Search

To summarize the literature on trans-arterial embolization in inflammatory musculoskeletal conditions, focusing on efficacy and safety. PRISMA guidelines were followed. A systematic literature search revealed 19 studies, with a total of 394 participants, eligible for inclusion. The included studies consisted of case reports/series and non-randomized interventional studies, with knee osteoarthritis and adhesive capsulitis of the shoulder as the most frequent conditions. In all studies except one, pain was reduced up to four years after treatment. All adverse events were transient. Due to high heterogeneity, meta-analysis was not possible. The included early studies showed encouraging results regarding efficacy and safety. However, randomized, placebo-controlled trials are warranted.

ObjectivePrior reports of the low profile Zenith Alpha abdominal graft (Cook Medical Inc, Bloomington, IN) have shown impaired limb graft patency to be the primary causes of reintervention. Special notices from the manufacturer have indicated certain instructions for use (IFU) violations as the main reasons for these complications. In the present study, we assessed the incidence of limb graft occlusion (LGO) and analyzed the effects of the detailed anatomic risk factors for LGO highlighted in the IFU and previously reported studies.MethodsA retrospective study was performed of 241 patients treated with the low profile Zenith Alpha at a single institution from October 1, 2015 to September 30, 2018. All computed tomography angiograms were analyzed using three-dimensional software. Data were extracted from the electronic medical records until the end of the study period (December 31, 2020). The cumulative incidence of LGO and LGO-related reinterventions were assessed. A regression analysis was performed to evaluate the possible risk factors associated with the development of LGO at specified time points. These included aortic and iliac diameters, graft component oversizing, iliac tortuosity and calcification, overlap of graft components, proximal alignment of ipsilateral and contralateral legs, and sealing zone in the external iliac artery. Reader agreement of iliac calcification and tortuosity was assessed in patients with LGO.ResultsA total of 33 limbs (7%) in 27 patients (11%) had become occluded. The cumulative incidence of LGO was 7% (95% confidence interval [CI], 5%-9%) per limb up to 3 years postoperatively. The previously described risk factors for LGO were studied using regression analysis; however, no positive association with LGO was identified. Heavily calcified common iliac arteries (CIAs) and external iliac arteries were protective against LGO compared with noncalcified vessels up to 3 years postoperatively (decreased risk, 17% [95% CI, −27% to −7%]; P = .001; and 15% [95% CI, −26 to −5]; P = .005, respectively). The reader agreement of iliac calcification and tortuosity showed substantial agreement (CIA intrareader kappa = 0.75; CIA interreader kappa = 0.62) and almost perfect agreement (intrareader kappa = 0.85; interreader kappa = 0.84), respectively.ConclusionsThe cumulative incidence of LGO after endovascular aneurysm repair with the Zenith Alpha graft was 7% per limb up to 3 years postoperatively. None of the analyzed risk factors suggested by the IFUs or current literature were positively associated with LGO. Objective: Prior reports of the low profile Zenith Alpha abdominal graft (Cook Medical Inc, Bloomington, IN) have shown impaired limb graft patency to be the primary causes of reintervention. Special notices from the manufacturer have indicated certain instructions for use (IFU) violations as the main reasons for these complications. In the present study, we assessed the incidence of limb graft occlusion (LGO) and analyzed the effects of the detailed anatomic risk factors for LGO highlighted in the IFU and previously reported studies.Methods: A retrospective study was performed of 241 patients treated with the low profile Zenith Alpha at a single institution from October 1, 2015 to September 30, 2018. All computed tomography angiograms were analyzed using three-dimensional software. Data were extracted from the electronic medical records until the end of the study period (December 31, 2020). The cumulative incidence of LGO and LGO-related reinterventions were assessed. A regression analysis was performed to evaluate the possible risk factors associated with the development of LGO at specified time points. These included aortic and iliac diameters, graft component oversizing, iliac tortuosity and calcification, overlap of graft components, proximal alignment of ipsilateral and contralateral legs, and sealing zone in the external iliac artery. Reader agreement of iliac calcification and tortuosity was assessed in patients with LGO.Results: A total of 33 limbs (7%) in 27 patients (11%) had become occluded. The cumulative incidence of LGO was 7% (95% confidence interval [CI], 5%-9%) per limb up to 3 years postoperatively. The previously described risk factors for LGO were studied using regression analysis; however, no positive association with LGO was identified. Heavily calcified common iliac arteries (CIAs) and external iliac arteries were protective against LGO compared with noncalcified vessels up to 3 years postoperatively (decreased risk, 17% [95% CI,-27% to-7%]; P = .001; and 15% [95% CI,-26 to-5]; P = .005, respectively). The reader agreement of iliac calcification and tortuosity showed substantial agreement (CIA intrareader kappa = 0.75; CIA interreader kappa = 0.62) and almost perfect agreement (intrareader kappa = 0.85; interreader kappa = 0.84), respectively.Conclusions: The cumulative incidence of LGO after endovascular aneurysm repair with the Zenith Alpha graft was 7% per limb up to 3 years postoperatively. None of the analyzed risk factors suggested by the IFUs or current literature were positively associated with LGO. (J Vasc Surg 2023;77:770-7.)

