Oxford Challenging Concepts in Interventional Radiology Cases with Expert Commentary: Part 1

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Challenging Concepts in Interventional Radiology and Endovascular Procedures
Published and forthcoming titles in the Challenging Concepts in series Anaesthesia (Edited by Dr Phoebe Syme, Dr Robert Jackson, and Professor Tim Cook) Cardiovascular Medicine (Edited by Dr Aung Myat, Dr Shouvik Haldar, and Professor Simon Redwood) Emergency Medicine (Edited by Dr Sam Thenabadu, Dr Fleur Cantle, and Dr Chris Lacy) Infectious Disease and Clinical Microbiology (Edited by Dr Amber Arnold and Professor George Griffin) Interventional Radiology and Endovascular Procedures (Edited by Dr Miltiadis Krokidis, Dr Irfan Ahmed, and Dr Tarun Sabharwal) Neurology (Edited by Dr Krishna Chinthapalli, Dr Nadia Magdalinou, and Professor Nicholas Wood) Neurosurgery (Edited by Mr Robin Bhatia and Mr Ian Sabin) Obstetrics and Gynaecology (Edited by Dr Natasha Hezelgrave, Dr Danielle Abbott, and Professor Andrew Shennan) Oncology (Edited by Dr Madhumita Bhattacharyya, Dr Sarah Payne, and Professor Iain McNeish) Oral and Maxillofacial Surgery (Edited by Mr Matthew Idle and Dr Andrew Monaghan) Respiratory Medicine (Edited by Dr Lucy Schomberg and Dr Elizabeth Sage)
Challenging Concepts in Interventional Radiology and Endovascular Procedures Cases with Expert Commentary Edited by Miltiadis Krokidis Consultant Vascular and Interventional Radiologist, Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Irfan Ahmed Consultant Vascular and Interventional Radiologist, Department of Radiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Tarun Sabharwal Consultant Vascular and Interventional Radiologist, Department of Radiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK 1
3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2015 The moral rights of the authors have been asserted Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2015934018 ISBN 978–0–19–164150–3 Printed in Great Britain by Ashford Colour Press Ltd, Gosport, Hampshire Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.
FOREWORD Interventional radiology has come of age, and has an established place in modern medical care. Its techniques have been shown to be clinically effective, safe, and less expensive than most equivalent open surgical procedures. There are now several excellent textbooks of interventional radiology which deal with all aspects of the discipline. The Cardiovascular and Interventional Radiological Society of Europe has created a robust examination, which is rapidly setting training standards in this discipline within Europe and beyond. This book does not aim to provide systematic instruction in the techniques of interventional radiology at either a basic or at an advanced level. Instead, the editors, Miltos Krokidis, Irfan Ahmed, and Tarun Sabharwal, have adopted an innovative and fresh approach—they have focused on important current issues in interventional radiology. In each case, instead of an exhaustive review of the literature and a series of vague statements presenting all views on an individual topic, they have chosen to deal with each issue with clarity and confidence, and have tried to offer a clear opinion on each subject. The book contains 31 cases. The emphasis is on endovascular procedures, but important nonvascular topics, mainly in interventional oncology, are also included. Each case has been written by either an interventional radiologist in training or a young staff radiologist. There are clear descriptions of techniques, examples of challenging cases, learning points, and a focus on these points by experts in the subject. The layout is clear, colourful, and easy to navigate. This approach has resulted in a fresh and topical volume, and a ‘no-nonsense’ practical approach. There is no attempt to cover each subject in a comprehensive fashion, or to present the latest research on each topic. But the trainee, or the young staff radiologist seeking guidance on some of the most important issues in this discipline, will enjoy reading this excellent and refreshing book, and will want to keep a copy within easy reach. Andreas Adam CBE, MB, BS(Hons), PhD, FRCP, FRCR, FRCS, FFRRCSI(Hon), FRANZCR(Hon), FACR(Hon), FMedSci Professor of Interventional Radiology, King’s College London
