Vendelín Chovanec

Wedged hepatic venography for targeting the portal vein during TIPS: comparison of carbon dioxide and iodinated contrast agents.

Purpose: Carbon dioxide (CO2) can traverse the hepatic sinusoids better than iodinated contrast medium and has been used by many interventionalists for wedged hepatic venography during transjugular intrahepatic portosystemic shunt (TIPS) procedures. Our study was designed to compare the extent of the portal vein opacification using either CO2 or iodinated contrast medium. Methods: Wedged hepatic venography for portal vein opacification during TIPS was performed using hand injection through a 6.5 Fr diagnostic catheter. Portograms of 36 patients performed with 10 ml of iodinated contrast medium were retrospectively compared with portograms of 45 patients performed with 30-40 ml of CO2. Opacification of the right portal vein branch including the portal vein bifurcation was defined as a successful study. Results: Using CO2 the right portal vein branch and the portal vein bifurcation were opacified in 87% of patients (39 of 45); only a part of the right portal vein branch was opacified in 6% of patients and no opacification of any portal vein branch was seen in 7% of patients. Using iodinated contrast medium, there was opacification of the portal vein bifurcation in 25% of patients (9 of 36), of a part of the portal vein branch in 36% and no opacification of any branch in 39%. There was one case of hepatic laceration from CO2 wedged venography which was treated with microcoil embolization. Conclusions: Using CO2 as a contrast medium, opacification of the portal vein bifurcation by wedged hepatic venography was seen in 87% of patients, in comparison with only 25% when iodinated contrast medium was used (p < 0.001). CO2 is superior to iodinated contrast medium for wedged hepatic venography during TIPS.

Influence of the Secondary Deployment of Expanded Polytetrafluoroethylene–covered Stent Grafts on Maintenance of Transjugular Intrahepatic Portosystemic Shunt Patency

PURPOSE To evaluate the effects of secondary deployment of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts in the treatment of dysfunctional transjugular intrahepatic portosystemic shunts (TIPSs) in comparison with other common approaches (conventional angioplasty or implantation of bare metal stents). MATERIALS AND METHODS A retrospective review of 121 dysfunctional bare metal TIPS presenting between 2000 and 2004 was conducted. The group was divided into four subgroups according to the type of intervention: conventional angioplasty (52 cases; 43%), bare metal stent deployment (35 cases; 28.9%), nondedicated ePTFE-covered stent-graft deployment (15 cases; 12.4%), and dedicated ePTFE-covered stent-graft deployment (19 cases; 15.7%). In all four groups, the primary patency after the specific intervention was calculated and mutually compared. RESULTS Primary patency rates after 12 and 24 months were 49.7% and 25.3%, respectively, in conventional angioplasty; 74.9% and 64.9%, respectively, with bare metal stents; 75.2% and 64.5%, respectively, with nondedicated ePTFE-covered stent grafts; and 88.1% and 80.8%, respectively, with dedicated ePTFE-covered stent grafts. CONCLUSIONS In the treatment of dysfunctional TIPS, better patency after the intervention was obtained by deploying dedicated ePTFE-covered stent grafts in comparison with conventional angioplasty, bare metal stents, and nondedicated ePTFE-covered stents.

Autologous vein stent-graft: feasibility study.

