Variation of a Persistent Primitive Hypoglossal Artery (PPHA) as Incidental Finding in the Diagnostic Clarification of Cerebral Vasculopathy Associated with Intracranial Vasculitis.

We present a very rare variation of a persistent primitive hypoglossal artery (PPHA) arising from the internal carotid artery, detected during a diagnostic angiography. A 50-year-old female patient was admitted with an atypical intracranial hematoma in the left frontal lobe. Catheter angiography revealed intracranial vasculopathy with segmental stenoses, a small aneurysm of the right internal carotid artery bifurcation and a "string of beads" appearance of the left carotid artery, consistent with fibromuscular disease. On the left side, a vertebral artery ending in the posterior inferior cerebellar artery (PICA) was detected, whereas on the right side the vertebral artery was aplastic. During selective angiography of the right common carotid artery, a persistent hypoglossal artery was seen supplying the basilar artery. The literature of persistent embryonal carotid-vertebrobasilar anastomosis and their anatomical variations is discussed with respect to clinical importance for ischemia, interventional procedures, and surgery.

Impact and Effectiveness of Dual Aspiration Technique in Stent-Assisted Mechanical Thrombectomy: Recent Improvements in Acute Stroke Management.

BACKGROUND AND PURPOSE: To evaluate feasibility and impact of dual aspiration technique (DAT) within stent-assisted mechanical thrombectomy on procedural parameters and clinical outcome. MATERIALS AND METHODS: Within 16 months, 76 consecutive patients (mean age 70.7 year; range 33-89) underwent stent-assisted mechanical thrombectomy. Of 52 enrolled patients (68.4 %) with occlusion of the anterior circulation, 22 patients (42.3 %) underwent DAT; 30 patients (57.7 %) were treated in conventional monoaspiration technique (MAT). Epidemiological data, clinical and imaging characteristics (mRS, NIHSS, ASPECTS) as well as procedural details were analyzed (TICI, number of retrieval, procedure time). Clinical outcome was determined with mRS at discharge and after 90 days. RESULTS: In the context of DAT additional carotid artery stenting was required in 45.5 % (10/22) in underlying tandem lesion (vs. 0/30 MAT). No differences were found in NIHSS at admission (MAT: 20.5, range 15-29; DAT: 18.6; range 11-25), mRS at admission (MAT: 4.6 vs. DAT: 4.57) or ASPECT score (MAT: 8.3, ±1.5; DAT: 8.4, ±1.5; P > 0.05). TICI ≥ 2b/3 was conducted in 90 % (MAT) and 100 % (DAT), respectively. The procedure time was longer in the MAT group (65 min, ±25.9, range 18-126) compared to the DAT group (49.7 min, ±15, range 32-101; P = 0.016). The clinical outcome increased from admission to discharge and in follow-up after 90 days (mRS ≥ 2: MAT: 53.3 %, DAT: 54.5 %; P > 0.05). CONCLUSIONS: The dual aspiration technique with an additional intermediate guide catheter placed closed to the stent retriever leads to decreased procedure time in the anterior circulation. Even in cases with higher thrombus load and treated in DAT, clinical outcome improved.

Common diagnostic flowcharts in vascular and endovascular surgery.

Vascular and endovascular procedures are typically very "clean" procedures, with a very low infection rate. However, these complications, although rare, are unfortunately associated with a high rate of morbidity and mortality. The first rule to effectively treat the infection is always prevention, but when the infection has been established the only solution is given by an early diagnosis and proper medical care and often surgical treatment. The hardest thing is to obtain is an early and correct diagnosis, especially for low-grade infections. The purpose of our work was to strengthen the conviction that only an integrated work as a team will enable effective and quick management of this serious complication.

Solitaire® stent for endovascular coil retrieval.

Coil migration during embolization is an emergency, requiring individual solutions. A 71-year-old female patient was referred to our hospital suffering from subarachnoid hemorrhage due to a ruptured giant aneurysm of the ophthalmic segment of the right internal carotid artery (ICA). During the endovascular procedure, a coil migrated in the ICA. Coil dislocation could be treated by either retrieval or fixation. On intention to treat we retrieved the coil with the self-expanding Solitaire(®) AB stent (Ev3, Irvine, CA, USA). The Solitaire(®) stent is established to perform mechanical thrombectomy for treatment of acute stroke. This report demonstrates the Solitaire(®) stent's potential for safe and effective retrieval of dislocated coils. Other retrieval systems will be discussed.

