M. Werk

Percutaneous Transluminal Laser Angioplasty versus Balloon Dilation for Treatment of Popliteal Artery Occlusions

Purpose: To compare the immediate results, complication rates, and long-term outcomes of percutaneous transluminal laser angioplasty (PTLA) versus balloon dilation alone in the treatment of popliteal artery occlusions. Methods: In a prospective nonrandomized study conducted between December 1994 and June 2000, 215 symptomatic patients with unilateral popliteal occlusions were treated with either dilation alone (88 patients: 52 men; mean age 62 years, range 48–83) or PTLA (127 patients: 70 men; mean age 64 years, range 49–86) using a 308-nm excimer laser followed by dilation. The average occlusion length was 10.4 cm (range 3–14). Results: PTLA was successful in recanalizing 105 (82.7%) arteries, while the recanalization rate for dilation alone was only 70.4% (62/88; p=0.045). After a mean follow-up of 36 months (range 6–52), the primary and secondary patency rates were 21.7% and 50.8%, respectively, in patients with PTLA and 16.3% and 35.2% in the angioplasty group (p=0.762). The complication rates associated with both techniques were similar. Conclusions: Although initial recanalization may be better with PTLA, it does not appear to add any long-term benefit over balloon dilation alone.

Short (1-10 cm) Superficial Femoral Artery Occlusions: Results of Treatment with Excimer Laser Angioplasty

Purpose: To evaluatenthe safety and long-term results after laser angioplasty of short occlusions ofnthe superficial femoral artery (SFA). Methods: Inna prospective trial in 312 patients with short occlusions of the SFA excimernlaser angioplasty for recanalization was applied. The average occlusion lengthnof the SFA was 7.5 cm (range 1–10 cm). The recanalization attempt wasndone using either a cross-over technique from the contralateral femoral arteryn(278 patients), antegrade technique (16 patients) or transpopliteal techniquen(18 patients). Results: Percutaneous transluminalnlaser angioplasty (PTLA) produced successful recanalization of the SFA in 286nof 312 patients (91.7%). In 26 patients (8.3%) recanalization was not possible.nThe reason for the unsuccessful PTLAs was obstructing calcified materialn = 8) which was resistant to laser application. Innnine cases obstructing calcifications resulted in positioning of the laserncatheter in subintimal tissue or perforation of the SFA. In another fournpatients there was an aberrant anatomy of the SFA which resulted in a directnvessel injury after advancing the laser catheter. In five patients subintimalnrecanalization failed. After a follow-up period of 36 months there was anprimary, primary assisted and secondary patency rate of 49.2%, 76.5% and 86.3%.nConclusion:Excimer laser angioplasty of shortnocclusions of the SFA is a feasible procedure with a low failure rate.nLong-term results are promising but additional interventions are required innmost patients to achieve a patency rate of 86.3% after 3 years. Further studiesnare needed to compare the clinical outcome of PTLA and PTA in short occlusionsnof the SFA. n

Excimer laser-assisted recanalisation of femoral arterial stenosis or occlusion caused by the use of Angio-Seal

Abstract. The aim of this study was to demonstrate the effect of excimer laser and balloon angioplasty of femoral artery stenosis and occlusion after use of a haemostatic puncture closure device. A haemostatic puncture closure device (Angio-Seal) was used in 6000 patients after diagnostic or therapeutic artery catheterisation. In 34 of those patients symptoms of peripheral artery disease occurred. Sixteen of those 34 cases were transferred to our clinic for excimer laser angioplasty. All 16 patients presented with symptoms of acute peripheral artery disease within 1–14xa0days: superficial femoral artery (SFA) occlusions (4 cases); superficial femoral artery stenosis (3 cases); high-grade stenosis of the common femoral artery (CFA; 3 cases); high-grade stenosis of CFA; SFA and profund femoral artery (PFA; 3 cases); and occlusions of CFA, SFA and PFA (3 cases). Before any procedure was performed, informed consent was given by the patient, which included the use of the Angio-Seal closure device. Every patient who had to undergo recanalisation procedures gave additional informed consent which especially included the usage of the excimer laser for recanalisation. A measurement of the walking distance, ankle–brachial systolic pressure index (ABI) and diagnostic angiography was performed in 13 cases before and immediate after as well as 3 and 6xa0months after therapeutic percutaneous transluminal laser angioplasty followed by balloon angioplasty (PTLA/PTA). In 3 patients the risks of PTLA/PTA was considered too high; those patients underwent surgical repair. Angiographic and clinical improvement was achieved in 13 of 13 patients. The mean walking distance increased from 81 to >400xa0m. The average ankle–brachial systolic pressure index (ABI) increased from 0.47 to 0.84. One patient developed a dissection of the SFA, and in 1 case a peripheral embolisation was seen. The PTLA/PTA technique is a successful therapeutic option for patients with femoral artery occlusion or high-grade stenosis after Angio-Seal application.

Treatment of long superficial femoral artery occlusions with excimer laser angioplasty: long‐term results after 48 months

Purpose: To evaluate clinical and hemodynamical long‐term results after laser angioplasty of long occlusions of the superficial femoral artery (SFA). Material and Methods: In a prospective trial of 452 patients with long occlusions of the SFA, excimer percutaneous transluminal laser angioplasty (PTLA) for recanalization was applied. The average occlusion length of the SFA was 25.5u2009cm (range 16–38u2009cm). The recanalization attempt was done with the crossover technique in 398 patients, in 36 patients with the antegrade technique and in another 18 patients with the transpopliteal technique. Results: The application of laser angioplasty demonstrated a successful recanalization of the SFA in 386/452 patients (85.5%). Recanalization with PTLA was not possible in 66 patients (14.5%). The main reason for the unsuccessful PTLAs was obstructing calcified material (n=28) resistant to PTLA application. After a follow‐up period of 48 months there was a primary, primary‐assisted, and secondary patency rate of 22.3%, 40.9%, and 43.2%, respectively. Conclusion: Laser angioplasty of long occlusions of the SFA is a feasible procedure with a low failure rate. Long‐term results are promising, but additional interventions are required in most patients if a patency rate of 43.2% is to be achieved after 4 years.

