Median Arcuate Ligament Compression Associated with Flow-Related Visceral Aneurysms

PurposeTo identify risk factors for rupture, and to determine outcomes of endovascular treatment of median arcuate ligament (MAL) compression–related visceral artery aneurysms (VAAs).Methods and MaterialsA retrospective review of patients who presented with MALC-related VAAs was performed from 1999 to 2021. A total of 21 patients (12 men) and 39 VAAs associated with MAL compression were encountered (mean age, 59 years). Imaging studies were reviewed for the number, morphology/size, and recurrence of aneurysms. Statistical analysis was performed to identify risk factors for rupture.ResultsTen patients presented with acute rupture, and 12 patients were symptomatic with nonspecific abdominal pain. Twenty-two aneurysms were fusiform in morphology and 17 aneurysms were saccular in morphology. Of the 14 aneurysms that presented with acute hemorrhage, 12 (86%) were fusiform in morphology (odds ratio, 9.0; P < .01). The mean aneurysm size was 1.3 cm, and the mean ruptured size was 0.6 cm. Thirty-one aneurysms were treated by endovascular techniques, and technical success was achieved in all cases. Fourteen patients were found to have an Arc of Buhler. No procedure-related adverse events occurred. No patient underwent surgical ligament release. The mean time of follow-up was 3.2 years, and no aneurysms recurred after endovascular treatment.ConclusionsMAL compression-associated VAAs are an important clinical entity that should be treated even at small sizes, particularly if they are fusiform in morphology. Endovascular therapy is safe and feasible and results in durable aneurysm exclusion.     

Parallel Covered Stents Technique in the Treatment of Abdominal Aortic Diseases

PurposeTo investigate the safety and efficacy of the parallel covered stents technique in the treatment of anatomically challenging aortic aneurysms, pseudoaneurysms, and dissections.Materials and MethodsData were retrospectively collected from 16 patients with abdominal aortic diseases who were treated with parallel covered stents (Gore Excluder, n = 14; Medtronic Endurant, n = 2) between January 2016 and July 2018. Patients were treated with this technique if they were unsuitable for either open repair or standard endovascular aortic repair with bifurcated stents. Such unfavorable anatomy included narrow aortic necks (≤18 mm), small vascular access (occluded or ≤6.0 mm), or compressed aortic lumens (≤18 mm). All patients were male, with a mean age of 64.7 ± 13.3 years. For true aneurysms (n = 4) and pseudoaneurysms (n = 4), the mean diameter and length of the proximal necks were 17.5 ± 2.6 mm (range, 14–21 mm) and 51.0 ± 12.5 mm (range, 39–75 mm), respectively. The minimal diameter of true lumen in cases with aortic dissection and penetrating ulcers (n = 8) was 14.8 ± 3.1 mm. Small or occluded femoral access was found in 3 patients.ResultsTechnical success was 100%. Minor type I endoleaks, which were seen on completion angiography in 5 patients, had all resolved within 3 months. There were no perioperative deaths. Postoperative complications included supraventricular tachycardia in 1 patient and pneumonia combined with heart failure in 1 patient. Patency of all stents was observed at a mean follow-up of 21.8 ± 10.1 months.ConclusionsThe parallel covered stents technique appears to offer a feasible solution for abdominal aortic diseases with unfavorable anatomy. Long-term follow-up is needed to further evaluate the safety and efficacy of this technique.     

No Advantage of Expanded Polytetrafluoroethylene and Fluorinated Ethylene Propylene–Covered Stents over Uncovered Nitinol Stents for Percutaneous Palliation of Malignant Infrahilar Biliary Obstruction: Results of a Single-Center Prospective Randomized Trial

