Endoscopic removal of a migrated coil after embolization of a splenic pseudoaneurysm: a case report

Development of an Injectable, ECM-Derivative Embolic for the Treatment of Cerebral Saccular Aneurysms

Cerebral aneurysms are a source of neurological morbidity and mortality, most often as a result of rupture. The most common approach for treating aneurysms involves endovascular embolization using nonbiodegradable medical devices, such as platinum coils. However, the need for retreatment due to the recanalization of coil-treated aneurysms highlights the importance of exploring alternative solutions. In this study, we propose an injectable extracellular matrix-derived embolic formed in situ by Michael addition of gelatin-thiol (Gel-SH) and hyaluronic acid vinyl sulfone (HA-VS) that may be delivered with a therapeutic agent (here, RADA-SP) to fill and remodel aneurysmal tissue without leaving behind permanent foreign bodies. The injectable embolic material demonstrated rapid gelation under physiological conditions, forming a highly porous structure and allowing for cellular infiltration. The injectable embolic exhibited thrombogenic behavior in vitro that was comparable to that of alginate injectables. Furthermore, in vivo studies in a murine carotid aneurysm model demonstrated the successful embolization of a saccular aneurysm and extensive cellular infiltration both with and without RADA-SP at 3 weeks, with some evidence of increased vascular or fibrosis markers with RADA-SP incorporation. The results indicate that the developed embolic has inherent potential for acutely filling cerebrovascular aneurysms and encouraging the cellular infiltration that would be necessary for stable, chronic remodeling.

Gastric Bleeding Caused by Migrated Coil: A Rare Complication of Splenic Artery Coil Embolization

Transarterial embolization (TAE) has emerged as the first-line treatment for visceral artery aneurysms or pseudoaneurysms-related bleeding. Coil migration is a rare and remote complication of endovascular embolization into the gastrointestinal lumen, with only fifteen cases reported upon conducting a literature review. It can occur immediately or several years after and potentially cause fatal bleeding owing to formation of aorto-enteric fistulas and infections. Here, we report a case of a patient who presented with upper gastrointestinal bleeding due to coil migration into the gastric lumen after transarterial embolization of splenic artery pseudoaneurysms.

Injectable hydrogels for vascular embolization and cell delivery: The potential for advances in cerebral aneurysm treatment

Cerebral aneurysms are vascular lesions caused by the biomechanical failure of the vessel wall due to hemodynamic stress and inflammation. Aneurysmal rupture results in subarachnoid hemorrhage often leading to death or disability. Current treatment options include open surgery and minimally invasive endovascular options aimed at secluding the aneurysm from the circulation. Cerebral aneurysm embolization with appropriate materials is a therapeutic approach to prevent rupture and the resultant clinical sequelae. Metallic platinum coils are a typical, practical option to embolize cerebral aneurysms. However, the development of an alternative treatment modality is of interest because of poor occlusion permanence, coil migration, and coil compaction. Moreover, minimizing the implanted foreign materials during therapy is of importance not just to patients, but also to clinicians in the event an open surgical approach has to be pursued in the future. Polymeric injectable hydrogels have been investigated for transcatheter embolization and cell therapy with the potential for permanent aneurysm repair. This review focuses on how the combination of injectable embolic biomaterials and cell therapy may achieve minimally invasive remodeling of a degenerated cerebral artery with promise for superior outcomes in treatment of this devastating disease.

Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer

Transarterial angiographic embolization is a highly effective, safe treatment for non-variceal upper gastrointestinal bleeding refractory to endoscopic intervention. However, intraluminal coil migration is a possible complication. Coil migration, while usually a self-limiting process, can lead to significant rebleeding. In our case, a patient presented with a life-threatening duodenal ulcer hemorrhage, likely precipitated by intraluminal endovascular coil migration after a recent gastro-duodenal artery embolization. He was successfully managed without endoscopic coil removal and had no additional gastrointestinal bleeding. It is important for endoscopists to be aware of this complication and weigh the risks and benefits of coil removal.

