儿童先天性股深动静脉瘘的介入栓塞治疗

目的 探讨采用弹簧钢圈及无水乙醇栓塞治疗儿童先天性股深动静脉瘘的临床疗效及安全性.方法 8例先天性股深动静脉瘘的儿童均经B超及动脉造影检查证实为股深动静脉瘘,均接受介入治疗.术中将2.7F微导管插至瘘口处,注入弹簧钢圈或无水乙醇以堵塞瘘支,10 min后再次于股动脉处造影,如果仍然有残余瘘口,使用同样的方法继续堵塞瘘支直至瘘口完全闭塞.实施血管内介入栓塞治疗后4周行血管造影复查,若仍有残余瘘口则再次进行栓塞.随访6个月至2年,观察临床症状及体征改变.结果 动脉造影可清楚地显示股深动脉及其分支以及瘘口情况,3例只见单一瘘口,5例合并多个微瘘口存在.8例患儿共实施介入栓塞术10次,释放弹簧钢圈共47枚,进行无水乙醇栓塞7次,技术操作均成功.无弹簧钢圈异位栓塞,未出现皮肤明显坏死、神经功能损害及心脑肺严重并发症,术中瘘口均立即闭塞.术后4周再次行血管造影复查,7例瘘口完全闭塞,临床症状较前改善,未见复发;1例可见股深动脉分支多发微小瘘口,先后共行3次介入栓塞术,仍见少许残余微瘘存在,但临床症状控制良好,无再发展.结论 介入栓塞治疗儿童先天性股深动静脉瘘是一种安全、有效的方法,有望成为儿童先天性股深动静脉瘘的首选治疗方法.     

经导管肾动脉节段性栓塞治疗肾动静脉畸形

目的：探讨经导管肾动脉节段性栓塞治疗肾动静脉畸形的栓塞材料及其效果。方法：9例因肾动静脉畸形（先天性者8例，获得性者1例）引起大量血尿患者，施行经导管肾动脉节段性栓塞治疗10次，栓塞材料为无水乙醇、聚乙烯醇颗粒、异丁基-2-氰基丙烯酸酯和弹簧圈。9例患者术后随访观察10-56个月。结果：9例患者栓塞术后肾动脉造影显示畸形血管完全闭塞，3d内血尿消失。随访期间，9例患者中，只有1例单纯应用弹簧圈栓塞患者术后6个月血尿复发，血管造影证实为侧支血管形成导致畸形血管再通，改行无水乙醇及弹簧圈栓塞，术后18个月血尿未再复发。9例患者均无严重并发症发生。结论：经导管肾动脉节段性栓塞是治疗肾动静脉畸形的安全有效的方法，栓塞材料以无水乙醇和弹簧 圈联合栓塞为最佳。     

无水乙醇栓塞治疗耳部动静脉畸形

目的 介绍22例耳部动静脉畸形无水乙醇介入栓塞治疗的经验.方法 对22例耳部动静脉畸形患者,通过局部穿刺或经导管内超选择径路达到耳部病变的异常血管团内,根据病变的血管团构筑,采用无水乙醇或稀释乙醇进行栓塞,间隔1个月进行电话随访,间隔3～4个月进行临床随访,根据临床检查或血管造影评价临床效果.结果 22例患者共进行了38次无水乙醇栓塞,每次无水乙醇的用量为4～65 ml.9例病变局限患者,1～2次栓塞后达到临床治愈;13例病变广泛患者,无水乙醇栓塞3～5次后,溃疡愈合,出血停止,耳呜消失或减弱.血管造影见9例异常血管团完全消失;8例血管团消失50%～75%;5例血管闭消失小于50%.最常见的并发症为可逆性局部坏死和水疱形成.结论 无水乙醇栓塞是耳部动静脉畸形安全、有效的治疗方式,并有可能成为首选的治疗方式.     

