Preoperative embolisation of renal cell carcinoma metastases to the spine - evaluation of procedural and clinical outcome.

Purpose: Renal cell carcinoma (RCC) is the fourth most common metastatic tumour of the spine. RCC metastases are highly vascular and might cause life-threatening intraoperative bleeding. That is why preoperative embolisation is performed to reduce intraoperative blood loss. The aim of this study was to evaluate the procedural and clinical outcomes of preoperative embolisation of RCC metastases to the vertebral column. Material and methods: In this single-centre retrospective study, data of 59 consecutive patients undergoing endovascular treatment prior to surgical resection were collected and evaluated. In all cases superselective catheterisation and occlusion of feeding vessels was attempted and performed if deemed safe and possible. Completeness of embolisation, procedural details, and the complication rate were evaluated. Surgical procedures were carried out within 48 hours after embolisation. The surgical approach was dependent on the anatomical site and osseous destruction. Intraoperative blood loss was estimated. Results: Fifty-nine patients with a mean age of 63 years were included. Complete embolisation was successful in 76% (45/59) and partial in 15% (9/59). Microspheres were the most commonly used embolic material. In 5 cases (8%) safe occlusion was not possible due to the radiculomedullary artery originating from the same pedicle as the tumour. Minor complications (vomiting, increased pain) occurred in 8 patients. Paraplegia (one transient and one permanent) was noted in 2 cases. Estimated intraoperative blood loss was 830 ± 410 ml. Conclusions: The results of our study show that preoperative embolisation is a feasible and effective method with a relatively high rate of occlusion and low complication rate.

Pelvic AVM Embolization: A Tricky Affair-Multicenter Retrospective Experience.

PURPOSE: Pelvic arteriovenous malformations (pAVMs) are congenital or acquired vascular anomalies, presenting with hematuria, menometrorrhagia, pelvic pain, and varices; they can be life-threatening in case of rupture. Surgical therapies have been proposed but endovascular embolization has been recognized as the primary modality. The aim of this article was to report a retrospective multicenter experience concerning embolization of pelvic AVMs and provide literature overview. MATERIALS AND METHODS: We describe 18 patients (14 female and 4 male) diagnosed with pAVM and treated with minimally invasive methods. The pre-procedural imaging evaluation was based on transpelvic and/or transvaginal color Doppler ultrasound, contrast-enhanced computed tomography, and/or magnetic resonance. In 3 cases, the malformation was congenital and in other 15, acquired. Most common symptoms were menometrorrhagia, hematuria, pelvic pain and pressure, and heaviness in the lower abdominal region. In 10 cases (56%), only 1 procedure was required. Eight patients underwent multistage treatment. RESULTS: Complete occlusion of the lesion in post-procedural angiography was observed in 12 patients (67%). No major periprocedural complications were observed. In 14 cases (78%), both satisfactory embolization and significant clinical improvement was achieved in long-term follow-up. Sixteen patients (88%) were at least satisfied with the clinical outcome. One patient reported subsequent successful pregnancy 5 years after the treatment. CONCLUSION: Hemodynamics of pAVM are variable and thorough understanding of the vessel anatomy is crucial in planning and choosing proper treatment. Both transarterial and percutaneous direct puncture embolization strategies appear safe, technically feasible, and clinically effective. CLINICAL IMPACT: In this manuscript, we discuss the role of interventional radiology methods in the treatment of pelvic arteriovenous malformations along with its advantages, limitations and possible complications. In addition to this, we review the current literature and confront our findings with those made by other authors. We believe that modern endovascular methods offer safe and reliable alternative for traditional surgical therapy and should be therefore considered during multidisciplinary treatment of these patients.

Contrast-Enhanced Ultrasound Feasibility in Assessing Carotid Plaque Vulnerability-Narrative Review.

The risk assessment for carotid atherosclerotic lesions involves not only determining the degree of stenosis but also plaque morphology and its composition. Recently, carotid contrast-enhanced ultrasound (CEUS) has gained importance for evaluating vulnerable plaques. This review explores CEUS's utility in detecting carotid plaque surface irregularities and ulcerations as well as intraplaque neovascularization and its alignment with histology. Initial indications suggest that CEUS might have the potential to anticipate cerebrovascular incidents. Nevertheless, there is a need for extensive, multicenter prospective studies that explore the relationships between CEUS observations and patient clinical outcomes in cases of carotid atherosclerotic disease.

Endovascular embolisation as minimally-invasive treatment for spinal dural arteriovenous fistulas - evaluation of long-term results.

