Catheter-directed Embolization Research Articles

Added Value of Computed Tomography Angiography Prior to Bronchial Artery Embolization for Hemoptysis: A Retrospective Two-Center Study

Objectives: The aim of this retrospective study was to evaluate the added value of pre-procedural computed tomography angiography (CTA) prior to bronchial artery embolization for patients presenting with hemoptysis.
 Materials and Methods: In this retrospective study, we evaluated patients admitted for hemoptysis from 2010 to 2021 and treated by catheter-directed embolization. After establishing quality criteria for pre-procedural computed tomography (CT), patients were divided into two groups depending on their pre-procedural imaging assessment: Quality CT-angiography (QCTA group) and suboptimal pre-procedural imaging (suboptimal CTA, unenhanced or no CT evaluation; control group). Groups were compared based on radiological success, procedure-related complications, and clinical success, including cessation of hemoptysis, recurrence rates, and overall mortality.
 Results: We included 31 patients in the QCTA group, and 35 in the control group. Clinical success was n = 24/31 (77.4%) in the QCTA group and n = 27/35 (77.1%) in the control group (p = 0.979). Technical success was n = 37/42 (88.1%) in the QCTA group and n = 39/42 (92.86%) in the control group (p = 0.820). Overall recurrence was 10.6%. Minor complications occurred in 27.3%, and one major complication was reported.
 The concordance between the affected bleeding lung and the identification of pathological arteries during angiography was better in the QCTA group (p = 0.045).
 The average number of culprit arteries (bronchial, non-bronchial systemic arteries [NBSA] or pulmonary) in the QCTA group was not significantly higher than that in the control group.
 Conclusions: Preprocedural QCTA better identifies the affected bleeding lung and bleeding vessels compared to direct angiography. No difference in clinical success, complications, recurrence rates, or mortality was observed.

Added Value of Computed Tomography Angiography Prior to Bronchial Artery Embolization for Hemoptysis: A Retrospective Two-Center Study.

The aim of this retrospective study was to evaluate the added value of pre-procedural computed tomography angiography (CTA) prior to bronchial artery embolization for patients presenting with hemoptysis. In this retrospective study, we evaluated patients admitted for hemoptysis from 2010 to 2021 and treated by catheter-directed embolization. After establishing quality criteria for pre-procedural computed tomography (CT), patients were divided into two groups depending on their pre-procedural imaging assessment: Quality CT-angiography (QCTA group) and suboptimal pre-procedural imaging (suboptimal CTA, unenhanced or no CT evaluation; control group). Groups were compared based on radiological success, procedure-related complications, and clinical success, including cessation of hemoptysis, recurrence rates, and overall mortality. We included 31 patients in the QCTA group, and 35 in the control group. Clinical success was n = 24/31 (77.4%) in the QCTA group and n = 27/35 (77.1%) in the control group (p = 0.979). Technical success was n = 37/42 (88.1%) in the QCTA group and n = 39/42 (92.86%) in the control group (p = 0.820). Overall recurrence was 10.6%. Minor complications occurred in 27.3%, and one major complication was reported.The concordance between the affected bleeding lung and the identification of pathological arteries during angiography was better in the QCTA group (p = 0.045).The average number of culprit arteries (bronchial, non-bronchial systemic arteries [NBSA] or pulmonary) in the QCTA group was not significantly higher than that in the control group. Preprocedural QCTA better identifies the affected bleeding lung and bleeding vessels compared to direct angiography. No difference in clinical success, complications, recurrence rates, or mortality was observed.

Safety, Efficacy, and Predictors for Late Reintervention AfterEmbolization of Renal Angiomyolipomas - Embolization renalangiomyolipoma.

