Ultraselective embolization using a 1.7-Fr catheter and soft bare coil for small intestinal bleeding

Use of the triple coaxial (triaxial) microcatheter system in superselective arterial embolisation for complex interventional cases: an initial experience with the system

LEARNING OBJECTIVE

To share our experience in utilising the triple coaxial (triaxial) system in superselective cannulation of arteries for complex embolisation procedures.

BACKGROUND

Percutaneous transcatheter selective embolisation is widely performed for a myriad of oncologic (e.g., trans-arterial chemo- or radio-embolisation) and non-oncologic (e.g., for embolisation of bleeding and benign conditions such as uterine fibroid and benign prostate hyperplasia) purposes. The cornerstone of such embolisation procedures is to achieve superselective cannulation of the arterial supply to the tumour/organ, preventing the complication of non-target embolisation. However, a multitude of factors, such as complex vascular anatomy, can pose challenges to achieving this goal.

CLINICAL FINDINGS/PROCEDURAL DETAILS

The triaxial system utilises two smaller microcatheters telescoped through each other over a microwire. We have adopted the triaxial system for specific cases due to its perceived superior torquability and trackability compared to the conventional coaxial system, in which superselective cannulation is anticipated to be challenging. The triaxial system is also favourable in situations where the inner microcatheter needs to be "sacrificed" after administering the embolics (e.g., after administering radioisotopes in radioembolisation, N-butyl cyanoacrylate [NBCA] glue or ethylene-vinyl alcohol copolymer [EvOH] Onyx). Through a case series with procedural details such as fluoroscopic time, contrast administered, etc., we hope to illustrate the utility and efficacy of the triaxial system as well as present pitfalls in its usage.

CONCLUSION

The triaxial system appears to be a valuable system for certain complex embolisation procedures and could be better suited than the conventional coaxial systems in these specific circumstances.

Diverticular hemorrhage of terminal ileum successfully treated by ultra-selective transcatheter arterial embolization using triaxial system: a case report

Small intestinal hemorrhage due to diverticulum is a relatively rare condition among gastrointestinal hemorrhages. We report a case of diverticular hemorrhage of the terminal ileum that was successfully treated by ultra-selective transcatheter arterial embolization using a triaxial system. A 25-year-old man was referred to our hospital due to melena. Abdominal contrast-enhanced computed tomography demonstrated marked extravasation of contrast medium in a diverticulum of the terminal ileum. We immediately attempted transcatheter arterial embolization after onset of hemorrhagic hypovolemic shock. Angiogram of the superior mesenteric artery revealed apparent hemorrhage at the end of the ileocolic artery. We performed embolization with 2 platinum coils using a triaxial system via the vasa recta of the terminal ileum. This procedure stopped extravasation of contrast medium. Postoperative course was uneventful, and he was discharged four days postoperatively. The triaxial system may facilitate high diagnostic ability to accurately identify target arteries of the ileal diverticular hemorrhage.

Use of 0.014-in. pushable bare platinum coils in super-selective embolization through the 1.6-Fr. microcatheter of the triaxial system

Background

A triple-coaxial (triaxial) system, which consists of a small microcatheter, a large microcatheter, and a 4-Fr. catheter, has been reported to allow super-selective catheterization. A 1.6-Fr. microcatheter has recently become available as the small microcatheter for the triaxial system, in addition to 0.014-in. pushable bare platinum coils that may be introduced into the 1.6-Fr. microcatheter.

Purpose

The purpose of the present study was to evaluate the feasibility of 0.014-in. pushable bare platinum coils in embolization through the 1.6-Fr. microcatheter of the triaxial system.

Material and Methods

Between November 2015 and October 2019, 19 embolizations were performed on 18 patients, 9 males and 9 females with a median age of 77 years (range, 41-88 years), using 0.014-in. pushable bare platinum coils through the 1.6-Fr. microcatheter of the triaxial system. The technical success rate, clinical success rate, and complications associated with the procedure were assessed. Technical success was defined as the successful delivery and placement of 0.014-in. pushable bare platinum coils, and clinical success as the immediate postembolic complete cessation of blood flow confirmed by digital subtraction angiography.

Results

Eighty-four 0.014-in. pushable bare platinum coils were delivered and 19 arteries were successfully embolized. The median number of 0.014-in. pushable bare platinum coils was 4 (range, 1-12). The technical success rate was 100% (84/84) and the clinical success rate was also 100% (19/19). There were no complications associated with the procedures.

