Direct Percutaneous Approach Research Articles

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Pre-surgical embolization of carotid body paragangliomas: advantages of direct percutaneous approach and transitory balloon-occlusion at the origin of the external carotid artery.

Different embolization techniques and materials are available for the pre-operative embolization of carotid body paragangliomas. In this study, we report the first experience of the direct percutaneous puncture technique under fluoroscopic guidance using the low-viscosity formula of SQUID-12. The additional use of a transitory balloon-blockage at the origin of the external carotid artery aims to confer higher protection by limiting the risk of non-target embolization and subsequent neurological sequelae. We retrospectively reviewed all cases of carotid body paragangliomas that have undergone pre-surgical embolization with a direct puncture technique and balloon-assistance at our institution between 2019 and 2020. The use of the liquid EVOH-based SQUID-12 as the sole embolic agent was the main inclusion criteria. A total of 9 patients with 9 carotid body paragangliomas were enrolled in this case series. The mean volume of the lesion was 309 mm3. The mean embolization-session time amounted to 88min. The average number of needles inserted was 2, and the mean volume of SQUID-12 used per case was 23ml. Successful total devascularization was obtained in all cases. No long-term sequelae due to the embolization procedure occurred. Pre-operative paraganglioma embolization with SQUID-12 using a direct puncture and balloon-assisted technique is a safe and efficient method with few complications.

Ultrasound-guided percutaneous embolization of post renal biopsy gonadal artery pseudoaneurysm

Hemorrhage is the most frequently encountered post renal biopsy complication; reported in 12% to 14% of patients. Although the vast majority of these are due to renal artery injury, involvement of gonadal arteries is also rarely seen. These may be managed by the endovascular route, which has several limitations in this subset of patients. We report a case of a 69-year-old male with rapidly progressive glomerulonephritis, who underwent renal biopsy and developed a testicular artery pseudoaneurysm (PA). Successful embolization of this PA was performed under ultrasound guidance using a direct percutaneous approach. This is the first such case reported in the literature.

Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.

Peripheral Arteriovenous Malformations: Imaging and Endovascular Management Strategies

AbstractThe peripheral high-flow vascular malformation (HFVM) comprises arteriovenous malformation (AVM) and fistula (AVF), shows varied clinical presentation (ranging from subtle skin lesion to life-threatening congestive heart failure), and frequently poses diagnostic and therapeutic challenges. Importance of assigning a specific diagnosis to the vascular malformation cannot be overstated, as the treatment strategy is based on the type of vascular anomaly. Although the International Society for the Study of Vascular Anomalies (ISSVA) classification system is the most commonly accepted system for classifying congenital vascular anomalies in clinical practice, the Cho–Do et al classification is of utmost help in guiding optimal mode of treatment in peripheral AVM. Although transarterial approach remains the most commonly employed route for peripheral AVM embolization, the role of transvenous and direct percutaneous approach is ever increasing and the final decision on the approach depends on angioarchitecture of the AVM. In this article, we review various commonly employed classification systems for congenital vascular anomalies, and describe clinical features, imaging and treatment strategies for peripheral arteriovenous malformation (PAVM).

A Simple Method for Percutaneous Reduction of Isolated Zygomatic Arch Fractures With a Dental Elevator: A Technical Note

Isolated zygomatic arch fractures are common fractures of the facial skeleton. Dislocation may result in facial disharmony and/or restricted mouth opening if not treated properly. Different methods of minimally invasive treatment of depressed fractures of the zygomatic arch have been described. Most of them are based on either a direct percutaneous approach with a malar hook, a temporal approach according to Gillies, or transorally according to Keen. For these methods, general anesthesia is often preferred. In this technical note, an alternative method of a percutaneous approach for reduction of a zygomatic arch fracture under local anesthesia is presented.

Safety and Efficacy of Embolization Using N-Butyl Cyanoacrylate via a Percutaneous Direct Approach for Endoleaks after Abdominal/Thoracic Endovascular Aortic Repair.

