Bilateral Embolization Research Articles

Bronchial Artery Embolization, an Increasingly Used Method for Hemoptysis; Treatment and Avoidance.

Objectives:Hemoptysis is an alarming symptom. It may cause some severe life-threatening complications. Hypertrophic and fragile bronchial artery causes hemoptysis and occurs mostly in bronchiectasis, sarcoidosis, active or sequelae tuberculosis, aspergilloma, lung cancer or cystic fibrosis. Bronchial artery embolization is one of the angiographic methods used in diagnosis and treatment for years performed by radiologists. Hemoptysis is used mostly in patients with hemoptysis. Using this method, surgical management with high mortality and morbidity rates can be avoided or better conditions for surgery can be provided via stopping hemorrhage before surgery. We aim to share the experiences of our hospital about patients who underwent bronchial artery embolization and compare our results with the literature.Methods:Thirty-nine patients (29 male, 10 female) underwent angiography-aiming embolization. Pathologies were hemoptysis in 37 patients, Castleman disease in two patients. Embolization was performed in 33 patients; 31 for hemoptysis, two for Castleman disease. Bilateral embolization was performed in six patients.Results:Computed tomography (CT) was helpful in diagnosing the side of bleeding in 91.8% of the patients with hemoptysis. Bronchoscopy was diagnostic in 53% of patients. Polyvinyl alcohol (n=27) was mostly used for embolization. Hemoptysis recurred in six patients (19.3%). All were managed successfully, of four with re-embolization. One major complication, transient blindness, was observed.Conclusion:Bronchial artery embolization is minimally invasive, more tolerable compared to surgery can be managed with high success and lower complication rates, especially hemoptysis and in some other situations. It provides time for evaluating the underlying disease and delaying surgery for elective conditions. That is why this method has been used increasingly.

Pulmonary arteriovenous malformation and follow-up imaging.

Image in medicine An 85-year-old Caucasian female with past medical history of hypertension, hyperlipidemia, polymyalgia rheumatica, coronary artery disease, Osler-Weber-Rendu syndrome (diagnosed 18 years ago), intermittent epistaxis and pulmonary arteriovenous malformation (AVM) was referred to the clinic for abnormal chest imaging. She underwent multiple bilateral AVM embolization 17 years ago. She had minimal shortness of breath without epistaxis, hemoptysis, hematemesis or hematochezia. One month ago, her chest X-ray revealed multiple embolization coils bilaterally (A). Computed tomography (CT) chest scan without contrast showed multiple embolization coils, multiple tortuous vascular malformations in both lungs with enlargement of left lower lobe AVM (B). Magnetic resonance imaging (MRI) brain 17 years ago did not show brain vascular malformation. The diagnosis of progressive Osler-Weber-Rendu or hereditary hemorrhagic telangiectasia (HHT) was made. She was referred to HHT center and underwent coiling. After that, she has been clinically stable and a repeat CT chest on the follow-up visit showed smaller left lower lobe AVM (B), so conservative management was planned. Figure 1 A) chest X-ray showing multiple embolization coils bilaterally; B) CT chest without contrast showing large AVM at left lower lobe (arrow); C) a repeat CT chest without contrast one year later showing smaller AVM at left lower lobe after coiling (arrow)

The First 48 Consecutive Patients with 3-Year Symptom Score Follow-Up Post-Prostate Artery Embolization (PAE) at a Single-Centre University Hospital.

Few studies on prostate artery embolization (PAE) follow patients up after 12months. We aimed to evaluate the symptomatic efficacy of PAE in our patient cohort at 3years. A total of 48 consecutive patients undergoing PAE from June 2012 to August 2014 were included in this retrospective study. All patients underwent formal urodynamics to confirm bladder outflow obstruction prior to PAE. International Prostate Symptom Score (IPSS) was performed at baseline, 3months, 12months and 3years post-PAE. Mean patient age was 65.6 ± 7.4, prostate volume 99.1 ± 56.6cm3, IPSS 23.5 ± 6.0, quality-of-life score 4.6 ± 0.9, Qmax 8.4 ± 2.8ml/s, post-void residual volume 185.8 ± 55.6ml. Technical success (bilateral embolization) was achieved in 43 out of 48 cases (89.6%). 11/39 bilateral PAE patients completing follow-up (2 died, 2 lostto follow-up) underwent surgery, indicating a 71.8% clinical success rate at 3 years. No significant change was demonstrated in IPSS or QOL between 1 and 3years for patients free from surgical intervention (IPSS 8.3 vs 10.0, p = 0.09 and QOL 1.3 vs 1.5, p = 0.23). 3/11 patients undergoing surgery had a prominent 'ball-valve' median lobe, and 1/11 patients had a high bladder neck elevation contributing to symptoms. Clinical success post-PAE remains high with few patients opting for surgery or experiencing a worsening of symptoms after 12months.

