Lawrence Han Hwee Quek

Delayed Recurrence of Type 1A Endoleak with Aortic Rupture and Hemorrhage After Endovascular Aneurysm Sealing (EVAS).

The Nellix endovascular aneurysm sealing system (Endologix, Santa Rosa, CA) or EVAS is a novel endoprosthesis used in endovascular treatment of aortic aneurysm. The current body of literature surrounding EVAS is limited [1–6], and of particular interest is Type 1A endoleak, due to the unique configuration of the proximal seal zone and limited understanding on its natural history [1, 2]. We hereby describe a case of delayed recurrence of type 1A endoleak associated with aortic wall disruption and retroperitoneal hemorrhage. This report fulfills our institution’s criteria for waiver of informed consent.

Inadvertent Ureteric Ligation: Diagnosis Using Multidetector Computed Tomography

Inadvertent ureteric ligation is an uncommon complication of laparoscopic surgery. We illustrate the appearance and utility of multidetector computed tomography in such a case after laparoscopic anterior resection.

Cone-beam CT acquisition during transradial TACE made easy; use of the swivel arm board

OBJECTIVEnTransradial access for peripheral intervention often requires certain modification from its coronary counterparts. One of the challenges during transradial transarterial chemoembolization (TACE) is the need for the access arm to be repositioned during cone-beam CT (CBCT) acquisition to allow for C-arm rotation. We recently introduced a swivel arm board to allow seamless repositioning of the access arm during and after CBCT acquisition. The purpose of this study is to detail the technique and feasibility of this useful adjunct to transradial TACE.nnnMETHODSnWe performed a retrospective study of consecutive cases of transradial TACE between November 2015 and March 2016, which represented the period where we introduced the swivel arm board to our transradial procedure. A total of 20 transradial TACE using the swivel arm board was performed in 17 patients. There were 13 males and 4 females. The mean age was 69.5 years old (range 48-82 years). Indications for TACE included hepatocellular carcinoma (n = 14) and metastatic liver disease (n = 3).nnnRESULTSnTransradial TACE was successful in all cases. A total of 40 successful arm repositioning using the swivel arm board for CBCT acquisitions were performed (100% success rate). There was no catheter or sheath dislodgement associated with the arm movements. No change in the microcatheter tip position was detected as a result of the arm repositioning. Hemostasis was successfully achieved in all the patients. There was no access related complication.nnnCONCLUSIONnThe swivel arm board is a useful adjunct to enable CBCT acquisition during transradial TACE. Advances in knowledge: Transradial TACE is a novel technique, and adaptation to allow for CBCT acquisition is currently challenging. This manuscript illustrates how to overcome the positioning difficulties with the use of the swivel arm board.

Diabetic foot limb salvage – a series of 809 attempts and predictors for endovascular limb salvage failure

BACKGROUNDnTo review patient characteristics and outcomes of in-patient diabetic foot limb salvage and identify risk factors predicting for endovascular limb salvage failure.nnnMETHODSnRetrospective study of limb salvage attempts in 809 patients between August 2013 and Julyxa02015.nnnRESULTSnSixty-eight percent of our study population were male with mean age at 65 years and 73% presented with Rutherford grade 6 critical limb ischemia, with the remaining 27% Rutherford grade 5. Eighty-one percent had toe pressures of less than 50xa0mm Hg, 64% had infrainguinal trans-Atlantic inter-society consensus (TASC II) C or D lesions while 78% had infrapopliteal TASC II C or D lesions. Seven hundred seventy-seven patients (96%) underwent endovascular-first approach limb salvage, with 95% requiring infrapopliteal angioplasty, with 84% of them requiring 2-vessel or 3-vessel revascularization. Thirty-two patients (4%) underwent surgical bypass limb salvage, with 63% performed as salvage procedures for failed angioplasties. The mean in-patient stay was 12.3xa0days within the endovascular group and 31.1xa0days within the bypass group (Pxa0<xa00.01). One-year limb salvage was successful in 88% of endovascular group, as compared with 72% in bypass group (Pxa0=xa00.01). Overall 1-year survival was 93% within the endovascular group and 88% within the bypass group (Pxa0=xa00.27). The mean in-patient cost was SGD

Feasibility Study of “Snuffbox” Radial Access for Visceral Interventions

5,518 within the endovascular group and SGD

A Question Mark on Thoracoabdominal Aneurysm

15,141 within the bypass group (Pxa0<xa00.01). Multivariate analysis showed that independent predictors for failure of endovascular limb salvage include end-stage renal failure (ESRF) (odds ratio [OR] 2.04, Pxa0=xa00.01), toe pressures <50xa0mm Hg (OR 2.15, Pxa0=xa00.01), infrainguinal TASC II patterns C or D (OR 1.99, Pxa0=xa00.03), and indirect angiosome revascularization (OR 2.03, Pxa0=xa00.02).nnnCONCLUSIONSnWithin our study population of Asian ethnicity, most in-patient diabetic foot peripheral arterial disease presented with Rutherford grade 6 disease, with mostly TASC II C or D lesions and required infrapopliteal revascularization. As most patients had multiple comorbidities and were poor surgical candidates, the majority underwent endovascular-first approach revascularization. Independent predictors of endovascular limb salvage failure include ESRF, toe pressures <50xa0mm Hg, infrainguinal TASC II patterns C or D, and indirect angiosome revascularization.

