Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions.

BACKGROUND AND PURPOSE: The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective. METHODS: We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately. RESULTS: We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P=0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P=0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P=0.009). The 3-month rates of favorable outcome (P=0.806) and mortality (P=0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1-Q3) follow-up of 10 (3-20) months. CONCLUSIONS: Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.

[Uterine fibroids embolization: results about 454 cases]. / Embolisation des fibromes utérins: résultats sur 454 cas.

OBJECTIVE: To determine the effectiveness of uterine arterial embolization (UAE) as primary treatment in the management of symptomatic leiomyomas. PATIENTS AND METHOD: UAE was performed on 454 patients (age range: 21-68) with menorrhagia, bulk-related symptoms or both, due to leiomyomas. The effectiveness of this therapy in the control of symptoms and reduction of uterine and leiomyoma volume was measured by clinical and imaging controls at 3, 6 and 9 months after the procedure. RESULTS: Four hundred and thirty-three patients were evaluated, and 42 failures were observed (9.6%). Six months after the procedure, 391 patients were symptom-free. Follow-up ultrasonic examination showed an average reduction of 55% in dominant myoma volume at 6 months, 70% at 1 year. Twenty-seven women became pregnant (30 pregnancies). Complications related to procedure, and requiring surgery, occurred in three cases. Principal complications are amenorrhoea and fibroid sloughs. Severe complications are rarely found. DISCUSSION AND CONCLUSION: UAE is an efficient therapy in the management of symptomatic myomas and proves to be a valid alternative to surgical procedure. The future of this mini-invasive and conservative technique appears to be a very promising one.

[Value of local ophthalmic artery fibrinolysis in severe forms of central retinal vein occlusion]. / Intérêt de la fibrinolyse locale intra-artérielle ophtalmique dans les formes sévères de l'occlusion de la veine centrale de la rétine.

PURPOSE: To assess the value of selective ophthalmic artery thrombolysis as a treatment for central retinal vein occlusion (CRVO) for which no alternative therapy is available. MATERIALS AND METHODS: Patients included in this study presented with recent severe non-ischemic CRVO. Urokinase (300,000 IU) was perfused for 40 minutes into the ophthalmic artery. Visual acuity, fundoscopy and retinal arteriovenous transit time were assessed during one year of follow-up. RESULTS: Five of the 13 patients treated experienced a marked improvement of vision (p = 0.05) and retinal perfusion within 24-48 hours, and exhibited progressive lesion regression at fundoscopy within 2-4 weeks. The clinical course of the 5 patients prior to treatment resembled that of combined central retinal artery and vein obstruction (CRAO/CRVO), which typically has a poor visual outcome. One patient relapsed 1 month after thrombolysis. No technical complications were observed. CONCLUSION: Although there was no control group, the short period between fibrinolysis and significant visual improvement combined with marked retinal perfusion improvement, suggests that local thrombolysis is beneficial for CRVO, especially recent CRAO/CRVO.

[Embolization of cerebral arteriovenous malformations]. / Embolisation des malformations artério-veineuses cérébrales.

Embolization is an important therapeutic tool for the treatment of cerebral arteriovenous malformations and is a part of the therapeutic strategy. In selected cases, it may lead to a total and permanent cure per se, but in most cases it will be an adjunctive therapy to radiosurgery. The authors review techniques of embolization, perioperative care, complications and applications of the treatment.

Percutaneous sclerotherapy for venous malformation of the lips: a retrospective study of 23 patients.

Labial venous malformations are relatively common. Depending on their size, they are responsible for functional and cosmetic handicap. When treatment is indicated, it will be based on percutaneous sclerotherapy, using Ethibloc or Aetoxysclerol, with surgery in some patients. Our purpose was to review 23 patients with soft-tissue venous malformations of the lips. Follow-up ranged from 6 months to 4 years. Sclerotherapy alone or with surgical resection achieved good results in 18 patients. In six patients mild improvement was obtained. No worsening of the initial clinical situation occurred, and no persistent complication was observed. We discuss the indications for treatment and the different types of sclerosing agent. Percutaneous sclerotherapy is safe and is effective for small and medium-size labial malformations. For larger lesions the treatment is more complex and combined long term sclerotherapy and surgery procedures may be required over several years.

Superselective ophthalmic arterial fibrinolysis with urokinase for recent severe central retinal venous occlusion: initial experience.

