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Background: The aim of this study was to examine the safety and efficacy of the SoundBite™ Crossing System for the recanalization of infrainguinal chronic total occlusion (CTO) lesions. CTOs are frequent among patients with severe claudication or critical limb ischemia. Failure to recanalize CTOs remains common and is associated with poor prognosis. The SoundBite™ Crossing System (SoundBite Medical Solutions Inc., Montreal, QC, Canada) is a newly developed device that uses a 0.018-inch wire (SoundBite™ Active Wire) to deliver acoustic shock waves to the distal tip of a steerable guidewire to facilitate directed penetration of the proximal cap and crossing of the occlusion., Methods: Symptomatic patients with de novo infrainguinal CTOs from 3 centers were enrolled in a prospective, single-arm feasibility study. The primary endpoint was 30-day device success defined as composite of technical success, defined as penetration and progression within the CTO with the SoundBite™ Active Wire followed by complete recanalization, and freedom from device-related major adverse events including death, urgent amputation, clinically-driven target vessel revascularization, perforation, type ≥C dissection, or distal embolization requiring intervention., Results: Thirty-seven patients including 41 CTO lesions were enrolled in this study. CTO length ranged from 10 mm to 270 mm (mean 97.9±77.4 mm), and moderate-to-severe calcification was present in 24 (58.5%) of the treated lesions. CTOs were successfully crossed in 34 (91.9%) patients. No device-related adverse events occurred, resulting in a 30-day device success rate of 91.9%. Compared with baseline, 30-day ankle brachial index (0.66±0.24 versus 0.89±0.20; P<0.001) and Rutherford class (3 [2, 4] versus 0 [0, 1], P<0.001) significantly improved., Conclusions: The SoundBite™ Active Wire Crossing System feasibility study demonstrates a favorable safety and efficacy profile for the SoundBite™ Active Wire in infrainguinal CTOs.

Context: Adrenal vein sampling (AVS) is required to identify a lateralized or bilateral aldosterone source in primary aldosteronism., Objectives: Our objectives were to compare basal and post-ACTH selectivity ratio (SR) and lateralization ratio (LR) and to determine the prevalence of basal contralateral suppression and its effect on surgical outcome., Patients and Intervention: Bilateral simultaneous adrenal vein samples were obtained before and after a 250-μg bolus of ACTH. Analyses were conducted on 171 technically successful AVS and on the subgroup of 66 operated patients with evaluable outcome data., Results: ACTH increased selectivity on both sides from 66.7% in basal samples (SR ≥ 2) to 91.8% poststimulation (SR ≥ 5). A discordance of lateralization between basal (LR ≥ 2) and post-ACTH (LR ≥ 4) values was observed in 28% of cases, which were mostly lateralized cases basally that became bilateral post-ACTH. Basal CL suppression is present in only 30% using absolute ratio of aldosterone between the opposite (nondominant) adrenal vein and the peripheral vein AOPP/AP below 1.5 vs in 77% using aldosterone/cortisol ratio (A/C)OPP/(A/C)P below 1.5. The absence of CL suppression was associated with a lower rate of response to adrenalectomy in terms of clinical and biochemical parameters with difference in clinical cure (55% vs 13% P = .0003) and overall cure (35% vs 9%, P = .0084) using AOPP/AP, but not when using (A/C)OPP/(A/C)P., Conclusions: Stimulation with ACTH is useful to improve selectivity of AVS but can frequently modify interpretation of lateralization. Basal ratios are as important as post-ACTH ratios to set an indication of adrenalectomy. AOPP/AP is superior to (A/C)OPP/(A/C)P to assess contralateral suppression. Infrequent CL suppression reveals frequent occurrence of contralateral hyperplasia in lateralized cases and helps predict postoperative outcomes.

