How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review.

PURPOSE: Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications. METHODS: We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia. RESULTS: Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive. CONCLUSIONS: We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

Transcatheter embolisation of renal angiomyolipoma.

INTRODUCTION: Angiomyolipomas (AML) are rare benign renal tumours which are associated with aneurysms that can cause haemorrhage. Embolisation of AML greater than 4 cm with a variety of embolic agents is now the first-line treatment in these cases. METHODS: This was a retrospective analysis of all patients who underwent AML embolisation at Beaumont Hospital from 2000 to 2006 to review the efficacy of embolisation in the treatment of AMLs. RESULTS: There were six patients in total (n = 6). One patient (16%) had a background of tuberous sclerosis. Half of the patients presented acutely with bleeding and abdominal pain (50%) while the other half were found incidentally. There were no mortalities overall and three patients (50%) developed post embolisation syndrome. Five patients (83%) had a good response to embolisation with no further growth or regression of the AML. CONCLUSION: Embolisation is a safe and effective method for treating patients with AML.

Emergency percutaneous transcatheter embolisation of acute arterial haemorrhage.

AIMS: The purpose of this study was to review indications, source of haemorrhage, method of embolisation and clinical outcome in patients referred to Interventional Radiology for the emergency management of acute arterial haemorrhage. METHODS: Retrospective review of patients undergoing emergency percutaneous embolisation over 4 years. Clinical details, computed tomographic findings, embolisation procedure details and clinical outcome are outlined. RESULTS: Patients (n = 41) were included with various clinical indications for embolisation [haemoptysis (n = 8), iatrogenic (n = 7), traumatic pseudoaneurysm (n = 3), retroperitoneal bleed (n = 3), GI bleed (n = 6), splenic rupture (n = 1), renal laceration (n = 1), epistaxis (n = 12)]. Embolisation material consisted of coils, embospheres, glue, and covered stents. Technical success was achieved in 100% of cases. One patient died 2 days after embolisation secondary to myocardial infarction. CONCLUSION: Emergency arterial embolisation is a potentially life-saving treatment. Although it is technically challenging, indications are becoming increasingly varied and outcomes are more successful because of the availability of microcatheters and effective embolisation materials.

Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms.

Arterial wall disruption, as a consequence of inflammation/infection, trauma (penetrating or blunt), or iatrogenic causes, may result in pseudoaneurysm formation. Currently, iatrogenic causes are increasing as a result of the growth of endovascular intervention. The frequency of other causes also seems to be increasing, but this may simply be the result of increased diagnosis by better imaging techniques, such as multidetector contrast-enhanced computed tomography. Clinically, pseudoaneurysms may be silent, may present with local or systemic signs, or can rupture with catastrophic consequences. Open surgical repair, previously the mainstay of treatment, has largely been replaced by image-guided occlusion methods. On the basis of an experience of over 100 pseudoaneurysms, treatments at various anatomical sites, imaging modalities used for accurate diagnosis, current changing therapeutic options for pseudoaneurysm management, approved embolization agents, and clinical follow-up requirements to ensure adequate treatment will be discussed. Image-guided direct percutaneous and endovascular embolization of pseudoaneurysms are established treatment options with favorable success rates and minimal morbidity. The pendulum has now swung from invasive surgical repair of pseudoaneurysms to that of image-guided interventional radiology.

Outcome and complications of bronchial artery embolisation for life-threatening haemoptysis.

BACKGROUND: Bronchial artery embolisation (BAE) has been established as an effective technique in the emergency treatment of life-threatening haemoptysis. However, few data concerning outcome are available. AIMS: To evaluate the short-term and long-term results of BAE in patients treated for life-threatening haemoptysis. METHODS: A retrospective analysis of eight patients with life-threatening haemoptysis treated with BAE. RESULTS: BAE resulted in an immediate cessation of haemoptysis in 7 (88%) patients. Long-term control of bleeding was achieved in five of these patients. Rebleeding occurred within 24 h in one patient, and two patients had recurrence of haemoptysis at 6 months and 1 year, respectively. In these three patients, repeat embolisation succeeded in the immediate control of haemoptysis, and no rebleeding was reported at 1-year follow-up. CONCLUSIONS: BAE is an effective procedure with which to stabilize patients with massive haemoptysis in the acute phase, and to definitively treat some patients in the longer term.

