Endovascular Treatment of Anterior Communicating Artery Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:Endovascular therapy has become an acceptable alternative to traditional clipping for the management of intracranial aneurysms. However, a limited number of studies have examined outcomes and complications specific to embolization of anterior communicating artery aneurysms.MATERIALS AND METHODS:A systematic review of the literature was conducted with the use of multiple data bases to identify reports on endovascular treatment of anterior communicating artery aneurysms between 1994 and 2012. Angiographic results, clinical outcomes, and complication rates were pooled across studies by using random-effects meta-analysis with subgroup analysis of outcomes by rupture status and time trend stratification.RESULTS:Fourteen studies, consisting of 1552 treated anterior communicating artery aneurysms, were included in this meta-analysis. The rate of immediate and long-term complete and near-complete angiographic occlusion was 88% (95% CI = 81–93%) and 85% (95% CI = 78–90%), respectively. Intraprocedural rupture rate was 4% (95% CI = 3–6%). The re-bleeding rate was 2% (95% CI = 1–4%) and the retreatment rate was 7% (95% CI = 5–12%). Morbidity or mortality caused by perioperative stroke occurred at a 3% (95% CI = 2–6%) rate. Overall procedure-related morbidity and mortality were 6% (95% CI = 4–8%) and 3% (95% CI = 2–4%), respectively. Outcomes did not differ between ruptured and unruptured aneurysms, nor did outcomes change over time, though these latter subanalyses were relatively underpowered.CONCLUSIONS:Endovascular therapy for anterior communicating artery aneurysms is associated with a high rate of complete angiographic occlusion. However, the procedure-related permanent morbidity and mortality are not negligible for aneurysms in this location.

The anterior communicating artery (AcomA) is the most common location for intracranial aneurysms in most series, and rupture of aneurysms in this location accounts for approximately 40% of aneurysmal subarachnoid hemorrhages in adults.^1–5 Aneurysms of the AcomA can be technically challenging from a surgical perspective because of complex regional flow dynamics, frequent anatomic variations, variable geometry, and the presence of critical perforators.^1,6–10 In the past 2 decades, the inherently less invasive endovascular approach has emerged as a feasible and acceptable treatment option for AcomA aneurysms.^11–14 Continual advancements in endovascular technique and adjuvant devices have led to an enlarging proportion of patients with AcomA aneurysms who are successfully treated with coil embolization.^10,11,15,16 A limited number of case series have detailed the clinical outcomes, angiographic results, and procedure-related complications specific for endovascular treatment in this location.^{10–13,15–24} We performed a systematic review of the published literature to better define safety and efficacy profiles for coil embolization of AcomA aneurysms beyond single-center experiences.     

The Preclose Technique in Percutaneous Endovascular Aortic Repair: A Systematic Literature Review and Meta-analysis

Purpose

To establish the efficacy and safety of the preclose technique in total percutaneous endovascular aortic repair (PEVAR).

Methods

A systematic literature search of Medline database was conducted for series on PEVAR published between January 1999 and January 2012.

Results

Thirty-six articles comprising 2,257 patients and 3,606 arterial accesses were included. Anatomical criteria used to exclude patients from undergoing PEVAR were not uniform across all series. The technical success rate was 94 % per arterial access. Failure was unilateral in the majority (93 %) of the 133 failed PEVAR cases. The groin complication rate in PEVAR was 3.6 %; a minority (1.6 %) of these groin complications required open surgery. The groin complication rate in failed PEVAR cases converted to groin cutdown was 6.1 %. A significantly higher technical success rate was achieved when arterial access was performed via ultrasound guidance. Technical failure rate was significantly higher with larger sheath size (≥20F).

Conclusion

The preclose technique in PEVAR has a high technical success rate and a low groin complication rate. Technical success tends to increase with ultrasound-guided arterial access and decrease with larger access. When failure occurs, it is unilateral in the majority of cases, and conversion to surgical cutdown does not appear to increase the operative risk.     

Adverse Events Related to Partial Splenic Embolization for the Treatment of Hypersplenism: A Systematic Review

Partial splenic embolization is a common procedure that reduces thrombocytopenia in patients with hypersplenism. The present review evaluated the adverse event profile of partial splenic embolization detailed in 30 articles. Although the technical success rate of the procedure in these papers is high, many patients experienced postprocedural complications. Minor complications such as postembolization syndrome occurred frequently. Major complications were less frequent but sometimes resulted in mortality. Underlying liver dysfunction and high infarction rates may be risk factors leading to major complications. Interventional radiologists should be aware of the complication profile of this procedure and further advance research in techniques dealing with hypersplenism.     

