Serkan Gür

Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy: long-term results of 139 patients in a single center.

PURPOSE To evaluate the immediate and long-term outcomes of percutaneous manual aspiration thrombectomy with provisional stent placement in treating acute and subacute iliofemoral deep venous thrombosis (DVT). MATERIALS AND METHODS One hundred and thirty-nine consecutive patients (75 women; mean age, 51 years) with acute (n=110) or subacute (n=29) iliofemoral DVT underwent endovascular treatment (total of 148 limbs). All patients were treated with percutaneous manual aspiration thrombectomy by using large-bore guiding catheters with adjunctive catheter-directed thrombolysis and stent placement, if needed. Venography was used to grade thrombus removal. RESULTS Thrombus removal was less than 50% in five limbs (3.4%), between 50% and 95% in 45 limbs (30.4%), and more than 95% in 98 limbs (66.2%). At least one stent was placed in 99 limbs. Recurrent thrombosis occurred in 27 patients, mostly during the first few months after the procedure. Rethromboses were more frequent among postpartum patients. One patient had a major pulmonary embolism. No major hemorrhage or procedure-related deaths occurred. CONCLUSION Manual aspiration thrombectomy is a safe, rapid, and effective treatment option for acute and subacute iliofemoral DVT. Hence, catheter-directed thrombolysis may not be required in a majority of patients.

Ultrasound-guided puncture of the femoral artery for total percutaneous aortic aneurysm repair.

PURPOSE The purpose of this study was to evaluate the outcomes of ultrasound-guided femoral artery access for total percutaneous endovascular repair of abdominal and thoracic aortic aneurysms. MATERIALS AND METHODS Total percutaneous aneurysm repair of the abdominal and thoracic aorta was performed in 52 consecutive patients (46 males, 6 females; mean age, 64.6±16 years; age range, 24-93 years) in a total of 85 access arteries. Of the aortic aneurysms repaired, 33 were abdominal, and 19 were thoracic. Ultrasound- guided puncture of the access artery was performed in all patients. The access artery was closed with a Prostar XL device at the end of the procedure. RESULTS The outer diameter of the vascular sheaths or the stent graft system ranged from 14 F to 27 F. All but one patient achieved successful closure of the arterial puncture with the closure device. One patient required surgical cutdown because of device failure. Two patients required long-duration manual compression. Technical success was achieved in 49 patients (94%). Forty-five patients (87%) were discharged on the first postoperative day. There were no complications of the access arteries one day or one month postoperatively, as determined by ultrasonography and computed tomography examinations, respectively. The mean diameters of the access arteries prior to and one month after the procedure were unchanged, as demonstrated by computed tomography. CONCLUSION Ultrasound-guided puncture of the common femoral artery for percutaneous closure of the access site has a high technical success rate and a very low complication rate. The addition of ultrasound guidance decreases the difficulty of the procedure and helps to avoid some of its complications.

Assessment of the coronary venous system by using cardiac CT.

PURPOSE We aimed to investigate the coronary venous system and its variations by using dual source computed tomography (CT). MATERIALS AND METHODS Retrospective assessment was carried out on 339 patients who underwent coronary CT angiography using 128-slice dual source CT for suspected coronary artery disease. The examinations were performed according to routine imaging protocols used to evaluate coronary arteries. The coronary venous system was evaluated in each case using maximum intensity projection and volume rendering technique multiplanar reformation reconstructions. In each patient, the presence and calibration of normal anatomy, as well as the variations of the coronary sinus, middle cardiac vein, small cardiac vein, posterior cardiac vein, great cardiac vein, anterior interventricular vein, posterolateral vein, left marginal vein, and anterolateral vein were recorded. RESULTS The coronary sinus, middle cardiac vein, great cardiac vein, and anterior interventricular vein were visualized in all of the patients. In all cases, one of the lateral or posterolateral veins of appropriate localization and diameter for cardiac resynchronization therapy was detected. The posterior cardiac vein was visualized in 87% of the cases, the left marginal vein in 87.9%, and the small cardiac vein in 20%. There was no significant difference in the diameters or visibilities of the coronary veins in terms of age. CONCLUSION The coronary venous system and its tributaries may be examined in detail using CT angiography examination performed according to the routine coronary CT angiography protocol used for dual source CT. Dual source CT may be a valuable tool for evaluation of the coronary veins prior to invasive procedures that are directed at the coronary venous system.

US-guided percutaneous thrombin injection of postcatheterization pseudoaneurysms.

PURPOSE This study retrospectively evaluated ultrasonography-guided (US-guided) percutaneous thrombin injection for the treatment of postcatheterization femoral and brachial artery pseudoaneurysms. MATERIALS AND METHODS Fifty-five patients with postcatheterization femoral artery (n = 53) or brachial artery (n = 2) pseudoaneurysms were treated using US-guided human thrombin (500 IU/mL) injection. Pseudoaneurysm size, thrombin dose, therapy outcome, and complications were documented. Follow-up color Doppler US was performed 7 and 30 days after treatment. Short-duration supplemental compression was applied to six patients at the first week follow-up examination after a reinjection of thrombin had failed. RESULTS Mean pseudoaneurysm volume was 20.3 ± 18.7 cm(3). The mean injected thrombin dose was 478 ± 238 IU. Thirty-eight (69.1%) of the 55 pseudoaneurysms were thrombosed with a single injection, and 11 of 17 pseudoaneurysms were thrombosed after a second injection. All (100%) of the 41 pseudoaneurysms that were diagnosed within the first two weeks of postcatheterization were successfully treated. The overall primary success rate was 89.1% (49 of 55 pseudoaneurysms). Supplemental compression promoted thrombosis in four of the six patients who had treatment failure with thrombin injection. The secondary success rate was 96.4% (53 of 55 pseudoaneurysms). There were no complications. CONCLUSION US-guided thrombin injection was most successful within the first two weeks, and the supplemental compression might aid in the closure of partially thrombosed pseudoaneurysms.

