Embolization Of Branches Research Articles

Callosal mutism after AVM embolization in territoy of distal anterior cerebral artery branches

Introduction: Callosum mutism (CM) is a rare complication of neurosurgical procedures. There is no previous report of its ocurrence after interventional endovascular procedures for intracranial lesions. Material and method: We present a case of CM after embolization of anterior cerebral artery branches for treatment of a left frontal arterio-venous malformation (AVM). After reporting the particularities of clinical and radiological presentation of such case, we preform a critical literature review and discusses the clinical and ethiological aspects of CM as well as its differences in relation to other genders of speech disturbances (like aphasias). Finally we provide a brief overview about present available methods of cortical function monitoring emphasizing their utility in therapeutic endovascular procedures in eloquent areas. Result and conclusion: In literature, there are no previous report of CM as a complication of therapeutic angiographic procedures. Its exact pathophysiology is unknown. It is usually believed that this syndrome may appear after lesion of any of the components of the dentate-thalamic-cortical pathway, as well as supplementary motor area and mesolimbic regions involved in speech production. The diagnosis of CM must be considered after a clinical picture of speech deficit after therapeutic endovascualr procedures in territory of distal branches of anterior cerebral artery, specially of frontopolar (FpA branch) and anterior internal frontal (AIFA) branches.

Single photon emission computed tomography (SPECT) for planning of surgical tactics in advanced liver resections

Aim. To determine the indications for staged treatment in planning of advanced liver resections using SPECT. Material and methods. There were 26 patients for the period 2007–2016 who required advanced liver resections at the surgical clinic of the Botkin Hospital. Anatomic FLR (aFLR) was less than 30% in all cases that is an indication for right portal branch embolization. Two-stage treatment has been applied in 15 patients (group 1) for the period 2007–2014. Preoperative examination has included SPECT since 2015. Indication for two-stage treatment was functioning FLR (fFLR) less than 30% (group 2). The second group included 11 patients. Results. In the first group (n = 15), all patients underwent right portal branch embolization. Nine of them underwent surgery including advanced right-sided hemihepatectomy in 5 cases and right-sided hemihepatectomy in 4 cases.Acute postoperative liver failure occurred in 1 (11.1%) patient (ISGLS class A). In the second group (n = 11) need for portal embolization was determined after SPECT. In 5 patients fFLR was over 30%. Thus, advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. Six patients had fFLR less than 30% and two-stage approach was indicated. Five patients underwent radical surgery: advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. There were no cases of acute postoperative liver failure and mortality in this group. Conclusion. Preoperative SPECT is able to predict high risk of acute postoperative liver failure after advanced liver resection. Therefore, certain measures for prevention of this complication may be considered.

Late results of embolization of a portal hepatic vein branches in patients, suffering extended hepatic tumors

Objective. To analyze late results of preoperative embolization of the portal hepatic vein branches (EPHVB) in patients, suffering extended hepatic tumors and extremely border-like small calculated residual hepatic volume(CRHV).
 Маterials and methods. From 2004 to 2014 yr the extended hepatic resection (HER) was performed in 285 patients, to whom EPHVB was applied (the main group), аnd in 353 patients as well, but without endovascular preparation (control group). In both groups dynamics of laboratory indices, structure of complications and lethality, late survival were studied.
 Results. In the main group a trustworthily lower rate of an acute hepatic insufficiency and connected with a lower postoperative lethality - accordingly 2.3 and 4.6%, comparing with a control group - 9.3 and 8.8%, were suggested. The laboratory data dynamics have witnessed a lesser intensiveness of postoperative hepatocytolysis and lesser degree of the hepatic synthetic function lowering in the main group, what have confirmed a better functional adaptation of hepatic residual in patients, to whom preoperative EPHVB was applied.
 Conclusion. Preoperative EPHVB permits to lower the postoperative complications and lethality rate in patients, suffering hepatic tumors, due to better functional adaptation of hepatic residual.

