Interdisciplinary Approach to Treatment of Vascular Anomalies
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The interdisciplinary model for the management of vascular anomalies relies essentially on effective collaboration and communication between various medical disciplines. In this paper, we discuss the various facets of an organized institutional collaborative model for managing these patients. The case for interdisciplinary collaboration, use of proper terminology, the vascular anomalies center (structure and work flow), referral bases, and collaboration with support group are briefly illuminated. The role of the interventionalists as primary members and leaders in this field is buttressed by the clinical knowledge and competent use of imaging modalities and minimally invasive interventions. (Source: Techniques in Vascular and Interventional Radiology)
Laser Treatment in the Management of Infantile Hemangiomas and Capillary Vascular Malformations
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Vascular lesions encountered in dermatology can be divided into vascular malformations and vascular tumors, namely infantile hemangiomas (IH). Vascular malformations can further be subdivided by their flow characteristics and vessel type. Slow, or low-flow lesions are either capillary vascular malformations (CVMs), venous malformations, or lymphatic malformations. Fast, or high-flow lesions include an arterial component, and are categorized as arteriovenous malformations. IH and CVMs are among the most common benign vascular lesions seen and treated in dermatology. CVMs are present at birth and grow as the individual does, whereas IH usually appear days to weeks later and may rapidly enlarge for a period of months to a year before gradually involuting. As the technology has evolved, early ...
The Role of Surgery in the Management of Congenital Vascular Anomalies
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Surgery is one of the modalities used to treat vascular lesions. Its role is to act in concert with interventional radiology and the various pharmacologic agents. The role of surgery in patients with hemangiomas is limited to nonresponders to propranolol, complications, and eyelid lesions. Corrective surgery would also normalize facial distortion and asymmetry which may result from a hemangioma. Concerning vascular malformations, cure may only be obtained in case of small, focal lesions. In larger, extensive lesions, the role of surgery is limited to debulking the mass. This is usually performed after preoperative embolization or sclerotherapy to reduce the amount of intraoperative blood loss. Surgery is usually not curative but would decrease the amount of disease needing to be sclerosed....
Pulmonary Arteriovenous Malformation Embolization: How We Do It
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We report our experience with an embolization technique that allows safe, controllable exclusion of pulmonary arteriovenous malformations using detachable coils, a single venous access site, coaxial catheter guidance, and 1 or 2 microcatheters. This technique is particularly useful when treating central lesions with a short feeding artery and when high flow increases the risk of coil migration and nontarget embolization. It affords precise placement and repositioning of coils prior to detachment. The technique facilitates safe and successful endovascular closure of these challenging lesions. (Source: Techniques in Vascular and Interventional Radiology)
Interventional Management of High-Flow Vascular Malformations
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High-flow vascular malformations are among the most challenging lesions in the field of interventional radiology. For an optimal long-term result, the clinician must have a full understanding of the types of lesions, their natural history, appropriate diagnostic studies, indications for treatment, and all the treatment options, including surgery, embolization, laser, and pharmacotherapy. Surgery should, in general, be used primarily for lesions that are completely resectable or are so bulky that embolization would not provide a satisfactory result. Embolization techniques are directed at elimination of the nidus of the lesion, using a variety of penetrating embolic agents both by direct puncture and transcatheter approaches. This paper reviews the principles and techniques primarily involv...
Endovascular Treatment of Slow-Flow Vascular Malformations
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Symptomatic slow-flow vascular malformations include venous malformations and lymphatic malformations, as well as combined anomalies. Endovascular therapy, consisting mainly of intralesional sclerosant injection, is now accepted as the primary treatment for most of these lesions. Magnetic resonance imaging and ultrasonography supplement physical examination for diagnosis and assessment of the extent of malformation. Endovascular treatment is usually carried out under general anesthesia. Sclerosants for venous malformations include ethanol, 3% sodium tetradecyl sulfate, and bleomycin. Lymphatic malformations can be injected with doxycycline, bleomycin, OK-432, or other sclerosants. Complications of sclerotherapy include tissue necrosis, peripheral nerve injury, hemoglobinuria, deep vein thr...
Medical and Genetic Aspects of Vascular Anomalies
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This manuscript provides an updated review of clinical and scientific or genetic updates in vascular anomalies, with an emphasis on essential information for the interventional radiologist. Citations include concise reviews and reliable websites which provide supplementary background. This manuscript elucidates the following: (1) not every vascular lesion is a hemangioma, (2) the Kasabach-Merritt phenomenon is not seen in association with typical hemangiomas, (3) many new basic research and genetic findings in vascular anomalies may influence the clinical evaluation and diagnosis (as well as provide rationale for future targeted therapies which may successfully ameliorate or eradicate these conditions), (4) it is essential to communicate with the clinician and patient to understand the his...
Introduction
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I remember very clearly an afternoon in Boston 30 years ago. Alex Berenstein and I had just given a presentation on arteriovenous malformation management to an illustrious group of interventionalists and vascular surgeons. At the end of the session, one of the senior (and well-known) vascular surgeons approached us at the podium and said, “Gentlemen, I admire what you're trying to do, but I think you must be out of your minds to devote yourselves to such a frustrating problem.” Several decades and 2000 cases later, I sometimes find myself in agreement with his assessment, but the progress which has taken place in every aspect of this field has made it more than worthwhile. Back then, all vascular lesions were referred to as “hemangiomas,” recommendations ranged from “leave it alo...
Table of Contents
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Previous topics
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Editorial board
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Table of Contents
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Prostatic Arterial Embolization: Post-Procedural Follow-up
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Prostatic arterial embolization (PAE) gained special attention in the past years as a potential minimally invasive technique for benign prostatic hyperplasia. Treatment decisions are based on morbidity and quality-of-life issues and the patient has a central role in decision-making. Medical therapy is a first-line treatment option and surgery is usually performed to improve symptoms and decrease the progression of disease in patients who develop complications or who have inadequately controlled symptoms on medical treatment. The use of validated questionnaires to assess disease severity and sexual function, uroflowmetry studies, prostate-specific antigen and prostate volume measurements are essential when evaluating patients before PAE and to evaluate response to treatment. PAE may be perf...
Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia: Short and Medium Follow-up
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To evaluate the short and mid-term results of prostatic artery embolization in patients with benign prostatic embolization. Retrospective study between March 2009 and June 2011 with 103 patients (mean age 66.8 years, 50-85) that met our inclusion criteria with symptomatic benign prostatic hyperplasia. The clinical outcome was evaluated by the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function, prostate volume (PV), prostate-specific antigen (PSA), peak urinary flow (Qmax), and post-void residual volume (PVR) measurements at 3 and 6 months, 1 year, 18 months, and 2 years after PAE and comparison with baseline values was made. Technical and clinical successes, as well as poor clinical outcome definitions, were previously defined. In t...
How to Perform Prostatic Arterial Embolization
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Prostatic arterial embolization (PAE) is an experimental alternative treatment for benign prostatic hyperplasia, with promising preliminary results. In comparison with surgery, its main advantages are the minimally invasive nature, outpatient setting, rapid recovery, and low morbidity. To avoid complications and to achieve technical success it is important to know the procedural technique in detail. In addition, for good clinical results, it is important to perform a bilateral and complete prostatic embolization. In this article, the different technical steps, including the initial site of puncture and the catheters and guidewires to be used, are described. Identification of the prostatic arteries is crucial. Correlation between computed tomography angiography and digital subtraction angio...
