The fate of calf perforator veins after saphenous vein laser ablation

PURPOSE

We aimed to assess hemodynamic changes in calf perforator veins (PVs) after endovenous laser ablation (EVLA) of saphenous veins.

METHODS

The series comprised 60 limbs of 41 patients (27 female, 14 male; median age, 43 years [range, 22–78 years]) who underwent EVLA for varicose veins. All patients were prospectively evaluated by means of color Doppler ultrasonography before and after the procedure.

RESULTS

EVLA did not change the rate of incompetent PVs (preoperatively, 154/483 [32%] vs. postoperatively, 167/501 [33%]; P = 0.173), but significantly increased the total number of all PVs (n=483 vs. n=501, P = 0.036). Following EVLA, 28% of the limbs had thrombosis of PVs, 34% had new US-detectable PVs, 42% showed new competency, and 52% showed new incompetency. New competent PVs were found more commonly in the medial leg (ablation site) than the lateral leg (nonablation site) (28.3% vs. 11.7%, P = 0.016), while new incompetent PVs were found more commonly in nonablation site than ablation site (31.7% vs. 18.3%, P = 0.086). Additionally, new competent PVs in the posterior leg were found more often in patients who had small saphenous vein ablation than patients who did not (30% vs. 0%, P = 0.002).

CONCLUSION

EVLA induces numerous changes in calf PVs. These changes seem to result from flow offloading in ablation site and onloading in nonablation site in the early postablation period.Perforator veins (PVs) connect the superficial veins with the deep venous system, and are usually seen in patients with chronic venous disease (CVD). However, the role of PVs in the cause and management of varicose veins and CVD continues to be debated despite significant research and clinical experience (1–3). The prevalence and diameter of PVs correlate well with the severity of CVD. Many previous reports have suggested that incompetent PVs may result in venous hypertension and play an important role in the development of recurrent varicose veins and nonhealing or recurrent venous ulcers after varicose vein surgery (4, 5).Elimination of superficial reflux has been classically accomplished through surgery. However, thermal ablation methods such as endovenous laser ablation (EVLA) and radiofrequency ablation are gradually becoming the treatment of choice (6, 7). The outcome of venous leg perforators after surgical eradication of superficial reflux has been reported in a few studies. Limited data show that superficial varicose surgery abolishes incompetence in some calf perforators and offer protection against development of new perforator incompetence (8). Ligation and stripping of great saphenous vein (GSV), ligation of small saphenous vein (SSV) with or without phlebectomies eliminate the reflux in 20% to 55% of limbs with preoperative incompetent PVs (8–11). However, to the best of our knowledge, there is no data in the literature about the effect of laser ablation of saphenous veins on leg perforators. The aim of this study was to evaluate the morphologic and hemodynamic changes in the calf perforators after EVLA of saphenous veins and elucidate factors that influence these changes.     

An innovative modification of the retrograde approach to angioplasty and recanalization of the superficial femoral artery

Endovascular therapy has been performed for chronic limb ischemia for nearly 50 years. Superficial femoral artery occlusions can be managed by the retrograde contralateral (“crossover”), antegrade ipsilateral, or retrograde popliteal (“facedown”) approaches. The retrograde approach was initially fraught with limitations and served as a backup option. Refinements to this technique have made it an enticing option and possibly the first choice in selected patients. We herein describe an innovative modification of this method.Endovascular therapy has been performed for chronic limb ischemia since 1964, with intraluminal and subintimal angioplasty of the superficial femoral artery (SFA) gaining popularity in the last decade (1). SFA occlusions can be managed by retrograde contralateral or antegrade ipsilateral approaches (2, 3); when these approaches fail, some practitioners resort to using a re-entry device (4, 5). The retrograde popliteal approach was initially fraught with limitations and served as a backup option (1, 4, 6). However, refinements to this technique have made this an enticing option (2–7), and it has been advocated as a first-line treatment in select patients (3). We herein describe another modification of this method.     

Development,growth, propagation,and angiographic utilization of the rabbit VX2 model of liver cancer: a pictorial primer and “how to” guide

The VX2 tumor is a leporine anaplastic squamous cell carcinoma characterized by rapid growth, hypervascularity, and facile propagation in the skeletal muscle. Since its introduction over 70 years ago, it has been used to model a variety of malignancies, and is commonly employed by interventional radiologists in preclinical investigations of hepatocellular carcinoma. However, despite the widespread and lasting popularity of the model, there are few technical resources detailing its use. Herein, we present a comprehensive pictorial outline of the technical methodology for development, growth, propagation, and angiographic utilization of the rabbit VX2 liver tumor model.The rabbit VX2 tumor model has played a longstanding role in experimental oncology. Developed in 1930–1940 by Rous et al. (1, 2), the VX2 tumor is a virus-induced anaplastic squamous cell carcinoma characterized by hypervascularity, rapid growth, and easy propagation in the skeletal muscle (3, 4). Since its introduction, the tumor has been used to model cancers of the head and neck (5), kidney (6), brain (7), lung (8), urinary bladder (9), uterus (10), liver (11, 12), bone (13), and pancreas (14). The high growth rate and the relatively large size of rabbit vasculature render the model particularly well suited for use by interventional radiologists, and in recent years the model has been employed in numerous studies pertaining to the imaging and locoregional treatment of hepatocellular carcinoma (15–19). However, despite the widespread and lasting popularity of the model, there are few, if any, comprehensive technical resources detailing its use, leaving many key procedural details to be conveyed anecdotally. Lack of a technical guide may also represent a barrier to entry of interventional radiologists into translational research. With that in mind, this review is intended to provide a complete pictorial overview of the development, growth, propagation, and angiographic utilization of the rabbit VX2 tumor model based on the experience of a single operator in order to serve as a reference for novice and experienced investigators alike.     

Diffusion-weighted MRI findings of treated and untreated retroperitoneal fibrosis

PURPOSE

We aimed to evaluate diffusion-weighted imaging (DWI) findings in patients with treated and untreated retroperitoneal fibrosis (RPF).

