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Background The purpose of this study was to evaluate the incidence and complications of accidental cannulation of retroperitoneal veins during venography for inferior vena cava (IVC) filter placement. Methods In total, 641 patients who underwent IVC filter placement were retrospectively reviewed. Incidence of accidental cannulation of retroperitoneal veins during venography (using 633 sheaths and 18 catheters, including 11 pigtail type and 7 end-hole–type catheters), along with the associated complications, were evaluated. Results The overall frequency of accidental cannulation of retroperitoneal veins was 5.4% (35 of 651) via venous approaches: 5.8% (24 of 411) via a right femoral approach, 3.9% (5 of 129) via a left femoral approach, and 5.4% (6 of 111) via a jugular approach. The most frequent veins cannulated were the ascending lumbar veins (4.6%, 25 of 540) via a femoral approach, and the median sacral vein (3.6%, 4 of 111) via a jugular approach. No significant difference in the frequency of accidental cannulation was observed between venography through sheaths and catheters (5.4% [n = 34] vs. 5.6% [n = 1; using an end-hole–type catheter]; P = 1.000). Injuries to 5 veins (0.8%), including 3 ascending lumbar veins, were observed. Inadvertent filter placement within the right ascending lumbar vein was observed in 1 patient (0.2%). Conclusions Accidental cannulation of retroperitoneal veins during venography for IVC filter placement is an infrequent occurrence, and in this patient series did not result in negative clinical outcomes. However, operators should be aware of the risk of accidental cannulation to prevent avoidable complications such as venous injury or filter misplacement.

The purpose of this study is to compare the technical success of transjugular intrahepatic portosystemic shunt (TIPS) in transplanted versus nontransplanted livers and to assess the clinical outcome of TIPS in liver transplant recipients.A retrospective audit of patients receiving a TIPS was performed in two institutions during 1996-2009. The technical success of the TIPS was compared for transplanted versus nontransplanted livers. Clinical success was defined as graft survival longer than 1 month with improvement in symptoms. The cohort was divided into grafts that survived less than 3 months versus 3 months or more. The model for end-stage liver disease (MELD) scores and portosystemic gradients before and after TIPS creation were evaluated for predictive value for graft survival. The TIPS stent type, MELD scores and portosystemic gradients before and after TIPS creation, and causes of liver disease were evaluated for their predictive value for ascites response after TIPS creation.Thirty-nine TIPS in transplanted livers were found, representing 5.5% (39/715) of all TIPS procedures performed and 2.0% (39/1992) of all liver transplant recipients. Ninety percent of TIPS in transplanted livers had ascites. The median time from transplant to creation of the TIPS was 29 months (2-127 months). The median MELD score was 16 before and 22 after the TIPS procedure. The technical success rates for TIPS were 97% (38/39) in transplanted livers versus 97% (657/676) in nontransplanted livers (p = 1.00). Intent-to-treat clinical success rates were 36% for all indications versus 31% for ascites only. There were no predictors for ascites response. Six-, 12-, and 24-month graft survival rates were 43%, 32%, and 22%, respectively. One-year graft survival for a MELD score less than 17 versus a score of 17 or higher was 54% versus 8%, respectively (p0.05).Transplantation does not pose a technical challenge to TIPS creation. One third of patients have a favorable outcome. MELD score is the only predictor of graft survival.

To characterize extrahepatic pseudoaneurysm regarding incidence and etiology and determine the effectiveness of endovascular management. A retrospective audit of 1,857 liver transplants in two institutions was performed (1996–2009). Recipients’ demographics, clinical presentation, transplant type, biliary anastomosis, and presence of biliary endoprostheses were noted. Pseudoaneurysms were classified into iatrogenic (associated with biliary endoprosthesis or angioplasty) or spontaneous extrahepatic pseudoaneurysms. Spontaneous and iatrogenic pseudoaneurysms were compared for time from transplant, presenting symptoms, location in the arterial anatomy, and 3-month graft survival. Arterial patency and 6-month graft survival were calculated. Twenty pseudoaneurysms were found (1.1 %, 20/1,857): 9 (0.5 % of transplants, 9/1,857) were spontaneous and 11 (0.6 % of transplants, 11/1,857) were “iatrogenic” (due to minimally invasive procedures: 4 angioplasty and 7 biliary endoprostheses). Sixty percent (12/20) underwent endovascular management (4 coil embolization and 8 stent-grafts). Technical success was 83 % (10/12) with a mean arterial patency of 70 % (follow-up mean, 4.9; range, 0–18 months). The 1-, 3-, and 6-month graft survival was 70, 40, and 35 %, respectively. Due to minimally invasive procedures, posttransplant extrahepatic pseudoaneurysms are no longer an exclusive complication of the transplant surgery itself. Endovascular management is effective to stabilize patients but has not improved historic postsurgical graft survival.

Saad W, Lippert A, Davies M, Arslan B, Kumer S, Waldman D, Turba U, Schmitt T, Matsumoto A, Angle J. Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients. Abstract: Purpose: To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients. Methods: A retrospective audit of liver transplant recipients in two institutions was performed (1996–2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization). Results: Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings. Conclusion: Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Patients who receive a left ventricular assist device (LVAD) are prone to develop end-stage renal disease. Primary arteriovenous fistula (AVF) maturation in these patients may be unsuccessful secondary to the nonpulsatile flow with an LVAD. Two patients with LVADs are described in whom assisted maturation aided long-term AVF patency.

Purpose To evaluate the feasibility of establishing a U-shaped inferior vena cava (IVC) catheter entirely from a transhepatic approach and to determine the catheter caliber that would provide adequate flow for hemodialysis. Materials and Methods Three pigs (weight, 45–50 kg) were used. A peripheral right hepatic vein was accessed transhepatically by using a 22-gauge needle, and a 0.018-inch wire was passed into the hepatic veins and IVC. An accessory right hepatic vein was accessed from the IVC. A snare was deployed in the accessory vein and used as a target for a second transhepatic 22-gauge needle pass. A wire was snared through the second transhepatic tract, around into the IVC, and through the first transhepatic tract. The 0.018-inch wire was upsized to a 0.035-inch platform. Measurements where made to tailor a U-shaped catheter from simple 10.2- and 12-F tubes by cutting them longitudinally (single long side hole) along the length of the IVC segment. The U-shaped hemodialysis catheter was placed over the wire and positioned so that the catheter opening lay in the IVC. With use of a dialysis machine, pressures and flow tolerance at set flow rates (100, 200, 300, 350, and 400 mL/min) were tested. Results All pigs underwent and survived successful catheter placements. All 10.2- and 12-F catheters tolerated flow rates up to 350 and 400 mL/min, respectively. Conclusions Establishing a U-shaped hemodialysis catheter with an entirely transhepatic approach is technically feasible. The 10.2-F U-shaped dialysis catheters provided a flow rate (>350 mL/min) that is appropriate for hemodialysis in human clinical settings.

