Percutaneous Transluminal Balloon Angioplasty Research Articles

The efficacy of atherectomy combined with percutaneous transluminal angioplasty (PTA)/drug-coated balloon (DCB) compared with PTA/DCB for infrapopliteal arterial diseases: A systematic review and meta-analysis.

With the development of endovascular therapies, some studies have indicated a therapeutic potential for infrapopliteal arterial revascularization with atherectomy (AT). This study was designed to perform a meta-analysis to investigate the efficacy of AT combined with percutaneous transluminal angioplasty (PTA) or drug-coated balloon (DCB) compared with PTA or DCB for infrapopliteal arterial diseases. This is a systematic review and meta-analysis. The Pubmed, Web of Science, and Cochrane Library were systematically searched for articles published up to November 2022, reporting using atherectomy devices for infrapopliteal arterial patients. Randomized controlled trials and retrospective studies were included, and clinical characteristic outcomes were extracted and pooled. Then, we analyzed the efficacies of the AT (AT + PTA or DCB) group and the non-AT (DCB or PTA) group for infrapopliteal arterial patients. We identified 6 studies with 1269 patients included in this meta-analysis. The risk ratios (RRs) of primary patency for patients treated with atherectomy group compared to non-atherectomy group at 6months was 1.03 (95% confidence intervals (CIs) 0.86-1.23, p = .74), at 12months was 1.05 (95% CIs 0.84-1.30, p = .66), in the subgroup analysis between AT combined with DCB and DCB alone, the RRs of primary patency was 1.56 (95% CIs 1.02-2.39, p = .04). The RRs of freedom from target lesion revascularization (TLR) at 6 months was 1.04 (95% CIs 0.93-1.17, p = .45), at 12 months was 1.20 (95% CIs 0.83-1.75, p = .33). The RRs of mortality at 6 months was 0.57 (95% CIs 0.29-1.11, p = .10), and at 12 months was 0.79 (95% CI 0.50-1.25, p = .31). The RRs of limb salvage at 12 months was 0.99 (95% CIs 0.92-1.07, p = .87). The standardized mean difference (SMD) of (Ankle-brachial index) ABI at 12months was 0.16 (95% CIs 0.06-0.26, p = .001). According to this systematic review and meta-analysis, no significant advantages were found with the addition of atherectomy to balloon angioplasty in the below-the-knee segment. Only in the analysis of a small subgroup of atherectomy + DCB versus DCB alone was the primary patency rate at six months significantly higher when adding atherectomy. No further significant differences were found related to 12months of primary patency, TLR, limb salvage, and mortality among groups.

Coaxial Method of PTA Balloon and Aspiration catheter using the delivery wire of a stent retriever for tandem occlusion: CoMBAt tandem occlusion.

Tandem occlusion, in which the intracranial artery is obstructed along with proximal carotid occlusive or stenotic lesions, occurs in 10-15% of patients with large vessel occlusion. Our study introduces a novel technique for tandem occlusion treatment that involves the simultaneous coaxial deployment of a percutaneous transluminal angioplasty balloon and aspiration catheters with the delivery wire of a stent retriever. After percutaneous transluminal angioplasty of the carotid lesion with a thin balloon catheter, the aspiration catheter was advanced over the balloon to eliminate the ledge between the catheter tip and delivery wire. After balloon removal, intracranial thrombectomy was performed using an aspiration catheter and stent retriever. This study aimed to evaluate the safety and efficacy of this approach. Medical records of patients with acute stroke due to tandem occlusion treated using our technique were analyzed for its effectiveness and safety. The puncture-to-recanalization time, modified thrombolysis in cerebral infarction (mTICI) grade, functional prognosis and incidence of hyperperfusion were assessed. Seven patients were included in this study. In all patients, mTICI 2b-3 recanalization was achieved after smooth delivery of the aspiration catheter from the carotid lesion to the intracranial thrombus. The median puncture-to-recanalization time was 52 min. Ninety days post-stroke onset, six of seven patients had a modified Rankin Scale score of 0-2, and none of the patients had perioperative hyperperfusion syndrome. Our technique allows simultaneous treatment of carotid and intracranial lesions, leading to faster recanalization. Furthermore, percutaneous transluminal angioplasty with a thin balloon may reduce the risk of hyperperfusion.

