Pseudoaneurysms are common vascular abnormalities that represent a disruption in arterial wall continuity. Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. A complete work-up will help in determining the cause, location, morphologic features, rupture risk, and clinical setting of the pseudoaneurysm; identifying any patient comorbidities; and evaluating surrounding structures and relevant vascular anatomy, information that is essential for treatment planning. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to a marked decrease in the morbidity and mortality rates for pseudoaneurysms.

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Endovascular therapy with PTA or PTS for central venous stenosis is safe, with low rates of technical failure. Multiple additional interventions are the rule with both treatments. Although neither offers truly durable outcomes, PTS does not improve on the patency rates more than PTA and does not add to the longevity of ipsilateral hemodialysis access sites.

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Background: The ATTRACT Trial previously reported that pharmacomechanical catheterdirected thrombolysis (PCDT) did not prevent the post-thrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis (DVT). In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral DVT. Methods: Within a large multicenter randomized trial, 391 patients with acute DVT involving the iliac and/or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. Results: Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio (RR)=0.95; 95% confidence interval (CI), 0.78-1.15; p=0.59). PCDT led to reduced PTS severity as shown by: lower mean Villalta and Venous Clinical Severity Scores [VCSS] (p<0.01 for comparisons at 6, 12, 18, and 24 months); and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; RR 0.65; 95% CI 0.45-0.94, p=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; RR 0.57; 95% CI 0.32-1.01, p=0.048; and VCSS ≥8: 6.6% versus 14%; RR 0.46; 95% CI 0.24-0.87, p=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling (p<0.01 for comparisons at 10 and 30 days) and greater improvement in venous diseasespecific QOL (VEINES-QOL unit difference 5.6 through 24 months, p=0.029), but no difference in generic QOL (p > 0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% (p=0.32), and recurrent VTE over 24 months was observed in 13% versus 9.2% (p=0.21). Conclusions: In patients with acute iliofemoral DVT, PCDT did not influence the occurrence of PTS or recurrent VTE. However, PCDT significantly reduced early leg symptoms and, over 24 Comerota et al.

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Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.