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Purpose: To investigate the demographics, clinical features, radiologic measurement, treatment, and outcomes of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) according to computed tomography (CT) classification. Methods: This retrospective study included 201 patients diagnosed with symptomatic SISMAD from November 2014 to December 2020. Symptomatic spontaneous isolated superior mesenteric artery dissection was categorized into four types based on CT images by Yun's angiographic classification. Their clinical characteristics, images features, treatment methods, and radiological outcomes were comparatively analyzed by CT angiographic types. Results: SISMADs were categorized into type I (13.9%) patent false lumen (FL) with both entry and re-entry; type IIa (37.3%), blind pouch of FL; type IIb (43.3%), thrombosed FL; and type III (5.5%), and the occlusion of superior mesenteric artery (SMA). Type IIb, the most common SISMAD, showed the largest true lumen (TL) residual diameter and the lowest percentage of TL stenosis. Type III positioned most proximally to SMA origin and had the maximum dissection length. Symptomatic spontaneous isolated superior mesenteric artery dissections underwent conservative (75.1%), endovascular (22.4%), and surgical (2.5%) treatment. Conservative treatment was more frequent in type I (85.7%) and type IIb (83.9%) than in type IIa (65.3%) and type III (45.5%). Endovascular intervention was more commonly utilized in type IIa (32.0%) and type III (36.4%) than in type I (14.3%) and type IIb (14.9%). Conservative patients achieved FL vanishment/shrinkage (57.8%), stabilization (26.6%), and enlargement (15.6%). After conservative treatment, type I showed angiographic FL stabilization; type IIa achieved FL shrinkage (48.1%), stabilization (22.2%), and enlargement (29.6%); type IIb exhibited FL vanishment/shrinkage (92.0%) and enlargement (8.0%). Cumulative rate of stent patency was 92.3% during 6-year follow-up. Conclusions: Conservative management with close follow-up is initially provided especially for types I and IIb. Morphological stabilization is more frequent in type I of patent FL with entry and re-entry. False lumen vanishment or shrinkage was more likely to occur in type IIb due to the thrombus absorption. Endovascular intervention has excellent long-term in-stent patency and is predominantly utilized in types IIa and III. Blood flow sustained into a blind-ending FL causes the TL compression and stenosis in type IIa. Type III with the occlusion of SMA has the high risk of bowel ischemia. Clinical Impact: According to Yun's angiographic classification of spontaneous isolated superior mesenteric artery dissection (SISMAD), type I (13.9%) has patent true and false lumen and the morphological pattern is maintained stable; type IIa (37.3%) possesses a patent blind-ending false lumen which might shrink, remain unchanged, or enlarge; and endovascular intervention is suggested when conservative treatment failed; type IIb (43.3%) recovers spontaneously due to the absorption of false lumen thrombus and conservative treatment is preferentially considered; type III (5.5%) with the occlusion of main trunk carries a high risk of bowel necrosis, early endovascular intervention is proposed, and open surgery might be necessary. [ABSTRACT FROM AUTHOR]

Background: Adequate antithrombotic therapy is essential to prevent thrombus formation during percutaneous endovascular interventions (PVI). We hypothesize that interventions for non-complex lesions of iliac arteries do not need procedural anticoagulation if patients are under dual antiplatelet therapy (DAPT). Methods: Iliac PVIs performed without procedural anticoagulation were retrospectively screened between 2017 and 2021. Baseline characteristics of patients, in-hospital events and 30-day follow-ups were obtained from hospital records. Each PVI was reviewed for procedural details. Primary safety outcome was thromboembolic events during intervention. Secondary safety outcome was adverse vascular events at 30-day follow-up. Procedure times of iliac interventions were compared to peripheral angiography procedures of patients with similar demographic characteristics. Results: We identified 108 iliac interventions without procedural anticoagulation, median age of 62 (interquartile range 56-68) years, 9 (8.3%) females. Median lesion length was 30 (19-50) mm. We observed a thrombotic finding in 4 (3.7%) procedures. Visible luminal thrombus was observed in 2 (1.9%) and introducer sheath thrombosis in 2 procedures (1.9%), all of which were in patients with in-stent lesions. No distal embolization was observed in final angiography of these procedures. At 30-day follow-up, acute limb ischemia was not observed and clinically driven target vessel revascularization was not required in any of the patients. Procedure time of iliac interventions was similar to that of lower extremity diagnostic procedures [18 (11-24) vs 18 (14-24) min, respectively, P =.364]. No major bleeding event was observed after iliac interventions. Conclusion: Non-complex lesions of iliac arteries can be managed within a time frame similar to that of lower extremity diagnostic procedures. These interventions can be performed safely without procedural anticoagulation, provided patient receives DAPT. Intervention of in-stent lesions should ideally be avoided without procedural anticoagulation. [ABSTRACT FROM AUTHOR]

