Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive.

OBJECTIVE: Transcatheter embolization with coils and other agents has been described as a treatment method for type II endoleak after endovascular aortic aneurysm repair (EVAR). Type I endoleak has not been treated commonly with such therapies, although most investigators believe they warrant definitive intervention. The liquid adhesive n-butyl 2-cyanoacrylate (n-BCA) is often used to treat congenital arteriovenous malformations. The objective of this study is to report our initial experience in treating type I endoleak with n-BCA and with a variety of other interventions. METHODS: A retrospective review was performed of 270 patients who underwent EVAR at our institution between January 1994 and December 2002. Of these, 24 patients had type I endoleak (8.9%), diagnosed either intraoperatively (n = 13, 52%) or during follow-up (n = 12, 48%). Among these 24 patients, 17 had proximal leaks and the remaining 8 patients had distal leaks. These cases form the focus of this study. RESULTS: Twenty-two leaks required endovascular intervention, with the following success rate: n-BCA, 12 of 13 cases (92.3%); extender cuffs, 4 of 5 cases (80%); coils with or without thrombin, 3 of 4 cases (75%). In one patient with persistent endoleak despite attempted endovascular intervention the device ultimately was surgically explanted, and the patient did well. Of six patients with endoleak initially managed expectantly, two eventually underwent attempts at definitive intervention, both with n-BCA. Three sealed spontaneously before definitive intervention could be performed; and in one 97-year-old patient who refused intervention, the aneurysm subsequently ruptured and the patient died. In total, 13 patients with type I endoleak underwent n-BCA transcatheter embolotherapy. No serious complications were directly related to this therapy. Colon ischemia developed in one patient, and was believed to be a result of thromboembolism during wire and catheter manipulation rather than n-BCA treatment. Twelve of these 13 leaks remain sealed at mean follow-up of 5.9 months (range, 0-19 months). CONCLUSION: Our initial use of n-BCA occlusion suggests that it may be an effective and safe method of treatment of type I endoleak after EVAR. In particular, n-BCA embolotherapy may be especially useful in treating type I endoleak not amenable to placement of extender cuffs. Larger case series and longer follow-up are needed before this treatment is more broadly recommended. Type I endoleak after EVAR can be treated successfully with a variety of endovascular methods, and surgical explantation is rarely required.

Endovascular abdominal aortic aneurysm (AAA) repair since the FDA approval. Are we going too far?

BACKGROUND: Since the FDA approval of endovascular devices for abdominal aortic aneurysm (AAA) repair, clinicians have been relaxing the strict inclusion criteria of the clinical trials. We have reviewed our experience during and after the clinical trials to examine changes in patient selection, technical aspects of the procedure, and outcome. METHODS: A review of a prospectively compiled database of all endovascular AAA repairs performed at our institution was performed. RESULTS: Endovascular AAA repair was attempted in 130 patients: 46 (35.4%) as a part of clinical trials (Group I), and 84 (64.6%) since the FDA approval of the devices (Group II). Significant differences in patient selection included: a higher proportion of short (<15 mm) proximal necks in Group II (28.6 vs 0.0%, p<0.001), and a higher proportion of iliac occlusive disease in Group II (48.8 vs 15.4%, p=0.001). Additional trends suggested that Group II AAA's were more complex, including increased proximal neck angulation, increased proximal calcification, increased presence of proximal thrombus, and increased iliac tortuosity. Significant differences in technical aspects of the procedure included increased usage of iliac angioplasty (46.4 vs 13.3%, p<0.001), iliac stenting (31 vs 8.9%, p<0.01), and conduit access to the external iliac artery (10.7 vs 0%, p=0.03) in Group II. Analysis of outcome revealed a decreased incidence of the following in Group II cases: conversions to open repair (2.4 vs 10.9%), lower extremity ischemia (3.6 vs 13.0%), and graft limb occlusion (2.4 vs 8.7%). Other major perioperative complications did not differ significantly between the 2 groups. However, although the overall rate of any endoleak noted in the postoperative course was decreased in Group II cases (26.2 vs 32.6%), the incidence of proximal or distal attachment site leaks has increased (11.9 vs 4.3%, p=0.14). Although this comparison did not reach statistical significance, the magnitude of the increase is concerning. CONCLUSIONS: Although we have been able to offer endovascular AAA repair to a larger number of patients since FDA approval, endovascular management of increasingly complex proximal necks and increased iliac artery disease appears to have increased the incidence of attachment site endoleaks. Although many of these leaks have been successfully managed with adjunctive endovascular procedures, their increasing incidence is worrisome and suggests that we may need to re-evaluate current inclusion criteria for using this technology. Although difficult access issues have been handled with adjunctive procedures, the presence of a short, angulated proximal neck may be difficult to overcome, and may not be well suited for endovascular repair with the currently available devices.

