Direct Percutaneous Embolization Research Articles

Minimizing blood loss with direct percutaneous polymethylmethacrylate embolization before corpectomy for vascular spinal tumors.

Standard surgical treatment for vascular spinal tumors, including renal cell carcinomas and hemangiomas, may result in significant blood loss despite preoperative arterial tumor embolization. This is a retrospective review of 12 patients who underwent direct percutaneous polymethylmethacrylate embolization (DPPE) with or without feeding artery embolization before partial or complete corpectomy for the resection of vascular spinal tumors (2013-2018). Estimated blood loss (EBL) was compared to the blood loss reported in the literature and to patients receiving standard arterial embolization before surgery. The mean EBL for 12 patients was 1030 mL; three of 12 patients required blood transfusions. For the single level corpectomies, the EBL ranged from 100 mL to 3900 mL (mean 640 mL). This mean blood loss was not increased in patients receiving only DPPE preoperatively versus those patients receiving preoperative arterial embolization in addition to DPPE (1005 vs. 1416 mL); in fact, the EBL was significantly reduced for those undergoing DPPE alone. In this initial study, nine patients treated with DPPE embolization alone before spinal tumor resection demonstrated reduction of intraoperative blood loss compared to three patients having arterial embolization with DDPE.

Direct Transorbital Approach for Treatment of Carotid Cavernous Fistula: An Illustrative Case Series.

Endovascular techniques have become the first-line treatment for carotid-cavernous fistulas (CCFs). Direct transorbital venous access may be used if anatomic constraints limit standard transarterial or transvenous access. We describe our institutional experience with the transorbital approach for Barrow Type A-D CCFs. Patients with CCFs undergoing transorbital endovascular treatment at our institution between 2017 and 2019 were retrospectively reviewed. Demographic, treatment, and outcome data were collected. Eight patients met inclusion criteria, 4 female and 4 male patients. The mean age was 43 years, with 6 right-sided CCF and 2 left-sided CCFs. Symptoms were present for an average of 1.5 months before treatment. All patients presented with eye pain and subjective visual changes. Seven (87.5%) patients presented with proptosis, 6 (75%) patients had elevated intraocular pressure (IOP), and 3 (37.5%) patients had ophthalmoplegia. Six CCFs (75%) were spontaneous, and 2 CCFs (25%) were traumatic. Barrow types were A (n = 1), B (n = 1), C (n = 1), and D (n = 5). All patients underwent direct percutaneous transorbital embolization with coils followed by Onyx. Three patients had undergone prior transarterial and/or transvenous treatment. A radiographic cure was obtained in all patients after direct transorbital embolization. After CCF cure, cranial nerve palsies resolved in 66.7% of patients, visual acuity in the affected eye was improved or stable in 75% of patients, and IOP had normalized in 85.7% of patients. Proptosis improved in all patients, with complete resolution in 75%. Direct transorbital embolization is a safe and potentially curative treatment for all 4 Barrow types of CCFs.

Preoperative percutaneous Onyx embolization of carotid body paragangliomas with balloon test occlusion.

The study aims to analyze our first experience with direct percutaneous embolization of carotid body tumors (CBTs) using ethylene-vinyl alcohol copolymer (Onyx) along with balloon test occlusion (BTO). A retrospective preliminary single-center study was conducted at the Otorhinolaryngology and Head and Neck Surgery Department and the Medical Imaging Department of the University Teaching Hospital. A consecutive series of three patients with CBTs was treated at the local institution between October 2018 and June 2019. All three patients underwent preoperative percutaneous embolization using ethylene-vinyl alcohol copolymer (Onyx 18) with the addition of BTO. Outcome measures were the percentage of tumor devascularization, intraoperative blood losses, and operation times. BTO was evaluated by clinical neurological examination and neurosonological transcranial Doppler examination of the middle cerebral artery (MCA). Devascularization of all three tumors was complete or near complete. All three tumors were surgically extirpated with excellent surgical outcomes. The blood losses were minimal, and the average operation time was 2 h and 8 min. BTO was positive in one patient, which was valuable additional information on carotid branches ligation limitations. The other two patients showed negative BTOs with the result of safety of eventual carotid arteries ligations. Preoperative direct percutaneous embolization of CBT with Onyx is a highly effective procedure that significantly facilitates surgery. BTO provides valuable additional information on the most appropriate and safe surgical approach.

