Long-term results of super-selective trans-catheter embolization of the vesical arteries for the treatment of intractable bladder haematuria.

PURPOSE: To evaluate the feasibility, safety and long-term efficacy of super-selective trans-catheter arterial embolization for the management of intractable bladder bleeding. MATERIALS AND METHODS: The records of 20 patients with intractable haematuria referred urgently for selective arterial embolization after failed conventional therapy, between 2013 and 2018, were retrospectively analyzed. Primary outcomes were technical (cessation of extravasation and/or stasis of flow within the target vessel) and clinical (bleeding control) success. Secondary outcomes included complication and re-intervention rates. RESULTS: Technical success was 90% (18/20 cases), as in 2 cases, embolization was not feasible. Super-selective embolization of the vesical arteries was feasible in 15/18 cases (83.3%). Selective proximal occlusion of the anterior division of the internal iliac artery was performed in two cases (11%) and embolization of the anterior division after coil blockage of the posterior division was performed in one case (5%). Bilateral and unilateral embolization was performed in 10 and 8 cases, respectively. Peri-procedural mortality rate was 5% (1/18 patients). One possible procedure-related death occurred due to myocardial infarction ten days following non-target embolization of the buttocks and the anterior abdominal wall. Mean time follow up was 35 ± 15 months. Bleeding reoccurred in three patients (16.6%), all successfully managed (one conservatively and two with further embolization). Clinical success was 85% (17/20 cases). During follow up 11 more patients died, due to underlying conditions not related to bleeding or the procedure. CONCLUSIONS: Super-selective angiographic embolization is feasible, safe and effective to control refractory, life threatening bladder bleeding and should be considered as a first line treatment, as to obviate the need for emergency surgery.

Long-Term Outcomes of Percutaneous Stenting of Aortic Endograft Limb Occlusion.

INTRODUCTION: To investigate the safety and efficacy of percutaneous stenting for the management of chronic ischemia caused by endograft limb occlusion following endovascular aortic aneurysm repair (EVAR). METHODS: This is a retrospective, single-center study investigating all patients who underwent percutaneous endovascular covered or bare metal stent placement for the management of intermittent claudication (IC) or critical limb ischemia following EVAR limb occlusion, between January 2010 and October 2017. Cases suffering from acute limb ischemia were treated surgically and were excluded from the analysis. Primary outcome measures were technical success and symptoms-free interval. Secondary outcome measures included clinically driven target-lesion reintervention (TLR)-free survival, primary patency, and complication rates. RESULTS: Of 29 limb occlusions, 11 limbs (11 patients; 100% male; mean age: 71.6 ± 6.9 years) were treated percutaneously and were included in the study. The majority suffered from IC (10/11; 90.9%) with a single case of rest pain. Technical success was obtained in 10 patients (90%). No major complications occurred. Mean follow-up time was 37.6 ± 25.7 months. Stent grafts were mainly used, while and in 2 cases (18.18%), only nitinol bare stents were deployed. According to Kaplan-Meier analysis, both symptoms-free interval and primary patency were 83.33% in up to 5 years follow-up. TLR-free survival was 100% at 5 years, as 2 cases of claudication relapse were managed conservatively. CONCLUSIONS: Percutaneous stenting for the management chronic ischemia due to EVAR limb occlusion is feasible and safe, with satisfactory long-term outcomes. Careful patient selection warrants clinical success.

Incidence and Endovascular Treatment of Isolated Atherosclerotic Popliteal Artery Disease: Outcomes from the IPAD Multicenter Study.

