Purpose: To analyze the long-term outcomes of a hybrid treatment method combining rotational atherectomy with drug-coated balloon (DCB) angioplasty in patients with total in-stent occlusion in the iliac and/or infrainguinal arteries. Materials and Methods: Between April 2014 and June 2017, 74 consecutive patients (mean age 66.7±9.7 years; 49 men) with total occlusion of a previously implanted stent underwent endovascular recanalization using the Rotarex system and DCB angioplasty. Half (37, 50%) of the patients had critical limb ischemia (CLI), and 30 (41%) of the procedures were performed in emergency. Mean lesion length was 22±15 cm. Results: Overall procedure success was achieved in 73 (98.6%) patients. Six (8.1%) CLI patients developed distal embolism that responded to thrombolysis. Three (4.1%) dissections did not require treatment, while 1 (1.4%) perforation necessitated stent-graft implantation. In all, 33 (44.6%) patients had an additional stent implanted, mainly due to a suboptimal outcome (n=28) or complications (n=5 including the stent-graft). The restenosis rate assessed by duplex ultrasound at 12 months was 20.5% (15/73); 4 (5.5%) patients underwent target lesion revascularization. Recurrent restenosis was more frequent in patients with Rutherford category 5 ischemia (p=0.005), in emergency procedures (p=0.021), after extensive procedures involving 3 independent vessel segments (p=0.016), and if a complication arose during the procedure (p<0.001). In multivariate analysis, only occurrence of a procedural complication was an independent predictor of recurrent restenosis at 1 year (OR 63.3, 95% CI 5.7 to 701.5). Conclusion: These findings imply that rotational atherectomy and DCB angioplasty may provide satisfactory outcomes in the treatment of total in-stent occlusion, with a satisfactory recurrent restenosis rate at 12 months.
The AngioSeal™ vascular closure device provides better local haemostasis than the StarClose™ device or manual compression during endovascular interventions requiring a direct puncture of PETE grafts.
Purpose The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR). Methods The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts. Results All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients. Conclusions The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.
Venous system aneurysms appear relatively rarely, and are even more rarely diagnosed, especially if asymptomatic. In the material of our clinic we provide a variety of practices in three patients with venous aneurysms depending on the location, symptoms and main disease. In some patients the occurrence of pulmonary embolism is the first symptom of venous aneurysms, having influence on the selection of further diagnostics, conservative treatment, as well as on endovascular or operating procedure. The proper diagnosis of a venous aneurysm takes place in case of doubling or tripling of the diameter of the basic dimension of the lumen, often with the presence of thrombotic material. Asymptomatic venous aneurysms are usually detected during routine pre-operative diagnosis also including duplex-Doppler studies. In the presence of pulmonary embolism positive angio-CT and scintigraphy raise the suspicion of venous aneurysm unless any other reason is apparent. There is no standard treatment of venous aneurysms. This has to do with the relatively low epidemiology, diversity of location, difficulties in determining the proper primary and secondary aetiology, anatomy and coexisting diseases. Despite the many unknowns a few issues should be considered before appropriate treatment is undertaken. Undoubtedly, the shape itself, the location and size of the aneurysm with the presence or not of thrombotic material are of great value in evaluating the risk of complications, including possibly lethal pulmonary embolism, local symptoms of venous hypertension and possible complications of surgery. In this paper we present 3 patients treated for venous aneurysms located in different regions: popliteal vein, brachial vein and iliac internal vein.
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