Percutaneous Femoral Approach Research Articles

A single center study of the efficacy and safety of Pro-Glide used for closure in thoracic endovascular aortic repair in patients with previous groin intervention.

This study aimed to evaluate the efficacy and safety of Pro-Glide, a suture-mediated vascular closure device, regarding technical success and complications in patients who had undergone aortic intervention and had previous groin intervention (PGI). One hundred and thirty-five patients who underwent percutaneous thoracic endovascular aortic repair via the femoral artery and were closed with the Pro-Glide device were analyzed retrospectively. PGI was defined as a history of open surgical access to the femoral artery or wide sheath (>18 F) placement due to endovascular or valvular intervention. The patients were divided into two groups 38 cases with PGI and 97 cases without PGI. The overall success rate of closure of the femoral artery with Pro-Glide was not statistically significant between the two groups (93.8% vs 92.1%, p = .711). Sheath sizes were compared between the groups and PGI (+) group had significantly higher sheath sizes compared to PGI (-) group (24.3 ± 1.1 F vs 23.8 ± 1.0 F, p = .011). Three patients in the PGI (+) group and six patients in the PGI (-) group experienced technical failure of the percutaneous femoral approach. Femoral complications were seen after the procedures in four patients in the PGI (+) group and four in the PGI (-) group. The PGI (+) group had a higher complication rate when compared to the PGI (-) group; however, this was not statistically significant (p = .181). The present study was conducted on a significantly larger sample compared to previous studies and the findings suggest that the Pro-Glide vascular closure device is a safe option for patients with a history of PGI and may not be considered as a contraindication.

Initial Experience With Leadless Cardiac Pacemakers at Auckland City Hospital

Leadless cardiac pacemaker (LCP) therapy is a relatively new technology introduced to address lead-related and pocket-related complications seen with traditional transvenous and epicardial pacemakers. These differ from traditional pacemakers as they are much smaller and directly implanted into the right ventricle via percutaneous femoral approach. Ten patients underwent LCP implantation with a Medtronic Micra device over a 2-year period from 29 October 2020; four of these were Micra VR and six Micra AV. These patients were followed in clinic with device checks at a maximum of 6-monthly intervals. All 10 patients had a successful device implant procedure. Post-procedure follow-up data were available for all patients and ranged 5–24 months. Mean age was 63.7 years (range 52–81) and 70% were male. Procedure duration was 47.8±13.9 minutes, fluoroscopy time was 6.2±3.5 minutes, and contrast volume was 45±29.7 mL. There were no procedural or in-hospital procedure-related complications. Two deaths were recorded post implant, which were both unrelated to the LCP implant. The electronic pacing performance showed all capture thresholds remained at <1V @ 0.24 ms. Initial experience with a leadless cardiac pacemaker shows successful implantation, with no adverse events and satisfactory procedural data. Pacing performance post implant is stable with acceptable parameters and device function.

Kissing Balloon “Valvuloplasty” of Obstructed Mechanical Aortic Valve: When You Are Running Out of Options

We report an unusual case where “stuck” bileaflet aortic prosthetic valve occluders were partly released by performing emergency balloon dilatation with 2 noncompliant balloons by a percutaneous femoral approach. (Level of Difficulty: Advanced.)

Simplified TAVR Procedure: How Far Is It Possible to Go?

Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.

Covered Endovascular Reconstruction of the Popliteal Artery Bifurcation in a Patient with a Popliteal Aneurysm

