Transluminal Balloon Dilatation Research Articles

Hemorrhagic pericardial tamponade in a hemodialysis patient with catheter-related superior vena cava syndrome: a case report

BackgroundIatrogenic complications of endovascular treatment for central venous stenosis have not yet been reported. Here we present a case of a patient on maintenance hemodialysis who developed catheter-related superior vena cava syndrome and subsequently suffered from hemorrhagic pericardial tamponade after undergoing percutaneous transluminal angioplasty and stenting.Case presentationA 72-year-old male patient presented with uremia, and had been receiving maintenance hemodialysis for the past five years. The patient initially presented with dysfunction of the dialysis catheter (a cuffed tunneled double-lumen catheter in the right internal jugular vein). Imaging examination revealed a segmental occlusion of the superior vena cava stretching from the distal end of the dialysis catheter up to right atrium entrance, apparent compensatory dilatation of the azygos vein, and abundant subcutaneous collaterals. The patient underwent percutaneous transluminal balloon dilatation and stenting (covered stent) of the superior vena cava in the Cath Lab. During the procedure, with forceful advancement of the guidewire, it was observed to progress for a distance before a “smoke” appeared, and an outward spillage of contrast agent was visible, which suggested a possible vessel puncture leading into the mediastinum. Unfortunately, postoperative hemorrhagic pericardial tamponade occurred and the patient developed cardiogenic shock. He experienced symptoms included chest tightness and breath shortness with a recorded blood pressure of 84/60mmHg. After draining 600 ml of bloody fluid through pericardiocentesis, the patient’s symptoms alleviated and his condition improved.ConclusionsThe case emphasizes the need for increased attention to iatrogenic endovascular injuries during catheter placement and endovascular treatment, such as causing pericardial hemorrhage leading to cardiac tamponade.

Long Non-Coding RNA MEG8 Suppresses Hypoxia-Induced Excessive Proliferation, Migration and Inflammation of Vascular Smooth Muscle Cells by Regulation of the miR-195-5p/RECK Axis

It has been recognized that rebalancing the abnormal proliferation and migration of vascular smooth muscle cells (VSMCs) helps relieve vascular injury. Presently, we aim to investigate whether long non-coding RNA (lncRNA) maternally expressed 8 (MEG8) plays a role in affecting the excessive proliferation and migration of VSMCs following hypoxia stimulation. A percutaneous transluminal angioplasty balloon dilatation catheter was adopted to establish vascular intimal injury, the levels of MEG8 and miR-195-5p in the carotid artery were tested by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Hypoxia was used to stimulate VSMCs, then the cell counting kit-8 (CCK-8) assay, Transnwell assay, and wound healing assay were conducted to evaluate the proliferation, and migration of VSMCs. The protein levels of RECK (reversion inducing cysteine rich protein with kazal motifs), MMP (matrix metalloproteinase) 3/9/13, COX2 (cytochrome c oxidase subunit II), macrophage inflammatory protein (MIP)-1beta, VCAM-1 (vascular cell adhesion molecule 1), ICAM-1 (intercellular adhesion molecule 1), and HIF-1α (hypoxia inducible factor 1 subunit alpha) were determined by western blot or cellular immunofluorescence. As the data showed, MEG8 was down-regulated in the carotid artery after balloon injury in rats and hypoxia-treated VSMCs, and miR-195-5p was overexpressed. Forced MEG8 overexpression or inhibiting miR-195-5p attenuated hypoxia-promoted cell proliferation and migration of VSMCs. In addition, miR-195-5p up-regulation reversed MEG8-mediated effects. Hypoxia hindered the RECK expression while boosted MMP3/9/13 levels, and the effect was markedly reversed with MEG8 up-regulation or miR-195-5p down-regulation. Mechanistically, MEG8 functioned as a competitive endogenous (ceRNA) by sponging miR-195-5p which targeted RECK. Moreover, the HIF-1α inhibitor PX478 prevented hypoxia-induced proliferation, and migration of VSMCs, upregulated MEG8, and restrained miR-195-5p expression. Overall, lncRNA MEG8 participated in hypoxia-induced excessive proliferation, inflammation and migration of VSMCs through the miR-195-5p/RECK axis.

