Accuracy of 3.0T magnetic resonance angiography for the detection of arteriovenous fistula dysfunction in hemodialysis patients requiring interventional therapy: a prospective study.

Background: Color Doppler ultrasonography (CDUS) is feasible to detect arteriovenous fistula (AVF) dysfunction in hemodialysis patients but is not sufficient to map the structure of fistula required for interventions. This study is designed to evaluate the diagnostic accuracy of three-dimensional time-of-flight magnetic resonance angiography (TOF-MRA) at 3.0T versus CDUS for AVF dysfunction, by using digital subtraction angiography (DSA) as reference. Methods: This prospective study enrolled 68 consecutive patients with dysfunctional AVF who underwent both CDUS and TOF-MRA at Shanghai Sixth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine. The analysis of the dysfunctional AVFs was divided into three regions: the feeding artery, fistula and draining veins. In the whole- and per-regional-based analyses, two observers who were blinded to the clinical and DSA results independently analyzed all CDUS and TOF-MRA datasets. The image quality and stenosis severity of the lesions on TOF-MRA were evaluated. A receiver operating characteristic curve was applied to analyze the detection of AVF dysfunction with TOF-MRA. Results: A total of 204 vessel regions were evaluated. The whole-region-based image quality of TOF-MRA was poorer in patients with a total occlusion (1.8±0.8) than in those with stenosis (2.7±0.6, P<0.001). In the whole-region analyses, TOF-MRA had higher sensitivity [99.1% (94.6-100.0%) vs. 82.9% (74.6-89.0%), P<0.001] and similar specificity [93.1% (85.0-97.1%) vs. 94.3% (86.5-97.9%), P=0.755] than CDUS. The per-region-based analyses showed that TOF-MRA yielded higher sensitivity [fistula region, 98.1% (88.4-99.9%) vs. 80.8% (67.0-89.9%); P=0.004; draining vein region, 100.0% (92.5-100.0%) vs. 85.0% (72.9-2.5%); P=0.003] and similar specificity [fistula region, 88.2% (62.3-97.8%) vs. 88.2% (62.3-97.9%); P>0.99; draining vein region, 100.0% (59.8-100.0%) vs. 87.5% (46.7-99.3%); P>0.99] than CDUS. Sensitivity and specificity of TOF-MRA were comparable to those of CDUS in feeding artery region. Conclusions: TOF-MRA is a feasible and accurate method to display AVF dysfunction in hemodialysis patients, and this method might fulfill the endovascular treatment planning requirements.

Thin-slab maximum intensity projection of CT angiography for collateral score and clot burden score evaluation: comparison with conventional CT angiography.

BACKGROUND: This study aimed to exam the effects of thin-slab maximum intensity projection (TS-MIP) of computed tomography angiography (CTA) for collateral score (CS) and clot burden score (CBS) evaluation in patients with large-vessel-occlusion (LVO) stroke in the anterior circulation. METHODS: Of 241 consecutive patients with LVO stroke admitted to our center between August 2015 and June 2020, 187 patients were enrolled. CS and CBS were evaluated on conventional CTA and TS-MIP separately. Outcome at 90 days was classified as good if modified Rankin scale (mRS) was ≤2 and as poor if mRS was >2. The correlations between CS and CBS and clinical outcomes were assessed. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic values of CS and CBS. Multivariate logistic regression analysis was performed to identify the independent predictors of 90-day good clinical outcomes. RESULTS: The correlation coefficient for clinical outcomes was significantly better for CS based on TS-MIP than that based on conventional CTA (-0.444 vs. -0.285, P=0.039); no significant difference was found in the CBS evaluation (TS-MIP: -0.356 vs. conventional CTA: -0.320, P=0.348). For predicting good clinical outcomes, TS-MIP-based CS was associated with larger area under the curve (AUC) (0.709 vs. 0.609, P=0.004) and higher sensitivity (69.1% vs. 42.0%, P=0.001) than CS based on CTA. In multivariable logistic regression analysis, the factors independently associated with good outcomes were National Institutes of Health Stroke Scale (NIHSS) score at admission (OR =1.147; P<0.001), TS-MIP-based CS (OR =0.326; P<0.001), final modified treatment in cerebral infarction (mTICI) score of 2b/3 (OR =0.098; P<0.001), and hemorrhagic transformation (OR =3.662; P<0.001). CONCLUSIONS: TS-MIP-CTA is superior to conventional CTA for evaluation CS and CBS, and TS-MIP-based CS may be a useful predictor of clinical outcome.

