WITH INTERNATIONAL PARTICIPATION
sIRcro :: Section for Interventional Radiology of the Croatian Society of Radiology
Hrabak M, Štern Padovan R, Lušić M, Šunjara V
To present our first experience with cardiac MR imaging, including indications, advantages and pitfalls of the technique.
Cardiac MR imaging was performed in 50 patients on 3 Tesla scanner after detailed cardiological evaluation and echocardiography. Clinical indications for the exam were listed as Class I and Class II diseases in Consensus Panel report endorsed by The Society for Cardiovascular Magnetic Resonance and The Working Group on Cardiovascular Magnetic Resonance of the European Society of Cardiology in 2004. The scanning techniques that were used included cine TrueFISP imaging in at least three planes with right and left ventricle function calculation; T1- and T2-weighted sequences for morphological evaluation of myocardium, pericardium and tumor composition; flow measurement through cardiac valves using phase-contrast angiography; perfusion MR imaging to detect myocardial ischemia and tumor vascularization; as well as late-enhancement imaging to depict distribution and extension of the scar tissue within myocardium.
Cardiac MR enabled precise evaluation of myocardial disorders, including myocarditis, cardiomyopathies, myocardial viability after infarction, and fibrofatty infiltration of the right ventricle wall in arrhythmogenic right ventricular dysplasia. It helped in differentiation between constrictive pericarditis and restrictive myocardial changes, as well as in staging and pathohistological characterization of cardiac tumors. MR assessment of ventricular function and valvular disease was more reproducible than echocardiographic assessment.
The main advantage of cardiac MR is the use of nonionizing radiation; hence it is important tool in long-term follow-up of patients with congenital heart disease. Contraindications for cardiac MR examination are the same as for MR imaging of other body parts, including implanted cardiac pacemaker/defibrillator, and metallic implants anywhere in the body. Cardiac MR exam is longlasting procedure, where scanning techniques and planes should be chosen according to specific clinical question in order to obtain clinically relevant data.
Brkljačić B, Čikara I, Ivanac G, Huzjan-Korunić R
Objective of this invited lecture is to present technique, indications and results of image-guided breast biopsies
Fine-needle aspiration cytology, core-biopsy and percuateneous image-guieded vacuum-assisted breast biopsies will be compared and discussed. Advantages and disadvantages of each method will be emphasized.
The sequence of FNAC-CB-VABB in our departmnet will be presented with the choice of each technique and the role of MMG, US and MRI in guidance will be discusses.
Image guided biopsy of breast lesion is mandatory for preoperative dianosis of breast cancer and other lesions.
Brkljačić B, Čikara I, Ivanac G, Žic R, Ajduk M, Patrlj L, Brnić Z
To present results of application of bipolar radiofrequency ablation system in the treatment of liver tumors, breast cancer and varicose veins
During 6-years period we treated 26 patients with colorectal cancer, who had 42 liver metastases, one patient with gastric cancer with one liver metastasis, one pt with pancreatic cancer with two metastases, and two pts with cholangicancer with two and one metastases. 32/42 metastases were treated, 1.3-5.8 cm in diameter, with 1-3 applicators. All were treated in general anaesthesia. We also treated six women with small breast cancers, inoperable due to various reasons. Five had IDC and one mucinous BCA, age range was 63-82 years. We also treated 25 patients with GSV varicosities and saphenofemoral reflux.
For liver metastases the technical success of 26/32 treated metastases was achieved. Four major complications were observed. In the 2-51 months F-U with CE-CT and US 15 pts died, in 14 pts new metastases were detected, and reablation was performed in 7 patients.
For breast cancer patients five tumors were completelly ablated w/o recurrence visible on CE MRI and US in 2-42 months follow-up. One patient was operated after five months in remission of CLL, without viable cancer on HP specimen
For vein patients GSV was completely trombosed in 20/25 pts, in 3 pts thrombosis was incomplete, one RFA was unsuccessful because of too narow GSV and one complete failure was noted.
Bipolar RFA is a safe and relatively efficient technique for local control of growth of liver tumors <5 cm in diameter, as well as for the treatment of small inoperable breast cancers and the treatment of varicose GSV
Ultrasound studies are routinely performed in stroke centers. Their greatest advantage is real-time, bedside evaluation of morphology and hemodynamic of brain vessels. The major goal is to identify large obstructive lesions in the extracranial cerebral arteries by means of carotid and vertebral color Doppler sonography (CDS) and of intracranial basal arteries by means of Transcranial Doppler (TCD). Microembolic signals (MES) detection by means of TCD, as well as cerebral vasomotor reactivity (VMR) testing enables addition information of the impact of carotid stenosis and risk for stroke. Neurosonological studies also identify dissections and less frequent causes of stroke, and lesions amenable for interventional treatment.
On the basis of carotid CDS, plaque location and characterization on gray scale imaging, flow disturbance and areas of stenosis on color Doppler sonography, and flow velocities on spectral Doppler sonography are obtained. The degree of the diameter of the internal carotid artery (ICA) stenosis is the main parameter used for therapeutic approaches since one third of strokes attributes to carotid stenosis. Multiple randomized trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CE) in reducing the risk of stroke. Therefore, guidelines for noninvasive screening for asymptomatic carotid disease were recently being published. Carotid angioplasty and stenting (CAS) was also introduced for this purpose, but currently still reserved for a defined group of patients. The long-term patency of the carotid artery after CE or CAS is an important factor for successful operation.
Noninvasive carotid and vertebral artery testing in combination with TCD for evaluation of the intracranial hemodynamic are feasible and important methods in everyday evaluation of stroke patients as well as patients with stroke risk factors.
Cambj Sapunar L, Radonić V, Opačak R, Mašković J
Peripheral arterial disease of atherosclerotic origin is often a multilevel disease that sometimes doesn’t follow TASC classification. In selected cases both- open surgery and endovascular treatment is required. Increasing number of papers report excellent long term results of hybrid arterial reconstruction for these complex lesions. We report our experience with hybrid therapy in patients with complex peripheral vascular disease.
In 18 months period 5 combined surgical- endovascular procedures were performed in a single session in the angio room. Under regional anesthesia endarterectomy of the common femoral artery was performed followed by endovascular procedure.
The primary success rate was 100%. In all patients limb salvage was achieved. In one patient two months after the procedure restenosis of common femoral artery occurred and it was successfully retreated with endovascular techniques.
Combined endovascular and surgical therapy allows one- step treatment which permits complete revascularization in a shorter time, reducing hospital stay and costs. A multidisciplinary approach requires careful planning, preprocedural imaging and follow up.
Kovačić Dujmović S,Budiselić B,Knežević S,Miletić D
Mašković J, Cambj-Sapunar L, Kordić A
Endovascular aortic aneurysm repair (EVAR) is now an established technique for treating many patients with infrarenal abdominal aortic aneurysm. Today EVAR have an enormous impact on the treatment of this challenging disease. Familiarity with the complications associated with this technique and understanding treatment options are crucial for the lifelong performance of stent graft.
RFA (Radiofrequency Ablation) has already become a common treatment for the patients with unresectable primary and secondary liver malignancies. After RFA patients develop post-ablation syndrome with fever and flu-like symptoms as side effects of the procedure. Mortality rate is around 1% in most of series published in the literature. Major complications after RFA are associated with approximately 2-5% of the patients. Total complication rate (major+minor) is around 10%. Complications are classified in three groups: vascular (e.g. portal vein thrombosis, hepatic vein thrombosis, hepatic infarction and subcapsular hematoma), biliary eg. Bile duct stenosis, biloma, abscess and hemobilia), and extrahepatic (eg. Damage to GIS, injury to gallbladder, pnuomothorax, tumor seeding). Most complications may be treated by either medical, percutaneous or surgical approaches. Early diagnosis is a crucial point for the early management.
Contrast Induced Nephropathy is a common and potentially serious complication following the administration of iodine contrast media in patient at risk of acute renal injury and is responsible for more than 12% of all hospital acute renal failures. In this presentation the possible risk factors for CIN development, management of CIN in every day practice, stages of chronic renal disease and consensus statements about prevention of CIN, the facts that are important for radiologists will be presented and discussed.
Magnetic resonance cholangiograpy (MRC) imaging is based on the use of heavily T2 weighted sequences to highlight static or slow flowing fluid which provide high signal intensity whereas the background appears hypointense. It is a passive procedure that displays the ducts in the resting state and hence more accurately displays the native caliber of the duct than ERCP. Duct caliber, anomalies, strictures, dilatation, filling defects (calculi), and extraductal collections of fluid (cysts, diverticula, and fistulas) can all be directly visualized by MRC. MR cholangiography may be useful in establishing the resectability of a malignant neoplasm such as hilar cholangiocarcinoma by helping determine the proximal extent of disease. If the lesion is determined to be resectable, the patient may undergo surgery immediately and avoid unnecessary ERC and stent placement. In addition, MR cholangiography can help delineate the biliary tract in proximal obstructions in which endoscopic retrograde cholangiopancreatography (ERCP) may not be successful and in distal obstructions in which percutaneous transhepatic cholangiography may be of limited value.
MR cholangiography offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient’s risk of developing postprocedure bacterial cholangitis.