Aims The role of atherosclerosis in the pathogenesis of aortic enlargement is uncertain. We aimed to evaluate the relationship between the diameters of the ascending, descending and abdominal aorta, and coronary artery calcification. Methods and results Individuals in the Copenhagen General Population Study underwent thoracic and abdominal computed tomography. Maximal aortic diameters were measured in each aortic segment and coronary artery calcium scores (CACS) were calculated. Participants were stratified into five predefined groups according to CACSs and compared to aortic dimensions. The relation between aortic diameter and CACS was adjusted for risk factors for aortic dilatation in a multivariable model. A total of 2678 eligible individuals were included. In all segments of the aorta, aortic diameter was associated to CACSs, with mean increases in aortic diameters ranging from 0.7 to 3.5 mm in individuals with calcified coronary arteries compared to non-calcified subjects (P-value < 0.001). After correction for risk factors, individuals with CACS above 400 had larger ascending, descending and abdominal aortic diameter than the non-calcified reference group (P-value < 0.01). Conclusion Enlarged thoracic and abdominal aortic vascular segments are associated with co-existing coronary artery calcification in the general population.

To compare aortic sac changes after endovascular aneurysm repair (EVAR) assessed by three-dimensional ultrasound (3D-US), two-dimensional ultrasound (2D-US), and traditional computed tomographic angiography (CTA).Using volume assessment with three-dimensional CTA (3D-CTA-volume) as the gold standard, this study investigated aortic sac changes at three and 12 months after EVAR with three different ultrasound methods (2D-US anterior-posterior (AP) diameter, 3D-US AP centerline diameter, and 3D-US partial volume), and traditional CT multiplanar outer-to-outer diameter (CT-MPR OTO diameter). From august 1st, 2011 to January 2014, consecutive EVAR patients (n = 113) were available for analysis in two time intervals; 1) between preoperative and three-month follow-up and 2) between three and 12 month follow-up.The risk of missing true aortic sac growth (false negative finding) at three-month postoperative visit using 3D-US partial volume, 3D-US AP centerline diameter, 2D-US AP diameter, and CT-MPR OTO diameter was 19%, 21%, 22%, and 18%, respectively. Corresponding low sensitivities (0% to 21%) and kappa-values (0.50) in detecting aortic sac changes were found. The risk of missing true growth between three and 12 months were lower (6%, 5%, 6%, and 6%, respectively), and matching sensitivities 33%, 33%, 17%, and 17%, respectively.All tested methods for aortic sac changes were as good as traditional CT-MPR OTO diameter and corresponded poorly with 3D-CTA-volume at three months postoperative visit but substantially better after 12 months where the residual sac change was more profound.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure that is potentially lifesaving in major noncompressible torso hemorrhage. It may also improve outcome in nontraumatic cardiac arrest. However, the procedure can be technically challenging and requires the immediate presence of a qualified operator. Thus, evidence-based training and assessment of operator skills are essential for successful implementation and patient safety. A prerequisite for this is a valid and reliable assessment tool specific for the procedure. The aim of this study was to develop a tool for assessing procedural competence in REBOA based on best-available knowledge from international experts in the field. Methods We invited international REBOA experts from multiple specialties to participate in an anonymous three-round iterative Delphi study to reach consensus on the design and content of an assessment tool. In round 1, participants suggested items to be included. In rounds 2 and 3, the relevance of each suggested item was evaluated by all participants to reach consensus. Interround data processing was done systematically by a steering group. Results Forty panelists representing both clinical and educational expertise in REBOA from 16 countries (in Europe, Asia, and North and South America) and seven different specialties participated in the study. After 3 Delphi rounds and 532 initial item suggestions, the panelists reached consensus on a 10-item assessment tool with behaviorally anchored rating scales. It includes assessment of teamwork, procedure time, selection and preparation of equipment, puncture technique, guidewire handling, sheath handling, placement of REBOA catheter, occlusion, and evaluation. Conclusion We present the REBOA-RATE assessment tool developed systematically by international experts in the field to optimize content validity. Following further studies of its validity and reliability, this tool represents an important next step in evidence-based training programs in REBOA, for example, using mastery learning. Level of evidence Therapeutic, level V.

Autologous fat grafting and implant surgery are used for volume restoration in plastic surgery. With the aim of producing a treatment superior to current solutions, we report a randomized, controlled, data assessor‐blinded clinical trial comparing fat grafts enriched with ex vivo‐expanded autologous adipose‐derived stromal cells (ASCs) to nonenriched fat grafts in breast augmentation. The intervention group received ASC‐enriched fat grafts (≥20 × 106 viable ex vivo‐expanded ASCs per milliliter fat), and the control group received conventional nonenriched fat grafts. Volume retention was measured by magnetic resonance imaging, and clinical photographs were taken simultaneously for outcome evaluation. ASC‐enriched fat grafts had significantly higher retention rates (mean = 80.2%) compared with conventional fat grafts (mean = 45.1%). Clinical photos showed statistically significant superior results in the intervention group, assessed by independent clinical experts. These results improve the prospects for using culture‐expanded ASCs in both reconstructive and cosmetic volume restoration and make the procedure an attractive alternative to conventional fat grafting and implants. This study is registered at www.ClinicalTrials.gov, number H‐16046960., Ex vivo‐expanded adipose tissue‐derived stromal cells ensure enhanced fat graft retention and superior clinical outcomes in breast augmentation. With a high survival of the injected volume, no second augmentation procedure was needed. The results improve the prospects for using expanded ASCs in reconstructive and cosmetic volume restoration and make the procedure an attractive alternative to conventional fat grafting and implants.

