Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

Effects of percutaneous cryoablation for renal tumor on overall and split renal function

PURPOSE

To evaluate retrospectively the influence of percutaneous cryoablation for small renal tumors on total and affected kidney function and risk factors associated with worsening function of the affected kidney.

MATERIALS AND METHODS

Between April 2016 and March 2022, 27 patients who underwent cryoablation for small renal tumors at our institution participated in this study, which investigated time-dependent changes in postoperative renal function. We evaluated estimated glomerular filtration rates (eGFRs) and split renal function revealed by scintigraphy using 99 m technetium-mercaptoacetyltriglycine (99mTc-MAG3) before cryoablation and at 1 week, 1 month, and 6 months after cryoablation. Numerous variables were analyzed to assess risk factors for worsening renal function.

RESULTS

Baseline eGFR (mean ± standard deviation) was 56.5 ± 23.7 mL/min/1.73 m2 (mean ± SD; range, 20.5-112.5). Mean eGFRs at 1 week, 1 month, and 6 months after cryoablation were 57.4 ± 24.5 (19.1-114.9), 57.1 ± 25.1 (21.5-114.9), and 53.8 ± 23.9 mL/min/1.73 m2 (20.0-107.5), respectively. Changes were statistically insignificant (p = 1.0000, = 0.6749, and = 0.0761, respectively). Regarding split renal function, mean baseline contribution of the affected kidney determined by 99mTc-MAG3 was 49.7% ± 6.0% (38.8-63.3%); these rates at 1 week, 1 month, and 6 months after cryoablation were 43.7% ± 8.8 (29.1-70.6%), 46.2% ± 7.7% (32.6-70.3%), and 46.0% ± 8.5% (32.5-67.6%), respectively. Differences from baseline were significant for all periods (p < 0001, < 0001, = 0.0001, respectively). Serum C reactive protein and lactate dehydrogenase at 1 day following cryoablation, tumor's nearness to the collecting system or sinus, and volume of ablated normal renal parenchyma were significantly correlated with decreased contributions of the affected kidney by > 10% after cryoablation.

CONCLUSION

Unlike total renal function, affected kidney function could worsen after cryoablation.

Embosphere microspheres size for bronchial artery embolization in patients with hemoptysis caused by bronchiectasis: a retrospective comparative analysis of 500-750 versus 700-900 μm microspheres

BACKGROUND

Bronchial arterial embolization (BAE) has been accepted as an effective treatment for bronchiectasis-related hemoptysis. However, rare clinical trials compare different sizes of specific embolic agents. This study aims to evaluate whether different Embosphere microsphere sizes change the outcome of BAE.

METHODS

A retrospective review was conducted on consecutive patients with bronchiectatic hemoptysis who were scheduled to undergo BAE treatment during a period from January 2018 to December 2022. The patients received BAE using microspheres of different sizes: group A patients were treated with 500-750 μm microspheres, and group B patients were treated with 700-900 μm microspheres. The cost of embolic microspheres (Chinese Yuan, CNY), duration of hospitalization, complications, and hemoptysis-free survival were compared between patients in group A and those in group B. A Cox proportional hazards regression model was used to identify predictors of recurrent hemoptysis.

RESULTS

Median follow-up was 30.2 months (range, 20.3-56.5 months). The final analysis included a total of 112 patients (49-77 years of age; 45 men). The patients were divided into two groups: group A (N = 68), which received 500-750 μm Embosphere microspheres, and group B (N = 44), which received 700-900 μm Embosphere microspheres. Except for the cost of embolic microspheres(group A,5314.8 + 1301.5 CNY; group B, 3644.5 + 1192.3 CNY; p = 0.042), there were no statistically significant differences in duration of hospitalization (group A,7.2 + 1.4 days; group B, 8 + 2.4days; p = 0.550), hemoptysis-free survival (group A, 1-year, 2-year, 3-year, 85.9%, 75.8%, 62.9%; group B, 1-year, 2-year, 3-year, 88.4%, 81.2%,59.4%;P = 0.060), and complications(group A,26.5%; group B, 38.6%; p = 0.175) between the two groups. No major complications were observed. The multivariate analysis results revealed that the presence of cystic bronchiectasis (OR 1.61, 95% CI 1.12-2.83; P = 0.001) and systemic arterial-pulmonary shunts (SPSs) (OR 1.52, 95% CI 1.10-2.72; P = 0.028) were independent risk factors for recurrent bleeding.

CONCLUSIONS

For the treatment of BAE in patients with bronchiectasis-related hemoptysis, 500-750 μm diameter Embosphere microspheres have a similar efficacy and safety profile compared to 700-900 μm diameter Embosphere microspheres, especially for those without SPSs or cystic bronchiectasis. Furthermore, the utilization of large-sized (700-900 μm) Embosphere microspheres is associated with the reduced cost of an embolic agent.

Transcatheter arterial embolization with N-butyl cyanoacrylate for postoperative hemorrhage treatment following pancreatoduodenectomy

PURPOSE

Postoperative hemorrhage (PPH) is a severe complication of pancreatoduodenectomy (PD) with a mortality rate of 5-20.2% and mortality due to hemorrhage of 11-58%. Transcatheter arterial embolization (TAE) has been widely recommended for PPH, however, TAE with N-butyl cyanoacrylate (NBCA) for PPH treatment has been reported rarely. Therefore, this study aimed to evaluate the safety and efficacy of TAE with NBCA for PPH treatment following PD.

METHODS

This retrospective study included 14 male patients (mean age, 60.93 ± 10.97 years) with postoperative hemorrhage following PD treated with TAE using NBCA as the main embolic agent from October 2019 to February 2022. The clinical data, technical and success rate, and complications were analyzed.

RESULTS

Among the 14 patients who underwent TAE, the technical and clinical success rates were 100 and 85.71%, respectively. Angiography revealed contrast extravasation in 12 cases and a pseudoaneurysm in 3 cases. One patient developed a serious infection and died 2 days after the TAE.

CONCLUSION

TAE with NBCA for PPH treatment following PD, especially for massive hemorrhage caused by a pancreatic fistula, biliary fistula, or inflammatory corrosion, can result in rapid and effective hemostasis with high safety.

Transarterial Embolization for Adhesive Capsulitis of the Shoulder: Midterm Outcomes on Function and Pain Relief

PURPOSE

To determine the safety and potential effectiveness of transarterial embolization for adhesive capsulitis of the shoulder.

MATERIALS AND METHODS

This prospective study analyzed consecutive adult patients with adhesive capsulitis referred for embolization between January 2018 and May 2023 after a poor response to treatment (symptoms and limitation of motion in ≥2 axes; ≤120° flexion, ≤50° external rotation and/or internal rotation with the shoulder abducted 90°) persisting for >3 months after having completed ≥6 weeks of analgesics and physical therapy. Different types of pain and mobility were measured before embolization and 1, 3, and 6 months after embolization. Overall upper limb function (Quick Disabilities of Arm, Shoulder, and Hand) and patient satisfaction were measured before and 6 months after embolization. Long-term follow-up comprised telephone interviews and clinical history reviews.

RESULTS

A total of 20 patients (12 [60%] women; median age, 50.7; interquartile ranges [IQR], 45‒55 years) were included; 6 (30%) had diabetes and 15 (75%) were off work. Median duration of symptoms before embolization was 39.4 weeks (IQR, 28‒49 weeks), and median duration of rehabilitation therapy was 12.8 weeks (IQR, 8‒16 weeks). Six months after embolization, significant improvements were observed in nocturnal pain (P = .003), pain on moving (P = .001), external rotation (P < .001), internal rotation (P < .001), active flexion (P < .001), passive flexion (P = .03), active abduction (P < .001), passive abduction (P < .001), and overall function (P < .001). Despite objective improvements, patient satisfaction was nearly unchanged. Only 1 patient experienced a mild adverse event.