METHODS

We analyzed magnetic resonance imaging examinations of 44 RPF patients (36 male, 8 female), of which 15 were untreated and 29 were under therapy. Qualitative DWI and T1 postcontrast signal intensities and the largest perivascular extent of RPF were compared between treated and untreated groups and correlated to erythrocyte sedimentation rate and C-reactive protein values. Quantitative DWI signal intensities and apparent-diffusion-coefficients were calculated in regions-of-interest, together with a relative index between signal intensities of RPF and psoas muscle in 15 untreated patients and 14 patients under treatment with remaining perivascular fibrosis of more than 5 mm.

RESULTS

The extent of RPF in untreated patients was significantly larger compared with the extent of RPF in treated patients (P < 0.0001). DWI signal intensities were significantly higher in untreated patients than in patients under therapy (mean, 27 s/mm² vs. 20 s/mm²; P = 0.009). The calculated DWI-index was significantly higher in untreated patients than in patients under therapy (P = 0.003).

CONCLUSION

Our data show significant differences in the DWI findings (b800 signal intensities and relative DWI-index) of patients with treated and untreated RPF. DWI is a promising technique in the assessment of disease activity and the selection of patients suitable for medical therapy.Retroperitoneal fibrosis (RPF) is a rare disease affecting the retroperitoneal space (1–3). It presents as retroperitoneal proliferation of fibrous tissue surrounding the retroperitoneal vascular structures and abutting the medial aspect of the ureters. Clinical findings of RPF are non-specific; the most common symptom is chronic back pain. Further symptoms include lower extremity edema, deep vein thrombosis, oliguria, and urinary tract infection (3). Computed tomography (CT) and magnetic resonance imaging (MRI) are the preferred imaging modalities for the diagnosis of RPF (3). Retroperitoneal fibrosis shows contrast enhancement of gadolinium containing contrast media in MRI (4). Medical treatment is classically based on steroids like prednisone (3). Recent studies suggested tamoxifen as another safe and effective treatment alternative (5).The assessment of disease activity is relevant for planning of further medical or surgical therapy (6, 7). Nowadays the disease activity is assessable by positron emission tomography tracer uptake (3), with a relatively low resolution and the need of ionized radiation. As an alternative, dynamic contrast-enhanced MRI was suggested for the evaluation of disease activity (7, 8). However, gadolinium may be contraindicated in patients with impaired renal function due to the potential development of nephrogenic systemic fibrosis (NSF) (9). This is especially relevant in RPF patients with postrenal failure due to ureteral compression. For those cases a supplemental method for the determination of disease activity would be helpful.Diffusion-weighted imaging (DWI) is a radiation-free unenhanced MRI modality that has been applied for the detection of bowel inflammation in patients with chronic inflammatory bowel diseases (10, 11), as well as for oncological retroperitoneal and abdominal applications (12–14). Therefore, we aimed to evaluate the application and findings of DWI in patients with treated and untreated RPF disease.     

Adverse effects of irreversible electroporation of malignant liver tumors under CT fluoroscopic guidance: a single-center experience

PURPOSE

We aimed to describe the frequency of adverse events after computed tomography (CT) fluoroscopy-guided irreversible electroporation (IRE) of malignant hepatic tumors and their risk factors.

METHODS

We retrospectively analyzed 85 IRE ablation procedures of 114 malignant liver tumors (52 primary and 62 secondary) not suitable for resection or thermal ablation in 56 patients (42 men and 14 women; median age, 61 years) with regard to mortality and treatment-related complications. Complications were evaluated according to the standardized grading system of the Society of Interventional Radiology. Factors influencing the occurrence of major and minor complications were investigated.

RESULTS

No IRE-related death occurred. Major complications occurred in 7.1% of IRE procedures (6/85), while minor complications occurred in 18.8% (16/85). The most frequent major complication was postablative abscess (4.7%, 4/85) which affected patients with bilioenteric anastomosis significantly more often than patients without this condition (43% vs. 1.3%, P = 0.010). Bilioenteric anastomosis was additionally identified as a risk factor for major complications in general (P = 0.002). Minor complications mainly consisted of hemorrhage and portal vein branch thrombosis.

CONCLUSION

The current study suggests that CT fluoroscopy-guided IRE ablation of malignant liver tumors may be a relatively low-risk procedure. However, patients with bilioenteric anastomosis seem to have an increased risk of postablative abscess formation.About 70% of hepatic metastases are nonresectable because of their anatomic location, the presence of comorbidities, or limited hepatic functional reserve (1). In these patients and in case of nonresectable primary liver tumors, percutaneous thermal ablation procedures, such as radiofrequency (RF) and microwave ablation, have become effective tools for treating hepatic malignancies (2–4). However, the effectiveness of RF and microwave treatment may be limited, either because of thermal damage to temperature-sensitive structures located in close proximity to the target tissue (5) or because of incomplete ablation of tumors adjacent to major hepatic vessels due to a phenomenon commonly termed “heat-sink effect” (6–10) which describes the loss of the applied thermal energy through the blood flow in those major vessels, whereby the effective energy application remains inadequate to ablate the target lesion.Irreversible electroporation (IRE) is a theoretically nonthermal ablation technique that delivers a series of high-voltage millisecond electrical pulses to the surrounding tissue, thus leading to irreversible disruption of the integrity of cell membranes and subsequent cell death by apoptosis (11–14). IRE may overcome the problems raised with thermal ablation: previous animal studies reported that bile ducts, blood vessels, nerves, and connective tissues are affected by IRE; however, regeneration is possible to some extent due to preservation of the tissue architecture (12, 13, 15–19). Moreover the feasibility of inducing cell death up to a vessel wall without any perivascular sparing was shown with IRE (12, 13, 18). The safety of IRE in the treatment of humans has been described (20). First reports have described potential complications after IRE, such as hemorrhage requiring blood transfusion (1.2%, two of 167 ablation procedures), portal vein thrombosis (3.2%, one of 31 ablation procedures), injury to bile ducts (1.8%, three of 167 ablation procedures), and infection (3.6%, six of 167 ablation procedures) (21, 22). However, few data are available for evaluating the potential risk factors associated with the occurrence of post-IRE complications.The purpose of this study was to review the frequency of mortality and morbidity after computed tomography (CT) fluoroscopy-guided liver IRE conducted at a single center and assess the factors influencing the occurrence of major complications.     

MRI features of breast lymphoma: preliminary experience in seven cases

PURPOSE

We aimed to evaluate the imaging features of breast lymphoma using magnetic resonance imaging (MRI).

