Amplatzer Vascular Plug to occlude the internal iliac arteries in patients undergoing aortoiliac aneurysm repair

Embolization of Vessels With Irregular Lumen Using the Coil Packing Technique Between the Amplatzer Vascular Plug II Lobes

INTRODUCTION

The Amplatzer Vascular Plug (AVP) series enables precise positioning and high migration resistance, allowing embolization in short segments; however, inadequate embolization or recanalization may occasionally occur. We hypothesized that leaks may occur when AVPs are implanted in vessels with irregular lumen due to insufficient adherence to the vessel. This hypothesis was tested by experiments with a vascular model. We employed a coil packing technique between the AVP lobes to embolize internal iliac arteries with an irregular lumen.

METHODS

Saline was injected through the Y-shaped glass tubes of the stenotic and the smooth model (without stenotic lesion), and the amount of leakage was measured when the AVP was deployed. The feasibility and effectiveness of filling coils between the lobes of AVP II were evaluated. A total of 11 cases were retrospectively reviewed using this technique for internal iliac artery embolization prior to endovascular aortic repair.

RESULTS

The amount of leakage was significantly higher in the presence of stenotic lesions. Insertion of a 2.2 F microcatheter from the side of the proximal lobe of AVP II and filling of coils was achieved in all 11 cases. Follow-up contrast-enhanced CT showed no recanalization, leakage, or other obvious complications.

CONCLUSION

Coil packing technique around Amplatzer Vascular Plugs could be an effective method and a reliable option for arterial embolization, especially in vessels with irregular lumens.

Degrees of macrophage-facilitated healing in aneurysm occlusion devices

Insufficient healing of aneurysms following treatment with vascular occlusion devices put patients at severe risk of fatal rupture. Therefore, promoting healing and not just occlusion is vital to enhance aneurysm healing. Following occlusion device implantation, healing is primarily orchestrated by macrophage immune cells, ending with fibroblasts depositing collagen to stabilize the aneurysm neck and dome, preventing rupture. Several modified occlusion devices are available currently on-market. Previous in vivo work demonstrated that modifications of occlusion devices with a shape memory polymer foam had enhanced aneurysm healing outcomes. To better understand cellular response to occlusion devices and improve aneurysm occlusion device design variables, we developed an in vitro assay to isolate prominent interactions between devices and key healing players: macrophages and fibroblasts. We used THP-1 monocyte derived macrophages and human dermal fibroblasts in our cell culture models. Macrophages were allowed device contact with on-market competitor aneurysm occlusion devices for up to 96 h, to allow for any spontaneous device-driven macrophage activation. Macrophage secreted factors were captured in the culture media, in response to device-specific activation. Fibroblasts were then exposed to device-conditioned macrophage media (with secreted factors alone), to determine if there were any device-induced changes in collagen secretion. Our in vitro studies were designed to test the direct effect of devices on macrophage activation, and the indirect effect of devices on collagen secretion by fibroblasts to promote aneurysm healing and stabilization. Over 96 h, macrophages displayed significant migration toward and interaction with all tested devices. As compared to other devices, shape memory polymer foams (SMM, Shape Memory Medical) induced significant changes in gene expression indicating a shift toward an anti-inflammatory pro-healing M2-like phenotype. Similarly, macrophages in contact with SMM devices secreted more vascular endothelial growth factor (VEGF) compared with other devices. Macrophage conditioned media from SMM-contacted macrophages actively promoted fibroblast secretion of collagen, comparable to amounts observed with exogenous stimulation via VEGF supplementation. Our data indicate that SMM devices may promote good aneurysm healing outcomes, because collagen production is an essential step to ultimately stabilize an aneurysm.

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair

Purpose

This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications.

Materials and Methods

Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors.

Results

IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication.

Conclusion

The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Results from the First-in-Human Study of the Caterpillar™ Arterial Embolization System

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.

Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma

Purpose:

Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries.

Materials and methods:

A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared.

Results:

A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001).

Conclusion:

Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.

