Cagatay Andic

Comparison of ultrasound guidance with the traditional palpation and fluoroscopy method for the common femoral artery puncture.

To compare the success and complication rates of ultrasound‐guided or palpation‐guided punctures of the common femoral artery in a prospective randomized study.

Ultrasound-Guided Supraclavicular Brachial Plexus Block for Analgesia during Endovascular Treatment of Dysfunctional Hemodialysis Fistulas

PURPOSE To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. MATERIALS AND METHODS US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0-10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. RESULTS Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ± 2.6. Pain scores were 0 (no pain) in 26 patients and 1-3 (mild, annoying pain) in 14 patients. The patients satisfaction with pain control was recorded as satisfied (very well) in all cases. The operators satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. CONCLUSIONS US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

Background and purpose Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. Materials and methods Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. Results 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3–51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. Conclusions Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.

Acoustic Radiation Force Impulse (ARFI) elastography quantification of muscle stiffness over a course of gradual isometric contractions: a preliminary study.

AIMS To evaluate the feasibility of quantitative analysis of muscle stiffness by Acoustic Radiation Forced Impulse (ARFI) elastography over a course of graduate isometric voluntary contractions. MATERIAL AND METHODS The stiffness of the bilateral biceps muscle of 13 healthy volunteers was measured in real time by ARFI elastography, while the forearm was in neutral-extended position, 90 degree self-flexed positions and 90 degree self-flexed position, with altered weights ranging from 1 to 8 kg placed on flattened palmar surfaces consecutively. The determined increases in biceps muscle stiffness were measured for both arms and correlated with the loadings weights adopted at progressive trial stages. RESULTS The mean shear wave velocity (SWV) values of biceps muscles in a neutral position, in 90 degree flex position and 90 degree flex position with 1 to 8 kg weights on palmar surfaces were 2.162+/-0.302 m/sec, 3.382+/-0.581 m/sec, and 3.897+/-0.585 to 5.562+/-0.587 m/sec, respectively. Significant correlations between the muscle SWV values and related palmar weights and between the SWV values of right and left sides at different trial stages were identified (r=0.951 and r=0.954, respectively). A mutual propagation path of deep regions to entire areas was described to account for the distribution of increase in stiffness with increases in palmar weights. The confidence of method regarding inter-observer difference was confirmed by the correlation analyses of the results (r=0.998). CONCLUSIONS ARFI elastography is a feasible imaging modality for quantifying the stiffness of isometrically voluntarily contracting muscles.

Delayed failure of rectovaginal fistula embolization with Amplatzer vascular plug 2.

We read with great interest the paper published by Guneyli et al. (1) in Diagnostic and Interventional Radiology along with the other impressive papers regarding the use of Amplatzer® Vascular Plugs (AVPs, AGA Medical Corp., Golden Valley, Minnesota, USA) (1–3). We would like to share our experience about using the AVP for treating a rectovaginal fistula (RVF). Although initially successful, this treatment unfortunately failed in the long-term follow-up. A 47-year-old female patient was referred to our department for interventional radiologic treatment of RVF, which occurred following a low anterior resection for T2N0M0 rectal cancer, performed 10 months ago in another center. On postoperative day 12 the patient suffered vaginal fecal discharge. Initial emergent loop diversion colostomy and primary surgical repair of the fistula six months later, were both unsuccessful. Double-contrast barium enema (Prontobario Colon, Bracco, Milan, Italy) revealed passage of contrast and air from rectum to vagina consistent with RVF, and embolization of the fistula was planned (Fig. 1a). Under the guidance of a 5 F vertebral catheter (Cordis, Johnson & Johnson, Miami, Florida, USA) and an angled hydrophilic 0.035-inch radiofocus glidewire (Terumo, Somerset, New Jersey, USA) the fistula was catheterized, and the wire accessed into the vaginal lumina. The glidewire was exchanged for a stiff Amplatz guidewire (Cook Medical, Bloomington, Indiana, USA). An 8 F long sheath and a dilator (Shuttle, Cook Medical) were inserted over the exchange wire into the fistula and advanced to the measured area. The dilator and the wire were removed, and angiography was performed through the guiding catheter to confirm satisfactory location of the guiding catheter. An AVP 2 was introduced through the 8 F sheath. While the medial part of the plug was in the fistula, the distal and proximal parts were in the vaginal and rectal walls, respectively (Fig. 1). The plug was deployed following confirmation of the device position. Postembolization angiography revealed occlusion of the fistula. The patient was discharged the next day. The control double-contrast barium enema examination at the first month revealed complete healing and the patient was free of symptoms (Fig. 2). However, the second control imaging performed at the third month, after relapsed complaints of the patient, revealed loss of the plug and reappearance of the fistula. In addition, there was a new blind-ended fistula towards the presacral space (Fig. 3). Although we could not demonstrate direct passage of contrast in to vagina, there was a late slight fluid discharge consistent with contrast material from the vagina. Figure 1. a–d. Lateral iodinated contrast study of the colon (a) demonstrates the passage of contrast material from the rectum to vagina through a fistulous tract. Treatment begins with the passage of the wire through the fistula (b). Panel (c) shows catheterization of the fistula tract. Repeat colonography (d) confirms position before deployment of a 12 mm Amplatzer Vascular Plug in the rectovaginal fistula tract. c a

