Method For Recanalization Research Articles

The new era in the treatment of deep vein occlusion

Abstract A non-invasive, conservative treatment has been a standard in treating acute and chronic deep vein thrombosis. This treatment turned out to be ineffective, particularly in the hip area. Also, it was demonstrated that it does not influence the frequency of manifestations of post-thrombotic syndrome. Previous attempts to surgically reconstruct deep veins, unlike arteries reconstruction, yielded no positive results and also increased hemorrhagic and embolic complications. Currently, already in the period of the acute thrombosis of deep veins, the methods of early re-canalization, both with the application of targeted thrombolisis, as well as of pharmacomechanical methods, are applied. Thanks to a wide array of image examination methods applied in pre-operational and intra-operational diagnostics optimum, it is possible to plan a revascularising treatment in the sick individuals suffering from the already developed manifestations of the post-thrombotic syndrome. The development of endovascular methods, made possible thanks both to the surgeons’ experience in the re-canalization field, as well as constant improvements of stents dedicated to the venous system, allowed for effective use of these techniques in curing the occlusion of deep veins. It was the case with the arterial system and works here as well. Applying the hybrid proceeding, combining opened techniques and endovascular ones, works very well in selected cases.

Trends in the Effectiveness of Endovascular Recanalization for Acute Stroke: Is a Change Taking Place?

Despite recent technical advances in endovascular recanalization, there is skepticism regarding its clinical effectiveness compared with intravenous thrombolysis for treating acute ischemic stroke. We aimed to delineate its effectiveness and safety and their change over time. Using a prospective, multicenter stroke registry database, we identified 872 patients with ischemic stroke who underwent recanalization therapy with intravenous thrombolysis alone (IVT; n=533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n=339) between April 2008 and January 2012. All subjects had National Institute of Health Stroke Scale score of 10 or more and arrived at the hospital within 4.5hours of onset. Propensity score was used to address baseline imbalances between treatment groups, but balance adjustment was not performed for subgroup analyses. The primary outcome was modified Rankin Scale score of 0-2 at discharge. The year-by-year effectiveness and safety of EVT and IVT were compared. Before 2010, the primary outcome was not associated with the recanalization method. However, in 2011, EVT increased the odds of having a primary outcome compared with IVT (adjusted odds ratio [OR], 1.87; 95% confidence interval [CI], 1.08-3.23). In 2011, EVT was superior to IVT regarding the achievement of a favorable outcome at 3months after stroke (OR, 1.99; 95% CI, 1.10-3.59). The odds of in-hospital mortality and 3-month mortality were not different over 4years. There might have been achange in the effectiveness of endovascular recanalization compared with intravenous thrombolysis, but the results remain tentative until prospectively evaluated.

Endovascular treatment of acute basilar artery occlusion: time to treatment is crucial

To evaluate the safety and efficacy of multimodal endovascular treatment (EVT) of acute basilar artery occlusion (BAO), including bridging therapy [intravenous thrombolysis (IVT) with subsequent EVT], to compare particular EVT techniques and identify predictors of clinical outcome. This retrospective, multi-centre study comprised 72 acute ischaemic stroke patients (51 males; mean age 59.1 ± 13.3 years) with radiologically confirmed BAO. The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings. Thirty- and 90-day outcomes were evaluated using the modified Rankin scale with a good clinical outcome defined as 0-3 points. Successful recanalization was achieved in 94.4% patients. Stepwise binary logistic regression analysis identified the presence of arterial hypertension (OR = 0.073 and OR = 0.067, respectively), National Institutes of Health Stroke Scale (NIHSS) at the time of treatment (OR = 0,829 and OR = 0.864, respectively), and time to treatment (OR = 0.556 and OR = 0.502, respectively) as significant independent predictors of 30- and 90-day clinical outcomes. Data from this multicentre study showed that multimodal EVT was an effective recanalization method in acute BAO. Bridging therapy shortens the time to treatment, which was identified as the only modifiable outcome predictor.