Purpose: To elucidate the safety and efficacy of embolization using N-butyl cyanoacrylate (NBCA) for endoleaks after abdominal/thoracic endovascular aortic repair (EVAR/TEVAR) via a direct percutaneous approach versus a transarterial approach.Materials and Methods: The retrospective design of the study was approved by the institutional ethics committee, and the requirement for informed written consent was waived. Sixteen patients underwent embolization for endoleaks after EVAR/TEVAR, which was diagnosed as type II, from March 2010 to December 2013 at our institution. The number of embolization sessions was 21. A direct percutaneous approach was used in 10 sessions, and a transarterial approach was used in 11 sessions. There were 11 and 15 embolic sites for the two approaches, respectively. The procedure time, amount of contrast media used, therapeutic effect, and complications were evaluated.Results: The mean procedure time (per embolic site) was 100 min (53-170) in the direct percutaneous approach, which was significantly shorter than the 191 min (76-275) in the transarterial approach. The mean amount of contrast media used during the procedure (per embolic site) was 12.8 ml (3-25) by the direct percutaneous approach, which was significantly lesser than the 71.8 ml (30-180) in the transarterial approach. Local control of the embolic site and interval increase in the size of aneurysm after embolization were not significantly different between the two approaches. In one case each, mesenteric hematoma and migration of the embolic agent occurred with a direct percutaneous approach, and a small arterial injury occurred with the transarterial approach; aneurysmal rupture/perianeurysmal hematoma and neurological dysfunction were not observed.Conclusion: A direct percutaneous approach is a feasible procedure for embolization of endoleaks after EVAR/TEVAR.

Vascular access and closure for cardiovascular intervention

### Learning objectives Selective coronary angiography initially required surgical cut down to access the brachial artery.1 Subsequently, in 1967 Melvin Judkins described a direct percutaneous approach via the femoral artery,2...

Surgical Methods of Zygomaticomaxillary Complex Fracture.

BackgroundZygoma is a major buttress of the midfacial skeleton, which is frequently injured because of its prominent location. Zygoma fractures are classified according to Knight and North based on the direction of anatomic displacement and the pattern created by the fracture. In zygomaticomaxillary complex (ZMC) fracture many incisions (lateral eyebrow, lateral upper blepharoplasty, transconjunctival, subciliary, subtarsal, intraoral, direct percutaneous approach) are useful. We reviewed various approaches for the treatment of ZMC fractures and discussed about incisions and fixation methods.MethodsA retrospective review was conducted of patients with ZMC fracture at a single institution from January 2005 to December 2014. Patients with single zygomatic arch fracture were excluded.ResultsThe identified 694 patients who were admitted for zygomatic fractures from which 192 patients with simple arch fractures were excluded. The remaining 502 patients consisted of 439 males and 63 females, and total 532 zygomatic bone was operated. Orbital fracture was the most common associated fracture. According to the Knight and North classification the most frequent fracture was Group IV. Most fractures were fixated at two points (73%).ConclusionWe reviewed our cases over 10 years according to fracture type and fixation methods. In conclusion, minimal incision, familiar approach and fixation methods of the surgeon are recommended.

Healing Study of Porcine Heart Transapical Wounds Closed Using a Remote Automated Suturing Technology

