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Background The purpose of this study is to determinate the cost-effectiveness of carotid endarterectomy (CEA) versus transfemoral stenting (TFS) and transcervical stenting (TCS) in a short- and long-term basis in symptomatic and asymptomatic patients. Methods From January 2003 to December 2014, patients from the vascular department, with symptomatic or asymptomatic carotid stenosis, who were clinically and anatomically suitable for TFS, TCS, or CEA, were included. Prospective cost data for each individual procedure and complication during follow-up were obtained from the diagnosis-related group. The quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios were estimated. Analysis of data was by treatment received. All statistical tests were two-sided. The significance level was 5%. Results A total of 349 patients were enrolled: 61 for CEA (17.5%), 159 for TFS (45.5%), and 129 for TCS (37%). A total of 220 (63%) patients were symptomatic and 129 (37%) were asymptomatic. The median procedural cost and overall cost were lower on CEA (5499€ and 5595€, respectively). However, QALYs, for symptomatic patients, were better on TCS (7.3), whereas for asymptomatic patients, QALYs were better on CEA (9.6). Cost-effectiveness for symptomatic patients was better with TCS (803€/QALY), and for asymptomatic patients, it was with CEA (654€/QALY). Conclusions TFS and TCS were associated with clinical outcomes equivalent to CEA on both symptomatic and asymptomatic patients. Cost-effectiveness ratios for symptomatic patients were better on TCS, whereas the CEA showed the best results in asymptomatic patients.

Background Pelvic congestion syndrome (PCS) is a frequent finding in adult women and transcatheter embolization of dilated and refluxing veins is the treatment of choice. The procedure can be performed through different venous accesses such as the transfemoral, transjugular, and the transbrachial access. The aim of this study was to demonstrate the feasibility and safety of the transbrachial approach for transcatheter embolization in this pathology in 201 women. Advantages and disadvantages of this access were discussed. Methods Between January 2007 and October 2020, female patients who underwent transcatheter embolization for PCS were selected. Embolization procedural details such as venous access sites and embolized veins were collected. Results Two hundred and one patients were selected for pelvic vein embolization due to PCS. The basilic vein was punctured in 103 patients (51.2%), the cephalic vein was chosen in 76 patients (37.8%) and deep brachial veins in 19 (9.6%). Technical success was observed in 198 (98.5%) cases. Only one major adverse effect was registered; one patient presented with hematoma of the arm that could be managed conservatively. Conclusion The transbrachial venous approach for PCS embolization is safe, effective and minimal invasive. It provides a significant patient comfort, has a low complication rate and can be performed on an outpatient basis.

Ischaemic stroke is a common cause of death and incapacity and is related in most cases to vascular disease. Intracranial vessel occlusion due to tumour emboli is a rare entity and adequate treatment for this condition is not defined. The use of mechanical thrombectomy devices is considered the treatment of choice for major intracranial vessel occlusion; however, no recommendation can be made in the case of tumour thrombembolia. This report describes two cases who presented with a middle cerebral artery occlusion due to tumour emboli and that were treated using the Solitaire thrombectomy device.

Anatomical variations of the renal arteries may complicate endovascular repair of infrarenal abdominal aortic aneurysms (AAA). Occlusion of renal branches may be necessary to seal the aneurysm sac efficiently. Depending on the size of the affected renal arteries and the supplied parenchyma, this can lead to loss of renal function. Iliac branch devices (IBDs) have been created in order to preserve the internal iliac artery in aortoiliac or isolated iliac aneurysms; however, IBDs have the potential to maintain patency of other arteries as well. This case report describes the off-label use of an IBD inside the main body of a bifurcated endoprosthesis in a patient with an AAA and multiple renal arteries in order to preserve the main renal artery that emerges directly out of the aneurysm sac. Special considerations such as limited craniocaudal dimensions for endoprosthesis placement and the reduced vascular space are discussed.

Scarce information exists regarding the usefulness of the endovascular approach in patients with thromboangiitis obliterans and critical ischemia. A 41-old-man diagnosed with Buerger’s disease had rest pain and a severe ulceration on the big toe. He had been scheduled for a big toe amputation. Typical findings of Buerger’s disease were found in the angiogram including below-the-knee involvement and corkscrew collateral arteries. Stenoses of the posterior tibial artery were angioplastied and the plantar artery was recanalized and angioplastied. Healing was achieved and the patient remains asymptomatic 21 months after the procedure. The outcome achieved in this case and recent series should encourage doctors dealing with this problem to attempt limb salvage by means of the endovascular approach.

The purpose of this study was to prospectively evaluate pathologic responses to transarterial prostatic embolization and its technical safety in a canine model.Ten adult male beagle dogs were surgically castrated and given hormonal therapy for 4 months to induce prostatic hyperplasia. After three months of hormonal therapy, the dogs were randomly assigned to a transarterial prostatic embolization group (n = 7) or a control group (n = 3). Dogs in the transarterial prostatic embolization group were subjected to embolization with microspheres 300-500 μm in diameter. Four months after the study was begun, all dogs were sacrificed for pathologic study. Transrectal ultrasound and MRI were performed to evaluate pathologic responses. The data on prostate size acquired with transrectal ultrasound were processed for statistical analysis by paired Student t test.The canine prostatic hyperplasia model was successfully established in 10 dogs. The increase in mean prostate size being as great as 572% after 3 months of hormonal therapy. An intraprostatic cavity was detected 1 month after transarterial prostatic embolization in all seven dogs. Four dogs had significant shrinkage of the prostate, and the other three had an increase in prostate size. Imaging examinations and necropsy revealed a huge cavity occupying almost the entire prostate in the three dogs with increased prostate size. No complications associated with transarterial prostatic embolization were encountered.Transarterial prostatic embolization is a safe procedure that can induce prostatic infarction and ablate the prostate. The findings suggest the procedure has potential clinical applications in the care of patients with benign prostatic hyperplasia.

