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Severe stenosis and/or thrombosis of the internal jugular vein could be managed through a novel technique herein reported. Recanalization can be achieved passing through the omolateral external jugular vein.

Objective Resting state electroencephalographic (EEG) rhythms are abnormal in multiple sclerosis (MS) patients, but it is unclear if they can reflect different neurophysiologic abnormalities in MS sub-types (phenotypes) such as relapsing–remitting (RR) and secondary progressive (SP). Methods We tested whether cortical sources of resting state EEG rhythms are abnormal in MS patients and differ between MS phenotypes. Resting state eyes-closed EEG activity was recorded in 36 RR, 23 SP, and 41 matched healthy subjects. EEG bands of interest were individually identified based on Transition frequency (TF), Individual alpha frequency (IAF), and Individual beta frequency (IBF). LORETA freeware estimated cortical EEG sources. Results Widespread TF −4 Hz (delta) and IAF (alpha) cortical sources were abnormal in the MS sub-groups compared to the control group. Furthermore, TF −4 Hz sources in central, parietal, and limbic regions were higher in amplitude in the SP compared to the RR sub-group. Conclusion Cortical sources of resting state EEG rhythms are abnormal in MS patients at group level and differ between RR and SP sub-groups. Significance Future studies should test the utility of these EEG markers in the diagnosis and management of MS clinical phenotypes and in the therapy evaluation.

PURPOSE: To report a retrospective evaluation of the 6-F Angio-Seal closure device in antegrade and retrograde common femoral artery (CFA) punctures during endovascular procedures in diabetic patients with critical limb ischemia (CLI). METHODS: From January 2005 to March 2009, 2374 diabetic CLI patients underwent interventional procedures in the lower limbs at a single center under systemic anticoagulation (heparin 70 U/kg). In this population, 2016 patients (1184 men; mean age 69.6+/-9.1 years) had 2372 CFA punctures treated with either manual compression [205 punctures in 161 (8.0%) patients] or Angio-Seal deployment (2167 punctures in 1855 patients) and were eligible for this analysis. In the study cohort, there were 1889 antegrade CFA punctures closed with the device in 1626 (87.6%) patients compared to 278 retrograde punctures sealed in 229 (12.4%) patients. The complications from the antegrade CFA punctures were compared to those from retrograde closure and manual compression. RESULTS: The success rate for achieving hemostasis after antegrade and retrograde Angio-Seal placement was 97.9% and 97.8%, respectively. Major complications following antegrade Angio-Seal deployment, retrograde Angio-Seal deployment, and manual compression occurred in 20/1889 (1.1%), 5/278 (1.8%), and 4/205 (2.0%) cases, respectively. All complications developed within 24 hours of the procedure. No further complications were recorded in the 18-month follow-up (range 1-36). The overall complication rates after antegrade puncture closure, retrograde puncture closure, and manual compression at 30 days was 2.5%, 4.0%, and 4.9%, respectively (p = NS). CONCLUSION: This retrospective study shows that the 6-F Angio-Seal is a valuable and safe vascular closure device for percutaneous transfemoral antegrade access in diabetic patients undergoing interventional procedures for CLI.

PURPOSE To report an alternative technique to the dual-lumen catheter for deployment of the Powerlink stent-graft in patients with angulated sacs and calcified aortic bifurcations. A maneuver is also presented to retrieve the delivery system when it is snagged on the stent. TECHNIQUE After cutdown of the right common femoral artery (CFA), a 9-F introducer sheath is placed percutaneously into the left CFA. A gooseneck catheter is introduced from the right CFA to capture a 0.035-inch hydrophilic guidewire inserted from the left. A 5-F straight catheter is passed over this guidewire from the left to the right CFA. In angulated aneurysm sacs, a 5-F Hunter catheter is introduced from the right femoral access to support a guidewire through the aneurysm to the suprarenal aorta. Then the guidewire is exchanged with a 0.035-inch Amplatz extra stiff wire, and the Hunter catheter is removed. In other cases, a 0.035-inch Amplatz extra stiff guidewire is placed up to the suprarenal aorta. The endograft delivery system is then deployed in the usual manner. A gooseneck snare is also useful in retrieving the delivery system when it is snagged on the stent at the endograft bifurcation. CONCLUSIONS This variant technique facilitates the deployment of the Powerlink stent-graft when faced with angulated aneurysms or acute and calcified aortic bifurcations. A gooseneck catheter is helpful in retrieving the delivery system's "olive" after endograft placement.

