J. Fritz Angle

Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and longterm followup

BACKGROUNDnThe purpose of this study was to review the results of percutaneous transluminal angioplasty (PTA), stenting, or both in the treatment of patients who present with symptoms and angiographic findings most consistent with chronic mesenteric ischemia.nnnSTUDY DESIGNnA retrospective analysis of 33 consecutive patients from a single institution who underwent PTA, stenting, or both for treatment of symptoms most characteristic of chronic mesenteric ischemia was performed.nnnRESULTSnThere were 12 men and 21 women with a mean age of 63 years (range 40 to 89 years). Median weight loss was 28 lb (range 6 to 80 lb). Postprandial pain was present in 88% of the patients (29 of 33). All lesions treated were stenoses. PTA alone was performed in 21 patients (32 vessels), and PTA and stenting were performed in 12 patients (15 vessels). PTA was technically successful in 26 of 32 vessels (81.3%); PTA plus stenting was technically successful in 15 of 15 vessels (100%) (p = 0.073). Complete alleviation of symptoms occurred immediately in 27 of the patients (82%), and 2 patients (6%) had significant improvement in symptoms. There were four immediate clinical failures (12%): two patients were found to have occult malignancy and one had immediate relief of symptoms after surgical release of the median arcuate ligament. Followup data were obtained in all patients with clinically successful procedures (mean 38 months, median 25 months, range 1 to 123 months). Angiographic followup was available in 52% of the patients (15 of 29), at a mean of 20 months. The primary longterm clinical success rate was 83.3% (24 of 29). Four of the five patients with recurrent symptoms were successfully retreated with endovascular therapy. The primary assisted longterm clinical success rate was 96.6% (28 of 29). The 5-year survival rate was 76.1%. Major complications occurred in 13% of the procedures, with a 30-day mortality rate of 0%.nnnCONCLUSIONnEndovascular therapy for treatment of mesenteric arterial stenoses is effective in the treatment of patients with symptoms and angiographic findings characteristic of chronic mesenteric ischemia.

Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion.

Subintimal recanalization can be a useful procedure in selected patients with severe peripheral vascular disease with tissue loss or rest pain and limited surgical bypass options. Technical failure occurs in approximately 20% of patient who undergo percutaneous intentional extraluminal recanalization due to inability to reenter the distal true lumen. A technique to improve technical success when performing subintimal recanalization when there is failure to reenter the distal true lumen or possibly when there is a limited segment of patent distal target vessel for reentry is proposed. Further evaluation of this technique is necessary to confirm its safety and determine its technical and clinical success.

MR angiography of the renal arteries

During, the past decade. MRA has evolved from an cxperimental technique into the modality of choice for the noninvasive evaluation of renovascular disease. The recent widespread application of MRA for these indications has been driven primarily by the advent of 3D contrast-enhanced MRA. which provides a fast, reliable technique for imaging large vascular territories and generates images, after postprocessing, similar in appearance to digital subtraction angiography. The cross-sectional volumetric nature of contrast-enhanced MRA affords some advantages over conventional catheter angiography. Although 3D contrast-enhanced MRA forms the backbone of vascular MR studies, several adjunctive sequences are employed to maximize the diagnostic yield of the examination. For example. flow-dependant imaging is used to complement the morphologic images of contrast-enhanced MRA by providing hemodynamic information. As such, MRA is unique among noninvasive imaging modalities in that it offers a comprehensive evaluation of anatomy and function. The availability and reliability of MRA extend renal artery screening to a wider spectrum of patients. Current applications of renal MRA range from detection of renal artery stenosis to evaluation for renal transplant donors.

Placement of transvenous pacemaker and ICD leads across total chronic occlusions

Objective: To establish a method of implantation for device leads across total venous occlusions.

Accelerated treatment using intensity-modulated radiation therapy plus concurrent capecitabine for unresectable hepatocellular carcinoma.

Patients with unresectable hepatocellular carcinoma (HCC) have limited treatment options. In this study, the authors investigated the feasibility, toxicity, and efficacy associated with intensity‐modulated radiation therapy (IMRT) and concurrent, chronomodulated capecitabine in the treatment of unresectable HCC.

Selection of Stents for Treating Iliac Arterial Occlusive Disease

Intravascular stents play an increasingly important role in the treatment of iliac artery occlusive disease and their use has expanded the indications for percutaneous endoluminal therapies. The past several years have seen a sharp increase in the number of commercially available covered and uncovered stents. Knowledge of their design and mechanical properties is crucial for selecting the appropriate stent for a particular type of lesion. In this article, the indications for and results of iliac artery stent placement are reviewed and the various characteristics of the currently available stents that may influence operator choice for use in specific lesions are discussed.