BACKGROUND AND PURPOSE: The use of cerebral protection during CAS in the treatment of carotid artery disease is matter of controversy. The purpose of this study was to evaluate the outcome of CASWBAP in a large cohort of patients, with ≤7 years9 follow-up. MATERIALS AND METHODS: Two hundred thirty-six patients with 255 symptomatic carotid stenoses and/or with high-risk-morphology plaques of >50% and asymptomatic plaques of >70% were prospectively identified. Patients underwent neurologic and carotid US examination before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Plain films of the neck were obtained immediately after the procedure and then at 1 and 3 months. RESULTS: Technical success was achieved in 253/255 (99%) patients. Primary stent placement was successful in 248/253 (98%) patients. Neurologic periprocedural complications within 30 days included 1 (0.4%) nondisabling stroke, 1 (0.4%) disabling stroke, 11 (4.3%) TIAs, and 1 (0.4%) death. The mean duration of follow-up was 23 ± 1.4 months (range, 3–84 months). During the follow-up period, there were 9 additional deaths (7 unrelated to the carotid disease and 2 stroke-related) and 2 strokes (in other vascular territories). The degree of stenosis decreased from a mean of 82% before the procedure to a mean of 30% immediately after. During follow-up, 38 (14.8%) angioplasties were performed due to restenosis in 19 (7.4%) patients, lack of stent expansion in 14 (5.4%), or both in 5 (1.9%). CONCLUSIONS: CASWBAP is effective and safe with a low incidence of periprocedural complications, providing satisfactory long-term clinical results.

The nutcracker syndrome (NS) is a rare condition characterized by the entrapment of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta. Clinically, it presents with flank pain, hematuria, and symptoms of pelvic venous congestion. Several surgical techniques have been described including left renal vein (LRV) transposition, autotransplantation, LRV bypass, superior mesenteric artery (SMA) transposition, gonadocaval bypass and nephrectomy. More recently, endovascular stenting of the renal vein has been proposed. We present two patients with NS who were successfully managed endovascularly, providing satisfactory mid-term clinical and imaging results.

Ruptured abdominal aortic aneurysm is related with a 100% mortality rate if left untreated. Even with surgical intervention or endovascular repair, mortality is still extremely high. However, there are conditions in which neither open surgical aneurysm repair nor endovascular aneurysm repair can be considered a viable therapeutic option because of comorbidities or anatomic reasons. We report a case of successful endovascular treatment in a patient with ruptured abdominal aortic aneurysm by occluding the abdominal aneurysm using the Amplatzer Vascular Plug (AVP II).

The purpose of this study was to analyze the outcomes of major lower extremity amputations (MLEAs) in a series, including diabetic patients, with the aim to study whether diabetes mellitus is a risk factor of in-hospital mortality and perioperative complications. A retrospective analysis of 283 MLEAs (221 of these patients were diabetic and 62 were nondiabetic) performed between January 1, 1998, and December 31, 2008, at the General Surgery Department and Diabetic Foot Unit of La Paloma Hospital in Las Palmas de Gran Canaria (Canary Islands) was done. The significant risk factors of mortality were >" xbd="324" xhg="301" ybd="1481" yhg="1446"/>75 years of age (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.4-11.7), postoperative cardiac complications (OR = 12.3, 95% CI = 3.7-40.2) and postoperative respiratory complications (OR = 3.8, 95% CI = 1.0-13.3). No statistically significant risk factors were found related to the presence of systemic and wound-related complications. In diabetic patients, the significant risk factors of mortality were postoperative cardiological complications (OR = 13.6, 95% CI = 3.1-59.6), postoperative respiratory complications (OR = 5.9, 95% CI = 1.0-35.5), and first episode of amputation (OR = 5.9, 95% CI = 1.4-24.3). There were no statistically significant differences in the outcome of major amputations between diabetic and nondiabetic patients. Hospital stay was significantly longer in diabetic patients ( P < .01) though when the patients with diabetic foot infections were excluded, this difference was not found.

Hemodynamic depression (HD) is a frequent complication related to carotid endartherectomy or carotid artery stenting (CAS), often not well tolerated in patients with coronary artery disease. The purpose of this study is to assess whether CAS without angioplasty is beneficial in patients with severe carotid artery disease before coronary revascularization surgery (CABG) regarding the occurrence of HD. Between October 2002 and August 2006, 39 CAS were performed in 35 patients before cardiac surgery. Outcome measures, including periprocedural and 30-day post stenting and cardiac surgery complications, were assessed. Twenty-seven patients underwent CABG and eight combined CABG and valve replacement. During or immediately after CAS there was no episode of bradycardia or hypotension necessitating medical treatment. In the period between CAS-CABG, there was no case of HD. We also found no myocardial infarction. There were five neurological complications, two of them in the period between CAS-CABG (one transitory ischemic attack (TIA) and one minor stroke) and three after CABG (one TIA and two strokes). Three of them were discharged symptom-free. CAS without angioplasty can be a safe alternative to treat patients with coexistence of carotid and cardiac disease, since does not produce hemodynamic depression, therefore diminishing the cardiac complications.

