Stevo Duvnjak

Endovascular treatment of superior vena cava syndrome

AIM The aim of this study was to report our experience with palliative stent treatment of superior vena cava syndrome. METHODS Between January 2008 and December 2009, 30 patients (mean age 60.7 years) were treated with stents because of stenosed superior vena cava. All patients presented clinically with superior vena cava syndrome and according caval stenosis confirmed by computed tomography. The causes of stenoses were non-small cell carcinoma in 22 patients and small cell carcinoma in 8 patients. RESULTS In all patients the stents were placed as intended in all patients there was an immediate clinical improvement with considerable reduction in the edema of upper extremities and head. There was, however, continous dyspnea in five patients (17%) and two patients (7%) had persistent visible collateral venous circulations on the upper chest. There were no stent associated complications. All patients were followed clinically till death and the median follow-up period was 2.8 months (15-420 days). During follow-up three cases of stent thrombosis (one complete and two partial thrombosis) were observed. CONCLUSION Palliative care with stent implantation for superior vena cava syndrome is a minimal invasive and safe procedure with good clinical effect giving the patients a significant better quality of their residual life.

Palliative Treatment of Superior Vena Cava Syndrome with Nitinol Stents

This study aims to retrospectively evaluate the outcomes following nitinol stent placement for malignant superior vena cava syndrome. A total of 25 patients with thoracic malignancies were treated with self-expanding nitinol stents for superior vena cava syndrome (E*Luminexx [Bard GmbH/Angiomed, Karlsruhe, Germany], Sinus-XL [OptiMed Medizinische Instrumente GmbH, Ettlingen, Germany], and Zilver Vena [Cook Medical Inc., Bloomington, IN]). It was seen that the procedural success rate was 76% with all stents deployed as intended and no procedure-related complications but in five patients with 50% residual stenosis and one patient with stent occlusion within 48 hours after stent deployment. Stent occlusion occurred in further two patients during follow-up: one patient developed infection, thrombosis, and occlusion in the stent seen at 2-month follow-up, and one patient had stent occlusion at 4-month follow-up. The clinical success rate was 96%. Stent compression leading to a greater than 50% reduction in stent diameter was observed in three patients at follow-up. Overall 22 patients died at a mean follow-up of 3.5 months for reasons related to their underlying malignancy. It was concluded that the stent treatment for superior vena cava syndrome is a safe treatment with good clinical effect in patients with superior vena cava syndrome in the terminal phase of malignant disease. In this small patient population, no trends were observed which would suggest that outcomes vary by stent type, though additional, large-scale studies are needed.

Endovascular treatment of nonvariceal acute arterial upper gastrointestinal bleeding

Transcatheter arterial embolization as treatment of upper nonvariceal gastrointestinal bleeding is increasingly being used after failed primary endoscopic treatment. The results after embolization have become better and surgery still has a high mortality. Embolization is a safe and effective procedure, but its use is has been limited because of relatively high rates of rebleeding and high mortality, both of which are associated with gastrointestinal bleeding and non-gastrointestinal related mortality causes. Transcatheter arterial embolization is a valuable minimal invasive method in the treatment of early rebleeding and does not involve a high risk of treatment associated complications. A multidisciplinary approach is necessary in the treatment of these patients and should comprise gastroenterologists, interventional radiologists, anaesthesiologists, and surgeons to achieve the best possible results.

Uterine fibroid embolization with acrylamido polyvinyl microspheres: prospective 12-month clinical and MRI follow-up study:

