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After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

The secundum type atrial septal defect (ASD) is a relatively common finding in the general population, occurring at a reported rate of 3.78 per 100,000 live births [1], and comprising approximately 6–10% of all congenital cardiac defects [2]. When faced with a symptomatic ASD, there are several methods of treatment available. Open surgery with occlusion of the ASD is the time-honored treatment [3], but percutaneous placement of an occluder device has been the preferred treatment for several years [4]. The choice for the closure method is mainly based on the severity of symptoms, the underlying medical condition, cardiovascular anatomy [5, 6], and the size of the septal defect [7]. Surgical repair has been practiced for more than 50 years and often is preferred when the ASD size is larger and the symptoms are more severe [3]. However, percutaneous occluder device placement has largely replaced surgery when the patient is incapable of withstanding a major procedure, when the septal defect is\24 mm [8], and when the septal defect is not located near other vital cardiovascular structures [6]. The Amplatzer septal occluder (ASO) device has been extensively studied for the percutaneous closure of both ventricular as well as atrial septal defects [9, 10]. Using the approach first described in 1976 by King and Mills [4], the Amplatzer device can be placed via a venous route, and may be secured without placing the patient under general anesthesia or using cardiopulmonary bypass. Although percutaneous device placement has been found to have a lower rate of overall complications than surgical closure [5], there have been several reports of adverse events in the literature [5, 6, 8]. The case presented here describes a complication that has not yet been reported, related to the migration of the device to the aortic arch.

A radiofrequency (RF) wire puncture technique was used in the recanalization of biliary anastomotic occlusions in five patients. The technical success of recanalization, which was defined as successful puncture and crossing of the obstruction followed by balloon cholangioplasty and internal-external biliary drainage without evidence of complications, was 100%. The average follow-up was 13 months (range, 11-16 months). For biliary occlusion recanalization, the RF wire may allow the use of percutaneous therapy in the treatment of a subset of individuals who would otherwise have to undergo open surgical intervention.

A case of inferior vena cava (IVC) stenosis after orthotopic liver transplantation was treated with balloon angioplasty and Wallstent placement. There was stent migration into the right atrium (RA), and percutaneous removal of the stent was attempted without success. Open cardiac surgery was required for stent removal and repair of aortic/RA fistula. Months later, recurrent IVC stenosis was successfully treated with placement of large Z stents after additional failed surgical repair. At 2 years follow-up, the patient is asymptomatic and Doppler ultrasonography demonstrated the stent to be patent and well-positioned.

To demonstrate the anatomic relationship of the internal jugular vein (IJV) with the common carotid artery (CCA) in order to avoid inadvertent puncture of the CCA during percutaneous central venous access or transjugular interventional procedures.One hundred and eighty-eight consecutive patients requiring either central venous access or interventional procedures via the IJV were included in the analysis. The position of the IJV in relation to the CCA was demonstrated by portable ultrasonography. The IJV location was recorded in a clock-dial system using the carotid as the center of the dial and the angles were measured. Outcomes of the procedure were also recorded.The IJV was lateral to the CCA in 187 of 188 patients and medial to the CCA in one patient. The left IJV was at the 12 o'clock position in 12 patients (6%), the 11 o'clock position in 17 patients (9%), the 10 o'clock position in 142 patients (75%) and at the 9 o'clock position in 17 patients (9%). The right IJV was at the 12 o'clock position in 8 patients (4%), the 1 o'clock position in 31 patients (16%), the 2 o'clock position in 134 patients (71%) and the 3 o'clock position in 17 patients (9%). In one patient the left IJV was located approximately 60 degrees medial to the left CCA; this was recorded as 2 o'clock on the left since it is opposite to the 10 o'clock position.Knowledge of the IJV anatomy and relationship to the CCA is important information for the operator performing an IJV puncture, to potentially reduce the chance of laceration of the CCA and avoid placement of a large catheter within a critical artery, even when ultrasound guidance is used.

