Endovascular and percutaneous embolization of a giant post traumatic arteriovenous fistula of inferior epigastric vessels.

BACKGROUND: Arteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of time. They tend to recruit multiple arterial feeders with remodelling in the feeding arteries, making them challenging to treat. CASE PRESENTATION: We discuss a rare case of a 60-year-old male who presented with complaints of a progressive painless swelling in right lower abdomen. There was a history of blunt injury to abdomen at the same site during alleged road traffic accident 3 years ago. On CT angiography, an arteriovenous fistula was localised to the anterior abdominal wall arising predominantly from the right inferior epigastric artery with a giant venous sac and terminating as a tortuous single venous channel into the right external iliac vein. Few other small feeders were also seen arising from branches of right superior epigastric artery along Winslow's pathway. The main challenge in endovascular management of this patient was embolization of a high flow shunt with a large venous sac and multiple arterial feeders. The dominant arterial feeder was embolized using vascular plug. The superficial location of the lesion offered an additional percutaneous window besides endovascular approach. The venous sac was percutaneously accessed and embolized using n-butyl cyanoacrylate after balloon occlusion of outflow vein. On follow up ultrasonographic evaluation at 3 months, near complete thrombosis of the venous sac was achieved. CONCLUSIONS: Traumatic arteriovenous fistulas involving the inferior epigastric vessels are rare clinical entities. CT angiogram and digital subtraction angiography help in the optimal diagnosis and treatment planning. The use of mechanical embolization devices to cause flow arrest offers an opportunity to use liquid embolic agents which offer better percolation within the lesion. Interventional radiology offers an ideal management of these complex high flow fistulas with a good technical success and acceptable safety profile.

Successful Ovarian Vein Embolization of a Multiparous Woman with Pelvic Congestion Syndrome.

Pelvic congestion syndrome (PCS) is a clinical syndrome supported by specific findings, such as ovarian vein's dilatation, that cause pelvic vein congestion. Although many theories are explaining the pathophysiologies of this condition, the underlying cause remains unknown. The clinical manifestations of PCS are various including chronic pelvic pain (CPP), voiding disturbances, or ureteral obstruction. Imaging modality, such as ultrasonography, computed tomography (CT scan), magnetic resonance imaging (MRI), and venography, are needed to confirm and exclude the differential diagnosis. Currently, American venous forum guidelines recommended endovascular therapy which is percutaneous embolization as the first option therapy of PCS. Here, we reported a 35-year-old woman with PCS who underwent successful percutaneous embolization therapy.

Pregnancy and delivery after percutaneous embolization with a combination of microvascular plugs and hydrogel-coated coils for unilateral diffuse pulmonary arteriovenous malformations: a case report.

Background: Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between the pulmonary arteries and veins; right-to-left shunts can cause hypoxaemia, emboli to systemic circulation, and brain abscesses. Cyanosis during pregnancy may increase the probability of premature birth or spontaneous abortion and may increase maternal cardiac complications. Case summary: We describe a case of a 24-year-old woman with diffuse multiple PAVMs localized to the left inferior lobe and chronic cyanosis. She had increased exertional fatigue and chronic headaches and was New York Heart Association class II, although her rest sitting peripheral oxygen saturation (SpO2) had remained unchanged at 83% over the past 20 years. She underwent percutaneous embolization with microvascular plugs and hydrogel-coated coils. A microvascular plug was placed as an anchor near the venous sac, followed by hydrogel-coated coil embolization of the proximal pulmonary artery. A total of six sessions of catheter intervention were performed. The embolization was successful, her hypoxaemia was relieved, and she was able to conceive and deliver. Three years have passed since the last session, and SpO2 97% has been maintained. Discussion: In the treatment of complex PAVMs, the combination of microvascular plugs and hydrogel-coated coils resulted in shorter procedure time, lower risk of migration of the embolus to the pulmonary veins, and less recanalization and revascularization. Percutaneous embolization of PAVMs resulted in safe delivery for the mother and child.

