An Alternative Treatment of Stump Occlusion of the Superficial Femoral Artery with Percutaneous Direct Puncture Followed by Antegrade Recanalization.

INTRODUCTION: The purpose of the study was to evaluate the efficacy and safety of the "percutaneous direct puncture of occluded superficial femoral artery (SFA)" technique for recanalization of SFA, after failure of antegrade recanalization in patients with limited access to retrograde popliteal and crural arteries. MATERIAL AND METHODS: Between April 2014 and November 2017, 10 patients with CLI (Critical limb ischemia) underwent endovascular recanalization with direct percutaneous puncture of occluded SFA after failed antegrade recanalization. All patients had a long segment (39,9 ±â€¯2.8 cm) occluded SFA without stump causing failed antegrade recanalization with a cannulated guidewire in the SFA origin. After unsuccessful attempts with the antegrade approach, the retrograde direct puncture technique of the occluded SFA was performed and followed by antegrade recanalization. Patients were followed up clinically with Doppler ultrasonography and according to the Rutherford scale at 1, 3, 6 and 12 months after discharge. RESULTS: Technical success was achieved in 8/10 patients (80%).The mean follow-up period was 25,1 ±â€¯9,6 months. One patient underwent major amputation, resulting in 90% limb salvage rate at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 60% at 12 and 24 months. Primary patency rates were 62.5% at 12 and 24 months and secondary patency rates were 87.5% at 12 and 24 months. CONCLUSION: Treatment of SFA occlusions without a stump in CLI patients via the percutaneous direct puncture of occluded SFA approach improved technical success and clinical recovery, especially in cases unsuitable for conventional antegrade and retrograde approaches.

Combined percutaneous direct puncture of occluded artery - antegrade intervention for recanalization of below the knee arteries.

PURPOSE: We aimed to assess the technical success of the combined percutaneous direct puncture of occluded artery - antegrade intervention technique, as well as the clinical effectiveness of treatment, on the basis of changes in the Rutherford classification. METHODS: Between June 2015 and July 2018, 441 patients underwent endovascular recanalization due to lower limb peripheral arterial disease at our center. Of these, 18 patients (4%; 15 males, 3 females; mean age, 63.2 years) had failed antegrade recanalization and percutaneous retrograde access because of long segment occlusion, arterial rupture or dissection. Combined percutaneous direct puncture of occluded artery and antegrade approach was applied to these patients. Clinical follow-up examinations were performed at 1 month, 3 months, 6 months, and annually thereafter. RESULTS: The mean follow-up period was 22.8±10.9 months. The mean procedure time was 93.6±28.2 min. Technical success was achieved in 14 patients (78%). Complete restoration of arterial flow in the punctured vessel could not be achieved in 4 patients (22%). Minor complications occurred in 4 of 18 procedures (22%). Amputation-free survival and limb salvage rates (83.3% and 100%, respectively) were the same for 12 and 24 months. CONCLUSION: Technical success in lower limb peripheral arterial disease may be improved with the use of a combined percutaneous direct puncture of occluded artery - antegrade intervention, particularly for patients in whom other techniques are not a viable option.

Endovascular Recanalization of Thromboangiitis Obliterans (Buerger's Disease) in Twenty-Eight Consecutive Patients and Combined Antegrade-Retrograde Intervention in Eight Patients.

PURPOSE: The aim of the study was to evaluate the technical success of the procedure and the clinical efficacy of treatment in patients with thromboangiitis obliterans (TAO) (Buerger's disease) based on a change in the Rutherford classification. MATERIALS AND METHODS: A total of 28 consecutive patients (26 males, 2 females, mean age 43.3 ± 5.32 years) underwent endovascular recanalization with a diagnosis of TAO, between April 2015 and July 2018. After unsuccessful attempts using the antegrade approach, retrograde approaches were used in 8 patients under ultrasound guidance. Clinical follow-up was routinely performed at 1-month, 3-month, 6-month, and 1-year intervals. RESULTS: A total of 28 TAO patients underwent 40 procedures in 32 limbs. Technical success was achieved in 28 of the 32 limbs (87.5%). In total, 45 of 59 (76.2%) below the knee arteries were treated successfully. One major amputation was performed, providing a 96.8% rate for limb salvage both at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 84% at 12 and 24 months. Primary patency rates at 12, 24, and 36 months were 84%, 78%, and 75%, respectively. Secondary patency rates were 87.5% both at 12 and 24 months. CONCLUSION: Endovascular treatment is a technically feasible and potentially effective treatment modality for Buerger's disease. Combined antegrade and retrograde interventions in TAO patients may improve technical success and clinical recovery, especially in cases where the antegrade approach has failed.

A Novel Technique in the Treatment of Lymphoceles After Renal Transplantation: C-Arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage After Lymphangiography.