Prostatic Artery Embolization (PAE) As Treatment for Lower Urinary Tract Obstruction Due To Benign Prostatic Hyperplasia: An Update of the Literature

Prostate artery embolization (PAE) as treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) was first undertaken in 2000 and since then utilization of PAE for the treatment of symptomatic BPH associated with failure of medical therapy or patients not being fit to undergo general anaesthesia or spinal anaesthesia for surgical treatment of the prostate gland has continued to be undertaken by well trained interventional radiologists in various well equipped interventional radiology units globally especially in the developed countries. PAE is a technically demanding procedure which is only undertaken by well trained interventional radiologists. PAE is undertaken under radiology imaging control via the left or right femoral artery or the radial artery under local anaesthesia. Super-selective catheterization of the small prostatic artery is undertaken with the use of fine microcatheters that traverse the pelvic arteries / internal pudendal arteries. The PAE procedure does involve introduction of microparticles to completely block the prostate arteries. The embolization agents include polyvinyl alcohol (PVA) and other synthetic materials including microspheres. Successful PAE does lead to necrosis and shrinkage of the prostate gland. With regard to the technical details of PAE, the interventional radiologist does obtain access into the arterial system by piercing the femoral artery or the radial artery under radiology imaging control including ultrasound scan with utilization of a trocar which is hollow. A guide-wire is threaded through the trocar and trocar is then removed. A cannula is passed over the guide-wire and once the cannula is in place the guide-wire is removed. The cannula does allow a sheath to be inserted into the artery. Contrast material is injected through the sheath under radiology imaging / fluoroscopic control which does allow the anatomy of the pelvic blood vessels to be illustrated including the anatomy of the internal pudendal artery as well as if the anatomy is normal or there is a variation in the anatomy of the pelvic vessels including whether or not there is tortuosity of the pelvic vessels or atherosclerosis of the vessels. The contrast angiography is utilized to guide the interventional radiologist to identify the prostate artery in order to advance the catheter to the ostium of the prostatic artery and this then enables the radiologist to inject polyvinyl alcohol or microspheres into the prostatic artery. The anatomy of the pelvic vessels does vary which is well known by all interventional radiologists. Successful PAE does refer to complete bilateral embolization of the prostatic arteries but at times the radiologist is only able to undertake unilateral embolization of a prostatic artery due to a variant anatomy of the pelvic vessel or tortuosity of the vessel or atherosclerosis. Over the past 18 years various case reports, case series, and studies of PAE either alone or in comparison with trans-urethral resection of the prostate have been reported in various journals. These publications have mostly shown that PAE is safe and efficacious in improving upon the IPSS, QoL, Q-max, Post -void residual urine volume, as well as reduction in the volume of the prostate. Some of the studies have shown almost equivalent in the IPSS improvement in comparison with the IPSS improvement pursuant to TURP. Nevertheless, some of the reported improvements in other functional outcomes have not been as good as that obtained following TURP. Additionally the studies had been reported with short and medium term-follow-up only hence generally one cannot confidently state what the overall long-term outcome of PAE would be. Nevertheless, PAE has be associated with minor complications mainly and not with major complications including major bleeding. TURP tends to be associated with higher incidence of retrograde ejaculation and erectile dysfunction in comparison with PAE in which the sexual function tends to remain stable. PAE tends to be associated with retention of urine / long period of urethral catheterization in comparison with TURP. The overall cost of PAE tends to be much cheaper in comparison with TURP because of the fact that PAE tends to be undertaken as an outpatient procedure without any hospitalization cost. Specific complications which could occur include non-target embolization that could lead to transient rectitis, or penile ulcer, urinary tract infection, and dysuria. PAE may be associated with pelvic and urethral pain of more than 1 to 3 days but PAE is not associated with dilutional hyponatraemia which occasionally occurs following TURP. There is need for more studies to be undertaken on PAE and to be reported with long-term follow-up to enable a consensus opinion to be made about the long term outcome of PAE. Meanwhile PAE could be undertaken on individuals who have failed medical therapy who are not fit to undergo surgery or who do not want to undergo surgery.