Popliteal artery aneurysms (PAAs) can present as extensive disease entities that predispose to distal ischaemic complications. Endovascular repair has become a common intervention but is typically limited to a single tube exclusion of the PAA that necessitates a distal landing zone. Presented is a technique of covered endovascular reconstruction of the popliteal artery bifurcation (CERPAB) using Viabahn Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA) covered stent grafts delivered via a percutaneous femoral approach in a patient with extensive PAA with anterior tibial artery (ATA) and tibioperoneal trunk (TPT) involvement. A 79 year old patient presented with a PAA (20 mm diameter) with irregular luminal narrowing extending into the proximal ATA (5 mm diameter) and TPT (6 mm diameter), which was regarded as aneurysmal (normal diameter 3 mm). The patient was asymptomatic but showed growth under surveillance. Under general anaesthesia and through a percutaneous antegrade left femoral approach a 9 × 150 mm standard profile Viabahn stent graft was placed in the popliteal artery as a main body through a 10 F sheath using a 0.035 inch wire. The ATA and TPT were cannulated separately with subsequent placement, simultaneous deployment and kissing balloon dilatation of 6 × 50 mm and 7 × 50 mm low profile stent grafts in the respective arteries using a 0.018 inch platform through a single sheath, overlapping the popliteal stent graft by 3 cm. Procedural angiography (Fig. 1) showed successful exclusion of the PAA with adequate run off distally. Post-operatively, dual antiplatelet therapy with clopidogrel and aspirin was started and the patient was discharged home the next day. Follow up computed tomography at three months showed adequate patency (Fig. 2) with no complications during this period.Figure 2(A) Computed tomography angiography at the three month follow up showing a patent covered reconstruction of the popliteal artery bifurcation by Viabahn stent grafts with 3 cm of overlap. (B) Volume rendered computed tomography scan reconstruction of the covered endovascular reconstruction at the three month follow up.View Large Image Figure ViewerDownload Hi-res image Download (PPT) CERPAB seems to be a possible modality for treatment of patients with PAAs and involvement of the ATA and TPT by reconstructing the popliteal bifurcation and successfully excluding the aneurysmal tract from the peripheral circulation. This procedure is reminiscent of covered endovascular repair of the aortic or femoral bifurcation and allowed exclusion of the PAA without a distal landing zone. To the best of the authors’ knowledge, this is the first time such a procedure has been reported.

Transcarotid Transcatheter Aortic Valve Replacement

The number of transcatheter aortic valve replacement (TAVR) procedures have increased dramatically over the last decade; so too have the number of TAVR centers. While a percutaneous femoral artery approach is the access of choice, many patients have peripheral artery disease that prohibits access despite newer smaller diameter TAVR delivery systems. It is imperative for TAVR programs to have a preferred alternative access technique. The transcarotid approach is advantageous because the surgical skills and endovascular techniques required should be familiar to most surgeons, and when not, are, in our experience, readily obtainable. Here we provide a detailed description of the technical aspects of our approach to transcarotid TAVR.

Clinical efficacy and safety of the PRO-glide device as a sUture-mediated ClosurE in Thoracic EndoVascular Aortic Repair in patients with previous groin intervention (from the PRODUCE-TEVAR Trial).

While the percutaneous approach is increasingly preferred, suture-mediated closure devices have been put into clinical practice to close the femoral artery during procedures requiring a large-sized introducer. However, scar in the groin is considered a contraindication or an exclusion criterion for percutaneous procedures. The aim of our study was to investigate the outcomes and safety of Pro-Glide device as suture-mediated closure device in patients who underwent thoracic endovascular aortic repair with percutaneous femoral access ≥22 F who had previous groin intervention. A total of 73 patients who underwent endovascular repair with percutaneous femoral access were retrospectively included in the study. Previous groin intervention was defined as history of open surgical access or large sheath insertion (>18 F) to femoral artery because of endovascular or valvular intervention. Patients were divided into two groups as who had previous groin intervention PGI (+) and had not PGI (-). A total of 73 patients [60 male (82.2%)] were included in the study. Seventeen patients had PGI, and 56 did not. When groups were compared in terms of sheath sizes, a significantly higher sheath sizes were used in PGI (+) patients (24.5 ± 1.1 F vs. 23.8 ± 0.9 F, p = 0.005). The overall success rate in the femoral approach with pre-close technique was statistically insignificant between two groups (94.1% vs. 96.4%, p = 0.55). One patient in PGI (+) group and two patients in PGI (-) had technical failure for percutaneous femoral approach. One patient (5.9%) in PGI (+) group and one patient (1.8%) in PGI (-) group had femoral complications after the procedures; however, there was no significant difference between the groups in terms of complications (5.9% vs. 1.8%, p = 0.13). Pro-Glide device may be a safe and less invasive method for femoral access in patients with PGI and might not be considered as a contraindication for patients with history of PGI.

