The role of vacuum-assisted mechanical thrombectomy in the management of acutely thrombosed arteriovenous fistulas and grafts.

PURPOSE: The purpose of this study is to evaluate the safety and efficacy of the mechanical thrombectomy with the Indigo System in the treatment of thrombosed arteriovenous fistulas and grafts. METHODS: A retrospective search of endovascular procedures performed from November 2018 to June 2020 was conducted. Inclusion criteria were: acute arteriovenous fistula or graft thrombosis that underwent endovascular mechanical thrombectomy with Indigo System. The following information was collected from each case: sex, age, fistula modality, fistula location, treatment modality, and outcomes. Endpoints evaluated were: technical and clinical success rates; primary, assisted primary, and secondary patency rates; complication rates. RESULTS: Twenty-six mechanical thrombectomy procedures for declotting of arteriovenous fistula thrombosis, using the Indigo System, were performed in 22 patients. Technical and clinical success was achieved in 23/26 cases (88%). Mean follow-up was 9 months (range 11-539 days). The 6-month primary, primary assisted, and secondary patency rates were 71%, 86%, 93% and the 12-month primary, primary assisted, and secondary patency rates were 71%, 72%, 80%, respectively. No technical or device-related complications were observed during thrombectomy, however two venous ruptures occurred on the angioplasty of the underlying stenosis. CONCLUSION: In conclusion, vacuum-assisted thrombectomy of acutely thrombosed arteriovenous fistulas and grafts with Indigo System is safe and effective, providing good short term patency rates.

Isolated iliac artery aneurysm in association with congenital pelvic kidney treated with iliac branch device: case report.

BACKGROUND: Association of abdominal aortic aneurysm with congenital pelvic kidney is rare and association with isolated iliac artery aneurysm is not yet described in the literature. CASE PRESENTATION: We present a case of successful repair of an isolated common iliac artery aneurysm associated with a congenital pelvic kidney treated by an endovascular technique. A 75-year-old man was referred for the treatment of an asymptomatic left common iliac artery aneurysm. A computed tomography angiography revealed an isolated left common iliac artery aneurysm and a left pelvic kidney. The maximum diameter of the aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the common iliac artery and the main artery that arose from the left internal iliac artery. The aneurysm exclusion was accomplished by using an iliac branch device (Gore Excluder Iliac Branch, Flagstaff, AZ). The 1 and 6 months computed tomography angiography after the procedure demonstrated complete exclusion of the aneurysm and preservation of all renal arteries. CONCLUSION: Treating patients with an association of iliac artery aneurysms and pelvic kidneys can be a challenge due the variable arterial anatomy. The use of iliac branch device is a safe and effective alternative in selected cases.

A Successful Chemoembolization of a Retroperitoneal Soft Tissue Sarcoma: A Case Report.

Retroperitoneal sarcomas are rare entities. They have a tendency of growing slowly, rendering the patient apparently healthy for long periods of time, before diagnosis. Besides, they have a worse prognosis than sarcomas arising in extremities, with a higher local recurrence rate and lower 5-year survival rate. We describe a case of a 71-year-old male patient, who had a very well succeeded treatment of a large retroperitoneal sarcoma with the combination of chemoembolization, systemic chemotherapy, surgery, and radiation therapy. Initially, it was noticed in an incidental way he had a large retroperitoneal mass (15 cm × 10 cm × 9.2 cm) through magnetic resonance, when he was 63. The case was considered inoperable by the treating physicians. After neoadjuvant therapy, the residual tumor could be completely excised by the responsible surgeon. With a follow-up of >5 years, since the end of treatment, the patient remains in complete remission and, probably, cured from his illness. Large retroperitoneal sarcomas are still a great challenge for oncologists. According to the medical literature, chemoembolization can benefit some patients, but most of them in a palliative setting. In our report, we believe its contribution was critical for a great outcome. In selected cases, it is possible this procedure may be an additional therapeutic modality, as part of a multidisciplinary approach.

Safety and Effectiveness of Suture-mediated Arterial Closure Device in Hepatocellular Carcinoma Patients Who Underwent Drug-Eluting Beads Transarterial Chemoembolization.

BACKGROUND: The number of transarterial percutaneous procedures has risen over the years, consequently reducing puncture site related complications has become a necessity. To this end, the use of arterial closure devices has been growing progressively and their benefits have become a focus of research. The purpose of this study is to assess the safety and effectiveness of a suture-mediated closure device, Perclose ProGlide® (Abbott Vascular, Redwood City, CA), in patients with liver disease and hepatocellular carcinoma who underwent transarterial liver chemoembolization with drug-eluting beads. MATERIALS AND METHODS: A cohort of 253 hepatocellular carcinoma patients who underwent 449 procedures of transarterial liver chemoembolization with drug-eluting beads using the Perclose Proglide device was prospectively studied. The main endpoints evaluated were the technical success of the device, defined as complete hemostasis achieved within 3 min after the closure, and the incidence of puncture-site complications. The secondary endpoints evaluated were the correlation between epidemiological factors, coagulation profile and degree of liver disease, and the occurrence of complications. RESULTS: Technical success was achieved in 96% of the cases. Among patients who underwent repeated procedures using the same vascular access, this rate was 95.3%. Puncture-site complications were observed in 7 procedures (1.56%); 4 (0.89%) were due to hemorrhage, 2 (0.44%) hematomas and 2 (0.44%) pseudoaneurysms; 2 (0.44%) due to limb ischemia; and 1 (0.22%) due to arterial dissection. Among them, 3 cases required intervention. The statistical analysis of demographic characteristics, Child-Pugh classification, and coagulation status did not show a significant correlation with the occurrence of complications. Of the 449 procedures, only 4 (0.89%) needed hospitalization due to puncture-site complications. CONCLUSIONS: The use of Perclose Proglide is safe and effective in patients with liver disease and hepatocellular carcinoma who underwent transarterial liver chemoembolization with drug-eluting beads.

