Tianxiao Li

Feasibility and midterm outcomes of percutaneous transhepatic balloon angioplasty for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction

OBJECTIVES This study evaluated the feasibility and outcomes of percutaneous transhepatic balloon angioplasty (PTBA) of the hepatic vein in the management of Budd-Chiari syndrome (BCS) secondary to hepatic venous outflow obstruction. METHODS From September 1996 to October 2008, 101 patients (52 males, 49 females) with BCS secondary to occlusion of the hepatic veins were prospectively treated using PTBA of the hepatic vein. Average age was 31.3 years (range, 15-57 years). Nineteen had concurrent inferior vena cava (IVC) obstruction. All the patients presented with symptomatic portal hypertension. PTBA, with or without stenting, was performed after hepatovenography. RESULTS PTBA was successfully performed in 92 of the 101 patients. Sixty-eight patients underwent PTBA of right hepatic vein, followed by stent placement in two. PTBA was performed in 11 patients with left hepatic vein occlusion and in 13 patients with dominant accessory hepatic vein occlusion. The technical success rate was 92 of 101 (91%). Hepatic venous pressure was significantly decreased after balloon angioplasty/stenting (P < .01, paired t test). Symptoms were significantly improved in the 92 patients who had successful PTBA. Three patients had acute hepatic vein thrombosis during or after PTBA. Two patients sustained intraperitoneal bleeding from the transhepatic puncture track, and one had intrahepatic hematoma. Pulmonary embolism developed in one patient during the operation. All complications were managed nonoperatively. There were no perioperative deaths. Within 1 year, 74 of the 101 patients returned for follow-up, and 51 patients had follow-up at 2 years. The primary patency rates were 84% (62 of 74), 78% (58 of 74), and 76% (39 or 51) at 6, 12, and 24 months after PTBA, respectively. The secondary patency rates were 95% (70 of 74), 92% (68 of 74), and 84% (43 of 51) at 6, 12, and 24 months. CONCLUSIONS PTBA of the hepatic vein is a safe and effective treatment of BCS. It is currently the most physiologic procedure, and the risk of postoperative encephalopathy is minimized because portal flow is not diverted. Midterm outcomes are satisfactory. Further investigation of the long-term outcomes is needed.

Warfarin anticoagulation before angioplasty relieves thrombus burden in Budd-Chiari syndrome caused by inferior vena cava anatomic obstruction

OBJECTIVES Pulmonary embolism (PE) is one of the major complications after percutaneous balloon angioplasty (PTBA) for Budd-Chiaris syndrome (BCS). The purpose of this study was to investigate the role of warfarin pre-treatment in the prevention of PE after PTBA in patients with large inferior vena cava (IVC) thrombus. PATIENTS AND METHODS From October 2002 to December 2009, 16 patients with symptomatic membranous or segmental IVC occlusion and large thrombus were treated with warfarin before PTBA. Eleven patients were men and 5 were women. The median age was 36 years, ranging from 21 to 52 years. The median duration of warfarin treatment before PTBA was 7 months, ranging from 3 to 12 months. Fourteen patients had membranous IVC occlusion and 2 had segmental occlusion. All 16 patients had significant thrombi underneath the obstructive lesions. PE diagnosis was based on clinical presentation and pulmonary computerized tomographic angiogram, if indicated. RESULTS In 14 of 16 patients, IVC thrombus was completely or near-completely resolved based on follow-up cavogram and PTBA was performed. In the other 2 patients, residual thrombus was demonstrated by cavogram at 12 months. PTBA and stent placement were carried out. IVC patency in the 16 patients was confirmed by completion cavogram. No major bleeding complication during warfarin pre-treatment aimed to keep international normalized ratio (INR) 2 to 3. There was no clinically significant PE or death in this group during follow-up, ranging from 6 to 40 months (median 21 months). CONCLUSION Spontaneous fibrinolysis of IVC thrombus occurs within 1 year in the majority of the patients treated with warfarin. Pre-treatment with warfarin prevents PE after PTBA in the patients with BCS with IVC membranous or segmental occlusion and large thrombus.

Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion.

BACKGROUND Endovascular recanalization and stenting has been used to treat patients with symptomatic nonacute intracranial vertebrobasilar artery occlusion (VBAO) refractory to aggressive medical treatment. This study was performed to analyze the perioperative complications of the procedures. METHODS Between February 2010 and March 2012, 27 consecutive patients (24 men, 3 women; age: 57 ± 10 years) with symptomatic, nonacute intracranial VBAO including 12 basilar artery occlusions and 15 vertebral artery occlusions were collected and retrospectively analyzed. RESULTS The median time between symptom onset and recanalization was 1.5 months (interquartile range [IQR]: 0.7-3.4) and between imaging-documented occlusion and recanalization was 9.5 days (IQR: 6-18 days). Recanalization was achieved in 96% of patients (26/27). Five (5/27; 19%) perioperative complications occurred. Two patients had dissections: 1 dissection resulted in termination of the procedure without successful recanalization, and the other was handled by the placement of 2 stents. There was 1 intraprocedural acute thrombosis that was successfully treated with balloon angioplasty. One patient experienced thrombus disruption and translocation during the procedure: thrombus was dislodged after disruption by the guidewire. There was 1 acute reocclusion after procedure: while recanalization was achieved again, there was no improvement in clinical outcome. CONCLUSIONS This study revealed that recanalization and stenting for nonacute VBAO may be technically feasible but that it is accompanied by a high risk of complication. The causative factors for perioperative complications need future study.

Interventional Therapy for the Treatment of Severe Hemobilia After Percutaneous Transhepatic Cholangial Drainage: A Case Series

From May 2003 to May 2010, a total of 9 patients with severe hemobilia after percutaneous transhepatic cholangial drainage (PTCD) were diagnosed using superselective angiography and cholangiography, and then were treated with interventional procedures. Two patients with hepatic arterio-biliary fistula underwent proximal and distal arterial embolization of the responsible vessel. Six patients with pseudoaneurysm had pseudoaneurysm occlusion with proximal and distal embolization. Another patient with biliary-portal vein fistula received a biliary fully covered stent placement. The effects in these patients were evaluated using superselective angiography immediately after the intervention and at 3- and 6-month follow-up. In all patients, hemobilia was stopped right after the treatment and no sign of recurrence was noted at 3- and 6-month follow-up after the interventional therapy. Our findings demonstrate that interventional therapy is a simple, minimally invasive, and safe approach for treating severe hemobilia in patients receiving PTCD.

Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms

Background Coil embolization of intracranial aneurysms is being increasingly used; however, thromboembolic events have become a major periprocedural complication. Objective To determine the safety and efficacy of prophylactic tirofiban in patients with ruptured intracranial aneurysms. Methods Tirofiban was administered as an intravenous bolus (8.0 μg/kg over 3 min) followed by a maintenance infusion (0.10 μg/kg/min) before stent deployment or after completion of single coiling. Dual oral antiplatelet therapy (loading doses) was overlapped with half the tirofiban dose 2 h before cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. Results Tirofiban was prophylactically used in 221 patients, including 175 (79.19%) who underwent stent-assisted coiling and 46 (20.81%) who underwent single coiling, all in the setting of aneurysmal subarachnoid hemorrhage. Six (2.71%) cases of intracranial hemorrhage occurred, including four (1.81%) tirofiban-related cases and two (0.90%) antiplatelet therapy-related cases. There were two (0.90%) cases of fatal hemorrhage, one related to tirofiban and the other related to dual antiplatelet therapy. Thromboembolic events occurred in seven (3.17%) patients (6 stent-assisted embolization, 1 single coiling), of which one (0.45%) event occurred during stenting and six (2.72%) occurred during intravenous tirofiban maintenance. No thromboembolic events related to dual antiplatelet therapy were found. Conclusions Tirofiban bolus over 3 min followed by maintenance infusion appears to be a safe and efficient prophylactic protocol for the endovascular treatment of ruptured intracranial aneurysms and may be an alternative to intraoperative oral antiplatelet therapy, especially in the case of stent-assisted embolization.