Endovascular Treatment of Intracranial Aneurysms with the WEB Device: A Systematic Review of Clinical Outcomes

BACKGROUND AND PURPOSE:Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis.MATERIALS AND METHODS:Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile.RESULTS:The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%–100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%–6.7% and 0%–17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3–27.4 months).CONCLUSIONS:Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.

With the emergence of detachable coils and results of the International Subarachnoid Aneurysm Trial and Barrow Ruptured Aneurysm Trial,^1,2 endovascular coiling has become the first-line option for ruptured intracranial aneurysms. It is also a widely accepted option for unruptured aneurysms that are anatomically suitable for endovascular approaches.³ However, coiling of large and wide-neck intracranial aneurysms is associated with low initial complete obliteration, a high incidence of recanalization (up to 20% at 12 months), and a 10% rate of retreatment.⁴ Promising technologies like flow-diverter stents have the potential to overcome some of the limitations of standard coiling for sidewall aneurysms,^5–7 but the management of large wide-neck bifurcation aneurysms remains challenging. Balloon and stent-assisted techniques have widened the indications for endovascular treatment of aneurysms with a wide neck and/or unfavorable anatomy that were otherwise unsuitable for coiling.^8–10 However, endovascular treatment of such complex intracranial aneurysms requires the use of complex endovascular techniques with double-stent placement in Y and X configurations. Bartolini et al¹¹ suggested that Y and X stent-assisted coiling was associated with a high rate of complications, 10% procedure-related permanent morbidity, and 1% mortality rate.In this context, a new endovascular device, the intrasaccular flow disruptor Woven EndoBridge (WEB; Sequent Medical, Aliso Viejo, California), specifically designed to treat wide-neck bifurcation intracranial aneurysms, has emerged in the past 5 years.^12–14 There is an emerging body of literature on the use of the WEB device, but to our knowledge, no study has specifically reviewed the evidence on its use. We, therefore, performed a literature review of this technique in the management of wide-neck bifurcation intracranial aneurysms. Our specific aims were to evaluate its feasibility, safety, and effectiveness to finally discuss its place in the endovascular treatment of bifurcation intracranial aneurysms.     

Pancreatitis-Associated Splenic Artery Pseudoaneurysm: Endovascular Treatment with Self-Expandable Stent-Grafts

We present a patient with a splenic artery pseudoaneurysm (SAPA) treated with placement of self-expandable stent-grafts. The procedure was complicated by stent-graft migration, but successful management resulted in lasting exclusion of the SAPA, while the patency of the splenic artery was preserved. This is the first report of self-expandable stent-graft treatment of SAPA.     

Conscious Sedation versus General Anesthesia during Endovascular Acute Ischemic Stroke Treatment: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.MATERIALS AND METHODS:In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.RESULTS:Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87–3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36–3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35–0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37–0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.CONCLUSIONS:Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Intra-arterial recanalization for acute ischemic stroke is commonly used in patients with large-vessel occlusion.¹ Timely recanalization of the occluded vessel with either IV-tPA or intra-arterial therapy is essential in preventing neuronal death and improving patient outcome.² A number of factors affect patient outcomes following endovascular recanalization, possibly including choice of anesthetic agent during the procedure. Moderate conscious sedation and general anesthesia with intubation are the 2 most commonly used anesthesia techniques for patients with acute ischemic stroke undergoing endovascular recanalization.³ General anesthesia is often the preferred method due to the perceptions of improved procedural safety and efficacy.³ However, conscious sedation and local anesthesia allow operators to monitor neurologic status during the procedure and avoid delays in procedure initiation.⁴ Furthermore, conscious sedation may be associated with improved hemodynamic stability compared with general anesthesia. Due to the continuing debate regarding anesthesia choices during intra-arterial treatment of acute ischemic stroke, we performed a meta-analysis of studies comparing outcomes of patients with stroke receiving general anesthesia and conscious sedation during the procedures.^5,6     

Endovascular Treatment of a Ruptured Profunda Femoral Artery Branch After Fogarty Thrombectomy of a Femoro-Femoral Crossover Arterial Graft: A Case Report and Review of the Literature

We present a very rare case of a life-threatening rupture of a profunda femoral artery distal branch after a Fogarty thrombectomy of a thrombosed crossover synthetic graft between the ipsilateral common femoral artery and a contralateral iliac-popliteal graft; the bleeding profunda femoral artery branch was successfully embolized with metallic coils through the axillary artery approach.     

