Catheter-directed hemorrhoidal embolization for rectal bleeding due to hemorrhoids (Goligher grade I-III): prospective outcomes from a Spanish emborrhoid registry.

OBJECTIVES: To evaluate the safety and efficacy of catheter-directed hemorrhoidal embolization (CDHE) by microcoil embolization for rectal bleeding due to hemorrhoids classified as Goligher grade I-III. METHODS: Eighty patients (62.5% males) with a mean age of 48 ± 9 years were recruited prospectively. All patients had symptomatic bleeding hemorrhoids. All patients were classified according to Goligher classification: grade I (13.7%), grade II (71.1%), grade III (15%), and no grade IV were recruited in this study. In all cases, microcoils were used to embolize the superior rectal artery(SRA), and microspheres if recurrence of bleeding occurred. Follow-up evaluation (1, 3, 6, and 12 months) included clinical examination and anoscopy. A questionnaire was conducted to determine improvement regarding bleeding, quality of life before, and the degree of patient satisfaction of each participant. RESULTS: Technical success was achieved in 100% of the cases. Fifty-five (68.7%) participants had the absence of rectal bleeding after 12 months of embolization. VAS and QL improved 4 points and 1.5 respectively after embolization. A total of 25/80 (31.3%) had a recurrence in rectal bleeding. Seventeen (21.3%) patients underwent a second embolization, and four patients (5%) were treated with open hemorrhoidectomy. No major complications were observed. Sixteen participants had minor complications. Subjective post-treatment symptom and QL surveys showed significant differences from the baseline survey. Likewise, the degree of satisfaction in the telephone survey at 12 months revealed a high degree of patient satisfaction (8.3±1.1). CONCLUSIONS: The present study demonstrates that CDHE is a feasible, well-tolerated, ambulatory, anal sphincter-sparing procedure for the treatment of internal hemorrhoids. CLINICAL RELEVANCE STATEMENT: CDHE is a simple procedure, well tolerated and accepted by patients, that preserves the anal sphincter and presents few complications when metal devices or microspheres are used as embolic agents. KEY POINTS: • The technical success rate of CDHE, defined as the closure of all the SRA in their distal segment, was achieved 100% of all patients. However, a second embolization treatment was required since 21.25% of the patients experienced rectal bleeding. • Overall, CDHE's safety profile is acceptable. After the procedure and 1 year of follow-up, no significant complications were observed. • Encouraging clinical outcomes have demonstrated CDHE in individuals with hemorrhoids and mild prolapse Goligher grades I-III with persistent rectal bleeding.

Mechanochemical Endovenous Ablation of Varicose Veins in Pediatric Patients with Klippel-Trénaunay Syndrome: Feasibility, Safety, and Initial Results.

PURPOSE: To evaluate feasibility, safety, and results of endovenous mechanochemical ablation (MOCA) for treatment of persistent embryonic and dysplastic veins in pediatric patients with Klippel-Trénaunay syndrome (KTS). MATERIALS AND METHODS: Thirteen MOCA procedures were performed in 11 patients (age range, 4-16 years) with KTS and symptomatic persistent embryonic or dysplastic veins during a 24-month period. All patients were evaluated with color Doppler (CD) ultrasound (US), contrast-enhanced MR imaging, and venography to assess the anatomy of the target vessels and patency of the deep venous system. All procedures were performed under general anesthesia with a ClariVein catheter and liquid sodium tetradecyl sulfate as the sclerosing agent. US and fluoroscopic guidance were used in all cases. Technical success rate, primary occlusion rate, adverse effects, and recanalization rates were evaluated. Clinical and radiological (CD US) controls were performed 1 day, 7 days, 1 month, and 6 months after the procedure and once a year thereafter, with a mean follow-up of 16 months (range, 6-25 months). RESULTS: Technical success and primary occlusion were achieved in all patients with no adverse events. During the follow-up period, CD US demonstrated partial recanalization and symptom recurrence in 2 patients (18%), 14 and 18 months after the initial procedure. These 2 patients had a second ablation procedure with no recanalization or symptom recurrence during the subsequent follow-up period. CONCLUSIONS: MOCA is feasible and appears to be a safe and effective technique for treatment of varicose veins in pediatric patients with KTS.

Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients.

PURPOSE: The purpose of this study was to determine the efficacy and safety of embolization treatment in pelvic venous disorders in women refluxing in the ovarian and or internal iliac veins in women with chronic pelvic pain. MATERIALS AND METHODS: A retrospective study conducted from January 2000 to June 2017 in 617 patients diagnosed with pelvic venous disorders (PeVDs) with a mean age of 43.2 ± 7.2 years were treated using an embolization procedure. A total of 520 were included, and 97 patients were excluded. The main inclusion criteria were PeVD symptoms for more than 6 months and transvaginal Doppler ultrasonography (TV-DUS) diagnosis of varicose veins in the pelvis with a diameter greater than 6 mm. The main objective was to embolize the 4 main pelvic venous plexi (ovarian and internal iliac veins) whenever possible. Follow-up was performed using clinical symptoms (visual analog scale) and TV-DUS at 1, 3, 6, and 12 months and then every year up to 5 years. RESULTS: The technical success (embolization of the 4 main pelvic veins) was achieved in 84.4% of the patients. The average follow-up was 58.7 ± 5.7 months. The visual analog scale was improved from 7.63 ± 0.9 points pretreatment to 0.91 ± 1.5 at 5 years. A total of 26 patients (5%) presented with symptom recurrence and pelvic varicose veins. There were 57 minor complications (10.9%) and 11 major complications (2.1%), with 7 cases (1.34%) of device migration to the lung. CONCLUSIONS: The embolization of pelvic varicose veins is a safe and effective procedure. The selection of the embolic agents and the number of veins needed to be treated.

A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes.

PURPOSE: To compare safety and efficacy of vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS). MATERIALS AND METHODS: A randomized, prospective, single-center study enrolled 100 women with PCS from January 2014 to January 2015. Patients were randomly assigned to 2 groups, and embolization was performed with FPCs (n = 50) or VPs (n = 50). Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60. Primary outcome (clinical success at 1 y using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared, and participants were followed at 1, 3, 6, and 12 months. RESULTS: Clinical success and subjective improvement were not significantly different at 1-year follow-up (89.7% for FPCs vs 90.6% for VPs; P = .760). Mean number of devices per case was 18.2 ± 1.33 for FPCs and 4.1 ± 0.31 for VPs (P < .001). Three FPCs and 1 VP migrated to pulmonary vasculature approximately 3-6 months after the embolization procedure; all were retrieved without complications. The FPC group had a significantly longer fluoroscopy time (33.4 min ± 4.68 vs 19.5 min ± 6.14) and larger radiation dose (air kerma 948.0 mGy ± 248.45 vs 320.7 mGy ± 134.33) (all P < .001). CONCLUSIONS: Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.

Challenges and Opportunities for Continued Success and Growth of Pediatric Interventional Radiology: A Communiqué From the Society for Pediatric Interventional Radiology.

OBJECTIVE: Pediatric interventional radiology (PIR) is a dynamic and growing subspecialty. We will detail our need to evolve like the emerging therapies and innovative imaging options that we provide to children. CONCLUSION: New interventional radiology training pathways, maintaining competency with small volumes of complex procedures, limited availability of pediatric-specific equipment, questions about the safety of sedation in the developing brain, and the dearth of PIR opportunities outside of North America provide challenges and opportunities for the vibrant community of PIR practitioners.

Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation.

The aim of this study is to correlate the US, laboratory, and cholangiography findings in pediatric liver transplant patients with biliary complications, trying to identify reliable decision-making tools for the management of these complications. Retrospective review was carried out of US results in 39 consecutive patients, from 2011 to 2013, with biliary complications after LT, documented by PTC. According to US biliary dilation, patients were classified as: mild, moderate, and severe, and according to laboratory findings as: normal or abnormal serum bilirubin and level of serum GGT. Data were correlated with PTC findings, divided in three groups: mild, moderate, and severe/occlusive BDS. There was no statistically significant correlation between the US findings and the laboratory findings and between US findings with PTC. There was a statistically significant correlation between GGT and cholangiography. In our series, abnormal US could not predict the severity of BDS on PTC. Bilirubin results were not able to predict the US findings either. GGT results demonstrated a statistically significant correlation with the severity of BDS found on PTC. These findings emphasize the role of GGT in the evaluation and decision of biliary interventions in pediatric liver transplant recipients.

