Carotid body tumor in a nine-year-old patient.

Carotid body tumors are rarely encountered pathologies in the pediatric age group but still exist in the differential diagnosis of cervical painless masses. Genetic and familial background should be studied in addition to contrast imaging studies. Complete subadventitial resection, with or without prior embolization, which is still controversial, is the mainstay of therapy. Follow-up gains importance due to its nature. Herein, we report a nine-yearold girl presented with a unilateral asymptomatic mass on the neck with a diagnosis of carotid body tumor treated surgically without embolization. We emphasize the specific aspects of the pediatric age group.

Splenic Arterial Embolization for Trauma and Beyond: A Case Series.

Splenic artery embolization plays an important role in the management of various medical and surgical conditions that are non-traumatic in etiology, in addition to its well-established and widely discussed role in managing splenic trauma. In nontraumatic emergencies of catastrophic bleeding originating from the spleen or splenic artery, splenic artery embolization can be effective in achieving hemostasis as a definitive management, temporary stabilizing measure, or preoperative optimization technique. In addition to emergency clinical conditions, splenic artery embolization can be performed electively as an alternative to splenectomy for managing patients with hypersplenism. Herein, we report 6 cases of splenic artery embolization performed at our center to highlight its various indications. This article aims to demonstrate the role of splenic artery embolization in different clinical scenarios and the considerations behind the techniques employed through illustrative cases.

Preoperative embolization and en bloc resection of a metastatic pheochromocytoma of the cervical spine.

This is a unique case of metastatic pheochromocytoma of the cervical spine treated with preoperative embolization and subsequent en bloc resection. A 65-year-old man with metastatic pheochromocytoma presented with two weeks of worsening neck pain, left arm and leg weakness and paresthesia, and urinary incontinence. Magnetic resonance imaging showed a metastatic osseous lesion at C6 with severe stenosis and spinal cord compression. The patient underwent successful preoperative angiographic embolization with a liquid embolic agent followed by C5-C7 laminectomy, en bloc tumor resection, and C3-T2 posterior spinal fusion. Six weeks postoperatively, the patient reported improving strength and resolving neck pain and paresthesias. While there is no standard paradigm for the treatment of metastatic pheochromocytomas of the cervical spine, preoperative embolization may minimize intraoperative blood loss and hemodynamic instability during subsequent surgical resection.

Extravasated contrast volumetric assessment on computed tomography angiography in gastrointestinal bleeding: A useful predictor of positive angiographic findings.

BACKGROUND: Gastrointestinal bleeding (GIB) is a severe and potentially life-threatening condition, especially in cases of delayed treatment. Computed tomography angiography (CTA) plays a pivotal role in the early identification of upper and lower GIB and in the prompt treatment of the haemorrhage. AIM: To determine whether a volumetric estimation of the extravasated contrast at CTA in GIB may be a predictor of subsequent positive angiographic findings. METHODS: In this retrospective single-centre study, 35 patients (22 men; median age 69 years; range 16-92 years) admitted to our institution for active GIB detected at CTA and further submitted to catheter angiography between January 2018 and February 2022 were enrolled. Twenty-three (65.7%) patients underwent endoscopy before CTA. Bleeding volumetry was evaluated in both arterial and venous phases via a semi-automated dedicated software. Bleeding rate was obtained from volume change between the two phases and standardised for unit time. Patients were divided into two groups, according to the angiographic signs and their concordance with CTA. RESULTS: Upper bleeding accounted for 42.9% and lower GIB for 57.1%. Mean haemoglobin value at the admission was 7.7 g/dL. A concordance between positive CTA and direct angiographic bleeding signs was found in 19 (54.3%) cases. Despite no significant differences in terms of bleeding volume in the arterial phase (0.55 mL vs 0.33 mL, P = 0.35), a statistically significant volume increase in the venous phase was identified in the group of patients with positive angiography (2.06 mL vs 0.9 mL, P = 0.02). In the latter patient group, a significant increase in bleeding rate was also detected (2.18 mL/min vs 0.19 mL/min, P = 0.02). CONCLUSION: In GIB of any origin, extravasated contrast volumetric analysis at CTA could be a predictor of positive angiography and may help in avoiding further unnecessary procedures.

Multimodal management of giant solid hemangioblastomas in two patients with preoperative embolization.

