Complex intracranial aneurysms: combined operative and endovascular approaches

OBJECTIVE: Endovascular management of complex intracranial aneurysms is increasingly being considered as an alternative to standard surgical clipping. However, little attention has been paid to the complementary nature of surgery and endovascular therapy. METHODS: Between September 1992 and May 1997, 12 patients with complex intracranial aneurysms were treated with combined operative and endovascular methods. Seven patients demonstrated subarachnoid hemorrhage (two of Grade II, two of Grade III, and three of Grade IV). Five patients demonstrated unruptured aneurysms, i.e., three giant aneurysms (one vertebrobasilar junction aneurysm, one middle cerebral artery bifurcation aneurysm, and one internal carotid artery-ophthalmic artery aneurysm), one large internal carotid artery-ophthalmic artery aneurysm, and one middle cerebral artery serpentine aneurysm. Management strategies involved either surgery followed by endovascular therapy (S-E; n = 5) or endovascular therapy followed by surgery (E-S; n = 7). S-E paradigms included aneurysm exploration followed by endovascular treatment (S-E1; n = 3), partial aneurysm clipping followed by endovascular aneurysm packing (S-E2; n = 1), and extracranial-to-intracranial bypass followed by endovascular parent vessel occlusion (S-E3; n = 1). E-S paradigms included superselective angiography followed by surgical clipping (E-S1; n = 2), Guglielmi detachable coil partial dome packing followed by delayed surgical clipping (E-S2; n = 2), proximal temporary vessel balloon occlusion followed by aneurysm clipping (E-S3; n = 2), and proximal permanent vessel occlusion followed by surgical aneurysm decompression for mass effect treatment (E-S4; n = 1). RESULTS: Eleven aneurysms (92%) were completely eliminated. The remaining aneurysm was 90% obliterated and remained quiescent at the 34-month follow-up examination, despite presenting with subarachnoid hemorrhage. No patient experienced repeat bleeding (follow-up period, 23+/-28 mo). There were no deaths. One patient achieved a fair outcome (Glasgow Outcome Scale score of III); all other patients experienced excellent outcomes (Glasgow Outcome Scale score of I). In all cases, the aneurysm management paradigm chosen had a positive effect on definitive therapy. CONCLUSION: Several factors can contribute to the complexity of intracranial aneurysms. Management strategies that combine operative and endovascular techniques in a complementary way, for the best possible outcomes for these patients, can be designed accordingly.     

Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.     

Saccular intracranial aneurysms: endovascular treatment with mechanical detachable spiral coils

PURPOSE: To evaluate endovascular treatment of saccular intracranial aneurysms with mechanical detachable spiral coils. MATERIALS AND METHODS: Fifty-three patients with 56 saccular aneurysms underwent endovascular treatment with spiral coils. All but five had symptomatic subarachnoid hemorrhage staged according to the Hunt and Hess classification as follows: stage IV or V (n = 20), stage III (n = 10), stage I or II (n = 20), and stage 0 (asymptomatic [n = 6]). RESULTS: Forty-seven aneurysms were occluded (100% occlusion) on follow-up angiograms with the following time distribution: 24 months for six aneurysms (six patients), 12 months for 14 aneurysms (11 patients), 6 months for 13 aneurysms (13 patients), 4 months for four aneurysms (four patients), and only immediate postprocedure study for 16 aneurysms (16 patients) (excludes two deaths and one failure). CONCLUSION: In this relatively small group, endovascular treatment with mechanical detachable spiral coils had a success rate of 90%, and it appears to be a rapid, reliable, and relatively safe technique in the treatment of life-threatening subarachnoid hemorrhage.     

Endovascular surgical approach to intracranial vascular diseases

PURPOSE: The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy. METHODS: All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used. RESULTS: For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation. CONCLUSIONS: As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.     

