Emergency endovascular treatment of an acute traumatic rupture of the thoracic aorta complicated by a distal low-flow syndrome

We report the case of a patient who suffered major trauma following a motorcycle accident that resulted in multiple fractures, bilateral hemopneumothorax, pulmonary contusions, and an isthmic rupture of the aorta with a pseudoaneurysm compressing the descending aorta. This compression was responsible for distal hypotension and low flow, leading to acute renal insufficiency and massive rhabdomyolysis. Due to the critical clinical status of the patient, which prevented any type of open thoracic surgery, endovascular treatment was performed. An initial stent-graft permitted alleviation of the compression and the re-establishment of normal hemodynamic conditions, but its low position did not allow sufficient coverage of the rupture. A second stent-graft permitted total exclusion of the pseudoaneurysm while preserving the patency of the left subclavian artery.     

Pulmonary artery false aneurysms secondary to Swan-Ganz pulmonary artery catheters

Several complications from the use of balloon-tipped flow-directed (Swan-Ganz) pulmonary artery catheters are recognized. One infrequent but life-threatening complication is false aneurysm formation associated with rupture or dissection of the pulmonary artery. We report 10 cases of catheter-induced pulmonary artery false aneurysms identified during a 9-year period. Initial presentation was radiologic in six patients and clinical (hemoptysis) in four. Later chest radiographic findings consisted of a well-defined, persistent pulmonary nodule or mass (three patients) or focal, dense parenchymal consolidation (six patients) that either persisted (two patients) or evolved into a nodule or mass (four patients) adjacent to the catheter tip. Cavitation of a pulmonary mass developed in one case. Two of eight deaths were caused by pulmonary artery false aneurysm formation and rupture with subsequent fatal hemorrhage. In one patient who survived, the false aneurysm was shown by pulmonary angiography and embolized with coils and Gelfoam. We conclude that pulmonary artery false aneurysms are life-threatening complications of pulmonary artery catheters and have characteristic chest radiographic findings.     

Pulmonary artery rupture during Swan-Ganz catheterisation: A case report

Catheter-induced pulmonary artery rupture is an infrequent complication that may occur during invasive cardiopulmonary monitoring. Fatal cases are uncommon and result from hemoptysis and flooding of the opposite lung with resulting hypoyxia. Alpha-1-antitrypsin deficiency is a rare genetic disorder characterised by low serum levels of alpha-1-antitrypsin, critical in maintaining connective tissue integrity. Besides pulmonary emphysema, recent observations suggest that alpha-1-antitrypsin deficiency may also be involved in vascular wall weakening, thereby predisposing arteries to dissection and aneurysm formation. In this article, we describe an autopsy case of pulmonary artery iatrogenic rupture due to insertion of a Swan-Ganz catheter in an 82-year-old woman suffering from pulmonary hypertension and alpha-1-antitrypsin deficiency. The exact source of bleeding could not be precisely identified during autopsy due to the extent of tissue hemorrhage, though postmortem angiography revealed a contrast medium extravasation from a branch of the left pulmonary lower lobar artery. The case herein emphasises the importance of postmortem angiography in facilitating the detection of vascular injuries, the importance of familiarity with intensive care techniques and procedures on behalf of forensic pathologists as well as in-depth knowledge of all possible contributing conditions and predisposing disorders in the pathogenesis of death.     

Referred pain to the ipsilateral forehead and orbit: An unusual phenomenon during bronchial artery embolization

