Vascular Interventional Radiology Research Articles

Comparing Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic and Asymptomatic Carotid Stenosis

Objective: In patients with symptomatic and asymptomatic carotid artery stenosis, this retrospective observational study compared the clinical outcomes and side effects of carotid endarterectomy (CEA) with carotid artery stenting (CAS). The study took patient-specific risk variables into account and concentrated on major adverse cardiovascular events (MACE), such as myocardial infarction (MI), stroke, readmission, and death. Material and Method: This was a retrospective observational study carried out at Vascular Surgery Department and Interventional Radiology department of two tertiary care hospitals in Rawalpindi, from Jan 2022 to March 2023. With a 30-day follow-up, 60 patients from two Pakistani tertiary care centres underwent either carotid end arterectomy and carotid artery stenting were included. Patient having asymptomatic and symptomatic carotid disease were selected for the procedure. The impact of risk factors on procedural success and development of major adverse cardiovascular events (MACE) was examined in the study. Data regarding 30-day postoperative parameters of the procedure were collected and evaluated. p< 0.05 is considered significant. Results: The majority of patients in our series were males 46(77%) compared to 14(23%) females in the study. There were no intraoperative mortalities in our patients. The mortality rate of CAS alone was 1(1.66%). Four patients developed complications. Three in CAS group and 1 in CEA group. Comorbidities were present in 46(77%). Conclusion: Compared to CEA, CAS is linked to a greater risk of stroke or mortality in patients with symptomatic carotid stenosis within 30 days of treatment. Patients' unique characteristics, age, comorbidities, and previous surgical experiences should guide the choice of treatment.

Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions

Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI). A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a 5-point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on ten previously videorecorded elective PVI cases. The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (IQR 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case. An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.

Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center

ObjectiveResuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution. MethodsWe performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests as appropriate for the variable type. ResultsWe identified 99 patients who underwent REBOA placement during the study period. The mean age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia. ConclusionsAlthough vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement.

Principles of Optimal Antithrombotic Therapy for Iliac VEnous Stenting (POATIVES): A national expert-based Delphi consensus study

ObjectiveManagement of antithrombotic therapy in patients undergoing venous stents has not yet reached consensus, and there are not any recommendations from published guidelines. We undertook a Delphi consensus from Chinese experts to develop recommendations regarding the preferred antithrombotic therapy in patients following venous stenting. MethodsThe phase 1 questionnaire was comprised of three clinical scenarios of venous stenting for non-thrombotic iliac vein lesions (NIVL), acute deep vein thrombosis (DVT), and post-thrombotic syndrome (PTS) and was sent to venous practitioners across China. In phase 2, the results of phase 1 were distributed to a panel of experts for evaluation along with a questionnaire encompassing a series of statements produced during phase 1. A modified Delphi method was used to reach consensus on recommendations through two rounds of surveys. ResultsThe phase 1 questionnaire was completed by 283 respondents. In phase 2, an expert panel consisting of 28 vascular surgeons and interventional radiologists was assembled and voted 17 statements relating to antithrombotic management after venous stenting for NIVL (4 statements), DVT (6 statements), and PTS (7 statements). The majority of the statements about the antithrombotic agent selection received a high consensus strength. ConclusionsBased on the national Delphi consensus of Chinese experts regarding antithrombotic therapy following iliac venous stenting in three common scenarios, most of the statements could be used to guide antithrombotic management following venous stenting. Further studies are required to clarify controversial issues including the dose and duration of anticoagulants, the role of antiplatelet agents, especially in patients with NIVL.

An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA)

Objective: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). Methods: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts’ responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round’s answers was also graded using Cohen’s kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. Results: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. Conclusions: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. Clinical Impact This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.

FORWARD Study of GORE VIABAHN Balloon-Expandable Endoprostheses and Bare Metal Stents in the United States, European Union, United Kingdom, Australia, and New Zealand When Placed to Treat Complex Iliac Occlusive Disease: Protocol for a Randomized Superiority Trial.