BACKGROUND: We aimed to evaluate the efficacy of percutaneous embolization after lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele. METHODS: Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele after renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range, 36-70) years, and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection. RESULTS: Lymphatic leakage was observed in 9 patients after lymphangiography, and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate embolization. The volume of lymphatic drainage reduced to less than 10 mL in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage was not observed in 4 patients after lymphangiography. Of these, 3 patients showed a reduction in the amount of lymphatic drainage after lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient did not respond to the treatment and was treated surgically. Prelymphangiography and postlymphangiography and embolization, the volume of lymphatic drainage was 113.07 ± 21.75 mL, and 53.84 ± 30.96 mL, respectively, and statistically significant decrease was detected (P < 0.005). CONCLUSIONS: Lymphangiography and CBCT-guided percutaneous embolization procedures might be an effective treatment method for patients with lymphocele refractory to treatment.

Higher dose intra-arterial milrinone and intra-arterial combined milrinone-nimodipine infusion as a rescue therapy for refractory cerebral vasospasm.

Background Cerebral vasospasm (CV) is a major cause of delayed morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Various cerebral protectants have been tested in patients with aneurysmal SAH. We aimed to research the success rate of treatment of CV via intra-arterial milrinone injection and aggressive pharmacological therapy for refractory CV. Methods A total of 25 consecutive patients who received intra-arterial milrinone and nimodipine treatment for CV following SAH between 2014 and 2017 were included in the study. Patients who underwent surgical clipping were excluded. Refractory vasospasm was defined as patients with CV refractory to therapies requiring ≥3 endovascular interventions. Overall, six patients had refractory CV. Long-term neurological outcome was assessed 6-18 months after SAH using a modified Rankin score and Barthel index. Results The median modified Rankin scores were 1 (min: 0, max: 3) and Barthel index scores were 85 (min: 70, max: 100) From each vasospastic territory maximal 10-16 mg milrinone was given to patients; a maximum of 24 mg milrinone was given to each patient in a session and a maximum of 42 mg milrinone was given to a patient in a day. Both milrinone and nimodipine were given to three patients. There was a large vessel diameter increase after milrinone and nimodipine injections. No patient died due to CV; only one patient had motor dysfunction on the right lower extremity. Conclusion Higher doses of milrinone can be used effectively to control refractory CV. For exceptional patients with refractory CV, high dose intra-arterial nimodipine and milrinone infusion can be used as a rescue therapy.

Memokath metallic stent in the treatment of transplant kidney ureter stenosis or occlusion.

PURPOSE: To determine the efficacy of the Memokath 051 stent (Engineers and Doctors, Hornbaek, Denmark) in the treatment of recurrent ureteral stenosis or occlusion in transplant kidneys. METHODS: From October 1985 through January 2004, 1,131 renal transplantations were performed at our center. Four patients who developed recurrent renal transplant ureter obstruction had nephrostomy catheters placed. Antegrade pyelography showed ureteral stenosis in three cases and complete occlusion in one patient. In each case, a Memokath 051 stent was inserted via an antegrade approach. Mean follow-up was 20 months (range 18-21 months). Creatinine levels were measured and ultrasonography was performed during follow-up. RESULTS: All stent procedures were technically successful. During follow-up, one stent migrated within 10 days after stent insertion and was removed cystoscopically. Another stent had to be removed in the 14th month due to resistant infection, and was replaced with a new Memokath 051 stent which remained patent for another 8 months. The other two stents were fully patent at the 18th and 21st month of follow-up, respectively. CONCLUSION: Placement of a Memokath 051 stent appears to be a promising treatment alternative to balloon dilation, double-J stents and open surgical intervention for ureteral stenosis or occlusion in kidney transplant recipients. Further study of larger series is necessary.

Ultrasound-guided glue injection as alternative treatment of femoral pseudoaneurysms.

The interventional angiographic techniques using the percutaneous femoral approach for endovascular revascularization are becoming increasingly more popular. These methods usually require larger sheaths, and most patients need postprocedural anticoagulation or antiplatelet therapy. As a consequence, the interventional procedure is associated with a higher rate of complications at the arterial entry site compared to diagnostic angiography. The reported incidence of iatrogenic pseudoaneurysm formation after coronary artery interventions ranges from 3.2% to 7.7%, and the rates noted after diagnostic angiography range from 0.2% to 1%.

Contrast-enhanced magnetic resonance angiography: evaluation of renal arteries in living renal transplant donors.

One of the most important steps before living-donor nephrectomy is assessment of renal vascular anatomy. The number, origins and lengths of the renal arteries and variations of renal veins must be determined in order to identify the kidney that is most suitable for transplantation. Digital subtraction angiography was long considered the standard procedure for this purpose, but this method has been replaced by non-invasive techniques. Contrast-enhanced magnetic resonance angiography is an accurate, safe and reliable method for imaging vasculature. This article reviews the technique and the clinical features of this method in the evaluation of living renal transplant donors.

