Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

A bulbar artery pseudoaneurysm following traumatic urethral catheterization

Traumatic urethral catheterization may result in a number of serious complications. A rare occurrence is the development of a urethral pseudoaneurysm. We report the case of a 13-year-old male who required placement of a Foley catheter for an orthopedic surgical procedure. The Foley was misplaced in the bulbourethra, resulting in the development of a bulbar artery pseudoaneurysm. Profuse bleeding via the urethra was noted after removal of the catheter, and the patient experienced severe intermittent hematuria during the postoperative period. Cystoscopy revealed a pulsatile mass within the bulbourethra. Angiography confirmed a bulbar artery pseudoaneurysm, which was successfully embolized with resolution of bleeding.

Ischemic Gastric Conditioning by Preoperative Arterial Embolization Before Oncologic Esophagectomy: A Single-Center Experience

PURPOSE

Surgical esophagectomy is the gold standard treatment of early-stage esophageal cancer. The procedure is complicated with significant morbidity; the most severe complication being the anastomotic leakage. Anastomotic fistulas are reported in 5-25% of cases and are mainly due to gastric transplant ischemia. Here, we report our experience of ischemic pre-conditioning using preoperative arterial embolization (PreopAE) before esophagectomy.

MATERIALS AND METHODS

The medical records of all patients who underwent oncologic esophagectomy from 2008 to 2015 were retrospectively reviewed. Patients were divided into two groups: patients who received PreopAE, and a control group of patients who did not benefit from ischemic pre-conditioning. The target arteries selected for PreopAE were the splenic artery, left gastric artery, and right gastric artery. Evaluation of the results was based on anastomotic leakage, postoperative mortality, technical success of PreopAE, and complications related to the embolization procedure.

RESULTS

Forty-six patients underwent oncologic esophagectomy with PreopAE and 13 patients did not receive ischemic conditioning before surgery. Thirty-eight PreopAE were successfully performed (83%), but right gastric artery embolization failed for 8 patients. Anastomotic leakage occurred in 6 PreopAE patients (13%) and in 6 patients (46%) in the control group (p = 0.02). The mortality rate was 2% in the PreopAE group and 23% in the control group (p = 0.03). Eighteen patients suffered from partial splenic infarction after PreopAE, all treated conservatively.

CONCLUSION

Preoperative ischemic conditioning by arterial embolization before oncologic esophagectomy seems to be effective in preventing anastomotic leakage.

Outcomes of Esophageal Arterial Embolization for Treatment of Hemoptysis

PURPOSE

To investigate safety and efficacy of esophageal arterial embolization (EAE) in addition to bronchial arterial embolization (BAE) for treatment of hemoptysis as well as the importance and characteristics of esophageal arteries in patients with hemoptysis.

MATERIALS AND METHODS

Between January 2013 and December 2014, 20 patients (13 men and 7 women, mean age 58.4 y) underwent EAE in addition to BAE for hemoptysis. Retrospective review of patient records was performed to evaluate major causes of hemoptysis, treatment indications based on CT findings, esophageal angiography findings, and outcomes after embolization including clinical success rate and complications.

RESULTS

Hemoptysis was caused by bronchiectasis (12 patients), tuberculosis (7 patients), and lobectomy (1 patient). CT showed lower lobe lung lesions in all (100%) patients. The esophageal arteries originated from the aorta between the carina and diaphragm (18 patients) or from the inferior phrenic arteries (2 patients) and were tortuous with longitudinal off-midline courses. Communications between the esophageal and the bronchial or inferior phrenic arteries were present in 12 patients. One patient who was treated using N-butyl cyanoacrylate developed dysphagia that resolved with medical treatment. Repeat BAE was performed in 2 patients 5 days and 20 days later, and the clinical success rate was 90% (18/20).

CONCLUSIONS

EAE in addition to BAE is safe in the treatment of hemoptysis and should be considered for lower lobe lesions.

Ultrasound-guided thrombin injection for treatment of superficial traumatic pseudoaneurysms and associated expanding hematomas: experience in five patients

Background

Angiography allows for excellent characterization and treatment of traumatic pseudoaneurysms. However, ultrasound-guided thrombin injection for pseudoaneurysm thrombosis allows for radiation-free treatment of superficial pseudoaneurysms and superficial expanding hematomas.

Methods

A retrospective review of 5 patient cases treated under this paradigm was performed following institutional review board approval. Outcomes following intervention were recorded and compared amongst the patient cohort.

Results

Ultrasound-guided closure of traumatic pseudoaneurysms allowed for reduced procedural times and procedural invasiveness.

Conclusions

As demonstrated by the following cases, ultrasound guided thrombin injection is a good method of primary treatment for superficial pseudoaneurysms, or as an alternative treatment in cases where transcatheter embolization fails.

