Primary Clinical Success Rate Research Articles

Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft?

This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms. Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted. The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality. In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.

Interventional Radiology in the Management of Abdominal Collections After Distal Pancreatectomy: A Retrospective Review

The purpose of this study was to assess the technical and clinical success and complications of imaging-guided percutaneous catheter drainage of peripancreatic fluid collections after distal pancreatectomy. Between January 2001 and February 2009, the cases of patients who underwent distal pancreatectomy were selected from a surgical database, and the cases of those who underwent subsequent interventional radiologic percutaneous drainage were identified. Details of percutaneous catheter drainage were recorded, and technical and clinical success was determined. Technical success was defined as successful percutaneous imaging-guided placement of a drainage catheter. Primary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage only. Secondary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage and additional manipulations (i.e., tube repositioning, additional catheter drainage) and no surgical débridement. Multifactor logistic regression analysis was used to identify predictors of drain failure. Between January 2001 and February 2009, 365 patients underwent distal pancreatectomy. Of these, 51 patients (14%; 25 men, 26 women; mean age, 53.4 years; range, 18-81 years) underwent 57 CT-guided percutaneous procedures for drainage of postsurgical peripancreatic fluid collection. The mean interval between surgery and drainage was 23.5 days (median, 17 days; range, 2-120 days), and the mean collection size was 7.3 cm in transverse dimension (median, 6.9 cm; range, 2.3-16 cm). The mean duration of catheter drainage was 39.7 days (median, 24 days; range, 3-220 days). The technical success rate was 100%, primary clinical success rate was 60%, and primary and secondary clinical success rates together were 95%. Three of the 51 patients (6%) needed surgery for definitive management of the collection. One of 51 patients (2%) had a complication of the interventional radiologic procedure. Catheter size and the need for additional catheter manipulation were significantly associated with drainage failure (p < 0.05). Catheter drainage of peripancreatic fluid collections after distal pancreatectomy is a technically safe and clinically effective procedure. Although extra manipulations may be needed to achieve clinical success, the combined primary and secondary clinical success rates are high.

Single-step versus multi-step transmural drainage of pancreatic pseudocysts: The use of cystostome is effective and timesaving

Background and aims. Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size. Design. Retrospective study at an academic tertiary referral center. Patients and methods. A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007. Results. The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001). Conclusions. The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.

Percutaneous Treatment of Traumatic Upper-extremity Arterial Injuries: A Single-center Experience

To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries. Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly. Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%. Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Clinical outcomes following endovascular treatment of the malfunctioning autologous dialysis fistula

There is limited long-term prospective data on the use of endovascular techniques and the use of thrombolysis in malfunctioning autologous haemodialysis fistulas. Prospective assessment of clinical outcomes following angioplasty with or without low-dose thrombolysis was undertaken in patients who presented with malfunctioning autologous haemodialysis fistulas. Consecutive patients referred to our department over a 6-month period were included. Twenty-five patients underwent percutaneous intervention by angioplasty alone (n = 14), angioplasty and stent (n = 2), thrombolysis alone (n = 2), angioplasty, thrombolysis and stent (n = 2) and angioplasty and thrombolysis (n = 5). Patients underwent clinical follow-up and were reviewed at 6, 12, 18 and 24 months to determine fistula status. Thirty-day mortality in the group was two patients. Statistical analysis was performed with Mann-Whitney, chi-squared and Kruskal-Wallis tests. Kaplan-Meier curves were constructed to compare primary and secondary patency rates. Technical success and initial clinical success rates were 88% and 76%, respectively. Primary and secondary clinical success rates at 6 months were 68% and 72%, at 12 months were 68% and 72%, at 18 months were 60% and 68% and at 24 months were 52% and 68%, respectively. There were no major complications following interventional procedures. There were four minor complications. After an initially successful procedure, five patients required subsequent intervention during the follow-up period. The overall fistula event rate was very low (five per 600 patient months or 0.0996 per access year) with a fistula loss rate of 0.14 per access year. Our results confirm that excellent clinical results can be achieved by percutaneous endovascular treatment in malfunctioning autologous fistulas, justifying their continued use as first-line management.