Radiological Anatomy of Prostatic Arteries
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One of the most challenging aspects of prostatic arterial embolization for patients with lower urinary tract symptoms and prostate enlargement or benign prostatic hyperplasia is identifying the prostatic arteries (PAs). With preprocedural computed tomography angiography it is possible to plan treatment and exclude patients when arterial anatomy is not suited, or when extensive atherosclerotic changes may affect technical success. There is an excellent correlation between the computed tomography angiography and digital subtraction angiography findings, enabling correct depiction of the male pelvic arterial anatomy (internal iliac branching patterns, relevant variants as accessory pudendal arteries, and PA anatomy). The prostate has a dual vascular arterial supply: a cranial or vesico-PA (na...
Patient Selection and Counseling before Prostatic Arterial Embolization
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Prostatic arterial embolization (PAE) for relief of lower urinary tract symptoms (LUTS) in patients with prostate enlargement or benign prostatic hyperplasia (PE or BPH) is an experimental procedure with promising preliminary results. Patient evaluation and selection before PAE is paramount to improve technical and clinical results. Our inclusion criteria for PAE include: male patients, age>40 years, prostate volume>30cm3 and diagnosis of PE or BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International Prostate Symptom Score [IPSS]>18, or quality of life [QoL]>3, or both) or with acute urinary retention refractory to medical therapy. Exclusion criteria include: malignancy (based on pre-embolization digital rectal and transrectal ultrasound [TRUS] ...
Benign Prostatic Hyperplasia: Clinical Manifestations and Evaluation
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Benign prostatic hyperplasia (BPH) is a very common condition, related to aging and causing symptoms, called lower urinary tract symptoms. On account of its huge prevalence, it is important for clinicians who are involved in the management of patients with BPH to be aware of the very strict recommendations for BPH evaluation. In this article, we describe the different steps and procedures doctors should follow to evaluate these patients; symptoms and signs of BPH are reviewed, as well as the clinical evaluation steps and examinations available. The basic evaluation of the patients with BPH should include, according to the recommendations of the most relevant international guidelines, lower urinary tract symptoms evaluation with appropriate symptom scores, digital rectal examination, voidin...
Benign Prostatic Hyperplasia: A Brief Overview of Pathogenesis, Diagnosis, and Therapy
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This article provides a general overview of benign prostatic hyperplasia evaluation and management. (Source: Techniques in Vascular and Interventional Radiology)
Treatment of Benign Prostatic Hyperplasia
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Lower urinary tract symptoms (LUTS) may be a sign of aging rather than a consequence of benign prostatic enlargement (BPE) or benign prostatic obstruction (BPO). Medical or invasive treatments should address the bothersome symptoms and the quality of life of patients. Alpha blockers and 5-alpha reductase inhibitors are most frequently used in benign prostatic hyperplasia (BPH) medical treatments, whereas Transurethral Resection of the Prostate (TURP) remains the “gold standard” for surgical treatments. Several minimal invasive treatments are emerging with promising outcomes. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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Prostatic arterial embolization is a minimally invasive technique, which is a potential alternative treatment for benign prostatic hyperplasia (BPH). Due to promising preliminary results, low morbidity, and suitability for outpatients, it is a very attractive procedure for patients and for physicians. (Source: Techniques in Vascular and Interventional Radiology)
Toc
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Forthcoming topics
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Editorial board
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Masthead
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Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices from Unconventional Systemic Veins in the Absence of Gastrorenal Shunts
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Balloon-occluded retrograde transvenous obliteration of gastric varices in the absence of a gastrorenal shunts can still be performed through unconventional venous routes, such as the left inferior phrenic (ascending portion or transverse portion), pericardial, and azygous-hemiazygous veins. This requires detailed knowledge of venous anatomy, impeccable preprocedural imaging for planning, and high-skill set techniques with smaller balloon-occlusion catheters. The technical results appear to be high (67%-83% depending on the access venous system available), but are lower than conventional balloon-occluded retrograde transvenous obliteration via the gastrorenal shunt. (Source: Techniques in Vascular and Interventional Radiology)
Inventory Used for Balloon-Occluded Retrograde (BRTO) and Antegrade (BATO) Transvenous Obliteration: Sclerosants and Balloon Occlusion Devices
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This article discusses the inventory used for BRTO and balloon-occluded antegrade transvenous obliteration in Japan and the United States and focuses on the inventory (including compatibility of inventory) that has worked and has become popularly used in the United States. The article also discusses the sclerosant mixture components, types and states (foam, froth, or liquid). (Source: Techniques in Vascular and Interventional Radiology)
Balloon-Occluded Antegrade Transvenous Obliteration With or Without Balloon-Occluded Retrograde Transvenous Obliteration for the Management of Gastric Varices: Concept and Technical Applications
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This article discusses the clinical and technical applications, technical considerations, and the outcomes of BATO. (Source: Techniques in Vascular and Interventional Radiology)
Pre– and Post–Balloon-Occluded Retrograde Transvenous Obliteration Clinical Evaluation, Management, and Imaging: Indications, Management Protocols, and Follow-up
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Patients with gastric variceal bleeding require a multidisciplinary team approach, which includes hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnosis and management tool for bleeding gastric varices (GVs) as it is with all upper gastrointestinal bleeding scenarios. Traditionally, in the United States, when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) is performed along the classic teachings of decompressing the portal circulation. However, TIPS has shown inconsistent effectiveness in controlling gastric variceal bleeding. Conversely, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice...
Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Conception, Evolution, and History
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The idea of transvenous obliteration of varices that complicate portal hypertension dates back to the 1970s. The clinical use of this minimally invasive procedure was probably lost with the advent of transjugular intrahepatic portosystemic shunt shortly afterward. The concept of retrograde obliteration of a gastrorenal shunt through the left renal vein originated from Olson et al at Indiana University. However, the Japanese (Kanagawa et al and subsequent authors) defined, developed, and technically perfected the clinical implementation of balloon-occluded retrograde transvenous obliteration. The evolution of balloon-occluded retrograde transvenous obliteration has come full circle, now gaining popularity in the United States, especially in patients who are not candidates for transjugular i...
Introduction
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Varices due to portal hypertension can occur throughout the gastrointestinal tract. These include esophageal, gastric, duodenal, mesenteric (small bowel, large bowel, and stomal), and internal hemorrhoids (piles). Patients with portal hypertension-related variceal bleeding require a multidisciplinary team approach, which includes gastroenterologists/hepatologists, diagnostic radiologists, and interventional radiologists. This is especially true for upper gastrointestinal variceal management. Upper gastrointestinal endoscopy is the first-line diagnostic and therapeutic tool for bleeding esophageal and gastric varices. Traditionally, in the West (Europe and the United States) when endoscopy fails to control esophageal or gastric variceal bleeding, a transjugular intrahepatic portosystemic sh...
Table of Contents
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Previous Topics
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Editorial Board
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Internet-Based Social Networking and Its Role in the Evolution of Chronic Cerebrospinal Venous Insufficiency
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This article will review this phenomenon, the Internet-based resources available to MS patients seeking information about CCSVI, and the responsibilities of physicians as they participate in these online discussions. (Source: Techniques in Vascular and Interventional Radiology)
Placebo Power
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A variable placebo response has been previously described in the multiple sclerosis (MS) literature and in sham surgical trials involving other patient populations. Conditioning and expectancy models are proposed to explain the biological mechanisms of a placebo response. Possibly, when neuroimmune mechanisms are involved in the disease process, placebo and treatment responses interact. The measurement of a placebo response related to endovascular procedures in MS may be scientifically and ethically challenging. Based on the factors associated with larger placebo responses, it is estimated that a significant placebo response may be associated with these procedures. The factors and mechanisms associated with marked placebo responses should be considered in the design of future studies relat...
