MELD-Na > 16 is associated with high peri-procedural and short-term mortality in patients with ruptured hepatocellular carcinoma treated with emergent transarterial embolization.

PURPOSE: To evaluate prognostic factors associated with peri-procedural (30 days) and short-term (90 days) mortality in the United States cohort of patients following emergent transarterial embolization for ruptured hepatocellular carcinoma. METHODS: Patients with ruptured hepatocellular carcinoma treated with emergent TAE between January 2001 and December 2019 were retrospectively identified (n = 24). Average age was 62 years (range, 23-78 year); 15 (62.5%) were men. Univariate and Cox proportional hazard modeling were used to determine independent predictors of overall survival (OS) following TAE. OS stratified by Model for End-Stage Liver Disease-Sodium score was assessed using Kaplan-Meier analysis. RESULTS: Twenty-one patients (88%) died during a mean clinical follow-up period of 328 ± 139 days. MELD-Na score (HR 1.22 per 1-unit increase; 95% CI 1.06-1.46; p = 0.005) and pre-rupture ECOG PS score (HR 8.1; 95% CI 1.28-51.2; p = 0.026) were independent predictors of decreased overall survival. There was no significant association between overall survival and presence of cardiovascular co-morbidities (p = 0.60), hemorrhagic shock on presentation (p = 0.16), portal vein thrombus (p = 0.08), vasopressor support required (p = 0.79), intubation required (p = 0.40), acute kidney injury (p = 0.58), and number of packed red blood cell transfusions (p = 0.22). The median OS was 64 days. Median OS was significantly greater in patients with a MELD-Na score ≤ 16 as compared to those with a MELD-Na score > 16 (166.5 days vs 9 days, p = 0.011). Cumulative OS rates in those with a MELD-Na score ≤ 16 at 30, 60, 90, and 360 days were 79%, 64%, 64%, and 25%, respectively, vs 33%, 33%, 11%, and 0%, respectively, in those with a MELD-Na score > 16. CONCLUSION: MELD-Na > 16 is associated with very high peri-procedural (67% at 30 days) and short-term (89% at 90 days) mortality in patients with ruptured HCC treated with emergent transarterial embolization. A better understanding of these prognostic factors may help guide treatment decisions and provide realistic expectations when counseling patients and their families.

A case of a large leiomyomatous uterus with multiple arteriovenous malformations and subsequent high cardiac output state with severe four chamber cardiac enlargement.

Uterine arteriovenous malformations (AVMs) are rare and potentially life-threatening. They can be congenital or acquired. Uterine artery embolization or hysterectomy are considered mainstays of management. AVMs can be associated with leiomyomas, and patients may require both procedures. We present a case of a 42-year-old woman with a massively enlarged leiomyomatous uterus supplied and drained by multiple large AVMs, leading to high cardiac output state with severe four chamber cardiac dilation. Management required a multidisciplinary team of interventional radiology, gynecologic oncology surgery, vascular surgery, cardiac anesthesiology, cardiology, and urology and a 2-day interventional approach of preoperative arterial embolization followed by hysterectomy.

Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome?

PURPOSE: To identify whether symptom relief and stent patency vary with use of long-term anticoagulation after stent placement for benign superior vena cava (SVC) syndrome. MATERIALS AND METHODS: Patients with benign SVC syndrome treated with stent placement between January 1999 and July 2017 were retrospectively identified (n = 58). Average age was 49 years (range, 24-80 y); 34 (58%) were women, and 24 (42%) were men. Average follow-up was 2.4 years (range, 0.1-11.1 y, SD 2.6). Of cases, 37 (64%) were due to a long-term line/pacemaker, and 21 (36%) were due to fibrosing mediastinitis. After stent placement, 36 (62%) patients were placed on long-term anticoagulation, and 22 (38%) were not placed on anticoagulation. Percent stenosis was evaluated on follow-up imaging by dividing smallest diameter of the stent by a normal nonstenotic segment of the stent and multiplying by 100. RESULTS: Technical success was achieved in all cases. There was no significant difference in number of patients who reported a return of symptoms characteristic of benign SVC syndrome between the anticoagulated (16 of 36; 44.4%) and nonanticoagulated (11 of 22; 50%) groups (P = .68). There was no significant difference in the mean percent stenosis between the anticoagulated (40.4% ± 34.7% [range, 0-100%]) and nonanticoagulated (32.1% ± 29.2% [range, 1.7%-100%]) groups (P = .36). No significant difference was found in the time (days) between date of procedure and date of return of symptoms (anticoagulated, 735.9 d ± 1,003.1 [range, 23-3,851 d]; nonanticoagulated, 478 d ± 826.6 [range, 28-2,922 d]) (P = .49). There was no difference in primary patency between groups (P = .59). Finally, 1 patient (2.8%) in the anticoagulated group required surgical intervention, whereas none in the nonanticoagulated group required surgical intervention. CONCLUSIONS: No significant difference was observed in clinical and treatment outcomes in patients who did and did not receive anticoagulation after stent placement for benign SVC syndrome. Management of benign SVC syndrome after stent placement may not require anticoagulation if confirmed by additional studies.