Long-term results of Talent endografts for endovascular abdominal aortic aneurysm repair

Since the introduction of endovascular aneurysm repair (EVAR), long-term follow-up studies reporting single-device results are scarce. In this study, we focus on EVAR repair with the Talent stent graft (Medtronic, Santa Rosa, Calif). Between July 2000 and December 2007, 365 patients underwent elective EVAR with a Talent device. Patient data were gathered prospectively and evaluated retrospectively. By American Society of Anesthesiologists category, 74% were categories III and IV. Postoperative computed tomography (CT) scanning was performed before discharge, at 3, 12 months, and yearly thereafter. Data are presented according to reporting standards for EVAR. The mean proximal aortic neck diameter was 27 mm (range, 16-36 mm), with a neck length <15 mm in 31% (data available for 193 patients). Deployment of endografts was successful in 361 of 365 patients (99%). Initially, conversion to laparotomy was necessary in four patients. Primary technical success determined by results from computed tomography (CT) scans before discharge was achieved in 333 patients (91%). Proximal type I endoleaks were present in 28 patients (8%) during follow-up, and 14 of these patients needed additional treatment for type I endoleak. The 30-day mortality for the whole Talent group was 1.1% (4 of 365). Follow-up to 84 months is reported for 24 patients. During follow-up, 122 (33%) patients died; in nine, death was abdominal aortic aneurysm (AAA)-related (including 30-day mortality). Kaplan-Meier estimates revealed primary clinical success rates of 98% at 1 year, 93% at 2 years, 88% at 3 years, 79% at 4 years, 64% at 5 years, 51% at 6 years, and 48% at 7 years. Secondary interventions were performed in 73 of 365 patients (20%). Ten conversions for failed endografts were performed. Life-table yearly risk for AAA-related reintervention was 6%, yearly risk for conversion to open repair was 1.1%, yearly risk for total mortality was 8.9%, and yearly risk for AAA-related mortality was 0.8%. Initially, technical success of endovascular aneurysm repair (EVAR) using the Talent endograft is high, with acceptable yearly risk for AAA-related mortality and conversion. However, a substantial amount of mainly endovascular reinterventions is necessary during long-term follow-up to achieve these results.

Endovascular Abdominal Aortic Aneurysm Repair Using an Anatomical Fixation Technique and Concomitant Suprarenal Orientation: Results of a Prospective, Multicenter Trial

Endovascular repair of abdominal aortic aneurysms with the Endologix Powerlink System has been shown to be a safe and effective alternative to open surgery in patients having an aortic neck diameter of up to 26 mm. We report the mid-term outcomes of an endovascular repair approach wherein the infrarenal bifurcated stent graft was placed at the aortoiliac bifurcation, with concomitant placement of a proximal extension having suprarenal orientation for proximal sealing. Between 2006 and 2008, eight US sites enrolled 44 consecutive eligible patients presenting with abdominal aortic aneurysm in a prospective, single arm pivotal trial approved by the Food and Drug Administration. Each patient received a Powerlink infrarenal bifurcated stent graft through anatomical fixation at the aortoiliac bifurcation and a suprarenal extension to achieve proximal sealing. Analysis of the primary endpoint (proximal type I endoleak) was evaluated using contrast-enhanced computed tomography scans at 30 days, with on-going long-term follow-up for safety and treatment effectiveness. Patients (89% male) presented at a mean age of 70 ± 10 years with mean maximal aneurysm sac diameter of 5.5 cm. Challenging infrarenal aortic neck anatomy was present in 93% of patients. Technical success was 100% over a mean procedure time of 129 minutes. No aneurysm-related deaths, conversions, ruptures, migrations, or type III or IV endoleaks have been observed. The majority of endoleaks (80%) observed to date are type II. Currently, the primary clinical success rate is 93%. Two endovascular secondary procedures have been performed for resolution of type IA or type IB endoleak, and one surgical intervention was performed for resolution of limb occlusion. Significant reduction in sac diameter is observed to up to 2 years. The combination of an anatomically-fixed Powerlink infrarenal bifurcated stent graft and a suprarenal proximal extension safely and effectively excludes aneurysms in eligible patients. Longer term follow-up will determine the durability of these findings.

