Efficacy of Peripheral Interventional Radiologists Performing Endovascular Stroke Therapy Guided by CT Perfusion Triage of Patients

PurposeTo assess safety and efficacy of intraarterial mechanical thrombectomy for treatment of ischemic stroke in a community hospital by peripheral interventional radiologists employing computed tomography (CT) perfusion imaging for patient selection.Materials and MethodsForty patients, 11 men (27.5%) and 29 women (72.5%), were treated between February 2008 and October 2011. Eligible patients had a National Institutes of Health Stroke Scale (NIHSS) score greater than 8 and diagnosis of large-vessel ischemic stroke by head CT angiogram, and met previously reported CT perfusion imaging triage criteria.ResultsThe baseline NIHSS score was 18.0 ± 7.9 (range, 8–35). Sixteen patients (40%) had a baseline NIHSS score greater than 20. Symptom onset was unknown in five patients. Symptom onset to device time in the remaining 35 patients was 254.8 minutes ± 150.9 (range, 75–775 min). A total of 65% of patients showed thrombolysis in cerebral infarction (TICI) 2a, 2b, or 3 flow following the procedure. Symptomatic intracranial hemorrhage was seen in four patients (10.0%). At 90 days, 32 patients (80%) were alive and eight (20%) had died. The modified Rankin scale (mRS) score at 90 days was no more than 2 in 20 patients (50.0%). The mean mRS score at 90 days was 2.9 ± 2.0 (range, 0–6). NIHSS score at 90 days was 5.1 ± 6.1 (range, 0–24). In patients with successful recanalization (ie, TICI 2 or 3 flow), a good clinical outcome (ie, mRS score ≤ 2) was achieved in 65.3% of patients (mean, 2.4 ± 1.9; range, 0–6), and 90-day mortality rate was 15.4%, compared with 28.6% in patients with TICI 0/1 flow.ConclusionsPeripheral interventional radiologists who use CT perfusion imaging for patient triage can have good neurologic outcomes and provide sustainable, safe, and complete around-the-clock coverage for endovascular stroke treatment.     

Endovascular Procedures versus Intravenous Thrombolysis in Stroke with Tandem Occlusion of the Anterior Circulation

PurposeStroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome.Materials and MethodsThirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days.ResultsPatients treated with EPs (n = 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n = 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P = .01), major neurologic improvement (EP, 64%; IV, 19%; P = .01), and independent outcome (mRS score ≤ 2; EP, 54% IV, 13%; P = .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P = .03) were observed less often. Rates of sICH (P = .12) and death within 7 days (P = .74) did not differ significantly.ConclusionsHigher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.     

Relationship of Thrombus Length to Number of Stent Retrievals,Revascularization, and Outcomes in Acute Ischemic Stroke

PurposeTo study the relationship between intracranial thrombus length and number of stent retrievals, revascularization rates, and functional outcomes in stroke.Materials and MethodsRetrospective data were collected from consecutive cases of stroke treated with endovascular procedures at a single institution from April 2012–September 2013. Thrombus length was measured in the anterior cerebral circulation. Demographic and clinical details; involved vessels; and procedural details, including the number of devices used and number of retrievals used for each device, were recorded. Revascularization rates and 90-day functional outcomes were recorded.ResultsData regarding the length of thrombus in the anterior cerebral circulation were available for 28 patients. There was no significant association between thrombus length and number of stent retrievals (P = .3780), final thrombolysis in cerebral infarction (TICI) score (P = .4835), or 90-day modified Rankin Scale score (P = .4146). There was a significant difference (P = .0280) between number of retrievals and final TICI score, with lower number of retrieval passes corresponding to higher final TICI scores.ConclusionsThe data suggest no relationship between thrombus length and number of stent retrievals, final TICI score, or functional neurologic outcomes at 90 days in stent retrieval thrombectomy for acute ischemic stroke. These results do not support a predictive value for thrombus length quantification in the evaluation of stroke.     

