Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Transcatheter arterial embolization of the subclavian and axillary artery branches for hemorrhage control

OBJECTIVE

To evaluate the effectiveness and safety of transcatheter arterial embolization (TAE) of the branches of the subclavian and axillary arteries for hemorrhage control.

METHODS

Between January 2015 and June 2022, 35 TAE procedures were performed for hemorrhage from the branches of the subclavian and axillary arteries in 34 patients (22 men, 12 women; 1 male underwent TAE twice; mean age = 76 years). Pre-TAE CT showed hematomas in the chest (n = 25) and abdominal walls (n = 3), shoulder (n = 2), and lower neck (n = 2). CT showed hemothorax in eight cases. Angiographic findings, embolization technique, and technical and clinical success of TAE were retrospectively assessed in all cases.

RESULTS

TAE was performed by transfemoral (n = 16), transradial (n = 12), and transbrachial (n = 7) approaches. Angiography revealed contrast media extravasation or pseudoaneurysms in 32 cases (91.4%). The most commonly embolized arteries were the internal thoracic (n = 12), lateral thoracic (n = 6), and thoracoacromial (n = 6) arteries. Technical and clinical success rates were 100 and 85.7%, respectively. A complication (skin necrosis after injection of the liquid embolic agent) developed in only one patient (2.9%) and was conservatively managed.

CONCLUSION

TAE is an effective and safe treatment for hemorrhage from the branches of the subclavian and axillary arteries.

ADVANCES IN KNOWLEDGE

Transfemoral approach has been used for TAE of the branches of the subclavian and axillary artery. Transradial and transbrachial approaches can also be considered.

Predicting Suitable Percutaneous Endovascular Arterial Embolization for Traumatic Abdominopelvic Injuries: A Retrospective Cohort Study

Purpose

This study evaluated the pre-procedural attributes of trauma patients to determine their suitability to undergo Percutaneous Endovascular Arterial Embolization (PEAE), and the current state of endovascular repair as an option for trauma-related injuries in traumatic abdominopelvic arterial injuries was explored.

Patients and Methods

We retrospectively evaluated the charts of 638 adults with traumatic abdominopelvic injuries treated from March 2011 to February 2021, extensively reviewing their pre-operative indices, pre-operative optimization requirements, and multi-modality imaging records.

Results

In total, 235 patients (30.63%) were “hemodynamically unstable” on admission, mainly due to hypotension (n=437 [68.5%]). Additionally, laboratory-defined acquired coagulopathies and inherited bleeding disorders were found in 268 patients (42.01%). The computerized tomography bleeding protocol was performed on 408 (63.94%) patients. Percutaneous endovascular therapy by arterial embolization was performed on 146 patients. The mean number of requested pre-intervention blood units for trauma patients significantly exceeded the number of units transfused post-intervention (P<0.0005). Apart from hemodynamics (ie heart rate, mean blood pressure); hemoglobin, and lactic acid levels were independently associated indices of PEAE outcomes (p <0.01).

Conclusion

Despite the recommendations from the Society of Interventional Radiology on endovascular intervention for trauma and bleeding risk, 36.84% of study patients had hemodynamic instability and other unfeasible parameters that would limit the option of minimally invasive procedures. Early recognition and consideration of suitable treatment options is essential for optimizing patient outcomes. It is imperative that standardized algorithms and management protocols based on available resources be developed.

Treatment Outcome of Traumatic Subclavian Artery Injuries

BACKGROUND

Traumatic subclavian artery injuries are associated with high morbidity and mortality. Thoracic cage and clavicle provide a well protection of the underlying subclavian vessels and nerves and also cause a very limited operation space during open surgery. The endovascular modality is less invasive and alternative to conventional open surgical reconstruction.

PURPOSE

The purpose of this study was to analyze the different therapeutic effects on limb salvage.

METHODS

A retrospective review of patients who presented with blunt or penetrating injuries to the subclavian arteries between March 2012 and March 2021.