CONCLUSION

Transarterial embolization is safe and potentially effective in treating adhesive capsulitis of the shoulder refractory to conventional treatment. Clinical improvements were maintained in the mid to long term.

Splenic artery embolisation for blunt splenic trauma: 10 years of practice at a trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has transformed the management of splenic trauma. The aim of this study was to review the outcomes and postprocedural management of blunt splenic trauma patients treated with SAE at a trauma centre over a 10-year period.

METHODS

Details of patients undergoing SAE for blunt trauma between January 2012 and January 2022 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information, splenic injury grades, embolisation efficacy, complications, and associated injuries and mortality. Data relating to Injury Severity Scores (ISS) and postprocedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained.

RESULTS

Thirty-six patients (24 male, 12 female) with a median age of 42.5 years (range 13-97 years) were identified. American Association for the Surgery of Trauma splenic injury grades were III (n = 7), IV (n = 20) and V (n = 9). Seventeen patients had isolated splenic injury and 19 had additional injuries to other organ systems. Median ISS was 18.5 (range 5-50). SAE succeeded first time in 35/36 cases, and upon the second attempt in 1/36 cases. No patients died because of splenic injury or SAE although four patients with polytrauma died owing to other injuries. SAE complications occurred in 4/36 cases. For survivors, vaccinations were administered in 17/32 cases, and long-term antibiotics were initiated in 14/32 cases. Formal follow-up imaging was arranged in 9/32 cases.

CONCLUSIONS

These data show that SAE is an effective means of controlling splenic haemorrhage secondary to blunt trauma with no patient requiring subsequent laparotomy. Major complications occurred in 11% of cases. Follow-up practice varied regarding further imaging, antibiotic and vaccination administration.

Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND

Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial.

PURPOSE

To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients.

METHODS

This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes.

RESULTS

Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points.

CONCLUSION

Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Early outcomes of transcatheter arterial embolization using imipenem/cilastatin for plantar fasciitis refractory to conservative therapy

OBJECTIVE

The conservative therapy for chronic plantar fasciitis works for a few patients, while surgical options have drawbacks. Before considering surgical options, transcatheter arterial embolization may help patients with plantar fasciitis who are experiencing discomfort resistant to conservative treatment.

METHODS

We report evaluation data of 10 patients treated with transcatheter arterial embolization using imipenem/cilastatin as embolic agents to relieve chronic pain due to plantar fasciitis. All the patients were refractory to conservative therapy.

RESULTS

The technical success of the procedure was found to be 100%. Further, effective pain relief was observed as there was no pain relapse in 6 months, and patients did not require any other form of therapy.

CONCLUSION

This report warrants further adequately designed randomized clinical studies for evaluating the efficacy of transcatheter arterial embolization in plantar fasciitis.

ADVANCES IN KNOWLEDGE

Resorting to surgical option for chronic pain relief in plantar fasciitis might be reconsidered and replaced with arterial embolization. However, adequately designed long-term clinical studies are required to prove its long-term efficacy.

Correlation between functional drainage and survival in malignant biliary obstruction after percutaneous biliary drainage

Purpose

Malignant biliary obstruction (MBO) is common in patients with advanced malignant tumors, leading to poor prognosis and hindering antitumor therapy. The purpose of our study was to assess the survival outcomes for patients under therapy after percutaneous transhepatic biliary drainage (PTBD) and identify prognostic factors associated with survival in patients with MBO.

Methods

From July 2010 to February 2021, 269 patients with MBO secondary to malignant tumor were divided into two groups (functional success and non-functional success). Survival time and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

Results

The overall median survival time after PTBD was 4.6 months (95 % IC:3.9-5.3). The 3- and 6-month survival rates were 68.0 % and 38.7 %, respectively. The median survival improved from 3.2 months to 8.4 months when the procedure achieved functional success. Multivariate analysis demonstrated that functionally successful drainage and antitumor treatment after PTBD were independent positive prognostic factors, but the total bilirubin after drainage and tumor size were independent negative predictive values.

Conclusions

Functionally successful drainage could prolong survival time in patients with malignant biliary obstruction. Palliative care after drainage can prolong patient survival and improve their quality of life.

Case Report: Combined transcatheter arterial embolization and aortic stent-graft have better efficacy for bronchial artery aneurysms

Bronchial artery aneurysm (BAA) is a rare and fatal condition that requires immediate treatment. However, conventional surgical and transcatheter arterial embolization treatments are less effective. In the present case, a 76-year-old hypertensive woman was admitted with dizziness and diagnosed with an unruptured bronchial artery aneurysm, which was treated by transcatheter arterial embolization and aortic stent-graft. The patient's clinical status was stable during the 4-year follow-up. Simultaneously, we reviewed 79 research papers, analyzing past BAA cases for their etiology, symptoms, and treatment outcomes. We found that catheter arterial embolization and aortic stent-graft implantation, especially for BAA of short-necked and arterial tortuosity, demonstrate superior efficacy compared to other methods. Therefore, we consider this approach to be the preferred choice in clinical BAA treatment.

CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms

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.

Preliminary Experience with a Low-Profile High-Density Braid Occluder for Transcatheter Embolization of Pulmonary Arteriovenous Malformations

This brief report describes safety, technical feasibility, and early treatment effectiveness of the low-profile braided occluder (LOBO; Okami Medical, San Diego, Caliornia) for embolization of 9 pulmonary arteriovenous malformations (PAVMs) in 4 patients (3 female and 1 male; age range: 33 to 63 years; 3 patients showed positive results for hereditary hemorrhagic telangiectasia genes). A total of 10 occluders were deployed in 10 vessels (median treated vessel diameters, 3 and 4 mm for LOBO-3 and LOBO-5 groups, respectively). All devices were successfully deployed into the feeder pulmonary arteries, achieving complete cessation of flow. There were no severe adverse events or device migrations. Available short-term follow-up computed tomography (6 PAVMs: median, 7 months; range, 1.5-7 months) demonstrated complete occlusion without persistence or recanalization. The early experience of embolization of PAVMs using a low-profile braided occluder showed it to be safe and effective. Further studies with larger cohorts and longer follow-up periods are warranted.

Nonoperative management with angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients: a systematic review and meta-analysis

PURPOSE

The objective of the present study is to provide a comprehensive review of the literature on associated outcomes of angioembolization in blunt abdominal solid organ traumas.

METHODS

The databases of Medline, Embase, and Cochrane Library were explored until 24 September 2021. All studies with data on the efficacy or safety of angioembolization in patients suffering from hemodynamically unstable blunt abdominal solid organ trauma were included. The primary outcomes were clinical success rate and mortality. Pooled event rates were calculated using a double arcsine transformation to stabilize the variance of the original proportion.

RESULTS

In total, 13 reports of 12 studies were included in the systematic review. According to the current meta-analysis, the angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients had a high clinical success rate [0.97 (95% CI 0.93-0.99)] and low mortality [0.03 (95% CI 0.01-0.07)]. Furthermore, no statistically significant difference was found between the various injured solid organs for either of these parameters. In addition, the technique-associated adverse events were seldom and tolerable.

CONCLUSIONS

For blunt abdominal solid organ trauma in hemodynamically unstable patients, this review shows that angioembolization exhibited a high clinical success rate, low mortality, and tolerable technique-related adverse events. Furthermore, the top possible indication for angioembolization in hemodynamically unstable patients is an individual who responds to rapid fluid resuscitation. However, high-quality and large-scale trials are needed to confirm these results and determine the selection criteria for appropriate patients in this setting.