Reported Outcomes After the Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency
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Chronic cerebrospinal venous insufficiency (CCSVI) has recently been implicated as a potential causal factor in the development of multiple sclerosis (MS). The treatment of jugular and azygous vein stenoses, characteristic of CCSVI, has been proposed as a potential component of therapy for MS. In the few short years since Dr. Paulo Zamboni published “A Prospective Open label Study of Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency”, there has been tremendous patient-driven demand for treatment. Concurrently, there have been numerous publications since 2009 addressing CCSVI and its association with MS. The purpose of this article is to present a brief review of CCSVI and its association with MS and to review the available literature to date with a focus on outcomes ...
Intravascular Ultrasound in the Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency
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Multiple imaging modalities have been used for the evaluation of chronic cerebrospinal venous insufficiency (CCSVI). These include Doppler ultrasound, magnetic resonance venography, computed tomographic venography, and catheter venography. Although each of these tests is considered to contribute valuable information to the evaluation, each modality has deficiencies, which can impact treatment. Intravascular ultrasound (IVUS) has a role in this evaluation owing to its ability to accurately assess vessel circumference and cross-sectional area in real time. This can aid in identifying significant stenoses and optimizing balloon sizing during angioplasty. In addition, intraluminal abnormalities that may be difficult to see with venography can be identified with IVUS, which can further determin...
Catheter Venography and Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency
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Multiple sclerosis (MS) is a disorder characterized by damage to the myelin sheath insulation of nerve cells of the brain and spinal cord affecting nerve impulses which can lead to numerous physical and cognitive disabilities. The disease, which affects over 500,000 people in the United States alone, is widely believed to be an autoimmune condition potentially triggered by an antecedant event such as a viral infection, environmental factors, a genetic defect or a combination of each. Chronic cerebrospinal venous insufficiency (CCSVI) is a condition characterized by abnormal venous drainage from the central nervous system that has been theorized to have a possible role in the pathogenesis and symptomatology of MS (1). A significant amount of attention has been given to this theory as a poss...
The Use of Doppler Ultrasound in the Diagnosis of Chronic Cerebrospinal Venous Insufficiency
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The objective of this article is to describe the technique our laboratory has used to assess patients for the presence of CCSVI using Doppler ultrasound. (Source: Techniques in Vascular and Interventional Radiology)
Using Magnetic Resonance Imaging as a Means to Study Chronic Cerebral Spinal Venous Insufficiency in Multiple Sclerosis Patients
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The goal of this work is to present a broad magnetic resonance imaging (MRI) protocol for use in the study of chronic cerebrospinal venous insufficiency (CCSVI). The CCSVI MRI protocol includes the following sequences: time-resolved contrast-enhanced 3D MR angiography, 2D time-of-flight MR venography, and 3D volumetric interpolated breath-hold examination to assess venous structural abnormalities; phase-contrast MR imaging at different levels in the neck and thoracic cavity to quantify flow through the veins, arteries, and cerebrospinal fluid; T2-weighted imaging, T2-weighted fluid-attenuated inversion recovery, and pre- and post-contrast T1-weighted imaging of the brain for examinations of parenchymal lesions; and finally, susceptibility-weighted imaging for quantification of iron deposit...
Chronic Cerebrospinal Venous Insufficiency and Multiple Sclerosis: History and Background
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Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system (CNS) most commonly characterized by focal areas of myelin destruction, inflammation and axonal transection. The multicentric inflammation and demyelination of the brain and spinal cord are associated with variable neurologic symptoms ranging from mild dysfunction to debilitating. Typically, these symptoms are marked by episodes of clinical worsening followed by improvement. The cause of this disease remains unclear currently, but the underlying etiology is generally considered to be immunologically based. Other factors, including genetic, environmental and infectious influences have been implicated, as well. Now recent studies have proposed that extracranial venous obstruction, termed chronic cerebros...
Introduction
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If you have ever doubted the power that a single individual can have on the lives of millions of people, then devote some time to read this issue of Techniques in Vascular and Interventional Radiology. By now, many people have heard about the work of Paolo Zamboni and its potential impact on patients suffering from multiple sclerosis (MS). The theory of chronic cerebrospinal venous insufficiency (CCSVI), at the very least, is potentially a different way to think about venous outflow from the central nervous system. Zamboni has proposed that stenoses in the internal jugular/azygos veins may have a role in the development of MS through an altered blood-brain barrier and iron-mediated inflammation in the cerebral extracellular matrix. This, in turn, may impact the clinical manifestations of t...
Table of Contents
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Previous Topics
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Editorial Board
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Past, Present, and Future Perspectives on the Endovascular Treatment of Acute Ischemic Stroke
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Interventional neuroradiology plays a continuously expanding and exciting role in the treatment of acute stroke, as evidenced by the development of several important advances, including the advent of multiple new devices and therapies. Furthermore, guidelines regarding endovascular interventions in the setting of acute stroke have been developed and used. In addition to technological advances, the field of pharmacology in the setting of acute stroke is constantly evolving. In a rapidly expanding field, we aim to review significant recent advances related to the endovascular treatment of stroke as well as provide perspective for future directions. (Source: Techniques in Vascular and Interventional Radiology)
Acute Stroke: Postprocedural Care and Management of Complications
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Endovascular treatment for acute ischemic stroke is an important alternative to thrombolysis with recombinant tissue plasminogen activator (rt-PA) for patients who present beyond the thrombolysis time window, those who are ineligible for rt-PA, or those who do not improve after intravenous rt-PA. These patients generally require special attention in the postprocedural period because, although not frequent, complications of endovascular procedures in acute ischemic stroke have the potential to be devastating. Neurocritical care is essential to reduce and appropriately treat complications after endovascular procedures. Neurointensivists and neurocritical care nurses are experts in both critical care and neurologic disorders and have special training to recognize early physiological derangeme...
Use of Stentrievers in Acute Stroke: Tips, Tricks, and Current Results
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This article is a synopsis of the available devices and different techniques. An extensive review of the literature summarizing all the data that have been published demonstrating their clinical impact and complications is also presented. (Source: Techniques in Vascular and Interventional Radiology)
Techniques and Results: Intracranial Stenting
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Recanalization rates with conventional pharmacologic thrombolysis and thrombectomy devices in the treatment of large-vessel occlusions are low. Moreover, these patients do not have favorable clinical outcomes. Better recanalization devices and approaches are needed. In this review, we describe current stents used in the intracranial circulation and their application in the treatment of acute ischemic stroke due to large-vessel occlusion. (Source: Techniques in Vascular and Interventional Radiology)
Techniques and Results—Penumbra Aspiration Catheter
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The objective of this article was to provide a comprehensive overview of the data on technical and functional outcome so far published for aspiration thrombectomy and resume techniques that can be used to optimize functionality of the Penumbra System. We focus on existing clinical data as well as our institutional experience and techniques. (Source: Techniques in Vascular and Interventional Radiology)
Acute Stroke: Techniques and Results With the Merci Retriever
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Acute ischemic stroke is one of the most prominent causes of death and disability in the modern world. Despite extensive research, the only Food and Drug Administration-approved pharmacologic treatment is intravenous recombinant tissue plasminogen activator (rt-PA). Although reperfusion remains the most robust predictor of clinical outcome, rt-PA has been linked to low recanalization rates in large-vessel occlusion. Endovascular techniques have been developed over past decade with several theoretic advantages over intravenous rt-PA alone, including longer treatment windows and higher recanalization rates in large-vessel occlusions. The Merci retriever thrombectomy device was approved by the Food and Drug Administration in 2004 for removing thrombus in acute ischemic stroke. In this article...
