CVIR Endovascular最新文献

Pulmonary sequestration (PS) is the second most common pulmonary congenital malformation, which involves non-functional lung tissue that lacks communication with the tracheobronchial tree and is supplied by aberrant systemic arteries, with venous drainage to either the pulmonary or systemic venous system. This anatomic malformation increases patients' risk of recurrent infection due to the lack of robust gas exchange. Hence, prompt intervention is warranted for favourable outcomes. Surgical resection is the gold standard treatment for PS. However, embolization of aberrant arteries prior to surgery is a promising adjunct to reduce the risk of intraoperative hemorrhage associated with the aberrant arterial supply. Here we report a case of a 47-year-old man with suspected symptomatic extralobar sequestration dual feeders from a subclavian common trunk with an anomalous pulmonary arterial connection. The patient underwent preoperative embolization of feeding and draining vessels using low-profile plug occluders. The patient tolerated embolization and surgical resection with < 50 ml blood loss. Two-month post-operative imaging demonstrated the stable position of plug occluders. This case highlights the role of preoperative embolization with low-profile plug occluders as a safe and effective strategy for achieving hemodynamic control and minimizing intraoperative bleeding risk in anatomically complex pulmonary sequestrations.

Background: To evaluate outcomes of Castor single-branched stent graft combined with in situ fenestration of the left subclavian artery for aortic arch disease.

Methods: A retrospective analysis of 30 patients undergoing TEVAR with Castor stent that was first implanted with the branch in the left common carotid artery (LCCA) followed by in situ fenestration of the left subclavian (LSA) between March 2022 and March 2024 was conducted. Perioperative and follow-up data were collected and analyzed.

Results: The study retrospective analysis of 30 patients comprised 16 (53.3%) with acute type B aortic dissections, 6 (20%) with thoracic aortic aneurysms, 2 (6.7%) with intramural hematoma, and 6 (20%) with penetrating aortic ulceration. The technical success rate was 96.7% (29/30). One patient required carotid-axillary bypass due to subclavian artery lateral wall opening. There were no cases of mortality, stroke, upper limb ischemia, paraplegia, or stent graft-induced new entry within the 30-day follow-up period. Median hospitalization was 11 (IQR, 9-14) days, with a median follow-up of 12 (IQR, 8-19) months. One patient (3.3%) suffered a fall-related cerebral hemorrhage unrelated to the procedure. Another (3.3%) developed left upper limb ischemia due to stent angulation, corrected with a cover stent. Subclavian artery patency was 96.6% (28/29), and carotid artery patency was 100%. No deaths, endoleaks, or stent migrations occurred.

Conclusion: The Castor stent combined with in situ fenestration is a feasible, effective, and safe strategy for aortic arch disease repair, especially in providing alternative approaches for aortic diseases that require reconstruction in both branches.

Background: Consistent with global trends, the incidence of placenta accreta spectrum (PAS) is increasing in Australia. Prophylactic internal iliac arterial balloon occlusion (PIIABO) is an endovascular intervention utilised to assist haemorrhage control during caesarean delivery in women with PAS, offering a potentially uterus-preserving alternative to hysterectomy. However, existing outcomes remain heterogeneous. This study aimed to evaluate the endovascular safety of PIIABO with immediate sheath removal in the management of PAS, with a secondary assessment of haemostatic and procedural outcomes.

Materials and methods: A 10-year retrospective, single-centre cohort study of all patients with suspected PAS who underwent PIIABO was conducted with data obtained from electronic medical records and Radiology Information System (RIS)/Picture Archiving and Communication System (PACS).

Results: Fifteen patients underwent PIIABO. The mean maternal age was 34.1 years, with a mean gravidity of 4.2 and a parity of 2.3; all had prior caesarean delivery and 93% had concurrent major placenta praevia (n = 14). Mean gestational age at delivery was 34.9 weeks. Diagnosis was established by MRI (n = 11, 87.5% concordance) and ultrasound (n = 4, 50% concordance). Twelve patients underwent hysterectomy, confirming 1 accreta, 3 increta, and 8 percreta; 3 patients preserved uterus, with intraoperative evidence of percreta (n = 2) or normal placentation (n = 1). Mean estimated blood loss was 2273 mL, and 11 patients received blood transfusions, including four who required ≥ 4 units of packed red blood cells. Mean balloon inflation time was 129.9 min, sheath dwell time 265.5 min, and operating theatre time 265.7 min. Mean dose-area product was 55.03 Gy.cm² with a mean fluoroscopy time of 10.7 min. Radiation exposure decreased by approximately 90% over the study period with increasing institutional experience. No endovascular complications or reinterventions occurred, and all mothers and neonates were discharged without long-term morbidity.

