Intraoperative Embolization Research Articles

Technical and clinical outcomes of 13 years of endovascular repair of infrarenal, atherosclerotic, penetrating aortic ulcers.

To report the technical and clinical outcomes of endovascular repair of all infrarenal, penetrating aortic ulcers (PAU) that were treated at a single institution over a 13-year period. This is a single-center, retrospective observational study. All patients consecutively treated for atherosclerotic, infrarenal PAU were included between 2010 and 2023. Outcomes were technical success, overall survival, PAU-related death, freedom from secondary rupture, freedom from secondary interventions, freedom from aortic expansion > 5 mm, freedom from type 1 and type 3 endoleak (EL), and freedom from stentgraft migration, each at 30 days, 1 year, 2 years and 5 years of follow-up. The study was registered at the German Clinical Trials Register (DRKS00028794). Forty-Seven patients were included (8 female patients, 17.0%) with a median age of 75.7 years (Interquartile range (IQR): 70.2-81.0). The median maximum aortic diameter was 39.7 mm (IQR: 33.6-45.2). Overall, primary and secondary technical success was achieved in 42 of 47 (89.4%) and 46 of 47 patients (97.9%). Implantation of a standard aorto-biiliac EVAR stentgraft was the most frequent procedure in 25 patients (53.2%). An aorto-monoiliac stentgraft system was used in 5 patients (10.6%). The remaining 17 patients (36.2%) were treated using an aorto-aortic tube stentgraft configuration. The median clinical follow-up was 5.1 years (IQR: 1.9-8.1) with a median imaging follow-up of 1.5 years (IQR: 0.4-5.0). Overall survival at 30 days, 1, 2, and 5 years of follow up was estimated at 100% (Confidence interval (CI), 100%-100%), 95.4% (CI, 89.4%-100%), 87.9% (CI, 78.4%-98.4%), and 82.0% (70.7%-95.2%), respectively. There was one PAU-related death (2.1%). Freedom from secondary intervention at 30 days, 1, 2, and 5 years of follow-up was 93.6% (CI, 86.9%-100%), 89.2% (CI, 80.6%-98.6%), 81.5% (CI, 70.7%-94.0%), and 75.2% (CI, 62.8%-90.2%), respectively. No patient who underwent either preoperative (n=1) or intraoperative embolization (N=7) of lumbar arteries (LA) and/or the inferior mesenteric artery (IMA) demonstrated type 2 endoleak during follow-up. A variety of alternatives to standard aorto-biiliac EVAR are required for endovascular PAU repair. To identify the optimal management strategy in these cases further studies are needed. Type 2 EL in abdominal PAU disease appears to be preventable by LA and/or IMA embolization.

Primary Intra-operative Embolisation During Urgent Parallel Graft Endovascular Repair in Paravisceral Symptomatic Aortic Pseudoaneurysm

Paravisceral aortic lesions present significant challenges for endovascular treatment. This retrospective analysis of consecutively treated patients from April 2017 to June 2021 aimed to analyse the outcome of primary intra-operative embolisation of aortic complicated pseudoaneurysms and gutter channels during parallel graft (PG) repair of paravisceral symptomatic aortic pseudoaneurysms. Patients with symptomatic pseudoaneurysms of the paravisceral aorta treated with PGs using chimney or periscope configurations were included. Thoracic endografts were positioned to exclude the aortic lesions. Coil embolisation of both the lesions and gutter channels was performed after graft deployment and prior to ballooning of the stent grafts. The primary endpoints were technical success (defined as exclusion of the pseudoaneurysm, target visceral vessel [TVV] patency, absence of gutter endoleaks) and clinical success (technical success+ resolution of symptoms+ absence of major adverse events) at 30 days. Secondary endpoints included overall survival, TVV patency, gutter endoleaks, and freedom from re-interventions during follow up. Six patients (four women) were treated for pseudoaneurysm rupture (three cases) and symptomatic aortic pseudoaneurysm (three cases) of the paravisceral aorta. The patients' anatomies were unsuitable for off the shelf devices and patients were all deemed to be at prohibitive surgical risk. A total of 15 TVVs were revascularised (comprising three coeliac arteries, five superior mesenteric arteries, and seven renal arteries) using 10 chimney and five periscope PGs. One coeliac artery was occluded. Seventy coils were deployed to embolise both the aortic ruptures and gutter channels. Both technical and clinical success rates were 100%. The median follow up was 17 months (IQR 5, 35), during which time three patients died due to non-aortic related causes. One coeliac artery (6%) was occluded, and no endoleak evidence was found. Primary intra-operative embolisation during parallel graft endovascular repair of paravisceral symptomatic aortic pseudoaneurysms may be both safe and effective in excluding the pseudoaneurysm when other options are unavailable.