Optional inferior vena caval filters: where are we now?

With the advent of newer optional/retrievable inferior vena caval filters, there has been a rise in the number of filters inserted globally. This review article examines the currently available approved optional filter models, outlines the clinical indications for filter insertion and examines the expanding indications. Additionally, the available evidence behind the use of optional filters is reviewed, the issue of anticoagulation is discussed and possible future filter developments are considered.

Efficacy and safety of the angioseal vascular closure device post antegrade puncture.

In this study, the efficacy and safety of the Angioseal vascular closure device post antegrade puncture of the common femoral artery (CFA) for lower limb vascular interventional procedures are evaluated. A retrospective analysis of the medical records of 60 consecutive patients who were referred for interventional procedures in the superficial femoral artery (SFA) or popliteal artery (popl. art.) was performed. Antegrade puncture was successfully performed in 58 of 60 patients (96.6%). Indications included right SFA angioplasty (n = 35), left SFA angioplasty (n = 17), right popl. art. angioplasty (n = 5), and left popl. art. angioplasty (n = 1). Hemostasis was achieved by, on an intention-to-treat basis, the Angioseal vascular closure device in 46 patients and manual compression in 12 patients. Manual compression was used instead of Angioseal because of severe calcified arterial wall plaques (n = 7), failed deployment of the Angioseal (n = 4), and left SFA dissection (n = 1). There were no major recorded complications in the Angioseal group despite the use of antiplatelet or anticoagulant medications. Twenty-three (50%) of the patients in the Angioseal group were discharged within 24 h. Thirty-seven of the 46 patients who received an Angioseal device had undergone a previous ipsilateral CFA puncture (time range, 2 days to 56 months; mean, 6.2 months). Nine of these patients had undergone ipsilateral Angioseal deployment in the previous 3 months. We conclude that the Angioseal vascular closure device is a safe and efficient means of achieving hemostasis post antegrade puncture.

Empyema and effusion: outcome of image-guided small-bore catheter drainage.

Empyema and complicated pleural effusion represent common medical problems. Current treatment options are multiple. The purpose of this study was to access the outcome of image-guided, small-bore catheter drainage of empyema and effusion. We evaluated 93 small-bore catheters in 82 patients with pleural effusion (n = 30) or empyema (n = 52), over a 2-year period. Image guidance was with ultrasound (US; n = 56) and CT (n = 37). All patients were followed clinically, with catheter dwell times, catheter outcome, pleural fluid outcome, reinsertion rates, and need for urokinase or surgery recorded. Ninety-three small-bore chest drains (mean=10.2 Fr; range, 8.2-12.2 Fr) were inserted, with an average dwell time of 7.81 days for empyemas and 7.14 days for effusions (p > 0.05). Elective removal rates (73% empyema vs 86% effusions) and dislodgement rates (12% empyema vs 13% effusions) were similar for both groups. Eight percent of catheters became blocked and 17% necessitated reinsertion in empyemas, with no catheters blocked or requiring reinsertion in effusions (p < 0.05). Thirty-two patients (51%) required urokinase in the empyema group, versus 2 patients (6%) in the effusion group (p < 0.05). All treatment failures, requiring surgery, occurred in the empyema group (19%; n = 12; p < 0.05). In conclusion, noninfected pleural collections are adequately treated with small-bore catheters, however, empyemas have a failure rate of 19%. The threshold for using urokinase and larger-bore catheters should be low in empyema.

Rasmussen's aneurysm: a forgotten entity?

We present the case of a rare entity which is a complication of a disease process that had almost disappeared from the Western World. With the recent resurgence in reported cases of Mycobacterium tuberculosis (TB) in Western communities, it is important to recognize complications and sequelae. A young alcoholic male with confirmed active TB suffered a cardiac arrest following massive haemoptysis. Multidetector computed tomography angiography diagnosed a Rasmussen's aneurysm, confirmed by digital subtraction angiography and then successfully embolized with glue. We outline this rare case and the embolization technique and review previously documented reports.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization.