Autosomal recessive omodysplasia: report of three additional cases

AIM: To determine the results of transluminal angioplasty in patients with Brescia-Cimino arteriovenous fistulae. PATIENTS AND METHODS: Thirty-one patients underwent transluminal angioplasty of 36 stenotic lesions related to Brescia-Cimino arteriovenous fistulae over a 5-year period. The lesions treated were characterized by review of pre-angioplasty fistulograms. Medical and radiological records were reviewed to assess medium-term patency of each patient's fistula. RESULTS: Angioplasty was performed successfully in 28 out of 31 patients initially (90% technical success rate). Duration of follow-up for the 31 patients ranged from 4 to 65 months (median = 34 months). At 6 months, seven patients required further surgical or endovascular intervention (18 patients remained event-free) and at 1 year, 10 patients required further endovascular or surgical intervention (14 patients remained event-free). Life-table analysis revealed primary patency rates of 77%, 64% and 39% at 6 months, 1 year and 2 years, respectively. At 6 months and 1 year, four and five patients, respectively, required surgical revision or closure of fistula. Secondary patency rates were 85%, 81% and 65% at 6 months, 1 year and 2 years, respectively. All patients with a primary patency at 2 years remained event-free during the follow-up period. CONCLUSIONS: Transluminal angioplasty is an effective treatment for stenoses developed in relation to Brescia-Cimino haemodialysis fistulae. Further endovascular procedures may be required, especially in the first 24 months, to preserve patency. These techniques extend the lifetime of fistulae, thereby preserving proximal venous access sites for future use. Our result is in broad agreement with results from other series.     

The endovascular treatment of cerebral arteriovenous aneurysms and malformations

Despite the progress made in cerebral aneurysm microneurosurgery, some morphologic and anatomic characteristics, or also clinical reasons, make surgical clipping of the aneurysmatic column difficult or unfeasible, justifying an endovascular therapeutic alternative. Despite the great progress made, the risk of endovascular intervention with microballoons is significant, particularly in the acute post-haemorrhagic phase: 17.9% mortality and 10.7% morbidity in endosaccular embolisation therapy with the detachable balloon maintaining the arterial lumen permeable. The use of the GDC system (Guglielmi Detachable Coil) has permitted the treatment of proximal and distal aneurysms in the carotid and vertebrobasilar arterial regions. Microcatheterisation also allows intravascular treatment of the vasospasm, by mechanical means--angioplasty, or by pharmacological vasodilatation. With the GDC system one can obtain a complete occlusion of small and medium aneurysms in over 85% of cases, definitive morbidity of 5% to 7% and mortality of 1% to 3%. The objective of AVM endarterial occlusions is to obliterate the nidus through the arterial pedicles that can be microcatheterised by means of a certain embolic agent (Cyanocrilate, PVA or other embolic products). Thus, it is possible to reduce the dimension of the nidus as well as diminish the severity of the arteriovenous shunt, later facilitating the operation or radiosurgery, with the possibility of complete surgical removal in 96% of patients after embolisation. The mortality directly related to this endovascular therapy is approximately 0.9% with severe morbidity below 2%. Complete obliteration of a cerebral AVM can be achieved with endovascular techniques in 15% to 20% of cases, particularly in small lesions, sustain AVMs require careful multidisciplinary discussion aimed at finding the best treatment for each case.     

Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents

PURPOSE: To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions. MATERIALS AND METHODS: Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound. RESULTS: With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P < .0001) was observed 1 year later. CONCLUSION: Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.     

Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts

PURPOSE: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. METHODS: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. RESULTS: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored (p = NS). The postoperative graft function rate was significantly better in the surgical group (p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis (p < 0.05). CONCLUSIONS: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops.     

MR imaging in the evaluation of the therapeutic effect of B-RTO for gastric varices

BACKGROUNDS/AIMS: Balloon-occluded retrograde transvenous obliteration (B-RTO) has become a new treatment option for gastric varices. In the present study, mid-term follow-up data after B-RTO were presented, and the role of magnetic resonance imaging (MRI) and MR-portography in the assessment of therapeutic effect was evaluated. METHODOLOGY: Twelve patients with gastric varices were treated with up to three sessions of B-RTO. The patients were followed up with MRI, MR-portography, and endoscopy for a mean of 12.3 months. RESULTS: In ten patients, one (n = 8) or two (n = 2) sessions of B-RTO were effective to produce immediate (< 2 weeks) variceal obliteration on MRI and MR-portography. Endoscopic confirmation of variceal eradication was obtained within three (n = 9) or six (n = 1) months after B-RTO in these patients. The remaining two patients who underwent three sessions of B-RTO showed only a significant reduction in variceal size immediately after B-RTO, but variceal obliteration was observed within three months with subsequent variceal eradication. There were no signs of exacerbation of gastric varices on MRI and endoscopy in any patient during the follow-up period. CONCLUSIONS: The results suggest that B-RTO is effective for the treatment of gastric varices. MRI and MR-portography may provide accurate assessment of therapeutic effect.     