We report the final results of the trial comparing the Amplatz thrombectomy device (ATD) with surgical thromboembolectomy (ST) to declot thrombosed dialysis access grafts (DAG). The study population consisted of 174 DAG, 109 of which were randomized to mechanical thrombectomy using the ATD and 65 of which were randomized to conventional surgical thromboembolectomy. Forty grafts were re-enrolled in the trial when they failed beyond the 90 days follow-up after the initial treatment. Thirty-one were re-enrolled for mechanical thrombectomy and nine were re-enrolled for surgical thrombectomy, resulting in a total of 140 ATD procedures and 74 surgical thromboembolectomy. Immediate thrombectomy success was defined as greater than 90% thrombus removal followed by the ability to dialyze after treatment, and analysis of long term success based on graft patency at 30 and 90 days, with successful dialysis. Immediate thrombectomy success with the ATD procedure was achieved in 79.2% and with ST in 73.4%. Patency of the graft, with successful dialysis, at 30 days with the ATD procedure was 79.2% and with ST was 73.4%. Patency of the graft, with successful dialysis, at 90 days with the ATD procedure was 75.2% and with ST was 67.8%. The data collected in this study provided a prospective comparison of mechanical thrombectomy with the ATD and ST performance in thrombosed DAG. The results of the performance of both methods were comparable. No statistically significant differences were seen.

A 77-year-old man had clinical and radiologic signs of graft infection develop 1 year after stent grafting for abdominal aortic aneurysm. Blood cultures grew Bacteroides fragilis, and cultures of the aneurysm sac grew Enterococcus. The patient's condition was successfully managed with staged extraanatomic revascularization followed by graft excision. Although stent graft infection to date is extremely rare, some aspects peculiar to the placement of these devices potentially could increase their susceptibility to infection. Recognition and standard techniques in management can lead to successful outcome. (J Vasc Surg 2002;36:180-3.)

Purpose: To review some aspects of the problem of splenic artery steal syndrome as cause of ischemia in transplanted livers and treatment by selective splenic artery occlusion. Materials and Methods: Eleven liver transplant patients from a group of 350 patients, nine men and two women, ranging in age from 40 years to 61 years (mean 52 years), presented with biochemical evidences of liver ischemia and failure, ranging from one to 60 days following orthotopic liver transplantation. Diagnosis of splenic artery steal syndrome was suspected by elevated enzymes, Doppler ultrasound and confirmed by celiac angiogram. Patients with confirmed hepatic artery thrombosis before angiography were excluded from the study. Embolization with Gianturco coils was performed. Results: All patients were treated by splenic artery embolization with Gianturco coils. The 11 patients improved clinically within 24 hours of the procedure with significant change in the biochemical and clinical parameters. Followup ranged from one month to two years. One of the 11 patient initially improved, but developed hepatic artery thrombosis within 24 hours of the embolic treatment, requiring surgical repair. Conclusion: Splenic artery steal syndrome following liver transplantation surgery can be diagnosed by celiac angiography, and effectively treated by splenic artery embolization with coils. Embolization is one of the treatments available, it is minimally invasive, and leads to immediate clinical improvement. Hepatic artery thrombosis is a possible complication of the procedure.

Abdominal aortic aneurysm (AAA) is a relatively common disease among the elderly population and may be present in up to 5.9% of the population aged 80 years. Abdominal aortic aneurysm more than 5 cm in diameter are more prone to rupture, with a significant mortality rate. Conventional surgical treatment is quite effective in the lower surgical risk population; however, in the population with a higher risk level the mortality and morbidity significantly increase. The development of less invasive techniques to treat AAA derived from the necessity to reduce the morbidity and mortality. The development of the endovascular endoprostheses was a significant landmark in the management of those patients with AAA, particularly the ones with increased risk. Although the stent-graft technology is still in its infancy, a large amount of information is available and an attempt to summarize this experience is presented herein. An extensive review of the stent-graft technology is presented, including variations in design and classification of the several systems available. Technical aspects of the use of endovascular prostheses are presented, as well as the most recent outcome information available. The problems of endoleaks is discussed and the techniques for treatment and outcomes presented. Finally, a summary of specific information on most of the devices available is presented.

Venous thromboembolism is a common cause of death. Acute massive pulmonary embolism (PE) is life-threatening and may require vigorous more invasive treatment. Several risk factors are related to increased incidence of massive PE. Anticoagulation is the most traditional treatment for PE but may not suffice in cases of massive PE. Systemic thrombolytic therapy, catheter-directed thrombolysis, percutaneous embolectomy, and more recently, percutaneous thrombus fragmentation techniques with a multitude of devices are now available to treat the most severe cases of massive PE. Successful treatment of PE includes implementation of a treatment protocol and the use of associated techniques and devices.