Objectives: Abdominal aortic aneurysm (AAA) rupture has a high mortality rate. Although the diagnosis of a ruptured AAA is usually straightforward, detection of impending rupture signs can be more challenging. Early diagnosis of impending AAA rupture can be lifesaving. Furthermore, differentiating between impending and complete rupture has important repercussions on patient management and prognosis. The purpose of this article is to classify and illustrate the entire spectrum of AAA rupture signs and to review current treatment options for ruptured AAAs., Methods: Using medical illustrations supplemented with computed tomography (CT), this essay showcases the various signs of impending rupture and ruptured AAAs. Endovascular aneurysm repair (EVAR) and open surgical repair are also discussed as treatment options for ruptured AAAs., Results: CT imaging findings of ruptured AAAs can be categorised according to location: intramural, luminal, and extraluminal. Intramural signs generally indicate impending AAA rupture, whereas luminal and extraluminal signs imply complete rupture. EVAR has emerged as an alternative and possibly less morbid method to treat ruptured AAAs., Conclusions: AAA rupture occurs at the end of a continuum of growth and wall weakening. This review describes the CT imaging findings that may help identify impending rupture prior to complete rupture., Teaching Points: • AAA rupture occurs at the end of a continuum of growth and wall weakening. • Intramural imaging findings indicate impending AAA rupture. • Luminal and extraluminal imaging findings imply complete AAA rupture. • Some imaging findings are not specific to AAA ruptures and can be seen in other pathologies. • EVAR has emerged as an alternative and possibly less morbid method of treating ruptured AAAs.

Purpose. Contrast-induced nephropathy (CIN) can contribute to acute kidney injury (AKI) in patients undergoing endovascular aortic aneurysm surgery. We evaluated the incidence of AKI together with the evolution of early biomarkers of renal injury in patients receiving bicarbonates or NaCl 0.9%. Methods. This study involved endovascular aortic aneurysm surgery patients. Group A (n = 17) received bicarbonates 3 mL/kg/h for 1 h before the procedure and then 1 mL/kg/h until 6 h after surgery, whereas group B (n = 17) received NaCl 0.9% using the same protocol. Biomarkers of renal injury from urine (interleukin-18 (IL-18), neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-β-D-glucosaminidase (NAG), and kidney injury molecule 1 (KIM-1)) and blood (NGAL, cystatin C) were measured at baseline and 3, 24, and 48 h postoperatively. Results. AKI occurred in 1 patient (2.9%), in the bicarbonates group. IL-18, NAG, NGAL, and KIM-1 significantly rose in both groups after the surgery. There was a greater rise in NGAL and IL-18 after 3 h in the bicarbonates versus NaCl 0.9% group: 1115% versus 240% increase (P = 0.03) and 338% increase versus 1.4% decrease (P = 0.01). Conclusions. Despite significant elevation in biomarkers of renal injury, we demonstrated a low rate of AKI following endovascular aortic surgery.

The use of computed tomography (CT) and magnetic resonance (MR) imaging has increased tremendously in the past 2 decades. Hence, pregnant and breast-feeding women, although generally healthier than the population at large, are also more likely to require contrast material-enhanced imaging. When a contrast-enhanced CT or MR imaging study is being considered for a pregnant or lactating patient, the potential risks to the fetus related to exposure to radiation, high magnetic fields, or contrast agents must be considered and weighed carefully against the risks of potential misdiagnosis due to withholding contrast agents and imaging studies. Fetal radiation doses up to 1 mGy are considered acceptable; with larger doses, the risk of carcinogenesis approximately doubles, although it remains low in absolute terms. No damage to a developing human fetus caused by MR imaging exposure has been documented. However, caution is advised, and risks and benefits must always be considered before evaluating a pregnant patient with MR imaging. The use of iodinated contrast agents is generally safe during pregnancy; nevertheless, these agents should be used with caution due to the risk of fetal hypothyroidism and should be administered only when the clinical situation clearly requires doing so. The use of gadolinium-based contrast agents during pregnancy remains controversial due to lack of human clinical data and potential toxicity. Use of all contrast agents is considered safe during lactation. It is hoped that this knowledge will help radiologists develop a consensus with their clinical colleagues regarding case management of pregnant and lactating patients., (RSNA, 2012)

Limited data are available regarding the optimal management of renal artery stenosis (RAS) with a coexisting renal artery aneurysm. We present a case of high-grade RAS treated successfully with a stent-graft deployment resulting in the exclusion of an associated aneurysm. This therapeutic approach induced the sustained normalization of the blood pressure without antihypertensive medication and the correction of biochemical abnormalities secondary to the RAS.

