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Percutaneous endovenous stenting has emerged during the past decade as the primary method of treating symptomatic venous outflow obstruction. A recognized complication of venous stenting is stent migration. The aim of the present systematic review was to identify the number of cases of stent migration in reported studies to recognize the risk factors that might be associated with this complication and the outcomes following migration.A review was conducted in accordance with the MOOSE (meta-analyses of observational studies in epidemiology) and PRIMSA (preferred reporting items for systematic review and meta-analysis) guidelines and registered in the PROSPERO. MEDLINE, EMBASE, and PubMed databases. Key references were searched using specified keywords. All relevant data for the primary procedure and subsequent presentation with stent migration were retrieved. The data were assessed as too low in quality to allow for statistical analysis.Between 1994 and 2020, 31 studies were identified, including 29 case reports and 2 case series, providing data for 54 events of venous stent migration with some data provided regarding the stent used for 47 of the events. The mean age of the 52 patients with stent migration was 50 years (range, 19-88 years) and 30 were men (57.6%). The stents for most of the reported cases were ≤60 mm in length (38 of 46; 82.6%). Only three of the reports were of stents14 mm in diameter (3 of 47; 3.6%). None of the studies had reported migration of stents100 mm long. In 85% of the migrated stent events, retrieval was attempted, with 65.2% via an endovascular approach. The immediate outcome was satisfactory for 100% of the reported attempts, whether by an endovascular or open surgical approach.The findings from our literature review suggest that the risk of migration is rare but might be underreported. Most of reported cases had occurred with shorter and smaller diameter stents. The paucity of reported data and the short-term follow-up provided suggest that more formal data collection would provide a truer reflection of the incidence. However, clear strategies to avoid migration should be followed to prevent this complication from occurring.

OBJECTIVE To evaluate the performance of the Zilver® Vena™ Venous Stent in the treatment of patients with symptomatic iliofemoral outflow obstruction. METHODS Between August 2012 and January 2015, 35 patients (mean age of 45.1 ± 15.5 years; 77.1% female) with symptomatic iliofemoral venous outflow obstruction were treated with the Zilver Vena Venous Stent (Cook Ireland, Ltd.) as part of this prospective, single arm, multicenter study. Study assessments included procedural success, major adverse events (MAEs), freedom from occlusion and qualitative patency at 6 and 12 month post-procedure, clinical symptoms of venous insufficiency, and reintervention with the treated venous segment. RESULTS The rate of freedom from occlusion at 6 month and 12 month was 88.2%. The rate of qualitative patency was 88.2% at 6 month and 85.2% at 12 month. Three MAEs were reported: one symptomatic pulmonary embolism and two clinically-driven reinterventions. Following stenting, clinical symptoms of venous insufficiency improved significantly from baseline at each follow-up, as measured by VDS (p

Cardiac output during exercise increases by as much as fivefold in the untrained man, and by as much as eightfold in the elite athlete. Increasing venous return is a critical but much overlooked component of the physiological response to exercise. Cardiac disorders such as constrictive pericarditis, restrictive cardiomyopathy and pulmonary hypertension are recognised to impair preload and cause exercise limitation; however, the effects of peripheral venous obstruction on cardiac function have not been well described. This manuscript will discuss how obstruction of the iliocaval venous outflow can lead to impairment in exercise tolerance, how such obstructions may be diagnosed, the potential implications of chronic obstructions on sympathetic nervous system activation, and relevance of venous compression syndromes in heart failure with preserved ejection fraction.

Venous thromboembolic disease causes significant mortality and morbidity in the oncologic patient population. Recently, minimally invasive endovascular technologies have been developed as an adjunct to antithrombotic therapy for the management of DVT and PE. The current and potential roles for endovascular treatment of cancer-associated venous thromboembolism (VTE) will be reviewed in this article.The recent NCCN guidelines recommend endovascular therapy in patients eligible for therapeutic anticoagulation who present with life-, organ-, or limb-threatening thrombosis. However, symptomatic non-life-threatening VTE can negatively affect QOL and physical function, both of which have prognostic implications in the cancer population. Endovascular therapies have been shown to improve physical function and QOL in prospective trials performed in a non-oncologic patient population as well as small retrospective studies in the cancer population. In addition to treating life- and limb-threatening thrombosis, endovascular therapy for VTE can improve QOL and physical function in comparison to anticoagulation alone. Prospective trials are warranted to assess the benefit of endovascular therapy for quality of life-years, performance status, and overall survival in the oncologic patient population.

Background Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care. Purpose To provide principles for delivering high quality of care in IR. Methods Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services. Results There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient’s condition with the interventional radiologists taking ultimate responsibility for the patient’s outcomes. Conclusions The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Purpose To assess safety and patency of the Venovo venous stent for the treatment of iliofemoral vein obstruction. Materials and Methods Twenty-two international centers enrolled 170 patients in the VERNACULAR study (93 post-thrombotic syndrome; 77 non-thrombotic iliac vein lesions). Primary outcome measures were major adverse events at 30 days and 12-month primary patency (freedom from target vessel revascularization, thrombotic occlusion, or stenosis > 50%). Secondary outcomes included the Venous Clinical Severity Score Pain Assessment and Chronic Venous Quality-of-Life Questionnaire assessments (hypothesis tested). Secondary observations included primary patency, target vessel and lesion revascularization (TVR/TLR), and assessment of stent integrity through 36 months. Results Freedom from major adverse events through 30 days was 93.5%, statistically higher than a pre-specified performance goal of 89% (p = 0.032) while primary patency at 12 months was 88.6%, also statistically higher than a performance goal of 74% (p p Conclusion The Venovo venous stent was successfully deployed in obstructive iliofemoral vein lesions and met the pre-specified primary outcome measures through 12 months. At 3 years, primary patency was 84%, reintervention rates were low, standardized quality-of-life and pain measures improved from baseline, and there was no stent migration or fractures. Level of Evidence Level 2—prospective, multicenter, controlled clinical study without a concurrent control or randomization. Pre-specified endpoints were hypothesis-tested to performance goals derived from peer-reviewed clinical literature. Registration clinicaltrials.gov Unique Identifier NCT02655887.

