Long-Term Outcome of Percutaneous Transhepatic Balloon Angioplasty for Portal Vein Stenosis after Pediatric Living Donor Liver Transplantation: A Single Institute’s Experience

PurposeTo evaluate retrospectively the long-term outcomes of percutaneous transhepatic balloon angioplasty performed for portal vein stenosis (PVS) after pediatric living donor liver transplantation (LDLT).Materials and MethodsBetween October 1997 and December 2013, of 527 pediatric patients (age < 18 y) who underwent LDLT in a single institution, 43 patients (19 boys, 24 girls; mean age, 4.1 y ± 4.1) were confirmed to have PVS at direct portography with or without manometry and underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, laboratory findings, manometry findings, patency rates, and major complications were evaluated. Follow-up periods after initial balloon angioplasty ranged from 5–169 months (mean, 119 mo).ResultsTechnical success was achieved in 65 of 66 sessions (98.5%) and in 42 of 43 patients (97.7%), and clinical success was achieved in 37 of 43 patients (86.0%). Platelet counts improved significantly. Of 32 patients undergoing manometry, 19 showed significant improvement of pressure gradient across the stenosis after percutaneous transhepatic balloon angioplasty. At 1, 3, 5, and 10 years after balloon angioplasty, the rates of primary patency were 83%, 78%, 76%, and 70%, and the rates of primary-assisted patency were 100%, 100%, 100%, and 96%. Two major complications subsequent to balloon angioplasty were noted: severe asthma attack and portal vein thrombosis.ConclusionsPercutaneous transhepatic balloon angioplasty is a safe and effective treatment with long-term patency for PVS after pediatric LDLT.     

Percutaneous Interventions in Failing “Necklace” Hemodialysis Grafts: Long-Term Outcomes

PurposeTo determine primary and secondary patency after percutaneous interventions for malfunctioning anterior chest wall (“necklace”) arteriovenous grafts (AVGs) for hemodialysis.Materials and MethodsRecords of six consecutive patients with subclavian artery–to–contralateral subclavian vein necklace AVGs were reviewed. Patients underwent 34 procedures, including 28 balloon angioplasties, 24 pharmacomechanical thrombolyses, and six stent placements. Patency intervals after graft placement and after first intervention were calculated.ResultsAfter 3 months, primary and secondary patency rates were 33% (two of six grafts) and 67% (four of six grafts), respectively. At 12 months, primary and secondary patency rates were 17% (one of six grafts) and 50% (three of six grafts), respectively. Median and mean primary patency times were 49 and 374 days, and median and mean secondary patency times were 293 and 575 days, respectively. The anatomic success rate of percutaneous interventions in malfunctioning AVGs was 97% (33 of 34 cases). At 3 years after implantation, the graft patency rate was 57% (four of seven grafts).ConclusionsPercutaneous interventions were effective at maintaining patency in failing necklace AVGs. However, their primary and secondary patency were inferior to those cited in extremity AVG guidelines set forth by the Society of Interventional Radiology.     

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.     

Factors Associated with Patency Following Angioplasty of Hemodialysis Fistulae

PurposePatency after percutaneous transluminal angioplasty of native hemodialysis arteriovenous fistulae (AVFs) is highly variable. This study aimed to identify predictors of patency following angioplasty in native AVFs.Materials and MethodsAll endovascular procedures performed in native AVFs between 2005 and 2013 at two institutions were retrospectively reviewed. Clinical, anatomic, biochemical, and medication variables were subjected to univariate and multivariate Cox regression analysis to identify predictors of postintervention primary and secondary patency.ResultsDuring the study period, 207 patients underwent first angioplasty of their AVF. Follow-up ranged from 14 days to 8 years, during which another 247 endovascular interventions were performed to maintain patency. Postintervention primary patency rates at 6, 12, and 24 months were 66%, 49%, and 29%, respectively. Postintervention secondary patency rates at 6, 12, and 24 months were 94%, 84%, and 79%, respectively. On multivariate adjusted Cox regression analysis, upper-arm AVFs (P = .00072), AVFs less than 6 months of age (P = .0014), presence of multiple stenoses (P = .019), and degree of initial stenosis (P = .016) were significantly associated with shorter postintervention primary patency. A previously failed AVF was the only significant predictor of postintervention secondary patency loss (P = .0053).ConclusionsAnatomic factors related to the AVF location, AVF age, and the extent of the lesion are important predictors of restenosis after balloon angioplasty. Traditional cardiovascular risk factors, metabolic and inflammatory markers, and medications were not associated with postintervention patency.     

