CVIR Endovascular最新文献

Background: Percutaneous endovascular repair (PEVAR) of infra-renal abdominal aortic aneurysms (AAA) is increasingly being performed due to the development of low profile endografts and the use of percutaneous closure devices. The feasibility and safety of the use of the INCRAFT AAA Stentgraft System and the ProGlide vascular closure system was assessed.

Methods: The PUCCINI trial prospectively enrolled patients undergoing elective repair of infrarenal AAA at 3 centres in the Netherlands and 3 centres in Belgium. Patients underwent PEVAR with endograft implantation followed by closure using the ProGlide closure device. Procedural success rates, complications and 30-day follow-up outcomes were collected.

Results: A total of 93 patients, 87% male, were enrolled. The mean aneurysmal diameter was 53.9 ± 10.2 mm. Successful ProGlide placement was achieved in 97.2% in the right and 89.8% in the left groin. Successful closure was achieved in 92.4% of right and 90% of left groins. One patient required surgical access and two surgical closure. Average blood loss was 155.6 ± 175.5ml. Blood transfusion was not required. Average length of hospital stay was 2.1 ± 1.3 days. Post-implantation endoleaks were present in 37 (40.2%) patients (type 1: 12, type 2: 25). At 30-days there was no aneurysmal growth and no deaths. Follow-up imaging showed endoleaks in 39 (41.9%) patients. (type 1:8, type 2:29, type 3:2).

Conclusion: The results from the PUCCINI trial demonstrate that the use of a low profile endoprosthesis for treatment of infrarenal AAA with percutaneous closure has a high rate of technical success and low rates of periprocedural complication.

Background: Macroscopic fat pulmonary embolism is extremely uncommon. Most cases occur in the context of fat grafting or long bone fractures. Macroscopic fat pulmonary embolism may be associated with cardiopulmonary compromise and is associated with high mortality. Mechanical thrombectomy is an emerging technique in interventional radiology, primarily investigated as a therapeutic approach for thrombotic pulmonary embolism.

Case presentation: We present a case report of a 73-year-old woman with macroscopic fat pulmonary embolism after a neck of femur fracture. Initially, she had severe circulatory shock, requiring multiple vasopressors and admission to the Intensive Care Unit. A percutaneous large-bore mechanical thrombectomy was performed, after which notable improvements to haemodynamic function and overall clinical trajectory were observed.

Conclusions: To our knowledge, this is the first report of mechanical thrombectomy in macroscopic fat pulmonary embolism. Further research is required to better delineate the role of mechanical thrombectomy in this rare condition.

Background: Classifying uterine fibroid using the International Federation of Gynecology and Obstetrics (FIGO) classification system assists treatment decision-making and planning. This study aimed to study whether different fibroid locations influence clinical outcomes following uterine artery embolization (UAE).

Methods: This is a retrospective cohort study of patients who underwent UAE for symptomatic uterine fibroid between December 2016 and January 2023 at our hospital. Changes in mean fibroid volume were compared based on MR images. Menstrual pain, excessive flow symptoms, and treatment satisfaction before UAE and 6 months after UAE were compared.

Results: A total of 149 premenopausal patients (mean age 45.7 ± 2.7 years) were included for analysis (FIGO 2/3, n = 57; FIGO 4-7, n = 92). Baseline menstrual pain, fibroid, and uterine volume before UAE were comparable between the two FIGO groups (p > 0.05). The menstrual flow index was higher for the FIGO 2/3 group (mean ± SD [min-max]: 9.4 ± 1.4 [4-10] vs 8.0 ± 2.3 [0-10], p < 0.001). Six months after UAE, the improvements in menstrual flow index (mean ± SD]: -3.7 ± 2.6 vs -2.6 ± 2.2, p = 0.035), fibroid volume (mean ± SD: -54.7 ± 21.7% vs -39.8 ± 16.2%, p < 0.001), and uterine volume (mean ± SD: -38.2 ± 16.3% vs -31.1 ± 11.6%, p = 0.008) in the FIGO 2/3 group were significantly higher than the FIGO 4-7 group. Both groups had comparable improvements in menstrual pain index (-2.1 ± 2.6 vs -1.8 ± 2.5, p = 0.008) and 88% of the patients were satisfied or very satisfied overall.

Conclusion: UAE treatment satisfaction was high for patients with fibroids at different FIGO stages. UAE treatment outcomes were better for patients with fibroids affecting the endometrium (FIGO 2/3).

Level of evidence: 3B, Retrospective observational study.

Background: Uterine fibroid embolization can be associated with significant pain due to fibroid ischemia and interventions of the procedure itself. Fentanyl and midazolam are commonly provided for sedation and pain relief, but are not tolerated by all patients. This report outlines a novel pain management strategy for uterine fibroid embolization in a patient who could not receive either opioids or benzodiazepines.

