Failure Of Embolization Research Articles

Open Microsurgical Cerebral Aneurysm Treatment After Failed Endovascular Therapy: An Evaluation of Aneurysm Treatment Frequencies in All Neurovascular Centers Across Austria and the Czech Republic Over 20 Years.

Endovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization. All 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included. On average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%. Open surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.

Role of Laparoscopy in Treatment of Uterine Arteriovenous Malformation after Failure of Uterine Arteries Embolization

Role of Laparoscopy in Treatment of Uterine Arteriovenous Malformation after Failure of Uterine Arteries Embolization

Predictive factors of selective transarterial embolization failure in acute renal bleeding: a single-center experience.

Transarterial embolization of renal artery branches (RTE) is a minimally invasive procedure commonly performed in life-threatening renal bleeding of different etiologies. Despite the widespread use of RTE, no consensus guidelines are currently available. Our aim was to investigate clinical and technical efficacy and to identify potential predictors for clinical failure of this procedure. All the RTE procedures performed in our Interventional Radiology unit in last 10years were retrospectively collected and analyzed. All selected patients underwent both pre-procedural computed tomography angiography (CTA) and post-procedural CTA within 30days. Clinical success was considered as primary endpoint. Demographic, laboratory, and diagnostic findings predictive of clinical failure of RTE were identified. Over a total of 51 patients enrolled, 27 (53%) were females and 33 (64.7%) had a renal bleeding of iatrogenic origin. Technical and clinical success was 100% and 80.4%, respectively. Hematoma volumes > 258.5 cm3 measured at CTA, higher pre- and post-procedural serum creatinine (Scr) levels, an increase in Scr value > 0.135mg/dl after the procedure, a worse post-procedural estimated glomerular filtration rate (eGFR), a post-procedural reduction of eGFR < 3.350ml/min, and a post-procedural reduction of platelet count (PLT) > 46.50 × 103/mmc showed a significantly higher rate of clinical failure. RTE is a safe and effective procedure in the management of acute renal bleeding of various origins. Hematoma volume, Scr, PLT, and eGFR values were found to be predictive factors of poor clinical outcome and should be closely monitored.

Preventive Proximal Splenic Artery Embolization for High-Grade AAST-OIS Adult Spleen Trauma without Vascular Anomaly on the Initial CT Scan: Technical Aspect, Safety, and Efficacy-An Ancillary Study.

The spleen is the most commonly injured organ in blunt abdominal trauma. Its management depends on hemodynamic stability. According to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS ≥ 3), stable patients with high-grade splenic injuries may benefit from preventive proximal splenic artery embolization (PPSAE). This ancillary study, using the SPLASH multicenter randomized prospective cohort, evaluated the feasibility, safety, and efficacy of PPSAE in patients with high-grade blunt splenic trauma without vascular anomaly on the initial CT scan. All patients included were over 18 years old, had high-grade splenic trauma (≥AAST-OIS 3 + hemoperitoneum) without vascular anomaly on the initial CT scan, received PPSAE, and had a CT scan at one month. Technical aspects, efficacy, and one-month splenic salvage were studied. Fifty-seven patients were reviewed. Technical efficacy was 94% with only four proximal embolization failures due to distal coil migration. Six patients (10.5%) underwent combined embolization (distal + proximal) due to active bleeding or focal arterial anomaly discovered during embolization. The mean procedure time was 56.5 min (SD = 38.1 min). Embolization was performed with an Amplatzer™ vascular plug in 28 patients (49.1%), a Penumbra occlusion device in 18 patients (31.6%), and microcoils in 11 patients (19.3%). There were two hematomas (3.5%) at the puncture site without clinical consequences. There were no rescue splenectomies. Two patients were re-embolized, one on Day 6 for an active leak and one on Day 30 for a secondary aneurysm. Primary clinical efficacy was, therefore, 96%. There were no splenic abscesses or pancreatic necroses. The splenic salvage rate on Day 30 was 94%, while only three patients (5.2%) had less than 50% vascularized splenic parenchyma. PPSAE is a rapid, efficient, and safe procedure that can prevent splenectomy in high-grade spleen trauma (AAST-OIS) ≥ 3 with high splenic salvage rates.

Superselective renal arterial embolization for severe postpercutaneous nephrolithotomy haemorrhage: clinical characteristics and risk factors for initial failure.

