Transcatheter arterial embolization in the management of gynaecological bleeding

Transcatheter arterial embolization was attempted in ten patients with gynaecological bleeding. It concerned eight malignant lesions (five cases of spinocellular carcinoma of the uterine cervix, one case of endometrium carcinoma, one case of choriocarcinoma and one case of vulvovaginal metastasis of hypernephroma), and two benign lesions (one uterine arteriovenous malformation and one bleeding after curettage). Bleeding could be stopped in six patients and considerably reduced in two. In two patients selective catheterization of the uterine artery was impossible due to atherosclerotic tortuosity in one and tumoral invasion in the other.     

内脏假性动脉瘤出血的栓塞治疗

目的 探讨内脏假性动脉瘤出血经导管栓塞治疗的方法及疗效.方法 回顾性分析7例以不同部位出血为主要表现的患者,行腹、盆腔相关动脉造影,明确出血原因为假性动脉瘤及其部位后行栓塞治疗.结果 7例中,肝动脉瘤2例,胃十二指肠动脉瘤3例,子宫动脉瘤2例.动脉造影能够清晰显示假性动脉瘤的部位、形态和供养血管.DSA造影动脉瘤呈现类圆形囊状突起,栓塞后再次造影见动脉瘤及其供血动脉消失,7例介入治疗均获成功.所有术后出血均停止.结论 DSA造影能明确假性动脉瘤的部位,经导管栓塞治疗假性动脉瘤是安全有效的.     

Transcatheter arterial embolization in gastric cancer patients with acute bleeding

The safety and clinical effectiveness of transcatheter arterial embolization for bleeding associated with unresectable gastric cancer was evaluated. Twenty-three patients with bleeding from unresectable gastric cancer underwent transcatheter arterial embolization. Of the 23 patients, eight showed signs of active bleeding, such as contrast extravasation or pseudoaneurysm, seven showed only tumor staining, and the remaining eight patients showed negative angiographic findings. All embolization procedures were successful without procedure-related complications. In all eight active bleeding patients, immediate hemostasis was achieved. The overall clinical success rate was 52% (12/23). Recurrent bleeding within 1 month occurred in one (8%) in 12 patients with initial clinical success. One patient showed partial splenic infarction after embolization of the splenic artery for active bleeding from the short gastric artery. Overall 30-day mortality rate was 43% (10/23). The median overall survival period was 38 days. In patients with bleeding from unresectable gastric cancer, transcatheter arterial embolization was found to be safe and effective for achieving immediate hemostasis for active bleeding. Although the clinical success rate was not high, the recurrent bleeding rate was low at 1 month post procedure.     

Transcatheter therapeutic embolization in the management of massive upper gastrointestinal bleeding.

Two methods of controlling life-threatening hemorrhage are infusion of vasospastic agents and embolization of the bleeding vessel. Gelfoam powder, Gelfoam sponge, and isobutyl cyanoacrylate have been used to control severe arterial and variceal hemorrhage from the upper gastrointestinal tract. The authors summarize their results and discuss gastric necrosis, a serious complication.     

Transcatheter arterial chemoembolization for hepatocellular carcinomas in patients with celiac axis occlusion

PURPOSE: To verify the hypothesis that most instances of celiac axis occlusion in patients with hepatocellular carcinoma (HCC) are caused by diaphragmatic compression and, therefore, transcatheter arterial chemoembolization (TACE) can be performed through the compressed lumen of the celiac axis. MATERIALS AND METHODS: The authors attempted to perform TACE in 36 consecutive patients with HCC and celiac axis occlusion. Spiral computed tomographic (CT) images were available in 26 patients. Initially, catheterization of the hepatic arteries was attempted through the occluded celiac axis. If it failed, catheterization was performed through the pancreaticoduodenal arcades. The causes of celiac axis occlusion were evaluated based on spiral CT and angiographic findings, access routes, technical success rates, and related complications in superselective catheterization of hepatic arteries. RESULTS: Among the 26 patients who underwent spiral CT, diaphragmatic compression of the celiac axis was demonstrated in 23. Selective catheterization of hepatic arteries was possible through the occluded celiac axis in 23 patients (64%). In nine (25%) of the remaining 13 patients, TACE was performed through the dilated pancreaticoduodenal arcades from the superior mesenteric artery. As a procedure-related complication, celiac axis dissection occurred in one patient (3%). CONCLUSION: Most patients with celiac axis occlusion had arcuate ligament compression. In TACE, the celiac artery occlusion could be traversed directly and this should be the initial approach.     

Transcatheter occlusion of the arterial supply to arteriovenous fistulas with Gianturco coils.

