Continuous Aspiration Thrombectomy in High- and Intermediate-High-Risk Pulmonary Embolism in Real-World Clinical Practice.

OBJECTIVES: We sought to assess the technical and clinical feasibility of continuous aspiration catheter-directed mechanical thrombectomy (CDT) in patients with high- or intermediate-high-risk pulmonary embolism (PE). METHODS AND RESULTS: Fourteen patients (eight women and six men; age range: 29-71 years) with high- or intermediate-high-risk PE and contraindications to or ineffective systemic thrombolysis were prospectively enrolled between October 2018 and February 2020. The Indigo Mechanical Thrombectomy System (Penumbra, Inc., Alameda, California) was used as CDT device. Low-dose local thrombolysis (alteplase, 3-12 mg) was additionally applied in three patients. Technical and procedural success was achieved in 14 patients (100%). Complete or nearly complete clearance of pulmonary arteries was achieved in nine patients (64.3%), whereas partial clearance was achieved in five (35.7%). A significant improvement in the pre- and postprocedural patients' clinical status was observed in the following fields (median; interquartile range): heart rate (110; 100-120/min vs. 85; 80-90/min; p < 0.0001), systolic blood pressure (106; 90-127 mmHg vs. 123; 110-133 mmHg; p = 0.049), arterial oxygen saturation (88.5; 84.2-93% vs. 95.0; 93.8-95%, p = 0.0051), pulmonary artery systolic pressure (55; 44-66 mmHg vs. 42; 34-53 mmHg; p = 0.0015), Miller index score (21.5; 20-23 vs. 9.5; 8-13; p < 0.0001) and right ventricular/left ventricular ratio (1.3; 1.3-1.5 vs. 1.0; 0.9-1.0; p < 0.0001). No major periprocedural bleeding was detected. CONCLUSIONS: CDT is a feasible and promising technique for management of high- or intermediate-high-risk PE to decrease thrombus burden, reduce right heart strain, and improve hemodynamic and clinical status. Some patients may benefit from simultaneous local low-dose thrombolytic therapy. Nevertheless, its criteria and role in CTD-managed patients require further elucidation.

Giant Splenic Artery Pseudoaneurysms: Two Case Reports and Cumulative Review of the Literature.

BACKGROUND: Giant splenic artery pseudoaneurysms (GSAPs) > 5 cm are a rare clinical entity. The aim of this study was to present our experience with 2 such patients successfully treated by coil embolization and surgery and review the pertinent literature. METHODS: A 58-year-old woman and 57-year-old man with a history of chronic pancreatitis were diagnosed with GSAP based on computed tomography (CT) angiography. The first patient had a 6-cm pseudoaneurysm, which was successfully treated with transcatheter coil embolization using a sandwich exclusion method. The second patient had two 7-cm lesions, which were successfully treated with distal pancreatectomy and splenectomy. RESULTS: Postembolization CT angiography at 12 months showed remaining calcified pseudocyst without evidence of pseudoaneurysm in the first patient. Both patients remained well and symptom-free at 12 months. CONCLUSIONS: Combined with the experience of the previous literature, we believe that management of GSAP should be tailored for each individual case depending on the location and number of pseudoaneurysms, the underlying etiology, and the patient's hemodynamic status. Embolization should be considered as the first-line treatment for clinically stable patients with GSAP, whereas GSAPs with a pseudocyst are best treated with surgery.

Central venous access ports in the interventional radiology suite - one-centre experience.

PURPOSE: Central venous access ports (CVAP) are widely used to provide long-term vascular access for the delivery of chemotherapeutic medications. The aim of this study was to evaluate the clinical outcomes and complications following CVAP implantation in the interventional radiology suite. MATERIAL AND METHODS: A retrospective analysis was conducted on 937 oncology patients who underwent CVAP implantation between January 2009 and June 2017. Information regarding patient characteristics, operative data, and procedural outcomes was collected and analysed. RESULTS: A total of 937 patients scheduled for CVAP were included in the final analysis. Initial success was achieved in 930 patients (99.3%), and overall completion was achieved in 933 patients (99.6%). There were 63 complications overall. Among these, 19 (2.0%) occurred during the intra- and perioperative period and 44 were late complications (4.7%). No CVAP-related mortalities were observed. CONCLUSIONS: The analysis in the present study revealed that the CVAP is a safe and effective route for long-term administration of chemotherapy with an overall complication rate of 6.7% throughout the entire device duration. The CVAP implantation procedure carried out in the interventional radiology suite provides an advantage in the management of procedural, vascular and catheter-related complications.