PURPOSE: To report the incidence and long-term outcomes following endovascular treatment of symptomatic, atherosclerotic isolated popliteal artery disease (IPAD). MATERIALS AND METHODS: This retrospective, multicenter study included all patients who underwent endovascular treatment of IPAD between January 2010 and December 2016 because of intermittent claudication or critical limb ischemia (CLI), in three tertiary University Hospitals. In total, 4717 peripheral arterial disease (PAD) procedures were analyzed. The study's primary outcome measures were: IPAD incidence, binary restenosis rate and freedom from target lesion revascularization (TLR). Secondary outcome measures included technical success, limb salvage rate and the identification of predictors of outcomes. RESULTS: The incidence of IPAD was 0.98% (46/4717 PAD procedures). In total, 46 patients (38 male; mean age 73 ± 12 years) underwent plain balloon (69.5%) or bail-out stenting (30.5%) procedures. Most patients suffered from CLI (65.2%). Mean lesion length was 52.5 ± 32.0 mm and 45.6% of the cases were occlusions. Severe calcifications were noted in 26.1%. Technical success was 100%. Mean time follow-up was 32.6 ± 25.6 months. According to Kaplan-Meier analysis, restenosis was 15.8, 40.9, 45.8% and TLR-free rate was 90.5, 79.0, 74.1%, at 1, 2 and 3 years, respectively. Survival and limb salvage rates were 73.6 and 88.1%, at 5 years, respectively. The major amputation rate for CLI patients was 10.0% (3/29 limbs), while no major amputations occurred in the claudication subgroup. Cox multivariable analysis detected baseline occlusion as an independent predictor of increased restenosis (HR 5.3; 95% CI 0.21-0.66, p = 0.02). CONCLUSIONS: Isolated popliteal lesions requiring treatment appear in nearly 1% of patients with PAD. Balloon angioplasty and bail-out stenting resulted in acceptable long-term clinical outcomes. Treatment of occlusions was correlated with increased restenosis rate.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study.

PURPOSE: To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB). MATERIALS AND METHODS: This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates. RESULTS: The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years. CONCLUSIONS: TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.

Recanalization of Occluded Transjugular Intrahepatic Portosystemic Shunts Using the Rösch-Uchida Stiffening Cannula.

PURPOSE: To report the safety and efficacy of occluded transjugular intrahepatic portosystemic shunts (TIPS) recanalization using the stiffening cannula (SC) technique. MATERIALS AND METHODS: This is a retrospective, single-centre, single-arm study, investigating the safety and efficacy of transjugular recanalization of occluded TIPS using the SC (Cook, Ind. USA), in cases of failure to cross the occlusion with standard angiographic catheters and balloons. Between October 2015 and October 2017, a total of 15 TIPS revisions have been performed due to shunt occlusion. In all cases in which the initial standard approach to cross the lesion failed, the SC technique was used. The study's primary efficacy outcome measure was technical success, and primary safety outcome measure was immediate procedure-related complications rate. Secondary outcome measures included restenosis and peri-procedural adverse events rates. RESULTS: Among 15 patients with shunt occlusion, seven (7/15; 46.5%) were successfully crossed via transjugular access, using standard angiographic catheters. In the remaining eight patients (nine procedures), recanalization with the SC technique was performed. Technical success was 100%. No complications or peri-procedural adverse events were noted. Restenosis rate was 11.1% (1/9 cases) as only one case of re-occlusion was noted, 3 months following recanalization using sole balloon angioplasty and successfully retreated using the SC technique and stent graft deployment. CONCLUSIONS: The SC technique is a safe and efficient option for the recanalization of occluded TIPS, in cases in which conventional lesion crossing is not feasible, in order to avoid percutaneous transhepatic access or new TIPS creation.

Computed tomography-guided percutaneous microwave ablation of hepatocellular carcinoma in challenging locations: safety and efficacy of high-power microwave platforms.

