Successful Ovarian Vein Embolization of a Multiparous Woman with Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is a clinical syndrome supported by specific findings, such as ovarian vein's dilatation, that cause pelvic vein congestion. Although many theories are explaining the pathophysiologies of this condition, the underlying cause remains unknown. The clinical manifestations of PCS are various including chronic pelvic pain (CPP), voiding disturbances, or ureteral obstruction. Imaging modality, such as ultrasonography, computed tomography (CT scan), magnetic resonance imaging (MRI), and venography, are needed to confirm and exclude the differential diagnosis. Currently, American venous forum guidelines recommended endovascular therapy which is percutaneous embolization as the first option therapy of PCS. Here, we reported a 35-year-old woman with PCS who underwent successful percutaneous embolization therapy.

Disappearing multiple visceral aneurysms in Vascular Ehlers-Danlos syndrome

OBJECTIVE

To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS).

METHODS

We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms.

RESULTS

Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.

Preoperative percutaneous Onyx embolization of carotid body paragangliomas with balloon test occlusion

Objectives

The study aims to analyze our first experience with direct percutaneous embolization of carotid body tumors (CBTs) using ethylene-vinyl alcohol copolymer (Onyx) along with balloon test occlusion (BTO).

Methods

A retrospective preliminary single-center study was conducted at the Otorhinolaryngology and Head and Neck Surgery Department and the Medical Imaging Department of the University Teaching Hospital. A consecutive series of three patients with CBTs was treated at the local institution between October 2018 and June 2019. All three patients underwent preoperative percutaneous embolization using ethylene-vinyl alcohol copolymer (Onyx 18) with the addition of BTO. Outcome measures were the percentage of tumor devascularization, intraoperative blood losses, and operation times. BTO was evaluated by clinical neurological examination and neurosonological transcranial Doppler examination of the middle cerebral artery (MCA).

Results

Devascularization of all three tumors was complete or near complete. All three tumors were surgically extirpated with excellent surgical outcomes. The blood losses were minimal, and the average operation time was 2 h and 8 min. BTO was positive in one patient, which was valuable additional information on carotid branches ligation limitations. The other two patients showed negative BTOs with the result of safety of eventual carotid arteries ligations.

Conclusion

Preoperative direct percutaneous embolization of CBT with Onyx is a highly effective procedure that significantly facilitates surgery. BTO provides valuable additional information on the most appropriate and safe surgical approach.

Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration- Complication and Bailout after Percutaneous Embolization of Orbital Meningioma

Presurgical devascularization of neoplasms of the head and neck can be achieved by endovascular as well as direct percutaneous embolization techniques. We report a case of percutaneous glue embolization of an orbital meningioma, complicated by delayed acute stroke due to the distal migration of polymerized glue in the left middle cerebral artery. To the best of our knowledge, this is the first report to discuss the percutaneous embolization of orbital meningioma complicated by stroke due to intracranial glue migration.

Spontaneous rupture of a renal artery pseudoaneurysm in a hemodialysis patient: A case report

RATIONALE

Renal artery pseudoaneurysm is a rare vascular lesion usually caused by trauma or percutaneous urological procedures. Spontaneous rupture of pseudoaneurysms without predisposing events, especially in hemodialysis patients, has rarely been reported.

PATIENT CONCERNS

A 25-year-old man receiving maintenance hemodialysis visited the emergency room because of sudden severe right flank pain. He had no history of trauma or urological procedures except for a left renal biopsy to diagnose Alport syndrome 10 years prior.

DIAGNOSIS

Contrast-enhanced computed tomography revealed a right perirenal hematoma with pseudoaneurysms.

INTERVENTIONS

On renal angiography, multiple pseudoaneurysms were observed in the right renal artery branches and embolization was performed.

OUTCOMES

Post-angiography showed no pseudoaneurysms. His abdominal pain improved, and he was discharged 2 weeks after embolization.

LESSONS

When maintenance dialysis patients complain of severe abdominal pain, spontaneous rupture of a renal pseudoaneurysm should be considered as a differential diagnosis, even if the patient has no history of trauma or previous urological procedures.

A rare cause of massive hemoptysis in a child: Bronchial Dieulafoy's disease - the first report of transcatheter treatment in pediatric age

We report a case of bronchial Dieulafoy's disease in the pediatric age. Angio-computed tomography scan and arteriography addressed us to diagnosis. Bronchial endoscopy with biopsy was avoided due to the high risk of developing a life-threatening hemorrhage. Transcatheter embolization of the bleeding bronchial artery was achieved with a MicroPlex® 10 HyperSoft 3D 3.5 mm × 80 mm System (MicroVention, Tustin, CA, USA). Dieulafoy's disease is an extremely rare lesion in the pediatric age, and the small diameter of the bleeding vessels may complicate the percutaneous approach with procedural failure. Currently, the novel thin and soft detachable coils allowed to widen the transcatheter embolization in the pediatric age.