Background: Hemangioblastomas are benign vascular neoplasms, World Health Organization grade I, with the most frequent location in the cerebellum. Complete microsurgical resection can be a challenge due to excessive bleeding, which is why preoperative embolization takes importance. Case Description: Two clinical cases are presented, a 25-year-old woman and a 75-year-old man, who presented with intracranial hypertension symptoms due to obstructive hydrocephalus; a ventriculoperitoneal shunt was placed in both cases; in addition, they presented with cerebellar signs. Both underwent embolization with ethylene vinyl alcohol copolymer, with blood flow reduction. After that, they underwent microsurgical resection within the 1st-week post embolization, obtaining, in both cases, gross total resection without hemodynamic complications, with clinical improvement and good surgical outcome. It is worth mentioning that surgical management is the gold standard that allows a suitable surgical approach, like in our patients, for which a lateral suboccipital craniotomy was performed. Conclusion: Solid hemangioblastomas are less frequent than their cystic counterparts. The treatment is the surgical resection, which is a challenge and always has to be considered as an arteriovenous malformation in the surgical planning, including preoperative embolization to reduce perioperative morbidity and mortality and get good outcomes.

N-Butyl cyanoacrylate embolization of an extremely rare variant of sequestration complex - a high-flow left-to-left shunt between systemic artery and pulmonary vein.

A 19-year-old female presented with hemoptysis. Computed tomography (CT) pulmonary angiography revealed aberrant vessels from descending thoracic aorta, draining into pulmonary veins (left-to-left shunt). She was managed by transcatheter embolization of the aberrant vessels using N-butyl cyanoacrylate (NBCA) with balloon occlusion. A systemic artery to pulmonary vein fistula is one of the least common congenital anomalies. Most of the reported cases have been managed by surgery. Only a few patients have been treated by transcatheter embolization, using coils or vascular plugs as the embolizing agents. To our knowledge, this is the first case of its kind that was managed by glue embolization. Favorable post-procedure results have led us to believe that glue embolization can be considered a suitable alternative to thoracotomy in such patients. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01659-5.

Deconstructive repair of a direct carotid-cavernous fistula via a posterior circulation retrograde approach.

We report a case of a 24-year-old patient who presented after a head trauma with a traumatic occlusion of his left internal carotid artery. He underwent diagnostic cerebral angiogram and was found to have a direct left carotid-cavernous fistula (CCF) with retrograde filling from the posterior circulation across the posterior communicating artery. Because of the severe injury to the left internal carotid artery (ICA), reconstructive repair of the ICA was not possible. The patient underwent deconstructive repair of the CCF by coil embolization using a posterior retrograde approach. Coils were successfully placed in the cavernous sinus and back into the left ICA with complete cure of the CCF and restoration of cerebral perfusion distal to the treated CCF. We review the types of CCFs, their clinical presentation, and their endovascular treatments. Retrograde access of a direct CCF is rarely reported in the literature, and we believe this approach offers a viable alternative in appropriately selected patients.

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy.

PURPOSE: To evaluate the efficacy and safety of selective aneurysmal sac neck-targeted embolization in endovascular aneurysm repair (EVAR) in patients with a hostile neck anatomy (HNA). MATERIALS AND METHODS: Between October 2020 and June 2022, patients with an abdominal aortic aneurysm (AAA) and HNA who underwent EVAR with a low-profile stent graft and a selective aneurysmal sac neck-targeted embolization technique were analysed. An HNA was defined by the presence of any of the following parameters: infrarenal neck angulation > 60°; neck length < 15 mm; conical neck; circumferential calcification ≥ 50%; or thrombus ≥ 50%. Before occluding the entire aneurysm during the procedure, a buddy wire was loaded prophylactically into the sac through the contralateral limb side. If a type Ia endoleak (ELIa) occurred and persisted despite adjunctive treatment such as balloon moulding or cuff extension, this preloaded wire could be utilized to enable a catheter to reach the space between the stent graft and sac neck to perform coil embolization. In the absence of ELIa, the wire was simply retracted. The primary outcome of this study was freedom from sac expansion and endoleak-related reintervention during the follow-up period; secondary outcomes included technical success and intraoperative and in-hospital postoperative complications. RESULTS: Among the 28 patients with a hostile neck morphology, 11 (39.5%) who presented with ELIa underwent intraprocedural treatment involving sac neck-targeted detachable coil embolization. Seventeen individuals (60.7%) of the total patient population did not undergo coiling. All patients in the coiling group underwent balloon moulding, and 2 patients additionally underwent cuff extension. In the noncoiling group, 14 individuals underwent balloon moulding as a treatment for ELIa, while 3 patients did not exhibit ELIa during the procedure. The coiling group showed longer operating durations (81.27 ± 11.61 vs. 70.71 ± 7.17 min, P < 0.01) and greater contrast utilization than the noncoiling group (177.45 ± 52.41 vs. 108.24 ± 17.49 ml, P < 0.01). In the entire cohort, the technical success rate was 100%, and there were no procedure-related complications. At a mean follow-up of 18.6 ± 5.2 months (range 12-31), there were no cases of sac expansion (19 cases of sac regression, 67.86%; 9 cases of stability, 32.14%) or endoleak-related reintervention. CONCLUSIONS: Selective aneurysmal sac neck-targeted embolization for the treatment of ELIa in AAA patients with an HNA undergoing EVAR is safe and may prevent type Ia endoleak and related sac expansion after EVAR.

