Artery Coil Research Articles

Experimental near-infrared spectroscopy-guided minimally invasive segmental artery occlusion.

Minimally invasive staged segmental artery (SA) coil- and plug embolization is a new method for paraplegia prevention associated with extensive aortic procedures. Near-infrared spectroscopy of the paraspinal collateral network (cnNIRS) has emerged as a non-invasive method for spinal cord monitoring. The aim of this study was to evaluate cnNIRS to guide minimally invasive SA occlusion. In a chronic large animal experiment, 18 juvenile pigs underwent two-stage minimally invasive staged SA coil- and plug embolization for complete SA occlusion. Coil-embolization was performed either by SA main stem occlusion (characteristic of pig anatomy) or separately for the left- and right SA. Lumbar cnNIRS was recorded during and after the procedure. Neurological status was assessed up to 3 days after complete SA occlusion. Mean time from SA coil embolization to minimum cnNIRS values was 11 ± 5 min with an average decrease from 101 ± 2% to 78 ± 8% of baseline (difference: -23 ± 9, P < 0.001). Lumbar cnNIRS demonstrated significant differences between left and right when SAs were occluded separately in all cases (-7 ± 4%, 1 min after first SA occlusion; P = 0.001). Permanent paraplegia occurred in 2 (11%) and any kind of neurological deficit-temporary or permanent-in 7 animals (39%). Association between lumbar cnNIRS and neurological outcome after minimally invasive staged SA coil- and plug embolization suggests positive correlation (R = 0.5, P = 0.052). Lumbar cnNIRS independently reacts to unilateral SA occlusion. cnNIRS-guided SA occlusion is feasible and may become a useful adjunct facilitating adequate and complete vessel occlusion.

Effectiveness of early endoscopic ultrasound-guided drainage for postoperative fluid collection.

Postoperative abdominal fluid collections (PAFCs) are a potentially fatal complication of pancreatobiliary surgery. Endoscopic ultrasound (EUS)-guided drainage has recently been shown to be effective in treating PAFCs of more than 4weeks old. Little is currently known, however, regarding the EUS-guided drainage of PAFCs of less than 4weeks. This study assessed the efficacy and safety of the early drainage (< 4weeks) of PAFCs via EUS guidance. The data of patients who had undergone EUS-guided PAFC drainage between July 2008 and January 2018 were retrospectively analyzed. Data of EUS-guided PAFC drainage were obtained from prospectively collected EUS database of our institute and reviewed of patients' clinical parameters based on electrical medical record. A total of 48 patients who had undergone EUS-guided PAFC drainage within 4weeks of pancreatobiliary surgery were enrolled. The indications of procedure included abdominal pain (n = 27), fever (n = 18), leukocytosis (n = 2), and increased size of PAFC during external tube drainage (n = 1). Technical success was achieved in all cases, and the clinical success rate was 95.8% (46/48). Four patients underwent secondary procedures. The median period from surgery to EUS-guide drainage was 14days (Interquartile range [IQR] 10-16), and median time to resolution was 23.5days (IQR 8.5-33.8). Adverse events occurred in two cases that were developed intracystic bleeding and were successfully resolved by arterial coil embolization. Early EUS-guided drainage is a technically feasible, effective, and safe method in patients who have developing PAFCs within 4weeks of pancreatobiliary surgery.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization

BackgroundAlthough not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles.Case presentationIn this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA).ConclusionsThe Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

The Hybrid Neurosurgeon: The Japanese Experience.

In Japan, hybrid neurosurgeons who perform both open surgical clipping as well as endovascular embolization for the treatment of intracranial aneurysms are common. Although many Japanese neurosurgeons can perform surgical clipping of middle cerebral artery aneurysms or internal carotid artery-posterior communicating artery aneurysms and coil embolization of cerebral aneurysms using simple techniques-only a limited number of neurosurgeons are able to perform surgical clipping and endovascular procedures for anterior communicating artery aneurysms, paraclinoid, or posterior circulation aneurysms using both treatment modalities equally and safely. The senior author's personal experience of more than 500 cases each of surgical clipping and endovascular embolization over the past 25years included 110 cases of basilar tip aneurysms and 104 cases of paraclinoid internal carotid artery (ICA) aneurysms. The safety and efficacy of both treatments appears to be the same, while the durability of surgical clipping is superior to that of endovascular embolization. Among the 110 basilar tip aneurysms, 18 patients were treated by surgical clipping and 94 were treated by endovascular embolization. The initial results of endovascular therapy seemed to be better than those of surgical clipping, although the rate of retreatment was higher. Among the 104 cases of paraclinoid ICA aneurysm, 23 patients were treated by surgical clipping and 81 were treated by endovascular embolization. The results of both treatments seemed to be same, while surgical clipping had apparently good long-term durability. Over the past 15years, the frequency of surgical clipping for basilar tip aneurysms has decreased, and the procedure may eventually be abandoned for this type of aneurysm. However, surgical clipping still offers several advantages in the treatment of paraclinoid aneurysms. Hybrid neurosurgeons can make reasonable decisions concerning the choice of treatment for cerebral aneurysms, as they perform both treatments and understand the benefits and drawbacks of each modality.

