Emergent Transcatheter Arterial Embolization Research Articles

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2.

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia. To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia. Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed. Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications. NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Intrahepatic cholangiocarcinoma with a tumor thrombus extending from the inferior vena cava to the right atrium: a case report

BackgroundVascular invasion involving a tumor thrombus in the inferior vena cava and/or right atrium is an unfavorable prognostic factor after intrahepatic cholangiocarcinoma resection. We report an intrahepatic cholangiocarcinoma case with a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium.Case presentationA 58-year-old man with epigastralgia was referred to our hospital after an emergent transcatheter arterial embolization was done following the radiological diagnosis of a ruptured hepatic tumor. The serum concentrations of carcinoembryonic antigen, carbohydrate 19-9, duke pancreatic monoclonal antigen type 2, and cytokeratin-19 fragments were elevated; meanwhile those of alfa-fetoprotein and des-γ-carboxy prothrombin were within normal ranges. A contrast-enhanced computed tomography scan showed a heterogeneously enhanced tumor, 13 cm in diameter, in the left lobe of the liver, enlarged lymph nodes along the lesser curvature of the stomach, and a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. We performed a left hemihepatectomy and tumor thrombectomy under total hepatic vascular exclusion to reduce the risk of sudden death. After dissection of the liver parenchyma along the left side of the middle hepatic vein, except for the left hepatic vein, the inferior vena cava just below the right atrium could be clamped by pulling down the left lobe of the liver toward the caudal side. The thrombus could be removed by incising the inferior vena cava under total hepatic vascular exclusion. Microscopic examination showed a tubular adenocarcinoma. Immunohistochemical staining was positive for cytokeratin-7, cytokeratin-19, and epithelial membrane antigen, but negative for arginase-1, glypican-3, and hepatocyte. The patient was pathologically diagnosed with an intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava. Adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered for 1 year. The patient remained in good health without cancer recurrence for over 4 years after the operation.ConclusionAn aggressive surgical approach may be indicated for intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava and/or right atrium to avoid the risk of impending death.

Successful treatment for intra-abdominal bleeding due to spontaneous rupture of huge liver cyst using transcatheter arterial embolization: a case report

Background: Non-parasitic simple liver cysts are one of the most common benign hepatic lesions. Although most liver cysts are asymptomatic and remain silent throughout the patient’s life, extremely large cysts can become symptomatic by direct compression to adjacent organs. Herein, we report a case of a spontaneously ruptured simple liver cyst, which is a rare presentation of a benign liver cyst. The patient’s liver cyst re-ruptured and was treated with transcatheter arterial embolization (TAE). Case report: A 62-year-old man presented to our hospital complaining of acute-onset lower abdominal pain. He had undergone laparoscopic fenestration of a huge liver cyst in another hospital 2 years prior. Computed tomography (CT) scan showed spontaneous rupture of a large liver cyst. Laparoscopic exploratory laparotomy showed no signs of ongoing intra-abdominal bleeding from the liver cyst; therefore, the operation was completed with peritoneal lavage. The patient was discharged from our hospital on postoperative day 5. Twelve days after the initial presentation, the patient was re-admitted to our hospital complaining of recurrence of lower abdominal pain. CT scan showed an enlargement of the previously ruptured liver cyst, with intra-abdominal bleeding and massive hematoma in the cyst. Extravasation of the cyst’s wall was also detected. Under the diagnosis of intra-abdominal bleeding from the artery in the wall of the huge cyst, emergent TAE was performed. Although the exact spot of extravasation was not detected, the anterior segment branch of the right hepatic artery, which corresponds to extravasation shown on the CT scan, was embolized. The patient was discharged from our hospital after 7 days, and the liver cyst remained stable without abdominal pain for more than 2 months. Conclusions: This case highlights a rare presentation of spontaneous rupture of a liver cyst with massive bleeding and the efficacy of TAE for the conservative treatment of ruptured liver cysts.