To identify the clinical characteristics of patients who underwent superselective renal arterial embolization (SRAE) after percutaneous nephrolithotomy (PCNL) and to explore the risk factors for failed initial SRAE after PCNL. Patients who underwent SRAE for severe haemorrhage following PCNL between January 2014 and December 2020 were included in the study. The clinical data of those patients and the parameters and characteristics of the perioperative PCNL and SRAE procedures were collected and analysed. A total of 243 patients were included in this study. A total of 139 patients (57.2%) had a pseudoaneurysm, 25 (10.3%) had an arteriovenous fistula, 50 (20.6%) patients had both a pseudoaneurysm and an arteriovenous fistula, and 29 (11.9%) had an arterial laceration. In 177 patients with single percutaneous access, 125 (70.6%) patients exhibited nontract haemorrhage, and 55 (31.1%) patients exhibited multiple bleeding sites. In 66 patients with multiple percutaneous access, 44 (66.7%) patients exhibited nontract haemorrhage, and 32 (48.5%) patients exhibited multiple bleeding sites. The decrease in Hb before SRAE was 41.4 ± 19.8g/L. The mean time between PCNL surgery and initial SRAE was 6.4 ± 4.9days. Serum creatinine was increased after the SRAE procedure. Initial SRAE was successful in 229 (94.2%) patients and failed in 14 (5.8%) patients. Multivariate regression demonstrated that hydronephrosis < 20mm, total ultrasonographic guidance, solitary kidney, previous ipsilateral renal surgery, PCNL duration > 90min and multiple bleeding sites were potential risk factors for initial embolization failure. Percutaneous access was not the most important reason for post-PCNL severe haemorrhage. SRAE is effective for the treatment of severe haemorrhage following PCNL; however, several factors have an impact on the success of initial SRAE. Additionally, the SRAE procedure may affect renal function.

Abstract Number ‐ 102: Middle Meningeal Artery Embolization Failure Profile: A Single Institution Retrospective Study

Introduction Middle Meningeal Artery (MMA) embolization has emerged as a qualitative treatment option for subdural hematomas (SDH). Multiple studies have compared MMA embolization to other alternatives, namely surgery, and conservative treatment, with some indicating that MMA embolization was as effective and safe as the other two options. This study aimed to identify predictors of failures in SDH patients undergoing an MMA embolization. Methods We retrospectively reviewed 52 patients receiving MMA embolization for subdural hematoma management at our institution from 2020 until July 5, 2022 either as primary or adjunctive management. Patients who were under the age of 18 were excluded. Our definition of failure was any MMA embolization requiring an additional surgical procedure to evacuate the hematoma or relieve persistent symptoms. Results 52 patients with mean age of 71±14 and male gender 36 (69.2%) were reviewed. Most common presenting symptom was headache27 (51.9%) followed by gait instability22 (42.3%).35 out of 52 patients underwent MMA embolization as primary management of chronic subdural hematoma without prior surgical treatment. Six out of the 35 patients (17.1%) required a rescue surgical treatment due to increased hematoma size or recurrence of symptoms. Our early trend shows that half of the patients whose MMA embolization failed had a possible onset of SDH between 2 to 4 weeks prior the embolization. This trend is similar to Khorasanizadeh et al. description in which they concluded that late‐stage SDH was more predicated to have a failure of MMA embolization compared to early‐stage SDH (1). Of the remaining three patients, one was diagnosed with metastatic prostate cancer to the bones and kidney. This patient passed away 12 days after the procedure despite a craniotomy post‐embolization. Conclusions More clinical trials are needed to further establish MMA embolization as standard of care in the management of cSDH in a subset profile of patients with higher success rates.

Failure of Coil Embolization in Secondary Postpartum Hemorrhage: A Case Report

Failure of Coil Embolization in Secondary Postpartum Hemorrhage: A Case Report

Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma.

Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.

ALPPS for Left Trisectionectomy with Reconstruction of the Hepato-caval Junction Using a Peritoneal Patch Under Total Vascular Exclusion.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may rescue remnant liver hypertrophy after failure of portal vein embolization (PVE).1 Venous reconstruction is unusual during the first step of ALPPS.2 We report herein an ALPPS for colorectal liver metastases with reconstruction of the hepato-caval junction during the first step. After failure of left PVE, a total ALPPS procedure was performed to achieve left trisectionectomy. A complete transection of the parenchyma was done to avoid extensive dissection during the second step in the context of the venous reconstruction. Total vascular exclusion (TVE) was applied selectively during venous reconstruction using a peritoneal patch.3 RESULTS: The first step lasted 285 min with 200 ml of blood loss, and 29 min of TVE. On postoperative day (POD) 5 there was a good recovery of liver function [prothrombin time 75%; bilirubin 25 µmol/L]. On POD 14, imaging showed an increase of the future remnant liver volume and function to 50% and 48%, respectively. The second step of ALPPS lasted 120 min, with transfusion of one unit of blood, allowing resection of seven liver metastases. Postoperative course experienced a biliary fistula, the patient was discharged on POD 31 and received adjuvant chemotherapy. There was recurrence of one liver metastasis, treated by percutaneous ablation before later resection of the primary. The patient was free of recurrence 12 months after ALPPS. Hepato-caval junction reconstruction can be performed during the first step of an ALPPS procedure, facilitated by the availability of a peritoneum patch.

