Rajesh I. Patel

SIR Reporting Standards for the Treatment of Acute Limb Ischemia with Use of Transluminal Removal of Arterial Thrombus

ACUTE limb ischemia is any sudden decrease or worsening in limb perfusion that causes a potential threat to limb viability (1). Acute peripheral arterial occlusion may be caused by in situ thrombosis or embolus. In this article, the term “thrombus” will be used to describe arterial occlusion caused by in situ thrombosis or embolus. Percutaneous or “open” surgical techniques can be used to remove the thrombus. Current percutaneous methods for transluminal removal of thrombus (TRT) include thrombolytic therapy (ie, catheter-directed, pharmacomechanic), percutaneous aspiration thrombectomy (PAT), and percutaneous mechanical thrombectomy (PMT). These methods may be used in combination. Surgical techniques entail an “open” procedure that necessitates an arteriotomy for the removal of thrombus. Of the various TRT methods used to treat acute limb ischemia, catheterdirected thrombolytic therapy with urokinase has been the most widely studied. Catheter-directed thrombolytic therapy has at least three theoretical and practical advantages over surgical thromboembolectomy: less endothelial trauma, angiographic visualization of the underlying lesion(s) and runoff vessels, and, in many cases, ready access for definitive transluminal therapies that address the underlying lesion (1,2). In addition, it has been suggested that gradual, lowpressure reperfusion may offer certain advantages over sudden, high-pressure reperfusion associated with surgical revascularization (1,3,4). Recently, the Food and Drug Administration recalled urokinase (Abbokinase; Abbott Laboratories, Abbott Park, IL). As a result, a critical evaluation of alternate methods to treat acute limb ischemia with use of other thrombolytic drug strategies, PAT and/or PMT, will be needed. Reporting standards for the treatment of peripheral arterial disease (PAD) and practice guidelines for thrombolytic therapy for acute limb ischemia have been published (1,2,5– 7). However, there is insufficient evidence in the literature to determine the best therapy in a given case of acute limb ischemia. This is because the literature is replete with individual or institutional reports of surgical and thrombolytic therapy that are either biased or lack concurrent controls and standardized reporting practices (1). The purpose of this document is to establish reporting standards for subsequent studies pertaining to TRT in the treatment of acute limb ischemia. Consistent data reporting is needed to help precisely define the safety, efficacy, and long-term outcome of TRT procedures (1,8,9). Only then can the appropriate treatment be determined for patients presenting with acute limb ischemia.

Endovascular Stent Placement for Angioplasty-induced Venous Rupture Related to the Treatment of Hemodialysis Grafts

PURPOSE To assess the use of endovascular stents for treating rupture after percutaneous transluminal angioplasty (PTA) in the maintenance of hemodialysis grafts. MATERIALS AND METHODS From February 1, 1994, to August 1, 1997, 683 hemodialysis-related angioplasty procedures were performed on 277 patients to treat thrombosed or poorly functioning polytetrafluoroethylene (PTFE) hemodialysis bridge grafts. In each of these procedures, angioplasty of the venous anastomosis or the outflow vein was performed. This study is a retrospective review to analyze uncovered endovascular stents placed to treat ruptures after PTA. RESULTS Fourteen ruptures were treated with use of an uncovered metal stent. Stent placement was technically successful in 11 of 14 patients, with clinical success in 11 of 14 cases. The primary patencies at 30, 60, 90, and 120 days were calculated by means of Kaplan-Meier life-table analysis; these were 63%, 54%, 46%, and 46%, respectively. The secondary patencies at 60, 120, and 180 days were 85%, 75%, and 75%, respectively. No complications were attributable to stent placement. The results are comparable to those of stents placed for reasons other than rupture, and support the efficacy of their use for this indication. CONCLUSION Endovascular stent placement is a safe and effective means of salvaging angioplasty-induced rupture that occurs during the treatment of hemodialysis grafts.