AIM OF STUDY: Spinal dural arteriovenous fistulas (sDAVF) are rare spinal cord lesions formed between a radicular artery and medullary vein leading to venous hypertension resulting in neurological impairment. Endovascular embolisation is a minimally-invasive method aiming to interrupt the shunt between the artery and vein. We report our experience with sDAVF treated endovascularly. MATERIAL AND METHODS: Clinical and procedural data of 16 consecutive patients diagnosed with sDAVF was reviewed. Pre- and post-operative neurological condition was evaluated using both the Aminoff and Logue disability scale and the VAS scale. Rates of complete occlusions, technical difficulties, and procedural complications were noted. RESULTS: Four of the patients were female and 12 were male; mean age was 62.4 years. Mean interval between symptom onset and treatment was 13.3 months. Complete occlusion was achieved in 88% (14/16 patients). Significant or moderate clinical improvement in long-term follow-up was observed in eight patients (50%). Recurrence was observed in two cases (13%). CONCLUSIONS AND CLINICAL IMPLICATIONS: While endovascular methods are being refined and thus achieving an increasing percentage of successful occlusions, patients should be closely monitored since this condition is recurrent and the clinical consequences of myelopathy can persist despite complete occlusion of the shunt.

The role of interventional radiology in treatment of patients with hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu disease is a rare autosomal dominant, multi-organ disorder that leads to formation of abnormal vascular connections resulting in devastating and life-threatening complications. Due to its multisystem character, wide range of clinical manifestations and variable expressivity, HHT remains a diagnostic challenge and requires close cooperation of specialists from various medical fields. Interventional radiology plays a key role in the management of this disease, helping maintain the health of HHT patients and minimize the risk of fatal complications. The aim of this article is to review clinical manifestations, diagnostic guidelines and criteria of HHT as well as to present the means of endovascular therapy in the management of HHT patients.

Unilateral Uterine Artery Embolization as a Treatment for Patients with Symptomatic Fibroids-Experience in a Case Series.

Background and Objectives: Uterine artery embolization (UAE) has become an accepted and widely performed therapy for patients with symptomatic (reporting at least two of the following symptoms: severe or prolonged menstrual bleeding, abdominal pain, tension in abdomen, problems with urination, constipation or anemia) uterine fibroids. Although in the majority of cases, bilateral occlusion is required to obtain a successful clinical outcome, there are patients in whom treatment of only one uterine artery could be attempted. There are several reasons for unilateral UAE: hemodynamic conditions, technical difficulties, anatomical variants and unilateral dominancy of blood supply to the fibroid. Our aim is to present our 10-year experience with unilateral UAE and evaluate the radiological and clinical outcomes. Materials and Methods: Records of 369 patients with fibroids who underwent UAE from 2010 to 2021 were analyzed. We identified 26 patients treated with unilateral uterine artery embolization and analyzed the data of these patients. All patients attended medical consultation, were assessed using a five-grade symptom scale and underwent MRI examination. Clinical response was evaluated at least 6 months after the procedure and was categorized to one of the following groups: complete improvement, partial improvement, no change and a worsening in symptoms. Results: Twenty-two patients (85%) reported at least partial improvement 6 months following the procedure. One patient required secondary embolization due to recanalization. The secondary procedure was successful, and complete improvement was achieved. One patient did not observe any clinical improvement, and in two cases, symptom recurrence was observed. All three patients were referred for surgical treatment. No major complications were noted. Overall, the success rate was 88%. Conclusions: The results of our study support the statement that elective unilateral embolization is an appropriate treatment in patients with a dominant uterine artery.

Ischemic and Hemorrhagic Cerebrovascular Events Related to COVID-19 Coagulopathy and Hypoxemia.

Since the very beginning of the COVID-19 pandemic, numerous researchers have made an effort to determine the molecular composition of the SARS-CoV-2 virus, and the exact pathomechanism through which the virus exerts such a devastating effect on the host/infected organism. Recent scientific evidence highlights the affinity of the virus towards ACE2 receptors, which are widespread in multiple human systems, including the central nervous system (CNS) and cerebral vessels. Such an affinity may explain endothelial dysfunction and damage that is observed in COVID-positive patients in histopathological studies, with subsequent dysregulation of the cerebral circulation leading to transient or acute cerebrovascular accidents. In this paper, we aimed to evaluate the effects of COVID-related hypoxemia and direct viral invasion on the cerebral circulation, with special respect to the postulated pathomechanism, vulnerable groups of patients, clinical course and outcomes, as well as diagnostic imaging findings.