Endovascular repair for iliac artery aneurysms

• Association between aortic dilation and neck size was observed • Radiological analysis revealed type 2 endoleak as dilatation cause in all cases • Several postoperative aneurysm dilatation cases required various preventive measures This study aimed to retrospectively determine the association between aortic dilatation and common iliac artery neck size. Consecutive patients who had undergone elective endovascular aneurysm repair for iliac artery aneurysms (IAAs) from January 2009 to December 2017 were evaluated. Aneurysm dilatations >3 mm were observed in five cases; two cases were LAND+ and three cases were LAND−. Radiological analysis revealed that type 1 and type 2 endoleaks caused dilatations in all cases. In LAND+ cases, endoleaks occurred due to blood inflow from the distal side of the aneurysm due to coil embolization failure, whereas in LAND− cases, endoleaks occurred due to retrograde inflow from the distal side of the internal iliac artery (IIA) and antegrade inflow from the lumbar artery. Decreased IAA diameters were significantly more common in the LAND+ group than in the LAND− group. Endoleaks are the major cause of postoperative dilatation in IAA. The neck size of the common iliac artery was determined to be a crucial factor contributing to postoperative dilation of IAA. Radiological analysis revealed that the endoleaks in the IIA and lumbar artery were responsible for dilatation in all cases. When the portion of the common iliac artery from the terminal aorta to the IAA was <16 mm in diameter, postoperative aneurysms decreased.

Dural arteriovenous fistula of the craniocervical junction along the first cervical nerve: A single-center experience and review of the literature

BackgroundDural arteriovenous fistulas (DAVFs) of the craniocervical junction (CCJ) are relative rare lesions. Most studies of DAVFs of the CCJ included the fistulas at the foramen magnum, first cervical (C1), and second cervical (C2) level. DAVFs of the CCJ along C1 spinal nerve are rare vascular lesions with distinctive features. Our aim is to review cases of DAVFs of the CCJ along C1 spinal nerve at our institution. MethodsFrom June 2008 and December 2021. We reviewed a consecutive series of intracranial and spinal DAVFs at our institution and collected all patients harboring DAVFs of the CCJ along C1 spinal nerve. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, treatment methods, and neurological outcome and complications after treatment. All image studies, including cranial computed tomography (CT) scan, cervical magnetic resonance imaging, CT angiography, and digital subtraction angiography (DSA) with rotational CT angiography were analyzed by experienced neuroradiologists. The authors also review of the literature of DAVFs of the C1 spinal nerve. ResultsThe authors identified 7 patients, including 5 men (71.4 %) and 2 women (28.6 %) with median age 54 years, range 48–72 years. Subarachnoid hemorrhage (SAH) occurred in 5 (71.4 %) patients, and progressive myelopathy in 2 (28.6 %). All fistulas except one received blood supply from the radiculomeningeal branch of the VA at C1 level. Venous aneurysms, being the source of bleeding, were detected in all fistulas with SAH. All patients except one were treated by surgical management. One fistula was treated by balloon-assisted Onyx embolization. Most patients had good neurological outcome following surgery. Complete obliteration of all fistulas treated by surgery was confirmed by follow-up DSA obtained 1 week after surgery. Two patients developed temporary pain and spasm of the trapezius muscle after the surgery. One patient resulted in poor neurological outcome and died due to sepsis and acute upper gastrointestinal bleeding one month after failed embolization. For patients with SAH, only one patient required ventriculoperitoneal shunt. ConclusionsDAVFs of the CCJ along the first spinal nerve are rare and a unique subtype of DAVFs at the CCJ. These fistulas account for 1.74 % of all intracranial and spinal DAVFs in the present study. SAH is the major manifestation of DAVFs at C1 spinal nerve that may be overlooked on routine initial DSA. Rotational CT angiography is useful for clarification of the angioarchitecture of these fistulas, including small feeding artery and venous varix. Surgical treatment by interruption of the intradural draining vein should be the treatment of choice for C1 spinal nerve DAVF

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection.

