PURPOSE:To determine if IVUS use in patients with chronic venous disease increases the rate of ulcer healing through identification and treatment of significant central venous stenoses not visualized on venography alone. MATERIALS AND METHODS:A retrospective review was performed of 170 patients (104 males and 66 females; mean age, 64 years) with Clinical, Etiology, Anatomy, and Pathophysiology 6 disease undergoing venography and intervention for active venous ulcers in 178 limbs at a single tertiary care center from 2010 to 2024. Patient demographics, ulcer characteristics, interventions performed, and outcomes were reviewed. Procedures with venography and with (n = 83 limbs, 47%) or without IVUS (n = 95 limbs, 53%) were compared. Analysis assessed baseline characteristics and procedural outcomes, including ulcer healing rates, symptom scores, and healthcare utilization. RESULTS:Patients who underwent IVUS assessment had a higher rate of complete ulcer healing (27% vs 13%; odds ratio, 2.8; P = .02) and larger decrease in ulcer size (P < .001). There was no significant difference in Venous Clinical Severity Score (P = .08). Lower healthcare utilization was observed in the IVUS group (13 wound care visits and 24 home health visits per patient-year, versus 14 wound care visits and 38 home health visits per patient-year), although this did not reach statistical significance (P = .06). CONCLUSIONS:In this retrospective cohort study, patients with active venous ulcers who underwent IVUS and venography experienced improved ulcer healing in comparison with those who underwent venography alone.

This study evaluates catheter failure rates between a helical-tip catheter and a traditional split-tip catheter among intensive care unit (ICU) patients undergoing tunneled dialysis catheter (TDC) placement. We analyzed 1734 TDCs placed over seven years in a retrospective fashion, focusing on 340 catheters used in an ICU setting. Of these, 112 were VectorFlow catheters (32.9

To compare outcomes of men undergoing prostate artery embolization (PAE) for return of lower urinary tract symptoms (LUTS) following failure of UroLift with a contemporaneous control group of men with benign prostatic hyperplasia and LUTS undergoing PAE as an index procedure. Over a four-year period, a prospectively maintained database identified 17 PAEs performed in men a mean of 48.4 months (range 33-93) following UroLift. These cases were compared to a contemporaneous control group of 49 men with prostate volumes < 100 g who underwent PAE; a 100 g threshold was utilized as these men would otherwise have been ineligible for UroLift themselves. International Prostate Symptom Severity (IPSS) scores were compared with the Mann-Whitney U test. Mean age of the UroLift cases was 67.0 years (range 57–82) and 67.6 years (range 54–83 years) among the controls (p=0.83). At baseline, mean prostate volume was 81 g among the prostatic lift patients and 70 g among controls (p=0.45). Mean IPSS baseline scores were 24.0 (range 15-32) among prostatic lift patients prior to PAE and 22.4 (range 8-34) among controls (p= 0.51). Post-intervention IPSS scores were collected at a mean of 3.1 months (range 0.33-5 months) following PAE for the UroLift patients and 4.0 (range 0.23-29 months) months for the control patients (p=0.36). Mean IPSS reduction following PAE was -14.4 (range -26-2) among UroLift patients and -11.3 (range -28-9) among controls (p=0.35). Men with prior failure of UroLift experienced similar improvements in LUTS as men with no prior prostatic intervention.

PurposeTo determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS).Materials and MethodsA retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions.ResultsTechnical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups.ConclusionsIn this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

