Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs.

BACKGROUND: Instrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs). METHODS: We reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery. RESULTS: The surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference. CONCLUSIONS: We found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Prevalence and clinical outcomes of vitamin D deficiency among Japanese multiple myeloma patients: a single-center observational study.

PURPOSE: Vitamin D plays a crucial role in skeletal metabolism and holds significant importance in the pathophysiology of multiple myeloma (MM). This study aimed to determine the prevalence of vitamin D deficiency among Japanese MM patients and its correlation with clinical outcomes. METHODS: Serum 25-hydroxyvitamin D (25(OH)D) levels were assessed in 68 MM patients at a single institution in Japan, analyzing their association with clinical status, laboratory parameters including procollagen type 1 N-propeptide (P1NP) and tartrate-resistant acid phosphatase 5b (TRACP-5b), health-related quality of life (HR-QOL) scores, and overall survival. Additionally, patients with suboptimal 25(OH)D levels received cholecalciferol supplementation (1000 IU/day), and changes in laboratory parameters were monitored. RESULTS: The median 25(OH)D level was 22 ng/ml, with 32% and 51% of patients exhibiting vitamin D deficiency (< 20 ng/ml) and insufficiency (20-29 ng/ml), respectively. The 25(OH)D levels were unrelated to sex, age, MM stage, or bone lesions, but the vitamin D-deficient group showed a tendency towards lower HR-QOL scores. Among patients achieving complete remission, vitamin D supplementation increased P1NP, while TRACP-5b remained unchanged. Overall survivals from vitamin D measurement and from MM diagnosis were significantly worse in the vitamin D-deficient group compared to the vitamin D-insufficient/-sufficient group. CONCLUSION: The study identified a considerable number of Japanese MM patients with insufficient serum vitamin D levels, with one-third being deficient. Additionally, vitamin D deficiency predicted poor overall survival in Japanese MM patients. Further investigation is required to determine whether vitamin D supplementation can improve the frailty and survival of vitamin D-deficient MM patients.

Impact of Brace-Related Stress on Brace Compliance in Adolescent Idiopathic Scoliosis: A Single-Center Comparative Study Using Objective Compliance Measurement and Brace-Related Stress.

Introduction: This study aimed to investigate the brace compliance and clinical background of patients with adolescent idiopathic scoliosis (AIS) who demonstrate different degrees of psychological brace-related stress. Methods: Forty-five patients initiating brace treatment with a Cobb angle between 25° and 45° were included. Patients receiving brace treatment for AIS were administered a questionnaire for brace-related stress (i.e., the Japanese version of the Bad Sobernheim Stress Questionnaire-Brace [JBSSQ-brace]). Based on their scores, we allocated the patients into two stress groups: mild-stress (≥16 points) and below-moderate-stress (<16 points). We investigated the character of brace compliance and brace-related psychological stress in all patients and compared the demographics and brace compliance between both groups. Results: Forty-one of 45 patients completed the study. The mean JBSSQ-brace scores were 18.7±5.1, 19.1±5.2, and 18.7±5.0 points at the 1-month, 4-month, and 1-year follow-ups, respectively. There was no significant change in JBSSQ-brace scores over one year after the brace prescription (P=0.332). There was no difference in-brace compliance between seasons during the first month of brace prescription (P=0.252). Both groups' overall brace compliance was comparable (below-moderate: 17.1±7.1 h/day vs. mild: 20.4±3.0 h/day; P=0.078). The mild-stress group showed better compliance than the below-moderate-stress group on weekdays (below-moderate: 17.0±6.9 h/day vs. mild: 20.5±2.8 h/day; P=0.048) and at nighttime (below-moderate: 82.3%±27.0%/nighttime vs. mild: 93.8%±12.4%/nighttime; P=0.008). Conclusions: Overall, brace compliance was comparable among patients with different brace-related stress, but brace compliance during weekdays and nighttime was significantly better in the mild-stress group.