PURPOSE To evaluate axillary artery access for the interventional treatment of carotid or splanchnic arteries that have angulated takeoff or complex anatomy when larger catheters (up to 9 F) are needed. TECHNIQUE The axillary artery approach was used to treat the left internal carotid artery (ICA) in 3 patients (2 angulated takeoffs and 1 bovine arch) and a celiac axis aneurysm. An 8-F, 45-cm-long introducer sheath was inserted for the carotid procedures, whereas a 9-F, 90-cm sheath was chosen for the celiac aneurysm. Cerebral protection and stenting were successfully performed in all carotid patients; an 8x40-mm stent-graft was implanted to exclude the celiac artery aneurysm. An 8-F vascular closure device was used in the axillary arteries; hemostasis was immediate, and no hematoma or other complications were recorded in follow-up. CONCLUSIONS This preliminary experience revisits the axillary approach as an alternative access route for interventional procedures. In association with a vascular closure device, this approach should be considered as a useful and safe option for those interventional procedures in which larger sheaths or catheters are required to cope with difficult arterial anatomies.

We present a case of a 73-year-old man in whom a celiac trunk aneurysm close to the hepato-splenic bifurcation was discovered and treated by using celiac-hepatic stent-grafts implantation and splenic artery embolization.

We report a case of post-surgical temporary functional stenosis of the sphincter of Oddi and biliary leak in a patient with a previous Billroth II reconstruction who had undergone cholecystectomy, surgical choledochotomy and sphincterotomy for biliary calculi. The patient was treated by creation of an internal/external biliary drainage using the T-tube access with an unreported technique.

The purpose of this study was to assess the technical performance and immediate procedural outcome of a new balloon catheter in the treatment of calcified lesions in infrapopliteal arterial disease. Sixty-one patients (81 vessels) with infrapopliteal arterial disease were evaluated. Seventy-four of the 81 treated vessels had total occlusions. The ReeKross 18 peripheral transluminal angioplasty catheter (ClearStream, Wexford, Ireland) is an 0.018-inch guidewire system with 4F sheath compatibility and a rigid shaft intended for enhanced pushability. Only technical procedural outcomes were recorded. In 37 of 61 patients (50 infrapopliteal severely stenosed or occluded vessels), an attempt with a standard balloon was made before the ReeKross 18 was used. In 24 patients, the ReeKross 18 was used as the primary catheter in 23 cases involving crural arteries and in 8 cases involving the foot. The ReeKross 18 crossed the lesion in 55 of 59 (93.2%) patients and 72 of 77 (94.5%) vessels, respectively. Postdilatation results for the 51 patients (64 target lesions) in whom ReeKross 18 balloon dilation was achieved showed

Mycotic false aneurysm caused by local arterial injury from attempted intravenous injections in drug addicts remains a challenging clinical problem. The continued increase in drug abuse has resulted in an increased incidence of this problem, particularly in high-volume urban centres. In the drug-abusing population, mycotic arterial pseudoaneurysms most often occur because of missed venous injection and are typically seen in the groin, axilla, and antecubital fossa. Mycotic aneurysms may lead to life-threatening haemorrhage, limb loss, sepsis, and even death. Any soft-tissue swelling in the vicinity of a major artery in an intravenous drug abuser should be suspected of being a false aneurysm until proven otherwise and should prompt immediate referral to a vascular surgeon for investigation and management. We report a case of rupturing mycotic pseudoaneurysm of the left common femoral artery treated by surgical resection followed by vessel reconstruction with autologous material. Unfortunately, at the time of discharge a sudden leakage from the vein graft anastomosis occurred, with subsequent massive bleeding, and required emergent endovascular covered stenting. To the best of our knowledge, this is the first reported case of femoral artery bleeding in a drug abuser treated by stent graft placement.

Recently developed neuroimaging techniques such as diffusion tensor (DT) magnetic resonance (MR) imaging, functional MR imaging (fMRI), and MR spectroscopy can be used to evaluate the microstructural integrity of white-matter fibers and the functional activity of gray matter. They have been widely employed to investigate various diseases of the central nervous system, and they can be useful tools for assessing the integrity and functional connections of the visual pathways and areas that play key roles in glaucoma. In vivo degeneration of the optic nerves can be noninvasively demonstrated by DT MR imaging. DT fiber tractography provides valuable information on the axonal density of postgeniculate fibers (optic radiation), and fMRI studies of patients with primary open-angle glaucoma (POAG) have demonstrated alterations involving the human visual cortex that are consistent with clinically documented losses of visual function. This article reviews some of the more recent data supporting the use of MR imaging techniques as reliable, noninvasive tools for monitoring the progression of human glaucoma.

