Percutaneous Endovascular Treatment Research Articles

Percutaneous endovascular treatment for isolated spontaneous superior mesenteric artery dissection: Report of two cases and literature review

Isolated spontaneous superior mesenteric artery (SMA) dissection is a rare and sporadically reported condition. Therapeutic options include medical treatment, surgery, and endovascular treatment. However, the optimal treatment strategy has still not been established. We herein present two patients with acute abdomen due to isolated spontaneous SMA dissection, in whom symptoms remained despite initial anticoagulation therapy. Percutaneous endovascular treatment with stenting of the dissected main trunk to achieve complete coverage of the entry site and balloon angioplasty for the distally involved side branches were performed successfully and resulted in complete resolution of the symptoms. According to our experience and previous case reports, early (within 1 week) elective percutaneous endovascular intervention with background anticoagulation therapy is a feasible and effective treatment strategy for symptomatic patients with isolated SMA dissection.

MDCT venography in the evaluation of inferior vena cava in Budd-Chiari syndrome

To assess the role of multidetector computed tomography (MDCT) venography in the evaluation of the inferior vena cava (IVC) in Budd-Chiari syndrome (BCS), its accuracy as compared to digital subtraction venography (DSV) and the potential of this technique to replace venography for the definitive diagnosis of BCS. Twenty-five suspected cases of BCS were prospectively enrolled in this study and underwent both MDCT venography and DSV. Two observers independently evaluated and graded both the axial and reformatted MDCT images for the presence, site, degree and length of IVC narrowing. The collateral pathways and the hepatic veins were also assessed in all cases. The degree of correlation between MDCT venography and DSV was expressed using Spearman's rank correlation coefficient (Rs). There was excellent correlation between MDCT venography and DSV in predicting the presence of stenosis and in grading the degree and length of IVC stenosis (Rs=0.58, p<0.05). Four patients had presence of a web within the IVC and the reconstructed MDCT venography images detected the flap of the membrane in all of them. In three cases of complete obstruction the cranial extent of the obstruction could be determined on the reconstructed MDCT venography images, while double catheter access through the femoral and jugular routes was needed to determine the same on DSV. MDCT venography was significantly more informative in depicting the presence and site of both intrahepatic and extrahepatic collaterals as compared to DSV. MDCT venography, in the present study, accurately provided information of both conventional CT and IVCgraphy, in the evaluation of the IVC in a non-invasive way. It helped overcome the shortcomings of CT in the evaluation of IVC and was better than DSV for the evaluation of collaterals, calcification and complete IVC obstruction. We suggest that CT venography can be used as a frontline investigation for the diagnosis of IVC obstruction and for planning surgery or percutaneous endovascular intervention.

Endovascular procedures for below the knee arteries in diabetics

Patients with below the knee (BTK) lesions may present either with intermittent claudication (IC) or with critical limb ischemia (CLI). Generally, these patients with a high incidence of diabetes have a high rate of myocardial infarction and mortality. So, even if, the surgery is potentially a very good technique with excellent results when the best conduit as a vein graft is used, the ratio benefice/risk seems too low for the IC patients. On another hand for the CLI patients a lot of reasons contraindicate or are unfair to the surgical option: lack of conduit, bad or unclear run-off or distal outflow site, bad local cutaneous conditions. Endovascular option by specialists with experience of coronary devices should be the treatment of choice. We review the different techniques and their recent upgrades in order to improve the percutaneous endovascular treatment of BTK lesions.

