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Angiography

Introduction Angiographic procedures were first performed only months after Roentgen’s discovery of X-rays. Haschek and Lindenthal injected mercury salts into an amputated hand and created one of the first recorded images of the arterial system ( Fig. 43.1 ). This showed the enormous potential of radiographic visualization of the arterial system. In 1924, Brooks reported concentrated sodium iodide arterial injection as a means of demonstrating lower…

Complications of ECMO and IABP

Introduction Intra-arterial devices used to assist in the management of critically ill patients with cardiopulmonary failure have become commonplace at most advanced medical centers in the past decade. Extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumps (IABP) are two of the most commonly utilized percutaneous strategies. Temporary use of inotropic medications and IABP is successful in weaning the majority of patients from cardiopulmonary support; however, a…

Central Venous Stenosis Associated With Arteriovenous Access

Introduction Arteriovenous (AV) access for dialysis is established by connecting an artery and a vein together to create the superficial, high-flow conduit necessary for easy access and efficient dialysis. This is ideally done by connecting an anatomically or surgically superficial vein to an artery, but can also be done by interposing a prosthetic conduit between the in-flow artery and out-flow vein. For success, there must be…

Arteriovenous Access: Fistula and Graft Intervention

Endovascular Treatment in the Management of Arteriovenous Access Arteriovenous access surgery provides a lifeline for those patients with end-stage renal disease in need of hemodialysis. The high flow arteriovenous anastomosis results in a durable, easily accessed, reliable means of needle cannulation for high flux hemodialysis. Despite the obvious benefits of modern arteriovenous access surgery, numerous challenges make management of these accesses difficult. First and foremost, arteriovenous…

Complications of Endovenous Treatments, Including: Thermal, Nonthermal, Sclerotherapy, and Foam Ablations

Introduction Endovenous ablation has become the treatment of choice for chronic venous disease (CVD) and chronic venous insufficiency (CVI). There are many different types of modalities to treat CVI, including thermal energy commonly with endovenous laser ablation (EVLA), radiofrequency ablation (RFA; ClosureFast, Medtronic), and less commonly with steam and cryotherapy. In addition, nonthermal ablations are effective in venous ablation and include ultrasound-guided foam sclerotherapy (USGFS), mechanical…

Complications of IVC Filters

Introduction Venous thromboembolic disease is estimated to occur in as many as 1 or 2 patients per 1000 in the United States, with about 60,000–100,000 deaths annually attributed to deep vein thrombosis (DVT) or pulmonary embolism (PE). In hospitalized patients, pulmonary embolism is the third most common cause of death. Anticoagulation is the cornerstone for the treatment of DVT and PE. Inferior vena cava (IVC) filters…

Complications of Iliofemoral Thrombolysis and Stenting for Venous Disease

Introduction Many patients with symptomatic iliofemoral deep vein thromboses (DVTs) are now undergoing intervention to minimize thrombus burden in order to decrease venous pressures and preserve valve function. For patients with extensive and/or severely symptomatic DVT, catheter-based intervention is standard of care. Current guidelines from the Society of Vascular Surgeons and American Venous Forum for treatment are acute proximal DVT with symptoms <14 days, good functional…

Tibial Interventions for Peripheral Arterial Disease

Introduction Endovascular treatment for tibial arterial disease has grown in popularity through technological advancement and improvement in techniques, allowing increased success in treating difficult lesions. With growing evidence for decreased morbidity and mortality, as well as equivalent limb salvage rates following endovascular therapy when compared with open bypass surgery, tibial percutaneous transluminal angioplasty (PTA) is now commonly used as first-line treatment for infrapopliteal atherosclerotic disease. The…

Complications of Endovascular Repair of Popliteal Artery Aneurysms

Introduction Popliteal artery aneurysms (PAAs) occur at an incidence of 7.39 per 100,000 people, accounting for 80% of peripheral artery aneurysms. Typically asymptomatic, they are most commonly found incidentally on peripheral arterial disease screening examinations or when screening is based on the known presence of an aortic aneurysm, which confers a 12%–40% chance of popliteal artery aneurysm occurrence. PAAs may occasionally cause symptoms related to compression…