Endovascular therapy of arteriovenous malformation in a male patient with severe post-coital pelvic pain.

PURPOSE: Congenital pelvic arteriovenous malformations (AVMs) are high-flow vascular lesions consisting of abnormal shunts between arteries and veins within a nidus. The rare presentation and extensive network of vasculature contributes to the difficulty in effective treatment. Optimal therapeutic options are determined based on the clinical presentation, the location of the lesion, and possible complications. CASE REPORT: A 24-year-old male patient with a history of recurrent pain following sexual intercourse presented with complaints of intense pelvic pain radiating to the perineal area. Computed tomography angiography (CTA) revealed a large venous aneurysm as an outflow vein of a right-sided pelvic AVM. Embolisation of the outflow veins was established along with direct percutaneous delivery of fibre coils and thrombin to the venous aneurysm of the AVM. With recurring symptoms and AVM recanalisation on angiography, another direct puncture and placement of pushable coils was made. Total AVM occlusion was achieved with no recanalisation on follow-up digital subtraction angiography (DSA), and the patient remained asymptomatic. CONCLUSIONS: Endovascular embolisation of the nidus area may result in a complete occlusion of an AVM. Therefore, a thorough understanding of the vascular anatomy of the AVM is essential in choosing an effective embolisation strategy and to minimise the risk of possible complications.

Percutaneous direct thrombin injection with hydrodissection to manage type II endoleak after endovascular abdominal aortic aneurysm repair.

Type II endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR). The management remains controversial. We present a case in which endoleak was successfully treated by direct percutaneous thrombin injection with hydrodissection. This method seems to be a safe and feasible alternative method for treatment of type II endoleak.

CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: A case report.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management. CASE REPORTS: We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed. CONCLUSIONS: Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.

[Embolization of the bronchial artery as a treatment of reccurent hemoptysis in patient with cystic fibrosis]. / Embolizacja tetnicy oskrzelowej w leczeniu nawracajacego krwioplucia u pacjenta z mukowiscydoza.

Hemoptisis is one of the possible complication in patients with cystic fibrosis, which has great influence on patients condidtion and their quality of life. There are few methods available for treatment of hemoptisis. Authors have reported case of 30-year-old patient with cystic fibrosis and hemoptysis, who was successful treated with right bronchial artery embolization.

[Superselective embolization of ileo-cecal artery branch in patient with massive bleeding from lower part of gastrointestinal tract]. / Superselektywna embolizacja galezi tetnicy kretniczo-katniczej u chorego z masywnym krwawieniem z dolnego odcinka przewodu pokarmowego.

Authors have reported a case report of 79-years-old male patient who in second day after endarterectomy of left cartoid artery presented massive bleeding from lower part of gastro-intestinal tract. After diagnostic examinations intravascular embolization of pathologic artery with use of microcoil has been performed. Treatment was succesful free from complications.

Angiomyolipoma rupture: does size always matter?

Angiomyolipoma (AML) is the most common benign renal neoplasm. Although asymptomatic lesions rarely lead to clinical dilemma, the management of ruptured tumours can become challenging. The size of the tumour has been widely accepted as a prognostic factor for intervention but there exists some evidence against considering the size as the only prognostic factor for intervention in AML. In our study, we described three recent cases of ruptured AML which were treated with different approaches - in two cases radical nephrectomy was performed, and in one patient a minimally invasive approach was adopted.

The application of prostate artery embolization in the management of intractable prostate bleeding.

