Amplatzer Plug Research Articles

Amplatzer Vascular Plugs Versus Coils for Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia.

Coil embolization of pulmonary arteriovenous malformations (PAVMs) has a high re-canalization/re-perfusion rate. Embolization with Amplatzer plugs has been previously described, but the long-term efficacy is not established. This study reports the experience of a referral medical center with the use of coils and Amplatzer plugs for treating PAVMs in patients with hereditary hemorrhagic telangiectasia. The study was approved by the Institutional Review Board with waiver of informed consent. The cohort included all patients who underwent PAVM embolization in 2004-2014 for whom follow-up imaging scans were available. The medical files were retrospectively reviewed for background data, embolization method (coils, Amplatzer plugs, both), and complications. Re-canalization of treated PAVMs was assessed from intrapulmonary angiograms (following percutaneous procedures) or computed tomography angiograms. Fisher's exact test and Pearson Chi-squared test or t test were used for statistical analysis, with significance at p<0.05. 16 patients met the study criteria. Imaging scans were available for 63 of the total 110 PAVMs treated in 41 procedures. Coils were used for embolization in 37 PAVMs, Amplatzer plugs in 21, and both in five. Median follow-up time was 7.7years (range 1.4-18.9). Re-canalization was detected in seven vessels, all treated with coils; there were no cases of re-canalization in plug-occluded vessels (p=0.0413). The use of Amplatzer plugs for the embolization of PAVMs in patients with hemorrhagic telangiectasia is associated with a significantly lower rate of re-canalization of feeding vessels than coils. Long-term prospective studies are required to confirm these findings.

3:09 PMAbstract No. 228 - Comparison of fluoroscopy time in proximal-to-mid splenic artery embolization with coils versus amplatzer plugs

3:09 PMAbstract No. 228 - Comparison of fluoroscopy time in proximal-to-mid splenic artery embolization with coils versus amplatzer plugs

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study

During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75±9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. The technical success rate was 97.6%. Failures were device migration (n=1), navigation failure (n=2), and release outside the target zone (n=1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111±51mL and the radiation dose was 127,777±89,528mGy/cm(2). The total fluoroscopy time was 854±538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n=41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Successful Closure of an Esophagopleural Fistula With an Amplatzer Occluder Sealed With Liquid Copolymer, With 3-Year Follow-Up and Review of Literature

Esophageal perforations may recur, and/or develop a mature fistulous tract to the pleura, despite prompt surgical management. Treatment of a chronic esophageal fistula is challenging and may require multiple reoperations. We describe the closure of a controlled, chronic, benign esophagopleural fistula using an Amplatzer occluder and sealed with a liquid copolymer after failed open repair. At 3 years postprocedure, the patient has no further recurrence or complication associated with the repair. Amplatzer plugs and occluders, designed for endovascular and cardiac procedures, are increasingly used off-label for the treatment of complex, recurrent, or otherwise difficult to manage bronchopulmonary, pleural, and esophageal fistulae.

False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection

Purpose: To present a rare case of disseminated intravascular coagulation (DIC) after thoracic endovascular aortic repair (TEVAR) and its novel treatment. Case Report: A 55-year-old man presented with DIC 10 months after TEVAR for chronic type B aortic dissection and descending thoracic aortic aneurysm. He had persistent retrograde flow in the false lumen with a stable aneurysm diameter. The false lumen was embolized with multiple Amplatzer plugs, which promoted false lumen thrombosis. Laboratory evaluation on postoperative day 7 demonstrated resolution of the coagulopathy. Follow-up at 18 months revealed no recurrent DIC; computed tomography angiography showed a stable aortic diameter and excluded thoracic aneurysm sac. Conclusion: This case demonstrates an unusual, potentially fatal postoperative complication of endovascular treatment of type B aortic dissections successfully treated with an innovative endovascular solution.

