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Objective/background: Proximal type I endoleaks are associated with abdominal aortic aneurysm (AAA) growth and rupture and necessitate repair. The Nellix™ EndoVascular Aneurysm Sealing (EVAS) system is a unique approach to AAA repair, where the appearance and treatment of endoleaks is also different. This study aimed to analyse and categorise proximal endoleaks in an EVAS treated cohort., Methods: All patients, treated from February 2013 to December 2015, in 15 experienced EVAS centres, presenting with proximal endoleak were included. Computed tomography scans were analysed by a core laboratory. A consensus meeting was organised to discuss and qualify each case for selection, technical aspects, and possible causes of the endoleak. Endoleaks were classified using a novel classification system for EVAS., Results: During the study period 1851 patients were treated using EVAS at 15 centres and followed for a median of 494 ± 283 days. Among these, 58 cases (3.1%) developed a proximal endoleak (1.5% early and 1.7% late); of these, 84% of 58 patients were treated outside the original and 96% outside the current, refined, instructions for use. Low stent positioning was the most likely cause in 44.6%, a hostile anatomy in 16.1%, and a combination of both in 33.9%. Treatment, by embolisation or proximal extension, was performed in 47% of cases, with a technical success of 97%., Conclusion: The overall incidence of proximal endoleak after EVAS is 3.1% after a mean follow-up period of 16 months, with 1.5% occurring within 30 days. Their occurrence is related to patient selection and stent positioning. Early detection and classification is crucial to avoid the potential of sac rupture., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To report the results of the ASCEND Registry of cases involving endovascular aneurysm sealing (EVAS) in combination with chimney grafts (chEVAS) for the treatment of para- and juxtarenal aortic aneurysms (AAA)., Methods: A retrospective, multicenter registry established in 8 vascular centers between 2013 and 2016 recorded the treatment results and follow-up of chEVAS procedures for nonruptured AAAs; data were analyzed using standardized outcome measures. In the observation period, 154 patients (mean age 72.3±7.7 years; 124 men) underwent elective treatment for de novo juxtarenal and pararenal aneurysms and formed the study group., Results: Sixty-two (40.3%) of the cohort were treated using a single parallel graft, 54 (35.1%) with double chimneys, 27 (17.5%) with triple chimneys, and 11 (7.1%) with 4 chimneys. The 30-day mortality was 2.8%, and there were 4 perioperative strokes (1 fatal). At 1 year, the freedom from all-cause mortality was 89.8% and the freedom from aneurysm-related mortality was 94.3%. There were 3 endoleaks within 90 days of the procedure, one type Ia and 2 type Ib. The freedom from type Ia endoleaks was 95.7% at 1 year. There were no types II or III endoleaks in this series; the freedom from all endoleaks was 94.2% at 1 year. Freedom from reintervention at 1 year was 89.2%. Target vessel patency rates at 1 year were 97.7%, 99.3%, 100%, and 100% for the left renal, right renal, superior mesenteric artery, and celiac axis stents, respectively., Conclusion: The ASCEND Registry supports a proof of concept for the use of polymer technology and EVAS with parallel grafts in managing patients with complex aortic disease. The future role of chEVAS will be defined by studies that assess mid- to long-term durability.

Purpose: To evaluate the safety and efficacy of a next-generation balloon-expandable stent-graft for the treatment of arterial occlusive disease in patients with de novo or restenotic lesions in the common and/or external iliac arteries., Methods: A prospective, multicenter, single-arm safety and efficacy study ( ClinicalTrials.gov identifier: NCT02080871) of the VBX Stent Graft for treatment of de novo or restenotic lesions in the iliac arteries was conducted under an Investigational Device Exemption at 26 US sites and 1 New Zealand center. The study eligibility criteria were established with the aim of enrolling more "real-world" patients compared with previous iliac stent studies supporting Food and Drug Administration approval. The study enrolled 134 patients (mean age 66±9.5 years; 79 men) with 213 iliac lesions. Three-quarters of the population (101, 75.4%) had Rutherford category 3 ischemia, and 43 (32.1%) patients presented with TASC II C/D lesions. The primary endpoint was a composite of device- or procedure-related death within 30 days, myocardial infarction within 30 days, target lesion revascularization (TLR) within 9 months, and amputation above the metatarsals in the treated leg within 9 months., Results: In all, 234 devices were implanted in 213 lesions with 100% technical success; 57 (42.5%) patients received kissing stents at the aortic bifurcation. No devices exhibited a discernable change in length after final deployment as determined by independent core laboratory quantitative angiographic analysis. At 9 months, 3 (2.3%) of 132 patients (1 lost to follow-up, 1 unrelated death) experienced a major adverse event (3 TLRs) related to the primary endpoint. At 9 months, there were no device-related serious adverse events or unanticipated adverse device effects., Conclusion: The next-generation balloon-expandable stent-graft demonstrated notable 9-month safety and efficacy in treating iliac occlusive disease in patients reflecting common clinical practice.

Background: Drug-coated balloons (DCBs) are a predominant revascularization therapy for symptomatic femoropopliteal artery disease. Because of the differences in excipients, paclitaxel dose, and coating morphologies, varying clinical outcomes have been observed with different DCBs. We report the results of 2 studies investigating the pharmacokinetic and clinical outcomes of a new DCB to treat femoropopliteal disease., Methods: In the ILLUMENATE Pivotal Study (Prospective, Randomized, Single-Blind, U.S. Multi-Center Study to Evaluate Treatment of Obstructive Superficial Femoral Artery or Popliteal Lesions With A Novel Paclitaxel-Coated Percutaneous Angioplasty Balloon), 300 symptomatic patients (Rutherford class 2-4) were randomly assigned to DCB (n=200) or standard angioplasty (percutaneous transluminal angioplasty [PTA]) (n=100). The primary safety end point was freedom from device- and procedure-related death through 30 days, and freedom from target limb major amputation and clinically driven target lesion revascularization through 12 months. The primary effectiveness end point was primary patency through 12 months. In the ILLUMENATE PK study (Pharmacokinetic Study of the Stellarex Drug-Coated Angioplasty Balloon), paclitaxel plasma concentrations were measured after last DCB deployment and at prespecified times (at 1, 4, 24 hours and at 7 and 14 days postprocedure) until no longer detectable., Results: In the ILLUMENATE Pivotal Study, baseline characteristics were similar between groups: 50% had diabetes mellitus, 41% were women, mean lesion length was 8.3 cm, and 44% were severely calcified. The primary safety end point was met (92.1% for DCB versus 83.2% for PTA, P =0.025 for superiority) and the primary patency rate was significantly higher with DCB (76.3% for DCB versus 57.6% for PTA, P =0.003). Primary patency per Kaplan-Meier estimates at day 365 was 82.3% for DCB versus 70.9% for PTA ( P =0.002). The rate of clinically driven target lesion revascularization was significantly lower in the DCB cohort (7.9% versus 16.8%, P =0.023). Improvements in ankle-brachial index, Rutherford class, and quality of life were comparable, but the PTA cohort required twice as many revascularizations. Pharmacokinetic outcomes showed that all patients had detectable paclitaxel levels after DCB deployment that declined within the first hour (54.4±116.9 ng/mL to 1.4±1.0 ng/mL)., Conclusions: The data demonstrate superior safety and effectiveness of the Stellarex DCB in comparison with PTA, and plasma levels of paclitaxel fall to low levels within 1 hour., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifiers: NCT01858428 and NCT01912937., (© 2017 The Authors.)

