Looking beyond the gunsight: A potential bailout technique for arterial and venous recanalization

The “gunsight approach” was initially described as the use of overlapping snares and through- and-through puncture of the portal vein and inferior vena cava for the creation of a transcaval portosystemic shunt. This technique can be adapted for the creation of an extra-anatomic chan- nel between any 2 locations where snares can be deployed. We explain the technique, discuss finer technical points, and describe 2 cases where refractory vascular occlusions are crossed using this technique. The first case involves an extensively calcified femoral arterial chronic total occlusion where subintimal tracking past the occlusion is achieved, but luminal re-entry is ham- pered by dense calcific plaque refractory to multiple re-entry devices. The second case involves a chronic venous occlusion along the femoral vein with loss of in-line flow due to prior stenting. In both cases, the gunsight technique was successfully used as a bailout option after standard recanalization techniques were unsuccessful

Emergency Intravascular Aortic and Iliac Artery Lithotripsy to Facilitate Thoracic Endovascular Aortic Repair of a Ruptured Thoracic Aortic Aneurysm: A Case Report

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for ruptured thoracic aortic aneurysms. Poor access vessels are a relative contraindication to TEVAR. Intravascular lithotripsy (IVL) has recently been shown to be effective in treating calcified and stenotic vessels. Prior to the introduction of IVL, plaque modification techniques to increase vessel compliance and luminal diameter were limited to technically complex and risky surgical and interventional radiologic procedures. We present a case demonstrating the use of IVL in the emergency setting to treat severe atherosclerotic stenoses in the abdominal aorta and the iliac artery to facilitate TEVAR of a ruptured thoracic aortic aneurysm

Emergency Intravascular Aortic and Iliac Artery Lithotripsy to Facilitate Thoracic Endovascular Aortic Repair of a Ruptured Thoracic Aortic Aneurysm: A Case Report

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for ruptured thoracic aortic aneurysms. Poor access vessels are a relative contraindication to TEVAR. Intravascular lithotripsy (IVL) has recently been shown to be effective in treating calcified and stenotic vessels. Prior to the introduction of IVL, plaque modification techniques to increase vessel compliance and luminal diameter were limited to technically complex and risky surgical and interventional radiologic procedures. We present a case demonstrating the use of IVL in the emergency setting to treat severe atherosclerotic stenoses in the abdominal aorta and the iliac artery to facilitate TEVAR of a ruptured thoracic aortic aneurysm

AngioVac Aspiration Thrombectomy of Right Atrial Thrombus is Safe and Effective in Cancer Patients.

The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer.RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred.This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success.A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P = 0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P = 0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death.AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer

Concomitant AngioVac thrombectomy and patent foramen ovale closure in a patient with a large right atrial thrombus and recent paradoxical embolic stroke.

A 59-year-old male with a history of gallbladder adenocarcinoma receiving chemotherapy and on therapeutic anticoagulation for portal vein thrombosis presented to the emergency department via ambulance after being found unresponsive and in cardiac arrest. Initial workup upon return of spontaneous circulation revealed a large right atrial mass, patent foramen ovale (PFO), and bilateral acute cortical infarctions. This constellation of findings were concerning for PFO-related paradoxical embolic strokes. Given the risk of recurrent paradoxical embolic events and the absolute contraindication to thrombolysis due to recent cerebral infarction, the decision was made to proceed with percutaneous vacuum-assisted thrombectomy using the AngioVac device. To prevent intraoperative thrombus propagation, PFO-closure was performed immediately prior to thrombectomy. Aspiration thrombectomy and PFO-closure were successful with complete thrombus removal and no intraoperative thrombus propagation. This case presents a minimally invasive and rapid treatment for a complex problem. An efficient and effective interdisciplinary team-based approach allowed the patient to resume cancer treatment relatively unabated

Classification of Genicular Artery Anatomic Variants Using Intraoperative Cone-Beam Computed Tomography

PurposeGenicular artery embolization (GAE) is a new treatment option for symptomatic knee osteoarthritis. Genicular arterial anatomy is complex with limited published reports. This study describes the genicular artery anatomy utilizing intraprocedural cone-beam computed tomography (CBCT) during GAE.Materials and methodsThis retrospective single-center study was approved by the institutional review board. All patients who underwent GAE between May 2018 and April 2022 were reviewed. Patients with a technically adequate CBCT were included in the analysis. CBCTs were analyzed to determine the presence, course, and branching patterns of the genicular arteries.ResultsA total of 222 patients underwent GAE and 205 (92%) were included for analysis. The descending genicular artery was present in 197 (96%) CBCTs with two branches in 152 (77%). The superior medial genicular artery (SMGA) was present in 186 (91%), superior lateral genicular artery (SLGA) in 203 (99%), inferior medial genicular artery (IMGA) in 195 (95%), inferior lateral genicular artery (ILGA) in 196 (95%), and median genicular artery (MGA) in 200 (97%). Four unique branching patterns were identified: common origin of SLGA and MGA (115, 56%), unique origins (45, 22%), trifurcation of SLGA, SMGA, and MGA (32, 15.5%), and common origin of SMGA and MGA (12, 6%). The recurrent ascending tibial was identified in 156 (76%) CBCTs and superior patellar artery in 175 (85%) CBCTs.ConclusionGenicular artery anatomy is complex with numerous common variants. CBCT is a powerful adjunct in GAE to rapidly identify target vessels for embolization and potentially decrease the risk of nontarget embolization