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Background and purpose The Woven EndoBridge (WEB) is an intrasaccular flowdisruptor that is increasingly used for the treatment of (wide-necked) aneurysms. We present our experience with the WEB for unruptured aneurysms. Materials and methods Between April 2014 and August 2019, 93 patients with 95 unruptured aneurysms were primarily treated with the WEB. There were 69 women and 24 men, mean age 61 years (median 58, range 37–80). Results Of 95 aneurysms, 86 had been discovered incidentally, 3 were symptomatic and 6 were additional to another ruptured aneurysm. Location was anterior communicating artery 33, middle cerebral artery 29, basilar tip 19, carotid tip 8, posterior communicating artery 4, posterior inferior cerebellar artery 1, superior cerebellar artery 1. Mean aneurysm size was 6 mm (median 6, range 3–13 mm). In one aneurysm additional coils were used and in another, a stent was placed. There was one procedural rupture without clinical sequelae. There were two thrombo-embolic complications leading to permanent deficit in one patient (mRS 2). Morbidity rate was 1.0% (1 of 93, 95%CI 0.01–6.5%) and mortality was 0% (0 of 93, 95%CI 0.0–4.8%). Angiographic follow-up at six months was available in 85 patients with 87 aneurysms (91%). Of 87 aneurysms, 68 (78%) were completely occluded, 14 (16%) had a neck remnant and 5 were incompletely occluded. Four aneurysms were retreated. Retreatment rate was 4.5% (4 of 87, 95%CI 1.7–13.6%). Conclusion WEB treatment of unruptured aneurysms is safe and effective. Additional devices are needed only rarely and retreatment at follow-up is infrequent.

Background and purpose Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. Materials and methods We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. Results Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1–6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. Conclusion The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

Background: Dual-energy X-ray absorptiometry (DXA) measurements are sensitive to artifacts from surrounding tissues. This study investigates the impact of abdominal aortic calcification (AAC) on bone mineral density (BMD) in patients with chronic kidney disease (CKD). Methods: In 88 patients with CKD stage G5D, lumbar spine BMD was measured in both anterior-posterior (AP) and lateral DXA projections. AAC was determined from lateral lumbar radiographs. Results: Median age was 51 ± 14 years, and 61 % were men. AAC was present in 59 %. There was no difference in lumbar spine BMD between patients with and without AAC (AP: 0.823 vs. 0.806 g/cm2, p = 0.66). The ΔBMD between AP and lateral projections was similar in patients with and without AAC (13.4 ± 6.7 % vs. 11.5 ± 6.3 %; difference 1.9 %, 95 % CI −0.9 to 4.7 %, p = 0.18). When comparing single vertebrae at levels with high vs. low degree of AAC within the same individual, there was no difference in BMD (AP: 0.827 ± 0.202 vs. 0.818 ± 0.291 g/cm2, p = 0.78), nor in the ΔBMD between AP and lateral projections (12.9 ± 8.1 % vs. 14.3 ± 8.3 %, p = 0.12). Conclusion: We could not detect an impact of AAC on lumbar spine BMD. These findings challenge the dogma that lumbar spine BMD by DXA is unreliable due to widespread AAC in patients with CKD.

Interpreting evidence in the arteriovenous (AV) access literature is challenged by the heterogeneity in terminology and the lack of standardization in outcomes. Below some of the terms used in this guideline are listed and how they have been interpreted in the context of this document. Because guideline development necessarily relies on aggregate data from systematic reviews and other individual studies, we can only hope to provide the user with conceptual definitions for certain concepts and outcome domains. At present, there is insufficient consensus to go beyond that point and define specific outcome measures or measurements. [...]

Age-related brain atrophy is a common finding, but neurodegenerative diseases such as Alzheimer's disease are associated with accelerated atrophy of the medial temporal lobe. In current practice for brain atrophy evaluation, several rating scales are being used such as the medial temporal atrophy (MTA), global cortical atrophy-frontal subscale (GCA-F) and posterior atrophy (PA) scales. Practical cut-offs to differentiate between normal and advanced brain atrophy are needed, because of their possible usefulness as a biomarker. A retrospective study was performed over a 1-year period resulting in a total of 79 subjects [27 patients with Alzheimer's disease (AD), 27 patients with minimal cognitive impairment (MCI) and 25 control subjects]. The MTA, GCA-F and PA scales were applied blinded and independent by two raters. Possible age- and disease-related cut-offs were computed. The MTA scale showed significantly better diagnostic performances and inter-rater agreement than the PA and GCA-F scales. We could not confirm the suggested MTA cut-off for each decade. However, an MTA score of >1 and >1.75 was considered pathological, respectively, in the population under and over 70 years. MTA can be of use in making distinction between age-related atrophy and abnormal increase of atrophy. Systematic assessment of regional brain atrophy through the use of MTA in MRI images could be a useful biomarker in aiding the early diagnosis of Alzheimer's disease.

Background: With the increasing age of acute stroke patients being admitted to hospitals, more data are needed on indications, complications and outcome of endovascular treatment (EVT) in the very elderly. Methods: Retrospective observational study with data collection from Belgian, Swiss, Canadian comprehensive stroke centers and Swedish EVT National database. All patients with acute ischemic stroke were eligible if aged older than or >= 90 years and treated with EVT +/- pretreatment with intravenous thrombolysis (IVT). Safety assessment comprised presence of peri-procedural complications, hemorrhagic transformation or other adverse events (= 2b), favorable clinical outcome (modified Rankin Score (mRS) 0-2) and 3-months mortality. Results: Inclusion of 112 nonagenarians (mean age 93.3 +/- 2.5 years; 76.8% women; pre-mRS = 2b) was achieved. Favorable outcome (mRS

To retrospectively analyse long-term patency and overall survival of cirrhotic patients treated with TIPSS using e-PTFE-covered stents. Additionally, prognostic factors for better patency and survival were analysed. Two hundred and eighty-five consecutive cirrhotic patients with severe portal hypertension-related symptoms were included. Follow-up, including clinical assessment and duplex ultrasound, was analysed up to end of study, patient’s death, liver transplantation or TIPSS-reduction. Patency rates and overall survival were estimated by the Kaplan-Meier method; potential differences in outcome between subgroups were calculated using the Pepe and Mori test. The 1-, 2- and 5-year primary patencies were 91.5 %, 89.2 % and 86.2 %, respectively, with no new shunt dysfunctions after 5 years’ follow-up. TIPSS revision was performed more often in ascites patients (P = 0.02). The 1-, 4- and 10-year survival rates were 69.2 %, 52.1 % and 30.7 %, respectively. Survival was higher in Child-Pugh class A-B (P = 0.04), in the recurrent bleeding group (P = 0.008) and in patients with underlying alcoholic cirrhosis (P = 0.01). Long term, primary patency of e-PTFE-covered TIPSS stents remains very high (>80 %); shunt revision was required more frequently in ascites patients. Overall survival was better in Child-Pugh A-B patients with recurrent variceal bleeding and alcoholic liver cirrhosis. • Long-term primary patency rate of e-PTFE-covered TIPSS stents remains very high. • No new shunt dysfunction was found after 5 years of follow-up. • Shunt revision was required more frequently in ascites patients. • Four and 10 years’ overall survival was 50 and 30 %, respectively.

