Use of stent grafts to repair hemodialysis graft-related pseudoaneurysms

PURPOSE: To review the author's early experience with stent grafts to repair hemodialysis graft-related pseudoaneurysms. MATERIALS AND METHODS: Eleven patients had undergone insertion of a stent graft to repair a pseudoaneurysm arising from a PTFE hemodialysis graft. The study group consists of seven women and four men with a mean age of 50.7 years. The primary indications for stent graft placement were: rapid enlargement of a pseudoaneurysm in four patients, difficulty with cannulating the graft in two patients, high risk of acute rupture in three patients, persistent bleeding from the pseudoaneurysm in one patient, and one was incidentally discovered during diagnostic fistulography. In 10 of the 11 patients, the pseudoaneurysm arose from the arterial limb of a loop-configuration graft. A stent graft was successfully deployed in all patients. The radiological and surgical records were reviewed. RESULTS: The Viabahn endoprosthesis was successfully inserted and deployed in all 11 patients. Six patients underwent subsequent interventions, which ended primary patency at 39 days, 40 days, 63 days, 104 days, 120 days, and 327 days after insertion of the stent graft. However, no additional interventions have been performed in five patients and primary patency continues. In these five patients the interval of continuing primary patency is 55 days, 92 days, 103 days, 139 days, and 196 days. In this small group of patients the primary patency rate is 71% at 3 months and 20% at 6 months. DISCUSSION: Early experience has demonstrated that a stent graft can successfully exclude a pseudoaneurysm from a hemodialysis graft and may prevent further enlargement and decrease the likelihood of rupture. However, in two of these 11 patients, the large pseudoaneurysm remained problematic and required subsequent surgical repair.     

Residual stenosis after conventional balloon angioplasty for hemodialysis shunt failure: treatment with metallic stent placement and post-balloon dilatation

PURPOSE: The usefulness of metallic stent placement and post-balloon dilatation was investigated for patients with residual stenosis after conventional percutaneous transluminal balloon angioplasty (balloon PTA) of dialysis shunt vessels. MATERIALS AND METHODS: Among 92 patients who had received balloon PTA for dialysis shunt vessels, seven patients who showed a residual waist on the balloon even under maximum inflation were enrolled in this study. In these patients with residual stenosis after balloon PTA, we inserted a stent in the residual stenosis, and post-balloon dilatation was immediately applied using the same balloon catheter. RESULTS: After balloon PTA, the average percent diameter stenosis declined to 45.5 +/- 7.30%, and the stenosis was further improved to an average of 19.3 +/- 7.09% after the placement of a stent and the additional balloon PTA. The average percent diameter dilatation of the balloon before the placement of a stent was 65.8 +/- 12.7%, while the average dilatation increased to 84.1 +/- 8.96% after the placement of a stent. Dialysis became possible immediately after the procedure in all cases. CONCLUSION: Metallic stent placement and post-balloon dilatation was effective for patients with residual stenosis after conventional balloon PTA of dialysis shunt vessels.     

覆膜血管内支架在外周动脉瘤和动静脉瘘中的应用

目的探讨覆膜血管内支架在外周动脉瘤及动静脉瘘中的临床应用疗效及安全性。方法回顾性分析我院2000年5月至2006年11月14例接受覆膜血管内支架治疗患者的临床资料。14例患者主要的血管病变为真性或假性动脉瘤、动静脉瘘。结果覆膜血管内支架的置放技术成功率为100%,无严重并发症和围手术期死亡,术后临床症状明显改善。1例患者出现I型内漏,但临床症状仍有改善。平均随访时间10个月。随访期内除1例患者仍有内漏外余无内漏。未发现支架移位和狭窄等并发症。结论覆膜血管内支架治疗外周动脉瘤及动静脉瘘具有创伤小、疗效确切、安全等优点,短期随访效果满意。     