Efficacy of endovascular treatment and feasibility of stent-assisted coiling in the presence of severe and symptomatic vasospasm

Background and purpose In patients with aneurysmal subarachnoid hemorrhage, deciding the optimal treatment strategy is challenging in the presence of severe and symptomatic vasospasm and the existing literature is limited. The purpose of this study was to evaluate the safety and effectiveness of endovascular treatment of intracranial aneurysms and the feasibility of stent-assisted coiling during severe and symptomatic vasospasm. Materials and methods Fifteen consecutive patients with 18 aneurysms who underwent endovascular treatment during severe and symptomatic vasospasm were included in the study. Patient and aneurysm characteristics, treatment technique, and clinical and angiographic outcomes were retrospectively evaluated. Results Aneurysms were treated by the following techniques: single catheter coiling in 9, stent-assisted coiling in 8 (3 aneurysms with Y-configuration double stents), and balloon-assisted coiling in 1. All patients showed angiographic improvement of vasospasm after treatment including a noticeable dilation of the spastic parent arteries following deployment of the stents. According to the immediate post-treatment angiography results, 14 aneurysms (77.8%) had class I occlusion and 4 (22.2%) had class II occlusion. Three patients died during the course of subarachnoid hemorrhage. Mortality was related to the poor grade (Hunt and Hess grade V) and cardiovascular complications in two and refractory vasospasm one patient. The remaining patients had favorable clinical outcomes at follow-up (modified Rankin Scale 0–2). Conclusions Endovascular treatment of intracranial aneurysms during severe and symptomatic vasospasm is safe and effective. Stent-assisted coiling in the presence of severe vasospasm is also feasible in wide-necked aneurysms with the additional benefits of mechanical vasodilation.

Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini.

Purpose To retrospectively evaluate the feasibility and effectiveness of endovenous laser ablation or ultrasound-guided foam sclerotherapy for Giacomini vein insufficiency. This is the largest cohort of patients treated for Giacomini vein insufficiency with endovenous laser ablation or ultrasound-guided foam sclerotherapy. Material and methods Over a three-year period, 23 females and nine males (age range, 19–67 years) treated for Giacomini vein insufficiency with or without saphenous vein insufficiency were retrospectively reviewed. Diagnosis of venous insufficiency was made by color Doppler ultrasonography. Symptomatic insufficiency of the Giacomini vein or the saphenous veins was treated with endovenous laser ablation. Ultrasound-guided foam sclerotherapy was used for tortuous incompetent Giacomini veins. The venous disease was categorized according to the clinical, etiological, anatomical, and pathological classification, and clinical severity was graded with the venous clinical severity score. Follow-up included clinical examination and color Doppler ultrasonography. Results Thirty-nine limbs in 32 patients were treated (25 endovenous laser ablation and seven ultrasound-guided foam sclerotherapy). All procedures were technically successful. One patient in the ultrasound-guided foam sclerotherapy group had a recurrence with successful repeated treatment. Recurrence was not seen in the endovenous laser ablation group. No complications were observed. All patients had resolution and improvement in 100% of their symptoms at 12 months of follow-up. Conclusion Giacomini vein insufficiency is mostly seen with insufficiency of the great saphenous vein and can be effectively treated with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