Persistent primitive hypoglossal artery (PPHA) represents the second most common carotid-vertebrobasilar anastomosis. The association of PPHA with intracranial aneurysms is not unusual. Treatment of aneurysms located on the PPHA itself is challenging due to the increased risk of ischemic complications secondary to the hypoglossal artery often being the sole contributor of flow to the posterior circulation. We report a case of a wide-neck aneurysm in a PPHA successfully treated using a stent-assisted coil embolization technique.

To prospectively evaluate the technical feasibility and safety of transcatheter arterial embolization (TAE) of the prostate in healthy pigs.The study was approved by the institutional ethics committee for animal research. Sixteen large white male pigs were randomly assigned to the embolization group (n = 8) or control group (n = 8). Selective angiography was performed in all animals after general anesthesia was induced. In the embolization group, microspheres 500-700 microm in diameter were used to occlude the prostatic branches. Three months later, the animals' sexual function while breeding with female pigs was subjectively evaluated by using a three-point scale. At necropsy, the prostates were removed for size measurement and histopathologic examination. Paired Student t and Wilcoxon rank sum tests were used for statistical analysis.TAE was technically successful in all animals, without associated complications. The mean prostate volume after embolization was significantly (P.001) reduced compared with the mean prostate volume for the group control. No significant difference (P = .328) in sexual function was noted between the two groups. Histologic examination revealed that the microspheres had occluded the arterioles of the prostate, with disappearance of the nearby partially normal gland structure and atrophy of the residual gland tissue.TAE of the prostate can induce shrinkage of the prostate without compromising the sexual desire and erectile function of animals. This finding suggests that TAE has potential as an alternative treatment for symptomatic benign prostatic hyperplasia in humans.

Purpose Endovascular treatment of aortoiliac aneurysms near or involving the hypogastric artery (HGA) requires HGA occlusion before endografting to avoid retrograde filling of the aneurysm. The purpose of this study is to evaluate clinical outcomes of bilateral HGA occlusion and determine if benefits gained by endovascular aneurysm repair (EVAR) outweigh the morbidity associated with the procedure. Materials and Methods Between 1999 and 2004, 128 patients with abdominal aortic aneurysm (AAA) were treated with bifurcated endograft placement. Bilateral coverage or embolization of HGAs was performed in 14 patients (10.9%). Embolization was achieved by deployment of coils and coverage was accomplished by extending the endoprosthesis into the external iliac artery. Clinical follow-up and computed tomographic angiography were performed at 1, 3, 6, 9, and 12 months and annually thereafter to detect potential aneurysm growth and endoleaks. Results During follow-up (range, 1–72 months), buttock claudication was noted in four patients (28.6%), including unilateral claudication in two and bilateral claudication in two. One patient experienced claudication longer than 12 months, which resolved within 18 months. De novo erectile dysfunction was seen in one patient, and pelvic ischemia was not found in any patient. There was no evidence of endoleak, aneurysm enlargement, or death associated with HGA occlusion. Conclusions In our series, complications of bilateral HGA occlusion before EVAR were moderate and resolved over time. The benefits gained from EVAR outweigh the clinical problems caused by bilateral HGA occlusion, as there are no technical complications added to the EVAR procedure.

Purpose To report a case of intimal dehiscence associated with endovascular intervention in patients with aortic dissection. Case report A 65-year-old man presented with a type B dissection extending to the level of the common iliac arteries. Two Talent stent-grafts were placed in the descending thoracic aorta to close the entry point, but 2 lumens remained. Three days later, abdominal pain prompted another imaging session, which demonstrated a large cylindrical filling defect in the abdominal aorta ("tube-in-tube") assumed to be a partially or completely dehisced intima. Fenestration marginally improved flow to the visceral vessels, and the patient improved clinically. However, 4 days later, recurrent ischemic symptoms prompted surgery; a complete dehiscence of the aortic intima starting at the descending aorta extended to the distal abdominal aorta. The aorta was resected, but the patient died from disseminated intravascular coagulation. Conclusions Intimal flap dehiscence associated with an endovascular procedure in the management of aortic dissection is an uncommon complication. Early detection and prompt surgical intervention of such a complication could save the patient's life. Endovascular procedures are unlikely to resolve the hemodynamic problem caused by a dehisced, distally migrated, collapsed intima.

To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease.From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter.Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedure-related complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66+/-0.04 before the procedure to 0.94+/-0.06 immediately after the procedure (p0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3-36), and the ABIs were stable. There was no mortality or amputation required in this series.Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.

Angioplasty has long been used in the treatment of peripheral arterial occlusive disease with variable long-term results. In this case report, we present a patient with marfanoid features and acute ischemia of the lower extremity. Angioplasty provided us with the means of emergently relieving the acute symptoms. The patient was subsequently found on further work-up to have hyperhomocysteinemia (HC) and appropriate medical therapy was initiated. We conclude that angioplasty should be considered in pediatric patients with acute occlusive limb ischemia, providing excellent immediate results to preserve the limb as well as the time to investigate the underlying causes.