Cholangiocarcinoma at the hepatic bifurcation, also known as Klatskin tumor, can infiltrate the hepatic duct bifurcation on either the right or left side. Infiltration of both hepatic ducts (bismuth type II, type III, or type IV) frequently indicates unresectability. Stent placement can relieve jaundice and improve liver function and quality of life. Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. MRCP is a noninvasive means of visualizing Klatskin tumors. Moreover, it reveals both communicating as well as dissociated bile duct regions and thus identifies bile duct segments suitable for stent placement.
In recent years the interventional therapy of extracranial vertebral artery stenosis has become a new treatment option, but it is still associated with a high restenosis-rate of about 50% after implantation of bare-metal stents. The implantation of drug-eluting stents is reported by several authors in smaller series with promising results with a restenosis-rate as low as 0 %. A series of 28 consecutive patients with symptomatic vertebral artery stenosis was treated at our center between 2003 and 2007 with DES. All patients had a symptomatic > 60 % stenosis at the origin of the vertebral artery or in the V1 segment and failed maximal medical therapy. After stent-implantation, the mean stenosis was reduced from 68% to 9%. In no patients a periprocedural TIA occurred. There were no strokes or deaths in the follow-up period. Re-Stenosis over 60% was seen in 6 patients (21,5 %) after a mean of 16 months. In the follow-up angiogram none of the stents was fractured, but stent-compression was observed in 33% (2/6) of the patients with a restenosis > 50% and in 87,5 % (7/8) of the patients with a restenosis of 25 -49 %. No strokes or worsening of symptoms occurred within the time of follow up despite the restenosis-rate of 21,5 %. In 5 patients the symptoms persisted, all other patients were symptom-free.
Endovascular treatment of vertebral artery origin stenoses with DES seems to be safe and effective. The rate of restenosis seems to be lower than in patients treated with PTA alone or with bare metal stents. However stent-compression is a matter of concern using coronary bare-metal or drug-eluting stents. Larger and randomized trials are required to establish the best treatment-strategy for symptomatic vertebral artery stenose
Batinić T, Opačak R, Štula I.
A 74-year old woman presented with a painful, enlarging mass in the middle portion of her left thigh. Four years previously she had undergone successful left femoropopliteal bypass with greater reversed saphenous vein due to persistent, invalidating peripheral vascular disease.
The color-doppler ultrasound showed a pseudoaneurysm of the body of the femoropopliteal vein graft which was confirmed by angiography and successfully treated with stent graft placement.
Reversed autologous saphenous vein was introduced for routine use in femoropopliteal bypass approximately 50 years ago. Aneurysmal degeneration of autologous vein graft is rare and unusual complication. Nonanastomotic aneurysm formation in vein graft has been uniformly associated with advanced atherosclerotic change of the vein wall.
Atherosclerotic change in these conduits commonly takes the form of occlusion rather than aneurysm.
The currently recommended therapy is surgical exclusion.
Percutaneous placement of a stent graft seems to provide an alternative to surgery for pseudoaneurysm of femoropopliteal vein graft.
Cambj- Sapunar L, Mašković J, Batinić T
Isolated iliac artery aneurysms (IIAA) greater than 3 cm in diameter are a rare but potentially dangerous condition with a high risk of rupture. Therefore early treatment is recommended. Purpose of this presentation is to report our single center experience with different endovascular treatment options for IIAA.
In carefully selected cases of common iliac aneurysms without compressive symptoms stent graft placement is a good alternative to open surgery. A variety of minimally invasive treatment options are reported for management of internal iliac aneurysms. The most popular treatment options are transluminal small coil embolization of distal branches, packing of the aneurismal sac with coils of various sizes and the combination of distal branches embolization with stent graft placement to close the origin of IIA. Percutaneous CT guided embolization of IIA aneurismal sac can also be preformed.
Technical success and long term results will be presented. Importance of careful preprocedural imaging for prevention of potentially fatal complications will be discussed.
Endovascular treatments have yielded promising short term results but long term follow up of these techniques is required.
Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic pathologies. These include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, aneurysmal leak, and traumatic transection. AAS heralds imminent aortic rupture. Highlighting acute aortic pathology as an AAS is therefore important to encourage prompt recognition of this condition and avoid diagnostic delays. The management of AAS remains a therapeutic challenge. The traditional surgical approach to acute "type B" (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. Studies show endovascular repair to be technically feasible with fewer complications. This review discusses AAS pathology and in particular assesses the current role for endovascular aortic repair in its treatment.
Perkov D, Smiljanić R, Dobrota S, Sjekavica I, Radoš M.
We report our experience in treatment steno-occlusive atherosclerotic lesions of superficial femoral artery (SFA) by using primary stenting.
Between 2006 and 2009, 59 patients (62 legs) underwent attempted percutaneous revascularization for atherosclerotic SFA steno-occlusive lesions (TASC A to TASC C) utilizing self-expanding nitinol stent SMART (Cordis Corp, USA), Astron Pulsar (Biotronik, Switzerland) and Protégé GPS (ev3, USA). Ankle-brachial index (ABI) measurement were obtained pre- and post-procedure. Follow-up protocol included clinical examination, color Doppler ultrasound and DSA in case of pathological CDUS findings. The patients were followed after 1, 3, 6, and 12 months and yearly thereafter.
Successful revascularization was achieved in 89 % of the cases. Mean follow up was 13,9 months (range 1-35 months). The mean lesion length was 6,3 cm; the mean stented segment length was 11,2 cm (range 4 – 28 cm). The mean pre- and post-intervention ABI were 0.64 +/- 0.16, and 0.92 +/- 0.16 respectively.
Primary implantation of a self-expanding nitinol stent in treatment of aterosclerotic SFA lesions is technically successful and safe to perform. This techinque provides good mid-term primary patency, improvement in ABI and pain-free walking distance.
Ključevšek T, Štalc M, Stankovič M
The purpose of our presentation is the evaluation of early results and complications of endovascular treatment of infrarenal abdominal aortic aneurysm (AAA) treated in Interventional Department on Clinical Institute of Radiology in Ljubljana. The aim of endovascular placement of stent-grafts is complete exclusion of aneurysms from circulation.
From January 2006 to January 2009 endovascular treatment of infrarenal aneurysms was performed in 123 patients, 109 male and 14 female, mean age 72.3 years. 68% of the treated patients were classified in ASA 3 or 4, others were in ASA 2. The indication for stent-graft placement was postulated on the basis of computer tomography angiography (CTA), co-morbidities, the age and also the wishes of the patients. All the patients had femoral approach. Average diameter of aneurysms before the treatment was 59 mm. Aneurysms of iliac arteries were associated in 13% of cases. We inserted just one unilateral endoprosthesis, in all other cases bifurcated endoprostheses were inserted. Immediately after the procedure control arteriography was done to evaluate the technical success of procedure. For later evaluation of aortic stent-graft placement CTA was done, exceptionally ultrasound.
Primary technical success was 99.2%. In one patient the insertion of aortic stent-graft failed because of difficulties with approach, but was successful at second attempt.
The early mortality (30 days after procedure) was 2.4 %. The rate of major complications was 9.8% (12 patients) and moderate 14.6%. Control CTA was done in 66 patients (53.7%). Control CTA was normal in 51 patients, endoleak II was found in 9 patients and endoleak I in 5 patients. One patient had thrombus in stent-graft. The most of patients with the procedure complications and abnormalities found on control CTA were successfully treated. In six patients ultrasound was done instead of CTA and was normal. Four patients died before control CTA. We don’t have data about control CTA (or US) for 47 patients (38.2%) yet.
The endovascular treatment of AAA in University Clinical Centre in Ljubljana is safe and efficient. The results are comparable with those in others published studies. It’s important and encouraging that the results are good also in the patients with co-morbidities, who are not appropriate for surgical treatment.
Raupach J., Lojik M., Krajina A., Chovanec V., Tuna M., Vojacek J., Harrer J
To evaluate mid-term results of endovascular treatment of complicated type B aortic dissection. This technique is alternative treatment to open surgery.
Between 01-05-2001 and 28-11-2008, 14 patients (2 female, 12 men) with complicated type B aortic dissection that required endovascular therapy were enrolled. In 13 patients, we covered primary entry with stentgrafts, including Medtronic Valiant (n=10) and Endomed Endofit (n=9). Indications for stentgrafting were rapid dilatation of aorta (n=4), renal and mesenteric ischemia (n=4), back pain and hypertension (n=3), contained rupture (n=2). In 1 patient the bare stents were used to treat a limb ischemia, 2 iliac stents were implanted.
Endovascular therapy was technically successful in all 14 (100%) patients. Mean time between onset of symptoms and treatment was 22 days (1-65). One patient died after stentgrafting 3 months later due to aortic rupture. Stroke with permanent deficit developed in one patient 3 days after therapy, one patient was suffered from retrograde dissection of the ascending aorta. Mean time follow-up time was 24 months (5-72). During follow-up no proximal endoleak was detected, thrombosis of false lumen in stentgrafting group was complete in 10 (83%) patients. Overall mortality during follow-up period is 2 (14,3 %) patients.
Mid-term results of endovascular therapy of complicated type B aortic dissection are promising. We use this approach as a first line therapy in our centre.
Novacic K, Vidjak V, Hebrang A, Popic J
Endovascular options for treatment of complex aortoiliac lesions are constatly evolving.
Technological advances in last decade, along with patients preference have shifted revascularization strategies from traditional open surgical repair toward endovascular treatments with balloon angioplasty and stent placement.