Embolization of Deep Femoral Artery Aneurysm with a Ligated Proximal Artery Using the Direct Percutaneous Puncture Technique.

We report a case of a deep femoral artery aneurysm with a ligated proximal artery that was successfully managed with endovascular therapy. An 84-year-old male was referred to our institute with a history of surgical resection of a left ruptured deep femoral artery aneurysm wherein another aneurysm was found on the peripheral side. Proximal artery ligation of the peripheral lesion was performed. The residual aneurysm had gradually enlarged after surgery, and contrast-enhanced computed tomography showed contrast effects in the aneurysm that extended to the distal artery. The aneurysm was successfully treated by direct percutaneous puncture embolization with N-butyl-cyanoacrylate.

A SERENDIPITOUS DETOUR: DIRECT PERCUTANEOUS EMBOLIZATION OF ECTOPIC VARIX

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Variceal bleeding can be a devastating complication of cirrhosis; a minority of varices develop at sites apart from the esophagus or the stomach. We present the case of an ectopic variceal bleeding complicated by hemorrhagic shock, managed by direct percutaneous embolization of an ectopic small bowel varix in a ventral hernia. CASE PRESENTATION: A 47-year-old woman with a history of decompensated alcoholic cirrhosis presented with sudden onset profuse bright red bloody output per rectum. She was hypotensive, tachycardic, and had a ventral hernia. Labwork was notable for anemia (hemoglobin 2.9 mg/dL). Computed tomography (CT) angiography of the abdomen and pelvis did not reveal a source of hemorrhage, but did show a large ventral hernia containing small bowel without signs of strangulation. She was treated with pantoprazole, octreotide, transfusions of packed red cells and fresh frozen plasma, vasopressor support, and mechanical ventilation. Esophagoduodenoscopy revealed mild non-bleeding esophageal varices. Colonoscopy revealed a few mild oozing sites of portal colopathy treated with cautery. Given the presence of chronic portal vein thrombus and extensive collaterals, there was concern for a small bowel ectopic varix. On review of initial imaging, a dilated varix was noted to track along a loop of small intestine in the ventral hernia. She underwent percutaneous puncture of the ectopic varix under ultrasound guidance, followed by extensive coiling and gel foaming of the superior mesenteric venous system. Following the procedure, the patient developed gastrointestinal bleeding necessitating massive transfusion. Repeat esophagoduodenoscopy demonstrated grade II esophageal varices with active bleeding treated with banding. Continued hemorrhage led to hemodynamic collapse, followed by the patient's demise. DISCUSSION: Small bowel varices can be challenging to diagnose; they may be treated with transjugular intrahepatic porto-systemic shunt (TIPS), enteroscopy, embolization, or surgery. Percutaneous embolization was chosen as the treatment modality in our patient due to profound hemodynamic instability and emergent need for homeostasis. This is usually carried out via a transjugular, transfemoral, or transhepatic approach. The serendipitous presence of a portion of the ectopic varix on a loop of small bowel in a ventral hernia afforded the unconventional approach employed here. There have only been a few cases managed via a similar approach based on our literature review. Embolization was carried out successfully, but was complicated by bleeding from other varices, perhaps due to increased pressure in the portal venous system. CONCLUSIONS: Direct percutaneous varix embolization may be employed in the critical care setting provided favorable anatomy is present. REFERENCE #1: Lim L, Lee Y, Tan L, et al. Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices. World J Gastroenterol. 2009 Aug 14; 15(30): 3823–3826. DISCLOSURES: No relevant relationships by Ajinkya Buradkar, source=Web Response no disclosure on file for William Haas; No relevant relationships by Danish Haque, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response no disclosure on file for Nikul Patel; No relevant relationships by Arooj Quadir, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