Congenital vascular malformations in the hand and forearm.

PURPOSE: To review a single-center experience in the management of symptomatic congenital vascular malformations of the hand and forearm with special attention to embolotherapy. METHODS: A retrospective chart review was performed to identify patients with vascular malformations referred for arteriography and possible intervention between 1983 and 1998. Arteriography and venography were performed in all patients to differentiate between true high-flow arteriovenous malformations (AVM) and low-flow primary venous malformations (PVM). The clinical and radiological data, procedural results, and follow-up data were retrieved and reviewed. RESULTS: In a 15-year period, 39 patients (22 men; mean age 22.5 years, range 1-51) had symptomatic vascular lesions diagnosed in the forearm and hand: 21 AVMs, 17 PVMs, and one complex lesion with both AVM and PVM. Thirty-four (87%) lesions were treated with immediate technical success achieved in 31 (91%) cases; 5 (13%) lesions were not amenable to percutaneous treatment. There were no major complications, but 3 embolized AVMs had significant residual flow (81.6% technical success on intention to treat basis). Long-term follow-up ranging to 5 years was available in 26 of the 34 treated patients; the mean symptom-free period was 30 months for the AVM patients and 30.5 months for the PVM group, with an average of 1.5 and 1.2 embolization procedures, respectively. CONCLUSIONS: Vascular malformations of the hand and forearm are extremely rare lesions that demand a multidisciplinary approach for optimal diagnosis and management. Microembolotherapy with or without surgery has offered the highest level of safety and success to date.

Transcatheter embolization of complex pelvic vascular malformations: results and long-term follow-up.

OBJECTIVES: Vascular malformations of the pelvis are rare and present a difficult therapeutic challenge. Surgical treatment is notoriously difficult and carries a high likelihood of recurrence. Surgical proximal ligation of a feeding vessel may in fact be contraindicated, because it can make subsequent transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic complex pelvic vascular malformations in 35 patients. METHODS: A retrospective review was conducted of a prospectively compiled database of all patients undergoing transcatheter therapy of a pelvic vascular malformation at our institution. RESULTS: The mean age of the patients was 34 years (range, 16 months-66 years), and 51% were male. The most common presenting symptoms included pain (59%), a visible or palpable lesion (62%), associated palpable pulsation or thrill (44%), hemorrhage (27%), congestive heart failure (18%), and symptoms due to mass effect (35%). A significant number of patients had undergone previous, unsuccessful attempted surgical treatment of the lesion (32%). The most common type of lesion noted on arteriography was arteriovenous shunting (89%). Patients required a mean of 2.4 embolization procedures (range, 1-11 procedures) over a mean period of 23.3 months (range, 1-144 months). The most common agents used were rapidly polymerizing acrylic adhesives. The most common vessels involved and treated were branches of the hypogastric artery (82%). More than one procedure were performed in 20 patients (53%). Seven were planned as staged embolizations, whereas 13 were due to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization therapy in five patients (15%). Eighty-three percent of patients were asymptomatic or significantly improved at a mean follow-up of 84 months (range, 1-204 months). CONCLUSIONS: Pelvic vascular malformations are difficult to eradicate completely, and recurrences are common. Many patients require multiple therapeutic interventions. However, most of these difficult cases have good results in the long term. Transcatheter embolization plays a significant role in, and may be the treatment of choice for, symptomatic pelvic vascular malformations.

Dysplastic nodules and hepatocellular carcinoma: sensitivity of digital subtraction hepatic arteriography with whole liver explant correlation.