Splenic artery embolisation in the non-operative management of blunt splenic trauma in adults

Background: The purpose of this study was to evaluate the splenic salvage rate with angioembolisation in the non-operative management (NOM) of blunt splenic injury.Methods: We conducted a retrospective analysis of patients presenting to our Level I trauma centre with computed tomography (CT)-confirmed splenic injury following blunt trauma and in whom angioembolisation was utilised in the algorithm of NOM. Data review included CT and angiography findings, embolisation technique and patient outcomes.Results: Between January 2005 and April 2010, 60 patients with splenic injury following blunt trauma underwent NOM, which included splenic artery embolisation (SAE). All patients included in the study required a preadmission. CT scan was used to document the American Association for the Surgery of Trauma (AAST) grade of splenic injury. The average injury grade was 3.0. The non-operative splenic salvage rate following SAE was 96.7% with statistically similar salvage rates achieved for grades II to IV injuries. The quantity of haemoperitoneum and the presence of a splenic vascular injury did not significantly affect the splenic salvage rate. The overall complication rate was 27%, of which 15% were minor and 13% were major.Conclusion: SAE is a safe and effective treatment strategy in the NOM of blunt splenic injury. The quantity of haemoperitoneum, the presence of vascular injury and embolisation technique did not significantly affect the splenic salvage rate.

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

PURPOSE

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications.

METHODS

During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications.

RESULTS

Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient.

CONCLUSIONS

Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

Intraprocedural Safety and Technical Success of the MVP Micro Vascular Plug for Embolization of Pulmonary Arteriovenous Malformations

This case series describes early experience, intraprocedural safety, and technical success of the MVP Micro Vascular Plug (MVP; Covidien, Irvine, California) for embolization of 20 pulmonary arteriovenous malformations (PAVMs) using 23 plugs in seven patients with hereditary hemorrhagic telangiectasia. There was no device migration, and all devices were successfully detached electrolytically. Immediate cessation of flow through the feeding artery was achieved in 21 of 23 (91%) deployments. There was one minor complication. This series demonstrates the MVP to be safe and technically successful in the treatment of PAVMs.

Transcatheter Arterial Embolization of Angiographically Visible and Occult Renal Capsular Artery Hemorrhage in 28 Patients

PURPOSE

To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA).

MATERIALS AND METHODS

Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively.

RESULTS

Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P < .05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%).

CONCLUSIONS

Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source.

Predictors of Clinical Outcome after Prostate Artery Embolization with Spherical and Nonspherical Polyvinyl Alcohol Particles in Patients with Benign Prostatic Hyperplasia

Purpose To assess predictors of outcome after prostate artery embolization (PAE) for benign prostatic hyperplasia with spherical particle polyvinyl alcohol (sPVA) and compare outcomes with the use of nonspherical particle polyvinyl alcohol (nsPVA). Materials and Methods This was a single-center retrospective institutional review board-approved study conducted from 2009 to 2015 in patients undergoing PAE with sPVA (n = 186; mean age ± standard deviation, 65.5 years ± 7.7) and nsPVA (n = 300; mean age, 65.3 years ± 7.6). The two cohorts were compared and analyzed for predictors of outcome with a Cox proportional hazards model and linear regression. Post-PAE prostate ischemia was measured with contrast material-enhanced magnetic resonance (MR) imaging in 23 patients with nsPVA and 25 patients with sPVA. The 24-hour post-PAE prostate-specific antigen (PSA) level was registered in 133 patients with sPVA. Prognostic values of MR imaging and PSA levels 24 hours after PAE were assessed with Cox and random-effects regressions. Results Predictors of clinical failure were older age (age over 65 years, P = .002), unilateral procedure (P = .002), and higher baseline International Prostate Symptom Score (IPSS, P = .033). Adjusted hazard ratio for clinical failure of sPVA was 1.273 (P = .16). Acute urinary retention was a predictor of lower IPSS after PAE (P = .002). The mean proportion of prostate ischemia was 11% with sPVA and 10% with nsPVA (P = .65). Lower IPSS after PAE was associated with a higher proportion of prostate ischemia (P = .009). Patients with a PSA level of at least 75 ng/mL (75 μg/L) 24 hours after PAE had a greater decrease in IPSS (P = .01). Prostate ischemic volume and PSA level 24 hours after PAE were correlated (Pearson r = 0.64, P = .014). Conclusion Clinical outcome was similar after PAE with sPVA and nsPVA. Younger age (up to 65 years), bilateral PAE, lower baseline IPSS, and acute urinary retention were predictors of better clinical outcome. The PSA level 24 hours after PAE correlated with prostate ischemia, and both correlated with clinical outcome. (©) RSNA, 2016.

Prostatic Arterial Embolization with Small Sized Particles for the Treatment of Lower Urinary Tract Symptoms Due to Large Benign Prostatic Hyperplasia: Preliminary Results

Background:

The clinical failure after prostatic artery embolization (PAE) with conventional particles was relatively high, in treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). We reported the results of PAE with combined polyvinyl alcohol particles 50 μm and 100 μm in size as a primary treatment in 24 patients with severe LUTS secondary to large BPH.

