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BackgroundAnti-glomerular basement membrane disease (GBM) disease is a rare autoimmune disease causing rapidly progressive glomerulonephritis and pulmonary haemorrhage. Recently, an association between COVID-19 and anti-glomerular basement membrane (anti-GBM) disease has been proposed. We report on a patient with recurrence of anti-GBM disease after SARS-CoV-2 infection.Case presentationThe 31-year-old woman had a past medical history of anti-GBM disease, first diagnosed 11 years ago, and a first relapse 5 years ago. She was admitted with severe dyspnoea, haemoptysis, pulmonary infiltrates and acute on chronic kidney injury. A SARS-CoV-2 PCR was positive with a high cycle threshold. Anti-GBM autoantibodies were undetectable. A kidney biopsy revealed necrotising crescentic glomerulonephritis with linear deposits of IgG, IgM and C3 along the glomerular basement membrane, confirming a recurrence of anti-GBM disease. She was treated with steroids, plasma exchange and two doses of rituximab. Pulmonary disease resolved, but the patient remained dialysis-dependent. We propose that pulmonary involvement of COVID-19 caused exposure of alveolar basement membranes leading to the production of high avidity autoantibodies by long-lived plasma cells, resulting in severe pulmonary renal syndrome.ConclusionOur case supports the assumption of a possible association between COVID-19 and anti-GBM disease.

Background Pregnancy is rare in women on hemodialysis. Recommendations for the treatment of secondary hyperparathyroidism (sHPT) and preservation of bone health in pregnant dialysis patients are lacking. Case presentation We present the case of a young woman with end-stage kidney disease (ESKD) due to lupus nephritis, who developed multiple brown tumors while on hemodialysis during her second pregnancy. During her first pregnancy sHPT was well controlled and no skeletal complications occurred. Before the second pregnancy she developed severe sHPT. During pregnancy, dialysis time was increased to 24 h per week, the patient was given oral calcitriol, and the dialysate calcium concentration was set at 1.5 mmol/l. In week 20 the patient complained about bone pain in her left hip. Magnetic resonance imaging revealed a cystic lesion compatible with a brown tumor. The baby was delivered in the 36th week by cesarean section. Further assessment identified multiple brown tumors of her skeleton, including the acetabulum, tibia, ribs, skull, thoracic spine and thumb. She required multiple orthopedic surgeries. Three months after pregnancy, etelcalcetide was started, which brought about a gradual improvement in her sHPT. Conclusions This case demonstrates that the combination of pregnancy and severe sHPT in dialysis patients can have deleterious consequences for bone health.

Background and aims Transjugular intrahepatic portosystemic shunts (TIPS) are used in patients with cirrhosis for the prevention of variceal rebleeding. Methods We retrospectively evaluated re-bleeding rate, patency, mortality, and transplant-free survival (TFS) in cirrhotic patients receiving TIPS implantation for variceal bleeding between 1994–2014. Results 286 patients received TIPS (n = 119 bare metal stents, n = 167 polytetrafluorethylene (PTFE)-covered stents) for prevention of variceal re-bleeding. Mean age was 55.1 years, median MELD was 11.8, and the main etiology of cirrhosis was alcoholic liver disease (70%). Median follow-up was 821 days. 67 patients (23%) experienced at least one re-bleeding event. Patients with PTFE-TIPS were at significantly lower risk for variceal re-bleeding than patients with bare metal stents (14% vs. 37%, OR:0.259; p

Early implantation (72h) of a transjugular intrahepatic portosystemic shunt (TIPS) after acute variceal bleeding (AVB) improves survival in highly selected patients.We retrospectively assessed bleeding control and survival of unselected cirrhotic patients undergoing early TIPS implantation within 72h. We compared the outcomes to patients meeting early TIPS criteria but receiving late TIPS within 3-28days after AVB and endoscopic/medical treatment.Forty-nine patients were included. Mean MELD was 14.4 (±4.4). Thirteen patients (26.5%) presented characteristics that were exclusion criteria in previous early TIPS trials (age75, CPS13, HCCMilan, previous beta-blocker/band-ligation, renal insufficiency). Bare metal and PTFE-covered stents were used in n=32 (65.3%) and n=17 (34.7%) patients, respectively, and showed similar early re-bleeding rates (9.9% vs. 7.1%; p=0.6905) and bleeding-related mortality (25.0% vs. 23.5%; p=0.9906). However, overall re-bleeding rate was lower with PTFE-TIPS (7.7% vs. 64.2%; p=0.0044) over a median follow-up of 18.5 months with a tendency towards improved survival (median 70.5 vs. 13.8 months; p=0.204). Additional 68 patients meeting stringent criteria but receiving late TIPS also showed a favorable bleeding-related mortality (8.8%), which was not achieved in similar n=34 patients by a medical/endoscopic strategy with bleeding-related mortality of 35.7%.An early TIPS strategy using covered stents and implementation of 'stringent criteria' results in a favorable outcome in patients with acute variceal bleeding.

Multidetector CT angiography (CTA) is a non-invasive imaging technique for evaluation of peripheral vascular disease. CTA might be particularly useful for assessment of intermediate- and long-term morphological outcome after endovascular treatment. Validation of CTA vs. the current imaging standard, colour Doppler ultrasonography (CDUS), for quantification of native and in-stent re-stenosis in the superficial femoral artery (SFA) is required.Seventy randomized patients who underwent stent implantation (n=47) or balloon angioplasty (n=23) underwent 6-month follow-up with CDUS and CTA. CTA was compared with CDUS in both sub-groups of patients in terms of binary re-stenosis (50% lumen narrowing) and re-occlusion. Agreement between CTA and CDUS was assessed using Kappa (κ) statistics with 95% confidence intervals, and correlation coefficients.Binary re-stenosis was detected in 16/70 (22.9%) patients by CTA and 17/70 (24.3%) patients by CDUS (κ=0.88, 95% CI: 0.80-0.96). Re-stenosis rates after balloon angioplasty were 39.1% (9/23) on CTA and CDUS (κ=0.82, 95% CI: 0.66-0.98), and after stent implantation 14.9% (7/47) on CTA and 17.0% (8/47) on CDUS (κ=0.92, 95% CI: 0.84-1.00). Re-occlusions were detected in 3/70 (4.3%) patients by both CTA and CDUS (κ=0.65; 95% CI 0.54-0.76). Significant correlations (r=0.85, p0.001) were noted between degree of re-stenosis on CTA and peak velocity ratio on CDUS. The correlation coefficient was higher in patients after balloon angioplasty (r=0.94, p0.001) than in patients after stent implantation (r=0.71, p0.001).CTA and CDUS show excellent agreement for evaluation of native and in-stent re-stenosis after endovascular treatment of SFA obstructions. CTA is an appropriate non-invasive imaging modality for follow-up after endovascular therapy.

