[Angioplasty with Sirolimus-coated Balloon: the New Standard in the Treatment of PAD?] / Angioplastie mit Sirolimus-beschichtetem Ballon: der neue Standard in der Behandlung der PAVK?

Endovascular revascularisation with paclitaxel-coated balloons for the treatment of peripheral artery disease has been shown to be an effective therapeutic option in the femoropopliteal segment. The antiproliferative effect of paclitaxel prevents restenosis. In contrast, in the infra-popliteal segment, the evidence is currently conflicting. However, there is evidence of an increased risk of amputation and mortality from the second year after angioplasty with paclitaxel-coated balloons. This may be due to a dose-dependent cytotoxic effect of paclitaxel. Sirolimus-coated balloons might therefore be an alternative because sirolimus is cytostatic rather than cytotoxic and thus has a wide therapeutic window.Three single-arm pilot studies (50, 25, and 50 patients, respectively) show that angioplasty with sirolimus-coated balloons leads to comparable results to those reported from paclitaxel-coated balloons (late lumen loss at 6 months: 0.29 mm; primary patency at 12 months: femoropopliteal 79%-82%, infra-popliteal 59%; freedom from target lesion revascularization at 12 months: femoropopliteal 83%-94%, infra-popliteal 86%). Randomised controlled trials comparing standard balloon angioplasty and paclitaxel-coated balloons for the treatment of intermittent claudication or chronic limb-threatening ischaemia are active and are expected to provide efficacy and safety results from mid 2024.This review presents the results of pilot studies on angioplasty with sirolimus-coated balloons for the treatment of peripheral artery disease and reviews currently ongoing randomised controlled trials.

[Endovascular Therapy of Splanchnic Artery Aneurysms: For Each and Every Aneurysm?] / Endovaskuläre Therapie von Viszeralarterienaneurysmata ­ geht das immer?

True visceral artery aneurysms (VAA) and visceral artery pseudoaneurysms (VAPA) are located in the celiac trunk, the superior mesenteric artery and inferior mesenteric artery. In addition to surgical treatment, endovascular embolisation therapy of visceral aneurysms and pseudoaneurysms is an alternative interventional method that has developed precipitously over the last two decades and is considered a first-choice method in many centres. The procedure is characterised by a high technical success rate with a low complication rate. This article presents the basic principles of endovascular treatment and discusses the indications and limitations of the procedure.

Sonographic Bedside Quantification of Pleural Effusion Compared to Computed Tomography Volumetry in ICU Patients.

OBJECTIVES: To date, the reliability of ultrasound for the quantitative assessment of pleural effusion has been limited. In the following study, an easy and cost-effective bedside ultrasound method was developed and investigated for specific use in the intensive care unit (ICU). METHODS: 22 patients (median age: 58.5 years, range: 37-88 years, 14 men and 8 women) with a total of 31 pleural effusions were examined in the ICU. The inclusion criterion was complete visualization of the effusion on chest computed tomography (CT). The ultrasound (US) examination was performed less than 6 h after the diagnostic CT scan. The pleural effusion volume was calculated volumetrically from the CT scan data. Within 4.58 +/- 2.87 h after the CT scan, all patients were re-examined with US in the ICU. The fluid crescent's thickness was measured between each intercostal space (ICS) with the patient in a supine position and a 30° inclination of the torso. The US measurements were compared to the calculated CT volumes using regression analysis, resulting in the following formula: V=13.330 x ICS6 (V=volume of the effusion [ml]; ICS6=sonographic measurement of the thickness of the liquid crescent [mm] in the sixth ICS). RESULTS: A significant correlation between the sonographically measured and the CT-calculated volumes was best observed for the sixth ICS (R2=0.589; ICC=0.7469 with p<0.0001 and a 95% CI of 0.5364-0.8705). CONCLUSION: The sonographic assessment of pleural effusions in a supine position and a 30° inclination of the torso is feasible for the volumetric estimation of pleural effusion. This is especially true for ICU patients with severe primary diseases and orthopnea who are unable to sit upright or lie flat.

[Drug-coated Balloon Angioplasty in Femoropopliteal Arteries - Is There a Class Effect?] / Drug-eluting Ballonangioplastie: Gibt es Klasseneffekte?