Cutting Balloon Angioplasty for Severe In-Stent Restenosis after Carotid Artery Stenting: Long-Term Outcomes and Review of Literature.

Cutting balloon-percutaneous transluminal angioplasty (CB-PTA) is a feasible treatment option for in-stent restenosis (ISR) after carotid artery stenting (CAS). However, the longterm durability and safety of CB-PTA for ISR after CAS have not been well established. We retrospectively reviewed medical records of patients with ISR after CAS who had been treated with CB-PTA from 2012 to 2021 in our center. Detailed information of baseline characteristics, periprocedural and long-term outcomes, and follow-up imaging was collected. During 2012-2021, a total of 301 patients underwent CAS. Of which, CB-PTA was performed on 20 lesions exhibiting severe ISR in 18 patients following CAS. No patient had any history of receiving carotid endarterectomy or radiation therapy. These lesions were located at the cervical segment of the internal carotid artery (n=16), proximal external carotid artery (n=1), and distal common carotid artery (n=1). The median time interval between initial CAS and detection of ISR was 390 days (interquartile range 324-666 days). The follow-up period ranged from 9 months to 9 years with a median value of 21 months. Four patients (22.2%) were symptomatic. The average of stenotic degree before and after the procedure was 79.2% and 34.7%, respectively. Out of the 18 patients receiving CB-PTA, 16 (88.9%) did not require additional stenting, and 16 (88.9%) did not experience recurrent ISR during the follow-up period. Two patients who experienced recurrent ISR were successfully treated with CB-PTA and additional stenting. No periprocedural complication was observed in any case. Regarding favorable periprocedural and long-term outcomes in our single-center experience, CB-PTA was a feasible and safe option for the treatment of severe ISR after CAS.

A Bayesian network meta-analysis for acute thrombosis after lower extremity artery endovascular treatment.

Various endovascular treatment devices have been widely used in the lower extremity arterial disease (LEAD). Their patency efficiency for target lesions has been well studied and reported. Comparison of the risk of acute thrombosis events between the different endovascular treatment devices is unclear. To rank the risk of acute thrombosis events when bare metal stents (BMSs), covered stents (CSs), drug-eluting stents (DESs), drug-coated balloons (DCBs), and conventional percutaneous transluminal balloon angioplasty (PTA) are used to treat LEAD through Bayesian network meta-analysis. We performed a network meta-analysis of randomized controlled trials comparing the risk of 1-year postoperative acute thrombosis between BMSs, CSs, DESs, DCBs, and PTA for treating LEAD. Bayesian random models were used for pooled endovascular treatment modality comparisons. We ranked these treatment modalities via the Bayesian method according to their surface under the cumulative ranking curve (SUCRA) and estimated probabilities. Nineteen studies (38 study arms; 2758 patients) were included. The Bayesian network ranking of treatments indicated that DCB had the lowest risk of acute thrombosis, PTA had the second-lowest risk of thrombosis, and CS, BMS, and DES had the highest risk of thrombosis. Regarding the treatment efficacy, the OR values of the loss of primary patency were significantly lower for DCB (OR = 0.44, 95% CI: 0.30-0.62), DES (OR = 0.36, 95% CI: 0.14-0.94), and CS (OR = 0.31, 95% CI: 0.18,0.56) than for PTA. When BMS was used as a reference, only the OR for CS was significantly lower (OR = 0.41, 95% CI = 0.21-0.82). Correspondingly, the Bayesian ranking of treatments from better to worse target lesion primary patency was CS, DES, DCB, BMS, and PTA. With the available research evidence and according to the network analysis ranking, DES appears to have the highest risk of acute thrombosis and DCB appears to have the lowest risk.