Abstract No. 512 Direct percutaneous treatment of peripheral vascular pathology

PurposeEndovascular treatment is the mainstay of therapy for peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, and arteriovenous fistulae. However, due to patient anatomy or clinical factors, endovascular treatment is not always possible and potentially morbid surgery may be required. An alternative to the endovascular approach is direct percutaneous puncture and embolization. In this study we report the efficacy and safety of direct percutaneous treatment of peripheral vascular pathology utilizing small gauge needles.Materials and MethodsA retrospective review of all patients (mean age, 59 years; 21% male) with peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, or arteriovenous fistulae treated with direct percutaneous puncture between January 2013 and March 2020.Results14/14 identified patients achieved technical success utilizing 19- to 25-gauge needles percutaneously. 8/14 (57%) underwent failed prior endovascular intervention and 10/14 (71%) patients underwent simultaneous angiography. Targets were located in the liver (3), uterus (2), mesentery (2), abdominal wall (1), kidney (1), gluteal region (1), knee (1), chest wall (1), breast (1), and lung (1). Embolic material utilized included ethylene-vinyl alcohol copolymer (Onyx), detachable coils, or thrombin. Mean fluoroscopy time, dose area product, and air kerma was 19 minutes, 277 Gycm2, and 1.06 Gy, respectively. 4/14 (29%) patients were deceased at follow up. One patient suffered recurrent postoperative infection after prior partial nephrectomy, endovascular renal embolization with coils and microspheres, and direct percutaneous renal pseudoaneurysm embolization with Onyx. The infection resulted in mortality 187 days after direct percutaneous embolization. The other 3 mortalities were not treatment related. There was 1 minor complication where a patient had continued blood loss after the procedure. The patient was managed conservatively, and the bleeding resolved.ConclusionsDirect percutaneous embolization is a feasible method of treating peripheral vascular pathologies in multiple organ systems. It should be considered alongside endovascular management, especially when previous endovascular embolization failed. PurposeEndovascular treatment is the mainstay of therapy for peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, and arteriovenous fistulae. However, due to patient anatomy or clinical factors, endovascular treatment is not always possible and potentially morbid surgery may be required. An alternative to the endovascular approach is direct percutaneous puncture and embolization. In this study we report the efficacy and safety of direct percutaneous treatment of peripheral vascular pathology utilizing small gauge needles. Endovascular treatment is the mainstay of therapy for peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, and arteriovenous fistulae. However, due to patient anatomy or clinical factors, endovascular treatment is not always possible and potentially morbid surgery may be required. An alternative to the endovascular approach is direct percutaneous puncture and embolization. In this study we report the efficacy and safety of direct percutaneous treatment of peripheral vascular pathology utilizing small gauge needles. Materials and MethodsA retrospective review of all patients (mean age, 59 years; 21% male) with peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, or arteriovenous fistulae treated with direct percutaneous puncture between January 2013 and March 2020. A retrospective review of all patients (mean age, 59 years; 21% male) with peripheral aneurysms, pseudoaneurysms, arteriovenous malformations, or arteriovenous fistulae treated with direct percutaneous puncture between January 2013 and March 2020. Results14/14 identified patients achieved technical success utilizing 19- to 25-gauge needles percutaneously. 8/14 (57%) underwent failed prior endovascular intervention and 10/14 (71%) patients underwent simultaneous angiography. Targets were located in the liver (3), uterus (2), mesentery (2), abdominal wall (1), kidney (1), gluteal region (1), knee (1), chest wall (1), breast (1), and lung (1). Embolic material utilized included ethylene-vinyl alcohol copolymer (Onyx), detachable coils, or thrombin. Mean fluoroscopy time, dose area product, and air kerma was 19 minutes, 277 Gycm2, and 1.06 Gy, respectively. 4/14 (29%) patients were deceased at follow up. One patient suffered recurrent postoperative infection after prior partial nephrectomy, endovascular renal embolization with coils and microspheres, and direct percutaneous renal pseudoaneurysm embolization with Onyx. The infection resulted in mortality 187 days after direct percutaneous embolization. The other 3 mortalities were not treatment related. There was 1 minor complication where a patient had continued blood loss after the procedure. The patient was managed conservatively, and the bleeding resolved. 14/14 identified patients achieved technical success utilizing 19- to 25-gauge needles percutaneously. 8/14 (57%) underwent failed prior endovascular intervention and 10/14 (71%) patients underwent simultaneous angiography. Targets were located in the liver (3), uterus (2), mesentery (2), abdominal wall (1), kidney (1), gluteal region (1), knee (1), chest wall (1), breast (1), and lung (1). Embolic material utilized included ethylene-vinyl alcohol copolymer (Onyx), detachable coils, or thrombin. Mean fluoroscopy time, dose area product, and air kerma was 19 minutes, 277 Gycm2, and 1.06 Gy, respectively. 4/14 (29%) patients were deceased at follow up. One patient suffered recurrent postoperative infection after prior partial nephrectomy, endovascular renal embolization with coils and microspheres, and direct percutaneous renal pseudoaneurysm embolization with Onyx. The infection resulted in mortality 187 days after direct percutaneous embolization. The other 3 mortalities were not treatment related. There was 1 minor complication where a patient had continued blood loss after the procedure. The patient was managed conservatively, and the bleeding resolved. ConclusionsDirect percutaneous embolization is a feasible method of treating peripheral vascular pathologies in multiple organ systems. It should be considered alongside endovascular management, especially when previous endovascular embolization failed. Direct percutaneous embolization is a feasible method of treating peripheral vascular pathologies in multiple organ systems. It should be considered alongside endovascular management, especially when previous endovascular embolization failed.