The sensitivity of 5-aminolevolinic acid (5-ALA) in detecting intraoperative glioblastoma (GBM) tissue compared to postoperative (18)F-fluoroethyl-L-tyrosine and T1 contrast uptake of tumor cells in positron emission tomography (PET) and magnetic resonance imaging (MRI) scans was investigated in a retrospective image correlative study.Ten patients with histological verified GBM in eloquent brain regions underwent 11 surgeries with neuronavigation and 5-ALA assisted tumor resection. Residual 5-ALA fluorescence was labeled intraoperatively on the navigation MRI scans and images were fused with postoperative (18)F-FET PET and T1 contrast MRI.Intraoperatively, at the end of save resection, in all patients 2-5 faint 5-ALA positive resection planes were detected (mean 3·6), compared to 0-4 (18)F-FET positive resection planes (mean 1·4) and 0-2 positive T1 contrast MRI resection planes in postoperative scans. The difference between the number of 5-ALA and (18)F-FET positive resection planes was statistically significant (P = 0·0002). The histological investigation of 5-ALA positive resection margins demonstrated infiltrative tumor in every case. Residual 5-ALA fluorescence on resection margins and postoperative (18)F-FET uptake areas or residual contrast T1 areas were colocalized in all cases, documented by pre-/postoperative image fusion.Residual faint 5ALA uptake is documented in large areas at the end of GBM resection and corresponds to tumor infiltration. These 5-ALA positive resection plans exceeded the (18)F-FET uptake areas in postoperative PET scans. Thus, intraoperative 5-ALA residual fluorescence seems to be a more sensitive marker than (18)F-FET PET for residual tumor in malignant gliomas.

The purpose of this retrospective population based study was to investigate the effect of the extent of surgery on overall survival in young versus adult glioblastoma patients in Vorarlberg/Austria during the last 4 years.Forty-eight patients (median age 62.5 years, ranging from 25-82 years, 19 female and 29 male) with histologically proven glioblastoma received surgery (16 biopsies, 18 partial and 14 complete resections) and postoperative chemo-irradiation with concomitant and adjuvant temozolomide. The median follow up of the patient population was 11.7 months (ranging from 3 to 36 months). Postoperative temporary morbidity was found in 5 out of 48 (10.4%) patients, and no mortality or permanent morbidity occurred. One infection led to revision surgery.Altogether, the 12/24 months overall survival was 54/20.2% with a median survival of 13.7 months. In younger patients (65 yrs, median 57.5 yrs, 28 patients), the 12/24 months overall survival was 68.4/34.3% with 16.9 months median survival, in the elderly patients (65 yrs, median 73 yrs, 20 patients) the 12/24 months overall survival was 28.8/5.8%, with 7.7 months median survival (Log-rank, p = 0.0005). Extent of surgery influenced overall survival of the adult group nearly significantly (biopsy versus complete resection: p = 0.06), but did not affect overall survival of the elderly (p = 0.5).Overall survival of elderly glioblastoma patients treated with surgery and chemo-irradiation with concomitant and adjuvant temozolomide is significantly reduced compared to the younger patients. In addition, in the elderly the extent of surgery did not influence the prognosis in our population.

Purpose Computed tomography angiography (CTA) is a time and cost saving investigation for postoperative evaluation of clipped cerebral aneurysm patients. A retrospective study was conducted to analyse image quality and artefact generation due to implanted aneurysm clips using a new technology. Methods MSCTA was performed pre- and postoperatively using a Philips Brilliance 64-detector-row CT scanner. Altogether, 32 clipping sites were analysed in 27 patients (11 female and 16 male, mean ages 52a, from 24 to 72 years). Clip number per aneurysm was 2.3 mean (from 1 to 4), 54 clips were made of titanium alloy and 5 of cobalt alloy. Results Altogether, image quality was rated 1.8 mean, using a scale from 1 (very good) to 5 (unserviceable) and clip artefacts were rated 2.4 mean, using a 5 point rating scale (1 no artefacts, 5 unserviceable due to artefacts). A significant loss of image quality and rise of artefacts was found when using cobalt alloy clips (1.4 versus 4.2 and 2.1 versus 4.0). In 72% of all investigations, an excellent image quality was found. Excluding the cobalt clip group, 85% of scans showed excellent image quality. Artefacts were absent or minimal (grade 1 or 2) in 69% of all investigations and in 81% in the pure titanium clip group. In 64-row MSCTA of good image quality with low artefacts, it was possible to detect small aneurysm remnants of 2 mm size in individual patients. Conclusion By using titanium alloy clips, in our study up to 85% of postoperative CTA images were of excellent quality with absent or minimal artefacts in 81% and seem adequate to detect small aneurysm remnants.

This article reports the results of carotid artery stenting during an 11-year period. Data from 168 carotid artery stenting procedures (symptomatic, n = 55; asymptomatic, n = 101; symptoms not accessible, n = 12) were retrospectively collected. Primary technical success rate, neurological events in-hospital, access-site complications, and contrast-induced nephropathy (n = 118) were evaluated. To evaluate the influence of experience in carotid artery stenting on intraprocedural neurologic complications, patients were divided into two groups. Group 1 included the first 80 treated patients, and group 2 the remainder of the patients (n = 88). In-stent restenoses at last-follow-up examinations (n = 89) were assessed. The overall primary technical success rate was 95.8%. The in-hospital stroke-death rate was 3.0% (n = 5; symptomatic, 5.4%; asymptomatic, 2.0%; p = 0.346). Neurologic complications were markedly higher in group 1 (4.2%; three major strokes; symptomatic, 2.8%, asymptomatic, 1.4%) compared to group 2 (2.4%; one major and one minor stroke—symptomatic, 1.2%, asymptomatic 1.2%), but this was not statistically significant. Further complications were access-site complications in 12 (7.1%), with surgical revision required in 1 (0.6%) and mild contrast-induced nephropathy in 1 (0.85%). Twenty-one (23.6%) patients had >50% in-stent restenosis during a mean follow-up of 28.2 months. In conclusion, advanced experience in carotid artery stenting leads to an acceptable periprocedural stroke-death rate. In-stent restenosis could be a critical factor during the follow-up course.

Liver abscess is a rare complication after pancreatectomy. Clostridium perfingens is a rare cause of intrahepatic infections.A 65-year-old woman with pancreatic cancer underwent explorative laparotomy, during which encasement of the hepatic artery by the tumor was found. Neoadjuvant radiochemotherapy with capecitabine was started, which caused tumor regression, and duodenopancreatectomy was performed. The portal vein was occluded and infiltrated by cancer and therefore was resected and not reconstructed. After a slow recovery, the patient developed hemorrhage at the gastrojejunal anastomosis, which was controlled by fibrin injection. Within a few days, she presented with signs of sepsis, and blood cultures yielded Clostridium perfringens, Streptococcus oralis, Staphylococcus aureus, and Candida albicans. The source of the sepsis proved to be a 9-cm liver abscess, which was drained; cultures grew C. perfringens, Hafnia alvei, and Enterobacter cloacae. Despite antibiotic treatment, the patient died from sepsis and multiorgan failure 27 days after pancreatic surgery.Such rare infections can follow pancreatic resection with neoadjuvant radiochemotherapy. Clostridium perfringens-associated liver abscess maintains a high mortality rate.

To prospectively determine whether cutting balloon angioplasty, when compared with conventional balloon angioplasty (CBA), improves morphologic and clinical outcome in patients with femoropopliteal in-stent restenosis.Patients with symptomatic femoropopliteal in-stent restenosis were randomly assigned to undergo CBA or peripheral cutting balloon angioplasty (PCBA) for treatment of lesions up to 20 cm in length. Patients were followed up clinically and with duplex ultrasonography (US) at 1, 3, and 6 months for occurrence of a restenosis of 50% or higher. The Fisher exact test and Mann Whitney U test were used for statistical analyses.Forty patients were enrolled; one patient was lost to follow-up. In the remaining patients, CBA was performed in 22 patients; PCBA was used in 17 patients. Average lesion length was 80 mm +/- 68 (standard deviation). Restenosis rates at 6 months were 65% (11 of 17; 95% confidence interval: 42%, 88%) after PCBA versus 73% (16 of 22; 95% confidence interval: 54%, 92%) after CBA (P = .73). Ankle brachial index (0.83 vs 0.75, P = .26) and maximum walking capacity on the treadmill (117 m vs 103 m, P = .97) at 6 months were also not significantly different between the two groups.PCBA failed to prove superiority compared with CBA for treatment of femoropopliteal in-stent restenosis in this pilot study. In restenotic lesions with an average length of approximately 8 cm, both treatment modalities yielded disappointing 6-month patency rates.