15-year experience in the use of portal vein embolization in patients with focal liver diseases

Background. Portal vein embolization allows increa­sing the future remnant liver in patients with malignant hepatic neoplasms, preparing for radical surgical treatment. The wide spread of this technique is interfered by the lack of a single execution algorithm. The purpose of this study was to analyze 15-year experience of preoperative portal vein embolization in patients with advanced liver tumors. Materials and methods. From 2003 to 2017 in the department of endovascular surgery of O.O. Shalimov National Institute of Surgery and Transplantology of the NAMS of Ukraine, 485 preoperative embolizations of the portal vein branches were performed in patients with liver tumors, the future remnant liver in which was below the threshold resectabi­lity level. Results. As a result of portal vein embolization, it was possible to achieve the future remnant liver increase by 88.2 % (from 237 to 446 cm3). It allowed performing the radical liver resection in 421 (86.8 %) patients. The analysis of laboratory data showed that the processes of hepatocytolysis associated with embolization and reduction of the synthetic function of the liver are reversible and complete within 3 weeks. Conclusions. Preoperative embolization of the portal vein branches makes it possible to expand the range of resectability of patients with advanced liver tumors and to reduce the risk of postoperative acute hepatic insufficiency.

Transarterial Embolization for Life-Threatening Spontaneous Hemopneumothorax

Two patients with life-threatening spontaneous hemopneumothorax had developed transpleural, nonbronchial, systemic collaterals from branches of the subclavian artery. It was thought that the collaterals had ruptured due to a collapsed lung and pneumothorax. Transarterial embolization of these arteries was performed, and hemostasis was obtained with no complications. A 37-year-old man underwent embolization of branches of the left internal thoracic artery and the left ascending cervical artery using gelatin sponges and metallic coils. A 33-year-old man underwent artery embolization for extravasation from a branch of the right thyrocervical trunk using n-butyl cyanoacrylate mixed with Lipiodol. Transarterial embolization of a transpleural, nonbronchial, systemic artery provided effective hemostasis in life-threatening spontaneous hemopneumothorax.

Ethylene vinyl alcohol copolymer for occlusion of specific portal branches during preoperative portal vein embolisation with n-butyl-cyanoacrylate.

To evaluate the safety and efficacy of ethylene vinyl alcohol copolymer (EVOH) injection for selective occlusion of portal branches considered at risk for non-target embolisation during preoperative portal vein embolisation (PVE). Twenty-nine patients (mean age, 57 ± 17 years) submitted to PVE with n-butyl-cyanoacrylate (NBCA) and additional EVOH for selected portal branches were retrospectively analysed. Indications for the use of EVOH and the selected portal branches were evaluated. Degree of hypertrophy of the future liver remnant (FLR) and kinetic growth were assessed by CT volumetry performed before and 3-6 weeks after PVE. Clinical outcome and histopathological analysis of portal veins occluded with EVOH were reviewed. EVOH was indicated intraoperatively for embolisation of selected portal branches that the operator reported at risk to provoke non-target embolisation with NBCA. Indications for the use of EVOH were embolisation of segment IV (n = 21), embolisation of segmental portal branches with early bifurcation (n = 7) and PVE in a 1-year-old girl with cystic hamartomas. All targeted portal branches were successfully embolised. There were no cases with non-target embolisation by EVOH. The degree of hypertrophy of the FLR was 14.3 ± 8.1% and the kinetic growth rate was 2.7 ± 1.8% per week. EVOH is safe and effective for embolisation of selected portal vein branches considered at risk for non-target embolisation. • EVOH is another effective liquid embolic agent for preoperative PVE. • EVOH is relatively simple to handle with a minimal risk of non-target embolisation. • During PVE, some portal branches considered complicated to occlude with NBCA may be efficiently embolised with EVOH.

Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients

PurposeTo evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment. Materials and MethodsThis prospective study was conducted between 2014 and 2015 on 25 consecutive patients (16 men and 9 women with a mean age of 53 y [range, 30–76 y]) with grade II–III hemorrhoids refractory to medical treatment. A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils. Over the following 12 months, clinical outcomes were evaluated using the French bleeding score, Goligher prolapse score, visual analog scale (VAS) score for pain, quality-of-life score. The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score. ResultsAt 12 months after embolization, clinical success was obtained in 18 patients (72%), 8 of whom had 2 embolizations. VAS score decreased from 4.6 to 2.3 (P < .01), and bleeding score decreased from 5.5 to 2.3 (P < .01). Quality-of-life and prolapse scores also showed improvement (P < .05), and no patients experienced any early or late complications. Complete clinical failure was observed in 7 patients. After coil embolization, the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence (P = .001). ConclusionsHemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II–III hemorrhoids.

A Stepwise Embolization Strategy for a Bronchial Arterial Aneurysm: Proximal Coil and Distal Glue with the Optional Use of a Microballoon Occlusion System.

This study aimed to demonstrate a transcatheter embolization strategy for bronchial artery aneurysms (BAAs) using coils for the proximal lesion and glue (n-butyl-2-cyanoacrylate [NBCA]) embolization for the distal lesion with or without the use of a microballoon occlusion catheter. Five patients with BAAs presenting with hemoptysis were enrolled in this study. A bronchial angiogram indicated a mediastinal BAA near the orifice, accompanied by dilated distal branches with or without intrapulmonary BAA. A stepwise procedure was performed. First, the intrapulmonary branches were embolized with glue, with or without the use of a microballoon catheter depending upon the anatomical and local flow hemodynamic conditions. Second, the mediastinal BAA was tightly packed with detachable coils. Glue embolization of intrapulmonary abnormal branches successfully controlled hemoptysis in all patients; microballoon catheters were used in five of the 10 arteries. The volume embolization ratio of coils within the mediastinal BAA ranged from 28 to 59%, and neither coil compaction nor signs of recanalization were observed during follow-up. The stepwise embolization procedure with the sequential use of glue (with or without a microballoon occlusion system) and detachable coils may represent a possible endovascular strategy for the treatment of complex BAAs. Level 4: Case Series.

Gore Iliac Branch Endoprosthesis for treatment of bilateral common iliac artery aneurysms

ObjectiveThe Gore Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) has recently been approved by the Food and Drug Administration for treatment of common iliac artery (CIA) aneurysms. Despite early excellent results in clinical trial, none of 63 patients were treated for bilateral iliac aneurysms. The goal of this study was to examine real-world experience using the Gore IBE for bilateral CIA aneurysms. MethodsA retrospective review of an international multicenter (16 U.S., 8 European) experience using the Gore IBE to treat bilateral CIA aneurysms was performed. Cases were limited to those occurring after Food and Drug Administration approval (February 2016) in the United States and after CE mark approval (November 2013) in Europe. Demographics of the patients, presentation, anatomic characteristics, and procedural details were captured. ResultsThere were 47 patients (45 men; mean age, 68 years; range, 41-84 years) treated with bilateral Gore IBEs (27 U.S., 20 European). Six patients (12.7%) were symptomatic and 12 (25.5%) patients were treated primarily for CIA aneurysm (aorta <5.0 cm). Mean CIA diameter was 40.3 mm. Four patients had aneurysmal internal iliac arteries (IIAs). Two of these were sealed proximally at the IIA aneurysm neck and two required coil embolization of IIA branches to achieve seal in the largest first-order branches. Technical success was achieved in 46 patients (97.9%). No type I or type III endoleaks were noted. There was no significant perioperative morbidity or mortality. IIA branch adjunctive stenting was required in four patients (one IIA distal dissection, three kinks). On follow-up imaging available for 40 patients (85.1%; mean, 6.5 months; range, 1-36 months), 12 type II endoleaks (30%) and no type I or type III endoleaks were detected. Two of 80 (2.5%) IIA branches imaged were occluded; one was intentionally sacrificed perioperatively. ConclusionsPreservation of bilateral IIAs in repair of bilateral CIA aneurysms can be performed safely with excellent technical success and short-term patency rates using the Gore IBE device. Limb and branch occlusions are rare, usually are due to kinking, and can almost always be treated successfully with stenting.

