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To retrospectively analyse the technical and clinical outcomes of embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy, and in addition, to analyse factors potentially influencing 30-day mortality.From November 1998 to November 2012, 34 patients underwent percutaneous embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic treatment. Demographic, laboratory, angiographic, and clinical follow-up data were collected.Indication for initial endoscopic sphincterotomy was benign (n = 28) or malignant (n = 6) disease. A precut sphincterotomy followed by sphincterotomy was performed in 13 patients (38 %), whereas the remaining 21 patients (62 %), underwent only sphincterotomy. Seven patients (20.6 %) were still on antithrombotic medication at the time of sphincterotomy. Angiographic evaluation revealed contrast extravasation (n = 31), pseudoaneurysm (n = 2), or a combination of both (n = 1). Embolization was successful in 33 of 34 patients (97 %). Recurrent bleeding occurred in three patients (9 %), and 30-day mortality was 20.6 % (n = 7). Factors significantly influencing 30-day mortality were INR (P = 0.008) and aPTT (P = 0.012).Angiographic embolization is very effective in stopping post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy. The rate of rebleeding is acceptably low, but 30-day mortality remains significant. Haemostatic disorders appear to significantly influence 30-day survival.• Transcatheter embolization is very effective in stopping major post-biliary sphincterotomy bleeding • The rate of rebleeding is acceptably low • Haemostatic disorders appear to significantly influence 30-day survival.

A fistula between the iliac artery and a bladder pouch is a rare but potentially life-threatening condition. In 3 patients presenting with massive hematuria after urinary diversion, an iliac artery pseudoaneurysm was found on imaging studies. These pseudoaneurysms were considered to be associated with a fistula between artery and pouch, causing the hematuria. All patients were successfully treated with a covered stent to exclude the pseudoaneurysm and the arteriovesical fistula. Clinical follow-up of 10 weeks, 16 months, and 27 months, respectively, showed no residual hematuria. In addition, no clinical signs of stent graft infection or thrombosis were identified during follow-up. In conclusion, the placement of a covered stent is a valuable therapeutic treatment option in the management of hematuria due to an arteriovesical fistula after urinary diversion surgery.

Objective To determine predictors of technical success, dysfunction recurrence and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVFs). Methods Retrospective analysis of first time PTA of 167 AVF in 162 patients (100 men, 66 ± 13 years). Anatomical (location, length, grade and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus and AVF age, side and location) were reviewed. Results 217 stenoses or segmental occlusions were treated. Technical success rate (84.4%) was higher in radiocephalic AVF compared to brachial artery–median vein AVF ( p = 0.030) and was negatively correlated with initial stenosis ( p = 0.049). Dysfunction recurrence was seen in 52.7% and correlated negatively with technical success ( p = 0.013) and AVF age ( p = 0.008). Early dysfunction (within 6 months) was negatively correlated with AVF age ( p = 0.016) and positively with diabetes ( p = 0.003). Higher AVF age resulted in higher primary ( p = 0.005) and secondary patency rates ( p = 0.037–0.005). Conclusions Technical success of PTA in hemodialysis AVF is affected by AVF type and initial stenosis and has significant effect on dysfunction recurrence, but not on AVF longevity. Younger AVF has increased risk for (early) recurrent dysfunction and lower patency rates. Patients with diabetes mellitus have higher risk for early dysfunction.

Objective Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice. Methods We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia. Results Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications. Conclusion The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

To evaluate the safety and feasibility of percutaneous stripping of totally implantable venous access devices (TIVAD) in case of catheter-related sleeve and to report a technique to free the catheter tip from vessel wall adherence.A total of 37 stripping procedures in 35 patients (14 men, 40%, and 21 women, 60%, mean age 53±14 years) were reviewed. Totally implantable venous access devices were implanted because of malignancy in most cases (85.7%). Catheter-related sleeve was confirmed as cause of persistent catheter dysfunction despite instillation of thrombolytics. A technique to mobilize the catheter tip from the vessel wall was used when stripping with the snare catheter was impossible. Technical success, complication rate, and outcome were noted.A total of 55.9% (n=19) of the 34 technically successful procedures (91.9%) could be done with the snare catheter. In 15 cases (44.1%), additional maneuvers to free the TIVAD's tip from the vessel wall were needed. Success rate was not significantly lower before (72.4%) than after (96.7%) implementation of the new technique (P=0.09). No complications were observed. Follow-up was available in 67.6% of cases. Recurrent catheter dysfunction was found in 17 TIVADs (78.3%) at a mean of 137.7 days and a median of 105 days.Stripping of TIVADs is technically feasible and safe, with an overall success rate of 91.9%. Additional endovascular techniques to mobilize the distal catheter tip from the wall of the superior vena cava or right atrium to allow encircling the TIVAD tip with the snare catheter may be needed in 44.1% of cases.