Complications of percutaneous transhepatic portal vein embolization

PURPOSE: Percutaneous transhepatic portal vein (PV) embolization (PTPE) is a useful preoperative procedure for extended liver resection. The purpose of the present study was to assess the frequency of technical complications of PTPE and to discuss the risks of this procedure. MATERIALS AND METHODS: PTPE was performed in 46 patients. Forty-seven procedures were performed because an initial puncture failure required that the procedure be performed twice in one patient. The technical success rate and technical complications were assessed. Complications were analyzed with regard to approach methods and puncture sites. Approach methods were categorized as contralateral or ipsilateral. Puncture sites were categorized into anterior, posterior, and lateral segments. The results were compared statistically with use of the Fisher exact test. RESULTS: Technical success was achieved in 45 of 47 procedures (95.7%). Complications occurred in seven of 47 procedures (14.9%), including pneumothorax in two, subcapsular hematoma in two, arterial puncture in one, pseudoaneurysm in one, hemobilia in one, and PV thrombosis in one. Subcapsular hematoma and pseudoaneurysm occurred in the same procedure. No patient died as a result of complications. There was no significant difference between the contralateral and ipsilateral approaches. The incidence of complications was significantly higher in procedures involving puncture of the posterior segment than in those involving puncture of the anterior segment (P =.0374). CONCLUSION: In cases in which the anterior segment cannot be visualized for puncture, PTPE via the lateral segment or transileocolic portal embolization should be considered rather than PTPE via the posterior segment.     

肾移植术后血管并发症的介入治疗

目的 探讨肾移植术后血管并发症介入治疗的价值。资料与方法 14例肾移植患者中，11例移植肾动脉狭窄，行球囊扩张或支架置入术；2例假性动脉瘤，行导管栓塞术；1例移植肾动脉血栓形成，行导管动脉溶栓术。结果 11例移植肾动脉狭窄患者均成功完成球囊扩张术，其中3例行支架置入术，术后患者血压均恢复正常，随3－35个月，未见狭窄；2例假性动脉瘤患者行栓塞术后，1例血流恢复正常，1例行移植肾摘除；1例移植肾动脉溶栓者，由于并发出血行移植肾摘除。结论 介入治疗是肾移植术后血管并发症有效的治疗方法。     

肢体及肾脏假性动脉瘤的介入治疗

目的评价肢体及肾脏假性动脉瘤应用覆膜支架及栓塞技术治疗的价值,分析相关的并发症及处理方法。方法3例肢体假性动脉瘤应用覆膜支架置入术将其隔绝,2例肾动脉假性动脉瘤应用明胶海绵栓塞。结果5例假性动脉瘤均完全闭合,2例置入覆膜支架者其远端动脉搏动正常。1例股动脉假性动脉瘤患者术中出现支架内血栓形成,溶栓后消失。1例患者由于其他原因,致穿刺部位又出现假性动脉瘤。结论应用覆膜支架及栓塞技术可使肢体及肾脏假性动脉瘤得到有效治疗,且创伤小,恢复快,尤其适用于不能耐受传统手术治疗者,远期疗效尚待进一步观察。     

Percutaneous mechanical thrombectomy for thrombosed vessels with a hydrolyser (hydrodynamic thrombectomy catheter): clinical experience

A hydrodynamic thrombectomy catheter was prospectively evaluated for the treatment of thrombosed vessels. Seven patients (7 males: age range from 56 to 82 years; mean age: 79 years) presenting with acute or chronic occlusion of peripheral native arteries (n = 6) and dialysis shunt (n = 1) were treated with the hydrolyser (Cordis, Johnson and Johnson, Japan). Mean occlusion time was 135 days (range: 2-300 days), and mean thrombus length 16 cm (range: 5-20 cm). Removal of the thrombus was successful in five patients (71%), regardless of the length of the thrombus. Mean procedure time was 20 minutes (range: 15-30 minutes). No major complications occurred. Adjunctive thrombolysis was required for persistence of the residual thrombosed distal vessel in one patient. Adjunctive balloon angioplasty was performed in two patients (one native vessel and one dialysis shunt), and stent placement was performed in one patient (dialysis shunt). In two unsuccessful cases, the hydrolyser could not be advanced to the distal side because of the solid thrombus. Therefore, thrombolytic therapy was chosen. However, this therapy failed because the guidewire did not pass within the thrombus. Surgery was performed in these two patients. We conclude from this clinical experience that percutaneous thrombectomy with a hydrolyser is a promising technique for the treatment of thrombosed vessels. Especially in the acute stage of thrombosed occlusion, percutaneous thrombectomy with a hydrolyser is superior to thrombectomy with a Fogarty balloon catheter because of its shorter procedure time and fewer complications.     

