Dimitrios Tsetis

Endovascular Treatment of Complications of Femoral Arterial Access

Endovascular repair of femoral arterial access complications is nowadays the treatment of choice in a group of patients who cannot tolerate vascular reconstruction and bleeding due to advanced cardiovascular disease. Endovascular procedures can be performed under local anesthesia, are well tolerated by the patient, and are associated with a short hospitalization time. Ninitinol stent technology allows for safe stent and stent-graft extension at the common femoral artery (CFA) level, due to increased resistance to external compression and bending stress. Active pelvic bleeding can be insidious, and prompt placement of a stent-graft at the site of leakage is a lifesaving procedure. Percutaneous thrombin injection under US guidance is the treatment of choice for femoral pseudoaneurysms (PAs); this can theoretically be safer with simultaneous balloon occlusion across the entry site of a PA without a neck or with a short and wide neck. In a few cases with thrombin failure due to a large arterial defect or accompanying arteriovenous fistula (AVF), a stent-graft can be deployed. The vast majority of catheter-induced AVFs can be treated effectively with stent-graft implantation even if they are located very close to the femoral bifurcation. Obstructive dissection flaps localized in the CFA are usually treated with prolonged balloon inflation; however, in more extensive dissections involving iliac arteries, self-expanding stents should be deployed. Iliofemoral thrombosis can be treated effectively with catheter-directed thrombolysis (CDT) followed by prolonged balloon inflation or stent placement. Balloon angioplasty and CDT can occasionally be used to treat stenoses and occlusions complicating the use of percutaneous closure devices.

Quality Improvement Guidelines for Percutaneous Catheter-Directed Intra-Arterial Thrombolysis and Mechanical Thrombectomy for Acute Lower-Limb Ischemia

Percutaneous catheter-directed intra-arterial thrombolysis is a safe and effective method of treating acute and subacute lower limb ischemia, as long as accurate patient selection and procedural monitoring are ensured. Although larger, controlled trials are needed to establish the role of PTDs in ALI, mechanical thrombectomy could currently be applied combined with lytic infusion in selected cases where rapid recanalization is required or as a stand-alone therapy when the administration of thrombolytic agents is contraindicated.

Standard of Practice for the Interventional Management of Isolated Iliac Artery Aneurysms

Isolated iliac artery aneurysms are uncommon, comprising less than 2% of all abdominal aneurysmal disease. Although they have a fairly innocuous natural history, when they have attained a large size they carry a significant risk of rupture. Rupture is associated with significant morbidity and mortality. Therefore, an early diagnosis and treatment are crucial. Over the last decade, interventional treatment options have become established alternatives to open surgical repair. These guidelines aim to review the pathogenesis, natural history, and presentation of isolated iliac artery aneurysms including a description of imaging and interventional treatment strategies.

Quality-Improvement Guidelines for Hepatic Transarterial Chemoembolization

Transarterial embolization: Defined as the blockade of hepatic arterial flow with different embolic materials (e.g., particles and gelfoam). Conventional transarterial chemoembolization (c-TACE): Defined as infusion of a mixture of chemotherapeutic agents, with or without ethiodized oil, followed by embolization with permanent (polyvinyl alcohol [PVA] particles or spherical embolic agents) or temporary (gelfoam) materials. Drug eluting beads–transarterial chemoembolization (DEB-TACE): Defined as injection of DEB loaded with chemotherapeutics into the tumor-feeding artery [4], with or without further embolization, using regular (i.e., unloaded) microspheres.