To retrospectively analyze the procedural and long-term clinical outcome of the selective embolization of renal angiomyolipoma. In addition, potential predictive factors for higher risk of late re-intervention were analyzed. Retrospective monocentric study, including 34consecutive patients, analyzing the safety, efficiency, and long-term clinical outcome of catheter-directed embolization of renal AML. Additionally, the difference in postembolization renal function between patients embolized in the acute and in the elective setting was analyzed. Secondly, we also evaluated whether volume/diameter of the AML and presence of intralesional aneurysms are risk factors for late re-intervention. Embolization of renal AML was performed to control volume (n = 21; 62 %) or to stop spontaneous hemorrhage (n = 13; 38 %) with angiographic success in all cases but was associated with renal abscess (n = 1) and pulmonary embolism (n = 1) without a significant difference in renal function before and after embolization (P = 0.513). Volume/diameter (P = 0.276/P = 0.21) and presence of aneurysms before embolization (P = 0.37) are not predictive for a higher risk of late re-intervention. Catheter-directed embolization is a safe and effective treatment modality for asymptomatic and bleeding renal AML, without a negative impact on renal function. Initial mass volume/diameter or presence/absence of intralesional aneurysms does not seem to be predictive for late re-intervention. · Complications related to renal angiomyolipoma embolization are rare.. · Embolization of angiomyolipoma will not reduce renal function.. · Initial volume or diameter of angiomyolipoma is not predictive for late re-intervention.. · Claesen E, Bonne L, Laenen A et al. Safety, Efficacy, and Predictors for Late Reintervention After Embolization of Renal Angiomyolipomas. Fortschr Röntgenstr 2023; 195: 319 - 325.

Embolic Agents: Coils.

Catheter-directed embolization is one of the cornerstones and defining procedures of interventional radiology. Armed with a plethora of agents and devices, interventionalists can acutely stop flow, usually of a blood vessel, to effectively treat pathologies from head to toe. The list of pathologies treatable by embolization is extensive and diverse, including life-threatening hemorrhage, aneurysms, lymphatic duct leaks, varices, pelvic congestion syndrome, benign prostatic hyperplasia, uterine fibroids, and cancer.

S2143 Hepatic Artery Pseudoaneurysm Due to Aortic Dissection: An Unusual Cause of Portal Hypertension and Bile Duct Compression

INTRODUCTION: Hepatic artery pseudoaneurysm is rarely seen as a result of aortic dissection. Life-threatening gastrointestinal bleeding requiring urgent therapeutic intervention can occur as a complication of pseudoaneurysm formation. CASE DESCRIPTION/METHODS: A 66 year-old male with a history of a type A aortic dissection which was repaired four years prior to presentation was evaluated in the the emergency department for multiple episodes of melena. He was previously treated at another institution for a biliary stricture with a metal stent. On physical exam, he was hemodynamically stable and had scleral icterus. Initial labs revealed hemoglobin 8.7 gm/dl, platelets 240 K/CUMM, aspartate aminotransferase 192 U/L, alanine aminotransferase 161 U/L, alkaline phosphatase 380 U/L, total bilirubin 21 mg/dl, and INR 1.6. ERCP revealed a patent stent in the common bile duct and no evidence of hemobilia. Subsequent esophagogastroduodenoscopy revealed three columns of large, non-bleeding esophageal varices with stigmata of recent bleeding. Endoscopic band ligation was performed. After completion of the procedure, abdominal aortic angiography revealed interval enlargement of a fusiform aneurysm of a false lumen of the common hepatic artery as well as resultant central compression of the adjacent portal venous system and intrahepatic bile ducts. The patient then had an episode of hypotension and tachycardia and required transfusion of four units of red blood cells. Interventional radiology emergently performed catheter-directed embolization of the common and right hepatic artery pseudoaneurysms, and the patient did not experience any further episodes of gastrointestinal bleeding. DISCUSSION: Our evaluation of this clinical case revealed two interesting points. In retrospect, the biliary stricture was the result of direct compression of the bile duct by the pseudoaneurysm, which may not have been appreciated by the endoscopist performing the initial procedure. Second, the etiology of this patient's portal hypertension was also a direct result of compression of the portal vein by the aneurysm. On his initial presentation, we did not make these associations, but further cross-sectional imaging led us to the correct answer. The patient benefited from early involvement of vascular interventional radiology, who were able to provide a therapeutic intervention via catheter-directed coil embolization. In cases where interventional radiology is unable to intervene, surgical management with vascular surgery may be necessary.Figure 1.: Aneurysmal dilation of the false lumen of the common hepatic artery (1.9 cm in diameter) causing extrinsic compression of the adjacent biliary tract and portal venous system.

