Murat Gedikoglu

Comparison of ultrasound guidance with the traditional palpation and fluoroscopy method for the common femoral artery puncture.

To compare the success and complication rates of ultrasound‐guided or palpation‐guided punctures of the common femoral artery in a prospective randomized study.

Ultrasound-Guided Supraclavicular Brachial Plexus Block for Analgesia during Endovascular Treatment of Dysfunctional Hemodialysis Fistulas

PURPOSE To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. MATERIALS AND METHODS US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0-10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. RESULTS Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ± 2.6. Pain scores were 0 (no pain) in 26 patients and 1-3 (mild, annoying pain) in 14 patients. The patients satisfaction with pain control was recorded as satisfied (very well) in all cases. The operators satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. CONCLUSIONS US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

Background and purpose Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. Materials and methods Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. Results 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3–51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. Conclusions Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.

Endovascular treatment of iliofemoral deep vein thrombosis in pregnancy using US-guided percutaneous aspiration thrombectomy.

PURPOSE We aimed to describe ultrasonography (US)-guided percutaneous aspiration thrombectomy in pregnant women with iliofemoral deep vein thrombosis. METHODS This study included nine pregnant women with acute and subacute iliofemoral deep vein thrombosis, who were severe symptomatic cases with massive swelling and pain of the leg. Patients were excluded from the study if they had only femoropopliteal deep vein thrombosis or mild symptoms of deep vein thrombosis. US-guided percutaneous aspiration thrombectomy was applied to achieve thrombus removal and uninterrupted venous flow. The treatment was considered successful if there was adequate venous patency and symptomatic relief. RESULTS Complete or significant thrombus removal and uninterrupted venous flow from the puncture site up to the iliac veins were achieved in all patients at first intervention. Complete relief of leg pain was achieved immediately in seven patients (77.8%). Two patients (22.2%) had a recurrence of thrombosis in the first week postintervention. One of them underwent a second intervention, where percutaneous aspiration thrombectomy was performed again with successful removal of thrombus and establishment of in line flow. Two patients were lost to follow-up after birth. None of the remaining seven patients had rethrombosis throughout the postpartum period. Symptomatic relief was detected clinically in these patients. CONCLUSION Endovascular treatment with US-guided percutaneous aspiration thrombectomy can be considered as a safe and effective way to remove thrombus from the deep veins in pregnant women with acute and subacute iliofemoral deep vein thrombosis.

Successful treatment of delayed aortobifemoral graft thrombosis with manual aspiration thrombectomy

We present a 67-year-old man who had undergone aortobifemoral synthetic graft surgery one year earlier. The patient experienced thrombosis of the graft nine months after the operation, and thrombectomy of the graft was planned. However, the patient refused to undergo repeat surgery for thrombus removal and was referred to our center for possible endovascular treatment. We treated the patient with percutaneous aspiration thrombectomy. The thrombi were chronic in nature but could be removed with minimal residue in any part of the graft by using repeated aspiration thrombectomy with 7 F guiding catheters. Underlying stenosis of both distal graft anastomoses was treated with percutaneous balloon angioplasty, and a self-expanding stent was deployed on the right distal anastomosis. A small fragment of thrombus embolized to the right popliteal artery and was removed with aspiration thrombectomy through a second antegrade puncture on the right side. We believe this is the first report of aspiration thrombectomy for an aortobifemoral graft thrombosis. The method was successful despite the chronic nature of the thrombi. Manual aspiration thrombectomy with largebore guiding catheters can be used as an effective recanalization method for delayed aortobifemoral graft occlusion and could be regarded as a good alternative technique to surgical thrombectomy in selected patients.

Efficacy of endovascular treatment and feasibility of stent-assisted coiling in the presence of severe and symptomatic vasospasm

Background and purpose In patients with aneurysmal subarachnoid hemorrhage, deciding the optimal treatment strategy is challenging in the presence of severe and symptomatic vasospasm and the existing literature is limited. The purpose of this study was to evaluate the safety and effectiveness of endovascular treatment of intracranial aneurysms and the feasibility of stent-assisted coiling during severe and symptomatic vasospasm. Materials and methods Fifteen consecutive patients with 18 aneurysms who underwent endovascular treatment during severe and symptomatic vasospasm were included in the study. Patient and aneurysm characteristics, treatment technique, and clinical and angiographic outcomes were retrospectively evaluated. Results Aneurysms were treated by the following techniques: single catheter coiling in 9, stent-assisted coiling in 8 (3 aneurysms with Y-configuration double stents), and balloon-assisted coiling in 1. All patients showed angiographic improvement of vasospasm after treatment including a noticeable dilation of the spastic parent arteries following deployment of the stents. According to the immediate post-treatment angiography results, 14 aneurysms (77.8%) had class I occlusion and 4 (22.2%) had class II occlusion. Three patients died during the course of subarachnoid hemorrhage. Mortality was related to the poor grade (Hunt and Hess grade V) and cardiovascular complications in two and refractory vasospasm one patient. The remaining patients had favorable clinical outcomes at follow-up (modified Rankin Scale 0–2). Conclusions Endovascular treatment of intracranial aneurysms during severe and symptomatic vasospasm is safe and effective. Stent-assisted coiling in the presence of severe vasospasm is also feasible in wide-necked aneurysms with the additional benefits of mechanical vasodilation.

Rupture of an Aneurysm of a Small Branch of the Superior Mesenteric Artery: A Case Report.

