Successful coil embolisation of tortuous portosystemic venous shunts using a steerable microcatheter in a patient with polysplenia after a Fontan-type operation.

Portosystemic venous shunts occur in patients with polysplenia after the Fontan operation. In the long term, these shunts are associated with hyperammonaemia and portal-systemic encephalopathy. Since some shunts are long and tortuous, catheter interventions to close them could be challenging. Instead, a steerable microcatheter could be used for coil embolisation of tortuous portosystemic venous shunts.

Outflow angle: a risk factor for thromboembolic complications in coil embolisation for treating unruptured middle cerebral artery bifurcation aneurysms.

BACKGROUND: Thromboembolic complications are a relevant risk in coil embolisation of cerebral aneurysms. This retrospective study aimed to assess the treatment outcomes of unruptured middle cerebral artery (MCA) bifurcation aneurysms and the predictors for thromboembolic complications based on the aneurysm morphological characteristics. We examined the following three features: inflow angle, outflow angle (OA), and bifurcation angle, formed by the aneurysm and neighbouring blood vessels. METHODS: A total of 32 MCA bifurcation aneurysms were retrospectively investigated in 32 patients treated consecutively at our institute between April 2008 and March 2019. The predictors for thromboembolic complications were analysed in two groups: patients with and without thromboembolic complications. RESULTS: Perioperative thromboembolic complications were detected in six patients (18.8%), including two and six intra- and post-procedural thromboembolic complications, respectively; all cases were resolved. Regarding the aneurysms' morphological characteristics, the group with thromboembolic complications showed a significantly smaller OA (55.58° ± 14.05° vs. 86.04° ± 28.58°, P = 0.01) than the group without complications. Multivariate analysis revealed that smoking habits and OA < 70° were significant predictors of thromboembolic complications (smoking habits: P = 0.01, odds ratio [OR]: 6.89, 95% confidence interval [CI]: 3.78-12.62; OA < 70°: P = 0.04, OR: 3.19, 95% CI: 1.52-6.56). CONCLUSIONS: Our findings indicate significant pre-procedural predictors of thromboembolic complications to consider for safe treatment; clipping should be preferred to coil embolisation in high-risk patients. The method of choice should be considered in each case to allow the safe treatment of unruptured MCA aneurysms.

Benefit of vessel closure with the Azur CX Peripheral Coil System in small children with complex CHD.

Vessel occlusion is a frequently used procedure to close congenital or acquired collaterals or communications. We report two cases of successful vessel closure, in small infants with CHD, using the Azur CX Peripheral Coil System. The low profile of the device, the controlled delivery of the coils, and the delivery through a microcatheter make it particularly interesting for the occlusion of highly tortuous vessels in children.

Transradial approach for collateral embolisation.

Significant aortopulmonary collaterals in cyanotic CHD patients require closure immediately before definitive intracardiac repair. Traditionally, the transfemoral access has been used for this purpose; however in a few cases, selective and stable hooking of collaterals may be extremely difficult. We describe a case in which we used a new approach for collateral embolisation in a difficult situation.

Left gastric artery aneurysm rupture: a rare cause of retroperitoneal bleeding: a case report.

INTRODUCTION: Visceral artery aneurysms are very rare. Patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on ultrasound, MRI or abdominal computed tomography. Among these, splenic artery aneurysms are the most common ones accounting for 60% of all splanchnic aneurysms and gastric and gastroepiploic aneurysms account for only about 4%. CASE PRESENTATION: We present a 61-year-old Caucasian male previously fit and well, presenting with sudden onset epigastric pain due to retroperitoneal haemorrhage secondary to ruptured left gastric artery aneurysm. Apart from a tender epigastrium, there were no other obvious signs elicited on abdominal examination. He had persistent tachycardia and haemoglobin drop from 10 g/dl to 6.7 g/dl. He underwent a contrast computed tomography which identified the ruptured left gastric artery. The aneurysm was controlled successfully with coil embolisation of the left gastric artery. At three-month follow-up, there was no evidence of the aneurysm. CONCLUSION: Clinical presentations that do not correlate with examination finding should prompt immediate extensive investigation. The aid of contrast computed tomography and minimally invasive radiological interventional is the key to a fruitful outcome for this very rare entity.

Combined endovascular and surgical approaches to treat intralobar pulmonary sequestration: a case report.

Pulmonary sequestration is a congenital abnormality of a non-functional pulmonary mass with anomalous systemic arterial supply. Surgical resection is the gold standard treatment, but it carries a risk of life-threatening haemorrhage from accidental injury of the anomalous artery. Endovascular embolisation has been introduced as a safe alternative, but does not eliminate the possibility of symptom recurrence. We report a case of a 61-year old woman with intralobar pulmonary sequestration treated with a combination of endovascular coil embolisation and surgical resection.