MR angiography of the mesenteric vasculature

MRA has evolved from a research tool to a robust clinical diagnostic modality. In many centers worldwide, it is the technique of choice for evaluating patients with suspected CMI, assessing operability of patients with pancreatic cancer, and investigating the portal system. Evolving indications include the assessment of liver transplant patients before and after transplant and of living related liver transplant donors. The search for the bleeding source in patients with gastrointestinal hemorrhage may be an indication in the future, once intravascular contrast agents become available.

Gadolinium-based contrast agents in angiography and interventional radiology.

Gadolinium is useful as an alternative contrast agent for diagnostic angiographic and interventional procedures in patients with renal insufficiency or a history of a severe reaction to iodinated contrast material. Gadolinium usually is used as a problem solver to answer specific diagnostic questions or guide interventional procedures that cannot adequately be defined with CO2 angiography. Because of dose limitations with Gd, careful planning is required prior to its use with angiography or interventional procedures.

Treatment of Type II Endoleak Using Onyx With Long-Term Imaging Follow-Up

PurposeThe purpose of our study is to report our experience with the use of an ethylene vinyl alcohol copolymer (Onyx) in an off-label fashion for the treatment of type II endoleak after endovascular repair of the thoracic (TEVAR) and abdominal (EVAR) aorta.MethodsA retrospective review of patients with type I and/or II endoleak treated with Onyx was performed. Data regarding the technical, clinical, and imaging outcomes were collected. Technical success was defined as decreased or eliminated endoleak on the first imaging follow-up. Clinical success was defined as unchanged or decreased aneurysm sac size on subsequent follow-up.ResultsEighteen patients (15 male, 3 female) with a mean age of 79xa0years (range 69–92) met inclusion criteria (16 abdominal aortic aneurysm, 2 thoracic aortic aneurysm). Sixteen patients had type II endoleak, and 2 had complex type II endoleak with a type I component. The interval between endograft placement and treatment was a mean of 30xa0months. Direct sac treatment approach was used in 13 patients; transarterial approach was used in 3 patients. Seven patients required the use of coils, N-butyl cyanoacrylate glue, or Amplatzer vascular plugs. The average volume of Onyx used per treatment was 5.6xa0mL (range 2.5–13). Duration of imaging follow-up was 0.75–72.5xa0months (mean 32.8). Sixteen of 18 (88.9xa0%) patients had initial technical and clinical success. Two of 18 patients (11.1xa0%) were initial technical failures, and 1 remained a failure despite a second treatment and attempted surgical ligation. Eight of 18 (44.4xa0%) of patients eventually required a second intervention, 5 (27.8xa0%) of them due to delayed clinical failure. Complications included 1 psoas hematoma, 1 transient L2 nerve paresis, and 1 intraperitoneal Onyx leak; all of these were without clinical sequelae.ConclusionOnyx with or without coil/glue/Amplatzer plug embolization is safe and useful in the treatment of type II endoleak after TEVAR and EVAR. However, long-term clinical and imaging follow-up is needed for early detection and management of recurrence of the primary endoleak or the development of new, secondary endoleaks or enlargement of the aneurysm sac.

Magnetic resonance urography for the assessment of potential renal donors: Comparison of the RARE technique with a low-dose gadolinium-enhanced magnetic resonance urography technique in the absence of pharmacological and mechanical intervention

The aim of this study was to determine whether magnetic resonance urography without pharmacological (diuretic) stimulation and mechanical compression allows conclusive evaluation of the urinary system in potential renal donors. In 28 consecutive patients magnetic resonance urography (MRU) was performed on a 1.5-T system. Two techniques, rapid acquisition with relaxation enhancement (RARE) and a gadolinium (Gd)-enhanced 3D fast low angle shot (FLASH) sequence were compared in the absence of adjunctive measures. Two reviewers assessed image quality, presence of artifacts and completeness of visualization of the collecting systems and ureters. Among the 53 MR urograms, there was no difference in image quality and presence of artifacts between RARE and Gd-MRU. Despite high image quality, visualization of the urinary collecting system was insufficient. Continuous visualization from the collecting system to the distal ureter was demonstrated bilaterally in only 14% of the RARE and 26% of Gd-enhanced MR urograms, respectively. Overall, Gd-enhanced MRU was superior to the RARE technique in displaying the segments of the urinary collecting system, but this difference was not found to be statistically significant. Neither the RARE technique nor the gadolinium-enhanced MRU technique is accurate enough to allow the evaluation of the collecting system and ureters in potential renal donors in the absence of pharmacological intervention and compression.