[Endovascular treatment of an hepatic artery pseudoaneurysm following pancreaticoduodenectomy]. / Tratamiento endovascular de un pseudoaneurisma de la arteria hepática posterior a duodenopancreatectomía.

Pseudoaneurysm formation is a serious complication in the context ofa pancreatic resection, reaching out a high mortality rate. Classically, surgery was the gold standard of treatment, but nowadays endovascular approach has been accepted as the first treatment option. The use of covered stents seems to be a safe and effective tool to treat this serious complication.

Incidence, management and outcomes in hepatic artery complications after paediatric liver transplantation: protocol of the retrospective, international, multicentre HEPATIC Registry.

INTRODUCTION: Hepatic artery complications (HACs), such as a thrombosis or stenosis, are serious causes of morbidity and mortality after paediatric liver transplantation (LT). This study will investigate the incidence, current management practices and outcomes in paediatric patients with HAC after LT, including early and late complications. METHODS AND ANALYSIS: The HEPatic Artery stenosis and Thrombosis after liver transplantation In Children (HEPATIC) Registry is an international, retrospective, multicentre, observational study. Any paediatric patient diagnosed with HAC and treated for HAC (at age <18 years) after paediatric LT within a 20-year time period will be included. The primary outcomes are graft and patient survivals. The secondary outcomes are technical success of the intervention, primary and secondary patency after HAC intervention, intraprocedural and postprocedural complications, description of current management practices, and incidence of HAC. ETHICS AND DISSEMINATION: All participating sites will obtain local ethical approval and (waiver of) informed consent following the regulations on the conduct of observational clinical studies. The results will be disseminated through scientific presentations at conferences and through publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: The HEPATIC registry is registered at the ClinicalTrials.gov website; Registry Identifier: NCT05818644.

Endovascular treatment of post-pharyngitis internal carotid artery pseudoaneurysm with a covered stent in a child: a case report.

CASE REPORT: We report a case of 4-year-old boy patient, who developed after a streptococcal pharyngitis a painful, pulsatile, and growing right-sided mass in the neck. Imaging studies revealed an extracranial right internal carotid artery pseudoaneurysm. The patient was successfully treated with stent-graft deployment. After 18 months of follow-up, the pseudoaneurysm is excluded from the circulation, the carotid artery is patent, and the patient is free from any neurological deficit. DISCUSSION: Covered stents might be considered as a valid therapeutic option to treat carotid artery pseudoaneurysms.

Update on orbital vascular anomalies in pediatrics: imaging studies and management. / Actualización en anomalías vasculares de la órbita en pediatría: diagnóstico por imágenes y tratamiento.

Orbital vascular anomalies (OVAs) are a heterogeneous group of disorders frequently found in the orbital cone, the periorbital region, or within the orbit itself. OVAs are divided into tumors and malformations. The most frequent clinical presentation is exophthalmos, associated or not with an alteration of the visual axis. They may also cause acute complications, being intralesional bleeding or cellulitis the most frequent, and chronic complications, such as amblyopia and long-term visual acuity impairment. The development of imaging techniques, the use of new drugs, and the implementation of innovative procedures in interventional radiology have resulted in a significant improvement in the diagnostic and therapeutic approaches to these patients, essential to an accurate diagnosis and management.

Las anomalías vasculares de la órbita (AVO) son un grupo heterogéneo de patologías que pueden presentarse con frecuencia en el cono orbitario, la región periorbitaria o dentro de la órbita misma. Las AVO se dividen en tumores y malformaciones. Su presentación clínica más frecuente es el exoftalmos, asociado o no a alteración del eje visual. Además, pueden presentar complicaciones agudas, como hemorragia intralesional o celulitis entre las más frecuentes, y complicaciones crónicas, como ambliopía y afectación de la agudeza visual a largo plazo. La evolución de las técnicas de imágenes, el uso de nuevos fármacos y la utilización de innovadores procedimientos en radiología intervencionista han posibilitado obtener una mejora significativa en los procesos diagnósticos y terapéuticos de estos pacientes, permitiendo un diagnóstico y tratamiento preciso.