Hepatic larva migrans presenting with upper gastrointestinal haemorrhage: A case report.

Visceral larva migrans (VLM) occurs because of a host inflammatory response to the migrating larvae of a nematode. Patients usually present with fever, hepatomegaly and abdominal pain; vascular arterial complications are uncommon. A 19-year female presented with fever, jaundice, abdominal discomfort and melena. Computed tomography (CT) revealed multiple discrete, clustered, complex hepatic cystic lesions consistent with VLM, along with an arterial pseudoaneurysm from the right hepatic artery which was managed with endovascular coil embolisation.

Measurement of the average radiation dose to the local skin and thyroid gland during intracranial aneurysm coil embolization.

INTRODUCTION: Intracranial aneurysm coil embolisation is a fluoroscopically guided procedure associated with high radiation dose. The increase in the number of coil embolisation procedures raises concern for the amount of radiation and the associated radiation risks to the patients. This research study was conducted to determine the average radiation dose to patients' thyroid glands and local skin during intracranial aneurysm coil embolisation and to establish preliminary local diagnostic reference levels for this procedure. In this paper, local skin dose refers to the absorbed radiation dose on the areas of the skin exposed to radiation during intracranial aneurysm coil embolisation, namely neck, face and scalp. METHODS: This study employed air-kerma area product meters to determine the local skin dose and diagnostic reference levels during intracranial aneurysm coil embolisation. In addition, thyroid radiation doses were measured using thermo-luminescent dosimeters on a phantom during simulation of embolisation procedures. RESULTS: The local skin doses as determined by air-kerma area product ranged between 33 and 125 Gy.cm2. The mean thyroid dose was 9.87 mGy. The established local diagnostic reference level was 52.1 Gy cm2, 17.8 min' fluoroscopy time and 503 image frames. CONCLUSION: The average air-kerma area product values and the proposed diagnostic reference levels were lower than most published values for intracranial aneurysm coil embolisation. IMPLICATIONS FOR PRACTICE: The established local diagnostic reference levels are recommended for use as radiation dose optimisation tool at the research site. The findings of this study cannot be generalised or applied to other hospitals. The complexity of the embolisation procedures was not classified for this study. Further research on diagnostic reference levels for intracranial aneurysm coil embolisation, taking into account the complexity of the procedures, is recommended.

Alpha Stent for Coiling of Unruptured, Wide-Necked, Distal Internal Carotid Artery Aneurysms: Safety and Effectiveness at 6 Months.

OBJECTIVE: The Alpha stent (CGBio), a new intracranial stent featuring a re-sheathable mesh design with improved wall apposition at the curved segment, was clinically evaluated. We report the 6-month follow-up results from a prospective, single-center study in which the stent was used for coiling of wide-necked distal internal carotid artery (ICA) aneurysms. MATERIALS AND METHODS: Between April 2016 and 2018, 50 patients (mean age, 56.5 years, 45 females [90%]) with 54 unruptured distal ICA aneurysms (average diameter: 5.6 ± 1.7 mm) were enrolled. The primary endpoint for effectiveness was successful coil embolization with the Alpha stent, and subsequent complete or near-complete occlusion at the 6-month magnetic resonance angiography assessment. The primary safety endpoint was the absence of serious adverse events (SAEs) up to 6 months from the procedure. RESULTS: The primary effectiveness endpoint was observed in 94.4% (51/54) aneurysms. In one patient with technical failure, the stent could not be deployed because of parent artery tortuosity; therefore, a different type of stent was used. Of the 53 aneurysms treated with the Alpha stent, complete occlusion was achieved in 64.1% (34/53) cases, and near-complete occlusion was achieved in 32.0% (17/53) cases by the 6-month follow-up. Two cases (3.7%) required retreatment because of major recurrence. In 4% (2/50) patients, SAEs, i.e., retinal artery thromboembolism and corona radiata lacunar infarction, were reported after the procedure. CONCLUSION: For endovascular treatment of unruptured, wide-necked, distal ICA aneurysms, coil embolization using the newly developed Alpha stent showed excellent procedural and mid-term clinical follow-up results in terms of effectiveness and safety.

Pulmonary artery coil embolisation prevented tumour progression in a patient with advanced squamous cell lung carcinoma.