Combined Antegrade Femoral Artery and Retrograde Popliteal Artery Recanalization for Chronic Occlusions of the Superficial Femoral Artery

PurposeTo evaluate the efficacy and safety of a dual femoral–popliteal approach in the supine position after failed antegrade recanalization attempts in chronic total occlusion (CTO) of the superficial femoral artery (SFA).Materials and MethodsFrom May 2011 to October 2012, 21 patients underwent dual femoral–popliteal recanalization for CTO of the SFA, with a mean lesion length of 87.4 mm ± 5.8. When contralateral antegrade recanalization of SFA occlusions via the common femoral artery could not be achieved, the occlusions were intrainterventionally accessed by retrograde approach via the popliteal artery, which was punctured anteriorly with gently flexed knee and crus extorsion. When the SFA had been recanalized, further angioplasty and stent placement procedures were completed via the femoral artery.ResultsA technical success rate of 100% (entailing puncture of the popliteal artery and SFA recanalization) was achieved, and no hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, or other complications developed. During a mean follow-up of 9.8 months ± 1.5, claudication severity, rest pain, and toe ulcers improved significantly. The pulse of the distal arteries, as well as the filling of the veins, could be distinctly felt. Ankle-brachial index changed from 0.48 ± 0.17 to 0.84 ± 0.11 at 1 year after intervention (P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 80%, and 42%, respectively.ConclusionsA dual femoral–popliteal approach in the supine position is an alternative backup option after failed attempts at the antegrade approach for patients with proximal barriers in CTO or lesions with major extending collateral vessels.     

Recanalization of Chronic Total Occlusions of the Superior Mesenteric Artery in Patients with Chronic Mesenteric Ischemia: Technical and Clinical Outcomes

PurposeTo evaluate the safety and outcomes of endovascular recanalization of chronic total occlusions (CTOs) of the superior mesenteric artery (SMA) in patients with chronic mesenteric ischemia (CMI).Materials and MethodsA single-institution retrospective review was performed of 47 consecutive patients (18 male, 29 female) who underwent endovascular stent placement for CTOs of the SMA between February 2006 and November 2012. All patients had symptoms of CMI. Procedural and follow-up data were collected for assessment of technical success, safety, and outcome.ResultsTechnical success was achieved in 41 of 47 patients (87%). Forty-two of the 47 procedures were performed from a femoral approach. Fifteen patients underwent concurrent revascularization of the celiac artery. All patients who underwent successful recanalization reported symptomatic improvement. Kaplan–Meier analysis revealed primary freedom from symptomatic recurrence of 95% at 12 months and 78% at 24 months. Symptomatic recurrence was observed in seven patients, all of whom underwent successful assisted or secondary endovascular procedures. Secondary freedom from symptomatic recurrence rates were 100% at 12 months and 88% 24 months. There were three (7%) minor access-related complications and no major complications.ConclusionsEndovascular stent-assisted recanalization of chronic SMA occlusions is safe and effective, with an acceptable rate of technical success and excellent midterm clinical outcomes.     

Percutaneous Metallic Stent Placement in Patients with Cancer Recurrence at Bilioenterostomy Site

PurposeTo investigate the outcomes of percutaneous metallic stent placement in patients with malignant bilioenterostomy obstruction and to assess the risk factors influencing stent patency.Materials and MethodsFrom August 2008 to January 2012, 53 patients with malignant bilioenterostomy obstructions were treated with percutaneous placement of biliary metallic stents; this included expanded polytetrafluoroethylene (ePTFE)–covered stent placement in 36 patients and uncovered stent placement in 17 patients.ResultsA total of 75 stents were successfully placed in 53 patients. No major complications occurred in any patients, and minor complications occurred in nine patients (17%). The mean serum bilirubin level, which was 3.6 mg/dL ± 0.7 before drainage, decreased significantly to 2.5 mg/dL ± 0.4 at 1 month after stent placement (P = .041). Successful internal drainage was achieved in 44 of the 53 patients (83%). Kaplan–Meier analysis showed a median overall survival time of 145 days (95% confidence interval, 100–190 d), a median stent patency time of 313 days (95% confidence interval, 46–580 d), and cumulative stent patency rates at 1, 3, 6, 9, and 12 months of 91%, 75%, 64%, 56%, and 45%, respectively. Multivariate Cox regression analysis showed that the use of uncovered stents (odds ratio, 2.924; P = .033) was the only significant independent factor associated with stent occlusion.ConclusionsPercutaneous metallic stent placement is a safe and effective method for the treatment of patients with malignant bilioenterostomy obstruction. Moreover, as uncovered stent placement is the only significant independent factor associated with stent occlusion, ePTFE-covered stent placement is preferable in these patients.     