Emergent Transcatheter Arterial Embolization via a Transpopliteal Approach for Internal Iliac Artery Injury during Lumbar Disk Surgery in the Prone Position.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

Management of Bleeding from Unresectable Gastric Cancer.

Bleeding from unresectable gastric cancer (URGC) is not a rare complication. Two major ways in which the management of this issue differs from the management of benign lesions are the high rate of rebleeding after successful hemostasis and that not only endoscopic therapy (ET) and transcatheter arterial embolization (TAE) but palliative radiotherapy (PRT) can be applied in the clinical setting. However, there are no specific guidelines concerning the management of URGC with bleeding. We herein discuss strategies for managing bleeding from URGC. A high rate of initial hemostasis for active bleeding is expected when using various ET modalities properly. If ET fails in patients with hemostatic instability, emergent TAE is considered in order to avoid a life-threating condition due to massive bleeding. Early PRT, especially, regimens with a high biologically effective dose (BED) of ≥39 Gy should be considered not only for patients with hemostatic failure but also for those with successful hemostasis and inactive hemorrhage, as longer duration of response with few complications can be expected. Further prospective, comparative studies considering not only the hemostatic efficacy of these modalities but the patients’ quality of life are needed in order to establish treatment strategies for bleeding from URGC.

Efficacy of Automated Supplying Artery Tracking Software Using Multidetector-Row Computed Tomography Images for Emergent Transcatheter Arterial Embolization.

To assess the reliability of a prototype automated supplying artery tracking software (ASATS) using multidetector-row CT (MDCT) images in emergent TAE. Consecutive 53 patients underwent 57 sessions of emergent TAE during 7months. Twenty-one cases were excluded due to a lack of CT data (n = 12) or negative angiographic findings (n = 9). Remaining 34 sessions of TAE and MDCT images in 32 patients (mean age 62.9years; age range 37-92years) were enrolled. ASATS was retrospectively conducted for the identification of supplying arteries which were confirmed with angiography (automated method). Manual modification was added as needed (semi-automated method). Two observers independently reviewed the MDCT images to detect supplying arteries (manual method). Detectability of supplying artery and time to analysis were compared among the automated, semi-automated, and manual methods by both observers. A total of 64 bleeding sites were demonstrated on angiography. The detectability was 28 (43.8%) for automated method, 53 (82.8%) for semi-automated method, 55 (85.9%) for observer 1, and 58 (90.6%) for observer 2. Detectability of semi-automated method was significantly better than of automated method (P = 0.000) and comparable with manual method by both observers (P = 0.193 and 0.081). Average time to analysis was 185.4s for automated method, 297.2s for semi-automated method, 186.2s for observer 1, and 243.7s for observer 2. ASATS has a sufficient ability to identify supplying arteries of bleeding by adding manual modification as needed and can be used for emergent TAE. Level 4, Case Control Study.

Is Emergency Transcatheter Hepatic Arterial Embolization Suitable for Spontaneously Ruptured Hepatocellular Carcinoma in Child–Pugh C Cirrhosis?