PS20. Long-term Results of Talent Endografts for Endovascular Abdominal Aortic Aneurysm Repair

Since introduction of EVAR, long-term follow-up studies reporting single device results are scarce. In this study we focus on the Talent® endograft. Between July 2000 and December 2007 366 patients underwent elective EVAR repair. Patient data were gathered prospectively and retrospectively evaluated. 74% of the patients were diagnosed ASA III and IV. Postoperative CT-scanning was performed before discharge, 6, 12 months and yearly thereafter. Data are presented according to reporting standards for EVAR (Chaikof et.al, J VS 2002) Mean proximal aortic neck diameter was 27 mm, with a neck length ≤15 mm in 31% (data available for 193 cases). Deployment of endografts was successful in 99% (362/366) of patients. Initially conversion to laparotomy was necessary in 4 cases. Primary technical success based upon results from CT-scans before discharge was achieved in 91% (332/366). 8% (28/366) patients had proximal type 1 endoleaks; during follow-up 14/28 patients needed additional treatment. 30-day mortality was 1.4% (5/366). Follow-up is reported till 84 months (n = 24 at 84 months). 34% (123/366) patients died during follow-up. In five patients mortality was AAA related (2 ruptured). Kaplan Meier estimates revealed primary clinical success rates of 98% at 1 year, 93% at 2 years, 88% at 3 years, 79% at 4, 64 % at 5 years, 51% at 6 years and 48% at 7 years, respectively. Secondary interventions had to be performed in 18% (66/366) of patients. Ten open conversions for failed endografts were performed. Life table yearly risk for AAA related reintervention was 6%, yearly risk for conversion 1.1%, and yearly risk for AAA-related mortality was 0.8%. Initially technical success of EVAR using the Talent endograft is high, with low yearly risk for AAA-related mortality and conversion. However, a substantial amount of -mainly endovascular- reinterventions is necessary during long-term follow-up to achieve these results

Finnish Multicenter Study on the Midterm Results of Use of the Zenith Stent-Graft in the Treatment of an Abdominal Aortic Aneurysm

To assess the midterm results of endovascular repair of abdominal aneurysm (AAA) with a Zenith stent-graft. Between January 2001 and December 2005, a Zenith stent-graft was employed for endovascular repair of an infrarenal AAA in 206 patients. The mean patient age (+/-standard deviation) was 73.2 years +/- 7.3. Bifurcated grafts were used in 196 patients (96.1%), aortouni-iliac grafts were used in seven patients (3.4%), and a tubular graft was used in one patient (0.5%). The mean follow-up period was 2.4 years +/- 1.7. The 30-day mortality rate was 2.9%. The overall survival rates at 1-, 3-, and 5-year follow-up were 93.3%, 78.7%, and 64.5%, respectively. None of the patients died of AAA rupture. The primary and assisted technical success rates 1 week after endovascular aneurysm repair were 82.0% and 90.3%. The primary clinical success rates at the 1-, 3-, and 5-year follow-up were 90.6%, 85.6%, and 83.5%. Twenty-seven patients (13.1%) underwent a secondary intervention during the study period. An 83% rate of freedom from repeat vascular intervention over a period of 5 years as well as an absence of structural failures or aneurysm ruptures demonstrates that a Zenith stent-graft is associated with good midterm results.