CONTENTS Experts viii Case 11. Below the ankle angioplasty: Contributors xi treatment rationale and access techniques 95 Panagiotis Kitrou and Konstantinos Katsanos Abbreviations xiv Section 2â•‡ Venous procedures Section 1â•‡ Aortic pathology and peripheral arterial disease Case 12. Dialysis access at risk: balloons or stent grafts? 105 Stavros Spiliopoulos and Dimitrios Karnabatidis Case 1. Thoracic endoprostheses for type B aortic dissections 3 Case 13. Phlegmasia cerulea dolens: Christos Lioupis, Rachel Clough, and Peter Taylor percutaneous treatment 111 Peter Mezes and Narayan Karunanithy Case 2. Management of endoleaks after thoracic endografts 11 Case 14. IVC filters and anticoagulation 119 Ali Alsafi and Mo Hamady Christopher Burke, Miltiadis Krokidis, and Hanno Hoppe Case 3. Juxtarenal abdominal aortic aneurysms: fenestrations versus chimneys 21 Case 15. TIPS and TIPS revision for Nadeem Shaida and Andrew Winterbottom Budd–Chiari patients. 129 Vyzantios Pavlidis and Elias Brountzos Case 4. Management of endoleaks after abdominal aneurysm endovascular repair 29 Section 3â•‡ Embolization Raymond Chung and Robert Morgan Case 16. Epistaxis: which embolic materials to use? 141 Case 5. Carotid artery stenting: how to Magdalena Jarząbek, Piotr Trojanowski, and treat restenosis 37 Małgorzata Szczerbo-Trojanowska Alessandro Cannavale and Fabrizio Fanelli Case 17. Massive haemoptysis: what to embolize? 151 Case 6. Iliac artery occlusions: surgical Kendrick Tang and Philip Kwok bypass, covered and uncovered stents 51 Case 18. Gastrointestinal bleeding: which Andrew Christie and Iain Robertson embolic material to use? 159 Case 7. SFA endoluminal bypass: the new era Bhaskar Ganai and Michael J Lee of critical limb ischaemia treatment 61 Case 19. Endovascular approach to the Aidan Shaw and Irfan Ahmed trauma patient 165 Case 8. Below the knee angioplasty: bare Athanasios Diamantopoulos versus drug-eluting stents 69 and Konstantinos Katsanos Stavros Spiliopoulos and Dimitrios Siablis Case 20. Uterine fibroid embolization: can fertility Case 9. Thrombolysis for acute lower limb ischaemia 79 be preserved? 171 Athanasios Diamantopoulos and Panos Gkoutzios Leto Maili, Aneeta Parthipun, and Irfan Ahmed Case 10. Renal artery stenosis: angioplasty or stent? 87 Case 21. Postpartum haemorrhage: what is Shirish Prabhudesai and Narayan Karunanithy the role of occlusion balloons? 179 Raj Das and Anna-Maria Belli
Contents vii Case 22. Percutaneous varicelectomy: coils or Case 27. Small renal tumours: is radiofrequency sclerosant agents? 187 ablation better than surgery? 225 Piero Venetucci, Miltiadis Krokidis, and Miltiadis Krokidis and Andy Adam Vittorio Iaccarino Case 28. Malignant biliary strictures: covered Case 23. Prostate artery embolization for or uncovered stents? 233 benign prostate hypertrophy 195 Miltiadis Krokidis and Adam Hatzidakis Aidan Shaw, Irfan Ahmed, and Tarun Sabharwal Case 29. Vertebroplasty of the cervical spine 239 Georgia Tsoumakidou and Afshin Gangi Section 4 Non-vascular procedures and interventional oncology Case 30. Percutaneous neurolytic coeliac plexus block 245 Case 24. Lung tumour radiofrequency ablation: Angie Galea, Richard Guinness, what are the success factors? 203 and Anthony Watkinson Victoria St Noble and Nicos Fotiadis Case 31. Vertebral augmentation techniques and Case 25. Tracheobronchial stenting: covered pain management: is there a role in versus uncovered 211 metastatic disease? 251 Riccardo Inchingolo and Tarun Sabharwal Gianluigi Orgera, Miltiadis Krokidis, and Case 26. Early-stage hepatocellular carcinoma: the Michele Rossi percutaneous approach 217 Venus Hedayati and Praveen Peddu Index 257
EXPERTS Professor Andreas Adam Professor Afshin Gangi Professor of Interventional Radiology Professor of Diagnostic and Interventional King’s College London Radiology Department of Radiology University of Louis Pasteur Guy’s and St Thomas’ NHS Foundation Trust Department of Radiology London University Hospital of Strasbourg UK Strasbourg France Dr Irfan Ahmed Consultant Vascular and Interventional Radiologist Dr Panos Gkoutzios Department of Radiology Consultant Vascular and Interventional Guy’s and St Thomas’ NHS Foundation Trust Radiologist London Department of Radiology UK Guy’s and St Thomas’ NHS Foundation Trust, London Professor Anna-Maria Belli UK Professor of