PURPOSE: We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR).
Small-bowel obstruction (SBO) continues to be a substantial cause of morbidity and mortality, accounting for 12%–16% of hospital admissions for the evaluation of acute abdominal pain in the United States (1). Most patients with SBO are treated successfully with nasogastric tube decompression. However, the mortality of SBO ranges from 2% to 8% and may increase to as high as 25% if bowel ischemia is present and there is a delay in surgical management (2–5).
Endovascular aortic aneurysm repair (EVAR) is an accepted alternative to open surgical repair in the treatment of thoracic aortic aneurysms (1–3). There are, however, important complications—such as endoleak formation, aneurysm expansion, or stent failure—that require life-long imaging surveillance. Contrast material–enhanced computed tomographic (CT) angiography is a rapid and easily available imaging method that depicts aortic aneurysms not only in the preoperative planning phase but also after EVAR. CT angiography can be used to detect endoleaks with a high degree of sensitivity. Furthermore, the volumetric data sets of isotropic voxels offer thin-section multiplanar reformatted images and enable accurate and reproducible volume and diameter measurement of the aneurysm sac (4–7). However, because patients require multiple follow-up studies after EVAR, the high cumulative dose of ionizing radiation is of concern (8). Software developments, including advanced image reconstruction algorithms, permit a substantial decrease in CT radiation dose when compared with examinations performed a decade ago (8). Partially iterative hybrid algorithms have been used since 2009 and have been reported to significantly decrease patient radiation dose in comparison with filtered back projection (FBP), which had been known as a well-established standard reconstruction algorithm (9–13). Model-based iterative reconstruction (MBIR), a fully iterative algorithm that models noise statistics and the parameters of the machine itself, shows considerable dose reduction potential in CT imaging of the chest, abdomen, and coronary arteries (9,14–19). The use of reduced tube energy for CT angiography is an attractive method with which to improve vessel attenuation and reduce patient exposure to radiation; however, the associated increase in image noise represents a potential problem, impairing the detection of small objects like endoleaks (20,21). Iterative algorithms could potentially compensate for the increased image noise, allowing for endoleak and in-stent thrombus detection without loss of diagnostic confidence.
Esophageal atresia (EA) is a common congenital anomaly of the esophagus, occurring in one in 2500 births (1). Although the treatment for EA has traditionally been primary or secondary surgical repair, postoperative morbidities occur, including anastomotic leak or stricture, recurrent fistula, gastroesophageal reflux (GER), tracheomalacia, and dysmotility (2–4). In fact, anastomotic strictures are found in up to 50% of patients after EA repair (2). When symptomatic, esophageal strictures demonstrate obstructive symptoms, such as dysphagia and food bolus obstruction, and this may result in failure to thrive.
The current standard-of-care protocol for yttrium 90 (90Y) radioembolization (RE) treatment of liver tumors is to perform arteriography with technetium 99m (99mTc) macroaggregated albumin (MAA) to delineate hepatic vascular anatomy, identify and possibly embolize extrahepatic vessels at risk for nontarget microsphere administration, and quantify hepatopulmonary shunts (1). Elevation of the lung shunt fraction (LSF) to greater than 20% or to a level that causes nontarget lung radiation dose greater than 30 Gy in a single 90Y RE procedure or more than 50 Gy in multiple 90Y RE sessions represents contraindications to resin (2) and glass (3) microsphere RE therapy, respectively. Although rare, such radiation exposure to the lungs may precipitate acute radiation pneumonitis, characterized by restrictive ventilatory dysfunction with imaging evidence of parenchymal consolidation that occurs 1–6 months after radiation therapy (4), or chronic radiation fibrosis, a condition of long-term scarring that may lead to chronic pulmonary insufficiency, pulmonary hypertension, and cor pulmonale (5). As many as 5% of 90Y RE candidates require activity reduction or therapy deferment because of LSF elevation (6), which conservatively occurs in 30% of hepatocellular carcinomas (HCCs) (7) (including more than 20% of patients with portal vein tumor invasion [8]) and may occur in patients with high metastatic disease burden (9). Since 90Y RE has shown clinical benefit in these populations (10), preprocedure identification of patient or tumor characteristics associated with LSF would be useful. The ability to predict high LSF (>20%) may preemptively highlight the need for application of techniques to reduce hepatopulmonary shunting at the time of planning mesenteric arteriographic imaging, such as arterioportal shunt closure (11); it may also allow early identification of patients who are clearly not candidates for 90Y therapy, which would allow for anticipatory selection of other therapies such as chemoembolization or systemic chemotherapy. On the other hand, the ability to accurately predict low LSF (<10%) could provide a basis for future studies that evaluate the safety of planning arteriography deferral in select cases, which would prevent unnecessary radiation exposure, reduce health care costs, and allow for earlier, more efficient 90Y treatment. With this in mind, our study was undertaken to identify liver tumor characteristics associated with low (<10%), intermediate (10%–20%), and high (>20%) LSF at 99mTc MAA imaging performed before 90Y RE.