Intra-arterial Thrombolysis: Tissue Plasminogen Activator and Other Thrombolytic Agents
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Recanalization rates with the administration of intravenous tissue plasminogen activator in acute ischemic stroke are low. Adjuvant endovascular techniques that achieve recanalization by direct intra-arterial (IA) delivery of thrombolytics, mechanical clot retrieval, clot aspiration, and stenting may complement intravenous pharmacotherapy. IA thrombolytics can be administered within 6 hours of symptom onset in anterior circulation strokes and within 24 hours in posterior circulation strokes. This review describes the indications, patient selection, and technique for IA administration of thrombolytics. (Source: Techniques in Vascular and Interventional Radiology)
Endovascular Treatment of Acute Ischemic Stroke: Current Indications
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This article will review the existing data to discuss the clinical and imaging factors that are relevant to patient outcomes, and which may be used to guide endovascular treatment decisions. Anterior circulation strokes represent the primary focus of this review. (Source: Techniques in Vascular and Interventional Radiology)
Neuroimaging in Acute Stroke: Choosing the Right Patient for Neurointervention
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Although the non-contrast computed tomography head continues as the sole mandatory imaging technique before intravenous thrombolysis, the increased availability of advanced infarct/penumbral imaging techniques and confidence in their use have led many to adopt them into routine practice—most particularly before intra-arterial interventions. Computed tomography versus magnetic resonance-based routes to imaging the cerebral vasculature, cell death, and parenchymal perfusion have differing advantages in terms of speed, availability, exposures to contrast and radiation, sensitivity, and resolution. Continued refinement and future developments, such as the ability to quantitate perfusion, promise to lead to tailored treatment protocols that respect the individual variations in anatomy, physio...
Current Indications and Results of Thrombolysis by Intravenous Recombinant Tissue Plasminogen Activator
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A number of landmark trials have proven the efficacy of thrombolysis by intravenous recombinant tissue plasminogen activator in the acute phase of the ischemic stroke. Despite the recently extended time window of 4.5 hours, the number of people who are being treated in most centers is low. Several reasons seem to account for this, including poor recognition of symptoms, delays in emergency transport, low levels of public awareness, or age limits originally imposed by drug regulatory rules. Trials are ongoing to possibly extend the indications to the treatment. A major effort is to extend the time window by bridging the treatment with neuroprotective approaches, or by identifying subgroups that may particularly benefit from recanalization and reperfusion. Procedures using ultrasounds or alt...
Elements of a Stroke Center
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The past decade has ushered in a refined understanding of—and commitment to—objective evidence-based practice of stroke management. Responding to the need for universal protocol-driven guidelines for stroke care, the Brain Attack Coalition published consensus statements with recommendations for primary stroke centers (Alberts MJ, et al, JAMA 283:3102-3109, 2000) and comprehensive stroke centers (Alberts MJ, et al, Stroke 36:1597-1616, 2005) in 2000 and 2005, respectively. These benchmark publications helped to define a new “standard of care” for stroke patients and laid the groundwork to establish formal certification for stroke centers. Although large randomized controlled trials evaluating the efficacy of these guidelines are currently underway, several recent reports suggest tha...
The Natural History of Acute Ischemic Stroke Due to Intracranial Large-Vessel Occlusion: What Do We Know?
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Acute ischemic stroke (AIS) is an important public health issue with major impact on not only patients and families but also on the society as well. Among patients who suffer from AIS, those who have the event due to large-vessel occlusion are thought to have the worse outcome. Because most of the effort in endovascular treatment of AIS is aimed toward this type of stroke, it is important to understand its natural history. The goal of this manuscript was to briefly discuss the natural history of AIS due to large-vessel occlusion based on recent literature. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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The management of acute ischemic stroke is a dynamic process that has been changing for the past 20 years. New medications and protocols for intravenous treatment became available and are considered the standard of care since mid-1990s. This has led to a revolution where we stopped contemplating the disease to actively treat it. Amazing advances in acute stroke neuroimaging are also changing the way we approach these patients. Imaging of the core infarct and salvageable brain tissue is being used more and more often and, in the future, after it is fully validated, will probably determine how the patient presenting with acute ischemic stroke should be treated. More recently, endovascular techniques (chemical and mechanical) have gained wider acceptance and are now also considered very impor...
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Venous Access Salvage Techniques
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For patients who need long-term central venous access but who have developed obstruction of the usual central veins, “salvage” access techniques offer successful alternatives. These techniques include translumbar inferior vena cava access, transhepatic inferior vena cava access, catheterization of small venous collaterals, and recanalization of occluded veins. Inferior vena cava access techniques allow a range of devices to be placed, including ports, infusion catheters, and hemodialysis catheters. Collateral vessels may be too small to allow for large-caliber devices, such as hemodialysis catheters. Success rates for these access techniques are high and complications are infrequent. These access routes are in general quite durable. Adults and children can be treated. Once placed, devi...
Evaluation and Management of Central Venous Access Complications
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This article discusses the most common and some unusual complications seen with the placement of these devices. We also briefly discuss the management of these complications. (Source: Techniques in Vascular and Interventional Radiology)
Diagnosis and Treatment of Central Venous Access–Associated Infections
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This paper provides readers with a basic understanding of the types of central venous access–associated infections as well as appropriate diagnostic techniques. Preventive measures are the most effective way to reduce rates of catheter-associated infection and are discussed in detail. Diagnosis and treatment of each type of infection are reviewed for nontunneled central venous catheters, tunneled dialysis catheters, and venous access ports. Readers should be able to employ the methods described in this paper to reduce the rate of central venous access–associated infections at their hospitals. (Source: Techniques in Vascular and Interventional Radiology)
Peripherally Inserted Central Catheter Placement in Infants and Children
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This article discusses our institution's step-by-step approach to operating a hospital-wide PICC service. (Source: Techniques in Vascular and Interventional Radiology)
Principles of Subcutaneous Port Placement
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This article will focus on the placement of these ports. (Source: Techniques in Vascular and Interventional Radiology)
Principles of Tunneled Cuffed Catheter Placement
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Tunneled cuffed catheters provide reliable and instant long-term intravenous access for a large variety of therapeutic purposes, including chemotherapy, parenteral nutrition, and apheresis. The most frequent application is for patients with renal failure as an access device for hemodialysis. In this capacity, the rate of catheter use has remained stable in the United States, despite the promotion of arteriovenous fistulas and arteriovenous grafts. The latter 2 procedures achieve superior longevity and much higher cost-efficiency. Tunneled catheters, however, serve as bridging devices during maturation of newly placed arteriovenous fistulas or as the final option in patients in whom fistulas and grafts have failed. High-quality vascular access is a hallmark of interventional radiology, and ...
Principles of Non-Tunneled Central Venous Access
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Non-tunneled central venous access has become an important tool in the management of the sick patient, particularly in the intensive care unit. Image guidance allows more precise placement of lines with overall lower complication rates compared with guidance by physical landmarks. The use of image guidance has brought a procedure traditionally performed by surgeons into the realm of the interventional radiologist. Techniques for placement of non-tunneled central venous catheters, hemodialysis catheters, and peripherally inserted central catheter lines will be discussed. (Source: Techniques in Vascular and Interventional Radiology)
A Concise History of Central Venous Access
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Central venous access has become a mainstay of modern interventional radiology practice. Its history has paralleled and enabled many current medical therapies. This short overview provides an interesting historical perspective of these increasingly common interventional procedures. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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The rapidly aging population and increased lifespan of individuals with chronic disease have resulted in an explosion in the demand for central venous access. Procedures once rare outside of the intensive care unit and operating room are now commonplace. For some, this responsibility represents a challenging burden in terms of coverage demands. For many, it represents a new service line with attractive economic potential. For patients, however, it more and more frequently represents an essential ingredient to the successful management of their care. (Source: Techniques in Vascular and Interventional Radiology)
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Magnetic Resonance Imaging–Guided Laser Ablation of Bone Tumors
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Image-guided thermal ablation of bone tumors is gaining acceptance in the oncology community. Computed tomography–guided radiofrequency ablation and cryoablation are widely available and are used in clinical practice. However, a potentially devastating complication of these techniques is thermal injury to the spinal cord and nerve roots in patients with tumors involving the vertebra, paraspinal tissues, or pelvis. Magnetic resonance imaging–guided laser ablation with quantitative magnetic resonance temperature imaging is a novel technique that allows for accurate imaging of the tumor, real-time placement of laser fibers, and real-time monitoring of the ablation zone. With this technique, target temperature thresholds are placed on critical neural elements to provide real-time feedback ...