Immediate and long-term results of the use of balloon angioplasty with stenting in the treatment of renal graft arterial stenosis

Aim. To assess the safety and efficacy of percutaneous transluminal balloon angioplasty with stenting for renal graft artery stenosis. Material and methods. From June 2018 to December 2022, 344 kidney transplants from a deceased donor were performed at the surgical clinic of City Clinical Hospital n.a. S.P. Botkin. The study group consisted of 220 men (63.9%) and 124 women (36.1%). The mean age was 46.46±11.74 (19–73) years. With a mean follow-up period of 20.05 (1-54) months, stenosis of the renal graft artery was diagnosed in 4 patients (1.16%). The mean time from transplantation to the diagnosis of stenosis was 4 (1–9) months. In addition, we diagnosed the development of this complication in 4 kidney transplant recipients operated in other centers. The mean time from transplantation to the diagnosis of stenosis in these patients was 103.25 (12–221) months. Thus, we have the experience in the treatment of renal transplant arterial strictures in 8 recipients: 4 men (50%) and 4 women (50%). The mean age was 48.25±11.97 (27–60) years. Stenosis was manifested by renal graft dysfunction with a progressive increase in urea and creatinine in 6 patients (75%), by arterial hypertension in 2 patients (25%). The mean, level of creatinine at the time of diagnosing stenosis was 290.75 (157–494) µmol/L, glomerular filtration rate was 22.87±12.19 (8–41) ml/min/1.73m2 . Results. In the early postoperative period, 1 complication was recorded in the form of pulsating hematoma of the common femoral artery, which required surgical intervention (complication class IIIA according to Clavien-Dindo). The mean hospital postoperative bed-days made 5.22 (4-8). The mean follow-up time was 22.75±7.4 (14–33) months. All recipients were alive throughout the whole follow-up period. In 7 of 8 recipients (87.5%), the graft was functioning, in 1 patient a progressive graft dysfunction was noted, for which chronic hemodialysis was started. Mean creatinine in recipients with a functioning graft was 156.71±33.4 (123–200) µmol/L; mean glomerular filtration rate was 41.57 ml/min/1.73m2 . Conclusions. Percutaneous transluminal balloon angioplasty with stenting is a safe and effective minimally invasive technique and should be considered as the operation of choice in the development of renal graft artery stenosis.

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

P96: Using Fenestrated Stent to Increase the Flow of ECMO of Superior Vena Cava Compression Syndrome

Introduction: Superior vena cava syndrome (SVCS) is an obstruction of the venous return to the heart through SVC or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. This case report details a situation in which reduced outflow in a VA ECMO would substantially improve by using a fenestrated stent of SVC. Case Presentation: A 54-year-old female presented to our medical center with weight loss and solid food dysphagia for three months. Chest CT scan showed a new mediastinal mass of 10x9x8cm with minor pericardial and pleural effusions. A transbronchial biopsy was attempted; however, the patient arrested during the bronchoscopy procedure. CPR was initiated, and the ECMO team was contacted for VA ECMO cannulation, which was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery, and the left femoral vein cannula size 23 Fr. ROSC was achieved, and the patient was transferred to the ICU. During the night shift, the ECMO flow was hard to maintain with fluids. First, that was due to the small arterial cannula. However, the issue was realized with the ECMO outflow volume issue. The next day, In the hybrid operating room, a fenestrated SVC stent was placed in SVC, brachiocephalic, and internal jugular veins (Figure 1). All patient hemodynamics improved post stenting, including ECMO, flows, especially outflow. Discussion: Endovenous treatment of SVC syndrome includes percutaneous transluminal balloon angioplasty (PTA), stenting, and thrombolysis performed alone or in combination. Stenting is usually in the SVC rather than several locations for SVC syndrome. However, our case is unique as the primary fenestrated stent was deployed in the SVC, and additionally, brachiocephalic and IJ veins were stented through the fenestration, which relieved the SVCS. In addition, it enhanced ECMO outflow flow instantly. Conclusion: This case illustrates that stenting in SVCS is a valid therapeutic option to increase ECMO flow in this patient group.Figure 1. Image A: Fluoroscopy showing SVC stenosis. Image B: redacted view of SVC fluoroscopy Image C: Balloon angioplasty of SVC stenosis under fluoroscopy. Image D: Fenestrated stent placement in the SVC under fluoroscopy. Image E: Stent deployed Internal jugular Image F: Post stenting image showing deployed brachiocephalic Internal jugular vein through fenestrations of primary stent.

Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage.

Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.

Markers of Restenosis after Percutaneous Transluminal Balloon Angioplasty in Patients with Critical Limb Ischemia.