Randomized Clinical Trial of Cutting Balloon Angioplasty versus High-Pressure Balloon Angioplasty in Hemodialysis Arteriovenous Fistula Stenoses Resistant to Conventional Balloon Angioplasty

PurposeTo compare the efficacy and safety of cutting balloon angioplasty (CBA) versus high-pressure balloon angioplasty (HPBA) for the treatment of hemodialysis autogenous fistula stenoses resistant to conventional percutaneous transluminal angioplasty (PTA).Materials and MethodsIn a prospective, randomized clinical trial involving patients with dysfunctional, stenotic hemodialysis arteriovenous fistulas (AVFs), patients were randomized to receive CBA or HPBA if conventional PTA had suboptimal results (ie, residual stenosis > 30%). A total of 516 patients consented to participate in the study from October 2008 to September 2011, 85% of whom (n = 439) had technically successful conventional PTA. The remaining 71 patients (mean age, 60 y; 49 men) with suboptimal PTA results were eventually randomized: 36 to the CBA arm and 35 to the HPBA arm. Primary and secondary target lesion patencies were determined by Kaplan–Meier analysis.ResultsClinical success rates were 100% in both arms. Primary target lesion patency rates at 6 months were 66.4% and 39.9% for CBA and HPBA, respectively (P = .01). Secondary target lesion patency rates at 6 months were 96.5% for CBA and 80.0% for HPBA (P = .03). There was a single major complication of venous perforation following CBA. The 30-day mortality rate was 1.4%, with one non–procedure-related death in the HPBA group.ConclusionsPrimary and secondary target lesion patency rates of CBA were statistically superior to those of HPBA following suboptimal conventional PTA. For AVF stenoses resistant to conventional PTA, CBA may be a better second-line treatment given its superior patency rates.     

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.     

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.     

Treatment of Esophagopleural Fistulas Using Covered Retrievable Expandable Metallic Stents

PurposeTo evaluate the clinical efficacy of placement of covered retrievable expandable metallic stents for esophagopleural fistulas (EPFs).Materials and MethodsDuring the period 1997–2013, nine patients with EPF were treated using covered retrievable expandable metallic stents. The underlying causes of EPF were esophageal carcinoma (n = 6), lung cancer (n = 2), and postoperative empyema for Boerhaave syndrome (n = 1).ResultsTechnical success was achieved in eight patients (88.9%). In one patient, incomplete EPF closure was due to incomplete stent expansion. Clinical success, defined as complete EPF closure within 7 days, was achieved in five patients (55.6%). Overall fistula persistence (n = 1) or reopening (n = 4) occurred in five patients (55.6%) 0–15 days after stent placement. The causes of reopening were due to the gap between the stent and the esophagus (n = 3) or stent migration (n = 1). For fistula persistence or reopening, additional interventional management, such as gastrostomy, stent removal, or stent reinsertion, was performed. Stent migration occurred as a complication in one patient with EPF from a benign cause secondary to postoperative empyema. In the eight patients who died during the follow-up period, the mean and median survival times were 78.8 days and 46 days, respectively.ConclusionsPlacement of a covered expandable metallic esophageal stent for the palliative treatment of EPF is technically feasible, although the rate of clinical success was poor secondary to fistula persistence or reopening. Fistula reopening was caused by the gap between the stent and the esophagus or by stent migration, and additional interventional treatment was useful to ensure enteral nutritional support.     

