Endovascular stent graft placement in the treatment of ruptured tuberculous pseudoaneurysm of the descending thoracic aorta: case report and review of the literature.

We report a successful repair of a ruptured tuberculous pseudoaneurysm of the descending thoracic aorta by endovascular stent graft placement. This procedure is starting to be accepted as an alternative method to surgery, and we review similar cases in the literature.

Angiographic signs in specific vasculitides.

Vasculitis, defined by inflammation in the blood vessel wall and reactive mural damage, may present with various clinical signs, depending on the organs involved. Infection, collagen vascular disease, and granulomatous disease or idiopathic inflammation of the vessels may result in various degrees of stenosis, obstruction, aneurysmal dilatation, or rupture. The definitive pathologic diagnosis is established by biopsy; however, the biopsy may pose significant risk to the patient; and the biopsy sample may not be adequate. Knowledge of the angiographic signs of various vasculitides should help in interpreting the clinical picture and reducing the need for biopsy. In this article, we describe the angiographic signs of the most common vasculitides, and review their clinical signs.

Endovascular treatment of AVF after hair transplantation.

Arteriovenous fistula (AVF) of the scalp is a very rare complication of hair transplantation. Only 9 cases have been reported in nearly half a century. The diagnosis is clinical but angiography is necessary for defining the angioarchitecture of the lesion. Due to technical developments, endovascular embolization has become the primary treatment for AVF of the scalp.

Carotid endarterectomy versus carotid artery stenting: findings in regard to neuroclinical outcomes and diffusion-weighted imaging.

The purpose of our study was to evaluate prospectively the frequency and significance of brain lesions after elective carotid endarterectomy (CAE) and carotid artery stenting (CAS) by using diffusion-weighted magnetic resonance imaging (DW MRI) and then to correlate imaging findings with neuroclinical outcomes. From February 2003 through March 2005, 95 consecutive patients underwent surgical endarterectomy or CAS (with a cerebral protection device) at our institution. A total of 59 CAE procedures were performed in 46 consecutive patients (mean age, 65.8 +/- 9 yr), and 56 CAS procedures were performed in 49 consecutive patients (mean age, 66.3 +/- 9 yr). Diffusion-weighted magnetic resonance imaging of the brain was performed in all patients within 24 hours of the procedure, both before and after. The post-procedural stroke rate was slightly higher in the CAS group, but this difference was not significant (5.4% vs 0). One early and 1 late death occurred in the stent group. Although the incidence of ischemic lesions was similar in both groups (surgery group, 12.5%; stent group, 13.5%), new DW MRI lesions were higher in the endarterectomy group (27.1% vs 12.5%, P=0.041). This difference was due chiefly to nonischemic lesions such as hemorrhage and watershed ischemia. In the analysis of patients with embolic ischemia, incidences of symptomatic stroke (P=0.046) and large infarct (P=0.013) were higher in the stent group. When we used protective devices during CAS, the incidence of embolic complications was similar to that of surgical enarterectomy. On the other hand, the clinical results of CAS need improvement.

An unusual vascular involvement in a patient with Behcet's disease: renal artery stenosis.

Behcet's disease (BD) is a rare multisystem inflammatory disorder characterized by recurrent ulcers affecting the mouth and genitals, various skin lesions, relapsing iritis, and vasculitis. Vascular events may dominate the clinical presentation in some patients with BD. Hitherto three forms of vascular disease such as venous occlusions, arterial aneurysms, and arterial occlusions have been reported in BD. Renal vascular involvement has reported in less than 1% of the patients with vascular BD. A case of BD with renovascular hypertension is reported. To our knowledge, a case of BD with renovascular hypertension treated with angioplasty and stent implantation has not been reported previously.

Fibromuscular dysplasia-related renal artery stenosis associated with aneurysm: successive endovascular therapy.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease. FMD of the renal arteries is one of the leading causes of curable hypertension. The simultaneous occurrence of FMD and renal artery aneurysm has been described previously. In this case, we present a fibrodysplastic lesion and an aneurysm in a renal artery treated with a percutaneous transluminal angioplasty and coil embolization.

"Extarterectomy" for tumors invading the carotid artery: an animal model.

OBJECTIVE: Carotid artery (CA) invasion by head and neck tumors is a challenging problem for the cranial base surgeon. Proposed methods for management have the disadvantage of constant or temporary interruption of the arterial blood flow and, as a consequence, cerebral ischemic complications. The objective of the study was to investigate the long-term effects of a novel technique, "extarterectomy," on the vascular wall and the arterial blood flow in an ovine model. METHODS: Wallstents were implanted bilaterally in the common CA of 5 sheep by the Seldinger technique. Six weeks after stent implantation, a segment of the arterial wall of about 2 cm in length was peeled off the external surface of the stent. Six months later, control angiography was performed. The animals were sacrificed after 18 months and the "extarterectomized" arteries were removed for the microscopic and macroscopic evaluation. RESULTS: There were no acquired neurological deficits in the study group. Extarterectomy was performed without any complication in every case. Control angiography confirmed patent CAs. Evaluation by light microscopy showed the "neointimal" layer within the interstices of the stent. CONCLUSION: Extarterectomy allows aggressive tumor removal together with the maintenance of blood flow through the CA and offers hope for those with tumors invading the CA.