A Case of Common Hepatic Artery Aneurysm Treated by Abdominal Aorta—Proper Hepatic Artery Bypass and Coil Embolization—

A Case of Common Hepatic Artery Aneurysm Treated by Abdominal Aorta—Proper Hepatic Artery Bypass and Coil Embolization—

S1513 Liver Biopsy Leading to Hemobilia Complicated by Cholangitis, Biliary Pancreatitis, and Massive Gastrointestinal Hemorrhage

INTRODUCTION: Percutaneous liver biopsies (PLB) are performed routinely to investigate liver masses, unexplained hepatomegaly or abnormal liver chemistries and are relatively safe in the absence of coagulopathy. Here, we present a rare complication of PLB: arterio-biliary fistula presenting with delayed onset of hemobilia, massive gastrointestinal hemorrhage, acute cholangitis and acute biliary pancreatitis requiring emergent embolization and antimicrobial therapy. CASE DESCRIPTION/METHODS: A 62-year-old female recently diagnosed primary biliary cholangitis presented with hematemesis, hematochezia and jaundice 1 week after percutaneous liver biopsy. On admission, she was febrile, hypotensive and tachycardic. Physical exam was notable for scleral icterus, jaundice and right upper quadrant abdominal tenderness with voluntary guarding. Rectal exam revealed a large amount of bright red blood. Laboratory data was significant for hemoglobin of 7.7 g/dL from 11.1 g/dL prior to liver biopsy, total bilirubin 7.5 mg/dL (1.0 unconjugated/4.5 conjugated), ALP 587 U/L, GGT 504 U/L, AST 98 U/L, ALT 83 U/L, lipase 3017 U/L. CT angiography of the abdomen showed contrast throughout the proximal hepatic and common bile ducts concerning for active bleeding from an arterio-biliary fistula resulting in hemobilia, moderate biliary dilation, and bowel contents concerning for intraluminal bleeding from the biliary system. She was treated with broad-spectrum antibiotics and successfully resuscitated with IV crystalloids and blood products. She underwent emergent mesenteric angiography with left hepatic artery and arterioportal fistula coil embolization which resulted in hemostasis and rapid normalization of liver chemistries. DISCUSSION: Major gastrointestinal bleeding complications due to iatrogenic arterio-biliary fistula formation after PLB are exceedingly rare, occurring less than 1% of the time due to needle intersection with the portal triad, resulting in epithelialized shunt formation between the hepatic artery and bile duct. This case represents a later presentation of hemobilia, which typically occurs within 24 hours of PLB. The accumulation of blood clots in the biliary tree can lead to life threatening cholangitis and biliary pancreatitis. Early recognition of this complication is essential as urgent embolization and aggressive antimicrobial therapy can lead to a significant reduction in mortality.Figure 1.: CT angiogram abdomen/pelvis: contrast visible in the common hepatic duct.Figure 2.: Pre-embolization: segment 3 branch of hepatic artery.Figure 3.: Post-embolization: segment 3 branch of hepatic artery.

S2072 Hematemesis Caused by Migrated Coil - A Rare Complication of Splenic Artery Coil Embolization

S2072 Hematemesis Caused by Migrated Coil - A Rare Complication of Splenic Artery Coil Embolization

S2332 Complete Occlusion of the Common Bile Duct Due to Erosion of a Gastroduodenal Artery Coil