Time to conventional angiography in gastrointestinal bleeding: CT angiography compared to tagged RBC scan.

To compare CT angiography (CTA) and tagged red blood cell (RBC) scan as a function of time from these initial imaging studies to subsequent conventional angiography and catheter-directed embolization in patients with gastrointestinal (GI) bleeding. An IRB-approved retrospective study was conducted of 35 consecutive patients diagnosed with GI bleeding that received angiography for planned catheter-directed embolization. Of these patients, 20 were diagnosed with bleeding using a tagged RBC scan, whereas 15 were diagnosed using CTA. The lengths of time between diagnostic study order to study completion, diagnostic study completion to angiography, and total time from diagnostic study order to angiography were calculated. The results of both groups were compared using a t test with p value of < 0.05 considered statistically significant. The mean time from diagnostic study order to study completion was 3h and 4min for the CTA group and 5h and 1min for the tagged RBC scan group (p value = 0.0001). There was no statistically significant difference between the time to angiography after completion of the preceding diagnostic study. The total mean time from diagnostic study order to intervention was 6h and 8min for the CTA group and 9h and 29min for the tagged RBC scan group, a statistically significant difference (p value = 0.028). In patients requiring conventional angiography for GI bleeding, CT angiography results in a faster time to angiography than tagged RBC scan, which appears to be due to the longer duration required to complete the tagged RBC scan. Decreasing time to angiography is vital, as GI bleeding can be fatal and earlier diagnosis and intervention has the potential to reduce morbidity and mortality, while also increasing sensitivity of angiography. These findings may assist ordering clinicians in deciding on the appropriate diagnostic study.

Pelvic congestion syndrome: A review of the treatment of symptomatic venous insufficiency in the ovarian and internal iliac veins by catheter-directed embolization

Pelvic congestion syndrome: A review of the treatment of symptomatic venous insufficiency in the ovarian and internal iliac veins by catheter-directed embolization

Transarterial embolization of peripheral arteriovenous malformations with ethylenevinyl alcohol copolymer - feasibility, technical outcomes, and clinical outcomes.

The technical and clinical outcomes of catheter-directed embolization for peripheral arteriovenous malformations (AVM) using Onyx® (ethylene-vinyl alcohol copolymer) are not well documented. The purpose of this study was to retrospectively assess the safety, technical outcomes and clinical outcomes of catheter-directed Onyx® embolisation for the treatment of symptomatic peripheral AVMs. Demographics, (pre-)interventional clinical and radiological data were assessed. Follow-up was based on hospital medical records and telephone calls to the patients' general practitioners. Radiological success was defined as complete angiographic eradication of the peripheral AVM nidus. Clinical success was defined as major clinical improvement or complete disappearance of the initial symptoms. 25 procedures were performed in 22 patients. The principal indications for treatment were pain (n = 10), limb swelling (n = 6), recurrent bleeding (n = 2), tinnitus (n = 3), and exertional dyspnoea (n = 1). Complete radiological success was obtained in eight patients (36 %); near-complete eradication of the nidus was achieved in the remaining 14 patients. Adjunctive embolic agents were used in nine patients (41 %). Clinical success was observed in 18 patients (82%). Major complications were reported in two patients (9 %). During follow-up, seven patients (32 %) presented with symptom recurrence, which required additional therapy in three patients. Catheter-directed embolisation of peripheral AVMs with Onyx® resulted in major clinical improvement or complete disappearance of symptoms in the vast majority of patients, although complete angiographic exclusion of the AVMs occurred in only a minority of patients.

Long-term clinical and radiological outcome of endovascular embolization of pancreatitis-related pseudoaneurysms.