Among cardiovascular diseases, chronic obliterating lesions of the arteries of lower extremities, which are one of the important problems of modern healthcare, are distinguished. In most cases, the cause of damage to the arteries of lower extremities is atherosclerosis. The most severe form is chronic ischemia, characterized by pain at rest and ischemic ulcers, ultimately increasing the risk of limb loss and cardiovascular mortality. Therefore, patients with critical limb ischemia need limb revascularization. Percutaneous transluminal balloon angioplasty is one of the least invasive and safe approaches, with advantages for patients with comorbidities. However, after this procedure, restenosis is still possible. Early detection of changes in the composition of some molecules as markers of restenosis will help screen patients at the risk of restenosis, as well as find ways to apply efforts for further directions of inhibition of this process. The purpose of this review is to provide the most important and up-to-date information on the mechanisms of restenosis development, as well as possible predictors of their occurrence. The information collected in this publication may be useful in predicting outcomes after surgical treatment and will also find new ways for the target implication to the mechanisms of development of restenosis and atherosclerosis.

Radiation protection measures used in Portuguese interventional radiology departments: A national survey

IntroductionThis study aimed to characterise radiation protection (RP) measures used in interventional radiology (IR) departments in Portugal with respect to European and national recommendations. MethodsAn online national survey was created to characterise the fluoroscopy technology as well as analyse the frequency of body fluoroscopy-guided intervention procedures (FGIP), RP education and training of the staff, and RP measures used daily. ResultsIn Portugal, most equipment for FGIP are single-sourced and have a flat panel detector (70%). The most commonly FGIP are percutaneous biliary drainage, percutaneous arterial and venous thrombolysis/thrombectomy, arteriovenous malformations embolization, and percutaneous transluminal balloon angioplasty for arteriovenous fistulas. Only a few staff members had received postgraduate education and training in RP (30%), with most nurses having not received RP education and training (40%). Some of the recommended RP measures lacked harmonisation. Additionally, >50% of the IR departments do not consider examination dose values to identify patients eligible for tissue reactions follow-up. ConclusionThis is the first study to examine the characteristics of IR departments in Portugal. We observed a lack of RP education and training among staff members; further, there was a need to update some RP measures in some IR departments according to the recommendations. Implications for practiceOur findings will be presented to the participating IR departments in order to update and promote RP best practices. Moreover, our findings will be presented to the national societies of the different professional groups in order to inform strategies for harmonising RP education and training of the staff.

Most complex brachiocephalic vein occlusion in hemodialysis patients can be treated with simple endovascular techniques in an office-based angiosuite

ObjectiveBrachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis. MethodsFrom January 2009 to January 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were BCV occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality. ResultsThe median age was 62 years (range, 23-91 years); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in nine cases (7.8%), that included seven using inside-out procedure. Initial management of the BCV stenosis was percutaneous transluminal balloon angioplasty alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in eight cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in 99.1% of patients. No intraoperative complications occurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. The mean postoperative monitoring was 23 months, the median was 12 months, and the range was 1 to 84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital, were required to preserve access performance. Eventually, 49 patients (42.6%) were stented. Eleven patients (9.56%) had infections, and six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients (7.8%) had access failure. Thirty-two patients (27.8%) died of unrelated causes during the follow-up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months, and secondary patency of 75% at 80 months. ConclusionsSuccessful endovascular revascularization of BCV obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.

Renal Artery Stenosis Complicated with Primary Aldosteronism.

Primary aldosteronism (PA) is a typical example of low renin hypertension, whereas renal artery stenosis (RAS) is a classic form of high renin hypertension. PA and RAS occurring simultaneously in a patient is challenging to diagnose. We report a 32-year-old woman with a 12-year history of resistant hypertension. She was identified to have elevated plasma aldosterone and renin levels with normal aldosterone/renin ratio (ARR). Imaging examinations identified bilateral adrenal thickening and subtotal occlusion of the anterior segment of the left renal artery. Adrenal venous sampling was performed and indicated the existence of unilateral aldosterone over-secretion. It may suggest that even though RAS led to non-suppressed renin, adrenal venous sampling remains to be an applicable approach to establish the diagnosis of aldosterone-producing adenomas, although the diagnostic value of ARR may be compromised due to non-suppressed renin level. The patient underwent a two-stage treatment. First, stenosis of the left renal artery was dilated by percutaneous transluminal renal balloon angioplasty. Two months later, laparoscopic complete left adrenalectomy was performed. Hematoxylin-eosin staining and CYP11B2 immunostaining suggested that this tumor was an aldosterone-producing adenoma. After the two-stage treatment, her blood pressure decreased to a normal level without antihypertensive drugs. This case report raises our awareness of the simultaneous occurrence of RAS and PA. Under this condition, ARR could lead to a false-negative PA. Adrenal venous sampling is warranted to achieve a confirmed diagnosis. For subjects with complex etiologies of secondary hypertension, multi-stage treatment may be required.