Atherosclerosis in intracranial or extracranial vessels in diabetic patients and the association with stroke subtype.

BACKGROUND: Diabetes mellitus (DM) is associated with increased prevalence and severity of atherosclerosis. This study aimed to assess the prevalence and location of atherosclerosis in intracranial and extracranial vessels in diabetic patients and to investigate their association with ischemic stroke subtype. METHODS: Diabetes patients (n=128) and nondiabetic patients (n=195) were enrolled. Brain MRI, MR angiography, and digital subtraction angiography (DSA) imaging findings in the two groups were retrospectively compared. The characteristics of atherosclerosis (prevalence, location, severity) and collateral flow in diabetic and nondiabetic patients and their association with stroke subtype were analyzed. RESULTS: Atherosclerosis in extracranial vessels was more common in diabetes patients than in nondiabetic patients (43.8% vs. 23.1%; P<0.001). Symptomatic stenoses were commonly in the proximal internal carotid artery (ICA) and proximal vertebral artery (pVA). Diabetes patients were more likely to have lacunar infarction (49.2% vs. 32.3%; P=0.002) and less likely to have large artery infarct (36.7% vs. 48.2%; P=0.042). DM (OR, 2.03; 95% CI, 1.96-4.30; P=0.006) and age >65 years (OR, 2.55; 95% CI, 1.24-5.22; P=0.011) were independent risk factors for lacunar infarct. Diabetes patients with symptomatic extracranial stenosis or occlusion, combined with good collateral circulation, had significantly higher risk of lacunar infarction than nondiabetic patients (47.8% vs. 30.5%; P=0.045). CONCLUSIONS: DM aggravates the severity of extracranial atherosclerosis. Lacunar stroke is relatively common in diabetic patients and could even be due to large artery disease (LAD).

Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model.

BACKGROUND: Stent insertion can effective alleviate the symptoms of benign esophageal strictures (BES). Magnesium alloy stents are a good candidate because of biological safety, but show a poor corrosion resistance and a quick loss of mechanical support in vivo. AIM: To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent. METHODS: Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance (stent group). The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models (control group). Esophagography was performed at 1, 2, and 3 weeks. Four, six, and five rabbits in the stent group and two rabbits in the control groups were euthanized, respectively, at each time point for histological examination. RESULTS: All stent insertions were well tolerated. The esophageal diameters at immediately, 1, 2 and 3 wk were 9.8 ± 0.3 mm, 9.7 ± 0.7 mm, 9.4 ± 0.8 mm, and 9.2 ± 0.5 mm, respectively (vs 4.9 ± 0.3 mm before stent insertion; P < 0.05). Magnesium stents migrated in eight rabbits [one at 1 wk (1/15), three at 2 wk (3/11), and four at 3 wk (4/5)]. Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was found significantly thinner in the stent group than in the control group (P < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits (P > 0.05). CONCLUSION: Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction. Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.

Evaluation of Quiescent-Interval Single-Shot Magnetic Resonance Angiography in Diabetic Patients With Critical Limb Ischemia Undergoing Digital Subtraction Angiography: Comparison With Contrast-Enhanced Magnetic Resonance Angiography With Calf Compression at 3.0 Tesla.