Purpose To report an iliac venous stent landing technique using only fluoroscopy in patients with May-Thurner syndrome (MTS). Material and Methods Sixty-five patients (69% female) who had self-expanding nitinol stents deployed for symptomatic MTS were retrospectively analyzed. Mean age was 50 years (range 18–80). The cephalic stent right lower corner was deployed to the right of the lumbar vertebra spinous process (SP), but not as far to the right as the right pedicle lateral border. Mode stent diameter and length were 14 mm (range 12–18) and 120 cm (range 60–180), determined by venography, respectively. The anatomical positions of the right common iliac artery, inferior vena cava (IVC), and stent were assessed relative to these bony landmarks on computed tomography venography. Results Position of the proximal right common iliac artery right lateral border lay a mean distance of 12 mm (±8 to the right of the SP and 13 mm (±7) left of the right pedicle lateral border. Mean position of the IVC right lateral wall lay 1 mm (±6) to the right of the right pedicle lateral border. Mean position of the cephalic stent right lower corner was 6 mm (±6) to the left of the right pedicle lateral border and 19 mm (±7) to the right of the SP. The mean space left between the cephalic stent right lower corner and the IVC right lateral wall was 5 mm (±5). Primary patency rate at 1 year was 88%. Conclusions Important vascular structures lie in predictable locations relative to bony landmarks, facilitating accurate venous stent placement using fluoroscopy only.

Objective To describe clinical practice experience of 11 C-Metomidate PET/CT as an adjunct to adrenal vein sampling (AVS) in the lateralization of aldosterone-producing adenomas (APA) in primary aldosteronism (PA). Context Accurate lateralization of APA in the setting of PA offers the potential for surgical cure and improved long-term cardiovascular outcomes. Challenges associated with AVS, the current gold standard lateralization modality, mean that only a small proportion of potentially eligible patients currently make it through to surgery. This has prompted consideration of alternative strategies for lateralization, including the application of novel molecular PET tracers such as 11 C-Metomidate. Design Clinical Service Evaluation/Retrospective audit. Patients Fifteen individuals with a confirmed diagnosis of PA, undergoing lateralization with 11 C-Metomidate PET/CT prior to final clinical decision on surgical vs medical management. Measurements All patients underwent screening aldosterone renin ratio (ARR), followed by confirmatory testing with the seated saline infusion test, according to Endocrine Society Clinical Practice Guidelines. Adrenal glands were imaged using dedicated adrenal CT. 11 C-Metomidate PET/CT was undertaken due to equivocal or failed AVS. Management outcomes were assessed by longitudinal measurement of blood pressure, ARR, number of hypertensive medications following adrenalectomy or institution of medical therapy. Results We describe the individual lateralization and clinical outcomes for 15 patients with PA. Conclusion 11 C-Metomidate PET/CT in conjunction with adrenal CT and AVS provided useful information which aided clinical decision-making for PA within a multidisciplinary hypertension clinic.

The purpose of this paper is to assess the applicability of direct computed tomography venography (DCTV) in assessing dominant inflow vein in the femoral confluence in extensive chronic iliofemoral venous obstruction, using venography as the gold standard. All DCTVs performed in symptomatic patients with previous iliofemoral deep vein thrombosis subsequently submitted to venography in the period from January 2014 to August 2018 were retrospectively reviewed. Two groups were defined depending on whether the femoral vein (FV) or the deep femoral vein (DFV) was the dominant inflow on venography in order to identify predictors of DFV as dominant inflow in DCTV. Statistical analysis was performed with SPSS V25. A total of 30 DCTVs and subsequent venographies were reviewed. Venography identified the FV as the dominant inflow in 18 (60%) and the DFV in 12 (40%) patients. Predictors for DFV as dominant inflow were identified as follows: larger DFV diameter 50 mm and 250 mm below lesser trochanter (8.73 ± 4.34 mm vs. 11.9 ± 3.52 mm; p = 0.043 and 5.4 ± 3.90 mm vs. 8.90 ± 2.70 mm; p = 0.011); lower FV/DFV ratio 150 mm below lesser trochanter (11.39 ± 20.01 mm vs. 1.05 ± 0.47 mm; p = 0.043); and presence of FV scarring/synechiae, collaterals and abnormal wall thickness (p = 0.003, p = 0.003 and p

To evaluate the performance of the Zilver® Vena™ Venous Stent in the treatment of patients with symptomatic iliofemoral outflow obstruction.Between August 2012 and January 2015, 35 patients (mean age of 45.1 ± 15.5 years; 77.1% female) with symptomatic iliofemoral venous outflow obstruction were treated with the Zilver Vena Venous Stent (Cook Ireland, Ltd.) as part of this prospective, single arm, multicenter study. Study assessments included procedural success, major adverse events (MAEs), freedom from occlusion and qualitative patency at 6 and 12 month post-procedure, clinical symptoms of venous insufficiency, and reintervention with the treated venous segment.The rate of freedom from occlusion at 6 month and 12 month was 88.2%. The rate of qualitative patency was 88.2% at 6 month and 85.2% at 12 month. Three MAEs were reported: one symptomatic pulmonary embolism and two clinically-driven reinterventions. Following stenting, clinical symptoms of venous insufficiency improved significantly from baseline at each follow-up, as measured by VDS (p 0.0001), CEAP "C" (p ≤ 0.0001), VCSS (p 0.0001), and CIVIQ (p 0.0001).Clinical results with the Zilver Vena Venous Stent were favorable through 12 month, with high patency rates, reduction of venous insufficiency symptoms, and low morbidity.

Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care.To provide principles for delivering high quality of care in IR.Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services.There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient's condition with the interventional radiologists taking ultimate responsibility for the patient's outcomes.The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Summary: A 74-year-old woman presented with acute symptomatic left thigh and calf swelling; imaging demonstrated evidence of occlusive thrombosis from the upper left common iliac vein to the mid-thigh. Single session zero-thrombolysis venous thrombectomy was performed using the ReVeneTM Thrombectomy Catheter.

Venous thromboembolism (VTE) is a major public health issue; deep vein thrombosis (DVT) affects about 1/1000 patients. Each year, VTE kills more patients in Western Europe than breast cancer, prostate cancer, acquired immune deficiency syndrome (AIDS) and road traffic accidents combined and is responsible for the deaths of approximately 370,000 European citizens (Cohen et al. in Thromb Haemost 98:756-764, 2007; Bĕlohlávek et al. in Exp Clin Cardiol 18(2):129-138, 2013). The recently published ATTRACT trial (Acute Venous Thrombosis Thrombus Removal with Adjunctive Catheter-directed Thrombolysis) (Vedantham et al. in N Engl J Med 377:2240-2252, 2017) concluded that the addition of catheter-directed thrombolysis to standard therapy with anticoagulation and compression stockings offers no significant clinical benefit over standard therapy in terms of reduction in the rate of post-thrombotic syndrome (PTS) at 2 years. It is the largest, prospective, multi-centre, randomised controlled trial (RCT) and represents the culmination over a decade of planning, execution and analysis. In this opinion article, we analyse why it was needed, what it demonstrated, some limitations, and the directions in which this important publication will take us.

The purpose of this work was to describe the results of a technique of simultaneous antegrade and retrograde vascular access (“criss-cross”) to the popliteal vein to achieve venous recanalization in patients with acute, extensive, iliofemoral DVT with concomitant popliteal and calf vein thrombosis. Seven patients were treated using this technique, in three patients as a bailout option after failed posterior tibial vein puncture and in four as a first option. Antegrade popliteal venous access was performed according to the usual technique using duplex ultrasound (DUS) guidance and thrombolysis (CDT), or thrombectomy (PMT) was performed. Following this, the retrograde sheath was placed under DUS guidance, a tibial vein was selectively catheterized and CDT, and/or a PMT was performed. Three patients underwent isolated CDT, another three had associated PMT, and one patient underwent iliofemoral PMT and catheter thromboaspiration of the popliteal and calf veins. Median thrombolysis duration was 72 h (24–72 h). SIR grade III thrombolysis was achieved in six patients and grade II in one patient. All patients underwent subsequent stenting of their iliac vein lesions. Minor complications were observed in two patients (ecchymosis), while one patient developed a hematoma on the popliteal fossa. This “criss-cross” technique represents a safe alternative to the distal (anterior or posterior tibial) vein access both as a bailout option after failed distal venous access as well as a primary approach due to its potential advantage of clearing larger thrombus volume. Experience in ultrasound-guided popliteal vein puncture is crucial to avoid complications. Case series, Level IV.

Background Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy. Methods This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates. Discussion This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence. Ethical committee reference C.A. 2111 Galway Clinical Research Ethics Committee Registration Clinical Trials.gov registration NCT03640689, Registered on 21 August 2018.

Objective: To investigate the feasibility and efficacy of localized, subtotal, cortical-sparing microwave thermal ablation (MTA) as a potential curative management for primary aldosteronism. The study investigated with equal importance the selected ablation of small volumes of adrenal cortex while sparing adjacent cortex. Method: An in-vivo study was carried out in swine (n = 8) where MTA was applied under direct visualization, to the adrenal glands at 45 W or 70 W for 60 s, using a lateral, side-firing probe and a non-penetrative approach. Animals were survived for 48 h post-procedurally. Animals were investigated for markers of histological, immunohistochemical and biochemical evidence of adrenal function and adrenal damage by assessing samples drawn intra-operatively and at the time of euthanasia. Results: Selected MTA (70 W for 60 s) successfully ablated small adrenocortical volumes (∼0.8 cm3) characterized by coagulative necrosis and abnormal expression of functional markers (CYP11B1 and CYP17). Non-ablated, adjacent cortex was not affected and preserved normal expression of functional markers, without increased expression of markers of heat damage (HSP-70 and HMGB-1). Limited adrenal medullary damage was demonstrated histologically, clinically and biochemically. Conclusion: MTA offers potential as an efficient methodology for delivering targeted subtotal cortical-sparing adrenal ablation. Image-guided targeted MTA may also represent a safe future modality for curative management of PA, in the setting of both unilateral and bilateral disease.