Surgical options for treatment of iliac occlusive dissease include autogenous or synthetic bypass, endarterectomy, extra anatomic bypass and intraoperative hybrid procedures.
Surgical procedures such as aortoiliac and aortofemoral bypass are associated with 74-95% primary patency rates, which are comparable and not superior to endovascular treatments.
The risks of surgery are significantly greater then the risks of an endovascular procedures not not only in terms of higher mortality and morbidity but also delay in patients return to normal activities.
Technical advances in stent technology has significantly increased the number of iliac lesions that can be treated endovasculary. Benefits of stent implantation are larger acute gain in vessel luminal diameter, scaffolding the lumen and enhancing primary long-term patency compared with balloon angioplasty alone. The TransAtlantic Inter-Society Consensus (TASC) document describes characteristic lesion morphology for ideal (type A) and unfavorable (type D) iliac lesion for endovascular therapy. In 2007. new TASC II document has been published due to inevitable techical advances and published studies which compared results of surgery and endovascular procedures in treatment of type B and type C lessions. On the basis of these data current TASC II reccomendations favor endovascular procedurs for type A, B and selected C lesions. Patients with type D lesions are generaly considered for surgical repair, but with new technology (re entry devices, stent grafts) more and more patients with those lesion are being treated endovasculary (on a case by case basis).
Occlusions of the iliac arteries may be approached with a success rate of 90%, serious complications rate of 1,4% and 3 year primary patency rate of 80%, and secondary patency rate of 86%. 30 day mortality risk is 0,5% which is much lower than the 4% weighted mortality risk for aortofemoral bypass.
In summary we can say that most iliac lesions can be treated endovasculary regardless of TASC classification. With new technologies ranging from local drug delivery, dedicated atherectomy devices and bioabsorbable stents it is expected that long term results will be improved.
To report results of endoluminal repair of mycotic aneurysms of the thoracic and abdominal aorta.
Between 10/1999 to 1/2008 five patients (1 woman, 4 men), age (20-69 years) were stentgrafting due to mycotic aortic aneurysms. A total of three thoracic and two abdominal aortic aneurysms were treated and followed up for a median of 9 months. Active infection was present in three of them and blood culture positive in two of them in time of therapy. These patients were treated due to imminent rupture of the aorta.
Two of the aneurysms have totally resolved and two were thrombosed without endoleak during follow-up. One patient died four months after the treatment due to persistent inflammation although long term antibiotics. One patient was 3 months later operated due to covered rupture of the oesophagus.
Endovascular treatment of mycotic aortic aneurysms is technically feasible and offers at least temporary protection against imminent rupture. However despite long-term antibiotics the progression of inflammation can occurs with fatal consequence.
Besim A, Cekirge S, Cil B
To show the effectiviness of endovascular treatment of PH secondary to A-P fistulas as an alternative to surgery
Fifteen cases who was diagnosed as having PH secondary to A-P fistulas had been treated endovascularly using various embolizing agents.
All of them succesfully treated endovascularly without the need of surgery.
A-P fistula is a rare disorder in which there is direct pumping of high pressure arterial blood into the low pressure portal sysetm via fistula between arterial and portal system hence PH develop.
Although surgery has traditionally been the method of choice for treating A-P fistulas, endovascular treatment techniques have been so rapidly increased that surgical treatment has almost fade out. With the advent of flow dependant microcatheters, various nonliquid or liquid embolizing agents, such as microcoils in different diameters, microspheres, detachable baloons, glue, onyx and etc…make the endovascular treatment more efficient, rapid and easy. Today endovascular treatment is the first choice of treatment modalitiy in many A-P fistula cases.Usually approach is from arterial side. If the size of the fistulous window permits it can be treated by selective embolization of the target artery by deploying various embolizing agents. It is very important to be sure that at the end of the procedure that the fistulous tract or at least the most distal portion of the feeding artery is exactly occluded. Otherwise recurrence is unavoidable. In some cases transarterial approach may not be adequate for example because of multiple tiny fistulous connections. In such cases approach from the venous side for impacting the fistulous tracts might be more appropriate.
Recurrence of A-P fistulas after surgical or endovascular treatment is not rear. Therefor these cases should be under close control for a resonable time after treatment.
Perkov D, Smiljanić R, Dobrota S, Radoš M, Štern Padovan R.
To present our results of percutaneous transluminal renal angioplasty (PTRA) and stent implantation in treatment of eight children with renal artery stenosis (RAS) and consequential development of malignant renovascular hypertension (RVH), regardless of administration of antihypertensive drugs.
In period between January 2000 and November 2007 endovascular interventional procedures on renal arteries were performed in 8 children (six boys and two girls), for treatment of malignant RVH caused by RAS. The mean patient age ± standard deviation was 10.8 years ± 3.7 yr (median age 9 years; range 8–17 years). Our indications for the PTRA procedure were severe RVH with arterial blood pressure (BP) values above 99th percentile, which did not respond to the application of the antihypertensive drugs. Renal artery stenting was performed due to restenosis after PTRA.
We performed 11 endovascular interventions on 9 main renal arteries in 8 children (10 PTRA and one stent placement). In 7 of 8 children the complete correction of RAS was achieved. Follow-up assessment in mean period of 39 months (range 6-84 months) showed normotension with no antihypertensive treatment in 6 children. One child had technically successful PTRA and improved BP with reduced antihypertensive treatment. Technical failure of endovascular intervention occurred in a boy with severe FMD, who underwent successful surgical autotransplantation of the kidney.
Endovascular therapy of RAS in children with consequential development of malignant RVH regardless of antihypertensive drugs represents the treatment of choice. PTRA and/or stent implantation are technically and clinically successful and safe to perform in this group of children. Optimal treatment results in children can be expected in clinical environment where successful interdisciplinary cooperation between pediatrician, interventional radiologist and pediatric surgeon may be achieved.
Besim A, Cil B, Peynircioglu B
To show the effectiviness of endovascular treatment of renal vascular injuries secondary to either ordinary trauma or iatrogenic trauma.
The frequency of blunt type renal trauma is 80%-90% with multiorgan involvement 80% and penetrating type is 10%-20% with multiorgan involvement around 75%.
Iatrogenic renal trauma in which usually renal vessels are injured could be secondary to renal biopsies, percutan litotripsies, endourulogic procedures, ESWL or intraoperative manuplations. High number punctures during biopsies or incorrect choice of puncture site such as too medial access are increasing factors of renal vascular injuries.
Renal vascular injuries usually follows by renal bleeding which it could be venous or arterial.
In severe acute bleedings usually anterior and/or posterior segmental arteries are injuried. In delayed bleedings however interlobar/lover pole arteries are injuried hence A-V fistulas, pseduoaneurysms occured. Predisposing factors are atherosclerosis, aging, hypertension, diabetes, systemic vasculitis, and blood dysgrasias.
The goals of treatment in renal vascular injuries is to control the hemorrage and to preserve the renal tissue as much as possible. Various embolising agents such as glue, coils etc... has been used for that purpose.
With the beginning of the new century, new techniques, which rapidly changed and revolutionized the treatment of varicose veins, have emerged. Basically, these techniques have made varicose veins treatment much less invasive in comparison to classic surgical approach, such as crossectomy and stripping. My intention is to present my professional and personal experiences with new techniques for varicose veins treatment - endovenous radiofrequency ablation, endovenous laser treatment, ultrasound guided foam sclerotherapy, and mini-phlebectomy.
Since 2006, when I was first informed about endovenous radiofrequency and laser treatment of varicose veins at the RSNA annual meeting in Chicago, my constant interest in this techniques brought up to numerous radiofrequency ablations of insufficient main stem veins, using Radiofrequency Induced Thermotherapy (RFITT), VNUS Closure, and VNUS FastClosure systems, as well as foam sclerotherapies of insufficient main stem veins and other varicose veins using Polidocanol in various concentrations. I also assisted in several endovenous laser treatments, using Biolitec and Fotona lasers, as well as mini-phlebectomies using Mueller phlebectomy hooks.
Up to my experiences, each system proved out to have its advantages and disadvantages - RFITT system proved out to be very well tolerated by patients, but relatively hard to use in an appropriate manner. VNUS Closure techniques proved out to be reliable, but more invasive and worse tolerated by patients. Foam sclerotherapy proved out to be cheap and well tolerated by patients, but not always entirely effective; it also showed some negative cosmetic side effects. Laser ablation and mini-phlebectomy proved out to be effective, but also potentially poorer tolerated by patients.
Newly developed minimally invasive techniques for treatment of incompetent veins provide patients with safe and rather effective options for managing of superficial venous disease. These advances give a great opportunity to radiologists not only to diagnose but also to treat varicose veins.
Poljakovic Z, Radoš M, Malojčić B, Šupe S, Matijević V, Unušić L, Alvir D
Endovascular treatment of intracranial aneurysms becomes more and more respectable method and recent suggestions consider it even as a first choice treatment, which should be offered whenever possible, while neurosurgical treatment should be preferred only if endovascular can not be used!
However, this method still has a complications rate of 6 – 23%
although several recently published studies showed a decline in complications rate with an overall trend of complications rates fall with a growing experience. Recent studies showed complication rates about 6-10% (~ 7%). In our work we will focuse on neurological complications in our own patient group, trying to identify the causes of those complications, and discussing our methods of preventing them and, if they still occured, treating them.