Methods:

From July 2012 to June 2014, we performed PAE in 24 patients (65–85 years, mean 74.5 years) with severe LUTS due to large BPH (≥80 cm³) and refractory to medical therapy. Embolization was performed using combination of 50 μm and 100 μm in particles size. Clinical follow-up was performed using the International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow (Q_max), postvoid residual (PVR) volume, the International Index of Erectile Function (IIEF), prostatic specific antigen (PSA), and prostatic volume measured by magnetic resonance imaging at 1, 3, 6, and every 6-month thereafter. Technical success was defined when PAE was completed in at least one pelvic side. Clinical success was defined as the improvement of both symptoms and QoL. A Student's t-test for paired samples was used.

Results:

PAE was technically successful in 22 patients (92%). Bilateral PAE was performed in 19 (86%) patients and unilateral in 3 (14%) patients. Follow-up data were available for 22 patients observed for mean of 14 months. The clinical improvement at 1, 3, 6, and 12-month was 91%, 91%, 88%, and 83%, respectively. At 6-month follow-up, the mean IPSS, QoL, PVR, and Q_max were from 27 to 8 (P = 0.001), from 4.5 to 2.0 (P = 0.002), from 140.0 ml to 55.0 ml (P = 0.002), and from 6.0 ml/s to 13.0 ml/s (P = 0.001), respectively. The mean prostate volume decreased from 110 cm³ to 67.0 cm³ (mean reduction of 39.1%; P = 0.001). The PSA and IIEF improvements after PAE did not differ from pre-PAE significantly. No major adverse events were noted.

Conclusions:

The combination of 50 μm and 100 μm particles for PAE is a safe and effective treatment method for patients with severe LUTS due to large BPH, which further improves the clinical results of PAE.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale, techniques, outcomes and future directions

The ability to modulate the future liver remnant (FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization (PVE), associating liver partition and portal vein ligation (ALPPS), and the recently reported transhepatic liver venous deprivation (LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Percutaneous transhepatic portal embolization using foam ethanolamine oleate and carbon dioxide (CO₂): a pilot study

BACKGROUND

Percutaneous transhepatic portal embolization (PTPE) can induce atrophy of the embolized- and hypertrophy of the residual area. These effects are advantageous in patients scheduled for extended hepatectomy.

PURPOSE

To evaluate the clinical safety and effectiveness of foam sclerotherapy with foam ethanolamine oleate (EO) and carbon dioxide (CO2) for PTPE before hepatectomy.

MATERIAL AND METHODS

We performed sclerotherapy for PTPE in 15 patients with: hepatocellular carcinoma (HHC; n = 9), bile duct carcinoma (n = 5), or metastatic liver tumor from colon cancer (n = 1). The foam contained 5% EO iopamidol (EOI) and CO2 at a 1:2 ratio. We compared the percentage of the pre- and post-PTPE future liver remnant (FLR) volumes and calculated the percent FLR volume (%FLR) increase after PTPE.

RESULTS

The amount of EOI used (range, 14-20 mL; median, 16.8 mL) was based on the volume of the target portal vein. Technical success was achieved in 14 of 15 patients (93%); the other patient presented with computed tomography evidence of recanalization 1 week after PTPE. The FLR volume before and after portal vein embolization was 599 ± 342 and 691 ± 318 cm(3), respectively (P < 0.01); the mean %FLR volume increase was 29.5%. There was no significant difference in the mean platelet count, total bilirubin, total aspartate aminotransferase, and total creatinine before and after PTPE. One patient suffered intra-abdominal bleeding that required transcatheter arterial embolization. No other patients developed major complications higher than grade 3.

CONCLUSION

Sclerotherapy using foam EOI and CO2 is clinically safe and effective for PTPE before hepatectomy.

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Usefulness of Cone-Beam Computed Tomography and Automatic Vessel Detection Software in Emergency Transarterial Embolization

BACKGROUND

This study was designed to evaluate the utility of dual phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software to guide transarterial embolization (TAE) of angiographically challenging arterial bleedings in emergency settings.

METHODS

Twenty patients with an arterial bleeding at computed tomography angiography and an inconclusive identification of the bleeding vessel at the initial 2D angiographic series were included. Accuracy of DP-CBCT and AVD software were defined as the ability to detect the bleeding site and the culprit arterial bleeder, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software. Clinical success was defined as the successful embolization. Total volume of iodinated contrast medium and overall procedure time were registered.

RESULTS

The bleeding site was not detected by initial angiogram in 20% of cases, while impossibility to identify the bleeding vessel was the reason for inclusion in the remaining cases. The bleeding site was detected by DP-CBCT in 19 of 20 (95%) patients; in one case CBCT-CT fusion was required. AVD software identified the culprit arterial branch in 18 of 20 (90%) cases. In two cases, vessel tracking required manual marking of the candidate arterial bleeder. Technical success was 95%. Successful embolization was achieved in all patients. Mean contrast volume injected for each patient was 77.5 ml, and mean overall procedural time was 50 min.

CONCLUSIONS

C-arm CBCT and AVD software during TAE of angiographically challenging arterial bleedings is feasible and may facilitate successful embolization. Staff training in CBCT imaging and software manipulation is necessary.

