Transcatheter Embolization Research Articles

Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain in female patients with radiology detection of gonadal vein dilatation and parauterine varices. It may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. Although transcatheter venography represent the gold standard for PCS diagnosis, it is performed after inconclusive noninvasive imaging such as Doppler Ultrasound, CT scan, and MRI. Once diagnosis has been confirmed, management of PCS include medical, surgical, and endovascular therapy. Medical and surgical treatments have been shown to be less effective than transcatheter pelvic vein embolization. This latter has been proven to be a safe, effective, and durable therapy for the treatment of PCS. Numerous studies have shown their results in PCS endovascular treatment, but neither of them has been subjected to an adequate randomized controlled trial. A well-designed randomized controlled trial is urgently needed to assess transcatheter embolization clinical success.

Multivessel endovascular therapy for undiagnosed vascular type Ehlers-Danlos syndrome. Successful percutaneous transcatheter coil embolization of hepatic artery pseudoaneurysm with stenting of right renal and iliac arteries in emergency setting

Among Ehlers-Danlos syndromes, the vascular type is the most severe because of its vascular complications. Transcatheter embolization of medium-sized arteries has become the first-line therapy for life-threatening hemorrhage. Ongoing multiple lesions causing hemorrhagic or ischemic complications in the acute phase can challenge patient management. Multivessel endovascular treatment has never been reported. In this study, we report successful single-session treatment by coiling of a ruptured pseudoaneurysm of the hepatic artery with stenting of dissected right renal and iliac arteries in a 46-year-old female. Percutaneous transfemoral approach was gained and sealed with a plug-based closure device. Genetic disease was subsequently confirmed by molecular analysis.

Arteriovenous fistulas after ultrasound-guided needle biopsy of kidney allografts and treatment outcomes after transcatheter embolization: A single-center experience in Japan.

Arteriovenous fistula (AVF) is one of the vascular complications after allograft biopsy, and their reported incidence rates range widely. Transcatheter embolization (TE) is a common AVF treatment in kidney allografts. However, information on AVF incidence and features and TE outcomes in Japanese kidney transplant (KT) recipients is lacking. This study investigated 270 protocol or clinically indicated kidney allograft biopsies in 129 KT recipients during 2010-2016 at a single-center using standardized methods (16-gauge needle and ultrasound guidance). We recorded the incidence and clinical features of AVF using currently recommended standardized methods of allograft biopsy and TE outcomes regarding allograft function up to 12 months after the procedure in Japanese KT recipients. AVF incidence was 2.6% (seven cases). The time from biopsy to AVF diagnosis was 7 (median, interquartile range: 5-117, range: 1-318) days. The time from biopsy to AVF diagnosis was significantly shorter in symptomatic cases (gross hematuria) than in asymptomatic cases (median 6 vs. 117 days, p = 0.034). Symptomatic patients underwent TE within a shorter time (0-6 days) than asymptomatic patients (25-104 days). There were no complications, and allograft function was stable up to 12 months after TE despite using contrast media and partial renal infarction. AVF does occur in certain probabilities. AVF formation can occur without apparent bleeding and exist for a long time after allograft biopsy. TE is a safe and immediate treatment for AVF in kidney allograft.

Spinal Cord Infarction after Transcatheter Embolization of Pelvic Arteriovenous Malformation.

An 80-year-old woman presented with abdominal and right lower limb pain. Radiological examination revealed pelvic arteriovenous malformations (pAVMs). Although transarterial embolization was repeated, dilation of the common iliac vein worsened. Four sessions of embolization were performed for the internal iliac vein. Paraplegia gradually occurred a day after the final procedure. Magnetic resonance imaging revealed thoracic spinal cord edema and paraspinal vasodilatation, suggesting spinal cord infarction. Additional angiography revealed a radiculomedullary vein draining into the spinal canal from the pAVM; hence, surgical interruption was performed. Incomplete venous embolization of the pAVM caused spinal cord congestion and infarction.

Hospitalizations for peptic ulcer disease in China: Current features and outcomes.