Interventional Radiology St Georges Medical School Dr Mo Hamady Department of Radiology Consultant Interventional Radiologist St George’s University Hospitals NHS Foundation Honorary Senior Lecturer Trust Department of Surgery and Cancer London Imperial College UK London UK Professor Elias Brountzos Professor of Interventional Radiology Ass. Prof Adam Hatzidakis Athens University Medical School Assistant Professor of Radiology Second Department of Radiology University of Crete Medical School Attikon University Hospital Department of Medical Imaging Athens University Hospital of Heraklion Greece Heraklion Greece Dr Fabrizio Fanelli Vascular and Interventional Radiologist Dr Hanno Hoppe Vascular and Interventional Radiology Unit Vascular and Interventional Radiologist Department of Radiological Sciences Linderhof Hospital Sapienza University Hospital Bern Rome Switzerland Italy
Experts ix Professor Vittorio Iaccarino Dr Robert Morgan Professor of Interventional Radiology Consultant Vascular and Interventional University of Naples Medical School Radiologist Department of Cardiovascular and Interventional Department of Radiology Radiology St George’s University Hospitals NHS Foundation University Hospital Federico II Trust Naples London Italy UK Ass Prof Dimitrios Karnabatidis Dr Praveen Peddu Associate Professor of Radiology Consultant Interventional Radiologist University of Patras Medical School Department of Radiology Department of Interventional Radiology King’s College Hospital NHS Foundation Trust Patras University Hospital London Rio UK Greece Dr Iain Robertson Dr Narayan Karunanithy Consultant Interventional Radiologist Consultant Vascular and Interventional Radiologist Department of Interventional Radiology Department of Radiology Gartnavel General Hospital Guy’s and St Thomas’ NHS Foundation Trust Glasgow London UK UK Ass Prof Michele Rossi Dr Konstantinos Katsanos Associate Professor of Radiology Consultant Vascular and Interventional Radiologist Department of Radiological, Oncological and Department of Radiology Pathological Sciences Guy’s and St Thomas’ NHS Foundation Trust Sapienza University of Rome London Italy UK Dr Tarun Sabharwal Dr Philip Kwok Consultant Vascular and Interventional Consultant Radiologist Radiologist Department of Radiology and Imaging Department of Radiology Queen Elizabeth Hospital Guy’s and St Thomas’ NHS Foundation Trust Kowloon London Hong Kong UK Professor Michael J Lee Professor Dimitrios Siablis Consultant Interventional Radiologist Professor of Interventional Radiology Beaumont Hospital University of Patras Medical School Professor of Radiology Department of Interventional Radiology Royal College of Surgeons in Ireland Patras University Hospital Department of Radiology Rio Beaumont Hospital Greece Dublin Ireland
x Experts Professor Małgorzata Szczerbo-Trojanowska Professor Anthony Watkinson Professor of Interventional Radiology Professor of Interventional Radiology Department of Interventional Radiology and The Peninsular Medical School Neuroradiology Department of Radiology Medical University of Lublin Royal Devon and Exeter Hospital NHS Foundation Lublin Trust Poland Exeter UK Professor Peter Taylor Professor of Vascular Surgery Dr Andrew Winterbottom King’s College London Consultant Vascular and Interventional Radiologist Department of Vascular Surgery Department of Radiology Guy’s and St Thomas’ NHS Foundation Cambridge University Hospitals NHS Foundation Trust Trust Cambridge London UK UK
CONTRIBUTORS Dr Ali Alsafi Dr Raj Das Specialist Registrar in Clinical Radiology Consultant Interventional Radiologist Imperial College Healthcare NHS Trust Department of Radiology London St George’s University Hospitals NHS Foundation UK Trust London Dr Christopher Burke UK Fellow in Interventional Radiology Department of Radiology Dr Athanasios Diamantopoulos Guys’ and St Thomas’ NHS Foundation Trust Consultant Vascular and Interventional Radiologist London Department of Radiology UK Guy’s and St Thomas’ NHS Foundation Trust London Dr Alessandro Cannavale UK Specialist Registrar in Radiology Vascular and Interventional Radiology Unit Dr Nicos Fotiadis Department of Radiological Sciences Consultant Interventional Radiologist Sapienza University Hospital Department of Radiology Rome The Royal Marsden NHS Foundation Trust Italy London UK Dr Andrew Christie Consultant