Purpose To assess the safety, feasibility, and effectiveness of coil embolization of the proximal internal iliac artery (IIA) before stent-graft extension in patients previously treated by endovascular aortic repair (EVAR). Materials and Methods Over a period of 9 years, 16 ipsilateral, proximal IIA coil embolization procedures were performed before stent-graft extension in 13 patients previously treated by a modular aortic stent graft. Indication for coil embolization and concomitant stent-graft extension were secondary (ie, late) distal type I endoleak ( n = 9) and late onset of an isolated common iliac artery aneurysm ( n = 7) as a result of increasing dilation of a common iliac artery during follow-up after EVAR; mean common iliac artery diameter before coil embolization was 26.1 mm (range, 15–35 mm). Clinical and radiologic follow-up (mean, 39 months; range, 6–102 months) was done in accordance with an established registry. Results All procedures were successful except for one performed with 0.035-inch coils. Clinically, buttock claudication was noted in five of 13 patients (38%). No type II endoleak occurred through the coil-embolized internal iliac arteries. The mean common iliac artery diameter at 6-month follow-up was 23.0 mm (range, 14–30 mm; P = .0005). Conclusions Ipsilateral coil or microcoil embolization of the proximal IIA before stent-graft extension in patients previously treated by an aortic stent graft seems to be safe and feasible, with favorable outcomes after a mean follow-up of 39 months.

Transarterial chemoembolization (TACE) is considered the gold standard for the treatment of unresectable hepatocellular carcinoma (HCC) in patients with a preserved liver function and in the absence of clear extrahepatic tumor spread. This review article deals with the radiological and clinical workup, the interventional technique of chemoembolization for HCC and gives an overview of the common as well as some rare and dramatic complications of TACE. Finally, some new trends and advances in clinical research with regard to the interventional management of HCC are discussed.

Purpose: To retrospectively analyze the technical and clinical outcome of percutaneous rheolytic thrombectomy with the use of the AngioJet device in thrombosed autogenous arteriovenous dialysis fistulas. Methods: A cohort of 38 consecutive patients (24 men; mean age 70.7±13.8 years) presenting with 59 thrombotic events in 39 autogenous dialysis fistulas were retrospectively analyzed. The AngioJet rheolytic thrombectomy device was used in all cases. Adjunctive therapies, as well as procedure-related complications, were noted. Primary, assisted primary, and secondary patency of the autogenous fistulas was assessed along with factors potentially influencing patency. Results: Initial technical success to recanalize the efferent vein was 100% (n=59), and a successful postprocedure dialysis session was possible in 97% (n=57) of cases. Adjunctive procedures included percutaneous thromboaspiration (n=4, 7%), balloon angioplasty (n=59, 100%), and stent placement (n=16, 27%). Complications related to thrombectomy occurred in 3 (5%) procedures (distal arterial embolus). Primary, assisted primary, and secondary patency rates at 12 months were 56.1% (95% CI 42.8% to 75.2%), 61.6% (95% CI 48.6% to 74.7%), and 86.2% (95% CI 74.9% to 97.5%), respectively. Risk factors for early fistula occlusion were greater patient age (p=0.045), the age of the fistula (p=0.045), previous stent insertion (p=0.019), and an upper arm fistula (p=0.047). Conclusion: Percutaneous rheolytic thrombectomy of autogenous dialysis fistulas is effective in restoring patency and allowing subsequent hemodialysis. The complication rate is acceptably low, and the large majority of the fistulas are still used for hemodialysis at 1-year follow-up. Older fistulas and upper arm fistulas are at higher risk for early rethrombosis.