INTRODUCTION: Endoscopic intervention remains the first-line method for treating upper gastrointestinal bleeding. In the case of bleeding duodenal ulcers and failed endoscopic hemostasis, visceral artery embolization has become standard of care at many centers because of its high efficacy and minimal side-effect profile. We present a patient who presented with ascending cholangitis due to complete occlusion of the CBD after migration of a gastroduodenal (GDA) coil. CASE DESCRIPTION/METHODS: 53-year-old male with history of duodenal ulceration and massive hemorrhage status post graham patch repair and suture ligation of the GDA followed by elective embolization of the GDA, complicated by disruption of the common bile duct (CBD) and hepatic artery hemorrhage status post stenting, presented 30 months after GDA embolization with transaminitis and recent hospitalization with Klebsiella bacteremia of unclear etiology. Subsequent outpatient ERCP revealed complete obstruction of the CBD at the level of the GDA coils. Manipulation of wires allowed for passage through a fistula that ended on the bulb side of the pylorus. Cholangioscopy revealed erosion of nearly the entire GDA coil into the bile duct entrapping multiple portions of the biliary wall. Various sites were probed with wire but without ability to pass. Patient was referred for percutaneous biliary tube placement and initial plan was to repeat ERCP after PTC to try to pull coils out of the duct with forceps. However, subsequent cholangiogram and intervention resulted in successful recanalization of distal CBD obstruction and placement of internal/external biliary drain. Intraluminal portion of the coil pack had migrated into the duodenum and was removed. A 10 mm × 60 mm covered stent was positioned under fluoroscopic guidance to reconnect the ducts. DISCUSSION: Percutaneous endovascular embolization is generally safe and capable of achieving hemostasis in 93% of emergent cases of GI bleeding nonamenable to endoscopic therapy. Coil migration causing biliary obstruction, although rare, has been previously reported including a few case reports involving the embolization of the hepatic arteries and one case in the English literature involving the GDA. ERCP with removal of the coils is the best management. When ERCP fails, as in our case, decompression of the biliary system by PTC or surgery should be considered.Figure 1.: ERCP showing GDA coils in the CBD.Figure 2.: ERCP cholangiogram showing complete obstruction of the CBD.Figure 3.: IR Cholangiogram showing recanalization of CBD.

Outcomes of Arterial Conduits in Vascular Reconstruction After Oncologic Resection of Locally Advanced Pancreatic Malignancies

To determine early and midterm outcomes of various conduit types for visceral artery reconstruction after resection of locally advanced pancreatic malignancies. Retrospective review of all patients who underwent resection for pancreatic malignancy with visceral reconstruction using superficial femoral artery (SFA), great saphenous vein (GSV), splenic artery (SA), cryopreserved allograft, or prosthetic graft (PG) between 2000 and 2019. The SFA donor limbs were revascularized with expanded polytetrafluoroethylene interposition grafts. End points for visceral and donor limb arterial reconstructions are primary and secondary patency, vascular complications, and mortality. Visceral reconstruction for oncologic resection was performed in 57 patients. Reconstructed arteries included proper hepatic (n = 24), common hepatic (n = 17), superior mesenteric (n = 22), right hepatic (n = 5), and left hepatic (n = 2) with multivessel reconstructions performed in 13 patients. Of 57 visceral reconstructions, 30 were performed with autogenous SFA; 27 had no preoperative evidence of peripheral arterial disease. Median follow-up for all patients was 9 months. The 30-day visceral reconstruction complications included pseudoaneurysms in one SFA conduit (requiring gastroduodenal artery coiling and covered stent placement) and one GSV conduit (requiring covered stent placement), thrombosis in one PG conduit and one GSV conduit (both requiring open thrombectomy), and anastomotic bleed from one SA conduit (requiring operative repair). The 30-day SFA harvest donor limb complications included one hematoma, one lymphocele, and one symptomatic edema. Early mortality occurred in three patients including one SA conduit with multiorgan failure, one GSV conduit pseudoaneurysm rupture secondary to pancreatic leak and one SFA conduit of unknown cause. Midterm visceral reconstruction complications included pseudoaneurysm in 6 patients (3 SFA conduits with 2 treated, 3 GSV conduits with all treated), and graft occlusion in 10 patients (3 SFA, 4 GSV, 1 cryopreserved allograft and 2 PG). One patient underwent percutaneous angioplasty for high-grade stenosis of a SA graft. This gave a primary and secondary patency for all visceral arterial reconstructions of 81% and 84%, respectively. Midterm SFA donor limb patency was 100% with median follow-up of 8 months. Late mortality occurred in 19 patients (33%) with 11 cancer-related deaths and 5 of unknown cause or unrelated to the primary cancer. Three late mortalities occurred secondary to mycotic graft pseudoaneurysm ruptures in the setting of bile and pancreatic leaks (1 GSV, 1 PG secondary reconstruction in SFA conduit patient and 1 SFA conduit). This preliminary study suggests that superficial femoral artery can be considered feasible conduit in oncologic reconstructions with low morbidity of the donor limb. Long-term follow-up is needed to identify oncologic and patency-related outcomes.TablePrimary end points by conduit choiceConduitNo. of patientsPrimary patencySecondary patencyMajor early visceral graft complicationsAll-cause mortality, % (vascular-related, %)Median follow-up, months (range)Superficial femoral artery3090%90%n = 1 pseudoaneurysm30 (7)8 (2-39)Cryopreserved allograft988%88%n = 00 (0)4 (1-23)Great saphenous vein838%38%n = 2 (1 pseudoaneurysm, 1 thrombosis)75 (25)11 (0-25)Prosthetic graft667%83%n = 1 thrombosis67 (0)12 (1-107)Splenic artery450%50%n = 1 anastomotic bleed50 (0)26 (1-52) Open table in a new tab