Impact of Intraoperative Branch Embolization for Type 2 Endoleak Prevention During Endovascular Abdominal Aortic Repair

Endovascular abdominal aortic repair (EVAR) has a significantly higher revision rate than open repair, primarily due to type 2 endoleak (2EL). Although 2ELs are considered benign, late open conversion (LOC) due to the expansion of the aneurysm diameter of the 2EL is a concern in the mid- and long-term. In this study, we investigated the impact of embolization of the inferior mesenteric artery (IMA) or lumbar artery (LA) at the time of the initial EVAR and its long-term outcomes. Between April 2008 and December 2021, 743 EVAR procedures for abdominal aortic aneurysms were performed at our institution. The patients were divided into 2 groups at the time of initial surgery, namely, 215 and 528 patients in the embolization (Group E) and nonembolization (Group N) groups, respectively. Branch embolization was performed in patients with an IMA diameter ≥3mm and LA diameter ≥2mm on preoperative computed tomography. Re-embolization with EL was performed in patients with a diameter enlargement ≥10mm, and LOC was performed in patients with continued enlargement ≥15mm after re-embolization. The mean follow-up period was 7.0years. The mean number of branch embolizations was 2.3±1.1. Intraoperatively, the operative time, fluoroscopy time, irradiation dose, and contrast medium use were significantly higher in Group E than in Group N. There was a significant difference between the 2 groups regarding shrinkage (Group E versus Group N: 45.6% versus 37.3%; P=0.03) and enlargement (Group E versus Group N: 9.3% vs. 19.5%; P<0.001) of the aneurysm diameter by>5mm after EVAR. In the mid- and long-term, the avoidance rate of 2EL reintervention was significantly lower in Group E at 5years (93.5% vs. 88.6%) and 10years (87.5% vs. 76.4%; P=0.04). LOC prevention was 5years; Group E: 100% vs. 96.9% for Group N and 10years; Group E: 98.8% vs. 92.5% for Group N, significantly lower in Group E (P=0.02). The impact of branch embolization at the time of the initial EVAR is believed to prevent enlargement of the aneurysmal sac and LOC. However, prolonged operation time, increased radiation exposure, and the use of contrast medium have been debated. To improve the long-term results of EVAR, embolisms of both the IMA and LA are required.

Intraoperative Challenges in Endovascular Treatment for Ruptured Intracranial Aneurysms

In aneurysmal subarachnoid hemorrhage, the highest therapeutic priority is to ensure immediate hemostasis without intraprocedural complications. This article outlines the possible intraoperative coil embolization complications for ruptured intracranial aneurysms and discuss strategies for their prevention and treatment.

The usefulness of contrast-enhanced subtraction magnetic resonance imaging for detecting endoleaks after endovascular aortic repair with prophylactic intraoperative sac embolization.

Metallic and hyperdense artifacts and T1-shortening substances in the abdominal aortic aneurysm (AAA) sac generated by embolic materials and lipiodol pose challenges in the identification of endoleaks on follow-up computed tomography (CT) or magnetic resonance imaging (MRI). To evaluate the usefulness of contrast-enhanced subtraction MRI (CES-MRI) for detecting endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) with intraoperative AAA sac embolization compared with CE-CT, this study was conducted. In this study, 28 consecutive patients who underwent EVAR with prophylactic AAA sac embolization were included. All patients underwent CES-MRI and CE-CT to detect endoleaks. The definitive diagnosis of endoleaks was a consensus reading of CE-CT and CES-MRI by two certified radiologists, in addition to angiography or reproducible radiological findings in the observational examination. Analysis was performed to evaluate which examination was better for detecting endoleaks. The sensitivity, specificity, and area under the curve of CE-CT and CES-MRI according to observer 1 were 50%, 100%, and 0.813 (95% confidence interval [CI] = 0.625-1.00) and 100%, 95%, and 0.997 (95% CI = 0.984-1.00), respectively, and those according to observer 2 were 50%, 100%, and 0.750 (95% CI = 0.514-0.986) and 100%, 95%, and 0.969 (95% CI = 0.903-1.00), respectively. Intolerable artifacts were significantly observed on CE-CT. The severity of the artifacts did not depend on the stent graft on CT and MRI. Although no significant difference was observed, CES-MRI tended to have better accuracy for endoleak detection in EVAR with intraoperative AAA sac embolization than CE-CT.