A Novel Resorbable Embolization Microsphere for Transient Uterine Artery Occlusion: A Comparative Study with Trisacryl-Gelatin Microspheres in the Sheep Model

PurposeTo evaluate angiographic recanalization, inflammatory reaction, and uterine damage after sheep uterine artery embolization (UAE) with a novel calibrated resorbable embolization microsphere (REM) and compare the results with control nonresorbable microspheres.Materials and MethodsSix hormonally artificially cycled sheep underwent bilateral UAE until stasis with either REM or trisacryl-gelatin microspheres (TGMS). At 7 days, control angiograms were obtained to assess the residual vascularization at arterial and parenchymal phases. The animals were then sacrificed for analysis of the presence of microspheres, inflammatory foreign body reaction, and surface areas of uterine damage.ResultsMean volume of microspheres injected per uterine artery (UA) or per animal did not differ between groups. At day 7, the flow was normal for six of six UAs that received embolization with REM versus only three of six UAs with TGMS (P = .0455, χ² test). Uterine parenchymography showed no defects in six UAs in the REM group versus five defects in six UAs in the TGMS group (P = .0060, χ² test). No REM or residual fragments of microspheres were observed on histologic analysis. TGMS were observed in tissues and accompanied by a mild inflammatory response. Necrosis rates were not significantly different between the two products, either in endometrium (REM 23.5% ± 28.8% [median 8.1%] vs TGMS 21.8% ± 23.7% [median 14.6%]) or in myometrium (REM 8.2% ± 22.7% [median 0.0%] vs TGMS 8.8% ± 20.8% [median 0.9%]). Endometrium alteration rate was lower with REM than with TGMS (39.7% ± 25.7% [median 34%] vs 60.6% ± 27.1% [median 71%]; P = .0060, Mann-Whitney test). Myometrium alteration rates were not significantly different between REM (45.7% ± 37.1% [median 63.0%]) and TGMS (37.8% ± 34.0% [median 19.1%]).ConclusionsAt 1 week after sheep UAE with REM, the recanalization was complete, the microspheres were completely degraded, and there was no remnant inflammatory response.     

Evaluating Patency Rates of an Ultralow-Porosity Expanded Polytetrafluoroethylene Covered Stent in the Treatment of Venous Stenosis in Arteriovenous Dialysis Circuits

PurposeTo evaluate the efficacy of an ultralow-porosity expanded polytetrafluoroethylene (ePTFE) covered stent in the treatment of autogenous arteriovenous fistula (AVF) and prosthetic arteriovenous graft (AVG) venous outflow stenoses.Materials and MethodsClinical and angiographic outcomes of 20 consecutive patients with arteriovenous dialysis circuits treated with the endoprosthesis were reviewed following institutional review board approval. Patients were followed routinely at 2 months and 6 months after stent placement, or earlier if clinically warranted. The primary endpoint was 2- and 6-month primary treatment area patency. Secondary endpoints included primary circuit patency, primary assisted patency, and secondary patency.ResultsEleven patients with AVFs and nine patients with AVGs were treated successfully with the covered stent. Primary treatment area patency rates were 85% ± 16 at both 2 months and 6 months. Primary circuit patency rates were was 65% ± 21 and 45% ± 22, respectively; primary assisted patency rates were 90% ± 13 and 85% ± 16, respectively; and secondary patency rates were 100% and 90% ± 13, respectively. Of the three cases of lost primary treatment area patency, two developed thrombosis and one developed recurrent stenosis. No significant differences were found between patients with AVFs and AVGs.ConclusionsData from this preliminary study suggests that the ultralow-porosity ePTFE covered stent may be a clinically viable option for treatment of venous outflow stenoses in arteriovenous vascular access circuits.     

Pharmacomechanical Thrombolysis of Symptomatic Acute and Subacute Deep Vein Thrombosis with a Rotational Thrombectomy Device

