Dammis Vroegindeweij

Balloon angioplasty combined with primary stenting versus balloon angioplasty alone in femoropopliteal obstructions: A comparative randomized study.

AbstractPurpose: To evaluate whether balloon angioplasty combined with stenting (ST) of symptomatic femoropopliteal disease would provide better results compared with balloon angioplasty alone (BA).n Methods: Fifty-one patients were randomized between ST (24 patients) and BA (27 patients). Follow-up comprised clinical and hemodynamic assessment and color-flow duplex ultrasound examinations.n Results: Residual stenosis (≥ 30% diameter reduction) occurred in three BA patients, but not in the ST patients. By life-table analysis the cumulative rate of clinical and hemodynamic success after 1 year with ST was 74% (SE 9%) and for those with BA 85% (SE 7%) (p= 0.25). The primary patency at 1 year assessed by color-flow duplex ultrasound was 62% (SE 9%) for ST-treated patients and 74% (SE 8%) for BA patients (p= 0.22). Occlusion occurred in five ST patients (21%) compared with two BA patients (7%).n Conclusion: ST does not improve clinical and hemodynamic outcome compared with BA. Moreover, the occlusion rate in ST-treated patients is higher.

Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function

BACKGROUNDnLittle is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function.nnnOBJECTIVEnTo determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function.nnnDESIGNnRandomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment.nnnSETTINGn10 European medical centers.nnnPARTICIPANTSn140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater.nnnINTERVENTIONnStent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin.nnnMEASUREMENTSnThe primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality.nnnRESULTSnForty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points.nnnLIMITATIONnMany patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting.nnnCONCLUSIONnStent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Comparison of Balloon Angioplasty and Simpson Atherectomy for Lesions in the Femoropopliteal Artery: Angiographic and Clinical Results of a Prospective Randomized Trial☆

PURPOSEnThis study involves a prospective randomized trial comparing clinical and angiographic results of balloon angioplasty (BA) and Simpson directional atherectomy (DA) in patients with short lesions in the femoropopliteal artery causing symptoms of intermittent claudication.nnnMATERIALS AND METHODSnThirty-five patients were treated with BA and 38 with DA. Procedural complications were seen in eight patients. Residual stenoses immediately after the procedure with between 30% and 50% diameter reduction (DR) were observed in three patients after BA and in five patients after DA. In all other patients, residual stenosis was less than 30% DR. Two study end-points during a 2-year follow-up were used: the angiographic occurrence of restenosis with a DR of 50% or greater or the recurrence of symptoms.nnnRESULTSnClinical success after 2 years, according to the criteria of the Society for Vascular Surgery/International Society for Cardiovascular Surgery, was seen in 79% of the BA patients and 56% of the DA patients (P = .07). The 2-year primary angiographic patency rates were 67% in patients treated with BA and 44% in patients treated with DA (P = .06). The secondary angiographically determined patency rates were 80% and 65%, respectively (P = .15).nnnCONCLUSIONnSimpson atherectomy is an interventional technique to treat arterial lesions in the femoropopliteal artery with an acceptably low complication rate. The clinical and angiographic results of DA and BA are comparable. DA should not be used to replace BA for routine treatment of short femoropopliteal lesions.

The Günther temporary inferior vena cava filter for short-term protection against pulmonary embolism

PurposeTo evaluate clinically the Günther temporary inferior vena cava (IVC) filter.MethodsEleven IVC filters were placed in 10 patients. Indications for filter placement were surgical pulmonary embolectomy in seven patients, pulmonary embolism in two patients, and free-floating iliofemoral thrombus in one patient. Eight filters were inserted from the right femoral approach, three filters from the left. Follow-up was by plain abdominal radiographs, cavography, and duplex ultrasound (US). Eight patients received systemic heparinization. Follow-up, during 4–60 months after filter removal was by clinical assessment, and imaging of the lungs was performed when pulmonary embolism (PE) was suspected. Patients received anticoagulation therapy for at least 6 months.ResultsTen filters were removed without complications 7–14 days (mean 10 days) after placement. One restless patient pulled the filter back into the common femoral vein, and a permanent filter was placed. In two patients a permanent filter was placed prior to removal. One patient developed sepsis, and one an infection at the insertion site. Clinically no recurrent PE developed with the filter in place or during removal. One patient had recurrent PE 7 months after filter removal.ConclusionThe Günther temporary IVC filter can be safely placed for short-term protection against PE. The use of this filter is not appropriate in agitated or immunocompromised patients.

Recanalization of Femoropopliteal Occlusive Lesions: A Comparison of Long-term Clinical, Color Duplex US, and Arteriographic Follow-up

PURPOSEnTo assess the merits of clinical examination, color-flow duplex ultrasound (US), and arteriography in the follow-up of patients who have undergone femoropopliteal artery recanalization for occlusive disease.nnnPATIENTS AND METHODSnRecanalization of the occluded femoropopliteal artery was attempted in 62 patients. Follow- up included clinical examination, ankle-brachial blood pressure measurement, and duplex US scanning at 4-month intervals during the first year, at 6-month intervals during the second year, and one a year thereafter. Failure of recanalization included substantial restenosis or reocclusion of the treated segment. Arteriography was performed at the end of the first year or earlier if recurrence was suspected. Agreement of clinical findings with those of duplex US and those of arteriography was determined with kappa statistics; a kappa value of greater than 0.75 represented excellent agreement.nnnRESULTSnRecanalization was technically successful in 51 patients (82%). Clinical patency was 63% (standard error [SE], 6%) after 1 year, 56% (SE, 7%) after 2 years, and 46% (SE, 9%) after 3 years. When technical failures were included, the patency rate at duplex US was 58% (SE, 6%) after 1 year, 40% (SE, 7%) after 2 years, and 33% (SE, 8%) after 3 years. The patency rate at arteriography was 53% (SE, 7%) after 1 year, 33% (SE, 7%) after 2 years, and 30% (SE, 8%) after 3 years. When arteriographic examination was considered the standard of reference, diagnostic accuracy in the identification of recurrent lesions was 94% at duplex US (kappa = 0.88) and 74% at clinical examination (kappa = 0.51).nnnCONCLUSIONnRates of restenosis or occlusion detected at follow-up with duplex US and arteriography were comparable. However, clinical examination alone helped detect fewer cases of recurrent disease.

