Endovascular Use of Cyanoacrylate-Lipiodol Mixture for Peripheral Embolization: Properties, Techniques, Pitfalls, and Applications

Endovascular embolization agents are particles and fluids that can be released into the bloodstream through a catheter to mechanically and/or biologically occlude a target vessel, either temporarily or permanently. Vascular embolization agents are available as solids, liquids, and suspensions. Although liquid adhesives (glues) have been used as embolic agents for decades, experience with them for peripheral applications is generally limited. Cyanoacrylates are the main liquid adhesives used for endovascular interventions and have a major role in managing vascular abnormalities, bleeding, and many vascular diseases. They can only be injected as a mixture with ethiodized oil, which provides radiopacity and modulates the polymerization rate. This review describes the characteristics, properties, mechanisms of action, modalities of use, and indications of the cyanoacrylate-Lipiodol® combination for peripheral embolization.

Embolization in Trauma: Review of Basic Principles and Techniques

Trauma is the leading cause of death in patients younger than 45 years. Over the last decade, there has been a progressive paradigm shift toward a nonoperative management of many blunt and penetrating injuries, placing interventional radiology in the forefront in this critical field. Transcatheter embolization is an established technique that plays a significant role in the modern treatment of traumatic injuries of the extremities, pelvis, and solid organs. The purpose of this article is to review the updated principles and techniques used in transcatheter embolization in trauma.

Multidisciplinary management of a rare case of mixed total anomalous pulmonary venous connection

INTRODUCTION

Mixed total anomalous pulmonary venous connection (TAPVC) is a extremely rare congenital heart disease.

METHODS

We report the initial management of a case of Mixed total anomalous pulmonary venous connection associated to right extralobar bronchopulmonary sequestration (BPS).

RESULTS

Mixed TAPVC associated to right extra-lobar BPS was diagnosed at birth in a full-term newborn. At one month of age, the patient underwent embolization of the BPS, complicated by coil entrapment in the right common iliac artery requiring urgent laparotomy. Few days later, the congenital cardiac repair was accomplished uneventfully. At 12-months follow-up, the patient did not have pulmonary hypertension, but presented a moderate stenosis of the right femoral artery, which was effectively treated with anticoagulation therapy.

CONCLUSIONS

The multidisciplinary approach allowed a successful treatment of these complex anomalies and the related potential complications.

Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions

Objective: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. Results: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. Conclusion: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.

Safety and efficacy of embolotherapy for severe hemorrhage after partial nephrectomy

BACKGROUND

Partial nephrectomy may be complicated by postoperative hemorrhage, which may be treated by transcatheter embolization.

PURPOSE

To assess the safety and efficacy of embolotherapy for hemorrhagic complications of partial nephrectomy and to analyze the potential correlation between multiple bleeding sites on angiography and surgical complexity.

MATERIAL AND METHODS

A cohort of 25 patients presenting with severe, postoperative bleeding after partial nephrectomy and treated with catheter-directed superselective embolization was included. Patients' demographics, radiological investigations before the embolization, and clinical outcome after embolization were analyzed. Mann-Whitney U test was used to analyze the potential difference in the RENAL score between patients with one or more bleeding sites in the resection area.

RESULTS

Selective renal angiography revealed multiple bleeding sites at the resection bed in 8 (32%) patients with amorphous contrast extravasation in 10 (40%) patients. Embolization with use of a microcatheter and microcoils was effective to stop the bleeding in all but one patient, the latter requiring a second embolization two days later. Transient decrease in renal function was noted in 3/25 (12%) patients with full recovery in two of the three. Patients with multiple bleeding sites did not show significantly different RENAL scores compared to patients with a single bleeding site (P = 0.148).

CONCLUSION

Embolotherapy for postoperative partial nephrectomy-related bleeding is safe and effective with a low rate of recurrent bleeding. The number of bleeding sites at the resection area did not correlate to the RENAL score.

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

A case of pulmonary arteriovenous malformation: role of interventional radiology in diagnosis and treatment

Pulmonary arterio-venous malformations (PAVMs) are abnormal pulmonary arteries and pulmonary veins communicating directly without interposition of a capillary bed and about 80-90% of patients with PAVMs eventually may present with hereditary hemorrhagic telangiectasia (HHT), remaining ones are sporadic cases. On the other hand, about 15-35% of HHT patients may present with PAVMs. The PAVMs have a tendency to grow and increase in size over time and various factors like puberty, pregnancy and pulmonary arterial hypertension (PAH) affect growth. This condition needs early diagnosis, aggressive management and vigilant follow up. Our article aims to review pulmonary AVMs as a rare cause of strokes in young patients. We will discuss the clinical presentation, diagnosis, complications, the therapeutic options and the follow up.