To evaluate the safety and efficacy of a hydrodynamic thrombectomy system in a prospective, multicenter randomized comparison with pulse-spray thrombolysis in hemodialysis grafts.Nine centers enrolled 120 adult patients with recently (/=14 days) thrombosed hemodialysis grafts. Graft venography was used to confirm occlusion in 62 patients randomly assigned to thrombectomy and 58 to thrombolysis. For thrombolysis, a mixture of 5,000 U of heparin and 250,000 U of urokinase was distributed throughout the thrombus, first to the venous then to the arterial graft end. For thrombectomy, the catheter was passed in the same sequence. Technical success was removal of 80% or more of thrombus. Clinical success was technical success plus the ability to dialyze. Also assessed were total procedure time, thrombus treatment time, procedure-related blood loss, other complications, and 30- and 90-day outcomes.Patient demographics were comparable. Technical success rates were 95% (59 of 62) for thrombectomy and 90% (52 of 58) for thrombolysis (P: =.31). Clinical success rates were 89% (55 of 62) and 81% (47 of 58), respectively (P: =.24). At 30 days, 69% (43 of 62) and 66% (38 of 58), respectively, could be dialyzed through the graft (P: =.70); at 90 days, the rates were 40% (25 of 62) and 41% (24 of 58), respectively (P: =.91). None of these differences or those for procedure-related blood loss and early and late complications were statistically significant. Thrombus treatment times of 16.8 minutes for thrombectomy and 23.4 minutes for thrombolysis were significantly different (P:.01).The hydrodynamic thrombectomy system is at least as efficacious and safe as pulse-spray thrombolysis but shortens thrombus treatment time.

Pulmonary blastoma is a rare and aggressive malignant tumor that affects children and adults. Recently a 3-year-old boy with a 2-year history of bilateral unilocular pulmonary cysts was transferred for evaluation of a cough and high spiking fever. A chest radiogram showed left pulmonary consolidation with pleural effusion, but thoracentesis was unsuccessful. Computerized tomography (CT) was suggestive of a pulmonary abscess, but CT-guided drainage did not yield any purulent fluid. Percutaneous biopsies were performed, and the cytology showed malignant cells. During thoracotomy, a large tumor involving the left lower lobe and pleural space was found, and a biopsy was performed. A frozen section showed blastemal and mesenchymal components devoid of neoplastic epithelium, consistent with the pleural variant of pulmonary blastoma. A left lower lobectomy, with tumor decortication of the pleural space, achieved total gross tumor removal. The child received aggressive multiagent chemotherapy, and midway through it he underwent elective excision of the opposite lung cyst. It has been 17 months since the lobectomy; he is off chemotherapy and has no evidence of disease. A review of the literature showed that a large number of pediatric pulmonary blastomas are associated with cystic lung disease. Because total tumor removal offers the only chance of a good long-term outcome, surgical excision or close follow-up of pulmonary cysts in children is strongly recommended.

BackgroundIn selected patients with chronic pancreatitis, extensive pancreatectomy can be effective for the treatment of intractable pain. The resultant morbid diabetes can be ameliorated with islet autotransplantation (IAT). Conventionally, islet infusion occurs intraoperatively after islet processing. A percutaneous transhepatic route in the immediate postoperative period is an alternative approach.MethodsA prospectively collected database of patients undergoing pancreatectomy with percutaneous IAT (P-IAT) was reviewed. Hospital billing data were obtained and median charges determined and compared with estimated charges for an intraoperative infusion method of IAT (I-IAT).ResultsThirty-six patients (28 women; median age 48years) underwent pancreatectomy with P-IAT. Median operative time was 232min (range: 98–395min) and median estimated blood loss was 500cc (range: 75–3000cc). Median time from pancreatic resection to islet transplantation was 269min (range: 145–361min). A median of 208248 IEq (2298IEq/kg) were harvested. Median peak portal venous pressure during islet infusion was 13mmHg (range: 5–37mmHg). Postoperative complications occurred in 15 patients (42%) and included hepatic artery pseudoaneurysm and portal vein thrombosis; the latter occurred in two patients with portal pressures during infusion >30mmHg. At a median follow-up of 10.7months, eight patients (22%) were insulin-free. Median pertinent charges for P-IAT were US$36318 and estimated median charges for I-IAT were US$56440. Surgeon time freed by P-IAT facilitated an additional 66 procedures, charges for which amounted to US$463375.ConclusionsPercutaneous transhepatic IAT is feasible and safe. Islet infusion in the immediate postoperative period is cost-effective. Further follow-up is needed to assess longterm results.