Aunque el tratamiento endoluminal agresivo para la patologia oclusiva de la arteria femoral superficial (AFS) es habitual, no estan claras las implicaciones de la nefropatia cronica (NC) en los desenlaces a largo plazo en esta poblacion. Examinamos las consecuencias del tratamiento endovascular de la AFS en pacientes sin y con diversos estadios de NC. Se examino una base de datos de pacientes sometidos a tratamiento endovascular de la AFS entre 1986 y 2007, y se definieron dos grupos: tasa de filtracion glomerular estimada (TFGe) ≤ 60 y > 60 ml/min/1,73 cm2. Se efectuo un analisis por intencion de tratar. Los resultados se estandarizaron segun los criterios del TransAtlantic Inter-Society Consensus (TASC-II) y la Society for Vascular Surgery. Para evaluar las variables tiempodependientes se efectuaron analisis de Kaplan-Meier. Tambien se efectuaron analisis de factor utilizando un modelo de riesgos proporcionales de Cox para las variables tiempodependientes. Los datos se presentan como medias ± desviacion estandar cuando es apropiado. Se trataron 525 extremidades en 535 pacientes (68% de hombres, edad media 66 ± 14 anos) que se sometieron a tratamiento endovascular por claudicacion o isquemia critica cronica de la extremidad (51%). Los pacientes del grupo con TFGe ≤ 60 eran de mayor edad y experimentaban con una frecuencia significativamente mayor coronariopatia, insuficiencia cardiaca congestiva, diabetes mellitus, e hiperlipemia. La distribucion de las lesiones TASC II fue equivalente (37% de lesiones TASC II C y D) pero el runoff tibial fue significativamente peor en dicho grupo. Ademas, en este grupo se efectuaron un mayor numero de intervenciones de flujo eferente y aferente. En pacientes con claudicacion, no se detectaron diferencias en la permeabilidad o salvamento de la extremidad entre aquellos con TFGe ≤ 60 y > 60. En pacientes con isquemia critica de la extremidad, no hubo diferencias de permeabilidad entre ambos grupos. Las tasas de salvamento de la extremidad fueron peores en pacientes con TFGe ≤ 60. Al respecto, seis factores se asociaron significativamente con su disminucion: presencia de perdida de tejido en el momento de la presentacion (riesgo relativo [RR] = 6,45, p = 0,003), runoff tibial de 0 o 1 vaso (RR = 2,56, p

Alors qu'on assiste a une banalisation du traitement des lesions occlusives de l'artere femorale superficielle (AFS) par des therapies endovasculaires, l'impact d'une insuffisance renale chronique (IRC) sur les resultats a long terme dans cette population de patients est encore mal definie. Nous avons analyse les resultats du traitement endovasculaire de lesions de l'AFS chez des patients ayant une IRC, a differentes phases de la maladie. Nous avons revu les informations d'une base de donnees concernant des patients ayant beneficie d'un traitement endovasculaire de l'AFS entre 1986 et 2007. Deux groupes ont ete definis: debits de filtration glomerulaire estimes (eGFR) ≤60 et >60 mL/min/1.73 cm 2 . Une analyse en intention de traiter a ete realisee. Les resultats ont ete analyses selon les criteres du TransAtlantic Inter-Society Consensus (TASC-II) et selon les criteres de la Society for Vascular Surgery. Une analyse de Kaplan-Meier a ete realisee pour evaluer les resultats au cours du temps. L'analyse des facteurs de risque a ete realisee a l'aide d'un modele de Cox pour les variables dependant du temps. Les donnees ont ete presentees en moyenne ± deviation standard quand cela etait approprie. Au total, 525 membres inferieurs chez 535 patients (68% d'hommes, âge moyen de 66 ± 14 ans) ont beneficie d'un traitement endovasculaire pour une claudication ou une ischemie critique (51%). Les patients ayant un eGFR ≤60 etaient plus âges et etaient significativement plus nombreux a avoir une coronaropathie, une insuffisance cardiaque congestive, un diabete, et une hyperlipidemie. La proportion des lesions TASC-II etait equivalente dans les deux groupes (37% pour les TASC-II C et D), mais le flux dans les arteres tibiales etat significativement moins bon dans le groupe eGFR ≤60. De plus, un plus grand nombre d'interventions ont ete necessaires pour traiter des lesions d'amont ou d'aval dans le groupe eGFR ≤60. Chez les patients ayant une claudication, il n'y avait pas de difference en ce qui concerne la permeabilite ni le taux de sauvetage de membre entre les groupes eGFR ≤60 et >60. Chez les patients ayant une ischemie critique, il n'y avait pas de difference en ce qui concerne la permeabilite mais le taux de sauvetage etait significativement moins eleve dans le groupe eGFR ≤60 par apport au groupe eGFR >60. En ce qui concerne le taux de sauvetage de membre, six facteurs ont ete identifies comme etant associes de facon significative a une reduction du taux de sauvetage de membre: presence de necrose tissulaire a l'admission (risque relatif [RR] = 6,45 ; p = 0,003), 0 ou 1 artere jambiere permeable (RR = 2,56 ; p p p p p p = 0,64), les lesions classees TASC C ou D ( p = 0,99), l'existence d'une occlusion aigue au moment de l'intervention ( p = 0,40), necessite d'un stenting adjuvant ( p = 0,67). L'IRC n'a pas d'impact sur la permeabilite apres interventions endovasculaires sur l'AFS. Le taux de sauvetage de membre est significativement moins eleve chez les patients ayant un eGFR ≤60 mL/min/1,73 cm 2 .

Pseudoaneurysm of the hepatic arteries is uncommon following liver transplantation and is usually iatrogenic. We describe a case of balloon angioplasty of a left hepatic artery stenosis complicated by an iatrogenic pseudoaneurysm. Resolution of the stenosis and the pseudoaneurysm was achieved through a combination of a bare stent and a balloon-expandable covered stent. The completion angiogram demonstrated excellent appearance of the patent hepatic arteries with exclusion of the pseudoaneurysm. No surgery was required. The graft and the patient did well for the following 6 months. Doppler ultrasound examination at 2 and 6 months postintervention revealed patent hepatic arteries and no evidence of the pseudoaneurysm.

Summary The cytostatic drug, sirolimis has shown prevention in neointimal hyperplasia after stent placement. Recent studies have shown persistent inflammation seen with drug-eluting stents (DES) may result in late stent thrombosis. The aim of this study is to compare effects of bare metal stents (BMS) and sirolimis DES on the neointima and vasa vasorum in stented rabbit aortas. Stents were implanted in eight New Zealand rabbits for 9 weeks. Group I rabbits received BMS. Group II rabbits received sirolimis DES. A balloon-mounted BMS or DES was placed in the infrarenal aorta. Following euthanasia, aortas were perfused with barium sulfate and sectioned for histology. After 9 weeks the qualitative intrastent luminal diameter was fairly uniform in both the DES and the BMS. The thickness of neointima was similar in both groups. The number of vasa vasorum in the sirolimis DES increased compared with the BMS (P

Purpose: To examine the evolving roles of endovascular and open approaches in treatment of symptomatic innominate artery (IA) disease. Methods: Patients treated for symptomatic IA lesions with or without involvement of the right common carotid and/or right subclavian arteries between 1997 and 2006 were identified. Charts and diagnostic studies were retrospectively reviewed. Results: Of 18 patients treated, 8 required open reconstruction. Ten patients with high-grade focal stenosis were stented. Immediate technical and clinical success was 100% among all patients. Mean follow-up time was 25 and 27 months for endovascular and open interventions, respectively. The primary patency rates were 78% ± 14 and 80% ± 10 for endovascular and open groups, respectively. Assisted primary patency rate was 100% for both groups. There were no peri-operative mortalities or neurological events. We encountered two systemic (pulmonary) complications and one access-related complication among open and endovascular patients, respectively. Conclusion: Endovascular repair is evolving as a primary mode of therapy for focal IA lesions while open approach is reserved for more extensive disease. Patho-anatomical characteristics of a given IAlesion along with peri-operative risk assessment determine a proper surgical approach.

