Embolization of peripheral arteriovenous malformations and fistulas with precipitating hydrophobic injectable liquid (PHIL®).

PURPOSE: This paper reports on the preliminary experience of a single center in the embolization of peripheral AVMs and fistulas with precipitating hydrophobic injectable liquid (PHIL®), focusing on technical aspects and short-term clinical outcomes. MATERIALS AND METHODS: Seven males and five females were included in this study, mean age 42.16 years. For ten of them, it was the first embolization treatment; two had been previously treated with Onyx® embolization. PHIL® was injected with a transarterial approach without other embolics during the same procedure. Lesions were localized in small bowel (1), colon (1), head face (5), forefoot (1), uterus (1) and thorax (3); all were symptomatic. After 30-day clinical follow-up, a contrast-enhanced CT or MR was acquired at 3 months from intervention to detect eventual lesion residual. RESULTS: After a single embolization procedure, complete technical success was obtained in 50%, while clinical improvement without additional therapies was appreciable in all patients. No technical failure occurred; in two cases, a small amount of PHIL® proximally refluxed in nontarget vessels without clinical effects. No tattooing effects of superficial lesions neither artifacts at CT and cone-beam CT controls were evident. CONCLUSIONS: PHIL® seems to be a safe and effective liquid embolic agent for the treatment of peripheral AVMs and fistulas; although a direct comparison between PHIL and Onyx was not performed, PHIL might present the advantages of reduced artifacts at postprocedural CT scan and no need for shaking time preparation, but it is more expensive due to lower volume of product for each package and slightly less radiopaque at fluoroscopy.

Emborrhoid in patients with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in five cases with a new coiling release fashion "Spaghetti technique".

PURPOSE: This manuscript reports on a preliminary experience concerning emborrhoid in patients affected by cirrhotic portal hypertension; furthermore, a novel customized technique of coils release, named "Spaghetti technique," is described. MATERIALS AND METHODS: Five patients with chronic anemia due to internal hemorrhoidal bleeding and cirrhotic portal hypertension were treated. Clinics and hemoglobin values were evaluated to objectively assess clinical conditions up to 3 months follow-up. Embolizations were performed with fibered coils, oversized, released stretched and not packed. RESULTS: Technical success, intended as occlusion of all superior hemorrhoidal artery branches, was 100%. In two patients, inferior hemorrhoidal arteries were embolized too. No patients reported major or minor complications. At 3-month follow-up, clinical improvement was obtained in four of the five patients; hemoglobin values improved or remained stable in the whole sample. CONCLUSIONS: Based on this limited experience, emborrhoid seems to be safe and effective at 3-month follow-up to improve symptoms in patients with cirrhotic portal hypertension and chronic anemia due to hemorroidal bleeding; the stretched fashion to release oversized coils provides effective embolization.

Embolization of high-flow priapism: technical aspects and clinical outcome from a single-center experience.

PURPOSE: High-flow priapism is an incomplete and painless persistent erection caused by trauma. Its diagnosis is performed thanks to clinic and imaging evaluation with detection of fistula/pseudoaneurysm in the cavernous tissue. This paper aims to retrospectively assess the efficacy and safety of superselective arterial embolization in patients with high-flow priapism. MATERIALS AND METHODS: From January 2008 to March 2017, nine patients with high-flow priapism have been treated in a single center with embolization. The main etiology was trauma in eight subjects. The patients were evaluated with laboratory examinations and clinical and imaging findings (color Doppler ultrasonography and angiography). The mean follow-up time after embolization was 24 months. RESULTS: Eleven procedures were performed in nine patients: two of them required a second treatment session because of recurrence after 1-2 weeks. Embolic agents were microcoils, microparticles (300-500 µm) and Spongostan. Restoration of erectile function was monitored by clinical and color Doppler evaluation during follow-up. CONCLUSIONS: Superselective embolization should be the procedure of choice in patients affected by high-flow priapism; this technique appears to be successful in preserving erectile function. The choice of the embolic agent is crucial, and it should be tailored for each patient.

Endovascular Treatment of Peripheral Vascular Blowout Syndrome in End-Stage Malignancies.

BACKGROUND: Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically. METHODS: Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications. RESULTS: Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities. CONCLUSIONS: Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.

Transarterial embolization of peripheral high-flow arteriovenous malformation with ethylene vinyl alcohol copolymer (Onyx®): single-center 10-year experience.