Background Uterine fibroid embolization (UFE) is an effective minimally invasive treatment aimed to obtain complete fibroid infarction. Purpose To evaluate the degree of fibroid infarction after embolization with acrylamido polyvinyl alcohol microspheres (Bead Block). Material and Methods This prospective study included 26 pre-menopausal women in the period October 2013 to January 2015. UFE with the use of Bead Block microspheres 700–900 µm was obtained until flow stasis was achieved. Contrast-enhanced magnetic resonance imaging (MRI) was used to define residual contrast enhancement in the total fibroid burden and enhancement >10% was defined as insufficient embolization. The dominant fibroid volume and total uterine volume changes were assessed. Clinical outcome was analyzed using the quality of life questionnaire (UFS-QOL). Results Twenty-four of the 26 patients (92%) had a technically successful UFE with complete flow-stop in both uterine arteries. Twenty-two of the 26 patients (85%) completed 3 months of MRI control and 20 patients (77%) completed 12 months of MRI control. There were 16 of 22 patients (73%) with complete fibroid burden infarction and/or without residual contrast enhancement of the fibroids of more than 10% at 3 months of control. Six of 22 patients (27%) had insufficient fibroid burden infarction with residual contrast enhancement of more than 10%. Twenty-two and 18 of 26 patients completed the 3-month and 12-month questionnaire, respectively. UFS-QOL analyses showed that 91% of the patients had significant clinical improvement. Conclusion Sixteen of the 22 patients had complete fibroid burden infarction using Bead Block microspheres (700–900 µm); however, unacceptably high insufficient fibroid burden infarction in almost one-fourth of the patients were recorded.

Endovascular Management of Type I Endoleak with Fenestrated Aortic “Cuff” and Afterwards Treatment of Endoleak Type III

Endovascular aortic repair (EVAR) has become preferable treatment of abdominal aortic aneurysms because of proven mortality reduction as well as complications reduction compared with open surgery. Endoleak remains a primary complication of EVAR, however, and occurs in 20 to 25% of the patients. EVAR patients thus undergo lifelong surveillance for the presence of aneurysm expansion and endoleaks usually via computed tomographic angiography. We describe the endovascular management of an enlarged aneurysmal sac size 3 years after EVAR due to combined endoleak of types 1 and 3. We needed to use a fenestrated aortic cuff, a main body graft extension, and an aortouniiliac converter device to seal the leak. This case highlights the potential challenges in identifying and treating type III endoleaks.

Life-threatening Arterioenteric Fistula Bleeding Treated by Embolization

Arterioenteric fistula (AE) is a rare condition in which delayed diagnosis and inconclusive results after diagnostic tests are major problems. AE can be primary or secondary. Secondary AEs are often observed after reconstructive vascular surgery or graft erosion, whereas primary AE fistula is caused by aneurysm, infection, radiotherapy, trauma, neoplasm, foreign bodies, or peptic ulcers [1]. Surgical treatment is an option but has a high mortality rate (25–90%), mostly as a result of hemorrhagic shock or sepsis, and further, the morbidity rate is up to 50% among survivors [2]. Operative treatment aims at resecting the fistula, usually by implanting an extraanatomical bypass or replacement of the aneurysm with an in-situ autologous graft [3]. Patients with serious comorbidity are challenging to treat, and endovascular treatment could be lifesaving in these patients in particular. Publications of treatment with stent graft or embolization in AE have reported high technical success and lower procedural mortality compared with surgery [4], although a report of uncontrollable hemorrhage after coil embolization with after patient exsanguination has been published [5].

Assessment of uterine fibroid infarction after embolization with tris-acryl gelatin microspheres

Abstract Purpose: To evaluate the degree of fibroid infarction after uterine fibroid embolization (UFE) with tris-acryl gelatin microsphere (Embosphere) visualized by contrast-enhanced magnetic resonance imaging (MRI) and evaluation of the clinical outcome measured with symptom and quality of life questionnaire (UFS-QOL) after 3 months follow-up. Materials and Methods: A prospective study included twenty-six pre-menopausal women. UFE with Embosphere of 500–900 μm was performed. Residual contrast enhancement in the total fibroid burden was analyzed and residual contrast enhancement ≤10% was defined as a satisfactory result after embolization. The dominant fibroids and total uterine volumes were assessed by MRI before and at follow-up. The UFS-QOL questionnaire answers were analysed and compared. Results: Twenty-five of 26 patients (96%) had a technically successful UFE. Twenty-four of the patients (92%) had MRI controls 3 months after UFE of which 23 patients had complete or almost complete fibroid burden infarction without residual contrast enhancement of the fibroids of more than 10%. One patient had insufficient fibroid burden infarction. Twenty-three of the patients had UFS-QOL analyses of which 96% had significant clinical improvement. Conclusion: UFE with Embosphere of 500–900 μm gave satisfactory MRI results with residual fibroid contrast enhancement ≤10% and good clinical effect in 96% of patients.