Platelet-derived microvesicles induce calcium oscillations and promote VSMC migration via TRPV4.

Rationale: Abnormal migration of vascular smooth muscle cells (VSMCs) from the media to the interior is a critical process during the intimal restenosis caused by vascular injury. Here, we determined the role of platelet-derived microvesicles (PMVs) released by activated platelets in VSMC migration.Methods: A percutaneous transluminal angioplasty balloon dilatation catheter was used to establish vascular intimal injury. Collagen I was used to activate PMVs, mimicking collagen exposure during intimal injury. To determine the effects of PMVs on VSMC migration in vitro, scratch wound healing assays were performed. Fluorescence resonance energy transfer was used to detect variations of calcium dynamics in VSMCs.Results: Morphological results showed that neointimal hyperplasia was markedly increased after balloon injury of the carotid artery in rats, and the main component was VSMCs. PMVs significantly promoted single cell migration and wound closure in vitro. Fluorescence resonance energy transfer revealed that PMVs induced temporal and dynamic calcium oscillations in the cytoplasms of VSMCs. The influx of extracellular calcium, but not calcium from intracellular stores, was involved in the process described above. The channel antagonist GSK219 and specific siRNA revealed that a membrane calcium channel, transient receptor potential vanilloid 4 (TRPV4), participated in the calcium oscillations and VSMC migration induced by PMVs.Conclusions: TRPV4 participated in the calcium oscillations and VSMC migration induced by PMVs. PMVs and the related molecules might be novel therapeutic targets for vascular remodeling during vascular injury.

Efficacy and safety of percutaneous transluminal balloon dilation to prevent progression of banding site stenosis after bilateral pulmonary artery banding.

To investigate the efficacy and safety of percutaneous transluminal balloon dilation (PTBD) for the treatment of bilateral pulmonary artery banding (bil-PAB) site stenosis. Although bil-PAB is an alternative initial treatment for high-risk neonates with hypoplastic left heart syndrome (HLHS) or critical aortic stenosis (cAS), those patients often suffer from desaturation because of progressive stenosis of the bil-PAB sites during the interstage period. We retrospectively evaluated the efficacy and safety of 11 consecutive PTBD procedures performed between 2006 and 2012 to treat bil-PAB site stenosis in four high-risk infants (three females) with HLHS or cAS. PTBD was repeated twice in two patients and three times in one patient over intervals. The mean balloon diameter (BD) and BD-to-band circumference (BC) ratio were 3.1 ± 0.5 mm and 0.31 ± 0.06, respectively. After the procedures, the mean minimum lumen diameter was dilated significantly from 1.1 ± 0.1 mm to 1.7 ± 0.3 mm (P < 0.01), and the mean peripheral oxygen saturation increased significantly from 75 ± 8% to 85 ± 4% (P < 0.01). All patients reached the next stage operation involving the Norwood & bidirectional Glenn or Ross procedure, after growth. No complications such as band rupture occurred. For progressive stenosis of bil-PAB sites, PTBD using a balloon size that did not exceed the BC (BD around 30% of the BC) was an effective and safe procedure.

Successful percutaneous transluminal balloon dilatation for hepatic venous outflow obstruction after pediatric liver transplantation: A series of cases

Whether percutaneous transluminal balloon dilatation (PTBD) or stent placement should be used in children with hepatic venous outflow obstruction (HVOO) is still controversial. The aim of the present study was to retrospectively describe experience in diagnosis and treatment of HVOO and to evaluate the outcome of PTBD in HVOO patients after pediatric liver transplantation (P-LT). From January 2001 to January 2011, 54 children received P-LT at our center. The clinical features of children with HVOO analyzed included demography, type of donor and liver transplant, the new-onset symptoms, liver function test, interventional examination, and treatment and outcome. Three children were treated successfully with PTBD without stenting. All patients received percutaneous interventional management successfully. In the total of eight episodes of PTBD across the stenosis, the mean pressure gradient ± standard deviation was 16.6 ± 7.90 mmHg before PTBD and 6.8 ± 2.27 mmHg after PTBD. The difference was significant (P < 0.05). All of the three HVOO patients were still surviving with primary graft functioning normally until the last follow up. HVOO after P-LT should be taken seriously. PTBD is an effective and safe treatment for HVOO in younger patients subjected to P-LT and re-venoplasty is recommended even in patients with recurrent HVOO.