Transjugular Renal Biopsy Bleeding Risk and Diagnostic Yield: A Systematic Review

This study aimed to better define the safety and efficacy of transjugular renal biopsy (TJRB) based on published studies. Seventeen published articles were included (1,321 biopsies). Complications were classified as major if they resulted in blood transfusion or additional invasive procedures. All other bleeding complications were considered minor. Diagnostic tissue was obtained in 1,193 procedures (90.3%). The total incidence of bleeding complications among 15 articles with complete data was 202 of 892 procedures (22.6%): 162 (18.2%) minor and 40 (4.5 %) major. These results show that TJRB is a feasible procedure for obtaining renal tissue for diagnosis and that most complications are self-limiting.     

Endovascular Treatment of Internal Carotid Artery Bifurcation Aneurysms: A Single-Center Experience and a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:Endovascular coiling of internal carotid artery bifurcation aneurysms can be challenging due to unfavorable morphologic features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of aneurysms at this location. We performed a systematic review and meta-analysis of published series on the endovascular treatment of ICA bifurcation aneurysms, including a tertiary referral center experience.MATERIALS AND METHODS:We performed a comprehensive literature search for reports on contemporary endovascular treatment of ICA bifurcation aneurysms from 2000 to 2013, and we reviewed our experience. We extracted information regarding periprocedural complications, procedure-related morbidity and mortality, immediate angiographic outcome, long-term clinical and angiographic outcome, and retreatment rate. Event rates were pooled across studies by using random-effects meta-analysis.RESULTS:Including our series of 37 patients, 6 studies with 158 patients were analyzed. Approximately 60% of the aneurysms presented as unruptured; 88.0% (95% CI, 68.0%–96.0%) of aneurysms showed complete or near-complete occlusion at immediate postoperative angiography compared with 82.0% (95% CI, 73.0%–88.0%) at last follow-up. The procedure-related morbidity and mortality were 3.0% (95% CI, 1.0%–7.0%) and 3.0% (95% CI, 1.0%–8.0%), respectively. The retreatment rate was 14.0% (95% CI, 8.0%–25.0%). Good neurologic outcome was achieved in 93.0% (95% CI, 86.0%–97.0%) of patients.CONCLUSIONS:Endovascular treatment of ICA bifurcation aneurysms is feasible and effective and is associated with high immediate angiographic occlusion rates. However, retreatment rates and procedure-related morbidity and mortality are non-negligible.

Internal carotid artery bifurcation aneurysms represent between 2.4% and 4% of all intracranial aneurysms.^1–4 The presence of multiple perforators in this area along with the angle of origin (often skewed toward the MCA or the anterior cerebral artery primarily) can make treatment challenging.³ Additionally, the increased hemodynamic stress at this level translates into a higher rate of recurrence compared with aneurysms in other locations.^4,5 Several studies have focused on the surgical management of ICA bifurcation aneurysms.^2,3,6–10 However, to our knowledge, there is limited evidence regarding their treatment by using endovascular techniques. To better understand the safety and efficacy of endovascular treatment for ICA bifurcation aneurysms, we report both our own experience and the results of a meta-analysis of the literature.     

Endovascular Treatment of Unruptured Paraclinoid Aneurysms: Single-Center Experience with 400 Cases and Literature Review

