Safety and Efficacy of Peripheral Embolization with EASYX Liquid Embolic Agent: A Multicenter Prospective Study

PurposeTo evaluate the clinical safety and efficacy of EASYX, a new nonadhesive precipitating liquid embolic agent based on a polyvinyl alcohol ether polymer labeled with iodine molecules, for peripheral embolization.Materials and MethodsThis open-label prospective multicenter study was conducted on 50 consecutive patients treated with embolization using EASYX in 3 academic hospitals from April 2018 to July 2019. Indications for embolization were symptomatic varicocele (n = 15), type II endoleak (n = 8), acute hemorrhage (n = 16), portal vein embolization (PVE; n = 9), or angiomyolipoma (AML; n = 2). Patient characteristics, technical and clinical success rates, pain at injection, and satisfaction of the interventional radiologists were assessed. Follow-up imaging was performed using ultrasound for varicoceles (at 1 month) and computed tomography (CT) for the other indications (at 3 or 6 months).ResultsThe immediate technical success rate was 98%. The clinical success rates were 100% for acute hemorrhage and type II endoleaks, 89% for PVE, 86% for varicoceles, and 50% for AMLs. Patients who underwent PVE showed significant hypertrophy of the future liver remnant at follow-up (P < .001), and 55.6% of patients proceeded to hepatectomy. The absence of artifacts on imaging allowed improved monitoring of the aneurysmal sac in patients with type II endoleaks. The satisfaction rate of the interventional radiologists was >90% for 5 of 7 items.ConclusionsEASYX as a novel copolymer liquid embolic agent was safe and efficient for peripheral embolization. The absence of tantalum allowed reduced CT artifacts on imaging follow-up, which was especially useful in patients with type II endoleaks.     

Biodegradable Polydioxanone Microspheres for Transcatheter Arterial Embolization: Proof of Principle

PurposeTo evaluate feasibility, embolization success, biodegradability, reperfusion, and biocompatibility of biodegradable microspheres (MS) made from polydioxanone (PDO) for transcatheter arterial embolization.Materials and MethodsUnilateral selective renal embolization of a segmental artery was performed in 16 New Zealand White rabbits with PDO-MS (100–150 μm and 90–315 μm). Animals were randomly assigned to different observation periods and underwent control digital subtraction angiography (DSA) and MR imaging immediately (n = 3), 1 week (n = 2), 4 weeks (n = 2), 8 weeks (n = 2), 12 weeks (n = 5), and 16 weeks (n = 2) after embolization. Kidneys were harvested for macroscopic and histologic analysis of embolization success, biodegradability, and biocompatibility.ResultsEmbolization was technically successful in 15 of 16 animals. One animal died of anesthesia-related circulatory failure. The 100–150 μm MS were injected easily through 3-F catheters; the 90–315 μm MS tended to clog with intermittent catheter obstruction. DSA and MR imaging showed successful target embolization in 13 of 15 animals. In 2 animals, the entire kidney was affected owing to catheter clogging, including a reflux of MS while flushing. Control DSA and MR imaging showed increasing vascular reperfusion with time. Macroscopic and histologic analysis revealed necrosis/infarction in areas in which embolization was achieved. MS were extensively degraded after 16 weeks, and overall inflammatory reaction was mild.ConclusionsBiodegradable PDO-MS induced effective embolization of target vessels while demonstrating good biocompatibility. MS increasingly dissolved at 16 weeks, partial reperfusion started at week 1, and complete reperfusion started at week 8, thus offering possible advantages as a temporary embolic agent.     