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Do AshSplit haemodialysis catheters provide better flow rates in the long term?

BACKGROUND: Recently, interventional radiologists have adopted an increasingly prominent role in the placement and management of hemodialysis catheters, as well as in the research and development of new and better catheters. The purpose of this study was to evaluate the viability and hemodialysis efficiency of the AshSplit catheter and the Permcath catheter. METHODS: 204 consecutive patients requiring radiological insertion of hemodialysis catheters were followed, retrospectively, over a 42-month period. Both hemodialysis catheters were placed using a combination of ultrasonic and fluoroscopic guidance and tunneled appropriately. Information collected included catheter insertion sites, insertion complications, catheter duration, and final outcome. RESULTS: Over the study period of two years, 269 catheters were placed into 204 patients with end stage renal failure. Patients received either an AshSplit (101 patients, 127 catheters) or a Permcath (103 patients, 142 catheters). Vascular access route of choice was the right internal jugular vein (67% AshSplit, 71% Permcath). Insertion complications occurred in 18 patients overall (6.6%), with only 1 requiring further intervention (hemopneumothorax). Flow rates averaged 259 mls/min for AshSplits and 248 mls/min for Permcaths (p < 0.001). Follow-up of catheter viability for 42 months yielded a mean AshSplit catheter duration of 246 days (range 6-932) and 239 days (range 1-1,278) for Permcath (p = 0.46). Reasons for catheter failure and elective catheter removal were similar in both groups; however, Permcaths required significantly more thrombolysis than AshSplits, p < 0.001. CONCLUSION: The AshSplit provides significantly better flow rates and less thrombolysis compared to the Permcath, with similar catheter dwell times.

Crossing ureteric strictures: microcatheters to the rescue when conventional methods fail.

Tight distal ureteric strictures can be most challenging to traverse both from above, by interventional radiologists, and below, by urologists. Despite the advent of numerous guidewires, manufactured from different materials, often ureteric strictures are too tight to allow conventional guidewires to pass through. We describe an alternative approach to cross tight ureteric strictures, using a microguidewire and microcatheter combination.

Combined terminal ileoscopy and biopsy is superior to small bowel follow-through in detecting terminal ileal pathology.

BACKGROUND: Several studies have compared small bowel barium examination with ileoscopy in assessment of terminal ileal disease. Some suggest that ileoscopy is superior in detection of terminal ileal disease whereas others suggest similar disease detection rates for both techniques. AIMS: The aim of this retrospective study was to determine if small bowel follow-through and ileoscopy with terminal ileum biopsy compare favourably at detecting pathology in the terminal ileum. PATIENTS AND METHODS: All colonoscopies with terminal ileoscopy performed over a 16-month period were reviewed. We determined which of these patients had also had small bowel follow-through studies within 2 weeks of colonoscopy. We compared the diagnoses of terminal ileum pathology using ileoscopy with terminal ileal biopsy versus small bowel follow-through. RESULTS: Forty-six patients had both terminal ileoscopy with biopsy and small bowel follow-through. In 19 patients, the terminal ileum was abnormal at ileoscopy and/or biopsy but normal at small bowel follow-through. In 27 patients, terminal ileum findings at small bowel follow-through and at ileoscopy and/or biopsy were compatible. CONCLUSIONS: This study suggests that examination of the terminal ileum by combined ileoscopy and biopsy may be superior to small bowel follow-through at detecting terminal ileal pathology. In our series, many patients received effective treatment that otherwise would not have been offered based on the small bowel follow-through results alone. Using combined ileoscopy and biopsy, microscopic inflammatory changes, otherwise missed without biopsy, can be detected. Retrograde ileoscopy is recommended in patients with a clinical history of organic diarrhoea and/or abdominal pain even in the presence of a normal small bowel follow-through.