Safety and efficacy of an integrated endovascular treatment strategy for early hepatic artery occlusion after liver transplantation

Background:Hepatic artery occlusion(HAO)after liver transplantation(LT)is typically comprised of hepatic artery thrombosis(HAT)and stenosis(HAS),both of which are severe complications that coexist and interdependent.This study aimed to evaluate an integrated endovascular treatment(EVT)strategy for the resolution of early HAO and identify the risk factors associated with early HAO as well as the procedural challenge encountered in the treatment strategy.Methods:Consecutive orthotopic LT recipients(n=366)who underwent transplantation between June 2017 and December 2018 were retrospectively investigated.EVT was performed using an integrated strategy that involved thrombolytic therapy,shunt artery embolization plus vasodilator therapy,percutaneous transluminal angioplasty,and/or stent placement.Simple EVT was defined as the clinical resolution of HAO by one round of EVT with thrombolytic therapy and/or shunt artery embolization plus vasodilator therapy.Otherwise,it was defined as complex EVT.Results:Twenty-six patients(median age 52 years)underwent EVT for early HAO that occurred within 30 days post-LT.The median interval from LT to EVT was 7(6–16)days.Revascularization time(OR=1.027;95%CI:1.005–1.050;P=0.018)and the need for conduit(OR=3.558;95%CI:1.241–10.203,P=0.018)were independent predictors for early HAO.HAT was diagnosed in eight patients,and four out of those presented with concomitant HAS.We achieved 100%technical success and recanalization by performing simple EVT in 19 patients(3 HAT+/HAS-and 16 HAT-/HAS+)and by performing complex EVT in seven patients(1 HAT+/HAS-,4 HAT+/HAS+,and 2 HAT-/HAS+),without major complications.The primary assisted patency rates at 1,6,and 12 months were all 100%.The cumulative overall survival rates at 1,6,and 12 months were 88.5%,88.5%,and 80.8%,respectively.Autologous transfusion<600 mL(94.74%vs.42.86%,P=0.010)and interrupted suture for hepatic artery anastomosis(78.95%vs.14.29%,P=0.005)were more prevalent in simple EVT.Conclusions:The integrated EVT strategy was a feasible approach providing effective resolution with excellent safety for early HAO after LT.Appropriate autologous transfusion and interrupted suture technique helped simplify EVT.

Endovascular treatment of diabetic foot ischemic ulcer–Technical review

This article is a technical review of the common techniques used in the treatment of lower-limb occlusive arterial disease associated with diabetes.The techniques described here reflect the author’s own practice and are methods that the author finds helpful in avoiding complications and in making the technical aspects of the procedures easier.

Successful endovascular treatment with long-term antibiotic therapy for infectious pseudoaneurysm due to Klebsiella pneumoniae:A case report

BACKGROUND Infectious common femoral artery pseudoaneurysm caused by Klebsiellapulmonary infection is a relatively infrequent entity but is potentially life andlimb threatening. The management of infectious pseudoaneurysm remainscontroversial.CASE SUMMARY We reported a 79-year-old man with previous Klebsiella pneumoniae pulmonaryinfection and multiple comorbidities who presented with a progressive pulsatemass at the right groin and with right lower limb pain. Computed tomographyangiography showed a 6 cm × 6 cm × 9 cm pseudoaneurysm of the right commonfemoral artery accompanied by occlusion of the right superficial femoral arteryand deep femoral artery. He underwent endovascular treatment (EVT) withstent–graft, and etiology of infectious pseudoaneurysm was confirmed. Then, 3-mo antibiotic therapy was given. One-year follow-up showed the stent–graft waspatent and complete removal of surrounding hematoma.CONCLUSION The femoral artery pseudoaneurysm can be caused by Klebsiella pneumoniaederiving from the pulmonary infection. Moreover, this unusual case highlights theuse of EVT and prolonged antibiotic therapy for infectious pseudoaneurysm.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients:A case report and review of literature

