Anna Maria Belli

Internal Iliac Artery Embolization with Bilateral Occlusion before Endovascular Aortoiliac Aneurysm Repair—Clinical Outcome of Simultaneous and Sequential Intervention

PURPOSEnTo retrospectively evaluate the clinical outcome of patients after simultaneous or sequential internal iliac artery (IIA) embolization for bilateral IIA occlusion.nnnMATERIALS AND METHODSnSixteen patients (65-88 y; mean, 75.6 y; two women), 11 with aortobiiliac aneurysms, three with bilateral common iliac artery (CIA)/IIA aneurysms, and two with unilateral CIA/IIA aneurysms, underwent IIA occlusion before endovascular aortoiliac repair. Eight patients underwent simultaneous bilateral IIA embolization before endovascular aortic repair (EVAR). Eight patients had sequential bilateral IIA occlusion. The outcome was assessed by clinical follow-up.nnnRESULTSnThere were no severe ischemic complications such as buttock necrosis or acute bowel, bladder, or spinal cord ischemia. Early ischemic complications occurred in 25% (buttock/thigh claudication, n = 3, 18.8%; and sexual dysfunction, n = 1, 6.2%) and had an onset not later than 6 months after intervention: buttock claudication resolved (n = 2) or persisted after aggravation by inferior mesenteric artery embolization for type II endoleak (n = 1). Impotence in a fourth patient persisted. The ischemic complication rate after 6 months was 30% (three of 10) because of a fifth patient who developed ischemic colitis with aggravation of ischemic heart disease after 15 months. The mean follow-up duration was 19.7 months. Patients with simultaneous embolization had a lower complication rate than those with sequential embolization (one of eight [12.5%] vs four of eight [50%], respectively).nnnCONCLUSIONSnIIA embolization for bilateral IIA occlusion can be performed with a complication rate comparable with results of previous studies of unilateral IIA embolization. Chronic buttock claudication may be aggravated by embolization of aortic side branches. Late complications can have an insidious course and be initiated by low-output cardiac failure. Bilateral IIA occlusion is recommended only in patients who are considered unfit for aortic surgery.

Giant high-flow renal arteriovenous fistula treated by percutaneous embolization

We report the case of a giant renal arteriovenous fistula after renal biopsy in a 30-year-old man with hematuria and hypertension. We performed percutaneous endovascular embolization using macrocoils to exclude the fistula. The patient made an uneventful recovery with no further hematuria and progressive reduction of blood pressure. Follow-up by digital subtraction angiography (DSA) at 6 months showed complete occlusion of the fistula with no evidence of renal parenchymal infarction. Although giant renal arteriovenous fistulas are generally treated by nephrectomy, this case shows that embolization is a reasonable alternative to surgery.

The Provision of Interventional Radiology Services in Europe: CIRSE Recommendations

Interventional Radiology (IR) is an essential part of modern medicine, delivering minimally invasive patient-focused care, which has been proven to be safe and effective in both elective and emergency settings. The aim of this document is to outline the core requirements and standards for the provision of Interventional Radiological services, including training, certification, manpower, and accreditation. The ultimate challenge will be the adoption of these recommendations by different countries and health economies around the world, in turn ensuring equal access to IR treatments for all patients, the appropriate distribution of resources for IR service provision as well as the continued development of safe and high-quality IR services in Europe and beyond.

Preliminary experience with cutting balloon angioplasty for iliac artery in-stent restenosis.

Purpose: To report our preliminary experience using cutting balloon angioplasty (CBA) in symptomatic iliac artery in-stent restenosis (ISR). Methods: Fourteen cases of hemodynamically significant iliac artery ISR (4 common and 10 external) were treated in 12 men (mean age 64 years, range 55–75). Of the 14 stents involved, 8 were balloon-expandable models and 6 were self-expanding. All patients had symptomatic deterioration of at least 1 clinical category over an average period of 50.2 months (range 6–120) post stenting. The mean length of ISR was 11.9 mm (range 2–48), and the average stenosis was 75.4% (range 52%–98%). Nine ISR lesions were focal (<10 mm), 4 were diffuse (>10 mm), and 1 extended outside the stent margins. Results: CBA was performed after conventional angioplasty failure in 7 lesions and as a primary treatment method in 7 lesions. Single (9 focal lesions) or multiple overlapping (5 diffuse or proliferative lesions) inflations were performed using 6-×10-mm (1 lesion), 7-×10-mm (3 lesions), and 8-×10-mm (10 lesions) devices. There was 1 contained rupture treated with a covered stent. In the remainder of the cases, the cutting balloons allowed successful treatment without further stent implantation. During a mean follow-up of 23.6 months (range 12–60), no patient showed clinical deterioration, and no recurrent ISR was detected with color duplex. Conclusion: CBA shows high immediate technical and midterm clinical success in symptomatic iliac artery ISR.

Laceration of the Common Femoral Artery Following Deployment of the StarClose™ Vascular Closure System

StarClose is a novel arterial closure device which achieves hemostasis, following arteriotomy, via a nitinol clip deployed on the outer arterial wall. Since its introduction to the market, several studies have shown StarClose to be both safe and effective, with few major complications encountered. We report a case of common femoral artery laceration following deployment of the StarClose vascular closure system. We conclude that the injury occurred secondary to intravascular misplacement of the nitinol clip.