To evaluate the effects of center experience and a variety of patient- and procedure-related factors on patient radiation exposure during prostatic artery embolization (PAE) in three Scandinavian centers with different PAE protocols and levels of experience. Understanding factors that influence radiation exposure is crucial in effective patient selection and procedural planning. Data were collected retrospectively for 352 consecutive PAE procedures from January 2015 to June 2020 at the three centers. Dose area product (DAP (Gy·cm2)) was selected as the primary outcome measure of radiation exposure. Multiple patient- and procedure-related explanatory variables were collected and correlated with the outcome variable. A multiple linear regression model was built to determine significant predictors of increased or decreased radiation exposure as reflected by DAP. There was considerable variation in DAP between the centers. Intended unilateral PAE (p = 0.03) and each 10 additional patients treated (p = 0.02) were significant predictors of decreased DAP. Conversely, increased patient body mass index (BMI, p

Objective Three-dimensional ultrasound (3D-US) has already demonstrated improved reproducibility with a high degree of agreement (intermodality variability), reproducibility (interoperator variability), and repeatability (intraoperator variability) compared with conventional two-dimensional ultrasound (2D-US) when estimating the maximum diameter of native abdominal aortic aneurysms (AAAs). The aim of the present study was, in a clinical, multicenter setting, to evaluate the accuracy of 3D-US with aneurysm model quantification software (3D-US abdominal aortic aneurysm [AAA] model) for endovascular aortic aneurysm repair (EVAR) sac diameter assessment vs that of computed tomography angiography (CTA) and 2D-US. Methods A total of 182 patients who had undergone EVAR from April 2016 to December 2017 and were compliant with a standardized EVAR surveillance program were enrolled from five different vascular centers (Rigshospitalet, Copenhagen, Denmark; Catharina Ziekenhuis, Eindhoven, Netherlands; L'hospital de la Timone, Paris, France; Cleveland Clinic, Cleveland, Ohio; and The Christ Hospital, Cincinnati, Ohio) in four countries. All image acquisitions were performed at the local sites (ie, 2D-US, 3D-US, CTA). Only the 2D-US and CTA readings were performed both locally and centrally. All images were read centrally by the US and CTA core laboratory. Anonymized image data were read in a randomized and blinded manner. Results The sample used to estimate the accuracy of the 3D-US AAA model and 2D-US included 164 patients and 177 patients, respectively. The Bland-Altman analysis revealed that the mean difference between CTA and 3D-US was −2.43 mm (95% confidence interval [CI], −5.20 to 0.14; P = .07) with a lower and upper limit of agreement of −8.9 mm (95% CI, −9.3 to −8.4) and 2.7 mm (95% CI, 2.3-3.2), respectively. For 2D-US and CTA, the mean difference was −3.62 mm (95% CI, −6.14 to −1.10; P = .002), with a lower and upper limit of agreement of −10.3 mm (95% CI, −10.8 to −9.8) and 2.5 mm (95% CI, 2-2.9), respectively. Conclusions The 3D-US AAA model showed no significant difference compared with CTA for measuring the anteroposterior diameter, indicating less bias for 3D-US compared with 2D-US. Thus, 3D-US with AAA model software is a viable modality for anteroposterior diameter assessment for surveillance after EVAR.

IntroductionPostembolisation syndrome (PES) is the most common side effect of vascular embolisation of solid organs. Although prophylactic corticosteroids are known to reduce the incidence and severity of PES, no trials investigating their efficacy have been conducted in men undergoing prostatic artery embolisation (PAE). We postulate that steroids can have a similar effect in reducing PES after PAE. This paper describes the rationale and detailed protocol for a randomised controlled trial evaluating the efficacy of dexamethasone (DEXA) in reducing PES after PAE.Methods and analysisIn this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 60 individuals undergoing PAE for benign prostatic hyperplasia. Participants will be randomised to receive IV DEXA (24 mg) or placebo (saline). The primary outcomes will be postprocedural fever, pain and quality of life. The secondary outcomes will include postprocedural nausea, postprocedural medicine usage, laboratory parameters (C reactive protein, prostate-specific antigen) and early PAE results.Ethics and disseminationEthics approval was obtained from the Danish Committee on Health Research Ethics in the Capital Region (H-20025910). The results from this trial will be disseminated through publication in peer-reviewed journals and national and international presentations.Trial registration numberClinicaltrials.gov identifier: NCT04588857; EudraCT number: 2020-000915-53.