肝癌合并动静脉瘘的DSA表现及介入治疗方法的探讨

目的探讨肝癌合并动静脉瘘的DSA表现及介入治疗方法。方法对673例经证实的肝癌患者先行(肠系膜上动脉)间接门脉造影及腹腔动脉或肝总动脉造影,再行肝动脉内灌注化疗和/或栓塞治疗。结果合并动静脉瘘者有151例(22.4%),其中动门静脉瘘127例,动肝静脉瘘有15例,混合型有9例;131例(86.8%)动静脉瘘患者施行了1次或多次肝动脉栓塞治疗,20例因动静脉瘘口不能有效栓塞和/或合并门静脉主干瘤栓而行单纯灌注化疗。结论DSA影像是肝癌合并动静脉瘘直观可靠的诊断方法,肝动脉灌注栓塞治疗是肝癌动静脉瘘患者最有效的治疗方法之一。     

硬脑膜动静脉瘘的综合治疗探讨

目的:探讨不同部位、不同类型的硬脑膜动静脉瘘的治疗方法.材料和方法:对29例经全脑数字减影血管造影(DSA)诊断为硬脑膜动静脉瘘患者采用血管内栓塞、手术夹闭瘘口-瘘口端引流静脉或静脉窦以及瘘口所在的静脉窦内支架置入等方法治疗.结果:29例硬脑膜动静脉瘘患者中,15例术后动静脉瘘完全闭塞,14例大部分闭塞;15例临床症状消失,余14例症状明显改善.无并发症发生.结论:硬脑膜动静脉瘘治疗的关键在于闭塞瘘口.根据其动静脉瘘的部位、供血动脉及瘘口的数量、引流静脉的特点等综合考虑是治疗成功的关键.     

肝癌重复介入治疗致靶血管损伤原因分析

目的:探讨多次动脉化学性栓塞术(TACE)治疗原发型肝癌过程中,肝动脉及其主要分支狭窄、闭塞的规律及其相关因素。方法:135例原发型肝癌病人行重复肝动脉介入治疗术,观察每次术后肝动脉及其分支新发生狭窄及闭塞的情况。并分析行化疗栓塞时导管末端在血管内的位置与血管闭塞率之间的关系。结果:135例中42例发生严重狭窄或闭塞,闭塞率按治疗频次呈单峰分布,治疗中期(第5-7次),肝动脉主干及大分支发生狭窄、闭塞的比例最高。导管末端与血管内膜接触者,靶血管的早、中期狭窄、闭塞率明显高于无接触组。结论:TACE治疗中导管末端与内膜接触是靶血管早、中期发生狭窄、闭塞常见的重要因素,在操作中应尽量避免。     

肝癌合并动静脉瘘的DSA表现和介入治疗方法初探

目的 探讨肝癌合并动静脉瘘的DSA表现及介入治疗方法.方法 对272例已证实的肝癌患者先行DSA造影,再行肝动脉内化疗栓塞治疗.结果 合并动静脉瘘者有113例(41.5%),其中肝动脉门静脉瘘98例,肝动静脉瘘7例,混合型8例,所有动静脉瘘患者均行了1次或多次肝动脉内化疗(TAI)和/或化疗栓塞治疗(TACE). 结论 DSA影像是肝癌合并动静脉瘘直观可靠的诊断方法.对于轻中度AVS用明胶海绵阻断瘘口血流后TACE安全有效,对重度流量大的AVS,则仅行TAI.     