Percutaneous Angioplasty Using a Paclitaxel-Coated Balloon Improves Target Lesion Restenosis on Inflow Lesions of Autogenous Radiocephalic Fistulas: A Pilot Study

PurposeTo determine whether the use of a paclitaxel-coated balloon (PCB) improves patency in patients undergoing percutaneous transluminal angioplasty (PTA) for recurrent juxtaanastomotic stenosis of radiocephalic arteriovenous fistulas (RCAVFs).Material and MethodsThis prospective study recruited hemodialysis patients with two short (< 2 cm) and separated inflow RCAVF lesions. After dilation of lesions using a 4-mm plain balloon (PB), half of the lesions were randomly selected for treatment with PTA using PCB (size, 4 mm; length, 2 cm) and PB (size, 5-mm or 6-mm) (group 1), and the other half were treated with PTA using PB alone (group 2). After the index PTA, dysfunction-driven angiography was performed to confirm target lesion restenosis (TLR). TLR and lesion patency were compared in the two groups by χ² test, t test, and Kaplan-Meier analysis.ResultsThe analysis of 20 lesions in 10 patients revealed that the TLR-free duration in group 1 was significantly longer than the TLR-free duration in group 2 (251.2 d vs 103.2 d; P < .01). The patency rate of the target lesion was significantly higher in group 1 than in group 2 at 6 months (70% vs 0%; P < .01) but not at 12 months (20% vs 0%; P > .05).ConclusionsThis early study suggests that, for improving short-term patency, PTA with PCB and PB is more effective than PTA with PB alone, warranting further study.     

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.     

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.     

The DENALI Trial: An Interim Analysis of a Prospective,Multicenter Study of the Denali Retrievable Inferior Vena Cava Filter

PurposeTo assess safety and effectiveness of a nitinol retrievable inferior vena cava (IVC) filter in patients who require caval interruption to protect against pulmonary embolism (PE).Materials and MethodsTwo hundred patients with temporary indications for an IVC filter were enrolled in this prospective, multicenter clinical study. Patients undergoing filter implantation were to be followed for 2 years or for 30 days after filter retrieval. At the time of the present interim report, all 200 patients had been enrolled in the study, and 160 had undergone a retrieval attempt or been followed to 6 months with their filter in place. Primary study endpoints included technical and clinical success of filter placement and retrieval. Patients were also evaluated for recurrent PE, new or worsening deep vein thrombosis, and filter migration, fracture, penetration, and tilt.ResultsClinical success of placement was achieved in 94.5% of patients (172 of 182), with a one-sided lower limit of the 95% confidence interval of 90.1%. Technical success rate of filter placement was 99.5%. Technical success rate of retrieval was 97.3%; 108 filters were retrieved in 111 attempts. In two cases, the filter apex could not be engaged with a snare, and one device was engaged but could not be removed. Filter retrievals occurred at a mean indwell time of 165 days (range, 5–632 d). There were no instances of filter fracture, migration, or tilt greater than 15° at the time of retrieval or 6-month follow-up.ConclusionsIn this interim report, the nitinol retrievable IVC filter provided protection against pulmonary embolism, and the device could be retrieved with a low rate of complications.     

Retrospective Review of Angiography before Cannulation of Newly Created Vascular Accesses in Hemodialysis Patients

PurposeTo investigate vascular access status before first cannulation and the clinical implications of angiography performed before cannulation.Materials and MethodsA retrospective review of 300 consecutive patients who underwent angiography after vascular access surgery and before cannulation between August 2004 and April 2010 was performed. Angiography was performed 4–6 weeks after the surgery but before the first cannulation.ResultsAngiography revealed 94 (31.3%) cases of severe stenosis (≥ 50% luminal narrowing) that required percutaneous transluminal angioplasty (PTA) or a second operation. No stenosis was observed in 122 (40.7%) cases, and mild stenosis (< 50% luminal narrowing) was observed in 84 (28%) cases. For the 94 cases with severe stenosis, PTA was performed in 66, and a second operation was performed in 16. In the other cases (n = 12), HD was maintained by a permanent catheter, or the patients were transferred to another institution. PTA was an immediate success in all patients who underwent the procedure except two. Of 84 patients with mild stenosis, 70 were followed for 1 year; vascular access dysfunction occurred in 15, and 11 of these underwent successful PTA. Of the 122 patients with normal angiographic findings, 102 were followed for 1 year, and vascular access dysfunction did not occur in any of these patients.ConclusionsEarly postoperative angiography before the first hemodialysis is helpful for the early detection and treatment of vascular access dysfunction.     

