Percutaneous Embolization of a High-Flow Pancreatic Transplant Arteriovenous Fistula

Percutaneous endovascular techniques were used to treat an arteriovenous fistula (AVF) associated with pancreatic transplantation. A pancreatic transplant superior mesenteric artery-to-superior mesenteric-vein AVF was successfully embolized while flow to the pancreas transplant was preserved. The embolization was aided by the use of Guglielmi detachable coils and a detachable balloon. No complications were encountered. At 23 months follow-up, the patient is doing well with no recurrence.     

Percutaneous embolization of a high-flow pancreatic transplant arteriovenous fistula

Percutaneous endovascular techniques were used to treat an arteriovenous fistula (AVF) associated with pancreatic transplantation. A pancreatic transplant superior mesenteric artery-to-superior mesenteric-vein AVF was successfully embolized while flow to the pancreas transplant was preserved. The embolization was aided by the use of Guglielmi detachable coils and a detachable balloon. No complications were encountered. At 23 months follow-up, the patient is doing well with no recurrence.     

Chronic Aortic Dissection: Stenting of Aortic True Lumen Obliteration with Late Dynamic Variations of Both Lumens

Percutaneous endovascular techniques were used to treat an arteriovenous fistula (AVF) associated with pancreatic transplantation. A pancreatic transplant superior mesenteric artery-to-superior mesenteric-vein AVF was successfully embolized while flow to the pancreas transplant was preserved. The embolization was aided by the use of Guglielmi detachable coils and a detachable balloon. No complications were encountered. At 23 months follow-up, the patient is doing well with no recurrence.     

Treatment of a TIPS-Biliary Fistula by Stent-Graft in a 9-Year-Old Boy

We report a 9-year-old male cirrhotic patient with acute occlusion of a transjugular intrahepatic portosystemic shunt (TIPS) due to a biliary-to-TIPS fistula which occurred 9 hr after the TIPS procedure. Immediate TIPS revision was performed and the fistula was treated by placement of an endoluminal stent-graft. At 12-month follow-up color Doppler examination demonstrated a patent shunt.     

Iatrogenic Arteriovenous Fistula in a Renal Allograft: The Result of a TAD Guidewire Injury

A case is presented of an iatrogenic arteriovenous fistula developing in a renal allograft following guidewire manipulation during transplant renal artery angioplasty. Hyperdynamic flow through the fistula was causing a shunt of blood away from the renal cortex as demonstrated on sonography and scintigraphy. Selective embolization was performed, correcting the maldistribution of flow to the peripheral renal cortex. The diagnosis and difficulty in management of asymptomatic renal arteriovenous fistulae is also discussed.     

Selective embolization of bilateral arterial cavernous fistulas for posttraumatic penile arterial priapism

A 22-year-old man suffered a hiking accident with perineal trauma and developed a nonpainful priapism secondary to bilateral arterial-cavernosal fistulas. To minimize the risk of impotence in this young patient, successive selective embolizations with autologous blood clot were performed to close the fistulas. This led to an uncomplicated full recovery. No fistula was detectable on Doppler ultrasonography at 1-year follow-up. Review of the literature confirms the safety of embolization with autologous clot. Received: 0/00/00/Accepted: 0/00/00     

High-output external duodenal fistula: Treatment with percutaneous transhepatic biliary/duodenal drainage

Percutaneous transhepatic drainage was successfully performed on a patient with a high-output duodenal fistula as a complication of Billroth II surgery, resulting in closure of the fistula. Received: 0/00/00/Accepted: 0/00/00     

Stent Placement on Fresh Venous Thrombosis

Purpose: To report on the efficacy of fixing fresh venous thrombus to the venous wall by stent placement. Methods: Seven patients underwent stenting to treat acute venous thrombosis. In two patients, the hemodialysis fistula was thrombosed with the thrombus extending into the brachial veins. In three patients, the hemodialysis fistula was patent but massive swelling of the ipsilateral arm was caused by proximal venous thrombosis. Two patients presented with iliac venous thrombosis within stented pelvic veins. Stent placement was preceded by other mechanical thrombectomy methods in all cases. Results: Attachment of thrombus to the venous wall was successful in all cases treated. Acute rethrombosis did not occur. Follow-up patency in dialysis patients was 7.2 ± 2.1 months. One patient had rethrombosis of the dialysis graft 3 months after primary treatment. Three patients developed restenosis within a mean period of 7.7 months. One shunt remained patent for 10 months with no event of reobstruction during follow-up. In both patients with iliac stent placement, the vein remained patent over a follow-up period of 8 and 12 months respectively. Conclusion: Stenting fresh venous thrombus can achieve immediate venous patency. It may be used as an alternative approach when all other percutaneous methods fail. Frequent restenosis within stented veins limits its use to very selected cases. Received: 0/00/00/Accepted: 0/00/00     

Vascular complications in lumbar spinal surgery: Percutaneous endovascular treatment

Four patients underwent endovascular treatment of vascular injuries complicating lumbar spinal surgery. In two patients with massive retroperitoneal hemorrhage, the extravasating lumbar arteries were successfully embolized with microcoils. Two patients with large iliac arteriovenous fistula (AVF) were treated, one with embolization using a detachable balloon and coils, which failed, and the other with placement of a stent graft after embolization of distal runoff vessels, which occluded the fistula. We conclude that acute arterial laceration or delayed AVF complicating lumbar spinal surgery can be managed effectively with selective embolization or stent-graft placement, respectively.     