Uretero-vaginal fistulas - clinical presentation, treatment and literature overview.

A uretero-vaginal fistula (UVF) describes an abnormal connection between the ureter and vagina causing urinary incontinence, frequent infection, and discomfort. Although UVF might be diagnosed after vaginal delivery, infertility treatment or pelvic radiation therapy, gynecological operations, especially total abdominal hysterectomy, remain the leading cause of ureteral injury and formation of UVF. Traditional ureteroneocystostomy was usually the treatment of choice in patients with UVF. Nevertheless, it is now frequently replaced by less invasive endoscopic and percutaneous procedures which are also highly effective and feasible. That is why, ureteral stenting became the first-line treatment in uncomplicated UVF. The aim of this review is to present clinical presentation of UVF and to assess the current state of knowledge about the diagnosis and management of uretero-vaginal fistula with special interest on minimally-invasive methods.

Maternal and perinatal outcomes in placenta accreta spectrum disorders with prophylactic internal iliac artery balloon catheterization and embolization.

OBJECTIVES: To summarize our five-year experience with managing patients diagnosed with wide range of PAS disorder and treated with prophylactic internal iliac balloon implantation prior to cesarean section and to assess maternal and fetal outcomes. MATERIAL AND METHODS: Retrospective cohort study. RESULTS: A total of 30 patients were included in the study. Hysterectomy was performed in 10 cases - partial hysterectomy in six and total hysterectomy in four. Median estimated blood loss was 1.18 L. In two cases technical complications were noted. In one case bilateral internal iliac artery thrombosis requiring urgent surgical intervention occurred. A total of 30 live infants were delivered. Mean birth weight was 2435 g and mean Apgar score at 1', 5' and 10' minutes was 6.8, 8 and 8.7 respectively. After average 30 days of hospitalization all infants and their mothers were discharged in good clinical condition. CONCLUSIONS: Placenta accreta spectrum remains a challenge for obstetricians and gynecologists and despite interdisciplinary approach is associated with numerous complications with life-threatening postpartum hemorrhage being the most serious one. Prophylactic placement of iliac balloons is a minimally invasive and safe endovascular technique which allows rapid and effective control of postpartum bleeding in patients with PAS, with low complication rate for both mother and the child.

Endovascular Treatment of Acute Ischemic Stroke With the Penumbra System in Routine Practice: COMPLETE Registry Results.

BACKGROUND AND PURPOSE: The purpose of the COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device) registry was to evaluate the generalizability of the safety and efficacy of the Penumbra System (Penumbra, Inc, Alameda) in a real-world setting. METHODS: COMPLETE was a global, prospective, postmarket, multicenter registry. Patients with large vessel occlusion-acute ischemic stroke who underwent mechanical thrombectomy using the Penumbra System with or without the 3D Revascularization Device as frontline approach were enrolled at 42 centers (29 United States, 13 Europe) from July 2018 to October 2019. Primary efficacy end points were successful postprocedure angiographic revascularization (modified Thrombolysis in Cerebral Infarction ≥2b) and 90-day functional outcome (modified Rankin Scale score 0-2). The primary safety end point was 90-day all-cause mortality. An imaging core lab determined modified Thrombolysis in Cerebral Infarction scores, Alberta Stroke Program Early CT Scores, clot location, and occurrence of intracranial hemorrhage at 24 hours. Independent medical reviewers adjudicated safety end points. RESULTS: Six hundred fifty patients were enrolled (median age 70 years, 54.0% female, 49.2% given intravenous recombinant tissue-type plasminogen activator before thrombectomy). Rate of modified Thrombolysis in Cerebral Infarction 2b to 3 postprocedure was 87.8% (95% CI, 85.3%-90.4%). First pass and postprocedure rates of modified Thrombolysis in Cerebral Infarction 2c to 3 were 41.5% and 66.2%, respectively. At 90 days, 55.8% (95% CI, 51.9%-59.7%) had modified Rankin Scale score 0 to 2, and all-cause mortality was 15.5% (95% CI, 12.8%-18.3%). CONCLUSIONS: Using Penumbra System for frontline mechanical thrombectomy treatment of patients with large vessel occlusion-acute ischemic stroke in a real-world setting was associated with angiographic, clinical, and safety outcomes that were comparable to prior randomized clinical trials with stringent site and operator selection criteria. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03464565.

Endovascular embolization as a treatment for symptomatic adenomyosis - results of preliminary study.

