Use Of Percutaneous Techniques Research Articles

Minimally invasive direct coronary artery bypass and percutaneous coronary intervention followed by transcatheter aortic valve implantation: A promising concept in high-risk octogenarians.

In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid). The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature. Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis. From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II. In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.

Minimally Invasive (Percutaneous) Pedicle Srews as the Treatment of Choice in Thoracolumbar Spine Fractures

Introduction. Minimally invasive techniques of transpedicular fusion have become very common and seem to displace classical open techniques. Pedicle screws fusion is the procedure of choice in unstable traumatic lumbar and thoracic spine fractures of.Aim. The aim of the study was to answer whether open techniques are still used in injuries or whether they have been completely replaced by MISS.Material and Methods. The manuscript presents an analysis of patients treated in 2017–2021 in the Department of Neurosurgery, Neurotraumatology and Pediatric Neurosurgery of Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University.Results. Based on the analysis of medical documentation, it was found that every case of traumatic thoracolumbar spine fracture in 2017–2021 was treated using minimally invasive techniques. According to the documentation, the last case of using open surgical technique in the case of trauma was in 2016. It was noted that percutaneous techniques dominated the surgical treatment of thoracolumbar spine fractures and replaced the classic techniques in our department, which are used only, in some cases, in treatment of non-traumatic spondylolisthesis.Conclusions. Therefore, percutaneous techniques are currently the procedure of choice in spine injuries fusion in our hospital. The use of percutaneous techniques reduces the surgical traumatization of tissues (it is important to avoid additional traumatization and blood loss in traumatic patients). It has been pointed out that these procedures are performed by neurosurgeons who, in teaching process, used percutaneous techniques often and now prefer this method. The use of percutaneous techniques has important aspect in the field of neurosurgical nursing, because care of the operated area consists in observing few (4–16) smaller wounds, not one long wound (as in classic techniques), and these wounds are located directly above the titanium screw tips, which must under neurosurgical nurse care. (JNNN 2022;11(1):3–7)

Sural Nerve Injury in the Achilles Tendon Repair with Dresden Instruments: Anatomical Study

Category:Trauma; HindfootIntroduction/Purpose:The surgical reconstruction of the Achilles tendon has evolved in favor of the use of percutaneous techniques over the traditional approach with wide approaches to reduce the complications inherent to this procedure. These percutaneous techniques can present lesions of the sural nerve. The objective of this study is to evaluate the distance of this structure with respect to the instruments used in the Dresden technique.Methods:Dissections were made in 16 anatomical pieces (ankles) to which a reproduction of the complete Achilles lesion was previously made and reconstructed using the technique to be studied. After this, the distance of the instrument position with respect to the sural nerve was measured, as well as other relevant measures, and the presence or absence of nerve injury was evaluated.Results:None of the pieces there was lesion of the sural nerve neither by direct injury nor by entrapment, in addition, an approximate distance of 10mm of the nerve was found with respect to the entry site of the percutaneous needles as described by the technique. The location of the nerve was always external to the Crural Fascia. We demonstrate a safety area in which the instruments can be used without lesions of the sural nerve.Conclusion:The technique described by Amlang with the use of Dresden instruments has a low rate of cutaneous complications and infection compared to the traditional approach for this injury, we find that if the risk of presenting injury is performed properly of the sural nerve is low and its reproduction, for the repair of Achilles injuries, should be considered as the first option over traditional open management.

Open Release of Pediatric Trigger Thumb.