PurposeTo retrospectively evaluate the efficacy and safety of pharmacomechanical thrombolysis (PMT) with the use of a rotational thrombectomy device for symptomatic deep vein thrombosis (DVT).Materials and MethodsBetween July 2012 and August 2013, 41 patients with acute or subacute DVT underwent PMT. The Cleaner thrombectomy device was used in a single-session technique for patients with lower-extremity DVT. Based on contrast venography, the extent of lysis was graded from I (< 50%) to III (complete).ResultsSixteen patients (39.0%) had a femoropopliteal thrombosis and 25 (61.0%) had an iliofemoral venous thrombosis. The mean duration of symptoms was 11.0 days (range, 3–25 d). The mean quantity of tissue plasminogen activator was 20.7 mg (range, 10–50), and the mean duration of the procedure was 74.3 minutes (range, 30–240 min). At the end of the PMT procedure, 29 patients (70.7%) had complete (grade III) thrombus resolution. Grade I and II lysis were noted in one (2.4%) and 11 (26.8%) patients, respectively. Thirty-eight of the 41 patients were treated with PMT in a single session, and three (7.3%) required an additional lytic infusion as a result of residual thrombi. The overall grade III, II, and I thrombus resolution rates, including the supplemental thrombolysis, were 73.2% (n = 30), 22.0% (n = 9), and 4.9% (n = 2), respectively. There was no mortality.ConclusionsUse of the Cleaner thrombectomy device is a promising alternative to current treatment modalities for the management of DVT in a single session of PMT.     

Endovascular Recanalization of Native Chronic Total Occlusions in Patients with Failed Lower-Extremity Bypass Grafts

PurposeTo investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts.Materials and MethodsRetrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication.ResultsThe mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively.ConclusionsEndovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.     

Long-term Outcomes of Coil Packing for Visceral Aneurysms: Correlation between Packing Density and Incidence of Coil Compaction or Recanalization

PurposeTo evaluate the correlation between packing density and the incidence of coil compaction or recanalization of visceral artery aneurysms (VAAs) after coil packing.Materials and MethodsBetween July 2004 and April 2012, coil packing was performed for 46 true visceral aneurysms (16 splenic, 11 pancreaticoduodenal, eight renal, six hepatic, three superior mesenteric, one right gastric, and one gastroepiploic) in 42 patients. The size and volume of the aneurysm, packing density, and the incidences of compaction and recanalization were evaluated retrospectively.ResultsThe mean follow-up period was 37 months ± 8 (range, 11–80 mo). The mean packing density was 19% ± 8 (range, 5%–42%), mean aneurysm size was 19 mm ± 8 (range, 5–40 mm), and mean volume was 4,108 mm³ ± 5,435 (range, 72–26,235 mm³). Compaction and recanalization occurred in two (4%) and 12 aneurysms (26%), respectively. The mean packing density was significantly lower in aneurysms with compaction or recanalization than in unaffected aneurysms (12% vs 22%; P = .00014). There was a significant difference in mean packing density between small (< 20 mm; 22%) and large (≥ 20 mm) aneurysms (15%; P = .0045). The mean size and volume were significantly larger for coil-compacted or recanalized aneurysms than for unaffected aneurysms (P < .05). In aneurysms with a packing density of at least 24%, no compaction or recanalization occurred.ConclusionsCoil compaction or recanalization after coil packing for VAAs more often occurs after insufficient embolization with low packing density and in patients with large aneurysms.     

Endovascular Venous Thrombolysis in Children Younger than 24 Months

PurposeTo evaluate the technical feasibility and safety of percutaneous endovascular thrombolysis for extremity deep venous thrombosis (DVT) in children < 24 months old.Materials and MethodsA retrospective chart review of a clinical and imaging database was performed for pediatric patients who underwent endovascular therapy for DVT between January 2010 and July 2013. Indications, techniques, technical and clinical success, and complications were reviewed. Techniques for thrombolysis included catheter-directed therapy (CDT) using alteplase infusion via a multi–side hole catheter, mechanical thrombectomy, and angioplasty. Short-term outcomes were assessed using surgical and imaging follow-up examinations for patency of the targeted vessel. Patients included 11 children (mean age, 9 mo; range, 3 wk–23 mo) who consecutively underwent endovascular thrombolysis for upper extremity (n = 6) or lower extremity (n = 5) DVT. The most common indication was preservation of venous access for future cardiac surgery or medical therapy.ResultsThe most common risk factor was the presence of a central venous catheter (10 of 11 patients). All patients with upper extremity DVT had congenital heart disease. CDT and angioplasty were performed in all patients. Venous patency was established in all patients. A grade III (95%–100%) thrombolysis response was achieved in seven patients, and a grade II (50%–95%) thrombolysis response was achieved in four patients. A major complication of pulmonary embolism occurred in one patient with upper extremity thrombolysis and was managed by intravenous systemic alteplase and heparin. No recurrence of thrombosis was found on average follow-up of 11.8 months (range, 1–41 mo).ConclusionsPercutaneous endovascular thrombolysis for extremity DVT is safe and technically feasible in children < 24 months old.     