Background: Air embolism (AE), especially when affecting the brain, is an underrated and potentially life-threatening complication in various endovascular interventions. This study aims to investigate experimental AEs using a new model to generate micro air bubbles (MAB), to assess the impact of a catheter on these MAB, and to demonstrate the applicability of this model in vivo. Materials and Methods: Micro air bubbles were created using a system based on microfluidic channels. The MAB were detected and analyzed automatically. Micro air bubbles, with a target size of 85 µm, were generated and injected through a microcatheter. The MAB diameters proximal and distal to the catheter were assessed and compared. In a subsequent in vivo application, 2000 MAB were injected into the aorta (at the aortic valve) and into the common carotid artery (CCA) of a rat, respectively, using a microcatheter, resembling AE occurring during cardiovascular interventions. Results: Micro air bubbles with a highly calibrated size could be successfully generated (median: 85.5 µm, SD 1.9 µm). After passage of the microcatheter, the MAB were similar in diameter (median: 86.6 µm) but at a lower number (60.1% of the injected MAB) and a substantially higher scattering of diameters (SD 29.6 µm). In vivo injection of MAB into the aorta resulted in cerebral microinfarctions in both hemispheres, whereas injection into the CCA caused exclusively ipsilateral microinfarctions. Conclusion: Using this new AE model, MAB can be generated precisely and reproducibly, resulting in cerebral microinfarctions. This model is feasible for further studies on the pathophysiology and prevention of AE in cardiovascular procedures. [ABSTRACT FROM AUTHOR]

Background: Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown.Methods: A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use.Results: From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI.Discussion: Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use. [ABSTRACT FROM AUTHOR]

Objectives: Vascular calcification is a well-known phenomenon and affects coronary and carotid arteries as well as other arterial beds. Presence of arterial calcification is associated with major adverse events in patients undergoing percutaneous coronary artery or carotid artery intervention. Even though there is a clear association between worse outcome and coronary-carotid calcification, there is no research that interrogated the relationship between iliac arterial calcification and clinical outcomes because of lack of data. Therefore, in this study, we aimed to investigate the impact of iliac arterial calcification on procedure success rates and long-term outcomes among patients undergoing endovascular intervention. Methods: The records of 453 consecutive patients who underwent endovascular intervention due to symptomatic peripheral artery disease were analyzed. Patients were divided into two groups based on the presence or absence of heavy calcification of iliac arteries. For each group, technical aspects of procedures and subsequent clinical outcomes were analyzed. Results: According to our study, the rate of restenosis following endovascular intervention at 6 and 12 months were similar between two groups. On the other hand, long-term restenosis was significantly higher in patients with heavy calcification of iliac arteries as compared to patients with low calcification on iliac arteries (32.2% vs. 12.8%, p < 0.05). Conclusions: Our data showed that there was a strong association between heavy calcification of iliac arteries and long-term restenosis in patients undergoing endovascular intervention. [ABSTRACT FROM AUTHOR]

Objective: There is a paucity of data regarding six-month readmissions in critical limb ischemia patients and the influence of management strategy during index-admission [endovascular, surgical, hybrid procedure, medical therapy, and amputation]. We aimed to investigate the incidence, predictors, and impact of management strategies on six-month readmission in patients with critical limb ischemia. Methods: A secondary analysis of the Nationwide Readmissions Database (2016–2017) was conducted. Propensity score matching was performed for subgroup analysis. Results: We identified 50,058 patients with primary diagnosis of critical limb ischemia. Six-month all-cause and critical limb ischemia-related readmission rate was 52.36% and 10.86%, respectively. The risk of all-cause readmission was lower with amputation but was similar among other subgroups. Patients receiving surgical [HR 0.62, CI(0.48–0.79), p < 0.001] and hybrid procedure [HR 0.65 (0.46–0.93), p = 0.02] had lower risk of unplanned critical limb ischemia-related readmission compared to endovascular, though the risk of unplanned revascularization/amputation during readmission was similar between the three strategies. The risk of non-critical limb ischemia-related readmission was higher with surgical [HR 1.13, CI(1.04–1.23), p = 0.003] and hybrid procedure [HR 1.17, CI(1.08–1.28), p < 0.001], driven by increased procedure-related/wound complications. Eventhough endovascular patients were older with more severe critical limb ischemia presentation, a lower proportion received home-health or placement upon discharge from index-admission. This could account for higher readmission without higher repeat revascularization in endovascular group. Conclusion: The risk of critical limb ischemia and non-critical limb ischemia-related readmission differ according to the management strategy. Significant differences in discharge disposition exist depending on revascularization strategy. Study findings identify opportunities for reducing readmissions by focusing on nonprocedural aspects like wound-care, discharge planning and placement. [ABSTRACT FROM AUTHOR]