To prospectively determine, in a randomized controlled trial, whether cutting balloon angioplasty (CBA) yields superior morphologic and clinical outcomes at 6 months compared with the 6-month outcomes after conventional percutaneous transluminal angioplasty (PTA) in patients with short de novo superficial femoropopliteal artery (SFA) lesions.This study was approved by the ethics committees of the two participating centers, and informed consent was obtained from all patients. The authors randomly assigned 43 patients (26 men, 17 women; median age, 69 years) who had 5 cm or shorter de novo SFA lesions in association with intermittent claudication or chronic limb ischemia to undergo CBA or PTA. The patients were followed up clinically, and restenosis was assessed with duplex ultrasonography (US) at 6 months. chi(2) and Mann-Whitney U tests were used to compare data between the two treatment groups.The US-determined 6-month restenosis rate was 32% (seven patients) in the PTA group versus 62% (13 patients) in the CBA group (P = .048). Sixteen (73%) PTA group patients versus eight (38%) CBA group patients were asymptomatic at follow-up (P = .059). There was no significant difference in ankle-brachial index (median, 0.83 vs 0.77 for PTA vs CBA group, respectively; P = .56) or pain-free walking distance (median,1000 m vs 600 m for PTA vs CBA group, respectively; P = .17) between the two groups.CBA did not prove to be superior to conventional PTA for treatment of short de novo SFA lesions and yielded increased restenosis rates at 6 months.

Background— Primary stenting with self-expanding nitinol stents of the superficial femoral artery yielded improved morphological and clinical results compared with balloon angioplasty with optional stenting until 12 months in a randomized controlled trial. We now report 2-year data on restenosis and clinical outcomes of these patients. Methods and Results— Of 104 patients with chronic limb ischemia and superficial femoral artery obstructions, 98 (94%) could be followed up until 2 years after intervention for occurrence of restenosis (>50%) by duplex ultrasound and for clinical and hemodynamic outcome by treadmill walking distance and ankle brachial index. Restenosis rates at 2 years were 45.7% (21 of 46) versus 69.2% (36 of 52) in favor of primary stenting compared with balloon angioplasty with optional secondary stenting by an intention-to-treat analysis ( P =0.031). Consistently, stenting (whether primary or secondary; n=63) was superior to plain balloon angioplasty (n=35) with respect to the occurrence of restenosis (49.2% versus 74.3%; P =0.028) by a treatment-received analysis. Clinically, patients in the primary stent group showed a trend toward better treadmill walking capacity (average, 302 versus 196 m; P =0.12) and better ankle brachial index values (average, 0.88 versus 0.78; P =0.09) at 2 years, respectively. Reintervention rates tended to be lower after primary stenting (17 of 46 [37.0%] versus 28 of 52 [53.8%]; P =0.14). Conclusions— At 2 years, primary stenting with self-expanding nitinol stents for the treatment of superficial femoral artery obstructions yields a sustained morphological benefit and a trend toward clinical benefit compared with balloon angioplasty with optional stenting.

Because stent implantation for disease of the superficial femoral artery has been associated with high rates of late clinical failure, percutaneous transluminal angioplasty is preferred for endovascular treatment, and stenting is recommended only in the event of suboptimal technical results. We evaluated whether primary implantation of a self-expanding nitinol (nickel-titanium) stent yielded anatomical and clinical benefits superior to those afforded by percutaneous transluminal angioplasty with optional secondary stenting.We randomly assigned 104 patients who had severe claudication or chronic limb ischemia due to stenosis or occlusion of the superficial femoral artery to undergo primary stent implantation (51 patients) or angioplasty (53 patients). Restenosis and clinical outcomes were assessed at 6 and 12 months.The mean (+/-SD) length of the treated segment was 132+/-71 mm in the stent group and 127+/-55 mm in the angioplasty group. Secondary stenting was performed in 17 of 53 patients (32 percent) in the angioplasty group, in most cases because of a suboptimal result after angioplasty. At 6 months, the rate of restenosis on angiography was 24 percent in the stent group and 43 percent in the angioplasty group (P=0.05); at 12 months the rates on duplex ultrasonography were 37 percent and 63 percent, respectively (P=0.01). Patients in the stent group were able to walk significantly farther on a treadmill at 6 and 12 months than those in the angioplasty group.In the intermediate term, treatment of superficial-femoral-artery disease by primary implantation of a self-expanding nitinol stent yielded results that were superior to those with the currently recommended approach of balloon angioplasty with optional secondary stenting. (ClinicalTrials.gov number, NCT00281060.).

This review describes peripheral use of cutting balloon (CB) angioplasty (CBA), its characteristics, and its distinction from conventional BA and describes the experimental and clinical background of its current use in peripheral arteries.

Background— Diabetic cardiomyopathy (DCM) is characterized by microvascular pathology and interstitial fibrosis, which leads to progressive heart failure; however, the pathogenesis of DCM remains uncertain. Methods and Results— Using the streptozotocin-induced diabetic rat model, we evaluated the natural course of DCM over a period of 1 year by serial echocardiography, Western blot analysis for vascular endothelial growth factor (VEGF), endothelial progenitor cell assays, myocardial blood flow measurements, and histopathologic analysis that included terminal dUTP nick end-labeling (TUNEL), capillary and cardiomyocyte density, and fibrosis area. Downregulation of myocardial VEGF expression preceded all other features of DCM and was followed by increased apoptosis of endothelial cells, decreased numbers of circulating endothelial progenitor cells, decreased capillary density, and impaired myocardial perfusion. Apoptosis and necrosis of cardiomyocytes ensued, along with fibrosis and progressive diastolic and then systolic dysfunction. To provide further evidence of the central role of VEGF in the pathophysiology of DCM, we replenished myocardial VEGF expression using naked DNA gene therapy via direct intramyocardial injection of plasmid DNA encoding VEGF (phVEGF 165 ). VEGF-replenished rats showed increased capillary density, decreased endothelial cell and cardiomyocyte apoptosis, and in situ differentiation of bone marrow–derived endothelial progenitor cells into endothelial cells. These anatomic findings were accompanied by significant improvements in cardiac function. Conclusions— These findings suggest that downregulation of VEGF may compromise microvascular homeostasis in the myocardium and thereby play a central role in the pathogenesis of DCM.

Transjugular intrahepatic portosystemic shunt (TIPS) creation using bare stents is a second-line treatment for complications of portal hypertension due in part to the relatively high number of reinterventions and the occurrence of new or worsened encephalopathy. Initially, custom-made stent-grafts were used for TIPS revision in cases of biliary fistulae. Subsequently, custom stent-grafts were used for de novo TIPS creation. With the introduction of the VIATORR(®) TIPS endoprosthesis a dedicated stent-graft became available for TIPS creation and revision. The VIATORR(®) demonstrated its efficacy and superiority to uncovered stents in retrospective analyses, case-matched analyses, and randomized studies. The improved patency of stent-grafts has led many to requestion the role of TIPS as a second-line therapy. Currently, randomized trials are warranted to redefine the role of TIPS in the treatment of complications of portal hypertension.