Background In recent years, adipose-derived stromal cells (ASCs) have been heavily studied for soft tissue regeneration, augmentation, and dermal wound healing. Methods In this review, we investigated the trends in injectable scaffolds for ASC delivery in the dermis, and injectable or implantable scaffolds for ASC delivery in the subcutis. A total of 547 articles were screened across three databases; of these, 22 studies were found to be eligible and were included. The scaffolds were subdivided and analyzed based on their tissue placement (dermis or subcutis), delivery method (injected or implanted), and by the origin of the materials (natural, synthetic, and combinatory). Results ASCs embedded in scaffolds generally showed improved viability. Neovascularization in the transplanted tissue was greater when undifferentiated ASCs were embedded in a combinatory scaffold or if differentiated ASCs were embedded in a natural scaffold. ASCs embedded in natural materials underwent more adipogenic differentiation than ASCs embedded in synthetic scaffolds, indicating an etiologically unknown difference that has yet to be described. Increased mechanical strength of the scaffold material correlated with improved outcome measurements in the investigated studies. Wound healing studies reported reduced healing time in all except one article due to contraction of the control wounds. Conclusions In future clinical trials, we recommend embedding ASCs in injectable and implantable scaffolds for enhanced protection, retained viability, and improved therapeutic effects. Trial registration This review was registered with PROSPERO: ID=CRD42020171534. Graphical abstract The use of scaffolds as a vehicle for ASC delivery generally improved cell viability, angiogenesis, and wound healing in vivo compared to utilizing ASCs alone. ASCs embedded in natural materials induced more adipogenesis than ASCs embedded in synthetic materials. Adipogenic-induced ASCs further increased this effect. The included studies indicate that the seeded scaffold material influences the differentiation of ASCs in vivo. All studies investigating the mechanical strength of ASC scaffolds reported improved outcome measurements with improved mechanical strength. The results suggest that scaffolds, in general, are favorable for ASC delivery. We recommend initiating clinical studies using scaffolds based on mechanical properties and tunability to improve ASC viability. For fat regeneration, natural scaffolds are recommended.

Purpose Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a salvage technique changing the paradigm in the management of noncompressible torso hemorrhage. However, training for the REBOA procedure is rarely performed. The endovascular training for REBOA (ET-REBOA) course was conducted to develop the endovascular skills of participants. Methods Sixteen residents and 12 specialists participated in this educational course. All participants were provided with precourse learning materials. The ET-REBOA course consisted of 2 sections; an ultrasound-guided sheath insertion on the puncture model, and a balloon manipulation on the vascular circuit model. A 13-item procedure checklist and the time required to perform the procedure were examined. Pre/post self-reported confidence score and course satisfaction questionnaire were obtained. Results Twenty-eight participants performed the 56 REBOA procedures. On the first attempt, the median total time for REBOA from ultrasound-guided vascular access to balloon inflation was 1,139 ± 250 seconds in the resident group and 828 ± 280 seconds in the specialist group. The median shortened time for completion was 273 seconds and 290 seconds respectively. A significant decrease in procedure task time was observed between first and second attempts in the resident group (P = 0.016), specialist group (P = 0.004), and in total among all participants (P < 0.001). Conclusion The ET-REBOA course significantly decreased the time taken to perform the REBOA procedure with high satisfaction of the participants. The course could be an effective curriculum for the development of endovascular skills for performing REBOA.

Keraunoparalysis is a transient paralysis of the extremities, which results from close contact with lightning. In this case report, a 58-year-old man came in close contact with a bolt of lightning. His left foot was pulseless, pale, cold and with absence of capillary refill. His symptoms were initially interpreted as arterial occlusion, and therefore bypass surgery and even amputation were considered. However, his symptoms resolved within hours. Therefore, clinicians must consider keranoparalysis as a differential diagnosis in patients struck by lightning.

Patient-specific rehearsal (PsR) is a new concept whereby a procedure can be rehearsed virtually using the exact patient’s anatomical data prior to performing the real procedure. The aim of this study was to ascertain if endovascular virtual-reality PsR simulation enhanced performance in real life. This was done by performing a systematic review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. A literature search was conducted in PubMed, Embase, The Cochrane Library and Web of Science concerning PsR in endovascular procedures. All publications were handled using Covidence. Reference lists were also screened. Data extracted from the studies were realism rating, procedure time, fluoroscopy time, contrast volume, number of angiograms and reduction of errors. Kirkpatrick’s four-level model for measuring the efficiency of training was used for guidance of the relevance of studies. The search yielded 1155 results after the exclusion of duplicates, and 11 studies were included. Four studies had a control group, including one randomized trial; the remaining seven were feasibility studies. The realism was rated high, and overall, the studies showed improvements in procedure time, fluoroscopy time and contrast volume after PsR. One study assessed and confirmed the reduction in errors after PsR. Only two studies included more than 15 patients in their cohort. Kirkpatrick’s model was applied to all studies, with one study reaching level 4. All studies found the concept of PsR to be feasible and realistic. The studies with a control group showed a reduction of overall procedure time, radiation exposure and potential errors in endovascular procedures following PsR.