RESULTS

Endovascular and open repairs were both effective for traumatic subclavian artery injury. There was no statistical difference in the limb salvage, mortality, procedure-related complication, reintervention rate and in-hospital medical complications. Intraoperative blood loss, red blood cell transfusion requirement and length of hospital stay were significantly lower in the endovascular intervention group.

CONCLUSION

Endovascular treatment represents an attractive alternative to the traditional surgical approach for the treatment of traumatic injuries in the subclavian.

Preoperative interventional artery embolization for the treatment of a giant malignant phyllodes tumor: A case report

Phyllodes tumors (PTs) are rare but complex fibroepithelial lesions of the breast. The present report describes an unusual case of a giant malignant PT with a rich blood supply treated with dominant blood supply internal thoracic artery interventional embolization before surgery. A 41-year-old woman without underlying systemic disease presented with a tumor >20 cm in diameter growing rapidly in the left breast. Radiological results indicated a giant circular tumor with a clear boundary occupying the whole breast, possible invasion of the major pectoralis muscle and several enlarged lymph nodes in the left axillary region. Computed tomography angiography showed a large mass with a rich and powerful blood vessel supply and preoperative interventional embolization was performed to block the internal thoracic artery. Three days after artery embolization, mastectomy and grade I axillary lymph node dissection were performed. The giant tumor measured 17x16x11 cm. The surgery successfully treated the pain and tumor necrosis and the patient received chemotherapy and local radiotherapy. No recurrence was found at the 14-month follow-up.

Intraperitoneal hemorrhage following primary cytoreductive surgery for ovarian cancer: Successful treatment with superior epigastric artery embolization

Hemoperitoneum often occurs due to abdominal trauma, abdominal tumors, gastro-intestinal perforation and more rarely it's spontaneous due to coagulopathies. Superior epigastric artery (SEA) iatrogenic damage is rarer than the Inferior epigastric artery injury, it may occur during laparotomy and, in most cases, it causes a rectus muscle hematoma. We present the case of a caucasian 44 years-old-woman with hemoperitoneum after cytoreductive surgery for ovarian cancer. Active bleeding from the distal branch of the SEA was diagnosed at computed tomography and coil embolization followed by surgical laparotomic drainage of the hemoperitoneum was performed. After initial resolution, active bleeding from the same vessel was observed. Further embolization of the same vessel was necessary to stop bleeding. Ultrasound follow-up showed a complete resolution of the hemoperitoneum.

Thoracic Trauma, Nonaortic Injuries

Trauma is one of the leading causes of death worldwide. Approximately two-thirds of trauma patients have thoracic injuries. Nonvascular injury to the chest is most common; however, while vascular injuries to the chest make up a small minority of injuries in thoracic trauma, these injuries are most likely to require intervention by interventional radiology (IR). IR plays a vital role, with much to offer, in the evaluation and management of patients with both vascular and nonvascular thoracic trauma; in many cases, IR treatments obviate the need for these patients to go to the operating room. This article reviews the role of IR in the treatment of vascular an nonvascular traumatic thoracic injuries.

Postpartum Hemorrhage: Rescue

Severe postpartum hemorrhage (PPH) occurs in around 1%-2% of deliveries and is a leading cause of maternal mortality and morbidity worldwide. Different treatments of PPH are proposed by the scientific society's guidelines; to date, pelvic artery embolization is an effective therapeutic strategy with the advantages of fast speed, repeatability, and the possibility of future fertility preservation. We compared the different PPH treatments, focusing especially on the role of interventional radiology reviewing pelvic vascular anatomy and emphasizing on the timing of embolization and various clinical conditions of PPH.

Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.

Thyroglossal duct cysts and site-specific differential diagnoses: imaging findings with emphasis on ultrasound assessment

Thyroglossal duct cysts (TGDCs) are the most common congenital abnormality of the neck, accounting for approximately 70% of congenital neck lesions. Two-thirds of thyroglossal duct anomalies are diagnosed within the first three decades of life, with more than half being identified before 10 years of age. The age of presentation, clinical examination and imaging are essential for an accurate diagnosis. This review aims to summarize the imaging findings of TGDCs and their main differential diagnoses with emphasis on ultrasound assessment. A focus on site-specific key differentiating between them is also addressed.

