Pre-emptive Aortic Side Branch Embolization during Endovascular Aneurysm Repair Using the Excluder Stent-Graft System: A Prospective Multicenter study.

PURPOSE: To evaluate the effectiveness and safety of pre-emptive transcatheter arterial embolization (P-TAE) for aortic side branches (ASBs) to prevent Type 2 endoleaks (EL2) before endovascular aneurysm repair (EVAR) using the Excluder stent-graft system (Excluder). MATERIALS AND METHODS: In this prospective, multicenter study, 80 patients (mean age, 79.1 years [SD ± 6.7]; 85.0% were men; mean aneurysmal sac diameter, 48.4 mm [SD ± 7.4]) meeting the eligibility criteria were prospectively enrolled from 9 hospitals. Before EVAR, P-TAE was performed to embolize the patent ASBs originating from the abdominal aortic aneurysm. Contrast-enhanced computed tomography (CT) was performed at 1 month and 6 months after EVAR. The primary endpoint was EL2 incidence at 6 months, and the secondary endpoints were aneurysmal sac diameter changes at 6 and 12 months, P-TAE outcomes, adverse events related to P-TAE, reintervention, and aneurysm-related mortality. RESULTS: All patients successfully underwent P-TAE without serious. Coil embolization was successful in 81.6% of ASBs. EL2 incidence at 6 months was identified in 18 of 70 (25.7%) patients. Aneurysmal sac diameter shrinkage (≥5 mm) was observed in 30.0% of patients at 6 months and in 40.9% at 12 months. Only 1 patient required reintervention for EL2 within 1 year of EVAR; aneurysm-related deaths were not observed. CONCLUSIONS: P-TAE for ASBs before EVAR using Excluder is a safe and effective strategy. It aids in achieving early aneurysmal sac shrinkage and reduces EL2 reintervention at 1 year after EVAR.

Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). MATERIALS AND METHODS: This multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65-97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. RESULTS: Coil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9-16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (-0.2 mm vs. -6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. CONCLUSION: P-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.

[Pelvic arteriovenous malformation : a case report].

A 70-year-old male presented with intermittent macroscopic hematuria. There was no history of previous trauma or pelvic operation. At first, we were unable to clarify the origin of the hematuria, but 3D computed tomography revealed an arteriovenous malformation (AVM) consisting of multiple feeding vessels arising from the bilateral, especially right, internal iliac artery. Treatment with transcatheter arterial embolization (TAE) with a combination of lipiodol and N-butyl-2-cyanoacrylate twice was effective. He needs to be followed up carefully for recurrence of AVM.

Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury.

OBJECTIVE: This study sought to confirm if thoracic endovascular aortic repair (TEVAR) was an appropriate therapeutic strategy for blunt thoracic aortic injury (BTAI). METHODS: Between 3/2005 and 12/2020, 104 patients with BTAI were brought to our hospital. The severity of each trauma case was evaluated using the Injury Severity Score (ISS); aortic injuries were classified as type I to IV according to Society for Vascular Surgery guidelines. Initial treatment was categorized into four groups: nonoperative management (NOM), open aortic repair (OAR), TEVAR, or emergency room thoracotomy/cardiopulmonary resuscitation (ERT/CPR). RESULTS: The patients' mean age and ISS were 56.7 ± 20.9 years and 48.3 ± 20.4, respectively. Type III or IV aortic injury were diagnosed in 82 patients. The breakdown of initial treatments was as follows: NOM for 28 patients, OAR for four, TEVAR for 47, and ERT/CPR for 25. The overall early mortality rate was 32.7%. Logistic regression analysis confirmed ISS > 50 and shock on admission as risk factors for early mortality. The cumulative survival rate of all patients was 61.2% at 5 years after treatment. After initial treatment, eight patients receiving TEVAR required OAR. The cumulative rate of freedom from reintervention using TEVAR at 5 years was higher in approved devices than in custom-made devices (96.0 vs. 56.3%, p = 0.011). CONCLUSIONS: Using TEVAR as an initial treatment for patients with BTAI is a reasonable approach. Patients with severe multiple traumas and shock on admission had poor early outcomes, and those treated with custom-made devices required significant rates of reintervention.

Three-dimensional images of contrast-enhanced MDCT for preoperative assessment of musculoskeletal masses: comparison with MRI and plain radiographs.

