Impact of System-F in Delivering Vascular Plugs for Aortic Side Branch Embolization During Endovascular Aneurysm Repair.

PURPOSE: This study aimed to illustrate the utility of our original system to deliver vascular plugs into aortic side branches during endovascular aneurysm repair (EVAR). TECHNIQUE: Our device, which we named "System-F," consists of a 14 Fr sheath, a 12 Fr long sheath with a side hole, a stiff guidewire as a shaft, and a parallelly-inserted delivery catheter navigated through the side hole into the aneurysm sac. Vertical motion and horizontal rotation of the side hole allow multidimensional movement of the delivery catheter within the aneurysm. This system was applied in 7 cases undergoing EVAR; 4 inferior mesenteric arteries and 14 lumbar arteries were embolized using vascular plugs. Type II endoleak (T2EL) was not observed in the follow-up survey of any case. Conclusion: The applicability of System-F for vascular plug placement in the side branches of abdominal aortic aneurysms has the potential to achieve high delivery capability and be widely applied for the prevention of T2EL. CLINICAL IMPACT: System-F has potential to change the strategies of pre-EVAR embolization.

Comparison of Slow-Infusion Magnetic Resonance Angiography with Sequential K-Space Filling and Computed Tomography Angiography to Detect the Adamkiewicz Artery.

BACKGROUND: Radiographic detection of the Adamkiewicz artery (AKA) before aortic surgery helps to avoid spinal cord ischemia (SCI). We applied magnetic resonance angiography (MRA) using gadolinium enhancement (Gd-MRA) by means of the slow-infusion method with sequential k-space filling and compared AKA detectability with that of computed tomography angiography (CTA). METHODS: A total of 63 patients with thoracic or thoracoabdominal aortic disease (30 with aortic dissection [AD] and 33 with aortic aneurysm) who underwent both CTA and Gd-MRA to detect AKA were evaluated. The detectability of the AKA using Gd-MRA and CTA were compared among all patients and subgroups based on anatomical features. RESULTS: The detection rates of the AKAs using Gd-MRA and CTA were higher in all 63 patients (92.1% vs. 71.4%, P = 0.003). In AD cases, the detection rates using Gd-MRA and CTA were higher in all 30 patients (93.3% vs. 66.7%, P = 0.01) as well as in 7 patients whose AKA originated from false lumens (100% vs. 0%). In aneurysm cases, the detection rates using Gd-MRA and CTA were higher in 22 patients whose AKA originated from the nonaneurysmal parts (100% vs. 81.8%, P = 0.03). In clinical, SCI was observed in 1.8% of cases after open or endovascular repair. CONCLUSIONS: Despite the longer examination time and more complicated imaging techniques compared to those of CTA, the high spatial resolution of slow-infusion MRA may be preferable for detecting AKA before performing various thoracic and thoracoabdominal aortic surgeries.

Endovascular treatment with Viabahn stent-grafts for arterial injury and bleeding at the visceral arteries: initial and midterm results.

PURPOSE: The purpose of the study is to evaluate the initial and midterm efficacy and safety of endovascular treatment (EVT) using Viabahn stent-graft (SG) for arterial injury and bleeding (AIB) at the visceral arteries. MATERIALS AND METHODS: Consecutive patients with visceral AIB who underwent EVT using Viabahn between January 2017 and February 2021 were retrospectively reviewed. Technical success, clinical success, peripheral organ ischemia, peri-procedural complications, bleeding-related mortality, 30-day mortality, neck length, re-bleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated. RESULTS: EVT using Viabahn was performed in 14 patients (mean age: 68.6 years; 12 males) and 15 arteries. The technical and clinical success rates were 100%. The rates of peripheral organ ischemia, peri-procedural complications, bleeding-related mortality, and 30-day mortality were all 0%. The mean neck length was 9.9 mm. No endoleaks or re-bleeding occurred during the follow-up (mean: 732 days). The SG patency was confirmed after 1, 3, 6, and 12 months in 78.6%, 78.6%, 78.6%, and 56.1% of the patients, respectively. CONCLUSION: EVT using Viabahn for AIB at the visceral arteries was safe and effective. SG occlusions without ischemia often occurred after 12 months.

Emergency endovascular treatment using a Viabahn stent graft for upper and lower extremity arterial bleeding: a retrospective study.

