Translumbar Puncture Research Articles

Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks

The aim of this study was to assess the initial experience, technical success, and clinical benefit of AneuFix (TripleMed, Geleen, the Netherlands), a novel biocompatible and non-inflammatory elastomer that is directly injected into the aneurysm sac by a translumbar puncture in patients with a type II endoleak and a growing aneurysm. A multicenter, prospective, pivotal study was conducted (ClinicalTrials.gov:NCT02487290). Patients with a type II endoleak and aneurysm growth (>5 mm) were included. Patients with a patent inferior mesenteric artery connected to the endoleak were excluded for initial safety reasons. The endoleak cavity was translumbar punctured with cone-beam computed tomography (CT) and software guidance. Angiography of the endoleak was performed, all lumbar arteries connected to the endoleak were visualized, and AneuFix elastomer was injected into the endoleak cavity and short segment of the lumbar arteries. The primary endpoint was technical success, defined as successful filling of the endoleak cavity with computed tomography angiography (CTA) assessment within 24 hours. Secondary endpoints were clinical success defined as the absence of abdominal aortic aneurysm (AAA) growth at 6 months on CTA, serious adverse events, re-interventions, and neurological abnormalities. Computed tomography angiography follow-up was performed at 1 day and at 3, 6, and 12 months. This analysis reports the initial experience of the first 10 patients treated with AneuFix. Seven men and 3 women with a median age of 78 years (interquartile range (IQR), 74-84) were treated. Median aneurysm growth after endovascular aneurysm repair (EVAR) was 19 mm (IQR, 8-23 mm). Technical success was 100%; it was possible to puncture the endoleak cavity of all treated patients and to inject AneuFix. Clinical success at 6 months was 90%. One patient showed 5 mm growth with persisting endoleak, probably due to insufficient endoleak filling. No serious adverse events related to the procedure or AneuFix material were reported. No neurological disorders were reported. The first results of type II endoleak treatment with AneuFix injectable elastomer in a small number of patients with a growing aneurysm show that it is technically feasible, safe, and clinically effective at 6 months. Effective and durable embolization of type II endoleaks causing abdominal aortic aneurysms (AAA) growth after EVAR is challenging. A novel injectable elastic polymer (elastomer) was developed, specifically designed to treat type II endoleaks (AneuFix, TripleMed, Geleen, the Netherlands). Embolization of the type II endoleak was performed by translumbar puncture. The viscosity changes from paste-like during injection, into an elastic implant after curing. The initial experience of this multicentre prospective pivotal trial demonstrated that the procedure is feasible and safe with a technical success of 100%. Absence of AAA growth was observed in 9 out of 10 treated patients at 6 months.

Fundamentals of Endovascular Surgery

Endovascular techniques are an important part of vascular surgery. The initial step in endovascular surgery is selection of the vascular access site and how to choose the ideal access site is described. Thereafter, the general technical principles of artery puncture (femoral, brachial, and axillary artery puncture as well as translumbar puncture) are described along with troubleshooting principles for each procedure. Once vascular access has been obtained through arterial puncture, it is maintained through placement of a guide wire. The placement of a sheath or guide is typically placed over the guide wire to maintain a stable pathway for catheter exchange or for placement of a device. Insertion of catheters and placement of vascular stents are discussed in detail, including troubleshooting techniques. Type of stents are discussed and include balloon expandable, self-expanding, and covered stents. Postprocedural management of the arterial access site is described. The need for large sheath access during aortic interventions is also presented. The review concludes with a numerical listing of the more than two dozen steps of the basic steps in endovascular procedures, and more than a dozen figures represent the aforementioned procedures. This review contains 21 references.

Guided Aspiration for Determining the Microbiological Aetiology of Aortic Vascular Graft and Endograft Infections