Pulmonary embolism attenuation is a potential imaging biomarker for pulmonary artery hemodynamic improvement after catheter-directed thrombolysis.

This study examined the potential correlation between pulmonary embolism (PE) attenuation on computed tomography pulmonary angiography (CTPA) and pulmonary artery hemodynamic response to catheter-directed thrombolysis (CDT) in 10 patients with submassive PE. Treatment parameters, PE attenuation, clot burden, computed tomography signs of right ventricle dysfunction and right ventricular systolic pressure at echocardiography were retrospectively analyzed to determine correlation with pulmonary artery pressure improvement using Spearman correlation. A single reader, blinded to the treatment results, measured PE attenuation of all patients. There was a significant positive correlation between PE attenuation and absolute pulmonary artery pressure improvement with a Spearman correlation of 0.741, p=0.014. When attenuation was greater than or equal to the median (44.5 HU, n=5), CDT was associated with significantly better pulmonary artery pressure improvement ( p=0.037). Clot attenuation at CTPA may be a potential imaging biomarker for predicting pulmonary artery pressure improvement after CDT.

Comparison of Covered Versus Uncovered Stents for Benign Superior Vena Cava (SVC) Obstruction.

PURPOSE: To identify whether long-term symptom relief and stent patency vary with the use of covered versus uncovered stents for the treatment of benign SVC obstruction. METHODS AND MATERIALS: We retrospectively identified all patients with benign SVC syndrome treated to stent placement between January 2003 and December 2015 (n = 59). Only cases with both clinical and imaging follow-up were included (n = 47). In 33 (70%) of the patients, the obstruction was due to a central line or pacemaker wires, and in 14 (30%), the cause was fibrosing mediastinitis. Covered stents were placed in 17 (36%) of the patients, and 30 (64%) patients had an uncovered stent. Clinical and treatment outcomes, complications, and the percent stenosis of each stent were evaluated. RESULTS: Technical success was achieved in all cases at first attempt. Average clinical and imaging follow-up in years was 2.7 (range 0.1-11.1) (covered) and 1.7 (range 0.2-10.5) (uncovered), respectively. There was a significant difference (p = 0.044) in the number of patients who reported a return of symptoms between the covered (5/17 or 29.4%) and uncovered (18/30 or 60%) groups. There was also a significant difference (p = < 0.001) in the mean percent stenosis after stent placement between the covered [17.9% (range 0-100) ± 26.2] and uncovered [48.3% (range 6.8-100) ± 33.5] groups. No significant difference (p = 0.227) was found in the time (days) between the date of the procedure and the date of clinical follow-up where a return of symptoms was reported [covered: 426.6 (range 28-1554) ± 633.9 and uncovered 778.1 (range 23-3851) ± 1066.8]. One patient in the uncovered group had non-endovascular surgical intervention (innominate to right atrial bypass), while none in the covered group required surgical intervention. One major complication (SIR grade C) occurred that consisted of a pericardial hemorrhagic effusion after angioplasty that required covered stent placement. There were no procedure-related deaths. CONCLUSION: Both covered and uncovered stents can be used for treating benign SVC syndrome. Covered stents, however, may be a more effective option at providing symptom relief and maintaining stent patency if validated by further studies.

