Pulmonary arteriovenous malformations: effect of embolization on right-to-left shunt, hypoxemia, and exercise tolerance in 66 patients

OBJECTIVE

This study assessed the effect and safety of percutaneous transcatheter coil embolization of pulmonary arteriovenous malformations.

MATERIALS AND METHODS

In 58 (88%) of 66 patients, all malformations with feeding vessels greater than or equal to 3 mm in diameter were embolized with steel coils. Arterial oxygen saturation at rest and exercise, intrapulmonary right-to-left anatomic shunt fraction ((99m)Tc-macroaggregate injection), maximum exercise capacity (incremental work rate test), and pulmonary function were measured before and after embolization. Complications were analyzed.

RESULTS

Three categories of patients were identified. Patients in group 1 (27%) had complete occlusion of all angiographically visible pulmonary arteriovenous malformations; patients in group 2 (61%) had complete occlusion of all malformations with feeding vessels greater than or equal to 3 mm in diameter, but with smaller lesions persisting; and patients in group 3 (12%) had incomplete embolization, with feeding vessels greater than or equal to 3 mm in diameter remaining. The mean right-to-left shunt after embolization was least in group 1 (7%), intermediate in group 2 (10%), and greatest in group 3 (19%). Arterial oxygen saturation and right-to-left shunt fraction returned to normal levels (>96% and <3.5%, respectively) in 33% of patients. A significant improvement occurred after embolization in carbon monoxide diffusing capacity per unit of alveolar volume and in exercise capacity in 16 and 10 patients, respectively. In 93 procedures, 12 complications (13%) occurred.

CONCLUSION

Coil embolization of pulmonary arteriovenous malformations is effective in reducing right-to-left anatomic shunt fraction and in improving arterial oxygenation. Coil embolization of pulmonary arteriovenous malformations is well tolerated and has a low complication rate.

Successful transcatheter retrieval of an embolized stent from the left ventricle

Systemic embolization complicating intracoronary stenting before deployment is a rare complication; although it was not associated with any clinical sequelae, great care should be taken to prevent this possibility. We report a case of the successful retrieval of an embolized stent from the left ventricle during percutaneous transluminal coronary angioplasty of a left anterior descending coronary artery.

Choice of device size and results of transcatheter closure of atrial septal defect using the amplatzer septal occluder

The impact of device size choice on closure results was analyzed in 138 (101 females, 37 males; age 0.5-84.0 years) consecutive patients who underwent transcatheter closure of the secundum atrial septal defect (ASD) using the Amplatzer septal occluder (ASO). The balloon stretched diameter (SD) of ASD was 19.5 +/- 7.2 mm in 123 patients with single defects, and 20.4 +/- 6.6 mm for the largest defects in 15 patients with multiple ASDs. The difference (delta) between ASO size chosen for closure and the stretched diameter of the defect was calculated and divided into groups: A (delta < -2 mm); B (delta -2.0 to -0.1 mm); C (delta = 0); D (delta 0.1-2.0 mm) and E (delta > 2 mm). The results demonstrated that immediate and 24-hour complete closure rates were significantly higher in patients in groups C and D (P < 0.001). However, at 6-month follow-up, the complete closure rates were similar in patients of groups A-D, while patients of group E had a lower closure rate of 75%. The complication rates were similar in all groups. In conclusion, a choice of a device size identical to or within 2 mm larger than the SD of the defect should be used to maximize the closure rates of ASD using the ASO.

Direct-puncture embolization of intraosseous arteriovenous malformation of jaws

PURPOSE

Our goal was to report our experience with direct-puncture embolization of intraosseous arteriovenous malformations (AVMs).

PATIENTS AND METHODS

Three cases of AVM in the mandible and 2 cases of AVM in the maxilla comprised this study group. The patients were embolized with fiber coils through direct puncture, and the coils were placed directly into the center of the intraosseous lesion, in some cases in conjunction with polyvinyl alcohol foam and N-butyl-2-cyanoacrylate through vascular access.

RESULTS

The acute arterial bleeding was controllable in 3 patients. The other 2 patients had pericoronal oozing bleeding and a warm soft pulsative mass on the left face, respectively; their symptoms and signs improved greatly. The pericoronal oozing of blood in all patients disappeared during a 3- to 13-month follow-up, and new bone formation was found on the follow-up radiography.

CONCLUSIONS

The embolization of the AVM of jaws by direct percutaneous puncture in conjunction with endovascular therapy is effective and safe, but longer follow-up is required to determine the true efficacy of this method of treatment.

