Eva Escobedo, MD

• Professor of Radiology
• UC Davis Medical Center
• Sacramento, California

If no such stump exists arrhythmia pathophysiology purchase calan online pills, then surgical intervention will likely be necessary to reestablish vascular patency blood pressure and age order calan from india. Over the past 20 years blood pressure medication drug test cheap calan 80mg with visa, a marked increase in the number of procedures for mesenteric revascularization has been performed arteria 23 purchase calan 80mg otc. Much of this increase is secondary to an escalated utilization of endovascular techniques pulse pressure 61 order calan overnight delivery. In a study performed by Razavi and Chung blood pressure 6240 proven calan 80mg, 70 symptomatic patients underwent stent placement for treatment of this disease. When stent placement is required, the choice of stent is generally dictated by the location and type of lesion. Lesions within the trunk of the mesenteric arteries may be treated with either balloon-expandable or self-expanding stents. Although bare metal stents are often used, covered stents may be employed in the setting of soft plaque, in arteries less than 6 mm in diameter (to reduce the risk for in-stent restenosis), or for the treatment of in-stent restenosis secondary to intimal hyperplasia. Balloon or stent advancement may be hindered by tortuosity of the iliac vessels, acute angle of the artery to be treated, and/or the presence of a tight or occlusive lesion. Treatment of tight or occlusive lesions may also be aided by predilation of the lesion with a low-profile balloon. Pharmacologic adjuncts to acute arterial occlusive mesenteric ischemia or chronic mesenteric ischemia include the use of intravenous heparin of 3,000 to 5,000 international units with a target activated clotting time of greater than 220 seconds. Intra-arterial nitroglycerin in 100 to 200 mcg boluses may be administered to prevent or minimize spasm. When a stent is deployed, 325 mg of aspirin and 300 mg of clopidogrel may be administered in the recovery room. Aspirin 81 to 325 mg should then be continued for life and 75 mg of clopidogrel should be administered for at least 30 days. Endovascular therapeutic approaches for acute superior mesenteric artery occlusion. Portal hypertension-related complications after acute portal vein thrombosis: impact of early anticoagulation. Summary Chronic mesenteric ischemia is a relatively uncommon clinical phenomenon due to the rich collateral circulation of the gastrointestinal tract. Catheter-directed angiography can be performed in patients with equivocal findings on noninvasive imaging or when intervention is anticipated. The primary goal of treatment is to improve blood flow to the mesenteric vascular bed. Endovascular therapy has taken on an increasing role in the primary management of chronic mesenteric ischemia in recent years. Although prospective comparisons of endovascular and open surgical approaches remain lacking, retrospective studies comparing these two approaches suggest that surgical bypass is associated with a more durable result. Open surgery, however, is associated with increased periprocedural morbidity and mortality when compared with endovascular approaches. In those patients who are surgical candidates and fail endovascular therapy, bypass generally remains an option. Endovascular thrombolysis in acute mesenteric vein thrombosis: a 3-year follow-up with the rate of short and long-term sequaelae in 32 patients. Transarterial thrombolysis of portal and mesenteric vein thrombosis: a promising alternative to common therapy. Percutaneous transhepatic recanalization and thrombolysis of the superior mesenteric vein. Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion. Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis. Transradial approach for transcatheter selective superior mesenteric artery urokinase infusion therapy in patients with acute extensive portal and superior mesenteric vein thrombosis. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical practice. Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. Translesional pressure gradients to predict blood pressure response after renal artery stenting in patients with renovascular hypertension. Endovascular management of atherosclerotic renovascular disease: early results following primary intervention. Visceral duplex scanning: evaluation before and after artery intervention for chronic mesenteric ischemia. Prospective evaluation of contrast-enhanced ultrasonography with advanced dynamic flow for the diagnosis of intestinal ischaemia. Median arcuate ligament syndrome: vascular surgical therapy and follow-up of 18 patients. Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience. Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting. Percutaneous management of chronic mesenteric ischemia: outcomes after intervention. Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease. Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. Intermediate-term outcomes of endovascular treatment for symptomatic chronic mesenteric ischemia. Results of single- and twovessel mesenteric artery stents for chronic mesenteric ischemia. Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia. Management of chronic mesenteric vascular insufficiency: an endovascular approach. Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes. Surgical and interventional visceral revascularization for the treatment of chronic mesenteric ischemia-when to prefer which Endovascular versus open revascularization for chronic mesenteric ischemia: a comparative study. Surgical or endovascular treatment for chronic mesenteric ischemia: a multicenter study. This generalization is supported by studies included in three meta-analyses of clinical series and a metaanalysis of randomized controlled trials. It has failed to show convincing benefit over optimal medical therapy in four randomized trials. Many physicians specializing in the treatment of patients with hypertension are reluctant to submit them to interventional therapy, which is an invasive procedure associated with potential complications, high costs, and possibly has no benefit over optimal medical control. This study comparing the effects of optimal medical therapy plus stent revascularization with medical therapy alone has a composite endpoint of cardiovascular and renal events: cardiovascular or renal death, myocardial infarction, hospitalization for congestive heart failure, stroke, doubling of serum creatinine, and need for renal replacement therapy. The increased risks are present in all age groups, ranging from 40 to 89 years old. The role of percutaneous renal artery angioplasty in this population is for medical treatment failures. Failure may manifest as poorly controlled hypertension, loss of renal function or mass, or episodes of unexplained flash pulmonary edema. Because loss of renal function or mass is less obvious and may occur even in well-controlled hypertension it is important to establish baseline parameters to be followed; generally, these are the serum creatinine value and the renal size. In the past renal size was measured on an abdominal X-ray; now it is more accurately measured by an ultrasound examination, which has the added bonus of eliminating the risk of radiation exposure. Ideally the ultrasound examination should include a Doppler flow study of the renal arteries to rule out stenosis and to establish baseline velocities. An abdominal bruit, particularly if it continues into diastole and is lateralized 3. Renal failure of uncertain cause, especially with a normal urinary sediment and <1 g of protein per daily urinary output 6. Coexisting, diffuse atherosclerotic vascular disease, especially in heavy smokers 7. Malignant hypertension, defined as hypertension with end organ damage including left ventricular hypertrophy, congestive heart failure, visual or neurologic disturbance, or advanced retinopathy 9. Unstable angina in the setting of suspected renal artery stenosis Society of Interventional Radiology. Quality improvement guidelines for angiography, angioplasty, and stent placement for the diagnosis and treatment of renal artery stenosis in adults. In a loose sense I am suggesting "drive-by angiography" on this patient set; however, I am not recommending "drive-by angioplasty or stenting. Indications for intervention that are accepted by the Society of Interventional Radiology, the American College of Cardiology, and the American Heart Association are listed in Table 45. The analysis indicates that the age distribution of patients with atherosclerotic lesions of the renal arteries was almost identical in males and females, the mean age being 52. These numbers vary depending on characteristics of the stenosis, such as its length, irregularity, multiplicity, the resistance of the distal vascular bed, and the available collateral blood supply. Difficulty measuring the pressure without affecting it, and the physiologic variations that occur during its measurement, make pressure gradient thresholds problematic. Ten percent of the peak systolic pressure and an absolute gradient of 10 or 20 mm Hg have been proposed by many interventionists as a measure of hemodynamic significance. Use of a pressure wire is recommended to determine a significant gradient both before and after angioplasty in these lesions. For females with fibromuscular hyperplasia the shape of the curve parallels that of subjects with atherosclerosis, but a decade earlier. Thus, there is a significant difference of unilateral lesions with respect to etiology. Thus, atherosclerotic lesions predominate in males and are more prevalent on the left side, whereas fibromuscular hyperplasia shows a striking predilection for the right renal artery and for female patients. Thirty percent of the 2,442 patients in the Cooperative Study of Renovascular Hypertension were nonwhite. A medical history and chart review is required to confirm that the patient has received optimal medical therapy and that intervention is appropriate. You should not proceed if the patient is normotensive on two medications, has normal renal function, and has no sign of renal atrophy. The choices are more difficult and numerous for the treatment of restenosis, especially in-stent restenosis. Brachytherapy has been safely used by a few investigators to increase primary patency and to treat restenosis with modest benefit. It is imperative that the interventionist plans to avoid complications as carefully as he or she plans for success. Plaques lining the aorta and renal arteries have the potential for renal or distal embolization. It is important to identify obstacles to successful and safe catheter manipulation and to be able to react to technical problems that become apparent during the procedure; however, some decisions need to be addressed preoperatively. The equipment that you need should be readily available in the room before the procedure is started. The most common complication associated with renal angioplasty involves the access puncture site. A pseudoaneurysm or hematoma at the puncture site is the most common complication; a retroperitoneal hematoma may be fatal. A femoral artery puncture guided by ultrasound has the advantage that it can evaluate plaque or a high femoral artery bifurcation that might complicate the puncture. It has a demonstrated superiority in obese patients and those with a weak arterial pulse40 but has the disadvantage that a high (retroperitoneal) puncture may be undetected unless the puncture site is evaluated fluoroscopically. Plan to puncture the skin 1 to 3 cm below this mark at a 45-degree cephalad angulation. Fluoroscope the result to make sure puncture has been made correctly; if not, remove the needle and guide wire and try again. Prophylactic hemodialysis and hemofiltration have not been validated as effective strategies. Fenoldopam, dopamine, calcium channel blockers, atrial natriuretic peptide, and L-arginine have not been shown to be effective. Use of furosemide, mannitol, or an endothelin receptor antagonist is potentially detrimental. Does the stenosis affect the main renal artery, an accessory renal artery, or branch vessels Each feature will affect the way we approach endovascular treatment and the prognosis. Most of these involve the renal artery ostium, which is the junction between the renal artery and the aorta. These stenoses are thought to be caused by aortic thickening and plaque that narrows the renal artery lumen like a curtain.

