Selective Angiographic Embolization Research Articles

Endovascular intervention in treatment of refractory epistaxis.

Angiographic embolization is an established method of treating intractable cases of posterior epistaxis. This study aimed to test the effectiveness and safety of this method in treating cases refractory to conservative methods. A descriptive retrospective analysis of consecutive cases referred to the department of interventional radiology with refractory epistaxis from January 2001 to December 2018 and received a selective angiographic embolization of the sphenopalatine artery was done. Only epistaxis of idiopathic origin was included in the study. During this period, 98 embolizations were performed. The success rate reached 81.6%. Minor complications were registered in 5%, with no single major complication. The length of stay was 10.5 ± 5.6. Selective angiographic embolization is an effective, safe, and minimally invasive method in treating refractory epistaxis.

Geniculate artery embolization for the treatment of refractory hemarthrosis following meniscal repair

The present case report describes a unique example of recurrent hemarthrosis and associated arthralgia in a 41-year-old male after laparoscopic left medial meniscus repair, which failed to resolve with conservative treatment and surgical revision. Due to the worsening symptomatology as evidenced by increasing volume of aspirated blood during serial arthrocenteses and gradually decreasing range of motion of the joint despite surgical revision, geniculate artery embolization (GAE) was recommended. GAE is not routinely utilized to treat postoperative complications following meniscus repair; however, in the present case, utilizing selective angiographic embolization of the geniculate arteries led to successful treatment of recurrent spontaneous hemarthrosis and associated arthralgia. At this point, the patient has been symptom free for nine months. Relevant patient history, along with progress monitoring data from follow-up visits, demonstrates that spontaneous hemarthrosis and associated arthralgia following laparoscopic medial meniscus repair may be successfully treated with GAE. This is a noteworthy finding which underlines the importance of investigating alternative therapies in treatment refractory cases. However, a thorough evaluation of the appropriateness of this intervention is of paramount importance and its potential benefits need to be determined on a case-by-case basis.

Varicocele due to renal arteriovenous malformation mimicking a renal tumor: a case report

BackgroundRenal arteriovenous malformation is an aberrant vascular connection between the renal artery and vein. Acquired renal arteriovenous malformation (arteriovenous fistulae) accounts for approximately 70% of renal arteriovenous abnormalities. Congenital renal arteriovenous malformation, relatively rare, can result in significant hematuria which may require arterial embolization or nephrectomy.Case presentationA 64-year-old Asian man presented to the Urology department in our hospital with gradual left scrotal swelling for 2 years. Ultrasound and computed tomography showed an irregular mass in the upper pole of his left kidney. Digital subtraction angiography confirmed cirsoid-type left renal arteriovenous malformation combined with left renal vein ostial stenosis. After digital subtraction angiography and selective segmental renal artery embolization, the varicocele was obviously alleviated.ConclusionsThe etiology diagnosis of varicocele is not always straightforward, and renal arteriovenous malformation should be considered in the differential diagnosis of varicocele and renal mass. Renal arteriovenous malformation is difficult to distinguish from renal tumor according to varicocele and computed tomography presentation, while magnetic resonance imaging and digital subtraction angiography help to make a definite diagnosis and selective renal angiographic embolization is one of the best treatments for renal arteriovenous malformation.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications.

BackgroundConflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT.Material/MethodsMedical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed.ResultsNo significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group.ConclusionsHemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.

The Impact of Perioperative Aspirin on Bleeding Complications Following Robotic Partial Nephrectomy

Perioperative administration of aspirin for high-risk urologic procedures is controversial. We evaluated whether continuation of perioperative aspirin alters bleeding complications in patients who undergo robotic partial nephrectomy (RPN). Retrospective review identified 214 consecutive patients who underwent RPN at our institution from May 2012 to March 2015. Comparisons were performed between 49 patients continuing aspirin (81 mg), 34 patients holding aspirin for at least 7 days before surgery, and 131 patients who had never taken aspirin. Overall bleeding complications included postoperative hemoglobin drop of >3 g/dL during admission, postoperative blood transfusion, or necessity for urgent selective angiographic embolization. Multivariable logistic regression was performed to assess the independent association between aspirin administration and bleeding complications. Patients continuing aspirin were older and had higher Charlson Comorbidity Index (CCI) compared with patients who held or never took aspirin (both p < 0.01). Compared with those who held or never took aspirin, patients continuing aspirin had similar rates of overall bleeding complications (27% vs 15% vs 14%, p = 0.13), hemoglobin drop >3 g/dL (24% vs 15% vs 14%, p = 0.24), and postoperative blood transfusion (4% vs 3% vs 2%, p = 0.43). There was a trend for more frequent need for embolization in patients continuing aspirin (6% vs 3% vs 1%, p = 0.07). On multivariate analysis controlling for CCI and RENAL nephrometry score, aspirin administration was not significantly associated with bleeding complications. Continuation of aspirin was associated with higher overall 30-day complications compared with the other groups (24% vs 12% vs 8%, p = 0.03). Continuation of perioperative 81 mg aspirin for patients undergoing RPN was not associated with significantly higher overall bleeding complications. Patients continuing aspirin had increased comorbidities and overall 30-day complications. While our data suggest that continuing perioperative aspirin is safe in select patients, larger studies are needed to confirm these findings.