PURPOSE: To investigate the effects of local ophthalmic arterial fibrinolysis on central retinal venous occlusion (CRVO). MATERIALS AND METHODS: Thirteen patients had recent severe nonischemic CRVO for which no alternative therapy was available. A flow-guide microcatheter was introduced coaxially via the femoral artery into the ophthalmic arterial ostium, and urokinase was perfused for 40 minutes. Vision, funduscopic findings, and retinal perfusion were assessed during 1 year of follow-up. RESULTS: Five of the 13 patients treated experienced visual improvement (P =.05) and retinal perfusion within 24-48 hours. Vision returned to normal within 24-48 hours in three patients, within 1 week in one patient, and within 1 month in one patient. These five patients exhibited progressive lesion regression within 2-4 weeks at funduscopy. Their clinical course prior to treatment resembled that of combined central retinal arterial occlusion (CRAO) and CRVO, which typically has a poor visual outcome. One patient relapsed 1 month after fibrinolysis. Of the remaining eight patients, one had normal vision at 12 months, and seven had no improvement. No technical complications were observed. CONCLUSION: Although there was no control group, the short period between fibrinolysis and substantial visual improvement, combined with marked retinal perfusion improvement, suggests that fibrinolysis is beneficial for CRVO, especially for recent CRAO and CRVO.

Pregnancy after embolization of uterine myoma: report of 12 cases.

OBJECTIVE: To treat uterine myomas with embolization, to look for pregnancy-induced myoma recurrences, and to assess pregnancy course and outcome after embolization. DESIGN: Observational clinical study. SETTING: University of Paris VII hospital. PATIENT(S): Nine women had embolization for symptomatic myoma, with 12 pregnancies observed. INTERVENTION(S): Embolizations were highly selective and performed bilaterally through the uterine arteries with polyvinyl alcohol. MAIN OUTCOME MEASURE(S): Pregnant women were evaluated by physical and sonographic examinations. RESULT(S): Before embolization, the mean uterine volume was 450 cm(3), and in six patients polymyomas were present. The median age at embolization was 40 years; the median delay before pregnancy was 9 months; and the median age at first pregnancy outcome was 41 years. Five early miscarriages occurred. The seven other pregnancies were uneventful, although three premature births and one case of late toxemia occurred unrelated to previous embolization. Three women delivered vaginally and four by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed. CONCLUSION(S): The results of this first series of 12 pregnancies after myoma embolization are promising. If these preliminary results are confirmed, embolization could be a major breakthrough in the management of myoma and could replace conventional medical and surgical treatments.

[Arterial embolization of uterine myoma: results apropos of 286 cases]. / Embolisation artérielle des myomes utérins.

OBJECTIVE: Report outcome in non-surgical treatment of symptomatic uterine myomata by particulate arterial embolization. PATIENTS: and method: Two hundred eighty-six women aged 21 to 53 years with symptomatic uterine fibroids initially programmed for surgery were studied. The size and number of myomata were determined by pelvic ultrasound. After retrograde transfemoral introduction of a 4 French catheter, the left and right uterine arteries were successively catheterized. PVA particles were injected by free flow until devascularization. RESULTS: Two hundred sixty-two patients were evaluable. Complete resolution of symptoms was obtained in 245 cases. There were 17 failures. A marked reduction in the size of the myomata was observed (60% at six months). Hemorrhage disappeared in 80% of the cases immediately. Thirteen pregnancies were observed. No recurrence were observed. Complications were rare. CONCLUSION: Particulate embolization is a new minimally invasive treatment for uterine myomata which provides a alternative to hysterectomy and can replace myomectomy in young women.

Balloon-assisted coil embolization for large-necked renal artery aneurysms.

An aneurysm of the right renal artery was discovered in a patient suffering from cerebral arterial angiodysplasia and arterial hypertension. The aneurysm was large necked, which made selective endovascular treatment very difficult. To perform the embolization of the aneurysm, a balloon remodelling technique was used. This prevented migration of coils within the arterial lumen.

[Preoperative devascularization of a vertebral metastasis with a spinal artery at the same level]. / Dévascularisation préopératoire d'une métastase vertébrale avec artère médullaire naissant au même étage.

An hypervascular and lytic thoracic (Th10) vertebral metastasis from kidney neoplasm causing cord compression was successfully resected after embolization. Because the anterior spinal artery arose at the same level, arterial embolization was only partial and completed by percutaneous vertebroplasty using Nbutyl cyanoacrylate.

Major complications of percutaneous embolization of skull-base tumors.