Interventional Radiologist Dr Angie Galea Department of Interventional Radiology Specialist Registrar in Clinical Radiology Gartnavel General Hospital Peninsula Radiology Academy Glasgow Plymouth UK UK Dr Raymond Chung Dr Bhaskar Ganai Fellow in Interventional Radiology Lecturer in Interventional Radiology Department of Radiology Royal College of Surgeons in Ireland St George’s University Hospitals NHS Foundation Department of Radiology Trust Beaumont Hospital London Dublin UK Ireland Mrs Rachel Clough Dr Richard Guinness Vascular and Endovascular Fellow Consultant Radiologist Department of Vascular Surgery Royal Devon and Exeter Hospital NHS Foundation Guy’s and St Thomas’ NHS Foundation Trust Trust London Exeter UK UK
xii Contributors Dr Venus Hedayati Dr Peter Mezes Consultant Radiologist Consultant Interventional Radiologist Department of Radiology North Bristol NHS Trust King’s College Hospital NHS Foundation Trust, Bristol London UK UK Dr Gianluigi Orgera Dr Riccardo Inchingolo Interventional Radiologist Interventional Radiologist Department of Radiological Diagnostic and Interventional Radiology Unit Oncological and Pathological Sciences “Madonna delle Grazie” Hospital Sapienza University of Rome Matera Rome Italy Italy Dr Magdalena Jarząbek Dr Aneeta Parthipun Fellow in Interventional Radiology, Fellow in Interventional Radiology Department of Interventional Radiology and Department of Radiology Neuroradiology Guys’ and St Thomas’ NHS Foundation Trust Lublin University Hospital London Lublin UK Poland Dr Vyzantios Pavlidis Dr Panagiotis Kitrou Specialist Registrar in Radiology Vascular and Interventional Radiologist Second Department of Radiology Department of Interventional Radiology Attikon University Hospital Patras University Hospital Athens University Medical School Rio Athens Greece Mr Shirish Prabhudesai Dr Miltiadis Krokidis Specialist Registrar in Surgery Consultant Vascular and Interventional Radiologist Department of Biosurgery and Surgical Technology Department of Radiology Imperial College Cambridge University Hospitals NHS Foundation Trust St Mary’s Hospital Cambridge London UK UK Mr Christos Lioupis Dr Nadeem Shaida Vascular and Endovascular Fellow Consultant Vascular and Interventional Department of Vascular Surgery Radiologist Guy’s and St Thomas’ NHS Foundation Trust Department of Radiology London Cambridge University Hospitals NHS Foundation UK Trust Cambridge Dr Leto Maili UK Consultant Vascular and Interventional Radiologist Dr Aidan Shaw Department of Radiology Fellow in Interventional Radiology St George’s University Hospitals NHS Foundation Department of Radiology Trust Guy’s and St Thomas’ NHS Foundation Trust London London UK UK
Contributors xiii Dr Stavros Spiliopoulos Dr Piotr Trojanowski Vascular and Interventional Radiologist ENT Surgeon, Department of Interventional Radiology ENT Department Patras University Hospital Lublin University Hospital Rio Lublin Greece Poland Dr Victoria St Noble Dr Georgia Tsoumakidou Specialist Registrar in Clinical Radiology Interventional Radiologist Department of Radiology Department of Radiology Royal Brompton Hospital University Hospital of Strasbourg London Strasbourg UK France Dr Kendrick Tang Dr Piero Venetucci Specialist Registrar in Radiology Vascular and Interventional Radiologist, Department of Radiology Department of Cardiovascular and Interventional Pamela Youde Nethersole Eastern Hospital Radiology Chai Wan University Hospital Federico II Hong Kong Naples Italy
ABBREVIATIONS A&E Accident and Emergency CI confidence interval AAA abdominal aortic aneurysm CIA common iliac artery ABC aneurysmal bone cyst CKD chronic kidney disease ABF aorto-bifemoral CLI critical limb ischaemia ABI ankle–brachial pressure index COPD chronic obstructive pulmonary ABPI ankle–brachial pressure index disease ACCF American College of Cardiology CPR cardiopulmonary resuscitation Foundation Cr creatinine ACT activated clotting time CSS cancer-specific survival ADHF acute decompensated heart failure CT computed tomography AFP alpha-fetoprotein CTA CT angiography AHA American Heart Association CTO chronic total occlusion ALI acute limb ischaemia CXR chest X-ray ALP alkaline phosphatase DEB drug-eluting balloon AP anteroposterior DFS disease-free survival aPTT activated partial DIC disseminated intravascular thromboplastin time coagulopathy