Safety and Effectiveness of Palliative Tunneled Peritoneal Drainage Catheters in the Management of Refractory Malignant and Non-malignant Ascites.

PURPOSE: To determine the safety and effectiveness of tunneled peritoneal catheters in the management of refractory malignant and non-malignant ascites. MATERIALS AND METHODS: An IRB-approved retrospective review was undertaken of patients who underwent ultrasound and fluoroscopy-guided tunneled peritoneal catheter placement for management of refractory malignant or non-malignant ascites between January 1, 2009, and March 14, 2014. RESULTS: A total of 137 patients (76 M/61 F, mean age 62.9 years) underwent tunneled peritoneal catheter placement for refractory malignant (N = 119; 86.9%) or non-malignant (N = 18; 13.1%) ascites. Technical success was 100% with no immediate complications. Nineteen patients (13.9%) experienced a total of 11 minor and 12 major complications. Nine patients developed a catheter-associated infection. The remaining complications included leakage at the dermatotomy site (N = 8), catheter dislodgement (N = 2), obstruction (N = 2), and groin pain (N = 2). Patients who developed a catheter-associated infection had a significantly longer catheter dwell time compared to those who did not develop an infection (median, 96.5 vs. 20 days; p < 0.01). Nine patients (6.6%) were lost to follow-up. Of the remaining 128 patients, 125 died and the majority had a catheter in place (90.4%) at the time of death. There was one catheter-associated death (bacterial peritonitis; 0.8%). The median time from catheter placement to death was significantly shorter in patients with malignant versus non-malignant ascites (18.5 vs. 85 days; p < 0.0001). CONCLUSIONS: Tunneled peritoneal drainage catheters are effective and relatively safe in the management of malignant and non-malignant ascites. Longer catheter dwell time may be a risk factor for catheter-associated infection, particularly in patients with a longer anticipated survival in the palliative setting.

Subarachnoid and intraperitoneal hemorrhage secondary to segmental arterial mediolysis: A case report and review of the literature.

Background Segmental arterial mediolysis (SAM) is an uncommon or underdiagnosed arteriopathy that presents with life-threatening hemorrhage. SAM can affect the intracranial, spinal, and visceral arteries, with reported cases of concomitant intracranial and visceral hemorrhage. Case description We present the case of a 61-year-old male with concurrent subarachnoid and intraperitoneal hemorrhage caused by simultaneously bleeding posterior spinal artery and splenic artery pseudoaneurysms. The posterior spinal artery pseudoaneurysms were treated with selective injection of polyvinyl alcohol particles into the posterior spinal artery, while the splenic artery pseudoaneurysm was treated with Gelfoam embolization. The constellation of imaging, clinical, and laboratory features led to a presumptive diagnosis of SAM, which remains the only reported cause of concurrent neurovascular and visceral artery aneurysm rupture. Conclusion SAM is a key diagnostic consideration in cases of concomitant intracranial, spinal, and visceral artery aneurysm rupture.

Evaluating safety of tunneled small bore central venous catheters in chronic kidney disease population: A quality improvement initiative.

INTRODUCTION: Peripherally inserted central venous catheters (PICCs) may adversely impact future successful arteriovenous fistulae (AVF). As part of a quality improvement project, the performance of tunneled small bore tunneled central venous catheters (TSB-CVCs), as alternatives to PICCs, was evaluated. METHODS: A retrospective observational study, involving individuals ≥18 years of age who underwent TSB-CVC placement by Interventional Radiology at Mayo Clinic, Rochester, MN between 1/1/2010 and 8/30/2013. FINDINGS: The study cohort included 92 patients with a median age of 55 (46-67) years, who underwent 108 TSB-CVC placements. Baseline renal disease was present in 71% (77/108). Most TSB-CVCs were placed in hospitalized patients (94%; 102/108); five French in diameter (61%; 66/108) and located in an internal jugular vein (84%; 91/108). Median catheter indwelling time was 20 (11-43) days (n = 84). TSB-CVC-related bloodstream infection, deep venous thrombosis (DVT), and superficial venous thrombosis (SpVT) rates per line were 0.009 (1/108), 0.018 (2/108), and 0.009 (1/108), respectively. Venous outcomes in a subgroup of 54 patients, who had documented PICC placements (n = 161) in addition to TSB-CVC (n = 58) were compared. TSB-CVC-DVT rate was lower than the PICC-DVT rate (0.017 [1/58] vs. 0.106 per line [17/161]; P = 0.04). The TSB-CVC-SpVT rate was not different from the PICC-SpVT rate (0 [0/58] vs. 0.037 [6/161] per line; P = 0.14). DISCUSSION: TSB-CVCs demonstrated an excellent safety profile in our study. These catheters should be preferentially utilized for arm vein preservation in advanced kidney disease. Their impact on future AVF success needs further evaluation.