Other Heat-Based Percutaneous Therapies Microwave ablation devices may have a role in treating larger lesions blood pressure heart rate cheap calan online american express. In fact blood pressure pills cheap calan 120mg on-line, given the low electrical and thermal conductivity of bone blood pressure reduction discount 240 mg calan, microwave energy may be better suited to treat bone tumors arteria3d full resource pack 80mg calan with mastercard. Modern percutaneous cryoablation devices employ room temperature blood pressure 200 100 order calan overnight, pressurized argon and helium gases for tissue cooling and heating hypertension 80 mg purchase calan cheap online, respectively. Cryoprobes are generally placed in parallel arrangement within the tumor, but alternate configurations may be used to contour the ice to cover irregularly shaped tumors and avoid vulnerable structures. To eliminate nonlethal temperatures in regions of overlap or at the tumor margin, cryoprobes should be within about 2 cm of each other and 1 cm of the margin. Treatment is usually performed with two 10-minute freezes separated by a 5-minute passive thaw, although freeze cycle length may be increased or decreased depending on the adequacy of tumor coverage and proximity of adjacent critical structures. Bone is an appropriate target for this therapy given its high acoustic absorption. Heating at the skeletal surface likely results in palliation of pain due to destruction of periosteal innervation. This technology is limited to treatment of lesions with an acoustic window, and interposed bowel or nerves can be injured if contained within the path of the transducer to the target lesion. Ethanol Ablation Simple and inexpensive, ethanol instillation leads to cellular dehydration, vascular thrombosis, tissue ischemia, and necrosis. Ninety-five percent ethanol mixed with dilute contrast material is directly injected into the tumor through a fine needle (20 to 25 gauge). Cementoplasty Cement instillation into axially loaded bone at risk for fracture is called cementoplasty, osteoplasty, or vertebroplasty when applied in the spine. The cement likely has a direct effect on nociceptors as well as stabilizes painful microfractures within metastases. Bone biopsy needles, 11 to 13 gauge in caliber, may be placed into the metastasis, usually through the same access site created during the ablation procedure. Frequent imaging is necessary to ensure proper filling of the tumor cavity and minimize the risk of cement intravasation or extension outside of bone, particularly in periarticular or perineural locations. The bone access needles should be removed with care to avoid leakage of cement along the access tracts. Patients may be assessed for weight-bearing after 1 hour under direct supervision, and limits to ambulation may be determined by patient pain and degree of underlying bone destruction. Serious toxicities occurred in three patients (5%), including solitary cases of local pain, neuropathic pain, and foot drop. Pain relief was durable through the 24-week follow-up period in 80% of the patients who reported excellent pain relief at the immediate postablation time point. Furthermore, eight of eight patients who were prescribed opioid analgesics prior to the procedure reduced their doses following cryoablation. A low attenuation ice ball surrounds the tip of one of two cryoprobes early (B) and late (C) during treatment of the tumor. Cementoplasty was performed to add structural support to this important weight-bearing region. No significant complication occurred, although two patients terminated treatment prematurely due to sonication-related pain. A small study of five patients by Hierholzer and colleagues54 found cementoplasty alone to significantly reduce pain from skeletal metastases, including three patients with tumors in nonaxial skeletal locations. Ethanol Ablation In a series of 27 painful bone metastases treated in 25 patients with one to three doses of 3 to 25 mL of 95% ethanol, Gangi and colleagues45 reported complete pain relief in 3 patients, 75% reduction in analgesics in 10 patients, 25% to 50% reduction in 5 patients, and minimal or no relief in 7 patients as measured 24 to 48 hours following the procedure. One serious complication occurred, specifically weakness after treatment of a vertebral metastasis extending into the brachial plexus. The risks during device placement are similar to other percutaneous needle insertion procedures, allowing for the relatively large caliber of bone access needles or drills. Thermal damage to the normal structures described previously may result in nerve dysfunction, bowel or bladder perforation, infection, skin burns, or tumor/fistula formation. These complications are minimized through measures to displace or insulate critical structures as well as intraprocedural monitoring with imaging and thermocouples. Cementoplasty Cementoplasty may be performed as solitary treatment or in combination with ablative therapy in the treatment of painful metastatic disease involving bone. Small pneumothorax during cryoablation of T2 vertebral body metastasis from renal cell carcinoma in a 51-year-old man required smallcaliber chest tube drainage overnight. Active contrast extravasation (arrow) into a moderate-sized prevesical hematoma immediately following cryoablation of a pubic body metastasis from papillary thyroid carcinoma in a 59-year-old man. Femoral neuropathy in a 58-year-old woman resulted from cryoablation of a psoas muscle metastasis from melanoma during which the ice ball encompassed the femoral nerve (arrow). Cement extravasation following combined ablation and cementoplasty of a painful periacetabular metastasis from renal cell carcinoma in a 71-year-old man. Percutaneous thermal and chemical ablative therapies can effectively treat these metastases in carefully selected patients. Cementoplasty is a useful adjunct in treating lesions at risk for pathologic fracture caused by axial loading and may even have direct analgesic effects when used alone. Several adjunctive techniques allow safe treatment of metastases even in relative proximity to normal critical structures. Ablation of osteoid osteomas with a percutaneously placed electrode: a new procedure. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. Delay in progression of bone metastases in breast cancer patients treated with intravenous pamidronate: results from a multinational randomized controlled trial. A randomized, controlled trial of intravenous clodronate in patients with metastatic bone disease and pain. Effect of oral clodronate on metastatic bone pain: a double-blind, placebo-controlled study. The palliation of symptomatic osseous metastases: final results of the Study by the Radiation Therapy Oncology Group. A randomized trial of a single treatment versus conventional fractionation in the palliative radiotherapy of painful bone metastases. Pain relief and quality of life following radiotherapy for bone metastases: a randomised trial of two fractionation schedules. A randomized trial of three single-dose radiation therapy regimens in the treatment of metastatic bone pain. Prospective randomised trial of single and multifraction radiotherapy schedules in the treatment of painful bony metastases. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem. Percutaneous radiofrequency ablation of painful osseous metastases: a multicenter American College of Radiology Imaging Network trial. Percutaneous radiofrequency ablation with a multiple-electrode switching-generator system. Radiofrequency and microwave ablation of the liver, lung, kidney, and bone: what are the differences Image-guided percutaneous thermal ablation for the palliative treatment of chest wall masses. Lethal isotherms of cryoablation in a phantom study: effects of heat load, probe size, and number. Percutaneous imageguided radiofrequency ablation of painful metastases involving bone: a multicenter study. Treatment of extraspinal painful bone metastases with percutaneous cementoplasty: a prospective study of 50 patients. Radiofrequency ablation of bone metastases induces long-lasting palliation in patients with untreatable cancer. Radiofrequency ablation in combination with osteoplasty in the treatment of painful metastatic bone disease. Combined cementoplasty and radiofrequency ablation in the treatment of painful neoplastic lesions of bone. Combined radiofrequency thermal ablation and percutaneous cementoplasty treatment of a pathologic fracture. Radiofrequency ablation therapy combined with cementoplasty for painful bone metastases: initial experience. Percutaneous osteoplasty as a treatment for painful malignant bone lesions of the pelvis and femur. Such treatment has been used mostly as salvage therapy after failure of standard of care systemic therapies. Additionally, this treatment is also being considered because response rates remain largely positive even in situations when the same drug that was used systemically and failed to elicit any kind of response is used intra-arterially. The goal of such therapies in first line, typically referred to as induction therapy, is to obtain the highest response as early as possible in the disease to downstage a nonsurgical candidate to a surgical candidate. At the time of diagnosis 20% are present and 30% to 50% will appear later in the course of the disease. Even if surgery is the best treatment option for liver metastases, it will be possible in only 20% of patients. Consequently, it is not surprising that systemic chemotherapy is the dominant form of therapy for patients with liver metastases. The advantage of such an intra-arterial approach is directly related to the first-pass extraction of the drug by the liver and inversely proportional to the body clearance of the drug. As a result, a permanent and easy access route had to be obtained using a port linked to an intra-arterial catheter. Furthermore, a femoral access will most often be needed for endovascular flow remodeling, even if the indwelling catheter is inserted through the axillary arterial route. Second, those arteries not providing flow to the liver (such as those feeding the stomach, duodenum, or pancreas) that arise between the perfusion hole in the catheter and the liver must be permanently occluded to avoid toxicity resulting from extrahepatic drug perfusion. In clinical practice, the gastroduodenal artery and the right gastric artery are the more frequent arteries requiring endovascular occlusion because it is rarely possible to place the perfusion hole of the catheter downstream of these two arteries. Occlusion of the right gastric artery is considered to be critically important to minimize toxicity from the infused drug to the liver as discussed in the results section. First, it is sometimes difficult to visualize the right gastric artery on hepatic artery angiography; second, it can arise from several places between the common hepatic artery and the distal part of the left branch of the hepatic artery. When its origin cannot be seen on the hepatic artery angiogram, it is often useful to perform selective angiography of the left gastric artery. In most instances, contrast will reflux into the right gastric artery, which Technique Access Route the catheter is usually introduced through the axillary or femoral artery. It was preferred because it allowed easier insertion of the catheter in the hepatic artery due to the naturally descending orientation of the initial part of the celiac trunk, thus avoiding the sharp angulation encountered when using the femoral access. Disadvantages of the axillary route include a higher rate of overall complications, some severe, such as 3% of aneurysm formation requiring arterial stenting, axillary artery thrombosis,13 and 0. These issues have led some to access the axillary artery through a surgical cut-down of a small branch, typically the thoracic-acromial artery. The retrieval or exchange of such catheters is risky enough that it is recommended that such a maneuver be performed through a femoral access. Schematic drawing of steps needed for implantation of an intra-arterial catheter with distal tip in the gastroduodenal artery. Normal anatomy (1), coil inserted in the right gastric artery (2), indwelling catheter in place with side hole in the distal part of the common hepatic artery (3), coils in the gastroduodenal artery around the catheter (4), flow of chemotherapy through the implanted catheter (5). Schematic drawing of a free-floating catheter implanted in the hepatic artery proper after coil occlusion of the gastroduodenal and right gastric arteries. Schematic drawing of a catheter implanted distally in a peripheral branch of the hepatic artery after coil occlusion of the gastroduodenal and right gastric arteries. Angiogram obtained after injection in the middle hepatic artery shows a branch for the left liver (arrow) and the gastroduodenal artery. Angiogram obtained after injection in the superior mesenteric artery shows a replaced right hepatic artery. After occlusion of the replaced right hepatic artery with an endovascular occluding device (arrow) the contrast medium is seen in the proximal part of the replaced right hepatic artery (arrowheads). Distal part of the 5 French indwelling catheter demonstrating a side hole (arrow). By shortening the catheter, distance from the side hole to the tip will be customized for each patient according to the anatomy. The right gastric artery has been occluded with coils (black arrowheads) and the tip of the indwelling catheter (white arrow) has been placed in the gastroduodenal artery, which has also been occluded with coils (arrows). Injection of contrast medium in the femoral-implanted port opacifies the complete hepatic vascularization and only hepatic arteries through side hole of the catheter. Note the collateral arterial pathways through the liver hilum that vascularized the right hepatic artery distal to the occluding device (white arrowhead). The absence of reported toxicities affecting the gallbladder makes it unnecessary to systematically embolize the cystic artery or other vessels providing flow to the gallbladder. The catheter tip can be stabilized by inserting the catheter deeply into the gastroduodenal artery (or when impossible in a distal branch of the hepatic artery). A side hole can then be created in the indwelling catheter within the hepatic artery upstream of its first bifurcation. After the catheter tip is placed within the gastroduodenal artery, coils or/and cyanoacrylate glue are carefully delivered around it to both affix the catheter and occlude the gastroduodenal artery.