Effectiveness of Exclusion of a Persistent Sciatic Artery Aneurysm with an Amplatzer™ Plug

Persistent sciatic artery is a rare developmental anomaly. In its complete form, it provides the major arterial supply to the lower leg since the femoral system is hypoplastic. These unique arteries are prone to aneurysm formation and most commonly present with complications related to aneurysm formation, which can lead to limb loss. We encountered a 68-year-old man presenting with bilateral lower-extremity ischemia who was found to have bilateral persistent sciatic artery aneurysms. One aneurysm had already thrombosed, but the other was still patent. We treated this patient with a hybrid open and endovascular repair on the patent side. The aneurysm was excluded with an Amplatzer™ plug (St. Jude Medical, Inc., St. Paul, MN) followed by a femoropopliteal bypass with saphenous vein in situ to revascularize the lower leg. To our knowledge, this is only the second report of a persistent sciatic artery aneurysm successfully treated with Amplatzer plug occlusion.

ASSA14-14-04 Transcatheter Closure of Patent Ductus Arteriosus in Children with Body Weight ≤ 8 kg

Background To explore the interventional experience and safety, efficiency of transcatheter closure of patent ductus arteriosus (PDA) in children with body weight ≤8 kg. Methods From May 2001 to August 2013,102 children with body weight ≤8 kg were diagnosed PDA. All patients were underwent transcatheter closure and aorta descendens angiography 6 min after the closure. To observe the therapeutic efficacy, we examed X-ray, ECG and echocardiography 24 h, 1 month, 3 month and 6 month after operation. Results In 102 patients, male 27, female 75, aged from 3 months to 2 years(0.9 ± 0.5 years), body weight from 5 to 8 kg (7.2 ± 0.9) kg.In 102 patients, there were funnel PDA 58, tubular PDA 39, window PDA 1 and irregular PDA 4. The narrowest PDA diameter of pulmonary artery side was 2∼10 (4.8 ± 1.6) mm by aortography. 25 patients used Amplatzer company PDA mushroom occluders, 5 patients used new type Amplatzer ADO-II occluders and 1 patient used Amplatzer Plug. 69 patients used domestic-made PDA mushroom occluders, 2 patients used domestic-made VSD occluders. The mushroom occluders waist diameter was from 6 to 16 mm. 87 patients mean pulmonary pressure were ≥25 mmHg and 43 patients mean pulmonary pressure were ≥50 mmHg before occlusion. The mean pulmonary pressure decreased with different extent after occlusion, which were consistent with dynamic pulmonary artery hypertention. 102 patients were all cured successfully and the closure achievement ratio was 100%. Conclusions PDA patients with low body weight had their own specificness. Interventional therapy has its risk. However, it is still a safe methods to treat PDA if we performed the procedure with cautiousness, selected occluder appropriately and prevent the complication.

Massive hemoptysis due to bronchopulmonary arterial fistula successfuly treated with amplatzer plug occlusion

We present the case of a 59-year-old male with massive hemoptysis secondary to a bronchopulmonary artery fistula formed as the result of a perihilar lung cancer. The hemoptysis was successfully treated by Amplatzer Plug (St. Jude Medical) embolization of the supplying pulmonary artery branch. At the same time, bronchoscopy was performed to tamponade the patients bleeding and avoid exsanguination. Biopsy of the mass demonstrated poorly differentiated non small cell carcinoma. Post procedure day 13 the patient underwent staging with PET CT which showed localized disease. His hemoptysis resolved.

Looking beyond lymph nodes: Beware of the lurking pseudoaneurysm!