Platelet rich clots are resistant to lysis by thrombolytic therapy in a rat model of embolic stroke.

BackgroundEarly recanalization of occluded vessels in stroke is closely associated with improved clinical outcome. Microbubble-enhanced sonothrombolysis is a promising therapy to improve recanalization rates and reduce the time to recanalization. Testing any thrombolytic therapy requires a model of thromboembolic stroke, but to date these models have been highly variable with regards to clot stability. Here, we developed a model of thromboembolic stroke in rats with site-specific delivery of platelet-rich clots (PRC) to the main stem of the middle cerebral artery (MCA). This model was used in a subsequent study to test microbubble-enhanced sonothrombolysis.MethodsIn Study 1 we investigated spontaneous recanalization rates of PRC in vivo over 4 hours and measured infarct volumes at 24 hours. In Study 2 we investigated tPA-mediated thrombolysis and microbubble-enhanced sonothrombolysis in this model.ResultsStudy 1 demonstrated stable occlusion out to 4 hours in 5 of 7 rats. Two rats spontaneously recanalized at 40 and 70 minutes post-embolism. Infarct volumes were not significantly different in recanalized rats, 43.93 ± 15.44% of the ischemic hemisphere, compared to 48.93 ± 3.9% in non-recanalized animals (p = 0.7). In Study 2, recanalization was not observed in any of the groups post-treatment.ConclusionsSite specific delivery of platelet rich clots to the MCA origin resulted in high rates of MCA occlusion, low rates of spontaneous clot lysis and large infarction. These platelet rich clots were highly resistant to tPA with or without microbubble-enhanced sonothrombolysis. This resistance of platelet rich clots to enhanced thrombolysis may explain recanalization failures clinically and should be an impetus to better clot-type identification and alternative recanalization methods.Electronic supplementary materialThe online version of this article (doi:10.1186/s13231-014-0014-y) contains supplementary material, which is available to authorized users.

Double solitaire mechanical thrombectomy in acute stroke: effective rescue strategy for refractory artery occlusions?

Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy. All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed. Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment (n = 5) and terminal ICA (n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45-87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0-2) was 50%. In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy.

COMPARISON OF LONG FULL COVERAGE STENTING VERSUS SHORT SPOT STENTING FOR SUBINTIMAL TRACT IN THE CHRONIC LONG TOTAL OCCLUSIONS OF SUPERFICIAL FEMORAL ARTERIES

Subintimal angioplasty (SA) is accepted as an effective method for recanalization of chronic femoropopliteal occlusions. However, there has been scarcity of data on the outcomes according to stenting strategies for coverage of subintimal tract, full stenting or short spot stenting. Between April

Abstract 186: Effectiveness of Endovascular Recanalization for Acute Stroke: A Transition Toward Superiority Over Intravenous Thrombolysis

Background: There is skepticism in clinical practice about the comparative effectiveness of endovascular recanalization compared to intravenous thrombolysis for acute ischemic stroke, and there is a paucity of information about effectiveness and safety trends. Methods: We identified 872 acute ischemic stroke patients who underwent recanalization therapy with intravenous thrombolysis only (IVT; n=533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n=339) from a prospective, multicenter stroke registry database between April 2008 and January 2012. All study subjects had NIHSS score ≥10 and arrived within 4.5 hours of onset. Inverse probability of EVT weighting by propensity score was used to remove baseline imbalance between treatment groups. Primary outcome was mRS score 0 – 2 at the time of discharge. Year-by-year effectiveness and safety of EVT over IVT were estimated with further adjustment by age, NIHSS score, onset to arrival time, duration of hospitalization and treatment year. Results: Before 2010, the primary outcome was not associated with treatment modality. However in 2011, EVT increased the odds of better primary outcome compared to IVT (adjusted OR, 1.87; 95% CI, 1.08 – 3.23). Also in year 2011, EVT became superior to IVT for mRS score 0 – 2 (1.99; 1.10 – 3.59) at 3 months after stroke. The odds of mortality during admission and at 3 month and symptomatic hemorrhagic transformation were not different between recanalization methods throughout the study period (see Figure). Subgroup analyses showed that effect estimates from EVT were significantly modified by total stroke volume of hospital (higher in ≥30 stroke cases per month) and time from onset to arrival (higher in ≥2-hour delay). Conclusion: Over time, endovascular recanalization has become superior to intravenous thrombolysis for improvement of clinical outcomes in acute ischemic stroke.