The recommendations for the use of and selection of covered stent grafts in patients with aortoiliac occlusive disease are limited. The GORE VBX FORWARD clinical study aims to demonstrate the superiority of the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (VBX device) for primary patency when compared to bare metal stenting (BMS) for the treatment of complex iliac artery occlusive disease. A prospective, multicenter, randomized control study in the United States, European Union, United Kingdom, Australia, and New Zealand will enroll patients with symptomatic, complex iliac artery occlusive disease. In this study, iliac artery occlusive disease is defined as a unilateral or bilateral disease with single or multiple lesions (with >50% stenosis or chronic total occlusion) each between 4 and 11 cm in length. In an attempt to more closely match real-world practices, patients with minor tissue loss (Rutherford class 5) and patients requiring hemodialysis will be included. Baseline aortoiliac angiography will be performed to assess target lesion characteristics and determine final patient eligibility. Once the patient is confirmed and guidewires are in place across the target lesions, the patient will be randomized in a 1:1 format to treatment with either the VBX device or a BMS. The BMS can be balloon- or self-expanding and must be approved for the iliac artery occlusive disease indication. Patients, the independent core laboratory reviewers, and Clinical Events Committee members will be blinded from the assigned treatment. Dual antithrombotic medical therapy is required through a minimum of 3 months post procedure. The primary end point is 12‑month primary patency and will be adjudicated by an independent imaging core laboratory and Clinical Events Committee. Key secondary end points will be tested for superiority and include technical, acute procedural, and clinical success; changes in Ankle-brachial index; patient quality of life; primary patency; freedom from restenosis; primary-assisted patency; secondary patency; freedom from target lesion revascularizations; cumulative reintervention rate; amputation-free survival; survival; and change in Rutherford category. Study follow-up will continue through 5years. Outcomes will be reported following study completion. Enrollment is anticipated to start in October 2023. The results of this study will provide definitive, level 1 clinical evidence to clinicians on the optimal choice of stent device to use for the treatment of complex iliac artery occlusive disease. The FORWARD study is powered for superiority and includes only complex, unilateral, or bilateral lesions involving the common or external iliac arteries. This study is a multidisciplinary endeavor involving vascular surgery, interventional cardiology, and interventional radiology across multiple countries with a blinded core laboratory review of end points in hopes that the outcomes will be widely accepted and incorporated into practice guidelines for optimal treatment of patients with complex iliac artery occlusive disease. ClinicalTrials.gov NCT05811364; https://clinicaltrials.gov/study/NCT05811364. PRR1-10.2196/51480.

Supporting endovascular practice in 2023 and beyond: the BSET Fellowship Programme

British Society of Endovascular Therapy (BSET) Fellowships were introduced to provide an opportunity for vascular or interventional radiology trainees to acquire new or more complex endovascular skills during a 6-month period in a UK-based endovascular unit of their choice. They were established in 2008 in response to the rapidly expanding field of endovascular practice, with the aim to support high quality endovascular training as well as a new hybrid skillset for those from a vascular surgical background. Since vascular surgery gained independence as a specialty in 2012, evolutions in both vascular surgery and interventional radiology training programmes have facilitated increased exposure to complex endovascular interventions. However, these Fellowships continue to offer a unique opportunity, where trainees benefit from a period of concentrated exposure, working to develop a specific subspecialty interest and ‘fine tune’ their skills in preparation for consultant practice. Further, these Fellowships also offer interventional radiology trainees to be exposed to a larger volume and variety of endovascular procedures, benefiting their future independent practice.

Analysis of endovascular therapy for peripheral arterial disease in all German hospitals.

Background: The quality of vascular care has significantly improved in part by the expansion of endovascular techniques for the treatment of symptomatic peripheral artery disease (PAD) in recent years. In Germany these are primarily provided by the three disciplines of vascular surgery, angiology, and interventional radiology (IR). However, the relative contribute of angiologists to the total number of cases performed is unknown. Patients and methods: In the present study, we analysed the respective contribution of vascular surgery, angiology, and IR to the delivery of endovascular revascularisations in symptomatic PAD in Germany based on the legally mandatory quality reports representative for the reporting year 2018. Results: Vascular surgery is the most common speciality reporting procedures in German hospitals (n=579; 25.1%), followed by IR (n=264; 11.5%), angiology (n=189; 8.2%) and cardiology (n=17; 0.7%). The combination of vascular surgery and IR was reported in 202 (8.8%), vascular surgery and angiology in 167 (7.2%) and angiology and IR in 65 (2.8%) hospitals, and 63 (2.7%) hospitals reported the combination of all three disciplines. Not every department performed catheter interventions. The analysis of procedures per centre revealed that angiology centres provided the highest numbers for both basic procedures and more complex techniques such as atherectomy, rotational thrombectomy, lithoplasty, selective thrombolysis or the use of re-entry devices. In total, angiology centres provided 24.4% of the total procedures or 23.9% of the so-called basic procedures as a surrogate for patient numbers. Conclusions: While each of the disciplines contribute significantly to the endovascular procedures, angiology centres perform more procedures per centre and more complex procedures than the other disciplines highlighting the important quantitative and qualitative contribution of angiology specialists to the care of vascular patients. The inpatient catheter interventional care of patients with PAD is still too rarely carried out in a multi-disciplinary manner in Germany.

