Radiological feeding tube insertion is a safe and effective procedure. Success rates are higher, and complication rates lower than PEG or surgical gastrostomy tube placement and innovative techniques for gastric and jejunal access mean that there are very few cases in which RIG is not possible. The principal weakness of radiologically inserted gastrostomies is the limitiation on tube size which leads to a higher rate of tube blockage. Per-oral image-guided gastrostomies have to an extent addressed this but have not been popularised. Currently many centres still consider endoscopic gastrostomies as the first line unless patients are too unwell to undergo this procedure or previous attempts have failed, in which case radioloically inserted gastrostomies are the technique of choice.

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A 23-year-old presenting with an acute history of back pain, leg swelling, and claudication was diagnosed with an extensive iliocaval thrombosis, extending from the popliteal veins into the inferior vena cava (IVC) and left renal vein. He was treated with a combination of endovascular techniques, including EKOS and AngioJet. An underlying congenital IVC stenosis and May-Thurner type iliac vein compression were subsequently treated with venoplasty and stenting. To our knowledge, this is the first report of the use of EKOS for renal vein thrombosis and we highlight the complementary nature of different endovascular techniques for managing complex venous thrombotic disease.

WHAT THIS PAPER ADDSThis systematic review and meta-analysis summarises the evidence for endoanchor use in EVAR and TEVAR to treat type Ia endoleak (TIaE) and graft migration. Endoanchor fixation in EVAR is technically feasible with at least comparable early outcomes to the latest generation of stent grafts in treating TIaE and graft migration. Evidence for endostapling in TEVAR is sparse, and results show lower technical success, higher peri-operative mortality, and potential serious adverse events. The current evidence is limited by short term data and a lack of case controlled trials. Further robust studies are required before endoanchor use can be recommended in routine clinical practice.Objective: Endoanchor fixation might be a potential adjunct for the prevention and treatment of type Ia endoleak (TIaE) and graft migration in thoracic or abdominal endovascular aortic aneurysm repairs (TEVAR or EVAR). This review aimed to explore the safety and effectiveness of endoanchor fixation in TEVAR and EVAR. Methods: A systematic review and random effects meta-analysis was conducted. Data sources were PubMed/ MEDLINE, Embase, and the Cochrane Library. Results: Seven EVAR and three TEVAR studies using the Heli-FXÔ EndoAnchorÔ system were included in the meta-analysis. A total of 455 EVAR patients underwent primary endoanchor fixation. Technical success was 98.4% (95% CI 95.7e99.8%). The rate of TIaE and graft migration was 3.5% (95% CI 1.7e5.9%) and 2.0% (95% CI 0.12e6.0%), respectively, after 15.4 months (95% CI 1.76e29.0) follow up. A total of 107 EVAR patients underwent secondary fixation with a technical success of 91.8% (95% CI 86.1e96.2%). Rates of TIaE and graft migration were 22.6% (95% CI 9.1e40.0%) and 0% after a mean 10.7 month (95% CI 7.8e13.6) follow up. Adverse events included three endoanchor fractures, three dislocated endoanchors, one entrapped endoanchor, and one common iliac artery dissection. All cause 30 day EVAR mortality was 0.82% (95% CI 0.20e1.85%). Sixty-six TEVAR patients underwent endoanchor fixation with a mean 9.8 month (95% CI 8.1e 11.5) follow up. Technical success was 90.3% (95% CI 72.1e99.4%). The rates of TIaE and migration were 8.7% (95% CI 1.0e18.9%) and 0%, respectively. Adverse events included two misdeployed endoanchors with one fatal aortic dissection. All cause 30 day TEVAR mortality was 11.9% (95% CI 5.4e20.6%). Conclusion:Endoanchor fixation in EVAR is technically feasible and safe, with at least comparable early outcomes to the latest generation of stent grafts. Endostapling in TEVAR is associated with lower technical success, higher peri-operative mortality, and potential serious adverse events. Current evidence lacks long term follow up and case controlled trials to recommend endoanchor use in routine practice.

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