Balloon valvuloplasty for critical pulmonary valve stenosis in a newborn

Abstract Critical pulmonary valvar stenosis causes cyanosis and can lead to potentially lethal in newborn infants. Following initiation of Prostaglandin infusion, percutaneous balloon pulmonary valvuloplasty (BPV) is considered to be the treatment of choice. The percutaneous femoral venous approach is the most preferred route for BPV in most cardiac centers. We present the case of a 5-day-old female infant with critical pulmonary valvar stenosis who successfully underwent BPV through the femoral venous access. The narrowed pulmonary valve was significantly improved after intervention. This was the first case at our center that was undertaken BPV at the earliest postnatal day.

Chimney with the Use of Nellix Device: An Alternative Solution for Type I Endoleak Treatment

Introduction - Endovascular aortic repair with chimney technique (Ch-EVAR) is commonly used in the treatment of type I endoleak when the patient is unsuitable for conversion to open surgery or custom made endograft implantation. Main issue with chimney technique is related to gutter endoleak; this risk may be reduced with the use of a Nellix device (Ch-EVAS), that could fill the gutter and reduce the incidence of type I endoleak. Methods - Sixteen consecutive patients (mean age 80.7 ± 7.0 years; 94% men) with prior EVAR were treated with ChEVAS between August 2015 and March 2018 in a single center. Indication for treatment was proximal type I endoleak in all patients, with associated neck dilation in 5 patients and migration in 5. The median diameter of residual aneurismal sac was 79.1 ± 2.4 mm The median time between original procedure and ChEVAS was 92.7±5.3 (range 1-148) months. Prior EVARs included different endografts (5 Zenith, 3 Endurant, 4 Talent, 1 Anaconda, 1 Fortron and 2 Nellix). In 12 patients (75%) preoperative CT scan showed the presence of suprarenal stent at the level of the visceral vessels. Two patients needed one chimney, ten patients needed double chimney and four patients needed three chimneys for a total of 34 target vessel overstented. In 30 visceral vessels a balloon expandable stent (Advanta atrium or Bentley BeGraft) was implanted, in the remaining 4 vessels a self-expandable stent (Viabahn Gore) was delivered. The Nellix endograft was implanted by bilateral percutaneous femoral approach in 11 patients Results - Technical success was achieved in 100% of the patients by completion angiography at the end of the procedure. No perioperative mortality was observed, one patient experienced non disabling posterior stroke at the end of the procedure. CT scan performed 1 month after the procedure showed sealing of 15/16 (94%) of type I endoleak , the remaining patient with residual proximal endoleak underwent a successful Onyx embolization one month later. At median follow-up of 13 months no recurrent endoleaks were recorded. All target vessel stented were patent with no need of reintervention. Conclusion - ChEVAS may serve as alternative treatment option in patients with type I endoleak where the implantation of fEVAR/brEVAR is hampered by the presence of previous endograt in site. Further follow-up and a multicenter study are needed to corroborate these preliminary results

Simplification des procédures TAVI : mise au point

After a first procedure carried out in 2002 by Pr Cribier's, Transcatheter Aortic Valve Replacement or TAVR revolutionized the management of aortic stenosis with a constant increase in the number of procedures performed worldwide. Experience of operators and teams and evolution of the technique has been accompanied by a drastic reduction in complications in patients at lower surgical risk. In parallel, the procedure was considerably simplified, carried out more and more under local anesthesia, with percutaneous femoral approach, secondary radial approach, prosthesis implantation without predilatation, rapid pacing on left ventricle wire and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety.