PURPOSE: The purpose of this work was to determine the sensitivity of hepatic digital subtraction arteriography (DSA) for the detection of hepatocellular carcinoma (HCC) and dysplastic nodules (DNs) when compared with pathological findings from whole liver explants. METHOD: Twenty-one patients 30-72 years old (mean 54 years) with cirrhosis and known or clinically suspected HCC (20 prior to chemoembolization) underwent hepatic DSA with subsequent transplantation within 80 days (mean 32 days). The prospective DSA report was compared with pathologic findings from explanted livers. RESULTS: Overall, DSA detected 31 of 95 HCC lesions for a sensitivity of 33%. Of these 31 lesions, 28 were hypervascular and 3 were hypovascular. DSA detected all six HCCs measuring >5 cm, all six HCCs measuring 3-5 cm, and all five HCCs 2-3 cm, resulting in a sensitivity of 100% (17/17) for HCC >2 cm. DSA detected 7 of 18 HCCs measuring 1-2 cm (sensitivity 39%) and 7 of 60 HCCs < or =1 cm (sensitivity 12%). Overall sensitivity for DSA in detection of HCC < or =2 cm was 18% (14/78 lesions). None of 17 DNs (0.2-1.5 cm in size) was identified on DSA. CONCLUSION: DSA is insensitive to small HCC (< or =2 cm), carcinomatosis arising within nodules, and DN.

The significance and management of the leaking endograft.

Endoleak is the persistence of blood flow outside the lumen of an endograft, but within an aneurysm sac or adjacent vessel being treated by the graft. Diagnosis may be difficult, and treatment remains somewhat controversial. The purpose of this article is to discuss the clinical significance and appropriate management of endoleaks within the context of our current understanding of this phenomenon. The diagnosis of an endoleak can be made by conventional angiography, duplex ultrasound, intravascular ultrasound (IVUS), and computed tomography (CT) angiography. All of these modalities are effective, although CT angiography may be the most sensitive. Endoleaks can be categorized into 5 classes: (1) perigraft flow around the proximal end of the endograft; (2) perigraft flow around the distal end of the endograft; (3) flow through a defect in the body of the endograft; (4) flow between segments of a multicomponent endovascular graft; and (5) flow between arterial branches within an aneurysm sac. The first 4 classes have been shown to represent a clinical situation in which systemic arterial pressure is transmitted to an inadequately excluded aneurysm sac, placing the sac at risk of rupture. In contrast, branch-flow leaks do not appear to carry an increased risk of rupture, provided there is no increase in aneurysm sac diameter. However, an increase in the diameter of an aneurysm sac after endograft implantation may be a sign of occult endoleak, even if not visualized by current imaging techniques. Thus, we believe that collateral branch leaks with no associated aneurysm sac expansion may be observed with regular follow-up by CT angiography. All other endoleaks should be treated with adjunctive endovascular maneuvers or explanation of the endograft with standard open repair-in short, routine follow-up imaging on endografts to detect the presence of late endoleaks or aneurysm sac expansion.

Report of a single-institution experience using the EVT endovascular abdominal aortic aneurysm graft in 25 patients.

The purpose of this study was to review a single-institution experience with the Endovascular Technologies [(EVT) Menlo Park, CA] transfemoral, endovascular system of abdominal aortic aneurysm repair. This study was performed at a medical center participating in the phase 1 and phase 2 evaluations of the EVT device. We reviewed the 25 cases performed at our institution. The patient population consisted of 21 males (84%) and 4 females (16%), with a mean age of 73.4 years. A total of eight tube grafts (32%) and 17 bifurcated grafts (68%) were attempted. Twenty-two of the twenty-five grafts were successfully implanted endovascularly (88%). Implantation failures were due to tortuosity or inadequate caliber of the iliac arteries, or incorrect positioning of the graft. The results show that endovascular repair of abdominal aortic aneurysms is an appropriate treatment for selected patients. Conversions to open repair have decreased as experience has grown; careful patient selection can minimize the number of unsuccessful implantations. Patient selection and accurate technique can also minimize the number of endoleaks.

Peripheral vascular disease evaluated with reduced-dose gadolinium-enhanced MR angiography.