Endovascular management of an isolated common iliac artery aneurysm: a case report

Isolated iliac artery aneurysms are rare, and treatment by conventional surgery gives good results. Endovascular repair of such aneurysms has recently become the preferred form of treatment, provided the appropriate anatomy for endovascular repair exists. We report the case of a 60-year-old man admitted in our department for an aneurysm of the left primitive iliac artery revealed by intermittent claudication and treated by a covered stent after embolization of the hypogastric artery by an Amplatzer Vascular Plug with a good result. This case highlights the importance of preservation of the collaterals of the hypogastric artery when you treat such entity; in order to avoid transient gluteal claudication and sexual dysfunction.

The use of the Amplatzer Vascular Plug in the prevention of endoleaks during abdominal endovascular aneurysm repair: A systematic literature review on current applications

OBJECTIVES

The Amplatzer Vascular Plug (AVP) is a vascular occlusion device designed to provide optimal embolization in several fields of the endovascular surgery. A full literature review was conducted to analyze AVPs in comparison with coils for the prevention of endoleaks during endovascular abdominal aortic aneurysm repair.

METHODS

A systematic review was designed under PRISMA statement guidelines for systematic reviews and meta-analyses. The results were updated with a subsequent electronic search using Medline and Scopus databases up to December 2019.

RESULTS

Eighteen articles making this comparison were found. In 79.7% of the cases, the target vessel was the internal iliac artery; in 1.6%, the common iliac artery; and in 16.7%, the inferior mesenteric artery. Risk of complications (buttock claudication, groin hematoma, endoleaks, and erectile dysfunction) after AVP was low. A cost comparison revealed that the mean cost for coils was around US$2262, while the average cost for the AVP was US$310.

CONCLUSIONS

The AVP is an effective and safe device for occluding peripheral vessels, proved to have lower complications rates. Compared with coil embolization, the AVP technique is potentially associated with lower procedural costs.

Coil-Covering Caliber-Conforming Stent Grafting: The 4CSG Technique

Stable coil placement is an imperative when treating arterial pathology at branch points. Coil kick and escape threaten distal organs, particularly as the pack tightens. Before the development of the VBX balloon-expandable stent graft (W.L. Gore, Flagstaff, AZ), vessel caliber change often precluded straightforward stent graft coverage with a single device to secure coils in place. We describe 3 cases using this unique feature of the Gore VBX device to accommodate challenging anatomy. All 3 patients recovered well.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience

PURPOSE

To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods.

MATERIALS AND METHODS

This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers.

RESULTS

Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case.

CONCLUSIONS

The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

Endovascular Embolization of Coronary Artery-Pulmonary Artery Fistulas with Double Coronary Aneurysms

A 75-year-old woman with chest discomfort and a continuous murmur was admitted to our hospital. During noninvasive examination, computed tomography angiography showed a coronary artery-pulmonary artery fistula with double giant coronary aneurysms (one was 42 mm× 32 mm× 32 mm, and the other was 25 mm× 20 mm× 17 mm) arising from the proximal part of the left anterior descending (LAD) artery. Stress myocardial scintigraphy showed ischemia at the LAD area. Given her frailty, the heart team, including cardiac surgeons, judged that surgical treatment would be difficult. Thus, endovascular embolization for the abnormal vessels was selected. After coronary angiography, two coronary aneurysms were embolized by 53 coils, and the feeding artery was embolized by two coils and one Amplatzer Vascular Plug 4™. A small pulmonary artery fistula remained after the procedures; thus, additional embolization was performed 3 months after the index procedure. Thereafter, angiography showed no flow into the aneurysms, and her symptoms improved.Endovascular embolization might be an effective treatment to achieve aneurysm occlusion in patients at high risk for surgical treatment. Although the present case had double coronary aneurysms with a large feeder vessel, the combination procedure of coils and vascular plug was able to embolize this abnormal vessel.

Endovascular management of pancreatitis-related pseudoaneurysms: A review of techniques

Objectives

To present the various techniques used in the management of pancreatitis-related pseudoaneurysms of visceral vessels.