Endovascular treatment options for visceral artery pseudoaneurysms depend on lesion location and size. Exclusion methods fall into two categories, embolization and stent placement, and these procedures aim to exclude the pseudoaneurysm from the circulation and if possible to maintain distal blood flow. Embolization of the afferent artery can be used in pseudoaneurysms that arise from a donor artery without collateral supply such as a visceral branch, whereas in the case of visceral arteries with well-established collateral supply, the embolization of both proximal and distal branches to the pseudoaneurysm is mandatory in preventing backflow from the collateral circulation. A direct embolization delivering coils or glue into the sac can also be performed if the aneurismal neck is narrow. Stent-graft placement represents another option to exclude the pseudoaneurysm, in the case of wide neck, reduced arterial tortuosity and large-diameter arteries. We present a case of common hepatic artery pseudoaneurysm involving the gastroduodenal artery origin treated by a combination of techniques. An hepatic stent-graft implantation plus retrograde embolization of the gastroduodenal artery through the pancreaticoduodenal anastomosis from the superior mesenteric artery was performed.

Recently developed neuroimaging techniques such as diffusion tensor (DT) magnetic resonance (MR) imaging, functional MR imaging (fMRI), and MR spectroscopy can be used to evaluate the microstructural integrity of white-matter fibers and the functional activity of gray matter. They have been widely employed to investigate various diseases of the central nervous system, and they can be useful tools for assessing the integrity and functional connections of the visual pathways and areas that play key roles in glaucoma. In vivo degeneration of the optic nerves can be noninvasively demonstrated by DT MR imaging. DT fiber tractography provides valuable information on the axonal density of postgeniculate fibers (optic radiation), and fMRI studies of patients with primary open-angle glaucoma (POAG) have demonstrated alterations involving the human visual cortex that are consistent with clinically documented losses of visual function. This article reviews some of the more recent data supporting the use of MR imaging techniques as reliable, noninvasive tools for monitoring the progression of human glaucoma.

We present an unreported technique used to treat with RF ablation hepatic subphrenic hepatocellular carcinoma. It consists in the combination of fluoroscopic and computed tomography guidance for lesions already embolized with lipiodol located at the hepatic dome, approached in parallel fashion with a 22-gauge chiba "finder" needle followed by the RF electrode.

PurposeThis study retrospectively evaluated the efficacy and safety of the 6F Angio-Seal (St. Jude Medical, St. Paul, Minn) as a closure device for transbrachial artery access for endovascular procedures in diabetic patients with critical limb ischemia.MethodsFrom January 2005 and September 2007, 1887 diabetic patients underwent interventional procedures in the lower limbs at a two diabetic foot centers. Patients presented with rest pain (16%), ulcers (80%), or gangrene (4%). Systemic anticoagulation with sodium heparin (70 IU/kg) was obtained for all patients at the beginning of the endovascular treatment. A total of 249 brachial arteries (238 patients) were evaluated for possible Angio-Seal use after endovascular recanalization of the leg. Color Doppler ultrasound imaging of the artery was obtained before revascularization only in patients with previous Angio-Seal placement in the brachial artery. No further imaging studies were done in the remaining brachial arteries where the Angio-Seal was deployed at the operator’s discretion. Impairment or disappearance of the radial pulse or onsets of hand ischemia or hand pain, or impairment of hand function during or at the end of the endovascular revascularization were all regarded as contraindications to Angio-Seal usage. Evidence of a highly calcified plaque of the brachial artery access site at the time of vessel puncture was regarded as an absolute contraindication to the Angio-Seal use. Patients were seen before discharge, at 1, 3, and 8 weeks after the procedure, and at 3-month intervals thereafter. Complications included hemorrhage, pseudoaneurysm, infection, and vessel occlusion.ResultsA total of 1947 Angio-Seal collagen plugs were deployed in 1709 diabetic patients (90.5%). The Angio-Seal was used for brachial artery closure in 159 patients (8.4%) in 161 procedures (159 in the left, 2 in the right brachial artery). In 79 patients (4.2%) in 88 procedures (87 in the left and 1 in the right brachial artery), the device was deemed contraindicated due to small vessel size in 73 patients (92.4%) or presence of calcium at the access site in five patients (6.3%). One patient (1.3%) refused the collagen plug closure after revascularization. The non-Angio-Seal group was evaluated for comparison. The success rate for achieving hemostasis in the Angio-Seal group was 96.9%. Five major complications (3.1%) at 30 days consisted of two puncture site hematomas >4 cm, two brachial artery occlusions, and one brachial artery pseudoaneurysm, with three patients requiring open surgery. Minor complications (7.50%) were three puncture site hematomas < 4 cm, three oozing of blood from the access site, and six patients had mild pain in the cubital fossa. No further complications were recorded in the 14-month follow-up (range 1-25 months) of a total of 140 patients.ConclusionsThis retrospective study shows that the 6F Angio-Seal is a valuable and safe vascular closure device for transbrachial access in diabetic patients undergoing interventional procedures for critical limb ischemia.