4:12 PM Abstract No. 209 Neovascularization in knee osteoarthritis: a new mouse model using micro computed tomography to delineate pathological vascular remodeling

To identify new arterial branches in a murine model for osteoarthritis Knee osteoarthritis (OA) is a common disease with significant morbidity (1). Treatment includes oral anti-inflammatories, intraarticular knee injection, and surgical arthroplasty. New theories propose increased hypervascularity of the joint and periarticular tissue. Some authors argue that homeostasis is tilted in knee OA to favor inflammation and hypervascularity; however, no animal model has demonstrated any discrete hypervascularity beyond a microscopic range. Limited human trials have been conducted studying embolization of unnamed arterial branches in juxta-articular tissues to treat pain (4). There has been no proof for causality of OA for new large angiographically evident arterial branches. We describe a murine model of knee OA hypervascularity by intraarticular collagenase injection. 18 animals were divided to groups of six. OA was induced in all left limbs and the right limbs served as control. Animals ambulated ad lib. The mice were sacrificed at 4, 8, and 12 weeks post injection. After deep sedation; via tail vein access 0.6 mg of papaverine was used for vasodilation followed by 100 U of heparin. Animals were sacrificed and median thoracolaparotomy was performed, followed by IVC transection and left ventricular cannulation to allow for sequential perfusion with phosphate buffered saline, paraformaldehyde, and a lead chromate based casting agent. After polymerization overnight, the hindlimb was disarticulated from the hip joint and scanned by μCT at 45 kVp, 177 μA, 200 ms integration time, and a voxel size of 16 μm. Unnamed branches of murine hindlimb arteries were counted from the last trifurcation of femoral artery through 2.5 mm below the tibial plateau. Experimental limbs had more branches than controls (mean of 11.6 vs 7.5; p <0.001), with an effect size of 1.3 (95%/ CI: 1.06-1.76). Time by group approached significance (p = 0.09). Interaction between intervention and time was not significant (p = 0.17). There is increased number of arterial branch vessels associated with knee OA in a murine model, similar to target vessels that have been embolized in human subjects.

Wunderlich syndrome. Clinical and therapeutic aspects of a long-term experience

Wunderlich's syndrome is defined as a clinical manifestation secondary to sudden spontaneous rupture of renal parenchyma in the absence of injury, resulting in hemoretroperitoneum. This syndrome may occur in patients with benign or malignant neoplasm of the kidney, arterial venous fistulae, immunovasculitis and other phlogosis of the kidney. We present 19 cases of acute spontaneous hemoretroperitoneum or Wunderlich's syndrome diagnosed from 1996 to 2009, related to the following conditions: 7 renal carcinomas, 4 angiomyolipomas, 2 adrenal hemorrhages, 1 bleeding polycystic kidney, 2 hemorrhagic renal cysts and three cases of immunovasculitis. Overall, 6 patients were treated with acetylsalicylic acid and 4 with dicumarolics for cardiovascular disease, while 13 patients were suffering from hypertension? In 19 cases there was no mortality and the following treatment was performed: 11 nephrectomy, 4 partial nephrectomy, 2 adrenalectomy, 2 selective embolization of intrarenal branches as single treatment, while in three other cases, the embolization was carried out from a surgical procedure, conservative (partial nephrectomy) in one case, ablative (nephrectomy) in two other cases. The spontaneous hemoretroperitoneum is a rare syndrome associated with acute kidney disease often unknown to the patient and only in selected cases with small hematoma; it is possible to perform arteriography with selective embolization of branches avoiding renal access surgery. So far, it is unknown to which extent anti-platelet and anticoagulant drug treatment contributes to this syndrome but, in our experience, they have increased the morbidity of the clinical condition.

Initial Experience with the E-liac® Iliac Branch Device for the Endovascular Aortic Repair of Aorto-iliac Aneurysm.