Magnetic resonance imaging findings in aggressive fibromatosis

Aggressive fibromatosis is a rare tumor, which may develop in fibromuscular structures of the body. Several reports in the literature have described the magnetic resonance findings of aggressive fibromatosis [l-6]. Only six cases with the use of Gd-DTPA have been reported [3,5,6]. We report a case of aggressive fibromatosis with emphasis on the use of MRI to characterize and localize these tumors. The MR features are correlated with the histopathological findings. The role of Gd-DTPA is also discussed.

Patterns of recurrent disease after recanalization of femoropopliteal artery occlusions

PurposeIn this prospective study we investigated the site, occurrence, and development of stenoses and occlusions following recanalization of superficial femoral artery occlusions.MethodsRecanalization of an occluded femoropopliteal artery was attempted in 62 patients. Follow-up examinations included clinical examination and color-flow duplex scanning at regular intervals. Arteriography was used to determine the localization of the recurrent disease relative to the initially occluded segment.ResultsDuring a mean follow-up of 23 months (range 0–69 months) 14 high-grade restenoses, indicated by a peak systolic velocity ratio ≧3.0, were detected by color-flow duplex scanning. Occlusion of the treated segment occurred in 11 patients. The cumulative 3-year primary patency rate for high-grade restenoses and occlusions combined was 44% (SE 9%). By arteriographic examination the site of restenosis was localized in the distal half of the treated vessel segment in 16 of 21 cases.ConclusionMost restenoses and occlusions occurred during the first year and most disease developed at the previous intervention site. The site of restenosis is more frequently in the distal part of the initially treated segment, a finding that may have therapeutic implications.

Ultrasound-Guided Percutaneous Transabdominal Treatment of a Type 2 Endoleak

AbstractWe describe a case of multiplenendoleaks following endovascular repair of an abdominal aorticnaneurysm, treated by various methods. A new transabdominal embolizationnapproach using color-flow duplex guidance isnpresented.

Mycotic aneurysm of the celiac trunk: from early CT sign to rupture.

AbstractWe present a case of the rapid development and rupture of a mycotic celiac trunk aneurysm. Initiallynon multislice computed tomography (ms-CT) there was a normal celiac trunk with minimal haziness of the surrounding fat. Only 2 weeks later the patient went into hypovolemic shock due to a ruptured celiac aneurysm. Although aneurysms of the visceral arteries are rare, they are of major clinical importance as they carry a life-threatening risk of rupture. This case illustrates the use of ms-CT in detecting and evaluating visceral aneurysms, in order to prevent emergency operation.

Comparison of intravascular ultrasonography and intraarterial digital subtraction angiography after directional atherectomy of short lesions in femoropopliteal arteries

PURPOSEnIn this study a group of patients undergoing directional atherectomy for localized occlusive disease in the femoropopliteal arteries, the value of intravascular ultrasonography (IVUS) to improve the efficacy of plaque removal was evaluated. The findings obtained by IVUS were correlated with intraarterial digital subtraction angiography (IA DSA) performed during the procedure. In addition, the patency rates at follow-up in patients undergoing atherectomy with and without IVUS were compared.nnnMETHODSnForty patients were treated by atherectomy because of segmental lesions of the femoropopliteal arteries causing intermittent claudication. Twenty-two patients underwent atherectomy, guided by biplane IA DSA only, and 18 patients were also studied by IVUS. The groups were divided by means of consecutive presentation, IVUS being used in the second part of the study period. The median follow up was 16 months (range, 0 to 40 months). Variables, measured by IVUS during the procedure, were the minimal transverse luminal diameter (MTLD) and the free luminal area. Patency rates at follow-up were determined by regular color flow duplex examinations. Color-flow duplex criteria for occlusions were absence of arterial flow and, for stenosis, a ratio of peak systolic velocities at the diseased segment and a normal segment of 2.5 or greater.nnnRESULTSnQualitative IVUS assessment prompted additional atherotome passages because of insufficient atheroma removal or nonaesthetic appearance of the vessel lumen in 15 of the 18 patients who underwent this examination. Only in four of these patients would abnormalities at IA DSA have been a reason for further attempts of atheroma removal. As for the quantitative findings during AT, after a first series of atherectomy passes the mean MTLD of the reference lesion resulted in an increase of the MTLD from a mean of 3.3 +/- 0.7 mm to 3.7 +/- 0.6mm (p = 0.001), and the free luminal area increased from a mean of 11.2 +/- 4.8 mm2 to 12.5 +/- 4.5 mm2 (p = 0.001). However the occurrence of restenosis during follow-up was comparable in patients monitored during the intervention by IVUS (1-year patency rate, 57%) and patients not studied by IA DSA only (1-year patency rate, 64%). In addition, the presence of an intimal dissection or a plaque rupture at IVUS examination did not predict restenosis.nnnCONCLUSIONSnThe application of IVUS resulted in an improved luminal enlargement by directional atherectomy but not in a better 1-year patency rate.