A Permanent Common Carotid Filter for Stroke Prevention in Atrial Fibrillation: Ex Vivo and In Vivo Pre-Clinical Testing

Background and purposeA novel, permanent, bilateral, common carotid artery (CCA) coil filter implant was designed to capture stroke-producing emboli in atrial fibrillation patients. Under ultrasound guidance, it is automatically deployed through a 24-guage needle and is retrievable up to 4 h post-procedure. We assessed the feasibility, safety, and effectiveness of the CCA filter in pre-clinical testing. MethodsIn a pulsatile flow simulator, the filter's embolic capture efficiency and integrity of simulated (1.2 mm diameter nylon balls) and actual thromboemboli were tested. Implant insertion, retrieval, and chronic safety were tested in sheep by ultrasound and X-ray. At termination, the CCAs were explanted and examined by pathology, histopathology and scanning electron microscopy. The fate of captured emboli was evaluated in sheep 3 weeks after upstream injection of autologous thromboemboli. ResultsIn the flow simulator, 10 filters captured 29 of 29 (100%) 1.2 mm diameter nylon balls. In the thromboemboli integrity test, all captured thromboemboli (99 of 99) were adherent to the filter, without fragmentation. All sheep (n = 30/60 implants) underwent successful CCA filter implantation. During follow-ups at 4, 12, 13, 23, and 31 weeks (6 sheep/12 implants at each follow-up), there were no (0%) major bleeds, CCA damage/stenosis, implant migration, flow obstruction, or thrombi detected by ultrasound. Two organized microthrombi (<100 μm) were observed by histopathology at the puncture site. After 3 weeks, autologous captured thromboemboli (n = 10) either completely regressed (5 of 5) or did not progress (5 of 5). ConclusionThese favorable pre-clinical results prompt clinical testing of the CCA filter in stroke prevention clinical trials.

Single-Institution Experience with Selective Internal Radiation Therapy (SIRT) for the Treatment of Primary and Secondary Hepatic Tumors.

Purpose: We aim to provide results of the real-world experience of a single center in Lebanon on the use of radioembolization to treat liver-only or liver-dominant tumors. Methods: This retrospective review included patients who were evaluated for radioembolization between January 2015 and June 2017 and who had a lung shunt fraction of 20% or less. Tumor responses were determined using the response evaluation criteria in solid tumors (RECIST).Results: Of the 23 Arab patients with a median age of 64 years (range, 36-87 years), eight had hepatocellular carcinoma, four had cholangiocarcinoma, and 11 had liver-only or liver-dominant metastases from other primary cancers. Most (n=17) had multifocal lesions, and 13 had a history of branched (n=8) or main (n=5) portal vein thrombosis. When appropriate, the gastroduodenal artery and middle hepatic artery were embolized for consolidation of radiotherapy; 18 patients required arterial coil occlusion, two had their cystic artery occluded, and one developed cholecystitis, which was successfully treated with antibiotics and supportive care. Another patient developed a post-radioembolization complication-a peptic ulcer unrelated to arterial reflux of microspheres because both the gastroduodenal and right gastric arteries were occluded. The median time to progression was seven months (range, 3-36 months), and median overall survival from radioembolization was 12 months (range, 3-40 months). Tumor responses included five complete responses, 13 partial responses, one stable disease, and four cases of progressive disease. Conclusion: Performing radioembolization in a non-referral, private center in Lebanon resulted in good patient outcomes with few complications.

Stability Analysis of Arteries Under Torsion.

