Treatment of intrahepatic arteriovenous fistula hepatocellular carcinoma with N-butyl-2-cyanoacrylate

Primary hepatocellular carcinoma （HCC） continues to be one of the most common malignancies with an incidence of approximately one million cases per year and a dismal prognosis; some authors have reported a median survival of 1～2 months after diagnosis. Although surgery remains the only hope for cure, few patients are candidates. As a result, the role of interventional radiology in the management of HCC has grown remarkably in the past decade. Transcatheter arterial chemoembolization （TACE）, by far, is the most common technique used to treat unresectable HCC, that is usually performed with the selective arterial administration of ACA-lipiodol emulsion of iodized and gelatin sponge particles to occlude temporarily tumor feeding vessels. Arteriovenous shunt has been reported in HCC and is usually as a recognized contrain-dication of TACE.     

Treatment of intrahepatic arteriovenous fistula in hepatocellular carcinoma with N-butyl-2-cyanoacrylate

Primary hepatocellular carcinoma (HCC) continues to be one of the most common malignancies with an incidence of approximately one million cases per year and a dismal prognosis; some authors have reported a median survival of 1 ～ 2 months after diagnosis. Although surgery remains the only hope for cure, few patients are candidates[1,2].     

Use of a balloon and N-butyl-2-cyanoacrylate for treatment of arteriovenous fistula

We report a patient who developed a large arteriovenous fistula in right lower extremity after gunshot injury. Because other endovascular methods failed, the patient was successfully treated with concomitant use of detachable latex balloon and N-butyl-2-cyanoacrylate (NBCA). The combination of detachable balloon and NBCA can be effectively used for endovascular treatment of peripheral arteriovenous fistulas in selected cases when effective embolization could not be achieved with other embolizing agents or their various combinations.     

N-butyl-2-cyanoacrylate for embolisation of carotid aneurysm

We report the use of an N-butyl-2-cyanoacrylate (NBCA) mixture for embolisation of six cases of carotid aneurysm after detachable balloons, and/or microcoils had been placed in the aneurysm. The mixture was injected into the aneurysm to prevent delayed bleeding or distal migration of the balloons, or microcoils. No subarachnoid haemorrhage or distal migration of the balloons or microcoils occurred up to 4.5 years after embolisation. Reflux of the NBCA mixture into the parent artery occurred in one patient, who had a neurological deficit which recovered in a month. NBCA mixture may be useful in embolisation of intracranial or skull base arterial aneurysms, for reducing the size of remaining lumen in an aneurysm at high risk of rebleeding which accommodate no more balloons or microcoils, or preventing possible delayed migration of balloons or microcoils. However, prevention of leakage of the mixture into the parent artery remains a problem.     

Transportal intravariceal sclerotherapy with N-butyl-2-cyanoacrylate for gastric varices

Four patients with gastric varices without catheterizable draining veins through a systemic vein were treated with transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate (NBCA). In all patients, the gastric varices were successfully obliterated with 2-5 mL of NBCA-lipiodol mixture injected via a microcatheter introduced into the varices with transhepatic or transileocolic portal venous access. No complications related to the procedure were encountered. Follow-up gastroendoscopy showed disappearance (n = 3) or marked decrease (n = 1) of the varices. Neither recurrent gastric varices nor variceal bleeding were observed during the follow-up period (6-46 months). Transportal intravariceal sclerotherapy is useful for obliteration of gastric varices in selected cases.     

Transcatheter arterial embolization of acute upper gastrointestinal tract bleeding with N-butyl-2-cyanoacrylate

PURPOSEl: To retrospectively analyze outcomes in patients who received an iodized oil formulation of N-butyl-2-cyanoacrylate to treat acute nonvariceal upper gastrointestinal tract bleeding. MATERIALS AND METHODS: Sixteen patients with acute upper gastrointestinal tract bleeding underwent angiography and transarterial embolization between April 2004 and December 2005. Patients with negative findings at arteriography and those with lesions in large vessels that did not necessitate a microcatheter for catheterization were excluded. Three types of embolization were used according to the accessible arteries: Localized embolization was used in the bleeding artery, and distal (segmental) or proximal embolization was used in the parent artery according to the final position of the catheter tip. Outcomes, including hemostasis, recurrent bleeding, and complications, were recorded. RESULTS: Immediate hemostasis was achieved in 14 patients (88%). One (6%) patient had technical failure due to arterial dissection, and one (6%) patient had therapeutic failure due to multiple ulcers and coagulopathy. Of the 14 patients with immediate hemostasis, one (7%) had recurrent bleeding 5 days after embolization. Both patients in whom hemostasis was not achieved (12%) died within 1 month of follow-up. Multiple gastric ulcers were seen in two (12%) patients who underwent embolization of a large area, and conservative treatment was sufficient. CONCLUSIONS: The results of this preliminary experience indicate that transarterial embolization with the iodized oil formulation is feasible and effective in the management of nonvariceal upper gastrointestinal tract bleeding; however, a larger number of cases should be investigated.     