Effect of growth hormone therapy in children with achondroplasia: growth pattern, hypothalamic-pituitary function, and genotype

PURPOSE: To evaluate the success rates of the implantation of stent grafts in the treatment of peripheral aneurysms. MATERIALS AND METHODS: In 13 patients with 15 aneurysms at the common iliac artery (n = 6), external iliac artery (n = 1), hypogastric artery (n = 2), femoral artery (n = 2) or popliteal artery (n = 4), implantation of dacron-covered nitinol stents was performed. The patients were followed up for three to 20 months (mean, 8.8 months) with intravenous digital subtraction angiography, CT or colour-coded Doppler sonography. RESULTS: In all cases, the aneurysm was successfully occluded after stent implantation. In one case with a popliteal aneurysm, kinking of the vessel caused thrombosis of the stent. The stent was successfully reopened. The aneurysm however, had to be surgically treated 9 months later. The primary and secondary patency rates at 6 months were 93% and 100%, respectively. CONCLUSION: The method described might be an alternative therapy to surgery. There are some limitations in respect of treatment of popliteal aneurysms.     

Dural posterior fossa AVM producing raised sagittal simus pressure. Case report

A patient with raised intracranial pressure secondary to a dural arteriovenous malformation (AVM) of the posterior fossa is presented. Direct shunting of arterial blood into the transverse sigmoid sinus caused a considerable increase of the sagittal sinus pressure (SSP) and elevation of intracranial pressure (ICP). Both ICP and SSP returned to normal values following obliteration of the dural AVM by selective embolization.     

Long-term outcome after frontal sinus obliteration with an ionomer bone substitute in the cat. I: Histological results

BACKGROUND: Osteoplastic frontal sinus surgery in combination with sinus obliteration may occasionally be performed for indications such as severe sinus inflammations, extensive wall fractures involving the nasofrontal duct, or osteomas. The material most frequently used for this obliteration is autogenous adipose tissue. Autografts such as muscle, cartilage, and bone chips have been also recommended for this purpose. In order to avoid the surgical procedure required for harvesting an autograft from other body sites, alloplastic materials have been suggested for frontal sinus obliteration. METHODS: In an animal study using cats, the mucous lining of the frontal sinus was removed, the nasofrontal duct sealed with semifluid ionomer cement, and the cavity filled up with a solid and porous ionomer-based microimplant. RESULTS: Histological investigations were performed up to two years after surgery. Increasing obliteration of the sinus cavity by bone regeneration, starting from the sinus wall, as well as formation of connective tissue between the cement grains was detected as early as one month after implantation. Osteoblasts lining the osteoid layer were considered to be an indication of active bone regeneration. Osteogenesis inside the sinus cavity continuously progressed during the following months. Two years after implantation, osteoid and newly mineralized bone encircled the microimplants leading to an almost complete obliteration. There was no evidence for mucosal regeneration or foreign body reaction. CONCLUSIONS: Because of its osteoconductive effect, biocompatibility, and biostability the ionomer-based microimplant is a suitable alloplastic material for frontal sinus obliteration.     

Reflections on the management of cerebral arteriovenous malformations

BACKGROUND: The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience. METHODS: A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates. RESULTS: The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure. CONCLUSIONS: In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered "good risk" malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered "poor risk" malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.     

Femoropopliteal angioplasty in patients with claudication: primary and secondary patency in 140 limbs with 1-3-year follow-up

PURPOSE: To determine the usefulness of percutaneous transluminal angioplasty in the femoropopliteal arteries in patients with claudication. MATERIALS AND METHODS: In a prospective study of 106 claudicants (71 men and 35 women, aged 41-90 years [mean, 67 years]), a total of 208 lesions in 140 limbs were treated. The patients were followed up for 12-36 months. The patency rates were based on determination of the ankle-brachial index. RESULTS: The hemodynamic success rate for all the treated limbs was 89%, 99% for femoropopliteal stenoses (n = 71) and 80% for femoropopliteal occlusions (n = 69). In multiple logistic regression analysis, a smaller number of diseased vessels (one to two vs three to seven) and milder lesion severity (stenosis vs occlusion) correlated favorably with early success. Survival analysis with the Kaplan-Meier method according to established criteria revealed 1-, 2-, and 3-year primary patency rates of 47% (27 of 57 limbs), 41% (14 of 34 limbs), and 43% (three of seven limbs), respectively. CONCLUSION: In selected cases, good primary success and acceptable long-term results can be achieved with femoropopliteal angioplasty in claudicants.     