[US-guided glue injection in the treatment of femoral pseudoaneurysms]. / Femoral psödoanevrizma tedavisinde US kilavuzlugunda perkütan glue enjeksiyonu.

PURPOSE: To evaluate the efficacy of US-guided glue injection in the treatment of femoral pseudoaneurysms. MATERIALS AND METHODS: In 13 patients, 14 femoral pseudoaneurysms were embolized with direct percutaneous glue injection with ultrasonographic guidance. We compressed the aneurysm neck during glue injection to prevent distal embolization. RESULTS: All of the patients were treated successfully. In each patient, complete occlusion of the pseudoaneurysm was achieved without complication. The procedure time varied between 5 and 20 minutes. CONCLUSION: Direct percutaneous glue injection with ultrasonographic guidance is an effective and easy method in the treatment of pseudoaneurysms.

[Case report: Direct percutaneous placement of tunneled hemodialysis catheter into the inferior vena cava in a patient with dialysis access problem]. / Diyaliz erisim yolu problemi olan olguda direkt perkütan yolla inferior vena kavaya tünelli diyaliz kateteri yerlestirilmesi.

The paired hemodialysis catheters were inserted into the inferior vena cava (IVC) via translumbar approach in a 48-year-old man for lack of other suitable access. The catheter tip was thrombosed 2 months after the procedure. After local streptokinase infusion, control venogram showed resolution of the thrombus. Translumbar catheterization of the IVC is a safe and effective way in patients with thrombosed central venous access.

[Percutaneous mechanical thrombectomy with arrow-trerotola device inpatients with thrombosed graft fistula]. / Tromboze greft arteryovenöz fistülü olan hastalarda Arrow-Trerotola cihazi ile perkütan mekanik trombektomi.

PURPOSE: To assess the safety and efficacy of the Arrow-Trerotola percutaneous thrombectomy device in the treatment of thrombosed hemodialysis access grafts in dialysis patients. MATERIALS AND METHODS: Ten patients with graft fistula occlusion underwent mechanical thrombectomy with Arrow-Trerotola percutaneous thrombectomy device. Thirteen thrombectomy procedures were performed in ten patients. Technical success, complications, primary and secondary patency rates were noted. RESULTS: The technical success rate was 84% (11 of 13 procedures). There were no major complications. The mean follow-up period was 8.5 months. The graft fistula are still functional in seven patients. In 3 of 7 patients, additional procedures were needed for patency. The 3-month primary and secondary patency rates were 66% and 77% respectively. CONCLUSION: Percutaneous mechanical thrombectomy with the Arrow-Trerotola device is an effective method for the treatment of the thrombosed hemodialysis grafts.

Central pontine myelinolysis secondary to cytomegalovirus hepatitis in a 10-month-old child.

We present a 10-month-old child with central pontine myelinolysis (CPM) secondary to chronic active hepatitis due to cytomegalovirus (CMV) infection. A total of 35 paediatric cases of pontine and/or extrapontine myelinolysis are reported and, to our knowledge, CPM secondary to CMV hepatitis in an infant has not been previously reported. The MRI findings are highlighted.

Diagnosis of complications in auxiliary heterotopic partial-liver transplant recipients: spiral CT findings.

BACKGROUND/AIMS: Imaging is important after liver transplantation to determine possible complications. The purpose of this study was to evaluate the spiral CT findings in auxiliary heterotopic partial liver transplant recipients and to determine the incidence of these complications with spiral CT imaging. METHODS: Twenty-one patients had auxiliary heterotopic partial liver transplantation at our institution during a two-year period. There were 16 males and five females with an age range of 4-58 years. All graft livers were transplanted to the right subhepatic space. Spiral CT was performed at least once after transplantation in twenty of the patients in order to evaluate vascular structures and determine possible complications. The 5mm and/or 8 mm thick sections were obtained through the abdomen before and after IV-contrast at the portal phase. Spiral CT findings were compared with ultrasonography (n=15), digital subtraction angiography (n=8), percutaneous transhepatic cholangiography (n=3) and laparotomy findings (n=2). RESULTS: Complications were detected in fourteen of the twenty-one patients. Spiral CT detected a total of 19/23 (83%) vascular complications in this study. All biliary complications (100%), 13/16 (81%) parenchymal changes and 14/14 (100%) different forms of fluid collections were also detected by spiral CT. In three patients with focal lesions, the infarcts were detected only by CT. It was not able to detect hepatic artery stenosis and one of the pseudoaneurysms of the hepatic artery. CONCLUSIONS: It is suggested that SCT in particular should be used in the evaluation of biliary complications, fluid collections and parenchymal changes of graft liver. It could be used in combination with other non-invasive imaging methods for evaluation of vascular structures.