Treatment of vertebral arteriovenous fistulas

Twenty patients with vertebral arteriovenous fistulas (eight spontaneous, six traumatic without vertebral artery transection, and six traumatic with vertebral artery transection) were treated by transvascular embolization techniques, resulting in complete fistula closure in all patients. The fistulas were located at C1-C2 in 45%, C2-C3 in 25%, C4-C5 in 15%, C5-C6 in 10%, and C6-C7 in 5%. Trauma was the most common cause: 30% followed knife wounds, 20% followed gunshot injuries, and 10% followed blunt trauma. Eight patients had spontaneous fistulas, two associated with fibromuscular dysplasia. Three patients-all with large, long-standing fistulas-developed neurologic deficits coincident with the abrupt closure of the fistula, which resolved with reestablishment of fistula flow. Two of these patients were treated by staged closure; the other one by gradual closure. In all three cases the result was complete fistula closure without neurologic sequelae. The remaining spontaneous fistulas were all closed by balloon embolization with preservation of the vertebral artery and without deficits. The six patients with traumatic fistulas without transection were cured by balloon embolization, without deficits; in four there was also preservation of vertebral flow. The other six patients had traumatic fistulas with transection and were all cured by balloon embolization with preservation of flow in two. Four patients required bilateral approaches to the fistula to achieve complete fistula closure. The only complication was a mild residual Wallenberg syndrome after occlusion of the posterior inferior cerebellar artery in the treatment of a transection located at C1. In our opinion, transvascular techniques are the treatment of choice for vertebral arteriovenous fistulas.     

Triaxial system in bronchial arterial embolization for haemoptysis using N-butyl-2-cyanoacrylate

Objective:

The application of bronchial artery embolization (BAE) using N-butyl-2-cyanoacrylate (NBCA) for haemoptysis was recently reported to be useful. A triple co-axial (triaxial) system consisting of a 4-Fr catheter, 2.7-Fr microcatheter and 1.9-Fr no-taper microcatheter has been developed. The aim of the present study was to evaluate the usefulness of the triaxial system in BAE using NBCA.

Methods:

12 patients with haemoptysis, 8 males and 4 females with a median age of 64 years (range, 49–88 years), underwent BAE between August 2012 and October 2014. Medical records and images were reviewed, and the technical success rate, clinical success rate, haemoptysis-free rate and complications were evaluated. Technical success was defined as the complete cessation of the target artery as confirmed by digital subtraction angiography, whereas clinical success was defined as the cessation of haemoptysis within 24 h of BAE. Recurrent haemoptysis was defined as a total of >30 ml of bleeding per day.

Results:

The target artery was embolized successfully in all patients, and the technical success rate was 100% (12/12). The cessation of haemoptysis was achieved in 11 out of 12 patients within 24 h, and thus, the clinical success rate was 92% (11/12). The 6-, 12- and 24-month haemoptysis-free rates were 89%, 89% and 76%, respectively. No patients exhibited any signs of complications such as spinal ischaemia.

Conclusion:

BAE using the triaxial system and NBCA appears to be a useful and safe procedure for haemoptysis.

Advances in knowledge:

The triaxial system contributes to safe and effective BAE using NBCA.     

Dominant-hemisphere arteriovenous malformations: therapeutic embolization with isobutyl-2-cyanoacrylate

Embolization treatment of 16 patients with dominant-hemisphere arteriovenous malformations (AVMs) is described. This group was selected from 50 patients with brain AVMs embolized with isobutyl 2-cyanoacrylate (IBC-2) over a period of 3 years. All 16 AVMs were cortical in location; six involved the rolandic and speech areas, and four had a deep component. Ten AVMs were embolized through a transfemoral approach, an intraoperative approach was used for four cases, and a combined transfemoral/intraoperative approach was used in two cases. Complete obliteration of the AVM was obtained in one case. Partial obliteration and complete surgical resection was obtained in three cases. Obliteration of 70%-95% of the AVM was obtained in six cases and 45%-70% of the AVM was obliterated in six cases. IBC-2 embolization of the venous drainage was observed in three cases. After embolization, eight patients remained neurologically unchanged. Three patients had mild neurologic deficits that resolved completely within 48 hr; one had a deficit that cleared up 1 week later; and one had a deficit that disappeared within 6 months. In three patients a mild permanent neurologic deficit was evident 6 months after embolization.     