This phenomenon can temporarily occlude either the collateral flow or the previously patent runoff vessels into the foot causing exacerbation of symptoms arteria johnson cheapest calan. Similarly blood pressure tracker order calan in india, distal embolization with segmental or total loss of a tibial vessel may remain initially asymptomatic due to the presence of other runoff vessels blood pressure examples cheap 80mg calan with amex. It should be noted blood pressure charts readings calan 80mg on line, however hypertension harmony of darkness discount calan amex, that asymptomatic distal embolization is not a benign event arrhythmia associates of south texas order calan with amex. Although larger particles as reported by Karnabatidis have a high likelihood of occluding runoff vessels, it is unclear if microscopic debris generated during routine interventions have any clinical sequelae in lower extremities. Recanalization of Occluded Stents and Stent-Grafts the most common cause of stent failure in lower extremities is neointimal tissue ingrowth or stent-adjacent lesions. As such, presence of material with embolic potential is typically discounted during interventions for occluded stents. Clot at various stages of organization, however, could exist, especially in totally occluded stent-grafts or recently occluded stents of any kind. Time of onset of symptoms and the tactile feeling during the passage of wire through a previously stented segment should provide clues as to the likelihood of presence of mobile thrombus. In such cases recanalization without preventive measures may lead to macroscopic thromboembolism. Atherectomy and Debulking Devices Use of some atherectomy or debulking devices may also increase the risk of distal embolization during lower extremity revascularization. Centers with more experience with one device tend to report lower embolization rates than others. In occluded arterial segments there is usually organized athrothrombotic debris that may not be adherent to vessel wall. Studies have shown that these particles consist of platelet and fibrin aggregates with or without trapped erythrocytes and inflammatory cells, cholesterol crystals, and extracellular matrix. Reestablishment of flow through channels filled with such unattached debris could release them into the distal circulation. The number of signals was proportionally higher during plaque excision and debulking. Despite this finding, only 1 of 60 patients in this analysis suffered from what was considered "clinically significant" distal embolization by the authors. Similar to other vascular territories, loss of flow in a named artery or major collateral branch of the lower extremity will likely harbor a poorer prognosis. It is therefore prudent to perform complete arteriography before and after any upstream interventions, especially in patients and interventions considered high risk for distal emboli. Use of anticoagulants after routine endovascular interventions has not been shown to prevent recurrence. Use of dual antiplatelet therapy has gained more acceptance and popularity before and after lower extremity arterial interventions. This may be caused by an extrapolation of the beneficial data from the coronary circuit to the carotid and peripheral arterial disease territories. There is currently no evidence that dual therapy is superior to monoantiplatelet therapy in the prevention of secondary peripheral arterial disease after endovascular interventions. Most patients undergoing peripheral interventions do not require special measures except appropriate anticoagulation and standard good practices, such as routine flushing of sheaths and catheters. In general, careful manipulation of devices across stenotic lesions, utilization of lower profile devices, minimization of the number of steps (such as catheter exchanges and balloon inflations), use of long balloons matching lesion lengths, and so on, all reduce the risk of distal emboli. In addition, familiarity with various specialty devices, such as atherectomy catheters, stent-grafts, recanalization tools, and drug-coated balloons as well as understanding their performance characteristics and limitations is paramount to good immediate and long-term outcome. Once the clot is removed and an underlying lesion exposed, care must be exercised in treating that lesion. Stenoses in freshly lysed arterial segments may harbor acute or organized residual clot, which could be released after angioplasty or debulking procedures. An unusual stenosis, such as a lesion in the middle of a synthetic graft or the angiographic appearance of any "filling defect," should raise the suspicion of adherent clot. For this purpose, the use of any one of the available distal protection devices would be adequate as long as the length of its wire matches the shaft length of the planned balloon or stent to be used. The short wires of rapid-exchange platforms are frequently incompatible with the required devices for lower limb interventions. An overloaded basket could release some of its content during recapture maneuvers, causing more distal embolization. A commonly used technique is to advance a guiding or aspiration catheter to the basket and apply suction to partially empty it before recapture. We routinely aspirate the sheath vigorously once the basket reaches its tip during removal. Proper anticoagulation will reduce the risk of in situ clotting as well as acute thrombosis of the vascular beds distal to an embolic occlusion, allowing the operator to treat the offending embolus. There has been no randomized study comparing unfractionated heparin with bivalirudin in peripheral interventions but reported experience with the latter reveals safety and efficacy equivalent to or better than heparin. Hence, compatibility of debulking devices with the wire of the distal protection devices should be considered before their application. Diamondback has its own dedicated wire (ViperWire) designed to prevent the advancement of the crown of the device beyond the wire tip. Applying good catheter techniques, using adequate pharmacologic adjuncts, and employing protection devices when indicated are common examples. Aspiration Embolectomy In case of distal embolization and loss of runoff vessels, the simplest and fastest approach is aspiration embolectomy using either a large lumen guide catheter or one of several specialty devices designed for this purpose. These are all manual aspiration catheters with variable performance characteristics. Familiarity with their specific dimensions and aspiration capabilities is critical to the success of rescue maneuvers. Long segment occlusions of previously stented vessels may contain a nonadherent organized clot that could embolize once partial flow is reestablished. Their placement distal to an occluded segment first requires the passage of a guide catheter