Technical Details and Clinical Outcomes of Transpopliteal Venous Stent Placement for Postthrombotic Chronic Total Occlusion of the Iliofemoral Vein

PurposeTo evaluate the technical aspects and early clinical results of stent placement for managing postthrombotic chronic total occlusion (CTO) of the iliofemoral vein through ipsilateral popliteal access.Materials and MethodsA retrospective analysis of 110 patients (44 men; mean age, 51 y; 118 limbs; 102 left limbs) with postthrombotic CTO of the iliofemoral vein treated with stent placement in a single institution from January 2007–December 2011 was conducted. All occlusions were initially accessed via ipsilateral popliteal veins under the guidance of venography or ultrasonography. Technical aspects, quality of life, stent patency, and Villalta scores were recorded at follow-up evaluation. Risk factors of in-stent restenosis and early in-stent thrombosis were evaluated using Cox proportional hazards regression model.ResultsPercutaneous recanalization was successful in 112 of 118 limbs (95%). The mean duration of the procedure was 43 minutes (range, 10–120 min). The quality of life and Villalta scores were significantly improved (P < .01). The 3-year primary, assisted primary, and secondary cumulative stent patency rates were 70%, 90%, and 94%. During a median follow-up period of 25 months (range, 1–52 mo), the relief rates of severe leg pain (visual analog scale > 5) and severe leg swelling (grade 3) were 72% (49 of 68) and 70% (64 of 91), respectively, and the healing of ulcers was successful in 78% (36 of 46) of the cases. After stent placement, the limbs with visible remaining collateral circulation had a higher rate of early in-stent thrombosis (22.5% vs 6.1%; P = .007). The patients with long stents extending below the inguinal ligament had a higher rate of in-stent restenosis (hazard ratio = 1.77–6.5; P = .0146).ConclusionsTranspopliteal venous stent placement is an effective, safe, and feasible method of managing postthrombotic CTO of the iliofemoral vein. The stent extending below the inguinal ligament is the major risk factor of in-stent restenosis. The visible remaining collateral circulation after stent placement may indicate persistent hemodynamically significant stenosis.     

Long-term Outcome of Percutaneous Interventions for Hepatic Venous Outflow Obstruction after Pediatric Living Donor Liver Transplantation: Experience from a Single Institute

PurposeTo evaluate retrospectively the long-term outcome of percutaneous interventions for hepatic venous outflow obstruction (HVOO) occurring after pediatric living donor liver transplantation (LDLT).Materials and MethodsBetween October 1997 and December 2012, 48 patients (24 boys, 24 girls; median age, 6 y) who had undergone LDLT were confirmed to have HVOO using percutaneous hepatic venography and manometry. All patients underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, patency rates, stent placement, and major complications were evaluated.ResultsTechnical success was achieved in 92 of 93 sessions (99.0%) and in 47 of 48 patients (97.9%), and clinical success was achieved in 41 of 48 patients (85.4%). During the follow-up period (range, 1–182 mo; median, 51.5 mo), 28 patients were treated with a single session of balloon angioplasty, and 20 patients who developed recurrent stenosis were treated with repeated percutaneous interventions. The rates of primary and primary-assisted patency at 1, 3, 5, and 10 years after balloon angioplasty were 64%, 57%, 57%, and 52% (primary patency) and 98%, 95%, 95%, and 95% (primary-assisted patency). Of six patients with stent placement, four had no recurrent HVOO after the stent placement, but two developed recurrent stenosis. The stent migrated to the right atrium in one patient.ConclusionsPercutaneous interventions were effective treatments for HVOO after LDLT.     

Feasibility of Percutaneous Cementoplasty Combined with Interventional Internal Fixation for Impending Pathologic Fracture of the Proximal Femur

