Stefano Merolla

Foot Embolization During Limb Salvage Procedures in Critical Limb Ischemia Patients Successfully Managed With Mechanical Thromboaspiration: A Technical Note.

Purpose: To illustrate the use of a mechanical thromboaspiration device originally designed for clot retrieval in acute stroke in the treatment of acute distal embolism occurring during percutaneous revascularization of the femoropopliteal and below-the-knee arterial segments. Technique: The Penumbra system was adapted for aspiration of thrombus in the distal foot arteries as a standalone device. The 2 over-the-wire, tapered lumen catheters have long working lengths (139 cm for the 4MAX to 153 cm for the 3MAX) that allow advancement below the ankle even with a retrograde contralateral approach. Once the occluded arterial segment is reached, the catheters are connected to the dedicated pump for continuous vacuum aspiration. The use of the device is illustrated in 3 diabetic patients (1 woman and 2 men; ages 88, 70, and 73 years, respectively) undergoing limb salvage procedures who experienced distal embolization that would have seriously jeopardized the foot circulation. The lumens of the occluded arteries were restored without complication. Conclusion: While further evaluation in a larger cohort of patients is needed, this initial experience using the Penumbra system in the peripheral vasculature suggests that this is a rapid, effective approach to address intraprocedural foot embolization and avoid possible grave clinical sequelae.

Downstaging disease in patients with hepatocellular carcinoma outside up-to-seven criteria: Strategies using degradable starch microspheres transcatheter arterial chemo-embolization.

AIM To evaluate the downstaging rates in hepatitis C virus-patients with hepatocellular carcinoma (HCC), treated with degradable starch microspheres transcatheter arterial chemoembolization (DSM-TACE), to reach new-Milan-criteria (nMC) for transplantation. METHODS This study was approved by the Ethics Committee of our institution. From September 2013 to March 2014 eight patients (5 men and 3 women) with liver cirrhosis and multinodular HCC, that did not meet nMC at baseline, were enrolled in this study. Patients who received any other type of treatment such as termal ablation or percutaneous ethanol injection were excluded. DSM-TACE was performed in all patients using EmboCept(®) S and doxorubicin. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed measuring the longest enhancing axial dimension of each tumor according to the modified Response Evaluation Criteria In Solid Tumors measurements, and medical records were reviewed. RESULTS DSM-TACE was successfully performed in all patients without major complication. We treated 35 lesions (mean 4.3 per patient). Six of eight patients (75%) had their HCC downstaged to meet nMC. Every patient whose disease was downstaged eventually underwent transplantation. The six patients who received transplant were still living at the time of this writing, without recurrence of HCC. Baseline age (P = 0.25), Model for End-stage Liver Disease score (P = 0. 77), and α-fetoprotein level (P = 1.00) were similar between patients with and without downstaged HCC. CONCLUSION DSM-TACE represents a safely and effective treatment option with similar safety and efficacy of conventional chemoembolization and could be successfully performed also for downstaging disease in patients without nMC, allowing them to reach liver transplantation.

Mechanical thrombectomy of acute ischemic stroke with a new intermediate aspiration catheter: preliminary results

Background and purpose To report clinical and procedural outcomes of acute ischemic stroke patients after endovascular treatment with the new thromboaspiration catheter AXS Catalyst 6. Methods Patients with anterior and posterior circulation stroke were selected. Successful reperfusion defined as a Thrombolysis in Cerebral Infarction (TICI) score ≥2 b and 3-month functional independence defined as a modified Rankin Scale (mRS) ≤2 were the main efficacy outcomes. Symptomatic intracranial hemorrhage and mortality were the main safety outcomes. Results 107 patients were suitable for analysis. Mean age was 73.18±12.62 year and median baseline NIHSS was 17 (range: 3–32). The most frequent site of occlusion was the middle cerebral artery (MCA) (60.7%). 76.6% of patients were treated with AXS Catalyst 6 alone without the need for rescue devices or thromboaspiration catheters. Successful reperfusion was achieved in 84.1%, functional independence in 47.6%, symptomatic intracranial hemorrhage occurred in 3.7%, and mortality in 21.4%. Conclusions Endovascular treatment with AXS Catalyst 6 proved to be safe, technically feasible, and effective. Comparison analyses with other devices for mechanical thrombectomy are needed.

Re: Baseline and Early MR Apparent Diffusion Coefficient Quantification as a Predictor of Response of Unresectable Hepatocellular Carcinoma to Doxorubicin Drug-Eluting Bead Chemoembolization

From: Fabrizio Chegai, MD Stefano Merolla, MD Laura Greco, MD Marco Nezzo, MD Lorenzo Mannelli, MD, PhD Antonio Orlacchio, MD Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology (F.C., S.M., L.G., M.N., A.O.) University Hospital Tor Vergata Viale Oxford 88 001133 Rome, Italy; and Department of Radiology (L.M.) Memorial Sloan–Kettering Cancer New York, New York

Bailout Alternative Use of Re-entry Device to Achieve a Chronically Occluded Superficial Artery Recanalization without Detectable Origin

SFA chronic total occlusion (CTO) without a proximal stump is a challenging situation for peripheral interventionist [1]. Sometimes, even the combined antegrade/retrograde approach with popliteal access doesn’t allow a safe and effective recanalization of such chronically occluded vessel; thus there is a need of additional technical improvements. We describe a technique to overcome this situation by the alternative use of a reentry device to crossoccluded SFA CTO without detectable origin in two patients with several comorbidities that precluded a surgical approach.

Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset:

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Trans-splenic Embolization Plus Partial Splenic Embolization for Management of Variceal Bleeding Due to Left-Sided Portal Hypertension

Bleeding from gastric fundal varices (GFVs) is generally less frequent but more severe than bleeding from esophageal varices [1], and currently a gold standard treatment does not yet exist. The presence of GFVs without esophageal varices could be a sign of splenic vein occlusion because blood drainage is diverted by the coronary vein into the portal system within a framework of so-called left-sided portal hypertension (LSPH) [2]. Often LSPH may be due to iatrogenic splenic vein injury or ligation [3]. The importance of differentiating between left-sided and generalized portal hypertension lies in the distinct therapeutic management of each disease process. In the patient described here, since it proved impossible to achieve a safe and effective embolization throughout a previously placed TIPS that did not allow gastric veins (GVs) decompression, a percutaneous trans-splenic embolization (PTSE) of GFVs and two partial splenic embolizations (PSEs) were performed with the aim to reduce the splenic venous outflow. Case Report

Retrograde Endovascular Stenting of Preocclusive Celiac Artery Stenosis with Loop Technique Associated with Pancreaticoduodenal Artery Aneurysm Embolization

condition is often self-limited and can be managed conservatively (3). The greater omentum is typically supplied by the right and left gastroepiploic arteries. Previous studies using nuclear medicine (4) reported omental perfusion by an extrahepatic branch arising from the right hepatic artery identified during planning before embolization, thus showing the possibility of an anomalous hepatic branch irrigating the omentum. In the present case, retrospective digital subtraction angiography analysis revealed the presence of an anomalous small branch arising from the right hepatic artery irrigating a nonliver territory (Fig 1) and posteriorly the omental infarct seen on CT. The prevention of nontarget embolization is critical in transarterial chemoembolization and transarterial embolization but may be even more critical in radioembolization, where such complications can be associated with significant morbidity. This case emphasizes the importance of recognizing extrahepatic branches of the hepatic artery during transarterial therapies to avoid nontarget embolization.

Repeated Transarterial Chemoembolization with Degradable Starch Microspheres (DSMs-TACE) of Unresectable Hepatocellular Carcinoma: A Prospective Pilot Study

Objective: The aims of this study were to: a) evaluate tumor response rates using modified-Response-evaluation-criteria-in-solid-tumors (mRecist) criteria, b) evaluate safety of Degradable Starch Microspheres Trans-arterial-chemo-embolization (DSMs-TACE) for unresectable hepatocellular-carcinoma (HCC) treatment. Materials and Methods: We prospectively enrolled 24 HCC cirrhotic patients (21/3 M/F, mean age 66.3 years) to be treated with repeated DSMs-TACE procedures, performed at 4-6 week intervals on the basis of tumor response and patients tolerance. Clinical and biochemical evaluations were performed before and after each procedure. Treatment response was also assessed by Computed-tomography (CT) or Magnetic-resonance-imaging (MRI)-scan 4-6 weeks following each procedure. Results: In our experience, DSMs-TACE was both safe and effective. A total of 53 DSMs-TACE procedures were performed (2.2 per patient). No procedure-related death was observed. Complete Response (CR) was observed in 5/24 (20.8%), 4/17 (23.5%) and 5/12 (41.6%) patients after the first, second and third procedure, respectively. At the end of each treatment, all patients experienced at least a partial response. At the end of the repeated procedures, no differences between mono- or bi-lobar disease were observed in patients with CR (64.2% vs 50%; p=ns). In most cases, treatment discontinuation was due to worsening liver function. Conclusion: DSMs-TACE is a valid, well-tolerated alternative treatment to Lipiodol-TACE or DEB-TACE, as it has demonstrated to achieve a relatively high percentage of complete tumor necrosis. CR rates were similar between patients with mono- or bi-lobar disease indicating the possibility of carrying-out repeated procedure in a safe and effective way in both types of patients.

Intraprocedural Foot Embolization during In-Stent Restenosis Superficial Femoral Artery Recanalization: Plantar to Pedal Loop Aspiration Thrombectomy Technique Using the Penumbra MAX Catheter

1. Kundu S. Review of central venous disease in hemodialysis patients. J Vasc Interv Radiol 2010; 21:963–968. 2. Van Tricht I, De Wachter D, Tordoir J, Verdonck P. Hemodynamics and complications encountered with arteriovenous fistulas and grafts as vascular access for hemodialysis: a review. Ann Biomed Eng 2005; 33: 1142–1157. 3. Schmidt A, Zeller T, Sievert H, et al. Photoablation using the turbobooster and excimer laser for in-stent restenosis treatment: twelve-month results from the PATENT study. J Endovasc Ther 2014; 21:52–60. 4. Dippel EJ, Makam P, Kovach, et al; EXCITE ISR Investigators.Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis). JACC Cardiovasc Interv 2015; 8:92–101.