Artificial Intelligence for Identification of Images with Active Bleeding in Mesenteric and Celiac Arteries Angiography.

PURPOSE: The purpose of this study is to evaluate the efficacy of an artificial intelligence (AI) model designed to identify active bleeding in digital subtraction angiography images for upper gastrointestinal bleeding. METHODS: Angiographic images were retrospectively collected from mesenteric and celiac artery embolization procedures performed between 2018 and 2022. This dataset included images showing both active bleeding and non-bleeding phases from the same patients. The images were labeled as normal versus images that contain active bleeding. A convolutional neural network was trained and validated to automatically classify the images. Algorithm performance was tested in terms of area under the curve, accuracy, sensitivity, specificity, F1 score, positive and negative predictive value. RESULTS: The dataset included 587 pre-labeled images from 142 patients. Of these, 302 were labeled as normal angiogram and 285 as containing active bleeding. The model's performance on the validation cohort was area under the curve 85.0 ± 10.9% (standard deviation) and average classification accuracy 77.43 ± 4.9%. For Youden's index cutoff, sensitivity and specificity were 85.4 ± 9.4% and 81.2 ± 8.6%, respectively. CONCLUSION: In this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of this study show the potential of an AI-based algorithm to accurately classify images with active bleeding. Further studies using a larger dataset are needed to improve accuracy and allow segmentation of the bleeding.

Performance of BeBack Crossing Catheter in Chronic Total Occlusion in Patients With Chronic Limb-Threatening Ischemia: A Single-Center Experience.

PURPOSE: To describe a single-center experience in the treatment of chronic limb-threatening ischemia (CLTI) with the application of BeBack catheter (Bentley InnoMed, Germany) in patients with arterial chronic total occlusion (CTO). MATERIALS AND METHODS: A retrospective review of patients who underwent limb revascularizations using the BeBack catheter between 2015 and 2022. All patients had an initial failed attempt using a traditional guidewire and catheter technique. Technical success was considered whenever a successful re-entry or lesion crossing using the study device was achieved. Procedural success was defined as recanalization of the occluded artery with residual stenosis of less than 30%, and improvement in ankle-brachial index (ABI) after 24 hours. A Rutherford score was assigned to each limb and affected anatomical segments and lesion length were documented. Procedural access sites and complications were noted. RESULTS: The study included 72 patients who underwent 78 procedures using the BeBack crossing catheter. Procedural success was achieved in 91% of cases, with a technical success rate of 92.3%. The most frequently involved occluded segments were the femoral and popliteal arteries. The average ABI improved from 0.59 to 0.95 after the procedure. The most used access site was the contralateral femoral, and the BeBack catheter was employed on 85 occasions. Only 1 patient suffered a severe immediate adverse effect, and during the 30-day follow-up period, 2 patients needed reintervention. Unfortunately, 3 patients died during the follow-up period. CONCLUSION: The BeBack catheter offers a viable option for the treatment of patients with chronic total occlusion, with high procedural success and a low complication rate. CLINICAL IMPACT: The BeBack catheter presents a notable advancement for clinicians managing chronic limb-threatening ischemia (CLTI) and arterial chronic total occlusion (CTO), showcasing over 90% procedural and technical success rates in this study. Its adept ability to navigate and recanalize occluded segments provides a robust alternative, especially when traditional techniques falter. This innovation may chane clinical strategies in vascular interventions, offering an efficient and reliable option, thereby potentially enhancing patient outcomes in limb revascularizations.

Retrograde tibial access for revascularization of chronic total occlusions in patients with chronic limb-threatening ischemia.

PURPOSE: To evaluate tibial single access in treatment of chronic total occlusions (CTO) in patients with ipsilateral chronic-limb ischemia (CLTI). MATERIALS AND METHODS: In this retrospective study, data was collected on patients treated for ipsilateral CTO via a tibial artery access between March 2017 and March 2021. Fifty-nine limbs in 57 patients, (42 men, average age 73 years; range 47-96) were treated. Patient's symptoms were classified in accordance with the Rutherford category. The end points were freedom from major amputation and the need for reintervention up to 1 year of follow up. RESULTS: Out of the 59 treated limbs, technical success was achieved in 57 (97%). The treated multilevel segments involved 5 common and 12 external iliac arteries, 23 common and 37 superficial femoral arteries, 23 femoropopliteal segments, 14 popliteal arteries, and 4 bypasses. Mean length of occlusion was 186 mm (range 7-670). Rutherford classification of the treated limbs was category 5 and 6 in 45 patients and category 4 in 14 patients. Three procedural complications occurred and were successfully treated during the same procedure. No immediate post-procedural complication was encountered. Median follow-up was 13 months (range 1-45.3). Reintervention was required in 9 limbs, after an average of 6 months. One year free from amputation rate was 91.2%. CONCLUSIONS: Single access via the ipsilateral tibial artery can be a useful, effective, and safe approach for treating CTO in CLTI patients.