Background— Drug-eluting stents represent a useful strategy for the prevention of restenosis using various antiproliferative drugs. These strategies share the liability of impairing endothelial recovery, thereby altering the natural biology of the vessel wall and increasing the associated risk of stent thrombosis. Accordingly, we tested the hypothesis that local delivery via gene-eluting stent of naked plasmid DNA encoding for human vascular endothelial growth factor (VEGF)-2 could achieve similar reductions in neointima formation while accelerating, rather than inhibiting, reendothelialization. Methods and Results— phVEGF 2-plasmid (100 or 200 μg per stent)–coated BiodivYsio phosphorylcholine polymer stents versus uncoated stents were deployed in a randomized, blinded fashion in iliac arteries of 40 normocholesterolemic and 16 hypercholesterolemic rabbits. Reendothelialization was nearly complete in the VEGF stent group after 10 days and was significantly greater than in control stents (98.7±1% versus 79.0±6%, P 2 , P P Conclusions— Acceleration of reendothelialization via VEGF-2 gene–eluting stents provides an alternative treatment strategy for the prevention of restenosis. VEGF-2 gene–eluting stents may be considered as a stand-alone or combination therapy.

Purpose To compare the diagnostic accuracy of contrast-enhanced magnetic resonance angiography (MRA) to that of digital subtraction angiography (DSA) in the detection, grading, and measurement of atherosclerotic stenoses involving the aortic arch arteries. Methods The MRA and DSA studies from 28 patients (16 women; mean age 61.6 years, range 24-83) being evaluated for possible aortic arch vessel disease were examined. The aortic arch vasculature was divided into 9 segments; within each segment, the presence and severity of stenotic or occlusive disease was determined based on a 5-point scale. In addition, stenosis length and distance to the branch were measured in 5-mm increments. Image quality was assessed using a 5-point scale. The accuracy, sensitivity, and specificity values, as well as the positive and negative predictive values in MRA's identification of lesions, were evaluated in comparison to DSA. Results In 28 patients, 189 segments were assessed by both methods. Of these, 173 were correctly rated by MRA, resulting in an accuracy of 91.5%. The accuracy dropped slightly to 86.5% when 11 "not assessable" lesions were included. Sensitivity and specificity for severity measurement were 88.5% and 95.6%, respectively. In 39 of 45 lesions, stenosis length measurements were identical by both methods, but there was a difference of 0.5 cm each in 6 lesions. Conclusions MRA as compared to DSA shows high accuracy in the detection and grading of lesions involving the aortic arch vessels. The noninvasive nature of this method recommends its use for screening, treatment planning, and follow-up in known or suspected arterial disease in aortic arch arteries.

In patients with liver cirrhosis, implantation of a transjugular intrahepatic shunt (TIPS) leads to reduction of portal pressure, but not of mortality compared with other therapies. The high stenosis rates of conventional bare stents causes high reintervention rates and costs and may be correlated with poor survival. ePTFE-covered stentgrafts provide much improved patency rates, but their impact on survival is unclear. All suitable patients receiving either bare TIPS (419/466) or undergoing implantation of ePTFE endoprostheses (89/100) in several centers in Austria up to 2002 were included in this retrospective analysis. Both patient groups were compared regarding survival with Kaplan-Meier and Cox regression analysis. Unmatched and 1:1-matched survival analyses were performed. Patients undergoing ePTFE stentgraft implantation had significantly higher survival rates in all analyses. The 3-month, 1-year, and 2-year survival rates were 93%, 88%, and 76% for the ePTFE-group and 83%, 73%, and 62% for conventional TIPS patients, respectively. The matched survival analyses validated these findings. The model of the stent, patient age, and Child-Pugh Class (CPC) were independent predictors of survival. In conclusion, patients undergoing ePTFE-endoprosthesis implantation had higher survival rates within 2 years after TIPS-implantation. This may be the result of improved patency rates after correct placement (up to the inferior caval vein [ICV]) of the ePTFE stentgraft. These data should be validated in a prospective series.

PURPOSE To assess the accuracy of moving-table MR angiography (MRA) in the evaluation of peripheral bypass grafts. MATERIALS AND METHODS There were 39 patients who had had peripheral bypass graft surgery and then subsequently underwent digital subtraction angiography (DSA) and contrast material–enhanced MRA, which was performed with moving-table software on a 1.0-T system before and during administration of 40 mL gadolinium. For evaluation, every bypass graft was divided into three parts and every leg into 14 segments. Disease severity was scored in four categories (0%–29%, 30%–69%, 70%–99%, 100%). Results were compared with those of the DSA. A total of 147 bypass graft segments and 938 vessel segments were classified. RESULTS In 132 of the assessable 147 bypass segments, disease gradings with both methods were congruent; however, 13 stenoses were misinterpreted by MRA for one grade and two additional lesions by two grades, leading to an accuracy in precise stenoses detection of 89.9%. The sensitivity and specificity values in the detection of bypass graft stenoses >69% (grade 3 + 4 lesions) reached 90.0% and 98.3%, respectively. In 821 of 938 vessel segments the accuracy of MRA in stenoses detection reached 87.5%. The sensitivity and specificity values in the detection of grade 3 + 4 lesions were 95.6% and 94.0% for the native vessels, respectively. CONCLUSION Moving-table MRA was as accurate in assessing bypass grafts as it was for the native arteries and showed a great accuracy in stenosis detection compared with DSA. Therefore, MRA is a promising modality for bypass graft surveillance and might be a noninvasive alternative to DSA in this regard.

Vertebroplasty is a radiological intervention for the augmentation of bone lesions with bone cement. Main indications are the treatment of osteoporotic vertebral body fractures, however also the treatment of tumorous lesions becomes more and more established. The indication for vertebroplasty of tumorous lesions is therapy-refractory pain in symptomatic hemangiomas, metastases and myelomas. By minimal invasive therapy stabilization of vertebral bodies and pain reduction may be achieved.

Background: In patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), prognostic scores may identify those with a poor prognosis or even those with a clear survival benefit. The ChildPugh score (CPS) is well established but several drawbacks have led to development of the model of end stage liver disease (MELD). Aim: The aim of the study was to compare the predictive power of CPS and MELD, to validate the original MELD formula, and to assess the predictive value of the determinants used in the two prognostic scores outside of a study setting. Patients: A total of 501 patients underwent elective TIPS placement and 475 patients fulfilled the inclusion criteria. Methods: Data of all patients undergoing elective TIPS in one university hospital and four community hospitals in Vienna, Austria, between 1991 and 2001, were analysed retrospectively. The main statistical tests were Cox proportional hazards regression model, the log rank test, Kaplan-Meier analysis, and concordance c statistics. Results: Median follow up was 5.2 years and median survival was 4.6 years. During follow up, 230 patients died, 75 within three months after TIPS placement. In stepwise proportional hazards analyses, independent predictors of death were creatinine level, bilirubin level, age, and refractory ascites. MELD was better in predicting survival in a stepwise Cox model but both scores were equally predictive in c statistics for one month, three month, and one year survival. Renal function was the strongest independent predictor of survival. Conclusions: Although MELD was the primary predictor of overall survival in multivariate analysis, c statistics showed that both scores can be used for patients undergoing TIPS with equal accuracy. For assessing prognosis in patients undergoing TIPS implantation, there seems little reason to replace the well established Child-Pugh score.