yThe role of the interventional radiologist (IR) in providing locoregional therapies for hepatocellular carcinoma (HCC), has grown substantially in the last 30 years, and especially in the recent decade, because of development of new techniques, improvement in existing devices, and better outcomes. However, a multidisciplinary patient management approach is critical for optimal decisions and care. HCC is usually discovered late in the course of the disease and, in general, has poor prognosis. 1 Surveillance for HCC in high-risk patients and recent improvements in surgical techniques (liver resection and transplantation) have contributed to better survival. 2 However, wide margins and the underlying cirrhosis limit the volume of liver that can be resected. 3–5 Liver transplantation offers an w75% survival rate in early HCC at 5 years, but, if malignant vascular invasion is found in the explant, survival rates decrease significantly. 6–8 Until the introduction of sorafenib (Nexavar, Bayer HealthCare Pharmaceuticals Inc, Wayne, NJ, USA), no systemic chemotherapy showed significantly increased survival in patients with advanced HCC. 9–11 Sorafenib may be effective in shrinking HCC (Fig. 1) and preventing recurrence after resection or local ablation. 12 External beam radiation has had a limited role in the treatment of HCC because of radiation toxicity to the adjacent normal liver. 13 Because of these limitations and others negative factors such as tumor location, excessive number of lesions, size, presence of portal hypertension, and poor liver function, image-guided locoregional therapies were developed and present several advantages in treating HCC. Image-guided therapies are in 2 main groups: (1) endovascular catheter-based procedures using digital subtraction angiography/fluoroscopy, such as transarterial chemoembolization (TACE) and radioembolization; and (2) ultrasound (US)-assisted or computed tomography (CT)–assisted percutaneous ablative procedures, including

To define predictive factors for endoleak type II (EL-II) based on quantifiable factors in the imaging studies of patients undergoing endovascular aneurysm repair (EVAR).The data on 208 consecutive patients (137 men; mean age 75.2 years, range 62-84) who underwent EVAR between the years 2003 and 2008 were retrospectively reviewed. The abdominal aortic aneurysm (AAA) diameter ranged from 4.8 to 12.8 cm. Data were collected on the type of AAA; the type of stent-graft (aortomonoiliac versus bifurcated); the performance of hypogastric artery embolization; the presence, number, diameter, and patency of aortoiliac branches identified on the pre and post-EVAR imaging studies; and the presence and type of EL-II (transient vs. persistent) with the goal of identifying any imaging-based predictive factors for the development of EL-II.Among the 208 cases, 11 patients had endoleaks other than type II and were excluded, leaving 195 patients for analysis. In all, 28 (13.4%) patients were diagnosed with EL-II. All had ≥4 patent lumbar arteries (mean diameter2.3 mm). Ten patients with a transient EL-II had a mean of 4.3 patent lumbar arteries, which had diameters2 mm (mean 1.5 mm). In the 18 patients with persistent EL-II, the mean diameter of the 4 lumbar arteries was 2.7 mm; at least 1 of the lumbar arteries was2 mm. The presence of at least 4 patent lumbar arteries (p0.001) and at least 1 patent hypogastric artery (p0.001) were predictive factors for EL-II. At least 1 lumbar artery2 mm in diameter was a positive predictive factor for the development of persistent EL-II (p0.001).Patent hypogastric and lumbar arteries are significantly associated with a higher risk of developing EL-II. Larger diameter lumbar arteries tend to be associated with persistent EL-IIs, while lumbar arteries2 mm would more likely be seen with a transient EL-II. If substantiated in larger studies, these angiographic criteria may guide early treatment of EL-II to avoid aneurysm sac expansion and potential rupture.