The surgical procedure is easy to perform and straightforward; however, attention must be given to several details in order to avoid surgical failure and complications. General anesthesia is required for this procedure. The extremity is prepared and draped in a sterile fashion with the patient in the supine position, and a tourniquet is utilized to facilitate surgical dissection. A transverse incision is gently made just adjacent to the thumb metacarpophalangeal (MP) flexion crease, above the so-called Notta nodule. The ulnar neurovascular bundle is retracted to the side, and the Notta nodule, a local enlargement of the FPL tendon2, is visualized at the A1 pulley. The pulley is incised longitudinally to allow for full IP joint extension. After verification of full passive motion, the tendon is inspected for any further abnormalities. Then, the tourniquet is released, and the wound is closed with absorbable sutures. We recommend the use of local anesthetics for postoperative pain control. In cases of a trigger thumb stuck in extension, full tenodesis flexion of the IP joint combined with smooth, full passive extension confirms a complete release. Nonoperative treatment modalities mainly include watchful waiting for spontaneous resolution3, occupational therapy (i.e., passive exercising)4,5, and splinting therapy6. However, prolonged stretching and splinting may move the nodule to a point distal to the stenotic pulley, thus resulting in a trigger thumb locked in extension with a loss of IP flexion. Alternative surgical treatment techniques involve percutaneous trigger thumb release or open release with alternative surgical approaches (e.g., an oblique or Brunner incision)7,8. Several reports have shown that open release of a trigger thumb leads to the most reliable outcomes in terms of achievement of range of motion and complications1,9,10. The main advantage of this procedure is the perfect visualization of the FPL tendon beneath the stenotic A1 pulley, which allows for a complete A1 release with clear vision. Such visualization cannot be provided with use of percutaneous techniques, which position the neurovascular bundle in potential danger for iatrogenic injury or may lead to incomplete pulley release8. Moreover, the use of this procedure allows parents to avoid the prolonged therapy and splinting associated with nonoperative treatment. Formal rehabilitation is usually not necessary postoperatively. Open release of a trigger thumb is a safe and reliable option that leads to full range of motion in 95% of children, which is substantially higher than for nonoperative treatment with therapy (55%) and splinting (67%)1. Even delayed open release may provide satisfactory outcomes9. Although spontaneous resolution without surgery has been reported in 63% of cases3, patients with a flexion contracture of >30° showed spontaneous resolution in only 2.5% of cases10. Furthermore, the open surgical technique has been shown to have a lower rate of complications (around 3.4%)11 compared with percutaneous techniques, which showed a 3.29 times increased risk of recurrence12 and relevant injury to the neurovascular bundle8. If the A1 is fully divided, recurrence is highly unlikely. Postoperative rehabilitation is very quick following open release of a trigger thumb because closure under local anesthesia provides a painless postoperative course, wounds heal within a few days, and children are allowed to resume play immediately once a bandage is applied. The use of surgical loupes is of paramount importance to safely perform this procedure.Place the skin incision adjacent but not directly onto the palmar MP flexion crease for better scar formation.Divide the skin very gently because the A1 pulley is located directly under the skin, and the FPL and radial nerve can be harmed easily. Retract the ulnar neurovascular bundle aside so as to allow for safe preparation until A1 division.Divide the A1 pulley until the Notta nodule on the FPL can safely glide distally into full IP extension. In some cases with large, distally-sitting nodules, the pulley incision must be extended distally into the oblique bundle.A sign that the entire A1 pulley is released is seeing the corner formed by the distal edge of the pulley and the longitudinal cut in the pulley. Additionally, the cut halves of the fully released pulley will rest completely in the sagittal plane of the thumb, no longer converging over the FPL tendon.Tight bands can exist proximal and distal to the A1 pulley and should be released as well if present.Check for a tight IP volar plate following A1 division, which may require postoperative splinting.For thumbs stuck in extension, tenodesis can be utilized to verify complete A1 release.Utilize absorbable sutures, local anesthesia, and a bulky dressing to allow a comfortable postoperative course. IP = interphalangealMP = metacarpophalangealFPL = flexor pollicis longusROM = range of motionANOVA = analysis of variance.

Percutaneous Urolithiasis Surgery in Military

Abstract. The clinical efficacy and safety of the use of percutaneous techniques in the treatment of kidney stones in 72 servicemen were studied. All percutaneous operations were performed by one operating team. It was found that percutaneous urolithiasis surgery was effective in 88.9% of people. Stone free rate was achieved in 83,8% of military personnel undergoing standard percutaneous nephrolitholapaxy and in 94.3% of patients undergoing minipercutaneous nephrolitholapaxy. With stones larger than 2 cm, the effect was observed in 81.8% of cases with standard surgery and in 96% of patients with mini-percutaneous approach. Percutaneous interventions in military personnel with stones larger than 2 cm were effective in 84,6% of patients with standard surgery and in 90% with mini-percutaneous access. Complications according to the Clavien-Dindo classification were found in 29,1% of servicemen: in 20,8% of cases of standard nephrolitholapaxy and in 8,3% of minipercutaneous nephrolitholapaxy. The bulk of the complications were Grade III 20,8%. Grade III IV were determined less frequently in 8,3% of cases. Urosepsis (Grade IV b) and death (Grade V) were not observed in our study. Duration of labor losses for conscripted servicemen were about 17 days, for contract servicemen when performing standard nephrolitholapaxy 12,8 days, for military personnel with minipercutaneous nephrolitholapaxy 11,2 days. The dismissal rate among conscripts was 18,2%. There were no contractual servicemen who were dismissed from the ranks of the Armed Forces of the Russian Federation, however, 14,7% of servicemen who underwent a standard operation and 11,1% of patients who underwent mini-percutaneous nephrolitholapaxy after surgery needed sick leave for a period of 15 days. In general, percutaneous techniques are common and effective methods of surgical treatment for military personnel suffering from urolithiasis. Mini-percutaneous approach for nephrolitholapaxy is safer than the standard approach, but it is less effective for coral calculi. Percutaneous methods for removing kidney stones are associated with a low rate of dismissal and short recovery times for military personnel.