Laparoscopic Resection of Ovarian Vessel Coils and a Tubal Occlusion Device

Video Objective To describe the anatomy of the ovarian vessels cephalad to the pelvic brim. Setting A 45 year old multiparous woman presents with chronic right pelvic pain following hysteroscopic tubal sterilization. Bilateral ovarian vein embolization was performed for suspected pelvic congestion syndrome. Her pain worsened post-embolization. After an extensive pelvic pain evaluation, the decision was made to remove her embolization and tubal occlusion coils. Interventions Laparoscopic dissection and removal of the right ovarian vessels above the pelvic brim is described. Multiple steps are required for a safe and complete resection: 1- Retroperitoneal access; 2- Maintaining hemostasis; 3- Traction/counter-traction; 4- sharp and blunt dissection; 5- judicious use of electrosurgical energy. Conclusion Successful dissection/resection of ovarian vessels is feasible and safe with in-depth knowledge of neighboring structures cephalad to the pelvic brim.

Endovascular preoperative embolization for temporomandibular joint replacement surgery.

This retrospective study evaluates the safety and effectiveness of preoperative endovascular embolization in patients who underwent temporomandibular joint (TMJ) replacement surgery. We included all patients treated with preoperative embolization of the internal maxillary artery (IMAX) between June 2016 and January 2019. All patients were treated by the same surgeon using standard surgical approaches and procedures. Periprocedural adverse events, blood loss during surgery and clinical follow-up are reported. Fourteen patients (12 females, median age 32.5) were treated with 21 embolizations of the IMAX (bilateral embolizations in seven patients) prior to TMJ replacement surgery with prosthetic joints (TMJ Concepts prostheses). Seven patients presented with TMJ ankylosis/degenerative joint disease/post-trauma deformity, four patients with Idiopathic Condylar Resorption and resultant mandibular displacement/hypoplasia, two patients with rheumatoid arthritis-associated condylar degeneration and resultant loss of mandibular position, and 1 patient being re-reconstructed following management of a prosthetic joint infection. Seven patients underwent bilateral prosthetic joint replacement. Four patients underwent additional facial skeletal surgery as part of their treatment. The mean blood volume loss during TMJ surgery was approximately 370 cc (range 100-800 cc). Joint space-specific blood loss was not recorded, but, as per the surgical team, was significantly decreased when compared to non-embolized patients. There were no intra-procedural complications. The median clinical follow-up was 3.5 months (range 1-24 months). The modified Rankin scale (mRS) was 0 before the procedure and at last clinical follow-up in all patients. After TMJ surgery, three patients reported paresthesia of the trigeminal nerve likely related to the residual condyle resection and two patients had mild facial nerve weakness (Temporal and/or Marginal Mandibular branch) related to the surgical exposures. Endovascular preoperative embolization of the IMAX is feasible, safe and likely effective in reducing blood volume loss in complex TMJ replacement surgery.

Prostate Embolization in Chronically Surveyed Patients: Effectiveness of Unilateral vs. Bilateral Embolization

Prostate Embolization in Chronically Surveyed Patients: Effectiveness of Unilateral vs. Bilateral Embolization

Mid-term follow-up of staged bilateral internal carotid artery aneurysm treatment with Pipeline embolization.