To compare a multislab balanced turbo field-echo magnetic resonance (MR) angiographic technique, without the use of a contrast agent, with digital subtraction angiography (DSA) for imaging of the renal arteries.Twenty-five randomly selected patients (eight women and 17 men; age range, 27-88 years; mean age, 72 years) suspected of having renal artery stenosis underwent both DSA and balanced turbo field-echo MR angiography. A consensus result was obtained among three radiologists in evaluation of main renal arteries on balanced turbo field-echo images and DSA images. Sensitivity, specificity, and negative and positive predictive values of the balanced turbo field-echo technique were calculated, and receiver operating characteristic analysis was performed for depiction of hemodynamically significant stenosis. Cohen kappa analysis was used to assess agreement between the two imaging methods in grading of stenoses and depiction of significant stenosis. Accessory renal arteries also were evaluated.Fifty main renal arteries and 11 accessory arteries were fully depicted with DSA. DSA depicted 11 stenotic lesions in the main renal arteries. In comparison, balanced turbo field-echo MR angiography enabled visualization of 46 of 50 main renal arteries to their first branching points and depicted 10 of 11 accessory arteries. Sensitivity, specificity, negative predictive value, and positive predictive value of this technique for depiction of significant stenosis were 100% (four of four), 98% (41 of 42), 100% (41 of 41), and 80% (four of five), respectively. The area under the receiver operating characteristic curve was 0.988. kappa was 0.782 for grading of stenoses and 0.877 for depiction of significant stenosis.Multislab balanced turbo field-echo imaging has potential as an MR angiography technique for depiction of normal and diseased renal arteries.

Pseudoaneurysm formation is a rare, but potentially life threatening delayed complication of major pancreatic surgery. Redo surgery several weeks after pancreaticoduodenectomy can be hazardous, especially in debilitated patients. Percutaneous, transcatheter exclusion of the pseudoaneurysm by means of embolic coils can be an efficient, safe and minimally invasive alternative to open surgery with good mid- and long-term results. We present our experience in Three patients undergoing transcatheter embolization of hepatic artery pseudoaneurysms detected several weeks after Whipple's operation.

The purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients--31.5%) or because of severe comorbidities (37 patients--68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 +/- 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.

Changes in lung signal between normal breathing and breathing pure oxygen is the basis for oxygen-enhanced ventilation MRI. An optimal technique guarantees a significant response to pure oxygen in well-ventilated lung tissue. To improve the sensitivity, we investigated the effect of ECG and respiratory triggering. Centric reordered single-shot rapid acquisition relaxation enhancement sequences (TE 4.2 ms, echo spacing 4.2 ms, bandwidth 650 Hz/pixel), with an inversion recovery preparation pulse (TI 700 ms), were used. Series of 20 measurements were performed with and without ECG and respiratory triggering in five young volunteers. Subsequently, series of 100 images were acquired during breathing normal air and pure oxygen (as "stimulus"). Ventilation maps showed by means of the z-score how far the response deviates from the signal intensities during the normal air condition. The standard deviation of the lung signal intensities was lowest for the cardiac-triggered series. In the ventilation maps, on the other hand, signal changes were statistically more significant in the respiratory than in the cardiac-triggered series. The average z-scores in the right (left) cranial part of the lung were 12.4 (13.0) and 9.2 (9.7) for respiratory and ECG-triggered acquisitions. We propose to use respiratory triggering as a means to improve the sensitivity of MR ventilation studies.

Our objective was to determine the efficacy of ultrasound-guided direct injection of human thrombin to close postcatheterization pseudoaneurysms and to evaluate the midterm results of this new percutaneous technique by ultrasound follow-up. One hundred one postcatheterization pseudoaneurysms in 100 patients were treated by direct injection of human thrombin (mean dose 200 IU, range 50-750 IU) under ultrasound guidance. Patient demographics, clinical data and ultrasonographic morphology of the pseudoaneurysms were analyzed. Midterm (mean 99 days, range 25-210 days) ultrasonographic follow-up was performed in 57 of 82 called patients (69.5%). Ninety-six of 101 pseudoaneurysms thrombosed completely after the first procedure. Of the remaining 5 pseudoaneurysms, 3 were treated successfully after the second attempt, and 2 patients underwent surgical repair; thus, the primary success rate was 95% (96 of 101), and the overall success rate was 98% (99 of 101). No changes in distal pulses or other adverse events were noted immediately or 1 day after the procedure. Ultrasound follow-up revealed complete disappearance of the pseudoaneurysm in 70% (40 of 57), presence of small, residual groin hematoma in 26% (15 of 57), and partial reperfusion of the pseudoaneurysm in 3.5% (2 of 57). Human thrombin injection under ultrasound guidance is a very effective and safe method of therapy. Failure (immediate and late) of the technique as well as procedure-related complications are very rare. In our institution, sonographically guided human thrombin injection has become the treatment of choice for postcatheterization pseudoaneurysms.