Open and endovascular aortic repair may be complicated by aortic vascular graft or endograft infection (VGEI). Confirming the microbiological aetiology is a key element in providing the best available treatment to patients with a VGEI. The primary aim of this study was to describe the technique of direct aneurysm sac guided aspiration (DASGA) in determining the microbiological aetiology in a cohort of patients with VGEIs, and to report its diagnostic value. This was a retrospective observational single centre study performed between the years 2011 to 2020 in Malmö, Sweden. Patients with a suspected aortic VGEI, where a DASGA was performed at the Vascular Centre, were included in the study. In total, 31 guided aspirations were performed in 27 patients (25 male [93%]; median age 77 years [range 57 - 82 years]). The combination of culture and 16S rRNA/18S rRNA gave a microbial aetiology in 25/31 (81%) DASGAs. Importantly, excluding three cases where infection was ruled out, this rate increases up to 89%. A polymicrobial aetiology was found in six (24 %) cases. The most common bacteria found were Cutibacterium spp. (n= 8) and Listeria monocytogenes (n= 4). In total, the dominant aetiology could be further characterised into normal gut flora (n= 12; 48%) or skin commensals (n= 8; 32%). No patients had persistent morbidity related to the DASGA. DASGA can be used successfully to determine the microbiological aetiology of open and endovascular graft infections. This method appears to be safe, with a high success rate for confirming the microbiological aetiology of VGEIs, particularly if standard culturing methods are combined with 16S rRNA/18S rRNA. Finding the causative microbial aetiology is crucial, and in the vast majority of cases translumbar puncture can be used without serious complications.

Multicenter experience in translumbar type II endoleak treatment in the hybrid room with needle trajectory planning and fusion guidance

ObjectiveThe objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. MethodsTwenty-six consecutive T2L patients in three different institutions were treated between March 2015 and September 2017 by direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting in a cardiovascular hybrid operating room with a workstation featuring needle trajectory planning and guidance software. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedure factors were analyzed with univariate analysis. ResultsAll patients (N = 26; 19 male, 7 female; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. The most common risk factors included hypertension, hypercholesterolemia, coronary artery disease, tobacco use, and diabetes. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.3 ± 7.5 mm; sac size had increased 10.1 ± 6.5 mm at the time of treatment. Onyx (Medtronic, Irvine, Calif) or glue (n-butyl cyanoacrylate) and coil embolization was used in 20 cases, and 6 patients were treated with coiling alone. There was no difference between the patients treated with coils alone and those treated with coils or glue (P > .05) in terms of freedom from failure. Total procedure time was 75.9 ± 40.7 minutes; contrast material volume, 19.9 ± 29 mL; fluoroscopy time, 13.74 ± 12.2 minutes; and radiation dose, 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 2.2 mm to 67.5 ± 9.8 mm. Average follow-up period was 214 days. In 19 patients, the sac reduced in size between 0.2 and 19.1 mm per 100 days; in 2 patients, there was continued AAA expansion (3.4-4.3 mm per 100 days); there was no change in the sac size in 5 patients after the procedure. There were no AAA ruptures during the study period. Once T2L was treated, the recurrence rate was low at 11.5%. ConclusionsThis initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L compared with transarterial or transcaval embolization because of its high success rate and technical ease.

Multicenter Experience in Translumbar Type II Endoleak Treatment in the Hybrid Room With Needle Trajectory Planning and Fusion Guidance

The objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. There were 26 consecutive T2L patients in three different institutions treated between March 2015 and September 2017 using direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting using a needle trajectory planning and guidance software (Needle ASSIST; GE Healthcare, Chicago, Ill). All patients (n = 26; 19 men, 7 women; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.27 ± 7.5 mm; sac size had increased 10.12 ± 6.5 mm at the time of treatment. Onyx (ev3, Covidien, Plymouth, Minn) or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients were treated with coiling alone. Total procedure time was 75.9 ± 40.7 minutes, contrast material volume was 19.9 ± 29 mL, fluoroscopy time was 13.74 ± 12.2 minutes, and radiation dose was 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 4.3 mm to 64.6 ± 9.3 mm. The average follow-up period was 214 days. In 18 patients, the sac reduced in size from 0.2 to 47.62 mm/100 days; in 3 patients, there was continued AAA expansion (0.6 to 4.31 mm/100 days); there was no change in the sac size in 4 patients after the procedure. Once treated, the recurrence rate of T2L was low (Fig). The patients with sac growth tended to be associated with higher body mass index and baseline estimated glomerular filtration rate levels (P = .09). This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent midterm efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L after endovascular aortic repair going forward.