Conclusion: PIIABO with immediate sheath removal demonstrated favourable procedural outcomes and a low complication rate in patients with PAS, supporting its safe implementation within a multidisciplinary care pathway.

Background: Pelvic and groin lymphoceles and lymphatic leaks remain challenging postsurgical complications. Ethiodized-oil (lipiodol) lymphangiography has been increasingly utilized as a combined diagnostic and therapeutic modality, but published experience with lipiodol-only management in this setting is limited. While transnodal glue embolization is well established, evidence on its long-term outcomes and safety profile remains sparse, with particular concerns regarding the potential risk of lymphedema. These gaps highlight the need for further evaluation of lymphangiography alone as a minimally invasive treatment option.

Materials and methods: This retrospective study included patients who underwent lymphangiography between January 2019 and March 2023 for persistent symptomatic pelvic lymphoceles or groin lymphatic leaks. Imaging findings, drain output, prior interventions, and clinical outcomes were reviewed. Technical success was defined as adequate visualization of the targeted lymphatic vessels. Clinical success was defined as resolution or minimal residual leak without need for further treatment.

Results: Ten patients (5 males, median age, 69 years) underwent lymphangiography for pelvic lymphoceles (n = 7) or groin lymphatic leaks (n = 3). The median interval from surgery to INL was 67.5 days (range, 12-108). Three patients had previously undergone surgical interventions, and four patients had undergone sclerotherapy without clinical improvement before INL was performed. Technical success was achieved in all patients (100%) with identification of lymphatic leak in all patients. Clinical success was achieved in 7 patients (70%) following lymphangiography alone, with a median time to resolution of 5.5 days (range, 5-12 days) and no immediate adverse events.

Conclusions: Lymphangiography using ethiodized oil contrast is a safe, and potentially effective minimally invasive treatment for pelvic and groin lymphatic leaks. These findings support a stepwise management approach, using lymphangiography as a first-line intervention before escalating to intranodal glue embolization.

Purpose: Removal of an adhered indwelling catheter in a totally implantable venous access device (TIVAD) can occasionally be challenging, particularly after prolonged implantation. The purpose of this paper is to present a modified endovascular technique for difficult TIVAD removal and to highlight its clinical relevance in cases where the catheter is firmly adhered to the vessel wall, making standard removal methods challenging.

Materials and methods: Between December 2015 and April 2025, a total of 3347 TIVADs were implanted, and 367 removal procedures were conducted. Among these, 355 (96.7%) catheters were successfully removed using the standard technique. Three (0.8%) were removed using the push-in techniques, and one (0.3%) was removed using the contralateral pull-through combined with the sheath-twist technique. In 8 (2.2%), the ipsilateral pull-through technique was required after failure of the initial approaches. The ipsilateral pull-through technique was performed using an introducer sheath and a handmade loop-snare constructed from a guidewire and a seeking catheter. Patient characteristics and procedural data were collected for analysis.

Results: The ipsilateral pull-through technique was successfully used to remove difficult-to-remove TIVADs in 7 of 8 patients. In the remaining patient, the indwelling catheter was firmly adhered to the segment extending from the innominate vein to the superior vena cava, where antegrade flow was absent and numerous collateral vessels were present. Although the occlusion was successfully crossed, catheter removal was aborted due to severe pain and concerns about potential superior vena cava rupture. One procedure-related complication was observed: catheter fracture on follow-up computed tomography in one of the seven successful cases. No other complications were observed. The subclavian vein, innominate vein, and superior vena cava were patent on follow-up computed tomography performed for cancer evaluation. The median indwelling duration in this cohort was 2473 days (interquartile range [IQR], 2017-3002 days), and the median procedure time was 60 min (IQR, 45.8-74.8 min).

Conclusion: The ipsilateral pull-through technique is a useful method to detach adhered catheters during difficult TIVAD removal.

Level of evidence: Level 3, Retrospective Study.

Background: This report describes an embolization technique using a steerable sheath and an Amplatzer vascular plug 2 (AVP 2) to treat a wide-necked aneurysm located at the ostium of the renal artery. Given this particular location, directly attached to the aortic wall, similar to a saccular aneurysm of the abdominal aorta, stent placement or embolization using coils or liquid agents was not feasible.

