Transcatheter Occlusion of Coronary-Pulmonary Fistula With a Liquid Embolic Agent After Evaluation by FFR.

A 58-year-old man was admitted for stable angina. The coronary angiogram revealed a coronary-pulmonary fistula with a nonsignificant atheroma. We decided to perform percutaneous embolization of the fistula in view of the symptoms and the hemodynamic assessment findings. Embolization was performed using a liquid embolic agent with no residual flow. (Level of Difficulty: Intermediate.).

Results of transvenous embolization of intracranial dural arteriovenous fistula: a consecutive series of 136 patients with 142 fistulas.

OBJECTIVE: Intracranial dural arteriovenous fistula (DAVF) is mainly treated with an endovascular approach. Two major treatment advances include transvenous embolization (TVE) with coils in 1989 and, more recently, transarterial embolization with Onyx. The aim of this study was to present a large monocentric series of patients with DAVF treated with TVE. This series reports more than 20 years of experience and describes the evolution of the medical management of these patients, as well as current indications for this treatment at the authors' center. METHODS: Consecutive patients treated for intracranial DAVFs with TVE from 1995 to 2018 were included. Clinical and imaging data were systematically collected. Univariate and multivariate analyses were performed to identify factors that were significantly associated with adverse clinical course or complications. RESULTS: In this study of 136 patients with 142 DAVFs treated with TVE, the occlusion rate was 90%. The median length of follow-up was 11 months. The rate of permanent complications was 5.1%, and the procedure-related mortality rate was 1.5%. Procedure-related mortality was associated with extension of thrombosis that was observed early in our experience. The introduction of a postoperative anticoagulation regimen has drastically decreased the occurrence of this complication. Other minor complications included cochleovestibular syndrome after embolization of lateral sinus DAVF and oculomotor nerve damage after embolization of cavernous sinus DAVF. CONCLUSIONS: TVE allows efficient occlusion of DAVF. It remains a valid option for DAVF located on a sinus that does not participate in normal venous drainage of the brain.

Giant intrahepatic venous malformation with localized intravascular coagulopathy. Follow-up and treatment during pregnancy.

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

[Abdomino-pelvic arteriovenous malformations: Clinical presentation and management]. / Malformations arterio-veineuses de l'abdomen et du pelvis : diagnostic et indications thérapeutiques.

Pelvic and abdominal arteriovenous malformations (AVM) are rare but is a grave condition. They can be sporadic or syndromic. Their presentation can be related to high flow shunting resulting in cardiac failure. Endovascular management is the treatment of choice in multidisciplinary approaches.

Long term follow-up of endovascular management of spinal cord arteriovenous malformations with emphasis on particle embolization.

OBJECTIVE: To determine long term safety and efficacy of endovascular treatment of spinal cord arteriovenous malformations (AVMs), with calibrated particle embolization as a firstline approach. METHODS: We reviewed clinical and imaging data of consecutive patients who underwent endovascular treatment for both nidal and fistulous type spinal cord AVMs in our center, from 1990 to 2015. Outcome at the last follow-up was assessed by an independent observer. RESULTS: Embolization of spinal cord AVMs was performed in 61 patients, including 46 (75%) with particles (exclusively in 29 patients), 30 (49%) with cyanoacrylate, and 6 (10%) with combined surgical treatments. Particle embolizations were iterative in 33 patients (median number of sessions 5 (range 3-6)). Neurological deterioration after treatment occurred in 5 patients (cyanoacrylate=4, surgery=1, particles=0; P<0.001). At a median follow-up of 6 years (range 3-13 years), angiographic cure was obtained in 11/61 (18%) patients (nidal type=6/53 (11%), fistulous type=5/8 (63%)). In progressive forms, neurological improvement occurred in 16/28 (57%) patients, stabilized in 9/28 (31%), and worsened in 3/28 (12%). In hemorrhagic forms, the rebleeding rate was 4/14 patient years without standard treatment, 0/322 patient years in partial iterative treatment, and 0/15 patient years in angiographically cured lesions (P=0.001). CONCLUSION: Our study suggests that particle embolization as a firstline therapy to treat spinal cord AVMs is safe and offers long term efficacy, especially for those with small, distal, and multiple shunts. Partial occlusion of the AVM may be sufficient to prevent rebleeding, without the potential risks of complete occlusion. Particle calibration and injection technique, 'one by one', are critical to safety. Cyanoacrylate embolization or surgery remains necessary if particle embolization fails to occlude large shunts.

