Super-selective transcatheter arterial embolization of a traumatic splenic arteriovenous fistula

We report a 61-year-old woman with arteriovenous fistula (AVF) of a splenic artery caused by traumatic injury, which was successfully occluded by percutaneous transcatheter arterial embolization (TAE). We embolized the AVF with a coaxial system using six microcoils. This case suggests that super-selective TAE for traumatic AVF of a splenic artery is an effective and primary choice of first treatment. The use of a microcatheter and microcoils is an alternative to surgery.     

Acute Small Bowel Hemorrhage in Three Patients with End-Stage Renal Disease: Diagnosis and Management by Angiographic Intervention

Three patients who had undergone hemodialysis for end-stage renal disease, presented with acute small bowel hemorrhage, and were treated with superselective transcatheter arterial embolization via coaxial microcatheters. In all patients pre-procedure upper gastrointestinal (GI) endoscopy and colonoscopy had failed to demonstrate the source of the hemorrhage. Selective diagnostic angiography revealed frank extravasations of contrast from the small bowel arteries (one jejunal artery and two ileal arteries). After superselection of feeding arteries with a microcatheter, transcatheter embolization using Gelfoam and microcoils was performed in all three patients. Immediate hemostasis was achieved in all patients and the patients were discharged free from symptoms 3-5 days after embolization. No evidence of intestinal ischemia or infarction was noted, with the time from procedure to last follow-up ranging from 4 to 12 months. We conclude that superselective angiography is a valuable tool for diagnosing and treating acute small bowel hemorrhage in patients with end-stage renal disease when endoscopic evaluation has failed.     

Transcatheter arterial embolization for chest wall metastasis of hepatocellular carcinoma

Hemothorax due to rupture of metastatic hepatocellular carcinoma (HCC) is a very rare complication with high mortality because of uncontrollable hemorrhage. A 71-year-old man treated by transcatheter arterial embolization for HCC with massive bleeding from chest wall metastasis is reported. Enhanced computed tomography and selective intercostal angiogram showed a hypervascular mass in the right chest wall and extravasation of contrast agent. After successful transcatheter arterial embolization with gelatin sponge particles and metallic coils, the patient recovered from shock without major complication. To our knowledge, a successfully treated case of hemothorax due to rupture of metastatic HCC has not previously been described.     

Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience

Objective

This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally.

Methods

Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems.

Results

On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period.

Conclusion

Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.     

Pseudoaneurysm embolization and vasopressin infusion for lower gastrointestinal bleeding due to recurrence of urinary bladder carcinoma

We report a case that was successfully treated for massive lower gastrointestinal (LGI) bleeding due to a recurrent urinary bladder carcinoma. Treatment consisted of combination therapy including embolization of an inferior gluteal artery (IGA) pseudoaneurysm and low-dose arterial vasopressin infusion via a sigmoid artery (SA). A 57-year-old man presented with life-threatening sudden, massive LGI bleeding due to an obturator lymph node (LN) metastasis from a urinary bladder carcinoma. Computed tomography showed that the LN recurrence had invaded all the way to the sigmoid colon, and there was a pseudoaneurysm with extravasation inside the recurrence. An angiogram revealed a left IGA pseudoaneurysm. We therefore excluded the pseudoaneurysm by embolization with microcoils. Following this treatment the bleeding decreased, but intermittent LGI bleeding continued. Endoscopic examination showed the tumor with a huge ulcer inside the colonic lumen, and continuous oozing was confirmed. A second angiogram showed no recurrence of the IGA pseudoaneurysm and no apparent findings of bleeding. Then a 3F microcatheter was placed in the SA selectively using a coaxial catheter system, and vasopressin was infused at a rate 0.05 U/min for 12 h. Bleeding completely ceased 2 days later. There were no signs of ischemic gastrointestinal complications. Massive LGI bleeding has not recurred in 5 months.     

Morphologic and histopathologic changes in the bowel after super-selective transcatheter embolization for focal lower gastrointestinal hemorrhage

PURPOSE: To evaluate the safety of superselective arterial embolization therapy in the lower gastrointestinal tract. The sequelae on normal enteric tissue in lower gastrointestinal arterial embolization were retrospectively reviewed. MATERIAL AND METHODS: To control hemorrhage and tumor blood supply, 14 patients were treated by superselective transcatheter embolization at different levels of the colonic and small intestine vessels via the superior and inferior mesenteric arteries using microcoils and/or gelatin sponge. Normal enteric tissues in the embolized areas were analyzed for the occurrence of ischemic changes by clinical follow-up, colonoscopy, and surgery. RESULTS: Normal bowel function was preserved in 13 patients. In 1 patient treated with numerous gelatin sponge particles delivered from the proximal arcade of the superior mesenteric artery, significant muscular fibrosis occurred. CONCLUSION: Superselective arterial embolization for lower gastrointestinal hemorrhage can be safely performed by minimizing the amount of embolic materials and delivering them as distally as possible.     