Objectives: Patients often require multiple access re-interventions to improve fistula patency and the overall usable lifespan of autogenous arteriovenous fistula (aAVF). There is no consensus on the appropriate number of re-interventions after which an access should be abandoned and new access placed. We evaluated whether repeated endovascular interventions for failing/failed aAVF are worthwhile or futile. Methods: A retrospective review was performed on aAVFs created between 2009-2014. Fistula function was evaluated until January 2017. Functional fistula patency (FFP) was defined as the total time of functional fistula use for hemodialysis, from time of cannulation to time of measurement or fistula abandonment, including all interventions performed to maintain/reestablish patency. Primary outcomes were FFP duration and number of post-dialysis interventions. Results: The study included 163 patients. Mean age was 67 (SD = 15.03). The only variable statistically different between functional fistulas and abandoned fistulas was obesity (p = 0.03). At the end of the study period, 145 (89.0%) patients continued to have functional fistulas, and 73 (44.8%) patients died, but had functional fistulas at time of death. Median FFP for the functional group was 3.18 years (range 0.01-7.01 years) and median number of interventions was 1 (range 0-13). In 18 patients (11%), the fistula was abandoned, most commonly due to thrombosis (47.1%), followed by infection (23.5%). No fistula was abandoned because of an unacceptable rate of reintervention. Median FFP in the abandoned group was 0.91 years (range 0.03-5.30 years), and median number of interventions was 0 (range of 0-5). Conclusions: Through repeated interventions on aAVFs, none of the patients in our study exhausted all hemodialysis access options prior to transplantation, death or loss to follow-up. These results may indicate repeated and/or more frequent revisions do not negatively affect the FFP nor do they increase the overall risk for abandonment of aAVFs. [ABSTRACT FROM AUTHOR]

Purpose: Patients with diabetes mellitus (DM) are known to be at higher risk for peripheral artery disease (PAD), amputations, and major adverse cardiovascular events, though it is unclear whether they are at any higher risk for repeat intervention. LIBERTY 360 offered an opportunity to study a real-world cohort of patients who underwent distal superficial femoral artery endovascular revascularizations. We aimed to describe patients with DM, their outcomes following peripheral vascular intervention, and the effect of DM on outcomes in the LIBERTY 360 cohort. Methods: LIBERTY 360 is a prospective, multi-center, non-randomized, mono-industry funded observational study of patients undergoing endovascular revascularization. Outcomes included 30-day and 1-year all-cause mortality, major amputation, target vessel/lesion revascularization, and a composite of those events. A multivariable regression model including DM was constructed to examine the effect of DM on outcomes. Multivariable survival estimates were made using Cox proportional hazards models. Results: A total of 1,204 patients were enrolled, of whom 727 had DM (60.4%). Patients with DM had significantly more comorbidities and a third required insulin for DM management. Patients with DM had more severe disease based on Rutherford classification at baseline. After adjusting for comorbidities and disease severity, DM patients had more frequent major amputations at 1 year (5.2% versus 1.2%; HR 2.71, 95%CI 1.05-6.98, p = 0.040). The 1-year rates of all-cause mortality and target vessel/lesion revascularization were not significantly higher for patients with DM. Conclusions: Diabetes mellitus was associated with increased major amputations at 1 year following endovascular revascularization after accounting for demographics, comorbidities, and PAD-related characteristics. Further research is needed to determine which aspects of PAD and DM are most strongly associated with poor outcomes following lower extremity revascularization. [ABSTRACT FROM AUTHOR]

Purpose: Two-dimensional perfusion angiography is a new method to quantify and evaluate tissue perfusion during endovascular intervention. The aim was to evaluate time-patterns and dynamics of contrast arrival and distribution before and after endovascular intervention in patients with critical limb threatening ischemia. Methods: Data were collected from 37 patients with critical limb threatening ischemia due to infra-inguinal occlusive disease having a successful endovascular procedure. two-dimensional perfusion angiography was used as a postprocessing software with analysis of numeric parameters related to arrival and distribution patterns of contrast. Results: Thirty-three patients were successfully analysed whereas four patients were excluded due to motion artefacts. All patients were successfully treated with recanalization of the superficial femoral, popliteal, below the knee-vessels or a combination. Short-term improvement at 30-day follow-up was noted both clinically and by ankle-brachial index and toe pressure measurements. A significant reduction in contrast arrival time between pre-and post-angioplasty runs was noted as measured by arrival time median 3.2 and interquartile range (2.5-4.2) vs. 2.6 (1.6-3.4) and time-to-peak 4.1 (3.6-5.0) vs. 3.1 (2.3-3.9) p 0.009. An increased wash-in rate was also observed 18.3 (12.6-21) vs. 30.1 (22-30.5) p=0.001 between pre-and post-angioplasty runs. Conclusions: The use of perfusion angiography for evaluation of foot-circulation during endovascular interventions provides new information regarding quantitative assessment of contrast inflow before and after endovascular intervention without the need for extra contrast or runs. No selective catheterisation is necessary. The technique is easily adopted in a clinical setting. Further studies are necessary to create robust clinical endpoints. [ABSTRACT FROM AUTHOR]

Background: We aimed to investigate the safety of endovascular procedures undertaken in a single outpatient center located in a rural, underserved area. Endovascular procedures for Peripheral Arterial Disease (PAD) have become increasingly common in outpatient settings; their safety is yet to be determined in a rural, underserved area with no stand-by vascular surgeon on site. Methods: We undertook a retrospective case review of endovascular procedures for the investigation and management of lower extremity PAD between December 2012 and August 2015. Patients were classified by Rutherford score, degree of stenosis and length of lesions. Complications were major (requiring hospitalization) or minor, including perforation, distal embolization, hematoma, and allergic reactions, which could be treated immediately in the catheterization laboratory with no sequelae. Patients were monitored in the facility and followed up using clinical, biochemical and radiological parameters at 24 h and 1 month. Results: A total of 692 patients underwent endovascular procedures for the investigation and/or treatment of PAD, of which 608 were interventional. Of these patients, 10.20% experienced procedural complications, of which 0.66% were classified as major, including wire retention and retroperitoneal hemorrhage. In total, 99.34% were discharged safely on the same day as the procedure. No adverse events were reported at follow up. Conclusion: Endovascular procedures for PAD can be performed safely in a rural outpatient setting with low complication rates. Most complications are minor and do not require hospitalization. Outpatient procedures for PAD are safe and may widen access to specialist procedures in areas of socio-economic deprivation. [ABSTRACT FROM AUTHOR]