Background Long-term outcome after embolization of pancreatitis-induced pseudoaneurysm is not yet determined. Purpose To assess the long-term efficacy and patients’ overall survival after embolization of pancreatitis-induced pseudoaneurysm. Material and Methods Patients referred for endovascular treatment of a pancreatitis-induced pseudoaneurysm between January 1998 and January 2014 were analyzed. Embolization procedures were performed by transcatheter techniques using different types of embolic agents. Demographic, technical-radiological, and clinical data were collected. Results Thirty-four patients were identified with a pancreatitis-induced pseudoaneurysm; the underlying disease was acute (n = 13; 38%) or chronic (n = 21; 62%) pancreatitis; seven patients (20.6%) had active bleeding when embolized, while in the remaining 27 patients (79.4%) the pseudoaneurysm was not bleeding. In all 34 patients, successful endovascular exclusion of the pseudoaneurysm was obtained after the first attempt. Minor complications occurred in 11 patients (30%); no major complications were noted. A new pseudoaneurysm on a different vessel was identified during follow-up in three patients (9%). In another patient (3%), the excluded pseudoaneurysm reopened during follow-up. All four recurrences occurred within the first 5 months after embolization. Long-term follow-up (mean, 6.6 years; range, 4 months–16 years) revealed estimated survival rates of 94%, 89%, and 75% after 2, 5, and 10 years respectively, without pseudoaneurysm-related death. Conclusion Catheter-directed embolization of pancreatitis-induced pseudoaneurysms is relatively safe and effective. Recurrence or new pseudoaneurysm formation was low and occurred within the first 6 months after embolization. Overall survival is high, with no pseudoaneurysm-related deaths.

Background and Purpose— We aimed to compare the ability of conventional Alberta Stroke Program Early CT Score (ASPECTS), automated ASPECTS, and ischemic core volume on computed tomographic perfusion to predict clinical outcome in ischemic stroke because of large vessel occlusion ≤18 hours after symptom onset. Methods— We selected patients with acute ischemic stroke from the CRISP study (Computed Tomographic Perfusion to Predict Response to Recanalization in Ischemic Stroke Project) with successful reperfusion (modified treatment in cerebral ischemia score 2b or 3). We used e-ASPECTS software to calculate automated ASPECTS and RAPID software to estimate ischemic core volumes. We studied associations between these imaging characteristics and good outcome (modified Rankin Scale score, 0–2) or poor outcome (modified Rankin Scale score, 4–6) in univariable and multivariable analysis, after adjustment for relevant clinical confounders. Results— We included 156 patients. Conventional and automated ASPECTS was not associated with good or poor outcome in univariable analysis ( P =nonsignificant for all). Automated ASPECTS was associated with good outcome in multivariable analysis ( P =0.02) but not with poor outcome. Ischemic core volume was associated with good ( P P =0.04) in univariable and multivariable analysis ( P =0.03 and P =0.02, respectively). Computed tomographic perfusion predicted good outcome with an area under the curve of 0.62 (95% CI, 0.53–0.71) and optimal cutoff core volume of 15 mL. Conclusions— Ischemic core volume assessed on computed tomographic perfusion is a predictor of clinical outcome among patients in whom endovascular reperfusion is achieved ≤18 hours after symptom onset. In this population, conventional or automated ASPECTS did not predict outcome.

Background Over the past decade, there has been a revival and a renewed interest for cerebrovascular bypass procedures. The superficial temporal artery (STA) has its value as a reliable donor vessel; however, a possible role for the middle meningeal artery (MMA) as a donor artery is still unclear. Objective To assess the feasibility of using the MMA as a donor vessel in cerebrovascular surgery. Methods We performed cadaveric dissections on 12 fresh specimens (23 sides) after bilateral silicone injection into the internal and external carotid arteries. We compared the size, diameter, and possibility to perform a bypass to the middle cerebral artery for both the MMA and the STA. Measurements were done using an electrical caliper. Additional measurements of the MMA and STA were performed on 20 random angiograms. Results There was no statistically significant difference in diameter of the MMA at its ostium being 2.4 mm, compared to 2.7 mm for the STA ostium (t-test; P = .21). The MMA could be mobilized over 4.1 cm, whereas the STA over 8.3 cm. Finally, the mean diameter of the donor vessel at the site of the anastomosis was 1.6 mm versus 1.9 mm for MMA and STA, respectively (P = .0026). We were able to perform an MMA and middle cerebral artery anastomosis on 17 sides. Conclusion These results suggest that the MMA is a potentially valuable donor vessel to be used in selected cases. The availability of a suitable MMA branch should be assessed preoperatively on the angiogram.

Multivisceral transplantation (MvTx) for diffuse venous portomesenteric thrombosis is a surgically and anesthesiologically challenging procedure, partly because of the risk of massive bleeding during visceral exenteration. Preoperative visceral artery embolization might reduce this risk. In three consecutive MvTx, the celiac trunk (CT) and superior mesenteric artery (SMA) were embolized immediately pretransplant. We analyzed demographics, serum D-lactate, pH, base excess, hemoglobin, blood pressure, transfused packed cell (PC) units, intervention time and outcome. Results are reported as median (range). All recipients were male (43, 22, 47 years old). Portomesenteric thrombosis followed antiphospholipid syndrome, neuroendocrine tumor and liver cirrhosis. A peritransplant D-lactate peak of 6.1 (5.1-7.6) mmol/L, lowest pH of 7.24 (7.18-7.36) and lowest base excess level of -9.5 (-7.6 to -11.5) were observed. Values normalized within 3 h posttransplant. Embolization and exenteration times were 80 (70-90) min and 140 (130-165) min, respectively, during which blood pressure remained stable, lowest hemoglobin was 6.1 (6.1-7.6) g/dL and three (2-4) PC were administered. All procedures were uneventful. Follow-up was 7 (4-9) months. The first patient died 4 months post-MvTx after an intracranial bleeding; the other patients are doing well. Our experience suggests that preoperative embolization of CT and SMA facilitates native organ resection in MvTx.