Factors Affecting Adverse Events after Venous Malformation Sclerotherapy

PurposeTo evaluate factors that contribute to adverse events (AEs) after embolization of venous malformations (VMs) using sclerosing agents.Materials and MethodsA retrospective review of patients who underwent direct puncture embolization of VMs with a sclerosing agent and adjunctive techniques, also termed as sclerotherapy, from 2016 to 2021 was performed. Three-hundred one embolizations in 137 patients (median age, 19.0 years; interquartile range, 12.8–31.5 years) were evaluated. The VM characteristics and embolization details were analyzed. Anticoagulation was also evaluated based on D-dimer levels. Cutaneous and noncutaneous AEs were analyzed. The AEs were categorized using Society of Interventional Radiology guidelines.ResultsVMs involving tissue planes were subcutaneous (n = 104), intramuscular (n = 84), and combined (n = 113). Overlying skin involvement was observed in 56% of the patients. Sodium tetradecyl sulfate was mainly used (83%). Periprocedural anticoagulation was used in 9% of the patients. Most AEs were minor (30/301, 9.7%), and only 1.7% (5/301) were major (21 cutaneous and 14 noncutaneous AEs). Age below 18 years (odds ratio, 4.4502; 95% confidence interval, 1.5607–12.6890; P = .0052) and overlying skin involvement (odds ratio, 7.1794; 95% confidence interval, 1.6226–31.7656; P = .0094) were factors associated with cutaneous AEs. All noncutaneous AEs developed in patients with intramuscular VMs; however, this association was not statistically significant. There was no severe hematologic AE or permanent consequence.ConclusionsThe overall AE rate after VM embolization was 11.6%; however, major AEs were rare (1.7%). Cutaneous AEs were associated with young age and overlying skin involvement. All noncutaneous AEs developed in patients with intramuscular VMs.     

Distal Radial Artery Access for Noncoronary Endovascular Treatment Is a Safe and Feasible Technique

PurposeTo evaluate safety and feasibility of distal radial artery (DRA) access for noncoronary interventional radiology procedures.Materials and MethodsAll interventional radiology procedures by means of DRA puncture from July 2017 to August 2018 were retrospectively reviewed. Eighty-two punctures in 56 patients were included, mostly in male patients (84% vs 16%). Mean age was 67.8 years (range, 33.3–87.3 years); mean height was 172 cm (range, 142–190 cm); and mean weight was 83 kg (range, 43–120 kg). Procedural characteristics, technical success, and complication rates were gathered from the medical records and follow-up ultrasound when available. Prerequisites for DRA access were adequate radioulnar collateral circulation, sufficient radial artery diameter, and informed consent in patients initially intended for conventional transradial access.ResultsProcedures included transarterial chemoembolization (n = 34), yittrium-90 pretreatment angiography (n = 21), yittrium-90 administration (transarterial radioembolization; n = 20), and embolization of visceral organs (n = 7). Both 4-Fr (n = 35) and 5-Fr (n = 46) sheaths were used. Technical success of DRA access was 97.6%, with conversion to transfemoral access in 2 cases (2.4%). No major complications were reported as a result of DRA access.ConclusionDRA access is a feasible and safe technique for abdominal interventional radiology embolization procedures. No radial artery occlusion or other major complications were observed in patients who underwent follow-up ultrasound.     

Evaluation of Technical Success,Efficacy, and Safety of Portomesenteric Venous Intervention following Nontransplant Hepatobiliary or Pancreatic Surgery

PurposeTo evaluate technical success, efficacy and safety of portomesenteric venous (PMV) intervention for PMV stenosis or occlusion following nontransplant hepatobiliary or pancreatic (HPB) surgery.Materials and MethodsA retrospective review identified 42 patients (mean age 60 y) with PMV stenosis (n = 33; 79%) or occlusion (n = 9; 21%) who underwent attempted PMV intervention following HPB surgery between June 1, 2011, and April 1, 2018. Main outcomes were technical success, primary patency rates, and complications. Technical success was compared by venous pathology and primary PMV patency based on anticoagulation status after the procedure using Fisher exact test. Rates of primary patency by stent group were estimated using Kaplan-Meier method.ResultsTechnical success was 91% (n = 38/42) and significantly higher in patients with stenosis (n = 33/33; 100%) vs occlusion (n = 5/9; 56%) (P = .001). Primary presenting symptom resolved in 28 (87%) patients, including 6 (100%) patients with gastrointestinal bleeding. At mean imaging follow-up of 8.6 months ± 8.8, primary stent patency was 76%. There was no significant difference in primary stent patency based on anticoagulation status after the procedure (P = .48). There were 2 (4.8%) periprocedural complications.ConclusionsPortomesenteric venoplasty and stent placement following nontransplant HPB surgery is safe with a high rate of technical success if performed before chronic occlusion.     

