Applications of the Amplatzer Vascular Plug to various vascular lesions

The Amplatzer^® Vascular Plug (AVP) can be used to embolize medium-to-large high-flow vessels in various locations. Between 2009 and 2012, 41 AVPs (device size, 6–22 mm in diameter) were used to achieve occlusion in 31 patients (24 males, seven females) aged 9–92 years (mean age, 54.5 years). The locations and indications for embolotherapy were as follows: internal iliac artery embolization before stent-graft repair for aorto-iliac (n=6) and common iliac artery (n=3) aneurysms, subclavian artery embolization before stent-graft repair for thoracic aorta (n=3) and arcus aorta (n=1) aneurysms, brachiocephalic trunk embolization before stent-graft repair for a thoracic aorta aneurysm (n=1), embolization of aneurysms and pseudoaneurysms (n=5), embolization for carotid blow-out syndrome (n=3), closure of arteriovenous fistula (n=8), and closure of a portosystemic fistula (n=1). Of the 41 AVPs, 30 were AVP 2 and 11 were AVP 4. The mean follow-up duration was 4.7 months (range, 1–24 months). During follow-up, there was one migration, one insufficient embolization, and one recanalization. The remaining vascular lesions were successfully excluded from the circulation. The AVP, which can be used in a wide spectrum of pathologies, is easy to use and causes few complications. This essay presents our experience with the AVP.The Amplatzer^® Vascular Plug (AVP, AGA Medical Corp., Golden Valley, Minnesota, USA) is a good alternative to other embolic materials (1). The AVP has many advantages over embolic materials such as coils or glue. It is retractable, and it can be repositioned. Use of the AVP has cost advantages over other embolic materials. It can be used safely in trauma patients or in patients before endovascular aortic repair (EVAR). It ensures permanent occlusion, and its migration risk is less than for coils. The results of embolization with the AVP have been excellent (2), and no contraindications for its use have been reported (3). All four types of AVP have two components: a vascular plug and a delivery wire. The plugs have radiopaque platinum marker bands at both ends (4). The AVP 2 contains a more densely woven nitinol mesh and minimizes migration and recanalization (5). The AVP 4 is used mostly in small, tortuous vessels (6). The AVP is made of self-expanding material, and it returns to its original shape after release from the catheter. It has a long delivery cable, is preloaded in a loader, and is delivered through guiding catheters ranging from 5 to 8 F in size. The AVP is released by rotating the delivery cable counterclockwise.Thirty-one patients (24 males, seven females) aged 9–92 years (mean age, 54.5 years), who underwent percutaneous occlusion with the AVP at our hospital between 2009 and 2012, were evaluated retrospectively. Patients with any pathology involving AVP use for embolization were included in this study. Patients in whom only other embolic materials were used were excluded. The study was approved by the Institutional Review Board and consent was obtained from the patients before the procedures. Most patients underwent general anesthesia. A transfemoral arterial or venous approach was used in most patients. In the patient with a portosystemic fistula, a transjugular approach was used. The procedures were performed under heparinization only in patients with a pulmonary arteriovenous fistula (AVF) or thoracic aorta aneurysm.In 24 of the 31 patients, we used only the AVP as the embolic material. In the remaining seven patients, we used the AVP with coils. In six of the 31 patients, more than one AVP was used. In total, 41 AVPs (30 AVP 2, 11 AVP 4), 6–22 mm in diameter, were used. The diameter of the AVP was selected to be 30%–50% larger than that of the targeted location in each patient. Computed tomography (CT) angiography was used most commonly for follow-up imaging (mean follow-up duration, 4.7 months; range, 1–24 months). This pictorial essay presents our experience using the AVP in various locations as material to embolize medium-to-large vessels with high flow.