Percutaneous Thermal Ablation: How to Protect the Surrounding Organs
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A variety of thermal ablation techniques have been advocated for percutaneous tumor management. Although the above techniques are considered safe, they can be complicated with unintended thermal injury to the surrounding structures, with disastrous results. In the present article we report a number of different insulation techniques (hydrodissection, gas dissection and balloon interposition, warming/cooling systems) that can be applied. Emphasis is given to the procedure-related details, and we present the advantages and drawbacks of the insulation techniques. We also provide tips on avoiding painful skin burns when treating superficial lesions. Finally, we point out the interest of temperature monitoring and how it can be achieved (use of thermocouples, fiberoptic thermosensors, or direct...
Effective Pain Palliation and Prevention of Fracture for Axial-Loading Skeletal Metastases Using Combined Cryoablation and Cementoplasty
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Approximately 1 million Americans develop cancer every year. It is estimated 350,000 people die with bone metastases annually in the United States. Certain cancers have a propensity to metastasize to bone, namely, breast, prostate, thyroid, kidney, and lung cancer, in decreasing order of frequency. On average, a patient with metastatic disease will experience a skeletal complication (fracture, hypercalcemia, or spinal cord compression) event every 3-6 months. However, the occurrence of these morbid events is not regular, with events clustering around periods of progression and becoming more frequent as the disease becomes more extensive and the treatment options decrease. Many patients with metastatic disease have osteolytic destructive tumors in locations at risk for fracture. Several fac...
Thermal Ablation of Painful Bone Metastases
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This article reviews the use of radiofrequency ablation and cryoablation in the treatment of painful bone metastases. (Source: Techniques in Vascular and Interventional Radiology)
Transcatheter Arterial Embolization for the Palliation of Painful Bone Lesions
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This article discusses the use of bland arterial embolization for the purpose of pain control in patients with both primary and metastatic bone tumors. Considerations for patient selection and preparation, procedural steps, overcoming technical challenges, potential complications, and follow-up care will be reviewed using case examples. (Source: Techniques in Vascular and Interventional Radiology)
Embolization of Spinal Tumors: Vascular Anatomy, Indications, and Technique
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Involvement of the spine by primary and secondary tumors can be associated with mechanical instability, pain, and neurologic complications, all of which can adversely affect a patient's quality of life. When surgical excision is planned, preoperative embolization of spinal tumors reduces intraoperative blood loss, making surgery safer and easier. Embolization of spinal tumors can also be used to palliate pain and improve neurologic symptoms in patients with unresectable tumors. A detailed knowledge of the spinal vascular anatomy is essential before performing spinal tumor embolization. Indications, contraindications, embolization technique, and potential complications must be fully understood to ensure a safe and effective procedure. Although the technique used may vary among operators and...
Transcatheter Intra-arterial Limb Infusion for Extremity Osteosarcoma: Technical Considerations and Outcomes
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This article will focus on the technical aspects of intra-arterial chemotherapy for the treatment of extremity osteosarcoma. (Source: Techniques in Vascular and Interventional Radiology)
Percutaneous Ablation of Benign Bone Tumors
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Percutaneous image-guided ablation has become a standard of practice and one of the primary modalities for treatment of benign bone tumors. Ablation is most commonly used to treat osteoid osteomas but may also be used in the treatment of chondroblastomas, osteoblastomas, and giant cell tumors. Percutaneous image-guided ablation of benign bone tumors carries a high success rate (>90% in case series) and results in decreased morbidity, mortality, and expense compared with traditional surgical methods. The ablation technique most often applied to benign bone lesions is radiofrequency ablation. Because the ablation technique has been extensively applied to osteoid osteomas and because of the uncommon nature of other benign bone tumors, we will primarily focus this discussion on the percutaneou...
Percutaneous Image-Guided Biopsy of the Musculoskeletal System
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Percutaneous image-guided biopsy plays an important role in the management of multiple pathologic conditions involving the musculoskeletal system. The vast majority of these conditions require histologic diagnosis to guide decision making concerning treatment. Percutaneous image-guided biopsy has supplanted open surgical biopsy as the primary modality for tissue diagnosis in this patient cohort. The safety, efficacy, and clinical outcome of percutaneous image-guided biopsy for a multitude of musculoskeletal conditions are well documented. Improvements in needle design and image guidance have continued to further the efficacy and safety of this diagnostic technique. Complications associated with percutaneous biopsy are minimal compared with those seen in open surgical biopsy, whereas diagno...
Introduction
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Cancer remains the second most common cause of death in the United States, accounting for nearly 1 of every 4 deaths. Although primary bone tumors, benign or malignant, are uncommon, osseous metastatic disease is a prevalent problem in oncology patients. Over the past decade, there has been remarkable growth in the use of image-guided oncologic interventions in the musculoskeletal system. (Source: Techniques in Vascular and Interventional Radiology)
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Forthcoming Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Pitfalls of Embolic Protection
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Some degree of distal embolization likely occurs during all transcatheter interventional procedures. The clinical sequela is defined by the sensitivity of the target organ to segmental ischemia and the burden of embolic load. The spectrum of clinical consequences varies from the extremes of stroke and no-reflow phenomena in the carotid and coronaries, respectively, to silent renal insult following renal stenting. The clinical sequela of stroke and myocardial infarction in these most sensitive end-organ distributions led to the birth of embolic protection science. Over the past 2 decades embolic protection has matured and we now have a menu of devices to consider based on our specific patient clinical and anatomic needs. The goal of this narrative is to provide an update on protection devic...
Is There an Indication for Embolic Protection in Renal Artery Intervention?
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The role of endovascular treatment of atherosclerotic renal artery disease is uncertain, particularly after the publication of the Angioplasty and Stenting for Renal Artery Lesions trial and other randomized trials. These trials have shown that nonselective treatment of patients with renal artery stenosis does not result in a benefit when compared with best medical therapy. However, all trials have identified a subgroup of patients who do respond favorably to revascularization. In particular, patients with a degree of chronic renal insufficiency, critical renal artery stenosis, and a recent decline in renal function are likely to respond positively to revascularization. Endovascular treatment of renal artery stenosis must be performed safely, particularly in the high-risk patient group wit...