Purpose: To report the 1-year results of a multicenter study of peripheral artery disease (PAD) treatment with a variety of endovascular treatment strategies employed in routine practice. Materials and Methods: The LIBERTY trial (ClinicalTrials.gov identifier NCT01855412) is a prospective, observational, core laboratory–assessed, multicenter study of endovascular device intervention in 1204 subjects (mean age 69.8±10.7 years; 770 men) stratified by Rutherford category (RC): claudicants (RC2,3; n=501) and critical limb ischemia (CLI) with no/minimal tissue loss (RC4,5; n=603) or significant tissue loss (RC6; n=100). Key outcomes included quality of life (QoL) measures (VascuQol and EuroQol) and freedom from major adverse events (MAE), defined as death (within 30 days), major amputation, and target vessel revascularization based on Kaplan-Meier analysis. Results: Successful revascularization was beneficial, with RC improvement noted across all groups. Thirty-day freedom from MAE estimates were high across all groups: 99.2% in RC2,3, 96.1% in RC4,5, and 90.8% in RC6. At 12 months, the freedom from MAE was 82.6% in RC2,3, 73.2% in RC4,5, and 59.3% in RC6 patients. Estimates for freedom from major amputation at 12 months were 99.3%, 96.0%, and 81.7%, respectively. QoL scores improved significantly across all domains in all groups with 12-month VascuQol total scores of 5.3, 5.0, and 4.8 for RC2,3, RC4,5, and RC6, respectively. Conclusion: The results indicate that peripheral endovascular intervention is a viable treatment option for RC2,3, RC4,5, and RC6 patients as evidenced by the high freedom from major amputation, as well as the improvement in QoL and the RC at 12 months. Furthermore, primary unplanned amputation is often not necessary in RC6. [ABSTRACT FROM AUTHOR]

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This study compares procedural complications and clinical outcomes between subintimal crossing versus intraluminal crossing during endovascular treatment of infrainguinal peripheral artery chronic total occlusions (CTO). We identified 1335 CTO interventions in 1001 patients from the multicenter Excellence in Peripheral Artery Disease (XLPAD) registry from January 2005 to October 2015. Outcomes included 30-day and 12-month all-cause death, non-fatal myocardial infarction or stroke, peripheral artery stent, or vessel, thrombosis (ST), need for any target limb endovascular or surgical revascularization, target limb major amputation and procedural complications. A subintimal crossing technique was necessary in 388 lesions (27% overall in 1335 lesions; 34% (n=351) in 1023 femoropopliteal lesions, and 12% (n=37) in 312 infrapopliteal lesions, p<0.01) with a lower procedural (p<0.01) and technical (p<0.01) success than the intraluminal in both femoropopliteal and infrapopliteal interventions. There were no significant differences in procedural complications, major adverse cardiac events, or clinically driven target limb revascularization at 1 year between the two groups, except a higher residual dissection rate in the subintimal crossing group than the intraluminal group in femoropopliteal target vessels (p = 0.04). [ABSTRACT FROM AUTHOR]

Objective The Food and Drug Administration and the Vascular Quality Initiative still utilize fluoroscopy time as a surrogate marker for procedural radiation exposure. This study demonstrates that fluoroscopy time does not accurately represent radiation exposure and that dose area product and air kerma are more appropriate measures. Methods Lower extremity endovascular interventions ( N = 145) between 2013 and 2015 performed at an academic medical center on a Siemens Artis-Zee floor mounted c-arm were identified. Data was collected from the summary sheet after every case. Scatter plots with Pearson correlation coefficients were created. A strong correlation was indicated by an r value approaching 1. Results Overall mean AK and DAP was 380.27 mGy and 4919.2 µGym2. There was a poor correlation between fluoroscopy time and total AK or DAP ( r = 0.27 and 0.32). Total DAP was strongly correlated to cine DAP and fluoroscopy DAP ( r = 0.92 vs. 0.84). The number of DSA runs and average frame rate did not affect AK or DAP levels. Mean magnification level was significantly correlated with total AK ( r = 0.53). Conclusions Fluoroscopy time shows minimal correlation with radiation delivered and therefore is a poor surrogate for radiation exposure during fluoroscopy procedures. DAP and AK are more suitable markers to accurately gauge radiation exposure. [ABSTRACT FROM AUTHOR]