INTRODUCTION: Prostate cancer is one of the most common malignancies affecting European men. Sequelae of the advanced malignancy require invasive procedures which may not be eligible especially for old, debilitated patients. The aim of this manuscript is to review the outcomes of prostate artery embolization in the management of refractory bleeding. MATERIAL AND METHODS: A PubMed database search was done for all English language articles on prostate artery embolization in prostate cancer, published between 2003 and 2019. For current review, information related to number, age of the patients, aetiology of the hematuria, bilateral or unilateral procedure, type of embolic material, technical and clinical success, complications, recurrent hematuria, hematocrit and hemoglobin levels were analyzed. RESULTS: A total of 10 original full-text comparative and non-comparative (case series) studies were reviewed. Minor complications described in the literature ranged from 10-50%. After prostate artery embolization, the recurrence of the haematuria occurred in 10-57% of the patients. Moreover, prostate artery embolization successfully treated lower urinary tract symptoms and urinary retention in prostate cancer patients. CONCLUSIONS: The procedure appears safe, burdened with low risk of complications and accomplishes technical and clinical success. It is a promising option for patients with hemorrhage, but due to the scarcity of data further investigations are needed.

Implementation of a regional multidisciplinary pulmonary embolism response team: PERT-POZ initial 1-year experience.

BACKGROUND: Pulmonary embolism (PE) is the third most common potentially life­threatening cardiovascular disease. A new approach of pulmonary embolism response teams (PERTs) has been introduced to provide rapid multidisciplinary assessment and treatment of patients with PE. However, detailed data on institutional experience and clinical outcomes from such teams are missing. AIMS: The aim of this study was to report our experience with the management of PE guided by the PERT-POZ within the first year of operation. METHODS: We performed a prospective study of PERT-POZ activations at a university care center between October 2018 and October 2019. Patient characteristics, therapies, and clinical outcomes were evaluated. RESULTS: There were 86 unique PERT-POZ activations, and PE was confirmed in 80 patients including: 9 patients (11.25%) classified as low­risk PE, 19 (23.75%) as intermediate­low risk, 38 (47.5%) as intermediate­high, and 14 (17.5%) as high­risk. Sixty patients (75%) received anticoagulation only, 28 (35%) direct oral anticoagulant, 7 (8.75%) vitamin K antagonist, 23 (28.75%) low-molecular-weight heparin, and 2 (2.50%) unfractionated heparin. Ten patients (12.5%) were treated with catheter­directed thrombectomy, 6 (7.5%) received systemic thrombolysis, 2 (2.5%) underwent surgical embolectomy, 2 (2.5%) were on extracorporeal membrane oxygenation support, and 2 (2.5%) underwent pharmacomechanical venous thrombectomy. There were 7 (8.75%) in­hospital deaths, and 2 (2.5%) deaths during a 3­month follow­up. Bleeding complications were rare: only 3 patients (3.75%) had major bleeding events, but none after administration of systemic thrombolysis. CONCLUSIONS: Our study demonstrated that after the creation of PERT-POZ with a precise activation protocol, patients with intermediate and high­risk PE received most optimal treatment strategies.

Endovascular treatment of arteriovenous malformation.

Vascular anomalies are common congenital or neonatal abnormalities. According to the approved classification of vascular lesions by Glowacki and Mulliken, hemangiomas and vascular malformations are distinguishable. Hemangiomas usually appear during the first days or weeks after birth and grow faster than the whole body of the infant. They are proliferating benign tumors that often involute. The opposite of hemangiomas, vascular malformations are present at birth, grow commensurately with the patient, demonstrate normal endothelial turnover, and never involute. The case of a young woman with an arteriovenous malformation (AVM) located on the left side of her face beneath the lower lip is described. The patient did not have any specific complaints except the cosmetic effect, which was a reddish and bluish discoloration of the skin over the lesion. The AVM was embolized with polyvinyl alcohol, and no subsequent surgery was performed. Follow-up ultrasound examination after a 12-month period showed no flow within the lesion area.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience.

BACKGROUND: Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies. METHODS: Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated. RESULTS: The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection. CONCLUSIONS: Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience.

BACKGROUND: Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)]. METHODS: Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated. RESULTS: All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases. CONCLUSIONS: Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

Rescue Implantation of Covered Stent in Pulmonary Artery Rupture During Balloon Pulmonary Angioplasty.

The ring-like lesions in chronic thromboembolic pulmonary hypertension (CTEPH) patients are sometimes difficult to dilate because they are hard and fibrotic. For this reason, slightly oversized balloons are used; however, this may result in an increased risk of vessel rupture. We present a 62-year-old female with residual pulmonary hypertension after pulmonary endarterectomy for CTEPH who underwent balloon pulmonary angioplasty (BPA). Implantation of a covered stent not only protects the ruptured vessel, but also keeps perfusion in the future.