Asymptomatic Intrahepatic Portosystemic Venous Shunt: To Treat or Not To Treat?

Intrahepatic portosystemic venous shunts (IPSVSs) are rare vascular malformations. They can be asymptomatic or present with various symptoms including encephalopathy. We present two cases of IPSVS, one involving a patient presenting with altered mental status and the other discovered incidentally. While there is no question that patients presenting with symptomatic IPSVS should undergo definitive treatment, there is no consensus regarding elective therapy for asymptomatic lesions.

Outcomes of Patients with Left Ventricular Assist Devices Undergoing Mesenteric Angiography for Gastrointestinal Bleeding

PURPOSE

To compare measures of clinical success, such as the need for subsequent intervention and mortality, in patients with left ventricular assist devices (LVADs) undergoing mesenteric angiography for gastrointestinal (GI) bleeding with respect to a control group.

MATERIALS AND METHODS

A retrospective study was conducted on 48 consecutive patients undergoing anticoagulation whose GI bleeding was assessed with angiography between August 2007 and June 2014: 24 patients with LVADs and 24 control patients without LVADs. The χ2 and t tests were used for statistical analysis.

RESULTS

Mean ages were 62.1 years ± 9.6 and 74.5 years ± 11.3 in the LVAD and control groups, respectively. No significant difference was observed in hemodynamic instability, presenting hemoglobin level and International Normalized Ratio, or hemoglobin nadir. Two patients with LVADs (8.3%) and 8 control patients (33.3%) had bleeding detected on angiograms (P = .032). Six embolizations were performed in patients with LVADs and 8 were performed in control patients. Clinical success was achieved in 2 of 6 patients with LVADs (33.3%) and 7 of 8 control patients (87.5%; P = .036). Seven patients with LVADs (29.2%) and 1 control patient (4.5%) underwent repeat angiography within 14 days (P = .020). Seven patients with LVADs (29.2%) and 4 control patients (18.2%) required postprocedural endoscopic or operative intervention as definitive therapy (P = .302). All-cause in-hospital mortality rates were 16.7% in the LVAD group and 4.2% in the control group (P = .032), and the respective all-cause 1-year mortality rates were 33.3% and 9.1% (P = .080).

CONCLUSIONS

A higher rate of clinical failure is observed in patients with LVADs presenting with GI bleeding compared with those without LVADs, with a more frequent need for subsequent endoscopic or surgical intervention.

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding

OBJECTIVE

Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days.

MATERIALS AND METHODS

Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates.

RESULTS

TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25-15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43-17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization.

CONCLUSION

TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia: a comparative study of medium- and large-volume prostates

OBJECTIVES

To compare the outcomes of prostatic arterial embolization (PAE) in treating large (>80 mL) in comparison with medium-sized prostate glands (50-80 mL) to determine whether size affects the outcome of PAE.

PATIENTS AND METHODS

A total of 115 patients (mean age 71.5 years) diagnosed with lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) refractory to medical treatment underwent PAE. Group A (n = 64) included patients with a mean prostate volume of 129 mL; group B (n = 51) included patients with a mean prostate volume of 64 mL. PAE was performed using 100-μm particles. Follow-up was performed using the International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow rate (Qmax ), post-void residual urine volume (PVR), the International Index of Erectile Function short form (IIEF-5), prostate-specific antigen (PSA) and prostate volume measured by magnetic resonance imaging at 1, 3 and 6 months, and every 6 months thereafter.

RESULTS

There were no significant differences between groups in baseline IPSS, QoL, Qmax , PVR, PSA level or IIEF-5 score. The technical success rate was 93.8% in group A and 96.8% in group B (P = 0.7). A total of 101 patients (55 patients in group A and 46 patients in group B) completed the mean (range) follow-up of 17 (12-33) months. Compared with baseline, there were significant improvements in IPSS, QoL, Qmax , prostate volume and PVR in both groups after PAE. The outcomes in group A were significantly better than in group B with regard to mean ± sd IPSS (-14 ± 6.5 vs -10.5 ± 5.5, respectively), Qmax (6.0 ± 1.5 vs 4.5 ± 1.0 mL/s, respectively), PVR (-80.0 ± 25.0 vs -60.0 ± 20.0 mL, respectively), prostate volume (-54.5 ± 18.0 mL [-42.3%] vs -18.5 ± 5.0 mL [-28.9%], respectively), and QoL score (-3.0 ± 1.5 vs -2.0 ± 1.0) with P values <0.05. The mean IIEF-5 score was not significantly different from baseline in both groups. No major complications were noted.

CONCLUSIONS

We found that PAE is a safe and effective treatment method for patients with LUTS attributable to BPH. The clinical and imaging outcomes of PAE were better in patients with larger prostate glands than medium-sized ones.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms as a result of large benign prostatic hyperplasia: A prospective single-center investigation

OBJECTIVE

To evaluate the effectiveness and safety of prostatic arterial embolization as a primary treatment for patients with lower urinary tract symptoms as a result of large benign prostatic hyperplasia.