Technical Success of the GoBack™ Crossing Catheter in Chronic Total Occlusion in Patients with Chronic Limb Threatening Ischemia.

PURPOSE: To assess the technical success of GoBack™ crossing catheter in chronic total occlusion. MATERIALS AND METHODS: A retrospective review of chronic limb threatening ischemia (CLTI) patients treated for chronic total occlusions (CTO) with the application of the GoBack™ crossing catheter (Upstream Peripheral Technologies, Haifa, Israel) between May 2020 and January 2021 was performed. Sixteen GoBack catheters were applied in twelve limbs in 12 patients (ten men, average age 75.7 years). Treated limbs were classified as Rutherford Category 5 and 6 in ten patients and four in two patients. Average occlusion length was 287 mm (62-466). All occluded arteries were heavily calcified. Technical success was defined as successful application of the GoBack catheter for lesion crossing or luminal reentry. RESULTS: Successful application of the four French catheter was achieved in 11 of the 12 cases (92%) for reentry in external iliac (1), superficial femoral (2), popliteal (2) and posterior tibial (1) arteries in six out of six cases (100%) and lesion crossing in popliteal (4), peroneal (1) and posterior tibial arteries in five out of six cases (83%). The 2.9 Fr catheter was successfully applied once out of four (25%) in lesion crossing in the posterior tibial artery. CONCLUSION: The GoBack™ 4 Fr crossing catheter in revascularization of CLI patients with CTO could be valuable when manual crossing or reentry is unsuccessful and is applicable from any access site.

Revascularization of multiple tibial arteries is not associated with improved limb salvage.

OBJECTIVE: We sought to determine the benefit of performing multiple tibial artery revascularization compared with single vessel revascularization for patients with chronic limb-threatening ischemia (CLTI). METHODS: We performed a single-center, retrospective cohort study of all patients with CLTI treated with below-the-knee endovascular intervention from 2012 to 2019. Group 1 included patients who had undergone single tibial artery revascularization. Group 2 included patients who had undergone multiple (two or more) tibial artery revascularization. More proximal disease, if present, was treated, in addition to the tibial disease. The primary endpoint was freedom from amputation. The secondary endpoints included the reintervention rates and all-cause mortality. RESULTS: A total of 527 limbs in 470 patients with CLTI (nonhealing ulcers, 62%; gangrene, 33%; and ischemic rest pain, 5%) were included in the present study. Of the 527 limbs, 245 (46%) had undergone single vessel revascularization and 282 (54%) had undergone multiple vessel revascularization. The mean follow-up was 19 ± 18 months. No difference was found in freedom from amputation between the two groups (68% vs 63%; P = .109). On multivariable analysis, the factors associated with amputation included dialysis (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16-2.45), dyslipidemia (OR, 1.37; 95% CI, 0.96-1.94), and gangrene (OR, 2.08; 95% CI, 1.50-2.98). No differences were found in the reintervention rates between the two groups (21.2% vs 16.7%; P = .13). The overall survival rate was 73% in both study groups. CONCLUSIONS: The results from the present large, single-center study have demonstrated that multiple below-the-knee vessel revascularization is not associated with improved limb salvage compared with single vessel revascularization.

Changing Paradigms in Below-the-Knee Arterial Interventions: Are We Saving Legs?