Background: Arteriovenous fistula (AVF) and arteriovenous fistula graft (AVG) access for hemodialysis can develop stenosis, eventually leading to thrombosis and access failure. Prompt endovascular intervention can salvage the access but restenosis does occur. Clinical course, restenosis pattern, and risk factors associated with initial stenosis of AVFs/AVGs in Asian hemodialysis patients were studied. Method: A retrospective study was conducted (January 2009-June 2012) on consecutive patients with renal failure who developed the first-time stenosis in the vascular access and were managed with endovascular intervention. One hundred fourteen patients (54 AVFs and 60 AVGs) were studied, and all clinical outcomes were recorded until October 2013. Results: The mean time from access creation to endovascular intervention for the first-time stenosis for patients with AVF and AVG was 23.5 (32.7 standard deviation [SD]) months and 12.5 (11.0) months, respectively. An average of 1.7 (range, 1-5) interventions were performed for AVFs, whereas 2.4 (range, 1-11) for AVGs (P = .008). Upon conclusion of the study, 23 patients with AVF survived with functional index access, whereas 10 passed away with a functional original access. The remaining 21 patients with AVFs failed, requiring new access, tunneled catheter, or peritoneal dialysis. Of the 60 patients with AVG, 6 survived and 8 died with functional index access; 46 required new access or other forms of dialysis (P = .000). Kaplan-Meier estimated that access patency and survival with functional access were significantly lower for AVGs than for AVFs after the first salvage intervention. Female patients had an increased risk of restenosis with both univariate (P = .016) and multivariate (P = .013) analysis. With univariate analysis (P = .039), patients with hyperlipidemia had a higher risk of developing restenosis in the vascular access. Conclusion: The clinical course and prognosis of failing AVFs and AVGs are distinct. The information on access prognosis and stenosis recurrence patterns will be helpful for patient counseling and planning of follow-up intervals, after the first-time intervention for access stenosis. [ABSTRACT FROM AUTHOR]

This analysis compared the angiographic outcomes of patients treated with orbital atherectomy for calcified common femoral artery (CFA) and superficial femoral artery (SFA) disease. The ideal revascularization strategy for CFA disease is unknown. Endarterectomy has been considered the standard of care for CFA disease for over 50 years. Endovascular intervention is becoming more commonly used to revascularize the CFA given the advances in technology and the less invasive nature of the procedure. Patient demographics, lesion characteristics, and procedure data for all CONFIRM patients with at least one CFA lesion location (n=147 patients; n=200 lesions) were compared to patients with at least one SFA lesion location (n=1508 patients; n=2367 lesions). The primary endpoint was angiographic complication, defined as the composite of dissection, perforation, slow flow, closure, spasm, embolism, or thrombosis. The CFA group had more patients with Rutherford class 4 and shorter lesion length. The CFA group had a higher final residual stenosis, shorter total run time, and shorter total inflation time. The primary endpoint was lower in the CFA group compared with the SFA group (17% vs 24%, p=0.02), driven by a lower dissection rate (10% vs 15%, p=0.04). Plaque modification of the CFA with orbital atherectomy was safe and compared favorably with SFA disease. The need for bail-out stenting was low. A randomized trial is needed to determine the ideal treatment strategy for calcified CFA disease. [ABSTRACT FROM AUTHOR]

Purpose: To compare the procedure and safety outcomes of the transradial approach (TRA) with the femoral approach (FA) for treating aortoiliac and femoropopliteal stenoses and occlusions. Methods: A single-center retrospective study was conducted involving 188 patients (mean age 66.4±10.8 years; 116 men) with lower limb claudication or critical limb ischemia who underwent aortoiliac (131, 62.4%) or femoropopliteal (79, 37.6%) interventions on 210 lesions over a 3-year period. Operator discretion determined TRA suitability; exclusions included Raynaud’s disease, upper limb occlusive disease, previous TRA difficulties, or planned hemodialysis. Lesion characteristics, clinical endpoints, and access site complications were compared. Results: FA was used primarily in 123 patients and the TRA (12 left and 53 right radial arteries) in 65 procedures. Eleven (16.9%) TRAs failed vs 9 (7.3%) FAs (p=0.42). Crossover to FA was due to occlusive lesions requiring alternative equipment in 9 cases and to tortuosity of the aortic arch vessels in 2 patients. The 134 FA interventions (balloon angioplasty, stents) were retrograde (112, 83.6%) or antegrade (22, 16.4%). There were significantly more TASC C/D lesions in the FA group (p=0.02). Sheath sizes (5-F to 8-F) did not differ between groups, and no significant differences were found between FA vs TRA in terms of procedure time (50.0±28.9 vs 46.8±25.1 minutes, p=0.50) or length of stay (2.2±0.6 vs 2.1±0.3 days, p=0.24). While there were no strokes, access site complications occurred in 6.0% of the FA patients vs 3.7% of the TRA patients (p=0.12). Conclusion: The transradial approach for aortoiliac and femoropopliteal interventions is safe and efficacious compared with the transfemoral approach for a range of lesion subtypes. Nevertheless, there remains a need for improvements in peripheral device and catheter technology to decrease transradial failure rates. [ABSTRACT FROM AUTHOR]

Background: Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events. Case Presentation: An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits. Conclusion: Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients. [ABSTRACT FROM AUTHOR]