METHODS

A total of 64 patients with prostates >80 mL were included in the study. Prostatic arterial embolization was carried out using a combination of 50-µm and 100-µm particles. Clinical follow up was carried out using the International Prostate Symptom Score, quality of life, peak urinary flow, postvoid residual volume, International Index of Erectile Function Short Form, prostate-specific antigen, and prostatic volume at 1, 3, 6 and every 6 months thereafter.

RESULTS

Prostatic arterial embolization was technically successful in 60 of 64 patients (93.8%). Follow-up data were available for 60 patients with a mean of 18 months. A clinical improvement, defined as reduction of International Prostate Symptom Score and increase of peak urinary flow, at 1 month, 3 months, 6 months, 12 months and 24 months, was achieved in 95.0%, 95.0%, 93.3%, 92.6% and 90.5%, respectively. A total of 42 patients had completed the follow up at 24 months after prostatic arterial embolization. There was an improvement in terms of mean International Prostate Symptom Score (pre-prostatic arterial embolization vs post-prostatic arterial embolization 27.0 vs 8.0; P < 0.01), mean quality of life (5.5 vs 2.0; P < 0.01), mean peak urinary flow (7.0 vs 13.0; P < 0.01), mean postvoid residual volume (130 vs 45.0; P < 0.05) and prostatic volume (121.0 vs 71.5, reduction of 40.9%; P < 0.01) were significantly different with respect to baseline.

CONCLUSION

Prostatic arterial embolization seems to be a safe and effective treatment method for patients with lower urinary tract symptoms as a result of large benign prostatic hyperplasia, and it might play an important role for patients in whom medical therapy has failed, who are not candidates for surgical treatment.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms due to large (>80 mL) benign prostatic hyperplasia: results of midterm follow-up from Chinese population

Background

Currently, large prostate size (>80 mL) of benign prostatic hyperplasia (BPH) still pose technical challenges for surgical treatment. This prospective study was designed to explore the safety and efficacy of prostatic arterial embolization (PAE) as an alternative treatment for patients with lower urinary tract symptoms (LUTS) due to largeBPH.

Methods

A total of 117 patients with prostates >80 mL were included in the study; all were failure of medical treatment and unsuited for surgery. PAE was performed using combination of 50-μm and 100-μm particles in size, under local anaesthesia by a unilateral femoral approach. Clinical follow-up was performed using the international prostate symptoms score (IPSS), quality of life (QoL), peak urinary flow (Qmax), post-void residual volume (PVR), international index of erectile function short form (IIEF-5), prostatic specific antigen (PSA) and prostatic volume (PV) measured by magnetic resonance (MR) imaging, at 1, 3, 6 and every 6 months thereafter.

Results

The prostatic artery origins in this study population were different from previously published results. PAE was technically successful in 109 of 117 patients (93.2%). Follow-up data were available for the 105 patients with a mean follow-up of 24 months. The clinical improvements in IPSS, QoL, Qmax, PVR, and PV at 1, 3, 6, 12, and 24 months was 94.3%, 94.3%, 93.3%, 92.6%, and 91.7%, respectively. The mean IPSS (pre-PAE vs post-PAE 26.0 vs 9.0; P < .0.01), the mean QoL (5.0 vs 3.0; P < 0.01), the mean Qmax (8.5 vs 14.5; P < 0.01), the mean PVR (125.0 vs 40.0; P < 0.01), and PV (118.0 vs 69.0, with a mean reduction of 41.5%; P < 0.01 ) at 24-month after PAE were significantly different with respect to baseline. The mean IIEF-5 was not statistically different from baseline. No major complications were noted.

Conclusions

PAE is a safe and effective treatment method for patients with LUTS due to large volume BPH. PAE may play an important role in patients in whom medical therapy has failed, who are not candidates for open surgery or TURP or refuse any surgical treatment.

Role of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleeding associated with anticoagulant therapy

PURPOSE

To evaluate safety and clinical efficacy of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleedings (SBs) in patients submitted to chronic anticoagulation therapy.

MATERIALS AND METHODS

From January 2007 to December 2012, 20 patients (mean age 75.8 years, range 68-91 years) with 23 SBs were retrospectively evaluated. Active bleeding was documented by contrast enhanced-multidetector row computed tomography (CE-MDCT). PTE was performed using different embolic agents. Technical success (TS), clinical success (CS), late success (LS) and mortality rate (M) related to the angiographic procedure and complications were evaluated.

RESULTS

CE-MDCT and digital subtraction angiography (DSA) identified active bleeding sites in 18 cases (18/20). In two cases (2/20) DSA did not confirm the arterial bleeding diagnosed on CE-MDCT. Twenty-three sessions of PTE were performed. TS, CS, LS and M were, respectively, 100, 85, 15 and 0%. No major complications were observed.

CONCLUSIONS

PTE could be considered a safe and effective "first line" approach to treat SB associated with anticoagulation therapy.