Risk factor analysis and angiographic findings in young myocardial infarction patients in tertiary care centre of rural population in South India

Background: Coronary Artery Disease (CAD) is the leading cause of death and accounts for around 12million deaths annually worldwide. The pattern of coronary artery involvement and clinical outcome varies with age suggesting different underlying pathophysiology. Better understanding this specific problem will lead to further improvement in management. The aim was to study the risk factors and angiographic findings in young patients with acute myocardial infarction.Methods: Thirty-nine patients were included in this study. Patients included in the study underwent elective angiographic performed by the percutaneous femoral approach using standard angiographic techniques. Echo and lipid profile were done to all patients. Data were analysed using MS-Excel.Results: In this study, 39 patients were included, 37 male and 2 female patients, the average age of the patients was 35.12 years. 59% of patients had hypertriglyceridemia, 23.1% of patients hypercholesteremia. 45.9% of male patients were having a history of smoking and alcoholism. 84.6% of patients had obstructive CAD, single vessel disease was observed in 59%, double vessel disease in 7.7%, triple vessel in 2.6% patients.Conclusions: Acute myocardial infarction in young predominantly affects males. Dyslipidemia, smoking and alcoholism were found to be common associated factors in young MI. This emphasizes the need for lifestyle modification for primary prevention. Coronary angiography revealed normal coronaries in 12% suggesting different underlying process other than atherosclerosis. With timely intervention and appropriate management, prognosis is good in young MI patients.

BP.10.06] BLOOD PRESSURE RESPONSE TO CATHETER-BASED RENAL SYMPATHETIC DENERVATION IN PATIENTS WITH RESISTANT HYPERTENSION

Objective: The efficacy of catheter-based renal sympathetic denervation (RDN) in terms of blood pressure (BP) reduction has been questioned, while “real-world” data from registries are needed. In the present study we report the complete set of 12 month data on office and ambulatory BP changes as well as the predictors for BP response to RDN from a national registry. Design and method: In 4 Greek hospital centers 79 patients with severe drug resistant hypertension (age: 59 ± 10 years, 53 males, body mass index: 33 ± 5 kg/m2, office BP and 24-hour ambulatory BP were 176 ± 15/95 ± 13 mmHg and 155 ± 14/90 ± 12 mmHg respectively, 4.4 ± 0.9 antihypertensive drugs) underwent RDN and were followed-up for 12 months in the Greek Renal Denervation Registry. Bilateral RDN was performed using percutaneous femoral approach and standardized techniques. Results: Reduction in office systolic/diastolic BP at 6 and 12 months from baseline was -30/-12 mmHg and -29/-12 mmHg, while the reduction in 24-hour ambulatory BP was −16/−9 mmHg and −15/−9 mmHg respectively (p < 0.05 for all). Patients that were RDN responders (85%, n = 58), defined as an at least 10 mmHg decrease in office systolic BP at 12 months, compared to non-responders were younger (57 ± 9 vs 65 ± 8 years, p < 0.05), had higher baseline office systolic BP (176 ± 17 vs 160 ± 11 mmHg, p < 0.05) and 24 h systolic BP (159 ± 13 vs 149 ± 11 mmHg, p < 0.05). Stepwise logistic regression analysis revealed that age, obesity parameters and baseline office BP were independent predictors of RDN response (p < 0.05 for both), but not the type of RDN catheter or the use of aldosterone antagonists. At 12 months there were no significant changes in renal function and no new serious device or procedure related adverse events. Conclusions: In our “real-world” multicenter national registry, the efficacy of renal denervation in reducing BP as well as safety is confirmed during a 12 months follow-up. Moreover, younger age, obesity and higher levels of baseline systolic BP are independently related to better BP response to RDN.