Endovascular or surgical treatment of femoropopliteal bypass (FPB) graft occlusion is a safe and effective procedure. However, there are some reports that recommend thrombolysis as an initial therapy [1, 2]. In situ thrombolysis (ITL), with later percutaneous transluminal angioplasty (PTA) of any anastomotic stenoses, is the usual endovascular therapy for this condition [1, 2]. On the other hand, there are cases where ITL, as well as primary stenting, may be contraindicated because of the relative risk of distal embolization [3]. We report a case of acute occlusion of a femoropopliteal prosthetic bypass graft where ITL was contraindicated, which was successfully treated with primary stenting. To our knowledge, this is the first report of primary stenting in acute FPB occlusion.

We report two patients with acutely thrombosed popliteal artery aneurysms that were successfully treated with a combination of thrombolytic therapy and placement of noncovered Wallstents.

Our purpose was to study the effectiveness of thrombolytic therapy in treating acute, subacute, and chronic arterial occlusions in a multicenter retrospective study. Intraarterial urokinase infusion was performed in 235 patients for occluded native arteries. There were 70 (30%) with acute and 26 (5%) with subacute occlusions, and 141 (59%) with chronic symptoms for longer than 3 mo. Complete thrombolysis was achieved in 60 (86%) of the acute, 20 (77%) of the subacute, and 106 (75%) of the chronic occlusions. Adjunctive interventional procedures were performed as needed. Long-term follow-up revealed a primary patency of 87%, 85%, and 76% for the acute, subacute, and chronic occlusion groups, respectively. We conclude that the rate of complete thrombolysis of chronic occlusions proved slightly more efficient for acute and virtually the same for subacute occlusions. Long-term follow-up demonstrated a higher failure rate with chronic than with acute occlusions, probably due to worsened peripheral vascular runoff. Cathet. Cardiovasc. Diagn. 44:159–169, 1998. © 1998 Wiley-Liss, Inc.

To evaluate the results of primary stent placement without initial thrombolysis in the treatment of iliac occlusions.During a 3-year period, 61 iliac artery occlusions were treated in 59 patients. The mean length of the occluded segment was 10 cm (range, 4-25 cm). The occluded arteries were treated with primary placement of self-expandable metallic stents.Successful recanalization with primary stent placement was possible in 56 of 61 occlusions (92% technical success rate). Mean Doppler ankle/brachial index increased from 0.51 to 0.90 immediately after treatment and was 0.91 on the last follow-up (P.05). Primary patency rate at 24 months was 73%, and secondary patency rate was 88%. Procedural complications included distal embolization (n = 4) and an episode of massive intra-abdominal bleeding. Three patients developed a hematoma at the puncture site that did not require additional therapy. Late complications included stent occlusion (n = 9) and significant stenosis related to intimal hyperplasia (n = 1). Mean follow-up period was 29 months (range, 7-55 months).Primary stent placement is an effective therapeutic option for iliac artery occlusions.

Purpose This work describes the early experience with the Cragg Endopro System I. The safety and efficacy of this device in the treatment of atherosclerotic lesions of the femoral arteries are evaluated. Materials and Methods Eleven patients with complex femoral artery lesions were treated. Ten patients presented with femoral artery occlusion and one had a 90% stenosis. All patients had life-style limiting claudication. Associated comorbid states included smoking ( n = 10), hypertension ( n = 4), hyperlipidemia ( n = 5), coronary artery disease ( n = 3), and diabetes ( n = 1). The stents were dilated to the size of the native artery in the first three patients. The protocol was modified and stents were overdilated by 1 mm in the remaining eight patients. An anticoagulation regimen was used in the first three patients and modified per protocol requirements in the remaining eight. Prophylactic antibiotics were given before the procedure. Follow-up studies included Doppler ultrasound and intravenous and intraarterial digital subtraction angiography. Results An antegrade femoral approach was used. Stent placement was successful in all patients. The mean lesion length was 9.9 cm (4–18 cm). Mean ankle/brachial index before treatment was 0.65 and increased to 0.87 after treatment. Mean follow-up was 17.2 months, and one patient was lost to follow-up. Complications included sepsis ( n = 1), fever ( n = 2), severe pain ( n = 4), thrombosis ( n = 5), and hematoma ( n = 2). Stent patency was improved after protocol modifications. Overall primary patency rate was 45% and secondary patency was 56%. Conclusion This early experience with the Cragg Endopro System I shows that recanalization of long femoral occlusions and stent-graft placement is feasible. The primary and secondary patency rates are low and the complication rate is high. Improved patency rates are expected with a more aggressive anticoagulation regimen and stent overdilation.

CAS is a well-established therapy for the carotid artery disease with a very low rate of complications when performed by experimented operators.

Our aim was to develop an easy-to-induce, reproducible, and low mortality clinically relevant closed-chest model of chronic myocardial infarction in swine using intracoronary ethanol and characterize its evolution using MRI and pathology. We injected 3-4 mL of 100% ethanol into the mid-LAD of anesthetized swine. Heart function and infarct size were assessed serially using MRI. Pigs were euthanized on days 7, 30, and 90 (n=5 at each timepoint). Postoperative MRI revealed compromised contractility and decreased ejection fraction, from 53.8% ± 6.32% to 43.79% ± 7.72% (P=0.001). These values remained lower than baseline thorough the followup (46.54% ± 11.12%, 44.48% ± 7.77%, and 40.48% ± 6.40%, resp., P<0.05). Progressive remodeling was seen in all animals. Infarcted myocardium decreased on the first 30 days (from 18.09% ± 7.26% to 9.9% ± 5.68%) and then stabilized (10.2% ± 4.21%). Pathology revealed increasing collagen content and fibrous organization over time, with a rim of preserved endocardial cells. In conclusion, intracoronary ethanol administration in swine consistently results in infarction. The sustained compromise in heart function and myocardial thinning over time indicate that the model may be useful for the preclinical evaluation of and training in therapeutic approaches to heart failure.