The aim of this study was to assess the efficacy of cutting-balloon angioplasty (CBA) in the treatment of anastomotic stenoses of peripheral arterial bypass grafts.Seventeen patients (12 men and five women; age range 54-79 years, mean age 66.5) with stenosis or occlusion at the proximal or distal anastomoses of peripheral bypass grafts were treated with CBA. The diagnosis of stenosis was based on clinical and colour-Doppler ultrasound findings and confirmed by angiography with measurement of the intraluminal transstenotic pressure gradients. The diameter of the selected cutting balloon was 1-mm smaller than the vessel distal to the anastomosis and, in the event of suboptimal outcome, the procedure was completed with repeat dilatation with a larger standard balloon (+1 mm).Technical success was obtained in 100% of cases. In three patients, CBA was performed after locoregional thrombolysis. No patient required stent placement or emergency surgery due to the presence of residual stenosis, suboptimal outcome or dissection. No complication occurred either during or after the procedure. During a mean follow-up period of 10.4 months (range 5-21 months), two restenoses developed at 9 and 7 months, which were treated with the same technique; in one patient with recurrent bypass occlusion at 5 months, a new bypass was created surgically owing to contraindications for locoregional thrombolysis. Cumulative primary patency at 12 and 18 months was 82.35%, whereas the two cases of restenoses treated with repeat CBA underwent further follow-up at 10 and 7 months, respectively.Our data confirm the efficacy of CBA in the treatment of anastomotic stenoses of peripheral arterial bypass grafts.

Aim To determine parameters predictive of avoidance of major (above-the-ankle) amputation after a technically successful peripheral angioplasty (PTA) in patients with diabetes with critical limb ischaemia. Methods From January 1999 to December 2003, 420 consecutive patients with diabetes admitted to hospital because of critical limb ischaemia underwent peripheral angiography and concomitant technically successful PTA. Transcutaneous oxygen tension (TcPO2) was measured before and after PTA. Major amputation at 30 days was recorded. Results After PTA, the iliac–femoral–popliteal axis was patent in all patients. In 67 patients, all three crural arteries were patent, in 143 patients 2 crural arteries were patent, and in 186 patients one crural artery was patent (104 peroneal, 62 anterior tibial, 20 posterior tibial). In 24 patients, all three crural arteries were occluded. Twenty-two major amputations were performed. Of these, 15 were performed in the 24 patients with occlusion of all the infrapopliteal arteries. Seven of the 186 patients in whom only the peroneal artery was patent required amputation. In patients not requiring amputation, TcPO2 increased from 15.5 ± 11.9 to 45.0 ± 12.0 mmHg (P = 0.000), while in those requiring amputation, TcPO2 increased from 9.6 ± 7.7 to 18.6 ± 8.1 mmHg (P

Type B aortic dissection is an uncommon yet potentially catastrophic clinical event that mandates prompt recognition and expeditious treatment. Patient survival depends on early and accurate diagnosis and prompt medical or surgical treatment. Unfortunately, when type B aortic dissection is associated with end-organ ischemia, medical treatment may not prove beneficial, with patients addressed to surgery; recently, either percutaneous fenestration or primary endovascular aortic repair has been proposed as a valuable alternative to surgery in this scenario. Although the ideal endograft has not emerged and improvement in the long-term behavior of the devices is required, endograft placement is becoming the first choice in patients with complicated type B aortic dissection requiring emergency treatment.

BACKGROUND: The aim of this study is to assess differences between axial computed tomography and duplex ultrasound, based on measurements of maximal aortic diameter in patients with abdominal aortic aneurysms. METHODS: From January 2002 until December 2004, 322 patients were admitted with an abdominal aortic aneurysm. All of them underwent abdominal duplex ultrasound scanning and computed tomography by separate laboratories in order to determine the maximal aortic diameter. The computed tomography technologists were blinded to all duplex results and vice versa. RESULTS: Mean computed tomography maximal aortic diameter was 56.17 mm and mean duplex maximal aortic diameter was 53.44 mm. Computed tomography measurements were greater than duplex in 97.83% of the patients. CONCLUSIONS: Axial computed tomography consistently overestimates the maximal aortic diameter measurements in patients with abdominal aortic aneurysms compared with duplex ultrasound.

The aim of this study was to evaluate the angiographic findings and the results of interventional treatment in iatrogenic lesions of the hepatic artery.Twelve patients (6 men and 6 women), aged 46 to 75 years (mean age 56.3 years), with acute hepatic bleeding secondary to percutaneous, surgical or laparoscopic procedures, were diagnosed using angiography and treated with endovascular percutaneous procedures.Angiography revealed 7 pseudoaneurysms, 3 arterial lacerations, 1 arterio-portal fistula e 1 arterio-biliary fistula that were treated by Trans-catheter Arterial Embolization (TAE) (n=11) and stentgraft placement (n=1). Only one patient had a relapse two days after TAE and died of haemorrhagic shock. The other patients had a benign clinical course with an average follow-up of 9.6 months.Interventional radiological procedures are effective in the management of iatrogenic lesions of the hepatic arterial vessels since they are minimally invasive, have a high success rate, and a low incidence of complications compared to the more complex and dangerous surgical or laparoscopic options.