PurposeTo prove that covered stents are more efficacious than uncovered stents regarding patency, safety, enabling of chemotherapy, and survival in percutaneous palliation of malignant infrahilar biliary obstruction.Materials and MethodsAfter failed endoscopic treatment, 154 patients with obstructive jaundice caused by unresectable infrahilar malignancy were randomly allocated to receive an expanded polytetrafluoroethylene and fluorinated ethylene propylene–covered or an uncovered nitinol stent. Occlusion rate, patency, and survival were assessed. Safety and clinical success in terms of chemotherapy were compared.ResultsThree patients were excluded post hoc. Fifteen patients died within 7 d and were excluded from patency analysis. Occlusion rates were 32% (21 of 66) for covered and 29% (20 of 70) for uncovered stents (P = .7). Estimated median patency durations were 308 d (95% confidence interval [CI], 178–438 d) for covered and 442 d (95% CI, 172–712 d) for uncovered stents (P = .1). Serious adverse events (P = 1.0) and 30-day mortality (P = .5) were equivalent between groups. At hospital discharge, median bilirubin reduction of 8 mg/dL was found in both groups (P < .001). In the covered stent group, 35 patients (48%) received palliative chemotherapy, vs 29 (37%) in the uncovered stent group (P = .2). Estimated median survival times were 96 days (95% CI, 68–124 d) with covered stents and 75 days (95% CI, 42–108 d) with uncovered stents (P = .6).ConclusionsIn malignant infrahilar biliary obstruction not amenable to endoscopy, no improvement in patency or survival with percutaneously placed covered stents could be confirmed. Covered and uncovered stent types exhibit similar safety profiles and clinical success rates.     

Elective Embolization of Splenic Artery Aneurysms with an Ethylene Vinyl Alcohol Copolymer Agent (Squid) and Detachable Coils

PurposeTo report the safety and efficacy of the embolization of splenic artery aneurysms (SAAs) with coils plus ethylene vinyl alcohol copolymer (EVOH) agent.Materials and MethodsA single-center retrospective study was conducted from 2016 to 2019 to collect SAAs. Twelve asymptomatic patients (mean age, 59 years) with 15 SAAs (mean size, 23.6 mm; size range, 15–40 mm) were treated with embolization. Embolization was performed with EVOH (Squid 8/34) and fibered detachable coils. Transfemoral embolization was performed with a microcatheter to achieve a splenic artery occlusion embolizing the SAA and its efferent and afferent branches. Follow-up was based on color Doppler ultrasound at 24 hours and on computed tomography (CT) angiography at 1 (n = 12) and 6 months (n = 12) after embolization. Mean number of coils and Squid vials used for each patient, major/minor complications, technical success, 30-day clinical success, cases of revascularization/reintervention, and mortality were assessed. Technical success was defined as complete exclusion of the aneurysmal segment and cessation of blood flow into the sac. Clinical success at 1 month was based on the absence of clinical symptoms and the exclusion of aneurysm revascularization on CT angiography.ResultsThe mean number of coils and Squid vials was 5.75 (standard deviation [SD], 1.58; range, 3–9) and 1.41 (SD, 0.49; range, 1–2), respectively. Both technical and 30-day clinical success were 100%, with no cases of aneurysm revascularization (CT angiography performed in all patients at 1 month and 6 months and in 3 patients at 24 months). No major complications or fatal events were recorded. In terms of minor complications, 2 cases of mild pancreatitis (transient amylases increase) and 1 case of focal splenic ischemia without clinical sequelae were recorded.ConclusionsEmbolization in SAAs using coils plus EVOH was safe and effective without SAA revascularization     

Endovascular Treatment of Malignant Superior Vena Cava Syndrome through Upper-Limb Access: A Comparison between Venous-Dedicated and Conventional Stents