A safe and reliable direct percutaneous approach for transapical access to the left ventricle would be a significant advance toward decreasing the invasiveness of intracardiac interventions. This report presents results from a surviving porcine beating heart model in which transapical access sites were closed using an automated suturing technique ultimately intended for percutaneous use. Through an approved protocol including general anesthesia, the cardiac apex in 10 beating pig hearts was surgically exposed, permitting transapical passage of a 0.035-in guidewire and a 5.5F, 0.9-mL Fogarty balloon catheter. An automated suturing device was passed over the guidewire and the Fogarty onto the transapical access site. Two pledgeted horizontal mattress sutures were simultaneously placed concentrically around the apical access site with a single squeeze of the device's lever. A 25F dilator was passed into the left ventricle over the guidewire and subsequently removed. The sutures were then secured using pledgeted titanium knots. Chest wall and skin incisions were closed. The animals were recovered from anesthesia and resumed a normal diet. Under general anesthesia, the transapical access site of each animal was re-exposed, five at 1-week and five at 2-week intervals. Hemostasis was complete, and all wounds healed well. The evaluation of transapical wound closures in this surviving porcine heart model demonstrates complete hemostasis and excellent healing through the use of this automated remote suturing technology.

Novel Use of Endoscopic Ultrasound to Successfully Treat Parastomal Varices with N-butyl-2-cyanoacrylate: Presidential Poster

Purpose: Describe a novel role for endoscopic ultrasound (EUS) in the treatment of parastomal varices with N-butyl-2-cyanoacrylate (NBCA). Case Report: A 74 year old female with a hx of ulcerative colitis s/p colectomy with end ileostomy, morbid obesity, COPD (O2 dependent), and Laennec's cirrhosis was transferred to our institution for transfusion dependent ostomy bleeding. The patient had over a dozen admissions to her local hospital and required 34 units of PRBC over the last year. CT demonstrated parastomal varices with cirrhotic liver morphology. Two previous attempts at transjugular intrahepatic portosystemic shunt (TIPS) were unsuccessful due to adverse anatomy. Options were discussed with the patient. A trial of beta-blockers was thought suboptimal given her COPD. A retrial of TIPS at our institution was offered but the patient refused. Consequently, we decided to employ EUS to localize the parastomal varices and then use NBCA to obliterate them. The patient was prepped with Mg citrate overnight. First, an adult gastroscope was advanced 20 cm into the stoma. No blood was seen and the mucosa was normal with no large vessels. Subsequently, a radial echoendoscope was used to visualize two prominent parastomal varices below the mucosal surface of the ileostomy by US. Flow was confirmed with Doppler. A linear echoendoscope was then inserted. Using a 22-G FNA needle, a mixture of 0.5 ml NBCA and 1.5 ml lipoidal was injected into the varices with good immediate effect. Lack of flow was confirmed after injection by Doppler. Ex-vivo, needle and scope channel were immediately flushed with Lipoidol. A total of 5.5 ml of glue was used. The patient tolerated the procedure well, was discharged home after 3 days, and has had no further episodes of bleeding. Discussion: Parastomal varices are a known complication of stoma creation in patients with portal HTN. Established treatments for parastomal varices include TIPS and surgery. We describe a case of parastomal varices in a patient who could not undergo either of these treatment modalities. Additionally, her significant comorbidities were a relative contraindication to even medical therapy with beta-blockers. Consequently, we employed EUS-guided NBCA glue to treat her parastomal varices. Though a few cases of parastomal varices treated with glue exist in the literature, all of the previous situations have employed a direct percutaneous approach. Consequently, this is the first reported case where EUS is successfully used for visualization and obliteration of varices in this patient population. Although further evaluation is warranted, EUS appears to be a safe and important adjunct modality in the treatment of stomal varices by NBCA glue injection.

Percutaneous Coil Embolization of and Internal Iliac Artery Endoleak under Ultrasound control

IntroductionType II endoleak with high risks of complications can be managed by endovascular catheterization or direct percutaneous approach if standard endovascular techniques failed as it is reported in our observation. ReportA 79-year-old patient was treated two months earlier by stent-graft for a retroperitoneal rupture of a right common iliac artery aneurysm. The 2 months follow-up CT-scan showed an endoleak from the right hypogastric artery without clearly outflow vessel. Ultrasound guidance was used to access the endoleak, which was then embolized with coils under fluoroscopy. DiscussionThis case illustrates the possible advantages of this technique in the treatment of endoleak.

