%-12.4%). Experience with the use of bioresorbable stents in PAD is still limited and is investigated only in small studies. The use of bioresorbable stents in PAD appears to be feasible and safe. With current published results, we are unable to fully answer all of the questions about the future use of bioresorbable stents in PAD, and use should be limited to study-related cases in PAD.

A pooled analysis of common femoral and profunda femoris endovascular interventions.

Atherosclerotic disease of common femoral and profunda femoris arteries has been historically treated with surgical endarterectomy. Endovascular treatment of common femoral artery and profunda femoris artery disease is increasingly reported in the recent literature. This review summarizes short- and mid-term outcomes of endovascular interventions to the common femoral artery and common femoral artery. All published series in the English language were identified through a systematic PubMed search. Standard descriptive statistics, reported as mean ± SD, were applied to perform the pooled analysis and calculate the overall outcome measures. Combined overall effect sizes were calculated using fixed-effect meta-analysis. The analysis included 20 studies with a total of 836 patients (897 limbs, mean age of 70.5 ± 4.3 years, critical limb ischemia 39.6%). Technical success was 95%. Angioplasty alone was undertaken in 68.8% of cases and stenting in 22.3%. Access complications occurred in 2.4% of cases. Post-operative major adverse limb events occurred in 2% and major adverse cardiovascular events in 1% of cases. Primary patency at 6, 12 and 24 months was 87%, 77% and 73%, respectively. Subgroup analysis revealed a significantly higher mean primary patency at 12 months for routine stenting compared to a selective stenting strategy (91.4% versus 75%; p < 0.05). Endovascular interventions to the common femoral artery and common femoral artery can be performed safely with high technical success. Endovascular therapy may be a favored approach over endarterectomy for highly selected patients of poor surgical risk, with limited life expectancy and those with wound-healing considerations such as re-operative fields or prone to infection.

Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome.

The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO. Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively. Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively. Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.

Abdominal Wall Grafts: A Viable Addition to Arteriovenous Access Strategies

We seek to present our experience with innovative abdominal wall arteriovenous access grafts for patients who have run out of traditional dialysis access options. We retrospectively reviewed our cohort of patients who have undergone creation of abdominal wall grafts. In all patients, an iliac artery was used for inflow and either an iliac vein or the distal inferior vena cava (IVC) was use for the outflow. Ringed polytetrafluorethylene (PTFE), nonringed PTFE, and bovine carotid artery were used as access conduits. Our 12-patient cohort had a mean primary patency of 17.4 months with mean secondary patency of 33 months. There were no operative deaths noted and 4 total graft infections. Abdominal wall grafts with iliac vessel inflow and/or outflow represent viable alternatives for patients who have exhausted more traditional dialysis access options.

56. Description and Outcomes of A Simple Surgical Procedure To Treat the Failing Forearm Arteriovenous Fistula

Introduction and Objectives: Atherosclerotic disease of common femoral and profunda femoris arteries (CFA/PFA) has been historically treated with surgical endarterectomy. Endovascular treatment of CFA and PFA disease has been reported in the recent literature. This review describes current endovascular treatments to the CFA and PFA. Methods: An electronic PubMed database search of all reports of CFA and PFA endovascular treatments in the English language was performed. Relevant studies were retrieved and analyzed. Results: Analysis of 19 studies was performed totaling 721 patients with a mean age of 70.5 years. Indications for treatment include claudication in 51.8%, critical limb ischemia in 45.5% and other in 2.8%. Technical success occurred in 96% of procedures with CFA treatment in 44% and PFA in 56% of cases. Angioplasty alone occurred in 69.4% of cases, stenting in 26% and thrombolysis or atherectomy in 4.6%. Mean ankle-brachial index increased by 0.23 following intervention. Access complications and groin hematomas occurred in 3.1% of cases; distal embolization in 1.3%. Mean peri-operative mortality was 0.27% with all-cause mortality of 15% over a mean follow-up period of 21 months. Mean primary patency was 79% at a mean follow-up of 12 months with secondary patency of 87.5% at a mean follow-up of 33 months. Routine stenting of the CFA or PFA led to a mean primary patency of 85.9% at a mean follow-up of 18 months. Endarterectomy or surgical bypass was undertaken in 8.8% of patients during the follow-up period, endovascular re-intervention occurred in 5.9% and major amputation in 2.7%. Conclusions: Endovascular interventions to the CFA and PFA can be performed safely and with high technical success. Mid-term patency when routine stenting is applied is comparable to surgical endarterectomy. Primary endovascular therapy may be a favored approach for high surgical risk patients given the low rate of procedural-related mortality and morbidity.