Arterial Embolotherapy for Endoscopically Unmanageable Acute Gastroduodenal Hemorrhage: Predictors of Early Rebleeding

Severe bleeding from gastrointestinal ulcers is a life-threatening event that is difficult to manage when endoscopic treatment fails. Transcatheter embolization has been proposed but factors that influence the angiographic outcome are not well documented. We aimed to identify predictors of recurrent bleeding within 30 days after transcatheter embolization for refractory hemorrhage from gastroduodenal ulcers. This retrospective single-center study of 60 consecutive emergency embolization procedures included hemodynamically unstable patients (41 men, 19 women; mean age, 69.4 +/- 15 y), referred from 1999 to 2008 for selective angiography after failed endoscopic treatment. Predictors of early rebleeding were tested with univariate analysis and a multivariate logistic regression model. The procedural success rate was 95%, the primary clinical success rate was 71.9% (41 of 57), and secondary clinical success was achieved in 3 patients (77.2%) after repeat embolization. No major catheterization-related complications occurred. Periprocedural mortality was 26.7% (16 of 60). Early bleeding recurrence was associated with coagulation disorders (P = .007), longer time to angiography (P = .0005), greater preprocedural blood transfusion volume (P = .0009), 2 or more comorbidities (P = .005), and use of only coils (P = .003). Two factors were independent predictors of embolization failure: coagulation disorders (odds ratio, 6.18; P = .027) and the use of coils as the only embolic agent (odds ratio, 6.24; P = .022). The median follow-up time was 7 months (range, 1 day to 103 months). Angiographic embolization should be performed early in the course of bleeding, and not with coils alone, in critically ill patients. It is important to correct coagulation disorders throughout the embolization procedure.

Abstract No. 176: Arterial Embolotherapy for Endoscopically Unmanageable Acute Hemorrhage from Gastroduodenal Ulcers: Predictors of Early Bleeding Recurrence