Percutaneous Closure of the Patent Ductus Arteriosus in Very Low Weight Infants: Considerations Following US Food and Drug Administration Approval of a Novel Device

Percutaneous Closure of the Patent Ductus Arteriosus in Very Low Weight Infants: Considerations Following US Food and Drug Administration Approval of a Novel Device

Risk Factors for Posttracheostomy Tracheal Stenosis

Objective To determine the incidence of posttracheostomy tracheal stenosis and to investigate variables related to the patient, hospitalization, or operation that may affect stenosis rates. Study Design A combined retrospective cohort and case-control study. Setting Tertiary care academic medical center. Subjects and Methods A total of 1656 patients who underwent tracheostomy at a tertiary care medical center from January 2011 to November 2016 were reviewed for evidence of subsequent tracheal stenosis on airway endoscopy or computed tomography. Forty-three confirmed cases of posttracheostomy tracheal stenosis (PTTS) were compared with a subgroup of 319 controls. Factors including medical comorbidity, type and setting of tracheostomy, and hospitalization details were analyzed. Results Five-year incidence of PTTS was 2.6%. Obesity was the sole demographic factor associated with stenosis. Hospitalization-related variables associated with stenosis included tracheostomy after 10 days of orotracheal intubation and endotracheal tube cuff pressure ≥30 mm H2O. The surgical variables associated with higher rates of stenosis included percutaneous technique and insertion of an initial tracheostomy tube size >6. Bjork flap creation was negatively associated with stenosis. In multivariable analysis, obesity and insertion of tracheostomy tube size >6 were identified as risk factors. Conclusion Greater than 10 days of orotracheal intubation prior to tracheostomy and endotracheal tube cuff pressure ≥30 mm H2O were associated with greater rates of subsequent tracheal stenosis. The only patient-related factor associated with tracheal stenosis was obesity. Surgical variables associated with increased rates of subsequent stenosis included placement of a tracheostomy tube size >6, use of percutaneous technique, and failure to create a Bjork flap.

Real-time navigation in spinal surgery: what has changed in surgical practice?

The authors have carried out a retrospective study to assess the advantages of real-time spinal navigation with 3D-fluoro images (O-arm® and StealthStation® navigation systems, Medtronic, Minneapolis, MN, USA) versus fluoroscopy in spinal surgery. The aim of the study is to ascertain whether this technology has affected surgical indications and clinical practice. From January 2009 to December 2013, 421 patients underwent image-guided spinal surgery procedures in our department. They were divided into two main groups: group 1: operated on with C-arm fluoroscopic control; group 2: operated on with real-time navigation with 3D-fluoro images. All patients with vertebral osteosynthesis underwent a postoperative CT scan to check the final position of the screws. The screw misplacement proved to be 5.8% in group 1 and 1.5% in group 2. The odds ratio was 4.2 (95% confidence interval 2.3-7.5) with statistical significance (P<0.0001). The results clearly show an increased number of percutaneous procedures in group 2, as well as longer open osteosynthesis. Navigation with 3D-fluoro images reduces screw misplacement, facilitates osteosynthesis in the most difficult vertebral segments and allows broader use of percutaneous techniques, when indicated.

