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The hemodialysis reliable outflow (HeRO) graft was designed for patients with failed arteriovenous accesses caused by an obstructed central venous outflow or patients who have exhausted all upper arm options. We describe a patient with severe stenosis of the superior vena cava (SVC) who experienced recurrent episodes of infection of permanent tunneled catheters, resulting in repeated hospitalizations. We successfully used the HeRO graft after angioplasty of the SVC. This indication for placing the HeRO graft has not been emphasized and mentioned previously in the literature. We also reviewed the literature regarding comparisons of this technique with other options.

Vascular access-induced limb ischemia is a known complication of arteriovenous fistulas and grafts. Many techniques have been adopted to prevent steal in high-risk patients and to treat steal in cases of moderate ischemia not controlled with conservative management. A major factor guiding treatment is access flow volume. Management is different when ischemia is combined with the excessive flow in contrast to the combination with normal flow. We describe the most popular techniques encountered in the English literature as a part of a stepwise approach to treating dialysis access steal syndrome. In absence of ischemia, when cardiac issues emerge due to extreme access flow volumes, some of these techniques are also used to decrease flow and protect the heart. Patient’s history, focused clinical examination, color duplex ultrasound examination, pulse oximetry and an angiogram are essential tools to approach this entity.

Abstract Coronary angiography and percutaneous coronary intervention (PCI) procedural details in swine are similar to those performed to humans, since their heart and coronary anatomy closely resembles. However, only a few detailed descriptions of the procedure are available, containing notable differences. We present a feasible and reproducible protocol for percutaneous coronary interventions in porcine experimental models, utilizing ultrasound-guided femoral approach. Nine female pigs were studied to explore the feasibility of superficial femoral arterial (SFA) access for coronary angiography and provisional PCI, as well as the most suitable guiding coronary catheters and angiographic projections for the above interventions. Experiments were performed under general anesthesia, using ultrasound-guided puncture of the SFA to gain arterial access. The Amplatzer AR1® catheter, and the Right Coronary Bypass® catheter were used for the selective engagement of the right and the left coronary artery, respectively. Successful arterial access and subsequent cardiac catheterization were performed in all pigs. Only one animal required a second puncture for femoral artery access. None of the 9 animals presented any significant tachycardia or hypotensive episode. One animal developed an access site-related complication following the first catheterization procedure. During follow-up, 100% success of SFA catheterization was achieved using the same ultrasound-guided technique. The ultrasound-guided superficial femoral artery access for coronary angiography and provisional interventions in porcine models is a quick and safe alternative to the carotid artery approach. The RCB and AR1 catheters may be the best choice for the quick and easy selective coronary engagement of the right and left ostia, respectively.

Pandemic outbreak has led health systems worldwide into a rapid reorganization in response to coronavirus infections, forcing interventional radiology units to adapt. Interventional procedures have evolved in number, type and setting and have arguably been optimized as a direct consequence of this pandemic; a result that will undoubtedly lead to radical change within the specialty. This paper explores the future of interventional radiology from various perspectives, and forecasts the new opportunities that will be presented, from the adaptation of the interventional radiology staff and angiography suite, to the immunological environment, and through to digital medical education. We analyze the economic impact and the future relationship we can expect with the rest of the medical industry.

Abstract Background We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. Materials and methods This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients’ 30-day survival rate, and procedure-related complications. Results In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. Conclusion TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.

Limb ischemia is a known complication of vascular access that may appear early postoperatively or after years. Over the last few decades, various techniques based on different physiological mechanisms have been used for treatment. A standardized treatment does not exist, and must be individualized based on the flow volume, and the type and location of the access. True and false vascular access aneurysms are another common complication of arteriovenous fistulas, which develop because of venous hypertension or repeated needling. Evidence in the literature regarding treatment of patients with steal syndrome and concomitant true arteriovenous aneurysms is scarce. A female with a brachiocephalic fistula complicated by steal syndrome and vascular access aneurysms was treated successfully with tapered graft placement and aneurysm exclusion.