Mechanism and Management of Retrograde Type A Aortic Dissection Complicating TEVAR for Type B Aortic Dissection

BACKGROUND This study is to investigate the causes, treatment methods, and preventive measures of retrograde type A aortic dissection (RAAD) complicating thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). METHODS From January 2005 to December 2013, 360 TBAD patients receiving TEVAR were enrolled in this study. Among them, 304 cases were male and 56 cases were female. They were from 19 to 85 years old, with a mean age of 52 ± 12.8 years old. The average follow-up time was 32 ± 11.3 months (3-63 months), the follow-up rate was 69.1% (249 cases), and the lost rate was 30.9% (111 cases). The reasons and the treatment methods of RAAD complicating TEVAR for TBAD were analyzed. RESULTS There were 5 cases of RAAD complicating TEVAR in TBAD (1.4%) patients, among them, 4 cases were male and 1 case was female. TEVAR operation failed in 1 case because of RAAD occurrence during TEVAR. This case was treated with open operation. In the other 4 cases, TEVAR operation was successfully carried out. During follow-up, RAAD was found in 3 cases within 1 month after TEVAR and in 1 case at 1 year after TEVAR. Conservative treatment was applied to 2 cases, whereas surgical operation treatment was performed in the other 3 cases. One case of conservative treatment patient was dead, and the other 4 cases are still alive. CONCLUSIONS Incomplete design of stent-graft system, rough handling and presence of vascular wall lesions are the main reasons of RAAD complicating TEVAR for TBAD. Surgical operation is the most effective treatment measure for RAAD complicating TEVAR for TBAD.

Wingspan Stenting for Severe Symptomatic Intracranial Atherosclerotic Stenosis in 433 Patients Treated at a Single Medical Center.

Purpose To investigate the safety and outcome of intracranial stenting for intracranial atherosclerotic stenosis (IAS). Materials and Methods Between July 2007 and April 2013, 433 consecutive patients with IAS >70% underwent intracranial Wingspan stenting, and the data were prospectively analyzed. Results Intracranial stenting was successful in 429 patients (99.1%), and the mean stenosis rate was improved from prestenting (82.3± 7.6)% to poststenting (16.6 ± 6.6)%. During the 30-day perioperative period, 29 patients (6.7%) developed stroke. The total perioperative stroke rate was significantly (P <0.01) higher in the basilar artery area than in others, whereas the hemorrhagic stroke rate was significantly (P <0.05) greater in the middle cerebral artery area than in others. The experience accumulation stage (13%) had a significantly (P <0.05) higher stroke rate than the technical maturation stage (4.8%). Clinical follow-up 6–69 months poststenting revealed ipsilateral stroke in 20 patients (5.5%). The one- and two-year cumulative stroke rates were 9.5% and 11.5%, respectively; the two-year cumulative stroke rate was significantly (P <0.05) greater in the experience accumulation stage (18.8%) than in the technical maturation stage (9.1%). Conclusion Wingspan stenting for intracranial atherosclerotic stenosis is safe and the long-term stroke rate after stenting is low in a Chinese subpopulation.

