Gianturco Coils Research Articles

Endovascular treatment of a patient with false aneurysm of splenic artery and sharp tortuosity of the arterial flow

A case of endovascular treatment of a patient with a large false aneurysm of the splenic artery resulting from arrosion of its wall into the cavity of a previously existing pancreatic pseudocyst is described. In addition to the rather rare occurrence of this pathology, a feature of this clinical case was the patient’s sharp tortuosity of the access vessels, including the iliac arteries, abdominal aorta, and the splenic artery. Thus, both the endovascular prosthetics of the affected splenic artery and its embolization according to the traditional method using standard angiographic catheters and Gianturco coils turned out to be technically impossible because of the inability to reach the lesion site, especially with access through the common femoral artery that typical for such interventions, which was used by us when performing diagnostic selective arteriography. The second stage was the embolization of the splenic artery by access through the left axillary artery by means of conducting of guiding catheter into the celiac trunk. Through the lumen of this catheter, we introduced a microcatheter, through which detachable microcoils (usually used in interventional neuroradiology) were introduced into the splenic artery proximal and distal to the aneurysm cavity. As a result, the affected area of ​​the splenic artery with aneurysm was completely turned off from the bloodstream and thrombosed, that allowed to avoid extremely risky open surgical intervention and eliminated the risk of rupture of the aneurysm. Medication support included hypotensive therapy to reduce the risk of rupture of the aneurysm (before and after surgery), analgesics for the relief of post-embolization pain, and antibiotics for the prevention of infectious complications associated with pancreatitis and the possible development of spleen infarction. Monitoring the effectiveness of the intervention in the postoperative period was carried out using ultrasound dopplerography.

Endovascular correction of venogenic erectile dysfunction in May–Thurner syndrome (clinical case)

Introduction. Secondary varicose small pelvic veins with the development of chronic venous insufficiency due to obstruction of the magistral venous vessels, in particular, the left common iliac vein and the right common iliac artery (May–Thurner syndrome), occupy a special place in the structure of the causes of venogenic erectile dysfunction (ED).The study objective is to present the clinical case of arteriovenous conflict (May–Thurner syndrome), leading to the development of secondary varicose small pelvic veins in men and venogenic ED, as well as modern methods of its verification and endovascular surgical repair.Clinical case. A clinical case of successful endovascular correction of venogenic ED is presented. The patient is diagnosed with: May– Thurner syndrome. Pelvic varicose disease С3 (according to CEAP Classification). Condition after endovascular balloon angioplasty and stenting of the left common iliac vein. Bilateral varicocele. Condition after bilateral varicocelectomy in 2018. Severe venogenic ED (pathological venous drainage, proximal type, International Index of Erectile Function (v. 5) – 12 points; Er3 according to the Unem Scale) in accordance with the Comprehensive Classification System for Chronic Venous Disorders. On July 24, 2019 endovascular occlusion of the Santorini’s plexus veins was performed with the installation of occlusion spirals in their lumen according to Gianturco. In order to provide visualization of the veins in the Santorini’s plexus, given the impossibility of cannulation of the deep vein of the penis, bilateral symmetrical cannulation of the cavernous bodies of the penis was carried out to perform cavernosophlebography. The left common iliac vein was catheterized according to the Crossover technique. Under phlebography control we ensured that the stent in the common iliac vein passed without signs of loss of its lumen. The internal pudental vein on the left was selectively catheterized. Hydrophilic guidewire was introduced through the veins of the periprostatic plexus into the right internal pudental vein. Selective catheterization of the periprostatic venous plexus was not possible due to pronounced tortuosity, valve flaps of the veins and small diameter of the catheterized veins. It was decided to pass the guidewire further through the right iliac vein system with access to the inferior vena cava. Further, the guidewire was again transferred to the left common iliac vein (double crossover). The left common femoral vein was punctured followed by the placement of 5 Fr introducer sheath according to Seldinger. The guidewire tip was fixed by the loop in the left common iliac vein, then captured and brought out through the introducer in the left common femoral vein. A catheter Сobra15 Fr was inserted through a crossover guide from the left common femoral vein into the right internal iliac vein and further into the periostatic venous plexus. Gradually veins of the Santorini’s plexus were selectively catheterized followed by Gianturco coils embolization.Conclusion. The first choice surgery for verified proximal type ED is endovascular occlusion of the veins in the Santorini’s plexus through the deep vein of the penis, which allows to change the hemodynamics in the penis and provide sufficient erection without resorting to endofalloprosthesis of the penis. Single or double-sided transfemoral access is suggested for patients when access through the deep vein of the penis is rather challenging or absent.