Purpose: To examine if the outcomes after endovascular treatment in hypertensive patients with renal artery fibromuscular dysplasia (FMD) and incidental atherosclerotic renal artery stenosis (ARAS) differ from the outcomes in patients with FMD alone.
Sympathetic renal denervation, or renal nerve ablation (RNA), has become the new buzz word in hypertension and interventional cardiology. Recent advances in catheter-based approaches have allowed sympathetic fiber interruption through transvascular techniques that are minimally invasive and can be delivered expeditiously and safely. Radiofrequency (RF) energy sources are currently the preferred modalities, but other sources of energy, such as cryoablation, microwave, high-intensity focus ultrasound, and local neurotoxic agent infusion, are under intense investigation. Results thus far have been encouraging and offer promise for the future. The role of the sympathetic nervous system (SNS) in the development of resistant hypertension and cardiovascular disease has long been known, and a great deal of work has been done through the years trying to explore potential interventions to interrupt the sympathetic influence on systemic vasculature and target organs. In this article we attempt an overview of time-dependent interventions on the SNS and examine approaches used in humans and in the many experimental models that offer a better understanding of the role of sympathetic activity in cardiovascular disease. Naturally we focus on methods and techniques addressing sympathetic renal denervation in patients with drug-resistant hypertension, examine the current state of the art, and attempt a look into the future.
Background: Whereas thermal ablation of incompetent saphenous veins is highly effective, all heat-based ablation techniques require the use of perivenous subfascial tumescent anesthesia, involving multiple needle punctures along the course of the target vein. Preliminary evidence suggests that cyanoacrylate embolization (CAE) may be effective in the treatment of incompetent great saphenous veins (GSVs). We report herein early results of a randomized trial of CAE vs radiofrequency ablation (RFA) for the treatment of symptomatic incompetent GSVs.
Background: Open bypass is the gold standard for treatment of mesenteric ischemia. With the refinement of endovascular therapy, visceral stenting is an attractive minimally invasive alternative, but the data are limited and which vessel responds best to stenting has not been addressed. This study compares the outcomes of superior mesenteric artery (SMA) and celiac artery (CA) stenting.
Background: Hepatic artery stenosis (HAS) after orthotopic liver transplantation is a significant risk factor for subsequent hepatic artery thrombosis (HAT). HAT is associated with a 30%-50% risk of liver failure culminating in retransplantation or death. Traditional treatment of hepatic artery complications has been surgical, with hepatic artery revision or retransplantation. Endovascular therapy of HAS, described primarily in the interventional radiology literature, may provide a less-invasive treatment option.
Objectives/Background: The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure.
Background: Hepatocellular carcinoma (HCC) is one of the most deadly cancers in the world and its incidence rate has consistently increased over the past 15 years in Canada. Although transarterial embolization therapies are palliative options commonly used for the treatment of HCC, their efficacy is still controversial. The objective of this guideline is to review the efficacy and safety of transarterial embolization therapies for the treatment of HCC and to develop evidence-based recommendations.
Background: Accurate antenna placement is essential for effective microwave ablation (MWA) of lesions. Laparoscopic targeting is made particularly challenging in liver tumours by the needles trajectory as it passes through the abdominal wall into the liver. Previous optical three-dimensional guidance systems employing infrared technology have been limited by interference with the line of sight during procedures
Objectives: Liver metastasis from a neuroendocrine tumour (NET) represents a significant clinical entity. A multidisciplinary group of experts was convened to develop state-of-the-art recommendations for its management.
Different types of expandable metallic stents, including bare or covered stents, have been used in the treatment of benign or malignant strictures involving nonvascular luminal organs. However, even after successful stent placement, subsequent formation of granulation tissue within the stent lumen remains a major problem and has been the center of attention, giving birth to various ongoing investigations to preserve stent patency (1–5). Therefore, it is essential to understand the pathophysiologic process of granulation tissue formation to develop ways to suppress it.
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