Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair.

OBJECTIVE: The objective of this study was to investigate the mid-term outcomes of embolization procedures for type II endoleak after endovascular abdominal aortic repair, and clarify the risk factors for aneurysm enlargement after embolization procedures. METHODS: This was a retrospective multicenter registry study enrolling patients who underwent embolization procedures for type II endoleaks after EVAR from January 2012 to December 2018 at 19 Japanese centers. The primary end point was the rate of freedom from aneurysm enlargement, more than 5 mm in the aortic maximum diameter, after an embolization procedure. Demographic, procedural, follow-up, and laboratory data were collected. Continuous variables were summarized descriptively, and Kaplan-Meier analyses and a Cox regression model were used for statistical analyses. RESULTS: A total of 315 patients (248 men and 67 women) were enrolled. The average duration from the initial embolization procedure to the last follow-up was 31.6 ± 24.6 months. The rates of freedom from aneurysm enlargement at 3 and 5 years were 55.4 ± 3.8% and 37.0 ± 5.2%, respectively. A multivariate analysis revealed that a larger aortic diameter at the initial embolization procedure and the presence of a Moyamoya endoleak, defined as heterogeneous contrast opacity with an indistinct faint border, were associated with aneurysm enlargement after embolization management. CONCLUSIONS: The embolization procedures were generally ineffective in preventing further expansion of abdominal aortic aneurysms in patients with type II endoleaks after EVAR, especially in patients with a large abdominal aortic aneurysm and/or a presence of a Moyamoya endoleak.

A 2-Stage Surgical and Endovascular Treatment of Rare Multiple Aneurysms of Pancreatic Arteries.

Aneurysms of pancreatic arteries (PAs) are often found incidentally during evaluation of other abdominal pathology. Aneurysms involving multiple PAs are rarely reported in the literature. In case reports of PA aneurysm, inferior pancreaticoduodenal artery is the usual site of aneurysm occurrence. PA aneurysms can be treated surgically by aneurysm exclusion, excision, and by endovascular techniques. However, no clear consensus exists regarding treatment modality, leaving the surgeon to determine the most appropriate approach bearing in mind their experience, anatomical location of the aneurysm, involved artery, and urgency of the procedure. We report a rare PA aneurysm involving dorsal pancreatic artery (DPA) and anterior inferior pancreaticoduodenal artery (AIPDA) associated with celiac stenosis that was incidentally diagnosed in a patient with hepatic hemangioma. In addition, we reviewed data from the literature on patients with diffuse or multiple PA aneurysms and discuss the treatment modality in these rare variants. Both surgical and endovascular procedures are equally advocated in treatment of multiple PA aneurysms. In our report, we demonstrate a 2-stage surgical and endovascular treatment modality; DPA aneurysm that was not suitable for endovascular treatment was surgically resected and an iliohepatic bypass was made between left common iliac artery and AIPDA to ensure good hepatic perfusion. One month after the first procedure, AIPDA aneurysm was treated with endovascular embolization. Two-stage surgical and endovascular procedure may represent a useful strategy to treat aneurysms involving multiple PAs.

Efficacy of venous sac embolization for pulmonary arteriovenous malformations: comparison with feeding artery embolization.

PURPOSE: To examine the efficacy of venous sac embolization (VSE) in comparison with transcatheter feeding artery embolization (FAE) for treatment of pulmonary arteriovenous malformations (PAVMs). MATERIALS AND METHODS: From 1989-2009, 21 patients underwent embolization of 37 PAVMs. Safety and long-term efficacy of VSE were evaluated retrospectively and compared with FAE. RESULTS: FAE was performed in 22 (18 simple and 4 complex type) PAVMs, and VSE was performed in 15 (14 simple and 1 complex type) PAVMs. There were significant differences between FAE and VSE in treated periods, PAVM location, coil type used, number of coil combinations and coils per PAVM, coil position, and reperfusion; there were no significant differences in most PAVM characteristics, follow-up durations (58 mo±54 vs 42 mo±42; P= .32), and minor complications (pleurisy [2 vs 2]). Reperfusion occurred in 11 (50%) of 22 PAVMs in the FAE group and no PAVMs in the VSE group (P<.01). Of 22 PAVMs in the FAE group, 17 (77%) were treated with 0.035-inch coils alone; of 15 PAVMs in the VSE group, 14 (93%) were treated with 0.018-inch interlocking detachable coils (IDCs), 0.018-inch pushable fibered coils, or IDCs and pushable fibered coils combined (P<.01). The number of coils used was 8±4 in the VSE group and 4±4 in the FAE group (P= .002). CONCLUSIONS: The high reperfusion rate in the FAE group was mainly due to the use of large 0.035-inch coils alone. Although more coils are needed, VSE can be used to treat PAVMs with a venous sac safely and achieve long-term efficacy.