Hepatogastric Fistula following Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Hepatogastric fistula (HGF) formation following transcatheter arterial chemoembolization (TACE) leads to increased morbidity and mortality. A 51-year-old Caucasian male with chronic hepatitis B virus-associated cirrhosis and unresectable hepatocellular carcinoma (HCC) presented to the Interventional Radiology Unit for TACE to achieve tumor necrosis. Following the procedure, the patient was admitted with symptoms of fever, epigastric and right upper quadrant pain secondary to the development of an abscess. The abscess was drained; however, an exceedingly rare HGF resulted that was favored to represent a direct invasion of HCC. HGF, the rare complication following TACE, leads to grave consequences and vigilant monitoring, for the development of this entity is recommended to reduce patient mortality. We present a case and literature review of HGF development following TACE for HCC.

Short-term results of transcatheter arterial embolization for abnormal neovessels in patients with adhesive capsulitis: a pilot study

BACKGROUND

Neovessels and accompanying nerves are possible sources of pain. We postulated that transcatheter arterial embolization of abnormal neovessels would relieve pain and symptoms in patients with adhesive capsulitis.

METHODS

Adhesive capsulitis was treated by transcatheter arterial embolization in 7 patients. Adverse events, changes in visual analog scale scores for night pain and overall shoulder pain, and changes in range of motion and American Shoulder and Elbow Surgeons scores were assessed at 1 week and at 1, 3, and 6 months after the procedure.

RESULTS

Abnormal neovessels were identified at the rotator interval in all patients. No major or minor adverse events were associated with the procedures. Transcatheter arterial embolization rapidly decreased nighttime pain scores from 67 ± 14 mm to 27 ± 14 mm at 1 week after the procedure, with further improvement at 1 and 6 months (6 ± 8 mm and 2 ± 5 mm, respectively). The American Shoulder and Elbow Surgeons score significantly improved from 17.8 ± 4.5 to 39.8 ± 12.0, 64.3 ± 13.9, and 76.2 ± 4.4 at 1, 3, and 6 months, respectively.

CONCLUSION

All patients with adhesive capsulitis had abnormal neovessels at the rotator interval. Transcatheter arterial embolization was feasible, relieved unrelenting pain, and restored shoulder function.

Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience

PURPOSE

To evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, California) as the primary treatment for acute and massive lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Between January 2008 and October 2013, all patients with focal massive LGIB who were treated by embolization were retrospectively analyzed. The study was approved by the hospital's ethics committee; informed consent was obtained in all cases. Onyx was chosen as the embolic agent in all cases in an intention-to-treat fashion. Embolization was indicated in 31 consecutive patients (mean age, 80 y ± 11.1). Multidetector computed tomography and digital subtraction angiography were performed in all patients.

RESULTS

Active bleeding was detected in all cases. A colonoscopy was performed in 11 patients. The correlation between multidetector computed tomography and angiography findings was 96.7%. The causes of bleeding were diverticula in 15 patients, iatrogenic in 7 patients, neoplasia in 3 patients, hemorrhoids in 2 patients, angiodysplasia in 2 patients, and unknown in 2 patients. Embolization was not possible in one patient, who required urgent left hemicolectomy. The technical success rate was 93.5%. The embolic material refluxed in one patient, causing an undesired embolization, without any clinical consequences. In the 30 patients who received embolization, the immediate bleeding control rate was 100%. Rebleeding at 30 days occurred in three patients (10%). There were no major complications, intestinal ischemia, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 23.7 months (range, 1-71 mo).

CONCLUSIONS

Control of massive LGIB using superselective embolization with Onyx is feasible and safe.

Portal vein embolization before right hepatectomy or extended right hepatectomy using sodium tetradecyl sulfate foam: technique and initial results

PURPOSE

To evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

A single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded.

RESULTS

PVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively.

CONCLUSIONS

Preoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Outcome and predictive factors of successful transarterial embolization for the treatment of acute gastrointestinal hemorrhage

BACKGROUND

Transarterial embolization (TAE) is an effective procedure for the treatment of acute gastrointestinal bleeding (GIB). Factors associated with clinical success have not been well delineated.

PURPOSE

To evaluate the technical and clinical successes of TAE for acute GIB in order to identify factors influencing clinical success and in-hospital mortality.

MATERIAL AND METHODS

This was a retrospective study of 70 consecutive patients with GIB who underwent angiography and embolization between January 2004 and December 2011. The technical success rate, clinical success rate, and in-hospital mortality were calculated by percentage. Clinical parameters, angiographic, and embolization data were assessed for factors influencing clinical success and in-hospital survival using univariate and multivariate analysis. Statistical significance was set at P value <0.05.

RESULTS

The technical success rate was 98.6%. The primary clinical success rate was 71.4% and the secondary clinical success rate after repeat embolization was 78.6%. Bowel infarction was the most serious complication of three (4.3%) patients. Failure to achieve 30-day hemostasis can be predicted in patients who have one or more of the following factors: hemoglobin concentration <8 g/dL (P = 0.004), coagulopathy (P = 0.005), upper GIB (P = 0.02), contrast extravasation (P = 0.012), and more than one embolized vessel (P = 0.005). In-hospital survival is affected by the amount of transfused packed red blood cells before embolization (P = 0.008) and post-embolization bowel infarction (P = 0.005).