Application of perimembranous ventricular septal defects closure solely by femoral vein approach under transesophageal echocardiography guidance

To investigate the feasibility and safety of perimembranous ventricular septal defects (PmVSD) closure solely by femoral vein approach under transesophageal echocardiography (TEE) guidance. Methods: From January 1, 2014 to May 31, 2016, 26 patients with PmVSD in Second Xiangya Hospital were selected, with age at 3.2-6.0 (4.3±0.7) years old and body weight at 15.0-19.5 (16.7±1.4) kg. The diameter of VSD was 3.5-4.8 (4.1±0.3) mm. All patients were treated by percutaneous PmVSD closure solely by femoral vein approach under TEE guidance. The effect of the procedure was evaluated by TEE and transthoracic echocardiography (TTE). The clinical follow-up study was conducted by TTE at 1, 3, 6 and 12 month (s) after the procedure. Results: Twenty cases were successfully treated with percutaneous PmVSD closure solely by femoral vein approach under TEE guidance, and the success rate was 76.9%. Six patients were converted to perventricular closure under TEE guidance because the guide wire in two cases or catheter in other cases could not pass through PmVSD. The diameter of symmetrical VSD occluder was 6.0-7.0 (6.2±0.4) mm. The procedural time was 12.0-64.0 (26.8±6.3) min. The residence time at ICU was 1.8-2.4 (26.8±6.3) h. The in-hospital time was 4.0-5.0 (4.4±0.5) d. There were 3 patients with immediate post-operative trivial residual shunt and incomplete right bundle branch block (IRBBB). All patients survived with no peripheral vascular injury or complications such as tricuspid regurgitation, pericardial tamponade and pulmonary infection. The residual shunt disappeared in 3 patients and IRBBB became normal rhythm in 3 patients at 1 month follow-up time point. No patients suffered from occluder malposition, residual shunt, pericardial effusion, arrhythmia (atrio-ventricular block), aortic valve regurgitation and tricuspid regurgitation. Conclusion: TEE-guided percutaneous PmVSD closureby femoral vein approach is safe and effective.

Bifurcated-bifurcated aneurysm repair is a novel technique to repair infrarenal aortic aneurysms in the setting of iliac aneurysms

BackgroundUp to 40% of abdominal aortic aneurysms (AAAs) have coexistent iliac artery aneurysms (IAAs). In the past, successful endovascular repair required internal iliac artery (IIA) embolization, which can lead to pelvic or buttock ischemia. This study describes a technique that uses a readily available solution with a minimally altered off-the-shelf bifurcated graft in the IAA to maintain IIA perfusion. MethodsFrom August 2009 to May 2015, 14 patients with AAAs and coexisting IAAs underwent repair with a bifurcated-bifurcated approach. A 22-mm or 24-mm bifurcated main body device was used in the IAA with extension of the “contralateral” limb into the IIA. Intraoperative details including operative time, fluoroscopy time, and contrast agent use were recorded. Outcome measures assessed were operative technical success and a composite outcome measure of IIA patency, freedom from reintervention, and clinically significant endoleak at 1 year. ResultsFourteen patients underwent bifurcated-bifurcated repair during the study period. Technical success was achieved in 93% of patients, with successful treatment of the AAA and IAA and preservation of flow to at least one IIA. The procedure was performed with a completely percutaneous bilateral femoral approach in 92% of patients. Three patients had a type II endoleak on initial follow-up imaging, but none were clinically significant. There were no cases of bowel ischemia or erectile dysfunction. One patient had buttock claudication ipsilateral to IIA coil embolization (contralateral to bifurcated iliac repair and preserved IIA) that resolved by 6-month follow-up. Two patients required reinterventions. One patient presented to his first follow-up visit on postoperative day 25 with thrombosis of the right external iliac limb ipsilateral to the bifurcated iliac repair, which was successfully treated with thrombectomy and stenting of the limb. This same patient presented at 83 months with growth of the preserved IIA to 3.9 cm and underwent coil embolization of the aneurysm. Another patient presented for surveillance 44 months after his original repair with component separation of the mating stent and the iliac bifurcated stent grafts. This was treated with a limb extension and endoanchors to fuse the endografts. Of the 13 patients who underwent bifurcated-bifurcated repair, 100% of the preserved IIAs remained patent at last follow-up. The composite outcome measure of IIA patency and freedom from reintervention and clinically significant endoleak at 1 year was 92% (n = 12/13). ConclusionsIn this small retrospective review, bifurcated-bifurcated aneurysm repair of aortoiliac aneurysms with preservation of perfusion to the IIA is technically feasible and safe with good short-term and midterm results in male patients.

