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Novel diagnostic and imaging techniques in endovascular iliac artery procedures.
De Boer, SW, Heinen, SGH, Goudeketting, SR, De Haan, MW, Mees, BM, Van Den Heuvel, DAF, De Vries, JPM
Expert review of cardiovascular therapy. 2020;(7):395-404
Abstract
INTRODUCTION Endovascular revascularization has become the preferred treatment for most patients with iliac artery obstructions, with a high rate of clinical and technical success. AREAS COVERED This review will describe novel developments in the diagnosis and treatment of iliac artery obstructions including the augmentation of preprocedural imaging with advanced flow models, image fusion techniques, and state-of-the-art device-tracking capabilities. EXPERT OPINION The combination of these developments will change the endovascular field within the next 5 years, allowing targeted iliac treatment without the need for radiographic imaging or iodinated contrast media.
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Modified calcium subtraction in dual-energy CT angiography of the lower extremity runoff: impact on diagnostic accuracy for stenosis detection.
De Santis, D, De Cecco, CN, Schoepf, UJ, Nance, JW, Yamada, RT, Thomas, BA, Otani, K, Jacobs, BE, Turner, DA, Wichmann, JL, et al
European radiology. 2019;(9):4783-4793
Abstract
OBJECTIVES To investigate the diagnostic accuracy of a modified three-material decomposition calcium subtraction (CS) algorithm for the detection of arterial stenosis in dual-energy CT angiography (DE-CTA) of the lower extremity runoff compared to standard image reconstruction, using digital subtraction angiography (DSA) as the reference standard. METHODS Eighty-eight patients (53 males; mean age, 65.9 ± 11 years) with suspected peripheral arterial disease (PAD) who had undergone a DE-CTA examination of the lower extremity runoff between May 2014 and May 2015 were included in this IRB-approved, HIPAA-compliant retrospective study. Standard linearly blended and CS images were reconstructed and vascular contrast-to-noise ratios (CNR) were calculated. Two independent observers assessed subjective image quality using a 5-point Likert scale. Diagnostic accuracy for ≥ 50% stenosis detection was analyzed in a subgroup of 45 patients who had undergone additional DSA. Diagnostic accuracy parameters were estimated with a random-effects logistic regression analysis and compared using generalized estimating equations. RESULTS CS datasets showed higher CNR (15.3 ± 7.3) compared to standard reconstructions (13.5 ± 6.5, p < 0.001). Both reconstructions showed comparable qualitative image quality scores (CS, 4.64; standard, 4.57; p = 0.220). Diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) for CS reconstructions was 96.5% (97.5%, 95.6%, 90.9%, 98.1) and 93.1% (98.8%, 90.4%, 82.3%, 99.1%) for standard images. CONCLUSIONS A modified three-material decomposition CS algorithm provides increased vascular CNR, equivalent qualitative image quality, and greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff on DE-CTA compared with standard image reconstruction. KEY POINTS • Calcified plaques may lead to overestimation of stenosis severity and false positive results, requiring additional invasive digital subtraction angiography (DSA). • A modified three-material decomposition algorithm for calcium subtraction provides greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff compared with standard image reconstruction. • The application of this algorithm in patients with heavily calcified vessels may be helpful to potentially reduce inconclusive CT angiography examinations and the need for subsequent invasive DSA.
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[The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease].
Mohebbi, N
Praxis. 2018;(13):683-687
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Abstract
The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.
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Magnetic Particle Imaging Guided Real-Time Percutaneous Transluminal Angioplasty in a Phantom Model.
Herz, S, Vogel, P, Dietrich, P, Kampf, T, Rückert, MA, Kickuth, R, Behr, VC, Bley, TA
Cardiovascular and interventional radiology. 2018;(7):1100-1105
Abstract
PURPOSE To investigate the potential of real-time magnetic particle imaging (MPI) to guide percutaneous transluminal angioplasty (PTA) of vascular stenoses in a phantom model. MATERIALS AND METHODS Experiments were conducted on a custom-built MPI scanner. Vascular stenosis phantoms consisted of polyvinyl chloride tubes (inner diameter 8 mm) prepared with a centrally aligned cable tie to form ~ 50% stenoses. MPI angiography for visualization of stenoses was performed using the superparamagnetic iron oxide nanoparticle-based contrast agent Ferucarbotran (10 mmol (Fe)/l). Balloon catheters and guidewires for PTA were visualized using custom-made lacquer markers based on Ferucarbotran. Stenosis dilation (n = 3) was performed by manually inflating the PTA balloon with diluted Ferucarbotran. An online reconstruction framework was implemented for real-time imaging with very short latency time. RESULTS Visualization of stenosis phantoms and guidance of interventional instruments in real-time (4 frames/s, ~ 100 ms latency time) was possible using an online reconstruction algorithm. Labeling of guidewires and balloon catheters allowed for precise visualization of instrument positions. CONCLUSION Real-time MPI-guided PTA in a phantom model is feasible.
