We report our experience with catheter-directed, ultrasound-assisted thrombolysis for acute pulmonary embolism (PE). We were particularly interested in the metrics to assess early success and the safety of this procedure in patients deemed to be at high risk for thrombolytic therapy. A retrospective evaluation of patients who underwent catheter-directed pulmonary thrombolysis in our practice during 29 months is reported. There were 62 patients considered, all of whom presented with acute PE as diagnosed by computed tomography (CT) angiography. The ratio of the right ventricle to left ventricle diameter (RV:LV) was noted, as were preprocedure pulmonary artery pressures (PAPs). Demographic data, significant medical history, and procedure details were recorded. CT scans were reviewed, and confirmatory RV:LV ratios were obtained. Standard thrombolysis protocol was followed (1 mg tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). Minitab v17 (Minitab, State College, Pa) was used for data analysis. Sixty-two patients had a CT diagnosis of acute PE and pulmonary hypertension (PAP >25 mm Hg). Twelve patients (19%) were deemed to have a high risk for bleeding. On CT angiography, the mean pretherapy RVaxial:LVaxial ratio was 1.5 ± 0.4. The mean pretherapy PAP was 55.0 ± 13.1 mm Hg. After 19.4 ± 3.4 hours of thrombolysis, the mean post-therapy PAP was 35.0 ± 10.7 mm Hg, with a pressure drop of 21.3 ± 11.8 mm Hg (39% decrease). Three patients (5%) suffered bleeding complications, two gastrointestinal bleeds and one rectus sheath hematoma. One of the three complications occurred in the high-risk group (1/12) and the other two in the general population of patients (2/50; Fisher exact test, P = .488). Minor bleeding complications (n = 11; 18%) included puncture site hematomas, ecchymosis, and traumatic hematuria. Considering all bleeding complications, increasing RVaxial:LVaxial ratio was a predictor of a bleeding complication, independent of all risk factors (likelihood ratio test, P = .005). Catheter-directed thrombolysis for acute PE effectively reduced mean PAP in patients with a dilated RV. As only three patients had notable bleeding complications, only one of whom was at high risk, we additionally conclude that this is a safe procedure. We encourage the use of catheter-directed, ultrasound-assisted pulmonary thrombolysis for the management of severe, acute pulmonary embolization with a dilated RV.

Despite the improvement in endovascular techniques, one aspect of aneurysmal disease that continues to be challenging is the management of aortoiliac aneurysms. Sacrificing the hypogastric artery (HGA) for effective treatment is not without sequelae, which may include buttocks claudication, colonic ischemia, spinal cord ischemia, as well as buttock and scrotal necrosis. This should be taken into consideration particularly in patients with previous intervention or potential additional future interventions. This review describes the current endovascular techniques for preservation of HGA perfusion.

Objective: The efficacy of radiofrequency ablation (RFA) for symptomatic varicose veins is well established. Alternatively, there is less consensus and little data on outcomes when treating great saphenous veins (GSV) of small diameter (:55 nun). The purpose of this study is to assess clinical and anatomical outcomes of RFA on symptomatic patients with small GSV.Methods: A retrospective analysis was performed on our symptomatic patients who received RFA of incompetent GSV without any concomitant adjunctive procedures between January 2008 and December 2011. Limbs with GSV thigh diameter <= 5 mm and >5 mm on duplex while standing were subject to review. Clinical success was defined as an improvement in Venous Clinical Severity Score (VCSS) at 3 months. Anatomic success was defined as absence of venous flow cm distal to the saphenofemoral junction on duplex ultrasound examination. Changes in CEAP class were noted.Results: In 307 patients, 55 limbs in 44 patients met inclusion criteria. Baseline median VCSS was 4 (interquartile range [IQR], 4, 5) for those patients with diameter <= 5 mm. Clinical success was seen in 83% of limbs at 3 months with a median VCSS change of -2 (IQR, -3, -1). None of the treated limbs had phlebectomy for symptomatic refluxing GSV varicosities prior to 3-month follow up. One phlebectomy was performed for cosmesis at 78 days postprocedure. Anatomic success was achieved in 96% of limbs at 3 months. Baseline median CEAP was 2 (IQR, 2, 2). The median CEAP change at 3 months was 0 (IQR, -1, 0). One patient experienced thrombus extension into the saphenofemoral junction at 4 days.Conclusions: In our experience, RFA of symptomatic small diameter GSV provides comparable clinical and anatomic outcomes to that of current published data. Our findings suggest that these patients benefit clinically from RFA.

effects of H2S on tissue stability and viability, and optimize conditions for transplantation and for the eventual induction of immunotolerance to composite tissue allotransplants.

OBJECTIVES:Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms.METHODS:Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months).RESULTS:Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%).CONCLUSION:While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.