CVIR Endovascular最新文献

Background: Genicular artery embolization (GAE) is an emerging, minimally invasive therapy for refractory knee osteoarthritis (OA), targeting pathological synovial hypervascularization. While technically well established in typical anatomy, rare congenital anomalies such as popliteal artery (PA) agenesis present unique procedural challenges and demand careful adaptation of endovascular technique.

Case presentation: A 56-year-old woman with refractory right knee OA and polymyalgia rheumatica presented with persistent pain despite extensive medical and surgical therapies. Angiography revealed complete absence of the PA, with distal lower limb perfusion entirely maintained through a dense network of arterial anastomoses. Detailed angiographic assessment and superselective catheterization allowed targeted embolization of hypervascular synovial branches while preserving critical collaterals. The procedure was technically successful and uneventful, providing substantial pain relief within two weeks, maintained at 3, 6, and 12 months. At 18 months, symptoms recurred and repeat GAE was considered. However, the symptoms resolved spontaneously, and no further embolization was required. Only mild swelling on exertion persisted. At the two-year follow-up, the patient reported sustained pain relief without further interventions.

Conclusions: This case illustrates that GAE can be safely and effectively performed even in the presence of rare congenital vascular anomalies such as PA agenesis. Meticulous angiographic assessment, precise differentiation of synovial from distal perfusion territories, and a tailored embolization strategy are essential to achieve safe and durable outcomes in such anatomically challenging scenarios. This case report underscores the adaptability of endovascular techniques and expands the evidence base for GAE in patients with rare vascular variants.

Background: Portal vein (PV) stenosis (PVS) is a common issue after pediatric liver transplantation (LT) and may be associated with severe morbidity. The purpose of this retrospective matched cohort study was to compare graft and patient survival after percutaneous angioplasty (PTA) for PVS in pediatric patients under 7 years with a control cohort without PVS and a cohort with chronic portal vein thrombosis (PVT).

Methods: This study included 31 patients with PVS (intervention group) and 62 patients without PVS (control group). Furthermore, 9 patients with chronic PVT were evaluated (negative control group). Primary endpoints were graft and patient survival. Secondary endpoints were comparison of liver function and clinical course (signs of portal hypertension), procedure-related complications, and long-term patency after PTA.

Results: Graft survival was comparable between the intervention and control group (p = 0.380), with 7-year survival rates of 93% (95% confidence interval [CI]: 84%, 100%) and 88% (95% CI: 80%, 97%), respectively. Graft survival was significantly higher in the intervention group compared to the negative control group p = 0.032; 7-year graft survival was 75% (95% CI: 50%, 100%). Patient survival was significantly higher in the intervention group (p = 0.034), with a 100% 7-year survival rate (95% CI: 100%, 100%) compared to 86% (95% CI: 78%, 96%) in the control group. Survival was reduced in the negative control group compared to the intervention group (p = 0.053). Seven-year patient survival in the negative control group was 88% (95% CI: 67%, 100%). There was one minor procedure-related complication (1/31 [3%]); long-term patency was 100%.

Conclusions: Seven-year graft and patient survival after PTA for PVS were on par with that of patients without PVS. Graft survival was lower for patients with chronic PVT. Clinical course and liver function after PTA were comparable to patients without PVS. These findings, together with the low complication rate and high long-term patency, provide additional evidence supporting the efficacy of PTA in the management of PVS.

Background: After a gastric variceal rupture, clinical practice guidelines recommend either transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO) as interventional options for secondary prevention. This study aimed to generate and compare TIPS and BRTO costing data to calculate the secondary prevention cost following gastric variceal bleeding, to encourage consideration of resource cost within decision-making.

Methods: All costs were included for patients treated between 1 January 2017 and 1 January 2024. Data on procedure, non-procedure, and ward costs were collected. Ward costs were only calculated for elective admissions to reduce bias from inpatient emergency procedures. All costs were measured from a healthcare system perspective and included direct and indirect expenses where relevant. A 5% indexation for inflation was applied to non-fixed costs from 2017 to the 2024 cost year. The cost to prevent gastric re-bleeding was then calculated by adjusting the costing data generated based on existing outcome data in the literature, utilising the largest existing meta-analysis on the efficacy of TIPS and BRTO in preventing re-bleeding.