PURPOSE: High-flow arteriovenous malformations (AVMs) are complex vascular lesions for which transcatheter embolization is considered as first-choice treatment nowadays. Multiple embolizing agents have been described, and among them, Onyx® seems to be promising; this is a liquid embolic agent, originally applied in neurointerventional radiology and recently adopted also in peripheral embolizations. The aim of this study is to report on a 10-year experience of transarterial embolization of peripheral high-flow AVM with Onyx® in terms of technical and clinical outcomes. MATERIALS AND METHODS: Retrospective analysis was conducted on patients affected by high-flow AVM and treated electively by transarterial embolization with Onyx®. Data collection included: preinterventional clinical radiological evaluations, procedural data and post-procedural clinical radiological assessment. Technical and clinical success was evaluated; follow-up was conducted 30 days after the last treatment session and yearly in case of success. RESULTS: Sixteen patients have been included, totally 38 embolizing procedures. Additional embolizing agents were required in 5 patients. Technical success was obtained in 11 patients; at 30-day follow-up, 15 patients showed improvements in symptoms, even those with incomplete embolization; however, after almost 1 year from treatment accomplishment, 7 patients showed relapse of symptoms and presented radiological signs of AVM recurrence. No clinically relevant complications occurred. CONCLUSIONS: In this series, in accordance with previous but limited published data, Onyx® appeared safe and technically effective to embolize high-flow peripheral AVM with transarterial approach. Clinical radiological follow-up is mandatory because new feeder recruitment has to be expected; patients should be informed of the concrete possibility of multiple treatment sessions.

Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries.

PURPOSE: Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience. MATERIALS AND METHODS: Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection. RESULTS: Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300-500 µm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment. CONCLUSION: Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

Sclerotherapy of peripheral low-flow vascular malformations: technical aspects and mid-term clinical outcome.

PURPOSE: The therapeutical management of low-flow vascular malformations (LFVMs) is challenging because of high recurrence rate; multiple strategies have been proposed. This paper aims to report a single-center experience of direct puncture sclerotherapy of peripheral LFVMs, focusing on technical aspects and clinical outcome in mid-term follow-up. MATERIALS AND METHODS: 16 patients have been treated for peripheral LFVMs (mean age 36.1 years), complaining mild pain, swelling of the region of interest, and cosmetic nuisance. Preprocedural US and MR were acquired; angiography performed only in doubt vascular supply. Standard procedure consisted of direct puncture of the nidus using 20-23 gauge needles under US guidance and injection of up to 15 ml foam of sodium tetradecyl sulphate under fluoroscopic guidance. Clinical and radiological follow-up were assessed at 1, 3, and 6 months. RESULTS: Lesions were localized: 8 in the upper and 5 the in lower limbs, 2 in the cheeks, and 1 in the vaginal labia. All procedures have been technically accomplished (100%). At 6 month follow-up, technical and clinical success were obtained in all cases, while radiological follow-up showed 81.2% (13 patients) complete vessels thrombosis after multiple sclerotherapy sessions. No major complications have been recorded; five patients (31.2%) referred minor complications. CONCLUSIONS: Sclerotherapy via direct puncture of LFVMs is a clinically effective procedure, well tolerated by patients, with reduced costs and mild minor complications rate; interventionalists should always clarify to the patients that multiple sessions would be performed and recurrences are expected at imaging follow-up despite clinical improvement.

Arterial embolizations with microvascular plug in extracranial and intracranial districts: technical results.

PURPOSE: A new detachable microvascular plug (MVP, Reverse Medical®, Irvine, CA, USA) has been recently developed; three models are available according to the size (MVP3-MVP5-MVP7). MVP3 and MVP5 are released through a 0.027″ microcatheter, MVP7 through a 4 Fr catheter. This series aims to describe an initial single-center experience examining intraprocedural safety and technical success of MVP. MATERIALS AND METHODS: Ten patients (mean age 55.1 years) have been treated for arterial embolization using MVP; eight extracranial and two intracranial arterial embolizations have been performed. The embolizations were because of: four bleedings, three aneurysms, two pseudoaneurysms, and one presurgical nephrectomy. RESULTS: MVP3 was used in five cases, MVP5 in four cases, and MVP 7 once. In all cases, the MVP was successfully released in < 1 min. In six patients, the MVP was the sole embolizing agent employed, while in four subjects, it was positioned complementary after coils. The technical and clinical success was obtained in 100%; hemorrhages were interrupted and aneurysms and pseudoaneurysms did not show recanalization at follow-up. CONCLUSIONS: MVP seems to be a safe embolizing device that interventional radiologists should consider when facing arterial embolization of both body and neuroarterial districts; the main advantage is related to MVP3 and MVP5 models that can be adopted for distal embolization thanks to the precise release through 0.027″ microcatheter.