An Idiopathic Membranous IVC Obstruction: Presenting as a Variant of the BCS

An Inferior Venacaval (IVC) lumen obstruction, whether it is partial or complete, is not a common phenomenon and it may be caused by the thrombosis or compression which may result from neoplastic or non neoplastic masses. There are cases which are idiopathic and which are typically referred to as membranous obstructions of the IVC. Here, we are presenting a 40 years old male with multiple tortuous veins over the abdomen, with non healing ulcers in the leg for 12 years, without ascites, who underwent a successful percutaneous transluminal balloon dilatation of the IVC membrane which was located above the hepatic veins, which resulted in a successful palliation of his symptoms.

Resultados a largo plazo del tratamiento mediante dilatación con balón en pacientes con estenosis subaórtica de membrana: un estudio de 24 años

Aim Percutaneous transluminal balloon dilation is an alternative to surgery in discrete subaortic stenosis (DSS). Methods We included 75 patients with percutaneously treated DSS, who were followed up for a mean period of 16 ± 6 years. Results Mean age at treatment was 18 ± 16 years old. The peak gradient decreased from 70 ± 27 mmHg to 18 ± 12 mmHg ( P < .001). One patient died immediately after dilation. During the follow-up there was one non-cardiac death, 11 patients demonstrated restenosis, 3 patients developed a thick fibromuscular ring and 1 patient developed a new distant membrane. Treatment age was lower in those who developed restenosis than in those who did not (11 ± 13 vs 22 ± 17 years old; P < .05). Twelve patients underwent redilation and four patients required surgery. Most patients (75%) remained free from redilation or surgery. The mean residual gradient was 31 ± 15 mmHg. Conclusion Gradient release remains after long-term follow up in most patients with discrete subaortic stenosis treated by percutaneous balloon dilation.

Anticoagulation With Warfarin for Budd–Chiari Syndrome with Chronic Inferior Vena Cava Thrombosis: An Initial Clinical Experience

To evaluate the initial clinical safety and feasibility of anticoagulation using warfarin for Budd-Chiari syndrome (BCS) with chronic inferior vena cava (IVC) thrombosis. Between October 2005 and June 2009, a total of 16 consecutive BCS patients with chronic IVC thrombosis were treated with warfarin. Warfarin was administered orally at 2.5 mg/d for approximately 3-12 months. Transluminal balloon dilatation of the IVC with a 30-mm balloon catheter was applied for the patients with complete resolution of the thrombus. Data relating to the technical success, angiographic results, complications, and final clinical outcome were collected retrospectively and follow-ups were performed at 1, 3, 6, and 12 months after the stent placement, and annually thereafter. Warfarin was successfully used for anticoagulation in all patients without any complications. Patients were followed up as outpatients for 6.43 ± 2.19 months, and in 14 cases, complete disappearance of the thrombosis was achieved with successful treatment by balloon dilation. In two patients with partial resolution of the thrombosis, Z-stent placement was initiated to compress the thrombus to prevent migration of the thrombosis, followed by dilation of the IVC. During the follow-up for 20.94 ± 10.31 months after the procedure, all the IVC remained patent without complications or pulmonary embolus, and all patients were alive with resolution of symptoms at the time of this study. The use of warfarin for anticoagulation proved to be simple, safe, and feasible for BCS with chronic IVC thrombosis.

