Dražen Perkov

Percutaneous embolization of idiopathic renal arteriovenous fistula using Amplatzer vascular plug II

Renal arteriovenous fistula (AVF) presents a rare but important condition that can be acquired, congenital, or idiopathic. Embolization techniques have recently been considered the first-line therapy in the treatment of these lesions, but they carry a possible high risk of distal migration of embolic agents into the venous and pulmonary circulation. This risk is especially important with large, high-flow fistulas. In this report, we present a case in which a 31-year-old man with a symptomatic idiopathic AVF was treated with embolization using the Amplatzer vascular plug II after unsuccessful superselective embolization using coils. This method allowed for complete occlusion of the high-flow fistula with good preservation of arterial supply to the renal parenchyma.

Transcatheter ovarian vein embolisation without renal vein stenting for pelvic venous congestion and nutcracker anatomy

The diagnosis of a nutcracker syndrome can be aggravated by overlap of a nutcracker phenomenon with other pathologies. In patients with nutcracker anatomy and predominantly pelvic congestion symptoms, ovarian vein embolization without left renal vein stenting could be considered a first line therapy.

Aortic Coarctation Associated with Aortic Valve Stenosis and Mitral Regurgitation in an Adult Patient: A Two-Stage Approach Using a Large-Diameter Stent Graft

We report a case of a staged surgical and endovascular management in a 62-year-old woman with aortic coarctation associated with aortic valve stenosis and mitral regurgitation. The patient was admitted for severe aortic valve stenosis and mitral valve incompetence. During hospitalization and preoperative imaging, a previously undiagnosed aortic coarctation was discovered. The patient underwent a 2-stage approach that combined a Bentall procedure and mitral valve replacement in the first stage, followed by correction of the aortic coarctation by percutaneous placement of an Advanta V12 large-diameter stent graft (Atrium, Mijdrecht, The Netherlands) which to our knowledge has not been used in an adult patient with this combination of additional cardiac comorbidities. A staged approach combining surgical treatment first and endovascular placement of an Advanta V12 stent graft in the second stage can be effective and safe in adult patients with coarctation of the aorta and additional cardiac comorbidities.

Endovascular Treatment of a Late False Aneurysm Complicating Open Suprarenal Mycotic Aneurysm Repair With a Cryopreserved Aortic Homograft

We report a patient who was initially treated for a suprarenal mycotic aortic aneurysm. The aneurysm repair was performed using a cryopreserved arterial homograft and debranching of visceral arteries. Five years later, the patient was referred due to a large symptomatic false aneurysm at the distal homograft anastomosis. Endovascular repair was indicated and performed using a bifurcated Medtronic composite stent graft. The procedure was uneventful, while control angiography showed complete exclusion of the false aneurysm. Within 6 months of follow-up, the endograft showed favorable position and maintained patency with no signs of endoleaks. We discuss the role of the cryopreserved homografts for in situ repair of mycotic aortic aneurysms and comment on possible late complications after placing those grafts.

Localization of Pancreatic Insulinomas with Arterial Stimulation by Calcium and Hepatic Venous Sampling - Presentation of a Single Centre Experience

Context Arterial stimulation and venous sampling (ASVS) is the most sensitive diagnostic method for occult insulinoma localization. We present our experience with this method and modifications used that proved to ensure greater safety and sensitivity with this rare pathology. Relationship between tumour size and changes in peak insulin values and release curves were also tested. Subjects and methods Six consecutive patients with biochemically established diagnosis of endogenous hyperinsulinism underwent preoperative non-invasive diagnostic tests with sensitivities calculated and compared for all methods. Certain modifications were used in ASVS procedure that included hepatic vein catheterization, order of arterial stimulation, time intervals between each stimulation, diagnostic insulin gradient level and the time frame for diagnostic rise of insulin. Peak insulin values and insulin gradients were compared with tumour size in each patient. Results In all patients, calcium stimulation accurately localized the insulinoma, with higher sensitivity than any other method. A more than 4-fold increase in insulin level was observed in all patients, after injection into the tumour feeding artery, while 2 to 4-fold increase was observed in the tumour neighbouring areas. Tumour size showed an inversely proportional correlation to peak insulin values in each artery that correctly located the tumour. Conclusion ASVS presents the most accurate and safe method for localization of occult insulinomas. A four-fold insulin gradient can be used as a limit for positive preoperative localization in order to secure a higher specificity.

Catheter directed thrombolysis for acute limb ischemia: eight cases in two years

Cardiologia CROATICA Introduction: Acute limb ischemia (ALI) is a challenging problem in angiology. It can be associated with significant morbidity or death even after successful limb revascularization. Management of ALI depends on the clinical status of the affected limb and patient comorbidities. We assessed the efficacy and complication of catheter directed thrombolysis for ALI in our institution during 2012 and 2013. Patients and Methods: During the period of 24 months, eight ALI patients were treated by catheter directed infusion with recombinant tissue plasminogen activator (r-tPA). Standard endovascular access and catheter techniques were involved starting with 5 mg bolus of r-TPA, followed by continuous infusion of 0.5-2 mg/h. Concomitant heparin at low dose was applied to prevent catheter-associated thrombus development. During r-TPA, infusion angiography was repeated to determine success of thrombus dissolution. Results: There were 5 males and 3 females, mean age of 74.8 years (range, 54-90 years). One patient had upper extremity ischemia, others had lower ALI. The average duration of symptoms was 3.6 days (1-10 days). Mean duration of r-TPA infusion was 24.2 hours (16 to 4 hours), with mean dosage of 36.6 mg (range 17 to 60 mg).Three patients (38%) had complete reestablishment of blood flow with catheter thrombolysis and mean ankle — brachial index (ABI) improved from 0.22 to 0.85. The other 4 patients (50%) had partial restoration of flow and needed additional endovascular or surgical intervention with final mean ABI improvement from 0.39 to 0.98. In one case catheter directed thrombolysis failed to reestablish blood flow and the patient underwent the bypass surgery. Only one patient had severe periprocedural complication (gastrointestinal bleeding) requiring a blood transfusion. Small access site hematoma was noticed in all of the treated patients. In the follow-up period (7 to 20 months) one patient had unfavorable course of affected limb which ended with an amputation 15 months after thrombolysis. The other seven patients were stabile, without significant impairment of the treated limb. Conclusion: Selective thrombolysis should be considered for ALI patients with the symptom onset less than 14 days and without motor deficit of the affected limb. It is a timeconsuming procedure with potential severe hemorrhagic complications. With the proper patient selection and coordinated multidisciplinary team, it could result in the reestablishment of flow and an acceptable bleeding complication rate.