Occlusion of internal iliac arteries during endovascular treatment (EVAR) of abdominal aortic (AAA) and common iliac artery aneurysms might be associated with ischemic pelvic complications. This study evaluates technical and clinical success, safety and mid-term results of a novel iliac branch device (IBD) for revascularization of the internal iliac artery (IIA) during EVAR. Retrospectively, we identified 21 men (mean age 73.3±6.2years) treated for aorto-iliac aneurysms by use of a novel IBD (E-liac®, Jotec Hechingen, Germany). We analyzed safety (30-day survival), technical (no type I and III endoleaks, "EL"), clinical (no ischemic complications) success, mid-term patency of this IBD, peri-procedural complications, occurrence of type II ELs, rate of re-interventions and additional treatment of the revascularized IIA for landing zone preparation. Twenty-three IBDs were implanted. Aneurysms of the ipsilateral IIA were present in 6/23 IIAs (26.1%). Super-selective branch embolization was performed in these patientsand the landing zone for the iliac sidebranch stent-graft was within the superior gluteal artery. Mean follow-up was 341days (range 4-1103days). Technical success and 30-day survival were 100%. Clinical success was 95.2%. Primary patency of the IBDs was 100% at 12 months. Peri-procedural complications occurred in 3/21 patients (14.3%), none of them related to the IBD. AAA-related type II ELs were found in 6 patients (28.6%), IBD-related ELs in 4/23 IBDs (17.4%) (two type Ib, two type II endoleaks). Overall re-intervention rate was 23.8%, IBD-related 8.7%. Utilization of the E-liac® IBD is safe and effective for the treatment of aorto-iliac aneurysms.

Роль ендоваскулярних методик ремоделювання печінки в хірургічній гепатології

Objective — to study the results of surgical treatment of patients with liver tumors who underwent embolization of the portal vein branches (PVE) as a remodeling of the planned hepatic remnant. Materials and methods. PVE was performed in 485 patients in the period from 2003 to 2018. For all patients the calculation of the volume of the planned hepatic balance was performed before PVE and before liver resection. The level of postoperative morbidity and mortality, as well as long-term overall and recurrence-free survival was investigated comparing a group of patients who were not treated with PVE before resection of the liver. Results. In all patients after the portal vein embolization, an increase in the residual volume of the liver was observed on average by 58.6 %. The degree of hypertrophy was found to depend on the extention of embolization performed. Radical resection of the liver was performed in 397 (81.9 %) patients. In the main group of patients, a decrease in the incidence of acute postoperative liver failure from 9.3 % to 2.3% was observed and the decrease in postoperative mortality from 8.8 % to 4.6 %. Compared to the group of patients, were the endovascular remodeling techniques before liver resection had not been used. Distant total 3-year and 5-year postoperative survival in these groups is not significantly different. Conclusions. Embolization of the portal vein branches is a necessary method of preparing patients with a small estimated hepatic remnant for expanded liver resection and allows to reduce postoperative morbidity and mortality in this group of patients.

Carotid Dosimetry and the Risk of Carotid Blowout Syndrome After Reirradiation With Head and Neck Stereotactic Body Radiation Therapy

Tocorrelate carotid dose and risk of carotid blowout syndrome (CBOS) after stereotactic body radiation therapy (SBRT), hypothesizing that carotid dose does not correlate with CBOS. We retrospectively reviewed 186 patients with recurrent, previously irradiated head and neck cancer treated between January 2008 and March 2013. Patients treated early in our experience with incomplete dosimetry were excluded from analysis (n = 111). A total of 75 patients were identified, providing 150 carotid arteries for analysis. Median follow-up was 8months (range, 1-91months) for all patients, and 37months for surviving patients (range, 31-91months). Patients were treated with linear accelerator-based SBRT to a median dose up to 44Gy (range, 40-50Gy) in 5 fractions delivered on a twice-weekly basis. Concurrent cetuximab was used in 63 patients (84%). The bilateral common, internal, and external carotid arteries were delineated 2cm above and below the planning target volume. The maximum dose to 0.1cm3 (D0.1cc), 1cm3 (D1cc), and 2cm3 (D2cc) of the carotid and the mean carotid dose from SBRT were recorded and analyzed for association with carotid bleeding events, using binary logistic regression. Median reirradiation interval was 20months (range, 3-423months), and median prior radiation dose was 70Gy (range, 52.5-140Gy). Sixteen patients (21.3%) received more than 1 course of SBRT, and the cumulative carotid doses from fused summary plans were recorded. The overall median D0.1cc, D1cc, D2cc, and mean carotid doses were 40.8Gy (interquartile range [IQR], 21.6-47.6Gy), 26.8Gy (IQR, 14.1-42.1Gy), 15.4Gy (IQR, 8.4-32.7Gy), and 15.0Gy (IQR, 8.9-23.3Gy), respectively. There were a total of 4 bleeding events (5.3%): 2 patients (2.7%) had mucosal bleeds that resolved after embolization of carotid branches, and 2 patients (2.7%) died from complications of CBOS. In the 2 patients with CBOS the D0.1cc was 48.4Gy and 47.6Gy, respectively. There was no significant association between bleeding events and D1cc (P = .280), D2cc (P = .571), or mean dose (P = .568). There was a trend toward increased risk of bleeding and D0.1cc (P = .080). These results demonstrate a low risk of bleeding after reirradiation with SBRT when 5 fractions are delivered on nonconsecutive days, even when tumor is completely encasing the carotid artery. Although limited by the low number of events, no significant association was found between dose-volume parameters and the risk of carotid bleeding. No CBOS was noted when D0.1cc was <47.6Gy.

