Peripheral embolization of diffuse hepatic arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia

Ivalon particles were used for hepatic arterial embolization of diffuse arteriovenous malformation in a patient with hereditary hemorrhagic telangiectasia. The methods of the procedure and possible complications are discussed.     

Embolization of hepatic arteriovenous malformations using radiolabeled and nonradiolabeled polyvinyl alcohol sponge in a patient with hereditary hemorrhagic telangiectasia: case report.

Polyvinyl alcohol sponge (PVA) radiolabeled with 99mTc-sulfur colloid was used to evaluate a large hepatic arteriovenous malformation (AVM) in a 71-yr-old white female prior to embolization. The patient had hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) with severe left-to-right shunting through the hepatic AVM which resulted in high-output congestive heart failure. The patient also had severe pulmonary hypertension. Scintigraphic imaging of the embolized radiolabeled PVA particles allowed us to be certain that the particles did not flow through the liver and inadvertently embolize the lungs; with the patient's already poor pulmonary status, embolization could have been fatal.     

Treatment of mandibular arteriovenous malformations by direct transosseous puncture: Report of two cases

Mandibular arteriovenous malformation (AVM) is a potentially life-threatening pathology requiring radical treatment. We report two female patients, aged 14 and 16 years, in whom occlusion of the AVM with Ethibloc after percutaneous transosseous puncture achieved definitive recovery. The first case was treated by direct injection of Ethibloc following inefficient arterial embolization with Ivalon particles. In the second case, Ethibloc was injected without previous arterial embolization. Control examinations performed at 6 months and 2 years confirmed complete calcification of the mandible in the first case and a total obliteration of the AVM on angiography in the second case.     

Transcatheter hemostasis in the genitourinary tract

Transcatheter hemostasis is applicable in a large variety of causes of genitourinary hemorrhage. The method is particularly useful in the management of trauma since temporary occlusion of the bleeding vessel usually produces cessation of hemorrhage without significant sacrifice of additional parenchyma. Control of arteriovenous fistulas requires an assessment of flow characteristics and careful tailoring of catheter and embolization technique; large emboli or glue is frequently required for occlusion of large fistulas, whereas small ones can be treated with Ivalon. Hemorrhage from renal or pelvic neoplasm is also effectively managed by transcatheter therapy.     

A Modified Metallic Coil Embolization Technique for Pulmonary Arteriovenous Malformations Using Coil Anchors and Occlusion Balloon Catheters

Purpose To evaluate the feasibility and efficacy of a modified metallic coil embolization technique for pulmonary arteriovenous malformations (PAVMs) using coil anchors and occlusion balloon catheters. Methods Five consecutive female patients with 6 PAVMs were included in the present study. One of the 6 PAVMs was of the complex type with four feeding arteries. An occlusion balloon catheter was inserted into the feeding artery as close to the venous sac as possible. The coil anchor, which was a simple W-shaped bent stainless steel wire with two markers at each end, was deployed prior to embolization to prevent the systemic migration of embolic materials. Then, metallic coils were deployed around the coil anchors under inflow stoppage using the inflated occlusion balloon catheter. In the complex-type PAVM, the main feeder was occluded by this technique and the other three small feeders were embolized with metallic coils only. Results In all 5 cases, occlusion balloon catheters could be inserted into the feeding arteries just proximal to the venous sacs, coil anchors were easily deployed, and complete occlusion was achieved without any migration of metallic coils or paradoxical embolism during the procedure. Conclusions The modified metallic coil embolization technique with coil anchors and occlusion balloon catheters was feasible and considered to be useful in preventing procedure-related complications.     

Vena cava filter scaffold to prevent migration of embolic materials in the treatment of a massive renal arteriovenous malformation

Transcatheter occlusion of high-flow arteriovenous malformations (AVMs) or arteriovenous fistulas may be complicated by migration of embolic materials intended to impede flow. Reducing antegrade flow during catheter embolization via balloon occlusion or inhibiting migration with anchoring devices may improve procedural safety in high-flow settings. We describe the use of an inferior vena cava filter as a scaffold to support complete vascular occlusion of a large renal AVM.     

A small pulmonary arteriovenous malformation as a cause of recurrent brain embolism

We report a case of recurrent paradoxical brain embolism mediated through a small pulmonary arteriovenous malformation (PAVM) with a 1.8-mm-diameter feeding artery. In this case, the further recurrent stroke was prevented successfully by PAVM embolization. Although embolization therapy is currently recommended only for PAVMs with feeding arteries greater than 3 mm in diameter, the therapy may be needed also in the smaller PAVMs.     