Endovascular treatment of large complex morphology aneurysms is challenging. High recanalization rates have been reported with techniques such as stent-assisted coiling and balloon-assisted coiling. Flow diverter devices have been introduced to improve efficacy outcomes and recanalization rates. Thromboembolic complications and in-device stenosis are certainly more worrisome when treatment of bilateral internal carotid arteries has been performed. This study aimed to report our experience with mid-term imaging follow-up of staged bilateral Pipeline embolization device placement for the treatment of bilateral internal carotid artery aneurysms. We reviewed the clinical, angiographic, and follow-up imaging data in all consecutive patients treated with bilateral internal carotid artery aneurysms who underwent elective Pipeline embolization. Six female patients were treated, harboring a total of 13 aneurysms. Of these, 60% were asymptomatic. Diplopia and headache were the most common symptoms. The most common location was the paraclinoid segment (6/13), including by cavernous segment (4/13) and ophthalmic segment (2/13). Successful delivery of the device was achieved in 12 cases. Difficult distal access precluded the deployment of the device in one case. The treatment was always staged with at least eight weeks' difference between the two procedures. All aneurysm necks were covered completely. There were no periprocedural complications. Angiographic follow-up ranged between 3 and 12 months, and computed tomography angiogram follow-up ranged between 2 and 24 months. Complete aneurysm occlusion was achieved in all cases. In our series, Pipeline deployment for the treatment of bilateral internal carotid artery aneurysms in a staged fashion is safe and feasible. Mid-term imaging follow-up showed permanent occlusion of all the treated aneurysms.

Palliative Prostate Artery Embolization for Prostate Cancer: A Case Series.

Prostate artery embolization (PAE) is recognized as a treatment for lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia. LUTS and urinary retention are common in men with prostate cancer (PCa). The purpose of this study was to estimate the efficacy and safety of palliative PAE on LUTS or urinary retention in men with advanced PCa. This prospective, single-center trial was conducted from March 2017 to November 2018. The trial protocol was registered online (ClinicalTrials.gov Identifier: NCT03104907). Only men with advanced PCa suffering from LUTS or urinary retention were included. The primary outcome was the ability to void without a catheter and International Prostate Symptom Score (IPSS) in non-catheter-dependent patients. The paired t test was used to analyze changes from baseline with 95% confidence intervals (CI). A p value < 0.05 was considered statistically significant. Seventeen patients were assessed for eligibility, and 15 patients with a mean age of 73.8years were enrolled. Four men did not complete follow-up: cancer-related death (n = 2), lost to follow-up (n = 1), and unsuccessful embolization due to severe atherosclerosis (n = 1). Bilateral embolization was achieved in ten cases, and urinary retention resolved in one of six patients. LUTS improved in the remaining (n = 5) patients by a mean 12.2-point reduction in IPSS (95% CI - 23.53; - 0.87). According to the CIRSE classification, two grade 1 and two grade 3 complications occurred. In this study, palliative PAE was safe and efficient for treatment for LUTS associated with PCa. Level 4, Case Series. Trial registration ClinicalTrials.gov Identifier: NCT03104907.

03:18 PM Abstract No. 124 Utility of Emboguide with cone-beam CT in identification and navigation of prostatic arteries in prostate artery embolization compared with conventional 2D fluoroscopy with overlay technique: a prospective study

To evaluate the role of embolization guidance software (Emboguide) with cone-beam CT in identifying prostatic arteries and assisting in endovascular navigation compared to conventional 2D angiogram with overlay technique for prostate artery embolization (PAE). IRB-approved prospective study (ClinicalTrials.gov Identifier: NCT03164629) was conducted, enrolling 50 patients undergoing PAE for benign prostatic hyperplasia or urinary retention, aged 50-79 with mean age of 65.7 years. 25 patients underwent PAE using Emboguide and 25 patients were treated with conventional 2D fluoroscopy with overlay. 300-500μm Embospheres were used in both groups. The primary outcome measurement was time to prostatic artery catheterization, which was defined as Emboguide display to catheter in prostate artery for the study group and display of 2D angiogram overlay to catheter in the prostatic artery for the control group. Prostatic arteries were identified in all 50 cases. Technical success (bilateral embolization) was achieved in 24/25 cases in both groups. Time to catheterization was 3 mins for the control group and 4.6 mins for the Emboguide group on the right (p<0.32) and 2.8 mins for the control group and 2.9 mins for the Emboguide group on the left (p<0.95). Fluoroscopy time was 44.5 mins for the control group and 33.0 mins for the Emboguide group (p<0.019). Total procedure time was 129.4 mins for control group and 84.6 mins for the Emboguide group (p<0.003). For additional parameter results, please refer to the table. Time to catheterization was not statistically significantly different between the 2 groups, however, Emboguide significantly reduced mean total procedure time and fluoroscopy time compared to conventional 2D fluoroscopic technique (p <0.05). These findings suggest Emboguide may be an additive tool for prostate artery identification, catheterization and can lead to reduced fluoroscopy and procedure times.Tabled 1Control Group vs Emboguide (with P Values)Parameter (mean)ControlEmboguideT-testProstate size (g)105.7109.80.814Time to catheterization (R) (min)3.04.60.32Time to catheterization (L) (min)2.82.90.95Fluoro time (min)44.5330.019Total procedure time (min)129.484.60.003Dose area product (mGy.cm2)30564255650.292Skin dose (mGy)251622720.628Contrast volume (mL)111.21290.064 Open table in a new tab