Purpose: To describe the feasibility and technical aspects of a proximal Nellix-in-Nellix extension to treat caudal stent-graft migration after endovascular aneurysm sealing (EVAS) in the in vitro and in vivo settings., Methods: In vitro studies were designed (1) to assess inner diameters of Nellix-in-Nellix extensions after postdilation with 12-mm balloons and (2) to test wall apposition in tubes with different diameters using a Nellix-in-Nellix stent-graft that extended out of the original Nellix stent-graft lumen by 10, 20, 30, and 40 mm. Simulated-use experiments were performed using silicone models in conjunction with a pulsatile flow pump. In the clinical setting, 5 patients (median age 74 years, range 73-83) presented at 2 centers with type Ia endoleak secondary to caudal Nellix stent-graft migration measuring a median 9 mm (range 7-15) on the left and 7 mm (range 0-11) on the right. Median polymer fill volume at the initial EVAS procedure was 42.5 mL (range 25-71). The median time to reintervention with a proximal Nellix extension was 15 months (range 13-32)., Results: In vitro, the inner diameters of the Nellix-in-Nellix extensions were consistent after postdilation. Cases with 10 and 20 mm of exposed endobag resulted in a poor seal with endoleak, while cases with 30 and 40 mm of exposed endobag length exhibited angiographic seal. Fill line pressures of the second Nellix were higher than expected. In the 5 clinical cases, chimney grafts were required in each case to create an adequate proximal landing zone. The Nellix-in-Nellix procedure was successful in all patients. There were no procedure-related complications, and no endoleaks were observed during a median 12-month follow-up. Reinterventions were performed in 2 patients because of in-stent stenosis and chimney graft compression, respectively., Conclusion: Proximal Nellix-in-Nellix extension can be used to treat caudally migrated Nellix stent-grafts and to treat the consequent type Ia endoleak, but the technique differs from primary EVAS. The development of dedicated proximal extensions is desirable.

Purpose: To report the first-in-human iliac artery experience of a new balloon-expandable covered endoprosthesis., Methods: A prospective, single-center pilot study recruited 30 symptomatic patients (mean age 64 years; 18 men) to evaluate the safety and early efficacy of the new Gore balloon-expandable covered endoprosthesis for the treatment of de novo or restenotic common and/or external iliac artery lesions. According to protocol, up to 2 discrete lesions could be treated with a maximum total treated length ≤110 mm. Follow-up included clinical evaluation with duplex ultrasound at 1, 6, and 12 months. Data are presented through 12-month follow-up. The primary safety endpoint was a composite of device- or procedure-related death, myocardial infarction, or amputation in the treated leg within 30 days of the index procedure. Multiple performance outcomes were also evaluated., Results: The primary 30-day safety endpoint was 0%. Per-subject estimates of primary patency, freedom from target lesion revascularization, and freedom from target vessel revascularization were 100% at 1 and 6 months and 96.6% at 12 months. Estimates of assisted primary and secondary patency were both 100% at 12 months. Freedom from major adverse events at 12 months was 100%. Most patients experienced improvements in Rutherford category, ankle-brachial index, and functional status that were sustained to 12 months., Conclusion: This positive first-in-human experience with the Gore balloon-expandable covered endoprosthesis suggests this device will have an important role in the management of aortoiliac occlusive disease.

Purpose: To show feasibility of the covered endovascular repair of the aortic bifurcation (CERAB) technique in conjunction with chimney grafts in aortic side branches for complex aortoiliac occlusive disease., Methods: Two European centers and one facility located in New Zealand participated in a retrospective observational study that enrolled 14 consecutive patients (mean age 61.2±8.9 years; 11 men) treated with CERAB in conjunction with chimney graft(s) between December 2012 and May 2015. Indications for treatment included disabling claudication in 9 and critical limb ischemia in 5. Lesions were classified as TransAtlantic Inter-Society Consensus II B (n=1), C (n=1), or D (n=12)., Results: A total of 15 chimney grafts were used to perfuse the inferior mesenteric artery (n=8), the right renal artery (n=4), and the left renal artery (n=3). Technical success was achieved in all cases. Procedural complications included 5 unintended dissections and 1 vessel thrombosis, all of which were successfully treated intraoperatively. Five patients developed access-site hematoma/ecchymosis (3 at the brachial access). Mean follow-up was 12 months (range 6-24) without death or loss to follow-up. One patient suffered occlusion of a CERAB limb and an IMA chimney graft; the former was recanalized, but the IMA graft was not; there were no signs of bowel ischemia. Ankle-brachial indices significantly increased from 0.54 (range 0.47-0.60) preoperatively to 0.97 (range 0.90-1.00) in 11 patients examined at 12 months, and all patients had an improvement in the Rutherford category. All CERAB limbs, including the one recanalized, were patent at the most recent follow-up, as were 14 of 15 chimney grafts., Conclusion: Chimney-CERAB is technically feasible and may offer an alternative to open surgery for complex aortoiliac occlusive disease. Further prospective studies are needed to confirm these findings.

Objective: The purpose of this study was to determine the long-term effectiveness of endovascular aneurysm sealing (EVAS) in the treatment of complex aortoiliac aneurysms with preservation of hypogastric artery flow., Methods: We reviewed all patients with abdominal aortic aneurysms (AAAs) and common iliac aneurysms (CIAs) enrolled and treated in prospective studies of EVAS using the Nellix endograft (Endologix, Irvine, Calif) at two centers from 2008 to 2014. Patients with 1 year or more of computed tomography follow-up underwent quantitative morphometric assessment by two independent vascular radiologists blinded to clinical outcome results. Hypogastric patency and CIA diameter changes over time were assessed and compared in three treatment groups: totally excluded CIA, partially excluded CIA, and untreated CIA., Results: Among 125 patients with EVAS, 68 patients (mean age, 75 ± 8 years; 79% men) had both AAA (mean diameter, 55.8 ± 2.0 mm) and CIA (median diameter, 23.4; interquartile range, 21.3-27.0 mm), with bilateral CIAs in 33 patients. Treatment of 101 CIAs included complete CIA exclusion in 40 (39.6%), partial CIA exclusion in 33 (32.7%), and no CIA treatment in 28 (27.7%), with successful AAA exclusion in all patients. Internal iliac flow was preserved in all 122 hypogastric arteries that were patent before treatment (14 hypogastric arteries were occluded at baseline). During the 5-year follow-up period (median follow-up, 24.7 months; range, 11.5-61.7 months), three patients required secondary treatment with hypogastric occlusion and graft extension to the external iliac. Thus, internal iliac flow was maintained in 98% of at-risk hypogastric arteries. There were no aneurysm-related clinical events, except for the three secondary treatments. Totally excluded iliac aneurysms did not change in diameter over time (P = .85), whereas untreated CIAs enlarged at a rate of 0.16 mm/y (95% confidence interval, 0.09-0.23; P < .0001). Partially excluded CIAs enlarged at a higher rate of 0.59 mm/y (95% confidence interval, 0.47-0.71; P < .0001). Enlargement ≥3 mm occurred only in partially treated CIAs larger than 3 cm., Conclusions: EVAS was effective in treating aortoiliac aneurysms with preservation of internal iliac patency in most cases. Complete CIA exclusion prevented aneurysm enlargement over time, whereas partial exclusion did not prevent continued CIA enlargement, particularly in larger aneurysms., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the early and 12-month results of a global registry of patients treated with endovascular aneurysm sealing (EVAS) for abdominal aortic aneurysms (AAAs)., Methods: The EVAS FORWARD Global Registry was a postmarket, multicenter, open-label, single-arm registry that enrolled 277 patients (mean age 75 years; 228 men) treated with the Nellix EVAS system for nonruptured AAAs at 18 sites over a 1-year period. The cohort had challenging aortic anatomy, with 17% having a proximal aortic neck length <10 mm, 8% a neck angulation >60°, and 20% an iliac diameter >25 mm. Baseline and follow-up computed tomography images were assessed by an independent core laboratory, and major adverse events were reviewed by an independent safety committee., Results: Three patients died within 30 days of the procedure (none device-related). There were 13 endoleaks recorded in this time frame: 8 type Ia, 1 type Ib, and 5 type II. Root cause analysis demonstrated that the majority of type Ia endoleaks were due to technical error (low device placement and underfilling of the endobags). Between 30 days and 1 year, there were 4 new type Ia endoleaks; all were treated. There was also 1 type III endoleak between a Nellix device and a distal extension limb. At 1 year, the persistent endoleak rate was 0.7% (1 type Ia and 1 type II). The Kaplan-Meier estimates of freedom from types I and II endoleak at 12-month follow-up were 96% and 98%, respectively. The estimate of freedom from open conversion (n=7) was 98% at 12 months and the rate of freedom from any reintervention was 92%. The need for secondary intervention was associated with aortic morphology; for patients meeting the requirements of the instructions for use (IFU), the freedom from reintervention at 12 months was 98% compared with 86% when the implant was outside the IFU (p=0.009). At 1 year, the estimates of freedom from aortic-related and all-cause mortality were 98% and 95%, respectively., Conclusion: The EVAS FORWARD Global Registry documents the 12-month outcome of EVAS in an unselected group of patients with challenging aortic morphology. The results at present appear acceptable with regard to perioperative outcomes and complications. The type II endoleak rate is low. The place of EVAS in the armamentarium of techniques to treat AAAs will be defined by durability data in the longer term., (© The Author(s) 2016.)