Endovascular Closure of Pulmonary Arteriovenous Malformations after Cryptogenic Stroke: A Case Series

ABSTRACT Background: To investigate the clinical characteristics and treatment of patients who presented with cryptogenic stroke due to pulmonary arteriovenous malformation (PAVM). Cryptogenic stroke is occasionally caused by paradoxical embolization due to a PAVM. Endovascular closure of the PAVM is the preferred treatment, as suggested by isolated case reports. Methods: The authors retrospectively reviewed the charts of 14 patients who underwent endovascular treatment of PAVMs after an ischemic cryptogenic stroke. The patients were treated by a single interventionalist over a 15-year time period at Columbia University Medical Center. Results: All patients had suffered a prior cryptogenic stroke and 50% (7/14) experienced more than one stroke. Nearly all patients (13/14) had been referred for closure of a patent foramen ovale (PFO) diagnosed by transthoracic echocardiogram (TTE). During catheterization, use of intracardiac echocardiography, probing of the septum and local injection of saline revealed that only 29% of patients (4/14) actually had a PFO. A total of 18 PAVMs were identified: 56% were isolated right-sided, 22% were isolated left-sided, and 22% were bilateral. The majority (16/18) were simple type PAVMs with a single feeding vessel. Gianturco coils were used to treat eight patients and Amplatzer devices were used to treat seven patients (two patients received both coils and Amplatzer). No patient suffered recurrent stroke after shunt closure. Conclusions: Endovascular closure of PAVMs after cryptogenic stroke appears safe and may reduce recurrent stroke risk in this select population. Frequently, PAVM is misdiagnosed as PFO by noninvasive TTE and incidentally discovered at catheterization to close the PFO.

КЛИНИЧЕСКИЙ СЛУЧАЙ ЭНДОВАСКУЛЯРНОГО ЛЕЧЕНИЯ КОРОНАРНО-ПРАВОПРЕДСЕРДНОЙ И ПОДКЛЮЧИЧНО-ЛЕГОЧНО-ПРАВОПРЕДСЕРДНОЙ ФИСТУЛЫ

The article gives a detailed analysis of examination and treatment of a patient with of coronary-right atrial and subclavian pulmonary- right atrial fistula. Coronary fistula is congenital anomaly when the coronary artery flows into chambers of heart that results in blood shunting and steal syndrome. The severity assessment of the clinical symptoms was performed by using ECG, x-ray chest, ECHO-CG, angiography. The embolization of the fistula using Gianturco coils and further estimation in one month and then in two months were conducted. As a result, the patient have decreased clinical symptoms of the disease i.e. walk distance increased, breath shortness decreased, lungs pneumatization increased, heart chambers size became normal. The endovascular embolization of coronary fistulas using coils is a highly effective and safe method, leading to improvement of the clinical picture.

Coronary-cameral fistulas: indications and methods for closure.

Coronary-cameral fistulas (CCF) are anomalous connections between one or more coronary arteries and a cardiac chamber, most commonly the right ventricle or right atrium. The major indications for closure are: significant left to right shunt, myocardial ischaemia, prevention of endoarteritis or rupture. Nowadays, the first option for treatment is transcatheter closure. According to the morphology of the fistulas the most appropriate occluder device should be selected: coils (e.g., Gianturco coils, controlled-release coils, PFM coils), vascular plugs or a patent ductus arteriosus (PDA) device or muscular ventricular septal defect (VSD) device. The way to deploy the occluders could be direct arterial or venous through an arteriovenous loop, according to the anatomy of the fistulas assessed by multiple angiograms in different projections. A test occlusion of the fistula with balloon catheter and simultaneous coronary angiogram is recommended for choosing the proper device type and size and the best position for deployment to achieve complete occlusion of the fistula without compromising the flow in coronary side branches.