Evaluation of transcatheter arterial embolization with coaxial microcatheter and micro-coil for vascular lesions]

Transcatheter arterial embolization using a coaxial microcatheter and micro-coil was performed in eight patients with vascular lesions; one each with aneurysm of the basilar artery, cerebellar artery, and pancreatic artery, pseudoaneurysm of the common hepatic artery, gastroduodenal artery, and gluteal artery, carotid-cavernous fistula, and thoracic paraspinal arteriovenous malformation. Complete occlusion was achieved in five patients with aneurysm and pseudoaneurysm by occluding the aneurysmal cavity and/or the orifice. A patient with recurrent carotid-cavernous fistula was also completely embolized. A case of basilar artery aneurysm resulted in partial occlusion because the posterior cerebral artery originated from the aneurysm. The unsatisfactory result in a case of paraspinal AVM was due to its wide extension with multiple feeding arteries. No apparent complication was seen. In conclusion, super-selective arterial embolization therapy with coaxial microcatheter and micro-coils was found to be a useful method for vascular lesions that would have been technically difficult to embolize with the standard catheter and coils.     

Preoperative transarterial embolization of spinal tumor: embolization techniques and results

BACKGROUND AND PURPOSE: The techniques of preoperative embolization of hypervascular spinal tumors, which has been known to be helpful for completing tumor resection, have not been described in detail. The purpose of this study was to analyze the technique and to evaluate the safety and value of preoperative transarterial embolization of hypervascular spinal tumors. METHODS: Eighteen patients with hypervascular spinal tumors underwent transarterial embolization before surgery. The lesions were located between the upper cervical and lower lumbar spine: C1-T1 (n = 6), T5-L3 (n = 11), and L5 (n = 1); they arose intradurally in six patients and extradurally in 12. Thirty-one arteries were embolized with polyvinyl alcohol (PVA) particles (150-500 microm), and, in 18 of these, pieces of gelatin sponge were added for proximal pedicular embolization. The criteria for judging the effectiveness of embolization were completeness of tumor removal and estimated blood loss during surgery. RESULTS: Tumor embolization was total in eight patients, nearly total in seven, subtotal in one, and partial in two. There were no symptomatic complications associated with embolization. Tumors were totally removed in 17 patients and nearly totally removed in one. The average estimated blood loss during surgery was 1100 mL (range, 200-6000 mL) for all 18 patients, and 1540 mL in patients with extradural tumors. CONCLUSION: Preoperative embolization of hypervascular spinal tumors is safe and effective. It can make complete resection of a tumor possible and can make an unresectable tumor resectable. Superselection or flow control is necessary to achieve effective devascularization and to avoid complications.     

介入栓塞治疗在骨与软组织肿瘤中的应用

目的 探讨介入在骨和软组织肿瘤临床治疗中的价值.方法 对28例经病理证实的骨与软组织肿瘤患者行选择性血管造影、动脉内灌注化疗和(或)栓塞治疗;观察治疗后临床、病理改变.结果 动脉灌注化疗和(或)栓塞治疗后23例疼痛缓解或消失;19例软组织消肿,肿瘤缩小;22例在介入治疗后1周内又接受手术治疗并经病理检查,显示瘤细胞不同程度变性、坏死、液化,以并用栓塞治疗者更为显著.肢体肿瘤患者66.4%(10/15)行保肢手术.结论 介入治疗是骨与软组织肿瘤的有效治疗方法,值得在临床上推广使用.     

Bone cement used as an embolic agent for active bleeding in vertebroplasty of metastatic lesions

We treated two cases of bleeding by injecting bone cement into tumor-feeding vessels of metastatic hypervascular tumors during a percutaneous vertebroplasty (PV) procedure. When the inner needle was pulled out after puncture of the metastatic vertebral tumor, active arterial bleeding from the outer needle cannula was noticed. Bleeding was not stopped by injection of Gelfoam particles through the cannula. Thus, bone cement was injected, which filled the tumor-feeding vessels, and bleeding stopped. Skin rash and high fever occurred 2-3 hours after the PV procedure, probably due to allergic reaction and massive tumor necrosis. To decrease the risk of active bleeding during PV for hypervascular bone metastases, arterial embolization of the feeding arteries should be performed 1 or 2 days prior to PV. If active bleeding occurs through the outer needle when performing PV, injection of bone cement after confirmation of bleeding from the tumor feeding vessels by vertebrography is effective.     