Endovascular repair of abdominal aortic aneurysms (EVAR) is now an established treatment modality for suitable patients presenting with aneurysm rupture. EVAR for ruptured aneurysms reduces transfusion, mechanical ventilation, intensive care. and hospital stay when compared with open surgery. In the emergency setting, however, EVAR is limited by low applicability due to adverse clinical or anatomical characteristics and increased need for reintervention. In addition, ongoing bleeding from aortic side branches post-EVAR can cause hemodynamic instability, larger hematomas, and abdominal compartment syndrome. Endovascular aneurysm sealing, based on polymer filling of the aneurysm, has the potential to overcome some of the limitations of EVAR for ruptured aneurysms and to improve outcomes. Recent literature suggests that endovascular aneurysm sealing can be performed with early mortality similar to that of EVAR for ruptured aortic aneurysms, but experience is limited to a few centers and a small number of patients. The addition of chimney grafts can increase the applicability of endovascular aneurysm sealing in order to treat short-neck and juxtarenal aneurysms as an alternative to fenestrated endografts. Further evaluation of the technique, with larger longitudinal studies, is necessary before advocating wider implementation of endovascular aneurysm sealing in the emergency setting., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

The published evidence on clinical outcomes of Nellix Endovascular Aneurysm Sealing for elective abdominal aortic aneurysm repair has confirmed low procedural morbidity and reintervention rate. This early clinical experience with Nellix is encouraging, despite the device and procedural steps being in evolution, and patients being treated outside of the recommended instructions for use. The long-term follow-up of a treated patient cohort is now available and demonstrates low aneurysm-related mortality and morbidity. The initial experience with the commercially available Nellix device was captured in a multicenter report involving 171 patients and two independently monitored, company-sponsored device registries (EVAS Forward Global Trial and Forward US Investigational Device Exemption Trial). All three clinical studies report a 99% procedural technical success, low mortality, and persistent endoleak rate with re-intervention rates comparable to conventional EVR device registries. Nellix EVAS is applicable to a range of aneurysm anatomies, including patients with isolated of concomitant iliac artery aneurysms. The post-procedural imaging appearances after Nellix EVAS are unique due to the AAA sac polymer, change with time, but are now well understood., (Copyright © 2016. Published by Elsevier Inc.)

Purpose: To assess the feasibility and safety of the endovascular aneurysm sealing (EVAS) technique in the treatment of acute abdominal aortic aneurysm (AAA)., Methods: A retrospective, multicenter, observational study was conducted at 8 centers (7 European and 1 in New Zealand) experienced with EVAS in the elective setting. From February 2013 to April 2015, 58 patients (mean age 74±9 years; 46 men) with an acute AAA were treated (28 ruptured and 30 symptomatic). The primary endpoint of the study was 30-day mortality; secondary endpoints included endoleak, reinterventions, and 30-day morbidity., Results: The overall intensive care unit and hospital stays were 2.2±6.6 days and 9.7±11.4 days, respectively. Thirty-day mortality rates were 32% (9/28) for the ruptured group and 7% (2/30) for the symptomatic group, with morbidity rates of 57% and 17%, respectively. Early endoleak was present in only 2 (3%) patients, one in each group; both leaks were type Ia. Reinterventions within 30 days were performed in 8 patients in the ruptured group; in the symptomatic patients, the only perioperative reintervention was embolization a type Ia endoleak. The mean follow-up was 9.3±3.1 months in the ruptured group and 12.4±5.4 months in the symptomatic group. The mean aneurysm diameter at 30-day follow-up was 71.8±16.0 mm compared with 74.7±15.7 mm preoperatively in the ruptured group and 66.1±13.5 mm compared with 65.8±13.0 mm in the symptomatic group., Conclusion: EVAS in the acute setting appears safe and feasible and concordant with the literature for endovascular aneurysm repair. More robust prospective and comparative data are required to establish the position of the technique in the treatment algorithm of acute AAA., (© The Author(s) 2015.)

Endovascular aneurysm sealing (EVAS) using the Nellix system is a new and different method of abdominal aortic aneurysm repair. Normal postoperative imaging has unique appearances that change with time; complications also have different and specific appearances. This consensus document on the imaging findings after Nellix EVAS is based on the collective experience of the sites involved in the Nellix EVAS Global Forward Registry and the US Investigational Device Exemption Trial. The normal findings on computed tomography (CT), duplex ultrasound, magnetic resonance imaging, and plain radiography are described. With time, endobag appearances change on CT due to contrast migration to the margins of the hydrogel polymer within the endobag. Air within the endobag also has unique appearances that change over time. Among the complications after Nellix EVAS, type I endoleak usually presents as a curvilinear area of flow between the endobag and aortic wall, while type II endoleak is typically small and usually occurs where an aortic branch artery lies adjacent to an irregular aortic blood lumen that is not completely filled by the endobag. Procedural aortic injury is an uncommon but important complication that occurs as a result of overfilling of the endobags during Nellix EVAS. The optimum imaging surveillance algorithm after Nellix EVAS has yet to be defined but is largely CT-based, especially in the first year postprocedure. However, duplex ultrasound also appears to be a sensitive modality in identifying normal appearances and complications., (© The Author(s) 2015.)