Background Cancer-related obstruction of large abdominal and pelvic veins might become symptomatic with clinical signs of lower limb venous congestion. Technical and clinical outcome after interventional treatment is not well studied yet. Purpose To retrospectively assess the technical and clinical outcome of endovascular management of symptomatic cancer-related iliocaval venous obstructive disease. Material and Methods From 1998 to 2013, 19 patients (15 men, 4 women; mean age, 63.6 years) referred for interventional treatment of cancer-related iliocaval obstructive disease were identified. Patients’ symptoms included unilateral ( n = 16; 84%) or bilateral ( n = 3; 16%) painful swelling of the lower limbs. Patients’ demographics as well as interventional and clinical outcome data were collected. Results All 19 patients underwent, under local anesthesia, stenting of the iliac vein ( n = 16; 84%) or inferior vena cava ( n = 3; 16%). Immediate technical success ( n = 19) was 100%; immediate clinical success ( n = 18) was 94.7%. During follow-up, seven patients (36.8%) presented with recurrent symptoms of painful limb swelling. Estimated survival after 3 and 6 months was 68.4% (95% confidence interval [CI], 47.8–82.3%) and 19.8% (95% CI, 11.9–29.2%), respectively. Conclusion Endovascular stenting of cancer-related iliocaval venous obstructive disease is safe and results in immediate relief of symptoms. However, recurrent venous obstruction is common. At 3 months follow-up, the majority of patients with iliac vein stenting were still alive.

Objective: To compare conventional and automated Alberta Stroke Program Early CT score (ASPECTS) to CT perfusion core volumes to predict functional outcome in acute ischemic stroke patients with successful reperfusion after thrombectomy. Materials and methods: Patients from the Computed Tomography Perfusion to Predict Response to Recanalization in ischemic Stroke Project (CRISP) study who achieved mTICI 2b or 3 reperfusion were included. Four independent physicians rated and reached consensus on the conventional ASPECT scores of the baseline CT. Automated ASPECT scores were determined with e-ASPECTS software (Brainomix, Oxford, UK). We used RAPID software (iSchemaView, Stanford, USA) to analyze CT perfusion core volumes. Good and poor functional outcome (GFO and PFO) was defined as a score of 0-2 and 4-6 on the modified Rankin Scale (mRS). Predictors of GFO and PFO were obtained by multivariate logistic regression. Results: We included 156 patients from the CRISP study. Interrater reliability for conventional ASPECTS was excellent (intra-class correlation coefficient 0.77). Median values for conventional ASPECTS, automated ASPECTS, and CT perfusion core volume were 7 (IQR 5-8), 9 (IQR 7-10) and 6.2 ml (IQR 0-17.7). Patients with GFO (59%) had lower baseline NIHSSS, lower rates of diabetes and smaller CTP infarct cores (p < 0.01 for all). Patients with PFO (25%) were older (p < 0.0001), had higher NIHSSS (p = 0.001), higher rates of diabetes (p < 0.0001) and larger CTP infarct cores (p < 0.05). In multivariate analysis CT perfusion core volume was associated with both GFO (OR 0.98; 95%CI 0.96-1.00) and PFO (OR 1.02; 95%CI 1.01-1.04)). Automated ASPECTS was a predictor for GFO (OR 1.26; 95%CI 1.04-1.53) but not PFO. Conventional ASPECTS was not associated with functional outcomes. Conclusion: In the setting of successful thrombectomy, CTP core volume is a better predictor of functional outcome than either conventional or automated ASPECTS.

To retrospectively analyse the technical and clinical outcomes of embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy, and in addition, to analyse factors potentially influencing 30-day mortality.From November 1998 to November 2012, 34 patients underwent percutaneous embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic treatment. Demographic, laboratory, angiographic, and clinical follow-up data were collected.Indication for initial endoscopic sphincterotomy was benign (n = 28) or malignant (n = 6) disease. A precut sphincterotomy followed by sphincterotomy was performed in 13 patients (38 %), whereas the remaining 21 patients (62 %), underwent only sphincterotomy. Seven patients (20.6 %) were still on antithrombotic medication at the time of sphincterotomy. Angiographic evaluation revealed contrast extravasation (n = 31), pseudoaneurysm (n = 2), or a combination of both (n = 1). Embolization was successful in 33 of 34 patients (97 %). Recurrent bleeding occurred in three patients (9 %), and 30-day mortality was 20.6 % (n = 7). Factors significantly influencing 30-day mortality were INR (P = 0.008) and aPTT (P = 0.012).Angiographic embolization is very effective in stopping post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy. The rate of rebleeding is acceptably low, but 30-day mortality remains significant. Haemostatic disorders appear to significantly influence 30-day survival.• Transcatheter embolization is very effective in stopping major post-biliary sphincterotomy bleeding • The rate of rebleeding is acceptably low • Haemostatic disorders appear to significantly influence 30-day survival.

ispartof: Journal of Vascular and Interventional Radiology vol:26 issue:6 pages:918-920 status: published

A fistula between the iliac artery and a bladder pouch is a rare but potentially life-threatening condition. In 3 patients presenting with massive hematuria after urinary diversion, an iliac artery pseudoaneurysm was found on imaging studies. These pseudoaneurysms were considered to be associated with a fistula between artery and pouch, causing the hematuria. All patients were successfully treated with a covered stent to exclude the pseudoaneurysm and the arteriovesical fistula. Clinical follow-up of 10 weeks, 16 months, and 27 months, respectively, showed no residual hematuria. In addition, no clinical signs of stent graft infection or thrombosis were identified during follow-up. In conclusion, the placement of a covered stent is a valuable therapeutic treatment option in the management of hematuria due to an arteriovesical fistula after urinary diversion surgery.

Context: Sclerostin, a Wnt antagonist produced by osteocytes, regulates osteoblast activity and is a well-established key player in bone turnover. Recent data indicate that the Wnt pathway may also be involved in vascular calcification. Objective: The present study tests the hypothesis that serum sclerostin levels are associated with vascular calcification in patients with chronic kidney disease (CKD) not yet receiving dialysis. Design, Setting, Participants, and Measurements: We performed a cross-sectional analysis in 154 patients with CKD. Aortic calcification (AC) was assessed by lumbar X-ray and scored with a maximum score of 24. In addition to traditional and nontraditional cardiovascular (CV) risk factors, serum sclerostin levels were assessed (ELISA). Regression analysis was performed to identify determinants of serum sclerostin and AC. Results: AC was present in 59% of patients. Older age (P < .0001), male sex (P = .006), lower estimated glomerular rate (eGFR) (P = .0008), lower bone-specific alkaline phosphatase (P = .03), and the absence of AC (P = .006) were identified as independent determinants of higher serum sclerostin levels. In univariate logistic regression, higher age, diabetes, CV history, higher body mass index, higher serum C-reactive protein and sclerostin levels and lower estimated glomerular rate were all associated with the presence of AC. In multivariate analysis, lower, not higher, sclerostin levels (P = .04, odds ratio [OR] per ng/mL of 0.24), higher age (P < .0001, OR per year of 1.17) and CV history (P = .02, OR for a positive CV history of 3.83) were identified as independent determinants of AC. Conclusions: In this cohort of patients with CKD, we found that patients with aortic calcifications (ACs) had higher sclerostin levels. However, in multivariate analysis, the association became inverse. Additional clinical and experimental studies are urgently required to clarify whether or not sclerostin protects against progression of vascular calcification.

