The Endovascular Treatment of Epistaxis.

Epistaxis or nosebleed is relatively common in the general population. Depending on the location of the bleeding in the nasal cavity, epistaxis can be divided in two types: anterior or posterior type. The anterior type is far more frequent, often self-limiting and, if needed, is relatively easy treatable. Posterior type epistaxis is rare and more likely to require medical attention. The cornerstone of the conservative therapy of posterior epistaxis is nasal packing. Only in patients with persistent or recurrent epistaxis, endovascular intervention or surgery is indicated. Both treatment options have a similar success and complication rate, but endovascular treatment, if feasible, has several advantages above surgical treatment. The choice of procedure should be made on a patient-to-patient basis, taking several parameters into account. In this pictorial essay we present an overview of the relevant radiological anatomy and a review of various causes of epistaxis, with the emphasis on the endovascular treatment.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Spontaneous ilio-iliac arteriovenous fistula due to an iliac artery aneurysm: a case-report.

A spontaneous arterio-venous ilioiliac fistula (AVF) caused by an iliac artery aneurysm (IAA) is a rare complication. We present the case of a 75-year-old man with previous aortic surgery 11 years before who was admitted at the Emergency Department for acute gluteal pain. He was suspected for a hip problem because of cup loosening on X-ray. A lumbar CT-scan to rule out nerve compression showed an aneurysm of the left common and internal iliac artery that was ruptured into the iliac vein. The AVF was treated endovascularly under local anesthesia by a sandwich technique (covered stent at the venous side and coils at the arterial side) with good results. The case demonstrates that lifelong follow-up of a patient with previous aortic surgery is mandatory.

Post-traumatic hepatic arterial pseudoaneurysm and arterioportal shunt.

The authors report the case of a 21-year-old man who suffered from a blunt abdominal trauma. Initial imaging revealed a liver laceration at the right lobe, a perirenal hematoma of the right kidney and a hematoma of the right adrenal gland. Follow-up MDCT-scan on day 10 after admission showed at the arterial-phase contrast-enhanced study perfusion alterations and two hepatic pseudoaneurysms. The diagnosis of pseudoaneurysm was confirmed and treated angiographically with superselective coil embolization. A follow-up CT-scan on day 17 showed at a nontreated area an arterioportal shunt and a wedge-shaped transient hepatic parenchymal enhancement. This was confirmed angiographically and subsequently treated with coil embolization.

Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysms: an institutional experience.

OBJECTIVES: Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still under investigation. Since installation of an urgent eEVAR kit in our hospital, all patients with a rAAA or urgent thoracic aortic aneurysm are candidates for eEVAR or eTEVAR (emergency thoracic EVAR), respectively. For this study, we analyzed all rAAA patients treated with eEVAR. METHODS: Data were recorded prospectively. Criteria for an eEVAR were an infrarenal neck > or = 15 mm, acceptable landing zone, angles below 70 degrees and a good femoral approach. We prefer preoperative angio CT-scan but in case of instability, an intra-aortic balloon can stabilize the patient during angiography (in the OR) to decide between open or eEVAR repair. Follow-up was performed on regular intervals by duplex or CT-scan. Thirty-day mortality and overall survival were calculated. RESULTS: Since 2006, nine male rAAA patients with a mean age of 73 years (range : 62-82) had eEVAR repair. Aneurysm diameter was 8 cm (range : 5.8-11). The Hardman index was 1.5 (range : 0-3). In eight patients an aorto-uni-iliac device was placed succesfully followed by a femorofemoral crossover bypass. The 30-day operative mortality was 12.5% (one patient with septic shock). Three patients showed a type 2 endoleak with stable diameter during follow-up but one patient showed expansion 4 years after treatment. CONCLUSIONS: Treating rAAA with eEVAR in selected patients with acceptable anatomy and a kit permanently available in the operating room yielded good results by a surgical team trained for both open and eEVAR repair. The conversion rate was low (11%) and the survival (immediate and 30-days) was excellent (87.5%).

Spontaneous hepatic rupture in a normotensive monoamniotic twin pregnancy: case report and review of the literature.