Methods: A 51 year old woman presenting with menorrhagia due to uterine fibroids was referred to interventional radiology for embolization. She was allergic to most opiates and had previously become agitated with IV midazolam, resulting in termination of a previous attempt at embolization. Thus, a combination of three analgesic modalities was used: intraarterial ropivacaine in the uterine arteries, superior hypogastric nerve block with ropivacaine, and intravenous acetaminophen. The patient underwent successful embolization and reported only intermittent pain of 1-2 out of 10 intensity.

Discussion: This combined analgesic cocktail represents a novel alternative to traditional sedation for uterine fibroid embolization and may serve as a viable option for patients with similar contraindications.

Purpose: To evaluate outcomes in patients aged ≥ 80 years following large-bore aspiration thrombectomy (LBAT) for the treatment of pulmonary embolism (PE).

Materials and methods: All patients ≥ 80 years of age with PE treated via LBAT at a single center were analyzed from September 2019 - August 2024. This included the octogenarian subgroup from a recently published retrospective analysis assessing all PE patients treated with LBAT at our center between September 2019 and January 2023. The following outcomes were evaluated: technical success, change in several hemodynamic measures including pulmonary artery pressure (PAP) and right ventricle to left ventricle ratio (RV to LV ratio), length of hospital and intensive-care-unit (ICU) stay, procedure-related complications, and 7- and 30-day mortality.

Results: Forty-eight patients aged ≥ 80 years underwent LBAT procedures for PE. Technical success was achieved in 46 cases (95.8%). The mean reduction in mean PAP was 3.6 mmHg. The mean reduction in RV to LV ratio was -0.42. The mean length of postprocedural hospital and ICU stays were 5.7 ± 3.6 days and 1.0 ± 1.6 days, respectively. There were 2 procedural complications, 1 pulmonary vascular injury involving a pulmonary artery pseudoaneurysm and 1 decompensation involving hypotension requiring vasopressor support. There were no major bleeding complications or cardiac injuries. All-cause mortality was 2.1% (n = 1) at 7 days and 6.3% (n = 3) at 30 days post procedure. PE-related mortality was 2.1% (n = 1) at 30 days.

Conclusion: LBAT is a technically feasible procedure for the treatment of PE in octogenarian patients and has a favorable preliminary safety and mortality profile.

Purpose: To evaluate access site adverse events following ClotTriever-mediated large-bore mechanical thrombectomy via small upper extremity deep veins (< 6-mm).

Materials and methods: Twenty patients, including 24 upper extremity venous access sites, underwent ClotTriever-mediated large-bore thrombectomy of the upper extremity and thoracic central veins for symptomatic deep vein obstruction unresponsive to anticoagulation. Patients without follow-up venous duplex examinations (n = 3) were excluded. Patients who had > 6-mm diameter veins accessed (n = 3) were excluded. Temporary purse-string sutures and manual pressure were used for access site hemostasis in all patients. Vein access site and diameter, technical success (defined as placement of the 13.5-French ClotTriever sheath followed by thrombectomy), and early (< 30-days) and late (> 30-days) access site-related adverse events (according to the Adverse Event Classification by the Society of Interventional Radiology criteria) were recorded.

Results: Fourteen patients (8 males, 6 females; mean age 51.7 ± 13.6 years) comprising 16 upper extremity venous access sites were included in this study. Access sites included: right brachial (n = 7), left brachial (n = 5), and bilateral brachial (n = 2) veins. The mean access site diameter was 4.3-mm ± 0.67-mm. Technical success was achieved via all access sites. Six (42.9%) patients underwent stent reconstruction following thrombectomy through the same accesses. After the procedure, all purse-string sutures were removed within 24 h. Three (21.4%) patients experienced small access site hematomas that did not require transfusion, intervention, or prolonged hospitalization. Initial follow-up venous duplex ultrasounds were performed at 29.3 ± 21.7 days following intervention. The mean follow-up interval to the second and third venous duplex ultrasounds were 124.3 ± 64-days and 225.1 ± 80.1 days, respectively. One (7.1%) patient developed right arm swelling six days after the procedure and was found to have thrombosis of the previously accessed right brachial vein. No other clinically or sonographically significant access site adverse events were observed.

Conclusion: ClotTriever-mediated large-bore thrombectomy via small upper extremity veins is safe with minimal access site adverse events.

Background: Lymphatic leaks are associated with significant mortality and morbidity. Intranodal lymphangiography (ILAG) involves the direct injection of ethiodised lipid into the hilum of lymph nodes. It is diagnostic procedure that can have therapeutic effects secondary to a local sclerosant effect. The aim of the study is to describe the technical and clinical success of ILAG and adjunctive lymphatic interventions performed as first line interventional techniques for lymphatic leaks refractory to conservative and medical management in a multicentre cohort of patients with symptomatic large volume lymphatic leaks.