PurposeTo retrospectively evaluate the technical and clinical outcomes of superior vena cava (SVC) stent placement through upper-limb venous access in malignant SVC syndrome (SVCS) and compare the efficacy of different nitinol stent types.Materials and MethodsBetween 2006 and 2018, 156 patients (132 male; mean age, 62 y; age range, 33–81 y) underwent SVC stent placement for malignant obstructions through upper-limb venous access with 1 of 3 types of nitinol stent: 1 venous-dedicated (Sinus-XL stent) and 2 non–venous-dedicated (E-Luminexx Vascular Stent and Protégé GPS). Cases of common femoral vein access or non-nitinol stents were excluded from further analysis. The mean duration of follow-up was 8 mo.ResultsTechnical success was achieved in 99.3% of cases. One patient died during the procedure as a result of cardiac tamponade. Balloon predilation was performed in 10 patients and postdilation in 126. Mean procedural time was 34.4 min (range, 18–80 min). Overall survival rates were 92.3%, 57.3%, and 26.8%, and overall primary patency rates were 94.5%, 84.8% and 79.6%, at 1, 6, and 12 mo, respectively. There were no statistically significant differences in primary patency rates between venous- and non–venous-dedicated stents or among different Stanford SVCS grading groups (P > .05).ConclusionsSVC stent placement through an upper-limb approach is a safe, fast, and effective technique. There is no evident benefit of venous-dedicated vs non–venous-dedicated stents in the treatment of malignant SVCS.     

Prevalence of and Factors Associated with Arterial Aneurysms in Patients with Hereditary Hemorrhagic Telangiectasia: 17-Year Retrospective Series of 418 Patients

PurposeTo estimate the prevalence of and identify characteristics associated with the presence of aneurysms in a cohort of patients with hereditary hemorrhagic telangiectasia (HHT).Materials and MethodsIn the study institution’s HHT database, 418 patients with a definite HHT diagnosis were identified based on the clinical Curaçao criteria and/or an HHT-associated genetic mutation. Regression modeling was used to evaluate the association between arterial aneurysms and older age, male sex, smoking, alcohol consumption, hypertension, hyperlipidemia, genetic mutations, the presence of arteriovenous malformations (AVMs) unrelated to the aneurysms, and HHT-related genetic mutations.ResultsForty-three (10.3%) patients had at least 1 aneurysm. Sixteen (3.8%) patients had multiple aneurysms. Of the variables analyzed, older age (odds ratio [OR] = 1.02; 95% confidence interval [CI]: 1.0–1.1), the presence of anatomically and flow-unrelated AVMs (OR = 3.2; 95% CI: 1.3–8.0), and the presence of activin A receptor type II-like 1 (ACVRL1) mutation (OR = 4.0; 95% CI: 1.5–10) were associated with the presence of at least 1 aneurysm.ConclusionsIn this cohort of patients with HHT, the prevalence of intracranial and visceral arterial aneurysms was estimated to be 10.3%. Older age, the presence of unrelated AVMs, and the presence of the ACVRL1 mutation were associated with the presence of arterial aneurysms. Further study is required to assess the clinical importance and risk of rupture of aneurysms in patients with HHT.     

Percutaneous Arteriovenous Fistula Creation with the WavelinQ 4-French EndoAVF System: A Single-Center Retrospective Analysis of 30 Patients

PurposeTo retrospectively assess the safety and efficacy of percutaneous arteriovenous fistula (pAVF) creation with the WavelinQ 4-F EndoAVF System.Materials and MethodsFrom February 2018 to June 2020, 30 pAVFs were created in 30 consecutive patients (men; age, 55.3 years ± 13.6). Of the 30 patients, 21 (70%) were already on hemodialysis using a central venous catheter. The primary outcome measures were technical success, complications, and cannulation rate. The secondary outcome measures included the number of secondary procedures needed for cannulation, maintenance time to cannulation, and pAVF survival.ResultsTechnical success was 100%. The adverse event rate was 6.7% (2/30), including a pseudoaneurysm of the brachial artery that developed immediately after sheath removal and an aneurysm of the anastomosis 17 days after the procedure, which was treated with a covered stent placed in the arterial side. The mean follow-up was 547 days ± 315.7 (range, 14–1,071 days). The cannulation rate was 86.7% (26/30). The mean time to cannulation was 61.3 days ± 32.5 (range, 15–135 days). The mean follow-up after cannulation was 566.2 days ± 252.7 (range, 35–1,041 days). Four pAVFs were thrombosed after cannulation, with 2 of them successfully declotted. Sixteen interventions were needed to achieve cannulation after the index procedure in 15 patients (overall, 0.53 procedures/patient). Seven maintenance endovascular interventions (following cannulation) were performed during the follow-up period in 6 patients (overall, 0.27 procedures/patient, 0.17 procedures/patient-years). For the pAVFs that were cannulated, patency was 96% at 1 year, and 82% at 2 and 3 years, according to the Kaplan-Meier survival analysis.ConclusionsThis initial experience suggests that pAVF creation is safe and can be successfully performed with high maturation and long-term patency rates. Larger-scale prospective studies are needed to validate the results.     

