Initial Experience Using the Transradial Approach for Endovascular Treatment of Vascular Pathologies: Safety and Feasibility

Background Endovascular treatment of vascular pathologies through the transradial approach has been increasingly used and has demonstrated a low rate of complications. Objective To report our initial experience in the endovascular treatment of cerebrovascular diseases with the transradial approach and to determine its safety and feasibility. Methods Consecutive patients who underwent the transradial approach for endovascular treatment of aneurysms and vascular malformations were reviewed at a single institution. Technical success, fluoroscopy time, and access-related complications were analyzed. Results Eight patients underwent endovascular treatment with the transradial approach. One arteriovenous fistula, one superficial temporal artery aneurysm, three arteriovenous malformations, and four aneurysms were treated successfully. The radial artery was successfully approached and a 6-F sheath was used in all the cases. Navigation of guiding catheters (5 and 6 F) was done without complications. The most commonly approached artery was the right internal carotid artery, followed by the right vertebral artery. Postoperative vasospasm was identified in three patients. Mean fluoroscopy time was 34.7 minutes. Conversion to transfemoral approach was not required. No postoperative complications were reported. Conclusions In our initial experience, the transradial approach is a safe and feasible alternative for the endovascular treatment of cerebrovascular pathologies.

Radiation Dose and Fluoroscopy Time of Diagnostic Angiography in Patients with Spinal Dural Arteriovenous Fistula

Purpose Spinal dural arteriovenous fistulas (SDAVFs) represent the most common indication for a spinal angiography. The diagnostic reference level (DRL) for this specific endovascular procedure is still to be determined. This single-center study provides detailed dosimetrics of diagnostic spinal angiography performed in patients with SDAVFs. Methods Retrospective analysis of all diagnostic spinal angiographies between December 2011 and January 2021. Only patients with an SDAVF who had baseline magnetic resonance angiography (MRA), diagnostic digital subtraction angiography (DSA), treatment and follow-up at this institution were included. Dose area product (DAP, Gy cm2) and fluoroscopy time were compared between preoperative and postoperative angiographies, according to SDAVF locations (common versus uncommon), MRA results at baseline (positive versus negative) and DSA protocols (low-dose, mixed-dose, normal-dose). The 75th percentile of the DAP distribution was used to define the local DRL. Results A total of 62 spinal angiographies were performed in 25 patients with SDAVF. Preoperative angiographies (30/62, 48%) yielded a significantly higher DAP and longer fluoroscopy time when compared to postoperative angiographies (32/62, 53%) (p < 0.01). The local DRL was 329.41 Gy cm2 for a nonspecific (n = 62), 395.59 Gy cm2 for a preoperative and 138.6 Gy cm2 for a postoperative spinal angiography. Preoperative angiography of uncommonly located SDAVFs yielded a significantly longer fluoroscopy time (p = 0.02). The MRA-based fistula detection had no significant impact on dosimetrics (p > 0.05). A low-dose protocol yielded a 61% reduction of DAP. Conclusion The results of the present study suggest novel DRLs for spinal angiography in patients with SDAVF. Dedicated low-dose protocols enable radiation dose optimization in these procedures.

Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma

Purpose: Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries. Materials and methods: A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared. Results: A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001). Conclusion: Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.

Portal Vein Embolization Using N-Butyl Cyanoacrylate-Glue: What Impact Does a Central Vascular Plug Have?

Purpose To examine if the addition of a central vascular plug (CVP) to portal vein embolization (PVE) with N-butyl cyanoacrylate-glue (NBCA) increases future liver remnant (FLR) growth. Material and Methods This is a single-center retrospective study of 115 consecutive patients with colorectal liver metastases undergoing PVE in 2013–2019. All patients were embolized with NBCA as the main embolic agent. In 2017–2019 NBCA was combined with a CVP in the central part of the right portal vein. Growth of the FLR and standardized FLR (sFLR) including degree of hypertrophy (DH) and kinetic growth rate (KGR) were analyzed, as well as procedure data such as use of cone-beam CT (CBCT), dose area product (DAP), fluoroscopy time and contrast dose. Results A total of 40 patients (35%) underwent PVE with a combination of CVP and NBCA. The DH was higher in these patients after 4 weeks, mean 13.6% (SD 7.8) vs. 10.5% (SD 6.4; p = 0.022), verified in multivariate analysis (coefficient 4.1, p = 0.015). A CVP did not significantly increase the resection rate (90% vs 82%, p = 0.4). Cone beam CT was used in 65 patients (57%). Use of CBCT did not affect FLR growth, and fluoroscopy time and contrast doses were not different in patients having a CBCT or not. Slightly lower DAP (median 3375 vs. 4499 cGy*cm2; p = 0.09) was seen in procedures where CBCT was used. Conclusion A CVP in addition to NBCA embolization was associated with increased growth of the FLR compared to NBCA alone.