Outcomes of prostate artery embolisation for benign prostatic hyperplasia in 10 cases at Steve Biko Academic Hospital.

BackgroundBenign prostate hyperplasia (BPH) remains a common cause of lower urinary tract symptoms (LUTS) in ageing men in South Africa and can impact significantly on the quality of life (QOL) of these patients. The Urology Department at Steve Biko Academic Hospital (SBAH) can generally only offer men with LUTS the following treatment options: watchful waiting, medical treatment and surgical management. In men with symptomatic BPH, who are refractory to medical treatment, where anaesthesia is contra-indicated because of co-morbidities or transurethral resection of the prostate (TURP) is contra-indicated because of the prostate size, the Urology and Radiology departments at SBAH recently introduced prostate artery embolisation (PAE).AimTo assess the outcome of PAE in 10 men with LUTS, secondary to BPH, by comparing their urinary symptoms, QOL and prostate volume before and 3 months after they underwent PAE in the Radiology Department at SBAH.MethodThe review included the first 10 men who had undergone therapeutic PAE for symptomatic BPH from May 2016 to September 2016. The subjective symptomatic feedback was assessed according to the International Prostate Symptom Score (IPSS) and the Global Quality of Life questionnaire, created by the American Urological Association (AUA). The reduction in the size of the prostate was measured on magnetic resonance imaging (MRI).ResultsEmbolisation was technically achieved in all 10 patients. Bilateral embolisation was performed on nine patients. One patient received unilateral embolisation secondary to unilateral tortuous and atherosclerotic changes of the iliac arteries. Within the 3-month follow-up, the mean IPSS score improved by 15.7 points (p < 0.0039), the mean QOL improved by 4.1 points (p < 0.0039) and the mean prostate volume reduction was 21.8 mL (p < 0.0039). Despite improvements observed, there was one clinical failure. No major complications were reported that increased hospital stay, required hospital readmission or required surgery.ConclusionThe study on the first 10 PAE performed in SBAH concludes that PAE is a safe and effective procedure with favourable short-term follow-up results. This indicates that PAE can safely be offered to patients, who are refractory to medical treatment and not suitable candidates for surgery, in urology departments such as in SBAH.

Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis

PurposeTo validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors.MethodsWe retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings.ResultsSeventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients’ median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis.ConclusionsOur non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than “pumping” and avoids the use of vasopressors.

Bladder wall and surrounding tissue necrosis following bilateral superselective embolization of internal iliac artery branches due to uncontrollable haematuria related to bladder tumor: case report

BackgroundCase of urinary bladder wall and surrounding tissue necrosis following bilateral superselective embolization of internal iliac artery branches due to unmanageable haematuria associated with aggressive bladder tumor.CaseWe achieved the bleeding control, but patient demonstrated severe postembolization syndrome at follow-up (low abdominal pain, arterial hypertension, hyperthermia). Severe bladder tissue and surrounding neoplastic tissue necrosis developed several days after procedure. Patient died from multiple organ dysfunction syndrome due to longstanding peritonitis.ConclusionsTumor ischemia and bladder wall and surrounding tissue necrosis, are possible serious complications ofembolization using calibrated microspheres. These complications can be very dangerous, and even fatal.

Outcome after prostatic artery embolization in patients with symptomatic benign prostatic hyperplasia.