Direct Percutaneous Puncture and Embolization of Visceral Pseudoaneurysm: Safety and Clinical Efficacy

Abstract Purpose The aim of the study is to assess the safety and clinical effectiveness of direct percutaneous embolization of visceral artery pseudoaneurysms. Materials and Methods Retrospective analysis of patients who had undergone direct percutaneous embolization of visceral artery pseudoaneurysms between January 2012 and May 2017 was performed. The study included 26 patients with a mean age of 36 years (range 10–71 years). The indications for direct percutaneous embolization included the inability to catheterize endovascularly (n = 24) or prior embolization (n = 2) of the feeding artery. Patient demographics, details of the procedure, complications, and outcomes were evaluated. Patients were followed for a mean of 15 months to assess for recurrence of the pseudoaneurysms on ultrasound. Results Splenic artery (n = 13), gastroduodenal artery (n = 4), right hepatic artery (n = 3), pancreaticoduodenal arteries (n = 3), left gastric artery (n = 2), and left hepatic artery (n = 1) were the embolized arteries. Etiology for pseudoaneurysm were pancreatitis (n = 20), trauma (n = 2), postoperative (n = 2), and few were incidentally detected (n = 2). N-butyl cyanoacrylate (NBCA) with lipiodol was used in 23 (88.4%) patients, coil in one (3.8%), and both coil and NBCA in two patients (7.7%). Embolization of the pseudoaneurysm was successful in all cases. No procedure-related complication was observed. Follow-up showed no recurrence of the pseudoaneurysm. Self-limiting splenic infarct was seen in six patients. Self-limiting abdominal pain was seen in all the patients with embolization with NBCA. One patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage. Conclusion Direct percutaneous embolization is safe and effective in the treatment of visceral artery pseudoaneurysms and should be considered as an alternative in patients with a failed endovascular approach.

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks

To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12months. Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68min (mean 51.36min). Mean fluoroscopy time was 16.7min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Direct Percutaneous Embolization of a Lymphocutaneous Fistula

AbstractLymphocutaneous fistula is a rare clinical condition and presents both a diagnostic and a therapeutic challenge. The authors report a case of secondary lymphocutaneous fistula that was undiagnosed and untreated on several occasions but was successfully treated with direct percutaneous embolization.

03:54 PM Abstract No. 244 Direct percutaneous puncture and embolization of visceral pseudoaneurysms: safety and clinical efficacy

To assess the safety and clinical efficacy of direct percutaneous puncture and embolization in treatment of visceral pseudoaneurysms. Retrospective analysis of all patients who underwent direct percutaneous puncture of pseudoaneurysm (PSA) and embolization between January 2012 to August 2018 was done. Study included 36 patients (27 male and 9 female) with mean age of 39 years (10-71 years). Indications for direct percutaneous embolization were : difficult catheterization of feeding artery, previous embolization of proximal artery, inability to identify feeding artery on angiography. Patients demography, details of endovascular procedure, complications and clinical outcomes were evaluated. Patients were followed up for recurrence of PSA and symptoms (mean follow : 1-24 months). 28 patients had pancreatitis related PSA, 3 patients had post traumatic PSA, 2 patients had postoperative PSA, 2 PSAs were incidentally detected. Splenic artery was the most commonly involved vessel (n=19). 15 patients had difficult catheterization, 12 patients had prior embolization of feeding artery, in 8 patients feeding artery was not identifiable on angiography and 1 patient had common hepatic artery dissection. NBCA (N-butyl cyanoacrylate) with lipiodol was used in 27 (75%) patients, coils were used in 1 (2.8%) patient and both coils and NBCA were used in 8 (22.2%) patients. Embolization of PSA was successful in all cases except in one case where feeder branch was embolized endovascularly using coils. No major procedure related complications were noted. Recurrent PSA noted in one case which was embolized with NBCA and coil. In another 2 cases, there was recurrence of PSA at sites other than previously embolized. Self limiting splenic infarct was seen in 6 patients. Mild abdominal pain was noted in patients embolized with NBCA. 1 patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage. Direct percutaneous puncture and embolization is a safe and effective treatment of visceral PSAs and can be considered as an alternative treatment in patients with failed endovascular approach. This is the largest study group of direct percutaneous embolizations of visceral PSA.

