Embolization Techniques Research Articles

Stand-alone transarterial flow diversion for treatment of carotid cavernous fistulas

ObjectiveCarotid-cavernous fistulas (CCFs) are rare arteriovenous communications allowing blood to flow from the carotid artery into the cavernous sinus. Although currently coil and/or liquid embolization remain the preferred treatment methods for CCFs, flow diverters (FD) stents represent a viable alternative to traditional embolization techniques. This study explores both the technical aspects and rationale behind using FD stents as a stand-alone treatment approach for CCFs. MethodsThe study includes records of 7 patients with CCFs treated at two comprehensive stroke centers from 2019 to 2023. Patients treated with FD stenting in conjunction with coil and/or liquid embolization were excluded from the study. ResultsFive patients were diagnosed with direct CCFs and 2 patients with indirect CCFs. Six patients were treated with the Surpass Evolve FD stent and 1 patient with the Pipeline FD stent. DSA follow-up was performed for an average duration of 14.4 months following FD placement. Complete fistula obliteration with no residual shunting was observed in all patients. Furthermore, all patients experienced a complete resolution of symptoms following treatment. ConclusionsThe authors’ experiences suggest the efficacy and safety of FD stenting as a stand-alone treatment option for CCFs. Compared to embolization, FD stents can better preserve the parent vessel and promote healing with less associated mass effect. Despite being a retrospective self-assessment with a relatively small sample size, to the authors’ knowledge, this study represents the largest individual case series of patients with CCF treated with stand-alone FD stenting.

Trans-arterial embolization for treatment of acute lower gastrointestinal bleeding-a multicenter analysis.

To assess the technical feasibility, safety, and clinical success rate of trans-arterial embolization (TAE) as an emergency treatment for acute lower gastrointestinal bleeding (LGIB). Consecutive patients who received urgent TAE due to active LGIB at five academic centers in Germany were retrospectively analyzed. LGIB was confirmed and localized using contrast-enhanced computed tomography (CT) or endoscopy. Outcome parameters including technical and clinical success rates as well as ischemia-related adverse events were analyzed. Furthermore, treatment-related variables that may affect technical and clinical success were analyzed using a regression model. One hundred and forty-one patients were included. TAE was performed in 91% (128/141) of patients. In 81% (114/141) of patients, TAE was performed due to active bleeding visible at angiography, the remaining 10% (14/141) underwent empiric embolization based on pre-interventional imaging. In 9% (13/141) of patients, no TAE was performed. Microcoils were the most used embolic 48.5% (62/128), followed by glue 23.5% (30/128) and Microparticles (8%; 10/128). In the case of bleeding visible in angiography, the technical success rate was 100% (114/114); the clinical success rate was 93.6% (120/128). Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% (18/128) of all patients after embolization. Thirty-day mortality was 14% (21/141). Regression analysis revealed no significant correlations but a statistical trend toward a higher incidence of bowel resection when glue was used (p = 0.090) and toward a higher 30-day mortality when an unselective embolization was performed (p = 0.057). TAE for LGIB has a high technical and clinical success rate. Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% of patients without identifying a significant correlation to the embolization technique or an embolic. Question Is trans-arterial embolization (TAE) viable as an emergency treatment for acute lower gastrointestinal bleeding (LGIB)? Findings TAE demonstrated a 100% technical and 93.6% clinical success rate in treating acute LGIB, with severe ischemia-related adverse events occurring in 14% of patients. Clinical relevance TAE is highly effective and has an acceptable complication rate in treating lower gastrointestinal bleeding, emphasizing the need for a direct head-to-head comparison between endovascular and endoscopic therapy.

Mesenteric Vein to Gonadal Vein Shunt Embolization in Patients with Portal Hypertension: Technical Considerations and Clinical Outcomes.