Restenosis After Balloon Angioplasty for Cerebral Vasospasm

Transluminal balloon dilatation for symptomatic vasospasm after subarachnoid hemorrhage is effective, and clinical studies have shown that it achieves long-lasting dilatation of spastic cerebral arteries. Delayed arterial renarrowing has not been reported. Here we report the case of a 58-year-old woman who presented asymptomatic and permanent restenosis after angioplasty for cerebral vasospasm.

Recurrence of hepatocellular carcinoma after liver transplantation presenting as anastomotic biliary stricture

A 52-year-old man visited our hospital complaining of anorexia and fatigue two months after receiving orthotopic liver transplantation for hepatocellular carcinoma. A laboratory investigation demonstrated a clinical picture of obstructive jaundice. T-tube cholangiography showed biliary stricture over the anastomotic site. Percutaneous transluminal balloon dilatation and stenting was attempted but failed. Magnetic resonance cholangiography showed possible tumor recurrence over the site of the anastomotic biliary stricture. A biopsy sample was obtained via ultrasound-guided aspiration and histopathological study revealed inflammatory and fibrotic changes. With high suspicion of recurrence of the hepatocellular carcinoma, surgical exploration was performed and an intraoperative frozen section proved the recurrence. We thus diagnosed this case as a recurrence of hepatocellular carcinoma after liver transplantation. To our knowledge, there have been no previous reports of early tumor recurrence after liver transplantation being the cause of an anastomotic biliary stricture.

Use of collagen in sealing of arterial puncture holes after heart catheterization

Percutaneously introduced absorbable purified bovine collagen was used to plug the hole at the site of femoral arterial puncture in 50 patients (42 men, 8 women; median age 58 [22-75] after percutaneous coronary angiography (n = 32; heparin dosage 100 IU/kg) or transluminal coronary balloon dilatation (n = 18; heparin dosage 200 U/kg). Local bleeding ceased after compression of 4 min in 48 of the 50 patients. A pressure bandage was needed additionally in the other two. Bed-rest lasted for 1-24 (median 19) hours. A haematoma of more than 6 cm diameter developed in five patients, but required neither transfusion nor surgical intervention. 39 of the 50 patients were re-examined after a median of 39 days: all of them had had a small pain-free swelling for 2-6 weeks over the puncture site. One patient developed a deep-vein thrombosis one week after the procedure, in another fever occurred after the same period, lasting for two days. These early findings are encouraging. The method may significantly shorten the time of arterial compression and bed-rest, as well as reduce the risk of a large haematoma after arterial punctures.

JEAN S. KAN, MD: A Conversation With Colin K.L. Phoon, MPhil, MD

Interventional pediatric cardiology is an established and mature subspecialty in its own right within pediatric cardiology. Although catheter-based techniques for relieving pulmonary stenosis and closing arterial ducts were reported in the 1960s, it is generally acknowledged that Rashkind’s and Miller’s 1966 report of balloon atrial septostomy for transposition of the great arteries heralded the era of therapeutic cardiac catheterization for congenital heart defects. However, broad application of catheter-based interventional techniques to congenital heart disease would await the development and description of a static, transluminal balloon dilation technique.

Endourological Management is Better in Early-Onset Ureteral Stenosis in Kidney Transplantation

Introduction The incidence of ureteral stenosis in kidney transplant recipients is 3%–8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. Objective The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. Patients and Methods Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. Results Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation ( P = .06) and the presence of a previous acute rejection episode ( P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. Conclusions Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.