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Vein arterialization for lower limb revascularization.
Houlind, K, Christensen, JK, Jepsen, JM
The Journal of cardiovascular surgery. 2016;(2):266-72
Abstract
Conventional bypass surgery is only possible when patent distal arterial outflow vessels are available. In patients with critical limb ischemia and occluded distal arteries, attempts have been made to establish retrograde perfusion through either deep or superficial pedal veins. Though historical results were disappointing, more recently limb salvage has been achieved after adopting a principle of 1) placing the anastomosis distally, and 2) actively destroying the distal valves. Experimental, para-clinical, and clinical data confirm that direct tissue nutrition is improved, angiogenesis stimulated, and collaterals opened. Only a limited number of cases have been reported in the literature and a number of different operative techniques have been described. The results in terms of limb salvage and wound healing vary widely. Generally, results are poorer than what would have been expected if femoro-distal arterial bypass had been possible. Recently, hybrid approaches have been developed to avoid extensive distal incisions by endovascular destruction of valves and closure of side branches. Also, a totally endovascular technique, including the position of a stent graft between the vein and artery, has been proposed and tested. These developments may in the future improve results by limiting incisional wound complications and make this treatment available to more patients who would otherwise have no other alternative than amputation.
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Drug coated balloons below-the-knee: just too early?
Fanelli, F, Cannavale, A
The Journal of cardiovascular surgery. 2016;(1):18-22
Abstract
Patients with infrapopliteal arterial disease are generally considered challenging due to the usual presence of multivessel atherosclerotic disease. Several treatment options have been used by different authors but none of them can be considered ideal. In the last few years drug coated balloons have gained popularity especially due to the extraordinary results in the femoro-popliteal region. Following the great success, physicians started to use this promising device also in the below-the-knee (BTK) region. The initial enthusiasm correlated to some studies is not confirmed by the largest randomized trial, IN.PACT Deep, comparing In.Pact DCB to standard PTA. This trial failed completely to show the superiority of drug coated balloon (DCB). The negative outcome was mainly correlated to safety issues with an amputation rate higher for the drug coated balloon when compared to the conventional balloon (8.8% DCB vs.3.6% PTA, P=0.08). A thorough evaluation has been performed to justify these negative outcomes, given the good results reported by other studies. But nowadays it is still difficult to find a clear explanation. Especially for this negative outcome and for the big difference, in term of results, between the different studies in the BTK region and also between the above and below the knee regions more trials are mandatory.
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What are the potential limitations of drug coated balloons and possible ways to overcome.
Werk, M
The Journal of cardiovascular surgery. 2016;(1):23-8
Abstract
In several independent randomized clinical studies, it has been shown that drug-coated balloons (DCBs) cause persistent clinically meaningful and statistically significant inhibition of restenosis in femoropopliteal arteries in comparison to percutaneous transluminal angioplasty with uncoated balloon catheters. The potential benefits of delivering an antiproliferative drug into the vessel wall using a balloon as transporter are manifold: 1) widespread applicability: balloon angioplasty is suitable for use in a wide range of lesions. The use of DCBs is technically less demanding and offers greater flexibility compared with stenting techniques. 2) Maintaining options: minimizing the use of durable implants is providing more options for following and complementary revascularization procedures; 3) proven efficacy: consistent, positive outcomes across studies and key subgroups have been demonstrated from the first preclinical studies to ongoing clinical trials. Beside the enthusiasm carried along with this novel technique and questioning if DCBs will become standard-of-care-therapy for the superficial femoral artery, the potential limitations have to be discussed.
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Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease.