Type II Endoleak Embolization after Endovascular Abdominal Aortic Aneurysm Repair with Use of Real-time Three-dimensional Fluoroscopic Needle Guidance

Current treatment for type II endoleak includes transarterial embolization and translumbar puncture, but each method has its drawbacks. With real-time three-dimensional fluoroscopy guidance, a cone-beam computed tomography (CT) image is created in which the needle trajectory is determined. The trajectory is superimposed on the fluoroscopy image, allowing real-time needle placement for precise embolization. We have used this method to treat five patients with complex type II endoleaks. All interventions were successful and uncomplicated. At 6-month follow-up, CT scan showed no recurrences. Direct puncture and injection with real-time three-dimensional fluoroscopy guidance shows encouraging results as treatment for complex type II endoleaks after endovascular abdominal aortic aneurysm repair (EVAR).

Translumbar Embolization for Type II Endoleaks After EVAR: A Multicenter Retrospective Review

Objective: Translumbar embolization (TLE) of type II endoleaks has been described for the treatment of enlarging aneurysms following EVAR. This technique is reported to have a very high rate of technical success and durability. The purpose of this study is to review our experience with TLE in controlling type II endoleaks, in arresting the increase in aneurysm growth, and limiting the need for subsequent intervention. Methods: A retrospective case review was performed on 13 patients with CT and/or angiographically confirmed type II endoleaks who underwent TLE at two institutions. Patients were treated with combinations of stainless-steal coils, Onyx, Cyanoacrylate (NBCA), thrombin, and/or poly vinyl alcohol (PVA) beads. Success was defined as clear resolution of the type II endoleak and/or an aneurysm diameter that was either stable or decreasing. Failure of the technique was defined as any persistent leak, an enlarging aneurysm sac, or the need for secondary intervention. Results: Thirteen patients underwent TLE for type II endoleaks associated with aneurysm enlargement. In two patients who underwent translumbar puncture, no endoleak could be identified, and no treatment was performed. TLE was successful in only 5 (45.5%) of the remaining 11 patients. Six patients (54.5%) had unsuccessful TLE. Of the 6 treatment failures; 2 patients required repeat interventions, 2 required open surgical repair (1 for rupture), 1 suffered colonic ischemia requiring resection, and 1 patient has a persistent type II endoleak. Conclusions: Our experience contrasts with previously published studies in that less than half of the patients treated had successful resolution of their endoleak with TLE alone. Although TLE is a useful technique for the management of type II endoleaks, many patients will require subsequent procedures. Close surveillance of patients after TLE is imperative to identify the patients who will require additional intervention. The practice gap addressed is the difficulty in obtaining adequate results using TLE in treating endoleaks. A small number of previously published studies showed high success rates. By identifying a lower success rate for TLE, we hope to impress the importance of vigorous surveillance after the procedure.

Endotension after endovascular treatment of abdominal aortic aneurysm: Percutaneous treatment

Endotension is one of the possible specific late complications of endovascular treatment of abdominal aortic aneurysm (AAA). We describe the treatment of endotension in a small group of 3 patients (all men, aged 58, 70, and 70-years-old) by translumbar puncture of the aneurysm sac and aspiration of its content. It was transudate and its culture was negative. Sac size reduced after aspiration in all patients and no subsequent enlargement was seen. Percutaneous translumbar puncture of the aneurysm sac with aspiration of sac content could be an easy and effective method of treatment in endotension. But a larger group of patients and long-term follow-up are needed.

Endoleaks after endovascular aneurysm repair lead to nonuniform intra-aneurysm sac pressure

This was a study of intra-aneurysm sac pressures in patients who presented with endoleaks after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). Twenty-five patients (18 men, 7 women) with endoleaks, age (IQR 68 to 80), underwent 31 direct intra-aneurysm sac pressure measurements, DISP at 16 months after EVAR (IQR, 14 to 26 months). Diameter of AAA was 59 mm (IQR, 52 to 67 mm). Six patients underwent DISP twice. Tip-pressure sensors were used through direct translumbar puncture of the AAA except in three patients (transabdominal puncture in 2; endoluminal in 1). Mean pressure index (MPI) was calculated between simultaneously registered intra-aneurysm sac and systemic pressures. Values presented are medians with interquartile range (IQR). Type I endoleaks (n = 1) showed MPI of 93% in the nidus and 62% in the thrombus. Type II endoleaks were associated with lower MPIs in the thrombus (35%; IQR 24% to 38%) when AAAs shrank (n = 4) compared with when the AAAs remained unchanged (n = 11; MPI, 78%; IQR, 47% to 85%) or expanded (n = 6; MPI, 74%; IQR, 58% to 87%; P = .019). The nidus of type II endoleaks (MPI, 79%; IQR, 70% to 90%) had higher pressure than the thrombus (45%, IQR, 34% to 85%; P = .047; n = 7). Successful embolization of type II endoleaks led to AAA shrinkage (n = 3; MPI reduction, 13% to 31%) or diameter stability (n = 3; unchanged MPIs, 37% to 44%). Type III endoleaks (n = 3) had MPIs in the thrombus of 33% to 70%. Endoleaks after EVAR pressurize the AAA sac nonuniformly, with higher, near-systemic, pressure in the endoleak nidus compared with the thrombus. Nevertheless, type II endoleaks in shrinking AAAs have lower intra-sac pressure than expanding or stable aneurysms, and successful endoleak embolization reduces pressure.