Aunque el tratamiento endoluminal agresivo para la patolog ia oclusiva de las principales ramas del cayado a ortico (tronco braquiocef alico (TBC), car otida com un izquierda (ACCI) y subclavia izquierda (ASCI)) es bastante frecuente, no est an claros los resultados a largo plazo en esta poblaci on. Examinamos los resultados a largo plazo del tratamiento endoluminal para la enfer- medad ostial del cayado a ortico en un centro m edico acad emico de referencia terciaria. Se reco- pilaron y analizaron retrospectivamente los resultados a partir de una base de datos prospectiva de aquellos pacientes sometidos a tratamiento endovascular de las principales arterias del arco a ortico por patolog ia oclusiva entre 1990 y 2004. Se seleccionaron los pacientes con lesiones ostiales esten oticas de las principales ramas del cayado a ortico. En todos los casos se revisaron

Alors qu'un traitement endoluminal agressif des lesions occlusives des principales branches de la crosse aortique (tronc arteriel brachio-cephalique (TABC), carotide primitive gauche (CPG) et sous-claviere gauche (SCG)) est couramment pratique, les resultats a long terme dans cette population de malades ne sont pas clairs. Nous avons etudie les resultats a long terme du traitement endoluminal des lesions ostiales de la crosse aortique dans un centre medical academique de reference tertiaire. Une banque de donnees prospectives des malades ayant un traitement endovasculaire de lesions occlusives atherosclereuses des troncs supra-aortiques proximaux entre 1990 et 2004 a ete etablie et analysee de facon retrospective. Les malades ayant des lesions stenosantes ostiales des principales branches de la crosse aortique ont ete selectionnes et les arteriographies ont ete etudiees dans tous les cas pour preciser les caracteristiques des lesions. La permeabilite a ete appreciee par un examen clinique systematique et, dans le cas des CPG et des SCG, un controle par echographie-Doppler a un, 6 et 12 mois apres l'intervention puis tous les 12 mois par la suite. Les resultats ont ete standardises suivant les criteres actuels du Trans-Atlantic Inter-Society Consensus et de la Society for Vascular Surgery. Des analyses de Kaplan-Meier ont ete realisees pour apprecier les resultats en fonction du temps. Une analyse des facteurs a ete realisee en utilisant un modele de risque proportionnel de Cox pour les variables dependant du temps. Les donnees sont presentees sous la forme d'une moyenne plus ou moins la deviation standard. Quarante-quatre malades (âge moyen 64 ± 2 ans, 59% de sexe masculin) ont eu 26 interventions sur la SCG, 11 sur la CPG et 8 sur le TABC pour des indications d'ischemie du membre superieur (29%) et de prevention ou de traitement d'un syndrome de vol coronaire (29%) ou pour des signes et des symptomes cerebro-vasculaires (42%). Le taux de succes technique a ete de 98%, avec une mortalite a 90 jours de 0% et un taux de complications majeures de 2%. Il n'y a pas eu d'accident vasculaire cerebral ou d'evenement embolique au niveau des membres superieurs. La permeabilite cumulee a ete de 88 ± 8% a trois ans, avec un taux de reintervention de 7%. Le taux global de recidive des symptomes a ete de 4%. Aucun facteur local ou general n'etait associe a un mauvais resultat. Le traitement endoluminal par stent des lesions ostiales des branches de la crosse de l'aorte fournit d'excellents taux de permeabilite a long terme au prix d'une morbidite, d'une mortalite et d'un taux d'interventions secondaires faibles. Avec un succes technique global de 98%, nos resultats sont comparables a ceux concernant les lesions situees plus distalement dans les branches de la crosse aortique et sont en faveur de la poursuite de l'utilisation du traitement percutane pour les lesions atherosclereuses des branches de la crosse aortique.

Reject analysis was performed on 288,000 computed radiography (CR) image records collected from a university hospital (UH) and a large community hospital (CH). Each record contains image information, such as body part and view position, exposure level, technologist identifier, and--if the image was rejected--the reason for rejection. Extensive database filtering was required to ensure the integrity of the reject-rate calculations. The reject rate for CR across all departments and across all exam types was 4.4% at UH and 4.9% at CH. The most frequently occurring exam types with reject rates of 8% or greater were found to be common to both institutions (skull/facial bones, shoulder, hip, spines, in-department chest, pelvis). Positioning errors and anatomy cutoff were the most frequently occurring reasons for rejection, accounting for 45% of rejects at CH and 56% at UH. Improper exposure was the next most frequently occurring reject reason (14% of rejects at CH and 13% at UH), followed by patient motion (11% of rejects at CH and 7% at UH). Chest exams were the most frequently performed exam at both institutions (26% at UH and 45% at CH) with half captured in-department and half captured using portable x-ray equipment. A ninefold greater reject rate was found for in-department (9%) versus portable chest exams (1%). Problems identified with the integrity of the data used for reject analysis can be mitigated in the future by objectifying quality assurance (QA) procedures and by standardizing the nomenclature and definitions for QA deficiencies.

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.

Hepatopulmonary syndrome (HPS) is a common complication of chronic liver disease. The definitive therapy is liver transplantation. Medical management, transjugular intrahepatic portosystemic shunt creation, and pulmonary arterial coil embolization have been described as temporizing measures until liver transplantation is performed. In earlier studies, the degree of right-to-left shunting in HPS has been shown to be an indicator of posttransplantation morbidity and mortality. The present article describes a case of type I HPS managed by liver transplantation and augmented by posttransplantation pulmonary arterial coil embolization to reduce the patient's posttransplantation morbidity.

We report on the clinical course of 2 patients who underwent laparoscopic Roux-en-Y gastric bypass for obesity and subsequently presented with biliary complications of choledocholithiasis in 1 case and sphincter of Oddi dysfunction in the other. The approach to these complex problems is described. Both patients underwent percutaneous transhepatic access to the common bile duct (CBD) for balloon sphincteroplasty. In 1 patient, percutaneous choledochoscopy was used for endoluminal visualization of the CBD. A literature review of the management of biliary problems after gastric bypass is presented. Although access to the CBD is limited, the options include percutaneous transhepatic instrumentation of the CBD, percutaneous or laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP), transenteric endoscopic cholangiopancreatography, ERCP using specialized endoscopes, and laparoscopic or open CBD exploration. Bile duct pathology after laparoscopic gastric bypass can be safely and effectively managed using a variety of techniques.