Impact of Chronic Kidney Disease on Clinical Outcomes of Endovascular Treatment for Femoropopliteal Arterial Disease.

PURPOSE: To evaluate effect of chronic kidney disease (CKD) on all-cause mortality, major adverse limb event (MALE), MALE and postoperative death (MALE + POD), and amputation after endovascular treatment of femoropopliteal disease. MATERIALS AND METHODS: A retrospective review from January 2002 to October 2011 was performed of 440 patients who underwent endovascular treatment of symptomatic femoropopliteal disease for claudication (n = 251) or critical limb ischemia (CLI) (n = 267). CKD stage was divided based on Kidney Dialysis Outcomes Quality Initiative classification. Outcomes and factors associated with amputation, MALE, and MALE + POD were determined. RESULTS: Patients with diabetes (hazard ratio [HR] = 2.2; 95% confidence interval [CI], 1.3-3.6; P = .002) and runoff score of 0 or 1 (HR = 2.0; 95% CI, 1.2-3.4; P = .01) relative to runoff score of 3 were at increased risk of amputation. Patients with baseline glomerular filtration rate < 45 mL/min/1.73 m(2) had a 17% increase in amputation for every 5-point decrease < 45 mL/min/1.73 m(2) (95% CI, 1.09-1.26; P < .001). Increase of 10 years in age (HR = 1.9; 95% CI, 1.5-2.3; P < .001), TransAtlantic Inter-Society Consensus class of C/D relative to A/B (HR = 1.6; 95% CI, 1.1-2.2; P = .01), and CLI (HR = 2.4; 95% CI, 0.5-0.9; P < .001) were associated with increased mortality. Female sex was associated with decreased risk of mortality (HR = 0.7; 95% CI, 0.5-0.9; P = .01). CONCLUSIONS: Worsening CKD is associated with higher amputation rates, all-cause mortality, and MALE + POD in patients undergoing endovascular treatment of femoropopliteal disease.

Percutaneous radiologic gastrostomy catheter placement without gastropexy: a co-axial balloon technique and evaluation of safety and efficacy.

PURPOSE: The purpose of this study is to evaluate the short-term safety and efficacy of a co-axial angioplasty balloon technique for percutaneous radiologic gastrostomy catheter placement (PRG). METHODS: A total of 65 percutaneous radiologic gastrostomy tube placements were performed with the co-axial angioplasty balloon technique from 10/1999 to 1/2014. This included 19 females and 46 males between the ages of 20-83. Without the use of T-fasteners for gastropexy, the gastrostomy tube was placed over a catheter-shaft angioplasty balloon as a co-axial system. The angioplasty balloon was used to sequentially approximate the stomach wall to the abdominal wall, dilate the tract, and was then used as a dilator to aid gastrostomy tube advancement into the gastric lumen. Technical success, complications, and dislodgements were evaluated by means of retrospective review of patient medical records and imaging. RESULTS: There was no procedural failure in any of the 65 placements. 30-day follow-up was available for 56 patients. 7 patients died within 30 days; none of the deaths were recorded as procedure-related. There was 1 major complication (1.5%) consisting of a colocutaneous fistula. There were 4 minor complications (6.2%). There was no occurrence of bleeding or skin infection while using this technique. CONCLUSIONS: PRG with the co-axial angioplasty-balloon technique is a safe and effective technique for gastrostomy placement.

The Timing and Presentation of Major Hemorrhage After 18,947 Image-Guided Percutaneous Biopsies.