Iatrogenic trauma of the axillary artery by non-vascular surgeons can occur during various general surgical procedures such as resection of soft tissue tumors or axillary lymph node clearance. Prompt recognition, appropriate initial management, and rapid transfer to a tertiary vascular surgery service, if needed, are key steps to ensuring patient safety. Here we present a case of iatrogenic axillary artery injury during the resection of a recurrent soft tissue tumor in a local hospital. The desperate application of a Kocher clamp on the bleeding axillary artery by the operating general surgeons controlled the bleeding but led to further arterial damage. The patient was transferred to our tertiary hospital, where the arterial injury was repaired using a vein interposition graft. Apart from the encountered intraoperative technical challenges, this case highlights the need for broader training of nonvascular specialist surgeons on the core principles of basic vascular surgical techniques and oncovascular surgery.

Abstract A 75‐year‐old male presented with an immediately threatened grade IIb acute ischemia of the left leg due to thrombosis of a femoro‐infrapopliteal prosthetic bypass graft. After an urgent Computed Tomography Angiography, an urgent graft thrombectomy was performed using a 5 Fr Fogarty catheter, which had a troublesome distal passage, causing a tibial A‐V fistula.

Abstract Surgical partial nephrectomy is still considered as the “gold standard” for the definitive management of small malignant renal masses, whereas treatment with image-guided percutaneous ablation is still mainly reserved for those patients who cannot undergo nephron-sparing surgical resection due to advanced age, underlying comorbidities or compromised renal function. Nonetheless, the recent evidence that underlines the long-term oncological equipoise of percutaneous ablation methods with surgical resection in combination with the reduced complication rate and cost supports the use of an image-guided minimally invasive approach as a first-line treatment. The purpose of this review is to offer an overview of the most widely used percutaneous renal ablation treatments (radiofrequency, microwave and cryoablation) with a focus on their main technical aspects and application techniques for curative ablation of small renal cell carcinoma (stage cT1a). The authors also provide a critical narrative of the relevant medical literature with an emphasis on outcomes of comparative effectiveness research, and appraise the percutaneous methods compared to surgery in the context of evidence-based practice and future research studies. Teaching Points • RCC is a common cancer and is increasingly detected incidentally at early stages. • There is long-term oncological equipoise of percutaneous ablation compared to surgical resection. • Large-scale trials are required to produce Level 1a evidence.

Background Several randomized controlled trials (RCTs) have already shown that paclitaxel‐coated balloons and stents significantly reduce the rates of vessel restenosis and target lesion revascularization after lower extremity interventions. Methods and Results A systematic review and meta‐analysis of RCTs investigating paclitaxel‐coated devices in the femoral and/or popliteal arteries was performed. The primary safety measure was all‐cause patient death. Risk ratios and risk differences were pooled with a random effects model. In all, 28 RCTs with 4663 patients (89% intermittent claudication) were analyzed. All‐cause patient death at 1 year (28 RCTs with 4432 cases) was similar between paclitaxel‐coated devices and control arms (2.3% versus 2.3% crude risk of death; risk ratio, 1.08; 95% CI, 0.72–1.61). All‐cause death at 2 years (12 RCTs with 2316 cases) was significantly increased in the case of paclitaxel versus control (7.2% versus 3.8% crude risk of death; risk ratio, 1.68; 95% CI, 1.15–2.47; —number‐needed‐to‐harm, 29 patients [95% CI, 19–59]). All‐cause death up to 5 years (3 RCTs with 863 cases) increased further in the case of paclitaxel (14.7% versus 8.1% crude risk of death; risk ratio, 1.93; 95% CI, 1.27–2.93; —number‐needed‐to‐harm, 14 patients [95% CI, 9–32]). Meta‐regression showed a significant relationship between exposure to paclitaxel (dose‐time product) and absolute risk of death (0.4±0.1% excess risk of death per paclitaxel mg‐year; P