The technique of direct intratumoral injection of permanent liquid polymerizing agent was initially described in 1994 and has evolved significantly with experience. We report complications that occurred in two patients during injection of Histoacryl and offer suggestions to prevent such complications in the future. In one patient, the glue settled in the right middle cerebral artery; in the second, the glue entered the left ophthalmic artery through a collateral branch. Although the fundamental injection technique has not changed, we suggest additional precautions and modifications to make this procedure a safer and more valuable element in the overall management of patients with difficult skull-base tumors.

[Aneurysm of the iliac artery in an elderly subject. Role of treatment with covered endoprosthesis]. / Anévrysme de l'artère iliaque du sujet âgé. Place du traitement par endoprothèse couverte.

BACKGROUND: Coated stents can be an alternative to open surgery for arterial aneurysms, particularly in patients with high operative risk. CASE REPORT: A 90-year-old man with advanced stage cardiopathy developed a 52 mm aneurysm of the iliac artery. Perioperative imaging (arteriography with marked catheter, CT-scan and endovascular ultrasonography) provided a precise description. The material used (PTFE coated thermal memory endoprosthesis, balloon in the hypogastric) provided effective exclusion. DISCUSSION: Endovascular treatment can be a useful alternative to open surgery for arterial aneurysm in the very elderly.

Therapeutic approach to arteriovenous malformations of the tongue.

Arteriovenous malformations (AVM) are developmental errors with a high complication rate because they are hemodynamically active. The aim of our study is to evaluate management of the rare subgroup of tongue AVM. From 1982 to 1994, 25 patients with AVM of the tongue presented to our department. All patients were discussed in our multidisciplinary staff consultation and were treated by embolization, surgery, or were followed-up clinically with no intervention. Thirteen patients were asymptomatic in a hemodynamically quiescent phase and did not require any kind of intervention. The 12 others underwent embolization procedures following which 6 became stable, 2 had complementary surgery, 1 was lost to follow-up, 1 had two minor bleeding episodes without the need for hospitalization, and 2 were improved. Arteriovenous malformations of the tongue must be followed clinically and treated only if they become active. Permanent embolization with a polymerizing liquid administered through supra-selective catheterization or by direct puncture of the malformation is recommended.

Giant perimedullary arteriovenous fistulas of the spine: clinical and radiologic features and endovascular treatment.

PURPOSE: To present the clinical and radiologic features of giant perimedullary arteriovenous fistulas (GAVFs) in 12 consecutive cases and to evaluate the results of endovascular treatment. METHODS: We retrospectively reviewed the clinical and radiologic data as well as the results of balloon endovascular treatment obtained from 1980 to 1989. RESULTS: GAVFs, defined as large intradural perimedullary direct arteriovenous high-flow shunts, are revealed mainly in childhood either by subarachnoid hemorrhage or by progressive neurologic disorders. MR imaging and myelography show major vascular dilatations. The angioarchitecture of GAVFs can only be assessed by selective spinal angiography. Ten patients were treated by balloon occlusion resulting in eight anatomic cures and six good clinical results. One balloon migrated to the venous side, leading to clinical deterioration. CONCLUSION: GAVF is a special subgroup of intradural perimedullary arteriovenous fistula. The endovascular approach should be the first line of treatment, with surgery reserved for special circumstances. Nondetachable balloon occlusion is a safe and efficient method for treating GAVFs.

[Recourse to particular arterial embolization in the treatment of some uterine leiomyoma]. / Recours à i'embolisation artérielle particulaire dans le traitement de certains fibromyomes utérins.

UNLABELLED: In 88 women between the ages of 34 and 51 years with one or several symptomatic uterine leiomyomata (menometrorrhagia, mass syndrome) after failure of medical treatment, particulate arterial embolization was proposed as an alternative to the scheduled surgical operation. Free-flow embolization with Ivalon particles (150 to 600 microns) was performed under local anaesthesia after femoral artery puncture and catheterization of the hypogastric then uterine arteries (5 F catheter) including occlusion Pelvic pain was frequently observed immediately after embolization, lasting 12 to 18 hours, and required analgesia. Necrobiosis syndromes can be observed in the case of very large leiomyomata. No immediate complications directly related to vascular catheterization were observed in this series, but complete necrosis of a very large leiomyomatous uterus required hysterectomy. Five embolization failures were observed. The following results were observed in the 80 interpretable cases with a follow-up of 6 to 60 months: the menstrual periods returned to normal in 60 (89%) of the 67 menorrhagic patients, after six months a volume reduction of myomata equal to 69% of initial volume was observed. CONCLUSION: in of 80 interpretable cases, embolization constituted an alternative to surgical treatment, which was avoided in 71 cases, 9 failures were observed. The results of this preliminary series must be valited by further studies.