A Comparative Study of a Small Series of Patients (50 Patients) with Pelvic Varicose Veins Treated with Plugs Alone or Plugs and Polidocanol.

LEVEL OF EVIDENCE: Level 2. PURPOSE: To compare the safety and efficacy of vascular plug (VP) and vascular plug and polidocanol foam (VPPF) treatments for embolization in pelvic congestion syndrome (PCS). MATERIALS AND METHODS: A comparative, prospective, two-center study enrolled 50 women with PCS from January 2019 to January 2020. The patients were divided into two groups, and embolization was performed with VP (n = 25) and VPPF (n = 25) treatments. The mean age of the patients was 45.6 years ± 6.9. Three clinical parameters were assessed: abdominal pain, dyspareunia, and lower limb pain. The primary outcome (clinical success at 1 yr using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared. The participants were followed-up at 1, 3, 6, and 12 months. RESULTS: At the 1-year follow-up, clinical success did not significantly differ between the two groups (VP vs. VPPF) regarding the improvement of the symptoms analyzed (pelvic pain, dyspareunia, lower extremity pain, and other symptoms (p < 0.05)). The mean number of devices per case was 4 ± 1.1 for the VP group and 2 ± 0.31 for the VPPF group (p < 0.001). No major complications were recorded in either group. The VPPF group had a significantly longer fluoroscopy time (42.8 min ± 14.2 vs. 25.4 min ± 7) and longer radiation dose (VPPF air kerma 839.4 ± 513 vs. VP air kerma 658.4 mGy ± 355 (all p < 0.001)). CONCLUSIONS: Embolization for PCS resulted in pain relief in 90% of patients; the use of polidocanol did not demonstrate changes in the clinical outcome. The use of a VP alone was associated with decreased fluoroscopy time and radiation dose.

Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry.

INTRODUCTION: Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO. METHODS AND ANALYSIS: The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques. ETHICS AND DISSEMINATION: Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL9261).

Pharmacokinetic analysis of topotecan after superselective ophthalmic artery infusion and periocular administration in a porcine model.

PURPOSE: To characterize the vitreous and plasma pharmacokinetics of topotecan after ophthalmic artery infusion (OAI) subsequent to superselective artery catheterization and to compare it with periocular injection (POI). METHODS: The ophthalmic artery of 4 pigs was catheterized and 1 mg of topotecan infused over a period of 30 minutes. The contralateral eye was subsequently used for administering topotecan by POI. Serial vitreous specimens were obtained by microdialysis and plasma samples collected and assayed for total and lactone topotecan. RESULTS: Maximum total topotecan concentration in the vitreous (median, range) was significantly higher after OAI compared with POI (131.8 ng/mL [112.9-138.7] vs. 13.6 ng/mL [5.5-15.3], respectively; P < 0.005). Median vitreous exposure calculated as area under the curve for total topotecan attained after OAI was significantly higher than after POI (299.8 ng·hour/mL [247.6-347.2] and 48.9 ng·hour/mL [11.8-63.4], respectively; P < 0.05). The vitreous to plasma exposure ratio was 29 after OAI and 3.4 after POI. Systemic exposure for total topotecan was low after both modalities of administration, with a trend to be lower after OAI compared with POI (10.6 ng·hour/mL [6.8-13.4] vs. 18.7 ng·hour/mL [6.3-21.7]; P = 0.54). CONCLUSION: Superselective OAI resulted in significantly higher vitreous concentrations and exposure and a trend toward lower systemic exposure than POI.

Congenital arterioportal fistulas: radiological treatment and color Doppler US follow-up.

