Transfemoral Embolization Research Articles

Technical Note: A serendipitous discovery - Incidental coarctation of the aorta during transfemoral embolization of a ruptured anterior communicating artery aneurysm

We present the first case of endovascular treatment of a ruptured anterior circulation aneurysm via a transradial approach in a patient with undiscovered aortic coarctation (CoA).A 29 year old male patient presented to the emergency department with a 1 day history of sudden-onset headache and vomiting.CT and CTA confirmed presence of acute subarachnoid haemorrhage and an anterior communicating (ACOM) artery aneurysm.Transfemoral endovascular angiography with a view to coiling was performed, however resistance was encountered distal to the aortic arch. On-table chest radiography demonstrated bilateral inferior rib notching confirming suspicion of a CoA.The procedure was converted to transradial access. The ACOM aneurysm was successfully coiled.This case highlights several important learning number points with particular regard to the rising era of transradial neuroendovascular management.

Improving Outcomes in Carotid Body Tumors Treatment: The Impact of a Multidisciplinary Team Approach

The purpose of this study was to evaluate how a multidisciplinary approach, including patients and familiar genetic counseling, preoperative succinate-dehydrogenase (SDH) gene mutation analysis, preoperative adjunctive endovascular procedures (PAEPs) and postoperative rehabilitative team may affect the outcomes in patients who underwent surgery for carotid body tumors (CBTs). Fifty-seven consecutive CBT resections were performed from January 1995 to December 2019 in a single center institution. Two groups of patients were compared: group A (1995-2003; n = 10) and group B (2004-2019; n = 47), treated before and after the establishment of a multidisciplinary approach to CBTs. Group A and group B were evaluated retrospectively and prospectively for SDH mutations, respectively. PAEPs (external carotid artery stenting, percutaneous transfemoral embolization or direct percutaneous puncture of the tumor with simultaneous embolization) were performed only in patients of group B, when the size of the tumor exceeded the 45 mm. Primary endpoints were blood loss (BL) and cranial nerve injuries. Secondary endpoint was the number of new silent masses (NSMs) discovered after genetic evaluation. SDH mutations were found in 2 patients of group A and in 11 patients of group B. There were no significant differences in mass diameter between the groups. A significant difference regarding the surgical procedure time was observed in the 2 groups, with a higher time in the group A (Group A: 180 ± 77.3; Group B: 138 ± 54.5, P= 0.04). BL was significantly lower in group B (203 ± 69.5 mL vs. 356 ± 102 mL; P = 0.0001), as well as for patients underwent PAEPs vs. those underwent direct surgery (n = 15, 149 ± 53 mL vs. n = 42, 273 ± 88 mL; P = 0.0001). No differences between transient and persistent cranial nerve injuries were observed between the 2 groups. Carotid reconstruction was necessary for 2 patients of group A (n = 2 vs. n = 0; P = 0.02). Unilateral tumor recurrence was detected in 7 patients, with a significantly higher rate (P ≤ 0.002) in patients carrying SDH mutations compared to those without SDH mutation (wild-type). SDH mutations detected in the groups lead to discover 7 NSMs (group A n = 1 vs. group B n = 6; P = 1.00). The impact of the multidisciplinary team suggests that surgical resection still remains the gold standard for the treatment of CBTs, but the use of PAEPs in selected cases may reduce surgical procedure time, BL and the need for reconstructive carotid surgery. Genetic counseling and SDH gene analysis allow to diagnose NSMs in asymptomatic patients. Larger studies should be considered to evaluate the effectiveness of postoperative rehabilitative program.

Transfemoral embolization of a large symptomatic renal angiomyolipoma in a horseshoe kidney: a case report and literature review

Renal angiomyolipomas (AML) are the commonest benign renal neoplasms. They are composed of blood vessels, adipose tissue, and smooth muscle in varying amounts. It is quite rare to find AML in a horseshoe kidney, although there is at least one such reported case discovered in pregnancy and managed by resection. Spontaneous hemorrhage which could be fatal is the most feared sequelae of AML. The first-line of management for AMLs was previously surgical excision. However, advances in minimally invasive techniques that have a lower risk of complications have broadened treatment options for reducing tumour size and preventing hemorrhage. One of such effective techniques is selective arterial embolization (SAE) of renal AMLs > 4cm. Patients not requiring any immediate intervention maybe followed up with active surveillance. In this case report, we present a case of AML in a horseshoe kidney that was successfully treated with transfemoral embolization as well as a review of the literature.