) in association with chemo-therapeutic agents has become a standard treat-ment for patients with metastatic colorectal cancer reaching a median overall survival of 22.7 months [1]. However, bevacizumab-therapy can be associ-ated with some adverse events, including bleeding (3%), gastrointestinal perforation (2%), arterial thromboembolism (1%), hypertension (5.3%), pro-teinuria (1%) and wound-healing complications (1%) [2–5]. Bleeding complications have been observed as pulmonary hemorrhage and/or hemop-tysis, mainly in patients with lung cancer; gingival and vaginal bleeding have also been reported, but are less common [2]. Herein, the occurrence of a (pseudo-)aneurysm within an asymptomatic renal angiomyolipoma in a patient with colorectal liver metastases treated with FOLFIRI and bevacizumab is reported. A 57-year-old woman underwent a laparoscopic low anterior resection for obstructing rectosigmoid carcinoma with concommitant diffuse liver metasta-ses. At pre-operative screening CT, a fat-containing mass lesion was detected suggestive of an angiomyo-lipoma (Figure 1). A true-cut biopsy of the renal lesion was performed. Pathological analysis confi rmed the diagnosis of an angiomyolipoma. One month postoperatively, chemotherapeutic treatment with FOLFIRI and buvacizumab was started to manage the liver metastases. Control CT-scan three months after start of the chemotherapeutic treatment showed a marked involution of the liver metastases, but also a (pseudo-) aneurysm within the angiomyolipoma. The (pseudo-) aneurysm had a diameter of 4.5 cm with peripheral thrombus-formation (Figure 2). It was agreed to exclude the (pseudo-)aneurysm by transcatheter embolization. Under local anesthesia, the feeding vessel was selectively catheterized (Figure 3a) and occluded by 250 μ microparticles (Embozene, CeloNova, Newnan, GA, USA) and microcoils (Microtornado, Cook Medical, Bjaeverskov, Den-mark) (Figure 3b). FU-CT two months later depicted a further shrinkage of the liver metastases and a full exclusion of the (pseudo-) aneurysm. Bleeding complications associated with bevaci-zumab-therapy potentially can be explained by the anti-angiogenic effect, thus inhibiting the growth of the endothelium which might result in vessel wall contiguity and pseudoaneurysm formation. In the present case, the exact pathophysiological mechanism for the development of the (pseudo-)aneurysm within the angiomyolipoma is not very clear. A vessel wall lesion might be induced initially by the true-cut biopsy. However, FU-CT one month after the biopsy showed no radiological sign of intralesional aneurysm formation. Bevaci-zumab therapy might have jeopardized endotheli-alization at a biopsy-injured vessel, a phenomenon which is similar to late bevacizumab-related surgi-cal site complications [6]. Also, bevacizumab ther-apy might have a direct effect on the physiology of the endothelium of the vascular components of the angiomyolipoma. Angiomyolipoma may harbor subtle microaneurysms not visible on imaging and a pseudoaneurysm may have developed spontane-ously at the site of such a microaneurysm with a susceptible and fragile endothelial lining [7].

