Use of a Polytetrafluoroethylene-Coated Vascular Plug for Focal Intracranial Parent Vessel Sacrifice for Fusiform Aneurysm Treatment

A Multicenter, Retrospective, Matched, Comparison Study of Clinical Efficacy and Cost-Effectiveness of Caterpillar Arterial Embolization Device versus Fibered Coils in Arterial Embolization

Background: The purpose of this study was to evaluate and compare the clinical effectiveness and costs of using the Caterpillar Arterial Embolization Device (Caterpillar) and fibered coils in arterial embolization cases. Methods: In this multicenter retrospective study, demographic, laboratory, and procedural data were collected on a total of 48 patients between February 2020 and September 2020. Data were collected on 16 Caterpillar placements and matched with 32 controls who underwent coil embolization of the same vessel with a similar size. Clinical and procedural outcomes including type and size of vessels, time to vessel occlusion, fluoroscopy time, total procedure time, and costs were analyzed and compared. Results: Relative time to occlusion was significantly decreased in the Caterpillar group compared to the controls (57 ± 34 s vs. 11 min 44 s ± 8 min 13 s, p = 0.00001611). Fluoroscopy time (6.9 ± 15 min vs. 19.2 ± 14, p = 0.017) and total procedure time (81.0 ± 36 min vs. 111.5 ± 49 min, p = 0.015) were significantly reduced compared to the coil group. Lastly, overall cost of embolic materials was 1050 ± 0 USD for the Caterpillar group compared to 2312.75 ± 1382.84 USD in the coil group (p = 0.000532). Conclusion: The Caterpillar embolic devices appear safe and effective in arterial occlusion. Compared to fibered coils, the Caterpillar device results in decreased time to vessel occlusion, decreased fluoroscopy and procedural time, and decreased costs, making the Caterpillar an appealing choice for arterial embolization.

Embolization of vascular abnormalities in children with congenital heart diseases using medtronic micro vascular plugs

This study aimed at evaluating our experience with Micro Vascular Plug (MVP) for embolization of vascular abnormalities in children with congenital heart diseases (CHDs). MVP is one of the most recent additions to the armamentarium for peripheral embolization. Data on its use in congenital cardiology are scarce. Medical records of children with CHDs who had embolizations with MVPs between April 2015 and September 2020 were reviewed. Immediate and follow-up data were assessed. A total of 153 patients underwent 172 procedures during which 240 embolizations using 259 MVPs were attempted. Median age and weight were 34.9 months (IQR, 4-75 months) and 12.5 kg (IQR, 4.8-19.4 kg), respectively. Targets were abnormal systemic arteries (n = 163), patent arterial ducts (n = 26), venous (n = 45), and coronary-cameral fistulas (n = 6). Median vessel diameter was 3.3 mm (IQR, 2.5-4 mm). Veins were larger than arteries (2.3 mm > 2.1 mm, p < 0.01). MVPs were implanted in narrower diameters compared to manufacturer's recommendations. Compared to veins, solitary implanted MVPs in arteries were additionally oversized at 12.4%, 5.1%, and 7.9% for MVP-3Q, 5Q, and 7Q, respectively. Additional occlusion material (16.7%) and 2 MVPs (5.8%) were needed at the same site for complete closure. Implantation and procedure success rates were 99.2% and 96.7%, respectively. Five complications were treated percutaneously (n = 4) and surgically (n = 1). Efficacy of vascular embolization using MVPs was demonstrated in the largest cohort of children with CHDs and a variety of clinical settings. Immediate and stable closure is obtained with a single device in most cases. Detailed device selection chart according to vessel type and diameter is proposed to achieve intended outcomes.

Embolization with MVP (Micro Vascular Plug®): experience on 104 patients in emergent and elective scenarios

AIM

To describe a 3 years experience of peripheral arterial embolization with Micro Vascular Plug (MVP) (Medtronic, USA).

MATERIALS AND METHODS

The following parameters were investigated: type of vascular injury, anticoagulation therapy at time of procedure, anatomical district, caliper of the target artery, course of the landing zone, additional embolics, technical and clinical success, device related clinical complications. Technical success was defined as complete embolization without deployment of additional embolics after MVP release. Primary clinical success was considered as hemodynamic stability in emergency setting and resolution of the underlying vascular pathology in elective cases; secondary clinical success was considered clinical success after a second embolization session.

RESULTS

116 MVP have been released in 104 patients (67 males and 37 females; mean age 61.3 years). The pullback release technique was adopted in each case. 85 patients were treated in emergent settings while in 19 patients the procedure was scheduled. The overall technical success was 75%. Primary clinical success was 96.1%, secondary clinical success 3% and clinical failure 0.9%. No statistical differences in terms of effectiveness were observed among patients assuming anticoagulation (p-value = 0.6). A straight and longer landing zone were statistically associated with higher technical success compared to curved and shorter ones, (p-values < 0.001 and = 0.048 respectively). MVP-3 and MVP-5 were the most frequently adopted models in this sample, in 29.8% and 49% of the patients respectively. No clinically adverse events directly related to MVP occurred; in 3 cases device migration was registered without clinical complications.

CONCLUSION

MVP is a safe and effective embolic agent. While eventual concomitant anticoagulation therapy did not influence the technical outcome, straight course and length of the landing zone are essential parameters to evaluate before deployment.

Therapeutic occlusion of the vertebral artery using a new penumbra occlusion device system and ruby coils (penumbra): A technical note

There are several methods to achieve the therapeutic sacrifice of the vessel, coiling brings the most commonly used. Penumbra occlusion device (POD) system is a newer modality for therapeutic large vessel occlusion, and it is the Food and Drug Administration approved only for peripheral vessels. We report a case where therapeutic vertebral artery (VA) occlusion was achieved with the POD system and Ruby coils for the first time. A patient was diagnosed with a new malignant-appearing tumor of the cervical spine. A conventional angiogram showed multiple tiny arterial feeders from the VA beyond scope of coil/onyx embolization, so we performed a balloon occlusion test followed by therapeutic sacrifice of the VA. A successful VA occlusion was achieved with significant reduction in the tumor blush, followed by open resection of the tumor. The patient had favorable postoperative course and without any neurological symptoms attributed to the VA occlusion.

MVP (Micro Vascular Plug®) embolization of severe renal hemorrhages after nephrostomic tube placement

Background

We report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing.

Materials and methods

Five patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages.

All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value.

After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP.

The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure.

Results

Technical and clinical successes were obtained in all patients.

Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula.

MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases.

MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization.

The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission.

Conclusions

According to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Recurrent posterior circulation infarcts secondary to vertebral artery external compression treated with endovascular deconstruction

When multiple, recurrent infarcts occur in spite of maximal medical management, the level of suspicion for atypical vascular injury should be heightened. We present a case of a patient who presented with recurrent posterior circulation infarcts despite optimized medical management. On imaging, he was found to have external anatomical vertebral artery muscular and/or osseous compression leading to repetitive vascular injury and strokes. Recurrent intimal injury and vertebral artery to intracranial emboli despite anticoagulation and subsequent dual antiplatelet therapy necessitated definitive operative management. Surgical bypass, external surgical decompression, reconstructive endovascular, and deconstructive endovascular techniques were carefully considered. A deconstructive endovascular approach was chosen as the least morbid option. The use of endovascular plugs such as a microvascular plug provides a quick and effective means of achieving a therapeutic parent artery occlusion in lieu of traditional coil occlusion. Although reserved as a last resort, parent artery occlusion can be a viable option to treat recurrent strokes, particularly in a nondominant vertebral artery.