Accentuation of Insufficient Landing Zone Using High-volume Three-dimensional Coils during Iliac Aneurysm Stent Grafting for Hypogastric Artery Preservation

Snuffbox radial access entails sheath insertion into the dorsal branch of the radial artery within the so-called anatomic snuffbox. The purpose of this report is to describe the technique and early experience in 50 visceral interventional procedures performed in 31 patients, which included liver embolotherapy, visceral arterial stent insertion, aneurysm embolization, and emergency embolization. In all cases, the procedures were successfully completed by using the snuffbox access, with a single case ofxa0asymptomatic pseudoaneurysm as the only access-related complication. Early experience showed that snuffbox radialxa0accessxa0isxa0technically feasible and represents a viable alternative to conventional radial access for visceral intervention procedures.

Transvenous Salvage of Migrated Large Volume Detachable Coil.

A 73-year-old man presented with an enlarging 5.5-cm Crawford type I thoracoabdominal aneurysm extending from the left subclavian artery to the celiac artery (Fig 1). He was unfit for surgery. To avoid complex customized thoracic and abdominal fenestrated endografts and long aortic segment coverage (with the attendant risk of spinal cord ischemia), two overlapping Multilayer Flow Modulators (Cardiatis, Isnes, Belgium) were deployed in an overlapping fashion (Figs 1–3), extending above the aortic

Inferior Mesenteric Artery Rendezvous for Revascularization of Aorto-iliac Occlusive Disease.

We describe the technique using high-volume three-dimensional coils to augment an insufficient stent-graft landing zone. This was performed to preserve hypogastric artery perfusion in the case of common iliac artery aneurysm which resides next to the internal iliac artery.

“Snuffbox” Distal Radial Access

To the Editor, Recently, large volume detachable coils such as Ruby coils (Penumbra, Alameda, California) have become available for use in peripheral intervention and presents as an alternative to conventional embolization techniques. We describe a case of coil migration during embolization of an aneurysmatic renal arterio-venous malformation (AVM) and describe our salvage technique. A 60-year-old woman was presented with right flank pain for 5–7 months duration, and a 33 9 32 9 29 mm hypervascular lesion was found in the right renal hilum on CT (Fig. 1). Time-resolved MR angiography showed the lesion to be the aneurysm sac related to a renal AVM (Movie 1), and she was referred for embolization. Through a right common femoral artery access, a 7-F renal double-curved guiding catheter (Cordis, Miami, Florida) was positioned in the right renal ostium and angiography revealed the aneurysm to be supplied by lower first-order branch of the main renal artery (Fig. 2A; Movie 2). Due to the large size and hilar location, it was difficult to resolve the exact branch supply of the aneurysm despite various angulations, and the decision was made to directly embolize the aneurysm sac with large volume detachable coils (without sacrificing the supplying artery) to minimize parenchymal loss. The aneurysm sac was accessed using a PX Slim Microcatheter (Penumbra) (Fig. 2A, inset) which would be the working catheter and a second catheter Renegade (Boston Scientific, Natick, MA) was also positioned within the sac as a back-up access (Fig. 2B, white arrow). The first coil, a 32 mm length 9 60 cm Ruby Coil, was deployed under fluoroscopy and was deemed to be in a stable position before detachment (Fig. 2B). A second coil of the same size was then deployed in a similar fashion. However, it was after detachment of the second coil that migration of a segment of the first coil into the right renal vein was noted (Fig. 3A, open arrow). For salvage, a 5-F sheath (Cordis) was inserted in right internal jugular vein and a 10-mm Amplatz snare (ev3/ Covidien, Plymouth, Minn) with a 65-cm, 5-F Bernstein catheter (Cordis) was used to snare the migrated coil segment, by which time, the migrated segment had extended into the inferior vena cava (Fig. 3B). The migrated segment was pushed back into the central core of the coil complex (Fig. 3C, white arrow and Movie 3). However, despite several attempts, it was difficult to release the captured segment completely from the snare and the captured segment followed the snare into the IVC during snare retrieval. This approach was then abandoned. The access was then changed to a 35-cm-long 5-F Brite tip sheath (Cordis) for additional catheter support. The migrated coil segment was again captured in the similar fashion and the snare/catheter combination and the tip of the sheath was Electronic supplementary material The online version of this article (doi:10.1007/s00270-016-1374-6) contains supplementary material, which is available to authorized users.