Uterine Arteriovenous Malformations.

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.

Usefulness of doppler techniques in the diagnosis of peripheral iatrogenic pseudoaneurysms secondary to minimally invasive interventional and surgical procedures: imaging findings and diagnostic performance study.

The pseudoaneurysm (PA) is a perfused sac directly connecting with the arterial lumen by an interruption of the vessel wall continuity, more commonly secondary to trauma or iatrogenic causes. Aim of our study was to determine the accuracy and usefulness of Doppler techniques in the diagnosis of peripheral iatrogenic PAs secondary to minimally invasive procedures. From a three year prospective research, 20 Duplex Ultrasound (DUS) studies in as many patients presenting with periarterial pulsating mass clinically suspected for PA secondary to minimally invasive procedures were selected. The PA final diagnosis was confirmed by angiography in 12 patients (60% cases), by computed tomography angiography in 5 patients (25%), by surgery in 2 patients (10%), and by magnetic resonance angiography in 1 patient (5%). The vessels involved by PA formation were: common femoral artery in 8 cases (40%); superficial femoral artery in 4 cases (20%); brachial artery in 3 cases (15%); popliteal artery in 2 cases (10%); superficial temporal artery (STA) in 2 cases (10%); dorsal medial digital artery of the foot in 1 case (5%). Our study confirmed the usefulness of doppler techniques in the diagnosis of peripheral iatrogenic PAs. Specifically, a sensitivity of 90-95%, a specificity of 100% and predictive values of 100% (VPP) and 83-90% (VPN) were reported. The radiologist must always suspect a PA in the differential diagnosis of lesions contiguous to an artery vessel. This is to prevent potential complications such as e.g. massive haemorrhage. In this order, DUS allows a careful selection of patients who require to undergo in-depth imaging methods or surgical therapy, thus contributing to a significant reduction of contrast medium and exposure to ionizing radiation.

Adrenal glands hemorrhages: embolization in acute setting.

BACKGROUND: Acute adrenal hemorrhages are a rare event compared to other abdominal visceral injuries because of the anatomic localization of the adrenal glands; main causes are trauma and ruptured neoplasms. This manuscript reports on a single center experience of transarterial embolizations of adrenal hemorrhages in emergency setting. METHODS: In this retrospective analysis from 2010 to date, 17 patients (12 men and 5 women, mean age: 59.8 years) presenting with adrenal bleedings were treated by endovascular embolization. The etiology was traumatic in 7 cases, ruptured neoplasm in 8 cases and spontaneous in 2 patients assuming oral anticoagulant therapy. After thin slice contrast enhanced CT, a superselective embolization was conducted with different embolizing agents according to the type of vessel lesion and operator preference. RESULTS: Technical success rate, considered as interruption of adrenal bleeding detectable at angiography, was 94.1%. Clinical success rate, considered as hemodynamic stability restoration within 24 hours from the procedure, was 82.3%. Vessels involved were the superior adrenal artery in 5 patients, the middle adrenal artery in 8 patients, the inferior adrenal artery in one patient and more than one adrenal artery in 3 patients. No procedure-related major complications occurred and no patients had infarctions, necrosis, abscess formation, or required long-term steroid supplementation. CONCLUSIONS: Acute adrenal hemorrhages can be safely and effectively managed by catheter directed embolizations; the source of bleeding has to be carefully investigated at CT and angiography because adrenal glands present with a wide and complex vascular arterial network.

MVP (Micro Vascular Plug®) embolization of severe renal hemorrhages after nephrostomic tube placement.

BACKGROUND: We report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing. MATERIALS AND METHODS: Five patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages. All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value. After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP. The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure. RESULTS: Technical and clinical successes were obtained in all patients. Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula. MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases. MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization. The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission. CONCLUSIONS: According to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Basilar vascular system supplied by only right proatlantal intersegmentary artery type 1 with aneurysm and left internal carotid occlusion: a case report and review from the literature.

Persistence of proatlantal artery (PA) is a rare condition. More than 40 cases were described in the literature. Aneurysm may involve the PA itself in approximately 2% of cases, most arising from the internal carotid artery (ICA) side of PA. This case was particular because the PA showed a saccular aneurysm on the posterior wall, probably due to atherosclerosis disease and other alterations: plaque ulcerative of ICA, occlusion of left ICA, and aberrant right VA.