Comparison of Uncovered Stent Placement across versus above the Main Duodenal Papilla for Malignant Biliary Obstruction

PurposeTo evaluate the differences in efficiency and complications of metal stent insertion across versus above the main duodenal papilla (MDP) in patients with malignant obstruction of the common bile duct (CBD). Materials and MethodsRecords of 98 consecutive patients who underwent stent insertion for malignant CBD obstruction between 2004 and 2010 were retrospectively reviewed. Fifty-one patients (group 1) and 47 patients (group 2) were treated with stent insertion across and above the MDP, respectively. Primary stent patency, overall survival, complications, and changes in serum bilirubin level following stent insertion were assessed. ResultsInfection appeared in 12 and four patients, respectively, in groups 1 and 2. The respective mean primary stent patency times were 307.8 days ± 20.2 and 490.7 days ± 40.7, and mean survival times were 245.1 days ± 17.4 and 286.3 days ± 20.2. Bilirubin reduction rates were 55.7% ± 16.6 and 61.1% ± 13.7 at 1 week and 84.2% ± 5.7 and 86.2% ± 5.7 at 1 month in groups 1 and 2, respectively. In group 2, the rate of infection was significantly lower (P = .044) and primary stent patency was longer (P = .019). However, there was no significant difference between groups in survival time (P = .074) or bilirubin reduction rate at 1 week (P = .083) or 1 month (P = .082). ConclusionsBile stent insertion above the MDP may achieve longer stent patency and a lower infection rate compared with placement across the MDP. For patients with malignant CBD obstruction, biliary stents should be placed above the papilla if papillary lesions are not invaded.

Percutaneous thrombectomy of AVF: immediate success and long-term patency rates.

The purpose of this study was to report the results obtained in a cohort of 520 cases of thrombosed arteriovenous fistulas (AVF) treated by percutaneous intervention over a period of 8 years. The methods used varied according to the individual characteristics of the case. A clinical success rate of 91.1% was obtained with no significant difference being noted among radial-cephalic, brachial-cephalic, and brachial-basilic AVFs. The mean primary patency for this group was 227.3 ± 14.6 days, and the mean assisted primary patency was 677.2 ± 44.6 days. The lower arm AVFs had both a primary patency and an assisted primary patency that were significantly better than the upper arm cases (p = 0.006 and 0.002, respectively). The primary patency for radial-cephalic AVFs was significantly better than that for brachial-cephalic AVFs (p = 0.021), but not for brachial-basilic cases (p = 0.122). Assisted primary patency for radial-cephalic cases was significantly superior to the values for either patients with a brachial cephalic (p = 0.046) or a brachial-basilic (p = 0.004). Complications occurred in seven cases (1.3%), all of which were venous ruptures. Blood flow was affected in four cases. Only one of these was salvaged with angioplasty balloon tamponade. In the remaining three cases, the AVF was lost.

Percutaneous Interventions in Failing “Necklace” Hemodialysis Grafts: Long-Term Outcomes

PurposeTo determine primary and secondary patency after percutaneous interventions for malfunctioning anterior chest wall (“necklace”) arteriovenous grafts (AVGs) for hemodialysis. Materials and MethodsRecords of six consecutive patients with subclavian artery–to–contralateral subclavian vein necklace AVGs were reviewed. Patients underwent 34 procedures, including 28 balloon angioplasties, 24 pharmacomechanical thrombolyses, and six stent placements. Patency intervals after graft placement and after first intervention were calculated. ResultsAfter 3 months, primary and secondary patency rates were 33% (two of six grafts) and 67% (four of six grafts), respectively. At 12 months, primary and secondary patency rates were 17% (one of six grafts) and 50% (three of six grafts), respectively. Median and mean primary patency times were 49 and 374 days, and median and mean secondary patency times were 293 and 575 days, respectively. The anatomic success rate of percutaneous interventions in malfunctioning AVGs was 97% (33 of 34 cases). At 3 years after implantation, the graft patency rate was 57% (four of seven grafts). ConclusionsPercutaneous interventions were effective at maintaining patency in failing necklace AVGs. However, their primary and secondary patency were inferior to those cited in extremity AVG guidelines set forth by the Society of Interventional Radiology.

Outcomes of Metallic Biliary Stent Insertion in Patients with Malignant Bilobar Obstruction

PurposeTo assess clinical outcomes of metal stent insertion in patients with bilobar bile duct obstruction by malignant tumors. Materials and MethodsRecords of 120 consecutive patients who underwent placement of metallic stents for palliation of malignant bilobar biliary obstruction between 1995 and 2010 were retrospectively reviewed. Single-duct stent insertion was performed in 44 patients with one liver lobe that accounted for more than 70% of total liver volume or only one patent lobar portal vein (group 1). Bilobar stent insertion was performed in 60 patients with approximately equal lobe sizes, patent lobar portal veins, or cholangitis at presentation (group 2). In 16 patients with discontiguous right anterior and posterior segmental ducts (group 3), three stents were deployed in the left lobar and right anterior and posterior segmental ducts. Overall survival, primary patency, and patient morbidity rates following stent insertion were assessed. ResultsNo significant differences in mean overall survival (group 1, 7.3 mo; group 2, 10.3 mo; group 3, 6.5 mo; P = .21) or mean primary stent patency (group 1, 4.2 mo; group 2, 5.9 mo; group 3, 3.5 mo; P = .17) were demonstrated. However, patients in group 3 were significantly more likely to require hospitalizations for cholangitis and additional invasive procedures for recurrent biliary obstruction than patients in groups 1 and 2. ConclusionsUnilobar and bilobar metal stent insertion led to similar outcomes when treatment decision was based on relative liver lobe volumes, lobar portal vein patency, and presence of cholangitis on presentation.