Percutaneous interventional therapy of persistent biliary fistulas.

BACKGROUND: Persistent biliary leakage is a challenging problem when conservative treatment methods fail. We present our experience with alternative percutaneous radiologic interventions to seal refractory biliary leaks. METHODS: From April 1998 to December 2005, a retrospective analysis of 23 patients with biliary leakage revealed six patients who were unresponsive to drainage were treated with use of Histoacryl (n = 5), microcoils (n = 2), or covered stent (n = 2) alone or in various combinations. RESULTS: In all patients, the biliary leakage ceased following a single procedure. Distally migration of microcoils into the abscess cavity was observed in a one coiling procedure, which was clinically insignificant. In one patient treated with covered stent, in-stent restenosis was seen in the postprocedural second year, which required another intervention. No recurrence of fistula was noted in the follow-up period (ranging from 6 to 47 months). CONCLUSIONS: Persistent biliary fistulas can be treated successfully by means of various percutaneous radiological interventions that can decrease the morbidity associated with prolonged external drainage and avert the need for surgery. We recommend superselective embolization, preferably with Histoacryl, for a safe and effective control of leakage. Although restenosis after stenting remains problematic, covered stents should be reserved as a feasible alternative for selected cases.

Acute mesenteric ischemia: endovascular therapy.

Acute mesenteric ischemia (AMI) is an abdominal emergency with a high mortality. Prompt revascularization can prevent intestinal infarction and reduce mortality. We report three cases of acute occlusive mesenteric ischemia without signs of intestinal necrosis, which were successfully managed with endovascular interventions. Mechanical thrombus fragmentation was performed and underlying chronic stenoses were treated with stent implantation. All the patients had pain relief immediately after the procedure, and none of them required surgery for bowel resection. The patients remained symptom free during a follow-up of 12-16 months. We suggest that endovascular treatment is a feasible option in patients with AMI and can prevent intestinal infarction.

Interventional radiological management of vascular complications following renal transplantation.

In this pictorial essay, we describe the angiographic appearance of the most common vascular complications following renal transplantation, such as arterial stenoses, arteriovenous fistulas, pseudoaneurysms, and thromboses, and illustrate their interventional radiological management.

Experience with mesocaval shunt with autologous jugular vein interposition in patients with Budd-Chiari syndrome.

BACKGROUND/AIMS: In the present era of interventional radiology and liver transplantation, the role of mesocaval shunt surgery for portal hypertension in Budd-Chiari syndrome is reviewed. METHODOLOGY: This study analyzed the management of 35 patients with Budd-Chiari syndrome between June 1994 and June 2004 in our institution. During this 10-year interval, 31 of the 35 patients with Budd-Chiari syndrome underwent shunt procedures and four patients underwent liver transplantation. Mesocaval shunts were preferred in 27 patients and seven of these patients required prior caval stenting. One portocaval shunt was performed in a patient having a thrombosed mesocaval shunt. In all mesoaval shunt procedures the patient's internal jugular vein was used as an interposition graft between the superior mesenteric vein and inferior vena cava. In four patients with thrombosed vena cava a mesoatrial shunt was performed using polytetrafluoroethylene graft while four patients with established cirrhosis underwent orthotopic liver transplantation. RESULTS: In the group of mesocaval shunts, 3 patients were lost in the early postoperative period with a mortality rate of 11%, 2 of them due to thrombosed shunts and one of them due to pneumonia. The median follow-up was 42 months (6-120 months) and one patient experienced shunt thrombosis and died afterwards due to the complications of portal hypertension. In the whole series the patency rate of the mesocaval shunt was 89%. CONCLUSIONS: Patients with Budd-Chiari syndrome can be managed by a combination o f shuntsurgery, interventional radiology and liver transplantation. Our results demonstrate the effectiveness of mesocaval shunt procedure with autologous jugular vein interposition to maintain long-term patency and survival.

Adverse effects of anesthesia in interventional radiology.

PURPOSE: The aim of the study was to evaluate adverse events related to the use of anesthesia and anesthetic procedures associated with interventional radiology. MATERIALS AND METHODS: We retrospectively evaluated 124 interventional radiological procedures performed with anesthesia within a one-year period. Patients were separated into four groups according to the duration of procedure, the type of procedure performed, anesthetic agents used, and complications associated with anesthesia. RESULTS: Of the 124 patients, 59 had neurovascular procedures, 10 underwent implantation of a tracheal stent, and 19 had painful procedures. Fifteen of 36 pediatric patients had diagnostic angiography, and 21 had interventional procedures. Two patients in the neurovascular intervention group had cerebral hemorrhage and cerebral infarctions, and anaphylactic reaction developed in one patient, who underwent percutaneous hepatic hydatic cyst drainage. CONCLUSION: Interventional radiological procedures seem to be safe from an anesthesiologist's point of view. However, morbidity and mortality in this patient population can be reduced when the potential complications associated with interventional radiology are well understood by the anesthesia team.