A 18-year-old man presented at our clinic with pain in the right flank following a motorbike accident. The diagnosis of renal artery dissection followed by thrombosis was made by computed tomography and confirmed by angiography. Successful revascularization was performed by means of repeated transcatheter injection of small doses of thrombolytic agents within the vessel, followed by deployment of a self-expandable stent. There were no complications, and the patient recovered well. Six months after stent placement, a selective renal angiogram showed excellent flow through the stented portion of the artery and normal parenchyma enhancement in the right kidney.

Aortoesophageal fistula secondary to thoracic aneurysm is rare and is usually fatal without prompt surgical intervention. A 79-year-old man with significant comorbidities and previous cancer surgery was admitted on an emergency basis because of the suspicion of a ruptured thoracic aortic aneurysm. Computed tomographic scan followed by angiography demonstrated a ruptured thoracic aneurysm with aortoesophageal fistula. An endovascular stent graft repair was performed with successful exclusion of both aneurysm and fistula. On postoperative day 6, dyspnea and an isolated episode of hemoptysis occurred. Endoscopy revealed the presence of a bronchoesophageal fistula, which necessitated double exclusion of the esophagus and feeding jejunostomy. At 6 months, clinical, bronchoscopic, and computed tomographic scan follow-up showed complete sealing of the aneurysm and resolution of the bronchoesophageal fistula. At 9 months, the patient was still alive but refused to undergo substernal gastric bypass in an attempt to restore oral feeding. Endovascular repair seems promising as an emergent and palliative treatment of aortoesophageal fistula. To the best of our knowledge, this is the first case in which a bronchoesophageal fistula developed after successful endovascular repair of aortoesophageal fistula. The pathogenesis of this complications remains unclear.

Ischemic colitis is an uncommon complication in patients with systemic lupus erythematosus but may be precipitated by colonoscopy. A 43-year-old female with systemic lupus erythematosus under treatment with immunosuppressive drugs and prednisone was submitted to colonoscopy because of a change in bowel habit. Apart from the presence of a small metaplastic polyp, colonoscopy showed only a few erythematosus areas in the sigma and left colon. Four hours after colonoscopy, the patient developed lower colic abdominal pain and mucous diarrhea followed by rectal bleeding from ischemic colitis. The patient was successfully treated with fluids, spasmolytic drugs, sodic heparin, antibiotics and enteral feeding. Awareness of the risk of this potential complication, secondary to colonoscopy, in patients with connective tissue disorders may lead to a prompt diagnosis and effective treatment, with a successful outcome.

Uterine artery embolization (UAE) is increasingly being used as an alternative treatment to hysterectomy for symptomatic fibroids. Symptoms of pelvic pressure, urinary frequency and menorrhagia are controlled in 73-98% of patients who undergo UAE. At the 1-year follow-up, the uterus may shrink by up to 55% but re-growth of fibroid may however occur. The rate of major complications and amenorrhoea following this procedure is low, ranging in most series from 1 to 3.5% and 1 to 7%, respectively. Nevertheless, the rate of amenorrhoea in women over 45 seems to be higher. In order to completely block the arterial supply to the fibroid, UAE is typically performed in both uterine arteries. Different embolic agents are used such as polyvinyl alcohol, gelfoam and more recently gelatine tris-acryl microspheres. After UAE, perfusion of the uterus is maintained. Uterine function is therefore conserved and although women who become pregnant after UAE seem to be at risk for malpresentation, pre-term birth, cesarean delivery and postpartum hemorrhage, successful pregnancies after UAE have been reported in some series. A major technical problem with UAE remains the possible presence of fibroid blood supply from other sources, such as the ovarian arteries or other pelvic branches, which can lead to failure of the procedure. In conclusion, although randomized trials are still underway, UAE appears a good option for those patients who whish to conserve their fertility or when surgery is contra-indicated. However, to evaluate the long-term effects of UAE longer follow up is required.