Rates and outcomes of hospitalizations for peptic ulcer disease (PUD) are unknown in mainland China. We aimed to describe characteristics and treatments of PUD inpatients in secondary and tertiary care hospitals registered in the national Health Statistics and Information Reporting System in 2015 and to explore factors related to inpatient outcomes. We retrieved and validated PUD hospitalization data from 4441 hospitals reporting to Health Statistics and Information Reporting System in 2015. Sensitivity analyses were performed to examine the robustness of findings considering different reporting rates across provinces. Current analyses focused on ulcer sites, complications, therapies, and rates of in-hospital death or unauthorized discharge. Total admissions for PUD were 443433 (mean age 55.14years), constituting 0.59% of all-cause hospitalizations of 2015 in 4441 hospitals. Duodenal ulcers were more common than gastric ulcers (44.69% vs 37.42%). About 61% of inpatients had complications (46.45% for bleeding and 14.66% for perforation). Over 96% of uncomplicated or bleeding inpatients were managed medically. Surgery was provided to 64.22% of perforated cases. Endoscopic hemostasis and transcatheter embolization were performed for 1.59% of the bleeding and 0.59% of the perforation cases. For all PUD cases, the average in-hospital mortality was 0.35%. Six percent of inpatients left hospitals without authorization. Multinomial logistic regressions showed that inpatient death and unauthorized discharge were associated with older age, gastric ulcer, bleeding, perforation, and comorbidity after controlling for gender, insurance status, hospital type, area, and region. Currently, pharmacologic management is dominant, and endoscopic hemostasis is notably underutilized for PUD hospitalizations in mainland China.

Bioactive-Tissue-Derived Nanocomposite Hydrogel for Permanent Arterial Embolization and Enhanced Vascular Healing.

Transcatheter embolization is a minimally invasive procedure that uses embolic agents to intentionally block diseased or injured blood vessels for therapeutic purposes. Embolic agents in clinical practice are limited by recanalization, risk of non-target embolization, failure in coagulopathic patients, high cost, and toxicity. Here, a decellularized cardiac extracellular matrix (ECM)-based nanocomposite hydrogel is developed to provide superior mechanical stability, catheter injectability, retrievability, antibacterial properties, and biological activity to prevent recanalization. The embolic efficacy of the shear-thinning ECM-based hydrogel is shown in a porcine survival model of embolization in the iliac artery and the renal artery. The ECM-based hydrogel promotes arterial vessel wall remodeling and a fibroinflammatory response while undergoing significant biodegradation such that only 25% of the embolic material remains at 14 days. With its unprecedented proregenerative, antibacterial properties coupled with favorable mechanical properties, and its superior performance in anticoagulated blood, the ECM-based hydrogel has the potential to be a next-generation biofunctional embolic agent that can successfully treat a wide range of vascular diseases.

Embolization Techniques for Arteriovenous Malformations in Parkes-Weber Syndrome

Multiple high-flow arteriovenous malformations (AVMs) are the hallmark of Parkes-Weber syndrome (PWS). Surgical resection has historically shown poor outcomes with PWS. The aim of this study was to assess the management of PWS in the current era. A retrospective review was performed from 2004 to 2017 on all patients presenting to a single institution for the management of PWS. Presentation, techniques, complications, and outcomes were reviewed. Fourteen patients (50% male) with PWS were seen at our institution, and mean age was 19.9years (range, 4.7-68.8). The lower extremity was affected in 12 (86%) and the upper extremity in 2 (14%) patients. All patients presented with pain and swelling in the affected limb. Seven (50%) patients presented with ulcers, of which 3 (43%) had extensive wounds. Five (36%) patients had echocardiographic evidence of high-output cardiac failure. All patients underwent angiography with the intention to treat. Three (21%) patients were found to have diffuse arteriovenous communication with no discrete AVM nidus and thus did not undergo intervention. The remaining 11 (79%) patients underwent transcatheter embolization of the AVM's arterial inflow. Six (55%) patients required multiple or staged inflow embolization procedures, with a mean of 3.3 (range, 1-10) interventions. Thirty-two arterial embolization procedures were performed in total. n-Butyl-2-cyanoacrylate (nBCA) adhesive was used in 22 (69%), microspheres in 8 (25%), and a combination of coils and nBCA adhesive in 2 (6%) cases. Technical angiographic success was seen in all patients. Six (55%) patients also had interventions to treat the venous component of the malformation, either concomitantly or during a separate procedure. This included radiofrequency ablation in 1 (17%), coil embolization in 1 (17%), sodium tetradecyl sulfate (STS) sclerotherapy in 2 (33%), and a combination of STS, coil embolization, and vein stripping in 2 (33%) patients. Ten (91%) patients experienced a partial response and 1 (9%) patient experienced no response to treatment. No patients had a complete response, as expected with the diffuse nature of this disease. There were no periprocedural complications. Two of 3 patients with complex wounds required major amputations for gangrene, including one above-knee and one below-knee amputation at 128months and 66months after the index procedure, respectively. AVMs in PWS can be successfully treated by a transcatheter approach. Multiple interventions are usually required. Patients with extensive wounds remain at risk for loss of limb.