A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding

Background and Objectives: Transcatheter arterial embolization (TAE) is the mainstay of treatment for acute major hemorrhage, even in patients with coagulopathy and spontaneous bleeding. Coagulopathy is associated with worsening bleeding severity and higher mortality and clinical failure rates. Furthermore, some unanswered questions remain, such as the definition of coagulopathy, the indication for TAE or conservative treatment, and the choice of embolic agent. This study aims to assess the efficacy and safety of TAE for spontaneous non-neurovascular acute bleeding in patients with coagulopathy. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients with coagulopathy who had undergone, from January 2018 to May 2023, transcatheter arterial embolization for the management of spontaneous hemorrhages. Results: During the study interval (January 2018-May 2023), 120 patients with coagulopathy underwent TAE for spontaneous non-neurovascular acute bleeding. The abdominal wall was the most common bleeding site (72.5%). The most commonly used embolic agent was polyvinyl alcohol (PVA) particles or microspheres (25.0%), whereas coils and gelatin sponge together accounted for 32.5% of the embolic agents used. Technical success was achieved in all cases, with a 92.5% clinical success rate related to 9 cases of rebleeding. Complications were recorded in 12 (10%) patients. Clinical success was significantly better in the group of patients who underwent correction of the coagulopathy within 24 h of TAE. Conclusions: Transcatheter arterial embolization (TAE) is effective and safe for the management of acute non-neurovascular bleeding in patients with coagulopathy. Correction of coagulopathy should not delay TAE and vice versa, as better clinical outcomes were noted in the subgroup of patients undergoing correction of coagulopathy within 24 h of TAE.

Transcatheter Arterial Embolization (TAE) of Cancer-Related Bleeding

Background and Objectives: Roughly 10% of cancer patients experience an episode of bleeding. The bleeding severity can range from occasional trivial bleeds to major bleeding. The treatment for the bleeding may vary, depending on the clinical condition and anatomical site, and may include various strategies, among which TAE is a cornerstone of major bleeding management. However, the existing literature on tumor hemorrhages is inconsistent. The objective of this multicenter retrospective cohort study was to evaluate the effectiveness and safety of arterial embolization in the treatment of tumor hemorrhages in patients with solid cancers. Materials and Methods: The data for patients with solid cancers undergoing TAE for the management of tumor hemorrhages from January 2020 to May 2023 were gathered. Results: A total of 92 patients with cancer-related bleeding were treated between January 2020 and May 2023. No bleeding was detected by X-ray angiography (XA) in 12 (13%) cases; therefore, a blind embolization was performed. The most common bleeding site was the liver (21.7%). A total of 66 tumor hemorrhages were spontaneous. The most commonly used embolic agent was polyvinyl alcohol (PVA) particles (30.4%). Technical success was achieved in 82 (89.1%) cases, with an 84.8% clinical success rate related to 14 cases of rebleeding. Proximal embolization was performed for 19 (20.7%) patients. Complications were recorded for 10 (10.9%) patients. The 30-day bleeding-related mortality was 15.2%. The technical success, clinical success, proximal embolization rate, and 30-day rebleeding were worse in the subset of patients undergoing TAE with coils. Conclusions: Transcatheter arterial embolization (TAE) represents a viable and potentially life-saving therapeutic approach in the management of tumor hemorrhages, demonstrating a notable effectiveness and safety. The TAE of bleeding tumors using coils resulted in a higher rate of non-superselective proximal embolization, with a trend toward lower clinical success rates and higher rebleeding episodes.

Transcatheter Arterial Embolization (TAE) in the Management of Bleeding in the COVID-19 Patient

Background and Objectives: Increasing attention is being paid to the coagulation disorders associated with SARS-CoV-2 infection. Bleeding accounts for 3-6% of COVID-19 patient deaths, and is often a forgotten part of the disease. The bleeding risk is enhanced by several factors, including spontaneous heparin-induced thrombocytopenia, thrombocytopenia, the hyperfibrinolytic state, the consumption of coagulation factors, and thromboprophylaxis with anticoagulants. This study aims to assess the efficacy and safety of TAE in the management of bleeding in COVID-19 patients. Materials and Methods: This multicenter retrospective study analyzes data from COVID-19 patients subjected to transcatheter arterial embolization for the management of bleeding from February 2020 to January 2023. Results: Transcatheter arterial embolization was performed in 73 COVID-19 patients for acute non-neurovascular bleeding during the study interval (February 2020-January 2023). Coagulopathy was observed in forty-four (60.3%) patients. The primary cause of bleeding was spontaneous soft tissue hematoma (63%). A 100% technical success rate was recorded; six cases of rebleeding resulted in a 91.8% clinical success rate. No cases of non-target embolization were observed. Complications were recorded in 13 (17.8%) patients. The efficacy and safety endpoints did not differ significantly between the coagulopathy and non-coagulopathy groups. Conclusions: Transcatheter Arterial Embolization (TAE) is an effective, safe and potentially life-saving option for the management of acute non-neurovascular bleeding in COVID-19 patients. This approach is effective and safe even in the subgroup of COVID-19 patients with coagulopathy.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Safety, Efficacy and Mid-Term Outcome for Transarterial Embolization (TAE) of Renal Angiomyolipoma (AML) Using Ethylene Vinyl Alcohol Copolymer Liquid Embolic Agent (EVOH)

Transarterial embolization (TAE) of renal angiomyolipoma (AML) is effective in treating and preventing hemorrhage. We report our experience using EVOH with a single-center retrospective study of all AML embolized with EVOH between June 2013 and March 2022 at the Montpellier University Hospital. A total of 29 embolizations were carried out in 24 consecutive patients (mean age: 53.86 years; 21 women and 3 men) with 25 AMLs for severe bleeding, symptomatic AML, tumor size > 4 cm, or presence of aneurysm(s) > 5 mm. Data collected included imaging and clinical outcomes, tuberous sclerosis complex status, change in AML volume, rebleeding, renal function, volume and concentration of EVOH used, and complications. Out of 29 embolizations performed for 25 AMLs, four were performed in an emergency. Technical success was achieved for 24/25 AMLs. Mean AML volume reduction was 53.59% after a mean follow-up time of 446 days using MRI or CT scan. Aneurysms on angiogram and the symptomatological nature of AML, as well as secondary TAE and multiple arterial pedicles, were statistically associated (p < 0.05). Two patients (8%) underwent nephrectomy after TAE. Four patients had a second embolization. Minor and major complication rates were 12% and 8%, respectively. Neither rebleeding nor renal function impairment was noticed. TAE of AML using EVOH is, thus, highly effective and safe.

Does the presence of systemic artery-pulmonary circulation shunt during bronchial arterial embolization increase the recurrence of noncancer-related hemoptysis? A retrospective cohort study

BACKGROUND

The presence of systemic artery-pulmonary circulation shunt (SPS) during the bronchial arterial embolization (BAE) procedure, has been inferred to be a potential risk factor for recurrence. The aim of this study is to reveal the impact of SPS on the recurrence of noncancer-related hemoptysis after BAE.

METHODS

In this study, 134 patients with SPS (SPS-present group) and 192 patients without SPS (SPS-absent group) who underwent BAE for noncancer-related hemoptysis from January 2015 to December 2020 were compared. Four different Cox proportional hazards regression models were used to clarify the impact of SPSs on hemoptysis recurrence after BAE.

RESULTS

During the median follow-up time of 39.8 months, recurrence occurred in 75 (23.0%) patients, including 51 (38.1%) in the SPS-present group and 24 (12.5%) in the SPS-absent group. The 1-month, 1-year, 2-year, 3-year and 5-year hemoptysis-free survival rates in the SPS-present and SPS-absent groups were 91.8%, 79.7%, 70.6%, 62.3%, and 52.6% and 97.9%, 94.7%, 89.0%, 87.1%, and 82.3%, respectively (P < 0.001). The adjusted hazard ratios of SPSs in the four models were 3.37 [95% confidence intervals (CI), 2.07-5.47, P < 0.001 in model 1], 1.96 (95% CI, 1.11-3.49, P = 0.021 in model 2), 2.29 (95% CI, 1.34-3.92, P = 0.002 in model 3), and 2.39 (95% CI, 1.44-3.97, P = 0.001 in model 4).

