Percutaneous Transvenous Embolization Research Articles

Percutaneous transvenous coil embolization (PTCE) for treatment of single extrahepatic portosystemic shunt in dogs

BackgroundThere is limited information regarding percutaneous transvenous coil embolization (PTCE) for single extrahepatic portosystemic shunt (PSS). This study aimed to describe the procedure and outcome of PTCE in dogs with a single extrahepatic PSS. Forty-two privately owned dogs were included in this study. All dogs were diagnosed with extrahepatic PSS by computed tomography (CT). Preoperative CT images were used to evaluate the diameter of the PSS for coil placement. A multipurpose balloon catheter was percutaneously inserted into the PSS via the jugular vein, and transvenous retrograde portography (TRP) and measurement of blood pressure in the PSS (pPSS) were performed during balloon inflation; one or more embolization coils were implanted via the catheter.ResultsIn most cases, preoperative median fasting and postprandial serum total bile acid (TBA) concentrations were high (fasting, 86.5 μmol/L [ 3.7–250.0 μmol/L]; postprandial, 165.5 μmol/L [ 1.5–565.0 μmol/L]). CT revealed that 30 dogs had left gastrophrenic shunt; eight had left gastroazygos shunt; and one each had left gastrocaval, splenocaval, splenophrenic, and left colocaval shunt. TRP revealed that intrahepatic portal vascularity was clearly detectable in all dogs. The median values of pPSS before and during the balloon occlusion were 4.8 mmHg [2.0–13.0 mmHg] and 8.6 mmHg [5.0–18.0 mmHg], respectively. The median number and diameter of coils used were 2 coils [1 – 5 coils] and 8.0 mm [4.0 – 12.0 mm], respectively. The median times of irradiation and PTCE were 9 min [4–26 min] and 40 min [23–75 min], respectively. The median fasting and postprandial TBAs significantly decreased to 8.2 μmol/L [0.3–45.1 μmol/L, n = 38, p = 0.0028] and 19.8 μmol/L [0.3–106.7 μmol/L, n = 38, p = 0.0018], respectively, approximately 1 month after PTCE. The clinical success rate of PTCE without requirement for a second surgery was 95.2% (40/42 dogs). During revision surgery, one dog underwent surgical ligation and, in another dog, an ameroid constrictor was placed.ConclusionsPTCE was clinically effective in treating single extrahepatic PSS in dogs. Preoperative CT and TRP prior to PTCE might be clinically valuable for choosing the size of embolization coils, deciding the appropriate location of coil implantation, and estimating the number of coils to be implanted. PTCE is a promising alternative to conventional surgical procedures for single extrahepatic PSS in dogs.

Congenital Portosystemic Shunts in Dogs and Cats: Treatment, Complications and Prognosis.

Congenital portosystemic shunts (CPSS) are a common vascular anomaly of the liver in dogs and cats. Clinical signs of CPSS are non-specific and may wax and wane, while laboratory findings can raise the clinical suspicion for CPSS, but they are also not specific. Definitive diagnosis will be established by evaluation of liver function tests and diagnostic imaging. The aim of this article is to review the management, both medical and surgical, complications, and prognosis of CPSS in dogs and cats. Attenuation of the CPSS is the treatment of choice and may be performed by open surgical intervention using ameroid ring constrictors, thin film banding, and partial or complete suture ligation or by percutaneous transvenous coil embolization. There is no strong evidence to recommend one surgical technique over another. Medical treatment strategies include administration of non-absorbable disaccharides (i.e., lactulose), antibiotics, and dietary changes, and are indicated for pre-surgical stabilization or when surgical intervention is not feasible. After CPSS attenuation, short- and long-term post-surgical complications may be seen, such as post-operative seizures and recurrence of clinical signs, respectively. Prognosis after surgical attenuation of CPSS is generally favorable for dogs and fair for cats.

Percutaneous transvenous coil embolization of congenital intrahepatic portosystemic shunts in small- and toy-breed dogs: 20 cases (2015-2021).