Aim Percutaneous transluminal angioplasty (PTA) is a well-accepted method to re-establish patency in stenotic and reoccluded vessels. One tool to improve results may be to use paclitaxel drug-coated balloon (DCB) catheters. This systematic review investigates whether there is a class effect among different DCBs. Methods The primary endpoint was "Freedom from Target Lesion Revascularisation" (FfTLR) after 12 months. A systematic literature search was performed in PubMed and risk of bias was assessed of the included trials. Efficacy of DCB vs. POBA (plain old balloon angioplasty) in binary outcomes was investigated with relative risks and number needed to treat (NNT). Results Ten trials including 1835 patients and investigating six different DCB were identified. A high risk of bias was found in these studies. There was a lower Late Lumen Loss at six months and a higher FfTLR and primary patency at one year after DCB-treatment. However, results varied greatly with NNTs ranging from three to thirty-three. Overall, there were no differences in ABI- and Rutherford-Outcome as well as incidence of adverse events. Conclusion Tested DCBs were able to improve PTA results at one year. There were large differences in efficacy between different DCB. A class effect cannot be confirmed yet. There is a risk of overestimating the effect of DCBs due to the high risk of bias in the included trials.

Postpartum woman with pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy: a case report.

INTRODUCTION: Pneumomediastinum is known to occur during labor. Patients typically present with chest pain and symptoms may be suspicious, for example of pulmonary embolism or aortic dissection. The condition itself, however, is rather harmless and self-limiting.Takotsubo cardiomyopathy is associated with psychologically or physiologically stressful events and its symptoms mimic myocardial infarction. Yet, symptoms often improve quickly as the initially impaired cardiac function is usually restored within days or weeks.Although the initial presentation of the patient in this case report was dramatic, the clinical course was positive and the patient could be quickly dismissed in a good general condition. To the best of our knowledge, no presentation of a combined occurrence of postpartum pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy exists. CASE PRESENTATION: We present the case of a 30-year-old Caucasian woman with sudden onset of thoracic back and chest pain approximately 24 hours after an otherwise unremarkable vaginal delivery. A contrast-enhanced chest computed tomography showed cervical and mediastinal emphysema without proof for pulmonary embolism or aortic dissection. She received a symptomatic analgesic treatment and was dismissed to the obstetrics department for monitoring.Within hours, slightly increased levels of troponin I were observed without corresponding electrocardiography changes. Immediate cardiac catheterization and a cardiovascular magnetic resonance imaging (performed within 24 hours) revealed basal to midventricular hypokinesia, but were otherwise unremarkable. A low-dose treatment for congestive heart failure was initiated, under which symptoms subsided within days. She was dismissed after 12 days in a good general condition. CONCLUSIONS: Although the clinical presentation of the combination of the diseases initially was dramatic, the prognosis is positive. In the context of the preceding delivery, knowledge about the postpartum pneumomediastinum lets the radiologist of the emergency department quickly make this diagnosis. The takotsubo cardiomyopathy, however, needs broader diagnostics to not miss intervention-requiring causes.

Signal-inducing bone cements for MRI-guided spinal cementoplasty: evaluation of contrast-agent-based polymethylmethacrylate cements.

OBJECTIVE: The purpose of this work is to evaluate two signal-inducing bone cements for MRI-guided spinal cementoplasty. MATERIALS AND METHODS: The bone cements were made of polymethylmethacrylate (PMMA, 5 ml monomeric, 12 g polymeric) and gadoterate meglumine as a contrast agent (CA, 0-40 µl) with either saline solution (NaCl, 2-4 ml) or hydroxyapatite bone substitute (HA, 2-4 ml). The cement's signal was assessed in an open 1-Tesla MR scanner, with T1W TSE and fast interventional T1W TSE pulse sequences, and the ideal amount of each component was determined. The compressive and bending strength for different amounts of NaCl and HA were evaluated. RESULTS: The cement's MRI signal depended on the concentration of CA, the amount of NaCl or HA, and the pulse sequence. The signal peaks were recorded between 1 and 10 µl CA per ml NaCl or HA, and were higher in fast T1W TSE than in T1W TSE images. The NaCl-PMMA-CA cements had a greater MRI signal intensity and compressive strength; the HA-PMMA-CA cements had a superior bending strength. CONCLUSIONS: Concerning the MR signal and biomechanical properties, these cements would permit MRI-guided cementoplasty. Due to its higher signal and greater compressive strength, the NaCl-PMMA-CA compound appears to be superior to the HA-PMMA-CA compound.

Percutaneous push-through gastrostomy by applying a CT-guided gastropexy.

PURPOSE: To evaluate the feasibility and complications of percutaneous push-through gastrostomy via a computed tomography (CT)--guided gastropexy. MATERIALS AND METHODS: From January 2005 to March 2008, 14 patients in whom an oropharyngeal passage with an endoscope was impossible received a gastrostomy using the push-through technique. To attach the stomach against the abdominal wall, a CT-guided gastropexy was performed in all patients before the gastrostomy. The initial gastric tube was replaced with a short, low-profile gastric tube 2 weeks after the gastrostomy procedure. Patients were monitored for complications and survival for 6 months. RESULTS: The CT-guided dual gastropexy and percutaneous push-through gastrostomy was successfully inserted in all patients. Six months follow-up of the patients revealed only minor complications: one gastrostomy leakage and two local wounds. CONCLUSIONS: CT-guided dual gastropexy combined with the push-type gastrostomy technique is practical and safe in patients in whom an oropharyngeal passage with an endoscope is impossible and represents an alternative method of gastric fixation for radiologically placed gastrostomy tubes.