BACKGROUND: Patients with critical limb ischemia (CLI) involving the below-the-knee (BTK) arteries are at increased risk of limb loss. Despite improvement in endovascular modalities, it is still unclear whether an aggressive approach results in improved limb salvage. OBJECTIVES: To assess whether an aggressive approach to BTK arterial disease results in improved limb salvage. METHODS: A comparative study of two groups was conducted. Group 1 included patients treated between 2012 and 2014, primarily with transfemoral angioplasty of the tibial arteries. Group 2 included patients treated between 2015-2019 with a wide array of endovascular modalities (stents, multiple tibial artery and pedal angioplasty, retrograde access). Primary endpoint was freedom from amputation at 4 years. RESULTS: A total of 529 BTK interventions were performed. Mean age was 71 ± 10.6 years, 382 (79%) were male. Patients in group 1 were less likely to be taking clopidogrel (66% vs. 83%, P < 0.01) and statins (72 % vs. 87%, P < 0.01). Several therapeutic modalities were used more often in group 2 than in group 1, including pedal angioplasty (24 vs. 43 %, P = 0.01), tibial and pedal retrograde access (0 vs. 10%, P = 0.01), and tibial stenting (3% vs. 25%, P = 0.01). Revascularization of two or more tibial arteries was performed at a higher rate in group 2 (54% vs. 50%, P = 0.45). Estimated freedom from amputation at 40 months follow-up was higher in group 2 (53% vs. 63%, P = 0.05). CONCLUSIONS: An aggressive, multimodality approach in treating BTK arteries results in improved limb salvage.

Short-term outcomes of inner branches for endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms.

OBJECTIVES: To report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: A retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates. RESULTS: Twenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up. CONCLUSIONS: Inner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.

Inguinal lymphadenopathy as a predicting factor for ipsilateral primary limb amputation after a successful endovascular treatment.

PURPOSE: To assess the correlation between inguinal lymph node characteristics and ipsilateral limb amputation rates in patients with ischemic foot ulcers after a successful endovascular treatment. METHOD: A retrospective review of patients who were endovascularly treated for ischemic foot ulcers between January 2015 and May 2017. Technical success was defined as arterial recanalization with stenosis less than 30 % and ankle brachial index improvement by > 0.2 after 24 h. Unilateral lymph node size, contrast enhancement, necrosis, and perinodular fat stranding were assessed on pre-procedural CTA. Primary endpoints were amputation and sepsis within 12 months following treatment. The relationship between lymph node characteristics and limb amputation and septic shock were examined. RESULTS: Endovascular treatment of 202 limbs in 202 patients (135 males; median age 72.8 years [42.2-93.7]) was technically successful. Forty-two (20.8 %) patients underwent amputation, six (3 %) patients had septic shock. There was a significant difference in lymph node sizes between the amputated and the non-amputated limbs (P = 0.000). Lymph node characteristics (size, enhancement, necrosis, and perinodular fat stranding) were significantly related to amputation (P < 0.001). Patients with perinodular fat stranding or increased node size were 5.940 and 1.109 times more likely to undergo limb amputation, respectively. Lymph node characteristics were also significantly related to septic shock (P < 0.05). CONCLUSIONS: Certain lymph node characteristics are associated with amputation in patients with ischemic foot ulcers, after a technically successful endovascular treatment of the limb. Large lymph node size and perinodular fat stranding are predictive of limb amputation.

Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms.

OBJECTIVE: The use of fenestrated and branched endografts for the treatment of complex aortic aneurysms is increasing. Despite the low morbidity and mortality associated with these repairs, reintervention rates in the midterm and long term remain a concern. The purpose of this study was to investigate our experience with reinterventions after fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: We performed a retrospective analysis of all patients treated with F/BEVAR at our institution during the years 2009 to 2019. Among them, we identified those who required reinterventions during the period of follow-up. Data collected included patients' demographics, type of treated aneurysm, indications for reintervention, and methods of repair. RESULTS: During the study period, 47 patients underwent F/BEVAR. A total of 160 branches were placed. Of those, 12 patients (25%) underwent 15 secondary interventions for late-occurring complications. Among those requiring reinterventions, mean age was 70 years (range, 59-80 years), and 10 (83%) were male. The majority of those requiring reinterventions were treated for thoracoabdominal aortic aneurysms. Mean time to reintervention was 14 months (range, 2-32 months). Indications for reinterventions included separation of side branches from fenestrations (nine), separation of side branches (three), type IA endoleak (one), type II endoleak (one), and limb occlusion (one). All endoleaks were detected on routine follow-up imaging. All reinterventions were performed using endovascular techniques. Mean follow-up after reinvention was 22 months (range, 1-53 months). During this period, no patient required open conversion. Follow-up imaging revealed successful obliteration of the endoleak, and none experienced continued growth of the sac. CONCLUSIONS: Reinterventions after F/BEVAR are not uncommon. The majority of reinterventions are performed for endoleaks that are due to failure at the level of the fenestrations or component separation. These endoleaks can be treated successfully with endovascular methods and do not require open conversion. Because of the possibility of development of late endoleaks, continual monitoring of these patients is required after the primary procedure.