CONCLUSIONS

The presence of SPS during BAE increases the recurrence probability of noncancer-related hemoptysis after BAE.

Efficacy and Safety of Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs) in Transcatheter Arterial Embolization (TAE) of Acute Non-Neurovascular Bleeding: A Multicenter Retrospective Cohort Study

Background and Objectives: Transcatheter arterial embolization (TAE) is part of the daily practice of most interventional radiologists worldwide. The ideal liquid embolic agent is far from being identified. Non-adhesive liquid embolic agents (NALEA) harden from the outside to the inside, resulting in deep penetration, known as "magma-like" progression, which permits a more distal embolization with good control of the embolic material. This multicenter retrospective cohort study aims to assess the efficacy, feasibility and safety of transcatheter arterial embolization (TAE) with ethylene-vinyl alcohol (EVOH)-based NALEAs (Onyx and Squid) in acute bleeding outside of the neurovascular area. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients who had undergone, from January 2015 to December 2022, transcatheter arterial embolization with non-adhesive EVOH-based agents in the setting of acute non-neurovascular bleeding. Results: Fifty-three patients underwent transcatheter arterial embolization for acute non-neurovascular bleeding. Eight (15.1%) procedures were performed in patients with coagulopathy. The most used concentration of EVOH-based NALEAs was 34 (i.e., 8%), with a mean dose of 0.5 (±0.3) mL. The mean CT-to-groin time, the mean procedure time, the mean CT-to-embolization time and the mean fluoroscopy time were 22.9 (±12.4) min, 27.5 (±7) min, 50.3 (±13.1) min and 7.5 (±2.8) min, respectively. Technical success was achieved in all cases with a 96.2% clinical success rate. Complications were recorded in six (11.3%) patients. No statistically significant differences were observed between the group of patients with coagulopathy and the group of patients without coagulopathy in terms of efficacy and safety endpoints. Conclusions: Transcatheter arterial embolization (TAE) performed with non-adhesive EVOH-based embolic agents is an effective, feasible and safe strategy for the management of acute non-neurovascular bleeding, even in the subgroup of patients with coagulopathy.

Coil Embolization of True, Common and Proper, Hepatic Artery Aneurysms: Technique, Safety and Outcome

PURPOSE

To retrospectively assess the safety and efficacy of coil embolization for catheter-directed true common and proper hepatic artery aneurysm exclusion.

MATERIALS AND METHODS

Nine consecutive patients (2005-2021) in two university centers presenting with true common and proper hepatic artery aneurysms (> 2 cm in diameter) were treated with 'frontdoor-backdoor' coil embolization. Patients presenting with a hepatic artery pseudoaneurysm, mycotic aneurysm or patients with small (< 2 cm diameter) aneurysms and followed up by imaging were excluded. Technical and clinical success was defined as complete coil-exclusion of the aneurysm on completion angiography and absence of post-embolization adverse events, in particular mass effect or hemorrhage, respectively. Patient characteristics, technical and clinical success, liver function tests and follow-up results were assessed based on the patients' electronic medical records.

RESULTS

Technical and 30-day clinical success was achieved in all procedures (100%). No major procedural complications were reported. Liver function test values were available in 6/9 patients, showing transient elevation of bilirubin in one patient. No end organ ischemia was reported. The mean clinical follow-up period of the study patients was 72 months (12-168 months). Long-term stable occlusion of the hepatic aneurysms was achieved in 9/9 patients (100%). One patient showed late complication (3 years) with coil migration into a bulbar ulcer, without aneurysm recanalization, however with fatal outcome.

CONCLUSION

Coil embolization for the endovascular exclusion of true common and proper hepatic artery aneurysms is safe and effective.

Bronchial Artery Embolization in Management of Hemoptysis in a Developing Country: An Initial Experience

Purpose This article evaluates the immediate success, recurrence rate, complications, and the culprit vessel of bronchial artery embolization (BAE) in patients presenting with hemoptysis.

Methods and Materials All patients who underwent BAE from July 1, 2018 to August 31, 2021 were included. BAE was done for moderate to severe hemoptysis or for mild hemoptysis which was recurrent and not controlled by medical management. Patients referred for surgical intervention and hemoptysis controlled on medical management were excluded.

Results One hundred and thirty patients underwent BAE in the study period. Mean age was 41.5 years and majority (73.1%) was male. Forty-three (33.1%) patients had mild, 46 (35.4%) had moderate, and 41 (31.5%) with the duration of symptoms ranging from 3 days to 25 years. Most common culprit vessel was posterior intercostal artery closely followed by the intercostobronchial artery. Hypervascularity was the most common angiographic abnormality encountered. On an average, 2.75 vessels were embolized per BAE with a wide range of 1 to 8 vessels. Hemoptysis control was seen in 96.1% patients immediately, 90.7 % at 1 month, 82.3 % at 3 months, and 66.9 % at 6 months. Overall recurrence was seen in 43 patients (33.1%). Chest pain was the most common minor side effect occurring in 77.1% cases.

Conclusion BAE is a safe and effective procedure that can be performed routinely in patients presenting with moderate to massive hemoptysis or with mild hemoptysis refractory to medical management.

Prophylactic Steroids for Preventing Postembolization Syndrome after Transcatheter Arterial Embolization of Renal Angiomyolipoma: A Comparative Study

Purpose

Postembolization syndrome (PES) after renal arterial embolization (RAE) can reduce the patient's tolerance of the procedure and extend the length of hospital stay. We aimed to assess the efficacy of steroid administration in preventing PES in patients undergoing RAE for angiomyolipoma (AML).

Material and Methods

Between May 2004 and March 2020, 29 RAE procedures in 26 patients with AML were performed. Patient information, including age, sex, tumor size, tuberous sclerosis complex-associated/sporadic AML, hemorrhagic/nonhemorrhagic AML, embolic material, steroid use, medication type, some blood laboratory parameters, hospital stay, and PES occurrence were retrospectively obtained. The prophylactic steroid protocol used in the study was as follows: 250 mg of intravenous methylprednisolone (Solu-Medrol) 2 h before the RAE procedure, followed by 2 days of intravenous prednisolone (Predonine; 2 mg/kg/day), which was tapered by halving the dose every 2 days within the course of 2 weeks. After the discharge, intravenous prednisolone was changed to oral prednisolone (Predonine). PES was defined as the presence of fever, pain, nausea, or vomiting. Data were compared between the steroid and non-steroid groups and between PES and non-PES groups.

Results

The PES incidence rate was 76%, and a comparison between the steroid and non-steroid groups revealed that steroid use significantly decreased the incidence of PES (P < 0.001), including fever (P < 0.001), pain (P = 0.005), and nausea (P = 0.028). The use of anti-inflammatory drugs during the hospital stay was significantly lower in the steroid group (P = 0.019). Moreover, in the steroid group, C-reactive protein level was significantly lower (P = 0.006), whereas white blood cell count was significantly higher (P = 0.004). Conversely, the median length of hospital stay was not significantly shorter in the steroid group (P = 0.292).

Conclusions

The prophylactic use of steroids before and after embolization of renal AML may be effective in preventing PES in this small retrospective study.

Clinical features and management of Chinese anti-neutrophil cytoplasmic antibody-associated vasculitis patients with spontaneous renal hemorrhage: a single-center report and systematic review

INTRODUCTION

Spontaneous renal hemorrhage (SRH) in ANCA-associated vasculitis (AAV) is rare but fatal. We aimed to characterize clinical manifestations and managements of AAV patients with SRH.

METHOD

Hospitalized AAV patients were screened from January 2000 to April 2021, at Peking Union Medical College Hospital (PUMCH). Also, a systematic review was based on retrieving all the relevant literature from PubMed, MedlinePlus, and Web of Science until April 2021. Clinical features, management, and prognosis of the patients were collected and concluded.