Treatment of type II endoleak with a transcatheter transcaval approach: Results at 1-year follow-up

This study assessed the feasibility and mid-term outcomes in the treatment of type II endoleak using transcatheter transcaval embolization (TTE). During an 8-month period, 12 patients underwent TTE. After direct transcaval puncture of the aneurysm sac, embolization was performed by injecting thrombin and placing coils. Systemic and intrasac pressures were recorded throughout the entire procedure. Computed tomography (CT) scans were performed at 24 hours, 30 days, 6 months, and 1 year after TTE to evaluate endoleaks and changes in sac diameter. Technical success was defined as the feasibility of the procedure; clinical success was defined as no evidence of leaks during the follow-up evaluation. TTE was feasible in 11 of 12 patients (technical success 92%). The mean systemic pressure was 117 mm Hg. The mean intrasac pressure before embolization was 75 mm Hg (range, 39 to 125 mm Hg), 16.5 mm Hg (range, 7 to 40 mm Hg) in 10 patients after embolization, and it increased in one patient. CT scans at 24 hours showed stable contrast medium inside the sac in 10 patients. Only minor complications were observed during follow-up. At the 1-year follow-up, no recurrence of leaks was noted, and sac diameter was reduced in 10 of 11 patients. As a result, TTE clinical success was obtained in 10 (83%) of 12 patients. TTE appears to be a feasible technique for the complete exclusion of type II endoleaks. Technical and clinical successes are comparable with other treatment strategies, and TTE should be considered an alternative to direct translumbar puncture of the aneurysm sac.

Endovascular treatment of endoleaks after endovascular abdominal aortic aneurysm repair: personal experience

This paper describes the different endovascular treatments (cuffs, endografts and embolisation) available for types I, II and III endoleaks occurring after endovascular abdominal aortic aneurysm repair (EVAR). From January 2000 to June 2006, 134 patients (118 men, 16 women; mean age 75.1 years) underwent EVAR. Ten patients (7%) developed significant endoleaks requiring endovascular treatment. Five endoleaks were type I, two were type II and three were type III. Of the five type I endoleaks, four were proximal and one was distal. The proximal endoleaks were treated by cuff deployment, whereas the distal endoleak was treated with a bifurcated graft. Of the two patients with type II endoleak, one was treated by translumbar puncture and coil embolisation, and the other was treated by superselective embolisation of the lumbar feeding vessel with nonresorbable particles. Of the three patients with type III endoleak, two were treated by deploying an aortouniiliac endograft inside the bifurcated graft and the other by implanting a cuff to restore continuity between the graft body and the contralateral limb. Endovascular treatment was successful in 6/10 cases, whereas three cases required surgical conversion. One patient did not undergo surgery owing to poor general condition. The reported incidence of endoleaks after EVAR is 10%-20%. Significant endoleaks should be treated promptly. Endovascular treatment can be done with different techniques, but success in not constant due to adverse anatomical conditions and technical difficulties.