The aim of this paper was to describe the obturator hook sign (OHS), a distinctive dilated angled vein similar to a hook, by computed tomography venography (CTV). It is identified mainly on direct CTV (DCTV) as opposed to indirect CTV (ICTV), evidencing obturator vein engorgement as a marker of hemodynamically significant collateralization and representing an indirect sign for chronic iliac vein outflow obstruction.All CTV studies of lower limbs performed from January 2014 to August 2018 in Galway University Hospital and the Galway Clinic were retrospectively reviewed. Data were analyzed using SPSS software (version 25.0; IBM Corp, Armonk, NY).In total, 531 CTV studies were reviewed, of which 122 (23%) were performed for acute deep venous thrombosis, 183 (35%) for follow-up after iliac stenting, and 109 (21%) for etiologic study of chronic venous disease. For the purpose of analysis for the presence of OHS, only first-time CTV studies were included in patients who were never submitted to venous intervention (n = 296), of which 40 were DCTV (14%) and 256 were ICTV (86%). Two groups were defined according to whether OHS was present, and significant predictors were identified: female sex (P = .038), younger age (P .0001), DCTV (P .0001), nonthrombotic iliac vein lesion (P .001), past history of iliofemoral deep venous thrombosis (P .0001), and dilated pelvic veins (P .0001). OHS was significantly more common in chronic occlusions compared with chronic stenosis or acute occlusion (P .0001). Findings from DCTV and ICTV were compared with results from ascending venography as the "gold standard," and the sign proved to have high specificity and positive predictive value (100% for both tests), whereas sensitivity and negative predictive value were low for both DCTV (65% [95% confidence interval (CI), 43%-84%] and 11% [95% CI, 7%-18%], respectively) and ICTV (8% [95% CI, 4%-14%] and 6% [95% CI, 9%-20%], respectively). From analysis of the remaining CTVs, particularly follow-up after iliac stenting, an interesting fact was recognized: successful venous stenting was associated with OHS disappearance, and stent occlusion was also sometimes associated with OHS reappearance or appearance de novo.The identification of hemodynamically significant lesions in patients with clinically significant chronic venous disease is the aim of any form of imaging. In this study, we have depicted a previously undescribed sign that is straightforward to identify, particularly in DCTV, immediately pointing us toward hemodynamically significant chronic iliac venous outflow obstruction diagnosis. It is too early to call it pathognomonic, but perhaps comparative analysis involving data from additional centers could lead to this conclusion.

Semaphorins are secreted or membrane-bound proteins implicated in neurodevelopmental processes of axon guidance and cell migration. Exploratory behaviour and motor learning was examined ethologically in Semaphorin 6A (Sema6A) mutant mice. The ethogram of initial exploration in Sema6A knockout mice was characterised by increased rearing to wall with decreased sifting; over subsequent habituation, locomotion, sniffing and rearing to wall were increased, with reduced habituation of rearing seated. Rotarod analysis indicated delayed motor learning in Sema6A heterozygous mutants. Disruption to the axonal guidance and cell migration processes regulated by Sema6A is associated with topographically specific disruption to fundamental aspects of behaviour, namely the ethogram of initial exploration and subsequent habituation to the environment, and motor learning.

Objectives The aim of this study was to assess factors influencing the clinical outcome and morphological changes of acute and chronic type B aortic dissection after thoracic endovascular aortic repair (TEVAR). Background Aortic remodeling after TEVAR may be associated with clinical outcome, complications, and endoleak development. Methods Sixty cases of TEVAR for complicated type B acute aortic dissection (AAD) (n = 29) and chronic aortic dissection (CAD) (n = 31) with a minimum follow-up of 3 years were retrospectively reviewed. Using computed tomography images, we assessed true lumen, false lumen, and total aortic short-axis diameters. Six procedural factors were analyzed in relation to aortic remodeling and other outcomes. Analysis of variance was used to compare short-axis, false lumen, and true lumen diameters during the follow-up period. Univariate and multivariate analyses were used to assess the relationship between procedural factors and multiple outcomes. Results A total of 100 stent grafts were implanted in 60 consecutive patients with acute aortic dissection (AAD) and CAD. Aortic remodeling consisting of false lumen thrombosis and shrinkage was more prominent in AAD than in CAD, especially within the first 18 months. Of note, the entire aortic diameter increased significantly cephalad to the stent graft in AAD. Only in the AAD group there was increased aortic remodeling related to post-dilation of the stent graft. Type I and II endoleaks occurred in 17 patients (28%); in AAD, embolization of the left subclavian artery after stent graft deployment was significantly associated with a lower risk of endoleak development, but this was not evident in CAD. Conclusions Aortic remodeling and clinical outcome after TEVAR can be influenced by procedural techniques (post-dilation and embolization of the left subclavian artery in patients with acute but not chronic aortic dissection).

Deep vein thrombosis (DVT) is a significant health problem, leading to the hospital admission of over 250,000 Americans each year. Its most serious acute complication, namely pulmonary embolus, kills approximately 100,000 each year, and is the third most common cardiovascular related mortality after myocardial infarction and stroke. Chronic leg problems following DVT include leg heaviness, tiredness, cramping and ulceration. These are termed the post-thrombotic syndrome. The current standard therapy of anticoagulation has changed little over 50 years. It does not remove or destroy thrombus, relying instead on the bodies own fibrinolytic mechanisms to do so. DVT needs to be more accurately categorized on an anatomical basis, and for a variety of reasons, the area of most importance is the iliofemoral region. The rationale for active, rather than passive, thrombus removal relies on multiple observations that, by doing so improves luminal patency, restores valvular function and has the potential to reduce th...

To report a combined procedure that opens the acutely thrombosed superior vena cava (SVC) to rapidly alleviate symptoms in seriously ill patients with SVC syndrome.Four patients aged 54 to 63 years old with underlying malignancies were referred for treatment of SVC syndrome. All received isolated pharmacomechanical thrombolysis (IPMT) with tissue plasminogen activator delivered in a Trellis Peripheral Infusion System that removed obstructive clot in minutes versus the 24 to 48 hours required for traditional catheter-directed thrombolysis. In each case, stents were inserted immediately following IPMT in a combined procedure lasting1 hour. Patients exhibited near-immediate relief of debilitating symptoms; completion venography demonstrated patent vessels with excellent blood flow.Combining IPMT with immediate stenting during the same session is an effective method for managing acute thrombotic SVC syndrome and limiting the exposure time and number of interventions performed on seriously ill patients.