Methods

The retrospective clinical study was carried out at the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. The fifteen patients included in the study were diagnosed with pseudoaneurysms of visceral arteries, as a complication of chronic pancreatitis. The diagnosis was made using contrast-enhanced computed tomography, followed by angiography. On admission, all patients were symptomatic, with varying degrees of abdominal pain. One patient was haemodynamically unstable. Treatments with endovascular techniques were analysed, along with their efficacy and outcomes. Coil embolisation was performed in 5 patients. Stent graft was used in 1 patient. Liquid embolic agents were used in 7 cases, of which 5 patients were treated with thrombin injection and 2 with Squid. A combination of techniques was used in 2 patients.

Results

The most common artery affected by pseudoaneurysm formation was the splenic artery (7/15; 46.7%), and the size of the pseudoaneurysms ranged from 27 mm to 85 mm. Primary technical success was achieved in 14 out of 15 patients (93.3%). One patient required reintervention. Two patients required splenectomy after embolisation due to splenic ischemia. No recanalisation was present at the follow-up computed tomography performed after 1 to 3 weeks, and no mortality was observed within 30 days.

Conclusion

Vascular complications of pancreatitis require accurate diagnosis and immediate treatment. Endovascular intervention is highly effective and is the preferred treatment option. The technique used is determined based on vascular anatomy and the patient’s haemodynamic status.

Amplatzer Vascular Plug for Arteriovenous Hemodialysis Access Occlusion: Initial Experience

Purpose

The Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN) is a recently developed self-expanding metallic device indicated for peripheral vascular embolizations. Herein, we describe use of this device in the treatment of vascular complications related to arteriovenous hemodialysis fistulas and grafts.

Materials and methods

This HIPAA compliant retrospective study was approved by the institutional review board with informed consent waived. Six patients with problematic arteriovenous access underwent access occlusion using the AVP. Procedure indications included vascular steal syndrome in five patients, and enlarging vascular aneurysms in one patient. Contraindications for surgical correction were determined by the referring surgeon. AVP embolizations were performed using devices oversized by 50% introduced through vascular sheaths positioned within vein segments just beyond the arteriovenous anastomoses. Noninvasive evaluation of the involved extremity was performed pre- and post-embolization in addition to clinical follow-up examinations. Measured outcomes included success of angiographic occlusion, improvement in distal arterial flow, AVP number, AVP diameter, time to access occlusion, and clinical symptomatic improvement.

Results

Technical success was 100%, with complete arteriovenous access occlusion accomplished in all cases, with an average of 1.5 AVPs used per patient. Mean time to access occlusion was 19.3 minutes. Angiographic improvement in distal arterial flow was immediately evident and resolution of clinical symptoms occurred in all patients, with mean long-term follow-up of 16 months. No procedure-related complications were encountered.

Conclusion

The Amplatzer Vascular Plug provides a minimally invasive and efficacious method for embolization of problematic arteriovenous hemodialysis access.

Hospital cost impact of orbital atherectomy with angioplasty for critical limb ischemia treatment: a modeling approach

AIM

The incremental cost of peripheral orbital atherectomy system (OAS) plus balloon angioplasty (BA) versus BA-only for critical limb ischemia was estimated.

MATERIALS & METHODS

A deterministic simulation model used clinical and healthcare utilization data from the CALCIUM 360° trial and current cost data. Incremental cost of OAS + BA versus BA-only included differential utilization during the procedure and adverse-event costs at 3, 6 and 12-months.

RESULTS

For every 100 procedures, incremental annual costs to the hospital were US$350,930 lower with OAS + BA compared with BA-only. Despite higher upfront costs, savings were realized due to reduced need for revascularization, amputation and end-of-life care over 6-12-month postoperative period.

CONCLUSION

Atherectomy with OAS prior to BA was associated with cost savings to the hospital.

Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome

OBJECTIVE

Occlusion of the internal iliac artery (IIA) may be necessary prior to endovascular aneurysm repair (EVAR) to prevent endoleak Type II. We compared efficacy and clinical outcome after proximal occlusion of an unaffected IIA (ProxEmbx) using an Amplatzer vascular plug (AVP) I vs distal occlusion of aneurysmatic IIA with coils and plugs (DistEmbx).