Transjugular Core Liver Biopsy with a 19-Gauge Spring-Loaded Cutting Needle

One hundred and five sequential transjugular core liver biopsies (TJLBx) were performed in 101 patients with coagulopathy and/or ascites using the 19-gauge Quick-Core Biopsy (QCB) needle. Two-hundred and seventy-three cores were obtained in 295 passes (92.5%). One-hundred and two of the 105 procedures (97.1%) led to a histopathologic diagnosis. One of the three nondiagnostic biopsies was done because of severe autolysis of the liver. There was one subcapsular hematoma, one hepatic arteriovenous fistula, and one liver capsular puncture. Two minor neck hematomas occurred. One death was reported (unrelated to the procedure). QCB needle TJLBx is an effective and relatively safe way to obtain core liver samples. Received: 0/00/00/Accepted: 0/00/00     

Embolization of Iatrogenic Vascular Injuries of Renal Transplants: Immediate and Follow-Up Results

Purpose: To evaluate the outcome in seven patients in whom iatrogenic vascular complications were treated with catheter embolization. Methods: Angiography showed an arteriovenous fistula in six of the seven patients, a pseudoaneurysm in three patients, and an arteriocaliceal fistula in three patients. Embolization was performed with GAW coils or microcoils in all cases. In three patients enbucrilate, polyvinyl alcohol, or absorbable gelatin powder was administered as an adjunct to the coils. Results: Angiographic success with total occlusion of the vascular injury was achieved in five of the seven patients and clinical success was achieved in four of seven cases. In two cases, nephrectomy after embolization was necessary because of renal artery occlusion or acute hemorrhage at the renal artery anastomosis, respectively. Infarction of 30%–50% of the renal parenchyma was seen in two cases. Conclusion: Angiographically successful embolization is not necessarily associated with clinical success. The complication rate is high.     

Are Covered Stents Really Effective at Closing Esophagotracheal Fistulas? Results of an Animal Study

Purpose: To determine whether covered self-expanding metal stents successfully exclude experimentally created esophagotracheal fistulas. Methods: Esophagotracheal fistulas were surgically created in the upper third of the esophagus in 12 minipigs and immediately sealed by implantation of a covered self-expanding metal stent (20 mm expanded diameter) in the esophagus. Before the animals were killed, after 3, 7, 14, 28, 30, and 36 days, the position of the stent and the sealing of the fistula were monitored fluoroscopically. The esophagus, trachea, and both lungs were examined histologically. Results: Creation of an esophagotracheal fistula was successful in all cases. All fistulas were widely patent at autopsy. The technical success rate for stent deployment and initial sealing of the fistula was 100%. During follow-up, five stents migrated distally, but none into the stomach. Therefore, the fistula was no longer excluded in five animals. In seven animals the stent sealed the fistula until the death of the animal. Tracheal narrowing necessitated additional tracheal stenting in three animals. Two minipigs died due to aspiration of food. Histologic examination showed signs of aspiration in all animals with stents in place for longer than 2 weeks. Conclusion: This experimental animal study revealed worse results for sealing of esophagotracheal fistulas with covered self-expanding metal stents than have been reported for the clinical use of these devices.     

Successful Transcatheter Embolotherapy with a New Platinum Microcoil: The Berenstein Liquid Coil

Purpose: To determine the usefulness of a new platinum microcoil, the Berenstein Liquid Coil for vascular embolization. Methods: Nine patients underwent transcatheter arterial embolization with liquid coils. The occluded vessels included the splenic artery in four patients, gastroduodenal artery in two, arteriovenous malformation or fistula in two, and middle hepatic artery in one. All coils were delivered with a saline flush through a Tracker-18 catheter. Results: All arteries except one were successfully occluded in a one-stage procedure using liquid coils. No friction was observed between the liquid coils and the microcatheter regardless of the tortuosity of the artery. Platelet counts in all patients had increased after splenic embolization. In two patients with liver tumors, perfusion to the inappropriate area during intraarterial chemotherapy was prevented by selective embolization. Life-threatening bleeding was successfully treated by gastroduodenal artery occlusion. No complications were encountered. Conclusion: The Berenstein Liquid Coil provides easy, safe, and rapid vascular occlusion.     