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas (ACF) secondary to iatrogenic or infectious disorders. From a PubMed search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case - an adult male who presented with ACF between commissures of the right and non-coronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV - is added, the world literature is briefly reviewed. A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital (47%) or acquired (53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea (21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23 (60%), single method in 14 (37%) (echocardiography in 12 and catheterization in 2), and at autopsy in 2 (3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12 (30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24 (63%). Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.

Management of Bleeding Gastric Varices in Patients with Sinistral Portal Hypertension

Sinistral portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage. Besides splenectomy, there is no consensus on the role of sclerotherapy and splenic embolization for bleeding gastric varices (GVs). This retrospective study summarizes our experience in managing GV bleeding from SPH in patients with pancreatic diseases. Patients with pancreatic diseases who had bleeding GVs from SPH in two tertiary hospitals were reviewed from January 2001 to December 2011. The etiology, clinical manifestations, diagnostic and therapeutic modalities were analyzed. Twenty-one patients (15.2 %) complicating bleeding GVs among 139 patients with SPH secondary to pancreatic diseases were enrolled. The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. Emergent endoscopic sclerotherapy was initially performed in five patients, and succeeded in two patients, while one patient died of massive hemorrhage. Initial transcatheter artery embolization using Gianturco coils was successfully performed in six patients. Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period. The incidence of bleeding GVs from SPH is relatively rare. Splenic artery embolization could be selected as a first-line choice for bleeding SPH, especially for patients in poor conditions, and sclerotherapy may not be preferentially recommended. Further studies are required to evaluate the optimum treatment algorithm for bleeding GVs from SPH.

Transcatheter patent ductus arteriosus closure with echocardiographic guidance: can radiation exposure be reduced?

The radiation dose from interventional cardiac catheterization is particularly relevant when treating children because of their greater radiosensitivity compared to adults. The transcatheter closure of patent ductus arteriosus (PDA), as well as other more complex pediatric interventions, have raised concerns regarding radiation exposure, particularly relevant when treating children. The purpose of this study is to show how to perform the transcatheter closure of PDA in children while giving less ionized radiation and to prove that the amount of radiation and contrast material can be reduced. Following appropriate device selection based on PDA morphology and diameter, transthorasic echocardiography images and control aortography findings were analyzed. The following devices were used during the procedure: Gianturco coils (10/63), an Amplatzer Duct Occluder (ADO, 31/63), Flipper coils (19/63), and an Amplatzer vascular plug (3/63). The scopy time, radiation dose, and contrast were 12 ± 6.4 mins, 28.1 ± 14.7 cmGy/cm²/kg, and 4.2 ± 2.3 cc/kg, respectively. In the control aortography shortly after the procedure, residual shunt was detected at various levels in 39.7% of patients, and 9.5% demonstrated residual shunt in real-time echocardiography. In the control aortography, the exposure to radiation was 13.3% of the total, and the amount of infused contrast was 27.2% of the total. Patients may be exposed to less radiation and contrast material if an echocardiographic evaluation, instead of a final control aortography injection, is performed after the transcatheter closure of PDA.

Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part I - Acyanotic Heart Defects

The purpose of this review/editorial is to discuss how and when to treat the most common acyanotic congenital heart defects (CHD); the discussion of cyanotic heart defects will be presented in a subsequent editorial. By and large, the indications and timing of intervention are decided by the severity of the lesion. Balloon pulmonary valvuloplasty is the treatment of choice for valvar pulmonary stenosis and the indication for intervention is peak-to-peak systolic pressure gradient >50 mmHg across the pulmonary valve. For aortic valve stenosis, balloon aortic valvuloplasty appears to be the first therapeutic procedure of choice; the indications for balloon dilatation of aortic valve are peak-to-peak systolic pressure gradient across the aortic valve in excess of 70 mmHg irrespective of the symptoms or a gradient ≥ 50 mmHg with either symptoms or electrocardiographic ST-T wave changes indicative of myocardial perfusion abnormality. The indications for intervention in coarctation of the aorta are significant hypertension and/or congestive heart failure along with a pressure gradient in excess of 20 mmHg across the coarctation; the type of intervention varies with age at presentation and the anatomy of coarctation: surgical intervention for neonates and young infants, balloon angioplasty for discrete native coarctation in children, and stents in adolescents and adults. Long segment coarctations or those associated with hypoplasia of the isthmus or transverse aortic arch require surgical treatment in younger children and stents in adolescents and adults. For post-surgical aortic recoarctation, balloon angioplasty in young children and stents in adolescents and adults are treatment options. Transcatheter closure methods are currently preferred for ostium secundum atrial septal defects (ASDs); the indications for occlusion are right ventricular volume overload by echocardiogram. Ostium primum, sinus venosus and coronary sinus ASDs require surgical closure. For all ASDs elective closure around age 4 to 5 y is recommended or as and when detected beyond that age. For the more common perimembraneous ventricular septal defects (VSDs) of large size, surgical closure should be performed prior to 6 to 12 mo of age. Muscular VSDs may be closed with devices. Patent ductus arteriosus (PDA) may be closed with Amplatzer Duct Occluder if they are moderate to large and Gianturco coils if they are small. Surgical and video-thoracoscopic closure are the available options at some centers. In the presence of pulmonary hypertension appropriate testing to determine suitability for closure should be undertaken. The treatment of acyanotic CHD with currently available medical, transcatheter and surgical methods is feasible, safe and effective and should be performed at an appropriate age in order to prevent damage to cardiovascular structures.