Clinical efficacy and safety of transcatheter embolization for vascular complications after percutaneous nephrolithotomy

Introduction

Percutaneous nephrolithotomy (PNL) is the preferred procedure for safe and effective surgical treatment of kidney stones. Hemorrhage is the most serious complication of PNL, resulting from pseudoaneurysm (PA) or arteriovenous fistula (AVF), and can usually be controlled with conservative treatment.

Aim

To evaluate endovascular treatments and outcomes of vascular complications observed after PNL.

Material and methods

We retrospectively reviewed data on 19 patients who underwent renal embolization due to post-PNL renal artery bleeding between March 2005 and September 2016. Embolization materials included embolization coils and glue. The incidence of post-PNL vascular complications and their endovascular treatments, outcomes, and the follow-up data were analyzed.

Results

Nineteen (1.1%) of 1,609 patients (mean age: 44.9 years, range: 19-75 years) underwent angiography and subsequent transcatheter embolization to control bleeding. The mean time to onset of hemorrhage was 7.2 days after PNL (range: 3-18 days). The PNL entry site was the lower calyx in 15 patients, the middle calyx in 3, and the upper calyx in 1. PA, AVF, and PA plus AVF occurred in 14, 5, and 3 of the 19 renal angiography patients, respectively. Embolization of the affected vessels was successful in all 19 patients. The embolization materials of coil, glue, and coil plus glue were used in 16, 3, and 2 patients, respectively.

Conclusions

Severe hematuria is a rare complication of PNL and can be successfully treated with transcatheter embolization.

Diagnosis and treatment of pelvic congestion syndrome: Single-centre experiences

BACKGROUND

One of the underestimated causes of chronic pelvic pain (CPP) in women may be pelvic congestion syndrome (PCS) that is defined as the presence of varicose of ovarian and pelvic veins associated with chronic pain in the region of the pelvis. This pain is present longer than 6 months and intensifies with prolonged standing, coitus and menstruation. The disease constitutes a diagnostic as well as therapeutic problem, thus posing a challenge for the clinician. Transcatheter ovarian vein embolization might be a safe and effective option for PCS treatment.

OBJECTIVES

The objective of this study was to evaluate the efficacy of ovarian vein embolization ovarian as a method of the PCS treatment.

MATERIAL AND METHODS

Between 2002-2012, 11 embolization procedures were performed in 10 women (age range: 34-43; median age 39) with the diagnosis of PCS. One patient underwent embolization procedure twice. In 1 case the combined therapy of endovascular embolization and surgical phlebectomy of vulvar varices was performed.

RESULTS

There were no major intrainterventional complications. In all the patients (100%) a significant improvement in the clinical status was noted. The procedure improved the quality of life in the patients. Three women (30%) had a mild recurrence of the symptoms at mid-term follow-up. Among 8 women who had complained of dyspareunia prior to embolization 6 patients reported complete pain relief, in other 2 cases the pain subsided partially. There was a significant decrease in the severity of symptoms associated with hemorrhoids.

CONCLUSIONS

We consider embolization of insufficient ovarian veins an effective and safe way of treatment in a well-selected group of patients with PCS.

Pulmonary artery rupture as a complication of Swan-Ganz catheter application. Diagnosis and endovascular treatment: a single centre's experience

Introduction

The placement of a Swan-Ganz catheter into the pulmonary artery may lead to a number of complications (2–17%). In less than 0.2% of cases Swan-Ganz catheterization results in serious vascular damage – pulmonary artery rupture (PAR). This paper presents two distinct forms of iatrogenic PAR treated endovascularly using different vascular devices.

Aim

To evaluate the effectiveness of endovascular treatment and the application of different types of vascular devices in the management of pulmonary artery rupture caused by Swan-Ganz catheterization.

Material and methods

In this retrospective study we evaluated 2 patients in whom Swan-Ganz catheter application was used for perioperative monitoring and resulted in pulmonary artery rupture. This complication was treated endovascularly by means of interventional cardiology.

Results

We report the cases of 2 patients with a pulmonary artery pseudoaneurysm formed in the perioperative period. In case 1, a single, 4-loop, 3 mm diameter coil was implanted. In case 2, a 5 mm Amplatzer Vascular Plug IV was applied. In both cases, the endovascular approach resulted in total occlusion of the feeding artery and reduced further extravasation of the blood.