The purpose of our study was to assess the results of hepatic artery embolization using N-butyl-2-cyanoacrylate and ethiodized oil for the treatment of small-bowel neuroendocrine metastases to the liver as part of a multimodality protocol for the treatment of liver metastases from neuroendocrine small-bowel tumors.Twenty-three patients underwent permanent embolization of the hepatic artery using cyanoacrylate and Lipiodol for treatment of liver metastases after radical resection of small-bowel neuroendocrine tumors. All patients received additional treatment including somatostatin, and most patients received interferon as well. Cumulative survival rates were estimated using the Kaplan-Meier method.Overall, 75 embolizations (range, 1-10; mean, 3.3) were performed. Median survival time was 69 months, and the estimated cumulative survival rates reached 95.7% and 65.4% for 1 and 5 years, respectively. Two deaths (8.7%) occurred within 1 month of treatment, and one patient experienced a vascular complication at the time of embolization.Permanent embolization of hepatic arteries as part of a multimodality treatment protocol is beneficial in long-term follow-up for patients with metastasized small-bowel neuroendocrine tumors. The use of cyanoacrylate as an embolic agent is safe and effective.

Purpose: To demonstrate our short and long-term results after transbrachial treatment of subclavian artery aneurysms and injuries with stent-grafts in elective and emergency settings. Methods: Ten of 12 consecutive patients (6 men; mean age 63.8 years, range 38–80) were treated electively with commercially prepared endografts delivered via a transbrachial access to repair a subclavian artery aneurysm (n = 3) or an injury from a misplaced central venous catheter (n = 7). Two patients required emergency treatment for a ruptured atherosclerotic aneurysm in one and an unintentional arterial puncture during placement of a central venous access in the other. Stent-graft patency during follow-up was assessed by physical examination with comparison of brachial blood pressures in all patients; computed tomography angiography (CTA) was performed in available patients. Results: Successful deployment of stent-grafts with sealing of the lesion was achieved in all cases. There were 2 (17%) procedural complications. One patient developed an access-site hematoma that required surgical revision. The second patient, who had a right subclavian injury, suffered an embolic cerebral infarction. The primary stent-graft patency during follow-up (mean 11.6 months) was 100%. CTA examinations in 7 patients at a mean 18 months showed strut dislocation at the thoracic outlet without luminal narrowing in 1 patient. A 50% intraluminal narrowing due to compression between the clavicle and the first rib occurred in another patient. Six patients with a mean follow-up of 23 months (range 0.3–4.5 years) are still alive with patent stent-grafts. Conclusions: Endovascular stent-graft treatment of subclavian artery aneurysms and injuries is a less invasive alternative to surgical repair. Long-term results must still be confirmed in further studies.

Purpose: To determine whether transjugular intrahepatic portosystemic shunt (TIPS) revisions with the Hemobahn stent-graft or the Viatorr endoprosthesis increase secondary patency rates. Methods: Between 1998 and June 1999, Hemobahn endoprostheses (W.L. Gore, Flagstaff, AZ, USA) were used for the revision of obstructed TIPS in seven patients, 51–67 years of age (mean 59 years). From June 1999 to 2000, the Viatorr endoprosthesis (W.L. Gore, Flagstaff, AZ, USA) was used for revision of obstructed TIPS in nine patients, 33–64 years of age (mean 49 years). Follow-up included duplex ultrasound, clinical assessment and venous portography. Results: The technical success rate of TIPS revision with the Hemobahn stent-graft was 100%. The pressure gradient decreased from a mean of 20 mmHg to 10 mmHg. The mean follow-up was 407 days (range 81–868 days). In two patients TIPS occlusion occurred at 62 and 529 days after stent-graft placement, respectively; in another two patients outflow tract stenosis occurred at 275 and 393 days, respectively. The technical success rate of TIPS revision with the Viatorr endoprosthesis was also 100%. The pressure gradient decreased from a mean of 27 mmHg to 11 mmHg. At a mean follow-up of 201 days (range 9–426 days), all Viatorr endoprostheses are still patent without in-graft stenosis, but angioplasty was required in two patients to treat a portosystemic pressure gradient > 15 mmHg. Four of the nine patients in the Viatorr group suffered from new encephalopathy after TIPS revision. Conclusion: The Viatorr endoprosthesis yielded optimal results with 100% in-graft patency rates at follow-up but had a high incidence of new encephalopathy, whereas the use of Hemobahn stent-graft for TIPS revision did not appear to improve the secondary patency rates in our series.

Objective: To report our initial experience with endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers as an alternative to surgery in patients with increased risk of perioperative morbidity and mortality. Method: During a 2-year period, eight patients with complicated penetrating atherosclerotic ulcers of the descending thoracic aorta were treated with the Gore Excluder stent-graft. Patients (mean age, 70.6 years) presented with two to five comorbid conditions causing an increased risk for surgical repair. In addition to painful events, three patients presented with severe hemoptysis, one patient with shortness of breath, and one patient with dysphagia. All patients underwent emergency computed tomography, and diagnosis of contained rupture was confirmed in five patients. Computed tomographic findings included one to three penetrating ulcers per patient (n = 4), pseudoaneurysms (n = 5), additional intramural hematomas (n = 4), mediastinal bleeding (n = 2), and hematothoraces (n = 4). Through an iliac or femoral access site, a total of 11 stent-grafts were implanted under general (n = 5), epidural (n = 2), or spinal (n = 1) anesthesia. Results: Deployment of stent-grafts was successful in all patients, and all sites of hemorrhage were sealed. The intramural hematoma resolved completely in three cases, and two pseudoaneurysms decreased in size. Intentional occlusion of the origin of left subclavian artery with the stent-graft in one patient was tolerated without left arm or cerebral symptoms. One patient experienced permanent paraplegia immediately after endovascular repair. There were no deaths during the hospital stay (range, 7-35 days; mean, 14.5 days). One patient was lost to follow-up after hospital discharge. The clinical observation period for the remaining seven patients was 38 to 99 weeks (mean, 60 weeks). Conclusions: Endovascular stent-graft repair in complicated penetrating atherosclerotic ulcers is an alternative therapeutic option to conventional thoracotomy, especially in patients at high risk of increased morbidity and mortality perioperatively and postoperatively. (J Vasc Surg 2002;36:720-6.)

Purpose: To investigate initial and long-term success rate after percutaneous treatment of iliac artery occlusion with angioplasty and stent deployment. To investigate the influence of vascular comorbidity, lesion length, stent placement and lesion coverage as possible predictors of outcome. Methods: Between January 1994 and December 1999, 80 iliac recanalizations were performed on 78 patients, median age 61.1 ± 11.5 (SD) years. All patients were followed up by clinical examinations, duplex ultrasound and intravenous digital subtraction angiography. Mean follow-up time was 2.0 ± 1.53 (SD) years. Multivariate Cox regression analysis was used to determine the influence of cofactors on patency. Results: One, 2 and 4 years after recanalization, primary patency was 78.1%, 74.5% and 64.0%; secondary patency was 88.8%, 88.8% and 77.9%, respectively. Patients with shorter occlusions, complete lesion coverage and patent ipsilateral femoral arteries had significantly longer patency rates. Complications included inguinal hematoma (n=1), technical failure (n=3) aortic dissection (n=1), embolic occlusions (n=7), gluteal claudication (n=1) and genital necrosis after subsequent urethral surgery in one patient with contralateral occlusion and ipsilateral overstenting of the internal iliac artery with subsequent stenosis. Complications were of permanent clinical significance in seven of 78 (9%) of the patients. In 17 (22%) cases, percutaneous reintervention was performed with angioplasty in the stent (n=16) or deployment of a new stent (n=1). Conclusion: Endoluminal stent placement has its place in an interdisciplinary therapeutic approach as a viable therapeutic alternative to major transabdominal bypass surgery and can be performed with comparable complication rates. Patients with short occlusions, patent femoral arteries, and stents covering the entire occlusion have significant longer patency.