Embolización directa de varices estomales en la hipertensión portal tras el tratamiento de metástasis hepáticas

We present the case of a man with a history of colorectal carcinoma and metastatic liver involvement who developed portal hypertension and recurrent bleeding from stomal varices after treatment with intra-arterial oxaliplatin and radioembolization with yttrium-90 microspheres. The definitive treatment for the bleeding episodes was embolization of the varices with coils using a direct percutaneous approach.

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

Percutaneous Transosseous Embolization of Internal Iliac Artery Aneurysm Type II Endoleak: Report of Two Cases

This report describes two cases of successful treatment of an internal iliac artery aneurysm (IIAA) type II endoleak utilizing a percutaneous transosseous access that could not be treated using an endovascular or standard percutaneous approach. A direct percutaneous approach through bone was chosen to avoid vital structures and the surrounding bowel. The procedure was successful and required minimal fluoroscopy time compared with other treatment options. We believe this procedure is an alternative to some of the more complex and technically challenging means of treating this lesion.

Orbital venous malformation: percutaneous treatment using an electrolytically detachable fibred coil

To report the efficacy of percutaneous treatment of an orbital venous malformation with an electrolytically detachable fibred coil. We report an instance of radiography-guided percutaneous treatment with an electrolytically detachable fibred coil in a 16-year-old boy with acute, spontaneous, painless proptosis on the left side, which progressed with time. Magnetic resonance imaging, angiography and orbitophlebography revealed a low-flow, intraorbital venous malformation. Percutaneous puncture and drainage were followed by a short remission. Following an acute recurrence, a single detachable fibred coil was deployed via a percutaneous approach under angiographic guidance. No radiological or clinical recurrences were observed over 4 years. Embolization of a deep orbital venous malformation with detachable fibred coils via a percutaneous approach can be highly effective, and may be considered before proceeding with open surgery.

Direct Percutaneous Approach for Endoluminal Glue Embolization of Stomal Varices

The present report describes the authors' experience with direct endoluminal embolization for bleeding stomal varices. Between December 1998 and July 2006, seven patients with enterostomies, portal hypertension, and recurrent stomal variceal bleeding resistant to medical treatment were treated at a single institution. Ultrasonography was used to guide direct puncture of the varices. Direct endoluminal embolization with cyanoacrylate glue was performed under fluoroscopic control imaging. Embolization was successful in six of seven cases. One patient with hepatocellular carcinoma and complete portal thrombosis had three recurrences treated with the same technique, with clinical success. Three patients died at 3, 8, and 18 months without recurrence of bleeding. Although further evaluation is indicated, direct percutaneous embolization appears to be a potential alternative treatment for bleeding stomal varices.

A Percutaneous Subcostal Approach for Intercostal Stones

Percutaneous upper pole access may be obtained via the supracostal or subcostal approach. The more cranial the location of the percutaneous nephrostomy tract, the greater the risk of incurring intrathoracic complications. We describe a technique for safely accessing the upper pole calix via a subcostal approach, even when the stone is located well above the 12th rib. In our patient the stone was located between the 11th and 12th ribs, and the upper pole extended to above the 10th rib. A 78-year-old man with multiple medical problems had a symptomatic upper right pole stone located between 11th and 12th ribs. Due to its size (3 x 2.2 cm), neither a ureteroscopic nor shockwave approach was thought feasible. We elected to angle the access tract both laterally and cranially in order to course below the 12th rib, but still enter the upper pole calix. Although this tract entered the calix obliquely, instruments were readily passed after sheath placement and the stone was completely removed. An ultrasonic lithotripsy device and suction was used to fragment and evacuate the stone. Postoperatively there were no intrathoracic or pulmonary complications. The direct percutaneous approach to the upper pole of the kidney requires careful methodology based on a clear understanding of the anatomy of the kidney and surrounding structures. For upper-pole renal calculi located above the 12th rib that are not amenable to shockwave lithotripsy or ureteroscopy, a subcostal angled percutaneous approach can be safely made in selected cases. With this method, the risk of intrathoracic complications may be reduced.