Conclusion

The use of 0.014-in. pushable bare platinum coils in super-selective embolization through the 1.6-Fr. microcatheter of the triaxial system appears to be feasible and safe.

Transarterial embolization of acute iatrogenic hemorrhages: predictive factors for mortality and outcome

OBJECTIVE

Iatrogenic hemorrhages occur in 0.5-16% of medical procedures. A retrospective study was conducted to analyze technical and clinical outcome of transarterial embolization (TAE) used for acute iatrogenic hemorrhage and to identify factors predicting outcome.

METHODS

All patients undergoing TAE for acute iatrogenic bleeding from 2006 to 2013 were retrospectively analyzed. Primary end points were technical and clinical success or failure and 30 day mortality.

RESULTS

A total of 153 patients underwent 182 TAEs. Factors associated with clinical failure were lower blood hemoglobin concentration, use of higher number of units of red blood cell concentrate, TAE performed at night or weekend, embolization of more than one vessel, shock state before digital subtraction angiography (DSA), and intensive care before TAE. In multivariate analysis, independent factors for clinical success were hemoglobin concentration, number of units of red blood cell concentrate, and TAE of more than one vessel. Technical failure was associated with female gender, failure to detect signs of bleeding in DSA, TAE of more than one vessel, and shock state before DSA. Bleeding related to anticoagulation medication resulted in a significantly higher mortality rate compared with bleeding due to the remaining causes (30% vs 15%, p < 0.05).

CONCLUSION

Despite excellent technical success, the mortality rate was significant. The only factors affecting clinical success were bleeding intensity and extent of injury. Bleeding attributed to anticoagulation is related to high mortality and therefore requires special attention.

ADVANCES IN KNOWLEDGE

This study gives insights into morbidity and mortality of iatrogenic bleedings and the technical and clinical success rates of TAE in a large study population.

Transcatheter arterial embolization of acute bleeding as 24/7 service: predictors of outcome and mortality

OBJECTIVE

To analyze times of occurrence and identify risk factors (RFs) for technical and clinical failure and mortality of transcatheter arterial embolization (TAE) of acute bleeding in a major hospital.

METHODS

All TAEs performed at our hospital from 2006 to 2013 (n = 327) were retrospectively analyzed.

RESULTS

TAEs were performed during regular weekday hours in 165 (50%) and during off-hours in 162 (50%) cases. With 40 regular and 128 off-hours/week, 3.25 times more TAEs were performed during regular hours. There was an even distribution across weekdays (Mon-Fri:16.9 ± 1.5%), while fewer TAEs were performed on weekends (Sat: 8.3%, Sun: 7.3%). Technical success of TAEs was 93.9% with a clinical success of 79.2% and a 30-day mortality of 18.4%. Shock was an RF for technical failure (p = 0.022). RFs for clinical failure were low hemoglobin (Hb) (p = 0.021) and transfusion of ≥6 units packed cells (p = 0.009). Independent RFs for mortality were clinical failure (p < 0.001), coagulopathy (p = 0.005), and shock (p < 0.001).

CONCLUSION

Our results provide no evidence for a subjectively perceived increase in TAEs during off-hours but rather appear to show that most TAEs are performed during regular hours. Prompt TAE to control acute bleeding is crucial to prevent a drop in Hb with shock and the need for transfusion, which may promote coagulopathy and rebleeding, all of which are risk factors for a negative outcome.

ADVANCES IN KNOWLEDGE

The presented analysis provides insights of occurrences and risk factors for success of transcatheter arterial embolization in acute bleeding in a large study population.

The Role of Transcatheter Arterial Embolization in the Management of Nonvariceal Upper Gastrointestinal Bleeding

Nearly 50 years ago, catheter angiography was introduced as a means of both diagnosing and treating nonvariceal upper gastrointestinal bleeding. Technological advances and innovations have resulted in the introduction of microcatheters that, using a coaxial technique, are capable of selecting third-order arterial branches and of delivering a wide array of embolic agents. This article reviews the imaging diagnosis of nonvariceal upper gastrointestinal bleeding, the techniques of diagnostic and therapeutic angiography, the angiographic appearance of the various etiologies of nonvariceal upper gastrointestinal bleeding, the rationale behind case-specific selection of embolic agents as well as the anticipated outcome of transcatheter arterial embolization.

Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature

Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.