Purpose: We report an unusual pattern of referred pain to the ipsilateral forehead and orbit observed during bronchial artery embolization (BAE) for massive hemoptysis due to pulmonary tuberculosis (TB) and postulate possible neural mechanisms for its occurrence. Methods: Seven men, from a series of 194 patients (171 men, 23 women) undergoing BAE (right bronchial artery 4, left 3) with gelatin sponge for control of massive hemoptysis due to pulmonary TB form the subject of this report. Results: Embolization was successful in achieving control of hemoptysis in these patients and there were no complications following the embolization. Transient, moderately severe, ipsilateral supraorbital and/or retroorbital pain occurred only during the injection of the gelatin sponge contrast mixture into the bronchial artery. The pain did not occur during the injection of heparinized saline or ionic contrast medium. Conclusions: Referred pain during BAE is an unusual phenomenon. Acute vessel distension triggering visceral sensations is probably the causative mechanism. Sympathetic afferents from the bronchi coursing through the posterior pulmonary plexus eventually pass to the trigeminal ganglion via the carotid sympathetic chain. The ophthalmic and maxillary divisions of the trigeminal nerve then mediate pain sensation to the ipsilateral forehead and orbit. Similarly, parasympathetic afferents from the pulmonary plexus crossing the nucleus of the spinal tract of the trigeminal nerve may be responsible for interexchange of impulses to the neurons in this nucleus. Sensory fibers of the ophthalmic and maxillary nerves relaying in this nucleus are then involved in this pain being referred to the forehead and orbit.     

A Rare Complication with an Anthéor Vena Cava Filter

A case of an embolization of an Anthéor vena cava filter into the pulmonary artery with disastrous exit 9 days after placement is described. The possible reasons are discussed.     

Anastomoses of the Ovarian and Uterine Arteries: A Potential Pitfall and Cause of Failure of Uterine Embolization

Four women with symptomatic uterine fibroids were treated by uterine artery embolization (UAE). In all cases both uterine arteries were embolized via a single femoral puncture with polyvinyl alcohol using a selective catheter technique. In three cases, the ovarian artery was not visible on the initial angiogram before embolization, but appeared after the second uterine artery had been treated. In one case of clinical failure following UAE, a repeat angiogram demonstrated filling of the fibroids from the ovarian artery. Anastomoses between uterine and ovarian arteries may cause problems for radiologists performing UAE and are a potential cause of treatment failure.     

Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm: review of radiological diagnosis and management

Iatrogenic pulmonary pseudoaneurysm is a well-known but uncommon complication related to Swan-Ganz catheters. The radiologist can play an important role in the diagnosis, prevention, and treatment of this potentially lethal complication. The authors present a case demonstrating the typical clinical and radiological presentation, and describe the role of interventional radiologic management.     

Treatment of Acute Aortic Type B Dissection with Stent-Grafts

Purpose: To evaluate the feasibility of endoluminal stent-grafts in the treatment of acute type B aortic dissections. Methods: In five patients with acute aortic type B dissections, sealing of the primary intimal tear with an endoluminal stent-graft was attempted. Indication for treatment was aneurysm formation in two patients and persistent pain in three patients. One of the latter also had an unstable dissection flap compromising the ostium of the superior mesenteric artery. The distance from the intimal tear to the left subclavian artery was <0.5 cm in four patients, who had typical type B dissections. In one patient with an atypical dissection the distance from the primary tear to the left subclavian artery was 4 cm. This patient had no re-entry tear. Talent tube grafts (World Medical Manufacturing Cooperation, Sunrise, FL, USA) were used in all patients. Results: Stent-graft insertion with sealing of the primary tear was successful in all patients. The proximal covered portion of the stent-graft was placed across the left subclavian artery in four patients (1× transposition of the left subclavian artery). Left arm perfusion was preserved via a subclavian steal phenomenon in the patients in whom the stent-graft covered the orifice of the left subclavian artery. The only procedural complication we observed was an asymptomatic segmental renal infarction in one patient. In the thoracic aorta thrombosis of the false aortic lumen occurred in all patients. In one patient the false lumen of the abdominal aorta thrombosed after 4 weeks; in the other three patients the status of the abdominal aorta remained unchanged compared with the situation prior to stent-graft insertion. As a late complication formation of a secondary aneurysm of the thoracic aorta was observed at the distal end of the stent-graft 3 months after the primary intervention. This aneurysm was treated by coaxial insertion of an additional stent-graft without complications. Conclusion: Endoluminal treatment of acute type B aortic dissections seems to be an attractive alternative treatment to surgical repair. Thrombosis of the false lumen of the thoracic aorta can be induced if the primary tear is sealed with a stent-graft. This could protect the dissected thoracic aorta from delayed rupture.     