A Rare Case of Coil Migration into the Duodenum after Embolization of a Right Colic Artery Pseudoaneurysm

Transcatheter arterial embolization is a safe and effective treatment for visceral artery aneurysms; nevertheless, some complications can occur. Coil migration to other organs after embolization is extremely rare, and only 16 cases have been reported previously. We report a rare case of coil migration to the duodenal lumen after embolization of a right colic artery pseudoaneurysm. To the best of our knowledge, this is the first case of coil migration after a right colic artery embolization. The patient exhibited no symptoms and was treated conservatively without any intervention. Some previous reports have demonstrated spontaneous coil passage and successful conservative management. Our case supports conservative treatment as the primary treatment for asymptomatic patients. Clinicians should assess the risks and benefits of coil removal in asymptomatic patients before performing any intervention.

Migration of Gastric Varix Coil After Balloon-Occluded Antegrade Transvenous Obliteration

This is a case report of a man with alcoholic cirrhosis who underwent transjugular intrahepatic portosystemic shunt and balloon-occluded antegrade transvenous obliteration for gastric fundal varices in 2017. After almost a year, we found extensive migration of the coil into the gastric fundus on upper endoscopy. Continued vigilant surveillance endoscopy may help detect this complication.

Embolization coil migration in the stomach and spontaneous excretion: a case report and review of the literature

Embolization coil migration to the gastrointestinal tract is a rare complication. This report describes our experience of coil migration in the stomach and spontaneous excretion. A 77-year-old man, who was diagnosed with esophageal squamous cell carcinoma with multiple lymph node metastases, had a bleeding left gastric artery and splenic artery pseudoaneurysm associated with an abdominal lymph node mass, that was treated by coil embolization, after which the coil migrated into the stomach. Because there were no complications such as active bleeding or peritonitis, our patient was followed carefully, and excretion of the coil was documented. No standard management exists for migrated coils. Conservative treatment is an option, as in this case.

Rare Complication of Interventional Radiology-guided Arterial Embolization of the Gastroduodenal Artery in the Setting of Acute Gastrointestinal Bleed: Migrated Coils in the Duodenum

A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding. The patient underwent an esophagogastroduodenoscopy (EGD), which showed frank blood in the duodenum interfering with the visualization. Hence, the patient underwent urgent interventional radiology (IR)-guided arteriogram and embolization. An EGD done 48 hours later showed a giant, non-bleeding, cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. The patient had no evidence of bleeding post embolization. The patient presented three months later with abdominal pain. Computed tomography (CT) abdomen showed multiple liver abscesses. IR-guided drainage of abscesses was performed, and the culture grew Streptococcus intermedius. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and barium enema were unremarkable. The patient was treated with a prolonged course of intravenous (IV) antibiotics and recovered without any further issues. IR guided arterial embolization can be lifesaving in cases where GI bleeding cannot be controlled endoscopically, however, it can lead to serious complications, including endovascular coil migration into the gastrointestinal (GI) lumen causing infection and re-bleeding. Endovascular coil migration can occur immediately or several years later, which can result in fatal bleeding and infection. The best approach to prevent and manage migrated endovascular coils in the GI lumen remains unclear.

Clinical Outcome of the Visible Coil During Endoscopy After Transcatheter Arterial Embolization for Gastrointestinal Bleeding

PURPOSE

This study was designed to evaluate the clinical outcome of the visible coil during endoscopy after transcatheter arterial embolization (TAE) for gastrointestinal bleeding.

METHODS

We retrospectively reviewed the medical records of 1415 patients who underwent TAE for gastrointestinal bleeding between 2001 and 2017. Among these 1415 patients, 70 underwent TAE using coils and consecutive follow-up endoscopy. Finally, 11 patients with an extravascular coil seen on follow-up endoscopic examination were included in this study. We evaluated the underlying cause of the gastrointestinal bleeding, the technical and clinical success rates, the type of extravascular coil after TAE, and the clinical outcomes of the extravascular coil seen on follow-up endoscopic examination.