Some of the Dilemmas About Creating Arteriovenous Fistulas for Hemodialysis

Abstract The native arteriovenous fistula for haemodialysis has been described as the Achilles heel but also the Cinderella of haemodialysis. Arteriovenous fistula has been the vascular access of choice for haemodialysis, because of lower cost, morbidity and mortality. The significance of a functioning vascular access is that it takes on a major role in determining a positive outcome. Yet, they are a cause of great stress, both for patients and healthcare professionals. About 80% of patients begin dialysis with central venous catheters, 20-70% of fistulas do not reach maturity, and a fifth, of all fistulas, thrombosed before use. A quarter die from poor vascular access. Insufficient number of vascular surgeons and inadequate training to create vascular access often lead to "congestion" of the bed stock in nephrology. Surgeons and radiologists perform all procedures related to vascular approaches, but the dominant role of nephrologists is in the organization of planning and realization of creating a vascular access. Initiation of dialysis in the elderly and diabetics, as a risk population of patients for arteriovenous fistula, is associated with many problems, among which the creation, functioning and maturation of the vascular access dominate. Hyperdynamic conditions, due to arteriovenous communication in patients with arteriovenous fistula, are cited as a possible mechanism for increasing morbidity. However, there is still no agreement within the nephrology community regarding the height of the hemodynamic load and the indication for closing the vascular access. There are many dilemmas associated with creating, care and using an arteriovenous fistulas, and that could be the reason and justification to form a team for vascular access, which would, in addition to nephrologists, include vascular surgeons, interventional radiologists and nurses.

Trans-Arterial Chemoembolization for the Treatment of Hepatocellular Carcinoma: A Single Tertiary Care Institute Experience

Introduction: Trans-arterial chemoembolization (TACE) is a mainstay therapeutic option indicated in early-stage non- resectable hepatocellular carcinoma (HCC) and has been shown to be associated with survival improvements. This study aimed to evaluate the radiological and clinical response of those who underwent TACE. Aims & Objectives: We aimed to evaluate the radiological and clinical response in patients who underwent Trans- arterial chemoembolization. Place and Duration of Study: This study was conducted in the Vascular Interventional Radiology Department, Dow Institute of Radiology, Dow University of Health Sciences, Ojha Campus Karachi for a period of 18 months between January 2021 and June 2022. Material & Methods: HCC patients (n=181) who underwent TACE as their primary treatment at Dow Hospital Ojha Campus Karachi between January 1st, 2021, and June 30th, 2022 were included. Inclusion criteria followed the Barcelona Clinic Liver Cancer (BCLC) and Child-Pugh staging systems. Tumor response was evaluated using “modified Response Evaluation Criteria in Solid Tumors (mRECIST)”, and patients were categorized into complete response (CR) or partial response (PR) groups. The study compared background, clinico-laboratory, and radiological features between these groups, including HCC sizes and CT scan findings before and after TACE. The retrieved data was entered and analyzed using SPSS version.21. Results: Of the total 118 patients, 51.70% showed CR to the TACE, while PR was noted in 48.30%. Age, sex, viral hepatitis, and co-morbids showed no intergroup differences. However, Child-Pugh stage and BCLC were significantly associated with tumor response. Similarly, laboratory parameters revealed significant mean differences between the two groups (p<0.001), except international normalized ratio and alanine transaminase. Those who had achieved CR had a mean number of tumor less than that of PR. Similarly, tumor size significantly decreased post-TACE (p<0.0001). Moreover, arterial-phase enhancement and portal venous and delayed phases washout tumors before TACE were reported in 76.30%. Over half of the patients had no residual tumor tissue after TACE. Tumors with arterial-phase enhancement and portal venous and delayed phases washout were highly susceptible to TACE.Furthermore, Child-Pugh classA had a greater estimated mean survival than class B (p<0.001). Conclusion: Over half of the patients showed complete response to the TACE. BCLC staging (B), Child-Pugh (stage A), and small tumors had a favourable effect on the radiological and clinical response in the early-stages of HCC. Tumors with an arterial-phase enhancement and portal venous and delayed phases washout were more susceptible to TACE.

Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma

In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology. Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

Risk of Hepatic Artery Complications After Liver Transplantation in Patients Who Received Pretransplant Transarterial Chemoembolization Therapy: A Single-Center Experience

Pretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center. We performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months. Among the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I=1.8% and Group II=1.9% (P=.9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P=.1 and .2, respectively). Our study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE.

#4066 EARLY EXPERIENCE OF ENDOVASCULAR CREATION OF ARTERIOVENOUS FISTULA IN SOUTHEAST ASIA

Abstract Background and Aims Creation of native arteriovenous fistulae(AVF) has been traditionally through open surgical technique. Endovascular creation of AVF (EndoAVF) has been shown to be an effective alternative to open surgery in Europe and North America. In Asia, EndoAVF creation is a novel technique and we report our early experience of EndoAVF creation in a case series of 18 patients. Method Between Nov 2021 to Aug 2022, ultrasound vein mapping was performed in a total of 39 patients. Eighteen patients were deemed suitable for EndoAVF and proceed for the procedure. EndoAVF creation was attempted by multidisciplinary team comprising of vascular surgeon, interventional radiologists and nephrologists. The patients were prospectively followed-up for at least 6-months. Baseline demographics, vascular characteristics, unassisted maturation, functional patency and freedom from intervention were studied. Results Table 1 shows the baseline demographics of the participants. Twelve patients (67%) were already initiated on hemodialysis via tunneled dialysis catheters during the procedure. EndoAVF was successfully created in 16 (89%) patients. Of which, 13 (72%) were WavelinQ while the remaining 5 (28%) were Ellipsys EndoAVF. The reasons of failures were inability to cannulate artery (n = 1) and vein (n = 1). Minor complications occurred in 6 patients: extravasation in 5 cases and hematoma in 1 patient. The brachial artery flow rates at creation and 1-month post-creation were 558 ± 328 and 583 ± 215 mls/min, respectively. Two participants (11%) underwent interventions to facilitate maturation of the EndoAVF. The median time to maturation was 70 (IQR 49 – 106) days while the median time to first successful 2-needle cannulation was 77 (56 – 127) days. At 6-months, 8 (50%) of EndoAVFs that were successfully created required further intervention to maintain patency, while 1 EndoAVF was abandoned from failure to mature despite intervention Conclusion EndoAVF can be created successfully in a Southeast Asian population. Further studies with more patients and longer follow-up periods are needed to assess long-term outcomes.

Practice Patterns in the Management of Chronic Limb Threatening Ischemia by BEST-CLI Investigators

BEST-CLI trial investigators had diverse practice patterns in treating complex chronic limb-threatening ischemia (CLTI). We assessed investigator practices and comfort towards complex open surgical and endovascular procedures. An electronic survey was sent out to 1180 BEST-CLI investigators at 150 sites in 2022, after trial conclusion and before announcement of results. The survey consisted of 43 questions focused on practice patterns. There were 238 investigators (20.2%) that submitted responses. Respondents were 80% male, 68.2% White, and 15.3% from outside the United States. Respondents included vascular surgeons (76.3%), interventional cardiologists (11.4%), and interventional radiologists (11.6%). The majority (72.6%) were in academic practice, with 39.1% in practice >20 years and 30.5% in practice 11 to 20 years. For initial CLTI workup, respondents always/usually ordered an arterial duplex (65.8%), computed tomography angiography (42.6%), magnetic resonance angiography (4.5%), and vein mapping (55.9%). Surgeon case volumes in a typical year, recorded as 0, 1 to 10, and >10, for alternative autogenous vein were 12.6%, 69.5%, and 17.8%; composite vein 17.2%, 79.9%, and 2.9%; prosthetic conduit 4%, 84.6%, and 11.4%; composite sequential bypass 58.8%, 38.2%, and 2.9%; bypass to pedal targets 8%, 81.7%, and 10.3%; and hybrid procedures 2.3%, 56.7%, and 41%. Postoperatively, 99% and 81.9% reported performing routine duplex surveillance of vein and prosthetic bypass, respectively. Among all interventionalists, yearly endovascular interventions were 0, 1 to 10, and >10, utilized radial access 54.5%, 37.6%, and 8%; pedal/tibial access 24%, 61%, and 24%; pedal loop revascularization 62.3%, 29.7%; 8%. The majority (86%) ordered routine duplex surveillance following endovascular revascularization. Most respondents reported routinely using paclitaxel balloons (88.1%) and stents (67.5%). There were 73.3% that altered practice when safety concerns were raised, whereas 63.9% resumed use of these devices. A minority reported always/usually using WIfI (25.8%), GLASS (8.3%), and a risk calculator (14.8%) in their clinical practice. There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced open and endovascular techniques and represent a real-world sample of technical expertise.