La thrombose « spontanee » de la veine sous-claviere (d'« effort ») est habituellement liee a la compression extrinseque de la veine a la jonction costo-claviculaire. Nous avons revu notre experience de cette entite au cours de la derniere decennie en nous concentrant sur le role de la thrombolyse et sur notre algorithme therapeutique. Tous les patients soignes pour ce probleme a l'universite de Rochester pendant la derniere decennie ont ete identifies et leurs dossiers ont ete revus retrospectivement. De 1996 a juin 2006, 34 patients presentant une occlusion complete spontanee de la veine sous-claviere documentee par phlebographie ont ete soignes, dont la moitie avec la notion d'un facteur d'exercice. Une thrombolyse par catheter dirige avant decompression immediate programmee du defile thoracique (DDT) a ete executee chez 26 patients, alors que la DDT etait faite seule chez huit patients. Le delai ecoule depuis le debut des symptomes etait le facteur principal influencant la decision, avec une moyenne de 5,5 jours chez les 26 patients adresses pour thrombolyse, et compris entre 1 mois et plusieurs annees dans le groupe qui a seulement ete opere. Chez les patients ayant une lyse, la repermeabilisation a ete obtenue 16 fois (62%), avec neuf fois une lesion residuelle. Tous sauf deux des 26 traites par thrombolyse ont eu une DDT avec ou sans angioplastie, et 13 ont egalement eu une reconstruction veineuse (huit des 16 chez qui la permeabilite avait ete reconstituee et cinq des huit chez qui elle ne l'avait pas ete). Les patients n'ayant pas de lyse ont ete traites par DDT, cinq (62%) n'ayant qu'une decompression et trois (38%) ayant une reconstruction veineuse. La thrombolyse n'a pas ete tentee (huit) ou a echoue (quatre) chez les 12 patients dont les symptomes etaient presents depuis plus de 14 jours. Avec un suivi moyen de 33 mois, la resolution des symptomes etait presque constante. La permeabilite primaire a 5 ans etait de 84% dans le groupe thrombolyse et de 83% dans le groupe de DDT isolee. En conclusion, le principal facteur influencant le choix therapeutique dans notre etablissement a ete le delai depuis le debut des symptomes. Les patients vus peu apres le debut de symptome ont eu une thrombolyse suivie d'une DDT, alors que les patients se presentant avec des symptomes chroniques n'avaient qu'une DDT ; dans les deux cas la reconstruction veineuse etait basee sur des resultats incomplets apres lyse. Nous n'avons pas eu de thrombolyse reussie chez un patient se presentant avec 14 jours ou plus de symptomes. Meme si le traitement optimal ne peut pas etre defini a partir de cette revue retrospective, notre algorithme a eu comme consequence un excellent controle a long terme de la permeabilite et des symptomes.

Imaging and management of postliver transplantation complications require an understanding of the surgical anatomy of liver transplantation. There are several methods of liver transplantation. Furthermore, liver transplantation is a complex surgery with numerous variables in its 4 anastomoses: (1) arterial anastomosis, (2) venous inflow (portal venous) anastomosis, (3) venous outflow (hepatic vein, inferior vena cava, or both) anastomosis, and (4) biliary/biliary-enteric anastomosis. The aim of this chapter is to introduce the principles of liver transplant surgical anatomy based on anastomotic anatomy. With radiologists as the target readers, the chapter focuses on the inflow and outflow connections and does not detail intricate surgical techniques or intraoperative maneuvers, operative stages, or vascular shunting.

The role of endovascular therapy for thrombosed dialysis access has grown despite the paucity of data on its viability. The purpose of this study was to characterize the outcomes of a universal endovascular dialysis declot policy at a tertiary medical center. A database of patients undergoing endovascular treatment of thrombosed dialysis access between 1997 and 2003 was maintained. A two-puncture, combined percutaneous mechanical and pharmacologic thrombectomy technique was used. Data were collected on the success rate, complication rate, long-term patency, and presence and location of stenosis. Fistulograms were reviewed in all cases to assess lesion characteristics and pre- and postprocedure results. Results were standardized to current Society of International Radiology and Society for Vascular Surgery criteria. Failure was considered as either an anatomic defect requiring therapy or loss of functionality of the fistula. Life-table analyses were performed to assess time-dependent outcomes. Cox's proportional hazard analyses were performed to identify factors associated with outcomes. Values are the mean +/- standard error of the mean. There were 114 patients (50% male; average age 58 years, range 21-78) who presented with 174 thrombosed grafts. Therapy was performed for 237 thrombotic events (median 2, range 1-5 thrombotic events per hemodialysis access). After successful declot, anastomotic venous stenoses were encountered in 72% and central venous stenoses in 18% of cases; no cause was found in 10%. All stenoses were treated with balloon angioplasty. The technical failure rate was 4.6%. The 30-day all-cause mortality rate was 1.7%, and major morbidity rate was 2.4%. There were 413 interventions (236 percutaneous transluminal angioplasty and/or 183 declot) performed to maintain patency, which amounted to 2.3 interventions per patient. Average primary functional dialysis life span was 6.7 months up to the primary thrombotic event. Aggressive endoluminal therapy added a further average of 12 months of functionality (defined as continued dialysis access). A universal policy of endovascular therapy for occluded dialysis access results in reestablishment of function in the majority of patients and will triple functional longevity. Furthermore, while this approach remains procedure-intensive, it carries low morbidity and mortality and preserves future sites of access.

Le role du traitement endovasculaire des thromboses d'acces pour hemodialyse s'est accru malgre le peu de donnees concernant sa viabilite. Le but de cette etude etait de caracteriser les resultats d'une politique universelle de traitement endovasculaire des thromboses d'acces pour hemodialyse dans un centre medical tertiaire. Une banque de donnees concernant les malades ayant eu le traitement endovasculaire d'un acces pour hemodialyse thrombose entre 1997 et 2003 a ete mise sur pied. Une technique combinee percutanee mecanique et pharmacologique avec deux points de ponction a ete utilisee. Les donnees concernant le taux de succes, le taux de complications, la permeabilite a long terme et la presence et la topographie des stenoses ont ete colligees. Les fistulographies ont ete revues dans tous les cas pour etudier les caracteristiques des lesions et les resultats avant et apres la procedure. Les resultats ont ete standardises conformement aux criteres actuels de la Society of International Radiology et de la Society for Vascular Surgery. L'echec a ete defini comme soit une lesion anatomique necessitant un traitement soit la perte de la fonctionnalite de la fistule. Une analyse actuarielle a ete realisee pour mesurer les resultats dependant du temps. Des analyses des risques proportionnels de Cox ont ete realisees pour identifier les facteurs associes aux resultats. Les valeurs considerees sont la moyenne ± la deviation standard de la moyenne. Il y a eu 114 malades (50% d'hommes, âge moyen 58 ans, extremes 21 et 78 ans) qui se sont presentes avec 174 greffons thromboses. Le traitement a ete realise pour 237 evenements thrombotiques (mediane 2, extremes 1 et 5 evenements thrombotiques par acces pour hemodialyse). Apres thrombectomie avec succes, des stenoses anastomotiques veineuses ont ete observees dans 72% des cas et les stenoses veineuses centrales dans 18% des cas. Aucune cause n'a ete trouvee dans 10% des cas. Toutes les stenoses ont ete traitees par angioplastie par ballonnet. Le taux d'echec technique a ete de 4,6%. Le taux de mortalite de toutes causes a 30 jours a ete de 1,7% et le taux de morbidite majeure a ete 2,4%. Il y a eu 413 interventions (236 angioplasties transluminales percutanees et/ou 183 decaillotages) realisees pour maintenir la permeabilite, ce qui represente 2,3 interventions par malade. La duree moyenne de permeabilite primaire de l'acces pour hemodialyse a ete de 6,7 mois jusqu'au premier evenement thrombotique. Un traitement endoluminal agressif a ajoute une moyenne supplementaire de 12 mois de fonctionnalite (definie comme le maintien de l'acces pour hemodialyse). Une politique universelle de traitement endovasculaire des acces pour hemodialyse occlus a entraine le retablissement de la fonctionnalite chez la majorite des malades et triple la longevite fonctionnelle. De plus, meme si cette approche multiplie les procedures, elle a une faible morbidite et mortalite et preserve les futurs sites d'acces.

