Manish Taneja

Long‐term follow‐up of the treatment of renal angiomyolipomas after selective arterial embolization with alcohol

Study Type – Therapy (case series)
 Level of Evidence 4

Endovenous Laser Therapy in the Treatment of Lower-limb Venous Ulcers

PURPOSE To assess the efficacy of endovenous laser therapy (EVLT) in the treatment of lower-limb venous ulcers secondary to venous reflux. MATERIALS AND METHODS Forty-four of 139 patients referred for EVLT from January 2004 to August 2007 had nonhealing venous ulcers. Preprocedural duplex ultrasound (US) was performed to document saphenous venous reflux secondary to saphenofemoral/saphenopopliteal junction incompetence, deep venous insufficiency, and deep vein thrombosis. Follow-up intervals were within 1 week, monthly until ulcer healing, and every 6 months thereafter. Mean follow-up period was 35.8 months (range, 8.1-59.3 months). RESULTS Mean great saphenous vein (GSV) diameter and length treated were 9.9 mm (range, 5.5-16.0 mm) and 36.7 cm (range, 20.0-60.0 cm). Mean laser energy used was 3,292 J (range, 1,392-4,971 J). Mean energy deposited per centimeter of vein was 93.6 J/cm (range, 45.2-182.0 J/cm). Mean laser time was 232 seconds (range, 99-347 sec). Fifteen patients with follow-up duplex US had no GSV flow at 6 months, with nonvisualization indicating complete obliteration. Ulcer healing occurred as early as 1 week after the procedure in some patients. Cumulative healing rates at 1, 3, 6, and 12 months were 82.1%, 92.5%, 92.5%, and 97.4%, respectively. No ulcer had recurred at 1 year, but ulcers recurred in five patients at 14, 14, 23, 35, and 52 months after EVLT, respectively. One patient with a nonhealing ulcer 2 years after treatment developed well differentiated squamous cell carcinoma. CONCLUSIONS Ulcer epithelization occurred with continued GSV occlusion and loss of flow. Most ulcers healed within 3 months with no recurrence at 1 year. Nonhealing ulcers should undergo biopsy to exclude malignant transformation.

Revascularization of an occluded brachiocephalic vein using Outback-LTD re-entry catheter

A 78-year-old man with end-stage renal disease and a right brachial-cephalic upper arm direct hemodialysis access presented with symptomatic central venous occlusion. The right brachiocephalic vein occlusion in this patient was refractory to wire traversal. Sharp recanalization of the central venous occlusion was done with an Outback LTD re-entry catheter (Cordis Corporation, a Johnson & Johnson Company, Miami, Fla). The track was balloon dilated and stented. When the conventional management options fail, this technique may be used to salvage a precious dialysis access and to relieve the patient from symptoms of central venous hypertension.

Bare nitinol stent enabled recanalization of long-segment, chronic total occlusion of superficial femoral and adjacent proximal popliteal artery in diabetic patients presenting with critical limb ischemia

PURPOSE To evaluate our experience of limb salvage with bare nitinol stent enabled recanalization of long length occlusions of superficial femoral artery (SFA) and adjacent proximal popliteal artery (PPA) in diabetic patients. METHODS A total of 573 patients underwent 842 lower limb interventions from August 2006 to September 2008 at our institute. A retrospective review was done of diabetic patients undergoing recanalization of long length SFA/adjacent PPA (>10 cm) occlusions with self expanding bare nitinol stents evaluating their impact on limb salvage. RESULTS Forty-four patients (mean age 65.2 years, M:F 25:19) underwent 49 long-length (>10 cm) SFA/PPA stenting procedures over a period of 26 months. Diabetics comprised 66% of patients (n=29, mean age: 63.7 years, M: F 19:10). The infrapopliteal distal run-off in this diabetic subgroup comprised one vessel (n=14/29, 48%), two vessels (n=12/29, 41%), and three vessels (n=3/29, 10%). The spectrum of critical limb ischemia included rest pain (n=8), ulcer (n=7) and gangrene (n=14). The lengths of occlusions recanalized were 10-39 cm. A total of 58 stents (individual length 10-17 cm, average diameter 6 mm, mean 2 stents per patient) were placed with average length of stented segment being 23.8 cm. Four patients had stents placed through ipsilateral popliteal artery approach with rest placed through femoral artery approach. Significant complications of the procedure included distal embolization (n=3) successfully managed with thrombolysis and popliteal arteriovenous fistula in one patient undergoing recanalization through popliteal approach, managed with covered stent placement. No procedure related mortality occurred during thirty-day follow-up period. All were followed up over an average duration of twelve months post-procedure. Three patients died due to associated medical conditions during this period. The following amputations were done on follow-up (three toe amputations, five forefoot amputations, three below-knee amputations, two above-knee amputations). The overall limb salvage rate was 80%. CONCLUSION Our study shows beneficial result of SFA/PPA stent placement in diabetic occlusions with significant concomitant infrapopliteal disease.