METHODS

Between 2009 and 2012, 22 patients underwent EVAR. In 9 patients with unaffected IIA, occlusion was performed by a single AVP. In 13 patients with aneurysmatic IIA, more distal embolization (DistEmbX) was conducted by using several coils and additional AVPs. Retrospectively, technical success, clinical outcome and complications were evaluated.

RESULTS

Embolization of the IIA was successful in all patients. Three patients with more DistEmbX of aneurysmatic IIAs suffered from new onset of sexual dysfunction after occlusion without statistically significant difference (p > 0.05). Transient buttock claudication was observed in three patients in each group. Bowel ischaemia did not occur. The procedure time (p = 0.013) and fluoroscopy time (p = 0.038) was significantly lower in the ProxEmbx group than in the DistEmbx group.

CONCLUSION

Proximal occlusion of an unaffected IIA and more distal occlusion of an aneurysmatic IIA prior to EVAR had the same technical and clinical outcome. However, proximal plug embolization of an unaffected IIA prior to EVAR was associated with shorter procedure and fluoroscopy time in comparison with more DistEmbX of aneurysmatic IIAs. Advances in knowledge: Proximal embolization of unaffected IIA and DistEmbX of aneurysmatic IIA before EVAR are both effective in preventing Type II endoleaks and have the same technical and clinical outcome.

Management of a Type Ia Endoleak With the Nellix Endovascular Aneurysm Sealing System

Purpose: To report the application of the Nellix endovascular aneurysm sealing (EVAS) device, including two chimney grafts, to successfully treat a type Ia endoleak. Case Report: An 87-year-old man had an asymptomatic 7.6-cm infrarenal abdominal aortic aneurysm (AAA) and a 4.5-cm right internal iliac artery aneurysm treated using an aortouni-iliac stent-graft. Two years after the index endovascular repair, an asymptomatic type Ia endoleak was detected on duplex ultrasound; the computed tomographic angiogram (CTA) demonstrated significant sac enlargement and stent-graft migration. Initial attempts to treat the leak with 2 aortic cuffs only reduced the size of the endoleak. Another procedure was undertaken using the Nellix device with chimney grafts to increase the proximal sealing zone above the existing stent-graft. Imaging postoperatively demonstrated successful resolution of the endoleak and continuing patency of both renal artery chimney stent-grafts. CTA at 6 months demonstrated persistent sealing of the endoleak. Conclusion: The use of the EVAS system may represent another endovascular solution that can be added to the clinician’s repertoire for treating type Ia endoleak after conventional endovascular repair of infrarenal AAA.

Splenic Artery Syndrome after orthotopic liver transplantation: a review

Splenic Artery Syndrome (SAS) has emerged as a controversial cause for graft ischemia in orthotopic liver transplant (OLTx) recipients. A complex combination of factors including hepatic artery hypoperfusion and portal hyperperfusion can result in SAS. Clinical and laboratory findings suggest graft ischemia but are generally non-specific. Conventional angiography findings of hepatic artery hypoperfusion with early and rapid filling of the splenic artery are suggestive of the diagnosis in the appropriate clinical setting. Treatment involves proximal splenic artery embolization, surgical splenic artery ligation, or in extreme cases, splenectomy. Most patients with SAS improve clinically following treatment. However, no randomized control trials are available to compare treatment options. Identification of at risk patients with pre-operative CT scans and intra-operative ultrasound has been proposed by some and may allow for prophylactic treatment of SAS.

Internal iliac artery embolization during an endovascular aneurysm repair with detachable interlock microcoils

Objective

The purpose of this study was to evaluate the effectiveness of detachable interlock microcoils for an embolization of the internal iliac artery during an endovascular aneurysm repair (EVAR).

Materials and Methods

A retrospective review was conducted on 40 patients with aortic aneurysms, who had undergone an EVAR between January 2010 and March 2012. Among them, 16 patients were referred for embolization of the internal iliac artery for the prevention of type II endoleaks. Among 16 patients, 13 patients underwent embolization using detachable interlock microcoils during an EVAR. Computed tomographic angiographies and clinical examinations were performed during the follow-up period. Technical success, clinical outcome, and complications were reviewed.