Percutaneous treatment of pulmonary embolism: diffusion and use of the technique in Italian interventional cardiology centers. Results of the PETER survey

Reperfusion in acute pulmonary embolism (PE) by percutaneous techniques is a valid therapeutic option when there is a formal contraindication to or failure of thrombolysis. In the last years, an increasing number of patients with acute PE have been treated with these techniques. In order to obtain a map of current availability and use of percutaneous techniques in PE, on behalf of the ANMCO Pulmonary Circulation Area, 56 Italian interventional cardiology and radiology departments, equipped with technology for percutaneous embolectomy, were invited to participate in a national survey. Questionnaires were e-mailed to each department from April to May 2015. Thirty-one out of 56 centers (54.8% in the North, 9.7% in the Center and 35.5% in the South of Italy) answered to the questionnaire. Percutaneous techniques were available in 90% of the cardiology departments involved, reporting also a good experience with their use in PE (77.4%). Only two responders were interventional radiology departments. AngioJet(®) and EkoSonic Endovascular System(®) (64.7% and 19.4%, respectively) were the most common devices used. Overall, in 2014, 62 patients were treated with percutaneous techniques, mainly in the North of the country. With regard to local diagnostic and therapeutic protocols, 61.3% of respondents reported owning one. Great interest was provided by participants in adhering to this national multicenter registry. Our results show the interest of Italian cardiology departments about percutaneous techniques as a therapeutic option for acute PE. Percutaneous techniques are largely available but still underused in routine clinical practice.

Contrast-enhanced ultrasound: Extended role outside 'regulations'.

Contrast-enhanced ultrasound (CEUS) has come a long way from the early pioneering days of ‘Doppler rescue’, interpreting the increased signal from vascular structures within potentially malignant tumours in the liver and the breast, and the improvement in the enhancement of large vessels. Early agents have fallen by the wayside, with newer agents allowing for lengthier imaging, using techniques that preserve the integrity of the microbubbles, and with improvement in separation of the acoustics of normal tissue and the microbubbles. The safety of microbubble contrast agents in the liver is undoubted, with adverse reactions seen less commonly than contrast agents used in other imaging modalities, further allowing for the safe progression into imaging other body structures. The true intra-vascular nature of the microbubble contrast is unique, potentially giving much better information in perfusion studies. The early indications for the use of CEUS, bound by the licensing constraints, were in the breast, liver, heart and peripheral vasculature. The legality of using the agents outside the licensing constraints is established and accepted, which has allowed clinicians to move into many other areas of the body, utilising the undoubted improvements microbubble contrast brings to the ultrasound (US) examination. CEUS is continuously being added to clinical practice in many areas by imaging pioneers, allowing the establishment of CEUS in many new areas. The addition of CEUS to the kidneys, pancreas, testis, aorta, spleen and salivary glands US examination improves the interpretation of findings, potentially reducing downstream imaging costs and alleviating patient anxiety. The singe area where non-licensed use of CEUS has been the most beneficial is in the assessment of the kidney. From the confirmation of normality, assessment of the simple and complex cyst to the establishment of intra-lesion vascularity in malignancy, CEUS has been unsurpassed for useful additional information to alter management. The kidney is likely to become the organ where CEUS is most frequently used, perhaps second to the liver in radiological practice. The use of percutaneous techniques to treat aneurysmal dilatation of the aorta, stent grafts in endovascular aortic repair (EVAR) results in life-long surveillance of complications, traditionally provided by computed tomography (CT). The use of CEUS has the potential to reduce the number of surveillance CT performed, with the additional benefit of alleviating the need for nephrotoxic contrast agents. Microbubble contrast agents are unique in two aspects: they are truly intravascular agents and any microbubbles in the aneurysmal sac indicate an endoleak, and they are not nephrotoxic, with no necessity to monitor renal function. The application in venous disease would also open opportunities for more accurate imaging. The usefulness of microbubble contrast agents in small parts is less clear; the interaction of the microbubbles with the transducer frequency is complex with the higher frequencies used in small parts imaging necessitating higher concentrations of microbubbles at the optimal size. Often, the use of CEUS in small parts is a component of the entire gamut of US: B-mode, colour and spectral Doppler, tissue elastography and CEUS, termed multiparametric US. This special issue contains articles that illustrate all the aspects of CEUS described above, allowing the establishment of the usefulness of this technique in clinical practice, increasing the knowledge pool that will eventually allow this technique to be fully accepted as an ideal and robust imaging tool. Most importantly, CEUS adds another layer of safety to the already safe US examination. This is surely also the tool for imaging in paediatrics – this may be just over the horizon.