Major Limb Amputations in Patients with Congenital Vascular Malformations

The need for major amputations in patients with vascular malformations is rare. This study reviews our contemporary experience with major amputations in patients with vascular malformations. A retrospective review from April 2014 to November 2018 identified 993 patients undergoing management of a vascular malformation involving the upper or lower extremity at a tertiary center. This population was analyzed to identify those requiring either a transfemoral or transhumeral amputation. This cohort was investigated for clinical course, surgical procedures, and outcomes. Five patients (0.5%) underwent major amputation, including 3 transhumeral and 2 above-knee amputations. The median age was 37.8years (interquartile range (IQR): 25.4-40.2), and 2 (40%) were male. Four (80%) patients had high-flow arteriovenous malformations, including 1 (20%) with Parkes-Weber syndrome. One (20%) patient had a low-flow venous malformation associated with Klippel-Trénaunay syndrome. All patients had malformation extending into the chest or pelvis, with the amputation being at the level of residual malformation. As such, amputation had been initially felt to be high risk because of the proximal extent of the lesions. Before amputation, a median of 11 procedures (IQR: 4-39) were performed per patient. This included 29 transarterial embolizations, 4 transvenous embolizations, 20 direct stick embolizations, 3 debulking procedures, 38 debridements, 6 skin grafts or muscle flaps, and 4 minor amputations. The median time course of treatment before amputation was 117months (IQR: 44-171). Indications for major amputation included chronic pain and recurrent bleeding in all 5 (100%) patients, loss of function in 2 (40%), nonhealing wounds in 2 (40%), and sepsis in 1 (20%) patient. There were no perioperative deaths. The median blood loss was 1,000mL (IQR: 650-2,750). All patients required transfusion of packed red blood cells with a mean of 1.6 units (standard deviation: 0.54). Transhumeral amputation was facilitated by transcatheter embolization in 1 (33%) and an occlusion balloon within the subclavian artery in 2 (66%) patients. The median length of stay was 6days (IQR: 5-13). The median length of follow-up was 132months (IQR: 68-186) from initial intervention and 12months (IQR: 8-31) from amputation. Two patients (40%) who had undergone transhumeral amputation required revision of the amputation site for recurrent ulceration at 2 and 38months. Of these, 1 patient underwent 3 transcatheter embolization procedures before revision and 1 underwent 1 embolization after revision. Although rare, successful amputation at the level of residual malformation can be performed in select patients with refractory complications of vascular malformations including intractable pain, bleeding, or nonhealing wounds. Specific preoperative and intraoperative measures may be critical to achieve satisfactory outcomes, and endovascular techniques continue to play a role after amputation.

The Treatment of Post-Partum Bleeding With Embolization

Aim: To assess safety and efficacy of transcatheter embolization in the treatment of post-partum bleedings.
 Materials and Methods: In a single institution, the outcome of 15 patients who underwent trans arterial embolization (TAE) for post-partum hemorrhages (PPH) were retrospectively reviewed.
 Eleven patients presented with hemodynamic instability requiring blood transfusion (73 %), four patients were hemodynamically stable (27 %). Arterial embolization was performed with gelatin sponge, particles and coils.
 Results: Mean follow-up time was 21.2 months (range 12-48 months). Technical success rate was 100%. The overall clinical success rate was 100%. No major complications that required intensive care treatment were registered during or after the procedures. No patient required emergency surgery and subsequent hysterectomy. During follow-up, four patients become pregnant after transcatheter arterial embolization, and delivered full-term and healthy infants.
 Conclusions: TAE is a safe method that allows to avoid surgery and hysterectomy for uncontrollable post-partum hemorrhage; a future normal pregnancy after embolization may be hypothesized.