儿童周围血管畸形的血管内治疗

目的 研究儿童外周血管畸形的血管内治疗方法及疗效。方法 对83例周围血管畸形患儿实施血管内治疗。本组病例术前或术中分别诊断为：动静脉瘘23例,蔓状血管瘤32例,海绵状血管瘤28例。治疗方法：①经导管栓塞术,经导管释放弹簧圈或明胶海绵栓塞治疗;②导管栓塞术结合局部注射硬化剂治疗。结果 栓塞治疗后造影证实,动静脉瘘和血管瘤均得到有效闭塞,临床症状、体征迅速改善,术后1～3年观察随访,治疗有效率100％,治愈率68．7％。无并发症。结论 采用血管内治疗方法治疗儿童外周血管畸形,是一种微创而安全、疗效特别显著的方法。     

颈外动脉供血型硬膜动静脉瘘的经血管治疗

目的：评估经动脉颗粒栓塞颈外动脉供血型硬膜动静脉瘘的应用技术和临床效果。材料和方法：１０例经血管造影证实的硬膜动静脉瘘患者,选择性插管入近病巢处的供养动脉或近供养动脉开口的主干动脉,在电视严密监视下缓慢注入ＰＶＡ颗粒直至血流静止、瘘道闭塞。术后１５分钟和６个月随访血管造影及评估临床情况。结果：７例术后瘘道完全闭塞,３例大部闭塞（８０％发以上）,６个月后随访血管造影者７例,均未显示瘘道。结论：经动脉采用颗粒栓塞颈外动脉供血型硬膜动静脉瘘,其操作简便,较为安全,临床效果好,应视为此类疾病的首选治疗方法。     

原发性肝癌合并动静脉瘘的介入治疗(附34例报告)

目的：探讨超选择性明胶海绵瘘口栓塞术对原发性肝癌所致动静脉瘘的治疗方法及疗效。方法：本组对34例经DSA检查确诊为原发性肝癌合并动-静脉瘘（AVS）行超选择性瘘口栓塞，根据瘘口闭塞及肿瘤染色情况确定是否行肿瘤碘化油栓塞治疗。闭塞瘘口材料主要为明胶海绵辅以弹簧圈。结果：34例中33例一次性瘘口闭塞成功，其中28例成功地行肿瘤栓塞治疗，1例因瘘口闭塞早期即发生肺栓塞症状，1月后行弹簧圈瘘口闭塞成功。结论：超选择性明胶海绵瘘口栓塞术对原发性肝癌所致的动静脉瘘的治疗是一种安全、有效、并发症少的治疗方法，能为肿瘤碘化油栓塞提供良好治疗环境。     

Retrograde venous coil embolization prior to transarterial chemoembolization in hepatocellular carcinoma with arterio-hepatic venous shunts

PURPOSEThis study explored the clinical efficacy of transcatheter retrograde shunt occlusion with coils to prevent pulmonary oil or particle embolization prior to transarterial chemoembolization (TACE) in patients with artero-hepatic venous shunts (AHVS) secondary to hepatocellular carcinoma (HCC).METHODSFrom July 2017 to January 2021, 6 patients with advanced, unresectable HCC were found to have an AHVS by hepatic arteriography at the time of attempted TACE. The AHVS was embolized retrogradely with metal coils through a transfemoral or transjugular venous approach. After venous embolization and confirmation of the absence of the AHVS, TACE was performed using an emulsion of iodized oil and doxorubicin or drug-eluting beads. Follow-up computed tomography (CT) was performed within 1 month after the first TACE to evaluate the results and complications.RESULTSHepatic angiography after venous embolization showed that AHVS had utterly disappeared in all patients during the operation. The immediate technical success of the retrograde venous embolization was 100%. The AHVS had disappeared entirely during the follow-up period through triple-phase enhancement CT scanning. According to the modified response evaluation criteria in solid tumors, TACE in all 6 patients had a disease control response rate of 100% (6/6) with complete response in 2 patients and partial response in 4 patients. One patient died during the 6-month follow-up, and the other 5 were still alive. No complications related to pulmonary embolism occurred.CONCLUSIONRetrograde venous coil embolization of AHVS via the draining hepatic vein appears to be a safe, feasible, and effective treatment to allow TACE treatment without pulmonary embolic events. This approach appears to provide better tumor control and effectively decreases the occurrence of pulmonary embolism.