Morphological and dynamic evaluation of complex cystic focal liver lesions by contrast-enhanced ultrasound: current state of the art

Complex cystic and cystic-like focal liver lesions (FLLs) encompass a spectrum of disorders ranging from non-neoplastic conditions to benign and malignant tumors. In this prospective, the possibility of non-invasive differentiation of these lesions is extremely important, because the clinical implications and therapeutic strategies vary considerably. Because of its advantageous cost/benefit ratio, widespread availability and easy execution, ultrasound (US) is the first-line imaging modality in most countries for the initial liver survey and represents the imaging technique that usually detects a complex liver cyst. However, US showed poor efficacy in the differential diagnosis of complex cystic FLLs. Thus, for years, computed tomography (CT) and magnetic resonance (MR) imaging have been used for further assessment of these lesions. Recently, the development of low mechanical index real-time contrast-enhanced ultrasound (CEUS) technique performed with the second generation of US contrast agents has led to an accurate depiction of macrovasculature and microvasculature. The technique yields information about contrast enhancement of the liver and FLLs almost as CT and MRI do, but in real time and without the use of ionizing radiation. To date, there is only a small amount of evidence about the role of CEUS in the less common setting of complex liver cysts. The aim of this review is to offer an up-to-date overview on the state of the art of CEUS in the study of the most common complex cystic focal liver lesions. To our knowledge, there are no literature comprehensive reviews on this topic.

Successful endovascular treatment of a spontaneous bleeding accessory spleen: A case report

Accessory spleens are often encountered in radiologic studies and they are not usually associated with symptoms. They could arise from autotransplantation of splenic tissue after splenic trauma or splenectomy (splenosis) [1]. In this case we describe a woman treated for splenectomy 20 years before and subsequently for adhesions, that suffered sudden left upper abdominal quadrant pain, weakness, and pale color. Contrast-enhanced computed tomography revealed free spilling in the abdomen and venous bleeding of a big accessory spleen; thus the patient underwent transcatheter arterial embolization with coils. Due to the 2 previous surgical operations in the splenic loggia, endovascular treatment compared to “open surgery” was the best choice in this case because of determined less complications, a shorter period of hospitalization, and a reduction of health cost.

Utility of a gel stand-off pad in the detection of Doppler signal on focal nodular lesions of the skin

PURPOSE

Gel pad is an aqueous, flexible, easy available, disposable spacer used for the ultrasound (US) scan of superficial or difficult-to-visualize areas. In clinical practice, it is widely used in B-mode US approach of superficial lesions but, to date, no data have been provided as to its efficacy in the Doppler detection of superficial flows. The aim of our study was to demonstrate the role of stand-off gel pad in the detection of the otherwise-missed peri- or intra-lesional flow signals on Doppler imaging.

MATERIALS AND METHODS

A total of 100 superficial lesions undergone to an US evaluation using a 7.5-12-MHz linear probe were evaluated prospectively with and without interposition of a gel stand-off pad to detect the presence or absence of vascularization and to classify the vascular pattern.

RESULTS

Peri- or intra-lesional flow was demonstrated in 56% of cases without and in 84% of cases with interposition of a gel stand-off pad; moreover, a statistically significant difference (p value < 0.001) was observed at Chi-square test in the identification of the flow pattern between the use and no use of the pad.

CONCLUSIONS

The use of a gel stand-off pad allows the detection of otherwise-missed peri- or intra-lesional flow signals on Doppler imaging, increasing the diagnostic role of this technique in differential diagnosis of superficial lesions.

Endovascular Treatment of Peripheral Vascular Blowout Syndrome in End-Stage Malignancies

BACKGROUND

Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically.

METHODS

Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications.

RESULTS

Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities.

CONCLUSIONS

Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.