Purpose To compare an injectable hydrogel embolic device with a pushable AZUR device procedurally, angiographically, and histologically in the embolization of porcine arteries. Materials and Methods In 12 pigs, embolization of renal, gluteal, and hepatic or thoracic arteries was performed with either injectable hydrogel embolic devices (two arteries per pig) or an AZUR device (one artery per pig). Follow-up angiography was performed before sacrifice in five pigs at 7 days after embolization and seven pigs at 90 days after embolization. The harvested tissues were evaluated histologically. Continuous and ordinal results were compared using analysis of variance and χ 2 tests. Results For the sites with embolization performed with injectable hydrogel, complete angiographic occlusion was obtained in 21 of 24 (88%) sites after treatment, 10 of 10 (100%) sites at 7 days, and 10 of 14 (72%) sites at 90 days. For the sites with embolization performed with AZUR devices, complete angiographic occlusion was obtained in 10 of 12 (83%) sites after treatment, 4 of 5 (80%) sites at 7 days, and 5 of 7 (72%) sites at 90 days. Statistically significant differences in angiographic occlusion were not observed at 7 days ( P = .13) or 90 days ( P = .35). The embolization time of the injectable hydrogel group (14 minutes ± 8) was significantly reduced ( P = .02) compared with the AZUR group (22 minutes ± 12). Differences between the groups in arterial wall damage were not evident at either 7 days or 90 days, although greater damage was observed in both groups at 90 days. In both groups, inflammation was nonexistent to minimal at 7 days and minimal to mild at 90 days. Conclusions Embolization of porcine arteries was as effective with injectable hydrogel embolic devices as pushable AZUR devices, as evidenced by the procedural, angiographic, and histologic results.

Despite the numerous stent-graft devices available, unsuitable anatomy is still the greatest exclusion criterion for endovascular abdominal aortic aneurysm (AAA) repair (EVAR). The present report describes an on-site preprocedural customization of a conventional Zenith stent-graft device just before the endovascular procedure that includes the creation of fenestrations and scallops as necessary for the patient's anatomy. Three patients with difficult anatomy in whom conventional AAA repair posed a high degree of risk were treated with customization of the stent-graft device to fit disparate renal arteries. A single fenestration for the left renal artery was made in two cases, and a single scallop was made in the other case to accommodate the superior mesenteric artery. Gold beads were used to mark the location of the fenestration and scallop. The three cases were successfully performed without perceptible endoleaks in the follow-up period, which ranged from 4 to 14 months. No procedure-related complications were detected; however, pneumonia developed in one patient 3 weeks after EVAR. The initial results with this technique are encouraging, and the role of EVAR can be significantly increased with the use of this customization technique when the interventionalist does not have access to the commercially available devices or when the waiting time is too prolonged to accommodate the patient's clinical situation.

The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF ( n = 5) or PA ( n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. Diagnoses were made by using computed tomographic angiography (CTA) and digital subtraction angiography. Fourteen lesions were in the common CA; eight were in the internal CA. Homemade devices and stent grafts from a variety of manufacturers were employed. Follow-up evaluations included clinical, CTA, and Doppler ultrasound assessments. All patients had resolution of the PA or AVF. In one patient with a large petrous PA, acute occlusion of the CA developed after placement of three balloon-expandable stent grafts, but there were no neurologic complications because the circle of Willis was functional. During follow-up ranging from 2 months to 13 years, asymptomatic 90% stenosis owing to stent compression was observed on Doppler ultrasound and angiographic examinations in a patient with an autologous vein–covered stent graft in the internal CA. Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis.

Embolization therapy is reported in 2 patients who had vascular complications following percutaneous subclavian vein catheterization. One had an arteriovenous fistula between the right internal mammary artery (IMA) and the brachiocephalic vein. The other patient presented with a pseudo-aneurysm of the IMA with life-threatening hemorrhage and a large thoracic hematoma. A detachable latex balloon was used for occlusion of the arteriovenous fistula in the first patient and a steel spring coil was used to embolize the IMA and the pseudo-aneurysm in the second patient. The lesions were successfully treated on follow-up of 30 months for the first patient and 37 months for the other.

