Elias N. Brountzos

A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting.

BackgroundPercutaneous metal stenting is an accepted palliative treatment for malignant biliary obstruction. Nevertheless, factors predicting survival are not known.MethodsSeventy-six patients with inoperable malignant biliary obstruction were treated with percutaneous placement of metallic stents. Twenty patients had non-hilar lesions. Fifty-six patients had hilar lesions classified as Bismuth type I (n = 15 patients), type II (n = 26), type III (n = 12), or type IV (n = 3 patients). Technical and clinical success rates, complications, and long-term outcome were recorded. Clinical success rates, patency, and survival rates were compared in patients treated with complete (n = 41) versus partial (n = 35) liver parenchyma drainage. Survival was calculated and analyzed for potential predictors such as the tumor type, the extent of the disease, the level of obstruction, and the post-intervention bilirubin levels.ResultsStenting was technically successful in all patients (unilateral drainage in 70 patients, bilateral drainage in 6 patients) with an overall significant reduction of the post-intervention bilirubin levels (p < 0.001), resulting in a clinical success rate of 97.3%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial liver drainage. Minor and major complications occurred in 8% and 15% of patients, respectively. Mean overall primary stent patency was 120 days, while the restenosis rate was 12%. Mean overall secondary stent patency was 242.2 days. Patency rates were similar in patients with complete versus partial liver drainage. Mean overall survival was 142.3 days. Survival was similar in the complete and partial drainage groups. The post-intervention serum bilirubin level was an independent predictor of survival (p < 0.001). A cut-off point in post-stenting bilirubin levels of 4 mg/dl dichotomized patients with good versus poor prognosis. Patient age and Bismuth IV lesions were also independent predictors of survival.ConclusionsPercutaneous metallic biliary stenting provides good palliation of malignant jaundice. Partial liver drainage achieved results as good as those after complete liver drainage. A serum bilirubin level of less than 4 mg/dl after stenting is the most important independent predictor of survival, while increasing age and Bismuth IV lesions represent dismal prognostic factors.

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.

Endovascular Treatment of Occlusive Lesions of the Subclavian and Innominate Arteries

Technical success is defined as less than 20% residual stenosis depicted by posttreatment digital subtraction angiography (DSA), without dissection or extravasation. Hemodynamic success is defined as the absence of bilateral brachial blood pressure difference and the availability of adequate inflow artery for the scheduled bypass procedure. Clinical success is defined as the resolution of the symptoms. Patency of the treated vessel (or segment) during follow-up is better demonstrated by means of imaging such as DSA. The use of other imaging methods such as magnetic resonance angiography (MRA) or color Doppler ultrasound are limited because of the presence of the metallic stent or the deep location of the treated segment. The indirect methods recommended for the lower extremity arterial endovascular procedures, such as ankle-brachial index (ABI) measurements, are not applicable for subclavian and innominate artery interventions [40]. As a result, many published reports use clinical criteria to evaluate the patency of the treated vessel. Primary patency is defined as the uninterrupted vessel patency with no procedure performed on the treated segment. Secondary patency is defined as whenever maintenance of patency requires a secondary intervention.

Pancreatitis-Associated Splenic Artery Pseudoaneurysm: Endovascular Treatment with Self-Expandable Stent-Grafts

We present a patient with a splenic artery pseudoaneurysm (SAPA) treated with placement of self-expandable stent-grafts. The procedure was complicated by stent-graft migration, but successful management resulted in lasting exclusion of the SAPA, while the patency of the splenic artery was preserved. This is the first report of self-expandable stent-graft treatment of SAPA.

Emergency endovascular treatment of a superior mesenteric artery occlusion.

Endovascular treatment of acute mesenteric ischemia is rarely reported. We report a patient with a 1-year history of chronic mesenteric ischemia who presented with acute worsening of his symptoms and peritoneal signs. Aortography depicted an occlusion of the superior mesenteric artery, which was successfully managed with immediate percutaneous angioplasty (PTA) and stent placement. The patient’s clinical condition improved markedly and an exploratory laparotomy performed the following day confirmed the viability of the intestine. He remains symptom-free 12 months after the procedure, and color Doppler follow-up showed that the stent is patent.

High-Flow Renal Arteriovenous Fistula Treated with the Amplatzer Vascular Plug: Implementation of an Arterial and Venous Approach

We present a 28-year-old man with a large symptomatic arteriovenous fistula (AVF) treated with embolization using the Amplatzer vascular plug (AVP). Although embolization may be considered the first-line therapy in the treatment of AVFs, there is an inherent high risk of migration of the embolic agents into the venous and pulmonary circulations. This case is illustrative of the ease and safety of using this device in high-flow renal AVFs.

Endovascular treatment of a bleeding secondary aorto-enteric fistula. A case report with 1-year follow-up.

We report a patient with life-threatening gastrointestinal bleeding caused by a secondary aorto-enteric fistula. Because the patient had several comorbid conditions, we succesfully stopped the bleeding by endovascular placement of a bifurcated aortic stent-graft. The patient developed periaortic infection 4 months later, but he was managed with antibiotics. The patient is well 1 year after the procedure.

Common Femoral Artery Anastomotic Pseudoaneurysm: Endovascular Treatment with Hemobahn Stent-Grafts

JVIR 2000; 11:1179–1183 STENT-GRAFTS are gaining widespread acceptance in the endovascular treatment of aneurysms, pseudoaneurysms, and arteriovenous fistulas because of the less invasive nature of their use compared to standard surgical procedures (1). Fully supported stent-grafts are used in the treatment of thoracic aortic aneurysms (1), abdominal aortic aneurysms (2), iliac artery aneurysms (3–6), superficial femoral artery (SFA) and popliteal artery pseudoaneurysms (7–10), and subclavian artery aneurysms and fistulas (11). Vascular lesions near mobile skeletal joints (ie, hip joint), although potentially treatable with fully supported stents or stent-grafts, are still managed with surgery (12) because of the perceived risk of stent failure or vascular injury caused by motion. To our knowledge, there have been no reports of a fully supported stent-graft placement across the hip joint for the treatment of aneurysmal lesions in humans. We describe our experience of endovascular management of a patient presenting with a common femoral artery (CFA) anastomotic pseudoaneurysm, treated with placement of fully supported stentgrafts. This patient also had a common iliac artery anastomotic pseudoaneurysm that was likewise treated with placement of fully supported stent-grafts.

Ruptured adrenal artery aneurysm: a case report

Abstract. A case of ruptured adrenal artery aneurysm is presented. The ultrasound, computed tomography and selective renal angiography findings are described in detail. Aneurysms of adrenal arteries are particularly rare. Early diagnosis is important because of their tendency towards rupture and subsequent high mortality rate.

Acute Carotid Stent Thrombosis: A Comprehensive Review.

Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role.