Distal Radial Artery Access for Noncoronary Endovascular Treatment Is a Safe and Feasible Technique

PurposeTo evaluate safety and feasibility of distal radial artery (DRA) access for noncoronary interventional radiology procedures.Materials and MethodsAll interventional radiology procedures by means of DRA puncture from July 2017 to August 2018 were retrospectively reviewed. Eighty-two punctures in 56 patients were included, mostly in male patients (84% vs 16%). Mean age was 67.8 years (range, 33.3–87.3 years); mean height was 172 cm (range, 142–190 cm); and mean weight was 83 kg (range, 43–120 kg). Procedural characteristics, technical success, and complication rates were gathered from the medical records and follow-up ultrasound when available. Prerequisites for DRA access were adequate radioulnar collateral circulation, sufficient radial artery diameter, and informed consent in patients initially intended for conventional transradial access.ResultsProcedures included transarterial chemoembolization (n = 34), yittrium-90 pretreatment angiography (n = 21), yittrium-90 administration (transarterial radioembolization; n = 20), and embolization of visceral organs (n = 7). Both 4-Fr (n = 35) and 5-Fr (n = 46) sheaths were used. Technical success of DRA access was 97.6%, with conversion to transfemoral access in 2 cases (2.4%). No major complications were reported as a result of DRA access.ConclusionDRA access is a feasible and safe technique for abdominal interventional radiology embolization procedures. No radial artery occlusion or other major complications were observed in patients who underwent follow-up ultrasound.     

Primary Conservative Therapy for Symptomatic Isolated Mesenteric Artery Dissection with Severely Compressed True Lumen or Large Dissecting Aneurysm

PurposeTo investigate the safety and effectiveness of primary conservative therapy for patients with symptomatic isolated mesenteric artery dissection (IMAD) with a severely compressed true lumen and/or a large dissecting aneurysm.Materials and MethodsA total of 35 consecutive patients (all men; median age, 53 y) with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture who were treated with primary conservative therapy between November 2018 and February 2020 were assessed. A severely compressed true lumen was defined as luminal stenosis > 70%. A large dissecting aneurysm was defined as dissecting aneurysm diameter ≥ 1.5 times larger than the normal mesenteric artery diameter.ResultsThere was a strong positive relationship among abdominal pain, degree of luminal stenosis, and length of dissection (R = 0.811; P < .001). Conservative treatment was successful in all patients. Abdominal pain was eliminated within 4.7 d ± 4.8 (range, 2–31 d) in all patients, within 3.6 d ± 1.2 (range, 2–6) in the 31 patients with minor or moderate abdominal pain, and within 13.3 d ± 11.9 (range, 6–31 d) in the 4 patients with severe abdominal pain. Complete or partial remodeling of the mesenteric artery was achieved in 6 (17.1%) and 29 (82.9%) patients, respectively, during 8.6 mo ± 4.3 of follow-up.ConclusionsPrimary conservative therapy can be used safely and effectively in patients with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture.     