Contemporary Systematic Review and Meta-Analysis of Early Outcomes with Percutaneous Treatment for Infrapopliteal Atherosclerotic Disease

PurposeThe need for specialty devices to improve the technical outcome of endovascular interventions is dependent on the rate of early failure in such procedures. This meta-analysis assessed procedural outcomes of such interventions to elucidate the rate of early procedural failures and the need for such specialty devices.Materials and MethodsMEDLINE and EMBASE were searched for contemporary studies (2000–2012) reporting procedural or short-term outcomes for revascularization of infrapopliteal atherosclerotic lesions. A random-effects metaanalysis was performed, which included post hoc comparisons among treatment groups.ResultsA total of 42 studies with 52 treatment arms representing 3,660 unique patients were included. Technical success rates were higher with bare metal stents (BMSs; 98.6%) than with atherectomy (92.2%; P < .05) or percutaneous transluminal angioplasty (PTA; 91.2%; P = .01), and higher with drug-eluting stents (DESs) than with PTA (P < .001). DES use had higher primary patency rates than atherectomy (P < .05), BMS use (P < .001), and PTA (P < .01). The 30-day rate of target lesion revascularization was significantly higher with PTA (8.1%) than with BMSs (2.2%; P < .05) and DESs (1.1%; P < .05). Thirty-day rates of major unplanned amputation (range, 1.5%–4.4%) and mortality (range, 0.9%–3.3%) were comparable among treatment groups. Significant heterogeneity among studies was noted for most PTA outcomes. Publication bias was evident for most PTA and DES outcomes.ConclusionsEarly failure of percutaneous therapies in patients with infrapopliteal atherosclerotic lesions is device- and technique-dependent. Specialty devices designed to reduce technical failure rates may therefore be of benefit in this selected group of patients. Study results are confounded by inconsistent data reporting, heterogeneity of treatment effects, and publication bias.     

Outcomes of Percutaneous Interventions in Transposed Hemodialysis Fistulas Compared with Nontransposed Fistulas and Grafts

PurposeTo compare postpercutaneous intervention outcomes of autogenous venous-transposition arteriovenous fistulas (AVFs) versus those of autogenous nontransposed AVFs (nAVFs) and prosthetic arteriovenous grafts (AVGs).Materials and MethodsA total of 591 hemodialysis accesses (195 transposed AVFs [tAVFs], 205 nAVFs, 191 AVGs) in 522 patients (278 male; mean age, 57 y; range, 15–91 y) underwent percutaneous transluminal angioplasty (PTA) and/or mechanical thrombectomy (ie, declotting). Access characteristics, surgical history, percutaneous interventions, postinterventional primary and secondary access patency, and follow-up data were collected. Cox proportional-hazards regression analyses, Fisher exact tests, and χ² tests were performed.ResultsMean follow-up period was 32 months. Mean access ages at initial percutaneous intervention were 260 days (tAVF), 206 days (nAVF), and 176 days (AVG; P < .01). One-year postinterventional primary patency (PIPP) rates were 25% (tAVF), 24% (nAVF), and 14% (AVG). One-year postinterventional secondary patency (PISP) rates were 77% (tAVF), 61% (nAVF), and 63% (AVG). Median PIPP durations were 138 days (tAVF), 121 days (nAVF), and 79 days (AVG; P = .0001). Median PISP durations were 1,076 days (tAVF), 783 days (nAVF), and 750 days (AVG; P = .019). Total interventions needed to maintain PISP were 2.4 (tAVF), 1.3 (nAVF), and 3.2 (AVG) per patient-year (P < .001), which included 1.9, 1.2, and 1.4 PTAs (P < .01) and 0.45, 0.15, and 1.8 declotting procedures, respectively (P < .001).ConclusionsBased on the number of percutaneous interventions needed to maintain PISP, these results confirm the current Dialysis Outcomes Quality Initiative access preference of nAVFs before tAVFs before AVGs. tAVFs offered superior postinterventional outcomes than AVGs. With additional interventions, tAVFs could even outperform nAVFs in terms of PISP.     