To describe outcomes of small- and toy-breed dogs with a congenital intrahepatic portosystemic shunt (IHPSS) treated with percutaneous transvenous coil embolization (PTCE). 20 small- and toy-breed dogs with an IHPSS. All dogs underwent CT angiography for shunt evaluation as well as PTCE. Medical records were reviewed for pertinent data, and owners and primary veterinarians were contacted for long-term follow-up information. Dogs ranged from 1.5 to 10.0 kg (mean ± SD, 6.32 ± 2.57 kg) in weight. The equipment used to perform PTCE tended to be smaller than that previously described for larger breed dogs. Intra- and postoperative complication rates were 20% (4/20) and 5% (1/20), respectively, and included hypotension, bradycardia, hypercapnia, ventricular premature contractions, hypothermia, and regurgitation. Dogs were discharged a median of 3 days (range, 1 to 3 days) after surgery, and all dogs survived to discharge. Clinical signs resolved in 95% (19/20) of the dogs a median of 21 days after the procedure. One- and 2-year survival rates were 92%. Three dogs had died by the time of data collection; 2 of these dogs died of causes related to the IHPSS 267 and 1,178 days, respectively, after the procedure. Percutaneous transvenous coil embolization was a safe and effective option for treatment of IHPSS in small- and toy-breed dogs and offered a minimally invasive alternative to open surgical techniques. Complication and survival rates in this cohort were similar to or better than those reported in previous studies evaluating PTCE and open surgical techniques for treatment of IHPSS in dogs.

Quantitative analysis of contrast-enhanced ultrasound estimates intrahepatic portal vascularity in dogs with single extrahepatic portosystemic shunt.

To evaluate the clinical impact on quantitative analysis of contrast-enhanced ultrasound (CEUS) on single extrahepatic portosystemic shunt (PSS) in dogs. 21 client-owned dogs with single extrahepatic PSS and 5 healthy Beagles. In all dogs, CEUS was performed to calculate the rising time (RT), rising rate (RR), and portal vein-to-hepatic parenchyma transit time (ΔHP-PV) from the time-intensity curve obtained in the hepatic parenchyma and portal vein. All dogs in the PSS group underwent preoperative CT angiography (CTA) and surgery. The CEUS variables in the PSS group were compared with those in the healthy dogs (control group) and were analyzed for shunt types and grades of intrahepatic portal venous branches based on CTA findings, intraoperative portal pressure, and surgical procedures. All 3 CEUS variables showed no significant differences between the PSS and control groups. The RT and ΔHP-PV in the left gastrophrenic shunt group were significantly longer than in the other shunt types. In the intrahepatic portal vascularity, the RT in grade 1 was significantly shorter than in grades 3 and 4, and the RR in grade 1 was significantly higher than in grade 4. The RT and ΔHP-PV were significantly correlated with portal pressure variables. The RT in dogs with partial ligation was significantly shorter than in dogs with complete ligation and percutaneous transvenous coil embolization. Quantitative assessments of CEUS may be useful for estimating intrahepatic portal vascularity in dogs with single extrahepatic PSS.

Protein C and comparative biochemical changes in dogs treated with percutaneous transvenous coil embolization of congenital intrahepatic portosystemic shunts.