PURPOSE: To demonstrate the utility of low-dose gadolinium-enhanced magnetic resonance (MR) angiography of two consecutive anatomic areas for assessment of peripheral vascular disease. MATERIALS AND METHODS: Fifteen patients underwent gadolinium-enhanced MR angiography for evaluation of lower extremity peripheral vascular disease after conventional digital subtraction angiography (DSA). MR angiography was performed with three-dimensional coronal gradient-echo acquisitions before and during administration of gadopentetate dimeglumine. Two separate, contiguous areas were studied with separate doses of 0.075 and 0.1 mmol/kg gadopentetate dimeglumine. MR angiography findings were compared with DSA findings; DSA was the standard of reference. Treatment options were determined first with MR angiograms and then with DSA images. RESULTS: For distinguishing greater than 50% stenosis from 50% or less stenosis, gadolinium-enhanced MR angiography yielded a sensitivity of 97%, a specificity of 96%, and an accuracy of 97%. In 146 (97%) of 150 anatomic segments, there was essential or total agreement on treatments determined with MR angiography and DSA. In two cases (one case of vascular stent placement and one case of surgical anastomosis), extent of disease was overestimated with MR angiography. The MR study of one infrapopliteal area was insufficient for evaluation. CONCLUSION: Accurate gadolinium-enhanced MR angiography of multiple peripheral vascular areas of the lower extremities can be performed in most patients with less than 0.2 mmol/kg contrast material.

A unique approach in the management of vena caval thrombosis in a patient with Klippel-Trénaunay syndrome.

Vena caval thrombosis has posed a surgical therapeutic challenge for many years. Historically, spiral vein grafts and synthetic materials used as prostheses have had variable results. The use of the stent may serve as a more promising alternative when used in the capacity to relieve caval obstruction. A case is reported in which a young woman with Klippel-Trénaunay syndrome has exercise intolerance and associated hypotensive cardiovascular collapse caused by inferior vena caval thrombosis. Recanalization of her inferior vena cava was successfully achieved and subsequently maintained through the placement of two Wallstents across the lesion. Although most venous stenting procedures have thus far been used in the treatment of venous obstruction caused by malignancy, inferior vena cava stenting in this patient with inferior vena caval thrombosis and Klippel-Trénaunay syndrome suggests that venous stenting might offer an alternative therapeutic modality in treating a broader spectrum of occlusive venous disease.

A multidisciplinary approach to the treatment of Paget-Schroetter syndrome.

To assess the results of thrombolytic therapy and surgical decompression of the thoracic outlet in the management of spontaneous axillary vein thrombosis (AVT), the records of 38 patients at New York University Medical Center (NYUMC) with AVT were reviewed. Excluded from this report were 20 patients who had AVT secondary to an underlying medical condition, a subclavian catheter, or a failed dialysis access graft. Of the 18 remaining patients with no underlying medical condition, all were found to have effort-related axillo-subclavian thrombosis, Paget-Schroetter syndrome. Urokinase was used for thrombolysis in 17 of the 18 patients, (94.4%) with complete lysis in 14 (82.4%). The remaining patient received anticoagulation only following a favorable response to an initial heparin infusion. Of the patients achieving complete thrombolysis, all but one received urokinase within 8 days of the onset of symptoms. Clot lysis revealed axillary vein compression secondary to a thoracic outlet syndrome in 11 patients, and these underwent staged transaxillary thoracic outlet decompression by first rib resection. All 17 patients have been followed for a mean of 21 months, and none receiving lytic therapy have reoccluded. Review of these data confirms earlier reports showing that with early diagnosis, thrombolysis and, if indicated, thoracic outlet decompression, patients with spontaneous AVT can expect excellent clinical results with a good long-term prognosis.

Angiographic diagnosis and management of gastrointestinal hemorrhage. Current concepts.

Gastrointestinal bleeding is now seen less often by the angiographer than in the past, owing to advances in pharmacology, endoscopy, and nuclear medicine. When patients with gastrointestinal bleeding are referred, it is often for therapy as well as diagnosis. Therapeutic options include infusion of vasoconstrictors and selective embolization, which is usually faster and more definitive. Depending on the agent used, embolization is generally quite safe and effective. The risk of ischemia is significant only in the colon or when collateral pathways have been previously interrupted. The management of variceal bleeding has changed significantly due to the advent of TIPS and the increasing availability of liver transplantation.

Celiomesenteric anomaly and aneurysm: clinical and etiologic features.