Midterm and Long-term Results of Percutaneous Endovascular Treatment of Venous Outflow Obstruction after Pediatric Liver Transplantation

To evaluate retrospectively the midterm and long-term results of percutaneous endovascular treatment of venous outflow obstruction after pediatric liver transplantation. During a 9-year period, 18 children with obstruction of a hepatic vein (HV) or inferior vena cava (IVC) anastomosis underwent percutaneous transluminal angioplasty (PTA) with balloon dilation or stent placement in case of PTA failure after liver transplantation. Patients' body weights ranged from 7.7 kg to 42.6 kg (mean, 18.8 kg +/- 9). Potential predictors of patency were compared between balloon dilation and stent placement groups. Forty-two procedures were performed (range, 1-11 per patient; mean, 2). Technical and initial clinical success were achieved in all cases. Major complications included one case of pulmonary artery stent embolization and one case of hemothorax. Three children (25%) with HV obstruction were treated with PTA and nine (75%) were treated with stent placement. Three children with IVC obstruction (75%) were treated with PTA and one (25%) was treated with a stent. There were two children with simultaneous obstruction at the HV and IVC; one was treated with PTA and the other with a stent. Cases of isolated HV stenosis have a higher probability of patency with balloon-expandable stent treatment compared with balloon dilation (P < .05). Follow-up time ranged from 7 days to 9 years (mean, 42 months +/- 31), and the primary assisted patency rate was 100% when stent placement was performed among the first three procedures. In cases of venous outflow obstruction resulting from HV and/or IVC lesions after pediatric liver transplantation, percutaneous endovascular treatment with balloon dilation or stent placement is a safe and effective alternative treatment that results in long-term patency.

Ultrasound guided treatment of pseudoaneurysm caused by puncture of the common femoral artery

Catheter-induced iatrogenic pseudoaneurysm is a complication on the rise as compared to the past. This is due to the increasingly frequent use of percutaneous endovascular intervention in the diagnosis and treatment of several diseases. We present a case which underlines the diagnostic and therapeutic role of color Doppler ultrasound (US) in this pathology.

Use of StarClose for Brachial Artery Closure after Percutaneous Endovascular Interventions

The objective of this study was to evaluate a percutaneous extravascular closure device (StarClose, Abbott Vascular, Redwood City, CA) after brachial endovascular approach. From 2004 to 2006, 29 patients received StarClose for brachial closure. Primary endpoints were successful deployment and absence of procedure-related morbidity, secondary endpoints were brachial artery patency on duplex and absence of late (> 30 days) complications. The device was successfully deployed in all patients. In two patients (6.8%) local complications occurred: one patient developed a large hematoma successfully treated with prolonged compression and a second patient presented with brachial artery occlusion requiring operative intervention. After a mean follow-up of 7.5+/-7.2 months, all patients had a palpable brachial/radial pulse; none had signs of infection, distal embolization or neurological deficits. On ultrasound b-mode imaging, the clip was visible as a 4 mm echolucent area at the outer anterior wall of the artery. Based on the peak systolic velocity ratios between the site of StarClose and proximal brachial artery (mean 1.08+/-0.2), none of the studied patients had a significant stenosis at the site of closure. StarClose is safe and effective in providing hemostasis following interventional procedures through the brachial artery; further advantages include patients comfort and early discharge.

Shaft Aneurysm of Femoropopliteal Expanded Polytetrafluoroethylene Graft Treated With a Covered Stent

Aneurysm formation is a known complication of native vein or synthetic grafts following peripheral bypass surgery. However, with improvement in the material used for prosthetic grafts, these complications are now uncommon. Open surgery has always been the treatment of choice for aneurysms, but the emergence of percutaneous endovascular intervention has led to a safer and easier way to treat aneurysms. In this article, a unique case of aneurysm in a reinforced expanded polytetrafluoroethylene graft placed 11 years ago during a femoropopliteal bypass surgery in a 77-year-old woman with peripheral arterial disease is presented. The aneurysm was treated percutaneously with a self-expanding covered stent resulting in complete isolation of the aneurysm with no complications encountered.