Main points

• Retrograde permanent coil embolization of artero-hepatic venous shunts (AHVS) via the draining hepatic vein allowed safe delivery of transarterial chemoembolization (TACE) for advanced hepatocellular carcinoma.
• There were no noticeable adverse events, such as pulmonary embolism, postoperative portal hypertension, or liver dysfunction.
• The AHVS did not recanalize in patients, and the overall response rate after TACE is effective.

The development of intrahepatic arteriovenous shunts is a complication in hepatocellular carcinoma (HCC) patients, ranging between 1.3% and 6.3% in patients with advanced HCC.¹ Because transcatheter arterial chemoembolization (TACE) has been recognized as a choice for palliative local treatment of unresectable and recurring HCC after surgery,^2,3 the development of artero-hepatic venous shunts (AHVS) is one of the main impediments and relative contraindications to TACE in patients with advanced HCC. In particular, high-flow AHVS seriously decreases the efficacy of TACE and increases the risk of portal hypertension, gastrointestinal bleeding, liver damage, pulmonary embolism, and lung metastases.^4-6 An AHVS also presents a clinical challenge in TACE treatment because anticancer drugs and any embolic materials deployed via an arterial approach to occlude the AHVS can migrate into the lung through the shunt.^7-10 Therefore, safe, simple, and effective treatment is needed to manage AHVS during TACE. Herein, we developed a transvenous, retrograde embolization of metal coils into the draining hepatic vein combined with TACE to manage HCC with AHVS. In this study, we explored its safety and effectiveness.     

Embolization of hepatic arteriovenous shunt with absolute ethanol in a patient with hepatocellular carcinoma

We report a 76-year-old man who had hepatocellular carcinoma (HCC) with arteriovenous shunting (AVS). Transcatheter chemoembolization (TACE) was selected as treatment because of poor pulmonary function. To prevent pulmonary embolism caused by the flow of embolic materials through the AVS, we performed embolization of the AVS with absolute ethanol under flow control by balloon catheters. Subsequently, we could perform TACE for HCC safely.     

Percutaneous Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts

Purpose To assess the role of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and transjugular intrahepatic portosystemic shunts (TIPS). Methods Between January 1999 and September 2004, 6 patients with HCC and TIPS were treated with either TACE (n = 3) or TACE in combination with PEI (n = 3). One patient had a known advanced, untreated HCC prior to TIPS. In the remaining 5 patients HCC was diagnosed 14, 17, 51, 69, and 76 months respectively after elective TIPS. TACE was performed using a mixture of 30–60 mg of epirubicin and 10 ml of lipiodol following superselective catheterization of tumor-feeding vessels. PEI was performed under CT guidance. Methods The mean follow-up time after treatment of HCC was 26.2 months (range 7–46 months). During follow-up, all patients were free of rebleeding. Two patients died 7 and 38 months after one session of TACE and PEI (77 months after TIPS) and three sessions of TACE (91 months after TIPS), respectively. The cause of death was liver failure (Child-Pugh class C) and peritonitis, respectively. A third patient underwent liver transplantation 24 months after TIPS and several sessions of TACE. In the remaining 3 patients, the HCC is well controlled 13, 30, and 46 months after repetitive percutaneous treatment without signs of hepatic deterioration or metastasis. Conclusion Transcatheter arterial superselective chemoembolization and percutaneous ethanol injection seems to be beneficial even in HCC patients treated with TIPS, provided that the liver function is adequate.     