Results: There were 38 patients in the study cohort, with a mean age 56.8 years (SD 12.0), and 25 patients (66%) were male. TIPS was performed in 27 patients (71%). The TIPS and BRTO groups had similar mean age, proportion of male sex, CP grading, and proportions of elective admissions. The median total cost for TIPS was AUD$11,922 (range $6307-$53,432), while the median total cost for BRTO was AUD$3632 (range $1818-$5174), p < 0.001. The adjusted cost to prevent future gastric re-bleed using TIPS was AUD$14,803, while the cost to prevent re-bleed using BRTO was AUD$3896.

Conclusion: The cost magnitude of both TIPS and BRTO was both low in an Australian model, and both remain good options for patients. However, the use of BRTO was associated with significantly lower upfront procedural costs than for TIPS for secondary prevention of gastric variceal bleeding. Costs should form a key component of the value of IR to modern healthcare.

Purpose: To evaluate the safety and effectiveness of microfibrillar collagen paste (MCP), coils, and coils combined with gelatin sponge for transhepatic access tract embolization following portal vein islet cell transplant.

Methods: A retrospective review was conducted at a single institution between January 2008 and October 2024, including 20, 28, and 21 consecutive islet cell transplant procedures requiring transhepatic access embolization with MCP, coils, and coil plus gelatin sponge, respectively. All procedures were performed via a right portal vein branch. MCP was performed using Avitene (BD). The average number of coils required in the coil plus gelatin sponge and coil-only groups were 1.8 and 1.6 coils per procedure, respectively. All patients were placed on therapeutic anticoagulation during the procedure and for at least two weeks post-transplant. Medical records were reviewed to compare laboratory results, portal venous pressures, post-procedure liver ultrasounds, and 30-day hemorrhagic events across the three groups.

Results: All procedures were technically successful. However, one instance of coil migration into a portal vein branch occurred in the coil plus gelatin sponge group (1/28, 3.5%). Baseline hemoglobin, platelet counts, and partial thromboplastin time did not differ significantly between groups (p > 0.05). A statistically significant lower international normalized ratio (INR) was observed in the MCP group compared to the gelatin sponge and coil-only groups (1.0 vs. 1.1 vs. 1.1, p = 0.0036 and 0.004). No statistically significant differences were found in hemoglobin changes, post-transplant portal venous pressures, or post-embolization hemorrhagic events (p > 0.05). One patient in the coil plus gelatin sponge group developed a large subcapsular hematoma (1/27, 3.7%), while another in the MCP group experienced a large right hemothorax (1/20, 5.0%).

Conclusion: MCP, coils, and coil plus gelatin sponge are similarly effective for transhepatic access closure following islet cell transplant in anticoagulated patients. However, coil embolization may require multiple coils and carries a risk of migration.

Introduction: The field of interventional radiology (IR) has witnessed rapid advancements, with an increasing emphasis on complex and high-risk procedures. Increasingly, new IR treatments are becoming both available and indicated for patients with complex comorbidities. As a result, anaesthetic expertise has become essential to ensure patient safety, optimise procedural outcomes, and manage perioperative complications. Despite this growing demand, dedicated anaesthetic teams in IR remain limited, which leads to concerns regarding patient safety and procedural efficiency.

Methods: A comprehensive literature search was conducted across multiple databases, including PubMed, Embase, and the Cochrane Library, to identify studies published up to September 2024 that examined the expanding scope of IR, with a focus on the increasing need for anaesthetic support. This commentary draws on the existing literature to discuss the interaction between anaesthesia and interventional radiology, with particular attention to procedural sedation, pain management, and the care of high-risk patients. This commentary also evaluates workforce limitations, logistical challenges, and potential benefits of increased anaesthetic involvement in IR.