PURPOSE: To assess the diagnostic performance of quiescent-interval single-shot magnetic resonance angiography (QISS-MRA) at 3 tesla in diabetic patients with critical limb ischemia (CLI) vs contrast-enhanced MR angiography (CE-MRA) using digital subtraction angiography (DSA) as the standard of reference. METHOD: Thirty-seven consecutive diabetic patients (mean age 71.8±7.2 years; 30 men) with CLI (Fontaine stage III-IV) underwent QISS-MRA and CE-MRA with calf compression; DSA was the standard. Image quality (5-point Likert-type scale) and stenosis severity (5-point grading) for QISS-MRA and CE-MRA were evaluated by 2 blinded readers in 1147 and 654 vessel segments, respectively. Per-segment and per-region (pelvis, thigh, calf) sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: Image quality of QISS-MRA was lower compared with CE-MRA in the pelvic region (p<0.001 in both readers) and thigh region (p=0.033 in reader 1 and p=0.018 in reader 2), whereas in the calf region, the image quality of QISS-MRA was better than CE-MRA (p=0.009 in reader 1 and p=0.001 in reader 2). In segment-based analyses, there was no difference between QISS-MRA and CE-MRA in sensitivity [89.5% vs 90.3% in reader 1 (p=0.774) and 87.6% vs 90.6% in reader 2 (p=0.266)] or specificity [94.2% vs 92.9% in reader 1 (p=0.513) and 92.9% vs 92.9% in reader 2 (p>0.999)]. In region-based analyses, QISS-MRA and CE-MRA yielded similar sensitivity and specificity in all areas but the pelvic region for reader 2 (specificity 95.5% vs 84.8%, p=0.041). CONCLUSION: QISS-MRA performed very well in diabetic patients with CLI and was a good alternative for patients with contraindications to CE-MRA.

Integrated application of antegrade and retrograde recanalization for femoral-popliteal artery chronic total occlusions: outcomes compared with antegrade recanalization.

BACKGROUND: To investigate the efficacy of retrograde recanalization for chronic total occlusion (CTO) of femoral-popliteal artery in patients with peripheral arterial disease. METHODS: In this single-center retrospective study, all patients who had undergone endovascular recanalization for femoral-popliteal CTOs at our center from June 2011 to October 2014 were included. Patients' demographics, immediate and follow-up outcomes were analyzed. RESULTS: A total of 205 patients with 238 CTOs were enrolled. In total, successful recanalization was achieved in 228 CTOs (95.8%). The antegrade procedure was successful in 196 CTOs. The retrograde procedure was successfully performed in 32 CTOs after failed antegrade procedure. Ankle-brachial index increased from 0.48±0.18 to 0.79±0.16 in antegrade group vs. 0.41±0.13 to 0.76±0.13 in retrograde group (P=0.438). Pulse score increased from 0.48±0.50 to 2.30±0.76 in antegrade group vs. 0.48±0.51 to 2.30±0.79 in retrograde group (P=0.771). At 12 and 24 months, primary patency rate was 86.2% (169/196) and 51.5% (101/196) in the antegrade group, and 75.0% (24/32) and 43.8% (14/32) in the retrograde group, respectively (P=0.346). Kaplan-Meier analysis showed limb salvage rates of 85.7% in the antegrade group vs. 78.1% in the retrograde group (P=0.198). CONCLUSIONS: Retrograde recanalization is effective for CTO of femoral-popliteal artery after the failure of an antegrade procedure; immediate outcomes and mid-term patency and limb salvage rate are comparable with that of antegrade procedure.

No inferiority of Tonbridge thrombectomy device for acute thrombus retrial compared with Solitaire device: an experimental evaluation with a canine distal external carotid-maxillary artery occlusion model.