Selective Arterial Embolization for Large or Symptomatic Renal Angiomyolipoma: 10 Years of Follow-up.

OBJECTIVE: To assess long-term outcome after selective arterial embolization (SAE) as first-line treatment for large or symptomatic AML. DESIGN, SETTING, AND PARTICIPANTS: Data from a prospectively maintained database on 71 patients who underwent SAE for large or symptomatic AML were reviewed. Patients with sporadic and tuberous-sclerosis-complex (TSC) were included. OUTCOME MEASUREMENTS: The main endpoints were re-embolization rates, occurrence of clinical events related to AML, size of AML, and renal function. RESULTS: Thirteen (19.1%) patients reported at least 1 major clinical event. Major complications affected 2 patients (2.9%), both ending in complete loss of renal unit function. Four renal units (5.9%) were eventually treated surgically. The re-embolization rate was 41.1%, with an average time from the initial to a repeat SAE of 2.18 years (range 0.31-10.65 years). The size of the tumor prior to SAE and after 5 and 10 years of follow-up were 8.9 cm (7-12), 6.5 cm (4-7.5), 7 cm (4-7.8), respectively [median (IQR)]. These results are translated to a size reduction of 27% in 10 years follow-up. Patients with TSC had larger tumors on long-term follow-up (77.8 vs 41.3 mm, P = .045). The long-term follow-up estimated average glomerular filtration rate was 81.97 (range 26-196). No patient needed renal replacement therapy, and disease-specific survival was 100%. CONCLUSIONS: SAE is a safe treatment option for patients with symptomatic or large AML. It represents a minimally invasive intervention with good long-term outcome. SAE may be offered as first-line treatment in most cases, though, it is associated with high retreatment rates.

Venous Malformations Sclerotherapy: Outcomes, Patient Satisfaction and Predictors of Treatment Success.

PURPOSE: To retrospectively evaluate the results of sclerotherapy for venous malformations, with emphasis on patient satisfaction, complications and predictors of positive response to treatment. MATERIALS AND METHODS: Three hundred and nine patients were treated with ethanol sclerotherapy for venous malformations in our center between the years 2000 and 2014. All of them were sent a self-assessment questionnaire for evaluation of their satisfaction and treatment complications. In total, 153 patients (mean age 21, range 6 weeks to 67 years) responded to the questionnaire. We analyzed clinical and imaging data from the medical records of these patients. RESULTS: Sixty-four (42%) patients had venous malformations in the lower extremities, 35 (23%) in head and neck regions, 33 (22%) in the trunk, 14 (9%) in the upper extremities and 5 (3%) in the buttock and genitalia. Complete relief of swelling, pain, functional and esthetic complaints was reported in 23%, 22%, 17% and 12% of patients, respectively. Thirty-eight (25%) patients reported being very satisfied with treatment outcomes, 55 (36%) were satisfied, 49 (32%) were not satisfied and 11 (7%) were very unsatisfied. We did not find significant correlations between patient satisfaction and demographics characteristics, lesion location, lesion size, tissue involvement or total sclerosant quantity. The rate of class 3 complications was 7% and that of class 4 complications was 2%. CONCLUSION: Ethanol sclerotherapy is an effective treatment for venous malformations. Nonetheless, this treatment has a significant complication rate. Patient satisfaction is independent of lesion characteristics and is not as high as may be expected.

Primary Retrograde Dorsalis Pedis Artery Single Access for Revascularization of Chronic Total Occlusion in Patients with Critical Limb Ischemia.

PURPOSE: To evaluate the dorsalis pedis artery (DPA) approach as a single access site for revascularization in patients with critical limb ischemia (CLI) when the femoral approach is hostile or unavailable. MATERIALS AND METHODS: A retrospective review of patients who underwent iliac and femoropopliteal ipsilateral revascularization via a single access site from the DPA between January 2017 and February 2018 was performed. Fifteen limbs in 15 patients (10 men and 5 women; average age 72 y; range, 49-96 y) with CLI and unavailable femoral access were included. Patients were unsuitable candidates for a surgical bypass graft. Treated limbs were classified as Rutherford category 5 and 6 in 12 patients and category 4 in 3 patients. Treated occluded segments involved 2 iliac arteries, 12 femoropopliteal arteries, 1 bypass graft, and 2 posterior tibial arteries. Technical success was defined as recanalization of the occluded artery with residual stenosis < 30% and improvement in ankle-brachial index after 24 hours. Patients were followed for up to 13 months. Endpoints were freedom from reintervention and limb salvage for 1 year. RESULTS: Technical success was achieved in 14 of 15 patients (93%). Stents were placed in 13 of 15 patients (86%). No complications were encountered immediately after the procedure. Median follow-up was 7.1 months (range, 1.4-13.5 mo). One patient was lost to follow-up. Reintervention was needed in 5 limbs after an average of 4.2 months. Limb salvage rate at 1 year was 83%. CONCLUSIONS: Using the DPA as a single access could be a valuable approach when traditional access sites are unavailable for treating patients with CLI.