Embolic Protection in Carotid Artery Stenting: New Options
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This article will offer a practical review of techniques to decrease distal embolization during CAS. We will review patient selection and provide a “cookbook” approach to procedural technique, emphasizing techniques unique to each of the various EPD systems currently available. We will also introduce the newer options in EPDs, provide practical tips on their use, and contrast their use and results with that of the existing EPD systems. We will provide practical procedural techniques that incorporate the use of various EPDs into strategies that will reduce distal embolization during CAS and also provide pertinent data referencing results of these devices seen in clinical trials. (Source: Techniques in Vascular and Interventional Radiology)
Detection and Treatment of Acute Thromboembolic Events in the Lower Extremities
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This article includes a discussion of detection methods as well as preventive and treatment strategies. (Source: Techniques in Vascular and Interventional Radiology)
A Role for Embolic Protection in the Management of Acute Limb Ischemia
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Distal embolization is a complication during lower-extremity revascularization procedures that may occur when intervening on acute or subacute lesions. Several studies have demonstrated the safety and feasibility of using embolic protection devices (EPD) and some interventionalists have adapted this technology for use in infrainguinal revascularization procedures. At present, there are no randomized trials to indicate the benefit, safety, and cost-effectiveness of EPD for this application and its use in the United States is considered off-label. However, based on our experience and a review of the published literature, we consider the use of EPD in acute lower-extremity ischemia a reasonable strategy. (Source: Techniques in Vascular and Interventional Radiology)
The Role of Embolic Protection in Peripheral Arterial Atherectomy
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Embolic protection devices were initially developed for use in the treatment of saphenous vein aortocoronary bypass graft stenosis as well as in carotid artery stenting because of the significant risk of atheroembolism and their use is well accepted. The use of these devices for lower-extremity arterial interventions is becoming well accepted because of the significant consequences of embolization in patients with limited circulatory runoff. This is especially true in the use of mechanical atherectomy devices for femoropopliteal arterial lesions. (Source: Techniques in Vascular and Interventional Radiology)
Embolization during Treatment of Deep Venous Thrombosis: Incidence, Importance, and Prevention
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The standard of care for the treatment of acute deep venous thrombosis (DVT) is anticoagulation, which often prevents the formation of new thrombus and reduces the risk of pulmonary embolism (PE) but fails to eliminate the clot burden. Patients who have thrombus remaining in their deep venous system despite therapeutic anticoagulation are at high risk for developing symptoms of the postthrombotic syndrome, a debilitating condition that adversely affects their quality of life. Strategies of thrombus removal for acute DVT, such as operative thrombectomy, catheter-directed thrombolysis, and pharmacomechanical techniques, are designed to avoid postthrombotic morbidity by restoring patency to the deep veins, but there is concern that these techniques may result in fragmentation of clot and pulm...
Introduction
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Almost every percutaneous vascular interventional procedure carries with it the potential for embolization of thrombus, atheromatous debris, air, or even portions of the vessel wall. Even interventional equipment may fail and fracture, becoming another potential source of embolic material. This issue of Techniques in Vascular and Interventional Radiology has a singular focus: the prevention and management of embolization in a variety of vascular beds. (Source: Techniques in Vascular and Interventional Radiology)
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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Editorial Board
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Neuroendovascular Therapies in Pediatric Interventional Radiology
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Transarterial embolization of head and neck tumors can be done for a variety of indications, including tumoral epistaxis and high-output cardiac failure, but is mainly done before surgical resection. This technique offers higher surgical cure rates and faster recovery, while decreasing surgical morbidity by curtailing blood loss and reducing the duration of surgery. Patients with epistaxis are considered for endovascular management when they have failed conservative management, including topical vasoconstrictors, cautery, and nasal packing (anterior and posterior). Sudden arterial bleeding in patients undergoing transsphenoidal or maxillofacial surgery is also considered an indication for endovascular management. If performed with the appropriate attention, endovascular management of epist...
Diagnostic Cerebral Angiography and the Wada Test in Pediatric Patients
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Pediatric cerebral angiography is a commonly performed procedure and its performance has many similarities to the technique used in adults. However, some notable differences exist, especially in the nuances of arterial access, catheter manipulation, patient sedation, and fluid/radiocontrast load. A thorough understanding of cerebral angiography and its application to pediatric patients is imperative to ensure appropriate selection of patients requiring cerebral angiography and to minimize risk while obtaining the desired information. The intracarotid sodium Amytal injection (Wada) test is a specialized procedure performed in the workup of patients with seizure disorders who are being considered for surgical resective therapy. However, Wada testing in children poses unique challenges, as wi...
Embolization in Neonates and Infants
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Several conditions presenting in the neonatal and infant period benefit from embolization, including hemangioma, vascular shunts, and tumors. The physiological delicacy and small size of newborns create distinct challenges. This paper discusses embolization of these patients and illustrates the techniques involved. (Source: Techniques in Vascular and Interventional Radiology)
Interventional Management of Vascular Malformations
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This article briefly discusses the diagnosis and interventional management of vascular malformations. (Source: Techniques in Vascular and Interventional Radiology)
Venous Interventions in Children
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Advanced medical treatment options have improved pediatric survival but often require invasive vascular procedures or venous access. These procedures increase the risk for thromboembolism in children, and there has been a corresponding increase in the reported incidence of deep venous thrombosis and postthrombotic syndrome in the pediatric population. Percutaneous venous interventions using catheter-directed therapy (CDT), like mechanical thrombectomy and infusion thrombolysis, have been used much less frequently in children, even though they have shown good results in adults. A multidisciplinary team including pediatric hematology, interventional radiology, and intensive care unit is suggested for management of venous thrombosis in children. Indications and contraindications for CDT in ch...
Interventions in the Chest in Children
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The scope for image-guided intervention in the chest is very wide and encompasses procedures in the heart, pulmonary and systemic vasculature, lungs and pleural cavities, airway, and esophagus. This review describes the most important procedures that are usually performed by radiologists. Percutaneous drainage is now the most common method of treating both empyemas and lung abscesses in children. Although most lung biopsies are carried out by other means, percutaneous biopsy and localization are important alternatives for the diagnosis of focal lung lesions. Esophageal strictures are common in children and are usually best treated by balloon dilatation. The use of retrievable or biodegradable stents has recently been introduced for refractory esophageal strictures. Similarly, balloon dilat...
The Practice of Pediatric Interventional Radiology
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There is a stark contrast between adult and pediatric interventional radiology practice. The essential elements of this all relate to working with children, including a need for greater procedural sedation and anesthesia; the psychology of working with children and their families; a skill set based around smaller bodies; and technology for smaller and growing humans. Interventional radiology departments that cater to children need to accommodate these factors so that sick children can access minimally invasive image-guided therapy in a safe and nonthreatening environment. (Source: Techniques in Vascular and Interventional Radiology)
Pediatric Interventional Radiology, Part Two
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This volume is the second of a two-part series in this journal on pediatric interventional radiology (PIR). As in the first pediatric issue, these articles are written by PIR experts sharing with you their practical real-world approaches to PIR and specific hard-earned tips and pearls. This volume starts with an article on PIR infrastructure, which includes suggestions on how to approach the patient and family. These topics are rarely directly articulated, but when practiced expertly, can make all the difference in your practice between a cooperative patient and happy family on one hand and dissatisfaction, increased operator stress, and poorer outcomes on the other. These relatively intangible elements of practice are even more important in pediatric than adult practice. A overarching ter...
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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Editorial Board
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Techniques in Vascular and Interventional Radiology: Pediatric Central Venous Access
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This article is meant to serve as a reference for decision making along with tips and pearls on how we approach placing CVACs in pediatric patients at our Children's Hospital. (Source: Techniques in Vascular and Interventional Radiology)
Pediatric Biliary Interventions
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The most common indication for percutaneous biliary evaluation and intervention in children is for the diagnosis and treatment of liver transplant complications, including strictures and bile leaks. Because liver transplants in children are commonly performed using a Roux-en-Y biliary-enteric anastomosis, endoscopic retrograde cholangiopancreatography is not technically possible; therefore, the first-line procedure for evaluation and treatment of biliary obstruction in this population is percutaneous transhepatic cholangiography (PTC). Percutaneous biliary intervention can be challenging in these patients, because ductal dilation may be minimal or altogether absent in pediatric transplant livers even in the setting of severe obstruction. However, with proper technique, including the use of...