PurposeTo identify predictors of early bleeding recurrence (< 30 days) after transcatheter embolization for refractory hemorrhage from gastroduodenal ulcers.Materials & MethodsRetrospective study of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 males, 19 females, mean age 69.4 ± 15 years) referred from 1999 to 2008 for selective angiography after failed endoscopic treatment. The embolic agents used were metallic coils, microspheres, gelatine sponge particles, and glue, sole or in combination. Predictors of early rebleeding were tested with univariate analysis and multivariate logistic regression model, respectively.ResultsThe technical success rate was 95%. The primary clinical success rate was 71.9% (41 of 57 patients). Secondary clinical success occurred in three additional patients (77.2%). No major complications related to catheterization occurred. The periprocedural mortality rate was 26.7% (16 of 60), mostly related to underlying conditions. Early recurrence of bleeding was associated with longer time to angiography (P=.0005), more units of packed red blood cells transfused prior to the procedure (P=.0009), number of co-morbidities ≥ 2 (P=.005), and the use of coils as the only embolic agent (P=.003). Two factors were non confounding predictors of embolization failure: time to angiography > 2 days (odds ratio=70.94; P<.05) and co-morbid diseases ≥ 2 (odds ratio=45.06; P<.05). The use of anticoagulant and/or anti-inflammatory medications before procedure tended to predict failure treatment (odds ratio=11.83; .05<P<.1).ConclusionAngiographic embolization for hemorrhage from gastroduodenal ulcers should be performed early in the course of bleeding and not with coils alone in otherwise critically ill patients. PurposeTo identify predictors of early bleeding recurrence (< 30 days) after transcatheter embolization for refractory hemorrhage from gastroduodenal ulcers. To identify predictors of early bleeding recurrence (< 30 days) after transcatheter embolization for refractory hemorrhage from gastroduodenal ulcers. Materials & MethodsRetrospective study of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 males, 19 females, mean age 69.4 ± 15 years) referred from 1999 to 2008 for selective angiography after failed endoscopic treatment. The embolic agents used were metallic coils, microspheres, gelatine sponge particles, and glue, sole or in combination. Predictors of early rebleeding were tested with univariate analysis and multivariate logistic regression model, respectively. Retrospective study of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 males, 19 females, mean age 69.4 ± 15 years) referred from 1999 to 2008 for selective angiography after failed endoscopic treatment. The embolic agents used were metallic coils, microspheres, gelatine sponge particles, and glue, sole or in combination. Predictors of early rebleeding were tested with univariate analysis and multivariate logistic regression model, respectively. ResultsThe technical success rate was 95%. The primary clinical success rate was 71.9% (41 of 57 patients). Secondary clinical success occurred in three additional patients (77.2%). No major complications related to catheterization occurred. The periprocedural mortality rate was 26.7% (16 of 60), mostly related to underlying conditions. Early recurrence of bleeding was associated with longer time to angiography (P=.0005), more units of packed red blood cells transfused prior to the procedure (P=.0009), number of co-morbidities ≥ 2 (P=.005), and the use of coils as the only embolic agent (P=.003). Two factors were non confounding predictors of embolization failure: time to angiography > 2 days (odds ratio=70.94; P<.05) and co-morbid diseases ≥ 2 (odds ratio=45.06; P<.05). The use of anticoagulant and/or anti-inflammatory medications before procedure tended to predict failure treatment (odds ratio=11.83; .05<P<.1). The technical success rate was 95%. The primary clinical success rate was 71.9% (41 of 57 patients). Secondary clinical success occurred in three additional patients (77.2%). No major complications related to catheterization occurred. The periprocedural mortality rate was 26.7% (16 of 60), mostly related to underlying conditions. Early recurrence of bleeding was associated with longer time to angiography (P=.0005), more units of packed red blood cells transfused prior to the procedure (P=.0009), number of co-morbidities ≥ 2 (P=.005), and the use of coils as the only embolic agent (P=.003). Two factors were non confounding predictors of embolization failure: time to angiography > 2 days (odds ratio=70.94; P<.05) and co-morbid diseases ≥ 2 (odds ratio=45.06; P<.05). The use of anticoagulant and/or anti-inflammatory medications before procedure tended to predict failure treatment (odds ratio=11.83; .05<P<.1). ConclusionAngiographic embolization for hemorrhage from gastroduodenal ulcers should be performed early in the course of bleeding and not with coils alone in otherwise critically ill patients. Angiographic embolization for hemorrhage from gastroduodenal ulcers should be performed early in the course of bleeding and not with coils alone in otherwise critically ill patients.

Balloon dilation only versus balloon dilation plus stenting for posttransplantation biliary strictures

Biliary strictures are a major cause of morbidity following liver transplantation. In the present prospective comparative trial, we evaluated balloon dilation vs. balloon dilation plus stenting with regard to technical and clinical efficacy as well as complications. A total of 32 patients with symptomatic biliary strictures after liver transplantation were assigned to balloon dilation (n = 17) or balloon dilation plus plastic stent placement (n = 15). The main outcome parameter was sustained clinical success defined as an interval of at least 3 months without further endoscopic intervention. Additional outcome parameters were assisted clinical success and treatment failure, as well as procedure-related complications. The initial technical success and primary clinical success rates in the dilation group were both 100 %; in the stent group, the corresponding rates were 100 % and 93 % (n.s.). The sustained clinical success was 71 % vs. 73 %, respectively (n. s.). The time interval to reach sustained clinical success was 6.1 and 5.1 months, respectively (n. s.). No significant differences were found in assisted clinical success or in treatment failure. Complications were observed in 4.3 % in the dilation group and 13.6 % in the stent group (P < 0.05). Independent of the treatment group, a sustained clinical success in anastomotic strictures was achieved in 100 %, whereas the success rate of strictures of the donor hepatic duct was 50 % and of strictures involving the hilum, only 14 % (P < 0.05). In patients with biliary strictures after liver transplantation, endoscopic balloon dilation alone was as effective as dilation plus stent placement. Stent placement was associated with a significantly higher complication rate. Endoscopic treatment of strictures of the biliary anastomosis is highly effective, whereas attempts to treat more complex strictures are less promising.