Elective Embolization of Splenic Artery Aneurysms with an Ethylene Vinyl Alcohol Copolymer Agent (Squid) and Detachable Coils

PurposeTo report the safety and efficacy of the embolization of splenic artery aneurysms (SAAs) with coils plus ethylene vinyl alcohol copolymer (EVOH) agent. Materials and MethodsA single-center retrospective study was conducted from 2016 to 2019 to collect SAAs. Twelve asymptomatic patients (mean age, 59 years) with 15 SAAs (mean size, 23.6 mm; size range, 15–40 mm) were treated with embolization. Embolization was performed with EVOH (Squid 8/34) and fibered detachable coils. Transfemoral embolization was performed with a microcatheter to achieve a splenic artery occlusion embolizing the SAA and its efferent and afferent branches. Follow-up was based on color Doppler ultrasound at 24 hours and on computed tomography (CT) angiography at 1 (n = 12) and 6 months (n = 12) after embolization. Mean number of coils and Squid vials used for each patient, major/minor complications, technical success, 30-day clinical success, cases of revascularization/reintervention, and mortality were assessed. Technical success was defined as complete exclusion of the aneurysmal segment and cessation of blood flow into the sac. Clinical success at 1 month was based on the absence of clinical symptoms and the exclusion of aneurysm revascularization on CT angiography. ResultsThe mean number of coils and Squid vials was 5.75 (standard deviation [SD], 1.58; range, 3–9) and 1.41 (SD, 0.49; range, 1–2), respectively. Both technical and 30-day clinical success were 100%, with no cases of aneurysm revascularization (CT angiography performed in all patients at 1 month and 6 months and in 3 patients at 24 months). No major complications or fatal events were recorded. In terms of minor complications, 2 cases of mild pancreatitis (transient amylases increase) and 1 case of focal splenic ischemia without clinical sequelae were recorded. ConclusionsEmbolization in SAAs using coils plus EVOH was safe and effective without SAA revascularization

The incidence and fate of endoleaks vary between ruptured and elective endovascular abdominal aortic aneurysm repair

BackgroundThe number of ruptured abdominal aortic aneurysm (r-AAA) patients who are treated by endovascular means is increasing as ruptured endovascular aneurysm repair (r-EVAR) enters the mainstream. However, even today, data on the incidence and behavior of endoleaks after r-EVAR are scarce. This study analyzed whether endoleaks behave differently after EVAR for rupture vs elective AAA repair. MethodsFrom 2002 to 2013, there were 2052 patients who underwent EVAR for treatment of rupture (n = 166 [8.1%]) and elective repair (n = 1886 [91.9%]) of infrarenal AAA. Follow-up included computed tomography angiography at 1 month, at 6 months, and yearly thereafter. All type I and type III endoleaks were treated at the time of or shortly after the diagnosis. Persistent type II endoleaks at >6 months after EVAR without a decrease in AAA sac underwent translumbar or transfemoral embolization procedures. Data were prospectively collected in a vascular database. ResultsDuring a mean follow-up of 30 months, patients had a significantly lower incidence of type II endoleaks after r-EVAR compared with elective endovascular aneurysm repair (e-EVAR; n = 15 [9.0%] vs n = 380 [20.2%]; P < .01). Although the incidence of type I endoleaks is similar after r-EVAR (n = 9 [5.4%] and e-EVAR (n = 83 [4.4%]; P = .68), the r-EVAR patients required stent graft explantation more frequently (n = 9 [5.4%] vs n = 20 [1.1%]; P < .01). Whereas the need for secondary intervention was comparable in both r-EVAR (n = 33 [19.9%]) and e-EVAR (n = 439 [23.3%]; P = .37) groups, patients undergoing percutaneous embolization procedures trended toward significance between the two groups (n = 11 [6.6%] vs n = 216 [11.5%]; P = .06) with endoleaks. ConclusionsCompared with e-EVAR, patients who undergo r-EVAR experience a similar incidence of type I endoleaks and a significantly lower incidence of type II endoleaks. The endoleaks in both e-EVAR and r-EVAR patients can frequently be managed by endovascular means. However, r-EVAR patients with type I and type II endoleaks are at a significantly higher risk for stent graft explantation.

