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Purpose Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation. Materials and methods 406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ± 15 years (range: 18–88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success. Results Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9–1353 days). Conclusion Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40 years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53 years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p = 0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26 h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p = 0.003). Average hospital LOS was 14 days in the treatment group and 38 days in the control group (p = 0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

Purpose The purpose of this study was to describe the safety and efficacy of hybrid recanalization procedures in a series of patients with obstructed central veins requiring cardiac implantable electronic device (CIED) revision. Methods Between 2008 and 2016, 38 consecutive patients (24 M; age 60.5 ± 16.2 years; range 25–87 years) with central venous obstruction underwent 42 recanalization interventions performed in conjunction with CIED revision or extraction. Fifty percent of patients (19/38) presented with veno-occlusive symptoms, and 13% (5/38) of patients had CIED leads with an ipsilateral upper extremity dialysis conduit. Results Ninety-one percent (38/42) of all procedures resulted in successful recanalization and CIED revision. Twenty-four percent (9/38) of all patients required secondary procedures due to recurrent stenosis, and 78% (7/9) of those requiring secondary procedures had indwelling dialysis conduits and/or clinical symptoms related to venous occlusion before the initial procedure. There were complications in 2 patients related to recanalization, and in 3 related to CIED revision. Conclusions Recanalization of central venous stenosis/occlusion in patients with CIED can be technically challenging but is successful in most patients. Symptomatic patients and those with dialysis conduits often require more aggressive revascularization interventions and may be at increased risk of complication or need for secondary interventions.

Background: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. Methods: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an “upfront OR for every patient” approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). Results: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P P =0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5–29; P =0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P ≤0.03). Conclusions: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis.Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded.Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy.Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.

Aneurysmal disease of the internal iliac vein is rare, with no standard indication for or accepted modality of treatment. Here we report an instance of unilateral, primary left internal iliac venous aneurysm and associated pelvic venous insufficiency. Following extensive workup for alternative causes, the aneurysm and left gonadal vein were coil embolized with good effect.

PURPOSE Small collections of contrast material are frequently seen within the otherwise thrombosed false lumen of an aortic dissection (AD). These collections can be divided into those without apparent communication with the aortic lumen (ie, pseudoaneurysms) and those with obvious communications (ie, ulcers). The present study was performed to test the hypotheses that pseudoaneurysms and ulcers differ in their distribution around the aorta and that the distribution of pseudoaneurysms is similar to that of small aortic branch arteries. MATERIALS AND METHODS Computed tomography (CT) scans in 187 patients with AD and thrombosed false lumens showed 335 intramural contrast medium collections, including 128 pseudoaneurysms and 207 ulcers. CT scans in 40 control individuals without AD were reviewed to localize small aortic branch arteries. The angular distributions around the circumference of the aorta of pseudoaneurysms and ulcers and the branch artery origins were tabulated and compared. The frequency of detection of small branch arteries arising from the contrast material collections was noted. RESULTS The angular distribution of pseudoaneurysms did not differ significantly from that of branch artery origins but did differ from that of ulcers. Pseudoaneurysms were found along the posterior, medial, and anterior walls of the aorta in the chest, sparing the lateral wall abutting the pleura. Ulcers tended to spare the arc containing branch artery origins. The composite distribution of ulcers and pseudoaneurysms appears uniform around the circumference of the aorta except at the T10–T12 levels. CONCLUSIONS Branch artery pseudoaneurysms spare the pleural surface of the aorta and have nearly the same distribution around the circumference of the aorta as the origins of small aortic branch arteries. In contrast, ulcers tend to spare branch artery origins. The characteristic appearance and distribution of pseudoaneurysms on CT can help differentiate them from ulcers.

Background. This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation. Methods. Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years. Results. PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures. Conclusions. PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.