ASA American Society of DIPS direct intrahepatic portocaval Anesthesiologists shunt AST aspartate aminotransferase DLco diffusing capacity of lung for ATA anterior tibial artery carbon monoxide AV arteriovenous DMSO dimethyl sulphoxide AVM arteriovenous malformation DP dorsalis pedis BAE bronchial artery embolization DPA descending palatine artery, BCLC pathway Barcelona Clinic Liver Cancer dorsalis pedalis artery pathway DSA digital subtraction angiography BCS Budd–Chiari syndrome DU Doppler ultrasound BMS bare metal stent DVT deep vein thrombosis BPH benign prostate hypertrophy ECA external carotid artery BTK below the knee ECG electrocardiogram CAS carotid artery stenting ECOG Eastern Cooperative Oncology CCA common carotid artery Group CCT controlled clinical trial EDV end diastolic velocity CDT catheter-directed thrombolysis eGFR estimated glomerular filtration CDU clinical decision unit, colour rate Doppler ultrasound EIA external iliac artery CEA carotid endarterecomy EL endoleak ce-CT contrast-enhanced computed ePTFE expanded polytetrafluoroethylene tomography ESC European Society of Cardiology CEMRA contrast-enhanced magnetic ET essential thrombocythemia resonance angiography EVAR endovascular aortic repair CFA common femoral artery FA facial artery
Abbreviations xv FAST focused abdominal LCA lateral calcaneal artery ultrasonography LPA lateral plantar artery FDG fludeoxyglucose LSA left subclavian artery FEV1 forced expiratory volume LUTS lower urinary tract symptoms in 1 second MAI mycobacterium avium- FEVAR fenestrated endovascular aortic intracellulare repair MCA medial calcaneal artery FiO2 fraction of inspired oxygen MDCTA multidetector computed FNA fine-needle aspiration tomography angiography FVC forced vital capacity MDT multidisciplinary team GA general anaesthetic MELD Model for End-Stage Liver Disease GCS Glasgow coma scale MFS metastasis-free survival GFR glomerular filtration rate MI myocardial infarction GGT gamma glutamyl transferase MIP multiple intensity projection GI gastrointestinal MPA medial plantar artery GP general practitioner MPR multiplanar reconstruction GTN glyceryl trinitrate MRA magnetic resonance angiography Hb haemoglobin MRI magnetic resonance imaging HCC hepatocellular carcinoma NAFLD non-alcoholic fatty liver disease HE hepatic encephalopathy NBCA n-butyl cyanoacrylate HFDU high-frequency duplex ultrasound NIHSS National Institutes of Health HHT hereditary haemorrhagic Stroke Scale telangiectasia NSCLC non-small-cell lung cancer HoLAP holmium laser ablation of the NTT number needed to treat prostate od once daily HR hazard ratio OLT orthotopic liver transplantation HTC haematocrit OS overall survival HU Hounsfield unit OSR open surgical repair ICA internal carotid artery PA peroneal artery ICBT intercostal bronchial trunk PaCO2 partial pressure of carbon dioxide ICER incremental cost-effectiveness in arterial blood ratio PAD peripheral arterial disease ICU intensive care unit PAE pelvic arterial embolization, IIAOB internal iliac artery occlusion prostate artery embolization balloon PaO2 partial pressure of oxygen in IM intramuscular arterial blood IMA internal mammary artery, internal PAOD peripheral arterial occlusive maxillary artery disease INR international normalized ratio PCA patient-controlled anaesthesia IPSS International Prostate PCD phlegmasia cerulea dolens Symptom Score PE pulmonary embolism ISR in-stent re-stenosis PEI percutaneous ethanol injection ISV internal spermatic vein PET positron emission tomography IVC inferior vena cava PMMA polymethylmethacrylate IVUS intravascular ultrasound PMT pharmacomechanical JRA juxtarenal aneurysm thrombectomy LAD left anterior descending artery PN partial nephrectomy LAO lateral anterior oblique PP pampiniform plexus