Background: Feasibility of single-session mechanical thrombetomy, without thrombolytics, for the treatment of the subacute deep vein thrombosis (DVT) of the lower extremity remains poorly described. Purpose: To evaluate the feasibility and efficacy of single-session endovascular treatment of DVT of the lower extremity that is more than 10 days old. Materials and Methods: From January 2010 to December 2013, single-session endovascular treatment was performed in 21 limbs of 21 patients (8 men and 13 women) with DVT more than 10 days old at our hospital. The mean age of the thrombosis was 21.5 days (range 11-45 days). Two patients had malignancy-related obstructions. A 14F introducer sheath was inserted through the popliteal vein followed by aspiration thrombectomy with a large bore catheter. Balloon angioplasty and/or maceration of the thrombus were added when needed. Stent insertions were performed for patients with combined iliac vein stenosis. Technical success, clinical success, mean procedure time, and complications were evaluated. Results: The technical success rate was 90.5% (19 of 21 patients). Among the 19 successful cases, aspiration thrombectomy alone was performed in 16 (84.2%) patients, additional balloon angioplasty of the femoral vein was performed in 2 (10.5%) patients, and both balloon angioplasty of the femoral vein and rotational thrombectomy were performed in 1 (5.3%) patient. Iliac vein stenting was performed due to combined iliac vein narrowing in 13 (68.4%) of the 19 successful cases. The mean procedure time was 86 minutes (26-179 minutes). All of the patients with technical success (19 of 21 patients) showed marked improvement in symptoms at the time of discharge (clinical success). Unexplained gastrointestinal hemorrhage developed in 1 patient. Conclusion: Single-session endovascular treatment is feasible and effective even for patients with aged deep vein thrombosis of the lower extremity more than 10 days old. [ABSTRACT FROM AUTHOR]

Purpose: To report the feasibility, technical considerations, and initial results of 2-dimensional (2D) perfusion angiography of the foot before and after endovascular interventions.Methods: A retrospective single-center study involved 21 patients (mean age 73.4±10.5 years; 14 men) with severe peripheral vascular disease [Fontaine stage III (n=10) or IV (n=14)] who underwent lower limb digital subtraction angiography (DSA) prior to and following endovascular treatment of above- and/or below-knee lesions. A standardized contrast administration protocol (15 mL iodixanol 320 mg I/mL at 3 mL/s via a 5/6-F antegrade sheath) was applied during DSA using a 2D perfusion-enabled image intensifier. Representative hindfoot and forefoot regions of interest were analyzed, and representative numeric density values [time to peak (TTP), peak density value (PDV), and area under the (time-density) curve (AUC)] were calculated using 2D perfusion-enabled angiographic software to assess foot perfusion. Values were compared before and after angioplasty and by level of treatment (above or below knee). The parameters were correlated with disease severity (stenosis vs occlusion) and symptom level (Fontaine stage).Results: A clinically significant improvement (29.4%) in the AUC was noted following angioplasty, reaching statistical significance within the hindfoot (p=0.03). No significant change in TTP or PDV was detected following angioplasty. Foot movement remained problematic when measuring time-density values. No statistical difference in perfusion values was appreciable between above- and below-knee angioplasty.Conclusion: Two-dimensional perfusion angiography of the foot allows quantitative evaluation using various density values with potential benefit for treatment planning and technical outcome analysis. Methodical restrictions currently remain, mainly regarding patient movement. [ABSTRACT FROM AUTHOR]

Purpose: To compare the objective performance goals (OPGs) and patient-centered outcomes of isolated tibial interventions in patients with tissue loss who were on hemodialysis (HD) to patients with tissue loss who were not on HD. Methods: Interrogation of a prospectively maintained database identified 242 critical limb ischemia (CLI) patients who underwent isolated tibial interventions for tissue loss in a single limb between 2007 and 2012. The 78 patients (mean age 66±12 years; 44 men) on HD were compared with 164 patients (mean age 50±13 years; 82 men) who were not on HD. There was an equal distribution of the tibial vessels treated; 152 (63%) patients had more than one treated tibial vessel. Patient-centered outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and no major amputation), amputation-free survival (AFS), and freedom from major adverse limb events (MALE) were evaluated. The Society for Vascular Surgery OPGs were defined at 30 days and 1 year. Results: The 30-day major adverse cardiac events was significantly higher (p=0.004) in the HD group (5, 5%) compared with the no-HD group (0%), but both remained under the stated OPG of ≤10%. The 30-day MALE rates were significantly higher than the stated ≤9% OPG at 13% and 18% for the no-HD and HD groups, respectively. At 1 year, the rates for AFS, freedom from MALE, limb salvage, and survival did not achieve the stated Society for Vascular Surgery OPGs in the HD group. Clinical efficacy was 61% and 25% at 3 years for the no-HD and HD groups, respectively (p<0.01). Overall, AFS was 54% and 22% and freedom from MALE was 56% and 27% at 3 years for the no-HD and HD groups, respectively (both p<0.01). Conclusion: Tibial intervention for tissue loss in patients on HD is a valid treatment option but is associated with a high MALE rate. Three-year outcomes remain relatively poor, with <25% success in terms of clinical efficacy and AFS. [ABSTRACT FROM AUTHOR]