Transcatheter occlusion of the patent ductus arteriosus: a comparison of two devices

BACKGROUND

Transcatheter occlusion of the arterial duct is a safe and effective alternative to surgical closure. The Rashkind umbrella occluder and the Cook coil are two established devices, although the former is no longer manufactured.

AIMS

To assess any difference in outcomes between the use of the Cook detachable coil and the Rashkind double umbrella in patent ductus arteriosus (PDA) occlusion.

METHODS

A retrospective study of 77 patients in whom PDA occlusion was attempted using the Cook detachable PDA coil from March 1996 to March 2000. A comparison was carried out with patients in whom occlusion was attempted using the Rashkind double umbrella between 1989 and 1996.

RESULTS

The rate of immediate complete occlusion was 24% compared with 29.9% for the Rashkind device. The figure for complete occlusion after 24 hours with the PDA coil was 63% compared with 61.5% in the Rashkind group (p > 0.1). The overall closure rate in the coil group was 72% versus 74.6% for umbrellas.

CONCLUSION

The outcome in terms of complete duct closure using the Cook coil is comparable with figures obtained using the Rashkind umbrella. Both devices have a good safety profile in the short and medium-terms.

Prospective comparison of costs and short term health outcomes of surgical versus device closure of atrial septal defect in children

OBJECTIVE

To compare surgical and device closure of isolated secundum atrial septal defect (ASD) in terms of hospital costs, clinical outcome, and impact on the patient and family.

DESIGN

Prospective, observational study.

SETTING

Paediatric tertiary referral centre.

PATIENTS

Consecutive local children with a secundum ASD, admitted between 1 May 1999 and 1 May 2001.

METHODS

Parents completed a standardised questionnaire at recruitment (on admission), at discharge, and one month after the procedure. Clinical and hospital generated cost data were collated at discharge.

RESULTS

62 children were included in the analysis: 19 who underwent surgical repair and 43 who underwent device closure with the Amplatzer septal occluder. Median procedure times and hospital stay were significantly longer for surgical patients (170 (147 to 180) v 92 (70 to 115) minutes and 88 (78 to 112) v 29 (28 to 30) hours, respectively; p < 0.01). There was no difference in the complication rate. No device patients required intensive care or blood products. The median values for postoperative pain score, analgesia use, and convalescence time were greater for surgical patients. The median cost of each procedure was similar, but higher nursing and laboratory costs contributed to a slightly greater total cost for surgical repair (Aus$12 969 ($11 569 to $14 215) v Aus$11 845 ($10 669 to $12 555), p = 0.03).

CONCLUSIONS

Device closure of ASD involves a shorter hospital stay, causes less discomfort and familial disturbance, and carries less cost than surgical closure. However, there should be guarded acceptance of this technique until long term data are available.

Experience with use of multiplane transesophageal echocardiography to guide closure of atrial septal defects using the amplatzer device

By providing unlimited imaging planes, multiplane transesophageal echocardiography (MTEE) should improve real-time guidance of interventional procedures. The potential advantages of MTEE in this scenario have not been systematically evaluated. We retrospectively reviewed our experience with MTEE-guided Amplatzer device closure of atrial septal defects (ASDs) MTEE angles used to obtain images for guiding all measurements and maneuvers were recorded. These angles were compared to the range of MTEE angles that are postulated to be available from biplane TEE. Images obtained using MTEE angles from 21 degrees to 70 degrees and from 111 degrees to l59 degrees were defined as only obtainable by MTEE. The MTEE probe was successfully introduced in all (89) patients. Thirteen patients (15%) had multiple defects. Ninety-five devices (5-32 mm in diameter) were deployed. In 66% of patients, balloon sizing and device deployment necessitated imaging planes that are only obtainable by MTEE. All devices were well positioned, with no impingement on inflows or outflows. At follow-up, 79 of 89 (88.7%) patients had no residual ASDs. Each of the remaining 10 patients (11.3%) had a small (<3 mm) residual defect. MTEE played an important role in guiding device closure of ASD, particularly during the phases of balloon sizing and device deployment.

[Embolization of cerebrovascular aneurysms with controlled microspirals (complications and technical problems)]

The paper summarizes five-year experience with mechanically detachable microspirals for embolization of 62 arterial aneurysms in 59 patients. The complications and technical problems associated with both the specific features of this technology and anatomic types of the structure of vessels and aneurysms are described. Methods for the prevention and treatment of these complications are proposed.