Efficacy of Pigtails for the Management of Refractory Malignant Ascites or Effusion: A Systematic Retrospective Chart Review of an Institution

Introduction: Malignant ascites and effusions have been observed in various diseases and persistent ascites or effusion from any of causes prompts the need for urgent first-line therapies. Refractory forms of ascites and effusion can cause noteworthy symptoms and can severely affect the quality of life (QoL). We therefore assessed the viability, efficacy, and patient-reported results of pigtails in the administration of refractory ascites or effusion due to malignancy.&#x0D; Aims &amp; Objectives: We aimed to assess the viability, efficacy and patient-reported results of pigtails in the administration of refractory ascites or effusion by malignancy.&#x0D; Place and duration of study: It was conducted in Vascular Interventional Radiology Department, Dow Institute of Radiology, Dow University of Health Sciences, Ojha Campus for a period of 18 months between January 2021 and June 2022.&#x0D; Material &amp; Methods: A retrospective chart review from a single center was done. All available data of the Interventional Radiology Department was utilized to identify patients(n=65) with refractory malignant ascites or effusion who underwent pigtail placement. Data analysis was performed using SPSS version 21, p?0.05 was taken as significant. Results: Procedural success rate was 100% for placement and similarly no mortality was observed. Duodenal, liver and ovarian cancer was the primary source of malignancy. The catheters, 8Fr (n=45, 69.20%) and10Fr (n=20, 30.80%) were implanted. Leakage was the highest experienced complication followed by dislodgement. Overall catheter mean survival time was [23.37days, 95%:21.63- 25.10]. The estimated mean [(24.46, 95%21.98-26.94 Vs 22.53, 95%20.08-24.97)]&#x0D; duration of catheter dwelling time for pleural effusion was greater than that of ascites (p&gt;0.05). Overall, estimated mean time for 8Fr catheter was greater than that of 10 Fr (p=0.048). Infection and leakage had an estimated mean catheter survival time lower than that of dislodgment and occlusion [log rank-chi square 13.64,p=0.003].&#x0D; Conclusion: Procedural success rate achieved was 100% and acceptable outcomes in terms of complications and catheter time. These minimally invasive treatment options should be utilized to soothe symptoms and improve the QoL.Furthermore, experimental studies with bigger sample size assessing the adverse outcome and ascertaining the possible cost savings should be performed.

A pilot study of the use of artificial intelligence with high-fidelity simulations in assessing endovascular procedural competence independent of a human examiner.

With increased need for vascular surgery trainees to gain endovascular surgery proficiency, current models of case-numbers and subjective visual assessment are inadequate in capturing the skills required in endovascular surgery. We explored the use of high-fidelity simulators in (1) assessing endovascular surgical competence; (2) clinical decision making; and (3) the reliability of an artificial intelligence (AI) assessor. Registrars, fellows and consultants from vascular surgery, interventional radiology and general surgery performed identical procedures on a high-fidelity simulator. Performance was independently assessed using a modified Reznick scale. Scores were compared to raw metric data extracted from the simulator, objective scores extracted from the recordings and analysed by AI. 22 participants were enrolled from vascular surgery (n = 6, 27.3%), interventional radiology (n = 10, 45.5%) and general surgery (n = 6, 27.3%). There were 12 trainees, 2 fellows and 8 consultants. Significant correlations between raw metric data and all categories of the modified Reznick scale except 'respect for tissue' were found. An AI demonstrated positive reliability in all categories, with some predictions being moderately correlated. The use of high-fidelity simulators to assess endovascular surgical competence has comparable correlations to the traditional assessment methods with global rating scales, which can be used in formative assessment. AI demonstrates an ability to support assessment but requires further research.