To assess the technical and clinical outcomes of percutaneous embolization for high-flow mesenteric vein to gonadal vein (MGV) portosystemic shunts. In this HIPPA-compliant, review board-approved study, patients who underwent embolization of MGV shunts between 2011 and 2023 were included. Patient demographic data, embolization technique, clinical outcomes, and complications were retrieved from the electronic health records. Technical success was defined as complete occlusion of the shunt on follow-up imaging. Clinical outcomes assessed were resolution/improvement of hepatic encephalopathy, improvement in liver function, changes to liver volumes, and occurrence of adverse events. Eight patients (mean age 59.5, 75% female) with nine MGV shunts were included. The indications for shunt embolization included medically refractory hepatic encephalopathy, bleeding duodenal varices, and transplant liver dysfunction. The mean maximum shunt diameter was 23.3mm. Embolization was most commonly performed with a combination of coils and N-butyl cyanoacrylate or vascular plugs. Complete MGV shunt thrombosis was achieved in 7/9 shunts post-embolization, and symptom improvement was noted in 7/8 patients. Child-Pugh scores improved post-embolization in 6/9 patients by a median of 3 points. Liver volumes also increased by a mean of 20.8 ± 17.7% post-embolization. Minor adverse events included new onset ascites, partial mesenteric/portal vein thrombosis, and new gastroesophageal varices without bleeding in four patients. Embolization of MGV shunts is technically feasible and effective for treatment of hepatic encephalopathy and increasing hepatopetal portal perfusion. There was an improvement in Child-Pugh scores and an increase in liver volumes in the majority of patients post-embolization.

Criteria for PAVM Reintervention.

Background/Objectives: To propose criteria for retreating previously embolized PAVMs and determining the effectiveness of the criteria to prevent paradoxical embolization. Methods: A retrospective review of patients with PAVMs treated at a single HHT center of excellence between 1 January 2013, and 10 September 2023, was performed. Patients with PAVM recurrence were either retreated or observed based on the following criteria for PAVM reintervention: 1. Embolic device(s) not creating a sufficiently dense matrix, such that a channel through them may be >/ 2 mm; 2. Accessory feeding artery or pulmonary collateral >/ 2 mm; 3. Hemoptysis in a patient with no other explanation. Results: A total of 438 PAVMs were treated in 151 patients, including 106 patients with definite, 14 possible, and 31 doubtful HHT. Post-embolization PAVM recurrence occurred in 36 patients (36/151, 23.8%), including 15 patients (15/151, 9.9%) with 22 PAVMs (22/438, 5.0%) meeting criteria for reintervention. A total of 21 patients (21/151, 13.9%) with recurrence did not meet reintervention criteria and were therefore observed. Pre-treatment paradoxical embolization occurred in 36 patients (36/151) for a lifetime prevalence rate of 23.7%. Post-treatment paradoxical embolization did not occur in any patients following PAVM embolization (0/151). There was one case of iatrogenic paradoxical embolization in a patient being treated for systemic collateral reperfusion and hemoptysis. However, this was not included given that it was not a spontaneous event. Conclusions: Utilizing modern embolization techniques and devices, the proposed reintervention criteria, and screening intervals, paradoxical embolizations can be effectively prevented in patients with PAVMs.

7040 Embolization Of Hepatic Metastases Is Effective For Palliative Management Of Severe Cushing Syndrome

Abstract Disclosure: S. Zhang: None. C. Musonza: None. A. Pillai: None. M. Ramos-Roman: None. J. Abramowitz: None. S. Mirfakhraee: None. P. Polanco: None. A.P. Dackiw: None. S. Al Mutar: None. A. Mallik: None. L. Jia: None. O. Hamidi: None. Background: Cushing syndrome (CS) due to metastatic endocrine neoplasms poses substantial treatment challenges. Arterial embolization and Yttrium-90 (Y-90) radioembolization for hepatic metastases are effective in the management of metastases due to neuroendocrine tumors (NETs). However, data are scarce on the role of embolization of liver metastases in patients with CS. Here, we report two cases of severe CS due to bulky hepatic metastases treated with embolization techniques. Case 1 A 49-year-old woman presented with severe ectopic CS and a 15-cm hepatic metastatic conglomerate. Liver biopsy showed NET of unknown primary. Treatment with subcutaneous octreotide and metyrapone (total daily dose 3000mg) resulted in modest improvement of serum cortisol from 89.8 to 45.8 mcg/dL. She was not a candidate for bilateral adrenalectomy or hepatectomy due to bulky hepatic metastases and subsequently underwent bland embolization to the hepatic conglomerate. Cortisol decreased from 63.9 mcg/dL to 13.8 mcg/dL after the initial procedure, but then rebounded to 35.8 mcg/dL. Serum cortisol decreased to 19.4 mcg/dL following additional embolization, and she was discharged on metyrapone 500mg three times daily. CS remained controlled 12 weeks after the procedure. Interval imaging showed a decrease in size of the dominant hepatic mass (9.7 cm). The patient is currently undergoing chemotherapy with carboplatin and etoposide. Case 2: A 40-year-old man presented to an outside institution with CS due to a 6.9 cm right adrenal mass and underwent adrenalectomy. Pathology showed oncocytic neoplasm of uncertain malignant potential. A year later, he presented to our hospital with recurrent CS and was found to have a 10.2 cm liver lesion, confirming stage IV adrenocortical carcinoma. FDG PET/CT did not show additional lesions. He was treated with osilodrostat and mitotane but his hypercortisolism remained uncontrolled. Mitotane was discontinued after a few doses due to side effects. Metastasectomy was attempted but halted due to extensive peritoneal carcinomatosis noted in the operating room. He was subsequently treated with Y-90 radioembolization to the liver metastasis. Afterwards, osilodrostat was held and serum cortisol decreased from 49.6 to 6.9 mcg/dL on day 14 post-procedure. Hydrocortisone was initiated for treatment of adrenal insufficiency. He received cisplatin, doxorubicin, and etoposide, but stopped after the first cycle due to side effects. Recent imaging showed a decrease in the hepatic lesion to 6.5 cm. Presently, the patient continues to have persistent adrenal insufficiency confirming remission of CS. Conclusion: These cases illustrate the potential efficacy of bland embolization and Y-90 radioembolization for palliative treatment of severe CS in patients with hepatic metastases. Presentation: 6/2/2024