An arteriovenous fistula of the superior mesenteric vessels leading to pseudoaneurysm formation is rare and most commonly occurs after blunt trauma or surgery. We describe a case of a superior mesenteric artery–superior mesenteric vein (SMA/SMV) pseudoaneurysm that was initially misinterpreted as an enlarging hypervascular nodal metastasis on surveillance computed tomography (CT) in a patient who had undergone ileal carcinoid resection. When the case was discussed at the specialist multidisciplinary meeting to consider surgical resection, it was noted that the apparent “hypervascular node” on CT had a signal void character on magnetic resonance imaging, which is atypical for a lymph node. Coronal CT reformat demonstrated a vascular origin from the superior mesenteric trunk. This resulted in the correct diagnosis of a pseudoaneurysm secondary to an SMA/SMV fistula. This avoided an unnecessary repeat surgery, and the patient underwent endovascular repair. In our patient, the distal was closed by 3-mm coils and the proximal was closed by an Amplatzer plug with successful results. Hence, it is crucial for radiologists to have a systematic approach and understanding of vascular-related abnormalities to avoid misdiagnosis that can potentially lead to unwanted morbidity.

Results of the Embolization of the Iliac Arteries with Amplatzer Plugs during the Endovascular Treatment of Aorto-iliac Aneurysms

To evaluate the short- and long term effectiveness of the Amplatzer plug (St Jude Medical) used to embolize the internal iliac arteries (IIA) or the common iliac artery (CIA) during the endovascular treatment of aneurysms of the infrarenal abdominal aortic and the common iliac arteries (EVAR) by analyzing the clinical and paraclinical data of patients treated with this technique.

O-027 Micro Vascular Plug (MVP) Assisted Vessel Occlusion in Neurovascular Pathologies: Technical Results and Initial Clinical Experience

PurposeEndovascular vessel occlusion may be necessary to treat a variety of neurovascular pathologies such as pseudo-aneurysms and giant aneurysms, iatrogenic and penetrating vascular injuries and direct arteriovenous fistulas of the...

Pelvic ischemia and quality of life scores after interventional occlusion of the hypogastric artery in patients undergoing endovascular aortic aneurysm repair

The aim of this study was to analyze the pelvic ischemic complications and their impact on quality of life after interventional occlusion of the hypogastric artery (IOHA) in patients undergoing endovascular aortic aneurysm repair (EVAR). Between January 2004 and April 2012, 638 consecutive patients with aortoiliac aneurysm treated by EVAR were prospectively registered in two teaching hospitals. We identified all EVAR patients who underwent IOHA. Demographic, clinical, and radiologic data were extracted from electronic databases and patient records as requested. All patients who survived the postoperative period took part in a quality of life survey, the Walking Impairment Questionnaire (WIQ), which included four items: pain, distance, walking speed, and stair climbing. Outcome measures included the 30-day rate of pelvic ischemic complications, the buttock claudication (BC) rate at 30 days and during follow-up, and the comparative WIQ scores between patients with persistent BC, those with regressive BC, and those who never had BC after the IOHA procedure. A total of 71 patients (97% men; mean age, 76 years ± 7.69) required 75 IOHA procedures. These were deemed proximal in 44 cases and distal in 31, with use of coil embolization in 64%, Amplatzer plug in 24%, or a combination of coils and plugs in 12%. The technical success rate was 100%. Two patients (2.8%) experienced fatal acute pelvic ischemic complications in the postoperative period after EVAR. Another patient died of iliac rupture during EVAR, leading to an operative mortality rate of 4.3%. Eighteen patients (25.3%) suffered BC, among whom 11 cases resolved at a median follow-up of 42 months. Young age (odds ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03) and distal IOHA (odds ratio, 3.5; 95% confidence interval, 1.01-11.51; P = .04) were independent predictors of BC occurrence. The actuarial rate of persistent BC was 85% at 18 months. The WIQ scores were lower for patients with persistent BC (median score, 35.04; interquartile range, 16.36; P = .001) compared with patients with regressive BC (median score, 76.5; interquartile range, 36.66; P = .02) or those who never experienced BC after the IOHA procedure (median score, 65.34; interquartile range, 10.94; P < .0003). Pelvic ischemia associated with IOHA may be severe and lead to fatality after EVAR. Our data show that BC may lead to severe quality of life impairment when it does not regress during follow-up.