Treatment of brain arteriovenous malformations by embolization and radiosurgery.

Embolization was used to reduce the size of brain arteriovenous malformations (AVMs) prior to radiosurgical treatment in 125 patients who were poor surgical candidates or had refused surgery. Of these patients, 81% had suffered hemorrhage, and 22.4% had undergone treatment at another institution. According to the Spetzler-Martin scale, the AVMs were Grade II in 9.6%, Grade III in 31.2%, Grade IV in 30.4%, and Grades V to VI in 28.8% of the cases. Most embolizations were performed using cyanoacrylate delivered by flow-guided microcatheters. Radiosurgery was performed using a linear accelerator in 62 patients treated by the authors, and 34 patients were treated at other institutions using various methods. Embolization produced total occlusion in 11.2% of AVMs and reduced 76% of AVMs enough to allow radiosurgery. Radiosurgery produced total occlusion in 65% of the partially embolized AVMs (79% when the residual nidus was < 2 cm in diameter). Embolizations resulted in a mortality rate of 1.6% and a morbidity rate of 12.8%. No complications were associated with radiosurgery. The hemorrhage rate for partially embolized AVMs was 3% per year. No patient with a completely occluded AVM experienced rehemorrhage. Angiographic follow-up review of AVMs embolized with cyanoacrylate demonstrated a 11.8% revascularization rate, occurring within 1 year. It is concluded that after partial embolization with cyanoacrylate, the risk of hemorrhage from the residual nidus is comparable to the natural history of AVMs and that the residual nidus can be irradiated with results almost as good as for a native AVM of the same size.

Cerebral dural arteriovenous fistulas: percutaneous transvenous embolization.

PURPOSE: To evaluate angiographic and clinical results in patients with a dural arteriovenous fistula (AVF) who underwent percutaneous transvenous embolization. MATERIALS AND METHODS: Retrospective chart analysis and radiologic studies were performed in 24 patients (aged 20-87 years) with a dural AVF treated with percutaneous transvenous embolization. Lesions were located in the transverse and/or sigmoid or superior sagittal sinus. Clinical follow-up was 3-44 (mean, 10.8) months. RESULTS: After percutaneous transvenous embolization of 24 dural AVFs, there was complete occlusion in 17 patients, important flow reduction in three, and moderate flow reduction in four. Twenty patients were clinically cured, 17 with complete occlusion and three with important flow reduction. In patients with moderate flow reduction, clinical improvement was good in two and moderate in one. One patient remained clinically unchanged. A transient complication was seen in one patient, and a permanent complication was seen in one patient. One patient, whose preexisting clinical status was poor, died. During long-term follow-up, the condition of two patients worsened. CONCLUSION: Percutaneous transvenous embolization appears to be effective in the treatment of dural AVFs. More experience is needed to evaluate long-term results.

Trisacryl gelatin microspheres for therapeutic embolization, II: preliminary clinical evaluation in tumors and arteriovenous malformations.

PURPOSE: To evaluate an embolic agent that is precisely calibrated, perfectly spherical in shape, and soft but nonresorbable for use in the embolization of vascular disease of the head, neck, and spine in humans. METHODS: We used supple, hydrophilic, and calibrated trisacryl gelatin microspheres 200, 400, 600, 800 and 1000 microns in diameter for superselective embolization in 105 patients (27 tumors, 14 facial arteriovenous malformations [AVMs], 37 spinal cord AVMs, 21 cerebral AVMs, and 6 miscellaneous diseases). We used particles in 200 to 600 microns in diameter for tumors and for facial AVMs, particles 400 to 600 microns in diameter for spinal cord AVMs, and particles over 1000 micros in diameter for cerebral AVMs. RESULTS: Delivery of the embolic material was easy: microspheres did not aggregate and catheters did not become obstructed by particles. It was possible to control the embolization through precise accounting of the amount of microspheres and matching of the particle size to the size of the pathologic vascular network. CONCLUSION: The microspheres are easy to use and allow precise control of the embolization procedure. Their physical characteristics make them a safe embolic agent.

Place of emergency arterial embolisation in obstetric haemorrhage about 16 personal cases.

Delivery bleedings which persist despite of an efficient medical treatment must be offered embolization without delay. Embolization is efficient in nearly 100% of cases; sometimes it has to be repeated. Embolization will it correct coagulopathy in few hours. It is a conservative treatment. It is nowadays undoubtedly the treatment of choice. Territorial organization for the hospital without interventional radiology is needed to organize the transfer of the bleeding patients without delay. Thus, mortality and morbidity as well as hysterectomy will not exist anymore.