Proximal splenic artery embolization for treatment of refractory ascites, a single-center experience.

Refractory ascites from portal hypertension can be managed with regular large-volume paracentesis (LVP) or transjugular intrahepatic portosystemic shunt (TIPS). Large-volume paracentesis is clinically unsatisfactory and many patients are ineligible or relatively contraindicated for TIPS or Denver shunt. Proximal splenic artery embolization (PSAE) using coils or plugs reduces but does not completely stop splenic arterial inflow, differing from distal splenic artery embolization techniques. By reducing splenic arterial inflow, splenic vein outflow is also decreased, lowering portal pressure and thus treating refractory ascites. In this institutional review board-approved single-center retrospective study, electronic medical records were reviewed to obtain demographics and baseline clinical and laboratory data, paracentesis data before and after PSAE, PSAE procedural details, and follow-up imaging up to 12months post-PSAE. Mixed-effects models were used for statistical analysis. Ten patients with LVP-dependent ascites meeting inclusion criteria underwent PSAE for refractory ascites from 2017 to 2024. Prior to PSAE, four patients had TIPS, three had liver transplants, and the remaining three were neither TIPS nor transplant candidates. In the month before PSAE, patients averaged 3.8±1.7 paracentesis sessions, draining a total of 20.84±10.39L of fluid monthly. Post-PSAE, the number of paracentesis sessions decreased to 2.1±2.7, 1.0±1.7, 0.4±1.1, and 0.0±0.0 at 1, 3, 6, and 12months, respectively (p=0.03). Corresponding ascitic volume drained decreased to 8.7±10.3, 2.7±6.4, 2.0±5.4, and 0.0±0.0L (p=0.01). Over the 12-month follow-up period, 6 of 10 patients became LVP-independent. Proximal splenic artery embolization can improve refractory ascites in certain patients with portal hypertension, thus providing safe and effective treatment as an alternative to TIPS.

Renal embolization for trauma: a narrative review.

Renal injuries commonly occur in association with blunt trauma, especially in the setting of motor vehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imaging modality to assess patients for renal injuries in the setting of blunt and penetrating trauma, and to help classify injuries based on the American Association for the Surgery of Trauma injury scoring scale. The management of renal trauma has evolved in the past several decades, with a notable shift towards a more conservative, nonoperative approach. Advancements in imaging and interventional radiological techniques have enabled diagnostic angiography with angiographic catheter-directed embolization to become a viable option, making it possible to avoid surgical interventions that pose an increased risk of nephrectomy. This review describes the current management of renal trauma, with an emphasis on renal artery embolization techniques.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.