METHODS

This retrospective study consisted of seven patients with pathologically confirmed breast lymphoma. The breast lymphomas were primary in six patients and secondary in one patient. All patients underwent preoperative dynamic contrast-enhanced MRI and one underwent additional diffusion-weighted imaging (DWI) with a b value of 600 s/mm². Morphologic characteristics, enhancement features, and apparent diffusion coefficient (ADC) values were reviewed.

RESULTS

On MRI, three patients presented with a single mass, one with two masses, two with multiple masses, and one with a single mass and a contralateral focal enhancement. The MRI features of the eight biopsied masses in seven patients were analyzed. On MRI, the margins were irregular in six masses (75%) and spiculated in two (25%). Seven masses (87.5%) displayed homogeneous internal enhancement, while one (12.5%) showed rim enhancement. Seven masses (87.5%) showed a washout pattern and one (12.5%) showed a plateau pattern. The penetrating vessel sign was found in two masses (25%). One patient with two masses underwent DWI. Both masses showed hyperintense signal on DWI with ADC values of 0.867×10⁻³ mm²/s and 0.732×10⁻³ mm²/s, respectively.

CONCLUSION

Breast lymphoma commonly presents as a homogeneously enhancing mass with irregular margins and displays a washout curve pattern on dynamic MRI. A low ADC value may also indicate a possible diagnosis of breast lymphoma.Breast lymphoma, which constitutes only 0.04%–0.5% of all breast malignancies (1), can be divided into primary or secondary breast lymphoma (2). The majority of breast lymphomas are diffuse large B-cell lymphoma (3). The spontaneous regression of a breast lymphoma is rare and the five-year overall survival rate is 53% (1, 4). Early-stage identification and the use of radiotherapy are favorable prognostic factors, while mastectomy is associated with a poorer survival (1, 5). Therefore, a preoperative diagnosis of breast lymphoma would mean an earlier diagnosis and likely avoid unnecessary aggressive procedures.Previous studies demonstrated mammographic and ultrasonographic findings of breast lymphoma (6–8). Most lesions were high-density masses without spiculated margins and calcifications on mammography and noncircumscribed hypoechoic masses on ultrasonography (6–8). However, none were pathognomonic.Data on the magnetic resonance imaging (MRI) of breast lymphoma are limited to some single case reports (4, 7, 9–19) and small sample size case series (8, 20–23). The morphology and time-signal intensity curve (TIC) of breast lymphoma on MRI are variable. Diffusion-weighted imaging (DWI) is a functional imaging technique that is useful for distinguishing lymphoma from other malignant tumors in other systems (24, 25). However, to the best of our knowledge, the value of DWI in differentiating breast lymphoma from other malignant breast lesions has not been discussed. Therefore, the purpose of this study is to assess the MRI and DWI features of breast lymphoma.     

CT-guided percutaneous cryoablation of central lung tumors

PURPOSE

Cryoablation has been successfully used to treat lung tumors. However, the safety and effectiveness of treating tumors adjacent to critical structures has not been fully established. We describe our experience with computed tomography (CT)-guided percutaneous cryoablation of central lung tumors and the role of ice ball monitoring.

MATERIALS AND METHODS

Eight patients with 11 malignant central lung tumors (nine metastatic, two primary; mean, 2.6 cm; range, 1.0–4.5 cm) located adjacent to mediastinal or hilar structures were treated using CT-guided cryoablation in 10 procedures. Technical success and effectiveness rates were calculated, complications were tabulated and intraprocedural imaging features of ice balls were described.

RESULTS

All procedures were technically successful; imaging after 24 hours demonstrated no residual tumor. Five tumors recurred, three of which were re-ablated successfully. A hypodense ice ball with well-defined margin was visible during the first (n=6, 55%) or second (n=11, 100%) freeze, encompassing the entire tumor in all patients, and abutting (n=7) or minimally involving (n=4) adjacent mediastinal and hilar structures. Pneumothorax developed following six procedures (60%); percutaneous treatment was applied in three of them. All patients developed pleural effusions, with one patient requiring percutaneous drainage. Transient hemoptysis occurred after six procedures (60%), but all cases improved within a week. No injury occurred to mediastinal or hilar structures.

CONCLUSION

CT-guided percutaneous cryoablation can be used to treat central lung tumors successfully. Although complications were common, they were self-limited, treatable, and not related to tumor location. Ice ball monitoring helped maximize the amount of tumor treated, while avoiding critical mediastinal and hilar structures.Malignant lung tumors represent a major cause of morbidity and mortality in developed nations (1). While surgical resection remains the treatment of choice for the local control of both non-small cell lung cancer and metastases to the lung, percutaneous image-guided ablative therapies, particularly heat-based ablation techniques such as radiofrequency (RF) ablation, have emerged as safe and effective alternatives in patients who are not surgical candidates (2–7). However, treatment of lung tumors using RF ablation presents technical challenges, including high electrical resistance of alveolar air, poor thermal conductivity of aerated lung, and the heat-sink effect of blood and air flow in well-perfused and aerated lung tissue (8, 9). In addition, RF ablation has a limited role in the treatment of tumors that are close to mediastinal and hilar structures (2–9). Since intraprocedural visualization of ablation zone margins is not possible during heat-based ablation procedures, treatment of central tumors could harm mediastinal and hilar structures, including the tracheobronchial tree. As a result, tumors close to central structures are generally not amenable to treatment using percutaneous heat-based ablation techniques (2–10). Also, RF ablation may interfere with conduction system of the heart and function of the pacemakers (11).A growing body of literature describes the successful use of cryoablation in the treatment of malignancies in the liver, kidneys, and soft tissues (12–14). The ability to deploy multiple, individually-controlled cryoablation applicators facilitates the creation of ablation zones of desired shapes and sizes that can be tailored to the morphology of the tumor being ablated (15, 16). Cryoablation is also monitorable; ice balls can be visualized by computed tomography (CT) as a distinct ovoid area of low attenuation during the procedure. As a result, the treatment can be optimized while minimizing the risk of harming nearby critical structures (12–16). Also, cryoablation may be less painful than RF ablation (17). Finally, it has been suggested that cryoablation may be better suited for the treatment of thoracic tumors adjacent to the mediastinum because it spares the architecture of collagen-containing structures relative to RF ablation and enables preservation of the integrity of the tracheobroncheal tree (18). Heat-based ablation methods may not be safe in the treatment of central lung tumors because of a possibility of bronchial disruption or perforation, which may result in bronchopleural fistula formation (19). Although cryoablation has been used to treat lung malignancies (19–31), there are limited data on the safety and effectiveness of percutaneous cryoablation of central lung tumors. In this study, we describe our experience with CT-guided percutaneous cryoablation of central lung tumors and the role of ice ball monitoring.     