OBJECTIVES: To present preliminary results of minimally invasive endovascular embolization as a treatment of symptomatic adenomyosis or adenomyosis with fibroids and to assess the long-term clinical outcome. MATERIAL AND METHODS: Between 2015 and 2020 twelve patients with symptomatic adenomyosis or adenomyosis with fibroids underwent uterine artery embolization (UAE). All patients were evaluated in terms of patient's overall satisfaction, relief of clinical symptoms, reintervention and hysterectomy as well as menopause rates. RESULTS: Mean age on admission was 48 years. Reported symptoms included: dysmenorrhea with the mean VAS score of 7.8, menorrhagia and problems with urination. Successful embolization was achieved in all patients (100%). A reduction in pelvic pain intensity assessed using VAS was observed in 11/12 (92%) of the patients - pain decreased by 6.2 points on average (from 7.8 to 1.6 pts). In one patient (8%) the recurrence of pain was observed. All patients reported decrease of menstrual bleeding and consequently improvement of everyday life quality. Avoidance of hysterectomy was achieved in 83% of the women. Five patients experience absence of menstrual periods for at least 12 months after the embolization resulting in menopause rate of 42%. Ten patients (83%) reported to be very or fairly satisfied with the results and would recommend this treatment to a friend. CONCLUSIONS: Uterine artery embolization might be safe and effective method of treatment for patients with symptomatic adenomyosis with or without fibroids with very high rate of satisfied patients.

Predictors of favorable outcome after endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion in young patients.

BACKGROUND: Mechanical thrombectomy (MT) became a standard of care for patients with acute ischemic stroke (AIS) with its efficacy demonstrated by meta-analysis and randomized studies. Although ischemic stroke is associated more with older patients, it may also have devastating neurological effects on young patients. PURPOSE: To present our experience with stroke patients aged <50 years treated with endovascular means and to evaluate clinical and procedural factors associated with outcome and mortality. MATERIAL AND METHODS: This study was conducted on 34 young stroke patients treated with MT. Clinical features including baseline results, radiological imaging, procedural details, and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated after three months using mRS. Mortality rate was calculated. RESULTS: The rate of successful recanalization (TICI ≥2c) was 79% (27/34). Symptomatic intracranial hemorrhage (sICH) was observed in 5 (15%) patients. After 90 days, the mortality rate was 12%. Favorable clinical outcome (mRs 0-2) was regained in 65% of the patients whereas satisfactory clinical outcome was seen in 85%. Poor clinical outcome (mRs >2) was observed in 9 (23.7%) patients. CONCLUSION: In conclusion, the results of this study demonstrate that MT for AIS in young patients is feasible and provides an excellent rate of arterial recanalization and high rate of favorable outcomes. Statistical analysis showed that shorter time from onset to arrival and reperfusion, successful recanalization and absence of hemorrhagic transformation are the predictors of favorable clinical outcome and overall survival rate.

Endovascular treatment of vertebrobasilar system aneurysms - long term results.

INTRODUCTION: Microsurgical treatment of VBSA is complex and challenging due to the deep location of the vessels and the proximity of important structures. Therefore, minimally invasive endovascular techniques have been introduced to the treatment of VBSA. The aim of this study was to present long-term results and technical aspects of VBSA embolisation. In this manuscript, we describe our experience in the treatment of VBSA with long-term results. Furthermore, we discuss the advantages and disadvantages of this treatment modality, paying special attention to the technical aspects. We believe that this is an important contribution to this topic because the number of previous reports is limited. It adds to a population that can be compared to patients treated using different methods. MATERIALS AND METHODS: We analysed the medical records of patients with aneurysms of vertebral and basilar arteries referred for endovascular treatment between 2015 and 2020. RESULTS: A total of 44 patients were selected for the study. From this group, 10 patients (22.7%) were admitted with SAH caused by ruptured VBSA. The median age of the patients was 58 years (31-80), with 27 (61.4%) females and 17 (38.6%) males. The majority of the VBSAs (35, 79.5%) were located on the basilar artery. Complete occlusion was achieved in 39 patients (88.6%). Procedural complications occurred in three cases (6.8%). In long-term follow-up, complete embolisation was achieved in 81.8% (36 of 44 patients). In 18.2% (eight patients), recurrence of VBSA was observed. Two patients were qualified for recoiling. Clinical follow-up was uneventful in 37 (84%) patients. Four patients (9%) reported mild headaches. Three (7%) patients required assistance for daily living. CONCLUSIONS: Endovascular embolisation of VBSA is feasible and provides an excellent rate of complete occlusion and a high rate of favourable long-term outcomes, which support using this technique as a first-line treatment. A relatively high rate of recurrence remains the major drawback, especially in cases of wide-neck VBSA.