In Situ Laser Stent Graft Fenestration of the Left Subclavian Artery during Thoracic Endovascular Repair of Type B Aortic Dissection with Limited Proximal Landing Zones: 5-Year Outcomes

PurposeTo assess safety and feasibility of in situ laser stent graft fenestration to revascularize the left subclavian artery (LSA) during thoracic endovascular repair (TEVAR) of type B aortic dissection (TBAD) with limited proximal landing zones with 5 years of follow-up.Materials and MethodsIn a single-center retrospective study, 130 patients with TBAD with limited proximal landing zones (≤ 1.5 cm) underwent in situ laser stent graft fenestration revascularizing the LSA during TEVAR from April 2014 to April 2019. Outcomes were assessed by CT angiography and clinic visits, including technical success rate, operative time, LSA patency, ischemic events, and late aorta-related complications during follow-up.ResultsMean age of patients was 53 y (range, 33–73 y). Primary technical success rate was 96.9% (126/130). Three chimney stents were placed instead of fenestration, and 1 LSA fenestration was combined with a left common carotid artery (LCCA) chimney stent. Mean operative time was 53 min ± 28 with fluoroscopy time of 40 min ± 15. There were no neurologic complications and no deaths, with a mean duration of hospital stay of 9 d (range, 5–21 d). At a mean follow-up of 42 mo (range, 5–60 mo), there was a 97% primary LSA patency. Four patients had a type I endoleak, which disappeared during follow-up. One LCCA became occluded after 6 months. No type II or III endoleaks were found. Retrograde type A aortic dissection and stent graft–induced new distal entry were not found during follow-up.ConclusionsIn situ laser fenestration to revascularize the LSA during TEVAR of TBAD with limited proximal landing zones was efficient, safe, and feasible based on 5-year follow-up.     

Effects of the Cerebral Aneurysm Treatment Method on Coil Packing Density and Its Relationship with the Ostium Area

PurposeTo test the following hypotheses: (a) balloon or stent assistance increases coil packing density (CPD) in the endovascular treatment of intracranial aneurysms, and (b) CPD correlates to ostium area (OA) and aneurysm volume (AV).Materials and MethodsThis retrospective study included 60 aneurysms (54 ruptured and 6 unruptured) treated with simple coiling (SC) (n = 18), balloon-assisted coiling (BAC) (n = 7), or stent-assisted coiling (SAC) (n = 35) at the authors’ institution between August 2017 and December 2019. AV and OA measurements were obtained from 3-dimensional digital subtraction angiography images using commercial software. Coil sizes were retrieved from patient files, and coil volume (CV) measurements were obtained from https://www.angiocalc.com/. Analysis of covariance, multivariate covariance analysis, and Pearson correlation analyses were performed.ResultsThe median value for AV, CV, CPD, and OA was 63.4 mm³ (range, 5.5–1,771.4 mm³), 23.13 mm³ (range, 2.03–296.95 mm³), 33.29% (range, 13.41%–81.02%), and 10.7 mm² (range, 2.7–49.9 mm²), respectively. Multivariate analysis showed that the CPD values were not significantly different among the treatment groups, although OA significantly differed between the SC and SAC groups (P < .05). Pearson correlations showed that similar to AV, OA was negatively correlated with CPD (r = ?0.321, P < .05).ConclusionsThe CPD value in cerebral aneurysms treated with BAC or SAC did not differ from that in aneurysms treated with SC.     

Changes in Modified Raymond–Roy Classification Occlusion Classes and Predictors of Recurrence-Free Survival in Patients with Intracranial Aneurysms after Endovascular Coil Embolization