Endovascular intervention for pelvic congestion syndrome is justified for chronic pelvic pain relief and patient satisfaction.

Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement. A retrospective study of patients treated for PCS at our institution from 2008 to 2012 was performed. Diagnosis was made clinically by the presence of pelvic pain, dyspareunia, and/or perineal varicosities. Clinical parameters, procedural details, and follow-up were reviewed. A questionnaire including a visual analog scale was sent to patients. Diagnosis was made in 15 women (mean age, 36years; mean parity, two). All had pelvic pain, 6 had dyspareunia, 14 had perineal varicosities, and 10 had concomitant LEVI. Fourteen had gonadal vein reflux (mean diameter, 7.4mm) and pelvic varicosities at angiography and had coiling (n= 12) and/or Amplatzer plug (St. Jude Medical, Inc, St. Paul, Minn) (n= 4). One patient had stenting ofastenotic left common iliac vein. All patients with concomitant LEVI had successful appropriate treatment. Eightpatients completed the questionnaire at a mean follow-up of 4years. The mean pelvic pain score went from 9.375 to 1.875post-procedure (P< .0001; Student t-test). Mean dyspareunia score went from 8.875 to 1.5 (P< .0001). Mean perineal varicosity pain score went from 9.285 to 1.285 (P< .0001). Two patients had recurrence with a mean pelvic pain score of 4.5 at a mean 21months. On a five-point Likert scale, all patients were satisfied (one) or extremely satisfied (seven) with treatment. Endovascular PCS treatment offers excellent pelvic pain relief and patient satisfaction. Women with pelvic pain, dyspareunia, or perineal varicosities with gonadal vein reflux and pelvic varicosities or iliac vein stenosis should not be denied treatment. A significant number may have concomitant LEVI and should be screened accordingly.

Endovascular Intervention for Pelvic Congestion Syndrome Is Justified for Chronic Pelvic Pain Relief and Patient Satisfaction

Objective Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement. Methods A retrospective study of patients treated for PCS at our institution from 2008 to 2012 was performed. Diagnosis was made clinically by the presence of pelvic pain, dyspareunia, and/or perineal varicosities. Clinical parameters, procedural details, and follow-up were reviewed. A questionnaire including a visual analog scale was sent to patients. Results Diagnosis was made in 15 women (mean age, 36 years; mean parity, two). All had pelvic pain, 6 had dyspareunia, 14 had perineal varicosities, and 10 had concomitant LEVI. Fourteen had gonadal vein reflux (mean diameter, 7.4 mm) and pelvic varicosities at angiography and had coiling (n = 12) and/or Amplatzer plug (St. Jude Medical, Inc, St. Paul, Minn) (n = 4). One patient had stenting of a stenotic left common iliac vein. All patients with concomitant LEVI had successful appropriate treatment. Eight patients completed the questionnaire at a mean follow-up of 4 years. The mean pelvic pain score went from 9.375 to 1.875 post-procedure (P Conclusions Endovascular PCS treatment offers excellent pelvic pain relief and patient satisfaction. Women with pelvic pain, dyspareunia, or perineal varicosities with gonadal vein reflux and pelvic varicosities or iliac vein stenosis should not be denied treatment. A significant number may have concomitant LEVI and should be screened accordingly.

Endovascular Exclusion of Complex Postsurgical Aortic Arch Pseudoaneurysm Using Vascular Plug Devices and a Review of Vascular Plugs

We report the management of a patient presenting with haemoptysis due to aortobronchial fistula. He had previously undergone emergency exclusion bypass of a ruptured pseudoaneurysm developing post-aortic coarctation repair. Computed tomography scan showed persistent filling of pseudoaneurysm sac from proximal and distal aortic ligature sites tied during previous exclusion bypass surgery. Successful exclusion of aneurysm was achieved by using 3 vascular plug devices (1 Amplatzer plug II and 2 Amender patent ductus arteriosus occluder devices). We also review types of Amplatzer vascular plugs and their use in peripheral vascular interventions.