PURPOSE: To evaluate the diagnostic capability of contrast-enhanced multidetector computed tomography (MDCT) for the preoperative assessment of musculoskeletal masses, in comparison with magnetic resonance imaging and plain radiographs (MRI+X-p). MATERIALS AND METHODS: Sixty-eight patients with musculoskeletal masses underwent plain radiography, MRI, and contrast-enhanced MDCT. The following five items were evaluated for all images: histological properties, vascularity, neurovascular involvement, calcification/ossification, and cortical/marrow involvement. The MDCT images with three-dimensional reconstruction were retrospectively compared with MRI+X-p. RESULTS: In 32 bone lesions, MDCT was superior/equal/inferior to MRI+X-p regarding histological properties in 4/10/18, vascularity in 0/11/21, neurovascular involvement in 0/26/6, calcification/ossification in 15/17/0, and cortical/marrow involvement in 29/3/0 cases, respectively. In 36 soft-tissue lesions, MDCT was superior/equal/inferior to MRI+X-p with histological properties in 1/18/17, vascularity in 0/12/24, neurovascular involvement in 1/24/11, calcification/ossification in 8/28/0, and cortical/marrow involvement in 7/29/0 cases, respectively. The MDCT evaluation of both calcification/ossification and cortical/marrow involvement in bone lesions was superior to that in soft-tissue lesions (p<0.05). There were no statistically significant differences between benign and malignant lesions in the evaluation of each of the five items. CONCLUSION: MDCT provided additional and more comprehensive information than MRI+X-p for the preoperative assessment of musculoskeletal masses, especially for calcification/ossification and cortical/marrow involvement. Three-dimensional contrast-enhanced MDCT images can be adopted equally to MRI for the preoperative evaluation of neurovascular involvement.

Use of the wallstent for symptomatic relief of malignant inferior vena cava obstructions.

PURPOSE: To report our experience with the Wallstent for the relief of congestive symptoms in patients with malignant inferior vena cava (IVC) obstructions. MATERIALS AND METHODS: We treated five patients with malignant obstructions of the IVC with a total of seven self-expandable stents. All obstructions were due to extrinsic compression; the procedures were indicated to relieve congestive symptoms in patients unresponsive to other therapies or in whom other treatments were contraindicated. Patients were evaluated for decrease in ascites and edema, weight loss, and patency, where available. RESULTS: All procedures were straightforward and obstructions could be successfully canalized. Inferior venacavograms obtained immediately after the procedure showed complete revascularization and disappearance of collateral circulation. Follow-up was carried out until death in four patients and until discharge in one. Of the five patients, four showed clinical improvement and one had no improvement. There was no recurrence of congestive symptoms. Except for one patient with partial migration of a stent, there were no important complications related to the procedure. CONCLUSION: Wallstents could be placed without complications in the IVC and were effective to ameliorate congestive symptoms in patients with malignant IVC obstructions.

Endovascular uncovered Wallstent placement for life-threatening isolated iliac vein injury caused by blunt pelvic trauma.

Isolated iliac vein injury caused by blunt pelvic trauma is a rare condition that is difficult to diagnose and often fatal. We report a case of a 52-year-old female who presented with life-threatening isolated iliac vein injury caused by blunt pelvic trauma that was successfully managed with endovascular uncovered stent placement. Although further studies are warranted to clarify the hemostatic mechanism, uncovered stent placement can be considered as an alternative treatment option to covered stent placement for life-threatening iliac vein injury when a covered stent is not rapidly available.

Curved nitinol stent-graft placement for treating blunt thoracic aortic injury: an early experience.