To evaluate the water diffusivity of normal-appearing white matter (NAWM) in patients with tuberous sclerosis complex compared with that in control subjects.Diffusion and conventional magnetic resonance (MR) imaging examinations were performed in 18 patients with clinically established tuberous sclerosis complex (10 male and eight female patients; mean age, 20.1 years; range, 12-30 years), as well as in 18 age-matched control subjects (nine male and nine female; mean age, 20.2 years; range, 11-28 years). Apparent diffusion coefficients (ADCs) were generated, and small elliptic regions of interest were manually placed both in perilesional NAWM and in six anatomic locations of NAWM remote from hamartomatous lesions. Perilesional ADCs were compared with those at the same anatomic site on the contralateral side of the brain (generalized linear regression analysis). ADCs from the predetermined sites in patients were compared with those in control subjects (generalized linear regression analysis).Supratentorial ADCs were higher in patients with tuberous sclerosis complex than in control subjects, and statistically significant differences were observed in the occipital white matter, frontal white matter, centrum semiovale, parietal white matter, and corona radiata (for each location, P.001). Significant increases were also seen in the perilesional NAWM compared with NAWM at the same anatomic locations on the contralateral side (P.001). Infratentorial ADCs were normal.Significant ADC increases were measured in the supratentorial NAWM.

Editor: Uterine arterial embolization is going to be accepted as a routine alternative to hysterectomy or myomectomy for the treatment of uterine symptomatic leiomyomata. The growing interest in this intervention has led to a strict analysis of each technical and clinical aspect of the procedure. Recently, particular interest has been focused on the evaluation of utero-ovarian anastomoses with the aim to clarify the role of this communication in the clinical failure of uterine arterial embolization and in some related complications (eg, transient or permanent amenhorrhea) (1,2). In the September 2002 issue of Radiology, Dr Razavi and colleagues (3) classified three main angiographic patterns of utero-ovarian anastomoses. We would like to make a comment regarding type I classification. In this kind of anastomoses, the ovarian artery connects to the intramural uterine artery before the fibroid supply through the tubo-ovarian segment. In these cases, the flow in the tubal artery is directed toward the uterus, without (type Ia) or with (type Ib) evidence of retrograde reflux in the direction of the ovary on selective uterine angiograms. The authors also stated that in type Ib anastomoses, care must be taken because of the possibility of flow reversal in the tubo-ovarian anastomoses toward ovary or aorta (4). For this reason, as recently reported in the literature (5), coil embolization of these anastomoses could be considered a feasible option. However, Dr Razavi and colleagues did not express any consideration about type Ia anastomoses. In our institution, we have seen four patients with bilateral type Ia utero-ovarian anastomosis (in a total of eight arteries). In all cases, ovarian arteries were visualized during preprocedural pelvic angiography with the tip of a pigtail catheter at the level of the renal arteries, while no evidence was found during selective arteriography of uterine arteries. In three of these patients, the selective embolization of uterine arteries was stopped at one side before the planned end point because of reverse flow in the tubo-ovarian anastomoses. We did not visualize a reverse flow toward the origin of ovarian arteries or aorta because we did not force the injection of contrast material to obviate eventual dislocation of residual embolic particles still in the lumen or at the extremity of the catheter. For the same reason, as soon as we opacified the tubo-ovarian tract, we immediately stopped the injection, as well. During review of preembolization angiograms, we noted that, in all cases, embolization was stopped at the side that gave minor supply to the uterus and to fibroids. We know that the possibility of having increased pressure in a uterine artery that is sufficient to reverse the flow in the uteroovarian anastomosis is directly related to occlusion of the distal vessels that feed the uterus. As soon as we close the vessels, we will achieve a risky reverse pressure toward the tubo-ovarian arteries. In case of a poor supply toward fibroids or the uterus, from one side, this evidence could occur after administration of a few milliliters of embolic material. On the basis of these findings, we suggest that type Ia uteroovarian anastomoses have a risk of reverse flow toward ovary and aorta that is directly related to the amount of supply to the uterus. Thus, we strongly suggest perfect targeting of the supply toward the uterus and fibroids by means of preembolization angiography of both uterine arteries in cases of type Ia anastomoses to discover the nondominant “dangerous” side, in which the injection of contrast material must be strictly controlled with fluoroscopy. Once tubo-ovarian anastomoses manifest reverse flow toward ovary or aorta, the vessel could be closed, as reported for type Ib anastomoses (5), with an increase in radiation exposure dose for the patient. Another option is to stop the session, as we did in all cases, and reconsider a second procedure in case of lack of clinical improvement of symptoms in a follow-up period.

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Purpose: To report the embolization of a renal artery aneurysm using Onyx, a radiopaque nonadhesive liquid embolic agent. Case Report: A 28-year-old woman with hypertension and fibromuscular dysplasia presented with a 20-mm renal artery aneurysm. In order to avoid any migration of embolic material into the parent vessel, a compliant balloon was inflated to exclude the aneurysm from the blood flow while injecting the liquid embolic agent. Complete aneurysm exclusion was achieved immediately, with no angiographic or duplex evidence of distal embolization or intra-aneurysmal flow. The Doppler ultrasound at 6 months confirmed aneurysm exclusion. Conclusions: The ease of use and nature of this material makes Onyx an effective and safe option in the treatment of wide-necked renal aneurysms.