RESULTS

In PUMCH, four out of 1640 AAV patients with SRH were included in our study; three had granulomatosis with polyangiitis (GPA) and one had microscopic polyangiitis (MPA). The ratio of men to women was 3 to 1, and the average age of onset was 55 years. The Birmingham Vasculitis Activity Score (BVAS) ranged from 21 to 23. Combining with documented reports, 13 patients were diagnosed as AAV complicated with SRH (including four from PUMCH), 7 with GPA, and 6 with MPA. Mean BVAS was 25.2 ± 6.6. The symptoms of SRH presented as severe back or abdominal pain. Patients with SRH to age- and gender-matched patients without SRH were compared, and we found that in the SRH group, the duration of disease was shorter, and BVAS, renal function, and inflammatory markers (WBC and ESR) were significantly greater, whereas Hb, Alb, and renal function greatly reduced.

CONCLUSION

This is the first summary of clinical features and treatments of SRH in AAV. Patients with AAV in early stage and with high disease activity appeared to be more likely to develop SRH. Key Points • This is the first summary of clinical features and treatments of SRH in AAV. • SRH more likely occurs in AAV patients in the early stage (≤ 3 months) and with high disease activity. • Clinicians should be aware of the possibility of SRH when AAV patients complain of back or abdominal pain.

Safety and effectiveness of uterine fibroid embolization in patients with scarred uterus

AIM

To evaluate the safety and effectiveness of uterine fibroid embolization (UFE) in patients with a scarred uterus caused by a previous myomectomy or cesarean section.

METHODS

A total of 140 patients who underwent embolization for symptomatic fibroids were included in this retrospective study. The patients were divided into two groups, those with a history of myomectomy and/or cesarean section (scarred uterus group, n = 56), and those without surgical history involving the uterus (no-scar group, n = 84). Demographics, embolization details, outcomes, and complications were analyzed.

RESULTS

The overall clinical success rate was 89.28% in the scarred uterus group and 95.24% in the no-scar group. There was no statistical difference in infarction rate or change in fibroid volume in follow-up magnetic resonance imaging between the groups. There was one major complication in the no-scar group, but there was no statistical difference in complications between the groups. The mean follow-up period was 25.9 months. The mean symptom-free time was 27.2 months in the scarred uterus group and 21.9 months in the no-scar group without a significant difference. There were no statistically significant differences in symptom changes, recurrence, and complication rates between the groups. Recurrence seen on imaging or regrowth was more common in the group with myomectomy history. However, there was no significant difference in symptom recurrence rates.

CONCLUSION

No statistically significant difference in technical and clinical outcomes was observed between the two groups. There was no significant increase in complication rates of UFE in scarred uterus group.

Portal vein embolization with absolute ethanol to induce hypertrophy of the future liver remnant

Background

Preoperative portal vein embolization (PVE) is widely used prior to major liver resection to reduce the risk of post-hepatectomy liver failure (PHLF). We evaluated the efficacy and safety of PVE using absolute ethanol.

Methods

Consecutive patients undergoing preoperative PVE between February 2003 and February 2020 at a high-volume tertiary institution were retrospectively reviewed. Hypertrophy of the future liver remnant (FLR) was determined by comparing volumetric data using semi-automated software on computed tomography or magnetic resonance imaging before and after PVE. Efficacy of absolute ethanol was evaluated by the percentage increase in the FLR volume and the ratio of the FLR to the total liver volume (TLV). Technical success and complications following PVE were evaluated. Feasibility of hepatectomy following PVE and the incidence of PHLF were determined.

Results

Sixty-two patients underwent preoperative PVE using absolute ethanol. The technical success rate was 95.2%. Median time interval between PVE and follow-up imaging was 34 days (range 6–144 days). The mean increase in FLR volume and ratio of the FLR to TLV were 43.6 ± 34.4% and 12.3 ± 7.7% respectively. Major adverse events occurred in 3 cases (4.8%) and did not preclude consideration of surgery. Forty-two patients (67.8%) proceeded to surgery for intended hepatectomy of which 36 patients (58.1%) underwent liver resection. Major post-operative complications occurred in 4 patients (11.1%) and there were no cases of PHLF.

Conclusion

Preoperative PVE with absolute ethanol is effective and safe in inducing hypertrophy of the FLR before partial hepatectomy to prevent PHLF.

Transarterial Embolization for Active Gastrointestinal Bleeding: Predictors of Early Mortality and Early Rebleeding

Background: The aim of this study was to determine predictive factors of early mortality and early rebleeding (≤30 days) following transarterial embolization (TAE) for treatment of acute gastrointestinal bleeding. Methods: All consecutive patients admitted for acute gastrointestinal bleeding to the interventional radiology department in a tertiary center between January 2012 and January 2022 were included. Exclusion criteria were patients: (1) aged < 18-year-old, (2) referred to the operation room without TAE, (3) treated for hemobilia, (4) with mesenteric hematoma, (5) lost to follow-up within 30 days after the procedure. We evaluated pre and per-procedure clinical data, biological data, outcomes, and complications. Results: Sixty-eight patients were included: 55 (80.9%) experienced upper gastrointestinal bleeding and 13 (19.1%) lower gastrointestinal bleeding. Median age was 69 (61−74) years. There were 49 (72%) males. Median hemoglobin was 7.25 (6.1−8.3) g/dL. There were 30 (50%) ulcers. Coils were used in 46 (67.6%) procedures. Early mortality was 15 (22.1%) and early rebleeding was 17 (25%). In multivariate analysis, hyperlactatemia (≥2 mmol/L) were predictive of early mortality (≤30 days). A high number of red blood cells units was associated with early rebleeding. Conclusion: This study identified some predictive factors of 30-day mortality and early rebleeding following TAE. This will assist in patient selection and may help improve the management of gastrointestinal bleeding.

Long-Term Efficacy and Recurrence Prediction of Prostatic Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

PURPOSE

To explore the efficacy of prostatic artery embolization (PAE) for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) during long-term follow-up and analyze predictors related to LUTS recurrence.

METHODS

This was a single-center retrospective study involving 125 BPH patients with LUTS who underwent PAE from February 2014 to February 2020. The median follow-up was 36 months. Clinical success was defined as reductions in the International Prostate Symptom Score (IPSS) and quality of life (QoL) score and no need for any other treatment for LUTS; otherwise, it was regarded as a clinical failure. Recurrence was defined as a clinical failure that occurred after an initial success. Cumulative clinical success rates, recurrence rates and re-intervention rates were evaluated. Friedman test was performed to compare differences in IPSS, QoL and prostatic volume (PV) among baseline and follow-up times. Predictors for LUTS recurrence were analyzed with the univariate and multivariate Cox regression model.

RESULTS

Technical success (bilateral PAE) rate was 92.8% (116/125). Significant differences in IPSS, QoL and PV were observed between baseline and follow-up time points (P < 0.001). The cumulative clinical success rates at 2, 3, 4 and 5 years were 82.4%, 65.5%, 52.4% and 37.4%. The cumulative recurrence rates and re-intervention rates at 1, 2 and 5 years were 6.8%, 12.7%, 60.4% and 5.9%, 10.2%, 50.8%, respectively. Unilateral PAE was an significant predictor of recurrence (P < 0.05).

CONCLUSIONS

PAE is an effective treatment option for LUTS. Unilateral PAE is a significant independent predictor of LUTS recurrence.

Comparison of n-butyl-2-cyanoacrylate and polyvinyl alcohol particles for bronchial artery embolisation in primary lung cancer: a retrospective cohort study

BACKGROUND

Bronchial artery embolisation (BAE) is an effective treatment option to control haemoptysis in primary lung cancer. However, no studies have investigated optimal embolisation material for BAE in lung cancer patients. Thus, this study aimed to compare the safety and efficacy of BAE performed using n-butyl-2-cyanoacrylate (NBCA) and polyvinyl alcohol (PVA) particles in primary lung cancer patients to determine which embolic material is better for patients with haemoptysis.