BACKGROUND AND PURPOSE:Paraclinoid aneurysms have been increasingly treated endovascularly. The natural history of these aneurysms has gradually been elucidated. The purpose of this study was to assess the safety and efficacy of endovascular treatment for these aneurysms.MATERIALS AND METHODS:We performed a retrospective review of 377 patients with 400 paraclinoid aneurysms treated between January 2006 and December 2012. Their clinical records, endovascular reports, and radiologic and clinical outcomes were analyzed. Because aneurysms ≥7 mm are at higher risk of rupture, we classified aneurysms as small (<7 mm) or large (≥7 mm).RESULTS:Overall, 115 of the 400 aneurysms (28.8%) were large (≥7 mm). Thromboembolic complications were found significantly more often with large aneurysms than with small ones (7.4% vs 1.0%, P = .001). Hemorrhagic complications were found only with small aneurysms (0.7%). The 6-month morbidity rates were similar for small (1.0%) and large (0.8%) aneurysms. Immediate angiographic outcomes were similar (P = .37), whereas recurrences and retreatment occurred more frequently with large aneurysms (P = .001 and P = .007, respectively). Multivariate analysis showed that aneurysm size was the only independent predictor for recurrence (P = .005). Most recurrences (81%) were detected by scheduled angiography at 6 months.CONCLUSIONS:Aneurysm size influenced the type of complication (thromboembolic or hemorrhagic) and the recurrence rate. Given the approximately 1% annual rupture rate for aneurysms ≥7 mm, analysis of our data supports the rationale of using prophylactic endovascular treatment for unruptured paraclinoid aneurysms ≥7 mm.

Paraclinoid aneurysms are located in the clinoid and ophthalmic segments of the ICA.¹ Because of the anatomic structures adjacent to the segments of the ICA (eg, anterior clinoid process, cavernous sinus, optic apparatus), microsurgical treatment of a paraclinoid aneurysm can be challenging.² With the development of novel devices and the need for less-invasive treatment, an increasing number of paraclinoid aneurysms have been treated by endovascular treatment. The natural history of unruptured intracranial aneurysms has been reported as represented by the International Study of Unruptured Intracranial Aneurysms and the Unruptured Cerebral Aneurysm Study (UCAS) by Japanese investigators.^3–8 According to these studies, the size and location of the aneurysms were regarded as leading predictors of rupture. The UCAS Japan investigators reported that the annual rupture rate of paraclinoid aneurysms was 1% overall when they were 7–24 mm in largest dimension.⁷ Therefore, aneurysms ≥7 mm would be good candidates for prophylactic endovascular treatment. There have been no studies reported, however, that analyzed the complication and recurrence rates relative to the annual rupture rate.^9–15The purpose of the present study was to assess the safety and efficacy of endovascular treatment for paraclinoid aneurysms in a cohort of 400 cases. The advantage of this study was that we could estimate the clinical outcome of endovascular treatment for these aneurysms in comparison with the natural history of an aneurysm of the same size in the same ethnic population by using the UCAS Japan data.     

Diffusion-Weighted Imaging–Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms.MATERIALS AND METHODS:A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model.RESULTS:Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%–56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%–85%; versus 45%; 95% CI, 33%–56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%–60%; P = .99) or stent-assisted (43%; 95% CI, 24%–63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions.CONCLUSIONS:One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events.

Coil embolization and flow diversion have proved highly efficacious options for the endovascular treatment of intracranial aneurysms. However, both techniques are associated with potential periprocedural complications, including aneurysm rupture, transient ischemic attacks, and ischemic stroke. Small, silent infarcts caused by thromboemboli are often seen on postprocedural diffusion-weighted imaging. While many of these lesions remain ostensibly asymptomatic, the long-term effects of such tiny infarcts remain unclear.^1–3Previous studies have reported that the rate of ischemic lesions on postoperative DWI ranges from 10% to 77% following coil embolization^4–15 and 51% to 63% following therapy with flow diversion.^16–19 However, baseline clinical and angiographic risk factors for postoperative DWI lesions, to our knowledge, have not been fully elucidated previously. We performed a systematic review and meta-analysis for the following: 1) to determine the overall incidence of perioperative infarcts on DWI in patients undergoing endovascular treatment of intracranial aneurysms; and 2) to demonstrate the relationship between treatment type, patient demographics, and aneurysm characteristics with postoperative infarcts on DWI.     

Comparing Endovascular and Surgical Treatments for Varicocele: A Systematic Review and Meta-Analysis

PurposeTo conduct a systematic review and meta-analysis to assess the relative efficacy of endovascular and surgical treatments for varicocele.Materials and MethodsPubMed and Embase databases were systematically searched to identify studies reporting on the outcomes associated with surgical or endovascular treatments of varicoceles. The studies that assessed the relative efficacy of surgical and endovascular treatments for patients with clinical varicocele were eligible for inclusion. Pooled data analyses were performed.ResultsA total of 16 studies incorporating 2,138 patients were included in the present meta-analysis. The pooled risk ratio (RR) values suggested that rates of adverse events were lower among patients who underwent endovascular treatment than those who underwent surgical treatment (RR, 0.63; 95% confidence interval (CI), 0.42–0.93; P = .02). Both treatments were associated with similar rates of recurrence (RR, 1.03; 95% CI, 0.78–1.36; P = .82) and pregnancy (RR, 1.03; 95% CI, 0.85–1.25; P = .82).ConclusionsThese data demonstrate that endovascular treatment for varicocele is associated with similar rates of recurrence and subsequent pregnancy outcomes compared with surgical treatment but with lower rates of adverse events.     

