Emergency arterial embolization of upper gastrointestinal and jejunal tumors: An analysis of 12 patients with severe bleeding.

PURPOSE: The goal of this study was to retrospectively assess the efficacy of emergency percutaneous transcatheter arterial embolization in patients with severe bleeding due to upper gastrointestinal or jejunal tumor. MATERIALS AND METHODS: Twelve patients (7 men, 5 women; mean age, 74 years±14 (SD); range: 54-86 years) with severe bleeding from the upper gastrointestinal tract, with failed endoscopic treatment not eligible for emergency surgery were treated by emergency percutaneous transcatheter arterial embolization. The bleeding cause was gastric tumor in 7 patients, duodenal tumor in 4 patients and jejunal tumor in one patient. Procedure details and follow-up were reviewed. RESULTS: Twelve embolization procedures were performed using various embolic agents. Embolization was achieved and bleeding was stopped in all patients. Five patients underwent surgery within the 30 days following embolization. In the remaining 7 patients, no bleeding occurred at 1 month follow-up in 6 patients and bleeding recurred in one patient at 1 month. In this later patient, endoscopic treatment was successful. CONCLUSION: The results of our study suggest that transcatheter arterial embolization is safe and effective in patients with severe arterial bleeding due to upper gastrointestinal or jejunal tumor. In some patients, transcatheter arterial embolization can be used as a bridge to surgery.

Arteriovenous fistulas induced by femoral arterial catheterization: percutaneous treatment.

PURPOSE: To evaluate the use of stent-grafts for the percutaneous closure of arteriovenous fistulas that develop after cardiac catheterization. MATERIALS AND METHODS: From January 1994 to November 1997, 14 arteriovenous fistulas in 13 patients (eight men, five women; age range, 46-65 years; mean age, 53.5 years) were treated. Eleven fistulas were situated between the deep femoral artery and the common femoral vein, and three fistulas were between the superficial femoral artery and the common femoral vein. All fistulas were closed with stent-grafts positioned in the artery at the level of the fistula. RESULTS: The percutaneous treatment of arteriovenous fistulas was successful in all cases. The findings at angiography performed after the procedure demonstrated the closure of the fistulas and the correct positioning of the prostheses; veins were no longer visible. One complication occurred--a partial thrombosis of the common femoral vein at the puncture site after manual compression. CONCLUSION: On the basis of the preliminary data, the authors believe that the percutaneous closure of arteriovenous fistulas with stent-grafts is a safe and effective alternative to conventional surgery.

Percutaneous endoluminal bypass of iliac aneurysms with a covered stent.

To evaluate the feasibility of percutaneous treatment of iliac aneurysms, a covered stent was inserted in nine men suffering from common iliac artery aneurysms (six cases), external iliac aneurysms (one case), or pseudoaneurysms (two cases). Placement of the stent was successful in all patients. In one patient, an endoprosthesis thrombosed after 15 days, but was successfully treated by thrombolysis and additional stent placement. At the follow-up examinations (mean period 22 months) all stent-grafts had remained patent. No late leakage or stenosis was observed.

Feasibility of intraoperative balloon angioplasty and additional stent placement of isolated stenosis of the brachiocephalic trunk.

OBJECTIVE: We sought to evaluate the feasibility and results of intraoperative balloon angioplasty and additional stent placement of isolated stenosis of the brachiocephalic trunk. PATIENTS AND METHODS: Between May 1993 and October 1996, we treated eight patients with local stenosis of the innominate artery. Seven lesions were situated in the proximal and one in the middle third of the brachiocephalic trunk. Five patients were men and three were women, with ages ranging from 55 to 72 years (mean 59.5 years). All stenoses provoked severe blood flow reduction and caused clinical symptoms. Procedures were performed in an operating suite with fluoroscopic imaging capabilities. Through an anterolateral cervical approach the right common carotid artery was surgically exposed and then clamped to avoid atheroembolization during the subsequent procedure. Retrograde catheterization was performed to reach the stenosis of the brachiocephalic trunk. The lesion was dilated with a balloon catheter and successively stented. Follow-up examinations (color-coded duplex sonography, accompanied by clinical inspection and systolic blood pressure) were scheduled every 6 months. RESULTS: In all patients the dilation of the stenosis of the innominate artery and the stent placement were successful without any side effects. No embolic events or other complications occurred. The postintervention angiography showed successfully dilated stenoses and patent stents in all cases. The technical success rate was 100%. CONCLUSIONS: On the basis of our preliminary data, we believe that, in selected patients, intraoperative balloon angioplasty of stenosis of the innominate artery with stent placement from the right common carotid artery approach is a safe and effective alternative to conventional operations.