Safety and Effectiveness of Ethylene Vinyl Alcohol Copolymer Embolization of Peripheral High-Flow Arteriovenous Malformations: Results of a Prospective Study

PurposeTo prospectively evaluate the efficacy and safety of a new ethylene vinyl alcohol (EVOH) copolymer–based embolic agent in the treatment of symptomatic peripheral arteriovenous malformations (AVMs).Materials and MethodsThis prospective single-center study evaluated EVOH embolization with 3 different formulations of EVOH (Squid Peri 12 cP, 18 cP, and 34 cP; BALT Germany GmbH, Düsseldorf, Germany) in patients with symptomatic AVMs. Between April 2018 and October 2019, 36 embolization procedures in 21 patients (3 males and 18 females; mean age, 34.7 years) were performed (inclusion criteria: symptomatic peripheral AVM, ≥14 years of age, and elective embolization). Symptoms, technical aspects (transarterial, transvenous, or percutaneous approach; plug or balloon occlusion), clinical and technical success (defined as the improvement of symptoms and complete angiographic eradication of the AVM nidus), adverse events, and short-term outcomes were assessed.ResultsThe mean volume of the embolic agent used per session was 3.4 mL of EVOH 34 cP (standard deviation [SD], ± 5.4), 6.2 mL ± 8.1 of EVOH 18 cP, and 4.6 mL ± 10.1 of EVOH 12 cP. Angiographic success was achieved in 18 patients (85.7%). The mean follow-up was 190 days (range, 90–538 days; median, 182 days). In the follow-up assessment, findings of magnetic resonance imaging showed that 19 patients (90.5%) had a persistent state of devascularization compared with postinterventional angiography. Amelioration or complete elimination of pain was achieved in 90.0% of the patients. One patient experienced a major adverse event; minor adverse events developed in 2 patients.ConclusionsIn this study, EVOH appeared to be a safe and effective embolic agent in peripheral AVMs and had a low rate of adverse events in a limited number of patients.     

Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding

PurposeTo assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for the treatment of acute lower gastrointestinal bleeding (LGIB).Materials and MethodsThe single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 men; mean age, 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as the absence of recurrent bleeding within 30 days of embolization.ResultsTechnical success for embolization of LGIB was achieved in 87% of the cases (134/154); clinical success rate was 76.1% (102/134) among the technically successful cases. Clinical success was 82.2% (60/73) for coils alone and 68.9% (42/61) for particles with or without coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 (5.3%) patients who underwent particle embolization with or without coils versus zero of 66 patients when coils alone were used (P = .09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the procedure were found in 3 of the 15 who underwent embolization with coils alone versus 8 of 18 who underwent embolization with particles with or without coils (P = .27).ConclusionsParticle embolization for the treatment of LGIB as second-line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.     

Bronchial Artery Embolization for Hemoptysis in Cystic Fibrosis Patients: A 17-Year Review