Abstract W P15: ADAPT Technique: A Direct Aspiration First Pass Technique for Stroke Thrombectomy

Background: The development of new revascularization devices has improved recanalization rates and time. We report our initial results with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization. Methods: A retrospective evaluation of a prospectively captured database of 81 patients at 6 institutions was performed on patients where the ADAPT technique was utilized. The device manufacturer suggested retail prices was tracked for all devices used during the procedure. The data represents the initial experience with this technique. Results: The ADAPT technique alone was successful in 63 of 81 (78%) cases. Eighteen cases required the additional use of a stent retriever or a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least TICI 2b recanalization was 34 minutes and 93% of cases were successfully revascularized. TICI 3 recanalization was achieved 53% of the time. On average, patients presented with an admitting NIHSS of 16 and improved to NIHSS of 6 by the time of hospital discharge. There were three procedural complications, none resulting in clinical sequelae. Discussion: This initial experience highlights the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a fast, simple and effective first approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

Differentiated approach to the use of the modern surgical technologies in patients with tubal infertility

Aim. To elaborate the differentiated approach to the surgical treatment of the patients with tubal and peritoneal infertility using the endoscopic and microsurgical methods and to evaluate its efficiency. Methods. 1840 female patients with infertility underwent complex clinical and laboratory examination, including endoscopy. 1257 patients underwent surgical treatment. Endo-video-surgical interventions were carried out in 1070 women, microsurgical techniques were applied in 187 patients. Results. The laparoscopic reconstructive plastic surgery was the most effective manipulation in patients with the disease of the distal part of the fallopian tubes and peritoneal adhesions. Treatment results were defined by the severity of distal part of the uterine tubes damage and severity of peritoneal adhesions in the pelvic cavity. The most favorable results of the treatment were noted after salpingo-ovariolysis (success rate 61.4%), by 2.3 times exceeding the pregnancy frequency after salpingoneostomy (26.9%; p 0.001) and by 1.6 times compared to fimbrioplasty (39.2%; p 0.001). In patients with proximal occlusion, results depended on the type of the tubular occlusion. In 69.7% patients with proximal occlusion due to synechiae, small polyps, foreign bodies, hysteroscopic interventions were an effective method of recanalization, allowing to restore the reproductive function in 40.2% patients. The microsurgical method demonstrated the 5.9 fold higher efficiency in patients with fibroid proximal occlusion of the uterine tubes compared to the laparoscopic methods (41.7% vs 7.1%). The microsurgical method was the most effective in patients with true fibrous proximal occlusion after the surgery on uterine tubes for tubular pregnancy and surgical sterilization. Conclusion. The differentiated approach to the surgical treatment of the patients with tubal infertility allowed to use the endo-video-surgical method in 85.1% of cases, improving the treatment’s results due to the decrease the surgical trauma and surgery duration, due to economic and cosmetic effect.