with a large enough inner diameter to accommodate the basket across the occlusion. This maneuver could prove difficult in severely calcified or fibrotic lesions without prior angioplasty. Furthermore, the passage of a large guide catheter itself can cause distal embolization by "plowing" embolic material downstream. The BareWire of the Emboshield device is not attached to the basket and can move independent of it. The Spider embolic protection system can be advanced through its own microcatheter and hence does not require a guide catheter. Adjunctive Pharmacotherapy the applications and dosing of thrombolytic therapies in acute limb ischemia is described elsewhere in this text. The following discussion is related to patients with acute procedural thromboembolic complications. Pharmacomechanical thrombolysis using automated mechanical thrombectomy devices with thrombolytic drugs in the treatment of procedural complications is reserved for in situ thrombosis. This patient was undergoing atherectomy and sustained an injury to the vessel wall, causing acute thrombosis. The incidence of true in situ thrombosis in adequately anticoagulated patients is likely to be significantly less than 3. These are usually treated by placement of stents rather than declotting maneuvers. Other Preventive Technologies A new and novel method of preventing distal emboli during lower extremity interventions includes the use of the Proteous embolic capture angioplasty balloon (Angioslide, Ltd. This device provides the operators with a balloon angioplasty catheter and the option of embolic capture in one device. Experience with the use of proximal protection devices in the periphery is limited and hence cannot be recommended at present time. Neither the lytic agents nor the mechanical thrombectomy devices are suited for atherosclerotic debris. The latter should be removed by aspiration using one of a variety of aspiration catheters as discussed earlier. Based on the mechanism of action of these agents and the experience in other vascular beds it is safe to assume that they are effective in reducing the risk of procedural thrombosis during peripheral interventions but may increase the risk of bleeding complications. Our understanding of their risk factors and clinical significance is improving, leading to better preventive strategies and treatment approaches. Predictors of distal embolization in peripheral percutaneous interventions: a report from a large peripheral vascular registry. Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery. Lesion types and device characteristics that predict distal embolization during percutaneous lower extremity interventions. Implications of in situ thrombosis and distal embolization during superficial femoral artery endoluminal intervention. Distal embolism during percutaneous revascularization of infra-aortic arterial occlusive disease: an underestimated phenomenon. Peripheral arterial endovascular interventions: early results using distal protection. Atheroembolization and peripheral vascular interventions: the evidence is mounting. Antithrombotic therapy in peripheral artery disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the U. Use of embolic capture angioplasty for the treatment of occluded superficial femoral artery segments. The most commonly used classification system for these diseases is based on the size of the vessel involved and is divided into large-, medium-, and small-sized-vessel vasculitis (Table 51. In this article, we review the epidemiology, clinical manifestations, diagnosis, and medical management of the major forms of vasculitis based on the classification system outlined previously. In particular, we will focus on large- and medium-sized-vessel vasculitis because patients with these conditions most often require angiographic imaging studies for diagnosis and/or disease monitoring. Extracranial complications may include stenosis of the great vessels with resultant ischemic complications or aortic disease with aneurysm formation and possible rupture. Although several bacterial and viral organisms have been evaluated as potential etiologic agents, to date the inciting trigger remains elusive. Recently, T cells producing interleukin-17 have also been implicated in disease pathogenesis. In response to immunologic injury, the artery releases growth and angiogenic factors that induce migration and proliferation of myofibroblasts, neoangiogenesis, and intimal proliferation. Macrophages tend to concentrate around the internal elastic lamina and fragmentation of this elastic layer often occurs. Although most macrophages are singly distributed, they may coalesce to form multinucleated giant cells. The absence of giant cells may be noted in up to onethird of biopsies and does not exclude the diagnosis. Occasionally, thickening and nodularity of the temporal arteries may be observed clinically. Jaw claudication from involvement of the facial and internal maxillary arteries supplying the muscles of mastication is present in only one-third of patients but is highly specific for this diagnosis. Other visual symptoms related to ischemia may include amaurosis fugax and diplopia. Constitutional symptoms, such as fatigue, fever, or weight loss, can also be present at diagnosis. These patients tend to be younger and do not have typical cranial manifestations, often resulting in a delayed diagnosis. Neurologic manifestations are less common and may include stroke, transient ischemic attack, or neuropathy. Abnormalities of the temporal artery (nodularity, swelling, diminished pulse, or tenderness to palpation) are predictive of a positive temporal artery biopsy. An aortic insufficiency murmur could indicate the presence of aortic root dilatation caused by involvement of the thoracic aorta. Complete blood counts often show a normocytic anemia and reactive thrombocytosis secondary to the inflammatory process. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. The 3D reconstruction images demonstrate long segments of smooth and tapered stenoses of the left subclavian/axillary artery (arrows) characteristic of vasculitis. Persistent vascular uptake is often present on serial imaging studies even when the patient is clinically in remission. A typical starting dose is between 40 and 60 mg of prednisone for 4 weeks followed by a gradual taper over several months. Studies have shown that the temporal artery biopsy can be diagnostic even after several weeks of corticosteroid therapy. In an early retrospective study comparing treated patients to a precorticosteroid-era group, it was demonstrated that cortisone significantly lowered the risk of visual loss. After 4 weeks of treatment, the daily prednisone dose should be tapered gradually by about 10% every 2 to 4 weeks. Disease relapses are common during prednisone taper and require an increase in the corticosteroid dosage.