Vascular tortuosity may impede blood flow, occlude the lumen, and ultimately lead to ischemia or even infarction. Mechanical loads like blood pressure, axial force, and also torsion are key factors participating in this complex mechanobiological process. The available studies on arterial torsion instability followed computational or experimental approaches, yet single available theoretical study had modeled the artery as isotropic linear elastic. This paper aim is to validate a theoretical model of arterial torsion instability against experimental data. The artery is modeled as a single-layered, nonlinear, hyperelastic, anisotropic solid, with parameters calibrated from experiment. Linear bifurcation analysis is then performed to predict experimentally measured stability margins. Uncertainties in geometrical parameters and in measured mechanical response were considered. Also, the type of rate (incremental) boundary conditions (RBCs) impact on the results was examined (e.g., dead load, fluid pressure). The predicted critical torque and twist angle followed the experimentally measured trends. The closest prediction errors in the critical torque and twist rate were 22% and 67%, respectively. Using the different RBCs incurred differences of up to 50% difference within the model predictions. The present results suggest that the model may require further improvements. However, it offers an approach that can be used to predict allowable twist levels in surgical procedures (like anastomosis and grafting) and in the design of stents for arteries subjected to high torsion levels (like the femoropopliteal arteries). It may also be instructive in understanding biomechanical processes like arterial tortuosity, kinking, and coiling.

Dolicho-arteriopathies (Kinking, Coiling, and Tortuosity) of the Carotid Arteries: A Study by Magnetic Resonance Angiography

Dolicho-arteriopathies (Kinking, Coiling, and Tortuosity) of the Carotid Arteries: A Study by Magnetic Resonance Angiography

A case of bronchial artery aneurysm causing hemoptysis - A rare case report

Hemoptysis is one common presenting complaint in respiratory clinics. Bronchial artery aneurysm is one of the rare causes of hemoptysis. Here, we present a case of a 64-year-old male, asthmatic, and hypertensive with a previous history of tuberculosis presented with hemoptysis. On bronchial angiogram, he was found to have a right bronchial artery aneurysm which was treated with bronchial artery coiling.

2386 Shock Liver: A Complication of Gastroduodenal Artery Embolization

INTRODUCTION: PUD is the most common cause of acute upper GI bleeding. Duodenal ulcers are 4x more likely to bleed than gastric ulcers. Posterior duodenal ulcers, are more likely to erode into the gastroduodenal artery (GDA) resulting in massive bleeding requiring intervention. Liver failure is a known complication of gastroduodenal artery embolization due to inadvertent embolization of the main hepatic artery [1,2]. CASE DESCRIPTION/METHODS: A 71 year old lady presented with a hemoglobin of 5.7 g/dL with a baseline of 10.7 g/dL. She was resuscitated with pRBCs and fluids to a hemoglobin of 8.7 g/dL. EGD showed an active 3 cm bleeding ulcer at the duodenal bulb with a visible vessel and adherent clot. Hemostasis was achieved with epinephrine, two hemoclips and gold probe cautery. On POD# 5, she had two melenic stools and an acute drop in hemoglobin reaching a nadir of 6.4 g/dL which prompted a repeat EGD. An ulcerated area on the posterior wall of the bulb was bleeding, hemostasis with epinephrine and three hemoclip deployment failed. Subsequently, she underwent gastroduodenal artery coiling. During the embolization, the coil was partially protruding into the hepatic artery. Coil repositioning failed. POD# 1, AST and ALT trended up to 2814 IU/L and 1375 IU/L from a baseline of 14 IU/L and 10 IU/L on admission, respectively. INR trended up from 1.23 to 1.8, she developed encephalopathy, was diagnosed with shock liver and transferred to outside liver transplant center. DISCUSSION: Technical success rates of transcatheter arterial embolization are extremely high (&gt;90%) while clinical success rates vary from 60%-90% [3]. This difference may be attributed to multiorgan failure, coagulopathy, and bleeding from trauma or invasive procedures [4]. A lack of understanding of the factors that influence clinical outcome also plays a role. Transcatheter therapeutic embolization has a very high rate of success and should be considered as an alternative to surgery in high-risk populations. [1,2]. Endoscopic embolization usually has a low rate of complications of rebleeding, infarction, and rarely coil migration [3,5,]. Coil migration has been described after embolization of the GDA, but infrequently been reported to be fatal. Our patient had movement of the sheath used to protect the hepatic artery and the catheter resulting in partial migration of the coils into the hepatic artery which led to shock liver. To our knowledge, few cases of coil migration inducing hepatic failure have been reported in the literature.