Results

Internal iliac artery embolizations using detachable interlock microcoils were technically successful in all 13 patients, with no occurrence of procedure-related complications. Follow-up imaging was accomplished in the 13 cases. In all cases, type II endoleak was not observed with computed tomographic angiography during the median follow-up of 3 months (range, 1-27 months) and the median clinical follow-up of 12 months (range, 1-27 months). Two of 13 (15%) patients had symptoms of buttock pain, and one patient died due to underlying stomach cancer. No significant clinical symptoms such as bowel ischemia were observed.

Conclusion

Internal iliac artery embolization during an EVAR using detachable interlock microcoils to prevent type II endoleaks appears safe and effective, although this should be further proven in a larger population.

Spinal cord involvement in patients with cirrhosis

A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases; this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic shunt. Hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, while sensory and sphincter disturbances have rarely been described and are usually less important. The diagnosis is assigned in the appropriate clinical setting on clinical grounds after the exclusion of other clinical entities leading to spastic paraparesis. Magnetic resonance imaging is often unremarkable; however, also intracerebral corticospinal tract abnormalities have been reported recently. The study of motor evoked potentials may disclose central conduction abnormalities even before HM is clinically manifest. HM responds poorly to blood ammonia-lowering and other conservative medical therapy. Liver transplantation represents a potentially definitive treatment for HM in patients with decompensated cirrhosis of Child-Pugh B and C grades. Other surgical treatment options in HM include surgical ligation, shunt reduction, or occlusion by interventional procedures.

Endovascular Aneurysm Repair for Multiple Aneurysms as a Sequel of Hypereosinophilic Syndrome

This case represents the first report of multiple arterial aneurysms including aortic, iliac, visceral, and coronary aneurysms associated with hypereosinophilic syndrome. It presents an interesting case of epinephrine abuse and the unfortunate sequelae. This case illustrates novel approaches in emergency repair of internal iliac artery aneurysm rupture and the management of visceral artery aneurysms and exemplifies how multiple endovascular technologies can be utilized even in the high-risk polymorbid patient.

Plugging and sealing technique by Onyx to prevent type II endoleak in ruptured abdominal aortic aneurysm

Control of back bleeding from the hypogastric artery into the aneurysm after endovascular aneurysm repair (EVAR) of a ruptured aorto-iliac aneurysm may be necessary in order to avoid a type II endoleak. It is an emergency situation and selective catheterization and embolization of the hypogastric artery may be time-consuming and more importantly, it has to be performed before complete exclusion of the aneurysm has been established. We describe a plugging and sealing technique that embolizes the hypogastric artery after the exclusion of a ruptured aorto-iliac aneurysm using the embolizing agent Onyx. The mortality rate of the 16 patients treated in our institute with this technique was 25% (4/16) at 30-day and 31% (5/16) at 90-day follow up. One patient had a type II endoleak at one-year follow-up. The EVAR procedure can focus completely on controlling the acute life-threatening situation, with the embolization performed at the end of the procedure.

Balloon-assisted coil embolization of the celiac trunk before endovascular aortic repair of thoracoabdominal aortic aneurysm

PURPOSE

Celiac trunk coil embolization before thoracic endovascular aneurysm repair (TEVAR) of a thoracoabdominal aortic aneurysm involving the celiac trunk can prevent type II endoleaks. One disadvantage of conventional coil embolization is the risk of coil displacement. We performed coil embolization under balloon occlusion of the celiac trunk to address this issue.

MATERIALS AND METHODS

Between December 2008 and January 2011, 5 patients (3 men and 2 women, mean age 76 years) were included in this study. For all patients, after confirming the collateral blood flow from the superior mesenteric artery via the pancreaticoduodenal arcades by using the balloon occlusion test, celiac trunk coil embolization proceeded under balloon occlusion of the proximal part of the celiac trunk.

RESULTS

Balloon-assisted coil embolization of the celiac trunk was completed for all patients without any complications. All coils were deployed as planned in the short segment of the celiac trunk without displacement. Coil migration, ischemic complications, and endoleaks via the celiac trunk did not arise in any of the patients over a follow-up period of 77-637 (mean 258) days.