HEMODIALYSIS GRAFT MECHANICAL THROMBOLYSIS WITH USE OF THE AMPLATZ THROMBECTOMY DEVICE : HISTOPATHOLOGIC EVALUATION OF EXTRACTED MYOINTIMAL TISSUE

PURPOSE To histopathologically evaluate material extracted from thrombosed hemodialysis access grafts by the Amplatz Thrombectomy Device (ATD). MATERIALS AND METHODS Thrombosed hemodialysis access grafts were recanalized with use of crossed catheter technique with introduction of the ATD through 8-F sheaths. After removal of the ATD from the introducer sheath, the tip of the device was visually inspected. Discernible tissue in the impeller/housing mechanism was gently extracted with a hemostat and preserved in formalin. Specimens were evaluated histologically with hematoxylin-eosin and smooth muscle immunoperoxidase stains. RESULTS The ATD was utilized in 18 patients with acutely thrombosed grafts. Sufficient tissue for pathologic evaluation was extracted from 10 devices. Histopathologic analysis yielded findings of fibrotic myointima in all 10 cases with positive smooth muscle stains. CONCLUSIONS The unexpected, although consistent, finding of intimal and myointimal tissue fragments in the impeller/housing mechanism of the ATD raises questions with respect to the mechanism of tissue extraction and concerns regarding the use of the device in native vessels. Further studies are indicated to determine whether this apparent intimal injury will have a deleterious effect on vessel patency.

Biliary Venous Fistula: An Unusual Complication of Fine-Needle Aspiration Biopsy of the Liver

© SCVIR, 1995 THE incidence of complications following fine-needle (external diameter < 1 mm; 20-23-gauge) aspiration biopsies (FNABs) in the abdomen is low, with a reported rate of 0.55%. Major complications including bile peritonitis, bacterial peritonitis, intrahepatic hematoma, tumor seeding, and death have been reported to occur in 0.003%-0.1% of cases (1,2). Blood may enter the biliary system in association with hepatic trauma, cholelithiasis, surgery, or percutaneous interventional procedures resulting in hemobilia. Bile entering the vascular system, or hyperbilirubinemia, is a rare clinical situation that has been reported in association with biliary obstruction from common bile duct stones and a normal blood vessel (3-11). However, we describe a patient with a nondilated biliary system and cavernous transformation of the portal vein (CTPV) who developed an acute biliary-venous fistula associated with severe hyperbilirubinemia or bilemia following percutaneous FNAB of the liver.

Mesenteric Angiography in the Diagnosis of Volvulus

Abbreviation: NOMI nonocclusive mesenteric ischemia MESENTERIC angiography for the diagnosis of intestinal volvulus has been described only rarely in the radiology literature, with the last report by Kadir et al (1) 21 years ago. Clinical findings of intestinal volvulus may mimic either occlusive or nonocclusive forms of intestinal ischemia and, therefore, requests for mesenteric angiography are often made. Mesenteric angiography is rarely requested specifically for the evaluation of volvulus because the diagnosis is suspected and confirmed by other means. The purpose of this pictorial review is to emphasize the angiographic signs of volvulus and to review the clinical presentation that may be treated with use of angiography in current practice. The reliable angiographic appearance of this uncommon problem should be familiar to practicing interventionalists so volvulus can be differentiated from other causes of bowel ischemia.

Percutaneous Embolization of an Intrahepatic Portal Vein Aneurysm

http://dx.doi.org/10.1016/j.jvir.2016.01.132 None of the authors have identified a conflict of interest. patient’s serum prostate-specific antigen level decreased to 5.42 ng/dL. Ischemic complications in the penis are rare and may result from trauma, inadvertent administration of vasoactive drugs, diabetes, vasculitis, circumcision, penile strangulation, foreign bodies, spider bite, or other uncommon conditions (1). In the present case, the penis ischemia was a consequence of nontarget embolization as a result of reflux of microspheres into the APA with distal migration and occlusion of small arteries in the penis. Accessory or aberrant pudendal arteries are present in 4%–75% of all men, and they may be solely responsible for arterial blood supply to the corpora cavernosa (2). This variation in the prevalence of accessory pudendal arteries is related to the modality used for their identification. These arteries have been found to provide the primary blood supply to the corpora cavernosa in 3.2% of patients (3). In the present case, coil embolization of the APA before delivery of the embolic material in the PA might have prevented distal migration of the spheres with nontarget embolization. However, the safety of this maneuver has not been demonstrated to our knowledge. In addition, some surgeons advocate that the preservation of this vessel during radical prostatectomy is mandatory to avoid erectile dysfunction caused by penile artery insufficiency (2). The present case highlights that even careful delivery of embolic materials in such small vessels may result in inadvertent reflux with nontarget embolization. Therefore, if flow-redistribution maneuvers cannot be achieved, interruption of the procedure should be considered. REFERENCES