INTRODUCTION: Mechanical thrombectomy (MT) has been widely accepted as a safe and effective treatment for acute ischemic stroke (AIS). Development of stent retriever devices has been intensively developed over the past two decades. In this study, we compared the effectiveness and safety of a new thrombectomy device with Solitaire FR for the treatment of AIS models. METHODS: Mechanical performance of stent retrievers was tested in vitro. Thrombin-induced thrombus was pre-injected into the right distal external carotid-maxillary artery in 18 dogs to create an acute thrombus occlusion model, and these animals were divided into a Tonbridge group (n=9, with Tonbridge stent Tonbridge Medical Technology) and a Solitaire group as control (n=9, with Solitaire stent, ev3 Neurovascular). Final flow restoration, side branches, recanalization time, distal vessel embolism, and device-related complications were recorded and compared. A post-procedure angiogram was obtained at 30 and 90 days after thrombectomy. Device manipulation-related damage to the arterial walls was evaluated histologically. RESULTS: In vitro test showed that the maximum friction within the microcatheter was 0.763 for the Tonbridge device and 0.784 n for the Solitaire (P>0.05). Slight increase in radial force was noticed for the Tonbridge (0.035 N/mm vs 0.031 N/mm of Solitaire, P>0.05). Eighteen and 16 retriever attempts were done in the Tonbridge (mean 2.0 attempts) and the Solitaire (mean 1.8 attempts) groups (P=0.74). The Tonbridge device led to good flow restoration in all nine (100%) models compared with eight (88.9%) in the Solitaire group (P=0.30). Side branches' influence (P=0.39), distal thromboembolism (P=0.60), and device-related complications (P=1.00) found no difference between the two groups. The rates of disruption of the internal elastic lamina (IEL) were 8.3% (2/24) and 4.2% (1/24) of the specimens, respectively (P=0.683). TICI 2b/3 flow of the right CCA were similar between the two groups at 1 (6/6 vs 6/6) and 3 months (6/6 vs 6/6) follow-up (P>0.05). CONCLUSION: Our preliminary study indicated this new device was technically feasible and effective to be used in thrombectomy for the treatment of acute thrombus occlusion in canine models.

Correction to: Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions.

The original version of this article unfortunately contained mistakes. The legends to Figs. 2-4 were incorrectly interchanged. The correct versions are given below. The original article has been corrected.

Elderly population have a decreased aneurysmal subarachnoid hemorrhage incidence rate than Middle aged population: a descriptive analysis of 8,144 cases in mainland China.

PURPOSE: Rupture of an intracranial aneurysm is a life-threatening acute cerebrovascular event. The purpose of this study was to investigate whether aneurysmal subarachnoid haemorrhage (SAH) incidence rate is higher or lower in elderly population than in middle aged population. MATERIALS AND METHODS: Aneurysmal SAH cases were collected retrospectively from the archives of 21 hospitals in Mainland China. All the cases were collected from September 2016 and backward consecutively for a period of time up to 8 years. SAH was initially diagnosed by brain computed tomography (CT). CT angiography (CTA) or digital subtraction angiography (DSA) was followed and SAH was confirmed to be due to cerebral aneurysm rupture. For cases when multiple bleeding occurred, the age of the first SAH was used in this study. The total incidence from all hospitals at each age group were summed together for females and males respectively; then adjusted by the total population number at each age group for females and males which was from the 2010 population census of the People's Republic of China. RESULTS: In total there were 8,144 cases of intracranial aneurysmal SAH, with 4,861 females and 3,283 males. For females the relative aneurysmal SAH incidence rate started to decrease after around 65 years old, while for males the relative aneurysmal SAH incidence rate started to decrease after around 53 years old. CONCLUSION: Our data tentatively suggest elderly patients may be at a reduced risk of rupture compared with patients who are younger while have similar other risk factors.

Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions.

OBJECTIVES: To investigate morphological characteristics used to predict recanalisation strategies in long-segment (>10 cm) femoral chronic total occlusion (LSF-CTO) angioplasty. METHODS: We retrospectively evaluated a range of morphological CTA and DSA features in patients who underwent recanalisation of LSF-CTO. The stage of CTO was classified into early (3-12 months) and late (>12 months) according to estimated duration. Characteristics including stump morphology, lesion length and calcification, proximal side branches, collaterals circulation, runoff vessels and concomitant arterial occlusion were used as predictors, and multivariate logistic regression analysis was performed to identify variables associated with late-stage CTO and retrograde technique. RESULTS: A total of 119 patients with 137 CTOs in 137 limbs were enrolled. Overall, successful recanalisation was achieved in 122 CTOs (89.1%). Flush occlusion [odds ratio (OR) 2.958; 95% confidence interval (CI) 1.172-7.465; p = 0.022], large collateral (OR 2.778; 95% CI 1.201-6.427; p = 0.017) and TransAtlantic Inter-Society Consensus II class D (TASC D) lesion (OR 1.743; 95% CI 1.019-2.981; p = 0.042) were predictors for late-stage CTO. Flush occlusion (OR 75.278; 95% CI 10.664-531.384; p < 0.001) and large collateral (OR 23.213; 95% CI 3.236-166.523; p = 0.002) were associated with high likelihood for retrograde approach. CONCLUSIONS: Flush occlusion and large collateral were associated with a CTO at late-stage which may require retrograde recanalisation. KEY POINTS: • CTO morphological characteristics help estimate lesion duration and optimise recanalisation strategies. • Flush occlusion and large collateral is associated with late-stage CTO and retrograde recanalisation. • Application of anterograde and retrograde recanalisation for long-segment femoral CTO is effective.