Methods: Multicentre retrospective study of all lymphatic interventions performed between 2017-2023 in patients with large volume lymphatic leaks (> 500 ml a day). Intranodal lymphangiography was performed initially with technical success defined as opacification of the lymphatics at the aortic bifurcation and demonstration of lymphatic leak on the index ILAG procedure or immediate post procedural CT was recorded. Lymphatic embolisation was performed with a combination of direct puncture or transvenous cannulation with glue and or coil embolisation of the thoracic duct or leak point and in cases with refractory leak. Clinical success was defined as reduction in drain output to less than 20 mL per 24 h, or no further insensible lymph leak. Time to clinical success after ILAG and adjunctive embolisation was recorded.

Results: ILAG alone lead to clinical success in 14 of 32 (44%) patients after a median of 14 days. Subsequent embolisation was performed in 12 refractory cases; this was successful in 8 (67%) at median of 8 days. Overall clinical success of all lymphatic interventions was 69% (22 of 32 patients) at a median of 11 days (IQR 5-34). No statistically significant correlation between the site of leakage, aetiology or embolisation technique correlated with clinical success. Decision to proceed to repeat ILAG or an adjunct procedure was made on a clinical basis, following multidisciplinary discussion.

Conclusions: ILAG can be employed a first line interventional therapeutic technique to treat clinically significant lymphatic leaks that are refractory to conservative and medical management. Adjunctive procedures, including embolisation, can be considered as part of clinical decision making after a period of 1-2 weeks' watchful waiting in continuingly refractory cases.

Background: Hepatic artery infusion pump (HAIP) chemotherapy is a locoregional treatment for intrahepatic malignancies. HAIPs are surgically implanted, and the catheter tip is typically inserted into a ligated gastroduodenal artery stump. Potential complications at the catheter insertion site include dehiscence, pseudoaneurysm or extravasation, and adjacent hepatic arterial stenosis and thrombosis. Bleeding complications can be treated with stent-graft placement or coil embolization across the injury site, typically with standard antegrade arterial approach into the hepatic arterial system by transfemoral or transradial access. However, in cases where an antegrade approach is not possible, alternative methods are necessary.

Case presentation: A patient presented with an enlarging hematoma due to bleeding at the gastroduodenal artery HAIP catheter insertion site. Emergent angiography revealed concomitant common hepatic artery occlusion and retrograde perfusion of the GDA via tortuous, diminutive hepatic collaterals which precluded standard antegrade approach. Collateral inflow from the dorsal pancreatic artery was utilized to opacify the right hepatic artery. The segment 5 hepatic artery was percutaneously accessed under fluoroscopic guidance, and microcoils were deployed both proximal and distal to origin of the gastroduodenal artery. The patient remained stable throughout the postoperative period and was discharged after an otherwise uneventful admission. Follow-up computed tomography demonstrated resolution of the hematoma and no bleeding or biliary complication from transhepatic access.

Conclusions: This report highlights the safety and efficacy of percutaneous transhepatic arterial access for endovascular management of HAIP associated bleeding at the gastroduodenal artery when standard antegrade interventions cannot be performed. Interventional radiologists caring for patients with HAIPs should be familiar with their potential complications and the range of techniques required for management.

Objective: To evaluate the safety and efficacy of chocolate balloons in patients with chronic limb-threatening ischemia (CLTI) and infrapopliteal artery disease, and compare them with conventional balloons.

Methods: This single-center retrospective study included 167 patients with CLTI and infrapopliteal who underwent endovascular intervention with or without chocolate balloons from September 1, 2019 to June 30, 2023. The primary endpoint was amputation-free survival (AFS). Secondary endpoints included major amputation, the absence of clinically driven target lesion revascularization (CD-TLR), the incidence of flow-limiting dissection, below-the-knee (BTK) stent implantation, change in Rutherford clinical grade, procedural success, and major adverse cardiovascular events (MACEs). Patients were followed at 30 days, 6 months, and 12 months to assess symptom improvement, vascular patency as determined by dual-function ultrasound or angiography, and survival.

Results: At 12 months, AFS was noted in 78.1% of patients in chocolate balloon group and 70.7% of those in conventional balloon group (p = 0.37). The chocolate balloon group demonstrated a significantly higher rate of CD-TLR absence, with 84.0% compared to 69.4% in the conventional balloon group (p = 0.04). The chocolate balloon group had a major amputation-free rate of 92.8%, slightly better than the 89.5% in the conventional balloon group (p = 0.58). Notably, the chocolate balloon group significantly reduced flow-limiting dissection (p = 0.02) and BTK stent implantation (p = 0.03) compared to the conventional balloon group.

Conclusion: Chocolate balloon reduces the incidence of flow-limiting dissection and BTK stent implantation in patients with CLTI and infrapopliteal. Compared with conventional balloons, there was less lesion revascularization at 12 months, but no significant benefit was found in improving ASF and reducing major amputation of the affected limb.