GW24-e2156 Transcatheter closure of patent ductus arteriosus in children with body weight less than or equal 8Kg

ObjectivesTo explore the interventional experience of transcatheter closure of patent ductus arteriosus (PDA) in children with body weight ≤ 8Kg.MethodsFrom May 2001 to October 2012, 81 children with body weight...

Transarterial treatment of congenital renal arteriovenous fistulas

Congenital renal arteriovenous fistulas (CRAVF) represent a distinct clinical entity with characteristic hemodynamic and angiographic features. Treatment is warranted given potential for growth with renal and hemodynamic compromise. We report our experience in a rare series of treated symptomatic CRAVFs. Over a 10-year period, patients treated for symptomatic CRAVFs (no history of predisposing renal pathology, instrumentation, neoplasm, or trauma) were retrospectively investigated for clinical presentation, imaging features, treatment outcomes, and complications. Technical success included delivery of embolic agent with complete obliteration of fistula. Clinical success included resolution of symptoms and freedom from recurrence and/or reintervention. Renal parenchymal loss was estimated by postembolization angiography and categorized as 0%, <25%, 25%-50%, or >50%. Twenty-five patients were referred with a presumptive diagnosis of intraparenchymal renal artery aneurysms. Of these, 10 had true intrarenal aneurysms, three had angiomyolipomas, and 12 had CRAVFs (mean age, 54; range, 29-71 years; eight women). Presenting symptoms included hematuria (eight gross, eight microscopic), refractory hypertension (diastolic blood pressure ≥ 90 mm Hg despite three or more medications; n = 6), flank pain (n = 8), high-output state (HOS; featuring tachycardia and jugular venous distention; n = 3), and flank bruit (n = 1). Defining angiographic features included a high-flow AVF fed by a single, enlarged intrarenal branch shunting into an aneurismal draining vein, occasionally featuring a calcified rim (four patients). All patients underwent transarterial embolization with coils (n = 5), coils and n-butylcyanoacrylate (n = 3), detachable balloons (n = 2), or Amplatzer plugs (n = 2). Technical success was 100%. Hematuria, tachycardia, jugular venous distension, pain, and bruit resolved in all. Hypertension improved in four of six patients (required less than three medications postembolization). Complications included postembolization syndrome in nine patients. Parenchymal loss was limited to <25% and observed in five patients without development of acute kidney injury or worsening hypertension. There were no recurrences or reinterventions at a mean follow-up of 55 months (range, 5-96 months). There was one death at 8 years follow-up from intercurrent coronary disease in a patient without high-output state. With greater awareness and accurate diagnosis, effective and durable transarterial treatment of CRAVFs can be safely performed.

Embolization of the Internal Iliac Artery Before EVAR: Is It Effective? Is It Safe? Which Technique Should Be Used?

To assess the clinical outcomes of internal iliac artery (IIA) embolization before endovascular aneurysm repair (EVAR). Between 2002 and 2011, 88 patients underwent IIA embolization prior to EVAR. Sixty-five patients underwent unilateral and 23 underwent bilateral IIA embolization. A total of 111 IIAs were embolized: 56 were embolized with coils, 41 with Amplatzer plugs, and 14 with a combination of embolic agents. The outcomes were assessed retrospectively by reviewing medical records and follow-up imaging. IIA embolization was technically successful in 95.7% of cases. Type 2 endoleak from previously embolized IIAs was seen in 4 cases, and in 1 case this was significant necessitating re-intervention. Buttock claudication was reported in 38% of cases, whereas new onset erectile dysfunction occurred in 10% of cases. No severe ischemic complications, such as spinal cord ischaemia or buttock necrosis, were reported. Analysis comparing unilateral versus bilateral embolization, simultaneous versus sequential embolization, and the type of embolic material used showed no statistical significance. IIA embolization is technically successful and effective in preventing significant type 2 endoleak in the majority of cases. It is a relatively safe procedure without major complications, but the incidence of buttock claudication and erectile dysfunction remain relatively high, and patients should be consented appropriately. There is no significant benefit for adopting a particular embolization technique, but there is a tendency towards reduced pelvic ischaemia with proximal embolization. Four cases of type II endoleak occurring after technically successful IIA embolization supports the school of thought that IIA should be embolized prior to coverage and extension of the distal landing zone.