Bronchial and non-bronchial systemic artery embolization for hemoptysis due to non-neoplastic lung diseases. Immediate effect and long-term results

Forty-four patients with massive or repeated hemoptysis due to nonneoplastic lung diseases were treated by embolization of the bronchial and non-bronchial systemic arteries with Ivalon particles or a mixture of Ivalon and gelatin sponge particles during the past five and a half years. Immediate control of hemoptysis was achieved in 43 patients (98%), and no spinal cord ischemia was observed. Among 30 patients followed for more than 12 months, successful control of hemoptysis was obtained in 22 (73%). Hemoptysis recurred in eight patients (27%); four underwent repeated embolotherapy alone, two underwent surgery alone, and two underwent repeated embolization and surgery. Successful control of hemoptysis was achieved after repeated embolization and/or surgery in all eight patients. It is concluded that embolization of bronchial and non-bronchial systemic arteries is an effective initial treatment for hemoptysis, and good long-term results can be obtained in combination with surgery.     

Use of the TriSpan Coil to Facilitate the Transcatheter Occlusion of Pulmonary Arteriovenous Malformation

Pulmonary arteriovenous malformation (PAVM) is a rare vascular malformation of the lung which may occur as an isolated entity or in association with hereditary hemorrhagic telangiectasia (HHT). Because of considerable risk of serious complications such as cerebral embolism, brain abscess and pulmonary hemorrhage, definitive treatment should be considered in most patients. Embolization with coils or detachable balloons is currently the preferred treatment. Paradoxical embolization of coils and balloons may happen, especially in patients with PAVMs with large feeding arteries. In this report we present our initial experience with the use of the TriSpan coil to lower the risk of coil migration during the transcatheter occlusion of PAVMs.     

Pulmonary Artery Access Embolization in Patients with Massive Hemoptysis in Whom Bronchial and/or Nonbronchial Systemic Artery Embolization Is Contraindicated

The objective of this paper is to present an alternative therapeutic approach for the treatment of patients with massive hemoptysis in whom bronchial and/or nonbronchial systemic arterial embolization is not possible. We describe a percutaneous procedure for pulmonary segmental artery embolization. Between May 2000 and July 2006, 27 adult patients with hemoptysis underwent percutaneous treatment at our department; 20 of 27 patients were embolized via bronchial and or nonbronchial systemic arteries and 7 patients were embolized via pulmonary artery. Femoral arterial access for systemic artery catheterization and femoral vein access for pulmonary arterial catheterization were used. Gelfoam particles and coils were used for embolization. In this study, we report on three cases of massive hemoptysis from a systemic arterial source in whom bronchial and/or nonbronchial arteries embolization was not possible. Percutaneous embolization via the pulmonary artery access was successful in all three patients. In conclusion, embolization via pulmonary artery is presented as an alternative approach for the management of hemoptysis in patients in whom bronchial arterial embolization is not possible.     

Preoperative embolization of angiomas of the face. Remote angiographic results

Preoperative embolization was performed on 27 patients with facial angiomas supplied by the external carotid branches. Sixteen were males and 11 females; 13 of these angiomas were high-flow arteriovenous (A-V), 14 were low-flow capillary malformations. Fourteen patients underwent surgical removal after preoperative embolization; in this group embolization was carried out with Spongel in 3 cases and with Lyodura in 11 cases. In 12 of these patients the last angiographic examination was performed 3-6 years later: angiography evidenced no recurrence in 8 cases (67%), while in 3 cases (25%) there was capillary residual angioma of negligible size. Treatment was unsuccessful in one patient only, due to the large recurrent A-V angioma. Thirteen patients underwent embolization only, which was carried out with Lyodura in 10 cases, and with Ivalon in 3 cases. On 12 of these patients the last angiographic study was performed 2-14 months later: there was recurrent A-V angioma in 5 patients (42%), who underwent a subsequent embolization; angiography evidenced no recurrence in the other 7 patients (58%). In both series, the best results were obtained in the patients with low-flow capillary angiomas. Embolization and subsequent surgical removal are the treatment of choice for facial angiomas; embolization alone is useful in the management of surgically inaccessible vascular malformations, and it can be the only treatment in patients with small low-flow angiomas when distal occlusion of the feeding vessels with Lyodura or Ivalon particles is performed.     

Therapeutic embolization of facial arteriovenous fistulae.