Real-world efficacy of DA-EPOCH-R/HD-MTX regimen in CD5-positive diffuse large B cell lymphoma: a single-institute analysis.

CD5-positive diffuse large B cell lymphoma (CD5+ DLBCL) is a high-risk lymphoma type. Recently, the PEARL5 (a Phase II trial of DA-EPOCH and Rituximab with HD-MTX therapy for newly diagnosed DLBCL with CD5 expression) study demonstrated the efficacy of the DA-EPOCH-R (cyclophosphamide, etoposide, doxorubicin, vincristine, prednisone, and rituximab)/HD-MTX (high-dose methotrexate) regimen for CD5+ DLBCL. In this report, we revealed the impact of the DA-EPOCH-R/HD-MTX regimen on the clinical course of CD5+ DLBCL in the real-world. We retrospectively compared CD5+ and CD5- DLBCL patients diagnosed from January 2017 to December 2020 and analyzed their clinicopathological characteristics, treatment, and prognosis. There was no difference in age, sex, clinical stage, and cell of origin; however, the CD5-positive group had higher lactate dehydrogenase levels and a worse performance status than the CD5-negative group (p=0.00121 and p=0.0378, respectively). International prognostic index (IPI) was worse in the CD5-positive group than in the CD5-negative group (p=0.0498), but NCCN-IPI (National Comprehensive Cancer Network-IPI) was no different between the two groups. The CD5-positive group was more frequently treated with the DA-EPOCH-R/HD-MTX regimen than the CD5-negative group (p =0.001857). Complete remission rate and 1-year overall survival did not differ between the CD5-positive and -negative groups (90.0% vs 81.4%, p=0.853; 81.8% vs 76.9%, p=0.433). We conclude that the DA-EPOCH-R/HD-MTX regimen is effective for CD5+ DLBCL in this single institute analysis.

Risk factors for celiac artery and superior mesenteric artery stenosis in preoperative lumbar and thoracolumbar spinal surgery patients.

BACKGROUND: Ischemic necrosis of the abdominal organs caused by compression of the celiac artery (CA) and superior mesenteric artery (SMA) by the median arcuate ligament (MAL) after correction surgery has been recognized as acute celiac artery compression syndrome (ACACS). Here, using contrast-enhanced computed tomographic (CT) images, we sought to determine the prevalence and degree of CA and SMA stenosis in spinal patients preoperatively, and the risk factors associated with the stenosis. METHODS: We retrospectively examined contrast-enhanced abdominal CT of 90 patients with preoperative lumbar degenerative disease, lumbar burst fracture, or adult spinal deformity. The trunks of the CA and SMA were detected using three-dimensional reconstructed CT. To investigate their degree of stenosis, we determined the ratio of the narrowest diameter of the stenotic segment to the distal normal lumen's diameter. Patients with a degree of stenosis ≥35% were defined as being in the group with stenosis and the remainder as in the group without. To determine the risk factors for stenosis of these arteries, the relationship between the stenosis and CA and SMA calcification or the median arcuate ligament (MAL) crossing the proximal portion of the celiac axis (MAL overlap) was also investigated. RESULTS: The average degree of stenosis of the CA trunk was 12.1% ± 13.9% and that for the SMA trunk was 8.5% ± 8.8%. There were 8 patients (8.9%) in the group with CA stenosis and 2 patients (2.2%) in the group with SMA stenosis. The number of patients in the group with CA stenosis was significantly greater than the number with MAL overlap or CA calcification (P < 0.05). DISCUSSION: The prevalence of CA or SMA stenosis was 11.2% of preoperative patients due to undergo thoracolumbar fusion surgery. Calcifications of the CA trunk and MAL overlap are risk factors for CA stenosis.

Incidence and causes of instrument-related complications after primary definitive fusion for pediatric spine deformity.