PurposeTo evaluate the utility of emergent transcatheter arterial embolization for spontaneously ruptured hepatocellular carcinoma (HCC) in patients with Child–Pugh class C (CPC) liver cirrhosis presenting hemorrhagic shock. Materials and MethodsA study of all 94 patients was retrospectively conducted from January 2006 to January 2016. Sixty patients underwent conservative treatment (control group) and 34 underwent embolization. ResultsEmbolization provided better stabilization of hemodynamic status than conservative treatment (91.2% vs 61.7%), with greater overall survival (OS) rates at 30, 60, and 120 days (73.5%, 52.9%, and 29.4% vs 33.3%, 13.3%, and 0%, respectively). Mean follow-up duration was 51.07 days (range, 3–237 d). Median survival time was longer for the embolization group than the control group, specifically for patients with a shock index (SI) of ≥ 0.6 to < 1 (106.0 d ± 39.4 vs 34.0 d ± 4.7) or ≥ 1 (18.0 d ± 7.5 vs 11.0 d ± 3.2), those with CPC scores 10 or 11 (88.0 d ± 29.4 vs 28.0 d ± 4.5), and those with segmental (165.0 d ± 20.6 vs 34.0 d ± 9.7) or lobar (54.0 d ± 7.9 vs 26.0 d ± 3.4) portal vein tumor thrombus (PVTT). SI ≥ 1, Child–Pugh score of 12/13, tumor size ≥ 10 cm, and PVTT were independent factors in poor prognosis for OS. ConclusionsEmergent transcatheter arterial embolization is an effective intervention for ruptured HCC in patients with CPC liver function in hemorrhagic shock, particularly those with a SI ≥ 1, Child–Pugh scores of 10/11, and first- or lower-order PVTT.

Primary hepatic angiosarcoma and potential treatment options

Angiosarcomas account for a mere 2-3% of adult soft tissue sarcomas, with an overall poor outcome. Depending on the primary site, angiosarcomas have distinct prognosis. Primary hepatic angiosarcomas (PHAs) are much rare tumors, with worse prognosis compared with other angiosarcomas. PHA is reported to be associated with vinyl chloride, but the majority of patients were still with unknown etiology. As PHA lacks specific symptoms, signs, or images, pathological diagnosis is necessary. The review summarizes 25 articles published from January 2000 to December 2012, including 64 cases of PHA with detailed information. Survival curves are estimated using the Kaplan-Meier method by SPSS 21.0. We find that the median survival time is 5 months; local excision alone or combination with adjuvant therapy is the optimal choice, with median survival time of 17 months. In addition, liver transplant is abandoned for high recurrence rate; emergent transcatheter arterial embolization is thought to be an efficient method for controlling intra-abdominal bleeding; and transcatheter arterial chemoembolization and chemotherapy may be helpful in improving survival.

Coil Migration Following Transcatheter Arterial Embolization

A 69-year-old man presented with hypovolemic shock caused by massive gastrointestinal bleeding. Angiography revealed active bleeding in a branch of the gastroduodenal artery (Picture 1a). The patient underwent emergent transcatheter arterial embolization (TAE), and angiography confirmed complete occlusion due to bleeding (Picture 1b). The patient’s condition rapidly stabilized; however, esophagogastroduodenoscopy performed seven days after TAE showed the presence of duodenal ulcers and a metal material impacted in the duodenal surface (Picture 2). Coil migration was highly suspected. We prescribed conservative management, and the patient was discharged after an uneventful hospital stay. No more bleeding episodes or additional sequelae were observed over the following months. The standard treatment for upper gastrointestinal bleeding

The Natural History of a Hepatic Angiosarcoma that was Difficult to Differentiate from Cavernous Hemangioma

A 69-year old man came to our hospital complaining of abdominal pain. Contrast-enhanced computed tomography (CT) showed a 65-mm ruptured mass in Couinaud segment 5 of the liver. The mass was treated with emergent transcatheter arterial embolization (TAE), followed by partial hepatectomy. Microscopically, the mass was determined to be an angiosarcoma. Six months previously, enhanced CT had shown a 15-mm mass diagnosed as a cavernous hemangioma in the same region of the liver. Even when the enhancement pattern of a small hepatic mass resembles that of hemangioma, the mass should be reassessed within several months to exclude a diagnosis of hepatic angiosarcoma.