Transacatheter arterial embolization for malignant osseous and soft tissue sarcomas. II. Clinical results

Purpose: To evaluate the clinical effects of transcatheter arterial embolization (TAE) on malignant bone and soft tissue tumors. Methods: TAE was performed in 10 patients with primary bone and soft tissue sarcomas and in 31 patients with metastatic bone tumors. The embolized arteries were the internal iliac artery in 30 cases, the intercostal artery in six cases, the lumbar artery in five cases, the suprascapular artery in three cases, and the iliolumbar artery, the internal pudendal artery, and the lateral sacral artery in one case each. The embolized material was gelatin sponge particles. The chemotherapeutic drugs were usually 20–40 mg of doxorubicin for primary and metastatic tumors and 50–100 mg of cisplatin only for primary tumors. In addition, 50–60 Gy of 10-MV radiotherapy with or without radiofrequency (RF)-capacitive hyperthermia in four sessions was administered before TAE for primary tumors only. Results: Even though the pain score increased immediately after TAE, 30 of 38 (79%) patients with pain (8 of 9 with primary tumors, and 22 of 29 with metastases) achieved pain control after TAE. A necrotic low-density area shown by computed tomography (CT) after TAE was found in 31 of 41 (76%) tumors [8 of 10 (80%) with primary tumors, and 23 of 31 (74%) with metastatic tumors]. The tumor size decreased in 14 of 25 (56%) primary and metastatic tumors after 3 months. Osteosclerotic changes appeared in two cases of metastatic tumors after 6 months. In five tumors resected after TAE, large areas of necrosis within the tumor were confirmed histologically. Transient local pain and numbness appeared after TAE, but were relieved by drug treatment within 1 week. No severe complications except a case of gluteal muscle necrosis were encountered after TAE. The 1-year survival rate of the patients with primary tumors was 38.1%, and the median survival was 18 months. The longest survival was 84 months. The 1-year survival rate of the patients with metastatic bone tumors was 38.9%; the median survival was 12 months. The longest survival was 24 months. Conclusion: TAE could be an effective treatment for pain control and local control of malignant bone and soft-tissue tumors.     

微钢圈对急性出血性疾病的栓塞治疗作用

目的 评价微导管—微钢圈系统在治疗急性出血性疾病中的作用。方法 对12例患有急性出血性疾病的患者施行了急诊血管造影及栓塞治疗。患者包括十二指肠出血4例，空肠出血2例，肝脏出血2例，肾脏出血2例，膀胱出血1例，阴茎外伤性持续勃起1例。所有病例均使用微导管系统进行供血血管的超选择插管，并使用微钢圈进行栓塞治疗。6例患者在使用微钢圈之前首先用明胶海绵颗粒进行栓塞。使用微钢圈数1—5个(平均2．1个)。结果 所有患者均达到完全止血的目的。单纯明胶海绵颗粒栓塞往往难以达到完全止血的目的。其中1例小肠出血的年轻患者在栓塞止血后行手术治疗以彻底解除病因。其他患者在随访期间(1周至10个月，平均4个月)均无再出血。未见明显与栓塞治疗直接相关的合并症发生。结论 应用微导管／微钢圈系统对急性出血性疾病进行治疗，其栓塞效果好且副作用小，值得在临床上大力推广。     

Peripheral transcatheter embolization with platinum microcoils.

Embolotherapy with platinum microcoils delivered through the Tracker-18 microcatheter (Target Therapeutics, San Jose, Calif) was performed in 16 patients when peripheral superselective catheterization with standard angiographic catheters was not possible. The Tracker-18 catheter could be directed distally into small peripheral vessels for delivery of the microcoils. These microcoils, with attached fiber strands, resulted in vascular occlusion within a few minutes in all cases. Embolotherapy was technically successful in all patients. The procedures were clinically successful in 15 of 16 patients (94%), and no complications were encountered. Embolization with platinum microcoils through the Tracker-18 catheter is useful when standard methods of embolization are not possible.     

Transcatheter Arterial Embolization for Tumor Seeding in the Chest Wall After Radiofrequency Ablation for Hepatocellular Carcinoma

Tumor seeding in the chest wall was depicted at follow-up CT obtained 9 months after radiofrequency ablation for hepatocellular carcinoma. Transcatheter arterial embolization was successfully performed, injecting emulsion of 10 mg of epirubicin and 1 ml of iodized oil followed by gelatin sponge particles via the microcatheter placed in the right eleventh intercostal artery. The patient died of tumor growth in the liver one year after the embolization, but no progression of the tumor seeding was noted during the follow-up period. We conclude that transcatheter arterial embolization was effective for the control of tumor seeding after radiofrequency ablation for hepatocellular carcinoma.     

