Percutaneous Transcatheter Embolization Research Articles

Role of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleeding associated with anticoagulant therapy.

To evaluate safety and clinical efficacy of percutaneous transcatheter embolization (PTE) in the treatment of spontaneous bleedings (SBs) in patients submitted to chronic anticoagulation therapy. From January 2007 to December 2012, 20 patients (mean age 75.8 years, range 68-91 years) with 23 SBs were retrospectively evaluated. Active bleeding was documented by contrast enhanced-multidetector row computed tomography (CE-MDCT). PTE was performed using different embolic agents. Technical success (TS), clinical success (CS), late success (LS) and mortality rate (M) related to the angiographic procedure and complications were evaluated. CE-MDCT and digital subtraction angiography (DSA) identified active bleeding sites in 18 cases (18/20). In two cases (2/20) DSA did not confirm the arterial bleeding diagnosed on CE-MDCT. Twenty-three sessions of PTE were performed. TS, CS, LS and M were, respectively, 100, 85, 15 and 0%. No major complications were observed. PTE could be considered a safe and effective "first line" approach to treat SB associated with anticoagulation therapy.

Pulmonary arteriovenous malformations: haemodynamics and shunt closure

The first description of pulmonary arteriovenous malformations (PAVM) was made already in 1897 by Churton [1]. PAVM are abnormal vascular structures that connect the pulmonary arterial bed directly to the pulmonary venous bed, thereby bypassing the pulmonary capillaries and resulting in an intrapulmonary shunt which, depending on number and size of the PAVM, may result in arterial desaturation and paradoxical systemic embolisation [2]. Because the PAVM are thin-walled vascular structures, they are prone to rupture, resulting in haemoptysis. A major step forward in the treatment of PAVM was the use of percutaneous transcatheter embolisation, using femoral venous access [3]. This procedure is safe and reduces the risk of paradoxical thromboembolisation and haemoptysis. Moreover, by reducing shunt flow, arterial oxygen saturation increases. Although percutaneous closure of PAVM has been performed for years, and a surprisingly small effect on pulmonary haemodynamics has been shown [4], the study by Vorselaars and co-workers in the present issue of the Netherlands Heart Journal [5] is the first to investigate the immediate consequences of PAVM closure on systemic haemodynamics. Using Finapres technology, which derives changes in stroke volume and systemic pressure from the pressure wave form as measured on a finger, they describe an overall decrease in stroke volume and cardiac output that corresponds in magnitude with the overall decrease in shunt fraction. This decrease in stroke volume is similar to the decrease in stroke volume, as measured directly by right heart catheterisation, observed in a case study at 4 months follow-up after PAVM [6]. It was speculated that such a decrease in stroke volume helped to explain the absence of an increase in pulmonary artery pressures [4], despite the fact that pulmonary vascular resistance should obviously increase as a consequence of the closure of the low resistance PAVM. The mechanism behind the observed decrease in stroke volume is unclear. It could be speculated that shunt closure and the accompanying increase in pulmonary vascular resistance result in a slight increase in right ventricular afterload, which limits right ventricular output. It is, however, more likely to assume that oxygen is regulated to fulfil the oxygen demand of peripheral tissues; shunt closure increases the oxygen content of arterial blood and hence for the same oxygen delivery, in the presence of improved oxygenation, less flow is required. The latter explanation is in accordance with the observation that the shunt fraction prior to embolisation (14 %) is similar in magnitude to the decrease in cardiac output (10 %) [5]. As pulmonary artery pressure increases during exercise, the driving pressure for the shunt flow increases, resulting in an increased shunt flow, which is accompanied by augmented arterial desaturation during exercise [7–9]. However, exercise capacity is surprisingly well-maintained in patients with PAVM, potentially due to the capability of the right heart to deal with volume overload. Indeed, although most patients report an increased exercise capacity and quality of life following shunt closure, an objective increase in exercise capacity is not found in all patients [10]. It is possible that changes in pulmonary and systemic haemodynamics upon shunt closure, which are relatively small under resting conditions, are exacerbated during exercise. Thus, while the study by Vorselaars in the present issue of the Netherlands Heart Journal provides an important observation in resting patients [5], a comprehensive evaluation of shunt flow, pulmonary and systemic haemodynamics and oxygen saturation during exercise prior to and following shunt closure would be of great benefit to enhance our understanding of the implications of shunt closure on exercise capacity.