BACKGROUND Endovascular approaches (thoracic endovascular aortic repair) have revolutionized treatment of thoracic aortic disease. OBJECTIVE We report our 20-year experience with this therapy. METHODS Four hundred twenty patients (mean age = 69.0 years; 54% male) underwent thoracic endovascular aortic repair (1993-2013), predominantly for fusiform aneurysm (n = 144), saccular aneurysm (n = 94), acute (n = 64) or chronic (n = 36) dissection, or traumatic injury (n = 39). Rupture was present in 80 patients (19.1%). Most patients (78.3%) were at high risk for open repair. Mean aortic diameter was 5.5 cm. Extent of repair included arch in 218 patients, total descending aorta in 193 patients, and thoracoabdominal aorta in 35 patients. RESULTS Thirty-day mortality occurred in 20 patients (4.8%). Neurologic events included stroke (5.0%) and spinal cord ischemia (permanent 1.7%, temporary 7.9%). Although dialysis was only required in 1.4% of the patients, 19% had renal failure by RIFLE (Risk, Injury, Failure) criteria. Endoleak occurred in 32.9% of the patients. Ten-year freedom from dissection, rupture, or need for reintervention in treated or adjacent aortic segments (ie, treatment failure) was 63.2%. Independent predictors included presentation with rupture, preexisting renal failure, or intervention on the arch aorta (all Ps < 0.03). Aortic pathology also independently predicted treatment failure (P = 0.026). The 15-year survival rate was 32.3%. Advancing age, presence of coronary artery disease, rupture, or postoperative renal failure (all Ps < 0.05), but not treatment failure (P = 0.926), independently predicted late mortality. CONCLUSIONS Thoracic endovascular aortic repair can be performed with acceptable results in a high-risk population. The risk of treatment failure persists, underscoring the importance of continued long-term endograft surveillance, but this does not seem to impact late mortality.

Background Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. Methods One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n = 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n = 105), rupture (n = 8), acute or chronic dissection (n = 8), and extension of dissection (n = 1). Open strategy included descending (n = 71) and thoracoabdominal repair (n = 19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n = 2) or without (n = 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. Results Early outcome included the following: 30-day mortality 4% (n = 5); stroke 2% (n = 2); permanent paraplegia 3% (n = 4); renal failure requiring dialysis 7% (n = 8, 5 temporary and 3 permanent); and tracheostomy 3% (n = 4). Visceral aorta intervention (odds ratio [OR] 3.5, p = 0.026) and maximum aortic diameter (OR 1.1, p = 0.001) but not treatment type ( p = 0.64) independently predicted an early composite outcome comprised of these variables. Ten-year survival was 56.2%. Baseline creatinine (hazard ratio [HR] 1.7, p p = 0.021), but not treatment type ( p = 0.225) predicted late mortality. Ten-year freedom from aortic rupture or need for reintervention was 78.3%. Treatment efficacy was improved after OAR (3-year freedom 96.7% vs TEVAR 87.5%, p = 0.026), and this was confirmed after Cox regression (TEVAR, HR 4.6, p = 0.046). Conclusions Intervention for CBAD can be performed with excellent results, either by an open or endovascular approach. The higher rate of treatment failure after TEVAR warrants modification of current device design or endovascular approach before broad application of this treatment strategy.

Purpose: To investigate the significance of increased perfusion associated with some hepatic hemangiomata during radionuclide blood volume imaging. Methods: Immediate dynamic planar projections and delayed SPECT imaging of a hepatic lesion were obtained after the administration of Tc-99m-labeled RBC. Scintigraphic data were compared with X-ray CT, contrast angiography and postresection histopathology. Results: A surgically proven, cavernous hemangioma with typical findings on delayed radionuclide blood-pool imaging showed markedly increased perfusion by scintigraphy. This correlated with arterioportal venous shunting (AVPS) on contrast angiography. Conclusion: Increased perfusion on radionuclide blood-volume imaging of hepatic hemangiomata may be a scintigraphic marker of AVPS. This may serve to identify patients with increased risk for spontaneous rupture or may identify them for the development of portal hypertension.

The incidence of acute kidney injury (AKI) after thoracic aortic endovascular repair (TEVAR) is variably reported at 1% to 34%. This study utilized the RIFLE (risk, injury, failure) criteria to evaluate the incidence, risk factors, and late implications of AKI after TEVAR.In all, 350 patients without prior dialysis requirement underwent TEVAR (1993 to 2013). The mean age was 68.7 years (54% male). The mean preoperative glomerular filtration rate was 76.5 ± 37.6 mL/min, with 39 patients (11.7%) in chronic kidney stage 3 or 4. The TEVAR was performed for rupture in 20.6%. The mean contrast volume administered was 95.7 ± 52.9 mL.Early mortality was seen in 17 patients (4.9%). Acute kidney injury defined as RIFLE classes risk, injury, or failure was seen in 59 patients (17%; risk = 36, injury = 14, failure = 9). Independent predictors of AKI included history of saccular aneurysm, presentation with rupture, or need for arch repair or red blood cell transfusion (all p0.05). Only 2 patients (0.6%) needed dialysis, with none requiring permanent dialysis. Importantly, 10-year freedom from dialysis was 97.7%. Development of AKI predicted early mortality (p0.001, odds ratio 9.8). Ten-year survival was 38.1%. Both injury and failure AKI classes independently predicted late mortality (p0.05).The prevalence of AKI after TEVAR as assessed by RIFLE criteria is higher than seen in previous reports. Despite its infrequent progression to permanent dialysis dependence, AKI remains an important risk factor for both early and late mortality. Future studies should evaluate strategies to reduce the incidence of AKI after TEVAR to improve both early and late outcomes.

