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Acute procedural thromboembolic events are serious complications affecting both short- and long-term outcome. Patients at high risk include those undergoing catheter-based interventions for acute limb ischemia and long segment de novo or stented occlusions of the lower limb arteries. Additionally, debulking procedures and angioplasty/stenting of complex lesions in patients with advanced disease have also been associated with a higher risk of distal embolization and in situ thrombosis. This article includes a discussion of detection methods as well as preventive and treatment strategies., (Copyright © 2011 Elsevier Inc. All rights reserved.)

N-butyl cyanoacrylate (NBCA) is an adhesive material, which has been used as an embolic agent in various vascular beds. Its role in the management of patients with acute massive hemoptysis has not been reported. In this article we report our experience with 12 such patients who underwent bronchial artery embolization using NBCA and compare the results with 36 procedures using polyvinyl alcohol (PVA) particles. As compared with PVA, NBCA embolizations appear more durable, leading to fewer rebleeds. There were 12 episodes of recurrent hemoptysis after 36 procedures using PVA (33%) with 8 being due to bleeding from a previously embolized vessel. Conversely, there were only 2 of the 12 patients who were treated by NBCA who experienced rebleed (16.6%). In this article, we describe the technical nuances of NBCA embolization of bronchial arteries and review potential pitfalls.

Catheter-directed thrombolysis (CDT) has been proposed as an alternative mode of therapy to anticoagulation in patients with massive, symptomatic deep vein thrombosis of the extremity. The major goal of therapy is to rapidly restore venous blood flow, reduce the pain and edema of the extremity, preserve venous valve function, and reduce chronic symptoms related to chronic venous hypertension (postthrombotic syndrome). In patients with iliofemoral deep venous thrombosis (DVT) standard angiographic techniques are used to instrument a lower extremity vein (popliteal) and venography is performed followed by catheter-directed infusion of a plasminogen activator directly into the thrombus. Following lytic infusion, the interventionalist must evaluate the venous drainage to determine if there is an anatomic lesion that requires further endovascular treatment (eg, iliac vein compression syndrome). Posttreatment therapy usually consists of warfarin therapy and venous compression stockings for at least 3 to 6 months. The purpose of this article is to review the technical approach used in treating iliofemoral DVT and highlight the hurdles that face interventionalists in attempting to broaden this procedure to most types of lower extremity DVT.

Angioplasty of chronic total occlusions (CTOs) has lower technical success rates with longer procedure times and poorer outcomes. Subintimal recanalization remains limited by the lack of controlled re-entry into the true lumen of the target vessel. We report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound scanner to achieve controlled true lumen re-entry in patients with peripheral CTOs. In a 4-month period, 6 patients with lower extremity (LE) ischemia from CTOs were treated. Occluded segments were crossed subintimally, and controlled re-entry was secured using the CrossPoint TransAccess catheter. This 6.2 F dual-lumen catheter contains an integrated 64-element phased array intravascular ultrasound scanner enabling targeting of structures. Intravascular ultrasound-guided luminal re-entry was achieved by advancing a 24-gauge needle to a desired length and delivering a 0.014" guide wire into the target lumen. The occluded segments were balloon dilated and stented using self-expanding nitinol stents. Effective luminal re-entry and re-establishment of antegrade flow occurred in all 6 patients. Time to recanalization ranged from 5 to 10 minutes. All patients were free of ischemic symptoms at 1 to 5 month follow-up. There were no procedure-related complications. Our preliminary results demonstrate the feasibility of using this catheter system for subintimal recanalization with controlled re-entry in CTOs. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

Femoral artery pseudoaneurysms, a complication of femoral arterial puncture, is increasing in frequency with the proliferation of endovacular interventions. Pseudoaneurysms have historically been treated by open surgical repair, and more recently by ultrasound-guided compression. Ultrasound-guided compression is painful, and has a relatively low success rate of 51% to 73%. Since 1991, ultrasound-guided thrombin injection has become a treatment option. During injection of thrombin into a pseudoaneurysm, immediate thrombosis can be demonstrated within seconds. The entire procedure can be accomplished within 5 minutes, is simple to learn, and can be performed safely on an outpatient basis., (Copyright 2003 Elsevier Inc. All rights reserved.)

Transarterial therapy for primary liver cancer is gaining more acceptance. The technique of transarterial treatment of such cancers is, however, quite varied. To determine the value of our approach, we analyzed our experience with transarterial oily chemoinfusion (TOCI) of primary liver cancer over a 4.9-year period. Since 1997, over 300 such procedures have been performed at our institution. We report the results of the first 253 procedures, which were performed using a subsegmental technique with a mixture of doxorubicin, cisplatin, ethiodol, with selective Gelfoam embolization. Actuarial survival rates at 1, 2, and 3 years were calculated with Kaplan-Meier and multivariate analysis was performed by Cox regression. The median overall survival was 28.6 +/- 4.5 months following diagnosis. By univariate analysis, TNM clinical stage I or II, Karnofsky score above 80%, absence of extrahepatic disease, absence of vascular invasion, unifocal disease, pretreatment alpha-fetoprotein levels less than 500 ng/ml, hypervascularity of lesions, and lesion size less than 5 cm were all strong predictors of favorable patient survival at 1, 2, and 3 years (75%, 60%, and 50% respectively). Based on our experience, TOCI with selective embolization has similar survival benefit as the traditional chemoembolization but is associated with fewer complications., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Alteplase (t-PA), a recombinant analogue of human tissue plasminogen activator, became the first genetically engineered thrombolytic approved by the Food and Drug Administration in 1987 for acute myocardial infarction (AMI). In addition to AMI, alteplase is currently approved for the treatment of acute ischemic stroke and pulmonary embolism, and we anticipate approval for catheter clearance in late 2001 in a 2-mg vial configuration. With the withdrawal of human neonatal kidney cell-derived urokinase, alteplase has become an alternative agent in peripheral vascular applications. Because few interventionalists had prior experience with the handling and dosage of alteplase, the Advisory Panel to the Society of Cardiovascular and Interventional Radiology established practice guidelines for use in noncoronary applications. Emerging clinical experience with contemporary dosing regimens shows a safety and efficacy profile similar to urokinase but with significantly reduced drug costs. Tenecteplase (TNK) is a genetically modified version of alteplase. TNK is the only plasminogen activator available that has shown a significantly enhanced safety profile versus alteplase in AMI. Approved for a 5-second, single-bolus injection in AMI, TNK possesses a longer half-life, increased resistance to plasminogen activator inhibitor, and improved fibrin specificity compared with alteplase. Because of its enhanced safety profile, TNK may be a desirable agent for peripheral vascular applications. Initial clinical studies with TNK in acute arterial and venous disease are ongoing. This article outlines the Advisory Panel guidelines for using alteplase and highlights features of tenecteplase., (Copyright 2001 by W.B. Saunders Company)