BACKGROUND The rupture of a splenic artery aneurysm(SAA)in pregnancy is an uncommon condition.However,it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment.Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases,the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.CASE SUMMARY We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy.After emergent initial resuscitation,the patient was diagnosed with a ruptured SAA through digital angiography.Immediately upon diagnosis,she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot.Next,surgery was performed to remove the hematoma under stable conditions.Although the fetus was found to be dead during resuscitation,the woman recovered without complications and was discharged 15 d postoperatively.CONCLUSION Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis:Two case reports

BACKGROUND Acute portal vein thrombosis(PVT)with bowel necrosis is a fatal condition with a 50%-75%mortality rate.This report describes the successful endovascular treatment(EVT)of two patients with severe PVT.CASE SUMMARY The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d.The second patient was a 48-year-old man who presented with acute abdominal pain.Following contrast-enhanced computed tomography,both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins.Hybrid treatment(simultaneous necrotic bowel resection and EVT)was performed in a hybrid operating room(OR).EVTs,including aspiration thrombectomy,catheter-directed thrombolysis(CDT),and continuous CDT,were performed via the ileocolic vein under laparotomy.The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients,respectively.CONCLUSION Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.

Endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate

Objective To explore the method and safety of endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate. Method A total of 11 patients with traumatic direct carotid cavernous fistulas treated by endovascular embolization with n-Butyl-2-Cyanoacrylate. (n-BCA) were retrospectively analyzed,including the

Endovascular treatment of intracranial dissecting aneurysm

Objective To analyze the clinical features of intracranial dissecting aneurysm and summarize the experience of its endovascular embolization. Methods 16 cases of intracranial dissecting aneurysm were treated by endovascular embolization. Among these 16 patients,3 patients were treated with single stent or double

Endovascular treatment of extracranial vertebral artery stenosis

Percutaneous angioplasty and stenting for the treatment of extracranial vertebral artery(VA) stenosis seems a safe,effective and useful technique for resolving symptoms and improving blood flow to the posterior circulation,with a low complication rate and good long-term results.In patients with severe tortuosity of the vessel,stent placement is a real challenge.The new coronary balloon-expandable stents may be preferred.A large variability of restenosis rates has been reported.Drug-eluting stents may be the solution.After a comprehensive review of the literature,it can be concluded that percutaneous angioplasty and stenting of extracranial VA stenosis is technically feasible,but there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.

Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Carotid cavernous sinus fistulas are abnormal communications between the carotid system and the cavernous sinus. Several classification schemes have described carotid cavernous sinus fistulas according to etiology, hemodynamic features, or the angiographic arterial architecture. Increased pressure within the cavernous sinus appears to be the main factor in pathophysiology. The clinical features are related to size, exact location, and duration of the fistula, adequacy and route of venous drainage and the presence of arterial/venous collaterals. Noninvasive imaging (computed tomography, magnetic resonance, computed tomography angiography, magnetic resonance angiography, Doppler) is often used in the initial workup of a possible carotid cavernous sinus fistulas. Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of treatment for these lesions. The endovascular approach has evolved as the mainstay therapy for definitive treatment in situations including clinical emergencies. Conservative treatment, surgery and radiosurgery constitute other management options for these lesions.

Endovascular treatment of post-laparoscopic pancreatectomy splenic arteriovenous fistula with splenic vein aneurysm

Splenic arteriovenous fistulas(SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography(CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient's recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.

Endovascular treatment of blood blister-like aneurysms in the internal carotid artery using a Willis covered stent

Background Despite the current availability of flow diverter devices(FDD), problems remains regarding optimal endovascular treatment(EVT) for blood blister-like aneurysms(BBAs) of the internal carotid artery(ICA). Objective To evaluate the safety and efficacy of EVT of BBAs in the ICA with a Willis covered stent. Methods 20 consecutive patients(5 men and 15 women) with ruptured BBAs underwent EVT using a Willis covered stent in two institutions from March 2013 to March 2018. Clinical observations, angiographic characteristics, and procedural and follow-up outcomes were retrospectively evaluated. Results 20 consecutive patients(5 men and 15 women) with ruptured BBAs underwent EVT using a Willis covered stent in two institutions from March 2013 to March 2018. Clinical observations, angiographic characteristics, and procedural and follow-up outcomes were retrospectively evaluated. Conclusion Our initial results demonstrate that reconstructive EVT using a Willis covered stent provides a viable approach to treat ICA BBAs. However, an expanded clinical evaluation and larger cohort are needed to confirm the results.