Treatment of an Acute Type B Dissection with an Intramural Haematoma in the Ascending Aorta by Percutaneous Endovascular Stent-Graft Placement

Acute type B dissections accompanied by an intramural haematoma in the ascending aorta are rare. However, progression of the intramural haematoma in the ascending aorta poses risks for the patients, which are similar to those of type A dissections, including pericardial effusions and consecutive tamponade. To date, no clear treatment guidelines exist for these patients. We report on successful percutaneous endovascular stent-graft treatment of an acute type B dissection accompanied by an intramural haematoma in the ascending aorta as primary and sole form of treatment.

Cerebral Aneurysms

Saccular intracranial aneurysms cause substantial morbidity and mortality. Recently, major changes have occurred in the way we think about and treat this disease. This review discusses the percutaneous endovascular treatment of intracranial aneurysms as compared with surgical intervention. The technological advances and supporting research contributing to this important change in practice patterns are reviewed.

Les complications vasculaires de la chirurgie discale lombaire

Vascular complications of lumbar disc surgery are rare (about 0,04% of discectomies) but very severe. Great variations of the anatomical lesions and of their clinical aspects may be observed. These lesions are often unrecognised during the operation and they are sometimes identified several years after the injury. The treatment is mainly surgical but percutaneous endovascular treatment has been recently performed successfully in several patients.

Current guidelines produce competent endovascular surgeons

This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Percutaneous endovascular treatment of acute sequential systemic emboli

A 65-year-old woman was evaluated for acute right lower-extremity ischemia secondary to embolization from atrial fibrillation and subtherapeutic anticoagulation. Her symptoms quickly evolved in a dynamic fashion to involve multiple vascular beds, including a transient ischemic attack, abdominal pain secondary to mesenteric ischemia, and contralateral lower-extremity ischemia. Synchronous emboli were treated by using mechanical and pharmacologic thrombolysis via an endovascular approach under local anesthesia. This intervention allows prompt evaluation of multiple vascular beds with good short-term outcomes and minimal morbidity.

Contemporary Endovascular Treatment for Disease of the Superficial Femoral and Popliteal Arteries: An Integrated Device-Based Strategy

Endovascular therapy for disease of the superficial femoral artery (SFA) and the popliteal artery remains controversial. Percutaneous treatment of this arterial segment presents a particular technical challenge, as the extent of disease varies from short, focal, and stenotic to long, diffuse, and occluded lesions. Over the last 2 decades, multiple therapies have been evaluated, including simple balloon angioplasty, directional atherectomy, stenting (both balloon-expandable and self-expanding), and more recently, intra-arterial radiation, laser, and cryotherapy. Regardless of which modality is used, however, endovascular therapy as a revascularization strategy has the potential to improve symptoms and quality of life and, in selected patients, to avoid limb amputation. While percutaneous endovascular treatment has been historically associated with high procedural success and favorable short and intermediate-term patency rates, long-term clinical results have proven disappointing. Conventional balloon angioplasty is limited by elastic recoil, dissection, and restenosis. Balloon-expandable stents (particularly in the distal SFA) are associated with late stent deformation and mechanical compression, with resultant late clinical failure. Newer self-expanding stents have shown improved initial results but have been limited by late mechanical fatigue and associated restenosis. With the development of several newer endovascular techniques in recent years, the possibilities for treating this condition have increased dramatically. Currently, no long-term comparative data exist regarding the role of these alternative technologies. This article summarizes and compares important data about new endovascular options for intervention therapy in SFA and popliteal disease. In addition, based on this analysis, we propose a contemporary treatment strategy, integrating older and newer technologies into a real-world algorithm.