Vessel geometry determines blood flow dynamics and plays a crucial role in the pathogenesis of vascular disease. In vivo assessment of three-dimensional (3D) vessel anatomy is vital to improve the realism of arterial flow model geometries and investigate factors associated with the localisation of atherosclerosis. The quantification of vascular geometry is also particularly important for the proper design and preclinical testing of endovascular devices used to treat peripheral arterial disease. The purpose of this study was to quantitatively evaluate the intersubject variability of 3D branching and curvature of the abdominal aorta and its major peripheral arteries. Contrast-enhanced renal MRA scans of healthy abdominal vessels obtained in 12 subjects (8 men, 4 women mean age 49 years, range 27-84 years) were segmented, and smoothed centerlines were determined as descriptors of arterial geometry. Robust techniques were employed to characterise non-planar vessel curvature, arterial taper, and 3D branching parameters. Noticeable 3D curvature and tapering were quantified for the proximal anterior visceral and renal branches. Mean 3D branching angles of 63.5+/-10.1 degrees and 73.1+/-6.8 degrees were established for the right and left renal arteries, respectively. Angles describing the ostial position and initial trajectory of the renal arteries confirmed the antero-lateral origin and direction of the right and the more lateral orientation of the left. The anterior visceral branches emerged predominantly from the left side of the anterior aortic wall. Branching parameters determined at the aortic bifurcation demonstrated mild asymmetry and non-planarity at this location. In summary, the results from this study address the scarcity of available in vivo 3D quantitative geometric data relating to the abdominal vasculature and reflect the geometric variability in living subjects.

Neuregulin-1 (NRG1) has been shown to play a role in glutamatergic neurotransmission and is a risk gene for schizophrenia, in which there is evidence for hypoglutamatergic function. Sensitivity to the behavioural effects of the psychotomimetic N-methyl-D-aspartate receptor antagonists MK-801 and phencyclidine (PCP) was examined in mutant mice with heterozygous deletion of NRG1. Social behaviour (sociability, social novelty preference and dyadic interaction), together with exploratory activity, was assessed following acute or subchronic administration of MK-801 (0.1 and 0.2 mg/kg) or PCP (5 mg/kg). In untreated NRG1 mutants, levels of glutamate, N-acetylaspartate and GABA were determined using high-performance liquid chromatography and regional brain volumes were assessed using magnetic resonance imaging at 7T. NRG1 mutants, particularly males, displayed decreased responsivity to the locomotor-activating effects of acute PCP. Subchronic MK-801 and PCP disrupted sociability and social novelty preference in mutants and wildtypes and reversed the increase in both exploratory activity and social dominance-related behaviours observed in vehicle-treated mutants. No phenotypic differences were demonstrated in N-acetylaspartate, glutamate or GABA levels. The total ventricular and olfactory bulb volume was decreased in mutants. These data indicate a subtle role for NRG1 in modulating several schizophrenia-relevant processes including the effects of psychotomimetic N-methyl-D-aspartate receptor antagonists.

The apparent incidence of iliopsoas muscle abnormalities is currently rapidly increasing secondary to the increased number of immuno-compromised patients, malignancies, chemotherapy, immunotherapy, multi-systemic disease and the wide availability of cross-sectional imaging. Disease of the iliopsoas compartment can present with non-specific or indolent clinical features, particularly where normal immune responses are attenuated. Delay in diagnosis can lead to inappropriate initial treatment and, in some cases, serious complications. Wider availability and application of modern cross-sectional imaging offers rapid, confident diagnosis. An understanding of iliopsoas compartment anatomy and pathways of disease spread are essential to recognising these clinically important conditions. We review the anatomy, clinical presentation and common imaging findings of iliopsoas disease as it presents through the emergency room.

As the techniques for endovascular treatment of aortic bifurcation disease become more widely known, it is not enough for interventional radiologists (IR) to be merely technically excellent at the procedural aspects of this important intervention. They must also become expert at managing the patient, and establishing direct contact not only with the patient, but also with the patient's primary doctor, usually their general practitioner. Younger IR physicians may have not had the opportunity to perform as many arterial catheter studies as their grayer counterparts for two main reasons: the shift towards non-invasive studies (US/CTA/MRA), and the encroachment of other specialties on the endovascular field of play. This is not a cause for despair. If you offer the best service, with the best results, you will, in time, get the referrals. However, you must be prepared to offer more than a glorified angiography service: critical to this is the establishment of an Interventional Radiology Clinic, as this then becomes the target for referrals from a variety of other specialties.

Catechol-O-methyltransferase (COMT) inactivates dopamine in prefrontal cortex and is associated clinically with a schizophrenia endophenotype. Using an ethologically based approach, the phenotype of mice with heterozygous COMT deletion was characterised by decreased rearing with increased sifting and chewing. Heterozygous COMT deletion is associated with a distinctive phenotype. This differs from that which we have reported previously for heterozygous deletion of the schizophrenia risk gene neuregulin-1.

The effect of inferior vena cava (IVC) stents crossing the ostia of the renal veins on renal function has not been reported. The purpose of this study is to report a single-institution experience with four cases of IVC stent implantation for malignant compression and/or invasion of the IVC causing severe lower-extremity edema. The patients' symptoms were successfully relieved, and follow-up imaging and serum creatinine measurements for the remainder of their lives revealed no evidence of renal impairment or renal vein thrombosis.