Outcome of immediate interventions in acute dysfunctional hemodialysis fistulas.

PURPOSE: To analyze the efficacy of interventions in acute dysfunctional hemodialysis fistulas, if intervention is performed immediately as recommended by European Best Practice Guidelines for Hemodialysis. MATERIALS AND METHODS: Over 3 years, all (n = 280) patients with an acute dysfunctional hemodialysis fistula were immediately referred to angiography, irrespective of the time of day. Angiography and, if possible, interventional revision (n = 241) were performed. Three groups of interest were established: interventionalist's experience (high/low), time of day (routine hours: 7 am-4 pm/emergency hours: 4 pm-7 am), lesion type (stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+thrombotic occlusion). For statistical analysis corresponding success rates, chi-square tests (p < 0.025) and logistic regression analysis (p < 0.05) were calculated. RESULTS: The total success rate was 62 % (149/241). The success rates were: interventionalist experience high/low 71 % (79/111)/54 % (70/130), p = 0.022; time of day routine/emergency hours 68 % (93/136)/53 % (56/105), p = 0.017; lesion type stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+occlusion 82 % (94/104)/39 % (13/33)/18 % (6/33)/59 % (36/61), p < 0.001. Relevant variables due to logistic regression analysis were high experience and the lesion types stenosis and combined stenosis+occlusion with odds ratios 2.300 (p = 0.012), 12.053 (p < 0.001), 3.189 (p = 0.003). CONCLUSION: Unrestricted implementation of immediate interventions in acute dysfunctional hemodialysis fistulas requires permanent availability of experienced interventionalists. The lesion types fibrosclerotic occlusion and thrombotic occlusion offer poor success rates for interventional revision.

Unusual spinal metastases from an adenoid cystic carcinoma of the maxillary sinus.

Adenoid cystic carcinoma (ACC), the second most common cancer occurring in the sinonasal tract, is an aggressive malignancy with a poor five-year survival rate. Spinal metastases to the vertebral column related to this cancer are rare. This report presents a patient with maxillary sinus carcinoma with vertebral metastases at the thoracic level and compression of the spinal cord seven years after surgical resection of the primary tumor. Eleven years after detection of the primary tumor the patient is still able to walk. The role of decompression and/or fusion in spinal metastases with neurologic deficits is still under debate, although recent studies have confirmed the beneficial role of surgical intervention in selected patients. This report represents an example of modern individual treatment of an aggressive tumor in a palliative situation. The epidemiology, clinical findings, treatment and outcome of this atypical distant metastasis in long-term survivors are presented.

[Recanalization of the lower leg: PTA or stent?]. / Rekanalisation am Unterschenkel: PTA oder Stent?

Percutaneous transluminal angioplasty (PTA) and stent placement are currently accepted methods for endovascular treatment of critical limb ischemia, if infragenual vessels are involved. Outcome results in high technical success and satisfactory clinical results for treatment of infrapopliteal lesions with regard to patency rates and amputation-free survival. These treatment modalities are also safe for the patients. The question whether PAT alone or additional stent placement is the better choice, is still unanswered due to limited data.

CAS: which stent for which lesion.

Current carotid stent designs and their attributes like scaffolding to reduce plaque prolapses and embolization, flexibility, adaptability and conformability to the vessel vary largely. Knowing that differences in behaviour due to stent design exist, especially due to the open cell design (which show high flexibility and therefore adaptability to the vessel but allows in theory easy particle penetration due to open structure) and closed cell designs (which show low flexibility and therefore low adaptability to the vessel but show high resistance to particle penetration due to closed cell design and high scaffolding), physicians have to be aware of these differences when planning carotid artery stenting procedures. The individual characteristics of each stent device may make it an attractive choice in one circumstance but render it less desirable in other situations; in approximately 75% of all procedures, all types of stents will achieve similar outcomes, making adequate device selection unnecessary; for the remaining quarter, careful preoperative screening is mandatory. The aim of this article was to review different stents with regard to latest designs intended for carotid stenting with regard to topics as mentioned above highlighting latest developments in specific designs especially developed for carotid lesion treatment.