Pediatric Arterial Interventions
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This article will focus on the management of renovascular hypertension, liver transplant hepatic arterial intervention, and the use of carbon dioxide gas as a contrast agent in the child. (Source: Techniques in Vascular and Interventional Radiology)
Nephro-Urology Interventions in Children
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This article covers the indications, techniques, aftercare, and complications for renal biopsy, nephrostomy insertion, percutaneous nephrolithomy procedures, and ureteric stent insertion. Renal biopsy and nephrostomy insertion are commonly performed in most pediatric centers. Percutaneous nephrolithomy may be limited to centers with a significant urology workload, but are complex procedures ideally performed as joint cases between urology and interventional radiology. (Source: Techniques in Vascular and Interventional Radiology)
Upper Gastrointestinal Access in Children: Techniques and Outcomes
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This article describes the radiologic techniques to obtain upper gastrointestinal access in children with poor oral intake and inadequate nutrition. Our goal is to provide a simple guide of radiologic gastrostomy and gastrojejunostomy procedures, their technical success, and long-term outcomes. Potential complications will be discussed as well as their management. It is important to emphasize that a multidisciplinary approach (pediatrician, dietitian, interventional radiologist, pediatric surgeon) is paramount for appropriate indications and management of patients with gastrostomies and gastrojejunostomies. (Source: Techniques in Vascular and Interventional Radiology)
Pediatric Image-Guided Nonvascular Musculoskeletal Interventions
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We describe our techniques for our more commonly performed MSK procedures, including corticosteroid injections, treating osteoid osteomas, and performance of image-guided bone biopsies and foreign body removal. (Source: Techniques in Vascular and Interventional Radiology)
Biopsy and Drainage Techniques in Children
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This article will focus on these differences and describe specific techniques applicable to pediatric patients. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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Children have benefited from interventional radiology (IR) techniques since the early days of the field. Pioneers in the field over the years have performed pediatric IR procedures, such as percutaneous nephrostomy, angiography, and abscess drainage, since the days of fluoroscopy, with the range of procedures increasing markedly with the development of ultrasound and CT. In the last 5 years, there has been emergence of a critical mass of dedicated practitioners, arising from the worlds of pediatric radiology (70%), interventional radiology (20%), and neuroradiology (10%). As a result, the field has started to develop an identity, with increasing potential to collaborate for scientific advancement and to advocate for the needs of its patients. In addition to the practice of self-identified ...
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Mandatory Radiation Safety Training for Interventionalists: The European Perspective
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Radiation protection (RP) knowledge is of paramount importance for interventionalists. All international bodies acknowledge the importance of education and training in reducing patient doses while maintaining the desired level of quality in medical exposures. The basic recommendations of the International Commission on Radiological Protection (ICRP) on RP training for Interventional Radiology (IR) are summarized as follows: a second, specific level of training in RP; specific additional training whenever new X-ray systems or techniques are implemented, and quality assurance programs, including RP training. The European perspective is discussed in the framework of the Directive on Medical Exposures: Competence in RP must be certified. The Member States of the European Union shall ensure tha...
How to Create a Quality Assurance Program for Radiation Safety in Interventional Radiology
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This article very briefly describes one simple example of a radiation safety quality assurance program. (Source: Techniques in Vascular and Interventional Radiology)
Measuring and Monitoring Radiation Dose During Fluoroscopically Guided Procedures
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The principal problem in measuring patient radiation dose during fluoroscopically guided procedures is that dose is not administered uniformly throughout the patient's body. Four dose metrics have been developed to quantify patient radiation dose for fluoroscopically guided procedures: fluoroscopy time, peak skin dose, reference dose, and kerma-area-product. Each metric must be understood to be used appropriately. Fluoroscopy time correlates poorly with other dose metrics. It should not be used as the sole method to estimate, monitor, or record patient radiation dose unless no alternative is available. Kerma-area-product is a good metric for estimating stochastic risk. Reference dose is a conservative method to estimate peak skin dose and deterministic risk and is recommended for this purp...
Managing Image Quality and Patient Dose in the Angiography Suite: Do You Really Need That Image Quality?
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This article reviews the basic tenets of minimizing patient dose in the angiography suite. In addition, it investigates technical parameters that can be manipulated, allowing the operator to achieve the image quality needed to successfully complete the task with the least dose delivered to the patient. While a detailed description of each manufacturer's operating instructions is beyond the scope of this article, general principles are reviewed so that operators can understand the questions and issues involved. The hope is that this will facilitate the adaptation of these principles, which can then be applied to any machine. The responsibility is then on the operators to become facile with their own technical environment, so the maximum benefit/risk ratio can be afforded patients. (Source: ...
Patient Radiation Management and Preprocedure Planning and Consent
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Protection of patients from excessive medical radiation has become a high priority in health care. As clinical physicians, interventional radiologists must remain cognizant of the radiation we use in daily practice. Radiation reduction begins before the procedure itself, as with appropriate preprocedural planning the amount of fluoroscopy and angiography used can then be reduced. Patients should be counseled regarding the potential for use of significant amounts of radiation when procedures associated with such doses are planned, as part of the process of obtaining informed consent. If significant radiation is used, patients should be alerted to have appropriate follow-up. The amount of radiation used can be reduced by careful attention to imaging technique. (Source: Techniques in Vascular...
Optimizing Dose in Computed Tomographic Guided Procedures
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This article reviews techniques to optimize patient exposure during CT-guided interventions. (Source: Techniques in Vascular and Interventional Radiology)
Operator Shielding: How and Why
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Staff are exposed to potentially high levels of radiation exposure during interventional radiology procedures. Radiation protection shielding devices should be used to help maintain personnel exposures as low as reasonably achievable. Body protection tools include lead aprons, thyroid shields, radiation protection cabins, and floor- and table-mounted shields. Eye protection tools include leaded glasses, ceiling-mounted shields, and protective patient drapes. Hand protection tools include leaded surgical gloves and protective patient drapes. For the most part, these radiation protection tools provide substantial dose reduction for personnel, with several notable exceptions. Leaded glasses without lateral protection do not provide adequate protection to operators because they are typically e...
Radiation Safety in Pediatric Interventional Radiology
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We describe specific strategies to improve patient and staff safety. These include staff education, safety checklists, a team approach, and formalized review and quality assurance programs. Practical steps to reduce patient dose are reviewed, and tools to assist in achieving the goal of optimizing radiation safety in children undergoing interventional procedures are provided. (Source: Techniques in Vascular and Interventional Radiology)
Interventional Radiology: Management of the Pregnant Patient
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This article reviews a practical approach to managing the dose of ionizing radiation during IR procedures where the patient is, or might be pregnant. (Source: Techniques in Vascular and Interventional Radiology)
Radiation Exposure and Uterine Artery Embolization: Current Risks and Risk Reduction
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Uterine embolization has become accepted into the mainstream of fibroid therapies and now is among the most common interventions for the condition. Because the procedure is based on angiographic techniques, it requires fluoroscopic and angiographic imaging, both dependent on exposure to ionizing radiation. Given the increasing popularity of this procedure, it is important to understand the potential impacts of this exposure on both individual patients and also the population as a whole. This review is intended to summarize the our current knowledge of the potential risks associated with the radiation exposure from procedure and how those risks might be controlled and reduced by adjusting techniques used during the procedure. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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Radiation safety is a hot topic in both the lay press and the medical literature. Within the last couple of years, reports of unrecognized, high radiation doses during brain perfusion studies, accidental exposures of pregnant patients, and high doses delivered to children have made headlines, while articles on the increased contribution to the population's medical radiation exposure and estimations of the cancer risk of computed tomography (CT) have recently been reported in the medical literature. Both patients and health care providers are keenly aware of this issue. Interventional radiology, as a contributor to the collective dose of the US population, comes in third behind CT and nuclear medicine. Nonetheless, for any given complex procedure, the dose to an individual patient has the p...