We analysed 95 patients who were endovasculary treated (coiled) for their aneurysms (101 aneurysms) during 2007 and 2008. Among those 95 patients 67 were symptomatic (ruptured aneurysms) and 28 asymptomatic. Two main groups of patients were then analysed considering their age, clinical state (HH 0-V), localisation of aneurysm, size of aneurysm, lenght of procedure, comorbidity, comedication and short-term outcome (periprocedural and immediate postprocedural complications).
In our group we had an overall complication rate of 7,2% which was three times higher in symptomatic (ruptured) group than in asymptomatic group (which is in accordance with results in literature). Most often (in 73%) we noticed thromboembolic incidents, which led to a permanent neurological deficit in 42% of affected patients, mostly symptomatic patients with no premedication. Other factors contributing to the complication rate were patients age, size (and morphologic characteristics) of aneurysm, comorbidity and length of the procedure.
According to our results, our endovascular centre can be considered as experienced, with complications rate as reported in recent literature. Most of our results are in complete agreement with already published, except of comorbity analysis. This parametre was not analysed in details before, but, to our opinion, is important while discussing indication and premedication for the endovascular procedure.
Krajina A, Lojik M, Raupach M, Chovanec V
Mechanical disruption of tissue integrity during surgical, endoscopic or percutaneous procedures can complicate treatment in wide range. Iatrogenic trauma was main reason for development of minimally invasive methods of treatment including interventional radiology. Among general causes of iatrogenic trauma belong inadequate skills, training, knowledge of anatomy, inappropriate psychological setting and experimental approach of the physician. The other causes can be preexisting, unrecognized anatomical anomalies or diseases of the patient.
Late diagnosis of iatrogenic trauma can result in hemorrhagic shock, permanent neurological deficit and infectious complication. Ultrasonographic examination is usually used as the first imaging modality and is followed by CT. There is relative advantage of imaging guided techniques for immediate visualization of extravasation and so called damage control. Possibility of axial tomography in conjuction with flat panel technology is extremely helpful in early diagnosis of intracranial bleeding during endovascular procedures. Arterial bleeding is the most effectively treated by transcatheter embolization of “non vital” artery. Deconstruction is usually simple, short procedure. Reconstruction of the artery is done by stent or stentgraft implantation. Temporary occlusion of bleeding artery with a balloon catheter with or without surgery can be also effectively used. Non bleeding complications are treated by percutaneous drainage. Iatrogenic trauma comprises wide range of injuries with various prognosis. Results of catheter therapy depend on patient´s primary disease and on his or her age. In conclusion we should analyze how iatrogenic trauma happens what can be learned from it and how it can be avoided and overcome in the future.
Grga A, Suknaic S, Hlevnjak D, Erdelez L, Škopljanac A, Cvjetko I
Single or multiple arterial stenoses produce impaired hemodynamics at the tissue level in patients with peripheral arterial occlusive disease (PAOD). Arterial stenoses lead to alterations in the distal pressures available to affected muscle groups and to blood flow. Chronic infrainguinal atherosclerotic arterial occlusive disease is caused by atherosclerosis involving the femoral, popliteal, and/or infrapopliteal arteries. Most people with atherosclerotic disease of the lower extremities are asymptomatic. Symptomatic patients may present with intermittent claudication, ischemic pain at rest, nonhealing ulceration or frank ischemia of the foot. Treatment depends upon clinical manifestations and includes risk management, medical therapy, supervised exercise and surgical or endovascular revascularization. We will show 5- year results of surgical revascularization procedures in Univesity Hospital Merkur, Zagreb.
Dragičević D, Cambj-Sapunar L, Mašković J, Batinić T
Limb salvage is a procedure for treatment of the causes of ischemia in the peripheral arteries of the lower limbs. This procedure consists of percutaneous transluminal angioplasty (PTA) of arteries of the infrapopliteal segment in the lower limbs, endovascular stents implantation and selective intraarterial thrombolityc therapy. The aim of this short review was to show our recent experiences of applying theese procedures in patologically corrupted arteries of the infrapopliteal segment.
Last 14 months 8 patients with critical limb ischemia (CLI)underwent infrapopliteal endovascular recanalizations in our angiography suite. Infrapopliteal PTA was chosen as first-line therapy. Implantation of the stent was performed in case of a suboptimal angioplasty result (eg, elastic recoil, significant residual stenosis, or flow-limiting dissection).
Technical success rate was 100%. Patients were followed up with regular clinical evaluation and DUS. Restenosis appeared only in one patient, by now.
On the basis of the obtained results it can be concluded that the limb salvage method in case of occluded arteries of infrapopliteal segment is fully justified. With modern endovascular techniques, both infrapopliteal PTA and implantation of the stents are safe, worthwhile and durable procedures.
The major criteria for assessing the indication of the treatment of the hydatid disease of the liver are primarily based on the imaging findings. Sonography is the major classification tool of the liver hydatidosis.
Percutaneous treatment should be based on “stage-specific approach”. The major indications (According to WHO classification) for percutaneous treatment of liver hydatid cysts include CE 1 (PAIR or Catheterization techniques), CE 2 (Catheterization or Modified Catheterization Techniques),CE 3 A (PAIR or Catheterization techniques) and CE 3 B (Modified Catheterization Techniques).
The patients with CE 4 and CE 5 should be regularly followed-up (Watch and Wait) since no treatment is indicated in these patients. The hydatid cysts which are perforated into biliary system, peritoneum and pleura are indicated for surgical treatment as a first option.
The long-term follow up of the lesions treated with percutaneous approach are highly successful and is reported to be over 98%. PT is associated with lower complication and recurrence rates and shorter hospital stay in comparision with the results of surgery.
Percutaneous approach is also a treatment alternative to surgery for HC located in the other organs such as spleen, kidney, peritoneum, lungs, soft tissue, orbita and parotid gland.
Take Home Points
1. CE and CE IIIA liver hydatid cysts are best suited for percutaneous treatment.
2. Percutaneous treatment should be based on “stage-specific approach”. HC in every stage is best treated by different percutaneous technique.
3. PT is associated with lower complication and recurrence rates and shorter hospital stay in comparision with the results of surgery.
4. PT is considered as a first treatment option
5. Percutaneous approach is also a treatment alternative to surgery for HC located in the other organs such as spleen, kidney, peritoneum, lungs, soft tissue, orbita and parotid gland.
Vidjak V, Novačić K, Hebrang A, Blašković D
To establish technical and long-term results of CAS in diffuse stenotic and non-occlusive changes in the ACC and ACI.
Carotid artery stenting (CAS) was used to treat 69 patients at Clinical Hospital Merkur over a period of 36 months. 16 of these patients were treated for diffusely stenotic or non-occlusive changes in the CCA and ICA which includes stenoses of a longer segment, dissection of the arterial wall, aneurysms, pseudoaneurysms and atherosclerotic ulcers . Cerebral protection was used in 13/16 (81.3%) of patients (distal filters, proximal occlusion). The procedure was carried out in 15/16 (93.8 %) symptomatic patients as well as 10/16 (62.5%) patients with secondary changes in the CCA and ICA. Balloon stent-graft (Jostent graft), closed-cell stent (Wallstent, Xact stent) and hybrid stent (Cristalo Ideale) were used. Regular follow-ups - 1, 3, 6 and 12 months after the procedure implied clinical (neurological) examination and imaging method – primarily CD (CTA, MR, DSA).
Technical success CAS was achieved in all (100%) patients, without local or general complications. In the period ≤ 30 days after the procedure, 1 patient (6.3%) had TIA (diffuse changes in the ACC) , without in-stent restenosis and without permanent neurological deficit. During the follow-up there were no findings of significant permanent neurological deficits nor mortality. The follow-up (neurological status, imaging method) after 6 months showed thrombosis of 1 stent (Jostent graft – used in the treatment of a significant ulcer in the ACI), however without significant clinical aggravation. After 12 months the results showed no significant additional stent restenoses/occlusions or a significant neurological deficit. Overall stent patency results 12 months after CAS show good results (patent stent without significant restenosis, normal clinical findings) in 15/16 (93.8%) patients.
CAS is a procedure in the treatment of CCA /ICA, followed by technically satisfactory, long-term success in the treatment of diffuse stenotic and non-occlusive changes.
Rubin O, Barišić D, Rubin M, Duić Ž
Christoph L. Zollikofer
To give an overview on the indications and results with the Rotarex® and Aspirex® rotational thrombectomy catheters
The head of the Rotarex® catheter consists of two superimposed cylinders with side slits. The inner cylinder is fixed to the catheter shaft, the outer cylinder to a rotating coated stainless steel spiral running through the catheter and driven by a reusable electric motor at 40’000-60’000 rpm (8F/6F). The rotating spiral creates a vacuum at the catheter tip and the abraded fresh or organised occlusion material is sucked through the cutting slitts, fragmented and transported by the rotating spiral through the cathteter into a collecting bag.
The Aspirex® catheter in contrast has a wedge shaped rounded head to form a blunt end and is fixed to the cathetershaft. It has a L-shaped window through which the fresh clot is sucked in by the same rotating spiral.
Both the Rotarex® and Apirex® catheters are “over the wire” systems requiring passage of the occlusion with a guide wire first (0.018”).