Total nephrectomy with nephron-sparing surgery for a giant bilateral renal angiomyolipoma: A case report.

The current report presents the case of a 50-year-old female who presented with a giant bilateral renal angiomyolipoma (AML). After assessing the patient's symptoms, the tumor size and renal function, the patient underwent a total nephrectomy for the right AML, which measured 28×20×14 cm and nephron-sparing surgery was performed without preoperative selective angiographic embolization for a further 3 AMLs in the left kidney, the largest of which had a diameter of 12 cm. The introperative bleeding volume was at an acceptable level and the renal function was stable. No local recurrence was observed and no dialysis was required during follow-up. The strategy of the treatment in this report should be considered when treating similar tumors.

Management of splenic trauma: a single institution’s 8-year experience

BackgroundManagement of splenic trauma has evolved, with current practice favoring selective angiographic embolization and non-operative treatment over immediate splenectomy. Defining the optimal selection criteria for the appropriate management strategy remains an important question. MethodsThis retrospective registry review was conducted at a Level I trauma center. The patient population consisted of 20,561 patients in the State Trauma Registry from April 2004 to May 2012. Splenectomy, angiography, splenic embolization, nonoperative, and noninterventional (NI) observation were the management strategies under study. Morbidity and mortality were the outcome measures. Morbidity and mortality by management strategy. ResultsDuring the 8-year study period, 926 (4.5%) patients sustained splenic injury. Observational management increased over time despite the similar distribution of splenic injury grade over the study period: grade I/II (50%), grade III (24.2%), and grade IV/V (25.8%). Mortality rates associated with each management strategy were the following: immediate splenectomy (IS; 25%), splenic embolization (SE; 3.9%), and angiography only or observation, that is, NI (6.5%) management. Injury severity score (ISS) was highest in IS (36.1 ± 1.3) compared with SE (29.1 ± 1.0, P = .001) and NI (21.6, P < .001). Splenectomy was required in 5 of the 129 (3.9%) patients managed with SE and 9 of the 677 (1.3%) patients managed by NI. Mortality was significantly lower among those managed by SE (odds ratio .12, 95% confidence interval: .05 to .32) or NI (odds ratio .21, 95% confidence interval: .12 to .35). This survival benefit was explained by the association of IS with systolic blood pressure <90, high ISS, low GCS at presentation, ISS, development of shock, need for transfusion, and multiorgan failure. ConclusionsIn this large 8-year single institution study, we observed an increase in nonoperative management by an increased application of angiography and embolization. An aggressive utilization of SE in patients with appropriate indications will result in low failure rates and improved mortality.

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate. An Analysis of 200 Consecutive Cases

Purpose: Clinical guidelines recommend partial nephrectomy (PN) as the preferred method of surgical excision of the small renal tumor whenever feasible. PN has comparable cancer cure rates to that of radical nephrectomy in this setting, and decreased risk of chronic kidney disease. A recognized devastating complication following partial nephrectomy is acute post-operative hemorrhage (APOH) from the reconstructed kidney. Risk factors for hemorrhage following partial nephrectomy remain poorly elucidated, as does the impact of hemorrhage on subsequent hospital stay. Identification of risk factors for hemorrhage may lead to a better understanding of and reduction of this complication. Material and Methods: We utilized a prospectively managed database comprised of patients undergoing open partial nephrectomy at our institution by the same surgical team from January 2006 to July 2012. Clinicopathologic factors assessed APOH for their relationships, including patient age, gender, diabetes, smoking, hypertension, coronary artery disease, American Society of Anesthesia Score (ASA), tumor size, RENAL nephrotomy score, pathologic result, cancer margin status, operative time, and intra-operative blood loss. The impact of APOH on subsequent hospital course was evaluated and compared with the entire cohort. Results: Data were analyzed from 200 consecutive patients. We identified 7 patients (3.5%) who experienced APOH. Compared with the entire cohort, APOH resulted in an increased hospital length of stay (median, 5 days; range, 2-11 days, p = 0.001), an increased transfusion requirement (median, 6 units; range, 1-16 units. p = 0.001), a greater risk of selective angiographic embolization (median, 2 procedures; range, 0-3, p = 0.001), and completion nephrectomy (n = 2, p = 0.001). One patient in the APOH group experienced cardiac arrest and was resuscitated. Clinicopathologic factors associated with