Embolization of hepatic arteriovenous shunt with absolute ethanol in a patient with hepatocellular carcinoma.

We report a 76-year-old man who had hepatocellular carcinoma (HCC) with arteriovenous shunting (AVS). Transcatheter chemoembolization (TACE) was selected as treatment because of poor pulmonary function. To prevent pulmonary embolism caused by the flow of embolic materials through the AVS, we performed embolization of the AVS with absolute ethanol under flow control by balloon catheters. Subsequently, we could perform TACE for HCC safely.

Coil embolization of a celiac artery aneurysm using the neck remodeling technique.

Aneurysms of the celiac trunk are rare. Untreated lesions enlarge progressively and may rupture spontaneously. We report the case of a 56-year-old man whose wide neck celiac aneurysm was successfully packed with coils with preservation of the native arterial circulation by percutaneous transcatheter embolization using the neck remodeling technique.

Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins.

Extrahepatic portal-systemic shunts cause portal-systemic encephalopathy. Direct communication between the inferior mesenteric vein (IMV) and the inferior vena cava (IVC) is a relatively rare pathway among the variety of portal-systemic shunts. This report describes a case of successful occlusion of an IMV-IVC shunt. Based on laboratory data and computed tomography findings, a 69-year-old woman with liver cirrhosis was diagnosed with portal-systemic encephalopathy due to a shunt between the IMV and the IVC. Her hepatic coma had not been adequately controlled by oral or intravenous pharmacotherapy. First, we placed a covered stent in the main trunk of the portal vein and the superior mesenteric vein (SMV) to block the SMV hepatofugal flow and splenic vein hepatopetal flow, but this therapy showed only a transient therapeutic effect due to recanalization. Next, we performed balloon-occluded retrograde transvenous obliteration (BRTO) of the portal-systemic shunt. After the BRTO, she has had no episodes of portal-systemic encephalopathy for 2 years.

Gas embolism caused by portal vein gas: case report and literature review.

INTRODUCTION: We describe a case of pulmonary gas embolism caused by portal vein gas (PVG) observed using echocardiography. Echography revealed gas flowing through the hepatic vein, inferior vena cava, right atrium, and right ventricle, as well as pulmonary hypertension. The patient was diagnosed as having pulmonary gas embolism caused by PVG. OBJECTIVE: We consider PVG routes to pulmonary circulation, diagnosis of gas embolism caused by PVG, and treatment of gas embolism caused by PVG. METHODS: We reviewed reports of eight cases of gas embolism caused by PVG and compared these cases to cases of gas embolism without PVG. RESULTS: Mortality of gas embolism caused by PVG was 67%, positive blood culture was observed in six cases, and pulmonary edema was seen in three cases. PVG initially excites microbubble formation, which causes tissue damage in the liver and liver abscess. A large volume of PVG causes portal obstruction. As a result, portal hypertension, a portosystemic shunt or gastrointestinal congestion can occur. PVG can travel to the systemic vein through the liver or portosystemic shunt without anomaly and cause pulmonary gas embolism, followed by arterial embolism. In this environment, sepsis easily occurs. Echocardiography is useful for diagnosis of gas embolism caused by PVG, but the gas can be seen intermittently. The view of pulmonary edema is important for pulmonary gas embolism caused by PVG. CONCLUSION: It is important to treat the underlying disease, but PVG must be considered and treated as the gas embolism's source.