The successful transcatheter treatment of a type IA endoleak after endovascular aortic aneurysm sealing with the Nellix EndoVascular Aneurysm Sealing system (Endologix Inc, Irvine, California) using proximal covered stent extension and transarterial N-butyl cyanoacrylate sac embolization is described. Three patients were treated using the same technique with a mean interval between the index procedure and reintervention of 9.3 months (range, 3-15 mo). No complications or endoleaks were seen on follow-up imaging. The mean follow-up time after reintervention was 10.3 months (range, 7-13 mo)., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Introduction: Percutaneous mechanical rheolytic thrombectomy is an effective treatment option for deep vein thrombosis as well as arterial and graft thromboses. Acute pancreatitis, a rare complication of this technique, is described in this case report., Case Report: A 40-year-old man underwent AngioJet mechanical rheolytic thrombectomy for iliocaval deep vein thrombosis. He subsequently developed acute pancreatitis. This case report outlines the clinical presentation of acute pancreatitis after rheolytic thrombectomy and also discusses the possible pathogenesis and etiological factors., (© The Author(s) 2014.)

Objective: This study evaluated changes in aortic neck diameter after endovascular aneurysm repair (EVAR) using a balloon-expandable stent (BES) endograft compared with a commercially available self-expanding stent (SES) endograft. We hypothesized that forces applied to the aortic neck by SES endografts may induce aortic neck enlargement over time and that such enlargement may not occur in aneurysm patients treated with a device that does not use a proximal SES., Methods: This was a retrospective quantitative computed tomography (CT) image analysis of patients treated with the Nellix (Endologix, Irvine, Calif) BES (n = 49) or the Endurant II (Medtronic, Minneapolis, Minn) SES (n = 56) endograft from 2008 to 2010. Patients with preimplant, postimplant, and at least 1-year serial CT scans underwent quantitative morphometric assessment by two independent vascular radiologists blinded to the outcome results. Changes in the infrarenal neck over time were compared with the suprarenal aorta for each patient., Results: Follow-up extended to 4.8 years for the BES and to 4.6 years for the SES, with no significant difference in median follow-up time (34 months for BESs and 24 months for SESs; P = .06). There were no differences in preimplant neck diameter (25.2 ± 0.9 mm vs 25.7 ± 1.1 mm; P = .54) or length (27.7 ± 3.7 mm vs 23.6 ± 3.7 mm; P = .12) between BESs and SESs at baseline. After implantation, neck diameter increased by 1.1 ± 0.5 mm in BES patients and 2.6 ± 0.5 mm in SES patients (P = .07) compared with the preoperative diameter. At 3 years, neck diameter increased by 0.5 ± 0.9 mm in BES patients and by 3.8 ± 1.0 mm in SES patients (P = .0002) compared with the first postoperative CT scan. The annual postimplant rate of increase in the infrarenal neck diameter was fivefold greater in SES patients (1.1 ± 0.1 mm/y) than in BES patients (0.22 ± 0.04 mm/y; P < .0001). There were no significant differences in the diameter of the suprarenal aorta at baseline or at 3 years and no differences in the annual rate of change in suprarenal aortic diameter between BES and SES endografts., Conclusions: EVAR using SES endografts resulted in progressive infrarenal aortic neck enlargement, whereas EVAR using BES endografts resulted in no neck enlargement over time. These data suggest that infrarenal neck enlargement after EVAR with SES endografts is likely related to the force exerted by SES elements rather than disease progression in the infrarenal neck., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Despite improvements in endograft devices, operator technique, and patient selection, endovascular repair has not achieved the long-term durability of open surgical aneurysm repair. Persistent or recurrent aneurysm sac flow from failed proximal sealing, component failure, or branch vessel flow underpins a significant rate of reintervention after endovascular repair. The Nellix device (Endologix, Irvine, Calif) employs a unique design with deployment of polymer-filled EndoBags surrounding the endograft flow lumens, sealing the aneurysm sac space and potentially reducing complications from persistent sac flow. This retrospective analysis represents the initial experience in consecutive patients treated with the device in real-world practice., Methods: This study was performed at six clinical centers in Europe and one in New Zealand during the initial period after commercialization of the Nellix device. Patients underwent evaluation with computed tomography and other imaging modalities following local standards of care. Patients were selected for treatment with Nellix and treated by each institution according to its endovascular repair protocol. Clinical and imaging end points included technical success (successful device deployment and absence of any endoleak at completion angiography), freedom from all-cause and aneurysm-related mortality, endoleak by type, limb occlusion, aneurysm rupture, and reintervention., Results: During a 17-month period, 171 patients with abdominal aortic aneurysms were treated with the Nellix device and observed for a median of 5 months (range, 0-14 months). The 153 male and 18 female patients with mean age of 74 ± 7 years had aneurysms 61 ± 9 mm in diameter with an average infrarenal neck length of 28 ± 15 mm and infrarenal angulation of 37 ± 22 degrees. Technical success was achieved in all but two patients (99%); one patient had a type Ib endoleak and another had a type II endoleak. Through the last available follow-up, type Ia endoleak was observed in five patients (3%), type Ib endoleak in four patients (2%), and type II endoleak in four patients (2%). There were eight limb occlusions (5%), among which seven were evident at the 1-month follow-up visit. Aneurysm-related reinterventions were performed in 15 patients (9%). There were no aneurysm ruptures or open surgical conversions., Conclusions: This first multicenter postmarket report of the Nellix device for infrarenal abdominal aortic aneurysm repair demonstrates satisfactory results during the initial learning phase of this new technology. The rate of aneurysm exclusion was high, and frequency of complications was low. More definitive conclusions on the value of this novel device await the results of the ongoing Nellix EVAS FORWARD Global Registry and the EVAS FORWARD investigational device exemption trial., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