创伤性肾动静脉瘘的介入治疗

目的 评价用介入技术治疗创伤性肾动静脉瘘(RAVFs)的安全性和疗效。方法 对8例不适宜做外科治疗的RAVFs患者进行了介入治疗，其中外伤性损伤4例，医源性损伤4例。6例行经导管超选择性肾动脉内钢丝圈栓塞术，2例行被覆膜支架置入患侧肾动脉内封闭瘘口。结果 血管造影显示肾内型动静脉瘘4例，累及肾动脉段-亚段级分支；主干(肾外)型动静脉瘘4例。治疗均获成功，治疗结束时复查血管造影显示瘘口被封闭。轻微并发症1例。医源性RAVFs患者术后失血症状迅速改善，肉眼血尿消失；4例术前存在心脏负荷过度症状患者，闭塞动静脉瘘后症状迅速改善，血管杂音消失。术后肾功能测定均属正常范围，其中2例肾动脉被覆膜支架置入患者，同位素肾扫描显示患侧肾脏形态、功能正常。术后随访10～42个月，2例分别于术后10，18个月死于与RAVFs无关的疾病。6例仍然生存，一般情况良好，未再针对RAVFs进行外科或介入治疗。结论 介入技术，包括经导管超选择性肾动脉内栓塞术和被覆膜支架置入术，是治疗创伤性、复杂型RAVFs的安全、有效的方法。     

N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding

PURPOSE: The purpose of this work was to describe the radiologic and clinical manifestations of n-butyl-2-cyanoacrylate pulmonary embolism (PE) after endoscopic injection sclerotherapy (EIS) for gastric variceal bleeding. METHOD: From 1992 to 1999, the medical records of 140 patients who had undergone EIS using n-butyl-2-cyanoacrylate were reviewed for identification of respiratory symptoms and amount of injection, and their pre- and postprocedure chest radiographs were reviewed to identify PE. In patients with PE, pre- and postprocedure chest radiographs (6/6), chest CT scans (3/6), lung perfusion scans (3/6), and follow-up chest radiographs (6/6) were analyzed retrospectively. RESULTS: Radiographically evident PE was observed in 6 (4.3%) of 140 patients. In comparison with patients without emboli, these patients received a higher mean volume of injection (4.2 vs. 1.8 ml) (p = 0.0011). Four of the six patients with pulmonary emboli had respiratory symptoms. Chest radiographs and CT scans showed unusual tubular or nodular, radiopaque pulmonary emboli along the pulmonary vessels. Multiple peripheral, wedge-shaped, subsegmental perfusion defects were seen on perfusion lung scans. In five of six patients, the radiographic abnormalities showed complete or partial resolution. There were no fatalities directly associated with PE. CONCLUSION: Radiographically evident PEs are uncommonly observed following EIS and appear to be more common in patients receiving a higher volume of liquid acrylate. Affected patients were either mildly symptomatic or asymptomatic, and there were no direct fatalities of this complication.     

N-butyl 2-cyanoacrylate embolization of spinal dural arteriovenous fistulae

BACKGROUND AND PURPOSE: Because they are not well established, we investigated the technical success and recurrence rates of n-butyl 2-cyanoacrylate (NBCA) embolization of spinal dural arteriovenous fistulae (SDAVF), and assessed clinical outcomes. METHODS: We retrospectively studied all patients with SDAVF treated by NBCA embolization at our institution over an 8-year period. Gait and micturition disabilities were analyzed. Follow-up periods averaged 3.1 years (range, 1 month to 8.9 years). RESULTS: NBCA embolization was feasible in 74% (20/27) of patients. Of 20 patients who underwent embolization, initial embolization failure occurred in two (10%) and fistula occurrence in three (15%). All five patients in whom NBCA embolization failed underwent surgery. All patients who underwent embolization had either improved (55%) or unchanged (45%) gait disability at last follow-up. Seventeen (85%) patients had improved (40%) or unchanged (45%) micturition disability, but three (15%) had worsened. Mean Aminoff gait disability grade significantly decreased at last follow-up (2.4 [1.4] average [SD] vs 3.2 [1.4] [P = .0008]). Mean micturition disability grade decreased, but not significantly (1.4 [1.0] vs 1.7 [1.1] [P = .28]). CONCLUSION: NBCA embolization of SDAVF was technically feasible in 75% of patients. Initial apparent successful embolization was achieved in 90%; the fistula recurrence rate (failure to occlude the draining vein) for NBCA was 15%. Comparing favorably to surgical series, NBCA embolization of SDAVF appears efficacious, significantly improving mean gait disability by almost one grade at last follow-up. Close clinical and angiographic surveillance is mandatory. Longer and more uniform follow-up is needed to determine if clinical improvement and stabilization after NBCA embolization are sustained.     

Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate

Objectives

To evaluate the efficacy of transcatheter arterial embolisation (TAE) using N-butyl-2-cyanoacrylate (NBCA) in the treatment of postpartum haemorrhage (PPH) due to ruptured pseudoaneurysm.

Methods

From March 2004 to December 2010, 33 patients underwent TAE using NBCA for massive PPH. Twenty-one patients (63.6 %) were in coagulopathic condition. Angiograms and medical records were retrospectively reviewed to determine technical/clinical success, complications and recurrent haemorrhage after TAE. Telephone interviews were conducted to obtain fertility-related data.

Results

Emergent angiograms revealed ruptured pseudoaneurysms at the uterine (n?=?17), vaginal (n?=?14), internal pudendal (n?=?3) and obturator (n?=?1) arteries, which were successfully embolised with NBCA. Four patients required additional embolisation of the uterine (n?=?3) or ovarian artery (n?=?1) with an absorbable gelatine sponge. Adequate haemostasis was achieved in 31 patients (93.9 %) after TAE. Two patients experienced persistent (n?=?1) or recurrent (n?=?1) haemorrhage, which required hysterectomy. There were no major embolisation-related complications. All 29 patients who were interviewed reported regaining of their regular menstruation. Nine patients had normal pregnancies and delivered healthy babies at full term.

Conclusions

TAE using NBCA is an effective treatment of PPH from ruptured pseudoaneurysms. In particular, NBCA is a potent embolic material in patients with coagulopathy. It does not seem to adversely affect future fertility.

Key Points

? Transcatheter arterial embolisation is a safe and effective treatment for postpartum haemorrhage. ? NBCA is potent embolic material to treat bleeding patients with severe coagulopathy. ? NBCA does not seem to adversely affect future fertility.     

Transarterial balloon-assisted n-butyl-2-cyanoacrylate embolization of direct carotid cavernous fistulas

BACKGROUND AND PURPOSE: Transarterial detachable balloon embolization of direct carotid cavernous fistulas (DCCFs) has become an optimal treatment. In a few cases, the parent artery has to be sacrificed to achieve morphologic cure. We present our experience with transarterial balloon-assisted n-butyl-2-cyanoacrylate (n-BCA) embolization of DCCFs in which there was failure to achieve angiographic cure and preservation of parent arteries. METHODS: Of 141 patients with traumatic DCCFs who had been treated by transarterial embolization with occlusion of the fistula and parent artery preservation, 18 received transarterial balloon-assisted n-BCA embolization-6 for residual fistula after the balloons detached, 7 for recurrent fistula because of premature balloon deflation or migration, and 5 for repeated puncture of the detachable balloon by the bony fragment at the cavernous sinus. A total of 27 procedures were performed with an average 1.5 attempts per patient, and the volume of the n-BCA mixture varied from 0.5 to 2.3 mL with a mean of 0.83 mL. RESULTS: All DCCFs were successfully occluded by the n-BCA mixture with preservation of parent arteries. One patient with a giant cavernous sinus varix had a fatal subarachnoid hemorrhage. One had a recurrence and was treated by internal carotid artery (ICA) occlusion. Five had asymptomatic pseudoaneurysms at the parent artery. There was no adhesion of the n-BCA mixture to the protective balloon or the microcatheter or n-BCA reflux into the parent arteries. CONCLUSION: Transarterial balloon-assisted n-BCA embolization is a feasible, efficient, and safe treatment for DCCFs when angiographic cure and ICA preservation are not achieved by transarterial detachable balloon embolization.     

Cirsoid renal arteriovenous malformation treated by endovascular embolization with n-butyl 2-cyanoacrylate

The authors report a rare case of renal arteriovenous malformation (rAVM) which was diagnosed by arteriography years after onset of intermittent haematuria. The rAVM of the cirsoid type was superselectively catheterized and embolized in toto with n-butyl 2-cyanoacrylate. Diagnostic imaging modalities and the technique of embolization are discussed. Received: 16 July 1999; Revised: 17 September 1999; Accepted: 20 September 1999