Said Habib

The Use of a Re-Entry Catheter in Recanalization of Chronic Inflow Occlusions of the Common Iliac Artery

Endovascular treatment of iliac artery occlusions can be unsuccessful due to a failure to break back into the true lumen, and lesions without a proximal stump can be particularly problematic. True lumen re-entry catheters have not been previously used for this type of lesion. The authors report eight patients, five males and three females, with lifestyle-limiting intermittent claudication referred for endovascular treatment. Imaging demonstrated unilateral chronic total occlusion of the common iliac artery in six patients and two patients with short patent stumps at the origin of the occluded common iliac artery. Endovascular therapy was initially unsuccessful due to an inability to re-enter the true lumen after crossing the occlusion in the subintimal plane. With the assistance of the Outback LTD catheter it was possible to achieve continuity of the dissecting tract with the true lumen, thus facilitating successful primary stenting in all eight patients. To our knowledge this is the first report of the use of the Outback LTD catheter in this type of lesion.

The Feasibility of Reentry Device in Recanalization of TASC C and D Iliac Occlusions

Aim: To determine the feasibility of subintimal angioplasty (SIA), aided by reentry device in iliac artery occlusions. Methods: Forty-eight patients with severe claudication (Fontaine-III, n = 24) or critical limb ischaemia (Fontaine-IV, n = 24) had SIA, aided with a reentry device, for chronic iliac occlusions TASC C (n =28) and D (n = 20). The primary outcome was arterial patency at duplex follow-up. Secondary outcomes were primary failure, postprocedural complications, stent use, late occlusions, and length of hospital stay. Results: The patency rate was 89% at a mean follow-up of 13 (±11) months. There were 2 primary failures, no postprocedural complications, and 5 late occlusions. Almost 80% of patients were ready for discharge within 24 hours. Conclusions: Subintimal angioplasty with a reentry device for long iliac occlusions provides a feasible option with excellent results and short hospital stay. A randomized trial of SIA of iliac occlusion versus open reconstruction is now required.

Re: Looby et al.: "Efficacy and safety of the Angioseal vascular closure device post antegrade puncture".

While in our experience the Angioseal device has proved useful in select patient groups, it is not without risk, and drawing conclusions on the basis of a cohort of 46 patients has the potential to miss a high rate of serious complication [2]. Over the past 18 months vascular interventional radiologists at our institution have deployed more than 250 Angioseal devices and have experienced 3 serious complications, all in patients with antegrade punctures. In two patients the common femoral arteries became occluded after device deployment. Attempts were made to reopen the artery following contralateral puncture; in both cases stents were successfully deployed following balloon angioplasty of the occlusion, restoring patency. In the third patient it was not possible to achieve hemostasis following deployment, despite manual compression. This patient required surgical exploration, which revealed that the device was positioned outside the artery. As noted by Looby et al. [1] we are not alone in experiencing such complications, and vessel occlusion, hematoma, and pseudoaneurysm formation have all been reported previously [3, 4]. During the same time period two other complications occurred at our institution following Angioseal use by other clinicians. One patient developed persistent bleeding from a puncture site following cardiac catheterization and required surgical intervention. A further patient developed short-distance claudication following Angioseal deployment after cerebral angiography. Angiography demonstrated a dissection flap at the site of puncture; this was successfully treated with a stent. Looby et al. comment that the Angioseal device should be used with caution if the common femoral artery contains multiple plaques [1]. We have found that it is possible to visualize the footplates during deployment and directly observe correct positioning using ultrasound, and as a result problems with the device being ‘‘snagged’’ by plaques can be recognized. Ultrasound can also be used to identify compromise of the arterial lumen or hematoma formation. In summary, although we recognize that the Angioseal device is useful in certain patient groups, it is not without risk of serious complication. To establish the true rates of complication following its use for antegrade puncture, larger studies are required.

Successful Extra-Anatomical Recanalization of Occluded Superficial Femoral Arteries Using the Outback Device—A Report of 2 Cases

Introduction: We report 2 cases where the Outback catheter facilitated extra-anatomical bypass after vessel perforation during attempted subintimal vessel dissection. Report: Attempted subintimal angioplasty of the superficial femoral artery (SFA) resulted in vessel perforation in 2 patients with chronic SFA occlusion and limb ischemia. Due to the lack of other endovascular or surgical options, the Outback catheter was used to reenter the patent lumen distal to the perforation. A stent graft was then deployed from proximal to the perforation to beyond the reentry point with successful outcomes. Discussion: Although the reentry devices are typically used to enter the lumen from the subintimal plane, this novel technique involves using the Outback catheter to enter from the extravascular compartment and facilitate bypass of the SFA occlusion via an extra-anatomical route. This novel technique can be used to restore in-line blood flow when attempted endovascular revascularization failed due to vessel perforation.

Inferior Vena Cava Filter Retrieval: A National Survey of Current Practice

Inferior vena cava (IVC) filters are recommended in patients with extensive lower extremity thromboembolism with contraindications to anticoagulation, including visceral bleeding, trauma, elective surgery and pregnancy. There is an increase in the complication rates on attempted filter retrieval beyond the recommended time frame of indwelling filters, which include failure of retrieval, device infection, IVC filter fracture and migration, thrombus formation, and IVC occlusion and perforation [1]. Hence, the British Society of Radiologists (BSIR) and United States Food and Drug Administration (US-FDA) have issued guidelines that recommend retrieval of temporary IVC filters in all patients within 9 weeks [2]. However, there is global evidence of poor temporary IVC retrieval rates, with means ranging from as low as 8 to 45% [1]. The main recurring causes remain poor patient follow-up following IVC filter insertion, lack of awareness and education amongst the referring clinicians [3]. Different management strategies have been implemented to ensure improved retrieval rates, including a multidisciplinary team approach involving the interventional radiologists (IR), referring clinicians and haematologists, as well as introducing a dedicated IR follow-up clinic or dedicated IR nurses and databases to ensure the filters are removed in a timely fashion [4]. There has also been continued discussion regarding the overall responsibility for ensuring the retrieval of the IVC filters [5]. Some suggest that this responsibility should solely lie with the referring clinicians, while others believe the IR consultant responsible for the filter insertion should be wholly responsible. Various methods are currently in practice to prompt clinicians to ensure requests are in place for the retrieval of the filters, which include specific instructions in the IVC filter insertion radiology reports and/or discharge summaries for the removal of the IVC filter within the time frame. This survey aims to obtain a snapshot of the current practices and estimated retrieval rates within various institutions in the UK. All BSIR members were invited by email to complete an online survey consisting of a single questionnaire in December 2017. Respondents were asked to provide estimated rates of retrieval according to the local institutional audit results and detail further explanation regarding the overall responsibility and the current practice of the IVC filter retrieval in their institution. The respondents were grouped into two categories depending on whom the IVC filter retrieval responsibility lain upon, IR team or referring clinicians. The attempted retrieval rates were divided into three groups: 75–100, 50–75 and \ 50%. Data collected from the survey were analysed to establish observations and associations between the current local practices and the overall retrieval rates. Fifty-seven respondents [interventional radiology (IR) consultants] from various institutions of district general hospitals and tertiary centres completed the survey. Thirtysix respondents had dedicated policies for the IR team to & Permesh Singh Dhillon permesh.dhillon@nhs.net