Utilising electroanatomic mapping during ablation in patients with CHD to reduce radiation exposure

Background: Patients with CHD can be exposed to high levels of cumulative ionising radiation. Utilisation of electroanatomic mapping during catheter ablation leads to reduced radiation exposure in the general population but has not been well studied in patients with CHD. This study evaluated the radiation sparing benefit of using three-dimensional mapping in patients with CHD. Methods: Data were retrospectively collected from the Catheter Ablation with Reduction or Elimination of Fluoroscopy multi-institutional registry. Patients with CHD were selected. Those with previous ablations, concurrent diagnostic or interventional catheterisation and unknown arrhythmogenic foci were excluded. The control cohort was matched for operating physician, arrhythmia mechanism, arrhythmia location, weight and age. The procedure time, rate of fluoroscopy use, fluoroscopy time, procedural success, complications, and distribution of procedures per year were compared between the two groups. Results: Fifty-six patients with congenital heart disease and 56 matched patients without CHD were included. The mean total procedure time was significantly higher in patients with CHD (212.6 versus 169.5 minutes, p = 0.003). Their median total fluoroscopy time was 4.4 minutes (compared to 1.8 minutes), and their rate of fluoroscopy use was 23% (compared to 13%). The acute success and minor complication rates were similar and no major complications occurred. Conclusions: With the use of electroanatomic mapping during catheter ablation, fluoroscopy use can be reduced in patients with CHD. The majority of patients with CHD received zero fluoroscopy.

A comparative study of new-type-retractor-assisted wiltse approach TLIF, MIS-TLIF and traditional PLIF in the treatment of single- level lumbar degenerative diseases

Background To compare the clinical efficacy of new-type-retractor assisted wiltse approach Transforaminal lumbar Interbody Fusion (TLIF), Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) and traditional Posterior Lumbar Interbody Fusion (PLIF)in single-level lumbar degenerative diseases. Methods A retrospective study was conducted by analyzing clinical and imaging information of consecutive patients with single-level lumbar degenerative diseases who underwent either the new-type-retractor assisted wiltse approach TLIF or the MIS-TLIF or the traditional PLIF. 87 concurrent patients with similar age ,weight and severity of the imaging and symptom between June 2016 and December 2019 were included(wiltse approach 29 cases; MIS-TLIF 28 cases; PLIF 30 cases).The three groups were compared for perioperative indicators(including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bed time), creatine kinase (CK), Visual Analogue Scale(VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy and fatty infiltration(including ratio of multifidus atrophy and ratio of lean-to-total cross sectional area(CSA)). Results Intraoperative blood loss, postoperative drainage volume and bed time in MIS-TILF group and wiltse group was significantly lower than PLIF group. The operative time and intraoperative radiation time of MIS-TILF group was significantly longer than wiltse group and PLIF group. CK level in wiltse and MIS-TILF group were significantly lower than PLIF group 1 and 3 days after surgery. PLIF group back pain VAS score was higher than wiltse and MIS-TLIF group. PLIF group displayed a higher ODI and a lower JOA score than the wiltse and MIS-TLIF group 6 months and 12 months after surgery. There was no significant statistical difference in lower limb pain VAS score and intervertebral fusion rate. Ratio of multifidus atrophy in the PLIF group was significantly higher than the wiltse group and the MIS-TILF group. Ratio of lean-to-total CSA (cross-sectional area) in PLIF group was lower than wiltse group and MIS-TLIF group after surgery. There was no significant difference between wiltse group and MIS-TLIF group except that MIS-TLIF group showed longer operation time and intraoperative fluoroscopy time while lower blood loss and drainage volume. 2 cases of durotomy and 2 cases of incision fat liquefaction occurred in PLIF group, 1 case of skin edge necrosis was found in MIS-TILF group. Patients were followed up at 3 months,6moyhs,12months after surgery, The mean follow-up time of the patients was 12.14±2.78 months in wiltse group, 13.57±2.60 months in MIS-TLIF group, and 12.73±2.80 months in PLIF group, with no significant diffirence among 3 groups. (P༞0.05) Conclusion Wiltse approach TLIF assisted with the new-type retractor is a more convenient and simple minimally invasive surgical method than traditional PLIF and MIS-TLIF, which requires a long learning curve, long operation and fluoroscopy time.