METHODS

This retrospective study was approved by the institutional review board, and consent was waived. The rates of hemostasis, complications, procedure time, dose-area product, and haemoptysis-free survival were retrospectively compared between primary lung cancer (non-small cell [n = 111] and small cell [n = 11]) patients who underwent BAE using NBCA (n = 58) or PVA particles (n = 64) between January 2004 and December 2019. Predictors of recurrent haemoptysis were analysed using the Cox proportional hazard regression model.

RESULTS

Among 122 patients (mean age, 66 ± 10 years; range 32-86 years; 103 men), more patients in the NBCA group (81.0%; 47 of 58) achieved complete hemostasis than did patients in the PVA group (53.1%; 34 of 64) (P = 0.002). No major complications were observed in either group. The procedure time (36.4 ± 21.6 vs. 56.3 ± 27.4 min, P < 0.001) was shorter, and the dose-area product (58.6 ± 64.0 vs. 233.5 ± 225.0 Gy*cm², P < 0.001) was smaller in the NBCA group than in the PVA group. The median haemoptysis-free survival was 173.0 in the NBCA group compared with 20.0 days in the PVA group (P < 0.001). The PVA use (P < 0.001) and coagulopathy (P = 0.014) were independent predictors of shortened haemoptysis-free survival.

CONCLUSION

BAE using NBCA showed significantly superior initial hemostasis with longer haemoptysis-free survival, shorter procedure time, and reduced radiation dose than BAE using PVA particles. The PVA use and coagulopathy were independent predictors of recurrent haemoptysis.

TRIAL REGISTRATION

Retrospectively registered.

Splenic vein embolization as a feasible treatment for patients with hepatic encephalopathy related to large spontaneous splenorenal shunts

INTRODUCTION AND OBJECTIVES

Although splenic vein embolization (SVE) has been performed for the management of patients with hepatic encephalopathy (HE) related to large spontaneous splenorenal shunts (SSRS) in recent years, its role remains poorly defined. In this study, we aimed to explore the safety and efficacy of SVE for HE patients with large SSRS.

MATERIALS AND METHODS

Data from cirrhotic patients who were confirmed to have recurrent or persistent HE related to large SSRS and underwent SVE from January 2017 to April 2021 were retrospectively collected and analyzed at our center. The primary endpoints were the change of HE severity at 1 week after embolization and the recurrence of HE during the follow-up period. The secondary endpoints were procedure-related complications and changes in laboratory indicators and hepatic function (Child-Pugh score/grade and model for end-stage liver disease score).

RESULTS

Of the eight cirrhotic patients included in the study, six were diagnosed with recurrent HE, and the others were diagnosed with persistent HE. Embolization success was achieved for all patients (100%), and no immediate procedure-related complications, de novo occurrence, or aggravation of symptoms related to portal hypertension were observed during the long-term follow-up. HE status was assessed at 1 week after embolization. The results demonstrated that the symptoms were mitigated in three patients and resolved completely in five patients. During the follow-up period, all patients were free of HE within 1 month after embolization, but one patient experienced the recurrence of HE within 6 months and another one experienced the recurrence of HE within 1 year. Compared with the preoperative parameters, the Child-Pugh score and grade were significantly improved at 1 week and 1 month after embolization (all P<0.05), and the serum ammonia level was significantly lower at 1 month after embolization (P<0.05).

CONCLUSIONS

SVE could be considered as a feasible treatment for patients with HE related to large SSRS, but further validation is required.

Transcatheter arterial embolization for gastrointestinal bleeding: Clinical outcomes and prognostic factors predicting mortality

We evaluated clinical outcome and prognostic factors predicting mortality of transcatheter arterial embolization (TAE) for acute gastrointestinal (GI) bleeding. Fifty-nine patients (42 men, 17 women; mean age 66.1 ± 17.0) who underwent 59 TAE procedures for GI bleeding during 2013-2018 were retrospectively evaluated. Clinical outcomes included technical success, adverse events, and rebleeding and mortality rate within 30 days. The technical success rate was 100%. Angiography showed contrast extravasation in 41 (69.5%) patients and indirect signs of bleeding in 16 (27.1%) patients. Two (3.4%) patients underwent prophylactic embolization. TAE-related adverse events occurred in 7 (11.9%) patients; adverse events were more common for mid GI or lower GI bleeding than for upper GI bleeding (22.6% vs 0%, P = 0.007). Rebleeding within 30 days was observed in 22 (37.3%) patients after TAE. Coagulopathy was a prognostic factor for rebleeding (odds ratio [OR] = 3.53, 95% confidence interval 1.07-11.67, P = .038). Mortality within 30 days occurred in 11 (18.6%) patients. Coagulopathy (OR = 24, 95% confidence interval 2.56-225.32, P = .005) was an independent prognostic factor for mortality within 30 days. TAE is an effective, safe, and potentially lifesaving procedure for GI bleeding. If possible, coagulopathy should be corrected before TAE as it may reduce rebleeding and mortality.

Embolization of bronchial arteries and nonbronchial systemic arteries with n-butyl-cyanoacrylate in patients with hemoptysis: A retrospective single-center study

OBJECTIVES

To evaluate the safety and efficacy of the embolization of bronchial arteries and nonbronchial systemic arteries with n-butyl-cyanoacrylate (NBCA) in patients with hemoptysis.

METHODS

We analyzed a total of 55 consecutive patients with hemoptysis (14 mild, 31 moderate, and 10 massive) treated with the embolization of bronchial arteries and nonbronchial systemic arteries with n-butyl-cyanoacrylate between November 2013 and January 2020. The main variables analyzed were the rates of technical success, of clinical success, of recurrence, and of complications. Statistics included a descriptive analysis and Kaplan-Meier survival curves.

RESULTS

Embolization was a technical success in 55 (100%) and a clinical success in 54 (98.2%). During follow-up (mean, 23.8 months; interquartile range, 9.7-38.2 months), hemoptysis recurred in 5 (9.3%) patients. The nonrecurrence rate was 91.9% one year after the initial procedure and 88.7% two years and four years after the initial procedure. Minor complications related with the procedure occurred in 6 (10.9%); no major complications occurred.

CONCLUSIONS

The embolization of bronchial arteries and nonbronchial systemic arteries with n-butyl-cyanoacrylate is safe and efficacious for controlling hemoptysis, resulting in low recurrence rates.

Safety and efficacy of transcatheter arterial embolization for management of refractory hematuria of prostatic origin

Objective

To estimate the safety and efficacy of transcatheter arterial embolization (TAE) in the treatment of refractory hematuria of prostatic origin (RHPO).

Methods

This retrospective study included 23 patients who underwent TAE for RHPO between May 2013 and August 2021. Technical and clinical success rates were calculated, and arteriogram findings and complications were detected.

Results

Embolization was performed 24 times in 23 patients. Technical success was achieved in 24/24 (100%) embolization procedures. Contrast agent extravasation was detected during 2 of the 24 angiographic procedures. Bilateral embolization was performed in 23 (95.8%) of the 24 procedures. The clinical success rate was 21/23 (91.3%), and hematuria stopped 1–4 days after TAE. No serious complications were observed.

Conclusion

TAE is a safe and effective minimally invasive technique for treating patients with RHPO.