We report the case of a giant renal arteriovenous fistula after renal biopsy in a 30-year-old man with hematuria and hypertension. We performed percutaneous endovascular embolization using macrocoils to exclude the fistula. The patient made an uneventful recovery with no further hematuria and progressive reduction of blood pressure. Follow-up by digital subtraction angiography (DSA) at 6 months showed complete occlusion of the fistula with no evidence of renal parenchymal infarction. Although giant renal arteriovenous fistulas are generally treated by nephrectomy, this case shows that embolization is a reasonable alternative to surgery.

Splenic artery aneurysms (SAAs) are not uncommon in patients with portal hypertension. They are usually diagnosed in preliminary examinations prior to orthotopic liver transplantation (OLT) and are treated surgically at the time of transplantation. In our case, the patient developed a giant SAA after liver transplantation. This was detected incidentally upon routine ultrasound follow-up, and the diagnosis was confirmed on magnetic resonance (MR) angiography. The patient was treated by endovascular embolization because it is believed that this minimally invasive approach is beneficial in an immunocompromised patient following OLT. After coil embolization, to achieve complete and immediate blood flow exclusion of the sac, it was decided to inject some glue ( N-butyl-2-cyanoacrylate) directly into the aneurysm. The aneurysm was successfully obliterated. To the best of our knowledge the use of cyanoacrylate glue in an SSA has never been reported.

Recently a few authors have reported experience regarding the safety and efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) in patients with critical limb ischemia (CLI) presenting long occlusions involving the popliteal trifurcation. Spinosa et al. described the use of this technique in 20 limbs (21 cases), with a limb salvage rate of 90% at 6 months. The authors concluded that the SAFARI technique can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry. Also, according to these authors the SAFARI technique improves technical success in the performance of subintimal recanalization, and limb salvage rates are comparable to those with antegrade subintimal recanalization [1]. Gandini et al reported the use of this novel technique in four out of 104 patients with CLI. In their paper those authors concluded that the SAFARI technique should be adopted as a ‘‘standard procedure’’ in CLI cases showing long occlusions involving the trifurcation and presenting risk of amputation [2]. While we agree with Spinosa et al. that the SAFARI technique should be adopted in the presence of failure to reenter the distal true lumen from an antegrade approach, we do not think that this technique should always be used as first choice in the presence of long occlusion involving the trifurcation. Indeed, the SAFARI technique is indubitably an attractive option but, in view of the limited number of cases reported in the literature, should not yet be regarded as a standard procedure. According to the literature [3–5], intraluminal or subintimal recanalization of long occlusions involving the popliteal trifurcation is normally achieved by the transfemoral approach. In the last 2 years more than 1000 diabetic patients with CLI have been successfully treated endovascularly at our two centers (Multimedica IRCCS, Milan, and Multimedica Santa Maria Hospital, Castellanza, Va.). In this large cohort of subjects the use of the SAFARI technique was deemed necessary in four cases only (one posterior tibial and three anterior tibial artery approaches) and, importantly, after unsuccessful repeated attempts at distal revascularization. To the present authors, direct puncture of the distal third of a calf artery is not free of serious complications, leading in certain instances to flowlimiting dissection (due to introducer sheath advancement or due to the puncture itself) as well as thrombosis of the accessed artery (mainly at the end of the intervention during manual compression of the puncture site). Also, as reported by Gandini et al., the ‘‘presence of ulcers at the entry zone is an important limitation to the performance of this type of approach.’’ Finally, this type of procedure is time-consuming, which is a main limitation in such critically ill patients (heart and renal comorbidities are often associated). In conclusion, at this moment in time the use of the SAFARI technique should not be regarded as the first option for the treatment of diabetic patients with CLI. In expert hands, however, it may be considered in selected cases, after unsuccessful attempts at revascularization from the femoral artery. Most importantly, when this novel approach is deemed necessary, surgical exposure rather T. Lupattelli (&) Department of Radiology and Interventional Radiology, Via milanese 300, Sesto San Giovanni, Milan 20099, Italy e-mail: tommasolupattelli@hotmail.com

The yin-yang sign is helpful in facilitating diagnosis of partially thrombosed true arterial aneurysms and false aneurysms. At contrast-enhanced CT, increased attenuation in one portion of the thrombosed aneurysm indicates the presence of a partially contrast material–filled lumen, whereas reduced attenuation in the remaining portion of the thrombosed aneurysm indicates the presence of a mural thrombus.