Early and midterm results after endovascular stent graft repair of penetrating aortic ulcers

To present early and midterm results after endovascular stent graft repair of patients with penetrating aortic ulcers (PAU). Between January 1997 and March 2008, a total of 202 patients received thoracic aortic endografting in our institution, 48 patients (32 men, median age 70 years, range, 48-89) with PAU. A retrospective analysis of these patients was performed. Thirty-one patients (65%) showed an acute aortic syndrome (8 contained rupture, 23 symptomatic). Follow-up scheme included postoperative computed tomography angiography prior to discharge, at 3, 6, and 12 months, and yearly thereafter. Mean follow-up was 31.3 months (1.3-112.6). Technical success was achieved in 93.7%. Primary clinical success rate was 81.2%. In-hospital mortality was 14.6%. Perioperative mortality was significantly (P = .036) higher in patients with acute aortic syndrome compared to asymptomatic patients (22.5% vs 0%). Postoperative complications occurred in 15 patients (31%), including 2 patients with minor strokes and 6, respectively, 5 patients with cardiac and/or respiratory complications. Early endoleaks were observed in 9 patients (19%), late endoleaks in another 2 patients. Reintervention was necessary in 4 out of 48 patients (8.4%). The actuarial survival estimates at 1, 3, and 5 years were 78% +/- 6%, 74% +/- 7%, and 61% +/- 10%, respectively. There was no aortic-related death during follow-up. Cox regression showed age (hazard ratio [HR]; 1.08, P = .036) and a maximum aortic diameter >50 mm (HR, 4.92; P = .021) as independent predictors of death. Endovascular treatment of penetrating aortic ulcers is associated with a relevant morbidity and mortality rate in frequently highly comorbid patients. Midterm results could prove a sustained treatment success regarding actuarial survival and aortic-related death. Emergencies show a significantly worse outcome, but treatment is still warranted in these symptomatic patients.

Chronische mesenteriale Ischämie: Technische und klinische Erfolgsrate der perkutanen Stentangioplastie

To evaluate the technical and clinical success rates of percutaneous stent revascularization in the treatment of chronic mesenteric ischemia (CMI). 17 patients (12 female) with typical symptoms of CMI were treated by percutaneous stent placement for stenoses of the splanchnic arteries (celiac trunk; superior mesenteric artery, SMA; inferior mesenteric artery, IMA). The primary and secondary technical success, primary and secondary clinical success, and the long-term clinical outcome were determined. A total of 24 stents were implanted in 21 splanchnic arteries (12 stents in the celiac trunk, 11 in the SMA and 1 in the IMA). The primary technical success rate was 91% (19/21 arteries), the secondary technical success rate was 95% (21/22 arteries). Clinical follow-up was available for 16 patients. The primary clinical success rate was 81% (13/16 patients). Following two secondary interventions, the secondary clinical success rate was 94% (15/16 patients). Long-term clinical success was achieved in 15 of 16 patients (94%) with a mean follow-up of 26 months. One patient died within 30 days of the intervention and two patients demonstrated major complications (1 dissection, 1 stent dislocation). None of the patients required surgical revascularization and none of the patients died due to recurrent mesenteric ischemia. Percutaneous stent placement for the treatment of CMI can be performed with a high technical and clinical success rate as well as an excellent long-term clinical outcome.

Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study

Biliary strictures are a major cause of morbidity following liver transplantation. In the present prospective comparative trial, we evaluated balloon dilation vs. balloon dilation plus stenting with regard to technical and clinical efficacy as well as complications. A total of 32 patients with symptomatic biliary strictures after liver transplantation were assigned to balloon dilation (n = 17) or balloon dilation plus plastic stent placement (n = 15). The main outcome parameter was sustained clinical success defined as an interval of at least 3 months without further endoscopic intervention. Additional outcome parameters were assisted clinical success and treatment failure, as well as procedure-related complications. The initial technical success and primary clinical success rates in the dilation group were both 100%; in the stent group, the corresponding rates were 100% and 93% (n. s.). The sustained clinical success was 71% vs. 73%, respectively (n. s.). The time interval to reach sustained clinical success was 6.1 and 5.1 months, respectively (n. s.). No significant differences were found in assisted clinical success or in treatment failure. Complications were observed in 4.3% in the dilation group and 13.6% in the stent group (P < 0.05). Independent of the treatment group, a sustained clinical success in anastomotic strictures was achieved in 100%, whereas the success rate of strictures of the donor hepatic duct was 50% and of strictures involving the hilum, only 14% (P < 0.05). In patients with biliary strictures after liver transplantation, endoscopic balloon dilation alone was as effective as dilation plus stent placement. Stent placement was associated with a significantly higher complication rate. Endoscopic treatment of strictures of the biliary anastomosis is highly effective, whereas attempts to treat more complex strictures are less promising.

Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery?

The aim of our study was to discuss the option of endovascular treatment compared to surgery for patients with endoscopically unmanageable nonvariceal hemorrhage of the upper gastrointestinal tract. From 2000 to 2006, 23 patients (male, 15 male; female, 8; mean age, 69 years) who failed endoscopic therapy for upper gastrointestinal hemorrhage were retrospectively evaluated. Twelve patients were operated on (SG), whereas 11 patients had an endovascular intervention (IG). Technical and primary clinical success rates and complications rates were calculated. Clinical parameters and comorbidities were related to outcome. The surgical group suffered less frequently from pre-existing pulmonary diseases (SG, 17%; IG, 55%; p = 0.05) and had a higher incidence of shock requiring catecholamines (p < 0.01) or plasma expander therapy (p < 0.01). There was no significant difference in the incidence of recurrent bleeding episodes (SG, 17%; IG, 27%; p = 0.35) and mortality rates (SG, 17%; IG, 27%, p = 0.35). Deaths in the IG were due to recurrent bleeding. In patients with unsuccessful endoscopic control of nonvariceal bleeding of the upper GI tract, surgery remains a very effective treatment. However, in patients with a high surgical risk due to unknown bleeding sources and/or severe pre-existing diseases/comorbidities, endovascular therapy offers an excellent treatment option. These patients should then be operated on as early as possible to minimize the risk of recurrent bleeding episodes, which are associated with high morbidity and mortality.

Angiographic Embolization for Gastroduodenal Hemorrhage

To examine the safety, efficacy, and predictors of outcome of angiographic embolization in the management of gastroduodenal hemorrhage. Retrospective record review. University-affiliated tertiary care center. All of the patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopist's decision. Patients with coagulopathy, hemobilia, and variceal or traumatic upper gastrointestinal tract bleeding were excluded from review. Between January 1, 1996, and December 31, 2006, 70 embolization procedures were performed in 57 patients. Technical success rate (target vessel devascularization), clinical success rate (in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention), and complications. The technical success rate was 94% (66 of 70 angiographies). The primary clinical success rate was 51% (29 of 57 patients), and the clinical success rate after repeat embolization was 56% (32 of 57 patients). Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer suture ligation (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, renal failure at presentation, immunocompromised status, multiple organ system failure, empirical (blind) embolization, and use of permanent vs temporary embolic agents. Repeat embolizations were helpful for postsphincterotomy bleeding. Major ischemic complications (4 patients [7%]) were associated with previous foregut surgery. Angiographic embolization for gastroduodenal hemorrhage was associated with in-hospital rebleeding in almost half of the patients. Angiographic failure can be predicted if embolization is performed late, following blood transfusion of more than 6 units, or for rehemorrhage from a previously suture-ligated duodenal ulcer.