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.     

Pseudoaneurysm: a complication of faulty technique in femoral arterial puncture

Pseudoaneurysm is a well-documented but rare complication of retrograde femoral arterial puncture. We present six patients in whom pseudoaneurysm complicated this procedure. The pseudoaneurysm arose from the superficial femoral artery in five patients and from the profunda femoris artery in one. An arteriovenous fistula also arose from the superficial femoral artery in one patient. In no patient did the pseudoaneurysm arise from the common femoral artery. Two mechanisms are postulated as to why pseudoaneurysms rarely complicate puncture of the common femoral artery.     

原位肝移植术后胆道狭窄的介入治疗

目的:探讨经T型管及其窦道和经皮肝穿刺胆道引流治疗原位肝移植术后胆道狭窄的可行性及其疗效.方法:对252例原位肝移植术后出现胆道狭窄的26例患者分别行胆道气囊扩张术、胆道引流术和胆道支架置入术.结果:3例胆道狭窄合并胆瘘患者和3例单纯吻合口狭窄患者,经气囊扩张术和胆道引流后痊愈.6例肝内外胆管多发狭窄患者,气囊反复扩张胆道狭窄段后,5例狭窄纠正而获得痊愈;1例气囊扩张治疗后出现肝内血肿,再次行肝移植.12例肝内外胆管多发狭窄合并胆泥的患者,经反复球囊导管扩张后,10例狭窄明显减轻,黄疸缓解;1例置入胆道支架,后因支架管阻塞而再次肝移植;1例治疗后狭窄仍存在,黄疸无缓解而再次肝移植.2例T型管引流口段狭窄行经皮肝穿刺胆道引流术后,狭窄明显减轻,黄疸缓解.结论:经T型管及其窦道和经皮肝穿刺胆道引流是治疗原位肝移植术后胆道狭窄的良好方法.     

Stent-graft treatment of traumatic carotid artery dissecting pseudoaneurysm

Introduction

Traumatic pseudoaneurysm of the internal carotid artery (ICA) is a rare but serious complication following blunt or penetrating trauma. These lesions are difficult to repair surgically. Endovascular management, including parent vessel occlusion, bare stent placement, and stent-assisted coil placement, are reported to be safe and effective but have certain disadvantages. Placement of covered stent grafts has been recently reported but without enough follow-up results to achieve consensus.

Methods

In this investigation, we present our experience with seven cases of traumatic ICA dissecting pseudoaneurysm treated with stent graft with follow-up between 1 and 33 months.

Results

Among the seven patients, one patient died due to septic shock 7 days after stenting. Follow-up angiography or Doppler ultrasound of the other six patients revealed optimal result with occluded pseudoaneurysm without restenosis of the ICA.

Conclusions

Our results suggest that placement of stent grafts is a safe and effective method for treating ICA traumatic-dissecting pseudoaneurysm.     

Thrombus formation during intracranial aneurysm coil placement: treatment with intra-arterial abciximab