Contemporary Endovascular Treatment for Disease of the Superficial Femoral and Popliteal Arteries:An Integrated Device-Based Strategy

Endovascular therapy for disease of the superficial femoral artery (SFA) and the popliteal artery remains controversial. Percutaneous treatment of this arterial segment presents a particular technical challenge, as the extent of disease varies from short, focal, and stenotic to long, diffuse, and occluded lesions. Over the last 2 decades, multiple therapies have been evaluated, including simple balloon angioplasty, directional atherectomy, stenting (both balloon-expandable and self-expanding), and more recently, intra-arterial radiation, laser, and cryotherapy. Regardless of which modality is used, however, endovascular therapy as a revascularization strategy has the potential to improve symptoms and quality of life and, in selected patients, to avoid limb amputation. While percutaneous endovascular treatment has been historically associated with high procedural success and favorable short and intermediate-term patency rates, long-term clinical results have proven disappointing. Conventional balloon angioplasty is limited by elastic recoil, dissection, and restenosis. Balloon-expandable stents (particularly in the distal SFA) are associated with late stent deformation and mechanical compression, with resultant late clinical failure. Newer self-expanding stents have shown improved initial results but have been limited by late mechanical fatigue and associated restenosis. With the development of several newer endovascular techniques in recent years, the possibilities for treating this condition have increased dramatically. Currently, no long-term comparative data exist regarding the role of these alternative technologies. This article summarizes and compares important data about new endovascular options for intervention therapy in SFA and popliteal disease. In addition, based on this analysis, we propose a contemporary treatment strategy, integrating older and newer technologies into a real-world algorithm.

Lower extremity arterial occlusive disease: Role of percutaneous revascularization

Percutaneous endovascular interventions for peripheral arterial disease are indicated in carefully selected patients with favorable anatomy and associated clinical symptoms. Although endovascular therapy appears to be hemodynamically equivalent to other modalities in isolated iliac disease, this does not appear to be the case for infrainguinal disease, particularly when the disease is diffuse and extensive. Such disease in these beds can often be treated surgically, although there is an increasing role for percutaneous therapies, particularly in patients at higher surgical risk. Catheter-based therapy should be considered an integral part of comprehensive medical therapy in patients with lower extremity peripheral arterial disease. Embarking on an endovascular approach to therapy should involve a frank physician-patient discussion of the risks, benefits, and durability of the proposed procedure tailored to anatomic locale and patient-specific factors.

Combined Open and Endovascular Stent Grafting of Internal Carotid Artery Fibromuscular Dysplasia: Long Term Results

BackgroundSymptomatic fibromuscular dysplasia (FMD) of the internal carotid artery (ICA) can present as thrombo-embolic ischemic events, spontaneous or post-traumatic dissection, aneurysmal degeneration or intracranial haemorrhage and needs definitive surgical treatment. Patients and methodsSix patients and nine ICA with FMD were revascularised using a carotid approach with minimal exposure of the common, external and internal carotid arteries for covered stent repair. All patients were female, the age ranged from 30 to 65 years (mean 44). ResultsOne patient suffered from a perioperative transient neurological deficit. Duplex revealed a patent stent. The patient fully recovered after 5h, not showing any changes on repeat CT scans. One patient developed a recurrent laryngeal nerve palsy. The symptoms gradually resolved within 1 month. No perioperative strokes or deaths occurred. During a mean follow up of 48 months (range 13–63) no thromboembolic neurological events, graft occlusions or haemodynamically significant stenoses occurred. ConclusionICA FMD stent grafting is an alternative to open surgery or percutaneous endovascular intervention with excellent long-term results.

Interventional Management of Renal Transplant Arteriovenous Fistula

Percutaneous needle biopsy has become an indispensable tool for the evaluation and management of patients with renal allograft dysfunction. But this invasive procedure is not without risk. Vascular injury in the form of arteriovenous fistula, pseudoaneurysm, or arteriocalyceal fistula may result in symptoms that require percutaneous endovascular intervention. In this article, the occurrence, detection, and treatment of biopsy-related renal transplant injury are described.