PurposeTo review safety and efficacy of bronchial artery embolization (BAE) for treatment of hemoptysis in adult patients with cystic fibrosis (CF) and to report 30-day, 1-year, and 3-year outcomes.Materials and MethodsBetween January 2001 and April 2018, 242 patients with CF were evaluated for hemoptysis. Thirty-eight BAEs were performed in 28 patients with hemoptysis. Technical success was defined as freedom from repeat embolization and hemoptysis-related mortality. Clinical success was defined as freedom from repeat embolization and mortality from any cause. Technical and clinical success were examined at 30 days, 1 year, and 3 years after initial BAE. Mean patient age was 32 years, and median follow-up was 4.8 years (range, 10 mo to 16.7 y).ResultsTechnical and clinical success rates at 30 days were 89% (25/28) and 82% (23/28), respectively. Success rates at 1 year were 86% (24/28) and 79% (22/28), respectively, and at 3 years were 82% (23/28) and 75% (21/28), respectively. The 30-day overall complication rate was 7.9% (3/38) with 2.6% (1/38) major complication rate and 5.2% (2/38) minor complication rate. Overall 3-year mortality rate was 25% (7/28).ConclusionsBAE is safe and effective in patients with CF presenting with life-threatening hemoptysis. BAE results in high rates of long-term technical and clinical success in this patient population despite progressive chronic disease. Repeat embolization is necessary only in a minority of patients.     

Genicular Artery Embolization for Refractory Hemarthrosis following Total Knee Arthroplasty: Technique,Safety, Efficacy,and Patient-Reported Outcomes

PurposeTo investigate the safety and efficacy of genicular artery embolization for treatment of refractory hemarthrosis following total knee arthroplasty.Material and MethodsPatients who underwent genicular artery embolization with spherical embolics between January 2010 and March 2020 at a single institution were included if they had undergone total knee arthroplasty and subsequently experienced recurrent hemarthrosis. Technical success was defined as the significant reduction or elimination of the hyperemic blush. Clinical success was defined as the absence of clinical evidence of further hemarthrosis. Clinical follow-up was performed 7–14 days after the procedure and at 3-month intervals thereafter via a telephone interview. A total of 117 embolizations, comprising 82 initial, 28 first repeat, and 7 second repeat, were performed.ResultsAn average of 2.5 arteries was treated per procedure. The superior lateral genicular artery was the most frequently embolized. The most utilized embolic size was 100–300 μm. Follow-up was available for all patients, with a median duration of 21.5 months. 65.9%, 25.6%, and 8.5% of patients underwent 1, 2, and 3 treatments, respectively. Complications occurred following 12.8% of treatments, of which the most common was transient cutaneous ischemia. Technical success was achieved in all cases. Clinical success was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively. 83% of patients reported being either satisfied or very satisfied with the overall result.ConclusionsTargeted genicular artery embolization with spherical embolics is an effective treatment for recurrent hemarthrosis with infrequent serious complications. Repeat embolization should be considered in cases of recurrence following initial therapy.     

Retrospective Comparison of Pulmonary Arteriovenous Malformation Embolization with the Polytetrafluoroethylene-Covered Nitinol Microvascular Plug,AMPLATZER Plug,and Coils in Patients with Hereditary Hemorrhagic Telangiectasia

PurposeTo evaluate effectiveness of the polytetrafluoroethylene-covered nitinol mesh microvascular plug (MVP) and compare it with other devices in pulmonary arteriovenous malformation (PAVM) embolization in patients with hereditary hemorrhagic telangiectasia (HHT).Materials and MethodsTwenty-five patients (average age 35 y; range, 15–56 y) with hereditary hemorrhagic telangiectasia (HHT) and de novo PAVM embolization with at least 1 MVP between November 2015 and May 2017 were retrospectively evaluated. Retrospective data were also obtained from prior embolization procedures in the same patient population with other embolic devices dating back to 2008. Technical success, complications, PAVM persistence rates, and category of persistence were analyzed.ResultsIn 25 patients, 157 PAVMs were treated: 92 with MVP, 35 with AMPLATZER vascular plug (AVP), 6 with AVP plus coils, and 24 with coils. The per-PAVM technical success rates were 100% with MVP; 97%, AVP; 100%, AVP plus coils; and 100%, coils. PAVM persistence rates and median follow-up were as follows: MVP, 2% (1/92) (510 d); AVP, 15% (3/20) (1,447 d); AVP plus coils, 20% (1/5) (1,141 d); coils, 46.7% (7/15) (1,141 d). Persistence owing to recanalization for MVP, AVP, AVP plus coils, and coils was 2%, 15%, 0%, and 33%. No difference was found between persistence rates of MVP vs AVP (P = .098). Embolization with a vascular plug (MVP or AVP) with or without coils had a statistically significant lower persistence rate (5.4%) than embolization with coils alone (46.7%) (P = .022).ConclusionsPAVM embolization with MVP had a high technical success rate and a low persistence rate comparable to AVP and lower than coil embolization alone.     