Hemophilic Chronic Synovitis: Therapy of Hemarthrosis using Endovascular Embolization of Knee and Elbow Arteries

Congenital hemophilia is a hereditary bleeding disorder that affects 1 in 5,000 males and is characterized by repetitive musculoskeletal bleeding episodes. Selective embolization of the knee and elbow arteries can prevent bleeding episodes. To evaluate the long-term efficacy of these procedures, we assessed the outcomes of 30 procedures performed in our center. We performed 30 procedures in 27 hemophilic patients, including 23 knee, and 7 elbow procedures. To evaluate the efficacy of selective embolization of knee and elbow arteries in people with hemophilia, we analyzed the number of bleeding episodes during 12months before the procedure compared with the amount of episodes that occurred 3, 6, and 12months after embolization. Twenty-nine of 30 procedures were classified as successful. The median of 1.25 episodes per month (range 0-3) observed before the procedure was reduced to 0 (range 0-1.67; p<0.001) at 3months, 0.17 (range 0-1.67; p<0.001) at 6months, and 0.33 (range 0-1.67; p=0.024) at 12months. Three patients remained free of bleeding events for more than 6months. Additionally, after the procedure there was a significant reduction in factor FVIII usage that sustained up to 12months after the procedures. No serious adverse events were observed. Selective angiographic embolization of knee and elbow arteries is a feasible procedure that can prevent repetitive bleedings, which would translate in better joint outcomes for these patients.

Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rates of nonoperative management

Bhullar, Indermeet S. MD; Frykberg, Eric R. MD; Siragusa, Daniel MD; Chesire, David PhD; Paul, Julia MSN; Tepas, Joseph J. III MD; Kerwin, Andrew J. MD

Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management

To determine whether angioembolization (AE) in hemodynamically stable adult patients with blunt splenic trauma (BST) at high risk for failure of nonoperative management (NOM) (contrast blush [CB] on computed tomography, high-grade IV-V injuries, or decreasing hemoglobin) results in lower failure rates than reported. The records of patients with BST from July 2000 to December 2010 at a Level I trauma center were retrospectively reviewed using National Trauma Registry of the American College of Surgeons. Failure of NOM (FNOM) occurred if splenic surgery was required after attempted NOM. Logistic regression analysis was used to identify factors associated with FNOM. A total of 1,039 patients with BST were found. Pediatric patients (age <17 years), those who died in the emergency department, and those requiring immediate surgery for hemodynamic instability were excluded. Of the 539 (64% of all BST) hemodynamically stable patients who underwent NOM, 104 (19%) underwent AE and 435 (81%) were observed without AE (NO-AE). FNOM for the various groups were as follows: overall NOM (4%), NO-AE (4%), and AE (4%). There was no significant difference in FNOM for NO-AE versus AE for grades I to III: grade I (1% vs. 0%, p = 1), grade II (2% vs. 0%, p = 0.318), and grade III (5% vs. 0%, p = 0.562); however, a significant decrease in FNOM was noted with the addition of AE for grades IV to V: grade IV (23% vs. 3%, p = 0.04) and grade V (63% vs. 9%, p = 0.03). Statistically significant independent risk factors for FNOM were grade IV to V injuries and CB. Application of strictly defined selection criteria for NOM and AE in patients with BST resulted in one of the lowest overall FNOM rates (4%). Hemodynamically stable BST patients are candidates for NOM with selective AE for high-risk patients with grade IV to V injuries, CB on initial computed tomography, and/or decreasing hemoglobin levels. III, therapeutic study.

Delayed hemorrhage after partial nephrectomy: 5 cases report

Objective To discuss the etiology and management of hemorrhage after partial nephrectomy because of renal cancer. Methods Of the 382 cases performed partial nephrectomy during a 10-year period, 5 patients(1.3%) had postoperative hemorrhage because of a renal artery pseudoaneurysm. The ages of these patients were from 42 to 63 years. All the tumors were malignant with an average diameter of 2. 8 cm. The renal pedicle was blocked in 2 cases with tumor size larger than 3 cm. The kidney was reconstructed with interrupted 0 chromic sutures in 8or U style. Delayed postoperative hemorrhage occurred from 6 days to 3 months. The blood loss was from 1000 to 4500mi. Shock or lower blood pressure occurred in 3 patients. Nephrectomy was performed in 1 patient and selective angiographic embolization was performed in other 4 cases. Results Angiography revealed renal artery pseudoaneurysm in all 5 cases at the third (4 cases) or fourth branch(1 patient).Percutaneous embolization was successful in 4 patients. Four cases were followed up for 2 to 9 years without complication. Conclusions Delayed postoperative hemorrhage following partial nephrectomy is an uncommon but potentially life-threatening complication. Super-selective angiographic embolization could be the first choice of treatment. Key words: Kidney neoplasms; Nephrectomy; Postoperative hemorrhage