Recanalization of refractory benign biliary stricture using magnetic compression anastomosis

Endoscopic or percutaneous treatments are preferentially attempted for benign biliary stricture (BBS). However, these methods are not feasible if a guide wire cannot be passed through the stricture. This study evaluated the usefulness and technical requirements of magnetic compression anastomosis (MCA) in refractory BBS. MCA was performed in patients with BBS that had not been resolved with conventional treatments. One magnet was delivered through the percutaneous transhepatic biliary drainage tract and the other magnet was advanced through three different routes. After magnet approximation and recanalization, an internal drainage catheter was placed for 6 months and then removed. Seven patients underwent MCA, and recanalization was successfully achieved in five. MCA failure in two cases was attributed to long stenotic segments and parallel alignment of the axes of the magnets. The mean follow-up period after recanalization was 485.2 days. Five patients with successful recanalization showed no MCA-related complications or restenosis. MCA represents an alternative nonsurgical method of BBS recanalization that cannot be treated with conventional methods.

Endovascular Treatment of Children With Cerebral Venous Sinus Thrombosis: A Case Series

Cerebral venous sinus thrombosis is a potentially serious condition affecting 0.56 to 0.67 per 100,000 children annually; adverse outcomes are common. The standard of care is anticoagulation with heparin. A proportion of patients, however, remain in a severe clinical condition and in these, endovascular therapy is an alternative treatment. There is little published literature on the use of endovascular treatments in children with cerebral venous sinus thrombosis. We retrospectively reviewed case notes and imaging in a consecutive series of nine children treated using endovascular therapy after diagnosis of cerebral venous sinus thrombosis. Clinical presentation, decision to escalate therapy, methods of recanalization, and clinical outcome were assessed. Nine children were treated (age range 18 months to 16 years). Diagnosis was made by computed tomography, computed tomography venography, magnetic resonance imaging, or magnetic resonance venography. Seven children were in a coma; one had signs of raised intracranial pressure with progressive cranial nerve palsies; and one was drowsy with a fluctuating hemiparesis. Eight children had been treated with heparin without improvement. Several endovascular methods were used including local tissue plasminogen activator, microguidewire and catheter disruption, balloon angioplasty, and thromboaspiration using the Penumbra device. Eight children had good functional outcomes. One child died as a result of uncontrolled intracranial hypertension secondary to cerebral venous sinus thrombosis. Endovascular therapy may have a role in the treatment of cerebral venous sinus thrombosis in children when medical therapy has failed and the patient is in a poor clinical condition.

Endovascular treatment of acute basilar artery occlusion

Endovascular treatment of acute basilar artery occlusion

Optimized amide proton transfer imaging of ischemic stroke

Optimized amide proton transfer imaging of ischemic stroke

Nanomaterials in Stroke Treatment

Stroke is the world’s second leading cause of mortality, with a high incidence of severe morbidity in surviving victims. About 87% of strokes are caused by ischemia, and the remainder is caused by hemorrhage. Ischemic stroke causes most deaths.1 Acute ischemic stroke results from a sudden decrease or loss of blood flow in cerebral arteries. Brain tissue has a relatively high consumption of oxygen and glucose, and depends almost exclusively on oxidative phosphorylation for energy production. Cerebral ischemia leads to the development of a cascade of pathological biochemical reactions, including the rapid depletion of the intracellular ATP pool, anaerobic glycolysis, lactate acidosis and membrane depolarization, glutamate excitotoxicity, the entry of Ca2+, Na+, and H2O into cells, activation of Ca-dependent proteins, mitochondrial dysfunction, overproduction of free radicals, activation of the immune system, gene overexpression, and, finally, cell death.1–3 Oxidative stress is one of the main mechanisms of stroke development. Free radical production and the activation of degradative enzymes lead to acute cell death through necrosis, but excitotoxic mechanisms can also initiate apoptosis.4 Besides causing cerebral cellular injury, oxidative stress also increases blood–brain barrier dysfunction.4,5 ### Stroke Treatment Major approaches developed to treat acute ischemic stroke fall into 2 categories, early recanalization (thrombolysis) and neuroprotection. There are ongoing trials aimed at evaluating the effectiveness of recombinant tissue–type plasminogen activator and acetylsalicylic acid in longer time windows with a finer selection of patients based on MRI and trials of novel recanalization methods.6 Neuroprotection is achieved by blocking of proinflammatory cytokines and cell adhesion agents, decrease of lipid peroxidation processes, and blocking of apoptosis.7 At least 25 clinical phase II and III trials are currently recruiting patients for the evaluation of new therapeutics for acute ischemic stroke.4 Despite these developments, the actual …