Clinical Results of Distal Embolization in Grade V Splenic Injury: Four-Year Experience from a Single Regional Trauma Center

PurposeTo evaluate the benefits and risks of splenic artery embolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) grade V blunt spleen injury (BSI)Materials and MethodsMedical records of 88 patients treated with SAE between April 2013 and May 2017 at a regional trauma care center were reviewed retrospectively. The BSI grade according to the AAST spleen injury scale (revised version 2018) was determined by using computed tomography (CT) images. A total of 42 patients (46.6%) had AAST grade V injury and were included in the analysis. Patient demographics, angiographic findings, embolization techniques, and technical and clinical outcomes, including splenic salvage rate and procedure-related complications, were examined.ResultsSAE was performed within 2 hours after admission for 78.5% of the patients. All patients underwent selective distal embolization (n = 42). Primary clinical success rate was 80.9% (n = 34), and secondary clinical success rate was 88.1% (n = 37). The clinical failure group consisted of 5 patients. Four patients underwent splenectomy, and 1 patient died due to acute respiratory distress syndrome after embolization. The splenic salvage rate was 85.7% (n = 36). No patient had sepsis at follow-up (median, 247.0 days; interquartile range, 92.0–688.0). Clinical success rates (P = .356) and spleen salvage rates (P = .197) of patients who were hemodynamically stable (n = 19) showed no significant differences from those who were unstable (n = 23).ConclusionsDistal embolization of grade V BSI is a safe and feasible procedure which is effective for successful spleen salvage.     

Treatment Outcomes of Embolization for Peripheral Arteriovenous Malformations

PurposeTo evaluate treatment outcomes of embolization for peripheral arteriovenous malformations (AVMs) in a tertiary referral center where ethanol is the primary agent of choice.MethodsA retrospective study was performed of 93 patients (median age, 31 years; range, 2–66 years) with peripheral AVMs treated with embolization (n = 442; median, 2 per patient; range, 1–82) between January 2010 and July 2016. Ethanol was used in most cases (n = 428; 97%). AVMs were classified as type I (n = 3), type II (n = 57), type IIIa (n = 5), type IIIb (n = 15), and type IV (n = 13) according to the Yakes classification system. Effectiveness of embolization was based on AVM devascularization on angiography: 100% (total), 90%–99% (near-total), 70%–90% (substantial), 30%–70% (partial), and 0%–30% (failure). Complications were graded according to the Society of Interventional Radiology classification.ResultsIn 69% of patients, 70%–100% devascularization was achieved. Total and near-total occlusion of the nidus were more often achieved in AVMs of types I and IIIa (both 100%) than in AVMs of types II, IIIb, and IV (56%, 67%, and 39%, respectively; P = .019). A total of 109 complications were identified: 101 minor (22.9%) and 8 major (1.8%). Major complications included wounds (n = 5), false aneurysm (n = 1), finger contracture (n = 1), and severe pain (n = 1) requiring therapy. The patient complication risk was significantly affected by the number of procedures (relative risk = 2.0; P < .001). Age, AVM location, and angioarchitecture type did not significantly affect complication risk.ConclusionsAVM embolization resulted in 70%–100% devascularization in 69% of patients, with few major complications. This study indicates that the type of AVM angioarchitecture affects the number of procedures needed and the achievability of AVM devascularization.     