For people enrolled in Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL), we sought to examine whether variation exists in the baseline medical therapy of different geographic regions and if any variations in prescribing patterns were associated with physician specialty. Patients were grouped by location within the United States (US) and outside the US (OUS), which includes Canada, South America, Europe, South Africa, New Zealand, and Australia. When comparing US to OUS, participants in the US took fewer anti-hypertensive medications (1.9 ± 1.5 vs. 2.4 ± 1.4; P < .001) and were less likely to be treated with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (46% vs. 62%; P < .001), calcium channel antagonist (37% vs. 58%; P < .001), and statin (64% vs. 75%; P < .05). In CORAL, the identification of variations in baseline medical therapy suggests that substantial opportunities exist to improve the medical management of patients with atherosclerotic renal-artery stenosis., (Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Objective: This study assessed preliminary results of the Ventana Fenestrated System (Endologix, Irvine, Calif) as an off-the-shelf integrated device for juxtarenal aortic aneurysm (JAA) or pararenal aortic aneurysm (PAA) endovascular repair., Methods: From November 2010 to April 2012, seven centers enrolled 31 patients with JAAs or PAAs in an international clinical trial of the Ventana Fenestrated System. Clinical and laboratory evaluations were done predischarge and at 1 month, with continuing follow-up through 5 years. Core laboratory computed tomography imaging assessments were performed at 1 month and at each subsequent follow-up., Results: Patients (mean age, 73 years; 90% male) presented with mean aneurysm sac diameter of 6.0 cm. One patient with a short, reversed tapered infra-superior mesenteric artery (SMA) neck was enrolled under a protocol waiver. Among the 31 patients, one of five Ventana device models was used to preserve main renal arteries, the SMA, and celiac arteries; 20 patients (65%) received the same Ventana device (aligned fenestrations, 28-mm diameter). Median fluoroscopy and procedure times were 49 and 197 minutes, respectively; median hospital length of stay was 3.0 days. The 1-month clinical success rate was 94% (29 of 31), with no perioperative mortality. One intervention on day 26 was done to resolve limb kink/occlusion. A type IA endoleak and renal occlusion secondary to procedural device damage led to a reintervention on day 52 and dialysis at 5 months. During follow-up to 23 months, three non-aneurysm-related deaths occurred. No aneurysm rupture or conversion to open repair has occurred. One late migration with endoleak and covered renal stent fracture/occlusion occurred at 8 months in the patient with a short, reverse tapered infra-SMA neck performed under a protocol waiver, which was managed successfully with bilateral renal bypasses and endovascular repair of the endoleak. Another patient underwent late endovascular interventions to resolve bilateral renal stenosis., Conclusions: The multicenter experience of the Ventana Fenestrated System supports its safety and early-term to midterm effectiveness for the endovascular repair of JAAs and PAAs. This off-the-shelf integrated system permits endovascular treatment of JAAs or PAAs; however, further expanded clinical experience and longer-term follow-up are needed to more fully assess this device system., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Customized fenestrated endovascular stent grafts have been investigated as an alternative to open surgery for repair of more complex juxtarenal aortic aneurysms (JAAs). The substantial time required to design and manufacture these devices has led to the desire for a standardized fenestrated endovascular system. We report the initial pilot study results of a potential "off-the-shelf" fenestrated device system to assess its initial safety and feasibility for endovascular repair of JAAs and pararenal aortic aneurysms (PAAs)., Methods: Following ethics committee approvals, consenting patients were evaluated for eligibility. Patients with aneurysms abutting or including the renal artery orifices who were not candidates for standard infrarenal endograft placement because of proximal aortic neck morphology were further assessed for anatomic suitability for this "off-the-shelf" device. There were a number of anatomic requirements, the most important being a stable infra-superior mesenteric artery aortic neck length ≥ 15 mm. Patients are assessed in-hospital and in follow-up at 1, 6, and 12 months, and annually thereafter to 5 years for adverse events and using contrast-enhanced computed tomography angiography with Core Laboratory interpretation of renal perfusion, device integrity, migration, endoleak, and aneurysm morphology., Results: Fifteen patients (87% male) with JAAs (93%) or PAAs (6.7%) presented at mean age of 77 years (range, 66-85 years) and with mean sac diameter of 5.9 cm (range, 5.1-7.9 cm). Four Ventana fenestrated stent graft models having aligned fenestrations (three models) or offset fenestrations (one model) and renal stent grafts were successfully implanted among the patients, and all renal and visceral arteries were preserved. Mean endovascular procedure time was 108 minutes (range, 71-212 minutes) with mean contrast usage and fluoroscopy time of 254 mL (range, 67-420 mL) and 55 minutes (range, 27-104 minutes), respectively. Five patients received blood products. Mean time to hospital discharge was 3.3 days (range, 2-9 days). In follow-up to 6 months and 1 year, no rupture, conversion to open repair, migration, type I/III endoleak, or renal loss/infarcts were observed. Two late nonaneurysm-related deaths have occurred. One secondary procedure for iliac limb kinking/occlusion and one secondary procedure for renal artery stenosis have been performed., Conclusions: Early experience supports procedural and initial postprocedural safety and demonstrates proof of concept for the off-the-shelf Ventana fenestrated system for the endovascular repair of JAAs and PAAs in selected patients. Continued follow-up and expanded multicenter clinical experience is warranted., (Copyright © 2013 Society for Vascular Surgery. All rights reserved.)

In this paper, we apply a 3-D flow model and a 1-D circulation model to the hemodynamic analysis of transjugular intrahepatic portosystemic shunt (TIPS), the therapy for treating acute portal hypertension (PH) induced diseases. Using the 3-D model we are able to simulate the blood flow within a patient-specific TIPS system which was reconstructed from a computed tomography image, and quantify such hemodynamic data as the wall shear stress and flow velocity. The 1-D model is used for the investigation of generic TIPS-induced hepatic circulation phenomena. By incorporating physiological data into the 1-D model we can reproduce some complex flow patterns such as the increased arterial flow after TIPS implantation, the formation of retrograde flow in the portal vein, etc. In particular, our model gives a quantitative analysis of the interplay between TIPS and hepatic flows. In conclusion, the presented computational model can be used for the theoretical analysis of TIPS, in which clinical decisions are often made based on contradictory considerations to balance the procedure-induced complications and the urgency of relieving acute PH symptoms.

Background: Evaluation of blunt abdominal trauma is controversial. Computed tomography (CT) of the abdomen is commonly used but has limitations, especially in excluding hollow viscus injury in the presence of solid organ injury. To determine whether CT reports alone could be used to direct operative treatment in abdominal trauma, this study was undertaken., Methods: The trauma database at Auckland City Hospital was accessed for patients who had abdominal CT and subsequent laparotomy during a five-year period. The CT scans were reevaluated by a consultant radiologist who was blinded to operative findings. The CT findings were correlated with the operative findings., Results: Between January 2002 and December 2007, 1,250 patients were evaluated for blunt abdominal injury with CT. A subset of 78 patients underwent laparotomy, and this formed the study group. The sensitivity and specificity of CT scan in predicting hollow viscus injury was 55.33 and 92.06 % respectively. The positive and negative predictive values were 61.53 and 89.23 % respectively. Presence of free fluid in CT scan was sensitive in diagnosing hollow viscus injury (90 %). Specific findings for hollow viscus injuries on CT scan were free intraperitoneal air (93 %), retroperitoneal air (100 %), oral contrast extravasation (100 %), bowel wall defect (98 %), patchy bowel enhancement (97 %), and mesenteric abnormality (94 %)., Conclusions: CT alone cannot be used as a screening tool for hollow viscus injury. The decision to operate in hollow viscus injury has to be based on mechanism of injury and clinical findings together with radiological evidence.

Purpose: To compare the outcomes of planned superficial femoral artery (SFA) and common femoral artery (CFA) antegrade punctures in patients undergoing endovascular interventions for infrainguinal occlusive arterial disease in a single center., Materials and Methods: Between August 2010 and July 2011, consecutive patients who underwent antegrade puncture of CFA or SFA for infrainguinal occlusive disease were studied. Data including sheath size, rate of closure device usage, and complications relating to the arterial puncture were classified according to Society of Interventional Radiology (SIR) classification and analyzed retrospectively., Results: There were 199 antegrade arterial punctures, of which 28 (14%) were planned SFA punctures, performed in 184 patients. All patients had ultrasound-guided puncture. The sheath size ranged from 4 F to 8 F. In 2 of 28 (7%) SFA punctures, a closure device was deployed compared with 43 of 171 (25%) CFA punctures. Six bleeding complications were noted in the CFA puncture group (6 of 171 [3.5%]), of which 2 required urgent operations (repair of a pseudoaneurysm and evacuation of retroperitoneal hematoma). In comparison, only one minor groin hematoma was noted in the SFA puncture group; this did not require any further treatment. No thromboembolic complications were associated with SFA puncture., Conclusions: Planned antegrade SFA puncture under ultrasound guidance can be performed safely in selected cases with no added morbidity. Interventionalists should have a low threshold for considering antegrade SFA puncture as a first-line access site, especially in patients with a hostile groin., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