BACKGROUND AND PURPOSE: The management of thrombus formation during coil placement in an intracranial aneurysm is important in minimizing periprocedural morbidity and mortality. We report on seven cases in which the primary treatment for thrombus formation during such coil placement was intra-arterial abciximab infusion. METHODS: Clinical and radiologic records of 100 consecutive patients who underwent coil placement in intracranial aneurysms at our institution during a 1-year period were reviewed. We identified seven cases (four ruptured aneurysms, three unruptured aneurysms) in which thrombus formation occurred during the procedure. RESULTS: Intra-arterial abciximab infusion, up to 5 mg, completely dissolved the thrombus in four of seven patients and almost completely dissolved it in two. In one patient with distal emboli, recanalization was not achieved. In two patients, an intravenous bolus of abciximab without 12-hour infusion was also given adjunctively. In one patient, leakage of contrast material occurred; this was related to the intra-arterial infusion. Clinically, no new neurologic deficits were directly related to the intra-arterial abciximab infusion. Six patients had good clinical outcome, and one patient died. CONCLUSION: Relatively low-dose, intra-arterial abciximab infusion can immediately dissolve an acute thrombus that forms during intracranial aneurysm coil placement. Although neither the optimal dose of intra-arterial abciximab nor the need to supplement the intra-arterial infusion with intravenous administration was established, we preliminarily found that low-dose intra-arterial abciximab infusion may be relatively effective and safe in this setting, even in patients with acute subarachnoid hemorrhage.     

Percutaneous puncture of venous bypass grafts for transluminal angioplasty

Percutaneous transluminal angioplasty was performed on 45 patients with vascular stenoses after vein bypass surgery. In 25 cases, the angioplasty catheter was introduced by direct puncture of the vein graft. The procedure was successful and reoperation was avoided in all but one of these cases. There were no complications. The experience has shown that in selected postoperative patients, direct puncture of the graft is safe and greatly facilitates performance of the angioplasty.     

Stent-graft placement for pseudoaneurysm of the aorta

PURPOSE: To evaluate the use of endovascular stent-graft placement to repair pseudoaneurysm of the aorta. METHODS: Six patients were treated with stent-grafts for pseudoaneurysms located in the thoracic aorta (n=2), thoracoabdominal aorta (n=3), and abdominal aorta (n=1). Etiologies of the pseudoaneurysms included leakage from surgical graft, penetrating atherosclerotic ulcer, pneumonia, perforated esophageal ulcer, and mycotic aneurysm. All patients were clinically considered to be at high surgical risk. RESULTS: Stent-grafts were successfully placed in all patients. There was one death in the perioperative period due to massive hemoptysis before stent-grafting. Two patients died of persistent infection. One patient with persistent perigraft leak died of rupture. Two other patients needed no further therapy for pseudoaneurysm. CONCLUSION: Stent-graft placement for pseudoaneurysm of the aorta can play the role of a temporizing method prior to surgical repair in high-risk cases and be a therapeutic alternative in cases without infection or perigraft leakage.     

21例假性动脉瘤的治疗策略

目的 探讨假性动脉瘤的部位、类型和发生原因,选择不同的治疗方法.方法 对21例假性动脉瘤患者(四肢动脉11例、脾动脉3例、肾动脉2例、髂总动脉2例、髂内动脉1例、胆囊动脉1例、阴茎动脉1例)选择不同的治疗方法,9例肢体动脉近大关节处假性动脉瘤采用球囊临时阻断血流下瘤体切除、血管吻合术或直接切开修补术,4例主干型假性动脉瘤采用覆膜支架腔内隔绝术,其中2例发生于髂内动脉开口处的髂总动脉主干型假性动脉瘤采用分支动脉栓塞和覆膜支架腔内隔绝术,6例终末型假性动脉瘤采用明胶海绵结合不锈钢圈栓塞术.结果 21例假性动脉瘤采用不同的方法治疗后瘤腔全部消失,11例肢体动脉假性动脉瘤患者术后远端血管搏动正常,未出现神经损伤,2例脾动脉主干近端、2例髂总动脉主干假性动脉瘤覆膜支架隔绝术后无内漏、远端血流通畅,6例终末型假性动脉瘤患者栓塞后瘤腔消失,出血停止,未出现脏器缺血坏死,其中1例髂内动脉二级分支多发假性动脉瘤患者,栓塞后1周因骨盆复合伤并发重度感染死亡.结论 根据假性动脉瘤的部化、类型和产生原因,选择不同的治疗方法,在尽量小的创伤下使各部位假性动脉瘤得到有效的治疗.     