Coronary artery-bronchial artery fistulas: report of two Dutch cases with a review of the literature

BackgroundCoronary bronchial artery fistulas (CBFs) are rare anomalies, which may be isolated or associated with other disorders.Materials and methodsTwo adult patients with CBFs are described and a PubMed search was performed using the keywords “coronary bronchial artery fistulas” in the period from 2008 to 2013.ResultsTwenty-seven reviewed subjects resulting in a total of 31 fistulas were collected. Asymptomatic presentation was reported in 5 subjects (19 %), chest pain (n = 17) was frequently present followed by haemoptysis (n = 7) and dyspnoea (n = 5). Concomitant disorders were bronchiectasis (44 %), diabetes (33 %) and hypertension (28 %). Multimodality and single-modality diagnostic strategies were applied in 56 % and 44 %, respectively. The origin of the CBFs was the left circumflex artery in 61 %, the right coronary artery in 36 % and the left anterior descending artery in 3 %. Management was conservative (22 %), surgical ligation (11 %), percutaneous transcatheter embolisation (30 %), awaiting lung transplantation (7 %) or not reported (30 %).ConclusionsCBFs may remain clinically silent, or present with chest pain or haemoptysis. CBFs are commonly associated with bronchiectasis and usually require a multimodality approach to be diagnosed. Several treatment strategies are available. This report presents two adult cases with CBFs and a review of the literature.

Comments on the article "Coronary artery fistula: a huge conus branch aneurysm".

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Haponiuk I. COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2014;11(4):444-444. doi:10.5114/kitp.2014.47350. APA Haponiuk, I. (2014). COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 11(4), 444-444. https://doi.org/10.5114/kitp.2014.47350 Chicago Haponiuk, Ireneusz. 2014. "COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm"". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 11 (4): 444-444. doi:10.5114/kitp.2014.47350. Harvard Haponiuk, I. (2014). COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 11(4), pp.444-444. https://doi.org/10.5114/kitp.2014.47350 MLA Haponiuk, Ireneusz. "COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm"." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 11, no. 4, 2014, pp. 444-444. doi:10.5114/kitp.2014.47350. Vancouver Haponiuk I. COMMENTARYComments on the article "Coronary artery fistula: a huge conus branch aneurysm". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2014;11(4):444-444. doi:10.5114/kitp.2014.47350.

Percutaneous Transcatheter Embolization of Pulmonary Artery Pseudoaneurysms Causing Massive Hemoptysis

Systemic bronchial arterial circulation is the most common source for massive hemoptysis. Rarely, the source of bleeding can be the pulmonary artery. We report 2 different case scenarios of massive hemoptysis due to different etiologies, in which the source of bleeding was the pulmonary artery. Both the patients were treated with percutaneous transcatheter embolotherapy using coils. The 2 cases highlight the importance of considering pulmonary arterial etiology as the cause of hemoptysis while reporting diagnostic computed tomography studies and tailoring the interventional technique toward performing pulmonary angiography instead of searching for a systemic arterial source for hemoptysis.

64-detector row CT evaluation of bronchial and non-bronchial systemic arteries in life-threatening haemoptysis

To retrospectively evaluate the depiction of bronchial and non-bronchial systemic arteries with 64-detector row CT in patients undergoing endovascular treatment for life-threatening haemoptysis. 64-detector row helical CT and conventional angiography of the thorax were performed in 28 patients (25 males, 3 females; age range, 18-65 years; mean age, 40 years) with life-threatening haemoptysis. CT images were analysed to identify abnormal bronchial and non-bronchial systemic arteries and also to localise them in two planes. Using multidetector CT (MDCT), 43 bronchial arteries were identified on the right side and 46 on the left side. 89% of the right bronchial arteries originated from the right intercostobronchial arteries. A common trunk of origin of the right and left bronchial artery was noted in 46% of cases. 23 non-bronchial systemic arteries were noted on the right side and 41 on the left side. Pleural thickening >3 mm was confirmed to be a good predictor of non-bronchial systemic supply. An internal mammary artery diameter of >3 mm and an inferior phrenic artery diameter of >2 mm were sensitive indicators for non-bronchial systemic supply. MDCT is a good investigation tool for evaluating life-threatening haemoptysis as it confirms the disease process, identifies the origin and ostial position of bronchial arteries, detects non-bronchial systemic arteries and acts as a roadmap for percutaneous transcatheter embolisation.