A superstable homogeneous lipiodol-ICG formulation for locoregional hepatocellular carcinoma treatment

Accurate identification of surgical margins for malignancy remains a challenge in the surgical therapy of cancer, and this encountered interoperative difficulties which directly contribute to the prognosis of patients. In recent years, indocyanine green (ICG) has been approved and applied in clinical settings for lesions detection, especially for the precise surgical resection. However, rapid clearance and poor stability greatly limit its clinical practicality. Herein, a super-stable homogeneous iodinated formulation technology (SHIFT) is designed to realize sufficient dispersion of ICG into lipiodol (SHIFTs) for transcatheter embolization (TAE) synergistic fluorescence-guided resection. Particularly, SHIFTs is prepared in a green physical mixture via a carrier-free manner, which possesses controlled morphology, long-term stability, and improved optical characteristics of ICG (fluorescence/photoacoustic/photothermal activities). Furthermore, the viscosity of the synthetic solvent is comparable to lipiodol, and further assessment demonstrated the same efficacy in computed tomography. The performance of SHIFTs in the fluorescence navigation was further evaluated in vivo by TAE therapy to the rabbit VX2 tumor model for a two-week monitor. The integration of near-infrared fluorescence surgery navigation and TAE could effectively guarantee the precise resection for hepatocellular carcinoma. This SHIFT system provides good potentials for ameliorating the dilemma of precise fluorescent navigation for surgical resection after arterial embolization in clinical practice.

Diagnosis and Management of Iatrogenic Hemobilia Secondary to Transjugular Intrahepatic Portosystemic Shunt Procedure

A patient with end-stage liver disease and subsequent refractory ascites was treated with a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The procedure was complicated by massive gastrointestinal hemorrhage with associated rettorragia. Computed tomography angiography (CT-A) was performed and revealed haemobilia due to an artero-biliary fistula between the right hepatic artery and an intrahepatic biliary branch. The patient underwent an attempt at percutaneous embolization. Bleeding was successfully stopped by the embolization of the fistula with coils.Hemobilia is a rare cause of upper gastrointestinal bleeding with an increasing incidence due to the widespread use of invasive hepatobiliary procedures. Hemobilia is an uncommon complication of TIPS procedures. Nowadays, transcatheter embolization is the gold standard in the management of hemobilia.

Endovascular embolization for pulmonary artery pseudoaneurysms with massive hemoptysis

Objective: To investigate the efficacy and safety of transcatheter embolization for the treatment of pulmonary artery pseudoaneurysms (PAPs) with massive hemoptysis via both arterial and venous access. Methods: The clinical data of 15 patients of pulmonary tuberculosis presenting with massive hemoptysis, who were confirmed by CTA/DSA with PAPs at the Second Affiliated Hospital of Hainan Medical University from January 2016 to February 2018, were retrospectively analyzed. The imaging presentation, technical and clinical success of endovascular treatment, and recurrence of hemoptysis within 1 year was recorded. Results: A total of 15 PAPs were involved. Fourteen PAPs were confirmed by pulmonary CTA and one by angiography. Six PAPs were visualized during bronchial artery angiography, 4 PAPs during pulmonary artery angiography, and 4 PAPs both. One PAP was not shown during catheter-directed angiography. Except for one patient who died of asphyxia due to severe hemoptysis undergoing embolization, hemoptysis relapse was achieved in 14 patients after endovascular treatment. During 12 months follow-up, one patient underwent surgical resection because of recurrent hemoptysis 2 weeks after embolization, and another patient with recurrence hemoptysis 3 months after embolization received repeated intervention and hemoptysis relapsed. Conclusion: Transcatheter embolization via dual access is effective and feasible for the treatment of PAPs with massive hemoptysis in patients with pulmonary tuberculosis, but still some risks.