Endovascular Therapy for Vasculogenic Erectile Dysfunction: A Systematic Review and Meta-Analysis of Arterial and Venous Therapies

PurposeTo systematically review and perform a meta-analysis on the safety and efficacy of endovascular therapy in the treatment of the two most common etiologies of vasculogenic erectile dysfunction (ED): veno-occlusive dysfunction (VOD) and arterial insufficiency (AI).Materials and MethodsPubMed, Web of Science, ScienceDirect, and Scopus databases were searched for published English literature regarding endovascular ED treatments. Case series (n ≥ 3) were included. Multiple data points were obtained, including demographic data, etiology, diagnosis method, imaging studies, treatment approach, technical success, clinical success, complications, and follow-up.ResultsSixteen relevant articles were obtained and a total of 212 patients with VOD and 162 with AI were identified. The VOD cohort were treated either percutaneously (60.4%; n = 128) or after surgical exposure of the deep dorsal vein (33.5%, n = 71), or it was unspecified (6.1%; n = 13). The most common embolic used was n-butyl cyanoacrylate (51.9%; n = 109). Meta-analysis found an overall clinical success rate of 59.8% in VOD patients. Complications occurred in 5.2% of patients (n = 11), with 9 considered to be mild and 2 considered to be severe. The AI cohort contained 162 patients most commonly treated via stenting of the internal pudendal artery (40.1%; n = 65). Meta-analysis found an overall clinical success rate of 63.2% in AI patients. Complications occurred in 4.9% of patients (n = 8), with 4 considered to be mild and 4 considered to be severe.ConclusionsEndovascular therapy for medically refractory ED is safe and may provide a treatment alternative to more invasive surgical management; however, conclusions are limited by the heterogeneity of clinical success definitions among the included studies.     

Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes

PurposeTo evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs).Materials and MethodsThis retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0–34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported.ResultsTechnical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome).ConclusionsProximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.     

Results from a United States Investigational Device Study of Adhesive Capsulitis Embolization in the Treatment of Shoulder Pain: The Adhesive Capsulitis Embolization Study

PurposeTo evaluate the safety and efficacy of arterial embolization to relieve shoulder pain secondary to adhesive capsulitis (AC).Materials and MethodsIn total, 20 patients (18 females, 2 males; mean age, 51 years) with AC resistant to >30 days of conservative treatment were enrolled in a multicenter prospective study. Adhesive capsulitis embolization was performed with 75-μm or 200-μm spherical particles. Subjects were assessed before and after the procedure with magnetic resonance imaging, visual analog scale (VAS; 0–100 mm) scores, Single Assessment Numeric Evaluation (SANE; 0–100) scores, and American Shoulder and Elbow Surgeons (ASES; 0–100) scores. Adverse events were recorded at all follow-up time points.ResultsHypervascularity was identified and embolization was technically successful in all patients, with 83 arteries embolized in 20 patients. Baseline VAS, SANE, and ASES scores before the procedure were 89.2 mm, 27.2, and 30.9, respectively. The 1-month (n = 19), 3-month (n = 18), and 6-month (n = 12) follow-ups demonstrated significant improvements. At the 1-month follow-up, VAS score decreased by 31.8 (P = 1.2E?11), SANE score increased by 22.1 (P = 1.8E?8), and ASES score increased by 14.2 (P = 4.3E?5). At the 6-month follow-up, VAS score decreased by 62.1 (P = 7.0E?11), SANE score increased by 55.4 (P = 4.1E?10), and ASES score increased by 44.5 (P = 1.8E?6). Due to the coronavirus pandemic, the study ended early; 6 patients did not complete the 6-month follow-up. No major adverse events were noted.ConclusionsInterim findings suggest that arterial embolization is safe and effective for patients with AC refractory to conservative treatment.     

Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia

PurposeTo report the outcome and distal access patency of the Subintimal Arterial Flossing with Antegrade-Retrograde Intervention (SAFARI) technique for chronic total occlusion (CTO) in critical limb ischemia (CLI).Materials and MethodsFrom January 2009 to June 2015, 220 SAFARI procedures were performed for 200 limbs in 191 patients (108 males [56.5%]; median age, 70 years old; range, 36 to 97 years old) with CLI (9.4% were Fontaine classification 3; and 90.6% were Fontaine classification 4). Distal access was obtained from the distal superficial femoral artery (n = 6), popliteal artery (n = 49), anterior tibial artery (n = 56), dorsalis pedis (n = 51), peroneal artery (n = 12), posterior tibial artery (n = 45), and lateral plantar artery (n = 1). Distal access hemostasis was obtained with internal balloon tamponade in 71.4% (n = 157). Outcome measurements were technical success, freedom from major amputation and complications. Preprocedural angiograms of clinically driven repeat interventions were reviewed in 73 cases for distal access patency.ResultsTechnical success was achieved in 80.5% (n = 177). Reasons for technical failure include inability to obtain distal access (n = 3), cross the occlusion retrogradely (n = 16), re-enter the true lumen (n = 9), and achieve antegrade blood flow after the procedure (n = 15). Freedom from major amputation for technically successful procedures was 84.7%, 82.9%, and 81.9% at 6, 12, and 24 months, respectively. There were 3 cases of distal access bleeding with 1case that required coil embolization. The distal access remained patent in 80.8% of observable cases with repeated endovascular intervention.ConclusionsDistal retrograde arterial access (SAFARI) technique is safe and effective in the treatment of CTOs in the context of CLI, after failure of antegrade revascularization.     

Percutaneous Treatments for Persistent Bronchopleural and Alveolar-Pleural Fistulae

Percutaneous glue embolization was investigated as a treatment for bronchopleural fistulae (BPFs) and alveolar-pleural fistulae (APFs) associated with persistent air leak. Seven consecutive patients with persistent air leak were treated with percutaneous glue embolization of the BPF/APF from both iatrogenic and spontaneous causes. Treatment was performed using direct n-butyl cyanoacrylate (nBCA) glue injection for discrete, visible fistulae (n = 4), fibrin glue spray for suspected tiny multifocal leaks (n = 2), or both (n = 1). The number of treatments required per patient was 1 (n = 3), 2 (n = 3), or 3 (n = 1). Technical success was achieved in all cases. Follow-up showed resolution of all air leaks, with mean chest tube removal at 7.1 days after the embolization. The follow-up duration ranged from 2 to 47 months. No significant procedure-related morbidity, mortality, or recurrence was encountered. Percutaneous treatment for persistent BPFs and APFs showed good efficacy in this small case series and warrants further investigation.     

Modified Surgical Drain–Guided Percutaneous Catheter Drainage of Postoperative Fluid Collection in Inaccessible Locations

PurposeTo investigate the feasibility and safety of a modified surgical drain–guided percutaneous catheter drainage technique for postoperative fluid collection in inaccessible locations.Materials and MethodsThe modified technique was used in 24 patients (age, 58.6 years ± 11.3; men, 58.3%) from September 2015 to March 2021. All fluid collections had no safe access route on preprocedural computed tomography (CT) images. Every patient had a long (>20 cm) and tortuous surgical drain, which prevented the use of conventional surgical drain exchange. A favorable midpoint of the surgical drain tract was punctured under either ultrasound or fluoroscopic guidance, and a guide wire was advanced into the fluid collection. Technical success was defined as the successful placement of a drainage catheter, and clinical success was defined as the complete evacuation of fluid collection without recurrence. Follow-up was performed using CT images and a chart review. Adverse events within 30 days of the procedure were evaluated.ResultsTarget fluid collections in the pelvic cavity (n = 9); subphrenic (n = 7), peripancreatic (n = 4), and subhepatic spaces (n = 3); and abdominal cavity (n = 1) were drained using catheters measuring 7–10.2 F in diameter and 25–30 cm in length. The technical success rate was 91.7% (22/24), and the clinical success rate was 90.9% (20/22). No procedure-related or catheter-related adverse events were observed. The median follow-up period was 8.2 months (range, 10–1,721 days).ConclusionsThe modified surgical drain–guided percutaneous catheter drainage technique is a useful alternative when conventional exchange techniques cannot be used because of long and tortuous surgical drain paths.     