3:50 PM Abstract No. 385 Embolization of residual endoleak or false aneurysm after surgical or endovascular repair of the ascending aorta

To illustrate with 3 patients the feasibility of endovascular and direct percutaneous embolization of complications following ascending aorta surgery and TEVAR, with contra-indication for conventional reintervention. 3 patients have been treated for complications of ascending aortic repair. Patient 1 presented type A dissection after surgical aortic valve replacement. Patient 2 presented type 3 endoleak after endovascular aortic arch repair with a bi-carotid branched Stent-Graft. Patient 3 presented a false aneurysm of the ascending aorta following Bentall surgery. Endovascular access has been used in 2 cases, while direct percutaneous access for the double branch Stent-Graft. Embolization was performed using Penumbra coils. Procedural details are illustrated. Follow-up angiogram and CT-scanner showed a complete occlusion in all 3 patients. No significant complications have been observed during the procedure and the close follow-up. Embolization after TEVAR or surgical repair of the ascending aorta can be an effective complementary treatment of endoleak or false aneurysm complications. Multidisciplinary decision is mandatory.

Pre-operative embolization of hypervascular spinal metastasis using percutaneous direct intra-tumoural injection with Onyx under local anesthesia

Intra-operative blood loss remains a major cause of perioperative morbidity for patients with hypervascular spinal metastasis undergoing surgery. Pre-operative embolization is used to reduce intraoperative blood loss and operative time. This is commonly performed under general anesthesia via a trans-arterial approach, which carries a risk of spinal stroke. We propose an alternative technique for embolization of hypervascular metastases using the Onyx embolic agent via a percutaneous direct intra-tumoural injection under local anesthesia and sedation to reduce embolization risks and procedure time, as well as operative blood loss and operative time. A 74-year-old man presented with thoracic myelopathy with back and radicular pain on background of metastatic renal cell carcinoma. Magnetic resonance imaging (MRI) revealed a 3cm mass centered on the right lamina of T10 with extension into the spinal canal. The patient underwent a percutaneous imaging-guided direct intra-tumoural contrast parenchymogram, and Onyx embolization via a single needle. Initial needle placement and tumour assessment was completed in 30min; embolization time was 15min. Complete devascularization was achieved with no complications. Surgical resection was performed with lower than expected operative blood loss (150ml) and operative time (90min). His pre-operative symptoms improved, and he was discharged home the following day. At 6-month follow-up there was no recurrence of his symptoms. Further evaluation of direct percutaneous intra-tumoural Onyx embolization for hypervascular spinal tumours is warranted.

Diagnosis and Management of Complications from Percutaneous Biliary Tract Interventions.

Complications related to percutaneous biliary tract interventions (PBTIs) can range from access site discomfort to life-threatening vascular complications. These complications are relatively uncommon, and most of them are self-limiting. However, major complications for which an increased level of patient care and/or a prolonged hospital stay are required and that may lead to death-albeit rarely-can occur. Some of the most common complications related to PBTI include pain, infection, bile leakage, and catheter blockage. These conditions can be easily recognized by using the patient's clinical history and laboratory examination results. However, the more uncommon complications, such as life-threatening hemobilia, acute pancreatitis, and catheter and stent fractures, may have nonspecific clinical manifestations, and the underlying pathologic condition may be found only when it is being sought specifically. It is important that diagnostic and interventional radiologists be aware of the wide spectrum of PBTI-related complications, as early recognition and treatment may prevent catastrophic situations. In addition, knowledge of the different treatment options is essential for guidance in interventional radiology procedures such as transarterial control of hemobilia, imaging-guided direct percutaneous embolization of pseudoaneurysms, and percutaneous treatment of catheter- and stent-related complications such as fractures. The authors review a wide spectrum of complications associated with PBTI and the percutaneous management of these conditions. They also highlight valuable lessons learned from morbidity and mortality rounds at a high-volume tertiary care center. ©RSNA, 2017.