Direct intra-aneurysm sac pressure measurement using tip-pressure sensors: In vivo and in vitro evaluation

Direct intra-aneurysm sac pressure measurement with percutaneous translumbar puncture is a new method for follow-up after endovascular aneurysm repair. The purpose of this study was to evaluate a tip-pressure sensor system for intra-aneurysm pressure measurement in an in vitro aneurysm model and in vivo in patients by studying intraobserver variability. We used 0.014-inch guide wire-mounted tip-pressure sensors. For the in vitro aneurysm model, saccular aneurysms filled with thrombus were inserted in a left-heart-driven aneurysm model. Pressure was measured simultaneously with guide wire pressure sensors in the lumen of the model and within the aneurysm thrombus. In vivo, intraobserver variability was evaluated with double percutaneous translumbar puncture of the abdominal aortic aneurysm (AAA) with pressure measurement in 15 patients (14 men, 1 woman; median age, 75 years [63-80 years]; median AAA diameter, 55 mm [47-80 mm]) at a median of 32 months (2-100 months) after endovascular aneurysm repair. Mean pressure index was calculated as the percentage of mean intraaneurysm pressure relative to simultaneous mean systemic pressure. In vitro, the difference in pressure between the tip-sensor measurements and the pressure output of the aneurysm model was 2 mm Hg (1-4 mm Hg) when the output varied between 150/50 and 200/100 mm Hg (n = 90). Mean pressure in the lumen of the model and within the aneurysm thrombus differed by 1 mm Hg (-5-15 mm Hg (n = 10). In vivo, intraobserver variability of mean pressure index (Bland-Altman plot) was 0% (-7%-17%; n = 15%). Direct intra-aneurysm sac pressure measurement with tip-pressure sensors mounted on 0.014-inch guide wires is a reliable and reproducible technique for measuring intra-AAA pressure both in vitro and in vivo.

Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks

Objective Our objective was to study intra-aneurysm pressure after endovascular aneurysm repair (EVAR) in shrinking, unchanged, and expanding abdominal aortic aneurysms (AAAs) with and without endoleaks. Methods Direct intra-aneurysm sac pressure measurement (DISP) by percutaneous translumbar puncture of the AAA under fluoroscopic guidance was performed 46 times during the follow-up of 37 patients (30 men; median age, 73 years [range, 58-82 years]; AAA diameter: median, 60 mm [range, 48-84 mm]). Three patients were included in two different groups because DISP was performed more than once with different indications. Tip-pressure sensors mounted on 0.014-inch guidewires were used for simultaneous measurement of systemic and AAA sac pressures. Mean pressure index (MPI) was calculated as the percentage of mean intra-aneurysm pressure relative to the simultaneous mean intra-aortic pressure. Results Median MPI was 19% in shrinking (11 patients), 30% in unchanged (10 patients), and 59% in expanding (9 patients) aneurysms without endoleaks. Pulse pressure was also higher in expanding (10 mm Hg) compared with shrinking (2 mm Hg; P < .0001) AAAs. Four of the nine patients with expanding AAAs underwent five repeated DISPs later in the follow-up, and MPIs were consistently elevated. Seven of the 10 patients with unchanged AAAs without endoleaks underwent further computed tomography follow-up after DISP; 2 expanded (MPI, 47%-63%), 4 shrank (MPI, 21%-30%), and 1 remained unchanged (MPI, 14%). Type II endoleaks (6 patients, 7 DISPs) were associated with wide range of MPI (22%-92%). Successful endoleak embolization (n = 4) resulted in pressure reduction. Conclusions Intra-aneurysm sac pressure measurement is an important adjunctive for EVAR evaluation, possibly allowing early detection of failures. High pressure is associated with AAA expansion and low pressure with shrinkage. Type II endoleaks can be responsible for AAA pressurization, and successful embolization appears to result in pressure reduction.

Treatment of Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Translumbar Puncture and Injection of Thrombin into the Aneurysm Sac

Treatment of Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Translumbar Puncture and Injection of Thrombin into the Aneurysm Sac

Treatment of Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Translumbar Puncture and Injection of Thrombin into the Aneurysm Sac

Objectives. The aim of this article is to report our experience in the use of a new technique for the treatment of type II endoleaks which appear after the endovascular treatment of abdominal aortic aneurysms.Materials and methods. In three patients with secondary type II endoleaks, we performed a translumbar puncture, introducing a 22-Gauge needle into the aneurysm sac under CT guidance. Once intrasac pressure had been registered, 1000U (2 ml) of human thrombin were slowly injected into the sac.Results. Complete sealing of the endoleak was achieved in all three patients, confirmed by the lack of contrast filling of the sac in the CT scans performed 5 min and 24 h after the procedure. Initial intrasac pressure was equal to systolic arterial pressure in the three patients. After the procedure, the pressure decreased by 30–40 mmHg. There were no complications during the procedure, which lasted 45–90 min. No endoleak recurrence has been observed in any of the three cases 6 months later.Conclusions. We present an alternative method of treating type II endoleaks, which could become the treatment of choice if and when a wider experience confirms our initial good results.