Introduction Central (superior vena cava, brachiocephalic, or subclavian) venous stenoses are a major impediment to long-term arteriovenous access in the upper extremities. The optimal management of these stenoses is still undecided. The purpose of this study was to determine the outcomes of primary angioplasty (PTA) vs primary stenting (PTS) in a dialysis access population at a tertiary referral academic medical center. Methods A database of consecutive hemodialysis patients undergoing endovascular treatment for central venous stenosis was developed for the period 1995 through 2003. This database was retrospectively reviewed. Vessels exposed to either primary high-pressure balloon angioplasty or primary stenting were examined. Vessels undergoing stenting after failed or suboptimal angioplasty were defined as failures at the time of stenting despite the potential continued patency upon completion of stenting. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazards analysis was performed for time-dependent variables. Data are presented as mean ± standard deviation where appropriate. Results PTS was used to treat 26 patients (35% male; average age, 57 ± 15 years) with 26 central venous stenoses, and 47 patients (45% male; average age, 57 ± 18 years) with 49 central venous stenoses were treated with PTA. The PTS group underwent 71 percutaneous interventions per stenosis (average, 2.7 ± 2.4 interventions), and the PTA group underwent 98 interventions per stenosis (average, 2.0 ± 1.6 interventions). The PTS group hemodialysis access site was an average of 1.0 ± 1.3 years old at the time of the initial intervention, and the hemodialysis access in the PTA group was an average of 1.1 ± 1.2 years old. Primary patency was equivalent between groups by Kaplan-Meier analysis, with 30-day rates of 76% for both groups and 12-month rates of 29% for PTA and 21% for PTS ( P = .48). Assisted primary patency was also equivalent ( P = .08), with a 30-day patency rate of 81% and 12-month rate of 73% for the PTA group, vs PTS assisted patency rates of 84% at 30 days, and 46% at 12 months. Ipsilateral hemodialysis access survival was equivalent between groups. Conclusions Endovascular therapy with PTA or PTS for central venous stenosis is safe, with low rates of technical failure. Multiple additional interventions are the rule with both treatments. Although neither offers truly durable outcomes, PTS does not improve on the patency rates more than PTA and does not add to the longevity of ipsilateral hemodialysis access sites.

Traumatic aortic rupture due to blunt trauma in the pediatric population is rare. The management of this unusual injury has largely been extrapolated from the adult literature and is evolving. Open surgical repair is the accepted treatment; however, endograft repair is a promising alternative, which can serve as a definitive or bridging technique in select patients who are high-risk surgical candidates. The authors report the successful deployment of an endograft limb to correct a traumatic pseudoaneurysm of the aorta in a high-risk pediatric patient.

Hepatic artery thrombosis is an uncommon complication of liver transplantation. However, it is a major indication for re-transplantation. The use of transcatheter thrombolysis and subsequent surgical revascularization as a graft salvage procedure is discussed. Four of 5 cases (80%) were successful in re-establishing flow and uncovering underlying arterial anatomic defects. None were treated definitively by endoluminal measures due to an inability to resolve the underlying anatomic defects. However, 2 of 5 cases (40%) went on to a successful surgical revascularization and represent successful long-term outcome of transcatheter thrombolysis followed by definitive surgical revascularization. We conclude that, definitive endoluminal success cannot be achieved without resolving associated, and possibly instigating, underlying arterial anatomical defects. However, reestablishing flow to the graft can unmask underlying lesions as well as asses surrounding vasculature thus providing anatomical information for a more elective, better planned and definitive surgical revision.

Purpose To evaluate the clinical efficacy, safety, and feasibility of implementing video glasses in a variety of interventional radiologic (IR) procedures. Materials and Methods Between August 2012 and August 2013, 83 patients undergoing outpatient IR procedures were randomized to a control group (n = 44) or an experimental group outfitted with video glasses (n = 39). State-Trait Anxiety Inventory (STAI) scores, sedation and analgesia doses, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), pain scores, and procedure times were obtained. Complications and adverse events related to the use of video glasses were recorded. Postprocedural staff surveys and patient satisfaction surveys were completed. Results Women had greater preprocedural anxiety than men ( P = .0056), and patients undergoing vascular interventions had greater preprocedural anxiety than those undergoing nonvascular interventions ( P = .0396). When assessed after the procedure, patients who wore video glasses had significantly reduced levels of anxiety (−7.7 vs −4.4, respectively; P = .0335) and average MAP (−6.3 vs 2.1, respectively; P = .0486) compared with control patients. There was no significant difference in amount of sedation and analgesia, HR, RR, pain score, or procedure time between groups. No significant adverse events related to the use of video glasses were observed. Postprocedural surveys showed that video glasses were not distracting and did not interfere or pose a safety issue during procedures. Patients enjoyed using the video glasses and would use them again for a future procedure. Conclusions Video glasses can be safely implemented during IR procedures to reduce anxiety and improve a patient's overall experience.

Purpose To report our early experience with the endovascular placement of stacked Zenith main body extensions (cuffs) in the treatment of focal thoracic aortic pathology in high-risk patients. Methods Between January 2003 and May 2004, 6 patients (3 men; mean age 59 years, range 37-82) with focal aortic pathology underwent endovascular repair using stacked 30 and 32-mm-diameter Zenith main body extensions. The setting was a university tertiary referral center for vascular disease. Indication for treatment included 2 descending thoracic aneurysms and individual cases of traumatic thoracic tear, diverticulum of Kommerell, thoracic pseudoaneurysm, and aortoesophageal fistula. Results All procedures were performed successfully, with a mean of 3 cuffs used. The patient with an aortoesophageal fistula expired after successful cuff placement due to sequela of massive pretreatment hemorrhage; fistula coverage was confirmed at autopsy. There were no type I endoleaks. Morbidity included an occluded right subclavian artery from traumatic passage of the device through the artery. No left subclavian arteries were covered. No neurological deficits or paraplegia was observed. The cuffs were patent in all surviving patients at an average follow-up of 7 months (range 3-12). Computed tomography in all survivors confirmed adequate cuff placement, absence of endoleak, and lack of cuff migration. Based on this experience, the following technical recommendations are offered: (1) right subclavian cutdown when needed to reach a lesion beyond the range of the sheath, (2) Dacron chimney placement, (3) stiff guidewire usage, (4) wire placement from the right subclavian artery through the common femoral artery if necessary to ease a sharp bend in the arch, and (5) cuff overlap of 25% to 50%. Conclusions In high-risk patients, focal aortic pathology can be successfully treated with off-the-shelf commercially available cuffs using a stacking technique with acceptable mortality, morbidity, and short-term durability.