To evaluate protein C (PC) activity after intrahepatic portosystemic shunt (IHPSS) percutaneous transvenous coil embolization (PTCE) in dogs; to identify if PC is associated with clinical status after intervention, and to compare PC with standard biochemical values. Retrospective case series. Forty-seven client-owned dogs with IHPSS undergoing PTCE. Records were reviewed for preoperative and postoperative PC, hematocrit (HCT), mean corpuscular volume (MCV), albumin (ALB), and blood urea nitrogen (BUN). Ultimate clinical status was classified as excellent, fair, or poor, based on ongoing medical management and the presence of clinical signs. Intrahepatic portosystemic shunt was considered to be completely or incompletely occluded intraoperatively based on angiography. Postoperative PC activity increased in 37/47 (78.7%) dogs with a mean increase of 38.7% ± 2.1%. Ultimate postoperative clinical status was excellent in 16/43 (37.2%), fair in 19/43 (44.2%), and poor in 8/43 dogs (18.6%). No association was detected between preoperative PC (46.8% ± 1.8%) and ultimate clinical status but mean postoperative PC (75.7% ± 1.4%), HCT, MCV, ALB, and BUN were higher in dogs with excellent clinical status. Postoperative PC activity was higher when shunts were completely occluded (96.3% ± 10.9%), which was a finding associated with excellent status. Postoperative, but not preoperative, PC activity was higher in dogs with better ultimate clinical status. Similar trends were noted in standard hematological and biochemical values. Complete occlusion of shunts was associated with a higher postoperative PC and superior ultimate clinical status. Postoperative PC may provide valuable information about the success of PTCE for IHPSS as it relates to the ultimate status and the need for additional procedures.

Outcomes of cellophane banding or percutaneous transvenous coil embolization of canine intrahepatic portosystemic shunts.

To compare clinical outcomes of dogs with congenital intrahepatic portosystemic shunts (CIHPSS) treated with cellophane banding (CB) or percutaneous transvenous coil embolization (PTCE). Dual-institutional retrospective study. Fifty-eight dogs with CIHPSS (2001-2016). Medical records of dogs undergoing CB or PTCE for CIHPSS were reviewed for signalment, body weight, hematologic values, shunt location, attenuation technique, procedure time, duration of hospitalization, complications, date of follow-up, and cause of death if applicable. Thirty-one dogs underwent CB, and 27 dogs underwent PTCE. No differences were detected between groups for gender, preoperative packed cell volume, albumin, cholesterol, or bile acids. Body weight was greater in dogs treated via PTCE. Shunts differed in location because dogs undergoing CB were diagnosed with more left divisional shunts compared with PTCE dogs. Procedural duration of CB and PTCE did not differ. Dogs treated with CB sustained more minor postoperative complications and were hospitalized longer than dogs treated with PTCE. The 1-year and 2-year survival rates were 89% for the CB group and 87% and 80% for the PTCE group, respectively. The proportion surviving at 5 years was 75% and 80% for CB dogs and PTCE dogs, respectively. CB and PTCE are associated with similar short-term and intermediate-term survival. PTCE is a minimally invasive alternative to CB via celiotomy. However, CB allows concurrent abdominal procedures requiring the same approach.

Prospective evaluation of outcome of dogs with intrahepatic portosystemic shunts treated via percutaneous transvenous coil embolization.

To report outcome and complications after percutaneous transvenous coil embolization (PTCE) and evaluate the clinical, laboratory, and imaging changes in dogs with intrahepatic portosystemic shunts (IHPSS) pre-PTCE and post-PTCE. Prospective clinical trial. Twenty-five dogs (15 dogs in imaging subgroup) with IHPSS. Clinical signs, hematologic, and biochemical parameters were recorded before and 3 months after PTCE. All dogs received the same medical treatment and underwent PTCE. In the imaging subgroup, ultrasonography, hepatic portal scintigraphy, and computed tomography-angiography were performed pre-PTCE and post-PTCE. All evaluated bloodwork values improved by at least 50% of their initial value, by 3 months post-PTCE. Liver volume increased after PTCE (P = .001), but remained lower than normal in 11/15 dogs. Hepatic arterial fraction decreased after PTCE (P = .029), consistent with increased portal blood flow to the liver. Twenty-four of 25 dogs were available for reevaluation at 3 months, and all abnormal clinical signs had resolved in 22/24 dogs. PTCE appears promising as a treatment for IHPSS, as clinical signs resolved in most cases, bloodwork abnormalities often normalized, and the procedure was performed safely with minimal complications. PTCE increased hepatic portal perfusion and liver volume in most dogs. These promising results justify a future randomized clinical trial comparing PTCE, other attenuation options, and medical management alone.