OBJECTIVE: To evaluate the clinical efficacy/safety of CT-guided percutaneous microwave ablation for HCC in challenging locations using high-power microwave platforms. MATERIALS AND METHODS: A retrospective review was conducted in 26 patients with 36 HCC tumours in challenging locations (hepatic dome, subcapsular, close to the heart/diaphragm/hepatic hilum, exophytic) undergoing CT-guided percutaneous microwave ablation in a single centre since January 2011. Two different microwave platforms were used both operating at 2.45 GHz: AMICA and Acculis MWA System. Patient demographics including age, sex, tumour size and location, as well as technical details were recorded. Technical success, treatment response, patients survival and complication rate were evaluated. RESULTS: Treated tumours were located in the hepatic dome (n = 14), subcapsularly (n = 16), in proximity to the heart (n = 2) or liver hilum (n = 2), while two were exophytic tumours at segment VI (n = 2). Mean tumour diameter was 3.30 cm (range 1.4-5 cm). In 3/26 patients (diameter >4 cm), an additional session of DEB-TACE was performed due to tumour size. Technical success rate was 100%; complete response rate was recorded in 33/36 tumours (91.6%). According to Kaplan-Meier analysis, survival rate was 92.3% and 72.11% at 24- and 60-month follow-up, respectively. There were no major complications; two cases of minor pneumothorax and two cases of small subcapsular haematoma were resolved only with observation requiring no further treatment. CONCLUSION: CT-guided percutaneous microwave ablation for hepatocellular carcinoma tumours in challenging locations and up to 5 cm in diameter can be performed with high efficacy and safety rates.

Advents in the Diagnosis and Management of Ischemic Colitis.

BACKGROUND: Ischemic colitis (IC) is a common type of ischemic insult, resulting from decreased arterial blood flow to the colon. This disease can be caused from either atherosclerotic occlusive vascular disease or non-occlusive disease. The aim of this study is to present the diagnostic methodology and management of this severe disease based on current literature. METHODS: A literature search has been done including articles referring to modern diagnosis and management of IC. RESULTS: IC is usually a transient disease, but it can also cause gangrene of the colon, requiring emergency surgical exploration. Diagnosis is troublesome and is based on imaging examinations, mainly computerized tomography, which in association with colonoscopy can delineate the distribution pattern and severity of disease. CONCLUSION: The majority of patients with mild disease have usually complete clinical recovery within a short period. The severe forms of the disease carry high morbidity and mortality rates and prompt surgical intervention is the only way to improve the associated severe prognosis.

Multi-center feasibility study of microwave radiometry thermometry for non-invasive differential diagnosis of arterial disease in diabetic patients with suspected critical limb ischemia.

AIMS: Diagnosis of vascular involvement in diabetic foot ulceration (DFU) remains challenging. We conducted a proof of concept study to investigate the feasibility of microwave radiometry (MWR) thermometry for non-invasive differential diagnosis of critical limb ischemia (CLI) in subjects with DFU. METHODS: This prospective, multi-center, study included 80 participants, divided into four groups (group N: normal control subjects; group DN: participants with diabetes and verified neuropathic ulcers without vascular involvement; group DC: participants with diabetes and CLI and group NDC: participants with CLI without diabetes). Vascular disease was confirmed with angiography. All patients underwent MWR (RTM-01-RES:University of Bolton, UK) to record mean tissue temperatures at various pre-determined foot sites. Comparisons of temperature measurements between study groups were performed using one-way ANOVA and Dunn tests. ROC analysis was performed to determine sensitivity, specificity and cut-off value of MWR for CLI diagnosis. RESULTS: Temperatures recorded in vicinity to the foot ulcers of participants with diabetes and CLI were similar to those with CLI without diabetes, but significantly lower than in subjects with neuropathic ulcers without vascular involvement and normal controls (group DC:29.30°C±1.89 vs. group NDC:29.18°C±1.78vs. group N:33.01°C±0.45 vs. group DN:33.39°C±1.37;P<.0001). According to ROC analysis, cut-off temperature value to diagnose CLI was <31.8°C (area under the curve: 0.984; 95% CI: 0.965-1.005;P<.001), with a sensitivity of 100.0% (95%CI: 90.26-100.0) and specificity of 88.37% (95% CI: 74.92-96.11). CONCLUSIONS: Tissue temperatures in vicinity to ulcers were significantly lower in participants with CLI, with or without diabetes, compared to non-ischemic controls. MWR could be used for differential diagnosis of arterial ischemia in subjects with DFU.