Recurrent and selective angiographic embolization for patients with haemodynamically unstable pelvic fracture

Objective To evaluate the effect of selective angiography and embolization for the pa-tients with haemodynamically unstable pelvic fracture. Methods Sixty-two patients with haemodynami-cally unstable pelvic fracture were treated in our hospital from 2002 to 2008. Their pelvie fractures were classified on the basis of their X-ray and CT data. By AO classification, there were 2 cases of type A2, 6 B1, 9 B2, 8 B3, 16 C1, 13 C2, and 8 C. There were 6 cases of open injury (by Gustilo classification, 1 type Ⅱ and 5 type Ⅲ). Of the 46 eases of multiple injuries, 12 had shock. While active fluid infusion and vascular medication were conducted, the angiograph was done for all patients, 59 of whom also received embolization. Results Seventy-nine angiographs were performed for the 62 cases, and 12 of them received more than twice angiographa. Exams revealed that 32 patients had suffered injury to more than 2 arteries. The injured arteries were sequentially superior gluteal artery, iliolumbar artery, lateral sacra] artery, obturator artery, inferior gluteal artery, internal pudendal artery, internal iliae artery and external lilac artery. Of the 59 cases of embolization, 56 were successful. Seven patients died due to severe abdominal organ injury. Forty-five patients got an average follow-up of 14 months (range, 6 to 52 months) . No severe complications were no-ticed. Conclusions Selective angiography and embolization is an effective intervention for patients with haemodynamically unstable pelvic fracture. It is mandatory to conduct recurrent angiographic embolization for patients with multiple artery injuries or delayed artery injuries. Key words: Pelvis; Angiography; Embolization, therapeutic

The role of selective angiographic embolization of the musculo‐skeletal system in haemophilia

The incidence of haemarthrosis as a result of a spontaneous periarticular aneurysm in haemophilia is very low. In these circumstances, angiographic embolization might be considered as a promising therapeutic and coagulation factor saving option in joint bleeds not responding to replacement of coagulation factor to normal levels. Moreover, embolization should be considered as a possible treatment for postoperative pseudoaneurysms complicating total knee arthroplasty in haemophilia. However, the pathological process of aneurysmal bleeding and clotting factor replacement is entirely different. While embolization is the treatment of choice for some periarticular complications that may occur, it is by no means a panacea for all resistant periarticular bleeds in haemophilia or for postoperative bleeding which usually settles with clotting factor replacement. Another use of arterial embolization is for the treatment of haemophilic tumours of the pelvis, because they can act as a focus for infection and cause cutaneous fistulas. When they present perforations and infections of endogenous origin, their course is usually fatal. Suitable treatment has been investigated on numerous occasions, most of the literature agreeing that the only curative treatment is surgical resection. However, surgical resection after performing arterial embolization to reduce the vascularization of the pseudotumour is a good alternative, thereby reducing the size of the pseudotumour and the risk of bleeding complications during surgery. It is important to bear in mind that despite its efficacy, arterial embolization is an invasive procedure with a reported rate of complications up to 25% (16% minor, 7% serious, 2% death).

Short- and Long-Term Results of Transcatheter Embolization for Massive Arterial Hemorrhage from Gastroduodenal Ulcers Not Controlled by Endoscopic Hemostasis

Severe bleeding from gastrointestinal ulcers is a life-threatening event that is difficult to manage when endoscopic treatment fails. Transcatheter embolization has been suggested as an alternative treatment in this situation. The present study reports on the efficacy and long-term outcomes of transcatheter embolization after failed endoscopic treatments were assessed in high operative- risk patients. A retrospective review of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 men, 19 women; mean [+/-SD] age 69.4+/-15 years) was conducted. Patients were referred for selective angiography between 1999 and 2008 after failed endoscopic treatment of massive bleeding from gastrointestinal ulcers. Mean follow-up was 22 months. Embolization was feasible and successful in 57 patients. Sandwich coiling of the gastroduodenal artery was used in 34 patients, and superselective occlusion of the terminal feeding artery (with glue, coils or gelatin particles) was used in 23 patients. Early rebleeding occurred in 16 patients and was managed with endoscopy (n=8), reembolization (n=3) or surgery (n=5). No major embolization-related complications occurred. Sixteen patients died within 30 days after embolization (including three who died from rebleeding) and 11 died thereafter. No late bleeding recurrences were reported. Selective angiographic embolization is safe and effective for controlling life-threatening bleeding from gastroduodenal ulcers. The procedure usually obviates the need for emergency surgery in these high-risk patients. Survival depends chiefly on underlying conditions.