Prevalent osteoporotic vertebral fractures more likely involve the upper endplate than the lower endplate and even more so in males.

BACKGROUND: While the importance of identifying osteoporotic vertebral endplate fracture (EPF) is being recognized; the pathophysiological understanding of EPF till now remain insufficient. In this population-based cross-sectional radiograph study, we aim to investigate the anatomic location characteristics of osteoporotic EPF. METHODS: This study analyzed the anatomical location of osteoporotic EPFs in elderly Chinese population (age ≥65 years). The T4-L4 radiographs of 1,954 elderly Chinese men (mean: 72.3 years) and 1,953 elderly Chinese women (mean: 72.5 years) were evaluated to identify EPF, and vertebral bodies were graded according to Genant's vertebral deformity criteria. RESULTS: Of the 101,582 endplates analyzed, there were 505 EPFs (males: 27.7%; females: 72.3%). Excluding those with both upper endplate and lower endplate involvements, the ratio of upper EPF to lower EPF was 9.63 for males and 4.3 for females (P<0.05). Thoracolumbar junction, particularly L1 (26.4% for males and 24.1% for females) and followed by T12 (20.7% for males and 19.7% for females), had highest prevalence of EPF. With an endplate divided into 5 segments of equal length in the anteroposterior direction and grade 0.5 & 1, grade 2 vertebral deformities analyzed, fractures occurred mostly at the middle segment (70.1% for upper endplates in males and 78.6% for upper endplates in females), followed by second anterior segment (20.9% for upper endplates in males and 14.4% for upper endplates in females). The most anterior and most posterior segments were not primarily involved in EPF. CONCLUSIONS: Osteoporotic EPFs more likely involve the upper endplate rather than lower endplate, with a trend for this effect to be greater in men than in women. These characteristics may help radiographic differential diagnosis for osteoporotic EPF.

Silicone-covered biodegradable magnesium-stent insertion in the esophagus: a comparison with plastic stents.

BACKGROUND: We determined the feasibility of, and tissue response to silicone-covered biodegradable magnesium- and plastic-stent insertion into the esophagus in rabbits. METHODS: The mechanical compression-recovery characteristics and degradation behaviors of the magnesium stent were investigated in vitro. A total of 45 rabbits were randomly divided into a magnesium- (n = 15) and a plastic- (n = 15) stent group, and underwent stent insertion into the lower third of the esophagus under fluoroscopic guidance; a control group (n = 15) did not undergo the intervention. Esophagography was performed at 1, 2, and 4 weeks. Five rabbits in each group were euthanized at each time point for histological examination. RESULTS: Silicone-covered magnesium stents showed similar radial force to plastic stents (p > 0.05). The magnesium stents degraded rapidly in an acidic solution, but 90.2% ± 3.1% of the residual mass was maintained after a 2-week degradation in a solution with a pH of 4.0. All stent insertions were well tolerated. Magnesium stents migrated in six rabbits (one at 1 week, one at 2 weeks and four at 4 weeks), and plastic stents migrated in three rabbits (one at 2 weeks and two at 4 weeks; p > 0.05). Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was similar in both stented groups (p > 0.05), and the esophagus wall was found to be significantly thinner in the stented groups than in the control group (p < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ from the control group (p > 0.05). CONCLUSIONS: Esophageal silicone-covered magnesium stents provided reliable support for at least 2 weeks, with acceptable migration rates and without causing severe injury or tissue reaction compared with plastic stents.