Balloon Occluded Retrograde Transvenous Obliteration of Bleeding Stomal Varices Using Sodium Tetradecyl Sulfate Foam: A Case Report

Stomal varices can develop secondary to portal hypertension in patients with a stoma. The bleeding is often recurrent and may be fatal with mortality rates of 3–4% (1). Treatment options include 1) direct pressure or ligation (1), 2) direct percutaneous embolization of the feeding portal branch using a coil or of the varix using glue (2, 3), 3) systemic therapy with vasoactive drugs (4), 4) surgical management (1, 5), 5) transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO) (6, 7). We present a patient with recurrent bleeding from a stomal varix that was controlled with BRTO using sodium tetradecyl sulfate (STS) (Omega Laboratories Ltd., Quebec, ONT, Canada) foam.

Absolute ethanol embolization of arteriovenous malformations in the periorbital region.

Arteriovenous malformations (AVMs) involving the periorbital region are technically challenging clinical entities to manage. The purpose of the present study was to present our initial experience of ethanol embolization in a series of 16 patients with auricular AVMs and assess the outcomes of this treatment. Transcatheter arterial embolization and/or direct percutaneous puncture embolization were performed in the 16 patients. Pure or diluted ethanol was manually injected. The follow-up evaluations included physical examination and angiography at 1- to 6-month intervals. During the 28 ethanol embolization sessions, the amount of ethanol used ranged from 2 to 65 mL. The obliteration of ulceration, hemorrhage, pain, infection, pulsation, and bruit in most of the patients was obtained. The reduction of redness, swelling, and warmth was achieved in all the 16 patients, with down-staging of the Schobinger status for each patient. AVMs were devascularized 100 % in 3 patients, 76-99 % in 7 patients, and 50-75 % in 6 patients, according to the angiographic findings. The most common complications were necrosis and reversible blister. No permanent visual abnormality was found in any of the cases. Ethanol embolization is efficacious and safe in the treatment of AVMs in the periorbital region and has the potential to be accepted as the primary mode of therapy in the management of these lesions.

Thoracic type Ia endoleak: direct percutaneous coil embolization of the aortic arch at the blood entry site after TEVAR and double-chimney stent-grafts

To introduce a novel percutaneous technique to stop blood entry at the lesser aortic arch curvature by coil embolisation in type Ia endoleak after TEVAR. A 61-year-old Marfan patient presented with type Ia endoleak of the aortic arch and a growing aortic arch pseudoaneurysm after TEVAR. Multiple preceding operations and interventions made an endovascular approach unsuccessful. Direct percutaneous puncture of the aneurysmal sac would have cured the sign, but not the cause of blood entry at the lesser curvature of the aortic arch. Direct CT-guided percutaneous puncture of the blood entry site in the aortic arch with fluoroscopically guided coil embolisation using detachable extra-long coils was successfully performed. Three weeks after the intervention, the patient developed fever because of superinfection of the pseudoaneurysm. The blood cultures and CT-guided mediastinal aspirate were sterile. After intravenous administration of antibiotics, the fever disappeared and the patient recovered. Six-month follow-up showed permanent closure of the endoleak and a shrinking aneurysmal sac. Direct percutaneous puncture of the aortic arch at the blood entry site of a thoracic type Ia endoleak after TEVAR and double-chimney stent-grafts with coil embolisation of the wedge-shaped space between the lesser aortic curvature and the stent-graft is possible. Endoleaks after thoracic endovascular aortic repair are common in 15-30 %. Most endoleaks can be treated by endovascular means. Direct percutaneous endoleak repair is described as a bail-out option. Direct percutaneous aortic arch coil embolisation of type 1a endoleak is possible. Antibiotic prophylaxis should be administered case by case, considering individual risk factors.

