Emergency percutaneous treatment of arterial iliac axis ruptures

Percutaneous Intervention of Iatrogenic Iliac Artery Vascular Complication

The mortality of patients from a retroperitoneal hematoma remains high if treatment is delayed or inappropriate. Percutaneous endovascular repair of iatrogenic vascular complications is quickly becoming the treatment of choice. Here, we report a case of a 76-year-old female with a non-ST-elevation myocardial infarction, whose cardiac catheterization revealed a 70% distal left main coronary artery (LMCA) stenosis. She underwent successful rotational atherectomy and deployment of drug-eluting stents of the distal LMCA. Following percutaneous coronary intervention, she suffered acute profound hypotension and was found to have a retroperitoneal hematoma. Given the high cardiac risk for vascular surgery due to recent intervention and overall comorbidities, she was immediately taken to the cardiac catheterization laboratory and had a diagnostic angiogram, which revealed a right external iliac artery perforation that was treated with a covered stent. She tolerated the procedure well. This case highlights the importance of early diagnosis of retroperitoneal bleed, the prompt decision to take the patient to the cardiac catheterization laboratory, and potential use of intravascular interventions to ensure a successful outcome.

Endovascular treatment of true renal artery aneurysms: a single center experience

PURPOSE

We aimed to report a single center's experience on endovascular treatment of true renal artery aneurysms (TRAAs), including treatment techniques and outcomes.

METHODS

This retrospective study was designed to evaluate the treatment and follow-up of TRAAs treated by a variety of endovascular interventional techniques over a period of 6 years. Six patients with nine TRAAs were identified; seven of the TRAAs were treated using different combinations of coil embolization and flow diverter stents. The clinical findings, aneurysm characteristics, endovascular methods and treatment outcomes were reported.

RESULTS

Seven TRAAs of six patients were treated, with a median aneurysm size of 20 mm. Three TRAAs were treated with primary sac occlusion (one with primary coil embolization, one with balloon and stent assisted coil and glue embolization, and one with amplatzer vascular occlusion device and coil embolization). The remaining four TRAAs of three patients were treated with flow diverter stents (Cardiatis, Silk, Pipeline, and Surpass). Immediate clinical success was achieved in patients treated with primary sac embolization (95% CI, 29.2%-100%). Among patients treated with flow diverter stents, one patient required an additional flow diverter at 6-month follow-up. The occlusion time in flow diverters ranged from 1 month to 12 months (median, 3.5 months) taking the repeat procedure into account. In patients treated with flow diverters, the clinical success rate was 100% (95% CI, 29.2%-100%) at one-year follow-up. Long-term follow-up ranged from 3 to 52 months. One intraprocedural complication was encountered with a flow diverter during deployment, which required additional stenting and tirofiban infusion. No other major complication was seen.

CONCLUSION

Endovascular treatment is an effective and safe method offering high success rates and low morbidity in the treatment of TRAAs and may supplant surgery as the primary therapy. Current experience in the use of flow diverter stents in TRAAs is limited to individual case reports with one brand of flow diverter device. Our small numbered series of four TRAAs shows our experience regarding endovascular treatment with different flow diverter brands.

Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Vascular complications associated with transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is now an accepted pathway for aortic valve replacement for patients who are at prohibitive, severe and intermediate risk for traditional aortic valve surgery. However, with this rising uptrend and adaptation of this new technology, vascular complications and their management remain an Achilles heel for percutaneous aortic valve replacement. The vascular complications are an independent predictor of mortality for patients undergoing TAVR. Early recognition of these complications and appropriate management is paramount. In this article, we review the most commonly encountered vascular complications associated with currently approved TAVR devices and their optimal percutaneous management techniques.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.