Concomitant aneurysm detection in an intracranial dolichoectasia mouse model using a MicroFil polymer perfusion technique.

OBJECTIVE: To assess the feasibility of using MicroFil polymer perfusion to detect concomitant saccular aneurysms in an intracranial arterial dolichoectasia (IADE) model in mice, and to report detailed histomorphometric features of these aneurysms. MATERIALS AND METHODS: IADE models were created in C57/BL6 mice via microsurgical injection of 25 mU elastase into the cisterna magna. The cerebral vasculature was perfused with MicroFil polymer and harvested at 1, 3, and 7 days, and 2 and 4 weeks (n=8 for each group). IADE was defined by a tortuosity index >10 combined with a 25% increase in diameter of the A1 segment of the anterior cerebral artery (ACA), internal carotid artery (ICA), or basilar artery compared with the baseline of controls, which received heat-inactivated elastase. Saccular aneurysm occurrence rate, location, and morphological parameters were investigated using macroscopic and microscopic analysis. RESULTS: IADE was present in 95% (36/38) of the subjects, with a mortality rate of 5% (2/40). Fifteen concomitant saccular aneurysms were detected in 8 (21%) of the 38 surviving mice, including 6 at the posterior communicating artery, 1 along the ACA, 2 along the anterior communicating artery complex, 3 along the ICA, and 3 along the middle cerebral artery. Rupture was confirmed in two aneurysms. Histological examination indicated that the aneurysms develop via arterial-wall remodelling, which is characterized by internal elastic lamina disruptions and muscular layer discontinuity in the media. CONCLUSIONS: The proportion of subjects developing saccular aneurysms in addition to IADE in our mouse model is similar to the 15% of patients with IADE who have concomitant saccular aneurysms.

Technical feasibility and tissue reaction after silicone-covered biodegradable magnesium stent insertion in the oesophagus: a primary study in vitro and in vivo.

OBJECTIVES: Determine the feasibility of and tissue response to biodegradable magnesium-silicone stent insertion into the oesophagus of rabbits. METHODS: Mechanical compression-recovery and degradation behaviours of the stents were investigated in vitro. Thirty rabbits were randomly divided into a magnesium-silicone stent group (n = 15) that received stent insertion into the lower 1/3 of the oesophagus under fluoroscopic guidance and a control group (n = 15). Oesophagography was performed at 1, 2 and 4 weeks. Five rabbits in each group were euthanized at each time point for histological examination. RESULTS: Magnesium-silicone stents showed good flexibility and elasticity, and degraded more slowly than bare stents at pH 4.0 and 7.4. All stent insertions were well tolerated. The oesophageal diameters at 1, 2 and 4 weeks were 9.7 ± 0.7, 9.6 ± 0.8 and 9.6 ± 0.5 mm, respectively (vs. 9.2 ± 0.8 mm before intervention; P > 0.05). Stent migration occurred in six rabbits (one at 1 week, one at 2 and four at 4). Microscopy demonstrated dilation of the oesophageal wall within 1 week of insertion. Oesophageal injury and collagen deposition following stent insertion were similar to control (P > 0.05). CONCLUSIONS: Oesophageal magnesium-silicone stent insertion was feasible and provided reliable support for 2 weeks without causing oesophageal injury or collagen deposition. KEY POINTS: • Mg stent provided apparently adequate radial force and silicone membrane reduced magnesium biodegradation • Stent insertion provided good support for at least 2 weeks before biodegradation • Stenting effectively resulted in oesophageal wall remodelling, without demonstrable injury.

String-like lumen in below-the-knee chronic total occlusions on contrast-enhanced magnetic resonance angiography predicts intraluminal recanalization and better blood flow restoration.