The purpose of this article is to retrospectively evaluate the technical and clinical outcomes of large-bore nitinol stents for treating malignant superior vena cava syndrome. In addition, we analyzed factors potentially influencing the outcome.Over a 7-year period, 78 consecutive patients presented with superior vena cava syndrome related to primary lung tumor (n=62) or malignant lymphadenopathies (n=16). The factors analyzed were Kishi score at admission, tumor type, and need for an additional balloon-expandable stent.Technical success was obtained in all but one patient (99%), who presented with a stent migration immediately after insertion. In 17 patients (22%), an additional balloon-expandable stent was needed for complete expansion of the nitinol stent. For patients with symptomatic malignant lymphadenopathies or primary lung tumor, overall survival rates were 50% (n=8) and 54% (n=34), respectively, at 6 months and 19% (n=3) and 34% (n=21), respectively, at 12 months (p=0.376). There was no difference in survival as a function of the Kishi score (p=0.80) or of the placement of an additional balloon-expandable stent (p=0.35). Finally, reocclusion events were noted in patients both with (n=1) and without (n=7) a balloon-expandable stent.Large-bore nitinol stents are highly effective for malignant superior vena cava syndrome. The survival rates of patients with caval vein stenosis due to either the primary tumor or secondary enlarged adenopathies were equal. An additional balloon-expandable stent was required in 22% of cases owing to incomplete expansion of the nitinol stent but was not associated with higher thrombosis rate.

Purpose To investigate prospectively the safety, tolerability, and efficacy of transarterial chemoembolization using superabsorbent polymer (SAP) microspheres loaded with doxorubicin for the treatment of hepatocellular carcinoma (HCC). Materials and Methods During the years 2006–2011, 64 patients underwent 144 transarterial chemoembolization with SAP microspheres procedures. Most of the patients were staged as Barcelona Clinic Liver Cancer class B (65%). The most frequent underlying liver diseases were hepatitis C (35%) and alcoholic liver disease (28%) resulting in Child-Pugh A (73.4%) or Child-Pugh B (17%) liver cirrhosis. Tumor response was assessed using modified Response Evaluation Criteria in Solid Tumors with magnetic resonance (MR) imaging performed 4–6 weeks after each procedure. Results Serious adverse events (n = 9) were ischemic or infectious in nature. Transarterial chemoembolization with SAP microspheres resulted in objective response rates of 67.5%, 44.5%, and 25% after first, second, and third sessions. There were 16 patients (25%) who underwent orthotopic liver transplantation after transarterial chemoembolization with SAP microspheres, of whom 2 experienced recurrent disease. During a median follow-up time of 14 months (range, 2–55 mo), 26 patients (40.5%) died. Median overall and transplant-free survivals were 20.5 months (95% confidence interval, 13.2–27.7) and 18 months (95% confidence interval, 14.2–21.8), respectively. Conclusions Transarterial chemoembolization with SAP microspheres has an excellent safety profile in cirrhotic patients, even in the presence of advanced liver disease (Child-Pugh B) or advanced stages of HCC. This treatment produced meaningful tumor response rates as assessed by MR imaging.

One month after onset of an acute biliary pancreatitis, a 75-year-old man developed refractory ascites. Duplex ultrasound and CT scan revealed a focal stenosis of the extrahepatic portal vein as confirmed by transhepatic direct portography. In the same session, this stenosis, responsible for symptomatic prehepatic portal hypertension, was successfully dilated and stented and afterwards a residual pressure gradient of 1 mmHg over the stented segment was measured. One week after the stenting procedure the patient was free of ascites and control physical and biochemical examination one year later is completely normal.

Arteriovenous fistula of the superficial temporal artery is quite rare. If it occurs, it is most often caused by trauma to the temporal region where the artery is very superficial to the skin. We present the first reported case of an arteriovenous fistula after temporal artery biopsy and review the literature on the pathophysiology, diagnosis, and treatment of arteriovenous fistula. ispartof: Annals of Vascular Surgery vol:27 issue:4 pages:500- ispartof: location:Netherlands status: published