The role of endovascular treatment of atherosclerotic renal artery disease is uncertain, particularly after the publication of the Angioplasty and Stenting for Renal Artery Lesions trial and other randomized trials. These trials have shown that nonselective treatment of patients with renal artery stenosis does not result in a benefit when compared with best medical therapy. However, all trials have identified a subgroup of patients who do respond favorably to revascularization. In particular, patients with a degree of chronic renal insufficiency, critical renal artery stenosis, and a recent decline in renal function are likely to respond positively to revascularization. Endovascular treatment of renal artery stenosis must be performed safely, particularly in the high-risk patient group with background chronic renal insufficiency. Atheroembolization occurs during renal artery revascularization, as demonstrated by ex vivo studies and the high embolic yield obtained in published series of protected renal artery revascularization. The evidence supporting embolic protection includes single-center series wherein excellent results for renal function preservation have been reported. One small, randomized, controlled trial demonstrated a significant benefit if both embolic protection and abciximab were used. There are unique demands on an embolic protection device in the renal artery circulation and a dedicated device has not been developed. Both distal filters and occlusion balloons have been successfully used. Both devices can normally be primarily passed through the stenosis, allowing the remainder of the procedure to be protected. Filters have the advantage of maintaining renal perfusion throughout the procedure. Distal occlusion balloons can capture embolic particles of all sizes although the clinical advantage is uncertain., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Biliary complications following liver transplantation result in major morbidity. We undertook a 10-year audit of the incidence, management and outcomes of post-transplant biliary complications at the New Zealand Liver Transplant Unit., Methods: Prospectively collected data on 348 consecutive liver transplants performed between February 1998 and October 2008 were reviewed. The minimum follow-up was 6 months., Results: A total of 309 adult and 39 paediatric transplants were performed over the study period. Of these, 296 (85%) were whole liver grafts and 52 (15%) were partial liver grafts (24 split-liver, eight reduced-size and 20 live-donor grafts). There were 80 biliary complications, which included 63 (18%) strictures and 17 (5%) bile leaks. Partial graft, a paediatric recipient and a Roux-en-Y biliary anastomosis were independent predictors of biliary strictures. Twenty-five (40%) strictures were successfully managed non-operatively and 38 (60%) required surgery (31 biliary reconstructions, three segmental resections and four retransplants). Seven (41%) bile leaks required surgical revision and 10 (59%) were managed non-operatively. There was no mortality related directly to biliary complications., Conclusions: Biliary complications affected one in five transplant recipients. Paediatric status, partial graft and Roux-en-Y anastomosis were independently associated with the occurrence of biliary strictures. Over half of the affected patients required surgical revision, but no mortality resulted from biliary complications., (© 2011 International Hepato-Pancreato-Biliary Association.)

Objective: All current aortic endografts depend on proximal and distal fixation to prevent migration. However, migration and rupture can occur, particularly in patients with aortic necks that are short or angulated, or both. We present our initial clinical experience with a new sac-anchoring endoprosthesis designed to anchor and seal the device within the aneurysm sac., Methods: The initial worldwide experience using a new endoprosthesis for the treatment of aortic aneurysms (Nellix Endovascular, Palo Alto, Calif) was reviewed. The endoprosthesis consists of dual balloon-expandable endoframes surrounded by polymer-filled endobags designed to obliterate the aneurysm sac and maintain endograft position. Clinical results and follow-up contrast computed tomography (CT) scans at 30 days and 6 and 12 months were reviewed., Results: The endograft was successfully deployed in 21 patients with infrarenal aortic aneurysms measuring 5.7 ± 0.7 cm (range, 4.3-7.4 cm). Two patients with common iliac aneurysms were treated with sac-anchoring extenders that maintained patency of the internal iliac artery. Infusion of 71 ± 37 mL of polymer (range, 19-158 mL) into the aortic endobags resulted in complete aneurysm exclusion in all patients. Mean implant time was 76 ± 35 minutes, with 33 ± 17 minutes of fluoroscopy time and 180 ± 81 mL of contrast; estimated blood loss was 174 ± 116 mL. One patient died during the postoperative period (30-day mortality, 4.8%), and one died at 10 months from non-device-related causes. During a mean follow-up of 8.7 ± 3.1 months and a median of 6.3 months, there were no late aneurysm- or device-related adverse events and no secondary procedures. CT imaging studies at 6 months and 1 year revealed no increase in aneurysm size, no device migration, and no new endoleaks. One patient had a limited proximal type I endoleak at 30 days that resolved at 60 days and remained sealed. One patient has an ongoing distal type I endoleak near the iliac bifurcation, with no change in aneurysm size at 12 months., Conclusion: Initial clinical experience with this novel intrasac anchoring prosthesis is promising, with successful aneurysm exclusion and good short-term results. This new device platform has the potential to address the anatomic restrictions and limitations of current endografts. Further studies with a longer follow-up time are needed., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Liver transplantation (LT) is established treatment for adults and children with acute or chronic liver failure, however there are insufficient donor organs to meet demand and 14% of New Zealand patients have died waiting or were de-listed due to deterioration whilst on the waiting list. Live donor liver transplantation (LDLT) offers an alternative graft source that enables timely transplantation, but also carries the risk of morbidity and mortality for the donor., Aim: To report the initial experience with LDLT in New Zealand., Methods: Review of donor and recipient outcomes for the first 20 cases., Results: 129 potential live liver donors were assessed for 68 recipients. Donors were evaluated according to a multi-step protocol including independent donor advocacy. Twenty LDLT were performed on 7 adults and 13 paediatric recipients using 5 right lobe, 2 extended left lobe, 2 left lobe, and 11 left lateral section grafts. Five donors (25%) experienced postoperative complications, none of which were life-threatening. Four recipients had acute liver failure and 16 had chronic liver disease including one retransplant. There was a high rate of recipient biliary complications (40%) but graft and recipient survival is 100% to date., Conclusion: LDLT has been successfully introduced in New Zealand with good donor and recipient outcomes.

This paper illustrates examples of popliteal artery pathologies imaged with contrast enhanced magnetic resonance angiography (CE-MRA) and magnetic resonance imaging (MRI) at a single tertiary referral centre. Popliteal artery pathologies were identified in 1710 patients referred over a 6-year period with symptoms suggesting lower limb arterial occlusive disease. Common pathologies such as atherosclerotic occlusive disease, thromboemboli and aneurysm disease are discussed as well as unusual pathologies such as cystic adventitial disease, mycotic aneurysm and arterial entrapment. The combination of CE-MRA and the excellent soft tissue resolution of MRI allow detailed evaluation of arterial and peri-arterial pathologies, and facilitate appropriate management decisions.