Purpose: To compare functional autonomy, quality of life (QOL), and pain control after endovascular and open repair (OR) of abdominal aortic aneurysms., Materials and Methods: Forty patients with a low surgical risk profile and anatomic compatibility for stent-graft therapy were randomized to receive OR or endovascular aneurysm repair (EVAR). Technical and clinical success as well as mortality were assessed in both groups and compared by Kaplan-Meier analysis. Functional autonomy and QOL were assessed by Karnofsky score and Short Form 36 (SF-36) questionnaire. Pain control was assessed by a numeric rating scale and Brief Pain Inventory questionnaire. QOL outcomes by means of the SF-36 and pain questionnaires were compared with use of mixed-effects models for repeated-measures analysis., Results: All procedures were technically successful in both groups. Three late clinical failures requiring surgical conversion or repeated intervention were observed in the EVAR group and one was observed in the OR group. There was no significant difference between groups in terms of functional autonomy or QOL. No difference in pain level was evident during the early postoperative period, whereas the pain level was lower in the OR group after 1 month. Opioid analgesic drug consumption was significantly greater in the OR group during the postoperative period. Mean hospitalization duration was shorter in the EVAR group than in the OR group (4.5 days +/- 2.4 vs 11.5 days +/- 8.1; P= .001)., Conclusion: EVAR has no advantage over OR in patients at low risk in terms of functional autonomy, QOL, and pain control. However, EVAR was associated with shorter hospitalization durations compared with OR.

Intravascular ultrasound (IVUS) produces images of arteries that show the lumen in addition to the layered structure of the vessel wall. A new automatic 3D IVUS fast-marching segmentation model is presented. The method is based on a combination of region and contour information, namely the gray level probability density functions (PDFs) of the vessel structures and the image gradient. Accurate results were obtained on in-vivo and simulated data with average point to point distances between detected vessel wall boundaries and validation contours below 0.105 mm. Moreover, Hausdorff distances (that represent the worst point to point variations) resulted in values below 0.344 mm, which demonstrate the potential of combining region and contour information in a fast-marching scheme for 3D automatic IVUS image processing.

A bifurcated stent graft device was successfully deployed to exclude an asymptomatic abdominal aortic aneurysm (AAA) with adequate proximal aortic neck morphology. At 6 months, a type II endoleak was successfully embolized through a proximal perigraft channel with metallic coils. The patient was seen with upper gastrointestinal bleeding and a pulsatile abdominal mass 11 months later. Surgical exploration revealed an aortoduodenal fistula in the vicinity of the previous embolization. We discuss the possible causes of this complication and review the literature on the subject. We conclude that aortoduodenal fistula can occur after endovascular AAA repair despite the absence of endoleak or AAA diameter increase on follow-up computed tomographic scan.

Purpose: To identify predictors of clinical outcome after percutaneous revascularization of the renal arteries., Materials and Methods: In 63 patients, the therapeutic response was retrospectively assessed after percutaneous revascularization of the renal arteries indicated for hypertension (41.3%), renal failure (4.8%), or both (53.9%). All patients underwent percutaneous transluminal renal angioplasty, complemented by stent insertion in 30 patients. The authors analyzed the role of clinical and imaging factors, including scintigraphy, Doppler sonography, and angiography for predicting clinical success., Results: In the hypertensive population, there were three cures (5.6%), 26 improvements (48.1%), and 25 failures (46.3%). Among patients with renal insufficiency, 12 were improved (37.5%), 11 were stabilized (34.4%), and nine deteriorated (28.1%). Predictors of favorable outcome for hypertension were shorter duration of hypertension, higher diastolic blood pressure, fibromuscular dysplasia, abnormal Doppler study, higher percentage of angiographic stenosis, and lower grade of aortic atheromatous disease. Predictors of favorable outcome for renal failure were nondiabetic status, abnormal Doppler study, and higher percentage of angiographic stenosis. Abnormal Doppler and scintigraphic examinations predicted successful treatment of hypertension in 60% and 53.8% of cases, respectively, and renal insufficiency in 85% and 60% of cases, respectively., Conclusion: Clinical and angiographic variables were the best predictors of therapeutic success for hypertension. Doppler sonography was useful in patients with renal failure.