Background: Squamous cell lung carcinoma (SqCLC) is a type of non-small-cell lung cancer, accounting for 25-30% of all lung cancer cases with a median advanced stage survival of 8-11 months. Here we present a rare case of long-term survival with metastatic SqCLC following coil embolisation of the right pulmonary artery.Case presentation: The 49-year-old patient was diagnosed with stage IV (cT4N3M1) SqCLC in 2007 due to a biopsy-proven central malignant tumour in the right lung and bilateral mediastinal lymphadenopathy. A magnetic resonance imaging scan also revealed a metastatic lesion in the liver. Soon after the diagnosis, the patient experienced pulmonary haemorrhage, which was managed by obturating the intermediate bronchus and performing coil embolisation of the right pulmonary artery. The patient also received chemotherapy in 2007 and 2009 without radiological changes. At three different time points in years 2010-2019, biopsies of the primary tumour were taken. All showed dense connective tissue with no indication of cancer growth. In 2020, a positron emission tomography scan showed no pathological metabolic activity in the lungs and liver. Currently, the patient remains in a stable clinical condition with a good performance status.Conclusion: The long-term clinical benefit indicates a direct effect of coil embolisation on tumour progression. We suggest that coil embolisation of tumour-feeding arteries could be considered as a potential treatment method for patients with SqCLC.

Coil embolisation of multiple cerebral aneurysms with lateral type I persistent primitive trigeminal artery: A case report and literature review.

The primitive trigeminal artery is an anastomotic vessel of the carotid-basilar artery system that occurs only transiently during the embryonic period. Persistent primitive trigeminal artery occurs in approximately 0.1-0.6% of the population. Here, we report the case of a 60-year-old woman with Fisher II grade subarachnoid haemorrhage. Computed tomography angiography demonstrated a lateral, Saltzman type I persistent primitive trigeminal artery with three cerebral aneurysms, including one anterior communicating artery aneurysm, one suspicious right anterior choroidal artery aneurysm and one distal basilar artery aneurysm supplied by the persistent primitive trigeminal artery. All three aneurysms were treated with coil embolisation. At the 8-month follow-up, the anterior communicating artery aneurysm had a neck remnant, the other two aneurysms exhibited complete occlusion. Persistent primitive trigeminal artery with multiple cerebral aneurysms is extremely rare, and only seven cases of persistent primitive trigeminal artery with multiple cerebral aneurysms have previously been reported in publications that included information on treatment. Most aneurysms were treated by open surgery. This is the first report of coil embolisation treatment of multiple aneurysms in persistent primitive trigeminal artery patients with follow-up results, and provides relevant and valuable information about the persistent primitive trigeminal artery and the endovascular treatment of multiple aneurysms in persistent primitive trigeminal artery patients.

Renal arteriovenous malformation: An unusual pathology.

Renal arteriovenous malformations are rare renal vascular abnormalities. More commonly, the term refers to the congenital type of malformation. Only a few cases have ever been presented and reported in the literature, mostly with a nidus. We present the clinical, ultrasound and computed tomography findings and discuss the management related to a 63-year-old male with a right congenital renal arteriovenous malformation without a nidus that was successfully managed with coil embolisation. Relevant literature is hereby reviewed to highlight characteristic imaging and appropriate treatment.

Coil Migration to the Duodenum 1 Year Following Embolisation of a Ruptured Giant Common Hepatic Artery Aneurysm.

INTRODUCTION: Transcatheter arterial embolisation is often performed for the treatment of visceral artery aneurysms. Here, the case of a patient who developed the rare complication of coil migration into the intestinal tract is reported, and a review of the literature is presented. CASE REPORT: A 30 year old woman with a ruptured giant common hepatic artery aneurysm, who had been treated with transarterial coil embolisation 1 year previously, was admitted to hospital complaining of passing the coils on defecation. Abdominal Xray and gastroscopy showed the migration of the coils through a duodenal fistula. Open repair was performed with the coils successfully removed and the duodenal fistula closed with omentopexy. At the 3 year follow up, there were no signs or symptoms of complications. CONCLUSION: Based on observations from this case, although coil migration to the intestinal tract is exceedingly rare, aneurysm rupture with enteric fistula can lead to coil migration.

Efficacy of the proximal balloon flow control method for endovascular coil embolisation as a novel adjunctive technique: A retrospective analysis.

Background and purpose In our previous study, we established the utility of 8-F balloon guide catheters for anterior circulation aneurysms. This study aims to assess the efficacy of the proximal flow control method using 8-F balloon guide catheters for coil deployment into the aneurysms as a novel adjunctive technique for aneurysmal coil embolisation along with local balloon neck remodeling, stent assist and double catheter techniques. Materials and methods We retrospectively analysed patients who underwent endovascular coiling of anterior circulation aneurysms between August 2013 and December 2017. Results Of 206 patients enrolled in this study, the balloon of the guiding catheter was inflated to assist coil deployment in 43 patients (20.9%). In addition, the proximal flow control method found utility in cases with small aneurysms and relatively narrow-necked internal carotid artery. We observed no intraprocedural complications in this study. Conclusion This technique enabled secure coil deployment without navigating another microcatheter or balloon catheter around the aneurysms.