Microcatheter embolization of Intractable Idiopathic Epistaxis

Purpose: To assess the efficacy and safety of microcatheter embolization in the treatment of intractable idiopathic epistaxis. Methods: Thirty-seven patients underwent microcatheter embolization in 1991–1998. We evaluated retrospectively the technical and clinical outcome, the number of complications, the duration of embolization in each case, and the number of blood transfusions needed. All embolizations were done with biplane digital subtraction angiography (DSA) equipment. The procedure was carried out under local anesthesia using transfemoral catheterization, except in one case where the translumbar route was used. Tracker 18 or 10 microcatheters were advanced as far as possible to the distal branches of the sphenopalatine artery. Polyvinyl alcohol (PVA) particles were used for embolization in most cases, while platinum coils or a combination of these two materials were occasionally used. The primary outcome was always assessed immediately by angiography. Follow-up data were obtained from patient records, by interviewing patients on the telephone or by postal questionnaires when necessary. The mean follow-up time was 21 months. Results: The embolization was technically successful in all 37 cases. A curative outcome was achieved in 33 cases (89%). The mean duration of the procedure was 110 min. Four patients (8%) had mild transient complications, but no severe or persistent complications were encountered. Twenty-three patients needed a blood transfusion. Slight rebleeding occurred in three patients during the follow-up; all responded to conservative treatment. One patient suffered two episodes of rebleeding within 2 months after primary embolization. Re-embolizations successfully stopped the bleeding. Conclusion: Embolization is the primary invasive modality for treating intractable idiopathic epistaxis. It proved both safe and effective over a relatively long follow-up.     

Pleural and pulmonary staining at inferior phrenic arteriography mimicking a tumor staining of hepatocellular carcinoma

Purpose: To describe the findings of pleural and pulmonary staining of the inferior phrenic artery, which can be confused with tumor staining during transarterial chemoembolization (TACE) of hepatoma. Methods: Fifteen patients who showed pleural and pulmonary staining without relationship to hepatic masses at inferior phrenic arteriography were enrolled. The staining was noted at initial TACE (n = 8), at successive TACE (n = 5), and after hepatic surgery (n = 2). The angiographic pattern, the presence of pleural change on computed tomography (CT), and clinical history were evaluated. Results: Draining pulmonary veins were seen in all cases. The lower margin of the staining corresponded to the lower margin of the pleura in 10 patients. CT showed pleural and/or pulmonary abnormalities in all cases. After embolization of the inferior phrenic artery, the accumulation of iodized oil in the lung was noted. Conclusion: Understanding the CT and angiographic findings of pleural and pulmonary staining during TACE may help differentiate benign staining from tumor staining.     

Penetrating atherosclerotic ulcer of the descending thoracic aorta: Treatment by endovascular stent-Graft

Purpose: To present four cases of penetrating ulcer of the descending thoracic aorta treated by transfemoral insertion of an endoluminal stent-graft. Methods: Four patients with penetrating aortic ulcers were reviewed. Three cases were complicated by rupture, false aneurysm, or retrograde dissection. All patients were treated by endovascular stent-graft and were followed by helical computed tomography (CT). Results: Endovascular stent-graft deployment was successful in all patients. However, in one case we observed a perigraft leak that spontaneously disappeared within the first month, and two interventions were needed for another patient. Following treatment, one episode of transient spinal ischemia was observed. The 30-day survival rate was 100%, but one patient died from pneumonia with cardiac failure 34 days after the procedure. In one patient, helical CT performed at 3 months showed a false aneurysm independent of the first ulcer. This patient refused any further treatment and suddenly died at home (unknown cause) after a 6-month follow-up period. Conclusion: Transluminal placement of endovascular stent-grafts for treatment of penetrating ulcers of the descending thoracic aorta appears to be a possible alternative to classical surgery. After treatment, follow-up by CT is essential to detect possible complications of the disease.     