Direct Percutaneous Puncture and Embolization of Ruptured Sinus of Valsalva Aneurysm

Direct Percutaneous Puncture and Embolization of Ruptured Sinus of Valsalva Aneurysm

A comparison of particulate and Onyx embolization in preoperative devascularization of carotid body tumors

Preoperative embolization of a carotid body tumor (CBT) is a useful adjunct prior to surgical excision because it decreases operative blood loss and improves surgical outcomes. Traditionally, this is performed by transarterial particulate embolization (TAPE). More recently, direct percutaneous embolization (DPE) with Onyx is recognized as a promising technique for preoperative embolization. We compared these two techniques in patients treated for CBTs at our institution. We retrospectively reviewed cases of preoperative devascularization of CBT from 1 January 1995 through 1 September 2012. Patient cases were placed into two groups: TAPE and DPE. Operative blood loss, operative length, angiographic devascularization, embolization procedure complications, operative transfusion requirements, postoperative hospital stay, intensive care unit (ICU) stay, and procedure-related mortalities were compared. A total of 17 patients underwent preoperative devascularization of their CBT with TAPE technique and ten patients using the DPE technique with Onyx. Average operative blood loss was significantly higher in the TAPE group (Mann-Whitney U test, p = 0.04). Operative time was also higher, although this difference was not significant. Two patients required intraoperative blood transfusions in the TAPE group while none required transfusions in the DPE group. There was no significant difference in ICU stay or length of hospitalization. One serious embolization procedure complication occurred in the TAPE group and none in the DPE group. Operative blood loss in the DPE group was significantly less than the TAPE group. Blood transfusion requirement, operative time, and complications were less in the DPE group, although they did not reach statistical significance.

A comparison of particulate and onyx embolization in preoperative devascularization of juvenile nasopharyngeal angiofibromas

Juvenile nasopharyngeal angiofibromas (JNAs) are hypervascular tumors that may benefit from preoperative devascularization to reduce intraoperative blood loss (IBL). The purpose of this study was to compare transarterial particulate embolization (TAPE) with the direct percutaneous embolization (DPE) technique using ethylene vinyl alcohol (Onyx, ev3, Irvine, CA) for the preoperative devascularization of a JNA. We retrospectively reviewed 50 consecutive JNA resections since 1995 for which preoperative embolization was either transarterial with particulate material (n = 39) or DPE (n = 11) using only Onyx. The IBL, transfusion requirements, operative time, and length of hospital admission were compared between the two groups. The mean IBL was 1,348.7 ± 932.2 mL particulate group, 569.1 ± 700.7 mL Onyx group (one-tailed Student's t test p = 0.003). The mean unit of packed red blood cells was 1.56 ± 2.01 units particulate group, 0.45 ± 1.04 units Onyx group (p = 0.009). The relationship between embolization type and IBL remained significant or strongly correlated when accounting for the Fisch stage of the tumor (p = 0.010 and p = 0.056, respectively, by a multivariate least squares fit; alternately p = 0.0003 and p = 0.023, respectively, in the subset of patients with Fisch stage III tumors only). We also found that the proportion of resections for which an endoscopic approach could be used was significantly higher in the Onyx group than the particulate group (81.8 and 18.2 %; Pearson p = 0.0002), and this was also significant both in our multivariate nominal logistic fit (p < 0.001) and in the subset of patients with Fisch stage III tumors (p = 0.018). Pre-operative DPE with Onyx of a JNA when compared to TAPE significantly decreased IBL and RBC transfusion requirement during surgical resection. The proportion of surgical resections performed from an endoscopic approach was higher in the DPE Onyx group, which may have affected the results.

Postcatheterization radial arteriovenous fistula: balloon-assisted direct percutaneous embolization with N-butyl cyanoacrylate and 50 % glucose solution in two sessions

We report an iatrogenic radial arteriovenous fistula (AVF) in a 74-year-old woman presenting with right radial bruit and pain 8 months after sheath removal for cardiac catheterization. She refused surgical ligation and underwent balloon-assisted direct percutaneous embolization of the draining vein with N-butyl cyanoacrylate (NBCA). Another draining vein that developed immediately after the procedure was conservatively treated with 1 month of continuous band compression. However, its diameter gradually increased and, as the patient desired complete remission, an additional procedure was conducted 2 months after initial treatment. A second balloon-assisted direct percutaneous embolization was performed using a 50 % glucose solution, which resulted in complete resolution. Although surgical repair is considered to be the standard treatment, in patients where surgery is not indicated, endovascular intervention-although complicated-may be an alternative treatment modality.