Symptomatic intracranial vertebral artery atherosclerotic stenosis (≥70%) with concurrent contralateral vertebral atherosclerotic diseases in 88 patients treated with the intracranial stenting

PURPOSE To investigate the safety, effect and instent restenosis rate of Wingspan stenting in treating patients with intracranial vertebral artery atherosclerotic stenosis (70-99%) concurrent with contralateral vertebral artery atherosclerotic diseases. MATERIALS AND METHODS Eighty-eight patients with severe symptomatic intracranial vertebral artery atherosclerotic stenosis (≥70%) combined with contralateral vertebral artery atherosclerotic diseases were treated with the Wingpsan stent. All the baseline, cerebral angiography, success rate, perioperative complications, clinical and imaging follow-up data were prospectively analyzed. RESULTS The success rate of stenting was 100%, and the mean stenotic rate was reduced from prestenting (84.9±6.8)% to poststenting (17.2±5.9)%. The perioperative stroke rate was 1.1%. Among eighty patients (90.9%) with clinical follow-up 8-62 months (mean 29.3±17.2) poststenting, five (6.3%) had posterior circulation TIA only, three (3.8%) had mild stroke in the posterior circulation but recovered completely, and another five patients greater than 70 years old died of non-ischemic stroke. Imaging follow-up in 46 patients (52.3%) 5-54 months (mean 9.9±9.9) following stenting revealed instent restenosis in 12 patients (26.1%) including 7 (58.3%) symptomatic restenosis. Age and residual stenosis were the two factors to significantly (P<0.05) affect instent restenosis. CONCLUSION Wingspan stenting in the intracranial vertebral artery atherosclerotic stenosis combined with contralateral vertebral artery atherosclerotic diseases has a low perioperative stroke rate and a good preventive effect on long-term ischemic stroke, but the instent restenosis rate is a little high.

Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy.

The aim of this study was to evaluate the safety and efficacy of multimodal reperfusion therapy (MMRT) for tandem internal carotid artery and middle cerebral arterial (TIM) occlusions. Cases of TIM occlusion were collected and retrospectively reviewed. The analyzed objects included etiology, sites of tandem occlusion, collateral flow, location and size of infarcts. Combined with mechanical recanalization techniques and its complications, the National Institute of Health Stroke Scale (NIHSS) score and imaging data that was derived pre- and post-procedure were further contrasted. The study enrolled six patients with TIM occlusions. The mean NIHSS score on admission was 17 (range 13–20) and the median time from puncture to recanalization was 141 min (range 60–230). The substantial recanalization rate (Thrombolysis in Cerebral Infarction 2b or 3) was 83.3% and no symptomatic intracerebral hemorrhage was observed. The mean NIHSS score after three days was 14 (range 10–19) and 9 (range 3–17) following discharge. However, one patient died of pulmonary infection one month after discharge. For the five patients who survived, the modified Rankin Scale was evaluated at three months, with scores of 3, 1, 3, 5 and 3, respectively. It is concluded that endovascular therapy for acute TIM occlusions are complex, MMRT may be relatively safe and effective.

Evaluation of the JRecan device for thrombus retrieval: efficacy and safety in a swine model of acute arterial occlusion

Objective To evaluate the recanalization efficacy and safety of a novel stent retriever in a swine model of acute arterial occlusion. Methods The JRecan thrombectomy device, a stent retriever with a weaving stent design, was evaluated in 18 occluded cervicocerebral vessels of swine. The flow restoration effect immediately upon deployment, the reperfusion rate after retrieval, thromboembolic events, and complications were assessed. The histologic structure of the renal arteries after retriever passage was measured to further assess the safety of JRecan. Results Immediate flow restoration was achieved in 66.7% of occlusions (12/18). The reperfusion rate was 94.4% (two Thrombolysis in Cerebral Infarction (TICI) 2b and 15 TICI 3). Distal thromboembolic events did not occur. Microscopic examination of the arteries after retrieval showed mild degrees of endothelial loss in 96.6% (29/30), fibrin or platelet deposition in 53.3% (16/30), and disruption of the internal elastic lamina in 10% (3/30), without severe pathologic lesions. Conclusions The JRecan is highly effective at clot removal with a favorable safety profile and merits further development as a stent retriever for the treatment of acute ischemic stroke.