Reduced k-space acquisition to accelerate MR imaging of moving interventional instruments: a phantom study.

PURPOSE: The goal of this study was to investigate the impact of reduced k-space sampling rates on the visualization of a moving MR-compatible puncture needle and to demonstrate the feasibility of keyhole imaging in interventional magnetic resonance imaging (MRI). MATERIAL AND METHODS: All experiments were performed in an open 1.0 Tesla MRI. MR images of a moving puncture needle were taken with different keyhole sampling rates from 15-100%, in 10% increments. The needle was submerged in a water-filled basin and was imaged in motion with a T1-weighted gradient-echo sequence with an initial acquisition rate of 1.4 s per image. An apparatus operated by a compressor unit enabled needle rotation and ensured reproducible needle movements. The median forward velocity of the needle tip was 2 cm/s. To evaluate the depiction of the needle, artifact diameter of the needle, contrast-to-noise ratio (CNR), and needle tip profiles (delineation) were measured. RESULTS: The needle position was determined with an longitudinal error of 3 mm and a transverse error of 0.8 mm with respect to the needle's orientation and the theoretically calculated trajectory. No significant correlation was found between the CNR and velocity. A reduction of k-space update rates caused neither a significant reduction of CNR nor a significant increase in artifact diameter or blurring of the needle profile. CONCLUSION: The application of keyhole imaging with update rates of greater than 15% is sufficient for the MR guidance of interventions with an signal-to-noise ratio >9 of the surrounding tissue and a target accuracy of >1 mm. Keyhole imaging can increase temporal resolution while ensuring unimpaired spatial resolution and image quality of the depicted instrument.

Effectiveness of sutureless percutaneous placement of cuffed tunneled hemodialysis catheters applying StatLock attachment devices.

PURPOSE: A prospective, randomized-controlled trail was conducted to evaluate the effectiveness of securing tunneled hemodialysis (HD) catheters with sutureless StatLock attachment devices (Bard Access Systems) compared to traditional suture fixation. METHODS: At a university teaching hospital 72 patients with chronic renal failure received cuffed tunneled HD catheters. In the study group (n=36) the HD catheters were secured with a sutureless StatLock attachment device, whereas the control group HD catheters were fixated with sutures only. The intended intermediate use of the tunneled HD catheters was 42 ± 7 days until the arteriovenous fistula was sufficient. All catheters were placed by an interventional radiologist using ultrasound for the puncture of the internal jugular vein. We evaluated the success and complication rate of tunneled catheter implantation. RESULTS: The primary success rate for implantation of HD catheters was 100%. There was an overall complication rate of 8.3% in the study group (one hematoma in the subcutaneous catheter tract and two central venous thromboses). In the control group the overall complication rate was 13.9% (two hematomas, one central venous thrombosis and two catheter displacements). The two catheter displacements required a HD catheter exchange. In addition, four local irritations at the HD catheter entry site were seen only in the control group and were rated as minor complications. CONCLUSIONS: The sutureless placement technique is safe and effective with a low complication rate, and is superior to the traditional suture fixation of tunneled catheters.

Evaluation of thermometric monitoring for intradiscal laser ablation in an open 1.0 T MR scanner.

PURPOSE: The purpose of this study was to evaluate different methods of magnetic resonance thermometry (MRTh) for the monitoring of intradiscal laser ablation therapy in an open 1.0 Tesla magnetic resonance (MR) scanner. MATERIAL AND METHODS: MRTh methods based on the two endogenous MR temperature indicators of spin-lattice relaxation time T1 and water proton resonance frequency (PRF) shift were optimised and compared in vitro. For the latter, we measured the effective spin-spin relaxation times T2* in intervertebral discs of volunteers. Then we compared four gradient echo-based imaging techniques to monitor laser ablations in human disc specimens. Criteria of assessment were outline of anatomic detail, immunity against needle artefacts, signal-to-noise ratio (SNR) and accuracy of the calculated temperature. RESULTS: T2* decreased in an inverse and almost linear manner with the patients' age (r = 0.9) from 70 to 30 ms (mean of 49 ms). The optimum image quality (anatomic details, needle artefacts, SNR) and temperature accuracy (+/-1.09 degrees C for T1-based and +/-1.11 degrees C for PRF-based MRTh) was achieved with a non-spoiled gradient-echo sequence with an echo time of TE = 10 ms. CONCLUSION: Combination of anatomic and thermometric non-invasive monitoring of laser ablations in the lumbar spine is feasible. The temperature accuracy of the investigated T1- and PRF-based MRTh methods in vitro is high enough and promises to be reliable in vivo as well.