微导管在肝癌介入治疗上的应用

目的探讨微导管在肝癌化疗性栓塞中的作用。方法将4F～5FYashiro、Kouno亲水超滑导管、5F牧羊钩导管作为导引导管插入肝总或肝固有动脉及肠系膜上动脉,3F微导管经导引导管置入肝段或肿瘤滋养动脉施行肝癌化疗性栓塞术。结果本组35例共行化疗性栓塞50例次,其中16例小肝癌行肝段栓塞,19例非小肝癌但癌灶尚局限者行左/右叶或右叶前、后叶栓塞。随访1～2年生存期分别为100％、87.5％及52.6％、42.1％。术后肝功能损害轻微,无并发症。结论在小肝癌、非小肝癌但癌灶尚局限者或伴有肝动脉异常迂曲、损伤后狭窄、发育变异的情况下,使用微导管提高栓塞精度对改善疗效和避免并发症具有十分重要的临床应用价值。     

Temporary Distal Balloon Occlusion for Hepatic Embolization: A Novel Technique to Treat What Cannot be Selected

Purpose

Particle embolotherapy for liver cancers, such as chemoembolization and yttrium-90 radioembolization, depends on microcatheter selection of the treatment vessel for injection of the embolic. Individually selecting vessels with a microcatheter can be time-consuming and difficult, especially when multiple branches are present in the treatment zone. This article describes a technique to perform an “inverse” embolization—protection of the selected vessel and embolization of the unselected vessels—a technique that has not yet been described.

Materials and Methods

Two cases of hepatic chemoembolization that would require subselection of multiple branch vessels using conventional technique are reported. In both cases the proper hepatic artery was selected with a soft, nondissecting neurovascular guide catheter. The nontarget hepatic vessel was selected with a neurovascular microcatheter occlusion balloon, and the balloon was inflated to protect that vessel. Embolization to multiple target vessels was then achieved by way of a single injection through the guide catheter.

Results

Both procedures were technically successful without complication. Postembolization angiography confirmed normal parenchymal enhancement in the protected zone and expected paucity of enhancement in the treated zone.

Conclusion

Temporary distal balloon occlusion is a useful technique to treat multiple artery branches with a single injection in cases where individual selection of the branches is difficult or time-consuming. Further study of this technique is warranted.     

经动脉途径低浓度氰基丙烯酸正丁酯栓塞治疗海绵窦硬脑膜动静脉瘘

目的 探讨经动脉途径低浓度(14%～25%)氰基丙烯酸正丁酯(NBCA)栓塞治疗海绵窦硬脑膜动静脉瘘(DCCFs)的可行性.方法 8例DCCFs患者均经动脉入路,使用微导管嵌顿技术注入低浓度NBCA行栓塞治疗.其中5例为经静脉入路栓塞失败者,3例为不可行静脉入路栓塞治疗者.结果 5例患者术后即刻血管造影DCCFs完全消失;随访6～12个月,临床症状完全消失,血管造影未发现DCCFs复发.3例患者术后即刻血管造影DCCFs残留,但血液分流量减少;随访3个月,血管造影血液分流明显减少、临床症状改善2例,血液分流和临床症状均消失1例.1例患者术后出现一过性眼部症状恶化、第Ⅵ脑神经麻痹,经治疗后3 d症状消失.结论 经动脉采用微导管嵌顿技术低浓度NBCA栓塞DCCFs是一种安全有效的方法,对于经静脉入路栓塞失败或不能经静脉入路治疗的患者,可能是一种较为理想的选择.     

Visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization for hepatocellular carcinoma

PURPOSE: To analyze visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Retrospective review was conducted of 255 tumors in 161 patients treated by TACE with catheterization of the most distal portion of the tumor-feeding branches. All TACE procedures were performed with use of a mixture of iodized oil and anticancer drugs followed by gelatin sponge particles. Arteriograms and spot radiographs obtained during TACE were reviewed to determine whether hepatic lymphatic vessels appeared. Serial computed tomography (CT) images after TACE were evaluated along with clinical symptoms in cases that exhibited lymphatic vessel visualization. RESULTS: Hepatic lymphatic vessels were demonstrated in eight tumors (3.1%) in eight patients during TACE. The mean tumor diameter was 1.7 cm +/- 0.7 (range, 1.0-3.3 cm), and mean volume of injected iodized oil was 1.7 mL +/- 1.0 (range, 1-4 mL). Lymphatic vessels were demonstrated followed by marked portal vein visualization (n = 5) or extravasation of a small amount of contrast material (n = 2). In the remaining patient, these were depicted during the early stage of the TACE procedure. On CT after 1 week, iodized oil in the lymphatic systems in the hepatoduodenal ligament was seen in six patients, and it was shown to have been retained in four of these patients on follow-up CT performed 2, 7, 11, and 21 months later, respectively. None of these patients presented any clinical symptom other than postembolization syndrome. CONCLUSIONS: Hepatic lymphatic vessels were demonstrated in 3.1% of tumors treated by ultraselective TACE. Iodized oil in the lymphatic vessels may be retained for a relatively long time without specific symptoms.     