Objective To evaluate the efficacy of peripheral angioplasty (PTA) in the treatment of diabetic patients with previous peripheral bypass graft and recurrent critical limb ischemia (CLI). Methods Between January and December 2006, 293 diabetic patients presenting with critical limb ischemia (CLI) according to the TASC 2000 criteria were admitted to our footcare centre. Among these patients, 32 of them had previously undergone bypass grafting: femoropopliteal in 26 patients, femoroposterior tibial in 3 patients, femoroperoneal in the remaining 3. All these patients underwent angiography and, whenever possible, a concomitant PTA procedure. Results Six patients presented with stenosis at the distal anastomosis, 2 with stenosis at the proximal anastomosis and in 5 patients both the distal and proximal anastomosis were stenosed. In 12 patients the graft was completely occluded. In 7 patients the graft appeared patent but all the infrapopliteal arteries were occluded. The average time interval between bypass and subsequent hospital admission because of CLI was 6.3±4.2 months for patients with patent grafts and 20.5±12.0 months for those with failing grafts ( p =0.004). A successful PTA was performed in 25 patients (78.1%). In all patients with patent grafts, PTA recanalized one infrapopliteal artery. Recanalization of the graft was obtained in all 13 patients with non-occluded graft. Recanalization of superficial femoral artery occlusion by means of PTA was obtained in 5 out of the 12 patients in whom the graft was completely occluded. Five patients underwent major amputation within 30 days and 3 further patients during the follow-up period. Patients were followed up until December 31 2007, with a mean follow-up of 1.89±0.27 years. Restenosis occurred in 7 (28.0%) of the 25 patients in whom a successful PTA was performed. In 5 of these 7 patients, PTA was repeated successfully. In 2 patients in whom a further PTA was not feasible a major amputation was performed. At the end of the follow-up period the cumulative primary patency rate was 72%, the assisted patency rate was 92%. Conclusions PTA is an effective method for revascularizing secondary obstructions in patients with graft failure (and no possibility of a redo graft). PTA also is effective in at least one subgenicular artery in patients with diabetes with inadequate run-off after femoropopliteal bypass grafting.

ObjectiveTo evaluate the early and late major amputation and survival rates and related risk factors in diabetic patients with critical limb ischemia (CLI).DesignRetrospective study.MethodsRevascularization feasibility, major amputation, survival rate and related risk factors were recorded in 564 diabetic patients consecutively hospitalized for CLI from 1999 to 2003 and followed until June 2005.ResultsPeripheral angioplasty (PTA) was carried out in 420 (74.5%), bypass graft (BPG) in 117 (20.7%) patients. In 27 (4.8%) patients both PTA and BPG were not possible. Twenty-three above-the-ankle amputations (4.1%) were performed at 30 days: 6 in PTA patients, 3 in BPG patients, 14 in non revascularized patients. In the follow-up of 558 patients (98.9%), 62 repeated PTAs and 9 new BPGs, 32 new major amputations (16 in PTA patients, 14 in BPG patients and 2 in non-revascularized patients) were performed. Major amputation was associated with absence of revascularization (OR 35.9, p

Objective Chronic cerebrospinal venous insufficiency (CCSVI) is a recently discovered syndrome mainly due to stenoses of internal jugular (IJV) and/or azygos (AZ) veins. The present study retrospectively evaluates the feasibility and safety of endovascular treatment for CCSVI in a cohort of patients with multiple sclerosis (MS). Methods From September 2010 to October 2012, 1202 consecutive patients were admitted to undergo phlebograpy ± endovascular treatment for CCSVI. All the patients had previously been found positive at color Doppler sonography (CDS) for at least two Zamboni criteria for CCSVI and had a neurologist-confirmed diagnosis of MS. Only symptomatic MS were considered for treatment. Percutaneous transluminal angioplasty was carried out as an outpatient procedure at two different institutes. Primary procedures, regarded as the first balloon angioplasty ever performed for CCSVI, and secondary (reintervention) procedures, regarded as interventions performed after venous disease recurrence, were carried out in 86.5% (1037 of 1199) and 13.5% (162 of 1199) of patients, respectively. Procedural success and complications within 30 days were recorded. Results Phlebography followed by endovascular recanalization was carried out in 1999 patients consisting of 1219 interventions. Balloon angioplasty alone was performed in 1205 out of 1219 (98.9%) procedures, whereas additional stent placement was required in the remaining 14 procedures (1.1%) following unsuccessful attempts at AZ dilatation. No stents were ever implanted in the IJV. The feasibility rate was as high as 99.2% (1209 interventions). Major complications included one (0.1%) AZ rupture occurring during balloon dilatation and requiring blood transfusion, one (0.1%) severe bleeding in the groin requiring open surgery, two (0.2%) surgical openings of the common femoral vein to remove balloon fragments, and three (0.2%) left IJV thromboses. The overall major and minor complication rates at 30 days were 0.6% and 2.5%, respectively. Conclusions Endovascular treatment for CCSVI appears feasible and safe. However, a proper learning curve can dramatically lower the rate of adverse events. In our experience, the vast majority of complications occurred in the first 400 cases performed.