PurposeTo evaluate the feasibility of percutaneous cementoplasty and interventional internal fixation for stabilization of impending pathologic fracture of the proximal femur.Materials and MethodsFrom May 2012 to August 2013, six consecutive patients (three men and three women; median age, 58.33 y ± 21.45; age range, 18–78 y) who underwent percutaneous cementoplasty plus interventional internal fixation for the treatment of metastases to the proximal femur were retrospectively analyzed. The Karnofsky performance status (KPS) and visual analog scale (VAS) score for pain were assessed before and 1 week after the procedure; moreover, the procedure duration, length of hospital stay, risk of fracture at the procedural site, and complications were assessed.ResultsThe KPS increased from 66.67 ± 12.11 (range, 60–90) before the procedure to 76.67 ± 13.66 (range, 60–100) 1 week after the procedure. For symptomatic patients (n = 5), the VAS score decreased from 6.80 ± 2.39 (range, 3–9) before the procedure to 1.80 ± 0.84 (range, 1–3) at 1 week after the procedure. The mean procedure duration was 90.00 minutes ± 10.56 (range, 72–102 min). The average length of hospital stay was 7 days ± 2 (range, 4–10 d). The only complication noted consisted of thrombophlebitis in one patient, on the operative side, at 15 days after the procedure. No cases of procedural site fracture during follow-up were noted (median, 192 d; range, 30–365 d).ConclusionsPercutaneous cementoplasty plus interventional internal fixation is a feasible technique for stabilization of impending pathologic fracture of the femur.     

SUPERA Interwoven Nitinol Stent Outcomes in Above-Knee IntErventions (SAKE) Study

PurposeTo report experience with the novel interwoven-wire self-expanding nitinol SUPERA stent (IDEV Technologies, Inc/Abbott Laboratories, Inc, Webster, Texas) for the treatment of severely diseased superficial femoral and popliteal arteries.Materials and MethodsConsecutive patients with severely diseased superficial femoral and popliteal arteries who received SUPERA stents (n = 80 patients [98 limbs]; mean age, 70.8 y; 80% male) were retrospectively identified. Patients were followed for an average of 14.3 months after intervention.ResultsTotal occlusions were present in 39% of the lesions, 21% had tissue loss, and 61% demonstrated calcification on fluoroscopy. Patients were prescribed dual antiplatelet therapy (aspirin and clopidogrel) for at least 30 days unless contraindicated, followed by aspirin alone indefinitely. The mean (± SD) lesion length was 143 mm (± 98). Based on need for clinical intervention, primary patency was 96.9% at 6 months and 85.8% at 12 months (Kaplan-Meier estimates). Assisted primary patency and secondary patency rates at 12 months were 96.8% and 100%, respectively. Ankle-brachial index increased from 0.60 at baseline to 0.83 at last follow-up (P < .001). No stent fractures were found by fluoroscopy inspection in 19 limbs (16 patients) that required reintervention.ConclusionsBased on experience with multiple operators at a single clinical center, the interwoven nitinol stent design provides a viable option for high-grade obstructive disease in the femoropopliteal artery.     

Combination Radiofrequency Ablation and Percutaneous Osteoplasty for Palliative Treatment of Painful Extraspinal Bone Metastasis: A Single-Center Experience

PurposeTo evaluate combined radiofrequency (RF) ablation and percutaneous osteoplasty (POP) in patients with painful extraspinal bone metastases.Materials and MethodsIn a retrospective study, 38 patients with 54 extraspinal bone metastases (ilium, n = 24; acetabulum, n = 21; femur, n = 7; ischium, n = 1; tibia, n = 1) were treated with RF ablation and POP. All patients had pain refractory to analgesic medication with intensity > 3 on a visual analog scale (VAS). Changes in quality of life were evaluated based on pain relief (VAS score), function on a Karnofsky performance scale, and analgesic dose before and immediately after the procedure and during follow-up. VAS score was the primary outcome, and the others were secondary outcomes.ResultsTechnical success was achieved in 37 patients (97.4%). Mean VAS score declined significantly from 7.1 ± 1.5 before treatment to 2.2 ± 2.0 at 24 hours after treatment (P < .05), 1.6 ± 1.8 at 3 months after treatment (P < .05), and 1.3 ± 1.8 at 6 months after treatment (P < .05). Pain relief immediately after the procedure was reported by 35 patients (92.1%); pain regressed completely in 7 (18.4%) patients. After 6 months, narcotic analgesia had been suspended in 32 of 33 patients (97.0%). Pain was controlled by nonsteroidal antiinflammatory drugs in 8 patients (24.2%), and no analgesia was necessary in 24 patients (72.7%). Mean Karnofsky performance scale score after treatment was higher than before treatment (P < .05). The major complication rate was 2.6% (1 of 38 patients), with one case of vasovagal shock. The minor complication rate was 23.7% (9 of 38 patients).ConclusionsRF ablation with POP is effective for pain relief and functional recovery in patients with painful extraspinal bone metastases and can significantly improve quality of life.     