OBJECTIVE: The objective of our study was to characterize the temporal and clinical manifestation of major bleeding events after biopsy to guide clinicians in the institution of appropriate surveillance. MATERIALS AND METHODS: We performed a retrospective review of percutaneous image-guided biopsies performed between September 1, 2005, and May 31, 2012, including 18,947 biopsy events. According to routine protocol, follow-up telephone calls were made to patients 24 hours after biopsy, and chart review was performed 3 months after biopsy. Bleeding complications were defined using the Common Terminology Criteria for Adverse Events (CTCAE, version 4.0) established by the National Cancer Institute. In patients with a grade 3 or greater bleeding complication, a retrospective chart review was performed to characterize the details of the complication including the timing of the complication and the primary clinical presentation of the event. RESULTS: Grade 3 hemorrhage was associated with 64 of 18,947 (0.3%) procedures, and there were three deaths associated with the biopsy event (0.02% or ≈ 2/10,000). Hemorrhage was most commonly associated with biopsy of a native kidney (17/1407, 1.2%). Twenty patients (31%) presented with a bleeding complication within 1 hour of biopsy. Twenty-seven patients (42%) presented within 2 hours of biopsy. Fifty-two patients (81%) presented within 24 hours, and the remaining 12 patients (19%) presented more than 24 hours after biopsy. Pain was the most common presentation of patients with bleeding complications, occurring in 39 (61%) patients. CONCLUSION: The incidence of major bleeding after percutaneous biopsies is very low, but delayed complications occur more frequently than anticipated. Pain is the most common clinical presentation of major bleeding complications.

Percutaneous cryoablation of stage T1b renal cell carcinoma: technique considerations, safety, and local tumor control.

PURPOSE: To describe the technical methods, safety, and local tumor control rate associated with percutaneous cryoablation of stage T1b renal cell carcinoma (RCC). MATERIALS AND METHODS: A retrospective review of a percutaneous renal ablation registry was used to identify 46 patients with a total of 46 biopsy-proven RCC lesions measuring 4.1-7.0 cm treated with cryoablation between 2003 and 2011. The main outcome parameters investigated were adjunctive maneuvers, complications, and local tumor progression, and cancer-specific survival rates. Complication rates were categorized and recorded using the Clavien-Dindo classification system. Progression-free and cancer-specific survival rates were estimated using the Kaplan-Meier method. RESULTS: The mean treated RCC size was 4.8 cm (range, 4.1-6.4 cm). Prophylactic tumor embolization was performed in 7 patients (15%), ipsilateral ureteral stents were placed in 7 patients (15%), and hydrodisplacement of bowel was performed in the treatment of 16 tumors (35%). A single technical failure (2.2%) was observed at the time of ablation. Thirty-six tumors (78%) had follow-up imaging at 3 months or later following ablation, including a single recurrence at 9 months after ablation. The mean duration of follow-up for the 35 RCC tumors that did not recur was 2.0 years (range, 0.3-6.1 y). Estimated local progression-free survival rate at 3 years was 96.4%. Of the 46 cryoablation procedures, there were 7 complications (15.2%) of grade II or worse. CONCLUSIONS: The results suggest that cryoablation represents a valid treatment alternative for select patients with clinical stage T1b RCC. Complications are frequent enough that multidisciplinary patient management should be considered.

Open surgical removal of a tilted and dislodged inferior vena cava filter through a lumbar branch without cavotomy.

Retrievable inferior vena cava (IVC) filters decrease the risk of pulmonary embolism. Retrieval is recommended but device migration, tilting, or perforation of the IVC by the filter may prevent successful removal. We present a case of a tilted IVC filter with the retrieval hook lodged in a lumbar vein preventing endovascular removal. A subcostal incision was used for open removal. The thrombosed lumbar vein was encircled with vessel loops, facilitating collapse of the filter. No cavotomy was made. This technique, with minimal variation, can be used to remove most nonthrombosed retrievable filters from the IVC, without the need for venotomy.

Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.