Successful treatment of aneurysmal bone cyst of the proximal fibula with embolization.

We present an 8-year-old girl with evolution of an aneurysmal bone cyst of the proximal fibula after intralesional surgery, treated successfully with one selective transfemoral embolization with N-2-butyl-cyanoacrylate. By the first 5days, the patient experienced complete pain relief. Post-embolization imaging follow-up showed progressive homogenous trabecular bone formation and gradual reduction of the size of the lesion. These findings canceled our initial consideration for surgical treatment. Three years after the embolization, healing of the lesion and remodeling of the proximal fibula were observed without evidence of recurrence. Our successful results with excellent response seen 3years after embolization are in favor and should increase the awareness of surgeons regarding embolization for aneurysmal bone cysts in difficult anatomic locations such as the proximal fibula.

A novel approach to the management of a ruptured Type II endoleak following endovascular repair of an internal iliac artery aneurysm

Endovascular repair of isolated iliac artery aneurysms is an established safe and effective management option. Type II endoleak is a potential complication, but rarely results in significant morbidity or mortality. We report a case of a patient who presented with a ruptured internal iliac artery aneurysm secondary to a Type II endoleak. To our knowledge this and the following method of managing this have not been previously reported. Established methods of managing endoleaks, such as intravascular transfemoral embolisation and open or laparoscopic ligation, were not possible. Therefore, we resorted to a novel approach to this type of aneurysm and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery.

Transarterial embolization of a high-flow maxillary arteriovenous malformation fed by multiple arteries

A high-flow maxillary arteriovenous malformation fed by multiple arteries, including bilateral internal maxillary arteries and ophthalmic artery, is reported. A combination of polyvinyl alcohol particles and N-butyl-cyanoacrylate mixed with lipiodol was progressively deposited within the distal vascular bed by transarterial superselective embolization of the branches of bilateral internal maxillary arteries, resulting in complete anatomic and clinical cure. The authors feel that this approach is more secure and effective compared with transfemoral venous embolization and direct transosseous puncture. It also avoids mutilating surgery.

Interventional Radiological Management of Prehepatic Obstruction the Splanchnic Venous System

The purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins. Twenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation. Obstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%). We conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction.

Carotico-cavernous sinus fistula

We present a rare case of carotico-cavernous sinus fistula who presented with proptosis with gradual diminision of vision following a roadside accident. Contrast enhanced CT scan and angiography confiruned the diagnosis and it was managed by transfemoral embolisation of right ICCF.

The Circumferential Antishock Sheet

Hemorrhage control in patients with pelvic ring disruptions remains problematic. To decrease bleeding, efforts have been made to acutely reduce and stabilize the pelvis. The goals of rapid pelvic reduction and stabilization are restoration of normal pelvic volume, protection of the early clot, and improved patient comfort. The use of military antishock trousers, hip spica casts, external fixators, antishock pelvic clamps, early open reduction/internal fixation, and open packing have been reported in the literature. A simple temporary technique of reduction is reported using a circumferential bed sheet. The sheet is placed between the iliac crests and the greater trochanters, encircling the pelvis. The circumferential sheet provides stabilization for transportation and allows transfemoral angiographic embolization or exploratory laparotomy at the receiving hospital. Definitive fixation can then be accomplished.

Temporary Percutaneous Aortic Balloon Occlusion to Enhance Fluid Resuscitation Prior to Definitive Embolization of Post-Traumatic Liver Hemorrhage

We successfully stabilized severe hemorrhagic shock following traumatic liver injury by percutaneous transcarotid supraceliac aortic occlusion with a 5 Fr balloon catheter. Then we were able to perform transfemoral embolization therapy of the hepatic arterial bleeding source. Transient aortic occlusion using a balloon catheter appears to be a useful adjunct in select cases where stabilization of the patient is necessary to allow successful selective embolization of the bleeding source.

