Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. MATERIALS AND METHODS: MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data. RESULTS: Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013). CONCLUSIONS: Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. CLINICAL IMPACT: Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.

The Use of Vascular Closure Devices for Brachial Artery Access: A Systematic Review and Meta-Analysis.

PURPOSE: To estimate the rates of technical success and adverse events of vascular closure devices (VCDs) in the brachial artery and compare the rates of adverse events with manual compression. MATERIALS AND METHODS: MEDLINE and Embase were searched for observational studies examining VCDs in the brachial artery. Meta-analyses were performed using random effects for the following outcomes: (a) technical success, (b) hematoma at the access site, (c) pseudoaneurysm, (d) local neurological adverse events, and (e) total number of adverse events. A pairwise meta-analysis compared VCD with manual compression for the outcomes of hematoma and the total number of adverse events. RESULTS: Of 1,761 eligible records, 16 studies including 510 access sites were included. Primary procedures performed were peripheral arterial disease interventions, percutaneous coronary intervention, and endovascular thrombectomy for ischemic stroke. The technical success rate was 93% (95% CI, 87%-96%; I2 = 47%). Data on the following adverse events were obtained via meta-analysis: (a) hematoma, 9% (5%-15%; I2 = 54%); (b) stenosis or occlusion at access site, 3% (1%-14%; I2 = 51%); (c) infection, 0% (0%-5%; I2 = 0%); (d) pseudoaneurysm, 4% (1%-13%; I2 = 61%); (e) local neurological adverse events, 5% (2%-13%; I2 = 54%); and (f) total number of adverse events, 15% (10%-22%; I2 = 51%). Angio-Seal success rate was 96% (93%-98%; I2 = 0%), whereas the ExoSeal success rate was 93% (69%-99%; I2 = 61%). When comparing VCD and manual compression, there was no difference in hematoma formation (relative risk, 0.75; 95% CI, 0.35-1.63; I2 = 0%; P = .47) or the total number of adverse events (relative risk, 0.75; 95% CI, 0.35-1.58; I2 = 76%; P = .45). CONCLUSIONS: Despite being off-label, studies suggest that VCDs in the brachial artery have a high technical success rate. There was no significant difference in adverse events between VCDs and manual compression in the brachial artery.

Percutaneous Transluminal Angioplasty for Below-the-Elbow Critical Hand Ischemia: A Systematic Review.

PURPOSE: To perform a systematic review assessing the safety and efficacy of percutaneous transluminal angioplasty (PTA) for treatment of critical hand ischemia (CHI) due to below-the-elbow (BTE) obstructive arterial disease. MATERIALS AND METHODS: MEDLINE and EMBASE systematic searches were performed from inception to December 2020 to identify studies assessing PTA for management of BTE obstructive arterial disease. Three independent reviewers performed abstract selection, data extraction, and quality assessment. The Newcastle-Ottawa Scale was used to assess individual study bias for non-randomized controlled trials. RESULTS: Eight studies comprising 176 patients with obstructive BTE vessel disease were included. All studies had a score >5 on the Newcastle-Ottawa Scale, indicative of high quality. All studies used low-profile balloons (1.5-4 mm) for PTA of stenotic lesions or chronic total occlusions (CTOs). The weighted average technical success and clinical success rates were 89.3% (range = 82%-100%) and 69.9% (range = 19%-100%), respectively, at a mean follow-up of 29.7 ± 17.1 months. The short-term (<30 days) complication rate was low at 4.7% and most commonly included access site hematomas, pseudoaneurysms, and radial artery perforation or re-thrombosis. Nearly 20% of patients required an amputation, and most (96%) were minor (either distal phalanges or digits). Only 2 patients required above-wrist amputations. The primary and secondary patency rate at 5 years were 38% and 54%, respectively. The cumulative 5-year mortality rate was 33.1%. CONCLUSIONS: PTA for CHI due to BTE obstructive arterial disease is feasible with a high technical success rate and a low short-term complication rate. Additional long-term comparative studies are required to unequivocally establish the clinical benefit of endovascular treatment compared with conservative management or surgical bypass.

Overall Impact of the COVID-19 Pandemic on Interventional Radiology Services: A Canadian Perspective.

PURPOSE: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada. METHODS: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics. RESULTS: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%). CONCLUSION: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

Three-stage approach to resection of left pancoast tumour with spinal and major vessel involvement.

Here we describe the successful outcome of a complex and challenging resection of a left-sided pancoast tumour involving the left subclavian artery and vertebral bodies. The resection was performed following neoadjuvant chemoradiotherapy in a multi-staged fashion involving multiple teams including thoracic surgery, plastic surgery, neurosurgery and vascular surgery. Each operation was less than 6 h, without complication, and the patient was discharged within 1 week of each procedure. This case report highlights the importance of multidisciplinary team collaboration and planning in order to achieve a successful oncologic outcome and a good quality of life following treatment of these challenging tumours. The patient had a good functional outcome and no evidence of recurrence 1.5 years later.