Cardiovascular and Interventional Radiological Society of Europe (CIRSE) position statement on renal denervation for resistant hypertension.

Hypertension is a major global healthcare challenge now recognised as the leading cause of mortality across the developed and developing world (1). Resistant hyperten- sion (systolic BP (140 mmHg on three or more medica- tions) makes up a significant minority of this group (5-15 %) and is associated with a considerably increased risk of cardiovascular events. Renal denervation (RDN) is emerging as a significant step forward in the treatment of patients with resistant hypertension. The publication of the Symplicity I and II trials has firmly established the pro- cedure with both proof of principle and short-term efficacy using randomised controlled trial methodology (2-4). Who is Eligible for RDN? At present the evidence only supports its use in resistant hypertension. This was defined in the trials as a clinic systolic blood pressure C160 mmHg (C150 mmHg in type 2 diabetes) on three or more antihypertensive medica- tions. Ideally, this should be supported with ambulatory blood pressure measurements to exclude the white coat phenomenon. In the trials, patients were excluded if the estimated GFR 45 ml/min/1.73 m 2 and local protocols should be in place if patients with an eGFR 45 ml/min/1.73 m 2 are to be treated.

Ruptured suprarenal artery aneurysm: Angiographic diagnosis and treatment by selective embolization

The case of a 78-year-old man with retroperitoneal hemorrhage due to a ruptured right inferior suprarenal artery aneurysm is presented. The diagnosis was made by angiography which allowed immediate embolization of the neck of the aneurysm, controlling hemorrhage and obviating the need for surgery. The patient made a full recovery with no evidence of further hemorrhage.

Executive summary of the joint position paper on renal denervation of the Cardiovascular and Interventional Radiological Society of Europe and the European Society of Hypertension

Renal denervation (RDN) was reported as a novel exciting treatment for resistant hypertension in 2009. An initial randomized trial supported its efficacy and the technique gained rapid acceptance across the globe. However, a subsequent large blinded, sham arm randomized trial conducted in the USA (to gain Food and Drug Administration approval) failed to achieve its primary efficacy end point in reducing office blood pressure at 6 months. Published in 2014 this trial received both widespread praise and criticism. RDN has effectively stopped out with clinical trials pending further evidence. This joint consensus document representing the European Society of Hypertension and the Cardiovascular and Radiological Society of Europe attempts to distill the current evidence and provide future direction and guidance.

Interventional Radiology Leads the Top-Cited Radiology Literature of the Last 67 Years

In a recent paper published in the American Journal of Radiology, Yoon et al. [1] analyzed the radiological literature from 1945 to 2012 to identify and characterize the 100 top-cited articles published in radiology journals, thus providing insight into the evolution of radiology during the last 60 years and defining researchers who have made outstanding contributions in the field. Using the Science Citation Index Expanded (1945–2012) database, they searched for the 100 top-cited articles published in 12 leading radiology journals, which included the ten journals with the highest impact factor (IF; Radiology with an IF of 6.069, Investigative Radiology with an IF of 4.670, European Radiology with an IF of 3.594, American Journal of Neuroradiology with an IF of 3.464, European Journal of Radiology with an IF of 2.941, Neuroradiology with an IF of 2.870, American Journal of Roengenology with an IF of 2.797, RadioGraphics with an IF of 2.760, Academic Radiology with an IF of 2.195, and Radiologic Clinics of North America with an IF of 2.163) as well as two journals of historical value—Acta Radiologica and British Journal of Radiology—which were published for the first time in 1921 and 1928, respectively. Of note, neither of these was a journal specifically dedicated to interventional radiology (IR). Selected articles were than analyzed according to number of citations, year of publication, publishing journal, authorship, institution and country of origin, type of article, radiological subspecialty, main topic, and radiological technique. We were pleased to read that IR was the most represented radiological subspecialty with 19 papers in the 100 top-cited articles followed by neuroradiology with 15 articles and breast imaging with 11 articles. This result is of great importance for our discipline because it highlights the value of IR in the ‘‘mainly diagnostic’’ radiological world. Moreover, the most common topic covered in the 100 top-cited articles was also in the interventional field because radiofrequency ablation of hepatic tumors was the topic of nine articles followed by the receiver operator characteristic curve with six articles and magnetic resonance imaging of the breast with four articles. In the list of the 12 ‘‘frequent authors’’ who contributed three or more of the top-cited articles, seven were interventional radiologists, and, notably, the first three positions were attributed to interventional radiologists. In the analysis by country of origin, the United States contributed 57 of the 100 top-cited articles followed by European countries, which contributed 36 of the top-cited articles. The highest from Europe were Italy with ten articles and Germany with nine articles. This article not only highlights the overwhelming importance of IR in the radiological world and the G. Mauri (&) Servizio di Radiologia, IRCCS Policlinico San Donato, Piazza Malan 2, San Donato Milanese, 20097 Milan, Italy e-mail: vanni.mauri@gmail.com

Executive Summary of the Joint Position Paper on Renal Denervation of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the European Society of Hypertension (ESH)

This joint position paper, composed by an author group of members of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the European Society of Hypertension (ESH), is being published jointly in the Cardiovascular and Interventional Radiology Journal and the Journal of Hypertension. The paper attempts to review the evidence and provide some guidance and forward direction for this new and potentially still valuable technique. The article presented here is a brief executive summary of the full paper which can be found on the CIRSE and ESH websites. Methodology