BACKGROUND: Spontaneous liver rupture during pregnancy is extremely rare, and often associated with hypertensive disorders. Maternal outcomes are poor and morbidity is high. CASE: A 27-year-old women (G1P0), pregnant with monochorionic-monoamniotic twins, developed extensive abdominal pain while she was electively admitted at 32 weeks for fetal pulmonary maturation. Diagnosed with preterm labor, a caesarean section was performed. Postoperatively, our patient deteriorated and a second laparotomy revealed an extensive liver rupture. There was no evidence of hypertensive disorders or hepatic tumors. After perihepatic packing and embolization, our patient required long-term treatment in our intensive care unit. She survived, and both mother and children are healthy after 6 months. CONCLUSION: Despite being rare, spontaneous liver rupture in absence of hypertensive disorders during pregnancy is associated with high maternal morbidity and mortality. Adequate treatment requires a multidisciplinary approach.

Angiographic findings and therapeutic embolization of late hemarthrosis after total joint arthroplasty.

OBJECTIVE: The objective of this study was to describe the angiographic findings of late spontaneous hemarthrosis after total joint arthroplasty and to illustrate the therapeutic role of angiography. MATERIALS AND METHODS: A retrospective multicenter study was performed looking for patients who underwent an angiography for spontaneous hemarthrosis occurring at least 1 month after total joint arthroplasty. Eight patients were included, all suffering from spontaneous hemarthrosis. One patient had an additional large extra-articular hematoma. RESULTS: Angiography in eight cases revealed hypertrophic vascular synovium in seven patients with an additional false aneurysm in one patient. Hypervascularization with pooling of contrast spots was seen in one patient. Five patients underwent selective arterial particulate embolization. Three patients were successfully embolized after one session, one was successful after two sessions, and one patient needed surgery after two embolization sessions. CONCLUSION: Angiography for late spontaneous hemarthrosis is very effective to exclude or establish vascular malformations and to establish the diagnosis of hypertrophic vascular synovium. Selective arterial embolization seems to be a good therapeutic option as alternative to open or arthroscopic synovectomy.

Spontaneous pseudo-aneurysm of the deep femoral artery treated by a covered stent.

PURPOSE: To present the management of a spontaneous pseudo-aneurysm of the deep femoral artery by an endovascular technique. CASE REPORT: An 82-year-old man presented with a painless pulsating mass at the level of the upper right thigh without any previous history of trauma, surgery or puncture of the femoral artery. The mass proved to be a pseudo-aneurysm of the deep femoral artery. Thrombin injection with simultaneous balloon inflation at the neck of the aneurysm did not result in a long-lasting thrombosis. Since both general and epidural anaesthesia were absolutely contra-indicated, and because of severe stenotic lesions of the femoro-popliteal axis, we chose to exclude this aneurysm under local anaesthesia with a balloon-expandable covered Jo-stent in order to maintain patency of the deep femoral artery. Twenty months postoperatively, the aneurysm is still thrombosed while the patency of both the superficial and deep femoral artery is preserved. CONCLUSIONS: This case demonstrates that an endovascular approach can be an excellent treatment for aneurysms of the deep femoral artery, thereby avoiding an open surgical procedure while preserving the patency of the deep femoral artery.

Long-term results of primary stenting for long and complex iliac artery occlusions.

OBJECTIVES: To evaluate the long-term results of recanalization with primary stenting for long and complex iliac artery occlusions. DESIGN: Retrospective non-randomized study. METHODS: Between 1996 and 2004, 38 patients underwent recanalization of an occluded iliac artery with subsequent stenting for TASC B lesions in 12 patients, TASC C in 10 and TASC D in 16. Thirty-one patients had Fontaine stage 2 B, four patients had stage 3 and one patient had stage 4. Two patients (5.4%) presented with acute ischemia and received trombolysis before recanalization. Patency results were calculated using Kaplan and Meier analysis. The mean follow-up was 26 months. RESULTS: Technical success was 97.4%. Thirty-day mortality was 2.7%. The primary patency rate was 94%, 89% and 77% at 1, 3 and 5 years respectively. Three re-occlusions (8.1%) and one restenosis (2.7%) were observed during follow-up. The secondary patency (SP) rate was 100%, 94% and 94% after 1, 2 and 3 years. Fifteen patients underwent an associated procedure. A kissing stent procedure in three patients, a contralateral PTA of an iliac stenosis in 8, a femoro-femoral bypass in 2, a femoropopliteal bypass in 1 and an femoral endarterectomy in 2. The procedure related complication rate was 5.4%. CONCLUSION: Long-term results of iliac recanalization are excellent without major complications if the procedure is technically successful. The endovascular procedure can be an alternative to an iliofemoral or aortobifemoral bypass in a high risk population.

The pelvic congestion syndrome: role of the "nutcracker phenomenon" and results of endovascular treatment.