Pancreatic serous cystic neoplasms with spontaneous hemorrhage in a young woman: A case report.

INTRODUCTION: Pancreatic serous cystic neoplasm (SCN) is usually benign and is often managed using imaging surveillance if asymptomatic. It has a higher incidence in females but is rare in younger age groups. Acute hemorrhagic complications associated with SCN are infrequent. Whether asymptomatic SCN can cause acute hemorrhage, especially in women of childbearing age, is not well-established. PRESENTATION OF CASE: A 30-year-old Japanese female, who was six months postpartum and under surveillance for asymptomatic pancreatic SCN, presented to the emergency department with gradually worsening left lateral abdominal pain. Regular ultrasound revealed no change in SCN size; however, no imaging surveillance had been conducted over the past two years. She had pain in the entire abdomen, which intensified around the navel and elicited guarding. Abdominal contrast-enhanced computed tomography revealed a cystic mass in the pancreatic tail with a contrast blush within the cyst and an adjacent retroperitoneal hematoma. Endovascular embolization was performed to control the hemorrhage. The patient had an uneventful medical recovery and was discharged five days after embolization. Five months after discharge, she underwent laparoscopic distal pancreatectomy and splenectomy as an elective surgery and was discharged uneventfully. DISCUSSION: Even with periodic imaging surveillance, pancreatic SCN can suddenly cause spontaneous hemorrhage. Clinicians should be aware that pancreatic SCN can potentially cause life-threatening complications, including spontaneous hemorrhage. CONCLUSION: We report a case of an unexpected complication with spontaneous hemorrhage in a young woman who was under imaging surveillance for pancreatic SCN. The patient was successfully treated with angioembolization and planned laparoscopic surgery.

Automated Feeder-Detection Software for Renal Cell Carcinoma Embolization: A Retrospective Evaluation of Detection Rate Using Transarterial Time-Resolved Computed Tomography Angiography.

PURPOSE: To evaluate the detection rate of feeding arteries in renal cell carcinoma with automated feeder-detection software and determine the optimal imaging phase for accurate feeder detection with transarterial time-resolved computed tomography angiography. MATERIALS AND METHODS: The performance of automated feeder-detection software was retrospectively evaluated using transarterial renal time-resolved computed tomography angiography images of 15 renal cell carcinomas (mean size, 22.1 mm); the images were obtained via the renal artery using a hybrid angio-CT system with 320-row computed tomography, across nine phases with 0.5-s intervals over a contrast delay time of 1.0-5.0 s. Automated feeder-detection software was applied to each phase in all tumors (135 image series in total). The feeder-detection rate (i.e., sensitivity) in each phase was evaluated, and the number of false feeders demonstrated by the software was counted for each tumor. RESULTS: A total of 22 feeders were identified. The feeder-detection rate was the highest (95.5% [21/22]) at delay times of 1.5 s and 2.0 s and lower in later phases. At delay times of 1.0 s and 1.5 s, the software demonstrated no or only a few (≤ 3) false feeders in 93.3% (14/15) of the tumors. In later phases, however, many (≥ 4) false feeders were observed in > 50% of tumors. CONCLUSION: The automated feeder-detection software showed a favorable feeder-detection rate and may be useful in transarterial embolization for renal cell carcinoma. The optimal delay time to avoid the demonstration of false feeders and achieve a high detection accuracy was 1.5 s. LEVEL OF EVIDENCE IV: Case Series.