Introduction

Percutaneous mechanical thrombectomy (PMT) refers to a heterogeneous group of devices and techniques used to fragment, ablate, and/or extract intravascular thrombus. The last decade has witnessed a remarkable evolution of PMT from an experimental curiosity to a mainstream technique in the armamentarium of the modern interventionist. This rapid evolution was the result of a number of factors: continued innovations in device design, experimental evaluation of PMT in a growing number of applications which culminated in the approval by the Food and Drug Administration (FDA) of several devices for clinical use, prominent support from the medical device industry which saw in PMT a new avenue of sales growth and, to some extent, the relative vacuum created after the withdrawal of urokinase from the US market. While PMT is currently a well-accepted first-line modality in the treatment of clotted hemodialysis access grafts, its role in other applications is less well-defined and varies widely depending on the specific application, and institutional experience and guidelines. This issue of Techniques in Vascular and Interventional Radiology summarizes the experience of some of the leading experts in the field. The authors introduce us to the basic principles of PMT and present the current clinical status of PMT in the main potential areas of clinical applications: native arteries and bypass grafts, synthetic arteriovenous (AV) grafts, native AV fistulae, deep venous application, pulmonary embolism, as well as in TIPS and the portal venous system. With the growing experience with PMT, certain clinical trends in the use of these techniques have become somewhat evident. The role of PMT devices in clotted synthetic hemodialysis access grafts is well established. The efficacy of end-hole catheter-based aspiration thrombectomy is well established, and this simple technique will remain a highly valuable technique in the management of peripheral arterial thromboembolic occlusions. However, the use of PMT devices in peripheral arterial occlusions remains controversial, despite growing evidence for its efficacy. This is most likely because of unabated concerns for the risk of embolic complications. Current experimental evidence favors the use of ablation-evacuation devices (such as devices classified under hydrodynamic PMT) over ablation-only devices in applications where embolization is less tolerable, as in the native arterial beds. Venous applications on the other hands have been more readily explored because of the lower perceived concern with the risk of embolization. As the potential indications, strengths, and limitations of PMT continue to evolve, it is important to realize that the full, real-life potential of these techniques in clinical practice is best accomplished when used in conjunction with other adjunctive techniques, such as simple suction thrombectomy, local pharmaco-thrombolysis, percutaneous atherectomy devices, transluminal balloon dilation, and stenting. The last three can, in fact, be invaluable in managing the most resistant component of thromboembolic occlusions, due to chronic organized thrombus or underlying atherosclerotic or fibrotic tissue. Although its role remains far from being clearly defined, PMT has become an important addition to the armamentarium of physicians caring for vascular diseases. As its role becomes better understood, its indications and limitations recognized, and as clinicians become more aware of its value, PMT will undoubtedly play a major role in the future management algorithms of thrombotic occlusive disorders.

Percutaneous Transluminal Laser Angioplasty Versus Balloon Dilation for Treatment of Popliteal Artery Occlusions

<b>Percutaneous Transluminal Laser Angioplasty Versus Balloon Dilation for Treatment of Popliteal Artery Occlusions</b>

Lens of the eye: radiation dose in balloon dacryocystoplasty.

To evaluate the absorbed radiation dose to the lens of the eye, which is the critical organ in the primary beam during fluoroscopically guided transluminal balloon dilation of the lacrimal drainage system (balloon dacryocystoplasty) for obstructive epiphora and to evaluate the possibility of deterministic radiation effect on the lens. The radiation dose to the lens of the eye during balloon dacryocystoplasty (which includes pre- and postintervention dacryocystography) was measured in 10 consecutive patients by using thermoluminescent dosimeters on the lids of both eyes as close as possible to the lenses. A C-arm angiographic unit coupled with a digital imaging system was used, with similar exposure and geometric parameters in all cases. The mean radiation dose to the lens of the treated eye was 4.6 mGy +/- 2.2 (dose range, 1.9-9.1 mGy) and to that of the untreated eye was 38.5 mGy +/- 17.5 (dose range, 14.7-67.8 mGy). The lens of the untreated eye receives a higher dose than that of the treated eye because of its closer proximity to the x-ray tube in a lateral projection. In the lens, even the highest measured radiation dose (67.8 mGy) still was well below the deterministic threshold for lens opacity and cataract formation.