[Long-term results after fibroid embolization]. / Langzeitergebnisse nach Myomembolisation.

Fibroids (leiomyoma) are the most frequent benign tumors of the uterus during female reproductive age. In the case of clinical symptoms, uterine artery embolization (UAE) is a well established treatment option for symptomatic fibroids, resulting in promising long-term results. In order to estimate long-term success after UAE, reduction of fibroids and uterus volume is less important than complete improvement and disappearance of fibroid-related symptoms. In addition to a high technical success rate and a low perioperative complication rate, UAE results in high short-term and long-term patient satisfaction (>87%) and improvement of symptoms (>81%). Candidates for UAE should be informed about potential reinterventions in terms of repeated UAE (up to 18% of cases) or surgical treatment options.

Precision of computer-aided volumetry of artificial small solid pulmonary nodules in ex vivo porcine lungs.

The purpose of this study was to investigate the precision of CT-based volumetric measurements of artificial small pulmonary nodules under ex vivo conditions. We implanted 322 artificial nodules in 23 inflated ex vivo porcine lungs in a dedicated chest phantom. The lungs were examined with a multislice spiral CT (20 mAs, collimation 16x0.75 mm, 1 mm slice thickness, 0.7 mm increment). A commercial volumetry software package (LungCARE VA70C-W; Siemens, Erlangen, Germany) was used for volume analysis in a semi-automatic and a manual corrected mode. After imaging, the lungs were dissected to harvest the nodules for gold standard determination. The volumes of 202 solitary, solid and well-defined lesions without contact with the pleura, greater bronchi or vessels were compared with the results of volumetry. A mean nodule diameter of 8.3 mm (+/-2.1 mm) was achieved. The mean relative deviation from the true lesion volume was -9.2% (+/-10.6%) for semi-automatic and -0.3% (+/-6.5%) for manual corrected volumetry. The subgroup of lesions from 5 mm to <10 mm in diameter showed a mean relative deviation of -8.7% (+/-10.9%) for semi-automatic volumetry and -0.3% (+/-6.9%) for manually corrected volumetry. We conclude that the presented software allowed for precise volumetry of artificial nodules in ex vivo lung tissue. This result is comparable to the findings of previous in vitro studies.

[Transjugular intrahepatic portosystemic shunt: evaluation of the impact of the stent's configuration on the patency rate]. / Transjugulärer intrahepatischer portosystemischer Shunt: Untersuchung des Einflusses der Stentkonfiguration auf die Offenheitsrate.

PURPOSE: To evaluate the impact of the configuration of the stent on the patency rate after transjugular intrahepatic portosystemic shunt with a self-expanding stent. MATERIALS AND METHODS: In total, 80 patients (60 male, 20 female; mean age 56 +/- 9.6, range 37 - 81) with a transjugular intrahepatic portosystemic shunt were evaluated. The primary technical success rate, interventional revision rate, and mean patency rate according to Kaplan-Meier were calculated. The angle of deviation of the blood flow at the portal venous inflow and central venous outflow were measured on projected angiograms (valid cases, n = 78). The following five angle groups were established: 1. portal venous inflow, 2. central venous outflow, 3. maximum, angle, 4. minimum angle, and 5. sum of both angles in the shunt system. Within each group, the Mann-Whitney Test and after dichotomic partition using the median Pearson's Chi-Square Test and Fisher's Exact Test were carried out to prove the dependency of the patency on the stent's configuration. RESULTS: The primary technical success rate was 93 %, the interventional revision rate was 28 %, and the mean patency rate was 17.5 months. The mean/standard deviation/median angle were as follows: 1. portal venous inflow 66.5 degrees / 19.2 degrees / 65 degrees , 2. central venous outflow 43.7 degrees / 14.0 degrees / 40 degrees , 3. maximum angle 69.1 degrees / 16.3 degrees / 65 degrees , 4. minimum angle 40.6 degrees / 13.3 degrees / 40 degrees , and 5. sum of both angles 110.2 degrees / 21.8 degrees / 110 degrees . The 2-sided values of significance in the Mann-Whitney Test/Chi-Square Test/Exact-Fisher Test were as follows: 1. portal venous inflow 0.112 / 0.066 / 0.083, 2. central venous outflow 0.960 / 0.919 / 1.000, 3. maximum angle 0.151 / 0.042 / 0.056, 4. minimum angle 0.578 / 0.622 / 0.632, and 5. sum of both angles 0.104 / 0.111 / 0.140. CONCLUSION: The shunt's patency rate when using a self-expanding stent is not dependent on the stent's configuration regarding the deviation of the blood flow at the portal venous inflow and central venous outflow, and the maximum, minimum and total deviation in the shunt.