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.

Risk Factors Associated with Clinical Failure of Uterine Artery Embolization for Postpartum Hemorrhage

PurposeTo identify risk factors for clinical failure of uterine artery embolization (UAE) for postpartum hemorrhage (PPH), with particular attention to the uterine artery diameter. Materials and MethodsThis retrospective study included 47 patients who underwent UAE for PPH between January 1, 2010, and January 31, 2021. Technical success was defined as the completion of embolization of the arteries thought to be the cause of the bleeding. Clinical success was defined as no recurrent bleeding or need for additional therapeutic interventions. Univariate and multivariate analyses were performed to examine the risk factors associated with clinical failure of UAE. ResultsOf the 47 patients, 6 had recurrent bleeding. Of the 6 patients, 4 underwent hysterectomy, and 2 underwent repeat embolization. The clinical success rate was 87.2% (41/47), with no major adverse events such as uterine infarction or death. In univariate analysis, there were slight differences in multiparity (P = .115) and placental abruption (P = .128) and a significant difference in the findings of a narrow uterine artery on digital subtraction angiography (DSA) (P = .005). In multivariate analysis, only a narrow uterine artery on DSA was a significant factor (odds ratio, 18.5; 95% confidence interval, 2.5–134.8; P = .004). ConclusionsA narrow uterine artery on DSA was a risk factor for clinically unsuccessful UAE for PPH. It may be prudent to conclude the procedure only after it is ensured that vasospasm has been relieved.

Feasibility of Neovessel Embolization in a Large Animal Model of Tendinopathy: Safety and Efficacy of Various Embolization Agents.

Targeting neovessels in chronic tendinopathies has emerged as a new therapeutic approach and several embolization agents have been reported. The aim of this study was to investigate the feasibility of embolization with different agents in a porcine model of patellar tendinopathy and evaluate their safety and efficacy. Eight 3-month-old male piglets underwent percutaneous injection of collagenase type I to induce patellar tendinopathies (n = 16 tendons). They were divided into four groups (2 piglets, 4 tendons/group): the control group, 50–100 µm microspheres group, 100–300 µm microspheres group, and the Imipenem/Cilastatin (IMP/CS) group. Angiography and embolization were performed for each patellar tendon on day 7 (D7). The neovessels were evaluated visually with an angiography on day 14. The pathological analysis assessed the efficacy (Bonar score, number of neovessels/mm2) and safety (off-target persistent cutaneous ischemic modifications and presence of off-target embolization agents). The technical success was 92%, with a failed embolization for one tendon due to an arterial dissection. Neoangiogenesis was significantly less important in the embolized groups compared to the control group angiographies (p = 0.04) but not with respect to histology (Bonar score p = 0.15, neovessels p = 0.07). Off-target cutaneous embolization was more frequently depicted in the histology of the 50–100 µm microspheres group (p = 0.02). Embolization of this animal model with induced patellar tendinopathy was technically feasible with different agents and allowed assessing the safety and efficacy of neovessel destruction. Particles smaller than 100 µm seemed to be associated with more complications.

Can Empirical Segmental Angioembolization of Splenic Artery Salvage Pancreatic Intraluminal Bleed?

Background Postpancreatectomy hemorrhage (PPH) and Hemosuccus Pancreaticus (HP) may present with slow but significant intraluminal bleed which may not be evident on imaging. We evaluated the efficacy of empirical segmental-angioembolization of splenic artery in intraluminal PPH and HP. Result This is a cross-sectional study done by analyzing all consecutive patients with PPH and HP who underwent empirical coil embolization of splenic artery. There were total of 137 pancreaticoduodenectomies (PD), 68 distal pancreatectomies (DP), 11 patients with median pancreatectomies (MP) and 134 admissions for acute pancreatitis and exacerbation of chronic pancreatitis during the study period. Eleven (5.1%) patients had PPH, of which two were managed surgically. Among nine patients, 4/9 (44.4%) with pseudoaneurysm on computed tomography angiography (CTA) were excluded. Among pancreatitis, 7 (5.2%) had HP, and 5/7 (71.4%) patients with pseudoaneurysm on CTA were excluded. Hence, seven patients, PPH—5 and HP—2, were included. Both HP patients were managed successfully with empirical segmental coil embolization of splenic artery. Among PPH, one patient required laparotomy for failed embolization. Overall, 6/7 (85.7%) had successful coil embolization. No reintervention, continued bleed, or blood transfusions were required postprocedure, and no splenic infarct or abscess was seen in any of the seven patients postembolization. The 72-hour rebleed rate was 1/7 (14.3%), which was managed surgically. Conclusion Empirical segmental coil embolization of splenic artery in intraluminal pancreatic bleed holds promise as a salvage life-saving procedure even when no blush or pseudoaneurysm is evident.