US-guided retrograde tibial artery puncture for recanalization of complex infrainguinal arterial occlusions

PURPOSE We aimed to describe the technical aspects and outcomes of the retrograde tibial approach and balloon predilation for recanalization of complex infrainguinal arterial occlusions and determine the efficacy of this approach in minimizing failure rates. MATERIALS AND METHODS Between September 2006 and April 2011, antegrade revascularization failed in 22 limbs with complex total occlusions within the infrainguinal arterial territory. For each of these antegrade failure cases in 22 patients, a retrograde tibial puncture had been attempted. Percutaneous recanalization and predilation were initially performed through tibial access, and final balloon dilatation or stent placement was performed from antegrade femoral access. The patients were followed up for functionality and wound healing. RESULTS Access from the tibial artery was successfully obtained for all patients (100%). Successful recanalization was obtained in 18 patients (82%). Retrograde access was performed from the anterior tibial/dorsalis pedis artery in 12 patients and posterior tibial artery in 10 patients. One major and one minor complications were documented. CONCLUSION Retrograde tibial recanalization technique in the infrainguinal complex arterial occlusion safely increases the success rates of percutaneous recanalization in the failed traditional approach and is a feasible endovascular option to avoid more invasive, time-consuming, and high-risk procedures.

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.

Easy Retrieval of Escaping Onyx Fragment with Percutaneous Manual Aspiration

The ability of embolization of arteriovenous malformations (AVMs) has increased with the use of Onyx liquid embolic material [1]. The application of the ethylene–vinyl alcohol copolymer (EVOH) in the endovascular treatment of intracranial AVMs was first described by Taki et al. and Terada et al. in the early 1990s [2, 3]. Onyx is an elastic polymer with a lavalike flow pattern that may be used within blood vessels and does not fragment during injection. Onyx is not absorbable and is capable of producing permanent vascular occlusion [4, 5]. Onyx can be used to embolize not only the intracranial AVMs but also the peripheral pseudoaneurysms and malformations [6]. A set of clinical complications that are related to the use of Onyx were described, including reflux of Onyx into the afferent artery peduncle, subarachnoid hemorrhage, and cerebral and pulmonary edema in part as a result of the dimethyl sulfoxide (DMSO) solvent used in Onyx [7, 8]. Extension of Onyx to the parent vessel is a rare complication that has been reported during treatment of AVMs. It has been shown that the Onyx substance can be retrieved with dedicated mechanical retrieval devices [9]. We encountered an escape of an Onyx fragment from the feeder artery into the parent superficial femoral artery while treating a peripheral AVM. We report successful removal of fragment that escaped from the feeder artery and a smaller fragment that embolized into the peroneal artery by simple manual aspiration.

Endovascular treatment of surgically implanted arterial graft thrombosis by using manual aspiration thrombectomy

The purpose of this study was to present our experience with guiding catheters in manual aspiration thrombectomy of occluded infra-aortic bypass grafts. This material was designed as a guiding catheter but was also used for thrombus aspiration. Six consecutive patients (all male; mean age, 61.0±5.7 years; range, 54-68 years) who underwent manual aspiration thrombectomy at the discretion of the operator for infra-aortic bypass graft thrombosis between 2002 and 2010 were retrospectively reviewed. The angiographic success described as either stenosis or residual thrombus less than 30% was 67%. Primary patency was 50%, and secondary patency was 66.7%. Additional stents were needed in four lesions of three patients. Manual aspiration thrombectomy is intended to remove both soft acute blood clots and hard organized embolic and thrombotic obstructions. Manual aspiration thrombectomy appears to be a safe and effective method for treating delayed graft thrombosis. This method provides an alternative to surgical thrombectomy, especially for patients who are not good candidates for the surgery.

Is unilateral breast enlargement always a sign of cancer

Breast swelling is caused by many etiological factors, but should alert central vein occlusion in hemodialysis patients when the permanent vascular access is in the same arm. The swelling of the breast is caused by venous hypertension in the venous plexus draining the breast. Endovascular treatment relieves venous hypertension and related clinical signs. Additional diagnostic workup or invasive interventions such as a biopsy should be avoided in such patients, as diagnosis is straightforward with the presence of a functioning arteriovenous fistula in the same arm.

Diffuse unilateral pediatric arteriopathy: successful treatment with repeated angioplasty.

We report a three-year-old girl exhibiting severe long-segment stenoses and occlusions with diffuse arterial involvement of the upper and lower extremities on the right side. The obstructive lesions, which caused atrophy of the right limb and chronic ulceration of the foot, were treated successfully with repeated percutaneous transluminal angioplasty. Obstructive peripheral arterial disease can cause growth retardation of the involved extremity, which can be salvaged by repeated endovascular therapy even in a small growing child.