OBJECTIVES: To determine whether string-like lumina (SLs) on contrast-enhanced magnetic resonance angiography (CE-MRA) predict better outcomes in diabetic patients with below-the-knee (BTK) chronic total occlusions (CTOs). METHODS: This study involved 317 long-segment (>5 cm) BTK CTOs of 245 patients that were examined using CE-MRA and treated using endovascular angioplasty. An SL with a CTO was slowly filled with blood on conventional CE-MRA. Univariate and multivariate analyses were performed to identify predictors of procedural success, recanalisation method and immediate blood flow restoration. The target-lesion patency and limb-salvage rates were assessed. RESULTS: SL-positive CTOs (n = 60) achieved a higher technique success rate, preferred intraluminal angioplasty and better blood flow restoration than SL-negative CTOs (n = 257, P < 0.05). Multivariate analyses revealed that lesion length was the independent predictor of procedural success (P = 0.028). SL was a predictor of intraluminal angioplasty (P < 0.001) and good blood-flow restoration (P = 0.004). Kaplan-Meier analyses at 12 months revealed a higher target lesion patency rate (P = 0.04) and limb-salvage rate (P = 0.35) in SL-positive CTOs. CONCLUSIONS: In patients with BTK CTOs, SL predicted intraluminal angioplasty and good blood-flow restoration for BTK CTOs. KEY POINTS: • Intraluminal recanalisation was more frequently used for BTK-CTOs with SLs than without • CTO length was the only independent predictor of successful CTO recanalisation • SL was the only predictor of intraluminal angioplasty for BTK-CTOs • SL and CTO length were predictors of good blood-flow restoration after recanalisation • Restenosis-free and limb-salvage rates were better for SL-positive CTOs than SL-negative CTOs.

Predictors for Better Blood-Flow Restoration of Long-Segmental Below-the-Knee Chronic Total Occlusions after Endovascular Therapy in Diabetic Patients.

OBJECTIVE: To prospectively investigate predictors for good restoration of blood flow of below-the-knee (BTK) chronic total occlusions (CTOs) after endovascular therapy in diabetes mellitus (DM) patients. MATERIALS AND METHODS: A total of 120 long-segmental (≥ 5 cm) BTK, CTOs in 81 patients who underwent recanalization were included in this study. After angioplasty, blood-flow restoration was assessed using modified thrombolysis in myocardial ischemia grades and classified as good flow (grade 3) and poor flow (grade 1/2). One hundred and six CTOs with successful recanalization were divided into a good flow group (GFG; n = 68) and poor flow group (PFG; n = 38). Multivariate logistic regression analyses were undertaken to determine independent predictors of blood-flow restoration. Receiver operating characteristic curves were constructed to determine the best cutoff value. The prevalence of target-lesion restenosis during follow-up was compared between two groups. RESULTS: Univariate analyses suggested that CTOs in GFG were characterized by lighter limb ischemia (p = 0.03), shorter course of ischemic symptoms (p < 0.01) and lesion length (p = 0.04), more frequent use of intraluminal angioplasty (p = 0.03), and higher runoff score (p < 0.01) than those in PFG. Multivariate regression analyses suggested that distal runoffs (p = 0.001; odds ratio [OR], 10.32; 95% confidence interval [CI]: 4.082-26.071) and lesion length (p < 0.001; OR, 1.26; 95% CI: 1.091-1.449) were independent predictors for good flow restoration. Kaplan-Meier analyses at 12 months showed a higher prevalence of non-restenosis in GFG (p < 0.01). CONCLUSION: Distal runoffs and lesion length are independent predictors for good flow restoration for long-segmental BTK, CTOs in DM patients who receive endovascular therapy.

Efficacy of Flow-Diverting Devices for Cerebral Aneurysms: A Systematic Review and Meta-analysis.

