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Endovascular Treatment of Dissection of the Aorta and Its Branches

Management of aortic dissection is complex and directed by multiple patient and disease-specific factors requiring a complication-specific approach. Appropriate aortic imaging is paramount for both diagnosis and treatment planning. Initial blood pressure, heart rate control, and monitoring in the intensive care unit setting are critical. Descending aortic dissections (Stanford type B, DeBakey III) complicated by rupture, rapid false lumen expansion, tissue malperfusion, or intractable pain or…

Endoleaks: Classification, Diagnosis, and Treatment

Clinical Relevance Endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) produces clinical results similar to those of open surgery after observation periods of 6 and 10 years, respectively, with EVAR having an advantage in postoperative mortality and morbidity. Unlike open repair where the branch vessels to the aneurysm are ligated, perigraft blood flow outside the endoprosthesis but inside the aneurysm sac may occur after…

The Management of Thoracoabdominal Aortic Aneurysms by Branched Endograft Technology

This chapter specifically describes the management of aortic aneurysms that involve both the thoracic and abdominal segments of the aorta and its associated visceral branches. The reader should note that extensive aortic pathologies commonly require solutions incorporating combinations of open surgery and fenestrated and branched endovascular solutions. Since the publication of the first edition of this book, the total endovascular repair of thoracoabdominal aortic aneurysms (TAAAs)…

Fenestrated Stent-Grafting of Juxtarenal Aortic Aneurysms

Continuous development in endovascular treatment of ab-dominal and thoracic aortic aneurysms, together with growing experience and encouraging results, have paved the way for a new generation of stent-grafts, to treat those previously unsuitable for conventional endovascular repair. One such advancement is the fenestrated graft, which allows extension of the proximal landing zone and preservation of the renal and visceral arteries. Since the first reported fenestrated endovascular…

Endovascular Aortic Repair

Clinical Relevance Abdominal aortic aneurysms (AAAs) occur in approximately 5% to 10% of the male population older than 65 years, and the incidence increases with advancing age. The risk of rupture is very low for aneurysms less than 5 cm in diameter, but increases substantially with aneurysms larger than 6 cm in diameter. Mortality rates for traditional open repair of AAAs vary widely, depending on the…

Vascular Anatomy of the Abdominal Aorta and the Inferior Vena Cava

Abdominal Aorta The abdominal aorta continues from the thoracic aorta as it passes posterior to the median arcuate ligament and between the crura of the diaphragm (aortic hiatus), in front of the body of the T12 vertebra and then descends slightly to the left of midline. Clinically, the abdominal aorta is often divided into suprarenal and infrarenal arterial segments. The rationale for this division is the…

Management of High-Flow Vascular Anomalies

Vascular anomalies are often poorly managed for a number of reasons: they are uncommon (other than the true infantile hemangioma), their mode of presentation is extremely variable, their classification has been very confusing and is still poorly understood by the majority of doctors, and their treatment is challenging. The interested interventional radiologist is in an ideal position to play a major, if not the lead, role…

Management of Low-Flow Vascular Malformations

The goal of sclerotherapy is to obliterate abnormal channels by damaging the endothelium, thereby resulting in subsequent inflammation and fibrosis. Venous malformations (VMs) are caused by abnormal development of the vein wall, with thinning and asymmetric disruption of the smooth muscle layer of the vein in association with endothelial cell abnormalities. This results in progressive, often asymmetric, dilation of the affected channels. Associated absence or insufficiency…

Congenital Vascular Anomalies: Classification and Terminology

Vascular anomalies are a complex group of developmental abnormalities due to inborn errors of vasculogenesis or angiogenesis that present significant challenges in diagnosis and management. Because of the rarity and diverse presentation of these anomalies, patients are often seen by multiple specialists before correct diagnosis can be reached and treatment instigated. Accurate and timely diagnosis is crucial, and a multidisciplinary team approach is essential for the…