Endovascular Coiling of Wide-Neck and Wide-Neck Bifurcation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:We present the results of a systematic review and meta-analysis examining outcomes of endovascular coiling of wide-neck and wide-neck bifurcation aneurysms with and without stent assistance. The aim of our study was to assess angiographic and clinical outcomes.MATERIALS AND METHODS:We performed a comprehensive literature search for all articles on the endovascular coiling of wide-neck and wide-neck bifurcation aneurysms. Studies meeting our inclusion criteria and abstracted data were selected by 2 independent reviewers. Primary outcomes were >6-month complete or near-complete angiographic occlusion, aneurysm recanalization, and aneurysm retreatment. Secondary outcomes included initial complete or near-complete occlusion, long-term good neurologic outcome, procedure-related morbidity, and procedure-related mortality. Data were analyzed by using random-effects meta-analysis.RESULTS:In total, 38 studies including 2446 patients with 2556 aneurysms were included. For all wide-neck aneurysms, immediate complete or near-complete occlusion rate was 57.4% (95% CI, 48.1%–66.8%). Follow-up near-complete occlusion rate was 74.5% (95% CI, 68.0%–81.0%). Recanalization and retreatment rates were 9.4% (95% CI, 7.1%–11.7%) and 5.8% (95% CI, 4.1%–7.5%), respectively. Long-term good neurologic outcome was 91.4% (95% CI, 88.5%–94.2%). For wide-neck bifurcation aneurysms, initial complete or near-complete occlusion rate was 60.0% (95% CI, 42.7%–77.3%), long-term complete or near-complete occlusion rate was 71.9% (95% CI, 52.6%–91.1%), and the recanalization and retreatment rates were 9.8% (95% CI, 7.1%–12.5%) and 5.2% (95% CI, 1.9%–8.4%), respectively.CONCLUSIONS:Our study of angiographic and clinical outcomes for patients with wide-neck aneurysms demonstrates that endovascular coiling with or without stent-assisted coiling is safe, with low rates of perioperative morbidity and mortality. Initial and long-term angiographic outcomes were generally satisfactory, but not ideal. These data provide some baseline comparisons against which emergent technologies can be assessed.

With the advent of stent-assisted and balloon-assisted coiling, wide-neck and wide-neck bifurcation intracranial aneurysms are increasingly treated with endovascular techniques to prevent hemorrhage or recurrent bleeding. Both stent-assisted and balloon-assisted coiling have been shown to be safe and effective in the treatment of these aneurysms by allowing for increased packing density and lower rates of parent artery occlusion compared with conventional coiling alone.^1–5 Even in the era of endoluminal and intrasaccular flow diverters, many wide-neck and wide-neck bifurcation aneurysms will continue to be treated with conventional coiling, particularly with stent assistance.^6–8We present the results of a systematic review and meta-analysis examining outcomes of endovascular coiling of wide-neck and wide-neck bifurcation aneurysms with and without stent-assisted coiling. The aim of our study was to assess both angiographic and clinical outcomes in order to provide overall data against which current and future emergent techniques can be compared.     

Endovascular Stenting for Restenosis of the Intracranial Vertebrobasilar Artery After Balloon Angioplasty: Two Case Reports and Review of the Literature

Percutaneous transluminal balloon angioplasty (PTA) has been used in the treatment of critical stenosis of the intracranial vertebrobasilar artery (VBA). PTA of the intracranial VBA carries the risk of fatal complications such as arterial dissection or acute occlusion as well as postoperative restenosis. The estimated risk of periprocedural complications and restenosis were approximately 20% and 27%. The use of recently developed stents could prevent these problems of PTA. We present two cases of restenosis of the intracranial VBA after PTA which stenoses were successfully retreated with endovascular stenting using flexible coronary stents without any complications. Neither restenosis nor other recurrent symptoms were observed during the 4- and 6-month follow-up period. Reviewing the literature of 33 cases and our 2 cases, the overall complication rates related to stenting and restenosis were 5.6% and 7.8%. Endovascular stenting for the treatment of intracranial VBA can reduce the risk of arterial dissection and restenosis.     