Background Arterial injuries to the extremities may result in severe hemorrhagic complications. Open surgical repair has been the standard of care for these patients, but endovascular management may be a valuable, less invasive alternative. Purpose To evaluate the safety, efficacy and long-term durability of embolotherapy for the management of hemorrhagic, traumatic vascular injuries in upper and lower limbs. Material and Methods Patients with traumatic or iatrogenic hemorrhagic vascular injuries to the extremities and managed with endovascular embolotherapy in the authors' institution between 1998 and 2010 were included in this retrospective study. Embolization was performed with different embolic materials; technical and long-term clinical outcome was assessed by review of the medical records or by telephone interviews of the referring physicians. Results Embolization was performed in 31 patients. In six patients the vascular lesion was traumatic, in the remaining 25 patients the lesion was of iatrogenic origin. Angiographic vascular lesions identified were: contrast extravasation ( n = 19, 61%), pseudoaneurysm ( n = 8, 26%), and pseudoaneurysm with arteriovenous fistula ( n = 3, 10%). Primary and secondary clinical success was obtained in 84% and 97% of cases, respectively. Procedure-related complications occurred in five patients (16%). Most of them were mild. One patient expired 34 days after the procedure due to amputation-stump infection, septicaemia, and multiple organ failure. Long-term outcome showed no recurrent bleeding or other embolization-related complications. Conclusion Embolotherapy for the management of hemorrhagic, traumatic vascular injuries in upper and lower limbs is relatively safe, very effective without recurrence or other embolization-related symptoms.

Purpose To assess retrospectively technical and clinical outcomes after transcatheter embolization in patients presenting with soft tissue bleeding associated with antithrombotic therapy and to determine factors potentially affecting the clinical outcomes after embolization. Materials and Methods There were 42 patients who underwent embolization for soft tissue bleeding associated with antithrombotic therapy. Principal clinical symptoms were hemodynamic shock (n = 21), abdominal pain (n = 9), back pain (n = 7), and buttock or thigh pain (n = 5). Ultrasound or computed tomography (CT) or both were performed in 40 patients (95%); 2 patients (5%) were immediately referred for angiography. Several laboratory and radiographic factors were analyzed to determine if any influenced the clinical outcome. Results A hematoma was identified in the anterior abdominal wall (n = 18 [43%]), in the retroperitoneum (n = 18 [43%]), or in the thigh or gluteal region (n = 6 [14%]). Embolization was successful in all patients; early recurrent bleeding with a fatal outcome was recorded in one patient (2%). In nine patients (22%), secondary surgical drainage of the hematoma was performed to manage a compartment syndrome. During follow-up (mean, 37.9 months; range, 0.03–85.28 months), 11 patients (26%) died; death was related to the bleeding in 6 patients (14%). Both activated partial thromboplastin time (aPTT) and prothrombin time (PT) were correlated with hematoma size. Prolonged aPTT before embolization was associated with a higher risk of bleeding-related mortality ( P = .04). Conclusions Transcatheter embolization was very effective in stopping soft tissue bleeding associated with antithrombotic therapy. However, there was still considerable morbidity and mortality after successful embolization. aPTT prolongation emerged as a risk factor for bleeding-related deaths.

Transcatheter arterial chemoembolization (TACE) is the standard treatment in selected patients with unresectable hepatocellular carcinoma (HCC). Drug-eluting particles are developed to reduce side effects and improve efficacy. We present safety data of a prospective randomized phase II study with doxorubicin-eluting superabsorbent polymer (SAP) microspheres.We prospectively included 30 HCC patients with different Barcelona Clinic Liver Cancer (BCLC) stages (A = 3, B = 19, C = 8) and randomly assigned them to receive conventional TACE (n = 14) (control group) or doxorubicin-eluting SAP microspheres (n = 16). The doxorubicin plasma level was assessed at different time points, biochemical analysis was performed, and side effects were reported following the Common Toxicity Criteria. Tumor response was assessed at 6 weeks according to the modified Response Evaluation Criteria in Solid Tumors (RECIST) criteria.There was a significantly lower plasma peak concentration (Cmax) of doxorubicin and smaller area under the curve (AUC) with SAP microspheres (mean Cmax 495 ± 293.9 ng/ml, mean AUC 69.7 ± 26.9 ng/ml min) compared to controls (mean Cmax 1,928 ± 560.8 ng/ml, mean AUC 165 ± 32.3 ng/ml/min; both p0.001). Furthermore, there were less grade 3 and no grade 4 adverse events in the SAP microsphere group. Tumor response was comparable between the groups.TACE with SAP microspheres leads to low plasma levels of the cytotoxic drug and therefore minimizes toxicity compared to conventional TACE.