RESULTS

Of the 11 patients, the most common underlying cause of gastrointestinal bleeding was a duodenal ulcer (n = 7). On angiography, the bleeding artery was most commonly found in the gastroduodenal artery (n = 6). The technical success and clinical success rates of TAE were 100% and 90.9%, respectively. The type of extravascular coil found on endoscopic examination was classified by submucosal migration (n = 6) and protrusion (n = 5). On second-look endoscopic evaluation, 10 of 11 (90.9%) patients showed healing ulceration. On the final-look endoscopic evaluation, healing ulceration without further bleeding was seen in one (9.1%) patient and scar formation was seen in ten (90.9%) patients.

CONCLUSIONS

Extravascular coil after TAE for gastrointestinal bleeding is rare, and the most common underlying cause is duodenal ulcer bleeding. The extravascular coils eventually show a healing process with adequate treatment of underlying bowel pathologies.

Coil Migration to the Duodenum 1 Year Following Embolisation of a Ruptured Giant Common Hepatic Artery Aneurysm

Introduction

Transcatheter arterial embolisation is often performed for the treatment of visceral artery aneurysms. Here, the case of a patient who developed the rare complication of coil migration into the intestinal tract is reported, and a review of the literature is presented.

Case report

A 30 year old woman with a ruptured giant common hepatic artery aneurysm, who had been treated with transarterial coil embolisation 1 year previously, was admitted to hospital complaining of passing the coils on defecation. Abdominal Xray and gastroscopy showed the migration of the coils through a duodenal fistula. Open repair was performed with the coils successfully removed and the duodenal fistula closed with omentopexy. At the 3 year follow up, there were no signs or symptoms of complications.

Conclusion

Based on observations from this case, although coil migration to the intestinal tract is exceedingly rare, aneurysm rupture with enteric fistula can lead to coil migration.

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Hepatic artery aneurysm is the second most common splanchnic aneurysm.

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Transcatheter arterial coil embolisation of a visceral artery aneurysm is often performed.

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This study reports a case of late coil migration to the intestinal tract after embolisation of a ruptured giant common hepatic artery aneurysm.

Laparoscopic endoscopic combined surgery for removal of migrated coil after embolization of ruptured splenic artery aneurysm

Splenic artery aneurysm is the most common visceral arterial aneurysm. Rupture of aneurysm is a rare event but associated with a high mortality. Endovascular coil embolization of bleeding splenic artery aneurysm has emerged as a promising minimal invasive treatment and considered safer than open surgery in selected patients. Nevertheless, several complications related to coils have been reported, the rarest being coil migration and erosion. We report a case of splenic artery coil migration into the stomach and its successful removal by laparoscopic endoscopy combined surgery.

Migrated embolization coil causes intestinal obstruction

Visceral artery pseudoaneurysm is a rare, potentially fatal entity, but proper identification and management with coil embolization can lead to good outcomes. Embolization coils can migrate to various destinations, causing delayed complications in several case reports. A case of small bowel obstruction due to migrated embolization coils from a gastroduodenal pseudoaneurysm 6 years after initial treatment is presented.

[Surgical Removal of Migrated Coil after Embolization of Jejunal Variceal Bleeding: A Case Report]

Jejunal variceal bleeding is less common compared with esophagogastric varices in patients with portal hypertension. However, jejunal variceal bleeding can be fatal without treatment. Treatments include surgery, transjugular intrahepatic porto-systemic shunt (TIPS), endoscopic sclerotherapy, percutaneous coil embolization, and balloon-occluded retrograde transvenous obliteration (BRTO). Percutaneous coil embolization can be considered as an alternative treatment option for those where endoscopic sclerotherapy, surgery, TIPS or BRTO are not possible. Complications of percutaneous coil embolization have been reported, including coil migration. Herein, we report a case of migration of the coil into the jejunal lumen after percutaneous coil embolization for jejunal variceal bleeding. The migrated coil was successfully removed using surgery.

Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

Background

Right hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 – 61% of cases when routine angiography is employed following a BDI.

We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI.

Case presentation

A 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed.

Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils.

Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully.

Conclusion

Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.