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Forthcoming Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Stenting for Atherosclerotic Renal Artery Stenosis
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Atherosclerotic renal artery stenosis (ARAS) is the most common cause of renal artery stenosis in the adult population. ARAS may result in progressive renal impairment, renovascular hypertension, and/or cardiac disturbance syndromes. Because medical therapy does not affect the progressive nature of this disease process, more aggressive treatments are needed to definitively treat ARAS. When performed correctly, renal artery stenting has been shown to stabilize or improve renal function and/or renovascular hypertension in 65-70% of carefully selected patients with ARAS. Therefore, percutaneous renal artery stenting should be considered the primary treatment for patients with symptomatic ARAS. (Source: Techniques in Vascular and Interventional Radiology)
Treatment of Renal Artery Fibromuscular Dysplasia
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This article focuses on the modern technical considerations in the diagnostic evaluation and endovascular treatment of renal artery fibromuscular dysplasia. (Source: Techniques in Vascular and Interventional Radiology)
Adrenal Vein Sampling
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Adrenal vein sampling is the gold standard for localizing aldosterone-secreting adenomas and for distinguishing adenomas from bilateral adrenal hyperplasia in patients with primary hyperaldosteronism. The importance of this distinction cannot be overstated because the former is curable surgically, whereas the latter is managed medically.Primary hyperaldosteronism has historically been underdiagnosed as a cause of hypertension, but recent reports highlight its ubiquitous nature with a prevalence of 5%-10% in screened hypertensive patients. Of such patients, up to 62.5% have a potentially curable adenoma as the underlying etiology.Adrenal vein sampling is a safe, highly effective procedure that is shown to alter the clinical management in 35.7% of primary hyperaldosteronism patients who woul...
Image-Guided Adrenal and Renal Biopsy
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Image-guided biopsy is a safe and well-established technique that is familiar to most interventional radiologists. Improvements in image guidance, biopsy tools, and biopsy techniques now routinely allow for safe biopsy of renal and adrenal lesions that traditionally were considered difficult to reach or technically challenging. Image-guided biopsy is used to establish the definitive tissue diagnosis in adrenal mass lesions that cannot be fully characterized with imaging or laboratory tests alone. It is also used to establish definitive diagnosis in some cases of renal parenchymal disease and has an expanding role in diagnosis and characterization of renal masses before treatment. Although basic principles and techniques for image-guided needle biopsy are similar regardless of organ, this p...
Percutaneous Ablation of Adrenal Tumors
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Adrenal tumors comprise a broad spectrum of benign and malignant neoplasms and include functional adrenal adenomas, pheochromocytomas, primary adrenocortical carcinoma, and adrenal metastases. Percutaneous ablative approaches that have been described and used in the treatment of adrenal tumors include percutaneous radiofrequency ablation, cryoablation, microwave ablation, and chemical ablation. Local tumor ablation in the adrenal gland presents unique challenges, secondary to the adrenal gland's unique anatomic and physiological features. The results of clinical series employing percutaneous ablative techniques in the treatment of adrenal tumors are reviewed in this article. Clinical and technical considerations unique to ablation in the adrenal gland are presented, including approaches co...
Transcatheter Renal Artery Embolization for Management of Renal and Adrenal Tumors
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This article reviews the indications and techniques involved in performing transcatheter arterial embolization for renal and adrenal tumors. (Source: Techniques in Vascular and Interventional Radiology)
Bowel Displacement and Protection Techniques During Percutaneous Renal Tumor Thermal Ablation
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Although bowel injury is a rare complication of renal radiofrequency ablation, the potential consequences can be devastating. Therefore, it is prudent to perform bowel displacement/protection procedures when feasible. The main bowel displacement techniques include hydrodissection, gas-insufflation, balloon interposition, and electrode torquing. In this article, these techniques are discussed and the steps involved in performing these procedures are enumerated. (Source: Techniques in Vascular and Interventional Radiology)
Introduction
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Renal and ureteric interventions are a broad set of interventions involving the kidney and ureter. Broadly, they represent an expanding field in interventional radiology particularly from the embolization and/or oncology standpoint. This collective of procedures involve several technical disciplines of interventions from percutaneous nonvascular oncology procedures, to percutaneous urological procedures, to transcatheter arterial procedures. Perhaps the most traditional category are the percutaneous urological procedures. These procedures are important to master for the interventional radiologist and are vital to institutions and clinical services for which the radiology service collaborates with. (Source: Techniques in Vascular and Interventional Radiology)
Table of Contents
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(Source: Techniques in Vascular and Interventional Radiology)
Previous Topics
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(Source: Techniques in Vascular and Interventional Radiology)
Editorial Board
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(Source: Techniques in Vascular and Interventional Radiology)
Drug Eluting Balloons
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Ever since the first percutaneous transluminal angioplasty (PTA) was carried out in Switzerland in 1977, restenosis remains a major drawback of this minimally invasive treatment intervention. Numerous attempts to increase vessel patency after PTA have included systemic medications and endovascular brachytherapy, but these techniques have not met our expectations in preventing restenosis. Nitinol stents have been shown to reduce rates of restenosis and target lesion revascularization in patients undergoing endovascular treatment of long femoropopliteal obstructions. Despite further technical refinements in nitinol stent technology, restenosis occurs in approximately every third patient undergoing femoropopliteal stenting. Similarly, initial clinical trials with drug-eluting stents have fail...
Distal Embolic Protection for Infrainguinal Interventions: How to and When?
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Distal embolization is a well-recognized complication during lower extremity revascularization procedures. Preliminary work has shown safety and feasibility of the use of embolic protection devices in this vascular territory. While many interventionalists believe that this technology offers a clear benefit for infrainguinal use based on the clinical safety data seen in other vascular beds, others believe that the exact role is poorly defined. All clinical experience to date has been with devices designed for other vascular territories and this has created a unique set of technical obstacles and potential risks. At present, clinical use is increasing despite a lack of data regarding which patients are at greatest risk for distal embolization, which anatomy is appropriate for the use of this...
Debulking Procedures: Potential Device Specific Indications
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This article will review the different indications for the use of these atherectomy devices including tips and specific device limitations. (Source: Techniques in Vascular and Interventional Radiology)
Treating the Diseased Superficial Femoral Artery
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Vascular disease involving the superficial femoral artery (SFA) is common. Once the decision to treat the SFA is made, the benefits and limitations of angioplasty and stents must be applied to each specific patient. Additionally, the potential role of covered stents as well as drug eluting stents must be considered. (Source: Techniques in Vascular and Interventional Radiology)
Percutaneous Revascularization of Chronic Total Occlusions
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Many patients with severe intermittent claudication (IC) or critical limb ischemia (CLI) have chronic total occlusions (CTO) in their lower extremity vascular bed. The successful treatment of these lesions is becoming increasingly more important as the population ages and the prevalence of diseases such as diabetes mellitus and its consequences increases. Many of these patients have significant comorbidities and may benefit from less invasive treatment options. Several endovascular techniques have now become well established in the treatment of these lesions. Additionally, several new adjunctive tools have been developed to enhance the technical success of CTO revascularization. These tools and techniques offer a minimally invasive alternative for limb salvage in this compromised patient p...