ObjectiveRepair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort.MethodsOf 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias.ResultsEarly mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P = .055) and performance of a hybrid procedure (P = .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P < .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P = .018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P = .017) and an endovascular or hybrid procedure (P = .001) independently predicted late aortic rupture or need for reintervention.ConclusionsIsolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.

To describe how peristomal varices can be successfully embolized via a percutaneous parastomal approach.The medical records of patients who underwent this procedure between December 1, 2000, and May 31, 2008, were retrospectively reviewed. Procedural details were recorded. Median fluoroscopy time and bleeding-free interval were calculated.Seven patients underwent eight parastomal embolizations. The technical success rate was 88 % (one failure). All embolizations were performed with coils combined with a sclerosant, another embolizing agent, or both. Of the seven successful parastomal embolizations, there were three cases of recurrent bleeding; the median time to rebleeding was 45 days (range 26-313 days). The remaining four patients did not develop recurrent bleeding during the follow-up period; their median bleeding-free interval was 131 days (range 40-659 days).This case review demonstrated that percutaneous parastomal embolization is a feasible technique to treat bleeding peristomal varices.

BackgroundSuccessful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles.MethodsSince the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months).ResultsMean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02).ConclusionAn endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.

A transjugular intrahepatic portosystemic shunt (TIPS) can potentially reduce the risk of perioperative complications in cirrhotic patients undergoing surgery but experience is limited. The aim of our study was to assess the clinical outcomes in consecutive cirrhotic patients with a patent TIPS undergoing major extrahepatic surgery.Between July 1992 and January 2007, 25 cirrhotic patients with a patent TIPS underwent abdominal or cardiothoracic surgery at a single center. Preoperative laboratory and clinical features and postoperative outcomes were reviewed.Mean subject age was 49+/-12 years. The TIPS was placed at a median of 20 days before surgery (range, 1 to 2338 d). In 19 patients, the TIPS had been previously placed for management of refractory ascites or bleeding varices whereas in 6 patients, the TIPS was specifically placed for portal decompression before planned surgery. The mean hepatic venous pressure gradient was significantly reduced from 19.6+/-5.5 to 8.7+/-2.9 mm Hg post-TIPS (P0.001). The mean preoperative Model for End Stage Liver Disease (MELD) score was 15+/-7.6 and Child-Turcotte-Pugh scores were A (8%), B (64%), and C (28%). Nineteen abdominal and 6 cardiothoracic surgeries were performed under emergent (32%) or urgent (24%) circumstances. Postoperatively, severe ascites developed in 29% and encephalopathy in 17%. The median postoperative intensive care unit and hospital stay were 1 day (range, 0 to 26 d) and 7 days (0 to 32 d), respectively. During a median follow-up of 33 months, actuarial 1-year patient survival was 74%. The 3 patients (12%) who died during their hospitalization all had MELD scoresor = 25 and required emergency surgery.Portal decompression via TIPS may allow selected cirrhotic patients to safely undergo major surgery with an acceptable rate of short-term morbidity and mortality.