An Expert-Based Review on the Relevance and Management of Type 2 Endoleaks Following Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

Ruptured abdominal aortic aneurysms (rAAAs) are life-threatening and require emergent surgical therapy. Endovascular aortic repair for rupture (rEVAR) has become the leading strategy due to its minimal invasive approach with expected lower morbidity and mortality, especially in patients presenting with hemodynamic instability and relevant comorbidities. Following rEVAR, intraoperative angiography or early postinterventional computed tomography angiography have to exclude early type 1 or 3 endoleaks requiring immediate reintervention. Persistent type 2 endoleaks (T2ELs) after rEVAR, in contrast to elective cases, can cause possibly lethal situations due to continuing extravascular blood loss through the remaining aortic aneurysm rupture site. Therefore, early identification of relevant persistent T2ELs associated with continuous bleeding and hemodynamic instability and immediate management is mandatory in the acute postoperative setting following rEVAR. Different techniques and concepts for the occlusion of T2ELs after rEVAR are available, and most of them are also used for relevant T2ELs after elective EVAR. In addition to various interventional embolization procedures for persistent T2ELs, some patients require open surgical occlusion of T2EL-feeding arteries, abdominal compartment decompression or direct surgical patch occlusion of the aneurysm rupture site after rEVAR. So far, in the acute situation of rAAAs, indications for preemptive or intraoperative T2EL embolization during rEVAR have not been established. In the long term, persistent T2ELs after rEVAR can lead to continuous aneurysm expansion with the possible development of secondary proximal type I endoleaks and an increased risk of re-rupture requiring regular follow-up and early consideration for reintervention. To date, only very few studies have investigated T2ELs after rEVAR or compared outcomes with those from elective EVAR regarding the special aspects of persisting T2ELs. This narrative review is intended to present the current knowledge on the incidence, natural history, relevance and strategies for T2EL management after rEVAR.

Intraoperative direct venous puncture and embolization for arteriovenous shunt below the conus medullaris: a prospective cohort study

BackgroundArteriovenous shunt below the conus medullaris (AVS-BC) is easily misdiagnosed and mistreated due to its rarity. Achieving an anatomical cure solely through endovascular or surgical means is challenging. This study...

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

Surgical Management of Central Lymphatic Conduction Disorders: A Review

AimRecent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is leading to a wide range of novel surgical interventions. We present here the state-of-the-art imaging technology and current spectrum of surgical procedures available for patients with these conditions. MethodDescriptive report of the newest lymphatic imaging technology and surgical procedures and retrospective review of outcome data. ResultsThere are currently two high-resolution imaging modalities for the central lymphatic system: multi-access dynamic contrast-enhanced MR lymphangiogram (DCMRL) and central lymphangiography (CL). DCMRL is done by accessing percutaneously inguinal and mesenteric lymph nodes and periportal lymphatics vessels. DCMRL provides accurate anatomical and dynamic data on the progression, or lack thereof, of the lymphatic fluid throughout the central lymphatic system. CL is done by placing a catheter percutaneously in the thoracic duct (TD). Pleural effusions are managed by pleurectomy and intraoperative lymphatic glue embolization guided by CL. Anomalies of the TD are managed by TD-to-vein anastomosis and/or ligation of aberrant TD branches. Chylous ascites and organ-specific chylous leaks are managed by intraoperative glue embolization, surgical lymphocutaneous fistulas, and ligation of aberrant peripheral lymphatic channels, among several other procedures. ConclusionThe surgical management of lymphatic conduction disorders is a new growing field within pediatric general surgery. Pediatric surgeons should be familiar with the newest imaging modalities of the lymphatic system and with the surgical options available for patients with these complex surgical conditions to provide prompt treatment or referral. Level of EvidenceV.

Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum

PurposeTo evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS). Materials and MethodsAn institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded. ResultsA total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475–1,000 mL) compared to 2,000 mL (IQR, 1,500–2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3–9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed. ConclusionsProphylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.

Innovative use of a self-expanding valve for valve-in-valve transcatheter mitral valve replacement: experience from a four-year single-center study.