Background Long-term outcome after embolization of pancreatitis-induced pseudoaneurysm is not yet determined. Purpose To assess the long-term efficacy and patients' overall survival after embolization of pancreatitis-induced pseudoaneurysm. Material and Methods Patients referred for endovascular treatment of a pancreatitis-induced pseudoaneurysm between January 1998 and January 2014 were analyzed. Embolization procedures were performed by transcatheter techniques using different types of embolic agents. Demographic, technical-radiological, and clinical data were collected. Results Thirty-four patients were identified with a pancreatitis-induced pseudoaneurysm; the underlying disease was acute (n = 13; 38%) or chronic (n = 21; 62%) pancreatitis; seven patients (20.6%) had active bleeding when embolized, while in the remaining 27 patients (79.4%) the pseudoaneurysm was not bleeding. In all 34 patients, successful endovascular exclusion of the pseudoaneurysm was obtained after the first attempt. Minor complications occurred in 11 patients (30%); no major complications were noted. A new pseudoaneurysm on a different vessel was identified during follow-up in three patients (9%). In another patient (3%), the excluded pseudoaneurysm reopened during follow-up. All four recurrences occurred within the first 5 months after embolization. Long-term follow-up (mean, 6.6 years; range, 4 months-16 years) revealed estimated survival rates of 94%, 89%, and 75% after 2, 5, and 10 years respectively, without pseudoaneurysm-related death. Conclusion Catheter-directed embolization of pancreatitis-induced pseudoaneurysms is relatively safe and effective. Recurrence or new pseudoaneurysm formation was low and occurred within the first 6 months after embolization. Overall survival is high, with no pseudoaneurysm-related deaths.

A Tough Pill to Swallow- Spontaneous Retropharyngeal Hematoma: A Rare and Unusual Complication of Rivaroxaban Therapy

Aims: We present the first case of a patient that developed a spontaneous retropharyngeal hematoma as a complication of rivaroxaban therapy. Case Presentation: A 49-year-old Caucasian male with chronic atrial fibrillation on rivaroxaban presented to the hospital with a rapidly expanding spontaneous retropharyngeal hematoma. He required emergent intubation for airway protection and subsequently was treated with catheterdirected embolization and surgical evacuation. Discussion: Our report presents a case of a spontaneous retropharyngeal hematoma on rivaroxaban therapy. Unfortunately, most patients with this complication typically present with insidious symptoms including mild neck pain and ear ache, and as a result the diagnosis can easily be overlooked. Therefore, it is of utmost importance that physicians maintain a high index of suspicion, as early recognition and appropriate therapy can reduce morbidity and mortality. Conclusion: This case highlights a rare but life-threatening hemorrhagic complication of rivaroxaban therapy. Case Study Naqvi et al.; CA, 4(4): 156-159, 2015; Article no.CA.2015.039 157

AorticFalse LumenThrombosis Induction byEmbolotherapy (AFTER) Following Endovascular Repair of Aortic Dissection

To report the use of a technique (AFTER: aortic false lumen thrombosis induction by embolotherapy) to achieve false lumen (FL) thrombosis and aortic remodeling in patients with residual FL patency after initial endovascular repair of aortic dissection. Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vessel endovascular reconstruction (STABLE) of type A (n = 13) and type B (n = 18) dissection. Of these, 10 patients (5 men; mean age 61 years) who had undergone repair of 4 acute type A, 3 acute type B, and 3 chronic type B dissections demonstrated re-entry tear(s) and FL patency associated with aortic expansion ≥5 mm or flow into a persistently dilated aortic segment. Catheter-directed embolization using coils, glue, or occlusion balloons was performed via a transfemoral approach to the true lumen at a mean of 7 months (range <1 to 26) after initial repair. Technical success was achieved in all patients, with no intraoperative complications. Thirty-day morbidity and mortality was nil. Mean follow-up was 63 months (range 13-96). Reversal or stabilization (<5-mm increase) of thoracoabdominal aortic growth occurred in 9 patients. Complete thrombosis of the thoracic and abdominal FL occurred in 2 patients. In 4, FL occlusion and subsequent thrombosis of the upstream thoracic segment was achieved. Four demonstrated partial FL thrombosis in the thoracic and abdominal aorta. One patient with chronic aneurysmal type B dissection died 4 months post-embolization from aortic rupture. The AFTER strategy appears to be a safe and promising adjunctive endovascular approach to treat residual FL patency or aortic enlargement post endovascular repair of aortic dissection. Elimination of FL flow and stabilization of aortic expansion may reduce the risk of late distal aortic complications.