Neuregulin-1 (NRG1) has been identified as a candidate susceptibility gene for schizophrenia. In the present study the functional role of the NRG1 gene, as it relates to cognitive and social processes known to be disrupted in schizophrenia, was assessed in mice with heterozygous deletion of transmembrane (TM)-domain NRG1 in comparison with wildtypes (WT). Social affiliative behavior was assessed using the sociability and preference for social novelty paradigm, in terms of time spent in: (i) a chamber containing an unfamiliar conspecific vs. an empty chamber (sociability), or (ii) a chamber containing an unfamiliar conspecific vs. a chamber containing a familiar conspecific (preference for social novelty). Social dominance and aggressive behavior were examined in the resident-intruder paradigm. Spatial learning and memory were assessed using the Barnes maze paradigm, while spatial working memory was measured using the continuous variant of the spontaneous alternation task. Barnes maze data revealed intact spatial learning in NRG1 mutants, with elevated baseline latency to enter the escape hole in male NRG1 mutants reflecting an increase in activity level. Similarly, although a greater number of overall arm entries were found, spontaneous alternation was unaffected in NRG1 mice. Social affiliation data revealed NRG1 mutants to evidence a specific loss of WT preference for spending time with an unfamiliar as opposed to a familiar conspecific. This suggests that NRG1 mutants show a selective impairment in response to social novelty. While spatial learning and working memory processes appear intact, heterozygous deletion of TM-domain NRG1 was associated with disruption to social novelty behavior. These data inform at a novel phenotypic level on the functional role of this gene in the context of its association with risk for schizophrenia.

Complex vascular anatomy often affects endovascular procedural outcome. Accurate quantitative assessment of three-dimensional (3D) in-vivo arterial morphology is therefore vital for endovascular device design, and preoperative planning of percutaneous interventions. The aim of this work was to establish geometric parameters describing arterial branch origin, trajectory, and vessel curvature in 3D space that eliminate the errors implicit in planar measurements. 3D branching parameters at visceral and aortic bifurcation sites, as well as arterial tortuosity were determined from vessel centerlines derived from magnetic resonance angiography data for three subjects. Errors in coronal measurements of 3D branching angles for the right and left renal arteries were 3.1 +/- 3.4 degrees and 7.5 +/- 3.7 degrees , respectively. Distortion of the anterior visceral branching angles from sagittal measurements was less pronounced. Asymmetry in branching and planarity of the common iliac arteries was observed at aortic bifurcations. The renal arteries possessed considerably greater 3D curvature than the abdominal aorta and common iliac vessels with mean average values of 0.114 +/- 0.015 and 0.070 +/- 0.019 mm(-1) for the left and right, respectively. In conclusion, planar projections misrepresented branch trajectory, vessel length, and tortuosity proving the importance of 3D geometric characterization for possible applications in planning of endovascular interventional procedures and providing parameters for endovascular device design.

The aim of this study was to assess factors influencing the clinical outcome and morphological changes of acute and chronic type B aortic dissection after thoracic endovascular aortic repair (TEVAR).Aortic remodeling after TEVAR may be associated with clinical outcome, complications, and endoleak development.Sixty cases of TEVAR for complicated type B acute aortic dissection (AAD) (n = 29) and chronic aortic dissection (CAD) (n = 31) with a minimum follow-up of 3 years were retrospectively reviewed. Using computed tomography images, we assessed true lumen, false lumen, and total aortic short-axis diameters. Six procedural factors were analyzed in relation to aortic remodeling and other outcomes. Analysis of variance was used to compare short-axis, false lumen, and true lumen diameters during the follow-up period. Univariate and multivariate analyses were used to assess the relationship between procedural factors and multiple outcomes.A total of 100 stent grafts were implanted in 60 consecutive patients with acute aortic dissection (AAD) and CAD. Aortic remodeling consisting of false lumen thrombosis and shrinkage was more prominent in AAD than in CAD, especially within the first 18 months. Of note, the entire aortic diameter increased significantly cephalad to the stent graft in AAD. Only in the AAD group there was increased aortic remodeling related to post-dilation of the stent graft. Type I and II endoleaks occurred in 17 patients (28%); in AAD, embolization of the left subclavian artery after stent graft deployment was significantly associated with a lower risk of endoleak development, but this was not evident in CAD.Aortic remodeling and clinical outcome after TEVAR can be influenced by procedural techniques (post-dilation and embolization of the left subclavian artery in patients with acute but not chronic aortic dissection).

Recent advances in pharmacotherapeutics and interventional techniques have resulted in resurgence in interest regarding the optimal means of management of hemodynamically significant pulmonary embolic disease. However, these various techniques have many associated disadvantages, and it is of paramount importance that the responsible physician has a detailed understanding of each of these so that the appropriate intervention be requested and performed. By way of background discussion and relevant cases in point, we consider each of these management options in turn, with particular reference to the advantages, disadvantages, and application of each.

Over the last decade, sequencing and characterisation of the mouse genome has been accompanied by unparalleled advances in functional genomics. In the context of drug action, we analyse the strengths and limitations of classical mutagenesis and gene targeting techniques, as well as alternative approaches such as chemical mutagenesis, gene trap, recombineering, transposon-mediated mutagenesis, chromosomal engineering, viral transgenesis and RNA interference. This review also focuses on the emerging importance of genetic manipulation in other species and related logistical issues of experimental work using mutants.