BACKGROUND: A Viabahn stent graft (SG) is a heparin-coated self-expandable SG for lower extremity arterial disease that exhibits high flexibility and accuracy in the delivery system. This study aimed to evaluate the short-term efficacy and safety of emergency endovascular treatment (EVT) using a Viabahn SG for upper and lower extremity arterial bleeding (ULEAB). METHODS: Consecutive patients with ULEAB who underwent emergency EVT using the Viabahn SG between January 2017 and August 2021 were retrospectively reviewed. The indications for EVT, location of artery, technical success, clinical success, limb ischemia, periprocedural complications, bleeding-related mortality, 30-day mortality, diameter of the target artery, diameter of the SG, neck length, rebleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated. RESULTS: EVT using the Viabahn SG was performed in 22 patients (mean age, 72.0 ± 13.0 years; 11 men) and 23 arteries (upper, 6; lower, 17). The indications for EVT were pseudoaneurysm (n = 13, 59.1%), extravasation (n = 9, 39.1%), and inadvertent arterial cannulation (n = 1, 4.3%). The anatomical locations of the 23 ULEAB injuries were the brachiocephalic (1 [4.3%]), subclavian (3 [13.0%]), axillary (1 [4.3%]), brachial (1 [4.3%]), common iliac (4 [17.4%]), external iliac (8 [34.8%]), common femoral (2 [8.7%]), superficial femoral (2 [8.7%]), and popliteal (1 [4.3%]) arteries. The technical and clinical success rates were 100%. The rates of limb ischemia, periprocedural complications, and bleeding-related mortality were 0%, whereas the 30-day mortality rate was 22.7%. The mean diameters of the arteries and SGs were 7.7 ± 2.2 and 8.9 ± 2.3 mm, respectively. The mean neck length was 20.4 ± 11.3 mm. No endoleaks or rebleeding occurred during the follow-up period (mean, 169 ± 177 days). Two SG occlusions without limb ischemia occurred in the external iliac and brachial arteries after 1 and 4 months, respectively. Subsequently, cumulative SG patency was confirmed after 1, 3, 6, and 12 months in 91.7%, 91.7%, 81.5%, and 81.5% of patients, respectively. CONCLUSIONS: Emergency EVT using the Viabahn SG for ULEAB was effective and safe according to short-term outcomes. Appropriate size selection and neck length are important for successful treatment. SG patency was good after 1, 3, 6, and 12 months.

Effects of temperature alteration on viscosity, polymerization, and in-vivo arterial distribution of N-butyl cyanoacrylate-iodized oil mixtures.

PURPOSE: Temperature alteration can modify the polymerization of n-butyl cyanoacrylate (NBCA)-iodized oil mixtures during vascular embolization; its effects on viscosity, polymerization time, and intra-arterial distribution of the NBCA-iodized oil mixture were investigated. MATERIALS AND METHODS: In vitro, the viscosities of NBCA, iodized oil, and NBCA-iodized oil mixtures (ratio, 1:1-8) were measured at 4-60 ºC using a rotational rheometer. The polymerization times (from contact with blood plasma to stasis) were recorded at 0-60 ºC using a high-speed video camera. In vivo, the 1:2 mixture was injected into rabbit renal arteries at 0, 20, and 60 ºC; intra-arterial distribution of the mixture was pathologically evaluated. RESULTS: The mixtures' viscosities decreased as temperature increased; those at 60 ºC were almost four to five times lower than those at 4 ºC. The polymerization time of NBCA and the 1:1-4 mixtures increased as temperature decreased in the 0-30 ºC range; the degree of time prolongation increased as the percentage of iodized oil decreased. The 0 ºC group demonstrated distributions of the mixture within more peripheral arterial branches than the 20 and 60 ºC groups. CONCLUSION: Warming reduces the mixture's viscosity; cooling prolongs polymerization. Both can be potential factors to improve the handling of NBCA-iodized oil mixtures for lesions requiring peripheral delivery. Temperature alteration influences the polymerization time, viscosity, and intra-arterial distribution of NBCA-iodized oil mixtures. Warming reduces the viscosity of the mixture, while cooling prolongs polymerization.

A Case of Human Immunodeficiency Virus-Positive Patient Diagnosed during the Treatment of Right Internal Iliac Pseudoaneurysm.

Isolated internal iliac artery aneurysms are rare, and there are no reports of human immunodeficiency virus (HIV)-related vasculitis in Japan. We report our experience with a 51-year-old man diagnosed with acquired immunodeficiency syndrome, discovered during the postoperative course when the patient exhibited remittent fever and susceptibility to infection after emergency interventional radiology therapy for a right isolated internal iliac artery aneurysm. The patient had positive treponema pallidum particle agglutination test result before admission, and tests for sexually transmitted disease showed positive results for HIV H-1 antibodies. The repeated fevers were attributed to HIV infection-related susceptibility.