Pseudoaneurysm of the superficial temporal artery after sagittal split ramus osteotomy: A case report.

Sagittal split ramus osteotomy (SSRO) is a widely performed orthognathic surgery; however, among the various reported complications of SSRO, pseudoaneurysms are rarely reported. Pseudoaneurysms are rare vascular lesions formed by damage to the arterial wall that can occur after trauma or postoperatively, causing uncontrolled bleeding. The present report describes a case of a pseudoaneurysm that occurred after SSRO in a 22-year-old female patient. Le Fort I osteotomy and bilateral SSRO were performed under general anesthesia to improve the gummy smile and mandibular asymmetry of the patient. While osteotomizing the medial side of the left SSRO, major bleeding occurred from the soft tissue of the posterior margin of the mandibular branch. Direct compression with gauze and a local hemostatic agent stopped the bleeding. Immediately after returning to the ward, bleeding was observed from the left wound site and marked swelling of the left buccal area occurred. Contrast-enhanced computed tomography revealed a pseudoaneurysm of the left superficial temporal artery (STA). Subsequently, arterial embolization for the pseudoaneurysm was performed. Overall, the present report describes a rare case of pseudoaneurysm of the STA as a postoperative complication of SSRO.

Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization.

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

The Use of an Iliac Branch Device: Single-Center Study of Endovascular Preservation of Internal Iliac Artery Flow.

Purpose: To determine the efficacy and safety of iliac branch device (IBD) implantation and to evaluate its limitations based on 7 years of experience in a single center. Materials and Methods: This single-center study included patients with bilateral common iliac artery aneurysms (CIAAs). We investigated follow-up CT and reviewed the internal iliac artery (IIA) patency and complications related to IBD. A retrospective analysis was performed and the overall survival rate and freedom from reintervention rate were reported according to the Kaplan-Meier method. Results: Of the 38 patients with CIAAs, only 10 (12 CIAAs) were suitable for IBD treatment. Five patients underwent unilateral IBD insertion with contralateral IIA embolization, and three (60%) showed claudication; however, symptoms resolved within 6 months. The 7-year freedom from IBD-related reintervention rate was 77.8%. No procedure-related deaths occurred. Conclusion: IBD has good technical success and long-term patency rates; however, anatomical factors frequently limit its application, particularly in Asians. Additionally, unilateral IIA embolization showed relatively mild complications and a good prognosis; therefore, it can be performed safely for anatomically complex aortoiliac aneurysms.

Pediatric anterior choroidal artery aneurysm successfully coiled after re-rupture.

Pediatric cerebral aneurysms are rare, and pediatric anterior choroidal artery aneurysms are very rarely reported. A 14-month-old male with no personal or family history of connective tissue disorders or Moyamoya disease presented with a right temporal intracerebral hemorrhage with intraventricular extension. CTA was negative for vascular pathology, but digital subtraction angiography revealed an anterior choroidal artery aneurysm that was successfully coiled. This case underscores the importance of performing digital subtraction angiography in children presenting with intracerebral hemorrhage concerning for vascular pathology even if non-invasive vascular imaging is negative.

Vertebro-Vertebral Fistula Occlusion Using a Woven EndoBridgeTM-Device.

Vertebro-vertebral fistulas (VVFs) are vascular lesions that may develop after trauma or spontaneously in association with connective tissue disorders. We present a rare case of a post-traumatic VVF in a young patient presenting with a painless swelling and a bruit in her left upper neck. Digital subtraction angiography showed an arteriovenous fistula between the left vertebral artery (VA) and the vertebral venous plexus with significant steal phenomenon. Endovascular therapy was performed using a Woven EndoBridgeTM (WEB)-device combined with coils that allowed preservation of the VA. The patient fully recovered from her symptoms and follow-up imaging showed stable occlusion. In conclusion, VVFs can be effectively treated using intrasaccular flow diverters such as the WEB-device, allowing for complete and stable occlusion while preserving the parent artery.