Revascularization: Infrapopliteal

In most countries, critical limb ischemia (CLI) has an incidence estimated to be 50 to 100 per 100,000 every year. CLI has a high mortality and morbidity rate and consumes important health and social care resources. , Aging of the population, increasing incidence of diabetes and renal failure, and limitations in the ability to reduce tobacco consumption explain the high likelihood of increased incidence in the…

Revascularization: Femoropopliteal

Acknowledgment The authors express their gratitude to Dr. Mahmood Razavi for his insight and support in writing this chapter. Femoropopliteal occlusive disease is present in a significant proportion of older patients, with about 20% of men and 17% of women older than 55 living with ankle-brachial indices (ABI) under 0.9. A smaller percentage (3%–7%) present with symptoms of intermittent claudication (IC) between the ages of 60…

Revascularization: Aortoiliac

Epidemiology Aortoiliac occlusive disease (AIOD) refers to stenotic or occlusive disease of the infrarenal aorta and iliac arteries, and is a significant cause of peripheral arterial disease (PAD). Epidemiologic studies reporting on PAD include both AIOD and infrainguinal arterial disease, with most patients having multilevel disease. Although more than half of patients with PAD can have a component of AIOD, femoropopliteal and infrageniculate disease are more…

Revascularization: Upper Extremity

Most of this chapter discusses management of occlusive disease of the subclavian and brachiocephalic arteries. Treatment of various conditions such as thoracic outlet syndrome and more distal lesions is also covered. Subclavian and Brachiocephalic Disease Symptomatic chronic ischemia of the upper extremity is commonly encountered in clinical vascular practice, comprising about 17% of symptomatic extracranial cerebrovascular disease ; 80% occurs in males. In contradistinction to chronic…

Acute Lower Extremity Ischemia

Acute lower extremity ischemia (ALI) is a serious condition with substantial morbidity and mortality. ALI refers to recent onset of lower extremity pain; long-standing lower extremity ischemia is dealt with elsewhere in this book. If ALI is severe and prolonged, the patient may develop progressive paresthesia, motor dysfunction, and eventually tissue infarction in the lower extremity. The rapidity plus severity of the onset of symptoms depend…

Vascular Anatomy of the Upper Extremity

Imaging Modalities of The Upper Extremity Imaging of the arterial and venous systems is an important component of the evaluation in many vascular disorders involving the upper extremity. This chapter provides a brief overview of vascular imaging, including ultrasonography (US), computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography. Real-time grayscale and color Doppler US is used to evaluate both the arterial and…

Closure Devices

After an arteriography or intervention, the access site must be effectively managed. The planning for access site control starts before gaining access. The operator must make sure that (1) the accessed artery is one that can be compressed, (2) the artery is of adequate size to allow manual compression versus the use of closure devices, and (3) the coagulation status has been taken into consideration. In…

Principles of Vascular Access

Invasive vascular imaging is based on the technique described by Sven Ivar Seldinger in 1953 ( Fig. 7.1 ). This elegant innovation, now known by Seldinger’s name, eliminated the need for surgical exposure of a blood vessel before catheterization, thus allowing the transfer of angiography from the operating room to the radiology department. Virtually all vascular invasive procedures and devices use this technique. Open full size…

Pharmacologic Agents Used in Image-Guided Interventions

As the need for interventional radiologic procedures continues to grow, there is increased interest in better periprocedural pain control. Interventional radiology (IR) plays a significant role in pain management, therapeutically (for chronic pain) and supplementally (for pain caused by intervention). Pain management is essential as IR practice becomes more invasive, readily available, and widely offered to individuals at high risk for both operative procedures and anesthesia.…

Radiation Safety and Protection in the Interventional Fluoroscopy Environment

The x-ray equipment available to perform imaged-guided interventions has accelerated in technical capability, allowing increasingly complex procedures to be performed. Consequently, procedures tend to be longer and the dose to the patient higher. The interventionalist is positioned closest to the anatomy being imaged and receives the majority of their exposure from x-ray radiation scattering from the patient. Typically, measures that reduce the dose to the patient…