Percutaneous embolization of refractory biliocutaneous fistula following radiofrequency ablation: A case report.

This case report presents a 73-year-old male with recurrent hepatocellular carcinoma who underwent serial surgical and interventional locoregional treatments, which resulted in asymptomatic intrahepatic bile duct dilatation. To address a recurrent tumor close to the pre-existing dilated bile ducts, radiofrequency ablation was performed, leading to a biliocutaneous fistula along the electrode tract. Attempts to close the refractory fistula by percutaneous transhepatic cholangial diversion and balloon dilatation of the stenotic central bile duct were unsuccessful. Ultimately, the fistula was successfully sealed with aggressive management, combining balloon-assisted retrograde fistulography and antegrade fistula embolization. This report aims to raise awareness of complex biliary complications after radiofrequency ablation in patients with preexisting bile duct dilatation, and emphasize the importance of aggressive intervention in cases of refractory biliocutaneous fistula based on our experience.

Minimizing blood loss with direct percutaneous polymethylmethacrylate embolization before corpectomy for vascular spinal tumors.

Background: Standard surgical treatment for vascular spinal tumors, including renal cell carcinomas and hemangiomas, may result in significant blood loss despite preoperative arterial tumor embolization. Methods: This is a retrospective review of 12 patients who underwent direct percutaneous polymethylmethacrylate embolization (DPPE) with or without feeding artery embolization before partial or complete corpectomy for the resection of vascular spinal tumors (2013-2018). Estimated blood loss (EBL) was compared to the blood loss reported in the literature and to patients receiving standard arterial embolization before surgery. Results: The mean EBL for 12 patients was 1030 mL; three of 12 patients required blood transfusions. For the single level corpectomies, the EBL ranged from 100 mL to 3900 mL (mean 640 mL). This mean blood loss was not increased in patients receiving only DPPE preoperatively versus those patients receiving preoperative arterial embolization in addition to DPPE (1005 vs. 1416 mL); in fact, the EBL was significantly reduced for those undergoing DPPE alone. Conclusion: In this initial study, nine patients treated with DPPE embolization alone before spinal tumor resection demonstrated reduction of intraoperative blood loss compared to three patients having arterial embolization with DDPE.

Direct percutaneous embolization of superior rectal veins via an inferior mesenteric vein in a pediatric patient: A case report.

Portal hypertension is a frequent syndrome characterized by an increased portal pressure gradient. The relevance of portal hypertension derives from the frequency and severity of its complications. Rectal varicose is relatively common in portal hypertension patients with meager bleeding rates; However, rectal variceal bleeding is a complicated and sometimes life-threatening condition. The management of rectal variceal bleeding has yet to be adequately established. Endoscopy, surgery, or transjugular intrahepatic portosystemic shunt placement (TIPS) can be performed in patients with gastrointestinal bleeding secondary to portal hypertension due to different etiologies. We present a successful case of direct abdominal percutaneous embolization of multiple and tortuous superior rectal varicose via the inferior mesenteric vein in a 7-year-old female patient with refractory rectal variceal bleeding, not susceptible to endoscopic, surgical, or TIPS management.

Preoperative percutaneous Onyx embolization of carotid body paragangliomas with balloon test occlusion.

Objectives: The study aims to analyze our first experience with direct percutaneous embolization of carotid body tumors (CBTs) using ethylene-vinyl alcohol copolymer (Onyx) along with balloon test occlusion (BTO). Methods: A retrospective preliminary single-center study was conducted at the Otorhinolaryngology and Head and Neck Surgery Department and the Medical Imaging Department of the University Teaching Hospital. A consecutive series of three patients with CBTs was treated at the local institution between October 2018 and June 2019. All three patients underwent preoperative percutaneous embolization using ethylene-vinyl alcohol copolymer (Onyx 18) with the addition of BTO. Outcome measures were the percentage of tumor devascularization, intraoperative blood losses, and operation times. BTO was evaluated by clinical neurological examination and neurosonological transcranial Doppler examination of the middle cerebral artery (MCA). Results: Devascularization of all three tumors was complete or near complete. All three tumors were surgically extirpated with excellent surgical outcomes. The blood losses were minimal, and the average operation time was 2 h and 8 min. BTO was positive in one patient, which was valuable additional information on carotid branches ligation limitations. The other two patients showed negative BTOs with the result of safety of eventual carotid arteries ligations. Conclusion: Preoperative direct percutaneous embolization of CBT with Onyx is a highly effective procedure that significantly facilitates surgery. BTO provides valuable additional information on the most appropriate and safe surgical approach.