PURPOSE:Direct superficial femoral artery (SFA) antegrade puncture is a valid alternative to common femoral artery (CFA) access for peripheral vascular interventions. Data investigating vascular closure device (VCD) hemostasis of distant SFA 6F access are limited. We aimed to investigate the safety and effectiveness of the Starclose SE® VCD for hemostasis, following direct 6F antegrade SFA access distal to the femoral head.METHODS:This prospective, single-center study included patients who were not suitable for CFA puncture and were scheduled to undergo peripheral endovascular interventions using direct antegrade SFA 6F access, at least 2 cm below the inferior edge of femoral head. Hemostasis was obtained with the Starclose SE® VCD (Abbott Laboratories). Primary endpoints were successful hemostasis rate and periprocedural (30-day) major complication rate. Secondary endpoint was the rate of minor complications. Clinical and Doppler ultrasound follow-up was performed at discharge and at one month.RESULTS:Between September 2014 and August 2015, a total of 30 patients (21 male; 70.0%) with a mean body mass index of 41.2 kg/m2 were enrolled. Mean age was 72±9 years (range, 67–88 years). Most patients suffered from critical limb ischemia (87.1%) and diabetes (61.3%). Calcifications were present in eight cases (26.6%). Reason for direct SFA puncture was obesity (100%). Successful hemostasis was achieved in 100% of the cases. No major complications were noted after one-month follow-up. Minor complications included two

The optimal transcatheter embolization strategy for patients with unresectable hepatocellular carcinoma (HCC) remains elusive. We conducted a systematic review and network meta-analysis (NMA) of different embolization options for unresectable HCC.Medical databases were searched for randomized controlled trials evaluating bland transarterial embolization (TAE), conventional TACE, drug-eluting bead chemoembolization (DEB-TACE), or transarterial radioembolization (TARE), either alone or combined with adjuvant chemotherapy, or local liver ablation, or external radiotherapy for unresectable HCC up to June 2017. Random effects Bayesian models with a binomial and normal likelihood were fitted (WinBUGS). Primary endpoint was patient survival expressed as hazard ratios (HR) and 95% credible intervals. An exponential model was used to fit patient survival curves. Safety and objective response were calculated as odds ratios (OR) and accompanying 95% credible intervals. Competing treatments were ranked with the SUCRA statistic. Heterogeneity-adjusted effective sample sizes were calculated to evaluate information size for each comparison. Quality of evidence (QoE) was assessed with the GRADE system adapted for NMA reports. All analyses complied with the ISPOR-AMCP-NCP Task Force Report for good practice in NMA.The network of evidence included 55 RCTs (12 direct comparisons) with 5,763 patients with preserved liver function and unresectable HCC (intermediate to advanced stage). All embolization strategies achieved a significant survival gain over control treatment (HR range, 0.42-0.76; very low-to-moderate QoE). However, TACE, DEB-TACE, TARE and adjuvant systemic agents did not confer any survival benefit over bland TAE alone (moderate QoE, except low in case of TARE). There was moderate QoE that TACE combined with external radiation or liver ablation achieved the best patient survival (SUCRA 86% and 96%, respectively). Estimated median survival was 13.9 months in control, 18.1 months in TACE, 20.6 months with DEB-TACE, 20.8 months with bland TAE, 30.1 months in TACE plus external radiotherapy, and 33.3 months in TACE plus liver ablation. TARE was the safest treatment (SUCRA 77%), however, all examined therapies were associated with a significantly higher risk of toxicity over control (OR range, 6.35 to 68.5). TACE, DEB-TACE, TARE and adjuvant systemic agents did not improve objective response over bland embolization alone (OR range, 0.85 to 1.65). There was clinical diversity among included randomized controlled trials, but statistical heterogeneity was low.Chemo- and radio-embolization for unresectable hepatocellular carcinoma may improve tumour objective response and patient survival, but are not more effective than bland particle embolization. Chemoembolization combined with external radiotherapy or local liver ablation may significantly improve tumour response and patient survival rates over embolization monotherapies. Quality of evidence remains mostly low to moderate because of clinical diversity.CRD42016035796 (http://www.crd.york.ac.uk/PROSPERO).

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