Renal artery pseudoaneurysm following open partial nephrectomy

Renal artery pseudoaneurysm (RAP) is an uncommon complication following an open partial nephrectomy. We present a case of RAP diagnosed four and a half months following open partial nephrectomy for renal cell carcinoma. RAP was managed by selective angiographic embolization using coils. The etiology and management of this potentially life-threatening condition is discussed. fig. 1. CT scan image of the abdomen post contrast showing a) a left RAP and b) subsequent resolution of the RAP following coil embolization. a b

Refractory Bleeding From Gastroduodenal Ulcers

We evaluated the efficacy and medium-term outcomes of transcatheter embolization to control massive bleeding from gastroduodenal ulcers after failed endoscopic treatment in high-operative-risk patients. Retrospective study of 35 consecutive emergency embolization procedures in hemodynamically unstable patients (24 men, 11 women, mean age 71+/-11.6 y) referred from 1999 to 2006 for selective angiography after failed endoscopic treatment. Mean follow-up was 27 months. Endovascular treatment was feasible in 33 patients and consistently stopped the bleeding. "Sandwich" coiling of the gastroduodenal artery was performed in 11 patients and superselective occlusion of the terminal feeding artery with glue, coils, or gelatine particles in 22 patients. Early rebleeding occurred in 6 patients and was managed successfully using endoscopy (n=2), reembolization (n=1), or surgery (n=3). No major complications related to catheterization occurred. Seven patients died within 30 days of embolization and 3 died later during the follow-up, but none of the deaths were due to rebleeding. No late bleeding recurrences were reported. Selective angiographic embolization is safe and effective for controlling life-threatening bleeding from gastroduodenal ulcers, usually obviating the need for emergency surgery in critically ill patients, whose immediate survival depends on their underlying conditions.

Delayed diagnosis of a pseudoaneurysm with recurrent hemarthrosis of the knee joint

This is a case report of recurrent hemarthrosis of the knee joint over 3 months. The patient, a 47-year-old male had three arthroscopic procedures with multiple joint punctures over a 3-month-period prior to our initial consultation. The first procedure (arthroscopic synovectomy) was done for suspected infection following a series of hyaluronic acid injections. Recurrent hemarthrosis developed subsequent to this. Upon further evaluation, a pseudoaneurysm of the superior middle genicular artery was detected and successfully treated with selective angiographic embolization.

Iatrogenic pulmonary artery rupture

Pulmonary artery rupture is probably the most devastating complication associated with the use of the pulmonary artery catheter. This rare but disastrous situation requires a clear intervention plan. The initial presentation of pulmonary artery ruptures may be as obvious as a massive pulmonary hemorrhage or as subtle as a cough associated with minimal hemoptysis, or it may even be totally asymptomatic. A patient presenting any clinical manifestation of pulmonary artery rupture may develop a pulmonary artery false aneurysm, which is the accumulation of blood in an aneurismal sac compressed by lung parenchyma. This condition requires intervention because delayed hemorrhage may occur and recurrence can be massive and fatal. Following an initial episode of suspected pulmonary artery rupture, the patient should undergo immediate radiological investigation. If a diagnosis of pulmonary artery false aneurysm is confirmed, selective angiographic embolization helps reduce morbidity and mortality. The incidence of pulmonary artery ruptures is probably underestimated because many hemoptysis episodes or radiological infiltrations associated with pulmonary artery catheter use are not investigated. Also, the natural evolution of the pulmonary artery false aneurysm is unknown. The incidence of spontaneous healing, bleeding recurrence or asymptomatic persistence is unknown following formation of a pulmonary artery false aneurysm.

Transarterial embolization of an inferior genicular artery pseudoaneurysm with arteriovenous fistula after arthroscopy

Arthroscopic meniscectomy of the knee is generally a safe and effective procedure with a low rate of vascular complications. We report here on a unique case of a 55-year-old man with a lateral inferior genicular artery pseudoaneurysm and a concomitant arteriovenous fistula that developed after arthroscopic meniscectomy; this was successfully treated with selective angiographic embolization. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after an arthroscopic procedure.