Exclusion of an internal carotid aneurysm by a covered stent.

The authors report a case of a patient with thromboembolic strokes caused by a high internal carotid artery aneurysm. Considering the position and the anatomic structure of this aneurysm the sac was excluded transluminally by placing an endovascular covered stent.

Combined surgical and endovascular treatment of a traumatic pseudo-aneurysm of the brachiocephalic trunk with anatomical anomaly.

The authors report a case of combined surgical and endovascular treatment of a traumatic pseudo-aneurysm of the innominate artery in which the left common carotid artery originated from the brachiocephalic trunk. After a conventional surgical intervention with the implantation of the left common artery on the left subclavian artery, to correct the anatomic anomaly, a safe and effective endovascular stent-graft placement excluded the aneurysm. This new technique proposes a good chance for polytraumatized patients to receive a better prognosis and a much faster rehabilitation.

[Percutaneous treatment of hilar cholangiocarcinoma completed by high-dose rate brachytherapy. Experience in the first 5 cases]. / Trattamento percutaneo del colangiocarcinoma ilare completato con brachiterapia con alto rateo di dose. Esperienza nei primi 5 casi.

Cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumor) is a slowly growing malignancy with early onset of symptoms and poor outcome since surgery allows radical resection in only a minority of cases. Percutaneously placed biliary stents offer a good palliation, but tend to obstruct after 6-8 months; then, retreatment requires exchange of the endoprosthesis or establishment of a permanent external-internal biliary drainage which offers, in some patients, a relatively long survival. Percutaneous intraluminal HDR brachytherapy might be a valid alternative as a definitive therapy or as a method to keep metallic stents patent for a long time. Five patients with hilar cholangiocarcinoma, diagnosed by means of ultrasound, Computed Tomography, percutaneous transhepatic cholangiography and transluminal biopsy, underwent double percutaneous external-internal biliary drainage. Dummy sources were introduced into the drainage catheters to allow dose distribution planning. The stepwise progression of the miniaturized high activity Iridium source inside the applicators, introduced into the drainage catheters, was controlled and monitored by a computer equipped with dedicated software. In the radiotherapy bunker, using the remote loading technique, percutaneous intracavitary high dose rate brachytherapy was delivered at the rate of 750 cGy per fraction, prescribed at 1 cm from the center of the catheter, once a week, for 4 weeks. Nevertheless, only 4 of 5 patients underwent the complete treatment. In one case, radiation treatment was discontinued after the first session because of digestive bleeding from a duodenal ulcer, supposingly as a consequence of the decubitus of a catheter tip. CT demonstrated rapid progression of the disease with neoplastic spread to the omentum and gallbladder wall thickening; a gallbladder malignancy was then suspected and the patient was no more eligibile for brachytherapy. Subsequently, Carey-Coons endoprostheses were inserted to prevent post-actinic strictures and removed after three months. After completing radiation therapy, control cholangiograms demonstrated in all cases improvement of neoplastic strictures. The first two patients we treated show no signs of tumor recurrence at 4 and 1 months, respectively, after endoscopic removal of the stents. The third patient is still bearing 2 Carey-Coons endoprostheses to be removed after 3 months. The last patient with supposingly partial success of bracytherapy, was treated with two Strecker nitinol stents.