Sp707 Endoscopic Recanalization Technique for Complete Ligation of Bile Duct after Cholecystectomy

Bile Duct Injury after cholecystectomy remains a major problem in current surgical practice. BDI is associated with poor survival, increased morbidity and impaired quality of life. The current standard practice for management of BDI is the following: Amsterdam Type A and B lesions (cystic and bile duct leak) should be treated with sphincterotomy and placement of stent; Type C lesions (strictures) should be treated by endoscopy (failures should be considered for surgery); Type D lesions (transection or ligation of the bile duct) should be treated by surgery. In this presentation, we will, for the first time, demonstrate an endoscopic method of biliary recanalization in three patients with complete ligation of the common bile duct. We will present three cases of patients that had undergone cholecystectomy and presented, after 2 to 4 weeks, clinical evidence of jaundice. By a three-step ERCP procedure, we accessed the common bile duct and passed a specialized needle through the complete stenosis. It was used a specialized needle catheter that presented some characteristics, such as an 18-gauge needle, internal channel that fitted a .35-inch guidewire, and a distal tip covered by a flexible metallic sheath with 10 cm length. At this first moment, we used a .35-inch guidewire to maintain proximal bile duct access and performed plastic stent (first case) or self-expandable metallic stent placement. In the first patient, it was a three step procedure that consisted in 8.5 Fr plastic stent placement, followed by balloon dilation of the stenosis with multi-stent placement, and finalized by the multi-stent removal. In the second and third cases, instead of a plastic stent, a self-expandable metallic stent was used. This alternative reduced the treatment to two steps and it was not necessary to perform a balloon dilation of the stenosis. A clinical resolution of the stenosis was observed in the three patients, with a mild narrowing of CBD in radioscopic images. It is important to know that, before performing this procedure, all patients had undergone a colangioresonance, which demonstrated that cranial and distal biliary stumps were aligned. Endoscopic recanalization of CBD was an effective technique and avoided surgery in patients with Type D bile duct injury. We hypothesize that patients whose MRCP demonstrate just CBD ligation are more likely to have a successful outcome, while those with complete transection should be referred to surgical evaluation, however we present a case series demonstrating feasibility of endoscopic recanalization by using a specialized needle catheter.

Subintimal angioplasty with a true reentry device for treatment of chronic total occlusion of the arteries of the lower extremity

To report the efficacy and safety of the Outback(®) LTD(®) Re-Entry Catheter in reentering the distal true lumen during percutaneous intentional extraluminal revascularization (PIER). Reentry catheters are used to treat chronic, total arterial occlusions of the lower extremities when standard methods of recanalization have failed. Success and complication rates of these catheters in the real world are uncertain and variable. A retrospective review of our peripheral catheterization database from January 2004 to September 2009 was undertaken to identify consecutive cases of peripheral chronic total occlusions (CTOs) requiring the use of the Outback reentry catheter. Patient demographics, indication for the procedure, location and extent of occlusion, procedural success, and complications were studied. A total of 51 patients were identified. Of the 51, 28 (54.9%) patients presented with nonhealing ulcer and 22 (43.1%) had lifestyle-limiting claudication. One patient presented with acute limb ischemia. There were 6 (11.8%) patients with common iliac artery occlusion, 2 (3.9%) with external iliac artery occlusion, 1 (1.9%) with common femoral artery occlusion, 35 (68.6%) with superficial femoral artery occlusion, 6 (11.8%) with popliteal artery occlusion, and 1 (1.9%) with tibioperoneal artery occlusion. Median lesion length was 230 mm. Procedural success was achieved in 49 patients (96.1%). There was 1 (1.9%) periprocedural complication. Use of Outback(®) LTD(®) Re-Entry Catheter is a safe and valuable option for PIER/subintimal angioplasty and recanalization in patients with symptomatic lower-extremity CTOs. However, long-term patency remains unknown.