Dual-energy computed tomography (DECT) can estimate tissue vascularity and perfusion via iodine quantification. The aim of this systematic review was to outline current and emerging clinical applications of iodine quantification within the gastrointestinal tract using DECT. The search was conducted with three databases: EMBASE, Pubmed and The Cochrane Library. This identified 449 studies after duplicate removal. From a total of 570 selected studies, 30 studies were enrolled for the systematic review. The studies were categorized into four main topics: gastric tumors (12 studies), colorectal tumors (8 studies), Crohn’s disease (4 studies) and miscellaneous applications (6 studies). Findings included a significant difference in iodine concentration (IC) measurements in perigastric fat between T1–3 vs. T4 stage gastric cancer, poorly and well differentiated gastric and colorectal cancer, responders vs. non-responders following chemo- or chemoradiotherapy treatment among cancer patients, and a positive correlation between IC and Crohn’s disease activity. In conclusion, iodine quantification with DECT may be used preoperatively in cancer imaging as well as for monitoring treatment response. Future studies are warranted to evaluate the capabilities and limitations of DECT in splanchnic flow.

Postembolization syndrome (PES) is the most common side effect of vascular embolization of solid organs. The aim of this review was to determine the incidence of PES and its individual components after prostatic artery embolization (PAE). A systematic review with a pre-specified search strategy for PubMed, Embase, Web of Science and Cochrane Library was performed according to PRISMA guidelines. Studies in English regarding PAE in humans with 10 or more participants were eligible for inclusion. No restrictions on participant demographics or PAE technique were imposed. The search returned 378 references, of which 32 studies with a total of 2116 patients met the inclusion criteria. The results for overall PES frequency and individual PES components were presented as median (interquartile range, (IQR)). Overall median PES frequency was 25.5% (12.5–45.8). The two most frequent individual PES components were dysuria/urethral burning and local pain, with a median frequency of 21.7% (13.8–33.3) and 20% (5.4–29.4), respectively. Most outcome measures were characterized by a marked lack of uniformity and inconsistency in reporting across studies. Development of a uniform reporting system would help the clinicians recognize and treat PES accordingly.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving but high-risk emergency procedure in patients with haemorrhagic shock. Lack of physicians with competence in the procedure is a barrier to implementation of REBOA. It is currently unclear how training and assessment of competence should be done. Objectives To report and evaluate research in training and assessment of competence in REBOA and femoral arterial access with the aim to investigate the effect of simulation-based training in the procedure and to provide suggestions for the future design of training programs and assessment tools. Methods Following PRISMA guidelines, PubMed, Embase, and Cochrane Library databases were searched for studies on training or assessment of competence in REBOA and femoral arterial access. Bias assessment was done using the Medical Education Research Study Quality Instrument. Evidence level was assessed using GRADE. Results Sixteen studies were included, six of them published as abstracts. Full-text studies included 189 trainees ranging in experience level from military medics to surgical specialists. Outcome measures were heterogenous; the most used were rater checklists, knowledge testing, and procedure time. All studies confirmed an effect of training of REBOA on procedural competence in a simulation setting but had a high degree of bias. No study developed or used an assessment tool supported by validity evidence and no study investigated mid and long-term outcomes. Conclusion Simulation-based training of REBOA improves skills, however, the evidence level is very low and data cannot answer important questions on effect size, skill transfer and retention, and optimal course design. To advance research and training programmes, an assessment tool supported by validity evidence with broad applicability is needed.

Prostate artery embolisation (PAE) is a new minimally invasive treatment for lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). The purpose of this study was to review the efficacy and safety of PAE in the treatment of BPH with LUTS. A systematic review performed according to the PRISMA guidelines with a pre-specified search strategy for PubMed, Web of Science, Cochrane Library and Embase databases protocol (PROSPERO ID: CRD42017059196). Trials studying the efficacy of prostate artery embolisation to treat LUTS with more than ten participants and follow-up longer than 6 months were included by two independent authors. Outcomes investigated were International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF-5), prostate volume (PV), prostate-specific antigen (PSA), peak void flow (Qmax), post-void residual (PVR) and complications. To summarise mean change from baseline, a meta-analysis was done using the random-effects model. The search returned 210 references, of which 13 studies met the inclusion criteria, representing 1,254 patients. Patients in the included studies with data available for meta-analysis had moderate to severe LUTS and a mean IPSS of 23.5. Statistically significant (p value < 0.05) improvements of all investigated outcomes were seen at 12-month follow-up. Major complications were reported in 0.3% of the cases. Our findings suggest that PAE can reduce moderate to severe LUTS in men with BPH with a low risk of complications. • Prostate artery embolisation (PAE) improved International Prostate Symptom Score (IPSS) by 67%. • Major complications after PAE are very rare. • Use of cone-beam CT may reduce risk of non-target embolisation.