Percutaneous thrombectomy in the treatment of acute pulmonary embolism: Initial experience of a single center

For years, the treatment of high-risk pulmonary embolism (PE) was based on two well-defined strategies: thrombolysis, whose benefits have been documented in randomized trials, and surgical embolectomy. However, mechanical reperfusion by percutaneous techniques is used in an increasing number of patients, and is a valid therapeutic option when there is a formal contraindication to thrombolysis, as rescue therapy when thrombolysis fails to improve hemodynamics, and/or when emergency surgical thrombectomy is unavailable or contraindicated.This article discusses the indications for the use of percutaneous techniques in PE, reports the initial experience of our center with the AngioJet® thrombectomy device (Possis Medical Inc., Minneapolis, MN, USA) and reviews the available evidence, the most recent recommendations and the main complications associated with this procedure.

Trombectomia percutânea reolítica no tratamento de tromboembolismo pulmonar de alto risco: experiência inicial de um centro

For years, the treatment of high‐risk pulmonary embolism (PE) was based on two well‐defined strategies: thrombolysis, whose benefits have been documented in randomized trials, and surgical embolectomy. However, mechanical reperfusion by percutaneous techniques is used in an increasing number of patients, and is a valid therapeutic option when there is a formal contraindication to thrombolysis, as rescue therapy when thrombolysis fails to improve hemodynamics, and/or when emergency surgical thrombectomy is unavailable or contraindicated.This article discusses the indications for the use of percutaneous techniques in PE, reports the initial experience of our center with the AngioJet® thrombectomy device (Possis Medical Inc, Minneapolis, MN, USA) and reviews the available evidence, the most recent recommendations and the main complications associated with this procedure.

Early graft failure after infrainguinal arterial bypass

Early graft failure (EGF), defined as failure within 30 days of an index procedure, is aserious complication after infrainguinal arterial bypass. EGF has not been examined by the use of national data since the widespread adoption of percutaneous treatments for arterial occlusive disease. We used data from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent infrainguinal arterial bypass from 2005 to 2011 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. The frequency of 30-day EGF was determined. Univariate and multivariate analyses evaluated risk factors for EGF. Of 23,468 patients who underwent open infrainguinal arterial bypass, 1,065 (4.5%) had EGF. Patients who had EGF were more likely to have a prolonged duration of stay (34.8% vs 12.0%, P< .001), greater rates of reoperation (82.1% vs 14.3%, P < .001) and increased 30-day mortality (5.1% vs 2.1%, P < .001). The rate of additional complications in patients who experienced EGF was 42.0%, compared with 25.4% in those who did not have EGF (P < .001). Patients who experienced complications in addition to EGF were more likely to have complications after graft failure (69.5% vs 31.3%). In multivariable analysis, EGF was associated with younger age, female sex, black race, obesity, thrombocytosis, increased international normalized ratio, femoral-to-tibial bypass, prosthetic graft, and emergent operation. The incidence of EGF after open lower extremity arterial bypass has not increased in an era of increased use of percutaneous techniques. Nevertheless, EGF occurs in almost 5% of patients and is strongly associated with additional complications and mortality. Identifying patients at risk for EGF may facilitate modification of contributing factors. Diminishing the incidence of graft occlusion will lead to decreased morbidity and mortality in this cohort of patients.

Pioneer re‐entry device for iliac chronic total occlusion: Truly a Paradigm shift

The number of percutaneous revascularization procedures performed for symptomatic peripheral arterial disease has significantly increased over the past several years. Traditionally, the use of percutaneous techniques were limited to certain anatomic subsets, such as stenosis or focal occlusions, with surgical treatment preferred for more extensive disease. More recently, endovascular specialists are facing the challenge of peripheral chronic total occlusions. Furthermore, unlike the coronary circulation, these occlusions are often very long and associated with other features of complexity such as severe calcifications. One of the primary issues concerning these lesions is the ability to safely achieve initial angiographic success. This article focus indeed on the Pioneer catheter, a new lumen re-entry device exploiting intravascular ultrasound imaging that was used in a case of totally occluded left common iliac artery with favorable results. The details of this technique, and how this catheter helped in re-entering the true lumen at the aortic bifurcation after subintimal dissection, are thoroughly discussed.

Retrograde Approach to a Diverticular Kidney Stone through a Vesicoureteral Cohen's Reimplantation: A Novel Surgical Technique

Cohen's technique is the standard treatment of vesicoureteral reflux in children. Its disadvantage is still the classic difficulty in subsequent retrograde ureteral access, requiring the use of percutaneous techniques in the treatment of kidney stones. We describe a novel surgical technique for retrograde catheterization of an adult ureter by a flexible ureterorenoscope, thereby facilitating the treatment of a symptomatic diverticular kidney stone. We compare our technique to other methods described in the literature.