To evaluate the success and safety of below-the-elbow interventions for upper extremity critical limb ischemia in arms without functional hemodialysis accesses. From June 2014 to June 2023, 22 forearm revascularizations for chronic limb ischemia were performed in 15 arms of 13 patients (6 female, 7 male) at a single center. Medical and procedural records were reviewed for baseline characteristics, procedural details, and outcomes. Clinical success was defined as improvement of ischemic symptoms, spontaneous healing of wounds, and healing of planned partial amputations. 6 interventions were performed in cases of connective tissue disease; all other cases were in patients with atherosclerotic disease. Ulceration or gangrene was present before 14 of 22 interventions. 4 interventions were performed in arms that had a previous dialysis fistula or graft that had been occluded at least 30 days prior to the intervention, and the remainder had no ipsilateral dialysis access. Balloon angioplasty was used in all cases; mechanical thrombectomy was also used in 6, and intravascular lithotripsy in 1 case. Technical success was 96% (21/22 cases). Among technically successful cases and after exclusion of 1 case due to lack of follow-up >30 days, 16 of 20 were clinically successful (80%). 9 of 20 healed a planned interphalangeal or digital amputation following revascularization; none had amputations at higher levels. Among cases with follow-up imaging, primary patency was 81% (13/16) at 1 month and 62% (8/13) at 3 months. For technical successes who had at least 6 months of follow-up, freedom from clinically driven target lesion revascularization (CD-TLR) was 71% (12/17) at 6 months. Overall freedom from CD-TLR was 65% (13/20) at an average follow-up of 16 months. There were 7 reinterventions among all cases; 2were for persistent symptoms after prior intervention; 2for new wounds on a different finger, appearing after the previous wound had healed; 1for acute thrombosis of the treated vessel; 1for return of symptoms after initial improvement; and 1 for target vessel restenosis on imaging in a high-risk patient although improvement in symptoms was noted. There were 5 minor adverse events consisting of self-limited extravasation or access site hematoma, and 1 moderate adverse event of early thrombosis of the target vessel. Below-the-elbow interventions for upper extremity critical ischemia in patients without functional hemodialysis accesses were safe with high rates of technical success, clinical success, and limb salvage.

Purpose: To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). Materials and Methods: Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). Results: After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008). Conclusions: ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Statins are widely utilized for coronary artery disease but their use in peripheral arterial disease is less prevalent despite consensus guidelines. We evaluated femoropopliteal stent patency according to statin intensity at the time of stent placement, and compared this effect to other covariates potentially influencing stent patency. A retrospective review identified 278 discrete femoropopliteal stent constructs in 216 patients over a 10-year period; Rutherford categories were 3 (16.3%), 4 (21.4%), 5 (50.0%) and 6 (12.3%). Stent construct locations were common femoral (1.8%), superficial femoral (77.9%), superficial femoral/popliteal (13.4%) and popliteal (7.6%) arteries; 63.8% of stents were paclitaxel-eluting. Primary unassisted patency of each stent construct was determined with duplex ultrasound, angiography, or computed tomographic angiography, alone or in combination; greater than 50% restenosis or stent occlusion was considered loss of patency. Statin intensity at the time of stent placement was categorized by American Heart Association (AHA) guidelines; additional covariates were analyzed with Cox proportional hazards modeling to assess for potential effects on stent patency. Patients on no statin at the time of stent placement were nearly three times as likely to undergo loss of primary unassisted patency as patients on moderate or high intensity statin therapy (hazard ratio 2.6, 95% CI 1.5-4.6, P=0.0007); moderate/high statin therapy conferred 19 additional months of median stent patency compared with the no statin group. In multivariate Cox modeling, antiplatelet therapy, anticoagulant therapy, drug-eluting stents (vs. bare-metal or covered stents) and Rutherford class were not predictive of stent patency (P = 0.22, 0.91, 0.69 and 0.41, respectively) whereas moderate/high intensity statin therapy patients had a hazard ratio of 0.54 for loss of primary unassisted patency compared with patients not on statins (P=0.006). Statin intensity at the time of index femoropopliteal stent placement was the most predictive examined variable influencing primary unassisted patency.

Abstract Background Statins are widely used in coronary and peripheral arterial disease, but their impact on patency of stents placed for peripheral arterial disease is not well-studied. The purpose of this study was to evaluate femoropopliteal stent primary patency according to statin intensity at the time of stent placement and compare this effect to other covariates that may influence stent patency. Materials and methods A retrospective review identified 278 discrete femoropopliteal stent constructs placed in 216 patients over a 10-year period; Rutherford categories were 2 (3.6%), 3 (12.9%), 4 (21.2%), 5 (49.6%), and 6 (12.6%). Stent locations were common femoral (1.8%), common femoral/superficial femoral (0.7%), superficial femoral (50.7%), superficial femoral/popliteal (32.7%) and popliteal (14.0%) arteries; 63.3% of stents were paclitaxel-eluting. Primary patency of each stent construct was determined with duplex ultrasound, angiography, or computed tomographic angiography. Greater than 50% restenosis or stent occlusion was considered loss of patency. Cox proportional hazard and Kaplan–Meier modeling were used to assess the effect of statin use and additional covariates on stent patency. Results Patients on any statin at the time of stent placement were half as likely to undergo loss of primary unassisted patency as patients on no statin therapy (hazard ratio, 0.53; 95% confidence interval, 0.19–0.87; P = .004). Moderate/high intensity statin therapy conferred 17 additional months of median stent patency compared to the no statin group. Antiplatelet therapy, anticoagulant therapy, drug-eluting stents (versus bare metal or covered stents), and Rutherford class were not predictive of stent patency (P = 0.52, 0.85, 0.58, and 0.82, respectively). Conclusion Use of statin therapy at the time of femoropopliteal stent placement was the most predictive examined variable influencing primary unassisted patency.