Summary Background Superior mesenteric artery aneurysm (SMAA) is an uncommon vascular disorder. Complications such as rupture have been reported. Once complication has been encountered both surgical and endovascular treatment techniques can be considered. Case Report We present a case of 68-year old male patient with SMAA rupture treated by endovascular modality. Conclusions Endovascular therapy is an effective and less invasive option for rupture of superior mesenteric artery aneurysm.

Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini.

Purpose To retrospectively evaluate the feasibility and effectiveness of endovenous laser ablation or ultrasound-guided foam sclerotherapy for Giacomini vein insufficiency. This is the largest cohort of patients treated for Giacomini vein insufficiency with endovenous laser ablation or ultrasound-guided foam sclerotherapy. Material and methods Over a three-year period, 23 females and nine males (age range, 19–67 years) treated for Giacomini vein insufficiency with or without saphenous vein insufficiency were retrospectively reviewed. Diagnosis of venous insufficiency was made by color Doppler ultrasonography. Symptomatic insufficiency of the Giacomini vein or the saphenous veins was treated with endovenous laser ablation. Ultrasound-guided foam sclerotherapy was used for tortuous incompetent Giacomini veins. The venous disease was categorized according to the clinical, etiological, anatomical, and pathological classification, and clinical severity was graded with the venous clinical severity score. Follow-up included clinical examination and color Doppler ultrasonography. Results Thirty-nine limbs in 32 patients were treated (25 endovenous laser ablation and seven ultrasound-guided foam sclerotherapy). All procedures were technically successful. One patient in the ultrasound-guided foam sclerotherapy group had a recurrence with successful repeated treatment. Recurrence was not seen in the endovenous laser ablation group. No complications were observed. All patients had resolution and improvement in 100% of their symptoms at 12 months of follow-up. Conclusion Giacomini vein insufficiency is mostly seen with insufficiency of the great saphenous vein and can be effectively treated with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

Endovascular Diagnosis and Successful Treatment of Massive Gastrointestinal Hemorrhage in Children

This study was presented partially at 11th European Congress of Paediatric Surgery 2nd 5th June, 2010, Berne, Switzerland Address for Correspondence: Dr. Abdulkerim Temiz, Department of Pediatric Surgery, Başkent University School of Medicine, Ankara, Turkey Phone: +90 322 458 68 68-1000 e-mail: aktemiz@yahoo.com ORCID ID: orcid.org/0000-0001-8789-6003 Received: 15 February 2018 Accepted: 6 April 2018 • DOI: 10.4274/balkanmedj.2018.0322 Available at www.balkanmedicaljournal.org Cite this article as: Temiz A, Gedikoğlu M, Serin Ezer S, Oğuzkurt P, Hiçsönmez A. Endovascular Diagnosis and Successful Treatment of Massive Gastrointestinal Hemorrhage in Children. Balkan Med J 2018;35:404-5 ©Copyright 2018 by Trakya University Faculty of Medicine / The Balkan Medical Journal published by Galenos Publishing House. Severe gastrointestinal hemorrhage is usually related to Meckel’s diverticulum, intussusception, or peptic disease in children (1). Visceral vascular anomalies very rarely cause upper gastrointestinal bleeding (2,3). We present four pediatric cases with massive upper gastrointestinal bleeding that were diagnosed and treated with endovascular techniques. Four patients aged from 6 to 15 years presented with a massive upper gastrointestinal bleeding. Written informed consent was obtained from all patients. All patients underwent endoscopy. Duodenal ulcer and hemobilia were detected in two and one patient, respectively. The bleeding source could not be detected by endoscopy in one patient. Although duodenal ulcer bleeding was stopped using adrenalin injection, massive upper gastrointestinal bleeding recurred after 1 week in one patient. Superselective celiac angiography was performed, and the bleeding sources were determined in all patients. Angiography was performed under the conditions of emergency intervention. All procedures were performed under general anesthesia. Arterial access was obtained by sonographic assistance in every patient via puncture of the common femoral artery. A micropuncture set and 4F systems were used. Embolization of bleeding was performed uneventfully using pushable and/or detachable coils. Gastroduodenal artery pseudoaneurysms were detected in two patients with duodenal ulcer (Figure 1). The bleeding was found from a branch of the right hepatic artery in the patient with hemobilia (Figure 2). Bleeding from the left gastric artery was detected by angiography during the active bleeding period in the patient in whom the bleeding source could not be detected by endoscopy. Coil embolization was performed successfully to stop the bleeding in all patients. Clinical and laboratory findings were stable after embolization. There was no recurrence of bleeding during the follow-up periods. Although several diagnostic techniques have been described for the determination of the cause and source of bleeding, endoscopy remains a reliable and an effective diagnostic tool to establish the cause of upper gastrointestinal bleeding. However, endoscopy is sometimes inadequate, especially in cases of intermittent or obscure bleeding (4). Endoscopy is generally useful for therapeutic interventions; however, it may be insufficient in some cases. Surgical treatment, which carries a high risk of morbidity, may be necessary. In such cases, selective visceral angiography facilitates the diagnosis and may also facilitate the use of endovascular treatment. As such, angiography may reduce surgical morbidity rates. The success rates of endovascular treatment in a large adult series were reported to be as high as 80% (5). 1Department of Pediatric Surgery, Başkent University School of Medicine, Ankara, Turkey 2Department of Radiology, Başkent University School of Medicine, Ankara, Turkey Abdulkerim Temiz1, Murat Gedikoğlu2, Semire Serin Ezer1, Pelin Oğuzkurt1, Akgün Hiçsönmez1 Endovascular Diagnosis and Successful Treatment of Massive Gastrointestinal Hemorrhage in Children Balkan Med J 2018;35:404-5