Massive hemoptysis treated with embolization of an ectopic bronchial artery arising from the right thyrocervical trunk: a case report

BackgroundEctopic bronchial artery and non-bronchial systemic arteries may be the culprit vessels of hemoptysis. The main cause of clinical failure of bronchial artery embolization is incomplete embolization caused by the misidentification of the culprit arteries by conventional angiography. Multidetector computed tomography angiography is useful for visualizing the culprit arteries.Case presentationAn 82-year-old man was admitted with hemoptysis. Preprocedural multidetector computed tomography angiography revealed an ectopic bronchial artery branching from the right thyrocervical trunk. Superselective embolization of the ectopic bronchial artery was performed using gelatin sponge particles and metallic coils. Hemoptysis was controlled by this procedure without any associated complications.ConclusionsEctopic bronchial arteries originating from the thyrocervical trunk are rare. Preprocedural multidetector computed tomography angiography is useful for visualizing the culprit arteries of hemoptysis, especially if a patient has an ectopic bronchial artery or an ectopic non-bronchial systemic artery.

Does Size Matter?

Infective endocarditis continues to be a challenging problem for the clinician given the varied clinical presentations, the options for medical management, and the complexities regarding the need for and timing of surgical management. The in-hospital mortality rate for infective endocarditis remains high at 15% to 20% with a 1-year mortality rate approaching 40%. There has been a trend toward earlier surgical management in appropriate candidates. The major reasons for early surgery are heart failure, uncontrolled infection, and prevention of embolization.

Minimally Invasive Approach to Pelvic Arteriovenous Malformation (AVM) Refractory to Embolization

Study Objective To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Design Case report. Setting Single center academic institution. Patients or Participants A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Interventions Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Measurements and Main Results Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. Conclusion In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization. To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Case report. Single center academic institution. A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization.

284 Wunderlich Syndrome - Case Report of a Surgical Emergency Due to Spontaneous Non-Traumatic Retroperitoneal Haemorrhage

Abstract A 42-year-old female with no other significant co-morbidities presented with complaints of sudden onset abdominal pain, she was in state of shock- her haemoglobin dropped drastically to 6.8g/dl from 11.8g/dl. She was resuscitated and was given blood transfusion. CT Scan was suggestive of retroperitoneal haemorrhage due to rupture of Renal angiomyolipoma (RAML). Patient underwent selective embolization of renal artery the next day and was discharged after 3 days of post-operative stay. Wunderlich Syndrome-is a rare condition in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces is most commonly caused due to spontaneous rupture of RAML.It is characterized by Lenk’s triad – Acute flank pain, flank mass, hypovolemic shock. Size of AML (&amp;gt;4 cm), prothrombotic states such as pregnancy are main causes of AML rupture. Patients are managed conservatively or with help of selective arterial embolization. Nephrectomy is last resort in a hemodynamically unstable patient or in cases of embolization failure. When dealing with acute abdomen with haemodynamic instability in non-traumatic cases it is essential to consider possibility of Wunderlich Syndrome. Early diagnosis, availability of Interventional radiology is key to successful management and potentially avoiding a Nephrectomy.

Repeated Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Management: Case Report

Aim: Middle Meningeal Artery (MMA) embolization has emerged as a viable neuroendovascular technique for the management of chronic subdural hematoma (SDH). Comparative analysis of various endovascular techniques for embolization is lacking. Guidance on operative techniques in situations of prior embolization failure is rare. Materials and Methods: In this case report, we present a patient with a chronic subdural hematoma that failed previous coil embolization of the MMA. Digital Subtraction Angiography showed the previously placed coil and continued distal flow to the dural membranes. Results: Onyx liquid embolization was completed successfully, effectively halting both anterograde flow to the MMA and retrograde flow from external circulation collaterals. Conclusion: This case report suggests that in situations of MMA embolization failure, follow-up angiography may be completed to determine if further embolization through other procedural techniques may be possible. The angiographic images contained here highlight the advantages of liquid embolization over coil embolization of the MMA in halting SDH angiogenesis.