Abstract 016: Endovascular Management of Major Vascular Access Site Complications During Transcatheter Aortic Valve Implantation (TAVI).

Background: Major vascular access site complications remain a challenge in the field of TAVI and are associated with higher 30 day mortality. However, outcomes following endovascular management with covered stents for such complications are not well established. Methods: We reviewed the one year data of patients who underwent TAVI at our institution with a Sapien valve by percutaneous femoral approach. Identified were patients who suffered major vascular complications according to the definitions set forth by the Valve Academic Research Consortium. We then compared the outcome of patients managed by an endovascular approach with a population whose femoral access site complications were managed surgically/endovascularly (85.7% surgically), as reported from the Partner trial. Results: A total of 16 patients experienced Major Vascular complications. TAVI was aborted on 2 patients due to access site complication. Excluded were 3 patients who had benign small ascending aortic dissections after successful valve deployment and 3 patients who were managed surgically. Ten remaining patients were managed by a pure endovascular approach with covered stents. Four of these patients suffered ilio-femoral dissection, 4 had perforation and 2 had both perforation and dissection. No significant difference was observed in pre and post procedure creatinine (1.01 vs 1.14, p=0.16) and none required dialysis within 30 days, as compared with 8.1% in Partner trial. We observed no statistically significant difference between the Partner trial cohort and our patients in 30 day all cause mortality (14.1% vs 10%, p=1), stroke rate (4.8% vs 0%, p=1), access site hematoma (22.9% vs 0%, p=0.1), retroperitoneal bleed (9.5% vs 0%, p=0.6), pseudoaneurysm (3.4% vs 0%, p=1), and gastrointestinal ischemia (1.6% vs 0%). No access site infection, stent thrombosis, or stenosis leading to limb ischemia were noted clinically at 30 day follow-up. Conclusion: Many patients with major vascular complications during TAVI can be treated with a pure endovascular approach. In our small series we observed no difference in concurrent complications when an endovascular repair can be rapidly initiated as compared to a primary surgical approach.

Blood pressure response to catheter-based renal sympathetic denervation in severe resistant hypertension: data from the Greek Renal Denervation Registry.

The efficacy of catheter-based renal sympathetic denervation (RDN) in terms of blood pressure (BP) reduction has been questioned, while "real-world" data from registries are needed. In this study, we report the complete set of 12-month data on office and ambulatory BP changes as well as the predictors for BP response to RDN from a national registry. In 4 Greek hospital centers, 79 patients with severe drug-resistant hypertension (age 59±10years, 53 males, body mass index 33±5kg/m2; office BP and 24-h ambulatory BP were 176±15/95±13 and 155±14/90±12mmHg, respectively, 4.4±0.9 antihypertensive drugs) underwent RDN and were followed-up for 12months in the Greek Renal Denervation Registry. Bilateral RDN was performed using percutaneous femoral approach and standardized techniques. Reduction in office systolic/diastolic BP at 6 and 12months from baseline was -30/-12 and -29/-12mmHg, while the reduction in 24-h ambulatory BP was -16/-9 and -15/-9mmHg, respectively (p<0.05 for all). Patients that were RDN responders (85%, n=58), defined as an at least 10-mmHg decrease in office systolic BP at 12months, compared to non-responders were younger (57±9 vs 65±8years, p<0.05), had higher baseline office systolic BP (176±17 vs 160±11mmHg, p<0.05) and 24-h systolic BP (159±13 vs 149±11mmHg, p<0.05). Stepwise logistic regression analysis revealed that age, obesity parameters, and baseline office BP were independent predictors of RDN response (p<0.05 for both), but not the type of RDN catheter or the use of aldosterone antagonists. At 12months, there were no significant changes in renal function and any new serious device or procedure-related adverse events. In our "real-world" multicenter national registry, the efficacy of renal denervation in reducing BP as well as safety is confirmed during a 12-month follow-up. Moreover, younger age, obesity, and higher levels of baseline systolic BP are independently related to better BP response to RDN.