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization

To determine the efficacy of percutaneous transcatheter embolization in the management of patients with spermatic varicocoeles persisting or recurring after surgery. Over a period of 10 years, 28 patients (age range 13-55 years) were referred for percutaneous transcatheter embolization of postsurgical, recurrent varicocoeles. Medical documents were retrospectively reviewed to evaluate past surgical history, subjective symptoms, and results of scrotal examination, ultrasound, and semen parameters. Pre-embolization venograms were analysed to assess the anatomy of the testicular vein. The technical and clinical outcomes of embolization were then determined. The 28 patients included in the study had undergone laparoscopic varicocoelectomy (39.3%), high retroperitoneal ligation (25%), or inguinal ligation (25%). Subjective symptoms were scrotal pain (60.7%) and a palpable scrotal mass (50%) exclusively on the left side. Venograms revealed abnormalities of the left testicular vein in all cases. Embolization was technically successful in all but two cases, thus yielding an occlusion rate of 93%; a single case of suspected thrombophlebitis was the only complication. After excluding two, technically unsuccessful cases and one patient who was lost to follow-up, 25 patients underwent scrotal examination after embolization, which revealed complete resolution in 20 cases (80%), partial improvement in four cases (16%), and no improvement in a single case (4%). Among the follow-up group of patients, of the 12 who initially presented with scrotal pain, six (50%) were symptom-free and four (33.3%) had partial improvement. Percutaneous transcatheter embolization of the testicular vein is technically feasible and effective for managing postsurgical recurrent varicocoeles.

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

Interlocking Detachable Coil Embolization by Technique of Dumbbell-Shaped Framing and Filling and Bridge Formation Under Balloon Dilatation for Huge Conglomerate Pulmonary Arteriovenous Malformation

A 60-year-old woman presented with a conglomerate pulmonary arteriovenous malformation (PAVM) size 8.2 × 7.2 cm on chest X-ray. Feeding arteries were A(a)(7) and A(b)(7) , A(8), and A(10). The diameter and length of the A(b)(7) neck were 15.5 and 16 mm, respectively. After percutaneous transcatheter embolization of A(8) and A(10), PTE of A(a)(7) and A(b)(7) was conducted under balloon occlusion with interlocking detachable coils using a technique of dumbbell-shaped framing and filling, making a bridge from A(b)(7) to the trunk of A(9) and A(10)across A(7). Follow-up computed tomography 10 months after treatment showed marked shrinkage of the PAVM.

Successful treatment of a bleeding duodenal varix by endoscopic band ligation

Bleeding from duodenal varices is a rare complication of portal hypertension. Most patients with duodenal varices have extrahepatic portal hypertension [1]. Due to the limited number of cases, different treatment modalities for duodenal varices have not been compared in randomized controlled trials and most of our current knowledge is obtained from case reports and small case series. So far, endoscopic therapy (sclerotherapy, band ligation, mini-loop ligation), radiological techniques (percutaneous transcatheter embolisation, TIPS-implantation) and surgical procedures have been used [2]. Compared to other treatment options endoscopic band ligation is a relatively noninvasive therapy. However, till now, only a small number of case reports regarding the use of this technique in the duodenum have been published [3-5]. A 78-year old woman was admitted to hospital because of hematemesis and melena. Two years previously, a neuroendocrine carcinoma of the head of the pancreas had been diagnosed and treatment with lanreotide (60 mg s.c. once a month) had been started. The patient s history further included insulin dependent diabetes mellitus, arterial hypertension and ischemic stroke. On admission the patient had severe anemia (hemoglobin 7.7 g/dl). After hemodynamic stabilization, gastroscopy was performed, which revealed esophageal varices with a diameter of >0.5 cm without signs of bleeding, a considerable amount of blood in the stomach and duodenum and a single varix in the superior part of the duodenum. A small ulcer was visible on this varix, indicating recent bleeding (Fig. 1). Band ligation of the duodenal varix was successfully performed. In addition, the patient received terlipressin and antibiotics. Abdominal MRI revealed tumor progression: the tumor in the head of the pancreas had increased to a diameter 9 x 5 cm, causing thrombosis of the portal vein. In addition, one liver metastasis (diameter 4 cm), peritoneal carcinosis and ascites were detected. Six days after endoscopic treatment, a second gastroscopy was performed. At this time the duodenal varix was hardly visible anymore and at the site where the band ligation had been performed there was a small flat ulcer covered with necrotic material (Fig. 2). During two months follow-up there were no further episodes of gastrointestinal bleeding. This case brings further evidence that bleeding from duodenal varices caused by portal hypertension can be treated successfully by endoscopic band ligation.