Conclusions

Despite its extremely low incidence, iatrogenic PAR is a serious, life-threatening complication of Swan-Ganz catheterization that requires urgent attention. Among available methods of treatment, percutaneous embolization is a relatively quick, safe, accurate and highly effective alternative to traumatizing surgery.

Hemorrhagic shock due to ruptured left and right gastric artery aneurysm

Case

We report a case of hemorrhagic shock due to a ruptured gastric artery aneurysm successfully treated with transarterial embolization. A 72-year-old woman with cholangitis presented with hemoperitoneum following a ruptured aneurysm of the gastric artery.

Outcome

Emergent computed tomography and angiography were carried out and the patient was found to have spontaneous bleeding from both branches of the left and right gastric arteries. Transcatheter embolization was carried out at the distal branch of both gastric arteries with a coil. The patient recovered well with no recurrent bleeding.

Conclusions

Although rare, visceral artery rupture should be considered in the differential diagnosis of unexplained hemorrhagic shock with abrupt onset of hemoperitoneum. Computed tomography and angiography are useful tools for obtaining prompt and accurate localization of the bleeding points.

Percutaneous embolization of a postnephrectomy arteriovenous fistula with intervening pseudoaneurysm using the Amplatzer vascular plug 2

Although renal arteriovenous fistula (AVF) is an uncommon condition, it may lead to high cardiac output heart failure and renal insufficiency. Recently, percutaneous transcatheter embolization has replaced traditional surgery as the first line of treatment. We report a case of a 68-year-old male who presented with a renal AVF and was treated by percutaneous transcatheter embolization using the Amplatzer Vascular Plug 2 (AVP 2; St Jude Medical, Plymouth, Minnesota) through an arterial access. To our knowledge, the use of AVP 2 device in the treatment of renal AVF as a single embolotherapy device through the transarterial route has not been previously reported in the literature. Our technique demonstrates the feasibility and safety of AVP 2 device in the treatment of renal AVF.

Endovascular treatment of PA pseudoaneurysm caused by Swan-Ganz catheter

The following case report describes a complication of Swan-Ganz catheterization and its endovascular treatment with a single coil. Application of this particular catheter in the pulmonary artery during cardiac surgery may lead to mechanical perforation and creation of an extravascular sac, which is called a pseudoaneurysm. There are different methods that lead to tamponade or closure of the leakage. Interventional cardiology procedures are nowadays the most appropriate way of treatment of Swan-Ganz catheter induced vascular complications.

New technology in the management of liver trauma

The liver is the second most frequently injured solid organ in patients with blunt abdominal trauma. Hence the diagnosis and clinical assessment of hepatic trauma is of great importance because of the relationship of the liver to high morbidity and mortality. Multi detector-row computed tomography is the main diagnostic modality for the examination of hepatic parenchyma and other associated organ injuries, such as acute or delayed complications. Based on clinical and radiological findings, the majority of patients are managed conservatively, with the most important criterion of surgical therapy being hemodynamic instability. Radiologists must demonstrate a high knowledge of imaging recommendations and standardization of reporting to enable the selection of the appropriate treatment algorithm. Transcatheter embolization therapy is a method of great potential for the management of patients with traumatic hepatic injuries.

Embolization in trauma: principles and techniques

Trauma continues to be the leading cause of death in the young population. Uncontrolled bleeding is a major factor in early mortality after trauma, contributing to 30 to 40% of trauma-related deaths. Transcatheter embolization techniques play a significant role in the comprehensive modern treatment of traumatic vascular injuries to solid organs and extremities. The purpose of this article is to review current principles and techniques in the use of embolization for the treatment of traumatic arterial injuries of solid organs and extremities.

Diagnosis and management of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformation is a rare anomaly that presents in several different ways. It can present as an isolated finding, or more often in the context of hereditary haemorrhagic telangiectasia. It can also complicate palliative surgery such as the Glenn operation for complex congenital heart disease with single ventricle physiology. Its management includes transcatheter embolization, which is the preferred mode of therapy, surgery (including resection of the affected lobe, segment, or the fistula itself), or rarely, medical therapy. Complications of the disease itself and of various modes of treatment are relatively common, and patients require close surveillance for possible recurrence, or development of new fistulas. In cases related to the Glenn operation, redirection of hepatic venous flow or heart transplantation may cure the problem.