Radiation management for interventions using fluoroscopic or computed tomographic guidance during pregnancy: A joint guideline of the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe with endorsement by the Canadian Interventional Radiology Association

Lawrence T. Dauer, PhD, CHP, Raymond H. Thornton, MD, Donald L. Miller, MD, John Damilakis, PhD, Robert G. Dixon, MD, M. Victoria Marx, MD, Beth A. Schueler, PhD, Eliseo Vano, PhD, Aradhana Venkatesan, MD, Gabriel Bartal, MD, Dimitrios Tsetis, MD, PhD, and John F. Cardella, MD, for the Society of Interventional Radiology Safety and Health Committee and the Cardiovascular and Interventional Radiology Society of Europe Standards of Practice Committee

Chronic venous disease progression and modification of predisposing factors

AIM This study evaluated long-term characteristics of chronic venous disease (CVD) progression and its correlation with the modification of specific risk factors. METHODS The contralateral limb of 73 patients (95% women; mean age, 48 +/- 12 years) undergoing varicose vein surgery was prospectively evaluated using physical and color duplex examination and classified by CEAP. After 5 years of follow-up, development of new sites of reflux among the contralateral, preoperatively asymptomatic limbs and modification of predisposing factors, including prolonged orthostatism, obesity, estrogen therapy (ET), multiparity, and elastic stockings use (ESU), were assessed. Data were analyzed with Pearson chi(2), t test, binary logistic regression, and Spearman rho. RESULTS Forty-eight new sites of reflux (superficial system, 37; perforators, 5; deep veins, 6) were revealed in 38 limbs (52%). CEAP scores significantly deteriorated: clinical, 2.2 +/- 0.5 from 0.1 +/- 0.03 (P < .01); anatomic, 3.8 +/- 1.2 from 2.6 +/- 2.5 (P < .05); disability, 1.9 +/- 0.7 from 0 (P < .01); and severity, 7.9 +/- 2.4 from 2.7 +/- 2.2 (P < .01). Patient compliance to predisposing factor modification was low; no change was observed during follow-up (orthostatism, P = .9; obesity, P = 0.7; ET, P = .9; multiparity, P = .4; ESU, P = .3). CVD progression was significantly lower in patients who controlled orthostatism vs those who maintained orthostatism or initiated it (P < .001) and in patients who controlled preoperative obesity vs those who became obese or maintained obesity (P < .001). Non-ESU patients had a significantly higher incidence of CVD progression vs those who started ESU or continued during the study (P < .001). By binary logistic regression analysis, orthostatism (P = .002; B coefficient value [BCV] = 1.745), obesity (P = .009; BCV = 1.602), and ESU (P = .037; BCV = 0.947) were independent predictive factors for CVD progression, whereas multiparity (P = .174) and ET (P = .429) were not. CONCLUSIONS In about half of patients with unilateral varicosities, CVD developed in the contralateral initially asymptomatic limb in 5 years. CVD progression consisted of reflux development and clinical deterioration of the affected limbs. Obesity, orthostatism, and noncompliance with ESU were independent risk factors for CVD progression, but ET and multiparity were not. Maintenance of a normal body weight, limitation of prolonged orthostatism, and systematic ESU may be recommended in patients with CVD to limit future disease progression.

Cutting balloons for the treatment of vascular stenoses

The aim of this article is to review the mechanism, technical characteristics, biological response and clinical applications of cutting balloon angioplasty in peripheral vessels. The cutting balloon is a non-compliant, balloon catheter equipped with three-to-four microtome-sharp atherotomes. When used appropriately, it is safe and easy to use, with a high immediate success rate and few complications, provided oversizing is avoided. There is some evidence that pre-dilation with a standard or high-pressure balloon may also predispose to vascular rupture. The cutting balloon has proved to be beneficial in treating difficult complex lesions in the coronary arteries. Early experience in non-coronary vessels shows that cutting balloon angioplasty can be used to treat peripheral bypass anastomotic and haemodialysis fistula stenoses that are resistant to conventional high-inflation pressures. Its application in de novo peripheral arterial lesions and non-coronary in-stent restenosis is still under discussion. Theoretically, this device induces a smaller degree of vessel wall injury localised to the area of incisions and sparing the interincisional segments; however, this postulated reduction in restenosis rates has not been confirmed in clinical practice.

Vibrational angioplasty in the treatment of chronic infrapopliteal arterial occlusions: preliminary experience.