Seventy-seven transjugular liver biopsies were performed with a coaxial, spring-loaded, 18-gauge cutting needle, the Biopty gun (Bard Biopsy System, Covington, GA, USA) on consecutive patients between July 1993 and February 1995. Fifty men and 27 women were included in the study; the mean age was 45 years (range 15-69 years). The average number of punctures per patient was 5.2, with a range of 2-9, yielding an average of 4.8 samples per patient (range 1-7). The length of the samples varied from 10 to 22 mm with a constant diameter of 1 mm. The mean time required to complete the procedure was 48 min (43-52 min). Histological diagnoses were obtained in 74 of 77 patients (96%), with non-diagnostic specimens attributed to excessive fragmentation (3 cases). Complications occurred in 10 patients (puncture site hematoma, carotid artery puncture, abdominal pain, vasovagal reaction, hepatic capsule perforation, and hemobilia). The latter two complications were self-limited. In our experience this transjugular hepatic biopsy method is promising for performing biopsies in patients with chronic liver disease, due to its high success rate and low morbidity rate.

To evaluate the usefulness of self-expandable metallic stents in the treatment of acute colonic obstruction secondary to colorectal neoplasm.Stents were placed in 12 patients with clinical and radiologic signs of acute colonic obstruction. After symptom improvement, patients underwent radiologic staging. Single-stage surgery was performed in patients without disseminated disease.Stent placement was successful in all patients. Signs and symptoms of intestinal obstruction resolved within 24 hours of stent placement in 10 patients (83%). In two patients with massive bowel dilation, improvement was evident 2 and 4 days after stent placement. Ten patients underwent elective single-stage surgery with partial colonic resection and creation of a primary end-to-end anastomosis without major complications. In two patients with disseminated neoplastic disease, stent placement was considered the primary palliative treatment.Metallic stent placement to relieve acute colonic obstruction secondary to colorectal carcinoma is a safe therapeutic alternative, allowing single-stage surgery in suitable cases. In patients who are not surgical candidates it is an adequate palliative option.

BACKGROUND & AIMS: Uncontrolled studies suggest that placement of a transjugular intrahepatic portosystemic shunt (TIPS) could be useful in the treatment of variceal bleeding. The aim of this study was to evaluate the efficacy and safety of TIPS in the elective treatment of hemorrhage from esophageal varices in a randomized controlled study that compared the effects of TIPS with those of endoscopic sclerotherapy (ES). METHODS: Sixty-three consecutive cirrhotic patients with hemorrhage from esophageal varices were included. Thirty-two patients were randomly allocated to ES and 31 to TIPS groups. RESULTS: One patient in each group died before the therapeutic procedure could be performed. During a mean follow-up period of 15 months, variceal rebleeding occurred in 51.6% of the patients in the ES group and 23% of those in the TIPS group. Uncontrolled rebleeding occurred in 10 of 31 patients in the ES group, whereas rebleeding did not occur in any patient of the TIPS group. Hepatic encephalopathy was more frequent in TIPS patients (33.3%) than in those treated by ES (13%). However, mortality was similar in both treatment groups. CONCLUSIONS: These preliminary results suggest that TIPS is more effective than ES in the prevention of variceal rebleeding in cirrhotic patients, even though no difference in survival was observed. (Gastroenterology 1996 Mar;110(3):832-9)

Aorta dissection is a serious vascular disease produced by a rupture of the tunica intima of the vessel wall that can be lethal to the patient. The related diagnosis is strongly based on images, where the multi-detector CT is the most generally used modality. We aim at developing a semi-automatic segmentation tool for aorta dissections, which will isolate the dissection (or flap) from the rest of the vascular structure. The proposed method is based on different stages, the first one being the semi-automatic extraction of the aorta centerline and its main branches, allowing an subsequent automatic segmentation of the outer wall of the aorta, based on a geodesic level set framework. This segmentation is then followed by an extraction the center of the dissected wall as a 3D mesh using an original algorithm based on the zero crossing of two vector fields. Our method has been applied to five datasets from three patients with chronic aortic dissection. The comparison with manually segmented dissections shows an average absolute distance value of about half a voxel. We believe that the proposed method, which tries to solve a problem that has attracted little attention to the medical image processing community, provides a new and interesting tool to isolate the intimal flap that can provide very useful information to the clinician.

