Ansar Z. Vance

Endovascular recanalization of native chronic total occlusions in patients with failed lower-extremity bypass grafts.

PURPOSE To investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts. MATERIALS AND METHODS Retrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication. RESULTS The mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively. CONCLUSIONS Endovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.

Subclavian steal: Endovascular treatment of total occlusions of the subclavian artery using a retrograde transradial subintimal approach.

Introduction In symptomatic subclavian steal syndrome, endovascular treatment is the first line of therapy prior to extra-anatomic surgical bypass procedures. Subintimal recanalization has been well described in the literature for the coronary arteries, and more recently, in the lower extremities. By modifying this approach, we present a unique retrograde technique using a heavy tip microwire to perform controlled subintimal dissection. Methods We present two cases of symptomatic subclavian steal related to chronic total occlusion of the left subclavian artery and right innominate artery, respectively. Standard crossing techniques were unsuccessful. Commonly at this point, the procedures would be aborted and open surgical intervention would have to be pursued. In our cases, retrograde access was easily achieved via an ipsilateral retrograde radial artery, using controlled subintimal dissection and a heavy-tipped wire. Results We were able to easily achieve recanalization in both attempted cases of chronic total occlusion of the subclavian and innominate artery, using a retrograde radial subintimal approach. Subsequent stent-supported angioplasty resulted in complete revascularization. No major complications were encountered during the procedures; however, one patient did develop thromboembolic stroke secondary to platelet aggregation to the stent graft, 9 days post-procedure. Conclusions Endovascular treatment is considered the first-line intervention in medically refractory patients with symptomatic subclavian steal syndrome. In the setting of chronic total occlusions, a retrograde radial subintimal approach using a heavy tip wire for controlled subintimal dissection is a novel technique that may be considered when standard approaches and wires have failed.

Basilar artery perforator aneurysms (BAPAs): review of the literature and classification

Basilar artery perforator aneurysms (BAPAs) are an uncommon subtype of perforating artery aneurysms, with only 18 published cases since their initial description in 1996 by Ghogawala et al. To date, there are only seven published cases of ruptured BAPAs treated using endovascular techniques. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. We describe a new endovascular approach to treating these aneurysms using staged telescoping stents, summarize all published cases of BAPAs, and present a unique classification system to enable future papers to standardize descriptions.

Transcatheter Embolization of Type I Endoleaks Associated With Endovascular Abdominal Aortic Aneurysm Repair Using Ethylene Vinyl Alcohol Copolymer

Purpose: To evaluate the feasibility, safety, and outcome of transcatheter embolization using ethylene vinyl alcohol copolymer (EVOH) of type I endoleaks associated with endovascular abdominal aortic aneurysm repair. Patient Population and Methods: Retrospective chart review was performed to identify 8 consecutive patients who had undergone EVOH embolization for type I endoleaks between 2012 and 2015. The primary approach used to access the endoleak was the perigraft technique, where the endoleak itself is catheterized at the anastomotic site. Results: Six type Ia and 2 type Ib endoleaks were treated. In 2 patients, a direct transabdominal approach was used to access the endoleak because it was inaccessible via the perigraft approach. Coils were used in addition to EVOH in 5 cases. Residual endoleak was noted in 1 case, whereas 2 patients developed a recurrent type I endoleak during follow-up. No EVOH complications were observed. The 5 remaining patients demonstrated freedom from endoleak and reintervention at a mean follow-up of 6.9 months. Conclusion: Type I endoleaks can be safely and effectively treated by embolotherapy with EVOH. Larger endoleaks resulting from grossly undersized endografts appear to be unsuitable for EVOH embolization.

Transpopliteal Access for Intraoperative Spinal Angiography with Combined Percutaneous Treatment of Spinal Hemangioma

Spinal angiography is commonly performed in the setting of spinal arteriovenous malformations, preoperative embolization of spinal tumors, and intraoperatively. Spinal hemangiomas are highly vascular tumors that can be managed with combined transarterial preoperative embolization and surgical resection or vertebral augmentation. When performing a combined spinal angiogram and embolization with subsequent vertebral biopsy and augmentation, the patient is generally intubated. The spinal angiography and embolization procedures are typically performed with the patient in the supine position via a traditional transfemoral access. At the completion of the angiogram and transarterial embolization, access site homeostasis is achieved with either manual compression or with the aid of a closure device. Depending on institutional protocols, many groin closure protocols may add 10–30min. After hemostasis is achieved, the patient is then flipped into a prone position while still intubated and with fresh groin hemostasis. The second procedure requires another prep and drape, often with limited access to the previous groin access site, potentially adding 10–20min to the case. In this case report, we present our initial experience with combined left transpopliteal approach spinal angiography, transarterial embolization of a T10 vertebral body followed by immediate vertebral biopsy and vertebral augmentation. A single prone approach using a transpopliteal access enables a single prep, access and monitoring of the arteriotomy site, as well as significantly shorter procedure times.

Radial access for cerebrovascular procedures: Case report and technical note:

Background Advantages of radial access over brachial/axillary or femoral access have been well described for several decades and include decreased cost, patient preference, and decreased major access site complications. Despite these advantages, radial access is rarely employed or even considered for neurointerventional procedures. This attitude should be reconsidered given several recent large, randomized, controlled trials from the cardiovascular literature proving that radial access is associated with statistically lower costs, decreased incidence of myocardial infarctions, strokes, and even decreased mortality. Radial access is now considered the standard of care for percutaneous coronary interventions in most US centers. Although radial access has been described for neurovascular procedures in the past, overall experience is limited. The two major challenges are the unique anatomy required to access the cerebral vasculature given very acute angles between the arm and craniocervical vessels and limitations in available technology. Methods We present a simplified approach to radial access for cerebrovascular procedures and provide a concise step-by-step approach for patient selection, ultrasound-guided single-wall access, recommended catheters/wires, and review of patent hemostasis. Additionally, we present a complex cerebrovascular intervention in which standard femoral access was unsuccessful, while radial access was quickly achieved to highlight the importance of familiarity with the radial approach for all neurointerventionalists. Results We have found that the learning curve is not too steep and that the radial access approach can be adopted smoothly for a large percentage of diagnostic and interventional neuroradiologic procedures. Conclusions Radial access should be considered in all patients undergoing a cerebrovascular procedure.