Effect of different surgical options for posterior inferior cerebellar artery aneurysms

Objective To explore the clinical effect of various surgical operations on the treatment of posterior inferior cerebellar aneurysm. Methods The clinical data of 36 patients with a total of 36 posterior inferior cerebellar aneurysms admitted to Department of Neurosurgery, Weihai Central Hospital from October 2014 to May 2017 were retrospectively analyzed. Among all 36 patients, 22 underwent transcatheter embolization, 9 underwent aneurysm clipping using craniotomy, and the remaining 5 underwent cerebral artery bypass surgery combined with transcatheter embolization. The treatment outcome was evaluated using Glasgow outcome scale(GOS) at discharge and modified Rankin scale (mRS) at follow-up. Imaging outcome was evaluated by digital subtraction angiography (DSA) or CT angiography (CTA). Results Of the 22 patients undergoing transcatheter embolization, 21 were completely embolized. Aneurysms in 8 of the 9 patients were successfully clipped. Successful vascular anastomosis and complete embolization were achieved in 5 patients undergoing cerebral artery bypass surgery combined with transcatheter embolization. Among the 36 patients, 9 cases developed non-newly developed postoperative neurological deficits and 1 died. Thirty-five patients were discharged with GOS grade Ⅴ in 18 cases, Ⅳ in 14 cases and Ⅲ in 3 cases. Thirty-five cases were reexamined by CTA or DSA at 2 weeks post operation, which indicated disappearance of aneurysm. At follow-up of 3 months to 1 year post operation, 3 cases(8.6%) of aneurysm recurrence were reported which had undergone interventional embolization, and the rest of 32 patients had no recurrence. Thirty-five patients were followed up for 1 year. The mRS score was 0-1 in 21 cases, 2 in 8, 3 in 3, 4 in 1 and 5 in 1 case. The rate of good outcome were 85.3% (29/34) and there was 1 patient lost to follow-up. Conclusions According to the specific condition, interventional embolization, craniotomy of aneurysm clipping, or cerebral artery bypass surgery combined with transcatheter embolization could be performed to treat the posterior inferior cerebellar aneurysm, which might lead to relatively good clinical outcome with low incidence of aneurysm recurrence. Key words: Incranial aneurysm; Embolization, therapeutic; Microsurgery; Treatment outcome; Inferior cerebellar artery

Safety and efficacy of embolotherapy for severe hemorrhage after partial nephrectomy.

Partial nephrectomy may be complicated by postoperative hemorrhage, which may be treated by transcatheter embolization. To assess the safety and efficacy of embolotherapy for hemorrhagic complications of partial nephrectomy and to analyze the potential correlation between multiple bleeding sites on angiography and surgical complexity. A cohort of 25 patients presenting with severe, postoperative bleeding after partial nephrectomy and treated with catheter-directed superselective embolization was included. Patients' demographics, radiological investigations before the embolization, and clinical outcome after embolization were analyzed. Mann-Whitney U test was used to analyze the potential difference in the RENAL score between patients with one or more bleeding sites in the resection area. Selective renal angiography revealed multiple bleeding sites at the resection bed in 8 (32%) patients with amorphous contrast extravasation in 10 (40%) patients. Embolization with use of a microcatheter and microcoils was effective to stop the bleeding in all but one patient, the latter requiring a second embolization two days later. Transient decrease in renal function was noted in 3/25 (12%) patients with full recovery in two of the three. Patients with multiple bleeding sites did not show significantly different RENAL scores compared to patients with a single bleeding site (P = 0.148). Embolotherapy for postoperative partial nephrectomy-related bleeding is safe and effective with a low rate of recurrent bleeding. The number of bleeding sites at the resection area did not correlate to the RENAL score.

First Experience of Transcatheter Leak Occlusion With Detachable Coils Following Left Atrial Appendage Closure