A diabetic foot infection is usually the result of a pre-existing foot ulceration and is the leading cause of lower extremity amputation in patients with diabetes. It is widely accepted that diabetic foot infections may be challenging to treat for several reasons. The devastating effects of hyperglycemia on host defense, ischemia, multi-drug resistant bacteria and spreading of infection through the foot may complicate the course of diabetic foot infections. Understanding the ways in which infections spread through the diabetic foot is a pivotal factor in order to decide the best approach for the patient’s treatment. The ways in which infections spread can be explained by the anatomical division of the foot into compartments, the tendons included in the compartments, the initial location of the point of entry of the infection and the type of infection that the patient has. The aim of this paper is to further comment on the existed and proposed anatomical principles of the spread of infection through the foot in patients with diabetes.Keywords: diabetic foot; infection; osteomyelitis; anatomy; amputation(Published: 1 October 2012)Citation: Diabetic Foot & Ankle 2012, 3: 18693 - http://dx.doi.org/10.3402/dfa.v3i0.18693

Intractable and recurrent ureteral stricture presents a continuous challenge to the urologist. We report on 5 patients with severe ureteral stricture who were successfully treated with self-expanding metallic stents. Ureteral stricture occurred at ureteroileal anastomotic sites after neoplasm resection in 2 cases, multiple upper ureteral strictures were related to multiple surgical procedures for correction of bladder exstrophy in 1 and a ureteral kink developed in 1. Treatment with transluminal balloon dilation provided poor results but self-expanding metallic stents were used successfully with no major complications. In the last patient the stent and the overlying ureter were removed due to recurrent reflux; the gross and histological ureteral changes are discussed in detail. The technical approach is described, alternative therapeutic options are considered and pertinent literature is reviewed.

The clinical results of percutaneous transluminal angioplasty (PTA) were evaluated in patients with renovascular hypertension, and the effect of PTA on blood pressure and renal function was determined.Between February 1982 and December 1990, 93 hypertensive patients underwent 123 renal artery PTA procedures. Mean patient age was 43.4 years (range, 12-78 years). Average baseline blood pressure was 162/111 mm Hg (range, 140-230/95-150 mm Hg). The cause of renovascular hypertension, as determined with angiography, was atherosclerosis in 37 patients, fibromuscular dysplasia in 27, and mixed disease in one; 28 patients had renal transplant arterial stenosis.In patients with atherosclerotic renal vascular disease or fibromuscular renal artery stenosis, systolic and diastolic blood pressure decreased significantly (P.001) at 96 months after PTA. In patients with renal transplant arterial stenosis, blood pressure also decreased significantly (P.001) at 12 months after PTA. Technical success was achieved in 78% of patients with atherosclerosis, 92% of patients with fibromuscular dysplasia, and 76% of patients with renal transplants. Complications were seen in 4.8% and were related to renal failure and vessel dissection.PTA is the therapy of choice in patients with renovascular hypertension due to fibromuscular dysplasia. Patients with atherosclerotic renal artery stenosis or stenosis of a renal artery in a transplanted kidney should be selected according to the anatomy of the lesion and clinical patient characteristics.

To determine the clinical outcome and the success of stent application for high-grade lesions of the infrapopliteal arteries compared with treatment with percutaneous transluminal angioplasty (PTA) in critical limb ischemia (CLI).In this ethics board-approved randomized prospective study, PTA or stent application was performed on 131 lesions in 88 patients with CLI. The primary end points were clinical improvement after endovascular treatment and limb salvage rate. Secondary end points were defined by the minimal lumen diameter (MLD) before and after the revascularization procedure, percentage of residual diameter stenosis (DS), binary restenosis rate (50% DS and70% DS), and incidence of target lesion revascularization at 9-month follow-up.At 3 months, the clinical status in the PTA group was less improved than that in the stent group (P = .008). At 9 months, there had been five minor and two major amputations in the PTA group and five major and five minor amputations in the stent group. MLD was significantly larger and the percentage of DS was significantly less in the stent group at completion angiography. At 9 months, the angiographic control showed better trends for the stent group in comparison to the PTA group despite that no significant differences were detected (MLD, 1.19 mm ± 0.92 vs 1.02 mm ± 1.02; DS, 38.68% ± 25.47 vs 43.31% ± 28.37).Infrapopliteal stent application is an effective treatment modality in CLI. The PTA and stent groups were essentially equal at 3 and 9 months except for the difference in clinical improvement in the stent group at 3 months.

The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results. The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques. Albeit infrequent, thrombosis can be present in the first 30 days. Its treatment consists in thrombectomy and anastomosis evaluation, but with an increase in morbidity, especially in patients with urgent reintervention. This is a case report of a patient with aortoaortic tube graft, who present critical left limb ischemia immediately after surgical procedure. Angiography showed complete occlusion of left common iliac artery, affecting the distal graft anastomosis. The occlusion was resolved with endovascular treatment, and a noncovered, self-expanding, nitinol stent was deployed (primary stenting) covering the distal bypass anastomosis, with no complications and complete lower limb perfusion recovery. One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

Mycotic aneurysms are uncommon, especially those located in visceral arteries. We present a case of a patient with two visceral mycotic aneurysms due to bacterial endocarditis, one located in right upper pole renal artery and the second in the splenic artery. Both aneurysms were treated as endovascular embolization using microcoils. In the aneurysm located at the renal artery, the technique of stent-assisted coils embolization was preferred to avoid coils migration due to its wide neck. The stent used was the Solitaire AB, which was designed for the treatment of intracranial aneurysms and was used recently in acute stroke as a mechanical thrombectomy device. Complete embolization of the aneurysm was achieved, preserving all the arterial branches without nephrogram defects in the final angiogram.

We have studied the rate of lower extremity amputations (LEAs) in the south of Gran Canaria. The incidence rate was 319.7 per 100,000 (95% CI, 258.6–380.8) per year in the diabetic subjects. The incidence of both diabetic and non-diabetic LEAs is the highest reported in Spain.