Unlabelled: Preliminary studies with 99mTc-apcitide (99mTc-P280), a synthetic peptide that binds to glycoprotein IIb/IIIa receptors expressed on activated platelets, have shown promising results in the detection of acute deep vein thrombosis (ADVT). The purpose of this study was to compare the diagnostic value of early and delayed imaging with 99mTc-apcitide in patients with suspected ADVT, using contrast-enhanced venography as the gold standard., Methods: Thirty-nine patients (17 women, 22 men; mean age 59 y) with signs or symptoms suggestive of ADVT (within 10 d of onset) and scheduled for contrast-enhanced venography were prospectively studied. The patients were injected with approximately 740 MBq (20 mCi) 99mTc-apcitide within 36 h of contrast-enhanced venography. Both anterior and posterior planar images (8-10 min/view) of the lower extremities using a dual-head gamma camera were obtained at 10, 60 and 120 min after the injection of 99mTc-apcitide. The three sets of images initially were interpreted randomly and separately by three experienced observers unaware of the clinical history, the site of ADVT and results of contrast-enhanced venography. All images from the three sets for a given patient were then analyzed together during a second session. Conventional contrast-enhanced venography was performed on 31 patients before 99mTc-apcitide scintigraphy and in the remaining 8 patients after 99mTc-apcitide scintigraphy. 99mTc-apcitide findings were considered positive forADVT when a focus of increased uptake was found to correspond to the location of a deep vein. Disagreements were resolved by consensus., Results: Twenty-two patients had ADVT observed on contrast-enhanced venography, whereas 17 had normal findings. Six cases of ADVT were infrapopliteal. One patient did not complete the third set of images with 99mTc-apcitide. The sensitivity of 99mTc-apcitide in detecting ADVT was 63.6% (14/22), 68.2% (15/22), 76.2% (16/21) and 86.4% (19/22) for images obtained at 10, 60 and 120 min and for the three sets analyzed together, respectively. The specificity was 82.4% (14/17), 76.5% (13/17), 88.2% (15/17) and 88.2% (15/17) for images obtained at 10, 60 and 120 min and for the three sets of images together, respectively., Conclusion: Although the set of 99mTc-apcitide images obtained 120 min after injection showed good overall diagnostic accuracy, the combination of at least two sets of images provided the highest accuracy in detecting ADVT.

Purpose: To compare the diagnostic value of carbon dioxide to that of iodinated contrast material for digital subtraction angiography of the abdominal aorta and lower extremities., Materials and Methods: Thirty-five patients underwent comparative CO2 and iodinated contrast material arteriography of the abdominal aorta and lower extremities. For each contrast study, three independent observers evaluated the degree of opacification and percentage of stenosis of each vessel, the degree of certainty of their observations, and the overall quality of the study. Data of CO2 and iodinated studies were compared using analysis of variance for repeated measures. Interobserver and intertechnique agreements were estimated with Cohen's kappa and intraclass correlation coefficient., Results: Iodine-based vascular opacification was superior to that with CO2 in the central and distal arteries (P = .02). The degree of certainty and overall quality score were higher for iodine than for CO2-based contrast studies (P = .00001). The interobserver agreement for categorizing stenoses was higher for iodine as compared to CO2-based angiography. No significant difference was observed between the mean stenosis values obtained with CO2 and iodine-based angiography in any segment. Intraclass correlation coefficient demonstrated a high degree of convergence of the two techniques for assessing the percentage of stenosis., Conclusion: CO2 can be used as an alternative to iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower extremities for investigating atherosclerotic disease.