To compare the risk of gluteal claudication after endovascular aneurysm repair (EVAR) of aortoiliac aneurysms by interventional exclusion of the internal iliac artery (IIA) with plugs or coils versus a branch iliac device to maintain pelvic blood supply and to identify risk factors for postoperative gluteal claudication.A retrospective analysis of a prospectively collected data set included patients with aortoiliac aneurysms treated with EVAR from January 2007 to December 2013 at a tertiary referral vascular unit. Descriptive and procedural data were obtained from a database of prospectively enrolled patients. Medical records of 112 consecutive patients treated with EVAR were scrutinized for graft-related adverse events and pelvic ischemia. The occurrence of gluteal claudication was determined from medical records.Iliac occlusion was performed in 115 limbs, and a branch iliac device was placed in 25 limbs. Gluteal claudication developed in 38% of limbs treated with IIA exclusion but in none of the limbs treated with branch iliac devices (P.001). Procedure time, fluoroscopy time, and use of iodine contrast material did not differ between the two groups. The incidence of gluteal claudication was higher when coils rather than plugs were used for embolization of the IIA before EVAR (P = .002).The findings suggest that the use of a branch iliac device significantly reduces the risk of gluteal claudication after EVAR of aortoiliac aneurysm.

AimsAccurate assessment of aortic dimensions can be achieved using contrast-enhanced computed tomography. The aim of this study was to define normal values and determinants of aortic dimensions throughout multiple key anatomical landmarks of the aorta in healthy individuals from the Copenhagen General Population Study.Methods and resultsThe study group consisted of 902 healthy subjects selected from 3000 adults undergoing cardiovascular thoracic and abdominal computed tomography-angiography (CTA), where systematic measurements of aortic dimensions were performed retrospectively. Individuals included were without any of the following predefined cardiovascular risk factors: (i) self-reported angina pectoris; (ii) hypertension; (iii) hypercholesterolaemia; (iv) taking cardiovascular prescribed medication including diuretics, statins, or aspirin; (v) overweight (defined as body mass index ≥30 kg/m2); (vi) diabetes mellitus (self-reported or blood glucose >8 mmol/L); and (vii) chronic obstructive pulmonary disease. Maximal aortic diameters were measured at seven aortic regions: sinuses of Valsalva, sinotubular junction, ascending aorta, mid-descending aorta, abdominal aorta at the diaphragm, abdominal aorta at the coeliac trunk, and infrarenal abdominal aorta. Median age was 52 years, and 396 (40%) were men. Men had significantly larger aortic diameters at all levels compared with women (P ConclusionNormal values of maximal aortic dimensions at key aortic anatomical locations by contrast-enhanced CTA have been defined. Age, sex, and body surface area were significantly associated with these measures at all levels of aorta. Aortic dimensions follow an almost identical pattern throughout the vessel regardless of sex.

The purpose was to evaluate endovascular aortic repair (EVAR) patients with known gluteal claudication using near infrared spectroscopy (NIRS), and secondly to assess the hemodynamic consequences of occluding one internal iliac artery (IIA) during EVAR. EVAR interventions with occlusion of one IIA were examined. Gluteal claudicants were recruited from the outpatient clinic at their annual EVAR control (Group A; n=7) and a second cohort was collected consecutively and prospectively before and after the intervention (Group B; n=10). A treadmill test (12% incline, 2.4 km/h) with NIRS (INVOS-5100) sensors applied bilaterally on the gluteal regions was performed. NIRS was used to asses muscle oxygenation. NIRS data was divided into baseline, exercise and recovery values. Recovery times and absolute NIRS values (oxygenation) from the two gluteal sides were compared. Mean recovery times (group A) of the occluded and patent sides were 512 sec [73-1207] and 137 sec [0-643] (p=0.046) respectively. Using 240 seconds (suggested by literature) as cut-off the sensitivity and specificity were both 71% for finding the occluded IIA. Group B revealed similar oxygenation level of the two gluteal regions pre EVAR. Post EVAR an overall absolute reduction of the oxygenation were noted and a significant difference in the recovery values of the two gluteal sides (p

Objectives The impact of intraluminal thrombus (ILT) on abdominal aortic aneurysm (AAA) progression can be investigated non-invasively by three dimensional contrast enhanced ultrasound (3D-CEUS). The aim was to validate 3D-CEUS ILT volume and thickness measurements against computed tomography angiography (CTA), and to determine inter- and intra-operator reproducibility. Methods The design was for a planned comparison of 3D-CEUS and CTA and of repeated 3D-CEUS measurements in a blinded set up. Consecutive patients with asymptomatic AAA (n = 137, maximum diameter 30–55 mm) from a single centre were consecutively assessed by CTA and 3D-CEUS in a blinded setup. After exclusion of failed CTA (n = 2) and inconclusive 3D-CEUS (n = 8), 127 3D-CEUS/CTA pairs were analysed by Bland–Altman plots. 3D-CEUS inter- and intra-operator reproducibility were determined in a subgroup (n = 30) measured twice by two blinded investigators. Results In 24 of 127 (19%) patients, no ILT was found on 3D-CEUS. Intraluminal thrombus absence was confirmed by 3D-CTA analysis in all but two cases. Mean ILT volume difference between 3D-CEUS and CTA was 2.2 mL (5% of mean volume) and range of variability (ROV) amounted to ± 10.2 mL. Mean ILT thickness difference was 0.6 mm with a ROV of ± 4.6 mm 3D-CEUS inter-operator variations of ILT volume and thickness measurements were low (ROV ± 8.8 mL and ±2.9 mm, respectively). The corresponding intra-operator ROVs were ±7.5 mL and ±3.3 mm, respectively. Conclusions 3D-CEUS demonstrated good reproducibility and a good agreement with CTA when estimating ILT volume and maximum thickness in AAA patients. It is a promising research tool to investigate potential interactions between ILT, AAA growth, and rupture.