Pyomyoma Following Uterine Artery Embolization (UAE) – Dual Case Report and Review of Literature

Background: Leiomyoma commonly referred to, as fibroids are benign smooth muscle tumors of the uterus. Leiomyomas are the most common solid pelvic tumors in women. The most commonly reported symptoms of leiomyoma are abnormal uterine bleeding and increased pelvic pressure. Uterine Artery Embolization (UAE) is a technique performed by interventional radiologists that involves the occlusion of the uterine arteries via a percutaneous femoral artery approach. This is one of many procedures that may be chosen to treat leiomyoma in symptomatic women and results in the devascularization and involution of the tumor. Pyomyoma is a rare condition that occurs when a leiomyoma has become infected and suppurated after infarction. The formation of a pyomyoma can lead to sepsis and death unless treated with aggressive surgical intervention and antibiotics. Case(s): This manuscript represents two cases of pyomyoma following Uterine Artery Embolization (UAE). The diagnosis and management of such a rare complication is described. Conclusion: The rarity of pyomyomas often leads to a missed or delayed diagnosis and subsequently life threatening complications such as peritonitis, septicemia, and respiratory distress syndrome may result. Upon confirmation of the presence of pyomyoma surgical intervention in the form of myomectomy or hysterectomy is the primary method of treatment.

Endovascular Repair of a Symptomatic Chronic Type A Aortic Dissection Using an Arch Branched Device

Management of ascending aortic dissections (type A) in octogenarians presents a unique surgical challenge. We present the endovascular repair of a symptomatic chronic type A aortic dissection using an arch branched device in a patient at high risk for open surgical repair. The patient is an 85-year-old man with a symptomatic, chronic type A aortic dissection and history of uncontrolled hypertension, dyslipidemia, chronic atrial fibrillation, and pulmonary hypertension. The patient originally presented 3 years earlier with an acute type B aortic dissection-penetrating aortic ulcer (PAU) and an intramural hematoma (IMH) that were initially managed medically. Follow-up computed tomographic angiography (CTA) performed for refractory pain during the same hospitalization showed enlargement of the PAU, IMH, and new pleural effusion. The patient subsequently underwent thoracic endovascular aortic repair (TEVAR) with left subclavian artery preservation. He was discharged home without complication. Surveillance CTAs at 1, 6, and 12 months were unremarkable. Follow-up CTA at 2 years demonstrated new type A dissection with focal saccular aneurysm of the ascending aorta. Primary entry tear was at the ostium of the left common carotid artery proximal to the existing TEVAR. Conservative management was initiated for prohibitive risk of open repair. The patient subsequently presented with occasional chest pain. He was considered to be a suitable candidate for endovascular repair using an arch branched device (Thoracic Branched Endosystems [TBE], W. L. Gore, Flagstaff, Ariz). Compassionate use of this investigational device was approved outside of existing protocols by the U.S. Food and Drug Administration as well as the local Institutional Review Board. Before beginning the endovascular interventions, aortic arch debranching was accomplished. Right common carotid-to-left common carotid-to-left subclavian artery bypass was performed using a 8-mm retropharyngeal tunneled Dacron graft. The proximal left common carotid artery was ligated and end-to-side anastomosis created with the distal left common carotid artery and Dacron bypass graft. An end-to-side anastomosis was then created between the Dacron graft and left subclavian artery. Next, through a percutaneous right femoral approach (26F), the innominate artery was cannulated and a buddy wire inserted. The TBE device (53 mm × 15 cm) was advanced over a stiff wire and placed into the aortic arch. To assist innominate artery branch port alignment, the buddy wire was retrieved from the right neck incision. Once adequate alignment was confirmed, the zone 0 TBE was deployed. The innominate artery branch component (20 mm × 12 mm × 6 cm) was delivered and deployed in standard fashion. Completion angiography demonstrated no evidence of endoleak. He was subsequently discharged in good condition. Treatment of high-risk patients with type A aortic dissection presents a surgical challenge. Endovascular treatment with branched devices may provide a suitable alternative to open repair in this patient population.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Splenic Artery Embolization in Patients After Orthotopic Liver Transplant.