Thrombin Injection for Treatment of Brachial Artery Pseudoaneurysm at the Site of a Hemodialysis Fistula: Report of Two Patients

We report two patients with arteriovenous hemodialysis fistulas that were complicated by brachial artery pseudoaneurysms. Each pseudoanerysm was percutaneously thrombosed with an injection of thrombin, using techniques to prevent escape of thrombin into the native brachial artery. In one patient, an angioplasty balloon was inflated across the neck of the aneurysm during thrombin injection. In the second patient, thrombin was injected during ultrasound-guided compression of the neck of the pseudoaneurysm. Complete thrombosis of each pseudoaneurysm was achieved within 30 sec. No ischemic or embolic events occurred. This technique may be useful in treating pseudoaneurysms of smaller peripheral arteries.     

Diagnostic angioscintigraphic evaluation of malignant hepatic tumors before catheter embolization: Determination of shunt,flow distribution,and reflux

Purpose: The aim of this study was to evaluate quantitatively arteriovenous shunts in malignant liver tumors by injection of ^99mTc macroaggregates of albumin (MAA) into the tumor-feeding artery after selective catheterization. Methods: In 40 patients with malignant liver tumors (33 hepatocellular carcinomas and 7 metastases of colorectal cancer), a mean dose of 200 MBq ^99mTc MAA was injected arterially during angiography. The embolized area and the lungs were then visualized using a gamma camera. A dedicated computer program calculated pulmonary shunt rates. Results: The majority of patients (n= 30) with hepatocellular carcinoma showed small shunts varying from 0 to 15%; only 3 of these patients had shunts ranging from 18% to 37%. In patients with colorectal carcinoma metastases (n= 7) the shunt varied from 0 to 3% (2 ± 1%), probably due to a physiological shunt in normal liver tissue in the embolized area. Importantly, the degree of shunt found bore no correlation to the tumor volume or to the pattern of vascularity on angiography. Conclusion: Diagnostic angioscintigraphy is a useful tool for pretherapeutic evaluation of the capacity of an individual tumor to retain particles and to measure extratumoral shunting; these are essential for therapy planning, as they can help to increase the safety and effectiveness of embolization.     

Successful percutaneous embolization of an intraoperative swan ganz catheter-related pulmonary artery injury

Intraoperative pulmonary artery injury due to Swan Ganz catheterization is a rare but potentially life-threatening injury which demands rapid recognition and treatment. Subsequent pseudoaneurysm formation can occur if not immediately recognized, and percutaneous embolization is a viable option for treatment in most settings. We report a case of a 59-year-old female who underwent coronary artery bypass surgery and suffered an intraoperative Swan Ganz catheter-related injury which led to life threatening hemorrhage with subsequent pulmonary artery pseudoaneurysm formation that was successfully embolized. This case report is pathognomonic for this injury and discusses risk factors, presentation, and treatment options of this rare but serious injury.     

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.     

Spasms of the hepatic artery following percutaneous transluminal angioplasty and tolazoline administration in a liver transplant patient

Vascular complications after liver transplantation include occlusion or stenosis near the sites of anastomosis in the hepatic artery, portal vein, and vena cava. Balloon angioplasty of these stenoses carries little risk and is a useful procedure for the treatment of these problems. Here we describe the case of a liver transplant patient who underwent balloon angioplasty for stenosis of the hepatic artery and who developed spasms of the hepatic artery which were aggravated following intraarterial administration of Tolazoline. Received: 0/00/000 Accepted: 0/00/00     

Subintimal Recanalization of Long Superficial Femoral Artery Occlusions Through the Retrograde Popliteal Approach