Endovascular treatment of chronic subdural hematoma in a dual-trained neurosurgical unit: Results and proposal of a randomized controlled trial protocol

IntroductionChronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence due to the rising life expectancy and the widespread use of anticoagulant and antiplatelet therapies. Insights into the inflammatory origins of cSDH led to the exploration of Middle Meningeal Artery (MMA) embolization as a therapeutic strategy. In recent years the endovascular treatment of MMA has gained momentum. Herein we present the initial experience of a dual trained neurovascular unit implementing this therapeutic technique. MethodsThis single-center, prospective pilot study aimed to evaluate the feasibility, safety, and efficacy of MMA embolization in the treatment of cSDH. Following ethical approval and informed consent, demographic, clinical, and radiological data were collected. Patients requiring emergent surgical treatment were excluded. The study focused on assessing clinical outcomes, including the Modified Rankin Score (mRS) and volumetric analysis of cSDH, before and after embolization. ResultsFifteen patients underwent MMA embolization, with a predominance of males (80%) and a mean age of 72.4 years. The most common presenting symptom was headache (53.3%). The average hospital stay was 3.9 days. Various embolization techniques were employed, with DMSO-EVOH being the most frequent. All procedures were successfully conducted without complications. Although not statistically significant, trends suggested better outcomes in patients with homogeneous cSDH on the CT scan, displaying the cotton wool sign on angiography and treated with EVOH-DMSO. ConclusionMMA embolization for cSDH demonstrates promise as a safe and effective treatment, potentially reducing the need for surgical intervention and recurrence rates. This study lays the groundwork for a larger, randomized controlled trial which protocol is herein presented.

Basic Setup and Coil Embolization Technique for Ruptured Cerebral Aneurysms

For treating ruptured cerebral aneurysms, it is important to understand the setup and basic technique of coil embolization. Safe and effective embolization relies on preoperative considerations that determine the treatment strategy, guide the optimization of the therapeutic environment, and help in the selection of appropriate device systems. Moreover, during aneurysmal embolization, basic techniques for microcatheter shaping and navigation, safe coil introduction, and precise use of occlusion balloons are indispensable. Microcatheter shaping should be based on three-dimensional digital subtraction angiography findings as well as the axes of the parent artery and aneurysm. The operator must understand the advantages and disadvantages of the two methods for navigating the microcatheter into the aneurysm. Furthermore, it is essential to preoperatively simulate and understand the approaches for managing aneurysmal embolization-related complications, such as intraoperative aneurysmal rupture and thromboembolism. Mastery of these steps is mandatory before undertaking embolization of ruptured cerebral aneurysms.

810. ROBOTIC ASSISTED CISTERNA CHYLI EMBOLIZATION FOR ABDOMINAL CHYLE LEAKAGE AFTER IVOR LEWIS ESOPHAGECTOMY

Abstract Background High output chyle leakage is a challenging complication following esophagectomy, carrying substantial morbidity and even mortality. Initial conservative management with parenteral feeding is commonly advised resulting in lengthy episodes of hospitalization and prolonged chest tube placement. Here, we present a case post Ivor-Lewis esophagectomy with high-output chyle leakage where we localized the leakage site to be at the cysterna chyli and subsequently treated it operatively combining robotics, fluorescence and embolization with glue. Methods A 74-year-old male underwent robotic-assisted minimally invasive Ivor Lewis esophagectomy for distal esophageal adenocarcinoma. Postoperatively, chylous fluid was drained from the chest up to 700-1300cc per day despite parenteral feeding. Lipiodol lymphangiography identified extravasation of contrast at the cysterna chyli and correct clipping of the thoracic duct. Due to failure of conservative management, on postoperative day 14, robotic-assisted exploration of the truncal region with intranodal injection of indocyanine green was performed. Results This innovative procedure revealed the leakage site medially of the coeliac trunc at the cysterna chyli. Lymphatic sealing was achieved via percutaneous endoluminal embolization using a microcatheter and Histoacryl® injections, resulting in an abrupt resolution of the leak and discharge with oral MCT diet on day 5 after reoperation. Conclusion This case demonstrated the feasibility and efficacy of an innovative multimodal technique combining the dexterity and fluorescence of robotic surgery with a laparoscopic application of an interventional radiology embolization technique. Because of the risk of venous emboli, we note that this technique should only be applied in cases of abdominal chyle leakage when the thoracic duct is interrupted. https://www.dropbox.com/scl/fi/sktltdc1be41jfq4dk3lt/Video-Presentation-ISDE-2024-Robotic-Embolisation-Abdominal-Chyle-leakage-Def.mp4?rlkey=1wni1dpnjg4swiajcjdfa6isn&st=wx30jbi7&dl=0

783. ROBOTIC ASSISTED CISTERNA CHYLI EMBOLIZATION FOR ABDOMINAL CHYLE LEAKAGE AFTER IVOR LEWIS ESOPHAGECTOMY

Abstract Background High output chyle leakage is a challenging complication following esophagectomy, carrying substantial morbidity and even mortality. Initial conservative management with parenteral feeding is commonly advised resulting in lengthy episodes of hospitalization and prolonged chest tube placement. Here, we present a case post Ivor-Lewis esophagectomy with high-output chyle leakage where we localized the leakage site to be at the cysterna chyli and subsequently treated it operatively combining robotics, fluorescence and embolization with glue. Methods A 74-year-old male underwent robotic-assisted minimally invasive Ivor Lewis esophagectomy for distal esophageal adenocarcinoma. Postoperatively, chylous fluid was drained from the chest up to 700-1300cc per day despite parenteral feeding. Lipiodol lymphangiography identified extravasation of contrast at the cysterna chyli and correct clipping of the thoracic duct. Due to failure of conservative management, on postoperative day 14, robotic-assisted exploration of the truncal region with intranodal injection of indocyanine green was performed. Results This innovative procedure revealed the leakage site medially of the coeliac trunc at the cysterna chyli. Lymphatic sealing was achieved via percutaneous endoluminal embolization using a microcatheter and Histoacryl® injections, resulting in an abrupt resolution of the leak and discharge with oral MCT diet on day 5 after reoperation. Conclusion This case demonstrated the feasibility and efficacy of an innovative multimodal technique combining the dexterity and fluorescence of robotic surgery with a laparoscopic application of an interventional radiology embolization technique. Because of the risk of venous emboli, we note that this technique should only be applied in cases of abdominal chyle leakage when the thoracic duct is interrupted. https://www.dropbox.com/scl/fi/sktltdc1be41jfq4dk3lt/Video-Presentation-ISDE-2024-Robotic-Embolisation-Abdominal-Chyle-leakage-Def.mp4?rlkey=1wni1dpnjg4swiajcjdfa6isn&st=wx30jbi7&dl=0

Evaluation of the Factors Influencing the Occurrence of Varicocele in Males Aged 15-35 in Mogadishu, Somalia

Testicular varicoceles, a common condition characterized by the dilation and enlargement of veins within the scrotum, are predominantly found in the adolescent and young adult age group. This condition can adversely affect testicular function in various ways, including decreased sperm production, reduced sperm quality, and even testicular atrophy. The prevalence of varicoceles varies across different regions, with estimates ranging from 15-20% in Somalia and other parts of Africa, 10-15% in Asia, and 15-20% in the United States and other parts of America. In the small island nation of Erub, the incidence is relatively lower, at around 5-10% of the male population. The exact etiology of varicoceles is not fully understood, but it is believed to be related to a combination of factors, such as genetic predisposition, anatomical abnormalities, and environmental influences. Certain risk factors, including obesity, sedentary lifestyle, and exposure to high temperatures, have been associated with an increased risk of developing varicoceles. While varicoceles can adversely affect testicular function and fertility, it is important to note that not all individuals with varicoceles experience fertility-related problems. The management of varicoceles often involves a multidisciplinary approach, with close monitoring and periodic evaluation being the recommended approach for asymptomatic individuals. In cases where varicoceles are causing symptoms or affecting fertility, various treatment options, such as surgical repair (varicocelectomy) or percutaneous embolization techniques, may be considered. Understanding the prevalence, etiology, and management strategies of varicoceles is crucial for healthcare professionals to provide appropriate care and support for individuals affected by this condition.

Endovascular Embolization of Intracranial Aneurysms Using Target Tetra Detachable Coils: Angiographic and Clinical Results from a Single Center.