Summary Renal transplant recipients have an increased risk of cardiovascular (CV) disease. Arterial stiffness (AS) and aortic calcifications (ACs) are well-known CV risk factors in patients with chronic kidney disease. We aimed to determine the prognostic value of AS and AC in incident renal transplant recipients (RTRs). We conducted a prospective study in 253 single RTR. AC were scored by means of lumbar X-ray. Carotid-femoral pulse wave velocity (PWV) was assessed in a subgroup of 115 patients. AC were present in 61% of patients. After a mean follow-up of 36 months, 32 CV events occurred in the overall group and 13 events in the PWV subgroup. When we accounted for age, gender, and CV history, AC score (HR, hazard ratio 1.09 per 1 unit increase; 95% CI 1.02–1.17) and PWV (HR 1.45 per 1 m/s; 95% CI 1.16–1.8) remained an independent predictor of CV events in Cox-regression analyses. Using receiver operating characteristics, the area under the curve for predicting CV events amounted to 0.80 and 0.72 for sum AC and PWV, respectively. Both AS and AC are strong predictors of future CV events in an incident RTR population. These vascular assessments are readily available and easy to perform, making them ideal tools for further risk stratification. (ClinicalTrials.gov number: NCT00547040)

Background Suboptimal stent-graft placement at the lower anastomosis during transjugular intrahepatic portosystemic shunt (TIPS) may result in early shunt stenosis and occlusion owing to incomplete covering of the parenchymal tract by the covered part of the stent-graft. Purpose To determine the optimal portal venous projection view for stent-graft placement during TIPS and the potential influence of the portal vein anatomy. Material and Methods On 76 cirrhotic patients (48 men and 28 women) selected for TIPS, rotational, three-dimensional (3D), catheter-directed angiography of the portal vein was performed. The 3D portograms were reviewed by two independent interventional radiologists to determine the optimal angiographic projection views for stent-graft placement. Intra-observer and inter-observer reliabilities were tested and subgroups of patient portal vein anatomy were categorized. Results Among all patients, the optimal portal venous projection views for stent-graft placement during TIPS centered around 27° (±14°) right oblique and 3° (±7°) craniocaudal. Of these, 56% were within the standard deviations. Intra-observer reliabilities were 0.60 and 0.62 for the two radiologists, respectively. Inter-observer reliability was 0.48. Anatomical variations in the patient population were: normal portal vein (67%), trifurcation at main portal vein (16%), right posterior portal vein as the first branch of main portal vein (3%), no right posterior portal vein (1%), and other variations (13%). Anatomical subgroups did not influence the best angiographic projection view significantly (F4,295 = 0.91, P = 0.457). Conclusion The mean optimal angiographic projection view for TIPS stent-graft placement was 27° right oblique and 3° craniocaudal. Patient anatomic variations do not play a significant role in determining the optimal angiographic view for TIPS stent-graft placement.

The anterolateral thigh flap (ALT-flap) has a widespread use throughout the body because of the many engineering options. The anterolateral thigh has a complex local vasculature which can be of importance for the surgical approach. In general, the flap receives its perfusion from branches of the lateral circumflex femoral artery (LCFA). The LCFA however has a large anatomic variance. CT-angiography can guide the surgeon in selection the must suitable site and aid in the surgical approach. ispartof: The British Journal of Radiology vol:89 issue:1063 pages:20150920- ispartof: location:England status: published

Objective To determine predictors of technical success, dysfunction recurrence and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVFs). Methods Retrospective analysis of first time PTA of 167 AVF in 162 patients (100 men, 66 ± 13 years). Anatomical (location, length, grade and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus and AVF age, side and location) were reviewed. Results 217 stenoses or segmental occlusions were treated. Technical success rate (84.4%) was higher in radiocephalic AVF compared to brachial artery–median vein AVF ( p = 0.030) and was negatively correlated with initial stenosis ( p = 0.049). Dysfunction recurrence was seen in 52.7% and correlated negatively with technical success ( p = 0.013) and AVF age ( p = 0.008). Early dysfunction (within 6 months) was negatively correlated with AVF age ( p = 0.016) and positively with diabetes ( p = 0.003). Higher AVF age resulted in higher primary ( p = 0.005) and secondary patency rates ( p = 0.037–0.005). Conclusions Technical success of PTA in hemodialysis AVF is affected by AVF type and initial stenosis and has significant effect on dysfunction recurrence, but not on AVF longevity. Younger AVF has increased risk for (early) recurrent dysfunction and lower patency rates. Patients with diabetes mellitus have higher risk for early dysfunction.

Objective Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice. Methods We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia. Results Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications. Conclusion The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

To evaluate operator radiation exposure during percutaneous interventions on hemodialysis arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs).Seventy-seven procedures were performed in 57 patients while the interventional radiologist wore two ring dosimeters, two thermoluminescent dosimeters at the lower legs, and a thermoluminescent dosimeter on the forehead. Dose-area product, fluoroscopy time, total procedure time, and radiation exposures to eye lens, hands, and legs were recorded. Variables were procedure type, access site side, and angiography equipment. Statistical analysis was performed with the signed-rank and Mann-Whitney U tests.Mean operator radiation doses for the left hand, right hand, eye lens, left leg, and right leg were 0.28, 0.28, 0.03, 0.11, and 0.12 mSv, respectively. Radiation exposure to the hands was significantly higher compared with that to the legs (P.0001). In recanalization procedures, fluoroscopy time, total procedure time, and mean number of angiographic runs were higher (all P.001) than those for percutaneous transluminal angioplasty (PTA), as were radiation exposures to the hands and left leg (all P.05). Left-sided access interventions resulted in higher doses to the right hand and leg (both P.05). For right-sided access interventions, doses to the left hand and leg were higher (P.0001). Eye lens radiation dose was significantly higher for procedures with the flat-panel detector system (P=.002).Operator radiation exposure to the hands, legs, and eyes during percutaneous interventional procedures performed on hemodialysis AVFs and AVGs is relatively low. Radiation exposure to the hands was higher than that to the legs, and the hand and leg closest to the AVF or AVG received a higher dose. Recanalization procedures resulted in higher doses to the hands and left leg than did PTA. Eye lens radiation dose may be higher with a flat-panel detector system.