OBJECTIVE: Various complications have been reported in the treatment of pediatric spinal deformities. Among these, instrument-related complications could be critical concerns and risks of reoperation. This study aimed to identify the incidence and causes of complications after primary definitive fusion for pediatric spine deformities. METHODS: The authors retrospectively collected data from 14 institutions about patients who underwent primary definitive fusion between 2015 and 2017. There were 1490 eligible patients (1184 female and 306 male), with a mean age of 13.9 years. The incidence, causes, and reoperation rates were analyzed according to 4 etiologies of pediatric spine deformity (congenital, neuromuscular, syndromic, idiopathic). The complications were also categorized as screw-, hook-, or rod-related complications, implant loosening or backout, and junctional problems. RESULTS: The incidence of overall instrument-related complications was 5.6% (84 cases). Regarding etiology, the incidence rates were 4.3% (idiopathic), 6.8% (syndromic), 7.9% (congenital), and 10.4% (neuromuscular) (p < 0.05). The most common causes were pedicle screw malposition (60.7%), followed by implant backout or loosening (15.4%), junctional problems (13.1%), rod breakage (4.8%), and other complications (6.0%). Univariate analysis showed that etiology, type of deformity (kyphosis), surgical procedure, operation time, and estimated blood loss were significant factors. Multivariate analysis revealed that etiology (neuromuscular), surgical procedure (combined approach), and operation time (> 5 hours) remained as significant risk factors. Among all patients with instrument-related complications, 45% (38/84) required revision surgery. Of these cases, > 50% were related to pedicle screw malposition. Medial breach was the most common complication regardless of location, from upper thoracic to lumbar spine. CONCLUSIONS: Pedicle screw malposition was the primary cause of overall complications and subsequent reoperation. In addition to more precise screw insertion techniques, meticulous confirmation of pedicle screw placement, especially of medial breach, may reduce the overall instrument-related complications and revision rates.

Carbon Dioxide Angiography for the Detection of Lower Gastrointestinal Arterial Bleeding Initially Occult to Angiography with Iodinated Contrast Media.

This study evaluated the utility of carbon dioxide (CO2) in angiography for the detection of lower gastrointestinal arterial bleeding initially occult to angiography with iodinated contrast media. Fourteen patients underwent CO2-enhanced angiography. In all patients, extravasation was identified by contrast-enhanced computed tomography but not by initial iodinated contrast-enhanced angiography. After iodinated contrast-enhanced angiography, CO2-enhanced angiography was performed from the same catheter position. The detection capability for extravasation on CO2-enhanced angiography was evaluated. CO2-enhanced angiography allowed for the visualization of extravasation and subsequent transcatheter arterial embolization in 11 of 14 (79%) cases, with extravasation seen during either CO2-enhanced angiography (n = 8) or subsequent repeat iodinated contrast-enhanced angiography immediately after negative CO2-enhanced angiography (n = 3). Conservative treatment was performed in the remaining 3 cases. In conclusion, CO2-enhanced angiography appears useful for identifying occult lower gastrointestinal bleeding.

Hemoptysis after coil embolization for pulmonary arteriovenous malformation: Histopathological confirmation of bronchial epithelium extension.

Coil embolization is widely performed for pulmonary arteriovenous malformations (PAVMs). We describe herein 2 cases of hemoptysis during long-term follow-up after coil embolization for PAVMs. For both cases, lobectomy was performed and histopathological examinations revealed chronic inflammation and bronchial epithelium extension into the sac of the PAVM. In addition, we performed a systematic review of previous reports of hemoptysis after embolization for PAVMs.

The Optimal Anatomical Position and Threshold Temperature of a Temperature Data Logger for Brace-Wearing Compliance in Patients with Scoliosis.