Ultrasound-guided lymphangiography and interventional embolization of chylous leaks following esophagectomy

Objectives

Postoperative chylothorax is a serious complication after transthoracic esophagectomy, and is associated with major morbidity due to dehydration and malnutrition. For patients with high-output fistula, re-thoracotomy with ligation of the thoracic duct is the treatment of choice. Radiologic interventional management is an innovative procedure that has the potential to replace surgery in the treatment algorithm.

Methods

Four patients with high-output chylous leaks following esophagectomy are presented. Ultrasound-guided lymphangiography with embolization of the thoracic duct and/or disruption of the cisterna chyli was performed to occlude the leakage site. Radiologic interventions and procedure-related outcomes are described in detail.

Results

In all four patients, ultrasound-guided lymphangiography of the groin with injection of Lipiodol was able to detect and visualize the leakage site in the lower mediastinum. In three patients, the leak could be successfully occluded by Lipiodol embolization. In one patient, embolization failed and the disruption technique was successfully performed. No procedure-related complications were observed.

Conclusions

In case of a postoperative chylothorax, radiologic intervention is feasible and safe. The procedure is indicated for high-output chylous fistulas after esophagectomy, and should be applied early after the diagnosis of this postoperative complication.

The characteristics of coronary-pulmonary artery fistulas and the effectivity of trans-catheter closure: a single center experience

Background

Due to the low prevalence, the optimal treatment strategy of coronary-pulmonary artery fistula (CPF) remains unclear, and there are no established therapeutic guidelines available. The purpose of this study is to investigate the characteristics of CPF, and evaluate the effectivity of trans-catheter closure (TCC) for CPFs.

Methods

Patients with CPFs were retrospectively reviewed and enrolled according to the inclusion criteria. The data of clinical manifestations, physical signs, electrocardiogram (ECG), echocardiography, coronary CTA, coronary angiography and intervention procedure were collected. The telephone follow-up was conducted to evaluate the prognosis.

Results

The most common presenting complaint was dyspnea (n=21, 48.84%), followed by chest pain (n=10, 23.36%), palpitation (n=6, 13.95%), dizziness (n=3, 6.98%), and syncope (n=3, 6.98%). Most patients were coupled with single fistula (n=17, 39.53%) or two fistulas (n=23, 53.49%). Thirty fistulas (41.67%) involved the left anterior descending (LAD) artery, 28 fistulas (38.89%) involved the right coronary, 9 fistulas (12.50%) involved the left main trunk, and 5 fistulas (6.94%) involved the circumflex branch. Most of the fistulous tracts originated within the proximal one-third of the coronary arteries, only 6 fistulous tracts (8.33%) originated from the distal segment of the coronary arteries. The size of fistulas arranged from 1 mm to 8 mm, with an average of 3.45 mm. Thirty-five patients (81.40%) with 63 fistulas (87.50%) were successfully treated by percutaneous transcatheter closure. Thirty-eight patients accepted the 6-month follow-up, 36 patients (94.74%) were asymptomatic and 2 patients (5.26%) with palpitation. In conclusion, patients with more fistulas, larger fistula diameter and more severe left-to-right shunt are always coupled with more obvious clinical manifestations. The trans-catheter coil embolization is an effective method for the closure of CPFs.

Conclusions

patients with more fistulas, larger fistula diameter and more severe left-to-right shunt are always coupled with more obvious clinical manifestations. The trans-catheter coil embolization is an effective method for the closure of CPFs.

Percutaneous closure of right coronary to superior vena cava fistula

Coronary artery to superior vena cava (SVC) fistula is a very rare congenital anomaly of the heart. It typically follows the course of sinoatrial-nodal branch. It can originate from the right coronary or circumflex artery. In the majority of cases, it terminates in the SVC close to the right atrium junction. Only five cases were treated in literature successfully through a transcatheter approach. We present a case with a symptomatic right coronary artery to SVC fistula treated with a unique percutaneous embolization using a guidewire loop/balloon occlusion technique. Controlled access and embolization of the fistula was achieved by through-and-through guidewire access across the coronary fistula from the arterial groin access to the venous groin access with balloon occlusion of the coronary artery fistula while detachable coils were positioned.

Pseudoaneurysm associated with arteriovenous fistula involving a superficial breast arteriole after vacuum-assisted removal of a benign mass: A case report

RATIONALE

Pseudoaneurysm (PA) with associated arteriovenous fistula (AVF) is most often secondary to vascular catheterization, percutaneous biopsy, surgery, or trauma. PA-AVF occurs mainly in large or median arterial territories but rarely in the superficial arterioles of the breast.