PurposeTo assess changes in modified Raymond–Roy classification (MRRC) occlusion classes and recurrence rates over time and evaluate recurrence-free survival after coil embolization and its predictors.Materials and MethodsDuring 2007–2016, 201 patients (mean age, 57.1 ± 13.4 years; 75.5% women) with 240 aneurysms treated with coil embolization were enrolled. MRRC Class I (n = 210), Class II (n = 14), Class IIIa (n = 10), and Class IIIb (n =6) closures were assessed. Recurrence was defined as recanalization in MRRC Class I closures or an increase of at least 20% in any of the dimensions of the remnants of the other classes. Recurrence-free survival and its predictors were analyzed using survival analysis.ResultsMost changes in MRRC class occurred in the first year after treatment. MRRC Class I closures had a slightly lower probability of change than that associated with other classes within 1–5 years, whereas Class IIIb closures remained unchanged. Rates of recurrence or regression for all classes were highest within the first year. The median recurrence-free survival times among patients with Class IIIa and Class IIIb closures were 11.56 and 5.55 months, respectively. Significant predictors of recurrence included aneurysm size of 13–24 mm, ruptured or wide-necked aneurysms, and MRRC Class IIIa or IIIb closures.ConclusionsClass changes and recurrence rates for all MRRC classes were highest in the first year. MRRC Class IIIb closures had the highest recurrence rate and the shortest recurrence-free survival. Recurrence risk increased in Classes IIIa and IIIb and with large, ruptured or wide-necked aneurysms.     

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries

PurposeTo evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR).Materials and MethodsAll patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery.ResultsFifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001).ConclusionsA potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.     

Bronchial Artery Aneurysm: Prevalence,Clinical Characteristics,and Long-Term Prognosis Following Bronchial Artery Embolization

PurposeTo investigate the prevalence, clinical characteristics, and long-term prognosis of bronchial artery aneurysm (BAA) following bronchial artery embolization (BAE).Materials and MethodsThe medical records of consecutive patients who underwent bronchial artery angiography between August 2013 and December 2019 were retrospectively reviewed. Patients who were diagnosed with BAA during this period were included in this study. The prevalence, patients’ characteristics, symptoms, comorbidities, angiographic findings, and long-term prognosis following BAE were investigated.ResultsBAA was observed in 20 of 508 patients who underwent bronchial artery angiography (3.9%). The patients’ median age was 69 (interquartile range [IQR], 63.5–76.7) years. The main causes of BAA were cryptogenic, bronchiectasis or cystic fibrosis, and pulmonary aspergillosis. The median diameter of ruptured BAAs was significantly smaller than that of unruptured BAAs (5.4 mm [IQR, 4.8–7.3 mm] vs 9.0 mm [IQR, 7.2–13.9 mm], P = .009). All the patients were successfully treated with BAE, without major adverse events. The median follow-up period after BAE was 970 (IQR, 561–1,796) days. The BAA-related survival rate was 100% at 2 and 3 years after BAE, and the overall survival rate after BAE was 89.2% (95% confidence interval [CI] 89.0–89.3) at 2 years and 74.3% (95% CI 74.0–74.5) at 3 years. BAA-related adverse events and mortality did not occur during the follow-up period.ConclusionsBAA was observed in 3.9 % (20/508) of the patients who underwent bronchial artery angiography. All the patients with BAA were successfully treated with BAE. BAA rupture and consequent mortality did not occur during the follow-up period.     

Transarterial Yttrium-90 Radioembolization of Hepatocellular Carcinoma Perfused by the Cystic Artery: Multi-institutional Feasibility Study

PurposeTo assess the safety and efficacy of transarterial yttrium-90 radioembolization via the cystic artery for patients with hepatocellular carcinoma (HCC) adjacent to the gallbladder with cystic artery supply.Materials and MethodsThis retrospective study included 17 patients treated at 4 institutions. Patients with HCC perfused by the cystic artery who received ablative-dose radioembolization were included. Median tumor size was 3.8 cm (range, 2.0–8.8 cm). Fourteen patients (82%) had Child–Pugh class A cirrhosis and 3 (18%) had class B cirrhosis. Adverse events, tumor response, and time to progression were analyzed.ResultsMedian dose to the tissue perfused by the cystic artery was 340 Gy (range, 200–720 Gy). There were no occurrences of acute cholecystitis warranting invasive intervention. Four patients (24%) experienced transient right upper quadrant pain, with symptom resolution within 3 mo. Six patients (35%) exhibited gallbladder wall edema on follow-up imaging. Two (12%) and 0 grade 3/4 increases in alkaline phosphatase and bilirubin were observed, respectively. Follow-up imaging demonstrated complete response in 13 target tumors (76%) and partial response in 4 (24%). There were no cases of target tumor progression during a median follow-up of 9 mo (range, 3–72 mo).ConclusionsDirect infusion of ⁹⁰Y microspheres via the cystic artery appears to have an acceptable safety profile, without resulting in acute cholecystitis warranting invasive intervention. In selected patients with HCC in whom other treatments may be contraindicated and the tumor is supplied via the cystic artery, treatment with selective ablative radioembolization can be considered.     