This study aims to review the outcome of patients with peripheral arterial disease (PAD) managed with endovascular first approach for revascularization in a tertiary referral center. Revascularization procedures were performed in 202 patients with 229 symptomatic limbs. Angiogram was performed in all patients except those contraindicated for contrast agent. Angioplasty revascularization was carried out on the same setting whenever feasible based on the angiogram findings. Bypass surgery was performed in patients with arterial condition not feasible for endovascular intervention or in those with unsatisfactory revascularization after endovascular treatment. Endovascular intervention was successfully performed in 198 limbs. Bypass surgery was required in 31 patients. Another 16 patients required a bypass after endovascular intervention due to unsatisfactory wound healing. The Kaplan-Meier estimated survival and amputation-free survival were 80% and 75.5% at 1 year and 73% and 57.6% at 2 years, respectively. Satisfactory limb salvage rate can be achieved in patients with PAD managed with endovascular first approach. [ABSTRACT FROM PUBLISHER]

Purpose:To present a systematic safety evaluation of the CrossBoss blunt microdissection catheter for crossing peripheral chronic total occlusions (CTOs). Methods: Between July 2010 and July 2011, 15 patients (all men; mean age 60.7±9.1 years) underwent endovascular treatment of 17 infrainguinal CTOs that were resistant to guidewire passage, so the blunt microdissection catheter was employed to recanalize the artery. Fourteen lesions were de novo and 3 were ¡n-stent restenoses. Sixteen lesions were in the superficial femoral artery; 8 of 17 CTOs were TASC II type D. Extensive calcification was present in 12 lesions. Mean lesion length was 182.9±66.2 mm (range 57-296). Results: Procedural success was 100% and successful crossing without the use of a re-entry device (technical success) was achieved in 15 cases. Twelve lesions were stented. Average fluoroscopy time was 36.5±21.2 minutes (143.8±76.9 Gy*cm² radiaton dose area product), during which a mean 172.1 ±62.2 mL of iodinated contrast were used. Two patients had access site hematomas that were treated conservatively, and there was no perforation, distal embolization, amputation, or need for urgent revascularization. During the mean follow-up of 11.4±0.1 months, 1 patient died, and none required an amputation or surgical revascularization. There was a significant improvement in ankle-brachial index (0.6±0.1 to 0.8±0.2, p=0.001) and symptoms as assessed by Rutherford class at 1 year. Four of 17 limbs required secondary revascularization procedures within 1 year. Conclusion: The CrossBoss blunt microdissection catheter facilitated successful crossing of CTOs in patients with infrainguinal lesions following unsuccessful guidewire crossing, with an acceptably low rate of periprocedural complications and significant improvement in symptoms. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the safety, comfort, and efficacy of an extravascularly deployed bioabsorbable plug-based vascular closure device (VCD) for sealing 6-F antegrade access sites in patients requiring peripheral endovascular intervention. Methods: A single-center, single-arm, prospective study to evaluate the 6-F ExoSeal VCD in terms of technical success, adverse events, and patient comfort enrolled 59 unselected symptomatic patients (42 men; mean age 72.1 ±9.3 years) suffering from peripheral artery disease in an 11-month period. Patients with high body mass index (BMI) or calcification at the access site were not excluded. Calcifications of the access vessel were scored as grades 1-4 from fluoroscopic images. The pain level during implantation was evaluated after the procedure using a visual rating scale. Results: Technical success rate was 98.3%; 1 primary device failure was converted to manual compression. In addition, 1 (1.7%) pseudoaneurysm, 2 (3.4%) minor hematomas, and 1 (1.7%) minor secondary bleeding were observed. There was no intravascular application of the device detected. Neither BMI, calcification of the access vessel (present in 74.6%, mean score 1.4±1.1), age, nor blood clotting had any statistically significant influence on adverse events. In total, 55 (93.2%) patients felt no pain during the VCD implantation. Conclusion: The tested VCD was safe, with an excellent technical success rate even in cases with severe access vessel calcification. [ABSTRACT FROM AUTHOR]

Purpose: To assess the outcome of patients with medically treated hyperhomocysteinemia (HHC) requiring intervention for critical limb ischemia (CLI). Methods: A parallel observational study was conducted to compare the clinical and revascularization outcomes of CLI patients who received standardized treatment for HHC preoperatively (folic acid and vitamin B12) vs. contemporaneous patients with normal homocysteine levels. The threshold for HHC diagnosis was 13.0 μmol/L. From 2009 to 2011, 169 patients underwent revascularization procedures for CLI. Of these, all 66 patients (40 men; mean age 69.6±11.2 years) with HHC (mean 17.3 μmol/L, range 13.5-34.9) were treated to normalize the homocysteine level prior to lower limb revascularization. The remaining 103 patients (58 men; mean age 72.7±8.1 years) had normal homocysteine levels (8.2 μmol/L, range 5-12.3) before revascularization. The primary endpoint was symptomatic and hemodynamic improvement in the treated HHC group. The secondary endpoints were all-cause survival, binary restenosis, reintervention, amputation-free survival, and major adverse events. The treated HHC cohort was compared to an age/sex-matched historical group of patients with untreated HHC from 2002 to 2006 before HHC pretreatment became routine. All interventions (endovascular, hybrid, and open) were performed by the same surgeon, and the groups were evenly matched. Results: Patients with HHC were treated for a mean 12.2 days, which significantly reduced their mean homocysteine level after 3 weeks to 10.1 μmol/L (range 6.2-14.4, p<0.05). After revascularization, immediate clinical improvement was similar between normal homocys-teine and medically corrected HHC groups. There was no significant difference in time to binary restenosis (p=0.822). Secondary endpoints and all-cause mortality were similar. Multivariate logistic regression showed that untreated HHC was a significant factor for graft occlusion and limb loss (p<0.0001), but medically corrected HHC was no longer predictive of adverse operative outcome. Conclusion: Patients with medically corrected HHC have similar outcomes compared to those with normal homocysteine levels. Thus, aggressively treating HHC with folic acid and vitamin B12 may help enhance the clinical outcome of CLI patients undergoing revascularization. [ABSTRACT FROM AUTHOR]