Long-term arteriovenous fistula prognosis for maintenance hemodialysis patients who accepted PIRRT by using arteriovenous fistula.

Maintenance hemodialysis (MHD) patients are often admitted to the hospital for severe morbidities. Prolonged intermittent renal replacement therapy (PIRRT) is required during the hospital staying. There are controversial opinions on the use of arteriovenous fistula (AVF) as vascular access for PIRRT in MHD patients. Patients with AVF who accepted PIRRT in our center between January 2014 and June 2021 were retrospectively screened. AVF dysfunction and patient mortality were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of AVF dysfunction. About 162 patients were included in our present study. Twenty-six experienced AVF dysfunction, of whom 53.8%, 19.2%, and 27.0% had percutaneous transluminal balloon angioplasty, surgical revision, and AVF reconstruction, respectively. The accumulated AVF dysfunction rates were 11.8%, 16.2%, and 21.0% in 1, 2, and 3 years, respectively. Multivariate analysis revealed that smoking (HR 2.750, 95% CI 1.181-6.402, p = 0.019), higher platelet (PLT, HR 1.009, 95% CI 1.000-1.017, p = 0.047), higher prothrombin activity (PTA, HR 1.039, 95% CI 1.012-1.066, p = 0.004), and lower diastolic blood pressure (DBP, HR 0.963, 95% CI 0.932-0.996, p = 0.026) were independent risk factors for AVF dysfunction. During the follow-up period, 37 patients died. Overall, the use of AVF for PIRRT might not dramatically increase the incidence of AVF dysfunction. And, Smoking, lower DBP, higher PLT, and higher PTA were associated with increased AVF dysfunction.

Impact of Chocolate percutaneous transluminal angioplasty balloon on vessel preparation in drug-coated balloon angioplasty for femoropopliteal lesion

PurposeTo compare the impact of Chocolate and conventional balloons on vessel preparation in percutaneous transluminal angioplasty.Materials and methodsThis single-center retrospective study included 111 endovascular therapy consecutive cases of femoropopliteal lesions using drug-coated balloon strategy with a 1:1 pre-dilation balloon diameter between February 2020 and August 2021, divided into the Chocolate percutaneous transluminal angioplasty (n = 48) and conventional (n = 63) groups. Before the availability of Chocolate balloons in Japan (December 2020), a standard semi-compliant or non-compliant balloon was used for vessel preparation. The primary endpoint was rate of severe dissection after pre-dilatation. Secondary endpoints were angiographic percent diameter stenosis, bailout stent rate, primary patency rate, and freedom from target-lesion-revascularization rate at six months.ResultsThere was no significant difference in patient and lesion characteristics. The procedural characteristics comprised balloon length 90 ± 37 and 149 ± 95 mm (P = 0.004) and inflation pressure 11 ± 3 and 16 ± 7 atm (P < 0.001) in the Chocolate and conventional groups, respectively. Regarding primary endpoint, rates of severe dissection were 4.2% and 25% (P = 0.003); regarding secondary endpoints, percent diameter stenosis was 18 ± 15% and 20 ± 17% (P = 0.409), and the rate of bailout stenting was 2.1% and 15.9% (P = 0.016) in the Chocolate and conventional groups, respectively. The primary patency rates at six months were 89.1% and 85.2% (P = 0.670), and freedom from target-lesion-revascularization rate at six months was 100% and 92.8% (P = 0.691) in the Chocolate and conventional groups, respectively.ConclusionChocolate percutaneous transluminal angioplasty balloons reduce the rate of severe dissection while maintaining a sufficient dilatation effect during drug-coated balloon vessel preparation.