Feasibility of Time-Resolved MR Angiography for Detecting Recanalization of Pulmonary Arteriovenous Malformations Treated with Embolization with Platinum Coils

PurposeTo assess the feasibility of time-resolved magnetic resonance (MR) angiography as a follow-up method after embolization for pulmonary arteriovenous malformations (PAVMs).Materials and MethodsEvaluation of 28 PAVMs in 10 patients previously treated with embolization with platinum coils was performed. The mean observation period after embolization was 49 months. All patients underwent unenhanced chest computed tomography (CT) and time-resolved MR angiography followed by transcatheter digital subtraction angiography within 5 weeks for a definite diagnosis. Two radiologists reviewed the CT and time-resolved MR angiography findings using a blinded method. On CT, the draining veins of the PAVMs were measured before and after embolization, and shrinkage rates were calculated. On time-resolved MR angiography, recanalization was diagnosed when the draining vein or aneurysmal sac or both were enhanced in the pulmonary arterial phase. Correlations between recanalization, the shrinkage rate of the draining vein, and the diagnostic accuracies of CT and time-resolved MR angiography were assessed and compared with digital subtraction angiography.ResultsFive lesions could not be measured on CT because of metallic artifacts. The mean shrinkage rates of the draining vein for recanalized and occluded PAVMs were 23% ± 19 (SD) for recanalized PAVMs and 47% ± 21 for occluded PAVMs (P = .001). The sensitivity and specificity were 93% and 53%, respectively, when the shrinkage rate threshold was set to 50%. On time-resolved MR angiography, the sensitivity and specificity were 93% and 100%, respectively, for Reader 1 and 100% and 93%, respectively, for Reader 2. The κ coefficient was 0.86.ConclusionsTime-resolved MR angiography appears to be a feasible method for PAVM follow-up examinations and to provide a more accurate diagnosis of recanalization compared with unenhanced CT.     

Embolization of Angiographically Visible Type I and II Utero-ovarian Anastomoses during Uterine Artery Embolization for Fibroid Tumors: Impact on Symptom Recurrence and Permanent Amenorrhea

PurposeTo compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE).Materials and MethodsA retrospective, institutional review board–approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05.ResultsTwenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1).ConclusionsThere were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.     

Ultrasound-Accelerated versus Standard Catheter-Directed Thrombolysis in 102 Patients with Acute and Subacute Limb Ischemia

PurposeTo compare the safety and efficacy of ultrasound-accelerated thrombolysis (UAT) and standard catheter-directed thrombolysis (CDT) in patients with acute and subacute limb ischemia.Materials and MethodsMedical records of all patients treated with thrombolysis for acute and subacute limb ischemia between August 2005 and January 2012 were reviewed. Coprimary (increase in ankle-brachial index, degree of lysis) and secondary endpoints (technical success, distal embolization, bleeding complications, need for additional interventions) were assessed. UAT was performed in 75 patients, and CDT was performed in 27 patients. Patients’ baseline demographic and clinical parameters and procedure details, including lytic drug infusion rate (P = .704 and P = .987), total infusion time (P = .787 and P = .377), and use of adjunctive procedures (P = .457), did not differ significantly between the two groups.ResultsComplete lysis was achieved in 72.0% (UAT) and 63.0% (CDT) of patients (P = .542); hemodynamic success was achieved in 91.8% (UAT) and 92.3% (CDT) (P = .956). Overall major and minor bleeding complications were observed in 6.9% (UAT) and 3.9% (CDT) of patients. Major (P = .075) and minor (P = .276) bleeding independently did not differ between UAT and CDT. Major and minor bleeding combined was lower: 6.7% (UAT) versus 22.2% (CDT) (P = .025). Overall target vessel patency after 8.0 months (range, 1.5–20.5 mo) was 73.5%; target vessel patency for UAT was 75.9% versus 64.3% for CDT (P = .379). Median long-term survival was not significantly different between UAT and CDT: 3.6 years (range, 2.42–5.33 y) versus 1.8 years (range, 1.33–4.92 y) (P = .061).ConclusionsBoth UAT and CDT are safe and efficient treatment modalities for patients with acute and subacute limb ischemia. The observed lower risk of total bleeding for UAT versus CDT may warrant prospective comparative trials.