Case presentation: A 45-year-old patient with a long medical history including heterozygous SC sickle cell disease, systemic lupus erythematosus, and a left iliac fossa kidney transplant presented with a partially thrombosed right renal artery aneurysm of 45-mm diameter. The aneurysm was located at the ostium of the renal artery that was occluded downstream. The aneurysm was directly attached to the aortic wall with a wide neck measured at 8 mm. Use of coils or liquid agents was not possible because of a very high risk of extra-target embolization. Lack of a patent right renal artery downstream precluded placement of a covered stent. Following multidisciplinary discussion, and due to the patient's high risk for aortic abdominal surgery, endovascular management with embolization was decided. Embolization was performed under local anesthesia, using fluoroscopic guidance and a cone-beam computed tomography three-dimensional road map. Following common right femoral artery access, a 7F steerable sheath was used to catheterize the aneurysm. An AVP 2 was then passed through the sheath in the aneurysm. Particular attention was paid to deploying the last disc of the AVP 2 in the aortic lumen to ensure closure of the aneurysm neck. Final aortic angiogram confirmed exclusion of the aneurysm. There were no intraoperative or postoperative complications. At computed tomography performed 7 months later, the AVP 2 remained in position, and the aneurysm was excluded and partially decreased in size.

Conclusions: In an anatomical presentation that was not a candidate for stent placement or classic embolization techniques, deployment of an AVP 2 using a steerable sheath successfully excluded the aneurysm. This procedure, performed under local anesthesia, obviated the need for abdominal aortic surgical repair or for an aortic stent graft.

Background: Intravascular lithotripsy (IVL) is an emerging technique for modifying heavily calcified arterial lesions, with primary application in peripheral arteries. We report the use of IVL for lesion preparation prior to stenting in a patient with severely calcified superior mesenteric artery (SMA) stenosis.

Case presentation: A 66-year-old man with type I adenocarcinoma of the esophagogastric junction (AEG Type I) and neoadjuvant FLOT chemotherapy was scheduled for Ivor Lewis esophagectomy. Preoperative CT angiography (CTA) revealed a high-grade ostial SMA stenosis due to extensive atherosclerotic calcification. To mitigate the risk of postoperative mesenteric hypoperfusion, percutaneous endovascular revascularization was performed. Following initial predilatation, IVL using a Shockwave 5.5 × 60 mm balloon catheter was employed for lesion preparation. Subsequently, an 8.0 × 24 mm balloon-expandable stent was successfully deployed with low-grade residual stenosis and no complications.

Conclusion: This case demonstrates that IVL represents a feasible and effective adjunct in the management of severely calcified visceral arterial lesions. It facilitates adequate lesion preparation and enables full stent expansion, even when the IVL balloon diameter is notably smaller than the stent diameter. This potentially represents a less traumatic approach to the vessel than alternative techniques. IVL may therefore be considered a therapeutic option in selected patients.

Background: This study evaluates the current evidence on the use of cone-beam computed tomography (CBCT) combined with advanced planning and guidance (APG) software in transarterial embolization for acute hemorrhage and reviews our institution's preliminary experience of use in emergency settings.

Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Embase were searched to identify studies using CBCT with software for transarterial embolization of hemorrhage. Inclusion criteria focused on studies utilizing CBCT and APG software for hemorrhage management, with data extracted on demographics, hemorrhage locations, equipment/software specifications, technical success and procedural metrics. Additionally, we report a single-center review of patient outcomes using CBCT with multi-organ APG software (EmboASSIST with Virtual Injection, GE HealthCare, Chicago, IL, USA).

Results: Nine studies met the inclusion criteria, including 71 patients. The most common site of bleeding was the lower gastrointestinal (GI) tract (62%). The mean technical success rate of embolization utilizing CBCT with APG was 94.3% (range: 82-100%). Three studies reported procedure time (mean 98.9 min, range 50-146 min), and two studies reported fluoroscopy time (mean 27.1 min, range 25-29.1 min). In our initial experience, all six cases were technically successful with favorable outcomes.

Conclusions: CBCT with APG software is a feasible and effective tool for hemorrhage embolization in emergency settings. Its potential ability to improve bleeding detection compared to digital subtraction angiography (DSA) may lead to reduced procedure time, lower radiation exposure, and enhanced patient outcomes.

Systematic review registration: NIHR-PROSPERO CRD 42024619227.