Introduction: Although strict compliance with brace wearing is important for patients with scoliosis, no study has analyzed the most ideal conditions for temperature logger accuracy. We evaluated the optimal brace position and threshold temperature for the logger and determined the reliability of its measurements in patients with scoliosis. Methods: Five temperature loggers were embedded into holes generated at five different brace positions (right scapula, right chest, left chest, lumbar, and abdomen) within the brace. We compared measurement errors at each position using different threshold temperatures to determine the ideal anatomical position and threshold temperature. Under the ideal conditions determined, we calculated the reliability of the temperature logger readings in three healthy participants. Results: Measurement errors (i.e., differences between the actual and logger-recorded brace wearing times) were the lowest at the 28°C and 30°C threshold temperatures when the logger was positioned at the left chest and at 30°C at the abdomen. Among these three temperature/position combinations, we considered the abdomen to be the least affected by the shape of the brace; thus, the placement of the temperature logger at the abdomen using a threshold temperature of 30°C was the most ideal condition. Conclusions: The placement of the temperature logger at the abdomen using a threshold temperature of 30°C was the most ideal condition, with the reliability of the logger being 97.9%±0.9%. This information might be useful for scoliosis management teams, and this temperature logger provides a valuable clinical tool.

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage.

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.

Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate.

PURPOSE: The aim of this study was to evaluate the usefulness of transcatheter arterial embolization (TAE) using the triaxial system with N-butyl-2-cyanoacrylate (NBCA) for acute arterial bleeding in comparison to TAE using the triaxial system with gelatin sponges (GS)　and/or coils. MATERIAL AND METHODS: Between October 2013 and November 2018, 95 patients with acute arterial bleeding underwent emergency TAE using the triaxial system. Six patients underwent multiple TAEs and thus, 104 TAEs using the triaxial system were performed. In 26 of the 104 cases, TAE were performed with NBCA (NBCA group), and in the remaining 78 cases, TAE were performed with GS and/or coils (control group). RESULTS: Hemorrhagic shock and coagulopathy more often occurred in the NBCA group. Procedure time was shorter in the NBCA group. The technical success rate was 100% in both groups (p > 0.99). The clinical success rate in the NBCA and control groups was 92% and 96%, respectively (p = 0.6). There was one minor complication (4%, 1/26) of liver dysfunction in a patient of the NBCA group, but no complication in the control group (p = 0.26). CONCLUSION: TAE using the triaxial system with NBCA may be useful for acute arterial bleeding, especially in patients with hemorrhagic shock and coagulopathy.

Large Lumbar Lordosis Is a Risk Factor for Lumbar Spondylolysis in Patients with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A retrospective, single-center, observational study. OBJECTIVE: The aim of this study was to determine the prevalence and the characteristics of adolescent idiopathic scoliosis (AIS) patients with concomitant lumbar spondylolysis. SUMMARY OF BACKGROUND DATA: The prevalence and features of lumbar spondylolysis in patients with AIS are unclear. METHODS: We included 357 patients with AIS who underwent correction and fusion surgery. Preoperative computed tomography (CT) images were used to assess the existence of lumbar spondylolysis. Cobb angles of the curves, parameters of spinal alignment, Lenke classification, and the presence of low back pain were compared between patients with and without spondylolysis. RESULTS: Of the patients included in the study, 6.1% had lumbar spondylolysis. They had significantly greater lumbar lordosis (LL) and sacral slope (SS) than those without lumbar spondylolysis. Logistic regression analyses and receiver-operating characteristic curves showed that LL was a significant risk factor (odds ratio: 1.059; 95% confidence interval: 1.018-1.103; P = 0.005) of associating lumbar spondylolysis with a cut off value of 56.5 degrees (area under the curve [AUC]: 0.689; sensitivity = 63.6%, specificity = 71.0%). CONCLUSION: We should be vigilant for lumbar spondylolysis in AIS patients whose LL and SS are large, especially with LL larger than 56.5°.Level of Evidence: 3.

Efficacy of lateral lumbar interbody fusion combined with posterior spinal fusion compared with three-column osteotomy for adult spinal deformity with severe lumbar sagittal deformity.