8:48 AM Abstract No. 123 - BRTO of gastric varices without an indwelling balloon: comparison between conventional BRTO with an indwelling balloon vs. intraprocedural replacement of the balloon with an amplatzer vascular plug

Purpose For 20-years the invariable feature of the BRTO procedure for the management of gastric varices (GV) was an indwelling balloon occlusion. The purpose is to compare between conventional BRTO (balloon dwelling over hours) and a new technique which replaces the balloon intra-procedurally with Amplatzer plugs. Materials and Methods A retrospective audit of BRTO procedures performed at a single institution utilizing 3% sodium tetradecyl sulfate foam was performed over 5-years (2007-2012). The cohort was divided into conventional BRTO (balloon-occlusion catheter left to dwell for hours and patient returned for balloon deflation) and the new BRTO-technique without an indwelling balloon occlusion catheter. The new technique uses a balloon-occlusion guide-sheath that allows placement of 16-mm Amplatzer plugs prior to balloon deflation. Once the Amplatzer plugs are in place, the balloon is deflated. Results 16 patients underwent 16 BRTO procedures with the new technique (Amplatzer group) and 46 patients underwent 47 conventional BRTO procedures with indwelling balloons (indwelling group). No difference in demographics or techical details (p>0.05). Technical results are shown in table. The Kaplan-Meier 6 month survival for Amplatzer- vs. Indwelling-group was 80% vs. 93%, respectively (p>0.05). The Kaplan-Meier 6 month rebleed rate for Amplatzer- vs. Indwelling-group was 7% vs. 8%, respectively (p>0.05). The balloon dwell time was significantly (p Conclusion In the absence of a major right to left shunt, the new technique of replacing the balloon occlusion with Amplatzer plugs is safe and effective. Table 1

Ureteric Embolization for Lower Urinary Tract Fistulae: Use of Two Amplatzer Vascular Plugs and N-Butyl Cyanoacrylate Employing the “Sandwich” Technique

This study describes and evaluated the effectiveness of occluding distal ureters in the clinical setting of urinary vaginal (vesicovaginal or enterovesicovaginal) fistulae utilizing a new technique which combines Amplatzer vascular plugs and N-butyl cyanoacrylate. This is a retrospective study (January 2007-December 2010) of patients with urinary-vaginal fistulae undergoing distal ureter embolization utilizing an Amplatzer-N-butyl cyanoacrylate-Amplatzer sandwich technique. An 8-12-mm type-I or type-II Amplatzer vascular plug was delivered using the sheath and deployed in the ureter distal to the pelvic brim. Instillation of 0.8-1.5 cc of N-butyl cyanoacrylate into ureter proximal to the Amplatzer plug was performed. This was followed by another set of 8-12-mm type-I or type-II Amplatzer vascular plugs in a technique referred to as the "sandwich technique." Five ureters in three patients were occluded utilizing the above-described technique during the 4-year study period. Mean maximum size Amplatzer used per ureter was 10.8 mm (range, 8-12). One ureter required three Amplatzer plugs and the rest required two. Two patients (3 ureters) were clinically successful with complete resolution of symptoms in 36-48 h. The third patient (2 ureters) was partly successful and required a second Amplatzer-N-butyl cyanoacrylate sandwich technique embolization. The mean clinical follow-up was 11.3 months (range, 1.7-29.2). The Amplatzer-N-butyl cyanoacrylate-Amplatzer sandwich technique for occluding the distal ureter is safe and effective with a quick (probably due to the N-butyl cyanoacrylate) and durable (probably due to the Amplatzer plugs) clinical response.