Gene therapy: applications in interventional radiology.

Gene therapy is a new and rapidly developing area in medicine. Although it is a new therapy method, recent studies look promising. Since vascular wall is a good target for this treatment, interventional radiologists should become familiar with this new therapy and be involved in this multidisciplinary collaboration.

[Pulsatile tinnitus as the presenting symptom of dural arteriovenous fistula in two cases]. / Dural arteriovenöz fistül saptanan iki olguda öncü belirti olarak pulsatil tinnitus.

Pulsatile tinnitus associated with normal otoscopic findings may present as the only sign of a potentially life-threatening serious disease such as a dural arteriovenous fistula (dAVF) of the transverse or sigmoid sinus. If left untreated, dAVFs may lead to focal neurologic symptoms, intracranial hypertension, or hemorrhage, and finally to death. We report two cases of dAVF presenting with pulsatile tinnitus. Following diagnosis, both patients underwent transarterial embolization, after which their symptoms resolved.

[The role of the interventional radiologist in central venous catheter dysfunction (pictorial essay)]. / Santral venöz kateter disfonksiyonlarinda girisimsel radyoloji.

Failure to aspirate blood from the lumen of venous catheters, inadequate blood flow and/or high resistance pressures during hemodialysis were accepted as catheter dysfunction. Other correctable problems such as residual lumen thrombus, external fibrin catheter sheath or malpositioned catheter tip were identified by contrast injection. Catheter malpositions were corrected by snare-mediated catheter repositioning or by exchange of the catheter over a guidewire. Catheters of inadequate length were exchanged over a guidewire to the appropriate position or replaced. Treatment of fibrin sheath formation included fibrin sheath stripping, guidewire catheter exchange, and urokinase infusion. Early catheter dysfunction is frequently due to mechanical problems such as inadequate positioning, kinking, or constriction. Delayed dysfunction usually results from thrombus formation, either within the lumen, around the catheter ("fibrin sleeve"), or in the host vein. In the management of catheter malfunctions and complications, interventional radiological techniques are safe and effective alternatives to standard surgical techniques.

Retrieval of intravascular foreign bodies with goose neck snare.

PURPOSE: to evaluate the efficacy and advantages of the snare systems in the retrieval of foreign bodies from vascular system. MATERIALS AND METHODS: the snare technique has been used for intravascular foreign body retrieval. We performed percutaneous extraction of intravascular foreign bodies using combination multipurpose catheters and a nitinol snare loop. In this report, we evaluated the patients who had performed endovascular device reposition or foreign body retrieval from 1998 to 2001. RESULTS: foreign body retrieval was performed in 15 patients. The foreign bodies consisted of seven fractured port catheters, one sheath fragment, one embolization coil, four wire fragments, one pace-maker transducer and one dislocated endovascular stent. In no case were surgical procedures required, and no complications were encountered. CONCLUSION: the snare technique is a useful and a safe method as an alternative procedure to surgery. This technique is highly effective with low rate complications.

[Persistent fetal carotid-vertebrobasilar anastomoses]. / Persistan fetal karotid-vertebrobaziler anastomozlar.

The primitive trigeminal, otic (acoustic), hypoglossal, and proatiantal intersegmental arteries are persistent fetal anastomoses between the carotid and vertebrobasilar circulations. These fetal anastomoses regress at roughly the rate at which the posterior communicating and vertebral arteries develop. The purpose of this study is to review the persistent fetal carotid-vertebrobasilar anastomoses with MRI and DSA.

Reliability of intrarenal Doppler sonographic parameters of renal artery stenosis.

PURPOSE: The goal of this study was to retrospectively evaluate false-negative results of Doppler sonography in the diagnosis of renal artery stenosis (RAS) using intrarenal criteria. METHODS: We reviewed the clinical data and Doppler sonographic data for all patients in whom a diagnosis of RAS had been confirmed angiographically between November 1992 and January 2001. Mean intrarenal acceleration and acceleration time values-data obtained directly from color Doppler sonography-and findings of angiographic examination of the kidneys and stenotic renal arteries were evaluated. RESULTS: During the study period, 55 cases of RAS had been angiographically confirmed in 46 patients (25 male and 21 female; mean age, 50 +/- 19 years [+/- standard deviation]). Intrarenal arterial acceleration, acceleration time values, or both were abnormal in 42 kidneys (76%) (group A) and normal in 13 kidneys (24%) (group B). The mean age +/- standard deviation was significantly higher for patients in group B (60 +/- 12 years) than for those in group A (47 +/- 20 years) (p > 0.05). In group B, most of the stenotic lesions were atherosclerotic, and in all kidneys but 1, the lesions were located at the renal ostium or the proximal half of the artery. CONCLUSIONS: Isolated use of intrarenal Doppler sonographic criteria for RAS may lead to an unacceptably high incidence of false-negative results in the diagnosis of this condition, especially in elderly patients.