PURPOSE: The clinical and radiological results of adult spinal deformity (ASD) patients with a severe lumbar sagittal deformity undergoing multilevel lateral lumbar interbody fusion (LLIF) + posterior spinal fusion (PSF) were compared to patients undergoing three-column osteotomy (3CO). METHODS: We defined severe lumbar sagittal deformity as fulcrum backward bending (FBB) pelvic incidence minus lumbar lordosis (PI-LL) ≧ 20 degrees. A total of twenty-five patients with an ASD were enrolled between 2013 and 2018. Fifteen patients were in the LLIF + PSF group, and ten patients were in the 3CO group. We evaluated patient demographics, clinical outcomes, and radiographic parameters such as the Cobb angle and spinopelvic parameters from standing X-ray films in each group. RESULTS: The LLIF + PSF group had a significantly shorter follow-up time than the 3CO group. Postoperatively, the LLIF + PSF group had significantly lower PI-LL and a shorter sagittal vertical axis than the 3CO group. Postoperative PI-LL changes in the LLIF + PSF group were significantly smaller than those in the 3CO group. There were no differences in other patient demographics, radiographic parameters, or clinical outcomes between the groups. CONCLUSION: Multilevel LLIF + PSF improved the PI-LL and SVA more than did 3CO for ASD patients with severe lumbar sagittal deformity. This indicated that the multilevel LLIF with open PSF can provide good clinical outcomes even in cases with severe lumbar sagittal deformity such as large FBB PI-LL in which 3CO techniques usually are needed.

Duodenal stenosis after transcatheter arterial embolization for rupture of an inferior pancreaticoduodenal aneurysm.

A 64-year-old man presented with epigastric pain and underwent contrast-enhanced computed tomography. Ruptured aneurysm of the inferior pancreaticoduodenal artery was diagnosed. TAE was successfully accomplished using coils, but vomiting appeared 9 days later. Duodenal stenosis was diagnosed from contrast-enhanced computed tomography and upper gastrointestinal endoscopy and was attributed to edematous changes in the duodenum. Conservative management led to successful recovery and discharge.

Incidence, Risk Factors, and Prevention Strategy for Proximal Junctional Kyphosis in Adult Spinal Deformity Surgery.

INTRODUCTION: Proximal junctional kyphosis (PJK) is an acute complication of adult spinal deformity (ASD) surgery and may require re-operation because of proximal junctional failure (PJF). PJK causes and prevention strategies remain unknown. This study aimed to investigate the differences in the backgrounds of patients with PJK, compared to those without PJK, in ASD surgery. METHODS: We included data from 86 patients who underwent ASD surgery between 2012 and 2018. There were 40 patients (46.5%) with PJK; 46 patients did not have PJK until the last follow-up. We evaluated patient demographics, clinical outcomes, and radiographic parameters, such as Cobb angle and spinopelvic parameters on standing X-ray films, in each group. RESULTS: There was no significant difference in patient demographics, clinical outcomes, or preoperative radiographic parameters. Postoperative pelvic incidence minus lumbar lordosis (PI-LL) and pelvic tilt (PT) were significantly lower in the PJK group, and thoracic kyphosis (TK) was higher. The cutoff values were 34.5° for TK, 0.5° for PI-LL, and 15.5° for PT. Other radiographic parameters were not significantly different. PJF developed in seven patients (17.5%) in the PJK group. PJF patients had significantly older age, higher postoperative TK, higher postoperative proximal junctional Cobb angle (PJA), more changes between pre- and postoperative PJA, and lower satisfaction scores on the Scoliosis Research Society Outcomes Questionnaire (SRS-22 satisfaction) than non-PJF patients in the PJK group. CONCLUSIONS: One risk factor for PJK was lower postoperative PI-LL that was 0° or less. In ASD surgery, the most critical factor in a PJK prevention strategy is to obtain a postoperative LL adjusted by PI, which is >0°.

Safety and utility of performing CT-guided biopsies of pulmonary lesions that arise after radiotherapy.