Background Untreated infectious thoracic aortic pathology (ITAP) has a dismal prognosis. Despite its high rates of morbidity in this setting, conventional open repair remains the gold standard therapy. Understanding the limitations of open repair, we describe outcomes for one of the largest series of ITAP treated with thoracic endovascular repair. Methods Of 170 patients undergoing thoracic endovascular repair (1993 to 2008), 20 presenting with ITAP were identified. Indications for intervention included aortobronchial (n = 10), aortoesophageal (n = 2), or aortocutaneous fistulae (n = 1), or mycotic aneurysms (n = 7). Underlying disease included fusiform aneurysm (n = 1), saccular aneurysm or pseudoaneurysm (n = 18), or dissection (n = 1). Four patients had ITAP from infected grafts. Follow-up was 100% complete (mean, 28.6 months). Results Median age was 73 years. A history of immunosuppression was present in 4; concurrent malignancy was present in 5. Arch repair was needed in 8; total descending, in 6. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Causes of in-hospital mortality (n = 3; 15.0%) included refractory hypoxemia (n = 1) and sepsis from tracheoesophageal fistula (n = 1) or pneumonia (n = 1). Dialysis was needed in 2; none sustained postoperative stroke or paraplegia. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients, with 3 attributed to recurrent ITAP. There was a trend for recurrence of ITAP when thoracic endovascular repair was originally performed in an infected graft (p = 0.08). At last imaging follow-up, 14 patients had a healed aorta. Conclusions Treatment with thoracic endovascular repair for ITAP can be accomplished with acceptable results. Late mortality is frequently related to underlying comorbidities, rather than complications from the aortic disease itself, suggesting that thoracic endovascular repair is an appropriate palliative therapeutic option in this high-risk cohort.

The aim of this study was to determine the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) in liver transplant (LT) recipients with refractory ascites/variceal bleeding and to compare the observed outcomes with those obtained in cirrhotic controls.Clinical features of 14 LT recipients referred for TIPS placement between August 1985 and September 2006 were reviewed and compared with published series and 28 cirrhotic control patients undergoing TIPS.The median age of the 14 LT recipients was 52 years, 57% had chronic hepatitis C virus and the median time from LT to TIPS placement was 46 months. Portal vein thromboses in two patients and a procedural complication in another patient precluded TIPS deployment. Among the 11 patients who completed TIPS, the mean hepatic venous pressure gradient was significantly reduced post-TIPS (18.3 +/- 6.1 to 9.0 +/- 3.5 mmHg, P0.01). However, only 50% of the patients with varices had no further bleeding and 57% of the refractory ascites patients required no further paracentesis. In addition to a single peri-procedural death and renal failure in three others, four patients (29%) developed infection and nine (82%) developed new onset or worsening encephalopathy at a median of 11 days post-TIPS. The 1-year patient survival of 14% was substantially lower than that observed in other series of LT recipients (57-67%) as well as the matched cirrhotic control group undergoing TIPS (58%).The frequent morbidity noted in LT recipients undergoing TIPS, coupled with the low 1-year patient survival, demonstrates that portal decompression provides only marginal short-term benefit in the absence of retransplantation.

Objective: Patients with aortic dissection were studied to define (1) anatomic and physiologic derangements in renal artery blood flow, (2) differences in clinically suspected renal malperfusion and true functional malperfusion, and (3) variations in endovascular interventions for the treatment of renal malperfusion. Methods: The cohort comprised 165 patients (mean age, 58 years) with dissections who were thought to have malperfusion sufficient to require arteriography. They were treated from 1996 to 2004 for acute (n = 115) or chronic (n = 50) aortic dissections (75 had type A, 90 had type B lesions). All patients had suspected peripheral vascular malperfusion (ie, cerebral, spinal, mesenteric, renal, or lower extremity vascular beds). Renal malperfusion was suspected in 88 patients secondary to worsening hypertension (n = 34), evolving renal insufficiency (n = 37), computed tomography evidence of impaired renal blood flow (n = 13), or a combination of factors (n = 4). Patients underwent angiographic and intravascular ultrasound studies. Renal malperfusion was confirmed with a systolic gradient between the aortic root and renal hilum (average, 44 mm Hg). Results: Right renal arteries arose exclusively from the true lumen in 115 patients (70%), the false lumen in 11 (7%), and both lumens in 37 (23%). Left renal arteries arose exclusively from the true lumen in 69 patients (42%), the false lumen in 32 (20%), and both lumens in 62 (38%). Angiographic confirmation of malperfusion existed in 59 patients (67%) of the 88 suspected of such, and in 31 patients (39%) of the 79 with suspected malperfusion of nonrenal tissues. Of the 90 patients with confirmed renal malperfusion, 71 underwent endovascular therapy, including isolated renal artery stenting (n = 31), as well as proximal aortic fenestration with or without aortic stenting (n = 24), or both renal and aortic intervention (n = 16). Residual pressure gradients averaged 8.1 mm Hg after these interventions. Five procedure-related complications (7%) occurred. The periprocedural postintervention mortality rate was 21% (n = 15), including multisystem organ failure (n = 7), false lumen rupture (n = 3), reperfusion injury (n = 2), cerebral ischemia (n = 1), cardiac arrest (n = 1), and unknown (n = 1). Conclusions: Percutaneous aortic fenestration and renal artery stenting are both technically feasible and associated with an acceptable complication rate. Most patients respond well symptomatically, obviating the need for immediate surgical relief of renal artery obstruction and allowing for renal malperfusion recovery.