Background Prostatic artery embolization (PAE) has recently been described as a promising alternative treatment for lower urinary tract symptoms (LUTS) due to an enlarged, benign prostate. Purpose To evaluate the safety, morbidity, and functional outcomes after PAE. Material and Methods Twenty-nine consecutive patients were included. All patients had computed tomography angiography before the procedure. Microcatheters were used for selective embolization of the PAs. Large side branches to non-target organs were embolized with coils. The PAs were embolized with calibrated 300–500 µm tris-acryl gelatin microspheres. Complications were recorded before discharge. Clinical visit was performed after three months, magnetic resonance imaging (MRI) after 6–12 months, and any further intervention recorded in the chart. Mean follow-up was 23 months. Clinical success was defined as no longer needing urinary catheter, no long-term complications, and no need of further interventions. Results Sixteen patients (55%) had permanent or intermittent catheter before the procedure. Bilateral embolization was performed in 26 patients (90%). Five patients underwent two procedures. Twelve of 16 patients (75%) with permanent or intermittent catheter were able to remove the catheter. Five patients were operated with transurethral resection of the prostate (TURP). Except for one patient, all patients without catheter at baseline improved in the International Prostate Symptom Score (IPSS) and had no further treatment. Twelve patients experienced complications; all were grade 1 according to the Clavien–Dindo classification. Conclusion PAE reduced LUTS symptoms in most patients without severe complications. The treatment did not exclude additional surgical treatment when needed.

Hereditary hemorrhagic telangiectasia, embolization, and Young’s procedure: oral surgical management

Hereditary hemorrhagic telangiectasia (HHT) case with history of embolization and Young’s procedure: surgical management. Introduction: Osler–Weber–Rendu disease hereditary hemorrhagic telangiectasia (HHT) is a genetic vascular dysplasia. It causes hemorrhagic manifestations, cutaneous and mucosal telangiectasia and visceral vascular shunts, which sometimes lead to brain abscesses after dental avulsion. Acute epistaxis can be managed by vascular ligature or selective embolization. In rare cases, management can even go as far as nasal closure. Observation: A case of five dental avulsions is described, in a patient affected by HHT who previously underwent a bilateral embolization in the area of the facial artery as well as Young’s procedure for frequent epistaxis. Comments-Conclusion: The management of patients affected by HHT needs rigorous hemostatic methods and outpatient postoperative monitoring. Additionally, the remarkable imaging from panoramic radiography used in this case was instrumental in keeping track of embolization, by clearly highlighting the arterial pathways.

Transnasal Endoscopic Sphenopalatine Artery Ligation Compared With Embolization for Intractable Epistaxis: A Long-term Analysis

Background Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and selective embolization both provide excellent treatment success rate in the management of intractable epistaxis. Few long-term studies comparing these approaches have been previously published. Recommendations often present these techniques as alternatives, but there is no clear consensus. Objective The purpose of this study was to evaluate and compare the clinical efficacy of sphenopalatine artery ligation versus embolization to control intractable epistaxis. Methods We performed a retrospective study including all patients referred to our tertiary medical center for severe epistaxis and treated by surgical ligation and/or embolization. The patients were classified into 2 groups: those who underwent TESPAL only and those who underwent endovascular embolization only. We evaluate and compare long-term clinical outcomes after surgical ligation or embolization for the control of intractable epistaxis in terms of effectiveness (recurrence rate) and safety (complication rate). Results Forty-one procedures of supraselective embolization and 39 procedures of surgical ligation for intractable epistaxis are reported and analyzed. No significant difference was observed between the groups in terms of demographic factors, comorbidities, or average length of hospital stay. The 1-year success rate was similar (75%) in both groups. Complications (minor and/or major) occurred in 34% cases in the embolization group and in 18% in the surgical group ( P = .09, ns). Bilateral embolization including facial artery was the only treatment method associated with a significant risk of complications ( P = .015). Conclusion TESPAL seems to provide a similar control rate with a decrease in the number of complications compared to selective embolization in the context of intractable epistaxis. Further studies are required.

Prostate artery embolisation: an initial experience from an Indian perspective.