PURPOSE: Pelvic Congestion Syndrome (PCS) is a less known pathologic condition in multiparous women. The major symptoms are: low abdominal pain, dyspareunia or postcoital ache, gluteal or thigh varices, and emotional disturbances. The purpose of this retrospective study is to evaluate the pathogenesis, diagnosis and immediate, and long-term clinical results of the endovascular treatment of PCS. METHODS AND MATERIALS: From February 1992 until January 2000, 67 diagnostic ovarian vein phlebographies followed by transcatheter embolization were performed in 66 patients with pelvic varicosities. These patients were traced back and submitted to a standardized questionnaire. The data of 48 patients was obtained this way. RESULTS: In 83%, extrinsic compression of the left renal vein between the aorta and the superior mesenteric artery--known as the "nutcracker phenomenon"--was observed together with congestion of the left ovarian vein and pelvic varicosities. The technical success rate of endovascular embolization was 96%. The initial clinical success rate was 86%, with a long-term benefit for 75% of the patients. After embolization there was a reduction in pain intensity, pain attacks, and emotional disturbances. Globally there was a mean reduction of complaints of 73% (Visual Analog Scale). CONCLUSION: The "nutcracker phenomenon" was detected in most of the treated patients and could explain the congestion of the left ovarian vein. Transcatheter embolotherapy is an effective way of treating pelvic varicosities, resulting in a great improvement of the quality of life for most of the patients. In experienced hands the procedure is relatively simple, and it is well tolerated. Moreover it can be performed in one step with the diagnostic phlebographic procedure.

Asymptomatic aneurysm of the hepatic artery. Management options.

Hepatic aneurysms are rare. The majority of patients present acutely with aneurysm rupture, with an attended high mortality. Diagnosis is difficult and often delayed, owing to the non-specific symptoms and lack of clinical findings. We present three cases of hepatic artery aneurysm diagnosed in a pauci- or asymptomatic stage, illustrating the different therapeutic options described when these aneurysms are diagnosed in this stage: expectant management, embolization, or surgery.

Insulinoma associated with liver lesions: value of MR imaging.

We report on a middle-aged woman who presented with clinical and biochemical findings of insulinoma. Preoperative evaluation by ultrasound, CT, and angiography located the pancreatic lesion but also revealed two focal liver lesions. The latter were interpreted as metastases. MR imaging with injection of superparamagnetic iron oxide particles not only localized the insulinoma but proved to be the only noninvasive technique capable to exclude presence of liver metastases preoperatively. This reversed management to minimal laparoscopic surgery. Recent literature of preoperative imaging evaluation of insulinoma and focal liver lesions is discussed.

Imaging of primary tumors and tumor-like conditions of the lumbosacral osseous spine.

Primary tumors of the osseous spine are rare. This article illustrates some aspects of imaging of tumoral pathology of the osseous spine. Plain film and CT scan still remain the initial imaging modalities in the work-up of tumoral pathology of the osseous spine. MR imaging however has proven its potentials in the detection of lesions in areas with superimposing structures which hamper reliable reading of the plain films or in areas with a complex bony anatomy such as the sacrum. MR imaging is exquisite in determining the local extent of tumoral lesions and in defining the relationship to adjacent central nervous system structures. In some tumors or tumor-like lesions, MR imaging allows to make a correct tissue-related diagnosis or to strengthen the diagnosis made on plain film/CT observations. In other case MR imaging only has a role in staging or may have definitely no role at all.

Traumatic type B aortic dissection.

A 37-year-old man was referred with thoracic pain after a deceleration trauma. He also had a cerebral contusion and a wrist fracture. There were no sings of hypovolemic shock. Computerized tomography (CT) of the chest and transoesophageal echocardiography (TEE) demonstrated a type B aortic dissection originating just distal to the left subclavian artery. There was a patent false lumen without rupture or distal ischaemia. Conservative treatment was given. A paralytic ileus developed and abdominal complaints persisted for several months. Angiography showed normal patency of mesenteric vessels. On follow-up, 3 years after the accident a slight aortic dilation was found on CT thorax without development of a post-dissection aneurysm. Blunt thoracic injury to the aorta usually gives rise to aortic rupture in the region of the isthmus, which can be complete or partial. In the latter case a false aneurysm may develop. An intimal tear after blunt trauma leading to type B aortic dissection rarely occurs. General principles regarding treatment of type B dissection also apply to this particular condition.