Rare complication of esophageal necrosis and perforation after fenestrated endovascular aneurysm repair.

Fenestrated endovascular aneurysm repair (FEVAR) is a minimally invasive technique used to treat complex abdominal aortic aneurysms. We present the case of a 69-year-old man with a juxtarenal abdominal aortic aneurysm treated with FEVAR. The patient experienced postoperative dysphagia and sepsis. Investigations revealed a perforated esophagus due to esophageal ischemia and necrosis, leading to complete esophagectomy and subsequent esophageal reconstruction. This case highlights esophageal necrosis and perforation as a potential complication of FEVAR and serves as a reminder to have a low threshold for investigating and emergently managing this condition, which otherwise has a high mortality rate.

Vascular Reconstruction of a Brachial Artery Aneurysm Proximally to an Arteriovenous Malformation.

Brachial artery aneurysms and arteriovenous malformations (AVM) are limb-threatening vascular anomalies. This patient presented with a bilobed brachial artery aneurysm in the antecubital fossa proximally to an AVM arising from the dorsal interosseous and ulnar arteries that had been treated with endovascular embolization, leaving the hand solely supplied by the radial artery. The aneurysm continued to increase in size and imaging revealed concomitant thrombus. A femoral vein interposition graft was used to repair the aneurysm, and postoperatively, the patient retained full left arm function.

Diagnosis and management of right external iliac vein "sandwich": A rare cause of iliofemoral deep venous thrombosis.

Several anatomic abnormalities predispose patients to iliofemoral deep venous thrombosis, the most common of which is compression of the left iliac vein between the right common iliac artery and lumbar vertebrae, or May-Thurner syndrome. Other areas of venous compression can occur but are rare. This case report describes the presentation, diagnosis, and management of a patient with compression of the right iliac vein "sandwiched" between the right internal and external iliac arteries. After treatment, the patient demonstrated significant improvement in symptoms.

Outcomes at a single center after subintimal arterial flossing with antegrade-retrograde intervention for critical limb ischemia.

OBJECTIVE: The subintimal arterial flossing with antegrade-retrograde intervention technique has been used to overcome antegrade recanalization failures for peripheral lower limb arterial occlusive disease. There are few outcomes published for this technique and we sought to evaluate outcomes at our institution over a 7-year period. METHODS: A retrospective review was performed of all subintimal arterial flossing with antegrade-retrograde intervention procedures of infrainguinal occlusive disease from 2009 to 2016. Retrograde and antegrade accesses were combined when occlusions could not be crossed from the antegrade direction. Baseline patient characteristics, procedures, procedure time, fluoroscopy time, contrast used, and radiation dose were collected. Posterior tibial waveforms, ankle-brachial index, limb salvage, vessel patency, and the presence of symptoms were assessed at follow-up. RESULTS: Treatment was performed in 52 limbs in 52 patients (35 men and 17 women; mean age, 77.62 ± 11.61 years) with critical limb ischemia and no appropriate venous conduit for surgical bypass. Among the cohort, 63.5% were diabetics, 98% had hypertension, 53.8% had a prior myocardial infarction, and 36.5% end-stage renal disease. The average Rutherford Category before the intervention was 5.08 ± 1.01. Retrograde pedal access was most commonly obtained in the anterior tibial artery/dorsalis pedis (55.7%), followed by the posterior tibial artery (40.3%). The technical success rate was 63.5% (33/52); adjunctive stenting was needed in 19 (36.5%) to optimize results. Preprocedural ankle-brachial index score was 0.54 ± 0.25, which improved after the procedure to an ankle-brachial index score of 0.77 ± 0.25. The primary patency rates at 3 and 6 months were 65% and 60%, respectively. The limb salvage rate at a mean follow-up of 5.4 months was 78.8%. There were 5 complications; 4 were hematomas managed conservatively and 1 was a major retroperitoneal bleed resulting in patient death. CONCLUSIONS: Retrograde pedal access is a viable revascularization technique for achieving limb salvage in patients with critical limb ischemia with acceptable patency for limb-threatening ischemia. This technique expands revascularization options after failed conventional endovascular antegrade approaches.

Successful balloon assisted percutaneous thrombin injection of right subclavian artery pseudoaneurysm.

PURPOSE: To report the use of a balloon catheter to facilitate percutaneous ultrasound-guided thrombin injection of a subclavian artery pseudoaneurysm. CASE REPORT: A 36-year-old man presented with hoarseness after the insertion of a right temporary internal jugular line. Arteriography showed a short neck right subclavian artery pseudoaneurysm. A 6 mm × 40 mm balloon catheter was positioned across the neck of the pseudoaneurysm to permit percutaneous ultrasound-guided thrombin injection. Immediate post-treatment angiogram demonstrated no filling of the pseudoaneurysm. Seven-month clinical and imaging follow-up confirmed resolution of the pseudoaneurysm and hoarseness. CONCLUSIONS: This clinical vignette highlights the potential of balloon catheter-assisted percutaneous ultrasound-guided thrombin injection as an alternative to open or endovascular repair of pseudoaneurysms of the subclavian arteries.