The Rotarex® catheter (6,8F) has been successfully used in peripheral arteries with acute (<14 d), subacute (<90d) and even chronic occlusion (>90d). With its specially designed head it is capable of abrading and framenting organised material. It therefore has been recommmendet for treating instent stenosis for debulking intimal hyperplasia prior to balloon angioplasty. Detailed indications and newer applications will be discussed.
The Aspirex® catheter (6,8,10F) was specially designed to remove fresh clot and to treat fresh occlusions of arteries, large veins including hemodialysis grafts. Recently an 11 F catheter has been developed for treating massive pulmonary embolism. Indications and results will be discussed.
Mechanical Thrombectomy with the Rotarex® catheter in peripheral arteries is an efficient and safe alternative to catheter lysis or surgical thrombectomy. The Aspirex® catheter has been successfully used in acute arterial and graft occlusions as well as in large veins and the pulmonary arteries
Mediane arcuate ligament syndrome ( MALS) is a rare entity and was first time described in the 1960s by Dunbar and colleauges. The mediane arcuate ligament is a fibrous arch that unites diaphragmatic crura on either side of the aortic hiatus. Usually it passes superior to the origin of the celiac artery. But in 10%-24% of people, the ligament can be inserted lower in position and therefore cross over the proximal portion of the celiac axis causing a characteristic indetation and symptoms (epigastric pain, postprandial pain and abdominal bruit).
This is a rewiev of a single case in a 55-year old tin woman presented with an epigastric pain, postprandial pain, weight loss and status post pulmonary embolism. Ultrasound presented oedema of gall bladder and oedema of pancreas. The focal narrowing in the proximal celiac axis was detected on contrast computed tomography (CTA) scan. Patient was sent to the Interventionaly Radiology Department to be treated with percutaneous angioplasty (PTA) and insertion of stent.
Rewiev by operator of CTA and 3D images suggested the diagnosis of MALS. Diagnosis raised on characteristic signs in CTA : hooked appearance of the focal narrowing in the proximal celiac axis, poststenotic dilatation and no atherosclerosis seen in the place of the narrowing. Angiography of celiac axis in lateral view was done in both expiration and inspiration phase. During expiration compression of the celiac axis typically increased which confirmed diagnosis. Patient was sent back to the surgeon for surgery treatment if necessary.
In symptomatic patient dividing the surrounding ligament with surgery is usually primary option. Placing nitinol stent and PTA are secondary option in residual stenosis after surgical procedure. Extrinsic pressure exertes on the celiac artery can likely result in slippage of the stent and/or failure of the material.
Smiljanić R, Radoš M, Perkov D, Šunjara M, Kaštelan Ž, Štern Padovan R
To show our first experience of N-butyl-2-cyanoacrylate embolization of interlobar arteries of right kidney in a patient with persistent macrohematuria, thus avoiding surgery.
Fifty-two year old woman was admitted to Urology clinic, with symptoms presenting as persistent, painless macrohematuria, followed by anemia. Hematuria occured previously in several occasions, due to nephrolithiasis and pyelonephritis. The patient underwent partial nephrectomy of upper pole of right kidney in 2004, and left kidney in 2007, due to arteriovenous fistulas.
During this hospital admittance there was no evidence of nephrolithiasis, and a flexible ureterorenoscopy was performed, precisely defining the bleeding site. Comparing the pyeloscopic and angiographic images, the bleeding teleangiectatic arteries were identified. By coaxial microcatheter technique, superselective embolization was performed with N-butyl-2-cyanoacrylate.
After the embolization, hematuria decreased within a day, to final termination in 3 days. The patient was discharged without an operative treatment with hemoglobin level within referent values.
Transcatheter embolization using N-butyl-2-cyanoacrylate offers an alternative to surgery in selected patients, as cheaper and faster option, accompanied by lower morbidity and shorter hospitalization period.
Neuroprotection during carotid artery stenting (CAS) is considered mandatory by the majority of interventionalists. The most common neuroprotection systems include distal filter devices or a distal balloon protection system. However these devices might have some disadvantages depending on the morphology of the lesion and in general, because neuroprotection is established only after passing the lesion with the device. In contrast to these, proximal endovascular clamping devices such as the MO.MA system (Invatec s.r.l., Roncadelle, Italy) or the NPS (WLGore) establish cerebral protection before first passage of the lesion and additionally can be used in lesions, where filter-devices are difficult or impossible to apply. The MO.MA-device is an 8-9 French single-catheter system that integrates the functional aspects of a cerebral protection-device and a shuttle sheath with a 5 or 6-F working. The system permits endovascular clamping of both, the common carotid artery (CCA) and the external carotid artery (ECA) via two independently inflatable low-pressure compliant balloons. Blood flow of the internal carotid artery is blocked during the procedure before a guidewire or other devices are advanced across the lesion. Dislodged material can be removed intermittently between the single steps of the procedure or at the end of the intervention by aspiration of blood through the working channel. The NPS-system consists of a 9F guiding-catheter with a balloon attached at the distal end for clamping the common carotid artery and a clamping-balloon for occlusion of the external carotid artery, which is introduced separately. Different to the MO.MA-system a connection of the guiding-catheter to the femoral vein can be established to create a steady retrograde flow through the internal carotid artery via the device into the venous system during the intervention to increase the “wash-out” of potential plaque-debris which could embolize to the intracerebral circulation. The MO.MA-system and the NPS are currently investigated in two multicenter registries, however available data already proof a high success-rate and safety of this concept for cerebral protection. Technical differences, case-examples and available data will be presented.
Acute gastrointestinal (GI) bleeding encompasses a wide spectrum of symptoms ranging from scant hematochezia, which can safely be evaluated in the outpatient setting, to massive hemorrhage resulting in shock. There are three possible categories of patients who can be referred for visceral angiography, when patients with minor bleeding are excluded.
The first category is comprised of patients with chronic intermittent bleeding resulting in sideropenic anemia. Angiography is indicated here to reveal vascular pathology, but never contrast extravasation. These patients have the greatest benefit from endoscopy alone.
The second category includes patients with severe life threatening bleeding that suddenly stops and the patient becomes hemodynamically stable with another episode of hemorrhage to occur. The intensity of bleeding can vary even from minute to minute. Angiography in these patients should be targeted by positive nuclear medicine scanning or by repeating identical angiograms within a few minutes. In extreme cases, provocative bleeding studies with intraarterial infusion of vasodilators, heparin or thrombolytics can be useful to identify the site of bleeding and decrease the number of negative angiograms.
The third category comprises patients with continued active bleeding. These patients progress rapidly into shock, and are best managed by urgent angiography with transcatheter bleeding control.
A clinical distinction must be made between upper GI and lower GI bleeding. Up to 90 % of all severe GI bleedings are from a lesion proximal to the ligament of Treitz which is borderline between upper and lower GI bleeding. Endoscopy is crucial both for excluding bleeding from gastroesophageal varices and for diagnosis of transpapillary bleeding (hemobilia and hemosuccus pancreaticus).
The causes of bleeding from the upper GI tract referred for endovascular treatment included duodenal ulcer (51 %), gastric ulcer (12 %), postsurgical bleeding (11 %), tumor (11 %), inflammatory condition (8 %), gastritis (3 %), postendoscopic sphincterotomy (3 %), and trauma (3 %). This group of patients despite adequate treatment had mortality rates as high as 25 to 30 %. Reports of angiographic accuracy have ranged from 60 % to 86 %.
Patients with lower GI bleeding tend to be more elderly than those with gastric and duodenal lesions. Angiographic accuracy is only 40-48 %. Localization of a bleeding site is of paramount importance, because limiting the extent of emergency bowel resection can drop operative mortality in cases when bleeding control cannot be performed by embolization. Diverticular disease is found in 2/3 of patients older than 80 years. Diverticula are formed at the site where vasa recta penetrates the muscular wall of the colon. Bleeding occurs from ruptured vasa recta at the lesion neck or when fecalith erodes a vessel over the apex of diverticulum. While diverticula are found in the left colon more frequently, right-sided diverticula appear to have a higher incidence of bleeding.
So called angiodysplasia is characterized by multiple arteriovenous shunts and predominates in the right colon and cecum and has a high tendency for recurrent hemorrhage. Both benign adenomatous polyps and adenocarcinoma may cause life-threatening bleeding. The colonoscopy is highly recommended even after successful transcatheter treatment. Iatrogenic bleeding after colonoscopic polypectomy may also occur and present even in up to 14 days after the intervention.
Erceg Gorislav, Ćurić Josip, Vavro Hrvoje, Borković Zdravko, Brkljačić Boris
Aortoilliac occlusive and stenotic disease is comonly treated by surgical or by endovascular means. However, in some specific cases, there is tendency to combine these techniques what is usually called hybrid approach.. The hybrid procedure combines the best of both worlds – minimal invasive surgery and stenting. It offers several advantages, shorter hospital stay, lower morbidity and mortality, and reduced cost and fewer embolic complications.
The hybrid procedures are performed within the last year in the operating room and cardiac surgery theater, with 25 iliac and 5 aortic stenoses treated until now.
A combined surgical and endovascular approach should be considered a viable alternative in selected patients with aortoiliac occlusive disease.
Knezević S, Budiselić B, Kovačić Dujmović S, Mieltić D.
Katicic M, Brajsa M, Skurla B, Prskalo M.