Transcatheter therapies for congenital heart disease in Taiwan

The heart is made up of many different cell types, including myocytes, fibroblasts and vascular cells. The cardiac myocyte, although not likely to divide, may respond to gross organ injury by a process of growth or hypertrophy. Cellular hypertrophy, though a normal biological adaptation, has the potential to contribute to the change in the shape and the size of the heart, such as occurs in chronic heart failure. We are now just beginning to understand the signals and early pathways involved in the cardiac myocyte growth response, some of which are reviewed herein.

Tratamento percutâneo vs. cirúrgico da persistência do canal arterial em crianças e adolescentes

INTRODUCAO: Estudos comparando os metodos percutâneo e cirurgico no tratamento da persistencia do canal arterial (PCA) sao raros na literatura. Nosso objetivo foi realizar analise comparativa entre os dois metodos de tratamento da PCA, enfatizando os aspectos de eficacia e morbidade. METODOS: Estudo observacional com 2 coortes de criancas e adolescentes > 5 kg e < 14 anos, portadores de PCA, tratados durante um projeto de avaliacao de incorporacao de novas tecnologias ao Sistema Unico de Saude (SUS), realizado em um hospital cardiologico de excelencia, em parceria com o Ministerio da Saude do Brasil. Foi feita analise prospectiva no grupo percutâneo entre 2009 e 2011 e retrospectiva no grupo cirurgico entre 2006 e 2011. RESULTADOS: Foram incluidos 80 pacientes no grupo percutâneo (60% do sexo feminino) e 39 no grupo cirurgico (51% do sexo feminino; P = 0,37). A mediana de idade e de peso dos grupos percutâneo e cirurgico foi de 39,4 meses vs. 25,5 meses (P = 0,04) e de 14 kg vs. 11,1 kg (P = 0,052), respectivamente. No grupo percutâneo, 78 pacientes (92%) tinham PCA do tipo A e o diâmetro minimo do canal a angiografia foi de 2,5 ± 1,2 mm. As proteses mais utilizadas foram Amplatzer®, molas de Gianturco e CeraTM. A tecnica cirurgica mais utilizada foi a clipagem. A taxa de sucesso dos procedimentos foi de 100% nos dois grupos. O grupo cirurgico apresentou maiores taxas de complicacao, incluindo quilotorax, infeccoes, necessidade de hemoderivados, hipertensao arterial sistemica e uso de opioides, como tambem maior necessidade de terapia intensiva. A mediana do tempo de internacao foi de 1,3 dia no grupo percutâneo e de 7,9 dias no grupo cirurgico (P < 0,01). A alta hospitalar, as taxas de oclusao foram semelhantes nos dois grupos (91% no grupo percutâneo e 87% no grupo cirurgico; P = 0,71). CONCLUSOES: Em decorrencia da menor morbidade, do menor tempo de internacao e da igual eficacia, o tratamento percutâneo da PCA deve ser considerado a modalidade terapeutica de escolha para pacientes selecionados.