Endovascular management of pancreatitis-related pseudoaneurysms: A review of techniques.

OBJECTIVES: To present the various techniques used in the management of pancreatitis-related pseudoaneurysms of visceral vessels. METHODS: The retrospective clinical study was carried out at the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. The fifteen patients included in the study were diagnosed with pseudoaneurysms of visceral arteries, as a complication of chronic pancreatitis. The diagnosis was made using contrast-enhanced computed tomography, followed by angiography. On admission, all patients were symptomatic, with varying degrees of abdominal pain. One patient was haemodynamically unstable. Treatments with endovascular techniques were analysed, along with their efficacy and outcomes. Coil embolisation was performed in 5 patients. Stent graft was used in 1 patient. Liquid embolic agents were used in 7 cases, of which 5 patients were treated with thrombin injection and 2 with Squid. A combination of techniques was used in 2 patients. RESULTS: The most common artery affected by pseudoaneurysm formation was the splenic artery (7/15; 46.7%), and the size of the pseudoaneurysms ranged from 27 mm to 85 mm. Primary technical success was achieved in 14 out of 15 patients (93.3%). One patient required reintervention. Two patients required splenectomy after embolisation due to splenic ischemia. No recanalisation was present at the follow-up computed tomography performed after 1 to 3 weeks, and no mortality was observed within 30 days. CONCLUSION: Vascular complications of pancreatitis require accurate diagnosis and immediate treatment. Endovascular intervention is highly effective and is the preferred treatment option. The technique used is determined based on vascular anatomy and the patient's haemodynamic status.

The effectiveness of bronchial artery embolisation in patients with haemoptysis.

INTRODUCTION: Bronchial artery embolisation (BAE) is one of the methods used in massive and recurring haemoptysis. The aim of the study is to determine the effectiveness and complications of bronchial artery embolisation in recurring haemoptysis. MATERIAL AND METHODS: The analysis included 47 embolisation procedures performed on 30 patients treated between 2011 and 2017 in the Department of Respiratory Medicine, Allergology and Pulmonary Oncology due to haemoptysis. The patient's age ranged between 18 and 71 years, while mean age at the time of BAE was 33.5 years. Patients with tuberculosis constituted 73.33% (n = 22) of the sample and underwent 31 embolisation procedures in total. The remaining part of the sample (n = 8) collectively underwent 16 BAEs. The analysis was conducted by verifying the medical documentation, as well as carrying face-to-face and phone conversations. RESULTS: Immediate control due to the inhibition of bleeding was obtained in 95.75% of cases. Recurrence within 3 days of BAE was reported in 5 patients (10.63%), and 4 re-embolisation procedures were conducted. In 10 patients (33.33%), recurrence was observed during the first year post-BAE, while it was reported in 17 cases during the whole observation period (56.66% of patients). The subjects who underwent re-embolisation demonstrated recurrence-free periods lasting from 2 days to 63 months. In patients with recurrence but no re-embolisation, the shortest and longest haemoptysis-free time was 2 and 35 months, respectively. 11 patients (36.66%) required several embolisation procedures during the whole observation period. CONCLUSIONS: BAE is a highly successful procedure in treating haemoptysis. The risk of complications is low.

Eyelid arteriovenous malformation treated with pre-surgical embolization: A case report.

Background Arteriovenous malformations are potentially serious vascular anomalies that are rarely encountered in the eyelid and require a multidisciplinary approach. Objectives We would like to describe the technical and clinical aspects related to the treatment of palpebral arteriovenous malformation with selective embolization, followed by surgical resection. Methods A 40-year-old patient presented with an isolated high-flow palpebral arteriovenous malformation. Transarterial embolization, using a liquid embolic agent (PHIL™), was performed in this patient. Results Angiographic and clinical follow-up revealed good results with clinical regression of the mass. Conclusion Although endovascular treatment of palpebral arteriovenous malformations is technically challenging, good functional and cosmetic result was achieved. Arteriovenous malformation embolization using PHIL™ seems to be very effective and makes subsequent surgical procedure safe and feasible. Level IV Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Post-traumatic acute thoracic aortic injury (TAI)-a single center experience.

BACKGROUND: We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI. METHODS: Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up. RESULTS: Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months. CONCLUSIONS: In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.