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Rossi M, Krokidis M, Kashef E, Peynircioglu B, Tipaldi MA. CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms. Cardiovasc Intervent Radiol 2024; 47:26-35. [PMID: 38030849 PMCID: PMC10770226 DOI: 10.1007/s00270-023-03620-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms is an effective, minimally invasive treatment that has been successfully used since the early 1990s, with refined and expanded techniques and tools currently offering excellent outcomes. Due to increased detection of such lesions in recent years, many of which are asymptomatic, revision of the indications for intervention and the correct endovascular treatment approaches has become essential. PURPOSE This document will presume that the indication for treatment is clear and approved by the multidisciplinary team and will define the standards required for the performance of each intervention, as well as their relative advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of the endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in endovascular treatments. The writing group reviewed the existing literature on visceral and renal artery aneurysms and pseudoaneurysms, performing an evidence search using PubMed to identify publications in English and relating to human subjects from 1990 to 2022. The final recommendations were formulated through consensus. RESULTS Endovascular treatment has an established role in the successful management of visceral and renal artery aneurysms and pseudoaneurysms, and this Standards of Practice document provides up-to-date recommendations for its safe performance.
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Affiliation(s)
- Michele Rossi
- Department of Surgical Medical Sciences and Translational Medicine, Sapienza University of Rome-Sant'Andrea University Hospital, Rome, Italy.
| | - Miltiadis Krokidis
- National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece
| | - Elika Kashef
- Imperial College Healthcare NHS Trust, London, UK
| | - Bora Peynircioglu
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Marcello Andrea Tipaldi
- Department of Surgical Medical Sciences and Translational Medicine, Sapienza University of Rome-Sant'Andrea University Hospital, Rome, Italy
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Results from the First-in-Human Study of the Caterpillar™ Arterial Embolization System. Cardiovasc Intervent Radiol 2023; 46:100-111. [PMID: 36450994 PMCID: PMC9713177 DOI: 10.1007/s00270-022-03300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To assess occlusion success and adverse events associated with the use of a self-expanding device for peripheral artery embolization. METHODS This prospective, single-arm, feasibility study was conducted using the Caterpillar™ Arterial Embolization Device composed of opposing nitinol fibers and a flow-occluding membrane. Twenty patients (24 embolization sites) were treated at four investigational centers in New Zealand and Australia and followed for 30 days. Embolization sites included mesenteric, accessory renal, and iliac arteries and their branches. Primary outcome measures were peri-procedural occlusion confirmed by angiography and freedom from device-related serious adverse events (SAEs) at 30 days. Secondary observations included time to occlusion and assessment of adverse events. RESULTS Peri-procedural occlusion was 100%, and freedom from a device-related SAE was 94.7% at 30 days. One patient had abdominal bloating that required hospitalization deemed possibly related to the device or procedure. Twenty-two of 24 embolization sites were occluded with one device (91.7%). Mean procedure duration was 11.7 ± 8.6 min (device deployment time: 1.8 ± 1.0 min), and mean fluoroscopy time was 241 ± 290.7 s. All embolization sites occluded during the procedure with 62.5% occluded within three minutes and 91.6% occluded within ten minutes. No devices migrated or required re-embolization. Freedom from device- and procedure-related adverse events was 84.2%. One patient died from aortic rupture during a subsequent adjunctive abdominal aortic endovascular procedure deemed unrelated to the embolization device or procedure. CONCLUSIONS This first-in-human study of the Caterpillar embolization device achieved peri-procedural occlusion in all patients with a 94.7% freedom from device-related SAE at 30 days. LEVEL OF EVIDENCE Level 2b-prospective, multicenter, single-arm, first-in-human clinical study. Pre-specified endpoints were analyzed using descriptive statistics.
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In Vitro Study of Particle Transport in Successively Bifurcating Vessels. Ann Biomed Eng 2019; 47:2271-2283. [PMID: 31165293 DOI: 10.1007/s10439-019-02293-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022]
Abstract
To reach a predictive understanding of how particles travel through bifurcating vessels is of paramount importance in many biomedical settings, including embolization, thromboembolism, and drug delivery. Here we utilize an in vitro model in which solid particles are injected through a rigid vessel that symmetrically bifurcates in successive branching generations. The geometric proportion and fluid dynamics parameters are relevant to the liver embolization. The volumetric flow field is reconstructed via phase-contrast magnetic resonance imaging, from which the particle trajectories are calculated for a range of size and density using the particle equation of motion. The method is validated by directly tracking the injected particles via optical imaging. The results indicate that, opposite to the common assumption, the particles distribution is fundamentally different from the volumetric flow partition. In fact, the amount of delivered particles vary substantially between adjacent branches even when the flow is uniformly distributed. This is not due to the inertia of the particles, nor to gravity. The particle distribution is rather rooted in their different pathways, which in turn are linked to their release origin along the main vessel cross-section. Therefore, the tree geometry and the associated flow streamlines are the prime determinant of the particle fate, while local changes of volumetric flow rate to selected branches do not generally produce proportional changes of particle delivery.