CONCLUSION

TAE is a feasible and effective management of acute GIB with high technical and clinical success rates. The factors influencing clinical success include hemoglobin concentration, coagulopathy, upper GIB, contrast extravasation, and more than one embolized vessel. The number of units of transfused packed red blood cells and post-embolization bowel infarction are important factors associated with in-hospital mortality.

Transarterial embolization for the treatment of massive bleeding in gynecologic and obstetric emergencies: a single center experience

Delayed treatment of the massive bleeding in gynecologic and obstetric conditions can cause high morbidity and mortality. The aim of this study is to assess the angiographic findings and outcomes of transarterial embolization in cases of massive hemorrhage from underlying gynecological and obstetrical conditions. This is a retrospective study of 18 consecutive patients who underwent transarterial embolization of uterine and/or hypogastric arteries due to massive bleeding from gynecological and obstetrical causes from January 2006 to December 2011. The underlying causes of bleeding, angiographic findings, technical success rates, clinical success rates, and complications were evaluated. Massive gynecological and obstetrical bleeding occurred in 12 cases and 6 cases, respectively. Gestational trophoblastic disease was the most common cause of gynecological bleeding. The most common cause of obstetrical hemorrhage was primary post-partum hemorrhage. Tumor stain was the most frequent angiographic finding (11 cases) in the gynecological bleeding group. The most common angiographic findings in obstetrical patients were extravasation (2 cases) and pseudoaneurysm (2 cases). Technical and final clinical success rates were found in all 18 cases and 16 cases. Collateral arterial supply, severe metritis, and unidentified cervical laceration were causes of uncontrolled bleeding. Only minor complications occurred, which included pelvic pain and groin hematoma. Percutaneous transarterial embolization is a highly effective and safe treatment to control massive bleeding in gynecologic and obstetric emergencies.

Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients

PURPOSE

To assess the safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding (LGIB) and to determine the prognostic factors that affect clinical outcome.

MATERIALS AND METHODS

All patients diagnosed with LGIB by angiography at a single institution from April 2006 to January 2013 were included in a retrospective study. The rates of technical success, early recurrent bleeding, major complications, clinical success, and in-hospital mortality for transcatheter arterial embolization were determined. The influence of possible prognostic factors on the outcome was analyzed.

RESULTS

A total of 112 patients were included (36 with small-bowel LGIB, 36 with colon LGIB, and 40 with rectal LGIB). N-butyl cyanoacrylate (NBCA) was the embolic agent for 84 patients (75.0%), whereas gelatin sponge pledgets (n = 20), microcoils (n = 2), polyvinyl alcohol particles with adjunctive gelatin sponge pledgets (n = 1), and blood clots (n = 1) were used in the other patients. The technical success rate was 96.4%. For the entire group, the rates of early recurrent bleeding, major complications, clinical success, and in-hospital mortality were 17.4%, 4.6%, 74.5%, and 25.0%, respectively. These were 15.2%, 4.8%, 75.3%, and 26.2%, respectively, in the NBCA group. Hematologic malignancy, immobilization status, and coagulopathy were significant prognostic factors for clinical outcomes.

CONCLUSIONS

Transcatheter arterial embolization is a safe and effective treatment for LGIB. NBCA could be used as a primary embolic agent for this procedure.

Usefulness of pelvic artery embolization in cesarean section compared with vaginal delivery in 176 patients

PURPOSE

To evaluate the efficacy and safety of transcatheter arterial embolization of the pelvic arteries for the treatment of postpartum hemorrhage (PPH) associated with cesarean section compared with vaginal delivery.

MATERIALS AND METHODS

A retrospective analysis of 176 patients undergoing transcatheter arterial embolization of the pelvic arteries for PPH from January 2006 through August 2011 was conducted at two institutions. The mean patient age was 33.9 years (range, 24-46 years). Data including delivery details, hematology and coagulation results, embolization details, and clinical outcomes were collected. Technical success was defined as cessation of bleeding on angiography or angiographically successful embolization of the bleeding artery. Clinical success was defined as the obviation of repeated embolization or surgical intervention.

RESULTS

The technical success rate was 98.8% (n = 174), and the clinical success rate was 89.7% (n = 158). Among 176 patients, 71 had cesarean sections, and 105 underwent normal vaginal deliveries. Of the 105 patients who underwent normal vaginal deliveries, 11 (10.5%) required repeat embolization or surgical intervention. Of the 71 patients who had cesarean sections, 7 (9.8%) required repeat embolization or surgical intervention. The clinical success rate and complication rate were not related to the mode of delivery. All women resumed menses after transcatheter arterial embolization, and most (n = 125) described their menses as unchanged. Subsequent spontaneous pregnancies occurred in 13 women.

CONCLUSIONS

The cesarean mode of delivery is not a predictor of poorer outcomes of transcatheter arterial embolization; however, further study is needed to clarify this relationship.