Background . The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta. Methods . From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery. Results . Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months). Conclusions . This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.

Our objective was to evaluate the accuracy of contrast-enhanced 3D MR angiography (MRA) in the follow-up of patients with endoluminally treated aortic aneurysms and correlate these findings with uni- or biphasic CT angiography (CTA). Forty MR angiograms in 32 patients with implanted aortic nitinol stent grafts were compared to CTA. Twenty-two MR examinations were correlated with arterial-phase CTA (uniphasic), and 18 MR examinations were correlated with biphasic CTA. Uniphasic CTA demonstrated three type-1/type-3 endoleaks and four reperfusion (type-2) endoleaks. In addition, MRA depicted two type-2 reperfusion endoleaks that were missed by CTA. Using biphasic CTA, two type-1/type-3 endoleaks and three reperfusion (type-2) endoleaks were detected; of those, delayed scanning detected three reperfusion (type-2) endoleaks missed during arterial-phase CTA. In addition to the findings by CTA, MRA depicted another type-2 reperfusion endoleak. Magnetic resonance angiography is at least as sensitive as uni- or biphasic CTA for detecting endoleaks and may consequently offer advantages in patients with contraindications to iodinated contrast agents.

Although the technical success of stent-graft implantation is established and relatively safe, data on the long-term safety and efficacy of endovascular repair are just emerging. Because several late complications of aortic stent-graft placement have been observed, life-long follow-up remains essential. Imaging methods form an integral part of every stage of endovascular aortic aneurysm repair. The current imaging strategy should include initial plain films, CT angiography, and color-coded Duplex sonography. Plain films are an excellent means to detect migration, angulation, kinking, and structural changes of the stent mesh, including material fatigue, at follow-up. Helical CT angiography is considered a potentially revolutionary method for the noninvasive complete postprocedural assessment of aortic sten-grafting. Current data justify the use of biphasic C angiography as the postprocedural imaging technique of choice in most patients [118]. Ultrasound offers the advantages of low cost and lack of radiation exposure. High-quality ultrasound reliably excludes endoleaks in patients after stent-grafting of AAAs. There is a substantial variability, however, in measuring the diameter of aneurysm sacs; thus, confirmation using an alternative study is prudent in cases that demonstrate a significant change in size during follow-up. MR angiography serves as an attractive alternative to CT angiography in patients with impaired renal function or known allergic reaction to iodinated contrast media. With current techniques, the visualization of aortic stent-grafts (with the exception of stainless-steel-based devices) is sufficient with MR angiography. There is evidence that MR imaging is superior to CT angiography in detecting small type 2 endoleaks or for excluding retrograde perfusion in patients with suspected endotension. The role of diagnostic catheter angiography is limited to assessment of vascular pathways in equivocal cases or for suspected endotension. Currently, a consensus view about postprocedural management after aortic stent-graft implantation is lacking. The authors propose performing a baseline CT angiography at discharge and a biphasic CT angiography and Duplex ultrasound scan at three months. In patients with no evidence of an endoleak, CT angiography, plain film and Duplex sonography (abdomen) should be repeated every year after endovascular repair. If an endoleak is present at follow-up, immediate appropriate treatment should be initiated.

To demonstrate the various presentations of acute aortic pathology and to present diagnostic and therapeutic approaches. Diagnostic imaging is the key to the reliable diagnosis of acute aortic pathology with multi-slice computed tomography angiography (CTA) as the fastest and most robust modality. Endovascular aortic repair (EVAR) with stent grafts and open surgical repair are therapeutic approaches for aortic pathology. CTA is reliable in diagnosing and grading aortic trauma, measuring aortic diameter in aortic aneurysms and detecting vascular wall pathology in acute aortic syndrome and aortic inflammation. CTA enables planning the optimal therapeutic approach. Stent graft implantation and/or an open surgical approach can address vascular wall pathology and exclude aortic aneurysms. Aortic emergencies have to be detected quickly. CTA is the imaging method of choice and helps to decide whether elective, urgent or emergent treatment is necessary with EVAR and open surgical repair as the main treatment approaches. • To present aortic pathology caused by trauma • To present acute aortic syndrome (aortic dissection, intramural haematoma and penetrating ulcers) • To present symptomatic and ruptured aortic aneurysm • To present infection (mycotic aneurysms/aorto-duodenal fistulae) or iatrogenic injury of the aorta • To understand different presentations for treatment planning (EVAR and open surgery)

Purpose: The stenosis or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) occurs in up to 75% of patients within 12 months after treatment. The aim of our investigation was to evaluate the feasibility, safety and efficacy of intraluminal high-dose rate brachytherapy (HDRBT) with Iridium-192 following TIPS revision to prevent restenosis due to pseudointimal hyperplasia. Materials and methods: Between September and November 1996, intraluminal BT was performed in five patients after TIPS revision. The indications for initial TIPS were a Budd–Chiari syndrome in two female patients and recurrent variceal bleeding by alcoholic liver cirrhosis in three male patients. TIPS was created with Wallstents (10 mm diameter in four patients) and Palmaz stent (10 mm diameter in one patient). The re-dilatation was done in all five patients 6 months after first stenting because of restenosis (>50% stent lumen reduction) or occlusion of the stent. A 5-French closed-tip, noncentered BT delivery catheter was used for subsequent radiotherapy. The whole length of the stent and performed dilatation (interventional length — IL) was taken as clinical target length (CTL). A 10-mm safety margin was added proximal and distal to the CTL due to uncertainties of BT source positioning, so forming the planning target length (PTL). To ensure that prescribed dose covers the whole PTL, the active source length (ASL) was 5 mm longer proximal and distal than PTL, so forming the reference isodose length (RIL). A dose of 12 Gy was prescribed in 3 mm distance from the source axis in the mid-plane of the applicator for three patients and in 5 mm distance for two patients. Results: A normal patency ( Conclusion: HDRBT following TIPS revision was safe and feasible in all patients. The exact impact of BT on the TIPS patency should be evaluated in larger clinical trials. Moderate dose escalation and use of today's commercially available centering radiation catheters seem to be necessary.

To compare the biocompatibility and performance of various stent-grafts to those of a bare stent in an ovine model with a subchronic (3 months) endpoint.Three different types of stent-grafts (ePTFE/nitinol, n = 8; polyester/nitinol, n = 8; and polycarbonate urethane/cobalt-alloy, n = 8) and a bare stent as a control (Ni-Co-Ti-steel-alloy, n = 8) were implanted in the iliac arteries in eight female sheep. One type of each stent-graft was implanted per animal, two implants at each side. The implantation sites for each type varied from animal to animal. Angiographic control and intravascular ultrasound (IVUS) imaging were performed before and after implantation, after 2 months, and before explantation at 3 months and were used to characterize patency and to assess intimal hyperplasia. After 3 months, the implants were retrieved and subjected to histologic evaluation (after methacrylate embedding, cutting, and histologic staining) to characterize the biologic response.Implantation was technically successful in all procedures. At 2 and 3 months after implantation, all segments in which stents had been implanted were patent. Marked neointima formation was found in the polyester-covered stent-graft that showed significant luminal narrowing of 50%, compared to the ePTFE-covered (24%) and polycarbonate urethane-covered endoprostheses (22%), as well as the bare stent (Wallstent; 9%; P.001). A minimal inflammatory vessel wall reaction was demonstrated for the polyester-covered and ePTFE-covered endoprostheses; the polycarbonate urethane-covered stent-graft's response was demonstrable but not significantly different from that of the Wallstent. At 3 months, the ePTFE-covered stent-graft showed incomplete (90%) endothelial coverage; in the other endoprostheses, complete but partially immature endothelialization was found.All stent-grafts induced an inflammatory vessel wall reaction with neointimal hyperplasia. The polyester-covered endoprosthesis caused a marked reaction with 50% luminal stenosis. Endothelialization was retarded with the ePTFE-covered stent-graft. The bare stent performed best in regard to neointimal formation and caused the least inflammatory response.