BACKGROUND: Blunt trauma-induced aortic injury traditionally has been treated with early open surgical repair. However, recently endovascular stent-graft technology is considered a less-invasive therapeutic alternative, and flexible stent-grafts, such as the Matsui-Kitamura stent-graft (MKSG), are being used widely. We report our experience with the curved MKSG in treating thoracic aortic injuries. METHODS: Nine patients with traumatic thoracic aortic injury underwent endovascular surgery (8, emergency; 1, elective) with curved MKSG. The study variables were Injury Severity Score, endovascular surgery duration, aortic and stent-graft diameter, stay in the intensive care unit, follow-up period, and mortality. An MKSG was constructed using the Matsui-Kitamura stent and a polyester fabric graft. The stent-graft was placed using the transfemoral approach and the wire-tug technique. RESULTS: The mean Injury Severity Score was 42.3; 5 patients required 6 emergency procedures before the endovascular procedure (pneumothorax or hemothorax drainage, 5; transarterial embolization, 1). In 8 patients (88.9%), we achieved complete pseudoaneurysm exclusion or hemostasis in the injured portion. There were no postoperative complications; blood loss was minimal, and the intensive care unit stay was 13.4 days. The overall hospital mortality was 22.2% (n = 2; causes of death were unrelated to MKSG placement). Neither intervention-related mortality during follow-up (mean, 237.7 days) nor late endovascular graft-related complications (endoleak or graft migration) were noted. CONCLUSIONS: Although this study is limited by a small sample size and short follow-up period, no collapse or stent-graft fractures were noted. Thus, MKSG placement for traumatic thoracic aortic injury appears a safe and effective therapy.

Ruptured hepatic abscess caused by fish bone penetration of the duodenal wall: report of a case.

The accidental ingestion of a foreign body into the gastrointestinal tract is not uncommon; however, the development of a hepatic abscess secondary to foreign body perforation is extremely rare. We report the case of a ruptured hepatic abscess caused by fish bone penetration of the duodenal bulb, resulting in generalized peritonitis. A 73-year-old man was admitted to our hospital with generalized abdominal pain and high fever. Computed tomography of the abdomen showed ascites and a heterogeneously enhanced mass with a less-dense center and a linear dense object. We diagnosed a ruptured hepatic abscess caused by a calcified foreign body, which was managed by peritoneal lavage, drainage of the hepatic abscess, and removal of the fish bone, followed by simple closure of the hepatoduodenal fistula. The patient's postoperative course was complicated by systemic inflammatory response syndrome, but he recovered eventually.

Transcatheter embolization of splenic artery pseudo-aneurysm rupturing into colon after post-operative pancreatitis.

Splenic pseudoaneurysms following chronic pancreatitis can rarely become a source of life-threatening bleeding by rupturing into various regions or components, including pseudocysts, the abdominal cavity, the gastrointestinal tract, and the pancreatic duct. In such cases, prompt diagnosis and therapy are warranted. We report herein the case of a 52-year-old man in whom a splenic pseudoaneurysm ruptured into the colon via a fistula with an abscess cavity, causing massive bleeding, which was successfully managed by trans-catheter arterial embolization (TAE).

Prophylactic stenting of the inferior vena cava before transcatheter embolization of renal cell carcinomas: an alternative to filter placement.

PURPOSE: To report the use of the self-expanding Wallstent as an alternative to prophylactic inferior vena cava (IVC) filter placement before embolization of renal carcinomas with tumor thrombus. CASE REPORTS: Two patients, a 71-year-old man and an 88-year-old woman, were diagnosed with extensive tumor infiltration of the IVC secondary to renal cell carcinomas. Prophylactic placement of an IVC filter before transcatheter embolization was unsuccessful in both cases; a reduced space for deployment would have left part of the filter inside the right atrium. Instead, a Wallstent was used to constrain the tumor thrombus against the vessel wall and, at the same time, protect the patency of the contralateral kidney. Adequate patencies were confirmed 9 months after stenting in the first patient and after 19 days in the second patient. There were no clinical manifestations of pulmonary embolism. CONCLUSIONS: Wallstent implantation is an alternative prophylactic measure before transarterial embolization of renal carcinomas if IVC filters cannot be placed.

Renal arteriovenous fistula with rapid blood flow successfully treated by transcatheter arterial embolization: application of interlocking detachable coil as coil anchor.

A 70-year-old woman presented to our outpatient clinic with a large idiopathic renal arteriovenous fistula (AVF). Transcatheter arterial embolization (TAE) using interlocking detachable coils (IDC) as an anchor was planned. However, because of markedly rapid blood flow and excessive coil flexibility, detaching an IDC carried a high risk of migration. Therefore, we first coiled multiple loops of a microcatheter and then loaded it with an IDC. In this way, the coil was well fitted to the arterial wall and could be detached by withdrawing the microcatheter during balloon occlusion ("pre-framing technique"). Complete occlusion of the afferent artery was achieved by additional coiling and absolute ethanol. This technique contributed to a safe embolization of a high-flow AVF, avoiding migration of the IDC.