CONCLUSIONS

Balloon-assisted coil embolization of the celiac trunk before TEVAR could be a feasible treatment option for suitable patients.

Challenging the evidence for pre-emptive coil embolisation of the internal iliac artery during endovascular aneurysm repair

OBJECTIVES

We retrospectively analysed the results of a strategy in which coverage of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR) was routinely performed without coil embolisation.

METHODS

From January 2010 until May 2012, 32 patients (96.9% men; mean age 73.0 years, range 52-89 years) underwent EVAR with stent grafts extended into the external iliac artery (EIA), all without prior coil embolisation. Aneurysm morphology was determined on preoperative computed tomography (CT) images. During follow-up, patients were interviewed about buttock claudication, and the occurrence of endoleaks and evolution of aneurysm diameter were recorded.

RESULTS

At baseline, the mid-common iliac artery (CIA) diameter was 33.5 ± 16.8 mm and seven patients presented with ruptured aneurysms. Mean follow-up was 14.3 ± 7.4 months. There were eight deaths, none related to IIA coverage. Buttock claudication occurred in seven (22.6%) patients, which persisted after 6 months in two cases of bilateral IIA coverage. No Type-I or -II endoleaks occurred related to IIA coverage. Aneurysm growth was not observed.

CONCLUSION

Endovascular treatment of aortoiliac and iliac aneurysm without pre-emptive coil embolisation of the IIA appears safe and effective. No IIA-related endoleaks or re-interventions occurred in our series. This approach saves operating time, contrast load and costs and may reduce complications. However, a larger population and longer follow-up is required to confirm our findings.

Application of Amplatzer vascular occluder in hepatic artery closure as a method of treatment of high-flow arterioportal fistula before liver transplantation

Background:

Arterioportal fistula (APF) is an abnormal, direct connection between hepatic artery or its branch and the portal vein. Fistula can be acquired or, rarely, congenital. One of the acquired causes of fistula is a liver biopsy. Patients with liver cirrhosis are particularly vulnerable to its development due to the large number of performed biopsies. APF increases mortality and morbidity of liver transplantation procedure and may be a contraindication to it. The authors present a patient with liver cirrhosis, in whom percutaneous APF closure facilitated liver transplantation.

Case Report:

We describe a case of a 50-year-old patient with liver cirrhosis and APF, probably formed as a result of liver biopsy. Due to the presence of a high-flow fistula, which elevated portal hypertension, patient did not qualify for the liver transplantation. Patient was transferred to the interventional radiology department, where the fistula’s vascular supply was endovascularly closed using the Amplatzer occluder. This subsequently enabled the execution of transplantation.

Conclusions:

Percutaneous closure of APF should be considered a relatively simple and fast-acting tool to facilitate or even enable liver transplant surgery. Currently, there are more and more products available such as e.g. Amplatzer occluder to simplify the procedure and shorten the duration of exposure to ionizing radiation.

Management of surgical splenorenal shunt-related hepatic myelopathy with endovascular interventional techniques

We present a case with hepatic myelopathy (HM) due to a surgical splenorenal shunt that was successfully treated by endovascular interventional techniques. A 39-year-old man presented with progressive spastic paraparesis of his lower limbs 14 mo after a splenorenal shunt. A portal venogram identified a widened patent splenorenal shunt. We used an occlusion balloon catheter initially to occlude the shunt. Further monitoring of the patient revealed a decrease in his serum ammonia level and an improvement in leg strength. We then used an Amplatzer vascular plug (AVP) to enable closure of the shunt. During the follow up period of 7 mo, the patient experienced significant clinical improvement and normalization of blood ammonia, without any complications. Occlusion of a surgically created splenorenal shunt with AVP represents an alternative therapy to surgery or coil embolization that can help to relieve shunt-induced HM symptoms.

The evaluation of a novel technique to treat saphenous vein incompetence: preclinical animal study to examine safety and efficacy of a new vein occlusion device

Objectives

We tested a novel technique to treat great saphenous vein (GSV) incompetence in an animal model.