Percutaneous Salvage of Thrombosed Immature Arteriovenous Fistulas

Thrombosed immature fistulas have historically been considered unsalvageable. However, advances in procedure and balloon catheter technologies have expanded the scope of endovascular treatments. This study investigates the efficacy, functionality, and cost associated with the use of percutaneous techniques for the salvage of thrombosed immature fistulas. Over a 2-year period and from a population of 18,000 patients on hemodialysis, 140 consecutive patients with thrombosed immature fistulas underwent attempts at salvage via thrombectomy procedures. All fistulas had thrombosed following access creation and had never been used for hemodialysis. Multiple approaches were utilized to gain access to the fistula, including trans-fistula cannulation, distal arterial puncture, and proximal retrograde venous access. Thrombectomy was performed via balloon maceration and aspiration. Accelerated maturation was achieved through sequential angioplasty of diffusely stenotic veins and elimination of competing branch vessels. Primary access, primary assisted, and secondary access patencies were calculated at 3, 6, 12, and 24 months. A cost analysis was performed based on procedure statistics and the 2009 Medicare reimbursement schedule and compared with data from the 2009 United States Renal Data Survey. Thrombectomy was successful in 119 (85%) immature clotted fistulas, and hemodialysis adequacy was achieved in 111 (79%) fistulas. The average maturation time from thrombectomy to cannulation for dialysis was 46.4 days, with an average of 2.64 interventions per patient. There were 5 (3.5%) cases of angioplasty-induced rupture, all of which were treated with stent placement. Clinically significant pseudoaneurysm formation occurred in 4 (2.8%) patients. At 12 months, secondary access patency of salvaged accesses was 90%. Based on 2009 Medicare outpatient billing rates per patient per initial access-year and the maturation times observed in the New York area, percutaneous salvage of thrombosed immature fistulas costs $4881 to $14,998 less than access abandonment and new access creation. Endovascular techniques can be used for the salvage of thrombosed nonmaturing fistulas. When analyzed within the initial access-year, this approach yields significant cost savings over access abandonment.

Massive Hepatic Necrosis with Gastric, Splenic, and Pancreatic Infarctions after Ethanol Ablation for Hepatocellular Carcinoma

Hepatic necrosis after ethanol ablation for hepatocellular carcinoma (HCC), although rare, is well known and described, particularly in patients with chronic liver disease. The present report describes a rare case of massive hepatic necrosis with partial gastric, splenic, and pancreatic infarctions after local treatment of liver HCC with ethanol ablation and discusses the reasons for this complication. With the increasing use of percutaneous techniques to treat liver tumors, it is imperative for the interventional radiologist to be aware of the potential vascular complications of these techniques. An appreciation of vascular anatomy via multidetector computed tomography (CT) and/or magnetic resonance (MR) angiography is important when planning image-guided interventions.

Increased Use of Percutaneous Technique for Totally Implantable Venous Access Devices. Is It Real Progress? A 27-Year Comprehensive Review on Early Complications

First implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD's implant. An extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient's number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence. A total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique. Despite the increased use of percutaneous technique for TIVADs' implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

Chronic total occlusions in peripheral vasculature: techniques and devices

Peripheral artery disease continues to increase in an ever-aging society and consumes a significant part of health resources. Chronic total occlusions account for a significant portion of the lesions encountered by endovascular interventionalists. Unlike the coronary circulation, these occlusions are often long and associated with other features of complexity. The two primary issues concerning these lesions are the ability to safely achieve intimal angiographic success and the long-term durability of therapy. Traditionally, the use of percutaneous techniques was limited to certain anatomic subsets, such as stenosis or total occlusions. However, recent advances in wire technology, re-entry catheters, alternative crossing tools and atherectomy devices have increased the interventional armamentarium for this challenging disease subset. This article will focus on some of the techniques in crossing chronic total occlusions lesions, as well as the available devices to improve long-term patency.

Challenges in the interventional therapy of prosthetic paravalvular leaks

Aims: Paravalvular leaks (PVL) are a rare complication of prosthetic valve replacement. In most cases PVL are asymptomatic, but some may cause symptoms due to regurgitation volume or haemolysis. Since re-operation carries significant risk, there has been a growing interest in the attempt to close PVL through the use of percutaneous techniques with occluder-devices.