Transjugular Endovascular Recanalization of Splenic Vein in Patients with Regional Portal Hypertension Complicated by Gastrointestinal Bleeding

Purpose

Regional portal hypertension (RPH) is an uncommon clinical syndrome resulting from splenic vein stenosis/occlusion, which may cause gastrointestinal (GI) bleeding from the esophagogastric varices. The present study evaluated the safety and efficacy of transjugular endovascular recanalization of splenic vein in patients with GI bleeding secondary to RPH.

Methods

From December 2008 to May 2011, 11 patients who were diagnosed with RPH complicated by GI bleeding and had undergone transjugular endovascular recanalization of splenic vein were reviewed retrospectively. Contrast-enhanced computed tomography revealed splenic vein stenosis in six cases and splenic vein occlusion in five. Etiology of RPH was chronic pancreatitis (n = 7), acute pancreatitis with pancreatic pseudocyst (n = 2), pancreatic injury (n = 1), and isolated pancreatic tuberculosis (n = 1).

Results

Technical success was achieved in 8 of 11 patients via the transjugular approach, including six patients with splenic vein stenosis and two patients with splenic vein occlusion. Two patients underwent splenic vein venoplasty only, whereas four patients underwent bare stents deployment and two covered stents. Splenic vein pressure gradient (SPG) was reduced from 21.5 ± 7.3 to 2.9 ± 1.4 mmHg after the procedure (P < 0.01). For the remaining three patients who had technical failures, splenic artery embolization and subsequent splenectomy was performed. During a median follow-up time of 17.5 (range, 3–34) months, no recurrence of GI bleeding was observed.

Conclusions

Transjugular endovascular recanalization of splenic vein is a safe and effective therapeutic option in patients with RPH complicated by GI bleeding and is not associated with an increased risk of procedure-related complications.     

Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments

BACKGROUND AND PURPOSE:Various endovascular techniques have been applied to treat blister-like aneurysms. We performed a systematic review to evaluate endovascular treatment for ruptured blister-like aneurysms.MATERIALS AND METHODS:We performed a comprehensive literature search and subgroup analyses to compare deconstructive versus reconstructive techniques and flow diversion versus other reconstructive options.RESULTS:Thirty-one studies with 265 procedures for ruptured blister-like aneurysms were included. Endovascular treatment was associated with a 72.8% (95% CI, 64.2%–81.5%) mid- to long-term occlusion rate and a 19.3% (95% CI, 13.6%–25.1%) retreatment rate. Mid- to long-term neurologic outcome was good in 76.2% (95% CI, 68.9%–8.4%) of patients. Two hundred forty procedures (90.6%) were reconstructive techniques (coiling, stent-assisted coiling, overlapped stent placement, flow diversion) and 25 treatments (9.4%) were deconstructive. Deconstructive techniques had higher rates of initial complete occlusion than reconstructive techniques (77.3% versus 33.0%, P = .0003) but a higher risk for perioperative stroke (29.1% versus 5.0%, P = .04). There was no difference in good mid- to long-term neurologic outcome between groups, with 76.2% for the reconstructive group versus 79.9% for the deconstructive group (P = .30). Of 240 reconstructive procedures, 62 (25.8%) involved flow-diverter stents, with higher rates of mid- to long-term complete occlusion than other reconstructive techniques (90.8% versus 67.9%, P = .03) and a lower rate of retreatment (6.6% versus 30.7%, P < .0001).CONCLUSIONS:Endovascular treatment of ruptured blister-like aneurysms is associated with high rates of complete occlusion and good mid- to long-term neurologic outcomes in most patients. Deconstructive techniques are associated with higher occlusion rates but a higher risk of perioperative ischemic stroke. In the reconstructive group, flow diversion carries a higher level of complete occlusion and similar clinical outcomes.