Pseudoaneurysms are common vascular abnormalities that represent a disruption in arterial wall continuity. Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. A complete work-up will help in determining the cause, location, morphologic features, rupture risk, and clinical setting of the pseudoaneurysm; identifying any patient comorbidities; and evaluating surrounding structures and relevant vascular anatomy, information that is essential for treatment planning. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to a marked decrease in the morbidity and mortality rates for pseudoaneurysms.

PURPOSE To determine the significance of hepatic artery steno-occlusive disease on the patency of anastomotic biliary strictures in liver transplant recipients after transhepatic balloon dilation. MATERIALS AND METHODS A retrospective review of records of all patients undergoing transhepatic balloon dilation for anastomotic biliary strictures after orthotopic liver transplantation was performed over an 8-year period. Patency of the anastomosis was based on subsequent cholangiography. The presence of hepatic artery steno-occlusive disease was determined by Doppler ultrasound and/or angiography. The anastomotic biliary stricture patency rates were calculated by the Kaplan-Meier method. RESULTS Thirty-eight patients who had undergone liver transplants underwent 53 balloon dilations for anastomotic biliary strictures (nine patients for arterial disease, 26 patients had patent arteries and three patients had arteries of indeterminate patency). Eight of the 53 strictures treated (15%) were refractory to balloon dilation: 10.5% of first comers and 27% of restenotic lesions. Two of the 53 strictures treated (4%) had significant complications: hemobilia requiring blood transfusion and ductal rupture. One-year cumulative primary patency rates for anastomotic biliary strictures for patients with arterial disease, patent hepatic arteries, and all-comers were: 0%, 45% ( P = .01), and 36%, respectively. One-year cumulative primary patency rates for choledocho-choledocal and choledocho-jejunal anstomoses in patients with patent arteries were 43% and 48%, respectively ( P = .10). CONCLUSIONS In the presence of hepatic artery disease there is a lower patency of anastomotic biliary strictures after balloon dilation. Imaging of the hepatic artery should be considered to stratify patients who will have a successful outcome.

The technical aspects of placing transjugular intrahepatic portosystemic shunts (TIPS) in liver transplant recipients with full allografts have well been described. In the era of live related hepatic donors, and the growing population of their recipients, it is likely that TIPS shunts will be placed in failing transplant lobes/segments. Growing allografts that are initially undersized can have an unconventional orientation of the hepatic and portal veins, which may also change with remodeling and rotation of the graft during their growth. The authors review the technical differences for TIPS procedures in transplants, particularly split grafts. They describe a technically successful TIPS procedure in an undersized and remodeled left lateral segment liver recipient and the additional difficulty this may pose.

PURPOSE To evaluate the efficacy of hepatic artery percutaneous transluminal angioplasty (PTA) in the treatment of hepatic artery stenosis (HAS). MATERIALS AND METHODS A retrospective analysis was performed of all cases of HAS documented by angiography from January 1995 to June 2003 at the authors' institution. Management was evaluated and long-term patency was documented by Doppler ultrasonography. The patency, restenosis, and hepatic artery thrombosis (HAT) rates were determined by the Kaplan-Meier method. The technical success of hepatic artery PTA was stratified according to the location of the stenoses relative to the anastomosis, as well as by the presence of associated hepatic arterial kinks. RESULTS Thrombosis was seen in 65% ± 13% of untreated HAS cases within 6 months. Stenotic lesions without associated arterial kinks had an improved technical success rate and a reduced complication rate of 94% and 10%, respectively, compared with lesions with associated hepatic arterial kinks treated with hepatic artery PTA (14% and 29%, respectively). The 1-year primary and primary assisted patency rates of hepatic artery PTA for all lesions were 44% ± 12% and 60% ± 11%, respectively, and were 65% ± 10% and 80% ± 8%, respectively, for lesions not associated with hepatic arterial kinks. The 1-year HAT rate and restenosis rate after hepatic artery PTA were 19% ± 10% and 32% 11%, respectively. The 1-year primary assisted patency rate for hepatic artery PTA with repeat PTA performed for restenosed lesions and surgical revascularization performed for failed PTA was 74% ± 10%. CONCLUSIONS Untreated HAS carries a high morbidity rate. Hepatic artery PTA can play a large role in the management of HAS by reducing the HAT rate more than threefold. With appropriate lesion selection, hepatic artery PTA will have better patency rates than those associated with hepatic artery stent placement.

ObjectivesThe objectives of this study were to examine factors predictive of success or failure after percutaneous angioplasty (PTA) and stenting (S) of the superficial femoral artery (SFA) and to compare the results of PTA/S with a contemporary group of patients treated with femoropopliteal bypass.MethodsA database of patients undergoing PTA and/or S of the SFA between 1986 and 2004 was maintained. Intention-to-treat analysis was performed. Patients underwent duplex scanning follow-up at 1, 3, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics and preprocedure and postprocedure runoff. Results were standardized to current TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazard analyses were performed to assess factors associated with patient survival and treatment efficacy.ResultsThree hundred eighty total limbs underwent PTA/S in 329 patients (67% male, 33% female; average age, 65 years). Mean follow-up was 1.8 years from the date of initial intervention. Indications for intervention were claudication in 66%, rest pain in 16%, and tissue loss in 18%. Runoff at the tibial level was 2.1 ± 0.8 patent vessels. Mean SVS ischemia grade was 3.1 (range, 1 to 5). TASC lesion grades were A (48%), B (18%), C (22%), and D (12%). Angioplasty alone was used in 63% of cases. Primary treatment failure (inability to cross lesion) was seen in 7% of patients. There was one periprocedural death. Primary patency rates were 86% at 3 months, 80% at 6 months, 75% at 12 months, 66% at 24 months, 60% at 36 months, 58% at 48 months, and 52% at 60 months. Assisted primary patency rates were slightly higher (P = not significant). By Cox proportional hazards analysis, patency of PTA/S was associated with higher preoperative ankle/brachial index (P = .016) and the performance of angioplasty only (P = .011). Failed or occluded PTA/S was associated with TASC C (P < .0001) and TASC D lesions (P < .0001). Patient death was associated with the presence of congestive heart failure (P = .003). Subgroup analysis revealed that primary patency rates are highly dependent on lesion type (A > B > C > D, P < .0001). PTA/S patency for TASC A and B lesions compared favorably to prosthetic and venous femoropopliteal bypass. Surgical bypass was superior to PTA/S for TASC C and D lesions.ConclusionsPTA and stenting of the SFA can be performed safely with excellent procedural success rates. Improved patency of these interventions was seen with increased ankle/brachial index and the performance of angioplasty only. Worse patency was seen with TASC C and TASC D lesions. Patency rates were strongly dependent on lesion type, and the results of angioplasty and stenting compared favorably with surgical bypass for TASC A and B lesions.