Mechanical thrombectomy using Rotarex system and stent-in-stent placement for treatment of distal femoral artery occlusion secondary to stent fracture – a case report and literature review

SummaryBackground:Treatment of peripheral arterial diseases may be distinguished into conservative and interventional management; the latter is divided into surgical and endovascular procedures. Management of peripheral artery stenosis and occlusion with vascular stents is associated with the risk of late complications such as restenosis, stent fracture or dislocation.Case Report:A 62-year-old woman with generalized atherosclerosis, particularly extensive in lower limb arteries, was admitted to the Department of Angiology 11 months after having an endovascular procedure performed due to critical ischemia of left lower limb. Because of stent occlusion, a decision to perform angiographic examination of lower limb arteries was made. Examination revealed occlusion of the superficial femoral artery along its entire length, including previously implanted stents. Distal stent was fractured with slight dislocation of the proximal segment. A decision was made to perform mechanical thrombectomy using a Rotarex system followed by a stent-in-stent placement procedure. Follow-up angiography and ultrasound scan performed 24 hours after the procedure revealed a patent vessel with satisfactory blood flow.Discussion:Nowadays, imaging diagnostics of peripheral artery stenosis involves non-invasive examinations such as ultrasound, minimally invasive examinations such as angio-MRI and MDCT, or invasive examinations such as DSA and IVUS. DSA examinations are used to confirm significant stenosis or occlusion of a vessel, particularly when qualifying a patient for endovascular treatment. Due to their anatomic location, the superficial femoral artery and the popliteal artery are subject to various forces e.g. those exerted by the working muscles. Mechanical thrombectomy and atherectomy are efficient methods of arterial recanalization used in the treatment of acute, subacute or even chronic occlusions or stenosis of peripheral vessels.Conclusions:Frequency of angioplasty and vascular stent implantation procedures is increased in patients with peripheral arterial disease, thus increasing the incidence of reported early and late complications such as acute stent thrombosis, restenosis and stent fractures. The Rotarex transcutaneous mechanical thrombectomy system is an efficient method of treating occlusions in arterial stents. It is also safe when performed by experienced operators.

Mechanical Revascularization for Acute Ischemic Stroke: A Single-Center, Retrospective Analysis

Endovascular mechanical revascularization (thrombectomy) is an increasingly used method for intracranial large vessel recanalization in acute stroke. The purpose of the study was to analyze the recanalization rate, clinical outcome, and complication rate in our stroke patients treated with mechanical revascularization. A total of 57 patients with large vessel stroke (within 3 h for anterior and 12 h for posterior circulation) were treated with mechanical revascularization at a single center during 24 months. The primary goal of endovascular treatment using different mechanical devices was recanalization of the occluded vessel. Recanalization rate (reported as thrombolysis in cerebral infarction [TICI] score), clinical outcome (reported as National Institutes of Health Stroke Scale [NIHSS] score and modified Rankin scale [mRS] score), as well as periprocedural complications were analyzed. The mean age of the patients was 63.1 ± 12.9 years, with baseline median NIHSS score of 14 (interquartile range, 9.5-19). Successful recanalization (TICI 2b or 3) was achieved in 41 (72 %) patients. Twenty patients (35 %) presented with favorable outcome (mRS ≤2) 30 days after stroke. Overall, significant neurological improvement (≥4 NIHSS point reduction) occurred in 36 (63 %) patients. A clinically significant procedure-related adverse events (vessel disruption, peri/postprocedural intracranial bleeding) defined with decline in NIHSS of ≥4 or death occurred in three (5 %) patients. The study showed a high recanalization rate with improved clinical outcome and a low rate of periprocedural complications in our stroke patients treated with mechanical revascularization. Therefore, we could conclude that endovascular revascularization (primary or in combination with a bridging thrombolysis) was an effective and safe procedure for intracranial large vessel recanalization in acute stroke.