A widely accepted technique to transplant the liver-bowel bloc is first to perform a piggyback anastomosis of the donor suprahepatic vena cava to the recipient vena cava; second to restore the arterial blood supply through an aortic interposition graft; and third to ensure venous drainage of the native foregut. The venous drainage of the native foregut can be restored through an end-to-end portocaval anastomosis between the donor infrahepatic vena cava and the recipient portal vein. Stenosis of this anastomosis can lead to portal hypertension presenting with upper GI congestion, bleeding, and hypersplenism. We report the successful treatment of this complication using an e-PTFE-covered stent inserted following balloon angioplasty.

Background/Aims: Sudden death is the major cause of cardiac mortality in dialysis patients, accounting for approximately 60% of cardiovascular deaths. A prolonged QT interval and arterial calcification have been associated with increased cardiovascular morbidity and mortality in different patient populations including patients with chronic kidney disease (CKD). In the present study, we aimed to elucidate the association of vascular calcification with corrected QT interval duration in patients with end-stage renal disease. Methods: We performed a single-center cross-sectional study in patients referred for renal transplantation. Patients taking QT-prolonging agents or with conduction abnormalities were excluded. Aortic calcifications were scored by means of lumbar X-rays. Results: In the final analysis, 193 patients (118 men, 52 years old) were included. A prolonged QT interval was observed in 26% of the patients. Multivariate analysis showed an independent and direct association between corrected QT duration and the extent of aortic calcifications (p = 0.0004) independent of age, gender, cardiovascular history, electrolytes and parameters of mineral metabolism. Conclusions: A prolonged QT interval is prevalent in patients with CKD stage 5D. Aortic calcification is associated with a prolonged QT duration, independent of traditional determinants.

This study was designed to assess the long-term outcome of selected patients with aortic, aortoiliac, and isolated common iliac aneurysms treated with the GORE EXCLUDER® stent-graft.Between December 1998 and June 2010, 121 nonconsecutive patients underwent insertion of a GORE EXCLUDER® stent-graft to treat an aortic (n=80; 66%), aortoiliac (n=25; 21%), or isolated common iliac (n=16; 13%) aneurysm. Procedural and follow-up data were collected prospectively. Primary endpoints are overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary endpoints are device- and procedure-related complications, including all types of endoleaks or endotension, and reintervention.The mean follow-up is 4.98 years (standard deviation, 3.18; median follow-up, 4.05 years). The estimated percentage overall survival (with 95% confidence interval) after respectively 5 and 10 years of follow-up is 74.5% (65.8; 81.3) and 57.8% (47.7; 66.7). The estimated intervention-free survival after respectively 5 and 10 years is 90% (84.3; 96.1) and 77.7% (67; 88.4). There was no aneurysm rupture during follow-up. Early postoperative complications occurred in 16 patients (13%); none were fatal. Late reinterventions were performed in 18 patients (15%). Finally, throughout the follow-up period, endoleaks were identified: type I (n=4; 3%); type II (n=39; 32%); type III (n=0; 0%); endotension was seen in 11 patients (9%).Aneurysm exclusion with use of the GORE EXCLUDER® stent-graft is durable through a mean follow-up of nearly 5 years. There was no postprocedural aneurysm rupture. Complications occurred throughout the follow-up period, requiring continued clinical and radiological surveillance.

To evaluate the safety and feasibility of percutaneous stripping of totally implantable venous access devices (TIVAD) in case of catheter-related sleeve and to report a technique to free the catheter tip from vessel wall adherence.A total of 37 stripping procedures in 35 patients (14 men, 40%, and 21 women, 60%, mean age 53±14 years) were reviewed. Totally implantable venous access devices were implanted because of malignancy in most cases (85.7%). Catheter-related sleeve was confirmed as cause of persistent catheter dysfunction despite instillation of thrombolytics. A technique to mobilize the catheter tip from the vessel wall was used when stripping with the snare catheter was impossible. Technical success, complication rate, and outcome were noted.A total of 55.9% (n=19) of the 34 technically successful procedures (91.9%) could be done with the snare catheter. In 15 cases (44.1%), additional maneuvers to free the TIVAD's tip from the vessel wall were needed. Success rate was not significantly lower before (72.4%) than after (96.7%) implementation of the new technique (P=0.09). No complications were observed. Follow-up was available in 67.6% of cases. Recurrent catheter dysfunction was found in 17 TIVADs (78.3%) at a mean of 137.7 days and a median of 105 days.Stripping of TIVADs is technically feasible and safe, with an overall success rate of 91.9%. Additional endovascular techniques to mobilize the distal catheter tip from the wall of the superior vena cava or right atrium to allow encircling the TIVAD tip with the snare catheter may be needed in 44.1% of cases.

We report two cases of a transjugular approach for biopsy of a deeply located focal liver lesion, using transabdominal US to guide the through-cut biopsy needle.

Purpose To assess the safety, feasibility, and effectiveness of coil embolization of the proximal internal iliac artery (IIA) before stent-graft extension in patients previously treated by endovascular aortic repair (EVAR). Materials and Methods Over a period of 9 years, 16 ipsilateral, proximal IIA coil embolization procedures were performed before stent-graft extension in 13 patients previously treated by a modular aortic stent graft. Indication for coil embolization and concomitant stent-graft extension were secondary (ie, late) distal type I endoleak ( n = 9) and late onset of an isolated common iliac artery aneurysm ( n = 7) as a result of increasing dilation of a common iliac artery during follow-up after EVAR; mean common iliac artery diameter before coil embolization was 26.1 mm (range, 15–35 mm). Clinical and radiologic follow-up (mean, 39 months; range, 6–102 months) was done in accordance with an established registry. Results All procedures were successful except for one performed with 0.035-inch coils. Clinically, buttock claudication was noted in five of 13 patients (38%). No type II endoleak occurred through the coil-embolized internal iliac arteries. The mean common iliac artery diameter at 6-month follow-up was 23.0 mm (range, 14–30 mm; P = .0005). Conclusions Ipsilateral coil or microcoil embolization of the proximal IIA before stent-graft extension in patients previously treated by an aortic stent graft seems to be safe and feasible, with favorable outcomes after a mean follow-up of 39 months.