ObjectivesThe purpose of this study was to determine whether performance on a simulator model of carotid artery stenting correlates with previous endovascular experience and to assess the effects of repetition and training.MethodsParticipants were stratified to untrained and advanced skill groups on the basis of number of endovascular procedures previously performed. Baseline performance was assessed by means of a pretest, and participants were randomized to practice and no-practice groups. Practice consisted of a 30-minute to 60-minute proctored session before taking a final test; those in the no-practice group proceeded directly to the final test without this session. Primary outcomes were completion of a standardized protocol and the length of time needed to complete all steps.ResultsTwenty-nine subjects (16 untrained, 13 advanced) participated fully in the study. Ninety-two percent of participants in the advanced group successfully completed the pretest, versus 63% in the untrained group (P = .09); mean time to successful completion was 29.9 ± 4.8 (mean ± SD) versus 48.0 ± 9.9 minutes, respectively (P < .001). Subjects who received no practice did not significantly improve their completion times between pretest and final test, whereas those who received practice did (novice, 47.9 ± 7.0 minutes vs 24.5 ± 2.9 minutes, P < .001; advanced, 29.6 ± 3.1 minutes vs 20.2 ± 4.1 minutes, P < .001). The group without previous training had significantly more time improvement from training than did the advanced group. Exit survey results showed that those who had the opportunity to practice more commonly believed that the simulator increased their endovascular skills and interest in vascular surgery (both P < .01 vs untrained group).ConclusionsPerformance on the carotid stenting simulator correlated with previous endovascular experience. Although both novice and advanced groups improved their time after a 30-minute to 60-minute proctored training session, improvement in the novice group was greater than that in the advanced group, which suggests that novices may benefit disproportionately from this type of training.

Objectives This study was performed to determine whether there is deterioration in renal function during follow-up in patients who have undergone endovascular aneurysm repair (EVAR), as recommended by the device manufacturers; to determine whether suprarenal fixation correlates with impairment of renal function; and to explore the potential implication of life-long surveillance of renal function with contrast-enhanced computed tomography. Methods One hundred forty-six consecutive patients underwent EVAR at our institution. Data from 113 of these patients who were free from preoperative renal insufficiency or postoperative renal disease were analyzed. Fifty-three patients received infrarenal (IR) fixation devices, and 60 patients received suprarenal (SR) fixation devices. All SR fixation devices were placed under investigational device exemption protocols. The average follow-up was 688 days. Sixty-five consecutive patients who had undergone open repair of an abdominal aortic aneurysm (AAA) served as the control group. Results Preoperative creatinine concentration, intraoperative blood loss, contrast volume, and number of contrast-enhanced procedures were not significantly different between the IR and SR groups. Two renal artery occlusions (1 SR, 1 IR; P = NS) were identified, and 8 renal infarcts (5 SR, 3 IR; P = NS). There was an increase in mean creatinine concentration in the open AAA, IR, and SR fixation groups at each time point in the analysis. Mean elevation in creatinine concentration at 12, 24, and 36 months was 0.10, 0.10, and 0.04 mg/dL, respectively, for open AAA repair; 0.20, 0.21, and 0.28 mg/dL for IR fixation; and 0.15, 0.21, and 0.12 mg/dL for SR fixation. At life table analysis, renal impairment at 36 months was seen in 36% ± 9% of patients in the IR group, 25% ± % of patients in the SR group, and 19% ± 6% of patients in the open AAA group ( P = .04 for IR fixation vs open AAA repair). Conclusions A decrease in kidney function is seen after EVAR, regardless of fixation level, that is independent of renal disease and renal arterial occlusion. In patients with normal renal function the site of proximal fixation does not affect postoperative creatinine concentration. The decrease in renal function is likely related to the repetitive administration of contrast agent.

PURPOSE To evaluate the safety and effectiveness of superselective microcoil embolization for the treatment of lower gastrointestinal (LGI) hemorrhage. MATERIALS AND METHODS A retrospective review of LGI superselective microcoil embolization data for a 10-year period was performed. During this period, twenty-two patients with evidence on angiography of LGI bleeding underwent superselective microcoil embolization. Hemorrhage was treated in the colon ( n = 19) and jejunum ( n = 3). Ivalon was used adjunctively in two patients and gelfoam was used as a secondary agent in two additional patients. Postembolization ischemia was evaluated objectively in 14 patients by colonoscopy ( n = 10), surgical specimen ( n = 3), and barium enema ( n = 1). All patients were followed for clinical evidence of bowel ischemia. Four patients died before further follow-up could be performed. Additionally, 122 cases of LGI hemorrhage treated with superselective microcoil embolization were identified in a review of the literature. A meta-analysis was then performed, combining the data in this study and the data from the literature, to estimate the rate of major and minor ischemic complications on a total of 144 superselective microcoil embolizations. RESULTS Immediate hemostasis was achieved in all 22 patients in this study. Complete clinical success was achieved in 86% of patients (19 of 22 patients). Rebleeding occurred in 14% of patients (3 of 22 patients) and each underwent colonoscopic intervention with success. Postembolization objective follow-up was performed in 64% of patients (14 of 22 patients). Ten patients underwent follow-up colonoscopy; one patient received a follow-up barium enema; and three patients underwent subsequent surgery. Colonic resection (one partial and one total) was performed in two patients. The partial colectomy was performed in a patient who had been diagnosed with colonic polyps and dysplasia. The total colectomy was performed on a patient with history of chronic LGI bleeding complicated by long-term anticoagulation therapy and a history of tubular adenoma resection. The third surgical patient (16 months old) underwent a follow-up exploratory laparotomy after embolization of a proximal jejunal branch of the superior mesenteric artery. None of the three patients who underwent surgery were found to have postembolic ischemic changes in the bowel specimen. Four patients in this study died, for reasons unrelated to hemorrhage or embolization, before further follow-up could be performed. The last four patients were followed clinically and experienced no symptoms of intestinal ischemia. A minor ischemic complication was reported in 4.5% of patients (1 of 22 patients), and there were no major ischemic complications (0%) in this series. A review of the data from 122 cases of LGI superselective microcoil embolization in the literature is also presented. Combined with the data in this study, the minor complication rate was 9% (13 of 144 patients), and the major complication rate was 0% (0 of 144 patients). CONCLUSION Superselective microcoil embolization is a safe and effective treatment for LGI hemorrhage.

Fibromuscular dysplasia (FMD) accounts for 10% of cases of renal artery stenosis. This study evaluates the anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD at an academic medical center. A retrospective analysis of records from patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) found 14 patients (all female) who underwent 19 interventions on 18 renal artery segments. Significant cardiovascular comorbidities were few in this patient population. The PTRA technical success rate was 95%. There were no periprocedural mortalities. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years. The restenosis rate was 25% at 8 years. Clinical benefit (improved or cured hypertension) was seen in 79% of patients overall; 65% of patients maintained this benefit at 8 years by life-table analysis. Percutaneous endovascular intervention for clinically symptomatic FMD of the renal arteries is technically successful, safe, and durable. Most patients demonstrate immediate clinical benefit and retain durable functional outcomes.