Staged endovascular occlusion of giant idiopathic renal arteriovenous fistula with platinum microcoils and silk suture threads

Large symptomatic aneurysmal renal arteriovenous (AV) fistulas usually present with a flank bruit, uncontrolled hypertension, and high-output cardiac failure. Traditionally, these have been treated surgically because of the risk of inadvertent pulmonary embolism with use of embolization techniques. The authors report a case of a giant renal AV fistula successfully treated with staged embolization with use of metallic coils and silk suture. This resulted in a graded reduction in the extreme flow through the fistula, followed by delayed thrombosis and cure of the patient's symptoms.

Endovascularly treated cerebral aneurysm using Guglielmi detachable coils acting as a nidus for brain abscess formation secondary to Salmonella bacteremia: case report

OBJECTIVE AND IMPORTANCE

Intracranial infections related to the various foreign materials used to secure intracranial aneurysms are extremely rare. The lack of neoendothelium formation across the necks of aneurysms, which is particularly prone to occur when the sac is incompletely packed by Guglielmi detachable coils (GDC), results in the absence of isolation of the coils from the circulation. Colonization of GDCs, which act as a foreign-body nidus after hematogenous spread from infections with bacteremia, may result in localized intracranial infection.

CLINICAL PRESENTATION

A 55-year-old woman developed meningitis and a brain abscess surrounding a giant aneurysm that was treated endovascularly with GDC 3 1/2 years earlier. Four weeks before she sought care, she experienced an infective illness with proven Salmonella bacteremia. Salmonella group D was isolated from cerebrospinal fluid.

INTERVENTION

The patient was treated successfully with long-term cephalosporin therapy. Follow-up imaging studies revealed regression of the abscess.

CONCLUSION

This case suggests that the GDC acted as a colonized foreign body, resulting in the surrounding abscess formation after infection with Salmonella bacteremia. Alternatively, the reaction of the surrounding tissue to the GDC was the predisposing factor and acted as the nidus for the abscess formation.

Endovascular coil embolization of cerebral aneurysm remnants after incomplete surgical obliteration

INTRODUCTION

The presence of an aneurysm remnant after incomplete or unsuccessful surgical clipping is associated with persistent risk of regrowth and rupture, and additional treatment is generally recommended. Attempts at surgical re-exploration are technically difficult and carry significant risk. Endovascular therapy can represent a valuable therapeutic alterative in these cases.

METHODS

We reviewed the information on 21 patients with postsurgical aneurysm remnants treated at our institution with endovascular coil occlusion between 1991 and 2000. Clinical outcome was measured using the modified Rankin scale. Statistical analysis of outcome predictors was performed using the two-tailed Fisher exact test.

RESULTS

Sixty-seven percent of the aneurysms were located in the anterior circulation. The median aneurysm size at the time of surgery was 9.9 mm (range 3 to 35 mm). The mean size of the aneurysm remnants before coiling was 6.4 mm (range 3 to 14 mm). Endovascular coiling resulted in total occlusion of the remnants in 81% of the cases. No major complications were associated with the endovascular treatment. Seventy-two percent of patients left the hospital without any functional impairment (modified Rankin scale 0 to 1). No cases of subarachnoid hemorrhage or symptomatic aneurysmal regrowth were noted after endovascular treatment over a mean follow-up of 22 months. Presence of disability or death was associated with an initial (presurgical) presentation with subarachnoid hemorrhage (P=0.04) and an interval between incomplete clipping and endovascular coil embolization </=1 month (P= 0.0005).

CONCLUSION

Endovascular coil occlusion of postsurgical aneurysm remnants is a safe and efficacious therapeutic alternative in selected cases. Postoperative angiography to identify aneurysm remnants that may be amenable to endovascular treatment should be considered in all patients.

Histopathologic findings in human cerebral aneurysms embolized with platinum coils: report of two cases and review of the literature

This report describes 2-week and 20-month histopathologic findings in small aneurysms embolized with platinum coils. Electron microscopy showed the presence of endothelial cells encroaching on the platinum coils at the orifice of the aneurysm in both cases. We confirm that endothelial growth can be induced as early as 2 weeks after embolization of small human aneurysms with platinum coils, similar to previous observations in animal models and human cases.

