Chieh Min Fan

Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases.

PURPOSE To determine the clinical outcome of hypogastric artery occlusion in patients who underwent endovascular treatment of aortoiliac aneurysmal disease. MATERIAL AND METHODS From January 1994 to March 1998, 94 patients underwent endovascular treatment of aneurysmal diseases involving the infra-abdominal aorta or iliac arteries. Preoperative and intraoperative radiologic data were reviewed. Discharge summaries, clinic visits, and phone calls formed the basis for clinical follow-up, with a mean follow-up period of 7.3 months (range, 1-24 months). RESULTS Because of the anatomy of the aneurysms, 28 patients required occlusion of one or more hypogastric arteries. One of the 28 patients died of unrelated causes before follow-up. Seven (26%) of the remaining 27 patients developed symptoms attributable to the hypogastric artery occlusions. Five patients developed new buttock or thigh claudication; of these five patients, three with initially mild symptoms noted complete or near complete resolution of symptoms upon follow-up. One patient with originally significant claudication at 2-year follow-up noted near resolution of symptoms. The other patient with severe pain did not improve significantly on final 1-year follow-up before his death (of unrelated causes). Other clinical complications were worsening sexual function in one patient and a nonhealing sacral decubitus ulcer that developed in a debilitated patient in the postoperative setting, which required surgery. No bowel ischemia was observed. CONCLUSION When treating aortoiliac aneurysmal disease through an endovascular approach, the occlusion of internal iliac artery is often necessary but carries with it a small but finite chance of morbidity.

“Recovery™” Vena Cava Filter: Experience in 96 Patients

The purpose of the study was to assess the clinical safety and efficacy of the “RecoveryTM” (Bard) inferior vena cava (IVC) filter. We retrospectively evaluated the clinical and imaging data of patients who had a “RecoveryTM” IVC filter placed between January 2003 and December 2004 in our institution. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. Follow-up computed tomography (CT) examinations of the abdomen and chest were evaluated for filter-related complications and pulmonary embolism (PE), respectively. “Recovery” filters were placed in 96 patients (72 males and 24 females; age range: 16–87 years; mean: 46 years). Twenty-four patients presented with PE, 13 with deep vein thrombosis (DVT) and 2 with both PE and DVT. The remaining 57 patients had no symptoms of thromboembolism. Indications for filter placement included contraindication to anticoagulation (n = 27), complication of anticoagulation (n = 3), failure of anticoagulation (n = 5), and prophylaxis (n = 61). The device was successfully deployed in the infrarenal (n = 95) or suprarenal (n = 1) IVC through a femoral vein approach. Retrieval was attempted in 11 patients after a mean period of 117 days (range: 24–426). The filter was successfully removed in nine patients (82%). Failure of retrieval was due to technical difficulty (n = 1) and the presence of thrombus in the filter (n = 1). One of the nine patients who had the filter removed developed IVC thrombus after retrieval and another had an intimal tear of the IVC. Follow-up abdominal CT (n = 40) at a mean of 80 days (range: 1–513) showed penetration of the IVC by the filter arms in 11, of which 3 had fracture of filter components. In one patient, a broken arm migrated into the pancreas. Asymmetric deployment of the filter legs was seen in 12 patients and thrombus within the filter in 2 patients. No filter migration or caval occlusion was encountered. Follow-up chest CT (n = 27) at a mean of 63 days (range: 1–386) showed PE in one patient (3%). During clinical follow-up, 12 of 96 patients developed symptoms of PE and only 1 of the 12 had PE on CT. There was no fatal pulmonary embolism in our group of patients following “Recovery” filter placement. However, the current version of the filter is associated with structure weakness, a high incidence of IVC wall penetration, and asymmetric deployment of the filter legs.

Leiomyosarcoma of the Uterus with Intravascular Tumor Extension and Pulmonary Tumor Embolism

We report the case of a 48-year-old woman presenting with recurrent uterine leiomyosarcoma (LMS) associated with right iliac vein and inferior vena cava (IVC) invasion and left lower lobe pulmonary tumor embolus. Because the prognosis and treatment differ from that of thrombotic pulmonary emboli, the differentiating imaging characteristics of intravascular tumor embolism are reviewed. To our knowledge, only two other cases of intravenous uterine leiomyosarcomatosis have been described in the existing literature, and this is the first reported case of the entity with associated intravascular tumor embolism.

Custom bifurcated stent-graft for abdominal aortic aneurysms: initial experience.

