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.     

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.     

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.     

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.     

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.     

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.     

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.     

Clinical Features and Endovascular Management of Iliac Artery Fibromuscular Dysplasia

PurposeTo identify the spectrum of clinical presentation of iliac artery fibromuscular dysplasia (FMD) and to evaluate the outcomes of endovascular management of iliac artery FMD for claudication.Materials and MethodsAll patients in a single institution with a diagnosis of FMD between January 1980 and December 2010 were identified. Iliac artery FMD was present in 14 patients. Associated risk factors included hypertension (79%), hyperlipidemia (64%), smoking history (36%), coronary artery disease (21%), diabetes (0%), and obesity (36%).ResultsIn eight (57%) patients, iliac artery FMD was incidentally found on imaging. Lifestyle-limiting claudication involving one or both extremities was present in six (43%) patients. All six patients were reported to have mild peripheral arterial disease based on ankle-brachial index measurements (0.7–0.9). These six patients underwent 10 endovascular procedures for claudication, including angioplasty (n = 8) and self-expanding stent placement (n = 2). Mean symptom-free survival was 56.3 months.ConclusionsIliac artery FMD that is amenable to endovascular treatment may be found incidentally or may manifest with disabling claudication.     

Internal Jugular Veins Outflow in Patients with Multiple Sclerosis: A Catheter Venography Study

PurposeTo investigate an examiner-independent catheter venography protocol that could be used to reliably diagnose venous outflow abnormalities in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency and to determine whether venous angioplasty is effective in the treatment of these abnormalities.Materials and MethodsA total of 313 patients with MS and 12 patients with end-stage renal disease underwent echo-color Doppler sonography and catheter venography of the internal jugular veins (IJVs) to evaluate contrast medium clearance time. In patients with venous outflow anomalies, balloon angioplasty of the IJVs was performed.ResultsA contrast medium clearance time cutoff value of 4 seconds or less provided the maximal combination of sensitivity and specificity for the right IJV (sensitivity, 73.4%; specificity, 100%) and left IJV (sensitivity, 91.4%; specificity, 100%). IJVs with a clearance time between 4.1 and 6 seconds had moderate delayed flow (MDF), and IJVs with a clearance time longer than 6 seconds had severe delayed flow (SDF); 89% of patients showed MDF/SDF through at least one IJV, 79% showed MDF/SDF through both IJVs, and only 5% showed normal flow in both IJVs. Balloon angioplasty was immediately able to improve flow in at least one IJV in 69% of patients, but venous flow was normalized in both veins in only 37% of patients; SDF persisted after angioplasty in 32% of patients.ConclusionsThere is a high prevalence of abnormal delayed flow through IJVs in patients with MS. Venous angioplasty was effective in only a minority of patients with SDF.     

Use of the Endurant Stent Graft System for Ruptured Infrarenal Aortic Aneurysms: Short-term Experience in Nine Patients

PurposeTo report the early results of use of the Endurant stent graft in the treatment of ruptured abdominal aortic aneurysms (AAAs).Materials and MethodsNine consecutive patients (seven men and two women; mean age, 76 y; range, 65–87 y) underwent endovascular aneurysm repair (EVAR) for a ruptured AAA with the Endurant stent graft between April and December 2012. EVAR was emergent in all cases. Early technical success, clinical success, major complication, and mortality rates were analyzed.ResultsIntraoperative immediate technical success was achieved in all nine patients. The 30-day clinical success rate was 67% (six of nine patients). The 30-day mortality rate was 33% (three of nine patients). During a mean follow-up of 6 months (range, 3–10 mo), none of the cases required reintervention; there was one late death attributed to probable endograft infection.ConclusionsThe short-term results of EVAR with the Endurant stent graft in patients with ruptured AAAs are encouraging.     

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.     

Revascularization for Critical Limb Ischemia Using the SpiderFX Embolic Protection Device in the Below-the-Knee Circulation: Initial Results

PurposeTo examine the safety and efficacy of the SpiderFX embolic protection device (EPD) in the below-the-knee (BTK) circulation in patients with critical limb ischemia (CLI).Materials and MethodsA single-center retrospective review was performed to identify patients with CLI and single-vessel runoff in whom the SpiderFX EPD was used in the BTK circulation. Technical success and device-related complications were the primary endpoints. Retrieval of macroscopic debris in the EPD, 1-year freedom from major adverse limb events (MALEs), and 30-day perioperative death were also evaluated. A major amputation, surgical bypass, endovascular thrombectomy, or endovascular thrombolysis was considered a MALE. Thirty-six patients (21 men; mean age, 75.8 y) treated between 2008 and 2013 had endovascular revascularization with use of the SpiderFX EPD in the BTK circulation.ResultsThe SpiderFX EPD was successfully deployed in all cases; the technical success rate of revascularization was 100%. Two minor and zero major complications were observed related to the SpiderFX. Two MALEs, a major amputation and a subsequent surgical bypass, were observed in the cohort. All MALEs occurred within 1 year of treatment (1-y freedom from MALE rate, 90%). Debris was retrieved in the SpiderFX device in 47% of patients.ConclusionsThe use of the SpiderFX EPD in the BTK circulation in patients with CLI is safe and frequently retrieves debris.     

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.     

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.     

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.     

Comparison of Intravascular Ultrasound with Conventional Venography for Detection of Extracranial Venous Abnormalities Indicative of Chronic Cerebrospinal Venous Insufficiency

PurposeTo investigate prevalence of extracranial abnormalities in azygos and internal jugular (IJ) veins using conventional venography and intravascular ultrasound (IVUS) in patients with multiple sclerosis (MS) being evaluated for chronic cerebrospinal venous insufficiency, a condition of vascular hemodynamic dysfunction.Materials and MethodsPREMiSe (Prospective Randomized Endovascular therapy in Multiple Sclerosis) is a venous angioplasty study that enrolled 30 patients with relapsing MS. The patients fulfilled two or more venous hemodynamic extracranial Doppler sonography screening criteria. Phase I of the study included 10 patients and was planned to assess safety and standardize venography, IVUS, and angioplasty and blinding procedures; phase II enrolled 20 patients and further validated diagnostic assessments using the two invasive techniques. Venography was considered abnormal when ≥ 50% lumen-diameter restriction was detected. IVUS was considered abnormal when ≥ 50% lumen-diameter restriction, intraluminal defects, or reduced pulsatility was detected.ResultsNo venography-related or IVUS-related complications, including vessel rupture, thrombosis, or side effects of contrast media were recorded among the 30 study patients. IVUS-detected venous abnormalities, including chronic, organized, thrombus-like inclusions were observed in 85% of azygos, 50% of right IJ, and 83.3% of left IJ veins, whereas venography demonstrated stenosis of ≥ 50% in 50% of azygos, 55% of right IJ, and 72% of left IJ veins. Sensitivity of venography for detecting IVUS abnormalities was 52.9%, 73.3%, and 80% for the azygos, left IJ, and right IJ veins, respectively.ConclusionsIVUS assessment of azygos and IJ veins showed a higher rate of venous abnormalities than venography. IVUS provides a diagnostic advantage over conventional venography in detecting extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency.     

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.