Percutaneous Image-Guided Cryoablation for the Treatment of Phantom Limb Pain in Amputees: A Pilot Study

PurposeTo prospectively evaluate percutaneous image-guided nerve cryoablation for treatment of refractory phantom limb pain (PLP) in a pilot cohort for purposes of deriving parameters to design a larger, randomized, parallel-armed, controlled trial.Materials and MethodsFrom January 2015 to January 2016, 21 patients with refractory PLP underwent image-guided percutaneous cryoneurolysis procedures. Visual analog scale scores were documented at baseline and 7, 45, and 180 days after the procedure. Responses to a modified Roland Morris Disability Questionnaire were documented at baseline and 7 and 45 days after the procedure.ResultsTechnical success rate of the procedures was 100%. There were 6 (29%) minor procedure-related complications. Disability scores decreased from a baseline mean of 11.3 to 3.3 at 45-day follow-up (95% confidence interval 5.8, 10.3; P < .0001). Pain intensity scores decreased from a baseline mean of 6.2 to 2.0 at long-term follow-up (95% confidence interval 2.8, 5.6; P < .0001).ConclusionsImage-guided percutaneous nerve cryoablation is feasible and safe and may represent a new efficacious therapeutic option for patients with phantom pains related to limb loss.     

Single-Center Experience in Prostate Fiducial Marker Placement: Technique and Midterm Follow-up

PurposeTo describe the technique, technical success, and complications of prostate fiducial marker implantation using transrectal ultrasound (US) guidance in patients undergoing image-guided radiation therapy.Materials and MethodsA retrospective review was performed of patients who underwent fiducial marker placement from January 2010–April 2013. In each case, gold markers were placed in the prostate using transrectal US guidance. Computed tomography (CT) was performed after the procedure and evaluated to confirm correct placement. Technical success, complications, and development of symptoms during radiotherapy were reviewed.ResultsTransrectal US–guided fiducial marker placement was performed on 75 patients (mean age, 62 y; range, 48–79 y) with a mean Gleason score of 7.25 (range, 6–10). Fiducial marker placement was confirmed in the intended location of the prostate or prostate bed for 297 of 300 markers (99%) on follow-up CT imaging. Two markers were placed just outside the prostate capsule, and one marker was lost. Complications included sepsis (n = 1; 1.3%), self-limiting perirectal or intraprostatic hemorrhage (n = 3; 4%), nausea (n = 1; 1.3%), transient hypotension (n = 1; 1.3%), epididymitis (n = 1; 1.3%), and urinary tract infection (n = 1; 1.3%). Complications were seen more frequently in patients with high tumor grade (P = .001) and in patients who developed metastatic disease (P = .01).ConclusionsTransrectal US–guided implantation of fiducial markers is technically feasible, is well tolerated, and has a good safety profile.     

CT Fluoroscopy–Guided Percutaneous Fiducial Marker Placement for CyberKnife Stereotactic Radiosurgery: Technical Results and Complications in 222 Consecutive Procedures

PurposeTo evaluate technical outcome and safety of computed tomographic (CT) fluoroscopy–guided percutaneous fiducial marker placement before CyberKnife stereotactic radiosurgery.Materials and MethodsRetrospective analysis was performed of 196 patients (106 men) undergoing CT fluoroscopy–guided fiducial marker placement in 222 consecutive procedures under local anesthesia from March 2006 to February 2012. Technical success was defined as fiducial marker location in the tumor or vicinity suitable for CyberKnife radiosurgery evaluated on postinterventional planning CT. Complications were classified per Society of Interventional Radiology (SIR).ResultsOne hundred ninety-six patients (age, 61.5 y ± 13.1) underwent percutaneous placement of 321 fiducial markers (mean per tumor, 1.2 ± 0.5; range, 1–4) in 37 primary tumors and 227 metastases in the thorax (n = 121), abdomen (n = 122), and bone (n = 21). Fiducial marker placement was technically successful in all procedures: intratumoral localization in 193 (60.1%), at tumor margin in 50 (15.6%), and outside of tumor in 78 cases (24.3%; mean distance to marker, 0.4 cm ± 0.6; range, 0–2.9 cm). Complications were observed in 63 placement procedures (28.4%), including minor self-limiting pneumothorax (n = 21; SIR class B) and self-limiting pulmonary hemorrhage (n = 35; SIR class A), and major pneumothorax requiring thoracostomy/drainage insertion (n = 14; SIR class D) and systemic toxicity of local anesthetic drug (n = 1; SIR class D).ConclusionsCT fluoroscopy–guided percutaneous fiducial marker placement can be performed with high technical success under local anesthesia in various anatomic regions. Although self-limiting in most cases, pneumothorax and pulmonary hemorrhage are frequently observed during fiducial marker implantation into lung tumors.