ObjectivesThe aim of this study was to assess the feasibility and efficacy of transcatheter leak closure with detachable coils in patients with incomplete left atrial appendage (LAA) closure. BackgroundIncomplete LAA closure is common after interventional therapies targeting the LAA, potentially hindering effective thromboembolic prevention. Detachable coils have found a wide range of applications for transcatheter vascular occlusion and embolization procedures. MethodsThirty consecutive patients at high thromboembolic risk with clinically relevant residual leaks (mean age 72 ± 9 years, 73.3% men, mean CHA2DS2-VASc score 4.4 ± 1.4, mean HAS-BLED score 3.6 ± 0.8) underwent percutaneous closure of the LAA patency using embolization coils. Transesophageal echocardiography was performed at 60 ± 15 days post-procedure. ResultsLAA closure had been previously attempted with the Watchman device in 25 patients, the Amulet device in 2 patients, and the LARIAT device in 3 patients. Baseline transesophageal echocardiography documented moderate and severe leaks in 20 (66.7%) and 10 (33.3%) patients, respectively. After a single procedure, 25 patients (83.3%) showed complete LAA sealing or minimal leaks. Five patients (16.7%) had moderate residual leaks; 3 patients of them were offered repeat procedures. Mean procedure and fluoroscopy times were 76 ± 41 min and 21 ± 14 min, respectively; the mean volume of iodinated contrast medium used was 80 ± 47 ml. Coil deployment was successful in all cases. The overall complication rate was 6.1%. After a median follow-up period of 54 days (range 43 to 265 days) and an average of 1.1 procedures/patient, transesophageal echocardiography revealed complete LAA sealing or negligible residual leaks in 28 patients (93.3%; 25 with no residual leak, 3 patients with minimal to mild residual leaks) and moderate residual leaks in 2 patients (6.7%). ConclusionsTranscatheter LAA leak occlusion using endovascular coils appears to be a safe, effective, and promising approach in patients at high echo time risk with incomplete LAA closure. (Transcatheter Leak Closure With Detachable Coils Following Incomplete Left Atrial Appendage Closure Procedures [TREASURE]; NCT03503253)

Embolization for gastrointestinal bleeding in patients with pancreatitis. Report of two cases and literature review

Gastrointestinal (GI) bleeding is rare but potentially fatal complication of pancreatitis. Early diagnosis and timely radiologic intervention are crucial for survival as when untreated the mortality of these patients is high. We present two patients, one with chronic pancreatitis and one with acute pancreatitis, both complicated with severe upper GI tract bleeding. Patients were successfully treated with transcatheter embolization after initial endoscopic hemostasis failed. The advances in endovascular devices and embolization materials and increased number of experienced interventional radiologists have increased the importance of angiographic embolization procedures as a safe minimally invasive therapeutic method of achieving successful hemostasis associated with the low incidence of complications. Due to its advantages over surgery, it should be considered treatment of choice in patients with upper GI bleeding refractory to endoscopy.

Akut Myeloid Lösemi Hastasında Transkateter Embolizasyon Gerektiren Masif Hematüri

Akut Myeloid Lösemi Hastasında Transkateter Embolizasyon Gerektiren Masif Hematüri

Management of extracranial arteriovenous malformations of the head and neck

The purpose of this study was to review the outcomes of the different therapies for extracranial head and neck arteriovenous malformations (AVMs).AVMs are high-flow congenital vascular anomalies. They are composed of a complex system of vessels directly connecting feeding arteries to draining veins forming a nidus.They may be potentially life-threatening due to progressive symptoms and infiltrative disease. Extracranial AVMs most commonly affect the head and neck area (47.4%) followed by the extremities (28.5%). AVMs are best characterized as being either focal or diffuse. Focal AVMs have good outcomes following adequate treatment. Diffuse lesions have multiple feeding vessel, which results in high rates of recurrence despite treatment.The management of AVMs includes conventional surgery and endovascular techniques. A combination of embolization and surgical resection has become the treatment of choice over the last years. The main goal of both forms of treatment being the complete blockage or resection of the nidus. Transcatheter embolization of vessels has evolved over the years and new embolic agents have emerged. The types of materials available for embolization are classified into mechanical devices, liquid agents and particulates. Efficacy, rate of recurrence and most common complications were evaluated.AVMs recurrence after embolization or resection is reported in up to 80% of cases. Incomplete resection and embolization can induce aggressive growth of the remaining nidus and the risk of progression is up to 50% within the first 5 years and recurrences can occur up to 10 years later.Although ethanol seems to be associated with the highest degree of cure and permanent occlusion, the overall complication rate reported was 48%. Other materials, such as cyanoacrylate, have obtained modest rates of complete remission, while the reported rates of complete regression of AVMs with Fibrin glue and Polyvinyl alcohol are above 50%. At present, there are no unified agreement on the ideal embolic agent.Therefore, a multidisciplinary approach is recommended to support decision making about the best therapeutic approach and to achieve optimal outcome. A long-term post-treatment follow-up is recommended to recognize early recurrence.