Prevalence and treatment of spontaneous intracranial artery dissections in patients with acute stroke due to intracranial large vessel occlusion.

OBJECTIVE: To identify the prevalence and therapeutic consequences of spontaneous intracranial artery dissection (IAD) at the acute phase of ischemic stroke. METHODS: We reviewed clinical and imaging data of consecutive patients attending our center for mechanical thrombectomy (MT) between January 2012 and November 2017. IAD was defined according to published criteria and our own angiographic criteria (no clot following MT, and normalization of the vessel caliber after stenting). RESULTS: IAD was retrospectively diagnosed in 13/391 (3%) patients (inter-rater agreement κ=0.885, P<0.001). It was an extending of extracranial dissection in 7/13 (54%) patients. A total of 21 recanalization approaches (with or without IV tissue plasminogen activator) were analyzed in 13 patients. A medical approach was used in 7/21 (33%), MT in 7/21 (33%) (stent retriever=6, thromboaspiration=1), and permanent stenting in 7/21 (33%). A rescue recanalization was necessary after 8/14 (57%) approaches without stenting. Stenting was associated with a best rate of recanalization (P=0.001) and with a trend towards a lower rate of ischemic recurrence (P=0.057). Stenting of a circulating false lumen failed to recanalize the artery in two patients. At the last follow-up, no patient had developed a subarachnoid hemorrhage due to the dissection. The outcome at 3 months was favorable in 8/13 (62%) patients. One patient died at 3 weeks owing to a severe cerebellar infarction. CONCLUSION: IAD is a rare diagnosis that should be systematically considered in patients with intracranial large vessel occlusion, especially in patients with extracranial artery dissection and when MT does not retrieve any clot. Stenting of IAD as first-line approach should be assessed in further studies.

Vulvar Arteriovenous Malformation in a 16-Year-Old Girl.

BACKGROUND: Congenital arteriovenous malformations (AVMs) are infrequent but represent a serious medical challenge because of their unpredictable progression and high hemodynamic activity. CASE: We report on the treatment of a voluminous vulvar AVM in a 16-year-old girl. After failure of medical therapy, we performed a radical surgical resection with preliminary embolization and flap reconstruction. SUMMARY AND CONCLUSION: A multidisciplinary approach is required for AVM management. Early intervention and complete surgical resection combined with preliminary embolization represents the ideal therapy.

[Treatment by embolization of small uterine myomata]. / Traitement par embolisation des leiomyomes utérins symptomatiques de volume modéré.

We examined the effectiveness of uterine artery embolization (UAE) as a primary treatment for small symptomatic myomatas (<50 mm diameter). One hundred patients aged from 29 to 68 years underwent UAE between 01/01/99 and 12/31/2002. Efficacy was judged by physical examination and imaging studies at 6 to 12 months. All the patients were evaluated. Treatment failed in five cases, while symptoms resolved in all the other patients. Five patients became pregnant. The main complication was amenorrhea. No serious adverse effects were observed. The efficacy and safety of this method make it a possible preventive treatment for pre-symptomatic myomata. If these findings are confirmed, they will open a new era in the treatment of fibroids.

Endovascular treatment of basilar tip aneurysms with Guglielmi detachable coils: predictors of immediate and long-term results with multivariate analysis 6-year experience.

PURPOSE: To analyze anatomic and clinical results and factors predictive of outcome in treatment of basilar tip aneurysms with Guglielmi detachable coils (GDCs). MATERIALS AND METHODS: During 6 years, 55 unselected consecutive saccular aneurysms in 53 patients (mean age, 47 years) were treated with GDC occlusion. Forty-one (75%) aneurysms were ruptured (Hunt-Hess and Fisher grades were assigned in patients); 14 (25%), unruptured. Clinical and angiographic evaluations were performed 6 months after treatment and during follow-up (mean follow-up, 2 years). Multivariate analysis was used to determine factors predictive of outcome. RESULTS: GDC occlusion was a success in 52 (95%) aneurysms, a failure in two (4%), and not attempted in one (2%). Occlusion at final follow-up, evaluated in 44 aneurysms, was complete in 34 (77%), near complete in four (9%), and incomplete in six (14%). At 6-12 months, mean aneurysmal occlusion rate significantly worsened because of revascularization (P <.001) but improved at final follow-up because of reembolization in 10 aneurysms (P =.009); it remained stable (P =.351) between initial and final follow-up. Multivariate binary logistic regression indicated that before treatment started, aneurysmal neck size was the only independent predictor of initial occlusion rate (P =.002) and revascularization (P =.004). After the initial procedure, sac size and initial occlusion rate were independent predictors of revascularization (P =.004 and.008, respectively), irrespective of neck size. Occlusion rate at 6-12-month follow-up was the only independent predictor of that at final follow-up (P =.021), regardless of shape of aneurysm. Overall morbidity was 2% (one of 51); mortality, 6% (three of 51). Mortality correlated significantly with Hunt-Hess grade 4 at admission (P =.003) and incidence of vasospasm (P =.058). CONCLUSION: GDC occlusion proved to be a safe effective therapeutic alternative to surgery in patients with ruptured or unruptured basilar tip aneurysms. Morphologic and clinical factors were respectively identified as predictors of the optimal anatomic and clinical outcomes.