Oclusão de fístula arteriovenosa pulmonar com plug vascular em paciente com embolia cerebral paradoxal prévia

A embolização percutânea transcateter tornou-se o tratamento de escolha para fístulas arteriovenosas pulmonares (FAVPs), na maioria dos casos em substituição à intervenção cirúrgica. Os dispositivos clássicos, tais como coils intravasculares e balões destacáveis, provaram ser um sucesso para oclusões percutâneas de FAVPs pequenas ou médias; porém, não são ideais nas fístulas maiores e de alto fluxo pelo risco de embolização para a circulação sistêmica. Relatamos o caso de uma mulher de 49 anos de idade com FAVP de alto fluxo e manifestações neurológicas isquêmicas prévias, submetida com sucesso a fechamento percutâneo com AmplatzerTM Vascular Plug II, um dispositivo projetado para oclusão de anormalidades vasculares.

Percutaneous transcatheter embolization with n-butyl cyanoacrylate of hepatic hemorrhagic lesions in urgent situations

To report on our clinical experience with and the success rate and safety of percutaneous transcatheter embolization with N-butyl cyanoacrylate (NBCA) as the lone primary embolic agent used for arterial embolization of hemorrhagic liver lesions. This retrospective study enrolled all patients who presented to the emergency room with hemorrhagic liver lesions during a two-year period and were treated by percutaneous transcatheter embolization with NBCA. Eight consecutive patients were evaluated, and 13 lesions were embolized exclusively with NBCA: eight pseudoaneurysms and five active bleeds. All patients were treated successfully using percutaneous transcatheter embolization with NBCA without re-bleedings or major complications. Percutaneous transcatheter embolization with NBCA is a safe and effective method for treating hemorrhagic lesions.

Coil embolization of a celiac artery aneurysm using the neck remodeling technique

Aneurysms of the celiac trunk are rare. Untreated lesions enlarge progressively and may rupture spontaneously. We report the case of a 56-year-old man whose wide neck celiac aneurysm was successfully packed with coils with preservation of the native arterial circulation by percutaneous transcatheter embolization using the neck remodeling technique.

Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

A Case of Successful Surgical Treatment of Migraine Headaches in a Patient with Sporadic Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations (PAVMs) are thin-walled aneurysms caused by abnormal communication between the pulmonary arteries and veins. Migraine headaches are sometimes the presenting clinical manifestation of PAVMs. Although embolotherapy, using detachable balloons or stainless steel coils, is generally accepted as the best choice for the treatment of multiple PAVMs, the mode of intervention for solitary PAVMs remains a subject of debate. We present a 43-yr-old woman with a 10-yr history of chronic migraines and dyspnea on exertion. She was discovered to have a large solitary centrally located PAVM, placing her at high risk of complications if she were to undergo percutaneous transcatheter embolization. She underwent successful surgical resection of her right middle lobe without complications, resulting in subsequent symptomatic improvement.

Ruptured hepatic artery aneurysm: A novel approach to distal control

We describe a unique method for obtaining distal control in a ruptured hepatic artery aneurysm. A 34-year-old man with Ehlers-Danlos syndrome type IV presented with a ruptured left hepatic artery aneurysm. The distal aneurysm was within the parenchyma of the liver. Proximal control was obtained with pledgeted sutures. The distal hepatic artery was difficult to control. Injection of 5 mL of thrombin into the distal left hepatic artery resulted in hemorrhage control. This technique should be considered in select patients in whom distal arterial control is challenging.

Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

Quality Improvement Guidelines for Percutaneous Transcatheter Embolization

Percutaneous Transcatheter Embolization of a Large Pulmonary Arteriovenous Fistula with an Amplatzer Vascular Plug

Percutaneous transcatheter embolization has become the treatment of choice for pulmonary arteriovenous fistulas (PAVFs), in most cases replacing surgical intervention. However, while "classic" devices, such as intravascular coils and detachable balloons, have proved to be successful for interventional occlusions of small or medium-sized PAVFs, they are not ideal in larger fistulas because of the risk for embolization to the systemic circulation. We describe the case of a 61-year-old woman with a symptomatic huge solitary pulmonary arteriovenous fistula (4.5 cm in diameter), occupying part of the lung in the lower right lobe with two feeding arteries (10 and 4 mm in diameter, respectively), who underwent successful transcatheter closure with an Amplatzer Vascular Plug, a new device designed for the occlusion of vascular abnormalities.

Multiple Hepatic Artery Aneurysms: Use of Transcatheter Embolization for Rupture

Aneurysmal disease of the hepatic artery is a rare and potentially life-threatening entity. Aneurysms occur anywhere along the hepatic artery and its branches, but they have a predilection for occurring as a solitary lesion of the common or right hepatic artery. Diffuse intrahepatic hepatic artery aneurysm is the rarest form and is especially challenging. Treatment of these lesions has been described in only a few case reports. We present a patient with ruptured intrahepatic hepatic artery aneurysms treated by percutaneous transcatheter embolization.