Disappearing multiple visceral aneurysms in Vascular Ehlers-Danlos syndrome.

OBJECTIVE: To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS). METHODS: We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms. RESULTS: Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.

US-guided percutaneous thrombin injection to treat non-femoral artery pseudoaneurysms: preliminary experience and review of the literature.

PURPOSE: To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP). MATERIALS AND METHODS: Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery. RESULTS: Eight consecutive patients (5 females, median age 73 years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm2 (range 32-2400 mm2), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease. CONCLUSIONS: Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.

The Clinical Problem of Pelvic Venous Disorders.

Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.

Left internal mammary artery access for embolization of the left subclavian artery in a patient with type II endoleak after thoracic endovascular aortic repair for a ruptured right-sided aortic arch aneurysm.

A 65-year-old woman had presented with a ruptured type B intramural hematoma associated with a right-sided aortic arch aneurysm, a large Kommerell diverticulum (KD) and an aberrant left subclavian artery (LSA). She underwent total aortic arch replacement with elephant trunk, thoracic endovascular aortic repair, and LSA ligation distal to the left vertebral artery. She subsequently developed a brisk type II endoleak into the KD via retrograde flow from the left vertebral artery. Percutaneous access of the left internal mammary artery with coil embolization of the proximal LSA and KD was performed. At 5 years, computed tomography angiogram showed complete thoracic aortic remodeling without an endoleak. The results from the present case have illustrated the novel use of the left internal mammary artery as an alternative access for LSA embolization in patients with type II endoleak and limited access options.

Pre-surgical embolization of carotid body paragangliomas: advantages of direct percutaneous approach and transitory balloon-occlusion at the origin of the external carotid artery.

PURPOSE: Different embolization techniques and materials are available for the pre-operative embolization of carotid body paragangliomas. In this study, we report the first experience of the direct percutaneous puncture technique under fluoroscopic guidance using the low-viscosity formula of SQUID-12. The additional use of a transitory balloon-blockage at the origin of the external carotid artery aims to confer higher protection by limiting the risk of non-target embolization and subsequent neurological sequelae. MATERIALS AND METHODS: We retrospectively reviewed all cases of carotid body paragangliomas that have undergone pre-surgical embolization with a direct puncture technique and balloon-assistance at our institution between 2019 and 2020. The use of the liquid EVOH-based SQUID-12 as the sole embolic agent was the main inclusion criteria. RESULTS: A total of 9 patients with 9 carotid body paragangliomas were enrolled in this case series. The mean volume of the lesion was 309 mm3. The mean embolization-session time amounted to 88 min. The average number of needles inserted was 2, and the mean volume of SQUID-12 used per case was 23 ml. Successful total devascularization was obtained in all cases. No long-term sequelae due to the embolization procedure occurred. CONCLUSIONS: Pre-operative paraganglioma embolization with SQUID-12 using a direct puncture and balloon-assisted technique is a safe and efficient method with few complications.

Congenital renal arteriovenous fistula presenting with gross hematuria and its management.

Renal arteriovenous fistula (AVF), an abnormal connection between artery and vein, results from development failure or following vascular injury. AVFs may cause various complications, i.e., secondary hypertension and hematuria. To manage AVF, it is recommended to bypass it from blood circulation surgically or by percutaneous embolization. The present study describes a woman with AVF, who primarily was managed percutaneously and then surgically.

