Management of Spontaneous Bleeding in COVID-19 Inpatients: Is Embolization Always Needed?

BACKGROUND: critically ill patients with SARS-CoV-2 infection present a hypercoagulable condition. Anticoagulant therapy is currently recommended to reduce thrombotic risk, leading to potentially severe complications like spontaneous bleeding (SB). Percutaneous transcatheter arterial embolization (PTAE) can be life-saving in critical patients, in addition to medical therapy. We report a major COVID-19 Italian Research Hospital experience during the pandemic, with particular focus on indications and technique of embolization. METHODS: We retrospectively included all subjects with SB and with a microbiologically confirmed SARS-CoV-2 infection, over one year of pandemic, selecting two different groups: (a) patients treated with PTAE and medical therapy; (b) patients treated only with medical therapy. Computed tomography (CT) scan findings, clinical conditions, and biological findings were collected. RESULTS: 21/1075 patients presented soft tissue SB with an incidence of 1.95%. 10/21 patients were treated with PTAE and medical therapy with a 30-days survival of 70%. Arterial blush, contrast late enhancement, and dimensions at CT scan were found discriminating for the embolization (p < 0.05). CONCLUSIONS: PTAE is an important tool in severely ill, bleeding COVID-19 patients. The decision for PTAE of COVID-19 patients must be carefully weighted with particular attention paid to the clinical and biological condition, hematoma location and volume.

[Percutaneous management of hemorrhages in pelvic fractures].

PURPOSE: To report our experience in the control of haemorrhage with the transcatheter embolisation technique. MATERIALS AND METHODS: Between 1999-2001, we treated 56 patients with important pelvic trauma. Forty-two were victims of car accidents and 14 of falls from great altitudes. Twenty presented acute symptoms due to blunt pelvic trauma, with massive bleeding, not treatable by drugs and blood transfusion. Diagnosis of pelvic haemorrhage was made with CT. When high-flow haemorrhage was found, the patient was referred for angiography. Embolisation was achieved after a diagnostic arteriography, with bilateral transfemoral approach and selective catheterisation of the internal iliac arteries. RESULTS: Technical success was achieved in 100% of cases: all the haemorragic sites were found and embolised. In only one patient with severe shock was it impossible to locate the site of contrast material extravasation on the first day; the patient was successfully treated on the second day with improvement of the clinical conditions. The obturator artery was involved in five cases, the gluteal artery in eleven. In eighteen patients, use of an angiographic catheter was sufficient to treat the haemorragic sites. Percutaneous control of the haemorrhage was obtained by using Gelfoam, Ivalon and coils. CONCLUSIONS: Percutaneous haemorrhage control is safe and effective, and not as costly or dangerous as the surgical option. We regard it as the treatment of choice in multiple trauma patients with important and high-flow pelvic haemorrhage.

[A transbranchial approach for the percutaneous therapy of pediatric varicocele].

PURPOSE: Male varicocele affects children with the same incidence as it does adults. The association between asymptomatic idiopathic varicocele and male infertility and the poor recovery of testicular function after varicocele repair in adulthood have called for noninvasive clinical and instrumental diagnosis and increasingly early treatment. The department of Pediatric Surgery at our Hospital has screened schoolchildren for the early diagnosis and treatment of childhood varicocele. Our Vascular and Interventional Radiology department has proposed percutaneous treatment for varicocele correction. We report our 10-year experience with percutaneous sclerotherapy of pediatric varicocele with a retrograde transbranchial approach. MATERIALS AND METHODS: From a screening programme involving schools 467 boys were selected who were positive for idiopathic varicocele at clinical examination and at Doppler CW, at rest and during Valsalva manoeuvre. Patients with grade III, or symptomatic grade II varicocele, testicular hypotrophy, or with a dilation of the testicular veins greater than 2.2 mm at baseline were referred for percutaneous treatment. Percutaneous treatment was performed with a transbrachial approach in the basilic vein. After searching for incontinence of the internal right spermatic vein, left renal phlebography was performed in order to identify any incontinence of the left spermatic vein. This vein was then selectively catheterised to perform sclerosis. Tungsten coil embolisation was also performed over a number of years. Follow-up consisted of clinical examination, Doppler CW, Doppler US, or colour Doppler US performed at 3, 6, and 12 months. RESULTS: The radiological procedure was only diagnostic in 78 cases (16.7%). Basilic vein spasm and collaterally-supplied varicocele forced us to discontinue the procedure. The use of materials with smaller diameters and the professional development of the radiological team helped improve the catheterisation rate with time. Using the transbrachial approach alone a total of 287 left-sided, 15 right-sided and 52 bilateral varicoceles were treated. Whereas in two cases of bilateral varicocele a dissection at the origin of both spermatic veins prevented the use of sclerotherapy--though the patients were found to be cured at follow-up with Doppler US--on the left the procedures were continued with a transfemoral approach due to difficulties with the transbrachial catheterisation. As for the left-sided varicoceles, sclerosis were performed in 230 procedures, whereas sclerosis and embolisation on 87 patients. The success rate was 92% for sclerosis, and 86% for sclerosis and embolisation. No major complications were observed. DISCUSSION: Percutaneous treatment is a minimally invasive and relatively non-traumatic interventional radiology procedure, able to confirm the presence of varicocele, accurately map the venous system and allow selective therapy. Our experience with 467 patients over 10 years has allowed us to compare two therapeutic options: sclerosis and sclerosis combined with embolisation. CONCLUSIONS: Percutaneous treatment of varicocele with the transbrachial approach proved to be a safe, effective, inexpensive, and minimally invasive procedure. It can be suggested as the first therapeutic option for varicocele correction, especially for boys and for bilateral forms.