Coarctation of the aorta

Controversy still exists in the literature regarding definitive therapy for repair of coarctation of the aorta. Major factors involve not only the timing of repair, but also the method of repair, whether surgical or by percutaneous transluminal balloon dilatation. Results and complications of coarctation repair using various methods of classification present a diversity of results. This report will focus on these issues and attempt to dispel the statement that either one method or the other is the "choice method" of repair for any and all types of coarctation. Also presented is a proposed classification we believe will assist in clarifying the choice of therapy and perhaps improve not only the reporting of results, but also the results themselves. Methods of repair are discussed to provide the surgeon with a complete armamentarium of operations that the surgeon would tailor to the individual anatomicopathological patterns of the patient who presents at the time of surgery. Copyright 2000 by W.B. Saunders Company

Balloon Dilatation in the Treatment of Ureteral Stenosis in Kidney Transplant Recipients

Objective: To assess the usefulness of balloon percutaneous dilatation as a starting treatment technique of ureteral stenosis in kidney transplant recipients. Patients and Methods: A total of 472 kidney transplants have been performed at our center between August 1981 and January 1997. The coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function had recovered, antegrade pyelography was performed to confirm ureteral stenosis and to determine its location. The dilatations are performed by means of 5-french balloon-fitted angioplasty catheters. Results: Thirty patients were diagnosed with ureteral stenosis during follow-up, i.e. an incidence of 6.3%. Transluminal balloon dilatation was made as a first therapeutic option in 18 cases. No immediate complications were observed following dilatation. Disappearance of the stenosis as well as maintenance of the improvement in creatinine levels were verified in 39% of cases (7 patients). Conclusions: Ureteral stenosis in kidney transplant recipients should be included as part of the differential diagnosis when there is a deterioration in renal function. Balloon dilatation is the technique chosen as initial treatment of juxtavesical ureteral stenosis because of its good reproducibility and its low morbidity.

Balloon Dilatation of Membranous Obstruction of the Inferior Vena Cava

Membranous obstruction of the inferior vena cava is a rare congenital anomaly that results in the primary type of Budd-Chiari syndrome. We describe the case of an 8-year-old boy initially diagnosed with intrahepatic portal hypertension, who underwent percutaneous transluminal balloon dilatation of an inferior vena cava membrane located in the suprahepatic inferior vena cava, which resulted in successful palliation of his symptoms.

27.10 Benefits of simultaneous transluminal balloon dilatation and opened surgery during elective arterial reconstruction

Patients undergoing repair of thoracoabdominal (TAA) or visceral aortic segment aneurysms typically require reconstruction of the renal arteries. The use of balloon expandable stents (BES) has been proposed as an alternative to endarterectomy or bypass for renal artery reconstruction (RAR) during open aortic aneurysm repair. We report technical aspects and long-term patency data for this method of right RAR during complex open aortic aneurysm repair.During the interval July 1, 2005 to December 31, 2007, a total of 67 patients underwent right RAR using a BES during concomitant TAA (type I: n = 2 [2.9%], type II: n = 8 [11.9%], type III: n = 13 [19.4%], and type IV: n = 22 [32.8%]), juxtarenal (n = 9 [13.4%]) or suprarenal (n = 13 [19.4%]) AAA repair. Indications for RAR were orificial stenosis (n = 21 [31%]) and/or technical considerations referable to the proximal aortic suture line. Patency of the renal stent was evaluated in patients with computed tomography angiography using three-dimensional reconstruction or with abdominal duplex evaluation at follow-up.The mean patient age was 75.1 years, 54.4% were male, and 18% of operations were in nonelective circumstances. Twenty-seven (39%) out of 67 patients had a preoperative creatinine level ≥1.4 mg/dL. Two patients (2.9%) developed permanent renal failure postoperatively (neither related to renal artery occlusion). Mean radiologic follow-up was 405 days (11-1281) with 98% stent patency noted. One patient had an early stent occlusion noted at 1 month. An additional patient was noted to have a nonflow-limiting dissection distal to the renal stent, and another was noted to have distal migration of the stent beyond the renal ostium; however, these findings were clinically silent.The use of BES during complex open aortic aneurysm repair affords a rapid and durable mode of RAR, obviating the need for endarterectomy and its associated technical complications.