Methods

V-block (VVT Medical Ltd, Kfar Saba, Israel), an occlusion device composed of a nitinol frame and anchoring hooks, was percutaneously deployed at the saphenofemoral junction in 12 sheep. Four of the 12 sheep were treated with adjunctive liquid sclerotherapy. Animals underwent duplex ultrasound, venography and histopathological evaluation immediately postimplantation at 30, 60 and 90 days.

Results

V-block was successfully deployed in all animals without adverse events. There was no device migration at follow-up. Histopathological analysis demonstrated V-block to be lodged within the GSV and surrounded by fibrous tissue in all samples. Obliteration of the GSV lumen, widespread intimal loss and multifocal medial smooth muscle loss was noted.

Conclusions

In this animal study V-block was deployed without complications, remained in stable position and led to GSV occlusion. This device has promise for future use in humans.

Pelvic abscess following internal iliac artery embolization prior to endovascular aneurysm repair

We describe a previously unreported case of abscess formation around the right internal iliac artery (IIA) after coil embolization prior to endovascular aneurysm repair (EVAR). A 75-year-old man was admitted for elective repair of a right common iliac aneurysm. The right IIA coil embolization and EVAR procedures were uncomplicated and assessment by postoperative computed tomography (CT) was satisfactory. The patient was readmitted 2 weeks after EVAR with right buttock pain and pyrexia. CT indicated an isolated abscess around the coil-embolized IIA. The patient was successfully treated with CT-guided percutaneous drainage.

Endovascular broad-neck aneurysm creation in a porcine model using a vascular plug

PURPOSE

Ruptured cerebral arterial aneurysms require prompt treatment by either surgical clipping or endovascular coiling. Training for these sophisticated endovascular procedures is essential and ideally performed in animals before their use in humans. Simulators and established animal models have shown drawbacks with respect to degree of reality, size of the animal model and aneurysm, or time and effort needed for aneurysm creation. We therefore aimed to establish a realistic and readily available aneurysm model.

MATERIALS AND METHODS

Five anticoagulated domestic pigs underwent endovascular intervention through right femoral access. A total of 12 broad-neck aneurysms were created in the carotid, subclavian, and renal arteries using the Amplatzer vascular plug.

RESULTS

With dedicated vessel selection, cubic, tubular, and side-branch aneurysms could be created. Three of the 12 implanted occluders, two of them implanted over a side branch of the main vessel, did not induce complete vessel occlusion. However, all aneurysms remained free of intraluminal thrombus formation and were available for embolization training during a surveillance period of 6 h. Two aneurysms underwent successful exemplary treatment: one was stent-assisted, and one was performed with conventional endovascular coil embolization.

CONCLUSION

The new porcine aneurysm model proved to be a straightforward approach that offers a wide range of training and scientific applications that might help further improve endovascular coil embolization therapy in patients with cerebral aneurysms.

Direct insertion of Amplatzer plugs to control lumbar arteries during open repair of type II endoleaks

Type II endoleak after endovascular repair of an infrarenal aortic aneurysm (EVAR) may be difficult to diagnose and treat in the best of circumstances. Management is more difficult in the patient with significant renal insufficiency. We report an 81-year-old man with stage IV chronic kidney disease and a rapidly expanding, asymmetric aortic aneurysm sac, 31 months after EVAR. A type II lumbar endoleak was diagnosed by duplex ultrasound imaging and managed successfully with open aortic exposure and direct insertion of Amplatzer plugs into two bleeding lumbar arteries due to complex anatomic factors.

Occlusion of the Internal Iliac Artery Prior EVAR

Purpose: We compared occlusion of the internal iliac artery (IIA) using coils or the Amplatzer vascular plug (AVP) II prior to endovascular aortic aneurysm repair. Materials and Methods: Occlusion of the IIA was performed in 32 patients (aged 74 ± 8 years) using coils (N = 17) or the AVP II (N = 15). We retrospectively compared procedural data, initial success, and clinical outcome in a 12-month follow-up. Results: Occlusion was successful in all patients without detection of an endoleak after 12 months. Procedure time and fluoroscopy time for coils versus plugs were 77 ± 35 versus 43 ± 13 minutes and 36 ± 19 versus 18 ± 8 minutes, respectively ( P < .003). Incidence of initial buttock claudication (BC) for coils versus plugs was 47% versus 27% and was significantly more severe after coil occlusion ( P = .03). After a 12-month follow-up, 2 patients of each group reported of mild BC. Conclusion: Occlusion of the IIA is safe and effective using coils or plugs. Initial BC is significantly more severe when coils are used, but after a 12-month follow-up, there is no significant difference. Using a plug is associated with a significant reduction of procedure time and radiation exposure.