Recurrent Page kidney in a child with a congenital solitary kidney requiring capsular artery embolization

We report an unusual case of a child with a congenital solitary functional kidney complicated by a sports-related posttraumatic Page kidney. The child developed severe hypertension and renal insufficiency requiring percutaneous intervention to preserve renal function. The literature is sparse with no definitive guidelines for the treatment of Page kidney. Following the initial unsuccessful treatment with percutaneous drainage and sclerotherapy procedures, the child ultimately required catheter-directed particle embolization of the capsular arteries to resolve a recurrent subscapsular hematoma definitively. This was successful in preserving renal function and stabilization of the clinical manifestations of the Page kidney.

Embolization of Nonliver Visceral Tumors

Catheter-directed embolization of visceral tumors, with the exception of the liver, has received limited attention in the literature. The visceral arterial anatomy can be complex and its understanding is critical for procedure planning and limiting complications. Embolization of splenic neoplasms is exceedingly rare. Preoperative embolization for adrenal, renal, and gut tumors plays an important role in select patients. Embolization has been used successfully in the treatment of pancreatic insulinomas and in limited cases of unresectable pancreatic adenocarcinomas. Embolization of bleeding visceral tumors can be accomplished with a high likelihood of success.

Abstract No. 24: Saphenous Vein Ablation Using Catheter-Directed Coil Embolization and Sclerotherapy

Abstract No. 24: Saphenous Vein Ablation Using Catheter-Directed Coil Embolization and Sclerotherapy

Effect of Catheter-Directed Arterial Embolization and Laparoscopic Endovascular Stapling on Stapled Vessel Integrity in a Porcine Model

Arterial embolization is a frequently performed adjunctive maneuver prior to laparoscopic splenectomy or nephrectomy to facilitate laparoscopic dissection and reduce intraoperative bleeding. However, little is known regarding the effect of laparoscopic stapling across thrombosed vessels with imbedded embolic materials. This study analyzed the stapled line integrity by comparing visceral arteries treated with either platinum coils or polyvinyl alcohol (PVA) particles. Using a porcine model, 30 visceral vessels including splenic and renal arteries were treated with either coil or PVA embolization, which was followed by laparoscopic stapling. Vessel integrity and bursting pressure analysis was performed using an in vitro flow circuitry. The mean bursting pressure of the coil and the PVA group was 158 +/- 56 and 350 +/- 34 mm Hg, respectively (p < .001). The lowest bursting pressure in the coil and the PVA group was 70 and 280 mm Hg, respectively. The highest bursting pressure in the coil and the PVA group was 225 and 420 mm Hg, respectively. The bursting pressure in the splenic artery between the PVA and the coil group was 345 +/- 29 and 150 +/- 54 mm Hg, respectively (p < .001). Significant difference in the bursting pressure in the renal artery was noted in the PVA and the coil group, which was 350 +/- 40 and 160 +/- 40 mm Hg, respectively (p < .001). Our findings showed that preoperative coil embolization followed by laparoscopic vessel stapling sustained a poor busting pressure. Such a practice appears to be unsafe based on our findings and should be performed with caution in a clinical setting.

Measurement of Blood Flow Before and After Embolization with Use of Fluorescent Microspheres in an Animal Model

Catheter-directed embolization has become a widespread technique for the treatment of benign and malignant neoplasms. The mechanism whereby embolization leads to selective atrophy of these neoplasms is largely speculative. As a potential model for the large regional perfusion differences between normal and neoplastic tissues, renal perfusion was studied before and after catheter-directed embolization. The working hypothesis was that embolization would create measurable changes in blood flow in the renal cortex and medulla. Microspheres (l0 microm in diameter) containing a series of different fluorophores were injected into the arterial system before and after the renal arteries were embolized with a series of larger (100-300 microm) particulate embolic agents. The distribution of the microspheres in the renal cortex, renal medulla, and liver was analyzed by fluorescence microscopy as well as by extraction of the fluorophores. The distribution of the fluorescent microspheres was readily assessed by fluorescence microscopy or extraction of the fluorophores. Before embolization, the renal cortex received approximately three times more flow than the medulla. After embolization, perfusion of the renal cortex and medulla decreased in parallel. Fluorescent microspheres are a powerful tool for measuring the changes in flow that occur after catheter-directed embolization. The fact that parallel decreases in flow were found in the renal cortex and medulla indicates that the distribution of each embolic agent was flow-directed. These results might provide insight into the mechanism of tumor atrophy after uterine artery embolization or hepatic chemoembolization.