同轴微导管肝动脉化疗栓塞联合射频消融治疗原发性肝癌

目的 探讨经肝动脉微导管化疗栓塞(TACE)联合射频消融(RFA)术治疗原发性肝癌(HCC)的疗效.方法 回顾分析1000例HCC的DSA表现与术前多层螺旋CT(MSCT)检查结果.其中179例病灶局限于1个肝段,采用微导管超选择插管栓寒.术后4周复查动态增强CT和(或)MR,对40例病灶碘油聚集不良者,进行RFA,术后1个月复查.结果 DSA发现直径3 cm以上肿块670例,3 cm以下病灶202例,子灶400例,动静脉瘘、动门脉瘘482例,异常血供430例,门脉癌栓362例.局限于1个肝段的病灶,微导管栓塞后4周,肿瘤局部控制率为77.6%;控制不良者行RFA后1个月,肿瘤局部控制率为97.5%.结论 DSA对于发现3 cm以下小病灶(含子灶)、肿瘤血供、动静脉瘘、动门脉瘘具有绝对的优势,对HCC的术前评价具有不可替代性的作用.RFA是HCC的有效的治疗方法,是TACE疗效不佳者的理想选择.     

Pressure measurements in arterial feeders of brain arteriovenous malformations before and after endovascular embolization

Arteriovenous malformations (AVMs) are composed of abnormal arterial and venous vessels in the brain causing arteriovenous shunts of arterialized blood directly from pial arteries to draining veins. The hemodynamics of these lesions is not well-understood. Changes in blood flow and pressure are probably related to the natural history of AVMs and may also play a major role in AVM treatment. In this study intra-arterial pressure was measured in feeding arteries of AVMs using a microcatheter that had been placed for subsequent embolization treatment (201 measurements were performed in 95 patients before and after the embolization procedure). Results show a direct relationship between pressure changes and degree of embolization. Since pressure changes during the embolization procedure are relatively small, it seems unlikely that these changes are the direct cause of rupture and periprocedural bleedings.     

Changes in rat liver microcirculation after experimental hepatic arterial embolization: comparison of different embolic agents

PURPOSE: To evaluate the effects of hepatic arterial embolization on hepatic microcirculation in the rat liver by using different particulate agents. MATERIALS AND METHODS: Polylactic acid microspheres, polyvinyl alcohol particles, and absorbable gelatin powder were injected into the hepatic artery of 50 rats. Saline was used as the control agent. Flow characteristics of hepatic microcirculation were qualitatively assessed on days 0 and 7 after embolization by using in vivo microscopy. Histologic specimens of the rat liver were analyzed. RESULTS: The polylactic acid (1-5 microns) injected into the hepatic artery was seen circulating through the sinusoids into the central venules. The slowing of flow observed with the injection of larger (50-200-micron) particles reflected the arterial occlusion occurring more proximally. After 7 days, all embolic agents caused vascular occlusion that led to necrosis and fibrosis. Networks of irregular, high-speed vessels that resembled arterioles and bypassed the normal sinusoids were observed. CONCLUSION: The necrotic areas observed after experimental distal occlusion of the hepatic arteries in the rats were bypassed by vessels similar to the capillarized sinusoids observed in the cirrhotic liver in humans. These vessels acted as sinusoidal shunts in the embolized territories.