Combined central retinal arterial and venous obstruction: emergency ophthalmic arterial fibrinolysis.

PURPOSE: To investigate the role of urokinase selectively perfused into the ophthalmic artery as an emergency treatment for combined central retinal arterial obstruction (CRAO) and central retinal venous obstruction (CRVO). MATERIALS AND METHODS: Over a 6-year period, 11 consecutive patients presented with recent combined CRAO and CRVO (< or =72 hours). Urokinase (300,000 IU) was selectively perfused via the femoral artery into the ophthalmic artery for 40 minutes. Evaluation criteria were Snellen visual acuity with best correction, funduscopic results, and retinal arteriovenous transit time assessed over a mean 3.5-year follow-up. Mean vision and retinal perfusion were tested by means of repeated-measures analysis of variance. The correlation between visual improvement and retinal perfusion improvement was evaluated by means of Spearman rank correlation. RESULTS: Substantial improvement in vision and retinal perfusion was noted in seven of the 11 patients treated. Mean vision improvement was significant (P =.009) within 24-48 hours after fibrinolysis, increased until 1 month after (P =.006), then remained stable throughout the follow-up (P >.10). Visual improvement correlated with retinal perfusion improvement during the period from before fibrinolysis to 24-48 hours after (P =.028). In all patients with improved results, retinal hemorrhages transiently increased. One patient had intravitreal hemorrhage shortly after fibrinolysis. CONCLUSION: For this uncommon clinical entity, which typically has a poor visual outcome, these results suggest that ophthalmic arterial fibrinolysis may restore retinal perfusion, which leads to rapid substantial visual improvement in many cases of combined CRAO and CRVO, without systemic complications, but it may be responsible for intravitreal hemorrhage.

Endovascular treatment of cerebral mycotic aneurysms.

PURPOSE: To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs). MATERIALS AND METHODS: Clinical and radiologic data of 18 MAs treated with EVT were retrospectively reviewed. There were 14 patients (11 men, three women), ranging in age from 28 to 64 (mean age, 44 years). All patients had endocarditis and positive blood culture. The aneurysms were located within the distal cerebral circulation (n = 13) or in the circle of Willis (n = 5). There were 12 ruptured aneurysms and six unruptured aneurysms. Distal or fusiform aneurysms were treated by means of parent vessel occlusion. Proximal saccular aneurysms were selectively treated. RESULTS: Endovascular treatment was successful for all aneurysms. No aneurysm bled after embolization during clinical follow-up. Follow-up angiograms obtained in 11 of 14 patients 6 months to 2 years after the procedures showed stable occlusions. Transient complications occurred in two cases, with worsening of hemiparesis and quadrantanopia. Five patients underwent surgical cardiac valve replacement within 1 week of EVT without neurologic complications. The late clinical outcome was normal neurologic status (n = 9) or permanent disability that was related to the initial stroke (n = 5). CONCLUSION: EVT is a reliable and safe technique that should be considered at the time of diagnosis of cerebral mycotic aneurysms.

Coil embolization of an aortic arch false aneurysm.

PURPOSE: To report the endovascular occlusion of an anastomotic false aneurysm of the ascending aorta. CASE REPORT: A 51-year-old patient developed an anastomotic false aneurysm at the level of the aortic arch after surgical replacement of the aortic root and arch for aortic dissection. The aneurysm expanded after 6 months and because of its saccular shape was treated by selective occlusion with detachable microcoils. Magnetic resonance angiography showed the stability of the occlusion after 2 years. CONCLUSIONS: Endovascular treatment with coils may be a good alternative to surgery for saccular anastomotic false aneurysms.