Coil Embolisation of Post Traumatic Giant Supraclinoid Pseudoaneurysm Presenting as Carotid Cavernous Fistula.

This report documents the occurrence, diagnosis and treatment of a 29 year-old male patient who presented with progressive swelling of the left eye with associated progressive loss of vision, three months after sustaining a closed head injury in a road traffic accident. Magnetic resonance imaging (MRI) showed a large, ill-defined lesion in the left supraclinoid and paraclinoid region with variable contrast enhancement. A four vessel Digital Subtraction Angiography (DSA) showed a large, supra-clinoid pseudoaneurysm which had ruptured inferiorly into the roof of cavernous sinus, forming direct carotid cavernous fistula (CCF) which lead to dilatation of the superior ophthalmic vein and subsequent peri-orbital oedema and chemosis of conjunctiva. Complete obliteration of the indirect CCF was achieved by coiling of the aneurysm alone. During follow up, patient reported a significant improvement in vision and follow up DSA after one year shows no recurrence with this technique.

Three-dimensional shaping technique for coil placement using the steam-shaped microcatheter for ruptured blood blister-like aneurysm.

Treatment of blood blister-like aneurysm (BBA) is a challenge due to its unfavourable morphology, small size and the friable neck of BBA. In the management of ruptured BBA, coil placement can be achieved by stent-assisted coil embolisation. We propose to incorporate a new technique using a steam-shaped microcatheter to improve safety. A 59-year-old woman was transferred to our hospital and diagnosed with subarachnoid haemorrhage (SAH) due to a ruptured BBA of the left internal carotid artery (ICA) at the C2 portion. For coil embolisation, we selected the aneurysm sac using a three-dimensional shaping technique and the jailing method. Post-embolisation angiography revealed complete occlusion of the aneurysmal sac. For safe treatment and stability of BBA, the shape of the catheter tip and the distal portion of the microcatheter are two important factors to consider. The proposed technique could help resolve the problem of catheter shaping in the treatment of BBA.

Non Surgical Management of Pseudoaneurysms.

BACKGROUND: The incidence of pseudoaneurysm has increased due to the large number of vascular procedures performed and the widespread use of anticoagulation therapy during procedures. Non-invasive methods for management of pseudoaneurysms comprise of ultrasound guided compression (USGC), thrombin therapy, arterial embolisation and endovascular stent graft insertion. We discuss our experience in the management of fourteen cases of pseudoaneurysms using non surgical techniques. METHODS: During a two year period, fourteen patients presenting with pseudoaneurysms of different regions were treated. RESULT: Of the fourteen patients, eleven were iatrogenic and three were attributable to trauma. There were six cases of pseudoaneurysms of the femoral artery following coronary angiography studies. One patient developed pseudoaneurysm of right popliteal artery after external fixation of fracture right tibia and fibula. Three cases of renal artery pseudoaneurysms occurred following percutaneous nephrolithotomy (PCNL). The cases were evaluated using a varying combination of color doppler, multidetector computerised tomography (CT) and angiography. These cases were treated with ultrasound guided compression (USGC), stent graft and coil embolisation. The selection of method was based on the location and size of pseudoaneurysms besides the efficacy of the technique. USGC was performed in seven, of which six were in the femoral artery and one supraorbital. The technique was unsuccessful in three of the seven, wherein stent graft was deployed in the femoral artery. Coil embolisation was utilised in three cases of renal artery pseudoaneurysms following PCNL. CONCLUSION: Follow up with color doppler and CT angiography within a week, 6 and 12 months period showed successful regression of pseudoaneurysms in all cases.

Wunderlich Syndrome due to Ruptured Pseudoaneurysm of Angiomyolipoma in First Trimester: A Rare Case Report.

Angiomyolipoma (AML) is a rare benign tumour of kidney which demonstrates rapid growth during pregnancy due to hormonal stimulation, leading to rupture. Majority of reported ruptured AMLs are in third trimester. We report a case of ruptured angiomyolipoma at 10th week of gestation, the earliest rupture known in singleton pregnancy. The AML had pseudo-aneurysm formation with extra-tumoural rupture during pregnancy, a finding never reported in literature yet. The patient had active bleeding with expanding peri-nephric haematoma during initial two days of conservative management. Hence, after counselling and taking prior informed written consent for Medical Termination of Pregnancy (MTP), computed tomography scan of abdomen with angiography followed by emergency coil embolization of the bleeding right upper polar segmental artery was done. After stabilization, MTP was done at 12th week of gestation. Counselling and consent for continuing or aborting the pregnancy is of utmost importance for best possible outcome for patient and foetus.

Transmural coil embolization-alternative technique for management of arterial perforation during subintimal angioplasty.

Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA) after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.