Purpose To evaluate the treatment of abdominal aortic aneurysm (AAA) with use of the endoluminal Talent stent-graft (TSG). Patients and Methods In 10 men, AAA treatment was attempted with use of the TSG. All patients presented significant surgical risk, with chronic obstructive pulmonary disease and coronary arteriopathy. The mean age was 65.5 years (range, 57–82 years). The mean proximal neck diameter was 25.8 mm (range, 21.6–34 mm). Five of the TSGs were straight tubes and five were bifurcated systems. The main body of the TSG is made of a polyester graft material mounted on a self-expandable nitinol frame. The bifurcated system uses polytetrafluoroethylene (PTFE) material for the legs and extensions mounted on a self-expandable nitinol frame. The bifurcated grafts used a 22 to 27-F introducer and the extensions, a 18-F introducer through a surgical cutdown technique. Results The TSG system was successfully implanted in nine patients and failed in one because of dislodgment after deployment, which required conversion to surgery. Four leaks occurred initially. One was sealed off with balloon dilation at the end of the procedure, one leak was treated with an additional extension, another leak disappeared spontaneously in 30 days, and the other leak required embolization 4 weeks after discharge. Seven patients were discharged on the third day after the procedure, and two patients were discharged at 1 and 2 weeks, respectively. Blood transfusion was necessary in three patients because of hematoma at the incision site in two patients, which required surgical revision for hemostasis, and because of transoperative bleeding in one patient. Follow-up time ranged from 2 to 15 months. The only death occurred 5 days postoperatively as a consequence of ischemic colitis and multisystem organ failure in the only patient who required surgery. Conclusion Treatment of AAA with the TSG system is effective for aneurysm exclusion. This device seems to provide a good alternative to surgery in patients who are otherwise considered to be at high risk for complications after direct surgical repair, but it is not without risk of complications.

Background: Pancreatitis after biliary stenting is a rare complication. To reduce this risk, some endoscopists routinely perform biliary sphincterotomy before stenting, but the value of this practice is not established. Methods: The incidence of pancreatitis was reviewed in patients undergoing biliary stenting with and without a biliary sphincterotomy. Results: Postprocedure pancreatitis occurred in 4 of 83 (4.8%) patients treated with transpapillary biliary stents. Patients with proximal biliary strictures were at significantly increased risk for postprocedure pancreatitis (4 of 24) versus those with distal or no strictures (0 of 59) ( p = 0.006). The four patients with pancreatitis after stenting had not undergone sphincterotomy. Of those treated conservatively, two cases were graded severe (one fatal), and one was mild. The other patient was markedly symptomatic from pancreatitis, but improved dramatically after treatment with a needle-knife sphincterotomy done within 24 hours of the original ERCP. Conclusion: The risk of pancreatitis following transpapillary biliary stenting is increased in patients with proximal biliary strictures. Such lesions (malignant or benign) may serve as a fulcrum, leading to medial deflection of the stent and compression of the pancreatic orifice. The hypothesis that sphincterotomy may decrease the risk of biliary stent–induced obstructive pancreatitis should be tested in patients with proximal biliary strictures. (Gastrointest Endosc 1997;45:46-51.)

Purpose To determine the feasibility of using the Amplatz thrombectomy device (ATD) to treat massive pulmonary embolism (PE). Patients and Methods Five patients (four men, one woman; mean age, 45.2 years) with massive PE underwent mechanical thrombectomy with the ATD, which creates a vortex that pulverizes and recirculates the clots within the pulmonary circulation. The patients were followed up for 7–18 months after thrombectomy. Results Marked improvement in pulmonary perfusion was observed in one patient and moderate improvement was observed in three patients at angiography and ventilation-perfusion scanning. No changes could be assessed in one patient who died shortly after the procedure. One patient developed hemoptysis during the procedure, most likely because of a reperfusion syndrome. A reduction in pulmonary artery pressure was observed in only one patient; the remaining patients had increased pressure. The four surviving patients were discharged within 8 days. Conclusion Mechanical thrombectomy with the ATD provides rapid debulking of thrombus in some patients with massive PE and has the potential to improve treatment and outcomes of the most sick patients.

Purpose To report the preliminary results in a trial comparing the Amplatz mechanical thrombectomy (MT) device with surgical thrombectomy (ST) to declot occluded dialysis access grafts. Patients and Methods Thirty-seven patients were randomly assigned by computer to either ST ( n = 18) or MT ( n = 19). Diagnostic fistulograms were obtained at the end of the procedure, and Doppler ultrasound was performed at 1-month follow-up. Plasma free hemoglobin levels were measured before, immediately after, and 24 hours after the procedure in the MT group. Success was defined as initial success with restoration of flow through the graft, primary patency at 30 days, and secondary patency at 30 days. Results Technical success with MT was 89%. Primary patency in the MT series was 47% and secondary 30-day patency was 68%. Technical success with ST was 83%. Primary patency in the ST series was 77% and secondary patency at 30 days was 77%. Angioplasty ( n = 18) and stent placement ( n = 6) were performed in the MT cases. Angioplasty was impossible in one patient. Immediately after MT, plasma free hemoglobin levels above normal were noted in 63% of the cases, but these levels were within normal levels after 24 hours in 88% of the cases. Conclusion Initial success of MT in patients with occluded dialysis access grafts is comparable to that of ST. No statistically significant differences in primary or secondary patencies were seen

This article provides a review of percutaneous biliary procedures, including percutaneous treatment of malignant biliary obstruction using internal/external drainage and stents, percutaneous treatment of benign biliary obstruction with catheters and stents, stone treatment with percutaneous lithotripsy, and percutaneous cholecystostomy and stone treatment.