The Aortic Bifurcation Angle as a Factor in Application of the Outback for Femoropopliteal Lesions in Ipsilateral Versus Contralateral Approaches.

PURPOSE: To assess the technical success of the Outback reentry device in contralateral versus ipsilateral approaches for femoropopliteal arterial occlusion. MATERIALS AND METHODS: A retrospective review of patients treated for critical limb ischemia (CLI) using the Outback between January 2013 and July 2016 was performed. Age, gender, length and site of the occlusion, approach site, aortic bifurcation angle, and reentry site were recorded. Calcification score was assigned at both aortic bifurcation and reentry site. Technical success was assessed. RESULTS: During the study period, a total of 1300 endovascular procedures were performed on 489 patients for CLI. The Outback was applied on 50 femoropopliteal chronic total occlusions. Thirty-nine contralateral and 11 ipsilateral antegrade femoral were accessed. The device was used successfully in 41 patients (82%). There were nine failures, all in the contralateral approach group. Six due to inability to deliver the device due to acute aortic bifurcation angle and three due to failure to achieve luminal reentry. Procedural success was significantly affected by the aortic bifurcation angle (p = 0.013). CONCLUSION: The Outback has high technical success rates in treatment of femoropopliteal occlusion, when applied from either an ipsi- or contralateral approach. When applied in contralateral access, acute aortic bifurcation angle predicts procedural failure.

The use of optional inferior vena cava filters of type Optease in trauma patients--a single type of filter in a single Medical Center.

BACKGROUND: Venous thromboembolism (VTE) is a frequent complication of patients who experienced major trauma. Prevention of VTE is usually by thrombophylaxis and or by the use of a retrievable filter. Lately, the use of a retrievable filter in trauma patients has increased despite evidence cautioning against its use. AIMS: To evaluate complications related to a single type of filter prophylactically used in a tertiary trauma center and search for risk factors that may preclude filter retrieval METHODS: 142 patients aged 16 through 60 who experienced a major trauma and were treated with a prophylactic IVC filter of type optease were evaluated. RESULTS: The median time from trauma to filter insertion was 2days and low molecular weight heparin at prophylactic dose was initiated in 92% once the filter was inserted. Nine patients developed IVC thrombosis and one of them died despite the use of thrombolytic therapy. Another 8 patients developed lower extremities deep vein thrombosis. The filter was left in place in 13 more patients after attempted filter removal was unsuccessful. Among patients with successful removal, the median dwelling time was 30days. There was no relationship between successful removal and age, sex, BMI, Glasgow coma scale, or injury severity score of patients when first evaluated. CONCLUSIONS: Of concern is the persistent complications related to IVC filter even with the prophylactic use of anticoagulants and the dose of radiation trauma patients were exposed during insertion and retrieval of filter. Thus, the routine use of IVC filter in trauma patients may not be desirable.

The Use of ExoSeal Vascular Closure Device for Direct Antegrade Superficial Femoral Artery Puncture Site Hemostasis.

PURPOSE: This study was designed to assess the efficacy and safety of the ExoSeal vascular closure device (VCD) to achieve hemostasis in antegrade access of the superficial femoral artery (SFA). METHODS: We retrospectively reviewed the outcome of ExoSeal VCD used for hemostasis in 110 accesses to the SFA in 93 patients between July 2011 and July 2013. All patients had patent proximal SFA based on computer tomography angiography or ultrasound duplex. Arterial calcifications at puncture site were graded using fluoroscopy. The SFA was accessed in an antegrade fashion with ultrasound or fluoroscopic guidance. In all patients, 5-7F vascular sheaths were used. The ExoSeal VCD was applied to achieve hemostasis at the end of the procedure. All patients were clinically examined and had ultrasound duplex exam for any puncture site complications during the 24 h postprocedure. RESULTS: In all procedures, the ExoSeal was applied successfully. We did not encounter any device-related technical failure. There were four major complications in four patients (3.6 %): three pseudoaneurysms, which were treated with direct thrombin injection, and one hematoma, which necessitated transfusion of two blood units. All patients with complications were treated with anticoagulation preprocedure or received thrombolytic therapy. CONCLUSIONS: The ExoSeal VCD can be safely used for antegrade puncture of the SFA, with a high procedural success rate (100 %) and a low rate of access site complications (3.6 %).