経静脈的胸管塞栓術により治療した難治性乳び胸の一例

経静脈的胸管塞栓術により治療した難治性乳び胸の一例

Platypnea-Orthodeoxia Syndrome Due to Venovenous Malformation

The platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by dyspnea occurring in the upright position and relieved in the supine position (platypnea) associated with oxygen desaturation noted in the upright position (orthodeoxia).1 A diagnosis of POS requires two of the following criteria: 1) orthodeoxia, 2) platypnea, 3) presence of an interatrial communication, 4) right-to-left shunt, and 5) absence of pulmonary arterial hypertension or right atrial hypertension.1,2 POS can originate in the heart, lungs, abdomen, or elsewhere due to either an intracardiac (cardiac POS) or intrapulmonary shunt, or a ventilation-perfusion mismatch.1 However, a venovenous malformation (VVM) as a cause of cardiac POS has never been reported in the literature.1 We report here the case of a 24-year-old female patient who presented with cardiac POS due to a VVM. The syndrome emerged insidiously 16 years after an extracardiac total cavopulmonary connection (TCPC) for a complex of congenital cardiovascular malformations and was successfully treated with percutaneous transvenous coil embolization.

A multimodality imaging approach for guiding a modified endovascular coil embolization of a single intrahepatic portosystemic shunt in dogs

Intrahepatic portosystemic shunts (IHPSS) in dogs are aberrant vascular anomalies that connect the portal and the systemic venous vessels. In most of the patients, the surgical approach is unfavourable due to the difficulties in isolating the IHPSS, making the option of a percutaneous transvenous coil embolization (PTCE) one of the safer occlusive procedures. This study describes the treatment of eight dogs with a single IHPSS using a multimodality imaging approach to guide the modified PTCE procedure. This new technique results in a decrease of 71% of the time of the entire procedure with the reduction of 91% in the time required involved the IHPSS identification and in the fluoroscopy exposure time avoiding the need for iodinated contrast agents during the procedure. Moreover, the placement of the catheter before the caval stent ensures its greater stability, enhancing the procedural safety in the phase when the coils are released and avoiding the risk of their dislocation.

A single burr hole approach for direct transverse sinus cannulation for the treatment of a dural arteriovenous fistula

A 55-year-old woman with a symptomatic Borden II/Cognard IIa+b transverse sinus dural arteriovenous fistula underwent an attempted percutaneous transvenous embolization which was ultimately not possible given the fistula anatomy. She...

Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: Long‐term outcomes in 14 patients

To evaluate the clinical outcomes of percutaneous transvenous embolization (PTE) for portosystemic shunt (PSS) associated with encephalopathy Fourteen patients with portosystemic encephalopathy (PSE) were enrolled in this retrospective cohort study. We evaluated technical success, clinical success, complication and outcomes. In cases in which PSS was one of main causes of PSE, three also had splenorenal shunts, four gastrorenal shunts, four superior mesenteric vein systemic shunts, one inferior mesenteric vein systemic shunt and two main trunk of portal vein inferior vena cava shunts. We used only ethanolamine oleate (EO) in five; EO and coils in five; EO, coils and n-butyl 2-cyanoacrylate (NBCA) in two; and coils and NBCA in two patients as embolic materials. The rate of primary and secondary technical success was 93% (13/14 patients) and 100%, respectively. No major complications were encountered related to PTE. Follow-up period was a median of 27 months (range, 12-79). All patients had sustained disappearance of PSE. PSE recurred in one patient because of another PSS development. Thus, clinical success was achieved in 93% (13/14 patients). The ammonia levels 1 year after PTE were significantly improved compared with pre-PTE (median, 102 vs 41 μmol/L) and maintained lower levels 2 and 3 years later. Child-Pugh scores did not change significantly. Esophageal varices were aggravated in 29% (4/14 patients). Five patients died, but no death of hepatic failure related to PTE was encountered. PTE could be one of the useful treatment options for PSE.