Objective This study aims to evaluate the impact of CO 2 venography on the planning and outcome of native arteriovenous fistula (AVF) creation. Methods Records of patients who underwent CO 2 venography prior to access surgery between January 2000 and December 2008 were reviewed. CO 2 venography was performed selectively in chronic kidney disease (CKD) in stage IV–V patients without suitable veins on clinical examination. Findings at surgery were compared to CO 2 venography images. Patency of AVFs was analysed by the Kaplan–Meier method. Differences in outcome of maturation were compared using a χ 2 test. Results A total of 209 CO 2 venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO 2 venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO 2 venography ( n = 2) or access was attempted with a vein which was thought to be unsuitable on CO 2 venography ( n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable ( P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively. Conclusion CO 2 venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Objective The objective of our study was to assess the diagnostic value of 64-MDCT angiography in the evaluation of failing hemodialysis arteriovenous fistulas (AVFs) in comparison with conventional digital subtraction angiography (DSA). Subjects and methods Thirty-six patients (22 men; mean age +/- SD, 65 +/- 15 years) with hemodialysis fistula dysfunction underwent MDCT angiography before DSA. Linear weighted kappa was used to calculate interobserver agreement for stenosis for both MDCT angiography and DSA on a 5-point scale. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the detection of >/= 50% stenosis or occlusion on MDCT angiography was calculated using DSA as the standard of reference. Wilcoxon's signed rank test and Mann-Whitney U test were used to compare differences in image quality between MDCT angiography and DSA and between MDCT angiography with the patient's arm stretched overhead or alongside the body, respectively. Results Interobserver agreement for detecting stenosis was excellent for both DSA (kappa = 0.86; 95% CI, 0.81-0.91) and MDCT angiography (kappa = 0.82; 95% CI, 0.77-0.87). Accuracy, sensitivity, specificity, PPV, and NPV of MDCT angiography for detecting >/= 50% stenosis or occlusion was 92.0% (95% CI, 86.8-95.3%), 90.2% (77.8-96.3%), 92.8% (85.9-96.6%), 85.2% (72.3-92.9%), and 95.4% (89.0-98.3%), respectively. No significant difference in image quality was seen between MDCT angiography and DSA (p = 0.3008) or between MDCT angiography with the patient's arm stretched overhead or alongside the body (p = 0.2912). Conclusion MDCT angiography is a reproducible and reliable imaging technique for detection of >/= 50% stenosis or occlusion in dysfunctional hemodialysis fistulas.

Endovascular aneurysm repair (EVAR) has become an established technique for the treatment of many infrarenal aortic aneurysms. Although EVAR is obviously less invasive than open surgical repair, it is not free of complications. These can potentially result in severe morbidity or even mortality, stressing the need for an early detection and subsequent treatment. In this review article, the pathophysiology, diagnosis, and treatment of the most common complications of EVAR, with the exception of endoleaks, are described.

Transarterial chemoembolization (TACE) is considered the gold standard for the treatment of unresectable hepatocellular carcinoma (HCC) in patients with a preserved liver function and in the absence of clear extrahepatic tumor spread. This review article deals with the radiological and clinical workup, the interventional technique of chemoembolization for HCC and gives an overview of the common as well as some rare and dramatic complications of TACE. Finally, some new trends and advances in clinical research with regard to the interventional management of HCC are discussed.

Purpose To assess the incidence and clinical significance of thrombotic, nonocclusive mural deposits in abdominal aortic stent-grafts incidentally found on follow-up computed tomography scans after endovascular aneurysm repair (EVAR). Materials and Methods Between 1998 and 2007, 288 patients underwent EVAR of an infrarenal aortic aneurysm. In the majority of cases, a Zenith stent-graft ( n = 187) or Excluder stent-graft ( n = 71) was implanted. Clinical and radiologic follow-up was performed prospectively according to the EUROSTAR registry, with mean follow-up periods of 4.69 and 5.05 years, respectively, for the Excluder and Zenith groups. Results Thrombotic deposits were found in 17% and 33% of patients in the Excluder and Zenith groups, respectively, which represents a significant difference ( P = .038). Clinically, no distal atheroembolic events were noted during follow-up, and there was no significant difference in survival between patients with and without thrombotic deposits ( P = .80). Conclusions Incidentally found thrombotic deposits in abdominal aortic endografts are common and device-specific, with a lower incidence in the Excluder group versus the Zenith group. These thrombotic deposits are clinically silent, do not require additional treatment at short-term and midterm follow-up, and do not affect the overall survival of the treated patients.

Purpose To assess the time period of onset, etiology, and outcomes of limb occlusion after endovascular repair of abdominal aortic aneurysms with supported endografts. Materials and Methods From 1998 to 2007, 288 patients underwent endovascular aneurysm repair (EVAR) to exclude an infrarenal aortic aneurysm. In the majority of patients, a Zenith stent-graft ( n = 187) or Excluder stent-graft ( n = 71) was implanted. Nine patients presented with limb occlusion during follow-up. All occluded stent-grafts were modular ( n = 8) or aortomonoiliac ( n = 1) Zenith endoprostheses. One additional patient who was previously treated with a Zenith aortomonoiliac stent-graft was referred to our institution for further treatment of stent-graft thrombosis. Results The initial clinical presentations were acute ischemia ( n = 5), buttock claudication ( n = 3), and incidental findings on follow-up imaging ( n = 2). Occlusion occurred within the first month after EVAR ( n = 5), between the first and second month after EVAR ( n = 2), 10 months after EVAR ( n = 1), and 4–5 years after EVAR ( n = 2). Underlying causes of occlusion were kinking of the stent-graft ( n = 5), small-diameter endograft limb with extension to the external iliac artery ( n = 3), and migration and dislocation of an endograft limb ( n = 2). Treatment consisted of catheter-directed thrombolysis and stent placement ( n = 3), surgical thrombectomy or bypass operation ( n = 5), and expectant management ( n = 2). Outcome of all revascularization procedures showed immediate clinical success in all patients and no late recurrent limb ischemia at a mean follow-up of 38.9 months. Conclusions Limb occlusion of aortic stent-grafts mostly occurs shortly after EVAR and can be related to underlying kinking of the metallic skeleton, extension of the stent-graft into the external iliac artery, or migration and dislocation of an endograft limb. Satisfactory and durable clinical outcomes can be obtained after appropriate revascularization.

Four children, three boys and one girl, with a median age of 9 years 8 months, underwent transjugular intrahepatic portosystemic shunt creation with an expanded polytetrafluoroethylene (e-PTFE)-covered nitinol stent. The stent-graft was successfully placed in all four patients without any complication. Clinical and biochemical improvement was noted in all four patients during follow-up. Radiological follow-up with use of duplex ultrasound showed a recurrent stenosis of the shunt 180 days after stent-graft implantation in one patient. This was treated with placement of an additional stent-graft, re-expanding completely the recurrent stenosis. In the other three patients, the stent-graft remained fully patent until the end of the study or until orthotopic liver transplantation. These preliminary results suggest that use of the Viatorr ePTFE-covered stent-graft in children is safe and feasible, with potentially the same high patency rate and improved clinical outcome as reported in adult patients.