Background/Objectives: Target tetra detachable coils (TTDCs) aid in achieving effective framing during the coil embolization of small intracranial aneurysms by maintaining a tetrahedral conformation within the aneurysm sac. We aimed to report the initial experience of patients treated for intracranial aneurysms using TTDCs, with a specific focus on efficacy and safety. Methods: We retrospectively reviewed the medical records of 41 patients who underwent the coil embolization of intracranial aneurysms sized ≤10 mm with TTDCs between April and May 2023. Post-procedural angiographic and clinical results were reviewed. Results: Of the 46 aneurysms (45 unruptured and 1 ruptured), 33 (71.7%) were treated with the stent-assisted technique and 13 (28.3%) using the simple coil embolization technique. Post-procedural angiography showed complete occlusion in 41 aneurysms (89.1%), neck remnants in 1 (2.2%), and residual aneurysms in 4 (8.7%). The mean packing density was 34.7% (19.3-46.8%), with TTDC coil length comprising a mean of 88.5% of the total coil length. No major device- or procedure-related complications were observed. During the follow-up, 40 aneurysms (93.0%) demonstrated complete occlusion, while neck remnants were observed in 1 (2.3%), and residual aneurysms in 2 (4.7%). No cases of recanalization were observed. Conclusions: The TTDC is a safe and effective device for the endovascular treatment of intracranial aneurysms. Follow-up studies are required to establish long-term results.

Covered stent combined with embolization treatment for complex congenital lower limb arteriovenous malformations: case report and literature review

BackgroundCurrently, the treatment outcomes for complex congenital arteriovenous malformations (AVMs) remain unsatisfactory. This article reports on the utilization of an abdominal aortic stent graft, in conjunction with embolization techniques, for managing acute heart failure triggered by complex congenital arteriovenous malformations in the lower limb.Case PresentationWe present a case involving a patient with congenital AVMs in the lower limb, who had suffered from prolonged swelling in the left lower limb and recently developed symptoms of heart failure. At the age of 67, the patient was definitively diagnosed with a complex congenital AVMs in the lower limb. This article delves into the practical experiences and limitations encountered in employing an abdominal aortic stent graft, coupled with embolization, to address acute heart failure caused by complex congenital AVMs in the lower limb.ConclusionsOur article presents the initial report on the challenges and limitations encountered in treating acute heart failure triggered by complex congenital AVMs in the lower limb, utilizing a combination of abdominal aortic stent graft placement and embolization techniques.

Value of Dual Arterial Access for Improved Angiographic Control for Double-Lumen Arterial Balloon Onyx Embolization of Multifeeder Complex Cranial Dural Arteriovenous Fistulas: A Technical Nuance

Here we describe our experience managing intracranial dural arteriovenous fistulas (DAVFs) via endovascular embolization using a transarterial embolization (TAE) technique with liquid embolic agents. We illustrate the technical nuance of using dual arterial access for angiographic control runs in complex DAVFs supplied by multiple feeders from 2 distinct arterial systems. Retrospective analysis of intracranial DAVF embolization as a single treatment technique at our institution from 2013 to2023. Twenty-three patients with intracranial DAVF who underwent endovascular treatment as their initial treatment were included. All embolizations were approached transarterially with Onyx (n= 19), n-butyl cyanoacrylate (n= 2), or a combination (n= 2). Twenty-two patients (96%) had angiographic evidence of complete fistula obliteration after initial embolization. Six DAVF TAEs were performed with dual arterial access for simultaneous embolic delivery and angiographic control intraoperatively. Two patients recanalized twice postprocedure, 1 of whom was found to have incidental new DAVF at follow-up. Median patient follow-up was 12 months (interquartile range, 6-36 months), with a median modified Rankin Scale score on discharge of 1 and a Glasgow Outcome Scale score at 3 months of5. In this initial series of patients with DAVF managed by endovascular embolization, dual arterial access was feasible, safe, and effective in achieving fistula obliteration. Dual-arterial access conveniently provides simultaneous access for control angiography and embosylate delivery intraoperatively.

Grouting technique-combining transvenous Onyx and coils for the embolization of complex non-cavernous intracranial dural arteriovenous fistulas.

Incomplete occlusion of cerebral dural arteriovenous fistula (DAVF) may lead to fistula recurrence and rebleeding, which may necessitate several embolizations and lead to worse clinical outcomes. Herein, we describe a grouting technique for endovascular embolization and its outcomes in a series of patients with complex intracranial DAVF. A total of 20 patients with aggressive type or symptomatic intracranial non-cavernous DAVF underwent endovascular transvenous embolization combining detachable coils and Onyx. Two microcatheters were positioned either in the distal segment of the involved sinus or near the draining veins. To achieve tight occlusion of the involved sinus, coils were carefully delivered through the first microcatheter, starting from the distal segment and then to the proximal segment. Next, Onyx was injected through the second microcatheter to reinforce and fill (grout) the interspace of coil mass and gradually refluxed to the mural channels and para-sinus cortical veins until the fistula was completely occluded. Successful embolization was achieved in all 20 patients. The initial angiographic results revealed the achievement of complete occlusion in 19 patients (95%). At the postembolization follow-up, complete obliteration of the fistula was achieved in all patients (100%). No symptom or angiographic recurrence was observed at the 2- to 5-year follow-ups. No patient required additional embolization or stereotactic radiosurgery. The proposed grouting technique combining detachable coils and Onyx appears to be promising for the elimination of complex intracranial non-cavernous DAVFs.