PURPOSE To evaluate the safety and efficacy of vibrational angioplasty in chronic infrapopliteal arterial occlusions. METHODS Twelve patients (9 men, aged 54 to 90 years) with 13 below-knee arterial chronic total occlusions were treated percutaneously using vibrational angioplasty. The occlusions were located in the anterior tibial artery (n=5), the tibioperoneal trunk (n=4), the peroneal artery (n=1), the posterior tibial artery (n=1), and in both the tibioperoneal trunk and peroneal artery (n=2). The length of the lesions ranged from 5 to 14 cm. RESULTS Recanalization was successful in 12 (92.3%) lesions. In 1 case, the wire perforated the arterial wall; the procedure was abandoned without clinical sequelae. The time to cross the occlusions with the wire ranged from 6 to 19 minutes. No other complications were observed. Clinical follow-up ranged to 18 months. Ten patients with ulceration or gangrene demonstrated good wound healing, and pain was alleviated in all successfully treated patients. CONCLUSIONS Vibrational angioplasty appears feasible as a means of safely recanalizing chronic total occlusions of the infrapopliteal arteries. Further experience should be acquired to assess its short- and long-term effects on this vascular territory.

MDCT anatomic assessment of right inferior phrenic artery origin related to potential supply to hepatocellular carcinoma and its embolization.

PurposeTo prospectively assess the anatomic variation of the right inferior phrenic artery (RIPA) origin with multidetector computed tomography (MDCT) scans in relation to the technical and angiographic findings during transcatheter arterial embolization of hepatocellular carcinoma (HCC).MethodsTwo hundred patients with hepatocellular carcinomas were examined with 16-section CT during the arterial phase. The anatomy of the inferior phrenic arteries was recorded, with particular reference to their origin. All patients with subcapsular HCC located at segments VII and VIII underwent arteriography of the RIPA with subsequent embolization if neoplastic supply was detected.ResultsThe RIPA origin was detected in all cases (sensitivity 100%), while the left inferior phrenic artery origin was detected in 187 cases (sensitivity 93.5%). RIPAs originated from the aorta (49%), celiac trunk (41%), right renal artery (5.5%), left gastric artery (4%), and proper hepatic artery (0.5%), with 13 types of combinations with the left IPA. Twenty-nine patients showed subcapsular HCCs in segments VII and VIII and all but one underwent RIPA selective angiography, followed by embolization in 7 cases.ConclusionMDCT assesses well the anatomy of RIPAs, which is fundamental for planning subsequent cannulation and embolization of extrahepatic RIPA supply to HCC.

Transcatheter Thrombolysis with High-Dose Bolus Tissue Plasminogen Activator in Iatrogenic Arterial Occlusion after Femoral Arterial Catheterization

AbstractPurpose: To assess the efficacy of percutaneous local thrombolysis with high-dose bolus recombinant tissue plasminogen activator (rt-PA) in patients with acute limb ischemia due to arterial thrombosis after cardiac catheterization. Methods: We treated eight patients (7 men; mean age 56 years) with thrombotic occlusion of both the common femoral artery (CFA) and external iliac artery (EIA) in six patients and of the CFA only in two patients. Two 5 mg boluses of rt-PA were injected into the proximal clot through a 5 Fr end-hole catheter and subsequently two additional boluses of 5 mg rt-PA were given through a catheter with multiple side-holes. In case of a significant amount of residual thrombus, a continuous infusion of 2.5 mg/hr of rt-PA was started. Results: Successful lysis was achieved in all patients. The mean duration of lysis was 2 hr 41 min. The mean total amount of rt-PA delivered was 23.16 mg. In four patients unmasked flow-limited dissections confined to the CFA were managed by prolonged balloon dilatation, while in the remaining four patients with extension of the dissection to the external iliac artery one or two Easy Wallstents were implanted. There was prompt relief of lower limb ischemic symptoms and signs in all patients. Two groin hematomas were conservatively treated. Clinical and color Doppler flow imaging follow-up with a mean duration of 15 months, showed no reappearance of ischemic symptoms or development of restenosis in any of the patients. One patient died 6 months after thrombolysis. Conclusions: Transcatheter thrombolysis with high-dose bolus rt-PA is a safe and effective treatment in patients with iatrogenic arterial occlusion after femoral catheterization. Underlying dissections should be treated by prolonged balloon dilatation but stent implantation is often required.