Tempofilter II implantation in patients with lower extremity fractures and proximal deep vein thrombosis

PURPOSE

We aimed to examine the efficacy and safety of Tempofilter II (B. Braun, Melsungen, Germany) implantation to prevent pulmonary embolism in patients with lower-extremity fractures and proximal deep vein thrombosis (DVT).

MATERIALS AND METHODS

The records of patients with lower limb fractures and proximal DVT who were implanted with Tempofilter II devices from May 2004 to August 2009 were reviewed. Data collected included success rate, occurrence of pulmonary embolism, retrieval rate, and complications.

RESULTS

A total of 176 eligible patients, including 129 males (73.3%) and 47 females (26.7%) with a median age of 42.0 years (interquartile range [IQR], 34.0–52.0 years) were included in the study. Filters were successfully implanted in 174 patients (98.9%). One patient experienced a pulmonary embolism after implantation and died. Filters were removed without complications in all other patients. Median filter implantation time was 27 days (IQR, 25.0–29.0 days). Visible organized thrombi were present on the surface of 144 (82.8%) of filters after removal, and the diameter of most thrombi (n=124) ranged from 0.5 to 1.0 cm. Filters migrated <2 cm in 104 patients (59.8%) and ≥2 cm in five patients (2.9%). In these five cases, three filters migrated into the right atrium and two migrated to the orifice of the renal veins.

CONCLUSION

Tempofilter II is safe and may be useful in cases of lower extremity fracture with proximal DVT for the prevention of pulmonary embolism. The filter is easily placed and retrieved, and associated with minimal complications.Acute pulmonary embolism (PE) is one of the most common causes of death in hospitalized patients (1, 2). The mortality rate of PEs is especially high in trauma patients, as these tend to develop latent PEs. Although the mortality associated with PEs has been greatly reduced by the application of inferior vena cava filters (VCFs) (3, 4), permanent VCF implantation is associated with long-term complications such as recurrent deep vein thrombosis (DVT), filter dislocation, migration, and rupture (5–8). Thus, for patients with a long life expectancy and transient risk for venous thromboembolism, nonpermanent VCF placement is preferred (6). Currently, two types of nonpermanent filters are available: temporary and retrievable filters. Retrievable filters can be used to prevent PE in trauma patients during the high-risk period while avoiding the complications associated with long-term placement (9, 10). If a thrombus is trapped by the filter, the filter can be maintained at the original position and removed after thrombus resolution (5). However, because the recommended usage time of this type of filter is relatively short (usually 12 days), the extraction rate is low and many are left in place permanently (11).The Tempofilter II (B. Braun, Melsungen, Germany) is a second-generation temporary caval filter with an indwelling time of up to six weeks (12). The filter is placed and retrieved by means of a tethered cable fixed to a subcutaneous anchoring device. There is only one prior large-scale study, including placement of 104 Tempofilter II filters in 103 patients with PE, DVT, or both (12). They reported only one case of PE after filter placement, no mechanical complications related to the filter, and successful retrieval in all but one case regardless of thrombus entrapment (12).The purpose of this study was to examine the efficacy and safety of the Tempofilter II in Chinese patients with lower extremity fractures and proximal DVT.     

The potential role of modern US in the follow-up of patients with retroperitoneal fibrosis

PURPOSE

We aimed to evaluate a standardized ultrasonography (US) algorithm for the visualization of pathologic para-aortic tissue in retroperitoneal fibrosis (RPF).

MATERIALS AND METHODS

Thirty-five patients with lumbar RPF of typical extent, as determined by abdominal magnetic resonance imaging, were included. Examinations were conducted using standardized abdominal US with axial sections obtained at the levels of the renal arteries, aortic bifurcation, and both common iliac arteries. Imaging of each section was acquired with fundamental B-mode (US) and tissue harmonic imaging, respectively. In addition, we examined RPF visualized using extended field-of-view US.

RESULTS

Tissue harmonic imaging adequately visualized RPF of typical extent in 33 patients (94.2%). Excellent and good visualization with mild artifacts were achieved in 25 (71.4%) and six (17.1%) patients, respectively. When RPF spread along the iliac arteries, excellent visualization was achieved in 38.7% for the left side and 34.5% for the right side. There were significantly fewer diagnostic examinations for the right iliac (27.6%) than for the left one (9.7%) (P = 0.016). Overall, harmonic imaging achieved significantly better visualization than fundamental B-Mode (P < 0.001).

CONCLUSION

We described the first systematic evaluation of RPF visualization by modern US techniques. The best imaging quality was found in the typical RPF location, at the level of the aortic bifurcation. These results advocate for the presented US algorithm as an efficient follow-up alternative to cross-sectional imaging in RPF patients.Chronic periaortitis or retroperitoneal fibrosis (RPF) is a rare fibrosing disease that affects para-aortic tissues (1–3). It typically presents as a proliferating lumbar process surrounding the ureters and retroperitoneal vascular structures (Fig. 1) (2, 4). Sporadic, atypical manifestations in pelvic and mesenteric regions are also possible (5).Open in a separate windowFigure 1. a–c.Typical extent of the retroperitoneal fibrosis surrounding the infrarenal aorta (a). Spreading of the fibrosis to the renal arteries and along the common iliac arteries (b). Standardized US examination with four transverse sections (c). AO, aorta; AIC, common iliac artery; RA, renal artery; RPF, retroperitoneal fibrosis.Magnetic resonance imaging (MRI) allows precise evaluation of the extent and complications (6). RPF presents as hypointense (often isointense to striated muscle) plaques in native T1-weighted magnetic resonance (MR) images with significant gadolinium contrast enhancement of active and untreated retroperitoneal fibrosis (7–9).Ultrasonography (US) is primarily used in patients with RPF for a rapid and practical diagnosis of consecutive hydronephrosis (6). RPF presents as a smooth-bordered mass with either an echo-poor or echo-free signal (10, 11). Two studies in the 1980s indicated that US revealed only a poor overall sensitivity in the detection of RPF (12, 13). Feinstein et al. (14) reported that only 25% of affected patients with computed tomography (CT)-mediated diagnosis of RPF showed corresponding ultrasonographic abnormalities. Since that time the quality of US scanners has improved dramatically, and modern techniques, such as tissue harmonic imaging (THI) and extended field-of-view US, have significant advantages for routine clinical diagnosis (15–17). Today, US has established itself as an effective and cost-efficient imaging method for the screening and follow-up of infrarenal aortic aneurysms (18, 19). US, however, is not used routinely for RPF follow-up, nor has a systematic evaluation of modern ultrasonographic methods been available to date.The aim of the present study was to evaluate the potential role of modern ultrasonographic techniques for the visualization of fibrous tissue in patients with prediagnosed RPF.     