The neuregulin-1 gene is widely expressed in the central nervous system and is associated with increased risk for schizophrenia. Using an ethologically based approach, the phenotype of neuregulin-1 heterozygous knockout mice was examined by revealing the individual elements of behaviour in the murine repertoire over the prolonged course of interaction with the environment. During initial exploration, neuregulin-1 mutants displayed a phenotype characterized by increases in locomotion and rearing free, with sex-specific alterations in sifting and grooming. Over subsequent habituation, certain initial effects endured while new phenotypic effects emerged, some of which were again sex-specific. These studies elaborate a pleiotropic role of neuregulin-1 in development, plasticity and function, including sexual dimorphism, by defining the elemental, temporal and sex-specific characteristics of the neuregulin-1 mutant ethogram.

Mutants with targeted gene deletion ('knockout') or insertion (transgenic) of D1, D2, D3, D4 and D5 dopamine (DA) receptor subtypes are complemented by an increasing variety of double knockout and transgenic-'knockout' models, together with knockout of critical components of DA receptor signalling cascades such as G alpha(olf)[G gamma7], adenylyl cyclase type 5, PKA [RIIbeta] and DARPP-32. However, it is increasingly recognised that these molecular techniques have a number of inherent limitations. Furthermore, there are poorly understood methodological factors that contribute to inconsistent phenotypic findings between laboratories.This review seeks to document the impact of DA receptor subtype and related transduction mutants on our understanding of the behavioural roles of these entities, primarily at the level of unconditioned psychomotor behaviour.It includes ethologically based and orofacial movement studies in our own laboratories, since these are the only studies to systematically compare each of the D1, D2, D3, D4 and D5 receptor and DARPP-32 signal transduction 'knockouts'.There is a particular emphasis on identifying methodological factors that might influence phenotypic effects and account for inconsistencies. The findings are offered empirically to (1) specify the extent of phenotypic diversity among individual DA receptor subtypes and transduction components and (2) indicate relationships between D1, D2, D3, D4 and D5 receptor subtype proteins, associated G alpha(i)/G alpha(s)/G alpha(olf)[G gamma7]-adenylyl cyclase type 5-PKA [RIIbeta]-DARPP-32 signalling cascades and behaviour. The findings are also offered heuristically as a base for such phenotypic comparisons at additional levels of behaviour so that a yet more complete phenotypic profile might emerge.

Effects of SKF 83822 [3-allyl-6-chloro-7,8-dihydroxy-1-(3-methylphenyl)-2,3,4,5-tetrahydro-1H-3-benzazepine], an agonist at dopamine D1-like receptors which stimulate adenylyl cyclase but not phosphoinositide hydrolysis, were studied topographically so as to clarify differences between these receptors in the regulation of behaviour. Using cloned receptors, SKF 83822 showed high, selective affinity for dopamine D1 and D5 over D2, D3, D4 and several non-dopamine receptors. SKF 83822 induced little intense grooming, but readily induced sniffing, locomotion and rearing; seizures were evident at higher doses, characterised by tonic convulsions, forepaw myoclonus and explosive hyperlocomotion. The dopamine D1-like receptor antagonist SCH 23390 [R(+)-3-methyl-7-chloro-8-hydroxy-1-phenyl-2,3,4,5-tetrahydro-1H-3-benzazepine] readily antagonised these responses to SKF 83822, particularly seizure activity. The dopamine D2-like receptor antagonist YM 09151-2 [cis-N-(1-benzyl-2-methyl-pyrrolidin-3-yl)-5-chloro-2-methoxy-4-methylaminobenzamide] did not alleviate seizures induced by SKF 83822; YM 09151-02 did, however, attenuate SKF 83822-induced sniffing, locomotion and rearing, and released vacuous chewing. These findings indicate that dopamine D1-like receptors linked to adenylyl cyclase can be differentiated from those not linked to adenylyl cyclase in terms of their roles in the topographical regulation of behaviour. For example, the seizure and vacuous chewing responses appear to involve dopamine D1-like receptors that stimulate adenylyl cyclase, while intense grooming involves those which do not.

The management of patients with aortic dissection is challenging and its treatment is an area of development and innovation. Conventional surgical techniques are associated with significant risks in terms of mortality and morbidity in such high-risk patients. As a result of cumulative advances in technology, classical surgical techniques have been improved and enhanced by the newer endovascular approaches, leading to novel surgical hybrid procedures. Impressive early results have been seen with frozen elephant techniques, revascularisation of the supra-aortic branches and branched/fenestrated thoracic endovascular aortic repair-alone procedures. This review describes the techniques involved in the latest hybrid procedures for aortic dissection and their outcomes.

To assess the effects of iliofemoral vein stent placement on symptomatic lower extremity swelling (LES), presumed to be lymphedema, in patients with cancer.During the period 2005-2013, 62 patients (38 female; age, 60.4 y ± 15.4) with histology-proven metastatic disease and LES resistant to standard therapies were evaluated and found to have venous outflow obstruction. Stents were placed in the iliofemoral veins or inferior vena cava, or both, and evaluated by color Doppler ultrasound or contrast-enhanced computed tomography during the follow-up period. Patient symptoms were assessed using the Venous Disability Score (VDS) and the Galway Limb Swelling score, a patient-directed, 5-question symptom scoring system.Stents were successfully placed in all patients. During the follow-up period, in-stent thrombosis occurred in 13 patients, and additional stents were placed in 3 patients to treat luminal narrowing. The mean VDS improved significantly (P.05): from 3.0 ± 0 on the day of the procedure to 2.95 ± 0.22 on day 3, 2.0 ± 0.33 on day 7, and 1.87 ± 0.34 on day 30. The mean Galway Limb Swelling score also improved significantly (P0.001): from 3.6 ± 0.74 on the day of the procedure to 1.96 ± 0.91 on day 3, 1.06 ± 0.78 on day 7, and 0.6 ± 0.66 on day 30. During the follow-up period, 60 patients died as a result of their underlying malignancy (mean, 230 d; range, 5-1,080 d).Iliofemoral or iliocaval venous stent placement may have a valuable role in patients with metastatic disease and symptomatic LES associated with venous obstruction.