Dialysis access fistulas: treatment of stenoses by transluminal angioplasty

Fifty-six balloon dilatations in 51 patients with upper-extremity dialysis access fistulas were performed over a 4-year period. Forty-four venous anastomotic lesions in patients with either internal or graft fistulas were dilated. Three arterial anastomotic lesions and nine distant venous stenoses were treated. Thirty-nine of 56 (70%) dilatations were initially successful. Of the initial successes, 28/35 (80%) were patent at 3 months, 19/27 (70%) at 6 months, 12/22 (55%) at 1 year, 7/14 (50%) at 2 years, and 3/9 (33%) at 3 years. Three complications (5%) were encountered. These included two graft thromboses and one pseudoaneurysm at the dilatation site. The procedure may be performed on an outpatient basis.     

创伤性动脉瘤的治疗

目的：探讨创伤性动脉瘤的外科手术治疗方法。方法：对近6年收治的创伤性动脉瘤39例进行回顾性分析。结果：24例行急诊手术治疗，动脉瘤切除后，10例作单纯动脉结扎，3例作动脉修补，26例用自体大隐静脉或人工血管移植重建血运，手术治愈37例，高位截肢2例，治愈率94．9％，术后随访26例（2个月－6年），均保存肢体。结论：外科手术仍是目前首选的外周创伤性动脉瘤治疗方法，应视具体情况选择手术方式，并重视感染性假性动脉瘤的治疗。     

Upper and midureteral calculi: percutaneous extraction with an occlusion balloon catheter

In 44 patients with one or more calculi in the upper two-thirds of the ureter, single-stage percutaneous nephrolithotomy was performed through a middle or upper calyceal nephrostomy after cystoscopic placement of an occlusion balloon catheter distal to the calculus; in 42, the procedure was successful. The occlusion balloon catheter permitted retrograde opacification of all systems for enhanced renal puncture. In the last 30 patients an attempt was made either to push the calculus upward mechanically or to flush it upward into the renal pelvis with carbon dioxide or dilute contrast material. This was successful in 24 of these patients. Prior overnight occlusion of the ureter by means of ureteral dilatation further facilitates dislodgment of the calculus, which was successful in 12 of 13 patients.     

Superior Mesenteric Artery Stent-graft Placement in a Patient with Pseudoaneurysm Developing from a Pancreatic Pseudocyst

Pseudoaneurysm is a relatively rare but serious complication of pancreatitis which is often fatal. We report successful stent-graft placement in the superior mesenteric artery in a 45-year-old man with a pancreatic pseudocyst that grew during therapy for chronic pancreatitis and developed into a pseudoaneurysm. After a stent graft was inserted in the superior mesenteric artery, the pseudoaneurysm disappeared and no further complications developed. Stent-graft placement was considered to be a useful therapy for pseudoaneurysms in the superior mesenteric arterial region.     

Percutaneous transfemoral arterial placement of 3 Fr. balloon infusion catheter for infusion chemotherapy of liver tumors

A 3 Fr. single lumen balloon catheter was successfully introduced for arterial infusion chemotherapy by percutaneous transfemoral arterial insertion. This balloon catheter was used combined with 6.3 Fr. outer catheter coaxially. After placing the catheter into the target artery, the balloon catheter was ruptured by injecting 1 ml contrast medium. On the other hand the balloon was made as a leak balloon catheter by a small needle puncture before use. Some merits of this system were as follows: Transarterial infusion chemotherapy can be followed immediately after making a diagnosis by transfemoral angiography. At the time of rupturing the balloon, we can see the area that must be infused under the conventional fluoroscopy. In the case of leak balloon catheter no blood regurgitation through the catheter was occurred during the procedure because of elasticity of the rubber. In 40 patients having liver tumor we performed this method combined with continuous infusion of 5-fluorouracil for 3 to 5 weeks and also once a week intra-arterial administration of mitomycin C and adriamycin. In some patients hyperthermia therapy was also carried out for the purpose of potentiation of cellular chemosensitivity by low temperature hyperthermia. The result of this therapy was as follows: CR; 10.3%, PR; 20.7%, NC; 63.9% and PD; 5.1%. No serious complications were encountered in our series except for some minor arterial troubles caused by catheter tip.