Stent placement in short unilateral iliac occlusion. Technique and 24-month results

Purpose: To determine the success rate and 24-month follow-up results of primary stent implantation for reconstruction of unilateral short iliac occlusion involving the aortic bifurcation. Material and Methods: In 90 patients attempts of percutaneous transluminal recanalization of a short unilateral occlusion of the iliac arteries were performed. In 72/90 patients, the treatment was successful. Stent implantation was performed after recanalization in all 72 patients. Pre-interventional angiography of successfully treated patients showed unilateral occlusions and contralateral stenosis in 34/72 patients. In 38/72 patients unilateral occlusion without contralateral stenosis was diagnosed. The recanalization of the common iliac artery obstructions were performed with a guidewire and excimer laser angioplasty. Totally 152 stents were used for the treatment of iliac occlusion. Standardized treadmill testing and color-coded Doppler ultrasound were performed before treatment and during the follow-up. Results: In all patients, stents were placed successfully; 5 major and 7 minor complications were observed. A clinical improvement of +2 to +3 according to the American Heart Association criteria was observed in 62 and 10 patients, respectively. Angiographic control was performed after 1-30 months. The primary angiographic patency rate was 83.1%. Angiography revealed significant restenoses in 4 patients successfully treated with transluminal angioplasty, and re-occlusion in 6 patients which were referred to surgery. The patency rate after 24 months was 90.0%. Conclusion: Primary stent implantation is an effective treatment for short iliac obstructions and represents a true endovascular alternative to surgery.

CT-gesteuerte Brachytherapie

Ziel:Analyse der Sicherheit und Effektivität CT-gesteuerternBrachytherapie zur Ablation von Lebermalignomen.Patienten und Methodik:21 Patienten mit 21 Lebermalignomen (19 Metastasen, zweinprimäre Lebermalignome) wurden mit perkutaner, CT-gesteuerterninterstitieller Brachytherapie mit n192Ir behandelt. Alle Patientennwiesen Umstände auf, die eine bildgeführte thermische Ablationnmit Radiofrequenz oder laserinduzierter Thermotherapie (LITT)neinschränkten: Tumordurchmesser ≥ 5 cm bei sieben, engenLagebeziehung zu Pfortader oder großen Lebervenen bei zehn, engenLagebeziehung zur Hepatikusgabel bei vier Patienten. DienDosimetrie erfolgte über unmittelbar nach CT-geführternApplikatorpositionierung akquirierte dreidimensionalenCT-Datensätze.Ergebnisse:Die mittlere Tumorgröße betrug 4,6 cm (2,5–11 cm). Dienminimale Dosis innerhalb des Tumorvolumens lag im Mittel bei 17nGy (12–20 Gy). Der Volumenanteil gesunden Leberparenchyms mitneiner Exposition > 5 Gy betrug 18% (5–39%) vomnLebergesamtvolumen abzüglich Tumorlast. Übelkeit und Erbrechenntraten bei sechs Patienten auf (28%). Ein Patient entwickelteneine Obstruktion des Ductus choledochus durch einnstrahleninduziertes Tumorödem in unmittelbarer Nachbarschaft.nLeberenzymparameter und Bilirubinwerte zeigten regelhaftndiskrete Anstiege ohne klinisches Korrelat. Die lokalenTumorkontrolle betrug 87% nach 6 Monaten und 70% nach 12nMonaten.Schlussfolgerung:CT-gesteuerte Brachytherapie ist sicher und effektiv. DienTechnik ermöglicht gegenüber thermischen Ablationsverfahren einenbreitere Indikationsstellung hinsichtlich Tumorgröße undnTumorlokalisation.Purpose:To assess safety and efficacy of CT-guided brachytherapynof liver malignancies.Patients and Methods:21 patients with 21 liver malignancies (19 metastases, twonprimary liver tumors) were treated with interstitial CT-guidednbrachytherapy applying a n192Ir source. In all patients, thenuse of image-guided thermal tumor ablation such as bynradiofrequency or laser-induced thermotherapy (LITT) was impededneither by tumor size ≥ 5 cm in seven, adjacent portal or hepaticnvein in ten, or adjacent bile duct bifurcation in four patients.nDosimetry was performed using three-dimensional CT data setsnacquired after CT-guided positioning of the brachytherapyncatheters.Results:The mean tumor diameter was 4.6 cm (2.5–11 cm). The meannminimal tumor dose inside the tumor margin amounted to 17 Gyn(12–20 Gy). The proportion of the liver parenchyma exposed ton> 5 Gy was 18% (5–39%) of total liver parenchyma minus tumornvolume. Nausea and vomiting were observed in six patients afternbrachytherapy (28%). One patient demonstrated obstructivenjaundice due to tumor edema after irradiation of a metastasisnadjacent to the bile duct bifurcation. We commonly encounterednasymptomatic increases of liver enzymes. Local control ratesnafter 6 and 12 months were 87% and 70%, respectively.Conclusion:CT-guided brachytherapy is safe and effective. Thisntechnique displays broader indications compared to image-guidednthermal ablation by radiofrequency or LITT with respect to tumornsize or localization.