Chronic venous insufficiency (CVI) as an advanced stage of chronic venous disease is a common problem that occurs in approximately 1-5 % of the adult population. CVI has either a nonthrombotic (primary) or postthrombotic (secondary) cause involving reflux, obstruction, or a combination of both. The role of venous obstruction is increasingly recognized as a major cause of CVI, with obstructive lesions in the iliocaval segment being markedly more relevant than lesions at the levels of the crural and femoral veins. Approximately 70-80 % of iliac veins develop a variable degree of obstruction following an episode of acute deep venous thrombosis. Nonthrombotic iliac vein obstruction also known as May-Thurner or Cockett's syndrome is the most common cause of nonthrombotic iliac vein occlusion. While compression therapy is the basis of therapy in CVI, in many cases, venous recanalization or correction of obstructive iliac vein lesions may result in resolution of symptoms. This document reviews the current evidence on iliocaval vein recanalization and provides standards of practice for iliocaval stenting in primary and secondary causes of chronic venous disease.

PURPOSE To evaluate the feasibility of endovascular techniques in treating venous outflow obstruction resulting from compression of the iliac vein by the iliac artery of the left lower extremity (MayThurner syndrome). MATERIALS AND METHODS A retrospective analysis of 39 patients (29 women, 10 men; median age, 46 years) with iliac vein compression syndrome (IVCS) was performed. Nineteen patients presented with acute deep vein thrombosis (DVT) and 20 patients presented with chronic symptoms. All patients presented with leg edema or pain. In the acute group, patients were treated with catheter-directed thrombolysis (120,000–180,000 IU urokinase/h) and angioplasty followed by stent placement. In the chronic group, patients were treated with use of angioplasty and stent placement alone ( n = 8), or in combination with thrombolysis ( n = 12). Patients were then followed-up with duplex ultrasound and a quality-of-life assessment. RESULTS Initial technical success was achieved in 34 of 39 patients (87%). The overall patency rate at 1 year was 79%. Symptomatically, 85% of patients were completely or partially improved compared with findings before treatment. Thirty-five of 39 patients received stents. The 1-year patency rate for patients with acute symptoms who received stents was 91.6%; for patients with chronic symptoms who received stents, the 1-year patency rate was 93.9%. Five technical failures occurred. Major complications included acute iliac vein rethrombosis ( n = 2). Minor complications included perisheath hematomas ( n = 4) and minor bleeding ( n = 1). There were no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications. CONCLUSION Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective.

Chronic venous insufficiency (CVI) affects millions of people in the United States. With CVI, higher venous pressure in the veins of the lower limb during exercise results in ambulatory venous hypertension and ulceration. The majority of cases of CVI occur after an episode of deep vein thrombosis (DVT). This results in damage to the valves in the deep venous system of the leg. Once damaged, the valves become scarred and incompetent, causing reflux of blood from the deep to the superficial venous system. Various theories are associated with the disease and ulceration process; the classic treatment of elevation, ambulation, and compression for venous disease remains unchallenged. A proportion of cases of CVI are caused by persistent venous obstruction, often superimposed upon valvular reflux. This article discusses techniques for endovascular reconstruction of iliac venous occlusions, which is an important cause of venous obstruction of the lower limb.

Purpose To evaluate the performance of portal venous puncture with use of magnetic resonance (MR) guidance, and to place a transjugular intrahepatic portosystemic shunt (TIPS) in a swine model. Materials and Methods A study of 12 swine was performed to evaluate the ability of interventional MR imaging to guide portal vein puncture and TIPS placement. Six swine had catheters placed in the right hepatic vein under C-arm fluoroscopy. A nitinol guide wire was left in the vein and the animals were then moved into an open configuration MR imaging unit. A TIPS needle set was used to puncture the portal vein using MR fluoroscopy. The animals were transferred to the C-arm, and venography confirmed portal vein puncture. A follow-up study was performed in six additional swine to place a TIPS using only MR imaging guidance. MR tracking was used to advance a catheter from the right atrium into the inferior vena cava. Puncture of the portal vein was performed and a nitinol stent was placed, bridging the hepatic parenchyma. MR venogram confirmed placement. Results Successful portal vein puncture was achieved in all animals. The number of punctures required decreased from 12 in the first animal to a single puncture in the last eight swine. A stent was successfully placed across the hepatic tract in all six swine. Conclusions Real-time MR imaging proved to be a feasible method to guide portal vein puncture and TIPS placement in pigs.

Endobronchial stents provide a noninvasive alternative to reconstructive surgery or permanent tracheostomy to maintain or restore airway patency. Tracheobronchial stenoses can be due to a variety of benign and malignant diseases, including postintubation stricture and lung cancer. Two main types of airway stents are now available—silicone-based devices and metallic stents. Silicone stents are easily removed if necessary and are predominantly used as a temporizing measure. Unfortunately, they are prone to blockage with mucus plugs and migration. Metallic stents are low-profile, easy to place, and do not migrate. However, they are almost impossible to remove after placement. The authors tend to use shorter balloon-expandable stents for focal bronchial stenoses such as occur posttransplantation, and use the longer, more flexible self-expanding stents for the trachea. Before deployment, all patients have thin-section computed tomography scans and bronchoscopy. Stents are usually inserted under general anesthesia and full intubation. Follow-up bronchoscopy and repeated interventions may be necessary over the long term in patients with benign disease. Stenting is a valuable option in the palliation of severe dyspnea in patients with malignant disease.