Purpose To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO). Materials and Methods A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement. Results Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9–14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency ( P = 0.006). Conclusion Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.

Effective management of type II endoleaks requires technical proficiency in multiple catheterization techniques depending on the supply and complexity of the endoleak. While the most commonly used access routes remain the transarterial and translumbar approaches, novel approaches such as transcaval access are increasingly being used in cases where the traditional techniques are unsuccessful or inadequate. The perigraft approach is an alternative novel option for endoleak embolization, which involves catheterization of the aneurysm sac between the common iliac artery and endograft. Our study aims to determine safety and effectiveness of the perigraft technique for embolization of type II endoleaks. Single-center retrospective review from 2014 to 2020 of 24 consecutive patients (12.5% female, mean age of 80.1 ± 6.4 years) who underwent 28 type II endoleak embolization procedures via a perigraft approach. Endpoints included technical success of perigraft catheterization, technical success of endoleak embolization, reintervention, freedom from AAA growth at follow-up, and adverse events. Technical success of perigraft catheterization and endoleak embolization were 92.9% and 89.3%, respectively. A combined transarterial and perigraft approach was employed in 30.8% (n = 8/26). Ethylene vinyl alcohol copolymer (Onyx) and coils were used in 92.9% and 46.4% cases, respectively. Freedom from AAA growth occurred in 85% (n = 17/20). Reintervention occurred in 20.8% (n = 5), including 4 repeat perigraft catheterizations. There were 2 SIR minor adverse events including a groin hematoma and dyspnea in a COPD patient. One major adverse event not related to the procedure was recorded involving an admission for atrial fibrillation and urinary retention. During follow up, 1 patient had AAA rupture 20 months after the successful index procedure requiring proximal snorkel extension and endograft relining. The 30-day mortality rate was 0. No type Ib endoleaks developed as a result of perigraft catheterization. The perigraft approach is safe and effective catheterization technique for embolization of type II endoleaks and can replace the translumbar and transcaval approaches in many cases with the advantage of not requiring sac puncture. Like the transcaval approach, it can be performed in a supine patient from a transfemoral approach and can be combined with other approaches if required. The perigraft approach is a useful addition to the armamentarium of catheterization techniques of type II endoleaks.

PURPOSE:This study aims to evaluate the safety and efficacy of novel approaches to type 2 endoleak access for the purpose of embolization using ethylene-vinyl-alcohol copolymer (EVOH) in patients with abdominal aortic aneurysm (AAA) sac expansion post endovascular abdominal aortic repair (EVAR).METHODS:A retrospective review of 43 consecutive patients (mean age = 80.2 ± 6.7 years) who underwent 52 embolization procedures for type 2 endoleaks using EVOH was performed at a single institution. Catheterization of the endoleaks was achieved using the transarterial (TA) and direct translumbar approaches (DTL), in addition to the novel direct transabdominal (DTA) and perigraft (PG) approaches. Endpoints included technical success of endoleak catheterization, technical success of endoleak embolization, endoleak persistence, endoleak recurrence, AAA sac area change, and adverse events.RESULTS:The TA, DTL, DTA, and PG approaches were used 25, 2, 14, and 19 times respectively, including nine procedures where a combination of approaches was used. The technical success rate of endoleak embolization was 98%. Five patients developed recurrent type 2 endoleaks, while five patients developed a type 1 endoleak. The persistent endoleak rate at a mean initial follow-up of 3 months was 34%. At a mean follow-up of 18 months, 58% of patients demonstrated absence of an endoleak, and 71% showed freedom from AAA sac enlargement. No major adverse events were recorded.CONCLUSION:The DTA and PG approaches were safe and effective in this cohort of patients undergoing embolization of type 2 endoleaks with EVOH.