Although some cases of vein of Galen aneurysmal malformation (VGAM) present initial clinical symptoms such as cardiopulmonary disturbance in the neonatal period, pial arteriovenous fistula is very seldom present as a clinical symptom immediately after birth. A neonatal patient, the first-born to his family, presented with tachypnea postpartum. This baby had a family history of hereditary hemorrhagic telangiectasia. A cerebral MR image revealed multiple macrocerebral arteriovenous fistulas (MCAVFs), resulting in a large partially thrombosed venous pouch within the cerebral cortex. Trans-arterial embolizations of the main two fistulas were performed using N-butyl cyanoacrylate (NBCA) with tantalum powder six months after birth. Post-embolization angiography confirmed the obliteration of the fistulas and magnetic resonance imaging (MRI) revealed thrombosis and reduction in size of the venous component. His tachypnea disappeared completely. There were no neurological complications due to the treatment. The prognosis of multiple MCAVFs mainly depends on the presence of medullar signs and symptoms and a delay before treatment. Pure glue endovascular intervention, as used in our case, is considered to be the first therapeutic choice to decrease the risk of neurological consequences. [ABSTRACT FROM AUTHOR]

Purpose: To document a heretofore unreported complication of the contrast agent iodixanol during an endovascular procedure. Case Report: A 76-year-old woman with a history of coronary artery disease was admitted to the emergency department for recurrent transient ischemic attacks. Before combined percutaneous transluminal coronary angioplasty and carotid artery stenting (CAS) using iodixanol, the patient suffered from concomitant unstable angina and recurrent transient ischemic attacks. The total amount of iodixanol used during the CAS procedure was 300 mL. Contrast-induced encephalopathy, which manifested as aphasia, stupor, and full hemiparesis immediately after the combined procedure, was diagnosed by urgent computed tomography. Treatment was based on anti-edema drugs, and the patient made a complete recovery within 48 hours, without any neurological sequelae. Conclusion: Although previously reported in relation to other types of contrast media, contrast-induced encephalopathy has never been described as a complication of an endovascular procedure using iodixanol. [ABSTRACT FROM AUTHOR]

The gold standard for preoperative evaluation of an aortic aneurysm is a computed tomography angiogram (CTA). Three-dimensional reconstruction and analysis of the computed tomography data set is enormously helpful, and even sometimes essential, in proper sizing and planning for endovascular stent graft repair. To a large extent, it has obviated the need for conventional angiography for morphologic evaluation. The TeraRecon Aquarius workstation (San Mateo, Calif) represents a highly sophisticated but user-friendly platform utilizing a combination of task-specific hardware and software specifically designed to rapidly manipulate large Digital Imaging and Communications in Medicine (DICOM) data sets and provide surface-shaded and multiplanar renderings in real-time. This article discusses the basics of sizing and planning for endovascular abdominal aortic aneurysm repair and the role of 3-dimensional analysis using the TeraRecon workstation. [ABSTRACT FROM AUTHOR]

Percutaneous endovascular intervention has gradually become the standard of care in the treatment of focal occlusive disease affecting the iliac arteries. Stent placement, as an adjunct to balloon angioplasty, represents a significant advancement because it can improve on the results of angioplasty and expand its applicability to more challenging lesions. Extensive aortoiliac occlusive disease, however, may still require conventional surgical reconstruction, although endovascular grafting and other technologies promise to offer less invasive therapeutic alternatives for such cases as well.Techniques of balloon angioplasty and endoluminal stent deployment must be viewed and learned within the larger context of interventional therapy in which imaging and percutaneous catheter skills emerge as the most critical components. [ABSTRACT FROM PUBLISHER]

Pseudoaneurysms, as a result of endovascular stent fracture, are a rare yet important vascular surgery complication. A 64-year-old man presented with a painful mass in the left groin with accompanying critical ischemia of the left leg. Diagnostic angiography revealed a pseudoaneurysm caused by stent fracture in the left external iliac artery. The patient was treated with embolization of the left external iliac artery and ultimately above-the-knee amputation. Awareness of this uncommon complication is important due to its potential risk of severe disability. [ABSTRACT FROM PUBLISHER]