Abano Terme, Italy
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Lorenzoni R.,UO Malattie Cardiovascolari | Ferraresi R.,Peripheral Interventional Unit | Manzi M.,Interventional Radiology Unit | Roffi M.,University of Geneva
EuroIntervention | Year: 2015

The guidewire (GW) is probably the most important tool for the endovascular treatment of arterial obstructions. In fact, the treatment of a lesion is only possible when the GW is passed beyond the target lesion. Lower limb percutaneous arterial revascularisation can be achieved using a variety of GWs which may differ in calibre, body, tip or coating. As the choice of an appropriate GW is critical for the success of a lower limb artery angioplasty, knowledge of the properties and performances of different GWs should be well known in order to tailor the choice of the device to the lesion characteristics and location, as well as to the intended revascularisation strategy. The aim of the present paper is to describe the constructive characteristics of GWs for lower limb arterial revascularisation, and to evaluate groups of GWs for each segment of the lower limb arterial vasculature. © Europa Digital & Publishing 2015. All rights reserved.


Ferraresi R.,Instituto Clinico Citta Studi | Palena L.M.,Interventional Radiology Unit | Mauri G.,Radiology Unit | Manzi M.,Interventional Radiology Unit
Journal of Cardiovascular Surgery | Year: 2013

The world is facing an epidemic of diabetes, consequently in the next years critical limb ischemia due to diabetic artery disease will become a major issue for vascular and endovascular operators. Revascularization is a key therapy in these patients because reestablishing an adequate blood supply to the wound is essential for healing avoiding a major amputation. In this paper, we summarize our experience in endovascular treatment of diabetic critical limb ischemia, focusing of the main technical challenges in treating below-the-knee vessels. We describe the following topics: 1) targets of the revascularization therapy: "complete" versus "partial" revascularization and the concept of wound related artery. Every procedure must be tailored on technically realistic strategies and on the general patient status; 2) the antegrade femoral access using both, the X-ray and the ultrasound guided techniques; 3) the chronic total occlusions crossing strategy proposing a step-by-step approach: endoluminal, subintimal, retrograde approaches. Particular attention has been given to the different retrograde approaches: pedal-plantar loop technique, trans-collateral approaches and the different types of retrograde puncture. For each step we provide a complete description of the technical details and of the suitable devices. Eventually we in brief describe: 3) acute result optimization and 4) prevention of restenosis.


Ferraresi R.,Instituto Clinico Citt Studi | Palloshi A.,Instituto Clinico Citt Studi | Aprigliano G.,Instituto Clinico Citt Studi | Caravaggi C.,Instituto Clinico Citt Studi | And 4 more authors.
European Journal of Vascular and Endovascular Surgery | Year: 2012

Background: Critical hand ischaemia (CHI) due to pure below-the-elbow (BTE) artery obstruction is a disabling disease and there is still no consensus concerning the most appropriate revascularisation strategy. The aim of this study was to assess the feasibility, safety and outcomes of percutaneous transluminal angioplasty (PTA) in the treatment of CHI due to pure BTE artery disease. Methods and results: Twenty-eight patients (age 62 ± 11 years; three females) with a total of 34 hands affected by CHI (one pain at rest; 18 non-healing ulcer; 15 gangrene) due to pure BTE artery disease underwent PTA. Most of the patients were males with a long history of diabetes mellitus, end-stage renal disease (ESRD) on haemodialysis and systemic atherosclerosis. The interosseous artery was free of disease in all cases, whereas the radial and ulnar arteries were simultaneously involved in 31/34 hands with long stenosis/occlusions (91%; mean length 155 ± 64 mm). The technical success rate was 82% (28/34), with only three minor complications. In the three cases with a functioning radial arteriovenous fistula, we successfully treated the ulnar artery. PTA was unsuccessful in 18% (6/34) hands due to inability to cross severely calcified lesions. The hand-healing rate was 65% (22/34). The predictors of hand healing were PTA technical success (odds ratio (OR) 0.5, confidence interval (CI) 0.28-0.88; p ≤ 0.0001) and digital run-off (OR 0.37, CI 0.19-0.71; p ≤ 0.003). The mean follow-up period was 13 ± 9 months. Six patients (18%) underwent secondary procedures due to symptomatic restenosis. In all these cases, a successful re-PTA was performed at a mean 6 months after the index procedure, and there were no major procedure-related events. Ten patients (36%) died during follow-up. Conclusions: Angioplasty of BTE vessels for CHI is a feasible and safe procedure with acceptable rates of technical success and hand healing. Poor digital run-off due to obstructive disease of the digital vessels can reduce the hand-healing rate after a successful PTA. Pure isolated BTE vessel disease seems to characterise patients with ESRD and diabetes mellitus. © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.