Transcatheter Closure of Patent Ductus Arteriosus

Patent ductus arteriosus (PDA) constitutes 6 to 11% of all congenital heart defects. While surgical ligation and video-assisted, thoracoscopic interruption of PDA are still available, transcatheter occlusion of PDAs has recently assumed a major role in closure of PDA. A large number of devices have been designed and tested both in animal models and human subjects, but only few devices (free and detachable Gianturco coils, GGVOD and Amplatzer duct occluder) are approved by the FDA for general clinical use. A few other devices are in clinical trials and are available only at institutions participating in clinical trials within or outside the US. At the present time, Gianturco coils for closure of very small and small PDAs and Amplatzer duct occluder for occlusion of small, moderate and large PDAs appear to be feasible, safe and effective in the majority of patients.

Percutaneous vs. Surgical Treatment of Patent Ductus Arteriosus in Children and Adolescents

Studies comparing percutaneous and surgical methods for the treatment of the patent ductus arteriosus (PDA) are rare in the literature. This study aimed to perform a comparative analysis between both PDA treatment methods with emphasis on efficacy and morbidity. Observational study with 2 cohorts of children and adolescents > 5 kg and < 14 years of age with PDA, treated under a study protocol to assess the incorporation of novel technologies to the Brazilian Public Health System (Unified Health System − SUS) at an excellence hospital, in partnership with the Brazilian Ministry of Health. A prospective analysis was conducted for the percutaneous group from 2009 to 2011 and a retrospective analysis was performed for the surgical group between 2006 and 2011. Eighty patients were included in the percutaneous group (60% female) and 39 patients in the surgical group (51% female; P = 0.37). The median age and weight of the percutaneous and surgical groups was 39.4 months vs 25.5 months (P = 0.04) and 14 kg vs 11.1 kg (P = 0.052), respectively. In the percutaneous group, 78 patients (92%) had type A PDA and the minimal ductal diameter at angiography was 2.5 ± 1.2 mm. Amplatzer®, Gianturco coils and Cera™ were the most commonly used devices. Clipping was the most commonly used surgical technique. The success rate of the procedure was 100% in both groups. The surgical group had higher complication rates, including chylothorax, infections, transfusions, systemic arterial hypertension, use of opioids and a greater need for intensive care. The median hospitalization time was 1.3 days in the percutaneous group and 7.9 days in the surgical group (P < 0.01). Upon discharge, occlusion rates were similar in both groups (91% in the percutaneous group and 87% in the surgical group; P = 0.71). Due to the lower morbidity, the shorter hospitalization time and similar efficacy, percutaneous treatment of the PDA should be considered the modality of choice for selected patients. Tratamento Percutâneo vs . Cirúrgico da Persistência do Canal Arterial em Crianças e Adolescentes Estudos comparando os métodos percutâneo e cirúrgico no tratamento da persistência do canal arterial (PCA) são raros na literatura. Nosso objetivo foi realizar análise comparativa entre os dois métodos de tratamento da PCA, enfatizando os aspectos de eficácia e morbidade. Estudo observacional com 2 coortes de crianças e adolescentes > 5 kg e < 14 anos, portadores de PCA, tratados durante um projeto de avaliação de incorporação de novas tecnologias ao Sistema Único de Saúde (SUS), realizado em um hospital cardiológico de excelência, em parceria com o Ministério da Saúde do Brasil. Foi feita análise prospectiva no grupo percutâneo entre 2009 e 2011 e retrospectiva no grupo cirúrgico entre 2006 e 2011. Foram incluídos 80 pacientes no grupo percutâneo (60% do sexo feminino) e 39 no grupo cirúrgico (51% do sexo feminino; P = 0,37). A mediana de idade e de peso dos grupos percutâneo e cirúrgico foi de 39,4 meses vs. 25,5 meses (P = 0,04) e de 14 kg vs. 11,1 kg (P = 0,052), respectivamente. No grupo percutâneo, 78 pa-cientes (92%) tinham PCA do tipo A e o diâmetro mínimo do canal à angiografia foi de 2,5 ± 1,2 mm. As próteses mais utilizadas foram Amplatzer®, molas de Gianturco e Cera™. A técnica cirúrgica mais utilizada foi a clipagem. A taxa de sucesso dos procedimentos foi de 100% nos dois grupos. O grupo cirúrgico apresentou maiores taxas de complicação, incluindo quilotórax, infecções, necessidade de hemoderivados, hipertensão arterial sistêmica e uso de opioides, como também maior necessidade de terapia intensiva. A mediana do tempo de internação foi de 1,3 dia no grupo percutâneo e de 7,9 dias no grupo cirúrgico (P < 0,01). À alta hospitalar, as taxas de oclusão foram semelhantes nos dois grupos (91% no grupo percutâneo e 87% no grupo cirúrgico; P = 0,71). Em decorrência da menor morbidade, do menor tempo de internação e da igual eficácia, o tratamento percutâneo da PCA deve ser considerado a modalidade terapêutica de escolha para pacientes selecionados.