Subclavian and vertebral arterial interventions.

Endovascular treatment of supra-aortic atherosclerotic arterial stenoses and occlusions using percutaneous transluminal angioplasty (PTA) and stent placement is an accepted first-choice procedure. Technical success, primary success, and midterm patency after PTA and stent placement for the treatment of stenosed or obstructed brachiocephalic arteries are promising and complication rates are low. Permanent miniaturization and device improvement makes treatment of atherosclerotic obstructive disease by endovascular means in brachial and cephalic arteries a safe procedure showing promising midterm patency rates.

[Does interventional therapy prolong the patency of hemodialysis fistulas and grafts?]. / Verlängert die radiologisch-interventionelle Therapie die Shuntnutzungsdauer bei hämodialysepflichtigen Patienten?

PURPOSE: To retrospectively evaluate procedural success and patency after endovascular treatment of acute dysfunctional hemodialysis fistulas and grafts in a non-preselected patient cohort. MATERIALS AND METHODS: 185 angiographies of hemodialysis fistulas and grafts on the upper extremities were analyzed for 120 patients (53 male, 67 female; mean-age 63.1 +/- 11.4, range 24 - 91). 70 % (n = 130) were native arteriovenous fistulas, 17 % (n = 31) were prosthetic grafts, and 13 % (n = 24) were non-specific. In total, 278 lesions requiring endovascular treatment were detected. 13 % (n = 35) of the lesions were located in the arterial inflow, 18 % (n = 49) in native arteriovenous anastomoses, 7 % (n = 19) in prosthetic grafts and 62 % (n = 171) in the venous outflow. The primary, secondary and cumulative patency after endovascular treatment was calculated. RESULTS: In 51 % (n = 94) of the cases endovascular treatment could be performed, in 8 % (n = 14) no lesion requiring treatment was detected, and in 42 % (n = 77) intervention was not considered possible. In 45 % (n = 124) of the detected lesions endovascular treatment was successful, in 18 % (n = 51) the intervention failed, and in 37 % (n = 103) intervention was not considered possible. The complication rate was 5 % (n = 10). The primary, secondary, and cumulative patency rates for 50 % of the hemodialysis fistulas and grafts after endovascular treatment were 65, 191, and 370 days, respectively. The results differed significantly from each other with p < 0.05 in the log rank test and log rank trend test. CONCLUSION: Endovascular treatment of acute dysfunctional hemodialysis fistulas and grafts is effective in restoring the patency for hemodialysis.

[Rational minimally invasive treatment of pAOD: when should a conservative approach, PTA, or stent be chosen?]. / Rationale minimal-invasive Therapie der pAVK: wann konservativ, wann PTA, wann Stent?

In order to obtain optimal results and satisfied patients, rational therapy of pAOD should strictly follow national and international society guidelines. In particular cases an individual therapeutic concept seems justified beyond these guidelines. Based on clinical data and driven by costs, aortic and iliac lesions may be treated by PTA or selective stent placement with equal results; however, long-term data justify also primary, direct stenting. For treatment of infrainguinal and popliteal stenotic lesions primary stenting should be restricted to PTA failure (dissection, recoil, occlusion); except for treatment of extended lesions, primary stenting compared to PTA alone seems beneficial in terms of midterm patency. Endovascular procedures below the knee and at the toe should be limited to existing limb-threatening ischemia in order to save the extremity; whether PTA or stenting is advantageous has not yet determined.