Purpose: To investigate the value of the retrograde popliteal artery approach for the percutaneous intentional extraluminal recanalization (PIER) of long superficial femoral artery (SFA) occlusions. Methods: During a period of 17 months, PIER through ultrasound-guided retrograde popliteal artery puncture was performed for 39 long SFA occlusions in 37 patients. In six patients, six additional iliac artery stenoses were also treated via the popliteal approach. Results: The procedure was technically successful in 32 (82%) of 39 SFA occlusions; in 29, lesions were treated with balloon angioplasty alone, and in three, stents were also used. Cumulative patency rate was 66% at 6 months, 62% at 1 year, and 59% at 18 months. Additional iliac artery stenoses were successfully treated in the same session. Complications included two minor hematomas and two SFA ruptures, which required no treatment. Conclusion: PIER through retrograde popliteal puncture is a safe and effective method in the treatment of long femoropopliteal occlusions, with a high technical success, low complication rate and a reasonable short-term patency rate. The technique offers an alternative in cases where standard PIER is unsuccessful or contraindicated.     

Brachial Artery Access for Percutaneous Renal Artery Interventions

Purpose: To evaluate the suitability of transbrachial access for endovascular renal artery interventions. Methods: During 37 consecutive endovascular renal artery interventions, the transbrachial approach was used on nine patients (mean age 63 years; range 41–76 years) for 11 renal artery procedures on native kidneys and one percutaneous transluminal angioplasty (PTA) on a transplanted kidney. The reason for using transbrachial access was a steep aorta-renal angle in five, and severe aorta-iliac atherosclerosis in the remaining patients. In addition to the intervention catheter in the left brachial artery, an additional nonselective catheter for controlling the procedure was inserted transfemorally (six patients) or via the contralateral brachial artery. Results: Eleven interventions (six PTAs, five stents) were successfully completed. The one failure resulted from impenetrable subclavian artery stenosis. The only major complication was a brachial artery pseudoaneurysm requiring surgical treatment. Conclusion: Transbrachial access is an effective and relatively safe technique for renal artery interventions when transfemoral access is not possible. Received: 0/00/00/Accepted: 0/00/00     

False pulmonary artery aneurysm induced by Swan-Ganz catheter: diagnosis and embolotherapy

A false aneurysm that formed after injury by a Swan-Ganz catheter to the pulmonary artery in a patient on long-term anticoagulant therapy is reported. The lesion was demonstrated both by computed tomography and pulmonary angiography. The case is unique in that the patient was successfully treated with percutaneous transcatheter embolization.     

Percutaneous implantation of a catheter with subcutaneous reservoir for intraarterial regional chemotherapy: Technique and preliminary results

Purpose: We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic and extrahepatic tumors. Methods: Two hundred patients with primary or secondary hepatic neoplasms, pelvic, pancreatic, renal, lingual, and breast cancer underwent the procedure. The access was the left axillary artery (188 patients) and the femoral artery (12 patients). The catheter tip was placed in the hepatic (170 patients), hypogastric (18), splenic (4), internal thoracic (2), gastroduodenal (3), renal (2) or the external carotid artery (1). The catheter was connected to a subcutaneous reservoir and filled with heparin; chemotherapeutic infusion was subsequently started. Results: One hundred percent immediate technical success was obtained. Forty-three of 200 (21.5%) patients had a complication: 29 patients had a catheter dislodgment, nine had arterial thrombosis, three had a pseudoaneurysm of the left axillary artery and two had a port pocket hematoma. Most complications (37/43, 86%) were treated percutaneously without interruption of chemotherapy. In only six cases (3% of the total population) was chemotherapy discontinued due to the complication itself. The mean duration of catheter patency was 7.2 months. Conclusion: Percutaneous placement of an intraarterial catheter is feasible and causes less discomfort to the patient than the surgical approach. The technique has an acceptable complication rate (21.5%), similar to that for surgical implantation (17.8%), with the advantage that in most cases the complications can be resolved percutaneously. This technique represents an alternative to surgical implantation in the treatment of liver metastases from colorectal cancer and opens new therapeutic possibilities for the local prolonged treatment of other kinds of tumor, though its clinical efficacy must be assessed in selected trials.