The endovenous ASVAL method: principles and preliminary results

PURPOSE

We aimed to investigate the feasibility and safety of the endovenous ambulatory selective varicose vein ablation under local anesthesia (eASVAL) method in a selected group of patients with varicose disease and present the short-term results of one-year ultrasonographic follow-up.

METHODS

Three hundred and ninety-five consecutive patients with varicose veins who had been treated with endovenous laser ablation (EVLA) were retrospectively reviewed over a period of two years. From this group, 41 patients who were treated using the eASVAL technique and had the great saphenous vein (GSV) preserved were included in the study. These patients had only limited segmental GSV reflux accompanied by a competent terminal valve. The eASVAL technique can be defined as EVLA of the proximal straight segments of the major tributaries connecting the symptomatic varicose veins with the GSV, followed by ultrasound-guided foam sclerotherapy of the superficial varicose veins themselves. The patients were assessed before and after the treatment by duplex scan findings and clinical assessment scores.

RESULTS

The GSVs were successfully preserved in all 41 cases, and all patients showed significant clinical improvement using the eASVAL approach (P < 0.001). Segmental reflux was no longer present in 75.3% of patients. The mean diameters of the GSVs were significantly reduced at one-year follow-up (8.5 mm vs. 7.5 mm, P < 0.001).

CONCLUSION

eASVAL is a feasible and safe procedure in selected patients, with promising results at one-year ultrasonographic follow-up. However, prospective studies are required, comparing this approach with the standard techniques.Ambulatory selective varicose vein ablation under local anesthesia (ASVAL) is a surgical treatment for varicose veins based on the ascending hypothesis that venous insufficiency progresses in an ascending manner, from the superficial tributaries to the saphenous vein (SV) and then to the sapheno-femoral junction (SFJ). Recent scientific data based on precise and detailed duplex scanning support this hypothesis (1–6). The ASVAL method recommends preserving the great saphenous vein (GSV), unless there is a serious terminal valve insufficiency, and suggests the surgical removal (phlebectomy) of the superficial varicose reservoir (SVR) as a primary treatment. The major argument in favor of preserving the GSV is the essential physiologic role that the GSV could play in superficial drainage and, to a lesser extent, its availability as revascularization material. Although the original ASVAL method is performed using simple phlebectomies, many patients refuse to have this treatment because they regard it as a surgical operation that would likely yield poor cosmetic results. Thermal endovenous techniques and foam sclerotherapy are less aggressive and are reported to be as effective as traditional surgical treatments (7). The question arises as to whether the ASVAL approach can be performed using endovenous techniques. To the best of our knowledge, this research will be a preliminary study describing the endovenous technique for the ASVAL approach.The purpose of this study was to investigate the feasibility and safety of endovenous ASVAL (eASVAL) technique and to present the short-term results with one-year ultrasonography (US) follow-up in a selected group of patients.     

Imaging of facial nerve schwannomas: diagnostic pearls and potential pitfalls

Schwannomas are uncommon in the facial nerve and account for less than 1% of tumors of temporal bone. They can involve one or more than one segment of the facial nerve. The clinical presentations and the imaging appearances of facial nerve schwannomas are influenced by the topographical anatomy of the facial nerve and vary according to the segment(s) they involve. This pictorial essay illustrates the imaging features of facial nerve schwannomas according to their various anatomical locations and also reviews the pertinent differential diagnoses and potential diagnostic pitfalls.Facial nerve schwannomas (FNSs) are rare slow-growing tumors, accounting for less than 1% of all temporal bone tumors. They are typically solitary, unilateral, and sporadic in nature. FNSs may be bilateral as part of neurofibromatosis-2 spectrum (1, 2). Rarely, multiple schwannomas may involve peripheral branches of the facial nerve (FN) (3). The age of presentation varies from 5 to 84 years. No gender or side predilection is seen (4, 5).Histologically, FNSs are neuroectodermal in origin. They are encapsulated, benign tumors arising from the Schwann cells. They may show intratumoral cystic change and hemorrhage (3, 4, 5). Malignant schwannoma of the FN is extremely rare (6). FNSs commonly present with peripheral facial neuropathy and/or various otologic symptoms including sensorineural and conducting hearing loss (2–5). Facial paralysis is often seen at a later stage or may not be seen at all. The reasons for this are thought to be neuronal tolerance induced by the extremely slow growth of the tumor, abundant tumor vascularity, and commonly associated dehiscence of adjacent bone (7). Occasionally, FNSs may present as an intraparotid mass or as an intracranial lesion (2–5).The clinical presentations and the imaging appearances of FNSs are influenced by the topographical imaging anatomy of the FN and vary according to the segment(s) they involve (8). Here, we briefly describe the anatomy of the FN, followed by general imaging features of FNSs on computed tomography (CT) and magnetic resonance imaging (MRI), and appropriate imaging protocols. Tumor involving each segment is reviewed in relation to its characteristic clinical presentations emphasizing diagnostic pearls and potential pitfalls. The imaging examples of FNSs illustrated in this pictorial review are all histopathologically proven cases.     

Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma

PURPOSE

Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma.

METHODS

Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared.

RESULTS

A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm³; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm³; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm³; IQR: 136, 371) (both, P = 0.002).