This study aimed to evaluate the feasibility, safety and usefulness of performing computed tomography (CT)-guided biopsies of pulmonary lesions that arise after radiotherapy. Seventeen patients (14 males and 3 females; median age: 69 years, range: 48-84 years) underwent CT-guided biopsies of pulmonary lesions that occurred in lung regions that had previously been treated with radiotherapy. Three patients underwent CT-guided biopsies twice, and thus, the total number of procedures was 20. We reviewed the subjects' medical records and images, and evaluated the rate for obtaining pathological diagnosis with the biopsy sample, subsequent clinical course, and complications associated with the procedure. In 19 of 20 procedures (95%), the CT-guided biopsy resulted in a pathological diagnosis being obtained. In 14 procedures, the pathological results were consistent with the patients' clinical courses. In the remaining 5 procedures, the lesions were pathologically diagnosed as benign, but they increased in size thereafter; so the lesions were considered to be clinically malignant. The results were considered to represent sampling errors. There were 3 minor complications (slight pneumothorax which did not require drainage) (3/20, 15%), and there were no major complications. In conclusion, performing CT-guided biopsies of pulmonary lesions that arise after radiotherapy appears to be feasible, safe and useful.

A Case of Cardiac Arrest during C1 Laminectomy for Irreducible Atlantoaxial Subluxation.

We report a case of cardiac arrest, which occurred during C1 laminectomy for irreducible atlantoaxial subluxation, with return of spontaneous circulation (ROSC) upon interruption of the laminectomy. A 60-year-old woman with rheumatoid arthritis presented with neck pain, bilateral finger numbness, and bladder-rectal disturbance. Simple radiograph images showed that the atlantodental interval (ADI) was enlarged to 8 mm, and magnetic resonance imaging revealed severe spinal stenosis at C1. She was diagnosed with cervical spondylotic myelopathy due to atlantoaxial subluxation. Cardiac arrest occurred twice during the C1 laminectomy and occipito-cervical fusion (Occ-C3), and ROSC occurred without any treatment. There was no postoperative worsening of neurological symptoms, and the improvement of sensory and motor palsy was favorable. The pathogenic mechanism was presumed to be trigeminocardiac reflex. Cardiac arrest during upper cervical spine surgery is an important intraoperative complication of which operators should be made aware.

Safety of Transcatheter Arterial Embolization for Visceral Artery Pseudoaneurysms: Incidence of Intraprocedural Rupture.

INTRODUCTION: Transcatheter arterial embolization is the first-line treatment for visceral artery pseudoaneurysms (VAPAs); however, the intraprocedural rupture of pseudoaneurysms is an important complication. The present study was performed to evaluate the safety of embolization for VAPAs, including the incidence of intraprocedural rupture. METHODS: Among 56 consecutive patients with 57 VAPAs who underwent treatment between April 2009 and October 2020, 46 patients with 47 VAPAs underwent embolization. Complications related to embolization including intraprocedural rupture, the technical success rate, and clinical outcomes were evaluated. Complications that required extended hospitalization, an advanced level of care, or resulted in permanent adverse sequelae or death were classified as major complications, while the remainder were considered to be minor. Technical success was defined as the completion of embolization. RESULTS: The intraprocedural rupture of pseudoaneurysms occurred in 3 out of 47 VAPAs treated with embolization (6%) and resulted in minor complications. One liver abscess requiring drainage was regarded as a major complication (2%). Focal infarction after embolization was observed as a minor complication in 20 cases. Complications occurred in 24 out of 47 cases (51%), comprising one major complication (2%) and 23 minor complications (48%). The technical success rate was 100% (47/47). Fifty-three out of 56 patients (95%) were alive in a median follow-up period of 18 months (range: 2 days-137 months). CONCLUSIONS: Embolization is safe and useful for the treatment of VAPAs; however, the intraprocedural rupture of pseudoaneurysms may occur, and, thus, care is needed during this procedure.