Computed tomography scan based prediction of the vulnerable carotid plaque

BackgroundPrimary to validate a commercial semi-automated computed tomography angiography (CTA) –software for vulnerable plaque detection compared to histology of carotid endarterectomy (CEA) specimens and secondary validating calcifications scores by in vivo CTA with ex vivo non-contrast enhanced computed tomography (NCCT).MethodsFrom January 2014 to October 2016 53 patients were included retrospectively, using a cross-sectional design. All patients underwent both CTA and CEA. Sixteen patients had their CEA specimen NCCT scanned. The semi-automated CTA software analyzed carotid stenosis using different HU values defining plaque components. The predictive values of CTA based detection of vulnerable plaques were calculated. Quantification of calcifications on CTA using region of interest (ROI)-function and mathematical equations was done manually, and validated by NCCT of the CEA specimen.ResultsThe semi-automated CTA software had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 89.1% (95% CI, 73.6% - 96.4%), 31.3% (95% CI, 12.1% - 58.5%), 75% (95% CI, 59.3% - 86.2%) and 55.6% (95% CI, 22.6% - 84.6%). Strong correlation between in vivo CTA and ex vivo NCCT in quantification of calcification was observed, but CTA systematically underestimated calcificationsscore (CALS) with increasing calcification.ConclusionThe CTA-software cannot be used in risk assessment of patients, due to poor specificity and NPV. The correlation between in vivo CTA and ex vivo NCCT was strong, proposing it to be used in both scientifically and clinical settings, but studies with larger sample sizes are needed.

Pulmonary arteriovenous malformations: a radiological and clinical investigation of 136 patients with long-term follow-up

AIM To assess the clinical outcome of patients with and without hereditary haemorrhagic telangiectasia (HHT) after embolisation of pulmonary arteriovenous malformations (PAVM) from a single national centre. MATERIALS AND METHODS The present register-based observational study including all patients with PAVM treated with embolisation at a reference centre for HHT and PAVM was undertaken over a 20-year period. Demographic data, HHT genotyping, clinical presentation, and outcome were registered. Patients with HHT were compared to the patients without HHT. Clinical examination, contrast-enhanced echocardiography, and computed tomography (CT) were used to assess the clinical outcome at follow-up. RESULTS One hundred and thirty-six patients with 339 PAVM underwent embolisation during the study period: 22 did not have HHT; 62% had HHT1, 10% had HHT2, 4% had JP-HHT, 8% had clinical HHT without identified genetic mutations. Solitary PAVM were more common among patients without HHT than with HHT. Mean follow-up after the first embolisation was 58 months. Mean age at first embolisation was 46.5 years, and at last follow-up 51.8 years. The clinical success without shunt at follow-up was 87%. The 30-day mortality related to the embolisation was 0%. Twenty patients died during follow-up (mean age 69 years). Most patients could be treated during one session, but many will need a long follow-up with repeated clinical examinations and embolisation. CONCLUSION The majority of patients referred for embolisation of PAVM had HHT. Multiple PAVM is associated with HHT. Patients with PAVM should be screened for HHT and patients with HHT for PAVM. Embolisation is a safe procedure with high clinical success.

Two cases of high-output heart failure as initial presentation of iliac arteriovenous fistula

We present two cases of females in their 40s presenting with biventricular heart failure being the consequence of a large arteriovenous fistula. Both patients had undergone abdominal surgery several years prior to the heart failure event with the initial finding of moderate pulmonary hypertension and high-output heart failure. CT revealed a large arteriovenous fistula between the common iliac artery and vein which subsequently was closed percutaneously.