Objectives Volume estimation is more sensitive than diameter measurement for detection of aneurysm growth after endovascular aneurysm repair (EVAR), but this has only been confirmed on three-dimensional, reconstructed computer tomography (3-D CT). The potential of 3-D ultrasound (3-D US) for volume estimation in EVAR surveillance is unknown. Design Prospective validation study comparing 3-D US with 3-D CT, using 3-D CT as the gold standard. Materials and methods From August 2011 to March 2012, 93 consecutive EVAR patients were enrolled and examined with both 3-D US and CT angiography (CTA). Image data were analysed in a mutual blinded setup using a 3-D interactive segmentation technique. Results The technical success rate of 3D-US was 98% (91/93). In 91 EVAR patients (F/M; 10/81) eligible for further analysis, the mean maximum volume (SD) was 126 (58) ml using 3-D US and 128 (58) ml using 3-D CT. The mean difference was 1 ml (0.4%) and the limits of agreement were −14 to 16 ml (−11; 12%). Conclusion Volume estimation of the aortic sac after EVAR using 3-D US is a feasible and accurate method using 3-D CT as the gold standard.

Vascular access and closure remain a challenge in transcatheter aortic valve replacement (TAVR). This single-center study aimed to report the incidence, predictive factors, and clinical outcomes of access-related vascular injury and subsequent vascular intervention. During a 30-month period, 365 patients underwent TAVR and 333 patients (94%) were treated by true percutaneous transfemoral approach. Of this latter group, 83 patients (25%) had an access-related vascular injury that was managed by the use of a covered self-expanding stent (n = 49), balloon angioplasty (n = 33), or by surgical intervention (n = 1). In 16 patients (5%), the vascular injury was classified as a major vascular complication. Absence of a preprocedural computed tomography angiography (CTA) of the iliofemoral arteries (OR 2.04, p = 0.007) and female gender (OR 2.18, p = 0.004) were independent predictors of the need for access-related vascular intervention. In addition, a high sheath/common femoral artery ratio as measured on preoperative CTA was associated with a higher rate of post-TAVR vascular intervention. The radiation dose, iodine contrast volume, transfusion need, length of hospitalization, and 30-day mortality were not significantly different between patients with versus without access-related vascular intervention. In conclusion, access-related vascular intervention in patients who underwent transfemoral-TAVR is not uncommon. Female gender and a high sheath/common femoral artery ratio are risk factors for access-related vascular injury, whereas preprocedural planning with CTA of the access vessels may reduce the risk of vascular injury. Importantly, most access-related vascular injuries may be treated by percutaneous techniques with similar clinical outcomes to patients without vascular injuries.

Objective/Background Surveillance after endovascular aortic aneurysm repair (EVAR) is mandatory and computed tomography angiography (CTA) is considered the standard imaging modality, although patients are exposed to ionizing radiation and nephrotoxic contrast medium. The primary aim of this study was to determine the diagnostic efficacy of duplex ultrasound (DUS) and contrast enhanced ultrasound (CEUS) using CTA as the gold standard. The secondary aim was to determine the clinical consequences of endoleaks missed by DUS and CEUS, or CTA. Methods All patients with EVAR for an aorto-iliac aneurysm between 1 August 2011 and 31 October 2014 were prospectively and consecutively enrolled. CEUS was added to the existing surveillance protocol, which included DUS, plain abdominal X-ray, and CTA at 3 and 12 months after stent implantation. Results In 278 patients, endoleaks were detected in 68, 69, and 46 cases by CTA, CEUS, and DUS, respectively. The sensitivity and specificity of DUS and CEUS were 46% and 93%, and 85% and 95%, respectively. CEUS and CTA were diagnostically equivalent, as opposed to DUS and CTA (p = .002). Endoleaks detected by CTA led to re-intervention in 11 (4%) patients. These endoleaks were also detected by CEUS; however, three out of 11 patients were missed by DUS and underwent re-intervention: limb extension, re-cuff, and attempt to coil lumbar leaks. Endoleaks missed by CEUS or CTA were type II endoleaks without sac expansion. Conclusion In surveillance programs after EVAR a diagnostic CEUS examination may replace CTA.

ObjectivesDiscrepancy between maximum diameters obtained with two-dimensional ultrasound and computed tomography (CT) after endovascular aneurysm repair (EVAR) is well known. The maximal diameter is ideally measured perpendicular to the centerline, a methodology so far only feasible with three-dimensional (3D) CT and magnetic resonance angiography (MRA). We aimed to investigate the agreement between 3D ultrasound and 3D CT and to determine reproducibility measures.MethodsProspective study comparing 3D ultrasound with 3D CT in 124 consecutive patients seen 3 or 12 month after EVAR.ResultsReplacing 2D with 3D ultrasound, the mean difference was improved from 6.0 mm to −1.3 mm (p