Endovascular repair of complex aortic aneurysms.

BACKGROUND: Surgery for complex aortic aneurysms (thoracoabdominal, juxtarenal and pseudoaneurysms) is associated with a high morbidity and mortality rate. Branched and fenestrated stent grafts constitute a new technology intended as an alternative treatment for this disease. OBJECTIVES: To describe a single-center experience with fenestrated and branched endografts for the treatment of complex aortic aneurysms. METHODS: We reviewed all cases of complex aortic aneurysms treated with branched or fenestrated devices in our center. Data collected included device specifics, perioperative morbidity and mortality, re-intervention rates and mid-term results. RESULTS: Between 2007 and 2012 nine patients were treated with branched and fenestrated stent grafts. Mean age was 73 years. Mean aneurysm size was 63 mm. Perioperative mortality was 22% (2/9). During the follow-up, re-interventions were required in 3 patients (33%). Of 34 visceral artery branches 33 remained patent, resulting in a patency rate of 97%. Sac expansion was seen in a single patient due to a large endoleak. No late aneurysm-related deaths occurred. CONCLUSIONS: Branched and fenestrated stent grafts are feasible and relatively safe alternatives for the treatment of complex aortic aneurysms involving the visceral segment. Further research is needed to determine the long-term durability of this new technology.

Optease vena cava filter optimal indwelling time and retrievability.

The purpose of this study was to assess the indwelling time and retrievability of the Optease IVC filter. Between 2002 and 2009, a total of 811 Optease filters were inserted: 382 for prophylaxis in multitrauma patients and 429 for patients with venous thromboembolic (VTE) disease. In 139 patients [97 men and 42 women; mean age, 36 (range, 17-82) years], filter retrieval was attempted. They were divided into two groups to compare change in retrieval policy during the years: group A, 60 patients with filter retrievals performed before December 31 2006; and group B, 79 patients with filter retrievals from January 2007 to October 2009. A total of 128 filters were successfully removed (57 in group A, and 71 in group B). The mean filter indwelling time in the study group was 25 (range, 3-122) days. In group A the mean indwelling time was 18 (range, 7-55) days and in group B 31 days (range, 8-122). There were 11 retrieval failures: 4 for inability to engage the filter hook and 7 for inability to sheathe the filter due to intimal overgrowth. The mean indwelling time of group A retrieval failures was 16 (range, 15-18) days and in group B 54 (range, 17-122) days. Mean fluoroscopy time for successful retrieval was 3.5 (range, 1-16.6) min and for retrieval failures 25.2 (range, 7.2-62) min. Attempts to retrieve the Optease filter can be performed up to 60 days, but more failures will be encountered with this approach.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones.

PURPOSE: To report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). PATIENTS AND METHODS: Twenty-two symptomatic patients (11 men and 11 women, age range 51 to 88 years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-µm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure. RESULTS: All stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (n = 3), for choledochalenteric anastomosis (n = 3), and for recurrent cholangitis (n = 1). Adjunctive "balloon push" (n = 4) and "rendezvous" (n = 1) procedures were needed to completely clean the biliary tree. None of these patients needed surgery. CONCLUSION: Complicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.

Histology of tissue adherent to OptEase inferior vena cava filters regarding indwelling time.

The purpose of this paper is to report on the histology of tissues found on retrieved filters with regard to indwelling time. Between February 2006 and January 2007, 28 Optease inferior vena cava filters (Cordis Europa, Roden, The Netherlands) were retrieved from 27 patients. Twenty-two filters were inserted prophylactically for trauma patients and six for patients with venous thromboembolism. Cavography was performed both before and after filter removal to evaluate the presence of thrombi or wall damage. Filters were retrieved with the snare and sheath method. All material adherents to the filters were examined histologically.The mean indwelling time of the filters was 24.9 days (range, 6-69 days). Red tissue fragments were seen on all the filters, consistent microscopically with clots and fibrin. On five filters (18%; mean indwelling time, 45.4 days) white tissue consistent with vascular intima was found. All postprocedure cavographies were normal. We conclude that most material adherent to the retrieved filters is thrombi, while vascular intima can be found in the minority of filters with a longer indwelling time.