Mendes, Cde A, Martins, Ade A, Teivelis, MP, Kuzniec, S, Varella, AY, Fioranelli, A, Wolosker, N
Clinics (Sao Paulo, Brazil). 2015;(10):675-9
Abstract
OBJECTIVES Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine. MATERIALS AND METHODS From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group. RESULTS No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers. CONCLUSIONS The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.
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Minilaparotomy as surgical approach for aortoiliac occlusive disease -- single center initial experience.
Neagoe, RM, Voicu, B, Sala, DT, Puskas, A, Suciu, H
Chirurgia (Bucharest, Romania : 1990). 2013;(5):689-94
Abstract
PURPOSE The purpose of this study was to emphasize the benefits and indications of performing minilaparotomy as surgical approach for occlusive aortoiliac disease. MATERIAL AND METHOD From January 2011 to July 2012, a total of 23 patients (19 men and 4 women), with a median age of 60 years (range 49-75) diagnosed with aortoiliac occlusive disease(n=22) or abdominal aneurysm (n=1), were included in a retrospective non-randomized clinical study. Among these patients 11 underwent aortic bypass procedure by minila parotomy approach (ML group) and 12 patients by standard laparotomy(SL group). Demographic and clinical data, operative data, postoperative recovery data and complications were analysed according to these two groups of patients. Follow-up consisted of clinical examination and duplex scanning at 1, 3,6 and 12 months postoperatively. RESULTS There were no significant differences between the minilaparotomy and standard laparotomy control groups concerning clinical and demographical data. Two surgical conversions to standard laparotomy were necessary (18.18%) in the ML group due to technical difficulties. The mean operative time was shorter in the ML group (124 ± 22 minutes) and the mean aortic clamping time was similar between the two groups.Major differences between the two lots were observed postoperatively;mean blood loss was more important in the SL group (550 ml) than in the ML group (350 ml) (statistical significance p=0.001, Student test). Patients who have undergone standard laparotomy required more fluids (10000 Â+-2000 ml) in comparison to the other group (6000 ± 1000 ml) p value=0.0001, while the duration of nasogastric suction and period before resuming a liquid diet was both shorter in the ML group (1.1 ± 0.5 days) than those from the SL group (2.5 ± 0.6 days) p value=0.001. The period spent in the ICU was significantly shorter for the ML lot of patients and the median hospitalization time was 5.6 days for patients in ML group,whereas in the SL group the median hospitalization time was 8.9 days (Student test - p value 0.01). We had no 30-day mortality in any of the groups included in the study. One patient from the ML group was readmitted in postoperative day 43 and re-operated on for a prosthetic limb graft thrombosis.Two patients were lost to follow-up and the mean follow-up was 9 ± 1.5 months. CONCLUSIONS Minilaparotomy as surgical approach for aortic diseases is a feasible, safe procedure on selected patients.
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Garlic for peripheral arterial occlusive disease.
Jepson, RG, Kleijnen, J, Leng, GC
The Cochrane database of systematic reviews. 2013;(4):CD000095
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Abstract
BACKGROUND Commercially available preparations of garlic have been reported to have beneficial effects on some of the risk factors associated with atherosclerosis. OBJECTIVES To assess the effects of garlic (both dried and non-powdered preparations) for the treatment of peripheral arterial occlusive disease. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). SELECTION CRITERIA Randomised trials of garlic therapy in patients with lower limb atherosclerosis were included. The main outcomes were objective measures of progression of underlying atherosclerosis (e.g. ankle pressure measurements, treadmill testing) and subjective measures (e.g. symptom progression). DATA COLLECTION AND ANALYSIS Two review authors (RJ and JK) independently extracted data and assessed trial quality. One author (RJ) contacted investigators to obtain information needed for the review that could not be found in published reports. MAIN RESULTS One eligible trial with 78 participants was found. Both men and women (aged 40 to 75) were included. The follow-up period was short, 12 weeks only.After twelve weeks of treatment, pain-free walking distance increased from 161 to 207 metres in the group receiving garlic and from 172 to 203 metres in the placebo group. This was not a statistically significant difference. There was no difference in change of systolic or diastolic blood pressure, heart rate, ankle and brachial pressures. No severe side effects were observed and nine patients taking garlic (28%) and four patients taking placebo (12%) complained of a noticeable garlic smell.Three trials were excluded from the review because they did not include any clinical measurements. AUTHORS' CONCLUSIONS One small trial of short duration found no statistically significant effect of garlic on walking distance.