Stephen D. Goode

Randomized clinical trial of stents versus angioplasty for the treatment of iliac artery occlusions (STAG trial).

The management of total iliac artery occlusion is now undertaken routinely using percutaneous techniques but there are no controlled data to indicate whether either balloon angioplasty or stent placement is preferable. This was a multicentre randomized trial to assess whether stents confer any safety or efficacy advantage over balloon angioplasty for complete iliac artery occlusion.

Assessment of Reverse Flow as a Means of Cerebral Protection during Carotid Artery Stent Placement with Diffusion-weighted and Transcranial Doppler Imaging

PURPOSE To assess the effectiveness of flow reversal as an alternative means of cerebral protection by using transcranial Doppler recordings and diffusion-weighted imaging (DWI) as surrogate markers of brain injury. MATERIALS AND METHODS Eighteen patients with symptomatic carotid artery disease were recruited. Magnetic resonance imaging was performed before the intervention and at 3 and 24 hours and 30 days after the intervention to detect new ischemic lesions with DWI. Transcranial Doppler recordings were made during the procedure to assess for microembolic signals (MESs). Data were compared against data from a historical control cohort of patients who underwent CAS placement with or without filter protection (n = 15 each) under the same protocol in a different study. RESULTS There were fewer periprocedural new lesions on DWI in the reverse-flow cohort compared with the historical control cohort with filter protection (P = .084). Reverse flow revealed significantly fewer MESs during the whole procedure compared with the filter-protected group (P = .01) but not the unprotected group (P = .55). There was a marked decrease in MES counts for reverse flow protection during the embologenic stages of the procedure (P = .004). CONCLUSIONS Use of the reverse flow device was associated with fewer overall lesions on DWI and proportionately fewer positive scans compared with the use of filter-type devices (P = .08, not significant). Transcranial Doppler recordings demonstrated a significant reduction in embolization to the brain during carotid artery stent placement with the use of reverse-flow cerebral protection.

Ten-year experience of retrievable inferior vena cava filters in a tertiary referral center

PURPOSE A significant proportion of patients undergoing surgery have an increased incidence of acute pulmonary embolus (PE). We analyzed all patients who had a retrievable inferior vena cava (IVC) filter placed preoperatively for PE prophylaxis and investigated the long-term outcomes of the patients who did not have their filter removed. METHODS Patients who underwent retrievable IVC filter insertion and attempted removal were identified from the radiology information systems database in a large tertiary referral university teaching hospital. Results of all clinical investigations (including computed tomography, magnetic resonance imaging, ultrasonography, and plain radiography) while the IVC filters were in situ were reviewed. RESULTS In total, 393 retrievable IVC filters were inserted, 254 with the indication of preoperative thromboembolic prophylaxis. Recurrent PE was reported in five patients (1.9%) despite the IVC filter. Of the 254 retrievable filters inserted prior to surgery, an attempt at retrieval was made in 168 filters (66.1%). Successful retrieval at the first attempt occurred in 143 cases (85.1%), while 25 cases failed or were aborted (14.9%). No attempt at retrieval was made in 86 (33.9%) patients and a significant proportion of these patients had undergone cancer surgery (P < 0.0107). In those patients where there was no attempt at retrieval, there was an association between cancer surgery and a shorter absolute survival time (P < 0.0001). CONCLUSION The majority of attempted filter retrievals were successful, and a proportion of nonretrieved IVC filters are accounted for in patients who underwent cancer surgery and ultimately died with the filter in situ. A departmental protocol is recommended to ensure the filter is removed where appropriate and possible.

Carotid and Vertebral Artery Intervention

Stroke is the third most common cause of death worldwide. Current treatments for significant carotid artery stenotic disease include carotid endarterectomy and carotid artery stenting. We present a synopsis of the current evidence available comparing these two treatments in addition to indications, technical aspects and post-procedural care for patients undergoing carotid artery stenting. Similarly we present the indications, technical aspects and post-procedural details for vertebral artery intervention.