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Vidmar J, Omejc M, Dežman R, Popovič P. Thrombosis of pancreatic arteriovenous malformation induced by diagnostic angiography: case report. BMC Gastroenterol 2016; 16:68. [PMID: 27400664 PMCID: PMC4940768 DOI: 10.1186/s12876-016-0485-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/30/2016] [Indexed: 01/08/2023] Open
Abstract
Background We report on a case of pancreatic arteriovenous malformation (PAVM) that obliterated shortly after diagnostic angiography (DSA). PAVM is a rare anomaly that presents with upper abdominal pain, signs of acute pancreatitis and massive gastrointestinal bleeding. The management of PAVM is rather complex, with complete treatment usually accomplished only by a total extirpation of the affected organ or at least its involved portion. DSA prior to treatment decisions is helpful for characterizing symptomatic PAVM, since it can clearly depict the related vascular networks. In addition, interventional therapy can be performed immediately after diagnosis. Case presentation A 39-old male was admitted due to recurring upper abdominal pain that lasted several weeks. Initial examination revealed the absence of fever or jaundice, and the laboratory tests, including that for pancreatic enzymes, were unremarkable. An abdominal ultrasound (US) showed morphological and Doppler anomalies in the pancreas that were consistent with a vascular formation. A subsequent DSA depicted a medium-sized nidus, receiving blood supply from multiple origins but with no dominant artery. Coil embolization was not possible due to the small caliber of the feeding vessels. In addition, sclerotherapy was not performed so as to avoid an unnecessary wash out to the non-targeted duodenum. Consequently, the patient received no specific treatment for his symptomatic PAVM. A large increase in pancreatic enzymes was noticed shortly after the DSA procedure. Imaging follow-up by means of CT and MRI showed small amounts of peripancreatic fluid along with a limited area of intra-parenchymal necrosis, indicating necrotizing pancreatitis. In the post-angiography follow-up the patient was hemodynamically stable the entire time and was treated conservatively. The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges. Long-term follow-up by way of a contrast-enhanced CT revealed no recanalization of the thrombosed PAVM. Conclusion The factors associated with the obliteration of PAVM during or after DSA are poorly understood. In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent. Asymptomatic PAVM, as diagnosed with non-invasive imaging techniques, should not be evaluated with DSA due to the potential risk of severe complications, such as acute pancreatitis.
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Affiliation(s)
- Jernej Vidmar
- Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloska cesta 4, 1000, Ljubljana, Slovenia. .,Jozef Stefan Institute, Laboratory of Magnetic Resonance Imaging, Ljubljana, Slovenia.
| | - Mirko Omejc
- Clinical Department of Abdominal Surgery, University Medical Centre, Ljubljana, Slovenia
| | - Rok Dežman
- Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
| | - Peter Popovič
- Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
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Dumont F, Goéré D, Honoré C, Elias D. Abdominal surgical emergencies in patients with advanced cancer. J Visc Surg 2015; 152:S91-6. [PMID: 26548722 DOI: 10.1016/j.jviscsurg.2015.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abdominal emergency in an advanced oncologic setting is defined as an acute life-threatening abdominal pathology in a patient with incurable cancer. These include bowel obstruction, infections and, more rarely, hemorrhage. To benefit the patient, surgery should both increase the survival and improve the quality of life. These two goals are of equal importance and must be achieved together. This is difficult because these patients are frail, often malnourished and have a poor performance status. They also have a high risk of post-operative morbidity and mortality, a major risk of symptom recurrence and a limited life expectancy. For patients near the end-of-life, a therapeutic decision for surgical intervention must respect ethical and legal standards. This review reports the surgical outcomes and median survival of these patients, specifies rules that must be known and respected, and presents non-operative interventional alternatives.
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Affiliation(s)
- F Dumont
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France.