Percutaneous transluminal angioplasty for symptomatic hepatic vein-type Budd-Chiari syndrome: feasibility and long-term outcomes

For management of Budd-Chiari syndrome (BCS), a step-wise therapeutic approach starting with medical treatment, followed by endovascular recanalization, transjugular intrahepatic portosystemic shunt, and finally liver transplantation has been adopted. We retrospectively analyzed 51 patients with symptomatic short segment (≤ 30 mm) hepatic vein (HV)-type BCS who underwent percutaneous transluminal balloon angioplasty (PTBA) with/without stenting to determine the feasibility, clinical effectiveness, and long-term outcomes. The intervention was technically successful in 94.1% of cases (48/51)—32 patients underwent PTBA and 16 patients underwent HV stenting. Procedure-related complications occurred in 14 patients (29.1%). The clinical success rate at 4 weeks was 91.7% (44/48). Nine patients underwent reintervention, six patients due to restenosis/occlusion and three patients with clinical failure. The mean primary patency duration was 64.6 ± 19.9 months (CI, 58.5–70.8; range, 1.2–81.7 months). The cumulative 1-, 2-, and 5-year primary patency rates were 85.4, 74.5, and 58.3%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 87.2, and 75%, respectively. The cumulative 1-, 2-, and 5-year survival rates were 97.9, 91.5, and 50%, respectively. Percutaneous transluminal angioplasty with and without stenting is effective and achieves excellent long-term patency and survival rates in patients with symptomatic HV-type BCS. With its lower incidence of re-occlusion and higher clinical success rate, HV angioplasty combined with stenting should be the preferred option especially in patients with segmental HV-type BCS.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions.

BACKGROUNDEndoscopic ultrasound (EUS)-guided main pancreatic duct (PD) access may be used when conventional endoscopic retrograde cholangiopancreatography (ERCP) techniques fail. The use of a percutaneous transluminal angioplasty balloon (PTAB), originally developed for vascular interventions, can be used to facilitate transmural (e.g., transgastric) PD access and to dilate high-grade pancreatic strictures.AIMTo describe the technique, efficacy, and safety of PTABs for EUS-guided PD interventions.METHODSPatients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database. PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire. The primary outcome was technical success. Secondary outcomes included incidence of adverse events (AEs) and need for early reintervention. RESULTSA total of 23 patients were identified (48% female, mean age 55.8 years). Chronic pancreatitis was the underlying etiology in 13 (56.5%) patients, surgically altered anatomy (SAA) with stricture in 7 (30.4%), and SAA with post-operative leak in 3 (13.0%). Technical success was achieved in 20 (87%) cases. Overall AE rate was 26% (n = 6). All AEs were mild and included 1 pancreatic duct leak, 2 cases of post-procedure pancreatitis, and 3 admissions for post-procedural pain. No patients required early re-intervention.CONCLUSIONEUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis.