Outcomes of Drug-Coated Balloon Angioplasty for Isolated Chronic Occlusion of the Popliteal Artery: A Retrospective Single-Institution Study

PurposeTo assess the 12-month safety and effectiveness of paclitaxel drug-coated balloon (DCB) for the treatment of patients with isolated chronic occlusions in popliteal arteries and evaluate the risk factors of lesion reocclusion.Materials and MethodsFrom January 2018 to December 2019, DCB angioplasty was performed in 54 limbs with isolated chronic popliteal artery occlusion of 48 patients (32 men) with a mean age of 71.5 ± 12.1 (range, 50–97) years, mean occlusive length of 6.3 ± 3.0 (range, 1–15) cm, and mean preoperative ankle-brachial index (ABI) of 0.42 ± 0.12 (range, 0.19–0.58). A total of 18.5% (10/54) of lesions were long-segment occlusions involving the entire popliteal artery from P1 to P3. Twenty seven of 54 limbs presented with critical limb ischemia (CLI) with a mean ABI of 0.33 ± 0.10 (range, 0.19–0.51). The primary endpoint was primary patency rate at 12 months. The secondary endpoints included technical success rate, 1-year secondary patency rate, limb salvage rate, and improvement in clinical symptoms. Univariate Cox regression analysis was used to determine the predictors of lesion reocclusion.ResultsThe technical success rate was 85.2% (46/54), and bailout stenting was performed in 14.8% (8/54) of lesions. The 12-month primary and secondary patency rates by the Kaplan–Meier estimate were 72.6% and 88.3%, respectively. Two thirds of the reocclusions occurred within 6 months after intervention. No 30-day mortality was observed. The limb salvage rate was 100% during a mean follow-up period of 13 months, and all minor amputations occurred in the limbs presented with CLI. The mean ABI increased from 0.42 before the procedure to 0.73 after the procedure. Patients younger than 60 years and the lesions exhibiting long-segment occlusions present as trending risk factors for lesion reocclusion.ConclusionsPaclitaxel DCB angioplasty is safe and effective in managing isolated chronic occlusion of popliteal arteries. Younger patients and long-segment occlusions of the popliteal artery are associated with a relatively higher reocclusion rate after the procedure.     

Computed Tomography Angiography Prediction of Successful Trasnscatheter Embolization for Type II Endoleak of Endovascular Abdominal Aortic Aneurysm Repair

PurposeTo evaluate the utility of computed tomography (CT) angiography before transarterial embolization (TAE) in predicting TAE’s technical success for type II endoleaks (T2ELs).Materials and MethodsFifty-eight patients (mean age, 74.4 years; range, 46–89 years) who underwent attempted TAE for T2EL from July 2014 to August 2019 and underwent CT angiography before the procedure were included. Each CT angiography result was assessed for a feeding artery that was traceable over its entire course from either the superior mesenteric artery or the internal iliac artery to the endoleak cavity. TAE was performed using coils and was considered technically successful if embolization of the endoleak cavity and feeding artery was performed. The technical success rates were compared between patients with and without traceable feeding arteries.ResultsA fully traceable feeding artery supplying 75% (44/59) of endoleaks in the cohort was identified. TAE was technically successful in 95% (42/44) of these cases but only in 13% (2/15) of the cases without a fully traceable feeding artery (P < .001). When the inferior mesenteric artery was the feeding artery, it was always fully traceable, and TAE was technically successful in 100% (33/33) of the cases. When a lumbar artery was the feeding artery, it was fully traceable in only 42% (11/26) of the cases. When the lumbar artery was not fully traceable, TAE was technically successful in only 13% (2/15) of the cases.ConclusionsThe traceability of a feeding artery over its entire course to an endoleak cavity using CT angiography was associated with TAE’s technical success. Lumbar feeding arteries were less likely to be fully traceable. TAE’s high failure rate when the feeding artery was not fully traceable suggests that translumbar embolization can be considered as an initial approach for theses patients.     