Several models of pain focus on the concept of pain behavior blood pressure 7850 order calan with amex, in which a person verbally or nonverbally expresses or displays his or her pain heart attack photo buy calan cheap, for example blood pressure fluctuation causes purchase calan 120 mg visa, by verbal complaint or facial expressions indicating pain pulse pressure 25 purchase genuine calan on-line. If a family member engages in pain behavior and this behavior is reinforced or supported by other family members arrhythmia 16 year old generic 80 mg calan fast delivery, it can lead to increased pain behavior and blood pressure medication effects on sperm discount calan 240 mg with visa, ultimately, higher levels of pain. Sherrill, Janet Deatrick, and Keith Sanford is typically regarded as maladaptive, research with couples suggests that it is also beneficial for partners to be able to have intimate conversations about pain. Specifically, conversations characterized by discussion of emotions, as well as provision of empathy, are associated with less pain and less painrelated distress (Cano & Williams, 2010). Family Interventions the fourth overarching question has to do with identifying types of family interventions that improve outcomes when one member has a medical condition. These interventions include programs designed to help patients and their families cope with and manage medical conditions, and they fall into two broad categories. First, couplebased interventions are intended for couples where one partner has a medical condition and they target both members of the couple. Second, parentbased interventions are intended for families where a child has a medical condition and they include a substantial parent component. All these family interventions may target a range of different goals such as decreasing symptoms of the medical condition, improving adherence to a treatment plan, improving emotional wellbeing in the patient and in family members, and improving family relationships overall. As might be expected for a new line of research seeking to develop effective treatments, the number of initial studies is still quite limited, and these initial studies often produce treatment effects that are small or nonsignificant. Although several different types of couplebased interventions have been developed, many of these interventions are designed to address five different areas (for a review, see Baucom, Porter, Kirby, Hudepohl, 2012). First, they have an educational component where both members of a couple are provided with medical information. Second, they build intimate and clear communication in which partners share their thoughts and feelings regarding the medical condition. Third, they help partners negotiate the process of making medical decisions together. Fourth, they help partners make adjustments in their relationships to accommodate changes that may have been caused by a medical condition, including changes in physical ability, appearance, and sexual functioning. At this point, evidence supporting the effectiveness of these types of interventions remains sparse. One small pilot study of women with earlystage breast cancer suggested that a couple based relationship intervention might be beneficial in several areas, including increased acceptance and relationship satisfaction, as well as decreased pain and fatigue. In contrast, a randomized clinical trial of a caregiverassisted cognitive skills training program for couples with a partner with lung cancer failed to find significant treatment benefits for emotional distress, quality of life, and caregiver stress. One of the largest randomized clinical trials for a couplebased intervention tested a partnerassisted emotional disclosure program for patients with gastrointestinal cancer. This study found that the treatment had nonsignificant effects on emotional variables but did have a small positive effect on relationship satisfaction. A followup analysis suggested that this effect was primarily noticeable in couples that initially did not talk about cancerrelated concerns and emotions before treatment. As it stands, there remain many unanswered questions about which types of interventions will be most effective for which types of people. Research regarding the effectiveness of parentbased interventions is also in its early stages. A metaanalysis identified three types of parentbased interventions that have been tested in randomized clinical trials (Law, Fisher, Fales, Noel, & Eccleston, 2014). First, cognitive Family and Health 261 behavioral approaches teach all family members to change thoughts and behaviors that may exacerbate symptoms of a medical condition or feelings of distress. Second, problemsolving approaches focus on helping family members develop problemsolving skills related to the illness. Third, systemic approaches help family members alter potentially problematic patterns of interaction. However, this metaanalysis failed to find significant effects for other important outcomes such as parent and child mental health, family functioning, and child medical symptoms. Other reviews of parentbased interventions have suggested that cognitive behavioral approaches may reduce medical symptoms and improve family functioning in youth with chronic pain and that systemic approaches may reduce medical symptoms and improve family functioning in youth with diabetes. In sum, although some results are promising, there remains a need for further research and development of parentbased approaches for families of children with medical conditions. Keith Sanford, PhD, is a professor in the Department of Psychology and Neuroscience at Baylor University. He serves on the editorial board of Journal of Family Psychology and Family Process, and he teaches graduate and undergraduate courses on advanced data analysis. He received his PhD in clinical psychology from Michigan State University, and he specializes in the development and validation of assessment instruments. His research program focuses on couples and family psychology; communication, emotion, and cognition in close interpersonal relationships; and associations between interpersonal relationships and health. Dyadic coping: A systemictransactional view of stress and coping among couples: Theory and empirical findings. Posttraumatic stress, family functioning, and social support in survivors of childhood Leukemia and their mothers and fathers. Marital adjustment, satisfaction, and dissolution among hematopoietic stem cell transplant patients and spouses: A prospective, fiveyear longitudinal investigation. Systematic review and metaanalysis of parent and familybased interventions for children and adolescents with chronic medical conditions. Parental Influence on Models of Primary Prevention of Cardiovascular Disease in Children. Couple resilience inventory: Two dimensions of naturally occurring relationship behavior during stressful life events. Asymmetrical effects of positive and negative events: the mobilizationminimization hypothesis. The goal is to create treatment plans individualized to the patient while supporting his or her psychosocial needs. Interventional oncologists require the ability to accomplish a thorough and comprehensive assessment of patients who have a variety of malignancies and a range of associated medical problems, including comorbidities, previous treatment history, and social status. Their skills are vital because of their ability to perform procedures in patients who have various malignancies with a range of medical problems and types of organ dysfunctions. Evaluation of cancer patients comprises several fundamental principles, including a complete medical history, performance status grading, quality-of-life assessment, physical examination, laboratory and data review, and an in-depth discussion with the patient and family regarding treatment options, choices of plans, rationale and expectation of the outcomes, and potential risks. Other components of the medical history, which are discussed in detail later, include history of present illness, review of systems, pertinent listing of previous medical and surgical details, review of records, hereditary and environmental factors, use of drugs and medications, allergies (both to prescription and over-the-counter drugs), and alternative treatments. Subsequently, the physician performs a relevant physical examination to obtain insight on organ dysfunction. The history and physical examination can be a fluid process, because such findings may prompt the health care provider to obtain additional medical history in a targeted fashion. The history and physical examination should be cohesive and similarly structured3 to provide a platform on which further diagnostic information from laboratory and ancillary data can build. A detailed review of adverse treatmentrelative events and symptomatology, as well as any treatment complications, should be brought forth. All symptoms associated with the primary diagnosis and the secondary effects of the tumor or different previous treatment versus current treatment should be explored in detail. Systemic complaints such as malaise, fatigue, lethargy, anorexia, weight loss, fevers, chills, and drenching night sweats are common. They also may manifest as constipation, diarrhea, melena, early satiety, nausea, vomiting, and/ or a change in bowel habits. An in-depth knowledge of the respective tumors can allow one to explore with the patients symptoms Medical History A comprehensive and thorough history and physical exam, even in the era of technology-driven medicine, provides the most vital and crucial basis for any resulting diagnosis or treatment plan. Other symptoms to review with all cancer patients include oropharyngeal soreness, chest pain, hemoptysis, flank and back pain, hematuria, and enlarged lymph nodes. Neurologic symptoms such as bowel or bladder incontinence, saddle anesthesia, gait instability, and back pain should raise concern for cord compression, requiring emergent workup and intervention. Pain is commonly associated with a variety of malignancies, and a verbally administered pain scale of 0 to 10 is a useful, easy way to assess severity and, therefore, to guide treatment, especially in older adults. Any coexisting medical problems should be elicited that may impact the primary oncologic diagnosis and specifically may influence choice and impact of certain therapies. Transfusion history should be obtained to assess risk factors for viral hepatitis and to assess prior transfusion needs. Any previous psychological disorders, including depression and anxiety, should be ascertained in order to facilitate patient discussion in the future, determine coping mechanisms, and determine whether any current or prior antidepressant/anxiolytic medications with significant hepatic metabolism may interact with planned interventional therapeutics. Surgical history must address the date of resection of the primary cancer, any history of prior liver resections, and placement of hepatic arterial infusion pumps or portal shunt. A complete list of any prior malignancies and their treatment dates should be obtained because this may influence subsequent therapeutic options. Examples of such include use of prior anthracyclines or radiotherapy because lifetime dose limitations may warrant changes in the treatment plan. A complete medical evaluation for the cancer patient should include the social history. It yields information regarding any occupational or environmental exposures that may associate with tumorigenesis. These details may have a significant impact on the choice of treatment and can affect compliance with therapies, ability to follow up, and capacity to cope and manage the side effects and toxicities of therapy. Because most patients typically use multiple medications that have some element of hepatic metabolism, it is essential to avoid concurrent use of hepatotoxic drugs. Because many patients may take alternative medicines or therapies without telling physicians or health providers, and these may interfere with the interventional therapies/procedures, investigational efforts should be taken to look into this issue. On the other hand, it is also important to note compliance in drugs and obstacles that prevent the patient from taking the drug(s) as prescribed. Any drug or food allergies and their reactions, particularly to antibiotics, should be recorded in detail. During the initial office visit, a full-systems approach should be obtained to gather information regarding the general health of the individual, including vital signs: blood pressure, pulse, respiratory rate; weight and height; and pulse oximetry. Following assessment of the vital signs, assessment of the overall health status of the patient should be obtained. Dry mucous membranes, poor skin turgor, and chapped lips can indicate a hypovolemic state. If these are found, it is useful to also ask about symptoms of orthostasis and to assess orthostatic blood pressures/heart Family History, social History, and Medications It is essential to have a detailed family history described for most common malignancies. An overall assessment of the skin can be indicative of the general health of the patient as well as point to specific organ dysfunction. It is caused by accumulation of the conjugated form of bilirubin,3 often associated with biliary obstruction or dilatation, and usually observed if the serum bilirubin level is greater than 3 mg/dl. Pathologically enlarged lymph nodes are typically detected by palpation when they are located in anatomically superficial areas. Specific attention should be made to the size, texture, and possible impingement on surrounding structures, including the trachea. The general approach to the head and neck exam should include assessment of alopecia because this may be indicative of poor nutritional status or prior chemotherapy. Specific attention should be made to the oropharynx: dentition; peritonsillar masses/erythema, which may be indicative of an abscess; white plaques, especially on the tongue and buccal areas, which may be concerning for thrush; and posterior oropharynx erythema and exudates. Asymmetry in the oropharynx may be indicative of masses and/or cranial nerve deficits. The general approach to the abdominal examination should include detection of ascites, abdominal masses and/or bruits, abdominal distention, hepatic and/or splenic enlargement, tenderness, and nodules. Patients with liver metastases or hepatocellular carcinoma can often present with a firm, enlarged, and irregular liver on palpation. Palpation of the liver edge within the right upper quadrant usually indicates hepatomegaly. The normal liver may be palpated 4 to 5 cm below the right costal margin but is often not detected within the epigastric area. Patients may have complaints of tenderness within the right upper quadrant with abdominal palpation and sometimes with percussion. Occasionally a vascular bruit over the liver caused by increased vascularity from the tumor can be appreciated. This complication can lead to portal hypertension and effectively decrease blood flow to the liver. Splenomegaly is detected by movement during inspiration because enlarged spleens typically are present just beneath the abdominal wall. A thorough cardiovascular and chest examination should be performed, particularly in those patients receiving any type of anesthesia or intra-arterial therapies. Evaluation of cardiac rate, rhythm, auscultation for murmurs and rubs, and a full assessment of peripheral pulses should be done. For patients with pulmonary involvement of their disease, physical exam findings can include decreased unilateral breath sounds and dullness to percussion caused by pleural effusion and/or lobar collapse and atelectasis. Inspiratory and/or expiratory wheezes may be a sign of intrinsic or extrinsic obstruction of the airways by tumor. This includes assessment of the cranial nerves, motor strength, sensation, cerebellar function, and gait. Dysfunction in any of these areas may be indicative of metastases to the brain parenchyma, leptomeninges, and/or the spinal cord, requiring emergent imaging and treatment. Spinal cord compression, for example, can present with either unilateral or bilateral weakness, back pain with focal vertebral tenderness, decreased rectal tone, and incontinence. It is a vital tool used to determine whether a patient can withstand the toxicities associated with various modes of treatment. Evaluation of quality of life can be particularly relevant for older patients, because this population is typically most concerned about changes in quality of life rather than disease progression and death. Tissue diagnose of malignancy is mandatory before any kind of therapy in most types of cancer.

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