Cardiac tamponade is defined as an accumulation of fluid within the pericardial sac that is large enough to impair the diastolic filling of the ventricles. There are numerous causes, including cardiac disease, malignancy, and trauma (penetrating, blunt, and iatrogenic). With increasing complexity of percutaneous endovascular interventions, interventional radiologists must learn to recognize the preexisting and iatrogenic presence of cardiac tamponade during procedures and be familiar with its treatment. Two cases of pericardial tamponade complicating central venous interventions are described. In addition, the clinical condition is discussed and its diagnosis and treatment are reviewed.

Intravascular ultrasound (IVUS) imaging and venography of the left common femoral and iliac veins were performed in 16 patients. The studies were evaluated for the anatomic cause of obstruction and how IVUS influenced endovascular management. IVUS demonstrated the cause of vessel compression in all 16 patients. Other findings, such as associated thrombus and guide wire localization within the residual vessel lumen, can modify the approach to intervention in as many as 50% of patients. IVUS is a useful adjunct in the diagnosis and endovascular management of iliac vein compression syndrome.

BackgroundRisk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair.MethodsAll patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy.ResultsThe complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P

Background The presence of penetrating aortic ulcers (PAUs) of the descending thoracic aorta has been associated with a poor long-term prognosis. Although early results have suggested acceptable outcomes for thoracic endovascular aortic repair (TEVAR) for PAU, few studies have described the late outcomes of this approach. Methods From 1993 to 2009, 37 patients (43.2% male; mean age, 72 years) underwent TEVAR for PAU. Associated intramural hematoma was present in 19. Comorbidities included hypertension in 31, chronic obstructive pulmonary disease in 16, coronary artery disease in 22, and renal failure (mean preoperative creatinine, 1.4 mg/dL). Urgent or emergent indications were identified in 22 patients (59.5%), including presentation with rupture in 15 (40.5%). Results TEVAR was successfully performed in all patients. Arch repair was performed in 14 and total descending repair in 13. Concomitant procedures included coronary artery bypass grafting (CABG) and total arch debranching in one patient electively presenting with an asymptomatic PAU. Early morbidity included stroke (5.4%), temporary paraplegia (5.4%), and need for dialysis (2.7%). In-hospital or 30-day mortality was seen in two patients (5.4%). By Kaplan-Meier analysis, median survival was 89.8 months. Independent predictors of late mortality included urgent or emergent presentation (odds ratio, 14.7; P = .007). Actuarial freedom from TEVAR treatment failure (ie, need for open or endovascular aortic reintervention, aortic rupture, or aortic-related death) was 81.6% ± 7.8% at 5 years. Analysis stratified by type of pathology (PAU vs PAU and intramural hematoma) showed no significant baseline differences in age, comorbidities, or extent of repair. By Kaplan-Meier analysis, however, presentation with PAU and intramural hematoma was associated with an increased risk for TEVAR treatment failure ( P = .033). Conclusions TEVAR can be safely accomplished for patients presenting with PAU. The presence of associated intramural hematoma may adversely affect the late outcomes of therapy, highlighting the need for careful planning, prudent balancing of the benefits of immediate vs delayed treatment of the fragile aortic wall, and the imperative nature of attentive follow-up in patients with PAU.