PATIENT CONCERNS

A 30-year-old woman underwent vacuum-assisted removal of breast fibroadenomas under ultrasonic guidance. On the follow-up visit, the patient complained of a painful enlarging lump in her left breast.

DIAGNOSES

An iatrogenic breast PA-AVF was diagnosed.

INTERVENTIONS

The patient was treated with surgical excision and ligation under local anesthesia.

OUTCOMES

At the 1-month follow-up, the wound was found to have healed well, and breast PA-AVF was eradicated.

LESSONS

Vacuum-assisted removal has been the first-line intervention for benign mass resection because of minimal invasion, but the risk of serious vascular complications remains. Careful duplex ultrasound examination prior to the procedure is highly recommended.

Successful ultrasound-guided percutaneous embolization of renal pseudoaneurysm by autologous blood clot: Preliminary report of a new method

We report the case of a 25-year-old female with renal arteriovenous fistula and pseudoaneurysm (PA) formation following renal core-needle biopsy, treated successfully by ultrasound-guided percutaneous embolization with autologous blood clot injection. After inserting a 15-gauge needle within the PA sac, 10 ml of blood was retrieved from the sac, and then reinjected into the PA as well as in the needle tract after the obtained blood completely clotted. The procedure was completed by manual compression of the flank. Follow-up sonographic examinations revealed no complication, and the PA size reduced gradually over time due to fibrotic shrinkage. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:592-596, 2017.

Totally Percutaneous Aneurysm Sac Embolization During Endovascular Aneurysm Repair

PURPOSE

To describe a sac embolization technique modification for type II endoleak prevention that makes a totally percutaneous approach feasible during endovascular aneurysm repair (EVAR) using the Excluder stent-graft.

TECHNIQUE

Percutaneous access of the common femoral arteries is obtained and 2 suture-mediated closure systems are placed on each side. A 16-F or 18-F sheath is placed for delivery of the Excluder stent-graft main body and a 16-F sheath is used on the contralateral side. After the stent-graft and contralateral limb component are delivered to their intended positions, a standard 0.035-inch hydrophilic guidewire is placed into the aneurysm sac through the same 16-F sheath. Then a 5-F, straight, 65-cm-long catheter is advanced over the standard wire into the sac in parallel with the contralateral limb. The contralateral limb is deployed, the standard guidewire is removed; coils are released through the 5-F catheter into the sac, followed by injection of 5 to 10 mL of double-component fibrin glue.

CONCLUSION

Totally percutaneous, nonselective sac embolization during EVAR, with a single access on each femoral artery, is feasible and helpful to physicians who wish to perform intraoperative sac embolization without relevant changes in their usual EVAR procedure.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

The role of percutaneous embolization techniques in the management of dural sinus malformations with atypical angioarchitecture in neonates: report of 2 cases

Dural sinus malformations (DSMs) are rare congenital malformations that can be midline or lateral in location. Midline DSMs have been reported to have a worse prognosis than lateral DSMs and have traditionally been more difficult to manage. The authors report 2 unusual manifestations of midline DSMs and their management with percutaneous transfontanelle embolization. The first patient (Case 1) presented at 21 days of life with a large midline DSM and multiple highflow dural and pial arteriovenous shunts. The child developed congestive cardiac failure and venous congestion with intracranial hemorrhage and seizures within a few weeks. The second patient (Case 2) presented with a large midline DSM found on prenatal imaging that was determined to be a purely venous malformation on postnatal evaluation. This large malformation resulted in consumptive coagulopathy and apneic episodes from brainstem compression. The patient in Case 1 was treated initially with endovascular embolization and eventually with curative percutaneous-transfontanelle embolization. The patient in Case 2 was treated with percutaneous transfontanelle embolization in combination with posterior fossa decompression and cranial expansion surgery.

Percutaneous transhepatic embolization of biliary leakage with N-butyl cyanoacrylate

Biliary leakage is a known complication after biliary surgery. In this report, we describe an uncommon treatment of a common biliary complication, wherein we used percutaneous transhepatic injection of N-butyl cyanoacrylate (NBCA) to treat a biliary leak in an 83-year-old patient.

Percutaneous embolization of an incidentally diagnosed pulmonary aneurysm in a scleroderma patient

A 59-year-old female with history of progressive scleroderma and pulmonary fibrosis was referred for biopsy of a pulmonary nodule that was discovered on computed-tomography (CT) chest surveillance, not present on prior CT- scan. Imaging was suspicious for granuloma, malignancy or aneurysm. CT- Angiography (CTA), performed immediately before the procedure, did not show enhancement of the mass, followed by placement of coaxial-needle into the mass. Suspicion of aneurysm was again raised and repeat CTA demonstrated contrast filling of the aneurysm. With the coaxial-needle in the aneurysm, embolization of the sac was performed using microfibrillar collagen, followed by confirmation of containment and thrombosis with CT.