Traumatic Sacral Fractures: Navigation Technique in Instrumented Stabilization

Sacral fractures are a challenge regarding treatment and classification. Surgical techniques using spinal navigation systems can improve treatment, especially if used in collaboration among different specialists. Between 2015 and 2017, we treated 25 consecutive cases of sacral fracture. Twelve patients (48%) underwent mechanical ventilation due to hypovolemic shock for severe thoracoabdominal trauma; bleeding was blocked with pelvic packing in 9 cases (36%) and transcatheter embolization in 2 cases (8%). External fixation was used in 7 cases (28%). In 20 cases (80%) spinal fractures were associated. All patients were operated on using spinal navigation by a team of neurosurgeons and orthopedic surgeons. The mean time from first observation to surgery was 18 days (range 8-31). Surgical treatment consisted of iliosacral fixation in 19 cases (76%) and spinopelvic fixation in 6 cases (24%). The mean number of screws for spinopelvic fixation was 9.67 (range 6-17) with a mean operation time of 323.67 minutes (range 247-471); in iliosacral osteosynthesis the mean screw number was 1.37 (range 1-3) and mean surgical time was 78.93 minutes (range 61-130). Postoperative computed tomography showed the correct screw placement. Wound infection occurred in 2 cases (8%), managed with vacuum-assisted closure therapy; in 1 case (4%) a sacral screw was removed for decubitus. Navigation systems in instrumented spinopelvic and sacropelvic reconstruction provide greater safety, reducing learning times and malpositioning. Multidisciplinary management allows us to achieve optimal results, especially when the sacral fracture is combined with spinal and pelvic lesions. The use of navigation systems could represent an important advancement.

Uterine artery embolization in obstetrics

Introduction. We did not find any publications or mentions in the Ukrainian medical segment of the Internet and special medical literature about previously performed similar operations (simultaneous caesarean section and embolization of the uterine arteries directly at the moment of birth), which allows us to consider the two operations performed «Prophylactic selective transcatheter embolization of uterine arteries» in pa­­tients with placenta previa percreta the first in Ukraine. Background. The prevalence of placenta previa and placenta percretaincreases from year to year as a result of an increase in the number of cesarean sections. Because of this, the percentage of women at high risk of massive life-threatening bleeding is also increasing. Predictions around the world show that the incidence of cesarean section will increase, which will lead to an increase in the number of placenta previa and placenta increta and thereafter maternal mortality, since the main cause of maternal mortality is bleeding (about 35 % of cases). The aim study was to asses of the effect of preventi­­ve selective embolization of uterine arteries with placenta previa percreta on the volume of blood loss during delivery, and the possibility of preserving the uterus and the reproductive function of women. Material and methods. In 2018—2019, we per­­formed two prophylactic selective transcatheter em­­bolizations of the uterine arteries in patients with placenta previa percreta. The delivery of these patients took place in the form of simultaneous endovascular embolization of the uterine arteries during cesarean section. The delivery algorithm was as follows: the first stage was the contralateral catheterization of the uterine arteries by transfemoral access. Next, corporal cae­sarean section was performed. After extraction of the fetus and clamping of the umbilical cord, uterine arteries were selectively embolized until the blood flow through them was completely stopped. Then, sepa­­ration/dissection of the placenta, metroplasty and suturing of the wound were performed. At the end of the operation, catheters from the uterine arteries were removed. Results and discussion. The entire embolization procedure (in total: from puncture of the femoral arteries to control angiography after embolization) took 27 minutes in the first case and 38 minutes in the second. The longer embolization time in the second case is partially associated with unilateral access and alternate catheterization of the uterine arteries. This was done to minimize post-procedural complications of the site of puncture of the femoral artery. Unfortunately, the technical conditions for these embolizations did not allow transradial access, which is possible from a practical point of view. The postpartum period was without complications. As the experience of these two operations showed, it was not possible to achieve the fullness of the «dry uterus» by embolization of the uterine arteries, but the volume of blood loss taking into account reinfusion in the form of washed red blood cells turned out to be lower than the median values of most cases and published studies described in foreign literature. Conclusions. Preventive selective transcatheter em­­bo­­lization of the uterine arteries before birth/removal of the placenta can be considered as a good preventi­­on of primary postpartum hemorrhage and thus to provide organ rescue. In pregnant women of high-risk groups, it is better to carry out catheterization of the uterine arteries in a planned manner before delivery, simultaneously with cesarean section, which is technically simpler.