Renal Artery Stump to Inferior Vena Cava Fistula: Unusual Clinical Presentation and Transcatheter Embolization with the Amplatzer Vascular Plug

Fistulous communication between the renal artery stump and inferior vena cava following nephrectomy is rare. We describe the case of a 52-year-old man with a fistula detected on investigation for hemolytic anemia in the postoperative period. The patient had had a nephrectomy performed 2 weeks prior to presentation for blunt abdominal trauma. The fistula was successfully occluded percutaneously using an Amplatzer vascular plug. The patient recovered completely and was discharged 2 weeks later.

Postnephrectomy fistula between the renal artery stump and inferior vena cava treated with Amplatzer vascular plug: gray-scale and Doppler sonographic findings.

Fistulous communication between the renal artery stump and the inferior vena cava is a rare complication of nephrectomy. We report a case of an adult male in whom a fistula was detected on investigation for persistent postoperative anemia. The fistula was initially identified with Doppler sonography and subsequently confirmed on a catheter angiogram. It was successfully occluded percutaneously with an Amplatzer vascular plug. The plug had a distinctive appearance on subsequent sonographic studies that was useful for follow‐up evaluation.

Modification of the Sandwich Technique to Preserve Flow in the Hypogastric Artery After Endovascular Repair of Aortoiliac Aneurysmal Disease: Our Initial Experience With Two Cases

BACKGROUND To describe modification of the sandwich technique to preserve flow in the hypogastric artery after endovascular repair of aortoiliac aneurysmal disease in patients with challenging anatomy. METHODS AND RESULTS The sandwich technique has been proposed as an option in patients with aortoiliac aneurysmal disease, in whom standard iliac branch device may not be technically feasible. We feel that even with the sandwich technique, there are issues with adequately treating these aneurysms in patients with short common iliac arteries with critical landing zones and in those with narrow-caliber external iliac arteries. We describe our experience with two patients we operated on using a modification of the originally described technique and their follow-up. CONCLUSIONS The modification of the sandwich technique is a promising alternative technique that would be useful in situations where standard endovascular grafts cannot be used in patients with challenging anatomy.

Hemodialysis Access Interventions: An Asian Perspective

The prevalence of end stage renal disease (ESRD) in Singapore is high, and is on an upward trend due to the high incidence of diabetes and an aging population. The crude rates (CR) for ESRD incidence increased from 213.2 per million population (pomp) in 1999 to 295.3 pomp in 2006 [1].

Chimney stent grafts in the era of custom-made devices: A comparative review of complex abdominal aortic aneurysm stenting

Introduction: Surgical treatment of abdominal aortic aneurysms (AAA) has evolved over the past 15 years. Fenestrated endovascular of AAAs (FEVAR) and Chimney endovascular of AAA (Chimney EVAR) are techniques that have been introduced and utilized over the past few years as alternatives to open surgical repair with its high associated morbidity and mortality. The purpose of this study is to compare the results of FEVARs and Chimney endografts in a single institution from an Asian perspective. Materials and Methods: We retrospectively reviewed all patients who underwent FEVAR and Chimney EVAR from January 2011 to August 2014 in a tertiary vascular institution. Results: During this study period, a total of 19 patients underwent Chimney EVAR, and 12 patients underwent FEVAR. All FEVAR patients were operated electively while five patients who underwent Chimney EVAR were operated in an emergency setting. Operative time was longer for FEVAR and more vessels were reconstructed. There was no difference in intraoperative technical events, postoperative general and specific complications between the two groups. One patient passed away within 30 days of repair with Chimney EVAR. Conclusion: In this limited retrospective series, short-term results of FEVAR and Chimney EVAR had no statistical difference. Chimney EVAR is an attractive and useful alternative for patients who are unable to undergo FEVAR.

Repair of a complex post-EVAR type III endoleak using a chimney aortouniiliac stent graft and femorofemoral crossover bypass

Post-EVAR type III endoleaks present a particular challenge as they carry a significant risk of rupture. We present a case of an 81-year-old gentleman, 10 years post-EVAR, with complex type III endoleak with component separation that was successfully treated with a combination of left renal artery chimney, aortouniiliac stent grafting and femorofemoral crossover bypass.