Multimodal Endovascular Palliation for Femoral Arterial Blowout in the Setting of Metastatic Vulvar Carcinoma

Endovascular treatment of femoral artery blow-out caused by skin malignancy

Background

Vascular blow-out syndrome is a life-threatening bleeding condition that usually occurs in the carotid arteries as a result of invasion of head and neck malignant tumors. There are several case reports in the literature on peripheral vascular blow out. To our knowledge, there is no other case report in the literature on blow-out in the femoral artery secondary to skin malignancy.

Case presentation

A 66-year-old male patient, who was diagnosed with skin squamous cell carcinoma (SCC) as a result of tissue sampling due to redness and stiffness in the left inguinal region, underwent emergency surgery with severe bleeding. Since edema and deformations on the skin did not render the operation possible, the patient was taken to the interventional radiology unit by applying pressure compression onto the bleeding area for urgent endovascular treatment. The patient was treated with a stent-graft.

Conclusion

The femoral blow-out is an emergency condition that needs to be managed aggressively, and if left untreated, it can cause serious bleeding, limb ischemia, limb loss, or death. Endovascular stent-graft placement is the first method that should be considered, and this method provides fast and effective treatment.

Endovascular Management of External Iliac Blowout Syndrome Secondary to Recurrent Sigmoid Cancer

Blowout syndrome caused by vascular invasion is a dreadful complication of late stage malignancies that carry high morbidity and poor overall prognosis in a compromised population. Endovascular management can offer minimally invasive and life-saving alternative for such acute conditions. We describe the case of a 62-year-old man with massive fresh bleeding per rectum and shock resulting from rupture of the left external iliac artery secondary to nearby infiltrative recurrent sigmoid cancer. This complication is rare, presents dramatically, and is frequently fatal. The patient was successfully treated with a stent graft deployment in order to achieve hemostasis and reinstituting the arterial integrity.

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.

An Academic Tertiary Referral Center's Experience with a Vascular Surgery-Based Uterine Artery Embolization Program

BACKGROUND

Despite growing endovascular experience within the vascular surgery community, some catheter-based interventions-such as uterine artery embolization (UAE)-remain outside the clinical scope of most vascular surgeons, owing in part to established referral patterns and limited awareness among referring colleagues. We present our experience with a vascular surgery-based, multidisciplinary UAE program at an academic tertiary referral center.

METHODS

In a collaborative effort between vascular surgeons and gynecologists, a pelvic vascular disease program has been established to provide palliative, prophylactic, and therapeutic embolizations including, but not limited to, UAE. For UAE, inclusion criteria are women over the age of 18 years with symptomatic uterine fibroids demonstrated on magnetic resonance imaging and a negative endometrial biopsy. Exclusion criteria are desire for future pregnancy and previous embolization(s). Technique and perioperative protocol is presented. Data including symptom resolution, reintervention rates, and complications were prospectively gathered and retrospectively reviewed.

RESULTS

Over an 18-month period, 30 patients with symptomatic fibroids were referred for potential UAE. Five patients were excluded because of uncertainty about future pregnancy wishes (4) and prior embolization (1). Twenty-four bilateral and 2 unilateral UAEs were performed (mean age, 46.3 years [range 28-53 years]). Presenting symptoms were pelvic and abdominal pain (25), cramps (25), menorrhagia (25), dysmenorrhea (25), urinary frequency (12), and dyspareunia (5). Technical success, defined as successful microcatheterization of uterine arteries and delivery of a particulate liquid embolic agent (embospheres, 500-700 microns), was 100%. There were no perioperative or delayed complications. Twenty-one patients (87.5%) reported complete symptomatic relief without further intervention at the time of last follow-up. Three patients (12.5%) reported pain relief but had persistent vaginal bleeding requiring hysterectomy 12 months after UAE. All patients underwent a 23-hr observation postoperatively for pain control. Mean follow-up was 7.4 months (1-23 months) and included pelvic ultrasound assessment of fibroid size at 1, 3, and 6 months after UAE and annually thereafter. One patient was lost to follow-up. Fibroid shrinkage was noted in all patients. Given the willingness and capability to work-up, admit, treat, and follow-up patients, vascular surgery was deemed the preferred service for UAE by the referring gynecologists.

CONCLUSION

Within the framework of a collaborative, multidisciplinary program, vascular surgery can play a prominent role in providing safe and effective UAE.

Peripheral Non-atherosclerotic Arterial Disorders: What Radiologists Need to Know

Peripheral non-atherosclerotic arterial disorders (NAADs) are a heterogeneous group of rather uncommon conditions that tend to manifest in subjects without atherosclerosis. Each of these conditions has distinctive pathophysiology; however, there are some common clinical and radiological characteristics and in some cases a common treatment approach that unifies these conditions to a specific group, hence the NAADs. Clinicians and radiologists often fail to recognize NAADs, and there might be a delay in the management of such patients; this may result in seriously adverse outcomes that could otherwise have been avoided or minimized. Knowledge of these conditions and of their radiological appearances is therefore important to help establish a correct diagnosis to allow the prompt initiation of treatment. The purpose of this pictorial review is to present a selection of NAADs cases and to discuss the radiological characteristics and the most common lines of therapeutic approaches.