Advances in Imaging Technology and the Growth of Vascular and Interventional Radiology: A Brief History

THE development of vascular and interventional radiology (IR) as a discipline or a set of patient-care techniques can be described from many viewpoints. One could study its pioneering and innovative physicians or assess how advances in catheters and other device-based technologies have influenced the course of vascular and IR. This article will focus on how imaging technology has shaped the discipline. The advent and subsequent evolution of the modern fluoroscopically based angiographic interventional suite enabled the development of early diagnostic angiography and subsequent interventions. Cross-sectional imaging techniques such as computerized axial tomography and real-time ultrasound (US) also enabled the development of specific interventions. These modalities have also had a profound influence on case selection and case mix and have helped catalyze the evolution of vascular and IR into an interventional specialty. The first iodine-based contrast arteriogram in a patient was reported in 1929 by Dos Santos (1), approximately 34 years after the discovery of the x ray (2) and almost simultaneously with the description of the first iodinated contrast medium (3). Without the benefit of fluoroscopy, a nonselective aortogram could be obtained only by a blind translumbar puncture advancing a stiff metallic cannula with use of surface anatomic landmarks. Filming consisted of a timed single radiographic exposure. Evolution of the translumbar technique was relatively glacial for three decades, probably for two reasons. First, there was no real push to develop it because there were few operative techniques for atherosclerotic occlusive disease or aneurysmal disease, and therefore there were few real indications for the procedure. Second, there was no practical imaging technique that allowed easy and effective visualization of catheter manipulation in real time.

Placement of an intracoronary stent via translumbar puncture

Translumbar puncture for access to the central arterial tree has been used for aortography and for selective coronary angiography in selected patients where conventional peripheral access is not possible. A single case report of coronary angioplasty through this access technique is available in the literature. We report a case of coronary stent placement using the translumbar approach to access the coronary arteries.

Direct Percutaneous Ureteral Approach for the Treatment of Ureteral Stenosis or Obstruction

Two cases are presented in which conventional approaches did not permit dilation of and stent placement in obstructed ureters. In patients with iatrogenic ureteral laceration or rigid ureteral kinking, direct percutaneous translumbar puncture may provide a safe alternative. The authors' technique is described.

Unsuspected inflow disease in candidates for axillofemoral bypass operations: A prospective study

Routine arteriography of the axillary, subclavian, and innominate arteries before axillofemoral bypass surgery has not been advocated because of the presumed rarity of stenosis of these inflow vessels. However, we have noted in this patient population with extensive atherosclerosis that inflow disease can cause axillofemoral graft failure despite normal preoperative clinical and noninvasive parameters. We prospectively determined the incidence of unsuspected inflow stenosis with arteriography in 40 consecutive candidates for primary (28) or secondary (12) axillofemoral bypass surgery. A new arteriographic technique with a single translumbar puncture was developed to safely and clearly visualize the potential inflow and outflow tracts. Ten of the 40 patients (25%) exhibited inflow stenosis greater than 50% of luminal diameter (unilateral in eight patients and bilateral in two patients). Seven were on the left side (five subclavian, two axillary) and five were on the right side (three subclavian, one axillary, one innominate). In eight of the 40 patients (20%) the stenotic inflow lesion was ipsilateral to the ischemic leg and therefore proximal to the preferred inflow site of an axillofemoral bypass. Upper extremity arterial pressure measurements suggested potential inflow artery stenosis in only three of the 12 (25%) instances. These findings show that equal arterial pressures in the upper extremities do not ensure adequate inflow for an axillofemoral graft. Routine arteriographic assessment of inflow intacts is recommended before axillofemoral bypass surgery.

Selektive Katheterangiographie in translumbaler Technik

By using a new 5-F-needle-sheath system for translumbar aortic puncture, it was possible to introduce 4-F-catheters of different lengths and shapes. In nine patients 19 vessels were selectively catheterised. There were no complications. The trans-lumbar approach to selective angiography is a simple and safe alternative to the more dangerous trans-brachial method.