Modulation of vascular remodeling induced by a brief intraluminal exposure to the recombinant R7020 strain of Herpes simplex-1

Vascular remodeling in response to injury or low shear stress (or both) is characterized by neointimal hyperplasia and luminal contraction. When profound, the response leads to restenosis after percutaneous endovascular intervention as well as to de novo stenosis in vein grafts. It has recently been reported that exposure of vein patches to neurovirulence-attenuated Herpes simplex virus-1 (HSV-1) decreases neointimal hyperplasia and increases luminal area. This experiment tested the hypothesis that R7020, a more highly attenuated mutant of HSV-1, would modulate the vascular remodeling response of experimental vein grafts chronically exposed to low shear stress. The external jugular veins of 31 New Zealand white rabbits were clamped and intraluminally exposed to vehicle (phospate-buffered saline solution, n = 11), R7020 2.5 x 10(8) plaque forming units [PFU]/mL (n = 8), or R7020 2.5 x 10(9) PFU/mL (n = 12) for 10 or 30 minutes at an average pressure of 80 mm Hg. After exposure, an end-to-side distal external jugular-to-common carotid artery anastomosis was created, resulting in a widely patent arteriovenous fistula. The external jugular was suture-ligated just proximal to the thoracic inlet, distal to a small 10- to 50-microm venous tributary, creating a reversed vein "graft" segment immediately and abruptly exposed to arterial pressure (48 +/- 3 mm Hg) and low shear stress (0.12 +/- .02 dyne/cm(2)). In the 29 animals (N = 31) that survived to harvest, 26 grafts were found to be patent and were analyzed further. Nine grafts were harvested within the first week after operation, snap frozen in liquid nitrogen, and assayed for the presence of the Herpes viral immediate-response protein ICP0 by Western blot analysis. The 17 remaining grafts were perfusion-fixed, excised, stained, and analyzed morphometrically by digital planimetry. In patent grafts, the hemodynamic environment of low shear stress was maintained (shear stress at harvest, 0.26 +/- .06 dyne/cm(2)). Western blot analysis revealed the presence of ICP0 in R7020-exposed vein grafts after 2, 3, 7, and 14 days; ICP0 was not detected in unexposed vein grafts or adjacent carotid arteries. After 4 weeks, vein grafts exposed to R7020 exhibited a statistically significantly increased ratio of luminal radius to wall thickness, indicating altered remodeling (vehicle, 6.7 +/- 1.3; R7020 2.5 x 10(8), 9.1 +/- 1.3; R7020 2.5 x 10(9) ratio, 11.3 +/- 1.4; P < .05 for high dose compared with vehicle). A brief exposure of the neurovirulence-attenuated HSV-1 strain R7020 results in an increased ratio of luminal radius to wall thickness in experimental vein grafts chronically exposed to low shear stress.

Percutaneous Therapy for Renal Artery Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) accounts for 10% of cases of renal artery stenosis. This study evaluates the anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD at an academic medical center. A retrospective analysis of records from patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) found 14 patients (all female) who underwent 19 interventions on 18 renal artery segments. Significant cardiovascular comorbidities were few in this patient population. The PTRA technical success rate was 95%. There were no periprocedural mortalities. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years. The restenosis rate was 25% at 8 years. Clinical benefit (improved or cured hypertension) was seen in 79% of patients overall; 65% of patients maintained this benefit at 8 years by life-table analysis. Percutaneous endovascular intervention for clinically symptomatic FMD of the renal arteries is technically successful, safe, and durable. Most patients demonstrate immediate clinical benefit and retain durable functional outcomes.

Pericardial Tamponade Complicating Central Venous Interventions

Cardiac tamponade is defined as an accumulation of fluid within the pericardial sac that is large enough to impair the diastolic filling of the ventricles. There are numerous causes, including cardiac disease, malignancy, and trauma (penetrating, blunt, and iatrogenic). With increasing complexity of percutaneous endovascular interventions, interventional radiologists must learn to recognize the preexisting and iatrogenic presence of cardiac tamponade during procedures and be familiar with its treatment. Two cases of pericardial tamponade complicating central venous interventions are described. In addition, the clinical condition is discussed and its diagnosis and treatment are reviewed.