Low-Profile Primary Stent Placement for the Treatment of Focal Calcified Ulcerated Stenosis in the Infrarenal Aorta

To analyze the immediate and midterm success of low-profile stent placement in calcified ulcerated lesions of the infrarenal aorta in patients with arterial occlusive disease. In this prospective case series, 13 symptomatic patients (eight men, five women; mean age, 64.8 years +/- 12.1; age range, 44-84 years) with focal calcified ulcerated stenoses of the infrarenal aorta were treated with stent placement by using a low-profile technique in a radiology intervention center during a 4-year period. Clinical examinations and duplex ultrasonography were used to evaluate the stents? patency and clinical success. Kaplan-Meier graphs were calculated to analyze the freedom-of-symptom rate. The initial technical success rate was 92% (12 of 13 patients). Due to extended calcifications, a residual stenosis of 50%-60% remained in one patient. No peri-interventional complications occurred. The mean follow-up was 26 months (range, 5-53 months). During follow-up, one patient had a restenosis after 7 months and presented clinically with Fontaine stage IIb. Two patients had iliac and/or femoral stenoses, and both presented with Fontaine stage IIb. One patient's symptoms originated from the lumbar spine. Primary patency and primary clinical success rates were 85% and 69%, respectively. According to Kaplan-Meier tables, the freedom-from-symptom rates were 92%, 84%, 73%, and 63% at 0, 7, 12, and 21 months, respectively. Low-profile stent placement in calcified, ulcerated lesions of the infrarenal aorta is an effective and safe treatment for symptomatic stenoses in patients with arterial occlusive disease after a mean follow-up of 26 months.

Efficacy of percutaneous radiofrequency ablation of osteoid osteoma in children

Percutaneous radiofrequency (RF) ablation of osteoid osteoma has high technical and clinical success rates. However, there are limited data on its use in the treatment of osteoid osteoma in children. To assess the safety and efficacy of CT-guided percutaneous RF ablation of osteoid osteoma in children and compare the outcomes with published data on its use in patients unselected for age. From January 2003 to July 2006, 23 children with osteoid osteoma were treated with CT-guided RF ablation using a straight rigid electrode. Their mean age was 11 years (range 3.5-16 years) and there were 15 boys and 8 girls. The procedures were carried out under general anaesthesia. Follow-up was performed to assess technical and clinical outcome. The mean follow-up period was 2.5 years (range 13-49 months). Technical success was achieved in 21 children (91.3%). Failure occurred in two children, in one due to failure to adequately localize the nidus within the dense sclerosis and in the other because of a short ablation time (2 min) because he developed hyperthermia. Clinical success was achieved in 18 patients within 2-5 days (primary clinical success rate 78.2%).These patients were allowed to fully weight-bear and function without limitation 1 week after the procedure. Pain recurrence was observed in two patients; one was treated successfully with a second ablation after 6 months (secondary clinical success rate 82.6%). Hyperthermia was observed in two patients during the procedure. Three other minor complications were observed: wound infection in one child and skin burn in two children. No major immediate or delayed complications were observed. Percutaneous CT-guided RF ablation is an effective and safe minimally invasive procedure for the treatment of osteoid osteoma in children. It has high technical and clinical success rates that are slightly lower than those of patients with a wider range of ages.

Primary Self-Expandable Nitinol Stent Placement in Focal Lesions of Infrarenal Abdominal Aorta: Long Term Results

To evaluate the technical and clinical success, safety and long term results of percutaneous transluminal angioplasty/self-expandable nitinol stent placement of infrarenal abdominal aorta focal lesions. Eighteen patients underwent PTA of focal atherosclerotic occlusive disease of distal abdominal aorta. Two symptomatic occlusions and 16 stenoses in 10 male and 8 female patients (mean age 68.2 years) were treated with primary self-expandable nitinol stent placement. Primary self-expandable nitinol stent placement was technically successful in all 18 procedures; clinical success was achieved in 100% of patients. No complications associated with the procedure occurred. During the 49.4 months of mean follow up (range 3-96, 4 months) all treated aortic segments remained patent. Endovascular treatment (primary self-expandable nitinol stent placement) of focal atherosclerotic lesions of distal abdominal aorta is a safe method with excellent primary technical and clinical success rates and favourable Long term results.