Elective Embolization of Splenic Artery Aneurysms with an Ethylene Vinyl Alcohol Copolymer Agent (Squid) and Detachable Coils

PurposeTo report the safety and efficacy of the embolization of splenic artery aneurysms (SAAs) with coils plus ethylene vinyl alcohol copolymer (EVOH) agent.Materials and MethodsA single-center retrospective study was conducted from 2016 to 2019 to collect SAAs. Twelve asymptomatic patients (mean age, 59 years) with 15 SAAs (mean size, 23.6 mm; size range, 15–40 mm) were treated with embolization. Embolization was performed with EVOH (Squid 8/34) and fibered detachable coils. Transfemoral embolization was performed with a microcatheter to achieve a splenic artery occlusion embolizing the SAA and its efferent and afferent branches. Follow-up was based on color Doppler ultrasound at 24 hours and on computed tomography (CT) angiography at 1 (n = 12) and 6 months (n = 12) after embolization. Mean number of coils and Squid vials used for each patient, major/minor complications, technical success, 30-day clinical success, cases of revascularization/reintervention, and mortality were assessed. Technical success was defined as complete exclusion of the aneurysmal segment and cessation of blood flow into the sac. Clinical success at 1 month was based on the absence of clinical symptoms and the exclusion of aneurysm revascularization on CT angiography.ResultsThe mean number of coils and Squid vials was 5.75 (standard deviation [SD], 1.58; range, 3–9) and 1.41 (SD, 0.49; range, 1–2), respectively. Both technical and 30-day clinical success were 100%, with no cases of aneurysm revascularization (CT angiography performed in all patients at 1 month and 6 months and in 3 patients at 24 months). No major complications or fatal events were recorded. In terms of minor complications, 2 cases of mild pancreatitis (transient amylases increase) and 1 case of focal splenic ischemia without clinical sequelae were recorded.ConclusionsEmbolization in SAAs using coils plus EVOH was safe and effective without SAA revascularization     

Prospective Study of Radial Artery Occlusion Following Transradial Arterial Access during IR Procedures

PurposeTo prospectively determine the rate of radial artery occlusion (RAO) in patients undergoing transradial access for intra-arterial interventions.Materials and MethodsSeventy-seven patients undergoing transradial access from August 2019 to March 2021 for 120 intra-arterial procedures (yttrium-90 mapping [n = 39] and radioembolization [n = 38], uterine artery embolization [n = 19], transarterial chemoembolization [n = 10], active bleed embolization [n = 8], angiomyolipoma embolization [n = 4], and other [n = 2]) were enrolled. The average patient age was 59 years ± 13.1 (range, 30–90 years), and 43 (55.8%) of the 77 patients were men. The patients underwent radial artery (RA) palpation, ultrasound evaluation, the Barbeau test, and the reverse Barbeau test prior to and following the intervention. Verapamil, nitroglycerin, and heparin were administered in a total of 114 (95%) of the 120 procedures prior to starting the procedure. The incidence of RAO and radial artery spasm (RAS) was calculated, and univariate logistic regression was performed to analyze the predictors of RAS.ResultsThe preprocedural RA diameter (3.0 mm ± 0.67) was not significantly different from the postprocedural RA diameter (3.0 mm ± 0.65, P = .904). The RAO rate was determined to be 0.8% (1/120), and this artery recanalized within 1 week. Due to the small number of occlusions, statistical analysis of predictors of RAO was not performed. The rate of RAS was 22.7% (27/119). None of the variables tested—including age, sex, RA diameter, initial versus repeat access, operator experience, and artery puncture technique—showed significant prediction for RAS. Patients were seen for follow-up after 111 (92.5%) of the 120 procedures.ConclusionsTransradial access resulted in a <1% rate of RAO.