Total endovascular repair for a persistent sciatic artery aneurysm with widespread limb-threatening arterial occlusion.

In the present report, we have described the case of a 79-year-old woman who presented with acute right lower limb ischemia and was diagnosed with bilateral persistent sciatic arteries and a right persistent sciatic artery aneurysm. Concomitant widespread thrombotic occlusion was present, extending from the orifice of the right internal and external iliac arteries to the below-the-knee popliteal artery. These complicated lesions were successfully treated using only percutaneous endovascular procedures, including stent-graft placement, bare metal stent implantation, and thrombolysis. Our report illustrates how a combination of techniques can achieve total endovascular repair of a persistent sciatic artery aneurysm accompanied by occlusion of the internal and external iliac arteries.

Efficacy of direct hemoperfusion for the removal of phenobarbital through blood concentration analysis.

AIM: Phenobarbital overdose can cause coma and even death. The consciousness disturbance is often prolonged due to its long half-life. In this study, we investigated the efficacy of direct hemoperfusion (DHP) for the removal of phenobarbital by measuring the blood levels of phenobarbital. METHODS: Study subjects included five patients with phenobarbital poisoning who were transferred to our hospital. Direct hemoperfusion was carried out in three of the five patients (six times in total), and the elimination rate was calculated by measuring the blood levels before and after DHP. Furthermore, the disappearance rate of phenobarbital without DHP was calculated in all five patients (seven times in total) for comparison with the elimination rate. RESULTS: The elimination rate of phenobarbital with DHP was significantly higher than the disappearance rate without DHP．. CONCLUSION: This study suggests that early introduction of DHP should be considered as a treatment option for phenobarbital poisoning.

Embolization using warmed glue via the triaxial microballoon occlusion system for various vascular disorders.

PURPOSE: We aimed to illustrate the benefits of using warmed glue for viscosity reduction via the triaxial microballoon system for the treatment of various vascular disorders. METHODS: Seven patients who underwent 10 treatment sessions for hemoptysis, type II endoleak, post-pancreatic surgical bleeding, spontaneous retroperitoneal bleeding, or ovarian tumor bleeding were evaluated based on technical and clinical outcomes. In the procedure, the triaxial system, consisting of a 4.5-Fr guiding catheter, a 2.8-Fr microballoon catheter, and a 1.9-Fr no-taper microcatheter, was advanced into the target lesion. Glue (33% n-butyl cyanoacrylate mixed with Lipiodol) warmed to 40°C was injected under balloon occlusion. RESULTS: The common hepatic, right bronchial, intercostals, internal mammary, costocervical, lateral thoracic, superior thoracic, thoracoacromial, inferior thyroid, iliolumbar, lumbar, internal pudendal arteries, and branch of the inferior mesenteric artery were successfully embolized; 100% technical success and 100% clinical success were obtained after each session. CONCLUSION: Our modified balloon-occluded glue embolization may lead to better handling with more distal glue penetration capability.

"Squid-Capture" Modified In Situ Stent-Graft Fenestration Technique for Recurrent Abdominal Aortic Occlusive Disease after Collapse of Balloon-Expandable Stent.

We present a case of an 85-year-old woman with bilateral limb-threatening ischemia caused by acute-on-chronic occlusion of the infrarenal aorta. The patient once underwent endovascular recanalization using nitinol and stainless-steel bare-metal stent implantation; however, the stainless-steel stent collapsed 3 months later. In the second endovascular therapy, "Squid-Capture" modified in situ stent-graft fenestration technique followed by stent-in-stent implantation with stent graft and bare-metal stent was successfully applied, and it can be regarded as a promising treatment option for the repair of abdominal aortic occlusive disease in some limited anatomical conditions.

Current Practices in Acute Blood Purification Therapy in Japan and Topics for Further Study.

Continuous venovenous hemodiafiltration is the modality of choice for acute blood purification therapy at almost all medical institutions in Japan. Nafamostat mesilate, an ultrashort-acting anticoagulant, is widely used for anticoagulation. Due to restrictions imposed by national health insurance, Japanese institutions use an effluent flow rate of 15 mL/kg/h, which is lower than the standard effluent flow rate used in the West. In addition, hemofilters are believed to adsorb cytokines, and thus some institutions also proactively perform continuous renal replacement therapy with a hemofilter at an early stage for cytokine modulation in patients with sepsis. Although some aspects of these Japanese practices differ greatly from Western practices, there has not been much evidence to support current standard methods. Therefore, Japanese researchers must continue working to produce evidence for those methods, at least those that are widely used in Japan.