PurposeThe study aims to report our very early experience with prostate artery embolisation in patients with benign prostatic hypertrophy (BPH) in an Indian setting.Material and methodsThis prospective study was approved by the Institutional Ethical Review Board, and informed consent was obtained from all the patients. Four patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent prostate embolisation. Embolisation was performed using polyvinyl alcohol (PVA) particles. International Prostate Symptom Score (IPSS), quality of life (QOL) score, postvoid residual volume, and prostate volume was recorded in each patient for 12 months. No major complications were seen in any patient.ResultsFour patients with a mean age of 74.2 years underwent prostate artery embolisation. It was successful in all the cases. Bilateral embolisation was performed in three patients and unilateral approach in one patient. Clinical improvement was characterised by a mean prostate volume reduction of 22% and mean IPSS reduction of 30% at 12-month follow-up.ConclusionsThe initial experience with prostate embolisation has been very rewarding and is a great alternative treatment for BPH. It is a very safe and effective procedure and can be an ideal procedure from an Indian perspective.

Endovascular Treatment of Type 1a Endoleak after Treatment of Suspending Rupture of Bilateral Internal Iliac Aneurysms for Preserving the Inferior Mesenteric Artery

An 86-year-old man presented with lower abdominal pain. Enhanced CT revealed large bilateral internal iliac arterial aneurysms. After embolization of the bilateral internal iliac arteries, leg type stent grafts were implanted. 1 month later an enhanced CT showed a type 1a endoleak, so additional endovascular treatment was necessary. A bifurcated type stent graft was lowered into the terminal aorta to bail out the inferior mesenteric artery. The type 1a endoleak disappeared, nor were complications. The use of this simple and easy technique can prevent serious and fatal complications after bilateral internal iliac artery embolization.

Prostatic Artery Embolization as an Alternative to Indwelling Bladder Catheterization to Manage Benign Prostatic Hyperplasia in Poor Surgical Candidates.

To prospectively assess discontinuation of indwelling bladder catheterization (IBC) and relief of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) following prostate artery embolization (PAE) in poor surgical candidates. Patients ineligible for surgical intervention were offered PAE after at least 1month of IBC for management of urinary retention secondary to BPH; exclusion criteria for PAE included eligibility for surgery, active bladder cancer or known prostate cancer. Embolization technical and clinical success were defined as bilateral prostate embolization and removal of IBC, respectively. Patients were followed for at least 6months and evaluated for International Prostate Symptom Score, quality of life, prostate size and uroflowmetric parameters. A total of 43 patients were enrolled; bilateral embolization was performed in 33 (76.7%), unilateral embolization was performed in 8 (18.6%), and two patients could not be embolized due to tortuous and atherosclerotic pelvic vasculature (4.7%). Among the patients who were embolized, mean prostate size decreased from 75.6±33.2 to 63.0±23.2g (sign rank p=0.0001, mean reduction of 19.6±17.3%), and IBC removal was achieved in 33 patients (80.5%). Clavien II complications were reported in nine patients (21.9%) and included urinary tract infection (three patients, 7.3%) and recurrent acute urinary retention (six patients, 14.6%). Nine patients (22.0%) experienced post-embolization syndrome. PAE is a safe and feasible for the relief of LUTS and IBC in highly comorbid patients without surgical treatment options.

Rebound hyperkalemia after cessation of ritodrine in a parturient undergoing cesarean section

A 36-year-old parturient with a suspicion of placenta accreta under tocolytic therapy with ritodrine infusion underwent emergency cesarean section under general anesthesia with propofol, ketamine, and remifentanil because massive bleeding was anticipated. The ritodrine infusion was discontinued 1 h before cesarean section. The baby was delivered 6 min after induction of anesthesia. However, after the manual removal of the placenta from the uterus, the bleeding was massive and uncontrollable. We rapidly transfused crystalloid, colloid, and red blood cells through potassium removal filter. Hyperkalemia (5.8 mmol/L) was detected just before blood transfusion. One hour later, hemostasis was still difficult, and hyperkalemia was promoted (6.1 mmol/L). Thus, glucose insulin therapy started with intravenous furosemide to treat hyperkalemia. Gynecologists decided to induce the Bakri balloon tamponade for the treatment of postpartum hemorrhage. At the end of surgery, plasma potassium level also reduced to 5.5 mmol/L. In the ICU, the bleeding still continued, and then radiologists performed bilateral internal iliac artery embolization for full hemostasis. Postoperative plasma potassium level was stable and 3.3 mmol/L in the next morning. Although one of the common adverse reactions of ritodrine is hypokalemia, we should also beware of a rebound hyperkalemia after its cessation.