Adult medulloblastoma: an analysis of survival and prognostic factors

PURPOSE: This analysis aimed to review the experience in the management of adult medulloblastoma at the University of California, San Francisco, and to identify important prognostic factors for survival and posterior fossa control. PATIENTS AND METHODS: We performed a retrospective review of 34 adult patients, age > or = 15, with cerebellar medulloblastoma treated with radiotherapy at the University of California, San Francisco from 1970 to 1994. All patients underwent a surgical procedure (complete resection in 17, subtotal resection in 10, and biopsy alone in seven), followed by craniospinal irradiation. Most patients treated after 1979 also received chemotherapy. Twenty were classified as poor-risk due to either incomplete resection or evidence of disease outside of the posterior fossa at diagnosis. RESULTS: The 5-year posterior fossa control and overall survival rates were 61% and 58%, respectively. The majority of relapses occurred in the posterior fossa (14 of 17). Multivariate analysis revealed that age (favoring older patients), gender (favoring female patients), and extent of disease at diagnosis (favoring localized disease) were important prognostic factors for posterior fossa control. There was a trend toward improved posterior fossa control with higher radiation dose to the posterior fossa in patients with a complete resection. Gender and extent of disease at presentation were significant prognostic factors for survival. The 5-year survival rates were 92% for female patients versus 40% for male patients, and 67% for patients with localized disease versus 25% for those with disseminated disease. The prognosis following recurrence was poor; all died of the disease. DISCUSSION: Survival for adult medulloblastoma was comparable to its pediatric counterpart. In patients with localized disease at presentation, gender (favoring female patients) and age (favoring older patients) were important prognostic factors for posterior fossa control and survival. In patients with disseminated disease at presentation, the prognosis is poor, and innovative therapy is needed to improve survival.     

The efficacy of topical ciprofloxacin in the treatment of chronic suppurative otitis media

We conducted a test of the efficacy of ciprofloxacin eardrops in 80 patients (95 ears) with otorrhea due to chronic suppurative otitis media in two treatment settings. One group (n = 40; 47 ears) received daily ciprofloxacin therapy plus aspiration in the clinic. The other group (n = 40; 48 ears) self-administered ciprofloxacin at home. Overall, otorrhea resolved in 88% of all ears within 12 days of the initiation of treatment. The clinic-treated patients tended to respond more rapidly than did the self-treated patients, but there was no statistically significant difference in success rates between the two groups. Side effects were negligible. We conclude that empiric topical ciprofloxacin therapy is an effective, safe and relatively inexpensive treatment for otorrhea in patients with chronic otitis media.     

Right-sided maze procedure for right atrial arrhythmias in congenital heart disease

BACKGROUND: Atrial fibrillation and flutter, commonly associated with congenital heart anomalies that cause right atrial dilatation, may cause significant morbidity and reduction of quality of life, even after surgical repair of the anomalies. METHODS: In an effort to reduce the incidence of atrial tachyarrhythmias after repair of right-sided congenital heart disease, we performed a concomitant right-sided maze procedure. RESULTS: Eighteen patients with paroxysmal atrial fibrillation or flutter (n = 12) or chronic atrial fibrillation or flutter (n = 6) aged 10.9 to 68.4 years (mean 34.9 years) underwent a right-sided maze in association with repair of Ebstein's anomaly (n = 15), congenital tricuspid insufficiency (n = 2), and isolated atrial septal defect (n = 1). There were no early deaths, reoperations, or complete heart block. Discharge rhythm was sinus (n = 16) or junctional (n = 2). Follow-up was complete in all 18 patients and ranged from 3.1 to 17.2 months (mean 8.1 months); all are in New York Heart Association class I. Early postoperative arrhythmias developed in 3 patients (all were converted to sinus rhythm by antiarrhythmic drugs). There were no late deaths or reoperations. CONCLUSIONS: The inclusion of a right-sided maze procedure with cardiac repair in patients having congenital heart anomalies that cause right atrial dilatation and associated atrial tachyarrhythmias is effective in eliminating or reducing the incidence of those arrhythmias.     

Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications

PURPOSE: To perform a feasibility study of the Amplatz Thrombectomy Device (ATD) in a variety of vascular territories with acute or subacute thrombosis. MATERIALS AND METHODS: Thirteen patients (mean age, 44.6 years) with multiple risk factors who had acute/subacute thrombosis of the inferior vena cava (IVC) and iliac veins (n = 3), superior vena cava (SVC) and/or subclavian veins (n = 3), lower extremity polytetrafluoroethylene (PTFE) graft (n = 2), iliac artery (n = 2), portal vein and transjugular intrahepatic portosystemic shunt (TIPS) (n = 2), and an IVC to pulmonary artery Fontan conduit (n = 1), were treated by means of mechanical thrombectomy with use of the ATD. Thrombolysis failed to recanalize the vessels when used before thrombectomy for 12-34 hours in three patients, and was contraindicated in three other patients. Thrombolysis was used as a complement to the ATD procedure in five patients. RESULTS: Technical success was achieved in 11 patients, and procedure success was achieved in 10 patients. Failure was observed in the remaining three patients. One patient with a PTFE graft was successfully declotted but thrombosis occurred 2 weeks later, requiring surgery. The other patient with a PTFE graft did not improve and needed surgery to declot and treat the distal anastomosis and distal circulation. The two patients with an occluded iliac artery underwent successful declotting but rethrombosis occurred in one shortly after the procedure requiring thrombolytic therapy. One patient with TIPS thrombosis improved and another patient with a thrombosed portal vein did not improve after thrombectomy. CONCLUSION: The ATD is useful for recanalization of acute/subacute clotted native vessels and grafts. The application of the device is broad, and although declotting can be achieved in most cases, long-term success may be limited by anatomical and technical problems of the grafts and multifactorial clinical problems of severely sick patients, as was the case in the series. The use of additional thrombolytic therapy may be necessary in a number of patients.     

Formation, therapy and prevention of false aneurysm of the femoral artery following diagnostic and interventional heart catheterization

OBJECTIVE: As pseudoaneurysm of the femoral artery after catheter introduction is a frequent complication, its causes and therapeutic options were investigated in a large patient collective. PATIENTS AND METHODS: In a prospective study with colour-Doppler duplex sonography of 6928 patients after diagnostic and of 3764 after interventional cardiac catheterisation, pseudoaneurysms were diagnosed in 80 patients (0.75%), 46 after diagnostic (0.66%) and 34 after interventional (0.9%) catheterisation. RESULTS: The incidence was higher in women than men (1.33% vs 0.58%; P < 0.05). Anticoagulation after sheath removal was the leading risk factor (n = 55, 68.8%), especially after interventional coronary intervention 85.3 vs 56.5%, P < 0.05). Local compression under duplex sonography monitoring was undertaken in 69 patients (86.3%), achieving aneurysmal obliteration in 53 (76.8%). Spontaneous thrombosis occurred in 15 of the remaining 27 patients, and surgical closure became necessary in 12. CONCLUSIONS: These data indicate a risk profile for the occurrence of pseudoaneurysm after cardiac catheterisation which can be dealt with by preventive measures. Local compression under duplex sonographic monitoring was the treatment of choice with a high success rate and low incidence of complications.     

Determination and analysis of antigenic epitopes of prostate specific antigen (PSA) and human glandular kallikrein 2 (hK2) using synthetic peptides and computer modeling

In comparison with pyeloplasty, endourologic procedures for the treatment of ureteropelvic junction obstruction offer good success rates with less morbidity and a shorter hospitalization; however, studies have found lower success rates and increased complications in patients with crossing vessels. Conventional diagnostic angiography and intravenous urography have both been used to identify crossing vessels at the UPJ; but, a reliable, less invasive, less costly, and simpler preoperative procedure to identify crossing vessels is needed. Helical CT with CT angiography is a promising noninvasive technique for the identification of crossing vessels at the ureteropelvic junction, which can be used for surgical planning of endourologic treatment of UPJ obstruction.