Occlusion of Pulmonary Arteriovenous Malformations Using the Amplatzer Vascular Plug/Duct Occluder for a Family With Hereditary Hemorrhagic Telangiectasia

An 8-year-old girl was referred because of frequent epistaxis and acrocyanosis. The family history showed that her father, aunt, uncle, and grandfather also experienced recurrent epistaxis. Based on her clinical information, we diagnosed her condition as hereditary hemorrhagic telangiectasia, also known as Rendu-Osler-Weber disease, which is characterized by multiple telangiectases, recurrent epistaxis, arteriovenous malformation, and familial inheritance. Chest radiography and computed tomography (CT) showed two large pulmonary arteriovenous fistulas (PAVFs) in the posterobasal and mediobasal segment of the left lower lung (Fig. 1). Percutaneous transcatheter embolization then was planned. After right heart catheterization and pulmonary angiography had been performed, we confirmed a large PAVF (diameter, 8.2 mm) in the posterobasal part of left lung, with a smaller lesion (diameter, 2.9 mm) in the pulmonary artery of the left middle lobe. A 10 9 12-mm Amplatzer duct occluder (AGA Medical Corporation, Golden Valley, MN, USA) was selected for the larger PAVF, and a Gianturco coil (4 9 3 mm; Cook Inc., Bloomington, IN, USA) was chosen for the smaller feeding artery (Fig. 1). After a successful procedure, percutaneous oxygen saturation at rest rose to more than 95% with room air compared with about 71% before the procedure. Recently, the girl’s father also was evaluated for mucocutaneous telangiectases on his tongue and in his nasal mucosa. Chest radiography and multidetector CT again showed bilateral multiple PAVFs. A cardiac catheterization with pulmonary angiography showed four large PAVFs of the right upper (feeding vessels of 2.8 mm), right lower (3.5 mm), left upper (3.2 mm), and left lower (4.2 mm) lung. Considering their large sizes, we decided to perform percutaneous closure using Amplatzer vascular plugs for all four PAVFs. Devices 30–50% larger than the selected vessel diameter were chosen: 4 9 7 mm for the right upper lesion, 6 9 7 mm for the right lower and left upper lesion, and 8 9 7 mm for the left lower lesion. Angiograms obtained at the end of each procedure confirmed good positioning of the devices with no significant residual flow (Fig. 2). About 20–30% of patients with hereditary hemorrhagic telangiectasia are thought to be affected with PAVFs [4]. Various methods for transcatheter embolization have been reported, including coils and detachable balloons. Although transcatheter embolization with coils is considered the preferred method for PAVFs, it is not ideal for large fistulas with large feeding arteries due to disadvantages such as the risk for paradoxical device embolization, the need for multiple coils, and the high recanalization rates [1–3]. The Amplatzer vascular plug/duct occluder has been reported as a new alternative for the occlusion of PAVFs. An additional advantage of the Amplatzer vascular plug is the relatively smaller introduction system than that used for the Amplatzer duct occluder. Although most reported cases involve adult patients, the reported familial case including an 8-year-old girl demonstrates that the Amplatzer vascular plug and duct occluder also provide excellent results for young patients with multiple large PAVFs. M. J. Cho Department of Pediatrics, Pusan National University Hospital, Ami-dong, Seo-gu, Busan 602-739, Republic of Korea

Transcatheter arterial embolization as therapy of renal angiomyolipomas: The evolution in 15 years of experience

ObjectiveThis study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally. MethodsTen patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems. ResultsOn an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period. ConclusionSelective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.