xvi Abbreviations PR per rectum TAA thoracic aortic aneurysm PSA prostate-specific antigen TACE transarterial chemoembolization PSV peak systolic velocity TAD thoracic aortic dissection PT posterior tibia, prothrombin time TASC Transatlantic Inter-Society PTA percutaneous transluminal Consensus angioplasty, posterior tibial artery TEVAR thoracic endovascular aortic PTFE polytetrafluoroethylene repair PTS post thrombotic syndrome TIA transient ischaemic attack PTT partial thromboplastin time TIPS transjugular intrahepatic PV percutaneous vertebroplasty portosystemic shunt PVA polyvinyl alcohol TLC total lung capacity PVD peripheral vascular disease TLR target-lesion revascularization RAS renal artery stenosis TOE transoesophageal RCC renal cell carcinoma echocardiography RCT randomized controlled trial tPA tissue plasminogen activator RFS recurrence-free survival TUEVP transurethral electrovaporization r-tPA recombinant tissue plasminogen of the prostate activator TUR transurethral resection SAFARI subintimal arterial flossing with TURP transurethral resection of the antegrade–retrograde intervention prostate SEMS self-expanding metallic stent UCSD ultrasound colour Doppler SFA superficial femoral artery UFE uterine fibroid embolization SIA sub-intimal angioplasty US ultrasound SIRT selective internal radiation UTI urinary tract infection treatment VA alveolar volume SLA superior labial artery VAS visual analogue score SMA superior mesenteric artery VC vital capacity SPA sphenopalatine artery VCF vertebral compression fracture SUV standard uptake value VRT volume rendering technique SVC superior vena cava VTE venous thromboembolism SVS Society for Vascular Surgery WIT warm ischaemia time
SECTION 1 Aortic pathology and peripheral arterial disease Case 1 Thoracic endoprostheses for type B aortic dissections Case 2 Management of endoleaks after thoracic endografts Case 3 Juxtarenal abdominal aortic aneurysms: fenestrations versus chimneys Case 4 Management of endoleaks after abdominal aneurysm endovascular repair Case 5 Carotid artery stenting: how to treat restenosis Case 6 Iliac artery occlusions: surgical bypass, covered and uncovered stents Case 7 SFA endoluminal bypass: the new era of critical limb ischaemia treatment Case 8 Below the knee angioplasty: bare versus drug-eluting stents Case 9 Thrombolysis for acute lower limb ischaemia Case 10 Renal artery stenosis: angioplasty or stent? Case 11 Below the ankle angioplasty: treatment rationale and access techniques
CASE Thoracic endoprostheses for 1 type B aortic dissections Christos Lioupis and Rachel Clough Expert commentary Peter Taylor Case history A 45-year-old man who was previously fit and well presented to the Accident and Emergency (A&E) department of a community hospital with a four-hour history of chest and abdominal pain, right loin pain, and loss of sensation of the right leg. His brother had died suddenly at the age of 38 of an unexplained cause. On examination his blood pressure was 170/110. There was a pulsatile mass in his left supraclavicu- lar fossa. His abdomen was soft and non-tender, and there were no pulses palpable in the right leg which had loss of sensation below the knee. A computed tomography (CT) angiogram showed an aneurysm of the left sub- clavian artery and an acute type B aortic dissection. The primary entry tear was located in the proximal descending thoracic aorta, just distal to the left subclavian artery. The right vertebral artery was dominant. There was evidence of true lumen collapse, with no filling of the right renal and partial occlusion of the right common iliac arteries (Figure 1.1). Clinical tip Immediate treatment with analgesia and antihypertensive medication was started before transfer to our hospital. The patient underwent urgent endovascular treatment because the acute type B dissection was complicated by both renal and critical right lower limb ischaemia. The CT scan demonstrated a 90° angulation of the aorta just distal to the origin of the left subclavian at its junction with the descending thoracic aorta. Coverage of the origin of the left subclavian artery was intended to secure an adequate proximal land- ing zone. The device was minimally oversized based on the non-dissected transverse aortic arch. The intima to intimal diameter was 25.5mm, the adventitia to adventitial diameter was 31.6mm, and the maximum diameter including the surrounding haema- toma was 40.3mm. A cTAG device (W.L. Gore & Associates, Flagstaff, AZ) measuring 31mm in diameter by 150mm in length was selected to provide no oversizing com- pared with the adventitia to adventitial diameter. Expert comment The use of a compliant device was essential to accommodate the 90° angulation in the aorta distal to the left subclavian artery origin. A short device was chosen to minimize the risk of paraplegia; the risk of this was increased because the left subclavian artery was covered by the device.