To describe the spectrum of radiologic findings in crutch-induced axillary artery injury and the effects of its unique pathophysiology on diagnostic evaluation and treatment. Three patients with axillary crutch-induced axillobrachial injury were studied angiographically and percutaneous intervention was performed in two cases. One patient required surgical bypass of a thrombosed axillary artery aneurysm. One patient responded to percutaneous transluminal angioplasty (PTA) of a focal axillary artery stenosis. One patient with an axillary artery aneurysm and distal thromboembolic disease was treated by both thrombolysis and surgical thromboembolectomy and later by PTA of an axillary artery intimal disruption. Chronic axillary crutch use may be associated with axillary artery stenosis, aneurysm formation, and secondary axillobrachial thromboembolic disease. Mural injury can be successfully treated by PTA and thromboembolic disease by thrombolytic therapy. Early identification of the axillary artery lesion is critical for long-term therapeutic results.

A case is reported of 38-year-old woman with chest pain attributed to a left lung sarcoidosis mass. The mass failed to diminish and symptoms failed to resolve with systemic corticosteroid therapy. CT-guided direct intralesional transthoracic injection of dexamethasone resulted in resolution of the patient's symptoms and a dramatic reduction in the size of the mass within 2 months.

Angiography and selective renal arterial embolization were performed in 17 patients with traumatic lesions of the kidney and hematuria. Of the patients 8 had retroperitoneal extravasation of contrast medium owing to rupture, 6 had traumatic arteriovenous fistulas and 5 had pseudoaneurysms.Immediate control of hemorrhage was achieved in 16 patients (94.1 per cent), while delayed control was obtained in 1. Hematuria recurred in 4 of the 17 patients (23.5 per cent) and resulted in total nephrectomy in 3 (17.6 per cent) despite repeated embolization in 2.Embolization alone was successful in 14 patients (82.4 per cent). According to the followup preservation of renal function and viable parenchyma was excellent in all embolized patients.Our results indicate that transcatheter embolization should be performed in patients with renal trauma and uncontrollable hematuria before any surgical attempt is made.

A case of successful obliteration of a bleeding splenic artery pseudoaneurysm secondary to necrotizing pancreatitis is reported. The material used for embolization was stainless steel coils. A variation of the technique is introduced. Instead of occluding the pseudoaneurysm cavity itself, embolization only of the afferent vessel is advised.

Eight patients with life-threatening hemobilia were treated by percutaneous transcatheter occlusive therapy. The bleeding was caused by a traumatic pseudoaneurysm of the hepatic artery in 6 cases (auto accident in 4, surgery in 1, biliary drainage in 1) and a true aneurysm of the hepatic artery in 2 (unknown etiology in 1 and mycotic in 1). Arterial catheterization was used in all cases except for one in which a direct percutaneous puncture was performed. Gelfoam alone was used as embolic material in 3 patients. In 1 patient each, the material used was gelfoam plus coils, coils alone, blood clot, n-butyl-cyanoacrylate and an occluding balloon catheter. In all cases the bleeding stopped and did not recur during the follow-up period which ranged from 9 months to 14 years. This experience indicates that transcatheter occlusive therapy is an effective method for the treatment of severe hemobilia.

Eleven cases of bleeding aneurysms and pseudoaneurysms, with and without arterio-venous fistula, involving different vascular territories were treated by transcatheter embolisation and the results are reported. Gelfoam was used in two cases and steel coils in the remaining nine cases. Embolisation by the steel-coil technique proved to be very efficient. The experience in these 11 cases shows that it is usually not necessary to embolise the aneurysm cavity but simply to occlude the feeding proximal vessel, consequently sparing the weak aneurysmic wall the risk of rupture and allowing the aneurysms to clot as a result of reduced or occluded blood flow.