S.S. Sabri

Outcomes of Covered Kissing Stent Placement Compared with Bare Metal Stent Placement in the Treatment of Atherosclerotic Occlusive Disease at the Aortic Bifurcation

PURPOSE To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation. MATERIALS AND METHODS A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented. RESULTS Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023). CONCLUSIONS The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes.

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79-100%), 86% (73-100%), and 94% (75-100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91-100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27-35%, 45-66%, and 45-91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2-8.7%, 10-20%, and 19-31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6-12 months); however, it is preserved in the long-term (1-3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83-98%, 76-79%, 66-85%, and 39-69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.

Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration.

PURPOSE To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). MATERIALS AND METHODS A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. RESULTS The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). CONCLUSIONS BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Endovascular Therapy for Hepatic Artery Stenosis and Thrombosis Following Liver Transplantation

Purpose: To evaluate the effectiveness of endovascular management of steno-oclusive disease in liver transplants. Methods: Retrospective review of liver transplant recipients with hepatic artery stenosis (HAS) or thrombosis (HAT) was performed. The HAS group was treated with balloon angioplasty with selective stent placement. The HAT group was treated with catheter-directed thrombolysis. Primary, unassisted, and assisted patency and graft survival rates were calculated. Results: In all, 31 patients were identified (21 males; mean age, 51 years). A total of 25 of 31 (81%) patients had HAS and 6 of 31 (19%) had HAT. Collectively, a total of 35 endovascular procedures were performed to treat HAS in 25 patients. Overall technical success rate was 91%, with 11% major complication rate. Primary-assisted patency rate and graft survival at 6 and 12 months were 87% and 81%, and 76% and 72%, respectively. Only 1 successful thrombolysis of HAT was achieved. Conclusion: Endovascular management is effective for HAS but not for HAT.

Endovascular Management of Visceral Arterial Aneurysms

Visceral artery aneurysms are rare entities involving the celiac, superior mesenteric or inferior mesenteric arteries and their branches. While the natural history of these aneurysms is not well known as many are found incidentally, a definite risk of rupture and subsequent mortality has been demonstrated. There are several endovascular methods that an operator may choose to treat visceral artery aneurysms, and selection of the appropriate technique depends on the type and size of aneurysm and the anatomy of the affected artery. It is the aim of this paper to describe the indications, technical considerations and endovascular methods of treatment of visceral artery aneurysms and pseudoaneurysms. The following techniques of angiographic intervention are presented and discussed: isolation, covered stents, coil packing, liquid embolic agents and percutaneous thrombin injection. Where appropriate, individual aneurysm and artery specific treatment considerations are emphasized. To guide and assist practice, a suggested treatment algorithm is presented.

Effect of transjugular intrahepatic portosystemic shunt placement on renal function: A 7-year, single-center experience

PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) creation has been shown to improve renal function in small series of patients with hepatorenal syndrome. The present study examined the effect of TIPS creation on renal function in a large series of patients undergoing TIPS creation who had varying degrees of baseline renal function. MATERIALS AND METHODS All de novo TIPS creations during a 7-year period at a single institution were retrospectively reviewed regardless of indication. Pre- and postprocedural laboratory values were obtained and used to calculate Model for End-Stage Liver Disease (MELD) scores and glomerular filtration rates. Subanalysis was performed based on degree of renal insufficiency and indication for the procedure. RESULTS A total of 201 successful conventional TIPS procedures were identified. Of those, 72 patients were excluded for lack of follow-up, death during the same hospitalization, lack of TIPS function, or end-stage renal failure requiring dialysis before TIPS creation, leaving 129 procedures. Patients with preprocedural creatinine levels of 1.2-1.9 mg/dL (n = 45) showed an improvement in mean creatinine from 1.5 to 1.1 mg/dL (P < 10(-12)) and patients with preprocedure creatinine levels greater than 2.0 mg/dL (n = 21) showed an improvement from 2.8 to 1.5 mg/dL (P < 10(-5)). MELD scores decreased in patients with creatinine levels greater than 2.0 mg/dL from 22.1 to 19.2 (P < 0.005) but increased in all other patient groups. Amount of iodinated contrast medium administered did not affect creatinine level changes. CONCLUSIONS TIPS creation improves renal dysfunction in chronic liver disease. Patients with poorer renal function benefit the most from TIPS creation.

Is fibromuscular dysplasia underdiagnosed? A comparison of the prevalence of FMD seen in CORAL trial participants versus a single institution population of renal donor candidates

Renal artery fibromuscular dysplasia (FMD) may be underdiagnosed. We evaluated the prevalence of FMD in CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) renal artery stent trial participants, in which FMD was an exclusion criterion for inclusion. We also evaluated the prevalence of FMD in a relatively healthy population of patients undergoing computed tomographic angiographic (CTA) screening for renal donor evaluation. All renal donor CTAs performed at our institution from January 2003 through November 2011 were retrospectively reviewed for the presence of FMD along with patient sex and age. These results were compared to angiographic core lab (ACL) findings for the CORAL trial. The CORAL ACL database contained 997 patients (mean age 69.3 years; 50% female). Fifty-eight (5.8%) CORAL trial patients (mean age 71.8 years; 75.9% female) demonstrated incidental FMD. The renal donor cohort included 220 patients (mean age 40.5 years; 64.5% female). Five (2.3%) demonstrated FMD (mean age 48.6 years; all female). The odds of FMD in the CORAL cohort were 2.65 times that seen in the renal donor cohort (95% CI: 1.12, 7.57). In conclusion, the 5.8% prevalence of renal artery FMD in the CORAL trial population, the presence of which was biased against, suggests underdiagnosis.

Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR

BACKGROUND Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT. METHODS We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT. RESULTS Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3±14.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0±37.5 vs. 21.8±44.3; P=0.052). CONCLUSIONS Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technique and Intraprocedural Imaging

Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique used as a therapeutic adjunct or alternative to transjugular intrahepatic shunts (TIPS) in the management of gastric varices. Occlusion balloons are strategically placed to modulate flow within the gastrorenal or gastrocaval shunt to allow stagnation of the sclerosant material within the gastric varix. The approach and complexity of the procedure depends on the anatomic classification of inflow and outflow veins of the varix. Ethanolamine oleate has been described as the main sclerosant used in this procedure. Recently, foam sclerosants have gained popularity as alternative embolization agents, which provide the advantage of better variceal wall contact and potentially less dose of sclerosant.

Chronic mesenteric ischaemia: 28-year experience of endovascular treatment

AbstractObjectiveTo report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI).MethodsA retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed.ResultsIn 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014).ConclusionTechnical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates.Key Points• Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms. • Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting • Although technical success rates are improved with the use of stents. • Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.