An overview of embolic agents

Therapeutic embolization is a common procedure in interventional radiology. A wide variety of agents are available, and each has its own place and use. Additionally, many new agents have appeared on the market in the past several years. The aim of this review article is to give a brief description of available agents, guide appropriate selection, and familiarize the reader regarding appropriate use and limitations.

Evaluation of the Nfocus LUNA, a new parent vessel occlusion device: a comparative study in a canine model

BACKGROUND

Parent artery occlusion is sometimes required to treat cerebrovascular lesions.

OBJECTIVE

We evaluated the Nfocus LUNA parent vessel occlusion (PVO) device in comparison with the Vascular Plug (AVP) used in the peripheral vasculature for large-vessel occlusion in a canine animal model.

METHODS

The subclavian arteries were targeted for occlusion in 7 canines. Each animal received 1 LUNA and 1 AVP device sequentially rotated between the left and right subclavian arteries. Angiographic assessment was performed serially after device placement until vessel occlusion was observed and then again immediately before the animal was killed. Three animals were euthanized at 1 month and 4 at 2 months post-implantation, after which the native artery segments containing the implanted device were harvested and preserved for subsequent histological analysis.

RESULTS

The LUNA PVO device and the AVP were accurately positioned and deployed in all cases. Acute occlusion times for the devices were not statistically different. In no instance was there any evidence of device migration. At 28 and 55 days, the LUNA implants showed nearly complete occlusion with small recanalization channels, whereas the AVP devices were associated with low occlusion levels and large residual vascular channels within the occluder.

CONCLUSION

The LUNA PVO device and delivery system can be accurately placed to occlude vessels without migration and with a performance that is similar to the AVP. The LUNA PVO device on average provided a higher degree of occlusion durability at both 1 and 2 months.

Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs

PURPOSE

To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms.

MATERIALS AND METHODS

Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure.

RESULTS

Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events.

CONCLUSIONS

Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.

Utility of the Amplatzer Vascular Plug in splenic artery embolization: a comparison study with conventional coil technique

PURPOSE

To retrospectively evaluate the role of the Amplatzer Vascular Plug (AVP) in proximal splenic artery embolization (SAE) compared with coils.

MATERIALS AND METHODS

Forty patients had proximal SAE performed with AVP(s) or coils as the primary embolic agent for splenic artery steal syndrome (n=23), trauma (n=5), portal hypertension (n=5), bleeding due to pancreatic pathology (n=4), and pre-splenectomy (n=3). Comparisons were made of occlusion and procedure time, cost, and radiation dose.

RESULTS

Eighteen proximal SAE procedures were successfully performed with AVP. Twenty-two procedures were performed with coils, including one failed AVP attempt, which was completed with coils. Precise deployment without migration was achieved in all 18 AVP cases. Seven of 22 (31.8%) coil procedures had distal migration without consequence. There was no statistically significant difference in mean occlusion time (24.4 min for AVP vs. 31.5 min for coils, P=0.13), procedure time (43.7 min for AVP vs. 53.8 min for coils, P=0.16), or cost ($1474.13 for AVP vs. $1722.51 for coils, P=0.69). There was significant difference in radiation dose (842 mGy for AVP vs. 1,309 mGy for coils, P=0.04). Fourteen of the 18 (78%) AVP devices required additional embolic material.

CONCLUSIONS

AVP with additional embolic agents is a useful alternative for proximal SAE because of precise deployment, resistance to migration, and radiation reduction. AVP use may be limited by vessel tortuosity. The occlusion time, procedure time, and cost were reduced but this was not statistically significant due to the need for additional embolic material.