Complications of Femoropopliteal Interventions for Occlusive Disease

Introduction There has been a dramatic change over the past several decades in management of patients with femoropopliteal occlusive disease transitioning from open to minimally invasive endovascular repair. Optimal medical therapy continues to be the first-line therapy for patients with claudication caused by femoropopliteal disease. This includes smoking cessation and cardiovascular risk reduction, including antiplatelet therapy, cholesterol manipulation, exercise therapy, and oral statins. Supervised exercise programs…

Aortoiliac Interventions for Occlusive Disease

Introduction Endovascular treatment of complex (TASC C and D) lesions of the aortoiliac arteries has been increasingly adopted since the early 2000s, especially after the introduction of stent grafts. Although the primary patency rates are reported to be 60%–86% at 5 years, which is lower than with direct revascularization, secondary patency rates are comparable ranging from 80% to 98%. In the most recent meta-analysis, the 5-year…

Thrombolysis in Acute Limb Ischemia

Introduction Acute limb ischemia (ALI) arguably presents one of the most challenging problems that vascular surgeons face. The diagnosis is often clinical, but the etiology and appropriate treatment strategy are not always straightforward. A missed or delayed diagnosis can have grave consequences, such as limb loss or even death. Its estimated incidence is 1.5 cases per 10,000 people annually. Each patient’s physical examination will vary based…

Complications in Angioplasty and Stenting of Mesenteric and Renal Artery Disease

Introduction Chronic mesenteric ischemia (CMI) is a relatively uncommon disorder, accounting for <1 per 100,000 hospital admissions in the United States. Prophylactic revascularization is not recommended in patients with either renal or mesenteric artery disease. Treatment is indicated in select patients who present with symptoms of chronic mesenteric ischemia, such as intestinal angina, weight loss, and fear of eating. This occurs because of the after-meal pain…

Mesenteric Embolization: Solid Organ, Pelvic Trauma, and GI Bleeding

Introduction The common goal of catheter-based embolization procedures is to cease the flow of blood mechanically in a particular vessel or vascular territory using either a temporary or permanent agent. In the history of interventional radiology, embolization has an established key role as a frequently used, clinically valuable, and widely applicable endovascular procedure. This is partly a result of its elegance and simplicity as a minimally…

Renal and Mesenteric Aneurysms

Introduction Aneurysms of the mesenteric circulation are a rare but potentially fatal pathology. Therefore, a thorough understanding of the natural history and treatment options available is critical to the vascular surgeon potentially faced with treating this entity. Successful treatment with standard open surgical techniques was first described in the 1950s. Since that time, a major paradigm shift toward endovascular treatment has occurred not unlike many vascular…

Complications of Endovascular Septal Fenestration in the Management of Patients With Aortic Dissection

Introduction Endovascular fenestration is used to manage complicated aortic dissection in a manner analogous to open surgical septectomy. The intent to create a large communication between the aortic true and false lumina providing free interluminal flow and equalization of pressure differentials. The technique depends on the clinical situation. The two most commonly reported include endovascular balloon septectomy and longitudinal guidewire-mediated septectomy. Balloon fenestration of the dissection…

Complications in the Endovascular Management of Aortic Dissection

Introduction Since its inception in 1992, thoracic endovascular aortic repair (TEVAR) was introduced as an alternative treatment option to conventional open surgery for patients with complicated Type B aortic dissection (TBAD), i.e., end-organ malperfusion, refractory hypertension or hypotension, and unrelenting pain. TEVAR is also now considered for treatment of dissections with aneurysmal degeneration with aortic diameter >55 mm or increased aortic diameter of >4 mm Tevar Versus Open…

Transcatheter Aortic Valve Replacement

Transcatheter Aortic Valve Replacement Introduction Aortic stenosis (AS) affects morbidity and mortality as populations continue to age. Recent studies have estimated the prevalence of calcific AS between 2% and 4% among adults over 65 years of age and, for many years, there were limited or no treatment options for certain subsets of patients. In the absence of intervention, once symptoms develop, severe aortic stenosis is associated…

Complications and Lessons Learned From Global Use of the Streamliner Multilayer Flow Modulator (SMFM) Device

Introduction Over the last two decades, endovascular aortic repair (EVAR) has become the preferred treatment with regard to aortic pathologies and is an alternative treatment for patients who do not qualify for open surgery. Although EVAR has been shown to have significantly fewer complications when compared with open surgery, it is associated with complications that can lead to severe morbidity or even mortality. Complication rates after…