Liver Tract Sealing with Hep-Plug™ Sealing System Improves Haemorrhage Control for Patients Undergoing Transhepatic Procedures

We read with great interest the article by Kortes et al. [1] entitled Occlusion of a Long-term Transpleural Biliary Drainage Tract Using a Gelatin Pledget (Hep-Plug), and congratulate the authors on their excellent paper. We have worked extensively with the Hep-Plug and helped in its development here in Sheffield and would like to propose it has further benefits for patients with regard to haemorrhage control and also potentially improved mortality rates. We have previously published our work on hepatic tract closure in CVIR journal in 2013 entitled Hepatic Tract PlugEmbolisation After Biliary Stenting. Is It Worthwhile? [2]. In this paper we proposed that the embolisation of the liver tract after transhepatic biliary intervention is a priority for patients and has improvements in outcomes for patients specifically with regard to haemorrhage control. When performing transhepatic procedures we undoubtedly cross not only small peripheral hepatic arteries, but also branches of the hepatic vein and portal vein. Quantification of haemorrhage from these vessels is difficult. Post-procedurally, we can be alerted to bleeding complications if the patient has catastrophic haemorrhage and becomes unstable. However, more often only subtle findings are apparent from a postprocedural CT or haemoglobin decrease on post-op bloods. Dedicated liver tract closure can help to prevent these serious post-operative bleeding complications. Our previously published paper [2] utilised an off-label biopsy plug device (Hunter device, Vascular Solutions, Minneapolis, theUSA) for tract closure. However, this device is not indicated for transhepatic interventions, and while providing a marker for embolisation to help in placement, it probably does not entirely close the tract due its limited swell and expansion properties. The device utilised in the attached article was theHep-Plug transhepatic sealing system (HepPlug, Vascular Solutions, Minneapolis, the USA) with specifically designed IFU to close the liver tract. The gelatin pledget has far superior radial expansion and embolic properties compared to theHunter device. Asmentioned byKortes et al. the properties of the gelatin pledget used in the HepPlug transhepatic closure system have previously been presented by Isenburg et al. [3] at the SIR conference in 2016. The degradation time of the pledget in there presented animal model was slow duringweeks 2–4 and significantly increased during weeks 4–12 post-insertion. At 26 weeks the pledget material was completely degraded and no residual gelatin tissue was present and the previous hole made in the liver parenchyma was completely obliterated. First-in-man Hep-Plug deployment was performed here in Sheffield, and we collated our initial cases and have presented this work at the Cardiovascular and Interventional Society of Europe Congress 2016 [4]. We showed superior haemorrhage control over the Hunter device and improved outcomes for patients undergoing PTC procedures. An interesting finding of this work was the fact that we showed a near-significant (P = 0.07) improvement in 30-daymortality for patients undergoing PTC procedures. We concluded this was due to improved liver tract closure and true sealing of the & Stephen D. Goode s.goode@sheffield.ac.uk

Superficial Temporal Artery Cut Down to Facilitate Endovascular Treatment of External Carotid Artery Pseudoaneurysms

Carotid pseudoaneurysms are rare but may present a lifethreatening condition, particularly when associated with rupture, occlusion, or thromboembolism [1]. The etiology of carotid pseudoaneurysms includes blunt or penetrating trauma and vasculitis, as well as iatrogenic and unknown causes [1]. Historically, carotid pseudoaneurysms have been managed operatively by repair or ligation with percutaneous stenting and coil embolization emerging during the past two decades [2]. The surgery often is complicated due to the presence of associated scarring; therefore, the endovascular option has become attractive alternative with minimal morbidity and high success rate. However, introduction of a sheath or guiding catheter into the common carotid artery (CCA) can be difficult in patients with adverse aortic arch anatomy or concomitant atherosclerotic disease in the peripheral vessels or aorta. In addition, selectively catheterizing the external carotid artery (ECA) can be challenging due to the distorted anatomy by the pseudoaneurysm. We submit an exceptional case of superficial temporal artery cut down to facilitate ECA coil embolization after failed conventional approach from the common carotid artery route. To the best of our knowledge, this is the first case in the literature that describes this technique to treat ECA false aneurysm.