Repair of popliteal aneurysm and spontaneous arteriovenous fistula in a patient with Marfan syndrome.

Isolated extremity arterial aneurysms remain a rare entity, and the development of a spontaneous arteriovenous fistula from such an aneurysmal segment in a young patient should prompt a search for an underlying genetic predisposition. Endovascular repair of aneurysms or arteriovenous fistulas in the popliteal artery is appropriate in select populations; however, open repair allows for a more durable reconstruction of both the arterial and any involved venous segments in patients who can tolerate the procedure.

Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair.

PURPOSE: To report the first clinical application of a novel technique using radiofrequency puncture to create retrograde in situ fenestrations during thoracic endovascular aortic repair (TEVAR). METHODS: Between June 2011 and December 2013, 40 TEVAR procedures were performed in our facility, including 10 cases in which in situ fenestration was planned. Two thoracic stent-graft models were deployed: the Valiant (n=5) and the Zenith TX2 (n=5). A 0.035-inch PowerWire radiofrequency guidewire delivered from a brachial approach was used to fenestrate the grafts covering a left subclavian artery (LSA) in 9 cases and a left common carotid artery in one. The fenestrations were serially dilated to 6 mm, and self-expanding Advanta V12 covered stents were positioned in the target arteries. RESULTS: Technical success was achieved in 6 of the 10 planned cases. Of the remaining 4 cases, stent-grafts were deployed in zone 3 in 2 cases (one received a chimney to the LSA). Another stent-graft was deployed in zone 2 without endoleak after fenestration was abandoned (the LSA had good filling via the vertebral artery). In the last case, the fenestration was unsuccessful in double-layered (proximal extension overlap) stent-grafts; a carotid-axillary bypass was required. There were no fenestration-related complications, but overall surgical complications included a case of paraparesis that resolved following spinal drainage and a death from a preexisting aortoesophageal fistula. There were no postoperative strokes. All fenestrations remained patent, and there were no endoleaks at a mean 12-month follow-up (range 1-33). CONCLUSION: Radiofrequency puncture is a viable alternative to needle or laser punctures for in situ fenestration during TEVAR. Early clinical results suggest technical feasibility and acceptable early outcomes.

Iliac branch graft in the treatment of complex aortoiliac aneurysms: early results from a North American institution.

PURPOSE: To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair. MATERIALS AND METHODS: From July 2007 to August 2009 (25 months), 14 patients (13 men, one woman) with a mean age of 70.1 years (range, 59.3-80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n = 11), juxtarenal aortic aneurysm with CIA involvement (n = 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6-35 mo). RESULTS: Technical success rate, as defined by successful implantation of IBG with no intraprocedural type I or type III endoleak, was 86% (12 of 14). A total of 14 IBGs were successfully deployed in 12 patients. Two cases of technical failure were related to excessive iliac tortuosity. The mean hospitalization duration was 6.5 days (range, 3-14 d), with zero mortality at 30 days. There were two cases of type II endoleak treated conservatively and a single case of IBG-related type III endoleak that required repeat intervention. The rest of the stent-implanted aortic and iliac aneurysms remained stable in size, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up. None of the patients who received IBGs had new symptoms of pelvic ischemia. CONCLUSIONS: Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of aortoiliac aneurysms.

Hypertonic preconditioning prevents hepatocellular injury following ischemia/reperfusion in mice: a role for interleukin 10.

Ischemia/reperfusion (I/R) of the liver occurs in many clinical scenarios including trauma, elective surgery, and transplantation. Events initiated by this process can lead to inflammation in the liver, culminating in local injury as well as distant organ dysfunction. Recent studies have suggested that hypertonic saline exerts anti-inflammatory effects, which may be beneficial in preventing organ injury. In the present study, we examine the effect of hypertonic saline on the development of liver inflammation following I/R in both rat and mouse models. Hypertonic pretreatment was shown to prevent liver enzyme release concomitant with a reduction in liver neutrophil sequestration. Hypertonic saline appeared to exert this effect by inhibiting liver tumor necrosis factor alpha (TNF-alpha) generation, an effect that culminated in reduced liver adhesion molecule expression. Hypertonic saline pretreatment was shown to augment liver interleukin 10 (IL-10) expression following I/R, as a potential mechanism underlying its anti-inflammatory effect. To examine the role of IL-10 in the protective effect of hypertonic saline on liver I/R injury, we used a murine model of I/R. In wild type mice, hypertonic pretreatment similarly prevented liver injury induced by I/R. However, in IL-10 knockout animals, hypertonic pretreatment was unable to prevent the liver enzyme release, TNF-alpha generation, or neutrophil sequestration induced by I/R. In conclusion, these findings define a novel mechanism responsible for the anti-inflammatory effects of hypertonic saline and also suggest a potential clinical role for hyperosmolar solutions in the prevention of liver injury associated with I/R.