A therapeutic alternative in the treatment of epididymal cysts: percutaneous sclerotherapy.

PURPOSE: Epididymal cysts are benign structures commonly seen during urological or ultrasound testicular examinations. They are treated only if symptomatic. Surgery is the standard treatment, although it carries a high risk of complications. We report our experience with sclerotherapy of epididymal cysts with sonographic assistance, and present an analysis of costs. MATERIALS AND METHODS: Between January 1999 and December 2000 we examined 48 epididymal cysts in 45 patients during ultrasound examinations. Except one, all of the patients were symptomatic. We decided to treat 25 symptomatic cysts that were more than 5 cm. in diameter. All of the patients refused surgery as they knew of the existence of the percutaneous method. The procedures were performed on a out-patient basis with ultrasound assistance and using 3% Polidocanol for sclerosis. Follow-up was at 3/6 and 12 months after treatment. If we found persistence of symptoms and/or a cyst was more than 5 cm of diameter, a second session was proposed. RESULTS: Twenty-five epididymal cysts were treated, with a technical success of 100%. Mean fluid evacuation was 36 ml; mean sclerosing agent injected was 4.5 ml. There were no complications. After 3/6 months 17/25 patients were free of symptoms (68%) and the cysts had disappeared in 15 of them (60%). After the repeat procedure, performed on only 4 patients, the number of symptom-free patients was 21/25 (84%). DISCUSSION: Epididymal cysts are often solitary cystic fluid collections that are occasionally reported during physical or ultrasound urological clinical examinations. They present as painless testicular enlargements on palpation and are echo-free at ultrasound examination. Percutaneous sclerotherapy has gained wide acceptance in the therapeutic handling of other pathologies and it appears as an ideal solution for this benign clinical condition of the superficial structures. Polidocanol, widely used on varicose vein therapies for its local anaesthetic properties, is the ideal sclerosing agent for superficial and delicate structures, such as epididymal cysts. The results of the present study have shown that symptomatic cysts may be cured in 84% of cases without complications and with low costs. CONCLUSIONS: Percutaneous sclerotherapy is a valid therapeutic alternative to surgery in the management of epididymal cysts: it is safe, effective, free of complications, less costly and shows good results in the follow-up.

Analysis of radiation doses in the percutaneous treatment of varicocele in adolescents.

PURPOSE: Varicocele is a common clinical condition that affects 15% of the male population and is an important cause of male infertility. Fluoroscopy-guided percutaneous treatment with retrograde sclerosis is a good alternative to surgery. We report our experience in calculating the total radiation dose to patient and the associated risk. MATERIALS AND METHODS: Our study was performed on 67 patients undergoing percutaneous treatment of varicocele with transbrachial approach and retrograde sclerosis. Thirteen dosimeters with two TLD detectors were positioned on the patients' skin. Calculation of the Entrance Surface Dose and application of appropriate transmission coefficients of the depth-dose allowed us to determine the Equivalent Doses for the single organs. Similar studies were conducted during plain abdominal x-ray and urography for comparative purposes. RESULTS: The mean effective dose during percutaneous treatment of varicocele was 18 mSv, whereas the dose for abdominal x-ray was 1.31 mSv and that for urography was 4.6 mSv. DISCUSSION AND CONCLUSIONS: Examinations involving the use of x-rays have been estimated to contribute to half of all the radiation absorbed by the population, and the number of both diagnostic examinations and interventional procedures is steadily rising. Radiation exposure, especially in children, requires special consideration. Percutaneous treatment of varicocele is a valuable alternative to surgery, not least because of reduced exposure. The use of specially-built lead coats and the creation of regional referral centres employing specialised staff are two possible measures that could further reduce radiation doses and dispel concerns about this procedure.

Optional vena cava filters: preliminary experience with a new vena cava filter.

PURPOSE: To prevent pulmonary embolism, some clinical situations only need a vena cava filter for several days, without the inconveniences of temporary vena cava filters in the short-medium term and without the drawbacks of permanent ones in the long term. We report our initial experience with a new definitive vena cava filter, easy to retrieve when it becomes unnecessary. MATERIAL AND METHODS: From the beginning of January 1999 to December 2001, 18 ALN vena cava filters were deployed. The approach used was transbrachial in ten patients, transjugular in seven, and transfemoral in the others. The indications were pelvic trauma in eleven patients, hip replacement in three; four filters were "prophylactically" placed before surgery in patients at high risk of thromboembolic disease (three with ileal or femoral or ileo-femoral thrombosis, and one without clinically manifest thromboembolic disease). Optional vena cava filters were evaluated for malpositioning, caval perforation, filter migration, acute caval thrombosis or access site thrombosis. Seven optional vena cava filters were retrieved. CT was performed before retrieving the vena cava filters to document the absence of thrombi inside the filters. The transjugular ap-proach was used to retrieve the filters. RESULTS: Technical success was achieved in all patients. No complications were encountered during the procedure; no migration or rupture of the filters was detected during the follow-up. No thrombosis of the vena cava or at the insertion site was encountered. The median retrieval time for the filters was 12': only the transfemoral filters required 15' of fluoroscopy. The median permanence was 63 days. No thrombi were found inside the filters. DISCUSSION: A definitive vena cava filter, easy to retrieve when it becomes unnecessary, is the ideal device in many clinical conditions: young subjects with pelvic fractures orthopaedic and gynaecologic interventions.