Nasal dorsal granuloma after nasal bone fracture

A granuloma on the nasal dorsum after nasal bone fracture is a rare complication, like postrhinoplasty nasal cysts which were previously rarely reported. The authors describe five cases of nasal dorsal granuloma following nasal bone fracture reduction. Rubbery hard non-tender fixed masses were noted in the nasal root area 1 to 10 months after nasal bone reduction. The masses were managed by excision using a direct percutaneous approach. Histopathologic findings were of chronic granulomatous inflammation with infiltrations of epitheloid cells and Langerhans' giant cells and necrosis-like tuberculous tubercles. Acid-fast bacilli (AFB) stains were negative. The exact cause of this granuloma is not known, but imbedded free mucosal fragment or effused antibiotic ointment of packed gauze through the fracture site, which could cause a tissue reaction, is thought to be the cause of the granuloma. In order to prevent this rare complication, we recommend that aggressive practices and overpacking should be avoided during nasal bone reduction.

Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention).

The nonoperative management (NOM) of abdominal trauma has gained increasing acceptance over the past decade. This approach has been extended to severe trauma patients previously considered as candidates for surgery. Consequently, the incidence of delayed and uncommonly encountered complications has increased. Causes of delayed complications are multiple and include: (a) abnormal or insufficient injury healing process; (b) retention of necrotic tissue; (c) secondary infection of initially sterile collections; and (d) underestimation of injury severity. The purpose of this review article is to explain the role of various imaging modalities in detecting post-traumatic delayed complications and to highlight the usefulness of minimally invasive techniques, including laparoscopy, biliary endoscopy, therapeutic angiography and image-guided drainage. Subsequent complications, which do not necessarily negatively influence the final outcome, are often predictable, virtually obligatory consequences of the successful NOM of high-grade or complex abdominal injuries. Between 50 and 60% of those patients with grade-IV or grade-V liver or splenic lacerations require some type of interventional treatment; therefore, indiscriminate discharge of patients with solid organ injury managed conservatively may be potentially harmful. As the incidence of complications is higher for more severe grade-IV or grade-V liver, spleen, or kidney injuries, scheduled follow-up CT scans may be rational in this subset of patients to identify potential complications amenable to early application of interventional techniques. Follow-up CT scans are unnecessary in stable adults or children with low-grade injury. Delayed splenic or hepatic rupture is one of the major concerns because this type of complication remains difficult to predict and historically often requires emergent surgery. These ruptures may benefit from NOM, should the same criteria as for primary rupture be respected. Conversely, parenchymatous focal pooling of contrast on initial CT is a good predictor for the development of delayed vascular malformation. In children, as a large part of splenic and hepatic vascular malformations resolve spontaneously, expectant observation may be indicated provided that a strict imaging follow-up is performed until complete disappearance of these lesions. If needed, embolization of parenchymal vascular lesions should be performed as selectively as possible in order to avoid functional parenchyma loss and to reduce the risk of secondary infection of hematoma or ischemic tissue. Technical improvements, such as microcatheter systems and direct percutaneous approach to targeted lesions, have widened the potential for safe endovascular management of acquired vascular malformations. Advantages and disadvantages relative to the different embolic agents are explained. Endoscopic retrograde pancreatography is the chief investigational tool for detecting biliary and pancreatic ducts injuries. The respective roles of endoscopic, percutaneous and surgical approaches in the management of these complications are discussed. The CT scan and ultrasound-guided drainage provide effective nonoperative options in the management of post-traumatic parenchymatous and (retro)-peritoneal collections. Treatment modalities of less common complications, such as bowel stricture or perforation, mesenteric vascular injuries and renal trauma-induced hypertension, are reviewed.