Techniques and Outcomes of Transjugular Intrahepatic Portosystemic Shunting in Infants with Budd-Chiari Syndrome

PurposeTo describe the technical aspects, feasibility, and outcomes in children with Budd-Chiari syndrome (BCS) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation during infancy.Materials and MethodsA retrospective review of infants with BCS undergoing TIPS creation between January 2012 and December 2018 was performed. Eight infants (5 males) underwent TIPS creation (7 for refractory ascites and 1 for refractory variceal bleeding) during the study period. The median age at TIPS creation was 10.5 months (range, 8–16 months). The median elapsed time between presentation and TIPS creation was 6.5 months (range, 0–13 months). The median weight and median pediatric end-stage liver disease score of the infants at the time of TIPS creation were 6.7 kg (range, 5.4–10 kg) and 13 kg (range, 8–18 kg), respectively.ResultsTIPS creation was successful in all patients. There were no immediate postprocedural complications. An 18-gauge hollow needle was manually curved, through which a 21-gauge Chiba needle was inserted to access the portal vein. All patients received 1 or 2 overlapping bare metal stents. One patient was lost to follow-up after the procedure. The median follow-up duration was 32 months (range, 14–51 months). Four of 7 infants needed reintervention. Two children died during the follow-up period. Two children successfully underwent living donor liver transplant, whereas the remaining 3 children were asymptomatic at the follow-up.ConclusionsTIPS creation was found to be safe and efficacious in improving portal hypertension and growth in these children, although, with a higher rate of reinterventions, possibly due to the use of small, bare metal stents.     

Strain Ultrasound Elastography of Aneurysm Sac Content after Randomized Endoleak Embolization with Sclerosing vs. Non-sclerosing Chitosan-based Hydrogels in a Canine Model

PurposeTo compare the mechanical properties of aneurysm content after endoleak embolization with a chitosan hydrogel (CH) with that with a chitosan hydrogel with sodium tetradecyl sulfate (CH-STS) using strain ultrasound elastography (SUE).Materials and MethodsBilateral common iliac artery type Ia endoleaks were created in 9 dogs. Per animal, 1 endoleak was randomized to blinded embolization with CH, and the other, with CH-STS. Brightness-mode ultrasound, Doppler ultrasound, SUE radiofrequency ultrasound, and computed tomography were performed for up to 6 months until sacrifice. Radiologic and histopathologic studies were coregistered to identify 3 regions of interest: the embolic agent, intraluminal thrombus (ILT), and aneurysm sac. SUE segmentations were performed by 2 blinded independent observers. The maximum axial strain (MAS) was the primary outcome. Statistical analysis was performed using the Fisher exact test, multivariable linear mixed-effects models, and intraclass correlation coefficients (ICCs).ResultsResidual endoleaks were identified in 7 of 9 (78%) and 4 of 9 (44%) aneurysms embolized with CH and CH-STS, respectively (P = .3348). CH-STS had a 66% lower MAS (P < .001) than CH. The ILT had a 37% lower MAS (P = .01) than CH and a 77% greater MAS (P = .079) than CH-STS. There was no significant difference in ILT between treatments. The aneurysm sacs embolized with CH-STS had a 29% lower MAS (P < .001) than those embolized with CH. Residual endoleak was associated with a 53% greater MAS (P < .001). The ICC for MAS was 0.807 (95% confidence interval: 0.754–0.849) between segmentations.ConclusionsCH-STS confers stiffer intraluminal properties to embolized aneurysms. Persistent endoleaks are associated with increased sac strain, an observation that may help guide management.