Introduction: The endovascular repair of abdominal aortic aneurysms has become increasingly common during the past decade. Despite aggressive attempts to treat endoleak and graft failure with endovascular salvage procedures, some grafts necessitate surgical removal. We reviewed our experience with late endograft explantation in an effort to identify technical maneuvers critical for success. Methods: Of 110 patients treated with aortic abdominal endografts at the University of Rochester Medical Center between August 1997 and June 2001, five (4.5%) needed late graft removal. Medical records, radiographic files, and case report forms were retrospectively reviewed. Results: One Talent (Medtronic AVE, Santa Rosa, Calif) and four Vanguard (Boston Scientific, Natick, Mass) grafts were removed at a mean of 32.7 months (range, 18 to 44 months) after implantation. One patient underwent conversion for rupture, three for endoleaks (one each with types I, II, and III), and one for stent separation from the graft material without endoleak or aneurysm expansion. Three cases were approached via the midline, one through a bilateral subcostal incision, and one through a retroperitoneal incision. Supraceliac aortic control was used in all patients. Removal of two of the Vanguard grafts necessitated extension of the aortotomy above the level of the renal orifices. One perioperative death occurred. The mean operative blood loss was 4700 mL (range, 1850 to 9000 mL), and length of stay was 19.8 days (range, 7 to 42 days). Conclusion: The morbidity and mortality rates associated with late removal of endografts are significant. Removal of Vanguard devices can necessitate extension of the aortotomy above the renal arteries. We believe that control of the aorta well above the proximal fixation site is the key to removal and that continuous aortic exposure via retroperitoneal exposure is the best option in this situation. (J Vasc Surg 2002;36:674-8.)

We report a case of arterio-portal fistulae in a 12-month-old-child following a segmental liver transplantation. The fistula, probably the result of mass ligature of a vascular pedicle during back table allograft reduction, is to our knowledge the first such case reported. Diagnosed on the third post-operative day, the fistula was successfully managed with transcatheter coil embolization. The child is well and asymptomatic, 33 months after transplantation. In addition to those seen in whole organ transplantation, there are a few complications specifically related to segmental transplantation. These complications, although infrequent, are a direct consequence of the back table liver partition, as in the case herein reported.

To overcome constraints imposed by iliac artery anatomy, the anatomic inclusion criteria for endovascular aortic aneurysm repair can be extended by means of intentional coil occlusion of one or both internal iliac arteries and extension of the distal limb of the graft into an external iliac artery. We reviewed our experience with this intervention to determine the safety and efficacy of this approach to aneurysm repair. Over a 30-month period, 84 patients underwent endovascular abdominal aortic aneurysm repair; 23 underwent intentional unilateral (22) or bilateral (1) internal iliac artery occlusion. Morbidity, mortality, and long-term clinical outcomes were evaluated in these 23 patients. Patients were specifically questioned about exercise-induced buttock and extremity symptoms. Our results showed that intentional internal iliac artery embolization to allow endovascular repair of abdominal aortic aneurysms is accompanied by significant morbidity and should be approached with caution.

This study was designed to test the hypothesis that unexpected alcohol withdrawal-like syndrome (AWLS) is more common following aortic, but not other, vascular or nonvascular procedures. All patients undergoing open aortic surgery at our institution in 1997 who survived at least 48 hr were identified, as were those undergoing carotid endarterectomy, infrainguinal bypass, and total colectomy. AWLS was defined as prolonged confusion or agitation and response to conventional treatment for withdrawal, providing that all other sources had been ruled out or a significant history was present. Our results show that, for unknown reasons, AWLS is more common after aortic surgery than after other vascular and high-stress, nonaortic intraabdominal procedures at our institution, and is associated with increased length of stay and morbidity. Because prophylaxis may improve outcome, better efforts to identify patients at risk are required.

Purpose To assess the use of doxycycline as a sclerosing agent after percutaneous drainage of postoperative lymphoceles. Materials and methods Symptomatic postoperative lymphoceles (n = 21) in 18 patients were treated by percutaneous tube drainage for an average of 10.8 days. Sclerosis was performed when the patient became asymptomatic, drainage had slowed to less than 30 mL/d and follow-up imaging (CT or US) showed either near complete or total resolution of the lymphocele. Doxycycline (500 mg) combined with 1% lidocaine (5 mL) was instilled into the cavity with use of a syringe after any remaining lymphocele fluid was removed through the tube. When possible, patients were instructed to perform a series of maneuvers for the next hour to distribute the sclerosing agent evenly throughout the cavity. After 1 hour, the sclerosing agent was aspirated from the cavity and the drainage tube was removed. Three patients with four lymphoceles underwent sclerotherapy immediately after percutaneous insertion of a drainage tube and aspiration of the lymphocele. No patients underwent previous sclerosis with any agent. Results Successful treatment of postoperative lymphoceles was achieved in 17 of 18 patients. Primary success was achieved in 17 of 21 lymphoceles treated. There were four lymphocele recurrences in three patients. Three of the four recurrences were successfully treated by means of repeated drainage and sclerotherapy. One recurrent lymphocele persisted after re-treatment with 1 g of doxycycline. This patient underwent successful surgical repair. There were no complications related to doxycycline sclerosis. The mean duration of drainage for initial and recurrent lymphoceles was 10.8 days (range, 0-30 days). Conclusion Sclerotherapy with use of doxycycline after percutaneous drainage is an easy, safe, inexpensive, and effective means of treating postoperative lymphoceles.

Objectives: The purpose of this study was to determine the long-term functional results after medial claviculectomy and venous patch angioplasty or bypass grafting using internal jugular vein after incomplete thrombolysis of effort thrombosis of the subclavian vein. Methods: The records of 11 patients with effort thrombosis who were treated over the past 9 years were reviewed. Patients have been followed up between 3 and 9 years at 6-month intervals with duplex imaging and contrast venography when indicated and have had an orthopedic evaluation of their shoulder function. Results: All reconstructed veins are patent, and only one patient complains of any arm swelling after prolonged usage. This patient is one of three with postphlebitic changes at the site of repair and has similar findings in her basilic vein. All patients have returned to their prethrombosis vocation without limitation. Four of the 11 patients have jobs requiring heavy physical labor. No patient describes any limitations of shoulder function, but one man who works as a diesel mechanic complains of shoulder aching with overuse with repetitive pulling. Three patients describe upper extremity paresthesias when lying on the operated side. Two patients (one man and one woman) are bothered by the large scar and indentation at the site of the incision. Every patient considers the overall result completely successful from a functional standpoint. Conclusions: Early subclavian venous repair performed through a medial claviculectomy is a durable operation with excellent long-term functional results. Half of the patients noted minor but significant symptoms, but all are uniformly able to return to normal function. (J Vasc Surg 2000;32:315-21.)

Purpose: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). Methods: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent—based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. Results: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. Conclusions: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.