Percutaneous embolization of bony pelvic neoplasms with tissue adhesive

Eight patients with tumors of the bony pelvis underwent embolization with isobutyl-2-cyanoacrylate (IBCA). Five patients had primary bone tumors, of which 2 were malignant and 3 were benign; 3 patients had metastases to the bony pelvis from the thyroid gland, kidney, and femur, respectively. Embolization was performed to minimize blood loss during resection of a giant-cell tumor in one patient and insertion of a hip prosthesis in another who had metastatic renal carcinoma. It was also done prior to scheduled surgery in one of the patients with aneurysmal bone cyst, but healing was sufficient to cancel the operation; in the other patient, embolization was the only therapy. Palliative embolization was performed in 4 patients with malignant tumors after other means failed to control pain or slow progression. IBCA appears to be an efficient means of occluding the vessels feeding selected primary bone tumors and metastases.     

Internal mammary artery embolization for hemoptysis

PURPOSE: The purpose of this study was to determine the factors influencing development of blood supply from the internal mammary artery and to discuss the value of embolization of the abnormal branches from this vessel using small particles following occlusion of the normal distal branches using microcoils in treating hemoptysis. MATERIAL AND METHODS: Five patients with hemoptysis underwent internal mammary artery embolization with coaxial microcatheter systems. Bronchoscopy, chest radiographs, and CT were performed to determine the site and extent of the basic disease before embolotherapy in all patients. RESULTS: In all patients, pulmonary lesions had extended from the lung to the adjacent pleural surface at the anterior lung field. Four patients underwent embolization from the proximal portion of the internal mammary artery following distal coil embolization. One patient who underwent only proximal embolization had recurrent bleeding. CONCLUSION: The internal mammary artery contributes to the perfusion of lesions responsible for hemoptysis when the basic lesion involves the pulmonary parenchyma adjacent to the anterior pleural surface. Initial distal occlusion of the internal mammary artery may improve the efficacy of embolization of this artery for hemoptysis.     

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.     

Microcatheter with a ball tip for hepatic embolization and intra-arterial chemotherapy

A microcatheter used mainly for cranial arterial embolization and chemotherapy was employed for hepatic arterial embolization. The tip of the microcatheter is inflated like a small balloon which then acts as a calibrated-leak balloon. A coaxial system employing a conventional catheter for abdominal angiography combined with a propulsion chamber was used. Successful chemotherapy and embolization by Lipiodol and Spongel was carried out even in cases in whom it has been considered impossible to insert a catheter into the desired arteries.     

Intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma: treatment by hepatic artery embolization

Seventeen patients with intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma were treated by emergency transcatheter arterial embolization. Fine-needle aspiration cytology was used to establish the histologic diagnosis in 11 patients with no history of hepatic malignancy. The other six patients had a pathologic confirmation of hepatic malignancy by open biopsy before admission. Pretreatment angiography showed extravasation of contrast material from the hepatic tumor in four patients (24%). In the other 13 patients, only hypervascular tumors were seen. Successful hemostasis was achieved in all patients. Fourteen patients survived after the embolization; the other three died immediately after embolization. Of the 14 patients, 11 died later (survival time ranged from 16 to 386 days). The remaining three patients are still alive at 3, 7, and 15 months, respectively, after the procedure. No serious complications related to embolization were encountered. Most patients had pain and fever. We conclude that emergency arterial embolization is an effective alternative to surgery for hepatic hemostasis in patients with spontaneous rupture of hepatocellular carcinoma.     

Embolization of the right gastric artery before hepatic arterial infusion chemotherapy to prevent gastric mucosal lesions: approach through the hepatic artery versus the left gastric artery

OBJECTIVE: The purpose of our study was to evaluate whether the hepatic artery or the left gastric artery is the better route of approach for selective embolization of the right gastric artery before hepatic arterial infusion chemotherapy using a port-catheter system. SUBJECTS AND METHODS: Eighty-six patients (56 men, 30 women; mean age, 62.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In the 75 patients who had not undergone gastrectomy, right gastric artery embolization was performed before port-catheter system placement to prevent gastric mucosal lesions. In 43 patients, the approach for embolization was through a microcatheter inserted from the hepatic artery site, and in the remaining 32 patients, the approach was from the left gastric artery. The success rates of these two groups were compared. RESULTS: Embolization was successfully accomplished at the first attempt in 72.1% of the 43 patients in whom the microcatheter was inserted from the hepatic artery site. In contrast, in 93.8% of 32 patients, embolization was successfully performed through the left gastric artery. The success rate of embolization was significantly higher in the latter group (p = 0.0173, chi-square test). A second attempt in which the catheter was redirected to another approach, performed on the same day in a majority of patients, resulted in successful embolization in an additional eight patients, with a final success rate of 92.0%. CONCLUSION: Embolization of the right gastric artery using microcoils through a microcatheter advanced through the left gastric artery may be the preferred method for the preparation of repeated hepatic artery infusion.