Arterial duct closure with detachable coils: application in the small child

Transcatheter closure of patent ductus arteriosus using controlled-release coils was performed in 16 patients weighing < 10 kg. No embolization occurred. Procedure-related complications occurred in 3 patients (18.8%): massive femoral hemorrhage in 1 and femoral artery thrombosis in 2. The ductus recanalized in 1 of them because of mechanical hemolysis caused by streptokinase treatment. This was the only patient who underwent another occlusion procedure. Complete occlusion was achieved in 7 patients (43.8%) immediately, in 13 (81.2%) the following day, and in all 15 patients who had completed the 6-month follow-up. During follow-up, flow velocities between the left and the main pulmonary arteries and between the descending and the ascending aortae did not differ significantly. Flow velocity was > 2 m x sec(-1) in 3 patients in the left pulmonary artery and in 1 in the descending aorta. Protrusion of the coil was seen in 3 of these patients. Flow velocity was also high in the main pulmonary artery in the 4th patient. In conclusion, coil occlusion of ductus arteriosus is feasible in the small child, but no more than half a loop of the coil should be left at the pulmonary site. High flow velocity does not always mean obstruction.

Delayed thromboembolic events 9 weeks after endovascular treatment of an anterior communicating artery aneurysm: case report

We present a case of delayed thromboembolic events that occurred 9 weeks after endovascular treatment of an anterior communicating artery aneurysm with GDC.

Endovascular management of basilar artery aneurysms associated with fenestrations

BACKGROUND AND PURPOSE

Arterial fenestrations are associated with saccular aneurysms that are often difficult to treat with open surgical techniques. We evaluated our experience with endovascular treatment of such aneurysms.

METHODS

Ten consecutive patients with 11 basilar artery aneurysms associated with fenestrations were treated with coils by means of the endovascular route between November 1994 and February 2000. All patients underwent endovascular embolization by the femoral approach, under general anesthesia. Twelve embolization procedures were perfomed in the 10 patients.

RESULTS

Nine proximal and two distal basilar artery fenestration aneurysms were treated successfully. The embolization was complete in 10 of the 11 aneurysms. It was incomplete in one case, and complete occlusion could not be achieved at the second attempt. There was one regrowth at 1-year follow-up, which was successfully treated again. Four of the aneurysms were treated initially with balloon remodeling, whereas one aneurysm with regrowth and one with incomplete occlusion were treated with balloon remodeling at the second embolization procedure. In one case, one limb of the fenestration was sacrificed.

CONCLUSION

Endovascular treatment of basilar artery aneurysms associated with fenestrations appears to offer advantages over traditional open surgical techniques.

Endovascular treatment of Hunt and Hess grade IV and V aneuryms

BACKGROUND AND PURPOSE

Controversy still surrounds the question of when and how to manage cases of subarachnoid hemorrhage of Hunt and Hess grade IV and V aneurysms. Several authors are in favor of surgical treatment, reporting improved clinical outcomes and lower mortality rates. Considering that endovascular procedures are currently being increasingly used to treat aneurysms, we investigated their use in the management of subarachnoid bleeding in a retrospective review of 80 patients.

METHODS

Eighty patients were admitted to our hospital between October 1992 and October 1998 with subarachnoid hemorrhage of Hunt and Hess grade IV and V aneurysms. Patients received standard resuscitation treatment, nimodipine to prevent vasospasm, CSF shunt when necessary, and selective occlusion with Guglielmi detachable coil. They were subsequently followed up for at least 1 year. Aneurysm occlusion was monitored with MR angiography and/or angiography at 6 months and at 1 year.

RESULTS

Of the 80 patients, 42 (52.5%) did well (Glasgow Outcome Scale score of 1 or 2) (62% of the 56 patients with grade IV and 25% of the 24 patients with grade V aneurysms), seven (8.75%) presented with poor neurologic status (Glasgow Outcome Scale score of 3), and 30 (37.5%) died during the first 6 months (26.7% of the patients with grade IV and 62% of the patients with grade V aneurysms). One patient was lost to follow-up. The main causes of death were consequences of initial bleeding in the patients with grade V aneurysms and vasospasm in the patients with grade IV aneurysms.

CONCLUSION

The results are at least as encouraging as the outcomes reported for the surgical series and suggest that early endovascular treatment of high grade hemorrhage is a feasible option, especially because endovascular maneuvers can be performed at any time, even during vasospasm.

Selective neck occlusion of a large complex aneurysm of the middle cerebral artery trifurcation with the UltraSoft coil

We present a case of an unruptured, large, complex, middle cerebral artery trifurcation aneurysm that was successfully treated by selective occlusion of the neck with a single, newly available UltraSoft coil. The satisfactory initial anatomic result was stable, as demonstrated on a 3-month follow-up arteriogram that indicated complete anatomic cure. The novel UltraSoft coil offers additional possibilities in the endovascular management of difficult-to-treat vascular lesions.

Blunt renal trauma: minimally invasive management with microcatheter embolization experience in nine patients

PURPOSE

To evaluate superselective embolization therapy for the management of arterial damage in patients with severe renal trauma.