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) is a minimally invasive option for patients with bioprosthetic mitral valve failure. Since January 2019, our center has been using a new innovative option, J-Valve, to treat patients with bioprosthetic mitral valve failure who were at high risk for open heart surgery. The aim of this study is to explore the effectiveness and safety of J-Valve and report the results from the four-year follow-up period of the innovative application of the transcatheter valve. Patients who underwent the ViV-TMVR procedure between January 2019 and September 2022 in our center were included in the study. J-Valve™ system (JC Medical Inc., Suzhou, China) with three U-shape grippers was used for ViV-TMVR via transapical approach. Data on survival, complications, transthoracic echocardiographic results, New York Heart Association functional class in heart failure, and patient-reported health-related quality of life according to the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) were collected during the four-year follow up. Thirty-three patients (mean age 70.1 ± 1.1 years, 13 men) were included and received ViV-TMVR. The surgery success rate was 97%: only one patient was converted to open-heart surgery due to intraoperative valve embolization to the left ventricle. During the first 30 days all-cause mortality was 0%, risk of stroke 2.5% and risk of mild paravalvular leak 15.2%; mitral valve hemodynamics improved (179.7 ± 8.9 at 30 days vs. 269 ± 49 cm/s at baseline, p < 0.0001). Median time from operation to discharge was six days, and there were no readmissions within 30 days from operation. The median and maximum follow-up durations were 28 and 47 months, respectively; during the entire follow-up, all-cause mortality was 6.1%, and the risk of cerebral infarction 6.1%. Cox regression analysis did not identify any variables significantly associated with survival. The New York Heart Association functional class and the KCCQ-12 score improved significantly compared with their preoperative values. The use of J-Valve for ViV-TMVR is safe and effective with a high success rate, low mortality and very few associated complications, representing an alternative surgical strategy for the elderly, high-risk patients with bioprosthetic mitral valve failure.

Prediction of cerebral ischemia during carotid stenting depending on the intensity of the preoperative ultrasound signal from the plaque

Carotid stenting is an effective method for improving cerebral perfusion; risk assessment of cerebral embolism associated with this intervention remains a hot research topic. Objective: to identify predictors of cerebral embolism associated with carotid angioplasty with stenting (CAS). Material and methods. A prospective exploratory research included 46 patients (age from 44 to 81 years, median 65 years) with atherosclerotic stenosis of the internal carotid artery, who underwent CAS and were treated at the Scientific Center of Neurology (Moscow). The study did not include patients with restenosis, stroke with severe disability, contraindications for antiplatelet therapy, statins, and MRI examination. All patients underwent preoperative ultrasonographic (US) examination and postoperative histological examination of particles in carotid stent embolic protection devices. The state of the brain was assessed before and 24 hours after CAS using diffusion-weighted MRI. To identify predictors of the development of cerebral embolism, the clinical characteristics of patients, together with ultrasonographic and morphological data, were examined in a multivariate statistical analysis.Results. Preoperative US signal from an atherosclerotic plaque of high (estimated above 35 dB) intensity was associated with dense matter (in a protective device) of the "fibrosis with calcification" and "calcification" type and with a high probability (80%; 95% confidence interval 71–85% ) predicted intraoperative embolization of cerebral vessels with the acute ischemic lesions (AIL) formation. In a low (not higher than 35 dB) intensity of the preoperative ultrasound signal, the probability of AIL formation was statistically significantly lower (50%). Conclusion. There is a direct correlation between the intensity of the ultrasound signal and the density of the substance in the protective device. A high intensity of the preoperative ultrasound signal (estimated above 35 dB) is an unfavorable predictor of AIL, associated with CAS (with a probability of about 80%).

Temperature sensitive nanogels for real-time imaging during transcatheter arterial embolization