Findings: Existing literature demonstrates the significant benefits of anaesthetic involvement in IR. The presence of an anaesthesiologist was associated with reduced procedural risks, enhanced patient satisfaction, and quicker postoperative recovery times. Despite these benefits, many IR departments remain under-resourced in terms of dedicated anaesthetic staff. Furthermore, training programmes for anaesthesiologists rarely focus on the unique demands of IR, creating a gap in specialist care. The growing complexity and risk associated with IR procedures underscore the need for expanded anaesthetic support in this field. Hospitals and healthcare systems should prioritise the integration of anaesthetic teams into IR, investing in specialist training and workforce expansion. Doing so can improve patient outcomes and the overall efficiency of IR procedures, reducing procedural risks, increasing patient satisfaction, and facilitating quicker postoperative recovery times.

Background: Femoropopliteal diffuse calcified occlusions (FPDCOs) are challenging, especially in high-bleeding-risk patients for whom a stentless strategy is preferred. We introduce FRAP-CROSS, combining Fracking and Rendezvous-PIERCE, to achieve intracalcium guidewire crossing and facilitate stentless revascularization.

Materials and methods: When bidirectional intracalcium wiring fails across dense calcification in FPDCO, FRAP-CROSS is applied. Fracking is initially performed by inserting a 20-gauge metal needle into a guidewire-uncrossable plaque and applying hydraulic pressure to create microfractures, facilitating subsequent guidewire crossing. If device tracking remains unsuccessful after guidewire passage, Rendezvous-PIERCE is employed. An 18-gauge needle is advanced toward the intralesional guidewire tip, and the guidewire is externalized through the needle (Needle Rendezvous). A 20-gauge needle is then advanced over the externalized guidewire to create a lumen within the calcification (inner PIERCE). After successful all-intracalcium crossing, balloon angioplasty is performed. Inadequate expansion prompts additional Fracking alone or with Jetstream atherectomy (JET-Frack). Drug-coated balloon (DCB) angioplasty completes the stentless strategy.

Results: A 90-year-old man at high bleeding risk with bilateral FPDCOs underwent FRAP-CROSS. The right limb required three Fracking and two Rendezvous-PIERCE; the left required four Fracking and two Rendezvous-PIERCE, respectively, with adjunctive JET-Frack. Following DCB-based stentless treatment, final angiography and intravascular ultrasound confirmed adequate luminal expansion and blood flow in both limbs, without major complications.

Conclusion: FRAP-CROSS provides a practical approach to achieve all-intracalcium guidewire crossing and stentless revascularization in complex FPDCOs. Further studies should assess its safety and long-term outcomes.

Background: To assess how patients interpret and adhere to the International HHT Guidelines' recommendation to avoid intravenous (IV) air and to evaluate whether misinterpretation of this guidance as a strict requirement for in-line bubble filters may inadvertently hinder access to care. An anonymous 15-question survey was distributed to 7000 members of the HHT Research Network. The survey assessed awareness of the guideline, perceived necessity of bubble filter use, and the practical consequences of filter use. Responses were excluded if incomplete or submitted by individuals under 18 years old.

Results: Of the 596 responses received (9% response rate), 446 met inclusion criteria. Most respondents (79%) were aware of the guideline, and 66% interpreted it as requiring use of an IV bubble filter. Notably, 16% of respondents reported refusing care, and 25% reported delaying treatment-most often patient-initiated-due to perceived filter requirements. The interventions affected included essential and, in some cases, urgent care. In total, 20 respondents (4%) reported experiencing a transient ischemic attack (TIA) during IV therapy; two of these occurred despite filter use, and none resulted in permanent deficits. Patients who did not use filters were significantly less likely to report difficulty accessing care (p < 0.05).

Conclusions: Although the guideline advises caution in avoiding IV air, many patients interpret it as mandating bubble filter use. This misunderstanding has been linked to delays in necessary care, increased patient frustration, and limited treatment access. These findings underscore the importance of clearer communication and education around guideline intent to mitigate unintended consequences.