MATERIALS AND METHODS

Nine consecutive patients with renovascular injuries after blunt trauma underwent superselective embolization. Six patients had pseudoaneurysms or traumatic arteriovenous fistulas. Three patients had frank, uncontained extravasation (two shattered kidneys, one complete pedicle avulsion) and were treated immediately after admission. Two patients were hemodynamically unstable. All patients underwent embolization with 3-F coaxial microcatheters and polyvinyl alcohol particles (n = 2) or 0.018-inch platinum microcoils (n = 7). Procedural and medical success and complications (eg, postembolization syndrome, abscess, permanent serum creatinine elevation, hypertension) were retrospectively assessed from the patients' records. Mean clinical follow-up was 11.9 months (range, 1-50 months).

RESULTS

In all cases bleeding was effectively controlled with superselective embolization in a single session. There was no procedure-related loss of renal tissue in eight cases; in one patient, a lower pole remnant of 20% of viable ipsilateral parenchyma was lost due to the procedure. In one patient, a coil migrated into a lumbar artery without causing clinical consequences. None of the patients developed abscess, hypertension, or procedure-related impairment of renal function.

CONCLUSION

Superselective embolization may be used for effective, minimally invasive control of active renovascular bleeding.

Pulmonary arteriovenous malformations: embolotherapy with superselective coaxial catheter placement and filling of venous sac with Guglielmi detachable coils

PURPOSE

To assess the value of superselective embolotherapy of pulmonary arteriovenous malformations (PAVMs) with coaxial microcatheters and 0.018-inch microcoils and to evaluate the technique of filling the venous sac with Guglielmi detachable coils (GDCs).

MATERIALS AND METHODS

Six consecutive patients (three men, three women; mean age, 46 years, age range, 18-74 years) underwent arterial embolization of nine PAVMs with superselective catheterization with a 3-F coaxial catheter system and embolization with 0.018-inch microcoils. The PAVMs varied in size from 1 to 6 cm (mean, 2.5 cm). Five of the lesions were also treated by filling the venous sac with GDCs. Success and outcome were evaluated by means of a review of patient records, angiographic findings, and telephone interview results.

RESULTS

Complete primary occlusion was achieved in eight of nine lesions; repeat embolization resulted in successful occlusion of one lesion. The superselective technique enabled successful embolization in one patient after a previous procedure performed with a 0.035-inch (Gianturco) coil had failed. Filling of the venous sac was performed in the presence of dilated draining veins and enabled successful occlusion of the feeding artery with microcoils in all cases. There were no complications.

CONCLUSION

Superselective embolization with microcatheters allowed easy catheterization and safe coil deployment. Filling of the venous sac reliably prevented systemic migration of GDCs in PAVMs with a large venous component.

Transcatheter occlusion of a large aortoazygos fistula using the Amplatzer device

This report describes the percutaneous embolization of an unusual aortoazygos arteriovenous fistula in a 22-month-old child. The large fistula (8 mm) was successfully occluded using a 12- to 10-mm Amplatzer Duct Occluder device using the arterial approach. The device was incompletely deployed into the abnormal vessel to avoid tearing of the intima by the sharp distal disk.

Hemostatic closure device after carotid puncture for stent and coil placement in an intracranial aneurysm: technical note

A 71-year-old female patient presented with a wide-necked carotid cavernous aneurysm for which stent and coil placement was planned. Arterial tortuosity required direct puncture of the common carotid artery for access. The procedure was performed while the patient was receiving antiplatelet and anticoagulative therapy. To avoid potentially hazardous and prolonged carotid compression, a closure device (Angio-Seal) was used at the end of the procedure. The postoperative period was clinically uneventful. Sonographic and angiographic follow-up of the carotid artery were performed.

[Aneurysms causing symptoms of brain tumors treated with endovascular method in MDS system]

Basing on own material 25 patients with symptoms of intracranial structures pressed by aneurysm sack have been presented. The patients were treated with endovascular method in MDS system at the Department of Neurosurgery, Copernicus Hospital in Łódź. The aneurysms were diagnosed basing on neurological symptoms--cranial nerves damage, focal brain lesion and headaches. The aneurysms surgically difficult and were qualified for endovascular treatment. Ninety two per cent of aneurysms were big or giant; 92% with a wide neck. Total or almost total aneurysm closure was obtained in 59% of cases. The patients were observed 6 to 71 months. Follow up of 11 patients (50% observed group) revealed complete recovery in 8, neurological improvement in 3 cases.