Giant mediastinal lymphocele after esophagectomy successfully treated with thoracic duct embolization.

A 64-year old man had developed a giant mediastinal lymphocele after undergoing esophagectomy for the treatment of esophageal squamous cell carcinoma. The thoracic duct was embolized with six micro-coils, followed by embolization using a 1:3 mixture of N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and ethiodized oil. Resolution of the lymphocele was achieved within 5 days after embolization. To the best of our knowledge, ours is the first reported case of thoracic duct embolization for the treatment of mediastinal lymphocele.

Use of a 4 mm Amplatzer Vascular Plug II in the treatment of a renal arteriovenous fistula: a case report.

BACKGROUND: We report the use of a 4 mm vascular Amplatzer for the occlusion of a renal arterovenous fistula between the renal artery, at the hylum trifurcation point, and an aneurismatic vein draining into the main renal vein, where there was no possibility to use any other device from the venous side, because of the diameter and the high flow, neither from the arterious side without sacrificing lobar branches. The device was implanted at the exact point of communication, like a patent foramen ovale occluder, with the distal disc into the artery lumen and the other two proximal discs into the venous side. CASE PRESENTATION: A 34-years-old Caucasian woman suffered several episodes of paroxysmal supraventricular tachycardia associated with dyspnoea, after the onset of post-pregnancy hypertension. She underwent CTA, spectral Doppler sonography and angiography which showed a renal arteriovenous fistula (RAVF) between the renal artery, at the hylum trifurcation point, and an extremely ectatic vein draining into the main renal vein of the right kidney. With both arterial and venous access, the RAVF was selectively embolized using a 4 × 6 mm Amplatzer Vascular Plug II, released into the communication between artery and vein ensuring the patency of vessels involved. The RAVF was almost completely excluded and the hemodynamic effects associated were also corrected. CONCLUSIONS: The use of this device, though in an alternative way, allowed the exclusion of the high flow A-V fistula without sacrificing any parent renal vessel and preserving the renal function.

Embolization of extrahepatic biliary leakage using NBCA.

Biliary fistula and bile leakage are complications that can occur during hepato-biliary or intestinal surgery and percutaneous biliary intervention. In some cases, spontaneous resolution is possible but more often re-intervention (surgical or percutaneous) is necessary. We present the case of a 45 y-o male patient who underwent duodenocefalopanreasectomy (Whipple procedure) with bilio-digestive anastomosis for adenoma of the duodenal papilla of Vater, complicated by the formation of a fistula through the bilio-digestive anastomosis. Conservative treatment with percutaneous biliary drainage was attempted in order to promote spontaneous resolution of the fistula. The persistence of the fistula brought the patient to treatment through interventional techniques. Sealing of the bilio-peritoneal fistula was obtained using N-butil-Cyanoacrylate .

Super selective percutaneous transhepatic coil embolization of intrahepatic pseudoaneurysm after pediatric liver transplantation: a case report.

BACKGROUND: Intrahepatic arterial pseudoaneurysms are a rare, life-threatening complication after pediatric liver transplantation. Treatment of choice represents interventional radiological management with endovascular embolization of the segmental artery proximal and distal to the aneurysm. However, this technique results in loss of arterial perfusion distal to the aneurysm with subsegment arterial ischemia. CASE PRESENTATION: We report a case of a 1-year-old girl with a pseudoaneurysm in the split-liver graft. Direct percutaneous, transhepatic access to the pseudoaneurysm was performed followed by super selective coil application into the aneurysm. CONCLUSION: Super selective percutaneous, transhepatic coil application is feasible even in pediatric patients after liver transplantation and results in preservation of the entire course of the liver artery.

Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration- Complication and Bailout after Percutaneous Embolization of Orbital Meningioma.

Presurgical devascularization of neoplasms of the head and neck can be achieved by endovascular as well as direct percutaneous embolization techniques. We report a case of percutaneous glue embolization of an orbital meningioma, complicated by delayed acute stroke due to the distal migration of polymerized glue in the left middle cerebral artery. To the best of our knowledge, this is the first report to discuss the percutaneous embolization of orbital meningioma complicated by stroke due to intracranial glue migration.