To compare the accuracy of wedged hepatic venous pressure (WHVP) measurement with use of an end-hole catheter or an occlusion-balloon catheter versus direct portal pressure (PP) measurement in patients with cirrhosis with sinusoidal portal hypertension and to investigate the factors that affect the results of these indirect measurements.In a cohort of 174 patients with cirrhosis referred for transjugular intrahepatic portosystemic shunt creation, indirect PP was measured with an end-hole catheter and an occlusion-balloon catheter placed in the right hepatic vein. Direct PP was measured by a pigtail catheter in the main branch of the portal vein.PP was more accurately estimated by the occlusion-balloon technique: mean WHVP measurements were 25.5 mm Hg ± 7.9 and 30.6 mm Hg ± 13.9, respectively, for the occlusion-balloon and end-hole catheter techniques, and the direct PP measurement was 25.0 mm Hg ± 7.0. The median absolute differences between direct and the indirect methods were 6.0 mm Hg with the end-hole catheter and 2.0 mm Hg with the occlusion-balloon catheter (P.0001, signed-rank test). Relative to direct PP measurements, the occlusion-balloon technique overestimated pressures in cases of higher Model for End-Stage Liver Disease (MELD) scores (Spearman ρ = -0.24; P = .0005).Compared with direct PP measurements, agreement was clearly higher for indirect WHVP measurement with occlusion-balloon catheters versus end-hole catheters. However, in patients with a high MELD score, there was an overestimation of PP with the occlusion-balloon method.

Open surgical rerouting and proximal ligation of one or more supra-aortic vessels prior to endovascular stent-graft placement has become an alternative to major open thoracic surgery in the treatment of complex thoracic aortic disease. Complications owing to failed surgical ligation of the left subclavian artery are rare. In this report, 3 cases of failed ligation are presented. Diagnosis was made by CT-scan and treatment was performed by transcatheter coil and plug embolization, avoiding redo neck surgery.

To evaluate the feasibility, safety, and efficacy of embolization of internal iliac artery aneurysm (IIAA) after percutaneous direct puncture under (cone-beam) computed tomography (CT) guidance. A retrospective case series of three patients, in whom IIAA not accessible by way of the transarterial route, was reviewed. CT-guided puncture of the IIAA sac was performed in one patient. Two patients underwent puncture of the IIAA under cone-beam CT guidance. Access to the IIAA sac was successful in all three patients. In two of the three patients, the posterior and/or anterior division was first embolized using platinum microcoils. The aneurysm sac was embolized with thrombin in one patient and with a mixture of glue and Lipiodol in two patients. No complications were seen. On follow-up CT, no opacification of the aneurysm sac was seen. The volume of one IIAA remained stable at follow-up, and the remaining two IIAAs decreased in size. Embolization of IIAA after direct percutaneous puncture under cone-beam CT/CT-guidance is feasible and safe and results in good short-term outcome.

Hybrid stent-graft procedures with visceral revascularization have been reported as an alternative treatment option for thoracoabdominal aortic aneurysms (TAAAs), although the potential advantages of reduced morbidity and mortality compared with open surgical repair have not been definitively demonstrated. Endovascular aneurysm repair is associated with endoleaks in as many as 20% of cases in some series, often requiring repeat intervention. In the present case, during follow-up after a hybrid TAAA repair, a patient developed a type II endoleak originating from a celiac artery that was not ligated at its origin. The endoleak was successfully treated by transcatheter coil embolization.

To assess the safety, feasibility and efficacy of catheter-directed thrombolysis for thoracic central venous thrombosis in both cancer and non-cancer patients. A retrospective case series of 68 patients, including 35 with active cancer and 33 without cancer, was analysed. They all received catheter-directed thrombolysis with alteplase or urokinase for symptomatic acute major thoracic vein thrombosis. Substantial clot lysis was obtained in 62 out of 68 patients (91%), the results being 88.6 and 93.8% for cancer and non-cancer patients respectively (P = 0.68). The mean infusion time in patients with and without cancer was 2.11 and 1.84 days respectively (P = 0.3259). Procedure-related complications occurred in two cancer patients (8.6%) and in seven non-cancer patients (21%) (P = 0.18). One cancer patient developed a fatal intracranial bleeding. Additional intervention after successful lysis was performed in cancer (n = 18; 51%) as well as in non-cancer patients (n = 29; 88%). Catheter-directed thrombolysis is a feasible and highly effective interventional procedure with an acceptable safety profile in selected patients with and without cancer for the treatment of symptomatic thoracic central venous thrombosis. In most cases, additional endovascular or surgical procedures are required to restore and maintain vessel patency after successful thrombolysis.