A Comparative Study of CT Fluoroscopy Combined with Fluoroscopy Versus Fluoroscopy Alone for Percutaneous Transhepatic Biliary Drainage

Purpose: We compared CT fluoroscopy (CTF) for the initial puncture of bile ducts with conventional fluoroscopic guidance in patients with malignant jaundice in whom percutaneous transhepatic biliary drainage (PTBD) was planned. Methods: Forty consecutive patients were randomized to two study groups: group A underwent PTBD under CTF and fluoroscopic guidance, group B underwent PTBD under fluoroscopic guidance alone. CTF-guided PTBD was performed using a combination of a helical CT scanner of the latest generation and a mobile C-arm; conventional PTBD was performed under fluoroscopic guidance in the angiographic unit. End points of the study were the success (a puncture that enabled safe placement of a guidewire in a suitable bile duct) and the complication rate (hemobilia, bile fistula, biliary peritonitis), the number of punctures required, the time needed for successful puncture of a suitable bile duct, and the patient's radiation exposure. Results: CTF-guided puncture of peripheral bile ducts suitable for PTBD was successful at the first attempt in 16 cases, under conventional fluoroscopic guidance, in only two cases. We found a significantly different number of punctures (1.2 in group A vs 2.9 in group B), a significantly shorter time for puncture in group A (mean 39 sec), but also a significantly higher skin exposure dosage in group A (mean 49.5 mSv surface dosage). There was no significant difference regarding the total procedure time. Only one complication occurred in group B (portobiliary fistula). Conclusion: CTF-guided initial puncture of bile ducts allowed a significantly reduced number of punctures and puncture times compared with puncture under conventional fluoroscopic guidance for placement of percutaneous transhepatic biliary drainage catheters.     

Failing Hemodialysis Arteriovenous Fistula and Percutaneous Treatment: Imaging with CT, MRI and Digital Subtraction Angiography

Purpose: To evaluate failing hemodialysis arteriovenous fistulas with helical CT angiography (CTA), MR angiography (MRA), and digital subtraction angiography (DSA), and to compare the efficacy of the three techniques in detecting the number, location, grade, and extent of stenoses and in assessing the technical results of percutaneous transluminal angioplasty (PTA) and stenting. Methods: Thirteen patients with Brescia-Cimino arteriovenous fistula malfunction underwent MRA and CTA of the fistula and, within 1 week, DSA. A total of 11 PTAs were performed; in three cases an MR-compatible stent was placed. DSA served as the gold standard for comparison in all patients. The presence, site, and number of stenoses or occlusions and the technical results of percutaneous procedures were assessed with DSA, CTA, and MRA. Results: MRA underestimated a single stenosis in one patient; CTA and MRA did not overestimate any stenosis. Significant artifacts related to stent geometry and/or underlying metal were seen in MRA sequences in two cases. Conclusions: CT and MRI can provide information regarding the degree of vascular impairment, helping to stratify patients into those who can have PTA (single or multiple stenoses) versus those who require an operative procedure (occlusion). Conventional angiography can be reserved for candidates for percutaneous intervention.     

Blocking of the hepatic vein outflow by neointima covering a wallstent across a membranous stenosis of the inferior vena cava

A 31-year-old man presented with idiopathic membranous obstruction of the suprahepatic inferior vena cava (IVC) and was treated by balloon dilation and placement of a Wallstent. The patient improved markedly. However, he developed obstruction of the hepatic vein outflow secondary to neointima formation over the stent that covered the hepatic vein ostia. The patient died of liver failure and septicemia. We believe that this is the first report of such a serious complication.     

CT-Guided Transfemoral Portocaval Shunt Creation

A patient with superior vena cava (SVC) occlusion presented with severe ascites and urgent transjugular intrahepatic portosystemic shunt (TIPS) was requested. The patient had a chronically occluded SVC. An alternative to classic TIPS was employed using CT guidance to traverse the left portal vein to the inferior vena cava with a small gauge needle. Fluoroscopic guidance was then used to snare a wire placed through the needle and then work from the femoral vein to create a portocaval shunt that passed through the caudate lobe. This procedure was a technical success and improved the patient's ascites.     

Traumatic Intimal Tear of the Renal Artery Treated by Insertion of a Palmaz Stent

A renal artery intimal injury induced by blunt trauma in a 23-year-old man was treated by percutaneous placement of a Palmaz endovascular stent. The patient was placed on anticoagulation for 2 months following stent insertion. Nuclide renal scans demonstrated recovery of normal renal function on the affected side at 9 months postprocedure. Received: 0/00/00/Accepted: 0/00/00     

Traumatic fistula between the left anterior descending coronary artery and a left ventricular pseudoaneurysm

A 44-year-old man presented with a fistula of the left anterior descending (LAD) coronary artery to a left ventricular pseudoaneurysm 6 months after a stab injury in the left anterior chest. The color Doppler echocardiography suggested, and angiography confirmed, the diagnosis and the lesion was treated successfully. Traumatic coronary artery fistulas are rare complications, and color Doppler echocardiography proved useful for the diagnosis. Received: 0/00/00/Accepted: 0/00/00     

Percutaneous untying of a knot in a retained Swan-Ganz catheter

A patient was referred to us with a tightly knotted Swan-Ganz catheter. The catheter could not be removed by conventional simple methods. We describe a minimally invasive means of removal of the catheter using an Amplatz gooseneck snare and an angioplasty balloon. This allowed the catheter to be removed without trauma.