Testicular size following embolization therapy for paediatric left varicocele.

Optimal management of varicocele testis in children and adolescents is controversial, but testicular hypotrophy has been suggested as an indication for treatment in adolescents. This report concerns the diagnosis and management of left varicocele in 30 patients aged 6-15 years and the influence of treatment on testicular size. The left testicle was significantly smaller than the right in 14 patients at enrollment in the study. All patients were treated in local anaesthesia with percutaneous transfemoral spermatic venography and embolization of that vein with spring coil, followed by 24-hour observation. There were no major complications. At follow-up 9 to 12 months after the treatment, the size of the left testis had increased in 12 patients. Spring-coil embolization of the spermatic vein proved to be a safe and effective technique for treatment of varicocele.

Multimodality Treatment of Deep Arteriovenous Malformations: Thalamus, Basal Ganglia, and Brain Stem

THE THERAPEUTIC APPROACH toward arteriovenous malformations (AVMs) located in the basal ganglia, thalamus, and brain stem has evolved from microsurgical resection as the predominant therapy to a combination of microsurgery, embolization, and radiosurgery. This multimodality treatment was used in the management of 32 patients with deep AVMs of all sizes. Twenty-two patients with surgically accessible AVMs (i.e., typically located in the brain stem and thalamus) underwent microsurgical resection. The AVMs of half of these patients were devascularized preoperatively with transfemoral embolization. Five patients with residual AVMs were then treated with radiosurgery. Ten patients had AVMs, typically located in the basal ganglia, that were surgically inaccessible. These patients underwent embolization to reduce the AVM size, and the postembolization nidus was then treated with radiosurgery. For patients treated early in the series with a predominantly surgical approach, the complete resection rate was 43%. For patients treated later in the series after radiosurgery was incorporated into the management scheme, the complete elimination rate was 72%. Overall, there were no deaths in this series, and the permanent treatment-associated morbidity rate was 9%. These results indicate that an individualized, multimodality approach can be used to eliminate both large and small deep AVMs with an acceptably low morbidity and mortality rate.

The long-term follow-up of transfemoral embolization of varicoceles

The long-term follow-up of transfemoral embolization of varicoceles

Penetrating atherosclerotic aortic ulcer with dissecting hematoma: control of bleeding with percutaneous embolization.

A case is presented in which left subpleural hematoma and hemothorax resulted from a penetrating atherosclerotic aortic ulcer with an aortic pseudoaneurysm and intramedial hematoma. Percutaneous transfemoral embolization of the ulcer with use of coils and thrombin resulted in stabilization of the patient's hemodynamic status. The patient died 6 days later of pneumonia. In certain clinical situations, treatment of bleeding from penetrating aortic ulcers with percutaneous embolization may stabilize the patient's condition, allowing elective surgical intervention.

Therapeutic Embolization of Facial Arteriovenous Fistulae

Two cases of percutaneous transfemoral embolization of facial hemangiomas and arteriovenous (AV) malformations are reported. In both cases, Ivalon shavings were injected through a percutaneously placed catheter to permanently occlude peripheral feeders of the AV malformation. In one case, because of the size of the large venous sacs associated with the malformation, a steel coil was introduced to form a baffle, over which several additional strands of surgical silk were introduced to obliterate these sacs. These cases emphasize the need for embolization of small feeding arteries to prevent recurrence by collateral channels. To achieve this, specific-sized emboli are necessary; Ivalon is a suitable embolic material.

Selective transfemoral embolization of the internal iliac artery in carcinoma of the bladder (author's transl)

Inoperable bladder cancer and massive bleeding is an indication for selective bilateral transfemoral embolization of the internal iliac arteries. The method is preferred to the open ligation of these arteries. Histoacryl is the optimal material for longterm vascular embolization. In five patients with bleeding inoperable bladder cancer (stage T4N2) immediate and permanent haemostasis and a regression of pain was achieved.