Our purpose was to assess the feasibility of orthotopic liver transplantation (OLT) in patients priorly having undergone transjugular intrahepatic portosystemic shunt (TIPS) with an expanded tetrafluoroethylene (e-PTFE)-covered endoprosthesis. In 48 patients an e- PTFE-covered endoprosthesis was inserted to treat severe complications of portal hypertension. In 36 patients the endoprosthesis was inserted during TIPS creation (de novo TIPS); in the other 12 patients the endoprosthesis was placed to repermeabilize the previously created, but occluded bare stent (revision TIPS). Eight of them (5 de novo and 3 revision cases) later underwent an OLT. The hospital records of these patients were reviewed from initial admission, through TIPS, the pre-OLT period, and OLT to current postoperative status. Five de novo and 3 revision cases underwent OLT 4–279 days (mean delay: 80.8 days) after TIPS procedure. All OLT’s were performed under veno-venous bypass surgery. De visu surgical inspection confirmed correct positioning of the fully patent stent graft, starting in the portal vein and ending at the junction of the hepatic vein to the inferior caval vein. No surgical difficulty was observed during proximal or distal clamping or during resection of the diseased liver. Correctly positioned e-PTFE-covered nitinol endoprostheses do not interfere with a later OLT and may not be considered as a contraindication in patients who need a TIPS as a bridge to OLT.

Background:Radiofrequency ablation (RFA) has emerged as a potential alternative for surgery in clinical oncology. This animal experiment was conducted to evaluate the feasibility of RFA in the treatment of renal tumor. Methods:Eighteen rabbits with renal implantation of VX2 tumors were divided into two groups. Group A (n = 12) was treated with RFA by using a cooled-tip RF system at 30 W for 80 to 180 seconds. Group B (n = 6) received a sham operation. The therapeutic efficacy was evaluated by survival rate, magnetic resonance imaging (MRI), and histology. Results:All animals in group B died within 3 months after tumor implantation. Total tumor eradication was achieved in 10 of 12 rabbits (83.3%) in group A, of which 5 rabbits survived longer than 6 months (absolute eradication) and another 5 rabbits were found free of viable tumor when killed (relative eradication). Two rabbits experienced local tumor relapse, lung metastasis, or both. Six-month survival rate of RFA-treated rabbits was significantly higher (P < .01) than that of control rabbits. The typical MRI appearances of the acute RFA lesion consisted of five characteristic concentric zones, which corresponded to central needle track (zone A), tumor coagulation (zone B), renal tissue coagulation (zone C), peripheral hemorrhage (zone D), and inflammatory layer (zone E) on histology. Conclusions:RFA may become a promising therapy for the treatment of renal tumor. MRI is a useful modality for assessment of renal tumor ablation.

Radiofrequency ablation (RFA) has emerged as an alternative for surgery in clinical oncology. This animal experiment was conducted to evaluate the feasibility of RFA in the treatment of pulmonary tumor.Eighteen rabbits with pulmonary implantation of VX2 tumors were divided into two groups. Group A (n = 12) was treated with RFA by using a cooled-tip electrode technique. Group B (n = 6) received sham operation. The therapeutic efficacy was evaluated by survival rate, magnetic resonance imaging (MRI), postmortem microangiography, and histology.All animals in group B died within 3 months after tumor implantation. Tumor eradication was achieved in 9 of 12 rabbits (75.0%) in group A, of which 4 rabbits survived longer than 3 months free of disease and another 5 rabbits were found free of viable tumor when sacrificed. One rabbit was subjected to incomplete tumor ablation and two rabbits suffered from local tumor relapse and/or lung metastasis. The 3-month survival rate of RFA-treated rabbits was significantly higher (P0.01) than that of control rabbits. The typical MRI appearances of the acute RFA lesion consisted of five characteristic concentric zones, which corresponded to central needle track (zone A), tumor coagulation (zone B), pulmonary parenchyma coagulation (zone C), peripheral hemorrhage (zone D), and inflammatory layer (zone E) on histology.Eradication of pulmonary tumor could be achieved with current RFA technique in rabbits. MRI is a useful modality for assessment of lung tumor ablation.