ABSTRACTSeveral vascular embolization materials are commonly used in clinical practice, however, having application defects of varying degrees, such as poor intraoperative imaging and easy recanalization of embolized blood vessels, they are challenging for application during Transcatheter arterial embolization (TAE). Thus, an intraoperative visible vascular embolization material with good embolization effect and biocompatibility can improve transcatheter arterial embolization clinical efficacy to some extent. Our study aimed to synthesize a novel vascular embolization material that can achieve complete embolization of arterial trunks and peripheral vessels, namely poly (N-isopropyl acrylamide)-co-acrylic acid nanogel (NIPAM-co-AA). Iohexol 200 mg/mL was co-assembled with 7 wt% NIPAM-co-AA nanogel to create an intelligent thermosensitive radiopaque nanogel (INCA), which achieves a good intraoperative imaging effect and is convenient for transcatheter arterial bolus injection due to its good fluidity and temperature-sensitive sol-gel phase transition. The normal rabbit kidney embolism model further confirmed that INCA could effectively use Digital subtraction angiography (DSA) to achieve intraoperative imaging, and real-time monitoring of the embolization process could avoid mis-embolization and leakage. Meanwhile, in a 42-day study, INCA demonstrated an excellent embolization effect on the right renal artery of New Zealand white rabbits, with no vascular recanalization and ischemic necrosis and calcification remaining. As a result, this radiopaque thermosensitive nanogel has the potential to be an intelligent thermosensitive medical vascular embolization material, providing dual benefits in TAE intraoperative imaging and long-term postoperative embolization while effectively addressing the shortcomings and challenges of commonly used clinical vascular embolization agents.

Efficacy and safety of prophylactic intraoperative sac embolization in EVAR for abdominal aortic aneurysm: A meta-analysis.

We aimed to investigate the effectiveness and safety of prophylactic sac embolization during endovascular aneurysm repair (EVAR) in patients suffering from abdominal aortic aneurysms. We performed a systematic literature search of PubMed, Web of Science, EMbase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Wanfang and China Biomedical Literature Database (CBM) to identify studies evaluating the outcomes of sac embolization vs. no embolization among patients who had received EVAR. The time limit of the search was from the establishing database to July 22, 2022. Outcome measures involved the type II endoleak rate, the other endoleak rate, the reintervention rate, mortality, and operation time. Fixed (no heterogeneity) or random effects models were constructed for each outcome. The outcomes are represented as the odds ratio (OR) with a 95% confidence interval (CI). Among the 2,622 studies screened, 13 studies involving 747 participants were included in the review. The incidence of early-term type II endoleak (OR = 0.2, 95% CI (0.13,0.31), P < 0.00001), mid-term type II endoleak (OR = 0.23, 95% CI (0.15,0.37), P < 0.00001), late-term type II endoleak (OR = 0.27, 95% CI (0.16,0.46), P < 0.00001) and reintervention (OR = 0.50, 95% CI (0.37,0.78), P = 0.002) within the sac embolization group were significantly lower than those in the non-embolization group. No significant differences were observed between the two groups were found for the other endoleak rates (OR = 0.67, 95% CI (0.34,1.32), P = 0.25), mortality (OR = 0.64, 95% CI (0.25,1.66), P = 0.36) and operation time operation (MD = 5.76, 95% CI (-8.30,19.83), P = 0.42). EVAR combined with sac embolization effectively reduces the incidence of type II endoleak and the reintervention rate without enhancing the operation time. Therefore, more high-quality studies are still needed for validation due to the limited amount and quality of included literature. https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022365648.

Percutaneous mechanical thrombectomy using the Rotarex®S device for the treatment of acute lower limb artery embolism: A retrospective single-center, single-arm study.

Acute limb embolism (ALE) is a challenging, highly morbid, and frequently fatal vascular emergency. Percutaneous mechanical thrombectomy (PMT) devices are an alternative treatment to restore perfusion by removing emboli in the limb arterial system. We evaluated the outcomes of treatment of ALE patients using PMT devices in our center. A retrospective review of ALE patients treated with Rotarex S (Straub Medical) at a single institution from 2018 to 2022 was performed. The primary outcome was technical success, defined as complete recanalization of the occluded segment with satisfactory outflow and good capillary filling of the distal parts of the foot without any major or obstructing residual emboli or thrombi either in the treated segment or in the outflow tract without the need for additional catheter-directed thrombolysis (CDT) or conversion to open surgery. Embolized segments treated, treatment outcomes, and perioperative complications were reviewed. A total of 17 ALE patients (29% men, 71% women; mean age, 73 years) underwent PMT procedures. The femoral arteries and popliteal arteries are the most commonly treated vessels, with both present in 59% of the patients. The technical success rate was 100%, but the majority of cases (82%) had concurrent percutaneous transluminal angioplasty or stent grafting, and two patients were treated with urokinase during the operation. There was one thrombotic recurrence that required amputation. There were no 30-day deaths. Complications included extravasation after PMT (two), intraoperative embolization of the outflow tract (one), access site hematoma (one), target artery thrombosis (one), and acute kidney injury (one). There were no severe bleeding complications. The Rotarex S device has a satisfactory success rate, although complementary use of various adjunctive techniques is frequently required. It seems to be a moderately effective tool for treating ALE to avoid CDT or open surgery. The device appears safe, with low risks of amputation and mortality rates, but special attention should be given to the potential for extravasation and distal embolism.

EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts.

Ectopic embolism caused by cyanoacrylate glue for the treatment of gastric varices with obvious spontaneous portosystemic shunts is a serious complication of endoscopic therapy. This study was performed to investigate the safety and therapeutic effect of EUS-guided coil placement and cyanoacrylate glue injection for gastric varices with obvious spontaneous portosystemic shunts. Six patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts were included in this study. We evaluated the success rate of variceal occlusion after intraoperative embolization, the postoperative rebleeding rate at 48 h and 2 weeks posttreatment, and the incidence of ectopic embolism and other adverse events. Gastroscopy and computed tomography portal venography (CTPV) were performed 7 months later. All patients underwent successful coil placement and cyanoacrylate glue injection under EUS guidance. The blood flow was confirmed by Doppler examination, the target vessels were successfully blocked, and no rebleeding had occurred at 48 h or 2 weeks after endoscopic treatment. Gastroscopy was repeated 7 months after endoscopic treatment, revealing local ulcer formation. CTPV was also repeated 7 months after endoscopic treatment, showing that the coils were present in the target vessels with no displacement, the portosystemic shunt vessels were occluded, and no ectopic embolization had occurred. The coil placement combined with cyanoacrylate glue embolism is a safe and effective method for patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts.

Management of a Gluteal Noninvoluting Hemangioma With Glue Embolization and Excision.

Noninvoluting congenital hemangiomas (NICHs) persist in a high-flow state into childhood and often require surgical excision. The inherent vascular nature of these tumors make effective surgical treatment challenging. Here we report on a patient that underwent intraoperative glue embolization and complete excision of a large gluteal NICH. Concurrent glue embolization followed by complete excision allows for decreased intraoperative blood loss and easier discrimination between the tumor and surrounding structures. Treating difficult vascular tumors with a multidisciplinary approach and subsequent intraoperative glue embolization with surgical excision allows for an effective, single-stage approach to NICHs.

Abstract No. 133 ▪ FEATURED ABSTRACT Multivessel pelvic embolization during cesarean hysterectomy for placenta accreta spectrum: A single-center experience and comparison to internal iliac artery balloon occlusion

Placenta accreta spectrum (PAS) is associated with high risks of morbidity and mortality, with potentially life-threatening hemorrhage during surgical management. Internal iliac artery balloon occlusion (IIABO) has yielded mixed outcomes. We compare intra-operative pelvic embolization to IIABO for patients undergoing cesarean hysterectomy for PAS.

Extended Use of Distal Embolic Protection Devices in Treatment of Distal Embolism During Lower Extremity Arterial Endovascular Interventions.

There is no consensus on the best treatment modality for acute distal embolization complications during endovascular interventions for peripheral arterial diseases. We report on 3 patients who underwent mechanical embolectomy using a distal embolic protection device (EPD). All patients showed angiographic evidence of distal embolism, which occurred during lower extremity limb salvage endovascular procedures. After embolectomy, all had complete recanalization of the involved vessel on completion angiogram, and none had any device-related complications or adverse outcomes from the embolization. This initial experience suggests that EPD can be used for both the prevention and treatment of intraoperative distal embolization during endovascular intervention of lower extremity arterial disease.

Comparison of One-Stage and Two-Stage Intraoperative Uterine Artery Embolization during Cesarean Delivery for Placenta Accreta: Report of Two Clinical Cases at a Tertiary Referral Medical Center.

Placenta accreta spectrum (PAS) described the anchoring placental villi attached or penetrating into/through the myometrium. PAS is clinically important because of the unpredictable bleeding amount when manually removing the defective decidualization at the endometrial-myometrial interface. Therefore, a multidisciplinary strategy for cesarean delivery with PAS is crucial. Postoperative embolization after cesarean hysterectomy in a hybrid suite was studied by many scientists. In this study, we demonstrated two cases of intraoperative embolization without hysterectomy in a hybrid operating room for cesarean delivery with placenta accreta. Our results show that intraoperative uterine artery embolization with a hybrid suite is a time-preserving and safe method for cesarean delivery with PAS owing to avoiding the risk of morbidity and mortality during patient transfer.