1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia. CASE DESCRIPTION/METHODS: A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery. DISCUSSION: Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.

Refractory Duodenal Ulcer and Upper Gastrointestinal Bleeding Following Yttrium-90 Transarterial Radioembolization

Abstract Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma. Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.

The biomechanics of the umbilical cord Wharton Jelly: Roles in hemodynamic proficiency and resistance to compression

The umbilical cord is a complex structure containing three vessels, one straight vein and two coiled arteries, encased by the Wharton Jelly (WJ) a spongy structure made of collagen and hydrated macromolecules. Fetal blood reaches the placenta through the arteries and flows back to the fetus through the vein. The role of the WJ in maintaining cord circulation proficiency and the ultimate reason for arterial coiling still lack of reasonable mechanistic interpretations. We performed biaxial tension tests and evidenced significant differences in the mechanical properties of the core and peripheral WJ. The core region, located between the arteries and the vein, resulted rather stiffer close to the fetus. Finite element modelling and optimization based inverse method were used to create 2D and 3D models of the cord and to simulate stress distribution in different hemodynamic conditions, compressive loads and arterial coiling. We recorded a facilitated stress transmission from the arteries to the vein through the soft core of periplacental WJ. This condition generates a pressure gradient that boosts the venous backflow circulation towards the fetus. Peripheral WJ allows arteries to act as pressure buffering chambers during the cardiac diastole and helps to dissipate compressive forces away from vessels. Altered WJ biomechanics may represent the structural basis of cord vulnerability in many high-risk clinical conditions.

Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer?

BackgroundThe exact contribution of preoperative coil embolization in distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for the prevention of ischemic liver complication is not fully elucidated.MethodsFrom January 2004 to July 2015, 31 patients underwent DP-CAR for the pancreatic body–tail cancer. Twenty-three patients received preoperative coil embolization. The characteristics and operative outcomes were analyzed retrospectively.ResultsThe median survival time and 1- and 3-year overall survival rates were 23.7 months and 74.2% and 34.4%, respectively. No 30-day mortality occurred in any of the patients. Postoperative liver infarction developed only in 8 patients (25.8%) even though 7 of 8 patients had undergone preoperative coil embolization. Tumor contact with the gastroduodenal artery (GDA)/proper hepatic artery (PHA) on preoperative multi-detector computed tomography (MDCT), tumor size, operative time, portal vein resection, and stenosis of the GDA/PHA after DP-CAR are related to liver infarction. Among them, postoperative stenosis of the GDA/PHA on MDCT, which was observed in all 8 patients with liver infarction, was the most closely related factor to postoperative liver infarction. Tumor contact with the GDA/PHA did not worsen the R0 resection rate or overall survival rate.ConclusionOur data indicate that preoperative coil embolization of the common hepatic artery is not useful in DP-CAR as long as GDA is completely preserved during surgery.

IP047. Isolated Iliac Artery Aneurysm—Endovascular Repair With Internal Iliac Artery Coiling: Case Report

Isolated iliac artery aneurysm occurring in the absence of abdominal aortic aneurysm is rare, accounting for only 2% of all intra-abdominal aneurysms. This case report highlights isolated right iliac artery aneurysm managed effectively with endovascular repair. Our patient is 76-year-old man, hypertensive for 3 years, with chronic obstructive pulmonary disease for 5 years, and recently diagnosed hypothyroidism, presented with complaints of right lower limb swelling since 10 days. He has no history of trauma, and no deep venous thrombosis on venous doppler. A computed tomography angiogram showed large 5 × 6-cm partially thrombosed aneurysm involving the right common iliac artery with right internal iliac artery arising from aneurysm (Fig 1). He underwent endovascular aneurysm repair with an Endurant II stent graft and right internal iliac artery coil embolization with Nestor coils 8 mm ×14 cm (to prevent endoleak) (Fig 2). The operative and preoperative periods were uneventful. After the procedure, the patient was moved to intensive care and monitored. Postprocedure duplex scan showed stent graft patent and no endoleak. Patient symptomatically better, right lower limb swelling subsided. He was discharged on postoperative day 4. Endovascular aneurysm repair is safe and effective modality of management of isolated iliac artery aneurysms.Fig 2IIA, iliac artery aneurysm.View Large Image Figure ViewerDownload Hi-res image Download (PPT)