Endovascular treatment of surgically implanted arterial graft thrombosis by using manual aspiration thrombectomy

The purpose of this study was to present our experience with guiding catheters in manual aspiration thrombectomy of occluded infra-aortic bypass grafts. This material was designed as a guiding catheter but was also used for thrombus aspiration. Six consecutive patients (all male; mean age, 61.0±5.7 years; range, 54-68 years) who underwent manual aspiration thrombectomy at the discretion of the operator for infra-aortic bypass graft thrombosis between 2002 and 2010 were retrospectively reviewed. The angiographic success described as either stenosis or residual thrombus less than 30% was 67%. Primary patency was 50%, and secondary patency was 66.7%. Additional stents were needed in four lesions of three patients. Manual aspiration thrombectomy is intended to remove both soft acute blood clots and hard organized embolic and thrombotic obstructions. Manual aspiration thrombectomy appears to be a safe and effective method for treating delayed graft thrombosis. This method provides an alternative to surgical thrombectomy, especially for patients who are not good candidates for the surgery.

Safety and efficacy of ventriculostomy procedures under dual antiplatelet therapy in patients treated with stent assisted coiling in subarachnoid hemorrhage

AIM Stent assisted coilling (SAC) is an alternative in the treatment of ruptured aneurysms. Stenting requires the use of dual antiplatelet agents. Hydrocephaly is a complication of subarachnoid hemorrhage (SAH) requiring ventriculostomy. Antiplatelet treatment reveal a risk of hemorrhage in ventriculostomy. Anti-aggregant effect starts at least four hours after the initial doses of treatment. However, in many studies, ventriculostomy was performed before antiplatelet treatment and the hemorrhagic complications were related to the procedure. The aim of this study was to determine the risk of ventriculostomy related hemorrhage in patients with impaired thrombocyte function and to contribute to the literature. MATERIAL AND METHODS Between 2011 and 2016, 53 patients treated with SAC due to SAH in our clinic were retrospectively evaluated. Hemorrhagic complication risks due to antiplatelet therapy related to ventriculostomy were retrospectively evaluated Results: All of the ventricular catheter procedures were performed at least 1 day after the dual therapy (in average 4,3 days after SAC). On 5 patients 1 ventriculostomy was performed, on 2 patients 2, and on 1 patient 6 ventriculostomies were performed. Although radiological hemorrhage was present on the catheter tract in 4 patients, no temporary or permanent neruologic deficit was observed. CONCLUSION Impaired thrombocyte functions pose a risk in ventriculostomy. Also, evaluating the risk of hemorrhage before the antiplatelet treatment reaches its full effect may lead to false results. Studies with small patient groups with antiagregant therapy and impaired thrombocyte functions also contribute to the literature. Larger studies regarding this subject are needed.

Successful Retrieval of the Detached Porous Metallic Tip of a Mechanical Aspiration Catheter during Thrombectomy in a Case with May–Thurner Syndrome: A Case Report

Modern, minimally invasive techniques used to treat deep venous thrombosis, such as percutaneous mechanical thrombectomy (PMT) and catheter-directed thrombolysis, have gained worldwide acceptance. PMT has the advantage of speed and is also associated with improved outcomes, shortened hospital stays, and low complication rates. The main complications associated with PMT have been primarily due to iatrogenic vascular damage resulting in perforation, embolic occlusion, and arteriovenous fistula formation; to date, there has been no publication in the literature describing complications resulting from device failure. We present an unusual complication of PMT resulting from detachment of the catheter tip during thrombectomy and bailout technique employed.