Streptococcus agalactiae infective endocarditis complicated by multiple mycotic hepatic aneurysms and massive splenic infarction: a case report

BackgroundThe burden of disease caused by Streptococcus agalactiae has increased significantly among older adults in the last decades. Group B streptococcus infection can be associated with invasive disease and severe clinical syndromes, such as meningitis and endocarditis.Case presentationWe present the case of a 56-year-old man who developed multiple mycotic aneurysms of the right hepatic artery and massive splenic infarction as rare complications of Streptococcus agalactiae infective endocarditis. The patient underwent urgent right hepatic artery ligation and splenectomy. The postoperative course was complicated by an episode of hemobilia due to the rupture of a partially thrombosed mycotic aneurysm into the biliary tree. Thus, selective radiological embolization of the left hepatic artery branches was necessary.ConclusionTo our knowledge, this is the first case reported of infected aneurysms of visceral arteries caused by Group B streptococcus infection. Clinical and laboratory findings were non-specific, while imaging features with computed tomography scan and angiography were highly suggestive. In our case, early recognition, culture-specific intravenous antibiotics and urgent surgical treatment combined with interventional radiology played a decisive role in the final result.

The effect of selective internal radiation therapy with yttrium-90 resin microspheres on lung carbon monoxide diffusion capacity

BackgroundSelective internal radiation therapy (SIRT) with embolization of branches of the hepatic artery is a valuable therapeutic tool for patients with hepatic malignancies; however, it is also associated with lung injury risk due to shunting. Diffusion capacity of the lungs for carbon monoxide (DLCO) is a clinically significant lung function test, and worsening in DLCO is suggested to reflect a limited gas exchange reserve caused by the potential toxicity of chemoradiotherapy or it may be a marker of related lung injury. This study aimed to examine the changes in DLCO during SIRT with resin microspheres in newly treated and retreated patients. Forty consecutive patients who received SIRT for a variety of malignant conditions were included. All subjects were treated with Yttrium-90 labelled resin microspheres. DLCO tests were performed after the procedures. In addition, patients were specifically followed for radiation pneumonitis.ResultsThe mean DLCO did not significantly change after the first (82.8 ± 19.4 vs. 83.1 ± 20.9, p = 0.921) and the second treatments (87.4 ± 19.7 vs. 88.6 ± 23.2, p = 0.256). Proportion of patients with impaired DLCO at baseline was not altered significantly after the first (37.5 vs. 45.0%, p = 0.581) and the second treatments (27.3 vs. 27.3%, p = 1.000). Also, percent change in DLCO values did not correlate with radiation dose, lung shunt fraction, or lung exposure dose (p > 0.05 for all comparisons). None of the patients developed radiation pneumonitis.ConclusionsOur results suggest that no significant change in DLCO in association with SIRT occurs, both after the first or the second treatment sessions. Further larger studies possibly with different protocols are warranted to better delineate DLCO changes after SIRT in a larger spectrum of patients.