BACKGROUND: To evaluate the efficacy of flow-diverting devices (FDDs) used in the treatment for intracranial aneurysms (IAs), we performed a meta-analysis of published literature on FDDs. METHODS: A systematic electronic database search was conducted using MEDLINE, PubMed, Springer, and EBSCO for all accessible articles on FDDs published until December 2014. Abstracts, full-text manuscripts, and the reference lists of retrieved articles were analyzed. Random effects meta-analysis was used to pool the occlusion rate outcomes across studies. RESULTS: Fifty-nine studies containing efficacy data on 2263 patients with more than 2493 treated aneurysms were included in the analysis. The overall complete occlusion rate was 82.5% (95% CI, 78.8%-86%) across studies. The success rate of FDD implantation was 97.4% (95% CI, 95.4%-99.4%). The occlusion rate for anterior circulation aneurysms was 83.3% (95% CI, 71.2%-95.4%); with regard to complete occlusion, the odds ratio for anterior circulation aneurysms was significantly higher than that of posterior circulation IAs (odds ratio, 1.93; 95% CI, 1.00-3.73). CONCLUSIONS: FDDs have high technical success rates in the management of IAs. Additional studies on well-designed, multicenter, randomized controlled trials will be required to validate the findings of the present study and to identify the best therapeutic strategy for IAs depending on their size, location, and characteristics.

Flow-Diverting Devices versus Coil Embolization for Intracranial Aneurysms: A Systematic Literature Review and Meta-analysis.

OBJECTIVE: To review the literature on flow-diverting device (FDD) treatments for intracranial aneurysms (IAs) and to compare the safety and efficacy of FDDs with coil embolization treatment (CET) for IAs using a meta-analysis of published studies. METHODS: A systematic electronic search was conducted of PubMed, Springer Link, EBSCO, and the Cochrane Database on all accessible published articles through September 2015. Abstracts, full-text manuscripts, and the reference lists of retrieved articles were analyzed. Studies that explicitly compared FDD and CET approaches to the treatment of IAs were included. Odds ratios (ORs) and 95% CIs were calculated for the complete occlusion rate and the morbidity rate using a random-effects model. RESULTS: Nine studies were included in the analysis, containing retrospectively collected data for 863 patients. FDD treatment showed a significantly higher complete occlusion rate than CET (OR = 3.13; 95% confidence interval [CI], 2.11-4.65) and the subgroup of stent-assisted coiling did (OR = 2.08; 95% CI, 1.34-3.24). FDDs did not achieve a significantly lower overall morbidity rate compared with CET (OR = 0.87; 95% CI, 0.45-1.69) or the SAC (stent-assisted coiling) subgroup (OR = 0.86; 95% CI, 0.33-2.26), and our results did not show a significant difference in mortality between the two techniques. CONCLUSIONS: FDD treatment of IAs yielded satisfactory results in complete occlusion rate compared with CET. The FDD procedure is feasible and has no significant difference in morbidity risk. Despite the findings reported herein, further validation with well-designed, multicenter randomized controlled trials is needed.

Rendezvous technique for recanalization of long-segmental chronic total occlusion above the knee following unsuccessful standard angioplasty.

PURPOSE: To assess the technical feasibility and efficacy of the rendezvous technique, a type of subintimal retrograde wiring, for the treatment of long-segmental chronic total occlusions above the knee following unsuccessful standard angioplasty. METHODS: The rendezvous technique was attempted in eight limbs of eight patients with chronic total occlusions above the knee after standard angioplasty failed. The clinical symptoms and ankle-brachial index were compared before and after the procedure. At follow-up, pain relief, wound healing, limb salvage, and the presence of restenosis of the target vessels were evaluated. RESULTS: The rendezvous technique was performed successfully in seven patients (87.5%) and failed in one patient (12.5%). Foot pain improved in all seven patients who underwent successful treatment, with ankle-brachial indexes improving from 0.23 ± 0.13 before to 0.71 ± 0.09 after the procedure (P < 0.001). At the end of the follow-up period, the visual analogue scale improved from 6.86 ± 1.57 to 1.57 ± 1.27 (P < 0.001). Non-healing ulcers in three patients either healed (n = 2) or improved (n = 1). No major amputation was necessary. Kaplan-Meier analyses revealed that stenosis-free rate was 83.3% at six months and 41.7% at 12 months. CONCLUSION: The rendezvous technique is a feasible and effective treatment for chronic total occlusions above the knee when standard angioplasty fails.