Purpose: To determine whether the rate of type II endoleaks following endovascular aneurysm repair (EVAR) can be decreased using a branch vessel management strategy., Methods: The branch vessel management strategy consisted of routine intraoperative embolization of all patent inferior mesenteric arteries (IMA) and thrombin injection into all aneurysm sacs that showed branch vessel filling on the "sacogram." Sixty-nine consecutive patients (65 men; median age 77 years, range 58-90) undergoing elective EVAR since the protocol was introduced in July 2003 were included; 69 consecutive patients (65 men; median age 76 years, range 60-90) who underwent EVAR immediately prior to the protocol were used as controls. Primary outcome measures were type II endoleak rates and secondary intervention rates., Results: The median follow-up was 36 months (range 0.25-72) for the pre-protocol group and 12 months (range 0.25-24) for the post-protocol group. The type II endoleak rate for the pre-protocol group was 26% compared to 14% for the post-protocol group (p=0.14). This difference was not significant on Kaplan-Meir analysis (p=0.23). The 18 type II endoleaks in the pre-protocol group included 14 lumbar endoleaks, 1 IMA endoleak, and 3 combined lumbar and IMA endoleaks. The 10 type II endoleaks in the post-protocol group included 9 lumbar artery endoleaks and 1 IMA endoleak. Ten (14%) patients in the pre-protocol group required 15 interventions for type II endoleak compared to 2 (3%) in the post-protocol group who required 3 secondary procedures for type II endoleak (p=0.03). This difference was not significant on Kaplan-Meier analysis (p=0.22). Of the 12 interventions for lumbar endoleaks, only 5 (42%) were successful., Conclusion: Although there was a trend toward lower type II endoleak rates with our branch vessel management strategy, this did not reach statistical significance. Our data also indicated that there is a high incidence of lumbar endoleaks, and they are difficult to treat. Therefore, we believe there should be ongoing research into means to prevent lumbar endoleaks.

Background: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Treatment options include liver resection, tumor ablation, and liver transplantation., Methods: We report the results of all patients undergoing partial hepatectomy for HCC with curative intent from a center where all major treatment modalities were available., Results: A series of 53 patients were identified, of whom 72% had underlying liver disease, mostly chronic hepatitis B infection. Altogether, 57% of patients underwent major resections, of whom 43% had histologically proven cirrhosis. Postoperative morbidity and mortality occurred in 41.5% and 7.5%, respectively. After a median follow-up of 34 months, the survival probabilities at 1, 3, and 5 years were 74.1%, 54.1%, and 42.6%, respectively. A total of 47% developed recurrent disease over the study period with a median disease-free survival of 13.8 months. The probabilities of recurrence at 1, 3, and 5 years were 35.2%, 49.4%, and 55.9%, respectively. Among those who developed recurrence, 76% died, with a median time to death from the time the recurrence was diagnosed of 7.8 months. There was a good association between the CLIP score and survival following liver resection. Multivariate analysis showed that only tumor recurrence and the presence of cirrhosis was a significant determinant of the risk of tumor-related death., Conclusion: These findings confirm that with careful patient selection liver resection for HCC can achieve good long-term patient survival and acceptable risks.

A novel endovascular technique to reduce flow through a transjugular intrahepatic portosystemic shunt (TIPS) is described in a patient with severe hepatic encephalopathy. This technique allows controlled and potentially adjustable partial closure of the TIPS without thromboembolic risk. The patient experienced a dramatic clinical improvement after the procedure.

Purpose: To retrospectively review the authors' experience with multi-detector row helical computed tomography (CT) in assessing 100 consecutive live potential renal donors., Materials and Methods: Hospital ethical committee approval was obtained; informed patient consent was not required. One hundred potential renal donors underwent multi-detector row CT assessment. Nonenhanced, arterial phase, and nephrographic phase examinations were performed. Delayed topograms were acquired to visualize the collecting system anatomy. A vascular radiologist prospectively interpreted the multi-detector row CT images. A second vascular radiologist, blinded to the initial results, retrospectively reviewed the images. Eighty candidates subsequently underwent donor nephrectomy, including 70 laparoscopic donor nephrectomies (LDNs) and 10 open donor nephrectomies (ODNs). Surgical findings served as the reference standard for 80 kidneys. The imaging findings in all 100 candidates (200 kidneys) were reviewed, although these findings were considered observational data only because there was no reference standard for 120 kidneys., Results: Multi-detector row CT findings predicted uncomplicated LDN in 67 of 70 patients. Small upper-pole capsular arteries arising from the distal main renal artery in two patients were not described in the multi-detector row CT report: In one patient, the arising vessels resulted in conversion to ODN because of bleeding; in the other patient, arterial reconstruction was performed. In another patient, conversion to ODN was necessary because of ongoing bleeding from an avulsed large lumbar venous tributary to the left renal vein. Observational data revealed that multiple renal arteries--most of which were accessory renal arteries--were seen in 52 (26%) kidneys. Early branching of the main renal artery was seen in 24 (12%) kidneys, and main renal arterial abnormalities were identified in six (3%). Capsular arteries were detected in 10 (5%) kidneys. Major variations in the anatomy of the main renal veins--including multiple right renal veins, a retroaortic left renal vein, and a circumaortic left renal vein--were seen in 28 (14%) kidneys. Large (>5 mm in diameter) systemic tributaries to the left renal vein were seen in 25 (25%) kidneys. There was no significant interobserver disagreement between the vascular radiologists., Conclusion: Multi-detector row CT findings can predict successful LDN in live potential renal donors., (RSNA, 2005)

Background: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding., Methods: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997-2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology., Results: The notes of 88 patients (male, n = 51; median age 69 years, range 8-99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of > or =50 from previous admission (P = 0.02); transfusion requirement of > or =5 units of blood within 24 h (P < 0.0001). Logistic regression analysis showed transfusion requirement of > or =5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40)., Conclusion: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of > or =5 units of blood to achieve haemodynamic stability.

Unlabelled: Liver transplantation (LT) is potentially curative for early hepatocellular carcinoma (HCC) but time spent on the waiting list exposes patients to the risk of tumour progression prior to transplantation., Aims: We prospectively evaluated the outcome for New Zealand patients listed for LT with a pre-transplant diagnosis of HCC., Methods: Patients with 1 to 3 tumours, up to 5 cm in diameter, and no vascular invasion or extra-hepatic disease on imaging, were considered eligible for LT. The results were analysed by intention to treat from the time of listing., Results: Fifty-nine patients were listed with a pre-transplant diagnosis of HCC between February 1998 and June 2004. Ten (17%) were de-listed before LT because of tumour progression, and 9 of 45 (20%) who underwent LT have experienced tumour recurrence up to 59 months post-transplant. For patients listed with a diagnosis of HCC, 5-year actuarial survival was 56.1% from the time of listing. For those listed and transplanted with a diagnosis of HCC, 5-year actuarial survival from the time of transplant was 63.5%. This is significantly worse than the 89.8% 5-year survival for patients transplanted without HCC over the same period (p=0.018) and this difference was entirely due to tumour recurrence., Conclusions: 37% of patients listed according to our criteria were either de-listed due to tumour progression or experienced recurrence after LT. Based on this experience strategies aimed at preventing waiting list drop out have been adopted, however expansion of tumour-related selection criteria cannot be recommended without a concomitant increase in donor organ availability.