Endoscopic retrograde cholangiopancreatography (ERCP), specialized endoscopic technique in which a side-viewing endoscope is guided into the duodenum to Papilla Vateri, and through cannula injection of a contrast medium opacified the bile or pancreatic ducts. A variety of therapeutic interventions is possible after their diagnostic visualization.
ERCP procedures have been carried out in University Hospital Merkur for more than 20 years (since 1986 yrs.). Acquiring experience, indications and contraindications for ERCP have been changed dramatically during this time; from exclusively diagnostic, to almost completely therapeutic nowadays.
The aim of this presentation is to overview our ERCP data during this period, with special intention to present increased number of various therapeutic procedures.
We compared the indications for diagnostic and therapeutic ERCP, kannulation success, and number of complications twenty years ago and nowadays.
A number of classic surgical procedures have been successfully replaced by endoscopic therapeutic procedures during last few decades.
It is well known that patients are exposed to significant amount od radiation during fluoroscopy-guided interventional procedures. This can results in high whole-body effective doses which carries the risk of stochastic effects, but also in considerable local skin doses and the risk of deterministic injuries. Hence, the doses in interventional radiology should be monitored and evaluated. Total patient dose is best measured with dose-area product (DAP)-meters, but as the DAP is not good predictor of skin doses in every case, skin doses also should be measured by ortochromic films. Apart from DAP and skin doses, fluoroscopy time and number of frames can approximately represent the radiation risk. Diagnostic reference levels are proposed for the most common interventional procedures, but DRLs should have only consultative but not restrictive role. High doses measured in a workplace alerts the need for the inspection of equipment, working practice and strict implementation of quality control programmes.
Smiljanić R, Perkov D, Dobrota S, Štern Padovan R
To present our experience with this relatively rare type of vascular pathology with succesful endovascular embolization.
We treated three patients with giant pseudoaneurysms (PSAN) of gastroduodenal artery in period from 2007 to 2009. All patients were diagnosed with chronic pancreatitis, with formation of pseudocyst and consequential gastroduodenal artery PSAN.
Two patients were treated with endovascular coil embolization of gastroduodenal artery proximal and distal to the site of extravasation, while the third patient was treated with stent graft implantation.
All three interventions were technically successful, with immediate cessation of contrast extravasation and relief of the symptoms within next few days. PSAN in all patients were followed after the interventions, and were found considerably smaller, with the development of pseudoaneurysm thrombosis.
Endovascular embolization is the treatment of choice in patients with gastroduodenal artery pseudoaneurysm.
Kordić A, Mašković J
As many as 25% of ischemic strokes occur in the vertebrobasilar region. Data on the prognosis of transient ischemic attack and minor stroke from a systematic review has shown that patients with posterior circulation events have a higher risk of subsequent stroke or death in the acute phase (up to 7 days after presenting symptoms) compared with patients who present with anterior circulation symptoms. Despite this, much less is known about the natural history of vertebral artery stenosis compared with carotid artery stenosis. Surgery for vertebral artery stenosis is technically difficult, potentially hazardous, and is not considered in most centers. Therefore, vertebral artery stenosis has traditionally been treated conservatively with medical care alone. Nonrandomized case series evidence suggests that vertebral artery stenosis may be treated endovascularly by percutaneous transluminal angioplasty (PTA) and/or stenting, potentially offering an alternative to surgery to relieve symptoms caused by significant stenosis.
Brkljačić B, Čikara I, Ivanac G, Božikov V
To evaluate results and follow-up of patients with thyroid toxic and autonomous adenomas treated by percutaneous US guided ethanol injection (PEI).
US-guided PEI was performed in 86 patients (80 female, 6 male) with toxic (55) and autonomous (31) thyroid adenomas in 12-years period. The mean volume of treated nodules was 20.8 ccm (range of 2.2-38 ccm). 96% ethanol was used, and the injected volume in mililiters was calculated as nodular volume in ccm x 1.5. The injection was performed every three-four days, until the total volume was injected. The evaluation of outcome was performed after 3-6 months, by thyroid scintigraphy, ultrasound, and serum hormonal assessment. After that patients status was reevaluated annualy or biannualy, while scintigraphy was performed at least once. Thirty five patients have over five years follow-up (5-12 years).
PEI was technically successful in 81/86 pts (94.2%). In 75/81 pts (92.6%) nodular volumes were reduced > 50%. Complete recovery was observed in 48/81 pts (59.3%), partial recovery in 24/81 pts (29.6%) and failure in 9/81 (11.1%); failure occured in five patients with toxic adenomas and four pts with toxic nodular goiters. Five to 12 years follow up in 35 pts demonstrated recurrence of hyperthyroidism in six patients (17.1%), after two, three, four, six, nine and eleven years, with scintigraphically hot nodules in treated (2) and non-treated (4) parts of the thyroid gland. All patients were retreated with PEI. 29/35 (82.9%) patients were euthyroid during the long-term folow up, with no new scintigraphically visible hot nodules.
Percutaneous US-guided ethanol injection is safe and relatively efficient alternative method for treatment of toxic and autonomous thyroid adenomas.
Angiography for GI bleeding (GIB) was first performed in patients by Baum and colleagues in 1965, identifying hemorrhage as contrast extravasation into the bowel. GIB is classified according to the origin: proximal to the ligament of Treitz is considered to be from the upper GI tract (UGIT), distal to this point to be lower GI tract (LGIT). Both types of GIB can be distinct clinically and also in epidemiology, prognosis, management and outcome. The hemorrhage could be acute, chronic, obvious or occult.
Acute upper GIB is best investigated and treated with endoscopy. For patients who fail theurapeutic endoscopy and who are considered to be high risk for surgery transcatheter arteriography and intervention (TAI) is the treatment of choice. TAI is the best method of treatment for bleeding into the biliary tree or pancreatic duct.
In patients with acute lower GIB who are hemodynamically stable colonoscopy is used for diagnosis and also treatment. For unstable patients with massive lower GIB emergent TAI is most appropriate. No large, prospective, randomized trials have been done to compare TAI with surgery. It depends on local experience and expertise.
Arteriography can detect active bleeding with little as 0,5 ml/min, but may be hampered by breathing or bowel movement. Unsubtracted images may be superior for detection of extravasates. Arteriography with provocation test should be reserved as last when other alternatives fail.
MDCTA has become a simple technique available at most institution. When using a large amount of contrast and a biphasic protocol a bleeding of 0,3 ml/min can be detected. MDCTA is without therapeutic capability.
Selective infusion of vasoconstrictors was one of the first angiographic treatments for GIB, but with multiple, late complications, such as intestinal and cardiac ischemia.
Most types of arterial hemorrhage can be treated with embolization. The most common indication in the UGIT is hemorrhage from duodenal or gastric ulcers, in the LGIT diverticular hemorrhage. Other frequent indications are false aneurysms, true visceral aneurysms, iatrogenic bleeds. Diagnostic angiography should include selective series of the celiac axis, SMA and IMA. In the UGIT the embolization proximal as well as distal to the bleeding point should be performed. Recurrent hemorrhage may be seen in up to 30% of cases as a result of the rich collaterals. Repeat embolization can be performed. The risk of ischemia after embolization in the UGIT is very low. The situation is different in the LGIT because there is less collateral supply and the risk of ischemia is higher. Superselective embolization must be performed with the use of co-axial microcatheters and microcoils, because of their ease of deployment and better visualization under fluoroscopy. The chance for recurrent hemorrhage is lower than in the UGIT, up to 15%. The combination of coil and embolic particles such as polyvinyl alcohol is favor in controlling bleeding compared with single therapy.
For embolization for UGIT hemorrhage prolonged clinical success is 50 to 80%, for LGIT 70 to 90%. Complications include systemic effects such as contrast induced nephropathy and allergic reactions, puncture site related complications and embolization procedure related complications such as bowel ischemia. All major and minor complication occur in no more then 10 % of patients.
Embolization is a safe and efficient procedure for controlling gastrointestinal bleeding if performed in a superselective catheter position.
Szikora I, Kerber Ch, Pabkaz S, Berentei Zs, Marosfoi M, Kulcsar Zs, Gubucz I
To investigate the capacity of a new liquid embolization device in reconstructing the surface of the parent artery at the aneurysm orifice resulting in reconstruction of laminar flow within its lumen.
Seven aneurysms in 7 patients were treated under an EC approved protocol. Indications included recurrence, acute subarachnoid hemorrhage (SAH) and incidental findings. Neucrylate AN, a new generation cyanoacrylate based embolic material was injected into aneurysms under flow control provided by temporary balloon occlusion across the aneurysm orifice with a total injection time ranging from 0:45 s to 2:30 minutes.
Three parophthalmic carotid and 2 basilar tip aneurysms were completely occluded. Small residual filling was observed in another two aneurysms. Reconstruction of laminar flow was confirmed by flow simulation studies in 3, and by microcatheter injection angiography in 2 cases. Technical complications resulting in balloon rupture occurred in 3 cases without any clinical sequalae. No distal or proximal migration of the embolic material was observed. One patient died from SAH induced vasospasm 10 days following procedure, one had a temporary visual field deficit and another one suffered temporary aggravation of a preexisiting mass effect due to a giant basilar tip aneurysm.