Two cases of percutaneous transfemoral embolization of facial hemangiomas and arteriovenous (AV) malformations are reported. In both cases, Ivalon shavings were injected through a percutaneously placed catheter to permanently occlude peripheral feeders of the AV malformation. In one case, because of the size of the large venous sacs associated with the malformation, a steel coil was introduced to form a baffle, over which several additional strands of surgical silk were introduced to obliterate these sacs. These cases emphasize the need for embolization of small feeding arteries to prevent recurrence by collateral channels. To achieve this, specific-sized emboli are necessary; Ivalon is a suitable embolic material.     

Percutaneous Transcatheter Embolization of a Large Pulmonary Arteriovenous Fistula with an Amplatzer Vascular Plug

Percutaneous transcatheter embolization has become the treatment of choice for pulmonary arteriovenous fistulas (PAVFs), in most cases replacing surgical intervention. However, while "classic" devices, such as intravascular coils and detachable balloons, have proved to be successful for interventional occlusions of small or medium-sized PAVFs, they are not ideal in larger fistulas because of the risk for embolization to the systemic circulation. We describe the case of a 61-year-old woman with a symptomatic huge solitary pulmonary arteriovenous fistula (4.5 cm in diameter), occupying part of the lung in the lower right lobe with two feeding arteries (10 and 4 mm in diameter, respectively), who underwent successful transcatheter closure with an Amplatzer Vascular Plug, a new device designed for the occlusion of vascular abnormalities.     

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.     

Peripheral embolization complicating bilateral renal infarction with gelfoam.

Selective arterial embolization is a technique with wide therapeutic applicability. However, regardless of the nature of the embolic particles, reflux into the aorta with peripheral embolization is a serious potential complication. A case is described in which this complication occurred. We recommend that all such embolizations be performed with a balloon catheter occluding the target artery.     

Dural arteriovenous fistula of the cavernous sinus with cortical venous reflux of the posterior fossa via a bridging vein

We describe a patient who had a dural arteriovenous fistula of the cavernous sinus with cortical venous reflux into the lateral mesencephalic vein and cerebellar hemispheric veins via a bridging vein connected with the basilar plexus. The fistula and reflux disappeared after transvenous embolization using interlocking detachable coils.     

Therapeutic embolization of aneurysmal bone cyst

Results of therapeutic embolization of aneurysmal bone cysts in five patients are described. Transcatheter arterial embolization was performed with Ivalon and Gelfoam particles and Gianturco coils. The postembolization period was characterized by complete relief of pain and decrease in size of the aneurysmal bone cyst in all patients. In patients whose follow-up was longer than 12 months, sclerosis and recalcification of bone were present. There were no complications.     

Total therapeutic embolization of the kidney for hypertension in a child with a mycotic aneurysm

A 7-year-old boy with bacterial endocarditis developed renal artery mycotic aneurysm and diffuse distal occlusions of the renal branches. Blood pressure in the patient returned to normal after obliteration of flow to the left kidney with Gelfoam, Ivalon, and a Gianturco coil. An end loop of the coil used for embolization remained in the lumen of the aorta against its lateral side. Improper coil placement did not result in complications; the boy later died due to neurologic and pulmonary complications. We discuss the therapeutic potential of renal embolization, as well as the risks of particulate and ethanol embolization, in the treatment of renal vascular hypertension from mycotic aneurysms.     

Transcatheter embolization of the kidney with butyl-2-cyanoacrylate: Experimental and clinical results

The technique and efficacy of therapeutic catheter embolization of the kidney with butyl-2-cyanoacrylate (Histoacryl) were studied in 80 rabbits (including control groups) and in 10 dogs. A mixture of butyl-2-cyanoacrylate, 50% glucose, and tantalum powder was used for the embolization. Complete and permanent vascular occlusion was found in nearly all cases. The main complication observed was a reflux of embolizing material into the lumbar arteries, which occurred in seven rabbits. Clinically, therapeutic embolization was performed in six patients with hypernephroma. The indication for embolization in these patients, as well as in two others with iatrogenic lesions, was pronounced hematuria. Cessation of bleeding was achieved in all cases. For embolization the coaxial catheter technique is recommended; in special cases with extensive arteriovenous shunts, adjunctive balloon occlusion would be advisable.     

Digital intravenous angiographic diagnosis of post-traumatic arteriovenous fistula

Persistent arteriovenous fistula after penetrating renal trauma is an uncommon but significant complication. In the past, renal arteriography has been essential for the diagnosis. Recently, introduction of a new radiologic technique, digital video subtraction angiography, has made possible diagnostic visualization of the major renal circulation following intravenous injection of contrast material. We present a case in which post-traumatic renal arteriovenous fistula was diagnosed and serially evaluated following therapeutic embolization by digital video subtraction angiography.