Rationale and Objectives We sought to assess changes in liver perfusion parameters induced by transjugular intrahepatic portosystemic shunt (TIPS) creation in cirrhotic patients with refractory ascites using dynamic MR perfusion measurements. Materials and Methods MR perfusion measurements were performed before and after TIPS creation in 15 cirrhotic patients all with refractory ascites. Measurements were performed over a time period of 120 seconds providing 60 images for each examination and calculations were done in both liver and splenic parenchyma. Different perfusion parameters were assessed: time to peak (TTP), time to inflow deceleration (TID), maximal or peak perfusion (C-peak) and the wash-in rate. Results TIPS procedures were successful in all 15 patients but were complicated by hepatic encephalopathy in 3 patients (20%), and in another 4 patients (26%), persistent refractory ascites was still noted during follow-up. Overall, liver TID values decreased significantly ( P = .001) after TIPS creation; liver wash-in values increased significantly ( P = .04) after TIPS. TTP values did not decrease significantly ( P = .16) and liver C-peak values did not change equally ( P = .99). Conclusion In cirrhotic patients with refractory ascites, TIPS induced a faster, but not an increased, contrast enhancement in the liver.

Purpose To evaluate the safety and efficacy of the Castaneda brush catheter in the treatment of thrombosed hemodialysis fistulas and grafts. Materials and Methods Twenty-six revascularization procedures with the Castaneda brush catheter combined with urokinase were retrospectively analyzed in 21 patients (mean age, 69 years; range, 35–87 y). Hemodialysis shunts were native arteriovenous (AV) fistulas ( n = 15; 16 procedures) or polytetrafluoroethylene grafts ( n = 6; 10 procedures). Major outcomes included procedure time, anatomic and clinical success rates, complication rate, and primary, primary assisted, and secondary patency. Results In 26 procedures, the brush catheter was used in combination with a mean dose of 239,792 IU urokinase (range, 60,000–300,000 IU). Additional angioplasty was performed in all procedures; five procedures (19%) required additional stent implantation. Mean procedure time was 99.2 minutes (range, 49–261 min). Anatomic and clinical success rates were 100% and 96.2%, respectively. Two minor complications (8%) occurred, neither of which was device-related: one case of extravasation treated by balloon tamponade and one hematoma at the distal puncture site without the need for surgery or transfusion. Primary patency rates were 87%, 62%, and 50% at 3, 6, and 12 months, respectively, for AV fistulas, and 50%, 33%, and 17%, respectively, for grafts. Assisted primary patency rates were 93%, 77%, and 70% at 3, 6, and 12 months, respectively, for AV fistulas, and 50%, 33%, and 17%, respectively, for grafts. At 3, 6, and 12 months, secondary patency rates were 93%, 85%, and 80%, respectively, for AV fistulas, and 83%, 67%, and 50%, respectively, for grafts. Conclusions The Castaneda brush catheter is a safe and effective pharmacomechanical thrombectomy device for the treatment of thrombosed hemodialysis grafts and native fistulas.

Purpose To retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of the parallel technique to treat transjugular intrahepatic portosystemic shunt (TIPS)–induced hepatic encephalopathy (HE) refractory to medical treatment. Additionally, factors potentially influencing clinical results after shunt reduction are assessed. Materials and Methods Seventeen patients (11 men and 6 women) presenting with TIPS-induced HE refractory to medical treatment underwent shunt reduction with use of the parallel technique. West Haven HE grades before shunt reduction were IV and III in seven patients each and II in three patients. Mean portosystemic pressure gradient (PSPG) before shunt reduction was 6.8 mm Hg (range, 2–16 mm Hg). Relations between change in patients' mental state and several clinical parameters were analyzed. Results In all patients, it was technically feasible to reduce the shunt with use of the parallel technique. PSPG after reduction increased by a mean of 5.8 mm Hg (range, 1–12 mm Hg; P n = 6), I ( n = 4), II ( n = 3), III ( n = 1), and IV ( n = 3). Clinical improvement ( n = 7; 41%) or complete disappearance ( n = 6; 35%) of HE occurred in 76% of the patients, which is statistically significant ( P = .0002). No clear relation could be established between change in mental state regarding HE and any of the potentially influencing factors. Conclusions Management of TIPS-induced HE with use of the parallel technique is feasible and safe. It results in an increase of PSPG, which is associated with an improvement in neuropsychiatric status in most patients.

The purpose of this study was to retrospectively assess the technical and clinical outcomes, overall survival and prognostic factors for prolonged survival after yttrium-90 ((90)Y) radioembolization as a salvage therapy for patients with chemorefractory liver-only or liver-dominant colorectal metastases.From January 2005 to January 2014, all the patients selected for (90)Y radioembolization to treat chemorefractory colorectal liver metastases were identified. Demographic, laboratory, imaging and dosimetry data were collected. Post-treatment technical and clinical outcomes were analyzed as well as overall survival; finally several factors potentially influencing survival were analyzed.In total 88 patients were selected for angiographic workup; 71 patients (81%) finally underwent catheter-directed (90)Y microsphere infusion into the hepatic artery 25 days (standard deviation 13 days) after angiographic workup. Median infused activity was 1809 MBq; 30-day toxicity included: fatigue (n = 39; 55%), abdominal discomfort (n = 33; 47%), nausea (n = 5; 7%), fever (n = 14; 20%), diarrhea (n = 6; 9%), liver function abnormalities and elevated bilirubin (transient) (n = 3; 4%). Gastric ulcer was found in five patients (7%). A late complication was radioembolization-induced portal hypertension (REIPH) in three patients (4%). Median time to progression in the liver was 4.4 months. Estimated survival at six and 12 months was 65% and 30%, respectively, with a 50% estimated survival after 8.0 months in this group of chemorefractory patients. Prognostic factors for worse survival were high preprocedural bilirubin, alkaline phosphatase and tumor volume levels.(90)Y microsphere radioembolization for chemorefractory colorectal liver metastases has an acceptable safety profile with a 50% estimated survival after 8.0 months. Pretreatment high bilirubin, alkaline phosphatase and tumor volume levels were associated with early death.

TEVAR has replaced open surgical repair as preferred treatment for complicated acute type B aortic dissection. But the literature on thoracic endovascular aortic repair (TEVAR) for ruptured type B dissection is scarce. Patients with Turner syndrome are at risk for aortic dissection and rupture at a young age with an immediate mortality rate of 63%. Only a few cases have been described and the best treatment is not yet established. We present a case of a 49 year-old woman with Turner syndrome who suffered from a ruptured aortic dissection Stanford type B. A TEVAR procedure was performed, but the life of the patient could not be saved. In this case report we discuss the lessons we learned as well as some unsolved questions about TEVAR for ruptured type B aortic dissection.