BACKGROUND: Congenital intrahepatic arterioportal fistulas (APFs) are a rare cause of portal hypertension in children. Doppler US is a useful diagnostic imaging modality. Transarterial embolization is a minimally invasive and effective therapy allowing occlusion of the fistula and restoration of liver hemodynamics. OBJECTIVE: To describe the clinical and radiologic findings, percutaneous treatment and role of D-US in the postembolization follow-up of children with APF. MATERIALS AND METHODS: Between 2002 and 2011, four children with APF were treated. Initial diagnosis and follow-up was performed with D-US and confirmed by arteriography, followed by endovascular embolization in all patients. RESULTS: D-US demonstrated abnormal arterioportal communications in all patients. Six endovascular procedures were performed in these four children. In two children, no residual fistula was seen on D-US after the first procedure and symptoms resolved. In the other two children, D-US demonstrated residual flow through the fistula, with resolution of pathological D-US findings and symptoms after the second endovascular procedure. All four children were successfully treated and asymptomatic at the end of follow-up. The mean follow-up was 24 months. CONCLUSION: Interventional radiology has a key role in the treatment of congenital APF. D-US is a noninvasive and effective tool for the diagnosis and follow-up of these patients.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients.

PURPOSE: To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients. MATERIALS AND METHODS: During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated. RESULTS: Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed. CONCLUSIONS: Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Asymptomatic leukemic-cell infiltration of the pancreas: US findings.

Pancreatic infiltration of leukemic cells is a very rare manifestation at the onset of acute lymphoblastic leukemia (ALL) in childhood. Pancreatic enlargement in this situation is unusual and pancreatic involvement is often associated with biliary obstruction, cholestasis and pancreatitis. We report a 3-month-old girl who presented with asymptomatic leukemic infiltration of the pancreas, demonstrated by US with heterogeneous pancreatic enlargement associated with multiple hypoechogenic lesions, without cholestasis. Although these manifestations are rare, ALL should be considered a cause of pancreatic enlargement.

The Impact of Adjuvant Sirolimus Therapy in the Surgical Management of Scrotal Slow-Flow Vascular Malformations.

OBJECTIVE: To describe the effects of oral sirolimus administered before and after surgical resection of slow-flow vascular malformations of the scrotum in pediatric patients. METHODS: Retrospective review of 3 patients presenting with complex lymphatic-venous malformations of the scrotum who received adjuvant oral sirolimus 3 months before and 3 months after surgical resection. Demographic data, clinical course, imaging findings, and management strategies were reviewed for each patient. RESULTS: In each of the 3 patients, there was a significant volume reduction of the lesion within the 3 months after initial dose of sirolimus. Scarce lymphatic leakage during and after surgery was reported, associated with an adequate wound healing. Two years after the last postsurgical dose of sirolimus, all patients remain asymptomatic without any lymphatic leakage or lesion recurrence. CONCLUSION: Combined lymphatic-venous vascular malformations of the male genitalia are rare but associated with high morbidity and challenging treatment options. Pre- and postsurgical adjuvant treatment with oral sirolimus seems to be a promising therapeutic option that provides reduction of the lesion size before surgery and improvement of postsurgical recovery and wound healing.

Ibero-American Society of Interventionism (SIDI) and the Spanish Society of Vascular and Interventional Radiology (SERVEI) Standard of Practice (SOP) for the Management of Inferior Vena Cava Filters in the Treatment of Acute Venous Thromboembolism.

OBJECTIVES: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). METHODS: a group of twenty-two interventional radiologist experts, from the SIDI and SERVEI societies, attended online meetings to develop a current clinical practice guideline on the proper indication for the placement and retrieval of IVCFs. A broad review was undertaken to determine the participation of interventional radiologists in the current guidelines and a consensus on inferior vena cava filters. Twenty-two experts from both societies worked on a common draft and received a questionnaire where they had to assess, for IVCF placement, the absolute, relative, and prophylactic indications. The experts voted on the different indications and reasoned their decision. RESULTS: a total of two-hundred-thirty-three articles were reviewed. Interventional radiologists participated in the development of just two of the eight guidelines. The threshold for inclusion was 100% agreement. Three absolute and four relative indications for the IVCF placement were identified. No indications for the prophylactic filter placement reached the threshold. CONCLUSION: interventional radiologists are highly involved in the management of IVCFs but have limited participation in the development of multidisciplinary clinical practice guidelines.