Transcatheter embolotherapy for gastrointestinal bleeding: a single center review of safety, efficacy, and clinical outcomes

PURPOSE

The purpose of this study was to assess safety, efficacy, and clinical outcomes following transcatheter arterial embolization (TAE) of acute gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

Ninety-five patients (male:female ratio = 53:42, mean age 62 years) that underwent 95 TAEs for GI hemorrhage between 2002 and 2010 were retrospectively studied. Seventy-six of 95 (80 %) patients had upper GI bleeds and 19/95 (20 %) patients had lower GI bleeds. A mean of 7 (range 0-27) packed red blood cell units were transfused pre-procedure, and 90/95 (95 %) procedures were urgent or emergent. Twenty-seven of 95 (28 %) patients were hemodynamically unstable. Measured outcomes included procedure technical success, adverse events, and 30-day rebleeding and mortality rates.

RESULTS

Bleeding etiology included peptic ulcer disease (45/95, 47 %), cancer (14/95, 15 %), diverticulosis (13/95, 14 %), and other (23/95, 24 %). Vessels embolized (n = 109) included gastroduodenal (42/109, 39 %), pancreaticoduodenal (22/109, 20 %), gastric (21/109, 19 %), superior mesenteric (12/109, 11 %), inferior mesenteric (8/109, 7 %), and splenic (4/109, 4 %) artery branches. Technical success with immediate hemostasis was achieved in 93/95 (98 %) cases. Most common embolic agents included coils (66/109, 61 %) and/or gelatin sponge (19/109, 17 %). Targeted versus empiric embolization were performed in 57/95 (60 %) and 38/95 (40 %) cases, respectively. Complications included bowel ischemia (4/95, 4 %) and coil migration in 3/95 (3 %). 30-day rebleeding rate was 23 % (22/95). Overall 30-day mortality rate was 18 % (16/89). Empiric embolization resulted in similar rebleeding (23 vs 24 %) but higher mortality (31 vs 9 %) rates compared to embolization for active extravasation.

CONCLUSIONS

TAE controlled GI bleeding with high technical success, safety, and efficacy, and should be considered when endoscopic therapy is not feasible or unsuccessful.

Long-term outcomes of coil packing for visceral aneurysms: correlation between packing density and incidence of coil compaction or recanalization

PURPOSE

To evaluate the correlation between packing density and the incidence of coil compaction or recanalization of visceral artery aneurysms (VAAs) after coil packing.

MATERIALS AND METHODS

Between July 2004 and April 2012, coil packing was performed for 46 true visceral aneurysms (16 splenic, 11 pancreaticoduodenal, eight renal, six hepatic, three superior mesenteric, one right gastric, and one gastroepiploic) in 42 patients. The size and volume of the aneurysm, packing density, and the incidences of compaction and recanalization were evaluated retrospectively.

RESULTS

The mean follow-up period was 37 months ± 8 (range, 11-80 mo). The mean packing density was 19% ± 8 (range, 5%-42%), mean aneurysm size was 19 mm ± 8 (range, 5-40 mm), and mean volume was 4,108 mm(3) ± 5,435 (range, 72-26,235 mm(3)). Compaction and recanalization occurred in two (4%) and 12 aneurysms (26%), respectively. The mean packing density was significantly lower in aneurysms with compaction or recanalization than in unaffected aneurysms (12% vs 22%; P = .00014). There was a significant difference in mean packing density between small (< 20 mm; 22%) and large (≥ 20 mm) aneurysms (15%; P = .0045). The mean size and volume were significantly larger for coil-compacted or recanalized aneurysms than for unaffected aneurysms (P < .05). In aneurysms with a packing density of at least 24%, no compaction or recanalization occurred.

CONCLUSIONS

Coil compaction or recanalization after coil packing for VAAs more often occurs after insufficient embolization with low packing density and in patients with large aneurysms.

Treatment of nonvariceal gastrointestinal hemorrhage by transcatheter embolization

Purpose. To investigate the sensitivity of mesenteric angiography, technical success of hemostasis, clinical success rate, and complications of transcatheter embolization for the treatment of acute nonvariceal gastrointestinal hemorrhage. Material and Methods. A retrospective review of 200 consecutive patients who underwent mesenteric arteriography for acute nonvariceal gastrointestinal hemorrhage between February 2004 and February 2011 was done. Results. Of 200 angiographic studies, 114 correctly revealed the bleeding site with mesenteric angiography. 47 (41%) patients had upper gastrointestinal hemorrhage and 67 (59%) patients had lower gastrointestinal hemorrhage. Out of these 114, in 112 patients (98%) technical success was achieved with immediate cessation of bleeding. 81 patients could be followed for one month. Clinical success was achieved in 72 out of these 81 patients (89%). Seven patients rebled. 2 patients developed bowel ischemia. Four patients underwent surgery for bowel ischemia or rebleeding. Conclusion. The use of therapeutic transcatheter embolization for treatment of acute gastrointestinal hemorrhage is highly successful and relatively safe with 98% technical success and 2.4% postembolization ischemia in our series. In 89% of cases it was definitive without any further intervention.