Transcatheter occlusive therapy is finding widespread clinical application. Numerous types of occlusive devices have been described. This report details the first three cases of occlusion of the arterial supply to arteriovenous fistulas with Gianturco stainless steel coils. Patients benefiting from this approach include those who refuse or cannot tolerate surgery, those in whom previous surgery failed, and those with chronic fistulas in whom surgery is likely to fail. The angiographer should make sure the coil is completely within the desired vessel, the feeding vessel is smaller than the coil to prevent passage through the fistula, and there is adequate collateral flow to distal organs to prevent infarction after occlusion of a major artery. This technique is useful as a nonsurgical treatment for a variety of arteriovenous fistulas and is within the capability of any experienced angiographer.     

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.     

Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) in patients with bleeding/rebleeding duodenal ulcers.

Material and Methods: Over a 6-year-period, 40 consecutive patients with bleeding/rebleeding after endoscopic therapy and/or surgery for duodenal ulcer were included in the study. Superselective angiographic catheterization and coil embolization were performed by the same interventional radiologist.

Results: Lasting hemostasis was achieved in 26 of 40 patients (65%). Transfusion requirement was reduced from median 14 (range 3-35) units of blood before TAE to 2 (range 0-53) units after TAE. Ten patients died, five because of continuous bleeding. No adverse effects as a result of TAE were seen.

Conclusion: TAE is an effective and safe treatment in a significant proportion of patients with bleeding duodenal/rebleeding ulcers after therapeutic endoscopy and/or surgery.     

Transcatheter occlusion of the gastroduodenal artery.

The gastroduodenal arteries of 7 patients were occluded for treatment of duodenal bleeding in 4, hepatic devascularization in 2, and redistribution of blood flow for intra-arterial chemotherapy in one patient. In 6 patients, occlusion was performed with Gianturco coils, and with Gelfoam in one. No major complication was encountered. This approach was successful in the control of bleeding from peptic ulcers, arteriovenous malformation and invasion of duodenum by retroperitoneal metastatic lymph nodes from carcinoma of the testicle. Occlusion of the gastroduodenal artery was utilized for further dearterialization of hepatic neoplasms. Redistribution of hepatic blood flow was accomplished by the occlusion of the gastroduodenal and replaced right hepatic arteries allowing infusion of chemotherapeutic agents into the entire liver through the left hepatic artery.     

Transcatheter gelfoam embolization in intractable prostatic bleeding

The authors describe a case in which protracted bleeding after a transurethral prostatic resection could not be controlled with repeated fulguration and resection. Hemostasis was obtained with transcatheter arterial Gelfoam embolization of both hypogastric arteries.     

Transcatheter Gelfoam embolization in intractable prostatic bleeding

The authors describe a case in which protracted bleeding after a transurethral prostatic resection could not be controlled with repeated fulguration and resection. Hemostasis was obtained with transcatheter arterial Gelfoam embolization of both hypogastric arteries.     

Transcatheter embolisation of arterial aneurysms

Eleven cases of bleeding aneurysms and pseudoaneurysms, with and without arterio-venous fistula, involving different vascular territories were treated by transcatheter embolisation and the results are reported. Gelfoam was used in two cases and steel coils in the remaining nine cases. Embolisation by the steel-coil technique proved to be very efficient. The experience in these 11 cases shows that it is usually not necessary to embolize the aneurysm cavity but simply to occlude the feeding proximal vessel, consequently sparing the weak aneurysmic wall the risk of rupture and allowing the aneurysms to clot as a result of reduced or occluded blood flow.     

Transcatheter occlusion of pulmonary arterial circulation and collateral supply: failures, incidents, and complications

Failures and complications were analyzed retrospectively in 45 patients treated with embolotherapy or occlusion of pulmonary arterial circulation. Pulmonary arterial branches were occluded with steel coils in 19 patients with pulmonary arteriovenous malformations, 17 with hemoptysis of pulmonary artery (PA) origin, and one with massive parenchymal shunt. Bronchial arterial supply to the lung was embolized with small particles in eight cases of hemoptysis and systemic to pulmonary arterial antegrade shunt secondary to chronic thromboembolism. Asymptomatic incidents included catheterization failures, vascular damage, partial occlusion, partial recanalization of the thrombus, ectopic deposition of a coil, and delayed bacterial contamination of the thrombus. A few cases of transient clinical and radiologic signs of pulmonary infarction were observed after complete occlusion of the PA and bronchial artery embolization. This complication was never observed after complete occlusion of main right or left PA, inferior right or left PA, or segmental branches. The management and prevention of these complications, the role of bronchial arterial collateral pathways, and the importance of the site of PA occlusion in the development of pulmonary infarction are discussed.     

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

Objective

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

Methods

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

Results

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

Conclusion

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Key Points

? Pelvic artery embolisation (PAE) is an important therapeutic option for postpartum haemorrhage. ? It seems safe and effective for PPH with placenta accreta (PA). ? PAE preserves the uterus and does not impair subsequent menstruation. ? PAE has few major complications.