CONCLUSION

Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.The liver is one of the most frequently injured solid abdominal organs in the setting of blunt abdominal trauma (1). Fortunately, most patients with blunt hepatic trauma have relatively stable vital signs and need only supportive treatment or transarterial embolization (TAE) (1–9). Only 15% of patients, who present with hemodynamic instability or fail with nonoperative management, require operative intervention to manage their liver injury.Embolic therapy has been shown to have a high success rate in hemodynamically stable patients with blunt hepatic injury. TAE is associated with decreased abdominal infections, decreased transfusions, and decreased length of hospital stay compared with operative management (2, 3, 7). However, angiography can only detect bleeding from the hepatic artery; it cannot locate bleeding from the hepatic or portal vein. In the literature, portal vein injuries are not commonly described and most are the result of penetrating injuries to the extrahepatic portal veins. Mortality after a portal vein injury due to trauma is primarily due to hypovolemic shock and can be as high as 50% or greater (10, 11).Since the intrahepatic portions of the hepatic and portal veins are low pressure systems, they can bleed insidiously. Nevertheless, this subtle bleeding may require multiple transfusions and result in a prolonged hospital stay. Relative to an extrahepatic portal vein injury, patients with an intrahepatic portal vein injury may have relatively stable vital signs and slowly decreasing hemoglobin levels (10, 11). In addition, traumatic occlusion and/or thrombosis of the portal vein may cause large hepatic parenchymal infarction.Computed tomography arterial portography (CTAP) is a useful method based on portal enhancement of the liver by infusion of contrast material through the superior mesenteric artery for evaluating the portal venous system (12–15) and is widely used in patients with hepatic tumors with portal venous invasion (13, 16, 17). CTAP has a high sensitivity and specificity in the evaluation of portal vein thrombosis due to tumor (90% sensitivity, 99% specificity, 95% positive predictive value, 97% negative predictive value) (14). However, few studies have focused specifically on the utility of CTAP in the evaluation of portal vein injury as a result of trauma.The liver has a dual blood supply and receives between 66% and 75% of its blood supply from the hepatic portal vein with the remainder supplied by the hepatic artery (18). CTAP reflects only portal venous perfusion while reperfusion CTAP (rCTAP) reflects hepatic arterial reperfusion. Both rCTAP and conventional computed tomography (CT) are useful for determining certain liver injuries. However, they do not specifically evaluate the portal vein.The purpose of this study was to compare CTAP, rCTAP, and CT for diagnosing portal vein injuries after blunt hepatic trauma. We hypothesized that CTAP would be superior to rCTAP and CT in assessing portal vein injury after blunt hepatic trauma.     

Genotype-phenotype correlations in hepatocellular adenoma: an update of MRI findings

Hepatocellular adenoma (HCA) is a generally benign liver tumor with the potential for malignancy and bleeding. HCAs are categorized into four subtypes on the basis of genetic and pathological features: hepatocyte nuclear factor 1α-mutated HCA, β-catenin-mutated HCA, inflammatory HCA, and unclassified HCA. Magnetic resonance imaging (MRI) plays an important role in the diagnosis, subtype characterization, and detection of HCA complications; it is also used to differentiate HCA from focal nodular hyperplasia. In this review, we present an overview of the genetic abnormalities, oncogenesis, and typical and atypical MRI findings of specific subtypes of HCA using contrast-enhanced MRI with or without hepatobiliary contrast agents (gadobenate dimeglumine and gadoxetate disodium). We also discuss their different management implications after diagnosis.Hepatocellular adenoma (HCA) is a rare, benign tumor of the liver that occurs predominantly in young and middle-aged women (1). In contrast to focal nodular hyperplasia (FNH), HCA may involve complications, such as a life-threatening bleeding and malignant degeneration (1–3). The strong association between the occurrence of HCA and the use of oral contraceptives was first acknowledged in 1970s (4), and the incidence of HCA is now thought to be 30 times greater in oral contraceptive users compared to nonusers (5, 6). A dose-dependent association and spontaneous regression following the withdrawal of estrogens have also been described (4, 7). However, the exact role of estrogen in HCA is still poorly understood.In this review, we present an overview of the typical and atypical magnetic resonance imaging (MRI) findings of different HCAs compared to FNH, and discuss various pitfalls that may be encountered with MRI.     

Why should we report posterior fossa emissary veins?

Posterior fossa emissary veins are valveless veins that pass through cranial apertures. They participate in extracranial venous drainage of the posterior fossa dural sinuses. The mastoid emissary vein, condylar veins, occipital emissary vein, and petrosquamosal sinus are the major posterior fossa emissary veins. We believe that posterior fossa emissary veins can be detected by radiologists before surgery with a thorough understanding of their anatomy. Describing them using temporal bone computed tomography (CT), CT angiography, and cerebral magnetic resonance (MR) venography examinations results in more detailed and accurate preoperative radiological interpretation and has clinical importance. This pictorial essay reviews the anatomy of the major and clinically relevant posterior fossa emissary veins using high-resolution CT, CT angiography, and MR venography images and discusses the clinical importance of reporting these vascular variants.Posterior fossa emissary veins pass through cranial apertures and participate in extracranial venous drainage of the posterior fossa dural sinuses. These emissary veins are usually small and asymptomatic in healthy people. They protect the brain from increases in intracranial pressure in patients with lesions of the neck or skull base and obstructed internal jugular veins (1). They also help to cool venous blood circulating through cephalic structures (2). Emissary veins may be enlarged in patients with high-flow vascular malformations or severe hypoplasia or aplasia of the jugular veins. They are associated with craniofacial syndromes (1, 3). Dilated emissary veins may cause tinnitus (4, 5).We aim to emphasize the importance of reporting posterior fossa emissary veins prior to surgeries that are related to the posterior fossa and mastoid region. Here, we review their embryology and anatomy based on high-resolution computed tomography (CT), CT angiography, and magnetic resonance (MR) venography images.     