Transvenous Variceal Embolization during or after Living-donor Liver Transplantation to Improve Portal Venous Flow

Diversion of portal vein (PV) flow from the partial liver graft in living-donor liver transplantation (LDLT) can be life-threatening and warrant interruption of large collateral vessels. The purpose of this study is to evaluate the clinical efficacy of percutaneous or intraoperative transvenous embolization of portosystemic collateral vessels to improve PV inflow during or after LDLT. From 2000 to 2007, 105 of 1,435 patients (7%) who had undergone LDLT underwent percutaneous (n = 17) or intraoperative (n = 88) venography to evaluate the status of PV inflow and portosystemic collateral vessels. Among these 105 patients, 19 underwent percutaneous (n = 6) or intraoperative (n = 13) transvenous embolization of portosystemic collateral vessels to improve PV inflow. This included 12 men and seven women with a mean age of 46.5 years. Successful embolization of the portosystemic collateral vessels with subsequently improved PV inflow was achieved in all 13 patients (100%) treated with the intraoperative approach and in four of six (67%) patients treated with the percutaneous approach. During follow-up (median, 8 months), Doppler ultrasonography showed adequate PV inflow in 17 of 19 patients, and follow-up computed tomography showed that collateral flow to the varices disappeared in 13 patients and decreased in four patients. One patient died of acute reactivated hepatitis 2 months after the procedure. Overall clinical success was achieved in 16 of the 19 study patients (84%). Transvenous embolization of varices may be an effective method to improve PV inflow in LDLT recipients.

後頭部皮下静脈穿刺による横・S状静脈洞部硬膜動静脈瘻の塞栓術：症例報告

【目的】Isolated sinusを伴うtransverse / sigmoid sinus dural arteriovenous fistula(TS/SS dAVF)に対するmastoid emissary vein (MEV)経由の塞栓術を報告する．【症例】静脈性梗塞で発症した46歳男性の左TS/SS dAVFに対して，通常の経静脈的アプローチが困難であったため，後頭部の皮下静脈を直接穿刺しMEVを経由して罹患静脈洞に至り，経静脈的コイル塞栓術を行い，完治が得られた．【結論】通常のアプローチが困難な場合にMEVが拡張発達して流出静脈となっていれば，この方法は簡便で良い治療オプションとなり得る．

Percutaneous Transvenous Embolization of Intracranial Dural Arteriovenous Fistulas with Detachable Coils and/or in Combination with Onyx.

This study evaluated angiographic and clinical results in patients with a dural arteriovenous fistula (DAVF) who underwent percutaneous transvenous embolization. Retrospective chart analysis and radiographic studies were performed in 23 patients (aged 11-70 yrs) with a DAVF treated with percutaneous transvenous embolization in the past five years. Lesions were located in the anterior cranial fossa, cerebellar tentorium, transverse-sigmoid sinus and cavernous sinus. All procedures were analyzed with regard to presentation, delivery, angiographical and clinical outcome. Data for 23 patients (age range, 11-70 yrs, mean age 49.5yrs) with DAVFs (cavernous sinus[ CS], n=17; transverse-sigmoid sinus, n=3; anterior cranial fossa, n=2; cerebellar tentorium, n=1) were retrospectively reviewed. The DAVFs were treated with coils or a combination with Onyx via different transvenous approaches, in 28 procedures. Cerebral angiography was performed to confirm the treatment. The mean clinical follow-up period was 22.1 months. Transvenous treatment of intracranial DAVFs can be safe and effective if various transvenous approaches are attempted. Percutaneous transvenous embolization with detachable platinum coils or a combination with Onyx is effective in the treatment of DAVFs.

Transarterial and Transvenous Embolization of a Tentorial Dural Arteriovenous Fistula

Various treatments of tentorial dural arteriovenous fistulas have been assessed, but there are only two pertinent literature reports on percutaneous transvenous coil embolization. We describe the case of a patient with tentorial dural arteriovenous fistula coiled transvenously.

Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

Background Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. Case Description This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. Conclusion Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.

Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein

Definitive endovascular treatment of dural arteriovenous fistulas (DAVFs) requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. Access to this site is often limited by occlusion of the sinus proximal and distal to the segment containing the fistula. The authors describe a technique in which the mastoid emissary vein is used to gain access to a Borden-Shucart Type II DAVF in the transverse-sigmoid sinus. Recognition of this route of access, if present, may facilitate endovascular treatment of these lesions. Access to the transverse sinus via this approach can be straightforward and may be underused.

Ａｇｇｒｅｓｓｉｖｅ Ｄｕｒａｌ Ａｒｔｅｒｉｏｖｅｎｏｕｓ Ｆｉｓｔｕｌａの血行動態と治療

We retrospectively analyzed the hemodynamic status and treatment results of aggressive intracranial dural arteriovenous fistulas (dAVFs) that presented with intracranial hemorrhage, cerebral infarction, status epilepticus, and symptoms of increased intracranial pressure (ICP). Out of 114 dAVFs we experienced since 1991, 31 were aggressive lesions. Eighteen cases presented with an intracranial hemorrhage, 4 with venous infarction, 3 with status epilepticus, and 6 with symptoms of increased ICP. We retrospectively analyzed the hemodynamic status (focusing on the retrograde leptomeningeal venous, and retrograde sinus drainage) and treatment results of these 31 cases. [cavernous sinus dAVF] Of 52 cases, retrograde leptomeningeal venous drainage (RLVD) was observed in 8, and 2 of these 8 cases presented with an intracerebral hematoma. One was successfully treated by surgical transvenous embolization, and the other by percutaneous transvenous embolization. [superior sagittal, transverse-sigmoid, and marginal sinus dAVF] Of 44 cases, RLVD was observed in 24 and retrograde sinus drainage in 3. Nineteen of these 27 cases presented with an aggressive pattern, including intracerebral hematoma in 8, venous infarction in 2, status epilepticus in 3, and increased ICP symptoms in 6. Eight of these 19 cases were treated only by endovascular procedures, 9 by surgical transvenous embolization, 2 by transarterial embolization combined with operation. [others] The location of dAVF in other cases was the cranial vault in 2 cases, anterior cranial base in 6, craniocervical junction in 7, and tentorium in 3. RLVD was seen in all of these 18 cases, and 10 presented with an aggressive course, including intracerebral hematoma in 8 and venous infarction in 2. Four cases were treated by transarterial embolization, and 6 by operation. Complete angiographic obliteration after treatment was obtained in 24 (77%) cases. The Glasgow Outcome Scale was GR in 18 cases, MD in 4, SD in 4, VS in 4, and D in 1. Procedure-related complications occurred in 2 cases. Aggressive lesions accounted for 2% of cavernous sinus, 43% of transverse-sigmoid & superior sagittal sinuses, and 55% of the other sinus or cortical dural AVFs. Impaired cerebral venous return due to RLVD was a main cause of the aggressive behaviors. Combined endovascular and surgical treatment was very effective for those lesions.

Carotid Artery Cavernous Fistulas

The treatment of carotid cavernous fistulas has undergone a fundamental transformation during the preceding 30 years. Endovascular techniques have not only largely replaced surgical management of this disease, but have also resulted in substantially lower rates of procedure-associated morbidity and mortality. Percutaneous transarterial occlusion of direct cavernous carotid fistulas with preservation of the carotid artery using detachable balloons is now considered the current preferred therapeutic objective. Concurrent progress in percutaneous transvenous embolization techniques and materials has led to more effective and better-tailored therapies for indirect (dural) carotid cavernous fistulas. The current understanding of the clinicopathologic mechanisms associated with carotid cavernous fistulas and the endovascular therapies used in the contemporary management of this condition are reviewed.