PURPOSE To evaluate expandable stents healed into vein wall as autologous vein stent-grafts for endoluminal grafting. MATERIALS AND METHODS Balloon expandable stents were placed into external jugular veins of eight dogs. Stent and vein patency was followed by ultrasonography. Five weeks after stent placement, jugular veins with endothelialized stent were harvested. The autologous vein stent-grafts were divided into two groups. In group A, autologous vein stent-grafts (n = 3) were placed immediately into Baker solution for microscopic examination. In group B, autologous vein stent-grafts (n = 3) underwent mechanical manipulation; they were compressed, mounted on angioplasty balloon, pushed through a 9-F sheath and dilated. The autologous vein stent-graft endothelialization and changes after mechanical manipulation were evaluated by light and electron microscopy. RESULTS Stent placement was successful in seven dogs. One stent migrated into the pulmonary artery. One well placed stent was damaged by compression dressing and thrombosed. At 5 weeks, gross and microscopic examinations revealed the autologous vein stent-grafts were fully covered by a 0.115- +/- 0.036-mm-thick neointimal layer. Small wall thrombus was observed in one autologous vein stent-graft. Repeated manipulations did not result in any intimal damage or stent loosening in the autologous vein stent-grafts. CONCLUSION Expandable stents healed into a vein have potential to be used as autologous vein stent-grafts for endoluminal grafting without risk of disruption during percutaneous transcatheter introduction.

TIPS creation in a patient with situs inversus totalis.

We describe the successful creation of a transjugular intrahepatic portosystemic shunt (TIPS) in a patient with complete situs inversus using a simple modification of the standard TIPS technique.

Popliteal Venous Aneurysm as a Cause of Recurrent Pulmonary Embolism

We report 2 cases of recurrent pulmonary embolism (PE) in popliteal venous aneurysm (PVA). Patients were 78-year-old and 72-year-old women. Both were initially seen for acute PE. Saccular and fusiform PVAs were diagnosed in each patient based on duplex ultrasound. However, despite anticoagulation therapy, both patients had PE. At the time of the event, 1 patient was receiving inadequate dose of low-molecular-weight heparin. The other patient was treated with warfarin and had adequate international normalized ratio at the time of re-embolism, and thus, an inferior vena cava filter was inserted. Both patients underwent successful aneurysm resection without any additional thromboembolic events.

Stent-grafts in TIPS

The transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous, minimally invasive method of reducing an increased portal pressure in patients with symptomatic portal hypertension. TIPS is done under local anesthesia on awake, mildly sedated patients and can be performed in emergency settings, in patients at both extremes of age, and in those with poor liver function and massive ascites who often are not considered candidates for shunt surgery. In the past decade, TIPS has been shown to be effective in variceal bleeding, refractory ascites, portal gastropathy, hepatic hydrothorax, and the Budd-Chiari syndrome [1]. During a TIPS procedure an intrahepatic shunt is performed by using an expandable stent to connect a large hepatic vein with a main branch of the portal vein. The major disadvantage of TIPS is the high rate of stenoses or occlusions necessitating careful follow-up of these patients and repeated interventional corrections of insufficient shunts. Depending on the definition of the shunt stenosis and surveillance protocols, stenoses of greater than 50% have been reported in 25% to 50% of cases within 6 to 12 months of shunt creation [2–5]. However, these patients were rarely symptomatic, and recurrent variceal bleeding was seen in fewer than 25% of patients with significant TIPS stenosis [6, 7]. The high rate of shunt stenoses is the major reason for the relatively poor cost effectiveness of TIPS when compared with endoscopic or surgical treatment. Significant research has been carried out to improve primary shunt patency. In a series of animal and human studies, several investigators have reported a significant reduction in the development of TIPS stenoses with the use of covered stents, i.e., stent-grafts. The graft material can provide a barrier between the flowing blood and the traumatized liver parenchyma. In addition to improving primary and secondary patency of TIPS, stent-grafts play an important role in sealing off an extrahepatic portal vein leak during TIPS [8]. Worsened encephalopathy after TIPS can be treated more easily by using a special design of constrained stent-graft creating shunt stenosis than by previously described shunt reduction methods [9]. The use of stent-grafts that traverse malignant hepatic tumor in TIPS potentially can prevent tumor invasion into the shunt and reduce the possibility of vascular spread and seeding of tumor in the lungs [10, 11]. The purpose of this paper is to analyze the causes of TIPS stenoses and occlusion and summarize the current results of experimental and clinical uses of stent-grafts. The role of stent-graft implantation in sealing an extrahepatic portal vein leak, a rare but potentially fatal complication of TIPS procedure, also is discussed.