Placement of a port catheter through collateral veins in a patient with central venous occlusion.

Long-term utilization of central venous catheters (CVCs) for parenteral nutrition has a high incidence of central venous complications including infections, occlusions, and stenosis. We report the case of a 31-year-old woman presenting with a malabsorption caused by short gut syndrome due to congenital aganglionic megacolon. The patient developed a chronic occlusion of all central neck and femoral veins due to long-term use of multiple CVCs over more than 20 years. In patients with central venous occlusion and venous transformation, the implantation of a totally implanted port system by accessing collateral veins is an option to continue long-term parenteral nutrition when required. A 0.014-in. Whisper guidewire (Terumo, Tokyo) with high flexibility and steerability was chosen to maneuver and pass through the collateral veins. We suggest this approach to avoid unfavorable translumbar or transhepatic central venous access and to conserve the anatomically limited number of percutaneous access sites.

A comparison of clinical outcomes with regular- and low-profile totally implanted central venous port systems.

The purpose of this study was to evaluate whether low-profile totally implanted central venous port systems can reduce the late complication of skin perforation. Forty patients (age, 57 +/- 13 years; 22 females, 18 males) were randomized for the implantation of a low-profile port system, and another 40 patients (age, 61 +/- 14 years; 24 females, 16 males) received a regular port system as control group. Indications for port catheter implantation were malignant disease requiring chemotherapy. All port implantations were performed in the angiography suite using sonographically guided central venous puncture and fluoroscopic guidance of the catheter placement. Procedure time, number of complications (procedure-related immediate, early, and late complications), and number of explantations were assessed. Follow-up was performed for 6 months. All port implantations were successfully completed in both study groups. There were two incidents of skin perforation observed in the control group. One skin perforation occurred 13 weeks and the other 16 weeks after port implantation (incidence, 5%) in patients with regular-profile port systems. Two infections were observed, one port infection in each study group. Both infections were characterized as catheter-related infections (infection rate: 0.15 catheter-related infections per 1000 catheter days). In conclusion, low-profile port systems can be placed as safely as traditional chest ports and reduce the risk of developing skin perforations, which occurs when the port system is too tight within the port pocket.

Radiological interventions for correction of central venous port catheter migrations.

PURPOSE: The purpose of this study was to evaluate radiological-interventional central venous port catheter corrections in migrated/malpositioned catheter tips. MATERIALS AND METHODS: Thirty patients with migrated/malpositioned port catheter tips were included in this retrospective analysis. To visualize the catheter patency a contrast-enhanced port catheter series was performed, followed by transfemoral port catheter correction with various 5-F angiographic catheters (pigtail; Sos Omni), gooseneck snares, or combinations thereof. RESULTS: One patient showed spontaneous reposition of the catheter tip. In 27 of 29 patients (93%), radiological-interventional port catheter correction was successful. In two patients port catheter malposition correction was not possible, because of the inability to catch either the catheter tip or the catheter in its course, possibly due to fibrin sheath formation with attachment of the catheter to the vessel wall. No disconnection or port catheter dysfunction was observed after correction. CONCLUSIONS: We conclude that in migrated catheter tips radiological-interventional port catheter correction is a minimally invasive alternative to port extraction and reimplantation. In patients with a fibrin sheath and/or thrombosis port catheter correction is often more challenging.

Radiological interventions for correction of central venous port catheter migrations.

The purpose of the study is to evaluate radiological-interventional central venous port catheter corrections in migrated/malpositioned catheter tips. Thirty patients with migrated/malpositioned port catheter tips were included in this retrospective analysis. To visualize the catheter patency, a contrast-enhanced port catheter series was performed, followed by transfemoral port catheter correction with various 5F angiographic catheters (pigtail, Sos Omni), goose-neck snare, or combinations thereof. One patient showed spontaneous reposition of the catheter tip. In 27 of 29 patients (93%), radiological-interventional port catheter correction was successful. In two patients, port catheter malposition correction was not possible because of the inability to catch either the catheter tip or the catheter in its course, possibly due to fibrin sheath formation with attachment of the catheter to the vessel wall. No disconnection or port catheter dysfunction was observed after correction. In migrated catheter tips, radiological-interventional port catheter correction is a minimally invasive alternative to port extraction and reimplantation. In patients with a fibrin sheath and/or thrombosis, port catheter correction is often more challenging.