Blister-like aneurysms (BLAs) are intracranial arterial lesions originating at nonbranching sites of the dorsal supraclinoid internal carotid artery and basilar artery. BLAs account for 0.3%–1% of intracranial aneurysms and 0.9%–6.5% of ruptured aneurysms.^1–6 They are attributed to subadventitial dissections resulting in a focal wall defect with absence of internal elastic lamina and media, leading, in most cases, to acute subarachnoid hemorrhage. The arterial gap is only covered with adventitia and thin fibrinous tissue.^4,7–10Ruptured BLAs have a high mortality rate. Furthermore, treatment of these lesions is technically difficult because they often lack a defined neck and the aneurysm sac has a very thin wall.^4,11–13 Thus, ruptured BLAs are associated with high rates of spontaneous or treatment-induced rebleed and death, regardless of treatment type.^2,4,13,14Many surgical techniques such as wrapping or trapping with bypass have been described for the treatment of these lesions. However, such techniques are often associated with high perioperative morbidity and mortality rates.^{8,10,11,13,15–20} Because of these results, endovascular techniques, both reconstructive and deconstructive, have emerged as the treatment of choice due to perceived lower rates of treatment-related morbidity and higher efficacy.^{2–4,12,21–25} However, because of the rarity of these lesions, most series on endovascular treatment of BLAs are small retrospective single-center case series. Thus, the efficacy and safety of endovascular treatment of these lesions have not been well-established.⁴ In addition, little is known regarding whether reconstructive techniques with parent artery preservation are associated with similar rates of angiographic occlusion and improved clinical outcomes compared with deconstructive parent artery sacrifice.¹³ Therefore, we performed a systematic review of the literature examining the overall efficacy of endovascular treatments for ruptured BLAs and comparing outcomes of reconstructive techniques such as stent placement, flow diversion, and stent-assisted coiling with deconstructive techniques such as parent artery occlusion and trapping. We also performed a subgroup analysis comparing the safety and efficacy of flow-diverter treatment with other reconstructive techniques.     

Accessory Splenic Artery: A Rare Cause of Upper Gastrointestinal Bleeding

CardioVascular and Interventional Radiology - Variations in the origin and branching pattern of splenic artery are relatively common and asymptomatic, but the presence of an accessory splenic...     

Clavicle Fractures: A Review of the Literature and Update on Treatment

Abstract

Clavicle fractures are common, and it is important for primary care physicians to be familiar with basic principles of evaluation and management in order to initiate treatment as well as discuss these injuries with patients and consulting orthopedic surgeons. These injuries are almost always the result of trauma (often a direct blow to the shoulder) and occur most often in the young male population. Evaluation begins with a thorough history and physical examination and typically progresses to plain radiographs identifying the fracture site and pattern. These fractures have been classified by Allman into groups I (mid-shaft), II (lateral), and III (medial); this classification, along with fracture characteristics (eg, displacement and comminution) is used to assist with determining the strategy for management. Although nondisplaced fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment, various forms of open reduction and internal fixation are now commonly used to treat fractures with little or no cortical contact between fragments. Open reduction and internal fixation has shown superior results compared with conservative management in recent trials of management of displaced fractures. Nonunion and malunion are rare, but may be symptomatic in a subset of patients. These complications may be addressed with open reduction and internal fixation, bone grafting, and osteotomy as needed.     

Transcatheter Splenic Artery Occlusion for Treatment of Splenic Artery Steal Syndrome After Orthotopic Liver Transplantation

Purpose: To review some aspects of the problem of splenic artery steal syndrome as cause of ischemia in transplanted livers and treatment by selective splenic artery occlusion. Materials and Methods: Eleven liver transplant patients from a group of 350 patients, nine men and two women, ranging in age from 40 years to 61 years (mean 52 years), presented with biochemical evidences of liver ischemia and failure, ranging from one to 60 days following orthotopic liver transplantation. Diagnosis of splenic artery steal syndrome was suspected by elevated enzymes, Doppler ultrasound and confirmed by celiac angiogram. Patients with confirmed hepatic artery thrombosis before angiography were excluded from the study. Embolization with Gianturco coils was performed. Results: All patients were treated by splenic artery embolization with Gianturco coils. The 11 patients improved clinically within 24 hours of the procedure with significant change in the biochemical and clinical parameters. Followup ranged from one month to two years. One of the 11 patient initially improved, but developed hepatic artery thrombosis within 24 hours of the embolic treatment, requiring surgical repair. Conclusion: Splenic artery steal syndrome following liver transplantation surgery can be diagnosed by celiac angiography, and effectively treated by splenic artery embolization with coils. Embolization is one of the treatments available, it is minimally invasive, and leads to immediate clinical improvement. Hepatic artery thrombosis is a possible complication of the procedure.