| | - D Goéré
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - C Honoré
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - D Elias
- Département de chirurgie oncologique, Gustave-Roussy Cancer Campus, Grand Paris, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
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Shah AA, Rehman A, Haider AH, Sayani R, Sayyed RH, Ali K, Zafar SN, Rehman ZU, Zafar H. Angiographic embolization for major trauma in a low-middle income healthcare setting--A retrospective review. Int J Surg 2015; 18:34-40. [PMID: 25865084 DOI: 10.1016/j.ijsu.2015.03.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/22/2015] [Accepted: 03/26/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Interventional radiology (IR) provides a range of adjunctive techniques to assist with hemorrhage control after trauma that can be employed pre- or post-operatively. The role of IR in lower-middle income countries (LMICs) remains unexplored. This study describes the use of adjunctive angioembolization (AE) in severely injured patients following its recent implementation at an urban trauma center in a LMIC. METHODS Adult patients (≥ 16 years) requiring AE from 2011 to 2013 at a single trauma-care facility were included. Data was collected on demographic parameters, transfer status, injury severity score (ISS), emergency resuscitation characteristics, AE and operative characteristics, complications, and in-hospital mortality. Descriptive analyses were performed. RESULTS Thirty six patients underwent AE for trauma-related hemorrhagic complications and were included in the study. Average age was 31.5 (± 11.3) years with a male preponderance (91.7%). Penetrating trauma (61.1%) was the most common type of injury. The primary mechanism of injury was gunshot (58.3%). The median ISS was 24 (IQR: 20-29). Pre-operative AE was performed in 23 (63.9%) patients and these patients had a lower median ISS (22) than those who underwent post-operative AE (p = 0.015). Hepatic (55.6%) and pelvic (33.3%) trauma more commonly required radiological intervention. Bleeding from the right hepatic (n = 14), and the right internal iliac (n = 6) arteries and/or their branches, were more often embolized. Microcoils were the preferred AE agents (61.1%). Median length of hospital stay was 7.5 (IQR: 3-14) days. Eight (22.2%) patients did not survive. CONCLUSION With the availability of multi-detector computed tomography and a dedicated interventional radiology suite, implementation of AE for the care of trauma patients in LMIC settings is possible.
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Affiliation(s)
- Adil Aijaz Shah
- Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Harvard School of Public Health and Harvard Medical School, Boston, MA, USA
| | - Abdul Rehman
- Aga Khan University Hospital, Department of Surgery, Karachi, Pakistan
| | - Adil Hussain Haider
- Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Harvard School of Public Health and Harvard Medical School, Boston, MA, USA
| | - Raza Sayani
- Aga Khan University, Department of Radiology, Karachi, Pakistan
| | | | - Kamran Ali
- Aga Khan University Hospital, Department of Surgery, Karachi, Pakistan
| | - Syed Nabeel Zafar
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Zia-ur Rehman
- Aga Khan University Hospital, Department of Surgery, Karachi, Pakistan
| | - Hasnain Zafar
- Aga Khan University Hospital, Department of Surgery, Karachi, Pakistan.
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Ierardi AM, Floridi C, Fontana F, Duka E, Pinto A, Petrillo M, Kehagias E, Tsetis D, Brunese L, Carrafiello G. Transcatheter embolisation of iatrogenic renal vascular injuries. Radiol Med 2013; 119:261-8. [PMID: 24297586 DOI: 10.1007/s11547-013-0343-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 03/18/2013] [Indexed: 12/30/2022]
Abstract
PURPOSE The aim of our study was to review our experience and long-term follow-up in the treatment of iatrogenic renal vascular injuries using transcatheter embolisation. MATERIALS AND METHODS Our retrospective analysis of cases collected in two interventional centres consists of a total of 21 patients who underwent renal arterial embolisation (RAE) for iatrogenic arterial kidney bleeding. Biopsy (n = 4), percutaneous nephrolithotomy (n = 4), nephron-sparing surgery (n = 4), guidewire-induced arterial perforation during coronary angiography or renal stenting (n = 3), percutaneous nephrostomy (n = 3), renal endopyelotomy/pyeloplasty (n = 2) and surgical nephrectomy were the iatrogenic causes. Seven patients presented with haemodynamic instability requiring blood transfusion (33.3%), the remaining were haemodynamically stable (66.7%). Diagnostic renal angiography revealed 9 actively bleeding vessels, 6 pseudoaneurysms, 4 arteriovenous fistulas and 1 arterio-calyceal fistula. In one patient selective renal arteriography was negative probably because the bleeding observed at CT angiography was self-limited. Twenty-one embolisation procedures were performed in 20 patients; one patient required a second embolisation 3 h after the first one. Embolisation was performed with microcoils, polyvinyl alcohol particles, embospheres, spongostan emulsion and vascular plug. RESULTS The technical success rate was 100%. The overall clinical success rate was 95%. Apart from a patient who died due to disseminated intravascular coagulation, no major complications requiring intensive care treatment were encountered during or after the procedures. No patient required emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared after RAE. CONCLUSIONS Percutaneous treatment can be proposed as a first-line treatment in iatrogenic renal arterial injuries, resulting in a safe and effective procedure.
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Affiliation(s)
- Anna Maria Ierardi
- Interventional Radiology, Department of Radiology, Insubria University, Viale Borri 57, 21100, Varese, Italy
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Friebe B, Wieners G. Radiographic techniques for the localization and treatment of gastrointestinal bleeding of obscure origin. Eur J Trauma Emerg Surg 2011; 37:353. [DOI: 10.1007/s00068-011-0128-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 05/31/2011] [Indexed: 12/11/2022]
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