Retrograde Popliteal Access in the Supine Patient for Recanalization of the Superficial Femoral Artery:Initial Results

To report an initial experience of superficial femoral artery (SFA) recanalization performed with a dual femoral-popliteal approach in the supine patient. From May 2008 to April 2010, 26 patients (16 men; mean age 68 ± 6.3 years) with intermittent claudication and chronic SFA occlusion (mean length 97.4 ± 3.8 mm, range 35-220) underwent percutaneous recanalization from a retrograde popliteal access. The common femoral artery was punctured with an antegrade (n = 9) or retrograde contralateral (n = 17) approach, then with the patient still supine and the knee gently flexed and medially rotated, the popliteal artery was punctured using an 18-G needle under ultrasound (10, 38.4%) or fluoroscopic (16, 61.5%) guidance with a roadmap technique. Once the SFA was recanalized, the procedure was completed with angioplasty and stenting from the femoral approach. At the end of the procedure, hemostasis at the popliteal access was obtained with manual compression (5-10 minutes). Technical success (puncture of the popliteal artery and SFA recanalization) was achieved in all cases. In the majority of patients (24, 91.6%), endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. Two small hematomas were found in the popliteal region, but no pseudoaneurysm or arteriovenous fistulas were seen on duplex examinations during a mean 12.5-month follow-up (range 6-28). Twenty (76.9%) SFAs were patent; in-stent restenosis occurred in the remaining 6 (23%). Primary patency was 80.7% at 6 months and 76.9% at 1 year. No stent fracture was observed. The retrograde popliteal approach with the patient in the supine position can be considered a "first choice" method for safe and effective SFA recanalization, especially in occlusions located at the distal and mid portion SFA.

Randomized Comparison of Three Palliative Regimens Including Brachytherapy, Photodynamic Therapy, and APC in Patients With Malignant Dysphagia (CONSORT 1a) (Revised II)

Because most esophageal cancers are diagnosed at an advanced stage, a majority of patients require palliative dysphagia treatment. Dysphagia severity and the need for repeated re-canalization procedures significantly affect patients' quality of life (QoL). The aim of this study was to establish whether combining argon plasma coagulation (APC) of the neoplastic esophageal tissue with another re-canalization method results in a longer dysphagia-free period compared with APC alone. We conducted a randomized trial in 93 patients with malignant dysphagia. Patients were followed until death. We compared three regimens of esophageal re-canalization; APC combined with high dose rate (HDR) brachytherapy, APC combined with photodynamic therapy (PDT), and APC alone. The primary outcome measure was the dysphagia-free period following randomization. Secondary measures were survival, QoL, treatment-associated complications, and treatment tolerance. A per-protocol analysis was carried out. The time to first dysphagia recurrence was significantly different between each combination treatment group and the control group (overall test: P=0.006; HDR vs. control, log-rank P=0.002, PDT vs. control, log-rank P=0.036), but not different between the combination groups (HDR vs. PDT, log-rank P=0.36). The median time to first dysphagia recurrence was 88, 59, and 35 days in the HDR, PDT, and control groups, respectively. There was no difference in overall survival between the study groups (P=0.27). No deaths, perforations, hemorrhages, or fistula formations were attributed to treatment. The only major complication was fever, occurring in three PDT patients. Minor complications were observed significantly more often in the combination treatment groups and included pain in both groups, transient dysphagia worsening, and skin sensitivity in the PDT group. The QoL 30 days after treatment in the HDR group was significantly better than in the other groups. In patients with inoperable esophageal cancer, palliative combination treatment of dysphagia with APC and HDR or PDT was significantly more efficient than APC alone, and was safe and well tolerated. APC combined with HDR resulted in fewer complications and better QoL than APC with PDT or APC alone (CONSORT 1b).