Radionuclide evaluation of lung perfusion after transcatheter closure of patent ductus arteriosus: analysis of frequently used two different type of coils

Impaired left lung perfusion (LLP) has been described after transcatheter closure of the patent ductus arteriosus (PDA). In this study, we aimed to evaluate lung perfusion scans (LPSs) following occlusion of PDA with two frequently used coils: Cook detachable coil and Gianturco coil. A prospective study of 89 patients who underwent PDA occlusion using the Cook coils in 49 and the Gianturco coils in 40, was conducted. LPSs were performed after a median period of 18 months. The relationships between the LPSs and continuous variables were assessed by Pearson correlation analysis and the cut-off value of the best correlated parameters to predict abnormal LPSs obtained by the Receiver Operating Characteristic (ROC) analysis. Decreased left lung perfusion (LLP) was found in 13 patients including 10 after using Cook coils and 3 after using Gianturco coils (p=0.077). LLP values were significantly correlated with the loops deployed at the pulmonary side, coil/ductal diameter ratio and number of coils deployed (p=0.002, p=0.006 and p=0.009, respectively). Number of loops deployed at the pulmonary side >1.4 (specificity 77%, sensitivity 85%, area under the ROC curve 0.804, 95%CI 0.661-0.947, p<0.001) and first coil/ductal diameter ratio >1.85 (specificity 70%, sensitivity 77%, area under the ROC curve 0.747, 95%CI 0.423-0.790, p<0.005) were the best discriminative cut-off values of decreased LLP. Impaired LLP may appear following transcatheter closure of PDA with either Cook detachable coils or Gianturco coils. This situation may be complicated with loops deployed at the pulmonary side, the use of relatively large size of coil with respect to the ductal diameter and the use of multiple coils.

Parkes-Weber Syndrome and Giant Superficial Femoral Artery Aneurysm. Treatment by Endovascular Therapy and Follow-Up of 8 Years

Congenital vascular malformations represent a wide number of diseases with a great variability of clinical features. The association between congenital vascular malformations and peripheral aneurysms is very rare. The present study reports a case of giant superficial femoral artery aneurysm (7-cm-long) associated with Parkes-Weber syndrome (capillary malformation, multiple arteriovenous fistulas [AVFs], skeletal hypertrophy of the affected limb) treated by positioning two covered self-expandable endoprostheses after embolization of AVFs with Gianturco coils. The peri- and postoperative course was uneventful and the postprocedural angiography showed the complete exclusion of the aneurysm sac. At last follow-up, after 87 months, the duplex scan and computed tomography scan showed regular patency of the vessels with thrombosis of the aneurysm sac and the presence of a large number of AVFs. The association between Parkes-Weber syndrome and peripheral aneurysms represents a very unusual entity. The lack of evidence does not allow the establishment of the most suitable treatment for this disease. Endovascular approach associated with previous embolization of AVFs may represent a valid alternative to traditional surgical repair, which is still burdened by a high percentage of complications and failures.

Muscular ventricular septal defect closure with Gianturco coil at Soetomo hospital (a case report)

Ventricular septal defect (VSD) is the mostcommon congenital heart disease (CHD)in children.1'2 It occurs in 1.5 to 3.5 of1,000 live births and constitutes 20% ofcongenital cardiac defects.1 The VSD may be small,medium or large and is classified based on its locationin the interventricular septum. There are four types ofVSD, i.e., perimembranous (80% ofVSDs), musculartype (5% to 20%) inlet or AV canal type (8%), andfinally, subpulmonary (5% to 7%).1-4 When multiplemuscular defects are seen, it is often referred to as"Swiss-cheese" type of VSD. 1•2The management strategies, which consist ofmedical, surgical and intervention techniques, depend toa large degree on the size of the VSD.1-4 Approximately40% of VSDs spontaneously and completely closed,with closure rates approaching 80-90% by age 2 years.2Indication ofVSD closure are symptoms of heart failure,left heart chambers overload and history of endocarditis.The surgical approach is considered gold standard butit is associated with morbidity and mortality, high cost,patient discomfort, sternostomy and skin scar.3 Since1988, percutaneous techniques have been conductedin order to reduce those drawbacks of surgery. Morerecently, percutaneous techniques and devices havebeen developed specifically for closure of muscularVSD (m VSD) and perimembranous VSD (pm VSD)using either the Rashkind double umbrella, the BardClamshell, the Button device, theAmplatzer septal, duct118 • Paediatr lrulones, Vol. 50, No. 2, March 2010or muscular VSD occluder, or the Gianturco coils.3AGianturco coils have been widely used to closeunwanted vascular communications and small- tomoderate- sized patent ductus arteriosus, withexcellent closure rates. In 1999, Latiff et al successfullyused this coil to close multiple muscular VSDs in a10-month old boy. Thus, percutaneuos closure ofVSDs using Gianturco coils is a feasible, reasonablealternative to surgery.5'6 We report a case of fouryear-old girl with muscular VSD who underwentcardiac catheterization and transcatheter closure withGianturo coil in Dr. Soetomo Hospital, Surabaya.