Vertebral artery stenosis (narrowing of the vertebral artery) is an important cause of posterior circulation ischaemic stroke. Medical treatment (MT) e.g. controlling risk-factors and drug treatment, surgery, and endovascular treatment (ET) are the prevailing treatment strategies for symptomatic vertebral artery stenosis. ET consist s of percutaneous transluminal angioplasty (balloon catheter through the skin), with or without stenting. However, optimal management of people with symptomatic vertebral artery stenosis has not yet been established. To assess the safety and efficacy of percutaneous transluminal angioplasty, with or without stenting, combined with MT, compared to MT alone, in people with episodes of cerebral ischaemia due to vertebral artery stenosis. We searched the Cochrane Stroke Group, MEDLINE, Embase, BIOSIS, and two other indexes in Web of Science, China Biological Medicine Database, Chinese Science and Technique Journals Database, China National Knowledge Infrastructure and Wanfang Data, as well as ClinicalTrials.gov trials register and the World Health Organization (WHO) International Clinical Trials Registry Platform to 23 July 2021. We included all randomised controlled trials (RCTs) that compared ET plus MT with MT alone in treating people aged 18 years or over with symptomatic vertebral artery stenosis. We included all types of ET modalities (e.g. angioplasty alone, balloon-mounted stenting, and angioplasty followed by placement of a self-expanding stent). MT included risk factor control, antiplatelet therapy, lipid-lowering therapy, and individualised management for people with hypertension or diabetes. Two review authors independently screened potentially eligible studies, extracted data, and assessed trial quality and risk of bias. We applied the GRADE approach to assess the certainty of evidence. The primary outcomes were 30-day post-randomisation death/stroke (short-term outcome) and fatal/non-fatal stroke after 30 days post-randomisation to completion of follow-up (long-term outcome). MAIN RESULTS: We included three RCTs with 349 participants with symptomatic vertebral artery stenosis with a mean age of 64.4 years. The included RCTs were at low risk of bias overall. However, all included studies had a high risk of performance bias because blinding of the ET was not feasible. There was no significant difference in 30-day post-randomisation deaths/strokes between ET plus MT and MT alone (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.77 to 7.07; 3 studies, 349 participants; low-certainty evidence). There were no significant differences between ET plus MT and MT alone in fatal/non-fatal strokes in the territory of the treated vertebral artery stenosis after 30 days post-randomisation to completion of follow-up (RR 0.51, 95% CI 0.26 to 1.01; 3 studies, 349 participants; moderate-certainty evidence), ischaemic or haemorrhagic stroke during the entire follow-up period (RR 0.77, 95% CI 0.44 to 1.32; 3 studies, 349 participants; moderate-certainty evidence), death during the entire follow-up period (RR 0.78, 95% CI 0.37 to 1.62; 3 studies, 349 participants; low-certainty evidence), and stroke or transient ischaemic attack (TIA) during the entire follow-up period (RR 0.65, 95% CI 0.39 to 1.06; 2 studies, 234 participants; moderate-certainty evidence). This Cochrane Review provides low- to moderate-certainty evidence indicating that there are no significant differences in either short- or long-term risks of stroke, death, or TIA between people with symptomatic vertebral artery stenosis treated with ET plus MT and those treated with MT alone.

Surgical Treatment of Wilkie's Syndrome by Vascular Transposition.

IntroductionSuperior mesenteric artery syndrome (SMAS), also called mesenteric duodenal compression syndrome, Wilkieʼs syndrome, chronic duodenal ileus or cast syndrome, is a rare clinical condition defined as a compression of the third portion of the duodenum in between the SMA and abdominal aorta (AA), due to narrowing of the space between them. SMAS is primarily attributed to loss of the intervening mesenteric fat pad, leading to partial or complete duodenal obstruction. Its manifestations are complex and non-specific, including postprandial epigastric pain, nausea, vomiting, early satiety, weight loss and anorexia. SMAS may present as an acute syndrome, or it may have an insidious onset with chronic symptoms. SMAS mainly affects females between 10 and 40 years of age. This study aims to discuss the safety and efficacy of vascular decompression of the duodenum by infrarenal transposition of SMA.MethodsThis single-centre prospective clinical study analysed 37 patients with Wilkie’s syndrome who underwent infrarenal transposition of the SMA between January 2012 and December 2021. The indications for the surgery were severe weight loss, uncontrolled upper abdominal pain, vomiting and other gastrointestinal (GI) symptoms that were severely debilitating to patients’ daily lives, along with radiological findings such as aortomesenteric angle < 25°, aortomesenteric distance <8 mm and distention of proximal part of the duodenum and the stomach. Ten patients (27%) concurrently had Nutcracker syndrome and seven patients (18.9%) had Dunbar syndrome (median arcuate ligament syndrome). Three female patients (8.1%) had all three above-mentioned vascular compression syndromes, which were treated in the same surgery. One male patient (2.7%) was after a laparoscopic duodenojejunostomy with symptoms that relapsed three months postoperatively, which was cured after the infrarenal transposition of SMA.ResultsTechnical operative and clinical success were achieved in all patients. There were no cases of anastomotic failure, SMA thrombosis or intestinal ischemia. All of the patients are currently living symptom-free. One patient (2.7%), four days postoperatively, had a lymphocele formed in the retroperitoneum, which was successfully drained by a CT-guided percutaneous pigtail catheter. Another patient (2.7%) after three months of surgery needed a re-laparotomy for adhesive obstruction of the second part of the duodenum and was treated by adhesiolysis and omentoplasty. One patient (2.7%), 2-year postoperatively, had a proximal SMA stenosis up to 60% where drug-eluting balloon percutaneous transluminal angioplasty (DEB PTA) was performed successfully. Finally, the upper GI symptoms were resolved in all 37 patients (100%).ConclusionWilkie’s syndrome, although rare, is frequently late-diagnosed or underdiagnosed. In cases of failure of conservative therapy, infrarenal transposition of the SMA can be considered a safe and feasible surgical option with more physiologically favourable outcomes comparable to gastrointestinal bypasses, especially in patients concurrently suffering from Nutcracker syndrome. Simultaneously, it also restores physiologic duodenal passage of gastroduodenal content without the need of creating a digestive tract anastomosis. To our best knowledge, we have the highest number of SMA transposition surgeries performed in a single centre for the treatment of Wilkie’s syndrome.