Successful endovascular treatment of intralobar pulmonary sequestration - an effective alternative to surgery.

INTRODUCTION: Pulmonary sequestration is a rare congenital malformation characterised by the presence of non-functional and dysplastic pulmonary tissue that lacks communication with the tracheobronchial tree and has an aberrant non-pulmonary blood supply. Depending on its location, presence of the pleura covering, and venous drainage, 2 forms of pulmonary sequestration have been described: intra- and extralobar. Traditionally, surgical resection was performed; however, a growing number of cases have been treated with endovascular intervention. CASE REPORT: A 38-year-old female patient was admitted to the hospital with severe haemoptysis for several hours. Examination at admission revealed tachycardia and tachypnoea. Computed tomography-examination disclosed the presence of an area of consolidation in the left lower lobe with a tortuous feeding artery arising from the descending aorta. Visible ground glass opacification indicated diffuse alveolar haemorrhage. Based on these findings, a diagnosis of intralobar sequestration of the left lung was made. The patient was consulted by a cardiothoracic surgeon and an interventional radiologist and qualified for endovascular treatment. In local anaesthesia femoral access was obtained and selective angiography of the common trunk of both bronchial arteries was performed. It depicted a dilated left bronchial artery supplying the sequestration and visible contrast extravasation. Embolisation of the vessel was performed with Glubran (n-butyl-cyanoacrylate). Control contrast injection showed complete elimination of the sequestration's blood supply with no residual capillary blush. Clinical improvement was observed. No complications were encountered, and the patient was discharged 7 days after the procedure. CONCLUSIONS: Arterial embolisation is a promising alternative to surgery in the treatment of symptomatic pulmonary sequestration.

Mechanical thrombectomy for acute ischemic stroke in the posterior circulation: assessment of efficacy and outcome and identification of prognostic factors.

BACKGROUND: Mechanical thrombectomy (MT) is well-established in the treatment of acute ischemic anterior circulation stroke. However, there is no evidence from randomized trials or meta-analyses that MT is safe and effective in the treatment of patients with acute ischemic posterior circulation stroke (PCS). PURPOSE: To evaluate the clinical and procedural factors associated with recanalization and outcome of patients with PCS treated with MT. MATERIAL AND METHODS: Forty-three patients with PCS (median age 73 years) who underwent treatment with MT were included. Data including demographics, baseline stroke severity, radiological imaging, procedure and post-procedure complications were documented. Clinical outcome was evaluated using the modified Rankin Scale (mRS). The patients were classified into two groups based on clinical outcome (favorable vs. unfavorable mRS after 90 days). RESULTS: Median baseline National Institute of Health Stroke Scale (NIHSS) was 17. Twenty patients were eligible for intravenous thrombolysis and received recombinant tissue plasminogen activator before MT. Successful recanalization was observed in 88.4% of patients. After 90 days, favorable outcome (defined as mRS 0-2) was achieved in 26 patients; six patients had an unfavorable outcome (mRs >2). Final mortality rate was 25.5%. Baseline NIHSS, onset to reperfusion time, procedure duration, and successful recanalization had a statistically significant association with outcome. Failed recanalization and occurrence of intracranial hemorrhage were found to be associated with a higher mortality rate. CONCLUSION: MT is feasible and effective method in treatment of PCS. Baseline NIHSS and onset to reperfusion time were found to be independent predictive factors of clinical outcome.

Predictors of outcome after mechanical thrombectomy for acute ischemic stroke in patients aged ≥90 years.

BACKGROUND: Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO). However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients. The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among nonagenarians with acute ischemic stroke treated with mechanical thrombectomy. MATERIALS AND METHODS: This retrospective, single-center study was conducted on 38 patients with LVO treated with MT. Clinical features including baseline results, radiological imaging, procedural details and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS) and after 3 months (mRS). RESULTS: The rate of successful recanalization (TICI ≥2b) was 84.2 % (32/38). Symptomatic intracranial hemorrhage (sICH) was observed in 3 (7.9 %) patients. After 90 days, the mortality rate was 47.4 %. Favorable clinical outcome (mRs 0-2) was regained in 28.9 % of the patients (11/38). Poor clinical outcome (mRs<2) was observed in 9 patients (23.7 %). CONCLUSION: Very elderly patients with LVO should not be excluded from MT even if prognosis for good clinical outcome in this age group remains low and the procedure is more challenging. Long-term outcome is predicted by stroke severity (baseline NIHSS and occluded vessel) and hospital arrival time.