Background: Aspirin is a widely used drug for prevention of thrombotic events in cardiovascular patients, but approximately 25% of patients experience insufficient platelet inhibition as a result of aspirin and remain at risk of cardiovascular events. This study aimed to investigate the value of a circulatingmicroRNA and platelet size as biomarkers of the individual response to aspirin therapy. Methods: Blood samples were collected from 50 healthy blood donors without antithrombotic medication and 50 patients with intermittent claudication on daily aspirin therapy. Based on results from the arachidonic acid stimulated aggregation test on Multiplate analyzer (ASPItest), patients were defined as aspirin resistant (n 1⁄4 10) or aspirin responders (n 1⁄4 40). Plasma levels of the specific microRNA were evaluated by RT-qPCR analysis and platelet distribution width (PDW) was used to assess platelet size variability. Receiver operating characteristic curves for the plasma level of microRNA and PDW were used to set cut-off values for discrimination between aspirin responding and aspirin resistant patients. Results: When defining aspirin resistance as an ASPItest 30 U, the optimal cut-off values for discrimination of aspirin responders and aspirin resistant patients were found to be PDW > 11.8 fL and a relative expression level of the microRNA > 4.5. Using these cutoff values we could define a PDW/microRNA-score with a specificity of 97.5% and a sensitivity of 80.0% in relation to detect aspirin resistance. The corresponding positive and negative predictive values were found to be 88.9% and 95.1%, respectively. Conclusion: Aspirin resistance can potentially be identified by microRNA levels in plasma combined with PDW. Contrast-enhanced Ultrasound Instead of CTA in EVARsurveillance Kim Kargaard Bredahl , Mikkel Taudorf , Lars Lonn , Katja Vogt , Henrik Sillesen , Jonas Eiberg a,c a Department of Vascular Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark b Department of Radiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark c University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark Abstract Introduction: In order to minimize the risk of endoleak, fracture, migration and eventually rupture after endovascular aneurysm repair, lifelong surveillance is mandatory. Computed Tomographic Angiography (CTA) is considered the standard image modality,Introduction: In order to minimize the risk of endoleak, fracture, migration and eventually rupture after endovascular aneurysm repair, lifelong surveillance is mandatory. Computed Tomographic Angiography (CTA) is considered the standard image modality, although patients are exposed to ionizing radiation and nephrotoxic contrast medium. Duplex Ultrasound (DUS) and Contrast-enhanced ultrasound (CEUS) have been suggested as alternative image modalities, and the aim of this study was to determine the diagnostic efficacy of DUS and CEUS, using CTA as the gold standard. Method: Patients who underwent EVAR for aorto-iliac aneurysm disease between August 1st 2011 and October 31st 2014 were prospectively and consecutively enrolled in a cross-sectional study. We added CEUS to our existing EVAR-surveillance protocol including DUS, plain abdominal X-ray and CTA performed at 3and 12 months after stent implantation. Results: Endoleaks were depicted by CTA in 66 (24%) cases out of 278 included patients. The sensitivity of CEUS was significantly better than the sensitivity of DUS, 88% (95%-CI: 80e96) and 47% (95%-CI: 35e59) (p < 0.001), respectively. Endoleak detection by CTA led to re-intervention in 11 (4%) cases, of which all were depicted by CEUS, but 3 were missed by DUS. Conclusion: In general, CTA can be replaced by CEUS in EVARsurveillance programs, although DUS may suffice in uncomplicated cases if preceded by a normal CEUS or CTA. Aortocaval Fistula (ACF) in Patients Operated for Ruptured Acute Aorta Aneurysm (rAAA): A Surgical Challenge Karina Warning, Kim Houlind, Hans Ravn Department of Vascular Surgery, Lillebaelt Hospital, Skovvangen 2-8, 6000

Objective To assess the incidence and outcome of graft limb occlusions after endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) in a high volume single centre. To quantify iliac artery tortuosity in patients with AAA and correlate this with limb occlusion. Design Data were collected consecutively and prospectively, and analyzed retrospectively. Materials Patients treated with Zenith bifurcated stent grafts from January 2000 to December 2010 at a tertiary referral vascular unit were analyzed. Routine regular office follow-up with computed tomography angiography (CTA) and, subsequently, duplex ultrasound imaging was performed. Patients with limb occlusions were identified. For each index patient, two controls were obtained, one immediately preceding and one following the index patient in the consecutive cohort of EVAR patients. Methods Demographics and CTA data on limb graft occlusions were recorded and compared with a defined control group. Three different indices were used to describe the tortuosity of the iliac vessels based on preoperative CTA: pelvic artery index of tortuosity (PAI), common iliac artery index of tortuosity (CAI), and a visual description of vessel tortuosity – the double iliac sign (DIS). Demographic data and indices were correlated for later occurring limb occlusion. Results 504 patients underwent EVAR and 18 patients experienced graft limb occlusion during a median follow-up of 28 months (range 0–133). Primary graft patency was 97% at 1 year and 96% at 3 years. Logistic regression showed that iliac artery tortuosity (DIS) ( p = .001) and body mass index ( p = .007) had a significant impact on graft patency. Conclusion A tortuous vessel on the preoperative CTA is associated with an increased risk of limb occlusion after EVAR. Adjunctive stenting of iliac segments deemed at risk is suggested, which is achieved without compromise of the aneurysm repair.