Percutaneous thrombin embolization of a pancreaticoduodenal artery pseudoaneurysm after failing of the endovascular treatment

Pancreatico-duodenal artery(PDA) pseudoaneurysms are rare vascular conditions with high mortality rates after rupture and they are frequently secondary to pan-creatitis, surgery, trauma or infection. Due to the high risk of rupture and bleeding, it is mandatory to treat all pseudoaneurysms, regardless of their size or symp-tomatology. First option of treatment is open surgical repair, but it has high mortality rate, especially in he-modynamically unstable patients. In the recent years, percutaneous ultrasonography(US)- or computed to-mography-guided thrombin injection was proposed as an alternative method for treating visceral aneurysms and pseudoaneurysms, but few reports described this therapy in case of peri-pancreatic pseudoaneurysms. We present a rare case of pseudoaneurysm of the PDA in a patient with no previous history of pancreatitis nor major surgery but with an occlusive lesion of the celiac axis. To the best of our knowledge this is the first reported case of PDA pseudoaneurysm successfully treated in emergency by single transabdominal US-guided injection of thrombin after failed attempts of percutaneous catheterization of the feeding vessel of the pseudoaneurysm.

Influence of the aspect ratio on the endovascular treatment of intracranial aneurysms: A computational investigation

Intracranial aneurysm, a localized dilation of arterial blood vessels in the Circle of Willis and its branches, is potentially life threatening, due to massive bleeding in the subarachnoid space upon rupture. In clinical practice, one minimally invasive surgical procedure is the implantation of a metallic stent to cover the aneurysm neck. This flow diverting device can reduce the flow into the aneurysm and enhance the prospect of thrombosis, a condition expected to reduce the risk of growth and rupture. The biomechanical and haemo-dynamic factors in stented and nonstented situations are studied by computational fluid dynamics. Unlike earlier models with straight or curved parent blood vessels, the aneurysm is now located near an arterial bifurcation. The influence of the aspect (depth to neck) ratio of the aneurysm on the flow dynamics will be emphasized, especially in the post-operation stages. More precisely, the maximum flow velocity, the variations of wall shear stress, the risk of stent migration and volumetric flow rate after endovascular treatment will be studied. Aneurysms with larger aspect ratios (i.e. smaller neck sizes for constant depth) generally pose a greater risk in terms of these flow parameters. These results will assist the applications and design of stents in future neurosurgical therapy. The approach is limited to a nonelastic model, without taking into account of questions like stent expansion and interaction with tissue.

The effects of stent porosity on the endovascular treatment of intracranial aneurysms located near a bifurcation

Intracranial aneurysm occurs when a cerebral artery develops an abnormal sac-like dilatation, and will cause massive bleeding in the subarachnoid space upon rupture. Endovascular stenting is a minimally invasive procedure in which a flow-diverting stent is deployed to cover the aneurysm neck, thereby restricting blood from entering the aneurysm and reducing the risk of rupture. The stent porosity, a crucial factor determining the intra-aneurysmal hemodynamics following treatment, is investigated by computational fluid dynamics techniques. Based on the computational results, a low porosity stent will dramatically reduce the flow velocity and the flow rate inside the side branch vessel. Conversely, a high porosity stent may not provide adequate flow reduction inside the aneurysm, possibly causing treatment failure. An advisable range of optimal stent porosity would be 60% to 75%, which can drastically reduce the flow rate into the aneurysm while preserving enough blood flow for the side branch vessel. Clinically, deployment of two or more flow-diverting stents may not increase treatment efficacy but can potentially lead to adverse effects due to side-branch hypoperfusion. The present quantitative analysis can also provide practical insight for future stent design.