Liver Biopsy and Microwave Ablation Complicated by Hemorrhagic Shock and Massive Hemoperitoneum: A Root Cause Analysis

Case Summary: A 47 year-old man with Child-Pugh class B alcoholic cirrhosis was found to have an indeterminate 2 cm right hepatic lobe lesion concerning for hypovascular hepatocellular carcinoma. The patient underwent CT-guided percutaneous liver biopsy followed by microwave ablation. Post-procedure blood loss was minimal, with no immediate complications; however, the patient presented < 48 hours later with hypotension and abdominal pain. CT angiography demonstrated large volume hemoperitoneum with active contrast extravasation from a branch of the right hepatic artery. Distal right hepatic artery branch embolization was performed. Within 24 hours, the patient developed refractory hypotension requiring repeat embolization of the right hepatic artery with no further contrast extravasation. Later that day, the patient developed elevated intra-abdominal pressure, worsening hypotension, and profound lactic acidosis with persistent coagulopathy. The patient was taken emergently to the operating room for exploratory laparotomy and evacuation of the hematoma. Despite these interventions, the patient developed cardiac arrest in the operating room and expired. Methods: A systematic root-cause analysis (RCA) was performed. Data was gathered and evidence collected from multiple hospital stakeholders (staff, nurses, advance practice providers, physicians, bed management, and hospital administrators). Causal factors, current practice paradigms, and root causes were investigated. Potential corrective actions were explored. Results: Detailed discussions were held with emergency, IR, hepatology, hematology, and medical and surgical ICU staffing. Cause and effect diagram was constructed - Figure. RCA revealed potential areas for institutional improvement including post-procedural follow-up (phone contact and lab monitoring), physician consultation methods (automatic consultations for high-risk patients), massive transfusion protocols (thromboelastrography correction of coagulopathy), and triage of patients to medical versus surgical intensive care units (ICU).Figure: Cause and Effect Fishbone Diagram.Discussion: This case highlights a fatal complication from liver biopsy and microwave ablation. Through this RCA, an institution-wide protocol through discussions with all stakeholders is needed to reduce future adverse events. Furthermore, this case emphasizes the need for early involvement of the hepatobiliary surgical service and appropriate triage of massive transfusion protocol patients to a surgical ICU.

Transarterial Embolization for Treatment of Symptomatic Polycystic Liver Disease

Background:Currently, treatment of symptomatic polycystic liver disease (PLD) is still a challenging problem, especially for these patients who are not feasible for surgery. Minimally invasive options such as laparoscopic fenestration and percutaneous cyst aspiration with sclerotherapy demonstrated disappointing results due to multiple lesions. Because the cysts in PLD are mostly supplied from hepatic arteries but not from portal veins, transcatheter arterial embolization (TAE) of the hepatic artery branches that supply the major hepatic cysts can lead to shrinkage of the cyst and liver size, relieve symptoms, and improve nutritional status. This study aimed to evaluate the effectiveness of TAE with a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized oil for patients with severe symptomatic PLD during a more than 2-year follow-up.Methods:Institutional review board had approved this study. Written informed consent was obtained from all patients. From February 2007 to December 2014, twenty-three patients (20 women and 3 men; mean age, 49.0 ± 14.5 years) infeasible for surgical treatments underwent TAE. Changes in the abdominal circumferences, volumes of intrahepatic cysts, hepatic parenchyma volume, and whole liver, clinical symptoms, laboratory data, and complications were evaluated after TAE.Results:Technical success was achieved in all cases. No procedure-related major complications occurred. The median follow-up period after TAE was 48.5 months (interquartile range, 30.0–72.0 months). PLD-related severe symptoms were improved remarkably in 86% of the treated patients; TAE failed to benefit in four patients (four patients did not benefit from TAE). The mean maximum abdominal circumference decreased significantly from 106.0 ± 8.0 cm to 87.0 ± 15.0 cm (P = 0.021). The mean intrahepatic cystic volume reduction rates compared with pre-TAE were 36% at 12 months, 37% at 24 months, and 38% at 36 months after TAE (P < 0.05). The mean liver volume reduction rates were 32% at 12 months, 31% at 24 months, and 33% at 36 months (P < 0.05).Conclusions:TAE with the mixture of NBCA and iodized oil appears to be a safe and effective treatment method for patients with symptomatic PLD, especially for those who are not good candidates for surgical treatments, to improve both hepatic volume and hepatic cysts volume.