Manzi M.,Interventional Radiology Unit | Cester G.,Interventional Radiology Unit | Palena L.M.,Interventional Radiology Unit | Alek J.,Interventional Radiology Unit | And 2 more authors.
Radiographics | Year: 2011

In the past 5 years, with the introduction of new techniques and dedicated materials, endovascular recanalization of distal tibial and pedal vessels has become a valid alternative to inframalleolar bypass for limb salvage in patients with severe arterial occlusive disease, particularly diabetics. Revascularization of the foot is now often performed by using percutaneous transluminal angioplasty; over a 4-year period, the authors performed more than 2500 antegrade interventional procedures in patients with critical limb ischemia, diabetes, and infrainguinal arterial disease. Intraprocedural angiography of the foot is crucial for successful planning and guidance of percutaneous transluminal angioplasty in tibial and pedal arteries, and its effective use requires both anatomic knowledge and technical skill. To select the best revascularization strategy and obtain optimal clinical results, interventional radiologists, cardiologists, and vascular surgeons performing below-the-knee endovascular procedures also must be familiar with the functional aspects of circulation in the foot. ©RSNA, 2011.


Purpose: To evaluate the efficacy and safety of "Direct Stent Puncture" technique for intraluminal stent recanalization in the femoro-popliteal segments. Methods and Materials: A cohort of diabetics who had symptomatic in-stent occlusion of the superficial femoral or popliteal arteries underwent endovascular recanalization. After antegrade failure, direct stent puncture technique was performed.The primary end-point was to efficacy assessment, intended as technical success and clinical improvement. The secondary end-point was safety assessment, intended as free of complication rate. Results: Fifty-four patients (37 men; 73.6. ±. 8.5. years) underwent direct stent puncture technique, after several unsuccessful antegrade attempts to cross the occluded stent. Technical success for intraluminal stent recanalization was achieved in 53/54 (98.2%) of cases and failed in 1/54 (1.8%).Clinical improvement was obtained in 51/54 (94.4%) of cases, with regression of the clinical symptoms and improvement of the TcPO2, from 3±18mmHg to 43±11mmHg after 15days (p<0.001).Free of complications rate was 92.5%. In 2/54 (3.7%) of cases distal embolization occurred, in 1/54 (1.9%) case a sudden vessel thrombosis was diagnosed after 12. hours and in 1/54 (1.9%) case hematoma at the stent puncture site was observed. Conclusions: Direct Stent Puncture technique is an efficacy and safety option for intraluminal stent recanalization in the femoro-popliteal segment in-stent occlusion. © 2013 Elsevier Inc.


Manzi M.,Interventional Radiology Unit | Palena L.M.,Interventional Radiology Unit | Cester G.,Interventional Radiology Unit
Journal of Cardiovascular Surgery | Year: 2011

Diabetics with critical limb ischemia (CLI) usually have significant multilevel arterial disease, very often with compromised outflow on the foot arteries. The combination of severe peripheral arterial occlusion with the increased blood flow requirement, necessary to achieve the healing of the skin lesions or surgical incisions, makes this population particularly challenging. Additionally, diabetics and CLI patients have a high rate of comorbities, that increase the surgical risks or contraindicate surgical by-pass. Since its initial applications, endovascular recanalization for tibial vessels and foot arteries has proven to be feasible and safe, especially in diabetics with CLI. Actually, it is an established treatment option for limb salvage, avoiding amputation in lot of cases and improving lesions healing. The development of new technologies, such as dedicated guidewire's or low profile catheter balloons helps the interventionists, but the knowledge of most important techniques could be indispensable to obtain the procedural success and clinical outcomes.