Objective: The goal of this study was to assess the value of quantitative and qualitative analysis of the early systolic rise on Doppler waveforms obtained before and after administration of captopril in patients suspected of having renal artery stenosis., Subjects and Methods: Seventy-one hypertensive patients (135 kidneys) were studied with transrenal Doppler sonography. Ninety-six kidneys were studied again after administration of captopril. All patients also underwent renal angiography. All Doppler studies were independently reviewed by two observers. Specific criteria for Doppler waveform patterns that were applied in the detection of renal artery stenosis included acceleration, acceleration time of early systolic rise, differential velocity of systolic rise, and resistive index. These criteria were then correlated with angiography, and receiver operating characteristic curves were generated., Results: On the basis of waveform pattern recognition. Doppler sonograms obtained before administration of captopril had a sensitivity of 81% and a specificity of 98% for the detection of renal artery stenosis greater than or equal to 50%. Sensitivity of Doppler sonography obtained after administration of captopril was 100%, and specificity was 100%. For renal artery stenosis greater than or equal to 70%, sensitivity was 94% and specificity was 89% before administration of captopril. The area under the receiver operating characteristic curve for the acceleration criterion was significantly larger after administration of captopril (p = .009) for the detection of renal artery stenosis greater than or equal to 50%. After captopril administration, an acceleration threshold value of 440 cm/sec2 for early systolic rise was associated with a sensitivity of 100% and a specificity of 94% for the detection of renal artery stenosis greater than or equal to 50%., Conclusion: Doppler sonography of the renal arteries performed before administration of captopril appears to be an excellent screening tool in the detection of severe stenosis (> or = 70%). Administration of captopril improves the detection of renal artery stenosis greater than or equal to 50% with Doppler sonography when observers use both morphologic and quantitative criteria.

Purpose: To compare the efficacy and safety of streptokinase (SK) and urokinase (UK) in the treatment of local thrombolysis., Patients and Methods: Over a 24-month period, 40 patients with 45 lower limb arterial occlusions of less than 45 days duration underwent intraarterial fibrinolysis. Twenty occlusions were treated with recombinant UK and tissue culture-derived UK, and 25 occlusions were treated with SK. The study was retrospective, but the two groups were very homogeneous in terms of vascular surgical history, medical risk factors, and occlusion characteristics., Results: Complete lysis (95% or more) was achieved in 84% of SK infusions and 89% of UK infusions. Endoluminal and surgical interventions as well as clinical outcomes of SK and UK treatment were comparable. However, infusion time was significantly longer for SK treatment: 28.5 hours versus 19.1 hours for UK treatment (P = .035). Complication rates were not statistically significantly different. Average length of stay in the intensive care unit was identical (2.2 days) for both groups, and the difference in hospital stay was not statistically significant (7.7 days for SK vs 8.7 days for UK)., Conclusion: At the concentrations and doses used, the efficacy and safety of SK and UK were comparable, despite longer SK infusion time.

Surgical treatment of an occluded or stenotic portacaval shunt carries a high risk of mortality, but the rate of restenosis after transluminal angioplasty is also high. The authors report high-grade stricture of a portacaval H-graft shunt in a 51-year-old man, who presented with hematemesis and melena. The patient was treated with concomitant balloon angioplasty and placement of a metallic stent through a percutaneous venous approach. The procedure was tolerated well by the patient, and stenosis had not recurred at follow-up 1 year later.

Two types of metallic endoprostheses may be placed via a transhepatic approach: 1) self expandable stents which open by themselves as soon as they are released from the carrier system, 2) balloon expandable stents which need to be dilated by a balloon catheter at the time of deployment. Gianturco and Wallstent endoprostheses belong to the first group and are most often used. The fenestrated wall of metallic endoprostheses preserves the patency of bile ducts joining the stented segment, which is a major advantage for hilar and intra-hepatic stenosis. Their design allows the endoprostheses to be incorporated into the bile duct wall, minimising biliary encrustation and leaving a wider internal lumen as compared to plastic stents. On the other hand, tumor ingrowth in the stented segment is possible and parietal incorporation makes the stent nonretrievable after a few weeks. A favorable indication is therefore extrinsic compression, especially in hilar and intra-hepatic segments. Whatever the indications, metallic stenting has an advantage in the treatment of biliary stenosis, either benign or malignant, owing to less traumatic positioning while their patency rate remains high.