Tunneled dialysis catheter tip design may affect freedom from catheter dysfunction and/or infection; improved performance within a critical care setting may reduce costs and need for catheter guidewire exchange or removal. This study compared rates of catheter failure between a symmetrical, helical-tip catheter (VectorFlow) with a conventional split-tip catheter (Ash-Split) among ICU patients undergoing tunneled dialysis catheter placement. A retrospective database identified a total of 1734 tunneled dialysis catheters placed at an academic institution over a 7-year period. Of these, 340 catheters (19.6%) were placed within ICU patients, which included VectorFlow (n = 112, 32.9%) and Ash-Split (n = 228, 67.1%) catheters. Rates of catheter failure requiring guidewire exchange or removal from a composite outcome of malfunction or infection were compared with Kaplan-Meier estimates, and covariates potentially influencing catheter failure were assessed with Cox proportional hazards modeling. Catheter failure occurred within 90 days in 34.8 ± 3.4% of ICU patients. Among patients with VectorFlow catheters, primary unassisted patency at 30, 60, 90 and 180 days was 87.4 ± 3.6%, 78.0 ± 5.1%, 75.1 ± 5.0% and 60.1 ± 8.2% compared with 75.0 ± 3.3%, 62.8 ± 4.1%, 60.7 ± 4.2% and 44.3 ± 5.5% among patients with Ash-Split catheters (P = 0.022). Cox modeling of body mass index, patient age, sex, left jugular (vs. right) placement and indication for placement (initiation of hemodialysis access vs. failed surgical arteriovenous access) showed no effect on catheter patency; patients with Ash-Split catheters had a hazard ratio of catheter failure 1.72 times higher than patients with VectorFlow catheters (P = 0.024) in univariate modeling and a hazard ratio of 1.81 in multivariate modeling (P = 0.017). The VectorFlow catheter was associated with significantly higher rates of primary patency than the Ash-Split catheter among ICU patients, independent of multiple clinical and anatomic factors. These data support a VectorFlow-first placement strategy within this patient population.

Endovascular revascularization is an established treatment modality for Rutherford 5-6 critical limb ischemia (CLI), with the goal of establishing in-line arterial flow to the wound bed. Although there is abundant evidence for above-the-ankle (ATA) procedures, below-the-ankle (BTA) procedures are not well studied. The present study aims to assess the safety and efficacy of BTA interventions in patients with Rutherford 5-6 CLI. A retrospective search identified 48 CLI patients who underwent 79 BTA procedures in 57 limbs. Mean age was 62.6 years (36 to 88 years). There were 20 females (41.7%) and 28 males (58.3%). Thirty-six patients (75%) had diabetes, and 13 (27.1%) had end-stage renal disease. All procedures were performed by two operators at a single tertiary medical center. Adverse events (AE) and technical outcomes were assessed per procedure. Technical success was defined as successful revascularization of the target artery. Limb salvage was assessed per limb and defined as freedom from major amputations (above the ankle). There were concurrent ATA interventions in 75 procedures, including 25 femoropopliteal and 75 tibial interventions. BTA treated arteries included 52 dorsalis pedis, 26 lateral plantar, 4 medial plantar, 21 pedal arches, and 2 metatarsal arteries. Mean follow-up time was 13.1 months (0.2 to 48.8 months). AE rate was 13.9%, all of which were minor, including 3 arterial dissections, 2 thrombotic events, 3 arterial perforations, and 1 arteriovenous fistula, all successfully managed with intraprocedural thrombectomy and/or angioplasty. There was 1 groin access hematoma managed conservatively. There was a single minor AE related directly to a BTA intervention; perforation managed with balloon tamponade. The technical success rate was 93.7%. Following revascularization, there were 22 repeat BTA percutaneous vascular interventions. Minor amputation rate was 28.1% including 12 toe/ray and 4 transmetatarsal amputations. There were 13 major amputations resulting in a limb salvage rate of 77.2% (44/57) at a mean follow-up time of 11.1 months (2.9 to 41.3 months). Concurrent BTA and ATA revascularization procedures were safe and technically feasible, with a high limb salvage rate. Further research is needed to determine the added benefit of BTA interventions in comparison to ATA interventions alone.

Dialysis-associated steal syndrome (DASS) occurs in 1–8

The role of interventional radiology in ensuring appropriate statin therapy among patients with peripheral arterial disease (PAD) has not been fully realized. We assessed the change in statin utilization post-revascularization among patients with PAD following interventional radiology efforts to increase patient education and provider notification.