In our limited experience, the Neucrylate AN liquid aneurysm embolic device proved to be safe and effective in reconstructing both the morphology and flow of the parent artery across aneurysms. Technical improvements of the protection balloons are needed to increase safety. Further follow up is being conducted to investigate long term efficacy.
A growing number of studies have demonstrated the clinical success of endovascular treatment in patients with critical limb ischemia (CLI) due to infrapopliteal lesions. The interventional success rate for endovascular treatment of infrapopliteal stenoses is up to 100%; however failure rates for occlusive lesions have ranged from 20% to almost 40% due to the inability to pass the occlusion with the guidewire from antegrade or reenter the true lumen distal to the occlusion. The transpedal access-technique has been described in the literature as a successful alternative in these cases. Different techniques, like the insertion of 4Fr or 3Fr-sheaths or the sheathless approach by inserting a support-catheter or the balloon directly through the pedal artery access site can be performed. In al larger series of 71 patients of our center, where an antegrade recanalization attempt was not successful, the transpedal access was possible in all cases. The interventional success in terms of passage of the occlusion from retrograde with the guidewire was 86% in this group. Balloons used for the sheathless approach was the Amphirion Deep (Invatec, Italy) with an outer diameter of 2.8 Fr. The guidewires used are the PT2 hdydrophilic coated 0.014” guidewire (Boston Scientific) in the first line and the Miraclebroth 0.014 CTO-guidewire (Asahi, Abbott) if the PT2 fails. An occlusion of the pedal artery at the access-site after completion of the intervention was seen in one patient with consecutive successful surgical thrombectomy and bypass-insertion. No other series adverse event was noted until discharge in our series. Clinical follow-up data and angiographical follow-up data will be presented.
Although surgical resection is accepted to be the only treatment with prolonged survival in patients with HCC most of the patients don’t have a chance for the resection because of some reasons such as multifocal diseases, large tumor size and comorbid diseases etc.Therefore RFA (Radiofrequency Ablation) has already become a common treatment for the patients with unresectable primary liver malignancies. Classical indications for HCC include 6 lesions less than 3.5 cm in diameter in patients without extrahepatic involvement. If liver volume is sufficient for the life of the patient it is also possible to ablate more than 6 lesions. After having the normal bleeding parameters procedure is carried out under either US or CT guidance by percutaneous approach. It is also possible to perform ablation intraoperatively when indicated.
RFA is a safe and effective method with successful results. It can also be repeated against tumor recurrence. Long-term results of RFA in HCC have already indicated that 5-year survival rates are compatible with the results of surgery
Patients with large liver tumors or diffuse liver metastases are not suitable candidates for major surgical procedure because the liver function could be severely compromised. Preoperative portal vein embolization (PVE) can induce hypertrophy of the future liver remnant (FLR), thus allowing safe surgical resection. We would like to introduce our results using this technique.
This study involved 30 patients which underwent PVE procedure. 12 patients were diagnosed with colorectal metastases and 17 patients with hepatocellular carcinoma (HCC) and 1 with cholangiocarcinoma (CH).
PVE was performed under general anaesthesia. A catheter was introduced through the common femoral artery into the superior mesenteric artery and indirect portograpyh was carried out. The portal vein was punctured under fluoroscopic guidance and the percutaneous transhepatic approach was used. Following portography, selected portal vein segments were embolized with polyvinil alcohol (PVA) particles and microcoils until stasis of blood flow was achieved. More proximal branches and access tract through the liver tissue were occluded with coils or Gelfoam particles.
The volume increase in the future remnant liver was evaluated by MR (1.5 Tesla, Fast T1 in transverse plane) or by MRCT, before and 30 days after portal embolization.
The procedure was successfully performed in all patients. In five patient we observed signs of postembolization syndrome and another patient had subcapsular hematoma. The volume of the FLR increased between 8 and 109%. The average increase in volume was 41%. Altogether, 25 patients underwent surgical resection. In five patient disease progression occurred and carcinoma spread to the previously healthy liver lobe.
In our opinion PVE is a safe and effective procedure that trigger a regenerative response and induce selective hypertrophy of the normal liver parenchyma. For this reason it increases the possibility of potentially curative resection for patients who would otherwise not have been candidates for extended surgery.
Pavlisa G, Ozretic D, Rados M
Stenting without coiling is being increasingly used as means of occlusion of intracranial aneurysms. We present a retrospective study with this technique on a limited number of patients.
We treated 6 patients with 8 unruptured intracranial aneurysms. 4 patients harbored a posterior circulation aneurysm, and 2 patients had an anterior circulation aneurysm. 5 of the patients were symptomatic, due to the compression of brainstem or cranial nerves. Stents were mainly of a closed-cell design, and in these 6 patients we deployed 13 stents.
Stents were successfully deployed in all but one patient, who had a giant fusiform basilar artery aneurysm, and the sizes of stents, used in a telescopic configuration, were not sufficient to bridge the entire aneurysm.
One patient died due to probably procedure-related rupture of the giant aneurysm. Other patients had an unremarkable post-procedural disease course, with a regression of size or complete occlusion of the aneurysm.
The sole stenting technique seems to be a feasible and effective technique, which needs to be evaluated on a larger population. High complication rate with one death in 6 of our patients may reflect the high-risk of these patients and limited treatment options. Extremely careful peri-procedural aneurysm assessment and follow-up is mandatory.
The purpose of this study was to demonstrate different possibilities in treating intracranial aneurysms and to evaluate outcome and summarize all patients with intracranial aneurysms surgically treated at our department since its foundation.
Data from medical records of patients with intracranial aneurysms treated in our institution since 1986 was obtained. Total number of patients, sex and age distribution, aneurysm localization, neurological condition at admittance to hospital, GCS and Hunt&Hess grade, surgical timing according to subarachnoid hemorrhage, duration of hospitalization, craniotomy type and outcome at discharge were retrospectively analyzed.
Between 1986 and 2008 large series of 1219 patients with intracranial aneurysm were treated.
There were 453 males and 766 females. Detailed medical records were available for 456 patients treated since 1999 due to computerization of our department at the time and better archiving of medical histories. Records for 763 patients treated earlier are partial and for those patients only sex, age and aneurysm localization were available for reviewing.
Outcome data was available for 418 patients. According to the evaluation at discharge 203 (48.6%) patients were excellent, 77 (18.4%) good and 54 (12.9%) fair. There were 46 (11%) patients of poor outcome and the remaining 38 (9.1%) died.
The factors related to poor outcomes were age of 60 years and over, Hunt&Hess grade II or more and aneurysm localization.
Our series of patients with intracranial aneurysms is the largest one in our country. Detailed retrospective evaluation of patient data showed that our results are comparable to other published series due to the standardized surgical principles and procedures.
Vidjak V, Novačić K, Hebrang A, Leder NI, Blašković D
GOAL: to establish 12 months after the procedure in a group of patients with TASC C SFA lesions:
1. incidence of stent fractures and their possible clinical influence
2. possible influence of various factors on stent fracture
311 patients (ABI clinical category according to Ruthenford) have been successfully treated with primary assisted stenting of SFA distal half at Clinical Hospital Merkur over a period of 7 years. 289 patients responded to the follow-up, 73 of whom satisfied the requirements in the moment of the procedure: a) absence of tandem PA lesion, SFA and ipsilateral iliac artery b) no previous endovascular treatment or surgery of the same artery c) absence of diabetes mellitus and non-smokers d) at least one ipsilateral fully patent run-off artery. ABI, CD SFA was analyzed in every patient as well as x-ray pictures taken from two angles with the enlargement of the area where stent would be placed. Self-expanding stents (118) from various producers (A,B,C,D-n4) were used; in 43 patients (58.9%) ≥ 1 stent was placed, and in 30 patients (41.1%) 1 stent (25.4%-30/118).
The analysis includes exclusively the above mentioned 73 patients, 65.8% (48/73) of whom had satisfactory clinical results 12 months after the procedure. Stent fractures were found in 41.1% (30/73) patients, of whom 48.9% (21/43) (≥ 1 stent), and 26.7% (9/30) (1 stent). Clinical deterioration of results but without stent fracture was found in 27.3% (6/22) patients (≥ 1 stent) and 14.3% (3/21) patients (1 stent). In patients (30) in whom stent fracture was found together with the overall total of stents (44.9%-53/118), 83.1% (44/53) were from the group (≥ 1 stent), and 16.9% (9/53) from the group (1 stent). The incidence of stent fracture differs depending on the type of stent utilized: stent type A – 56% (42/75), stent type B – 34.8% (8/23), stent type C – 14.3% (2/14), stent type D – 16.7% (1/6).
TASC C lesion in the distal half of SFA treated with stenting show satisfactory results 12 months after the procedure. Clinical results are poorer if such lesions are treated with ≥ 1 stent of the appropriate length rather than one stent. Stent fractures in patients treated with more stents additionally make clinical results worse. Incidence of stent fractures of the distal half of SFA is not the same for different types of stents, which should be taken into consideration when treating these types of lesions.
Endovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well. From June 1999 to January 2009, wee treated 92 patients with TEVAR. One was patient with syphilitic aneurysm, 45 was patients with acute aortal syndroma and 46 was patients with atherosclerotic aneurysms. Eight of patients with atherosclerotic aneurysms have aneurysm with diameter greater then 10 cm. All aneurysms were repaired with Medtronic Valiant stent-graft. There were no perioperative deaths. Mean length of stay was 6.3 days. Technical success was achieved in all 8 patients. Mean follow-up was 14.2 months. During the follow-up period there was no evidence of endoleak or stent-graft migration. These results support endovascular treatment in high-risk patients with giant aneurysm of descending thoracic aorta.
