Segmental Arterial Mediolysis

Teaching Point: Segmental arterial mediolysis is a rare cause of acute abdominal pain due to dissection and/or aneurysm formation in visceral arteries with subsequent stenosis, occlusion, or haemorrhage

Three-dimensional rotational angiography is preferable to conventional two-dimensional techniques for uterine artery embolization

PURPOSEWe aimed to investigate the potential benefits of three-dimensional rotational angiography (3DRA) compared to two-dimensional (2D) roadmapping to visualize the uterine artery (UA) origins during uterine artery embolization (UAE) procedures.MATERIALS AND METHODSSixty-three UAE cases performed under 3DRA guidance were reviewed retrospectively to determine if there was an optimal angiographic projection angle for identifying UA origin. Digital subtraction angiogram (DAS)-like images of the pelvic vessels were generated from the 3DRA scans at six different angles: left anterior oblique (LAO) 25°, 35°, 45°; and right anterior oblique (RAO) 25°, 35°, 45°. Two experienced interventional radiologists assessed if these angles could effectively serve as a roadmap to guide catheterization of the UA. Assessment was validated against original 3DRA scans to determine the percentage of true and false positives.RESULTSNo single projection angle was found that could consistently be utilized for UA catheterization. The projection angles used during 3D roadmapping for both the left and right UA showed two clusters with both a wide spread: RAO 20° to 50° and LAO 20° to 50°. More than 50% of the DSA-like images at RAO and LAO 45° appeared to be adequate for UA catheterization, but validation against the 3DRA revealed 28% of these images were suboptimal and deceptive, due to unappreciated overlapping vessels.CONCLUSIONNo standard projection angles can be recommended with 2D roadmapping to consistently visualize UA origin. The 3DRA can be as a useful tool for UAE to achieve reliable and consistent visibility of the UA origin

Embolization therapy for type 2 endoleaks after endovascular aortic aneurysm repair: imaging-based predictive factors and clinical outcomes on long-term follow-up

PURPOSETo evaluate the technical, radiological, and clinical outcomes after type 2 endoleak (T2EL) embolization in patients with a growing aneurysm sac after endovascular aortic aneurysm repair (EVAR). Additionally, to determine clinical and imaging-based factors for outcome prediction after embolization of a T2EL.METHODSA single-institution, retrospective analysis was performed of 60 patients who underwent a T2EL embolization procedure between September 2005 and August 2016 to treat a growing aneurysm sac diameter following EVAR. The patients’ electronic medical records and all available pre- and post-embolization imaging were reviewed. Statistical analysis methods included logistic regression models for binary outcomes, proportional odds models for ordinal outcomes, and linear regression models for continuous outcomes. The Kaplan–Meier method was used to estimate the overall survival probability.RESULTSTechnical, radiological, and clinical success rates after T2EL embolization were 95% (n = 57), 26.7% (n = 16), and 76.7% (n = 46), respectively. Persistent aneurysm sac expansion was found in 31 patients (51.7%). Unsharp or blurred T2EL delineation on pre-interventional computed tomography (CT) was a predictive factor for a post-embolization persistent visible endoleak and persistent growth of the aneurysm sac (P = 0.025). Median survival after T2EL embolization was 5.35 years, with no difference observed between patients with persistent sac expansion compared with patients with stable or decreased sac diameter.CONCLUSIONProgression of the aneurysm sac diameter was observed in half the study patients, despite technically successful T2EL embolization. Unsharp or blurred T2EL delineation on pre-interventional CT seemed to be an imaging-based predictor for a persistent T2EL and progressive aneurysm sac growth after embolization

Prospective, randomized, multicenter clinical study comparing a self-expanding covered stent to percutaneous transluminal angioplasty for treatment of upper extremity hemodialysis arteriovenous fistula stenosis

Use of a covered stent after percutaneous transluminal angioplasty (PTA) was compared to PTA alone for treatment of upper extremity hemodialysis patients with arteriovenous fistula (AVF) stenoses. Patients with AVF stenosis of 50% or more and evidence of AVF dysfunction underwent treatment with PTA followed by randomization of 142 patients to include a covered stent or 138 patients with PTA alone. Primary outcomes were 30-day safety, powered for noninferiority, and six-month target lesion primary patency (TLPP), powered to test whether TLPP after covered-stent placement was superior to PTA alone. Twelve-month TLPP and six-month access circuit primary patency (ACPP) were also hypothesis tested while additional clinical outcomes were observed through two years. Safety was significantly non-inferior while six- and 12-month TLPP were each superior for the covered stent group compared to PTA alone (six months: 78.7% versus 55.8%; 12 months: 47.9% versus 21.2%, respectively). ACPP was not statistically different between groups at six-months. Observed differences at 24 months favored the covered-stent group: 28.4% better TLPP, fewer target-lesion reinterventions (1.6 ± 1.6 versus 2.8 ± 2.0), and a longer mean time between target-lesion reinterventions (380.4 ± 249.5 versus 217.6 ± 158.4 days). Thus, our multicenter, prospective, randomized study of a covered stent used to treat AVF stenosis demonstrated noninferior safety with better TLPP and fewer target-lesion reinterventions than PTA alone through 24 months

Case report: Immediate revascularization for symptomatic hepatic artery pseudoaneurysm after orthotopic liver transplantation? A case series and literature review

IntroductionHepatic artery pseudoaneurysm (HAPA), a rare vascular complication that can develop after liver transplantation, is associated with a high mortality rate and graft loss. To salvage the liver graft, immediate revascularization, either through surgical or endovascular intervention, is required. However, currently there is no consensus on the optimal strategy. Here, we report three cases of liver transplant recipients diagnosed with HAPA and treated with immediate revascularization. In addition, we present an overview of HAPA cases described in the literature and make recommendations on how to treat this rare complication.MethodsAll adults transplanted in our center between 2005 and 2021 were retrospectively reviewed. Literature search was done in PubMed for original studies between 1980 and 2021 reporting early hepatic artery (pseudo) aneurysm after liver transplantation requiring either surgical or endovascular intervention.ResultsFrom a total of 1,172, 3 liver transplant patients were identified with a symptomatic HAPA and treated with immediate revascularization. HAPA occurred 73, 27, and 8 days after liver transplantation and was treated with immediate revascularization (two surgical and one endovascular intervention). Literature review identified 127 cases of HAPA. HAPA was managed with endovascular therapy in 20 cases and by surgical intervention in 89 cases. Overall reported mortality rate was 39.6%, whereas overall graft survival was 45.2%.ConclusionImmediate surgical or radiological interventional excision and prompt revascularization to salvage liver grafts is feasible but still associated with a high mortality

Portal hypertension after combined liver and intestinal transplantation, a diagnostic and therapeutic challenge?

A widely accepted technique to transplant the liver-bowel bloc is first to perform a piggyback anastomosis of the donor suprahepatic vena cava to the recipient vena cava; second to restore the arterial blood supply through an aortic interposition graft; and third to ensure venous drainage of the native foregut. The venous drainage of the native foregut can be restored through an end-to-end portocaval anastomosis between the donor infrahepatic vena cava and the recipient portal vein. Stenosis of this anastomosis can lead to portal hypertension presenting with upper GI congestion, bleeding, and hypersplenism. We report the successful treatment of this complication using an e-PTFE-covered stent inserted following balloon angioplasty