Ruptured angiosarcoma of the liver treated by emergency catheter-directed embolization

Angiosarcoma is a rare primary malignant neoplasm of the liver with a poor prognosis. Here, we report a case of a patient with a ruptured hepatic angiosarcoma which was treated by emergency catheter-directed embolization, followed by left-sided hemihepatectomy.

Congenital Vascular Anomalies.

Congenital vascular anomalies are rare. The cardiovascular specialist should nevertheless be aware of the more common types of vascular anomalies and understand the implications for patient treatment and the likelihood of associated morbidity. The presentation of congenital arteriovenous malformations can range from asymptomatic or cosmetic lesions, to those causing ischemia, ulceration, hemorrhage, or high-output congestive heart failure. Treatment of large, symptomatic arteriovenous malformations often requires catheter-directed embolization prior to the attempt at complete surgical excision. Later recurrence, due to collateral recruitment, is frequent. Graded compression stockings and leg elevation are the mainstays of treatment for the predominantly venous congenital vascular anomalies. Most congenital central venous disorders are clinically silent. An exception is the retrocaval ureter. Retroaortic left renal vein, circumaortic venous ring, and absent, left-sided or duplicated inferior vena cava are relevant when aortic or inferior vena cava procedures are planned. The treatment of the venous disorders is directed at prevention or management of symptoms. Persistent sciatic artery, popliteal entrapment syndrome, and aberrant right subclavian artery origin are congenital anomalies that are typically symptomatic at presentation. Because they mimic more common diseases, diagnosis is frequently delayed. Delay can result in significant morbidity for the patient. Failure to make the diagnosis of persistent sciatic artery and popliteal entrapment can result in critical limb ischemia and subsequent amputation. Unrecognized aberrant right subclavian artery origin associated with aneurysmal degeneration can rupture and result in death. The treatment options for large-vessel arterial anomalies are surgical, sometimes in combination with endovascular techniques.

Congenital vascular malformations: when and how to treat them.

Congenital vascular malformations may involve arterial, venous, and lymphatic structures, can present in a variety of forms, and present many diagnostic and therapeutic challenges. Two-thirds of all congenital vascular malformations are predominantly venous, and their management will be emphasized in this article, because of the focus of this issue. The majority of the venous malformations are asymptomatic and should be treated conservatively. However, the clinical presentation of venous malformations associated with lymphatic anomalies is variable, and management may be more challenging. The diagnosis and management of arteriovenous malformations is straightforward. Selective catheter-directed embolization of the feeding arteries, occasionally followed by tumor excision, is the treatment of choice. Hemangiomas often will grow rapidly and then begin to regress. When they produce troublesome symptoms and are well localized, they should be excised. Deeply seated or diffuse malformations require a complete diagnostic evaluation to select the most appropriate time and type of intervention. Both our own experience and that of others can provided some basis for therapeutic recommendations in treating the different vascular malformations.

Congenital vascular malformations: When and how to treat them

Congenital vascular malformations may involve arterial, venous, and lymphatic structures, can present in a variety of forms, and present many diagnostic and therapeutic challenges. Two-thirds of all congenital vascular malformations are predominantly venous, and their management will be emphasized in this article, because of the focus of this issue. The majority of the venous malformations are asymptomatic and should be treated conservatively. However, the clinical presentation of venous malformations associated with lymphatic anomalies is variable, and management may be more challenging. The diagnosis and management of arteriovenous malformations is straightforward. Selective catheter-directed embolization of the feeding arteries, occasionally followed by tumor excision, is the treatment of choice. Hemangiomas often will grow rapidly and then begin to regress. When they produce troublesome symptoms and are well localized, they should be excised. Deeply seated or diffuse malformations require a complete diagnostic evaluation to select the most appropriate time and type of intervention. Both our own experience and that of others can provided some basis for therapeutic recommendations in treating the different vascular malformations.