PURPOSE To evaluate if stent placement is superior to percutaneous transluminal angioplasty (PTA) in the treatment of chronic symptoms in short femoropopliteal arterial lesions. MATERIALS AND METHODS One hundred fifty-four limbs in 141 patients who ranged in age from 39 to 87 years (mean age, 67 years) were randomized to PTA ( n = 77) versus PTA followed by implantation of Palmaz stents ( n = 77). Inclusion criteria were patients with intermittent claudication ( n = 108, Society of Vascular Surgery/International Society of Cardiovascular Surgery [SVS-ISCVS] categories 1–3) or chronic critical limb ischemia ( n = 46 with either ischemic rest pain [category 4] or minor tissue loss [category 5]), short stenosis or occlusion (lesion length ≤ 5 cm), and at least one patent run-off vessel at angiography. Follow-up included clinical assessment, measurement of ankle/brachial index (ABI), color duplex ultrasound, and/or angiography at 6 or 12 months. Angiographic follow-up between 12 and 36 months was available in 46 limbs (29.9%). RESULTS In the PTA group, initial technical success was achieved in 65 of 77 limbs (84%) versus 76 of 77 (99%) limbs in the stent group (χ 2 value=0.009). Overall, major complications occurred in 3.9% ( n = 6); n = 4 in the PTA group compared to n = 2 in the stent group. There was no difference between groups of treatment: hemodynamic/clinical success at 1 and 2 years in the PTA group was 72% and 65% versus 77% and 65% in the stent group (Gehan P value=.26). The cumulative 1-and 2-year angiographic primary patency rates were 63% and 53%, respectively, for both groups. The secondary 1-and 2-year angiographic patency rates were 86% and 74% in the PTA group versus 79% and 73% in the stent group ( P = .5). CONCLUSION After stent placement, the primary success rate was significantly higher than after PTA. However, 1-year angiographic and clinical/hemodynamic success was not improved.

PURPOSE: To evaluate the safety and efficacy of an endoluminal prosthesis for treatment of peripheral arterial occlusive disease (PAOD). MATERIALS AND METHODS: A self-expanding endoprosthesis with an expanded polytetrafluoroethylene tube inside a nitinol support structure was implanted in 127 patients with symptomatic PAOD in the iliac (61 limbs) and femoral arteries (80 limbs). Clinical category status, ankle-brachial index, and color duplex flow imaging results were recorded before treatment, at discharge, and at 1, 3, 6, and 12 months after treatment. Aspirin was administered throughout the study, and heparin was administered during and for 2 days after the procedure. RESULTS: Endoprosthesis deployment was technically successful in all patients. Complications occurred in 24 of 141 procedures and included three major complications. Early thrombosis (within 30 days) occurred in one iliac and three femoral arteries. Late restenosis or reocclusion was observed in five iliac and 14 femoral arteries within t...

The aim of this study was to determine the potential of contrast-enhanced magnetic resonance (MR) angiography in the evaluation of peripheral bypass grafts. Digital subtraction angiography (DSA) served as a standard of reference. Thirty-five patients with previous bypass graft surgery underwent DSA and contrast-enhanced MR angiography within 2 weeks. MR angiography was performed using a three-dimensional fast gradient-echo sequence after administration of gadopentetate dimeglumine. Every leg was divided into 11 segments and scored in five categories of stenosis. MR angiography findings were compared with those of DSA. A total of 38 bypass grafts and 454 segments in 27 patients were included in the evaluation. In 33 (87 %) bypass grafts stenosis grading with both methods corresponded, and in 5 (13 %) cases stenosis was overestimated on MR angiography. Agreement in detection of hemodynamically significant stenosis (stenosis = 50 %) was 94.7 % with a sensitivity of 100 % and a specificity of 91.3 %. In 340 (83.0 %) vascular segments there was conformity in graduation, in 69 (16.88 %), there was a difference of one or more grades on MR angiograms. Forty-four segments (9.6 %) were not assessable due to technical limitations. Contrast-enhanced MR angiography is an useful noninvasive tool in the detection of failing peripheral vascular bypass grafts.

To investigate whether placement of a polyester-covered stent-graft increases the primary patency of transjugular intrahepatic portosystemic stent shunts (TIPSS).Between 1995 and 1997 Cragg Endopro or Passager MIBS stent-grafts were used for the creation of TIPSS in eight male patients, 35-59 years of age (mean 48 years). All patients suffered from recurrent variceal bleeding and/or refractory ascites due to liver cirrhosis. Seven stent-grafts were dilated to a diameter of 10 mm, one to 12 mm. Follow-up was performed with duplex ultrasound, clinical assessment, and angiography.The technical success rate for creation of a TIPSS was 100%. The mean portosystemic pressure gradient decreased from 25 mmHg to 12 mmHg. In seven of eight patients TIPSS dysfunction occurred between 2 days and 3 years after stent-graft placement. In one patient the TIPSS is still primarily patent (224 days after creation). The secondary patency rates are 31 days to 3 years.The primary use of polyester-covered stent-grafts for TIPSS did not increase primary patency rates in our small series.

Ist in der Therapie einer femoropoplitealen Obstruktion die Palmaz-Stentimplantation der PTA uberlegen? Methodik: 62 Patienten, 24 Frauen und 38 Manner, mit einem Durchschnittsalter von 67 Jahren (39 bis 87 Jahre) wurden fur eine perkutane Ballonangioplastic (PTA) alleine (n=37) oder eine PTA gefolgt von einer Palmaz-stent Implantation (n=33) randomisiert. Follow-up-Untersuchungen wurden klinisch, mit ABI („ankle-brachial index”) und Duplex-Ultraschall 1, 3, 6 und 12 Monate nach Intervention durchgefuhrt, erganzt durch eine i.v. DSA nach 6 oder 12 Monaten. Ergebnisse: Wir beobachteten 4 primare technische Versager in der PTA Gruppe (10,8%), keine Fruhthrombose, verglichen mit einem primaren Versager (3,0%) und 3 Fruhthrombosen (9,0%) nach Stentimplantation. Die kumulative primare angiographische Offenheitsrate („life-table analysis”) bei PTA betrug 82% und 72% (6 und 12 Monate) gegenuber 81% und 60% bei Stentimplantation. Die sekundaren Offenheitsraten betrugen 97% and 88% fur PTA, 88% und 72% nach Stentimplantation. Die Unterschiede waren jeweils nicht signifikant. Schlusfolgerungen: Trotz geringerer Anzahl an primaren technischen Fehlern, verbesserte sich nach Stentimplantation weder die klinische noch die angiographische Einjahresoffenheitsrate im Vergleich zur PTA alleine.

1. Benussi S, Pappone C, Nascimbene S, et al. A simple way to treat atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardiothorac Surg. 2000;17:524-9. 2. Cox JL, Canavan T, Jaquiss RD, et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg. 1991;101:406-26. 3. Garrey WE. Auricular fibrillation. Physiol Rev. 1924;4:215-50. 4. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659-66. 5. Melo JQ, Adragao P, Neves J, et al. Surgery for atrial fibrillation using intra-operative radiofrequency ablation. Rev Port Cardiol. 1998;17: 377-9.