Successful endovascular treatment of transplant intrarenal artery stenosis in renal transplant recipients: Two case reports

Transplant renal artery stenosis(TRAS) is a relatively rare complication after renal transplantation. The site of the surgical anastomosis is most commonly involved, but sites both proximal and distal to the anastomosis may occur, as well. Angioplasty is the gold standard for the treatment of the stenosis, especially for intrarenal lesions. We report two cases of intrarenal TRAS and successful management with angioplasty without stent placement. Both patients were male, 44 and 55 years old respectively, and they presented with elevated blood pressure or serum creatinine within three months after transplantation. Subsequently, they have undergone angioplasty balloon dilatation with normalization of blood pressure and serum creatinine returning to baseline level. Percutaneous transluminal balloon renal angioplasty is a safe and effective method for the treatment of the intrarenal TRAS.

Endovascular treatment for left innominate vein aneurysm: Case report and literature review

Innominate vein aneurysms originating from the mediastinum are very rare. Previous treatments for this condition often required thoracotomy. We report a case of a 43-year-old male who presented a mediastinal mass by chest radiography. Contrast-enhanced CT and venography confirmed the diagnosis of left innominate vein aneurysm. The patient underwent endovascular treatment with stent placement and coil embolization of the left innominate vein. The patient remains well 18 months after surgery. The objective of this report is to discuss the diagnosis and endovascular treatment results of innominate vein aneurysm and to review the relevant literature to enhance and expand the pool of knowledge for this abnormality.

Plaque characteristics after endovascular treatment in patients with intracranial Plaque characteristics after endovascular treatment in patients with intracranial atherosclerotic disease

Background:Endovascular treatment(EVT)is an alternative option for symptomatic intracranial atherosclerotic disease(ICAD).However,the effect of EVT treatment on ICAD plaques is still unclear.This study describes the ICAD plaque characteristics after EVT treatment and analyzes the effect of different EVT treatments on plaque characteristics.Method:From 2017 January to 2022 January,ICAD patients who underwent endovascular treatment and had follow-up high-resolution magnetic resonance image(HRMRI)were enrolled in the study.Multiple plaque characteristics,including plaque enhancement,plaque burden,were measured based on preoperative,and follow-up HRMRI.Plaque characteristics and postoperative plaque changes were analyzed between different treatment groups.Result:Finally,50 intracranial atherosclerotic plaques in 45 patients were included.Including 28 male patients and 17 female,media age 63.0 years old.Among 50 plaques,41 received percutaneous angioplasty(including 22 plain balloons and 19 drug-coated balloons(DCB))and the other 9 underwent stenting.Stenosis rate,plaque burden and eccentricity index at the lesion site were significantly decreased after EVT compared with preoperative periods(p<0.001).And only the DCB group showed a significant reduction in plaque enhancement at follow-up(p<0.001).No significant preoperative and postoperative changes in other plaque characteristics were found.Conclusion:EVT treatment could compromise the characteristics of intracranial periarterial atherosclerotic plaques,and DCB treatment may result in a reduction in plaque enhancement after treatment.

Endovascular treatment of wide-necked intracranial aneurysms using of ＂remodeling technique＂ with the HyperForm balloon

Background Aneurysms with wide-necked or a large neck/fundus ratio, especially located on an arterial bifurcation or a small artery, are challenges for interventional neuroradiologist because of the risk of coil migration or coil protrusion into the parent vessels. Our study was designed to improve the efficacy and safety of the ＂remodeling technique＂ with the HyperForm balloon for these difficult aneurysms and was confirmed by a follow-up result. Methods From June 2004 to September 2006, forty-two patients （20 men, 22 women） with wide-necked or large neck/fundus ratio aneurysms were treated by using the ＂remodeling technique＂ with the HyperForm balloon. Results Forty wide-necked aneurysms were successfully treated with the HyperForm balloon remodeling technique with only two failed cases. Final results consisted of total occlusion in 34 cases （80.9%）, subtotal in 4 （9.5%） and incomplete in 2 （4.8%）. One aneurysmal rupture occurred, but no clinical consequence was shown. No thromboembolic events were observed during treatment. Final angiographic follow-up time ranged from 3 to 18 months. Conclusions The ＂remodeling technique＂ with the HyperForm balloon is a very useful tool in the treatment of wide-necked or unfavorable neck/fundus ratio intracranial aneurysms - located on an arterial bifurcation or a small artery and, especially, located on the bifurcation of a large artery and a small one. In our experience, this technique provided a safe and efficient treatment for difficult aneurvsms when the standard remodelina techniaue miaht have failed.