Integration of Endovascular Therapy of Ruptured Abdominal and Iliac Aneurysms in the Treatment Algorithm: A Single-Center Experience in a Medium-Volume Vascular Center

Purpose: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. Materials and Methods: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. Results: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. Conclusion: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

Mechanical recanalization in ischemic anterior circulation stroke within an 8-hour time window: a real-world experience

PURPOSE We aimed to assess the safety and effectiveness of mechanical recanalization in patients with ischemic stroke in the anterior circulation within 8 h since symptoms onset and with unknown onset time. We compared time intervals <6 h vs. 6-8 h/unknown onset time, as only limited data are available for a time window beyond 6 h. METHODS Our cohort included 110 consecutive patients (44 males; mean age, 73.0±11.5 years) with ischemic stroke in the anterior circulation due to the acute occlusion of a large intracranial artery who underwent mechanical recanalization within an 8-hour time window or with unknown onset time. All patients underwent unenhanced computed tomography (CT) of the brain, CT angiography of the cervical and intracranial arteries and digital subtraction angiography. Perfusion CT was performed in patients beyond a 6-hour time window/with unknown onset time. We collected the following data: baseline characteristics, presence of risk factors, neurologic deficit at the time of treatment, time to therapy, recanalization rate, and 3-month clinical outcome. Successful recanalization was defined as Thrombolysis in Cerebral Infarction score of 2b/3 and good clinical outcome as modified Rankin scale value of 0-2 points. RESULTS Successful recanalization was achieved in 82 patients (74.5%): in 61 patients treated within 6 h (73.5%), 7 patients treated within 6-8 h (63.6%), and 13 patients with unknown onset time (81.3%). Good 3-month clinical outcome was achieved in 61 patients (55.5%): in 46 patients treated within 6 h (55.4%), 5 patients treated within 6-8 h (45.5%), and 10 patients with unknown onset time (62.5%). Recanalization success or clinical outcome were not significantly different between patients treated at different time windows. CONCLUSION Our data confirms the safety and effectiveness of mechanical recanalization performed in carefully selected patients with ischemic stroke in the anterior circulation within 8 h of stroke onset or with unknown onset time in everyday practice.

Long-term experience with endovascular therapy of the descending thoracic aorta

BackgroundTo review single centre experience of endovascular treatment of descending thoracic aorta.MethodsBetween May 1999 and September 2012, 72 patients were treated overall (53 men, 19 women, mean age 60.1 years) for degenerative aneurysms (n = 5), ruptured aneurysms (n = 4), aortic ulcers (n = 8), infected aneurysms (n = 4), type B aortic dissections (n = 23), and traumatic aortic injuries (n = 28).ResultsThe technical success rate was 98.6%, 30-day mortality was 8.3%, 1-year mortality was 13.8%, and overall mortality was 22.2%. Mortality caused by the treatment of aortic diseases was 6.9%. Permanent stroke occurred in 1 patient, and paraplegia developed in 1 patient. In a group of 23 patients whose left subclavian artery (LSA) was covered, claudication of the left upper extremity developed in 2 cases.ConclusionsEndovascular therapy offers a very effective and less invasive alternative to the surgical approach for a wide range of the thoracic aortic disease. The main advantage of using TEVAR seems to be in acute conditions when a stent graft stabilizes the aorta and prevents further bleeding and organ ischemia. Regular follow-up is mandatory for early recognition of specific TEVAR complications.

TIPS creation in patients with persistent left superior vena cava.

Transjugular intrahepatic portosystemic shunt is a minimally invasive endovascular procedure that has played an important role in the treatment of acute or repeated variceal bleeding or refractory ascites. The standard venous access route for this procedure is the right jugular vein. Sometimes it is better to use the left jugular vein because of lower probability of life threatening complication or technical failure. In this case reports the authors have described their experience with TIPS creation in two patients with persistent left and absent right superior vena cava and recommend using the left jugular vein as an access route in this rare anatomical variant.