Gianturco self-expandable stents were used successfully in the management of 5 patients with tracheobronchial pathology. Placement was performed under endoscopic and fluoroscopic guidance. None of the patients has experienced complications secondary to the stent placement, and in all of them the clinical problems resolved satisfactorily. Longer follow-up is required to determine the place of tracheobronchial stenting in patients with respiratory compromise.

BACKGROUND AND PURPOSE: A major concern during carotid artery stent placement is the potential for cerebral embolism. Diminishing the number of device manipulations across the lesion might reduce procedural stroke risk. For this purpose, we report our initial experience with carotid stent placement without the use of either balloon angioplasty or distal protection devices. MATERIALS AND METHODS: Eighty-seven consecutive patients with 100 carotid stenoses compose this series. Ninety four of the 100 hundred stented carotid arteries were either symptomatic (58 [58%]) or had a greater than 70% stenosis (36 [36%]). Six percent of them were asymptomatic and had stenosis between 50% and 70%. Patients underwent neurologic evaluation before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Carotid sonography and plain films of the neck were performed immediately after the procedure and then at the same time intervals. RESULTS: Primary stent placement was successful in 98 of 100 case subjects. In 2 case subjects, predilation was necessary before stent deployment. Neurologic periprocedural complications included 1 nondisabling and 1 disabling stroke and 5 transient ischemic attacks. The mean duration of follow-up was 23 months (range: 10–36 months). During the follow-up period, there were 5 deaths, all unrelated to the carotid disease, and no major stroke. The degree of stenosis decreased from a mean of 78.85% before the procedure to a mean of 21.23% immediately after. CONCLUSIONS: In this series, carotid stent placement without the use of either balloon angioplasty or distal protection devices was safe and effective with a low incidence of periprocedural complications.

Aneurysms of the extracranial internal carotid artery (EICA) are infrequent. They are difficult to treat with conventional surgery because of their distal extension into the skull base. We report three cases of EICA aneurysms in two symptomatic patients successfully treated with polytetrafluoroethylene self-expanding endografts using an endovascular approach. The aneurysms were located distal to the carotid bifurcation and extended to the subpetrous portion of the internal carotid artery.

Pulmonary arteriovenous malformations are rare anomalies that carry a considerable risk of serious complications such as cerebral thromboembolism or abscess and pulmonary hemorrhage. The first-line treatment of such malformations is detachable coil or balloon embolotherapy. However, coils and balloons may migrate and cause paradoxical embolism especially in malformations with large arteriovenous shunts. We report a case in which we used a new vascular occlusion device (amplatzer vascular plug), to occlude a pulmonary arteriovenous fistula in a patient with Rendu-Osler-Weber syndrome.

SummaryWe report the endoluminal treatment of a para-anastomotic aneurysm with an endovascular stent-graft. A straight stent graft was inserted through the femoral artery into the abdominal aorta. The angiogram performed after the procedure showed total exclusion of the aneurysm. The patient has been asymptomatic for a 2 year follow-up period. We consider that this is a feasible technique in patients with high-risk for surgery, but more experience is required to evaluate the efficacy of the procedure.

We report our experience with the use of a self-expanding stent in the treatment of a severe innominate artery stenosis resulting in right upper limb ischemia. A 45-year-old woman was admitted for right upper limb ischemia, asymmetry of the carotid pulse and the lack of pulse in the right upper extremity. The patient had a history of chain smoking, hypertension, hypercholesterolemia, and acute myocardial infarction one year ago. She was diagnosed of the innominate artery stenosis by angiography one year ago at another hospital. At the time of admission her blood pressure was normal in the left arm and absent in the right upper limb. Arteriography showed a severe stenosis subocclusion of the innominate artery with an inverse flow of the ipsilateral vertebral artery. As the patient was not considered to be a surgical candidate due to instable angina, stent placement was indicated. After placement through an axillary approach an angiogram showed a patent right subclavian artery without residual stenosis. Angiographic follow-up showed a patent innominate arterial lumen two years after the procedure. The patient continued to be asymptomatic during six years follow-up. Blood pressure remained normal in both upper extremities, without any ischemic signs. Our experience indicates that placement of an endovascular stent is an effective therapeutic option in selected patients with symptomatic stenosis in the innominate artery when a surgical treatment is contraindicated.

This study was performed with approval from the ethics committee for animal research of the local government. The purpose of the study was to evaluate the technical feasibility of a technique for subxiphoid access to the normal pericardial space with a micropuncture set in 10 large white pigs. With fluoroscopic guidance, a fine needle was inserted through a subxiphoid approach into the anterior mediastinal space to puncture the pericardium, and a micropuncture set was placed in the pericardial space successfully in all animals without complications. Necropsy at 24 hours did not reveal hemomediastinum, hemopericardium, or laceration of the pericardium. Results of the experiments in animals indicated that the technique was feasible and safe. © RSNA, 2005