Hypersplenism (thrombocytopenia, leukopenia, anemia) syndrome and ascites occur after orthotopic liver transplant. These conditions can be treated by open splenectomy. Splenic artery embolization has been practiced as an alternative surgical method. Between January 2013 and January 2015, twenty-one orthotopic liver transplants were performed at the National Scientific Medical Research Center, Astana, Kazakhstan. Of these patients, 3 subsequently received splenic artery embolization 12, 8, and 6 months after transplant: 2 patients who had been diagnosed with primary biliary cirrhosis and 1 patient with hepatitis B virus -related liver cirrhosis. Two patients received a right-lobe living orthotopic liver transplant, and 1 patient received a deceased donor transplant. Indications for splenic artery embolization (ascites, splenomegaly) were based on clinical and ultrasonographic investigation and laboratory findings (thrombocytopenia, platelet count < 60 × 109/L, leukocytopenia, and white blood cell count < 2 × 109/L). Two recipients had leukothrombocytopenia and refractory ascites, and 1 had only thrombocytopenia. Splenic artery embolization was performed via a percutaneous femoral artery approach under local anesthesia. Transcatheter splenic artery branch occlusion was performed by deploying occlusion material. Preoperative spleen size ranged from 17.5 × 8.0 cm to 22.0 × 12.5 cm; ascites volumes were > 1000 mL. In all patients, ascites and platelet levels decreased after splenic artery embolization. In 1 patient with leukopenia, white blood cell count normalized. After embolization, 1 patient had severe abdominal pain requiring analgesia medication, and 2 patients had fever that lasted 3 days. Patients were discharged 6 to 9 days after embolization. One patient developed a perisplenic abscess without fever 1 month after discharge, and the abscess was drained using an ultrasound-guided percutaneous procedure. Splenic artery embolization is a safe and effective minimally invasive method for treating hypersplenism and ascites in orthotopic liver transplant recipients and an alternative to open splenectomy.

4A.03

Objective: The EnligHTN I, the first-in-human study using a multielectrode ablation system for renal denervation (RDN) in patients with drug resistant hypertension (dRHT) demonstrated efficacy and safety at 6 and 12 months. The aim of this study was to report the complete set of 24 month data on office, ambulatory and home blood pressure (BP) changes as well as long term safety. Design and method: We studied 46 patients (age: 60±10 years, 4.7 ± 1.0 antihypertensive drugs, body mass index: 32 ± 5 kg/m2) with dRHT on >or=3 antihypertensive medications who had a systolic BP>or=160 mmHg (>or=150 mmHg for diabetics). At baseline, the average office BP, 24-hour ambulatory BP and home BP were 176 ± 16/96 ± 14 mmHg, 150 ± 14/83 ± 13 mmHg and 158 ± 16/90 ± 12 mmHg respectively. Bilateral RDN was performed using percutaneous femoral approach and standardized techniques. Results: Reduction in office BP at 18 and 24 months from baseline were -24/-10 mmHg and -29/-13 mmHg, while the reduction in 24-hour ambulatory BP and in home BP at 24 months were -13/-7 mmHg and -11/-6 mmHg respectively (p < 0.05 for all). Apart from higher body mass index (33.3 ± 4.7 vs 29.5 ± 6.2 kg/m2, p < 0.05), there were no differences in age, baseline office BP, heart rate, diabetes mellitus and baseline antihypertensive drug therapy in patients that were RDN responders at 24 months [defined as 10 mmHg decline in office BP compared to baseline (74%, n = 34)]. Stepwise logistic regression analysis revealed no prognosticators of RDN response (p = NS for all). At 24 months apart from a trend for renal function decrease, there were no new serious or life-threatening adverse events related with the procedure. Conclusions: The EnligHTN I study provides evidence that the multielectrode ablation system constitutes a safe method of RDN in patients with dRHT and is accompanied by a sustained reduction of office, ambulatory and home BP at 24 months after the procedure. However, no predictors of RDN response were identified at long term follow-up.