Diffuse Renal Cortical Hemorrhage in the Setting of Subcapsular Hematoma: Diagnosis and Treatment with Embolization

PurposeTo describe radiologic findings, embolization technique, and clinical outcomes in patients with renal subcapsular hematoma and diffuse cortical hemorrhage. Materials and MethodsTen patients with renal subcapsular hematoma and diffuse cortical hemorrhage were reviewed. Nine of the 10 had undergone procedures (nephrostomy, n = 4; biopsy, n = 4; embolization of a cerebral aneurysm, n = 1) and 1 patient was receiving oral anticoagulation. Computed tomography (CT), angiography, and embolization of bleeding sites were performed in all patients. ResultsCT and angiography revealed subcapsular hematoma with diffuse cortical hemorrhage at the level of the interlobar and/or arcuate branches. Total embolization of intrarenal arterial branches was required in 3 patients. Partial embolization, which also resulted in permanent functional loss, was required in 4. The functional loss was likely caused by the embolization procedure and the underlying renal disease. In these 4 patients, renal failure was demonstrated by scintigraphy in 3 cases and based on the need to start chronic hemodialysis in 1 case. In the remaining three patients, embolization did not compromise renal function. ConclusionsDiffuse cortical hemorrhage unrelated to the site of puncture may be seen in some cases of subcapsular hematoma. The cause is likely the laceration of transcortical capsular arteries secondary to enlargement of the subcapsular hematoma. In the present case series, embolization achieved hemorrhage control, but loss of renal function was observed in patients with underlying renal disease.

RESULTS OF RADICAL SURGICAL TREATMENT OF CHOLANGIOCARCINOMA

Radical operations of cholangiocarcinomas are connected with the great number of post-operative complications, and lethality reaches 15-30 %. The most debatable questions remain the choice of the operation type depending on localization and spreading of a tumor and also the expedience of using mini-invasive technologies as a preoperational preparation to the radical surgical treatment. We would like to share the little experience of the radical surgical treatment of cholangiocarcinomas. The research aim is to analyze results of radical surgical treatment of patients with cholangiocarcinoma. Matherials and methods. We have analyzed the outcomes of surgical treatment in 18 patients with cholangiocarcinomas. Tumor localization was determined according to the Bismuth-Corlett classification. Type 1 tumors were found in 2 (11.1 %), type 2 in 4 (22.2 %), type 3А in 5 (27.8 %), type 3B in 4 (22.2 %), type 4 in 1 (5.6 %), and distal localization in 2 (11.1 %) patients. As biliary decompression, 9 (50 %) patients underwent percutaneous transhepatic biliary duct drainage (PTBD), and another 9 (50 %) patients were operated without preoperative biliary decompression Pre-operative embolization of portal vein branches with the aim to increase the low volume of liver after anticipated resection was performed in 4 (22.2 %) patients. Results. After the embolization of portal vein branches, the estimated residual volume of hepatic parenchyma increased from 33.4 % to 45.7 %. Patients with cholagiocarcinomas of different localization performed the radical operations: isolated hepaticocholedochus resection in 5 (27.8 %) patients, hepaticocholedochus resection combined with Taj Mahal hepatic resection in 1 (5.6 %), right hemihepatectomy in 5 (27.8 %), left hemihepatectomy in 4 (22.2 %), extended right hemihepatectomy in 1 (5.6 %), and pancreoduodenal resection in 2 (11.1 %) patients. Complications of radical surgeries were observed in 4 (22.2 %) patients. Lethal outcomes occurred in 3 (16.7 %) patients. Conclusions. Radical operations are attended with complications in 22,2 % and lethality in 16,7 %. As a preoperative preparation it is possible to use mini-invasive interventions for the biliary decompression and increase of hepatic parenchyma volume.