Transarterial embolization in Wunderlich syndrome due to recanalization of giant renal angiomyolipoma pseudoaneurysm: a case report and literature review

BackgroundAcute spontaneous bleeding from renal angiomyolipoma (AML) is one of the causes of Wunderlich syndrome, a rare and potentially fatal clinical condition. Clinical deterioration will occur if there is a delay in urgent management. There are several management options for renal angiomyolipoma rupture. However, until now little is known about the case of recanalization from post-coil embolization of renal angiomyolipoma. There is no guideline about embolization technique for the management of recurrent bleeding after embolization or coil recanalization of renal angiomyolipoma.Case presentationA 55-year-old male has Wunderlich syndrome caused by recurrent bleeding of giant AML of the left renal due to coil recanalization compounded by a pseudoaneurysm and other bleeding site in bilateral giant renal angiomyolipoma which is showed by contrast-enhanced abdominal computed tomography scan. The patient underwent urgent transarterial embolization and some blood transfusion. Clinical improvement occurred and the patient discharged several days later.ConclusionsEmbolization for spontaneous bleeding or rebleeding of renal pseudoaneurysms may become the first choice of treatment in bilateral multiple renal angiomyolipoma rather than other managements which are available to preserve renal function.

Antegrade embolization of varicocele with cyanoacrylate glue: a case report

BackgroundVaricocele embolization is an effective, minimally invasive treatment option, with a symptom improvement rate of around 90%. However, anatomical variations and post-embolization recurrences pose challenges to its efficacy. This article discusses the antegrade embolization technique as a viable alternative for cases in which retrograde embolization fails, offering a broader spectrum of treatment options for varicocele.Case presentationThis case report details the treatment of a 27-year-old male with a left varicocele, diagnosed during infertility assessment, using an alternative embolization technique. Despite initial failed attempts at retrograde catheterization via the femoral vein, a direct inguinal puncture of the left testicular vein was successfully performed under ultrasound guidance. A mixture of Glubran® and Lipiodol® was used for embolization, achieving varicocele embolization without complications. The patient was discharged 2 hours post-procedure, with follow-up confirming the procedure’s effectiveness and safety.ConclusionThis article introduces a less invasive, ultrasound-guided technique for varicocele embolization, presenting a viable alternative to surgery when conventional retrograde methods fail.Graphical

Embolization techniques of spontaneous direct carotid-cavernous fistulae: a single-center experience.

Spontaneous direct carotid-cavernous fistula (CCF) are usually caused by a ruptured carotid cavernous aneurysm. We studied treatment of spontaneous direct CCFs in a single-center cohort of a high-volume tertiary referral center, reporting anatomical details, technical approaches of treatment, and outcomes. Adult patients with a spontaneous direct CCF treated between 2010-2022 with follow-up MRI and/or DSA imaging available were retrospectively analyzed. We studied age, sex, clinical presentation, angiographic findings, treatment techniques, outcomes, and complications. Out of 80 patients with CCFs, twelve patients were treated for a non-traumatic direct CCF (15%) in 13 sessions. Median age was 65years. Two patients had an underlying connective tissue disorder. In 10 cases, the direct CCF was caused by a ruptured cavernous carotid aneurysm. The direct CCFs were treated by endovascular transarterial embolization (10 cases), transvenous embolization (1 case), or surgery (1 case). Selective closure of the shunt was possible in 10 patients. Two patients were treated with parent vessel occlusion (PVO; one endovascular; one surgical, with bypass). Complications occurred in 2 / 12 patients (17%), with permanent morbidity in two patients (17%): trigeminal neuralgia after PVO and new infarct after surgical PVO and bypass. Selective closure of CCF resulted in no morbidity. There was no mortality in our series. Spontaneous direct CCFs are caused by rupture of a cavernous carotid aneurysm in most cases. Selective closure of the shunt, usually feasible transarterially with coils, achieves good results. Reconstructive endovascular techniques are preferred to minimize treatment related neurological complications.