BACKGROUND: Although an arteriovenous fistula (AVF) is the hemodialysis access of choice, its prevalence continues to be lower than recommended in the United States. We assessed the association between past peripherally inserted central catheters (PICCs) and lack of functioning AVFs. STUDY DESIGN: Case-control study. PARTICIPANTS & SETTING: Prevalent hemodialysis population in 7 Mayo Clinic outpatient hemodialysis units. Cases were without functioning AVFs and controls were with functioning AVFs on January 31, 2011. PREDICTORS: History of PICCs. OUTCOMES: Lack of functioning AVFs. RESULTS: On January 31, 2011, a total of 425 patients were receiving maintenance hemodialysis, of whom 282 were included in this study. Of these, 120 (42.5%; cases) were dialyzing through a tunneled dialysis catheter or synthetic arteriovenous graft and 162 (57.5%; controls) had a functioning AVF. PICC use was evaluated in both groups and identified in 30% of hemodialysis patients, with 54% of these placed after dialysis therapy initiation. Cases were more likely to be women (52.5% vs 33.3% in the control group; P = 0.001), with smaller mean vein (4.9 vs 5.8 mm; P < 0.001) and artery diameters (4.6 vs 4.9 mm; P = 0.01) than controls. A PICC was identified in 53 (44.2%) cases, but only 32 (19.7%) controls (P < 0.001). We found a strong and independent association between PICC use and lack of a functioning AVF (OR, 3.2; 95% CI, 1.9-5.5; P < 0.001). This association persisted after adjustment for confounders, including upper-extremity vein and artery diameters, sex, and history of central venous catheter (OR, 2.8; 95% CI, 1.5-5.5; P = 0.002). LIMITATIONS: Retrospective study, participants mostly white. CONCLUSION: PICCs are commonly placed in patients with end-stage renal disease and are a strong independent risk factor for lack of functioning AVFs.

Lumbar artery pseudoaneurysm caused by a Gunther Tulip inferior vena cava filter.

Inferior vena cava (IVC) filters are widely used to decrease the risk of pulmonary embolism in patients with contraindications to anticoagulation. Complications include local hematoma, access site deep venous thrombosis (DVT), filter migration and embolization, leg penetration through the IVC wall, IVC occlusion, and filter fracture with embolization. Other rare complications include leg penetration into adjacent organs including duodenum and ureter. Lumbar artery pseudoaneurysms are rare and may be spontaneous, iatrogenic, or traumatic. To date, there have been 3 case reports of lumbar artery pseudoaneurysms caused by IVC filters. We present an additional case of a lumbar artery pseudoaneurysm caused by a Gunther Tulip IVC filter treated successfully with selective embolization.

Pancreas transplant venous thrombosis: role of endovascular interventions for graft salvage.

Venous thrombosis of pancreas transplant allografts often leads to graft loss. We evaluated the efficacy of emergent endovascular techniques to salvage thrombosed pancreatic allografts in a series of six patients. Of the 76 pancreas transplants performed between 2002 and 2006, six patients were diagnosed with venous thrombosis on MRI between 2 and 28 days posttransplant (mean, 9 days). Five patients were systemic-enteric (donor portal vein anastomosis to recipient iliac vein) and one patient was portal-enteric (donor portal vein anastomosis to recipient superior mesenteric vein). Conventional venography confirmed the diagnosis of venous thrombosis in all patients. One patient was treated with catheter-directed venous thrombolysis and balloon thrombectomy. Another patient was treated with rheolytic thrombectomy alone. The remaining four patients were treated with a combination of these mechanical and thrombolytic techniques. Completion venography revealed >50% clot reduction and resumption of venous drainage in all patients. One patient required additional intervention 16 days later for recurrent thrombosis. Two patients required metal stent placement for anastomotic stenoses or kinks. One patient required pancreatectomy 36 h after attempted salvage secondary to a major hemorrhage and graft necrosis. Two patients recovered pancreatic function initially but lost graft function at 8 and 14 months, respectively, from severe chronic rejection. Patient survival was 100%, long-term graft survival was 50%, rethrombosis rate was 16.6%, and graft loss from rejection was 33%. In conclusion, early recognition and treatment of venous thrombosis after pancreas transplantation has acceptable morbidity and no mortality using short-term endovascular pharmacomechanical therapy.

Percutaneous protective coil occlusion of the proximal inferior mesenteric artery before N-butyl cyanoacrylate embolization of type II endoleaks after endovascular repair of abdominal aortic aneurysms.

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.