Percutaneous closure of patent ductus arteriosus: A multiinstitutional registry comparing multiple devices

There are no guidelines and multiple devices available now for closure of PDA. We sought to determine which devices are used and their outcomes. Prospectively collected data on closure of PDA at 12 US catheterization labs was entered into the MAGIC data registry between November 2005 and September 2008. PDA closure was accomplished in 357 of 359 attempted closures during the study period. Mean age, weight, and minimum ductal diameter were 4.3 ± 6.8 years, 18.7 ± 18.4 kg, and 2.1 ± 1.4 mm, respectively. Devices used were Gianturco coils (161/359), Amplatzer Duct Occluder (ADO, 174/359), Flipper coils (18/359), and other devices (6/359). Gianturco coils had the least fluoroscopy and contrast exposure (8.7 ± 7.5 min, P = 0.00001, 2.6 ± 1.4 cm(3) kg(-1), P = 0.00001). Immediate angiographic success rates were 96.9% (156/161) for Gianturco coils, 89.7% (156/174) for the ADO, 100% (18/18) for Flipper coils, and 66.7% (4/6) for other devices. Major complication rates were 0.6% for Gianturco coils (1/161), 1.7% for ADO (3/174), and 83.3% for other devices (4/6). Minor complication rates by device were 1.9% for Gianturco coils (3/161), 2.3% for ADO (4/174), and 16.7% (1/6) for other devices. Gianturco coils, the ADO and Flipper coils were immediately successful with low complication profiles. The ADO and Gianturco coils were the predominate devices. The ADO was the device of choice for PDA > 3 mm with good success. In PDA < 3 mm, the Gianturco coil is as effective and safe as the ADO with less cost, less radiation, and less contrast exposure. © 2010 Wiley-Liss, Inc.

Immediate Echocardiographic Surveillance After Transcatheter Closure of a Patent Ductus Arteriosus: A Feasible Method to Assess Residual Shunt

To evaluate the feasibility of echocardiography after transcatheter closure of patent ductus arteriosus (PDA) with coils. Between April 1998 and December 2006, 131 patients had transcatheter coil occlusion of their PDA using Gianturco coils. We hypothesized that post-procedural hemolysis would not occur if a residual shunt < 1 mm or if no continuous waveform was detected by echocardiography. Immediately after coil implantation, patients without and with a residual shunt as detected by echocardiography were designated to groups A and B, respectively. The clinical presentations, laboratory data and outcomes were compared between the two groups. There were 101 patients in group A and 30 patients in group B. Patients in group B had larger ductal diameter (2.8 +/- 0.9 mm vs. 1.6 +/- 0.8 mm; p < 0.001), larger Qp/Qs (1.9 +/- 0 .9 vs. 1.3 +/- 0.4; p = 0.001), higher frequency of more than one coil used (14/30 vs. 11/101; p < 0.001), and female predominance (22/30 vs. 53/101; p = 0.043) compared with group A. Trivial residual shunt was noted in 6 patients in group A and 20 patients in group B on the day after embolization. All shunts spontaneously closed within 6 months in patients of group A, while five patients in group B had a persistent shunt at the 1-year follow-up and thereafter. Although the patients in group B had higher residual shunt rate than group A during follow-up (p < 0.001), none of these patients suffered from hemolysis. Echocardiography is a feasible tool to assess residual shunt after PDA closure. If a residual shunt < 1 mm or if no continuous waveform is detected by echocardiography, the risk of developing hemolysis is low.