Occurrence of Vascular Lake Phenomenon as a Predictor of Improved Tumor Response in HCC Patients That Underwent DEB-TACE.

PURPOSE: To evaluate incidence and predictive factors for the vascular lake phenomenon (VLP), as well as to compare local and overall tumor response in patients with and without VLP induced during DEB-TACE for HCC. METHODS: A total of 200 consecutive patients with 323 HCC nodules underwent first-session DEB-TACE from 2011 to 2014. Patients were divided in two groups, according to the presence of the VLP during DEB-TACE. Pre- and post-treatment imaging studies (CT or MRI) were performed. Primary endpoint was assessment of tumor response, evaluated by mRECIST. Comparison of response rates between the VLP group and the non-VLP group was performed. Secondary endpoints were the determination of incidence rate and predictive factors for the VLP. RESULTS: The VLP was observed in 39/323 (12.1%) of the nodules treated. At multivariate logistic regression analysis, tumor size ≥3 cm in diameter (OR 13.95; 95% CI 3.60-54.05), presence of a pseudocapsule (OR 6.67; 95% CI 1.45-30.59) and alpha-fetoprotein levels (OR 1.004; 95% CI 1.000-1.007) remained predictive for the VLP occurrence. On a nodule-based analysis (p < 0.001), target lesion response analysis (p = 0.003) and overall response analysis (p = 0.004) the VLP group presented a higher objective response rate than the non-VLP group. CONCLUSION: VLP is observed in 12% of the patients and happens more frequently in large and encapsulated tumors. It seems to be associated with better local and overall responses in HCC patients who underwent DEB-TACE.

Systematic Literature Review on Evaluation and Management of Isolated Spontaneous Celiac Trunk Dissection.

BACKGROUND: The purpose of this study is to perform a systematic literature review of isolated spontaneous celiac trunk dissection (ISCTD), to evaluate initial clinical and diagnostic aspects, treatment modalities, and outcomes. METHODS: A retrospective search of MEDLINE, Cochrane, and SciELO databases was performed, using the terms celiac artery dissection, celiac trunk dissection, hepatic artery dissection, splenic artery dissection, or left gastric artery dissection to identify instances of ISCTD. Patients with associated aortic and/or other visceral artery dissection were excluded. When available, the following information was collected from each case: gender, age, associated risk factor, symptoms, diagnostic method, treatment modality, and outcome. RESULTS: A total of 60 publications were identified between 1987 and 2015, with 11 cases series and 49 case reports, achieving a total of 169 patients identified with ISCTD. Such information was collected: 99 patients were male and 17 female, with an average age of 53.1 years and the most common symptom was abdominal pain. Diagnosis was mainly made with computed tomography. The most common associated conditions were hypertension and smoking in 31% and 23% of the cases, respectively. Conservative treatment was performed in 79% of the cases. CONCLUSIONS: The profile of patients with ISCTD is male, middle aged, and almost all suffer from abdominal pain. Initial conservative treatment seems adequate for most cases, but a few patients will require interventional treatment. Clinical and radiological long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection.

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Safety and feasibility of same-day discharge of patients with hepatocellular carcinoma treated with transarterial chemoembolization with drug-eluting beads in a liver transplantation program.

PURPOSE: To evaluate the safety and feasibility of same-day discharge of patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with the use of drug-eluting beads (DEBs) and elucidate the prognostic factors for hospital admission. MATERIALS AND METHODS: A total of 266 DEB chemoembolization procedures in 154 consecutive patients listed for liver transplantation or identified for potential HCC downstaging were performed with the outpatient treatment protocol. Endpoints evaluated were admission to the hospital after the procedure for clinical reasons, readmission to the hospital within 1 month of the procedure, and procedure-related morbidity and mortality. In the evaluation of prognostic factors for admission, parameters of patients discharged the same day were compared with those of patients admitted overnight. RESULTS: Same-day discharge was feasible in 238 cases (89.5%), and 28 (10.5%) needed overnight admission. The main reason for overnight admission was postprocedural abdominal pain (n = 23; 67.8%). The procedure-related complication rate was 2.6%, and there were no readmissions or deaths during the first 30 days after chemoembolization. Chemoembolization performed for downstaging and the use of more than one vial of embolic agent were associated with an increased need for overnight admission (P = .012 and P = .007, respectively). CONCLUSIONS: Same-day discharge of patients with HCC treated with DEB chemoembolization in a liver transplantation program is safe and feasible, with low complication and admission rates. Treatment for HCC downstaging and the use of more than one vial of embolic agent were associated with an increased need for hospital admission.

Endovascular stenting of brachial artery occlusion in critical hand ischemia.

Critical upper limb ischemia caused by atherosclerosis is uncommon. Endovascular treatment, with angioplasty or stenting, has been successfully performed for subclavian and below the elbow diseases; however, there's a lack of report regarding the treatment of brachial artery disease causing critical hand ischemia. In this article, we describe the treatment of a brachial artery occlusion with endovascular stenting in a patient with chronic upper limb ischemia.