PURPOSE To describe a custom bifurcated stent-graft for possible treatment of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS Five male patients (mean age, 76 +/- 6 years), who had AAA (mean diameter, 4.7 +/- 0.4 cm) and who were considered to be at high risk for conventional surgery, were treated with a custom modular bifurcated stent-graft constructed with bifurcated 24-mm x 12-mm (upper body diameter x iliac limb diameter) Cooley Veri-Soft Woven polyester grafts and Gianturco-Rösch Z stents. The stent-graft body was delivered through 20-22-F sheaths, and the contralateral iliac limb was delivered through a 16-F sheath by means of surgical exposure of the common femoral arteries. A flared distal limb extender (12 mm to 14 mm) was created for one patient to accommodate a large common iliac artery. RESULTS Stent-grafts were successfully deployed without complications in all five patients. There were no proximal or distal leaks. A lumbar-to-inferior mesenteric artery leak was seen in one patient at 24 hours. At 6-month follow-up, all devices were intact, with complete exclusion and shrinkage of the aneurysm in four of five patients. Aneurysm size remained stable in the one patient with a lumbar-to-inferior mesenteric artery leak. CONCLUSION A custom, bifurcated stent-graft was utilized for endovascular treatment of AAA. Long-term follow-up is necessary for the device.

Development of a Research Agenda for Endovenous Treatment of Lower-extremity Venous Reflux: Proceedings from a Multidisciplinary Consensus Panel

VENOUS reflux (VR) affects millions of patients worldwide and is a common cause of chronic venous disease (1). Existing surgical therapies for VR have major disadvantages, including the need for general anesthesia, potential hospitalization, perioperative discomfort, prolonged recovery time, operative risks, and high costs. In recent years, the fusion of radiofrequency and laser energy technology with advancing image-guided interventional capabilities has stimulated the development of several minimally invasive endovascular techniques capable of treating VR (2,3). However, there has been no coordinated effort to determine what basic and clinical research studies are most critical to optimally refine these techniques and evaluate their long-term efficacy. To address this important question, a multidisciplinary meeting of prominent venous disease experts was convened in October 2004 by the Cooperative Alliance for Interventional Radiology Research (CAIRR), the clinical trials network of the Society of Interventional Radiology (SIR) Foundation. The purpose of the meeting was to establish and prioritize a research agenda for endovenous VR interventions that includes basic science/ technology research, pilot clinical studies, and pivotal clinical trials. MEETING ORGANIZATION

Development of a research agenda for endovascular treatment of venous thromboembolism : Proceedings from a multidisciplinary consensus panel

VENOUS thromboembolism (VTE) is a frequent cause of death, cardiopulmonary morbidity, and late limb disability (1,2). In recent years, minimally invasive endovascular methods have been used to treat deep vein thrombosis (DVT) and pulmonary embolism (PE), the two most common manifestations of VTE (3,4). Although early clinical experiences suggest that these techniques have significant potential to improve patient outcomes, there has been no coordinated effort to determine what research studies are needed to refine these techniques and scientifically validate their long-term efficacy. To address these issues, a multidisciplinary meeting of prominent venous disease experts was convened in October 2004 by the Cooperative Alliance for Interventional Radiology Research (CAIRR), the clinical trials network of the Society of Interventional Radiology (SIR) Foundation. The purpose of the meeting was to establish a prioritized research agenda for endovascular VTE interventions that includes basic science/technology research, pilot clinical studies, and pivotal clinical trials.

The vanguard stent-graft: practical approach

The Vanguard prosthesis (Boston Scientific Vascular, Natick, MA) has been in clinical use since 1996 for endoluminal repair of abdominal aortic aneurysm, with more than 3,500 implants worldwide. The device is a second-generation modular stent-graft consisting of a nitinol metal framework covered with polyester graft material. Proximal aneurysm neck diameters of 20 to 25 mm and lengths of greater than or equal to 15 mm are required for both the tube and bifurcated stent-graft. An infra-aneurysmal neck with the same dimensions allows placement of tube stent-graft. Neck angulation of greater than 60° and/or iliac artery angulation greater than 90° are exclusion criteria. Iliac artery attachment sites must be less than or equal to 13 mm in diameter and greater than or equal to 15 mm in length. Distal limb extensions and a proximal cuff are available. Careful preprocedural imaging and planning ensures a smooth, successful procedure. Flushing the preloaded delivery systems with iced saline before insertion in the body is an important feature of the Vanguard stent-grafts. The delivery process is simple, requiring withdrawal of an outer sheath while maintaining stability of the entire system. Intraprocedural problems such as negotiating an angled neck, proximal and distal leaks, difficult cannulation of the contralateral stump, and long or short grafts are discussed.