Palussiere J.,Interventional radiology unit
Diagnostic and interventional imaging | Year: 2012

The indications for radiofrequency bone ablation in the case of benign tumours (osteoid osteoma, osteoblastoma) are curative, whereas for bone metastases, the prime aim is palliative analgesia. The failure rate for osteoid osteomas is low (<15%), and 70 to 90% of patients with metastases experience considerable relief, but if the treatment fails, it can be offered again. In the spine, heating can damage neighboring nerve structures, which means they need to be protected (CO(2) dissection). Radiofrequency ablation may be combined with an injection of cement. The osteonecrosis resulting from heating is painful and justifies performing the procedure under general anesthesia. Copyright © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.


Palena L.M.,Interventional Radiology Unit | Cester G.,Interventional Radiology Unit | Manzi M.,Interventional Radiology Unit
CardioVascular and Interventional Radiology | Year: 2012

In-stent reocclusion is a frequent complication of endovascular treatment and stenting, especially in the superficial femoral artery. Neointimal hyperplasia is the main cause of this problem, but in many cases, it occurs as a result of the presence of stent strut fractures. The two treatment options are endovascular and surgical intervention. The effectiveness of endovascular interventions in patients with critical limb ischemia has been well established, but in some cases, crossing the occluded stent is difficult. We describe a new technique to recanalize long in-stent superficial femoral artery occlusions characterized by direct stent puncture, followed by retrograde-antegrade recanalization after antegrade failures. © 2011 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).


Palena L.M.,Interventional Radiology Unit | Manzi M.,Interventional Radiology Unit
Journal of Endovascular Therapy | Year: 2014

Technique: After a failure of antegrade recanalization of the tibial and foot vessels, an antegrade pedal access can be performed in the pedal or plantar artery. After crossing the plantar arch and the occlusions in the opposing circulation pathway of the foot, a rendezvous with the antegrade catheter is performed, followed by final angioplasty and hemostasis.Conclusion: An antegrade pedal approach to the opposing circulation in the foot may be considered for below-the-ankle recanalization after standard antegrade recanalization failure in patients who are not candidates for a retrograde puncture. © 2014 INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS.Purpose: To describe a novel technical strategy to approach below-the-ankle chronic total occlusions after failed antegrade recanalization in patients who are not candidates for retrograde puncture.


Palena L.M.,Interventional Radiology Unit | Manzi M.,Interventional Radiology Unit
Journal of Endovascular Therapy | Year: 2012

Purpose: To describe advanced retrograde access (transmetatarsal or transplantar arch) for endovascular treatment of critical limb ischemia (CLI) and foot salvage. Methods: From September 2011 to March 2012, 28 CLI patients (24 men; mean age 71.9±10.6 years) being treated for foot salvage had failed antegrade recanalization, and percutaneous retrograde access at the pedal or plantar artery was unavailable. Advanced retrograde access techniques were required to recanalize the target vessel to restore blood flow to the compromised tissue. After local administration of verapamil to control spasm, the first dorsal metatarsal artery was preferentially accessed with a 21-G needle. When the first metatarsal artery was occluded and not fluoroscopically viewable, the plantar arch was punctured directly. After puncture, a 0.018- or 0.014-inch guidewire and microsheath were inserted for retrograde recanalization of the foot and tibial arteries with balloons sized to the target vessels. Results: Retrograde transmetatarsal artery access was performed in 25 cases and direct transplantar arch access in 3. Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 24 (86%) cases, with <50% residual stenosis and no complications. The 4 technical failures were due to spasm or no true lumen re-entry after successful transmetatarsal (n=3) and transplantar arch access. During amean 5-month follow-up (range 1-8), clinical improvement was obtained in the patients having technically successful tibial and foot artery recanalization; the transcutaneous pressure improved from 12.5±6.7 to 49.8±9.5 mmHg. There were no major and only 8 minor amputations. Amputation-free survival estimated by Kaplan-Meier analysis was 71% at 6 months. In patients with failed advanced access, the clinical condition did not improve. Conclusion: The advanced retrograde access technique appears feasible and beneficial as a rescue strategy in challenging patients with a failed antegrade approach who are unsuitable for retrograde pedal/plantar access. © 2012 by the International Society of Endovascular Specialists.

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