Primary hepatic angiosarcoma: imaging findings and palliative treatment with transcatheter arterial chemoembolization or embolization

To describe the image findings and results of transcatheter arterial chemoembolization (TACE) or transcatheter arterial embolization (TAE) for treating primary hepatic angiosarcoma. A retrospective review of the electronic medical database from 2002 to 2007, revealed six patients with primary hepatic angiosarcoma confirmed by percutaneous liver biopsy. The computed tomography (CT) and angiography imaging findings, the TACE or TAE results, and the post-procedure course were evaluated in all patients. On CT and angiography, each tumour appeared as a solitary mass or as multiple nodules or masses with heterogeneously early and progressive enhancement. One of the two patients with tumour response to TACE died 8 months after initial presentation, and the remaining patient was still alive at the last follow-up 12 months after initial presentation. However, two patients with no response to TACE and two patients who underwent emergent TAE for tumour rupture died 1 week to 5 months (mean 2.1 months) after initial presentation. Primary hepatic angiosarcoma appears as a solitary or multiple, hypervascular lesions with heterogeneously early and progressive enhancement on CT and angiography. Although TAE may be the primary procedure for achieving emergent bleeding control caused by the rupture of hepatic angiosarcomas, TACE may be effective for treating patients with a dominant hepatic angiosarcoma with or without intrahepatic metastases.

Placental polyp with prominent neovascularization

Placental polyp is a potentially life-threatening disorder that develops after abortion or parturition. Evaluation of neovascularization by multimodal imaging is potentially useful in management of placental polyp in a woman who wishes to preserve fertility.

Emergent Transcatheter Arterial Embolization in Hemodynamically Unstable Patients With Blunt Splenic Injury

Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Emergency department presentation of spontaneous rupture of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is common in areas with endemic viral hepatitis B or C. The incidence of spontaneous rupture of HCC is about 10% (1–3). Sponteneous rupture of HCC is a true life-threatening emergency condition in which patients present with abdominal pain, abdominal distention, and hypovolemic shock. It may occur as a terminal event in patients with advanced disease or may present in an otherwise healthy individual (4). Variations in clinical presentation pose a challenge to the clinician in view of the need for rapid diagnosis and management. In the case presented here, the patient considered himself to be active and in good health and was unaware of having the serious illness, HCC. The patient presented to our Emergency Department (ED) in hypovolemic shock requiring immediate resuscitation and, later, emergent transcatheter arterial embolization (TAE).

ANALYSIS OF SPONTANEOUS RUPTURE OF HEPATOCELLULAR CARCINOMA WITH SPECIAL REFERENCE TO SPONTANEOUS HEMOSTASIS

There are many reports describing that spontaneous rupture of hepatocellular carcinoma necessitated emergency treatment as acute abdomen. However, we obtained interesting and specific findings as a mechanism of spontaneous hemostasis of the ruptured carcinoma when operation was performed after spontaneous hemostasis. Ten cases of spontaneous rupture of hepatocellular carcinoma, experienced at Iwakuni National Hospital from January 1981 to December 1991, were divided into 3 groups; the conservative therapy group (group I), emergent transcatheter arterial embolization group (group II) and operative group followed by spontaneous hemostasis (group III). The diagnostic methods included the confirmation of bleeding by abdominal puncture, autopsy and/or imaging diagnosis. The condition of group III was better than group I and group II in the hepatic functional reserve and general status. The operative finding showed that the perforated portions of the carcinoma were covered with surrouding tissues such as the greater omentum, diaphragm and lesser omentum. We think that bleeding is stopped in some cases of group II without the emergent transcatheter arterial embolization. It might be premature determination that emergent transcatheter arterial embolization contributed to the hemostasis in all cases.

Ruptured Hepatoma Managed as Embolization Followed by Hepatic Resection

Two cases with ruptured hepatocellular carcinoma are presented. Emergent transcatheter arterial embolization (TAE) was performed and the intraperitoneal hemorrhage was successfully controlled. The liver damage sustained at TAE continued for around 1 month and the hepatectomy was carried out after a sufficient recovery of the hepatic reserve (21 and 35 days after TAE, respectively). It should be emphasized that successful treatment of ruptured hepatoma is achieved with early diagnosis, cessation of bleeding with TAE and hepatectomy under good conditions.