A rare cause of massive hemoptysis in a child: Bronchial Dieulafoy's disease - the first report of transcatheter treatment in pediatric age.

We report a case of bronchial Dieulafoy's disease in the pediatric age. Angio-computed tomography scan and arteriography addressed us to diagnosis. Bronchial endoscopy with biopsy was avoided due to the high risk of developing a life-threatening hemorrhage. Transcatheter embolization of the bleeding bronchial artery was achieved with a MicroPlex® 10 HyperSoft 3D 3.5 mm × 80 mm System (MicroVention, Tustin, CA, USA). Dieulafoy's disease is an extremely rare lesion in the pediatric age, and the small diameter of the bleeding vessels may complicate the percutaneous approach with procedural failure. Currently, the novel thin and soft detachable coils allowed to widen the transcatheter embolization in the pediatric age.

Tratamiento percutáneo de la hemoptisis. Anatomía, fisiopatología y metodología / Percutaneous treatment of hemoptysis. Anatomy, physiopathology and methodology

Resumen Se presentan los resultados de 105 pacientes con hemoptisis amenazante tratados mediante embolización arterial por cateterismo percutáneo por vía arterial sistémica y/o arterial pulmonar. Se describe la técnica del procedimiento y los hallazgos angiográficos. Se muestra la utilidad de la fibrobroncoscopía y de la radiografía de tórax para identificar la zona sangrante como diagnóstico previo al procedimiento. Entre mayo 2000 y septiembre 2015 se admitieron en el Servicio de Hemodinamia 105 pacientes con diagnóstico de hemoptisis amenazante, 76 masculinos (72.4%); edad media: 41 (±18.65 DS) años. El 93% (98/105) fue tratado con éxito. En el 90% (88/98) se efectuó embolización por arterias bronquiales y/o no bronquiales sistémicas y en el 10% (10/98) por vía arterial pulmonar. Cuando la afección era bilateral la angiografía sola no posibilitó identificar el sitio de sangrado. Al 60% (63/98) se le hizo fibrobroncoscopía flexible y se pudo ubicar el pulmón sangrante en el 84% (56/63). Cuando la afección era unilateral, la radiografía de tórax previa al procedimiento facilitó la ubicación del área de sangrado en el 47%. No se observaron complicaciones graves ni muertes vinculadas al procedimiento. El tratamiento de la hemoptisis masiva por vía percutánea tiene alto porcentaje de éxito primario con muy baja tasa de complicaciones. El tratamiento por vía arterial pulmonar es un abordaje alternativo. La fibrobroncoscopía flexible es un importante complemento en esta entidad.

Abstract We present the results of 105 patients with life-threatening hemoptysis who were treated with the systemic arterial and/or pulmonary artery routes. We also describe the procedure techniques and the angiographic findings. We show the usefulness of the flexible fiberoptic bronchoscopy and chest radiography to identify the bleeding zone previous to the procedure. From May 2000 to September 2015, a total of 105 patients were admitted to the Catheterization Laboratory with a diagnosis of life-threatening hemoptysis; 76 were male (72.4%) and mean age was 41 ± 18.65 years. Treatment was successful in 93% (98/105). In 90% (88/98) the approach was via the bronchial arteries and/or non-bronchial systemic arteries, and in 10% (10/98) the approach was via the pulmonary artery. In bilateral affection angiographic images alone could not identify accurately the site of the lung bleeding. Flexible fibrobronchoscopy was performed in 60% (63/98) and located the bleeding area in 84% (56/63). In unilateral affection, chest radiography previous to the procedure located the bleeding area in 47%. No complications or death were related to the procedure. The treatment of life threatening hemoptysis by a percutaneous way has a high percentage of primary success with a very low incidence of complications. Pulmonary arterial route treatment is an alternative approach. Flexible fibrobronchoscopy is an important complement to this entity.