Endovascular management of vascular complications in renal allograft - An observational study

Context: Role of endovascular management of vascular complications in renal transplant recipients. Aims: To present our experience in endovascular management of vascular complications in renal transplant recipients with a literature review. Settings and Design: A retrospective observational study. Materials and Methods: This is a retrospective analysis of postrenal transplant recipients referred to our department for the evaluation and endovascular management of vascular complications from January 2010 to December 2014. Cases of transplant renal artery stenosis (TRAS) and common iliac artery (CIA) stenosis were treated with percutaneous transluminal balloon angioplasty with or without stenting. Intraparenchymal pseudoaneurysms, arteriovenous fistula (AVF), and active contrast extravasation cases were managed with coil and/or glue embolization. Treated patients were followed up with serial blood pressure measurements, serum creatinine estimation, and Doppler evaluation in the postprocedure period and at 3-month and 6-month intervals. Results: Among a total of ten patients, there were five TRAS, two intraparenchymal pseudoaneurysms with active contrast extravasation, one AVF, one active renal bleed with peri-graft hematoma, and one right CIA stenosis. Intraparenchymal pseudoaneurysms, AVF, and active extravasations were postbiopsy. All treated patients showed improved renal function, increased hematocrit, improved blood pressure control in the postprocedure period, and follow-up. Conclusions: Vascular complications in renal transplant patients may lead to graft dysfunction, increased morbidity, and even graft loss if left untreated. Endovascular interventions are first-line treatments with excellent short- and long-term outcomes.

Vascular Quality Initiative Surveillance ofFemoropopliteal Artery PaclitaxelDevices.

This study sought to determine the safety and efficacy of paclitaxel (PTX) devices in the treatment of peripheral artery disease involving the femoropopliteal artery. A meta-analysis of PTX devices for the treatment of femoropopliteal artery disease reported a mortality signal. This was a multicenter cohort study using an integrated clinical data surveillance system to conduct a prospective, propensity score-matched survival analysis of 2,456 patients in the Society for Vascular Surgery Vascular Quality Initiative from January 2017 to May 2020. The study compared PTX drug-coated balloon angioplasty versus percutaneous transluminal balloon angioplasty, PTX drug-eluting stents versus bare-metal stents, and any PTX device versus any non-PTX device. The primary outcome was 2-year survival. Secondary endpoints were successful ambulation and interventional success. Treatment with any PTX device versus any non-PTX device was associated with increased 2-year survival (89.5% vs 86.7%; HR: 0.79; 95% CI: 0.72-0.87; P = 0.004), improved interventional success (81.6% vs 77.6%; HR: 0.82; 95%CI: 0.74-0.91; P< 0.001), and higher rates of independent ambulation at 1 year (86.0% vs 83.4%; HR: 0.85; 95%CI: 0.79-0.91; P = 0.008). Treatment with PTX drug-coated balloon angioplasty was associated with improved survival at 2 years (88.9% vs 85.7%; HR: 0.77; 95%CI: 0.70-0.86; P = 0.005), while PTX drug-eluting stent therapy was associated with similar survival compared with bare-metal stent therapy (91.3% vs 89.6%; HR: 0.84; 95%CI: 0.70-1.01; P = 0.36). In this prospective, active surveillance of a national clinical registry, PTX-containing devices were associated with increased survival at 2 years and improved clinical outcomes at 1 year. (VQI DELTA Paclitaxel Device Safety Analysis [VQI-PTX]; NCT04110288).