Effectiveness of a Real-Time X-ray Dosimetry Monitor in Reducing Radiation Exposure in Coronary Procedures: The ESPRESSO-Raysafe Randomized Trial

Background—Several methods to reduce radiation exposure in the setting of coronary procedures are available on the market, and we previously showed that additional radiation shields reduce operator exposure during radial interventions. We set out to examine the efficacy of real-time personal dosimetry monitoring in a real-world setting of radial artery catheterization. Methods and Results—In an all-comer prospective, parallel study, consecutive coronary diagnostic and intervention procedures were performed with the use of standard radiation shield alone (control group) or with the addition of a real-time dosimetry monitoring system (Raysafe, Billdal, Sweden, monitoring group). The primary outcome was the difference in exposure of the primary operator among groups. Additional endpoints included patient, nurse, second operator exposure and fluoroscopy time. A total of 700 procedures were included in the analysis (n = 369 in the monitoring group). There were no differences among groups in patients’ body mass index (p = 0.232), type of procedure (intervention vs. diagnostic, p = 0.172), and patient sex (p = 0.784). Fluoroscopy time was shorter in the monitoring group (5.6 (5.1–6.2) min vs. 7.0 (6.1–7.7) min, p = 0.023). Radiation exposure was significantly lower in the monitoring group for the patient (135 (115–151) µSv vs. 208 (176–245) µSv, p < 0.0001) but not for the first operator (9 (7–11) µSv vs. 10 (8–11), p = 0.70) and the assistant (2 (1–2) µSv vs. 2 (1–2) µSv, p = 0.121). Conclusions—In clinical daily practice, the use of a real-time dosimetry monitoring device reduces patient radiation exposure and fluoroscopy time without an effect on operator radiation exposure.

Abstract 1122‐000023: In a Hub‐and‐Spoke Network, Spoke‐Administered Thrombolysis Reduces Mechanical Thrombectomy Procedure Time and Number of Passes

Introduction : The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion (LVO) stroke is controversial. Some data suggest IVT could increase MT difficulty. Within our hub‐and‐spoke telestroke network, we examined how spoke‐administered IVT affects hub MT procedure time and number of passes. Methods : Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. Procedure time, fluoroscopy time, and number of passes were obtained from operative reports. Statistics were performed using permutation resampling and linear regression in R. Results : Of 113 patients, 50 received IVT. Baseline characteristics and NIHSS were similar between groups, however the last known well‐to‐groin puncture time was shorter among IVT patients (4.4 ±1.8 hrs vs. 10.5 ±5.7 hrs, p<0.001). In patients that received IVT, mean MT procedure time was decreased by 19 minutes (50 ±29 mins vs. 69 ±47, p = 0.01) and mean fluoroscopy time was decreased by 12 minutes (21 ±16 mins vs. 33 ±31 mins, p = 0.02). Linear regression modeling showed IVT was associated with improved procedure time and fluoroscopy time even when controlling for last known well (p = 0.02 and p = 0.02, respectively). For patients that achieved TICI2b‐3 reperfusion, there was a trend for reduced groin puncture‐to‐reperfusion time by 13 minutes in IVT patients (30 ±22 mins vs. 43 ±49 mins, p = 0.07). IVT‐treated patients required less MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p<0.001), and the proportion of IVT patients requiring 2 or few passes was significantly higher (91.6% vs 59.3%, p = 0.01). Moreover, IVT was associated with decreased number of passes even when controlling for last known well (p = 0.01). For patients that received IVT, there was a trend for improved TICI2b‐3 reperfusion at the end of MT (93.9% vs. 83.8%, p = 0.06). IVT did not result in increased intracranial hemorrhage (IVT = 10% vs. 18%, p = 0.17). Conclusions : Within our network, hub MT following spoke‐administered IVT was faster and required fewer passes, even when controlling for last known well. Furthermore, IVT did not result in worsened reperfusion following MT. This retrospective analysis suggests IVT does not impair MT, but instead may enhance it.

A pilot randomized trial to study the success rate of early precut fistulotomy and its effect on radiation dose in patients with difficult biliary cannulation

Background: Role of precut fistulotomy in reducing fluoroscopy time and the radiation dose in difficult selective biliary cannulation is unknown. Methods: We performed a randomized trial where patients with difficult biliary cannulation were randomized into 2 groups: early precut fistulotomy (precut five minutes after failed standard biliary cannulation) or late precut fistulotomy (precut fifteen minutes after failed standard biliary cannulation). We compared the success rates of selective biliary cannulation, fluoroscopy time, radiation dose, complication rates, need for repeat endoscopic retrograde cholangiography (ERC) and need for other interventions Results: Of the 130 eligible patients screened, 40 patients were randomized. The technical success was comparable between early and late group. The fluoroscopy time and radiation dose were significantly less in the early group [4 minutes (3, 6) vs 15 minutes (8, 28), p=0.001] and [1.35 mGy (0.90, 1.63) vs 2.40 mGy (1.58, 3.25), p=0.010] respectively. In the late group, 60% required need for rescue precut fistulotomy. One patient from late group developed post ERC pancreatitis while 1 from early group developed perforation. Three needed other interventions due to failed second attempt. Conclusion: Early precut fistulotomy has comparable technical success and reduces the radiation dose as compared to late precut fistulotomy for difficult biliary cannulation.