Bronchial artery embolization for hemoptysis caused by metastatic hepatocellular carcinoma

Because of its extremely rare incidence, the safety and efficacy of bronchial artery embolization (BAE) for the treatment of hemoptysis caused by pulmonary metastasis from HCC are not well known. We therefore evaluated the safety and efficacy of BAE in these patients. Data from 18 patients with hepatocellular carcinoma (HCC) and pulmonary metastasis who received BAE for the treatment of hemoptysis between 2003 and 2021 were retrospectively reviewed. Technical and clinical success were achieved in 100% and 94% of patients, respectively. Of the 18 embolization procedures, six were performed using polyvinyl alcohol (PVA) particles only, five were performed using gelfoam only, three were performed using gelfoam plus microcoils, one was performed using PVA plus microcoils, one was performed using embospheres, one was performed using lipiodol plus PVA and gelfoam, and one was performed using hystoacryl with microballoon protection. In eight patients for whom CT just before BAE and at follow-up were available, the mean size of the largest metastatic tumor decreased from 5.1 to 3.7 cm (P = 0.035). Hemoptysis recurred in three patients (17%) during follow-up. The median overall and hemoptysis-free survival periods were 149 days and 132 days, respectively. BAE is an effective and safe option for the treatment of hemoptysis in patients with pulmonary metastasis from HCC, with a favorable clinical success rate and a low rate of hemoptysis recurrence. In addition, we also observed BAE to have a positive antitumor effect on pulmonary metastases from HCC, but this requires confirmation in a future study.

CIRSE Standards of Practice on Bronchial Artery Embolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing bronchial artery embolisation to effectively treat haemoptysis. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2

BACKGROUND

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia.

PURPOSE

To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia.

MATERIAL AND METHODS

Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed.

RESULTS

Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications.

CONCLUSION

NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients

BACKGROUND

There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay.

PURPOSE

To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding.

MATERIAL AND METHODS

The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32).

RESULTS

The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding.

CONCLUSION

In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Ovarian Vein Embolization With N-butyl-2 Cyanoacrylate Glubran-2® for the Treatment of Pelvic Venous Disorder

Background: There are few reports in the literature on the use of Glubran-2 for the embolization of ovarian veins in patients with pelvic venous disorder (PeVD). In addition, a consensus on the efficacy and safety of Glubran-2 has not been reached. Purpose: To investigate the safety and efficacy of ovarian vein embolization (OVE) with N-butyl-2 cyanoacrylate (NBCA) Glubran-2 for the treatment of PeVD. Material and Methods: Between January 2013 and January 2020, 21 women (mean age, 43.9 ± 13.3 years) with PeVD who underwent OVE with Glubran-2 were evaluated. Of those patients, ovarian vein or pelvic venous plexus insufficiency was verified by duplex ultrasound and/or multislice computer tomography (MSCT). The symptoms and signs of PeVD included chronic pelvic pain (CPP) (21/21; 100%), dyspareunia (12/21; 57.1%), dysmenorrhea (10/21; 47.6%), and vulvar varices (3/21; 14.3%). The medical data were retrospectively reviewed. Results: Glubran-2 was employed as the sole embolic material in 18 cases (85.7%) and used to perform rescue embolization in 3 cases (14.3%) due to CPP recurrence 1 month after initial embolization using microcoils. Technically successful embolization was achieved using Glubran-2 in all patients. No Glubran-2 related complications were noted. Neither persistent nor recurrent CPP was observed during follow-up, for which the mean was 62 ± 38 months (range, 12-102 months). Clinical efficacy was evaluated, and all patients exhibited complete or slight improvement of CPP after embolization. The visual analog scale (VAS) score significantly decreased from pre-intervention to post-intervention (p < 0.001). Six patients (28.6%) gave birth to healthy babies during follow-up after embolization with Glubran-2. Conclusions: Ovarian vein embolization with Glubran-2 is a feasible and safe treatment for CPP secondary to PeVD. This treatment may represent a potential and attractive alternative when patients desire symptom relief and want to continue reproducing. Larger studies are warranted to confirm the findings of this study.

Endovascular repair of visceral artery aneurysms and pseudoaneurysms in 159 patients: twelve years' experience of clinical technique

OBJECTIVES

The purpose of this study was to evaluate the therapeutic efficacy and safety of endovascular treatment for patients with visceral and renal artery aneurysms (VRAAs). Twelve years of experience with interventional procedures and treatment options in our center were also worth discussing.

METHODS

From January 2009 to December 2020, clinical data of 159 consecutive patients with VRAAs were retrospectively analyzed. Patients' demographic and clinical data were recorded, and the safety and efficacy of endovascular therapy were evaluated. In addition, interventional procedures were also described.

RESULTS

A total of 159 patients underwent angiography, and 154 patients were successfully treated with endovascular therapy, with a technical success rate of 96.9%. Of the 154 patients with successful endovascular therapy, 3 patients died within 30 days of treatment, with a 30-day mortality rate of 1.9%, and the remaining patients were clinically successful, with a clinical success rate of 98.1%. Fifty-seven patients underwent emergency interventional treatment due to ruptured aneurysm. There were statistically significant differences in hemoglobin before and after emergency treatment (78.5 ± 22.0 g/dL vs. 93.8 ± 15.0 g/dL, P = 0.00). No other serious complications occurred except death in 3 patients.

CONCLUSION

Endovascular treatment of VRRAs is safe and effective and can significantly improve the symptoms of patients, especially those with ruptured aneurysms.

Development of a model to predict recurrence after bronchial artery embolization for non-cancer related hemoptysis

Background

Relapse after effective bronchial arterial embolization (BAE) for controlling hemoptysis is not uncommon. Studies reported diverse predictors of recurrence. However, a model to assess the probability of recurrence in non-cancer related hemoptysis patients after BAE has not been reported. This study was to develop a model to predict recurrence after BAE for non-cancer related hemoptysis.

Methods

The study cohort included 487 patients who underwent BAE for non-cancer-related hemoptysis between January 2015 and December 2019. We derived the model’s variables from univariate and multivariate Cox regression analyses. The model presented as a nomogram scaled by the proportional regression coefficient of each predictor. Model performance was assessed with respect to discrimination and calibration.

Results

One-month and 1-, 2-, 3- and 5-year recurrence-free rates were 94.5%, 88.0%, 81.4%, 76.2% and 73.8%, respectively. Risk factors for recurrence were underlying lung diseases and the presence of systemic arterial-pulmonary circulation shunts. This risk prediction model with two risk factors provided good discrimination (area under curve, 0.69; 95% confidence interval, 0.62–0.76), and lower prediction error (integrated Brier score, 0.143).

Conclusion

The proposed model based on routinely available clinical and imaging features demonstrates good performance for predicting recurrence of non-cancer-related hemoptysis after BAE. The model may assist clinicians in identifying higher-risk patients to improve the long-term efficacy of BAE.

Scheduling surgery after transarterial embolization: does timing make any difference to intraoperative blood loss for renal cell carcinoma bone metastases?

PURPOSE

Our purpose is to clarify the optimal timing of surgery after transarterial embolization (TAE) for renal cell carcinoma (RCC) bone metastases.

METHODS

This retrospective study included 41 patients with RCC bone metastases embolized between 2013 and 2019. Different-sized particulate and/or liquid embolic agents were used for TAE. Embolizations were categorized into groups 1-3 according to the interval between TAE and surgery (group 1: <1 day, group 2: 1-3 days, group 3: >3 days). Degree of embolization after TAE was graded visually based on angiographic images (<50%, 50%-75%, 75%-90%, >90%). The relationship between the TAE-surgery interval and intraoperative blood loss (IBL) and the correlation between IBL and embolization grade were examined. Lesion sizes and the relationships among lesion localizations and contrast media usage, intervention time, and IBL were also analyzed.