The development of aneurysmal disease involving the rarely encountered celiomesenteric anomaly is extremely unusual. Aneurysmal disease of the celiac or superior mesenteric arteries is itself an extremely uncommon finding, accounting for less than 10% of all visceral artery aneurysms. The existence of aneurysmal disease involving a celiomesenteric anomaly has been alluded to only briefly in two previous clinical reports. We review the case of a young woman with aneurysmal disease involving a common celiomesenteric trunk. The patient underwent excision of the aneurysm with successful vascular reconstruction. Although extremely unusual, the development of this extremely rare lesion can be predicted on the basis of specific etiologic theories. Variations in the patterns of embryologic formation of the visceral arteries account for the development of celiomesenteric anomalies, whereas atherosclerosis, medial degeneration, and infection lead to the development of most visceral aneurysms. Surgical treatment of celiac or mesenteric aneurysms is almost always indicated. Awareness of potential vascular anomalies and patterns of collateral circulation are necessary for appropriate surgical intervention.

Primary hyperparathyroidism associated with two enlarged parathyroid glands.

An increasingly recognized although small percentage of patients with primary hyperparathyroidism have enlargement of two parathyroid glands. We have treated nine patients with primary hyperparathyroidism associated with such double parathyroid gland enlargement. In four of these patients, marked asymmetry of the two enlarged glands was noted and the failure to recognize and excise a second enlarged parathyroid gland resulted in persistent or recurrent hyperparathyroidism. In one of these patients, the second enlargement was present in a super-numerary mediastinal gland. The subsequent excision of the second enlarged parathyroid gland resulted in normocalcemia in each instance. This contrasts with five patients in whom initial excision of two enlarged glands resulted in normocalcemia with no recurrence of hypercalcemia. Only three patients fulfilled the histologic criteria of true double adenomas. The remainder showed multiglandular hypercellularity. This experience supports identifying all parathyroid glands and recognizing that even minimal enlargement of a gland may be important pathophysiologically, regardless of its histopathologic classification. Excision of both enlarged glands, even if asymmetric, is appropriate.

Congenital arteriovenous malformation of the female pelvis: a gynecologic perspective.

Nine female patients with the rare congenital arteriovenous malformation of the pelvis were treated at New York University Medical Center in the past 8 years. The patients varied significantly in the anatomic location of the arteriovenous malformation, clinical presentation, and natural course of disease. A gynecologic perspective on the management of this condition is presented, which ranges from a conservative approach with preservation of childbearing potential to extensive pelvic surgery. The important role of modern interventional radiology technology and the multidisciplinary approach are stressed. The unpredictable course of disease after any intervention should be emphasized in planning the management of pelvic arteriovenous malformation.

Antibiotic prophylaxis in vascular and interventional radiology: a rational approach.

The current medical and surgical literature was reviewed to determine the rationale for the use of prophylactic antibiotics during surgical procedures. Specifically, the experimental basis for the timing and duration of administration of the antibiotics was considered, and the expected pathogens in each type of surgery were cataloged. High-risk patient groups were identified. The risk of infectious complications during interventional radiologic procedures was reviewed, and appropriate choices of drugs were determined by analogy to the corresponding surgical procedures.

Uterine arteriovenous malformation successfully embolized with a liquid polymer, isobutyl 2-cyanoacrylate.

A uterine arteriovenous malformation was diagnosed angiographically in a 27-year-old woman presenting with recurrent menometrorrhagia. Bilateral hypogastric artery embolization with a liquid polymer, isobutyl 2-cyanoacrylate (Bucrylate), resulted in subsequent normal menses. Bucrylate offers a number of advantages over other agents previously used to embolize uterine arteriovenous malformations.

Deep venous thrombosis: detection by probe compression of veins.

The sonographic detection of echogenic, soft-tissue mass within the veins of the lower extremities assures the diagnosis of deep venous thrombosis (DVT). However, the sonographic diagnosis remains inconclusive when fresh thrombus and/or artifacts are present within the lumen of the vein. The present study attempts to augment the clinical utility of real-time sonography in the detection of DVT, based on the premise that total obliteration of the vein lumen by probe compression should not be possible in the presence of venous thrombi. Sonography and contrast venography of the lower extremity were performed in 20 patients with clinical suspicion of DVT. The presence of thrombi was confirmed in 14 patients. Probe compression failed to obliterate the lumen of the veins containing thrombi. The authors conclude that the technique of probe compression is useful for rapid and noninvasive detection of venous thrombi.