Purpose Accurate stenosis quantification in the carotid arteries is of great clinical importance. We aimed to compare the diagnostic accuracy of multi-slice computed tomography angiography (CTA) to digital subtraction angiography (DSA) for the detection and grading of atherosclerotic lesions involving the supraaortic arteries. Materials and methods We retrospectively analyzed 30 patients (10 women; mean age, 67 years). CTA was performed after administration of 100 ml Ultravist 370 (Bayer Schering, Germany), at a flow of 5 ml/s, using a Philips Brilliance 16MDCT scanner (Philips, Best, Netherland) at a collimation of 16 mm × 0.75 mm prior to DSA. The supraaortic arteries were divided into 17 segments, and, within each segment, the presence and severity of stenotic or occlusive lesions was determined, based on a four-point scale (0–49%, 50–69%, 70–99%, occlusion), by four independent readers using the NASCET criteria. Sensitivity and specificity of MDCT was calculated for the detection of moderate (50–69%) versus significant stenoses (70–99%) and occlusion. Results There were 291 segments assessed with both methods. Thirteen lesions were “not assessable” on CTA. DSA identified 53 significant lesions, and CTA 56 significant lesions. With regard to significant lesions, CTA overrated six lesions and underestimated six lesions, resulting in a sensitivity, specificity, and accuracy of 86.4%, 97.6%, and 95.9%, respectively. For the detection of stenoses greater than 50%, sensitivity, specificity, and accuracy were 90.2%, 95.8%, and 94.8%, respectively. Conclusions Compared to DSA, CTA shows high accuracy in the detection and grading of lesions involving the supraaortic arteries enabling its use in the detection and treatment planning for stenoses of the supraaortic vessels.

BACKGROUND: The purpose of this retrospective population-based study was to investigate the incidence of subarachnoid haemorrhage from small (5 mm and below) cerebral aneurysms and their localisation in consecutive patients surgically treated in the State of Vorarlberg/Austria. METHODS: Altogether, during the last 4 years, 82 patients after spontaneous subarachnoid haemorrhage (mean age 53.7 years, range 21–84 years, 47 females and 35 males) were referred to the Neurosurgical Department of the Academic Teaching Hospital Feldkirch, serving for all 360,000 inhabitants of the State (corresponding to a subarachnoid haemorrhage incidence of 5.7/100,000/year). In 70 patients (85.4%), a cerebral aneurysm was detected by computed tomography angiography and/or digital cerebral angiography. Out of these, 47 patients (66.2%, mean age 52.1years, range 24–77 years) were treated with aneurysm clipping and included in the study. Preoperatively, computed tomography, computed tomography angiography and/or digital cerebral angiography were assessed for amount of blood, aneurysm size and localisation, respectively. Clinical status was graded according to the Hunt and Hess classification at admission and according to the Glasgow Outcome Scale at discharge. FINDINGS: According to Koivisto categories, 18 aneurysms were localised at the anterior cerebral artery, 17 aneurysms at the middle cerebral artery, 11 at the internal carotid artery, and 1 at the vertebrobasilar artery. The mean aneurysm diameter was 7.7 mm (range 3–30 mm). In 34% of the aneurysms the diameter was 5 mm or smaller (n = 16), in 51% between 6 and 10 mm (n = 24) and in 15% between 11 and 30 mm (n = 7). Only 1/17 ruptured middle cerebral artery aneurysms (5.9%), 4/11 internal carotid artery aneurysms (36.4%) and the vertebrobasilar artery aneurysm were small. However, in 10/18 anterior cerebral artery aneurysms (55.6%) the diameter was 5 mm or below. CONCLUSIONS: In conclusion, in our consecutive patient series with clipped cerebral aneurysms after subarachnoid haemorrhage, one third had small ruptured aneurysms, with the anterior cerebral artery complex as the main predilection site. Therefore, despite the previously reported low rupture risk, incidental small aneurysms should also be considered for therapy, depending on localisation and individual risk factors.

Percutaneous transcatheter embolization of splanchnic artery aneurysms is a minimally invasive and alternative therapy to conventional surgical intervention. Due to a high-grade stenosis at the origin of the celiac trunk, a retrograde approach to the celiac trunk pseudoaneurysm via the gastroduodenal artery was necessary. To prevent undesirable embolization into the peripheral left gastric artery initial occlusion of the central portion of the left gastric artery was performed with microcoils using a Tracker catheter. Complete occlusion of the celiac trunk itself and the short adjacent segments of the celiac artery was achieved by using a mixture of N-butyl-2-cyanoacrylate and ethiodized oil as the embolizing agent.

We thank Dr Golledge for the important comments. We undisputedly agree that the primary treatment goal in patients with intermittent claudication is the reduction of cardiovascular events by optimal medical treatment. In the future, it may be worth designing a large trial to assess whether durable improvement of patients’ exercise capacity due to revascularization in conjunction with systematic exercise training may have a beneficial effect on cardiovascular morbidity and mortality rates. Unfortunately, a 46% restenosis rate …

This paper reports our experience with endovascular techniques for the retrieval of lost or misplaced intravascular objects. Over 12 years, 78 patients were referred for interventional retrieval of intravascular foreign objects. In this retrospective study, radiological procedure records and patients' medical records were reviewed to determine the exact removal procedure in every case, to report success rates, and to identify significant procedure-related complications. Written, informed consent was obtained from all patients prior to the intervention; this retrospective analysis was performed according to the guidelines of the Institutional Review Board. Thirty-six of seventy-eight foreign objects (46%) were located in the venous system, 27 of 78 (35%) in the right heart, and 15 of 78 (19%) in the pulmonary arteries. For foreign object removal, in 71 of 78 (91%) cases a snare loop was used, in 6 of 78 (8%) cases a sidewinder catheter combined with a snare loop was used, and in 1 case (1%) a sidewinder catheter alone was used for foreign object removal. In 68 of 78 (87%) cases, primary success was achieved. In 3 of 78 cases (4%), foreign objects were successfully mobilized to the femoral vessels and surgically removed. In 7 of 78 cases (9%), complete removal of the foreign object was not possible. In 5 of 78 cases (6%), minor complications occurred during the removal procedure. In conclusion, endovascular retrieval of lost or misplaced intravascular objects is highly effective, with relatively few minor complications. On the basis of our findings, these techniques should be considered as the therapy of choice.

Purpose: To investigate whether primary nitinol stenting in the superficial femoral artery (SFA) is beneficial to patients' quality of life (QoL). Methods: One hundred four patients (55 men; mean age 66±19 years) with chronic limb ischemia and SFA disease were randomly assigned to primary stent implantation (n=51) or balloon angioplasty (n=53) with optional stenting for a suboptimal angioplasty result (17 of 53). QoL was measured by the SF-36 questionnaire at baseline and at 3, 6, and 12 months post intervention. Results: QoL was significantly improved post intervention and up to 12 months in both treatment groups. Significant inverse associations were observed between QoL parameters and restenosis. Comparing primary stenting (n=51) versus balloon angioplasty with optional stenting (n=53) by the intention to treat, no significant differences in QoL were observed. Analyses of stented patients (n=68) versus balloon angioplasty (n=36) patients, however, demonstrated significantly improved measures of QoL after stenting. Conclusion: Endovascular revascularization of SFA disease improves QoL, and restenosis negatively affects QoL outcomes. After stent implantation, whether primary or secondary, QoL was significantly ameliorated compared to balloon angioplasty alone. However, it remains to be proven in larger cohorts whether primary stenting yields a QoL benefit compared to balloon angioplasty with optional secondary stenting.