Purpose: To present a new intravascular device for the treatment of aorto-iliac aneurysms. Methods: This new device was tested in five dogs with abdominal aortic aneurysm created experimentally by overdilation of a balloon-expandable stent with a 16 or 18 mm wide PTA balloon catheter. The design of the device is based on a self-expanding aortic stent which consists of two stretchable circular frames filled with a textile Dacron mesh membrane that is suspended horizontally into the infrarenal abdominal aorta proximally to the aneurysm. The frames are part of a preshaped double helical structure that is introduced longitudinally through a catheter in a parallel fashion and forming the desired shape at the vessel site to be occluded. Two iliac stent-grafts are introduced in a low-profile status through the membrane sealing the aneurysm sac and holding the stent-grafts in place. After stent-graft expansion, a new bifurcation located more proximally than the natural one is created. The follow-up of the dogs was performed clinically and angiographically, and specimens were evaluated histomorphologically. Results: The membrane device can be introduced through a 9 Fr vascular sheath. Technical success was achieved in four of five dogs. Nine of ten stent-grafts could be fixed securely within the membrane, thus preventing dislocation. Aneurysms were excluded immediately, and blood flow to the external iliac arteries was restored by the stent-grafts. At 6–9 months follow-up of technically successful implanted devices, there were no endoleaks, no migration, no stenoses at contact sites between the implant material and vascular wall, and no stenosis or occlusion of the stent-grafts. At microscopic evaluation, the interspace between the membranes was filled with thrombotic material, thus ensuring exclusion of the aneurysm. Conclusion: This new device was found to be flexible, low profile and useful in excluding abdominal aortic aneurysm in the experimental setting.

The purpose of this study was to develop an abdominal aortic aneurysm model that more closely resembles the morphology of human aneurysms with potential for further growth of the sac. An infrarenal abdominal aortic aneurysm (AAA) model was created with a double-layered peritoneal patch in 27 domestic swine. The patch, measuring in average from 6 to 12 cm in length and from 2 to 3 cm in width, was sutured to the edge of an aortotomy. Pre- and postsurgical digital subtraction aortograms (DSA) were obtained to document the appearance and dimensions of the aneurysm. All animals were followed with DSA for up to 5 months. Laparoscopic examination enhanced by the use of laparoscopic ultrasound was also carried out in 2 animals to assess the aneurysm at 30 and 60 days following surgery. Histological examination was performed on 4 animals. All the animals that underwent the surgical creation of the AAA survived the surgical procedure. Postsurgical DSA demonstrated the presence of the AAA in all animals, defined as more than 50% increase in diameter. The aneurysmal mean diameter increased from the baseline of 10.27 +/- 1.24 to 16.69 +/- 2.29 mm immediately after surgery, to 27.6 +/- 6.59 mm at 14 days, 32.45 +/- 8.76 mm at 30 days (p0.01), and subsequently decreased to 25.98 +/- 3.75 mm at 60 days. A total of 15 animals died of aneurysmal rupture that occurred more frequently in the long aneurysms (or =6 cm in length) than the short aneurysms (6 cm in length) during the first 2 weeks after surgery (p0.05). No rupture occurred beyond 16 days after surgery. Four animals survived and underwent 60-day angiographic follow-up. Laparoscopic follow-up showed strong pulses, a reddish external appearance and undetectable suture lines on the aneurysmal wall. On pathology, the patches were well incorporated into the aortic wall, the luminal wall appeared almost completely endothelialized, and cellular and matrix proliferation were noted in the aneurysmal wall. A reproducible technique for the creation of an infrarenal AAA model was developed using a peritoneal patch in swine. The aneurysm model proved to have potential for further growth of the sac and a tendency to rupture. Because of the growth potential, this might be a better model than those with a noncompliant aneurysmal wall for the preclinical evaluation of stent-graft devices.

A case of soft-tissue fibrosarcoma with pulmonary metastases in a dog is reported. Although three attempts of fine-needle aspiration (FNA) biopsy failed to provide definitive tumor diagnosis, results of angiography strongly indicated a soft-tissue sarcoma. Transcatheter arterial embolization (TAE) using particles of gelatin sponge was performed following selective angiography. The mass was decreased in size on reevaluation 2 weeks after embolization. The dog was euthanized on the request of the owners due to overall failing health. Necropsy and pathological study confirmed the diagnosis of soft-tissue fibrosarcoma with pulmonary metastases. In a review of the literature, angiographic findings of soft-tissue sarcoma in the dog of this report were similar to those in human beings, suggesting a potential role for angiography in the differential diagnosis of suspect soft-tissue fibrosarcomas and for guiding FNA or surgical biopsy. Previous reports have also shown therapeutic embolization to be an effective treatment both in experimental animal study and in clinical practice in the human; therefore, TAE could be an effective adjunctive treatment of soft-tissue fibrosarcoma in the dog.

RATIONALE AND OBJECTIVES To compare a new 7 Fr. Helix thrombectomy catheter with Amplatz thrombectomy devices (ATD) with respect to clot fragmentation efficiency, hemolytic potential, and risk for vascular trauma. MATERIALS AND METHODS Particle size was evaluated following the maceration of 8-to-10-day-old clots, each weighing 6 +/- 0.01 g. The clots were macerated using devices of various sizes, including the 7-Fr. Helix thrombectomy catheter, the 7-Fr. over-the-wire (OTW), 8-Fr. ATD and the 6-Fr. ATD. The number of particles by weight was quantified. The 7-Fr. Helix and the 8-Fr. ATD were tested in the native iliac vein of six dogs without presence of clots. Blood samples were obtained before, during, and at 1, 3, 6, 24, and 48 hours after the procedure, to monitor the hemolytic effects. The treated iliac veins were examined histologically. RESULTS Most of the clot was fragmented into particles