The rupture of aorta is a serious condition, many patients die before they reach hospital. Since 1990's, the only treatment possibility was surgical repair with high 30-day mortality (33- 50%).
After introducing stentgrafts in 1991, the endovascular approach became feasible and first abdominal aortic rupture was treated by stentgraft in 1994. Today, it is an established method for the treatment of ruptured infrarenal abdominal; rupture, pseudoaneurysm and dissection of descendent thoracic aorta. 30-day mortality is 20- 30%. Some reqirements are necessary for emergency SG placement- 24-hours availabile well trained team is mandatory. Stentgraft of adequate size should be on stock and favorable anatomic conditions should be present. Multislice CTA is a single diagnostic method needed. Hypotensive haemostasis reduces additional aortal tearing.
Between October 2007 and March 2009, 12 patients (9 male and 3 female) were treated with percutaneouse SG implantation for aortic rupture or prevention of posttraumatic pseudoaneurysmal rupture. All AA ruptured spontaneousely, 4 patients developed posttraumatic thoracic and one pseudoaneurysm ruptured during the procedure. Two left subclavian arteries were covered, one reopened with stent.
All the patients were under general anaesthesia.
All SG were placed by radiologists, in two patients thoracic SG were placed intraoperatively through AIC due to small pelvic arteries.
1 patient (8 %) died due to complications in 30-days after the procedure, one limb of SG thrombosed, resulting in limb amputation.
In 9 patients, haemostasis was achieved surgically, in 3 pts Prostar XL was successfully used.
Emergency stentgraft placement is a feasible method, resulting as an outstanding treatment option for patients with ruptured infrarenal AAA or posttraumatic thoracic pseudoaneurysm. 30-day mortality seems lower as in surgery, also in our limited series. Close cooperation with other specialities, especially vascular surgeons is necessary for good results.
Historically, the depiction of thoracic aortic disease has been limited to conventional angiography. Although long considered to be the “gold-standard” of vascular imaging, conventional angiography is relatively invasive, time-consuming, and costly. Over the last two decades, marked advances have been made in the noninvasive imaging techniques, in many cases making conventional angiography an obsolete procedure for the detection, diagnosis, and display of the aorta and aortic pathology. Computed tomography (CT), magnetic resonance (MR) imaging, and transesophageal echocardiography (TEE) represent three outstanding, commonly available noninvasive modalities for imaging the thoracic aorta. The purpose of this lecture is to describe the protocols and techniques for each imaging modality, and demonstrate the imaging appearance of commonly encountered vascular pathologies of the thoracic aorta, including aortic aneurysms and aortic dissections.
Erceg G,Curic J, Vavro H, Rados S, Borkovic Z, Brkljacic B
Endovascular procedures for peripheral arterial disease (PAD) were performed in 661 patients over the last three years. 315 iliac arteries (275 stenoses and 40 occlusions) were treated with a procedural success rate of >95%; and patency rates of 90% (stenosis) and 72% (occlusions) at 1 year, 82% (S) and 68% (O) at 2 years, and 74% (S) and 64% (O) at three years.
250 SFA lesions were treated (185 stenoses and 65 occlusions) with the procedural success rate of >90%, and patency rates of 67% (S) and 60% (O) at 1 year, 59% (S) and 52% (O) at 2 years, and 50% (S) and 43% (O) at three years.
In atherosclerotic renovascular hypertension PTA was performed and stent implanted in 31 patients (RI < 0.75, EDV>90 cm/s), with the procedural successs rate of >98%, and patency rates of 90% at 1 year, 81% at 2 years and 74% at 3 years. Five FMDs were treated with PTA only, with 100% success rate and 3-year patency rate.
Subclavian artery lesions with symptomatic steal syndromme were treated in 35 patients, with the technical success rate of >92%, and patency rates of 92% at 1 year, 85% at 2 years, and 78% at three years.
Krajina A, Hulek P, Chovanec V, Raupach J, Fejfar T, Jirkovský V, Renc O
Portal hypertension (PH) is a syndrome that naturally develops in diseases and conditions that impede the natural drainage of the portal vein. In the initial stages of liver cirrhosis, the patient is threatened more by the effects of PH than by the consequences of hepatocyte function impairment due to cirrhosis per se. Variceal bleeding is one of the major manifestations of PH. Another important source of bleeding in PH is gastrointestinal mucosal congestion (so called portal gastropathy), which is most common in the stomach. Ascites due to PH affects survival and quality of life, signals poor prognosis and bears the risk of kidney function deterioration and spontaneous bacterial peritonitis. The Budd Chiari syndrome is a condition caused by occlusion of the large hepatic veins leading to congestive necrosis of the liver parenchyma and congestion of the gut. This is due to acute postsinusoidal (posthepatal) PH. The transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous, minimally invasive method of creating a portosystemic shunt for decompression of PH and may be an adequate treatment of all these manifestations of PH.
The most frequent indication of portosystemic collaterals embolization during TIPS is a recent history of acute variceal bleeding, especially if the bleeding source was gastric varices. Adjuctive embolotherapy significantly lower the rebleeding rate in comparison to TIPS alone.
Recanalization of segmental occlusion or stenosis of the portal or splenic vein can release compartmental PH.
There were 95 TIPS and 75 liver transplants performed in 10 millions inhabitants in Czech republic in 2005.
The purpose of our study was to find out weather transcatheter arterial embolization (TEA) is safe for the patients with blunt abdominal trauma who are hemodynamically unstable but they transiently well respond to the initial fluid and blood resuscitation compared to surgical management.
In the emergency room x-ray of the pelvis and ultrasound of abdomen were performed for the patient with blunt abdominal trauma. Patients were classified according to classification of trauma patient in a class II - marginally stable and will probably later require surgery or TAE.
Spiral contrast computed tomography (CTA) was performed showing contrast extravasation from the vessels and solid organ injury in abdomen. Conventional angiography confirmed the findings in the CTA and TAE was performed through femoral retrograde approach by different curved guiding catheters, microcatheters and embolic materials (temporary – gelfoam and permanently – microcoils). The angiographic and clinical success rate, recurrent bleeding rate, procedure related complications and clinical outcomes were evaluated.
From June 2006 to January 2009 21 marginally stable patients, 8(38%) woman and 13(62%) male, mean age 46,5 years with blunt abdominal trauma underwent TAE 6-24 hours after reception in the emergency room. Contrast computed tomography largely contributes to management orientation of trauma victims.
All patients underwent TAE for injuries in one reagion. 7(33.3 %) patients had embolization of one artery and 14(66.7%) patients of 2 or more arteries. Recurrent bleeding occurred in one patient(4.8%) and she was managed with a successful second TAE. The angiographic and clinical success rates were 100% and 95,2%. There were no serious ischemic complications. All patients were discharged after clinical improvement without surgery.
Spiral CTA has been recognized to be modality of choice for investigation of blunt trauma allowing for a rapid screening of injures in all organic systems.
As a nonsurgical treatment TEA can be performed safely for patient with blunt multiple trauma who are in hemorragic hypotension if their hemodynamics are improved by medicamental and fluid support.
Traumatska ruptura aorte predstavlja drugi vodeći uzrok smrtnosti u prometnim nesrećama. Ostali uzroci rupture aorte uključuju druge vrste deceleracijskih ozljeda: padove sa visine, „crush sindrom“, zatrpavanje i sl. Na mjestu ozljede umire 75-90% ozljeđenika. Oko 8% stradalih preživi do bolnice u hemodinamski stabilnom stanju, ali 50% umire prije terapijskog zahvata. Epidemiološki podaci ističu važnost pravodobne dijagnostike i liječenja. Moderni dijagnostički modaliteti uključuju MSCT angiografiju, klasičnu anfiografiju, transezofagusni UZV, MR angiografiju.
S obzirom na česte teške udružene ozljede ostalih organskih sustava, potrebno je procijenti prioritete zbrinjavanja, pri čemu krvarenje iz rupture aorte ima prioritet. Kod pacijenata bez aktivnog krvarenje iz rupture aorte, moguće je zbrinjavanje drugih ozljeda koje ugrožavaju pacijenta (ozljede glave, abdomena) uz medikamentoznu i slikovnu kontrolu ozljede aorte (TEE).
Tipični kirurški pristup uključuje ekspoziciju kroz torakotomiju i nekoliko tehnika: 1) klemanje i izravno šivanje aorte, 2) pasivni (Gottov) shunt i 3) neki od modaliteta održavanja perfuzije donjeg dijela tijela uz korištenje stroja za izvantjelesni krvotok.
Uz smrtnost 7-50%, najčešće poslijeoperacijske komplikacije uključuju pneumoniju, bubrežno zatajenje, paraplegiju itd. Postotak apraplegije kao komplikacije izravno je ovisam o korištenoj kirurškoj tehnici.
Kirurško liječenje traumatske rupture torakalne aorte je uspješno i daje trajne dobre rezultate. Usavršavanje kirurške i tehnike protekcije organa od ishemije značajno samnjuju incidenciju mogućih teških komplikacija nakon takvih zahvata.