Clinical,pathological, and imaging characteristics of primitive neuroectodermal tumors of the spine

Primitive neuroectodermal tumors (PNETs) located in the spine are extremely rare, and information concerning these tumors in the medical literature is limited to single case reports. This pictorial essay presents the clinical, pathological, and imaging characteristics of PNET of the spine.Primitive neuroectodermal tumors (PNETs) are malignant tumors thought to arise from the neural ectoderm and comprise undifferentiated small round cells (1–3). PNETs located in the spine are extremely rare, and information concerning these tumors in the medical literature is limited to single case reports (4–5). This pictorial essay presents the clinical, pathological, and imaging characteristics of PNET of the spine.     

Accessory hepatic vein recanalization for treatment of Budd-Chiari syndrome due to long-segment obstruction of the hepatic vein: initial clinical experience

PURPOSE

We aimed to investigate the feasibility and effectiveness of accessory hepatic vein recanalization (balloon dilatation/stent insertion) for patients with Budd-Chiari syndrome (BCS) due to long-segment obstruction of the hepatic vein.

METHODS

From March 2010 to December 2013, 20 consecutive patients with BCS, due to long-segment obstruction of three hepatic veins, treated with accessory hepatic vein recanalization (11 males, 9 females; mean age, 33.4±10.9 years; range, 22–56 years) were included in this retrospective study. Data on technical success, clinical success, and follow-up were collected and analyzed.

RESULTS

Technical and clinical success was achieved in all patients. Each patient was managed with a single accessory hepatic vein recanalization procedure. No procedure-related complications occurred. The diameter of the accessory hepatic vein was 8.45±1.47 mm (6–11 mm) at the stem, and there were many collateral circulations between the hepatic vein and the accessory hepatic vein. The mean pressure of accessory hepatic vein decreased from 47.50±5.59 cm H₂O before treatment to 28.80±3.47 cm H₂O after treatment (P < 0.001). Abnormal levels of total bilirubin, albumin, aspartate aminotransferase, and alanine transaminase improved after the treatment. During the follow-up, three patients experienced restenosis or stenting of the accessory hepatic vein.

CONCLUSIONS

In BCS due to long-segment obstruction of the hepatic veins, it is important to confirm whether there is a compensatory accessory hepatic vein. For patients with a compensatory but obstructed accessory hepatic vein, recanalization is a simple, safe, and effective treatment option.Budd-Chiari syndrome (BCS) is a rare disease characterized by hepatic venous outflow obstruction at the level of the hepatic vein (HV) or inferior vena cava (IVC) resulting in portal hypertension (1, 2). Thrombus is the most frequent cause in Western countries, whereas membranous webs are more common in Asia (2). HV recanalization has been reported as a simple, effective, and safe method for patients with BCS due to hepatic venous obstruction (1, 2). However, if the patients display long-segment obstruction of the HV, recanalization is always difficult with a high failure rate of 31%–100% (1, 2). Even when successfully managed, there is a risk of HV reobstruction after treatment (2).Various treatments, including transjugular intrahepatic portosystemic shunt (TIPS), surgical shunts, and liver transplantation have been described as potential treatment options for BCS (3–6). However, there are only a few studies on accessory hepatic vein (AHV) recanalization for treatment of BCS. In this study, we present our initial clinical results of AHV recanalization in 20 patients with BCS due to long-segment obstruction of HV.     

Comparison of diffusion-weighted MRI acquisition techniques for normal pancreas at 3.0 Tesla

PURPOSE

We aimed to optimize diffusion-weighted imaging (DWI) acquisitions for normal pancreas at 3.0 Tesla.

MATERIALS AND METHODS

Thirty healthy volunteers were examined using four DWI acquisition techniques with b values of 0 and 600 s/mm² at 3.0 Tesla, including breath-hold DWI, respiratory-triggered DWI, respiratory-triggered DWI with inversion recovery (IR), and free-breathing DWI with IR. Artifacts, signal-to-noise ratio (SNR) and apparent diffusion coefficient (ADC) of normal pancreas were statistically evaluated among different DWI acquisitions.

RESULTS

Statistical differences were noticed in artifacts, SNR, and ADC values of normal pancreas among different DWI acquisitions by ANOVA (P < 0.001). Normal pancreas imaging had the lowest artifact in respiratory-triggered DWI with IR, the highest SNR in respiratory-triggered DWI, and the highest ADC value in free-breathing DWI with IR. The head, body, and tail of normal pancreas had statistically different ADC values on each DWI acquisition by ANOVA (P < 0.05).

CONCLUSION

The highest image quality for normal pancreas was obtained using respiratory-triggered DWI with IR. Normal pancreas displayed inhomogeneous ADC values along the head, body, and tail structures.Diffusion-weighted magnetic resonance imaging (DW-MRI) has increasingly expanded to abdominal organs thanks to newer technical developments. Diffusion-weighted imaging (DWI) can provide great details of functional and anatomic information that can be used in the differential diagnosis of abdominal pathological conditions. Investigators have recently reported that DWI can be utilized to detect pancreatic cancer (1, 2) and analysis of apparent diffusion coefficient (ADC) can help differentiate pancreatic masses (3–6). The single-shot spin-echo echo-planar imaging combined with parallel imaging technique is commonly employed for pancreatic DWI studies. Breath-hold DWI is the most common technique used for signal acquisition, especially on 1.5 Tesla (T) magnetic resonance (MR) system, because of its time efficiency. However, there are several disadvantages of breath-hold DWI, including poor signal-to-noise ratio (SNR), limited scan volume and significant artifacts (7, 8). Respiratory-triggered and free-breathing techniques are also used for signal acquisition in pancreatic DWI studies. Compared to breath-hold, the advantages of respiratory-triggered and free-breathing techniques are higher SNR due to multiple signal acquisitions, larger scanning range and less artifacts; their main disadvantage being the longer scanning time (9). Additionally, techniques of fat suppression, such as chemical shift selective (CHESS) and short tau inversion recovery, are essential for DWI in the pancreas for improving the contrast ratio and contrast-to-noise ratio of lesions with respect to normal pancreatic tissues (1, 6, 10).Previously, most investigations were performed using 1.5 T MR scanners. Pancreas imaging using DWI with 3.0 T MR system needs to be further clarified and understood due to its increasing application, which may be a challenging task because of specific absorption rate and various artifacts from high sensitivity to magnetic field inhomogeneity and physiological movement (11). The aim of this study was to investigate different DWI techniques to visualize normal pancreas using a 3.0 T MR scanner and determine the best image acquisition technique in terms of artifacts, SNR, and ADC.     