RESULTS

Forty-six pre-operative TAEs (single lesion at each session) were performed in this study (26 in group 1, 13 in group 2, 7 in group 3). Lesion sizes and distributions were similar between groups (p = 0.897); >75% devascularization was achieved in 40 (TAEs 86.96%), but the IBL showed no correlation with the embolization rate (r=0.032, p = 0.831). The TAE-surgery interval was 1-7 days. The median IBL in group 1 (750 mL; range, 150-3000 mL) was significantly lower than those in the other groups (p = 0.002). Contrast media usage (p = 0.482) and intervention times (p = 0.261) were similar for metastases at different localizations. IBL values after TAE were lower for extremity metastases (p = 0.003).

CONCLUSION

Bone metastases of RCC are well-vascularized, and to achieve lowest IBL values, surgery should preferably be performed <1 day after TAE.

Bronchial artery embolization for hemoptysis: A systematic review and meta-analysis

Objective

To assess the safety and efficacy of bronchial artery embolization (BAE) for hemoptysis.

Methods and materials

Databases with articles published in English, including Pubmed, Embase, Web of science and Chochrane library, were comprehensively searched to get accurate, up-to-date and sufficient literature about BAE for hemoptysis until March 2020. The technical success rates, immediate control rates, recurrence rates, mortality rates, and total complication rates (minor and major complication rates) extracted from the articles were pooled to estimate and assess the efficacy and safety of BAE using random-effect and fixed-effect models.

Results

21 articles published between 2008 and 2019, which include a total of 2511 patients, were studied to evaluate the safety and efficacy of BAE. The technical success and immediate control rates are 99.9% (95%CI: 99%–100%) and 99.5% (95%CI: 97.8%–99.2%), respectively. This study showed hemoptysis recurrence in 23.7% (95%CI: 18.5%–28.9%) with a mortality rate of 2% (95%CI: 0–3%). Additionally, the assessment of complications revealed a total complication rate of 13.4% (95% CI: 7.6–19.2%), in which 0.2% (95% CI: 0.2–0.4%) were major complications and 10% (95% CI: 4.7–9.6%) were minor complications.

Conclusion

BAE is an effective, safe, and feasible procedure with a low complication rate for hemoptysis patients. However, recurrence of hemoptysis is still at high risk after BAE due to different underlying diseases.

Transcatheter Arterial Embolization in Acute Non-Variceal Gastrointestinal Bleedings: A Ten-Year Single-Center Experience in 91 Patients and Review of the Literature

Objective: To report the safety and efficacy of trans-arterial embolization (TAE) for upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) due to different etiologies in 91 patients for ten years. Methods: A retrospective analysis of GIB treated between January 2010 and December 2020 was performed. TAE was performed using different embolic agents (coils, particles, glue, gelatin sponge, and EVOH-based agents). Technical success, secondary technical success, clinical success, and complications were evaluated. Results: Technical success was achieved in 74/91 (81.32%) patients. Seventeen patients (18.68%) required re-intervention. Secondary technical success was achieved in all cases (100.0%). Clinical success was achieved in 81/91 patients (89.01%). No major complications were recorded; overall, minor complications occurred in 20/91 patients. Conclusions: TAE is a technically feasible and safe therapeutic option for patients with GIB from a known or blind anatomic source where endoscopic therapy has failed or is deemed unfeasible.

Angiographic features of pulmonary arteriovenous malformations: a new imaging classification system, BRAND, to guide embolisation

AIM

To introduce a new classification system for pulmonary arteriovenous malformations (PAVMs) based on the BRanches, ANgles and Diameter of the feeding artery (BRAND), which is intended provide a better understanding of the vascular structure of PAVMs and facilitate the selection of therapeutic strategies for embolisation.

MATERIALS AND METHODS

Twenty-one patients with PAVMs from 2005 to 2020 were reviewed retrospectively. According to angiographic morphology, classified the PAVMs using the BRAND classification.

RESULTS

A total of 41 PAVMs were treated with transcatheter embolisation. Based on the BRAND classification, there were four branches (9.8%), four acute angles (9.8%), and 32 occlusion sites >4 mm in diameter (78%). A total of 30 PAVMs (73.2%) were treated with occluders and plugs while the rest were embolised with coils (26.8%). Immediate technical success was achieved in all patients. In feeding arteries with acute angles, balloon-assisted tracking and trans-septal puncture techniques were used to facilitate the advancement of delivery systems. All origins of branches were preserved. Mean SaO₂ increased significantly from 79.5 ± 7.5% before embolisation to 92 ± 5.3% after embolisation (p<0.05). During a median follow-up of 5.4 years, two patients (9.5%) developed new PAVMs and required a second procedure. One patient (4.8%) underwent repeat embolisation due to the reperfusion of previously embolised PAVMs with coils.

CONCLUSIONS

BRAND classification is well suited to address the challenging feeding arteries of PAVMs and allow precise placement of the delivery system, leading to minimal procedural risk and high success rates.

Selective Arterial Embolization of Renal Angiomyolipomas with a N-Butyl Cyanoacrylate-Lipiodol Mixture: Efficacy, Safety, Short- and Mid-Term Outcomes

Selective arterial embolization (SAE) for renal angiomyolipoma (rAML) is effective to treat or prevent bleeding. We report our experience using a cyanoacrylate–Lipiodol mixture. We performed a single-center retrospective review of all rAMLs embolized with cyanoacrylate glue between July 2014 and June 2020. Demographics, tuberous sclerosis complex (TSC) status, clinical presentation, angiography features, and follow-up data were recorded. Pre- and post-procedure rAML sizes and volumes were estimated from computed tomography (CT) or magnetic resonance imaging (MRI) studies. Kidney function was assessed before and after the procedure. We identified 24 patients (22 females and 2 males, mean age 51 years) treated for 27 AMLs, either prophylactically (n = 20) or as an emergency (n = 4). Technical success was achieved for 25/27 AMLs; two patients, each with a single AML, required nephrectomy and repeated embolization, respectively. Major complications occurred in three patients and minor complications such as postembolization syndrome in 15 patients. AML volume reduction after embolization was 55.1% after a mean follow-up of 15 months (range, 1–72 months). Factors associated with greater volume reduction were a smaller percentage of fat (p = 0.001), larger initial rAML volume (p = 0.014), and longer follow-up (p = 0.0001). The mean creatinine level did not change after SAE. Embolization of rAMLs with a mixture of cyanoacrylate and Lipiodol is feasible, safe, and effective in significantly decreasing tumor volume.

Urgent Transcatheter Arterial Embolization for Wunderlich Syndrome With Hypovolemic Shock Secondary to Ruptured Renal Angiomyolipoma

Purpose: Wunderlich syndrome (WS) with hypovolemic shock secondary to ruptured renal angiomyolipoma (rAML) represents an urgent condition. Hence, we reported our experience with transcatheter arterial embolization (TAE) using different embolic materials under this condition.

Methods: This retrospective study consisted of 22 patients. Embolic materials including particles, microcoils, and liquid embolic agents were selectively used based on the decisions of interventional radiologists. Technical success was defined as the complete occlusion of bleeding vessels on the final renal angiogram. Clinical success was defined as the absence of re-hemorrhage needed for repeat endovascular or surgery treatment after TAE.

Results: The articulated materials were used when WS presented without aneurysms; a combination of particulate materials and microcoils or Glubran 2 alone were used for WS with aneurysms. The technical success based on 24 episodes of TAEs in 22 patients was 100% (24 of 24). Repeat TAE was achieved in two patients with hemorrhages re-occurring two days after the initial embolization with microcoils alone. The clinical success was 90.9% (20 of 22). No nontarget embolization or embolization-related complications occurred during the TAE procedure. Of the patients, 27.3% (6 of 22) experienced minor complications of post-embolization syndrome (PES). During a median follow-up time of 34 months, no recurrent hemorrhage that required repeat endovascular or surgical treatment for hemostasis occurred.

Conclusion: Urgent TAE with the selective use of different embolic materials is an effective alternative to control WS with hypovolemic shock secondary to ruptured rAML. The condition of presenting with or without aneurysms may determine the embolic materials employed.