Background: This investigation was undertaken to define the value of laparoscopy in the staging of patients with colorectal carcinoma metastatic to the liver., Methods: The clinical details of 59 consecutive patients with colorectal liver metastases undergoing laparoscopy prior to planned hepatectomy were entered prospectively on a computerized database. All patients were staged preoperatively with thin slice (5-7 mm) helical computed tomography chest, abdomen and pelvis. Synchronous metastases were defined as those found during, or on imaging carried out within 1 month of, colorectal resection. Criteria for laparoscopic unresectability were: (i) histologically proven extrahepatic disease; (ii) bilateral inflow or outflow involvement; (iii) the presence of cirrhosis in patients requiring an extended resection (lobectomy or greater); or (iv) hepatic metastases involving more than six hepatic segments., Results: In 24 patients with synchronous metastases (median age 65 years, range 32-81 years) all were resectable on laparoscopic criteria, of whom 21 were resected. Extrahepatic disease was found at laparotomy in three patients. In 35 patients with metachronous metastases (median age 64 years, range 32-81 years) laparoscopy could not be performed in five patients because of adhesions, and three patients were deemed unresectable on laparoscopic criteria. Of the remaining 27 patients, 25 underwent resection while two proved unresectable. Overall eight of 54 evaluable patients had unresectable disease and laparoscopy correctly identified three patients., Conclusions: Following computed tomography scan, 15% of patients with metastatic colorectal carcinoma will be found to have unresectable disease. Laparoscopy will identify approximately half. Laparoscopy is of no greater value in staging synchronous versus metachronous metastases.

A significant number of stenosing lesions at the hepatic hilus represent benign disease rather than hilar cholangiocarcinoma. It is unclear, however, which perioperative investigations are useful for defining benign lesions in this location. A series of 49 consecutive patients who presented with obstructive jaundice due to a stenosing lesion at the hepatic hilus were investigated by documenting elevated plasma bilirubin levels, the presence of weight loss, and elevated carcinoembryonic antigen (CEA) and Ca 19-9 concentrations. Radiologic investigations included direct cholangiography, transabdominal ultrasonography, computed tomographic (CT) scans and magnetic resonance imaging (MRI). A tissue diagnosis was obtained in all patients, and the preoperative investigations were reviewed to assess their accuracy for predicting malignancy. The final tissue diagnosis was a benign lesion in 12 patients (benign idiopathic strictures 10, choledocholithiasis 2). Among the 37 patients who presented with a malignant lesion, 2 had metastatic colorectal cancer, 7 had gallbladder cancer, and 28 had hilar cholangiocarcinoma. Of the 12 patients with benign lesions, 4 (33%) had elevated tumor markers (CEA and CA 19-9), 12 (100%) had cholangiograms suspicious for malignancy, and 9 (75%) had CT and MRI features consistent with a malignant diagnosis. Thus among patients presenting with hilar strictures approximately one-fifth are due to nonmalignant causes, but the preoperative diagnosis is difficult and resection remains the most reliable way to rule out malignancy in this site.

Purpose: We present a retrospective review of a single tertiary hospital experience in renal artery stent revascularization with distal protection in patients with ischemic nephropathy. The objectives of the study included preliminary assessment of the effect of distal protection on procedure-related acute deterioration in renal function and on renal salvage., Material and Methods: All patients had significant atherosclerotic main renal artery stenosis, documented at preprocedural imaging, and a degree of chronic renal impairment before revascularization. Forty-six renal arteries were treated in 37 patients with preprocedural renal impairment, which was mild in 10 patients, moderate in 19 patients, and severe in 8 patients. Median patient age was 72 years (range, 59-85 years). All patients underwent primary stenting of renal artery ostial stenoses with adjuvant use of a filter device (Angioguard guide wire system; Cordis Corp, Division of Johnson & Johnson, Miami, Fla) in the distal main renal artery. The filter baskets were recaptured for pathologic analysis., Results: Overall, in 95% of patients, including all patients with preprocedural mild or moderate renal impairment, renal function was stabilized or improved after revascularization. In 5% of patients decline in renal function was unchanged. No patients had acute postprocedural deterioration. Mean follow-up was 12.5 months (range, 2-28 months). These results are better than in most reports in the literature and also better than in a historical group of similar patients with ischemic nephropathy who underwent stent revascularization without distal protection at the same institution. The improved results are thought to be due to prevention of cholesterol atheroembolization during the procedure by the distal filter baskets. Sixty-five percent of the distal protection baskets contained embolic material, including fresh thrombus, chronic thrombus, atheromatous fragments, and cholesterol clefts., Conclusion: A distal protection device may significantly improve results during stent revascularization. There are a number of unique demands on a renal protection device, and the ideal device has not yet been developed.

Purpose: To report a new technique of endoluminal thoracic aortic arch aneurysm repair using a scalloped stent-graft., Case Report: A 79-year-old man presented with a 7.5-cm thoracic aneurysm involving the inner curve of the aortic arch. Endoluminal repair was performed with a scalloped stent-graft that allowed perfusion of the brachiocephalic (innominate) artery. Preliminary extra-anatomical left common carotid and subclavian artery bypass grafting had been performed to allow coverage of the origins of these vessels., Conclusions: The use of fenestrated endoluminal grafts in the aortic arch can be achieved safely and may increase the treatment options for the high-risk patient.

Objective: Focused assessment with sonography for trauma and emergency ultrasound for abdominal aortic aneurysm are now practiced widely by non-radiologists in emergency departments worldwide. Various credentialling programs have been proposed for novice sonographers; however, their feasibility has been questioned. We adopted the Australasian College for Emergency Medicine (ACEM) credentialling process for emergency ultrasound to determine whether it is feasible for emergency physicians in the Australasian environment., Methods: Three full-time emergency medicine specialists and a post-Fellowship Examination trainee at Auckland Hospital undertook the credentialling process., Results: All four participants had sufficient scans to complete the process after 16 months. Accuracy for focused assessment with sonography for trauma, 90% (95% CI 83-95%), and abdominal aortic aneurysm, 99% (95% CI 90-100%), is similar to that previously reported., Conclusion: The ACEM credentialling process for focused assessment with sonography for trauma and abdominal aortic aneurysm is practical and achievable for emergency medicine specialists working in the Emergency Department at Auckland Hospital. Further studies are necessary to determine whether this holds true for other major trauma centres in Australasia.

Aim: The majority of patients with hepatic malignancies are not suitable for potentially curative resection due to tumour size, location, inadequate hepatic reserve or widely spread disease. Radiofrequency ablation (RFA) is a novel technique of local tumour destruction by heat. The aim of this study was to report the initial experience with RFA in the management of primary and metastatic liver tumours in New Zealand., Methods: Patients who underwent RFA between February 2000 and August 2001 were included. The clinical, pathological and follow-up information of individual patients entered prospectively on a computerised database was collated and analysed., Results: Thirty one procedures were performed in 30 patients (18 male, median age 58 years). Nineteen procedures were performed percutaneously under ultrasound guidance and twelve were carried out as part of a surgical procedure. Eight patients had primary tumours, and 22 patients had metastatic tumours (colorectal 9, neuroendocrine 7, non-colorectal non-neuroendocrine 6). The median diameter of treated lesions was 25 mm (range 5 60 mm). The median number of treated lesions per patient was 2 (range 1 6). Twenty four of the 31 procedures were classified as curative (all disease treated). Six patients with neuroendocrine tumours underwent cytoreduction only and were classified as palliative. Eight patients (4 percutaneous, 4 surgical) developed complications leading to 3 prolonged hospital stays (bile leak, abscess and burn). There was no treatment-related mortality. At a median follow up of 12 months (range 1 22 months), 6 patients (all treated with percutaneous RFA) have developed tumour recurrence in treated lesions, 5 patients have developed new liver lesions, 16 are alive and disease free, and 3 have developed extra hepatic disease., Conclusions: RFA is safe but significant complications can occur. RFA and enteral resection should not be undertaken together, as there is an increased risk of hepatic sepsis and abscess. RFA performed percutaneously is associated with a higher rate of recurrence than RFA performed at operation.