BackgroundWe previously reported an improvement in early mortality for patients presenting with acute type A dissection with malperfusion using a strategy of initial percutaneous intervention to restore end-organ perfusion and delayed operative repair after resolution of the malperfusion syndrome. This study evaluates the late outcomes with this approach.MethodsA total of 196 patients were admitted with acute type A dissection (1997–2007). Seventy patients with ischemic end-organ dysfunction underwent percutaneous fenestration or branch vessel stenting. Operative therapy was planned after resolution of the reperfusion injury. Outcomes were compared for patients with (MP) and without (UC) dissection with ischemic end-organ dysfunction.ResultsThe mean age of the patients was 57.1 years, and 173 patients underwent operative repair (n = 126 UC group; n = 47 MP group). The remaining 23 patients in the MP group died before repair from complications of malperfusion (11) or aortic rupture (12) while awaiting resolution of the malperfusion syndrome. Operative mortality was seen in 9.2% of all patients (9.5% in UC group vs 8.5% in MP group; P = 1.0). On analysis of the entire cohort (n = 196), the mean survival was higher for the uncomplicated group (95.9 months for UC group vs 53.7 months for MP group; P < .001). A subgroup analysis of patients who underwent operation (n = 173) revealed similar mean survival (95.9 months for UC group vs 80.5 months for MP group; P = .45).ConclusionA strategy of immediate reperfusion, stabilization, and planned operative repair for acute type A dissection with malperfusion still carries a significant risk for early and late mortality. However, those patients who survive the initial malperfusion and undergo repair have a similar operative and late survival when compared with those patients presenting with uncomplicated dissection.

Background Iliac artery endoconduits (ECs) have emerged as important alternatives to retroperitoneal open iliac conduits (ROICs) to aid in transfemoral delivery for thoracic endovascular aortic repair (TEVAR). We present, to our knowledge, the first comparative analysis between these alternative approaches. Methods All patients undergoing TEVAR with either ROIC (n = 23) or internal EC (n = 16) were identified. The mean age of the cohort was 72.4 ± 11.5 years (82.1% female). Device delivery was accomplished in 100% of cases. The primary outcome was the presence of iliofemoral complications, which was defined as: (1) the inability to successfully deliver the device into the aorta via the ROIC or EC approach; (2) rupture, dissection, or thrombosis of the ipsilateral iliac or femoral artery; and/or (3) retroperitoneal hematoma requiring exploration and evacuation. Secondary outcomes were 30-day mortality and rates of limb loss, claudication, or revascularization. Results At a median follow-up of 10.1 months, the incidence of iliofemoral complications was less for the EC approach compared with the ROIC technique (12.5% vs 26.1%; P = .301). No patients sustained limb loss. Revascularization was performed in two patients after ROIC. Lower extremity claudication occurred in one patient after EC. Early mortality was seen in one patient who underwent EC. Two-year Kaplan-Meier survival for the entire cohort was 74.4%, and did not differ between groups (ROIC, 78.3% vs EC, 68.8%; P = .350). Two-year Kaplan-Meier freedom from limb loss, claudication, or revascularization did not differ between the two approaches (ROIC, 91.3% vs EC, 93.8%; P = .961). Conclusions Results of this early comparative evaluation of alternative access routes for TEVAR suggest that an EC approach is safe, effective, and associated with low rates of early mortality and late iliofemoral complications. In selected patients, the EC may be considered an appropriate delivery route for transfemoral TEVAR.

ObjectiveOpen repair for acute type B dissection with malperfusion is associated with significant morbidity. Thoracic aortic endovascular repair has been proposed as a less-invasive therapy for acute type B dissection with malperfusion. Benefits of thoracic aortic endovascular repair include the potential for false lumen thrombosis. Its risks include both early morbidity and mortality, and uncertain late results with potentially unstable landing zones. We present the first long-term analysis of an alternative endovascular approach consisting of percutaneous flap fenestration with true lumen and branch vessel stenting to restore end-organ perfusion.MethodsOutcomes were analyzed for 69 patients presenting with acute type B dissection with malperfusion from 1997 to 2008. All patients were evaluated with angiography and treated with a combination of flap fenestration, true lumen, or branch vessel stenting where appropriate.ResultsMean age was 57.3 years. Identified malperfused vascular beds included spinal cord (5), mesenteric (40), renal (51), and lower extremity (47). Major morbidity included dialysis need (11), stroke (3), paralysis (2), and 30-day mortality (n = 12, 17.4%). Mean Kaplan–Meier survival was 84.3 months. Although late mortality was associated with age (P < .0001), neither the type nor the number of malperfused vascular beds correlated with vital status at last follow-up (P > .4). Freedom from aortic rupture or open repair at 1, 5, and 8 years was 80.2%, 67.7%, and 54.2%, respectively.ConclusionPresentation with acute type B dissection with malperfusion carries a significant risk for both early and late mortality. Percutaneous approaches allow for rapid restoration of end-organ perfusion with acceptable results. These long-term results can serve as comparative data by which to evaluate newer therapies for acute type B dissection with malperfusion, such as thoracic aortic endovascular repair.