Clinical trials have shown a beneficial effect of mechanical thrombectomy in acute ischemic stroke patients treated within six up to even 12 h after symptom onset. This treatment was already performed in selected hospitals in Belgium before completion of the randomized controlled trials. Outcome data on these procedures in Belgium have not been published. We performed a retrospective multicenter study of all patients with acute ischemic stroke treated with mechanical endovascular therapy in four hospitals in Belgium. Clinical outcomes, as measured by the modified Rankin Scale (mRS), site of arterial occlusion, reperfusion and the association between these variables were studied. The study included 80 patients: 65 patients with an occlusion in the anterior circulation and 15 with an occlusion in the posterior circulation. Good functional outcome (GFO) rates, defined as mRS 0-2 at 90 days, were 42 % in all patients, 44 % in anterior circulation stroke and 34 % in posterior circulation stroke. Reperfusion was achieved in 78 % of patients; more (100 %) in patients with posterior compared to patients with anterior circulation stroke (72 %; p = 0.02). The rate of GFO was greater in patients with reperfusion versus patients in whom reperfusion was not achieved (adjusted OR 8.2, 95 % CI 2.0-34.2). Symptomatic intracerebral hemorrhage was documented in 5 % of all patients. Endovascular treatment with mechanical devices for acute ischemic stroke in Belgium results in GFO and reperfusion rates similar to recently published results in the endovascular-treated arms of randomized clinical trials. Rates of symptomatic intracranial hemorrhage are low and comparable to other cohort studies and clinical trials. ispartof: Acta Neurologica Belgica vol:116 issue:1 pages:7-14 ispartof: location:Italy status: published

Background The purpose of the study was to find a relationship between the configuration of autogenous upper arm arteriovenous fistulas (AVFs) at the elbow and high access flow rates. Methods Forty-seven patients with well-functioning autogenous upper arm AVFs at the elbow were included. The configuration of the AVF and access flow rate was determined by duplex scanning. Results Hemodialysis access-induced distal ischemia scores and access flow rates were comparable in AVFs with 1 or 2 efferent veins (1829.9 ± 1121.3 mL/min, range [400–5000] vs. 1988.5 ± 1324.5 mL/min, range [130–5000]; P = 0.61). The basilic vein had statistically significant larger diameters than the cephalic vein (8.1 ± 2.7 mm, range [2.7–11.0] vs. 5.8 ± 2.5 mm, range [3.8–13.0]; P = 0.02), but no statistically significant difference in flow rates were observed (1884.5 ± 889.0 mL/min, range [824–3600] vs. 1130.0 ± 1258.4 mL/min, range [400–5000]; P = 0.53). Access flow rates were higher in AVFs with the brachial artery as afferent artery than when the radial artery was used (1909.5 ± 1273.2 mL/min, range [550–5000] vs. 1188.6 ± 642.7 mL/min, range [130–2800]; P = 0.02). Conclusions There is no difference in access flow rates in autogenous AVFs at the elbow with 1 or 2 efferent veins. Autogenous AVFs at the elbow on the radial artery have lower access flow rates than AVFs on the brachial artery.

We report a case of an unusual and late presentation of an asymptomatic contained rupture after modular stent-graft implantation to treat an aortobiiliac aneurysm. Follow-up computed tomography (CT) scans 4 and 5 years after endovascular aneurysm repair showed a homogeneous, nonenhancing, but clearly growing, pelvic collection. CT-guided drainage of the collection was performed, and cultures of the evacuated brown fluid were negative for any infection. Control CT scan after drainage showed a complete collapse of both the collection and the previously excluded iliac aneurysms. A direct communication between the sterile pelvic collection and the excluded iliac aneurysm was suggested on this CT imaging and confirmed afterwards by surgery. From these imaging and surgical findings, this pelvic collection can be considered as an atypical presentation of an asymptomatic contained rupture of the excluded aneurysm.

PURPOSE To evaluate the safety, feasibility, and clinical efficacy of percutaneous transhepatic injection of β-cell grafts in patients with type 1 diabetes mellitus. MATERIALS AND METHODS Between December 2001 and November 2003, 15 patients with C-peptide–negative type 1 diabetes underwent 31 percutaneous injections for intraportal implantation of β-cell grafts. Grafts consisted of cultured β-cell preparations as previously described. In 13 cases, the transplant procedure was done under sedation, whereas in 18 cases, general anesthesia was given. In all procedures, percutaneous access to the right portal vein occurred under ultrasound (US) guidance with use of a microbore puncture needle. The subsequent catheterization of the main portal vein was performed under fluoroscopic and angiographic control with use of a microbore delivery catheter and guide wire. Clinical, biochemical, and radiologic evaluation was performed before and after the procedure. RESULTS In all cases, it was possible to access the portal vein (median number of needle passes, 1; range, 1–6). The volume of cultured β-cell grafts injected for each transplantation averaged 0.58 mL (range, 0.26–1.60 mL) and the mean recorded procedure time (from puncture to catheter withdrawal) was 19 minutes (range, 10–80 min). Three patients presented with transient abdominal pain immediately after the procedure; postprocedural duplex US of the liver revealed a patent portal vein and end branches in all cases and a minor perihepatic fluid collection in another three patients. From the end of week 1 to week 3, a mean 3.8-fold increase in liver aminotransferase levels was measured in all recipients after the first implantation session. A similar increase was seen in only one patient after a second transplantation session. At 6 months after transplantation, 13 of 15 patients (86%) had a functioning graft with plasma C-peptide levels greater than 0.5 ng/mL. CONCLUSIONS The combined US, fluoroscopic, and angiographic monitoring of percutaneous transhepatic injection with use of a microbore delivery catheter is a safe and reproducible radiologic procedure for transplantation of -cell grafts in diabetic patients. Increased posttransplantation C-peptide levels, which demonstrate acceptable graft function, can be obtained.

The purpose of this study was to evaluate possible pain sensation differences in patients after retrograde varicocele embolization either with n-butyl-(2)-cyanoacrylate (NBCA) or with n-butyl-(2)-cyanoacrylate + methacryloxysulfolane (NBCA-MS). Transcatheter varicocele embolization was performed in 64 consecutive patients (62 left, two bilateral). Embolization was done with NBCA (n=32) or NBCA-MS (n=32). Immediately after the procedure, patients were asked to evaluate pain during embolization using a visual analog scale (VAS). Statistical analysis was done with Student's t test. Mean pain score on VAS was 3.23 (range: 0-8) for NBCA and 3.28 (range 0-9) for NBCA-MS. This difference was not significant (P=0.932). Independently of the type of glue, no difference in pain sensation (P value 0.421) was found between patients younger than 18 (n=29) and patients older than 18 years of age (n=35) (younger than18, mean 3.52; older than 18, mean 3.05). No difference in mean pain experience level (P=0.323) was seen in 11 patients with vessel wall perforation (23.4%) during the procedure (3.89; range: 0-8.5) in comparison with those without perforation (mean pain sensation level: 3.13; range: 0-9). No difference in pain experience was found after transcatheter varicocele embolization either with NBCA or NBCA-MS. Age and vessel wall perforation have no influence on pain sensation independently of the type of glue.