Traumatic diaphragmatic injury: a review of CT signs and the difference between blunt and penetrating injury

PURPOSE

We aimed to present the frequency of computed tomography (CT) signs of diaphragmatic rupture and the differences between blunt and penetrating trauma.

MATERIALS AND METHODS

The CT scans of 23 patients with surgically proven diaphragmatic tears (both blunt and penetrating) were retrospectively reviewed for previously described CT signs of diaphragmatic injuries. The overall frequency of CT signs was reported; frequency of signs in right- and left-sided injuries and blunt and penetrating trauma were separately tabulated and statistically compared.

RESULTS

The discontinuous diaphragm sign was the most common sign, observed in 95.7% of patients, followed by diaphragmatic thickening (69.6%). While the dependent viscera sign and collar sign were exclusively observed in blunt-trauma patients, organ herniation (P = 0.05) and dangling diaphragm (P = 0.0086) signs were observed significantly more often in blunt trauma than in penetrating trauma. Contiguous injury on either side of the diaphragm was observed more often in penetrating trauma (83.3%) than in blunt trauma (17.7%).

CONCLUSION

Knowledge of the mechanism of injury and familiarity with all CT signs of diaphragmatic injury are necessary to avoid a missed diagnosis because there is variability in the overall occurrence of these signs, with significant differences between blunt and penetrating trauma.Traumatic diaphragmatic injury has been found in 3%–8% of patients undergoing surgical exploration after blunt trauma and in 10% of patients with penetrating trauma (1, 2). The rate of initially missed diagnoses on computed tomography (CT) ranges from 12% to 63%. A missed diagnosis can later present as intrathoracic visceral herniation and strangulation with a mortality rate of 30%–60% (2, 3). In this era of increasing nonoperative management for most cases of blunt abdominal trauma, it becomes essential to diagnose diaphragmatic rupture on imaging to ensure early and timely operative repair of the rupture. The reasons for missed early diagnoses include potentially distracting and more severe thoracic and abdominal visceral injuries and lack of familiarity with all the imaging appearances and signs of diaphragmatic rupture (2, 4).Various imaging modalities including chest radiographs, ultrasonography, CT, and magnetic resonance imaging have been used in the diagnosis of diaphragmatic rupture (1). Currently, multidetector CT (MDCT) is the modality of choice for the detection of diaphragmatic injury. MDCT has increased the accuracy of diagnosis of diaphragmatic rupture. MDCT has inherent technical advantages, such as rapid, volumetric data acquisition for the chest and abdomen within a single breath hold, minimization of motion artifacts, thin-section reconstruction and sagittal and coronal reformat-reducing partial-volume effects that assist in diagnosing subtle defects (1). MDCT also aids in detecting the associated chest, abdomen, ribs, and bony injuries in these polytrauma patients. Various studies have revealed CT to have a variable sensitivity and specificity of 61%–87% and 72%–100%, respectively, for the diagnosis of diaphragmatic rupture (1, 5–7). Killeen et al. (6) demonstrated that the sensitivity for detecting left-sided ruptures (78%) is higher than for right-sided ruptures (50%). This finding has been attributed to the better soft tissue-fat contrast on the left side and the difficulty in diagnosing subtle liver herniation on the right side.Various signs of diaphragmatic rupture have been described on CT. These signs have been divided into direct and indirect signs and signs of uncertain/controversial origin, according to Desir and Ghaye (8), and have been tabulated in 2, 3).

Table 1.

CT signs of diaphragmatic injury^a

Single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm

PURPOSE

We aimed to evaluate the safety and effectiveness of single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm.

METHODS

Hospital database was screened for patients who underwent single-stage endovascular treatment between February 2008 and June 2013 and seven patients were identified. The procedures included unilateral carotid artery stenting (CAS) (n=4), bilateral CAS (n=2), and proximal left subclavian artery stenting (n=1) along with ipsilateral intracranial aneurysm treatment (n=7). The mean internal carotid artery stenosis was 81.6% (range, 70%–95%), and the subclavian artery stenosis was 90%. All aneurysms were unruptured. The mean aneurysm diameter was 7.7 mm (range, 5–13 mm). The aneurysms were ipsilateral to the internal carotid artery stenosis (internal carotid artery aneurysm) in five patients, and in the anterior communicating artery in one patient. The patient with subclavian artery stenosis had a fenestration aneurysm in the proximal basilar artery. Stenting of the extracranial large vessel stenosis was performed before aneurysm treatment in all patients. In two patients who underwent bilateral CAS, the contralateral carotid artery stenosis, which had no aneurysm distally, was treated initially.

RESULTS

There were no procedure-related complications or technical failure. The mean clinical follow-up period was 18 months (range, 9–34 months). One patient who underwent unilateral CAS experienced contralateral transient ischemic attack during the clinical follow-up. There was no restenosis on six-month follow-up angiograms, and all aneurysms were adequately occluded.

CONCLUSION

A single-stage procedure appears to be feasible for treatment of patients with severe extracranial large vessel stenosis and concomitant ipsilateral intracranial aneurysm.The concomitance of severe extracranial large vessel stenosis and unruptured ipsilateral distal intracranial aneurysm is often detected incidentally and their management is not clear (1). Although there are many studies in the literature that report different treatment approaches, there is no definite consensus on the management of the concomitant lesions (2–14). Various treatment options have been suggested, such as initial treatment of the aneurysm before revascularization of the stenosis, treating both lesions in the same surgical session and correcting the stenosis without treating the aneurysm (1, 5, 6, 9–11, 14–16). Few studies have reported single-stage endovascular treatment of both lesions as an effective method (17–19). On the other hand, the treatment of each lesion by this technique may lead to procedure-related undesired events such as cerebral ischemia/stroke or aneurysm rupture.In this study, we aimed to present the radiologic and clinical results of seven consecutive patients who underwent single-stage endovascular treatment of severe extracranial large vessel stenosis and concomitant unruptured ipsilateral intracranial aneurysm and discuss the safety and feasibility of this approach. In addition, distinct from the limited number of similar studies in the literature, we present our experience with bilateral carotid artery stenting (CAS) and proximal subclavian artery stenting during single-stage endovascular treatment.