Two consecutive ruptured intracranial aneurysm in patient with multiple intracranial aneurysms.

When aneurysmal subarachnoid hemorrhage due to multiple aneurysms is suspected, identifying the rupture site is essential to determine the exact surgical site, but it may not be easy. Even if embolization is adequately performed, complications may remain. Typical complications include rebleeding and hydrocephalus in the early phase and delayed cerebral ischemia in the delayed phase. Herein, we describe a case of rupture of an intracranial aneurysm after performing embolization for a different ruptured intracranial aneurysm in a patient with multiple intracranial aneurysms. Patients with multiple intracranial aneurysms need to be considered for closer observation than those with a single ruptured intracranial aneurysm, even if the patient's prognosis is good.

Embolización de un pseudoaneurisma de la arteria cística secundario a colecistitis aguda / Embolization of a pseudo aneurism of the cystic artery secondary to acute cholecystitis

RESUMEN Se presenta el caso de un paciente varón de 55 años con antecedente de colecistitis aguda, que durante la hospitalización presentó anemia por hemobilia secundaria a un pseudoaneurima de la arteria cistica. Se realizó, como tratamiento de primera elección, embolización con microparticulas de alcohol polivinílico (PVA) de la arteria cistica, logrando detención del sangrado.

SUMMARY We present the case of a 55-year-old male patient with a history of acute cholecystitis who presented during his hospitalization haemobilia due to a pseudoaneurysm of the cystic artery. Embolectomy of the cystic artery with polyvinyl alcohol microparticles was performed stopping the bleeding.

Middle meningeal artery embolization in the management of chronic subdural hematoma in medically complex pediatric neurosurgical patients: technical note.

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Unraveling the enigma of Adamkiewicz: exploring the prevalence, anatomical variability, and clinical impact in spinal embolization procedures for bone metastases.

BACKGROUND: The artery of Adamkiewicz (AKA) is vital for spinal cord blood supply. Its role in embolization procedures for bone metastases can cause serious complications. We explored its prevalence, anatomical variation, and effect on spinal embolization using N-butyl cyanoacrylate (NBCA) in patients with bone metastases. PURPOSE: To understand the impact and variability of AKA in spinal embolizations in cases of bone metastases to reduce complications and improve patient outcomes. MATERIAL AND METHODS: We examined data from 454 patients who underwent spinal embolization with NBCA between 2009 and 2018. The presence, anastomoses, and tumor features of AKA were assessed via pre-procedure imaging and angiography. Complications were classified per the CIRSE Classification System. RESULTS: AKA was found in 22.8% of patients, predominantly left-sided and originating from T8 to L1. Direct and indirect anastomoses were present in 66.6% and 33.4% of patients, respectively. Extra-compartmental invasion was linked with direct anastomosis (P = 0.004). High-grade complications were rare but included one instance of bilateral lower limb paralysis. Partial embolization was necessary in 22.8% of cases due to AKA. CONCLUSION: The study underscores the need for rigorous preoperative evaluation of AKA origin and anastomoses in patients undergoing spinal embolization for bone metastases. Given the significant presence of AKA and related anastomoses, especially with renal extra-compartmental tumors, caution is advised to reduce complications and optimize patient outcomes. Further research is required for best practice guidelines involving bone metastases and AKA.

Cervical extradural arteriovenous fistula with radiculopathy managed endovascularly.

Background: Extradural arteriovenous fistulas (AVFs) of the cervical spine are extremely rare, and typically manifest as slowly progressive myelopathy caused by mass effect. This is a unique case of extradural AVF of the cervical spine manifesting with purely radicular symptoms and treated endovascularly with coil and liquid embolization. Case Description: A 55-year-old woman presented with neck pain and right upper extremity radiculopathy persisting for 9 months. Imaging studies demonstrated an AVF spanning from C4-C6 with extension into the C5-C6 foramen supplied primarily from the deep cervical branch of the costocervical trunk. The patient underwent successful coil and liquid (Onyx) embolization. Six-week postoperatively, the patient's symptoms completely resolved and magnetic resonance imaging and angiographic imaging confirmed complete obliteration of the fistula. Conclusion: While extradural AVFs typically present with myelopathic symptoms, they may present with solely radicular symptoms and can be successfully treated endovascularly.