Impact of Multidisciplinary Team Meetings on Decision Making in Vascular Surgery: A Prospective Observational Study

This cohort study aimed to prospectively determine the impact of multidisciplinary team meetings (MDTs) on treatment plans in vascular patients. The weekly MDT at the institution consisted of a structured discussion of vascular cases in the presence of at least one representative of each specialty from vascular surgery, angiology, and interventional radiology. Participants were asked to examine the cases entered on the digital MDT platform and to fill in forms with a detailed open text treatment recommendation for each patient. Individual recommendations were compared with the final MDT decision, which was based on a shared decision after discussion of clinical and radiological data. The primary endpoint was the agreement rate. The rate of decision implementation was determined to verify the adherence to MDT recommendations. Four hundred consecutive case discussions in 367 patients between November 2019 and March 2021 were included, excluding patients needing urgent treatment, yielding MDT discussion in 88.5% of carotid artery cases, 83% of aorto-iliac cases, and 51.7% of peripheral arterial cases, which included 56.9% of the chronic limb threatening ischaemia cases. The overall average agreement rate was 71% ± 41%. Analysis according to the specialty of the attending physician showed agreement rates of 82% ± 30% for senior vascular surgeons, 62% ± 44% for junior vascular surgeons, 71% ± 43% for interventional radiologists, 58% ± 50% for angiologists (p < .001), and 75% ± 38% considering only senior practitioners. The inter-rater agreement, resulted in kappa coefficients of 0.60 - 0.68 for senior vascular surgeons, 0.29 - 0.31 for junior vascular surgeons, 0.39 - 0.52 for interventional radiologists, and 0.25 for angiologists. The MDT treatment decision was implemented in 353 (96.2%) cases. The impact of MDT discussion on treatment recommendations and the adherence to MDT recommendations were significant and in line with results reported from other specialties.

Eficacia y seguridad de la embolización de arterias uterinas en el manejo de la hemorragia posparto

ObjectiveTo demonstrate the safety and efficacy of endovascular treatment in postpartum hemorrhage. Material and methodsWe conducted a retrospective observational study with a sample from our Interventional Vascular Radiology unit, from 2004 to 2020. Patients who developed postpartum hemorrhage treated by arterial embolization were selected. Inclusion criteria were established to standardize the study group. Variables for the study of the efficacy and safety of the technique are defined. ResultsThe final sample of the study was 56 patients. Technical success turned was 100%, while clinical success after endovascular treatment was 92.85%, with a hysterectomy rate due to failed arterial embolization of 7.14%, with uterine rupture observed in 3 cases as a cause of postpartum hemorrhage. No technique-related mortality was recorded. The rate of periprocedural complications was 3.56%, the same as that of late complications. No major or infectious complications were recorded. The pregnancy rate after embolization was 23.52%. ConclusionsSelective arterial embolization of the uterine artery in postpartum hemorrhage is a safe and effective procedure, being a therapeutic alternative in the face of failure of pharmacological and obstetric management, with preservation of fertility.

Radiology Nursing Saudi Career Development Program: Single Center Experience

The vast variety and complexity of procedures done in vascular interventional radiology necessitates highly specialized and experienced nursing care throughout the procedures. Although no specific qualification is currently required to practice as Vascular Interventional radiology (VIR) nurse in Saudi Arabia, most employers require prior experience in intensive care units, emergency rooms, or post anesthesia care units. Here we report our institutional experience in specialized nursing training in vascular interventional radiology. This proposed program prepares graduate nurses to practice VIR nursing with greater level of competency.

Evaluation of hemodialysis vascular access involving multidisciplinary integration: Perspective from Latin America and Peru.

The perspective of vascular access care in patients with end-stage renal disease has migrated from nephrology-centered or vascular surgery-centered care to multidisciplinary-focused patient-centered care. This new perspective should not only be theoretical but also have practical utility. A non-multidisciplinary focus can contribute to the low prevalence of arteriovenous fistula (AVF) in the population. Latin America has multiple health systems and the coordination of vascular access is heterogeneous. In Peru, there is a high prevalence of central venous catheter use with its associated complications, such as stenosis, thrombosis, infection, and recurrent hospitalizations in the context of fragmented care. However, in the last few years, there has been an effort to integrate the communication between vascular surgery, interventional radiology, and nephrology to improve vascular access care. In this review, we analyze the availability of care, the intervention, and the future directions from the experience of both perspectives.